USAID AFYA PWANI QUARTERLY PROGRESS REPORT
JANUARY-MARCH 2018 This publication was produced for review by the United States Agency for International Development. It was prepared by Dr Eileen Mokaya, Chief of party, Afya Pwani.
USAID AFYA PWANI
FY 2018 Q2 PROGRESS REPORT
1st January 2018 – 31st March 2018
Award No: Aid-615-C-16-00002
Prepared for Mr. Vincent Ojiambo United States Agency for International Development/Kenya C/O American Embassy United Nations Avenue, Gigiri P.O. Box 629, Village Market 00621 Nairobi, Kenya
Prepared by Pathfinder International-Kenya The Watermark Business Park, Karen, Fountain Court, 1st Floor Ndege Road, off Langata Road P. O. Box 1996 – 00502 Karen NAIROBI, KENYA Office : +254-20-3883142/3/4 Mobile : +254-733-618359/+254-722-516275 Fax : [+254 20] 2214890 www.pathfinder.org
DISCLAIMER The authors’ views expressed in this report do not necessarily reflect the views of the United States Agency for International Development or the United States Government.
USAID AFYA PWANI PROGRESS REPORT JANUARY-MARCH 2018 1
I. AFYA PWANI EXECUTIVE SUMMARY ...... 10
II. KEY ACHIEVEMENTS (QUALITATIVE IMPACT) ...... 24
SUB-PURPOSE 1: INCREASED ACCESS AND UTILIZATION OF QUALITY HIV SERVICES ...... 24 Output 1.1: Elimination of Mother to Child Transmission (eMTCT):...... 24 Output 1.2: HIV Care and Support Services ...... 31 Output 1.3: HIV Treatment Services ...... 35 Output 1.4 HIV Prevention and HIV Testing and Counseling ...... 49 Output 1.5: Tuberculosis/HIV Co-infection Services ...... 58
SUB-PURPOSE 2: INCREASED ACCESS AND UTILIZATION OF FOCUSED MNCH and FP, WASH and NUTRITION ..... 63 Output 2.1: Maternal, Newborn and Health services ...... 63 Output 2.2: Child Health Services ...... 73 Output 2.3 Family Planning Services and Reproductive Health (FP and RH) ...... 81 Output 2.4 Water, Sanitation and Hygiene (WASH) ...... 87 Output 2.5 Nutrition...... 94
SUB-PURPOSE 3: STRENGTHENED AND FUNCTIONAL COUNTY HEALTH SYSTEMS ...... 96 Output 3.1 Partnerships for Governance and Strategic Planning ...... 96 Output 3.2: Human Resources for Health (HRH)...... 98 Output 3.3 a): Health Products and Technologies (HPT)...... 100 Output 3.3 b): Health Products and Technologies- Facility Report ...... 105 Output 3.4: Monitoring and Evaluation Systems ...... 109 Output 3.5 Quality Improvement ...... 116
III. ACTIVITY PROGRESS (QUANTITATIVE IMPACT) ...... 118
IV. CONSTRAINTS AND OPPORTUNITIES ...... 119
VI. PROGRESS ON CROSS CUTTING THEMES: GENDER AND YOUTH ...... 139
VII. GRANTS ...... 155
VIII. PROGRESS ON ENVIRONMENTAL MITIGATION AND MONITORING ...... 156
IX. PROGRESS ON LINKS TO OTHER USAID PROGRAMS ...... 156
X. PROGRESS ON LINKS WITH GOK AGENCIES ...... 157
XI. PROGRESS ON USAID FORWARD ...... 158
XII. SUSTAINABILITY AND EXIT STRATEGY ...... 158
XIII. SUBSEQUENT QUARTER’S WORK PLAN ...... 159
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XIV. FINANCIAL INFORMATION ...... 159
BUDGET DETAILS ...... 159
OBLIGATIONS VS EXPENDISTURES ...... 160
NEW AWARDS ...... 161
COUNTY ANALYSIS ...... 162
DISAGGREGATED BY EARMARKS ...... 162
XV. ACTIVITY ADMINISTRATION ...... 162
XVI. SUCCESS STORIES ...... 162
LIST OF ANNEXES & ATTACHMENTS ...... 171
Table 1 Afya Pwani Performance Summary Table Jan-March 2018 ...... 14 Table 2 PMTCT settings achievement for the reporting period (January to March 2018) against the Country Operational Plan (COP) 2017 Targets...... 26 Table 3: PMTCT_STAT summary achievements by County, January to March 2018 ...... 26 Table 4 Support group sessions conducted in Q2 ...... 32 Table 5 Defaulter tracing in Afya Pwani supported counties Jan 18- March 18 ...... 32 Table 6 Differentiated Care Service Delivery- March 31st 2018 ...... 34 Table 7 Reasons for not Clients Not Linked ...... 36 Table 8 TX_CURR >15 Yrs. Analysis ...... 38 Table 9 TX_CURR <15 Yrs. Analysis ...... 39 Table 10 Number of CLHIV seen in Pediatric ART Clinics, Jan-March 2018 ...... 39 Table 11 CME Sessions conducted in Kwale County ...... 40 Table 12 Analysis of Jan-Mar cohort 2017 at 12 months ...... 42 Table 13 Viral Load Uptake in Q2 FY18 ...... 43 Table 14 EID tests done during the Quarter ...... 49 Table 15 Viral load tests done during the Quarter: ...... 49 Table 16 Yields per testing modalities Jan- Mar 2018 ...... 51 Table 17 Q2 HTS Yields Per County ...... 52 Table 18 PNS HIV testing approach (March 1 - 30, 2018) ...... 53 Table 19 GeneXpert utilization Jan-Mar 2018 ...... 59 Table 20 IPT Uptake Jan- March 2018 ...... 59 Table 21 TB/HIV Integration Jan – Mar 2018 ...... 61 Table 22 Drug Resistant TB Patients as at March 2018 ...... 62 Table 23: No of clients reached during outreaches and maternity open days ...... 70 Table 24: Number of children below 5 years with fast breathing treated by CHVs- Community Level ...... 74 Table 25: Immunization Uptake per Sub-County ...... 78 Table 26 Number of Clients Reached During Integrated FP In-Reaches Jan – Mar 2018 ...... 84 Table 27 Afya Pwani Training on Comprehensive School Health, Management and Promotion of WASH ...... 88 Table 28 Sensitization of Village Elders Jan-Mar 2018 ...... 89 Table 29 Summary of SLTS roll out participants ...... 94 Table 30 Summary of Challenges and Recommendations for January-March 2018 ...... 119 USAID AFYA PWANI PROGRESS REPORT JANUARY-MARCH 2018 3
Table 31 Key Findings from Line Listing of Clients Jan-Mar 2018 ...... 127 Table 32 Corrective Action Plans Apr-Jun 2018 ...... 134 Table 33 Composition of Likoni Hospital Support Group formed as result of Project supported training follows: ...... 140 Table 34 Number of adolescents reached with anti- stigma messages ...... 141 Table 35 Number of positive pregnant adolescents escorted girls escorted for FANC/PNS and linked to CCC ...... 141 Table 36 Breakdown of the Binti kwa Binti groups ...... 148 Table 37 summary of escorted adolescents this quarter (Jan-Mar 2018) ...... 149 Table 38 Subsequent Quarter's Work Plan ...... 159 Table 39 Budget Details 159 Table 40 Obligations vs Expenditures (I) ...... 160 Table 41 Obligations vs Expenditures (II) ...... 160 Table 42 Budget Notes 161 Table 43 New Awards 161 Table 44 County Analysis 162 Table 45 Disaggregated by Earmarks ...... 162
Figure 1 Maternal HAART Uptake January-March 2018 ...... 28 Figure 2 EID Cascade for Q2 of FY 18 in Afya Pwani supported sites ...... 30 Figure 3 Linkage per County, January -March 2018 ...... 36 Figure 4 TX _CURR <15 Years at SAPR, FY 18 ...... 37 Figure 5 TX _CURR >15 Years at SAPR, FY 18 ...... 38 Figure 6 Viral Load Uptake at SAPR FY18 ...... 44 Figure 7 HTS Achievement SAPR FY 18 ...... 50 Figure 8 HTS performance compared to FY 18 targets Per County ...... 50 Figure 9 HTS Performance for <15 Years- Oct 2017-March 2018...... 54 Figure 10 HTS Performance for <15 Years, Oct 2017-March 2018...... 54 Figure 11 Afya Pwani Counties Q2 HIV RTK Reporting Rates ...... 57 Figure 12 Trends for uptake of 1st and 4th ANC (Jan-Mar 2017) – (Jan-Mar 2018) ...... 68 Figure 13 Trends for Skilled deliveries against live births from Jan 2017-Jan 2018 ...... 68 Figure 14 Trends in Maternal and Neonatal Outcomes Oct 2017-Mar 2018...... 69 Figure 15 Kilifi County– Pneumonia Trends among Children <5 ...... 74 Figure 16 Kilifi County – Diarrhea trends among children <5 ...... 77 Figure 17 KILIFI COUNTY IMMUNIZATION UPTAKE FOR Q1 AND Q2 ...... 77 Figure 18 Uptake of FP Services, New clients and re-visits for Jan-Mar 2017, Apr-Jun 2017, Jul – Sept 17, Oct – Dec 17 and Jan – Mar 18 ...... 82 Figure 19 Trends in FP Method Mix for Dec 2017 to Mar 2018 ...... 83 Figure 20 Quarterly CYP Trends Comparing Oct-Mar 2018 ...... 83 Figure 21 KILIFI COUNTY CYP DISTRIBUTION - JAN - MAR 2018 ...... 84 Figure 22 FP uptake among Adolescents by age comparing Quarter 1 and 2 ...... 85 Figure 23: FP Commodity Reporting Rates April 2017- March 2018 ...... 87 Figure 24 Diarrhea Cases in Dida Dispensary October 2017-March 2018...... 91 Figure 25 Distribution of EHPTs Months of Stock ...... 100 Figure 26 Determine stock status in Kwale, Kilifi and Mombasa ...... 102 Figure 27 Family Planning commodities reporting rates as per DHIS2- 12th April 2018 ...... 103 Figure 28 Kaloleni and Rabai Commodity Supervision Findings Chart ...... 104 Figure 29 Kaloleni and Rabai Tracer Commodity stock status ...... 104 Figure 30 Commodity Management Indicator Analysis for USAID Afya Pwani HVFs Visited Thrice (N=17) ...... 106 Figure 31 IQCare GreenCard module interface ...... 110
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Figure 32 Kilifi county DHIS/IQCare comparison ...... 111 Figure 33 Kwale county DHIS/IQCare comparison ...... 111 Figure 34 CPGH Defaulter Tracing Analysis ...... 113 Figure 35 Defaulter Tracing Analysis ...... 113 Figure 36 Mombasa county comparison of Electronic & Manual ART register ...... 114 Figure 37 Mombasa county Electronic & Manual TP register comparison ...... 114 Figure 38 Lamu County Comparison of 711 & 731 Reporting Rates ...... 115 Figure 39 Proportion of babies with initial cord care using chlorohexidine within 30 minutes of delivery in Moi Voi County Referral Hospital...... 117 Figure 40 Afya Pwani Data Verification tool ...... 126 Figure 41 Comparison of clients receiving FP Commodities- NOV 17- JAN 18 ...... 129 Figure 42 Afya Pwani DHIS2 Reporting Rates ...... 130 Figure 43 MOH 711 DHIS2 Reporting rates Q2 ...... 131 Figure 44 MOH 731-1 (HTS) DHIS2 Reporting rates ...... 131 Figure 45 MOH 731-2 (PMTCT) DHIS2 Reporting rate ...... 132 Figure 46 MOH 731-3 (Care & Treatment) DHIS2 Reporting Rate ...... 132 Figure 47 EMR Data Verification ...... 137 Figure 48 EMR patients missing VL and EMR patients missing HIV diagnosis date ...... 138 Figure 49 Adolescent FP Services Uptake in 16 High Volumes Facilities ...... 151 Figure 50 Obligations vs. Current and Projected Expenditure ...... 161
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ACRONYMS AND ABBREVIATIONS ADR Adverse Drug Reactions AIDS Acquired Immune Deficiency Syndrome AMSTL Active Management of Third Stage Labour ANC Antenatal Care APH Antepartum Hemorrhage APHIA AIDS, Population and Health Integrated Assistance APHIAplus AIDS, Population and Health Integrated Assistance-People-centered, local universal access and sustainability ART Antiretroviral Therapy ARV Antiretroviral ASRH Adolescent Sexual Reproductive Health AYLHIV Adolescents and Youth Living with HIV AYSRH Adolescent and Youth Sexual Reproductive Health AWP Annual Work Plan BEmONC Basic Emergency Obstetric and Newborn Care BMI Body Mass Index BTL Bi-Tubal Ligation CASCO County AIDS and STI Control Officer CBD Community Based Distributor CBP Community Based Promoter CBROP County Budget Review and Outlook Paper CCC Comprehensive Care Center CD4 Cluster of Differentiation 4 CDC Center for Disease Control and Prevention CDCS Country Development Cooperation Strategy CEmONC Comprehensive Emergency Obstetric and Newborn Care CHEW Community Health Extension Worker CHMT County Health Management Team CHS Community Health Strategy CHV Community Health Volunteer CLTC County Leprosy and Tuberculosis Coordinator CLTS Community Led Total Sanitation CME Continuing Medical Education CNC County Nutrition Coordinator COP Chief of Party COR Contracting Officer Representative CPGH Coast Provincial General Hospital CSB Corn Soy Blend CQI Continuous Quality Improvement CU Community Unit CWC Child Welfare Clinic CYP Couple Years Protection DBS Dry Blood Samples DCOP Deputy Chief of Party DDIU Data Demand and Information Use DISC Drop in Support Centre DOT Directly Observed Therapy USAID AFYA PWANI PROGRESS REPORT JANUARY-MARCH 2018 6
DQA Data Quality Assessment EBI Evidence Based Interventions EID Early infant diagnosis EMTCT Elimination of Mother to Child Transmission EmONC Emergency Obstetric and Newborn Care EMR Electronic Medical Records FANC Focused Antenatal Care FBO Faith Based Organization FBP Food By Prescription FCDRR Facility Consumption Data Report and Request Form FMAPS Facility Monthly ARV Patient Summary F&Q Forecasting and Qualification FP Family Planning FSW Female Sex Worker GBV Gender-Based Violence GOK Government of Kenya HAART Highly Active Antiretroviral Therapy HC Health Center HCSM Health Commodities and Services Management HCW Health Care Worker HEI HIV Exposed Infant HFMC Health Facility Management Committee HINI High Impact Nutrition Interventions HIV Human Immunodeficiency Virus HMIS Health Management Information System HMT Health Management Team HPT Health Products and Technology HRIO Health Records Information Officer HRH Human Resources for Health HSS Health Systems Strengthening HTC HIV Testing and Counseling HTS HIV Testing Services HVF High Volume Facility IFAS Iron and Folic Acid Supplementation IMAM Integrated Management of Acute Malnutrition IMCI Integrated Management of Childhood Illness IPC Infection Prevention Control IPT Isoniazid Preventive Therapy IUCD Intrauterine Contraceptive Device IUD Intrauterine Device IYCF Infant and Young Child Feeding KAIS Kenya AIDS Indicator Survey KeHMIS Kenya Health Management Information System Project KEMSA Kenya Medical Supplies Agency KEPI Kenya Extended Programme on Immunization KHSSSP Kenya Health Sector Strategic and Investment Plan KHQIF Kenya HIV Quality Improvement Framework KP Key Populations KQMH Kenya Quality Model for Health LTFU Lost to Follow Up USAID AFYA PWANI PROGRESS REPORT JANUARY-MARCH 2018 7
MAM Moderate Acute Malnutrition MCH Maternal and Child Health M&E Monitoring & Evaluation MNCH Maternal, Newborn and Child Health MNH Maternal and Newborn Health MOH Ministry of Health MPDSR Maternal and Perinatal Death Surveillance and Review MSM Men Who Have Sex with Men MSW Male Sex Worker M2M Mother 2 Mother NACS Nutritional Assessment Counselling and Support NASCOP National AIDS and STI Control Program NCD Non-Communicable Disease NDMA National Drought Management Authority NGO Non-governmental Organization OI Opportunistic Infection OJT On Job Training ORS Oral Rehydration Salts ORT Oral Rehydration Therapy OTP Outpatient Therapeutic Therapy OVC Orphans and Vulnerable Children PAC Post-Abortion Care PBB Program Based Budgeting PEP Post Exposure Prophylaxis PEPFAR President’s Emergency Plan for AIDS Relief PHASE Personal Hygiene and Sanitation Education PHPD Positive Health Dignity and Prevention PHO Public Health Officer PITC Provider Initiated Testing and Counseling PLHIV People Living with HIV PMP Performance Monitoring Plan PMTCT Prevention of Mother to Child Transmission PNC Post-Natal Care PNS Partner Notification Services POC Point of Care PPH Post-partum Hemorrhage PRC Post-Rape Care PrEP Pre-Exposure Prophylaxis PSS Psychosocial Support Service PT Proficiency Testing QA Quality Assurance QI Quality Improvement RED Reach Every District RH Reproductive Health RTK Rapid Test Kits RUTS Ready to Use Supplementary Food RUTF Ready to Use Therapeutic Food SAM Severe Acute Malnutrition SCASCO Sub-County AIDS Control Officer SCHMT Sub-County Health Management Team USAID AFYA PWANI PROGRESS REPORT JANUARY-MARCH 2018 8
SCLTC Sub-County Leprosy and Tuberculosis Coordinator SCHRIO Sub-County Health Records Information Officer SDGs Sustainable Development Goals SI Strategic Information SIMS Site Improvement Monitoring System SLTS School Led Toy SMS Short Message Service SOP Standard Operating Procedure SRH Sexual and Reproductive Health SW Sex Workers SWG Sector Working Group STI Sexually-transmitted Infection TA Technical Assistance TB Tuberculosis TOT Trainer of Trainers TWG Technical Working Group UNAIDS Joint United Nations Program on HIV/AIDS UNFPA United Nations Population Fund USAID United States Agency for International Development USG United States Government VCT Voluntary Counseling and Testing VMMC Voluntary Medical Male Circumcision VL Viral Load WASH Water, Sanitation and Hygiene WHO World Health Organization WIT Work Improvement Team WRA Women of Reproductive Age YFS Youth Friendly Services YLHIV Youth Living with HIV YPLA Young Person with Living with AIDS 3Ps Pathfinder International, Plan International and Palladium Group
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I. AFYA PWANI EXECUTIVE SUMMARY
During the January-March 2018 quarter the United States Agency for International Development (USAID) funded Afya Pwani project continued to work towards its goal of increasing access to and availability of Human Immunodeficiency Virus (HIV), maternal and neonatal and child health (MNCH), Reproductive Health (RH)/Family Planning (FP), water, sanitation and hygiene (WASH) and Nutrition health services, all whilst strengthening health systems across the five coastal counties of Mombasa, Kilifi, Kwale, Taita Taveta and Lamu Counties respectively this quarter. Key highlights from this quarter include the official launch of the MV Afya Bora Visiwani boat launch which took place at the King Fahad Hospital on the 13th of March 2018 in Lamu. The event was organized by the Afya Pwani project in conjunction with the Lamu County Health Management Team (CHMT). Key guests for this event included but is not limited to, the H.E Governor Fahim Twaha of Lamu County, Honorable County Executive Committee (CEC) for Health Raphael Munywa, Honorable Yahya Shee (MCA for the Mkomani area), and Chief Officer for Health- Dr Mulewa amongst key stakeholders This quarter, the Project also received a request for termination from the German Foundation for World Population- an Afya Pwani grantee. This grantee was selected to implement two grants in HIV Care and treatment and MNCH/FP in Mombasa & Kwale and Kilifi Counties respectively. Although Afya Pwani had already conducted due diligence regarding the standard provision RAA29 Protecting Life in Global Health Assistance, the organization’s board determined that they will not impose the requirements of this provision on their global activities, on this basis, these grants were terminated. To ensure proposed activities are still implemented, the Project reviewed the applications that had previously been submitted in response to the Request for Applications (RFA) in December 2016 and selected two organizations; Women Fighting AIDS in Kenya (WOFAK) and Ananda Marga Universal Relief Team (AMURT) to implement the HIV Care & Treatment and MNCH/FP grants respectively. In compliance with the requirements of the Afya Pwani contract, a request was submitted to USAID for approval before the project can formally engage these organizations. Project staff also built on the work that was done last quarter to identify and initiate the signing of Memorandums of Understanding (MOU) with 18 facilities (7 in Mombasa and 11 in Kwale); this quarter an additional 4 facilities in Taita-Taveta and 14 in Kilifi County were also selected and will be supported by the grants mechanism (see Annex VI for the full list of facilities receiving PIPs). The project also finalized the MOU signing with all the 36 facilities identified across the 4 counties. The activities to be implemented by these facilities are largely focused on addressing the gaps identified in provision of quality care and treatment and service delivery to clients and will complement the support provided by the Afya Pwani staff and community grantees. In terms of other key administrative updates that took place during this quarter, Afya Pwani saw a change in key personnel where Dr Anisa Omar, former Deputy Chief of Party (DCOP) stepped down in January 2017 and was replaced by Dr Martin Sirengo who started on the 1st of March 2018. The Afya Pwani team also worked to modify the Afya Pwani contract to include the Determined, Resilient, Empowered, AIDS- free, Mentored, and Safe women (DREAMS) initiative which will be implemented in Mombasa County in the next quarter, as well as changes in budgets following directives from USAID. Qualitative Impact During the reporting quarter, the project supported elimination of mother to child transmission (eMTCT) services in 221 health facilities (69 in Kwale, 25 in Mombasa, 56 in Taita Taveta, 64 in Kilifi and 27 in Lamu). The comprehensive eMTCT support this quarter continued to focus on improving antenatal care (ANC) coverage, strengthening identification of HIV-infected women, providing highly active antiretroviral therapy (HAART) and infant prophylaxis, improving early infant diagnosis (EID) services, and analyzing
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retention among maternal and HIV-exposed infant (HEI) cohorts. Key HIV service delivery achievements for the quarter include a total of 29,346 pregnant women knew their HIV status at ANC, including 586 known positives who accessed services at Afya Pwani sites. Of the pregnant women newly counseled and tested, 388 (1.3%) tested HIV-positive while 932 women (96 percent of the total positive) received maternal HAART. This quarter, a total of 1,998 PLHIV were also linked to treatment against 2,322 identified positives, resulting in an 86% linkage rate. Of the 324 newly identified PLHIV that were not linked in the testing sites, 51 were confirmed to have been linked to other facilities, 80 were still at various stages of treatment preparation (requested more time before starting ART but in contact with the counselors for further counseling sessions) and 8 had died before starting ART, 3 are HIV/TB co-infected patients and the rest in- patients. In terms of HIV Testing Services (HTS), of note is that the project is still on course to achieving its annual target for HTS; as it stands the project has reached 221,351 clients at the Semi-Annual Program Review (SAPR) against an annual target of 335,526, an achievement of 66%. The project however did not meet its target for under 15 years; a total of 14,396 (45%) were tested against a target of 16,162. In the remaining half of the year, Afya Pwani will build on this quarter’s successes and will deploy more counselors to pediatric service areas like Child Welfare Clinics (CWCs), pediatric wards to improve and strengthen testing of children of HIV positive adults and siblings of HIV infected children as part of efforts to reach more children with HTS services. Please see SUB-PURPOSE 1: INCREASED ACCESS AND UTILIZATION OF QUALITY HIV SERVICES for a comprehensive report on the achievements and progress made to increase access and availability of HIV health services. Between January and March 2018, Afya Pwani was able to reach 13,891 new clients with focused antenatal care (FANC) services, an increase of 4,410 clients, compared to 9,481 who were reached in the previous quarter. This progressive increase is attributed to the concerted efforts by project staff to waiver ANC profiling fees during maternity open days, and to raise awareness on importance of ANC attendance. The project also adopted a target based approach during mobilization- where each CHV is expected to mobilize at least 10 1st ANC clients. Notably, the project has also recorded significant increases in clients attending 4 ANC clinics during this reporting period, an indication of successful ‘retention’ of clients mobilized during maternity open days in the ANC clinic through Afya Pwani’s Mama and Binti kwa Binti groups, and change of attitudes among community members which can be ascribed to the joint efforts by the project and health providers to sensitize communities, improve relationships between health providers and their clients and the mama group sessions. This reporting period 5,611 clients received at least 4 ANC services, compared to 1,605 reached in the previous quarter, a significant increase that highlights that the Project’s key strategies are making an impact in terms of increasing access and availability of vital services across Kilifi County (See SUB-PURPOSE 2: INCREASED ACCESS AND UTILIZATION OF FOCUSED MNCH AND FP, WASH AND NUTRITION) During the quarter under review, 8,597 children under 1 year were also fully immunized compared to 7,392 in the previous quarter, an increase of 1,302. The positive result is attributed to consistent community mobilization activities and in reaches supported and facilitated by Afya Pwani, as well as continuous engagement of Afya Pwani grantees at the community level. In addition, a total of 45 integrated in reaches were also conducted throughout Kilifi County targeting Women of Reproductive Age (WRA) with FP services and children who are below 5 years with growth monitoring and immunizations (See Output 2.2: Child Health Services). In terms of increasing access and availability of high quality RH/FP services across supported sites, this quarter there was an increase of new FP clients 8,912 as compared to the previous quarter, where only 6,771 new clients received these services. This positive trend can be attributed to an overall increase in demand for FP across the Counties. Additionally, this quarter FP client retention also increased to 13,475, from 7,984 in the previous quarter, and the uptake of Couple Year Protection (CYP) from 16,838 clients
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last quarter to 26,898 this quarter. The increase is attributable to more clients accessing long acting FP methods especially during in reaches that were supported by Afya Pwani. For more information on these positive trends please see Output 2.3 Family Planning Services and Reproductive Health (FP and RH). This quarter has also seen increased provisions of WASH and Nutrition services within 15 selected HVFs in Kilifi County. On a positive note, 20 villages have also acquired open defecation free (ODF) status; a milestone that will be celebrated in the next quarter. In terms of Nutrition services, the Project has continued to focus on supporting capacity building of health service providers on Baby Friendly Hospital Initiatives (BFHI) and Infant and Young Child Feeding (IYCF) for health care workers and community health volunteers (CHVs). Project staff also focused on building the capacity of community members to start small gardens and crop production at household level through the distribution of seeds, the nutrition status of the beneficiaries is further expected to improve. In this quarter, Afya Pwani continued to support health systems strengthening (HSS) activities at the Sub- County and County levels respectively. Under partnership for governance and strategic planning, the project targeted to facilitate County Health Departments to align planning and budgeting processes to the budget circular timelines. The project also provided technical support to develop health sector working group (SWG) reports to inform allocation of health sector resources for the priority interventions. The departments received TA on the development of strategic plans (2018/22) and provided input in the County Integrated Development Plan (CIDP). In the same period, the project’s human resources for health (HRH) interventions sought to strengthen HRH stakeholders’ forums to advise the department on HRH planning and collaboration to fast track HRH implementation. This quarter, Afya Pwani also brought the five counties together in the quarterly inter-county HRH cross-learning forum to promote learning HRH and adoption of innovations for scale up. Commodity security TWGs continued to provide commodity security oversight in the five counties. Out of the five TWGs, the Mombasa, Kilifi and Taita Taveta teams were supported to hold quarterly TWG meetings. Through these meetings, the TWG developed quarterly plans aimed at addressing emerging commodity security priorities for each county. Specifically, the TWGs led monthly commodity stock status and data reviews to inform capacity building interventions, supply chain planning and commodity redistribution. In Kilifi specifically, HIV test kits stock reviews revealed low stock status prompting commodity redistribution from Kwale. In addition to the inter and intra-county commodity redistribution, the counties were sensitized on quantification of test kits and supply chain planning. Building on the project’s strategic information implementation in the first year, Afya Pwani provided targeted support during the quarter to strengthen strategic and patient line data use. Through the project’s continued EMR support at the facility level, health workers are being facilitated and mentored on use of EMR data for HIV case management. For more information please see SUB- PURPOSE 3: STRENGTHENED AND FUNCTIONAL COUNTY HEALTH SYSTEMS. Lastly, Afya Pwani also supported the establishment of, and trained 37 work improvement teams (WIT) in Kilifi, Lamu and Mombasa. The teams will receive technical support to implement QI projects. In Taita Taveta, the project supported a 100-day rapid results initiative (RRI) at the Moi Voi County Referral Hospital (CRH) targeting various hospital departments. Nine WIT received TA to initiate various Quality Improvement (QI) projects at the department level to improve health service delivery and accelerate uptake of QI in the county. Moi Voi County Referral Hospital (CRH) will serve as the County’s QI model site to provide lessons for QI scale up. Constraints and Opportunities For a full list of the challenges and opportunities that Afya Pwani project staff have experienced during the January and March 2018 quarter, please see IV. CONSTRAINTS AND OPPORTUNITIES
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Quantitative Impact Please see Table 1 below.
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Table 1 Afya Pwani Performance Summary Table Jan-March 2018 Q1 2018 to Date Organization unit Afya Pwani Indicator Technical Area Cascade Age bands Q1 Q2 Q1 to date Perf % Achiev Afya Pwani COP17 TARGETS
Number of HTS_TST <15 (Coarse) 7,167 7229 14,396 45% individuals 32,324 who received >=15 (Coarse) 100,53 106853 207,390 68% 303,202 HIV Testing 7 Services Total 107,70 114082 221,785 66% 335,526 (HTS) and 4 received their test results.
Number of HTS_TST_Pos <15 (Coarse) 127 149 276 27% 1,012 individuals >=15 (Coarse) 1989 2173 4,162 49% 8,538 who received HIV Testing Total 2,116 2322 4,437 46% 9,550 Services (HTS) and received their test results (Positive). Computed Indic 1 Positivity <15 2% 2% 2% 3% Positivity >=15 2% 2% 2% 3% Positivity Total 2% 2% 2% 3%
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Number of TX_NEW <15 (Coarse) 108 150 258 28% 916 adults and >=15 (Coarse) 1583 1848 3,431 43% 7,934 children newly Total 1,691 1998 3,687 42% 8,850 enrolled on antiretroviral therapy (ART) Computed Indic 2 Linkage <15 85% 101% 93% 91% Linkage >=15 80% 85% 82% 93% Linkage Total 80% 86% 83% 93% Number of TX_CURR <15 (Coarse) 3205 3429 3429 77% 4,437 adults and >=15 (Coarse) 42,610 43711 43711 86% 51,049 children with HIV infection Total 45,815 47140 47140 85% 55,486 receiving antiretroviral therapy (ART). Numerator: PMTCT_STAT Denominator 24,754 29632 54,386 50% 109,486 Number of Numerator 24,732 29339 54,071 49% 109,486 pregnant women with Known Positives 485 571 1,056 40% 2,628 known HIV Newly Tested Positive 284 373 657 32% 2,085 status at first antenatal Total Positive 769 944 1,713 36% 4,713 care visit (ANC1) (includes those who already knew their HIV status prior
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to ANC1). Number of new ANC clients in reporting period
Number of PMTCT_ART New on ART 276 356 632 25% 2,562 HIV-positive Already on ART 477 581 1,058 52% 2,032 pregnant women who Total on ART 753 937 1,695 37% 4,594 received ART to reduce the risk of mother-to- child- transmission during pregnancy. Computed Indic 3 PMTCT Positivity 3% 3% 3% 4% ART Uptake - New Pos 97% 95% 96% 123% ART Uptake - All Pos 98% 99% 99% 97% Number of PMTCT_EID 0<=2 Months 341 457 798 infants who 2<12 Months 213 487 700 had a virologic HIV Total Tested 554 944 1,498 33% 4,594 test within 12 months of birth during the reporting period
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Number of PMTCT_HEI_POS 0<=2 Months 11 16 27 HIV-infected 2<12 Months 13 31 44 infants identified in Total Positive 24 47 71 22% 318 the reporting period, whose diagnostic sample was collected by 12 months of age. Excludes confirmatory testing
ART PMTCT HEI POS Initiated ART 0<=2 Months 9 14 23 initiation and 2<12 Months 13 29 42 age at virologic Total Initiated ART 22 43 65 25% 255 sample collection. Computed indicator HEI Positivity 4% 5% 4% 6% HEI ART Uptake 92% 91% 92% 80% Number of adults and
pediatric patients on ART with
suppressed viral load results (<1,000 copies/ml)
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documented in the medical records and/or supporting laboratory results within the past 12 months. 4th ANC 1,501 5611 7,112 18% 38,482 Skilled Birth 4,018 8734 12,752 38% 33,351 Attendance Fully 7,446 10941 18,387 45% 40,628 Immunized Children(FIC) under 1 year PNC Infants 4,862 9275 14,137 34% 41,048 receiving Postpartum care within 2-3 days Total 3,890 6676 10,566 62% 17,153 Underweight
Couple Years 16885 38764. 55,650 132% 42,048 of Protection 1 (CYP) in USG supported programs Number of 7888 11400 19,288 45% 43,018 children
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who receive d DPT3 by 12 months of age in USG- assisted programs Children 1-12 7990 11752 19,742 49% 40,628 months of age who received measles vaccine by the time they were 12 months of age Number of 15 15 15 100% 15 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)
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Maternal 6 17 23 deaths Perinatal 166 296 462 Death Number of 120750 24687 145,437 71% 205,831 children under five (0- 59 months) reached by nutrition specific intervention s through USG supported programs Number of 9236 13981 23,217 50% 46,000 pregnant women reached by nutrition specific intervention s through USG supported programs Number of 81 81 81 100% 81 health facilities with established capacity to manage
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acute under nutrition Custom: 120750 24687 145,437 71% 205,831 Number of children U5 who received Vitamin A from USG supported programs Number of 5058 11854 16,912 62% 27,445 children under five years old with diarrhea, who received Oral Rehydration Therapy (ORT), defined as receiving oral rehydration salt (ORS) solution) Number of 30 156 186 37% 500 individuals receiving nutrition- related professional training
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through USG- supported programs Number of 389 219 608 122% 500 people trained in maternal and/or newborn health and nutrition care through USG supported programs Number of 207 161 368 74% 500 community health workers (CHWs) trained in maternal and/or n newborn health and nutrition care through USG supported programs
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II. KEY ACHIEVEMENTS (QUALITATIVE IMPACT)
SUB-PURPOSE 1: INCREASED ACCESS AND UTILIZATION OF QUALITY HIV SERVICES
Output 1.1: Elimination of Mother to Child Transmission (eMTCT): During the reporting quarter, the project supported eMTCT services in 221 health facilities (69 in Kwale, 25 in Mombasa, 56 in Taita Taveta, 64 in Kilifi and 27 in Lamu). The comprehensive eMTCT support focused on improving antenatal care (ANC) coverage, strengthening identification of HIV-infected women, providing highly active antiretroviral therapy (HAART) and infant prophylaxis, improving early infant diagnosis services, and analyzing retention among maternal and HIV-exposed infant cohorts. A) Early Identification of HIV-positive pregnant women and increase for demand services i) Demand creation for testing During the quarter under review, Afya Pwani intensified efforts to create demand for HTS in ANC, child welfare clinic (CWC), maternity and post-natal care (PNC) departments. Health education remained one of the main demand creation activities conducted in all catchment facilities of the five supported counties to create demand for HTS services among pregnant and breastfeeding women. With support from the Afya Pwani project, the CHMTs have continued to encourage and strengthen health education in facilities on HTS and HIV prevention, care and treatment every morning before offering any services to patients. Additionally, in Kilifi county, and in partnership with the county health management teams (CHMTs), Afya Pwani supported a joint consultative meeting in Kilifi County to discuss and refine strategies to promote and create demand for ANC services. Afya Pwani also supported an eMTCT meeting for nurse managers and PMTCT coordinators from seven sub-counties1 of Kilifi county with a total of 23 participants supported. This meeting was to re-energize teams following the conclusion of a protracted nurses’ industrial action which adversely impacted on the uptake and access to ANC and PMTCT services for five months preceding the reporting quarter. The strategies identified and instituted during the meeting to create demand for ANC services included door to door identification and referral for early testing of pregnant women, conducting home visits by community health volunteers (CHVs) to follow up ANC and PMTCT defaulters and encourage 4th ANC Visits. During the reporting period sub-county medical laboratory technologist (SCMLTs), sub-county AIDS & STIs coordinators (SCASCOs), Pharmacists in Kilifi North, Kilifi South, Malindi, Kaloleni, Rabai, Magarini and Ganze Sub-Counties were supported with airtime to facilitate follow ups of all pregnant and lactating women who may have defaulted and/or LFTU. In Mombasa County, the Project provided mentorship to 17 health care workers from eight supported sites2 to improve HIV testing uptake and improve eMTCT outcomes. The health care workers were mentored on the current PMTCT guidelines and provided with assorted job aids on PMTCT. CHVs and mentor mothers continued to provide health education on the importance of HTS testing in facility waiting bays and during home visits to drum up support for services. During the quarter, the Project supported 112 health education sessions in facilities3 on HIV testing services (HTS), early ANC visits, safe delivery and PNC, these sessions were conducted by health workers and mentor mothers.
1 Kilifi North, Kilifi South, Malindi, Magarini, Ganze, Kaloleni, Rabai 2 CPGH, Port-reitz, Likoni, Kisauni, Mlaleo, Nguuni, Mwakirunge, Chaani. 3 Mvita Health Centre, Tudor Sub County Hospital, CPGH, Ganjoni Clinic, Railway Dispensary, Likoni Sub County Hospital, Mrima Health Centre, Shikadabu Health Centre, Mbuta Dispensary, Chaani Dispensary, Magongo Health Centre, Bokole CDF, Jomvu Model, Miritini CDF, Port-reitz Hospital.
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Further, between January and March 2018, the project through grantees4 worked in Mombasa with 72 CHVs, peer educators and other community owned resource persons (COPRs) to conduct 58 community dialogue sessions through which 67 pregnant women were identified and escorted for first ANC to promote early HIV testing. Additionally, the program, through support the HIV free generation (HFG), identified and trained six male champions in Mombasa county, who were deployed in Likoni Sub-County to promote male involvement in PMTCT. In Taita-Taveta, a total of a total of 311 pregnant women were referred from the community to health facilities for first ANC visit with 6 testing HIV positive and got linked into PMTCT services in several facilities5. Afya Pwani also supported Kwale and Taita-Taveta Counties to conduct community dialogue sessions on importance of mothers starting ANC early to reduce missed opportunity and promote early initiation of car; a total of 280 community members (91m, 189f) were reached in Taita Taveta.
In Kwale county, where traditional birth attendants (TBAs) play a very key role in PMTCT due to factors such as high illiteracy levels, poverty, long distances to health facilities and negative socio-cultural beliefs, a total of 120 TBAs from Msambweni, Gombato, Mbuwani and Muhaka Health facilities were trained on PMTCT and enrolled as birth companions for early ANC referral. These TBAs are expected to educate pregnant women within their catchment communities on the importance of skilled delivery, ANC visits and HIV testing. They were also sensitized on Anza SASA strategy and are expected to cascade the training to pregnant women and thereby increasing testing at ANC. ii) ANC testing and retesting in 3rd trimester, labor and delivery and postnatally Afya Pwani, continued to support several facilities6 within catchment with HTS counselors to ensure 100% HTS testing in ANC, CWC and post-natal care (PNC) in addition to engaging the Kilifi CHMT for a circular to facilitate HTS provision by nurses in the county. This support was aimed at improving early identification of HIV positive pregnant and breastfeeding mothers and other PMTCT settings. In Lamu county, Afya Pwani supported Lamu East and Lamu West SCMLTs to redistribute rapid test kits (RTKs) to specific facilities7 faced with stock-outs to ensure availability of HTC Services at the MCH. During the reporting quarter, a total of 29,346 pregnant women knew their HIV status at ANC, including 586 known positives. Of the pregnant women newly counseled and tested, 388 (1.3%) tested HIV-positive while 932 women (96 percent of the total positive) received maternal HAART. Table 2 below shows the overall program wide HTS in PMTCT settings achievement for the reporting period (January to March 2018) against the Country Operational Plan (COP) 2017 targets.
4 NEPHAK, HIV Free Generation, Moving the Goal Post, CIPK, and Reach out Trust 5 Njukini, Ndovu, Moi, Taveta, Mgange Nyika) 6 Coast provincial general hospital (CPGH), Magongo, Tudor and Likoni 7 Sinambio Dispensary, Witu Health Centre, Lamu Hospital, Shella
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Table 2 PMTCT settings achievement for the reporting period (January to March 2018) against the Country Operational Plan (COP) 2017 Targets. Indicator COP 2017 Q2 (Jan – % Achieved Target Mar 18)
Number of sites 221 221 100%
Number of pregnant women with known status 109,486 29,346 27%
Number of HIV positive pregnant women identified 4,713 974 21%
Number of pregnant women known to be HIV positive 2,628 586 22% (known positives) Number of newly identified HIV positive pregnant women 2,085 388 19% (new positives) Number of HIV infected pregnant women on HAART 4,594 932 20%
Table 2 above highlights that a total of 29,346 pregnant women attending 1st ANC got to know their HIV status through ANC during the quarter against the COP 2017 target of 109,486 which is a 27% achievement against expected quarterly target of 25%. Out of the 29,090 pregnant women tested for HIV, a total 974 HIV infected pregnant women were identified against a COP 17 target of 4,713 (21%) HIV-positive pregnant and lactating women, with 388 (40 %) new positives and 586 (60 %) known positives. A total of 932 (96%) pregnant women were issued with maternal HAART between January and March 2018. The project remains on course to achieve the overall COP targets by end of FY 18 (except for PMTCT POS and PMTCT EID tests), with all but Mombasa county achieving respective county targets as shown in Table 3 below using PMTCT STAT as an example. Table 3: PMTCT_STAT summary achievements by County, January to March 2018 County COP Target Achievement % Achievement Kilifi 40,721 10,987 27% Mombasa 32,590 7,602 23% Kwale 23,243 6,995 30% Taita Taveta 9,912 2,488 25% Lamu 3,020 1,267 42% Afya Pwani 109,486 29,339 27%
At county level, the performance against the COP17 target for the reporting period shows varying trends with Mombasa at 23% (7,602/32,590), Kilifi at 27 % (10,987 /40,721), Kwale at 30 % (7,066 /23,243), Lamu at 42% (1,267/3,020) and Taita Taveta at 25% (2,488 /9,912). Mombasa County was the only county not on track to achieve their quarterly PMTCT STAT target. This is mainly due to high number of private
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practitioners currently not reporting through the DHIS2. The project has started engagements with these private practitioners through support to the Mombasa CHMT to sensitize, train and support them in reporting HIV prevention, care and treatment data. The project recorded a high number of known positive clients, reporting 60% (586 out of 974 positives identified), which is attributed to more known positive clients desiring to have children due to the success of the PMTCT program. iii) Improving ART uptake for pregnant & breastfeeding mothers Afya Pwani continued to support human resources for health in high-volume public, private and Faith Based Organization (FBO) sites through placement of nurses, registered clinical officers (RCOs), laboratory and pharmaceutical technologists to enable such very high volume (VHV) and high-volume facilities (HVFs) cope with the client need after the prolonged nurses’ industrial action that affected ANC/PMTCT/child welfare clinic (CWC) services for five-months in the preceding reporting quarters. During the quarter, the project also continued to support and strengthen MCH/ART integration in all the five supported counties with 84 service providers in Lamu capacity built on FP integration in comprehensive care centers (CCCs) in 18 supported facilities8. The project also continued to build the capacity of HCWs to provide quality, integrated and updated PMTCT care as per the revised 2016 ART and PMTCT guidelines with 56 health care workers oriented from various facilities9 of Lamu county. In Mombasa county, Afya Pwani supported targeted mentorship and on job training (OJT) to HCWs in the 10 project sites10 on integration of ART into maternal and newborn health (MNCH) and EMTCT guidelines. Afya Pwani also supported 48 mama psychosocial support group sessions targeting pregnant and new mothers/breastfeeding mothers where 518 women were reached. Health facilities used the sessions to fast track enrollment of mother-baby pairs in addition to improving the adherence and retention rates for HIV-positive pregnant women and HIV-exposed infants. To further strengthen ART uptake and adherence to treatment, Afya Pwani supported integration of ART into the MCH department in 20 ART sites out of the targeted 24 sites in Mombasa county. During the reporting period, Afya Pwani continued to support mentor mothers in the delivery of individualized PMTCT services through task shifting, defaulter tracing and case management of mother/baby dyads in 12 VHV and HVF facilities11. To strengthen adherence to HAART treatment of PMTCT clients, Afya Pwani, supported a total of 90 support group sessions for PMTCT clients reaching 2, 127 HIV infected pregnant and lactating women in Lamu County with a further 20 support groups for pregnant and lactating women meeting monthly in 60 support group sessions in Kwale county12 reaching 386 women. All counties reported impressive uptake for both maternal HAART as shown in Figure 1 below.
