USAID AFYA HALISI QUARTERLY PROGRESS REPORT

Deputy Governor of County, Dr. Mathew Owili officially receiving reproductive health equipment donated by Afya Halisi during the World Contraceptive Day.

Date of Submission: 31st October 2018

USAID KENYA AFYA HALISI PROJECT FY 2018 Q4 PROGRESS REPORT

July 1 – September 30, 2018

Award No: AID-615-A-17-00004

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

Prepared by Afya Halisi Jhpiego offices, 2nd Floor, Arlington Block, 14 Riverside, off Riverside Drive, P.O Box 66119-00800 Nairobi Office tel: +254 732 134 000

USAID/KENYA & EAST AFRICA AFYA HALISI PROGRESS REPORT FOR Q4 FY 2018 i

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.

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TABLE OF CONTENTS

ACRONYMS AND ABBREVIATIONS ...... iv

I. EXECUTIVE SUMMARY ...... 1 Qualitative Impact ...... 1 Quantitative Impact ...... 1 Constraints and Opportunities ...... 7 Subsequent Quarter’s Work Plan ...... 7

II. KEY ACHIEVEMENTS (Qualitative Impact) ...... 7

III. ACTIVITY PROGRESS (Quantitative Impact) ...... 62

IV. CONSTRAINTS AND OPPORTUNITIES ...... 63

V. PERFORMANCE MONITORING ...... 63

VI. PROGRESS ON GENDER STRATEGY ...... 63

VII. PROGRESS ON ENVIRONMENTAL MITIGATION AND MONITORING ...... 68

VIII. PROGRESS ON LINKS TO OTHER USAID PROGRAMS ...... 68

IX. PROGRESS ON LINKS WITH GOK AGENCIES ...... 68

X. PROGRESS ON USAID FORWARD...... 70

XI. SUSTAINABILITY AND EXIT STRATEGY ...... 70

XII. GLOBAL DEVELOPMENT ALLIANCE ...... 71

XIII. SUBSEQUENT QUARTER’S WORK PLAN ...... 72

XIV. FINANCIAL INFORMATION ...... 77

XV. ACTIVITY ADMINISTRATION ...... 78

XVII. GPS INFORMATION ...... 78

XVIII. SUCCESS STORIES ...... 82

ANNEXES & ATTACHMENTS ...... 87 Annex 1: Afya Halisi - From Commitment to Action: Framework for Action by , Kisumu and on Adolescents and Youth Sensitive Services ...... 87 Annex 2: Schedule of Future Events ...... 93

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ACRONYMS AND ABBREVIATIONS

CQI Continuous Quality Improvement ANC Antenatal Care CYP Couple Years of Protection AWP Annual Work Plan CPR Contraceptive Prevalence Rate AYSRH Adolescent and Youth Sexual CSO Civil Society Organizations and Reproductive Health CME Continuous Medical Education AYP Adolescent and Young People CMSG Community Mother Support AFP Advanced Family Planning Group AEFI Adverse Events Following CHX Chlorhexidine Immunization CBHIS Community Based Health AMTSL Active Management of Third Information System Stage of Labor CHSSIP County Health Sector Strategic BEmONC Basic Emergency Obstetric and and Investment Plan Newborn Care CHEW Community Health Extension BFCI Baby friendly Community Worker Initiative COCs Combined Oral Contraceptive BFHI Baby-friendly Hospital Initiative COFASD Community Forum for Advanced BTL Bilateral Tubal Ligation Sustainable Development BCS+ Basic Counseling Skills plus DMPA Depot Medroxyprogesterone CHAI Clinton Health Access Initiative Acetate C4C Counseling for Continuation DHIS District Health Information CAC Community Action Cycle Software CBD Community-based Distribution DQAs Data Quality Audits/Assessments CBO Community Based Organization DFH Division of Family Health CBRM Community Based Referral DOOH Digital Out-Of-Home Mechanisms DPO Disabled Persons Organization CCA Clean Clinic Approach CBMNC Community-based maternal and CEC County Executive Committee newborn care CCC Comprehensive Care Center EBF Exclusive Breastfeeding CEMD Confidential Enquiry into Maternal ECD Early childhood development Deaths EMMP Environmental Mitigation and CEmONC Comprehensive Emergency Monitoring Plan Obstetric and Newborn Care ESCACON East, Central and Southern CICA County Institutional Capacity African College of Nursing Assessment EPI Expanded Program on CH Child Health Immunization CHA Community Health Assistant ETAT Emergency Triage Assessment CHC Community Health Committee and Treatment CHAI Clinton Health Access EHA Essential hygiene action International EmONC Emergency Obstetric and CMTC County Medicines and Newborn Care Therapeutics Committee ETL Extract Transform Load CHMT County Health Management FANC Focused Antenatal Care Team FGM Female Genital Mutilation CHU Community Health Unit FP Family Planning CHV Community Health Volunteer FACES Family AIDS Care and Education CHS Community Health Strategy Services CLTS Community Led Total Sanitation FHOK Family Health Options of Kenya

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FIC Fully Immunized Child KCGTRH Government GIC Generic Instructor Course Teaching and Referral Hospital GMP Growth Monitoring Promotion KPA Kenya Pediatric Association G-ANC Group Antenatal Care KEMSA Kenya Medical Supplies Authority GBV Gender Based Violence KQMH Kenya Quality Model for Health GoK Government of Kenya KEPI Kenya Expanded Program for HINI High Impact Nutrition Intervention Immunization HCW Health Care Worker K-CHIC County Health Insurance HRH Human Resource for Health Cover HRIO Health Records Information KDHS Kenya Demographic Health Officer Survey HMIS Health Management Information KAPPd Kenya Action Plan for the System Prevention and Control of HCD Human Centered Design Pneumonia and Diarrhea HFs Health facilities KIWASH Kenya Integrated Water, HH Household Sanitation, and Hygiene HSS Health System Strengthening KESH Kenya Environmental Sanitation HWTSS Household water treatment and and Hygiene safe storage KANCO Kenya AIDS NGOs Consortium HTSP Healthy timing and spacing of KMET Kisumu Medical and Education pregnancy Trust HPAC Health Promotion Advisory LARC Long-Acting and Reversible Committee Contraceptives HCWM Healthcare waste management LDHF Low dose high frequency iCCM Integrated Community Case LNG-IUS Levonorgestrel intrauterine Management system IPC Infection prevention and control LAPM Long Acting Permanent Method IFAS Iron and folic acid LOA Letters of Agreement supplementation LCHV Lead CHV IEC Information Education MEL Monitoring Evaluation and Communication Learning IUCD Intrauterine contraceptive devices MIYCN Maternal, Infant, and Young Child IMAM Integrated Management of Acute Nutrition Malnutrition MNH Maternal and Newborn Health IMCI Integrated Management of MOH Ministry of Health Childhood Illness MOE Ministry of Education IGA Income Generating Activities MFL Master Facility List IGWG Interagency Gender Working MEDS Mission for Essential Drugs and Group Supplies IYCF Infant and Young Child Feeding MPDSR Maternal and Perinatal Death iHRIS Integrated Human Resource Surveillance and Response Information System M2MSG Mother to Mother Support Group ICC Inter-agency Coordination MUAC Mid Upper Arm Circumference Committees MLM Middle Level Managers IRB Institutional Review Board MCA Member of County Assembly JOOTRH Jaramogi Oginga Odinga MOU Memorandum of Understanding Teaching and Referral Hospital mCPR Modern contraceptive prevalence KMC Kangaroo Mother Care rate MNP Multiple Micronutrient Powder

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MNCH Maternal, Newborn and Child QIT Quality Improvement Team Health REC Reach Every Child MMUST Masinde Muliro University of RED Reach Every District Science and Technology RMC Respectful maternity care MVA Manual Vacuum Aspiration RMNCAH Reproductive Maternal, Newborn, MCSP Maternal and Child Survival Child and Adolescent Health Program RMHSU Reproductive Maternal Health MYWO Maendelo ya Wanawake Services Unit Organization RRI Rapid Response Initiatives MCH Maternal Child Health RBF Results Based Financing MR Measles Rubella RH Reproductive Health NACS Nutrition Assessment Counseling SBA Skilled Birth Attendant and Support SBCC Social and Behavior Change NHIF National Hospital Insurance Fund Communication NNAK National Nurses Association of SCHMT Sub-County Health Management Kenya Team NCAHU Neonatal, Child, and Adolescent SCMPDSR Sub county maternal and Health Unit perinatal deaths surveillance and NHPplus Nutrition Health Program plus response OJT On job training SGBV Sexual and Gender Based OPV Oral Polio Vaccine Violence ORS Oral rehydration salts SRH Sexual Reproductive Health ORT Oral rehydration therapy SDT Step down training ODF Open Defecation Free SDO Service Delivery Officer OOH Out-Of-Home SGS Small Group Sessions OOP Out of pocket SDPs Service Delivery Points PBCC Provider based behavior change STI Sexually Transmitted Infection PIFP Provider Initiated Family Planning TA Technical Assistance PSBI Possible severe bacterial TBA Traditional Birth Attendant infection TOTs Training of Trainers PMP Performance monitoring plan TWG Thematic Working Group PNC Post Natal Care USAID United States Agency for PPFP Post-Partum Family Planning International Development PAFP Post Abortion Family Planning UNICEF United Nations International PPH Postpartum hemorrhage Children's Emergency Fund PPR Performance Planning and USG United State Government Review UBT Uterine Balloon Tamponade PTBI Preterm Birth Initiative UHC Universal Health Coverage PET Pre-Eclampsia Treatment VCAT Value Clarification and Attitude PPIUCD Postpartum intrauterine Transformation contraceptive devices VAS Vitamin A supplementation PLGHA Protecting Life in Global Health VSC Voluntary Surgical Contraception Assistance VSLA Village Savings and Loaning PSK Population Services Kenya Activities PY Planning Year WASH Water Sanitation and Hygiene POP Progestin only pills WCD World Contraceptive Day PHO Public Health Officer WRA Women of Reproductive Age PATUMA Pamoja Tuangamize Magonjwa WIT Work Improvement Team Program WHO World Health Organization

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I. EXECUTIVE SUMMARY

Qualitative Impact The US Agency for International Development’s (USAID) Kenya and East Africa awarded the Afya County and National Support Program (Afya Halisi) cooperative agreement in September 2017 to a consortium led by Jhpiego Kenya with partners Save the Children and PS Kenya. The project aims to deliver quality and integrated services in the areas of family planning (FP)/reproductive, maternal, newborn, child and adolescent health (RMNCAH), nutrition, and water, sanitation and hygiene (WASH) to those most in need in the four focus counties of Kitui, Migori, Kakamega and Kisumu (23 sub-counties including Kakamega County Government Teaching and Referral Hospital ). The project is designed to strengthen the capacity of national, county and sub-county leaders and systems so they can enhance the efficiency of health systems to increase sustainability, prioritize populations most in need to increase equity, and scale-up high- impact interventions and practices to improve quality. This report highlights Afya Halisi achievements in Quarter 4 (July – September 2018) of Program Year 1 (PY1 Q4) and cumulative achievements in Year 1. During the period under review, the project continued to provide support to the four focus counties aimed at accelerating the reduction of preventable maternal, newborn and child deaths within a generation; strengthening the capacity of county and sub-county leadership and systems; delivering quality, integrated services in the areas of family planning (FP)/reproductive, maternal, newborn, child and adolescent health (FP/RMNCAH), nutrition, and water, sanitation and hygiene (WASH); and increasing care seeking and health promoting behavior. The interventions were tailored to sub-county, community and facility level needs in order to have the most impact at population level. Working closely with the CHMTs/ SCHMTs, the project provided targeted technical support (based on the costed joint work plans), using focused and strategic sub-county-specific approaches to address the key issues identified from the health facility assessments conducted in Quarter 2. Sub-purpose 1: Increased availability and quality delivery of FP/RMNCAH, nutrition and WASH services The project continued to support high impact family planning interventions aimed at improving access to quality family planning services in the public and private sector facilities. During the reporting period, the project supported a total of 594 out of 603 (99%) health facilities to provide FP counseling and /or services. There was a 14% increase in the CYP achievement from 128,295 in PY1Q3 to 146,180 in the reporting period, with the private sector contributing 16%. Cumulatively, the project achieved a CYP of 419,006 against PY1 target of 599,508, an achievement of 70% against PY1 target. The project continued to provide focused TA and mentorship at facility level based on site specific TA plans and joint work plans to ensure that all the sites provide high quality services. At the end of PY1, the coverage for 4th ANC visits was at 46%; Kakamega highest at 49%, Kisumu at 48%, Migori at 47% and Kitui at 41%. The coverage for SBA based on population estimates in DHIS2, was lower than the performance achieved against the target with the project's overall coverage for SBA at 66% at the end of PY1. At county level, Kakamega County skilled birth attendance coverage was 82%, Migori at 72%, Kisumu at 61% and Kitui at 55%.

The project continued to engage the county health departments to operationalize facilities to provide emergency maternal and newborn health services. As a result of this effort, the number of EmONC facilities increased from 109 (15 being CEmONC) in PY1Q2 to 141 facilities (17 being CEmONC) during the reporting period. Out of the 17 CEmONC facilities, seven are in Migori, six in Kitui, three in Kisumu and one in Kakamega. During the reporting quarter, there were a total of 38 maternal deaths, with 92% of them being audited. In addition, there were 436 perinatal deaths with 93% of them being audited. In PY1, a total of 89 maternal deaths and 1,325 neonatal deaths were reported. Out of these, 92% of the maternal deaths

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were audited while 80% of the perinatal deaths were audited. This is still a very high number of maternal and newborn deaths that are largely preventable.

During the quarter, the project supported MOH to fully immunize 25,456 children under one bringing the total FIC in Year 1 to 76,002, an achievement of 86% of the PPR target of 88,104. Investments in nutrition services, reached 13,447 pregnant women with combined Iron and Folic Acid supplementation (IFAS), cumulatively totalling 42,742, an achievement of 67% against PY1 target. A total of 37,706 children under five years received Vitamin A supplementation in PY1Q4, bringing the total to 265,870 children who received Vitamin A supplementation in the last six months, an achievement of 144% against PY1 target). During the quarter under review, 6,274 children under five were treated for pneumonia in project supported health facilities. A cumulative total of 17,855 children under five were treated for pneumonia in PY1, an achievement of 101% of the annual target. This represents 78% of under-five children with pneumonia that were treated with antibiotics as at end of PY1. In addition, 16,429 children under five were treated for diarrhea, bringing the total in PY1 to 49,937 children, an achievement of 43% against PY1 target. This represents 73% of under-five children with diarrhea that were treated with ORS and Zinc as at end of PY1. The project continued to support WASH and IPC activities in Kakamega, Migori and Kitui counties at facility level and CLTS at community level. Investments in WASH resulted in 140 villages verified as ODF against a PPR target of 50, an achievement of 280% of the target; the number of people accessing basic sanitation services was 39,114 against a target of 15,000, an achievement of 261%. The project supported training of ToTs on Clean Clinic Approach (CCA) for middle managers to positively influence the health leadership to prioritize and invest in WASH in project supported health facilities and communities.

A total of 1,258 IPC guidelines, 410 Kenya Environmental Sanitation and Hygiene policy documents and 410 copies of the CLTS protocols were distributed. The project procured, delivered and distributed WASH start up supplies for priority health facilities including equipment for environmental cleaning, waste management, personal protection and hand hygiene to 75 health facilities (Kakamega 20, Kitui 30, and Migori 25). During the reporting period, through the project’s support, a total of 51 pit latrines were repaired; 61 waste pits and 29 placenta pits fenced. To increase access to safe drinking water, the project rehabilitated 52 water springs (Kakamega 16, Migori 30, and Kitui 6), enabling 47,507 people access to safe water (Kakamega 27,225, Kitui 6,000, and Migori 14,283) against the annual target of 26,000 people, a 183% achievement.

Sub-purpose 2: Increased care seeking and health promoting behavior for FP/RMNCAH, nutrition and WASH During the reporting quarter, the project carried out three - 3D/HCD exercises focusing on 4 ANC visits, SBC (Kitui), Nutrition - EIBF/EBF (Kakamega) and Child Survival – Immunization (Migori). These three are in addition to the HTSP 3D/HCD exercise carried out in in Q3 (April, 2018) of PY1. The key outputs of the 3D/HCD activities were the customized communication strategies that addressed contextual behavioral factors affecting the uptake of RMNCAH services within project areas. Subsequent to the 3D/HCD immersions, the project produced customized IEC and collateral to support its SBC and demand creation activities. The project supported the airing of radio spots and interviews in support of on-ground demand creation activities around immunization, AYSRH and HTSP. A total of ten TOTs were trained in Counselling for Choice (C4C) methodology that is the key to addressing discontinuation and will be cascaded down to the counties in PY2. The project trained 80 CHVs in the ETL Community Facilitation Methodology and 112 officers in the 3D/HCD SBC approach.

During the quarter under review, the project obtained the necessary ethical and administrative approvals from John Hopkins University and the local IRB (Amref) to conduct the gender analysis study. County-

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level study entry and buy in meetings were held with the Kakamega, Kitui, Kisumu and Migori CHMTs. The recruitment process for the study team and development of the study operation manual was initiated during the quarter under review. The findings of the study will be utilized to inform PY2 context-specific gender integration interventions.

Sub-purpose 3: Increased MOH stewardship of key health program service delivery During the reporting period, the project implemented the activities agreed upon in the joint work plans to address the county/sub-county needs. Afya Halisi provided technical support at various county level technical working groups.

Quantitative Impact Table 1 below shows a summary of the achievements against the Project’s Performance Monitoring Plan (PMP) targets in Year 1. Further details are provided in Section III of the report. PY1Q1 had no results given that the project was implementing start-up activities during that period. Table 1. Summary of project results against Year 1 targets Indicator FY18 Y1Q1 Y1Q2 Y1Q3 Y1Q4 Total % target Achievement FP/RH HL.CUST FP 14.0 Number of Health Workers 300 0 220 375 595 198% trained in commodity management through USG supported programs CUST Number of men 120 0 88 145 233 194% CUST Number of women 180 0 132 230 362 201% HL.CUST FP 15.0 Total number of Health 700 168 724 613 1505 215% Workers trained in FP/RH through in-service training CUST Number of men 238 89 285 204 578 243% CUST Number of women 462 79 439 409 927 201% HL.CUST FP 16.0 Percent of USG-assisted 15% 59% 50% 40% 40% 40% service delivery points (SDPs) that experience a stock out at any time during the reporting period of a contraceptive method that the SDP is expected to provide CUST Denominator 662 699 594 594 594 CUST Numerator 99 413 298 239 239 HL.7.1-3 Average stock out rate of 15% 24% 13% 11% 17% 17% contraceptive commodities at Family Planning (FP) service delivery points CUST Denominator 662 699 594 594 1887 CUST Numerator 99 165 80 67 312 HL.7.1-1 Couple Years protection in USG 599,508 144,531 419,006 70% supported programs 128,295 146,180 HL.7.1-1-a Urban HL.7.1-1-b Rural 599,508 144,531 128,295 146,180 419,006 70% HL.7.1-2 Percent of USG-assisted service 100% 87% 99% 99% 99% 99% delivery sites providing family planning counseling and/or services HL.7.1-2-a Numerator 726 699 594 594 594 HL.7.1-2-b Denominator 726 799 603 603 603 HL.7.2-2 Number of USG-assisted community 2,400 0 172 2,374 2,546 106% health workers (CHWs) providing Family

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Planning (FP) information, referrals, and/or services during the year HL.7.2-2-a Number of men 912 0 90 695 785 86% HL.7.2-2-b Number of women 1,488 0 82 1679 1,761 118% HL. CUST FP 18.0 Total adolescent clients (10- 36,595 10,497 9,403 11,290 31,190 85% 19) receiving FP services Maternal Health HL.CUST MCH 6.0 Number of USG-supported 274 109 123 141 141 51% facilities that provide appropriate life-saving maternity care (this will be defined as seven signal functions for BEmONC and nine signal functions for CEmONC) BEmONC 252 94 112 124 124 49% CEmONC 22 15 11 17 17 77% HL.CUST MCH 7.0 Number of women who 58,228 15,448 16,443 17,075 48,966 84% received at least 4 ANC visits during the latest pregnancy HL.CUST MCH 8.0 Total number of Community 2,400 135 276 2,331 2,742 114% Health Workers (CHWs) trained in maternal and/or newborn health through USG supported programs. CUST Number of Female 912 84 166 1,608 1,858 204% CUST Number of Male 1,488 51 110 723 884 59% HL.CUST MCH 9.0 Number of Health care 1,200 160 929 860 1,949 162% workers trained in maternal and/or newborn health care through USG supported programs CUST Number of Female 456 65 575 549 1,189 261% CUST Number of Male 744 95 354 311 760 102% HL.6.2-1 Number of women giving birth who 72,732 22,261 21,488 22,122 65,871 91% received uterotonics in the third stage of labor (or immediately after birth) through USG- supported programs HL.CUST MCH 10.0 Number of births in a 72,732 22,469 23,325 24,089 69,883 96% given year attended by a skilled birth attendant (SBA) such as doctor, nurse, or midwife HL. CUST MCH 17.0 Total adolescent clients 23,584 10,094 9,404 8,822 28,320 120% (10-19) receiving ANC Child Health HL.CUST MCH 4.0 Number of children who 88,104 28,264 24,611 26,288 79,163 90% received DPT3 by 12 months of age in USG- assisted programs HL.CUST MCH 5.0 Children who received 88,104 26,422 25,684 26,119 7,8225 89% measles vaccine by the time they were 12 months of age HL.CUST MCH 11.0 Number of children under 88,104 25,536 25,010 25,456 76,002 86% one fully immunized HL.6.3-2 Number of newborns who received 83,642 13,228 16,006 19,560 48,794 58% postnatal care within two days of childbirth in USG-supported programs HL.6.6-2 Number of cases of childhood 17,742 4,474 7,107 6,274 17,855 101% pneumonia treated in USG-assisted programs HL.6.6-1 Number of cases of child diarrhea 116,056 17,897 15,611 16,429 49,937 43% treated in USG-assisted programs

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Nutrition HL.9-1 Number of children under five (0-59 184,685 31,590 228,164 37,706 265,870 144% months) reached by nutrition-specific interventions through USG-supported programs HL.9-1-a Number of children whose 37,786 14,965 14,330 13,447 42,742 113% parents/caretakers received behavior change communication interventions that promote essential infant and young child feeding behaviors HL.9-1-b Number of children 6 - 59 months who 184,685 31,590 228,164 37,706 265,870 144% received vitamin A supplementation in the past 6 months HL.9-1-c Number of children under five who 67,312 5,422 5,314 6,859 17,595 26% received zinc supplementation during an episode of diarrhea HL.9-1-d Number of children under five who received Multiple Micronutrient Powder (MNP) supplementation HL.9-1-e Number of children under five who received treatment for severe acute malnutrition HL.9-1-f Number of children under five who were admitted for treatment of moderate acute malnutrition HL.9-1-g Number of children under five who received direct food assistance HL.9-1-h Number of male children under five 90,496 15,479 111,800 18,476 145,755 161% reached by USG-supported nutrition programs

HL.9-1-i Number of female children under five 94,189 16,111 116,364 19,230 151,705 161% reached by USG-supported nutrition programs HL.9-2 Number of children under two (0-23 9,200 1,077 1,185 10,698 10,698 116% months) reached with community-level nutrition interventions through USG-supported programs HL.9-2-a Number of male children under two 3,956 528 581 5,242 5,242 133% (0-23 months) reached with community-level nutrition interventions through USG-supported programs HL.9-2-b Number of female children under two 5,244 549 604 5,456 5,456 104% (0-23 months) reached with community-level nutrition interventions through USG-supported programs HL.9-3 Number of pregnant women reached by 63,631 14,965 14,330 13,447 42,742 67% nutrition-specific interventions through USG- supported programs HL.9-3-a Number of women receiving iron and 59,695 14,965 14,330 13,447 42,742 72% folic acid supplementation HL.9-3-b Number of women receiving 63,631 14,965 14,330 13,447 42,742 67% counseling on maternal and/or child nutrition HL.9-3-c Number of women receiving calcium supplementation HL.9-3-d Number of women receiving multiple micronutrient supplementation

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HL.9-3-e Number of women receiving direct food assistance of fortified/specialized food product HL.9-3-f Number of women < 19 years of age 5,727 10,265 9,722 8,868 28,855 504% HL.9-3-g Number of women > or = 19 years of 57,904 4,700 4,608 4,579 13,887 24% age HL.9-4 Number of individuals receiving 240 61 267 797 1,125 469% nutrition-related professional training through USG-supported programs HL.9-4-a Number of non-degree seeking 240 61 267 797 1,125 469% trainees HL.9-4-b Number of degree seeking trainees

HL.9-4-c Number of new degree seeking trainees HL.9-4-d Number of continuing degree seeking trainees HL.9-4-e Number of men 75 18 91 281 390 520% HL.9-4-f Number of women 163 43 176 516 735 451% HL. CUST N1.0 Number of health facilities with 104 104 104 105 105 101% established capacity to manage acute under- nutrition HL. CUST N2.0 Number of Children under five 21,248 3,249 2,959 3,444 9,652 45% who are underweight HL. CUST 2.0-a Male 9,349 1,432 1,300 1,447 4,179 45% HL. CUST 2.0-b Female 11,899 1,817 1,659 1,997 5,473 46% HL. CUST N3.0 Total Number of children under 304,832 306,510 306,510 306,510 306,510 101% five years HL. CUST 3.0-a Male 152,416 153,255 153,255 153,255 153,255 101% HL. CUST 3.0-b Female 152,416 153,255 153,255 153,255 153,255 101% WASH Number of people gaining access to a basic 15,000 0 6,414 32,700 39,114 261% sanitation service as a result of USG assistance Male 7,200 0 2,928 15,696 18,624 259% Female 7,800 0 3,486 17,004 20,490 263% Urban Rural 15,000 0 6,414 32,700 39,114 261% Number of communities verified as “open 50 0 31 109 140 280% defecation free” as a result of USG assistance Number of individuals trained to implement 500 379 440 819 164% improved sanitation methods Male 310 161 223 384 124% Female 190 218 217 435 229% HL.81.1 Number of people gaining access to 26,000 0 47,507 47,507 183% basic drinking water services as a result of USG assistance HL.8.1-1.a Number of Men 12,480 0 22803 22,803 183% HL.8.1-1.b Number of Women 13,520 0 24704 24,704 183% HL.8.1-1.c Urban HL.8.1-1.d Rural 26,000 0 47507 47,507 183% HL.8.2-4 Number of basic sanitation facilities 65 0 72 72 111% provided in institutional settings as a result of USG assistance

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Institution Type (School/Health Facility) 65 0 72 72 111% School 2 2 Health Facility 65 0 70 70 108%

Constraints and Opportunities During the quarter under review, the key challenges that affected activity implementation included:  Stock out of Implanon NXT and IFA. The project mitigated this shortage through redistribution and facilitated transportation from KEMSA to the counties.  Inadequate data collection tools: Isolated facilities did not have the current MoH 2016 version reporting tools. As a stop gap measure, the project facilitated photocopying of the tools based on need.  Inadequate number of providers trained to proficiency to offer voluntary surgical contraception (BTLs and vasectomy). The project will continue to engage the gynecologists in the level 4/ 5 health facilities to mentor doctor / nurse teams.  Delayed NHIF & Linda Mama rebates: The re-imbursement process is slow and the funds are not going directly to the facility accounts as the case should be, instead going to the county accounts. The project will continue to engage the counties with a view to reaching a solution to unlock and avail the funds to the facilities.

Subsequent Quarter’s Work Plan Transitioning to PY2 Q1, the project will refocus support based on a revised prioritization matrix and provide differentiated levels of support based on need and gradually weaning off support in mature sites / sub-counties. Interweaving strategies to locate women and children in the hard-to-reach areas, geographies with poor RMNCAH indicators, and rapidly intervening to address the pregnancy continuum of care, will help address maternal mortality and morbidity across the four counties. The PY2 work plan and budget was developed and submitted for review. The review has been done by USAID and the comments are being addressed. Once this is approved, the project will provide for targeted service delivery, continue to build the capacity of health care workers and CHVs on family planning, MNH, immunization, nutrition and WASH in the supported facilities based on need. The Kitui baseline assessment and the gender analysis that was initiated during the quarter under review will be finalized. The project will finalize the distribution of MNH point of care equipment that were procured during the reporting period as well as, supplies, registers and reporting tools for both facility and community health service delivery. The draft community health strategy was finalized and will be discussed with USAID for approval and subsequent roll out. The project will continue to advocate for increased budgetary allocation by county health departments to adequately address RMNCAH, Nutrition, Community Health services and WASH programs.

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II. KEY ACHIEVEMENTS (QUALITATIVE IMPACT)

Sub-purpose 1: Increased availability and quality delivery of FP/RMNCAH, nutrition and WASH services

Output 1.1.: Strengthened FP/RMNCAH, nutrition and WASH service delivery at health facilities, including referral from lower level facilities and communities. 1.1.1 Strengthen facility service readiness, quality of care and measurement to increase effective coverage of FP/RMNCAH, nutrition and WASH services

Family Planning During the quarter under review, Afya Halisi continued to support high impact family planning interventions aimed at improving access to quality family planning services in the public and private sector facilities. During the reporting period, the project supported a total of 594 out of 603 (99%) health facilities to provide FP counseling and/or services. During the quarter, the project achieved a couple-years of protection (CYP) of 146,180, an increase of 14% compared to the CYP of 128,295 in PY1Q3 period. The project achieved a total CYP performance of 419,006 in PY1, an achievement of 70% against the PPR target of 599,508 as shown in Figure 1 below.

