USAID AFYA PWANI FY 2016 Q4 PROGRESS REPORT

14 June – 30 September 2016

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

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

Prepared by Pathfinder International-Kenya The Watermark Business Park, Karen, Fountain Court, 1st Floor Ndege Road, off Langata Road P. O. Box 1996 – 00502 Karen NAIROBI, KENYA Office: +254-20-3883142/3/4 Mobile: +254-733-618359/+254-722-516275 Fax: [+254 20] 2214890 www.pathfinder.org

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

USAID AFYA PWANI PROGRESS REPORT FOR Q4 FY 2016 i

I. AFYA PWANI EXECUTIVE SUMMARY ...... VII

II. KEY ACHIEVEMENTS (QUALITATIVE IMPACT) ...... 1

SUB-PURPOSE 1: INCREASED ACCESS AND UTILIZATION OF QUALITY HIV SERVICES ...... 1 1.1: Elimination of Mother-to-Child Transmission (eMTCT): ...... 1 1.2: HIV Prevention and HIV Testing and Counselling ...... 6 1.3: HIV Care and Support Services ...... 8 1.4: HIV Treatment Services ...... 10 1.5: TB/HIV Co-infection Services ...... 12

SUB-PURPOSE 2: INCREASED ACCESS AND UTILIZATION OF FOCUSED MNCH AND FP, WASH AND NUTRITION ... 14 2.1: Maternal, Newborn and Child Health services ...... 14 2.2: Child Health Services ...... 16 2.3 Family Planning Services and Reproductive Health (FP and RH) ...... 17 Water, Sanitation and Hygiene (WASH) ...... 20

SUB-PURPOSE 3: STRENGTHENED AND FUNCTIONAL COUNTY HEALTH SYSTEMS ...... 21 3.1 Partnerships for Governance and Strategic Planning...... 21 3.2 Human Resources for Health (HRH) ...... 21 3.3 Health Products and Technologies (HPT) ...... 21

Lessons Learned ...... 23

III. ACTIVITY PROGRESS (QUANTITATIVE IMPACT ...... 25

IV. CONSTRAINTS AND OPPORTUNITIES ...... 26

V. PERFORMANCE MONITORING ...... 27

VI. PROGRESS ON GENDER STRATEGY ...... 30

VII. PROGRESS ON ENVIRONMENTAL MITIGATION AND MONITORING ...... 30

VIII. PROGRESS ON LINKS TO OTHER USAID PROGRAMS ...... 31

IX. PROGRESS ON LINKS WITH GOK AGENCIES ...... 31

X. PROGRESS ON USAID FORWARD ...... 32

XI. SUSTAINABILITY AND EXIT STRATEGY ...... 33

XII. SUBSEQUENT QUARTER’S WORK PLAN ...... 33

XIII. ACTIVITY ADMINISTRATION ...... 33

USAID AFYA PWANI PROGRESS REPORT FOR Q4 FY 2016 ii

XIV. SUCCESS STORY ...... 34

ANNEXES & ATTACHMENTS ...... 35

Annex I: Schedule of Future Events ...... 35

Annex II List of Tracer Commodities...... 35

Annex III – List of High Volume Facilities for Commodity Management Indicators Reporting ...... 36

Table 1 Summary of Contract Deliverables and Status To-Date ...... vii Table 2 Afya Pwani EID Samples for July-September 2016 ...... 4 Table 3 Number of Clients Tested and Linked to Care July-September 2016 ...... 7 Table 4 Afya Pwani Rapid Test Kit Reporting Rates for July-September 2016...... 8 Table 5 Afya Pwani Defaulter Tracing Rate for July-September 2016 ...... 9 Table 6 Afya Pwani Viral Load Testing for July-September 2016 ...... 11 Table 7 Afya Pwani CD4 Tests for July-September 2016 ...... 11 Table 8 Patients on treatment for MDR TB ...... 13 Table 9 Patients on Isoniazid Prophylactic Treatment (IPT) ...... 13 Table 10 GeneXpert Testing for July-September 2016 ...... 14 Table 11 Kinondo Kwetu Clinic Supply Chain Management Analysis ...... 22 Table 12 Quarterly and Cumulative achievements for DDIU, DHIS2 & DQI ...... 29

Figure 1 Afya Pwani PMTCT Cascade July-September 2016...... 5 Figure 2 Afya Pwani EID Yield Jul-Sep 2016 ...... 6 Figure 3 APHIAplus Nairobi-Coast Transition to Afya Pwani: Care and Treatment ...... 12 Figure 4 Afya Pwani Care and Treatment by County 2016 ...... 12 Figure 5 1st and 4th ANC visits trends in April-June and July-September ...... 15 Figure 6 Trends in maternal and neonatal Indicators April-June and July-September 2016 15 Figure 7 Trends in Child Health Indicators: April-June and July-September 2016...... 17 Figure 8 Perf. Analysis-Uptake of FP Services, New clients (July 2015-September 2016) 18 Figure 9 Perf. Analysis- Total CYP Distributed July-June, 2016 compared to April- June, 2016 18 Figure 10 Perf. Analysis- CYP Contribution by Method, July-September, 2016 ...... 19 Figure 11: CYP Comparison of CYP for individual methods in April-June and July- September 19 Figure 12: Contraception commodity reporting for July – September 2016 ...... 20

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ACRONYMS AND ABBREVIATIONS

AIDS Acquired Immune Deficiency Syndrome AMSTL Active Management of the Third Stage of Labor ANC Antenatal Care APH Antepartum Hemorrhage APHIA AIDS, Population and Health Integrated Assistance APHIAplus AIDS, Population and Health Integrated Assistance-People-centered, local universal access and sustainability ARI Acute Respiratory Infection ART Antiretroviral Therapy ARV Antiretroviral ASRH Adolescent Sexual Reproductive Health AYSRH Adolescent and Youth Sexual Reproductive Health BEmONC Basic Emergency Obstetric and Newborn Care BTL Bi-Tubal Ligation CACC Constituency AIDS Control Council CBO Community Based Organization CCC Comprehensive Care Center CD4 Cluster of Differentiation 4 CDC Center for Disease Control and Prevention CDCS Country Development Cooperation Strategy CEmONC Comprehensive Emergency Obstetric and Newborn Care CHAI Clinton Health Access Initiative CHMT County Health Management Team CHS Community Health Strategy CHV Community Health Volunteer CITC Community Initiated Testing and Counselling CME Continuing Medical Education COP Chief of Party COR Contracting Officer Representative CPGH Coast Provincial General Hospital CPR Contraceptive Prevalence Rate CQI Continuous Quality Improvement DCOP Deputy Chief of Party DDIU Data Demand and Information Use DFH Division of Family Health DHS Demographic Health Survey DISC Drop in Support Centre DOT Directly Observed Therapy DQA Data Quality Assessment EBF Exclusive Breastfeeding EBI Evidence Based Interventions EID Early infant diagnosis EMTCT Elimination of Mother to Child Transmission EmONC Emergency Obstetric and Newborn Care EMR Electronic Medical Records FBO Faith Based Organization FCDRR Facility Consumption Data Report and Request Form FDG Focus Group Discussion FIC Full Immunization Coverage USAID AFYA PWANI PROGRESS REPORT FOR Q4 FY 2016 iv

FMAPS Facility Monthly ARV Patient Summary FP Family Planning FSW Female Sex Worker GBV Gender-Based Violence GOK Government of Kenya GREAT Gender Roles Equality and Transformation GUC Grants under Contracts HAART Highly Active Antiretroviral Therapy HCSM Health Commodities and Services Management HCW Health Care Worker HEI HIV Exposed Infant HFMC Health Facility Management Committee HINI High Impact Nutrition Interventions HITS HIV-Infected Infant Tracking System HIV Human Immunodeficiency Virus HMT Health Management Team HPT Health Products and Technology HRH Human Resources for Health HTC HIV Testing and Counseling HTS HIV Testing Services HVF High Volume Facility IDU Injection Drug User IEE Initial Environmental Examination IMCI Integrated Management of Childhood Illness IPT Isoniazid Preventive Therapy ITN Insecticide Treated Net KAIS Kenya AIDS Indicator Survey KEMSA Kenya Medical Supplies Agency KHSSSP Kenya Health Sector Strategic and Investment Plan KHQIF Kenya HIV Quality Improvement Framework KP Key Populations LTFU Lost to Follow Up MCH Maternal and Child Health M&E Monitoring & Evaluation MNCH Maternal, Newborn and Child Health MNH Maternal and Newborn Health MOH Ministry of Health MSM Men Who Have Sex with Men NASCOP National AIDS and STI Control Program NGO Non-governmental Organization OI Opportunistic Infection OJT On Job Training ORS Oral Rehydration Salts ORT Oral Rehydration Therapy OVC Orphans and Vulnerable Children PEP Post Exposure Prophylaxis PEPFAR President’s Emergency Plan for AIDS Relief PF Partnership Framework PHPD Positive Health Dignity and Prevention PITC Provider Initiated Testing and Counseling PLHIV People Living with HIV PMP Performance Monitoring Plan PMTCT Prevention of Mother to Child Transmission USAID AFYA PWANI PROGRESS REPORT FOR Q4 FY 2016 v

