USAID KENYA AND EAST AFRICA AFYA JIJINI YEAR 2 ANNUAL WORK PLAN
JULY 2016 This publication was produced for review by the United States Agency for International Development. It was prepared by IMA World Health. USAID KENYA Afya Jijini YEAR 2 ANNUAL WORK PLAN
Award No: AID-615-C-15-00002
Prepared for Ms. Katherine Farnsworth United States Agency for International Development/Kenya and East Africa c/o American Embassy United Nations Avenue, Gigiri P.O. Box 629, Village Market 00621 Nairobi, Kenya
Prepared by: IMA World Health 1730 M Street N.W. • Suite 1100 Washington, DC 20036
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.
CONTENTS
Introduction...... 1
Afya Jijini Y2 Proposed Activities ...... 2
Sub-Purpose 1: Increased Access and Utilization of Quality HIV Services ...... 2 OUTPUT 1.1: eMTCT ...... 3 OUTPUT 1.2 AND OUTPUT 1.3: HIV CARE, SUPPORT, AND TREATMENT SERVICES ...... 5 OUTPUT 1.4: HIV TESTING AND COUNSELING (HTC), VOLUNTARY MEDICAL MALE CIRCUMCISION (VMMC), GENDER- SENSITIVE HIV PREVENTION, AND DREAMS ...... 8 GENDER-SENSITIVE HIV-PREVENTION SERVICES ...... 12 DREAMS ...... 14 OUTPUT 1.5: TB / HIV CO-INFECTION SERVICES ...... 17
Sub-Purpose 2: Increased Access and Utilization of Focused Maternal- Newborn Health (MNH), FP, WASH, and Nutrition Services ...... 20 OUTPUT 2.1: MNH SERVICES ...... 21 OUTPUT 2.2: CHILD HEALTH ...... 25 OUTPUT 2.3: FP ...... 27 OUTPUT 2.4: WASH SERVICES ...... 29 OUTPUT 2.5: NUTRITION SERVICES ...... 32
Sub-Purpose 3: Strengthened and Functional County Health Systems ...... 35 OUTPUT 3.1: PARTNERSHIPS FOR GOVERNANCE AND STRATEGIC PLANNING ...... 35 OUTPUT 3.2: HRH ...... 37 OUTPUT 3.3: HEALTH PRODUCTS AND TECHNOLOGIES ...... 38 OUTPUT 3.4: STRATEGIC M&E SYSTEMS ...... 41 OUTPUT 3.5: QI SYSTEMS ...... 43
III. Project Management ...... Error! Bookmark not defined.
Annexes and Attachments ...... Error! Bookmark not defined. ATTACHMENT 1: GANTT CHARTS ...... 46 ANNEX I: YEAR II BUDGET ...... Error! Bookmark not defined. ANNEX II: PROPOSED INTERNATIONAL TRAVEL Error! Bookmark not defined.
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ACRONYMS AND ABBREVIATIONS ACF Active Case Finding ADR Adverse Drug Reaction ADT ARV Dispensing Tool AGYW Adolescent Girls and Young Women AJSGP Afya Jijini Small Grants Program AMTSL Active Management of Third Stage of Labor ANC Antenatal Care AOC Ambassador of Change ARI Acute Respiratory Infection ART Antiretroviral Therapy AWP Annual Work Plan AYSRH Adolescent Youth Sexual and Reproductive Health BCC Behavior Change Communication BEmONC Basic Emergency Obstetric and Newborn Care BFHI Baby-Friendly Hospitals Initiative BMI Body Mass Index CBD Community-Based Distribution/Distributor CBHIS Community-Based Health Information System CBO Community-Based Organization CCC Comprehensive Care Centre CEmONC Comprehensive Emergency Obstetric and Newborn Care CHEW Community Health Extension Worker CHMT County Health Management Team CHV Community Health Volunteer CME Continuing Medical Education CNTF County Nutrition Technical Forum COP Country Operating Plan CWC Child Welfare Clinic CYP Couple Year Protection DDIU Data Demand and Information Use DICE Drop-In Center DOTS Directly Observed Therapy, Short Course DQA Data Quality Assurance DREAMS Determined, Resilient, Empowered, AIDS-Free, Mentored, and Safe Women EBF Exclusive Breastfeeding EBI Evidence-Based Intervention ECD Early Childhood Development EID Early Infant Diagnosis EMMP Environmental Monitoring and Mitigation Plan EmONC Emergency Obstetric and Newborn Care EMR Electronic Medical Record eMTCT Elimination of Mother-to-Child Transmission of HIV EQA External Quality Assurance FMP Family Matters Program FP Family Planning FSW Female Sex Worker GBV Gender-Based Violence GOK Government of Kenya HCA HIV Cohort Analysis HCBF Healthy Choices for a Better Future HCW Health Care Worker HCWM Healthcare Waste Management HEI HIV-Exposed Infant HINI High-Impact Nutrition Intervention HPT Health Products and Technologies USAID/KENYA AFYA JIJINI YEAR 2 WORK PLAN ii
HQ Headquarters HR Human Resources HRH Human Resources for Health HRIO Health Records and Information Officer HRIS Human Resource Information Systems HSS Health Systems Strengthening HTC HIV Testing and Counseling HTS HIV Testing Services ICF Intensified Case Finding IEC Information, Education, and Communication IEE Initial Environmental Examination IFAS Iron and Folic Acid Supplementation IMA IMA World Health IMAM Integrated Management of Acute Malnutrition IMCI Integrated Management of Childhood Illness IPC Infection Prevention and Control IPD Inpatient Department IPT Isoniazid Preventative Therapy IPV Intimate Partner Violence KMC Kangaroo Mother Care KQMH Kenya Quality Model for Health LARC Long-Acting, Reversible Contraception M&E Monitoring and Evaluation MCH Maternal Child Health MDR-TB Multi-Drug Resistant TB MER Medication Error Reporting MHMC My Health, My Choice MIYCN Maternal Infant and Young Child Nutrition MNH Maternal-Newborn Health MNCH Maternal, Newborn, and Child Health MOH Ministry of Health MPDSR Maternal and Perinatal Death Surveillance and Response MSM Men Who Have Sex with Men MSW Male Sex Workers MTC Medicines and Therapeutics Committee NAC Nutrition Assessment and Counseling NASCOP National AIDS and STI Control Program NCC Nairobi City County NHP+ Nutrition Health Program Plus OJT On-the-Job Training OPD Outpatient Department ORS Oral Rehydration Solution ORT Oral Rehydration Therapy OVC Orphans and Vulnerable Children PAC Post-Abortion Care PLHIV People Living with HIV PMTCT Prevention of Mother-to-Child Transmission PNC Post-Natal Care PPFP Post-Partum Family Planning PPH Post-Partum Hemorrhage PRC Post-Rape Care PrEP Pre-Exposure Prophylaxis PSM Patient Self-Management PSS Psychosocial Support PSSGs Psychosocial Support Groups PT Proficiency Testing
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QA Quality Assurance QI Quality Improvement QIT Quality Improvement Team RCM Respectful Care Module RDQA Routine Data Quality Assessment RH Reproductive Health RMNCH Reproductive, Maternal, Newborn, and Child Health RRI Rapid Results Initiative RTK Rapid Test Kit SBA Skilled Birth Attendance SCHMT Sub-County Health Management Team SDA Small Doable Action SMLT Sub-County Medical Laboratory Technologist SOP Standard Operating Procedure SRH Sexual and Reproductive Health STI Sexually Transmitted Infection TA Technical Assistance TB Tuberculosis TOR Terms of Reference TPA Treatment Preparation and Adherence TPS Treatment Preparation and Support TWG Technical Working Group UCLTS Urban Community-Led Total Sanitation VL Viral Load VMMC Voluntary Medical Male Circumcision WASH Water, Sanitation, and Hygiene WHO/AFRO World Health Organization - Regional Office for Africa WIT Work Improvement Team
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Introduction
Afya Jijini is a three-year contract (with two option years) that contributes to USAID/Kenya’s Country Development Cooperation Strategy Sub-Intermediate Result 2.2.2 for “improved county-level institutional capacity and management of health service delivery” in Nairobi City County (NCC) The project’s purpose is to improve and increase access and utilization of quality health services in NCC through strengthened service delivery and institutional capacity of health systems. Afya Jijini seeks specifically to achieve three main sub-purposes:
Sub-Purpose 1: Increase access and use of quality HIV services. Sub-Purpose 2: Improve access and uptake of maternal, neonatal, and child health (MNCH); family planning (FP) and reproductive health (RH); Water, Sanitation and Hygiene (WASH); and nutrition services. Sub-Purpose 3: Strengthen county and sub-county health systems.
The following priorities guided FY17 work plan development:
Overall: Afya Jijini enters Y2 having created a strong foundation for outcome achievement across sub- purposes and technical areas. Y2 offers the opportunity to scale up proven, evidence-based interventions (EBIs) initiated in Y1. The evidence base – including Y1 programmatic experience and quantitative and qualitative data from the Afya Jijini baseline and gender analysis completed in Y1 - provide invaluable guidance on focusing the project’s efforts to achieve overall contractual goals.
Sub-Purpose 1: The President’s Emergency Plan for AIDS Relief annual targets for Afya Jijini increased for Y2, in view of the 90-90-90 treatment goals and Kenya’s adoption of the test and treat strategy in July 2016. In FY17, Afya Jijini is expected to initiate 9,068 new patients on antiretroviral therapy (ART) and achieve viral load (VL) suppression for 39,343 people living with HIV (PLHIV) currently on treatment. Additionally, the Determined, Resilient, Empowered, AIDS-Free, Mentored, and Supported (DREAMS) program is in its second and final year. The project will intensify support to adolescent girls and young women (AGYW), their sexual partners, and community members in line with the DREAMS core package of interventions.
Sub-Purpose 2: The project will continue working within NCC and high-volume facilities to implement interventions for improved access to maternal, neonatal, and child health services. These activities will increase uptake of 4+ antenatal care (ANC) visits, access to Comprehensive Obstetric and Newborn Care (CEmONC) and Basic Emergency Obstetric and Newborn Care (BEmONC) services at 34 facilities and improved surveillance of maternal and neonatal deaths. The project will also continue building on successes in increasing uptake and access to FP services, and supporting the county to maintain 80% immunization coverage and adopt Integrated Management of Childhood Illness (IMCI) guidelines. Within WASH, the project will strengthen Oral Rehydration Therapy (ORT) corners and infection control within facilities and access to clean water within the community level and in households with children under five. Nutrition interventions will focus on the first 1,000 days, as well as improved identification and treatment of malnourished children under five through project’s outreach efforts in early childhood development (ECD) centers and within communities.
Sub-Purpose 3: The project will continue technical assistance (TA) to strengthen the county’s capacity to develop and implement plans and systems for health service delivery. In Afya Jijini’s first year, the project supported the county to establish quarterly stakeholder forums, develop an annual work plan, and streamline supervision efforts to health facilities. These efforts, along with plans to increase coordination within the county and among the project’s 10 sub-counties are expected to improve supervision and management of the critical health systems building blocks. During FY17, the project will strengthen sub- county and facility level leadership and governance, improve facility-level human resources for health
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(HRH) performance management, scale-up and strengthen the quality of labs and the supply chain, and improve data demand and information use (DDIU).
Afya Jijini Y2 Proposed Activities
Sub-Purpose 1: Increased Access and Utilization of Quality HIV Services
Introduction NCC ranks among the top five leading counties contributing to the HIV burden in Kenya. While not necessarily leading in prevalence, it is home to more than 10 percent (nearly 180,000 people) of PLHIV. It features factors that put people at increased risk of contracting HIV, particularly among key populations and young girls, including rapid urbanization, high levels of poverty in ever-growing informal settlements, and lingering HIV stigma and discrimination.
Targets In FY17 Afya Jijini will: Test at least 193,130 clients, with a focus on scaling up testing in high yields areas (outpatient, inpatients, tuberculosis (TB) clinics, ANC, family and partner testing, key population, and youth). Identify 9,467 positive adult clients link them to ART. Identify 487 positive children and link them to ART. Maintain 43,715 PLHIV on treatment and ensure viral load suppression for 39,343 PLHIV Initiate 9,068 PLHIV on ART and achieve 90% retention rates Ensure 95% of ANC clients are offered HIV testing and identify 1,531 prevention of mother-to- child (PMTCT) mothers and link them to ART as core part of elimination of mother-to-child transmission (eMTCT).
Approach Afya Jijini supported NCC to scale-up HIV services in Y1 for adults and pediatrics. By the close of Y1, Afya Jijini supported 43 eMTCT sites, 22 high-volume care and treatment facilities, and 36 sites with TB/HIV services. The First 90: During Y1, the project provided HIV testing services (HTS) to 242,972 clients, achieving 271% of its target. Of these, 10,817 tested positive (314% of target), an overall positivity yield of 4.5% (with higher yields among certain sub-populations). The Second 90: Overall, treatment linkages of all new positives was 55% for Y1; however, it increased greatly to 81% by Q4 (with higher linkages for TB and PMTCT patients). The Third 90: Through file audits and outreach, the project rapidly increased VL coverage, reaching 84% of all patients on ART by the end of Y1. VL suppression stands at 84% (adults and children) in patients with documented results (and 95% among women in PMTCT).
Ambitious COP16 targets and adoption of the Test and Treat strategy in July 2016 call for strengthened support to NCC in scaling-up access to HIV services to achieve the 90-90-90 targets. Afya Jijini will work closely with the county to roll-out the new guidelines to all supported care and treatment sites, focusing on high-volume sites (sites with >500 HIV patients in HIIV care and treatment). The “Test and Treat” strategy requires an intensified focus on identifying clients testing HIV-positive and same day initiation on ART.
As described in Sub-Purpose 3, the project’s Health Systems Strengthening (HSS) Team will also coach the county and sub-counties, concentrating on the most high-impact and high-volume sites while ensuring that systems strengthening approaches (such as supervision, planning, quantification of commodities, reporting of both service delivery as well as commodity consumption) are supported. To
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promote sustainability, Afya Jijini will continue supporting and participating in technical working groups (TWGs), County Health Management Team (CHMT) and Sub-County Health Management Team (SCHMT) planning meetings, and donor affinity groups. Working with these TWGs is critical to program success, as they provide institutional memory and reduce the impact even after the end of the project.
At the site level, project UHAI TA teams will work closely with health facilities to support site-specific work plans to improve HIV integration and service delivery. Site level approaches to strengthen service delivery will include continuing medical education (CMEs), on-the-job trainings (OJTs), mentorship, support to psychosocial support groups (PSSGs), and lab networking (see Output 3.3) and, where needed, supplements to the workforce. Specific cadres, such as clinical workers in the Comprehensive Care Centres (CCCs) and HTS Counselors, will also be deployed strategically at high-volume health facilities to support scale-up of Test and Treat. The project will also integrate PMTCT services into five new maternal and child health (MCH) clinics, as well as improve HIV-exposed infant (HEI) follow-up through defaulter tracking and HEI analysis.
OUTPUT 1.1: eMTCT
Background and Rationale In Y2, Afya Jijini will concentrate on maintaining the progress from Y1 while strengthening efforts to ensure that HEIs are tracked throughout the full eMTCT cascade. Afya Jijini’s baseline assessment found that site-level capacity to delivery PMTCT services varies. However, access to HIV testing is high: 90% of pregnant women were tested for HIV (Note: this is of all facilities surveyed, as compared to Afya Jijini- supported sites, where 98% of pregnant women in ANC currently opt for HTS). Access and uptake of services throughout the PMTCT cascade diminishes for enrollment on ART and access for HEI to early infant diagnosis (EID). Additionally, the baseline found gaps in availability of tools and use of standard operating procedures (SOPs) to track mothers and HEIs, including defaulters.
Program data demonstrate similar outcomes within the PMTCT cascade. While the project successfully linked 91% of pregnant women testing HIV-positive to ART and achieved viral suppression in 95% of clients in its first project year, there are gaps in adherence to PMTCT interventions and tracking mother- baby pairs throughout the PMTCT cascade. For example, an audit of 112 HIV-infected infant charts (from current and previous years, but conducted in Q4) showed that 33% of mothers/pregnant women and 30% of infants did not receive any PMTCT interventions. Fourteen percent of the mothers were identified in the third trimester or later, 41% of the infants tested after six weeks in outpatient department (OPD)/inpatient department (IPD), and 26% of the mothers had adherence issues.
Approach In FY17 Afya Jijini support is focused on 45 health facilities for improved eMTCT service delivery. Of these, six sites (Marura Nursing Home, Korogocho Health Center, Kariobangi South Clinic, Redeemed Gospel, St. John’s Hospital, and Brother Andre Dispensary) are new, 25 facilities serve greater than 500 clients for first ANC, and 20 facilities have less than 500 clients for first ANC.
Progress toward eMTCT objectives will be supported by 26 eMTCT/MCH nurses that are shared equally between Sub-Purpose 1 and Sub-Purpose 2 to improve overall delivery of services in MCH settings, including improved uptake of focused antenatal care and HIV testing. These eMTCT nurses will complement facility-based efforts by providing OJT and mentorship and also tracking eMTCT-MCH integration efforts. The project’s Y2 strategies are designed to ensure that high rates of HIV testing continue, and, by integrating PMTCT services into the remaining five MCHs, services will reach mother- baby pairs together and they will be more easily tracked. Mentor Mothers based at Afya supported facilities will lead eMTCT psychosocial support (PSS) efforts and defaulter tracking. Improved use of data, such as QI efforts (see Output 3.5) and training on HEI cohort analysis (HCA), will allow health
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facilities to identify means for improvement in tracking mother-baby pairs until completion of the PMTCT cascade. The project will also explore engagement of community-based Mentor Mothers to provide necessary PSSGs on a more frequent and accessible basis through the Afya Jijini Small Grants Program (AJSGP). Additionally, the project’s activities under Output 2.1 will increase ANC attendance, facility-based deliveries, and safe breastfeeding practices, all of which contribute to reduced risk of mother-to-child HIV transmission.
Activity 1.1.1: Identify 3,159 HIV-positive pregnant women through testing and re-testing. By implementing strategies to ensure that HIV testing is available at all entry points, Afya Jijini will test 74,717 pregnant women, with the aim of identifying 3,159 HIV-positive pregnant women in Y2. Mentor Mothers will provide patient education in MCH waiting rooms about the importance of HIV testing for pregnant women. UHAI teams will conduct CMEs to improve capacity of HTS providers and print and distribute information, education, and communication (IEC) materials and job aids at high-volume sites without them. The project will conduct quarterly joint supervision and mentorship with the SCHMT and the county. Afya Jijini will help train 60 eMTCT nurses, using the National AIDS and STI Control Programme (NASCOP) curriculum on the new guidelines for 60 facilities, 15 of which are from private facilities. Please see Output 3.4 for activities to ensure continuous supply of rapid test kits (RTKs).