700,000 599,508 600,000 500,000 419,006 400,000

CYP 300,000 197,838 173,857 198,754 200,000 143,882 83,931 78,102 85,029 100,000 57,121 - Kakamega Kisumu Kitui Migori Project CYP target 83,931 197,838 143,882 173,857 599,508 Jan-March 2018 20,750 24,897 27,429 71,455 144,531 April-June 2018 18,372 23,315 25,441 61,167 128,295 July-Sept 2018 17,999 29,890 32,159 66,132 146,180 PPR 2018 results 57,121 78,102 85,029 198,754 419,006 % Achievement 68% 39% 59% 114% 70%

Figure 1. CYP achievement by County, Year 1

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In the private sector health facilities, the performance in CYP improved from 14,598 in PY1Q3 to 16,354 in PY1Q4. The total CYP achievement in the private sector health facilities in PY1 was 67,071, contributing to 16% of the project’s overall CYP as shown in Figure 2 below.

450,000 30% 400,000 25% 25% 350,000 300,000 20% 250,000 16% 15% 200,000 CYP 150,000 11% 11% 10% 100,000 5% 50,000 - 0% Y1Q2 Y1Q3 Y1Q4 PPR 2018

Project Year 1 results 144,531 128,295 146,180 419,006 Private sector Year 1 results 36,119 14,598 16,354 67,071 % Private sector contribution 25% 11% 11% 16%

Figure 2. CYP Performance in Private sector facilities and contribution to project performance in Year 1

During the reporting quarter, a total of 613 health workers (204 male and 409 female) were trained on FP across the 4 counties through central training, CME, whole-site orientation and mentorship. This brought the total health workers trained in PY1 to 1,505, translating to an achievement of 215% against PPR target of 700. The over-achievement resulted from the skills gap that was noted in the project supported health facilities. Migori contributed the largest number of health workers trained, at 936 (407 male and 529 female), followed by Kisumu at 255 (70 male and 185 female), Kitui at 239 (81 male and 158 female) and lastly Kakamega at 75 (20 male and 55 female). The trainings included LARC standardization, on-site trainings in PPFP and trainings in FP compliance in all the focus sub-counties. During the quarter, the project intensified efforts in capacity building of community health workers (CHWs) to enable them to offer FP messages and correct myths and misconceptions about FP as well as refer clients to health facilities for FP services. The CHWs were also to assist in mobilization of clients for in-reach and outreach services for hard to reach populations. In PY1Q4 period, the project reached 2,374 CHWs (695 male and 1,679 female) who received training on FP technical module, bringing the cumulative total to 2,546 CHWs (785 male and 1,761 female) reached with the training, an achievement of 106% against PPR 2018 target of 2,400. At county level, Out of the 2,546 CHWs, 255 (10%) were from Kakamega County, 690 (27%) from Kisumu, 914 (36%) from Kitui and 687 (27%) from Migori County. At the end of all the sessions, the CHVs were reminded of the fact that family planning is voluntary and uptake of the services does not have any target attached, but depends on individual decision and need not be forced, enticed or incentivized to consider any method of family planning.

FP compliance In PY1, all Afya Halisi project staff were taken through the eLearning course on US Abortion and FP Requirements as part of FP compliance monitoring. All project staff completed the eLearning course, with all the certificates being submitted to USAID. As new project staff join the project, Afya Halisi will ensure that they undertake the eLearning course as part of end of probation

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requirements. This will help project staff to focus on identifying and addressing vulnerabilities in programs before they become violations. During Q2 of PY1, the project identified potential vulnerability/violations in project supported health facilities in Kakamega as a result of Ipas’ interventions on comprehensive abortion care services. Ipas is a non-governmental organization that works to ensure that women can obtain safe, respectful and comprehensive abortion care. The project reported these potential vulnerabilities/violations to USAID. The project also held discussions with the CHMT/SCHMTs and facility staff in-charges during various forums to address the FP compliance issues. The project conducted sessions on FP compliance for various HCWs in project supported health facilities in Kakamega. In addition, the project generated and shared a one pager fact sheet with project supported health facilities and CHVs as part of continued sensitization on FP compliance. The county specific activities were as detailed below.

Kakamega county During the quarter, the project provided FP service delivery support in all the 50 project supported health facilities in the three focus sub-counties and Kakamega County Government Teaching and Referral Hospital (KCGTRH). Kakamega achieved a CYP of 17,999 a reduction from the previous quarter’s CYP of 18,372. This was mainly attributed to erratic supply of FP commodities. The implants were the commonly available method in the months of June and July across the county. The total CYP for year 1 was 57,121, an achievement of 68% against the county’s PPR target of 83,931.

Strengthening LARC service delivery: Afya Halisi project supported scale up of LARCs in 36 (72%) of the supported health facilities to ensure increased access to LARCs. MOH LARCs mentors cascaded skills to 37 service providers in 5 health facilities giving an annual total of 75 HCWs from 51 health facilities. To support service delivery for LARC, 81 IUCD sets, and 81 implant removal were distributed in 50 health facilities. 15 HCWs received onsite mentorship on implant removal to increase provider capacity to offer comprehensive FP services. To support community health services, 253 community health workers were trained in FP to strengthen demand creation for FP services. Currently 30 CHVs in Kakamega are providing refills in the various select CUs.

Scale up of PPFP: In order to support scale up of PPFP, 66 HCW from 34 high volume facilities were trained on PPFP in Q4 bringing the total of staff trained to 101HCWs from 40 facilities for PY1. The program also procured and distributed 29 PPIUD sets in the supported health facilities.

Scale up of Voluntary Surgical Contraception: The project supported a team of surgeon-nurse teams to provide BTL services in outreach sites including the Khwisero SCH during the world Contraception day celebrations. A total of 50 clients received BTL in the reporting quarter, bringing the total clients reached in PY1 to 132 clients. In PY2, the project will scale up provision of BTL services to clients in need.

Strengthening BCS+: A total of 66 HCWs from 34 health facilities were oriented on BCS+ and C4C as a strategy to improve uptake and retention of clients on family planning giving a year 1 total of 90 providers from 36 health facilities reached during project year one. Strengthening of BCS+ ensured that there is improved method satisfaction among the clients and reduced method discontinuation.

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FP Compliance: A total of 11 project staff based in Kakamega underwent the mandatory training on the US abortion and FP requirements with 100% pass rate. Additionally, 97 healthcare workers from 50 facilities were sensitized on FP compliance and received the one pager on compliance totaling to 327 healthcare workers reached during PY1.

Supporting world day celebrations: Afya Halisi supported Kakamega County to commemorate the world contraceptive day (WCD) that was celebrated on 26th September 2018 at Khwisero Sub- County. About 500 people attended the function which was graced by the First Lady of Kakamega County. Integrated FP camps were held in various sub-counties in commemoration of the same event.

Kisumu County During the quarter, the county achieved a CYP of 29,890 bringing the total in PY1 to 78,102 against the county’s PPR target of 197,838, an achievement of 39%. All the 123 health facilities supported by the project were providing FP counseling and/or services. Key attributable achievements of the of the project include increasing the pool of LARC providers across different health facilities, increasing the social franchises providing LARCs, supply of FP equipment and improving FP compliance Scale up of LARC: The project supported MOH LARCs mentors to strengthen skills of 168 service providers in 43 health facilities giving an overall total of 255 HCWs from 67 health facilities for year 1. Additionally, the project conducted capacity building of 647 CHWs to equip them with knowledge for demand creation and community based distribution (CBD). The project procured and distributed 189 IUCD sets, and 197 implant removal sets which were distributed in 123 health facilities

Scale up of PPFP: The project supported classroom based training with a focus towards skills competency acquisition on PPFP for 43 high volume facilities where a total of 169 healthcare workers were reached during the quarter, reaching an overall total of 255HCWs from 43 facilities in year 1. To strengthen immediate PPIUCD uptake, the project procured 81 PPIUCD sets that were distributed to 75 supported health facilities. The project is using Afya Halisi SDOs to track PPFP uptake especially for methods given within the 48 hours of delivery.

Scale up of Voluntary surgical contribution: During the reporting period, 45 clients were done BTL culminating to a total of 206 BTLs carried out as compared to 70 in the previous year’s performance. The significant increase was contributed to by the project supporting roving surgical teams and revitalization of the BTL theatre at JOTRH. In addition, the project was able to support mentorship of 10 medical officers and 2 Reproductive Health Clinical Officers in offering permanent FP methods.

Strengthening BCS+: Afya Halisi supported orientation sessions on BCS+ and C4C where a total of 168 HCWs from 43 health facilities were reached. This brought the total to 255 providers from 67 health facilities reached in PY1.

FP Compliance: A total of 17 project staff based in Kisumu underwent the mandatory training on the US abortion and FP requirements. The project sensitized a total of 459 healthcare workers from 119 facilities on FP compliance.

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World Contraception day (WCD) celebrations: Afya Halisi supported Kisumu County to commemorate the World Contraceptive Day (WCD) that was held on 26th September 2018, with the climax in Simba Upepo Health Centre. Integrated FP camps was held at the venue reached 234 clients with FP information, 74 received DMPA, 149 received implants and 6 received pills. Additionally, 10 new ANC clients received services while 40 children received Vitamin A. During this event, Afya Halisi handed over the procured equipment including IUCD sets, PPUICD sets and Implant removal sets.

Migori County During the quarter, a total of 175 out of 180 (97%) health facilities provided FP counseling and/or services. The county achieved a CYP of 66,132, bringing the total achievement to 198,754 against the county’s PPR target of 173,857, an achievement of 114%. To achieve this, the project supported various MOH staff capacity building activities; training of 32 mentors on LARC standardization and mentorship on LARC in 26 facilities reaching 119 HCWs during facility in- reaches. Orientation on Basic Counseling Skills plus (BCS+) using the cards was also conducted, reaching a total of 86 HCWs from 35 health facilities. The project also conducted mentorship on Counseling for Continuation (C4C) and Provider Initiated Family Planning reaching a total of 92 HCWs.

Scale up of LARC: The project utilized the 25 MOH LARC mentors to cascade skills to service providers in 57 health facilities where a total of 121 service providers were reached through mentorship, culminating into 337 HCWs from 131 health facilities during PY1. Additionally, the project conducted capacity building of HCWs through a facility level step down training (SDT)1 where a total of 56 HCWs from 23 facilities were trained on LARCs including LNG IUS. During the LARC trainings, providers were also given skills on implant removal to ensure they were able to serve clients seeking implant removal services. To support equipment availability, the project procured 240 sets of IUCD sets and 140 implant removal sets which were distributed to 143 health facilities within the county.

Scale up of PPFP: To improve the uptake of PPFP, the project conducted whole-site orientation in 14 high volume facilities reaching a total of 195 healthcare workers during the quarter. This brought the total number of service providers trained in PY1 to 307 HCWs from 35 high volume facilities. To strengthen PPIUCD services, in addition to the training, the project procured and distributed 140 PPIUCD sets to 94 supported health facilities. In collaboration with Advance Family planning project, Afya Halisi conducted a performance review meeting for PPFP service provision where poor data capture was identified as the main barrier to programmatic decisions. Going forward, the project will scale up immediate PPFP within 48 hours as a high impact intervention to improve HTSP.

Scale up of Voluntary surgical contribution: During the reporting period, two BTL camps were held in Uriri and Kuria West sub-counties where a total of 56 women received BTL. This was a significant increase compared to the previous quarter where only 4 clients were done BTL. In total, 72 clients were done BTL in year 1. Migori county has had shortage of providers trained in

1 Step down training is a cost effective method of training HCWs where trained and certified LARC mentors are used to cascade the skills to other service providers by undergoing a two-day theory and demonstration/counter demonstration followed by a three-day practicum.

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permanent FP methods. To address this gap, the project supported a team of 5 BTL nurses and surgeons from Kakamega County to provide BTL services as well as mentorship of 6 providers (3 Doctors, 1 RH clinical officer and 2 nurses) in Migori county. These providers are expected to help reduce unmet need for permanent methods in Migori County

Strengthening BCS+: In order to improve method satisfaction among the clients and reduced method discontinuation, the project supported orientation of 192 HCWs from 33 health facilities on BCS+ and C4C in the quarter under review, bringing the total in Year to 370 providers from 113 health facilities. During the reporting period, 785 women received LARC services out of which only 40 (5%) came for method discontinuation. Eighteen (45%) of those intending to discontinue the method desired to have a pregnancy. Using these findings, Afya Halisi will strengthen tracking of method discontinuation/switching which will be implemented as a learning agenda. In addition, Afya Halisi project strengthened monitoring of FP compliance requirements.

FP Compliance: A total of 36 project staff based in Migori underwent the mandatory training on the US abortion and FP requirements. Additionally, 254 healthcare workers from 20 facilities were sensitized on FP compliance totaling to 408 healthcare workers reached during PY1.

World Contraception day (WCD) celebrations: During the reporting period, Afya Halisi supported Migori County to commemorate the world contraceptive day (WCD) that was held on 26th September 2018, with the climax held at Pau Nyuka grounds in Suna East. Themed “It’s your life, it’s your choice”, the event aimed at inspiring women especially adolescent girls to make the right decisions regarding their contraceptive choices. Integrated FP camps were held in various sub-counties in commemoration of the same event where a total of 176 women were reached with family planning services.

Kitui county

During the quarter, the county achieved a CYP of 32,159, an increase of 26% from the previous quarter’s CYP of 25,441. This increase is attributed to the project interventions that included; capacity building of HCWs, availing commodities, equipment support and, support for inreaches, outreaches and FP camps. This brought the total in PY1 to 85,029 against the county’s PPR target of 143,882, an achievement of 59%. The project provided FP service delivery support in 246 out of 250 (98%) project supported health facilities. The project will intensify efforts aimed increasing FP uptake even as clients are empowered to make informed decisions on FP. Scale of PPFP: The project continued to promote post-partum family planning in four hospitals in the county: , Kitui, Kyuso and Tseikuru. A total of 133 clients benefited from FP services in the postpartum period in these hospitals (121 implants, 2 POPs, 8 BTLs and 1 female condom). Seventy-five health care providers from 10 facilities were trained on the ten modules of Postpartum family planning through whole site orientation. Most providers lacked skills in PPIUCD insertion. In Year 2, the project will support mentorship of providers in PPUICD.

Family Planning equipment distribution: Afya Halisi supported MOH with various FP equipment including: 271 IUCD sets, 134 PPIUCD sets, 104 cut down sets and 267 implant removal sets. The project did distribute equipment to 127 Dispensaries, 75 health centers and 16 hospitals. The allocation for the sites was informed by the facility assessment conducted last quarter. These are meant to improve FP service delivery especially LARC.

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FP compliance: In addition to US Abortion and FP Requirements certificate, all the Kitui staff including the HRH took the protecting life global e-learning certificate course during the reporting quarter. This has enabled the team to monitor compliance during their routine support to both the MOH and public health facilities. No violations or potential vulnerability was reported in the quarter.

World contraceptive day celebration: The project supported the County in celebrating the WCD at level 4 hospital grounds. Speakers during the launch highlighted the importance of embracing family planning as a development component and as a measure to curb the high teenage pregnancies in the county. The activity was integrated with a FP camp where 42 clients received BTL services.

Maternal and Newborn Health In Year 1, the project implemented an integrated provision of high impact MNCH interventions aimed at enhancing access to quality antenatal services, skilled care during childbirth, immediate newborn and postnatal care and improved access to child health interventions.

Scale up of EmONC services: In Year 1, the project worked with counties' health departments to operationalize facilities to provide emergency maternal and newborn health services. At the end of Q2 (January-March 2018), there were a total of 109 EmONC health facilities, 15 of these being comprehensive sites (CeMONC). Sustained technical assistance and operational support realized a rise to 141 facilities, 17 of whom are CEmONC sites at the end of Y1Q4 period. The project assessed functionality of these facilities on a quarterly basis to ensure consistent and readiness to provide emergency services. Out of the 17 CEmONC facilities, 7 are in Migori, 6 in Kitui, 3 in Kisumu and one in Kakamega. The numbers reported in Year 1 reflects the facilities that were fully functional in provision of recommended emergency care services. At the end of Year 1, Muhoroni hospital - in Kisumu; Rongo and Awendo hospitals - in Migori; Navakholo sub county hospital in Kakamega and and Ikutha hospitals in Kitui were all at advanced stages of being CEmONC sites. The counties have instituted mechanisms to facilitate the operationalization of the facilities including renovation of some of the structures (Kitui and Migori) and employment of health care workers (Kitui). To address human resources gaps, the project hired health care workers in Kisumu, Migori and Kitui to support the functionality of these facilities, as explained in the later stages of this report. The project identified gaps on equipment and some facilities received equipment.

In addition, the project supported capacity building activities to improve service providers’ skills and knowledge on provision of EmONC services. In Year 1, a total of 1,949 service providers (Kakamega 250, Kitui 478, Kisumu 476 and Migori 745) received CMEs and trainings on various EmONC topics including; the five-day EmONC training, targeted sessions on management of eclampsia, PPH and UBT, essential newborn care, partograph use, AMTSL and shock management. During the reporting quarter, project supported health facilities recorded a total of 38 maternal deaths, with 92% of them being audited as shown in Figure 3. In addition, there were 436 perinatal deaths with 93% of them being audited. In Year 1, the health facilities recorded a total of 89 maternal deaths and 1,325 neonatal deaths. This is equivalent to 1 maternal death in every 785 deliveries conducted by a skilled health provider and 1 neonatal death for every 53 deliveries. This is still a very high number of maternal and newborn deaths that are largely preventable. In Migori, half of the 29 maternal deaths in Year 1 occurred in Q4. In the same county,

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17 of the 29 maternal deaths occurred in Migori County Referral Hospital. The project started advocacy with the county governments in Kitui, Migori and Kisumu to operationalize more comprehensive emergency facilities.

100% 100% 100% 90% 91% 93% 91% 92% 100% 86% 88% 89% 87% 100% 93% 80% 92% 92% 88% 91% 89% 91% 60% 58% 40% 56% 55% 56%

20%

0%

Proportion of maternal deaths audited Proportion of perinatal deaths audited

Figure 3. Maternal and Perinatal deaths audited at health facilities, Year 1

In Year 1, 48,966 pregnant women completed 4 ANC visits, which represents 84% achievement of the targeted 58,228 as shown in Figure 4. There was a 6% increase (from 15,448 in Y1Q2 to 16,443 in Y1Q3) in the cumulative performance in Y1Q3 and a 4% improvement in Y1Q4, from 16,443 in Y1Q3 to 17,705 achieved in Y1Q4.

90% 93% 70,000 84% 100% 78% 60,000 76% 80% 50,000 40,000 60% 30,000 40% 20,000 4thANC visit 20% 10,000 - 0% Kakamega Kisumu Migori Kitui Project PPR Target 7,570 18,633 18,633 13,392 58,228 Total Achievement 6,834 14,562 17,416 10,154 48,966 % Achievement 90% 78% 93% 76% 84%

Figure 4. 4th ANC visit cumulative achievement, Year 1

In the same reporting period, the project achieved a total of 69,883 births attended to by skilled personnel, a 96% achievement against the target of 72,723 as shown in Figure 5 below. Total contribution of the private sector was 16% and 17% in the project achieved results for completion of 4 ANC and skilled care at birth respectively.

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80,000 140% 70,000 120% 120% 114% 60,000 96% 100% 50,000 79% 81% 80% 40,000 SBA 60% 30,000 20,000 40% 10,000 20% - 0% Kakamega Kisumu Migori Kitui Project PPR Target 9,456 23,274 23,274 16,728 72,732 Total Achievement 11,360 18,355 26,548 13,620 69,883 % Achievement 120% 79% 114% 81% 96%

Figure 5. Skilled birth attendance cumulative achievement, Year 1 At the end of Year 1 implementation, coverage for 4th ANC visit was at 46%, Kakamega highest at 49%, Kisumu at 48%, Migori at 47% and Kitui at 41%. However, it should be noted that coverage of skilled birth attendance based on population estimates provided by DHIS2 was lower than the performance achieved against the target with the project's overall coverage for skilled birth attendance at 66% as at end of Year 1. At county level, Kakamega County skilled birth attendance coverage was 82%, Migori at 72%, Kisumu at 61% and Kitui at 55%.

Capacity building of CHVs: During the quarter, the project supported MOH to conduct MNH refresher training for 2,331 CHVs, bringing the total CHVs trained in Year 1 to 2,742 CHVs against the annual target of 2,400, a 114% achievement. The training equipped the CHVs with technical knowledge to enhance their capacity in supporting community MNH services delivery, especially in providing information on maternal health to improve knowledge of mothers on pregnancy related risk, birth planning, pregnancy related complication, danger signs, importance of ANC among others. This is expected to contribute to increased utilization of maternal health services, and improvements on 4th ANC, skilled birth attendance, and utilization of Post Natal Care (PNC) services. The CHVs were also sensitized on Chlorhexidine for umbilical cord care for the prevention of bacterial infections that causes sepsis and death in newborns. Further to that, the CHVs were taken through key concepts of Kangaroo Mother Care for low birth weight newborns, specifically on the prolonged skin to skin contact between baby and the mother’s chest to provide warmth, initiate prompt breastfeeding, reduction of severe infection/sepsis amongst other benefits to newborns and more so low birth weight babies.

Contribution of private sector health facilities to Maternal and Newborn Health: During the quarter under review, the project continued to provide MNH support in the supported private facilities. As a result of the project’s support, there was an improvement in 4th ANC attendance, and skilled birth attendance (SBA) in the reporting quarter compared to Y1Q3 as shown in Figure 6 below.

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60,000 25% 21% 50,000 20% 16% 40,000 13% 13% 15% 30,000 10% 20,000

10,000 5% 4thANC visit - 0% Y1Q2 Y1Q3 Y1Q4 PPR 2018 Project Year 1 results 15,448 16,443 17,075 48,966 Private sector Year 1 results 3,267 2,135 2,238 7,640 % Private sector contribution 21% 13% 13% 16%

Figure 6. Private sector contribution to 4th ANC performance in Year 1

The 4th ANC attendance in private sector increased from 2,135 in Y1Q3 to 2,238 in Y1Q4, bringing the total 4th ANC attendance in Year 1 to 7,640, a contribution of 16% to the project performance.

Similarly, skilled birth attendance increased from 3,396 in Y1Q3 to 3,504 in Y1Q4 bringing the total skilled birth attendance performance for PY1 in private sector to 11,729, a contribution of 17% to PY1 performance. The noted improvement of MNH indicators in the private sector is attributed to the project’s support in intensified integrated outreaches and in-reaches where ANC services were also provided free of charge in all the 4 counties. Demand for ANC services was created through community mobilizers and CHVs attached to the private facilities who integrate demand creation sessions for more impact. The in-reaches and outreaches provided opportunities for the private providers to market their delivery services, some of which were subsidized through the efforts of Afya Halisi. Three outreaches that were done evidently showed an increase in the 4th ANC attendance.

The county specific activities with outputs achieved during Year 1 implementation are described below.

Kakamega County At the end of Year 1, the project had identified 23 facilities with the potential to provide basic emergency obstetric and newborn care. Out these, only 8 facilities (7 BEmONC and 1 CEmONC) consistently met the assessment on provision of all the relevant signal functions. The only facility that has comprehensive functions is the Kakamega County Referral Hospital (KCGTRH) where the project provided enhanced support including training in emergency maternal and newborn care and quality improvement. In Year 1, the project reached 250 health care providers with capacity strengthening on various aspects or maternal and newborn care. The major trainings were EmONC, essential newborn care, quality improvement and respectful maternity care. The topics discussed during CMEs included obstructed labor, PPH and AMTSL, correct use of partograph, and proper documentation in ANC and PNC registers. During the training, the project integrated sessions on mainstreaming gender norms in provision of maternal health services.

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Of the 22 maternal deaths that occurred in Year 1, only one was not audited. During the same period, 368 perinatal deaths majorly caused by birth asphyxia, were reported in the county. Auditing of the perinatal deaths remained a major challenge in the main hospital due to inadequate technical staff to offer guidance on the clinical audits and the subsequent response.

Kisumu County In Year 1, the project conducted quarterly EmONC assessments all the 83 potential EmONC health facilities (73 BEmONC, 10 CEmONC) in Kisumu County. A total of ten facilities had capacity to provide BEmONC services and three facilities were able to provide CEmONC services. In the same period, Afya Halisi provided direct support for capacity building to 476 health care providers from the six focus sub counties on different aspects maternal and newborn care. The topics covered included emergency preparedness and care for maternal and newborn emergencies, post-natal care, essential newborn care, AMTSL, PPH, use of uterine balloon tamponade (UBT), eclampsia and use of partograph.

Of the 10 maternal deaths that occurred in Q4, 8 were audited. As a follow up in one of the recommendations during the maternal death audits, Afya Halisi provided technical support through a mentorship plan for the surgical teams. There was a revision of the MPDSR meeting structures with a re-orientation of the national MPDSR guidelines to the sub-county teams. Mapping of the pregnant women was done through the community health structures with targeted community level conversations. Maternity open days were held in 31 of the targeted 83 EmONC sites, although all the facilities struggled to maintain the essential functions in maternal and newborn care.

Migori County In the last quarter, Afya Halisi continued to scale up provision of quality EmONC services across public and private facilities. The scale targeted 80 high volume facilities, 100% increase compared to 38 facilities that were supported in the previous quarter. EmONC CMEs were conducted in 70 health facilities that reached 863 healthcare workers. Topical subjects addressed during the CMEs included; PPH management, neonatal resuscitation, antenatal corticosteroids and eclampsia. Lack of partographs was one of the key challenges that the project experienced in the previous quarters. As a result, Afya Halisi procured 3,000 maternity files that were distributed across all the health facilities. This excluded the facilities that receive maternity files from the PTBI study project. This was followed up with intensive mentorship on the use of the partograph where 204 health care workers from 61 health facilities were reached. This resulted in improvement in deliveries with a complete partograph from 54% in quarter 2 to 75% in quarter 4. BEmONC assessments were conducted in all the 80 sites where 72 (90%) met all the signal functions. Missing functions were mainly lack of vacuum extractors and IV antibiotics. Afya Halisi supported the county to redistribute Mama Packs where 2,500 mama packs were supplied to 60 facilities with poor SBA coverages. The helped to increase SBA in these facilities. Lack of 24-hour maternity services was one of the main challenges where more than 60% of the facilities conducting deliveries did not operate for 24 hours.

Over the year, the project supported a total of 745 health care workers in knowledge and skill enhancement in different aspects in maternal and newborn care. In addition, the project supported CHVs to map a total of 651 pregnant women who are at different gestation stages.

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Kitui County Kitui reported the highest increase in women with skilled birth attendance by 17%, from 4,156 in Y1Q2 to 4,853 in Y1Q4 with an overall performance of 81% of the year’s target of 16,728. Initiation of maternal waiting homes in the county contributed to this performance, with Kyuso sub county hospital achieving marked improvement in births by skilled care, from average of 35 deliveries per month in 2017 to an average of 46 deliveries in second half of Year 1. Out of the county’s PPR target of 82 health facilities (77 BEmONC, 5 CEmONC) in the six sub-counties, 35 health facilities met the seven signal functions for BEmONC and six health facilities met the nine signal functions for CEmONC. Capacity building efforts through trainings and CMEs in maternal and/or newborn health care were conducted across the project reaching a total of 478 health care workers. During the training, an important element in the respectful care emphasized was value clarification and attitude transformation (VCAT). Maternity open days were conducted in all the BEmONC health facilities in all the six sub counties. During the open days, pregnant women and the general public were taken through a maternity tour and educated on labor and delivery to demystify unfounded notions on child birth processes at health facilities.

Strengthening Preterm care: This was done across all the focus counties. In Kakamega County, three facilities were identified to provide buddy mentorship on care for pre-mature infants. In Kisumu County, additional KMC centers of learning were established bringing the total to 26 facilities from 18 in Q2. In Migori County, 69 facilities providing KMC were supported through orientation of 185 HCWs. The project collaborated with the Preterm Birth Initiative (PTBI), a Migori-based study project to strengthen the quality of PTB care in 9 intervention sites. CMEs on KMC to commemorate the world KMC day celebrations were held across 8 facilities where 194 healthcare workers were reached. A follow up of beneficiaries of KMC was done during the event where 8 mother baby pair who underwent successful KMC gave their experiences. Kitui county has 68 facilities identified in Q2 with functional KMC spaces. Afya Halisi maintained its support initiated in Q2 by providing technical sessions on preparedness and management of pre-term labour. An emerging issue is the community’s stigmatization of families with pre-terms, some of them considering the pre-terms and very low birth weights as unfit to thrive. The project’s community health strengthening team supported community conversation to highlight the need for family and community support in care of the preterm and small babies.