8 Gongoni Health Centre, Marikebuni Dispensary, Marereni Dispensary, Marafa Health Centre, GoK Prison Dispensary, Malindi Hospital, Muyeye Health Centre, Gede Health Centre, Matsangoni Health Centre, Kilifi Hospital, Chasimba Health Centre, Vipingo Health Centre, Mtwapa Health Centre, Rabai Health Centre, Mariakani Hospital and Bamba Sub County Hospital 9 Faza Health Centre, Kizingitini Dispensary, Shella Dispensary, Lamu Hospital, Mokowe Health center, Hindi Dispensary, Muhamarani Dispensary, Hongwe Catholic dispensary, Mpeketoni Hospital and Witu Health Centre 10 Chaani, Mvita, Likoni, Bokole, Magongo, Jomvu Model, Ganjoni, Kisauni, Portreitz, Mlaleo 11 Rabai, Mariakani, Mtwapa, Matsangoni, Muyeye, Marafa, Marereni, Ganze, Bamba, Oasis and Chasimba 12 Msambweni, Diani, Mkongani, Tiwi, Lunga Lunga, Vitsangalaweni, Kikoneni, Kinango, Mazeras and Samburu health facilities
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Maternal HAART Uptake Jan-Mar, 2018 1200
1000
800
600
400
200
0 Lamu Taita Taveta Kwale Kilifi Mombasa Afya Pwani # HIV+ve 31 63 203 325 352 974 #Maternal HAART 29 62 181 309 351 932 % Uptake 94% 98% 89% 95% 100% 96%
# HIV+ve #Maternal HAART % Uptake
Figure 1 Maternal HAART Uptake January-March 2018
During the quarter under review, Health facilities were supported to continuously account for missed opportunities with mentor mothers conducting home visits to trace and bring back mothers and their infants. The project also supported CHMTs to facilitate successfully traced clients on prophylaxis to be corrected in the District Health Information System (DHIS 2) and account for all missed opportunities. Continuous mentorship, age specific PMTCT support groups, provision of ARV commodities in integrated MCH settings and support for commodity consumption, forecasting, and reporting was supported at all sites during the reporting quarter. Improving Quality of eMTCT services i) Strengthen Continuous Quality Improvement (CQI) Afya Pwani continued to support site-level capacity-building including re-orientation of health care workers (HCWs {nurses, RCOs}) on the new PMTCT guidelines after a prolonged industrial action of more than five months across all the five counties during the reporting period. This was done mainly via on job trainings (OJTs), joint support supervisions and mentorships, monthly county and sub-county eMTCT data quality assessment, data review meetings, focused onsite and offsite mentorships, continuous medical education (CME), and OJT to promote uptake of HIV counseling and testing services (HTS) among pregnant and breastfeeding women; orientations on commodity management and rapid test kit (RTK) forecasting and allocation meetings at county level; data documentation, review, and reporting; as well as county stock taking forums. The project also supported five county level eMTCT technical working group (TWG) meetings tasked with safeguarding the quality of PMTCT services within the counties. Project staff also continued to support quality and work improvement teams (QITs and WITs) within MCHs and strengthened its case management of all HIV infected pregnant and lactating women through the placement and support of mentor mothers and case managers in all VHV and HVFs. The project supported sensitization of 25 service providers in isoniazid preventive therapy (IPT) for PMTCT pregnant Mothers Living with HIV.
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In Lamu county, Afya Pwani supported the establishment of a county QIT and four facility13 QITs during the reporting period. The project additionally supported the training of Lamu CHMT members and health care workers from the four facilities in Kenya Quality Model for Health (KQMH) following which the project supported the respective QITs to identify key performance CQI indicators to be reviewed quarterly including retention of mother-baby dyads in care, proportion of PCRs done (6 weeks, 6 months, 12 months) and proportion of HEIs with an antibody (AB) test done at 18 months.
The project in close collaboration with county and sub-county HMTs (S/CHMTs) developed, printed and distributed PMTCT dashboards for facility use to monitor performance and quality of services provided. The project also supported the sensitization of all supported 221 sites in the use of the PMTCT dashboards as part of its commitment to working towards increasing access and availability of high quality PMTCT services for clients. ii) Improving uptake of Early Infant Diagnosis (EID) for HEI and Viral load monitoring for Pregnant and breastfeeding mothers Afya Pwani supported HCWs through sensitizations on EID, initiation of infants on ARV prophylaxis, prompt follow up of HEI for early dry blood spots (DBS) collection, baseline and regular viral load (VL) monitoring of pregnant and breast-feeding women following the national recommendation with an aim of achieving the third ‘90’ of the cascade. The project strengthened HIV screening for all lactating women attending immunization clinics for Penta 1 (six weeks postnatally) in all facilities of the five supported counties to ensure all HEIs are captured and DBS for polymerase chain reaction (PCR) taken. During the reporting quarter, a total of 1,541 PCR reaction tests were processed of which 897 were initial tests while the repeat tests and confirmatory tests were 563, and 81 respectively as shown in Figure 2 below. The initial PCR tests done was 92% of an estimated 974 HIV-exposed infants (HIV-positive pregnant mothers used as proxy) in the quarter. Out of the initial 897 PCR tests taken in the quarter, 46% (481) were done within 2 months of age.
13 Lamu county hospital, Mpeketoni sub-county hospital, Witu health centre and Faza Sub-County Hospital
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EID Cascade Q2 2018 1,200
1,000 974 897
800
600 481
60% 400
200 43
4.8% 23 0 Q1
# of +ve women # of PCR done # of PCR < 2/12 #+Ve HEIs # Initiated on ART
Figure 2 EID Cascade for Q2 of FY 18 in Afya Pwani supported sites
Figure 2 above highlights that during the quarter under review, Afya Pwani data reported 43 infants identified as HIV-positive, according to the EID website, all of whom were validated. All 43 infants (100%) have been enrolled on treatment; although it should be noted that one infant passed away. Project staff have ensured that all HEI positive infants have been audited as part of CQI to improve access and availability of high quality EMTCT health services. Key findings from the infant audits highlighted that reasons associated with mother-to-child transmission (MTCT) were mainly, lack of skilled deliveries (37% of the cases), missed Infant prophylaxis (41%), missed maternal HAART (26%), late Polymerase Chain Reaction (PCR) tests after 2 months (70%) and lack of attendance to ANC by the mothers (30%).
As mentioned above, one HIV positive infant passed away during the quarter, subsequently Afya Pwani ensured that the Project supported an infant mortality audit in the facility that reported an infant death to ascertain what the cause of death was. During the audit it was confirmed that the cause of death was identified as delay of ART initiation due to late presentation in the in-patient ward, having never been tested for HIV before following a home delivery. Moving forward, Afya Pwani will continue to strengthen early identification and referral of HEIs from the community using CHVs and mentor mothers to minimize such cases of delayed identification of HEIs and initiation on ART as part of efforts to curtail infant mortality due to HIV and as part of broader efforts to increase access and availability of high quality health services. iii) Strengthen service delivery in private facilities supported by Afya Pwani During the quarter under review, Afya Pwani project staff supported and facilitated initiated discussions with the Mombasa and Kilifi CHMTs on modalities to support private practitioners registered and
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practicing in the counties to provide quality PMTCT services while at the same time reporting through the Ministry of Health (MOH) District Health Information System (DHIS2) platform. More specifically, this exercise was implemented in Mombasa, Taita Taveta and Kilifi Counties where all private practitioners in the counties as part of efforts to facilitate targeted and prioritized support to the private practitioners based on the volume of clients they see. Further, Afya Pwani continued to support S/CHMTs in the distribution of commodities to private facilities providing PMTCT services. iv) Commodity security for RTKs and ARVs During the reporting period SCMLTs, SCASCOs, Pharmacists were also supported with airtime, for timely and accurate reporting of rapid test kits (RTKs) as part of efforts to increase access and availability of high quality health services. Additionally, the project also supported an orientation and sensitization of 14 facility in-charges on commodity management and reporting. The key areas addressed during these sessions included proper filling of Facility Consumption and Data Report & Request Form (FCDRR) tool, commodity quantification and reporting to ensure availability of RTKs, Antiretrovirals (ARVs), Dry Blood Sampling (DBS) and vacutainers in the facilities. By building the capacity of health service providers to improve commodity supply chain management and documentation
Lessons Learned 1. Strengthened case management through mentor mothers are effective in ensuring retention of mother baby pairs in care and doing defaulter tracing.
2. Mother-baby pair register is an effective tool for longitudinal follow up of mother-baby pairs and it helps to easily identify missed appointments and missed services for immediate follow up which has helped to improve retention.
3. Identification of early pregnancies at community level where women are encouraged/linked to care early in pregnancy leads early antenatal clinic attendance hence timely identification of HIV infected pregnant and consequently better maternal and neonatal outcomes.
4. Regular facility PMTCT data review meetings and establishment of WITs at MCH at the high- volume sites have greatly improved the quality of the PMTCT program seeing reduction in laboratory rejection rates of PCR requests and repeat PCR tests mis-captured as initial tests.
Output 1.2: HIV Care and Support Services i) Provision of ART and PHDP Services including defaulters. To ensure that People Living with HIV (PLHIV) live quality healthy lives, Afya Pwani has continued to support the provision of Positive Health Dignity Prevention (PHDP) services for PLHIV in all the five counties. In Taita-Taveta County, Afya Pwani conducted 144 health talks by peer educators reaching 1,728 clients with messages on adherence, disclosure, condom use, dual contraception, family testing, TB screening, hygiene and good nutritional practices being emphasized. In Kwale County peer educators conducted 96 PHDP sessions in 10 facilities14 reaching 786 (278 M, 508 F) PLHIV. Thirty peer educators in 16 facilities15 in Kilifi County were supported with lunch and transport reimbursements as they conducted 562 health education sessions with 7,513 people benefiting, while in Mombasa county 1,872 PLHIV
14 Msambweni, Diani, Mkongani, Tiwi, Lunga Lunga, Vitsangalaweni, Kikoneni, Kinango, Mazeras and Samburu health facilities. 15 Rabai, Mariakani, Chasimba, Mtwapa, Vipingo, Kilifi County Hospital, Matsangoni, Gede, Muyeye, Malindi, Marafa, Mambrui, Gongoni, Marereni, Ganze and Bamba.
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benefited from 273 PHDP sessions in 20 facilities16 guided by 47 CHVs and 8 peer educators. Please see Table 4 for more information on these figures. Table 4 Support group sessions conducted in Q217 Support group sessions conducted in Q2 County General Adolescents Pediatric Unsuppressed Kilifi 63(3593) 40(753) 58 (1654) 24(220) Taita Taveta 21(295) 1 (13) 1 (45) 4 (148) Mombasa 46(1588) 21(847) 6(233) 6(187) Kwale 32 (786) 5(87) 5(81) 5(157)
During the quarter under review, Afya Pwani has also supported PLHIV support group sessions which have been acting as avenues of promoting PHDP whereas PLHIV are encouraged to use dual methods of FP and correct and consistent condom use, disclosure to trusted family member or friend, partner and family testing, treatment and prevention for STIs etc. In total, more than 330 support group sessions were conducted in the quarter reaching over 8,000 PLHIVs. In Mombasa County specifically, Afya Pwani supported 12 discordant couples support groups reaching 1,872 PLHIV, and scheduled home visits benefitting 118 PLHIV who were not virally suppressed. Table 5 Defaulter tracing in Afya Pwani supported counties Jan 18- March 18 Defaulter tracing in Afya Pwani supported counties Jan 18- March 18 County Missed Traced % Still % still Transferred % Died % Lost % Appointment Back traced following on out transferred died to LTFU back follow out Follow up Kilifi 1669 1354 81% 200 12% 74 4% 41 2% 0 0% Mombasa 558 235 42% 288 52% 21 4% 2 0% 11 2%
Kwale 274 154 56% 79 29% 21 8% 8 3% 12 4% Taita 266 Taveta 163 61% 89 33% 12 5% 7 3% 0 0%
Total 2767 1906 69% 656 24% 128 5% 58 2% 23 1%
ii) Defaulter Tracing To further improve retention during the quarter, Afya Pwani continued to address the challenge of defaulters using appointment diaries in all supported facilities to schedule client appointments, where those clients who did not turn up for their scheduled appointments were line listed at the end of every clinic day and follow up initiated through sending of SMS reminders, phone calls or home visits. Responses are documented in the client follows up register, returnees within seven days continue with care while the non-returnees are defaulters and scheduled for physical follow up by CHVs with their outcomes
16 Mvita Health Center, Tudor Sub County Hospital, CPGH, Ganjoni Clinic, Railway Dispensary, Likoni Sub-County Hospital, Mrima Health Center, Shika Adabu Health Center, Mbuta Dispensary, Chaani Dispensary, Magongo Health Center, Bokole CDF, Jomvu Model, Miritini CDF, Portreitz Hospital, Kongowea Health Center, Bamburi Health center, Kisauni Health Center, Mlaleo Health Center and Utange Dispensary, Mikindani Health Center. 17 NB: Brackets denotes the number of PLHIV reached in the sessions.
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documented in the register. During the quarter, there were 2,767 documented missed appointments in supported facilities, 69% (1,906) of them were brought back to care, 5% (128) were confirmed to have transferred to other facilities within and outside their counties, 2% (58) were confirmed dead, 1% (23) lost to follow up and 24% (656) are still being followed up. In Mombasa County, three facilities18 utilizing electronic medical record (EMR) have been using the in-built Short Built Service (SMS) platform to remind clients of their missed appointments and encouraged them to visit the facility as soon as possible.
iii) Specific opportunistic infection screening and prevention To prevent opportunistic infections (OIs) among PLHIV, the project team across all the five counties ensured that all PLHIV were offered Cotrimoxazole or Dapsone prophylaxis during their clinical visits. In Lamu County, the project supported mentorship by the CHMT on STI screening; TB screening using the Intensified Case Finding (ICF) cards and provision of IPT in 10 health facilities.19 The project has also provided support for tests needed by PLHIV that are poor such as CrAg for Cryptococcal meningitis and biochemistry for clients on ART with kidney or liver complications. iv) Nutritional services, Mental Health Screening and Management and preventing other infections. Afya Pwani continues to leverage on partnership with the counties to ensure that every client on HAART receives Nutrition Assessment Counselling and Support (NACS). To this end, this quarter SCHMTs were supported to conduct support supervision which focusing on NACS reaching 34 health facilities20 in four counties (Kilifi (10), Kwale (8), Taita-Taveta (6), Mombasa (10)) with 79 (49f,30m) health workers benefiting. The key issues addressed included NACs coverage for PMTCT clients, where there were missed opportunities identified, capacity building other cadres on NACs, OJT on reporting and anthropometric measurements. Afya Pwani also procured anthropometric equipment’s to be used at health facilities across the supported counties including 100 height boards, 50 Body Mass Index (BMI) wheels, 15 weighing scales and 100 child Mid-Upper Arm Circumference (MUAC) tapes. The uptake of mental health screening among PLHIV has been poor largely due to lack of capacity of health care workers to provide the services. To address this, Afya Pwani will conduct CME sessions on the use of Patient Health Questionnaire-9(PHQ9) targeting 50 HVFs by the time the Annual Program Review (APR) for depression screening, CRAFFT part B and CAGE -AID for adolescents and adults respectively, for alcohol and drug use/addiction screening. Priority will be given to newly identified PLHIV, unsuppressed PLHIV and those with poor adherence on screening using MMAS-4 and MMAS 8. v) Differentiated care service delivery. Between January and December 2018, Afya Pwani has continued to support the implementation of differentiated care service delivery to improve on the quality of care to clients in some selected supported sites to reduce the burden on the health care system. As at the end of March, 29 facilities were implementing Differentiated Service Delivery (DSD) with 4,316 PLHIV given six months’ prescriptions with drug refills at 3 months’ intervals as shown in the table below. This is an improvement from 18 facilities
18 Kisauni, Kongowea, Portreitz 19 Faza Health Center, Kizingitini Dispensary, Shella Dispensary, Lamu Hospital, Mokowe Health center, Hindi Dispensary, Muhamarani Dispensary, Hongwe Catholic dispensary, Mpeketoni Hospital and Witu Health Center 20 Kilifi County Referral Hospital, Ganze Sub -County Hospital, Bamba health center, Matsangoni health center, Muyeye health center, Malindi Sub-County Hospital, Marafa Dispensary center, Gongoni health center, Gede health center, Rabai health center, Lunga Lunga sub county hospital, Diani health center, Tiwi health center, Vitsangalaweni Dispensary, Kwale county referral hospital, Kinango health center, Msambweni sub county hospital, Kinondo kwetu health center, Moi Voi county referral hospital, Mwatate sub county hospital, Ndovu health center, Njukini health center, Taveta Sub-County hospital, Kisauni Dispensary, Coast general referral hospital, Bamburi Dispensary, Likoni health center, Kongowea Dispensary, Ganjoni health center, Mvita sub county hospital, Tudor health center, Port Reitz health center, Mlaleo Dispensary.
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that were implementing DSD in quarter one (see chart below) with only 1,609 PLHIV on the a DSD model. Scale up of DSD is ongoing to reach 50 sites at the end of the next quarter. Mentorship sessions and sensitization through CMEs was conducted in 2 facilities in Kwale (Samburu, Vitsangalaweni) and Lamu (Lamu and Mpeketoni) and counties reaching 63 service providers (30M, 33F). Please see Table 6 below for more detailed information. Table 6 Differentiated Care Service Delivery- March 31st 201821 DIFFERENTIATED CARE SERVICE DELIVERY AS AT MARCH 31ST, 2018
At enrolment After 12 Months on treatment County Sex Files Well Advanced Stable Unstable on DSD reviewed appointments
Lamu M 248 16 2 150 80 78 F 443 31 3 311 98 133 Mombasa M 1891 79 69 914 819 740 F 3769 137 100 1997 1513 1607 Kilifi M 661 53 8 1275 442 593 F 1616 106 5 1677 173 412 Kwale M 597 21 8 171 398 81 F 1195 42 16 341 795 162 Taita Taveta M 543 28 4 262 210 142 F 1228 90 2 622 358 368 Afya Pwani M 3940 197 91 2772 1949 1634 F 8251 406 126 4948 2937 2682
vi) Improved access and utilization of standard package of care for adolescents and young people Adolescents and young (AY) people face unique challenges that impact their adherence to treatment and eventually their treatment outcomes. The suppression rates among children and adolescents in the project range from 50-65%. To provide services tailored for young people and improve on these outcomes, adolescent friendly clinics have been supported in CPGH, Mlaleo, Portreitz, Jomvu Model, Chaani, Likoni Sub-County Hospital in Mombasa County and facilities in Malindi Hospital, Kilifi County Referral Hospital, Mtwapa Health Center, Mariakani Hospital, Gede Health Center and Muyeye Health Center in Kilifi County. In Taita Taveta County, Afya Pwani facilitated and supported adolescent clinics at Taveta Sub- County Hospital and Moi County Referral Hospital reaching 89 adolescents with a pediatric clinic at Moi Voi serving 19 children during the period. Further, the project also supported Five support groups in Msambweni, Tiwi, Kinango, Mazeras and Diani in Kwale County to hold monthly meetings; a total of 15 sessions were conducted during the quarter under review, reaching 87 (32M, 55F) adolescents. In Kilifi County, adolescent support groups were also conducted in Gede, Mariakani, Mtwapa, Rabai, Malindi,
21 NB:112 (35m, 77f) PLHIV of the total on DSD appointments, are on community model at Mwatate Sub-County Hospital
USAID AFYA PWANI PROGRESS REPORT JANUARY-MARCH 2018 34
Muyeye and Bamba with a total of 33 sessions supported reaching 298 adolescents. In Taita-Taveta, the four adolescent support groups which were formed in first quarter at Wundanyi, Taveta and Wesu Sub- County Hospitals and Moi Country Referral Hospital, will be meeting during school holidays for treatment literacy sessions, address disclosure, SRH health issues, mental health and substance use concerns. Between January and March 2018, the Project also supported the Sagalla Youth Center to continue providing health services including HTS, Sexual Reproductive Health (SRH) and peer support to those living with HIV. To ensure that the community provided unwavering support to the youth center, 12 community opinion leaders and 13 religious leaders were sensitized on the activities of the youth center and the importance of allowing youth to be meeting at the center for HIV and SRH updates and activities. A total of 13 youths were supported by the project to meet for health education on HIV and RH as one of the entry point for HIV testing. These peer support groups have proven to be critical as they are an important source of psychological support, helping to build confidence, resilience, reducing anxiety and promoting a sense of belonging. Because of their common experiences, they can also help adolescents living with HIV to cope with fear, hopelessness, stigma and discrimination, and they can facilitate problem solving. Peer support groups can also be reliable sources of practical information, motivation and positive reinforcement for adherence to treatment, disclosure, sexual and reproductive health issues, and addressing mental health and substance use concerns. Further, during this quarter, 70 (22M, 48F) caregivers from Msambweni and Lunga Lunga health facilities in Kwale County, were trained on care and management of the Children Living with HIV (CLHIV). The caregivers who assume the role of parent for a child, become the sole or main providers of all the emotional, material and financial support for these CLHIV. In Lamu County, 56 health care workers (21M,35F), were updated on standard package of care for adolescent and young people. The project supported distribution of 20 copies of revised ART guideline and 20 copies of HIV job aids. A CME was also conducted to health workers at Kilifi County Referral Hospital on Adolescent Package of Care which reached 40 service providers (16M, 24F). The purpose of the CME was to sensitize health care workers on the adolescent package of care since most service providers had gaps in skills on how to handle Adolescents. This will contribute to result of having better treatment outcome and retention of children and adolescents who are on treatment. Lessons learnt 1. Clients who have gone through PHDP tend to adhere well to treatment from anecdotal evidence in facilities. 2. Support groups for PLHIVs (adults, youths/adolescents and pediatrics) are still very essential and critical for the empowerment of clients to take charge of their own care. 3. Adolescents can be free to discuss their challenges in a safe environment, free of stigma discrimination and judgement. 4. Peer learning sessions promotes learning and sharing of ideas on drug adherence and reduction of stigma among adolescents and youths living with HIV. 5. Care giver training makes the caretakers to be more empowered to take care of their children and adolescents living with HIV.
Output 1.3: HIV Treatment Services A) Linkage to increase uptake of care and support services among PLHIV In Q2, a total of 1,998 PLHIV were linked to treatment against 2,322 identified positives being 86% linkage. Of the 324 newly identified PLHIV that were not linked in the testing sites, 51 were confirmed to have been linked to other facilities, 80 were still at various stages of treatment preparation (requested more
USAID AFYA PWANI PROGRESS REPORT JANUARY-MARCH 2018 35
time before starting ART but in contact with the counselors for further counseling sessions) and 8 had died before starting ART with 3 being TB patients and the rest inpatients. Afya Pwani has also helped to conduct refresher trainings for HTS counselors in Mombasa, Kilifi and Kwale counties to partly address the high number of newly identified PLHIV declining treatment (68 in the quarter) by emphasizing the importance of thorough pre-test counseling as the foundation for good linkage to care. Please see Figure 3 below:
Linkage per County, January -March 2018
Total Afya Pwani 1998 324
Taita Taveta 163 4
Mombasa 715 126
Lamu 65 0
Kwale 461 93
Kilifi 594 103
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Figure 3 Linkage per County, January -March 2018
To improve the linkage to over 90% Afya Pwani will continue with individualizing care where all counsellors are responsible for linkage of identified positives through intense psychosocial and treatment preparation counselling, physical escort to treatment clinics within the health facility, use of expert clients for psychosocial support of newly identified clients for treatment, telephone follow up of identified clients and use of referral tools registers, directories and referral forms to track and ensure enrolment to treatment. Table 7 Reasons for not Clients Not Linked Reasons for not linked County Unlinked Linked in Still on treatment Declined Died Unaccounted another preparation-linked treatment before for facility- after the reporting starting confirmed period ART
Kilifi 103 18 28 0 0 57 Kwale 93 23 42 5 1 22 Lamu -4 0 0 0 0 -4 Mombasa 126 8 10 61 7 40 Taita 4 2 0 2 0 0 Taveta
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Total Afya 322 51 80 68 8 115 Pwani
In Lamu County, there were six extra PLHIV that started treatment in the quarter who were referrals from non-supported non-ART sites to project supported facilities. vii) Increasing uptake of ART. As at the SAPR, Afya Pwani had 47,142 PLHIV on treatment against an APR target of 55,486, an achievement of 85%. The achievement for children was 77% (3,417 out of 4,437) and that of adults >15 years was 86% (43,723 out of 51,049). All of which is a positive indication that the Project’s interventions and key strategies are proving to be effective in the fight to ensure that all clients who test positive for HIV and effectively link to ART in a timely manner. The graphs below provide a more comprehensive picture of the situation on ground.
TX _CURR <15 Years at SAPR, FY 18 4000 3355 3429 3500 3205 3000
2500
2000 Net gain 74
1500
1000
500 150 0 TX_CURR Q1 TX_NEW Q2 EXPECTED TX_CURR Q2 TX_CURR Q2
Figure 4 TX _CURR <15 Years at SAPR, FY 18
USAID AFYA PWANI PROGRESS REPORT JANUARY-MARCH 2018 37
TX _CURR >15 Years at SAPR, FY 18
50000 44458 43711 45000 42610
40000 Net loss 747 35000
30000
25000
20000
15000
10000
5000 1848
0 TX_CURR Q1 TX_NEW Q2 EXPECTED TX_CURR Q2 TX_CURR Q2
Figure 5 TX _CURR >15 Years at SAPR, FY 18
Table 8 TX_CURR >15 Yrs. Analysis TX_CURR >15 Yrs. Analysis County TX_CURR Q1 TX_NEW Q2 Expected TX_CURR Q2 TX_CURR Q2 Net gain/loss
Kilifi 13,678 561 14239 14289 50 Kwale 7,006 431 7437 7086 -351 Lamu 1,115 53 1168 1186 18 Mombasa 17,015 673 17688 17105 -583 Taita Taveta 3,796 150 3946 4045 99
Of further night that Counties has been contributing to most losses at 583 and 351 respectively. Kilifi had a gain of 50 clients among the clients >15 years old, PLHIV in the period which is attributable partly to children who were transitioned to adult care from the < 15 years’ age set and transfers in. In Kwale County, majority of the loss was from Diani Health Center, Kinondo Kwetu Health Center, Kinango Hospital, Ukunda Diani Catholic, Vanga Health Center and Taru Dispensary due to missing appointments, transfers to other facilities and deaths. In Mombasa County, most of the losses were from Likoni Catholic, Chaani, Mikindani and Mvita facilities following of manual audit by conducting list listing of the treatment numbers by project staffs to ascertain the accuracy of the reported figures. During the quarter under review, the pediatric <15 years’ age set had better retention patterns across all the Counties, with Mombasa, Kwale and Lamu gaining [77], [9] and [3] clients respectively as shown in Table 9 below. Kilifi had 26 adolescents who were transitioned to > 15 years’ age category.
USAID AFYA PWANI PROGRESS REPORT JANUARY-MARCH 2018 38
Table 9 TX_CURR <15 Yrs. Analysis TX_CURR <15 Yrs. analysis County TX_CURR Q1 TX_NEW Q2 Expected TX_CURR Q2 TX_CURR Q2 Net gain/loss
Kilifi 1453 53 1506 1480 -26 Kwale 688 30 718 727 9 Lamu 107 14 121 124 3 Mombasa 681 42 723 800 77 Taita Taveta 276 13 289 282 -7
As per Output 1.2: HIV Care and Support Services, Afya Pwani has adopted a case management approach that seeks to provide individualize care to every child. This means that the status of each child will be known at any moment and special attention given to the needs of the child22. For children in boarding schools, their appointments dates are scheduled to coincide with school holidays and given enough drugs to cover the term with instructions to come to the clinic when he/she child falls sick. In the next quarter, caregiver trainings will be prioritized by project staff to improve adherence to ART, appointment attendance, as well as to promote age appropriate disclosure among children and adolescents. Please see Table 10 below for more information on the figures per county. Table 10 Number of CLHIV seen in Pediatric ART Clinics, Jan-March 2018 Number of CLHIV seen in Pediatric ART Clinics, Jan-March 2018 County Facility Number of children seen in Pediatric ART clinics
Taita Taveta Moi Voi County Referral Hospital 40 Kwale Msambweni County Referral Hospital 20 Mombasa CPGH 458 Chaani 27 Kongowea 62 Mikindani 25 Kisauni 33 Likoni 321 Kilifi Malindi Sub-County Hospital 215 Muyeye Health Center 37 Gede Health Center 52 Mariakani Sub-County Hospital 70 Mtwapa Health Center 62 Kilifi CRH 170 Ganze 37
22 . Special pediatric ART clinic days have been set up in HVFs of Moi Voi, CPGH, Chaani Dispensary, Kisauni Health Center, Mikindani Health Center, Likoni Sub-County Hospital, Malindi Hospital, Kilifi County Referral Hospital, Mtwapa Health Center, Mariakani Hospital, Gede Health Center, Muyeye Health Center and Msambweni County Hospital for this purpose.
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Total 1629
Test and Start As reported in the section on linkage under Output 1.4 HIV Prevention and HIV Testing and Counseling of this report, the project linked to ART 1,998 (86%) of the 2,322 newly identified PLHIV in the quarter. The project has strengthened the implementation of the Test and Treat strategy throughout all the supported sites through mentorship and CMEs Between January and March 2018, 56 (21m and 35 f) health care workers from 10 facilities23 in Lamu County were oriented and mentored on the ART guidelines to increase uptake HAART among PLHIV. In Taita Taveta County, informed by data, the CHMT and Afya Pwani identified knowledge and skills gaps in HIV case management and conducted 10 CME sessions on the ART guidelines reaching 285 (99M, 176F) from 22 facilities24. Please see Table 11 below: Table 11 CME Sessions conducted in Kwale County CMEs conducted in Kwale County Facility CME topic Male Female Total Lunga Lunga Sub-County Hospital ART guidelines 8 12 20 Samburu Health Center ART guidelines updates 7 23 30
Tiwi Health Center ART guidelines updates 11 19 30
Kwale Hospital PEP/PREP 11 29 40 Kikoneni Health Center ART optimization 8 7 15 Kinango Sub-County Hospital ART optimization 10 14 24 Mazeras Dispensary Adherence to ART 7 6 13
23 Faza Health Center, Kizingitini Dispensary, Shella Dispensary, Lamu Hospital, Mokowe Health center, Hindi Dispensary, Muhamarani Dispensary, Hongwe Catholic dispensary, Mpeketoni H ospital and Witu Health Center 24 Moi CRH, Taveta SCH, Mwatate SCH, Wundanyi SCH, Wesu SCH, Ndovu HC, Mgange Nyika HC, Nyache HC, Mbale HC, Kishushe HC, Mgange Dawida HC, Bura HC, Marungu HC, Maungu HC, Mpizinyi HC, Miasenyi Disp, Maktau Disp, Kwamnengwa Disp, Mwashuma Disp, Modambogho Dispensary, Dawson Mwanyumba Disp and Manoa Dispensary.
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The health workers were sensitized on HTS and linkage to treatment and prevention, initial evaluation and follow up for PLHIV, standard package of care for PLHIV, adherence preparation, monitoring and support, ART for infants, children, adolescents and adults, TB/HIV co-infection prevention and Test And start Jan-March 2018 management as well as post exposure prophylaxis N=67 Sites, 1203 PLHIV (PEP) and oral pre-exposure prophylaxis (PrEP). In Kwale County, 172 (62M, 110F) health care >30 days 11% workers from 7 facilities were reached with CME on topics as shown on the table on the right. 15-30 days Seventy-seven (77) [39M, 38F] service providers 8% from 13 facilities25 in Kilifi County received CME sessions and and mentorship on the ART cascades Same day this quarter, while in Mombasa County, the 57% project team continued to provide targeted mentorship in 13 facilities26 on the revised ART guidelines to support early ART start for all 1-14 days identified PLHIV reaching 27 health workers 24% (12M,15F). To further provide services in facilities that did not have adequate clinical staff, Afya Pwani has placed three medical officers at CPGH, Kinondo Kwetu and Msambweni County Hospital, Test and Start Jan--March 2018, n=67 sites, 1203 clinical officers at Tudor, Kinondo Kwetu, CPGH, PLHIV Ganjoni and Utange to ensure that clients can M F Total access high quality health services. Same day 180 514 694 1-14 days 91 195 286 As a result of the interventions mentioned above, 15-30 days 31 63 94 project staff were able to work with health service >30 days 37 92 129 providers to review 1,203 clients who were newly started on ART from 67 facilities. Review of these clients files showed that 57% of them were started on the same day, 24% had started between day 1 -14, 8% between 15-30 days after testing positive and lastly 11% for those who were started after 30 days. (See pie chart above.)
Cohort Analysis Between January and March 2018, Afya Pwani also conducted cohort analysis for 712 clients from 27 facilities with functional EMR, who started ART in the same quarterly period to find out information about their retention patterns. Of note is that out of 712 clients started on ART, 466 (65%) were still active on ART at the time of the review, 49 (7%) had transferred out, 171 (24%) were lost to follow up and 10 (1.4%) had died. Retention patterns were similar among males and females (69% versus 71%) and trends were significantly higher among those who started ART after 14 days than those who started on the same day of HIV diagnosis (73% versus 66%). These trends can be attributable to the more treatment preparation counseling given to those who started later as they were followed up several times before accepting to start ART; additionally, these are also more likely to have accepted the diagnosis by the time they were
25 Kilifi Hospital, Mtwapa HC, Vipingo HC, Oasis Medical Center, Mtepeni Dispensary, Gongoni Health Center, Marereni Dispensary, Marikebuni Dispensary, Marafa Health Center, GK Prison Dispensary, Baolala Dispensary, Muyeye Health Center and Cowdry Dispensary 26 CPGH, Likoni, Portreitz, Ganjoni, Mvita, Kisauni, Mlaleo, Utange, Bamburi, Magongo, Chaani, Mikindani, Miritini.
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starting ART than those who started on the same day. Moving forward, as part of efforts to fully understand the dynamics around retention for clients in this era of “Anza Sasa” and to develop appropriate interventions, an in depth qualitative and quantitative study will be done by the project to be able to profile the characteristics and behaviors of these clients to implement interventions that are responsive to their needs. In the meantime, the project has continued to focus on supporting thorough pre-test counseling as the foundation for effective post-test counselling and treatment preparation for those who test positive. In the next quarter, adherence counselors will also be deployed to HVFs with poor retention patterns as well as strengthening psychosocial support through peer educators and support groups. Table 12 Analysis of Jan-Mar cohort 2017 at 12 months ANALYSIS OF JAN-MARCH COHORT 2017 AT 12 MONTHS, N= 712 PLHIV ON ART IN 27 EMR SITES. WHEN STARTED Sex # in Active LTFU Dead Transfer Defaulter % ART cohort out s Retention
SAME DAY M 81 49 24 2 6 0 65% F 239 147 70 0 21 1 67%
1-14 DAYS M 62 40 13 2 5 2 70% F 128 90 23 2 8 5 75%
>14 DAYS M 67 0 47 15 0 3 2 73% F 135 0 93 26 4 6 6 72%
TOTAL M 210 136 52 4 14 4 69% F 502 330 119 6 35 12 71% 712 466 171 10 49 16 70%
Quality Assurance(QA)/Quality Improvement (QI) –adherence to guidelines and standards i) Quality Improvement Initiatives This quarter under review, the project has embarked on strengthening or reactivating WITs in HVFs so that they can review their own performance using their own data, identify gaps and develop interventions to address those gaps in quality of care. To this end, in Taita Taveta county, 28 (15M, 13F) health care workers from Moi County Referral Hospital, Taveta Sub-County, Mwatate Sub-County Hospital, Wundanyi Sub-County Hospital and Wesu Sub-County were taken through a CME on Kenya HIV Quality Improvement Framework (KHQIF) and supported to form work improvement teams in their facilities. WIT meetings for eleven facilities27 in Kwale County were supported in the quarter, each of which have been implementing their respective QI projects. In Mombasa County, Afya Pwani trained 10 facilities28 on the KHQIF and supported them to establish WITs, two WIT meetings at Bokole and Ganjoni have been documented so far.
27 Msambweni, Kwale, Lunga Lunga and Kinango Hospitals, Diani, Tiwi, Kikoneni, Samburu health Centers, Mazeras, Dispensary and Kinondo Kwetu Medical Center. 28 Portreitz, Tudor, Likoni, Bamburi, Kisauni, Mlaleo, Kongowea, Ganjoni, Mikindani, Kisauni MAT Clinic.
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While in Lamu County, the County CQI WITs in four health facilities (Lamu County Hospital, Mpeketoni Sub-County Hospital, Witu Health Center and Faza Sub-County Hospital) were established and members trained on how to go about identifying and implementing QI projects at their various facilities. In Kilifi County, Afya Pwani supported a quarterly County QIT meeting where 15 CHMT members (9M, 6F) participated in the meeting. Fifty-four (54) health care providers from 20 Health facilities29 were trained on the KQMH and supported to form WITs and ongoing coaching to make them functional. In the next quarter, Afya Pwani will build on these successes as part of its commitment to addressing the quality of care gaps in supported facilities which have been negatively curtailing uptake of health services across the five coastal counties being supported by the Project.
Improving the uptake of Viral Load monitoring among patients on ART i) Demand creation for VL among PLHIV During the quarter under review, health care Table 13 Viral Load Uptake in Q2 FY18 workers were also sensitized on the need for VL Uptake in Q2 FY18 treatment monitoring for PLHIV on ART; County Tests Suppressed Suppression improving the ability of health workers in % identifying clients due for viral loads has increased. In addition, the project also supported the Lamu CHMT to mentor 56 (21M and 35F) Mombasa 4462 3686 83% health care workers from 10 facilities30 on viral Kilifi 3357 2680 80% load uptake and conducted 5 CMEs on the same Kwale 2049 1578 77% in Taita Taveta County reaching 50 (24M, 26F) Taita Taveta 1229 905 74% health care workers from Moi County Referral Lamu 269 195 72% Hospital, Taveta Sub-County Hospital, Mwatate Afya Pwani 11,366 9,044 81.5% Sub-County Hospital, Wesu Sub-County Hospital and Ndovu Health Center respectively. Following the CME, all clients who were due for viral load have since been line listed and have been called to come to the facility for viral load testing. Broadcasting on the importance of viral load test was done with the use of Frontline SMS platform with 402 messages being sent (324 Moi County Referral Hospital and 78 Taveta Sub-County Hospital).
The importance of Viral Load testing has also been a permanent topic this quarter during the support group meetings supported by the project to not only create demand for viral load but also promote enhance adherence through championing viral load suppression as a treatment goal for each member of the support group. In Mombasa County, the project successfully engaged 48 peer educators across project supported sites to promote viral load uptake, by line listing clients due for viral load and calling them to come for sample collection. In Kilifi County, 33 (17M, 16F) service providers from Gede Health Center, Muyeye Health Center, Matsangoni Health Center and Oasis Medical Center were sensitized through CME on the need for treatment monitoring for PLHIV on ART. Lists of clients due for viral loads were generated and facilities supported with airtime to call the clients to come for viral load sample collection. Afya Pwani supported facilities with peer educators were also engaged and facilitated to call these clients and where
29 Malindi Hospital, Kilifi Hospital, Mariakani Hospital, Mtwapa, Gede, Vipingo, Tsangatsini, Matsangoni, Vitengeni, Rabai, Bamba, Gongoni, Chasimba, Marafa, Baolala, Marereni, Mambrui, Ganze, Gotani and Muyeye.
30 Faza Health Center, Kizingitini Dispensary, Shella Dispensary, Lamu Hospital, Mokowe Health center, Hindi Dispensary, Muhamarani Dispensary, Hongwe Catholic dispensary, Mpeketoni Hospital and Witu Health Center
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necessary physically follow them up, for those who had missed to come for their regular/scheduled visits to have their viral loads checked.
As shown in the chart below, at SAPR, 21,205 viral tests had been done against a target of 46,241 (TX_CURR at APR FY 17) resulting in an overall performance of 46%. Considering that over 50% of PLHIV had a viral load test from June 2017 and are not due for another viral load, the project is on course to achieving 100% uptake of viral load for those on ART in supported facilities. In the next quarter, Afya Pwani will build on the successes from this quarter and project staff will endeavor to improve the rate at which the making of clinical decisions is based on viral load results through mentoring of health care workers on the interpretation of viral load results, the team will also work to support the procurement of new stickers to mark files for clients with new results. Lastly, Afya Pwani will also work to conduct of clinical review meetings for at least 50 HVFs. Please see Figure 6 below for more information on viral load uptake.
Viral Load Uptake At SAPR FY18
50000 46241 45000 40000 35000 30000 46% 25000 21205 81.5% 20000 17281 15000 10000 5000 0 TX_CURR APR FY 17 Tests done Suppressed Figure 6 Viral Load Uptake at SAPR FY18
ii) Improving viral load suppression among PLHIV on ART To achieve the 3rd 90, project staff have focused on utilizing the following strategies to improve suppression among PLHIV on ART: Utilization of unsuppressed PLHIV register, unsuppressed PLHIV support groups, Viremia Clinics, Multi-Disciplinary Team (MDT) meetings and working with the Pwani Regional HIV clinical TWG. In the next two quarters project staff will focus on scaling up these strategies to cover at least 50 facilities that account for 83% of the number of PLHIV supported in the five counties. iii) Unsuppressed PLHIV Register Afya Pwani has also embraced the use of the unsuppressed PLHIV register as a tool to guide the management of unsuppressed clients. Once unsuppressed viral load results are received in the facility, the clients are called and given their results as well as entered in the Unsuppressed PLHIV register for follow up. They are also enrolled in a support group for enhanced adherence, assigned adherence manager, grouped in cohorts for follow up where same clinic days will be given, files separated, stickers put on files for easy identification. Monthly or even short follow up is done for the clients depending on needs until excellent adherence is maintained for three months, a repeat VL done with appropriate action taken depending on the results. So far, the register is in use in 13 facilities in Taita Taveta county in 13
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facilities31 with 350 unsuppressed PLHIV being managed using the tool. Eight (8) high volume facilities (Bambara Health Center, Mlaleo, Likoni Sub-County Hospital, Tudor Sub-County Hospital, Ganjoni Clinic, Port Reitz Sub-County Hospital and Kisauni Health Center) in Mombasa County have started using the unsuppressed PLHIV Register while 10 facilities32 in Kilifi County and 13 facilities33 in Kwale utilize it consistently. iv) Multi-disciplinary team meetings To improve how clients are managed in the supported facilities, the projected has also continued to support the strengthening of facility based MDTs this quarter for discussion and managing unsuppressed/complicated cases in the respective facilities. So far, 12HVFs34 have functional MDTs in Kwale County that have discussed 116 of the 415 unsuppressed clients in those facilities in the quarter while Taita Taveta has six functional MDTs (Moi County Referral Hospital, Mwatate Sub-County Hospital, Taveta Sub-County Hospital, Wundanyi Sub-County Hospital, Wesu Sub-County Hospital and Ndovu Health Center) that have discussed 93 of the 350 unsuppressed PLHIV from those facilities. Kilifi County has 14 facilities35 and Mombasa 7 facilities36 with functional MDTs respectively; indications that the project does take its quality of care mandate seriously and is working to improve access and availability of services across the board. v) Capacity building on managing unsuppressed clients
31 Moi CRH, Mwatate SCH, Taveta SCH, Wesu SCH, Ndovu HC, Wundanyi SCH, Bura HC, Ndilidau HC, Challa Disp, Njukini HC, Kitobo Disp, Rekeke HC, Mata Disp. 32 Mariakani Hospital, Malindi Hospital, Kilifi Hospital, Gede HC, Muyeye HC, Gongoni HC, Ganze HC, Matsangoni HC, Chasimba HC, Vipingo HC 33 Lunga Lunga, Kikoneni, Kinondo Kwetu, Diani Health center, Tiwi Health center, Kwale Hospital, Kinango Hospital, Samburu Health center, Mkongani Health center, Mazeras HC, Msambweni Hospital, Taru Dispensary, MacKinnon Dispensary 34 Msambweni Hospital, Diani Health Center and Kinondo Kwetu Health services in Msambweni Sub County, Lunga Lunga hospital, Kikoneni Health Center and Vitsangalaweni Dispensary in Lunga Lunga sub county, Kwale Hospital, Tiwi and Mkongani Health centers in Matuga sub county and Kinango Hospital, Samburu Health Center and Mazeras Dispensary in Kinango sub county 35 Mariakani Hospital, Malindi Hospital, Vipingo Health Center, Kilifi Hospital, Mtwapa Health Center, Gede Health Center, Vipingo Health Center, Muyeye Health Center, Rabai Health Center, Marereni, Bamba Health Center, Matsangoni Health Center, Chasimba Health Center and Ganze Health Center 36 Portreitz, Tudor and Likoni, Kisauni, Bamburi, Ganjoni, Mikindani.