PPH Postpartum Hemorrhage PSS Psychosocial Support Services PrEP Pre-exposure Prophylaxis QA Quality Assurance QI Quality Improvement RH Reproductive Health RHIS Routine Health Information System RTK Rapid Test Kits SDGs Sustainable Development Goals SI Strategic Information SMS Short Message Service SOP Standard Operating Procedure SRH Sexual and Reproductive Health SW Sex Workers STI Sexually-transmitted Infection TA Technical Assistance TB Tuberculosis TFR Total Fertility Rate TOT Trainer of Trainers TWG Technical Working Group UNAIDS Joint United Nations Program on HIV/AIDS UNFPA United Nations Population Fund USAID United States Agency for International Development USG United States Government VCT Voluntary Counseling and Testing VMMC Voluntary Medical Male Circumcision VL Viral Load WASH Water, Sanitation and Hygiene WHO World Health Organization YFS Youth Friendly Services YLHIV Youth Living with HIV 3Ps Pathfinder International, Plan International and Palladium Group

USAID AFYA PWANI PROGRESS REPORT FOR Q4 FY 2016 vi

services and laboratory networks were also supported by Afya Pwani across the 317 facilities in the coast.

In Kilifi County, the Project focused on addressing the common causes of maternal and neonatal and morbidity and mortality. More specifically, Afya Pwani focused on capacity building in the areas of Basic Emergency Obstetric and Newborn Care (BEmONC), increased utilization of focused antenatal care (ANC) services (completion of 4 Focused Antenatal Care (FANC) visits), and increased skilled delivery attendance and post-natal care (PNC) services and immunization services. Consequently, 8,570 women attended their first ANC and 4,713 women completed their 4th ANC visit. Nutritional assessment counselling and support (NACS) for pregnant women, and immunization for children under five years was also provided; 7,275 children were fully immunized during the quarter and linkages for Food by Prescription (FBP) through Nutritional HIV Program (NHP) plus was also facilitated. In respect to Reproductive Health (RH)/Family Planning (FP) the Project and conducted RH/FP mentorship, on job training (OJT), and program support supervision focused on long acting reversible and permanent contraception (LARC and LAPM) integration with HIV services, scaling up activities across the seven sub-counties in Kilifi County (i.e. Kilifi North, Kilifi South, Ganze, Kaloleni, Rabai, Malindi and Magarini) while focusing on priority interventions as defined in the work plan. During the quarter the following numbers of clients accessed RH/FP services: 11,331 new FP clients; 23,715 revisit clients and 35,046 women accessed Couple Years of Protection (CYP) courtesy of Afya Pwani. The Project focused on interventions at both the facility and community levels to improve community’s access and utilization of quality integrated services.

Quantitative Impact Despite the fact that the Project’s year one work plan was approved towards the end of the quarter, Project staff were still able to operate on minimal activities to achieve this quarter’s targets across all indicators except for the number of HIV positive pregnant women who were initiated onto Antiretroviral Therapy (ART) and the number of children who needed to be dewormed (see Section III). For all the other indicators the Project has surpassed its targets as set by USAID, a positive indication of the efficacy of Afya Pwani’s interventions to increase the availability and utilization of health services across the five counties. Constraints and Opportunities The first quarter of the project has not uncovered any significant management or operational changes. Multiple programmatic challenges have been documented within this report, as well as the lessons learnt and subsequent recommendations made to address these challenges in the next quarter (see Section IV). Subsequent Quarter’s Work Plan During the Oct-December quarter, the Project Launch will take place in ; appropriate USAID approvals for all IECs and external communications will be sought in accordance with the time frame set in the Branding Implementation and Marking Plan for the same. In the next quarter, Project staff anticipates that the procurement of project vehicles and motor boat will have been completed. Project staff have already requested for expression of interests from grantees; USAID approvals will be sought for the selected grantees. Additionally, the Project will also begin baseline data collection and all partners’ activities will commence in the areas of WASH, Nutrition and HSS. Afya Pwani will also begin to implement its communication plan with preparation of a quarterly e-newsletter and some project briefs for further dissemination as well as organize orientations for all staff (including partner staff) on Afya Pwani’s Branding and Marking requirements.

USAID AFYA PWANI PROGRESS REPORT FOR Q4 FY 2016 viii

II. KEY ACHIEVEMENTS (QUALITATIVE IMPACT)

SUB-PURPOSE 1: INCREASED ACCESS AND UTILIZATION OF QUALITY HIV SERVICES

1.1: Elimination of Mother-to-Child Transmission (eMTCT): Sub-purpose 1: Increased Access and Utilization of Quality HIV Services Output 1.1: Elimination of Mother-to-Child Transmission (eMTCT) Between July and September Afya Pwani project data has shown that less than 5% of the infants tested at Project supported sites were HIV positive, a positive indication that the Project’s eMTCT interventions are proving effective. The sections below provide more information on the key eMTCT activities that were implemented during the quarter under review and the key achievements that have resulted from the same. a. Early identification of HIV-positive pregnant women and increase for demand services To reduce eMTCT of HIV, the Project supported capacity building activities to reach more women in the early stages of pregnancy and to reduce the number of missed opportunities for HIV Testing Services (HTS). More specifically, the Project supported and facilitated mentorship of Health Care Workers (HCWs) in facilities across all of the five Afya Pwani counties. During these mentorship sessions, HCWs were able to discuss the importance of Postnatal testing for women who had missed their HIV test during pregnancy, how to reach women who had and others who tested negative during the first Antenatal Care (ANC) visit and how to ensure that all pregnant women who tested positive HIV were enrolled into care and initiated on to HAART and infants initiated onto prophylaxis. In , for example, the Afya Pwani Project supported the provision of mentorship of five HCWs from three facilities1 on the provision of HTS to pregnant mothers attending ANC. Additionally, seven HCWs from seven facilities2 also received mentorship on HIV integration in Maternal and Child Health (MCH) services, as part of the efforts to support early identification of HIV-positive pregnant women and increase for demand services. The Project also supported mentor mothers in Mombasa County as they continued to support pregnant women living with HIV and mothers across ten facilities3. By supporting these mentor mothers, the Project ensured that HIV positive pregnant women and mothers linked to these facilities received psychosocial support services (PSS) and counselling during group therapy meetings that were focused on preventing HIV MTCT, infection and re-infection by their spouses and/or of their children, as well as the importance of good nutritional habits and WASH. In the next quarter, the Project will also support HIV Exposed Infant (HEI) graduations to celebrate mothers who have successfully made it through the eMTCT process and to motivate the newly enrolled mothers. Afya Pwani staff were also able to support and conduct health talks by Community Health Volunteers (CHVs) at Project supported facilities in Kwale County on the importance of couple counselling and testing to promote early identification of HIV positive mothers. Consequently, the Project has seen an increased uptake of couples testing during ANC in four facilities4 in the county, which is a positive indication that the Project has been able to improve the early identification of HIV pregnant women and demand for quality HIV health services in the County. During the same period, the Afya Pwani project also supported and facilitated mentorship of six health workers on how to integrate HTS into PNC in maternity wards in Kinango Hospital, Msambweni Hospital and Kwale Hospital. These activities were supplemented by the provision of mentorship and On-Job-Training (OJT) to twenty nine HCW from eighteen facilities5 which focused on early linkage to care for those who tested HIV positive and HAART integration into MCH. By doing so, the Project has been able to