Activity 1.1.2: Improve eMTCT-MCH integration. The project will integrate PMTCT services into five MCHs. To do this, the Afya Jijini will train 45 nurses on ART, including establishing efforts to fast track HIV-positive pregnant women onto ART. Integration efforts at all 45 PMTCT sites will be supported through OJT, CMEs, and joint mentorship and supportive supervision with the SCHMT. Monthly Work Improvement Team (WIT) meetings will monitor quality of care.
Afya Jijini will reduce missed opportunities for access to RH services for HIV-positive women by integrating FP/RH services into 25 CCCs. The project’s FP/RH Field Assistants will train CCC healthcare workers (HCW) to offer FP services and ensure that family planning commodities are readily available. Women wishing to receive RH services in the CCCs will be fast-tracked. Mentor Mothers will track referrals for long-acting methods within the facility. The project will also support printing and dissemination of RH job aids to all supported sites.
Activity 1.1.3: Enroll 3,159 HIV-positive pregnant women on ART and achieve 90% VL suppression. UHAI teams will strengthen HCW capacity to appropriately collect VLs and follow-up clients. Necessary job aids and IEC materials will also be distributed. The NASCOP curriculum described in Activity 1.1.1 provides training on how to track pregnant women across the cascade. Joint supportive supervision and mentorship with the SCHMTs will reinforce capacity to monitor ART treatment outcomes. WITs meetings will also review progress along the eMTCT cascade, with a specific emphasis on retention in care and VL suppression rates. As described in Output 3.3, the project will support daily VL sample networking.
Activity 1.1.4: Support and track HEI. The project will support EID services for all expected 3,238 HEI by ensuring EID commodities are available, conducting CMEs on the new NASCOP guidelines, and providing reporting tools. The project will review EID services during mentorship and supportive supervision undertaken with SCHMTs. The project will also ensure EID is provided at the Child Welfare Clinics (CWCs) for testing of infants, as per the algorithm, and re-testing of the HIV-negative breastfeeding mothers at six weeks, 14 weeks, and every three months until cessation of breastfeeding. As described in Output 2.1, community health volunteers (CHVs) will help identify HEIs and deliver health talks at community level emphasizing the importance of HEI follow-up. Finally, the project’s eMTCT nurses will work with 45 facilities to better monitor HEI outcomes by conducting HCA. Afya Jijini – working with the county- will train 120 eMTCT nurses and CCC clinicians HEI cohort analysis.
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Activity 1.1.5: Increase mother-baby retention in the eMTCT cascade. Mentor Mothers will help retain mother-baby pairs in the eMTCT cascade. At a minimum, the project will allocate 45 facility-based Mentor Mothers to manage PSSG, conduct defaulter tracing, and participate in QI initiatives that will review retention along the eMTCT cascade. The project will also train 30 Mentor Mothers and allocate them to community-based initiatives to complement defaulter tracing and PSS at the facility level. Afya Jijini will ensure the mother-baby pair registers are available at supported health facilities and also used correctly. Sub-grantees under the AJSGP will manage deployment of Mentor Mothers within target communities and facilities, in collaboration with Afya Jijini.
Activity 1.1.6: Boost eMTCT-focused stakeholder collaboration. Stakeholder collaboration will support the sub-county to ensure that eMTCT activities are planned and managed appropriately. Similarly, collaboration with partners will also ensure that project resources are used effectively and there is no duplication of effort. Afya Jijini will support quarterly eMTCT sub-county TWGs. The project will also engage private clinics near residential areas and informal settlements to ensure their services are incorporated into referral networks. These providers will be invited to attend quarterly sub-county meetings. These facilities will also receive job aids and IEC materials and be included in CMEs or trainings on the new guidelines. The project will also aim to conduct joint mentorship and supportive supervision with the SCHMT to these private sector providers each quarter.
Activity 1.1.7: Strengthen ART linkages for HIV-positive infants. Mentor Mothers and the project’s linkage web (see Output 1.4) will ensure that all infants testing HIV-positive are tracked and initiated on ART. Afya Jijini will also expand the project’s facility-based Mentor Mothers program initiated in Y1 to communities by supporting community-based Mentor Mothers through small grants and existing community-based initiatives. The Mentor Mothers model will complement the facility-based work and mobilize clients for services, including following-up HIV-positive infants. Male involvement activities will be incorporated through community small grants and other Evidence-Based Interventions (EBIs) under Sub-Purposes 1 and 2, and include community initiation/cultural activities and ceremonies, sporting activities targeting men, and activities that promote uptake and access to couple/partner testing and care for infants testing HIV-positive.
Activity 1.1.8: Strengthen family-centered HIV testing and care. Family testing and linkages to care and treatment will ensure that needs of caregivers are appropriately met (and increase the likelihood that HIV-positive infants will receive services). See Output 1.4 for a more detailed description of this approach.
Activity 1.1.9: Increase adolescent-friendly ANC services. Adolescent-friendly services will be scaled- up in 10 health facilities, including health facilities that will receive referrals from DREAMS activities in Makuru kwa Njenga. Special clinic days scheduled concurrently with the PSSGs will be provided by identified HCW who can most effectively engage with AGYW in providing ANC services.
OUTPUT 1.2 AND OUTPUT 1.3: HIV CARE, SUPPORT, AND TREATMENT SERVICES
Background and Rationale In Y2, Afya Jijini will build from successes achieved in Y1 to achieve ambitious targets to enroll 9,068 patients onto ART; maintain 43,715 patients in care, and achieve VL suppression for 39,343 patients. In the project’s first year, treatment linkages of all new positives was 55%. However, it increased greatly to 81% by Q4 (with higher linkages for TB and PMTCT patients). Through file audits and outreach, the project rapidly increased VL coverage, reaching 84% of all patients on ART by the end of Y1. VL suppression stands at 84% (adults and children) in patients with documented results. The project’s baseline assessment indicated that approximately half of the surveyed facilities can track ART patients USAID/KENYA AFYA JIJINI YEAR 2 WORK PLAN 5
(even defaulters and pediatric patients), representing important potential in tracking and achieving adherence.
Approach In Y2, Afya Jijini will scale-up proven HIV approaches, including fast tracking roll-out of the Test and Treat strategy, ensuring functionality of the linkage web (described below), and ensuring access to VL testing. Activities will support 40 sites, with focus on 22 high-volume care and treatment sites that provide ART to more than 28,000 patients (or 88% of patients currently on ART). In line with Test and Treat, HIV-positive patients will be immediately enrolled onto ART and patients on care will be transitioned to ART.
Treatment Preparation and Adherence (TPA) Counselors and peer educators will reinforce the project’s “Testing and Linkage Web” and help support the PSS needs for adults and children. The project will continue ensuring functionality of the “Testing and Linkage Web” in the 22 high-volume HIV sites. This system ensures inter-connectivity between intra-and inter-facility testing points, treatment preparation support (TPS) points, and linkage to CCCs to better track and support clients testing positive. All clients testing at the various testing points are escorted by peers (expert clients) to the TPA Counselors for additional counseling and treatment preparation. Then, the client is escorted to the CCC (and does not need to wait in the queue) or referred to another CCC if preferred. If the clients opts for referrals, s/he is then tracked by the peer educator to ensure they are enrolled in ART.
Afya Jijini will boost viral suppression to 90% in Y2 by implementing interventions to increase access to VL testing and overall adherence to treatment. Facility-based WITs will lead monthly reviews of all VL data to identify treatment failures. Afya Jijini will continue to also cascade the work of the USAID-funded ASSIST project and Kenyan Quality Model for Health (KQMH) model to sites. The project will continue boosting viral load uptake through daily sample transport, as opposed to the historical one or two days per week. Peer educators and/or TPA Counselors will establish and ensure facility-based PSS efforts continue to achieve improved ART adherence and patient self-management (PSM) for adult and pediatric patients. PSS will be tailored to patients newly enrolled on ART (either transitioning from care or newly diagnosed), those with VL suppression needs, for caregivers, and for pediatrics, youth, and adolescents. The project will also support the county in rolling out the differentiated model of case that fast tracks stable patients in project-supported CCCs.
Kenyan Ministry of Health (MOH) data from 2015 indicates that 64% of pediatric HIV cases have been identified; 67% are enrolled on ART and, of those, there is a 51% VL uptake. Currently, the project is supporting pediatric ART services in 40 sites. Specific pediatric approaches to boost identification, enrollment, and retention are described in this section and in Output 1.1 (eMTCT).
Activity 1.2.1: Initiate 9,068 new clients (8,732 adults and 336 pediatrics) on ART. Peer educators and TPA counselors in Afya Jijini’s linkage web will ensure 8,732 adults testing HIV-positive are initiated that same day on ART. If the patient prefers to be referred to another facility, the TPA counselor will track this referral to be sure its completed. The project will update referral directories and linkage diaries at all sites to further facilitate linkages.
In line with Test and Treat, Afya Jijini will prioritize transition of 2,780 patients on care only from 13 facilities that have greater than 100 patients on care, but not ART. The project will also continue engaging peer educators and CHVs to support all CCCs in defaulter tracing by conducting daily line listing and follow-up through phone calls and physical visits for all defaulters. Among pediatric cases, 336 HIV-positive children will be newly initiated on ART. As described in Outputs 1.1 and 1.4, these children will be identified primarily through index testing, PMTCT efforts, and linkages with USAID’s Nilinde for testing Orphans and Vulnerable Children (OVC).
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Activity 1.2.2: Boost HIV treatment adherence support. Afya Jijini will focus PSS for new patients on ART and patients with non-suppressed VL, as these are priority intervention populations. Daily morning PSSGs, led by peer educators and TPA counselors, will continue. Appointment keeping will be also be supported by electronic medical record (EMR) systems that automates SMS for clients missing appointments and through use of appointment diaries, tracked by the peer educators or TPA Counselors.
For improved adherence among children, the project will support children, adolescent, and youth PSS clubs. It will support the implementation of the adolescent package of care at the facility-level, and also implement PSM, especially for those 15-19 years old who are becoming more independent. Facilities will be equipped with play therapy materials and other materials for adolescent and youth PSS. Peer support groups and PSSGs will be initiated for caregivers as well as HIV-negative partners. These efforts will be led by peer educators. Additionally, the project will conduct pilot male only PSSGs for adult males and adolescent males to address specific adherence challenges that were identified during the project’s gender analysis.
Activity 1.2.3: Sensitize HCWs on new ART guidelines. The project will train approximately 100 HCWs on the new Test and Treat guidelines and provide mentorship and OJT for other clinicians, supporting one CME per quarter at all high-volume facilities. The project and the county will jointly supervise ART services quarterly through supportive supervision.
Activity 1.2.4: Scale-up and support pediatric ART. Afya Jijini will build on achievements in Y1 to reduce gaps in pediatric ART coverage. Afya Jijini will support the county to adopt and integrate pediatric ART scale-up more distinctly into its NCC HIV/AIDS Strategic Plan. Counties and sub-counties will be supported to integrate the pediatric HIV treatment work plan into county and sub-county level work plans and to convene a semi-annual meeting to monitor the progress completed at the sub-county level. The project will distribute job aids, materials, and reporting tools related to pediatric ART enrollment and retention. As described in Output 3.3, Afya Jijini will strengthen pediatric ART commodity management by advocating for facilities to keep buffer stocks of supplies related to children’s testing services, and by providing quarterly CMEs on commodity management updates. The project will continue to hold monthly data review meetings that will include tracking pediatric ART uptake.
Activity 1.2.5: Strengthen HIV defaulter tracing. The project will help sites improve defaulter tracing efforts through chart abstraction and line listing of all active clients and defaulters. Peer educators will be used to call all defaulters with phone contacts and will conduct home visits for clients with locator information. Afya Jijini will ensure that tools such as appointment diaries and defaulter registers are printed and available at all high-volume sites.
Activity 1.2.6: Increase VL uptake and suppression. To increase VL uptake for more than 90% of patients on ART Afya Jijini will deploy six phlebotomists at high-volume facilities to increase daily sample collection. As further described under Output 3.3, the Afya Jijini lab network system is supported by four motorcycle riders to transport samples to KEMRI laboratory. The point-of-care EMR system that is being rolled out also prompts clinicians when VL testing is due. The monthly WITs meetings will monitor VL uptake and suppression. Patients will be educated on VL suppression during PSSGs, through IEC materials, and during health talks led by the peer educators at health facilities. Non-suppressed clients will be identified through WITs and the VL registers. Specific PSSGs for non-suppressed patients will focus on addressing issues to improve ART adherence.
Activity 1.2.7: Roll out the Differentiated Care Model. During Y2, the project will establish a fast track desk, to be led by peer educators or a nurse, for stable HIV clients at 14 high-volume facilities. ART prescriptions will be dispensed and pre-packaged by the pharmacist and recorded in the pharmacy dispensing tool. The ART distribution form will be filled when the ART is distributed to the patient.
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Additionally, Afya Jijini will support the county to adopt community-based adherence interventions, including establishment of community-based PSSGs and community level ART distribution, both of which will be supported through a sub-grant. The county currently believes community-based approaches accommodated within the new guidelines are more suitable for rural areas, so the project will need to work with the county to develop their buy-in for these new approaches, which may require learning visits to other areas in Kenya where these community-based approaches are successfully being implemented.
Activity 1.2.8: Target key populations for HIV care and support. Afya Jijini will continue working with the USAID-funded national LINKAGES mechanism to strengthen identification and linking of HIV-positive key populations to care and treatment services. Through sub-grants, the project will support existing Drop-In Centers (DICEs) to provide treatment and PSS for key populations. Additionally, Afya Jijini will ensure the DICEs receive other facility-based HIV treatment and care support, such as CMEs, OTJ, mentorship, and joint supportive supervision.
Activity 1.2.9: Improve HIV treatment stakeholder collaboration. Afya Jijini will continue to support two facility in-charges meetings at the sub-county level each quarter. The project will also support two TB/HIV stakeholders meeting to discuss TB/HIV collaborative efforts at the county level.
OUTPUT 1.4: HIV TESTING AND COUNSELING (HTC), VOLUNTARY MEDICAL MALE CIRCUMCISION (VMMC), GENDER-SENSITIVE HIV PREVENTION, AND DREAMS
Background and Rationale In Y2, Afya Jijini will achieve the following COP16 targets for Output 1.4: Test 189,089 adults for HIV; identifying 9,467 new HIV-positive clients. Test 4,041 children for HIV; identifying 487 new clients. Provide VMMC services for 751 clients. DREAMS will reach 3,651 AGYW in Mukuru kwa Njenga with a customized package of DREAMS services.
Afya Jijini’s Y2 efforts are also guided by the project’s baseline findings, notably: There is an important schism between facility enrollment in a proficiency testing (PT) program (47%) and actually obtaining satisfactory scores on the test (23%). There are relatively high percentages (about 70%) of facilities with acceptable hygiene and safety supplies, such as the use of sharps and waste containers; availability of water, soap, and disinfectant; and use of disposable gloves. Around half of facilities provide nutrition counseling and referral services for HIV-positive adult and pediatric patients. Services such as sexually-transmitted infection (STI) screening (including for PLHIV and key populations), and counseling on FP and safe pregnancy for HIV-positive patients are found at about 60% of facilities. Only 14-15% of facilities have both the ability to conduct VMMC and emergency surgical supplies required for it.
Additionally, the baseline assessment’s qualitative interview respondents reported that Afya Jijini should target key populations with health education and intensified screening (for STIs, HIV), anti-stigma and discrimination interventions (especially that propagated by HCWs), improving access to care and treatment by making health facilities friendly to key populations (especially female sex workers [FSWs] and men who have sex with men [MSM]). During Y1, the project reached 4,469 key populations (3,957 FSW, 512 MSM) with HTS, achieving 187% of its KP HTS target. Positivity yields were generally higher USAID/KENYA AFYA JIJINI YEAR 2 WORK PLAN 8
for MSM, ranging from 4.5-5.5% as compared to 2.1-2.9% for FSWs. Overall, the project linked 62% of these clients to care and treatment sites, using LINKAGES’ peer educators to provide a minimum package of care services and follow-up throughout the project year. The project intensified its tracking and linkages work in later quarters, especially with MSM, improving this figure to 81% in Q4 (with the remaining clients still being tracked and counseled).
Y1 successes that will also guide Output 1.4 activities include: Deployment of HTS counselors to test 242,972 clients through both facility and community-based efforts identified 10,817 patients and generated an overall positivity yield of 4.4%. During Y1, the high-volume facilities generated 93% of all HIV tests. HTS was scaled-up to 78 facilities, with HTS being provided at all entry points. Line listing of index family and partners was a leading strategy for identifying positives: 4,900 were successfully line listed, with 189 identified as positive and 182 linked to treatment. Afya Jijini also supported the county to conduct a Rapid Results Initiative (RRI) for boda boda riders, the first ever, which resulted in testing 10,208, with 81 HIV-positive. The project increased testing points from 38 to 90, improving both pediatric and adolescents IPD and OPD entry points and collaborated with Nilinde to reach OVCs with HTS services in April and August The project procured penile and vaginal models to be used by HTS counselors in condom efficacy counseling and education at the testing points.
Approach To reach COP16 targets, Afya Jijini will build from the Y1 successes and gaps that are noted above using the project’s combination prevention approach.
Figure 1: Afya Jijini Y2 Combination HIV Prevention Approach
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Activity 1.4.1: Provide strategic HTS. The interventions described below will test 189,089 adults for HIV (identifying 9,467 positive clients) and 4,041 children (identifying 487 positive children). This section also describes condom distribution activities as well activities designed to address stigma reduction.
Increase demand for HTS services: HTS demand creation will be generated through multiple strategies, including the DREAMS program to reach 3,044 AGYW with HTS. The project will also leverage its Adolescent Youth and Sexual Reproductive Health (AYSRH) model described below to boost demand among AGYW and other priority populations.
Figure 2: Afya Jijini AYSRH Approach The model leverages Community-Owned Resource Persons - Ambassadors of Change (AOC)/DREAM Mentors - whose role is to identify the vulnerable adolescents and young people, counsel them, refer them to CHVs for services (including contraception commodities provision). The AOCs and Mentors
also peer escort the adolescents and young people to the linked facilities for uptake of services.