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During the quarter under review Afya Pwani identified gaps in management of unsuppressed clients among health care workers during the baseline survey conducted in year one. To address this gap, a CME on the management of unsuppressed clients was supported at Lunga Lunga Afya Pwani Service Delivery/Clinical Manager (Left) sensitizing Ndovu Health Center, health workers on ART guidelines. and Msambweni hospitals where 76 (46 male, 30 female) service providers drawn from rural health facilities in Lunga Lunga and Msambweni Sub- Counties benefitted. More specifically, the CME focused on adherence assessment, enhanced adherence counseling and support, home visits, treatment monitoring, use of 2nd line ART regimen and setting up of Viremia clinics. In Taita Taveta County, 8 CME sessions and mentorship for health workers on management of unsuppressed clients were supported reaching 80 (35M, 45F) health workers who were drawn from the MCH and CCC departments in 13 health facilities37. They were also updated on use of unsuppressed register to manage unsuppressed PLHIV clients. vi) Unsuppressed PLHIV support groups To provide psychosocial support to unsuppressed clients this quarter, Afya Pwani has partnered with the CHMTs to establish and operationalize support groups for unsuppressed clients that are linked viremia clinics (where they exist). Mombasa has six38 and Kwale Counties have five39 facilities that have unsuppressed support groups respectively. Whilst in Taita Taveta, they are functional viremia support groups at Moi Voi County Hospital, Mwatate and Taveta Sub County Hospitals. In Kilifi, 8 support groups of unsuppressed Viral Load clients were supported reaching 220 clients in 24 sessions at 6 facilities which are Rabai, Mariakani, Mtwapa, Kilifi Hospital, Ganze and Gede. Across all these groups, clients are taken through enhanced adherence counselling while assessing the possible barriers to adherence and review psychological, emotional, and socio-economic factors that may have contributed to poor adherence. It is hoped that by providing these much-needed PSS services these clients will see improvements in their viral suppression rates so that they can lead normal healthy lives. viii) Viremia clinics: To provide more individualized and focused care to unsuppressed PLHIV, Afya Pwani is working with tall five CHMTs to set aside specific clinic days for unsuppressed clients. So far, 740 in Mombasa and 10 facilities41 in Kilifi Counties respectively have established viremia clinics. Thirteen (13) health facilities42 in Taita Taveta County have viremia clinics having provided individualized care to 350 unsuppressed PLHIVs
37 Moi CRH, Taveta SCH, Mwatate SCH, Wesu SCH, Ndovu HC, Wundanyi SCH, Mbale HC, Mgange HC, Bura HC, Challa Disp, Njukini HC, Kitobo Disp and Ndilidau HC. 38 Portreitz, Mikindani, Bamburi, Ganjoni, Tudor, Kisauni 39 Tiwi, Msambweni, Samburu, Kinango and Mazeras 40 Bamburi H/C, Mlaleo, Likoni SCH, Tudor SCH, Ganjoni Clinic, Port Reitz SCH and Kisauni H/C 41 Gede, Mariakani, Mtwapa, Rabai, Malindi, Muyeye, Kilifi Hospital, Gongoni, Vipingo and Oasis Medical Center 42 Moi CRH, Mwatate SCH, Taveta SCH, Wesu SCH, Ndovu HC, Wundanyi SCH, Bura HC, Ndilidau HC, Challa Disp, Njukini HC, Kitobo Disp, Rekeke HC, Mata Disp
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in those facilities and 7 facilities43 in Kwale county served 284 unsuppressed PLHIV through viremia clinics in the period. Strengthen the activities of the regional HIV TWG: Between January and March 2018, the Afya Pwani project also continued to support the Pwani regional HIV Clinical TWG who have been meeting monthly to discuss difficult and complex cases referred from facility MDTs in Members of the Pwani Regional HIV TWG listening to a question raised by the SCASCO of Msambweni on Abacavir Mombasa, Kilifi, Kwale, Taita hypersensitivity during a meeting on 15th March, 2018 at the Taveta and Lamu Counties and to Afya Pwani Greenwood Boardroom. give guidance on the appropriate case management for these clients. So far over 30 cases have been discussed and feedback given to facilities. The TWG through NASCOP will also be leading the clinical mentorship in the region; mentors were identified and trained, introduction to the counties is ongoing. Strengthened Laboratory services i) Improved laboratory commodity management: Afya Pwani continued to collaborate with the CHMTs to ensure optimal laboratory commodity management practices were practiced in supported facilities to avoid stock out of commodities like rapid test kits for HIV testing services. Laboratory staff from 21 facilities44 were mentored on commodity management. In Lamu County a CHMT supportive supervision on PMTCT, HIV Care and Treatment, TB and Laboratory services supported by the Afya Pwani, reached 56 health care workers (21M, 35F) from 10 facilities45 who were mentored on commodity management and reporting. The key areas addressed included, commodity reporting tools (FCDRR), Commodity quantification and reporting to ensure availability of RTKs, DBS and vacutainers in the facilities. Thus, the facilities have improved in commodity management: stock taking, dispensing and reporting. During this reporting period, there were no stock outs of RTKs reported. ii) Strengthening the quality of laboratory services To build on the successes of the previous quarter, project continued to work towards strengthening the existing laboratory systems, by conducting and facilitating quarterly Sub-County Laboratory Coordinators meetings for Kwale, Kilifi and Lamu Counties respectively. This was done, to optimize efficient sample referral networks for both viral load and sputum for GeneXpert, reducing sample rejection rates, proficiency testing (PT) and corrective measures for failed testers. Afya Pwani staff also conducted Laboratory Mentorship on Quality Management systems, Laboratory Biosafety, Test SOPs, Test interruptions, Waste management, Injection Safety, Blood safety and appropriate filling of viral load forms
43 Tiwi, Msambweni, Kinango, Diani, Kinondo, Mazeras, Kwale. 44 Wesu HC, Marafa HC, Matsangoni HC, Bamba HC, Ganjoni HC, Kilifi CRH, Gede HC, Kinondo Kwetu hospital, Kwale CRH, Kwale CRH, Ganze HC, Mwatate SCH, Ndovu HC, Diani HC, Taveta SCH, Tiwi HC, Moi Voi CRH, Malindi SCH, Kinango SCH, Matuga HC, Msambweni HC and Lungalunga SCH. 45 Faza Health Center, Kizingitini Dispensary, Shella Dispensary, Lamu Hospital, Mokowe Health center, Hindi Dispensary, Muhamarani Dispensary, Hongwe Catholic dispensary, Mpeketoni Hospital and Witu Health Center.
USAID AFYA PWANI PROGRESS REPORT JANUARY-MARCH 2018 47
in the 22 facilities46. A meeting on quality Mwatate SCMLT (Right) offering OJT on viral management systems for Malindi Sub-County was load and EID testing to Laboratory staff at conducted that focused on quality assurance and Maktau Health Center. assessment to enable the laboratory system to function effectively towards Laboratory accreditation with 40 (29M,11F) health care workers were participating. Afya Pwani is also supporting Malindi Sub-County Hospital and Msambweni Sub-County Hospital Laboratories towards stepwise accreditation process in collaboration with other partners. In Mombasa County, to ensure that all viral load samples were accepted at the laboratory, 17 health providers (8F, 9M) from 5 HVFs (Kongowea, Tudor, Portreitz, Likoni, and CPGH) were trained through OJTs on safe collection and transportation of Viral Load samples. Similar OJT was done in Kilifi County with 25 (9M, 14F) service providers from Kokotoni Health Center, Rabai Health Center, Kombeni Health Center, Makanzani Health Center and Bwagamoyo Health Center benefiting. In Taita Taveta County, Afya Pwani supported laboratory staff meetings in the 4 Sub-Counties (Voi, Wundanyi, Mwatate and Taveta) which was attended by 75 (47M, 28F) staff from 60 participating health facilities47. These meetings focused on improving proper commodity management for RTKs, sample referral networks for both viral load and sputum for GeneXpert, HIV Testing especially targeting and linkage, PT and corrective measures for failed testers. The four Sub-County Medical Laboratory Technologists were supported with transport and lunch allowance to conduct laboratory services supervision in the quarter and offer OJT on sample harvesting for VL and EID. iii) Laboratory networking services During the quarter under review, the project has continued to run an efficient laboratory networking system supporting all the five supported counties to transport viral load, EID and GeneXpert samples and results from facilities to testing labs and back. Three motor riders have been deployed to Mombasa, Kwale and Kilifi Counties with turnaround time from sample collection to receipt of results reducing to less than one week in these counties. In Lamu and Taita Taveta Counties, transport reimbursement is made to health care workers to bring samples to a central collection hub. This quarter, the Afya Pwani project also continued to ensure that the CPGH molecular laboratory runs optimally by facilitating the seconding of three technologists to the laboratory and providing logistical support. The laboratory conducted 2,367 EID and 19,221 viral load tests in the quarter. Tables 14 and 15 below provide more information:
46 Wesu HC, Marafa HC, Matsangoni HC, Bamba HC, Ganjoni HC, Kilifi CRH, Gede HC, Kinondo Kwetu hospital, Kwale CRH, Kwale CRH, Ganze HC, Mwatate SCH, Ndovu HC, Diani HC, Taveta SCH, Tiwi HC, Moi Voi CRH, Malindi SCH, Kinango SCH, Matuga HC, Msambweni HC and Lunga Lunga SCH 47 Maktau HC, Bura HC, Dembwa Disp, Mpizinyi HC, Kighangachinyi Disp, Mrughua Disp, Manoa Disp, Mbagha Disp, Shelemba Disp, Msau Disp, Kwamnengwa Disp, Mwashuma Disp, Saghaighu Disp, Dawson Mwanyumba Disp, Modambogho Disp, Manoa Disp, Mwatate SCH, Shelemba Disp, Msau Disp, Kighombo Disp, Horesha Clinic, Joy Medical Clinic, Mwambirwa SCH Challa Disp, Njukini HC, Mahandakini Disp, Chumvini Disp, Rekeke HC, Mata Disp, Ndilidau Disp, Kitobo Disp, Kimorigo Disp, Eldoro Disp, Kiwalwa Disp, Taveta SCH, Miasenyi Disp, Kajire Disp, Makwasinyi Disp, David Kayanda Disp, Maungu Model HC, Ndome Disp, Ghazi Disp, Kasigau HC, Buguta HC, Marungu HC, Sagalla HC, Ndovu HC, Tausa HC, Moi CRH, Nyache HC, Mbale HC, Kishushe Disp, Sangeroko Disp, Mgange Nyika HC, Mgange Dawida HC, Werugha HC, Mwanda HC, Wesu SCH, Wundanyi SCH, Mvono clinic and Dawida Clinic
USAID AFYA PWANI PROGRESS REPORT JANUARY-MARCH 2018 48
Table 14 EID tests done during the Quarter Month Total Rejected Tested Valid Positive Valid Failed Samples Samples Samples Positive/Negative Negative Samples/ Received (Including Results Results Results Repeats) January 711 0 845 796 41 755 0 February 694 0 547 500 24 476 0 March 809 0 975 885 41 844 0 Total 2214 0 2367 2181 106 2075 0
Table 15 Viral load tests done during the Quarter: Month Receiv Rejected Non- Virally Repeats Total Tests ed Samples Suppressed Suppressed Done Sample (Including s Repeats) January 5867 0 841 4543 80 5831
February 6368 0 1231 5324 101 6877 March 6659 0 1054 5038 421 6513 Total 18894 3 3126 14905 602 19,221
Lessons learnt
1. In instances where classroom trainings are not possible, well-structured staggered CME with mentorship can achieve the same results or even better as training. 2. Good psychosocial support, adherence counseling and improved quality of care is important for retention of clients on treatment. 3. Regular support supervision plays an important role in improving quality of HIV care and treatment services offered in facilities. 4. Attaching case managers for clients with unsuppressed viral load has shown some improvement in clients adhering to medication. 5. OJT has proved to be an effective skill transfer modality in building capacity of service providers. 6. Regular laboratory support supervision is paramount in ensuring quality laboratory services are offered to clients. 7. Empowering service providers to access results from the National AIDS and STI Control Council (NASCOP) viral load dashboard reduces turn-around time and motivates service providers.
Output 1.4 HIV Prevention and HIV Testing and Counseling a) Improving HTS During the quarter under review, HIV testing continued to be offered with a goal of identifying over 90% of people living with HIV and link over 90% of the identified HIV positive individuals to HIV treatment in the Afya Pwani Project sites. High yield facilities, index client and testing of sexual partners (Partner
USAID AFYA PWANI PROGRESS REPORT JANUARY-MARCH 2018 49
Notification Services [PNS]) of newly identified PLHIV and clients on ART with unsuppressed viral loads HIV testing approaches were implemented, monitored and scaled up as appropriate. This quarter Afya Pwani HTS services continued to be informed by HIV positive identification gaps and Linkage based on weekly HTS reports from HVFs and PNS sites. Please see Figure 7 and 8 below for more detailed information on these trends during and the previous quarter.
HTS Achievement SAPR FY 18 66% 250000 221786
200000 167763
150000 107704 114082 100000 83882 83882
50000
0 Target Achievement Target Achievement Target Achievement Q1 Q2 SAPR
Figure 7 HTS Achievement SAPR FY 18
HTS performance compared to FY 18 targets per County
HTS_POS 358 779 Taita
Taveta HTS_TST 20567 24979
HTS_POS 1673 682
HTS_TST 61958 20062 Mombasa HTS_POS 117 286
Lamu HTS_TST 9732 10300
HTS_POS 939 2360
Kwale HTS_TST 51063 54424
HTS_POS 1350 1006
Kilifi HTS_TST 78565 3876
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Figure 8 HTS performance compared to FY 18 targets Per County
USAID AFYA PWANI PROGRESS REPORT JANUARY-MARCH 2018 50
Of note is that the project is still on course to achieving its annual target for HTS; as it stands the project has reached 221,351 clients at SAPR against an annual target of 335,526, an achievement of 66%. The project however did not meet its target for under 15 years, 14,396 (45%) were tested against a target of 16,162 (see section on pediatric testing below). To increase the numbers of the clients reached, the Project will facilitate and support the deployment of more counselors to pediatric service areas like CWCs, pediatric wards to improve and strengthen testing of children of HIV positive adults and siblings of HIV infected children as part of efforts to reach more children with HTS services. By SAPR of FY18, as shown in the chart below, Mombasa and Kilifi Counties achieved both their HTS and newly identified positives targets. This is attributable to the good uptake of HTS services in the two counties with Afya Pwani’s investments in HTS counselors. Of note is that, Kwale, Lamu and Taita Taveta counties did not achieve their targets by SAPR; In Lamu County for example there are inadequate numbers of counselors available to cover the Counties HVFs. The entire county has only one employed lay counselor based at Lamu County Referral Hospital with most tests being conducted by nurses, laboratory technologists and HTS volunteer counselors. Currently Afya Pwani cannot recruit HTS counselors as it is a central support county.
In Kwale, testing has been affected by the persistent refusal of nurses to offer HTS, with many facilities being manned by nurses alone. To address this challenge, advocacy through the nurses’ union is ongoing to solve the stalemate led by the county in partnership with Afya Pwani and other stakeholders. A joint meeting to solve the stalemate is planned in the last week of April. In addition, to ensure that HTS is offered in the high-volume, high yielding sites, the project recruited 7 HTS counselors through the County Public Service Board and deployed them to 7 facilities48 in Q2 of FY18 with their impact expected to demonstrate through the Q3 performance.
Table 16 Yields per testing modalities Jan- Mar 2018 Yields per testing modalities Jan - Mar 2018
Modality Kilifi Kwale Lamu Mombasa Taita Taveta Afya Pwani
Index Tested 344 23 0 659 0 1026 Positive 3 0 0 45 0 48 % Yield 0.87% 0.00% 0.00% 6.83% 0.00% 4.68%
Inpatient Tested 775 164 12 1518 425 2894 Positive 6 4 1 67 10 88 % Yield 0.77% 2.44% 8.33% 4.41% 2.35% 3.04%
Other PITC Tested 16074 15189 1482 9714 7346 49805 Positive 343 452 35 193 113 1136 % Yield 2.13% 2.98% 2.36% 1.99% 1.54% 2.28%
TB Clinic Tested 405 95 68 572 45 1185
48 Msambweni, Diani, Tiwi, Kwale, Kinango, Mackinnon Rd, Mazeras
USAID AFYA PWANI PROGRESS REPORT JANUARY-MARCH 2018 51
Positive 25 18 7 48 12 110 % Yield 6.17% 18.95% 10.29% 8.39% 26.67% 9.28%
VCT Tested 10953 2281 1924 10485 753 26396 Positive 201 75 14 330 13 633 % Yield 1.84% 3.29% 0.73% 3.15% 1.73% 2.40%
PMTCT ANC Tested 10865 7039 1260 7391 2477 29032 Positive 119 77 6 158 18 378 % Yield 1.10% 1.09% 0.48% 2.14% 0.73% 1.30%
As shown in the Table 16 above, testing in the TB clinic continues to give highest percent yields with low absolute numbers. Afya Pwani will continue to ensure that all TB clients are tested for HIV and those positive linked to ART. Targeted testing employed in Mombasa and Taita Taveta counties using the HTS screening tool also gave improved yields. In Kwale and Kilifi Counties, the project will continue to strengthen the use of the HTS screening tool in the inpatient departments to improve the yields. It should be noted that Mombasa County had better HTS yields of 2.8% mainly because of the early uptake of PNS compared to the other counties; Table 17 Q2 HTS Yields Per County an indication that this particular strategy has Q2 HTS Yields Per County b) Partner Notification Services Testing County HTS_TST HTS_POS Yields % Approach/Index client testing Kilifi 38775 697 1.8% In Mombasa county, the yields in index clients Kwale 29165 554 1.9% were high at 6.83% largely due to PNS which started being implemented in the county and Lamu 4746 63 1.3% proper documentation done also, unlike in Kilifi, Mombasa 30349 841 2.8% where PNS testing was mixed up therefore not 11047 167 reflecting in index clients yields-this has been Taita Taveta 1.5% corrected in the next quarter. Afya Pwani Afya Pwani 114082 2322 2.0% started implementing PNS testing approach in selected high yielding facilities to learn and then quickly scale up to cover at least 74 facilities providing 90% of the projects yields by the end of the FY18. So far, 18 testing sites49 in Kilifi, Mombasa and Kwale counties have started to offer PNS services with 189 contacts being tested, in March 20 clients were identified to be HIV positive (10.6% positivity rate) and 19 of them linked to ART. During the quarter Afya Pwani also conducted sensitization sessions for CHMTs and healthcare workers on PNS to get buy in and support for the same. Trainings to HTS providers have also been prioritized during the quarter in Mombasa and Kilifi Counties. In Kilifi County, a total of 92 (54f,38m) HTS providers who included laboratory technologists, nurses and lay counselors
49 Kilifi County Hospital, Mariakani SCH, CPGH, Magongo HC, Jomvu HC, Miritini HC, Mlaleo CDF, Kisauni HC, Tudor SH, Likoni SCH, Kongowea HC, Portreitz SCH, Chaani HC, Kinondo Kwetu, Gongoni HC, Malindi hospital, Mambrui Dispensary and Muyeye HC
USAID AFYA PWANI PROGRESS REPORT JANUARY-MARCH 2018 52
from 3850 sites were trained, whilst in Mombasa County 34(1M,33F) providers from 15 facilities51 were trained in the previous quarter. In the next quarter, Afya Pwani will continue to build on the successes reported this quarter and will work to scale up PNS through trainings, CME, OJTs, follow up mentorship, weekly reporting and supportive supervision to other sites. The Project’s decision to scale up this strategy is as a result of the figures that are shown in Table 18, which capture below shows total PNS performance in March 2018 from 18 sites that provided weekly PNS reports. It should be noted that the slow uptake of PNS uptake is partly because it is a highly skilled approach that requires dedicated trained providers. Providers mostly learn elicitation of sexual partners and ability to convince partners for testing through practice. It is therefore expected that most providers will gain confidence and improve on performance as they practice more of this approach hence a high likelihood of increased identification of positives through PNS. In terms of Table 17 above, it highlights that in March 2018, 178 newly identified index clients participated in PNS eliciting 336 contacts for testing. Most of the elicited were children of index clients, with males above 15 years eliciting more sexual contacts than females of the same age. Known HIV positive contacts accounted for 9% of the elicited (31 against 336), uptake of HTS among elicited was 67% (189 against 281) while HIV positivity among tested was at a high of 10.5% (20 against 189) with a very high linkage of 95% (19 out of 20) which is attributed to disclosure preparation of index client and offering of PNS at ART facilities. This will be scaled up as a best practice for all HTS sites. During the quarter there was also high identification and linkage of males above 15 years (10 and 9 respectively). Afya Pwani will pursue PNS as a strategic approach to identification of men and young people below age 30 years in the remaining part of FY2018. Table 18 PNS HIV testing approach (March 1 - 30, 2018) PNS HIV testing approach (March 1 - 30, 2018) <15 years >15 Females >15 Males Totals total Index screened 23 111 44 178 Contacts elicited 159 82 95 336 Known HIV Positive Contacts 6 12 13 31 Eligible Contacts 127 76 78 281 Contacts Tested 98 52 39 189 Newly Identified Positives 4 6 10 20 Linked to HAART 4 6 9 19
50 Ganze health center, Bamba Sub-County hospital, Marafa health center, Rabai health center, Ngomeni Dispensary, Baricho Dispensary, Dagamra Dispensary, Mambrui Dispensary, Garashi Dispensary, Sabaki Dispensary, Marereni Dispensary, Adu Dispensary, Makanzani Dispensary and Ngomeni Dispensary. Kilifi North Sub-County training was attended by 28 HTS providers (19 Female and 9 Males) from Kilifi county hospital, Gede health center, Chasimba health center, Kizingo health center, Muyeye health center, Matsangoni health center, Vipingo health center, Ngerenya dispensary, Mtondia health center, Konjora dispensary, Mnarani dispensary, Kizingo dispensary, Watamu dispensary and Zowerani dispensary. Kaloleni sub County training was attended by 30 HTS providers (21 Females and 9 Males) from Mariakani sub county hospital, Rabai health center, St Luke hospital, Jibana Sub-County hospital Chalani dispensary, Kizurini dispensary, Kinarani dispensary, Tsangatsini dispensary, Gotani health center and Makombani dispensary 51 Coast Provincial General Hospital, Likoni Sub county hospital, Portreitz Sub-County hospital, Mbuta model health center, Mrima health center, Mlaleo health center, Bamburi health center, Kongowea health center, Tudor sub county hospital, Miritini CDF, Ganjoni health center, Mvita health center, Kisauni dispensary, Jomvu health center and Chaani health center
USAID AFYA PWANI PROGRESS REPORT JANUARY-MARCH 2018 53
c) Reaching children with HTS HTS Performance for <15 Years ,Oct In Q2 6,670 children under 15 years 2017-March 2018. were tested (through different approaches, the main being index Target HTS_TST Number tested client testing), identifying 149 Target HTS_POS Number Positive positives with a total of 150 children
linked to treatment being 101% 16162
linkage rate. The extra child linked 14396
to treatment had been identified in 8081
the previous reporting period but 8081 7229 was linked between January and 7167
March 2018. To enhance
506
276
253 253 149 identification of children, Afya 127 Pwani will prioritize deployment of Q1 Q2 SAPR HTS counselors to pediatric service areas such as OPD and IPD, ANC and Figure 9 HTS Performance for <15 Years- Oct 2017-March CWC to reduce missed 2018. opportunities for pediatric testing and use the HTS screening tool to optimize targeted testing. Index client testing/PNS for children of index adult clients and siblings of HIV positive childrenFigure will 10 also HTS be Performance enhanced by for conducting <15 Years, file Oct reviews 2017 -andMarch those found 2018. without family testing will be followed up for testing. Priority follow up will be given to pregnant mothers,
mothers with children in CWC and unsuppressed adults. i) Reaching adolescents with HTS Five integrated outreaches targeting adolescents and youth were done in the month of January and February in Gede Madukani, Gede stage, Timboni, Dongokundu and Chafisi Villages within Dabaso Location of Kilifi North Sub- County respectively. The services offered included health education on promotion of RH services, safe sex practices for those who are sexually active, HIV prevention and HIV testing was offered to 63 (39M, 24F) youths, one male was identified to be positive, was linked to Gede Health Center and started on treatment. Interventions which proving to work towards increasing access and availability of high quality HTS for adolescents across Afya Pwani supported STRATEGIES TO ENGAGE MEN counties. - Male Champions Program in Kilifi iii) Reaching men with HTS services -Influential men who are role models in the To reach men who cannot access HTS during community are approached to volunteer. regular hours due to work commitments, Afya -Trained on RH/MNCH issues including HTS. Pwani continued with providing extended hours testing that included HIV testing during lunch, after -Advocate for involvement of fellow men in hours and weekends at CPGH, Miritini CDF Health the care of their families. Center, Jomvu Health Center, Portreitz Sub-County Advocate for HTS and accompany those Hospital, Magongo Health Center, Likoni Sub- willing for HTS. County Hospital and Mrima Health Center which are in urban centers and near EPZ factories reaching 366 men, 6 were identified to be positive and were all linked to ART. It should be noted that the yields for these interventions have been low at
USAID AFYA PWANI PROGRESS REPORT JANUARY-MARCH 2018 54
1.7% and moving forward targeting modalities will be employed to the approach to improve the yields. PNS and index client testing will also be scaled up to reach men, especially targeting male dual partners of newly identified PLHIV and of unsuppressed clients. HIV self-testing will also be promoted to reach partners of ANC clients and guidance on referrals for confirmatory testing, counseling and linkage to treatment for those who may test positive provided. The project will also leverage on the success of the male champions initiative implemented by the MNCH program in Kilifi to utilize men to reach fellow men in advocating for HTS. Afya Pwani has also engaged Kaya Elders and the Council of Imams and Preachers of Kenya to provide HTS services to men utilizing cultural/traditional and religious platforms respectively including the uptake of HIV self-testing for those who cannot make to the facilities for HTS. iv) Improving the quality of HIV Testing Services 1. Refresher trainings/CMEs/updates In Q2, Afya Pwani in collaboration with Kilifi county Department of Health services offered updates in new HTS guidelines to 88 (34M, 54F) providers who attended the three PNS trainings in Malindi Sub-County, Kilifi North Sub-County and Kaloleni Sub-County. The HTS updates helped the counselors to better understand the changes in the new HTS guidelines, which include emphasis on the Five Cs of consent, confidentiality, counselling, correct results and connection; implementing target testing to reduce the number of people tested for HIV while still improving on identification and observe the test retest recommendations accuracy. Each of the 88 HTS provider received a copy of the new HIV testing guidelines 2015 (2016 Reprint) and screening tools for infants, children and younger adolescents and adolescents aged above 15 years of age and adults to help improve on identification of HIV positive clients. In Kwale County, 35 (15M, 22F) HTS providers drawn from facilities from all the four sub- counties benefited from a three-days refresher training conducted by the project. The project further supported a CME on Provider Initiated Testing and Counselling (PITC) at Msambweni County Referral Hospital with 45 (32M, 13F) clinical officers benefiting who offer services at OPD, IPD and special clinics such as eye, Ears, Nose and Throat (ENT) and skin and chest clinics etc. This sensitization built the capacity of the health workers to have a high index of suspicion for HIV, offer HTS or make an appropriate effective referral to either the Voluntary Testing and Counselling (VCT) room or the laboratory with proper linkage to the CCC when they receive a positive result. Similarly, CME sessions were also conducted in Moi Voi and Taveta Hospitals in Taita Taveta County reaching 35(7M, 28F) health care workers from the OPD and pediatric wards with the aim of improving the quality of PITC for children. These interventions will also be done in Kwale, Lunga Lunga and Kinango Hospitals in Q3 to increase the uptake and quality of PITC. STRATEGIES TO ENGAGE MEN In Lamu County, 56 (21M, 35F) health care workers from 10 facilities52 were given OJT on the new HTS testing algorithm to 1. Index client testing/PNS ensure HTS services are provided per the standard guideline. In 2. Extended hours testing Mombasa County two CME sessions were conducted to prepare 3. Working with religious and cultural groups the HTS counselors for the rolling out of HIV self-testing once test 4. Male champions kits are supplied. Counselors were also sensitized on the 5. HIV self-testing implementation of target testing strategy where only clients
eligible for testing according to the test-retest recommendations and screening tools are tested. Additionally, strategies to improve on linkage were also discussed which included offering quality HTS services, treatment literacy and follow up of
52 Faza Health Center, Kizingitini Dispensary, Shella Dispensary, Lamu Hospital, Mokowe Health center, Hindi Dispensary, Muhamarani Dispensary, Hongwe Catholic dispensary, Mpeketoni Hospital and Witu Health Center.
USAID AFYA PWANI PROGRESS REPORT JANUARY-MARCH 2018 55
unlinked clients beyond three months after testing. Thirteen HTS providers from Mombasa (all female) from 11 HVFs53 attended the CMEs held at the Afya Pwani offices. 2. Proficiency testing (PT) Afya Pwani has continued to partner with the CHMTs to ensure that HTS providers undergo regular quality assurance practices such as PT. The project has supported the distribution of PT panels and PT results to HTS providers as well corrective OJTs to those who failed the PT. In the reporting period, Malindi and Kaloleni SCMLTs were supported to offer OJT for corrective actions to HTS providers who had failed round 16 proficiency Test. The OJT was on the on the testing algorithm, the technique and timing of HTS. Facilities which had PT failures in the two sub-counties were Mariakani Hospital, Gotani Health Center, Tsangatsini Dispensary, Shangia Dispensary, Kinarani Dispensary, Baolala Dispensary, Malindi Hospital, Sabaki Dispensary, Jilore Dispensary, Kakuyuni Dispensary and Shakahola Dispensary. Seventeen (9M, 8F) HTS providers were reached during the OJT/Mentorship exercise. In Taita Taveta County, during the Laboratory staff meetings in the four sub-counties of Voi, Wundanyi, Mwatate and Taveta, the 75 (47M, 28F) laboratory staff who attended were trained on the job on PT so that they can share the information and knowledge acquired with other facility staffs. 3. Counselor support supervision Afya Pwani project also supported and facilitated counselor support supervision for 48 (13M, 35F) HTS providers which took place once a month for three months. In Kilifi County, 21 counselor supervision sessions were conducted reaching 249 (164M, 95F) HTS counselors while 3 counselor group supervision meetings were held in Taveta, Voi and Wundanyi Sub-Counties of Taita Taveta County reaching 43 (13M, 30F) HTS services providers. In Kwale County 12 HTS providers (4M, 8F) attended counselor supervision in the period. The group counselor supervision sessions focused on addressing burn-out and psychosocial issues resulting from HTS engagement. The sessions foster efficacy, efficiency, personal and professional growth and development. Through supervision, counselors can deal with their own issues like; low self-esteem, poor interpersonal relationship either at work, home/family, and transference issues which can distort the therapeutic relationship. Supervision also helps counselors overcome the physical, mental and emotional exhaustion which accumulates counseling clients who come to the sessions with different emotional issues. The supervisees also gain knowledge, updates and skills which are necessary in establishing professional counseling sessions with their clients. CME sessions were held with clinical staff at the target health facilities to provide diagnostic referrals of symptomatic patients for HTS. 4. On the job training/Mentorship: In Q2, Afya Pwani staff offered mentorship to nine health facilities54 in Mombasa addressing gaps in HTS optimization, poor linkage, compliance with national algorithm and proper documentation. HTS providers were guided on test re-test recommendations and eligibility screening for the general population, key populations (KPs), expectant mothers and negative partner in discordant relationships. Counsellors were encouraged to provide testing in all facility service entry points, use job aids to screen for eligibility of clients for HIV testing, use of linkage tools for effective linkage of all testing positive and improving partner notification services as part of efforts to increase access and availability of high quality HTS services for clients. 5. RTK Commodities During the quarter under review, Afya Pwani also provided technical support to the supported counties to do correct reporting of RTKs consumption into DHIS2, quantification and ordering. Through the support, the report
53 CPGH, Portreitz Sub-County Hospital, Tudor SCH, Likoni SCH, Kongowea HC, Mlaleo HC, Chaani HC, Jomvu HC, Kisauni HC, Miritini HC and Chaani HC 54 Coast provincial general hospital (CPGH), Kongowea Health Center, Mvita Health Center, Miritini Health Center, and Stella Marris Clinic, Mlaleo Health Center, Mary Immaculate Hospital, Mwakirunge Dispensary and Kiembeni Dispensary
USAID AFYA PWANI PROGRESS REPORT JANUARY-MARCH 2018 56
rates for RTKs have been above 90% in all the counties. Figure 11 below, provides more information on the RTK reporting rates for this quarter:
Figure 11 Afya Pwani Counties Q2 HIV RTK Reporting Rates
Of further note, this quarter Afya Pwani supported RTK allocation exercises by providing TA and the logistical support for meetings where health service providers were capacity built to be able to ensure that Afya Pwani sites do not experience RTK commodities stock outs. During the quarter, a Laboratory coordinators meeting was supported in Kilifi with 18 (14M, 4F) laboratory managers participating. Lastly, this quarter, the project has also redistributed 12,000 number of RTKs to facilities that were running out of RTKs to avoid missed opportunities for HTS. Lessons learnt 1. Regular mentorship and supervision visits in health facilities to update health workers on HTS guidelines has helped in scaling up HTS and linkage of those tested HIV positive. 2. Monthly meetings by health workers to discuss issues of scaling up HTS and improve on linkage, has ensured most HIV positive clients are enrolled in CCC. 3. Physical escort of HIV positive individuals to the CCC for direct linkage to care and enrollment of HIV positive patients before discharge has proved to be a good practice which ensures that no missed opportunities in enrolling them to CCC. 4. When one is referring a client to another facility, one should be sensitive to the patient age, cultural and lifestyle issues to refer effectively. 5. PNS is reaching more men with a higher yield in identification of men living with HIV. 6. Having a dedicated PNS counselor, provision of transport, telephone and airtime is key in PNS implementation. 7. HTS services are sustained when the hospital managers and administrators are involved in planning and implementation of PITC services.
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8. Use of the new HTS register has made follow up of unlinked clients easy and the documentation is done in the same registers reducing paper work for service providers.
Output 1.5: Tuberculosis/HIV Co-infection Services a) Improved coverage for TB screening among PLHIV i) Active case finding: To enhance case detection, Afya Pwani has been carrying out mentorship, so that health providers refer clients who screened positive for TB for GeneXpert testing and those found negative are provided with Isoniazid Preventive Therapy (IPT). In addition, the use of the presumptive register was also emphasized to the health care providers. S/CHMTs were supported to conduct a validation exercise on correcting IPT numbers in the DHIS 2 from the supported facilities. In Mombasa, Kilifi and Lamu Counties, Afya Pwani continued to focus on increasing access to and utilization of TB/HIV health services and improving coverage of TB screening among PLHIV. During the quarter, the project supported mentorship to 71 (27M, 44F) healthcare workers in 22 health facilities55 on TB screening at CCC using the ICF cards for both adult and pediatrics and ensuring proper documentation is done. Through this mentorship, the project teams emphasized that clients who screened positive for TB should have samples taken for GeneXpert testing and those found negative are provided with IPT. In addition, the use of the presumptive register was also emphasized to the health care providers. S/CHMTs were supported to conduct a validation exercise on correcting IPT numbers in the DHIS 2 from the supported facilities.
This quarter, Afya Pwani also focused on scaling up active case finding in HVFs to identify TB clients among the patients served in those facilities. More specifically, health care workers supported to conduct active case finding at the facility at Chaani Health Center, Magongo Health Center, Malindi Hospital, Mariakani Hospital, Kilifi County Referral Hospital, Mtwapa Health Center and Kwale Sub-County Hospital. Additionally, the capacity of 42(19M, 23F) service providers comprising of clinical officers, laboratory technologists, public health officers (PHOs) and community health assistants to conduct active case finding was enhanced through mentorship.
Moreover, the project also leveraged on activities during the World TB day to provide education on TB prevention and management to the community working with CHVS in order accelerate diagnosis. More specifically, Afya Pwani supported CHVs to screen 120 suspected clients for TB, 81 samples for GeneXpert collected, 3 were positive TB, 11 had chest X-ray done with 2 having features suggestive of TB, with all the 5 being started on anti-TB and were tested for HIV. Active case finding was also done in work places (Panal Freighters, Mega Garments, Prime fuels, Bamburi Cement, Huduma Center and Voyager Hotel) in Mombasa county targeting the workers at an increased risk reaching 898 people, 29 had abnormal chest x-rays, 169 GeneXpert samples were harvested with 2 being positive. A total of 16 clients were started on anti-TBs and 92 tested for HIV, 4 were HIV positive who were linked to treatment.
55 Likoni, Chaani, Jomvu, Portreitz, Kisauni, Bamburi, Magongo, Bokole, Faza, Kizingitini, Shella, Lamu Hospital, Mokowe, Hindi, Muhamarani, Hongwe Catholic, Mpeketoni Hospital, Witu, Malindi Hospital, Mariakani Hospital, Kilifi County Referral Hospital and Mtwapa Health Center
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ii) GeneXpert Utilization: This quarter, the project continued to support logistics of sputum collection and transportation to Central Reference lab (CRL) and link to gene expert machines through the Motorbike riders in Kwale, Kilifi and Mombasa. For Lamu and Taita Taveta, transport Table 19 GeneXpert utilization Jan-Mar 2018 reimbursement is done for GeneXpert utilization Jan-Mar 2018 specimen transportation to County Testing Facility Total Tested MTB+ RS MTB+ RR the receiving and Testing Kilifi Malindi Hospital 1046 80 0 Labs. Facilities are now able Kilifi Hospital 506 47 2 to access GeneXpert results Taita Taveta Moi Voi CRH 2017 114 0 in a timely manner which Taveta SCH 528 27 0 has improved in the Mombasa Likoni SCH 216 42 1 management of TB clients. Coast PGH 1861 352 11 To increase the utilization of Port Reitz SCH. 112 16 0 GeneXpert tests, 4 Shimo La Tewa H/C 1098 163 6 sensitization meetings were Mtongwe H/C 141 14 1 conducted reaching 55 Kwale Msambweni Hospital 217 16 0 (12M, 34F) service providers Total Tested 7742 871 21 from Mariakani Hospital,
Moi Voi Hospital, Taveta Hospital and Kilifi Hospital. To ensure continuity of services at Malindi and Kilifi hospitals, Afya Pwani fitted in new air conditioners to the labs to enable the GeneXpert machines to function well. In the quarter, as shown in Table 19 above, 7,742 GeneXpert test were done in supported counties, 871 were found to have Rifampicin sensitive TB while 21 had Rifampicin resistance. All the patients were started appropriate treatment in the quarter.
iii) IPT among PLHIV Between January and March 2018, project staff worked with health service providers to conduct file reviews following reports that not sites were providing IPT for pregnant mothers as recommended. To address this gap mentorship for 95 (61M, 34F) service providers from Table 20 IPT Uptake Jan- March 2018 45 facilities56 on IPT administration IPT Uptake Jan- March 2018 for all eligible pregnant and Male Female Total breastfeeding women who are HIV County < 15 Yrs. > 15Yrs < 15 Yrs. > 15Yrs positive and screening negative for Mombasa 17 146 48 259 470 TB to increase uptake of IPT Kilifi 18 126 8 172 324 amongst this vulnerable groups. At Malindi Hospital and Gongoni Kwale 24 46 6 74 149 Health Center CME sessions on IPT Taita Taveta 5 89 9 263 366 were conducted this quarter Lamu 65 18 3 35 121 reaching a total of 35 (15M, 20F). Total 64 425 74 803 1420 Support supervision on IPT was
56 Kisauni, Likoni Catholic, Chaani, Portreitz, Kilifi Hospital, Malindi Hospital ,Nyache HC, Mbale HC, Kishushe Disp, Mgange Nyika HC, Mgange Dawida HC, Werugha HC, Wesu SCH, Wundanyi SCH, Maktau HC, Kwamnengwa Disp, Mwashuma Disp, Bura HC, Mwatate SCH, Manoa Disp, Dembwa Disp, Mpizinyi HC, Kighangachinyi Disp, Dawson Mwanyumba Disp, Modambogho Disp, Shelemba Disp, Msau Disp, Mwambirwa SCH, Kighombo Disp, Maungu HC, Marungu HC, Miasenyi Disp, Kasigau HC, Buguta HC, Sagalla HC, Ndovu HC, Tausa HC, Ndome Disp, Ghazi Disp and Moi CRH, Challa Disp, Njukini HC, Mahandakini Disp, St. Joseph Chumvini, Rekeke HC, Mata Disp, Ndilidau Disp, Kitobo Disp, Kimorigo Disp, Eldoro Disp, Kiwalwa Disp and Taveta SCH.
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conducted in Lamu, Kilifi, Mombasa and Taita Taveta counties symptoms reaching 137 (56M, 81F) health care workers from 30 facilities57. Among the action points from the supervisions included line listing of PLHIV eligible for IPT, calling them for uptake and the IPT tools to fill in data. To correct incomplete and inaccurate IPT data that has been reported in DHIS 2, Afya Pwani project staff are working with the SCASCOs to conduct data validation and upload correct numbers in DHIS2. iv) HIV/TB integration and uptake of ART among TB/HIV co-infected patients: The project has continued to prioritize HIV testing for TB clients to increase on both identification of PLHIV as well as ensure good outcomes for the clients. Ninety-two percent (92%) of TB clients in the five supported counties were tested for HIV in the 2nd quarter with uptakes of 100% ,99% and 98% in Lamu, Kilifi and Taita Taveta counties respectively. The uptake in Mombasa county was low at 90% (536 out 593), with 57 TB patients not tested for HIV in the reporting period having been followed up and tested later. The co-infection rates ranged from low of 16% in Lamu to high of 34% in Taita Taveta. In Lamu County, all the HIV/TB co-infected clients were started on ART, one client died at Moi Voi County Referral Hospital in Taita-Taveta before starting ART. Five clients with severe disease in Kilifi County were started on ART beyond the reporting months ART, while 13 clients in Mombasa county were not started on ART including those with advanced disease that HIV treatment was delayed. To avoid missed opportunities for both HTS and ART for eligible TB clients, Afya Pwani has identified the facilities with gaps in quality of care and prioritized customized capacity building interventions for them in the 3rd quarter. In the concluded, quarter, to improve the uptake of ART among TB/HIV coinfected clients, the project supported 11 CME
57 Faza Health Center, Kizingitini Dispensary, Shella Dispensary, Lamu Hospital, Mokowe Health center, Hindi Dispensary, Muhamarani Dispensary, Hongwe Catholic dispensary, Mpeketoni Hospital, Witu Health Center, Gongoni Health Center, Marikebuni Dispensary, Chasimba Health Center, Mariakani Hospital, Kilifi Hospital, Gede Health Center, Matsangoni Dispensary, Mgange Dawida HC, Werugha HC, Wesu SCH, Wundanyi SCH, Maktau HC, Kwamnengwa Disp, Mwashuma Disp, Bura HC, Mwatate SCH, Kisauni, Likoni Catholic, Chaani and Portreitz.
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Table 21 TB/HIV Integration Jan – Mar 2018 TB/HIV Integration Jan – Mar 2018 County No. of No. % No. HIV % No. % TB tested tested positive TB/HIV started Linked Clients for HIV for HIV co- on ART to ART infected Taita 134 131* 98% 46 34% 45¥ 98% Taveta Mombasa 593 536 90% 129 24% 116 90% Kilifi µ 574 567 99% 148 26% 148 100% Kwale€ 262 251 96% 61 25% 55 89% Lamu 74 74 100% 12 16% 12 100% Afya Pwani 1637 1559 96% 396 23% 376 95%
*1 male from Bura HC declined to be tested, 1 male from Kitobo Dispensary declined to be tested, 1male child from Werugha HC was not tested as mother refused to give consent saying will be tested when schools close.
¥1 male from Moi CRH died before starting ART.
µ 2 died shortly after TB diagnosis, 5 were missed opportunities for HIV testing.
€ 1 declined HTS, 4 on going counselling, 6 missed opportunities. Of the positive, 1 died before starting ART, 4 were effectively referred to start ART from nearer facilities while 1 declined ART, still being followed up with counselling. sessions on TB/HIV at Lunga Lunga, Kikoneni, and Diani Health center, Tiwi Health Center, Kwale Hospital, Kinango Hospital, Samburu Health center, Mkongani Health Center, Mazeras HC, Msambweni and Vitsangalaweni Dispensary reaching 330 (212M, 118F) service providers. To improve the uptake of ART among TB/HIV coinfected clients, the project supported 3 CME sessions on TB/HIV at Wesu Sub-County Hospital, Wundanyi Sub-County Hospital and Maungu Health Center reaching 45 (13M,32F). During the quarter, Afya Pwani continued to support activities to ensure that there is strengthening and integration of HIV/TB services. A HIV/TB Consultative forum was supported in Malindi Sub-County to carry out joint TB/HIV planning, review HIV/TB performance and develop strategies to accelerate intensified TB case finding and active case finding, scaling up of IPT uptake and ensure all TB patients are tested for HIV. Sixty (60) service providers (24M,36F) from 16 facilities58 participated. In Mombasa County, Bokole Health Center and Portreitz Hospital were supported to conduct CME sessions on TB/HIV integration reaching 46(18M, 38F) participants. The project also mentored 48 service providers from Chaani, Kisauni, Mvita, Likoni, Magongo, Kilifi Hospital, Gede Health Center, Mtwapa Health Center, Mariakani Hospital and Rabai Health Center on HIV testing of HIV and linking the clients who test positive to ART.
58 Malindi Hospital, Muyeye Health Center, Sabaki Dispensary, GK Prison Dispensary, Ganda Dispensary, Mshongoleni Dispensary, Gahaleni Dispensary, Madunguni Dispensary, M’Mangani Dispensary, Kakuyuni Dispensary, Jilore Dispensary, Kakoneni, Baolala Dispensary, Chakama Dispensary, Bombi Dispensary and Shakahola Dispensary.
