USAID (APHIAPLUS IMARISHA)

ANNUAL PROGRAMME REPORT

APHIAplus IMARISHA Staff Participating in a Radio Program at Radio Jambo in Turkana to Sensitize the Public on Accelerating Children's HIV/AIDS Treatment (ACT) Initiative and the 90-90-90 Strategy

APHIAplus IMARISHA Supported Mwelekeo Support Group in Tana River Community Members Drawing Water from Alakara Shallow Well in County Making Soap as an Income Generating Activity County Developed with Support of APHIAplus IMARISHA

USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 1

USAID KENYA APHIAPLUS IMARISHA

FY 2015 QUARTERLY PERFORMANCE REPORT

01 July – 30 September 2015

Award No: AID-623-A-12-00015

Prepared for Ruth Tiampati, AOR 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: African Medical and Research Foundation Wilson Airport, Lang’ata Road P.O. Box 30125, GPO 00100

DISCLAIMER

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

USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 2

TABLE OF CONTENTS

I. APHIAPLUS IMARISHA EXECUTIVE SUMMARY ...... 12 II. KEY ACHIEVEMENTS (QUALITATIVE IMPACT) ...... 16 III. ACTIVITY PROGRESS (QUANTITATIVE IMPACT) ...... 157 IV. CONSTRAINTS AND OPPORTUNITIES...... 158 V. PERFORMANCE MONITORING ...... 159 VI. PROGRESS ON GENDER STRATEGY ...... 168 VII. PROGRESS ON ENVIRONMENTAL MITIGATION AND MONITORING ...... 169 VIII. PROGRESS ON LINKS TO OTHER USAID PROGRAMS...... 170 IX. PROGRESS ON LINKS WITH GOK AGENCIES ...... 171 X. PROGRESS ON USAID FORWARD ...... 172 XI. SUSTAINABILITY AND EXIT STRATEGY ...... 175 XII. GLOBAL DEVELOPMENT ALLIANCE (IF APPLICABLE) ...... 176 XIII. SUBSEQUENT QUARTER’S WORK PLAN ...... 176 XIV. FINANCIAL INFORMATION ...... 180 XV. ACTIVITY ADMINISTRATION ...... 183 XVI. FOR ANNUAL REPORTS ONLY ...... 184 XVII. GPS INFORMATION ...... 185 XVIII. BENEFICIARY STORY ...... 186

USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 3

LIST OF TABLES

Table 1: Key Achievements from October 2014– September 2015...... 13 Table 2: HIV Testing and Counselling Performance by County ...... 17 Table 3: Summary of SIMS Progress in Pre-ART Patient Monitoring in Supported Facilities ...... 22 Table 4: APHIAplus IMARISHA SIMS Assessment Summary (Quarter 4) ...... 25 Table 5: Summary Of TB ICF in the Selected Facilities across NAL for the Period July to September 2015 ...... 30 Table 6: Summary of CQI Projects Conducted In Facilities in Four Counties Supported by APHIAplus IMARISHA (Period: July – September 2015)...... 31 Table 7: Summary of Genexpert Status and Placement across NAL as of September 2015 ...... 45 Table 8: Summary of Genexpert Results across 8 Counties ...... 46 Table 9: Summary of Maternal and Neonatal Outcomes across In NAL (July – Sep 2015) ...... 61 Table 10: Number of Children Immunized ...... 65 Table 11: Voluntary Medical Male Circumcisions Undertaken During (Jan-Sept 2015) ...... 71 Table 12: Issues/Challenges Identified while Implementing VMMC Activities and Suggested Solutions ...... 72 Table 13: Numbers of PEPFAR Priority Private Health Facilities in NAL ...... 73 Table 14:Numbers of HCWs Oriented on Various Health Topics in Private Health Facilities in NAL ...... 74 Table 15: Specialist Services Given by Clinical Specialist in NAL Over the Reporting Period ...... 76 Table 16: High Impact Nutrition Interventions Carried Out in NAL ...... 77 Table 17: Registers and Guidelines Delivered to Turkana County by APHIAplus IMARISHA ...... 84 Table 18: Number of Clients Reached Through Outreaches with Nutrition Services ...... 87 Table 19: Monthly cPwP Attendance at Referral Hospital ...... 93 Table 20: Number of Deliveries Undertaken by Domiciliary Midwives in ...... 95 Table 21: Clients Feedback on Areas to be addressed ...... 98 Table 22: Number of MNCH Clients Reached Through Voucher Services at SIMAHO ...... 98 Table 23: Number of Households Linked To Microfinance / Funding Institution ...... 104 Table 24: Number of People Participating in Viable Economic Strengthening Activities ...... 104 Table 25: Isiolo County Caregivers Groups Which Have Been Linked For Funding From Other Projects...... 107 Table 26: The Savings and Number of Groups Mentored by Each Agent ...... 108 Table 27: Performance of SILC groups ...... 109 Table 28: Amount Accessed by SILC Groups in County ...... 111 Table 29: Number of People Reached with Nutrition Services in County ...... 116 Table 30: Number of People Reached with Nutrition Services in County...... 117 Table 31: Number of People Reached with Nutrition Services in Turkana County ...... 119 Table 32: Nutrition Services Provided to OVC During OVC Station Days Events in Turkana County ...... 119 Table 33: Number of People Reached with Nutrition Services in County ...... 120 Table 34: Number of People Reached with Nutrition Services in Tana River County ...... 121 Table 35: Key Outcomes from the 4 PD Hearth Sessions in Tana River County ...... 122 Table 36: Number Of People Reached with Nutrition Services in ...... 124 Table 37: Number of People Reached with Nutrition Services in Isiolo County ...... 125 Table 38: Number of WASH Hardware Developed Since Project Inception in The Northern Arid Lands...... 130 Table 39: Isiolo County Caregivers Groups which Have Been Linked for Funding ...... 143 Table 40: Number of Clients Reached with HCBC Services in NAL ...... 153 Table 41: Number of Active Patients on Type of Regimen by the End of the Reporting Period ...... 160 Table 42: Sample of PEPFAR Summary Report from OLMIS for FH-K LIP ...... 162 USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 4

Table 43: Sample of PEPFAR Essential Services Report from OLMIS for FH-K LIP ...... 162 Table 44: HEI Outcomes Before and After Data Reconstruction at Health Centre ...... 166 Table 45 APHIAplus IMARISHA Collaboration with other USAID Programs ...... 170 Table 46: APHIAplus IMARISHA Collaboration with GoK Agencies ...... 171 Table 47: List of Local Implementing Partners Funded During The Quarter Include Remained The Same...... 174

USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 5

LIST OF FIGURES

Figure 1: Testing Disaggregated by Age Groups Per County...... 18 Figure 2: Number of Children tested: Comparison between quarter 3 and quarter 4 across NAL ...... 18 Figure 3 Comparison of Positivity Rates across 8 Counties ...... 18 Figure 4: Number of PLHIV Identified Across 8 Counties Supported By APHIAplus IMARISHA in the Period July to September 2015...... 19 Figure 5: HTC to Care Linkage Cascade in Transitioned Facilities in APHIAplus IMARISHA Counties ...... 20 Figure 6: Number of Clients Enrolled Into Care and Treatment across NAL between July and September 2015 ...... 21 Figure 7: CD4 Access in Supported Facilities across 8 Counties Supported By APHIAplus IMARISHA (July - September 2015) ...... 21 Figure 8: A Comparison of Number of Patients Currently On HAART between March (SAPR) & September 2015 (APR) .... 22 Figure 9: A Comparison of the Achievement versus Target of Number of Clients Newly Initiated On HAART ...... 23 Figure 10: Adult Treatment Access in Supported Facilities across NAL Counties between July and September 2015 ...... 23 Figure 11: Crude % Viral Load Access as Of the End of September 2015 ...... 26 Figure 12: Crude VL Access for Eligible ART Patients as of the End of September 2015 ...... 27 Figure 13: 1st Viral Load Suppression Rates between October 2014 and September 2015 ...... 27 Figure 14: VL Suppression Rates for Patients Accessing 2nd VLs between October 2014 And September 2015...... 28 Figure 15: Defaulter Tracking Activity Yields across the 8 Counties Supported by APHIAplus IMARISHA for the Period between July and September 2015 ...... 29 Figure 16: TB Cascade across 8 Counties Supported by APHIAplus IMARISHA for the Period between July and September 2015...... 29 Figure 17: Samburu Annual FP Commodity Reporting Rates...... 34 Figure 18: Quarter 4 FP Commodity Reporting Rates ...... 35 Figure 19: Quarter 4 IMAM Commodities Reporting Rates ...... 35 Figure 20: Quarter 4 Malaria Commodities Reporting Rates ...... 35 Figure 21:HCMP Practice/Demonstration Session...... 36 Figure 22:Web Based ADT Milestones ...... 36 Figure 23:HCMP Milestones ...... 36 Figure 24:Treatment Access in Four Facilities in Turkana County...... 37 Figure 25: Bin Card Availability in Three Facilities for the Period March to September 2015 ...... 37 Figure 26: Bin Card Completeness in Three Facilities for the Period March to September 2015 ...... 38 Figure 27: Bin Card Accuracy in Three Facilities for the Period March to September 2015 ...... 38 Figure 28: Variance in Stock levels ...... 38 Figure 29: Commodity DQA HRH Commodity Management Capacity Gaps Findings ...... 39 Figure 30: Commodity DQA Storage Condition Findings ...... 39 Figure 31: Commodity DQA Tools Availability and Use Findings ...... 39 Figure 32 C.C.C Medicine Cabinet and Main Drug Store at Katilu Sub County Hospital ...... 40 Figure 33: Kaizen at Garbatulla Sub-County Hospital CCC ...... 40 Figure 34: Summary of Samples Networked In the Period July to September 2015 ...... 42 Figure 35: Annual Trends in DBS Collection from 2012 To 2015 ...... 43 Figure 36: Isiolo County EID by Entry Point for the Period July to September 2015 ...... 44 Figure 37: DBD Collection by Age, Positivity & Enrolment into Care for , Jul- Sep 2015 ...... 44 Figure 38: Turkana County EID Cascade between October 2014 and September 2015 ...... 45 Figure 39: Online Reporting Rate Trends for Garissa County ...... 47

USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 6

Figure 40: Online Reporting Rate Trend for Isiolo County ...... 47 Figure 41: RTK Online Reporting Rate Trends by Quarter for the Period October 2014 to September 2015 ...... 47 Figure 42: Trends in Online RTK Reporting Rates for Samburu County: Comparison between 2014 And 2015 ...... 48 Figure 43: Trends of Tana River County Online Reporting Rates for the Period October 2014 to September 2015 ...... 48 Figure 44: Trends of Turkana County Online Reporting Rates for the Period October 2014 to September 2015 ...... 48 Figure 45: eMTCT Cascade across the 8 Counties Supported By APHIAplus IMARISHA in The Period July to September 2015...... 56 Figure 46: Uptake of Prophylaxis among HIV +Ve Pregnant Women across NAL for the Period October 2014 to September 2015...... 57 Figure 47: Option B+ Uptake across NAL for the Period October 2014 to September 2015 ...... 57 Figure 48: EID Cascade across 8 Counties Supported by APHIAplus IMARISHA for the Period July to September 2015 ...... 58 Figure 49: DBS Samples by Age and Positivity across 8 Counties Supported By APHIAplus IMARISHA for the Period July to September 2015 ...... 58 Figure 50: Number of Women Attending 1st ANC Between July To September 2015: Achievement Versus Target ...... 58 Figure 51: A Comparison between the 1st ANC, 4th ANC and SBA across 8 Counties Supported By NAL in July to September 2015 ...... 59 Figure 52: Trends in 4th ANC Visit across 8 Counties Supported By APHIAplus IMARISHA between October 2014 and September 2015 ...... 60 Figure 53: Number of Deliveries Conducted By a Skilled Birth Attendant between July and September 2015 across 8 Counties Supported By APHIAplus IMARISHA: Achievement versus Target ...... 60 Figure 54: Trends in Uptake of SBA across 8 Counties Supported By APHIAplus IMARISHA between October and September 2015 ...... 61 Figure 55: Contraceptive Method Mix across 8 Counties in NAL (July - September 2015) ...... 63 Figure 56: CYP and LARC Uptake Trends across NAL for the Period October 2014 to September 2015...... 64 Figure 57: Percent FP Access (Crude Estimate) Across the 8 Counties Supported By APHIAplus IMARISHA in the Period October 2014 to September 2015 ...... 65 Figure 58: Trends of Clients Referred to Health Facilities for Services through the Boma Model Implementation in Samburu County (January to September 2015)...... 66 Figure 59: CEC Health Samburu County Displaying the IMCI Chart in Her Office (Left) and A CHMT Member Sensitizing HCWs On ORS/ZN Scale Up ...... 70 Figure 60: IMCI Training Sessions at the Provincial General Hospital ...... 71 Figure 61: Percentage of Circumcisions Undertaken by Age-Group for Q1 (Jan-Mar), Q2 (Apr-June) and Q3 (Jul-Sept) ...... 72 Figure 62 APHIAplus IMARISHA C&T Officer Offering Support to HCWs at Wamba Catholic Mission Hospital ...... 74 Figure 63: Number of Patients Seen by Different Clinical Specialists ...... 76 Figure 64: Findings of Nutrition Assessment in Isiolo County Referral Hospital ...... 88 Figure 65: CHVs Sensitization on Scaling Up of Skilled Birth Attendance at Nachola Dispensary ...... 94 Figure 66: Facility In-Charge and CHVs at Lesidai Dispensary in Samburu Central Sub-County Receiving Maternal Shelter Equipment and Supplies ...... 95 Figure 67: Trends in 4th ANC Visits, Skilled Birth Attendance and Postnatal Care in Samburu County ...... 96 Figure 68: Trends in Immunizations in Samburu County (Oct, 2014 - Sept, 2015) ...... 97 Figure 69: Trends of Skilled Birth Attendance at Habaswein SCH from 2013-2015 ...... 99 Figure 70: Patient Engagement in HIV Care Since the WELTEL SMS Intervention at Isiolo CRH, April-July 2015 ...... 101 Figure 71: HIV Clinic Attendance at Scheduled Visits Enrolled and Not Enrolled in WELTEL, Isiolo CRH, April-August 2015 ...... 101 Figure 72: Comparison of Pregnant Women Enrolled in WELTEL and Those Not Enrolled in WELTEL, Isiolo District Hospital MNCH Clinic, April-September, 2015 ...... 102 USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 7

Figure 73: Olla Nagele Caregivers with Their Livestock Ready for Sale at Isiolo Livestock Market ...... 105 Figure 74: Inuka Caregivers Ground member Takes Care of Seedlings ...... 106 Figure 75: A Caregiver Inspects Her Tomato Crop for Pests ...... 106 Figure 76: Mama Sallo of Drib Gombo Women Group With Bales of Hey ...... 107 Figure 77 CHVs Group in Wamba Receiving the Donkey Cart ...... 108 Figure 78: Jane Achukule of Kaputir CU Sells Clothes and Consumables from Her New Shop ...... 110 Figure 79: A Member of Echami FFS on His Farm In ...... 111 Figure 80: Mwelokeo Group Making Soap ...... 113 Figure 81: Training Instructor Displays a Set of Vase Made by the Trainees...... 113 Figure 82: PD Health Outcomes from One of the Sites ...... 123 Figure 83: Elevated Plastic Water Tank at Wajir DH MNCH Department and Marere Shallow Well, ...... 131 Figure 84: El-Wak DEB Shallow Well and Training of Local Artisans on Hand Pump Installation, ...... 131 Figure 85: Showing Stages in Construction of Ngeriyoi Infiltration Shallow Well, Samburu County...... 132 Figure 86: Completed Ngaremara and Alakara Shallow Wells, Isiolo County ...... 133 Figure 87: The Newly Installed 50 M3 Elevated Steel Water Tank in Elelea, Turkana ...... 134 Figure 88: Plastic Water Installed at County Referral Hospital, Marsabit County ...... 134 Figure 89: The 10m3 Plastic Water Tank at Mercy Girl’s Primary School in Laisamis Sub County, Marsabit County ...... 135 Figure 90: Showing Participants during CLTS Master Certifiers Training in Wajir and Isiolo Regions...... 136 Figure 91: Demonstration on Use of a Tippy Tap For Handwashing and Community Members Constructing Latrine at Household Level, Samburu County...... 137 Figure 92: Number of OVC Accessing HIV Services in NAL...... 138 Figure 93: An Improved Shelter Under Construction in Wajir County Figure ...... 147 Figure 94: An Renovated Shelter in Wajir County ...... 148 Figure 95: Data and Reporting Verifications in Isiolo County Referral Hospital ...... 161 Figure 96: Comparison of Month on Month MOH 711A Reporting Rate for 2014 and 2015...... 164 Figure 97: ART Data Before and After Data Reconstruction ...... 165 Figure 98: Findings of Routine Data Quality Audit of the EMR system in St. Patrick’s Kanamkemer ...... 168 Figure 99: Organizational Development and Systems Strengthening Score by LIP...... 173 Figure 100: Overall Organizational Development and Systems Strengthening Ranking By Thematic Area/ Element ...... 174

USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 8

ACRONYMS AND ABBREVIATIONS

AAC Area Advisory Committees CPWG Child Protection Working Group ADT ART Dispensing Tool cPwP Community Prevention with Positives AIC Africa Inland Church CQI Continuous Quality Improvement AIDS Acquired Immune-Deficiency Syndrome CRH County Referral Hospital AGM Annual General Meeting CRS Catholic Relief Services ANC Ante- Natal Care CSI Child Status Index APHIA AIDS, Population, Health Integrated Assistance CSO Civil Society Organization APR Annual Performance Report CU Community Unit ART Anti Retroviral Therapy DANIDA Danish International Development Agency ARV Antiretrovirals DBS Dry Blood Sample Applying Science to Strengthen and Improve ASSIST DHIS District Health Information System Systems ASRH Adolescent Sexual and Reproductive Health DM Domiciliary Midwives‘ BCC Behavior Change and Communication DMPA Depot Medroxyprogesterone Acetate BEmONC Basic Emergency Obstetric and Newborn Care DPT Diphtheria, Pertussis and Tetanus BMI Body Mass Index DQA Data Quality Assessment BRHC BroadReach Health Care EBI Evidence-Based Intervention C4D Communication for Development EBF Exclusive Breastfeeding C&T Care and Treatment ECD Early Childhood Development CASCO County AIDS and STI Coordinator ECDE Early Childhood Development Education CBO Community Based Organization EPAGK Emergency Pastoral Assistance Group of Kenya CCC Comprehensive Care Centers EID Early Infant Diagnosis CDC Center for Diseases Control EMP Environmental Management Plans CHAI Clinton Health Access Initiative EMR Electronic Medical Records CHC Community Health Committee eMTCT Elimination of Mother to Child Transmission CHEW Community Health Extension Worker ENA Essential Nutrition Actions CHRIO County Health Records Information Officer EWS Early Warning System CIPAD Culture Information and Pastoralist Development FANC Focused Ante-Natal Care CME Continuous Medical Education FBF Fortified Blended Flour CHMT Community Health Management Team FBO Faith Based Organization CHV Community Health Volunteer FBP Food by Prescription CHW Community Health Worker F-CDRR Facility Consumption Data Reports and Requests CLTS Community-Led Total Sanitation FFS Farmer Field School CM Community Midwife FGM Female Genital Mutilation CME Continuing Medical Education FHK Food for the Hungry Kenya CMLT County Medical Laboratory Technologist FP Family Planning CNTF County Nutrition Technical Forums FSW Female Sex Worker CNC County Nutrition Coordinator GAM Global Acute Malnutrition

USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 9

GBV Gender Based Violence MC Male Circumcision GMP Growth Monitoring and Promotion MCA Member of County Assembly GOK Government of Kenya MCH Maternal and Child Health HAART Highly Active Antiretroviral Therapy MDR Multi Drug Resistance HBC Home Based Care MNCH Maternal Neonatal and Child Health HC Health Center MOA Ministry of Agriculture HCA HEI Cohort Analysis MOH Ministry of Health HCBC Home and Community Based Care MSM Men who have Sex with Men HCM Health Communications and Marketing MUAC Mid Upper Arm Circumference HCMP Health Commodities Management Platform MWA Millennium Water Alliance HCSM Health Commodities and Services Management NACS Nutrition Assessment, Counseling, and Support HCW Health Care Worker NAL Northern Arid Lands HEI HIV Exposed Infant NASCOP National AIDS and STI Control Program HES Household Economic Strengthening NDMA National Drought Management Authority HII High Impact Interventions NEMA National Environment Management Authority HINI High Impact Nutrition Interventions NEP North HIV Immunodeficiency Virus NEWS North Eastern Welfare Society HMIS Health Management Information System NHIF National Health Insurance Fund HP Horse Power NVP Nevirapine HPAC Health Promotion Advisory Council Meeting ODF Open Defecation Free Organizational Development and System HSCM Health Commodities and Services Management ODSS Strengthening HTC HIV Testing and Counseling OJT On-the-Job ICF Intensified Case Finding ORS Oral Rehydration Salts IEC Information, Education and Communication ORT Oral Rehydration Therapy IGA Income Generating Activities OTP Outpatient Therapeutic Programme IMAM Integrated Management of Acute Malnutrition OVC Orphans and Vulnerable Children IMCI Integrated Management of Childhood Illnesses PD Positive Deviance INGO International Non-Governmental Organization PE Peer Educator IYCN Infant and Young Child Nutrition PBF Performance -Based Financing KEMSA Kenya Medical Supplies Agency PGH Provincial General Hospital KWFT Kenya Women Finance Trust PHASE Personal Hygiene And Sanitation Education LARC Long-Acting Reversible Contraception PITC Provider-Initiated Testing and Counseling LIP Local Implementing Partners PLHIV People Living with HIV LMIS Logistics Management and Information System PMTCT Prevention of Mother to Child Transmission LSE Life Skills Education PNC Postnatal Care MARP Most At Risk Population POC Point of Care M2M Mother to Mother Support Group PwP Prevention with Positives M2MSG Mother to Mother PWHE Pastoralists Women for Health and Education MAM Moderate Acute Malnutrition QI Quality Improvement

USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 10

RDQA Routine Data Quality Audit SS Stepping Stone RH Reproductive Health STI Sexually Transmitted Infection Reproductive, Maternal, Newborn and Child RMNCH TA Technical Assistance Health RTK Rapid Test Kits TAT Turnaround Time SAIDIA Samburu Aid in Africa TB Tuberculosis SAM Severe Acute Malnutrition TBA Traditional Birth Attendants SAPR Semi Annual Performance Report ToT Trainer of Trainers SBCC Social Behavior Change and Communication TWG Technical Working Group SCAAP Suguta Campaign Against AIDs Programme UNFP United Nations Population Fund SCH Sub County Hospital UNICEF United Nations Children's Fund SCMOH Sub County Medical Officer of Health URC University Research Corporation United States Agency for International SDH Sub District Hospital USAID Development sdNVP Single Dose Nevirapine USG United States Government SCHMT Sub County Health Management Team VAS Vitamin A Supplementation SFP School Feeding Program VCT Voluntary Counseling and Testing SHG Self Help Group VIP Ventilated Improved Pit SILC Savings and Internal Lending Communities VL Viral Load SIMAHO Sisters Maternity Home VMMC Voluntary Medical Male Circumcision SIMS Site Improvement through Monitoring System WASDA Wajir South Association SMS Short Message Service WASH Water Sanitation and Hygiene SND Strategies for Northern Development WFP World Food Programme SOL Shepherds of Life WHO World Health Organization SOP Standard Operating Procedure WSMC Water and Sanitation Management Committee SRH Sexual and Reproductive Health YPE Youth Peer Educators SRHR Sexual and Reproductive Health and Rights Zn Zinc

USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 11

I. APHIAPLUS IMARISHA EXECUTIVE SUMMARY

Qualitative Impact

APHIAplus IMARISHA continued to make good progress towards achieving the annual targets for all the service areas during the reporting period. This was achieved despite the challenges that continued to be faced with the on and off insecurity that prevailed in some of the counties of the NAL especially Garissa, Wajir and Mandera.

APHIAplus IMARISHA continued to prioritize potentially high yield HTC services including family centered testing of identified HIV infected individuals, testing of OVCs and their care givers, and targeted HTC among MARPS through BCC interventions as well as scaling up PITC in the 8 priority high burden/volume facilities in each of the NAL counties. This ensured that quality HIV/AIDS care and treatment services continued to be provided in the facilities supported by the project as much as possible. However, one major challenge faced was the shortage of test kits which hampered the testing and especially in Turkana County. During the period under review, a total of 665 clients tested positive in the supported sites while 536 (81%) clients were enrolled into care.

The project continued implementing focused community activities to improve early ANC attendance and retention among expectant mothers among other high impact interventions by attaching dedicated Community Health Volunteers for MNCH to priority facilities on a performance basis. The results of this approach can be seen in the improved Fourth ANC attendance from 33,202 in the last APR to 39,516 this reporting year and the project will continue to scale up this approach. The project also continued with mentorship and technical assistance to health care workers as well as supporting interventions that led to increased uptake of the MNCH/RH/FP/Nutrition High Impact Interventions for the marginalized and far flung communities. The BOMA model, UMATI concept, maternal shelters among other innovations continued to show positive results and hence increasing the uptake of skilled delivery, immunization uptake among others.

The project will continue to focus on the areas that need extra effort to improve their performance over the next reporting period such as clients newly enrolled in ART, scale up HIV testing once the RTKs are available as well as improving immunization and Vitamin A uptake. With the training of county level ODF certifiers in this reporting period, the project is now focused on verification of all self declared ODF villages and so an improved performance in this indicator is expected in the coming year.

APHIAplus IMARISHA continued to work closely with the eight County Health Management and sub County Health Management teams to address their health issues as well as conduct some supportive supervision visits in their counties. Our continued presence has been greatly appreciated in the counties that have experienced health challenges due to the recurrent insecurity.

Quantitative Impact

During the period under review, APHIAplus IMARISHA made significant progress towards achieving annual project targets for the key service areas as summarized in Table 1 below which shows 21 selected indictors

USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 12 which provide a general overview of the project performance. The detailed results against targets are presented in the performance data table.

Table 1: Key Achievements from October 2014– September 2015

Total APR Quarterly Achievements APR Achievements Targets Service Key Indicators Area Oct 2014 – Oct – Dec Jan – Apr – Jul to Oct – Sep Performance September 2014 Mar 2015 Jun 2015 Sep 2015 2015 (%) 2015

1) Number of individuals who received

HTC Testing and Counseling (T&C) services for 145,712 159,279 91% 47,672 22,551 24,378 51,111 HIV and received their test results 2) Number of adults and children with

C&T advanced HIV infection newly enrolled on 1,929 3,035 64% 523 455 491 460 ART 3) Number of adults and children with

C&T advanced HIV infection receiving 8,235 9,688 85% 7,493 7,245 7,442 8,235 antiretroviral therapy (ART) [CURRENT] 4) Number of HIV positive adults and children who received at least one of the Clinical following during the reporting period: 10,077 10,985 92% care 9,306 9,306 8,976 10,077 clinical assessment (WHO staging) OR CD4 count OR viral load 5) Number of pregnant women with known

PMTCT HIV status (includes women who were 59,230 77,793 76% 23,707 13,858 8,121 13,544 tested for HIV and received their results)

6) Number of HIV positive pregnant

PMTCT women who received antiretroviral to 591 779 76% 121 172 151 147 reduce risk of mother to child transmission

7) Number of Children who have received MNCH 83,839 97,379 86% Measles vaccine by 12 months 21,104 21,124 22,345 19,266

8) Number of children less than 12 months

MNCH of age who received DPT3 from USG- 88,875 107,453 83% 21,944 21,497 23,599 21,835 supported programs

9) Number of children who have received

MNCH the third dose of Pneumococcal conjugate 89,160 107,453 83% 23,808 20,707 23,720 20,925 vaccine by 12 months of age

10) Number of deliveries with a skilled birth MNCH 53,432 52,310 102% attendant (SBA) in USG - assisted programs 12,663 12,453 14,655 13,661 11)Number of pregnant women attending at MNCH 39,516 34,500 115% least 4 ANC visits 9,145 9,592 11,301 9,478

12) Couple Years of Protection (CYP) in

FP/RH USG-supported program at project- 39,821 - - 8,168 8,168 10,576 17,689 supported facilities

13) Number of children under 5 years of age

Nutrition who received Vitamin A from USG- 324,606 470,000 69% 86,927 47,190 128,528 61,961 supported programs

USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 13

Total APR Quarterly Achievements APR Achievements Targets Service Key Indicators Area Oct 2014 – Oct – Dec Jan – Apr – Jul to Oct – Sep Performance September 2014 Mar 2015 Jun 2015 Sep 2015 2015 (%) 2015

14) Number of males circumcised as part

VMMC of the minimum package of MC for HIV 10,283 5,897 174% 16 1,172 2,494 6,601 prevention services

15) Number of the targeted population reached with individual and/or small group

Prevention level preventive interventions that are based 56,699 56,016 101% 10,499 5,871 12,321 28,008 on evidence and/or meet the minimum standards required

16) Number of MARP reached with individual and/or small group level

Prevention interventions that are based on evidence 21,723 6,815 319% 2,292 4,852 4,902 9,677 and/or meet the minimum standards required

17) Number of OVC served by OVC OVC 43,309 30,000 144% programs 38,171 37,367 37,277 43,309

18) Number of eligible adults and children

ES provided with Economic Strengthening 37,031 30,951 120% 16,054 22,795 27,785 37,031 services 19) Number of households adopting Food products preservation and storage 5,304 5,007 106% Security 988 988 3,328 7,386 technologies 20) Number of people in target areas with WASH 49,495 55,550 89% access to improved drinking water supply 5,404 5,975 7,594 30,522

21) Number of people in target areas with

WASH access to improved sanitation facilities as a 30,115 36,120 83% 2,697 2,888 4,730 19,800 result of USG assistance

Constraints and Opportunities

The most significant constraint faced by the project during the reporting period remains the on and off insecurity experienced in Wajir, Mandera, Garissa and parts of Turkana, Isiolo and Samburu. The other major constraint was the test kit shortages which affected the identification of HIV positive clients especially in Turkana. However, despite these challenges, the project has been able to make great strides towards achievement of the annual targets. This is a testament of the hard work and determination of the entire APHIAplus IMARISHA team. Our collaboration with the County governments and other partners on the ground has been fruitful and will continue to be an area of focus for the project. We will continue with these collaborative actions and will leverage our efforts in a bid to ensure improved health outcomes for the NAL communities. We will also continue to focus our implementation in the safer areas of the affected counties until the security situation improves.