The project will also implement demand creation efforts through collaboration with Nilinde for OVC testing and with LINKAGES for HIV testing for key populations.
Facility-level HIV testing: 69 HTS Counselors will be deployed at all high-volume sites to ensure testing at all entry points. HCW in all supported facilities will also be sensitized on the new HTS guidelines. 4,041 pediatrics and adolescents will be tested by support from the HTS Counselors at service delivery points. PLHIV will also be line listed for family testing.
Ensure linkage of at least 90% of HIV+ clients to treatment: Linkage to ART steadily improved throughout Year 1 (Q1-54%, Q2 56%; Q3 64%; Q4 – 80%). The project will continue supporting full operationalization of the Testing and Linkage web presented by deploying TPA counselors and peer USAID/KENYA AFYA JIJINI YEAR 2 WORK PLAN 10
educators at sites. The model for the testing and linkage web is presented below. As described in Output 1.2 and 1.3 the This system ensures inter-connectivity between intra-and inter-facility testing points, treatment preparation support (TPS) points, and linkage to CCCs to better track and support clients testing positive. All clients testing at the various testing points are escorted by peers (expert clients) to the treatment preparation counselors for additional counseling and treatment preparation. Then, the client is escorted to the CCC (and does not need to wait in the queue) or referred to another CCC if preferred. Or, if he or she expresses a preference to receive ART elsewhere, the TPA counselor calls another TPA counselor to prepare to receive the client directly. In this way, the client is jump-started into enrollment and is greeted by a friendly face to help him/her navigate the system. Family testing also occurs at the CCC. The system is sensitive to some of the key loss points related to HIV testing, such as a lack of tracking for referred patients across sites (via the TPA counselors/TPS points, who are responsible for tracking), and reduction to the waiting required for enrolling at the CCC.
Figure 3: Afya Jijini Testing, Linkage, and Referral Web
Improve adherence to Infection Prevention Control (IPC) measures at all HTS service delivery points: Compliance to IPC standards and medical waste management will be improved through mentorship and CMEs at the facility level. As needed, the project will also provide color-coded bins and bin liners for HTS waste disposal.
Condom promotion and distribution: The project will improve condom promotion and distribution through sub-county and facility-based CMEs on condom efficacy and printing and dissemination of condom demonstration job aids. As needed, the project will distribute penile and vaginal models and distribute condom tracking tools to all facilities. The project will work with the facilities to ensure availability of male and female condoms. USAID/KENYA AFYA JIJINI YEAR 2 WORK PLAN 11
Support HIV stigma reduction efforts: The UHAI teams will refresh HCW on stigma reduction and mitigation through CME to focus on role plays and case studies discussions. PSSG activities as described under Outputs 1.1, 1.2, and 1.3 will support disclosure of HIV status as a means of stigma reduction.
Link HIV-positive youth and adolescents to peer networks: The project will link HIV-positive adolescents and youth to existing online peer networks hosted by Safaricom and LVCT Health to enable them access peer-led PSS and age-appropriate information to enhance adherence to care and treatment and positive living among them (LVCT Hotline Number 1190 – one2one).
Internal HIV Quality Assurance (QA): Lot-based validation will be conducted for every new lot of HIV RTKs. Joint supervision undertaken with the CHMT and SCHMT will enhance quality of HIV testing and results. Counselor supervisors will conduct observed practice with all HTS counselors’ semi-annually and provide face-to-face feedback. To monitor client feedback, Afya Jijini will also implement a system to conduct exit interviews on a periodic basis for all facilities providing HTS. Counselors support supervision will be conducted monthly at the sub-county level to monitor provider burnout and enhance quality of counseling at all the supported facilities.
External QA measures: Afya Jijini will support quarterly distribution of PT panels and dissemination of results. UHAI teams (in collaboration with the sub-county) will work with sites with unsatisfactory results. Annual refresher workshops will be held for all HTS providers.
Supply chain strengthening for ensuring continuous availability of RTKs: Please see Output 3.4.
Activity 1.4.2: Support facility-based VMMC. Afya Jijini will provide VMMC services for at least 751 beneficiaries. The project will support one five-member VMMC team consisting of a surgeon, assistant surgeon, IPC officer, HTS Counselor, and mobiliser, to be based at Mbagathi District Hospital. The team will conduct outreach and VMMC services at Mathare North Health Center, Korogocho, Biafra, and Mukuru Health Centers (areas with higher patient loads and strategic locations). The project will also continue to support these sites with VMMC commodities and offer OJT, mentorship, and supportive supervision. During the RRIs, the project will print IEC materials that will be distributed by mobilizers in lead up to the days the VMMC services are offered. Mobilization will be targeted toward 10 – 14 and 15 – 29 years old age groups. Linking with DREAMS efforts, the project will establish and refer male partners of AGYWs to VMMC services at Mukuru Health Center.
GENDER-SENSITIVE HIV-PREVENTION SERVICES
Background and Rationale Major Sub-Purpose 1-related findings from the Gender Analysis that will guide Y2 activities include:
HIV Prevention: AGYW and women’s generally submissive roles in relationships made it difficult to negotiate for safe sex or to refuse unwanted sex, despite high levels of knowledge among males and females on HIV prevention and condom use. In addition, although almost all migrant FSW had heard of HIV, knowledge around prevention and transmission was mixed, with many misconceptions still existing. MSM, male sex workers (MSW), and FSW who had disclosed their status faced societal discrimination as well as stigma and discrimination from HCW. For VMMC, men and adolescent boys were ostracized if they were not circumcised; however, a dangerous belief was noted in some informal settlements where some believed that circumcision provided 100% protection against HIV. USAID/KENYA AFYA JIJINI YEAR 2 WORK PLAN 12
HIV Treatment: Women fear backlash, violence, and conflict with their partner if they disclose their status or HIV treatment regimen. Due to anticipated “disclosure violence,” this may result in issues with seeking treatment, adhering to treatment, and hiding medical cards and medicines by the women. Many women living with HIV report high levels of anticipated stigma, resulting in a desire to hide their status from family and friends for fear of being discriminated against. Adolescent boys have poor treatment adherence due to fear of stigma among their peers for what it means to be “a man,” a feeling of invincibility, and vulnerability in the transition from boyhood to adolescence. Men have lower rates of treatment adherence, presenting significant health risks for themselves and their sexual partners. FSW may avoid taking treatment in fear of being seen with it and losing clients, while others may diligently take it to prolong their working life. eMTCT: Uptake of eMTCT services was relatively higher in NCC compared to other areas of the country, yet pregnant women feared testing and treatment—primarily due to fear of intimate partner violence (IPV) if they disclosed to their partner. In informal settlements pregnant women may delay seeking care until late in the pregnancy, sometimes as late as into their third trimester. AGYW faced additional stigmatization that sometimes prevented ANC attendance and uptake of PMTCT services, while FSWs may avoid care altogether to avoid stigmatization and potential loss in clientele. Findings also suggest that when male partners accompanied a pregnant woman health outcomes were significant. However, only 4.5% of men nationally participated in PMTCT, primarily due to gender norms that suggested healthcare was relegated to the women’s domain, and due to the significant economic opportunity cost of missing work—and much needed income—to attend clinic visits. These gender norms were further reinforced by behavior change communication (BCC) for MCH and eMTCT that depicted mothers and children and excluded men from the picture both literally and figuratively.
Overall, the baseline findings suggest that the project should leverage opportunities where men are traditionally reached to increase uptake of services for HIV prevention, including VMMC, and for accessing HIV testing, care, and treatment services, and for TB.
The following activities will be implemented in Y2 in collaboration with Output 2.1 to address gender- related concerns for access and uptake of eMTCT: Refine the project’s We Men Care model to address appropriate male engagement and gender- sensitive approaches for ANC attendance so that partners are addressed together and safe breastfeeding practices for HIV-positive breastfeeding women are promoted. Train Guidance and Counseling teachers (through DREAMS) and We Men Care Clinics male champions to support GBV prevention through reinforcing positive gender norms and practices.
Given links to IPV among HIV-positive women and pregnant women, the following activities will be implemented: Work with the sub-counties to offer comprehensive Post-Rape Care (PRC) at three select Gender- Based Violence (GBV) Clinics (Mukuru Health Centre, Dandora II Health Centre, and Kayole I Hospital) to address both acute and chronic violence support.
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Support sub-county GBV TWG quarterly meetings in Kasarani, Embakasi East and West Sub- Counties, where a majority of the informal settlements are located. Develop and source 1,000 Sexual- and Gender-Based Violence Guidelines/SOPs, referral directories, and GBV Reporting Tools. Strengthen the chain of PRC specimen custody through improving the transport network in three sub-counties: Kasarani, Embakasi East and West. Support 20 men and women to participate in relevant national and international commemorations including 16 Days of Activism against GBV and International Day for the Elimination of Violence Against Women (providing critical community awareness creation). Develop and maintain a project GBV dashboard for Data for Decision Making, working closely with Afya Jijini’s Monitoring and Evaluation (M&E) department.
Planned gender-sensitive activities to improve uptake and adherence to HIV care and treatment include: PSSGs for HIV-positive pregnant women, discordant couples, men-only groups, and male-only adolescent groups. Explore expansion of care and treatment services at alternative times (e.g., evenings, weekends) and as the project implements the differentiated care modules to also offer ART within the community. Monitor adherence and VL suppression through review of data disaggregated by gender and age; when appropriate, identify and design gender-specific interventions for ensuring VL suppression among both genders. Afya Jijini’s cough monitors (described under Output 1.5) plan to identify men for TB and HIV testing.
Gender-specific activities to address prevention concerns include: Reach 1,549 (10-14 years) and 1,229 (13-17 years) AGYW with the Healthy Choices for a Better Future (HCBF) and My Health, My Choice (MHMC) EBI through DREAMS to improve gender empowerment through reduction of sexual risks and building their negotiation skills. Monitor access to gender equitable HTC and linkages for HIV-positive clients. Track referrals and uptake of VMMC, HTS, and ART of male sexual partners of DREAMS AGYW. Integrate consistent positive messaging in VMMC clinics, focusing on promoting positive male norms and changing harmful gender norms.
DREAMS
Background and Rationale Afya Jijini’s DREAMS activity covers Mukuru kwa Njenga Ward in Embakasi East Sub-County, reaching nine villages (Wapewape, Vietnam, Riara, Kware, Sisal, Milimani, Zone 48, MCC/AA, and Motomoto). The project is implementing activities from DREAMS prescribed core intervention areas (Empower Girls and Young Women, Reduction of Sex Partners, Strengthening Families, and Community Mobilization for Social Norm Change) as well as other cross-cutting DREAMS activities for communications, M&E, and coordination. Implementation is carried out by a team of technical staff and community –based facilitators including Field Assistants, DREAMS Mentors, EBI facilitators, Combined Socio-Economic Approaches Facilitators, and Community Mobilizers, including Men as Equal Partners facilitators.
In Y1, most trainings, with the exception of Pre-Exposure Prophylaxis (PrEP), were conducted. As DREAMS enters its second and final year, the project will begin to roll-out the cash transfer program. It will also ensure safe spaces are fully operational, including staffed with HTS counselors, and there will be targeted mobilization and service provision for male sexual partners for VMMC, HTS, and ART. Gender norms and GBV activities will be rapidly scaled-up and the project will complete EBI sessions. DREAMS USAID/KENYA AFYA JIJINI YEAR 2 WORK PLAN 14
has also linked with health facilities for referrals (MMM Clinic and Mukuru Health Center for GBV and PrEP, and Mama Lucy Kibaki Hospital for PrEP sample processing). Afya Jijini’s Y2 targets for DREAMS recipients by age group are presented below.
Figure 4: FY17 DREAMS Targets Intervention 10-14 15-19 20-24 Total Post-Violence Care 239 451 451 1,141 Community Mobilization & Norms Change 716 1,353 1,353 3,422 HIV Testing & Counseling 638 1,203 1,203 3,044 Social Asset Building 478 751 451 1,680 Parenting/Caregiver Programs 478 902 1,380 Education Subsidy 159 977 153 1,289 School-Based HIV & Violence Prevention 797 752 1,549 Cash Transfers 301 302 603 Condom Promotion & Provision 1,053 1,203 2,256 Increase Contraceptive Method Mix 451 901 1,352 Combination Socioeconomic Approaches 301 1,029 1,330 PrEP 115 488 603 Total 3,505 8,610 7,534 19,649
Activity 1.4.3.1: Empower AGYW (Core Area 1). The interventions in this technical service area empower AGYW to reduce their risk of violence (and decrease their HIV acquisition risk consequently). The intervention package includes: increased consistent use and availability of condoms, PrEP, violence prevention and post-violence care, HTS, increasing contraceptive method mix, and social asset building.
EBIs for different age cohorts including HCBF for the 10-14 years in-school adolescents and MHMC targeting 13-17 years adolescents in out-of-school settings will be conducted to reduce overall risk and exposure to HIV and sexual-related violence. Condom promotion and distribution will be provided at safe spaces and mentors will also distribute.
To increase contraceptive mix, contraceptive counseling will be provided by the project’s RH/FP Assistants at target health facilities and safe spaces. AGYW will also be reached through Community- Based Distributors (CBD), who will counsel the women and provide contraceptives. AGYW peers escorts will link the AGYW to other AYSRH services where need be.
PrEP will be initiated, with 20 HCW trained on PrEP for provision at two identified facilities: one public and one private health facility (Mukuru MMM Clinic and Mukuru Health Centre) that are already offering ART. The project will conduct a county and sub-county sensitization forum to ensure awareness and supervision of PrEP at the two sites.
Violence prevention and post-violence care activities, to address both acute and chronic violence, will be implemented by one trained GBV Counselor at Mukuru Health Center and the AYSRH Nurse Champions at linked health facilities in Mukuru kwa Njenga to reach 1,141 AGYW. The project will also continue supporting cross-cutting GBV activities especially community awareness creation, as well USAID/KENYA AFYA JIJINI YEAR 2 WORK PLAN 15
strengthening referral and support to other medico-legal services. The project will also identify and collaborate with rescue shelters for abused AGYW to ensure protection.
3.044 AGYW will tested for HIV at the project’s safe spaces and linked health facilities. HTS Counselors will be deployed during social asset building sessions held at the safe spaces and during other DREAMS activities including community integrated outreaches. Linkages and tracking of HIV-positive AGYW, including pregnant AGYW, to appropriate care and treatment services will continue.
Afya Jijini will continue to scale-up the Social Assets Building interventions to reach 1,680 AGYW. The project intends to increase the safe spaces from 15-30 to adequately reach out the vulnerable AGYW (many of which are donated space), also intensified support and OJT for DREAMS mentors will continue.
Activity 1.4.3.2: Interventions to reduce risk of/among AGYW sex partners (sub-granting component within Norms Change). These interventions aim to characterize “typical” sexual partners of AGYW so that they can be reached with appropriate HIV interventions. Afya Jijini completed the Male Sexual Partners characterization where boda boda riders, men in the public transport sector and religious leaders were characterized as among a 20-35 year old age group. Having successfully trained 15 Community Mobilizers to conduct community mobilization outreaches and forums on GBV and norms change, mobilization and linkages of the male sexual partners to targeted HTS, ART, and VMMC services will continue. Promotion and provision of condoms to male sexual partners at community level will also continue. The Afya Jijini sub-grant program will identify community-based organizations (CBOs) to build awareness of community norms and reduce risk among sexual partners.
Activity 1.4.3.3: Strengthening families. Afya Jijini will continue strengthening the AGYW families economically and building their capacity to parent positively. Parenting/caregiver programs will be scaled up through Families Matter Program (FMP) to reach 1,380 AGYW parents/caregivers. FMP will be facilitated by 10 Afya Jijini trained FMP facilitators ensuring fidelity to the intervention design.
Unconditional cash transfers will also be provided to 603 vulnerable AGYW selected through criteria including: AGYW who are mothers with no source of income; AGYW in child-headed households; AGYW living with critically sick parent(s)/caregivers and the AGYW living with elderly caregivers. Cash transfers will be done on a rolling basis through a selected financial institution. Verification with the Government of Kenya (GOK) Single Registry will be done prior to roll-out to ensure that beneficiaries of other cash transfers programs are not targeted.
Education subsidies will also be provided to cover primary, secondary, and other short courses to improve access to education and reduce dropout rates among 1,289 AGYW. Selection will be done by an Afya Jijini formed multi-sectoral vetting committee (comprised of representatives from the Ministry of Education, Ministry of Social Services, Children’s Department, AGYW, religious leaders, and CBO representatives) to ensure the most-deserving cases are identified and benefit from the intervention. Vocational training will also be offered through identified Vocational Training Institutions such as Hi- Tech College (offering catering, hairdressing, fashion and design, tailoring, computer training) and linkages for industrial attachment/apprenticeship done through the Public Private Partnerships with AA, Kenya Commercial Bank Foundation, Barclay’s Bank, Equity Bank, Kenya Women Finance Trust, and Safaricom Foundation.
The most effective social protection approaches for promoting healthy practices and decreasing risk of violence among AGYW have been those that use both economic and social approaches. The project is providing a platform for 1,330 AGYW for financial savings programs through financial capability and entrepreneurship trainings, linkages to microfinance institutions and formation of savings and table banking groups to build the culture of saving as well as linkages to national government funding
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including Uwezo Fund, Youth Enterprise Development Fund, and other like-minded Private Public Partnerships products like 2jiajiri by Kenya Commercial Bank Foundation.
Activity 1.4.3.4: Interventions to mobilize communities for change. Through the AJSGP, Afya Jijini will implement school-based and community mobilization interventions aimed at educating AGYW, young men, and mobilization of communities about HIV prevention. Under the school-based HIV prevention, the project is rolling out HCBF EBI targeting 10-14 years adolescents to reach 1,549 AGYW.
School management sensitization forums and community-school sensitization and linkages to DREAMS activities will continue. In-school counseling sessions and talking compounds initiatives will continue in the identified 56 schools within Mukuru kwa Njenga. Periodically, the project will organize for sports for social change activities to create a platform to provide or refer for biomedical services (HTS, PrEP, etc.) to the AGYW (adhering to parental consent guidelines).
Community Mobilization/Norms Change provides an essential support framework for HIV prevention programs as well as serving as a platform to engage boys and men and the community in addressing negative social norms increasing AGYW’s HIV risk. These will be rolled out to reach 3,422 Community members. The Men as Partners sessions targeting AGYW will continue as well as community outreaches.