1 Coast Provincial General Hospital (CPGH), District Hospital and Dispensary. 2 Mvita Health Centre (HC), Kisauni Dispensary, HC, Chaani HC, Shika Adabu HC, Dispensary. 3 CPGH, Kongowea, Bamburi, Magongo, Tudor, Shika-Adabu, Kisauni, Portreitz and Magongo. 4 Kinango Hospital, Ndavaya Dispensary, Vigurungani Dispensary and Samburu HC. 5 Eshu Dispensary, Ukunda Catholic Dispensary, Mwaluphamba Dispensary, Kizibe Dispensary, Vanga HC, McKinon Road Dispensary, Ng’ombeni Dispensary, Waa Dispensary, Lutsangani Dispensary, Mnyenzeni Dispensary, Magodzoni Dispensary, Mwanda Dispensary, Matuga Dispensary, Mbuguni Dispensary, Ndavaya Dispensary, Taru Dispensary & Vigurungani Dispensary. USAID AFYA PWANI PROGRESS REPORT FOR Q4 FY 2016 1

build the capacity of the health workers in Kwale County to be able to identify HIV positive pregnant women earlier as part of the Project’s broader goals to eMTCT of HIV in the coastal region. In Taita- Taveta County the Project was able to facilitate OJT, mentorship and support supervision for one hundred and one health workers from twenty one health facilities6 on the importance of the mother- baby dyad receiving integrated services to increase early detection of HIV as well as to increase demand for the same. Lastly, Afya Pwani also facilitated a meeting with Lamu’s County Health Management Team (CHMT) on the eMTCT and how to get to zero new infections. Key topics that were addressed during the meeting included HTS for all pregnant women, enrollment and initiation onto HAART for all HIV positive pregnant women as well as the administration of infant prophylaxis for HEI. During the meeting, Lamu’s County AIDS and STI Control Office (CASCO) promised to ensure that all facilities would have enough tests kits, that new ANC clients would be tested for HIV and the HIV positive clients should be started on Option B+; a total of six CHMT members attended the meeting. b. Addressing the supply and availability of services To address the challenges affecting the supply and availability of eMTCT services in Mombasa County, Afya Pwani facilitated the provision of transport and support supervision for four sub-county laboratory coordinators from Kisauni, , Mvita and Likoni areas in a bid to improve and support the stable provision of Rapid Test Kits (RTKs), Dry Blood Samples (DBS) and Vacutainers across all of these facilities. In Kilifi County, the Project supported and conducted mentorship sessions and OJT for sixteen HCWs from eight7 HVFs on strategies for improving the integration of HIV services into MCH and at Comprehensive Care Centers (CCC) to increase the availability of quality eMTCT services for pregnant women and other vulnerable clients from communities in Kilifi County. During the same period under review, the Project also supported capacity building sessions on commodity quantification and reporting, and OJT on commodity Facility Consumption Data Report and Request (FCDRR) to improve the supply of vital commodities in the County, and to ensure that there were adequate supplies and availability of eMTCT services in the County. It should also be noted that between July and September, 2016 there were no stock outs of RTKs, Antiretrovirals (ARVs), DBS and vacutainers in all project supported facilities in Kilifi. As a result of Afya Pwani project interventions, six facilities have been able to successfully integrate CCC health services into MCH services; namely Kilifi, Malindi and Mariakani Hospitals as well as , Vipingo and Muyeye HCs. Afya Pwani also supported and facilitated the implementation of activities aimed at increasing the availability of eMTCT services and stable commodity supplies in Kwale County. The Project supported the redistribution of RTKs across sixty nine supported sites to ensure that they continued to support early identification of HIV infected pregnant women and to increase the availability of much needed eMTCT services for vulnerable and marginalized communities in Kwale. Lastly, the Project also supported and conducted mentorship sessions for CHMT members and OJT for ten HCWs on commodity management and reporting through remote planning across three HVFs8 in Lamu County between July and September 2016. Other key areas that were addressed include: commodity reporting tools (including FCDRR), as well as commodity quantification and reporting to ensure availability of RTKs, ARVs, DBS and vacutainers in the facilities. It should be noted that the County did experience stock outs of RTKs at Lamu CH and Mpeketoni SCH in August due to delays, but the County managed to coordinate with the Kenya Medical Supplies Authority (KEMSA) to re-stock RTKs in these facilities in late September. The Project also built the capacity of HCWs to integrate CCC into MCH as was done in previously in Kilifi County; as a result of these interventions Lamu CH and Mpeketoni SCH facilities have been able to successfully integrated HIV services in MCH thus reducing missed opportunities and increasing the overall availability of services. The Afya Pwani project also supported and facilitated the provision of airtime for Sub-County Medical Laboratory Technologists (SCMLTs) to improved and ensure that there was timely and accurate reporting of commodities into the Health

6 Sagalla HC, Ndome Dispensary, Manyani Dispensary, Ghazi Dispensary, Bura HC, Mwatate Sub-County Hospital (SCH), Moi CRH, Kasighau HC, Marungu HC, Mata Dispensary, Rekeke HC, Kimorigo Dispensary, Njukini HC, Eldoro Dispensary, Kiwalwa Dispensary, Kitobo Dispensary, Mgange Nyika HC, Mbale HC, Wundanyi SCH, Wesu SCH and Ndovu HC. 7 Malindi SCH, Kilifi County Hospital, Mariakani SCH, Oasis, Mtwapa HC, Gongoni, Marafa, Vipingo, Bamba, Gede, Rabai, Ganze, Muyeye, Chasimba, Matsangoni, Mambrui, Marereni. 8 Lamu County Hospital, Mpeketoni SCH and Witu HC. USAID AFYA PWANI PROGRESS REPORT FOR Q4 FY 2016 2

Commodities Management Platform (HCMP) database for RTKs to avoid stock outs during the quarter to ensure consistent availability of eMTCT service. c. Enrollment and retention of HIV-positive pregnant women and HIV-exposed infants (HEI): To increase the enrollment and retention of HIV positive pregnant women and HEI infants into care, Afya Pwani also supported the mentoring of 17 mentor mothers and MCH nurses on the importance of mother-baby pair follow up for the first 24 months of life, initiation onto infant prophylaxis as well as the feeding options for infants at the CPGH, Portreitz District Hospital and Shika Adabu, Utange and Kisauni Dispensaries. In Kilifi, the Project also conducted OJT and mentorship for thirty five HCWs across twenty four health facilities, thereby building the capacity of these service providers on the following eMTCT related issues: enrollment into care and retention of all HIV positive pregnant women, strengthening defaulter tracing mechanisms as well as HEI registers and cards. To celebrate the number of new infant infections averted, the Project will also facilitate a HEI graduation in the coming quarter. In Kwale County, Afya Pwani supported eleven mentor mothers and CHVs from eight facilities9 with TA to build their capacity to support the two hundred and one women living with HIV linked to them and their facilities. It should be noted that Afya Pwani supported mentor mothers to provide peer support for women with infants, ensuring that mother-baby pairs are retained on care and adhere to treatment and are able to access services when needed. Mentor mothers work closely with HTS providers at the facilities by ensuring that all pregnant and breastfeeding women who turn out to be HIV reactive are linked to treatment and other support services; they also conduct PHDP sessions, utilizing monthly PMTCT support group meetings to reach these vulnerable and marginalized clients. The Project was able to facilitate a total of thirty PHDP Sessions for HIV positive pregnant women and mothers this quarter. Afya Pwani also worked with facility staff from Mwatate SCH, Mpizinyi HC, Njukini HC, Ndovu HC and Moi CRH to strengthen their capacity to report and upload data on HEI into the National AIDS and STI Control Program (NASCOP) EID website in Taita-Taveta County. Lastly, Afya Pwani also collaborated closely with CHMTs in Lamu County to support the provision of OJT and mentorship on eMTCT in the three HVFs10 in the County to increase the enrollment and retention of HIV positive pregnant women and HEIs. These OJT and mentorship sessions focused on enrollment of clients (adults and pediatric) into care and retention of HIV positive pregnant women. Moreover, ten HCWs also received mentorship on HEI registers and HEI cards as well as ways of strengthening defaulter tracing mechanism to ensure all mother and infants who have defaulted are reintegrated into treatment and care services. d. Increasing PMTCT service quality The Afya Pwani project has placed significant focus on increasing the quality of PMTCT health services since the Project was first implemented in July. As such the Project has supported mentorship sessions on continuous quality improvement (CQI) to increase the availability of and access to high quality PMTCT health services for HIV infected women and their infants in four out of the five counties supported by the Project. In Mombasa County for example fifteen HCWs from twelve facilities11 were provided with technical updates on HAART integration in MCH and viral load monitoring for all HIV positive pregnant women; whilst the Project produced and distributed an assortment of PMTCT focused job aids to eleven of these facilities. The Project also supported and facilitated the strengthening of laboratory networks for EID samples to be tested from seventy five PMTCT sites in Kilifi County. The Project reimbursed the transport costs incurred by the peripheral facilities to transport EID samples to the testing labs to encourage timely and effective transport of specimens so clients could get their results back in a shorter time. By supporting these interventions, the Afya Pwani project has ensured that HCWs are now able to do EID for all HEI and as a result of these activities, two hundred and eighty eight samples were transported during the July-September, 2016 quarter. By strengthening the quality of laboratory networks in Afya Pwani supported sites through the activities

9 . Mkongani HC, Kwale Hospital, Samburu HC, Kinango Hospital, Diani HC, Msambweni Hospital, Vanga HC and LungaLunga HC. 10 Lamu County Hospital, Mpeketoni SCH and Witu HC. 11 CPGH, Mvita, Railways, Kongowea, Kisauni, Utange, Shika Adabu, Jomvu, Chaani, Miritini MCM, Ganjoni and Mbuta Dispensaries respectively. USAID AFYA PWANI PROGRESS REPORT FOR Q4 FY 2016 3

mHealth platforms and support of health workers and CHVs to be able to trace back defaulters more efficiently and in a more timely manner. Efforts continue in Kilifi County where more resource input in terms of transport and airtime will be required to improve defaulter tracing rates due to the vast terrain.