Subsequent Quarter’s Work Plan

Project implementation is planned to proceed in line with the approved work plan for year 4. With the current tense and fluid security situation in the Garissa, Wajir and Mandera counties, the project continues to observe the situation closely and limiting project activities where necessary. We are working closely with our local staff in the region to ensure that project implementation continues as much as possible while ensuring USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 14 security of our staff and assets. The project will continue to keep USAID updated on the security situation in these counties. The next quarter will also be focused on developing the work plan for the 5th year of the project.

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II. KEY ACHIEVEMENTS (QUALITATIVE IMPACT)

Result 3: Increased Use of Quality Health Services, Products and Information IR 3.1: Increased Availability of an Integrated Package of Quality High-Impact Interventions at Community and Facility Level Expected Outcome 3.1.1 Improved capacity of public sector facilities to provide reliable and consistent high quality package of high impact interventions at community, dispensary, Health Center, and district health facility levels. Expected Outcome 3.1.2 Increased capacity of District Health Management Teams to plan and manage service delivery, including effective linkages with health activities to support drought response. Expected Outcome 3.1.3: Increased number of functional community units to promote preventive health behavior, identify, refer/manage complication Expected Outcome 3.1.4 Increased availability of essential newborn care and resuscitation, nutrition, safe and clean water at point of use, and prevention and management of childhood illnesses. Expected Outcome 3.1.5 Expanded coverage of high impact interventions for women and men of reproductive age, youth, vulnerable groups, most at risk populations, mothers, newborns and children. During quarter 4, APHIAplus IMARISHA continued to provide support to 104 supported facilities across the NAL region implementing the service delivery strategy that emphasizes sustainability of integrated technical assistance and mentorship within the county health systems and activities, and that prioritizes high burden, high volume facilities focusing on HIV/AIDS including TB management, MNCH, and Nutrition. The project worked collaboratively with County and sub county HMTs as well as healthcare workers to improve quality of services at facility and community level. During the period under review, HTC coverage was 51,111 against a target of 37,471 representing 136% achievement. This was an improvement of quarter 3 performance of 29,054 (73% of the target). The project supplemented county HTC capacity by deploying short term certified lay counsellors. A total of 460 patients were newly initiated on ART while 530 more were gained from 3 sites previously supported by other partners in Turkana and Marsabit Counties. This increased the number of current on ART from 7,350 as reported at the end of June to 8, 235 by APR. A total of 1,027 viral load samples were networked in the quarter bringing the total number of samples networked in COP15 to 4, 126. This saw the VL access for eligible clients (number of ART patients receiving at least 1 viral load test) close at 61% as at APR. The project continued to focus on eMTCT and 13, 544 pregnant women received HIV testing during the reporting period, 147 (1.1%) tested HIV positive and of these, 147 (100%) received ARV prophylaxis. In line with reducing the burden of HIV in TB infected patients, 870 (94%) of all TB cases were counselled and tested for HIV an improvement from the last quarter‘s 89%. 149 (17%) identified HIV positive of whom 139/149 (93%) received HAART and CPT.

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HIV Testing and Counselling (HTC) The project continued to support HTC activities across the 8 counties in order to contribute towards ensuring that 90% of all people living with HIV know their HIV status. Efforts towards ensuring focused PITC, effective referral and linkage in the facilities were sustained in the period under review. The referral and linkage system initiated in the last quarter is at various stages of development in the eight counties. However, in the main testing sites, the project supported HTC counsellors who also formed part of the referral system for HIV positive clients to ensure 100% enrolment. Other strategies employed to increase uptake of the service included targeted HTC during integrated outreaches to specific groups e.g. during cultural festivals such as the Tobong’u Lore in Turkana county and passing out of age sets in Samburu County; OVC testing, Key populations testing and family based testing where clients were encouraged to bring family members for testing in the facility and home based testing especially for children was carried out where this was not possible. There was also further sensitization to other non-testing facilities (in maintenance counties) towards referral of symptomatic patients for testing in order to reduce missed opportunities. Table 2: HIV Testing and Counselling Performance by County Jul to Sept 2015 County Target Achievement Number % Garissa 4,978 5,126 103 Isiolo 1,752 3,838 219 Mandera 1,068 3,627 340 Marsabit 1,103 3,178 288 Samburu 3,076 7,427 241 Tana River 1,692 8,155 482 Turkana 21,800 15,114 69 Wajir 2,002 4,646 232 Total 37,471 51,111 136

Challenges experienced during the reporting period included sporadic shortage of test kits (Turkana County), insufficient supply (Garissa) and targeted supply in some maintenance counties (for only PMTCT) and testing sites limited to county referral and sub-county referral hospitals. The program is still working with the county teams to ensure successful implementation of the HTC referral and linkage system. Based on the Figure 1 below, quarter 4 recorded an increase in the number of children tested in all but two counties (Wajir and Tana River). Samburu recorded the highest number of children < 15 years tested followed by Turkana. This is attributed to the government led and driven strategy of ensuring routine paediatric HTC that was embraced in Samburu County and initial implementation of the ACT strategy in Turkana. From lessons learnt in Turkana and Samburu, the project will work with the rest of the counties to ensure routine paediatric and adolescent testing at policy level. Additionally more children were tested in Quarter 4 (4,234) as compared in quarter 3 (3,868) denoting an increase of 9%. Comparison of the performance in the two quarters per County is shown in Figure 1 below.

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Figure 1: Testing Disaggregated by Age Groups Per County.

Figure 2: Number of Children tested: Comparison between quarter 3 and quarter 4 across NAL

HTC Yield The project recorded a positivity rate of 1.3% across the 8 supported counties. Isiolo County recorded the highest positivity rate (4.4%) with Mandera recording the lowest (0.2%) as shown in Figure 3 below. Turkana recorded 1.1% positivity rate mainly occasioned by 2 months test kit unavailability hence may not be representative of the HIV burden. Supply of test kits normalized in third month of the quarter.

Figure 3 Comparison of Positivity Rates across 8 Counties The project was able to meet the set target for HIV positives identified in 7 out of the 8 counties except for Turkana County that achieved only 163(59%) of the set target of 277. Overall, APHIAplus IMARISHA was

USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 18 able to identify 665 PLHIV across 8 counties against the set target of 494, realizing 135% achievement. See the Figure 4 below:

Figure 4: Number of PLHIV Identified Across 8 Counties Supported By APHIAplus IMARISHA in the Period July to September 2015

Cascade of HTC to Care linkage in supported facilities (Continuum of care cascade) Linkage to care for those identified positive marks the entry point to the second UNAIDS target of 90% of all people diagnosed with HIV receive sustained ART. In the period under review, 665 PLHIV were identified across the 8 counties in the supported sites of whom 536 (81%) were enrolled into care. Of those enrolled 100% were staged according to WHO classification and 95% accessed a baseline CD4 test, an increase of 22% from the previous quarter. The CD4 testing gap was identified in Marsabit County due to posting of new staff to the CCC. However, this knowledge gap has been bridged through ongoing mentorship. PIMA machines were deployed to Marsabit and Garissa Counties, Turkana East and South Sub- Counties as a stop gap measure occasioned by CD4 machine breakdown and for Turkana County to supplement CD4 machine at Katilu Sub- County referral hospital. In Wajir County, one Laboratory personnel has capacity to run CD4 tests. The project plans to have OJT sessions with the other laboratory staff to equip them with skills so that there is no down time when the trained staff is way. In Turkana, Wajir and Mandera counties, the project enrolled more clients into care and treatment than those tested in the supported facilities occasioned by referrals from other non-ART testing sites. Summary of performance by county is shown in Figure 5 below. All enrolled PLHIV were initiated on CPT.

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Figure 5: HTC to Care Linkage Cascade in Transitioned Facilities in APHIAplus IMARISHA Counties Care and Treatment The project continues to provide mentorship to the HCWs to ensure that >90% of the PLHIV in the program receive sustained ART in line with the global 90-90-90 goal. In collaboration with the CHMTs across the 8 counties APHIAplus IMARISHA provided HCW mentorship, OJT, CMEs and in some counties didactic training in collaboration with NASCOP and FUNZO Kenya. Furthermore, there was distribution of job aids and tools to ensure proper and efficient service delivery in line with the national guidelines. This has seen more clients eligible for ART mopped up and initiated on lifesaving antiretroviral drugs. The project also invested in ensuring that counties were supported in patient monitoring, commodity availability as well as quality assurance using the SIMS tool. During the period under review, the project enrolled 536 new PLHIV in the supported counties. This represents 83% (536/649) achievement against target. Garissa (84%), Isiolo (69%) and Turkana (56%) counties recorded the lowest achievements. Turkana County had challenges with identification of PLHIV due to test kit supply interruptions for most of the quarter; the county identified total of 182 PLHIV (163 in the supported facilities; 19 from outreach activities) against a target of 277. Garissa County also reported test kit supply interruptions. Isiolo County on the other hand was able to surpass the target by identifying 169 PLHIV against a target of 64 (264%) but enrolled 74 against a target of 107(69%). This means that 95 clients identified in Isiolo County were not enrolled in the supported facilities. These point to a weakness in the HTC to care and linkage system in the county which will be sorted out through further mentorship and CQI.

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Figure 6: Number of Clients Enrolled Into Care and Treatment across NAL between July and September 2015

CD4 Cascade The project supported the county teams to improve CD4 access to Pre-ART clients to ensure timely initiation of HAART. This was done through sample networking, utilizing the PIMA machines on a rotational basis ( Turkana, Samburu) and as a back-up in case of the main county CD4 machine downtime ( Garissa, Marsabit). During the period under review, there were 1,117 pre-ART patients (both existing ones and newly enrolled) eligible for CD4 testing. Generally, there was an improvement of CD4 access during this quarter (1,045/1,117; 94%) compared to the previous quarter where access was 73%, see Figure 7 below.

Figure 7: CD4 Access in Supported Facilities across 8 Counties Supported By APHIAplus IMARISHA (July - September 2015)

However, CD4 access in Samburu County was notably higher (375%) occasioned by the decision of HCWs to use CD4 testing to monitor ART patients due to prolonged VL TAT experienced during the quarter as a result of challenges in the national reference laboratory. This was addressed during TA and the situation will resolve in the coming quarter. Further, while there was 100% CD4 access in all but 2 counties (Marsabit and Wajir), there is a gap of access for the pre-ART clients already in care. Moreover, there are a number of clients eligible to be started on but are yet to make the transition, pointing to inefficiencies in the system. Only 460/617 clients with CD4<500 were initiated on HAART during the quarter. SIMS analysis also revealed sub-optimal Pre-ART patient monitoring as required by the rapid advice, see Table 3 below. Through TA the project is working with the HCWs in the supported facilities to develop patient line lists from where clients due for clinical monitoring tests are duly scheduled.

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Table 3: Summary of SIMS Progress in Pre-ART Patient Monitoring in Supported Facilities

April April May May June June July/ July/2015 July/ 2015 /2015 /2015 /2015 /2015 June/2015 /2015 /2015 2015

Components

SamburuCRH () Kisima St.Mary’s St.Monica’s MarsabitCRH MoyaleSCRH SololoMH

Pre-ART patient Monitoring (CD4 testing) Yellow Red DG Red Red DG DG

Patients on HAART During the period under review, the project was able to scale up the number of PLHIV on HAART. The project recorded a total of 8,235 patients currently on ART compared to 7,245 recorded at SAPR. There was a net increase of 990 clients and 85% achievement against target. There were 460 newly initiated clients and 530 gained from other new sites in Turkana (Kainuk and Kalemungorok) and Marsabit (Tumaini Medical clinic) Counties after site reassignment. In order to continue improving this performance, the project has strengthened PITC, linkage and retention in care and, through laboratory support, improving CD4 networking for clients on care so that those eligible are started on treatment. There will be sustained mentorship to ensure that HCWs implement the Rapid Advise so that all eligible clients already in care are initiated on HAART. In addition to this the chronic care system is being strengthened through appointment systems in the facilities and clear defaulter management protocols which the project has established. However, two counties registered a net reduction in number of patients on HAART. Garissa registered a loss of 115 patients due to hand over of two sites (Modogashe and police line dispensary) to another implementing partner in addition to a data cleaning exercise in the previous quarter to establish the correct number of patients. In Wajir County, the reduction of 37 patients was as a result of insecurity experience earlier in the year whose consequence was patients defaulting and others transferring out to other counties.

Figure 8: A Comparison of Number of Patients Currently On HAART between March (SAPR) & September 2015 (APR)

Generally, most counties were able to meet their HAART initiation targets with the exception of Turkana, Tana River and Isiolo. In Turkana County, there were challenges in identification of PLHIV due to test kit unavailability and this caused underperformance in the whole treatment cascade. However, there were efforts made towards mop up of the already existing pre-ART patient. During TA, the project team worked with the

USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 22 facility staff to develop line lists from where clients were duly scheduled, contacted and CD4 tests done using the PIMA machine when on site or networked to the main county and sub-county referral hospital machines. In Isiolo County, there were issues with linkage of identified PLHIV (74/169 linked) into care although 100% of those newly enrolled were staged, were able to access baseline CD4 tests and those eligible started on HAART. The project has noted this and will continue to work with the county team to strengthen the HTC into care linkage system. Tana River County had challenges of transitioning pre-ART patients to HAART. The project will continue to provide targeted TA to ensure that the HCWs provide timely clinical monitoring and ART initiation.

Figure 9: A Comparison of the Achievement versus Target of Number of Clients Newly Initiated On HAART

Adults on HAART

Figure 10: Adult Treatment Access in Supported Facilities across NAL Counties between July and September 2015

Generally, the adult treatment access was at 81% (compared to 83%) in the previous quarter. This means that although the project has registered a net increase in the patients on HAART, the rate of enrolment of patients into care was higher than the rate of transition of pre- ART patients to ART. This was observed in Tana River, Isiolo and Samburu Counties. Wajir County registered a drop due to loss of patients as a result of insecurity. In Turkana County, the proportion of adults on HAART compared to those on care remained unchanged although there was a net increase in both.

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Pediatric HAART

During the period under review, there was sustained investment in all counties to ensure increase in paediatric uptake. There was investment towards increased identification through OVC testing during station days, family based testing, PITC in the wards and in outpatient clinics including the nutrition clinic. Samburu County recorded significant gains owing to the county government driven policy that saw adoption of mandatory HTC for children. This was initiated in the previous quarter and this quarter Samburu county has recorded 174 paediatrics on care (up from 138) and 171 children on ART (up from 113). In Turkana County, the project officially launched the ACT strategy with the objectives and work plans being shared with the county health leadership. In addition to the launch, there was increased community mobilization for paediatric testing through the mass media. The care and treatment team conducted a series of radio talk shows in the local radio station, Radio Jambo. Through the talk shows, the public were educated on HIV in general, how HIV affects children, the importance of HTC in pregnancy, importance of early enrolment and retention of HIV positive children in care and subsequent initiation on HAART. The aim of the talk shows was to create demand for services by the public. Additionally, the project also mainstreamed paediatric HIV messages during the Turkana Cultural festival (Tobong’u Lore). The 10 finalists of the Turkana Festival Beauty pageant were also trained as ACT ambassadors and will play a pivotal role in community education and mobilization during the community dialogue days. All HCWs in the supported facilities were also informed of the ACT strategy and paediatric scale up activities have already begun. The project has also identified key support staff (more HTC lay counsellors, mentor mothers, peer educators and expert patients) who will be engaged and deployed by the project to support ACT strategy implementation. In addition, through project support 4 staff (in addition to two supported by NASCOP) from the county participated in the national TOT ACTS tool kit training rolled out by NASCOP. The purpose of the tool kit was to standardize the training approach in support of paediatric ART scale up across the country. These TOTs will be pivotal to the tool kit roll out in the county. In the subsequent quarter, the project will conduct further sensitization at the sub-county level and focus on capacity building using the tool kit as well as activation of work improvement teams (WITs) to conduct improvement projects in support of paediatric care and treatment, In general, the proportion of paediatrics on HAART compared to those on care also remained unchanged compared to the last quarter. However, Turkana (75% in quarter 3; 89% at APR), Samburu (82% in quarter 3; 98% at APR) and Garissa (86% in quarter 3; 94% at APR) showed marked increase in the proportion of children on ART. In Mandera, there was an increase in the number of children enrolled all of whom were initiated on ART according to the national guidelines. Wajir County registered a drop of 1 paediatric on ART but a general increase in paediatric enrolment; Marsabit and Isiolo Counties scaled up enrolment but with marginal HAART initiation. These point to staff capacity issues within the health facilities which will be sorted out during targeted TA and mentorship.

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A critical link in ensuring optimal treatment outcomes in paediatrics is care giver support. Having empowered caregivers will reduce the barrier to access and retention in care and treatment for all identified HIV positive children in the counties. The project currently supports care giver support groups with various economic strengthening activities. This will be the avenue the project will continue to use to emphasize biomedical issues with respect to care and treatment to ensure early case identification (through improved family based testing), initiation of HAART, optimal patient monitoring, disclosure and adherence to treatment. SIMS During the current and previous quarters, the project team in conjunction with the USAID team conducted SIMS assessment in Turkana, Samburu, Isiolo and Marsabit. This revealed some system gaps in paediatric care and treatment (see Table 4 below). The critical ones were poor paediatric treatment monitoring and absence of a system that ensures routine HIV testing for all paediatrics in the facilities. The corollary is missed opportunities in identifying HIV infected children and initiating treatment and switching regimens for those eligible. In response to this, the project has put in place measures to ensure increased paediatric testing at CWC, inpatient and nutrition clinic. Table 4: APHIAplus IMARISHA SIMS Assessment Summary (Quarter 4)

April April May May June June /2015 /2015 /2015 /2015 /2015 /2015 24/06/2015

Maralal St. St. Marsabit Components CRH Kisima Marys Monica CRH SCRH Sololo MH

Routine HIV Light Light Light testing for Green Green Green children Red Red Red Red

Paediatric Dark Light monitoring Green Red Red Yellow Green Red Yellow

HIV Treatment Monitoring The third goal of the global 90-90-90 strategy is to ensure that 90% of all PLHIV receiving ART are virally suppressed. During this reporting period, APHIAplus IMARISHA sustained investments in measures to improve HIV treatment monitoring by improving access to VL testing through sample networking across the 8 counties. By the end of September 2015, a total of 4,216 VLs had been networked to the national reference laboratory, making the crude VL access for patients in the program 51% (See Figure 11 below). According to the national guidelines, patients are eligible for VL testing after six months of treatment. In compliance, the project networked samples from patients meeting this criteria. Therefore when the number of patients on HAART excludes those starting ART between April and September the VL access is 61% as indicated in Figure 11 below. Of the 4,216 samples networked, 3,654 (87%) results were received. This is due to the backlog occasioned by lack of reagents in the national reference laboratory in August and September 2015, but this has since been resolved. The project invested in sample networking, dissemination of the rapid advice through facility based CMEs, job aids and mentorship of HCWs on collection of DBS for viral load. In order to reduce TAT, Turkana County was linked to the AMPATH national reference laboratory in and this has seen reduction in TAT and 100% of the results received and documented in the patient‘s files. In the coming year the project will sustain these investments to ensure improved VL access. The viral suppression rates for the clients receiving results were 73% (2,678 / 3,654). Isiolo county and Garissa county recorded the highest VL suppression rates at 85% and 81% respectively while Turkana showed the lowest suppression rates at 64%. This is attributed to the high defaulter rates and the project has

USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 25 addressed this by standardizing the treatment preparation sessions, defaulter tracing, closer follow up of defaulters and enlisting patients in PSSGs.

Figure 11: Crude % Viral Load Access as Of the End of September 2015

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Figure 12: Crude VL Access for Eligible ART Patients as of the End of September 2015

Figure 13: 1st Viral Load Suppression Rates between October 2014 and September 2015 Patients with the first VL> 1000 are closely monitored through shorter appointment dates when they are given continuous adherence counseling and treatment support. The re-suppression rate in this group is 91% (528/ 580) as shown in Figure 14 below. Clients with persistent VL >1000, are switched to second line regimens.

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Figure 14: VL Suppression Rates for Patients Accessing 2nd VLs between October 2014 and September 2015

In order to ensure >90% viral suppression, the project has invested in a defaulter tracking mechanism to ensure client retention into care and treatment and subsequent adherence monitoring. Additionally, the project also invested in strengthening the treatment preparation sessions (TPS) which focus on patient literacy to ensure self-efficacy and better treatment outcomes. This was done through mentorship of HCWs, expert patients on TPS to enable them to support the clients and patient support groups. These will be sustained but the project will also ensure that biomedical issues are addressed in the sessions and documented. Furthermore, through the BCC component and in collaboration with MOH, 30 HCW in Isiolo region (Marsabit 10; Isiolo 10; Samburu 10) were trained on stigma reduction strategies as a way of curbing stigma in the health system as well as the community. The project will also increase community engagement through BCC for stigma reduction messaging in addition to training more HCW in other counties particularly in Turkana. Client retention Defaulter management The figure 15 below shows a summary of the defaulter tracking activities during the quarter. The project sustained investment in the defaulter tracking system through provision of airtime for reminder phone calls, provision of appointment diaries, deployment and facilitation of expert clients and provision of support for patient psychosocial support groups. During the quarter, 1,160 defaulters were identified and through phone calls and home visits 689 were traced. Efforts to link them back to the health facilities included tracing through phone calls, home visits and inquiry through the psychosocial support groups. This resulted in 404 being linked back to the facilities while 35 were confirmed as transfer outs and 18 were confirmed dead. There are 210 clients yet to be traced in order to establish their status and the project will sustain efforts to do so. As part of the clinic re-engagement strategy, the clients linked back to the facility were taken through adherence counselling sessions and given shorter clinic appointments (as feasible) in order to ensure that their barriers to adherence are addressed. Some issues cited by the defaulters include lack of food, alcoholism among others. In order to deal with the issues of client retention and defaulter management, a strong facility community linkage system is required. The project has invested in establishing the system through mentorship of HCWs, provision of tools, job aids and development of county specific referral directories.

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Figure 15: Defaulter Tracking Activity Yields across the 8 Counties Supported by APHIAplus IMARISHA for the Period between July and September 2015

TB / HIV Co-management HTC, Immediate HAART and CPT

Figure 16: TB Cascade across 8 Counties Supported by APHIAplus IMARISHA for the Period between July and September 2015

In the quarter under review, a total of 926 TB cases were detected across the 8 counties. 870 (94%) were tested for HIV with 149 (17%) testing HIV positive. There were some missed opportunities for testing which can be attributed to staff capacity gaps and documentation. During the quarter, test kit supply to the TB clinics was consistent in most counties due to testing prioritization negotiated with the county teams. TB clinics were prioritized in test kit supply in the facilities. However, in Turkana County, there was a generalized test kit shortage and this contributed to the lower testing rate (88%). 139/149 (93%) of the TB/HIV were started on HAART. 10 patients (2 in Turkana, 2 in Marsabit, 2 in Isiolo and 4 in Samburu) were still undergoing treatment preparation. 100% (139/139) were initiated on cotrimoxazole. Intensified case finding The project invested in mentorship to HCWs to ensure that all HIV positive clients enrolled in CCC are screened for TB using the standard national ICF tool. During this quarter, chart abstractions of sampled patient files in supported facilities across the 8 counties revealed the TB screening rate had increased from 80% in previous quarter to 87%%. ICF tool utilization rate also improved from 81% to 88% in the period under review. The project will sustain targeted mentorship to improve TB screening to 100% and ensure that TB/HIV patients get early treatment for improved outcomes. The table below summarizes TB screening rate by county.

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Table 5: Summary Of TB ICF in the Selected Facilities across NAL for the Period July to September 2015

County Total Files Total files with Total Files with ICF No. of Patients ICF utilization TB screening examined ICF tool Tool duly filled screened for TB rate (%) rate (%)

Turkana 562 562 464 464 83 83

Marsabit 187 187 172 172 92 92

Isiolo 20 19 19 19 100 95

Samburu 20 20 20 20 100 100

Garissa 120 102 88 88 86 73

Tana River 50 45 42 42 93 84

Mandera 193 193 190 190 98 98

Wajir 28 28 28 28 100 100

Grand total 1180 1156 1023 1023 88 87

Infection Prevention and Control (IPC) During the quarter, the project supported a number of activities towards improved IPC in the supported facilities. These include distribution of posters with cough etiquette messages (they also act as teaching guides during health talks), orientation of HCWs on TB IPC plans and their importance (done in collaboration with sub-CHMTs in Samburu County) and ensuring fast tracking of coughers in the clinics. Further there was establishment of IPC committees in 6 out 8 supported facilities in Tana River bringing the number of facilities with IPC plans to 7 up from only 1 past in the quarter. With the sensitization of staff in Samburu County, this number is expected to increase in the following quarter. In general N95 masks were available and in use. Isoniazid Preventive Therapy (IPT) In general, IPT uptake across all 8 counties was still low by the end of quarter 4. However, the project supported some activities in support of scale up. A total of 45 HCWs (20 Wajir; 25 Marsabit) were oriented on IPT. The requisite data capture tools and commodities are available in the counties although Samburu County reported stock out of Isoniazid. The project will continue with sensitization, capacity building and mentorship support to ensure optimal uptake of IPT Integration of services The project continues to advocate for integration of TB/HIV services as means to ensure more efficient service delivery and better treatment outcomes for the TB/HIV co-infected clients. In Garissa, Mandera, Wajir and Marsabit, the TB clinic and CCC are not integrated and clients access services by referral. Nonetheless, Moyale sub-county referral hospital began the process of integrating TB and HIV care. In Samburu county 4 out of 7 facilities have integrated services while Tana River has 6 out of 8 of its facilities provide integrated TB/HIV care. Isiolo County has all of the supported facilities providing integrated services.