Institutionalizing of Maternal Perinatal Death Surveillance and Response: In Year 1, the project continued to support MPDSR processes at county, sub county and facility level. Migori, Kakamega and Kitui had established county level MPDSR systems, although with some deviation from the national guidelines. Particular focus was placed on establishing MPDSR structures with the private sector. In the reporting period, 71 health care workers from the private facilities in the four counties were trained on use and adoption of the national MPDSR structures.

Kakamega County At project inception, there were no functional MPDSR structures in Kakamega and the project set out to institutionalize the structures. As such and because of management changes in all the counties, the project conducted a management-level orientation on MPDSR at county and sub county levels. Subsequently, the project supported quarterly sub-county MPDSR meetings for the three sub-counties and the county’s main referral hospital. The project ensured that maternal death audits were conducted and supported response plans. During the audit, some interventions were proposed to address identified gaps including; improving availability of blood and its products, encouraging service providers to consider use plasma expanders especially for the high volume

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sites, improving on partograph use to monitor labour and decision making to reduce third delay. It was also agreed that there should be standardization of referral notes to facilitate in-depth documentation as most of the mothers who were referred had incomplete documentation on the processes of care. While maternal deaths audits have been conducted and reported promptly in the DHIS, review of perinatal deaths was a gap at project inception. All the 8 maternal deaths that occurred in Q4 were audited. In addition, all but one of the 22 maternal deaths that occurred in PY1 were audited and reported in DHIS2. At project inception (Q2), only 20% of the 118 perinatal deaths that occurred were audited while 99% of the 111 perinatal deaths that occurred in Q4 were audited, a 79% increase in the proportion of perinatal deaths that were audited.

Kisumu County Kisumu county had the highest proportion of maternal deaths against institution based deliveries. In the period of implementation in PY1, there were a total of 26 maternal deaths, a ratio of one maternal death in every 706 deliveries. Jaramogi Oginga Odinga Teaching and Referral Hospital (JOOTRH) had the highest number of maternal deaths, accounting for 9 of the 26 cases. Perinatal deaths remain very high in the county with Q2 reporting 51 deaths, Q3 - 84 deaths and Q4 - 101 deaths. However, long term structural and service delivery efforts have been put in place to reduce the perinatal deaths and these will be monitored for impact. In Q3 and Q4, the project supported formation of sub county maternal and perinatal deaths surveillance and response (SCMPDSR) committees, some of whom had been inactive for more than six months. Although the county had an active county level surveillance system, the project advised on the control and management of the large number of participants noted in the county forums. In response to the gaps identified, the county conducted had two blood drives to improve on availability of blood and its products in the blood bank. Another gap noted during the audits was monitoring of women in labour and post- delivery care, particular observation of vital signs. In the year under review, Afya Halisi supported provision of monitoring equipment to the main referral facilities in Ahero, Kisumu county hospital and JOOTRH. Advocacy on procurement of essential drugs and drug redistribution to improve availability of the commodities was done. The project supported the county to draft a referral strategy to improve referral path ways especially for the sub county hospital. The project’s technical team provided on-site technical guidance on safe surgery practices to the surgery team at Ahero county hospital, one of the three government-funded CEmONC facilities. Migori County In Q4, Afya Halisi supported MPDSR meetings at facility, sub-county and county level where a total of 82 facility MPDSR meetings were held, 8 quarterly sub-county MPDSR meetings held and one county meeting held. During the quarter, there were 16 maternal deaths that occurred in the county totaling to 29 maternal deaths in Year 1. The main causes of the deaths noted in the audits were bleeding in 5 (17%) of the cases, 7 (24%) were due to complications of anemia, 3 (10%) due to eclampsia, 2 (7%) due to ruptured uterus and 12 (41%) due to other causes that included Sepsis, HIV and complications of abortion. Eighty percent of the maternal deaths were as a result of the third delay, 7% due to the second delay and 13% due to the first delay. Key activities supported by the Afya Halisi to reduce maternal and perinatal deaths included; sensitization on the MPDSR guidelines, adoption of MPDSR tracker for timely reporting of maternal deaths and targeted capacity building initiatives including mentorship, OJT and CMEs.

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Kitui County In Q4, all the four maternal deaths that occurred in the county were audited. The perinatal deaths were still high in the county, averaging 32 per month. Afya Halisi started capacity strengthening efforts targeting the high volume facility because of the large cases of newborns received in these facilities. In Mwingi, advocacy efforts to have increase service coverage at the main maternity hospital were realized as the hospital deployed a registered clinical officer to the maternity department. Almost two thirds of the perinatal deaths occurred in two facilities – mission hospital and Kitui referral hospital. Mutomo mission hospital was severely affected by an exodus of health care workers who joined the county government public service during staff recruitment. As the only comprehensive emergency care facility in Kitui South, Afya Halisi deployed two nurses to support the facility as part of health systems strengthening efforts. Immunization During the quarter, the project supported MOH to fully immunize 25,456 children under one bringing the total FIC in Year 1 to 76,002, an achievement of 86% against the PPR target of 88,104 as shown in Figure 7.

100,000 97% 95% 86% 100% 90,000 80% 80,000 71% 80% 70,000 60,000 60% 50,000 FIC 40,000 40% 30,000 20,000 20% 10,000 - 0% Kakamega Kisumu Kitui Migori Project PPR Target 12,335 27,312 18,502 29,955 88,104 Total achievement 9,927 19,512 18,035 28,528 76,002 % achievement 80% 71% 97% 95% 86%

Figure 7. FIC cumulative achievement, Year 1 The project’s coverage for fully immunized children as at end of Year 1 (January to September 2018) was 78% as shown in Figure 8 below.

100% 86% 86% 80% 81% 78% 78% 80% 73% 72% 70% 70%

60%

40%

20%

0% Kakamega Kisumu Migori Kitui Project

FIC coverage as at Y1Q3 FIC coverage as at Y1Q4

Figure 8. FIC coverage trends, as at end of Y1Q3 and Y1Q4

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The project contributed to the results through strengthening provision of services in health facilities by training HCWs on REC approaches, micro-planning, middle and operational level management, ensuring vaccine/commodity security and supporting MOH teams to conduct supervision. In addition, the project mobilized community members through CHVs and HCW during outreaches and door to door campaigns. The counties of Kisumu, Kakamega and Kitui still have some recalcitrant pockets with high number of unimmunized children. The project will prioritize support to these areas in Year 2. The project built the capacity of 152 HCWs on immunization in Year 1. This resulted in improved capacity of health facilities to update their micro-plans, monitor EPI fridge temperature and conduct preventive maintenance. The project is working with CHMTs, SCHMTs and HCWs to address gaps that were noted before training. These gaps included: inadequate maintenance of cold chain, partially filled temperature monitor charts and incomplete updating of immunization monitor charts.

Contribution of private sector health facilities to immunization services In the project supported private sector facilities, a total of 11,011 children under one were fully immunized by the time they were 12 months of age in Year 1. This is a contribution of 14% to the project performance in Year 1 as shown in Figure 9 below.

80,000 25% 20% 70,000 20% 60,000 14% 50,000 12% 11% 15%

40,000 FIC 30,000 10% 20,000 5% 10,000 - 0% Y1Q2 Y1Q3 Y1Q4 PPR 2018 Project Year 1 results 25,536 25,010 25,456 76,002 Private sector Year 1 results 5,086 3,048 2,877 11,011 % Private sector contribution 20% 12% 11% 14%

Figure 9. Contribution of private sector facilities to project performance in Year 1

The performance in child immunization in the private sector was contributed to by the intensified outreaches and in-reaches carried out in quarter 4 of PY1 in all the four counties. The project also strengthened defaulter tracing in private health facilities. Supervisors took HCWs through permanent registers and helped them identify immunization defaulters. Community mobilizers and CHVs were issued with defaulter tracing books with list of defaulters and contacts of the parents or guardians. The mobilizers and CHVs visited the households of the defaulters to understand the reasons for their missing of immunizations and referred them accordingly. Outreaches were organized in locations with most defaulters to increase coverage. Due to Afya Halisi’s support, a number of private facilities started offering immunization services. Afya Halisi advocated for issuance of cold chain equipment and vaccines to private sector facilities to begin immunization services especially in Kakamega County where GAVI has been providing technical and material support for immunization. With the technical support of Sub county public health nurse, most private facilities were able to start providing immunization services competently

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and 2 health facilities received EPI fridges procured through World Bank/GAVI. Afya Halisi will train private providers on EPI in PY2.

The county specific activities with outputs achieved during the reporting period are described below;

Kakamega County In Q4, 3,414 children under one year received Penta 3 vaccine bringing the cumulative performance of the project in Year 1 to 10,359, an achievement of 84% against the PPR target. In addition, in Q4, 3,226 were fully immunized, bringing the cumulative performance of the project in Year 1 to 9,927, an achievement of 80% against the PPR target. This performance was achieved through defaulter tracing and outreaches in community units with unimmunized children. KANCO/GAVI HSS supported review meeting, installation of fridges and outreach services. Afya Halisi trained 60 HCWs on REC (demography, problem identification and resource allocation) and operational level issues; cold chain maintenance, use and assessment of fridge tag. After the training, HCW developed micro-plans for their respective health facilities. GAVI and UNICEF supported the installation EPI training session in Kakamega of procured EPI fridges.

Kisumu County In Q4, 6,670 children under one year received Penta 3 vaccine, a 12% increase compared to Q3. Moreover 6,443 were fully immunized, a 9.6% increase compared to Q3. This brings the cumulative performance of the project for Penta 3 to 20,351, an achievement of 75% against the target and for FIC to 19,512, an achievement of 71% against the target. The project supported SCHMT and CHMT to conduct DQA and install fridges that had been procured by World Bank/GAVI. In addition, the project supported outreach services and immunization defaulter tracing in informal settlements especially in Kisumu East. The project supported county and sub county teams to inspect and install 42 EPI fridges. County biomedical engineering team identified the following defects/gaps: no cooling system, fridge not switched on, room too small leading to temperature violations, lack of defrosting, lack of electricity, and lack of training of users. Migori County In Y1Q4, 10,306 children under one year received Penta 3 vaccine and 9,834 were fully immunized, bringing the cumulative performance of the project for Penta 3 to 30,638, an achievement of 102% against PY1 target and for FIC to 28,528, an achievement of 95% against the target. The project achieved this by supporting vaccine commodity security in health facilities, intensifying outreach and defaulter tracing including door to door immunization and supporting sub county and county teams to supervise health facilities.

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The project facilitated the sub counties’ EPI mentors to provide facility level mentorship to 310 HCWs on EPI operations and REC reaching 133 (74%) immunizing facilities in the eight sub counties. Other key areas mentored on included; EPI session and vaccine management, cold chain maintenance, use of immunization diary and permanent registers for defaulter tracing and documentation in the immunization primary registers. In addition, 60 CHVs were mentored on defaulter tracing. These capacity building sessions will improve the readiness and quality of immunization services in the facilities. The project will support EPI focused low dose high frequency mentorship in PY2 to reach all the 180 immunizing facilities including the CHVs. In Y1Q3 and Y1Q4, the project provided financial and logistics support to sub county EPI coordinators to collect all antigens and diluents from the regional EPI depot in Kisumu. This was to ensure ready availability of adequate stocks of vaccines for immunizations and minimize missed opportunities in facilities. To strengthen daily facility immunization service readiness, the project supported the county MOH maintenance department to install 19 electric powered refrigerators donated by the national government at both the sub county depots and health facilities during Q4. This was to support accelerated action by county in a national immunization rapid results initiative (RRI) targeting unvaccinated children in the country. Healthcare workers in the facilities where installations were done were on – job trained on the maintenance of the cold – chain equipment. Overall, the county now has 164 (90%) from the initial 145 public health facilities with functional EPI fridges. Facilities providing daily immunizations increased from 135 (75%) in Q2 to 158 (88%) as at the end of year 1. However, inadequate space and poor state of some EPI cold chain rooms in Rongo and Awendo sub county depots and some health facilities delayed the completion of the installations of the 37 EPI refrigerators. The project will support the county to finalize the installations of the remaining 15 EPI refrigerators and repair of dysfunctional EPI fridges in the county (and redistribute the EPI fridges to lacking facilities) in PY2. Kitui County In Y1Q4, 5,898 children under one year received Penta 3 vaccine and 5,953 were fully immunized, bringing the total performance of the project for Penta 3 to 17,815, an achievement of 96% against the target and for FIC to 18,035, an achievement of 97% against the PPR target. During the reporting period, the project strengthened the capacity of HCWs and middle level managers through training and low dose high frequency mentorship. The project trained 39 participants (17 male, 22 female) on EPI middle level managers training. The objective of the training was to equip health care workers with knowledge and managerial skills for implementation of quality immunization services in Kitui. The project also supported sub county health management teams to conduct supportive supervision. In addition, the project strengthened commodity security by training HCWs on vaccine forecasting and providing financial and logistical support to sub counties to collect vaccines from Nairobi depot. The project is collaborating with Clinton Health Access Initiative (CHAI) to strengthen vaccine stock management to enable sub counties to collect their stock on a quarterly basis. The project will ride on CHAI’s Chanjo platform to achieve this. At community level, Afya Halisi supported 27 outreach sessions in Q4 and immunization defaulter training.

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Child Health During the quarter under review, 6,274 children under five were treated for pneumonia in project supported health facilities. A cumulative total of 17,855 children under five (101% of the annual target) were treated in Year 1. This represents 78% of under-five children with pneumonia that were treated with antibiotics as at end of Year 1 as shown in Figure 10 below.

120% 106% 99% 96% 94% 98% 100% 89%90% 92% 92% 85% 85% 85% 87% 85% 81%80% 78% 80% 69% 58% 60% 37% 40%

20%

0% Kakamega Kisumu Migori Kitui Project

Y1Q2 Y1Q3 Y1Q4 Year 1

Figure 10. Proportion of pneumonia cases treated with Antibiotics, Year 1 In addition, 16,429 children under five were treated for diarrhea, bringing the total in Year 1 to performance to 49,937 children under five (43% of annual target) treated for diarrhea. This represents 73% of under-five children with diarrhea that were treated with ORS and Zinc as at end of Year 1 as shown in Figure 11 below. The project achieved these through strengthening capacity of HCW on IMNCI, ETAT+, strengthening use of ORT corner, improved documentation and by disseminating pediatric case management guidelines.

100% 89% 84% 83% 84% 78% 79% 79% 75% 74% 73%76% 80% 73%73% 73% 70% 73% 65% 67% 60% 60% 44% 40%

20%

0% Kakamega Kisumu Migori Kitui Project

Y1Q2 Y1Q3 Y1Q4 Year 1

Figure 11. Proportion of diarrhea cases treated using ORS and Zinc, Year 1 During the reporting quarter, the project built capacity of 109 HCW in public and private health facilities on IMNCI, bringing the total of HCWs trained in Year 1 to 201. In addition, 33 HCWs participated in ETAT+ Generic Instructor Course (GIC) training. Mentors assisted health facilities to set up triage systems and 2 health hospitals have set up emergency trays for handling childhood emergencies. In addition, some of the trained 18 ToTs have co-facilitated training and mentorship

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sessions. Out of the 18 ToTs developed in Year 1, seven are from Kakamega, 2 from Kisumu, 5 from Migori and 4 from Kitui County. The ToT have also created a WhatsApp group where they share experiences and what they do (ETAT+ related) post-training. In Q4, the project trained 62 CHV on iCCM, bringing the number of CHV trained in year one to 110. Trained CHVs have so far treated 21 children for diarrhea and referred 31 children with diarrhea and 15 with pneumonia to health facilities for treatment. In year two, the project will support community dialogue on WASH, pneumonia and diarrhea in community units implementing iCCM. The county specific activities with outputs achieved during the reporting period are described below;

Kakamega County The project conducted a one-day sensitization meeting of 10 IMNCI ToTs from Kakamega County (5 male, 5 female) to update them on the revisions that had been made on the national IMNCI curriculum. The ToTs then trained 53 healthcare workers (18 male, 35 female) from Khwisero, Navakholo and Matungu sub counties. The project supported ETAT+ instructor training, this was a follow up to ETAT+ provider training. A total of seven participants (M-4, F-3) were from Kakamega. All achieved effectiveness and competency during the training. They will support the project in training providers and conducting mentorship in the subsequent quarters. This has improved the management and triaging of sick children especially in Khwisero Health Center. The project supported the training of 40 CHVs, 8 CHAs and 8 Child health focal persons from 4 CU and link health facilities (Namirama B, Lusumu B, Shinoyi A and Ematiha) in Navakholo Sub County on iCCM. Navakholo Sub County has high cases of children with diarrhea in Sensitization session in KCGTRH for IP addition to a very rugged road terrain. After the training, neonatal register the MOH and Afya Halisi provided the CHV with reporting tools. CHV have managed 6 children with watery diarrhea at home with ORS and Zinc Sulphate. To improve ORT corner use, the project disseminated assorted ORT corner supplies to 38 health facilities in the county. In order to improve the documentation of newborn services, the project together with the DFH sensitized 38 health care workers on the new inpatient register for pretesting in two health facilities in Kakamega- the KCGTRH and Matungu Sub County Hospital.

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Kisumu County Afya Halisi mentored and reached 73 health care workers (31 male and 42 female) in Kisumu county. The mentorship has assisted the health care providers to manage childhood illness using IMNCI guidelines. To improve quality of care and documentation of newborn services, the project together with the DFH currently pretesting the new neonatal inpatient register in two health facilities in Kisumu JOOTRH and Chulaimbo Sub county Hospital. Kisumu County receiving the neonatal IP Migori County register To improve the identification and correct treatment of diarrhea and pneumonia in under 5 children, the project supported the training of 24 frontline HCWs (19 male, 5 female) in the 8 Afya Halisi supported sub counties in Q4. The project reproduced and disseminated job aides for sick child triage, diarrhea and pneumonia management to nine priority high volume health facilities to facilitate reference during the identification/classification and correct treatment of cases. Trained health care workers are using the IMNCI guidelines to manage the different childhood illness Afya Halisi also supported the establishment of five ETAT+ Tots in Migori. Thereafter, the Tots participated in the mentorship of other healthcare workers on key neonatal/childhood skills – neonatal resuscitation among others. The project supported the county to reproduce the iCCM implementation plan 2016 – 2020 that was developed with the support of the previous USAID funded project, MCSP. During Q3, the project supported the training of 30 CHVs, 3 community CHAs and 3 facility CHAs in three identified hard – to – reach CUs with high prevalence of diarrhea. In Q4, the project supported the MOH team to conduct support supervision, 62 CHV (included those previously trained by MCSP) were supervised. At community level, CHV successfully managed 46 children with watery diarrhea and referred 31 children with diarrhea and 18 children with pneumonia for treatment in health facilities. In Komenya CU in Uriri, the CHVs at the community level reported a marked reduction in diarrheal cases in the households after sensitization of community members on personal hygiene. To improve correct case identification/classification and treatment at the health facilities, the project disseminated Kenya Pediatric Protocols (v2016) and policy guidelines for management of diarrhea in children below 5 in Kenya (v2014) to 32 high volume facilities in the county. The project supported facility – level low dose high frequency mentorships and continuous medical education (CME) in 102 (57%) high volume facilities reaching a total of 372 frontline clinical officers and nurses (and another 352 other health staffs including pharmaceutical technologists, health records officers and support staffs) to improve integration and documentation. To revitalize the operations of ORT corners in the management of dehydration (diarrhea) cases in children, the project procured and distributed basic ORT equipment to 9 health facilities in the county in Q3. In addition, the project procured and disseminated 120 ORT registers to health facilities to strengthen documentation of the diarrhea cases seen and managed in the facilities. The project will support the operations of ORT corners in the management of dehydration at facility

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level. Sub county and health facilities will be supported on feasible forecasting and ordering of adequate stocks of ORS and Zinc sulphate to avoid sporadic stock – outs experienced in a few facilities in PY2. Kitui County Afya Halisi supported capacity building of 30 HCWs (18 male, 12 female) on IMNCI, translating into 59 HCWs trained on IMNCI in year 1. The objective of the training was to equip health care workers on how to; assess and examine children, check for other routine services like immunization and nutrition; classify children’s illnesses using the color coded system; identify and administer appropriate treatment to sick children; and to counsel the mother or care giver on when to come to hospital and develop an appropriate follow up plan. In addition, three HCWs comprising of 1 male medical officer, 1 female medical officer and 1 female nurse participated in ETAT+ GIC. The use of ORT corner has remained sub-optimal in project sites. To improve ORT corner use, the project distributed ORT supplies and disseminated diarrhea policy guidelines to 30 health facilities in Kitui. At the community level, the project built the capacity of 20 CHVs on iCCM. The iCCM training was done in 3 community units (CU) from Mwingi North (Tyaa Kamuthale CU, Mulangoni CU) and Mwingi Central (Ukasi CU). This training sought to build the capacity of CHVs to manage childhood illnesses at the community level. However, the suspension of the PATUMA model by the county government has stalled the full roll out of iCCM. The project has reached out to the county health management team to help fast track the recruitment of new CHVs.

Nutrition The project implemented activities in the nutrition focus counties’ of Migori (8 sub-counties) and Kakamega (3 sub-counties and KCGTRH). During the quarter, Afya Halisi reached 13,447 pregnant women with combined Iron and Folic Acid supplementation (IFAS) bringing to total 42,742 pregnant women who received IFAS, an achievement of 67% against PY1 target. In addition, 37,706 children under five years received Vitamin A supplementation in Q4, bringing the cumulative achievement to 265,870 children who received Vitamin A supplementation in the last six months, an achievement of 144% against PY1 target. Moreover, 6,859 children with diarrhoea received Zinc in Q4, a 29% increase compared to Q3. In total, 17,595 children with diarrhoea in Kakamega and Migori received Zinc supplementation in PY1, an achievement of 26% against the target. The project also reached 10,698 children under two years (0-23months) with community level nutrition interventions in PY1, an achievement of 116% against the annual target of 9,200. Vitamin A Supplementation and Deworming in early year education: During the quarter, the project supported MOH to provide Vitamin A supplementation to 37,706 children 6-59 months, bringing to total 265,870 under five children reached with Vitamin A supplementation in the last six months, an achievement of 144% against the projects PPR target of 184,685. The project achieved the results by accelerating Vitamin A supplementation (VAS) in ECD centers during Malezi Bora campaigns that was conducted during the reporting period, in addition to the routine Vitamin A supplementation. During the Malezi Bora campaigns, the project collaborated with the Ministry of Health and Ministry of Education.

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In Kakamega, the project integrated MUAC screening in EYE during Malezi Bora activities identifying 14 cases of severe acute malnutrition and 44 cases of moderate acute malnutrition, who were referred to link health facilities for management. In the quarter under review, 12,149 children were supplemented with Vitamin A, bringing those supplemented for the last six months to 59,692 (81%). The project supported integrated DQAs through MEL team and mentorship through HINI to improve documentation of Vitamin A. The project will support mapping of EYE centers and support supplementation of children in EYE centers in October and May of year two.

In Migori, in the quarter under review, 25,557 children 6 – 59 months were supplemented with Vitamin A. The project supported integrated DQAs and mentorship was done through HINI. The total children supplemented with Vitamin A in the last six months were 206,178 (186%). The project will continue to support Vitamin A in EYE bi annually during Malezi bora.

Strengthen capacity for baby friendly community initiative (BFCI): The project built the capacity of 56 HCWs and 770 CHVs in BFCI. In addition, the trained HCWs and CHVs mobilized community members to form mother to mother support groups (CMSGs). Community members have formed 236 CMSGs and established 743 kitchen gardens. In Kakamega, Afya Halisi trained 143 CHVs (46 male and 97 female) on the nutrition technical module as a foundation for BFCI implementation in quarter three. In quarter 4, the project trained 32 (8 male and 24 female) HCWs from 12 health facilities linked to 40 CUs. From the training, the project supported the HCWs to train 559 CHVs and CMSG members. From the BFCI household visits conducted by CHVs during the quarter under review, a total of 3,001 children aged 0- 23 months were reached. A total of 59 mothers of newborns were reached with messages on exclusive breastfeeding in BFHI implementing CUs and 262 in other Afya Halisi supported CUs. Overall, the project reached 3,651 children aged 0 – 23 months with community level interventions translating to 153% of the target. The project has formed 142 CMSG within the county and reached 413 pregnant women at household level with messages on nutrition.

From the BFCI data, the number of children reached steadily increased in the months within the quarter due to scale up. The CHV reports showed that 88% of children were initiated on breastfeeding within one hour of delivery while 90% went on to breastfeed exclusively as shown in Figure 12 below. Introduction of solid and semi-solid foods and intake of animal source foods were at 88% and 78% respectively. Pre-lacteal feeding is a major problem since 24% of newborns are given pre-lacteal feeds. The CUs have challenges with data quality and these are being addressed per CU.

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100 88 90 88 90 78 80 70 60 50

40 Percent 30 24 20 10 0 Initiation of Prelacteal feeding Exclusive Introduction of solid Animal source foods breastfeeding breastfeeding and semi solid foods

Type of feeding/food

Figure 12. Performance of BFCI indicators in 40 CUs in Kakamega County

The project also conducted immersions at community level on the accelerator behaviors: initiation of breastfeeding within one hour of delivery and exclusive breastfeeding for six months. FGDs were conducted with community members in the three sub counties. The findings varied from one sub-county to another. For instance, some wanted to be provided messages through radio while others indicated that they would not listen to radio. As a result, the program will conduct immersions at community level within the BFHI and BFCI CUs and use these to ensure that implementation is based on the findings. In PY2, the project will scale up BFCI, and intensify CMEs, household visits and self-assessments to improve BFCI capacity.

In Migori, during the quarter, the project trained 24 HCWs from 9 health facilities in Rongo, Uriri, Awendo and Kuria East sub counties linked to 10 CUs on BFCI. Subsequently, the health facilities developed work plans which led to the training of 211 (78 male and 133 female) CHVs. This brings the total CUs implementing BFCI in Migori county to 43 (39%). As at end of PY1, the project had 94 CMSGs in the county with more to be formed in the scale up BFCI CUs. During the quarter, the project reached 5,935 children 0 – 23 months through BFCI. Additionally, in BFHI sites (7 health facilities), the project reached 419 mothers of newborns in BFCI and 693 in non BFCI CUs with messages on breastfeeding during the reporting quarter, bringing the total children reached in PY1 to 7,047, an achievement of 104% against the target.

100 86 83 84 80 60 40 19

Percentage 20 9 9 0 Jan - Mar Apr- Jun Jul- Sep Quarter

Initiation of breastfeeding wihtin one hour Pre lacteal feeding

Figure 13. Initiation of breastfeeding vs prelacteal feeding

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From the data collected through BFCI, there is an inverse relationship between pre lacteal feeding and initiation of breastfeeding within one hour of delivery. As initiation of breastfeeding increases, pre-lacteal feeding decreases and vice versa. The pregnant women reached at household level through BFCI during the quarter were 205. There are a total of 94 CMSG with 3,371 mothers attending the group meetings during the quarter. A total of 743 kitchen gardens have been established by mothers at household level. The project will start year two by improving BFCI capacity through self-assessments and CMEs and scale up mid-year.

Strengthened capacity for baby friendly hospital initiative: At the onset of the program in Q2, Afya Halisi supported continuous medical education (CME) in health facilities based on performance on breastfeeding indicators, focusing on the lowest performing and also trained 62 Health Care Providers (HCW) on Maternal, Infant, and Young Child Nutrition (MIYCN), which formed the foundation for implementation of BFHI and baby friendly community initiative (BFCI). Kakamega County In the quarter under review, the project trained 27 (6 male and 21 female) HCW on BFHI from Matungu and Navakholo sub county hospitals. The facilities then conducted baseline assessment for the two hospitals on BFHI. Key findings from the assessment included: HCW not familiar with the ten steps to successful breastfeeding, inadequate and outdated policies, inadequate support to mothers for early initiation, exclusive breastfeeding, hand expression of breast-milk, and maintaining skin-to-skin contact. To bridge these gaps, the project supported continuous medical education (CME) and printed assessment tools for facilities to track their progress towards being baby friendly. The project then supported the training of 40 (7 male and 33 female) Community Health Volunteers (CHVs) on BFHI for Navakholo hospital as Matungu Community Units (CUs) had already been trained. The project intends to continue with CME and self-assessments in year two to improve BFHI capacity. Migori County In quarter three, Afya Halisi trained of 35 health care workers from 8 hospitals on BFHI with the aim of improving their capacity on optimal infant and young child feeding (IYCF) practices to enable them offer practical support to mothers. Though the project started implementation by supporting CMEs on initiation of breastfeeding and exclusive breastfeeding in facilities that had low coverages, the project intensified CMEs in BFHI and health facilities linked to BFCI CUs. Subsequently in quarter 4, the project continued with capacity building (both technical and non- technical staff) focusing on the 10 steps to successful breastfeeding, supporting 3 CMEs for each of the BFHI facilities. Additionally, during the quarter under review, the project sensitized 35 hospital managers and 348 CHVs (84 male and 264 female) attached to the BFHI hospitals. The CHVs are to integrate breastfeeding messages to the mothers and caregivers during home visits, mother to mother support group meetings and strengthen linkages between the hospitals and the community. As a result, the project reached 419 mothers of newborns with messages on breastfeeding at community level in BFHI facilities. To promote progress towards baby friendliness, the project Strengthened capacity for High Impact Nutrition Interventions (HINI): Migori County In quarter 3, the project trained 30 sub county managers on HINI to improve their capacity to supervise and implement nutrition services; and also integrated HINI facility assessment with the

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larger baseline facility assessment for the county. Subsequently in quarter 4, the project supported HINI mentorship for all the 8 sub counties. Mentorship for some sub county nutritionists who were technically weak was done by a more skilled nutritionist. Some of the findings during HINI mentorship include: use of mother child booklets to determine nutrition status and improved documentation in the CHANIS and CWC registers. Challenges noted included: task shifting to staff without proper orientation on growth monitoring and inadequate anthropometric equipment. At the end of the quarter, the project then conducted an assessment for 165 health facilities to ascertain progress of implementation after mentorships sessions. The gaps highlighted in the assessment report will be used to determine areas of mentorship that will be specific to facilities. The project will continue to support HINI mentorship based on gaps identified during the HINI gaps assessment. In quarter two, Afya Halisi trained 30 HCWs in Nyatike on Growth Monitoring and Promotion (GMP). Strengthened capacity for Integrated Management of Acute Malnutrition (IMAM): As a follow up action to the IMAM assessment that the project conducted in quarter three, that aimed at identifying gaps in the implementation of IMAM, 24 IMAM mentors mentored 43 facilities in documentation and reporting improved through mentorship of HCWs.