Cross-Cutting DREAMS Activities M&E: Afya Jijini will provide and train HCWs and volunteers on DREAMS reporting tools. To improve data quality, the project will conduct routine data quality audits (RDQAs) at the safe space level and hold monthly DREAMS data quality review meetings. The project will build capacity of HCWs, Mentors, and EBI facilitators to deliver and report on quality programs through on-site mentorship and weekly supportive supervision.
Communications: Afya Jijini DREAMS project will also collaborate with USAID’s Health Communication and Marketing Program on BCC message development, development, and production of IEC materials.
Coordination: The DREAMS team will organize quarterly review meetings for the DREAMS Advisory Committee (including sub-committees), organize for periodic cross-learning exchange visits for staff and volunteers per need, participate in planning and review meetings both internally and with other DREAMS implementers as requested by USAID, and organize for weekly support supervision at all levels.
OUTPUT 1.5: TB / HIV CO-INFECTION SERVICES
Background and Rationale In Y2, 6,849 TB clients will be tested for HIV, 3,019 TB clients enrolled on ART, and 41,903 PLHIV screened for TB. Afya Jijini’s baseline assessments identified gaps in TB programming; for example, only slightly more than half of the 73 facilities reviewed during the project’s baseline assessment, had SOPs required for provider-initiated counseling and testing (53%). The baseline also found regular TB screening of HIV-positive patients at 59%, with provision of isoniazid preventative therapy (IPT) also low at 58%. The baseline further found ART for TB/HIV positive patients (55%), and ART for pediatric TB/HIV patients (45%). In Y1,the project tested and diagnosed1,839 of the 8,014 TB patients HIV positive (representing 23% positivity). The project will continue scaling up HIV testing for TB patients as well as strengthening enrollment and retention in HIV care and treatment services.
Afya Jijini strengthened TB-HIV services during Y1, improving overall screening coverage and frequency, accuracy of diagnosis via GeneXpert, IPC, and pediatric TB interventions, representing great improvement from what was found in Q1: that NCC lagged in MDR-TB case detection (61%, compared
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to the national target of 83%), low GeneXpert utilization (below 20% at some sites) and poor TB-HIV screening practices at certain sites. At the end of Y1, the annual TB-HIV cascade made the following advances: Identified 3,867 new TB cases (among PLHIV and non-PLHIV), with 3,635 (94%) of all TB patients tested for HIV, 1,175 (32%) of which tested positive, and 1,154 (98%) of these new HIV- positive TB clients were enrolled on ART. Additionally, the project began making progress in pediatric TB case finding identification and treatment through several strategies.
Afya Jijini will continue addressing gaps by increasing TB defaulter tracing and linking them back into care and treatment, ensuring all TB/HIV co-infected patients are initiated on ART, focusing on screening all HIV-infected individuals and improving IPT uptake to reduce co-infection rates, increase HIV testing rates for all TB patients, and continue working to achieve the goal of increasing completion rates to up to 90%.
Activity 1.5.1: Strategically scale the “Mirror Mirror” model for Active Case Finding (ACF). In Y1 Q3, Afya Jijini rolled out an intensified facility-community, community-facility model for scaling up TB- HIV collaborative activities: The “Mirror-Mirror” model. This model supports intensified case finding (ICF) at the facility level by using trained cough monitors, linking all TB suspects to the TB clinics for definitive diagnosis, HIV testing for those who turn TB-positive, and supporting both contact tracing and HIV family testing on the TB platform. At the community level, this model conducts quarterly ACF in crowded settings, such as ECD centers in informal settlements, and linking suspect TB cases to facilities where the facility-based activities take place, as described above (thus completing the loop).
This model involves two phases: one that occurs at the facility level (including wards, CCCs, MNCH clinics, OPDs, and IPDs), and one that occurs at the community level. The project will continue engaging the 36 trained cough monitors in 36 high-volume TB facilities to screen for TB at all service delivery entry points (with a focus on the highest yield areas – IPD for pediatric clients, and OPD for adults), while also continuing to train untrained HCWs and CHVs on TB ICF, supporting outreach activities in informal settlements to identify, trace, and escort TB suspects to health facilities for testing, care, and treatment. Afya Jijini will provide CMEs on the use of suspect registers, and support the cough monitors to provide health education, conduct contact tracing and HTS of index clients and their family and household members, and monthly data review and feedback. The cough monitors will also ensure that all patients that test HIV-positive are linked to care and treatment services.
The second phase of “Mirror Mirror” will implement the cough monitor model at the community-level as well, where they will also be trained to provide health education, family testing, conduct community ICF and contact tracing, and link TB suspects and HIV-positive patients to the necessary facilities for further testing, care, and treatment. Focusing initially in Mukuru and Mathare Valley (and expanding to informal settlements in Kangemi, Deep Sea, Githogoro and Mukuru kwa Njenga and Mukuru Reuben), these cough monitors will target children by conducting screening at ECDs and schools; and will target men in the communities by screening at matatu stops for drivers and callers, at salons and barber shops, and at leisure facilities. Both the facility and community-level cough monitors will be trained on properly documenting all suspects in the presumptive TB registers, with sputum sample testing with GeneXpert.
Activity 1.5.2: Strengthen community TB treatment monitoring and defaulter tracing. Afya Jijini will also support the identified and trained cough monitors to do direct observed therapy (DOTS) to TB patients under the supervision of HCWs. And in an effort to better ensure retention in treatment, the project will intensify defaulter tracing and continue documenting outcomes among clients in their communities.
Activity 1.5.3: Improve IPT provision. In Year 2, Afya Jijini will continue conducting facility-based CMEs, providing TA and developing SOPs on IPT, including commodity forecasting, to ensure that facilities are stocked with six-month packs of TB treatment. The project will also continue rolling out IPT
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to facilities, coordinating re-distribution of IPT from facilities with a surplus to those without while making sure not to compromise availability of six months’ supply. Additionally, Afya Jijini will continue supporting WITs to follow-up on IPT during their routine monthly meetings.
Activity 1.5.4: Strengthen IPC at high-need facilities. Afya Jijini will conduct an IPC training for 72 HCWs and 36 cough monitors in Y2, matched with the provision of TA and CMEs on how to develop, implement, evaluate, and revise IPC work plans to select facilities. These efforts will zero in on the key challenge in that HCWs do not understand or adopt IPC behaviors. Each facility will have an IPC focal person work with their peers to develop and monitor an IPC plan. IPC focal people will also ensure that environmental, administrative, and individual measures are adhered to and implemented. The project will support WITs to monitor IPC at their monthly meetings, and will procure and distribute critical IPC supplies.
Activity 1.5.5: Boost TB-HIV integration and provision of immediate ART for TB clients. The project will continue increasing TB detection and prompt treatment through integrating TB and HIV services within project-supported TB clinics and CCCs. It will engage HTS counselors at TB clinics and mentor and sensitize HCWs at TB clinics on the new HIV guidelines. The project will provide TA and CMEs to HCWs at CCCs to ensure that PLHIV are screened for TB at every appointment (and it’s documented properly), and by ensuring that TB suspects at CCCs receive further GeneXpert testing and linked to treatment accordingly.
Activity 1.5.6: Strengthen pediatric TB diagnosis and treatment. Afya Jijini will continue improving pediatric case finding and treatment by meeting children where they and their parents are most likely to be found, including at facilities’ OPDs and IPDs, community ECDs and daycare centers, and schools. The project will provide OJT to HCWs on clinical diagnosis, including conducting OJT to 160 HCWs on NPA and NG aspirate for GeneXpert at eight facilities, ensuring that HCWs know where and how to concentrate ACF at these facilities. Afya Jijini will further sensitize HCWs on the new pediatric formulation and will provide TA to HCWs to ensure that under five, HIV negative contacts with smear positives are initiated onto IPT in order to increase ACF of dually-infected children. Lastly, the project will build on the successful ECD platform to identify potential child TB suspects in order to better reach this underserved population. Through school screenings, health talks, IPC and distribution of IEC materials to at least two schools per month, as well as coordinating with existing CHVs in ECDs located in informal settlements to support pediatric TB ICF, the project will support the County to improve efforts to identify and properly link pediatrics with TB to facilities for care and treatment. During Y2, the project will work with the Sub-County TB/Leprosy Coordinators (SCTLC) to develop a CHV-facility pediatric linkage tool that connects ECDs with health facilities for TB formally. The project will also continue supporting HCWs on conducting contact tracing for child contacts of sputum-positive TB patients by working with existing CHVs to carry out contact tracing.
Activity 1.5.7: Multi-drug resistant (MDR)-TB strengthening. In Y2, Afya Jijini will effectively identify and treat MDR cases by continuing to network all project-supported high-volume facilities with GeneXpert as the first test, including supporting laboratory sputum networking for facilities with no TB diagnostic capacity. In order to ensure that health facilities are prepared to support MDR-TB patients, including those with relapsed TB, Afya Jijini will conduct three days of MDR-specific OJT to 80 HCWs at the MSF France Center of Excellence, and targeting and providing facility-based CMEs and updates on MDR-TB for each UHAI cluster. The project will also support PMDT clinical meetings at five sub- counties supported by Afya Jijini, will conduct six-month TB screening of all HCWs at the 36 TB facilities, and will collaborate with TB ARC to develop a Nairobi City County MDR emergency response plan in order to better organize facilities and the County to be prepared to properly address an increase in MDR-TB.
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Activity 1.5.8: Strengthen county TB coordination. The project will continue collaborating with TB ARC and other partners to conduct and implement project activities. This includes coordinating with these partners and the county to continue holding semi-annual data quality assessments (DQAs), monthly data review meetings, quarterly TB data and activity review meetings, and monthly joint supervision with the Sub-County TB/Leprosy Coordinators and Sub-County Medical Laboratory Technologists (SMLTs). Additionally, given the success of Afya Jijini’s involvement in World TB Day in Y1, the project will again support the county with preparations for World TB Day, ensuring ACF occurs in advance and during the awareness day.
Note: Training on GeneXpert alert will be conducted under lab activities (Output 3.3).
Sub-Purpose 2: Increased Access and Utilization of Focused Maternal-Newborn Health (MNH), FP, WASH, and Nutrition Services
Introduction Sub-Purpose 2 focus on ensuring coverage of 50% of the population in informal settlements to MNCH, FP, WASH and nutrition services. In Nairobi, neonatal and maternal mortality has unfortunately not seen much progress, particularly in hard-to-reach informal settlements. The NCC currently reports a maternal mortality ratio of about 200/100,000. However, due to the high number of deliveries, it ranks number fourth in the country in terms of absolute numbers of maternal deaths. The interlinked nature of MNH directly translates to an even higher neonatal mortality in the county (nearly 42 per 1,000 live births). Improving facility- and community-based family planning, nutrition services, and WASH interventions are critical to helping contribute to improved gains. However, the county currently lacks the manpower and skills to ensure they are scaled up in a quality manner across sub-counties and sites.
Approach The project’s overall approach to Sub-Purpose 2 is described below. Annual targets for Y2 are yet to be received. Y2 approaches are therefore based upon Y1 targets.
Community-level: In Y1, Afya Jijini trained more than 340 CHVs on the MNCH module. These CHVs will be engaged to work closely with facility-based Community Health Assistants to mobilize, identify, and refer pregnant women and mothers, including adolescents and youth, and male partners within the informal settlements for ensuring uptake of appropriate MNCH services. These CHVs will be engaged and managed by sub-grants to CBOs during Y2. In addition, the project trained CHVs within WASH and nutrition to advance those project activities, including identifying and referring malnourished children and promoting appropriate high-impact nutrition intervention (HINI) messaging.
Facility-level: Frontline HCWs need additional training and skills practice in MNH. Traditional classroom trainings may only introduce the skills, but ensuring that HCWs fully develop the needed skillsets requires constant mentorship. Following the various Emergency Obstetric and Newborn Care (EmONC) trainings conducted by Afya Jijini and other partners in Y1, the project will work with the county to identify MCH champions from among the 54 supported maternities. These MCH Champions are highly-skilled nurses that can provide OJT and mentorship to HCWs in identifying danger signs in pregnancy and postnatal periods. They will support scale-up of assisted vaginal delivery and other aspects of EmONC, newborn resuscitation, neonatal survival, kangaroo mother care (KMC), and post- partum family planning (PPFP). These MCH Champions will also support review and audit of maternal and neonatal deaths within 24 -48 hours, and mentor WITs. The project will also support them in holding regular sharing and progress reporting, not just on EmONC, but on achievements in mentoring other frontline HCWs.
UHAI teams will work with 10 roving RH/FP Field Assistants who will increase coverage of TA to the project’s supported sites. They will: USAID/KENYA AFYA JIJINI YEAR 2 WORK PLAN 20
Ensure distribution of equipment, tools, and registers, as needed. Guide WITs to monitor quality and process indicators, including correct use of partograph, active management of the third stage of labor (AMTSL), HCW attitudes, and promotion of 4+ ANC visits. Collaborate with PIMA to conduct annual EmONC assessment on the barriers impeding provision of quality MNH services in NCC facilities and advocate with the sub-counties and county to fill gaps. Support integration of eMTCT services in MCH settings (see Output 1.1).
OUTPUT 2.1: MNH SERVICES
Background and Rationale Baseline findings and foundational work in Y1 inform programmatic priorities for Y2. According to the baseline, ANC attendance of the recommended 4+ visits is around 61% in Nairobi. The baseline assessment also found that only 35% of facilities in NCC offer BEmONC services, with fewer than 10% offering CEmONC (and only 20% of facilities offer c-sections). Additional findings call for mentorship and training on managing labor and delivery complications. For example, partograph is available at 97% of sites, but only 57% use it during delivery and only 6% use it correctly, creating a missed opportunity for improved labor management. As a result, facility-based neonatal mortality was measured at 26.3 babies per 1,000 live births at the three largest maternities within the baseline, higher than the national average of 22 per 1,000 in the KDHS 2014). Post-natal care (PNC) also bears attention – only about half of deliveries in Nairobi receive any PNC at all (KDHS 2014). These data illustrate the need for both community behavior change interventions (that drive uptake of services) and facility-based mentorship and support to improve quality of care. During Y2, the project will target 54 maternities that contribute to 85% of NCC’s deliveries, primarily within informal settlements of Makadara, Embakasi, Kasarani, and Ruaraka.
Activity 2.1.1: Strengthen county and sub-county MNH service quality and coordination. Afya Jijini will continue supporting routine county MNCH and sub-county MNCH TWGs for better coordination of services and to share MNH best practices. In addition, the project will support county MNCH focal person to attend and contribute to national EmONC and MNH meetings. Afya Jijini will further coach the county and sub-counties to improve the monitoring and quality of MNH services by helping the county and sub-counties update and review Reproductive Maternal Newborn and Child Health (RMNCH) scorecards (PIMA developed the RMNCH scorecard for the counties, and Afya Jijini will help it to be cascaded to sub-counties). The project will also provide TA for supportive supervision at all sub-counties on a quarterly basis linked to quarterly Maternal and Perinatal Deaths Surveillance and Response (MPDSR). Afya Jijini provides support that includes printing and disseminating new MPDSR guidelines; trainings, OJT, mentorship, and CMEs on MPDSR. It also helps convene quarterly county and monthly sub-county MPDSR meetings. The project will also organize quarterly sub-county MNCH/FP forums with the MNCH/FP TWG. Finally, Afya Jijini will ensure the county links to Output 3.3 activities to ensure the availability of life-saving MNH commodities and supplies at all 54 maternities.
Activity 2.1.2: Boost ANC attendance (uptake and completion of 4+ visits). Community-level: CHVs will regularly map and track all pregnant mothers in the community to identify high-risk deliveries, promote the benefits of ANC, and link to PMTCT services. They will also provide follow-up for missed ANC appointments. These CHVs will also sensitize pregnant women and their partners on relevant pregnancy messaging, including tetanus toxoid vaccine, iron and folic acid supplementation (IFAS), counselling on FP/birth spacing, safe birth and emergency planning, environmental and personal hygiene, and presumptive treatment of hookworm infestation. CHVs who are trained on the cMNH module will work in the catchment communities to map out all pregnant women and link them to a facility for FANC, delivery, and post-partum family planning (PPFP).
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Facility-based: Afya Jijini will use several activities to ensure that pregnant women achieve 4+ ANC visits. The project’s UHAI teams, RH Field Assistants, and MCH Champions will provide TA, mentorship, and CMEs on ANC promotion talks, as well as assisting HCWs to understand how to promote ANC uptake and through health talks that emphasize the importance of ANC attendance in the first trimester. MNCH WITs will hold monthly meeting to review progress on ANC attendance and use findings from exit interviews to guide interventions and change ideas. The project will train targeted health care workers (HCWs) through mentorship/OJT and CMEs on discussing the importance of 4+ ANC visits, birth preparedness, and recognition of danger signs during pregnancy, labor, and post-natal care (PNC) with mothers. The training will also focus on helping HCWs better counsel women on key newborn and child health issues, such as immunization uptake. This training will focus on: tetanus toxoid to prevent maternal and neonatal tetanus (promotion and provision), Iron and Folic Acid supplementation (IFAS) to prevent anemia, promote prompt treatment of malaria (for clients who may have been exposed), client counseling on personal hygiene to prevent intestinal worms infestation, and recommended presumptive treatment of hookworm infestation with Mebendazole 500mg STAT any time after the first trimester.
The HCWs will further promote uptake of services through mentoring and providing OJT and supportive supervision for identified gaps (including low uptake of outreach activities). The project will work with health facilities to provide detached clinics for spouses to support pregnant women to seek health services promptly and in a timely manner, and to conduct defaulter tracing of ANC mothers through quality improvement programs to monitor the completeness of 4 ANC visits. The project will continue to embrace public-private partnerships by engaging more private and FBO facilities and/or other creative arrangements to facilitate timely/effective referrals as part of complication-readiness planning. Furthermore, the project will strengthen HCW capacity in private and FBO facilities on Basic Emergency Obstetric and Newborn Care (BEmONC) signal functions. The project will look for opportunities for point-of-service integration with PMTCT and FP services, increasing efficiencies and therefore client satisfaction/attendance.