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Continuous Quality Improvement APHIAplus IMARISHA supported facilities to adopt continuous quality improvement in order to improve quality of services. The project has supported establishment of WITs in high volume facilities across the 8 counties. These teams have taken up various CQI activities in order to improve service delivery. Table 6 below is a summary of some of the CQI activities conducted during the quarter. Table 6: Summary of CQI Projects Conducted In Facilities in Four Counties Supported by APHIAplus IMARISHA (Period: July – September 2015)

Facility CQI project Indicators Achievement Status of CQI Comments project(complete (Actual vs. / on-going) Target)

TURKANA COUNTY

St Patricks‘ Scale up TB % of files with TB 80 %; Target is Ongoing Chart abstractions will Dispensary screening of ICF cards with 100% continue on a monthly CCC clients at screening basis until TB screening St. Patricks‘ documented is improved CCC

Transition CCC Number of files 100% complete There is continued of Clients files transitioned to manual patient files from manuals EMR. updating while the EMR to EMR system is updated daily

St. Monica‘s Improve HTC % of clients linkage Target: 100% On-going HTC to care linkage dispensary to care linkages to care at the register was introduced at St Monica facility Achievement: to the facility and as a 100% result all the 14 HIV +ve clients identified have documented linkages

MARSABIT COUNTY

Sololo Improve Established Target: 4 On going The Patient support Mission Facility – community based support groups group forum will Hospital Community patient support formed provide opportunity to linkage groups fight stigma , improve Achievement: 6 client retention, groups formed; treatment adherence 3formal and enhance family meeting have testing been done so far. 21 client having successfully linked

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Facility CQI project Indicators Achievement Status of CQI Comments project(complete (Actual vs. / on-going) Target)

Marsabit Increase VL Proportion of Target: 100% Out of 165 clients Pending clients have CRH access clients accessing access 100 clients were been contacted and tests VL testing below 1000copies scheduled Achievement: while 65 had above 100copies 165 (93.7%) of ART clients eligible have accessed VL test for monitoring

ISIOLO COUNTY

Isiolo County Initiate TB IPC Number of TB Target: 16 Each facility draft Draft of IPC plan plan treatment sites facilities will be shared with shared with ICRH CCC health facilities with facility in charges staff and in place. IPC plan in place Achievement: during routine Initial TAs. The remaining discussions facilities will be reached held with from this quarter. County TB coordinator

Isiolo County Improve Proportion of Target: 100% Ongoing for We have achieved 100% referral nutrition patients file with routine nutritional assessment hospital monitoring documented Achievement: documentation which was enhanced nutrition 100% of all during SIMs assessment and clients files preparation. action taken have the Nutrition Activity is ongoing. screening tool in place

SAMBURU COUNTY

Archers Post Improve No of HEI with Target: 100% Ongoing DBS for all HEI taken Health Centre management of documented DBS and networked to HEI results according to Achievement: KEMRI. Results schedule DBS for the awaited. remaining (45%) HEI taken and networked to KEMRI

Catholic Integration of Integrated all HIV Complete 100% Services integrated and Hospital PMTCT into and MNCH provided at one stop

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Facility CQI project Indicators Achievement Status of CQI Comments project(complete (Actual vs. / on-going) Target)

Wamba MCH at services at a one Catholic stop in the MCH Hospital Wamba

WAJIR COUNTY

Wajir CRH Number of % of HIV Positive 100 %; Target complete Improve facility and HIV positive clients from the is 100% community linkages of clients referred entry points linked client to the CCC to care onsite and from all testing number sites points reporting

Scale up VL Proportion of Target: 100% Ongoing N/A testing for ART eligible clients clients accessing VL Achievement: 61% VL access

MANDERA COUNTY

Mandera Scale up VL Proportion of Target: 100% Ongoing N/A District testing for ART eligible clients Hospital clients accessing VL Achievement: 57% VL access

Takaba DH Scale up of Number of persons Target: 100% Ongoing Two lay counsellors HCT services at counseled and testing of all recruited and mentored the facility tested at the facility clients visiting by the project is based static and outreach the facility. at the facility sections Achievement: 90%

TANA RIVER COUNTY

Hola CRH Target: 100% No of HEI with Improve Achievement: Facility targets to collect documented DBS management of 80% of HEI Ongoing all the DBS samples by results according to HEI identified have end of October 2015 schedule documented DBS result

Strengthen Target: 100% Number of HIV Integration of Continue keeping good positive women on Achievement:80 Ongoing RH/FP documentation contraception % of the HIV Services in pregnant PMTCT and women

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Facility CQI project Indicators Achievement Status of CQI Comments project(complete (Actual vs. / on-going) Target)

CCC enrolled on contraception

Health Supply Chain Management

CROSS CUTING

Commodity Reporting Rates The project invested in efforts to improve commodity reporting rates by supporting quarterly commodity management committee review meetings through county pharmacists ,distribution of reporting tools, monthly information sharing with sub county health management teams and continuous mentorship of health care workers. However, commodity reporting continues to be a challenge in the NAL region hence the project will sustain investments to improve the same. With a focus on FP commodity reporting in one of the counties, the attempts have yielded a slow but steady rise in the reporting rates as demonstrated by Samburu

Figure 17: Samburu Annual FP Commodity Reporting Rates The reporting rates for FP, IMAM and Malaria commodities during the quarter were as follows;

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Figure 18: Quarter 4 FP Commodity Reporting Rates

Figure 19: Quarter 4 IMAM Commodities Reporting Rates

Figure 20: Quarter 4 Malaria Commodities Reporting Rates

Capacity Building

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Figure 21:HCMP Practice/Demonstration Session Two sensitization trainings were undertaken during the reporting period; Web based ART Dispensing Tool (ADT) training and Health Commodities Management Platform(HCMP) reaching a total of 36 health care workers sought from all the eight(8) IMARISHA supported counties. The trainings were aimed at promoting efficient commodity management at the facility, sub county and county levels. The Web based ADT will promote closer patient monitoring (has the ability to link with the NASCOP website and access individual patient VL results when posted; prompts when clients default clinic appointments; has the ability to be interlinked between more than one dispensing point among other features). The HCMP is able to improve supply chain visibility from the county level to the facility level. The following charts summarize the critical milestones in implementation of Web based ADT and HCMP across NAL.

Figure 22:Web Based ADT Milestones

Figure 23:HCMP Milestones

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COUNTY SPECIFIC INTERVENTIONS

Turkana County Commodity Audits In the first and second quarter of 2015, baseline and follow-up commodity audits were completed in six high volume health facilities in the County in collaboration with the MOH. This activity also provided an opportunity for the Technical team to provide mentorship on appropriate use of the available inventory management tools at the facility level. The facilities in which this activity was completed include St. Patrick‘s, St. Catherine‘s, AIC Kalokol, St. Monica, RCEA and Katilu with the following findings

Figure 24:Treatment Access in Four Facilities in Turkana County

Owing to the continuous supply of ART commodities, >95% of all the eligible patients in these health facilities are initiated on the appropriate regimen in a timely manner. The exceptions of whom are as a result of intensified adherence preparation where needed. The commodity audit tool used also assessed the availability of key commodities across the different sub-program areas e.g. HIV/TB, MNCH etc. For each of the commodities assessed the bin cards characteristics of interest included; availability, completeness in filling, accuracy in filling of the bin cards balances against the actual physical stock at the time of audit and where there were variances we took note of what was over and under reported. The findings of the audits were shared with the health facilities on every occasion and the results of the baseline compared to the follow-ups conducted within 3 months.

Figure 25: Bin Card Availability in Three Facilities for the Period March to September 2015 Similar improvements were also seen in the filling of specific bin cards characteristics. In most of the bin cards; Name, strength, pack size and expiry dates are primarily filled up well. The transactions and filling of issue unit which was previously not done well has greatly improved.

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Figure 26: Bin Card Completeness in Three Facilities for the Period March to September 2015

Even though accuracy continues to improve, first moving commodities like ORS and ZNSO4 tablets still have variances. Additionally facilities have continued to rightly place bin cards conveniently next to commodities to prompt all health workers to update record. Due to the high workload, staffs were advised to do periodic forecasting (weekly /twice weekly) to reduce undocumented visits to the store.

Figure 27: Bin Card Accuracy in Three Facilities for the Period March to September 2015

Figure 28: Variance in Stock levels

Commodity DQA In the second quarter, a commodity DQA was conducted in collaboration with the MOH Lokori PHC, Lokichar RCEA and Katilu. In the audited health facilities, to ensure provision of pharmacy services, task shifting had been done with existing facility staffs even though none of the staff handling commodities in the audited facilities were trained on commodity management.

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Figure 29: Commodity DQA HRH Commodity Management Capacity Gaps Findings In these facilities, commodity specific support supervision had been conducted only once in Lokichar RCEA.

Figure 30: Commodity DQA Storage Condition Findings In all the audited facilities, there were designated medical stores with adequate shelving, space, pallets and lighting. However none had instituted storage room temperature monitoring systems and the standard commodity management tools were available as shown in the figure below. The critical transactional tools were missing and this was discussed with the county pharmacist and the facility management teams. The county will pick up provision of the same.

Figure 31: Commodity DQA Tools Availability and Use Findings

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County commodity management committee support During the second quarter the County Commodity Management Committee reactivation meeting was held to respond to the commodity management capacity related challenges identified during the commodity DQA conducted in Turkana South health facilities. In quarter 4, 2 meetings were held to discuss commodity matters in the county where the substantive agenda included discussion of quarter 3 procurements for essential medicines. Commodity fill rates per facility and facility commodity management practices were discussed. The acceptance committee verified that the receipts were in line with the orders previously placed to KEMSA. Under commodity management, it was unanimously agreed the commodity management practices at facilities could do better with action points being; immediate commodity audit for received essential supplies. Technical Assistance and Mentorship Building on the gaps identified from the SIMS exercise, the mentorship in health facilities focused on documentation, inventory management where job aids and guidelines were also distributed. The mentorship reached a total of 52 HCWs (23M 29F). The positive impact of previous TA visits was noted due to the good uptake and maintenance of inventory management tools in the CCC medicines cabinet, pharmacy and drug stores.

Figure 32 C.C.C Medicine Cabinet and Main Drug Store at Katilu Sub County Hospital Isiolo County TA and mentorship was provided to Isiolo DH, Garbatulla sub county hospital and Kinna health center which included; kaizen at Garbatulla CCC as shown below.

Figure 33: Kaizen at Garbatulla Sub-County Hospital CCC

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The staff at Kinna and Garbatulla facilities were taken through proper record keeping practices. Pharmacy job aids (good dispensing records, good inventory management practices, quantification guide, and good record keeping practices, medication use counseling check list, Pharmacovigilance tools, and Pharmacovigilance posters) were provided. Other mentorship activities undertaken included;  Chart reviews at Kinna and Garbatulla to ensure timely initiation on ART and timely and correct switch to second line for failing patients  Mentorship of MNCH staff on option B plus  Review of rapid advice with the 2 pharmacy staffs at the county referral hospital

Samburu County At Wamba mission hospital, staff were mentored on use of bin cards for monitoring of Samburu East sub county stocks and a DAR ARV/OI delivered. At Wamba health center, a meeting was held in collaboration with the Samburu East sub-county team to chart a way forward in relation to the low ART commodity reporting rates with the following agreed strategies for improvement;  Sub-County MOH and Sub-CASCO to reinforce the importance of reporting to all health care workers during supervision and facility in charges meetings  Sub-County pharmacist to share a list of non-commodity reporting facilities at the end of every month with the rest of the SCHMT  Networking with Samburu (Maralal) and IDH pharmacy for Kaletra syrup supply to avoid stock out due to KEMSA delivery delays ensured 100% initiation of reactive HEIs at Maralal DH.

Successes noted during the reporting period  Uninterrupted supply of ARV commodities in all supported facilities  Acquisition and redistribution of bin cards  Distribution of TB commodities daily activity registers, FCDRRs  Complete FMARPS data reconstruction at Kainuk sub county hospital  Acquisition and Distribution Job aids, SOPs, Bin cards, FCDRRs, Pharmacovigilance tools and guidelines for the different service areas and pasted on walls where necessary  County pharmacy staff meeting held in the month will serve as an avenue through which commodity reporting issues can be sorted

Laboratory Strengthening During this reporting period, APHIAplus IMARISHA worked with the CHMTs to strengthen laboratory services in the region. The project supported various aspects of the same including sample networking (CD4, Gene Xpert and viral load), OJT and mentorship of laboratory staff and other HCWs to improve the quality of samples collected for networking as well as to update staff on the recent changes in the HIV testing algorithm in line with communication from the Ministry on Health (discontinuation of KHB). Furthermore, the project supported the proficiency testing process in order to assure the quality of HIV tests conducted in the NAL region. The overarching goal is to realize the improvement of quality of care through laboratory monitoring. Specific activities conducted and their outcomes within the period under review include were as follows:

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Sample networking APHIAplus IMARISHA supported the county teams to network samples to respective processing laboratories within the county and at national level. This was done to support clinical monitoring of patients as well as diagnostics. The Figure 34 below summarizes the samples networked by type per county.

Figure 34: Summary of Samples Networked In the Period July to September 2015

CD4 testing Across NAL CD4 testing is done using both POCT (PIMA) and the higher capacity machines (FACS CD4 analyzers) based at the county and sub county referral hospitals. In Garissa county, the FACS CD$ analyzer in Garissa PGH developed challenges in the tail end of the quarter but CD4 testing was supplemented using the PIMA machine borrowed from Tana River County through facilitation from the project. In general, there is a declining trend on CD4 testing after dissemination of the rapid advice in August 2014 which advocates for VL as the monitoring test for patient on ARVs in addition to raising the CD4 cut off from 350 to 500cells/um. During the quarter, it was observed that Samburu County had increased its CD4 uptake. After discussions with the county team it was established that clinicians has become resorted to CD4 testing as a monitoring tool owing to the delays experienced in the TAT of VL results networked to KEMRI (there were challenges in the national reference laboratory). However, this was sorted out and in the coming quarter this should have been resolved. In Marsabit County, the PARTEC machine developed challenges but with support from the project, the facility was provided with a replacement from the vendor in 3 days as theirs was being repaired. There was minimal disruption of CD testing in the county. Additionally, the county has a PIMA machine in Sololo which supplements CD4 testing efforts in the upper part of the county further reducing TAT and increasing access for the pre-ART clients. Generally, CD4 reagents were available and there were minimal interruptions in CD4 testing Viral Load testing Quarter 4 saw an increase in the number of samples networked compared to the last quarter. The project supports networking of samples from 7 counties to KEMRI in Nairobi. In the same period, there was backlog of samples in the KEMRI national reference laboratory in Nairobi in August and September 2015 occasioned by lack of reagents, but this has since been sorted out. The corollary was that there were pending results by the close of the quarter: Samburu 86, Tana River 75, Isiolo 83, Garissa 68 and Wajir 20. During the

USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 42 quarter the connection of Turkana County to the AMPATH laboratory in Eldoret was completed. This saw a reduction of TAT for Turkana samples and a 100% reception of results. In order to ensure that samples collected are of good quality, the project laboratory team provides OJT and mentorship to HCWs to improve collection, storage and documentation of the same. This has seen a reduction in sample rejection rate with minimal rejection rates reported in Garissa (1.3%), Isiolo (5%), Samburu (2.3%), Tana River (2%) and Marsabit (1.5%). These will be further reduced through sustained TA and mentorship. Early infant diagnosis The following activities were conducted per county Garissa DBS samples for EID were networked to KEMRI HIV-R lab in Nairobi. Total of 14 PCR samples were collected during the quarter and one (1) sample tested Positive. The PCR Positive infant was successfully followed up and enrolled into care as summarized in Figure 35 below. From the entry points, 64% of the infants were referred from the CCC while 34% from the MNCH.

Figure 35: Annual Trends in DBS Collection from 2012 To 2015

Isiolo DBS sample for EID were networked to KEMRI HIV-R lab in Nairobi for PCR testing. Total of 18 samples were networked during the Quarter, two infant tested PCR Positive and were successfully followed up and enrolled into care. The average age of testing was 7wks to 3months. Analysis by entry points shows that 89% of the infants were referred from the MCH while 11% from the PSC/CCC as shown in Figure 36 below.

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Figure 36: Isiolo County EID by Entry Point for the Period July to September 2015

Marsabit During the quarter 4, five (5) PCR samples were networked for EID testing, none tested positive. The mean age at testing was 7 weeks to 3 months. During the year, 39 DBS were tested and two (2) were PCR positive. The infants were successfully followed up and enrolled into care. HEI testing was integrated in the other clinics with more infants were seen at MCH 76% and CCC 21% while maternity 3%. Samburu Total of 21 PCR test were networked during the quarter. One sample tested Positive. The positive HEI was followed up and status identified as mother moved out of the County. From the previous quarter, 3 positive HEI were successfully followed up enrolled into care. MCH was the entry point for most infant 76% followed by Maternity at 19%. Below is the EID summary for the quarter 4, July-Sep 2015, test by Age,

Figure 37: DBD Collection by Age, Positivity & Enrolment into Care for Samburu County, Jul- Sep 2015

Tana River 25 PCR samples were networked for EID testing and one tested positive. The positive HEI was successfully followed up and enrolled into care. Average testing age was 7wks-3months and the positive HEI for the USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 44 quarter was 14 month. HEI testing was integrated in the other clinics with more infants referred form MCH 64%, CCC 5% and no data 30%. Turkana Figure 38 summarizes the Turkana county EID cascade. A total of 16 HIV positive infants were identified during the year.

Figure 38: Turkana County EID Cascade between October 2014 and September 2015

Wajir and Mandera A total of 3 EID DBS were networked to KEMRI during the quarter under review and none of the children tested positive. In Mandera County, one sample was networked and the child was also HIV negative. Gene Xpert testing By the end of September 2015, there were 10 Gene Xpert analyzers in the NAL region spread across all counties; two (2) are yet to be installed in the course of October 2015 for Garbatulla SCH and Laisamis MH. APHIAplus IMARISHA through the sample networking platform is currently supporting the TB Gene Xpert sample to be networked to the Gene Xpert sites. Below is the summary of Gene Xpert analyzer sites per County. Table 7: Summary of Gene Xpert Status and Placement across NAL as of September 2015

County Facility Status

Isiolo Isiolo Tb Manyatta clinic Functional

Garbatulla SCH to be installed

Marsabit Moyale CRH Functional

Marsabit SCH Functional

Laisamis MH to be installed

Samburu Maralal CRH Functional

Turkana CRH Functional

Tana River Hola CRH Functional

Garissa Garissa CRH Functional

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Wajir Wajir CRH Functional

Mandera Mandera CRH Functional

The supported facilities are networked as follows: Isiolo-18HFs, Marsabit 21HFs, Samburu 16HFs, Turkana 24HFs, Tana River 17HFs, Garissa 14HFs and Wajir 6HFs. During the period under review a total of 762 samples were networked with the various machines for testing. Table 8 below summarizes the results per county. There were 3 Rif positive cases in Garissa county all of whose samples were forwarded to the culture reference laboratory. Table 8: Summary of Gene Xpert Results across 8 Counties MTB MTB Invalid County positive Negative Rif Resistant Errors results Turkana 1 6 0 2 0 Marsabit 35 183 0 0 0 Isiolo 25 81 0 3 7 Samburu 42 139 0 7 8 Garissa 33 101 3 9 6 Tana River 0 0 0 0 0 Mandera 3 37 0 Wajir 10 21 0 0 0

Grand total 149 568 3 21 21

Online reporting During the period under review, APHIAplus IMARISHA supported efforts to ensure complete, timely and accurate reporting of RTKs. The project invested in airtime for modems in addition to mentorship, OJT and facilitation for the CMLTs to follow up on reporting. In Turkana County, APHIAplus IMARISHA supported the Turkana County laboratory technical working group to carry out its mandate which saw the team conduct month to month forecasting and quantification of test kits. However, Turkana County experienced sporadic test kit stock outs in many facilities and redistribution was done through the technical working group. In Marsabit County, there was a decline in reporting rates owing to the deployment of new staff in some facilities. These were taken through OJT and mentorship and the reporting rates are expected to improve in the next quarter. By the end of September 2015, counties recorded over 90% reporting rate with the exception of Tana River and Marsabit. The following is the summary of performance per county:

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Figure 39: Online Reporting Rate Trends for Garissa County

Figure 40: Online Reporting Rate Trend for Isiolo County

Figure 41: Marsabit County RTK Online Reporting Rate Trends by Quarter for the Period October 2014 to September 2015

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Figure 42: Trends in Online RTK Reporting Rates for Samburu County: Comparison between 2014 And 2015

Figure 43: Trends of Tana River County Online Reporting Rates for the Period October 2014 to September 2015

Figure 44: Trends of Turkana County Online Reporting Rates for the Period October 2014 to September 2015

Quality assurance APHIAplus IMARISHA supported the county teams in distributing PT panels. The following is a summary of events per county Samburu USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 48

During the year, two PT panel rounds were received, Round 13 and 14. In Round 14, 76 panels were received; processing and feedback collection is ongoing. In Round 13, a total of 84 panels were received and the response rate was 83% (70/84). From the responses, satisfactory performance was 54% (38/70) passed while 46% (32/70) failed. Causes of failures were: incorrect results- 16% (5/32), wrong algorithm – 31.2% (10/32) and incomplete results -56% (18/32). Garissa A total of 123 Proficiency tests (PT) were received for Round 14 and the respective sub-county lab coordinators were supported to distribute to the HTC providers. Feedback from the HTC providers is currently being collected and to be submitted to NHRL for ranking. Isiolo A total of 121 PT panels for round 14 were received and distributed to the HTC providers in the county. Feedback collection from the HTC providers is ongoing. Marsabit For Round 13 & 14, 206 & 210 PT panels were received while feedback for round 14 is pending. Analysis of feedback results for round 13, 101 out of 206 responded and 78 (77%) of responses were satisfactory while 23 (23%) were unsatisfactory. The unsatisfactory responses were due to incorrect results 70% (16/23), wrong algorithm 4% (1/23) and incomplete results 26% (6/23). Tana River A total of 73 PT panels for Round 14 were received during the quarter and distributed to the HTC counselors. The feedback analysis is pending the dispatch of pending panels in the Counties. Capacity Building The capacity building approaches used by the project are through OJT; CMEs; sensitizations and one-on-one mentorship sessions. The table below provides a summary of the number of HCWs reached with the different approaches throughout the quarter (July to September 2015).

Training/ No. of HCWs by County Mentorship/ OJT/CME and Garissa Isiolo Mandera Marsabit Samburu Tana Turkana Wajir Total area of coverage River Reached Long Acting 0 55 30 0 25 0 25 60 195 Reversible Contraceptives (LARC) training in collaboration with (FUNZO) Long Acting 0 0 0 0 0 35 0 0 35 Reversible Contraceptives (LARC) OJT IPT sensitization 0 0 0 25 37 0 20 82 Rapid Advice 30 37 10 0 20 41 0 30 168 dissemination (Training /mentorship/ OJT) Orientation on TB 0 0 0 0 20 0 0 0 20 Infection Prevention Control Plan USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 49

Management of 0 0 35 0 25 0 0 0 60 HEI (CME/ OJT) FANC 30 0 0 0 35 0 0 0 65 (CME/OJT) Mentorship on 0 28 0 0 0 0 14 0 42 SOPs writing & cold chain maintenance (Laboratory) Basic Laboratory 0 0 0 0 0 0 6 0 6 Information System (BLIS) Gene Xpert 0 0 0 0 0 0 0 20 20 utilization Sensitization on 0 0 0 0 0 0 48 0 48 EID and VL algorithms, sample collection and quality Assurance ( Didactic training sessions) EMTCT Training 0 0 10 0 21 0 0 0 31 (Mentorship) EMTCT training 0 0 0 0 32 0 53 0 85 (didactic in collaboration with FUNZO) HTC New 0 0 22 0 0 7 0 0 29 Algorithm Immunization 30 0 0 0 0 0 0 0 30 guidelines Data review to 35 0 0 0 0 0 0 0 35 promote data demand and information use Viral Load (OJT) 0 12 0 0 0 0 0 0 12 Infection 0 6 0 0 0 0 0 0 6 Prevention at Maternity (CME/ OJT) Continuous Quality 0 0 20 0 30 0 0 0 50 Improvement Zinc and ORS 70 45 115 therapeutic supplementation for diarrhoea management (Sensitization/ OJT / Mentorship) BEmONC 0 0 0 0 35 0 0 0 35 Point of Care 0 0 4 0 0 0 0 0 4 Testing using PIMA Mentorship on TB 0 0 6 0 0 0 0 0 6 ICF tool FP/HIV 0 0 8 0 0 0 0 0 8 Integration Training on Stigma 0 10 0 10 10 0 0 0 30 USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 50

and Discrimination IQCare system 0 0 6 8 0 0 0 14 (Training / OJT / Mentorship) Web Based ADT 4 4 3 6 5 7 4 3 36 training Mentorship on 0 0 0 0 20 0 0 0 20 HMIS tools TB/ HIV 0 0 0 0 37 0 0 0 37 integration OJT on targeted 0 0 0 0 0 14 0 0 14 Family Based Testing Kenya Mentor 8 Mother Program (TOT training) Defaulter tracing 0 0 0 0 15 0 0 0 15 mechanism (mentorship / OJT) Grand total 1353 reached by APHIAplus IMARISHA

Summary of care and treatment activities

Garissa County  The county MoH staffs were sensitized on the 90-90-90 goals and all interventions have been aligned to meeting these targets.  Continued mentorship of the PITC counselors placed at the Garissa County Referral Hospital and Simaho to upscale HTC uptake. There were no reports of RTK stock-outs as a result of this continuous mentorship.  In conjunction with the Garissa county CASCO, SCASCO and other CHMT representatives, Technical Assistance was offered to HCWs in key priority facilities in Garissa sub-county (Garissa CRH, SIMAHO and Iftin SCH)  A total of 20 pre-ART clients on care accessed CD4 tests through the sample networking system during the reporting month. 11 of these patients attained counts of <500 cells and thus qualified for Anti- retroviral therapy. This mop-up of pre-ART clients for CD4 testing is ongoing until all clients get tested.  To improve defaulter management at Garissa County Referral Hospital, appointment diaries were provided at the CCCs. The expert clients are thus able to monitor patient clinic revisits and identify defaulters at an early stage. This led to the successful linking back to care 21 clients out of the 25 registered defaulters at Garissa CRH. 4 clients are still being tracked by the CHVs while no deaths were reported in the month of August.  Conducted mentorship to the HCWs on the five ―I‘s‖ of TB control (Intensive case finding, Immediate ART initiation, Infection control, Isoniazid Preventive Therapy and Integration of HIV/TB services) in facilities offering TB/HIV services by building their capacity to offer integrated, quality TB/HIV services.

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 Conducted mentorship at Garissa County referral Hospital on routine HIV testing for all the newly detected cases of TB. This was effectively done through the monthly HIV/TB integration meeting. All the 12 new TB cases detected at the clinic were offered HTC in which 1 tested positive for HIV and has been managed appropriately.  Sensitized the CHWs on the indications of the Gene Xpert for MTB diagnosis and MDR-TB surveillance for optimal utilization of the service. The sputum specimens have also been incorporated into the existing sample networking/referral network in the county. This has greatly improved the management of TB in the County.

Isiolo, Samburu and Marsabit  Provided mentorship to the laboratory staff at Isiolo County Referral Hospital on lab preparation for KENNAS exit audit in preparation for ISO 15189 certification. This included review of SOPs, Quality manual, Competency assessment, QA/QC documentation, Corrective actions and instituting the preventive actions.  Activated and configured the PIMA analyzers for online results transmission at Solo MH & Maralal CRH.  Continued to support Sample networking  Commodity & Job aids distribution; 3 jobs aids for new HIV testing algorithm were distributed to Wamba Mission Hospital (2) and Wamba health center (1). Proficiency testing (PT) panels for Round 14 were distributed and processing was carried out .The County lab coordinator was supported to distribute and re-collect the feedback for submission to NHRL.  USAID SIMS assessment carried out at Isiolo CRH, Wamba Mission Hospital, Garbatulla SCH and Kinna HC. It was successful except for staff safety training which was noted as a gap.  On-site trainings and installation of CD4 Point of care (POC) PIMA analyzer at Sololo MH, Marsabit County on 20th and 21st July 2015 and Maralal CRH, Samburu on 22nd and 23rd July 2015 was conducted. The training approaches used was a mix of didactic lectures and practical OJT sessions. The proposed strategies for PIMA use in the counties are either stationing PIMA analyzer at high volume facilities then networking samples from surrounding ART facilities or using it in a rotational manner where clients are occasionally mobilized in respective ART facilities on a given clinic day  Conducted mentorship for the 5 HCW at Hospital on TB IPC, 7 steps of patient management of TB in community and health care settings. Emphasis was on early screening and detection of suspected TB cases, patient education on cough etiquette, respiratory hygiene and first tracking of coughers especially in OPD filter clinic and CCC. This saw a reduction in waiting time for TB suspected patients in the outpatient department.  Held a joint meeting with the Moyale D.H management on TB IPC where the management agreed to; evaluate the status of IPC; triage all; conduct periodic surveillance of TB in health care workers and formation of IPC committee.  Family based testing was conducted in September.10 index clients were reached and tested. 2 HIV positive family members identified and were successively enrolled in the clinic  Conducted on job training on VL and CD4 sample collection. This involved training the HCW on packaging of samples to ensure integrity and minimize rejection at the processing laboratory. In an effort to scale up testing, clients were mobilized and samples collected. 35 ART clients accessed viral load testing while 14 pre-ART clients accessed CD4 testing. Out of the 14 CD4 tests conducted, 9 clients had CD4 <500 and were started on ART during the month.