Kakamega County At the onset of the program, the project conducted an IMAM capacity assessment then integrated IMAM mentorship with HINI mentorship. IMAM mentors were also identified and oriented. The project identified 8 facilities for scale up of IMAM that would be supported with mentorship in Year 2.There are a total of 31 IMAM sites within the Afya Halisi implementing sites. The project will support IMAM scale up in specific facilities and mentorship for the facilities with gaps from the IMAM assessment. Migori County Through Afya Halisi’s support, documentation and reporting rates at IMAM sites has improved. From the initial findings of the IMAM capacity assessment, Migori as a county was at 55%. The project supported mentorship in quarters 3 and 4 and in quarter 4, reaching 74 IMAM facilities. Some of the challenges included faculty or inadequate anthropometric equipment, inadequate knowledge and skills, inadequate documentation, low reporting rates, and subsequently a stock out of IMAM commodities in the health facilities due to lack of reports. At the end of the quarter, the project conducted a capacity assessment on IMAM whose results are in the graph. In PY2, the project will support scale up of IMAM sites and mentorship for those facilities that still have gaps based on the IMAM capacity assessment.

WASH The project’s WASH focus remains in Kakamega, Migori and Kitui counties. Afya Halisi is implementing WASH in healthcare facilities (HCFs) and Community Led Total Sanitation (CLTS) at communities.

The project’s WASH performance by county in Year 1 is summarized in Table 2 below.

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Table 2. Summary of WASH performance by County in Year 1 Indicator County/Achievement Kakamega Kisumu Kitui Migori Project Villages verified as ODF PPR Target 14 12 24 50 Y1 Achievement 49 0 91 140 % Achievement 350% 0% 379% 280% Number of people PPR Target 4,200 3,600 7,200 15,000 gaining access to a basic Y1 Achievement 15,854 0 23,260 39,114 sanitation service % Achievement 377% 0% 323% 261% Individuals trained to PPR Target 140 120 240 500 implement improved Y1 Achievement 327 274 218 819 sanitation methods % Achievement 234% 228% 91% 164%

People gaining access to PPR Target 16,000 10,000 26,000 basic drinking water Y1 Achievement 27,225 6,000 14,282 47,507 services % Achievement 170% 143% 183% Basic sanitation facilities PPR Target 12 28 25 65 provided in institutional Y1 Achievement 22 20 30 72 settings % Achievement 183% 71% 120% 111%

Orientation of HCWs on WASH in health facilities: To address some of the gaps identified in WASH in health facilities (HFs) by the Afya Halisi health facility assessment, the project trained an additional 142 (109 male and 33 female) healthcare workers (Kakamega 38; Migori 47; and Kitui 57) on infection prevention and control (IPC) in quarter four. The participants included county and sub county management teams and health facility staff. The health care workers (HCWs) trained subsequently oriented their respective HFs on IPC, reaching 52 health facilities and 988 HCWs across three counties as summarized in Table 3 below. These orientations IPC whole-site orientation in Khwisero sub targeted knowledge and positive HCW behavior on county, Kakamega County. waste management and IPC. Participating HFs formed IPC committees and drafted facility-level waste management plans.

Table 3: Health facility and health care workers reached on IPC Activity Kakamega Migori Kitui Total Number of HFs received IPC orientation 23 20 9 52 HCWs reached with whole site IPC orientation 339 474 175 988 IPC committees formed 23 20 12 55

The project organized a training of trainers on Clean Clinic Approach (CCA) for middle managers in county and sub county government in Kakamega and Migori. This innovative approach seeks to positively influence the health leadership to prioritize and invest in WASH in HFs and influence positive WASH behaviors among HCWs, so as to achieve incremental improvements in WASH in HFs. and the CCA TOTs will support CCA roll out in selected sub counties in year one. During CCA, participants developed standards for CCA in HFs, and generated a checklist that the teams

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will use to conduct WASH inspections within HFs. In year two, quarter one, the project will hold another TOT for Kitui. Then Afya Halisi will work with the three counties to harmonize the CCA checklist. Afya Halisi will support TOTs to roll out the CCA approach in identified sub counties in year two. Dissemination of WASH guidelines: This quarter the project procured and disseminated across the three counties 1258 IPC guidelines, 410 Kenya Environmental Sanitation and Hygiene revised 2016 policy, and 410 copies of the CLTS protocols. A total of 1655 documents were disseminated to HFs that had received whole site orientations across the three counties (Kakamega 175, Kitui 700, Migori 780), and are expected to serve as reference documents for IPC and waste management within HFs, as well as on CLTS. The project disseminated these reference documents to HFs that had received whole site orientations. In Kakamega 175 IPC, guidelines were disseminated while, 115 CLTS protocol were disseminated to public health staff and other healthcare workers during CLTS forums held in the counties. In Kitui, the project disseminated 700 IPC guidelines in all the 349 health facilities, 60 KESH policy guidelines and 60 CLTS protocols through sub-county public health officers.

Distribution of WASH start-up supplies for health facilities During the reporting period, the project procured, delivered and distributed WASH start up supplies for priority health facilities. The items included equipment for environmental cleaning, waste management, personal protection and hand hygiene to improve WASH and IPC practices in the facilities. The project distributed these supplies to 75 HCF across the WASH-supported counties (Kakamega 20, Kitui 30, and Migori 25). For sustainability, the project will advocate, through A healthcare facility receiving WASH start up CCA, for increased allocation for WASH supplies supplies from Afya Halisi Project in HFs.

Improving basic sanitation facilities in institutional settings: In PY1, the project supported 72 facilities across the three counties (Kakamega 22, Migori 30, Kitui 20) to improve sanitation within an institutional setting, an achievement of 111% against the annual target of 65 facilities. During the reporting quarter, the project carried out an assessment on sanitation facilities in 75 health facilities to understand the existing sanitation gaps. The assessment findings revealed among other things: broken/lose or missing latrine doors, leaking roofs, unlockable doors, filled up latrines, blocked wastewater drains, non-fenced waste and placenta pits. The project supported sanitation improvement and renovations in these facilities through minor repairs. Overall, the project fixed/repaired 51 latrines, fenced 61 waste pits and 29 placenta pits, cleaned gutters, unblocked soak pits and restored water services in eight health facilities. Additionally, the project supported fabricating and fixing of placenta pit covers. In PY2, the project will advocate to health facilities to mobilize available resources (such as RBF, Linda mama and FIF) for such minor improvements.

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Increasing access to safe water: Water is a basic commodity and key component in WASH. During the quarter, the project rehabilitated 52 springs (Kakamega 16, Migori 30, and Kitui 6), against a target of 26 springs in PY1. Through this support, Afya Halisi enabled 47,507 people access to safe water (Kakamega 27,225, Kitui 6,000, and Migori 14,282) against the annual target of 26,000 people, an achievement of 183%. Afya Halisi conducted a number of improvements around the springs. Specific activities included: clearing and opening wastewater drains, fencing springs, refilling existing chlorine dispensers, and forming and/or strengthening the water management committees to ensure water sources are maintained and used sustainably. The project also analyzed water quality analysis using bacteriological, physical and chemical parameters.

The county specific summaries are described below. Kakamega County In Kakamega County, the project the project supported works aimed at improving sanitation in 22 health facilities. This work included repairs to blocked drainages, minor plumbing works, fencing of waste pits, fencing placenta pits, reinforcing placenta pit covers and repair of bathrooms and latrines. The project further advocated to Health Facility Management Committees to use funds available in the facilities for such minor works. To improve water quality supply in Kakamega County, the project did minor rehabilitation on 16 springs that included fencing the spring catchment area and forming and strengthening water management committees. To enhance water quality improvement, the project trained CHEWs on the WASH technical module to transfer knowledge and skills in water quality and management including supporting CHVs to distribute water purification products such as Aquatabs and PUR and filling water dispensers with chlorine. Migori County In Migori County, the project supported works aimed at improving basic sanitation in 30 facilities (28 health facilities and ECD sections in two primary schools. The project also advocated to Health Facility Management Committees to use funds available in the facilities for such minor works. In Migori, the project rehabilitated 30 springs with minor improvements. In all sites, the project worked with Ministry of Water staff. Kitui County To increase access to an improved sanitation facility in health facilities, the project assessed 26 HFs in Kitui. The project conducted minor repairs of latrines/toilets, and fenced/rehabilitated waste pits in 22 HFs while an additional four HFs did the renovations themselves with mentoring from project staff.

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To improve services in health facilities, the project provided WASH mentorship in 16 HFs this quarter. These health facilities developed action plans for incremental improvements to address these gaps.

Before and after Photos of the latrine improved after mentorship at Muthungue Dispensary in Kitui East During the quarter, Afya Halisi assessed six springs in Kitui and helped communities to clear the drains to improve the water quality. In Kitui, 6,000 the project also and trained the water management committees in these six communities on water source protection, operations and maintenance and using water sustainably. A total of 33 (17 male, 16 female) committee members were trained from Miambani ward in Kitui Central sub-county. The project also fenced four additional water sources (three springs and one shallow well).

Kwa Sulu spring in Kitui Central before project Kwa Sulu spring in Kitui Central after project intervention intervention

Activity 1.1.2. Strengthening adolescent and youth-friendly services at health facilities: During the reporting period, the project continued to put in place and strengthen structures to enable implementation of AYSRH activities in the four focus counties. Details of the status of AYSRH activities are articulated in Annex 1 of this report.

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Activity 1.1.3. Quality improvement approaches to strengthen facility services: The project finalized a Quality Improvement (QI) strategy to guide in institutionalization of QI in project supported health facilities and CUs. The new KQMH standards and checklists were launched during Year 1 implementation and the project applied the tool in Kisumu and Kakamega. The county specific QI activities are outlined below;

Kakamega County In Year 1, the project supported formation of QI teams in KCGTRH, Matungu sub-county, Navakholo sub-county and Khwisero sub-county hospitals. In collaboration with Kakamega county government, the project supported trainings on KQMH to 55 HCWs from the three sub- counties and the KCGTRH inQ3. In Q4, twenty-three quality improvement coaches drawn from the three sub-counties were trained on aspects providing QI mentorship to the work improvement teams. During the training of the coaches, an orientation on the KQMH assessment tool was done and KCGTRH used the tool in the assessment of the facility on status of quality management.

Kisumu County In Kisumu county, the project set up a collaborative effort with Amref Health Africa and the county government to roll out the electronic KQMH scoring tool. Ten health facilities that included JOOTRH, Kisumu County Hospital, Chulaimbo Hospital, Muhoroni and Nyakach sub-county hospitals were supported on whole-site orientation on QI. In the reporting period, the project supported orientation of 254 HCWs on the improvement science. Quality improvement teams (QITs) have been set up to initiate quality improvement initiatives. The project supported two county technical working group and provided inputs in the revision of the county QI charter. In Q3, the project worked with the Kisumu county to test an online scoring tool based on the DHIS platform. Use of this tool will be instituted after adoption by the national HIS program. In addition, the project sensitized private health facility managers on basic quality improvement methodologies as espoused in the KQMH implementation guidelines.

Migori County During the reporting period, Afya Halisi conducted training on KQMH where 35 QI coaches from the county and sub-county were trained on the same. This followed with training of the service providers on QI where a total of 60 healthcare workers were trained, totaling to 102 trained in PY1. The trained coaches were supported to reorganize SC QITs across all the eight supported sub counties and cascaded mentorship to the health facilities. This led to the formation and re- activation of WIT in 82 high volume facilities. In all these facilities, QI projects have been established and the WIT are at different stages of the team maturity index. Key projects being implemented by these WITs include; scaling up of skilled delivery and improving 4th ANC coverage and community strategies to reduce teen age pregnancies. Additionally, mentorship on 5S was done in Kuria West where 3 facilities were supported to re-organize and improve the work spaces in MCH and Maternity.

Kitui County In Year 1, the project supported a whole-site orientation for 37 HCWs on work area improvement in Migwani Hospital in Mwingi West and a similar session at Kyuso sub-county hospital. Departmental work environment improvement teams were created and the MCH and maternity teams started to hold meetings. Following management changes at the county’s health department,

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a new team was instituted to support QI approaches across the health sector. The project has identified a new team of coaches and was in the process of inducting them at the end of Year 1.

Activity 1.1.4. Stock management, inventory, forecasting and ordering for quality health: During the quarter under review, the project continued support supply chain management initiatives aimed at ensuring commodity security across the four project supported counties; distribution logistics as well as the information systems for the purposes of coordination. There were delays in the supply of commodities from KEMSA to the counties during the reporting period. In the quarter under review, the percentage of USG supported facilities experiencing stock out of any commodity in the 5 categories (COCs or POPs, IUDs, DMPA, condoms and implants) was 40% (against a target of 15%) down from 59% and 50% in PY1Q2 and Q3 respectively. The project addressed the issue of stock outs by training HCPs on forecasting and quantification. This resulted in substantial improvements in availability of these commodities during the reporting quarter. The challenges faced during the previous quarters included the fact that KEMSA had been waiting for all health facilities in a county to make orders, or waiting to incorporate orders from a neighboring county to maximize on transportation logistics. Supplies from KEMSA to the counties were also dependent on whether other commodities such as Malaria drugs were included in the forecasts. To address the issue, the project had discussions with KEMSA and agreed that KEMSA will be making the deliveries to the sub-county level to save on time, and the project will work with respective CHMTs/SCHMTs to distribute the commodities to the SDPs. This arrangement worked well for Kakamega and Kisumu counties, with all project supported health facilities receiving the commodities. This contributed significantly to the reduced stock out rates in Q4. However, gaps still exist in the stock management for immunization antigens with the supplies being erratic and the nutrition commodities being rationed by UNICEF through KEMSA.

Activity 1.1.5. Establish functional referral and counter referral system in health facilities: In Kisumu County, the project supported the county to draft a referral strategy to improve referral path ways especially for Ahero sub county hospital. In addition, during MPDSR audit meetings conducted in Kisumu, some of the interventions agreed on to address identified gaps included the need to have standardization of referral notes to facilitate in-depth documentation as most of the mothers who were referred had incomplete documentation on the processes of care. Activity 1.1.6. Drive high-quality data use for decision-making and QI: During the quarter under review, the project continued to collaborate with SQALE project to roll out community Quality Improvement (QI) activities within three community units in Migori County. This involved completing the second phase of training for CHAs from three CUs in Migori County and strengthening of Work Improvement Teams. The project will take a step further to train CHAs in-charge of the 88 project supported CUs in Year 2 to entrench community Quality Improvement (QI) activities.

Output 1.2 Strengthen delivery of targeted FP/RMNCAH, nutrition and WASH services at community level, including effective referral to mobile and/or static facilities. Activity 1.2.1. Strengthen CU functionality: During the quarter under review, the project finalized Community Unit Technical Assistance (TA) plans for each of the 66 project supported CUs and developed criteria for selection of Community

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Units that the project will support in Year two. The CUs in Kitui deferred development of CU Technical Assistance packages for year two since the Ministry of Health had suspended all CHVs in Kitui County at the time they were developing TA plans with project support. The project also supported 70 CUs among them 19 in Kisumu, 17 in Kakamega and 34 in Migori to hold monthly review and reporting meetings at health facilities where the CU are linked. Community Units in Kitui only held reporting meetings in July and August 2018 before the CHVs were suspended.

At the start of the project, 55% of the 88 project supported CUs were holding their reporting meetings away from the facility but have since relocated to health facilities to strengthen the community facility linkage. The project also procured and distributed 88 chalkboards (MOH 516) and provided photocopies of MOH 513 and MOH 514 to 15 CUs in Kakamega and 10 CUs in Kisumu. The chalkboards are being used by the CUs to display health indicators to the public and for use to illicit community conversations. To enhance CHV retention and motivation, the project provided technical support to ensure 15 CUs register as CBOs and open bank accounts to encourage savings that they can use to start up Income Generating Activities (IGA) as a way to motivate and bond CU members. These CUs were encouraged to start their own income generating activities. As a result, CUs have begun engaging in IGAs such as cattle rearing, table banking, merry go round, poultry rearing, goat rearing and tree planting. As at September 2018, Makale A CU in Mating Sub-County, Kakamega had the highest bank savings of 50,000/= with about three CUs having nothing but at least with a newly opened bank account. All the 64 CHCs trained with support from Afya Halisi participated in their respective CU activities among them CU planning and development of TA packages.

In Year 1, the project engaged in various activities that contributed to strengthening community health systems. The project first conducted entry, introductory and planning meetings in all the four project supported counties. The meetings largely involved all the County and Sub-county health managers in charge of community health activities. The meetings yielded sub-county level CHS activity plans for year one to guide implementation. The project then selected 88 CUs for enhanced support, among them 22 in Kitui, 17 in Kisumu, 15 in Kakamega and 34 in Migori using a data-driven methodology that prioritized programming using a needs-based lens. The CUs were subjected to a functionality assessment using the standard MOH functionality scorecard.

The project supported refresher training for 140 CHAs among them 34 in Kisumu, 26 in Kakamega and 42 in Migori and 1042 CHVs among them 547 in Migori, 238 in Kisumu and 159 in Kakamega the community strategy basic module. 40 CHAs (28 male 12 female) and 98 (36, male, 63 female) in Kitui were taken through fresh basic module training since they did not have prior training in Community Health Strategy. The fresh and refresher trainings were necessitated by the high attrition of CHVs then transfers and new deployments for CHAs which created a need to strengthen their capacity to supervise, monitor, manage and support the implementation of community based health care activities.

To strengthen CU governance, the project supported fresh training for 64 CHCs among them 19 in Kisumu, 13 in Kakamega and 32 in Migori Counties. Kitui County missed out since they had not formed CHCs as the organ is not part of the PATUMA model. The trained CHCs have since been providing leadership, governance and oversight in implementation of CU activities including monthly meetings, planning for community dialogue days and action days. The project ensured

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that all the CUs re-organize their leadership to have an all-inclusive structure that incorporates CHVs, CHAs and CHCs.

The project also drafted a Community Health and Demand Creation Strategy to guide community engagement and implementation of demand creation interventions, taking into consideration the varied county contexts. This strategy will be refined further and used to inform project implementation in year two.

The county specific activities are detailed below:

Kakamega County During this quarter, the project finalized Community Unit Technical Assistance plans for all 92 CUs which include the 15 identified for enhanced support; supported 25 CUs hold monthly review and reporting meetings at link health facilities; provided technical support to 15 CUs register as CBOs to enhance CHV retention and motivation and encouraged them to open bank accounts to start IGA as a way to motivate and bond CU members. These CUs were encouraged to start their own IGAs. As a result, CUs have begun engaging in IGAs such as Cattle rearing, table banking, merry go round, poultry rearing, goat rearing and tree planting. All the 13 CHCs trained with support from Afya Halisi participated in their respective CU activities among them CU planning and development of TA packages.

Progressively from beginning of the year, the project has engaged various activities that contributed to strengthening community health systems. After successful introductory and planning meetings with the SCHHMT/ CHMTs, the project supported refresher training for 26 CHAs (8 males, 18 female) and 159 CHVs (55 males, 118 female) on the community strategy basic module and supported fresh training for 13 CHCs to strengthen CU leadership and governance. These CHCs have since been providing CU governance and participating in CU monthly meetings, planning for community dialogue days and action days. CHCs have also began making efforts towards resource mobilization to support implementation of community activities while ensuring accountability and transparency. Some of the CHCs have already made efforts to meet MCAs and ward administration so that so that they can assist in supporting CUs with resources to execute their activities e.g. at Lusumu B CU linked at Butingo facility.

Kisumu County During this quarter, the project finalized Community Unit Technical Assistance plans for all 23 CUs, which include the 17 identified for enhanced support. A total of 17 project support CUs held monthly review and reporting meetings at health facilities where they are linked, an average of 198 CHVs (79 male, 119 female) were in attendance monthly. The meetings reviewed community data and made action plans to address emerging issues such as capacity and skills gaps in counseling, FP services delivery and MNCH key messaging was identified. The project built capacity of CHVs in areas that were identified to have gaps.

So as to enhance CHV retention and motivation, the project will in year two encourage the CUs to register as CBOs, open bank accounts and start some. The CUs however lack the management skills and diversity of investment ideas. In the coming year, the project will build capacity of CUs Village Savings and Loan Activities (VSLAs) to improve management and diversify their

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knowledge base as well as support those that have no mechanisms to institute sustainability mechanisms.

To improve CHCs accountability and supervision, some CHCs members were involved in the community dialogue days, community MPDSR training and monthly review meetings as well as sharing of the community score card review meetings.

Migori County During this quarter, the project finalized Community Unit Technical Assistance plans for all 34 CUs identified for enhanced support. A total of 37 project support CUs held monthly review and reporting meetings at health facilities where they are linked, an average of 547 (143 male, 404 female) CHV’s and CHC members were in attendance monthly. In all the meetings, the CHWs presented their households visit reports and discussed their progress and challenges in their various community activities. In these meetings, the CHEWs and CHAs assessed the level of knowledge, understanding and interpretation of the CBHIS indicators by the CHVs. The feedback meeting provided the CHVs and CHAs an opportunity for continuous monitoring and evaluation of demand creation for community level health services. To enhance CHV retention and motivation, the project provided technical support to ensure 22 CUs register as CBOs and open bank accounts to start Income Generating Activities as a way to motivate and bond CU members. A number of CUs have initiated savings, and have shown great potential of doing better. Plans are underway to strengthen the IGAs of the various CUs through mentorship and training on entrepreneurship.

Since Y1Q2, the project has consistently supported CUs in Kisumu in various activities that contributed to strengthening community health systems. After successful entry and planning meetings, the project selected 34 CUs with poor performance on poor indicators for intensive support. The project supported fresh training for 34 the CHCs to strengthen CU leadership and governance. In addition, the project supported refresher training for CHVs in the 34 CUs. The CHCs were tasked with the responsibility of advocating for 24-hour operations of rural health facilities and nurse houses within the health facility compounds or within areas for ease of access to ensure skilled health personnel attend to all childbirths. In all the CUs, the CHC members were also tasked with the action of facilitating registration of the CUs as community based organizations or self-help groups to help in resources mobilization.

The lead CHVs (LCHVs) for each of the 34 CUs supported were also engaged in mentorship and coaching sessions together with their respective CHAs to help them improve on their leadership skills. The Lead CHVs have now been empowered to be able to champion the interests of the CHVs and the CU at large and ensure community gatekeepers and key stakeholders are reached out for their active support and involvement in the CU level health activities. The LVCHs are now much able to conduct meetings and make records of deliberations and follow up on CHCS from Koderobar CU members during one of action plans towards improving FP/RMNCAH, the work planning meetings nutrition and WASH services.

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Kitui County During this quarter, the project supported 25 CUs held monthly review and reporting meetings at health facilities where they are linked, an average of 205 CHV’s were in attendance monthly. In all the meetings, the CHWs presented their households visits reports and discussed their progress and challenges in their various community activities. In these meetings, the CHEWs and CHAs assessed the levels of knowledge, understanding and interpretation of the CBHIS indicators by the CHVs. These meetings provided the CHVs and CHAs an opportunity for continuous monitoring and evaluation of demand creation for community level health services as well as to mentor Community Health volunteers, besides reviewing MOH 514 data.

The County Government of Kitui suspended its County Community Health Services PATUMA model citing wrong selection criteria, distribution, under performance of CHVs, resistance of CHVs by community members.

Cumulatively, the project engaged in various activities that contributed to strengthening community health systems. Before suspension of the PATUMA model, Afya Halisi supported fresh training for 40 CHAs (28 male, 12 female) and 99 (36 male, 63 female) CHVs on the community strategy basic module since they did not have prior training in Community Health Strategy. The fresh trainings were necessitated by the need to strengthen their capacity to supervise, monitor, manage and support the implementation of community based health care activities.

Activity 1.2.2. Support community health service delivery:

Maternal, Perinatal Death Surveillance and Response: The project supported MOH to conduct sensitization of CHVs on and establishment of 141 Community autopsy committees among them 10 in Kitui, 82 in Kisumu, 34 in Migori and 15 in Kakamega. All CHVs from project supported CUs were sensitized on Maternal and Perinatal Death Surveillance and Response (MPDSR) to enhance identification, reporting and review of maternal and perinatal deaths as well as execute relevant counter strategies to avert future deaths. In Kakamega, the project supported MPDSR sensitizations for 15 CUs reaching 253 CHVS. Participants included local government and national government administrators, health facility in- charges, CHVs and local leaders. After the training, 15 community MPDSR committees were constituted covering 15 CUs and mandated to meet monthly. A total of three maternal deaths and six perinatal deaths occurred in Khwisero and Matungu; they were reviewed and audited at community level.

In Kisumu, to improve maternal and newborn survival, the project provided MPDSR orientation to 348 community stakeholders including CHVs, chiefs and CHC members. The participants were drawn from 82 CUs within the supported sub counties. After the MPDSR orientations, the CUs formed 82 MPDSR committees that have initiated monthly meetings. One MPDSR committee discovered a TBA who would deliver mother but most of the delivered newborns would end up dying. The committee and the sub county management talked to the TBA and in response to discourage the practice, recruited her as a RMNCH ambassador to start referrals for skilled delivery.

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In Migori, the project worked with MOH to establish 34 MPDSR committees that conducted monthly review and analysis of maternal and perinatal deaths. Sub-county CHS focal persons together with CHVs and CHAs participated in various MPDSR committees in review of maternal and perinatal deaths. The committees reviewed and provided recommendations based on identified gaps and probable factors contributing to the deaths. The project will build the capacity of the MPDSR committees to develop and implement action plans aimed at preventing future deaths. The CHAs and CHVs were assigned specific roles to help in reversing the trends of maternal and perinatal deaths. As a result of recommendations from MPDSR committees, CHVs and CHAs have so far conducted several dialogue meetings with targeted community members and reached out to 726 pregnant mothers with messages on danger signs during pregnancy and also assisted them in developing individualized birth plans. The CHVs also managed to refer 133 pregnant mothers for skilled childbirth and made post-natal care visits to 291 post-partum mothers and their newborn babies to assess for any incidences of danger signs.

In Kitui, the project supported MOH to carry on with committees’ monthly surveillance, reporting and review of maternal deaths for 10 Committees established in quarter three. The project supported maternal verbal autopsy meetings in Mwingi Central that revealed religious beliefs by the Kavonokya sect was a major cause for the 1st delay. The community was educated on recognition of danger signs and intervention to prevent maternal and perinatal mortality. The other causes of death included poor access to health care services at night, impassable roads and bridges destroyed by rains. As a result, an action day to provide ANC services was held during which about 300 community members including 52 adolescents and young mothers were reached with information and services. The project will support communities around areas with impassable roads to lobby the county to repair roads to enhance access to skilled care for pregnant mothers. The project supported five maternal and six perinatal autopsies during the quarter under review in Mwingi Central and Kitui East Sub County during the year under review. One maternal death review in Kitui East that occurred in the month of September is awaiting review. Post-partum hemorrhage (PPH) is the leading cause of maternal mortality for four women, two in Kitui East and two in Mwingi Central died of PPH and one woman from Mwingi Central died of unknown cause.

Defaulter Tracing: The project worked with MOH to conduct active line listing and defaulters who were then followed for identification and linking back to the health facilities for services. In Kakamega, the project worked with MOH to conduct active line listing and defaulters for 1,500 ANC clients, 7,071 immunization clients and 173 PNC clients, who were linked to services. One major challenge was mothers starting ANC close to delivery dates. CHVs have been sensitised to ensure all HHs are visited on a monthly basis to identify any pregnant mothers and children not immunised/ defaulters then link them back to health facilities.

In Kisumu, due to active community surveillance 613 children aged under one year that had missed immunization were traced and immunized. This was after the project conducted a household mapping for using the REC approach in Kisumu Central sub-county. In Migori, the project supported tracing and referral of 507 ANC defaulters, 68 PNC defaulters and 1,323 immunization defaulters.