1.4: HIV Treatment Services Afya Pwani has also prioritized efforts on early initiation of ART to achieve the 3rd 90- achieve viral suppression (90% of all people receiving ARVs are virally suppressed) and delay primary clinical events (AIDS and non-AIDS defining) and TB. The Project has worked towards ensuring that intense support is given to HVFs and to ensure that quality services reach most of the patients in need across the five coastal counties being supported by the Project. a) Quality improvement for adult treatment In Kwale County, fourteen HCWs from ten health facilities29 received onsite mentorship and orientations on the new ART guidelines, whilst another nine HCWs were mentored on HTS and ART integration to scale up access to treatment for clients in the County. In Mombasa County, seven HCWs from six facilities30 were mentored on HTS and ART integration in other departments including TB and MNCH Clinics to increase access to treatment. These activities were further supplemented by supporting the provision of mentorship of another ten HCWs on ART guidelines and protocols. In Taita- Taveta County the Project also supported mentorship of health workers on ART guidelines at the twenty one CCCs31 where Project staff placed significant emphasis on the need to line list patients on care, so that they can be contacted for initiation into treatment. Afya Pwani also supported a pharmacist from Voi sub-county with transport to enable him to visit ten health facilities32 to redistribute much needed HIV/TB commodities and copies of DAR for OI drugs and ARVs. Project staff also supported the distribution of copies of the Facility Monthly ARV Patient Summary (F-MAPS) and FCDRR forms to facilities in the counties. Lastly, the Project also supported with photocopying and binding for distribution to other sub-counties to improve commodity reporting for ARVs. The Project also supported and facilitated the provision of mentorship on how to improve the summarizing of monthly results in the MOH 711 register for thirty five HCWs from twenty four facilities in Kilifi County. b) Treatment for children and KPs The Project also built the capacity of ten HCWs from CPGH, Tudor, Ganjoni, Utange, Mbuta, Shika Adabu, Mikindani MCM, Bokole, Bamburi, Kisauni, Mvita and Railways facilities in Mombasa County. These health workers were mentored on the pediatric ART guidelines and protocols using the new guidelines that have been endorsed by the MOH. Similar activities were also held in Taita Taveta where the Project conducted and facilitated mentorship for thirty health workers from five facilities33 on the same topic. To increase access to and utilization of quality HIV services, Afya Pwani also supported orientations for six HCWs working at Mvita Drop In-Center in Mombasa on the new ART treatment and protocols to reach KPs by the CASCO and Afya Pwani staff. c) Strengthened laboratory services Afya Pwani also ensured that high quality viral load testing services were offered to patients on treatment as per national guidelines and protocols. More specifically the Project supported the transportation of specimen from facilities to testing labs for CD4 and GeneXpert and from the sub- county level laboratories to CPGH laboratory for viral load testing and EID to increase access and utilization of HIV treatment services. In Mombasa County a motorbike rider was hired to ferry viral load specimen from facilities to CPGH to improve and strengthen the laboratory network for CD4 and EID. Overall, the CPGH laboratory maintained a turnaround time of ten days on EID and twenty five

29 Msambweni Hosp, Kinango Hosp, Kwale Hosp, LungaLunga HC , Vitsangalaweni Disp, Samburu HC , Kikoneni HC, Mazeras Disp, Diani HC & Tiwi HC 30 Mvita, Shika Adabu, Utange, Mikindani, Ganjoni, Kisauni Disp 31 Sagalla HC, Ndome Disp, Manyani Disp, Ghazi Disp, Bura HC, Mwatate SCH, Moi CRH, Kasighau HC, Marungu HC, Mata Disp, Rekeke HC, Kimorigo Disp, Njukini HC, Eldoro Disp, Kiwalwa Dis, Kitobo Disp, Mgange Nyika HC, Mbale HC, Wundanyi SCH, Wesu SCH and Ndovu HC 32 Kasighau HC, Bughuta HC, Marungu HC, Sagalla HC, Miasenyi Disp, Tausa HC, Ndovu HC, Ndome Disp, Ghazi Disp and Manyani Disp 33 Moi CRH, Mwatate SCH, Wesu SCH, Taveta SCH, Wundanyi SCH and Ndovu HC USAID AFYA PWANI PROGRESS REPORT FOR Q4 FY 2016 10

Figure 5 1st and 4th ANC visits trends in April-June and July-September

Increasing the number of women giving birth at the facility in the presence of a skilled birth attendant (SBA) is one of the main focuses of the Afya Pwani’s MNH health interventions. The Project supported and facilitated program visits and review meetings for facility staff and S/CHMTS, all of whom have played a significant role in encouraging and advocating the importance of safe deliveries by skilled attendants at the facility. Afya Pwani also supported OJT and mentorship as part of capacity building efforts focused on safe motherhood both at the facility and community levels respectfully. A total of 6,748 deliveries under skilled attendance were reported across Project supported facilities in the seven Kilifi Sub-Counties during the quarter. This figure was a reduction to the previous figures 8,386 deliveries; reasons which can be attributed to the transitioning between projects and the fact that the Project was only implementing minimal activities as the work plan was being approved. To increase the number of women delivering at the facility, the Project will need to focus on scaling up community mobilization and awareness and strengthen facility and community linkages to improve the uptake of services; all of which will be supported and implemented by Afya Pwani in the next quarter once all project activities are underway.

Figure 6 Trends in maternal and neonatal Indicators April-June and July-September 2016

Between July and September 2016, 6,600 live births were recorded in Kilifi, despite these successes, six maternal deaths and forty neonatal deaths were also reported across the same sites. It should be noted that these figures have improved from the last quarter where forty nine neonatal deaths were reported. Cognizant that more needs to be done to reduce the number of maternal and neonatal deaths, the Project supported Maternal and Perinatal Death Surveillance and Reviews (MPDSR), where Eclampsia, Post-Partum Hemorrhage (PPH), Ante-Partum Hemorrhage (APH) were found to be the

USAID AFYA PWANI PROGRESS REPORT FOR Q4 FY 2016 15

most common causes of maternal deaths. In the case of neonatal mortality, prematurity, respiratory distress and sepsis were found to be the most common causes of neonatal deaths. Moreover, it was also noted that delayed referrals from rural communities to facilities and from Tier 2 to Tier 3 for emergency care were also contributors to maternal and neonatal mortality across in the county. In the next quarter, the Project will focus on supporting the implementation of high impact maternal and newborn care interventions as per the work plan to reduce the incidences of maternal and neonatal mortality as well as continue working with the community structures to strengthen and increase timely referrals for expectant mothers. Highlights of key activities for the quarter were as follows: a) Capacity Building The Project continued to work with the CHMT and SCHMTs to provide targeted TA and need-based capacity building OJT and mentorship on various MNH service areas including TB screening in the ANC clinics, Intermittent Prevention treatment (IPT) of Malaria and the provision of ARVS to HIV positive pregnant women as well as support supervision for HCWs. More specifically, the support supervision supported by the Project during the period under review focused on improving the quality of services provided at Maternity, MNCH and post-Natal care (PNC) clinics. A total of twenty four health facilities were visited and supervised during this quarter, including: Kilifi County Hospital, Malindi and Mariakani Sub-County Hospital, Oasis, Mtwapa, Gongoni, Marafa, Vipingo, Bamba, Gede, Rabai, Ganze, Muyeye, Chasimba, Matsangoni, Mambrui, Marereni, Bwagamoyo, Mwangatini, Baricho, Bomani, Tsangatsini, Sosoni and Takaungu HCs respectively. b) Emergency Obstetric and Newborn Care (EmONC) Afya Pwani also provided TA and mentorship on the common causes of maternal deaths such as Post- Partum Hemorrhage (PPH), Ante-Partum Hemorrhage (APH) and Pre-Eclamptic Toxemia (PET) among others to health workers in the priority fifteen EmONC sites in Kilifi County: Kilifi County Hospital, Malindi and Mariakani Sub-County Hospital, Mtwapa, Gongoni, Marafa, Vipingo, Bamba, Gede, Rabai, Ganze, Muyeye, Chasimba and Bwagamoyo HCs. To strengthen MPDSR, the Project also supported and facilitated a meeting hosted by the CHMT and other key stakeholder from the County to orient them on the updated MPDSR guidelines and MPDSR tools. Meetings to restructure the MPDSR teams and how to strengthen the MPDSR reviews will also be supported by the Project in the next quarter. During these meetings there was a general consensus that the maternal and perinatal reviews need to be done at both the facility and community level with support of the SCHMTs and CHMT, and that these teams will play a pivotal role in following up the recommendations made during the reviews, and that Afya Pwani staff will also provide technical support on the same.