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 Conducted mentorship on treatment preparation session (TPS) to improve adherence and retention for those starting ART and for those with VL > 1000 copies in readiness for 2nd line. The activity involved availing jobs aids and SOPs on counseling.  Held psychosocial support group meeting to discuss on ways of improving community linkages and referral to and from the community and of strengthening of defaulter tracing. The meeting identified modalities of work protocol and schedule of routine monthly meetings.  A Cross border (Kenya and ) collaborative meeting was held whose objective was to identify areas of leveraging defaulter tracing across the international borders, sharing of best practices in HIV/TB/RH programming and other cross border health related issues. Some key outcomes of the meeting were: sharing defaulter list and engaging case managers on either sides on use of the community strategy approach to map physical address of patient which will be piloted in Moyale  Conducted mentorship at Isiolo District Hospital for the nurse in charge. She was sensitized on the use of the current maternity register and the same was implemented immediately with cleaning of data for all HIV+ patients in the maternity register and appropriate linkage. The Medical Officer intern was mentored on PMTCT provision for all HIV positive mothers and appropriate referrals as per the new guidelines.  At the MNCH, the team was mentored on the correct use of FCDRR, filling of page summaries and use of the page summaries to know when to reorder and to generate consumption reports. Also, the team was mentored on the use of the current ANC register.  Conducted Kaizen in Garbatulla CCC dispensing point and Kinna drug store where data and records were updated.  In the pharmacy, mentorship was done around IPT provision for children .This was successfully networked and IPT provided to one child in Merti Sub County through the TB coordinators office.  In the SIMS assessment, all facilities supply chain indicators scored green and dark green except in Kinna where the facility was low on Nevirapine stocks hence a yellow score. According to the facility, this was because they were in-between orders however; the facility was still networked with Garbatulla (central site) to ensure replenishment of the same in good time.  Distributed pharmacy job aids (good dispensing records, good inventory management practices, quantification guide, and good record keeping practices, medication use counseling check list, pharmacovigilance tools, and Pharmacovigilance posters to the facility.  Mentored the MNCH staff on option B plus and assisted in the reconstruction of HEI registers at Kinna and Garbatulla health Centers.  Introduced bin-cards at Samburu East Sub County medicines at Wamba Mission drug stores.  Samburu (Maralal) and Isiolo District Hospital pharmacy were networked for Kaletra syrup supply to ensure 100% initiation of reactive HEIs.  Conducted chart reviews at Kinna and Garbatulla health centers to ensure timely initiation on ART and timely and correct switch to second line for failing patients.  Held a joint meeting with the Samburu East sub-county team to resolve the low ART commodity reporting rates. In attendance were SCASCO, SCMOH SCLTB and sub county pharmacist. The meeting resolved for TA team to provide reporting tools and the SCMOH and SCASCO to reinforce the importance of reporting to all health care workers during supervision and facility in charges meetings.

Turkana County

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 Scale up of the Community HTC in Kalokol Division targeting the fisher folk was undertaken. The activity was planned alongside the Director of Public health and Liaison for AIDS HealthCare Foundation (AHF). APHIAplus IMARISHA oriented the Health care workers (HTC Counselors & Mobilisers) while AHF provided allowance for the staffs.  The TA team was successfully able to carry out an assessment at three villages whose hosting facilities included Kalokol AIC Health Centre, St. Mary PHC dispensary and Namukuse Dispensary. During this exercise the startup test kits were redistributed to the facilities for the exercise. The HTC Registers and consumables were provided.  Provided technical assistance to RCEA Lokichar health center on identification of mentor mothers and expert clients who are to assist in defaulters tracing and patient education.  Conducted mentorship for HCWs on patient monitoring using viral load.  Held a meeting with CHVs and Expert clients to assist in patient defaulter tracing at the community level.  Reviewed TB/ART registers and to check on completeness as well as patient management.  The TA team identified as TOTs for the roll out ACTS initiative participated in the National pediatric and adolescent HIV Toolkit training on national pediatric and adolescent toolkit by NASCOP in Nairobi.  Held a meeting with all-county pharmaceutical staff to forge the way forward on some of the current challenges experienced in the county including understaffing, poor commodity management practices and low commodity reporting rates. The discussions focused on the standard LMIS tools for HIV/TB, FP and Malaria to ensure that all team members understood the facility recording and reporting requirements. All the relevant recording and reporting tools were reviewed and discussed.  Conducted a County vaccine commodity status assessment .This was done at the County KEPI stores for vaccines to establish the current challenges experienced in the supply chain. The county received all vaccines in July and these have been equally redistributed appropriately to the sub counties.  Held a County Commodity management committee meeting and discussed procurement of essential medicines and the order fill rates. Facility commodity management practices were noted as requiring improvement.  TA was conducted in Turkana Central at St. Monica‘s Dispensary, St. Patrick‘s dispensary and St. Catherine‘s. Focus was on all eligible patients to be put on treatment immediately. Random assessment of the bin cards was also done to ensure that all were up-to-date. In MNCH availability of vaccines and tracer commodities was also assessed. During this circuit, 8 HCWs (3 female and 5 male) were mentored on good inventory management practices.  Conducted TA in Turkana South county facilities with a lot focus on Katilu health center. In the facility, chart reviews and line listing of all the patients was done. During the exercise all the defaulters were flagged for immediate follow-up, flagging was also done for all pre-ART patients due for CD4 and all ART patients due for baseline/repeat viral loads.  CME session was conducted on appropriate use of second line drugs using the national job AIDS. Temperature monitoring and charting for vaccines was strengthened in Katilu health center. Positive impact of previous TAs was noted with good uptake and maintenance of inventory management tools in CCC medicines cabinet, pharmacy and drug stores.

Mandera County  Conducted mentorship for CHWs on HTC at Dandu Community unity. USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 54

 Held a CME on dissemination of the rapid advice booklet at Elwak Sub county Hospital for 1 Medical officer, 1 records officer, 1male counselor and 4 male nurses.  Conducted mentorship for 2 male Nurses, 2 male VCT counselors and 2 male Lab technologist on VL testing  Distributed Implanon NXT commodity to Mandera west, South and North sub counties.  Held a meeting with the Takaba sub-county health management team to deliberate on project support and way forward on the MOH mentorship cascade at the sub county level. As a result, an MOH TA team was constituted and weekly CME sessions at Takaba sub county Hospital were inaugurated.  Conducted mentorship for 8 HCWs (2 male clinical officers, 2 male and 1 female nurse, 1 laboratory technologist and 2 female VCT counselors) on HTC scale up and focus strategy. 2 lay counselors were placed at Takaba sub county hospital to optimize PITC in the facility.

Tana River  Meetings held with the CHMT representatives, CASCO and respective DASCOs to discuss the need to align HIV program activities to the current global 90-90-90 targets approach and they pledged their support.  Rapid Advice dissemination-offered clinical mentorship on Laboratory monitoring of PLHIV (pre-ART and ART clients), TB/HIV co-infection management.  Sensitizations on the indications and use of Gene Xpert in MTB diagnosis and MDR-TB Surveillance in preparation for the installation of the machines in Hola County Referral Hospital and Garsen Health Centre .  Distributed Job aids and Rapid advice reference materials to Hola referral hospital and Garsen Health centre.  Prepared viral load results analysis for the key ART facilities and discussed the outcome and the appropriate interventions with the concerned clinicians.  Repeat viral load test tracking registers were placed in all the ART sites for monitoring suspected ART treatment failure clients. This is to ensure these clients access timely repeat testing (after 3 months of intensified adherence counselling) so as to facilitate ART switch for confirmed cases without undue delays.

MATERNAL, NEONATAL AND CHILD HEALTH/REPRODUCTIVE HEALTH/FAMILY PLANNING AND PREVENTION OF MOTHER TO CHILD TRANSMISSION

ELIMINATION OF MOTHER TO CHILD TRANSMISSION (eMTCT) During the quarter under review, a total of 13,544 mothers were tested in ANC, maternity and labor ward; 70% (13,544/19,405) achievement against target. Out of these 147 (1.1%) were HIV positive. The testing coverage for women attending ANC was 51% (13,544 tested against 26,300 attending first ANC) compared to 55% (13,226/23,741) in the previous quarter. There was a general decline in testing owing to test kit supply challenges across all counties. While there were test kit deliveries within the quarter, the demand was greater than the supply due to order fill rate challenges. In order to manage test kit shortages in the maintenance counties, the project jointly discussed prioritization of test kits supply within the facilities to ensure that ANC got first priority. The project team and the CHMTs have engaged the HCWs in this discussion in the maintenance counties so that test kit allocation is rationally and deliberately done within the USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 55 facility. However, the general HTC testing achievement against target was 136% compared to 70% in ANC. This shows that not all facilities prioritized ANC when test kits were delivered. The project response to this is to further engage the HCWs by providing TA and mentorship in conjunction with the CHMTs to ensure that ANC is fully covered.

Figure 45: eMTCT Cascade across the 8 Counties Supported By APHIAplus IMARISHA in the Period July to September 2015

During the quarter, 147/147 (100%) of the identified HIV+ mothers were given prophylaxis. All were receptive to interventions compared to last quarter where there were some women (2/196; 1% of those testing positive) who initially declined treatment (these have since been put on prophylaxis after extensive follow up and counseling). In lieu of lessons learnt in some innovations initiated in the previous quarter (e.g. tele-counselling in Samburu county, mentor mothers approach in Turkana), the project sustained investments in these approaches with positive results with more HCWs empowered to provide adequate counselling and support to the women in their journey. Additionally the project continued investments in TA, mentorship and facility based CMEs with emphasis on the rapid advice and proper documentation. APHIAplus IMARISHA has also supported facilities to adopt integration of eMTCT into ANC where the HIV positive mothers and their infants are followed up in MCH to reduce lost opportunities due to referral to CCC. Currently 42 (28%) out of the 152 supported facilities have integrated eMTCT in MCH. In Turkana County, roll out of the KMMP program saw training of 8 TOTs and sensitization of Turkana County CHMT/ SCHMTs on the KMMP approach in order to get administrative support for the same. There were 8 mentor mothers formally recruited to act as case managers in the high volume facilities. Their role is to provide psychosocial support to the mothers and ensure follow up of the mother baby pairs up to 18 months. These efforts will be sustained to ensure 100% PMTCT uptake as well as follow up on HEI. Other interventions to improve PMTCT uptake include community engagement (advocacy, education, stigma reduction) and follow up of mothers using the CHVs trained by the program, engagement of community opinion leaders (e.g. church leaders in Samburu County) and implementation of the BOMA model and UMATI concept. The community engagement activities have helped to reduce stigma particularly towards testing and subsequent treatment, although more needs to be done. The CHVs have been pivotal in defaulter tracing to ensure retention of HIV +ve mothers and the subsequent enrolment and follow up of their infants. There was also investment in psychosocial support groups. Generally, uptake of prophylaxis has shown an upward trend over the year, see Figure 46 below.

USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 56

Figure 46: Uptake of Prophylaxis among HIV +Ve Pregnant Women across NAL for the Period October 2014 to September 2015

100% of the women on prophylaxis during the quarter were on option B+ as recommended by the national guidelines. There was consistent supply of the regimens in all supported facilities contributing to the high uptake.

Figure 47: Option B+ Uptake across NAL for the Period October 2014 to September 2015

EARLY INFANT DIAGNOSIS (EID) During the period under review, a total of 139 HEI accessed a DBS test out of whom 8 (6%) were HIV positive. 5 out of the 8 children were successfully enrolled into care; 1 in Samburu transferred out of the county and 2 in Turkana County are currently lost to follow up (See Figure 48 below). These infants originated from Lokichar and Katilu area from where the project has engaged CHVs to trace them and assist in linking them back to the health facility. Mother baby pairing has helped to ensure that HEI access their first DBS between 6 – 8 weeks of age as recommended by the national algorithm. Most of the children tested were aged between 7 weeks and 3 months and followed by those aged 6 weeks. Out of the 8 positive infants identified, 4 (50%) were aged between 3 to 9 month. See Figure 48 below.

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Figure 48: EID Cascade across 8 Counties Supported by APHIAplus IMARISHA for the Period July to September 2015

Figure 49: DBS Samples by Age and Positivity across 8 Counties Supported By APHIAplus IMARISHA for the Period July to September 2015

ANTENATAL CARE (ANC)

Figure 50: Number of Women Attending 1st ANC between July to September 2015: Achievement versus Target

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During the quarter, the total number of women attending 1st ANC visit was 26,300 (73%) against a target of 35,794. This represents population coverage of 70%. This was an improvement compared to the previous quarter where the achievement was 66% (23,741/35,794) and a population coverage of 63%. Turkana, Isiolo and Tana River were able to meet their targets while Garissa (57%) and Wajir (41%) recorded the lowest achievements. The project continued to ensure improved uptake of ANC services in line with the WHO recommendation (at least four focused ANC visits for all pregnant women). The women are counseled by HCWs on the importance of FANC during the first visit. Other interventions made to improve ANC included extensive engagement with CHVs as community advocates with the added role of referring mothers for FANC as well as providing basic counseling and education to the mothers before referral. To this end, APHIAplus IMARISHA invested in training 1,145 CHVs attached to various CUs during this reporting period across NAL on MNCH/FP and Nutrition modules. Additionally, the program supported integrated outreaches (Garissa) and implementation of the BOMA model and UMATI concept in Samburu County. In collaboration with the Samburu County government, the project was able to support implementation of the UMATI concept during the 2015 edition of the International Camel Derby which saw 2,993 women reached with various health messages out of whom 15 were able to access the 1st ANC visit, given an appointment for the second visit and referred to the health facility of their choice. APHIAplus IMARISHA sustained mentorship of CHVs in Samburu County to build their capacity to effectively implement the BOMA model. During the period under review, 272 women from Kisima and Bendera community units were referred to the health facilities for FANC services. However, there were some referral data capture issues noted which will be sorted out during mentorship of the CHVs. Another major challenge compromising performance in Samburu County was insecurity experienced in Samburu North Sub-County during the period. This generally affected the community access to health services. Garissa County continued to experience challenges with HRH. Key services were affected due to an exodus of health workers due to insecurity in the county.

Figure 51: A Comparison between the 1st ANC, 4th ANC and SBA across 8 Counties Supported By NAL in July to September 2015

The number of women attending 4th ANC visit was 9,478 (8,625) which represents 110% achievement of project target with population coverage of 18%. This was lower than last quarter (11,301 women completing 4 visits; 31% population coverage). This was attributed to challenges with insecurity in parts of Samburu as well as late presentation at the ANC for the first visit as is the case across all 8 counties although there are more women accessing skilled deliveries than those completing 4 visits. Nevertheless, there has been a steady increase in the number of women completing 4 ANC visit over the year as shown in Figure 52 below. The project will sustain the aforementioned strategies to improve community advocacy through CHVs (trained by

USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 59 the project) to counsel and refer pregnant mothers to the health facilities and ensure that mothers are retained through to the 4th visit.

Figure 52: Trends in 4th ANC Visit across 8 Counties Supported By APHIAplus IMARISHA between October 2014 and September 2015

SKILLED BIRTH ATTENDANCE (SBA)

Figure 53: Number of Deliveries Conducted By a Skilled Birth Attendant between July and September 2015 across 8 Counties Supported By APHIAplus IMARISHA: Achievement versus Target

During the quarter, 13,661 women against a target of 13, 078 (104%) women accessed skilled delivery. This represents 37% of the expected number of deliveries for the period; which is low compared to the national SBA coverage (61%). This is because across NAL while more women attend at least 1 ANC visit, they prefer to deliver at home due to socio-cultural issues e.g. preference of TBA assisted delivery. In other counties e.g. Garissa, incidence of insecurity experience earlier in the year has seen healthcare workers leave the county and this has affected access to skilled birth attendants in various far flung facilities. Similarly, Samburu experienced incidences of insecurity in Samburu North Sub-County generally affecting access to health facilities. The project invested in interventions to improve skilled deliveries including mentorship of HCWs to support mothers to develop individualized birth plans (across 8 counties) right from the first contact; provision of safe motherhood vouchers in Garissa County (which saw 66 women access skilled delivery); support for taxi referrals in Habaswein Sub-County in Wajir which assisted 99 women to access skilled delivery at Habaswein Sub-County referral hospital. In Samburu County APHIAplus IMARISHA supported scale up of maternal shelters. Borrowing lessons from Kisima Model Health Center maternal shelter, 2 new maternal shelters were established; one in Lesidai (Samburu Central) and another in Nachola (Samburu North). The project supported the Samburu CHMT to develop SOPs and data capture tools for the maternal shelters in order to standardize practice as the service expands. Further, after being trained on the BOMA

USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 60 model, the Samburu County CHVs referred 112 mothers from Kisima and Bendera CUs for skilled deliveries. HCWs were also mentored on data demand and information use for decision making. Skilled delivery trend charts are developed and the HCWs review their monthly performance and the way forward developed for quality improvement. In general, there has been an upward trend in uptake of skilled deliveries across NAL, with the last 6 months being closing at over 100% achievement as demonstrated by Figure 54 below.

Figure 54: Trends in Uptake of SBA across 8 Counties Supported By APHIAplus IMARISHA between October and September 2015

Maternal and Neonatal Outcomes

Table 9: Summary of Maternal and Neonatal Outcomes across In NAL (July – Sep 2015) Neonatal outcomes Maternal County No. of Babies Neonatal Live Births Still births outcomes Discharged alive Deaths Garissa 2,352 102 2,325 11 5 Isiolo 1,093 52 1,041 16 0 Mandera 2,320 57 2,218 2 3 Marsabit 1,505 42 1,463 12 0 Samburu 959 23 891 10 2 Tana River 1,052 43 868 4 1 Turkana 3,059 121 2,824 52 5 Wajir 2,278 84 2,213 11 1 Grand Total 14,618 524 13,843 118 17

During this reporting period, 95 %( 13,843/14,618) of the neonates were discharged alive and 0.8% (118/14,618) died in the neonatal period (see table 9 above). Some causes of neonatal deaths were prolonged labor (at home or due to delayed referral from a lower level facility), prematurity and respiratory distress. There were 17 maternal deaths recorded across the 8 counties with Garissa and Turkana reporting the highest number (5). Obstructed labor followed by postpartum hemorrhage were the most common maternal complications. Some interventions to improve maternal and neonatal outcomes included training of 30 USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 61

HCWs on BEmONC (Mandera County), facilitation of perinatal mortality audits in conjunction with DANIDA SRH project in Turkana County and support for community verbal autopsies in conjunction with the Isiolo CHMT. Moreover, in Isiolo, the project collaborated with the CHMT to institute Maternal and Perinatal Death Surveillance and Review (MPDSR) committees in all health facilities providing maternity services in addition to sensitizing 54 HCWs on how to conduct maternal death audits. In Samburu County, the project invested in interventions both at the facility and community levels. At the facility level, HCWs were trained on BEmONC to ensure increased preparedness for skilled deliveries through strengthening the signal functions. This is in addition to building the capacity of HCWs on the management of maternal complications through OJT, mentorship and trainings. There was advocacy with the County government to equip the health facilities for proper management of maternal complications and also upgrade some Sub County health facilities from BEmONC to CEmONC facilities. At the community level, the project trained community gate keepers such as religious leaders, cultural leaders, morans and traditional birth attendants (TBAs) on the importance of skilled deliveries. The roles of TBAs have been redefined to refer and accompany mothers to the health facilities rather than conduct home deliveries. POSTNATAL CARE SERVICES (PNC) Post-natal care (PNC) is an essential service and contributes to early detection of birth complications. The program has invested in establishment of PNC services through provision of TA, OJT and mentorship to strengthen the capacity of health facilities in offering postnatal services. 13,661 (100%) mothers and babies delivering in the health facilities were able to access PNC within 48 hours. There are a number of women who deliver at home but still visit the health facility after delivery for PNC. However, there have been data capture challenges and the program, through TA will work with the county teams to ensure that services offered are reported. BASIC EMERGENCY OBSTETRIC AND NEWBORN CARE (BEmONC) The three BEmONC focus counties are Samburu, Wajir and Mandera. In the third quarter, following consultations with USAID and in view of slowed activity in Wajir and Mandera due to insecurity, Isiolo County was included as an additional focus county. Samburu County The program conducted a BEmONC mid-term evaluation where some findings included the number of staff trained in BEmONC had reduced by one third due to staff transitions as a result of reshuffles and transfers to other sites; none of the BEmONC facilities provided all signal functions at the time of evaluation mainly due to lack of critical equipment, commodities, policy documents, inadequate documentation and limited staff competencies. Some interventions to improve the situation were redistribution of BEmONC pharmaceutical commodities (Magnesium Sulphate and Oxytocin); and mentorship of HCWs on BEmONC activity reporting which resulted in improved reporting rates from 6% to 28% in September. This is expected to rise in the following quarter with sustained mentorship. Further, a poster presentation was done in partnership with CHMT and this was presented in the USAID supported MNCH implementing partners forum held in . After this forum a work plan was developed to accelerate BEmONC activities in Samburu County. Some challenges experienced in the quarter included frequent staff rotations to other departments; lack of basic equipment; inadequate skills on use of available equipment and pharmaceutical in the facility; shortage of reference materials; high staff turnover; new staff of which some require training; lack of inventory management system for the equipment available in the facility. Isiolo County

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APHIAplus IMARISHA working in collaboration with PIMA supported the CHMTs to undertake Basic emergency Obstetric and New Born Care (BEmONC) assessment. There was orientation of county health facility and HMT teams on BEmONC concepts and training of enumerators for baseline assessment. The baseline assessment was conducted covering 20 facilities. Data is in the process of entry by the M&E team and will be shared with PIMA for final analysis and action in collaboration with the health management team. Wajir County The project had planned to train selected HCWs in the last quarter on BEmONC but this was postponed to the next quarter on advice of the CHMT due to other competing priorities. Mandera County 30 additional healthcare workers across the county were trained on BEmONC. Other interventions made during the quarter included distribution of job aids, distribution of BEmONC equipment procured by DANIDA SRHR project, training of 60 HCWs on IMCI in collaboration with UNFPA. Some challenges were high staff turnover owing to insecurity and poor health seeking behavior among the community. FAMILY PLANNING The promotion of ―healthy planning and healthy spacing‖ and ensuring access to preferred contraceptive methods for women and couples is essential to securing the well-being and autonomy of women and their families, while supporting the health and development of communities. During this reporting period, a total of 31, 796 (compared to 27,466 in the previous quarter) individuals accessed family planning methods across NAL. This represents a 16% increase in the uptake of FP in the next quarter. The method mix was as summarized in the Figure 55 below.

Figure 55: Contraceptive Method Mix across 8 Counties in NAL (July - September 2015)

Injections were the most popular choice with 425 uptake followed by condoms at 34% with IUCDs being the least popular at 3% uptake which was an improvement from 1% in the last quarter. Uptake of other long acting reversible methods (implants) increased from 4% in quarter 3 to 6% in the quarter under review. The program invested in capacity building of HCWs to empower them to provide LARC having trained an USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 63 additional 234 HCWs. In addition to training, there was mentorship of HCWs on the different methods leading to improved reporting and recording as well as quality of services. Overall the program recorded CYP of 17, 689 in quarter 4 across the 8 counties.

Figure 56: CYP and LARC Uptake Trends across NAL for the Period October 2014 to September 2015

Over the year, there has been an increase in uptake of LARC with the previous quarter recording the highest uptake. Isiolo County recorded the highest CYP while Wajir County recorded the largest improvement from CYP of 864 in quarter 3 to 4,187 by the end of quarter 4. This is attributed to the increased HCW capacity to counsel women and provide LARC. The project will sustain investments in ensuring increased uptake of long acting methods. Community engagement is also critical in ensuring increased FP uptake. Some community interventions carried out included training of 1,145 additional CHVs during this period on community MNCH/FP across the NAL. With the increased training of HCWs and community engagement through the CHVs, uptake of long acting methods and FP in general is expected to increase. There were other community engagement activities including engagement of church leaders and other community resource persons in Samburu County and the project team and CHMT were invited to discuss various aspects of MNCH, FP as well HIV and stigma reduction messages. Consequently 859 people were reached with these messages. Additionally, the project through trained CHVs referred 674 women to health facilities across Samburu County for family planning services. In the other counties, CHVs played a pivotal role in referring women for FP services in the health facilities however, there were challenges in documentation; these will be sorted out through sustained mentorship. It is estimated that the number of WRA in the region during the year is 1,033,994. By the end of quarter 4, the crude FP access for WRA across NAL was 3.1%. Figure 57 below summarizes the trends of crude estimates of FP access across NAL

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Figure 57: Percent FP Access (Crude Estimate) Across the 8 Counties Supported By APHIAplus IMARISHA in the Period October 2014 to September 2015

A total of 10 facilities out of the 104 supported sites have integrated FP services in the CCC in order to increase access of FP services among HIV clients. The project will work to ensure that this improves in the next quarter through sustained mentorship of HCWs, engagement with the CHMT and provision of the relevant reporting tool. IMMUNIZATION 79% (19,266 against a target of 24,345) children were vaccinated against measles, 81% (21,835 against a target of 26,863) received the 3rd dose of Pentavalent and 78% (20,925 against a target of 26,863) received the Pneumococcal vaccine. This represents a population coverage of 55% for the measles, 56% for Pentavalent 3 and 54% for the Pneumococcal antigen. The achievements were due to investments in outreaches [Beyond zero, facility outreaches, and implementation of the UMATI concept (Samburu only)]. Additionally, HCWs emphasized the importance of immunization during ANC, postnatal clinics and at the CWC. The project invested in community engagement through the CHVs whose function is to educate mothers and refer them to the facility. There was also education of postnatal mothers about importance of completing the immunization schedule at the maternity before discharge and to all mothers during health talks in the MCH Clinic including those who bring sick children. The project also invested in ensuring that there are no stock out of vaccines and proper maintenance of cold chain. Community health volunteers have been trained to mobilize and refer women and couples with children less than one year for immunization at the nearest facility of choice.