In Kitui, during the quarter under review, CHVs, village administrators, village elders, assistant chiefs and chiefs traced 625 immunization defaulters. Zero dose children had contact with health

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care workers during national polio campaigns, Kitui South sub-county used the opportunity to identify and immunize missed opportunities. Afya Halisi supported MOH in Kitui South sub- county to map nomadic community in Mutha ward, the effort will be duplicated in Kitui East and Mwingi North sub-counties where nomads reside.

TBA Mapping and Role Re-designation: In quarter four, the project supported MOH in the identification and verification of 1520 TBAs across the four counties. Out of the 1,520 TBAs, 827 were from Kitui, 265 from Kakamega, 215 from Kisumu and 213 from Migori. In Year 2 of project implementation, all mapped and willing TBAs will be taken through role re-designation to have them take up new roles either as birth companions, CHVs, CHC members or even hygiene promoters among other roles. In Kakamega, a total of 265 TBAs were mapped out of which 57 are from Khwisero sub-county, 87 from Mating sub-county and 121 from Navakholo sub-county. At Khalaba Health Centre the TBAs are being motivated by the facility when they bring clients for delivery they are given a small token. There are 10 TBAs who are linked at the facility. In Kisumu, 215 active TBAs were mapped from the six project supported sub-counties. In Migori, 213 TBAs well known across the eight sub-counties of Migori were identified. Initial discussions with them revealed their desire to shift from their practice and be engaged in sensitization and referrals of pregnant mothers to seek skilled services at local health facilities such as antenatal care, skilled delivery, and post-natal care services. So far one converted TBA from Suna West Sub County has been involved in providing basic education to pregnant mothers and has so far made referrals to 16 mothers for skilled delivery (her story is annexed to this report)

In Kitui, the project supported MOH to identify and verify 827 TBAs. Among these, 702 were given basic information on importance of ANC, skilled deliveries, postnatal care, family planning, gender mainstreaming, exclusive breastfeeding, early initiation of breastfeeding, AYSRH and immunization. Afya Halisi advocated to MOH to put up maternity waiting areas and equip them with adequate staff and necessary supplies to improve skilled deliveries, Kyuso Sub County Hospital and Ikutha Sub County Hospital have started hosting antenatal clients.

Activity 1.2.3. Conduct integrated outreaches, including outreaches targeted at hard to reach populations: Afya Halisi supported coordination meetings in Kisumu, Kakamega and Migori. In addition, the project supported outreach services in all the four project counties.

In Kakamega, Afya Halisi supported 30 integrated outreaches in Kakamega. CHVs mobilized community members for ANC, PNC and immunization services. In Kisumu, the project supported 10 integrated outreaches in Kisumu. CHVs mobilized community members for ANC, PNC and immunization services.

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Immunization outreaches ongoing in Kisumu West

In Migori County, during the reporting quarter, the project supported county and sub county EPI coordinators to conduct the RRI planning meeting and targeted supervisions. Consequently, HCWs and CHVs from 64 facilities with the highest unimmunized children from Jan 2017 to June 2018 were supported to conduct a 3 – days door – to – door immunization from 28th – 30th Aug 2018 across all the sub counties. This was conducted in the respective facilities’ identified hard – to – reach areas. Kuria West had the highest number of facilities (12, 19%) supported owing to its high numbers of unvaccinated children and unsatisfactory ratings in the previous quarters. Unimmunized children were common in the following places: mining areas, health facilities near Tanzania and informal settlements.

In Kitui County, during the quarter under review, CHVs, village administrators, village elders, assistant chiefs and chiefs traced 625 immunization defaulters and non-immunized children. Caregivers cited the following reasons as causes for defaulting: Fear of young, aged or multi- parous women being harassed by HCW, and lack of clothes for newborns. Commercial sex workers or women living in abject poverty were also found to be unlikely to take their children for immunization services. In quarter four, the project mapped three nomadic community manyattas: Mokorongo, Movuko and Inyale in Kitui South during the 4th polio campaign. The MOH team that accompanied Afya Halisi team immunized 20 children against Measles. Afya Halisi will complete the mapping exercise in Year 2.

Activity 1.2.4. Scale-up Community Based Distribution: The project supported training of 3,756 CHVs on FP technical modules within FY 1 Q4, to equip them with, among other things, skills and knowledge provision of FP services at the community level. Specifically, the CHVs are expected to provide counselling for FP services for women with unmet need, refer those ready to start FP method to link health facilities, distribute condoms and refill pills for eligible clients.

After the training, all the 3,756 CHVs visited household to provide FP messages, and participated in various FP dialogue sessions (section 2.1.2). In Kisumu County, six CUs are supporting CBD, mainly distributing male condoms. Thee CUs are from Kisumu Central (Nyalenda, Manyatta, and Shauri Moyo Kaloleni CU) and Muhoroni (Wangaya CU 2; Koru Central and Upper Tamu CUs). The 6 CUs reached a total of 487 with condoms within the months of July to September.

In Kakamega, all the Afya Halisi supported in Navakholo, Khwisero and Navakholo are involved in distributuin of male condoms for family planning. In Mogori, all the Afya Halis supported CUs distributed male condoms both for HIV prevention and FP. Some of the current gaps in CBD are

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weak commodity management practices among the CHVs, which has been corrected and CHVs are completing and submitting consumption data and placing request. The other key challenge has been hesitance by health care workers in link facilities to issue FP commodities for CBD. The project is already holding advocacy discussion with reproductive health coordinators for support.

Activity 1.2.5. Strengthen referral mechanisms between the community and facility: In Migori, in order to build the capacity of the CHVs for defaulter tracing, the project supported orientations/sensitizations of 48 CHVs (32F, 67%) from all the four community units (Masara, Nyasoko, Arombe A and Arombe B) of Wiga ward – the worst performing ward in Suna West sub county with poor ratings in Measles/Rubella 1 and FIC on the MCH booklet and their roles in the community. Key immunization areas of focus included: vaccines in the national routine immunization schedule; emphasis on importance and increase referral of children for OPV 0 and MR1 and MR2 (two vaccines with low uptake in the ward); enhanced defaulter tracing and referral of unimmunized children to nearby facilities for immunization services. Follow – up at the end of quarter four (after the orientation done early in the quarter) showed that a total of 46 unimmunized/defaulters were referred by CHVs for immunizations from the community to the facility. The project will strengthen similar orientations to CHVs in year two to facilitate home visits and defaulter tracing and referral for immunization.

During the year, the project supported the joint quarterly review meeting between the facility and community healthcare workers in Kituka dispensary, Nyatike Sub County. This was aimed at identifying barriers and solutions to achieving immunization targets especially for the MR1 at the facility. Common barriers identified were:long distance to health facilities and poor inter-facility linkage for updating of immunization data in the primary and secondary registers.

The project will support targeted community – level outreaches in the hard – to – reach areas will and advocate for strengthening of inter-facility communication through online platforms (WhatsApp) where feasible. The project will support monthly/quarterly facility – community review meetings to improve community – facility linkages targeting to improve the quality of immunization, child health and other integrated RMNCAH services/targets.

During the reporting period, the project sensitized all the supported CUs on establishing a Community Based Referral Mechanisms (CBRM). Each CU has an idea of how to attend to emergency referrals. In Kakamega, community units have engaged local boda riders to offer referral services who are called upon in emergency settings. In Migori, all of the 34 project supported community units have established their various local mechanisms for managing referrals especially for uptake and utilization of maternal and newborn health services and also in emergency settings. For instance, a common mechanism in all the community units has been the identification and use of reliable and known local motorcycle riders to assist in facilitating transportation of pregnant women to the health facilities for skilled child births. The motorcycle riders’ cell phone contacts are kept by the CHVs and the pregnant women and are called upon when required.

Activity 1.2.6. Strengthen accountability and support mechanisms between community and facility: The project worked with MOH to establish CU link desks in 94 health facilities among them 43 in Kakamega, 34 in Migori and 17 in Kisumu. The CHV desks provide an opportunity for CHVs to

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learn and improve skills in provision of health education at link health facilities, assist in patient registration, BP weight measurement, clerking of clients, taking anthropometric measures, conducting health education and taking clients through the charts and health data displayed on the talking walls.

In Kakamega, the project supported 15 CUs to conduct facility-community meetings and 43 health facilities to establish CU link desks in Kakamega. The desks also have files for clients referred to health facilities. At the link desk we also have Defaulter tracing diaries which makes it easy for CHVs to identify defaulters traced at any point. In Kisumu, all the 17 CUs have set up link desks at the health facilities.

In Migori County, the project worked with MOH to establish CU link desks in 34 heath facilities in Migori. The CHV desks is helpful in coordinating issues of tracing and referrals from health facility to community and vice versa. This has so far helped in ensuring the CHVs are familiar and at ease with the health facilities’ staff. The meetings at the health facilities have also helped the CHAs and health facility CHEWs to address HFs related data for use by the CHVs to reach out to the community members for household’s health promotion and tracing of various defaulters.

In Kitui, the project supported 14 facilities-community linkage meetings in July and August 2018 to discussed performance of both community and facility level indicators; community - facility referrals and community health activities. Some of the community health activities discussed during the meetings were community MPDSR, defaulter tracing, family planning and community data management.

Output 1.3 Strengthen county health systems for delivery of FP/RMNCAH, nutrition and WASH services. 1.3.1 Strengthening Community Multi-Sectoral Networks and Coordination

Support counties to address WASH gaps: Afya Halisi supported forums to deliberate on WASH and particularly community-led total sanitation (CLTS) across supported counties. For instance, in Migori County, the project supported one CLTS forum that gathered partners implementing CLTS and county government to deliberate on how to realize the county’s dream of becoming ODF by March 2019. The county resolved to put more resources to support triggering and follow up targeting 600 villages across the county, to accelerate achieve achievement ODF status by March 2019.

In Kakamega County, the project supported the MOH to convene a WASH stakeholders’ forum to discuss the importance of WASH coordination in the county, chart the way forward on how to strengthen the forum, and explored options for organizing a single WASH coordination forum in the county. Currently, two forums exist: one chaired by Ministry of Water and the other Ministry of Health. In another WASH forum, the County tasked a small working group to develop a county healthcare waste management (HCWM) plan to address waste management comprehensively within the entire county. Afya Halisi will continue offering technical assistance during this process to complete the draft plan in year two.

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In Kitui County, with the support of WASH partners, the County convened a post-ODF forum and invited all WASH sector players to prepare for County ODF celebrations and chart way forward on how to introduce sanitation marketing as post-ODF initiative. The county told Afya Halisi engaging in sanitation marketing would be the project’s ideal entry point to support the County’s post-ODF initiative. Afya Halisis has planned three key activities under sanitation marketing for Kitui: training PHOs in sanitation marketing, upgrading artisans’ skills and training community and natural leaders.

Community Systems Strengthening: The project supported the Ministry of Public Health in Kisumu, Kakamega and Migori to host one County Level Community Health Strategy Technical Working Group (TWG) meeting during the last quarter of the year one. In Kitui, the meetings were supported by other Community Health partners and Afya Halisi only participated in the meeting. The County Level Community Health Strategy TWGs meeting provided an opportunity to strengthen the coordination and implementation of CHS activities at County level. These meetings particularly helped Afya Halisi to further understanding the scope, jurisdiction and operation of various partners with an intention of creating networks, linkages, synergy and avoid duplication in support of activities at community level, strengthening the collaboration between Afya Halisi and other USG funded projects in Migori county such as LVCT SQALE.

Activity 1.3.2. Supportive Supervision for improved quality of services: In Kakamega, during the reporting period, Afya Halisi in conjunction with MOH intensified integrated supportive supervision across all the 51 health facilities in the target sub-counties 14 of which were private health facilities. Some of the areas identified and strengthened in nutrition included: Vitamin A supplementation, growth monitoring and promotion through child welfare clinic, IFAS during pregnancy, Zinc supplementation in diarrhea management. Key issues addressed during the supervisor were documentation and strengthening referral and linkage from community to HF and vise-versa

In Migori County, the project supported the county and sub-county HMT to conduct EPI focused supportive supervision reaching a total of 154 (85%) of the HFs. Ineffective facility – community linkages in several health facilities were highlighted as the commonest challenge facing the achievement of immunization coverage. The project will continue to support the strengthening of facility – community linkages in year two to improve the immunization indicators in the county especially MR1 coverage and reduce Penta 1/MR1 drop – outs. During quarter four period, the project supported the county and sub-county child health teams to conduct facility level child health focused supportive supervision reaching a total of 154 (85%) health facilities. Major gaps identified were low numbers of frontline HCWs trained in IMNCI and ETAT+, basic ORT corner equipment and ORT registers missing in a number of facilities and inadequate key IMNCI job aids and pediatric protocols.

In Kitui County, during the reporting period, Afya Halisi project supported integrated child health and immunization focused supportive supervision in 47 HFs in Kitui. The objective of the supervision was to identify gaps in the provision of child health and immunization services and address them.

During the integrated supportive supervision, the supervision team mentored staff on provision of child health services, preventive maintenance of EPI fridge, vaccine monitoring and proper

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documentation. Furthermore, staff were mentored on how to fill the registers correctly and submit accurate and timely data and on how to report notifiable diseases. Key recommendations from the visits included: health facilities to strengthen use of ORT register, immunization in health facilities to take place daily, healthcare providers to be trained on REC approach, health facilities to generate immunization defaulter lists, non-immunizing health facilities and those using domestic fridges to receive EPI fridges, immunization ledger books and immunization monitor charts to be updated promptly, initiation of immunization outreach services in HF with high number of defaulters, and high volume health facilities to reorganize services in MCH.

Supportive Supervision for CHVs to improved quality of services: During this quarter, the project support MOH to conduct support supervision for CHVs in Kisumu, in Kakamega, in Migori and in Kitui. The CHVs from Kitui County were however not supported this quarter because they had been suspended by the County Government. Cumulatively the project has supported two quarterly visits in Kitui and three quarterly support supervision visits for the remaining three counties specifically during quarter two, quarter three and now quarter four. Every CHV is expected to receive at least three visits from his/her supervising CHA annually to ensure consistent support towards quality house hold level service provision, in year two the project will intensify support visits. Overall, a total of 52 CUs in Kisumu, 71 CUs in Migori, 22 in Kitui and 31 CUs in Kakamega counties received this support. The main gaps identified were inadequate IEC materials to support dissemination of key health messages, inadequate ability to identify and address house hold level health concerns, stock out of MOH 514 for use by CHVs during community service delivery and skewed visits by CHVs to preferred households in the community.

In Kakamega, the project supported CHAs, sub-county and county CHMTs to conduct support supervision to 31 CUs spread across three project supported sub-counties in Kakamega county. The main gaps identified were inadequate IEC materials to support dissemination of key health messages, inadequate ability to identify and address house hold level health concerns, stock out of MOH 514 for use by CHVs during community service delivery and skewed visits by CHVs to preferred households in the community. The project will continue addressing these gaps through dissemination and distribution of the CHV SBC toolkit, other IEC materials and MOH 514 for use by the CHVs.

In Kisumu, the project supported CHAs, sub-county and county CHMTs to conduct support supervision to 52 CUs spread across six project supported sub-counties in Kisumu County. The support visits were used to improve health indicators, assess the performances of CHVs at house hold level and establish challenges faced by CHVs in health services delivery. Key findings during the supervision included, lack of reporting tool, outdated chalk board and some data quality issues. As a result, data tools and data quality issues were integrated in MNCH and family planning trainings during the last quarter of the year eight CUs were trained in data tools and quality reporting. In addition, the project is in the process proving the updated version of the chalk boards and improve access to data reporting tools.

In Migori, the project supported CHAs, sub-county and four county CHMTs to conduct support supervision to 414 CHVs (122 male; 292 female) drawn from 71 CUs spread across eight project supported sub-counties in Migori County. The support visits were used to improve health indicators, assess the performances of CHVs at household level and establish challenges faced by CHVs in health services delivery. The visits revealed that majority of CHVs were doing great work

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in household level health promotion, defaulter tracing and referrals for health care services. Few challenges noted were that some CHVs cover wide areas with sparsely distributed households which causes a lot of fatigue to them hence at times do not provide quality attention to some households. It was also noted that some CHVs are involved in so many other community level assignments from family to social groups and from other partners on the ground with different and competing priorities/demands. The SCCSFP and CHAs recommended continuous capacity development of the CHVs through on job trainings, coaching and mentorship on data quality management. There is need to strengthen provision of CBHIS reporting tools to support generation of data quality for decision making.

In Kitui, the CHVs were not supervised since they had been suspended by the County Government of Kitui. However, for quarter two and quarter three, the project supported CHAs, sub-county and county CHMTs to conduct support supervision to 22 CUs spread across six project supported sub- counties in Kitui County. The support visits were used to improve health indicators, assess the performances of CHVs at house hold level and establish challenges faced by CHVs in health services delivery. Key findings during the supervision included inadequate supply of reporting tools and some data quality issues.

Activity 1.3.4. Health financing: Financing health care has been identified as a barrier to access to health care and increases the likelihood of impoverishment of households through out of pocket payments. Fairness in financial contributions towards health care is a key component of modern day approaches to health system assessments. The traditional sources of health-care financing are taxation, private insurance, out of pocket (OOP) payments charged at the point of health care delivery and social insurance. Private and social insurance reduce the barrier to access and spread the risk of ill health away from the household. It is against this backdrop that Afya Halisi in PY1 continued to engage the CHMTs / SCHMTs in collaboration with the NHIF county officers to sensitize the communities and CHAs on the Linda Mama program. The activities hinged largely on sensitizing the health facility in- charges and the community members on NHIF accreditation, enrollment and claims process facilitated by officials from the county level NHIF offices. The lessons learned will help the Project to advance this agenda in a more structured way in PY2.

The counties are at various stages of developing Universal Health Care (UHC) aimed at ensuring that everyone can obtain essential health services of high quality without suffering financial hardship. Nationally, Kisumu, , and , were selected as pilot counties that would generate the required feedback to guide the countrywide rollout afterwards. Resource constraints require that counties determine their own definition of essential services. UHC cannot provide access to all possible health services, the counties will be supported to make choices and priorities set. The project will continue to engage the counties in setting out what best suits the county needs, capacities, and the community expectations. Kakamega County In the three project supported sub counties of Kakamega County, the project continued to ride on the Oparanya care (Imarisha Afya ya Mama na Mtoto program) supported by the county notably in selected high volume sites that record high skilled birth attendance. The financial rebates given to the mothers serves as an incentive to attract the mothers to attend ANC, deliver at facility level and also attend PNC and immunizations. Some facilities also procured mama parks that incentivize the mothers to deliver at facility level. The project supported Linda Mama enrollment through

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various activities including young mother’s clubs and maternity open days. This resulted in a total of 7,082 mothers being enrolled onto the Linda Mama program. Sensitization meetings for Linda Mama / NHIF enrollment were done jointly with NHIF officers reaching 71 HCWs in the three sub-counties. Whereas most of the private facilities under Linda Mama were receiving rebates, only five public facilities received their reimbursements in the quarter under review.

Kisumu County A total 335 HCWs were sensitized Linda Mama / NHIF enrollment across the 6 sub-counties in Kisumu county. Additionally, through project support, pregnant women were enrolled for Linda Mama where a total of 1,825 women were enrolled during the quarter under review.

UHC Initiatives: The county being one of the four UHC pilot counties, launched a household registration towards a social health financing scheme (Kisumu Care) using a tool that is able categorize the household poverty levels / social economic status. This borrows largely from the Makueni Model and the Kitui county (K-CHIC) structure. This data will be used to determine the indigents and at the same time be utilized as a platform for NHIF registration. The county has conducted detailed health facility assessments to determine the available package of services, staffing, equipment and commodities as well as the infrastructure. The project team participated in the development of a road map on implementation and sustainability adopted from the national framework. The county aims to map out and enroll 150,000 households for Super Cover, with an annual premium of Ksh 6,000. This is envisioned to work in a complimentary manner with the national UHC initiative once it is officially launched. A UHC bottle neck analysis meeting for the county will be held next quarter.

Migori County In Migori County, the project continued to support the strengthening of Linda mama enrollment and rebates across all the sub-counties. The project supported sensitization meetings for Linda mama and NHIF enrollment jointly with NHIF officers, where a total of 106 healthcare workers in 3 sub-counties were sensitized. Additionally, through project support, 1,734 pregnant women were enrolled for Linda mama. A total of 19 health facilities were empaneled; with 9 health facilities receiving their reimbursements during the quarter. Whereas most of the private facilities under Linda mama were receiving rebates, only six public facilities were able to receive rebates. The project team participated in the County Universal Health Care (UHC) steering committee meeting and discussed strategies for increasing Linda mama enrollment; increasing coverage of quality care and improving the rate at which reimbursements are done to the facilities. The project will continue to work closely with stakeholders to ensure increased enrollment and rebates. Below is a breakdown of project support towards Linda Mama and UHC.

Kitui County During the quarter under review, Kitui county launched the - Kitui County Health Insurance Cover (K-CHIC) at Katulani Hospital in Kitui Central sub county, targeting 270,000 households. Afya Halisi collaborated with the CHMTs/ SCHMTs to support the roll out by encouraging mothers to enroll on this social health protection scheme during community engagements, young mother’s clubs and maternity open days. A total of 80,000 households (30% of the target) has so far been enrolled. The Governors of Kitui and Makueni counties are working on an MoU that will facilitate the enrolled members to access health services in any facility across the two counties. The project and MoH teams continued to sensitize the community to enroll on the NHIF and Linda mama

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program. It is unfortunate that the Linda mama program does not apply to private sector facilities in Kitui county. The project will continue to advocating for NHIF and Linda mama rebates being ploughed back to the facilities to be used to improve the quality health services. Additionally, to support full utilization of the Linda Mama funds the project is working closely with the NHIF and facility managers to mobilize clients for enrollment during maternity open days, outreaches and in reaches.

During the quarter under review, 127 (92 female, 35 male) service providers drawn from Mwingi Central sub county and community members were sensitized on Linda Mama focusing more on the benefits and process of enrollment. Cumulatively 19 health facilities have been empaneled / accredited and 1,735 mothers registered in the county.

Activity 1.3.5. Support counties to address HRH gaps: In PY1, a total of 66 health care workers were engaged on contract basis (Kisumu -7; Kitui -55 and Migori -4); the numbers will be topped up to make a total of 100 in PY2. All the 66 HRH staff engaged on a contract basis, were taken through an induction process and plans are underway to have their biodata entered into the iHRIS system starting this quarter and will be updated on a quarterly basis, within two weeks after the end of each quarter. This information will be used for the purposes of workforce analysis, planning, budgeting, interventions and program evaluation at county level. Discussions are ongoing with IntraHealth to have one of the Afya Halisi staff have access to iHRIS system and facilitate the entries.

The project signed Letters of Agreement (LoA) with the County Secretaries of Cabinet detailing the among other things the transition process for the HRH staff engaged by the project and deployed at facility level. The project is not supporting HRH staff in Kakamega county. However, the county is benefitting from staff engaged through other USAID funded mechanisms. Table 4 below summarizes the HRH staff by cadre and county that are already on board and working across various facilities.

Table 4. Project supported HRH staff by cadre and county County / Cadre RCOs Nurses HRIOs Total PY2 Target Deficit Kitui 9 41 5 55 60 5 Kisumu 0 7 0 7 20 13 Migori 0 2 2 4 30 26 Total 9 50 7 66 110 44

The recruitment process is ongoing to top up the numbers to reach the target for PY2 and monitoring the transition process. The project will continue to engage the counties and agree on the cadres of staff to be recruited in line with the specific county needs.

Activity 1.3.6. Commodity and supply chain management at county and sub-county level: During the quarter under review, the project facilitated the training of 13 ToTs on commodity and supply chain management. The ToTs drawn from counties will help to decentralize the trainings to sub county level. This will have the effect of reaching more HCWs at the sub-county level drawn from both public and private sector sites. A total of 375 HCWs were trained on commodity management during the quarter under review, bringing the cumulative total to 595 against PY1 target of 300 (198% achievement). This has resulted in reduction of stock out of the tracer

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commodity -DMPA from 24% in Q2 to 11% in Q4 against a target of 15%. However, in the month of September 2018, Kisumu and Kakamega reported 0% stock out of DMPA. The project will in PY2, extend these trainings to CHVs to handle community-based-distribution (CBD) for MNH- FP (Vit A, ORS-Zn, Oral and Injectable contraceptives) of commodities. In Kakamega and Kisumu Counties, the project facilitated distribution and re-distribution of family planning commodities from sub county stores to facilities. There was an agreement with KEMSA to supply commodities to sub county level to save on time occasioned by routine that has always delays the dispatch of these commodities to the facility level. DHIS Reporting: During the period under review, the reporting timeliness in Afya Halisi supported health facilities improved to 98%, with Kitui recording the lowest at 89% (an improvement from 80% in Q3). This improvement is attributed to the trainings on DHIS and FP dashboard and emphasizing sing the fact reporting rates affect the availability of commodities directly. Figure 14 below depicts the trends of FCDRR reporting rates in the four counties.

100

80

60

40 Percent

20

0 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18

Kisumu Migori Kitui Kakamega

Figure 14. FCDRR Reporting Timelines, October 2017 to August 2018

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Sub-purpose 2: Increased care seeking and health promoting behavior for FP/RMNCAH, nutrition and WASH Output 2.1. Increased knowledge of and demand of FP/RMNCAH, nutrition and WASH services Activity 2.1.1. Identify and support context-specific strategies for healthy behaviors: During the quarter, Afya Halisi carried out three 3D/HCD undertakings focusing on MNH – ANC/SBC (Kitui), Nutrition – EIBF/EBF (Kakamega) and Child Survival – Immunization (Migori). These three are in addition to the HTSP 3D/HCD exercise carried out in Kisumu County in Y1Q3 of PY1. In total, the project managed to deliver customized communication strategies in each of the four health areas mentioned above. These communication strategies provide guidance to the project during implementation of SBC activities geared towards addressing the behavioral drivers critical to the project’s mandate. During the said 3D/HCD exercises, MOH personnel and relevant SBC partners were invited to the 3D workshops and also participated in the subsequent community HCD immersions. The process was designed An HCD session with young adolescent & youth mothers in to serve as both a practical training Navakholo, Kakamega County occasion for the participants and also as vehicle for delivering contextual SBC solutions. This new methodology has raised a lot of interest and excitement, especially from county MOH officers, leading to requests for Afya Halisi to support 3D/HCD immersion and develop solutions that address behavioral drivers in other thematic areas like AYSRH (Teen Pregnancy) and WASH. The communication strategies developed through this process have been disseminated across all four Afya Halisi counties at forums like the County HPACs, CHMT meetings and stakeholders’ forums. Development of context-specific IECs and Afya Halisi collateral: Following the 3D workshops and HCD field immersion activities, Afya Halisi developed briefs and worked with creatives to craft communication campaigns and materials to support its SBC interventions and demand creation activities. Some of the campaigns developed for Afya Halisi are the “Uliza Awinja” and “Tazama Mbele” campaigns addressing HTSP factors.

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“Tazama Mbele” & “Uliza Awinja” communication campaigns developed for Afya Halisi based on the outputs of the 3D/HCD methodology.