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b) Surveillance for Multidrug Resistant (MDR)-TB. Afya Pwani supported MDR Clinical review meetings for Zonal TB Coordinators and clinicians from 25 facilities59 with MDR patients to meet and discuss the progress of the patients on treatment. During these meetings, clinical staff reviewed patients, shared experiences and challenges on case management and uptake of GeneXpert tests. Table 22 Drug Resistant TB Patients as at March 2018 Drug Resistant TB Patients as at March 2018 County Facility # of DR Treatment Status clients Taita Taveta Wundanyi Sub-County Hospital 3 Continuation phase Mbale Health Center 1 Continuation phase Kajire Dispensary 1 Continuation phase Moi County Referral Hospital 1 Continuation phase Kilifi Chalani Dispensary 1 Continuation phase Chamari Dispensary 1 Continuation phase Gotani Dispensary 3 Continuation phase Jambo Clinic 1 Continuation phase Kadzinuni Dispensary 1 Intensive phase Malindi Sub-County Hospital 2 Continuation phase Mariakani Sub-County Hospital 3 2 intensive phases, 1 Continuation phase Matsangoni Health Center 3 Continuation phase Mjanaheri Dispensary 1 Continuation phase Mtwapa Health Center 1 Continuation phase The Omar project 1 Continuation phase Viragoni Dispensary 1 Intensive phase Kwale Samburu Health Center 1 Intensive phase MacKinnon Rd Dispensary 3 Intensive phase Vitsangalaweni Dispensary 1 Continuation phase Tiwi Health Centre 1 Continuation phase Kafuduni Dispensary 1 Intensive phase Mombasa Mlaleo Health Centre 2 On treatment Kisauni Health Center 1 On treatment Jomvu Health Center 1 On treatment Total 36
Drug resistant (DRTB) surveillance in Kwale, Kilifi, Taita Taveta and Lamu Counties is very low, evident from the low GeneXpert utilization in the testing labs of these counties. Afya Pwani continues to sensitize health workers to increase screening for DRTB and increase referrals for GeneXpert testing, 143 (65M,
59 Matsangoni Health Center, Kilifi Hospital, Gede HC and Kadzinuni Dispensary Mariakani Hospital, Chalani Dispensary, Gotani Health Center, Chamari Dispensary, Marikebuni Dispensary, Mjanaheri Dispensary, Mtwapa HC, Malindi Hospital and Omari Project Drop in Center, Kongowea, Portreitz, Kisauni Health Center, Likoni Hospital, CPGH, Tudor Hospital and Magongo Health Center, Mackinnon Road, Kafuduni, Samburu, Tiwi and Vitsangalaweni
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78F) health care workers from the rural facilities and the SCHMTs were sensitized in Kilifi, Kwale and Taita Taveta Counties. These sensitization sessions covered among others the definition of DRTB, classification, epidemiology, treatment and the eligibility criteria for GeneXpert testing. These efforts ensure early diagnosis, prompt screening and management of MDR TB that will reduce the mortality and morbidity for PLHIV with MDR TB co-morbidity. Below is a list of facilities with MDR clients on treatment in project supported sites. Lessons learnt 1. MDR TB clinical review meeting are effective in providing quality care to MDR patients since views and skills of several health care workers are incorporated into the management of the client as opposed to a single clinician. 2. Collaboration with both SCASCOs and SCMLTs in joint planning and implementation of the TB/HIV activities is paramount in success of the activities. 3. Involving the SCASCOs in doing IPT data validation was found to be effective in Mombasa county. The same strategy is in use the other counties in quarter 3. 4. Frequent health talks at the waiting bays helps with the uptake of active case finding to identify TB suspects. SUB-PURPOSE 2: INCREASED ACCESS AND UTILIZATION OF FOCUSED MNCH AND FP, WASH AND NUTRITION
Output 2.1: Maternal, Newborn and Health services a) Address sociocultural barriers to utilization of Maternal and Neonatal Health (MNH) services i) Engaging opinion leaders as agents of change: Cognizant of the retrogressive socio-cultural practices that impede access and uptake of vital MNCH services in Kilifi County, Afya Pwani has consistently worked with opinion leaders as agents of change to improve uptake of these services. During the reporting period, the project focused on building the capacity of these opinion leaders to be able to disseminate positive health information on the importance of MNH services to community members. HERAF, one of the project’s grantees supported and facilitated three sensitization meetings targeting leaders from Mtondia, Zowerani and Ganda areas. Participants were drawn from local administration, village elders, Nyumba- Kumi60 leaders, religious leaders, traditional doctors, CHVs, TBAs, Persons with Different Abilities (PWDAs) women and youth representatives. A total of 96 (45M, 51F) opinion leaders were engaged. The leaders were taken through a guided discussion to identify harmful social practices that hinder women from utilizing maternal health services where some of the practices identified include but are not limited to: Compromised decision-making power of women because of the “Mwenye Syndrome”, myths, misconceptions and reliance on traditional doctors over seeking hospital services. During these meetings, they were also re-oriented on services that are offered to expectant women, nursing mothers and their young babies in health facilities. Emphasis was laid on the role of opinion leaders in empowering communities on the importance of starting ANC early, and ensuring they visit the facility at least four times during their pregnancy. They were also taken through the advantages of facility-based deliveries over home deliveries and the need for healthy timing and spacing of pregnancy. The opinion leaders were thereafter tasked to utilize the existing social structures and forums to disseminate MNCH information and advocate for uptake of MNCH services. During the quarter under review, Afya Pwani also supported and facilitated a review meeting for opinion leaders at Chasimba Dispensary, where they shared best
60 A community policing concept, established to enhance security at village level. It is made of clusters of 10 houses, located next to each other, each cluster has clear leadership structures.
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practices, challenges encountered in their work and came up with possible solutions to the challenges. Engaging the leaders in advocating for ANC uptake and skilled deliveries has progressively resulted in increased acceptability of MNCH services. ii) Targeted community dialogue meetings with expectant mothers: Guided by previous engagements with community members where the project team were able to identify harmful practices carried out by expectant women (such as use of traditional medicines as pain killers to calm labor pains), Afya Pwani grantees conducted eight community dialogue meetings, targeting expectant women in Takaungu, Cowdry, Jilore, Mjanaheri and Madunguni Dispensaries to address and dispel these retrogressive sociocultural practices that were curtailing uptake of health services. These dialogue meetings have and will continue to play a pivotal role in disseminating positive health information on the risks of utilizing traditional medicine during pregnancy as well as giving birth at home. The project team also utilized these forums to enhance knowledge of women on MNCH services available, their importance and where they can be accessed. During the meetings, the women were sensitized on the benefits of attending at least 4 ANC clinics, the advantage of facility based delivery over home delivery and the need to ensure their children are fully immunized. The participants acknowledged the importance of these services, and appreciated the new knowledge gained, promising to honor their ANC schedules and finally delivering in the health facilities. A total of 292 women were reached with information and referred for ANC services; numbers that project staff will work on building on in the next quarter as part of the Project’s commitment to increasing access and availability of high quality MNCH services in Kilifi County. b) Increase demand creation for MNH services i) Scaling up maternity open days: Poor health service provider attitudes, high-cost of ANC and delivery services, inadequate knowledge on importance of early/completion of ANC attendance and facility delivery coupled with myths and misconceptions about the procedures undertaken to assist women during childbirth e.g. Episiotomies and caesarian sections, negatively influence women’s decisions to seek ANC, delivery and PNC services in health facilities. These factors have contributed to low ANC uptake often resulting in birth complications and even deaths. In a bid to avert this, Afya Pwani initiated the maternity open days, a targeted group dialogue approach that brings together expectant women, creating a safe space where women can discuss their fears and apprehensions about childbirth with health service providers freely, as well as provide feedback and suggest areas of improvement the facility teams. During these maternity open days, clients are also able to discuss what happens in a maternity unit providing a platform for health care workers to address any fears that they may have. During this reporting period (Jan-March), Afya Pwani supported and conducted 15 maternity open days in select HVFs61 in Magarini, Kilifi South, Kilifi North, Ganze, and Rabai Sub-Counties; this is an increase from the 5 done in the previous quarter. A total of 935, 1st ANC clients were reached during these open days. Project staff have received extensive positive feedback about this intervention and facility management have also been very open to responding to the complaints raised, especially with regard to poor attitudes among health care workers. Additionally, the Afya Pwani supported maternity days have also provided an opportunity for health service providers to reassure clients of improved quality services, a gesture which has seen an increase in 4 ANC attendance and hospital deliveries.
61 Marafa-68, Marikebuni-40, Garashi-87, Marereni-33, Gongoni-63, Kizingo-86, Pingilikani-52, Makanzani 69, Matsangoni-64, KCH-45, Chasimba-64, Takaungu-56, Vitengeni-59. Jibana-68, Malindi Hospital-81,
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The maternity open days have proven effective in mobilizing 1st ANC clients and working to address the issue of late initiation to ANC (the main reason for low 4th ANC attendance as most of the clients start ANC very late). The project also utilized the maternity open days to create awareness and register the expectant women to the Linda Mama Initiative62. This has helped address the challenge on lack of money for ANC profiling and delivery which has been a barrier to accessing ANC services. Participants of a maternity open day touring the maternity unit In the next quarter, Afya Pwani will deploy additional strategies to increase MNCH uptake including political engagement for mobilization, awareness creation and registration for Linda Mama. ii) Increased support and scaling- up Mama group sessions: During the quarter under review, Afya Pwani built on the success of the Mama Group concept and leveraged on the ANC clients mobilized during the maternity open days, to establish additional 15 Mama Groups63 and 5 Binti Kwa Binti64 groups, up from 5 in the October-December 2017; subsequently a total of 935 women are now being followed through the ANC Linda Mama registration during a maternity open day cascade. Of note is that these groups have successfully served as peer
6262 A government funded health scheme that ensures pregnant women and infants have access to quality and affordable health services. For more information on the Linda Mama Initiative, please the following link: http://www.nhif.or.ke/healthinsurance/lindamamaServices 63 For clients above 24 years 64 For clients below 24 years
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support networks for pregnant women encouraging each other to complete the ANC visits, deliver within the facility and attend Post-Natal Care (PNC) services. This initiative has improved the women’s health seeking behavior and improved uptake of 2nd, 3rd and 4th ANC services, and subsequently PNC, FP and Immunization. Outside the health facility, the members of these groups advocate for early initiation to ANC services for pregnant mothers, facility based deliveries and child immunization. Afya Pwani supports and facilitates the group’s monthly meetings, where, clients get the routine ANC services alongside a comprehensive package of information as requested by themselves. Additionally, peer to peer education sessions are conducted, where they share experiences and bond. A good outcome of this initiative, is that the Mama groups have started a Voluntary Savings and Loaning Association (VSLA) as part of strengthening economic empowerment and livelihoods for the group members and their families. Afya Pwani is planning to bring entrepreneurs to train the women on income generating activities and entrepreneurship.
By design, the Mama groups are tailored to encourage pregnant women to look forward to meeting again because of the meaningful engagement they are involved in during the sessions. The bonds established by the group members Clients attend Afya Pwani supported Maternity Open Days have also encouraged retention, as the group members keep reminding each other of their next appointment. The women are retained in these groups up to six months post-delivery to foster exclusive breast feeding, ensure the infants and their mothers receive PNC services, FP information and immunization services. iii) Working with CHVs and TBAs as birth companions: Aware of the respect and value accorded to the TBAs by community members, the project has purposively continued engaging the TBAs together with CHVs to identify and refer expectant mothers to get skilled services. Further, during the quarter under review, project supported three sensitization meetings for CHVs and TBAs attached at Cowdry, Takaungu and Kakuyuni Dispensaries respectively, as part of efforts to enhance their ability to disseminate information to community members; a total of 66 CHVs and 15 TBAs benefited from these sensitization sessions. Part of these efforts have resulted in the increase of ANC visits, deliveries and PNC as illustrated in the section below:
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c) Improve access to MNH services by optimizing functional existing County health services i) Maternal health services and outcomes: ANC services: During this reporting period, Afya Pwani project reached 13,891 new clients with FANC services, an increase of 4,718 clients, compared to 9,173 who were reached in the previous quarter. This progressive increase is attributed to the concerted efforts to waive ANC profiling fees (which has become an attraction) during maternity open days, improved engagement of CHVs and TBAs and scaling up Mama groups (a concept that has proven very successful). Project staff also supported the implementation of a target Women with disability receive services at Karisa based approach during mobilization whereby- Maitha Stadium on 26th January 2018. each project supported CHV is expected to mobilize at least 10 - 1st ANC clients, as part of efforts to increase access and availability of high quality health services. The project has also recorded significant increases in clients attending 4 ANC clinics during this reporting period, an indication of successful retention of clients mobilized during maternity open days in the ANC clinic through mama and Binti kwa Binti groups. These interventions have encouraged and promoted a change of attitude among community members due to joint efforts by the project and health providers to sensitize communities, improve relationships between health providers and their clients and the mama group sessions. This reporting period 5,611 clients received at least 4 ANC services, compared to 1,501 reached in the previous quarter. Cognizant that some of People with Different Abilities (PWDA) have a set of distinct health needs and requirements, Afya Pwani supported and facilitated sensitization sessions for health care workers on the provision of MNH services for PWDA was also conducted. This was coupled by an outreach targeting PWDA at KCH65 which also took place this quarter, where a total of 38 women were reached with MNCH/FP information and services including ANC services, Skilled delivery, PNC, immunization and FP. The project will continue supporting initiatives such as the one above as it works to fulfill its mandate to increase access and availability of high quality health services. Figure 12 below shows the trends in 1st and 4th ANC attendance over time.
65 Kilifi County Referral Hospital
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Figure 12 Trends for uptake of 1st and 4th ANC (Jan-Mar 2017) – (Jan-Mar 2018)
Figure 12 above illustrates an improvement in some of the key indicators during the quarter under review; an indication that the strategies being employed by the project are leading towards an improvement of maternal outcomes. Skilled birth attendance: In the period (Apr-Jun), a total of 8,734 skilled deliveries were conducted in the project supported facilities across the seven sub-counties in Kilifi, an increase of 4,716 deliveries as compared to the 4,018 deliveries in quarter one as shown in Figure 13 below:
Figure 13 Trends for Skilled deliveries against live births from Jan 2017-Jan 2018
As indicated in Figure 13, 97% (8,444) of these deliveries resulted in live births, while 290 were still births (123 fresh still births [FSB] and 118 macerated stillbirths [MSB]). To address the issue, the project is strengthening the Maternal and Perinatal Death Surveillance Reports (MPDSR) teams to ensure improved documentation and that all incidences are aptly captured in line with the national tools and guidelines.
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Lack and late ANC attendance by some clients, delays in accessing skilled delivery services at the facility, inadequate knowledge among health care providers in partograph use and newborn care, were the main reasons for the high number of still births. To address these issues, in this quarter under review, Afya Pwani will conduct training for health service providers on Kangaroo Mother Care (KMC), Essential Newborn care, and FANC, and supported CMEs on partograph use, and facility data and performance reviews, which is expected to reduce this deaths in the next quarter.
Maternal and neonatal deaths: Twelve (12) maternal deaths occurred and all deaths have been audited to establish causes and remedial measures identified to reduce such deaths in future. The main causes of maternal death were Ante-partum Hemorrhage (APH), Post-Partum Hemorrhage (PPH), Ruptured uterus and Pre-Eclamptic Toxemia (PET)/Eclampsia. Further, a total of 55 neonatal deaths were also recorded during the quarter; figures which are partly attributable to the fact that a lot of women in Kilifi are still not accessing and/or completing 4 ANC services as recommended; complications from home deliveries, as well as unavailability of ANC lab investigations to help detect early and manage pregnancy related conditions e.g. Anemia. Lack of blood has also been cited as major contributor to maternal and neonatal deaths. Other reasons include, improved documentation of the same, increased hospital delivery hence deaths notified, unlike before where deaths went unnoticed and unreported. Afya Pwani strives to mitigate these deaths through maternity open days and frequent feedback sessions to the county department of health to address community and health systems issues that contribute to the deaths. Figure 14 below shows trends in maternal deaths, stillbirths and Neonatal deaths.
Figure 14 Trends in Maternal and Neonatal Outcomes Oct 2017-Mar 2018
Integrated outreaches: Afya Pwani project has continued supporting integrated outreaches to address inequities in access to MNCH services and commodities, usually brought about by distance to health
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facilities, rough terrains and occasional flooding. The project supported three integrated outreaches in three facilities66. Table 23 below shows the number of ANC clients seen during in reaches, outreaches and maternity open days:
Table 23: No of clients reached during outreaches and maternity open days Item Outreaches Maternity open days Total New ANC clients 68 935 1003 Revisit clients 112 428 54067 Total 180 1363 1543
In the coming quarter, the Project will continue to support targeted integrated outreaches after re- mapping and use of target allocation for MNH services, for hard to reach areas. Maternity shelters: Building on its commitment last quarter to focus efforts on supporting maternity shelters in the County, Afya Pwani continued to actively engage the Kilifi CHMT to champion the revitalization of the Kilifi County and Malindi Sub-County Hospital maternity shelter. The Malindi Hospital maternity shelter is now operational, though not at full scale due to staffing challenges. Negotiations and lobbying efforts are still ongoing on how to kick start the maternity shelter at Kilifi County Hospital.
Lab networking for ANC profile: Lack of ANC profiling is a barrier in the uptake of MNCH services. Most facilities in Kilifi County lack laboratory reagents. This situation has often resulted in missed opportunities in ANC uptake and unnecessary referrals. To address this challenge, Afya Pwani project advocated for procurement of laboratory reagents for the HVFs to the CHMT. The project has also negotiated for a waiver for the ANC profiling charges especially during the maternity open days making the services more affordable and accessible and has increased uptake of ANC services. d) Strengthened health facility capacity to offer BEmONC/ CEmONC services Continuous Medical Education Health workers filling a partograph during a CME at During the reporting period, the project Rabai HC supported 16 CME sessions reaching a total of 380 health workers on MNCH in 9 facilities68. Discussion topics were selected depending on the challenges identified in MNCH/FP service areas, which included but not limited to: Proper use of Partograph, Newborn resuscitation, management of PET, management of APH & PPH, Active Management of Third
66 KCH in KN sub-county, Marikebuni and Marikebuni in Magarini SC 67 Of these revisits, 90 were 4th ANC visits (28 reached during outreaches and 62 during maternity open days)
68 Cowdry-1(9HCPs), Rabai 3(61 HCPs), Malindi-1(44), Gede-2(51), Gongoni-2(24), KCH-3(98), Marafa-2(37), Matsangoni- 1(32), Mariakani 1 (24).
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Stage Labor (AMSTL) and use of Oxytocin. The CME sessions are intended to build health service provider skills and confidence in MNCH service provision to improve maternal and neonatal outcomes. The project also facilitated expertise referral by Basic Emergency Obstetric and Neonatal Care (BEmONC) trainers to go to health facilities to capacity build staff in these facilities with no trainers. e) Enhance provision of quality MNH services
Supportive supervision and mentorship visits to strengthen quality of MNH services: Working with the S/CHMTs, the Afya Pwani project has continued to facilitate supportive supervision and the targeted joint RH support supervision aimed at improving health providers performance. These supervisory visits are an opportunity to improve knowledge and skills of health providers and ensuring that vital MNH procedures are being implemented as per National guidelines. The program supported 9 support supervisory visits (5 routine and 4 targeted RH joint support supervision (in both private and public facilities) for 10 facilities in Kilifi South, 10 in Kilifi North, 10 in Ganze, 8 in Kaloleni and 12 in Magarini, resulting in a total of 123 health care workers mentored on proper partograph use, PNC documentation, newborn resuscitation and infection prevention. During the supervisory visits, the following challenges were identified and corrective action plans developed. In quarter 3, the program will continue to facilitate the County and sub-county teams to conduct support supervision for quality service delivery, and targeted mentorship sessions.
Data and performance review meetings: During the quarter under review, Afya Pwani supported seven data and performance review meetings in seven facilities69 reaching 97 health workers in Magarini (63) and Kilifi North (34). Some of the issues discussed included: Poor health service providers attitudes, cost of services, long waiting time, inadequate client knowledge on importance of ANC attendance and hospital deliveries, poor documentation and inability to utilize data for decision making with the following remedial interventions. In the next quarter, the team will support and conduct client exit interviews to assess quality of services, conduct regular staff meetings to discuss public relations issues, motivate clients for ANC and delivery services, facility process mapping and reduction of waiting time, mapping out of pregnant women in catchment populations, and scaling up of mama and Binti kwa Binti groups. Additionally, the team will also continue to work with the HSS team to lobby and advocate for the apt implementation of the free maternity services (FMS) in line with the existing national guidelines. Data Quality Audits: During the quarter under review, Afya Pwani also supported the implementation of MNCH/FP DQAs in 38 facilities as a baseline for the County Rapid Results Initiative (RRI) that was launched on 23rd March 2018. The DQA took place between 12-16th March 2018. Out of all the maternal and child health indicators, key priority indictors were picked, including Perinatal death review at KCH
69 KCH-50, Malindi SC Hospital-58, Chasimba-33, Matsangoni-31, Vitengeni-39, Vipingo-38, Marafa-19
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those linked to HIV indicators. The findings of the DQA will be shared in the next quarter report.
Maternal and perinatal death audits: As part of its commitment to reduce preventable maternal and perinatal mortality, Afya Pwani together with the Kilifi CHMT established a County MPDSR committee as per the MOH MPDSR guidelines during the quarter under review. The MPDSR committee meets to discuss feasible and immediate interventions that are within the capacity of the county to apply remedial solutions to the causes of maternal and perinatal death. This quarter the project worked on establishing similar committees at the sub-county level. The project supported the county team to train SCHMTs on MPDSR guidelines and tools. Five sub-county teams: Kaloleni, Rabai, Kilifi North, Kilifi South, and Ganze were engaged during the training where a total of 64 members of the SCHMTs were trained. Post training, the sub-county teams were tasked to sensitize facilities in their sub-counties on the same and fast track establishment of verbal autopsy teams in communities. In the next quarter, the project will support the county to establish MPDSR committees in Malindi and Magarini, and support SCHMTs to help facilities establish verbal autopsy committees as part of the Project’s commitment to increasing access and availability of high quality MNCH services especially for vulnerable and marginalized communities living in Kilifi County.
Strengthen delivery of quality newborn care services: This quarter the Afya Pwani team focused on working with the CHMT to advocate for new born units in the two Sub-County Hospitals that still do not have newborn units i.e. Mariakani and Malindi Sub-County Hospitals, who both are experiencing challenges in regards to infrastructure and staffing gaps. Project staff also identified that there are major knowledge gaps when it comes to the provision of neonatal health services amongst health care providers. As such Afya Pwani trained [27] health workers on Kangaroo Mother Care (KMC), [23] service providers on Essential New Born Care, [23] on PNC and [19] on FANC to enable the facility staff to better manage pre-term and newborns effectively and enhance availability of high quality newborn care. s To who? Why?
Participants during trainings (from left) FANC (break out session), KMC (Dr. Anisa, County Executive Committee member for Health, Kilifi County giving opening remarks) and NBC (role play session)
Best Practice Use of “Target based approach “during mobilization for community participation i.e. 10 pregnant women per CHV. Inviting pregnant women as major stake holders for RH service delivery, for discussion for service improvement makes them feel appreciated and involved, hence utilize services.
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Ensuring safety and conducive environment during maternity open days to encourage women to talk and complain freely on what barriers there are.
Lessons learnt 1. When competent facilitators are sent to facilities for CME, the impact is higher since they take so serious because of the competent facilitator. 2. When CMEs are data, gap and performance driven, there is relevance and hence interest from HCPs, compared to the routine CMEs that do not address specific gaps and challenges in facility but address professional hours required by professional bodies. 3. Review meetings are more meaningful when administration and community are involved in one meeting, as it enhances commitment by all players since all will acknowledge performance, identify gaps together and discuss specific high impact intervention 4. Target based approach, apart from improving commitment by facility and community members, thus enhancing high turnout for services, it filters out the inactive CHVs. 5. Dialogue with the consumers of the service bring out ‘the real issues’ to be addressed compared to routine dialogues where participants say, ‘what they think’ is the issue affecting access & utilization of services. 6. When safety is guaranteed, women will air out pertinent barriers freely, enhancing implementation of High impact interventions (HII). 7. Involvement of SCHMT as coaches during maternity open days enhances ownership and sustainability of dialogue meetings. 8. The pregnant women have several reasons for not coming for ANC, not completing 4 ANC visits and for not delivering in hospital, while HCW have perceived reasons which are different from real issues. Health care workers prioritize poverty and illiteracy which are secondary and not health care worker issues like attitude and cost of services. 9. When clients share their bad versus good experiences during meetings, it encouraged those who have never delivered in facilities to do so and discourages home deliveries, as opposed to health care workers telling the advantages of facility deliveries, and disadvantages of home deliveries. 10. When health care workers are shown their performance disaggregated by sub-county and at the facility level, and see how they positively or negatively contribute to overall performance, it triggers action unlike the blanket performance presentation where they do not acknowledge their individual contribution, hence minimal or no action to improve. 11. The Mama Group meeting register is a quick way of early detection and following ANC defaulters, compared to the longitudinal ANC register which is challenging to detect ANC defaulters timely.
Output 2.2: Child Health Services Increase demand for child health services i) Engaging Community Health Volunteers to identify and refer clients for child health services:
The project supported a refresher session for 25 CHVs (16F, 6M) on Integrated Community Case Management (ICCM), where participants were capacity built on the case definitions, recommended community interventions, documentation and referral systems for the same as per the national guidelines. Post-training, these CHVs were then tasked to identify cases of fast breathing, and to treat or refer clients showing signs of the same to the nearest health facility for treatment. Table 24 below aptly
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highlights the number of children below the age of 5 years who were diagnosed with fast breathing at the community level and those who were treated with Amoxicillin by trained CHVs. Table 24: Number of children below 5 years with fast breathing treated by CHVs- Community Level Indicator Q1 Q2 Number of children 0-59 months age presenting with fast breathing 74 82 Number of children 0-59 months age presenting with fast breathing treated with 24 46 Amoxycillin
During the reporting period, 56% (46) of all babies who were identified and diagnosed with fast breathing were treated with Amoxycillin by project supported CHVs, as compared to 32% (24) who accessed the same service the previous quarter; an increase of 24% which illustrates that the strategies that Afya Pwani is implementing is having a positive impact when it comes to access and availability of child health services. Of note is that severely ill children actively referred to nearby health facilities using the quickest means (use of an ambulance). To address cases of immunization defaulting during the quarter, Afya Pwani staff facility service providers and Community Health Extension Workers (CHEWs) shared lists of immunization defaulters with CHVs linked to project supported facilities, who were tasked with physically tracing these defaulters and referred them back to the facility using Form 100 (the community facility referral tool). As a result, at least 427 immunization defaulters were traced and referred to the nearest health facility during the quarter. Immunization defaulter tracing was conducted alongside sensitizations for parents on the importance of immunizations and growth monitoring for their children aged five years or less.
KILIFI COUNTY - PNEUMONIA TRENDS AMONG CHILDREN <5
6,000 5,019 5,000
4,000
3,000 2,002 2,000
1,000
- Oct-Dec 17 Jan - Mar 18 Figure 15 Kilifi County– Pneumonia Trends among Children <5
ii) Community Dialogue to promote Immunization Afya Pwani also supported and conducted a community dialogue session to create awareness on the need to ensure that all children under five years are fully immunized. This dialogue session was conducted in Kadzuhoni Village in Magarini Sub-County and was focused on targeting mothers with young children and sought to establish reasons for immunization defaulting, some of the reasons noted were ignorance of
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the importance of immunization, distance from facility, while several other community members cited lack of time. Following the dialogue, participants received positive and accurate information on the function of all the recommended immunizations and encouraged to ensure they utilize these services to avoid ill health of their children. A total of 70 women were reached with this positive health information; numbers that project staff will work on improving in the next quarter as part of efforts to increase access and utilization of child health services in Kilifi County. b) Strengthen delivery of quality child health services (IMCI to include diarrhea management, immunization, malaria, Pneumonia, Ear infections and malnutrition) i. CME and OJT for Health Service Providers During the quarter, Afya Pwani supported and conducted CME sessions for 48 (32F, 16M) service providers from seven health facilities70 on the Kenya Expanded Program for Immunizations (KEPI). The main purpose of these CME sessions was to refresh service provider knowledge on vaccine forecasting, in the fight against stock outs and wastage of vaccines which has been negatively affecting delivery of quality child health services. This activity was necessitated by high staff turnover which has been contributing to poor forecasting and quantification of vaccines at the facility level which has resulted in over stocking and under stocking of the same. More specifically, during the CME sessions, participants were taken through the key elements of vaccine forecasting i.e. Target populations, previous consumption, and the number of immunisation sessions conducted regularly. Additionally, they were also taken through- how to go about determining/calculating the vaccine wastage factor. During these sessions, the Sub-County Public Health Nurse (SCPHN) emphasized the key steps involved in calculating wastage factor, i.e. Establishing the balance brought forward from the previous year, determining all receipts for the year, calculating the beginning balance to the vaccines received, calculating vaccines used from the ledger books, vaccines administered, and wastage rates. CME participants were also reminded about the minimum and maximum stock levels which facilities should be able to determine and use when ordering vaccines. This quarter 41 nurses (29 F, 12 M) from 23 health facilities71 in Rabai and Kaloleni Sub-Counties received OJT on KEPI SOPs (including information on defrosting of vaccines refrigerators and sterilization procedures) as part of efforts to improve the quality of health services provided to clients seeking services from Afya Pwani supported sites. Supportive supervision was also conducted in 25 facilities72 in the County to improve quality of child health services being provided; more specifically project staff provided feedback in real time, OJT and mentorship during these interventions. Additionally, Project staff used these visits with SCPHN and the respective facility in-charges to provide TA on the effective implementation of the existing national guidelines on ORT equipment and documentation, IMCI service delivery and records, as well as immunization procedures and records. Of further note this quarter, is that facilities in Kilifi County did experience Zinc stock outs in January and February 2018, during which the project was able to procure four cartons of the same from Kwale County, which were later distributed to four HVFs. Additionally, the Zinc and ORS consignment for Kilifi County was received in March after significant negotiation and lobbying from Afya Pwani team through the County pharmacist.
70 Mtwapa HC, Vipingo HC, Msumarini Disp, Chasimba HC, Rabai HC, Kokotoni Disp, Bwagamoyo Disp, Kambe Dispensary 71 Ribe Disp, Kombeni Disp, Kambe Disp, Lenga Disp, Kamkombani Disp, Makanzani Disp, Jibana Disp, Mganboni Disp, Chalani Disp, Vishakani Disp, Kasemeni Disp, Gotani Disp, Kinarani Disp, Makomboani Disp, Bwagamoyo Disp, Rabai HC, Tsangatsini Disp 72 Ganze HC, Mtwapa HC, Vipingo HC, Chasimba HC, Rabai HC, Matsangoni HC, Marafa HC, Gongoni HC, Marereni HC, Muyeye HC, Kilifi County Hosp, Kijanaheri MC, Mambrui Disp, Kizingo Disp, Dzikunze Disp, Msumarini Disp, Bwagamoyo Disp, Makanzani Disp, Bamba HC, Malindi Hosp
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In regard to, the ORT corners for project supported sites, Afya Pwani staff identified that several health facility staff preferred keeping the Oral Rehydration Therapy (ORT) permanent registers at the Pharmacy due to staff shortages at the OPD and MCH. To address this issue, project staff provided support supervision where staff highlighted the importance of keeping the ORT registers at the clinic and not the Pharmacy; as part of efforts to ensure that all these cases are aptly reported and documented. In Kaloleni and Rabai, the Kilifi County Medical Engineering Technologist was also supported to conduct supervision on cold chain and maintenance in 23 health facilities supported by the Project. This exercise was aimed at establishing and improving cold chain status in the seven Sub-Counties and to give recommendations, as well as to check sterilization equipment (and facilitate the repair or service on the same based on need). It should be noted that some of the key issues identified during these supervision visits, include the fact that health workers including nurses could not attend to basic faults of vaccine refrigerators and therefore needed a training on the same, and that in some cases, facilities also lacked vaccines refrigerators all together. c) Classification of Diarrhea with dehydration or No dehydration During the reporting period, a total of 7,864 children under 5 years of age were treated for diarrhea at Afya Pwani supported sites as compared to 5,058 children in the previous quarter, an increase of 1,706; This increase in reported diarrhea cases is partly attributable to contamination of water points during the flash floods that were experienced during the quarter, to help mitigate these challenges Project staff are already working to distribute water purification tablets as part of efforts to increase access to clean and safe water during these floods. In Bamba, a catchment area for Bamba Health Centre, a suspected outbreak of diarrhea disease was also reported in March 2018. As such, the public health department in collaboration with Afya Pwani conducted health education, mass water treatment and specimen collection for disease surveillance, that revealed food poisoning as the cause for the diarrhea. Afya Pwani has continued to support WASH related interventions to reduce chances disease outbreaks through water treatment, CLTS activities as well as messaging on disease prevention. At the community level, 1,250 children under one year who had diarrhea were identified, an increase of 1,089 from 161 children who were identified the previous quarter (see the reasons mentioned above). At least 71 of the identified children who were between the age of 12 and 59 months were treated with Zinc and ORS in line with national guidelines on the same. The project also supported supervision for 15 HVFs73 on child health during which facility health service providers received mentorship on how to record Zinc and ORS information on the permanent register as part of efforts to increase the quality of child health services being provided at these sites. Figure 16 provides a snapshot of these trends over the current and previous quarters.
73 Kilifi County Hospital, Malindi Sub-County hospital, Mtwapa health centre, Vipingo health centre, Chasimba health centre, Babai Health centre, Bamba health centre, Vitengeni health centre, Matsangoni health centre, Gede health centre, Marafa health centre, Gongoni health centre, Marereni health centre, Muyeye health centre
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KILIFI COUNTY - DIARRHEA TRENDS AMONG CHILDREN <5 12,000 10,426 10,000
8,000
6,000 5,058
4,000
2,000
- Oct-Dec 17 Jan - Mar 18
Figure 16 Kilifi County – Diarrhea trends among children <5
a) Immunization During the quarter under review, 8,597 children under 1 year were fully immunized compared to 7,392 in the previous quarter, an increase of 1,302 clients. This increase can be attributed to the consistent community mobilization activities and in reaches that have been supported by the Afya Pwani, as well as the Project’s continuous engagement of Afya Pwani grantees at community level whose work has been focused on demand creation. In addition, a total of 45 integrated in-reaches were conducted throughout Kilifi County targeting Women of Reproductive Age (WRA) with FP services and children who are below 5 years with growth monitoring and immunizations.
KILIFI COUNTY IMMUNIZATION UPTAKE FOR Q1 AND Q2 14000
12000 11580 11400 11752 10941
10000 9275 8498 7947 7976 8000 7392
6000 4862 4000
2000
0 Q1 Q2 Q1 Q2 Q1 Q2 Q1 Q2 Q1 Q2 OPV 0 BCG PENTA3 MEASCLES FIC
Figure 17 KILIFI COUNTY IMMUNIZATION UPTAKE FOR Q1 AND Q2
Figure 17 above provides a more detailed picture of the immunization uptake for Kilifi County over the October 2017 and March 2018 period. Table 25, below is an illustration of the period at which newborn
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babies were first reached with immunizations at either facility or community level. During the reporting period, more children (7,723 of 9,390) were vaccinated within two weeks of delivery as compared to the previous quarter (4,862 of 8,498). This is attributable to increasing community involvement through community dialogues, male involvement and door to door awareness creation by CHVs that are supported by the Project. Table 25 below provides more detailed information regarding the total number of clients that received immunization services over the quarter being reviewed and the previous quarter as well. Table 25: Immunization Uptake per Sub-County Sub-County Oct - Dec 2017 Jan - Mar 2018 Newborns Newborns Total Newborns Newborns Total BCG immunized immunized BCG immunized immunized within 2 after 2 within 2 after 2 weeks weeks of weeks of weeks of of delivery delivery delivery delivery (BCG only) (OPV0+BCG) (BCG only) (OPV0+BCG) Ganze Sub-County 593 875 1468 900 177 1077 Kaloleni Sub-County 459 448 907 1278 533 1811 Kilifi North Sub- 1170 262 1432 2095 567 2662 County Kilifi South Sub- 998 356 1354 1091 268 1359 County Magarini Sub-County 625 610 1235 1422 510 1932 Malindi Sub-County 847 773 1620 1775 189 1964 Rabai Sub-County 170 312 482 714 61 775 Total 4862 3636 8498 9275 2305 11580
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During the period under review, 9,390 new born babies received BCG vaccination and 7,723 of them received both BCG and OPV0. Of note is that only 1,667 babies did not receive OPV0 for showing up after 2 weeks of delivery, as compared to 3,636 (4,862 of 8,498) babies who showed up after 2 weeks in the previous quarter. This success is as a result of the community dialogues, increased community mobilization, male involvement and the positive roles that Skilled Birth Attendance (SBA) are now taking in regards to promoting child health in the County. The Project has also focused on addressing and reducing the number of immunization defaulters. To track immunization defaulters, the project also supported 15 HVFs to complete the immunization permanent Nurse at Mtwapa Health Centre updates registers, a gap that was created during the 5 immunization permanent register using client’s card months industrial strike in 2017, that affected service recording and reporting. The process involved working retrogressively to key in missing data on the permanent register. As a result, the facility is able to identify true immunization defaulters and list them down in a separate book which is shared with CHEWs who then hands over the list to CHVs for tracing. During the quarter, a total of 427 immunization defaulters were identified, traced and referred to health facilities as part of efforts to increase access and availability of high quality child health services. b) Facility In-Charges Meetings Between January and March 2018, the Project supported monthly sub-county facility in-charges meetings in all the seven sub-counties. The main purpose for the meetings was to review performance and map out strategies that would lead to improved performance and scale up quality of services. These meetings are also apt platforms for SCHMTs to give service related updates to public health officers, facility in-charges, laboratory technologists, pharmaceutical technologists, nutritionists and student nurses who were on attachment. During these meeting the following cross-cutting issues were shared: a) Introduction to MNCH/HIV/TB/WASH Rapid Results Initiative (RRI) As earlier mentioned, during this quarter SCHMTs introduced the RRI concept to health service providers, where meeting facilitators highlighted what the key strategies, indicators and timelines were. The RRI supported this quarter was launched on 19th March 2018 and is due to run through till 26th June 2018. Of note is that a baseline Data Quality Audit (DQA) was conducted on 12th through 16th March 2018. The theme for the RRI was “accelerating quality health service delivery”. Afya Pwani invested heavily this quarter to support this RRI by supporting the provision of transport and lunch for service providers as well as facilitating and conducting data collection and TA during the same as part of efforts to improve both uptake and coverage of MNCH/RH/FP/nutrition and WASH indicators in Kilifi County.
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c) Introduction to “Linda Mama” Program74 Prior to the roll out of the Linda Mama program, project staff also conducted sensitizations on the initiative for facility in charges as part of efforts to familiarize them on how the initiative worked and what the registration process looked like should they be enrolling any women coming to their respective facilities. The Linda Mama initiative was designed to cater to pregnant women from ANC to 4 PNC visits with free maternal health care. Pregnant women are registered into the program on first contact and forms submitted to National Health Insurance Fund (NHIF) for reimbursement as follows KES 2,500 per delivery, KES 600 for ANC 1st visit and KES 250 for subsequent ANC visits, KES 250 for PNC to a maximum of 4 PNC visits as from March 2018. Looking forward, this government run initiative has significant potential to promote access and availability of high quality maternal care, especially for WRA from vulnerable and marginalized areas, and so the Afya Pwani team will continue to leverage on the program to increase uptake of safe and quality maternal newborn care. d) Data Review Between January and March 2018 Sub- County Health Records and Information Officers (SCHRIOs) presented data on the HIV cascade, FP, Maternal Newborn Health (MNH), nutrition and child health targets (against performance) to the County teams. By supporting these review meeting, Afya Pwani was working towards ensuring that facility in-charges monitor their performances, and validate their data before entering it into DHIS2 (all whilst highlighting the program areas that needed change of Participants are taken through immunization strategy/interventions for better microplanning during facility in charges meeting at performance). Malindi. Moving forward, facility in charges agreed to update the afore mentioned immunization permanent register to improve number of fully immunized Children (FIC) by identifying and tracing immunization defaulter. Best Practices Defaulter tracing for immunization defaulters coupled with health education on importance of completion of immunizations increased uptake and coverage of Immunizations. Involvement of CHV in identification, treatment and referral of children with fast breathing and diarrhea increases child health in the community. Immunization data reviews that were conducted during the quarter led to increased commitment by health service provider to update immunization registers and work closely with community strategy teams for immunization defaulters’ follow up.
Lessons learnt 1. Integration of FP, Immunization, ANC, HIV, nutrition and WASH services during in-reaches facilitated service provision to more clients in a shorter period using less money.
74 “Linda mama” started in 2017, initially called Free maternity services (beyond Zero), under the umbrella of NHIF
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2. Immunization clients who default due to distance to health facility need to be reached through outreaches; that will be increased in the next quarter. 3. Immunization and other child health clients born to young mothers (<19 years) are likely to default more than their counterparts who are born to mothers who are above 19 years hence the need to create a strategy to reach out to this special group to reduce rate of defaulting.
Output 2.3 Family Planning Services and Reproductive Health (FP and RH) a) Increase uptake of FP services i. Community sensitization meetings This quarter Afya Pwani supported two community dialogue forums to increase awareness of RH/FP at Gongoni Dispensary and Takaungu of Magarini and Kilifi North Sub-Counties respectively. Sites selection was based on community demand through respective CHEWs. These forums aimed to challenge and demystify myths about RH/FP, with the goal of creating a social environment that is more supportive of spacing of pregnancies for better health of the mother and child. During these discussions, it was apparent that many community members still associate FP with infertility, hence the hesitation for uptake. The community members were sensitized on the ‘concept of contraception’, where information on short acting and long-term methods were shared. They were also informed of the criteria used by health providers to inform suitability for different contraceptives so as to reduce the side effects of these contraceptives. By dispelling these untruths linked to FP, it is anticipated that more women will take up these services. A total of 56 women were reached with information, numbers that project staff will build on in the next quarter as part of its commitment to increase uptake of FP services in line with the United States Government (USG) FP compliance.
ii. Door to door campaigns To increase reach of accurate RH/FP information to clients with unmet need of FP and the communities at large, Afya Pwani also supported door to door campaigns in Gede and Mambrui areas, where CHVs visited households to teach WRA about FP, and the methods available. By supporting this activity community members were able to ask questions and share their concerns pertaining to FP use; helping to dispel myths and also reach out to women who shy away from public forums because of ‘Mwenye Syndrome’. During the activity, a total of 1,332 women were reached with FP information, and 294 women were referred for FP services at Gede Health Centre and Mambrui Dispensaries. All of which are positive indications that Afya Pwani is making gains in terms of increasing uptake of FP in the County.
iii. Enhancing Male involvement in Family Planning Aware of the role of men in decision making in all facets of the family including RH in Kilifi County, Afya Pwani built on the gains made during the last quarter with Male Champions, and continued to invest more in empowering male champions to be powerful and impact behavior change agents within their communities; helping to involve male partners in FP discussions and the communication between husbands and wives and addressing the myths and misconceptions related to FP. This quarter Afya Pwani’s male champions embarked on creating awareness on the importance of RH/FP by reaching out to other men during community meetings and one on one sessions. These educative sessions are intended to make men understand their role in supporting the wellbeing of the family by managing their family
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sizes and promoting health timing and spacing of pregnancies (HTSP) for the good health of their wives and their children. Also serving as role models in their communities, four of the champions, allowed and escorted their wives to receive FP services, three of whom opted for Bi-Tubal Ligation (BTL). This initiative has seen positive results across the board and in some communities, this has resulted in progressive change on the hard line taken by most men on FP.
“Allowing my wife to undergo BTL has eased my work, my friends believe me more when I tell them family planning is not harmful to the health of the woman, and since then, I have been able to refer 5 of my neighbors for the same service” -Male Champion Chaung.
The project intends to train more champions in the next quarter as part of efforts to build on the successes that have been achieved this quarter.
The project also trained 30 influential men from Malindi Sub-County on advocacy and counselling for RH including but not limited to Village elders, leaders of motor riders’ associations, teachers and youth group leaders. It should be noted that training focused on strengthening the capacity of the select participants on community leadership, communication, and counselling for RH/FP. At the end of the training, Afya Pwani, worked with participants to develop action plans to disseminate the information shared to advocate for the uptake of FP in their own communities. These participants were also tasked to educate other men on the need for FP while dispelling myths and misconceptions. They are also expected to refer couples for FP information and services in their respective link facilities.
It should be noted that all the community sensitization meetings, door to door campaigns, male involvement, integrated in reaches as well as FP integration focused activities supported during the quarter, have all resulted in a significant increase in FP uptake in Kilifi county. For example, this quarter the project reached 8,912 new FP clients with high quality FP services which included access to and utilization of both Long Acting and Permanent (LAPM) methods as well as injectable contraceptives, pills and condoms. Please see Figure 18 below which has more information on these trends for the quarter:
FAMILY PLANNING NEW CLIENTS VS REVISITS
New Clients Revisits
17922
12836
7984 6771
OCT - D E C 1 7 JAN - M A R 1 8
Figure 18 Uptake of FP Services, New clients and re-visits for Jan-Mar 2017, Apr-Jun 2017, Jul – Sept 17, Oct – Dec 17 and Jan – Mar 18
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Trends in FP Method Mix fo Dec 2017 to Mar 2018
50,000 19,300 1,413 2,496 10,048 732 1,976 3,092 4,554 20 139 1,192 2,547 341 458 0 Pills/oral contracep Injections IUD Implants Sterilization Condoms Natural method
Oct - Dec Jan - Mar
Figure 19 Trends in FP Method Mix for Dec 2017 to Mar 2018
From Figure 19 above, there was an increase of new clients 8,912 as compared to the previous quarter 6,771 as well as FP client retention which increased from 7,984 to 13,475 during the reporting period. These positive trends can be attributed to the demand creation activities that the project has been implementing over the quarter. During the reporting period, the number of WRA who accessed FP services is 23,816 and the number of clients who accessed Couple Year Protection (CYP) is 26,898, an improvement from the previous quarter where a total of 16,838 clients were seen, and only 18,444 clients accessed CYP. This success can be attributed to this increase to the in reaches that were supported by Afya Pwani during this quarter. The Project will continue to support more in reaches in the next quarter; ensuring FP compliance as recommended by USG regulations on voluntarism, informed choice of FP method and consent so that clients access the FP method of their choice. Figure 20 below shows the trend in CYP for January to March 2018.