Table 10: Number of Children Immunized Measles Pentavalent 3 Pneumococcal

% % % Achieveme Achieveme Achieveme County Target Achieveme Target Achieveme Target Achieveme nt nt nt nt nt nt

Garissa 4,260 3,249 76% 4,330 3,390 78% 4,330 3,293 76%

Isiolo 1,258 1,254 100% 1,461 1,272 87% 1,461 1,284 88%

Mandera 3,608 2,103 58% 3,668 2,203 60% 3,668 2,208 60%

Marsabit 2,428 2,184 90% 2,642 2,320 88% 2,642 2,298 87%

Samburu 1,685 1,638 97% 2,051 2,233 109% 2,051 1,876 91% USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 65

Tana 1,705 1,524 89% 1,922 1,911 99% 1,922 2,017 105% River

Turkana 4,403 3,653 83% 5,711 4,701 82% 5,711 4,121 72%

Wajir 4,999 3,661 73% 5,080 3,805 75% 5,080 3,828 75%

Grand 24,345 19,266 79% 26,863 21,835 81% 26,863 20,925 78% Total

Figure 58: Trends of Clients Referred to Health Facilities for Services through the Boma Model Implementation in Samburu County (January to September 2015) Summary of MNCH/RH/FP activities Garissa County  The project facilitated a joint APHIA/Garissa CHMT support supervision to high volume facilities in Lagdera and part of Balambala sub-County. Key activities included;-Provision of TA on the new PMTCT rapid advice, FANC and immunization.-Strengthening FP commodity security and reporting.  Clinical mentorship for the PMTCT/ART site in MNCH clinic at the CRH which now offers comprehensive PMTCT services that include the provision of ART that was previously provided in the CCC. This effort markedly reduced missed opportunities which was common earlier due to the cross referrals between the clinics.  SOPs and job aides were provided to the CRH PMTCT site in order to boost the quality of services offered at the site.  The project further donated a four door metallic cabinet and stationaries to the PMTCT site in the CRH to improve record keeping.  A PMTCT CQI meeting was held at the CRH MCH unit attended by 10 HCWs comprising of a representative of MNCH, CCC, CASCO and the IMARISHA program. The objective of the meeting

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was to address the gaps in PMTCT update. The key outcome was the establishment of PMTCT site as a comprehensive ART site  The project participated in the impact assessment on HRH by AMREF consultant at PGH MNCH, Police line dispensary, and Medina HC. Key services were affected due to exodus of health workers due to insecurity.  Garissa Sub-County data review was held. Key outcome included; inadequate documentation for the low immunization indicators, mentorship was planned to address the data gaps in the coming months.  Supported integrated outreach services in 6 health facilities in Garissa and Masalani sub-Counties.  Distribution and dissemination of BEmONC, PMTCT, AMLST SOPs and job aides to the high volume facilities in Garissa County.  Participated in the joint APHIA/Garissa sub-CHMT support supervision for 12 health facilities. Key activities included;-Provision of TA on the new PMTCT rapid advice, FANC and immunization. And strengthening FP commodity security and reporting.  Safe motherhood voucher system monitoring and verification visits. During the July-Sept 2015, the voucher beneficiaries were 186 ANC clients, 66 skilled deliveries, 104 postnatal and 69 FP clients.  The project supported the training LARC training for 54 FP service providers from Garissa County. The participants were taken through 2-day theory and one-day practical session.  Planning meeting held with CHMTs on the training of CHWs on Family planning  The project facilitated the training of 50 CHVs (34 Male & 16 Female) on Family planning. The CHVs were drawn from various community units.  Strengthen FP commodity reporting through OJT to 15 services providers in P1 facilities.  Mentorship on FP/HIV integration for 3 MNCH staff, strengthening of PITC at Masalani Sub-County Hospital FP clinic.  Mentorship 5 service providers on contraceptive commodity mix and FP commodity reporting at Masalani.  The project provided logistic and technical support for the Polio campaign for Garissa County. The exercise was successful, with the County surpassing its target  The project participated in a USAID-Measure Evaluation supported MNCH Data review meeting for all health facilities in Garissa County. Key gap noted was inadequate documentation and under reporting. Key actionable points included; the reorientation of all the newly recruited health workers and conducting OJT and mentorship on regular basis.  Linkages of 40 service providers from both public and private health facilities for IMCI training by CHAI.  Initiation of additional integrated outreach services for 6 health facilities in Garissa County  Distribution of 6000 Mother-child booklet for Garissa and Ijara sub-County health facilities Isiolo County  Mentorship of HCW for them to educate pregnant women and couples about benefits of skilled care during pregnancy and retain those who report for first ANC until they reach the WHO recommended 4th attendance.  TA team worked with their community based counterparts to intensify referral by community health volunteers and peer educators.  Mentorship of Health care workers and OJT on FANC where by HCW are encouraged to take time in counseling ANC women and couples on birth preparedness and individual birth plan.  Promoting MPDSR in collaboration with the CHMT and targeting all the health facilities that provide delivery services as well as surveillance at the community level where a verbal autopsy is encouraged.

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 Orientation of 54(21 male and 33 female) health care workers on how to scale up maternal death audits.  Conducted BEmONC baseline assessment covering 20 Health facilities.  25 health care workers were trained to provide LARC through support from FUNZO Samburu County  Distribution of job aids, reporting material and reference material has been distributed to15 health facilities visited in the year four.  Demand creation for health services was also done during the cultural and other events such as the Maralal International Camel Derby, OVC station days, water management committee meetings, dialogue days, home visits, during BOMA model approaches in the 2 IMARISHA supported community units and religious leaders‘ engagement.  Capacity building of HCWs on the need for health messages and one to one counseling of mothers, establishment of facility psychosocial support groups in Maralal CRH.  Mentorship of HCWs on HEI services done at Archers Post  Distribution of HCA recording and reporting tools, SOPs and other reference materials. There was sensitization was also done to the HCWs on the utilization of the tools and this followed up with ongoing mentorship on the services.  In the 2015 edition of the Maralal International Camel Derby, APHIAplus IMARISHA in partnership with the County government supported the UMATI outreaches where 2993 clients were reached with various services of which 15 women were provided with the first ANC service among other services.  Building the capacity of HCWs and CHVs through mentorship and OJT both in the health facilities and community units especially the ones supported through the project namely Kisima and Bendera.  Set up and equipping of two maternal shelters namely Lesidai in Samburu Central and Nachola in Samburu North.  Capacity building of HCWs on BEmONC to ensure increased preparedness for skilled deliveries through strengthening the signal functions  BEmONC mid- term review  In partnership with FUNZO Kenya supported training of 25 HCWs of 25 HCWs on LARC. Mandera and Wajir Counties  Routine mentorship and TA of HCWs  Support for taxi referrals for mothers in labor at Habaswein sub - county Hospital  60 service providers were trained on Long Acting Reversible methods(LARC) by the project and FUNZO Kenya  Training of the CHVs in the community units in order to strengthen family planning service uptake. Marsabit County  Routine mentorship and TA provided to MNCH staff covering various aspects e.g. e MTCT, FANC, Skilled delivery, etc.  The project leveraging on AMREF Danida sexual and reproductive health right project continued the use of trained community health volunteers to refer mothers for FP services.  Mentorship on FP/HIV integration Tana River County  Routine mentorship and TA of HCWs

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Turkana County  Technical assistance targeted at integration of PMTCT into MCH  Training of 8 KMMP TOTs  Sensitization meeting targeting the TCG (Turkana County Government) health heads and CHMT/SCHMT  Recruitment of mentor mothers in 8 (Kalokol AIC, St. Mary‘s PHC, Namukuse, St. Patrick‘s, St. Monica, Lokichar RCEA, Katilu and Lokori PHC) facilities.  Training of 25 HCWs on PMTCT in collaboration with FUNZO  Training of 234 CHVs on community MNCH/FP  Participation in county review of maternal/new born perinatal outcomes  Through the DANIDA SRH support, the program supported perinatal mortality audits at the county level.  To enhance immunization coverage, IMARISHA invested in intensive TA to the HCWs especially on reporting and commodity management  Supported Polio campaign.

PILOTING OF ORS AND ZINC FOR DIARRHOEA MANAGEMENT During the period under review APHIAplus IMARISHA and the Clinton Health Access Initiative (CHAI) continued to support the CHMT in scaling up ORS/ Zn for diarrhea management as part of IMCI building up on work done in the earlier quarters. In the previous quarter, baseline data was collected as part of an MNCH baseline survey across the county. During this reporting period data entry and analysis was done by CHAI and the gaps identified included inadequate knowledge among the HCWs, unavailability of reference materials and lack of functional ORT corners at the health facilities. To address these gaps the project in partnership with the County developed an action plan for both facility and S/CHMT level. At the County level the project partnered with the CHMT and CHAI and implemented three broad activities namely: 1) capacity building of HCWs on IMCI through training, OJT, mentorship and CMEs, orientation of HCWs on IEC, 2) distribution of reference materials and reporting tools and 3) plans for equipping the ORT corners. Specific activities undertaken during this reporting period include:  Dissemination of the preliminary findings of the IMCI baseline survey in a health facility in charges meeting  Sensitization of facility in-charges on the general concepts of child health and IMCI. These HCWs were drawn from 16 facilities in Samburu East, 28 facilities in Samburu Central and 14 facilities in Samburu North. The sensitization was done during the annual work plan development process and the sessions were well received and the sub counties prioritized child health interventions in the facility and sub County work plans. Furthermore the CEC for health also expressed full support for these activities including ensuring budgetary allocations for the activities. This shows good ownership of the programme by the county health team and is a prerequisite for sustainability of the programme.

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Figure 59: CEC Health Samburu County Displaying the IMCI Chart in Her Office (Left) and A CHMT Member Sensitizing HCWs On ORS/ZN Scale Up

 Oriented 70 health facility in-charges in the specific concepts of ORS / Zn scale up in the management of diarrhea in children.  Distributed IMCI guidelines, policy documents & diarrhea prevention and treatment posters to the 58 health facilities  Supported, through CHAI, the sourcing of Zinc and ORS from other counties through the coordination of the County Pharmacist as most of the facilities were stocked out. A consignment of ORS and Zn co- packs will be delivered in October through the project support.  Supported training of HCWs on IMCI. The trainings have been ongoing and by end of September, 96 HCWs from Samburu County had been trained. The training will continue in October until most HCWs (at least 2 HCWs per facility) in the health facilities are trained. APHIAplus IMARISHA has continued to support trainees from Samburu Central while CHAI has supported participants from Samburu North and East Sub-Counties. These trainings have applied the top bottom cascade whereby the 10 County based TOTs who were trained earlier in the year in turn facilitate the training of HCWs. This has enabled the programme to achieve training of high numbers of HCWs in a cost-effective way.  The trainees have been provided with ORT corner registers for equipping their respective health facilities  Further, the participants trained in IMCI developed individual work plans which they have started implementing back at their facilities and communities  After the IMCI training at least 6 HCWs reported having established ORT corners at their health facilities by end of September

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Figure 60: IMCI Training Sessions at the Nakuru Provincial General Hospital

VOLUNTARY MEDICAL MALE CIRCUMCISION (VMMC)

APHIAplus IMARISHA continued to support provision of VMMC services in 3 sub-counties in Turkana County namely, Turkana West, Turkana North and Kibish. The tables and figures below summarize the achievements since recommencement of services in January 2015. Through the 4 mobile VMMC teams, the project was able to offer 2,935 MCs during this reporting period representing an increase of 15% from that undertaken in the previous quarter (2,494). So far a total of 6,617 MCs have been undertaken since October 2014 (including 16 MCs done in December 2014). During the reporting period there were 15 mild and moderate post-operative adverse events, mainly infections that were managed by dressing and antibiotics. There was one case of intra-operative hematoma and the bleeder was identified and sutured. All the adverse events resolved following management and this helped in ensuring continued community confidence in the service offered as shown by the good uptake amongst the younger clients.

Table 11: Voluntary Medical Male Circumcisions Undertaken During (Jan-Sept 2015) Month/ Ages < 1 1 - 9 10-14 15-19 20-24 25-29 30-49 50+ Totals Qtly January 0 13 16 22 10 0 0 0 61 February 0 53 135 141 99 16 4 0 448 March 1 14 141 358 113 26 10 0 663 1,172 April 0 33 152 346 244 44 29 1 849 May 0 59 140 200 134 50 33 1 617 June 0 47 186 292 262 115 120 6 1,028 2,494 July 0 25 118 375 227 84 87 0 916 August 0 33 167 544 335 134 61 1 1,275 September 0 53 212 199 206 49 25 0 744 2,935 Totals 1 330 1,267 2,477 1,630 518 369 9 6,601 Per cent of all MCs 0% 5% 19% 38% 25% 8% 6% 0% USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 71

Figure 61: Percentage of Circumcisions Undertaken by Age-Group for Q1 (Jan-Mar), Q2 (Apr-June) and Q3 (Jul-Sept) A review of service uptake by age-group is summarized in the table and figure above. Analysis of the data shows that uptake of MCs has consistently remained highest in the 15-19 year old bracket. While uptake is also good amongst the 10-14 year olds, uptake amongst the 20-24 year olds has increased across the quarters such that by the end of September 2015, uptake was amongst this age-group was second at 25% to the 15-19 year old bracket which was 38% of all MCs done this year. Uptake by men older than 25 years while having improved during this reporting quarter from the previous one, remains low with contributing to 6% of all MCs done. The improved uptake amongst the 20-24 year olds can be attributed to increased acceptance of the service following increased mobilization efforts with the communities through engagement with community leaders including religious and political leaders as well as chiefs as described under 3.2 below. Moving forward APHIAplus IMARISHA will continue to engage with the USAID-funded Health Communication and Marketing (HCM) through Film Aid and the Turkana VMMC taskforce meeting to explore approaches that will increase uptake of VMMC by the older boys and men borrowing on experiences from other parts of the country. Some of the progress made includes identification of MC champions in Turkana West and utilization of them in mobilization of clients and to increase acceptability of the service among the community. The challenges identified while implementing VMMC and proposed solutions are summarized in Table 12 below.

Table 12: Issues/Challenges Identified while Implementing VMMC Activities and Suggested Solutions Issue/ Challenge Recommended Solutions 1. Circumcision related stigma: in the more remote - Identify social networks and MC champions who have areas of the county individuals who have undergone the procedure and support them to speak positively undergone the procedure are ridiculed about the procedure in appropriate forums e.g. in churches, during chief barazas and during celebration of national days. - Use appropriate films from Film AID for demand creation ensuring - Engage MCAs and Opinion leaders with VMMC information

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and request for their leadership in advocating for the practice amongst the wider community. - Conduct community entry for VMMC activities in North and Kibish in partnership with MOH and local leaders 2. Pastoralist lifestyle for youth aged 15 to 29 years − Identify food distribution points and use as moonlight outreach who are mostly newly married and always herding centers livestock and therefore feel the waiting period of 1½ months before one can have sex is too long

3. Negative attitude amongst the married on the − Loop in women to get support for their husbands to be service as they do not perceive HIV infection as a circumcised (Female Partner involvement) threat to their unions and so do not see the need to − Support wives of identified champions so that they start take up the service discussions of VMMC at their forums − Provide the wives with demand creation materials such as lessos 4. Low acceptance among older populations especially − Increase mobilization coverage 25 years and above − Routine community entries involving Political/Religious class and local leaders‘ i.e. chiefs, Ngimoroketc − Use of VMMC champions 5. Low network coverage and most of clients do not − Strictly using physical contacts, rather having phone numbers have phones in some areas hindering follow-up of local leaders i.e. chiefs, teachers, Religious leaders coverage

PRIVATE SECTOR ENGAGEMENT During the period under review, APHIAplus IMARISHA provided technical and logistic assistance to 41 PEPFAR priority private health facilities (private for profit and faith-based) in Garissa, Tana River, Marsabit, Isiolo, Samburu and Turkana Counties to improve MNCH/FP/RH/HIV services as shown by the table below. Table 13: Numbers of PEPFAR Priority Private Health Facilities in NAL County Project- Tier MNCH/FP ART HCT PMTC supported minimum sites T sites Private 2 3 4 package Facilities Isiolo 6 4 2 0 6 2 6 6 Samburu 9 5 3 1 4 2 9 9 Marsabit 12 6 4 2 4 6 12 12 Tana River 3 2 1 0 3 3 3 3 Garissa 1 0 1 0 1 1 1 1 Turkana 10 6 1 0 10 8 10 10 Total 41 30 11 5 45 22 41 41

Apart from the support given to both public and private health facilities, the specific support to private health facilities during this reporting period include:

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Human Resources for Health: The project continued to provide technical and logistical support to 21 Domiciliary Midwives in Tana River and Isiolo Counties to improve community based MNCH/FP and delivery services. The project also supported placement of expert clients and CHVs at 22 private health facilities to improve defaulter tracing, mobilization and referral of clients. The project also deployed 16 lay counselors to 8 private health facilities to support HTC outreaches for MARPs. The project recruited mentor mothers in the selected 8 (Kalokol AIC, St. Mary‘s PHC, Namukuse, St. Patrick‘s, St. Monica, Lokichar RCEA, Katilu and Lokori PHC) facilities to support PMTCT uptake. During the quarter, the project linked 184 private services providers to Funzo/MOH led trainings on the new HIV algorithm, PMTCT, Nutrition and HIV, in addition to other capacity building activities supported by the project that through OJT, CMEs and clinical mentorship.

Figure 62 APHIAplus IMARISHA C&T Officer Offering Support to HCWs at

Wamba Catholic Mission Hospital

Leadership and Governance: The project in collaboration with the CHMT provided mentorship and OJT on facility management skills to 16 private health facilities in Tana River County. During the quarter, a USAID team conducted a SIMS at Wamba Mission Hospital in Samburu County, which demonstrated big improvement in areas of quality improvement teams, adult/adolescent treatment, care and support as well as PMTCT and HTC. Some of the areas that needed remedy included; TB/HIV infection control and ART viral load monitoring. The project continued to collaborate with the respective CHMT‘s to integrate and facilitate participation of the private health facilities in the MOH led support supervisions and data review meetings. APHIAplus IMARISHA facilitated support supervision for 32 FBO health facilities in NAL where mentorship on various facility management skills were imparted. During the quarter, Work Improvement Teams (WITs) were re-activated in the Catholic Hospital Wamba. Medicines and Commodities: During the quarter, in collaboration with the CHMT, follow-up commodity audits were completed in St. Patrick‘s, St. Catherine‘s, AIC Kalokol, St. Monica, and RCEA Lokichar in Turkana County. The technical team provided mentorship on appropriate use of the available inventory management tools at the facility level. The project provided four OJT sessions on commodity management to 11 private service providers from Heri Tana and Bora Imani clinics in Tana River County. The project linked Wamba Mission Hospital for the provision of Gene Xpert machine which will enhance the management of TB/HIV patients and the placement of CD4 POC PIMA at Sololo Mission Hospital. Health Information: The project distributed and disseminated job aides and SOPs on HIV/MNCH to 15 private health facilities in NAL. The current NASCOP HIV reporting tools were also distributed. Capacity building Table 14:Numbers of HCWs Oriented on Various Health Topics in Private Health Facilities in NAL Activity County Topic People

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OJT Tana Delta New 90 – 90- 90 approach 9 OJT Tana North Indicator on 1st ANC against 4th ANC visit 5 OJT Tana Delta Leadership and Governance 7 OJT Tana Delta Medicine and Commodities 5 CME Tana River - Galole immunization 9 CME Tana River New HTC algorithm 6 Training Samburu LARC 5 Mentorship Samburu Quality improvement 10 CME Samburu Dissemination of rapid advice 16 Training Samburu Diarrhea Management 12 Training Samburu BEmONC 6 Training Marsabit IQ care 3 Training Marsabit IPT 6 Mentorship Marsabit Waste management and Lab biosafety 6 Training Turkana PMTCT 10 Training Turkana FP 8 Mentorship Turkana Commodity management 16 Mentorship Turkana HIV and Nutrition 5 Training Isiolo LARC 4 OJT Isiolo ART eligibility assessment 6 Mentorship Isiolo ART rapid advice 7 Training Garissa LARC 6 Training Garissa ART 4 Mentorship Garissa PMTCT 3

SPECIALIST CLINICAL OUTREACH PROGRAM During the quarter, AMREF was able to support specialist outreaches to one of the NAL Counties, Turkana, bringing clinical specialists to 3 hospitals through 20 visits. In this demand driven activity, health facilities identify cold cases requiring professional intervention by specialist clinicians. A booking is initiated and when a critical number is attained, the specialists are identified by AMREF and then flown/ driven out to attend to the cold cases in pre-arranged circuits covering the whole county. From July to September 2015 specialists in 8 clinical specialty areas were flown in to attend to the patients, carrying out 1,256 consultations and 145

USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 75 specialized operations (see Table 15 below). Over the same period 267 staff in the facilities underwent on- the-job training (30 doctors, 73 nurses, 7 lab staff and 54auxiliary staff) for a total of 168 hours.

Table 15: Specialist Services Given by Clinical Specialist in NAL over the Reporting Period

Hospitals Consultations Operations Teaching Informal Teaching Formal Kakuma IRC 317 5 27 0 Kakuma Mission 711 131 79 15 Lodwar 228 9 42 5 Grand Total 1,256 145 148 20

Figure 63: Number of Patients Seen by Different Clinical Specialists

FACILITY-BASED NUTRITION SERVICES During this reporting period, facility-based nutrition activities continued to focus on increasing uptake of High impact Nutrition interventions (HiNi) at facility and community levels, creating an enabling environment for Nutrition Assessment Counselling and Support (NACS) by, for example, improving mechanisms for nutrition service implementation, organizational networks and referral pathways. In addition to the routine technical assistance, mentorship and on-job trainings, efforts continued to be put in place to ensure adequate and accurate documentation of assessment results and categorization of clients‘

USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 76 nutrition status at all priority one facilities. Adoption of the nutrition service form that was developed in the previous quarter and monitoring of the availability and use of reporting tools and registers was also strengthened during this quarter. Remarkable improvements were noted in the supply of the Food by Prescription commodities in Marsabit, Samburu, Isiolo, Tana River, Garissa and Wajir Counties. However, Turkana and Mandera Counties continued to lack the commodities in all the facilities. As reported last quarter, the Nutrition and Health Programme (NHP) that is responsible for procurement and distribution of the commodities is still putting up distribution structures. High Impact Nutrition Interventions The specific interventions that were supported during the reporting period are summarized in table below:

Table 16: High Impact Nutrition Interventions Carried Out in NAL High Impact Nutrition Contributing activities Outcomes intervention component Promotion of exclusive  World Breastfeeding Week Launch Increased awareness breastfeeding and complementary supported in Tana River, Wajir and among Health care workers feeding Garissa Counties on the Baby Friendly  2 advocacy and sensitization meetings for Hospital Initiative 32 Health Care Workers in facilities in MTMSG and Community Garissa and Mbalambala Sub Counties Health Volunteers (CHVs)  6 facility and community based Mother To continue to protect and Mother Support group (MTMSG) defend Exclusive Breast meetings in Garissa and Wajir counties Feeding (EBF) were conducted/held Improved capacity of

 20 CHVs and MTMSG leaders supported caregivers on Infant and to disseminate information on EBF for the Young Child Nutrition first 6 months in Wajir (IYCN) to improve under-  Trained 38 CHVs on importance of young five feeding child feeding, growth monitoring and dietary diversity in Marsabit County

Vitamin A supplementation  27 Early Child Development Education Improved coverage of VAS (ECDE) teachers and 15 Nutritionists sensitized on Vitamin A Supplementation (VAS), deworming and Growth Monitoring and Promotion (GMP) in Turkana, Tana River Counties  1,872 under-fives dewormed in ECDE centers in Turkana and Tana River Counties  24 under-fives received VAS, during Turkana County Cultural festival in August 2015  Technical Assistance (TA) for 49 Health Care Workers (HCWs) in Tana River and Wajir Counties on Vitamin A supplementation, documentation and reporting  Supported County Nutrition Coordinator (CNC) Wajir to deliver Vitamin A supplies

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to 25 Health Facilities (HFs) during support supervision Zinc for diarrhea management,  Iron Folic Acid Supplementation (IFAS) Timely management iron folate supplementation (IFAS) tablets/supplies delivered to 25 HFs in /treatment of diarrhea for pregnant women and use of Wajir County diseases at key contact iodized salt  Mentored 39 HCWs and reinforced the points to improve child messages that all pregnant women health attending antenatal clinics should get iron/folate tablets (60mg iron/0.5g folate)  Zinc tablets delivered to 25 HFs  Trained 77 CHVs on child health & ZN/ORS supplementations during diarrhea management Management of Acute The project conducted an assessment to The findings will inform Malnutrition determine the capacity of facilities to manage the project‘s areas of focus acute malnutrition. The assessment focused on: in the coming quarter and  Is the facility providing nutrition services in year 5. (screening for malnutrition, classification of malnutrition, out-patient treatment, stabilization center, counseling, and referral for other services) at the moment?

 Does the facility have guidelines, protocols and SOPs for management of acute malnutrition?

 Is the person (s) offering the services at the facility been trained on Nutrition

 Does the person(s) offering the services have confidence and technical ability to diagnose, categorize and manage acute malnutrition

 Does the facility have the necessary materials and equipment

 Does the facility have adequate nutrition commodities?

Key activities and outputs from the counties are elaborated below: WAJIR COUNTY Wajir County Nutrition situation: According to the Long Rains Assessment conducted between 27th July and 7th August, 2015, the nutrition situation has deteriorated in Wajir North from poor to critical with prevalence of Global Acute Malnutrition (GAM) increasing from 8.8 percent to 14.3 percent. And as per the National Drought Management Authority reports released August, 2015, there was an increase in the USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 78 proportion of children under five years who are undernourished and those at risk of malnutrition which is a clear indication of general worsening food security situation in the county. Wajir County drought situation as at August 2015 is at alert level and the proportion of children at risk of malnutrition is expected to increase in the coming months as the dry spell progresses and milk availability becomes constrained. SMART Nutrition Surveys conducted in June 2015 in collaboration with MoH and other nutrition actors indicated GAM rate of 17.8 %. From the findings, there is need for increased nutrition surveillance in the county. The project continues to align activities to the Wajir County Nutrition Action Plan (Wajir CNAP). The CNAP provides a coordinated framework for High Impact Nutrition Interventions by government and nutrition stakeholders for maximum impact at all levels. In addition to increasing uptake of HiNi at facility and community levels, the project continued to work with the Ministry of Health to create an enabling environment for Nutrition Assessment Counseling and Support (NACS). For example, to avoid relapse of clients discharged from the various Nutrition programmes, referral pathways such as linking clients with other services provided by the agriculture, food security, social protection, education, and rural development sectors was enhanced. The enabling environment for NACS was enhanced through orientation of health care providers on nutrition performance indicators and reporting, training of CHVs attached to Ministry of Health (MOH) and Local Implementing Partners (LIPs) on child health care and nutrition, hosting Wajir County Nutrition Technical Forum and coordinating World breastfeeding Week through County Health Management Teams. It also included routine technical assistance to health facilities to strengthen micronutrient supplementation and documentation, community sensitization on prevention and control of cholera at key contact points at Maternal Child Health/TB/Comprehensive Care Centre clinics. The project also supported nutrition support supervision and leveraging of resources with Nutrition and HIV Programme and Global Fund TB projects. Routine Technical Assistance: The project continued to provide regular mentorship and technical assistance and on-the-job training to 38 HCWs from Wajir County & Referral Hospital (CRH), 6 sub-county hospitals and 10 lower level health facilities. The mentorship/ technical assistance focused on integration of nutrition services across the continuum of care, micronutrient data collection and reporting at the CCC/MCH/TB clinics and provision of NACS. The need for a ―client-centered‖ approach to service delivery was also emphasized. This has fostered referrals, improved inter-departmental linkages and holistic management of malnutrition. The routine mentorship and on the job training on NACS approach has enabled the facilities and 38 health care workers to integrate nutrition services in the CCC/MCH/TB clinics thereby enhancing delivery of an integrated package of HiNi for Maternal, Infant and Young Child Nutrition (MIYCN) and people living with HIV and TB.

High Impact Nutrition Interventions, Nutrition in HIV/AIDS and TB: During the quarter, the project oriented 24 HCWs drawn from Wajir CRH, Griftu, and Eldas SCHs on nutrition performance indicators and reporting and provided on-the-job training on the 90-90-90 strategy. Provision of quality Nutrition Assessment Counseling and Support was also emphasized. The HCWs were oriented on the following key areas:  ART Guidelines (2011), Diagnosis and management of malnutrition in HIV-infected adult patients, Nutrition Assessment Counseling and Support/FBP protocol and Diagnosis and Management of Under-Nutrition  Nutrition data management systems and overview of nutrition commodities  Standard treatment guidelines for HIV & TB  High impact Nutrition interventions(HiNi) and national targets  Receiving, storage and inventory management records and linking service data to commodity tools & quantification of nutrition commodities USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 79

 Nutrition commodities data collecting and reporting tools and completing commodity tools  M&E issues for HIV and TB Nutrition The orientation has enhanced knowledge and skills of 24 HCWs thereby enabling them to effectively promote quality nutrition interventions and services at all levels of Wajir County health system.

CHVs training on child health care, Nutrition ZINC/ORS supplementation: In light of the prevailing cholera outbreak in Wajir County and as part of response plans, the project in collaboration with MOH and LIPs trained an additional 77 CHVs from Community Units (CUs) and LIPs on HiNi with a special focus on therapeutic zinc supplementation during diarrhea, optimal hand washing –how and when to wash hands, food hygiene, treatment and safe storage of household water, waste storage methods, and other child health care practices. The CHVs are currently disseminating key messages gained to Orphans and Vulnerable Children and their caregivers, People Living with HIV and the general community. Awareness campaigns that stress on the importance of personal hygiene especially hand washing, water treatment, community hygiene to best protect at-risk populations from cholera and similar illnesses are also currently going on.