Mass media support: During the reporting quarter, Afya Halisi supported the airing of radio spots, presenter mentions and interviews with experts in support of on-ground demand creation activities around HTSP, AYSRH and Immunization. The said radio spots, presenter mentions and interviews were aired on local vernacular radio stations popular in Afya Halisi counties. The vernacular stations were selected using a strict criteria comprising of geographical coverage, audience demographics, listenership, intensity (loyalty) and value for money (cost-effectiveness). Training of Afya Halisi staff, partners and MOH staff in cutting-edge SBC strategies: In Q4 of PY1, Afya Halisi trained 10 TOTs in the Counselling for Choice (C4C) approach. The C4C methodology is designed to address counselling factors that lead to discontinuation of modern FP methods. The 10 ToTs will begin the process of cascading down the C4C approach to the rest of the project’s operatives and MOH in PY2. In pursuit of the objective to increase care-seeking and health-promoting behaviours in its implementation counties, the project also trained relevant personnel in ETL and 3D/HCD. Afya Halisi trained 80 CHVs in the ETL community facilitation technique that enables CHVs to introduce and sustain meaningful community discussions around any given health topic. As earlier mentioned, the project also trained county MOH officers, Afya Halisi officers and other county SBC partners in the 3D/HCD methodology for community engagement and communication development. The total 112 participants attended the 3D workshops and HCD immersions and were trained in the methodology. Interpersonal Communication (IPC) activities: In the Q4 reporting period, the project has prioritized IPC activities/events targeting youth and adolescents. A myriad of AYSRH events have been held throughout the breadth of Afya Halisi implementation counties. AYSRH sessions were held in schools and colleges where reproductive health matters (e.g. delaying sexual debut, prevention of teenage pregnancy and accessing reproductive health services) were discussed together with other topics relevant to this audience such as life-planning skills, A good example is an outreach christened “Chanua Fresher” held at

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Rongo University targeting mostly the new first year students and the surrounding community. During the outreach 411 youth (165 male and 246 female) were reached with AYSRH messages. RH services were integrated into the sessions and 03 pills, 09 injections, 22 implants, 00 IUCDs and 18 condoms were taken up by the youth attending the outreach. The bulk of Afya Halisi IPC activities were carried out by CHVs. They do this at forums such as Community Action Days and Facility Open Days. In addition to the CHV-led forums, Afya Halisi personnel, MOH officers sponsored by the project and other community champions (e.g. youth champions, role-models and opinion leaders) have also carried out IPC sessions in furtherance of the project’s objectives. The key IPC approaches employed by project staff during their community engagement sessions include one-to-one sessions (e.g. during A CHV talking to Youth at Mulutu Catholic household visits) and Small Group Sessions Dispensary on Life skills & AYSRH (SGS) that are suitable for medium-sized audiences (10 – 20 participants) usually at formal/informal workplaces. Opinion leaders have also lent their support to the Afya Halisi agenda by voicing support for the project at churches, funerals and barazas and urging community member to uptake the quality services availed to them through the MOH/Afya Halisi partnership. Support groups such as “Young Mothers Clubs” and “Young Fathers Clubs” have been formed in a number of health facilities that had sufficient number of clients in the youth/adolescent cohort. These support groups provide safe spaces for youth to air their concerns and discuss solutions to their problems without being judged. A good example of a facility providing safe spaces for the youth to discuss their issues is the Sori Lakeside Hospital which has set aside Tuesdays as a special day for the youth. This has led to a drastic increase in the uptake of services. During one such session, 12 young mothers took up FP methods, 25 received ANC services and 28 received PNC services. Support for health days: During the reporting period, Afya Halisi supported the World Contraception Day (WCD) celebrations across all its four counties. The project offered both technical assistance (during planning) and financial support to the counties in support of this all important day that is used to raise awareness around modern contraception. Over the PY1 implementation period, Afya Halisi has also supported other health days and campaigns that contributed towards it goals such as the Malezi Bora Week. Coordination: Afya Halisi supported four county HPACs in its four counties of operation in Y1Q4 of PY1. The project also extended the same support in Q2 and Q3. In total, the project has supported 12 HPACs in PY1. HPACs are convened by the Health Promotion Officers in each county. All partners, government departments and even private sector players with components of SBC in their programming are invited to the forum to deliberate on matters such as health days, emergency risk communication and SBC support for immunization campaigns (e.g. measles & polio). Afya Halisi also used these forums to disseminate the outputs of its 3D/HCD activities.

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Activity 2.1.2. Encourage demand for services: During the reporting period, the project supported 152 focused community dialogue days among them 48 in Kisumu, 43 in Kitui, 31 in Migori and 30 in Kakamega. The dialogues were focused on different thematic areas reaching 595 during FP dialogues, 1,408 during AYSRH dialogues, 467 during MNH, 200 during nutrition dialogues, 1,918 during child health dialoques,410 during gender, 702 with TBAs and 183 during WASH dialogue sessions. In total, the project reached 435 in Kakamega, 2,886 people (700 male, 2186 female) in Kitui, 978 people (437 male, 541female) in Migori and 1,714 people (448M, 1,266F) in Kisumu. Community dialogue sessions held in Y1Q2 and Y1Q3 relied heavily on allowing the community members to choose a topic of discussion during the dialogue day based on performance of indicators. The project then resorted to supporting focused dialogues in Y1Q4 by having a predetermined topic of discussion before the dialogue day informed by performance on indicators and mobilizing the key required community cohorts likely to benefit more from the dialogue. Cumulatively for year one the project has reached 7,733 (2,310 male, 5,423 female) and 439 adolescents.

The county specific activities are detailed below.

Kakamega County During the quarter, the project supported 30 focused community dialogue days in Kakamega reaching 435 people. Of these, 200 were reached during the nutrition dialogue, 65 during the WASH dialogue, 102 during immunization dialogue and 68 during the gender dialogue sessions. Some of the actions agreed on during the dialogue day include ensuring every household has access to and uses a sanitary facility, and promotion of skilled delivery services provided in health facilities for all pregnant mothers and babies. The dialogue meetings were supported by MOH staff, CHCs and CHVs, the project has reached 1,135 people among them 534 adults (342 male, 793 female) and 280 adolescents (109 male, 217 female). Topics discussed during the dialogue days included the importance of pregnant mothers completing at least four ANC visits, adolescent pregnancy, latrine coverage, uptake of long-term family planning methods and registration to Linda mama program.

Kisumu County During the quarter, the project supported 48 focused community dialogue days in Kisumu reaching 1,714 people (448 male, 1,266 female), of this 414 people, were reached during an family planning dialogue, 158 people, during the MNH dialogue, 564 people, during AYSRH dialogue; 118 people, during child health dialogue, 118 people, during WASH dialogue and 342 people, during gender dialogue. Adolescents mentioned that enticement by older men for financial gains is among the causes of early teenage pregnancies. Cumulatively, the project reached 2,090 adult community members (597 male, 1493 female) and 18 adolescents (8 male, 10 female). During these dialogue days, a total of 117 community members (53 male, 64 female) were referred for various FP/MNACH/nutrition services, among them 60 for family planning, 27 for maternal health, 20 for child health and 10 for nutrition services.

Migori County During the quarter, the project supported 31 focused community dialogue days in Migori reaching 978 people (437 male, 541 female), of this 181 people (87 male, 94 female) were reached during an FP dialogue, 309 people (103 male, 206 female) during the MNH dialogue, 210 people (126 male, 84 female) during AYSRH dialogue and 278 people (121 male, 157 female) during the child

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health dialogue. All the dialogue sessions in cooperated discussions on gender, WASH and high impact nutrition interventions. The dialogue sessions elicited a lot of information relating to factors that affect effective utilization of health services on immunization, AYSRH, MNH and sustained behavioral change on nutrition and WASH aspects. Community members agreed to pay more attention to antenatal care visits and uptake of skilled child birth to reverse the trends on maternal and perinatal deaths. Community members in Kuria East, Kuria West and Nyatike sub-counties identified context specific barriers to service uptake for ANC and skilled child birth and raised them for action with sub-county health management teams (SCHMT) and health care providers through their CHCs.

Some of the key actions agreed include tracing of all ANC and immunization defaulters and referring them to the HFs; establishment of pregnant mothers support groups in each village; discussions with TBAs to halt their business of assisting mothers in child birth; advocacy for active male involvement in matters of health of pregnant mothers, newborns and children; active parent- adolescent communication on sexual and reproductive health issues; construction and use of functional pit latrines; construction and use of functional hand washing facilities at homesteads and at health facilities; practicing of exclusive breastfeeding and deworming of children to improve on their health. The duty bearers were also asked to ensure drugs are available at the HFs so as to encourage community in seeking health services from them. HCW from the MOH were also urged to ensure services at the facilities are provided with high quality measures and with very little delays. Cumulatively the project reached 1622 adult community members (671 male, 951 female) and 301 adolescents (134 male, 167 female). During these dialogue days, a total of 242 community members (101 male, 141 female) were referred for various FP/MNACH/Nutrition services, among them 143 for family planning, 47 for ANC, seven defaulters for immunization.

Kitui County During the quarter, the project supported 43 community dialogue days in Kitui reaching 2,886 people (700 male, 2186 female), of this 634 (171 male, 463 female) were reached during the AYSRH dialogue; 130 (32 male, 98 female) during a dialogue session with parents; 1420 (497 male, 923 female) during an integrated community dialogue day for immunization, skilled delivery, PNC and immunization dialogue and 702 TBA during a dialogue session targeting TBAs. Topics covered during the dialogue sessions with adolescents include menstrual hygiene, delaying age of sexual debut, STIS and life skills. Adolescents were able to open up and share a lot compared to what they do in general dialogue sessions. Some of the challenges raised by adolescents include: lack of parental guidance on reproductive health issues and inconsistent supply of sanitary pads causing girls to miss school or engage in sexual activity in exchange for money to purchase pads. The majority of adolescents reported that they were Adolescents Sexual Reproductive Health Orientation sexually active and hence no need for at Kasaala Africa Inland Church abstinence message. The majority wanted information on family planning, though they strongly believe that it is for the married women (biased branding).

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Cumulatively, the project has reached 2886 people (700 male, 2186 female). In quarter three, the project utilized dialogue days to introduce CHVs to community members so as to reduce community resistance during household visits. The dialogue days focused on discussion cases of unskilled delivery, teenage pregnancies and unmet family planning needs. Unskilled delivery was attributed to distances to hospitals/cost of transport, lack of 24/7 services for both maternity and immunization services/under staffing in dispensaries, lack of food/hot drink post-delivery. The CHVs were tasked to map pregnant women and children under one-year-old. The village elders, assistant chiefs and chiefs will provide support.

Output 2.2. Improved gender norms and socio-cultural practices

Activity 2.2.1. Conduct a gender analysis: During the quarter under review, the project obtained the necessary ethical and administrative approvals from John Hopkins University and the local IRB (Amref) to conduct the gender analysis study. County-level study entry and buy in meetings were held with the Kakamega, Kitui, Kisumu and Migori CHMTs. The recruitment process for the study team and development of the study operation manual was initiated during the quarter under review. The findings of the study will be utilized to inform PY2 context-specific gender integration interventions.

Activity 2.2.2. Conduct routine analysis of sex- and age-disaggregated data: The project continued to foster the utilization of data capture tools that enabled staff to collect and disaggregate data for various facility and community level activities (where appropriate) by sex. The project continuously reviewed sex and age-disaggregated data where relevant during performance review meetings with S/CHMTs. Reporting on key performance indicators has incorporated that level of disaggregation.

Activity 2.2.3. Expand channels to promote positive gender and sociocultural norms and practices, including equitable decision-making: During the quarter under review, the project continued to expand avenues to reach men, women, boys and girls with the aim of improving access and utilization of maternal and child health outcomes as well the adaptation of healthy WASH and nutrition behaviours. Targeted community dialogues were held in the four counties to address gender-related barriers and constraints to access. (reported under Output 1.2). Kakamega county Two gender focused dialogues were conducted in the Shirere CU linked to KCGTRH and the Emalindi community linked to Emalindi dispensary reaching a total of 115 people (77 female, 38 male). These dialogues brought to fore the occurrence of GBV that is associated with power imbalances in relationships, alcohol consumption. It was noted that there is continued vulnerability of young girls to defilement due to the long distances they are required to cover to attend school, misconception around HIV cure when an infected person has sexual intercourse with a virgin, and being orphans. In one of the dialogue days, the community discussed use of “Manyasi “which is a local herb used by pregnant mother to cleanse their breasts after giving birth to allow room for initiation of breastfeeding. It’s believed that if a mother fails to cleanse the breast that was suckled by the husband during love making, giving the same breast to a baby might result in the death of the baby. During the dialogue men agreed that they will be ensuring the Manyasi is packed for the mother as she goes to deliver in order to avoid delays in initiating the baby to breastfeed within an hour after delivery.

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Migori county Discussions on gender were incorporated in all the dialogue meetings conducted on MNH, FP, AYSRH and WASH. The dialogue meetings unearthed various issues that are believed to impede equal participation of male and female gender in decision making concerning health matters. These include male dominance in social, economic and political spheres in which decision making is influenced and controlled by the men who also occupy key leadership positions in the community; the continued occurrence of early marriage for girls among the Kuria community in which most girls aged 15-18 are considered mature enough to be married off; Preference for male children which in turn influences household decision on family sizes. This is further reinforced by women preference of male children to daughters for protection upon demise of husbands and for defense from disinheritance of properties and more so land; illiteracy among majority of women contributes to their lack of autonomy and access to information which in turn affect their access to quality preventive and curative health care services, among others. The project held youth focused where boys and girls were reached with messages of how to identify risky behaviors, and how to prevent early pregnancies. Kitui county Channels of engagement included focused meetings for adolescents and young persons and traditional birth attendants. The activities revealed that the current family planning branding strategies are not sensitive and responsive to the needs of the youth; the services at the facility level are not male friendly; while men remain the main decision-makers on RH related matters at household level, they are not targeted with information on reproductive health issues; children living with disability are neglected by the parents and they do not get basic health services e.g. immunization; among other gender concerns. Activity 2.2.4. Build capacity of HCWs, CHVs and champions to discuss gender norms and sociocultural beliefs and provide gender responsive services: During the reporting period, diverse strategies were used to sensitize providers and SCHMT to enhance their understanding on gender norms and how these influences behaviours, decision making and service utilization with focus on FP/RMNCAH, WASH and nutrition. These training also sought to build their capacity to identify gender and socio-cultural barriers in the communities.

Whole site gender orientation: In Kakamega county, a total of 335 health providers (male 63; Female 106) were reached through a whole site gender orientation -Matungu had 54 participants (male 20; female 34); Khwisero had 115 participants (male 43; female 72); Lurambi had 88 participants (male 31; female 57); and Navakholo had 78 participants (male 33; Female 45). In Kisumu County,40 participants (males 11; female 29) from one sub-county hospital in Kisumu West were reached through the whole site gender orientation. In Kitui county, 115 participants - Mwingi Central had 55 participants (males 26; female 29); Kitui central had 60 participants (male 19; female 41) attended a whole site gender orientation. In Migori County, 53 participants (male 22; female 31) drawn from one dispensary in Uriri and one SC hospital in Nyatike underwent a whole site gender orientation. These orientations brought to fore the need for the project in liaison with the supported facilities to develop mechanisms aimed at addressing provider attitude as an impediment to delivery of quality services. The participants were drawn from various levels of health care, county, sub-county, health centre and dispensaries. The county gender directors and representatives from the county gender technical working groups supported in undertaking these sensitizations.

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SCHMT and private sector sensitization: The project also conducted a sensitization of SCHMT and in charges of private health facilities during Q4. In Kakamega county, 21 C/SCHMT members (male 13; female 18) were trained on how gender influence health behaviours, resulting in participants developed action plans to guide their gender integration activities for the months of

August and September. In Kisumu County, 84 SCHMT (male 40; female 44) from M uhoroni, Nyakach, Kisumu East and Kisumu West were oriented on gender norms and their implications on health outcomes. In Kitui county, 53 SCHMT (male 21; female 33) from Kitui south and Mwingi West underwent the orientation. Migori County had 165 (male 70; female 95) SCHMT and representatives from private health facilities in Uriri, Suna East, Kuria West and Kuria East attended a one-day gender sensitization.

Hourly sensitizations: During the reporting period, the project supported hourly sensitization meeting for providers, CHVs and CHEWs on gender in the context of referral and linkage of clients for FP/RMNCAH services. These sessions aimed at improving facility-community linkages in promoting sustainable demand and utilization of quality healthcare services. In an effort to integrate gender in project training, two one-hour sessions were conducted in Kakamega on BFCI and BFHI with 27 participants (male 6; female 21) and 34 participants (male 4; 30 female) were sensitized on gender considerations in the implementation of Expanded Program on Immunization(EPI). In Kitui County, 45 providers and SCHMT members (male 22; female 23) from Kitui East SC underwent a 3-hour sensitization on gender as a determinant of health. Cumulatively, 866 providers underwent a one- day gender sensitization; 24 CHVs and 4 CHEWs and 270 providers underwent 1-3-hour sensitization on gender. In PY1, a total of 45 project staff (Migori 11, Kitui 20, Kakamega, and Kisumu 14) underwent a 1-day orientation to enhance their understanding and capacity to integrate gender in project activities. The orientation aimed at equipping staff with knowledge on gender transformative programming, and the importance of applying gender-sensitive approaches throughout the project life cycle. The training utilized the Interagency Gender Working Group (IGWG) Gender and Sexual and Reproductive Health 101 guide2, and the Jhpiego’s Gender 101 Facilitation Guide.

Activity 2.2.5. Create county forums to improve gender equity and response to gender discrimination:

During the quarter, the project contributed to the structuring of the Migori county AYRH steering committee and was included in the GBV TWG. In addition, the project team participated in the drafting of the Migori county SGBV policy and review of the Kisumu county gender mainstreaming plan. Overall, in PY1, the project provided technical assistance in the development of county strategies plans, namely the Migori County five year (2018-2022) multi-sectoral roadmap to improve the sexual reproductive health for adolescents and youth; The Migori county SGBV policy and the Kisumu county gender mainstreaming 5-year strategic plan. The project will in liaison with the county gender offices seek to engage actively in forums that promote a multi-pronged approach in addressing the outcomes associated with gender inequalities, namely school dropout due to teen pregnancies or child marriage, GBV due to power inequalities, poor decision making due to patriarchal societies and limited male involvement. In overall, the project has in collaboration with the County Gender Directors, and CHMT conducted sessions with

2 https://www.igwg.org/wp-content/uploads/2017/07/gender101facguide.pdf.

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S/CHMT and representatives from private facilities on the need for gender sensitive service delivery. Output 2.3: Increased practice of key nutrition and WASH behaviors in target communities

Activity 2.3.2. Scale up CLTS, market days and WASH products: The project verified an additional 109 villages as ODF (Kakamega 47, Migori 62) during the reporting quarter, bringing the total villages verified in Year 1 to 140 villages. This is almost three times the annual target of 50 villages verified ODF. The project went further to support the county MOH team in Migori to rollout third party certification of villages as ODF during the reporting period. A total of 62 villages were submitted for certification of which 57 (92%) were certified by trained Migori County MOH certifiers. The achievements were attributed to building the CLTS capacity of county MOH teams and MOH readiness to achieve ODF status by March 2019 (Migori) and 2020 (Kakamega). Once the PHOs were trained on CLTS, they triggered villages and intensively followed these villages to achieve verification and certification. The project also supported monthly review meetings in both Kakamega and Migori to track implementation progress. In Migori, the project built on MCSP achievements by picking villages that had been triggered but not followed.

During the quarter, Afya Halisi trained an additional 31 PHOs, CHEWs and CHAs on CLTS methodology and implementation. This brought to total 72 staff trained on CLTS. In addition, 240 CHVs were trained on WASH technical module and other water related trainings (Kakamega 200, Migori 40) in Year 1. The trained CHVs assist in following up triggered villages, promoting improved sanitation and hygiene behaviors and distributing water purification products at household level. In Year 2, the project will support county MOH teams to trigger additional villages and intensify follow up to verify more villages as ODF. Since Kitui County has been certified as an ODF county, Afya Halisi will support Kitui County with post-ODF activities focused on WASH marketing. Sub-purpose 3: Increased MOH stewardship of key health program service delivery Output 3.1. Strengthened coordination, M&E capacity Output 3.2. Strengthened capacity to develop evidence-based policies, strategies and guidelines No activity was implemented under this output as the project awaits the lifting of the national level support embargo.

Lessons learned A significant number of adolescent/youth and women seeking healthcare services cannot access them because they lack identification cards (IDs). To register and access crucial healthcare financing instruments like Linda Mama and/or NHIF, one needs an ID card. Afya Halisi is looking at partnering with NHIF and government departments such as the “State Department for Migration and Border Control and Registration of Persons” during outreaches in order to bring services closer to vulnerable and underserved populations.

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III. ACTIVITY PROGRESS (QUANTITATIVE IMPACT) This section has been included as an attachment.

IV. CONSTRAINTS AND OPPORTUNITIES During the quarter under review, the key challenges that affected activity implementation included:  Stock out of Implanon NXT. The project mitigated this shortage through redistribution and facilitated transportation from KEMSA to the counties.  IFAS stock outs especially in Navakholo sub county HFs. This was mitigated through redistribution.  Inadequate data collection tools: Isolated facilities did not have the current MoH 2016 version reporting tools. As a stop gap measure, the project facilitated photocopying of the tools based on need.  Inadequate number of providers trained to proficiency to offer voluntary surgical contraception (BTLs and vasectomy). The project will continue to engage the gynecologists in the level 4/ 5 health facilities to mentor doctor / nurse teams.  Delayed NHIF & Linda Mama rebates: The re-imbursement process is slow and the funds are not going directly to the facility accounts as the case should be, instead going to the county accounts. The money is not redirected to facilities. This demoralizes the facilities and so eroding the gains made health care financing. The project will continue to engage the counties with a view to reaching a solution to unlock and avail the funds to the facilities.  High staff turnovers more so in the private sector and staff shortages affecting service delivery especially 24 hour services in the lower level sites and missed opportunities for skilled birth attendance.  A significant number of adolescent/youth seeking healthcare services cannot access them because they lack identification cards (IDs). To register and access crucial healthcare financing instruments like Linda Mama and/or NHIF, one needs an ID card. As a mitigation measure, the project will partner with NHIF and government departments such as the “State Department for Migration and Border Control and Registration of Persons” during outreaches in order to bring services closer to vulnerable and underserved populations. The opportunities that enhanced service delivery uptake included: supportive and conducive working environment provided through the county leadership; leveraging resources from the various partners within the counties; some facilities received the Linda Mama, RBF as well as NHIF rebates; use of data for decision making at the sub-county level and functional community health strategy platforms enabling easy roll out of the community level initiatives. GAVI is implementing a 3-year project in Kakamega to boost immunization services in the county. This provides an opportunity for collaboration and synergy.

V. PERFORMANCE MONITORING

In the quarter under review, the project continued to support the focus counties, sub-counties, health facilities and community units on strengthening health information system. Activities ranged from strengthening documentation and reporting; use of data for decision-making; target setting and annual work plan development. In the reporting quarter, Afya Halisi initiated the procurement of MOH registers and reporting tools as a stopgap measure while advocacy is ongoing for counties to allocate resources for printing of the tools. The contracting process for the

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consultancy firm that is to undertake the Kitui baseline assessment was completed, after all approval from Jhpiego and USAID were done. The baseline assessment will be done in quarter one of PY2. Specific M&E activities that were done across the focus counties are outlined below; Strengthening Health Information Management System During the reporting quarter, Afya Halisi continued to strengthen reporting and use of data for decision making in the focus sub-counties for MOH and Non-DHIS reports. This was done in liaison with the SCHRIOs. Afya Halisi coordinated collection and entry of service data and non- DHIS reports into the internal system, Jhpiego Health Information System (JHIS), to improve the quality of data in DHIS2 across the focus sub counties. The project conducted data validation and cleaning to ensure data concurrence between JHIS and DHIS2. In addition, the project continued to strengthen complete, accurate and timely reporting in PY1 through availing of monthly airtime to a total of 49 SCHRIOs and HRIOs in the four focus counties to facilitate timely upload of data into DHIS2. The continuous follow up with the MoH team led to significant improvements in reporting rates for key MOH reports in all the four focus counties as shown in Figure 15.

100% 100% 100% 100% 99% 100% 100% 99% 99% 100% 99% 99% 97% 80% 60% 40% 20% 0% Kakamega Kisumu Migori Kitui

MoH 705 A Q2 MoH 705 A Q3 MoH 705 A Q4 MoH 711 Q2 MoH 711 Q3 MoH 711 Q4 MoH 710 Q2 MoH 710 Q3 MoH 710 Q4

Figure 15. Reporting rates for summary reports in project supported counties, Year 1

The project also supported distribution and display of data charts within supported health facilities in all the four focus counties to enhance use of data for decision making and to show trends in performance of RMNCAH/FP and nutrition indicators.

Mentorship of HCWs on RMNCAH and nutrition reporting tools and indicators: During the reporting quarter, the project conducted mentorships to HCWs on RMNCAH reporting tools and indicators in targeted health facilities. The focus of the mentorships was on indicator definition, documentation and reporting. Some of the indicators that the HCWs were struggling to understand included PNC within 2 to 3 days and adolescents presenting with pregnancy. Use of partographs to monitor labor was also sub-optimal. The mentorship sessions provided an opportunity to clarify the indicator definitions and review the facility data.

In Kisumu County, the project conducted the mentorships in 28 targeted high volume facilities reaching 91 HCWs (64 female, 27 male), bringing to total 232 HCWs reached in PY1. Emphasis was placed on PNC indicators, which were previously underreported. Following the mentorships,

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there was improved reporting rates for PNC data from 43% in Q2 to 98% in Q4 for Kisumu County as shown in Figure 16 below. Similar trends were observed in the other project focus counties.

6000 98% 100%

5000 80% 58% 4000 43% 60% 3000 40% 2000

20% Proportion (%)

Number clientsof 1000 0 0% Q2 (Jan-Mar) Q3 (Apr-Jun) Q4 (Jul-Sep)

Live birth PNC Infants receiving PNC services within 2-3 days Proportion of PNC infants receiving Postpartum within 2-3 days

Figure 16. Comparison of PNC for infants (2-3 days) and live births in Kisumu County, Year 1

In Migori County, the project supported mentorship of 118 HCWs (70 female, 48 male) on documentation and reporting, bringing to total 240 HCWs reached in PY1. During the mentorships, the project distributed latest versions of registers to the health facilities. The project made emphasis to the HCWs to ensure complete documentation of MOH registers, use of SOPs in completing the registers and timely submission of SCHRIO mentoring HCW on MOH tools at facility MOH reports to SCHRIOs. Macalder Mission Hospital in Migori

In Kitui County, the project conducted targeted facility mentorships reaching 95 HCWs (58 female, 37 male) from 83 health facilities, bringing to total 339 HCWs reached in PY1. The focus was on documentation of MOH tools (PNC, ORT register, MOH 204A, and CWC), FP/RMNCAH indicator definitions and interpretation. In addition, the project supported training of 25 newly posted HCWs in Mwingi Central sub-county on MOH registers and reporting tools during the reporting quarter. The project also supported training of 46 HRIOs and 10 C/SCHMT members on DHIS2, RMNCAH scorecard and FP dashboard. Following the training, a team comprising of eight SCHRIOs and two CHRIOs met to update the RMNCAH scorecard at facility level to foster use of data for decision making.

Orientation of CHVs on Community Based Health Information tools: To strengthen CBHIS, the project supported orientation of 45 CHVs (8 female and 37 male) in Kisumu County during the quarter under review. The orientation targeted the four community units supported by the project and this resulted in the improved documentation and reporting. In addition, the project continued to support monthly data review meetings and dialogue days in the four focus counties to enable understanding of the indicators and use of the data by the CHVs and CHEWs.

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Quarterly Data and Performance Reviews During the reporting quarter, Afya Halisi supported quarterly performance review meetings that focused on FP/RMNCAH/Nutrition and WASH indicators across the focus sub-counties.

In Kakamega County, the project initiated the involvement of the ward administrators in data review meetings. The gaps noted during the review meetings included; lack of anthropometric equipment in most facilities, stock out of FP commodities, decline in immunization and skilled birth attendance coverage and low PNC services uptake. At KCGTRH, it was noted that the introduction of charging fee for ANC profile affected the facility’s performance as clients were utilizing the periphery facilities to avoid the cost. Various action points were developed which included; initiation of mentorship on documentation of PNC services, and use of CHVs to conduct mapping of pregnant women and immunization defaulters. In addition, the project supported the distribution of anthropometric equipment in facilities that were in need.

In Kisumu County, the review meetings brought on board the SCHMT, CHAs, facility in charges and ward administrators. The meetings were attended by 247 HCWs (102 male, 145 female). Selected facilities categorized as most improved, best performed and the least performed shared experiences, challenges and best practices that in either way influenced the performance of indicators. The gaps identified during the meetings included; poor documentation and reporting of PNC and adolescent indicators. In Kitui County, some of the major concerns noted across by the stakeholders were low uptake of ANC services, deliveries and deworming of children. In order to increase 4th ANC visits, the team recommended involvement of male partners during community dialogue to empower them on the importance of ANC clinics for pregnant mothers.

Data quality audits/assurance: During the reporting quarter, Afya Halisi trained 30 HCWs (15 female, 15 male) from Kisumu County and 21 HCWs (11 male, 10 female) from Kakamega County as DQA mentors. In Kitui County, the project finalized selection of 30 HCWs who will be trained as mentors. The mentors who included nurses, HRIOs and PHOs were selected based on their experience and involvement in RMNCAH activities.

In addition, Afya Halisi in collaboration with the CHRIOs and SCHRIOs conducted routine data quality audits in Kakamega, Kisumu, Kitui and Migori counties. Major issues identified included; inaccurate FCCRR tabulations, lack of page summaries in some of the registers, lack of data validation before submission, and documentation gaps in postnatal care registers in some of the facilities.

In Kisumu County, the project conducted integrated DQA using the national DQA tool, following its dissemination through support from Tupime Kaunti project. The DQA findings included; lack of diary for appointments, lack of defaulter tracking list, inconsistent data between the reports and registers, and lack of revised edition of registers in some facilities. The recommendations included; facilities to have a map indicating hard to reach areas and evidence of use of the map in planning for outreaches; HCWs to enter and summarize data daily as they immunize children and update appointment diaries for defaulter tracking and tracing. Figure 17 below shows the DQA findings in some of the project supported health facilities in Kisumu County.

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Figure 17. DQA findings in Kisumu County, PY1 Q4

In Kakamega County, the project facilitated the first phase of county planning for the next financial year (2018/2019) by supporting the annual performance review (APR 2018) for three sub counties (Khwisero, Matungu and Navakholo) in the county. The APR focused on review of data for the year 2017/2018 with the outcome being the Sub-County Health Sector APR report for the respective sub counties.

In Migori County, the project conducted DQA in 85 health facilities during the reporting quarter. The DQA findings included; lack of CHANIS and poor filing system for old registers and tally sheets. Identified documentation errors and omissions were rectified and updated in DHIS2. In addition, the project supported the health facilities to prepare DQIP and dashboards for use in addressing the identified data quality gaps. In Kitui County, the project in collaboration with the Mwingi West SCHMTs conducted review and cleaning of data on adolescents presenting with pregnancy in 57 high volume facilities, reaching 64 HCWs (39 female, 25 male). The review was informed by the need to ascertain the adolescent pregnancy cases following a previous DQA that showed that HCWs were double reporting data on the indicator.