Activity 2.1.3: Increase safe deliveries within NCC. Community-level: CHVs will map available transport that can be used for labor emergencies (such as boda boda), as well as form community MNH committees that support transport of mothers in labor at night (a major barrier to skilled birth attendance [SBA] in Nairobi). CHVs will also work as ambulance coordinators for facilities and provide BCC messaging on the importance of SBA. In the three sub- counties with the highest maternal death burden (Langata, Kamukunji, and Embakasi), Afya Jijini will strengthen the community-health facility interface to reduce the "first and second delays" that compromise timely and effective management of PPH. This will be done by advocating for early clinic attendance (i.e. within the first trimester in case of low hemoglobin levels and/or anemia), and also address insecurity by escorting pregnant women in specific situations of risk during the day and at night through the Nyumba Kumi initiative as a community lead.
Facility-based: The project will support all 54 maternities to be either BEmONC or CEmONC compliant, including ensuring continuous supply of magnesium sulphate for pre-eclampsia/eclampsia, antibiotics for infection, and uterotonics for post-partum haemorrhage (PPH); and with necessary equipment. The project will help 34 of the 54 supported maternities offer BEmONC signal functions. Afya Jijini will provide supplemental HCW training through OJT and mentorship on correct use of partograph for decision making, AMTSL, management of PPH, administration of anti-hypertensives, and other key EmONC signal functions. In Y2, Afya Jijini will focus on strengthening HCW skills in assisted vaginal delivery (AVD), manual removal of the placenta and retained products of conception, administration of uteronic drugs within one minute, and administration of anti-convulsant drugs. In addition, the project will work with facility-based Champions to support sites in need of additional support in the correct use of the partograph. The project will use a mix of trained facilitators, program staff and facility-based Champions to reinforce skills according to assessed needs and the project’s work plan. The project will also continue emphasizing the importance of infection control
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during labor, delivery, and PNC by facilitating IPC OJT, CMEs, and mentorship to HCWs in targeted high-volume facilities and under-performing facilities. Based on ongoing MNH assessments, Afya Jijini will continue providing basic equipment for EmONC for all health facilities to be EmONC compliant, conduct safe deliveries, and manage maternal complications. The project will also continue acquiring and distributing necessary MNH/EmONC job aide, guidelines, tools, registers, and protocols. The county and sub-counties will also participate in annual BEmONC assessments (led by PIMA) to monitor progress in safe deliveries. The project will build the county’s capacity to continue these assessments after the project ends (as well as carry out MPDSR).
Improving HCW attitudes through training and coaching: The project will address HCW attitudes toward women, youth, and key populations seeking MNH and/or eMTCT services as a central strategy for improving uptake of MNH services. Afya Jijini will continue providing trainings on the Respectful Care Module (RCM) as part of the comprehensive MNH training that is integrated into the EmONC training. WITs will take a lead role in mentoring and supporting HCWs to address quality maternity care through RCM. The project will guide maternity/MNCH WITs to conduct exit interviews on a semi-annual basis at sampled maternity units and at the community level to document quality of care feedback and any cases of maternal abuse at facilities. The WITs will organize sensitization meetings on respectful care and review the completed exit interviews, support the facilities to document the feedback using questionnaires, and support dissemination of exit interview results. Facility in-charges’ meetings and county and sub-county meetings will also review and evaluate feedback from the abuse reporting system. At the site level, HCWs at maternities will meet on a monthly basis to analyze the feedback on respectable maternity care and use the information to improve the quality of MNH services.
Activity 2.1.4: Improve uptake and provision of PNC at target health facilities. Afya Jijini seeks to ensure newborns are examined within the first 48 hours and at least three additional postnatal contacts are done at Day 3 (48–72 hours), between days 7–14 after birth, and six weeks after birth during Y2.
Community-level: Project-trained CHVs will encourage mothers and their partners to bring infants back for a post-natal check-up at mandated intervals through individual and community outreach. The CHVs will specifically promote exclusive breastfeeding (EBF) and skin/cord care (e.g. use of chlorhexidine) and neonate thermal care (e.g. promoting KMC at home), early detection of newborn danger signs or illnesses, and prompt and accompanied referral to the nearest facility. The project will work closely with CHVs to refer any home delivery to the facility within 48 hours and ensure that facilities review mothers in the postnatal ward. The project will advocate with the County to offer weekend services to improve access (targeted monthly weekend in-reaches will only be in high-volume facilities).
Facility-level: The project will scale-up several interventions designed to improve facility PNC. Afya Jijini, in collaboration with the CHMT, SCHMTs, and facility in-charges, will provide targeted capacity building to HCWs on resuscitation, KMC, early initiation of breastfeeding, cord care, proper use of antibiotics, and conducting a postnatal review within 48 hours (including a review for home births). This will be done by scaling up Kangaroo Mother Care (KMC) in maternities with newborn units (NBU) as a means of improving thermal care in Langata, St. Mary’s Hospital and Pumwani Maternity. The project will support scale-up use of 7.1% Chlorhexidine Gluconate through capacity building of HCWs and OJTs and trainings at high-volume maternities once the Ministry releases the circular. The project will further support thermal care and EBF through promotion of EBF throughout the continuum of care (COC) for pregnant mothers and initiation of BF within one hour after delivery through health talks in the postnatal wards, support breastfeeding support groups at facilities and communities through continuous health talks on EBF while they await their CWC appointments and in the postnatal ward. The project will work with facility Champions for newborn resuscitation to ensure that all staff working in the labor ward, pediatric ward and NBU are mentored on how to resuscitate a newborn and how to manage severe asphyxia. The newborn health support will include training on essential newborn care as part of EmONC support. WITs will help maternities develop and track newborn-specific process indicators. The project
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will identify and support the MCH Champions to mentor HCWs on quality newborn survival, with a focus on neonatal resuscitation.
In Y2, Afya Jijini will continue scaling-up the KMC as an intervention for low birth weight in selected CEmONC facilities. The project saw initial KMC success in Mama Lucy Kibaki, Mbagathi, and Pumwani Hospitals during Y1. During Y2, the project will expand KMC to additional high-volume MNH facilities. UHAI teams will train new HCWs on KMC, distribute KMC guidelines to target facilities, and support CHVs to conduct active post-discharge follow-up on mothers and newborns discharged from KMC wards. The project will also continue helping sites work toward being a baby-friendly hospital initiative (BFHI) in all maternities, sensitizing HCWs on BFHI, supporting joint county/sub-county-project quarterly facility supervision of BFHI in maternities.
In Y2 Afya Jijini will support and encourage HCWs to monitor all newborns admitted to the pediatric ward during the perinatal period within the first week, review the cases, and have action points implemented as per the guidelines to improve sick newborn care and newborn health outcomes. In addition, the project will support KMC promotion in maternities to reduce the incidence of new infections in the NBU and decongest the unit, as well as address the special needs of premature infants. HCWs and champions in the labor ward, NBU and KMC rooms will be trained on newborn resuscitation, including care of the premature and low birth weight infants. The project will advocate for the county to procure continuous positive airway pressure machines (CAPs) to manage sick and premature newborns. The project will further support mentorship/OJT and CMEs to HCWs for timely detection of newborn danger signs or illnesses (e.g. infection, jaundice, difficulty in breathing, feeding), and promptly manage at the facility level and/or through accompanied referrals to the nearest facility by CHVs. Afya Jijini will also set the stage to begin strengthening integrated well-child services (e.g., growth monitoring, immunization, integrated management of childhood illness [IMCI]). The project will also strengthen HCW skills through mentorship and OJT to ensure that newborns are assessed for any danger signs before being discharged and during the targeted postnatal visits. The project will further support operationalization of national chlorhexidine guidelines in supported facilities.
Activity 2.1.5: Improve maternal PNC. Community-level: CHVs will sensitize community leaders and other stakeholders on messaging to encourage proper PNC, organizing PNC orientation meetings for all opinion leaders and gatekeepers in high- volume maternity catchments. Afya Jijini will also collaborate with Community Health Extension Workers (CHEWs) to carry out this work. CHVs will also carry out home visits to educate parents and caregivers about PNC and its benefits (nutritional recuperation) and identify and link postnatal mothers in the community to FP and PMTCT services. To increase PNC uptake the project will work closely with CHVs to refer babies delivered at home for review and management at facilities within 48 hours, review mothers in the postnatal ward, and book clinic appointments, as per the guidelines. The project will also support redoubling of information, education, and communication (IEC)/Behavior Change Communication (BCC) efforts during ANC to promote optimal and timely PNC care seeking behavior. CHVs will map out pregnant women at the community level and refer them for services, as well as discourage home deliveries and emphasize on mothers’ health focusing more on postpartum orientations, which includes: postpartum danger signs (detection of sepsis, PPH, headaches that warrant checkup, etc.), IYCF, and maternal nutrition (link to Output 2.5 activities).
Facility-level: Through mentorship and OJT, the project will ensure HCW provide the GOK MNCH package of post-delivery services: EBF, chlorhexidine cord care, presumptive antibiotic therapy for high- risk babies, neonatal resuscitation, pre-term delivery management, etc. In addition, Afya Jijini UHAI Teams and RH/FP Field Assistants will coach HCWs in critical post-birth maternal messaging, including promoting early and EBF at delivery, and in all postnatal care visits; reinforcing key newborn care messages among families and providers (e.g. delayed bathing, skin-to-skin contact and immunization); educating mothers on post-partum danger signs, good nutrition, and providing PPFP counselling. To
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improve access to services and reduce barriers throughout the COC, health talks will be offered by CHVs and HCWs on FANC, the danger signs during pregnancy, labor and postnatal stages, the importance of skilled birth attendants (SBA), and targeted PNC.
Activity 2.1.6: Scale-up gender-sensitive approaches to MNH. The Afya Jijini baseline found that studies showed a positive impact of male engagement on health outcomes—including a two-fold increase in women who delivered a baby with SBA when their male partner joined at least one ANC appointment. However, barriers to men’s participation persist, particularly in informal settlements in NCC, where many men are engaged in piece-meal work and day labor and cannot afford to miss work to attend clinic appointments with their partners and children. Further, men and boys in informal settlements felt that MCH was not relevant to them, and felt excluded by general MOH messaging and by HCW attitudes that did not feel supportive to men. As a result, the project launched the We Men Care model. In Y1, the model was launched at 10 high-volume sites and reached more than 6,000 men, resulting in improved understanding and support for the spectrum of MNCH and RH services. As part of this strategy, Afya Jijini worked with ANC HCWs to identify a semi-detached space in the ANC clinics where male partners receive health and counseling services. These detached spaces offer men who accompany their pregnant and breastfeeding partners to MNCH visits an opportunity to meet with a We Men Care Champion. He initiates dialogue on relevant MNCH topics, such as the danger signs of pregnancy and childbirth, the importance of a birth plan, etc. The men concurrently receive other health services, such as getting their blood pressure, weight, and body mass index (BMI) checked, and HTS. The approach responds to study findings that show men often feel self-conscious, bored, or stigmatized waiting in crowded ANCs. During Y2, the project will continue to support 17 high-volume facilities with high HIV, MNCH, and eMTCT patient loads to implement We Men Care. This will be complemented through the project’s MCH 7/7 services, allowing more men to attend due to availing evening and weekend hours.
OUTPUT 2.2: CHILD HEALTH Background and Rationale Data indicates an acute need to improve child health within NCC’s health facilities and within communities and households: Children continue to die from diarrhea, acute respiratory infection (ARI), and lack adequate vaccination coverage. Nationally, child mortality stands at 52/1,000 live births by age five (KDHS 2014). The Afya Jijini baseline found a need to focus on scaling up access to evidence-driven facility interventions during Y2, including ORT corners and IMCI management (especially ARI). The baseline found that less than half of facilities provide ORT for children with diarrhea (47%) and an even lower proportion (21%) are able to manage children under five-years old with acute febrile illness, as per the national IMCI guidelines. Nairobi possesses fewer fully immunized children as compared to national averages, with 60.4% fully immunized 12-23 months children compared to 67.5% nationally. At one year, 74% of children are immunized (below the county target and national averages). The Afya Jijini baseline found a relative drop (~40%) of measles immunization in comparison with other completing vaccines such as DPT3 and OPV/IPV3, the reason of which is unknown (and will be probed further in Y2). The project will work with 439 facilities in Y2 to achieve high immunization coverage for children at one year. Child malnutrition also contributes to morbidity and mortality (and is discussed under Output 2.5). The project will foster close collaboration and integration of child health activities and nutrition under the respective outputs. For example, IMCI is promoted and referenced above at the facility and community levels (through education and referrals), which addresses nutrition through messaging as an important precondition to child health. Growth monitoring at the ECD level is linked to facility nutrition interventions as well.
Activity 2.2.1: Strengthen county and sub-county planning and supportive supervision for child health. Afya Jijini will work closely with the county and sub-counties to improve the overall planning, coordination, and oversight of key child health activities. Specifically, the project will help the county hold monthly and quarterly data review meetings on IMCI and immunizations, providing coaching on
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data analysis and developing action plans to meet gaps. Afya Jijini will also support C/SCHMTs to conduct quarterly joint supportive supervision on the provision of quality, high impact child health services at target high-volume facilities in informal settlements. Afya Jijini will support the 10 sub-counties to map out and engage facilities in providing the basic minimum essential package for child health (this will include mapping out private facilities in the informal settlements).
Activity 2.2.2: Improve facility child health service provision. Mentor HCWs in effective child health services provision: In Y2, the project will continue supporting facilities with OJT and mentorship that supports child health topics on-site to improve skills of HCWs caring for infants and young children. Afya Jijini will support health facilities to provide the basic minimum essential package for child health by helping sub-counties to identify facilities that require initiation onto the package, training HCWs and facilitators from the identified health facilities on the basic minimum essential package for child health, providing tools and job aids, and supporting the sub-counties to conduct monthly review meetings with facility in-charges to review progress. Afya Jijini will also continue training HCWs on critical child health areas that impact survival, including the rollout of new IMCI guidelines. UHAI teams will also coach sites in treatment of diarrhea with ORT and zinc, the roll-out of newly introduced vaccines, IMCI, basic life support, and commodity supply chain management. The mentorship will help boost the provision of health talks that cover key child health topics during CWC and other child health visits. Topics include proper hygiene for mother and baby, danger signs of pneumonia and other child killers, infant and young child nutrition, and immunization encouragement.
Scale-up routine immunization and prepare sites and the County for new vaccines: Between October 2014 to September 2015, 116,994 (81%) children in NCC were estimated to have been fully immunized. In Y2, Afya Jijini will continue prioritizing the “basics” of vaccinations at all sites, while providing additional technical support to sites identified with poorer vaccination rates (<80%), with the aim of scaling immunization coverage up to 90% and above. Core activities include ensuring HCWs administer the initial baby vaccines before discharge (BCG and polio) to all neonates in target health facilities. The project will help sites scale-up weekend in-reach activities to new facilities to administer initial baby vaccines before discharge or within 48 hours of the PNC check for home deliveries. Afya Jijini will also help sites plan their immunization activities on a monthly basis, including proper implementation and monitoring of the immunization schedule and prompt defaulter tracing by CHVs. Focus will be to reach every child with immunization through CHVs mapping all under-fives in the informal settlements and referring them for services. The project will support sub-counties and facilities to develop and monitor immunization micro-plans, and sensitize MNCH HCWs on infection prevention to ensure that injection safety procedures are followed in facilities with maternities. It will also supporting quarterly county and sub-county immunization planning and review meetings. The project will also support high-volume MNCH facilities serving informal settlements to offer weekend in-reach vaccination activities. Historically, immunizations and other child health services were only available during daytime working hours Monday-Friday, resulting in many households failing to bring in their children for services due to time and job constraints. During Y1, Afya Jijini piloted offering key services on the weekend, which indicated higher uptake and coverage of immunization and other services (and resulted in cost savings by reducing the numbers of community outreaches needed).
Afya Jijini will continue providing job aids, guidelines, and reporting tools to support timely monthly reporting and disease surveillance, including but not limited to, vaccine-preventable disease outbreaks, as in the case of polio, and help the county to respond to these outbreaks by training and mentoring HCWs in each sub-county on using the reporting tools to ensure that immunization data is of quality and accurate. The project will also support weekly disease surveillance reporting at facilities, monthly disease surveillance meetings at the sub-county level, and quarterly disease surveillance at the county level. Afya Jijini will train all HCWs on newly-introduced vaccines (such as the new rotavirus vaccine, Injectable Polio Vaccine, and pneumonia vaccine), and will work with the CHMT and SCHMTs to identify private facilities in informal settlements that can be trained and supplied with national immunization tools USAID/KENYA AFYA JIJINI YEAR 2 WORK PLAN 26
(training, vaccines, job aids, and reporting tools) for them to offer immunization services at no-cost or minimal cost.
Continue support for ORT corners: Please see Output 3.4.
Source and distribute child health supplies: The project will work with the county and sub-counties to identify, source, and distribute critical child health commodities and supplies to sites. Specifically, Afya Jijini will procure and distribute equipment (e.g., scales, oxygen, oximeters) to sites in need, as well as provide TA on commodity re-distribution (as needed) for oral rehydration solution (ORS) and zinc across sites. It will also help source and provide relevant IEC materials at the facility and community levels.
Activity 2.2.3: Strengthen knowledge of and uptake of infant and child health services at the household and community level. CHVs will motivate mothers to access facility-based child health services within 24 hours of recognizing the signs of diarrhea and ARI, with a focus on four sub-counties with informal settlements (Embakasi, Ruaraka, Kasarani, and Makandara), completing a mapping exercise of under fives to guide this work. CHVs will also identify disabled children under five and link them to individualized services. Specifically, they will focus on reaching every child with immunization through CHVs mapping of all under-fives in the informal settlements and referring them for services, offering information on growth monitoring, EBF, commentary feeding, danger signs, follow-up of diarrheal cases and children with fever and signs of pneumonia (e.g. difficulty in breathing) and refer them to the facility. The project will continue organizing quarterly awareness-raising forums, and support CHVs and facility in-charges to organize quarterly community dialogue days on prevention of diarrheal diseases and ARIs in informal settlements. Afya Jijini will also support CHVs to educate families and project-linked ECDs on the importance of vaccination, particularly for newly-introduced vaccines, importance of breastfeeding, complementary feeding to infants, growth monitoring, management of diarrhea with ORS and zinc, and how to identify signs of pneumonia, dehydration and any other childhood illnesses. The project will work with CHVs to strengthen the referral mechanism for children with diarrhea and ARI, and source and distribute IEC materials in prevention and care of children with diarrheal and ARI diseases at the community level.