Maternal & Child health campaigns: The project through the County Health Management Team (CHMT) supported the commemoration of World Breastfeeding Week (WBW) from 1st -7th August, 2015 in Wajir. The project provided banners (with messages promoting exclusive breastfeeding, utilization of maternal and child health services), refreshments for the county launch and engaged CHVs and MTMSG leaders to mobilize and encourage parents/care givers to take their children to health centres and hospitals for immunization, growth monitoring, ORS, Vitamin A, deworming and receive insecticide treated mosquito nets to protect them from malaria. The theme for the WBW celebrations were “Breastfeeding and Work; Let’s Make it Work!” At the CUs, the project supported breastfeeding talks by CHVS and MTMSGs and facilitated CHVs to disseminate nutrition education information.

Integrated nutrition support supervision: To enhance knowledge, competence and skills of HCWs on implementation of the comprehensive package of HiNi, micronutrient data collection and reporting hence improved health and nutrition outcomes; the project supported the CHMT to conduct nutrition supportive supervision to 25 health facilities. Some of the key findings from the supervision was the inadequate reporting on Vitamin A, Iron, folic acid supplementation, zinc for diarrhea management among other issues. As a result of the visit, 7 sub-county hospitals and 18 lower level health facilities have been supported to scale up HiNi, integrate nutrition services in the CCC/MCH/TB Clinics. A total of 38 healthcare providers at sub- county and rural health facilities were mentored and provided with real-time on-the-job training on HiNi using the nutrition on-the-job-training tool. To sustain gains of the visit, the project will continue to support quarterly nutrition support supervision for follow up/monitoring at facility levels to improve the nutrition performance indicators and reporting and improve the performance of health facilities and sub-county hospitals so that they perform according to national guidelines During the visit, the CNC delivered adequate supplies for HiNi e.g. Vitamin A, Iron Folic Acid tablets, Zinc tablets, Global fund TB commodities, Ready to Use Supplementary Feeds (RUSF) and Ready to Use Therapeutic Feeds (RUTF), data collection and reporting tools and nutrition related job-aids. County Nutrition Technical Forum supported: To strengthen Wajir County MoH coordination and partnership among the key nutrition actors, APHIAplus IMARISHA hosted Wajir County Nutrition Technical Forum (CNTF) on 23rd July 2015. This has harnessed synergy in the efforts of the nutrition stakeholders and continues to present an opportunity to accelerate action towards achieving the targets of the HiNi indicators and an avenue for resource mobilization to address critical nutrition gaps. Therefore in light of the anticipated El-Niño, the CNTF identified partnerships in WASH, education, health and livelihoods

USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 80 sectors that can be drawn up to mitigate the impact of the above normal rains. Some of the opportunities identified was the need to preposition adequate Nutrition commodities at various strategic points.

MANDERA COUNTY Nutrition situation: According to the Long Rains Assessments, the nutrition situation has remained very critical in Mandera County but stable due to extremely high vulnerabilities. The nutrition SMART survey conducted in June 2015 indicated a GAM rate of 25% and Severe Acute Malnutrition GAM rate of 4.1%. According to the latest NDMA bulletin released, the percentage of children (<5yrs) at risk of malnutrition based on Mid Upper Arm Circumference (MUAC<135mm) for the month of August was 23.0%. When compared to the previous month, it had increased by 1.9%.

Due to the volatile security situation in Mandera, the project continued to remotely support the County to ensure continued provision of quality High Impact Nutrition services in the county. Some of the activities implemented focused on training of CHVs on child health care and nutrition, coordinating World breastfeeding Week campaigns through CHMTs, orientation of HCWs on nutrition performance indicators and reporting, and linkages and collaborations with Global fund TB. Food by Prescription (FBP) Programme for HIV and TB clients: The County has not received any supplies of FBP from NHPplus and Global fund TB projects. The project is currently liaising with these projects to see timely supply of nutrition commodities Orientation of HCWs on nutrition performance indicators tracking and reporting (LMIS tools), HiNi, Nutrition in HIV/AIDS and TB: During the quarter, the project oriented 15 HCWs drawn from Mandera County Referral Hospital on nutrition performance indicators and reporting and provided on-the- job training on 90-90-90 strategy. Provision of quality Nutrition Assessment Counseling and Support was also emphasized. The HCWs were orientated on the following key areas:  ART Guidelines (2011),Diagnosis and management of malnutrition in HIV-infected adult patients, Nutrition Assessment Counseling and Support/FBP protocol and Diagnosis and Management of Under-Nutrition  Nutrition data management systems and overview of nutrition commodities  Standard treatment guidelines for HIV & TB  High Impact Nutrition Interventions (HiNi) and national targets  Receiving, storage and inventory management records and linking service data to commodity tools & quantification of nutrition commodities  Nutrition commodities data collecting and reporting tools and completing commodity tools  M&E issues for HIV and TB Nutrition The orientation has enhanced knowledge and skills of 15 HCWs thereby enabling them to effectively promote quality nutrition interventions and services at all levels of Mandera County health system. Training of CHVs on Child Health Care and Nutrition: In collaboration with MoH and LIPs, the project trained an additional 43 CHVs from CUs and LIPs on Child Health Care, and Nutrition (ZN/ORS supplementations). The training entirely focused on HiNi, general child health care practices, with a special focus on therapeutic zinc supplementation during diarrhea, optimal hand washing –how and when to wash hands, food hygiene, treatment and safe storage of household water, waste storage methods, and other child health care practices. The CHVs are currently disseminating messages/knowledge gained to OVC/PLHIV households and general community at key contact points. Maternal & Child health campaigns: The project through the County Health Management Team (CHMT) supported the commemoration of World Breastfeeding Week (WBW) between 1st and 7th August, 2015 in USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 81

Mandera. The project provided banners (with messages promoting EBF, utilization of maternal and child health services) and refreshments for the county launch. Integrated nutrition support supervision: To enhance knowledge, competence and skills of facility based HCWs in Mandera Sub-County Hospitals; the project facilitated the CNC Mandera to undertake nutrition support supervision on nutrition performance indicators and reporting, mentor HCWs on nutrition commodity data collection and reporting and quantification of nutrition commodities. During the trip, the CNC was able to identify opportunities for improvement, provide on the job and mentorship on facility level reporting of nutrition indicators and discuss with Sub-county Nutrition Officers on how to ensure smooth transition of nutrition commodities from one level to another. These are some of the outcomes following the visit:

 Limited storage capacity at facilities improved after guidance was given on how to effectively use space  Placing orders for FBP commodities was the greatest challenge affecting supply of FBP Programme for all facilities. The CNC provided on the job training on ordering/full supply items. The project will continue to support nutrition support supervision since it‘s an opportunity for supervisors to experience the challenges faced by health facilities and HCWs and collaborate to identify practical strategies to address them.

TANA RIVER COUNTY During this reporting period, the project continued to partner with the MOH and other partners to implement activities across the communities with an emphasis on delivery of quality health services and capturing data which is critical for decision making. Promotion and delivery of nutrition messages to the community during different forums, mentorship of HCWs, Vitamin A supplementation exercise, WBW activities and County Health Management Team consultative meetings are some of the activities implemented during the quarter. The County Government also sensitized communities on nutrition resilience especially with the acute food shortages during the dry season witnessed during the quarter and the upcoming El Nino rains. Key activities and outputs from Tana River County Facility based MTMSG meetings- The project supported 2 MTMSG meetings in Wachakone and Chewani for information sharing and dissemination on MIYCN practices including Baby Friendly community initiatives. Group discussions primarily focused on the care and nutrition of mothers and children under five years, 38 mothers were reached. World Breastfeeding Week activities- The project supported 2 advocacy and sensitization meetings for HCWs both in Hola County Referral Hospital and Ngao Sub County Hospital. The launch was in form of a breakfast meeting to sensitize and advocate for breastfeeding at the workplace. These meetings involved all the departmental heads, private sector and union leaders in the county. This has since increased awareness within facilities on the need to support breastfeeding at the work place and the benefits of breastfeeding to the society at large. Orientation of ECD teachers on Vitamin A, deworming and GMP- The project continued to work with the relevant stakeholders to promote child survival programmes. To this end, 7 ECD centers in the Tana Delta Sub County were targeted with training on growth monitoring, vitamin A and deworming. This will raise their skill levels on identification and referral of children with or at risk of malnutrition to the nearest

USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 82 health facilities for appropriate nutrition interventions. The teachers will in the subsequent months provide these services at their ECD centers and share the data with link facilities for data entry into the DHIS. Integration of Nutrition into the CCC/TB and MCH clinics: 10 HCWs were oriented on nutrition performance indicators & reporting (LMIS tools), vitamin A data capture and reporting, screening for malnutrition at the Child Welfare Clinics (CWC) and referrals to appropriate interventions. The project also continually provided mentorship at the same clinics. County Nutrition Technical Forum: The project supported one CNTF in the county to discuss Vitamin A status in the county, nutrition indicators analysis (Supplementary Feeding Program/Out Patient Therapeutic Programme), Feedback from workshop on complimentary feeding and El-Niño rains preparations. The CHMTs were challenged to take up their leadership roles, to work better, take responsibility for delivery of quality health care services. GARISSA COUNTY The quarter under review continued to witness insecurity in some parts of the county which continued to affect the implementation of activities. The project however rode on support of the County Ministry of Health and the LIPs in delivering services to the community. Technical support, OJTs and mentorship was done for the high volume facilities. To increase the uptake of HiNi and MIYCN practices both for the HCWs and the community, the project supported breastfeeding advocacy and MTMSG meetings during the August 2015 World Breastfeeding Week. Other key nutrition partners and the County Government utilized outreaches to deliver key food security and nutrition messages and integrated support supervision to monitor progress of key deliverables while at the same time building the capacity of HCWs on identified gaps. Nutrition surveillance was critical during this quarter due to deteriorating food security situation and information and data collected was used for decision making to come up with interventions for preventing and reducing malnutrition rates during the County Steering Group meetings. Key activities and outputs in Garissa County included: World Breast Feeding Week: The project supported 2 sensitization and advocacy meetings in Garissa and Mbalambala Sub Counties. The main agenda was to galvanize multi-dimensional support from all sectors to enable women everywhere to work and breastfeed while promoting actions by employers to become Baby and Mother-Friendly. This has led to increased awareness among HCWs on breastfeeding and work. 2 MTMSG meetings were also held to promote IYCN. Integration of Nutrition into the CCC/TB/MCH clinics: During the quarter, the project continued to give technical support to 10 HCWs at the CCC/MCH and TB clinics. Correct documentation of all children supplemented with Vitamin A, assessment of children at the CWC, FBP reporting into DHIs and daily health education for mothers at MCH was emphasized. HCWs at Garissa County Referral Hospital, Police Line, SIMAHO and Iftin hospitals are now tracking daily data entries for monitoring progress of key nutrition indicators. The project also supported redistribution of nutrition commodities to other satellite facilities from the central site in Garissa. Facility based Mother to Mother Support Group meetings: To bridge the knowledge gaps in MIYCN and increase the uptake of HiNi in the community, the project supported 4 MTMSG meetings in partnership with MOH. These forums provides an excellent opportunity to deliver social behavior change communication messages on health and nutrition as they are more readily accessed by women who will later be agents of change within their communities

TURKANA COUNTY USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 83

Using SIMS as a guide to and for monitoring provision of quality nutrition services, the project worked with Nutritionists at St. Catherine‘s Dispensary, Katilu Health Centre, Reformed Church of East Africa (RCEA) Lokichar Health Centre and Lokori Primary Health Care (PHC) to ensure accurate and complete documentation of assessment, categorization and counseling of adult and pediatric clients. The use of the nutrition service form that was developed the previous quarter was also cascaded to the facilities in Turkana South and East. Availability and use of nutrition LMIS registers and tools was also monitored during the period; the project facilitated the delivery of 241 various nutrition services registers from NASCOP to the County. However, the continued lack of food by prescription commodities continued to affect delivery of nutrition services especially in the Faith Based Facilities. As part of the project‘s sustainability strategy, 134 CHVs and 7 Community Health Extension Workers (CHEWs) from various CUs were trained on Nutrition using the Community Health Strategy Nutrition Module. The developed action plans from each CU will be implemented in the coming quarter In addition to provision of HINI in health facilities, the project continued to support provision of HiNi such as Vitamin A supplementation (VAS), deworming and growth monitoring and promotion (GMP) in additional implementation structures such as ECDs. This was done through sensitization of 20 ECDE teachers on the importance of the above 3 services. As a result of these efforts, 7 ECDE centers managed to provide VAS to 200 children in Lokichar Division. The rest of the 13 ECDE centers plus additional centers to be trained will be supported to provide VAS in the coming quarter. The project also took advantage of the Turkana Cultural services to provide VAS to 24 under-fives, MUAC screening to 310 under-fives and deworming for 310 under -fives. Finally, the project supported the county to launch the Turkana County Nutrition Action Plan. The plan serves as a road map for stakeholders‘ decisions on nutrition programming goals and strategies. Nutrition Situation: Generally, there have been some slight improvements in the overall nutrition situation in the county as evidenced by GAM rates scores (with ranges from 17.4% to 28.7% in 2014 to 16.4% and 24.5% in 2015), NDMA Early Warning System (EWS) bulletin and routine health facility nutrition data. However, the early warning phase classification for the county has deteriorated from normal in July to alert in August and September 2015. The worsening trend is attributed to halted nutrition and health outreaches in parts of the county and the deteriorating food security situation. The identified hot spots that require immediate interventions are Turkana North, Kibish, Loima and South (Lokichar) and plans are underway at county level to address the deteriorating situation. Nutrition- HIV: The project continued to support the county to provide quality Nutrition HIV services at facilities. This was done through routine technical assistance, mentorship and on job training to 5 Nutritionists and HCWs at our priority one facilities. Following the baseline SIMS that was done last quarter at St. Catherine‘s Dispensary, RCEA Lokichar Health Centre, Katilu Health Centre and Lokori PHC, focused and sustained efforts were directed towards addressing the identified gaps such as documentation of anthropometric measurements and Nutrition counseling. The roll out of the nutrition service form was cascaded to Turkana South and East and is currently used to document nutrition counseling and/or education in all the above facilities. Availability and use of reporting tools and registers was also ensured. For sustained availability and use, the project facilitated the delivery of the following registers and guidelines from NASCOP to the county: Table 17: Registers and Guidelines Delivered to Turkana County by APHIAplus IMARISHA REGISTERS/GUIDELINES NUMBER OF PIECES

MOH 407A 100

USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 84

MOH 407B 15

MOH 409 38

MOH 733B 17

MOH 734 17

MOH 734A 17

MOH 734B 17

NUTRITION-HIV guidelines 20

Drug-Food interactions wall chart 6

The registers were handed over to the County Nutrition Coordinator for distribution. However, as reported last quarter, supply of Food by Prescription has not resumed. All facilities were out of stock the entire period. This continued to have a significant impact on individual nutrition counseling of clients Training of CHVs on Nutrition: Sustained community active case finding, complete referral and availability of quality curative and preventive services at the health facility and community level are some of the strategies that have been proven to have a significant impact in the fight against malnutrition. This however can only happen when there are skilled human resource at all levels. To enhance availability of skills and for sustained availability of these services, the project trained 134 CHVs and 4 CHEWs from Katilu, Lokichar, Kanamkemer, Napetet and Kalokol CUs on Nutrition using the Community Strategy Nutrition Module. In the coming quarter, the project will work with the trained CHVs and CHEWs to incorporate easy doable nutrition actions such as cooking demonstrations, nutrition and health education, hygiene promotion in their community activities Sensitization of Nutritionists on Key HiNi indicators: in an effort to improve coverage and reporting of key High Impact Nutrition Interventions at facility and community levels, the project conducted a 1 day sensitization forum for 15 Nutritionists from Turkana East. The forum provided an opportunity for Ministry of Health Turkana East to have an open factual discussion on the status of some of the key high impact interventions. Following the sensitization forum, the Sub-County Nutritionist has reported that there is more vigilance in data capture and data entry into the DHIS. Sensitization of ECDE teachers on Growth Monitoring and Promotion (GMP), VAS and Deworming: the project continued to support to explore alternative implementation structures for select High Impact Interventions. To this end, the project brought together 20 ECDE teachers from Turkana South to learn more about the importance of the vitamin A supplementation, routine growth monitoring and deworming. So far 7 ECDE centers have conducted VAS to 200 children with the rest planning to conduct the same in the coming quarter. Turkana County Nutrition Action Plan: The project supported the County government to launch the Turkana County Nutrition Action Plan for the period 2012-2017. The plan serves as a road map for all nutrition and food security activities in the County. The project will continually use the work plan to inform planning.

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MARSABIT COUNTY During the quarter under review, the food security situation in the county worsened as a result of the long dry spell. According to August 2015 Marsabit County Drought bulletin, Socio Economic Impact indicators report, livestock body conditions continue to deteriorate following a decline in quantity and quality of pasture and water. Resource based conflicts have been reported in some Marsabit South Sub Counties as pressure increases on limited grazing and water resources causing disruptions on market operations hence impacting on elements of food availability and accessibility. As a result milk production and consumption has decreased in August when compared to July. More importantly coping strategies index for the month was 1.38indicating reduced food availability. As a result of the strategies mounted by the project, key achievements during the quarter include; capacity building of 37 CHVs to facilitate screening and referral of malnourished children in hard to reach areas and provision of nutrition education on food preservation and food storage techniques to 122 OVC caregivers, supplementation of Vitamin A in Early Childhood Development centers to 345 under-fives, Nutrition and Agricultural field day that reached 133 farming individuals and orientation of 16 HCWs on nutrition performance indicators & reporting (LMIS tools), High Impact Nutrition Interventions, Nutrition in HIV/AIDS & TB in Saku Sub County, Moyale, Marsabit South and North Sub Counties and supporting Nutrition survey in Marsabit Sub County. Key outputs from Marsabit County are elaborated below. Support Marsabit County Nutrition survey: As part of ongoing nutrition surveillance in the County and in collaboration with other nutrition partners, the project supported MOH on surveillance of nutrition indicators with the objective of estimating the current prevalence of acute malnutrition in children aged 6 – 59 months in Marsabit South Sub Counties in September 2015. Other specific objective is to compare the overall nutritional changes with the previous GAM and SAM, determine the morbidity rates amongst children aged 0‐59 months over a two week recall period, to estimate the coverage of Measles, BCG vaccination and deworming for children 9-59 months and 6-59 months respectively and determine the coverage for zinc supplementation and vitamin A supplementation among the children 6-59 months. Below is the preliminary analysis of the report. The preliminary findings indicate a slight decrease in underweight and stunting levels in 2015 as compared to 2014; from 35.4% to 32.7% and 33.8 % to 25.9%.respectively. This significant decrease is attributed to project interventions, particularly on health education on child feeding practices and health seeking behavior along with Vitamin A supplementation at ECD Centers. Technical Assistance at Priority one facilities: During the quarter the project supported orientation of 16 HCWs in Marsabit County Referral Hospital, Sololo Mission Hospital, Moyale Sub County Hospital, Loiyangalani Dispensary and Laisamis Mission Hospital on nutrition performance indicators & reporting, High Impact Nutrition Interventions, Nutrition in HIV/AIDS &TB was undertaken by the project. As a result of the technical support, adoption of the LMIS tools improved significantly in satellite sites and priority facilities. This further improved the documentation and reporting of Nutrition HIV services in three sites provided with FBP commodities in the county. ECD Teachers GMP, vitamin A supplementation and deworming: The project supported 21 ECD teachers who were previously trained and provided reporting booklets to enable them undertake growth monitoring at schools. 854 children under-fives were assessed for malnutrition and 38 moderately malnourished cases referred to nearest health facilities. 345 children were supplemented with Vitamin A and 145 dewormed during the exercise. MUAC tapes and reporting tools was provided by HCWs at nearest health facilities

USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 86

Training of CHWs on Nutrition, Zinc and ORS supplementation: CHVs have been major players in the implementation of primary healthcare and continue to play a critical role in mobilizing communities in taking care of their health and providing basic healthcare at community level. The project supported the MOH in training 37 CHVs on key high impact nutrition interventions including the promotion of good practices such as maternal and infant & young child nutrition through exclusive breastfeeding, optimal complementary feeding, maternal nutrition and hand washing; improving intake of micronutrients such as Vitamin A supplements for children, iron and folic acid supplements for pregnant women, use of iodized salt for the general public, zinc supplements for diarrhea management, use of multiple micronutrient powders for young children; use of diversified local foodstuffs and fortified foods; deworming; identifying, screening and referring malnourished children, women and the elderly and promoting healthy lifestyles to reduce diet related diseases. The volunteers contributed in supplementation of supported in 2834 children under-fives with Vitamin A in July and Aug 2015. SAMBURU COUNTY County Nutrition Technical Forum: The project participated in the monthly County Nutrition Technical Forum (CNTF) in which progress on the various nutrition interventions in the County were discussed. One of the key agenda was the status of the Food by Prescription programme in the County. Redistribution of FBP commodities that had a short expiry as well as making the Catholic Hospital at Wamba a site for dispensing of FBP to serve the numerous clients enrolled at the facility were some of the key action points from the meeting.

County Steering Group on Nutrition and Food Security Issues: Due to the prevailing drought situation in the County, the County Steering Group (CSG) meeting was convened to discuss the potential effects of the drought on the Food and Nutrition security of the households and come up with a response plan especially for the high alert areas of Samburu East. The response plan was shared with the National Government for support. The whole process was coordinated by the National Drought Management Authority (NDMA).

Routine Data Quality Audit: In conjunction with USAID the project conducted an RDQA in 3 facilities namely Maralal County Referral Hospital, Sirata Dispensary and Kisima Model Health Centre. The report indicated that was a good performance on services and data quality in the health facilities that receive regular direct technical assistance (TA) from the project. However, there were gaps in the outlying facilities where no regular TA was conducted by the project. Integration of outreach data with the health facility reporting was also noted as a gap. To address this, the project will collaborate with the Sub- County Health Management Team in the coming quarter to provide regular TA in these facilities.

Nutrition Outreaches Activities: During the reporting period, the project continued to work with the Ministry of Health to improve access to various nutrition services during the quarter. This was done through OVC station days and the Maralal International Camel Derby. Services offered included MUAC assessments, vitamin A supplementation and Iron/Folic Acid supplementation. For example, during the 2015 edition of the Maralal International Camel Derby, the following nutrition services were provided; Table 18: Number of Clients Reached Through Outreaches with Nutrition Services Service Number reached Vitamin A 233 Diarrhea cases treated with Zinc and ORS 10 Multiple Micro nutrients supplementation 32 Nutrition counseling 90 Growth monitoring 68

USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 87

No. reached with health messages on utilization of 500 indigenous No. reached with health messages on food 450 preservation No. reached with sack gardening health messages 450

The report was shared with Maralal County and Referral hospital for integration with the facility reports. ISIOLO COUNTY Nutrition and HIV

During the quarter the project continued to reinforce the capacity building initiatives by strengthening the technical assistance to promote nutrition service as a key component of the minimum package of care for people living with HIV. Six Health Care Workers were mentored on accurate categorization of severe and moderate acute malnutrition and prescription of appropriate interventions and Nutrition Logistic Information System.

As a result, during the reporting period, 82% of clients who attended the CCC clinic at Isiolo County and Referral hospital were assessed counseled and only 47% of the eligible received Food by prescription (FBP). The County had FBP stock outs in the months of July and September.

The table below shows the number of people eligible for malnutrition and the number that received Nutrition support during the period.

Figure 64: Findings of Nutrition Assessment in Isiolo County Referral Hospital Mother to mother support groups: Working through FHK, 45 active members of mother to mother support group at Waso dispensary were trained on TB management, hand washing, kitchen gardens and on food preparation and preservation methods. The mothers are currently promoting nutrition interventions in Waso location. As a result of this, hand washing at critical times is practiced within themselves and at the neighborhoods. USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 88

IR 3.2: Increased Demand for an Integrated Package of Quality High-Impact Interventions at Community and Facility Levels Expected Outcomes 3.2.1: Reduced social, economic, and geographic barriers to accessing and utilizing services Expected Outcome 3.2.2: Increased capacity of districts to organize appropriate communications strategy Expected Outcome 3.2.3: Increased capacity of facilities to provide client-centered, humane and dignified care

Expected Outcome 3.2.4: Increased capacity of community units to mobilize communities During this reporting period, the project‘s BCC community based volunteers reached 11,275 people (4,630 males; 6,645 females) using evidence informed behavioral Interventions (EBIs) and distributed 40,408 condoms (40,405 male; 3 female) to their peers and the general community. The composition of those reached was 3,791 Key populations (421 males; 3,370 females), 7,116 youth out of school (4,004 males; 3,112 females), 136 youth in school (71 males; 65 females) and 232 young people (134 males; 98 females) with RESPECT K Intervention aimed at increasing HTC and adherence to care and treatment. Referrals included to cervical cancer screening for 222 females, HTC for 508 people, STI screening and treatment for 272 people, TB screening and treatment for 175 people, Psycho social support for 66 people and family planning for 176 people. Towards increasing capacity of facilities to provide client – centered, humane and dignified care, the project supported a seven day TOT Stigma and Discrimination Elimination training for 25 participants (9 males; 17 females) from 28/9/2015 to 4/10/2015 in Marsabit Town. The participants were selected CCC health workers, expert patient clients, LIP staff and part of the project team drawn from Isiolo, Samburu and Marsabit Counties. The aim was to equip participants with knowledge, skills and positive attitudes to provide non stigmatizing services in the course of duty back at their work stations to increase access and adherence to ART. After the training, the participants specifically agreed to give feedback to colleagues at their work stations, followed by providing health talks at facility level during monthly support group meetings of mother to mother, PLWHIV, TB clients at the TB Manyattas and defaulter tracing from the CCC to the community and vice versa. They also planned to undertake Community level health education meetings to eliminate HIV related stigma and discrimination in churches, mosques, social groups and at the work place and during health action days such as the World AIDS Day. The impact of this training will be measured by the increased uptake of HTC, enrolment to care and treatment and the suppressed viral load among clients relative to the baseline figures at the link health facilities. County specific achievements are summarized below. TURKANA COUNTY Female Sex Work Peer Education activities: Through one-on-one sessions and small group discussions, FSW PEs reached 1,869 female peers with HIV prevention messages, distributed 1,470 (1,470 male; 0 female) condoms and referred 52 women for HTC. Added to the 6,391 FSW reached by June 2015, the project reached 7,861 FSW as at end of September 2015 against a target of 1,030.

USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 89

Fisher folk reached with Influencing attitudes on Violence against Women and HIV and AIDS: The project supported the SASA! training for five days at Lodwar Lodge, Lodwar Town from 14th to 18th September 2015 targeting 26 fisher folk (14 males; 12 females) drawn from Eliye Springs, Namukuse, Kalokol and Long‘ech along . The aim of the training was to create awareness to help the community members, leaders, service providers, and all partners to explore the implications of men‘s use of power over women and the community‘s silence about this. It was noted that subsequently, this violence contributed significantly to HIV infection and hindered access to HIV Prevention services. The project collaborated with NASCOP who availed two national master trainers. At the end of the training, participants produced work plans which the project will use to monitor and support awareness raising activities aimed at increasing access to HTC, care and treatment linkage and community support activities. Youth out of school interventions: The project technically supported YPE to reach 909 youth out of school (452 males; 457 females) with health messages and referrals. Added to the 4,242 youth (2,363 males; 1,879 females) reached by June 2015, the project has reached 5,151 youth (2,815 males; 2,336 females) against a target of 12,960 with Tuko Pamoja Life Skills Education as at the reporting period. Voluntary Medical Male Circumcision (VMMC) Community Entry process: A total of 260 Stakeholders comprising the Sub County MOH (SCMOH), opinion shapers, youth, women and religious group leaders participated in the community entry processes in the 3 divisions of Turkana West Sub County guided by the APHIAplus IMARISHA road map for demand creation approaches for VMMC uptake amongst men older than 25 years. The project supported community entry processes in Turkana North and Kibish from 13th to 19th September 2015. The targeted areas included Kataboi, Nachukui, Lowarengak, , Karebur, Kokuro, Kibish, Napak, Kaikor, Kaaleng, Milimatatu, Kanakurdio and Kaeris. Funding timelines for other USG partners such as Film Aid ran parallel and therefore the synergy was not realized fully during the VMMC community entry process for Turkana North and Kibish. Targeted technical support to initiate and strengthen facility to community linkages The project further carried out technical support to Katilu health centre, PHC Lokori, AIC Kalokol, St Mary‘s Kalokol and St Monica to initiate and strengthen facility to community linkages to ensure comprehensive service provision to clients. The project team and the respective health facility staff developed directory of non-clinical services available at the community level where they could appropriately refer clients. TANA RIVER COUNTY Female Sex Workers Peer Education Activities: The FSW PEs reached 374 female peers with HIV prevention messages as well as condom distribution and referred 27 people for Family Planning services. Attrition due to migration out of the project site affected reporting rates. Men having Sex with Men Activities: MSM PEs reached 421 male peers with BCC messages on HIV prevention, distributed 1,400 male condoms to their peers and referred 207 people for HTC and 66 for psycho social support. Youth out of school Peer education sessions: The project supported Youth out of school PEs to reach 5,827 youth (3,360 males; 2,467 females) with health messages through small groups and one on one sessions and distributed 15,105 male condoms to their peers and the general population. Increased capacity of the county to organize appropriate communications strategy; The project participated in a quarterly Health Promotion Advocacy (HPAC) meeting co-organized by the MOH and the APHIAplus HCM on 2/08/2015 at Milele hotel, Hola as part of building the capacity of the county to

USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 90 organize and implement their communications strategy in line with the national communication guidelines along given health thematic areas. GARISSA, WAJIR, MANDERA COUNTIES Due to low HIV incidence cluster in Garissa, Wajir and Mandera Counties there were no specific HIV prevention related BCC interventions undertaken. MARSABIT COUNTY Female Sex Workers Peer Education activities: FSW PEs reached 203 female peers with HIV prevention messages, distributed 2,409 (2,406 male; 3 female) condoms, referred 144 women for Cervical Cancer screening, 69 people (28 males; 41 females) for HTC, 272 people (143 males; 129 females) for STIs screening and treatment & 26 people (10 males; 16 females) for TB screening and treatment. ISIOLO COUNTY FSW Peer Education: FSW PE reached 775 female peers with HIV prevention messages, distributed 20,024 male condoms and made HTC and STI screening referrals as at September 2015. In addition to the 1,972 FSW reached as at June 2015, the project reached 2,747 FSW as at September 2015 against the APR target of 1,540. Youth Out of School Peer Education: APHIAplus IMARISHA supported Youth PEs to reach 380 youth (192 males; 188 females) with health messages and referred 31 people (19 males; 12 females) for HTC. There was attrition for lack of financial motivation since the project changed focus from this target group to key populations. Added to the 7,959 youth (4,071 males; 3,888 females) reached in the last quarter, the project reached 8,389 youth (4,263 males; 4,076 females) against a target of 9,360 as at APR 2015. SAMBURU COUNTY FSW Peer Education: The trained FSWPE reached 149 peers with behavioral change messages and referred 78 people for cervical cancer screening, 149 people for HTC, 149 people for STI screening and treatment, 149 people for TB screening and treatment and 149 people for family planning. The major challenge experienced was attrition occasioned by seasonal migration, volunteer competing priorities and illiteracy that affected timeliness and quality of reports. The project team is working with the group leaders to pair semi- literate members with literate ones to improve on quality or reports and to motivate them to continue working. IR 3.3 Increased Adoption of Healthy Behaviors Expected Outcome 3.3.1: Improved Home-based healthy Practices with a Focus on the High Impact Interventions Expected Outcome 3.3.2: Improved Compliance with Preventive and Curative Protocols Expected Outcome 3.3.3: Improved Appropriate Health Care-Seeking Behavior

In early July before the onset of the nationwide teachers strike, school health club patrons and trained teachers mentored 136 members of school health clubs (71 males; 65 females) on Life Skills Education (LSE) aimed at promoting abstinence in Turkana County. Further, the trained RESPECT K facilitators reached 73 vulnerable youth (31 males; 42 women) consisting of ages 15-19 years (1 male; 6 females), 20-24 years (27 males; 32 females) and over 25 years (3 males; 4 females) with the EBI aimed at increasing access to HTC as at APR 2015. Specific achievements by county are summarized below. USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 91

TURKANA COUNTY Youth in schools reached with LSE and ASRH: In early July 2015, the trained LSE teachers reached 136 youth in school (71 boys; 65 girls) with LSE messages through small groups and one on one session using the Tuko Pamoja LSE curriculum that aims at building the young people‘s skills on abstinence and being faithful only. The project collaborated with the ministry of education at the County level to technically support this activity. Added to the 3,248 youth (1,503 males; 1,745 females) reached as at June 2015, the project reached 3,384 youth (1,574 males; 1,810 females) against a target of 4,752 as at APR 2015. The National teachers strike, competing academic calendar for the third term and teacher transfers disrupted the implementation of planned LSE activities. RESPECT K: The RESPECT K facilitators reached 212 vulnerable youth (129 males; 83 women) aged 20 to 24 years with the EBI. Added to the 275 youth (106 males; 169 females) reached as at June 2015, the project reached 487 youth (235 males; 252 females) against a target of 1,152 with the EBI as at APR 2015. Community Prevention with Positives (CPwP): A total of 8 PLWHIV support groups conducted regular monthly meetings to enhance drug adherence and psychosocial support (PSS) based on the work plans developed by the trained cPwP facilitators (10 females and 8 males) during their training in the previous quarter as well as technical support from the project team. Limited funds to purchase snacks and refreshments, facilitation fees for cPwP facilitators during the monthly meetings, Stigma and discrimination and other individual material needs continued to affect the groups. The project team linked the groups with other structural interventions within the result four component and some groups are already engaged in income generation such as those from Lowarengak, St. Patrick‘s, Lorgum (green house) and Kalokol (trained on value addition and fish preservation). The project team is keenly looking for other actors to financially support the groups to meet the increased demand for disposable household income among group members. A TOT Stigma and Discrimination Elimination training for selected CCC health workers, expert patient clients, LIP staff and part of the project team is planned for October 2015 to equip participants with knowledge, skills and positive attitudes to provide non stigmatizing services in the course of duty back at their work stations which will further increase adherence to ART. MARSABIT COUNTY Community Prevention with Positives: To strengthen support groups of PLWHIV, the project team met with representatives of PLWHIV groups (both men and women) and the facility staff to improve on ART adherence and contribute to the WHO 90- 90-90 strategy in Marsabit County. Consequently, the subsequent meetings were as follows; Marsabit Referral hospital (on 5/9/2015 at St. Stephen ACK Hall in Marsabit1), Sololo Mission Hospital (active meetings since July to date) and Moyale Sub County referral hospital (held initial meetings with facility staff and group leaders). The Sololo meetings registered an average monthly attendance of 50 people consisting of 14 children (4 males; 10 females), 1 adolescent (0 males; 1 female) and 35 adults (8 males; 27 females). There were 3 new clients consisting of (1 male; 2 females). The project provided snacks and refreshments to support the meetings. The topics discussed included the importance of psychosocial support, adherence counseling, prevention of opportunistic infections, positive living, disclosure, among others. The group

1 The project team met with 16 leaders of Duran Dema Umbrella HIV psycho social support group drawn from Saku (Marsabit Central) to strategize on how to contribute to the WHO 90-90-90 Strategy. The MOH was represented by the CASCO, CCC in charge, MCH in charge, Maternity in charge, outpatient in charge and TB clinic nurse as well as two Expert patient counselors. The group leaders resolved to reactivate group meetings in their respective zones where the project committed to initially support the meetings of the 16 groups from Saku with snacks and refreshments based on the available resources. USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 92 members were receptive of the messages and showed renewed enthusiasm to participate in the group activities and honor the tenets of positive living. ISIOLO COUNTY Community Prevention with Positives: The project team met with the representatives of the PLHIV support groups and the facility in charges of Garbatulla and Kinna Health Centre with a view to resuscitating PLHIV support groups and came up with a calendar of future activities based on the Isiolo County Referral Hospital (ICRH) experience. Table 19 shows the cPwP attendance from April 2015 to September 2015 at the Isiolo CRH. Table 19: Monthly cPwP Attendance at Isiolo County Referral Hospital Month Pediatrics Adolescents Adults Total Male Female Male Female Male Female Male Female Total April 8 10 0 0 10 33 18 43 61 May 7 8 0 0 9 39 16 47 63 June 5 22 3 0 5 33 13 55 68 July 8 21 3 0 6 23 17 44 61 August 3 10 1 2 11 43 15 55 70 September 10 16 0 2 5 40 15 58 73 Cumulative Total 41 87 7 4 46 211 94 302 396 attendance Average Attendance 7 15 1 1 8 35 16 50 66 per meeting This signifies an average attendance of 66 people (16 males; 50 females) per month comprising of an average of 21 children (7 males; 15 females), 2 adolescents (1 male; 1 female) and 43 adults (8 males; 35 females). The major challenge facing adolescents is the competing school academic calendar that makes it difficult for them to meet at the health facility on scheduled days. Stigma during this experimental stage also hinders disclosure to friends and eventual attendance of meetings. The project is monitoring this to develop more adolescent friendly psycho social support activities for this group. The project is using cPwP as one of the strategies to retain clients on care and treatment for improved adherence to ART. The CCC staff and medical social workers coordinated and technically back stopped the meetings while the project financially supported the meeting logistics (snacks and refreshments) and offered technical assistance. RESPECT K: The project reached a total of 20 vulnerable youth (5 males; 15 women) from 15 years and above with the RESPECT K EBI comprising 7 people (1 male; 6 females) aged 15-19 years, 6 people (1 male; 5 females) aged 20 – 24 years and 7 people (3 males; 4 females) aged over 25 years. The facilitators discussed goal setting with the clients to reduce the risk of HIV infection.

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IR 3.4 Increase Program Effectiveness through Innovative Approaches Expected Outcome 3.4.1: Development of new approaches to increase use of quality services at community and facility levels, especially among the marginalized During the period under review, APHIAplus IMARISHA continued to support innovative approaches in the respective NAL Counties to increase program effectiveness. These included: Maternal shelters

Kisima Maternal Shelter: The project continued to strengthen the maternal shelter at Kisima model health center that has recorded a significant and sustained increase in skilled deliveries at the facility. The improved maternal outcomes at the health facility has led to a special recognition from the County government as well as a high profile visit by the EU commissioner for International Cooperation and development of lessons on how to improve maternal and child outcomes.

Nachola Maternal Shelter: During the quarter, the project engaged with the CHMT, HCWs and CHVs of Nachola community in Samburu North Sub-County to operationalize the maternal shelters. The project held sensitization meetings with the CHVs and HCWs on reproductive health issues and scale up of skilled deliveries was identified as a key priority in this community. Thereafter, the CHVs undertook a community health action day in which they renovated the maternal shelter using local materials, while the project supported equipping of the maternal shelter with the basic items and the shelter is now fully operational.

Figure 65: CHVs Sensitization on Scaling Up of Skilled Birth Attendance at Nachola Dispensary

Lesidai Maternal Shelter: After community sensitization, the Lesidai health facility maternal shelter in Samburu Central was also constructed through community effort. The project supported the equipping of this shelter and now operational. The CHVs were also sensitized on the key maternal health issues including the importance of skilled birth attendance and would be supported to enhance referrals of mothers from the community to the maternal shelter at the health facility. The project developed draft standard operational procedure (SOP) for the establishment and operationalization of the traditional maternal shelters.

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Figure 66: Facility In-Charge and CHVs at Lesidai Dispensary in Samburu Central Sub-County Receiving Maternal Shelter Equipment and Supplies

Maternal shelter at Habaswein Sub-County Hospital in Wajir: The maternal shelter renovation is being supported by the DANIDA-SRH Project. This is an innovation in strengthening maternal and child health care with the aim of reducing maternal mortality in the platform of access in skilled birth deliveries. APHIAplus IMARISHA contribution has been to offer guidance to the DANIDA –SRH team on the steps and procedures to establish the shelter as well as engaging the County Health Teams on the significance of the shelter with a goal of reducing maternal mortality in the region. The renovation has since been completed and awaiting formal handed over to the ministry of health.

Ngadakarin Bamocha model in Turkana: During the quarter under review, the project has completed the modification of the Kotaruk Mobile container clinic and is in the process of procuring equipment and supplies with the goal of having a fully-functional clinic in the coming quarter. Meanwhile, the project team has been engaging the community through the dialogue days and health action days to sensitize and conduct referrals to Naipa Dispensary for services. The CU has reached a total of 180 households with preventive health information that has prompted referrals for child and maternal care, HTC services, TB screening as well as family planning services. Supportive supervision was conducted to the community health volunteers with a focus of enhancing utilization of project supported grant for IGA creation by the CHVs to ensure sustainability of the activities by the volunteers.

Domiciliary Midwives: In coordination with the respective CHMTs, the project continued to provide technical and logistic support to 25 Domiciliary Midwives (DM) to offer MNCH/FP and community midwifery services in Tana River and Isiolo Counties. The Domiciliary Midwives conducted 60 deliveries during the quarter under review among other MNCH/FP services as shown in the Table below;

Table 20: Number of Deliveries Undertaken by Domiciliary Midwives in Tana River County Domiciliary Clinic July 2015 August 2015 September 2015

Bora Imani 4 3 6

Heri Tana 7 6 8

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Mwangaza 1 0 2

Wema private 8 5 10

Total 20 14 26

In Isiolo County the project in collaboration with the CHMT had an orientation for the domiciliary mid wife‘s on Community Health strategy and new updates in MNCH, the two facilities renovated and supplied with equipment‘s by the project, started working in mid-July after a number of negotiation meeting between CHMT, RH/FP coordinator, APHIAplus IMARISHA and the midwife‘s in ensuring they got the facility/Clinic Numbers for reporting and the reporting tools, good progress has been made, in the meantime the mid wife‘s who do not have nursing homes are referring their clients to Isiolo County Referral hospital for skilled delivery as they also get other service like family planning and child welfare. In the just concluded quarter 30 Mother were either accompanied or referred for skilled delivery, while 18 were delivered and then referred immediately for further management at the referral hospital. BOMA model: During the quarter, the project supported acceleration of referral services by the CHVs who were trained on the BOMA model in the earlier quarters. The CHVs received additional mentorship aimed at increase in uptake of the high impact interventions especially in maternal, newborn and child health but also other community based health services. Further, the CHVs had also been trained on the RH/ FP technical module in the previous quarter and they applied these skills in their community sensitization and referral work. In spite of the persistent insecurity (in Samburu North) and drought that resulted in displacements of people, there was an increase in access to the MNCH services mostly attributed to the work of these CHVs. The table and graph below outlines the trends in the key MNCH indicators of 4th ANC visits, skilled birth attendance and postnatal care.

Figure 67: Trends in 4th ANC Visits, Skilled Birth Attendance and Postnatal Care in Samburu County

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UMATI Concept

To increase the access to various MNCH/FP/HIV services, the project continued to utilize the Umati concept through facilitation of HCWs to provide services during various community forums. During the quarter, some of the various fora participated in service provision include:  The OVC station days conducted in conjunction with the LIPs in which 3200 OVC received various services including HTC, nutritional screening, deworming, and vitamin A supplementation among others.  Religious fora where 427 persons were reached with various RH / MCH / HIV and stigma reduction messages during a church service. In a previous meeting 15 religious leaders representing 15 churches had been oriented on MNCH and HIV services and their roles in enhancing access to these services. Also, in another Church session, 50 people were reached with RH and HIV services and stigma reduction messages. This was also followed by another church services facilitated by persons with disability (PWD) 282 people were reached with RH and HIV prevention messages  During the 2015 edition of the Maralal International Camel Derby cultural festival, the program in partnership with the County government supported the UMATI outreaches and reached 2,993 clients with various services of which 15 women were provided with the first ANC service among other services. Using other innovative outreaches, an additional 1,528 women were reached with health messages during the quarter. The concept was applied in other activities and continued to contribute to the good access to services by the communities in Samburu. The table and graph below outline the performance on some of indicator i.e. immunization in which the CHVs were much involved in sensitizing and referring.

Figure 68: Trends in Immunizations in Samburu County (Oct, 2014 - Sept, 2015)

Client feedback Mechanism: APHIAplus IMARISHA continued to provide technical assistance in the scale-up of the Client feedback mechanism in both public and private health facilities in Garissa and Tana River Counties. During the period under review, the project provided technical assistance in the implementation of the Client feedback mechanism at Tarasaa catholic dispensary in Tana River, and SIMAHO in Garissa. Feedback from the clients has helped in developing interventions in improving service

USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 97 delivery. The clients have appreciated their consideration in evaluating the services and provision of suggestions on the areas of improvement.

Table 21: Clients Feedback on Areas to be addressed Facility Sub County Issues Tarasaa Catholic Dispensary Tana Delta . Only one HCW available increasing waiting time when clients are many . When the HCW is away the facility has to close or alternatively supported by a CHW. Sister Maternity Home Garissa sub- . Inadequate delivery equipment especially (SIMAHO) County delivery beds . Un-cooperative staff at night

Electronic cash register: After the successful implementation and maintenance for the last one year in Garissa Provincial General Hospital and Wamba Catholic Mission Hospital in Samburu County and following the official hand over of maintenance of the cash register system to the hospital administration; the project has continued to provide technical support to the hospital to enhance the capacity for revenue collection, financial planning and management through use of electronic cash registers. The electronic cash register has formed an integral part of the technological innovations that the hospital is applying to address various management issues. As the result of the success of the cash registers, the Garissa CHMT implemented the same models in Bura Sub-County Hospital and Masalani Hospital

Safe motherhood voucher system: To improve the uptake of RH/MNCH services, the project has continued to support the implementation of a safe motherhood voucher system that will encourage poor women to access ANC, skilled deliveries, FP and GBV services from Sister Maternity Home (SIMAHO) in Garissa County. Below is the performance of the voucher services at SIMAHO during the period under review; Table 22: Number of MNCH Clients Reached Through Voucher Services at SIMAHO Services July August September Totals ANC 73 42 71 186 Deliveries 34 20 12 66 FP 26 33 10 69 Postnatal 36 26 42 104

Habaswein Taxi voucher services: With the establishment of the new sub county hospital in Habaswein at the periphery of the town, transport was noted as the obstacle to access to skilled delivery by poor pregnant women. The distance has affected service accessibility specifically skilled birth deliveries. The project has been supporting taxi referrals with the objecting of strengthening skilled deliveries. During the quarter under review, a total of 99 mothers have been referred for skilled birth deliveries compared to 120 mothers in the preceding quarter. The project will continue to support taxi voucher services intervention to bridge the distance and transport cost barrier for accessibility of maternal health services and scale-up the program to other NAL Counties. USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 98

Figure 69: Trends of Skilled Birth Attendance at Habaswein SCH from 2013-2015

Livestock Based Health Insurance: To increase demand and access to health services, APHIAplus IMARISHA is collaborating with NHIF to implement livestock based health insurance in Turkana County through Local Implementing Partners and CBOs. To date, 8 health facilities have been accredited to provide outpatient services in Turkana County. These include: Lopiding SCH, AIC Lokichoggio health centre, Kakuma Mission hospital, Makutano health centre, Lokitang hospital, Lodwar District hospital, GK prisons Dispensary and AIC Kalokol Health centre. However, NHIF have also revised the cost for medical cover upwards from Ksh. 2,000 to Ksh 6,000, which poses a challenge to households who were prepared to contribute one goat. This has delayed the uptake and registration of member, since the new NHIF rates are higher than the value of a goat at community level. In light of this, the project is currently engaged in sensitisation and discussions with OVC caregiver groups to agree on how to raise the difference. APHIAplus IMARISHA continues to engage the National Health Insurance Fund (NHIF) on accreditation of additional health facilities. A list of 16 facilities in Turkana County (both private and public facilities) was submitted for consideration during the previous reporting period. NHIF officials have established a county office in Turkana and are in the process of recruiting the benefits and quality assurance officer to fast track facility inspection for accreditation. Registration for membership to the NHIF health insurance scheme within the catchment of the accredited facilities will proceed once the beneficiary groups agree on the way forward. Engaging Muslim religious leaders in the uptake of RMNCH/FP services in Wajir County: Stringent cultural practices and beliefs have led to low utilization of RMNCH/FP services in the county. The project together with DANIDA-SRH Project has brought on board the religious leaders in an effort to strengthen service utilization and access through community sensitization and advocacy. This is an innovative approach that can change the health seeking behaviors towards RMNCH/FP services. The project in collaboration with MOH and DANIDA-SRH project, have planned for 8 sensitization sessions across the entire County in October-December 2015. Performance Based Financing: During the quarter, APHIAplus IMARISHA continued to jointly engage with MOH to provide TA support to health facilities in Samburu County to implement initiatives aimed at improving on the performance of the 10 PBF indicators. As part of the independent verification agency the project supported the data verification for the April to June quarter.

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As a result of the successful implementation of PBF pilot in Samburu County, the World Bank funded a scale-up of this initiative to the rest of the 7 NAL Counties. Training of the S/CHMTs from the scale up Counties was conducted during the quarter and plans are underway to roll out of training to the HCWs in these Counties. APHIAplus IMARISHA continues to be a key stakeholder of the PBF and the County continues to provide learning ground for those who intend to implement PBF. Some outcomes include facilities undertaking maintenance and beautification activities to improve the environment and make the facilities attractive to clients to improve access to services. Other facilities have also ensured the community members are active participants in health facility management committees and provide linkage to the communities, sensitizing them on available services. This has resulted in improved quality of services as shown by 13 quality indicators measured by the programme. For example, there has been increased number of skilled deliveries demonstrated through correct filling of partographs. WELTEL SMS technology: WelTel Kenya phase 2 project is a collaboration of APHIAplus IMARISHA, the WelTel International mHealth Society (WelTel), and University of British Columbia (UBC). WelTel Kenya 2 project aims to conduct comprehensive evaluation of the implementation and impact of the WelTel SMS-based mHealth intervention on client engagement in HIV, MNCH and TB in NAL as well as incorporate the use of cell phones to link clients to the health care providers so that they are better engaged and retained in care, based on the prior proof of concept, WelTel Kenya1 trial. A clinic population cross sectional survey of patients attending HIV, MNCH and TB clinics in six health facilities in three NAL counties (Isiolo, Samburu, and Marsabit) and two additional health facilities from more populous neighboring counties (Meru and hospitals) was conducted in October 2014 to February 2015. The results of the baseline demographic survey of patients attending HIV, MNCH, and TB clinics in the NAL facilities were reported at the Kenya MOH eHealth Conference in August, 2015. In brief, the survey included 553 participants, with 325 (61%) from facilities in NAL, and 208 (39%) from neighboring county facilities. In NAL, 95 (29%) participants reported nomadic lifestyles. Overall, 400 (75%) participants owned a mobile phone at all sites including 211 (65%) from NAL and 189 (91%) from the adjacent county facilities. Out of those who did not own a mobile phone, and of those not able to send an SMS, 133 (87%) mentioned that a trusted individual could respond on their behalf. Overall, 444 (94%) responded that they would like to receive a weekly SMS from their health care providers, with a mix of text messaging and phone calls. Defaulting in HIV care is a regional problem. Attending clinic appointments is a surrogate marker for engagement in clinical care and known to be associated with improved clinical outcomes. There are currently about 1,350 active HIV CCC clients in the Isiolo CRH. Since April, WelTel has enrolled about 506 clients in the last 6 months (37.48%). At the beginning of the study period, only 37.3% of patients attended their HIV CCC appointments on time. However, over the past six months, this increased to over 62.3% as seen in the graph below.

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Figure 70: Patient Engagement in HIV Care Since the WELTEL SMS Intervention at Isiolo CRH, April-July 2015 To consider the impact of WelTel on HIV clinic attendance, comparison done for patients receiving the WelTel service versus standard clinical care alone over the same time period shows that WelTel enrolled clients in the HIV CCC department were more likely to attend their CCC appointment on time (67.5% versus 54.3% for non-WelTel clients) and were less likely to default their appointment (6.1% versus 7.6% for non-WelTel clients).

Figure 71: HIV Clinic Attendance at Scheduled Visits Enrolled and Not Enrolled in WELTEL, Isiolo CRH, April-August 2015 The overall HIV clinic data shows that the proportion of patients attending appointments on time almost doubled from April to August (37.3% to 62.3%) and by comparing those enrolled in WelTel to those that

USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 101 weren‘t, those enrolled in WelTel are more likely to attend CCC appointments on time (67.5% versus 54.3%) and slightly less likely to default on their appointments (6.1% WelTel versus 7.6% standard care). Attending ANC visits is known to be associated with improved pregnancy and early childhood outcomes. Over 1,020 clients were enrolled into the WelTel service at the Isiolo CRH MNCH clinic as of 1st October 2015.

Figure 72: Comparison of Pregnant Women Enrolled in WELTEL and Those Not Enrolled in WELTEL, Isiolo District Hospital MNCH Clinic, April-September, 2015 Overall, the WelTel clients had a higher mean of the number antenatal visits (2.99) as compared to non WelTel clients (2.74) over the reporting period. Despite the successes, the shortcomings included; the unreliable cellular data connectivity in the region and the high level of illiteracy and remoteness continues to be a challenge in the region.

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IR 4.1 - Marginalized, Poor and Underserved Groups have Increased Access to Economic Security Initiatives through Coordination and Integration with Economic Strengthening Programs Expected Outcome 4.1.1: Marginalized, Poor and Underserved Groups Accessing Economic Security Initiatives

Expected Outcome 4.1.2: Target Groups Actively Participating in Viable Economic Activity APHIAplus IMARISHA continued to implement HES activities through 23 LIPs across the 8 counties of NAL. Capacity building to LIP staff was also done focusing on different HES aspects such as creation and maintenance of groups‘ HES/IGA files, training on a SILC Management Information System (MIS) as well as induction on poultry record keeping and business planning. Project staff supported LIPs to deliver economic strengthening services with focus on capacity building of IGA group‘s for improved household nutrition and increased income. Some of the areas prioritised for capacity building include: pest and disease control for vegetables, management of poultry parasites and diseases, diversification of income generating activities, record keeping, enhancing of collaboration and linkages with other funding partners and microfinance providers, GOK service departments like Veterinary and Livestock production department, and Department of Trade for Hand crafts. Through the guidance of the project staff LIPs conducted community level IGA trainings through Ministry of Agriculture and Livestock staff. Eight (8) IGA groups across NAL were trained on value addition, milk processing and fish preservation, while the 30 newly formed beneficiary groups will be reached with community-based trainings and capacity building. During the reporting quarter, an environmental audit assessment was conducted for IGA beneficiary groups in six (6) counties (Turkana, Isiolo, Samburu, Marsabit, Garissa and Tana River). APHIAplus IMARISHA staff also conducted an Organizational Development and Systems Strengthening (ODSS) capacity assessment for the 23 LIPs across NAL, the assessment will help identify gaps in management and technical capacity of LIPs. This will act as the basis for designing the mentorship program to LIPs/CBOs on Enterprise Development and organizational management in the next quarter. Summary findings are shared below under annex X (Progress on USAID forward). During this reporting period, LIPs continued to organize and formed 30 new IGA-focused groups and 51 new SILC groups through a self-selection process. Since the inception of the project a total of 234 IGA- focused groups have been formed across the 8 NAL Counties. The number of SILC groups continued to grow with more members borrowing from the savings to start new businesses. SILC activities were key to empowering women giving them confidence to venture into formal financial institutions for loans. Below are some highlights on outcomes from these economic strengthening initiatives for this reporting period building on earlier successes:  To date, 141 SILC groups (2,513 beneficiaries) have been formed, and have made savings of Ksh. 5,328,491 (USD 53,300). Through savings and internal lending communities‘ initiative (SILC), the group members have reported increased self-confidence, increased resilience to shocks as a result of improved social safety net (social fund), expansion of small businesses as a result of loaning and source of capital to start new income generating activities.