Development of Annual Work Plans and MOH Target Setting: During the quarter under review, Afya Halisi supported the counties in development of the 2018/2019 annual work plans. The support was at sub-county level in Kakamega, Kisumu, Migori and Kitui Counties. The activities included sensitization of the facility in charges and community health assistants (CHAS) on the AWP template, which was then followed by a two days’ consolidation done by the SCHMT. In Kisumu County, the consolidation was jointly supported by Afya Halisi and HSDSA projects. In Kitui County, the meeting provided an opportunity for setting of population targets and entry of the same into DHIS2 for all health facilities. Kisumu and Kakamega counties finalized the county 2018/19 AWPs while Kitui County will be finalizing in October 2018.

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Strengthen functionality of M&E TWG: During the quarter under review, Afya Halisi project together with Tupime Kaunti jointly supported Kakamega County M&E TWG. The meeting was attended by 17 members (8 female, 9 male). This was inclusive of 3 implementing partners. The M&E TWG terms of reference was finalized during the meeting. In Migori, the project participated in the County M&E TWG that was conducted during the quarter. A total of 15 health sector development and implementing partners participated. Among the key areas discussed included the FP-RMNCAH scorecard, partner mapping, County Health Sector Strategic and Investment Plan and County M&E plan roadmap. The project worked with the other partners to develop key SOPs to address missed opportunities in service delivery and reporting. In addition, Afya Halisi supported Migori County Health M&E Unit to analyze data and produce the 5th issue of the County Bulletin including health sector fact sheet that was printed by Tupime Kaunti project. This was done through training of 18 sub-County Program Officers on data analytics including use of QGIS to develop map scorecards and provision of technical guidance in data analysis and presentation in both the bulletin and factsheet. VI. PROGRESS ON GENDER STRATEGY In PY1, the project continued to address gender inequalities to access of services by men, women, boys and girls using strategies that included mainstreaming a gender module in the various capacity building initiatives at facility and community level; HCD immersions; development of age and gender appropriate FP related messages (currently under review); and development of a project community health engagement strategy outlining the various platforms that will enable the project to reach a wider audience. The gender analysis study commenced during the quarter under review, having gotten all the necessary IRB approvals. The findings of this study, will contribute to the finalization of the gender strategy to inform utilization of approaches that will identify and address gender-related barriers to access of FP/RMNCAH services. The strategy will further outline the high impact gender transformation initiatives for possible adaptation in the Afya Halisi project.

VII. PROGRESS ON ENVIRONMENTAL MITIGATION AND MONITORING Afya Halisi continued to follow and implement the Environmental Mitigation and Monitoring Plan (EMMP) that was developed and submitted to USAID to guide environmental mitigation measures. The project worked closely with the health facilities to ensure that both general waste and hazardous waste, was disposed of in the approved manner. For detail on the progress in implementing the project’s EMMP, refer to the attached EMMP progress report.

VIII. PROGRESS ON LINKS TO OTHER USAID PROGRAMS During the quarter under review, Afya Halisi project continued to collaborate with USAID funded mechanisms as well other funding agencies to share information, leverage resources and avoid duplication of effort. The collaborative activities accomplished through such linkages are shown in Table 5 below.

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Table 5. Collaborative activities accomplished through linkages, Year 1 National Mechanism/ Other Activity/Achievement USAID partner UNICEF /GAVI Growth monitoring and immunization services support. FP 2020 Dissemination on progress of FP data G-ANC Dissemination of Group ANC finding. Hoping to start the initiative in 6 facilities in Kitui HRH Kenya Training of HCWs on the performance appraisal process in Migori County Population Council Participated in the dissemination of study findings on “Exploring Opportunities For Preventing And Managing Pre-Eclampsia/Eclampsia” that was conducted in selected facilities in Kakamega and Kitui counties.

IBTCI Jointly reviewed the findings of the baseline survey for Kakamega, Kisumu and Migori Counties, discussed and reached an agreement on the contagious issues/ findings. G-Amini Collaborated in the implementation of AYSRH activities in Migori county including the official launch of the Multi-sectoral AYSRH implementation road map and action plan 2018 -2022. LVCT SQUALE -Collaborated to train 3 community units Kitui on Community QI. SQUALE. -Collaborated to train 3 community units in Migori on Community QI. SQUALE conducted a household survey in Migori and shared the findings with Afya Halisi with recommendations on the areas to focus on to improve the quality of community level interventions. World Bank, DANIDA and -Supported Kitui County with funding for training of HCWs on MNH and procurement of GIZ MNH commodities. -Supported Kakamega County with funding for training of HCWs on MNH and procurement of MNH commodities. Tupime Kaunti -Brought together USG partners to deliberate on engagement process with the counties to ensure that all speak as a team to the counties. -Afya Halisi participated in county level quarterly performance review meetings organized by Tupime Kaunti for Kakamega and Migori counties; participated in standardization of RMNCAH and MPDSR data reviews. FACES The FACES project supports AYSRH support with a bias towards HIV services. Worked together in integrating FP services during the AYSRH forums FHOK and Plan International Supported demand creation activities leads the advocacy arm on creation of demand for the youth to access various services at the facilities. Amref Health Africa -Strengthening of WITS /QITS at the level 4 and 5 health facilities using the KQMH model. -WASH program Support for outreach activities KMET In collaboration with the Kakamega and Kisumu counties , has supported the scale up of UBT in the management of Post –Partum Hemorrhage Training staff on ENC and resuscitation, infant feeding practices, KMC and supplying and PTBi supplying equipment for the care of the pre-term babies including incubators. Clinton Health Access -Collaborated in training of HMTs (Pharmacists, nurses & HRIOs) on family planning Initiative dashboard. -Training the Kitui team on Chanjo online. NHP Plus -Supported the project with MUAC tapes for BFCI sites -Have started discussions on collaborating in 2 learning centres in Kitui East. NHP Plus will support Nutrition and Afya Halisi will integrate AYSRH, Child Health and immunization activities in the learning centers and link CUs.

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The project will continue to collaborate and leverage resources with these partners in delivery of services.

IX. PROGRESS ON LINKS WITH GOK AGENCIES In PY1, the project worked jointly with the CHMTs/ SCHMTs and other line Ministries at the County and Sub county level to implement the areas of support agreed upon during the joint work planning sessions at the beginning of the year. Priority was given to FP and AYSRH interventions in all the counties. The key achievements between PY1Q2 – Q4 include:  Ministry of Education: Between Q2 and Q4, Afya Halisi in conjunction with the ministry of health worked, together with ministry of education ECD section during Vitamin A supplementation in ECD centers. The ECD teachers supported mobilization and supervision of the exercise.  Ministry of Agriculture: Between Q2 and Q4, the project worked together with the Ministry of Health worked in conjunction with the Ministry of Agriculture to roll out BFCI at Community level, teaching the CUs on how to set up an ideal kitchen garden including what and how to grow the selected crops.  Kenya Midwifery Chapter (2 MOH) / ESCACON (2), NNAK Nurses now (3) /AYSRH (3) conference: The project supported 11 MOH staff to attend the conferences as shown.  KEMSA and MEDS: KEMSA continued to avail essential MNH commodities to the counties based on the pull system. MEDS supplied subsidized commodities mainly to the private sector facilities.  Ministry of Education: In the quarter under review, Afya Halisi in conjunction with the ministry of health worked, together with ministry of education in training of AYSRH on life skills and sexual reproductive health  Ministry of Gender and Youth Affairs: Formation of TWG, mobilizing for youth activities and training of MoH on gender in health.  Kenya Pediatrics Association: Providing technical oversight for ETAT+ trainings.  KEMSA and MEDS: KEMSA continued to avail essential MNH commodities to the counties based on the pull system. MEDS supplied subsidized commodities mainly to the private sector facilities.

X. PROGRESS ON USAID FORWARD To continuously improve the way USAID delivers foreign assistance to the counties, Afya Halisi continued to embrace new partnerships, working closely with local civil society organizations (CSOs) and other local implementing partners to advance the MNH agenda. These included collaborative engagements with the following entities:  Oparanya Care / Imarisha Afya ya Mama na Mtoto program: The initiative is an incentive scheme that has seen an increased uptake on MNH services including SBA in Matungu, Khwisero and Navakholo sub counties. This has provided an enabling environment for the project to advance the MNH agenda. Imarisha Afya ya Mama na Mtoto program, is a combined effort by the Kakamega County Government, UNICEF and the Swedish Government. Mothers enroll in the program for 18 months and money is given to them in instalments of Ksh. 2,000 upon accomplishing given milestones (Completion 4 ANC visits, SBA, 4 PNC).

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 Linda Mama Project: The sub counties received funding and this was a motivation to the staff. The facilities were able to procure consumables, motivate staff and also encourage staff to take up locum positions when they are officially on leave or off duty and get a little extra pay. This is quite strategic in addressing staff shortages in the health facilities.  K-MET: Collaborated with all the RMNCAH implementing partners in scaling up of UBT for the management of postpartum hemorrhage at facilities.  FACES: Has vibrant youth groups addressing HIV issues in the selected HFs where Afya Halisi is supporting RMNCAH programming. This has provided a good platform to infuse FP / AYSRH agenda.  FHOK and Plan International: Advocacy and demand creation for the youth to access various services at the facilities.

XI. SUSTAINABILITY AND EXIT STRATEGY The project continued to promote capacity strengthening of the MoH mentors in the various service delivery technical areas, to provide mentorship to service providers at facility level. The Project is committed to MoH / community -driven programming across the various service areas and building the systems/ structures for sustainability. During the quarter under review, and PY1, the measures taken to ensure sustainability of the initiatives included but not limited to:  Advocacy: Afya Halisi continued to advocate for increased county level funding/ resource allocation for RMNCAH / FP/ Nutrition and WASH programming. This included sessions with the Governor Kitui County and the MCAs in Migori County. Migori county has been able to allocate 10 million shillings towards family planning.  Technical Working Groups (TWG) and Quality improvement teams (QITs): Strengthening the existing and formation of new ones where they did not exist to continuously monitor and ensure that high standards of care are maintained in service delivery.  Joint work planning: Implementation of the joint work plans with clear commitments on MoH contribution.  Mentorship Teams: Developing and standardizing a pool of MoH mentors that to be used in giving facility level targeted technical support.  Commodity Management: Capacity building of HCWs on commodity management, needs identification, sharing and re-distribution of commodities.  Community health services: Working off existing community level platforms, supported by the counties, to address RMNCAH issues at community level and enhance community facility linkages.

XII. GLOBAL DEVELOPMENT ALLIANCE

Not Applicable

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XIII. SUBSEQUENT QUARTER’S WORK PLAN

Table 6 below shows the project’s subsequent quarter’s work plan.

Table 6. Collaborative activities accomplished through linkages, Year 1 Planned Actions from Previous Quarter Action Status Explanations for Deviation this Quarter Management activities Launch of Afya Halisi at national level Incomplete National Embargo Launch Afya Halisi at county, and sub-county levels Complete Nil deviation Identify and recruit project staff based on the proposed Complete Nil deviation staffing plan Introduce new staff to Afya Halisi project approach, Complete Nil deviation including orientations to gender and FP compliance, and project management concepts and tools. Establish offices in Kitui (the main project base) and Migori. Complete Nil deviation In Kakamega and Kisumu, integrate project staff into county-level offices and health facilities. County, Sub-county, facility and community level Complete Nil deviation introductions Procure essential office equipment and supplies Complete Nil deviation Development of joint work plans (county/sub county and Complete Nil deviation high volume health facilities (30) Equipment needs assessments / Training needs Complete Nil deviation assessment /HRH needs assessments Kitui Baseline Assessment Process ongoing Tendering process complete and awarded. Profile of successful candidate to be shared with USAID for approval. Gender assessment Data collection Nil deviation ongoing in Kitui County Conducted facility assessments for four counties Complete Nil deviation Sub-purpose 1: Increased availability and quality delivery of FP/RMNCAH, nutrition and WASH services

Output 1.1.: Strengthened FP/RMNCAH, nutrition and WASH service delivery at health facilities, including referral from lower level facilities and communities. Family Planning Capacity building of HCWs on postpartum and post Ongoing Nil deviation abortion family planning Capacity building of HCWs on Implants removal Ongoing Nil deviation Counseling for Continuation Ongoing Nil deviation LARC scale up Ongoing Nil deviation Permanent methods (PM) scale up Ongoing Nil deviation FP commodity management and reporting Ongoing Nil deviation Strengthen FP data reporting/ FP compliance Ongoing Nil deviation KQMH for RH/FP Ongoing Nil deviation

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FP Compliance Ongoing Nil deviation. Systematic monitoring going on routinely; potential vulnerability identified in Kakamega as a result of Ipas and Marie Stopes interventions on CAC and LARCs Whole site orientation on AYSRH including VCATs Ongoing Nil deviation Integrated outreaches in hard to reach areas Ongoing Nil deviation Maternal and Newborn Health MPDSR including verbal autopsies Ongoing Nil deviation Scale up of EmONC services Ongoing Nil deviation Respectful Maternity Care Ongoing Nil deviation Scale up KMC availability Ongoing Nil deviation Scale up Chlorhexidine use Complete Nil deviation CQI through KQMH Ongoing Nil deviation Centers of learning per sub-county Ongoing Nil deviation Routine follow up for pregnant AYPs Ongoing Nil deviation Linking young mothers with return-to-school opportunities Ongoing Nil deviation (in collaboration with Ministry of Education [MOE]) Young mothers’ clubs formation Ongoing Nil deviation Capacity strengthening of CHVs/CHAs on MNH technical Complete Nil deviation modules Enrolment for NHIF (Linda Mama Program) Ongoing Nil deviation Maternity open days Ongoing Nil deviation Community dialogue days Ongoing Nil deviation Sensitization of CHVs on PNC Ongoing Nil deviation Integrated outreaches Ongoing Nil deviation MNH in-reaches Ongoing Nil deviation TBA re-designation as birth companion Ongoing Nil deviation Mother baby package as value addition for SBA Ongoing Nil deviation MNH equipment e.g. BP machines, thermometers Ongoing Nil deviation Minor renovation of maternity units e.g. curtains, floor Ongoing Nil deviation Community KMC Ongoing Nil deviation Child Health iCCM training for CHVs from Kitui Central, Kitui East and Complete Nil deviation Mwingi West. Defaulter tracing for immunization services Ongoing Nil deviation Post training follow up for IMNCI, ETAT+, EPI plus Ongoing None Mentorships and OJT Cold chain maintenance Ongoing None OJT for EPI logisticians, HCWs, technicians Complete Nil deviation Train CHVs in ‘hard to reach’ villages in focus sub Complete Nil deviation Counties Support training of HCWs in the priority sub-counties Complete Nil deviation

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Support mentorship of HCWs in areas of low diarrhea/ Complete Nil deviation pneumonia burden or areas where trainings have already taken place Train CHVs in ‘hard to reach’ villages in focus sub Complete Nil deviation Counties Support training of HCWs in the priority sub-counties Complete Nil deviation Support the development of ETAT+ ToTs Complete Nil deviation Support operationalization of ORT corners in the priority Complete Nil deviation sub-counties Print and distribute IMNCI data collection tools for the Complete Nil deviation facilities Print and distribute the paediatric protocols to supported Complete Nil deviation facilities Output 1.3: Strengthened county health systems for delivery of FP/RMNCAH, nutrition and WASH services Nutrition HINI baselines and IMAM capacity assessments On course Nil deviation Standardization of IMAM mentors On course Nil deviation IMAM mentorships On course Nil deviation Training of county and sub county on HINI On course Nil deviation HINI mentorship On course Nil deviation Training of HCWs and CHVs on BFHI On course Nil deviation CMEs On course Nil deviation Neonatal training Postponed to To be implemented after BFHI accommodate in PY2 BFHI trainings as foundation GMP training On course Nil deviation BFCI follow ups On course Nil deviation Training of EYE teachers On course Nil deviation Training of HCWs and CHVs on BFCI On course Nil deviation Community Health Services Training of CHVs on MNH technical Module Completed Nil of deviation Training of CHVs on FP technical Module Completed Nil of deviation CHV sensitization on MPDSR Completed Nil of deviation Support monthly review meeting Completed Nil of deviation Support monthly dialogue days Completed Nil of deviation Support quarterly action days Completed Nil of deviation Support targeted outreaches Completed Nil of deviation Training of CHAs, CHVs on Basic Module Complete Nil deviation Training of CHCs Complete Kitui CHC trainings to be done after basic CHV training. Targeted Household IPC/Visits Complete Nil deviation Targeted supportive supervision and mentorship Complete Nil deviation.

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Support supervision in Kitui, Kakamega and Kisumu Complete Nil deviation counties Technical support for the development of a county Complete Nil deviation formulary through the County Medicines & Therapeutics committee in Kitui County Offer technical assistance to major facilities and sub Ongoing Nil deviation counties to offer quality care and reduce wastage, loss and implement good inventory management process and reduce discrepancies in reporting to less than 5%. Sub-purpose 2: Increased care seeking and health promoting behavior for FP/RMNCAH, nutrition and WASH Output 2.1: Increased knowledge of and demand for FP/RMNCAH, nutrition and WASH services Carry out an SBC strategy workshop and develop specific Complete for FP, Competing tasks / rescheduled SBC strategies for each of the Afya Halisi service delivery MNH and Nutrition for Q4 domains / service delivery areas Prototype two SBC strategies with requisite target Complete Nil deviation audience. Complete recruitment of community frontline workers Complete Nil deviation (Community Mobilizers) and train them in context specific strategies for SBC Continue with demand creation effort to drive traffic into Complete Nil deviation facilities and increase the uptake of services Complete facility capacity assessment and identify gaps Complete Nil deviation in service provision Train private sector providers to close the skills gap in Ongoing Nil deviation areas identified during capacity assessment Output 2.2: Improved gender norms and sociocultural practices Gender whole site sensitization on gender norms Complete Nil deviation Equip health facilities and health care providers with skills Complete Nil deviation and capacity on Maternal, Infant and Young Child Nutrition (MIYCN) Orientation meetings for project staff Complete Nil deviation Capacity strengthening of CUs Complete Nil deviation Design of Standardized Messages and Communication Ongoing Nil deviation Materials - SBCC Toolkit (workshops/task force meetings) Contribute towards finalization of the gender analysis Complete Nil deviation protocol Contribute towards county forums on AYSRH,FP and Ongoing Nil deviation Gender Contribute to development of AYSRH appropriate IEC Ongoing Nil deviation materials Output 2.3: Increased practice of key nutrition and WASH behaviors in target communities ECD training on Nutrition Complete Nil deviation WASH C/SCHMT WASH in healthcare training in Kakamega Complete Nil deviation county WASH stakeholders meetings in Kakamega and Migori Complete Nil deviation counties

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Dissemination of WASH guidelines in Kitui, Kakamega Complete Nil deviation and Migori CCA Training Complete Nil deviation WASH in HCFs training Complete Nil deviation ODF Verification of villages Complete Nil deviation CLTS Training Complete Nil deviation IPC training and orientation Complete Nil deviation Spring rehabilitation Complete Nil deviation Sanitation improvement in health facilities Complete Nil deviation Water analysis in HFs Complete Nil deviation CHEW training on WASH Technical Module Nil deviation Dissemination of WASH guidelines in Kitui, Kakamega Ongoing Procurement of printing and Migori services still on going. Orientation of CHVs WASH modules Complete Nil deviation Identification of springs for development Complete Nil deviation Identification of facilities for improving sanitation Complete Nil deviation CLTS roll out (training and roll out) Complete Nil deviation Training on WASH and nutrition integration Complete Nil deviation Procurement of WASH start up supplies Ongoing Nil deviation Sub-purpose 3: Increased MOH stewardship of key health program service delivery Output 3.1: Strengthened coordination, M&E capacity Conduct sub-county review and prioritization meetings Complete Nil deviation (GIS, Dashboards, and Scorecards) Orient targeted health facilities on M&E tools and DHIS2 Complete Nil deviation Conduct quarterly data quality assessments Complete Nil deviation Quarterly data review meetings at sub-county level Complete Nil deviation Implement Kitui baseline assessment On-going Nil deviation Implement Health Capacity Assessment and HINI Complete Nil deviation assessment Nutrition DQA Complete Nil deviation County Nutrition Action plan Complete Nil deviation

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XIV. FINANCIAL INFORMATION

Cash Flow Report and Financial Projections (Pipeline Expenditure Rate)

Actual expenditure quarter July- 30,000,000 September 2018

25,000,000 Actual expenditure quarter April-June 2018

20,000,000 Actual expenditure quarter January- March, 2018 15,000,000 Actual expenditures Quarter October- 10,000,000 December 31, 2017

5,000,000 Obligations

0 Obligations Expenditures

Figure 18. Obligations vs. Current and Projected Expenditures - $Millions

Table 7. Budget Details

T.E.C: $66,336,770 Cumulative Obligations: $25,791,049 Cumulative Actual Expenditures: $7,932,125

Obligations 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter Actual Actual Actual Actual Expenditures Expenditures Expenditures Expenditures 25,791,049 292,954 912,392 2,805,480 3,921,298 Personnel 122,325 349,695 504,651 582,766 Fringe Benefits 43,764 120,123 183,005 221,428 Travel 46,035 90,003 501,890 810,331 Equipment 151,873 Supplies 174 14,586 323,318 80,177 Contractual 4,140 117,345 339,123 1,392,312 Construction Other Direct Costs 34,224 99,764 457,858 450,174 Total Direct Costs 250,662 791,515 2,461,716 3,537,188 Total Indirect Costs 42,292 120,877 343,764 384,110 Total Estimated 292,954 912,392 2,805,480 3,921,298 Costs

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Table 8. Budget Notes Salary and wages Salaries and wages are in line with Jhpiego’s Human Resource policies. Fringe Benefits Calculated as per Awards conditions and prevailing Jhpiego approved NICRA rates. Travel Travel costs are in relation to Project staff. Participant travel is generally charged to Programmatic Costs. Equipment Equipment costs relate to procurement of project vehicles, copiers and a generator, this will be procured fully by end of the third quarter Contractual The contractual are consistent with agreements signed with PSKenya and Save the Children Other Direct Costs Other direct costs include programmatic activities aligned to the detailed implementation plan and general office operating costs. Total Indirect Costs Calculated as per award conditions. Total Estimated Cost Total of all costs

XV. ACTIVITY ADMINISTRATION  The project signed Letters of Agreement (LoA) with the County Secretaries of Cabinet detailing the among other things the transition process for the HRH staff engaged by the project and deployed at facility.  The procurement process was accomplished as per the PY1 procurement plan. The project is in the process of distributing the equipment based on need as detailed in the facility assessment report and also having rationalized the equipment procured by GAVI and USAID.

 The procurement of an additional five utility vehicles was completed and the vehicles arrived and two are stationed in Kitui county, 2 in Migori and 1 is serving the Kakamega and Kisumu counties. This has drastically cut the projects expenditure on taxi hires.

 USAID Family Health team field visit to Migori County, for routine program monitoring, took place between 16th and 20th of July 2018. A total of 8 health facilities and 2 Community units. The team used this opportunity to provide environmental compliance and finance updates to the Afya Halisi team.

 With an increased staffing level, there was need for a more spacious office space for the Kakamega county team. The project acquired office space situated at Holden Mall, Plot number 1/823 Kakamega Municipality to provide a conducive office environment. The sub- county offices at (Navakholo and Khwisero) are functional.

Personnel The newly recruited 3 AYSRH SDOs reported and are working, one covering Migori county; one in Kitui county and one covering both Kakamega and Kisumu counties. An additional four SDOs also reported to augment the project staffing levels in Kisumu, Kitui and Kakamega counties for a period of six months. Contract, Award or Cooperative Agreement Modifications and Amendments: No cooperative modification or amendment was done during the quarter under review

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XVI. INFORMATION FOR ANNUAL REPORTS ONLY

A. Budget Disaggregated by County

OBLIGATION 1ST QUARTER 2ND QUARTER 3RD QUARTER 4TH QUARTER

Total: $

County #1: _Kitui___ $829,727.75 $829,727.75 $829,727.75 $829,727.75

County #2: _Kisumu $429,539.25 $429,539.25 $429,539.25 $429,539.25

County #3: _Kakamega $778,429.50 $778,429.50 $778,429.50 $778,429.50

County #4: _Migori $918,449.00 $$918,449.00 $$918,449.00 $$918,449.00

County #: _National $132,494.00 $132,494.00 $132,494.00 $132,494.00

Budget Disaggregated by Earmarks

(Earmarks for 2012 funds shown below; new should be added if/when appropriate.)

OBLIGATION Q1 Q2 Q3 Q4

Rule of Law and Human Rights

Good Governance

Political Competition and

Consensus-Building Civil Society

HIV/AIDS (USAID)

Tuberculosis

Malaria

MCH Water $207,334.75 $207,334.75 $207,334.75 $207,334.75

MCH Polio

Other MCH $917,836.25 $917,836.25 $917,836.25 $917,836.25

Family Planning and $1,752,781.75 $1,752,781.75 $1,752,781.75 $1,752,781.75

Reproductive Health Water Supply and Sanitation

Nutrition $210,686.25 $210,686.25 $210,686.25 $210,686.25

Basic Education

Agriculture

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Inclusive Financial Markets

Policy Environment for Micro

and Small Enterprises Strengthen Microenterprise

Productivity GCC- Adaptation

GCC- Clean Energy

GCC- Sustainable Landscapes

Biodiversity

C. Sub-Awards

Sub- Sub- Sub- Sub- Date Last Names of Counties Partner Awardee Awardee Awardee Awardee Audit of Implementation Name Start Date End Date Amount Conducted

Population 1 January 24 June $6,229,013 Kitui, Kisumu, Services 2018 2022 Kakamega and Migori Kenya

Save the 1 January 24 June $10,085,610 Kitui, Kakamega and Children 2018 2022 Migori

D. List of Deliverables

None in this reporting period.

E. Summary of Non-USG Funding

Table 9 below identifies funding that is leveraged from non-USG sources during the reporting period.

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Table 9. Summary of non-USG Funding that Afya Halisi is leveraging on Project/Donor Grant # Technical Focus Geography Expenditures between 1 Oct 2017 – 30 June 2018 G-Amini #123309 Improving the use of FP among adolescents in Migori $USD.171,943.78 Merck for Mothers rural Group ANC #121999 Study looking at a new model of antenatal care Kisumu $USD.140,554.80 Bill & Melinda which will increase health of pregnant and Gates Foundation recently delivered mothers and increase rates of skilled birth attendance uptake of post- partum family planning The Challenge #123709 Providing technical and financial support to Migori $USD.97,716.39 Initiative selected counties to increase overall use of Gates Institute family planning Advanced Family #113800 Working with county leaders and key Kakamega & $USD.58,377.27 Planning stakeholders to conduct advocacy for increased Migori Gates Institute support for family planning Safe Surgery #124042 Development of a policy implementation Kisumu $USD.32,186.26 Medtronic framework for safe surgery, including C- sections at the county level. This will contribute to addressing RMNCAH priority area of decreasing maternal deaths, as surgical intervention is a key intervention in preventing hemorrhage. Training, recognition and appropriate deployment of skilled medical/clinical officers by county MOH leadership to surgical sites Advocating for resource allocation to create new and strengthen existing theatres, prioritizing access to essential safe surgery drugs, supplies and equipment _ A costed implementation plan and gap analysis is ongoing TOTAL $USD.500,778.50

F. Type of Accounting System Used During Reporting Period

Jhpiego uses QuickBooks accounting software for capturing financial transactions and SAP for financial reporting.

XVII. GPS INFORMATION Refer to attachment

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XVIII. SUCCESS STORIES

A Community Health Volunteer Going the Extra Mile Success Story 1: By Victor Ouko, Maxwell Muganda and Hudson Inyangala Proud to Be a Community Health Volunteer While motivation has always been viewed as monetary, Afya Halisi, a 5-year project funded by United States Agency for International Development (USAID), has found that community health volunteers (CHVs) can be motivated to provide quality services to their community in more sustainable and cost effective ways.

Meet Joyce Sayo Robi, a community health volunteer (CHV) linked to Nyamagongwi Dispensary, Kuria East Sub county of Migori County. She was selected by her community seven years ago as a health resource person. She dedicated herself and worked tirelessly for her community to ensure that quality of life of her community was improved. Through support from one of the health partners, she underwent gender based violence training to advocate for girls’ rights and prevent female genital mutilation (FGM), a common practice among the Kuria community. She also attended community strategy training courtesy of a previous USAID funded project – MCSP. The knowledge and skills she acquired helped her to understand the different approaches in community health services. Through Afya Halisi, she got trained on family planning (FP) and maternal and new-born health (MNH). She learned how to promote good health practices, educate fellow women on benefits of family planning, and be on the front line for basic health care, referring patients to health facilities when necessary and dispelling myths and misconceptions surrounding family planning among Kuria community. "I do this because I want to help my community and see healthy families," says Robi. “Without community health Volunteers, many people would die and even fewer people would be using family planning services that they need.”