QUARTERLY CYP TRENDS COMPARING OCTOBER 2017 TO MARCH 2018
40,000.00 33,484.42 30,000.00 18,444.44 20,000.00 10,000.00 - Oct-Dec 17 Jan - Mar 18
Figure 20 Quarterly CYP Trends Comparing Oct-Mar 2018
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KILIFI COUNTY CYP DISTRIBUTION - JAN - MAR 2018 Condoms Natural method Pills/oral contracep 0% 2% Sterilization 1% 4% Injections 14%
IUD 27%
Implants 52% Figure 21 KILIFI COUNTY CYP DISTRIBUTION - JAN - MAR 2018
During the period under review, implants (52%) were by far the most popular method of choice for clients, followed by IUDs (27%) and injections (14%). Implants remain the FP method of choice because of the high levels of discretion attributable to it in light of the fact that many of these clients experience the effect of ‘Mwenye Syndrome’ clients seeking these services. The table below provides more information on the actual numbers of clients who received FP counselling and the full range of FP methods during the quarter under review. The most popular FP method during the In-reaches was implants (1,033) followed by injectable (538).
Table 26 Number of Clients Reached During Integrated FP In-Reaches Jan – Mar 2018 Item Number Reached during in reaches Total Number clients counselled 2549 Number of clients who received Pills 221 Number of clients who received Injectable 538 Number of clients who received Implants 1033 Number of clients who received IUCD 72 Number of clients done cervical cancer screening 1367 Number of Implant removals 95 Number of IUCD removals 24
The project also continued to focus on adolescents and youth during the quarter through interventions that are well elaborated under youth friendly services’ section. During the quarter, 358 adolescents aged between 10 and 14 an increase of 317 from 41 clients the previous month; at least 1,902 more adolescents aged 15 to 19 received FP methods at facility level. This success is still attributable to the afore mentioned efforts to reach out to adolescents, increased access points for FP as well as presence of Afya Pwani grantees in the community.
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FP uptake among Adolescents by age comparing Quarter 1 and 2 3000 2287 2000 1095 1000 358 41 0 Adolescent 10-14 yrs Adolescent 15-19 yrs
Oct - Dec 17 Jan - Mar 18
Figure 22 FP uptake among Adolescents by age comparing Quarter 1 and 2
To promote and facilitate integration of FP services into different service delivery points across supported facilities, the project supported and facilitated peer educators and Mentor Mothers to provide accurate FP information to WRA and their partners at HIV Care and Treatments in 16 HVFs75 in Kilifi County. For example, at Kilifi County Hospital, Malindi Sub-County Hospital, Mariakani Sub-County Hospital and Mtwapa Health Centre, comprehensive FP services are provided at HIV care and treatment departments by competent health service providers. More specifically, the project staff supplied FP job aids and Tiahrt Charts to all supported sites, and Pathfinder International’s adolescent cue cards to the 16 HVFs mentioned above as part of efforts to increased access and availability of high quality FP services for adolescents and youth. At Mtwapa Health Centre for example, Afya Pwani has provided technical assistance (mentorship) for FP integration, by serving clients together, filling in clients FP information into both HIV and FP tools. In the next quarter, the Project will continue to provide TA, mentorship and OJT to health service providers to maintain and improve the uptake of Long Acting Reversible Contraception (LARCs) and permanent methods of FP across the seven sub-counties while ensuring that the supported facilities continue to adhere to the USG legislative and FP policy requirements of voluntarism and informed consent. b) Improve the quality of FP services provision As part of efforts to improve the quality of FP service provision in the County, Afya Pwani supported the provision of OJT on FP service delivery. During the quarter, 45 (38 F, 7M) nurses from Rabai [19], Kilifi North [11], Kilifi South [6], Ganze [5], Magarini [4] were mentored on insertion of implants, infection prevention and client FP counselling during integrated in reaches. Trainings on LARC and BTL are scheduled for the next quarter. This quarter, Afya Pwani also procured and distributed assorted FP supplies to 16HVFs76 in Kilifi County to support the provision of high quality FP services. These supplies included color coded buckets for disinfection of contaminated equipment, Sodium Hydrochloride, clean gloves, cotton Wool, disposable speculums, Elastoplast, gauze bandages, Lugol’s Iodine, Orange sticks,
75 Kilifi County Hospital, Malindi Hospital, Mariakani Hospital, Mtwapa health center, Vipingo health center, Chasimba health center, Rabai health center, Bamba health center, Ganze health center, Vitengeni health center, Marereni health center, Marafa health center, Gongoni health center, Muyeye health center 76 Kilifi Hosp, Malindi Hosp, Mariakani Hosp, Bamba HC, Ganze HC, Gongoni HC, Marereni HC, Marafa HC, Gede HC, Matsangoni HC, Vipingo HC, Mtwapa HC, Oasis MC, Chasimba HC, Rabai HC, Kijanaheri MC
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Povodine Iodine, spirit swabs, Steranious for quick sterilization of contaminated equipment, sterile gloves, strapping, surgical blades, surgical spirit, veronica buckets for hand washing, and vinegar. This quarter, Afya Pwani also supported and facilitated a FP Technical Working Group Meeting which took place in February 2018 and was attended by a total of 32 (17F, 15M) participants. The following partners and organization were in attendance: Afya Pwani staff, MOH staff and other stakeholders like KEMRI, NCPD, KMYDO, Plan Kenya, Red cross, Moving the Goal Post, Intrahealth. During this meeting the County Reproductive Health Coordinator emphasized on the importance of developing youth specific interventions that would reduce cases of teenage pregnancies and home deliveries. High volume facilities commodity supportive supervision: This was conducted jointly with SCPFs in 9 HVFs77 in Kilifi County during the quarter. The supervision was integrated and covered all program commodities including County RH coordinator makes opening remarks during quarterly TWG RMNCH/FP. Commodities in February 2018. stocked and stored appropriately in the facilities and inventory management carried out using stock cards in the Pharmaceutical Stores and using the FP Register in the FP Clinics. Cognizant that some facilities were going to run out of stick, project staff worked to facilitate the distribution of some commodities e.g. Combined Oral Contraceptive pills where moved from Ganze Health Center to Kilifi County Hospital and even Depot- Medroxyprogesterone Acetate Injection vials. Of note is that this quarter, there was exemplary management of FP commodities in Gede and Muyeye Health Centers respectively, where the FP Register page summaries were routinely updated upon completion of every page and not at the end of the month as was the case with some of the facilities. Where this was not happening, corrective OJT was done.
Reporting rates: This quarter, the project supported the Sub-County Pharmaceutical Facilitators with airtime to enter data to ascertain rate of commodity consumption and inform when it time to restock. The project also mentored Kilifi County Commodity Security TWG to be able to effectively monitor reporting rates and conducts data review meetings to ensure all commodity reporting is done. The County FP reporting rates have progressively improved as shown in Figure 23 below which highlights the reduction in stock-outs of FP commodities across the County.
77 Kilifi County Hospital, Bamba and Malindi Sub-County Hospitals and Ganze, Matsangoni, Muyeye, Marafa, Gongoni and Gede Health Centers
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KILIFI COUNTY FP COMMODITY REPORTING RATES APR 2017-MAR 2018 120
100 99.4 99.5 96.9 96 97.8 80 87 87.1 81 74 77 60 66.7 69.1
PERCENTAGE 40 REPORTI NG RATE 20
0
MONTH
Figure 23: FP Commodity Reporting Rates April 2017- March 2018
Output 2.4 Water, Sanitation and Hygiene (WASH) INCREASED ACCESS AND UTILIZATION OF WATER, SANITATION AND HYGIENE SERVICES
Improved access to safe and adequate water for drinking, domestic and animal use
a) Improving access to safe water for schools and health facilities
During the quarter under review, two water storage tanks (5000 liters capacity) were installed at Mutoroni and Kirosa Primary Schools in Magarini Sub-County as part of efforts to improve harvesting of rainwater for 875 (B-481, G-394) pupils to improve access to safe water for schools and health facilities. To build on this support Afya Pwani has also already finalized the process for the installation and procuring of additional storage tanks which will be ready for distribution in the next quarter. The project is also finalizing the installation of water pipeline extensions for select communities as part of efforts to increase access to safe water. This quarter, Afya Pwani also supported training of four different community groups as part of efforts to build the capacity of community stakeholders to increase access to safe water for schools and health facilities; participants included but were not limited to members of local water management committees, local artisans, health facility management committee members and school board of management on water governance from Ganze, Kaloleni and Magarini Sub-Counties. The training reached a total of 15 local water artisans (12M, 3F) drawn from 12 project sites78 and health facility management committee members from nine health facilities79 reaching a total of 31 committee members (19M, 12F). Additionally, a total of 20 (11M, 9F) water management committee members from the following 10 water points were also trained; Guruguru, Chalani, Birini, Gongoni, Kambicha, Mikiriani, Chanagande, Dida, Dzinkunze and
78 Ganze, Marereni, Bamba, Gongoni, Mariakani, Jaribuni, Kinarani, Madamani, Marafa, Tsangatsini, Gotani and Vishakani 79 Gongoni, Chalani, Dzikunze, Sabaki, Bamba, Fundi-Issa, Adu, Tsangatsini and Dida.
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Tsangatsini. By building the capacity of these key stakeholders, it is hoped that these actors will help improve access and availability of safe water for these communities. Table 27 Afya Pwani Training on Comprehensive School Health, Management and Promotion of WASH Group No of No. of Total Beneficiaries locations Males females trained trained trained
Local artisans 12 3 15 Ganze, Marereni, Bamba, Gongoni, Mariakani, Jaribuni, Kinarani, Madamani, Marafa, Tsangatsini, Gotani and Vishakani
Health facility 19 12 31 Gongoni, Chalani, Dzikunze, Sabaki, management Bamba, Fundi-Issa, Adu, Tsangatsini and committee Dida.
Water 11 9 20 Guruguru, Chalani, Birini, Gongoni, management Kambicha, Mikiriani, Chanagande, Dida, committee Dzinkunze and Tsangatsini.
Board Members 22 14 36 Lwandani, Danicha, Mutoroni, Baricho, Barakajembe, Mambrui, Kisurini, Mwaeba, Miyani, Chalani, Walea, and Shangia schools
Between January and March 2018, project staff also supported the training of 36 (22M, 14F) board members on comprehensive school health, management and promotion of water, sanitation and hygiene practices. Participants were drawn from the following 12 target primary schools80 in Ganze, Magarini and Kaloleni Sub-Counties respectively. b) Verification and Selection of 60 small Scale entrepreneur (Private water Vendors) During the reporting period, Afya Pwani worked closely with the Ustadi Foundation- one of the Afya Pwani’s grantees to identify and verify 60 water kiosks (as the current existing water service providers- KIMAWASCO based in Kilifi and MAWASCO based in Malindi) that the Project would work with and support as part of efforts to increase access to safe water. The main criteria of inclusion of the water kiosks from which private vendors for mentorship were (1) Water kiosk or tap yard water source that get more than fifty (50) clients a day, (2) A water source that is strategically placed within the community, (3) Kiosk operator/ kiosk owner or kiosk operators operating as private water vendors and (4) Kiosk operators willing to attend training and willing to disseminate water quality prime messages to their clients after training. This verification assessment process focused on the following key areas-tariff setting for water sale, regular maintenance of records and water points, water treatment and Licensing and customer care services. Consequently, 15 private water vendors were identified from four Sub-Counties in Kilifi County and will be supported in the next quarter. Ultimately this activity is geared towards contributing to a 10% increase of the target population practicing use of household water treatment technologies in Kilifi County. Lastly, during the quarter under review, Afya Pwani supported two inductions that were aimed at equipping these small-scale water vendors with knowledge and skills on water quality management at the tap yard/water kiosks and water storage mechanisms. It is hoped that following these interventions,
80 Lwandani, Danicha, Mutoroni, Baricho, Barakajembe, Mambrui, Kisurini, Mwaeba, Miyani, Chalani, Walea, and Shangia schools
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these service providers will build on their existing skills and knowledge to be able to increase access and availability of safe water. c) Promote the utilization of water for multiple use This quarter, Afya Pwani continued to promote integrated activities aimed at increasing access and availability of high quality value to the nutrition interventions through productive use of water in select communities. More specifically, project staff supported the installation and setup of two sites for the small-scale farms, where two shade nets complete with drip kits for the farms were installed and demonstrations done by Agricultural officers at Gongoni Health Center and Kagombang’aze Village in Bamba location respectively. These interventions were specifically targeted at the Kagombang’aze Women’s Group which has 22 members and the Tushauriane Group with 25 members in Gongoni health center. In order to ensure proper use of the shade nets, Afya Pwani supported with training of both groups on shade net set up, good farming practices, good crop husbandry and maintenance. Both groups meet thrice in a week to carry out farming activities at their respective farms; a total of 47 families are benefitting directly from the small-scale farming integrated intervention. Of note is that the demand of access to safe water at community and institutional level is high due to prolonged drought and few protected water sources. Provision of storage facilities and extension of water pipelines to institutions will guarantee protection of vulnerable children and communities as a result of reduced water related shocks from long distances and scarcity.
Access and uptake to sustainable sanitation within the Program area 1. Scaling up of Community led total sanitation (CLTS)/School led total sanitation (SLTS) interventions
Improving access to sanitation at both community and institution level ensures that the environment and the program beneficiaries’ lives are safe and healthy with proper disease transmission barriers/measures in place. The promotion of safe use of sanitation facilities for disposal of feces is one of the key intervention that Afya Pwani is using to contribute to the realization of the rural open defecation free (ODF) Kenya roadmap by 2030 and consequently reduce diarrheal diseases especially among children and mothers, using the CLTS approach as the key strategy. During the Quarter under review, Afya Pwani built on the gains from the previous quarter to accomplish the following success: a) Sensitization of village elders on CLTS
During the reporting period a total of four sensitization meetings were conducted for village elders on CLTS strategy, where the main aim was to equip participants with accurate information on key CLTS concepts so that when the CLTS process is implemented in their villages, the elders and their Balozi wa Nyumba Kumi (elders of ten house cluster) take lead on the process and champion the same at village level for increasing the pace towards ODF attainment. These sessions were facilitated by public health officers drawn from the county health department.
Table 28 Sensitization of Village Elders Jan-Mar 2018 Sub-County Venue Elders sensitized Male Female Total Magarini CDF Hall at Gongoni 5 0 5 Malindi Furunzi, Kaoyeni and Maziwani 4 1 5 Ganze Ganze sub county hall 2 3 5
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Kilifi North Konjora, Fumbini and Mikingirini 3 2 5 TOTAL 14 6 20
Of further note is that during these meetings, project staff took the opportunity to the CLTS process was discussed in detail during these trainings and possible ways of fast tracking the same in their communities. Moving forward, regular village meetings with their Balozi wa Nyumba Kumi to sensitize them on the CLTS Model prior to Public Barazas will henceforth be held at village level to gain more support for the process from the leaders whose villages have challenges. In addition, the provincial administration will get reports from the elders on a regular basis and participate in joint CLTS review meetings. b) CLTS follow up and review meetings As part of efforts to increase access to sustainable sanitation, the Project supported eight CLTS post- triggering follow up and review meetings in Jaribuni, Vitengeni, Dida and Mwahera Villages. More specifically, a total of 561 new latrines were constructed in Mwahera, Vitengeni Jaribuni and Ganze Villages since CLTS triggering took place. The CLTS interventions have led to increased access to improved sanitation for a total of 2,939 people (1,322M, 1,612F) during the reporting period. Of further note, is that as a result of Afya Pwani supported CLTS investments in these areas, Dida location has since received certified ODF status with all 732 households having fly free latrines and functional hand washing facilities. A total of 5,947 (2,676M, 3,271F) community members now have access to improved sanitation as a result of the interventions mentioned above. Moving forward Afya Pwani will focus on supporting the implementation of sustainable sanitation interventions i.e. Sanitation marketing in Dida location in the subsequent reporting period following the national quality assurance exercise that has been planned and as part of efforts to ensure that these gains are sustained well beyond the life of the Project. It should be noted that the verification of villages that have attained ODF status ensures that the certification process is done in line with national guidelines and declare the communities as ODF. The Afya Pwani project is actively involved in scaling up the CLTS within the Kilifi County; during the quarter under review the project completed the verification of five villages claiming ODF within the target community (Mnarani, Ndonya, Marina, Mikanjuni, and Timbetimbe in Ganze and Kilifi South). It should also be noted that there are 20 other villages that are due for their newly acquired ODF status celebration in May 2018. The impact of these interventions can already be seen across project supported sites; for example, Dida Dispensary serves 17 out of 20 villages that are due to be certified as ODF. Please see Figure 24 below.
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Diarrhea Cases in Dida Dispensary Oct 2017-Mar 2018 30 24 25 20 15 15 10
Numberofcases 5 0 Oct to Dec 2017 Jan to Mar 2018 Period
Figure 24 Diarrhea Cases in Dida Dispensary October 2017-March 2018
Initiation of Sanitation marketing During the quarter Afya Pwani also focused on working with communities to implement sustainable sanitation for improved services. The availability of an enabling environment that promotes the implementation of an effective sanitation scale up strategy that addresses both the needs on the supply and demand side as well as overcoming the technical challenges of latrine construction is key to increasing access and availability of services. To this end, the Project initiated the procuring of five Makiga interlocking stabilized soil pressing machines. The Makiga interlocking blocks will enable communities to construct sustainable, upgraded and hygienic latrines at household level. In the next quarter the Project will focus on facilitating and conducting further sensitizations of communities and training of local artisans on sanitation marketing and on local based innovative sanitation technologies using Makiga interlocking block manufacture. Additionally, during the quarter, the project, in collaboration with SPEAK, and support from USAID conducted training on sanitation marketing aimed at enhancing skills on latrine construction by use of different sanitation technologies to improve for sustainable and improved sanitation. This was done for 45 (21-F, 24M) CHVs within the target program areas. The participants are now supporting communities in ensuring access to latrine improvement materials for upgrading their latrines as they climb up the sanitation ladder.
2. Support construction and rehabilitation of sanitation and waste management Between January and March 2018, Afya Pwani also supported and facilitated an Environmental Impact Assessment (EIA) in preparation of the construction for the incinerator Kamkomani Dispensary in Kaloleni Sub- County, Ganze Health facility and Marereni Dispensary. The assessment was done by Green Kenya Corporation LTD and the report had been shared with all relevant stakeholders. Please see the draft EIA reports pending approval by the National Environment Management Authority (NEMA), after which the construction of the incinerators will begin.
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3. Social behavior change communication for Uptake of desirable Hygiene Promotion Practices and behaviors for prevention of childhood diarrhea Promote water safety improvement practices Point of use water treatment is key strategy in the fight to safeguarding the quality of household water and goes a long way in prevention of diarrheal disease among household members and children under 5 years. During the Quarter, the project purchased and distributed 35,000 Aqua Tabs and 32,400 Purr sachets for water treatment at the household level in Ganze, Magarini and Kaloleni through trained WMC members, HFMC members, artisans and community based CLTS promoters and public health workers. A total of 28,080 sachets of PURR and 26,300 aqua tabs were distributed for water treatment at household level during the same quarter; a total of 806,800 liters of water was treated. In the next quarter, monitoring on the continuous use of the water treatment chemicals will go on as planned to ensure proper use as part of efforts to improve the water quality at the household level as the Project works to protect the health of the communities in Kilifi during the current rainy season. Enhance community engagements on hygiene promotion As part of efforts to promote and encourage the uptake of positive hygiene and sanitation behavior change at the community level, Afya Pwani has worked to the project has incorporated regular dialogues to reinforce the desirable hygiene practices at household level. Moreover, Afya Pwani supports the community hygiene champions in carrying out regular dialogues and engagements with communities. During the reporting quarter, three community dialogues were held in three villages; Milimani, Mwaeba and Kichwa cha Kati in Ngomeni in Magarini South Sub-County where 81 families were reached with hygiene promotion interventions. Demonstrations were also done on the proper installation of tippy taps, hand washing and water treatment at the household level. In addition, the Afya Pwani supported hygiene champions also conducted assessments to determine the level of uptake for hygiene practices at the household level on small immediate doable actions; handing washing, latrine use and household water treatment to ensure prevention of Diarrhea in 11 villages of Magarini Sub-County-Ngomeni location; Kichwa cha Kati, Ngomeni B1, Garithe B, GaritheA, Ngomeni B2, Ngomeni B3, Ngomeni A, Mwaeba, Rasi, Milimani, Kasimani. Analysis of the data is ongoing and once completed the report will be shared to inform on replication and improvement in implementation. In addition, SPEAK (Afya Pwani grantees) also conducted and facilitated community hygiene forums with the Miyani Community Unit on improving healthy hygiene behaviors to prevent childhood diarrhea, reaching a total of 11 CHVs were reached. These discussions focused on hand washing with soap, Tippy taps, safe water storage and treatment methods at point of use (POU). Demonstrations on water treatment methods, proper water storage methods and hand washing practices and products for promoting hand washing was done.
World Water day celebration This quarter, Afya Pwani took the lead in working with the County and other partners to commemorate World Water Day as part of global efforts to increase awareness on the effectiveness of household water treatment, hand washing practices in prevention and control of diarrheal and related illnesses. The event took place at Bamba Health Center and was attended by high-level guests from the County, NGOs and other implementing partners as well as local community including school going children. In the celebration, the project supported community groups to create awareness on water safety practices and environmental cleanliness through songs, poems and drama and by printing the banners with the messages about the theme. The theme for the event was “Nature for Water: Exploring Nature-Based Solutions to the Water Challenges We face in the 21st Century.
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WASH Partners/stakeholders consultative meetings During the quarter, Afya Pwani supported and ne WASH stakeholder’s consultative meeting was held in January 2018. Achievements and challenges in the WASH sector in the county were shared by the various sub counties. Partners and the County government shared plans for the current year as well as discussed, the main challenges experienced in the WASH sector in the county which were identified as; Inadequate supply of clean safe water in certain parts of Kilifi, high saline levels in BH water, Inadequate sanitation services in schools, jigger’s infestation in some areas as lack of clear sanitation census and no online reporting of sanitation achievements. The WASH partners and the respective Kilifi Sub-Counties resolved to work closely in a coordinated manner with joint planning to address the challenges and realize improved WASH status and services. In this forum Afya Pwani program shared the planned interventions to address some challenges in the program target areas. Support County TWGs During the quarter the project supported county WESCOORD review and planning meeting on in the month of February. During the meeting the partners reviewed and planned various activities implemented and planned for the key WASH events. Implementation of school hygiene and sanitation promotion interventions
Rolling out of the school led total sanitation Improved practices among school children has a positive effect on their health and that of their families. School led total sanitation (SLTS) approach is an effective way of ensuring all school environments and their catchments become safe and clean to minimize disease transmission. This is part of the comprehensive school health approach that the project is using to ensure uptake of good hygiene and sanitation practices among school going children who are good change agents at the household level and influencing behavior change. Involving teachers, parents and pupils in the promotion of sanitation and hygiene in schools creates culture of ownership and sustainability of school hygiene promotion. During the Quarter of January-March,7 primary schools in Kaloleni sub county participated in the launch of good sanitation and hygiene practices at their respective schools; Chanagande, Miyani, Migundini, Chalani, Shangia, Musifuni and Baraka. In each school, demonstrations were conducted on installation of tippy taps and hand washing as well as water treatment. Parents and pupils were encouraged to do the same at their homes. A total 6,232 (B-3,014, G-3,218) pupils participated in the school led total sanitation triggering on hygiene and sanitation. The roll out of the SLTS has resulted into installation of hand washing station (Tippy tap) in the schools and improved sanitation. Schools children are particularly influential in ensuring their parents put up latrines and related hygiene facilities for promoting sanitation. Through these concerted efforts it is anticipated that the prevention of diarrheal illnesses among school children can be realized over the project period.
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Table 29 Summary of SLTS roll out participants No Name of School Boys Girls Total
1 Chalani 366 315 681
2 Chanagande 653 699 1,352
3 Musufini 374 410 784
4 Baraka 271 280 551
5 Shangia 369 374 743
6 Migundini 483 558 1,041
7 Miyani 498 582 1,080
Total 3,014 3,218 6,232
Output 2.5 Nutrition INCREASED ACCESS TO AND UTILIZATION OF NUTRITION SERVICES
a) Strengthening the capacity of the county to provide and lead in nutrition service delivery To improve on service provision to mothers and young children, health care workers undertook a BFHI self-assessment in 67 health facilities to establish practice of service delivery for child survival indicators. The assessment was intended to identify gaps in relation to BFHI strategy implementation and provide guide to facilitate training of health care workers. The results of the assessment provided a guide for action plans to implement (BFHI) strategy in all health facilities. Findings of the assessment revealed that 22 out of 67 (32%) facilities are compliant with BFHI guidelines. Following the findings, the project supported the BFHI training for the CHVs in the month of March to enhance staff capacity in related service provision. b) Strengthening the Health facility capacity to provide Nutrition Services Afya Pwani also supported the dissemination of maternal, infant and young children nutrition knowledge, attitudes, practices and beliefs survey results to department of health and nutrition stakeholders in the county. The main objective of this survey was to collect baseline information on knowledge, attitudes, beliefs and practices among mothers/caregivers in Kilifi County. A total of 67 (DOH (53), Partners [14]) participants were present during the session. The findings indicate high prevalence of key breastfeeding practices; however, timely initiation of breastfeeding, provision of pre-lacteal feeds, and knowledge on the benefits of colostrum is low. In terms of provider knowledge, health care workers attitudes and perceptions on Infant Young Child Nutrition (ICYN) are positive; BUT not necessarily translating into practice for some of the indicators. The findings revealed low awareness of MNPs. In addition, over a half (57.3%) visited the ANC 4 or more times during the last pregnancy as per the recommendation. Cultural factors were also reported NOT to be a major barrier to dietary practices – and that significant progress had been made to address the issues (based on information from FGDs). Considering these preliminary findings, Afya Pwani have since set out strategies to address these gaps. A training on baby friendly community initiatives was conducted for facilities health care workers and CHEWs from the 15 HVFs that are being supported. To improve on knowledge and skills of health workers on nutrition, CME sessions
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were conducted in Kilifi South (Mtepeni, Junju, Vipingo, Rabai) where 24 health care workers (15F and 9M) benefitted in Kilifi South focused on Malnutrition and importance of reporting.
c) Support relevant community structures and groups to enhance nutrition services at community level i) Sensitization of mothers to mama groups To further promote good nutrition and enhance ANC uptake among mothers, two Mama Groups’ sessions were conducted in Rabai Health Center facility where 27 mothers attended the sessions. Key issues shared during these sessions include but were not limited to the importance of ANC attendance, FP, exclusive breastfeeding and importance of delivery in a health facility. Moving into the next quarter, Afya Pwani staff will endeavor to use this information for informed decision making in terms of how to better support relevant community structures and groups to enhance nutrition services at the community level. d) Improved household’s food security and nutrition initiatives in target communities.
i) Support household food Security initiatives To further support improvements on food security initiatives during the quarter, 5 groups in Mariani village and 1 in Gongoni were supported with seeds to plant in their Kitchen gardens a total of 130 (M 10 F 120) people benefitted from seed distribution. These Afya Pwani supported groups have established seed beds and planted over the current rainy season, after which is it hoped that the households will harvest these crops for nutrition purposes as part of efforts to improve the household’s food security and nutrition initiative in target initiatives to contribute to the reduction of malnutrition levels among children and women. Of further note, is that with the help of Afya Pwani grantees, the project was able to work towards increase food security at the household level in Magarini, Kilifi North and Ganze Sub-Counties respectively by working with County stakeholders to help advise farmers/households on the suitable and appropriate crops to cultivate in their respective areas. Moving forward, a total of 20 household farmers (5 in Malindi, 5 in Magarini, 5 in Kilifi and 5 in Ganze) were identified during the previous activity to establish kitchen gardens that will act as learning sites for balanced diets, cooking demonstrations, weaning diets demonstrations and supplementary feeding demonstration. Project staff have also worked to ensure that the capacity built to be able to sell some of their produce to increase their household income. e) Promote strategies for enhancing newborn, infant and young child feeding strategies Strategies to improve IYCF are a key component of the child survival and development programs in Kilifi; there is evidence underscoring the essential role breastfeeding and complementary feeding as major factors in child survival, growth and development. To further improve skills of CHVs IYCF Afya Pwani also conducted a five-day training was conducted in two CUs in Rabai and Kilifi North Sub-Counties. Main topics covered included, maternal nutrition, exclusive breastfeeding, complementary feeding, counselling skills of breastfeeding mothers, risks of mixed feeding and various conditions of the breastfeeding, as well as responsive feeding of infants and young child. A total of 77 CHVs (F- 60, M-17), benefited from this training during the quarter. Following the BFHI assessment and the need to improve health care workers knowledge and skills, 26 ((M 7 F 19) health care workers were trained on Baby Friendly Community Initiative package. The training is aimed at empowering health care workers to implement BFHI guidelines in health facilities and at community level. The health care workers developed action plans that will be implemented in the various health facilities and catchment areas in the county. The training was led by a national trainer from the division of family health and nutrition. The training is intended to enhance implementation of other
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trainings focusing on promotion of MNCH services and ensure that health facilities implement the IYCF guidelines as per the program design. f) Integrated outreaches During the reporting period Afya Pwani supported the County Department of Health to conduct three integrated medical outreaches in pre-select sites in the county organized by the nutrition unit of the County government. These integrated outreaches reached a total of 149 children (M-75 and F-74) in Mitsedzini, Chivara and Mwangea village helping to increase access and availability of high quality nutrition and MNCH services for these areas. SUB-PURPOSE 3: STRENGTHENED AND FUNCTIONAL COUNTY HEALTH SYSTEMS
Output 3.1 Partnerships for Governance and Strategic Planning a) Strengthen planning and budgeting process in the sector i) Program Based Budgets (PBB) Development and Implementation During the quarter, Afya Pwani provided TA to Kilifi, Mombasa, Lamu and Taita-Taveta counties to finalize draft sector working group (SWG) reports. The TA on development of these reports commenced in the previous quarter after issuance of the budget circular on August 31, 2017 where the circular provides the provisional budget ceilings for each department. The SWG reports will facilitate alignment of health sector allocations to priority service delivery and development areas during the FY 2018/19 Program Based Budgets (PBB) preparation process. Further, the team supported the counties to revise their priority health programs (general administration, Preventive and promotive and clinical and curative) and sub- program (HIV/AIDS, Reproductive, Maternal, Neonatal and Adolescent Health [RMNCAH], TB and Malaria) resource allocations to align the proposed budgets to the affirmative ceilings provided for in the County Fiscal Strategy Paper (CFSP) released on February 28, 2018. Ultimately, the final draft reports were shared with the County Executive Committee (CEC) members of health from the four counties for onward submission to the respective county treasuries. By supporting these activities, Afya Pwani is working towards progressively integrating service delivery and deepening sustainability efforts. Between January and March 2018, Kwale, Kilifi, Mombasa and Taita -Taveta counties were also supported to commence development of their FY 2018/19 PBB. More specifically, the Project provided TA to the teams to rationalize allocation of the health department resources to the three main program areas: general administration, preventive and promotive and clinical and curative health services. Through this process, counties allocated resources to priority programs and particularly activities that will address emerging issues around HIV/AIDS, RMNCAH and non-communicable diseases (NCDs). During these PBB development exercises, Afya Pwani collaborated with the respective county treasuries to sensitize the departments of health on the CFSP contents and particularly departments’ allocation ceilings for development and recurrent expenditure. The project will continue supporting health department advocacy efforts including forums to foster meaningful engagement with the respective assembly budget and health committees and treasury. Moving forward, the Afya Pwani team will provide technical support to county health managers in developing advocacy tools for increased resource allocation in the next quarter. To further enhance PBB implementation in Kilifi County, Afya Pwani facilitated worked through the CEC’s office to help develop a financial decentralization agenda which would then be tabled to be reviewed by the CEC. This activity was specifically implemented as a direct response to the current centralized county financial management systems within treasury which continues to constrain the health department’s operations due to the unpredictability of access to funds. This TA was offered as a result of the fact that the Chief Officers for Health often lack adequate control and mandate to effectively manage resources to
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improve the health sector performance at the County level. As such, the CEC deliberated on the decentralization agenda that the Afya Pwani team helped to develop, and a cabinet memo was generated and tabled for mentioned before the County Assembly in February 2018 and was later approved for implementation. The Project will continue to provide support in establishing a framework to facilitate the department of health to implement the system and effectively discharge its mandate. ii) County Integrated Development Plan and Strategic Plan Development During the quarter under review Afya Pwani also provided TA during the development of the County Integrated Development Plan (CIDP) to assist in mainstreaming of the health-related Sustainable Development Goal (SDGs). The forum brought together the project team among other relevant stakeholders81 in a consultative county meeting to discuss and build consensus on approaches to align the CIDP to SDG priorities. Specifically, the project team supported the health department to align SDG Goal 3 on good health and well-being and Goal 5 on gender equality for inclusion in the health sector CIDP priorities. Afya Pwani will continue offering TA to ensure the same indicators are mainstreamed into the County Health Sector Strategic Plan (CHSSP) currently under development and cascaded down to annual work plans (AWP). In Mombasa, the project worked with the CHMT to review and finalize the draft health sector inputs for incorporation into the CIDP 2018-2022; more specifically, Afya Pwani worked with the CHMT and the its respective program officers to review health sector activities under each health system building block and to realign the document to reflect program priorities following the program based approach. Through this exercise, the department aligned programs to sub-programs, and the expected outcomes with an emphasis on high impact indicators for RMNCAH, HIV, youth and gender activities. As a result, the CHMT was able to contribute to the overall agenda and priorities of the CIDP thus giving higher prominence to the health agenda for enhanced resource mobilization. Afya Pwani also provided TA for the end term review of the current strategic plan and in establishing a roadmap for developing the subsequent Kilifi Health Sector Strategic and Investment Plan that will be implemented in the 2018-2022 period. During the review process, the project supported the county in conducting a stakeholder mapping analysis and in facilitating a two-day stakeholder consultative forum on February 6 and 7, 2018 to prepare the team for the data collection and analysis exercises and the eventual development of the strategic plan. In this forum, the department established a technical working group (TWG) tasked with the responsibility of conducting a situational analysis. The analysis findings will inform the 2018/22 strategic and investment priorities for the health sector. The plan will highlight short and medium-term sector priorities for implementation during the period. iii) FY2018/19 Annual Work Plan (AWP) Development Kilifi, Kwale, Mombasa and Taita -Taveta counties were also facilitated to conduct mid-term performance reviews of AWP for FY 2017/18. The reviews assessed AWP implementation progress, measured the extent to which implementation had improved health outputs, outcomes and impacts while documenting challenges, gaps, lessons learned and best practices. The reviews in these counties revealed overall poor performance for RMNCAH including ANC visits and FIC immunization indicators which was attributed to the industrial action during the second half-year 2017/18. Consequently, counties aligned AWP priorities and opportunities for scale up to respond to the identified gaps and developed a roadmap with adjustments for the remaining half-year. The project is currently facilitating the counties to develop the FY 2018/19 AWP.
81County treasury, Kilifi CHMT, other county departments and development partners
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b) Strengthen stakeholder coordination and collaboration i) County stakeholders’ forums Afya Pwani also supported institutionalization of county stakeholders’ forums to establish a coordinated approach for addressing health-related matters with partners and other sectors in Lamu, Taita Taveta and Kwale Counties. In Lamu, the intersectoral development advisory group comprising the departments of health, lands, and water, the county assembly, County Public service board (CPSB) and other stakeholders discussed solutions to the cross-sectoral challenges hindering the provision of and access to quality health services and proposed possible solutions. The project was brought on board as a member of the secretariat’s steering committee during the intersectoral dialogue meeting, where six key resolutions were suggested including but not limited to: digitization of health facilities, human resource for health (HRH) management and development, facility upgrades, M&E, health finance, research, evidence-based medicine and health legislation. The milestones will be implemented jointly with assistance from the relevant sectors and will be included in the county integrated development plan (CIDP) currently under development. In Taita Taveta, the health stakeholders’ forum provided participants with an opportunity to highlight contributions to the overall improvement of healthcare services in the county. The forum provided an opportunity for the county to strengthen its partnerships and revitalize stakeholder engagement which had stalled. Stakeholders also identified areas of synergy and collaboration, provided additional inputs and identified the activities they will support over the medium-term period. During the meeting, Afya Pwani staff also sensitized the health department management team led by the Chief Officer for Health and other stakeholders on the SWG report contents including resource allocation to priority health programs and distribution of resources across economic categories. The forum provided an apt opportunity for the County to discuss the initiation of the Universal Healthcare (UHC) policy which seeks to provide insurance coverage among households and increase access to affordable and quality healthcare for healthy and productive population. Engagements with stakeholders (like the above) are expected to improve inter-sectoral engagements and eventually interventions for the department’s service delivery priorities. Additionally, Afya Pwani and Health Informatics Governance and Data Analytics (HIGDA) projects supported the department of health in Kwale to institutionalize and operationalize the monitoring and evaluation (M&E) technical working group (TWG). In this meeting, the department was supported to validate the terms of reference (TOR) and build consensus on a mechanism for institutionalizing M&E in the county planning framework. The meeting involved other stakeholders from the CHMT, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), Kenya National Bureau of Statistics (KNBS), National AIDS Control Council (NACC) and Council of Governors (COG) who are members of the TWG and facilitated sharing of M&E policy guidelines including performance framework for County governments and sensitization on the county learning mandate which holds a peer-to-peer learning forum targeting the five project target counties.
Output 3.2: Human Resources for Health (HRH) a) HRH planning strengthening at the County
The project facilitated County HRH stakeholders’ committee meetings in Kilifi, Kwale, Taita-Taveta and Lamu counties during the January-March 2018 quarter under review. During these meetings, Taita-Taveta
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and Lamu reconstituted the HRH stakeholders’ committees which disintegrated due to the leadership changes in the health department management after the 2017 general elections. The committee in Lamu was also supported to set HRH priorities for the year and identify HRH areas of collaboration with development partners. Development of the HRH Strategic plan (2018-2022) for the health department was also highlighted as a priority to provide a basis for HRH budgeting for FY 2018/19. In Taita-Taveta, the HRH stakeholders committee discussed findings of the concluded HRH critical staffing gaps report and set the HRH agenda for the year. Afya Pwani will provide technical support to build the capacity of the newly constituted HR unit in the health department and support roll out and use of the Integrated Human Resources Information System (IHRIS) in health facilities to inform HRH decision making. The Kwale and Kilifi stakeholders’ fora were jointly facilitated by Afya Pwani and the HRH Kenya Project. The committees have been fairly active in addressing HRH issues facing them.
During the same period the project provided technical support in the Inter-County HRH TWG and stakeholders’ forum which was held in Kilifi. The forum brought together six counties; Kilifi, Mombasa, Kwale, Taita-Taveta, Lamu and Garissa to share HRH challenges and highlight responsive HRH innovations from the respective counties. The counties also demonstrated progress made regarding staffing data capture on IHRIS. In doing, counties experiencing challenges with the system were identified for follow- up support and capacity building initiatives. b) County HRH assessment and staffing data analysis During the quarter, Afya Pwani staff also offered technical support to HVFs as part of efforts to improve HRH data entry in the IHRIS system. More specifically, the project co-hosted a skills building workshop with HRH Kenya targeting IHRIS focal persons from the facilities and county health departments in the five project target counties. During the forum, counties nominated focal persons to lead HRH data capture on IHRIS in their respective facilities. It should be noted that the counties are also being supported to acquire IHRIS log in credentials for the newly trained users. The medium and low volume facilities were clustered in sub-counties and will receive centralized IHRIS support from the designated sub-county focal persons.
c) Recruitment of Facility Based Contract Health Workers Between January and March 2018, the Project also worked closely with the county public service boards (CPSB), the departments of health and county human resources units to deploy the newly hired health workers prioritizing health facilities where critical staffing gaps had been identified. Similarly, the new hires were inducted on their roles as county workers and Afya Pwani’s role in their management. The project and counties also sensitized the health workers on the public service human resource policies and procedures manual among other relevant manuals to enhance their understanding of the employment terms of engagement. Additionally, Mombasa county and Afya Pwani signed a Memorandum of Agreement (MOA) to pave way for the advertisement and consequently recruitment of facility Based health works for the county. The health department will continue to receive TA to fast track these processes. d) Capacity development of S/CHMT’s in leadership management and governance The project initiated engagements with Pwani University and the Kenya School of Government (KSG) Mombasa campus to develop tailored skills buildings programs to address capacity gaps in SCHMT. Subsequently, Pwani University is working on a HRH skill building program targeting in-service intermediate HRH Managers in public health facilities while KSG Mombasa campus in working on a leadership and governance skills building program targeting newly appointed hospital board members and facility management committee members.
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Output 3.3 a): Health Products and Technologies (HPT) a) Strengthen county commodity management oversight and planning During the quarter, Mombasa, Kilifi and Taita-Taveta counties held commodity security TWG meetings. The project also supported HIV test kits allocation committee meetings in four counties; Kwale, Mombasa, Kilifi and Taita-Taveta. In Mombasa, the TWG meeting developed a quarterly work plan for the January-March 2018 period. The commodity security activities included commodity data review, identification of a model site to be developed as a center of learning jointly with Afya UGAVI, monthly commodity stock status monitoring as well as planning for forecasting and quantification data collection. The TWG selected Tudor Sub-County Hospital as a proposed model site for the county. In addition, the TWG conducted stock assessment and provided a briefing to the CEC for health to inform the health department on the stock status of tracer commodities in the county. The forecasting and quantification (F&Q) data collection teams were also sensitized and facilitated to start data collection in 1482 selected facilities. Upon completion, the data will be utilized to generate the forecasting and quantification report for the FY 2018/19 and inform the county’s budget for the same period. As shown in Figure 25 below the findings from the stock status review process illustrate that most tracer commodities had enough stocks to last the county for between 3-5 months. Excess commodities were observed for a few set of tracer commodities for TB and Malaria.
Figure 25 Distribution of EHPTs Months of Stock
During the quarter under review, the TWG in Kilifi developed an AWP for FY 2018/19 which highlighted commodity management issues as priorities for the county; namely F&Q, supply planning, commodity management support supervision, data review meeting, fast-tracking of disposal of expiries as well as
82 Mombasa F&Q Facilities: Bokole CDF Dispensary, Junda Dispensary, Shimo-La Tewa Health Centre (GK Prison), Magongo (MCM) Dispensary, Kisauni Dispensary, Mrima CDF Health Centre, Mvita Dispensary, Mlaleo CDF Health Centre, Kongowea Health Centre, Railways Dispensary (Mombasa), Utange Dispensary, CDC Ganjoni Dispensary, Likoni Sub-County Hospital, Coast Provincial General Hospital (CPGH), Port Reitz Sub-County Hospital and Tudor Sub-County Hospital.
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facility-based mentorship for Kilifi County Referral Hospital, Marereni Dispensary and Rabai Health Centre by application of Kaizen. These planned activities were executed across all the seven83 sub-counties in Kilifi in close coordination with the county TWG. The sub-counties’ finalized compilation of F058 documents for expired health products were submitted for disposal approval by the county health department. In Taita Taveta, the TWG reviewed the health department’s commodity orders alongside the available budget in collaboration with the Sub-County teams from Taveta, Mwatate, Voi and Wundanyi respectively. The practice was adopted by the County as part of efforts to ensure appropriate rationalization of requirements based on Sub-County needs. Further, documentation and approval of expiries disposal for Wundanyi Sub-County were completed and the commodities moved to Moi Voi Referral Hospital for incineration; it should be noted that this disposal was also approved by NEMA. Afya Pwani also supported HIV test kits allocation in Mombasa, Kilifi, Kwale and Taita Taveta. Project staff facilitated a stakeholder’s forum which brought together commodity managers from the five project counties, Kenya Medical Supplies Authority Medical Commodities Program (KEMSA-MCP), Clinton Health Access Initiative (CHAI), NASCOP and Afya UGAVI. During this forum, partners discussed challenges and recommendations for better supply chain management of test kits. The forum highlighted concerns with weak quantification of requirements by the counties, challenges during stock outs and excess test kits in different facilities as well as poor planning for unexpected outreaches and delays in commodity re-supply. Project staff also facilitated and supported, follow up planning and test kit allocation meetings in Kilifi and Kwale as part of efforts to avert test kits expiries. This was achieved through inter- and intra-county commodity redistribution which also averted test kits stock outs in Kilifi. Importantly, all including the two counties were sensitized on quantification of test kits, timely ordering. As illustrated in Figure 26 below, Afya Pwani supported Kwale County to reduce the excess test kits to appropriate levels from as high as seven months of stock in November and December 2017. The average stock status for Mombasa and Kilifi counties have been sustained around the three months-worth of stock. The orders placed to KEMSA in March were scaled up to ensure prolonged lead time has been considered in each county.