OUTPUT 2.3: FP Background and Rationale NCC features nearly a million women of reproductive age (985,524), with many at risk of unexpected or unwanted pregnancy. Currently, Nairobi has a contraceptive prevalence rate of 62.6%, with 58.3% using a modern method. The total unmet FP need is estimated at 11.1% (KDHS 2014). Afya Jijini’s baseline found that approximately 78,000 women/couples have been protected from unplanned pregnancies through these services provided by an average of 97 facilities, with modern contraception use around the same as the KDHS. Implants have become one of the most popular methods in informal settlements, followed by the injectable contraceptives and oral contraceptive pills. During Y2, the project will work with 394 health facilities/sites to increase access and uptake of voluntary FP, with a special focus on 125 facilities that contribute 85% of the contraceptive prevalence rate (CYP) in NCC. The project will also expand CBDs as a key entry point for FP and to increase access in informal settlements. Y2 activities are:
Activity 2.3.1: Strengthen County and sub-county FP coordination and service delivery. Strengthen the county to plan, deliver, and monitor FP services: The county FP TWG will be supported on a quarterly basis to address planning and coordination. County FP focal people will be supported to attend semi-annual national TWGs and relevant technical meetings. Afya Jijini will continue supporting FP committees to advocate for increased budget allocations at the county level for FP commodities and activities (especially for training of staff and community-based FP activities) and ensure its inclusion in annual work plans by helping the FP focal people to hold advocacy meetings with the county government budget committee. In response to unmet FP need among postnatal mothers, the project will
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advocate with the County Health Management Team (CHMT) to address resource allocation and supply- chain issues related to IUCDs and/or other long-acting, reversible contraceptives within delivery rooms and postnatal clinics (link to activities under Sub-Purpose 3, as well as Output 2.3 activities). Afya Jijini will further support quarterly integrated supportive supervision by the county on the quality of service delivery (including FP inventory management/stocks and provision of long-acting reversible contraception [LARC] to project facilities), working closely with the sub-counties. Afya Jijini will also continue helping NCC to prepare for national celebrations, including World Population Day and World Contraceptive Day. The county and sub-counties will work with CHVs and HCWs to mobilize communities and offers outreaches or in-reaches as lead up to these days. At the sub-county level, Afya Jijini will encourage the SCHMT FP focal people to attend quarterly county FP TWG meetings, to ensure their needs are heard.
Activity 2.3.2: Improve access and quality of facility-based FP services. Strengthen facility capacity to deliver FP services: High-volume sites (approximately 125 that contribute to 85% of CYP) will be assessed, equipped, and supported to promote, manage, and provide FP services. In Y2, Afya Jijini will work with SCHMT members to assess all target sites for integration and quality of FP services (including for youth-friendliness). It will sensitize the county’s, sub-counties’, and facilities’ FP focal point people on the FP service integration, including offering “one-stop shops.” UHAI teams will help sites develop a capacity strengthening plan to ensure that FP is integrated into the CCC (if it exists) and other avenues, such as MNCH, ANC, etc. The UHAI teams will provide quarterly FP integration assessments in project-supported sites, supporting and engaging FP service providers in 15 of the high- volume CCCs1 for comprehensive FP integration, supporting highly-qualified service providers to provide bi-monthly mentorship to other service providers in high-volume facilities. The project will ensure that facilities give timely reports on DHIS2 through training, mentorship, support supervision, and provision of tools at supported facilities. The project will track monthly FP data as a means to help sub-counties zero-in on under-reporting sites for further interventions. CHVs will also report community-level data, which will be aggregated with the facility data and reported on a monthly basis. The project will track CYP contributions per method on a monthly basis. The unmet need will be computed through population data at the county level on the number of women of reproductive age not accessing modern FP methods. Strengthen HCW skills in FP provision and counseling: Afya Jijini UHAI teams and RH/FP Field Assistants will provide mentorship, OJT, and CMEs on providing integrated, informed FP services at target sites. The project will support highly-skilled HCWs (Champions) on FP to coach and mentor other HCWs in facilities, and facilitate monthly meetings for the highly-qualified FP service providers to discuss mentorship methods. Facilities will review FP progress, with the goal of boosting uptake among clients (such as promoting post-partum insertion of the copper IUD in high-volume maternities) and on the provision of comprehensive post-abortion care (PAC) services, including organizing a sensitization meeting on FP PAC to HCWs from BEmONC facilities. The project will provide job aids, guidelines, and registers to ensure optimal FP provision. The project will also sensitize HCWs and facility-based volunteers on BCC and youth-friendly approaches, using IEC materials and health talks during ANC to improve uptake of FP services after delivery. At the facility level, HCWs and CHVs will support health talks and will provide counseling to clients who need the methods. HCWs will be trained to provide adolescent and youth sexual and reproductive health (AYSRH) services in targeted facilities to address specific barriers to access that young people identified during the project’s Gender Analysis (e.g. husbands demanding that their wives deliver up to 3-4 children in succession so that they cannot get “sponsors,” and the belief that contraceptives make their wives lose their shape by adding weight, bringing an extra expense for buying new clothes). Finally, the project will work closely with facilities and
1 St Mary, Mbagathi, Kangemi, Mathare North, Dandora II, Kahawa West, Getrudes, Kariobangi North, Mukuru MMM, Westlands, Kasarani, St. Francis, MLKH, STC Casino, and Kayole. USAID/KENYA AFYA JIJINI YEAR 2 WORK PLAN 28
the sub-counties to improve their reporting and tracking abilities, ultimately assisting them to use data and observation to monitor performance and gauage changes in contraceptive trends and unmet need.
FP compliance: Afya Jijini will continue building upon the Y1 efforts undertaken to sensitize HCWs on the main components of FP compliance including: 1) no FP target/quota setting, 2) no incentive or financial rewards, 3) no denial of rights or benefits for refusing any or all FP methods, 4) ensuring facilities have a variety of methods available, including LARC, to provide choice, and 5) providing comprehensive information to inform choice. Afya Jijini will work with the county, sub-county, and facility FP focal people and facility in-charges on FP compliance and supporting the sub-county team members to monitor facilities’ adherence to the FP compliance plan. At the facility level, the project will support in- charges with CMEs to monitor FP compliance at all sites.
Activity 2.3.3: Strengthen household and community access to FP messaging and commodities. The project will support previously trained CBDs to deliver evidence-based messages on FP and distribute oral contraceptives and condoms within target communiities. Youth CBDs will work with youth, peer educators, and other youth entry points to increase access for young people. CBDs will counsel clients on all FP methods and refer them or escort them to health facilities for LARC services. (To date, 50 CBDs are operational in Embakasi, Kasarani, Ruaraka, and Makadara, and all are attached to specific facilities). Afya Jijini will ensure CBDs link to CHEWs for commodity supplies, supportive supervision, and reporting. CBDs will hold monthly review meetings on community FP distribution. The project will also train a sub-set of the trained 2,148 CHVs on FP BCC (with a GOK-approved curriculum) so that they can improve their delivery of messages that address sociocultural and other barriers to equitable FP uptake. Messages will include healthy timing and spacing of children, advantages of contraceptives, and reduce myths and misconceptions associated with FP methods at community level. The facility-based male champions will give health talks on the importance of healthy timing and spacing (HTSP) of children during community dialogue. The project will further monitor performance to gauge any changes in CPR though community and facility data all reported in the DHIS2 and also through household surveys. Activity 2.3.4: Offer gender-sensitive FP approaches. Afya Jijini’s Y1 Gender Analysis found that FP and sexual reproductive health (SRH) were often viewed as a “female domain,” excluding men and boys who didn’t feel that it was relevant to them. However, the analysis found that men typically held more sexual power over women and girls, including decision-making over use of condoms, indicating a need for male engagement approaches on FP. In addition, key populations, including MSM and MSW, often had neglected SRH needs. They were generally not included in messaging and also faced stigmatization when seeking SRH services. As a result, during Y2 Afya Jijini will work with the county to re- design/adapt IEC materials for health facility and community health talks so that they are gender- sensitive and attractive for clients, depending on audience.
OUTPUT 2.4: WASH SERVICES
Background and Rationale Data indicates poor WASH practices within Nairobi, both in health facilities and at the household and community level in informal settlements. The 2014 KDHS found that while NCC fared slightly better with observed handwashing in households than other counties nationally, it still only stood at 39%. In NCC, 54% of households had drinking water on their premises, with 46% of the sources piped water (KDHS 2014). Approximately 23% of households have an improved, non-shared waste facility (i.e. flush toilet, latrine, etc.), which is likely much higher in urban informal settlements. Afya Jijini’s Y1 baseline found that there were nearly four times as many households without functional latrines (65,846) as households without appropriate water treatment (17,256), indicating a need to focus on waste management, reducing open defecation behaviors, and interventions to reduce diarrhea and cholera risk. In addition, the baseline found poor WASH reporting at the health facility level, impeding data collection USAID/KENYA AFYA JIJINI YEAR 2 WORK PLAN 29
and analysis (only about 30% of facilities surveyed in the baseline collected WASH indicators at all). Based on these findings, Afya Jijini will strengthen community-facility WASH interventions for diarrhea prevention and prioritize strengthening the county’s ability to plan, resource, and implement sustainable, effective WASH activities during Y2.
Activity 2.4.1: County-level WASH support. Assess county WASH practices: Afya Jijini will work with stakeholders to conduct two WASH-related assessments in Y2: a baseline assessment for urban WASH indicators, including solid waste management, latrine coverage, and hygiene standards and practices; and a WASH assessment in ECD centers that were not assessed in Y1. These assessments were planned based on the initial WASH assessments in Y1 and joint planning with stakeholders (county, KIWASH, and others). They will help target further interventions in Y2.
Strengthen the WASH TWG and establish three new WASH TWGs: The project will continue to strengthen the County WASH TWG, ensuring it meets annual objectives, such as advocating for the provision of piped water in informal settlements through the Maji Safi initiative. Afya Jijini will also help the county establish three new TWGs on school wash, hygiene promotion, and urban sanitation, which the WASH TWG identified in Y1 as a need to better coordinate and improve in these areas. The project will also support key WASH county staff to participate in relevant inter-agency coordination conferences and fora, as appropriate.
Strengthen awareness and promote uptake through global awareness days: Afya Jijini will support NCC to hold mobilization activities and outreach through the relevant World Health Days, including the Global Handwashing Day and World Toilet Day.
Improve water quality monitoring at informal settlement public water points and distribute water treatment products at targeted public places: The project will work with the county government to initiate treatment of public water points in supported informal settlements by procuring and distributing water treatment products in targeted public places. Afya Jijini will train the County to monitor the quality of water (testing and sampling) in public water points in informal settlements, including schools, ECDs, community water points, and sampled households, on a quarterly basis.
Activity 2.4.2: Sub-county and facility-level WASH support. Improve sub-county WASH coordination and facility oversight: Afya Jijini will assist sub-counties without TWGs to form them, establishing membership roles and responsibilities, developing/adopting terms of reference (TOR), and establishing modest goals. The project will also support quarterly WASH/IPC review meetings for sub-county public health officers and other WASH stakeholders to increase coordination and oversight of health facilities and their catchment communities.
Train county and sub-county HCWs on evidence-based WASH messaging: In Y2, the project will train HCWs within the county and sub-counties on evidenced-based WASH messages, including handwashing, for inclusion in service delivery. The project will assist SCHMTs to conduct handwashing observational audits and other QI projects to boost handwashing adherence through quarterly supervisory visits and audits.
Support functional ORT centers at supported facilities: Afya Jijini will conntinue supporting 64 ORT corners to reduce diarrhea-related deaths in children under five. The supported 28 WASH Champions will ensure availability of equipment, supplies, and commodities critical to the ORT corner; ensure availability of IEC materials at the ORT corner and health facility; conduct health education targeting parents and caregivers; conduct hand washing demonstrations; mixing and administering ORS; and report WASH issues at the ORT corner and health facility.
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Sensitize HCWs on health care waste management (HCWM) and IPC: The project will sensitize HCWs at 30 sites on HCWM and IPC, using the findings from the Y1 HCWM plan assessment. Additionally, based on the findings from the Y1 facility WASH assessment, the project will continue supporting facilities to develop and/or operationalize WASH improvement plans to ensure that all facilities are properly- equipped with clean water, hand washing stations, safe latrines, and proper waste disposal.
Procure and distribute HCWM commodities: The project will also procure and distribute important supplies, such as bins, liners, and equipment (such as heavy duty gloves, shredders, macerators, waste transfer trolleys, and personal protective equipment) according to the HCWM referral plans and reported need. HCWM/IPC IEC materials at health facilities (including posters, SOPs, murals, and T-shirts) will reinforce these messages.
Activity 2.4.3: Community-level WASH support. Support public water treatment points and distribute water treatment: As discussed above, Afya Jijini will work with the county government to initiate treatment of public water points in supported informal settlements by procuring and distributing water treatment products in targeted public places. At the community level, Afya Jijini will also provide point-of-use water treatment products in target communities that are identified as a high need (households of OVC, PLHIV, and communal water points); install adequate functional hand washing points in schools (tippy taps, taps), and monitor the functionality of the water points on a quarterly basis, including procuring hand washing facilities for schools, ECDs, and day cares.
Implement and scale Urban Community-Led Sanitation (UCLTS) in Nairobi’s informal settlements: In Y1, Afya Jijini began working with the County to implement a UCLTS plan in target informal settlements. In Y2, the project will continue conducting community dialogue forums to discuss WASH in targeted communities (estimated 60 forums), including supporting post-triggering meetings in triggered villages and schools (approximately 120 meetings). Afya Jijini, working with sub-counties, will mobilize communities to conduct an assessment on community-level open defecation as part of UCLTS via the AJSGP. The project will help communities then hold triggering sessions (estimated 50 in Y2) in new ECD centers and primary schools, linking to surrounding communities in informal settlements, based on the key findings from this assessment. In Y2, Afya Jijini will also support the CHMT and SCHMTs to conduct monthly post-triggering follow-up, working with the CHMT, SCHMTs, and external verifiers to confirm open defecation-free claims by villages, providing IEC materials for WASH education and advocacy in schools and communities (including murals, T-shirts, posters, pamphlets, fact sheets, fliers, calendars, and banners). The project will also train CHVs on UCLTS, supporting them to conduct triggering sessions in each sub-county.
Small Doable Actions (SDA): The project will train informal settlement-based CHVs on WASH messaging to improve sanitation uptake through the project’s SDA concept, endorsed by the GOK. SDA helps households identify small steps to move them from inadequate to ideal hygiene practices, such as washing hands properly at key times, treating and drinking safe water, and properly disposing of fecal and menstrual waste. CHVs will first visit families with an assessment card to examine hand washing, water treatment, feces disposal, and menstrual hygiene management practices. CHVs will then use the SDA approach to negotiate improved WASH practices with household members/caregivers to positively impact the whole family’s health and quality of life. The SDA approach complements the MOH’s UCLTS efforts to promote sanitation uptake. Afya Jijini will work through CBOs with trained CHVs, possibly through the AJSGP, to implement the SDA concept and WASH activities in informal settlements, especially in schools.
Support additional community-based WASH support activities: Afya Jijini will also continue implementing community-based WASH strategies in sites surrounding high-volume/priority health facilities. Y2 planned WASH community activities include: Identify and develop community sanitation champions in target informal settlements, support
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CHVs to undertake WASH activities in ECDs and primary schools, and to hold monthly review meetings at ECDs in each sub-county. Identify, train, and reward hygiene champions in ECDs and schools on an annual basis through the AOC school health clubs; procure hand washing facilities for ECDs and primary schools. Establish and support volunteer community sanitation teams that will work with CBOs to conduct monthly clean-up, garbage collection, and hold WASH days.
OUTPUT 2.5: NUTRITION SERVICES
Background and Rationale Nairobi faces myriad nutrition challenges at the household, community, and facility level that result in high malnutrition for children under five. The 2014 KDHS found that 17.2% percent of children under five were stunted, for example. Under-nutrition begins during the first 1,000 days: Pregnant women in Nairobi feature low micronutrient intake during pregnancy (just over half of women had received iron during their most recent pregnancy). The nutrition challenges continue through birth and shortly thereafter, with 61% of children breastfeeding within one hour (KDHS 2014). Vitamin A and iron consumption among children also need reinforcement, as does deworming. At the household level, poor understanding and feeding practices contributes to these statistics. Household and community-level education and BCC messaging are needed to equip families with the knowledge that will enable them to prevent malnutrition (especially in the first 1,000 days). Concurrently, the county, sub-counties, and health facilities need additional trained HCWs and evidence-driven implementation strategies (based on coverage of the HINI package) to support community-level efforts. During Y2, the project will mobilize the county to roll out HINI within target health facilities and catchment areas, attempting to cover the majority of the estimated 686,029 under-fives in NCC. Afya Jijini will work with 160 integrated management of malnutrition (IMAM) sites, 52 CCCs, and 32 maternities and their catchment areas on the activities described below.
Activity 2.5.1: County-level nutrition support. Support county nutrition technical forum (CNTF) quarterly and sub-county technical forums monthly: Afya Jijini will support quarterly county-level coordination meetings with nutrition stakeholders, including supporting the quarterly CNTF. This was an area of acute need identified during Y1 stakeholder meetings, which found a lack of coordination and investment in nutrition work across the county. In addition to conducting joint planning for nutrition activities to reduce duplication, the newly-energized CNTFs help create an enabling environment for nutrition improvement that includes innovation sharing and resource sharing (in Y1, for example, Afya Jijini and Concern Worldwide collaborated services across mutual projects in the county). The project also uses the CNTF as a forum for nutrition advocacy within county government, to boost investment and awareness. The county, for example, will advocate for commodities and coordination to conduct more regular semi-annual deworming campaigns for children 6-59 months, working with SCHMT members to work with CHVs to conduct advance community mobilizations. Afya Jijini will also help sub-counties hold sub-county forums on a monthly basis, with two per month, to increase collaboration at the local level. The County-level quarterly coordination meetings [CNTF]) serves as a primary coordination forum to discuss strategies and progress toward boosting county investment (financial, human resources, etc.) into nutrition, as well as increasing awareness of nutrition objectives among county stakeholders. The forum involves other stakeholders from other relevant sectors, including the Ministry of Agriculture, Education, and the Children’s Department to increase advocacy on these multi-sectorial issues and increase the likelihood of success.