2.2: Child Health Services The Project also provided TA and support for health workers to ensure that facilities supported by the Project were able to provide high-impact, high quality child health interventions that were aimed at improving child survival and development in the supported sites. Afya Pwani also supported technical visits which were aimed at making sure that providers are able to treat children using the Integrated Management of Childhood Illnesses (IMCI) guidelines. The Project will provide more support to CHWs in the next quarter to improve mobilization of mothers to take children to health facilities for growth monitoring and immunization services, as well as trace and refer immunization defaulters back to the facility. Facilities will also be supported to reduce barriers to access, with the aim of reaching every child with immunization (RED). The figure below aptly illustrate the immunization services provided and supported by Afya Pwani to children less than 5 years of age during the July-September period. During this quarter, the Project was able to reach 7,275 children, who are less than 1 year with full immunization coverage, whilst 7,221 children were also reached with the measles vaccination. There were also slight decreases in the number of children reached with the measles vaccines and those who were dewormed during this period as compared to the previous quarter. Despite these downward trends, there were also marked increases in the number of children who accessed Vitamin A supplementation and who received treatment for pneumonia which are positive indications that despite implementing minimal

USAID AFYA PWANI PROGRESS REPORT FOR Q4 FY 2016 16

activities; the Project was still able to reach a significant number of children in need of high quality CH services.

Figure 7 Trends in Child Health Indicators: April-June and July-September 2016

Next quarter, the Project intends to work with the facilities and CHVs to ensure that all eligible children are fully immunized and defaulters are traced and encouraged to complete immunization. a) Management of diarrhea Cognizant that diarrhea is one of the biggest causes of infant and under 5 mortality and morbidity in Kilifi County, the Project supported the provision of fully functional Oral Rehydration Therapy (ORT) corners that provide Oral Rehydration Salts (ORS) and Zinc to children with diarrheal diseases across all Afya Pwani supported Maternal and Child Health (MCH) service delivery sites. The Project also provided TA and reminders to all health workers during program visits on the importance of ORT corners and the need to ensure that all ORT corners are fully functional. Health workers also received mentorship on the need to document all cases of diarrhea seen and managed at project supported facilities to make sure that all these cases were aptly documented in the ORT register. Kilifi County also had to make an emergency order for zinc and ORS, to cover some facilities like Tsangatsini Dispensary which was experiencing a shortage of the same during the quarter.

2.3 Family Planning Services and Reproductive Health (FP and RH) During the period July – September 2016, the Afya Pwani Project provided support to one hundred and four health facilities34 to strengthen, and continuously improve access to and delivery of quality RH/FP services for marginalized and underserved populations in the County. Afya Pwani also focused on ensuring that the high quality RH/FP services it supports are effectively integrated with HIV and other services to minimize missed opportunities and to increase reach.

FAMILY PLANNING During the quarter, 11,331 new clients were provided with FP services which included injectable contraceptives, pills, implants, and Intra Uterine Contraceptive Devices (IUCDs). While ensuring availability of the full range of methods, the Project continued to provide TA on commodity requisition to ensure consistent availability of FP methods, counseling and informed choice so that clients could retain their rights to voluntarily consent to use the FP methods of their choice. The figure below aptly illustrates the trends for uptake of FP services during the July-September 2016 quarter in Kilifi.

34 Kilifi North (20), Kilifi South (19), Ganze (16), Malindi (12), Magarini (21), Kaloleni (9) and Rabai (7).

USAID AFYA PWANI PROGRESS REPORT FOR Q4 FY 2016 17

Figure 8 Perf. Analysis-Uptake of FP Services, New clients (July 2015-September 2016)

The figure above illustrates the uptake analysis of FP services and the number of new clients who have sought FP services in Kilifi County for the period under review. When compared to the last quarter, there were marked reductions in the number of new clients across the county from 13,928 in the April- June 2016 period to 11,331 this quarter (except for Malindi and Kaloleni). As mentioned previously, these reduced numbers can be attributed to the fact that Project staff were unable to implement a full range of activities until the Project’s work plan was approved, which happened towards the end of the quarter. As such, the Project expects these number to increase in the next quarter as all activities will be implemented. Afya Pwani was also able to reach 23,715 revisit clients who were able to access FP services across supported sites in the county. The Project was also able to reach 35,046 women with Couple Years of Protection (CYP) compared to 37,427 clients in the April-June period. As mentioned previously, these reductions can be attributed to the fact that Project staff were transitioning from APHIAplus Nairobi-Coast to the Afya Pwani project and due to the fact that Project staff were only able to implement a limited number of activities until the Project’s work plan was approved. The Project’s investments in targeted TA focused on Long Acting Reversible Contraception (LARCs) and Long Acting Permanent Methods (LAPMs) of contraception, FP camps and outreaches for marginalized, underserved and hard to reach populations has resulted in the sustained trends in CYP achievements. The figure below shows the trends of CYP between April and June 2016 and July and September this year.

Figure 9 Perf. Analysis- Total CYP Distributed July-June, 2016 compared to April-June, 2016

During this reporting quarter LARCs (Implants and IUCDs) contributed to 41% and 31% of the CYP respectively, whilst Medroxyprogesterone injectable contraceptives contributed to 21% of the CYP both of which are positive indications that that Project has been able to increase availability and utilization of long term, modern method mix of contraception in Kilifi’s seven sub-counties. The Project will continue to provide TA to maintain this trend and further improve the utilization of LARCs among vulnerable and marginalized populations in Kilifi County, whilst ensuring supported facilities continue

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Project technical officers worked jointly with sub-county RH coordinators to visit twenty four health facilities35 across the County to provide program support and mentorship for health workers. During these visits Project and sub-county staff were able to identify gaps in RH/FP service delivery and address the same using coaching and OJT on the provision of LARCs, screening of cervical cancer, FP compliance, Integration of FP in Post-natal care (PNC), Immunization, Post-Abortion Care (PAC) and in HIV services, RH/FP commodity consumption and requisition reporting, infection prevention and data quality. During the same period, the Project laid emphasis on LAPM of contraception while focusing on the full range of method mix, informed consent and voluntarism. A total of forty two (twenty nine females and thirteen males) health workers were reached through the activities above. The Project also worked to support the following strategies to fulfill its mandate to increase access to and utilization of RH/FP health services: a) Youth Friendly Services (YFS) at facility Afya Pwani also supported the provision and expansion of youth and adolescent friendly services for supported health facilities in Kilifi County. To increase access to and utilization of Adolescent and Youth Sexual Reproductive Health (AYSRH) services, technical support was provided and review meetings and supervision facilitated for four Youth Friendly Sites (YFS) sites at Malindi and Kilifi Hospitals and Mtwapa and Rabai HCs respectively. Inadequate capacity building for health workers on AYSRH as well as inadequate space are significant barriers to scaling up of YFS in the county; in the next quarter the Project will advocate for additional space and capacity building of HCWs by conducting orientations and CMEs to address these challenges. b) Family Planning Commodity Reporting The Project supported effective and timely contraceptive commodity consumption and requisition in all supported facilities, into the DHIS2. The table below provides a snapshot of the timely commodity reporting rates for July – September 2016. As is illustrated below the FP reporting rates have fluctuated significantly for Ganze, Kilifi North and South sub-counties, with some remaining stagnant and other illustrating significant decreased and or increases over the 3 month period, which can be attributed to variance in capacity and capability amongst health workers to document and accurate and effectively report on FP commodities. Next quarter, Project staff will work towards promoting consistency in reporting on the same.

Figure 12: Contraception commodity reporting for July – September 2016

Water, Sanitation and Hygiene (WASH) Project activities will be carried out next quarter as Afya Pwani partners were still mobilizing for start- up. For more detailed information on these activities please see Attachment I which contains detailed information on the WASH and nutrition activities for October-December, 2016.

35 Kilifi North-2, Kilifi South-6, Magarini-3, Malindi-3, Rabai-1, Kaloleni-2, and Ganze-3 USAID AFYA PWANI PROGRESS REPORT FOR Q4 FY 2016 20

SUB-PURPOSE 3: STRENGTHENED AND FUNCTIONAL COUNTY HEALTH SYSTEMS

3.1 Partnerships for Governance and Strategic Planning Afya Pwani partners implementing this component of the Project were still mobilizing for start-up, as such the Project activities that were due to take place this quarter will take place next quarter. For more detailed information on these activities please see Attachment I which contains all of the Partnerships for governance and strategic planning activities for October-December, 2016.