83 Kilifi South, Kilifi North, Ganze, Malindi, Magarini, Kaloleni, Rabai Sub-Counties respectively.
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Figure 26 Determine stock status in Kwale, Kilifi and Mombasa
b) Strengthen Pharmacovigilance In this quarter, Afya Pwani trained 64 health workers on pharmacovigilance in Kilifi and Taita-Taveta counties. Additionally, the Project also undertook a pharmacovigilance continuous medical education (CME) session for 40 health workers from Kilifi County Referral Hospital. To facilitate the establishment of a pharmacovigilance reporting feedback mechanism from the national Pharmacy and Poisons Board (PPB) to the counties, Afya Pwani staff also initiated discussions with PPB to pave way for the design of this provision. If provided, the mechanism will provide counties with reporting trends data to inform tracking and review of adverse events and poor-quality medicines in the counties. The feedback will also enable the project to identify gaps in electronic pharmacovigilance reporting for appropriate interventions. c) Improve commodity data quality at Facility Level Between January and March 2018, Afya Pwani also facilitated a one-day county commodity data review feedback meeting by the CHMT and SCHMTs from Mvita, Likoni, Kisauni, Nyali, Changamwe and Jomvu Sub-Counties as part of effort to improve commodity data quality at the facility level. During the review, participants analyzed commodity reporting rates, data quality issues as well as challenges related to commodity reporting. It was observed that; 1) Some facilities were consistently not reporting commodity data, 2) Other facilities did not offer some commodities yet they formed part of the overall expected reports and 3) Lacked reporting tools especially for FP. During the reviews, the teams set performance targets aimed at improving availability of reports and agreed to fast track among them provision of commodity reporting tools and review facility targets in District Health Information (DHIS2). In Taita Taveta, commodity data review sensitizations were also done targeting Sub-County pharmaceutical facilitators from Taveta, Mwatate, Wundanyi and Voi areas respectively. The commodity reporting rates on DHIS2 were also outlined and discussed with each Sub-County highlighting the
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challenges experienced for discussion. It emerged that the key challenges were lack of access rights for reporting by the Sub-Counties, erroneous listing of some facilities as part of the expected reports and non- reporting due to lack of tools. It was agreed that each Sub-County works with the County Health Record Information Officer (HRIO) to ensure rights for data entry are appropriately assigned. Lastly in Kwale, Afya Pwani developed and disseminated a data quality assessment tool for HIV tests kits commodity management. This was developed as a requirement by the Kwale allocation team to support validation of quality of HIV test kits data for proper quantification. The tool was adopted for use by Sub- County Laboratory managers to assess the quality of data in the respective Sub-Counties. The data assessment is currently being undertaken targeting at least 50 testing facilities in Kwale. As shown in the Figure 27 below, reporting for FP commodities in Mombasa, Kwale and Kilifi have remained high during the quarter. Following the data review recommendations, the data for Taita Taveta is being corrected.
Figure 27 Family Planning commodities reporting rates as per DHIS2- 12th April 2018
d) Build the capacity of S/CHMTs and facility staff for good commodity management To build the capacity of facility level staff on commodity management, the Afya Pwani team trained 64 (M- 28: F-36) health workers from Taita Taveta and Kilifi counties on basic commodity management and appropriate use. In Kwale County, the Afya Pwani project supported a training specific for Laboratory Commodity Management for 24 (M-11: F-13) laboratory personnel. The trainings in each county were aimed at improving/refreshing commodity management skills. During the training, respective counties were provided with technical support to design sub-targets for commodity management improvement. These targets included provision of feedback to the respective facility staff on the concepts learned, enhancing use of inventory management tools and job aids as well as quarantine for expired commodities in readiness for disposal. Between January and March 2018, SCHMT members in Kilifi were also mentored on commodity management supervision and supported to supervise 62 facilities across all the sub-counties except Kilifi North and Ganze. This supervision was aimed at assessing the health facilities’ adherence to good
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commodity management practices and stock status among other indicators. These exercises also sought to identify commodity management gaps for targeted immediate and/or follow up mentorship as well as commodity redistribution. Figure 28 below demonstrates the inventory management practices observed in Kaloleni and Rabai Sub-Counties. Most facilities had good management information systems (71%) while storage practices and availability and use of job aids and references where mostly average at 68% and 66% respectively. The main gaps identified were in Pharmacy inventory management (44%) as well as pharmacy human resource capacity for good commodity management.
PHARMACY MANAGEMENT SCORE
67
66
65
44
% AVERAGE SCORE %AVERAGE 20
PHARMACY STORE MANAGEMENT P H A R M A C Y P H A R M A C Y PHARMACY HUMAN AND STORAGE INFORMATION RESOURCES AND I N V E N T O R Y RESOURCES PRACTISES SYSTEM REFERENCES MANAGEMENT
Figure 28 Kaloleni and Rabai Commodity Supervision Findings Chart
Figure 29 Kaloleni and Rabai Tracer Commodity stock status
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As demonstrated in Figure 29 above, the stock levels of essential medicines in (sampled) facilities showed that 80% of sampled tracers were in stock while 16% were stocked out and 4% were under stocked. The project will continue working with SCHMT to mentor commodity managers to better manage stocks status to avoid stock outs. The support will mainly target to address the causes of stock outs and understocking of the 20% Tracer essential health products. During the supervision, the SCHMT also collected expired program commodities and shipped them to Rabai Health Center and Mariakani Sub-County Hospital for collection by KEMSA. Additionally, the SCHMT conducted redistribution of commodities and OJT on commodity management in all the visited health facilities, where each facility was also supported to develop a work plan to rectify challenges observed during supervision.
Output 3.3 b): Health Products and Technologies- Facility Report i) Build the capacity of S/CHMTs and facility staff for good commodity management
During the quarter under review, a total of 23 HVFs84 were visited for commodity management supportive supervision during the quarter. The visits were done jointly with SCHMT members and KEMSA MCP joined the visits to four facilities in Kilifi County in February 2018. On the job training on various aspects of commodity management for example proper inventory management, good storage practices, logistics management information systems and pharmacovigilance was done to 138 health workers from different cadres85 (M- 61 and F-77). Job aids were also distributed during the visits to further equip the health workers with knowledge and skills on good commodity management in the different departments86 handling commodities.
84 Bamba SCH, Coast PGH, Diani HC, Ganze HC, Gede HC, Gongoni HC, Kilifi CRH, Kinango SCH, Kinondo Kwetu Clinic, Kwale SCH, Lunga SCH, Malindi SCH, Marafa HC, Matsangoni HC, Miritini CDF Dispensary, Moi Voi CRH, Msambweni CRH, Muyeye HC, Mwatate SCH, Ndovu HC, Taveta SCH, Tiwi RHTC and Wesu SCH. 85 Pharmaceutical Technologists, Pharmacists, Nurses, Registered Clinical Officers, Nutritionists, Laboratory Technologists, Laboratory Technicians and Support Staff 86 Pharmacy, Medical Stores, Comprehensive Care Clinic, MNCH/FP Clinic, Nutrition Clinic, TB Clinic and Laboratory
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COMMODITY MANAGEMENT INDICATOR ANALYSIS FOR USAID AFYA PWANI HIGH VOLUME FACILITIES VISITED THRICE (N=17)
100.0 90.0 80.0 70.0 60.0 50.0 40.0
PERCENTAGE 30.0 20.0 First Visit 10.0 0.0 Second Visit Third visit
INDICATORS Figure 30 Commodity Management Indicator Analysis for USAID Afya Pwani HVFs Visited Thrice (N=17)
Analysis In Figure 30 above, the indicators to the left are supposed to increase over time while the ones to the far right are supposed to decrease over time. Previously there was a trend where output indicators were increasing but outcome indicators, for example stock status indicators either stagnating or decreasing. During the quarter under review, this seems to have reversed with even the outcome indicators registering an improvement for example stock between minimum and maximum stock levels. These positive trends can be attributed to the sustained support to the facilities from Afya Pwani all of which has resulted in data supported, improvements over the quarter. Moving forward, these gains need to be sustained and also scaled up to all other facilities through support to the S/CHMTs, who need to conduct supervision visits in order to see these improvements sustained across the board.
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a) Re-distribution of HPT During the January-March 2018 quarter, project staff identified during visits to Malindi Sub-County Hospital that the allocation of HIV Test Kits at the Sub-County and County levels was sub-optimal and this had led to some facilities not receiving test kits at all and some not getting enough. Upon further investigation, project staff ascertained that test kits were running out in the big hospitals in Kilifi County due to issues at these smaller facilities. Taita Taveta County was also found to have the same problem but Mombasa, Kwale and Lamu were fine. The immediate problem was solved through Mombasa County Laboratory Team During the HIV Test Kits redistribution from the counties with Allocation Meeting at the USAID Afya Pwani Training Centre test kits to Kilifi and Taita Taveta, all on 28th March 2018 of which was facilitated and supported by the Afya Pwani team. In addition to redistribution of test kits, project staff also worked with the CHMTs during the March- April 2018 allocation as part of efforts to prevent stock outs. These allocation meetings were organized by Afya Pwani in all the counties, where the Laboratory coordinators and SCASCOS doing the allocation were advised to factor in the consumption in the month of March 2018 and also consider the lead time from KEMSA which was another full month (April 2018). In Kwale County the SCMLTs called the facilities to determine the stocks on hand at the end of March 2018 instead of going by what was in the Health Commodities The projection screen for the Mombasa County HIV Test Kits Management Program (HCMP) Allocation Meeting on 28th March 2018. [February 2018] ending balance. In Kilifi, Mombasa and Taita-Taveta, the average monthly consumption was multiplied by six instead of four to factor in those two months, after which the ending balance as at February 2018 was subtracted to determine quantities to allocate per facility.
It should be noted that Counties that delay before ordering essential medicines and medical supplies (EMMS) from KEMSA are not receiving sufficient supplies, result in stock outs of FP commodities. This has affected various parts of Kilifi County throughout 2017, and has also affected Mombasa County between the January to March 2018 period. These issues were raised with the KEMSA MCP Liaison Officer for Kilifi County who promised to raise it up with her managers. Moving forward, an amicable solution would be to
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revive supplies to the Sub-County stores which would also help to serve private facilities that offer FP services as well. b) HPT Registers During the quarter under review, project staff also identified a mismatch between the current FP Register- MOH 409, and the Facility Contraceptive Consumption Data Report and Request Form (FCCDRR) which is the reporting form for FP commodities. The former currently does not have any columns for “Change of Method” any more but that information is required in the report. The register has only one space for implants and yet there are both one-rod (Implanon-NXT) and two-rod (Jadelle) implants. The tools need to be revised at the Reproductive and Maternal Health Services Unit (RHMSU).
C) Zinc/ORS CO-Packs During the quarter under review, the Zinc/ORS co-packs shortage that Kilifi County was experiencing in the previous quarter, was addressed and the problem alleviated. Follow up was done with KEMSA by both Afya Pwani and the CHMT after it was missed during the December-January 2018 distribution of EMMS to Kilifi County, despite the fact that there were stocks in the KEMSA warehouse. To address this issue, a backorder was done and the supplies reached the county in March 2018. Afya Pwani staff also liaised with the Kenya Red Cross who supplied FEFOL tablets (Iron Folic Acid Supplementation [IFAS]) to help facilities facing shortages in Kilifi County.
It should also be noted that during the quarter under review, there was a pediatric TB medicines crisis after a batch of pediatric RH expired on 28th February 2018 and the RHZ expired on 31st March 2018, where the TB clinician at Kwale Sub-County Hospital did not know what to do with the clients needing these drugs urgently (the RH did not arrive until 28th February 2018). She was advised to give the children RHZ since it could not harm them instead of either giving expired RH or letting them miss their daily dose. TB coordinators and Pharmacists in the counties supported by the Afya Pwani project, were advised to split the TB Patient Packs expiring in August 2018 and add them to the supply boxes for all patients, so as to combine efforts to utilize them, since The Pharmaceutical Technologist, Rehema Kugula, allocating the same to individuals from March in the Medicines Store at Gongoni Health Centre 2018 onwards would lead to some continuation medicines expiring before the patients complete their six-month treatments. It should be noted that Afya Pwani project staff have been able to use innovative tools like WhatsApp groups to help spread the pivotal roles in helping to spread messages about the shortages of EMMS and the mitigation measures that were put in place.
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d) 22nd International AIDS Conference 2018 During the quarter under review, project staff also submitted an abstract entitled “Increasing availability and access to life-saving ART commodities through improved inventory management and forecasting using a commodity management supportive supervision scored checklist: Case study of five coastal counties of Kenya”; this abstract has since been accepted to be presented as a poster. This is an apt opportunity to showcase Afya Pwani’s commodity management work to an international audience.
e) Airtime for Commodity Data In addition to the support supervision, and TA aimed at assisting with redistribution of commodities and EMMS, Afya Pwani also supported County and Sub-County officers by facilitating the provision of airtime to upload commodity data into DHIS2 and HCMP respectively. This airtime was also used to purchase data bundles for the Pwani Commodity Managers WhatsApp group which is a platform that Project staff created to better allow information on commodities and EMMs to be shared easily. Lastly, Afya Pwani has also been facilitating the provision of transport for the redistribution of commodities during routine TA trips using project vehicles as part of efforts to increase access and availability of HPT at the facility level across the five counties.
Output 3.4: Monitoring and Evaluation Systems a) Strengthen M&E oversight in all the 5 counties for effective continuous monitoring, decision making and planning. To enhance County M&E systems, Afya Pwani supported establishment of the M&E TWG for the department of health in Kwale. The oversight body will provide the department with a mechanism for stakeholders’ engagement and a shared platform to address M&E priorities. The TWG was ART Stock Taking Exercise at Ganze Health Center facilitated to develop terms of reference (TOR) and identify CCC to Establish Proper Inventory Management. health sector M&E priority areas including resource allocation From left: William Mwamkonu, the facility to health information systems (HIS) and institutionalization of Pharmaceutical Technologist, George Ochoki, the Subcounty Pharmaceutical Facilitator and Antony health department AWP reviews. The project also supported Mwangi, Commodity Management Advisor, dissemination of M&E guidelines and created a roadmap for USAID Afya Pwani the development of the county M&E plan. The TWG members are drawn from the county, sub-county, hospital management teams (HMT), development/implementing partners, civil societies, Faith-based Organizations (FBOs) and national health research institutions. Afya Pwani will continue to provide TA in the development of the M&E plan for FY 2018/20 in the next quarters. b) Strengthen the use of data collection tools including EMR to enhance patient management and ease reporting During the quarter, Afya Pwani provided IQCare trouble shooting for all HVFs in the five counties, where project staff focused on providing the following assistance: Computer maintenance, network repair and software updates. In response to the modifications in the Ministry of Health (MOH) manual data collection tools (reports and registers), the project strategic information team also upgraded the system’s data
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collection tools to the latest versions. The team also supported four87 HVFs to fast track transition from the BlueCard Electronic Medical Records (EMR) module to the Greencard module (with latest MOH) tools). As a result, the facilities have access to new features including real time notifications on patient bookings to automate appointment management, viral load alerts and nutritional assessments as well as sliders with summaries with critical patient information. Ultimately, real time access will improve responsiveness of HIV care by providing health workers with the information they require to customize care. Facilities will also be able to generate and submit reports from the EMR to DHIS 2 based on the new tools. Figure 31 below provides a snapshot of what the new BlueCard EMR module looks like:
Figure 31 IQCare GreenCard module interface
c) Strengthen county and facility plans and mechanisms for DQI In this quarter, the strategic information (SI) team supported the county to conduct Routine Data quality audits (RDQAs) in Kilifi, Kwale, Mombasa, and Taita Taveta counties covering 37 facilities88. The data audits were aimed at providing information on the quality of routine data captured in the EMR, DHIS2 and manual tools. Findings from the DQAs provided insights on EMR uptake, reporting gaps, data use and quality issues for verification and correction. Consequently, all facilities were supported to conduct data cleaning and develop data quality plans for data issues that required further follow up. Between January and March 2018, Afya Pwani project staff also supported and worked closely with health facilities to generate patient line data from the EMR for all active patients. The line lists revealed gaps on issues viral load (VL) uptake, retention in care (defaulters and lost to follow up
87 Kilifi County Hospital, Msambweni Hospital, Tiwi Rural Health Centre, Kinondo Kwetu Health Centre 88 Gede Health Center, Gongoni Health Center, Muyeye Health Center, Oasis, Vipingo Health Center, Mariakani, Rabai Health Center, Malindi Sub-County Hospital, Mtwapa Health Center, Kilifi County Hospital, Wesu, Wundanyi, Njukini, Taveta Sub- County Hospitals, Mwatate Sub-County Hospitals, Moi Voi County Hospital, Bamburi Health Center, Coast General Hospital, Jomvu Health Center, Kisauni Health Center, Kongowea Health Center, Likoni Sub-County Hospital, Mikindani (MCM) Health Center, Mlaleo Health Center, Mrima Health Center, Port Reitz Sub-County Hospital, Shika Adabu Health Center, Tudor Sub- County Hospital, Lunga Lunga Sub -County Hospital, Vitsangalaweni Health Center, Kwale Sub-County Hospital, Kinondo Kwetu, Waa, Tiwi , Diani Health Center and Msambweni Sub-County Hospital.
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patients) IPT and IQCare PMTCT module uptake. Further, as part of efforts to address these gaps, Afya Pwani also facilitated mentorship of health care workers on how to use the lists for data cleaning and targeted service delivery including provision of VL services and documentation of result to improve patient health outcomes. While conducting the date quality audits, Afya Pwani did a comparison of January 2018 reports in DHIS2, manual tools and IQCare for key indicators in HIV Care and Treatment such as patients enrolled in care, currently in care, starting ART, currently on ART, TB screening and clinic visits. Sampled health facilities showed overall improvement in data concurrence in manual and electronic tools as shown in graphs below.
Current on ART, IQCare/DHIS2, January 2018
IQTools Manual Tools
3000 2835 2638 2500 23462316
2000
1500 1194 1020 10251036 1000 744 746 684 698 652 652 536 607 539 540 438 500 402
0
Vipingo Rabai Mtwapa Mariakani KCH Oasis Gede Gongoni Muyeye Malindi
Figure 32 Kilifi county DHIS/IQCare comparison
Current on ART, IQCare/DHIS2, January 2018
IQTools DHIS 2 Tools
761 761 746 746 800 702 702 700 624 624 600 477 477 500 410 420 345 400 308 300 228 193 200 75 74 100
0
TiwiHealth Diani Health Diani Hospital Kinango Kinondo Kwetu KwaleSub District Lungalunga DistrictHospital Vitsangalaweni Dispensary Waa
Dispensary
Msambweni
Dispensary
Centre
Centre Hospital
Figure 33 Kwale county DHIS/IQCare comparison
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In the same period, Afya Pwani also conducted OJT for 106 health care workers on how to generate daily bookings, missed appointments and defaulters from the EMR. The TA was provided in response to documented challenges HVFs face when managing attrition using manual tools. This support was provided in the 37-high volume EMR facilities in the four counties of Mombasa, Kwale, Taita-Taveta and Kilifi that are being supported by the Afya Pwani project. The project team also highlighted patient records with missing telephone contacts in the EMR for updating to ensure patients can be reached whenever necessary for follow up. Health workers were also supported to generate line lists of unsuppressed clients and defaulters for CHVs to conduct defaulter tracing and appropriate management. Further, available hard copy VL results were flagged and facilities assisted to develop an action plan on EMR records updates. Ultimately, the facilities will be supported to ensure documentation of VL in the EMR is done prior to filing of hard copies as a best practice.
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CPGH Defaulter Tracing Analysis 100% 100% 90% 90% 79% 80% 76% 80% 70% 70% 70% 70% 60% 56% 60% 50% 50% 40% 40%
30% 24% 30%
20% 19% 19% 20% 10% 10% 10% 3% 0% 0% 0% 0% Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18
Traced Back Lost
Figure 34 CPGH Defaulter Tracing Analysis
Kongowea Health Centre Defaulter Tracing Analysis 100% 100% 86% 82% 76% 76% 80% 71% 80%
60% 60% 39% 40% 40%
20% 20% 12% 14% 7% 0% 2% 2% 0% 0% Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18
Traced Back Lost
Figure 35 Defaulter Tracing Analysis
The Afya Pwani team also went further and reviewed hard copy EMR Treatment Preparation register and ART register for January 2018 both for quality of data and concurrence of numbers. It should be noted that there were minimal discrepancies with the data, an apt indicator that the EMR uptake in the counties is improving. The graphs below highlight details of the findings.
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Comparison of Electronic & Manual ART register; Jan 2018
Manual ART Register Electronic ART Register
60 46 49 50 40 40 34 30 24 24 21 16 17 17 20 11 11 13 11 13 7 7 10 10 10 10 10 10 6 6
0
Mikindani Mlaleo Bamburi CPGH Jomvu Kongowea Likoni ShikaAdabu Mrima Reitz Port Kisauni Tudor
Figure 36 Mombasa county comparison of Electronic & Manual ART register
Comparison of Electronic & Manual TP register; Jan 2018
Manual Treatment Preparation Register Electronic Treatment Preparation Register
50 42 40 35 26 28 30 22 24 20 19 16 17 17 17 20 12 12 13 11 11 11 9 11 10 9 9 10 5
0
Bamburi CPGH Jomvu Kongowea Likoni Mikindani Mlaleo ShikaAdabu Mrima Reitz Port Kisauni Tudor
Figure 37 Mombasa county Electronic & Manual TP register comparison In conclusion, facility-specific DQA reports have been filed, with action points on corrective measures documented and facilities are currently conducting data cleaning exercises on all identified gaps. The filed reports will be referenced during follow up DQA exercises. Afya Pwani will continue providing technical support to the facilities to ensure optimal EMR use for HIV service delivery. d) Institutionalize data use at facility and S/CHMT levels for decision making Between January and March 2018, Lamu CHMT was also supported to review performance of service delivery statistics for the October-December 2017 quarter. The data reviews facilitated information sharing and data use by comparing targets with achievements. The data reviews also provided an opportunity for interpretation of indicators. The review meeting took a holistic approach, focusing on all service delivery indicators both HIV and RHMNCAH. As a result, it emerged that the presentation of the County’s service delivery performance was not well aligned to the 90:90:90 global treatment targets.
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Specifically, the presenters did not know how to calculate the first 90 and translate it further to the second and third 90s. In response, Project staff worked with the CASCO to conduct a session on how to derive the 1st 90 from population based targets. In addition, further review of data showed poor performance of 1st 90 due to low uptake of inpatient testing at the Lamu Hospital and the CASCO tasked to mentor health care workers on the need for targeted testing. This quarter project staff also did a comparison of reporting rates between the October-December 2017 and January-March 2018 quarters which showed that there have been marked improvements in reporting rates, as a result of the strategies laid out during the previous review meeting as shown below. For example, one of the strategies that has been successfully utilized includes but is not limited to the use the Lamu County data quality improvement WhatsApp group that provides reminders to health care workers to submit reports within the stipulated timeframe as well as a peer learning platform on different indicators. Moving into the next quarter, the Afya Pwani team will continue to support the CHMT to maintain the gains made.
Lamu County_Comparison of 711 & 731 Reporting Rates
96.10% 86.30% 84.10%
65.10%
Oct-Dec 2017 Jan-Mar 2018
MOH 711 MOH 731-3
Figure 38 Lamu County Comparison of 711 & 731 Reporting Rates
Additionally, lateness in reporting was highlighted as a major challenge in the county. Further interrogation on the reporting trends revealed delays in relaying facility and departmental data to the county records department. During the quarter under review, the county health records and information officer (CHRIO) was tasked to improve mechanisms for data receipt and entry by use of report trackers, to enable follow-up on non-reporting facilities. Afya Pwani will continue building the capacity of relevant teams in addition to providing data trends to improve on timely reporting and/or quality data. During the review meeting, the participants were sensitized on use of Health Information Systems (HIS) the e- learning portal for self-paced orientation on the revised HIV HMIS tools, as well as the Moodle mobile application that allows users to download training presentations and videos for reference. The platforms will ensure that health workers and partners updated on the all reporting requirements.
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Output 3.5 Quality Improvement a) Strengthening Quality Improvement (QI) at County and Sub-County levels During this quarter, Afya Pwani supported quarterly County Quality Improvement Team (CQIT) meetings in Mombasa and Kilifi counties. The meetings brought together a total of 20 participants drawn for the county, sub-county and hospital management teams89. Mombasa, Lamu and Kilifi counties, were supported to develop terms of reference (TOR) for the CQIT. The CQIT in Mombasa received TA to develop guidelines to govern the operations of the quality management unit. Afya Pwani also supported the CQIT to conduct CME’s on quality improvement principles to the work improvement teams (WIT) in Likoni, Port Reitz and Tudor Sub-County Hospitals. The CMEs were aimed at fast tracking the development and implementation of QI projects at facility level. Kilifi90 and Lamu91 received technical support to develop annual QI plans. Lamu also developed key performance indicators for the CQIT, a QI work plan for the year 2018 and an M&E frame work for the CQIT and QIT at facility level. The plans were incorporated into the county AWP for FY 2018/2019. Inclusion of QI activities in the AWP means that QI will be included in the Facility QI training in Kilifi county M&E frame work to enhance performance management of QI. In the period under review, Moi Voi County Referral Hospital, through an executive decision, was identified as a model site for quality management (QM) roll out. To fast track QM initiatives, the project supported a QI rapid results initiative (RRI) in Moi Voi County Referral Hospital. The 100-day RRI which commenced in mid-January 2018 was aimed at accelerating uptake of QI by the CCC, MNCH, laboratory, pharmacy, inpatient departments, outpatient department, nutrition, rehabilitative services and records WIT. The teams were supported to identify priority areas for QI intervention and reported implementation progress in weekly QI review meetings. The maternity WIT for example, has improved partograph documentation in the maternity and initiated a decision-to-incision QI project which has reduced turnaround time for emergency C-sections from 4hours and 30mins to 2 hours and 20 minutes. Figure 38 below illustrates the proportion of babies receiving cord care with chlorhexidine within 30 minutes of delivery to reduce probability of neonatal sepsis and ultimately neonatal morbidity and mortality.
89 Mombasa: Tudor, Port Reitz, Likoni Hospitals and Nyali/Kisauni, Mvita, Changamwe and Likoni Sub-Counties. 90 Kilifi CRH, Malindi Sub-County Hospital, Mariakani Sub-County Hospital, Mtwapa Health Center, Gede Health Center, Vipingo Health Center, Rabai Health Center, Bamba Sub-County Hospital, Gongoni Health Center, Chasimba Health Center, Ganze Health Center, Gotani Dispensary, Malindi Health Center, Tsangatsini Dispensary, Matsangoni Health Center, Vitengeni Dispensary, Marafa Health Center, Baolala Dispensary, Marereni Dispensary, Mambrui Dispensary 91 Lamu County Referral Hospital, Faza Sub-County Hospital, Mpeketoni Sub-County Hospital, Witu Health Center.
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Proportion of babies with intial cord care using chlorohexidine in the first 30 min after delivery
100 Goal 90 80 70 60 50
percentage 40 30 20 10 0 1 2 3 4 5 6 7 8 9 10 11 12 Weeks Figure 39 Proportion of babies with initial cord care using chlorohexidine within 30 minutes of delivery in Moi Voi County Referral Hospital.
The project also supported QI CMEs targeting 30 members of the hospital WIT. Lessons from the RRI will inform scale-up of QI interventions to Taveta, Wesu and Mwatate Hospitals. Afya Pwani also facilitated the implementation of a customer satisfaction survey for the hospital. The survey in the County Referral Hospital will give the CQIT, Hospital QIT and WIT insights into the customers’ perception of quality of care and inform the project’s scale up of similar interventions to other facilities in the five target counties. The CQIT also received technical support to develop QI annual plans for inclusion in the AWP for FY 2018/2019.
b) Strengthening QI at Facility Level
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During the quarter, Afya Pwani trained 118 health care workers including nurses, doctors, HIROs, pharmacists from 30 health facilities and two health department units92 in Kilifi93 and Mombasa94. The training covered basics on QI and QI best practices in line with the health care delivery model. The training was aimed at improving the participants understanding of continuous quality improvement (CQI) and transfer skills on integration of CQI activities into day to day health service delivery efforts. The training further demonstrated implementation of the Plan Do Study Act (PDSA) to enable WITs to develop and implement small tests of change. The training also focused on data collection/analysis and teamwork approach in QI implementation. As a follow up, the facility QI teams will be supported to implement QI at the program and facility level by Identifying areas in their scope of work to apply CQI principles and methodologies to develop home grown solutions to the challenges identified in health care and especially in HIV and MNCH.
III. ACTIVITY PROGRESS (QUANTITATIVE IMPACT) Please see Attachment II for the full performance summary tables.
92 Mombasa substance abuse and public health units 93Kilifi - 20 facilities: Mtwapa HC, Vipingo HC, Chasimba dispensary, Bamba sub county hospital, Rabai HC, Mariakani sub county hospital, Malindi sub county hospital Marereni HC, Tsangatsini dispensary, Ganze HC, Vitengeni HC, Magarini sub county hospital, Baolala HC, Gotani HC, Gede HC, Marafa HC, Gongoni HC and Mambrui dispensary 94 Mombasa - 10 facilities: Likoni sub county hospital, Ganjoni dispensary, Port Reitz hospital, Bamburi HC, Mlaleo HC, Kisauni dispensary, Kongowea HC, Jomvu model HC, Mikindani dispensary, Miritini CDF dispensary), Nyali/Kisauni, Changamwe/Jomvu, Mvita, and Likoni sub counties.
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IV. CONSTRAINTS AND OPPORTUNITIES
Table 30 Summary of Challenges and Recommendations for January-March 2018
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Challenges Recommendations
Sub-Purpose 1
User fee charges for ANC profile testing in the public Continuous engagement with the CHMTs to either waive facilities in Mombasa County and private and FBO or subsidize ANC profiling costs with a long-term plan for facilities in all the other counties as well limiting universal the counties to increase budgetary allocations to health access to PMTCT services. services.
Shortages of RTKs in some facilities due to low Technical support for quantification meetings at county quantifications of commodities leading to HIV testing and sub-county level in which MOH teams are supported missed opportunities. to properly quantify and report utilization of RTKs.
Reports from support groups and the defaulters who are Supported PHDP and support group therapies for clients, traced back, indicate that stigma (especially self-stigma), especially new and those brought back after defaulting. religious belief and use of herbal medicine are contributing factors for defaulting.
Tracking of clients referred from one facility to the other, Peer educators help with tracking of referrals. CHMTs especially the newly diagnosed positive who wish to committed to developing referral directories to enable enroll in another facility is sometimes difficult especially easy follow up. when private facilities are involved.
Not all health care workers are updated on the ART On job training and support supervision in progress to guidelines especially the newly employed staff. update the newly employed staff on ART guidelines.
Inconsistent defaulter tracing activities due to lack of Lobby health care workers to make use of available support in Lamu which is a central support county. resources at the facilities i.e. CHVs and facility airtime to facilitate defaulter tracing. HSS team also supporting the county in program-based budgeting.
Lack of reminders among adolescents on time to take One on one sessions with the respective caregivers of the medication. adolescents were conducted and empowered them to provide closer care to their adolescents.
Caregiver support inadequate to the adolescents.
High-levels of stigma in schools since not all students and Continue engagement of teachers living with HIV to reach teachers reached with stigma reduction messages. many students and teachers with stigma reduction messages.
Inability to perform CD4 tests in some facilities due to Referring of samples to CPGH or Kinango Hospital through breakdown of CD4 machines in Kwale county. the lab networking support.
Not all health care workers are updated on the ART On job trainings, CMEs and mentorship done to update guidelines especially the newly employed ones. the newly employed staff on ART guidelines.
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Frequent inter department changeover of staff within the Lobby with the CHMT to ensure health care workers in facilities and transfers affecting quality of ART services in key ART service delivery points are not transferred to Witu and Mpeketoni resulting to missed opportunities. other facilities or to other departments at a go. At least one experienced nurse/clinical officer should be retained to ensure continuity of quality ART services and to provide on job training to the newly posted staff.
In adequate supply on the new ART guidelines for health The project continues to photocopy on a need basis and care workers to refer to. distribute to facilities.
In adequate clinical staff in some facilities leading to Rotational clinicians from Afya Pwani support some of unqualified health care workers attending to ART clients. these sites.
Stigma is still a challenge in some facilities, this has been The project is on the process of recruiting adherence demonstrated during support group sessions. counselors in the affected facilities.
Poor technical skills among different service providers on The frequency of conducting support supervision and specimen harvesting mostly DBS from infants mentorship for technical and skills transfer will be increased.
Remote facilities cannot access online results due to poor VL and EID hard copy results will continue to be printed network connectivity. and sent to facilities.
Breakdown of the CD4 machines making baselines CD4 The samples for the CD4 are taken to CPGH or Kinango test delayed in Kwale county. through the lab networking support.
Stock outs of DBS kits in facilities Outsourced from other counties and redistributed.
Shortage of HIV test kits in some facilities, leading to Sourced some test kits from Kwale county and some clients not to be tested. redistributed to the facilities which were lacking. Supported a meeting for SCMLTs and CMLTs to enable them to do proper allocation of HIV test kits.
HTS counselors are still very few in the project supported Advocating for more counselors from the counties and facilities making saturation of facilities with testing and project to hire a few more to ease the gap. Meetings with counseling hard. the nurses to advocate for resumption testing is underway.
Some of the PNS providers trained by Afya Pwani to Afya Pwani participated more in selection of HTS support implementation of PNS have left the counties providers who were trained Kaloleni Sub-County and they were trained in and joined other programs, 5 PNS Taita Taveta to ensure that HTS counselors were trained providers have left (2 male left Kilifi) and 2 females left first. Mombasa counties. While health care such as nurses and clinical officers may not practice PNS in the health facilities and communities.
Back log of samples for GeneXpert testing at Moi CRH Some samples were sent to Taveta SCH for testing and following sensitization of health workers on GeneXpert staffs at the Moi CRH worked for extra hours to clear the utilization with many samples being collected. back log.
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IPT data not consistently reported and entries to DHIS2 Provided facilities with IPT interim reporting tools and not done. encouraged them to report every month to enable SCHRIOs to enter in DHIS2. The SCHRIOs have been supported in making entries in DHIS2.
Breakdown of GeneXpert Machine in Lamu and Malindi. Lobby with TB program to repair the machine. Machine is now under repair expected to start functioning soon. A new air conditioner was installed to provide conducive temperature for functioning of the GeneXpert machine in Malindi.
Inconsistency of supply of GeneXpert reagents. Redistribution of the reagents from CPGH as the county waits redistribution from reference lab and KEMSA.
Challenges Encountered Recommendations
Sub-Purpose 2
Delivery rooms are dusty and disorganized affecting the Project staff and working with facility staff to ensure all quality of care for clients seeking services. delivery rooms are organized and are cleaned daily as part of efforts to ensure that clients delivering in these rooms receive the best of care and are not exposed to infections.
Stock outs of room temperature Syntocinon Project staff will work with HPT advisor and liaise with the Sub-County SPF to order room temperature Syntocinon to ensure that there are no stock outs and that the facilities improve their forecasting and quantification of the same for better commodity supply management.
Monitor charts for Vitamin A and immunizations not in Project staff will liaise with facility staff and ensure that place. all Vitamin A and immunization monitor charts from the SCPHN office are collected, distributed and displayed across all facilities.
Expired drugs not documented Afya Pwani’s commodity advisor will work closely with the facility teams to build their capacity to document all expired drugs as part of efforts to improve commodity supply management.
Inadequate space for RH services e.g. post abortion care Cognizant that some facilities lack adequate space to provide SRH services work with the SCMOH to lobby for more space.
Immunizations and Antenatal services scheduled in some Work with the facility teams to ensure that facilities. immunizations and Antenatal services are provided on a daily-basis. The Project team will investigate what the root causes are for the inadequate service provision.
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Maternity register without page summaries Afya Pwani staff will work at the facility level and carry out DQAs to ensure that all maternity and ANC registers are updated with page summaries.
Service charter not available Project staff will work to put up service charter for the facility.
Weight for under ones taken but height not taken Afya Pwani staff will build the capacity of service providers to take weight as well as height for infants during their assessments at the CWCs.
Vitamin A and immunization monitor chart for 2018 not Facility staff have been informed that that the Vitamin A in place and Immunization charts for 2018.
Bin cards not updated Project staff have informed the relevant health facility staff to update bin cards as per national guidelines and protocols on the same.
AL/DAR register not in place AL/DAR registers have been ordered and will be distributed to facilities lacking the same. Disease surveillance not done Intensify disease surveillance
Hand washing facility at the staff toilet not available Project staff have discussed the issue with the facility management team and solutions are being considered as to how to be able to put in place hand washing facility as part of WASH efforts. Health care worker prefer using tally sheet to the Afya Pwani in collaboration with MOH to constantly permanent register. support facility in charges to ensure that permanent registers are updated. Some facilities do not have community units attached to Use other existing community mechanisms e.g. Nyumba them hence difficulties tracing immunization defaulters Kumi to trace defaulters.
Outbreaks of diarrhea diseases during rainy season Advocate for preparedness mechanism for quick response to disease outbreaks as well WASH interventions prior to rain season. Marie Stopes conducts in-reaches in the facilities Advocate for streamlining of commodity management specially to insert implants and IUCDs. However, they use through CHMT and liaising with Marie Stoppes and other their own commodities and documentation is not partners to align reporting tools. properly done to show that they have issued commodities to the institution and this leads to data errors during reporting.
There’s a mismatch between the new FP Register and the Health workers have been advised to improvise by Facility Contraceptives Consumption Data Report and dividing the slot for implants into two but revision of the Request Form (FCCDRR. The new register doesn’t have tools (both the register and the FCCDRR is the best columns for change of method and yet the reporting form solution). requires this data. Both the old and the new FP Registers have only space for implants without specifying either 1-
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rod (Implanon-Nxt) or 2-rod (Jadelle). This is causing confusion and data errors.
Most health facilities/schools especially in Ganze don’t Support installation of additional rainwater harvesting have adequate water supply as a good enhancer to storage tanks and pipeline extension to strategic areas for sustain hand washing practice general hygiene. Pressing priorities by the county government Joint planning meeting with inclusion of the county resulting into postponement of scheduled activities. chiefs/officials.
SUB-PURPOSE 3
Advocate through the health and budget committee to Centralized payment system at treasury and the limited influence devolvement of the payment system to the departmental control on allocated resources. county departmental level. Lack of sustained engagement mechanisms between Institutionalization of engagement forums between county treasury and the health department. treasury and health departments.
CHMTs still view budgeting processes as a prerogative of Identify planning and budget champions among the the treasury and not as part of their core mandate. CHMT. to be in constant linkage with treasury and consider hiring a health economist to be primarily responsible for guiding the department through the budget cycle. Functioning of County HRH Stakeholders committees is There is need to institutionalize County HRH Stakeholders destabilized the moment counties undergo changes in Committees to ensure stability regardless of change in political leadership as well as health department leadership. leadership. Limited pharmaceuticals human resources to implement Building the capacity of other cadres on pharmaceuticals effective commodity management practices. commodity management.
Inadequate resource allocation for procurement and Align county F&Q processes with county budgeting cycle commodity management. to inform allocation of resources for procurement of health commodities. Poor data use culture among facility HWs to provide Build the capacity of facility HMT to strengthen visibility targeted health interventions. of routine data among HWs to inform patient case management and facility performance reviews. Gender
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Shortage of updated tools for reference at health The USAID Afya Pwani Deputy Chief of Party has facilities. requested for tools on behalf of the programs team. Photocopies of tools are being made and distributed in the meantime.
Defaulting psychological support by GBV survivors. The GBV Center in CPGH is being operated under a private-public partnership. Afya Pwani has established that clients are given PEP for 28 days during the first visit because many clients lack of finances for regular transport to the health facility. Clients typically visit the GBV center once after 28 days and often do not return for services thereafter. The Project is consulting on how to best address this issue. Lack of tangible legal redress provided to GBV survivors The Gender team will address this in the following in terms of quality and documentation. quarter. Links are being sought with FIDA.
V. PERFORMANCE MONITORING PERFORMANCE MONITORING Improving Data Quality During the January- March 2018 quarter, the Afya Pwani project continued to focus improving data quality across all the health facilities that the project was supporting. Of note is that the six-month-long industrial action by health care workers significantly affected documentation of services, and due to extra high workload amongst the health service providers still at work, especially staff working in non-HIV sections (which bore the brunt of the heavy workload), there were challenges when it came to data collection and reporting. For example, facilities with a limited number of health care workers had difficulties effectively updating all relevant HIV care registers and forms in line with national guidelines and protocols. Poor documentation affects the accuracy of reports and contributes significantly to low data quality and doubt, regarding whether reports emanating from such facilities are a true reflection of health service delivery statistics. To improve data quality from Afya Pwani supported sites, project staff prioritized data quality assurance during the reporting period under review. More specifically, project staff worked to establish the quality of the data, and facilitated cleaning of facility data as part of efforts to enhance data reliability for effective performance monitoring. To this end, the team, in collaboration with the five counties/sub- counties M&E units, made several facility visits to verify reports and provide technical support in reporting and documentation. During these visits, project staff identified that some of filled source documents (MOH registers) were completely or partly missing. It was also realized that there was a lack of transition to the new tools, which was resulting in inconsistent reporting thus hindering the reliance of data facilities submitting through MOH 731 and DHIS2.
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Moreover, during the quarter under review, the Afya Pwani team also developed and adopted a data verification form (See the Figure 39 below) for easier and faster identification of data discrepancies at the source and after data upload to DHIS2. The form picks data from the MOH 731, DATIM, and DHIS2; at the time of verification, the person conducting the verification also picks the value of each indicator as it is in MOH 731 summary for the current reporting period as it is without any modification. Upon completion of filling the DATIM summary, the aggregated figure is entered in the DATIM column. In case there are any discrepancies between the figure in MOH 731 and DATIM for any indicator, the issue is discussed with the health care workers in the facility, especially the one that prepared the report or the section of the report. The cause of the error (s) is identified and addressed. The project hopes that with this verification method now in place, that when repeated over time, health care workers are going to integrate quality whenever they populate and submit reports periodically.
Figure 40 Afya Pwani Data Verification tool
Specific interventions and outputs on improving data quality in our Counties of implementation below: i. Mombasa County a. Mombasa-Likoni Catholic Clinic, Between January and March 2018, the Project supported a facility data verification exercise at the Likoni Catholic Clinic in Mombasa for data documented and reported in Q1 FY2018; during this exercise it was identified that there was poor documentation in patient files and lack of use of HIV Care & Treatment registers. It was also identified that there were a questionable data errors regarding the number of patients on ART indicator, between Q1 (549) and Q2 January-March 2018 (368). When followed up, it was also noted that the facility was missing the Daily Activity and ART registers, thus they were unable to accurately record and count the actual patients on ART. As a corrective measure, the facility was issued with new registers from the county, and the team provided TA on their use. The team also facilitated a line listing exercise, which provided a status of each patient in the facility. It should be noted that the following: Out of the 368 patients identified in the facility, 296 patients had a documented active status in the patient files. The rest were unknown; a total of 70 out of 296 active patients were missing a viral load test/result and lastly 30 defaulters were identified and were being followed up. Moving forward it was agreed that Afya Pwani would implement the following corrective action plan: The facility staff was tasked with documenting the status of unknown patients and that health service providers were issued with all the necessary ART registers and mentored on the use.
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b. Mombasa-Chaani MCM Dispensary: During the quarter under review, project staff also supported a follow up visit at the Chaani MCM Dispensary in Mombasa as there was a loss of 37 out of 299 patients between October and December 2017 and January 2018. During the visits, project staff identified that there were challenges regarding both quality of care and reporting. Moving forward, the Afya Pwani team line listed the clients, after which it was found that 41 lost patients were still being reported as active (this was corrected and the actual figures reported during this quarter); 32 defaulters in the quarter were listed for follow-up and only 86 out of 230 active patients had their Viral Load status in the patient files. Other issues identified, included challenges by health service providers using the updated NASCOP HIV tools; gaps that have been addressed by training from Afya Pwani staff on the new tools. c. Mvita Dispensary: Project staff also supported and facilitated routine data quality checks at Mvita Dispensary during the quarter under review, whereby it was highlighted that that the number of current on ART client numbers had been over reported in December 2017. Additionally, it was also identified that non-use of the ART registers was a major challenge that needed to be addressed moving forward. As part of efforts to verify client numbers, project staff line listed and identified the active ART patients seeking services at the facility; health service providers are now and are following them up using the relevant ART registers. The table below highlights the findings from the line listing of clients done at the three facilities during the quarter. Please see Table 31 below:
Table 31 Key Findings from Line Listing of Clients Jan-Mar 2018 Facility Current on Current on ART Net Actual Defaulters LTFU ART Dec Jan 2018 Loss Number on 2017 ART Likoni Catholic 549 367 -182 367 36 Clinic Mvita Dispensary 235 187 -48 235 13 31
Chaani MCM 262 232 -30 232 37 Dispensary
Crosscutting issues across all three facilities: In addition to the facility specific challenges that have been discussed above, project staff also highlighted that all three sites lacked DAR and ART registers which significantly hindered report generations; the lack of use and actual registers resulted in all the facilities not having a clear picture of their ART numbers. Other facilities were visited as part of routine monitoring, data collection and verification exercise. To address this gap, Afya Pwani ensured that facilities were issued with ART registers and mentored on their use. After being mentored on the use of the tools, health service providers at Mvita Health Center for example, could now list and identify their actual numbers on ART. They have since updated the ART register and follow the active patients in the DAR. Further, 13 defaulters & 31 LTFU patients were also identified and were being followed up following the support from the project. Lastly, during the line listing exercise in Chaani Dispensary, project staff identified 37 defaulters who were listed for follow-up; to improve TA on documentation in the patient files was done at the facility. Because of these interventions, project staff have seen improvements in data quality and reporting as well as understanding of the indicators. Refresher trainings and orientation on the new tools has provided the facility teams with an
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understanding of indicators and address knowledge gaps, and the roll out of new tools will better align the NASCOP reportable indicators to PEPFAR MER guidelines.