Support planning of nutrition days: Afya Jijini will support the county and sub-counties in hosting Malezi Bora Week and World Breastfeeding Week, building on its success from Y1 (which increased uptake of immunizations, nutrition, and EBF outreach in informal settlements). The project will organize planning meetings in preparation for these events, provide IEC materials for the events (including banners and T- USAID/KENYA AFYA JIJINI YEAR 2 WORK PLAN 32
shirts, distributing nutrition commodities, reporting tools, and IEC materials), and work with the sub- counties to provide supportive supervision during these events.
Encourage quarterly nutrition supportive supervision: The project will work with the C/SCHMT to provide supportive supervision to the facilities on the HINI package, especially to the 162 sites with IMAM capability. It will also help with the planning and dissemination of nutrition guidelines for the county, and print and disseminate nutrition IEC materials to facilities lacking them during Y2.
Activity 2.5.2: Facility-based nutrition strengthening activities. Strengthening Nutrition Assessment and Counseling (NACS) services: Afya Jijini will strengthen NACS provision (availability and quality) at target CCCs and ANCs. UHAI teams will provide on-the-job training and mentorship on NACS for CCCs. The project will also strengthen the quality of anthropometric measurements and categorization of PLHIV through continued provision of OJT and coaching. Afya Jijini will collaborate with Nutrition and Health Program Plus (NHP+) to disseminate registers, summary tools, and anthropometric tools (BMI wheels, scales, etc.) and work with the SCHMTs to provide supportive supervision to CCCs and assess their NACS services (including conducting quarterly checks on nutrition data MOH 407 A&B). Training will ensure that HCWs assess all pregnant women at ANC and offer micronutrient supplementation to pregnant and breastfeeding women and children. In Y2, Afya Jijini will ensure that all HCWs nutritionally assess every pregnant woman at every ANC visit and provide ongoing nutritional counseling.
Further strengthening facility HINI provision: The project will also coodinate with the USAID-funded national nutrition mechanism NHP+, to support the sub-counties on improving nutritional outcomes in facilities (especially among PLHIV and breastfeeding women). During Y2, the project plans to train 100 HCWs on Maternal, Infant, and Young Child Nutrition (MIYCN) as part of the GOK HINI package, placing a strong emphasis on counseling and health education for mothers and caretakers on BCC topics like proper handwashing. Afya Jijini will also ensure target sites provide zinc and ORS at ORT corners, support de-worming campaigns, and offer Vitamin A supplementation.
Capacity building: Afya Jijini will target health facility staff of both in-patient and out-patient centers, as well as those working in the maternal and child health (MCH) departments, for training. Capacity building will employ a range of strategies, including the recommended trainings, OJTs and mentorship. Nutrition screening services will be integrated into other departments such as MCH, pediatric outpatient, CCC, and TB. Integrated services will be promoted to address the co-existence of other co-morbidities in malnourished patients and in ECDs to optimize messaging and modeling of nutrition.
The trainings will include integrated management of malnutrition (IMAM), MIYCN, the HINI package, and continuing medical education (CMEs) and OJTs on different areas following identification of gaps through support supervision at facilities. For example, the project will use national guidelines to support OJTs on the importance of Vitamin A and documentation at high-volume facilities. The project also successfully provided anthropometric and reporting tools to sites in need.
Strengthen IMAM at priority health facilities: During Y2, the project will continue strengthening IMAM services. Afya Jijini will partner with the county to train 100 HCWs at sites across all sub-counties and ensure that all 162 IMAM sites possess needed IMAM equipment and supplies. As part of the training, the project will place a special emphasis on client counseling on how to improve Infant and Young Child Feeding practices (dietary diversity, EBF, etc.) as a key future prevention component. WITs will reinforce nutrition QI standards, expanding their scope during Y2. The WITs will review the outpatient therapeutic cards and registers of children admitted with acute malnutrition on a quarterly basis, tracking patient outcomes and suggesting health facility change ideas. SCHMTs will conduct quarterly supportive supervision to their IMAM sites.
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Improving maternal nutrition (see also Output 2.1): Afya Jijini will improve maternal nutrition through several strategies. First, the project will conduct on-site gap assessments focused on maternal nutrition at sites suspected to be under-performing. The project will also ensure that the IMAM/focal nutrition sites stock and offer IFAS to pregnant women. During pre-natal visits, the project will help HCWs promote exclusive breastfeeding as well as other MIYCN messages in advance of birth that improve infant and young child well-being. In addition, the project will strengthen ANC services by ensuring that all pregnant women receive nutrition counseling in anemia prevention and improved IYCF practices on all areas, including early initiation of breastfeeding after birth, exclusive breastfeeding for six months, and continued breastfeeding and appropriate complementary feeding to achieve this. Afya Jijini will also conduct stock monitoring to ensure the availability of IFAS at all targeted facilities; provide a 7-day training for HCWs on providing maternity and ANC services with the Maternal Infant and Young Child Nutrition (MIYCN); and ensure appropriate standard operating procedures (SOPs) and IEC materials are available at the facilities, including MIYCN counseling cards.
Vitamin A supplementation: The project will work with the county to ensure all children ages 6-11 months receive Vitamin A dosing through Malezi Bora campaigns at targeted health facilities.
Activity 2.5.3: Community-based nutrition support activities. Deploy trained CHVs for improved community-based nutrition: The project will train and engage leading CHVs, identified and trained in Y1, to promote nutrition messaging and relevant community HINIs. In Y2, Afya Jijini will continue working with CHVs to support the community-linked aspects of the intervention package. Afya Jijini will further train/refresh 60 CHVs on maternal and child nutrition, and engage the CHVs to support child health nutrition at the community level through the ECD model. ECDs and daycare centers are increasing within informal settlements, as families need childcare (mostly under the age of five) as they seek casual work. In Y1, Afya Jijini, mapped and recorded 1,367 ECDs and daycare centers, with nearly 60,000 children enrolled and began using these ECDs as entry points for health services (with a focus on WASH and nutrition) targeting both the children and the surrounding catchment communities. In Y2, the project will scale up the ECD model for nutrition services (active case findings, growth monitoring, deworming) and WASH (UCLTS, distribution of water treatment tablets, targeted cleanup days), as needed. Afya Jijini also provides technical assistance to the school health section, as needed, to carry out activities at schools, mainly for de-worming, health education, and hand washing practices, and reports out on these activities at the County coordination forum.
At sub-counties, community outreaches hold community cooking/nutrition demonstrations in the targeted informal settlements and are held in conjunction with the Ministry of Agriculture in some sub- counties. These demonstrations emphasize promotion of good dietary practices. During Malezi Bora weeks, CHVs will be supported to hold health sessions during community gatherings that focus on good nutrition among target households, dietary practices, and handwashing (WASH).
The baseline and other project observations show that uptake of optimal breastfeeding practices, iron and folate supplementation (IFAS) among pregnant women, multi-nutrient powders (MNPs) and the use of zinc within diarrhea management requires additional focus. The project will strengthen focus in these areas during community conversation/outreach activities and by disseminating IEC materials on these areas in public places.
The project will focus on implementing community-level SBCC activities that help households to develop a plan for improved nutrition across a number of comprehensive dimensions, including maternal nutrition, dietary diversity, exclusive breastfeeding (EBF), and IYCF.
For example, CHVs will lead community conversations during nutrition weeks. CHVs will help communities/villages form EBF support groups, as well as help women seek support and tips to proceed with EBF when it becomes challenging. The CHVs will conduct quarterly visits at ECDs to monitor
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child growth and nutrition and link clients to supplemental food and nutrition services (including household counseling visits and coaching), where needed. CHVs will organize social mobilization activities leading up to de-worming campaigns, and will help distribute and administer Vitamin A and de- worming medicine. CHVs will conduct quarterly malnutrition active case finding (ACF) and outreach activities in the community and follow-up on acute malnutrition cases, linking those identified to livelihood support and safety nets.
The project will focus especially on implementing BCC activities at community level that help households develop a plan for good dietary practices and also provide counseling on good nutrition. For example, CHVs will lead community conversations during nutrition weeks. CHVs will help communities/villages form EBF support groups as well. They will conduct quarterly visits at ECDs to monitor child growth and nutrition and link clients to supplemental food and nutrition services where needed. CHVs will organize social mobilization activities leading up to the deworming campaigns, and help distribute and administer Vitamin A and dewormers. CHVs will conduct quarterly malnutrition ACF and outreach activities in the community and follow-up on acute malnutrition cases, linking those identified to livelihood support and safety nets.
For the targeting first 1,000 Days, Afya Jijini will support maternal nutrition through promoting IFAS and nutritional assessments and counseling of pregnant women at the facility level, while promoting EBF at the community and facility levels. The project plans to support MIYCN trainings for CHVs and HCWs and will ensure that they are facilitated with job aids and SOPs to implement baby-friendly hospital initiatives (BFHI) and baby-friendly community initiatives (BFCI).
Sub-Purpose 3: Strengthened and Functional County Health Systems
Introduction Afya Jijini is cognizant that health systems are by nature complex, adaptive and dynamic. Rapid changes to health systems may thus be accompanied with deterioration of health services delivery and downward trends in health outcomes. With devolution of health services, many counties, including Nairobi, require broad-based health systems support and strengthening if improved health outcomes are be achieved.
Approach Improved health outcomes in Nairobi require quality service delivery in communities and at health facilities as well strong management from the county and sub-county for resources, supplies, technical guidance and training. Afya Jijini’s HSS Team will continue to support each level of the NCC health system—county, sub-county, facility, community—to strengthen the role each must play to achieve project objectives.
National level. At the national level, the project will continue to support the CHMT members to participate in national TWGs, especially related to HIV, MNH, improving devolution, and human resource (HR) planning, among other priority areas.
County and sub-county level. Afya Jijini will continue supporting the CHMT to assume full leadership of its responsibilities under devolution, including support to sub-county health teams and facilities. In Y1, the County and Afya Jijini agreed to an aligned supervision structures, organized by four clusters to cover all ten sub-Counties, as a model for effectiveness and strong collaboration for supporting and monitoring sub-county and facility performance. The project will continue to engage with these structures as county level for improved oversight to health services.
OUTPUT 3.1: PARTNERSHIPS FOR GOVERNANCE AND STRATEGIC PLANNING
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Background and Rationale Devolution has wrought many challenges, including frequent HCW strikes due to issues of motivation and remuneration, as well as supply chain and financial management challenges. Afya Jijijni will work with the CHMT and sub-county health teams to better manage, deliver, and report on health services in the devolved context and in compliance with international guidelines and GOK policies.
Activity 3.1.1: County-level governance and partnerships strengthening. Develop, refine, and finalize key policy, guidance, and planning documents: In Y1, Afya Jijini supported the development of the new NCC HIV/AIDS Strategic Plan and the County’s HCWM Plan. For the first time since devolution, the sub-counties developed sub-county-specific AWPs with support from the project. The project will continue supporting the county with TA and mentorship to develop and roll out these plans. Specifically, the project will finalize and disseminate the County Health Policy, Strategic Plan, and Capacity Development Plan. The project will support dissemination and distribution of the newly- developed health policy at the sub-county level by convening dissemination meetings and will support development of a County Referral Strategy. Additionally, it will help the county develop asset disposal guidelines, in accordance with the HCWM Plan. In Y2, Afya Jijini will facilitate monthly meetings with the Department of Health Policy, Planning, and Research to monitor the implementation of the AWP, strategic plan, and other plans. Afya Jijini will support the sub-counties to hold semi-annual performance reviews of all relevant plans and strategies mentioned, as well as the county M&E plan. Afya Jijini will provide TA for the County and sub-counties to develop their 2017/2018 AWPs in Y2, drawing on lessons learned from implementation of Y1 plans.
Figure 5: Critical Capacity Assessment and Planning Documents to be Completed in FY17 Document Status County Health Policy Draft under review by the county County Health Strategic Plan Draft under review by the county County HIV and AIDS Strategy Completed and to be launched County Partnership Engagement and Draft under review by the county Collaboration framework Revised supportive supervision tools Draft undergoing final review (already shared (county) with sub-counties for input) County capacity assessment Assessment conducted, completed, and Afya Jijini working on the report
Strengthen stakeholder coordination and support: Afya Jijini will continue to support the county to best coordinate stakeholders for improved service delivery and reduced duplication of services. The project will finalize the first Stakeholder Engagement Framework and sensitize sub-counties on it. Afya Jijini will support semi-annual county health stakeholder meetings as a stakeholder coordination mechanism at the county2 and sub-county levels, according to the framework, as well as check-in with the county and coach them on adherence to the framework. It will also support the HSS semi-annual stakeholder forum (county-level) and quarterly sub-county stakeholder forums, the county’s preference for timing and coordination mechanisms.
Provide TA in performance-based financing and financial management: Working with the USAID-funded HPP+ project, Afya Jijini will help the county link annual work planning (2017/18) to performance-based budgeting and financing. Afya Jijini will closely collaborate with HPP+ to support the county and sub-
2 The county forums include more than 100 invitees from government ministries, NGOs (international and local), universities (international and local), the private sector, and faith communities. A full list of participants can be shared upon request. USAID/KENYA AFYA JIJINI YEAR 2 WORK PLAN 36
counties to hold quarterly finance sub-committee meetings. The projects will engage the county and sub- county health committees to lobby for additional funding for the health sector and monitor performance- based budgeting performance. Afya Jijini will also coordinate with HPP+ to provide TA to the Department of Health Policy, Planning, and Research to budget more effectively for the county health sector. It will roll out performance-based budgeting in Level 4 and 5 facilities, working closely with HPP+. Finally, Afya Jijini will advocate for gender sensitive budgeting and planning both at county and sub-county budgeting level, working closely with County Health Services.
Activity 3.1.2: Sub-county level governance and partnerships strengthening. Afya Jijini will strengthen the sub-county planning units in planning and budgeting, helping them advocate for increased budgetary allocations to the health sector using key financial information and evidence generated (e.g. analysis of budget allocations, sub-county health accounts etc.) Additionally, Afya Jijini implement a coaching and mentoring plan on leadership and governance, based on the project capacity strengthening plans, for the SCHMTs, and will conduct quarterly coaching and mentoring sessions for each SCHMT, helping them monitor their AWP achievement. The project will also help sub-counties strengthen their partnerships through developing frameworks and guidance mechanisms as well as holding regular coordination meetings with partners.
Activity 3.1.3: Facility-level governance and partnerships strengthening. Afya Jijini will conduct quarterly coaching and mentoring sessions for each hospital board of the four referral facilities. The project will also work closely with the County HR and Administrative Office to assess the capacity of the newly-appointed health facility management committees to fulfill an oversight/leadership role in facility leadership and governance. The project will thereafter develop a health facility management committee orientation package, which includes orientation and competence building. It will also provide training in relevant leadership and management topics based upon need, such as linking AWPs with performance- based budgeting and helping facilities better cost services as part of improved planning and resource mobilization.
OUTPUT 3.2: HRH
Background and Rationale NCC features an extensive healthcare workforce, necessitating strong technical support in how to recruit, manage, and support these cadres in a newly-devolved environment. During Y1, Afya Jijini focused on the fundamentals of HRH: assessing capacity at multiple levels, improving coordination in this dynamic environment, and better tracking the workforce at the county and sub-county level. The baseline assessment found that the county would benefit from an improved training strategy across all levels to ensure that all personnel have the basic skills and competencies to carry out their work, as well as a way to monitor performance. Y2 activities are:
Activity 3.2.1 County-level HRH strengthening. Collaborate directly with related national USAID HRH and other donor activities. Kenya still benefits from a number of HRH-linked donor-funded projects that offer critical technical guidance, tools, and resources that will benefit the Afya Jijini project. In Y2, we will continue meeting with the USAID-funded HRH projects, to ensure that we coordinate our interventions and link NCC to relevant HRH trainings in leadership, management, governance, and other topics. This includes participating in quarterly joint planning meetings with these national HRH mechanisms, in the fora described below, and focusing Afya Jijini HSS initiatives more at the sub-county level than at the county level where these other projects are already working.
Review the county HRH TWG TORs and revive its implementation: Afya Jijini will explore establishing a County HRH TWG. Afya Jijini will collaborate closely through regular meetings and collaborative planning with
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the new USAID-funded national HRH mechanism. In Y2, Afya Jijini will also continue participating in the NCC Health Workforce Coordinating Committee, working with IntraHealth in its role there.
Participate in the validation of the Nairobi County HRH Strategic Plan: The project will work with partners to support the county and sub-counties to develop their individual HRH strategic plans; disseminate the plans through dissemination workshops; and provide TA to selected high-volume facilities to develop facility-level HRH implementation plans.
Assess and strengthen HRH capacity, particularly leadership skills development: At the most immediate level, Afya Jijini will continue supporting the county to analyze staffing gaps for service delivery. It will continue building the capacity of the county (with a focus on sub-counties) to transition staff from donor-funded projects to its own payroll. Based on the HRH capacity assessments carried out in Y1, the project will provide TA to the county to develop an HRH capacity development plan to guide CMEs and roll out iHRIS, a tracking system/database to track HCW in-service trainings across technical areas. The plan will cover on-site mentorship, training modules, and other learning methods, including CMEs and OJTs.
The project will then support the County and sub-counties to continuously populate the in-service training activities into the iHRIS and Trainnet databases. Afya Jijini will also continue providing trainings for C/SCHMT Committees on governance, supervision, and leadership. This will also include providing Leadership Development Plus and Kenya Medical Training College management trainings to select facility-based HCWs holding management roles. Lastly, the project will support semi-annual HRH CMEs for SCHMTs and high-volume facilities.
Activity 3.2.2: Sub-county level HRH strengthening. Afya Jijini will implement several activities during Y2 designed to improve the overall HRH management at the sub-county level. First, the project will cascade the HRH Advisory committees to the sub-county level, helping each SCHMT establish these committees, understand their TOR and roles of members, recruit and orient members, and develop realistic annual objectives. In addition, through the Committees and other mechanisms, Afya Jijini will help the sub-counties each review and disseminate the HRH Strategic Plan to the sub-county level, ensuring their operations adhere or support the plan. Finally, similarly to Y1 at the county level, the project will help sub-counties develop a two-year capacity plan and provide leadership skills development in alignment with those plans during Y2.