3.2 Human Resources for Health (HRH) As with partnerships for governance and strategic planning, Project activities for HRH will take place next quarter as partners were still mobilizing resources for start-up (see Attachment 1 for list of activities).

3.3 Health Products and Technologies (HPT) Provision of quality health services is also largely dependent on the availability of appropriate HPT. During this quarter Afya Pwani supported the following activities geared towards increasingly the availability of appropriate HPT: a) Support to General Hospital EID/Viral Load Lab Commodity Security Afya Pwani helped support inventory management by facilitating the use of stock control cards for Viral Load and EID Reagents and consumables at the CPGH. This was done in a bid to improve proper quantification and ordering of the commodities from KEMSA to reduce and finally abolish stock outs. Cognizant that the ordering cycle in for commodities in the coastal counties occur monthly, the Project worked to increase the maximum Months of Stock (MOS) for the reagents to two months to introduce a one month buffer stock. Plans are in place to renovate a room that can be used as a Laboratory Store in the Comprehensive Care Clinic linked to CPGH in order to enhance storage space and increase buffer stock to two MOS. During the quarter, there were only two (2) stock out days for Abbot Viral Load Reagents and no stock out at all for the Cobas Reagents and Abbot EID Reagents respectively. By working to ensure that all facilities have sufficient commodities and stocks of reagents the Project has been able to work towards achieving the ‘third 90’ by ensuring that HIV clients get their Viral Load results in a timely and effective manner. Towards the same purpose of achieving the ‘third 90’, Purple- top EDTA Vacutainers and latex gloves were also distributed to facilities in Mombasa County for use in whole blood collection for Viral Load analysis. Utilization of expired commodities has been a challenge for health workers, as such the Project worked with health workers to discourage the use of expired consumables, especially expired tubes for blood collection. b) Support to Commodities Redistribution for Continuation of Services and Prevention of Wastage through Expiry: Afya Pwani also facilitated the redistribution of short-dated PIMA CD4 machine reagents from Bughuta HC and Wesu Sub-county Hospital in Taita Taveta County to Mwatate Sub-county Hospital which was experiencing a stock out. Project staff also facilitated the provision of technical support to health workers and facility staff on how to transfer CD4 samples from Moi Voi Referral Hospital which did not have reagents for their FACSPresto machine to Mwatate Sub-county Hospital to ensure continuation of services. The SCMLT from Changamwe/Jomvu was also alerted to re-distribute almost expiring HIV RTKs to Miritini MCM Dispensary which was also facing HTS service delivery challenges because the Nursing Officer In-charge going on annual leave and the only remaining Nursing Officer had been overwhelmed. c) Commodity Related Supportive Supervision and OJT: Commodity related intensive supportive supervision was conducted with support from Afya Pwani in thirteen health facilities36. Different gaps were also identified and TA provided on proper inventory management for commodities, how to fill stock control cards and DARs and improper storage of commodities. During

36CPGH, Utange Dispensary, Railways Dispensary, Ganjoni Health Center, Miritini MCM Dispensary, Jomvu Mikanjuni Model Health Center, Miritini CDF Dispensary, Chaani Dispensary, Magongo MCM Dispensary, Mbuta Health Center, Likoni Catholic Dispensary and Shika Adabu Dispensary in Mombasa County and Kinondo Kwetu Clinic in Kwale County. USAID AFYA PWANI PROGRESS REPORT FOR Q4 FY 2016 21

especially with CHVs and mentor mothers as result of the APHIAplus Nairobi-Coast project that recently closed. This has helped to Community Health Extension Workers (CHEWs) to remain committed and active to increasing availability of health services despite the challenges implementing the community health strategy effectively. Moving forward, it should be noted that communities in Afya Pwani counties are very receptive to new ideas and willing to learn, despite their illiteracy level being high, but the commonly held myths and misconceptions will need to be effectively addressed in order to see the uptake of health services increase dramatically. Building the capacity of CHVs to address the issues within their communities through community dialogue days and engaging the buy- in of religious and cultural leaders are potential avenues to address these issues. Project staff also learnt that CHVs based at the facilities play a major role when it comes to improving linkages and demand creation at the community level and that CHVs in conjunction with CCC staff have been able to effectively and continuously mobilize clients to attend support group meetings. Other lessons learnt include the fact that health workers still need to be sensitized on the new ART guidelines and protocols to improve the quality of HIV health services provided and that more emphasis needs to be placed on linking positive clients to care and treatment as there is still some missed opportunities of clients. This can be done by continuing to strengthen the referral skills of CHVs as well expanding the utilization of the Anza Sasa Campaign that the Project is already supporting.

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III. ACTIVITY PROGRESS (QUANTITATIVE IMPACT Please see Attachment II for the full performance summary tables.

APHIAplus Nairobi-Coast Transition to Afya Pwani Performance Summary Totals Cumm Oct-Dec Jan-March April-June July-Sept Oct-15 to Oct -Dec Jan-March April-June July-Sept Target(Oct- Indicator 2015 2016 2016 2016 June-16 % Achvt 2015 Achvt 2016 Achvt 2016 Achvt 2016 Achvt 15 to June- Targets Targets Targets Targets Achvt 16) Number of pregnant women who were 25,110 26,146 26,800 28,427 26,800 29,097 26,800 28,717 105,510 112,387 107% tested for HIV & received their results PMTCT Number of HIV positive pregnant women who 700 708 1,306 2,006 1,306 1,296 1,306 794 4,618 4,804 104% received ART

Number who received Testing and HTC 90,122 87,574 90,122 87,146 90,122 129,658 90,122 126,665 360,488 431,043 120% Counseling (T&C) services Number of adults and children newly 1,800 1,680 1,800 1,497 1,800 2,222 1,800 2,885 7,200 8,284 115% enrolled on ART ART Number of adults and children Currently on 41,200 40,841 42,338 40,328 42,338 42,153 42,338 44,930 42,338 44,930 106% ART Number of children dewormed at least 30,100 38,892 30,100 28,140 30,100 36,978 30,100 27,990 120,400 132,000 110% once in a year Number of children MNH under 5 years of age 25,199 24,566 25,199 23,559 25,199 63,480 25,199 44,346 100,796 155,951 155% who received Vitamin A Number of children <1 21,877 19,849 21,877 20,453 21,877 17,936 21,877 22,787 87,508 81,025 93% year fully immunized Couple Years of FP/CYP 61,229 64,327 61,229 61,439 61,229 55,723 61,229 56,554 244,916 238,043 97% Protection (CYP) Number of pregnant women attending at 16,019 13,925 16,019 14,248 16,019 14,480 16,019 16,118 64,076 58,771 92% least 4 ANC visits Deliveries Number of deliveries with a skilled birth 22,090 21,761 20,414 20,987 20,414 23,234 20,414 21,556 83,332 87,538 105% attendant (SBA)

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coordination of activity implementation and reporting through facilitation of communication (Air-time and data bundles to all the Sub-County and County-level MOH core teams) to support the data value chain, including referral systems as well as strengthening Data Quality Improvement (DQI) and data quality audits. Afya Pwani also strengthened MOH structures by supporting and facilitating the provision of joint supportive supervision by S/CHMTS for sub-county and County broad-based stakeholder’s using data review structures and processes cum feedback and monthly action planning meetings as well as District Health Information System (DHIS2) data cleaning and support hosting of quarterly data review meetings. The Project also worked to support health workers with TA and technical support to record and report on the national tools by: providing on-site mentorship to health providers and information for staff at sub-county hospitals and ART sites as well a and providing on-site TA and mentoring of the health information staff on use of DHIS2 to report all activities. Afya Pwani’s M&E department have also supported the following interventions geared towards improving and strengthening DDIU across Project supported counties: Field Performance Monitoring Technical Assistance visits where technical, management and field program staff routinely visited project sites across the zone to assess progress with activity implementation, provide TA and to hold discussions with stakeholders on project progress and challenges; Monthly and Quarterly Feedback meetings by Project staff to assess the progress of activities implemented by the CHWs; Program Performance Review Meetings where Afya Pwani staff supported and co-facilitated Sub-County and County level program review meetings involving S/CHMTs and IPs at the County level to discuss experiences, best practices, and resolve common problems. The Project’s M&E team has continued to play a lead role in ensuring that the Project works closely with, and participates in, the County, Sub-County and facility Annual Work Plan (AWPs) reviews and action planning processes; Sub- county and consolidated County AWP development all whilst ensuring alignment of project activities with GoK priorities and targets. i) Strategic Monitoring and Evaluation Systems: During the quarter the Project has continued to collaborate with other partners in the consortium (i.e. Palladium) to focus on quality improvement systems strengthening. More specifically, Afya Pwani continued to encourage program managers to adopt and progressively implement the Kenya Quality Management for Health Model for Health (KQMH). The Project’s knowledge management interventions have also been able to respond continuously to the need to recognize interventions at the facility and management structures, where results, lesson learned and challenges are continuously shared to enhance data and performance ownership. The Project also provided TA visits to the facilities on the ‘MyCheck Tool’ and as a critical strategy to improve quality; this involved documentation of checks on key aspects of ART and checks on selected outcomes like baseline CD4 results, the presence of guidelines, adherence counseling, TB screening, Cancer of the Cervix Screening, other baseline tests, mentorship and retention into treatment etc. This data was then continuously used as a basis for taking relevance corrective actions to improve project interventions and programming. Between July and September 2016 the Project has also continued to reach out to NASCOP and participate in HIVQUAL analysis. It should be noted that HIVQUAL, KQMH and CQI collaborative approaches have also been woven into Afya Pwani’s program TA framework; all coastal counties now have strategic plans that focus on QI. Lastly, Afya Pwani’s also ensured that mentorship teams have been established at several hospitals across the 5 counties whereby most members are new and have been selected to fill in missing disciplines (as was the case in Mombasa, Lamu and Kwale Counties this quarter) and that new members that cover missing disciplines were added. It should also be noted that the SCHMTs have fully owned the process of selection and adjustments of mentorship teams which is a great step towards sustainability of the mentorship program. During the quarter a meeting was held with the Mombasa, Kilifi, Kwale and Taita Taveta CHMTS to discuss sustainability of the mentorship program as