Taita-Taveta In this County during the quarter under review, four facilities (Moi Voi County Referral, Taveta Sub-County Hospital, Wundanyi Sub-County Hospital and Mwatate Sub-County Hospital) underwent data verification exercises to help identify data quality gaps and to address the same. The exercise revealed some gaps were noted both on manual registers and in EMR/IQ Care system where the two reports had discrepancies. This was however due to lack of data capture tools and missed entries in the IQ care system. Other findings include but are not limited to: Inconsistences in data generated in the registers and the EMR; Undocumented patient status; Odd regimens given; Patients missing IPT details and TB screening Missing as well. To address these gaps, the facilities came up with the line lists for the gaps identified and cleaning was done and completed to ascertain accurately the number of clients each facility has under their custody as active, missed appointments, defaulters, LTFU, Transfer Out, and dead. Moreover, the team worked in hand with the county teams to avail required tools – registers and reporting tools in all the health facilities. The team also provided technical support and shall continue with follow up aimed at ensuring proper utilization for the tools and generation of data that meets all the dimensions of the data quality reported through DATIM, Joint Partner Health and Environment System (JPHES), and DHIS2 platforms.
Kilifi County In Kilifi the project carried data verification to establish the accuracy of the data submitted in the between October 2017 to February 2018 across all seven sub-counties in the County. The major findings from the data verification visits are as follows: Data collection tools were available across facilities; Archiving of reports in majority of the facilities was being done well; There was a variation from one facility to another on documentation gaps; FIC documentation challenges in the permanent register for immunization was cutting across all the facilities; There was over reliant of tally sheets to generate reports for immunization and CWC instead of the source register; Inconsistent use of codes to fill some columns in the different service registers; Task-shifting between technical staff and support staff in service documentation; High discrepancies were noted to be between facility summaries and registers, thus summaries and DHIS 2had minimal discrepancies; PNC seemed not a priority service in most facilities thus registers not in use and final ORT corner registers are not consistently updated. The graph below provides a snapshot of some of the data verification findings supported during the January-March 2018 quarter being reviewed.
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Comparison of clients receiving FP Commodities- NOV 17- JAN 18 2500 2000 1500 1000 500 0 KCH Matsangoni Gede Mnarani Mtondia Reg 846 412 400 179 213 Summ. 1997 381 381 179 289 DHIS 1997 381 381 176 282
Figure 41 Comparison of clients receiving FP Commodities- NOV 17- JAN 18
Considering the findings above, project staff have supported the implementation of the following corrective action measures to address the gaps identified above: Mentorship and OJT on data collection and reporting tools; Consistent supportive supervision to lower units; Sensitization of health workers on data demand and use; Data cleaning to ensure constancy between Registers, summaries and DHIS2; Quarterly data review meetings to be done; Proper documentation; Filling of ANC & CWC Register as per codes; Report ANC 4th visits only once excluding 5thor 6th visits to avoid double reporting in next monthly reports; Routine documentation in immunization register and tally sheet; Routine documentation in both MOH 731 and HEI; Consistence follow-up of PNC clients and documentation; Routine data cleaning and verification before submission; Routine treatment of diarrhea using ORS and ZINC; and lastly use IMCI case classification guidelines. Kwale County Between January and March 2018, the Project also supported and facilitated data review of reports that facilities submitted during the quarter as part of efforts to improve the quality of data at these sites and to identify possible data errors before and after entry in DHIS2. When compared to previous periods, project staff identified that several facilities in the County had reported gains in clients currently on ART while other facilities recorded losses in same section of care and treatment. Regarding HTS and linkage some facilities reported to have linked clients than the positives recorded in the period while other facilities had less linked than the positives identified in the facilities. Whilst in the case of PMTCT, the project endeavored to identify any reported missed opportunities in testing and HAART through simple computations based on the reported figures per facility. Moving forward, it is clear that health care workers have not yet mastered the correct definitions of data elements in MOH 731 and the interrelatedness of the various sections of the report. As such there is need for continuous one on one or group medical education sessions to share experiences in the compilation of the reports. Some reports are submitted without verification thus making it difficult to ascertain the quality of the report. This creates room for blame among health care workers whenever they are asked to explain the numbers recorded in their report. Moreover, the lack of ownership of facility level data is also an issue that is affecting data quality especially when clarification is needed and or an issue is raised. Subsequently, the project shall support printing of performance dashboards to be updated immediately
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after data has been verified and before submission to the next level. The project has disseminated targets on all performance areas to all facilities for easy monitoring of performance. Additionally, in some facilities, there was poor documentation at the point of care where patient cards do not have information on the last visit to the clinic thus making it difficult to ascertain the correct number of clients the facilities have on ART. The project conducted line-listing of all clients in the facilities to determine the correct number of clients in each facility. Reporting in DHIS2 In the spirit of strengthening accurate and timely reporting in the DHIS2, Afya Pwani facilitated the provision of data bundles for the five county M&E teams by with data bundles to facilitate timely upload of verified facility reports to DHIS2 reporting aiming to achieve 100% in timeliness and accuracy as well as other parameters of data quality. In addition to bundles the project offers technical support in correct interpretation of service trends as reported from facilities and helps the program team to identify issues for technical follow up at facility level. The results of this support are detailed in Figure 42 below:
Afya Pwani DHIS2 Support: Reporting Rates on Selected Reports 120
101.4 95 97.8 97.4 95.4 100 93.4 91.7 91.9 92.3 88.3 89.4 90.6 84.3 81 77.3 78.8 78.1 80 72.5 69.3 67.7
60
40 Reporting Rates (%)
20
0 MOH 711 MOH 731-1 HTS MOH 731-2 PMTCT MOH 731-3 C & T Selected HMIS Report
September 2017 October 2017 November 2017 December 2017 January 2018 February 2018 March 2018
Figure 42 Afya Pwani DHIS2 Reporting Rates
The reporting rate at the baseline month (September 2017) remains the lowest in the current reporting period clearly indicating that Afya Pwani SI team is committed to ensuring such performance does not happen again. It is such commitment that prompts the project to strive towards harmonizing DATIM and DHIS2 data through supporting data management processes for both systems. It is noteworthy to note that January 2018 recorded the highest reporting rate in all MOH 731 departmental reports, something that can be attributed to increasing awareness on the poor performance recorded in the three last months of December 2017. The project continued to support such efforts in February and March 2018 to minimize as much as possible the low rates experienced at Annual Program Review (APR) FY17. The March 2018
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rate is the lowest in the quarter. The detailed trends for each of the counties the project supports are presented below:
MOH 711 Reporting Rates in Afya Pwani Supported Counties 120
100
80
60
40
Reporting Rates (%) 20
0 Kilifi County Kwale County Mombasa County Lamu County Taita Taveta County MOH 711 Afya Pwani Supported Counties
September 2017 October 2017 November 2017 December 2017 January 2018 February 2018 March 2018
Figure 43 MOH 711 DHIS2 Reporting rates Q2
MOH 731-1 (HTS) Reporting Rates in Afya Pwani Supported Counties 120
100
80
60
40
Reporting Rates (%) 20
0 Kilifi County Kwale County Mombasa County Lamu County Taita Taveta County MOH 731-1 HTS Afya Pwani Supported Counties
September 2017 October 2017 November 2017 December 2017 January 2018 February 2018 March 2018
Figure 44 MOH 731-1 (HTS) DHIS2 Reporting rates
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MOH 731-2 (PMTCT) Reporting Rates in Afya Pwani Supported Counties 120
100
80
60
40 Reporting Rates (%) 20
0 Kilifi County Kwale County Mombasa County Lamu County Taita Taveta County MOH 731-2 PMTCT Afya Pwani Supported Counties
September 2017 October 2017 November 2017 December 2017 January 2018 February 2018 March 2018
Figure 45 MOH 731-2 (PMTCT) DHIS2 Reporting rate
MOH 731-3 (Care & Treatment) Reporting Rates in Afya Pwani Supported Counties 120 100 80 60 40
20 Reporting Rates (%) 0 Kilifi County Kwale County Mombasa County Lamu County Taita Taveta County MOH 731-3 C & T Afya Pwani Supported Counties
September 2017 October 2017 November 2017 December 2017 January 2018 February 2018 March 2018
Figure 46 MOH 731-3 (Care & Treatment) DHIS2 Reporting Rate
In March 2018, Afya Pwani worked with the Kwale M&E team to conduct a deep dive of data from the sites in the County. The increased attention to data quality among Sub-County M&E staff resulted in the rejection of some reports necessitating a review and a repeat at the facilities thus delaying timely reporting. In Mombasa, the deep fall in March, unlike in Feb where there was 94%, 95% and 98% HTS,
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PMTCT and Care and Treatment reporting respectively, the transition of the MOH 731 data tool which began in March 2018, has had a negative toll on reporting rates as in the chart above. Moreover, data verification and validation that the project supports before data upload to DHIS2 led to identification of data errors early enough in Nyali and Kisauni Sub-Counties for the new MOH 731 reporting tool in DHIS2 platform, which has hindered completion of the MOH 731 in DHIS2. For Mvita Sub-County, facilities submitted the new MOH 731, for which changes in the platform had not been made. In Taita-Taveta County, the reporting rates have remained consistent 95% on average for the last 5 months since November 2017. This has been made possible through setting early deadlines for data entry in the DHIS2 i.e. By the 7th of every month rather than date 15th which is set nationally which makes it possible to follow up none reporting facilities on time. Capacity Building in Documentation and Reporting Through Refresher Trainings on HIV New Reporting Tools Refresher training for the newly revised tools was also done in all the four sub-counties in Taita-Taveta during the quarter under review i.e. Wundanyi, Voi, Mwatate and Taveta where facility service providers were sensitized on the HIV reporting tools that cover HTS, PMTCT and Care and Treatment on how to correctly capture information on the registers and how to extract the report in to the MOH 731. All the facilities in the County were represented in the training however a major concern was lack of enough tools in the facilities which is currently being handled by NASCOP meanwhile plans are underway to make few copies as we wait for the distribution from NASCOP. In Mombasa County, facility service providers were sensitized on the HIV reporting tools, covering HTS, PMTCT and Care and Treatment service providers. There was 80% coverage for HTS providers in Afya Pwani supported sites and Refresher training for the revised HMIS tools at Mwatate Sub-County Hospital. 100% coverage for both PMTCT and Care & Treatment service areas. Reporting Compliance Every month the Afya Pwani team conducts mandatory data collection, verification, cleaning, analysis, presentation and reporting exercises across project supported sites. More specifically, the purpose of this exercise is to ensure that the project has reliable data to make improved decisions and to aptly track performance. Between January and March 2018, the Afya Pwani team successfully completed the data collection exercise; results which have been fed into DATIM and JPHES respectively. Project staff used source tools to carry out the exercise, where the findings were verified using the facility summary tools. As part of data collection follow up during the quarter, Afya Pwani project staff have also been provided with data to make sure they track their own performance and make decisions across different project areas. DATIM data collection and verification exercise were also successfully done during the period and data findings shared monthly. These data findings were also shared and follow up done by the Program teams, for example, in Mwakirunge Dispensary three mothers were reported to have missed HAART for pregnancy in the October-December 2017 quarter. On follow-up and verification, the identified mothers from Mwakirunge Dispensary were confirmed to have been issued with HAART but had not been
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documented. Project staff will continue to follow up on these individual cases as the team goes through the process of data collection and verification across all supported facilities. DATIM Data Quality Between January and March 2018, Afya Pwani staff conducted rapid line-listing (data verification) in facilities that had reported abnormal variations in current on ART and other indicators to ascertain the actual number of clients in each facility. In Mombasa, the Line listing was done in CPGH, Mvita Clinic, Likoni Catholic and Chaani MCM. In Kwale it was done in N’gombeni, Shimba Hills, Vitsangalaweni, Godo, Taru dispensary, Mackinon Road Dispensary, Kilibasi, Mazeras Dispensary, and Kafuduni Dispensary respectively. Other areas of follow up identified during data verification were as highlighted in Table 32 below. Action points were undertaken at that point or highlighted for follow up in the coming quarter.
Table 32 Corrective Action Plans Apr-Jun 2018 Facility Gaps on Action Point Way Forward & Verification Status Tudor SCH Over reporting of KP TA provided and MOH 731 Continuous monitoring. mothers in Mar 2018 731 manual and DHIS2 report platform corrected. Lack of documentation of patients enrolled in care in Treatment Prep Register. Mbuta Health Lack of registers hindered- Data cleaning Data cleaning is Center MOH 731 report- Facility follow-up with the currently ongoing and generation. s-county teams for TA on 11 defaulters have been documentation and identified for follow-up. reporting. Mvita Dispensary Documentation of IPT Mentorship has been done Further follow up & outcomes in the register to the service providers. mentorship to be done Challenge in using the ART with the s-county team. Cohort register and DAR (OIS). CPGH Poor documentation and Joint TA and supervision Continuous follow up data transcription from the has been planned with the and mentor ship to be registers to the reporting sub-county. done in Q3-2018. platforms. Data review meeting to be Nonuse of some registers done. e.g. presumptive TB register. Shika Adabu Poor documentation of Joint TA and supervision Continuous follow up Dispensary ART registers. has been planned with the and mentor ship to be s-county. done in Q3-2018.
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TA on Reporting and Documentation During the quarter under review, Project staff continued to invest resources in providing targeted TA at the facility level to identify and address the gaps highlighted during the data verification exercises. Through these efforts reporting gaps were identified and sorted as follows; Taita Taveta In Taita-Taveta health service providers from 10 facilities were reached with mentorship that was focused on data capture and reporting. For example, in the case of Kitobo Dispensary, project staff were experience challenges extracting data on the number of current on ART, it was initially reported that 46 clients were currently on ART, but following the mentorship from project staff, the true figure was actually 84. In the case of Moi County Referral Hospital, health service providers were used to omitting PMTCT mothers in the facility summary reports, an issue that Afya Pwani, through their mentorship activities addressed. Other facilities that benefitted from Afya Pwani facilitated mentorship during the quarter, includes, Mwatate Sub-County Hospital, Taveta Sub-County Hospital, Wundanyi Sub-County Hospital, Ndilidau, Ndovu, Maungu Health Center. Mombasa In Mombasa County, Afya Pwani project staff focused on providing TA on reporting and documentation at Tudor Hospital and Railway Dispensary. Of note is that March 2018 reports revealed that the Maternal and Child Health service providers had a challenge documenting and reporting the ‘Known Positive’ mothers due to the changes in the ANC register on ‘HIV result’ section. To help address this gap, project staff provided targeted TA on the changed ANC register and the apt corrections made in the MOH 731 report. Regarding IPT documentations, project staff did note some gaps regarding documentation of final status of IPT for their patients. Facility site assessment at Kongowea Health Center also revealed that 30% of CLHIV files, 70% of adult files and 90% of PMTCT Mothers’ files had documentation of IPT status. Afya Pwani’s EMR DQA also revealed poor documentation of IPT in all EMR sites. Of further note is that Mikindani MCM Dispensary reported a variance of (-)108; for patients, currently on ART between Dec 2017 and Jan 2018. Upon further investigation, during the DATIM monthly verification exercise, it was noted that there was a counting error in December 2017. Further investigation also revealed that there were several clients who defaulted in Q1. Findings were shared with the program officer for follow-up. Kilifi During the quarter, Project supported HRIOs managed to visit all sites for support in documentation and data collection where they identified several gaps including but not limited to documentation of starting clients on ART in PMTCT and the CCC, and provision of infant prophylaxis. Additionally, Afya Pwani HRIOs also verified data and made appropriate corrections and documented explanation for the missed opportunities identified by facilitating orientations and OJTs on documentation in service registers for PMTCT, HTS, Care and Treatment, PNC, ANC, maternity and delivery, FP, WASH and Nutrition and IPT. With the new tools distributed to the facilities, the project also embarked on supporting health care workers to understand the different sections in the registers and reporting summaries as part of efforts to build their capacity to collect and report facility level data. Kwale Afya Pwani also continued to provide TA for health service providers in Kwale County on use of the revised MOH tools as part of efforts to improve the data quality coming from the supported facilities in the
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County. More specifically, project staff conducted OJT and provided mentorship on summarizing the DAR, updated ART register as well as the MOH 731 and HTS registers at 1495 facilities. Because of these interventions, project staff have seen improved quality of data and all registers are now up to date. Lastly, Project staff also facilitated the distribution of new HIV reporting tools i.e. DAR, HIV guidelines, Kenya Mentor Mothers Program (KMMP), PNC, ANC, ART, counseling, testing and linkage registers to 1996 facilities. Data Demand and Information Use (DDIU) Between January and March 2018, Afya Pwani also focused efforts on building the capacity of health service providers to better utilize their data for improved decision making by facilitating and organizing data review meetings, development and updating of data use charts, and supporting continuous quality improvement (CQI). In facilities where EMR is updated the project also continued to provide technical assistance in helping service providers generate line-lists for all patients due for viral suppression and for those who are unsuppressed. Patients not or on IPT, defaulters etc. and they can utilize this information in management of their clients. In Kilifi this quarter, Muyeye, Gede and Mtwapa conducted data review meetings focusing on n RMNCAH/FP, HTS, Care and Treatment as well as PMTCT performance. Following these meetings, Afya Pwani project staff helped facility staff to develop corrective action plans to address their performance gaps; more specifically, health workers at these sites agreed to conduct more outreaches, focus on establishing Traditional Birth Attendant (TBA clubs) [to provide a forum for sharing of positive health information] and after care services like escorting clients after testing positive as well as complete documentation in service registers especially the ORT register. In Lamu County, project staff focused on supporting the CHMT to conduct data and performance reviews by providing data analysis, dissemination and interpretation of data and indicators for HTS and Care and Treatment program areas. Because of the meeting, important decisions on measures to improve data quality and timely reporting as well as complete documentation were made. Moving forward into the next quarter, Afya Pwani has already scheduled five facility based data review meetings prioritizing the following HVFs: Moi County Referral, Wundanyi Sub-County Hospital, Mwatate and Taveta Sub-County Hospital to review their respective performance for both this and the October-December 2017 quarter. As part of promoting DDIU, Afya Pwani project staff have designed, developed and distributed live charts focused on the core data elements and indicators which will be filled at the end of each month once reports to be submitted to sub- Live charts displayed in facilities in Kilifi counties are populated and verified. The charts have been printed and mounted across supported facilities to help monitor trends on different indicators in HTS, Linkage, PMTCT, Care and treatment and
95 Magodzoni, Mwaluphamba, Shimba Hills, Matuga, Ng`ombeni, Vyongwani, Mazumalume, Mwapala, Msulwa, Kichaka Simba, Mwaluvanga, Mbuguni, Kiteje and Kizibe Dispensaries. 96 Kwale Hospital, Magodzoni, Mwaluphamba, Shimba hills, Matuga, Ng`ombeni, Vyongwani, Mazumalume, Mwapala, Msulwa, Kichaka simba, Mwaluvanga, Mbuguni, Kiteje, Kizibe, Waa, Lukore, and Mkongani Dispensaries and Tiwi Health Center.
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defaulter tracing; all of which is hoped to provide simple analysis on these key program areas to improve DDIU on the same. Additionally, project staff have also invest resources this quarter in mentoring health care workers to be able to correctly determine the data need to fill in each row and column of the charts, to facilitate availability of accurate data for decision making at the point of generation. Promoting DDIU through EMR Data verification and Reports Dissemination During the quarter under review, the project also supported the completion of data verification in all EMR sites (11) of which 9 are currently at the point of care (POC). The data verification process included a review of the hard copy and electronic tools including registers to identify gaps. It should be noted that the installation and adoption of EMR across project supported sites has significantly improved the accuracy and timeliness of the MOH 731 report and below is a graphical comparison of the patients current on ART in IQCare and DHIS2 for the January MOH 731 report. Figure 47 below provide more information on the same.
Current on ART Jan 2018
Current on ART (DHIS) Current on ART (IQCare) 761761 746746 800 702702 700 624624 600 477477 420410 500 345 400 308 300 193228 200 74 75 100
0
Waa Dispensary Waa Diani HC Diani SCH Kinango Kinondo Kwetu KwaleSCH SCH Lungalunga MsambweniDH HC Tiwi Vitsangalaweni
Figure 47 EMR Data Verification
It should also be noted that the project team also took the opportunity to train health care workers on how to generate line lists of missed appointments, defaulters and booked patients to improve patient care and retention. The process included action planning and facility specific RDQA reports have been filed at the facility level. The project also worked with health care workers to update the missing data in the system. The graphs below provide more information on the some of the variables reviewed during the verification process.
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Patients Missing VL results in IQCare Patients Missing HIV diagnosis date in As at Jan 2018 IQCare As at Jan 2018 Waa Dispensary 100% Vitsangalaweni 52% Waa Dispensary 100% Kinango SCH 38% 98% Diani HC 31% LungaLunga SCH 69% LungaLunga SCH 29% 19% Diani HC Kwale SCH 23% 10% 3% Msambweni DH 16% Kinondo Kwetu 2% Tiwi HC 13% 1% Kinondo Kwetu 4% Kinango SCH 1% 0% 20% 40% 60% 80% 100% 120% 0% 50% 100% 150%
Figure 48 EMR patients missing VL and EMR patients missing HIV diagnosis date
Continuous Quality Improvement Data plays an important role in improving the quality of services in health care settings; cognizant of the of, during the quarter under review, Afya Pwani has supported the establishment of quality improvement teams (QITs) and work improvement teams (WITs) across supported facilities in the five coastal counties. Additionally, the SI department has also taken the initiative and provided detailed analysis of performance trends to all HVFs to enable the teams to discuss the key priority areas that need improvement. Afya Pwani supported facilities have also been able to review the yields of supported and completed activities to make appropriate changes or adjustments this quarter as part of the Project’s mandate to increase access and availability of high quality health services. Lastly, it should be noted that the project has been working to integrate data in all WIT meetings, which has helped to ensure discussions are focused on real issues based on evidence- subsequently performance has improved greatly as a result of these interventions.
Data Quality Control As a follow, up to the just concluded M&E and HIV/TB TWGs, there was a recommendation that six members of the Sub-County management teams (Laboratory Coordinators, HIV Coordinators, HRIOs, TB Coordinators, Nutrition, and the Pharmacists) should hold monthly meetings to identify and address M&E and Service delivery through targeted interventions and address challenges emerging and previously identified. Since institutionalization of regular routine data quality checks is a function of the M&E TWG and a compulsory item in the county M&E Plans, the project intends to support these forums at the four sub-counties in Kwale to meet immediately after data entry and before the 15th of every month to review the Laboratory, TB, HIV Care, Commodity, and Nutrition data for each month, develop action plans for each month based on emerging and reemerging data quality gaps, and design long-term interventions/measures to eliminate the data quality issues. The systemic approach shall increase our efficiency in the county now that plans to integrate DATIM data into the routine facility data calendar is underway.
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Priorities in quarter 2, FY 2018 Moving forward, Afya Pwani will continue to conduct facility data review meetings in the next quarter, where the following facilities will be prioritized: CPGH, Tudor Sub-County Hospital, Mikindani MCM, Likoni Catholic, Mvita Clinic and Kongowea Health Center. During these meetings, project staff will also focus on the following areas: Importance of Quality of Care Indicator documentation in patient files; Transition of ART patients to the new ART register for quality patient monitoring; DHIS2 data gaps and quality of reporting and cohort analysis for monitoring retention. Data Quality Action Plan for April-June 2018: Plans for close monitoring with the Sub-County teams to enable facilities to understand reporting on the indicators. Facility data review meetings to be facilitated in the third quarter. Updating the ART patients to the new ART registers DHIS2 data cleaning with SCASCOs and SCHRIOs.
VI. PROGRESS ON CROSS CUTTING THEMES: GENDER AND YOUTH
HIV SERVICES During this reporting period, 24 health providers (9F and 15M) were trained on GBV case management in Kwale County. A three-day training on GBV case management reached 30 community health volunteers and 8 peer educators (3M and 35F). The latter contributes to the community-facility and SGBV management referral system for prevention and management of GBV against vulnerable population groups. In Kwale County, screening of CCC clients for SGBV as per 2016 ART guidelines was conducted reaching 30 clients (10M and 20F). The project commemorated International Women’s Day on 8th March 2018 by supporting two in-reaches at two health facilities in Mlaleo Health Center and Kongowea Health Center respectively. In total, 132 clients (41M and 91F) were reached with HTS, GBV, HIV prevention and support messages; one client turned HIV positive. Male engagement activities centered on leadership by men, demand creation for health services, support to contribute to HIV 90:90:90 targets, advocacy for PMTCT and four ANC visits. Because of these activities, 51 women were referred for ANC services in Taita Taveta county and 43 hard to reach men were educated and tested for HIV in Kwale-Diani. Community education and dialogue sessions were conducted to address gender norms, stigma, and discrimination including practices that fuel the spread of HIV and lead to poor uptake of health services. These sessions reached 268 people (74M and 194F). Efforts to enhance access and utilization of the standard package of care for adolescents and youth (AY) including SRH services, reached three hundred and seven (307) AY aged 15 – 24 years. Partnership in Kwale County continues between Afya Pwani and USAID K-Yes to enhance uptake of AYSRH services by adolescents and youth. a) Improved access and utilization of standard package of care for adolescents and young people USAID K-Yes and USAID Afya Pwani Collaboration in Kwale County During the quarter under review, Afya Pwani worked with the K-YES initiative to facilitate the allocation of K-YES youth mobilizers to three Afya Pwani supported HVFs in Kwale County, namely: Vitsangalaweni, Diani and Msambweni. Additionally, project staff also introduced the K-YES initiative to four SCASCOs in Matuga, Lunga Lunga, Kinango and Msambweni as part of efforts to promote collaboration between the initiative, Afya Pwani and these County stakeholders as project staff work to increase access and availability of high quality health services. Moving forward, Afya Pwani team will continue to support the K-YES youth mobilizers to HVFs in Kwale County by facilitating the introduction of these mobilizers to the
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Kwale County SCHMTs and grantees as part of efforts to create demand for HTS, SRH and ANC services. Of further note is that the two adolescent support groups attached to Kinondo health facility were established this quarter namely; Jiinue Youth Support group comprised of 14 members (2M and 12F) and the Uwezo Teens Support Group, also with a membership of 14 teenagers. Both youth support groups met twice this reporting period. Clinical staff facilitating the meetings of the two support groups noted that the poor socio-economic status of adolescent and youth clients is a leading cause of poor adherence and defaulting- issues that the Afya Pwani team will endeavor to address with assistance from the County and other relevant stakeholders. ii) Promoting adherence counseling and psychosocial support through support groups of adolescent and young people Between January and March 2018, Afya Pwani supported and conducted a five-day training on Positive Health and Dignity Prevention (PHDP) was conducted in Mombasa County in partnership with County and SCASCOs and the community strategy focal person using a curriculum adapted from the 2014 Prevention with Positives. The training was aimed at enhancing and maintaining the dignity of individuals living with HIV thus creating an environment that reduces the probability of new HIV infections and re-infections by clients. The training was held from 25th to 30th March 2018 had 20 participants (4M and 16F) who were mobilized from Likoni, Mrima and Shika Adabu Health Centers in Likoni Sub-County of Mombasa. In the next quarter, training participants are expected to form support groups for AY living with HIV, including training on PHDP and providing psychosocial support (PSS) with close monitoring and support from adherence counselors. The topics covered during the training included: HIV/AIDS HTS, treatment and follow up, HIV/AIDS common opportunistic infections (OIs), disclosure of HIV status, partner or family testing and engagement, condom use, FP, STIs, HIV Education & Counseling, Peer Counseling skills, Screening for GBV, Continuum of care, Self-Care, Stigma and Discrimination, Disclosure issues as well as loss and grief. Additionally, Afya Pwani partnered with Shika Adabu Likoni Hospital in Mombasa to conduct adherence counselling sessions for adolescents and PLHIV through support groups at health facilities. Of note is that young people are becoming more candid about factors affecting their adherence to ART for instance, during one support group meeting, a 22-year-old male client at Likoni Sub-County Hospital confessed that his drug and alcohol abuse were the underlying reasons for his persistent unsuppressed viral load, adding that he was ready to change and improve his life. The adherence counselor on duty conducted a tailored one on one session with the client to enhance viral suppression. The composition of Likoni Hospital Support Group formed as result of Project supported training follows (see Table 33): Table 33 Composition of Likoni Hospital Support Group formed as result of Project supported training follows: County Number of adolescent in the support group. Total 15-19 20-24 M F M F M F Mombasa (Likoni Facility). 6 3 5 6 11 9
During the quarter under review, Afya Pwani also supported a meeting to address ART adherence was held at Mwatate Sub-County Hospital for 18 adolescents from the following areas in Taita Taveta: Manoa, Mbilinyi, ingila, Kishamba, Landi, Majengo, Modambogho, Mgeno, Mwatate, Jora, Ziwa and
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Mwachabhaza. The meeting was facilitated by a mentor mother who is also a peer educator from Mwatate Sub-County Hospital. The meeting discussed psychological support and promotion of adherence to ART based on PHDP Guidelines as part of efforts to ensure that all HIV positive clients in are virally suppression. To enhance the access and utilization of the standard package of care for adolescents and youths, 150 AY aged 15 – 24 years were reached with HIV prevention and support information through sessions addressing HIV stigma and discrimination in Mombasa County. The discussions covered the following topics: Stigma: the four levels of stigma manifestation which include individual level, interpersonal level, institutional level and community level. Possible remedies to stigma reduction stigma were also mentioned and discussed. The feedback from discussions revealed that stigma is the major cause of non-adherence among the adolescents and youth. During these sessions, Afya Pwani supported CHVs were engaged in defaulter tracing, follow up of missed appointments, referral of young adolescents for early ANC visits considering its contribution to PMTCT, to help support uptake and utilization of HIV care and support services among youth aged 15-24 years as indicated below: Table 34 Number of adolescents reached with anti- stigma messages County Number of adolescents reached with anti- stigma Total messages 15-19 20-24 M F M F M F
Mombasa (Likoni and Shika Adabu 60 32 20 38 80 70 Facility)
Of note is that 21 pregnant adolescent girls were escorted by CHVs for Focused Ante-natal care (FANC), Post- natal care (PNC) and HIV Services in Mombasa, Table 34 provides more information in regard to breakdown per age group. Table 35 Number of positive pregnant adolescents escorted girls escorted for FANC/PNS and linked to CCC County Number of Total Number of positive pregnant adolescents adolescent girls escorted girls escorted for FANC/PNS and escorted for linked to CCC FANC/PNC 15-19 20-24 15-19 20-24 Mombasa 06 15 21 00 02 (Shika Adabu Facility).
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a) HIV Prevention activities to vulnerable populations i) Provision of recovery and HIV prevention services for survivors of sexual GBV. 1. Train providers on integration of GBV case management in health service provision in all facilities
In Kwale County, 24 participants (9F and 15M) received continuous medical education (CME) on the management of SGBV conducted at Tiwi Rural Health Center. The CME focused on post-rape care (PRC) services and provision of Youth-friendly services (YFS) using Pathfinder’s E2A project tool “Thinking Outside the Separate Space”. Five health providers who received comprehensive training on SGBV management were sensitized on prevention services through HIV Testing Services and the provision of Post-exposure prophylaxis (PEP) to GBV survivors. Because of the CME, use of government reporting tools has improved. Even though PRC services are on offer, health providers are often reluctant to sign the PRC form because of the very real possibility of being required to testify in court. Provider misgivings regarding potential court appearances persist despite the Tiwi facility in charge’s reassurances to the contrary. Based on his training database, about five staff have been trained on management of sexual violence according to the facility in charge and are therefore up to date on the tools and procedures as required. The YFS orientation session on “thinking outside the separate space” helped providers explore available options to reach heterogeneous populations of AY with various health services and information such as the mainstreamed model where all health providers are non-judgmental and respectful, to AY accessing health services being provided according to the National Guidelines on the provision of YFS. The latter can be implemented across a range of health facility types in both rural and urban areas and may serve and attract a wide range of young people. Of note is that the facility has a separate space model offering YFS, but due to the work load of health service providers, AY are seen alongside the general population. Other options such as selected hours, targeted outreaches, community models, and index client testing were discussed as well. Feedback sessions from clients on how to strategically reach more AY were recommended due to geographical variations among adolescents specifically in Kwale County. The separate space model is not an ideal means of addressing the heterogeneous health needs of AY in settings such as Kwale - a medium-HIV burden county, ranked 24th highest nationally in terms of HIV prevalence. The Kwale HIV and AIDS epidemic exhibits characteristics of a generalized and concentrated epidemic trend with Key Populations (KPs) leading in acquisition and transmission of HIV along the coastal strip. Kwale County has an estimated prevalence of 5.7% (National HIV Estimates 2014). AYSRH services for AY were discussed coupled with entry points for AY services such as the VCT room, OPD and the ANC as places where AY populations can be reached. In Mombasa County, Afya Pwani facilitated a three-day training on Gender concepts, GBV and Multi- sectoral response coordination for 30 community health volunteers and 8 peer educators (3M and 35F) received. The role of the CHV and peer educators is to facilitate referrals and follow-up of GBV survivors for PRC services at health facilities and police stations within Changamwe County. The trained CHVs and peer educators will also be required to document referrals and work closely with sub-county health management teams. 2. Work with local administration, County Departments & NGOs to establish safe spaces for GBV survivors and networks for prevention and management of GBV against PLHIV/women/Minors and other vulnerable population groups Afya Pwani staff are members of the multi-sector coordination SGBV response committee team at the Port Reitz Health Center, whose main role is to improve the quality of health services available to (S)GBV
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survivors. Eighty percent (80 %) of GBV cases referred to the GBV center at CPGH are from Changamwe – Jomvu Sub-County- hence the motivation to revitalize the PRC services at Port Reitz Hospital. Two meetings were held within the quarter, where discussions highlighted the importance of accurate and complete documentation, evidence collection and storage, evidence provision updates, involvement of the government chemist in meetings, securing client privacy within the facility, and sending out requests for support to stakeholders to strengthen and improve services for GBV survivors. Of note is that the project is currently consulting with CPGH GBV Center on strategies to improve adherence to psychosocial counselling and legal support to GBV survivors with high defaulter rates after completion of their 28-day regimen of PEP. Safe spaces in the counties have not yet been identified pending determination of the level of staff capacity building required. 3. Design a community-facility SGBV management and referral system to facilitate SGBV survivors’ access to health and support services Between January and March 2018, Afya Pwani worked with sensitized health care workers and trained CHVs on the SGBV management team to conduct referrals for PRC health services. However, there are gaps in documentation of referrals- especially by CHVs. To mitigate this problem, the project is formulating a documentation system for CHVs and Male Champions. These efforts will support existing multi–sectoral coordination committees based at health facilities, specifically, Port Reitz Hospital, which includes paralegals and counsellors to enhance coordination. A health talk on PRC was also conducted and supported this quarter by an Afya Pwani grantee for 14 female clients at the outpatient department in Taita-Taveta County (at Wundanyi Sub-County Hospital). More specifically, participants were educated about GBV and how the vulnerabilities involved are linked to HIV infection (e.g. rape, socio-economic vulnerabilities). Clients were also encouraged to refer to the multi-sectoral coordination response in cases of rape, ensuring that they take the survivor for treatment within 72 hours for first aid and PEP. Emphasis was made on reporting cases to the nearest police station, and timely provision of legal and psychosocial support. Participants were also informed about the basics of evidence preservation such as clothing, nail clippings etc... that can help in tracing and arresting a perpetrator. Due to the patriarchal nature of relations in Taita County, male engagement was encouraged to enhance uptake of health services in general, and enhance disclosure for those who are HIV positive. 4. Male Engagement Afya Pwani project staff also continued to invest resources in promoting male engagement as part of efforts to increase access and availability of health services, by helping to identify, refer and engage partners of expectant mothers during and post-pregnancy contributing to early ANC and HTS by the expectant mother and her partner/spouse. In Taita Taveta County, the following cadres of are engaged to mobilize boys and men: CHVs, community mentor mothers, TBAs and male champions. The latter are all engaged purposely to identify expectant women and their male partners within the community, initiate health talks and discussions, provide referrals for ANC visits and/or Feedback meeting by Male Champions at Njukini escort them for ANC and PMTCT services. This is a Health Center continuous activity at all health facilities collaborating with Njukini Community Unit which is linked to Njukini Health Center, Chumvini, Mahandakini, Chala and Ndilindau. Knowledge provision is focused on
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the importance of four ANC visits including PMTCT, and the contents of the birth plans such as the importance of saving before delivery to address expenses involved such as transportation, sanitation items, and knowledge of danger signs in pregnancy and nutritional requirements of pregnant and/lactating mothers. In Werugha, Taita Taveta County, 14 out of the 15 engaged male champions reached during the first quarter at Multi-purpose Werugha have already created demand for ANC and HTS through provision of referral services to expectant women who are accompanied by their partners or spouses for ANC and HTS. Monitoring of male champions progress is done via feedback meetings with individual champions. Because of these male engagement efforts, 51 pregnant women were referred for their first ANC services this quarter as follows: Wundanyi Sub-County Hospital had 22 first ANC visits, Wesu Hospital had 16 first ANC visits (where one woman was identified as being HIV positive), Mghange had 9 and Mbale had 4 first ANC visits. During the quarter under review, the Project also facilitated sensitizations and HIV testing for males in Kibundani -Diani in Msambweni Sub-County in Kwale, in collaboration with HIV testing providers from Diani health Center. During these sessions, positive health information on HIV and AIDS including the importance of HTS and barriers hindering men- especially elderly males was discussed. Some of the key issues that were raised include but were not limited to long waiting times and heavy work schedules. Of note is that 43 out of 50 male participants were tested for HIV- none tested HIV positive. Other topics covered were the leadership and mobilization roles of male champions in PMTCT, the basics of HIV/AIDS, risk factors of mother to child transmission and measures to reduce MTCT, introduction to PMTCT and the services involved, barriers to success of PMTCT, demand creation and community mobilization, cultural drivers to mother to child transmission such as massages for pregnant women, stigma and discrimination reduction strategies, disclosure, ART literacy Chaani Chief addressing community members and adherence. Mentorship will be provided in during the community education session in Changamwe Sub-County the coming quarter on community sensitization to facilitate male involvement in PMTCT. 5. Community Education and dialogue sessions to address gender norms and practices that fuel HIV & AIDS and poor uptake of health services In February 2018, two community education sessions were conducted in Mombasa County at Kingorani and Chaani Community Units within Mvita and Changamwe Sub-Counties respectively. In King’orani, a total of 65 people were reached (M- 19 and F-46). In Chaani, a total of 34 people were reached (6M, 28F). The meeting addressed gender norms and practices that fuel HIV/AIDS, including sensitizing the community to identify and counter them. Some of the norms highlighted were gender inequality in education among women, leading to lower access to SRH services including PRC services, power imbalances between the sexes that enhance patriarchal decision-making, early marriages of teenage girls with the permission of parents and guardians, and financial disparities that lower the negotiating power of women at many levels including negotiating for safe sex. An emerging issue of concern was that girls
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with parents infected by HIV/AIDS drop out of school to take care of their sick parents, and to generate income for the family. This often leads to transactional sex and vulnerability to HIV infection. It was agreed that any cases of girls dropping out to school due to early marriages would be reported to the area Chief’s office for immediate action and that every parent and neighbor had to ensure that all girls and boys were enrolled in school and that those with experiencing financial burdens were assisted to apply for bursaries. It also emerged that pregnant mothers typically prioritize the first ANC visit but abscond subsequent visits based on positive feedback by the health care provider at the during the first ANC visit. During the quarter under review, five community dialogue sessions were held in Kinondo in Kwale County; namely Déjà vu, Biga, Mwabungo, Kiuzini and Zigira, reaching a total of 169 community members (49M and 120F). Sessions focused on correct and consistent condom use, access to HTS, uptake and requirements for use of both Post-exposure and Pre- exposure prophylaxis for vulnerable populations such as female sex workers (FSWs) and the HIV negative spouse in cases of discordant couples. 6. Screening CCC clients for GBV A total of 30 (10M and 20F) stable Kingorani ward administrator addressing participants during the community education session in Mvita Sub-County PLWHIV were also screened for GBV, TB and differentiated care this quarter by health care providers from the Kinondo Kwetu Clinic during the quarter under review. As a result, 30 contacts were reached (10M and 20F); all the clients stated they had not experienced abuse. 7. International Women’s Day 2018 The theme for this year’s International Women’s Day that was held on the 8th of March 2018 was “Press for Progress” – a strong call to motivate and unite friends, colleagues and whole communities to think, act and be gender inclusive. In Mombasa County, two events to commemorate International Women’s Day 2018 were conducted through facility-based in-reaches. Local communities were mobilized for all health services and two facilities created awareness on/and conduct HTS, and TB screening. One in-reach was conducted at Mlaleo Health Center with the help of 5 HTS counsellors, 10 nurses and 10 mobilizers as well as CHVs linked to the facility; a total of 78 clients (50F and 28M) were reached with information on PEP, TB/HIV and STIs. Of note is that one client tested positive and was linked to the CCC clinic for treatment. At Kongowea Health Center, 54 participants (13M and 41F) were reached with information on the multi-sectoral response to GBV together with information on partner and family testing. It should be noted that several female participants admitted to having experienced IPV (Intimate Partner violence/GBV) but thought it was normal due to ignorance and group mentality. A total of 40 clients (8M and 32F) were tested for HIV where no one tested positive. Three facilitators, 4 mobilizers and 3 HTS counsellors participated in this activity.
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8. Supervision Between January and March 2018, project staff also focused on facilitating and providing supervision at: Port Reitz Hospital GBV Room 11, Likoni District Hospital, Likoni Catholic Dispensary, Bokole Dispensary, Tiwi Rural Health Center and National Empowerment Network of People Living with AIDS in Kenya ([NEPHAK] is an Afya Pwani Grantee) as part of efforts to improve the quality of services being offered to (S)GBV clients. More specifically, the supervision provided focused on how to better support GBV survivors in terms of referrals by CHVs for psychosocial support, follow-up of GBV survivors and counselling. GBV screening at the CCC was also encouraged for clients and relevant referrals discussed. Other focus areas included strategies to reach AY with health services, male engagement strategies, training content and availability and use of Standards of Practice (SOPs) at health facilities as required. Lessons Learned 1. Strategies to provide tangible legal redress to SGBV survivors will be important focuses during the remaining project period. This has been a challenge due to the inadequate number of trained paralegals and limited support mechanisms for GBV survivors. 2. Trained male champions require reference points or material to guide the health messaging given to the community around the four ANC visits (not just the first ANC visit), HTS, PMTCT, PNC, joint decision-making on FP Method choice, birth plans and nutrition. This will enhance quality checks aside from the feedback meetings. Training of staff on Gender Mainstreaming will improve gender programming at all component levels. This activity is scheduled for the April-June 2018 quarter. Highlights of Planned activities for the next quarter 1. Conduct a Gender Mainstreaming Session for Afya Pwani Project staff to improve the quality of Gender programing while addressing gender issues in Health. 2. Strengthen documentation of the community-facility referral system and linkage to support for GBV survivors. 3. Identification and strengthening of Safe Spaces to support GBV survivors 4. Provide tangible legal redress to GBV survivors. 5. Continued supervision of Community-facility entities such as CHV and facility staff on management of SGBV and strategies to reach AY outside the separate space, while improving quality of AYSRH for AY per the workplan.
MNCH/FP, WASH AND NUTRITION SERVICES As concerted efforts are put in place by the county to address FP issues and barriers, the project is cognizant of the fact that AY contribute significantly to these indicators in Kilifi. According to the KDHS 2014, AY constitute 24% and 36% of the population in Kilifi County respectively; 47.5% of the population is aged 15 years and below, and 19.7% are aged between 15-24 years. This data means that AY cannot be ignored in health service provision. In recognition of this fact, Afya Pwani has put in place initiatives to identify, and reach AY with accurate health information and services. This report highlights activities undertaken during the quarter to reach adolescents and youth, lessons learned, challenges and recommendations.