Despite not being paid to provide these vital services to members of her community, Robi wakes up each day eager to do her work. She puts on a branded t-shirt, which she received from a partner who supported MNH activities, -Maternal and Child Survival Program (MCSP) and packs her bag to work. She stands out and feels empowered to serve the community.

Community Resource Person

She clearly understands the staff shortages at the link facility and has made it a routine to support the health worker in the mornings before going for home visits in her village. Through on job training, she is able to help the service provider perform basic duties such as: providing health education and promotion to patients, taking weight and height, screening children for malnutrition using mid-upper arm circumference (MUAC) tape and deworming. “Task shifting and sharing is a common practice in community health service provision,” She says with a smile. “Sometimes I feel for the nurse when she is overwhelmed with work: attending to sick babies, antenatal mothers are waiting on the queue, family planning clients need her attention, a mother has come in second stage and must be assisted to deliver a healthy baby” exclaims Robi. “I have no choice but to assist my community members.” Robi asserts that she understands the health concerns of the people of Nyamagongwi, because she has lived in this community for more than 20 years.

She values immensely the education and training that goes hand in hand with her work. Most community members greet her cheerfully as she walks through the community. Being a family planning champion, she advocates for contraceptive use. “There are myths and misconceptions surrounding family planning uptake among my fellow Kuria women,” she says. Lack of correct information coupled with male dominance hinders access to family planning uptake. “Family planning is good for you,” she says. “It helps

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you recover from your last delivery and be strong for your next. Your baby benefits because you will give all your love to the baby before you think of another one. And you know what? You will have time for your husband and love will grow.” She continues, “Give yourself two to three years before carrying another pregnancy. By the way do you have the means to take care of so many? Think clearly about these issues before becoming pregnant again. You are young and you need to engage in income generating activities to support your husband in taking care of the family.” Explains Robi with a well-shaped mind from the numerous community level trainings she has had. Robi then refers one of the mothers who were not on contraceptives to the health facility for health services.

Community Role Model

Robi is married to an elder in the dominant Kuria clan, and the community looks up to her as a role model. She is a community resource person and provides advice and information, especially ahead of health campaigns like polio and measles vaccinations. She visits households to provide basic health services or to let the parents know about new services in the community. She is called upon to provide health education sessions the community during the chiefs’ meeting and during community dialogue days. To enhance her skills, Robi frequently asks her facility in-charge to clarify issues which are not clear to her. She applauds the facility in-charge for her patience and understanding in giving her continuous guidance. “I feel proud when my work is appreciated. I don’t have to be paid in cash, but I know God is the only one who can pay me well. I do everything to the glory of God” Robi says with a smile. “I love community service” she adds. Robi is in the process of mobilizing the rest of CHVs to initiate an income generating activity to sustain the team.

Nutrition Transect Walk Through Lubanga Village Matungu Sub County

Success Story 2: Noel Shinali (Matungu Sub County Nutritionist); Brenda Ahoya and Hudson Inyangala One sunny afternoon in Lubanga village, having finished my work at the sub county office and thoughtful about the impact of the trainings we had given to the community health volunteers (CHVs), I decided to promenade leisurely through the village, guided by one of the CHVs attached to Lubanga Dispensary, enjoying the cool breeze from the surrounding forests. As we perambulated up and down the dusty tree lined earth roads, my interest was to understand why the community had such high levels of nutrition related problems and whether the interventions put in place were making any difference. I observed the water resources, wastewater flows, sanitation facilities, food crops, the animals, all the while analyzing the local nutrient cycle and discussing the issues with myself in light of the malnutrition cases that flock the facilities. At the Local Primary School At the nearby primary school, the lunch break bell reverberated through the air and I could see a stream of children, glad in their tattered white tops and green shorts walking hastily headed home for lunch. Curiously, I enquired from the CHV what meal the children expect to get at home. She thoughtfully replied: “In this community, the children will mostly find a maize meal – sugarless porridge, some black tea with Mandazi bought from the local Kiosk or some cassava or sweet potatoes we saw in the farms. Sometimes they will have plain plantain and water. Remember most households do not prepare breakfast and so the children will have gone to school without a meal in the morning” Asserted Apio, the CHV guiding me through the village. How about infants? I asked Apio. “Infants too are fed on a maize meal- porridge throughout the day and would later be fed on ugali with vegetable soup for supper”. I could quickly see how imbalanced the diet was. “That had been the typical nutrition cycle for the community for a long time before we were trained on baby friendly community initiative (BFCI)”, explained Apio. “Now things are changing after we got trained in July this year supported by Afya Halisi project. We are now educating the community about food groups, maternal and child nutrition. We were also trained on how to take MUAC measurements and one of the duties mandated was to undertake quarterly nutrition screening of children

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under 5 years using MUAC. The first nutrition screening we did, identified 15 undernourished children and referred them to Lubanga Dispensary and they are undergoing treatment”. “We conduct household visits, screen the children and make referrals to the facility. I have so far referred 5 who were severely malnourished, 10 had moderate malnutrition, while 2 were normal but had other health complications from the time we had the training in July this year”. Explained Apio. At the school, the children are dewormed and vitamin A supplements given to the ECD children. In June 2018, Afya Halisi Project trained 33 health workers attached to 12 health facilities from the three focus sub counties of Matungu, Khwisero and Navakholo on baby friendly community initiative (BFCI). The training was then cascaded down to CHVs with a total of 165 CHVs (attached to four health facilities) trained in Matungu sub county. Out of these, 20 CHVs were attached to Lubanga Dispensary. The training on BFCI included content on maternal, infant and young child nutrition and included growth monitoring, child stimulation and kitchen gardening. Growth monitoring at community level includes screening using MUAC. At the Health Centre We meet patients waiting patiently on benches to receive health services. Mothers too, with their babies wait for MCH services. The CHV explained that uptake of health services had really improved especially among children after home the home visits. Mothers in the community have gained much interest in the health of their children. Mothers proactively reach out to us CHVs to go and assess their children “Apio kuja uniaangalilie mtoto wangu kama ako sawa”; loosely translated to “Apio come and check my child to ascertain if he is healthy), affirms CHV Apio. The mothers whose children were malnourished and were rehabilitated, saw great improvements in their children; these has encouraged mothers to seek services. The CHVs have also started establishing a kitchen garden at the facility for demonstration to mothers that will help to improve complementary feeding. Afya Halisi supported mentorship on HiNi in Lubanga Dispensary with a focus on IMAM. This was used to build capacity of staff at the facility on IMAM and is the first in a serious of mentorships to support the facility to become and IMAM site. In PY2, the project will support more mentorship on IMAM and the sub county will issue data sets to the facility to ensure that it operates as an IMAM site. At Saka Homestead At the homestead of Joseph Saka, we meet one and half year-old Tanisha, a beneficiary of food supplement issued at the facility after the household screening. Baby Tanisha is under a caregiver since her biological mother, a class 6 school dropout travelled to for casual jobs. This is a typical child rearing practice in the community. Tanisha’s father does not give child support; it’s her mother who sends some money. The caregiver, Agnes confirmed that baby Tanisha had improved and is quoted saying “she was pale and feeble, I didn’t know what to do with her”. She weighed 7 kg at the initial screening (-3 SD weight for age). At Ouma Homestead Our next home visit leads to the homestead of Ouma to meet baby Moses aged 1 year and 5 months. Baby Moses’ initial screening categorized him with severe acute malnutrition and stunted (-3 SD weight for height and -3 SD height for age). He had been exclusively breastfed for one month and thereafter introduced to mixed feeding. The mother also stopped breastfeeding him at seven months of age, as his mother conceived another child. Myths and beliefs played role here as its believed that once a mother conceives, breastfeeding must stop. On follow up with Moses’s mother, 18-year-old Angengo, on his progress, she explains that he has gained appetite and was physically active. “People told me that Moses was weak because I was having another pregnancy” Beatrice confirms the taboo. “Before the intervention, the baby was pale, unable to stand, docile, would just lie in the same place unlike children of his age” - Apio reminiscences. “Now the boy can stand, play within a short period; the food supplement and nutrition education has helped a lot” affirms Angengo, the baby’s mother.

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At Baby Esther’s Home Baby Esther (1 year 4 months old) born to a teenage mother who is a small vendor business lady. Her mother leaves early in the morning to attend to her business issues leaving the baby with her elderly parents all day. She prepares plain porridge and instructs the parents to give the baby whenever she is hungry. At 1 year 4 months, baby Esther looked 6 months old, completely non- responsive, with delayed milestones. The baby’s mother had given up hope and was disinterested in taking her to the facility for support and treatment. Whitney Houston (the CHV taking care of this household) visited the home following the BHFCI training in July 2018 supported by Afya Halisi, and assessed the baby. She took the initiative to take the baby to the health center. The baby was assessed and categorized as severely malnourished and stunted (-3SD weight for age and -3 SD height for age). The facility team initiated the necessary intervention and asked the CHV to closely monitor the baby. The baby has since improved, is now able to crawl, looks healthy and jovial and is gaining weight. The grandfather, Gregory professes that he didn’t know there existed a health facility at Lubanga that could turn around his granddaughter whom they had all lost hope. “This is good news; I will be seeking treatment there. Before the baby was inattentive, I would call her but she would not respond. These mothers of today have poor caregiving practices unlike former days” says Gregory. I dint know that the baby’s health would turn around using available food from our farm. He approves that children should eat eggs. “I know the taboo behind egg eating, I was close to my grandfather and I know. The secret behind the taboo prohibiting infants from eating eggs was meant to restrict mothers from cooking eggs meant for breeding. Then, rearing chicken and ensuring that the family had enough was a responsibility of the father” explains Gregory. It’s worth noting that the egg remains one of the most affordable nutrient dense food available here given our social economic condition. The project will continue to educate the community on BFCI and the proper use locally available foods to address malnutrition. The transect walk was refreshing to learn that a lot of progress has been made. Beyond Healthcare: The Story of Nzawa Health Centre Success Story 3: By Emmah Mwangi, Zipporah Mureithi and Hudson Inyangala Obstetric complications are the leading causes of death among women of reproductive age in many developing countries with an estimated 40% of pregnancies likely to complicate; 15% experiencing serious or long‐term complications and 1.7% developing fatal complications (Starrs 1997; De Bernis et al. 2003). The lifetime risk of death due to pregnancy‐related complications is 250‐fold higher among women in developing than in developed countries [(WHO) 2003]. It has been estimated that 88–98% of these deaths are avoidable (Hafez 1998) and 70% are related to five direct obstetric conditions: post‐partum hemorrhage, puerperal sepsis, pre‐eclampsia and eclampsia, obstructed labor and abortion (Starrs 1997; AbouZahr 2003). It is therefore important for mothers to acquire the aid of a skilled attendant to improve the management of pregnancy‐related complications as an effective means to reduce maternal mortality.

This sounds like fiction to the community around Nzawa Health Centre in Mwingi West Sub-county of Kitui County. Obvious of the risks of home deliveries, the coverage of SBA at the facility was less than 11%; with only 62 deliveries (average of 5 deliveries per month) being conducted at the facility against an expected 215 deliveries annually in the year 2016. In the year 2017, things continued going south, with skilled birth attendance dropping further to only 20 deliveries the whole year. This was occasioned by the prolonged nurses strike. As at the 30th September 2018, the facility had recorded 72 deliveries, a significant improvement. “We have no idea why the deliveries at facility level are this low. We have well trained staff and the basic equipment needed to conduct deliveries, but the mothers are not coming. Between January to April 2018, Nzawa HC recorded an average of 4 deliveries per month despite the fact that the ANC attendance is quite high” exclaimed the nursing officer in-charge of the facility.

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The Afya Halisi project team, listened to the story of the health facility in-charge and noted a gap in the community to facility linkage. The facility has one community unit linked to the facility. To bridge this gap, the project team in collaboration with the facility team and the CHVs planned for a maternity open day for expectant women. Thirty expectant women and 1 man attended and had a one on one dialogue on utilization of Nzawa Health Centre during delivery. From the dialogue, the women indicated that the reasons for not utilizing the maternity were; fear of mistreatment during labor, fear of routine episiotomy, lack of hot water for showering after delivery, lack of food, fear of being tested for HIV, lack of BCG vaccine for the newborns and a slow referral process in cases of emergencies. The facility staff promised to implement change ideas on improving the care offered before, during and after delivery. After a needs assessment, Afya Halisi project supported 2 staff from the facility for an EmONC training, and one staff was trained on respectful maternity care (RMC). “This has seen us improve the quality of care that we provide to the mothers, more and more mothers are coming to the facility and this is boosting our flow of funds from the Linda Mama rebates. The resources will be ploughed back into service delivery to further improve the quality of care” Explained the nurse in-charge. “The trainings were reinforced with frequent CMEs and low dose high frequency training sessions on the main killers of mothers and newborns to ensure that all staff are trained. The watchman and other support staff were not left out to make sure that everyone at the facility has a role to play” - added the nurse in-charge. Additionally, the project supported a community dialogue event at the facility in May 2018 to address health care financing and spherically enrollment on to the Linda Mama program. With the rebates from the Linda Mama program, the facility started providing food / tea to the mothers in the maternity unit. The project purchased an electric kettle for the facility to be used in warming water for bathing, and provided an additional 2 delivery sets and a multi-purpose trolley. “The facility staff are friendly and they take good care of us while in labor. There are curtains to ensure that people do not see you while in the process of giving life. Medicines are available and we are not told to go and buy. We are given hot water to shower and there is food at the facility. I am happy that I could safely deliver at this facility” – added Lydia, a 34-year-old mother of four who delivered at the facility and had brought the child for immunization. Over time, there has been a gradual improvement in skilled birth attendance at the facility. The project, on a monthly basis supports a BEmONC assessment and mentorship at the facility to maintain the quality of the skilled deliveries. Nzawa Health Centre has been ear marked as one of the centers that shall be supported by the project to establish a maternity shelter in the second year of implementation. To address documentation, the project engaged a health records and information officer to support the facility to manage information and enhance data use for decision making. “Given the improved service delivery, we are having mothers crossing over from Kitui West Sub County to deliver at the facility. For the mothers, it is the extras that go beyond health care that matters. The little things that can easily be taken for granted. As the Nzawa Health Centre community, we appreciate the support and guidance from USAID through the Afya Halisi program. This is just the beginning, the struggle continues, and we have set our eyes on establishing a maternity shelter to serve as a waiting home for the mothers. This will go a long way in addressing the first level of delay”. Concluded the nursing officer in charge Nzawa Health Centre.

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ANNEXES & ATTACHMENTS

Annex 1: Afya Halisi - From Commitment to Action: Framework for Action by Migori, Kisumu and Kakamega on Adolescents and Youth Sensitive Services

The project intensified support for AYSRH interventions across the 4 counties during the reporting period. These included capacity building for health workers on youth appropriate services as well as offering information and services to adolescents and youth through various forums.

During the quarter under review, a total of 11,290 adolescents were able to access FP services slight increase from the previous quarter’s 9,403. The overall year’s performance was 31,190 a 85% achievement of the set target. In terms of county performance Migori had 15,801 clients receiving FP services compared to the other counties which had 8,205 (Kisumu), 5,098 (Kitui) and 2,086 (Kakamega). Some of the barriers to adolescents and youth accessing FP services included; religious and cultural beliefs, stigma at community level and service provider attitude. In some instances, the opening hours for services were not conducive for the youth. In Year 1, the project revitalized youth TWGs and stakeholder forums at both county and sub- county level in order to strengthen coordination of AYSRH interventions. Other interventions included capacity building for HCW in delivery of youth appropriate services, adolescent and youth focused outreach services and, utilizations of forums like youth events to offer services. A total of 564 health workers (224 male, 340 female) received training on AYSRH in Year 1. Table 10 below shows uptake of FP services by adolescents (10-19 years) in PY1. Table 10. Performance in adolescents (10-19 years) receiving FP services in Year 1 County PPR Target Y1Q2 Y1Q3 Y1Q4 PPR 2018 % Achievement Kakamega 5,123 462 806 818 2,086 41% Kisumu 12,077 2,792 1,926 3,487 8,205 68% Kitui 8,783 1,592 1665 1,841 5,098 58% Migori 10,612 5,651 5,006 5,144 15,801 149% Project 36,595 10,497 9,403 11,290 31,190 85%

Teenage pregnancy continues to be a challenge in the supported counties. Apart from investing in prevention of teenage pregnancy, it is important to ensure that youth who get pregnant are able to access quality ANC services and skilled birth attendance in order to reduce complications. It is also important to ensure that the affected youth are supported to prevent repeat pregnancy and those who are willing are able to return to school. During the reporting quarter, a total of 8,822 adolescents received ANC services, bringing the total to 28,320 for PY1, an achievement of 120% of the set target. All counties were able to achieve results above the set targets. This was because of interventions put in place by the project to ensure the clients accessed services including starting teen mothers’ clubs, utilizing CHVs in mapping of pregnant teens and linking them to care and capacity building of HCW on AYSRH to enable them offer youth appropriate services. Table 11 below shows trends in uptake of ANC services by adolescents (10-19 years) in PY1.

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Table 11. Performance in adolescents (10-19 years) receiving ANC services in Year 1 County PPR Target Y1Q2 Y1Q3 Y1Q4 PPR 2018 % Achievement Kakamega 3,302 1,018 1,399 1,314 3,731 113% Kisumu 7,783 3,185 2,737 2,353 8,275 106% Kitui 5,660 2,332 2,286 2,131 6,749 119% Migori 6,839 3,559 2,982 3,024 9,565 140% Project 23,584 10,094 9,404 8,822 28,320 120%

All counties implemented activities at varying levels. Below is a summary of county level activities. Kitui County AYSRH Stakeholders’ Forum: Afya Halisi in collaboration with MOH supported an AYSRH stakeholders’ Forum for Mwingi North Sub-County. There were 15 participants (11 male and 4 female) including; SCHMT, representatives of religious groups (both Christian and Muslim), Ministry of Education, Children Office, Ministry of Youth, CARE International and local administration. Key discussion points were; high number of teenage pregnancies, SGBV targeting young people and inadequate AYSRH information in schools and in the community. The meeting proposed several interventions including formation of Sub-County and Community AYSRH TWG, revitalization of the school Health Program, holding community dialogues on AYSR focusing on parents and adolescents separately and, identification and utilization of youth champions. AYSRH Youth Fair: Afya Halisi in collaboration with MOH supported a Youth fair at Kimangao Catholic Parish where a total of 32 youths (23 female, 9 male) participated. The youths were given health education on; prevention of unplanned pregnancies, personal Hygiene and life skills (goal setting, mentors and role models). The health education was integrated with other activities including ball games and talent shows. Young mothers’ clubs: Afya Halisi in supported Young Mothers’ clubs for adolescents aged 14- 19 years at Kyuso, Tseikuru, Mulinde Disp, Mwingi, Migwani, Mutha, Ikutha and Katulani Hospitals. A total of 287 young mothers were reached with information on danger signs in pregnancy, PPFP, Maternal Nutrition, Infant and Young Child Feeding, individual birth planning and importance of SBA. Out of these, 37 young mothers are on family planning while 17 girls have already gone back to school. 6 girls have not gone back due to poverty. Young Mothers club meeting at Kyuso sub-Countyt Hospital

Ukasi young fathers club: the project supported 2 meetings for Ukasi young fathers. Topics discussed included childhood illnesses with emphasis on diarrhoea and fever, STI/HIV prevention and management. They also had a combined meeting with young where they sensitized on FP methods including their side effects and also myths and misconceptions about FP. The group proposed to have their spouses attend future meetings

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AYSRH forums in schools: During the quarter under review the project supported SRH education in 7 schools reaching a total of 1258 students (902 F, 356M) in the following age groups: 10- 14yrs (424), 15-19yrs (660) and 20-24yrs (174). The young people were equipped with knowledge on sexuality and biological functions of the reproductive organs and life skills. The project will embark on working with other stakeholders and media to come up with best messages to address the emerging issues in AYSRH.

A HCP sensitizing young people at Ndauni Pry School on SRH and menstrual hygiene Kisumu County Kisumu County according to DHIS2 2017, has a teen pregnancy rate of 37%, far higher than the national percentage of 26%. The project targets adolescents and youth aged 10-24 years to raise their competency in comprehensive sexuality education, health promotion and prevention and enhance access to quality sexual reproductive health services. During the quarter, the project targeted the youth and adolescents through the following service delivery models: facility/clinical based Interventions, community based interventions and systems level interventions. AYSRH County and Sub County Stakeholder and Multi Sectoral Forums: During the reporting period, the project supported County and Sub County adolescent and youth stakeholder’s forum to identify and appreciate partnership from all stakeholders and align the resources support to leverage efforts for effective engagement of this age group. Challenges facing the youth were noted to include; teenage pregnancy, risky behaviour predisposing to HIV, Drug and Substance Abuse, Sexual and Gender Based Violence among others. The meeting resorted to strengthen the AYSRH technical working group at County and cascade Sub County level, and cascade down to the Sub Counties, and have functional intra agencies bringing together other government line ministries and partners to address contextualized challenges of the adolescents and youths. Partners were mapped and their areas of support identified and a plan of collaboration at Sub county level. Muhoroni, Nyando and Kisumu West Sub County conducted their Sub County Specific Stakeholders meeting to address their Sub County specific and contextualized issues.

HCWs Sensitization on AYSRH: The project supported sensitization of 101 HCWs (45 male and 56 female) comprising of clinical staffs and community health assistants running the community strategy component, from Kisumu West (40), Nyando (29) and Muhoroni (32) sub counties on AYSRH interventions to increase access to information and services by the adolescents and youth. The participants discussed barriers to adolescents and youth accessing information and services including limits on services and benefits, shortage of providers trained in adolescent health, the fear of confidentiality, and services that focus on adults or children, overlooking the particular needs of teens. After the sensitization, teams developed workplans for these interventions in their facilities. Interventions included youth focused outreaches and dialogue days, formation of adolescent youth groups and male engagement sessions for prevention and involvement in FP/RH issues.

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Young Mothers Clubs: During the quarter under review, the project supported the formation of 10 young mother’s clubs Kisumu East, Nyando, Nyakach and Muhoroni. During the meetings the mothers were educated on the importance of ANC, SBA and PNC as well as immunization for their babies. Dialogue with Youth Living with Disability: During the reporting period, the project supported a dialogue session for adolescents and youths living with disability at Joy Land Secondary school for the Physically disabled in Kisumu East Sub County. This also served as an opportunity to meet the reproductive health needs of the group including FP for the vulnerable girls, VMMC for the boys, STI screening and SGBV screening. The participants also received career Youth living with disability during the SRH counselling and mentorship. dialogue session in Kisumu East sub- Engaging Key Populations Adolescents and youths: county In collaboration with Community Forum for Advanced Sustainable Development (COFASD), Afya Halisi supported a dialogue session with street adolescents, adolescent sex workers and youths from the sprawling informal settlements and peri Urban slums in Kisumu. During the session service providers from Nyalenda Health Centre offered health education on SRH and STI/ HIV prevention. A total of 38 girls were reached with information and 5 took up FP methods of choice. Engaging Adolescents and Youths Living with HIV: During the reporting period, Afya Halisi, recognizing the SRH needs of the adolescents and youth living with HIV, collaborated with FACES project in Muhoroni Sub County, and offered FP Counselling and Service provision to adolescents and youths living with HIV between the ages of 15-24 years with FP services. The session was carried out at the young friendly center located at the Muhoroni Sub County Hospital. A total of 28 adolescents and youths were given family planning counselling, and 19 took up a method.

Reaching the Very Young Adolescents- Teens Festival: During the reporting period, the project supported a Teens Festival, which brought together teens from the peri urban slums of Kisumu both in school and out of school. The event focused on causes and ways of preventing teen pregnancies, drug and substance abuse and risky behaviors among the teens. The event used creative arts to package health information. A total of 398 teens were reached with health information, while 38 received different contraceptives methods.

International Youth Week: The event was marked at Obwolo Grounds in Kisumu East Sub County. The theme of the Week was creating safe spaces for youths, spaces in which the adolescent and youths feel free to engage and discuss matters concerning their health, social, economic and political issues. Afya Halisi supported provision of health services, where a total of 38 adolescents and youths received various contraceptives methods. Kakamega County The project the supported sub-counties to implement interventions that improved access to services and information by the adolescents and youth.

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AYSRH County and Sub County Stakeholder and Multi-Sectoral Forum: In collaboration with Jhpiego’s Advanced Family Planning (AFP) program, the project supported the Kakamega County Teenage Pregnancy stakeholder forum which was graced by the Kakamega County First Lady. The meeting discussed strategies of addressing teenage pregnancy including empowering youth with SRH information through various forums. Matungu Sub County AYSRH Stakeholders Forum: Matungu Sub County being the leading Sub County in teen pregnancies in Kakamega County, was supported by Afya Halisi to convene a stakeholder’s forum that brought together line government ministries, and County administration. The discussions were around ways of reducing teenage pregnancy. Areas of urgent support were identified including prevention outreach sessions with Boda Boda riders, SRH programs in Tertiary colleges and holding parental and caregiver sessions. The stakeholders agreed on the formation of a technical working group/ intra agency coordination team to address the issues of the adolescents and the youths. HCWs Sensitization on AYSRH: During the quarter under review, 35 HCWs (11 male and 24 female) Health care workers were sensitized on AYSRH. They included nurses, clinical officers, and community health assistants (CHA), from Matungu Sub- County. After the sensitization the teams developed facility and community based work plans for AYSRH interventions including outreaches, formation of youth groups and youth clubs. Youth dialogue meeting: During the reporting period, the project supported 2 youth dialogue meetings in Kakamega (50) and Navakholo (45) where a total of 95 youths (40 male and 55 female) were reached. The youth were provided with AYSRH information and encouraged to seek services. Champions and group leaders were identified to lead the process of mobilization of the youths for SRH services and for health education.

Mapping of adolescents: Using the selected youth champions and group leaders, the project supported mapping of pregnant teens and those with children in the immunization bracket to link them to services at the nearest facilities including ANC, SBA, PNC and immunization for their children. In year 1, an estimated 250 pregnant youths and adolescents had been identified at different gestational periods and linked to care.

Migori County Afya Halisi in PY1 focused on adolescent and youth looking at primary prevention and secondary prevention of pregnancies including care and support provided to them. These was done through different strategies. Youth outreaches: During the quarter, the project supported 14 outreaches in Nyatike reaching 3462 young people among them 400 students from Rongo University. At the Rongo University event, the theme was “Chanua fresher’s” and 63 students received different FP methods of their choice. Adolescents from primary and secondary schools were encouraged to participate through their school health clubs forming the above impressive turn out during the outreaches. Teachers were among stakeholders involved. AYSRH focused dialogue and education sessions: Afya Halisi supported different sub counties to conduct youth dialogues sessions where youth listed challenges they experienced services as; staff attitude, cost of family planning services particularly removals of implants once inserted, issues of confidentiality and myths and misconception on family planning. During the youth

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dialogues the project reached 1586 young people (Uriri 527, Suna West 107, Rongo 154, Awendo 450, and Kuria East 348). In addition to reaching out to the youth through the dialogues the project engaged the young adolescent through education sessions on sexuality, myths and misconception on sex and body changes. 179 Adolescents were reached in Suna west (119) and Suna East (60). Youth engagement sessions: The project also reached out to youths during sporting activities with services and information and reached 409 (Suna East 297, Kuria East 112)

Whole site orientation on AYSRH: The project supported whole site orientation on AYSRH for all facility staff including community health workers where a total of 468 staff (189M and 279F) were reached as follows: Nyatike 137 (57M and 80F), Suna East 30 (8M and 22F), Suna West 71 (32M and 39F), Kuria East 46 (14M and 32F), Kuria West 75 (32M and 43F) and Uriri 109 (46M and 63F). The staff were oriented on the importance of having adolescent and youth friendly services, communication and counseling with adolescents and youth, adolescent’s contraception/myths and misconception about Family planning and community approaches to AYSRH.

First time mothers’ clubs: Under the leadership of the Sub County teams the project supported in initiation of 10 First time mum club meetings and the young mothers being taken through health education sessions. The first time adolescent mothers received services through group antenatal care approach and reached 85 clients in Kuria East, while 182 young mothers were reached in Nyatike. Emphasis to delay second and subsequent pregnancies among the mothers was reiterated. Some of these groups were linked to a community based organization (3 Way care) that in partnership will start small scale business for the group.

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Annex 2: Schedule of Future Events

The scheduled activities for Quarter 1 of 2019 are included in Table 12 below.

Table 12. Schedule of upcoming events in Y2Q1. Date Location Activity October 2018 Kakamega, Kisumu , Kitui , Migori World Handwashing day October 2018 Machakos NNAK Conference October 2018 Bondo Kisumu county UHC Bottleneck Analysis Meeting November 2018 Kakamega, Kisumu , Kitui , Migori World Toilet Day November 2018 Kakamega, Kisumu , Kitui , Migori World Hand Washing Day November 2018 Nairobi-Movenpic Hotel And Medical Women's International Association (MWIA) Residences Regional Conference Of The Near East And Africa Region December 2018 Kakamega, Kisumu , Kitui , Migori World Aids Day Commemoration December 2018 Kisumu USAID FHT Field Visit December 2018 Mombasa KPMA Conference

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