USAID AFYA PWANI PROGRESS REPORT FOR Q4 FY 2016 28

VI. PROGRESS ON GENDER STRATEGY

During the July-September 2016 quarter, the Afya Pwani project focused on planning the implementation of the Gender based activities as Project staff awaited the approval of the work plan by USAID. The Afya Pwani Gender strategy is focused on addressing gender inequity, inequality and Gender Based Violence (GBV) through interactive gender and rights mainstreaming and integration at all levels of the health system. The Project’s strategy is premised on establishing and strengthening local ownership of the gender agenda by building the capacity of CHMTs, SCHMTs, facility management teams and CUs to be able to better mainstream and integrate gender and rights in their policies, management and service delivery by taking ownership and responsibility of plans, activities and accountability processes based on local needs. Through the local ownership model, the Afya Pwani Project has begun to plan and implement activities aimed at devolving different gender equity and equality for health interventions through advocacy of policy at the county level; policing and prevention advocacy and mobilization at both the county and sub-county level; post-violence care and protection at the health facility and community level and lastly education and awareness (at institutional, household and individual levels). During the period under review, Project staff worked closely with SCHMTs and other relevant county offices to not only share the value addition of incorporating gender at the facility but to then formulate an informal plan on how to: develop SOPs, utilize cue cards on Sexual Gender Based Violence (SGBV) for counselling, implement CMEs on GBV management as well as training male champions in FP, eMTCT, and MNCH at the facility, sub-county and county levels. Additionally, Project staff also participated in the Coastal Counties HIV data review meeting at the Baobab Hotel, as well as a KPs meeting at a Drop in Support Centre (DISC) and other supported facilities in Mombasa as well as the quarterly supportive supervision exercise/meetings by the SCASCOs. Moving forward to the next quarter, the Project team will attempt to address the gaps identified during the SIMS that were carried out during the quarter, as well as building on some of the structures that were set up during the previous project where applicable such as male champions; utilizing the existing government SOPs to formulate others like SGBV counselling cue cards, training CHVs among others activities.

VII. PROGRESS ON ENVIRONMENTAL MITIGATION AND MONITORING

As part of its efforts to mitigate the impact of the Afya Pwani, the Project has put in place and implemented measures that have been specifically designed to eliminate, reduce or offset the undesirable effects of all project activities on the environment. The Project has been guided by the standard mitigation requirements established by counties and the Environmental Mitigation and Monitoring Plan (EMMP) that was submitted to USAID at the project’s initial stages. During this quarter, the Project has ensured that all mitigation requirements have been strictly complied with during the implementation of all Afya Pwani’s activities that took place during the period under review in Mombasa, Kilifi, Kwale, Taita-Taveta and Lamu. The Project also supported OJT for health workers on segregation of waste, proper documentation and procedures for proper disposal of expired commodities, especially for facilities where health workers were reported to have previously disposed of commodities without following proper procedures (e.g. breaking ampoules of medicines and pouring into the sink). In regards to monitoring, the Project has been able to determine whether mitigation is being implemented as per the EMMP and determining whether these outlined mitigation measures have been sufficient and effective. Lastly, it should be noted that Afya Pwani’s environmental compliance is guided by the EMMP and the county environmental mitigation

USAID AFYA PWANI PROGRESS REPORT FOR Q4 FY 2016 30

requirements that have been embedded within the program, and that project staff will continue to implement it across all supported facility sites in the next quarter.

VIII. PROGRESS ON LINKS TO OTHER USAID PROGRAMS

During the July-September 2016 quarter, Afya Pwani continued to liaise and coordinate with other county mechanisms to ensure quality and continuity of service delivery and strengthened systems. More specifically, the Project has continued to work with the USAID/University Research Co (URC) Applying Science to Strengthen and Improve Systems (ASSIST) project to support the implementation of quality work improvement teams in select HVFs that are conducting training gap assessments and across all the supported 5 counties. During the July-September, 2016 quarter, the Afya Pwani project was transitioning from the APHIAplus Nairobi-Coast mechanism and as such, project staff focused efforts on working closely with the Palladium group to support the scale up and expanded implementation of the IQCare system (which had been previously been supported by APHIAplus Nairobi-Coast) by conducting data quality assessment which were used to inform the process. Additionally, the Afya Pwani team also supported the provision of Technical Assistance (TA) and mentorship to help identify facilities which would be brought on board to fully operationalize the IQCare system in the five counties supported by the Project. At the national level, the Afya Pwani project continued to work closely with the USAID/Measure Evaluation PIMA Project to support the Community Health Services unit (CHSU), together with United Nations Children’s Fund (UNICEF) and other partners with an aim of informing the drafting the National Community Health Policy and revision of the Community Health Strategy.

IX. PROGRESS ON LINKS WITH GOK AGENCIES

Between July and September 2016, Afya Pwani project staff have worked towards strengthening the links with GOK agencies as part of efforts to support activities that will work towards fulfilling the Project’s overall mandate to increase the utilization of and access to high quality health services in the five coastal counties. During the period under review, Project staff supported the MOH by participating in a stakeholder planning meeting39 (September 27th, 2016) that was led by the National AIDS Control Council (NACC) for a National Symposium on Condoms for 200 participants that were drawn from the MOH, Treasury, Trade and Industrialization, Kenya Bureau of Standards (KEBS), Kenya Medical Supplies Agency (KEMSA), Pharmacy & Poisons Board (PPB), County Governments, development and implementing partners that are supporting health/HIV and AIDS related programs and the private sector. Additionally, Afya Pwani project staff also participated in the MOH and USAID/HIV & AIDS Core Project Research Symposium: Strengthening HIV/AIDS Treatment, Care and Support Programs (which was held on 22nd September 22, 2016, which provided an apt opportunity for the MOH and its supporting partners could discuss existing gaps and opportunities in HIV programming and to identify ways to address these issues as well as several findings from 5 HIV Core studies were presented40. Afya Pwani project staff are avid members of the Reproductive and Maternal Health Services Unit (RMHSU) MOH AYSRH Technical Working Group (TWG); during the quarter under review staff were able to participate in a stakeholder

39 Pathfinder International is a member of the Conference Media, Communication and Publicity sub team 40 The following findings were presented during the meeting: Intimate partner violence and power relationships in HIV counseling and testing; Results from an intervention piloted in Nairobi: secondary analysis of clinical HIV treatment data; TB tech: decision–support reminders for medical providers to improve IPT prescription rates among HIV positive adults in western Kenya; Effectiveness of cell phone counselling on PMTCT retention and uptake of early infant diagnosis in Kisumu, Kenya and an assessment of current record systems to track early warning indicators of pediatric ARV resistance in Kenya.

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meeting on Most at Risk Adolescents (MARAs) to discuss findings of a Situational Analysis of Policy and Health Care for MARA’s which occurred on 11th August 2016. Project staff also participated in a John’s Hopkins Center for Communication Programs learning event on the 15th of September 15th, 2016, which brought together the Social and Behavior Change Communication (SBCC) community of practice to discuss tools to reach youth and improve RH/FP service delivery. These discussions have proven useful as the Afya Pwani team moves forward to address these challenges in Kilifi County. In addition, Project staff also supported the FP MOH FP Technical Working Group (FP TWG)41 in a meeting on 23rd September 2016 to share and review the new proposed goal for strategic FP indicators for Kenya. During this meeting, Kenya FP stakeholders and USAID CA’s42 deliberated on the FP goal revision process, tools and model in a bid to reach consensus on the proposed goal. Project staff also attended a meeting on August 16th, 2016 to discuss planned FP advocacy initiatives with the RHMSU/MOH and stakeholders. Lastly, Afya Pwani also supported the National Council for Population & Development (NCPD)/Presidency-Ministry of Devolution & Planning, State Department of Planning by participating in the Task Force assisting the NCPD secretariat to organize World Contraception Day 2016 festivities; where the theme was ‘Adolescent Pregnancy’ as part of efforts to support activities geared towards increasing and expanding access to RH/FP health services.