Activity 3.2.3: Facility-level HRH strengthening. Afya Jijini will also continue working with health facilities to improve their HRH performance management systems by supporting four county referral facilities (Mama Lucy Kibaki Hospital, Mutuini Hospital, Mbagathi District Hospital, and Pumwani Maternity Hospital) to develop and utilize an action plan to improve staff performance. The project will convene meetings and provide technical support to improve performance management; supporting these four referral hospitals to complete semi-annual performance reviews; and help sites to develop a reward and recognition program for improved performance. In addition, we will more broadly help sites develop quarterly HRH monitoring processes, noting retention, turnover, and vacancy rates. Afya Jijini’s UHAI teams will continue supporting HR data population into iHRIS at all project facilities through working with HRH Capacity Bridge. The project will emphasize use of HR data for management and decision- making, providing technical and logistical support to the county to ensure that iHRIS is continuously updated. The project will also continue coaching sites on using iHRIS data for HR management and decision-making at high-volume health facilities.
OUTPUT 3.3: HEALTH PRODUCTS AND TECHNOLOGIES
Background and Rationale
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Afya Jijini’s baseline assessment illustrated the stark outcomes of HPT challenges within NCC. It found, for example, only 55-65% of facilities observed possessed four critical antibiotics for labor and delivery. Uterotonics and anti-convulsants were also in short supply. Medical supplies were also a challenge, with only 69% of sites possessing new syringes for injection and 65% had sterile gloves for patient care. Health facilities also frequently lacked adequate storage for medication (nearly 70%) and safety and security SOPs. During Y1, Afya Jijini used several strategies designed to improve commodity availability and reporting, including improving coordination and joint planning, leveraging multiple projects; implementing on-site sub-county and health facility mentoring; and establishing electronic reporting systems to better forecast and track commodities.
Activity 3.3.1: County and sub-county level HPT strengthening. Afya Jijini will work on operationalizing the county commodity security TWG in Y2, building it into a more robust entity that regularly meets and has clear TOR. It will also launch commodity security TWGs at the sub-county level, supporting the sub-county commodity management committees to meet on a quarterly basis and conduct supportive supervision to address commodity issues. Afya Jijini will then work with the TWG to improve the county’s commodity and supply chain management, with a focus on data reporting and commodity management systems. Afya Jjini will provide supportive supervision to the CHMT and with the SCHMTs to strengthen use of commodity data by defining roles and responsibilities, regular monitoring of commodity reporting rates, and building capacity to use national electronic platforms such as DHIS2 and KEMSA LMIS. In Y2, the project will support joint participation in quarterly national-level activities related to commodity security (such as national ART, FP, and laboratory commodity quantification). It will also provide TA and support quarterly commodity data reviews, including comparison of services utilized with commodity data (e.g., actual vaccine utilization, use of RTKs and Test and Treat targets), as well as redistribution of commodities based on this information.
Activity 3.3.2: Strengthen facility-level commodity management (inventory management and commodity security). Afya Jijini will work with supply chain pharmacists and laboratory officers to conduct site-based HPT assessments for all remaining high-volume health facilities that have not been assessed. The project’s Supply Chain Advisor and UHAI teams will continue building sites capacity to plan, forecast, and manage medicines and supplies through training and on-site mentoring to facility-level laboratories and pharmacies. This will include reviewing commodity management practices at target sites and coaching them to improve efficiency. The project will also continue training and mentoring select health commodity managers, including laboratory technologists, pharmacy managers, and other HCWs, on accurate forecasting and quantification, product selection and re-ordering, accurate forecasting and quantification, using an EMR, and developing buffer stocks. UHAI teams will mentor them at least monthly through site visits that examine inventory management, audit, storage, and distribution (including reporting on ARVs and opportunistic infection pharmaceuticals). Afya Jijini will also improve storage conditions at challenges sites by implementing the “5S” approach to improving the work environment, expediting disposal of expired commodities safely to free up space, and advocating for re- fitting of pharmacies and drug stores.
Activity 3.3.3: Strengthen facility-level commodity management (information systems). During Y2, the project will continue to review the existing commodity reporting systems at each site to ensure continuous commodity availability. Afya Jijini will work with high-volume sites via mentorship to improve inventory records management to enhance accountability, conducting spot checks and coaching. It will also support the county, sub-counties, and all target facilities to implement, strengthen, and scale-up an EMR (such as ADT) for accurate and timely commodity and essential medicine reporting. Each site will possess an electronic reporting system with the capacity to upload data to national commodity platforms, such as DHIS2 and KEMSA LMIS.
Activity 3.3.4: Strengthen facility-level commodity management (patient safety). Afya Jijini will continue prioritizing patient safety interventions during Y2, including setting up, scaling-up, and
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reinforcing pharmaco-vigilance systems (including protocols). The systems will monitor and track adverse drug reactions (ADRs), medication error reporting, and poor quality medicine reporting in all high- volume sites, in collaboration with the Pharmacy and Poisons Board. In Y2, Afya Jijini will continue reviewing existing Medical Therapeutic Committees at priority facilities (Mbagathi, Mama Lucy, Pumwani, and Mutuini) and patient safety safeguards that some facilities have formed in order for them to serve as a best practice for other sites. This includes capacity building of skills in product selection, formulary management, quantification, medication use evaluations and rational use of medicines. The Supply Chain Advisor and UHAI teams will continue to mentor health facility staff on patient safety, such as to complete ADR and poor medicine recording and reporting to ensure patient safety. It will also print and distribute IEC tools, job aids, and protocols on pharmaco-vigilance to reinforce best practices.
Activity 3.3.5: Strengthen facility-level commodity management (QA). In Y2, Afya Jijini will develop or refine the SOP manual for all key ART pharmaceutical management activities, including laboratory activities, in high-volume health facilities. At each health facility, the project will ensure that they possess key pharmacy reference materials, including the Kenya Essential Medicines List, formularies, clinical and treatment guidelines, and other reference texts. The project will identify Pharmacies of Excellence to begin supporting an exchange visit program for HCWs/pharmacists in nearby health facilities. The project will also integrate ART pharmacies into OPD pharmacies for sustainability, and will advocate with the county to recruit and engage medical laboratory staff to achieve optimal service ratios at laboratories.
Activity 3.3.6: Collaborate with related USAID and donor-supported HPT projects. Afya Jijini will continue working closely with USAID-funded and other donor HPT/supply chain projects. Afya Jijini will engage these projects through joint planning and collaboration meetings to develop a collaboration and sustainability plan for scaling their activities down to the sub-county and health facility level, meet with other partners working with HPT in Nairobi City County via national program-level TWGs, and organize regular meetings with KEMSA. During Y2, Afya Jijini will specifically meet and collaborate with: USAID’s global supply chain mechanism, the Procurement and Supply Management project JSI’s InSupply, to increase commodity data visualization and use at county and sub-county level KEMSA, to support pharmaceutical commodity management electronic systems that are in place Palladium, to implement of IQCare supply chain module CHAI, to scale-up and maintain web ADT Other partners working in HPT in Nairobi County e.g. University of Maryland, AMREF
Activity 3.3.7: Laboratory-strengthening activities. County-level lab strengthening: Afya Jijini will convene quarterly lab stakeholder forums where HCWs and managers can discuss and jointly plan lab strengthening interventions. The project will also ensure lab issues are covered within the county health commodity quarterly meetings. In addition, Afya Jijini will continue mentoring participants and supporting SMLT meetings at the county level to harmonize lab activities across sub-counties.
Sub-county level lab strengthening: As with the county, Afya Jijini will advocate for inclusion of lab issues within sub-county health commodity TWGs. In addition, the project will support county level laboratory in-charges meetings for best practice sharing and enhanced coordination of laboratory activities. During Y2, Afya Jijini will focus in particular on strengthening online commodity reporting through the HCMP platform and DHIS2 at the county level, encouraging data review and use for planning. The project will also conduct biosafety/biosecurity training targeting medical laboratory technologists to ensure adherence to biosafety standards, a challenge identified during Y1.
Facility-level lab strengthening: Afya Jijini will continue to strengthen the lab referral network for specimens by supporting daily sample networking for VL, CD4, and GeneXpert tests. This process has significantly improved sample flow, providing more timely results to clients and clinicians. The project will also ensure USAID/KENYA AFYA JIJINI YEAR 2 WORK PLAN 40
that all sites with labs possess and are oriented on the relevant lab guidelines, job aids and possess SOPs for the labs. Where needed, the project may procure buffer stock for sample management consumables to reduce stock issues.
Afya Jijini will improve lab quality assurance and operations through several strategies during Y2. The project’s UHAI teams and technical advisor will work with the county and sub-counties to conduct quarterly lab joint support supervision with the C/SMLTs. Supervision will focus on examining and improving commodity management and laboratory quality management systems. On-site mentorship will be provided to address the gaps identified during supervision. The project will offer OJTs and CMEs at the facility level (working with SMLTs) on identified commodity management issues, as well as biosafety/security. The project will continue to mentor staff on preventative maintenance for laboratory equipment, enroll high-volume facilities on External Quality Assessment (EQA), provide quarterly EQA corrective actions, and supporting a semi-annual EQA performance sharing forum, which will focus on TB and HIV.
In Y2, the project will mentor four laboratories on World Health Organization (WHO) Strengthening Laboratory Management Toward Accreditation (SLMTA) implementation, conduct quarterly quality audits to assess their facility-level implementation, and work with the Kenya Accreditation Services to conduct a mid-term assessment on these labs. The project will support the four laboratories toward achieving at least three stars on the WHO AFRO Stepwise Quality Improvement Assessment by providing the following trainings: 1) implementation of laboratory quality management systems training to laboratory managers, in-charges, and laboratory QA officers; 2) extending SLMTA training to laboratory technologists, and 3) providing SLMTA mentorship training to sub-county medical laboratory coordinators.
OUTPUT 3.4: STRATEGIC M&E SYSTEMS
Background and Rationale Afya Jijini strengthens data collection, analysis, and use as part of its mandate to foster strong, accountable health systems. The Y1 baseline assessment affirms the need for this work to continue. In that assessment, only 11% of high-volume health facilities reported complete and accurate program data (far short of the five-year target of 50%). Data use also needs attention, with less than half (46%) of surveyed health facilities reporting quarterly data review and use forums. During Y1, the project took stock of the current data systems and immediately began addressing the most critical needs: ensuring sites had the necessary forms, equipment and trained manpower to report across different indicators, while also beginning to strengthen data quality and review. An initial series of DQAs found a number of ghost and inactive HIV patients, for example, at target CCCs. The baseline assessment also found that basic positions, teams (e.g., quality or work improvement) and systems were in place, but without a “culture” of acquiring high (i.e., international) standards, accreditation, or even concepts of client satisfaction.
During Y2, the project will build on its initial efforts and also apply the results from its Y1 baseline assessment that found county-level capacity gaps in M&E for health. For example, Afya Jijini will work with sub-county and health facilities health records information officers (HRIOs) to not only build their capacity to capture, record and report accurately and timely, but to create forums for feedback and discussion of the importance of quality data management for informed decision making. Additionally, the project will train and encourage them to assume additional roles such as analyzing trends and differences, bringing them together with facility managers and in-charges to present evidence that can be used for improved policy making.
Activity 3.4.1: Build county capacity to monitor and evaluate priority health service delivery areas effectively. Afya Jijini will support the M&E TWG to meet on a quarterly basis and ensure county M&E
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leadership participate in national TWG activities. The M&E TWG will play a critical role – with Afya TA – in conducting semi-annual county workplan data review meetings and mainstreaming performance trackers in programming. It will facilitate collaboration across stakeholders, sharing information and reinforcing joint work between Afya Jijini and the USAID-funded PIMA/DQAs from Measure Evaluation project and provide support in documenting the utilization, gaps and current efforts in existing M&E tools. The project will further support the finalization of the county’s data collection and analysis plan, and help roll out important TA components (such as providing trainings and updates on DHIS2 indicators and advocating for the use of service agreements to maintain computers and IT infrastructure at facilities). At the sub-county level, Afya Jijini will help staff upload and review data to DHIS2, both for completeness and to guide supportive supervision and coaching.
Afya Jijini will also build county capacity in data quality, an area that requires extensive reinforcement. In Y2, the project will continue supporting monthly and quarterly data review meetings for the County, sub- counties, and facilities as a means of institutionalizing the DQA exercise at the facility and sub-county levels, as well as more extensive use of data for improved decision-making. The project will also support the county to review, update, and disseminate DQA SOPs.
Activity 3.4.2: Improve facility-level data collection and use. Collaborate with partners (Palladium Group) to scale-up IQCare system to incorporate all modules: The project will scale-up the EMR system in project-supported facilities by engaging short-term data clerks to support data reconstruction and migration to EMR in 10 identified scale-up sites, procuring and distributing ICT infrastructure for EMR deployment (including computers, LAN, and back-ups), and organizing quarterly CMEs to EMR-supported sites. These efforts will further ensure that the county has access to critical internet, computer, and equipment maintenance and services so that it can use the cloud-based health information systems.
Develop and implement a service performance dashboard to inform/facilitate decision-making: Afya Jijini will help sites develop a collection, flow chart, and data analysis plan and will support facilities to develop and implement service performance dashboards to inform and facilitate decision-making, including for maternity, MNCH, 90-90-90, and eMTCT cascades. HCW skills will be strengthened in M&E technical areas through trainings and CMEs on DDIU and other areas, DHIS2 entry, and improving data quality. Each health faclity will conduct regular feedback on HRIOs contributions to “big picture” service delivery status and changes, as well as monthly data reviews, and the project will provide mentorship on DHIS2 (with the sub-county M&E team).
Support quarterly sub-county DQA and RDQA at health facilities: The project will engage the UHAI and M&E teams to support high-volume facilities with organizing monthly RDQA and quarterly/semi-annual DQA, in collaboration with the county and sub-counties. TA will help ensure timely submission of data at the county level by training facility staff on how to access rights and use DHIS2; engage the UHAI teams to continue providing regular mentorship, CMEs, and OJT on using data tools, reporting, ensuring quality of data, and creating data use demand at the facility level; and engage IT personnel to support facilities with software and hardware needs.
Activity 3.4.3: Strengthen and integrate community health information systems (CBHIS). In Y2, Afya Jijini will continue training and mentoring facility CHVs, Mentor Mothers, and peer educators on CBHIS. The project will synchronize CBHIS reporting with affiliated catchment facilities to continue strengthening and integrating community health information systems with other key health service delivery data platforms (for HIV, FP, MNCH, TB, WASH, and nutrition) at the health facility level. Afya Jijini’s technical teams will also continue training and mentoring identified CHVs to effectively collect key health service delivery data (HIV, FP, MCH, TB, and nutrition), provide it on time to the health facility, and complete monthly data reviews that improve the regularity and completeness of data.
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OUTPUT 3.5: QI SYSTEMS
Background and Rationale According to the Afya Jijini baseline assessment, only about half of the 157 surveyed facilities reported having a formal quality committee that meets more than four times per year. However, fewer facilities can attest to stricter steps such as having a written plan reviewed and updated annually (38%), or having the quality goals selected and discussed among the staff (36%), and having periodic meetings to assess client satisfaction as a component of such quality improvement (36%). During Y1, the project expanded USAID-funded ASSIST project and KQMH process including establishment of facility-based work improvement teams. In Y2, progress against QI objectives will continue by helping sites develop robust QI goals and plans, particularly around respectful care and client satisfaction.
Activity 3.5.1: Strengthen county- level QI coordination and processes. County QA/QI coordination: In Y2, Afya Jijini will continue strengthening the County-level QI Units (which contain a cross-section of people, including CHMT representatives, community leaders, and CBOs) - developed through the USAID-funded ASSIST project - to share findings and best practices and conduct cross-County QI projects. The project will support monthly QI coordination meetings with sub-county QI focal people; quarterly QI TWG meetings; quarterly supportive supervision for WITs; and meetings to develop, validate, and disseminate a client feedback and response plan. The project will also help the county develop an award recognition system for QI achievement and establish other QI interventions that promote good customer care, such as SMS and social media platforms.
Link to additional QI projects: Afya Jijini will continue linking and meeting regularly with USAID and other donor-funded QI projects to jointly plan and leverage resources and ensure that the national QI mechanism county-level activities are integrated into the Afya Jijini QI plan. The project will also continue to support the QA/QI unit heads to attend scheduled national QA/QI TWG meetings.
County support to site-level QI processes: The project will continue working with the County technical teams to identify and train more coaches on QI principles, using the national syllabus, and will support County- level implementation of the KQMH, guided by the draft Kenya Health Improvement Policy. Specifically, the county and sub-county will conduct quarterly site supervision for WITs and ensure high volume facilities adopt service based QA/QI guidelines e.g. KHQIF. The project will also help the county conduct semi-annual QA reviews in 30 high-value sites and develop a WIT/QIT dashboard to monitor the functionality of QI infrastructures. The sub-counties will facilitate monthly complaint resolution review meetings and create awareness of the client feedback platforms by using facility-based venues, community PSSGs, WITs, and other community forums.
Promote leadership involvement in QA/QI activities. In Y2, the project will organize an annual QA/QI forum for high-level leadership (including the County executive, county top management, and heads of high- volume facilities) aimed at strengthening buy-in for sub-county and facility-level QI.
Activity 3.5.2: Strengthen facility-level QI processes and initiatives. Afya Jijini will continue supporting QI updates to already-trained HCWs in each WIT that was established in Y1 to help sites build HCW capacity in providing high-quality HIV, TB, MNCH, and FP services across units. It will also train 60 HCWs in MNCH and HIV quality improvement. Support will include: supporting coaching sessions for each WIT on at least a bi-weekly basis; conducting monthly meetings for coaches at the sub- county level to build their capacity, share experiences and develop action points; and supporting coaches to participate in the project’s leadership and governance program (as defined in Output 3.1) to enhance their leadership skills. The project will help sites develop QI SOPs to structure WIT meetings (and ensure equal gender balance and participation within the teams); develop a WIT and QIT functionality dashboard to monitor the functionality of QI structures; and support 30 facilities to carry out 5S and
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process mapping and to improve their client flows for HIV, MNCH, and OPD. The project will support semi-annual QI collaborative learning sessions designed to share best practices. The meetings will document change ideas and success stories to be shared on county media platforms, conferences, and journals.
Activity 3.5.3: Scale-up community level QA/QI. Afya Jijini will initiate QA/QI activities with the selected local sub-grantees supporting community services during Y2 in an effort to improve the quality of those services provided. Afya Jijini will also establish community WITS in hot spots for maternal and neonatal deaths. Afya Jijini will also establish 10 community WITs for MNCH and within community PSSGs for the HIV differentiated care model during Y2 and link them to health facility WITs. The project will also support peer learning among the community WITS, helping them exchange best practices and change ideas to improve service delivery uptake and adherence.
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ANNEXES AND ATTACHMENTS
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ATTACHMENT 1: GANTT CHARTS
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