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Increased access to youth appropriate MNH information and services a) Increased access to adolescent and youth appropriate MNH information and services i) Capacity Building of health service providers In a bid to enable service providers to offer quality SRH services to AY, service providers at Kilifi County Hospital were capacity built during the last quarter of 2017. A total of 32 health providers were reached with information on provision of youth-appropriate services. Building on these activities, project staff worked with these health service providers to implement plans to serve youth separately in a designated area in Kilifi county hospital’s maternity wing97. In the meantime, the facility also has a room in the CCC set aside for youth to access basic information. The latter room is equipped with youth resource material and is manned by a youthful peer educator who provides information and makes referrals according to need. This quarter project staff continued to work closely with the 27 staff who attended the CME on improving access and availability of MNH information and services for AY at Malindi Sub-County Hospital. More specifically, the project has continued to work with these providers to ensure that the hospital’s CCC implements a mainstreamed YFS model98 whereby any provider, whether they offer contraceptive services, Afya Pwani Kilifi school in-reach targeting adolescent boys and STI services, HIV treatment and girls with AYSRH information. care, maternity services, other SRH services, primary care services, or any other type of health service are non-judgmental to all young clients, ensure privacy and confidentiality, and offer quality counselling and referrals to other services, if needed. Of further note, the demand generation strategies in the mainstreamed YFS model aim to attract, and retain young clients through peer educators onsite and in the community, tailored IEC materials, publicity of special hours for youth consultations, promotion of services among young people in facility catchment areas, and engagement with gatekeepers to reduce social barriers to service keeping. During school holidays, Malindi Sub-County Hospital staff have designated youth days to enable AY to access care and treatment services. Despite these efforts, staff acknowledge that service provision models/strategies can be scaled up further to better address Kilifi youth heterogeneity. ii) Empowerment of adolescents/young pregnant women working through USAID Afya Pwani grantees and County AYSRH stakeholders
97 Separate space for YFS model features SRH services for young people provided in a separate room/building within a public or private facility; at least one dedicated and trained YFS provider, offering a range of YFS services, and sometimes includes a separate waiting area. This model can be implemented at all levels of health care facilities, but is most common in larger primary health centers or hospitals that have sufficient space for a separate YFS area, rather than at the lowest level of health facilities. 98 The mainstreamed YFS model is also called the “whole facility” model. Features: Non-Judgmental, privacy and confidentiality; all (or most) health providers/staff offer high-quality TFS as part of routine service delivery, sometimes offer special opening hours for youth; and have specific demand generation strategies.
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Afya Pwani project data has identified that school drop-outs and unintended teen pregnancies rates are highest in the Vipingo area in Kilifi County. To address this issue, project staff invested in reaching in- school AY with age appropriate SRH information in three schools in Kilifi South: Shariani, Vipingo Central and Chondari Primary in Vipingo. Students in Vipingo were reached with information on sexuality and life skills. During interactions with the boys and girls, the Project emphasized prevention of teen pregnancies, sexual violence and HIV awareness creation/prevention in an effort to equip these young people with information on what to do when approached by strangers or requested to indulge in retrogressive activities such as drug use and illicit sex. Gender issues were discussed and addressed including positive images of boys and girls. More importantly, the youth were given a toll-free number (1,190 LVCT hotline) to call for free, accurate SRH information that guaranteed confidentiality and anonymity. This quarter, the Project also supported the formation of Binti kwa Binti groups through the stewardship of the project’s MNH Manager. These are groups for young pregnant women 24 years and below who are encouraged to attend ANC clinics early, and continue attending 4 ANC clinics (per WHO recommendations) then deliver at the facility and continue with hospital visits until the baby is 6 months of age. Binti Kwa Binti groups (with the following numbers of members) have been formed in Rabai (28), Gongoni (26), Dzikunze (43), Matsangoni (48) and Kizingo (42). Next quarter (April-June 2018), Binti Kwa Binti groups will be formed in Bamba, Vipingo, Gotani, Vitengeni, Chasimba, Mariakani, Marereni and Malindi. Of note is that the Binti Kwa Binti group discussions center on AY specific MNH information and how to access the same. Self-esteem and acceptance is also discussed coupled with options for young women to live their lives optimally, including returning back to school. To enhance socializing among the young women, they are encouraged to form groups and set aside funds as savings for later use in small business ventures. The project has established contact with the National Government Affirmative Action Fund (NGAAF) office in Kilifi county which has agreed to support the women with seed funds and pay school fees for young girls unable to continue with their education due to lack of school fees. The Project also focuses on supporting young women who have experienced sexual and gender-based violence (SGBV). The Binti Kwa Binti groups are important because they create an opportunity for women to know, and become accountable to one another during hospital visits where they keep tabs of each other. Since Binti group information is documented in a separate book at facility level, it is relatively easy to keep track of these women, and to identify if one or two have missed an appointment. Providers can quickly track the number of women in the group, how many have visited the facility for ANC, and how many eventually delivered at the facility. The Binti kwa Binti groups have also provided an appropriate platform for young women to attend their clinics and some have delivered at the facility. For instance, at Rabai Health Center, five young women had delivered at the facility as at end of March 2018; more are expected to deliver as they approach their Expected Delivery Dates (EDD). A breakdown of the Binti kwa Binti groups can be seen in Table 36 below: Table 36 Breakdown of the Binti kwa Binti groups Facility Total number of ANC visit no as at 30th Number delivered as at women March 2018 30th March 2018 Rabai Health Center 28 4th 5 Gongoni Health Center 26 3rd 1 Dzikunze Dispensary 43 4th 12 Kizingo Health Center 42 3rd 1 Matsangoni Health 48 1st 0 Center
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During the reporting period under review, Afya Pwani grantees continued to work with project staff to support CHVs and mentor mothers to conduct facility level health sessions for community members at Vipingo and Mtwapa Health Centers in Kilifi South respectively. A total of 58 young mothers 30 (15- 19years) and 28 (20-24years) were sensitized on the importance of personal hygiene, exclusive breast feeding, knowing their HIV status, developing an individual birth plan, early visits to ANC, honoring clinic dates and encouraging their partners to accompany them to the clinic. Of note is that the success of these sensitizations is also attributable to the guidance from nurses at Vipingo and Mtwapa Health Centers respectively in Kilifi. Moreover, during the quarter under review, a total of 18 CHVs (3M 15F) linked to Vipingo and Mtwapa Health Centers were engaged to escort at least one (1) pregnant adolescent girl/young woman each month for 1st ANC visit attendance and subsequent visits and follow ups. This initiative undertaken to ensure that a woman achieves at least 4 ANC visits, delivers at the facility, ensures that the child is reviewed within 2 hours post-natally and receives necessary immunizations. Table 37 below is a summary of escorted adolescents this quarter (January-March 2018): Table 37 summary of escorted adolescents this quarter (Jan-Mar 2018) Activity 15-19 years 20-24 years Number of adolescent girls escorted for 28 46 FANC/PNC Kilifi Number of HIV positive pregnant 00 04 adolescent girls escorted for FANC and linked to CCC
iii) Support AY friendly forums at community level Community level forums were held to address retrogressive socio-cultural, gender and religious practices and beliefs in Kilifi County that contribute to the low uptake of vital MNH services by AY and result in unwanted pregnancies and neonatal and maternal deaths. This quarter Afya Pwani facilitated and helped to organize forums were held with parents of school going children to encourage them to take an active role in educating their children, and become more proactive in nurturing them to function better in society. In Vipingo, a session was held with parents and local administration including the area chief, where poor school performance and contributing factors were discussed including the role of parents in the issue. Parents were also challenged to take an active role in the upbringing of their children to enable them make sound decisions, reduce their vulnerabilities, and subsequently mitigate cases of teen pregnancies and sexual violence. Three separate forums were held in Malindi with representation from youth, religious leaders and other opinion leaders to address issues affecting area youth. The meetings were convened to discuss SRH issues affecting the youth and the role of the parents and the community at large. Emerging issues include inaccurate and incorrect information around sexuality, early marriages and defilement, which the community attributed to a myriad of factors including weak parenting and limited access to youth appropriate information. It was agreed that it was everyone’s responsibility to ensure that AY are protected, go to school and that older people/adults speak out in on these issues. Moving forward, it was noted that the provision of age appropriate and accurate SRH information was identified as being key, and the group was given key contacts to call toll free to access information including LVCT SRH contact. iv) Advocacy and lobbying for AYSRH Between January and March 2018, the Project With regards to lobbying and advocating for youth appropriate services, the project participated in the development of the Kilifi county AWP in February
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2018 and ensured that the work plan was AY responsive by looking at health activities geared towards addressing the health needs of the AY. A case in point, is inclusion of staff capacity building on provision of youth appropriate services, and use of job aides on contraception for service providers developed by Pathfinder International I.e. Adolescent cue cards. In the latter instance, the project supported development and printing of the cue cards for use at facility level to promote FP use by youth based on informed choice. Discussions at facility level were also held to lobby for space that AY could use to access health information and services. Of further note is that the Sub-County Public Health Nurse has confirmed that Ganze and Vitengeni Health Centers have on-going construction projects where some space could be designated for AY use; this is work in progress as Afya Pwani continues to engage County stakeholders to push for this agenda as part of efforts to increase access and availability of high quality health services for AY in the County. This is also true of Rabai Health Center. Lessons learned 1. AY in Kilifi County view education as a secondary need, at least going by the projects’ engagement with them. In all the Binti Kwa Binti groups, youth have been offered opportunities to go back to school. However, this has not been taken up by any youth. Continued engagement with the young people will enable the project to establish reasons for, develop mitigation plans. 2. The introduction of refreshments to be taken during Binti Kwa Binti group meetings is a great motivation for young women to attend clinics. 3. In Kilifi, societal gender norms such as early marriage inadvertently contribute negatively to the wellbeing of AY e.g. During dialogue sessions, parents talked of forcibly marrying off their adolescent girls/young women if they became pregnant while living at home with them.
Increased demand for child health services for young mothers i) Advocacy and Key Stakeholder Meetings This quarter, Project staff have continued to invest in interventions geared towards ensuring that ORS, Zinc, Dispersible Amoxil tablets and nutritional supplement are available for young mothers across project-supported facilities and that there is adequate stock of the same. These supplies have been utilized by both the general population as well as adolescent and teen mothers. For the 16 select HVFs where AY services are to be strengthened per the Kilifi county AYSRH framework, Afya Pwani has worked to ensure that the requisite drugs/supplies are also available and accessible to them.99 ii) Capacity building of health service providers and CHVs on RH/FP During the October-December 2017 quarter, 30 CHVs were capacity built in Rabai Sub-County. During this quarter, these CHVs have been playing an instrumental role in reaching the community with accurate FP information and commodities. More specifically, a total of 738 women aged 15-19 years were reached with FP commodities by CHVs in Rabai during the January – March 2018 quarter. At Takaungu Dispensary, a total of 371 women were reached this reporting period; A hundred and fifty-two women aged 15-19 years at Kilifi County Hospital, 93 at Vipingo Health Centre and 174 women in Gongoni Health Center. These are facilities that the project has engaged with CHVs to reach communities with RH/FP information. During the quarter, bi-weekly meetings with the CHVs, CHEWs and counselors in Vipingo, Oasis and
99 These are Mtwapa Health Center, Rabai Health Center, Gongoni Health Center, Mariakani Sub-County Hospital, Kilifi Sub- County Hospital, Chasimba Health Center, Malindi Sub-County Hospital, Bamba Health Center, Vipingo Health Center, Matsangoni Health Center, Gede Health Center, Marereni Dispensary, Ganze Health Center, Vitengeni Health Center, Gotani Health Center and Oasis Medical Center (a private facility)
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Mtwapa health facilities in Kilifi were also held to verify the data collected on FANC, people tested, defaulters traced and referrals. The focus was to ensure that required SRH data was captured in facility MOH tools. Early feedback from USAID Afya Pwani supported health facilities appears to indicate improvements in data capture - for instance, 519 women aged 15-19 years were documented as having received FP commodities this quarter in Mtwapa. Anomalies identified in March 2018 i.e. Double reporting/ duplication of data by the CHVs who are engaged by different partners in the same target area - was not repeated since USAID Afya Pwani together with the help of the CHEWs and community focal strategy person were able to identify CHVs to be engaged in specific areas during the current quarter. Please see below.
Adolescent FP Services Uptake in 16 High Volumes Facilities 2465 1729
407 484 21 92
Adolescent Family Adolescent Family Adolescent Family Adolescent Family Youth Family Youth Family planning uptake 10- planning uptake 10- planning uptake 15- planning uptake 15- planning uptake 20- planning uptake 20- 14 yrs. Oct to Dec 14 yrs. Jan to March 19 yrs. Oct to Dec 19 yrs. Jan to March 24 yrs. Oct to Dec 24 yrs. Jan to March 2017 2018 2017 2018 2017 2018
Figure 49 Adolescent FP Services Uptake in 16 High Volumes Facilities
Figure 49 above shows the FP uptake for 16HVFs100 in Kilifi County that the project is supporting to increase access for FP and AY appropriate services. It depicts an increase in FP uptake over time from October-December 2017 to January to March 2018, a positive trend that project staff will work on building on in the next quarter. The Binti kwa Binti support group forums have also proven to be an apt platform to discuss RH/FP with young women/mothers as this is one of the topics discussed during their meetings. The ‘Bintis’ are encouraged to practice child spacing and challenged not to compete with mama groups comprised of older women – some of whom gave birth too soon, too often and even too old. iii) Strengthened youth responsive services to increase uptake of FP Between January and March 2018, a total of 70 facility in- charges from Magarini and Malindi Sub-Counties were reached with information on provision of youth appropriate services during an in-charges meeting held in Malindi on 8th February 2018. The team discussed AY characteristics and ways of reaching them with correct
Afya Pwani MNCH Manager RH/FP taking participants through a session on use of an RH/FP job aids and the adolescent cue cards.
100 These are Mtwapa Health Center, Rabai Health Center, Gongoni Health Center, Mariakani Sub-County Hospital, Kilifi Sub-County Hospital, Chasimba Health Center, Malindi Sub-County Hospital, Bamba Health Center, Vipingo Health Center, Matsangoni Health Center, Gede Health Center, Marereni Dispensary, Ganze Health Center, Vitengeni Health Center, Gotani Health Center and Oasis Medical Center (a private facility).
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information101. At the same meeting, the facility in-charges were oriented on the use of Pathfinder developed FP/RH adolescent cue cards which were then given to the Sub-County Public Health Nurse to share in select facilities in Malindi Sub-County. While visiting facilities in Malindi, Mtwapa and Rabai, staff were given adolescent cue cards and capacity built on their use. The cue cards were distributed at various service delivery points including MCH, FP and the CCC. Guidelines on provision of AY friendly services were also provided at Kilifi County Hospital, Malindi, Rabai, Mariakani Sub County Hospital and Mtwapa Health Center. Lessons learned 1. Appropriately YFS oriented CHVs can play a critical role in identification, provision and referral of health services to the youth. Challenges 1. Age specific adolescent data is not available in some registers MOH specifically- the immunization permanent register; the MOH 711 does not capture the age of revisit clients. Afya Pwani plans to capture adolescent, teen and youth data in a hard cover black book as the project discusses other options with the relevant county stakeholders.
Improved Gender Norms and Practices a) Conduct CMEs for health care providers to offer quality GBV prevention and support services and sensitization: During the January and March 2018 quarter, two CMEs were held at Kilifi County Hospital and at Vipingo Health Center which was attended by 19 people (5M, 14F). The CME was aimed at increasing health care provider capacity to competently attend to survivors (both adults and children) of SGBV where the following topics were discussed: Taking patient histories, physical examination and psychological assessment, investigation and forensic management. Project staff also took participants through a session on use of an RH/FP job aid the adolescent cue cards treatment and counselling and follow up care and referral as part of efforts to increase access and availability of high quality services at the Gender Based Violence and Ms. Judy Kinya facility in-charge taking participants through the session
101 Facilities represented include Gahaleni dispensary, Muyeye Health Center, Kakoneni Dispensary, Adu Danisa, Burangi, Marereni Dispensary, GK Prison Dispensary, Kambi ya Wama Dispensary, Shakahola Dispensary, Marikeni Dispensary, Gondani Dispensary, Marafa Health Center, Ngomeni Dispensary, Mshongoleni Dispensary, Mmangani Dispensary and Malindi Sub-County Hospital.
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Recovery Center (GBVRC). As a way forward, it was agreed that teams strengthen documentation using the MOH 363, 364 and 365 tools. In Vipingo, a CME was held with staff to discuss situations of compromised service provision, increase awareness on patient rights as well as orient health care workers on the provisions of the Sexual Offences Act (2006) as a component of PRC. A total of 36 staff (11M 25F) were reached with information on patient rights, stigma and discrimination and the Sexual Offences Act. During these discussions, it was apparent that aside from the patient rights, health care workers continued to need further empowerment on their own rights as providers. Lastly, staff also noted the different types of sexual offences, some of which they did not know were punishable by law e.g. Indecent acts. b) Support establishment of psychosocial support groups for child and adult survivors Technical support was provided at Malindi Sub-County Hospital to staff working at the GBVRC in a bid to help them establish a support group for survivors of sexual violence accessing the facility. More specifically, GBVRC staff were taken through requirements for establishment and running of support groups and what to cover for the duration of time that a support group is running. It was agreed that a support group be formed in the April-June 2018 quarter after development of a schedule of how to run, and finalize recruitment of, potential members to the support group. c) Holding of feedback and sensitization meetings with CHVs to share GBV work and other program related work During the quarter under review, Afya Pwani also facilitated and conducted a feedback meeting was held with CHVs from Malindi in January 2018, where CHVs were able to share their monthly reports, success stories, give updates on any actions previously agreed upon, discuss challenges and generate a way forward. It was clear that CHVs have been active in identifying and referring cases of sexual violence as the CHVs drawn from Shella, Central and Bara Community Unit shared their experiences and sought ways forward for cases which they felt were beyond their ability to address. CHVs have also been active in following up SGBV cases and linking them with the relevant authorities. Of note is that these CHVs have been experiencing some challenges, which include but are not limited to slow legal processes and the frustration of CHVs and clients when cases are thrown out of court. CHVs were encouraged to do their best in every situation. One of the reported CHV successes was the arrest of a man caught violating his daughters, and of another male suspect who had raped a school girl. Both cases are pending in court. d) Vipingo interagency feedback meeting During the quarter under review, Afya Pwani conducted a feedback meeting with the Vipingo Youth social address members; this is a group of individuals drawn from different professional backgrounds with a common interest in addressing social issues affecting young people in Vipingo. Membership comprises the police, adolescents and youth, ministries of health, education, interior and coordination; paralegal, agencies, Voluntary Children’s Officer (VCO) and the children’s department with a total of 16 people (10M 6F) in attendance. The key focus of the meeting was to review progress with members as well as agree on the way forward. Members gave feedback on activities carried out January 2018 where they had visited schools and held discussions with school children from Vipingo Primary, Vipingo Central and Shariani Primary. More specifically, the school in-reaches were held to build resilience among the school going children in the wake of rising cases of teen pregnancies, high school drop-out rates and cases of defilement, often reported late at the hospital. Members reported being warmly received in all schools visited and ready acceptance by the school teaching fraternity. Student attendance was overwhelming reaching boys and girls from classes 4 to 8. The one hour to one and a half hour sessions covered the following topics in all three schools: unwanted pregnancies and Sexually Transmitted Infections (STIs), the impact of dropping out of school, the Sexual Offences Act, the children’s rights, types of GBV and
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importance of education, in and out of school security and the importance of discipline. Drawing from the Projects’ past experience of working with schools, the following were agreed as a way forward: separation of students by age and sex to ensure maximum concentration and participation by the pupils, sensitization of teachers as a first step in order to use them as additional manpower during meetings and to have a standardized approach by the different teams on what would be discussed and covered. A toolkit for engaging with young boys and girls was proposed aka the Gender Roles, Equality, and Transformations (GREAT) which is a package of evidence-based, scalable, life-stage tailored intervention to transform gender norms, reduce GBV, and promote gender-equitable attitudes and sexual and reproductive health (SRH) among adolescents ages 10-19. It was agreed that this would be used by the teams once they were printed for uniformity. During the meeting, the terms of reference for engagement were shared and discussed as well. The team agreed that the structure was important for standardization. The team is scheduled to meet to update on progress and status of implementation within the April-June quarter. e) Sensitize police, community and opinion leaders on gender and (S)GBV Between January and March 2018, Afya Pwani also conducted a sensitization with community members from Shella to discuss reasons for sexual violence, defilement and teen pregnancies. The dialogue centered around the role of the individual, parents and community in addressing these vices in the society. It emerged that societal expectations are varied as to who should take responsibility over looking after the AY in the community. The community was informed that the main responsibility of looking after youth lay with parents as immediate family members; however, schools and religious institutions should also be involved because of their critical role as agents of socialization. At Central Community Unit, community members were taken through different sexual offences with the main message being that a girl who is below 18 years of age cannot give consent to sex. During the discussions, many community members argued that sometimes the girls ‘take themselves to the men’. As such, the men do not have any other option than to accept the girls. In the same breath, some community members argued Community dialogue session at Shella that if a young girl got pregnant, the automatic thing to do was to take her to the man who had impregnated her -- regardless of her age. This matter was clarified with community members present, who were urged to be proactive in spreading the correct messages to their neighbors, family and friends. f) Advocacy through special gender activities Afya Pwani also supported and facilitated International Women’s Day festivities that were held on 8th March 2018 under the theme “Press for Progress”. The initial preparation plan for the celebrations, led by the CEC for Gender, Mrs. Maureen Mwangovya, together with other stakeholders was to hold the event in Dida, Ganze Sub-County. Planned activities lined up included outreaches targeting women and children, as well as advocacy for girl child education and desisting from retrogressive cultural practices including giving birth solely for the sake of naming family members and relatives. Things changed when
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politicians got involved in the event resulting in the ceremony being commemorated in Malindi where the area MP is a woman. The event was therefore coordinated by the Minister, although partners were involved as well. The County MP’s message to partners was to push for more involvement of women, in line with Kilifi County’s own push to have 50% representation of ministers as women. The area MP, Ms. Aisha Jumwa prevailed on the community to desist from having kangaroo courts and settling cases of defilement and rape out of court. The Kilifi governor acknowledged the gap in education among girls in Kilifi county, pointing out measures that the county government is making to address the issue.
Lessons learned 1. Grassroot leadership is key in addressing deeply entrenched cultural issues at community level. 2. School based activities targeting young people have potential to reach many youth and ensure more meaningful interaction owing to the enclosed environment.
Highlights of Planned activities for the next quarter 1. Supply assorted PRC equipment in select facilities e.g. pediatric speculum). 2. Support establishment of psychosocial support groups for child and adult survivors. 3. Support facilities to strengthen documentation through use of the MOH 364.
VII. GRANTS
In the last reporting period, Afya Pwani formally engaged 19 out of the approved 20 organizations to implement demand creation activities at the community level to support the project achieve its strategic objectives; of note is that formal engagement with one grantee is still on-going, and will be finalized in the next quarter. During the quarter under review, the Project received a request for termination from one grantee; The German Foundation for World Population. This grantee was selected to implement two grants in HIV Care and treatment and MNCH/FP in Mombasa & Kwale and Kilifi Counties respectively. Although Afya Pwani had already conducted due diligence regarding the standard provision RAA29 Protecting Life in Global Health Assistance, the organization’s board determined that they will not impose the requirements of this provision on their global activities, on this basis, these grants were terminated. To ensure proposed activities are still implemented, the Project reviewed the applications that had previously been submitted in response to the Request for Applications (RFA) in December 2016 and selected two organizations; Women Fighting AIDS in Kenya (WOFAK) and Ananda Marga Universal Relief Team (AMURT) to implement the HIV Care & Treatment and MNCH/FP grants respectively. In compliance with the requirements of the Afya Pwani contract, a request was submitted to USAID for approval before the project can formally engage these organizations. In the last quarter (October-December 2017), the project facilitated initial disbursements to the grantees and conducted introductory meetings to the relevant county and sub-county stakeholders to pave way for activity implementation. During the quarter, the project noted accelerated activity implementation by the grantees. To facilitate activity implementation, the project facilitated disbursements of the 2nd tranche of funds to 10 grantees who had satisfactorily implemented activities and accounted for their initial advances. Disbursements to the other grantees will be done in the next quarter when they are expected to have finished implementing the planned activities planned for the 1st quarter. Details of activities implemented by the grantees during the quarter are reported under each sub purpose in this report. Afya
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Pwani will continue to monitor progress on implementation of activities and provide technical and capacity building support where necessary for improved service delivery. As outlined in the approved Afya Pwani Grants Manual and approved Year 2 workplan, the project will also continue to provide support to select facilities through ‘Partner Implemented Projects’ (PIPS) that will be administered through Memoranda of Understanding(MOU) signed with the facilities which allows the project to directly pay for all allowable costs. In the last quarter, the Project had identified and initiated the MOU signing process with 18 facilities; 7 in Mombasa and 11 in Kwale to be supported under this mechanism. During the quarter the project identified an additional 4 facilities in Taita-Taveta and 14 in Kilifi County to be supported (see Annex VI for the full list of facilities receiving PIPs). The project also finalized the MOU signing with all the 36 facilities identified across the 4 counties. The activities to be implemented by these facilities are largely focused on addressing the gaps identified in provision of quality care and treatment and service delivery to clients and will complement the support provided by the Afya Pwani staff and community grantees. Activity implementation under this mechanism has commenced by most of the facilities in Kwale and Mombasa, activity implementation by facilities in Taita-Taveta and Kilifi will commence in the next quarter since the MOUs signing was finalized toward the end of the quarter. Details of the specific activities implemented under this mechanism are described under the relevant outputs of Sub-Purpose 1 of this report. To strengthen the capacity of grantees to deliver quality services in the respective thematic areas, Afya Pwani facilitated one quarterly review meeting per county where grantee performance for the previous period was reviewed and feedback provided on areas of improvement. One of the priority areas identified was the inadequate capacity of grantees to implement activities to compliment the Afya Pwani objectives and targets. To address these gaps, Afya Pwani organized a three-day service delivery skill building workshop bringing together representatives of all grantees implementing HIV Care & Treatment and MNCH/FP activities. A total of 37 staff from 17 organizations attended the workshop which focused on emphasizing the expected standards in implementation of activities on the eMTCT, 90:90:90 cascade and MNCH/FP. Discussions on areas such as PHDP & PLHIV Case Management, effective community-facility linkages, formation and management of functional support groups, Afya Pwani strategies on MNCH demand creation, data use for decision making, report writing and documentation of success stories among others were discussed in detail during the workshop. It is envisaged that following this workshop, the grantees will utilize the skills to strengthen the implementation to facilitating an efficient community- facility linkage mechanism while contributing to the overall project targets and objectives. Afya Pwani will continue to provide on-going mentoring and capacity building support on any gaps and weaknesses to strengthen the grantees capacity.
VIII. PROGRESS ON ENVIRONMENTAL MITIGATION AND MONITORING
Please see Appendix I which contains the detailed Environmental Mitigation and Monitoring Report (EMMR) for the January- March 2018 quarter. IX. PROGRESS ON LINKS TO OTHER USAID PROGRAMS
During the January and March 2018 quarter that is under review Afya Pwani continued to collaborate with the Linkages program (being implemented by FHI360) to ensure that there is effective linkage of Key Populations (KPs) living in Mombasa, Kwale and Kilifi wanting to seek high quality HIV services from Afya Pwani supported sites. The Project has also continued to strengthen service delivery at the Malindi Comprehensive Care Clinic (CCC) and Kisauni Health Center with the aim of ensuring a comprehensive HIV
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package of interventions was available to People Who Inject Drugs (PWIDs) at the Methadone clinics in these respective areas. During the quarter under review, project staff continued to work closely with stakeholders from across all the five project supported Counties. For example, this quarter, in Taita Taveta, Afya Pwani participated in a meeting with County health stakeholders meeting that was held on 29th to 31st January 2018 at Safari Lodge Hotel in Voi [convened by the County]. The agenda was to map out partners in health in the County for better coordination. Among the USG supported partners present were Afya Pwani, Nilinde and Africa Medical and Research Foundation X. PROGRESS ON LINKS WITH GOK AGENCIES
Many indicators are on the rise following the end of the national nurse’s industrial action that ended towards the end of 2017. During the industrial action all service delivery ground to a halt resulting in underperformance across most of the indicators. Some of the collaborative activities with the Counties in the reporting period included participation in activities to celebrate the World TB (WTB) day that was commemorated on the 24th March 2018 across all counties. The theme of the WTB day was “Mulika TB, Maliza TB”. Afya Pwani provided logistical support in Kwale, Mombasa, Kilifi and Taita Taveta counties in addition to collaborating with the CTLCs for ICF of TB cases. Afya Pwani also participated in the Mombasa County dialogue day on the 22nd March 2018 at Wild Waters. The meeting brought together stakeholders in all sectors including health to share and discuss successes and challenges in different sectors. Among the key highlights for health was the upgrading of CPGH in line with the vision of improved service delivery pillar of the Mombasa Vision 2030 strategy and the challenge of garbage management to public health. The County has committed to intensify efforts for a cleaner city and improved service delivery through strategic investments in human resource and commodity security. Afya Pwani participated in the Kilifi HIV Consultative meeting that was held at Pride in Paradise hotel in Shanzu, on 9th of April 2018 to discuss and review HIV data performance. Among the key issues discussed was the rising number of HIV positive children recorded at the Kilifi County Hospital and the significant drop of ANC attendance between the first and 4th ANC visit. It was agreed that a HEI audit be done and is currently underway and will be followed by a corrective action plan including community mobilization and health systems support. Additionally, the MNCH Kilifi program in collaboration with the office of the County Executive Committee (CEC) Member and the Kilifi Woman Representative has embarked on a massive advocacy and community sensitization exercise with the aim to reverse trend. In Kwale County, the HTS services have been underperforming much more than other counties owing to nurses go slow in addition to the ongoing court case against one nurse for alleged misdiagnosis. Afya Pwani, supported discussions between the nurse’s union and the County government of Kwale (on 25th April 2018) with the aim to lift the stalemate so that nurses can resume testing. The key output of the meeting was that the County will form now on be more proactive in supporting the nurse in court and also facilitate the withdrawal of the case and the union engages the nurses on a return to testing formulae. In Lamu County, support supervision services are now going on smoothly following the procurement and hand over of a speed boat, by Afya Pwani, to the CHMT. Joint Supervisions were also carried out across all counties to provide support for the three sub-purposes of HIV/TB, MNCH/WASH/Nutrition and Health systems. Key issues that were noted across all counties is the inadequate HRH in service delivery, health care worker training gaps and data quality issues.
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XI. PROGRESS ON USAID FORWARD
Following the conclusion of the Country Operational Plan (COP) FY18 process, Afya Pwani has already modified the annual workplan (AWP) to be in line with the COP FY18 priorities. Accordingly, we have also begun discussions with the grantees to revise their workplans to align them to the new direction so as to optimize our resources and efforts for results.
XII. SUSTAINABILITY AND EXIT STRATEGY
To ensure sustainable impact and continued improvement of high quality HIV, MNCH, RH/FP, WASH and nutrition health service delivery in the five coastal counties, Afya Pwani successfully conducted a two-day workshop for the Project grantees in all the five counties to work with our health care service delivery and their activities will enhance increase in demand creation during the January and March 2018 quarter under review. More elaborate information on the Project’s grantees is captured in the VII. GRANTS Section. During the quarter under review, project staff have worked towards ensuring that all activities implemented have been in: 1) Full alignment with national policies and guidelines; 2) Focused on supporting the implementation of targeted and tailored TA, OJT and mentorship to address the specific needs of health workers, CHVs and S/CHMTS to ensure that the Project is providing tangible and measurable value addition, 3) Strengthen community networks for service delivery through CHVs and facility referral networks to ensure a continuum of service delivery for vulnerable and marginalized clients (including KPs, adolescents and youth). Whilst focusing on strengthening referral systems and linkages between health facilities and surrounding communities and vice versa. This has enabled Afya Pwani to reduce the risk and numbers of loss to follow‐ up and defaulting clients. Afya Pwani has also continued to facilitate and support the systematic involvement of all key actors and stakeholders including collaborating with other USAID funded mechanisms like NILINDE and LINKAGES, promoted local buy-in and ownership by holding joint activities with S/CHMTS and the MOH all of which has fostered an environment that places sustainability at the core of how the Afya Pwani team does business. In the next quarter, the project will continue to build on the gains made this quarter (especially with the two grantees coming on board), with all partners and sub- grantees expected to have been selected, Afya Pwani’s project activities will be in full swing and all efforts focused on strengthening and improving access to and utilization of high quality health services for the betterment, health and wellbeing of all the communities and Kenyans living in all five of the Afya Pwani supported counties. Sustainability and capacity building of S/CHMTs, health service providers, peer educators and CHVs working directly with intended beneficiaries, especially those most at risk, is a priority for the Project as it works toward increasing ownership and sustainability of interventions of project activities. By supporting capacity building of these stakeholders, Afya Pwani is ensuring that the positive outcomes resulting from its interventions extend beyond the life of the Project. The devolution of health care services, with the MOH linked to County Governments, Sub-counties and health facility levels through which the HIV/MNCH/FP/WASH/NTRITION response can be monitored and delivered is essential. It allows effective collaboration with project staff at similar organizational levels. Achieving operational sustainability in a resource-limited setting is practical and feasible. The Afya Pwani project develops and institutionalizes a QA/QI system as the basis of attaining graduation and sustainability of services. Use of national standards, guidelines, existing health system structures, logistics and information management are vital for ensuring sustainability.
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NUTRITION & ECONOMIC LIVELIHOOD STRENGTHENING: UNCOVERING THE SECRET TO LIVING POSITIVELY OLE MODEL IN SELF ECONOMIC STRENGTHENING AND DEPENDABILLITY Mr. Bege Abdallah is a good example to give when it comes to self-reliance. In 2005 Abdallah was diagnosed with Tuberculosis (TB), he tried to treat it three times but could not be cured. He later on decided to do a HIV test which turned positive, he explained to his wife who was also found to be positive after visiting Kinondo clinic in Kwale County. Abdallah developed complications within his lungs as well as hernia which saw his health deteriorate. Having gone through several succesful procedures, he could not do much as his body had now become weak and he was unable to earn Mr. Bege and the wife reflecting on the miles they have any income due to his ailing health. As a travelled result, he had to close down his hotel, lost his job as a driver and could not longer sell Makuti to look after his family. In 2008, his wife decided to grow cassava in their small piece of land so as to make some foney to feed the family but this did not go on so well. Abdallah was initially enrolled to care in Msambweni but later transferred to Kinondo where his wife was also seeking services. At the beginning of his treatment he was frustrated by the fact that during appointment days lines were long and services were being offered very slow- almost taking the whole day. “Those days accessing services at the CCC were hectic because of the long lines of clients waiting to be served, it took me the whole day and so many programs had to stop back at home, the few crops planted were eaten by animals with no one to look after them. Topics were addressed at the facillity but in a group and so our challenges were not really addressed. My viral load was very high by then because most of the appointment days were not flexible,” Abdallah says. Then the USAID Afya Pwani project came in to support of Kinondo Kwetu. The Project has since working on improving access and utilization of HIV services by incresing clinic days and reducing waiting times. As a result, Abdallah like many other patients has been able to access the services he needs in a timely manner, all of which has seen his and his wifes’ health vastly improve. Following these improvements, Abdallah has been able to boost his nutrition by growing vegetables including but not limited to Kale, Okra and Egg plants. Far from using the same for his food, he is also selling some to neighbors and the community surrounding him. The support groups they have been attending have really improved their understanding of Positive Health, Dignity, and Prevention (PHDP) messages, viral load suppression and good adherence. Currently Abdallah has suppressed his viral load and that of the wife has come down to undetectable levels. “My family wishes to thank the efforts of Afya pwani who have boosted us especially here in kwale. When one has a good body immune system and suppressed viral loads, it becomes easy for them to run their activities normally and even strengthen themselves not only depending on the few coins given during
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support groups," Abdallah conludes. In the support group known as Nia Njema, Abdallah serves as an example of a non dependent of financial support and one who has strengthened himself economically.
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MY DREAMS ARE VALID: LIVING POSITIVELY WITH HIV
Johannes (not his real name) a 22-year-old man, is a resident of Mombasa County, Likoni Sub-County, Shika Adabu area; married with two wives, and 3 children. Johannes is the sole bread winner for his two housewives. Johannes works as a salesperson in a shop in Mombasa Juakali area; he lives with the second wife in Mombasa while the first wife stays in Kisumu his hometown. Johannes has been HIV negative until he tested HIV positive after his first wife witnessed the second wife taking her ARVs medication in hiding then later advised him to go for HIV testing, He then took his two wives for counseling and testing where him and the second wife tested positive while the first wife tested HIV negative. Johannes and the first wife are therefore discordant Couples. He says he loves the first wife and uses condoms consistently and correctly and that he would not wish for her to get infected.
Johannes immediately enrolled for comprehensive care clinic at Shika Adabu Dispensary in Mombasa and was adhering well on his ARV drugs, He later joined an active support group named adolescent and youths living with HIV and became an active member of the support group in Shika Adabu Dispensary, this support group enabled them to have platform where each and every member is able to learn from one another and share different experiences they are having in their day to day living and various ways on how to live positively.
This however changed when Johannes started defaulting from taking his drugs and also stopped attending the support group where he was a very active member since he joined for one and a half month; with our intervention on Defaulter tracing in partnership with Shika Adabu Dispensary CCC staff we were able to track Johannes and brought him back on care and support group.
Johannes opened up during male champion’s workshop which was supported by the partnership for a HIV free generation in partnership with Shika Adabu Dispensary, Mrima and Likoni Sub County Hospital. He shared how the wife’s unfaithfulness made him stop taking drugs and also led the wife into giving birth to an HIV positive child a situation Johannes says would have been salvaged if only the wife was attending her clinic appointments and also adhering to her drugs as required, he managed to sort his issues with the wife and they are now raising their child who was born HIV positive.
Johannes was also trained on positive health and dignity prevention as a facilitator and will soon be engaged in rolling out the intervention to the other community members living positively. He is living healthily and is strictly adhering to his drugs and during one of the positive health and dignity prevention training sessions, Johannes stated that ’I rather carry my clinic card, my wife’s and child’s so that i can always remind us of the clinic date than money in my pocket, I thought that it was not possible to live a normal live with HIV until I met people living with HIV look more better than the negatives. I am grateful for the opportunity given. I am ready to educate the community on importance of eMTCT, adherence, faithfulness and living positively’.
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SANITATION AGANST ALL ODDS-IDZA KALU Idza Kalu a resident from Gongoni, smiles near her newly constructed toilet which has helped ensure that she now has a clean and private toilet to use. In the past, her household members have been going to the bathroom in the nearby bush putting Idza and her family at risk. Her new toilet came about as a result of a sensitization by SPEAK (an Afya Pwani Grantee) in January 2018 in her village. With assistance from SPEAK she was able to construct a three-door, flushable toilet that requires very little water to flush and keep clean. Beside her toilet, she has placed a hand washing facility with soap. Idza is thankful to the project for a wakeup call to redefine sanitation through community dialogues and sanitation marketing towards Open Defecation Free (ODF). ``Since I constructed my toilet and a handwashing station with water and soap a month ago, my household expenditure towards medication for illnesses like typhoid has reduced- something that I did not anticipate. I feel relieved!’’ she says. According to Idza, she hopes to become a WASH champion and sensitize other households within her village and beyond to construct sustainable toilets, thereby contributing to ODF uptake.
Above:Idza Kalu(left) poses for a photo with community health volunteers beside her newly constructed modern toilet.
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IGAs: IMPROVING WOMEN LIVES Despite living in a busy town like Mtwapa, Mrs. Malka from Mtwapa did not however have any source of income. Her husband provides for everything, but this was hardly enough to feed her and their four children, a 6-year-old boy, a 3-year-old girl and 1-year-old twin boys. She had to struggle to make ends meet by doing causal work such as washing clothes accompanied with her twins as she could not leave them behind. Mrs. Malka also had to sell cassava (depending on the season) in her neighborhood to earn an extra coin.
In November 2017, the USAID Afya Pwani project grantee, SPEAK began activities in Kilifi South Sub-County, Mtwapa location. The program entailed training mothers with children under 5 years on cross sector community driven approaches to improve household food security and diversity as well as small scale businesses that include agribusiness. Encouraged by project staff and agricultural extension officers, Mrs. Malka joined the trainings hoping that the new ideas of starting a small-scale business would improve her family’s income and secure better living conditions. Mrs. Malka’s children cooking cassava. The After attending the training sessions organized by the mother has gone to sell cassava and the eldest child aged 6 years has to cook for her younger project, Mrs. Malka applied the knowledge that she sister as instructed by their mother. learned and saw immediate results after starting her own liquid soap making business. She started getting customers within the first week of her sales and by the second week was already receiving orders for supply of the liquid soap that earned her KES 2,100. Making a daily profit of KES 300 from the liquid soap business and 100 from the clothes washing, Mrs. Malka has improved her house hold food security and other opportunities to her family. "Now I have something that gives me more money and meets my daily needs without much support from my husband. The income helps me pay rent whereas my husband now pays for school fees and saves for future family development,’’ Demonstrating on how liquid soap is prepared Said Mrs. Malka. (Mrs. Malka in the center) at Mtwapa health facility. (Photo taken by Khadija Ali, nutrition Mrs. Malka is one of the 70 mothers who have benefited officer Mtwapa. from the USAID supported project to initiate and train on “Pilot-Cross sector activities” in Kilifi South Sub-County. Apart from supporting the nutrition program, the program also helps improve household food security. Between November and December 2017, the project piloted cross sector activities to 70 mothers in Kilifi South Sub County at Vipingo and Mtwapa. With the knowledge they got, their businesses have improved and for those who did not have businesses, they started which has helped to contribute to household food security and increase number of children (under 5 years) by USG-Supported nutrition programs,’’ said purity Mwangombe, the Kilifi South Sub County nutrition officer.
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When the Pilot-Cross-Sector activity program started in Kilifi South very few mothers were engaged in IGAs however currently almost 80% of those trained have started their own businesses, from the little saving they had or from other sources. These business successes have helped mothers to improve and maintain their house hold food security and hence reduce poverty.
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MY BIG FIGHT FOR HIV STIGMA
Veronica is a 47-year-old mother of three who lives in Misisinenyi village, Mwatate Sub-County, Taita- Taveta County. Despite her lack of employment, Veronica has a very important job in her community- she is a stigma champion fighting against discrimination of people who are HIV positive. She first found out about her status after she lost a child who had been ill for a prolonged period of time. After the death of her child, she then decided to be tested for HIV (that was mid-2000). She was diagnosed with HIV and decided to disclose her status to her family. Despite the fact that they stigmatized her, she chose to live a positive life and has since become the voice for anti-stigma and discrimination in her society. Through training as a community mentor mother and Prevention of Mother-To-Child Transmission (PMTCT) ambassador, Veronica has successfully demonstrated her skills to many people in the community in her efforts in changing the community against HIV stigma. “I have decided to fight stigma against HIV testing and treatment wherever I go and to the people I meet, by disclosing my HIV status to them thereby demonstrating a positive living with HIV. Many people do not believe that I am positive because of how healthy I am", Veronica says. She also uses herself as the living testimony of losing a child who believe she died of HIV because of negligence of HIV testing. Veronica is often called upon to counsel people living in denial; for example, there was a client in Wundanyi Constituency who was in denial and bedridden at that time. She counselled the client and the family by using herself as a living testimony where after the client accepted their condition and was put on care and treatment. Apart from disclosure, she has always focused on educating people on the importance of early HIV testing as many people wait until they become totally sick. She also focuses on sharing information on the importance of correct and consistent condom use among positive clients, adolescent and youth and sexually active people. Veronica’s efforts and that of other mentor mothers has greatly contributed to the successful progress of the USAID Afya Pwani project as they have participated in the implementation of various activities in the community they represent and have also increase access to HIV care and treatment.
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TRIUMPH OF INDEX TESTING
Benson is a resident of Byubu Village in Bamba ward, Ganze Sub-County in Kilifi. He is married to 47-year- old Sidi and together have been blessed with 6 children the youngest being 1 year and 10 months. Benson and his wife are subsistence farmers who cultivate cereals for their family’s consumption and surplus sold at the local market to meet other bills. For a better part of 2017 Benson Karisa and his wife had been battling with poor health, the two had been ailing frequently under attacks of different diseases not knowing the cause. Benson would monthly seek treatment from Midoina Dispensary, the nearest health facility. Whenever he went, he would ‘dodge’ the HIV virus test for fear of turning out positive as well as the stigma that is associated with it in his village. In February 2018, a door to door outreach had been organized in his village and his house was one of the houses that was visited. At first, he didn’t want anything to do with counselors that he chased them away. Later his wife Sidi, came and inquired what services were being offered and agreed to do an HIV test together with their young son. The testing was done far away from the home for fear of her husband noticing. The HIV test results turned out positive and she was further advised to go to the Bamba Sub- County Hospital for a confirmatory test. When she went home, she talked to the husband and explained what had happened and convinced him to accompany her to the hospital the next day to take the same tests. Reluctantly, Benson agreed to accompany his wife to the health facility. At the hospital, they were seen by a counselor who discussed and took them through the testing process. Benson says the counselor was very friendly, knowledgeable and understanding, “Were it not for that counselor in the counselling session I probably would be in denial, hate myself and think of doing the unbelievable,” he says, adding that the counselling helped them a lot because they were taken through it together with his wife. The counselor also took time to take them through the medication process which he says they have been able to follow well. He explains that since they started the medication they have seen a great improvement and has stopped falling sick every now and then; apart from few instances which he attributes to the medicine side effects and believes that soon all will be well once the body gets used to the medicine. Sidi, says that she has learnt the importance of taking the medication and being the home keeper, she has taken the role of ensuring that they both take the medication at the right time. For Sidi, she is very grateful because were it not for the outreach in their village, she would not have known her status as the health facility is far from the village, a big contributor to why most people in the area do not know their HIV status and those that know are also stigmatized. She further explains that she has learnt new ways of taking care of herself to enable them live longer and take care of their children. As a couple, they explain that despite the long distance to the health facility where they get their medication, they are determined and willing to do all it takes to make sure that they never miss their scheduled appointment as they now understand the importance of the medication. Moving the Goal Post, a grantee of the USAID Afya Pwani project together with Ganze Health Centre and Bamba Sub-County Hospital have and will continue to conduct outreaches in this Sub-County in the hope to continue reaching more people around the area with information on the importance of getting tested for HIV and seeking the right treatment if found to be positive.
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