X. PROGRESS ON USAID FORWARD

A core part of Afya Pwani’s mandate is to strengthen partnerships and governance at the sub-county, county and national level, as well as to build the capacity of the community structures and local implementing partners that it supports in order to promote sustainability and to maximize the impact of the Project. The July-September, 2016 quarter predominantly focused on start-up activities, which includes finalizing advertisements for sub-grantees and LIPs who will partner with Pathfinder International and its consortium of partners as the project progresses. In these advertisement, Afya Pwani staff have placed significant emphasis on the fact that potential grantees need to be locally based as part of efforts to promote sustainable development and health outcomes across the five coastal counties through high- impact partnerships and local solutions. During this quarter, Afya Pwani staff also worked with existing USAID funded mechanisms like Linkages (supports KPs), TWGs and Sub-County, County structures and organizations, like CHMTs, RHMSU and NASCOP as part of efforts to build, strengthen and expand intersectoral and multilevel partnerships that will serve as catalysts for growth and progress in the health sector not only in the five counties but at the national level as well. Afya Pwani also have a strong mandate to support MEL, now that the Project’s work plan has been approved, cluster teams and the Project’s RMU teams will be working towards implementing, documenting and improving the game-changing approved activities and innovations across the five counties. During this quarter, one member of the Afya Pwani team was selected by NASCOP to make a presentation on the "Utilization of information technology towards achieving first 90” in Taita Taveta; an apt illustration of the contribution that Afya Pwani has made to the USAID Forward during the quarter.

41 FP TWG members: RHMSU-chair; USAID Office of Population Health and Nutrition (OPH) Kenya, I Choose Life (ICL), MSH, Maternal and Child Survival Program (MCSP), Population Council, World Vision, Clinton Health Access Initiative (CHAI), Futures Group, MSD/Merck, DSW, Population Services (PS) Kenya, Bayer Healthcare, FHI360, Pathfinder, Measure Evaluation, Jhpiego, NCPD, Funzo Kenya and World Health Organization (WHO), 42 Post International Conference on FP (ICFP) Thematic Group participants include: Marie Stopes Kenya, Track 20, Pathfinder International, MCSP/Jhpiego; FHI360; APHIAplus Kamili; APHIAplus Imarisha; NCPD; Measure Evaluation-PIMA; MSH, PS Kenya; PRB Kenya/East Africa and the Population Council.

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XI. SUSTAINABILITY AND EXIT STRATEGY

To ensure sustainable impact and continued improvement of high quality HIV, MNCH, RH/FP, WASH and nutrition health service delivery in the five coastal counties, Afya Pwani has developed and begun to implement its HSS strategy fully cognizant of its eventual exit. During the quarter, project staff have worked towards ensuring that all activities implemented have been in 1) full alignment with national policies and strategies; 2) ensured that that the TA provided has been targeted and tailored to the specific needs of health workers and CHVs to add real value and 3) 4) strengthen community networks for service delivery through CHVs and facility referral networks to ensure a continuum of service delivery include strong linkages between health facilities and surrounding communities and vice versa. By focusing on strengthening linkages between the facility and community Afya Pwani been able to reduce the risk of loss to follow‐up and defaulter tracing which has also improved the efficiency of preventive messages resulting from reinforced and complementary messages between health facilities and the CHVs linked to them. Afya Pwani has also facilitated and supported the systematic involvement of all key actors and stakeholders, promoted local buy-in and ownership of project activities and process, especially in and not limited to the collection, monitoring, and usage of clean and reliable data; all of which has fostered an environment whereby sustainability of health outcomes is at the core. In the next quarter, with the work plan being fully implemented, Afya Pwani and its staff will continue to strengthen all of the activities above as well as those affecting human resources for health, gender and youth cognizant that these components are critical if the gains made by the Project are to be sustained before the lifespan of Afya Pwani.

XII. SUBSEQUENT QUARTER’S WORK PLAN

All WASH, nutrition and HSS activities (except for HPT) were not able to be implemented during this quarter as partners were still mobilizing for start-up. As such, all activities that were scheduled to happen this quarter will be implemented in the Oct-December 2016 quarter. For a full list of all WASH, nutrition and HSS activities affected, please see Attachment I.

XIII. ACTIVITY ADMINISTRATION

During this quarter there have been no significant changes in Personnel or Contract amendments.

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ANNEXES & ATTACHMENTS

ANNEX I: SCHEDULE OF FUTURE EVENTS ANNEX II: LIST OF TRACER COMMODITIES ANNEX III: LIST OF HIGH VOLUME FACILITIES (PHARMACY)

Annex I: Schedule of Future Events

DATE LOCATION ACTIVITY Orientation of Afya Pwani partners on Branding and Nairobi 10/2016 Marking

10/2016 Kilifi Develop facility scene setter Review of selected small grants and submission of paper Nairobi & Mombasa 11/2016 work for USAID approval

11/12 2016 (Subject to USAID approval and Mombasa Afya Pwani Project Launch availability of key personnel)

12/2016 Nairobi Produce Afya Pwani e-newsletter

TBD Mombasa HRH policies and strategies dissemination

TBD Mombasa Functional Stakeholder Forum

TBD Mombasa Post-award brief for grantees under contract

Annex II List of Tracer Commodities

1. Amoxicillin caps 250mg 2. Cotrimoxazole Susp. 240ml/5ml 3. Sulphadoxine Pyrimethamine tablets 4. Ferrous Sulphate 200mg tablets

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5. Folic Acid 5mg tablets 6. Oxytocin Injection 7. Magnesium Sulphate Injection 8. Zidovudine/Lamivudine/Nevirapine 60mg/30mg/40mg Paed. FDC 9. Isoniazid 300mg tabs 10. Ready to Use Therapeutic Food (RUTF) Satchets 11. Artemether/ Lumefantrine tabs 20mg/120mg (24's) 12. Cotrimoxazole tabs 960mg 13. Implants 1 Rod 14. Zinc Tabs/ORS packs 15. Paracetamol tabs 500mg 16. TB Patient Pack 17. Tenofovir/ Lamivudine/ Efavirenz300mg/150mg/600mg tabs

Annex III – List of High Volume Facilities for Commodity Management Indicators Reporting

1 Coast Province General Hospital Mombasa 2 Kilifi County Hospital Kilifi 3 Malindi SC Hospital Kilifi 4 SC Hospital Mombasa 5 Tudor SC Hospital Mombasa 6 Likoni SC Hospital Mombasa 7 Mtongwe Dispensary Mombasa 8 Kinondo Kwetu Dispensary Kwale 9 Kongowea Health Centre Mombasa 10 Mariakani SC Hospital Kilifi 11 Mtwapa Health Centre Kilifi 12 Bamburi Dispensary Mombasa 13 Kinango SC Hospital Kwale 14 Mikindani MCM Dispensary Mombasa 15 Moi Referral Hospital, Voi Taita Taveta 16 Taveta Sub-County Hospital Taita Taveta 17 Oasis Medical Centre Kilifi 18 Kisauni Disp Mombasa 19 CDC Ganjoni Disp Mombasa

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20 Gede H Centre Kilifi 21 Msambweni County Hosp Kwale 22 Vipingo H Centre Kilifi 23 Mlaleo CDF H Centre Mombasa 24 Mwatate SC Hospital Taita Taveta 25 Rabai Health Centre Kilifi 26 Bamba SC Hospital Kilifi 27 Gongoni Health Centre Kilifi 28 Chasimba Health Centre Kilifi 29 Ganze Health Centre Kilifi 30 Gotani Dispensary Kilifi 31 Municipal Health Centre, Malindi Kilifi 32 Tsangatsini Dispensary Kilifi 33 Matsangoni Health Centre Kilifi 34 Vitengeni Dispensary Kilifi 35 Marafa Health Centre Kilifi 36 Baolala Dispensary Kilifi 37 Marereni Dispensary Kilifi 38 Mambrui Dispensary Kilifi 39 Kwale SC Hosp Kwale

40 Lunga SC Hosp Kwale

County Total Number of High Volume Facilities Mombasa 11 Kwale 5 Kilifi 21 Taita Taveta 3 NB: The last two facilities were added to increase the number to 40 and are not high volume facilities.

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