 The project facilitated linkage of 28 IGA groups (See table 23 below) to formal microfinance and other development partners to benefit from loans and the community resilience fund. The groups received a USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 103

total of Ksh. 4,294,000 (USD 43,062.30). To date, a total of 546 households have been linked to formal financing institutions. Some of the microfinance institutions include; KWTF, KCB, YETU microfinance, Uwezo fund and Njaa Marufuku Kenya. Four members (women) from Mt. Marsabit Dairy serviced their loans with KWTF and have taken a new loan to expand their business. The women are now able to pay school fees, purchase scholastic material and cater for other household needs. Table 23: Number of Households Linked To Microfinance / Funding Institution Number of Households linked to Microfinance Institutions County No. of IGA Number of Funding Institution Groups Households 4 104 KWFT Marsabit 4 130 Uwezo fund 2 15 Catholic diocese of Marsabit 1 22 KCB Isiolo 3 30 Uwezo fund 1 15 Njaa Marufuku Kenya 4 60 Community Resilience fund - REGAL IR Garissa 2 28 Uwezo Fund 1 8 Women enterprise fund Tana River 1 20 Uwezo Fund 1 15 Njaa Marufuku Kenya Turkana 2 42 Uwezo Fund 2 54 Misean Care (DoL) TOTAL 28 546

 38,019 people were reached with economic strengthening services during this reporting period (see Table 24 below), bringing the total to 142,727 people reached with economic strengthening services since the project inception. This was made possible through engagement of LIPs and beneficiary groups in 3 main economic strengthening initiatives; SILC, Small business development and Livelihood opportunities (Agro-based, Livestock -based, and Handcraft). Table 24: Number of People Participating in Viable Economic Strengthening Activities

Economic strengthening initiative County Savings & Internal Small business Livelihood Lending development opportunities Communities Isiolo 384 1,273 3992

Marsabit 630 2,184 2,682

Samburu 2,808 344 6,747

Turkana 766 306 2176

Wajir 861 0 565

Mandera 624 1014 300

Garissa 490 745 463

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Tana River 3,450 1,650 2,577

Total 10,013 7,516 19,502

Below is a summary of specific achievements by County. ISIOLO COUNTY During this reporting period, APHIAplus IMARISHA facilitated the 3 LIPs in Isiolo County to support 59 IGA groups, 2 FFS and 22 SILC groups. Mentorship and capacity building mainly focused on SILC, Farmer Field Schools, Livelihood and IGA activities; Livelihood Opportunities Livestock-based Activities: APHIAplus IMARISHA facilitated follow-up and mentorship of 13 care-giver groups which were supported with rainbow roosters‘ chicken through FHK – Isiolo. Each of the 13 groups received 45 chickens to grow and expand their poultry business enterprises. Much effort was directed at poultry house hygiene, disease control and prevention, feeding and record keeping in order to address the challenges faced by the groups engaged in poultry farming during the initial stages. Some of the challenges include; overcrowding, poor feed quality, changes in climatic conditions, poor ventilation and sanitation affected the chicken. The groups were linked to the Ministry of Livestock and the SIDAI Super Service stores for technical services on treatment and case management of poultry disease and outbreaks. The group plans to sell the cocks for meat while the hens will be kept for production of eggs for sale. Seven caregiver groups from Ngaremara area in Isiolo were supported with 27 goats for livestock trade expansion through FHK- Isiolo. APHIAplus IMARISHA facilitated the training of these groups on record keeping prior to donating the goats to them. The groups were linked with the Ministry of Livestock who will provide further training and other services as need arises. The project facilitated 4 groups affilitated to a local implementing partner; Pastoralists Women for Health and Education (PWHE) to develop livestock trade business plans as they planned to expand their business. Through PWHE, the groups were supported with goats and sheep worth KShs. 250,000. The shoats were sourced from the Merti and Biliqo markets. The group sells 10 goats on weekly basis to Isiolo market. Each live animal gives an average profit margin of KShs. 400 per sale, which translates to Ksh 16,000.00 per month. Part of the proceeds go to members to take care of their household needs and the remainder into their group business expansion. Agro-based Activities :

Figure 73: Olla Nagele Caregivers with Their Livestock Ready for Sale at Isiolo Livestock Market

USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 105

The APHIAplus IMARISHA project through FHK –Isiolo provided a drip kit to the group to support the tree nursery project. Through this support, Inuka caregivers group also established a tree seedlings nursery for income generation as the enterprise of choice by the group. The group targets the increased demand for seedlings arising from the new settlements in Isiolo town and its outskirts. The group has so far made KShs.1,000 in profits from the sale of seedlings. They used the money to purchase 10 ‗Kenbro‘ chicks to expand their poultry business. The group lacks constant supply of the planting materials especially the seeds for establishment of seedlings, due to lack of a seed store/outlet within the county. The project is discussing with SIDAI (REGAL IR) to stock agricultural seeds at their outlets in the county. The project will help the group to identify sources of planting materials and train them on tree nursery as a business in the coming quarter. The project linked the group to the Kenya Forestry Services Isiolo Office to train them on proper tree nursery establishment. In anticipation of the El-nino rains, most groups had prepared their farms for crop production. Figure 74: Inuka Caregivers Ground member Takes APHIAplus IMARISHA linked the groups to the Care of Seedlings Ministry of Agriculture for support with seeds. During the quarter, the Naretate Caregivers group and Checheleso Caregivers groups continued to farm using water from Isiolo River and Isiolo Sewer treatment plant respectively. They carried out the farming at both group and individual farms. The groups face challenges such as pests and diseases, and APHIAplus IMARISHA linked them to Amiran Kenya for training on crop protection.

Voluntary Savings and Lending/SILC APHIAplus IMARISHA facilitated the FHK- SILC supervisor to provide support to 3 SILC groups based in Garba Tulla. The groups had saved a total of KSh15, 000 but had not started lending to its Figure 75: A Caregiver Inspects Her Tomato Crop members. They were advised to start lending so as to for Pests meet the financial demands of its members to start and grow their own businesses. Twenty two self-help groups were actively engaged in SILC and had savings of KShs.255, 900. Sixteen caregivers groups comprised of 350 members (34 men and 316 women) had merry-go-round activities and were contributing KShs.194, 040 per month. The groups are also engaged in poultry farming, livestock trade, crop farming and small businesses. APHIAplus IMARISHA facilitated linkage of 3 groups to Uwezo fund and Njaa Marufuku Kenya project for funding to expand their IGAs. Through women‘s ‗Uwezo‘ fund, Rwalo and Pathfinder Caregivers Groups benefited with loans of KShs.50,000 and KShs.100,00 respectively. The groups lend the money to its members with interest. By the time of reporting, the groups had started repaying the loan to ‗Uwezo‘ fund. USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 106

Emejeng caregivers group benefitted from ‗Njaa Marufuku Kenya‖ project which is run under the Ministry of Agriculture. Table 25: Isiolo County Caregivers Groups Which Have Been Linked For Funding From Other Projects Name of Group M F Financial Institution / Type of Fund Amount (KShs.) Rwalo 0 23 Uwezo Fund 50,000 Pathfinder 0 15 Uwezo Fund 100,000 Emejeng Caregiver Group 8 6 Njaa marufuku Kenya 150,000

Farmer Field Schools Tupendane and Mungaano FFS remained active in the reporting quarter. Tupendane FFS continued with their merry-go-round and table banking activities. The active members are 25 and they make a monthly contribution of KShs.200 through table banking and KShs.300 weekly in the merry-go-round. The members use the money to boost their own individual businesses and take care of immediate household needs. Most of the members undertake farming as a business. They also lease out their water pumps at a rate of KShs.200 per day. On a good month, they make an average of KShs.2400 which is given to members as a loan. MARSABIT COUNTY During the reporting period, APHIAplus IMARISHA facilitated mentorship on enterprise/IGA and SILC development for 586 OVC care givers (459 women and 127 men in the county) to the Waye Godha, Goro Mudha, Madho Adhi, Turbi, Kalacha, Loiyangalani, Laisamis, Wayesa, Somaro and Township self-help groups in the four sub-counties. Livelihood Opportunities Two LIPs (FH/K, CIPAD) helped train two hundred and thirty members (230) from Dirib Gombo, Turbi, Kalacha, Loiyangalani, Laisamis and Wind Master Self-Help Groups on livestock based enterprises, Hand crafts and sack garden. This was conducted in collaboration with county government staff. Newly formed Care Givers groups in Marsabit north and south identified small scale business, fodder production, collection of natural salt (Muludhe) and hand crafts as their IGA of choice. Waye Godha Care Givers were trained on greenhouse management, the group produced bundles of kale and spinach for household consumption and sold the surplus. Dirib Gombo women group was trained on fodder establishment, pasture harvesting and management practices as well as hand crafts development. The group members were linked to a buyer (Pastor Muthaura) who is interested in buying harvested pasture and also supported by REGAL-AG. Goro Mudha self-help group made a total of KShs.7, 500 from the sale of vegetable crops they planted in small kitchen gardens (Kale, and spinach). Dirib Gombo, Wind master and Wayesa SHG got a total of KShs.25, 000 from the sale of livestock based products (eggs, live chickens and donkey transportation services). Huruma self-help group made ksh.18, 400 from Figure 76: Mama Sallo of Drib vegetables and eggs. Total income for the 5 groups from sale of surplus Gombo Women Group With vegetables and livestock products amounted to KShs.50, 900.00 Bales of Hey Two groups that were trained on recordkeeping during the previous reporting period were assessed on their ability to repay loans and linked to microfinance and lending

USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 107 institutions for funding to expand their business. Following the tracking of income and cash flow, 22 members of the Mt. Marsabit Dairy and Wind Master Self-help Groups have been linked with Kenya Women Trust Fund (KWTF) and 30 members of Goro mudha had been linked to Kenya Commercial bank in Moyale for funding to expand their income generating activities. Voluntary Savings and Lending (SILC) SILC reporting improved following the training and engagement of SILC agents. Currently, the 26 SILC groups have regular meetings on monthly basis and have made savings of KShs. 995,400.00. Through savings and internal lending communities‘ initiative (SILC), the group members have reported improved cohesion among the members, expansion of small businesses in town as a result of loaning, improved understanding and skills resulting from frequent trainings, mentoring and sharing of experiences

Figure 77 CHVs Group in Wamba Receiving the Donkey Cart

Table 26: The Savings and Number of Groups Mentored by Each Agent NO OF SAVINGS SILC AGENT NAME ACTIVITIES GROUPS TOTAL HELLEN AKULE 3 67,200 Savings, loaning, home visits HALIMA ABDIRAHMAN 3 59,000 Savings, loaning, home visits ASHA JILLO GALGALLO 4 531,800 Savings, loaning, home visits FATUMA ABDULLAHI 4 88,800 Savings, loaning, home visits

JOSPHINE HARABORE 7 188,600 Savings, loaning, home visits

MBORE NIFFO 5 60,000 Savings, loaning, home visits TOTAL 26 995,400

SAMBURU COUNTY

Livelihood Opportunities

A CHVs group in Wamba was provided with a donkey cart by the project as an IGA, the group is now generating an average income of six hundred shillings a day. The cart is mostly used to ferry water, firewood and building materials. On average they generate Ksh 16,400 on monthly basis. Agro-based Activities

40 households in Maralal and Wamba benefitted from 40 drum irrigation kits procured by the project while another 97 OVC households in Archers Post, Suguta Marmar, Kisima and benefitted from drip irrigation kits for establishment of kitchen gardens. The households have planted mixed vegetables including kales, spinach and amaranths. 3 drum kits provided to Wamba Girls and 3 Wamba Boys Secondary schools are also fully functional and income from the sale of produce to be harvested from the school farms will USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 108 support in the payment of school fees of the OVC enrolled in the program and attending school in the two schools.

Livestock based Activities

11 caregivers‘ groups were issued with 575 rainbow roosters this quarter benefiting 189 households in Kisima, another 1,843 (586M: 1257F) caregivers received improved poultry management messages in different forums, 900 (100M: 800F) caregivers were reached with messages on new farming methods while 77 and 32 caregivers in Sirata and Suguta Marmar respectively were trained on food preservation and modern farming techniques during the station days. Follow up was also made to 464 OVC households in Wamba and Maralal, Kisima, Suguta marmar and 2 secondary schools in Wamba and Maralal who received improved poultry during the previous quarter, they are now benefitting from poultry produce; the female chickens have started laying eggs and are consumed at the household and surplus eggs are sold for income at a cost of 20 kshs per egg, the males are ready for the market and are fetching on average ksh 700 per rooster. A household is making Ksh. 800 monthly on average from the sale of surplus eggs. 26 households received goats from SCAAP LIP last year. To date 5 goats are pregnant and three goats have since kidded thus boosting the economic status of the households as well as providing milk. 10 households continued to reap benefits from the goats issued to them in the previous year. Some of the benefits received from the goats include milk and improved household social status resulting from increased number of livestock. Two (2) groups were supported with materials to grow and expand their handcraft IGA. The groups received beads for beadwork and raw materials for making the traditional open shoes (akala) for sale at Suguta town. TURKANA COUNTY

Voluntary Savings and Lending:/SILC

A total of 150 new members joined SILC groups during this quarter, bringing to a total of 11 SILC groups formed in Turkana County. The 11 groups in Turkana made a total savings of Ksh. 432,150 during the quarter. The table below shows the performance of SILC groups in Turkana County.

Table 27: Performance of SILC groups Social Membership Savings Group Name fund M F Total 1. MBELE SILC 0 13 13 2,800.00 200 2. NG’AMESEKIN AAKUJ SILC 3 22 20 6,000.00 100 3. AKITANAK SILC 3 12 15 7,000.00 2,000.00 4. TUMAINI SILC 8 13 21 120,000.00 4,000.00 5. APEDOR SILC 7 12 19 82,740.00 22,700.00 6. BARAKA SILC 5 12 17 65,290.00 26,680.00 7. AKING’OL KOSI SILC 1 27 28 100,420.00 7,840.00

USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 109

8. AKIRICHAKIN 2 13 15 8,000.00 2,000.00 9. NEPKO 3 15 18 3,900.00 1,500.00 10. AIC Kalokol PSS 0 23 23 1,7000 11. KIYA 7 17 24 19,000 12. St. Patrick’s M2M 5 23 28 69,000 Total 39 179 213 501,150.00 67,020

Small Business Development

During the quarter under review, more beneficiaries set up new small scale businesses (shops for clothing, household goods, and foodstuff) due to small grants and loaning from their SILC groups. Twenty five (25) CHWs from Elelea CU received training on business skills facilitated by MOLD staff. Following the training the group identified selling petrol and bulk sugar as their business of choice. The group will use the Ksh 100,000 received from APHIAplus IMARISHA as a grant to set up the business.

Forty-seven (47) CHWs from Kaputir CU received a small grant of Ksh 150, 000 from APHIAplus IMARISHA. The group decided to use the grant as a revolving fund to loan members as capital for setting up small scale businesses. A total of 17 members benefited from the first round of disbursement (Ksh 10,000 and 5,000 each). The members have set up small shops at Kaputir trading centre stocked with a wide range of products including; cereals, vegetables, clothes, and consumables.

Livelihood Opportunities

The project continued to mentor eighteen groups on record keeping marketing and management of IGAs. More effort was directed towards the improvement and expansion of livelihood activities with focus on Handcrafts, Crops and Livestock based IGAs. Some of the groups mentored during this quarter include; TWAP, Akirichakin, KIYA, St. Patricks M2M, Lokori OVC Caregivers, Kiniamarai, Kalokol M2M, Narorinyot, Atanak group, Nadapal SHG, Tumaini Canaan, Tumaini Soweto, Ameteki, Kalokol Fisher folks, Natiir 1, Elelea and Kaputir CHW group. Lokori (Echami), TWAP, Nadapal and KIYA have since increased their crop production capacity and are producing vegetable products, tomato and water melon for member household nutrition and sale at the local market in Lokori, Lodwar, Kakuma and Lokichoggio town. Despite the reduced water flow due to drought, members of the Echami caregiver group in Lokori made on average, a monthly income of Ksh 6,000 each from sale of surplus vegetables. Figure 78: Jane Achukule of Kaputir CU KIYA received a donation of a new set of irrigation drip kits Sells Clothes and Consumables from from the Ministry of Health to expand their vegetable farm. Her New Shop The project has procured small scale irrigation drip kits for St. Catherine Napetet PLHIV group, Akirichakin in Kakuma, Nadoto and Kalokol M2M groups to increase profit margin through efficient water utilization and minimised wastage. The groups have identified and are in the process of fencing additional land for installation of the drip kits.

USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 110

Farmer Field School

The project continued to facilitate Diocese of Lodwar, AIC Lokori LIP and Tumaini LIPs to mentor FFS. Alongside their vegetable production IGA, Thirty four (34) OVC Caregivers at AIC Lokori LIP identified poultry as a profitable IGA through a self-selection process. The additional IGA will improve their household nutrition as well as diversify their livelihoods.

The group received the support of the LIP in addition to member contribution, and is now constructing a poultry house, to enable them to start a poultry multiplication program. KIYA introduced tomato crop under open drip irrigation and are now expanding their vegetable garden with the new irrigation drip kit donated by Ministry of Agriculture.

Due to increased drought the water flow from River Turkwel significantly reduced, thus limiting the amount of water available for irrigation. The drought significantly reduced the land under irrigation and hence reduced profits for Echami OVC caregivers in Lokori. Ms Namukuny a caregiver reported that she farmed half of her land size in Echami farm. She highlighted the following. “My land is five basins and I have planted two basins with cowpeas, I make sales of Ksh.200 to300 a day five days a week. My earning is ksh.1500 per week, translating to Ksh.6000 per month. Despite the reduced income I have been able to buy food for my family and so far I bought a female goat from this farm production”.

GARISSA COUNTY Voluntary Savings and Lending (SILC): All the 7 groups that previously engaged in merry-go round in the entire Garissa County have transformed to SILC through the support of LIP staff and 6 SILC agents trained on SILC methodology in the previous reporting period. 4 of the groups have already started savings and lending while 3 groups undergoing training and will start saving at the beginning of next quarter.

Figure 79: A Member of Echami FFS on His

Farm In Lokori

Table 28: Amount Accessed by SILC Groups in Garissa County Group Social Fund Other fund Total

Township SILC group 340 4,600 4,940

Wathajir SILC 160 2,200 2,360

Halwathaq SILC group 210 3,100 3,310

ADC SILC group 120 1,600 1,720

USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 111

TOTALS 830 11,500 12,330

Livelihood Opportunities

Agro-based Activities 6 joint follow up and supervision visits were made jointly by the APHIAplus IMARISHA Project Officer, MOA extension officer and AMIRAN agronomist to provide technical support on agronomic practices for tomatoes, watermelons, kales, spinach and onions at the Alfarouk Centre demonstration site on agro-based enterprises established in the last quarter The crops grown in the agro-based demo plot (tomatoes, onions, water melons, kales and spinach) are now ready for harvest and are a source of nutritious diet to the OVC at the Alfarouk Children Centre. Livestock based Activities A joint visit with the Ministry of Livestock (MoL) Officer to 4 (Waberi, Galbet, Iftin and Halwathaq) beneficiary caregiver groups that were identified for poultry support was done. The poultry houses were inspected and technical advice on the hygiene and disease/pest importance in poultry production was offered to beneficiaries. The birds will be delivered in the coming quarter. 28 OVC care givers (all female) from 2 IGA groups (Wathajir and Galbet milk marketing groups) that identified milk as their IGA of choice during the previous quarter received a 2 day training on milk value addition and mentored on business development and management skills. The training focused on milk hygiene, yoghurt production and Mala making. The training/demonstration was intended to protect and promote the consumer‘s health by safeguarding them from wholesome milk and hazards caused by communicable infections from animal to man and from man to man through milk. Care giver groups were targeted strategically to improve their IGA capacity to achieve vibrant milk business and to protect consumer health. The milk hygiene code of practice is aimed at guiding and streamlining hygienic practices in primary production, handling, processing and distribution of milk and milk products. Follow up will be made in the coming quarter to track application of knowledge and encourage adoption of the practice. The 28 OVC caregivers are currently engaged in milk vending at Garissa market and handle 1500 liters daily generating a profit Ksh. 400 to Ksh1, 200. TANA RIVER COUNTY Voluntary Savings and Lending (SILC) Tana River County has a total of 51 active SILC groups, 46 are saving, while 5 are in the SILC orientation stage. The 46 groups with 913 members (116 male; 797 Female) made a total income of Ksh. 3,354,671. The table below shows SILC savings for the 46 groups from July to September 2015. SILC adoption in Tana River County has continuously maintained an upward trend in growth both in membership and savings as shown in the diagram below. The total savings and the social fund used in shock resilience doubled since the beginning of the year. The women reported that access to household income through the IGA has greatly contributed to their self- esteem and empowered .in the community During the quarter under review, 2 SILC groups linked to KICE LIP had a total share out of Kshs 801,270. The highest savings shared out was Ksh. 43,930 and the lowest being Ksh1, 860.

USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 112

Baikirafa had a total savings of Ksh. 507,060 during the share out, the group has been linked to YETU, microfinance in the region for finance education and mentorship. Small Business Development

Mwelokeo Psychosocial support group is engaged in soap making for income. The group makes soap with medicinal properties from a locally available herb, Neem popularly known as ‗Mukilifi/mwarubaine‘. The soap has medicinal properties capable of fighting jiggers that are a major menace in Tarasaa Division, Tana Delta Sub- County. In one month the group produces 200 pieces of Neem soap sold at Ksh. 40per piece, making an average net profit of Ksh 8000 per month. The group made a total of Ksh. 24, 000 during this reporting period. The proceeds from the soap are used as a revolving fund to buy poultry for members. Each household benefits with six birds, so far 6 Figure 80: Mwelokeo Group Making Soap members have received the birds. Livelihoods Opportunities

Handcraft

APHIAplus IMARISHA facilitated Maridhiano LIP to train Malakoteni and Garsen OVC Caregiver groups of 28hhs (2M; 26F) on bead making. They learnt how to decorate handbags, make flower and fruit vases. The training will enable the two groups to grow and expand their IGA from making mats and selling water. The market for flower vases and handbags is promising, with a good profit margin. The price for one vase is between Khs1000 and 1500 while the handbags range between Ksh 300 and 2500. During the training the group made products worth Ksh. 16,000 from raw material worth Ksh 10, 000. Figure 81: Training Instructor Displays a Set of Vase Made by the Trainees

MANDERA COUNTY:

Livelihood Opportunities Household Economic Strengthening (HES) activities implemented in Mandera County include: distribution of poultry which had been procured through three (3) Local Implementing Partners (LIPs) to targeted beneficiaries, trainings of caregivers on improved poultry, kitchen gardens, food preservation and Savings and Internal Lending Communities (SILC). Livestock based activities

USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 113

Two beneficiary groups were trained on improved poultry keeping for nutrition and income generation. The training focused on improved management practices, how to start poultry keeping, selection of the breeding stock, housing, feeding, collection of eggs, brooding, rearing chicks, poultry diseases and vaccinations and how to use income for nutrition. Following the training, 27 households received poultry procured by the project through Local implementing partners. Follow up and mentorship was done for 7 beneficiary groups (95 members) that benefited in Elwak, Lafey, Arabia and Kutulo. Mentorship focused on management of IGAs and group dynamics by both the LIP and Gok staff facilitated by the project. 50 of these households benefited from the distribution of dairy goats in the previous reporting period. Agro-based Activities The project facilitated LIPs to conduct basic agronomy training at for Al-Uteibi OVC group, with focus on nutrition sensitive agriculture and establishment of multistory / kitchen gardens for household nutrition, and sale of surplus. The trainings were conducted by Ministry of Agriculture staff. Vegetable seeds such as Sukuma wiki, spinach, tomatoes and water melons were distributed to 48 OVC households engaged in small scale farming.

WAJIR COUTY

Savings and Internal Lending communities (SILC) To date, a total of 22 SILC groups have been formed in Wajir County; of these 18 groups are currently saving and lending and 4 new groups are undergoing training. LIPs and SILC FAs were facilitated to train and support the existing 18 SILC groups through the first cycle of SILC activities with savings and lending activities conducted throughout the period. They also supported the other 4 other groups through the training phase. Four days refresher training on SILC methodology for 7 SILC FAs and 3 supervisors was also done. The training participants were drawn from the 3 (WASDA, OPAHA & SND) LIPs in Wajir County. Small business development Three LIP staff and 23 CHVs (17M: 6F) were trained on IGA management and business plan development. The CHVs and LIP staff were taken through group formation techniques, identification of viable business enterprise, and introduction to business plan canvas. They were also mentored on the 9 building blocks of business model canvas. Livelihood Opportunities Two LIPs, OPAHA and WASDA mobilized and formed a total of 19 new care giver groups and mentored them on IGA management and group dynamics. A further 236 OVC household (12 groups) at Tarbaj, Habaswein, Abakore and Kutulo locations were mobilized to form IGA groups. A PLHIV support group in Bute town benefitted from a donkey and a donkey cart through project support. This is expected to generate income for the group and improve their living standard. Further, OVC caregivers have been mobilized into caregivers groups in all the OVC sites ready to be linked up by the HES component for livelihood support. Livestock based Activities Two LIPs (SND & OPAHA) procured and distributed poultry to 91 vulnerable OVC households. The poultry are expected to economically strengthen the OVC households through egg production and USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 114 subsequent sale of the eggs and other chicken products for income. A total of 458 beneficiaries have benefitted from the poultry support. Another 20 vulnerable OVC households benefited from dairy local goats procured and distributed by the project through WASDA (LIP), while 236 OVC households (12 groups) at Tarbaj, Habaswein, Abakore and Kutulo Locations were mobilized and formed into economic strengthening groups. A total of 19 caregiver groups (linked to OPAHA and WASDA LIPs) were organized into groups and were mentored on IGA management and group dynamics.

USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 115

IR 4.2 Improved Food Security and Nutrition for Marginalized, Poor and Underserved Populations Expected Outcome 4.2.1: Increase in food security, improved nutrition and sustainable livelihoods amongst the target groups APHIAplus IMARISHA continued to raise the skill and knowledge levels of LIP staff on nutrition and food security during this reporting period. This was done through regular technical assistance, mentorship and on- job training. Adoption of alternative sources of livelihoods by beneficiaries was also promoted. Specifically, 2 beneficiary groups that were trained during the quarter will be receiving 450 chicks each as well as feeds. These efforts will contribute to improved access to food by the households. With the care and feeding practices indicators still very poor in NAL, the project continued to work with LIPs and CHVs to disseminate key nutrition messages at various fora. This was done through caregiver forums and station days at health facilities. Key activities undertaken by county are summarized below. WAJIR COUNTY According to the Long Rains Assessment conducted between 27th July and 7th August 2015 by the Kenya Food Security Steering Group (KFSSG) in Wajir County, improvements in food security situation were not recorded. This is due to significant rainfall deficits and worse conditions for livestock and low water availability. The current areas under crisis phase are Griftu, Elda's and Hadado. During the period under review, 696 targeted population that included 360 OVC/ PLHIV and 36 children under five, 276 producer groups and 24 school health club members were reached with food security and nutrition services in the county. The number reached with the respective nutrition services are summarized in table below Table 29: Number of People Reached with Nutrition Services in Wajir County Nutrition Services Number Reached

Nutrition Counseling and education 696

MUAC Screening 36

Referral for nutrition support and services 45 undernourished PLHIV

During HIV Testing and Counseling (HTC) outreaches undertaken by OPAHA LIP in Wajir, 36 OVC and 65 PLHIV were screened for malnutrition, 45 PLHIV were found to be moderately undernourished and were referred and linked to Wajir County Referral Hospital CCC and admitted to the Food-By-Prescription (FBP) program. Training of school health clubs on nutrition corners/gardens: To improve the health and nutrition status of Orphans and Vulnerable Children (OVC) in schools, the project trained 24 school health club members from Jogbaru and Wajir primary on Nutrition gardens/corners. The objective of the trainings was to contribute to learning about good nutrition, incorporating nutrition into the school programs thereby increasing knowledge of dietary diversity and ways to ensure food security. The training also provided an avenue to combine theory and practice, children transferring skills to the community using the techniques of behavior change communications which move beyond message dissemination to supporting individuals and communities in making the transition to healthier practices. The project intends to use garden-based learning

USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 116 which has the potential of increasing the relevance and quality of children‘s education by introducing them to food and nutrition-related knowledge and skills. Through WASDA in Wajir, the project and MoA will continue to provide ongoing technical assistance visits to the gardens. The schools cater for more than 200 OVC supported by the project OVC caregivers training on improved poultry keeping for nutrition and income generation: During the quarter, the project trained 12 OVC caregivers on improved poultry keeping for nutrition and income generation. The training focused on improved management practices, how to start poultry keeping, selection of the breeding stock, housing, feeding, collection of eggs, brooding, rearing of chicks, poultry diseases and vaccinations and how to use income for nutrition. The caregivers received 49 improved poultry breeds from WASDA LIP funded by the project. The training was facilitated by the Sub-County Livestock Production Officer Wajir East. Nutrition and Health Education: In light of the prevailing cholera outbreak in Wajir, the project facilitated 18 CHVs and 10 M2MSG leaders to educate 360 OVC caregivers and PLHIV in Barwaqo CU on healthy dietary practices and high impact nutrition interventions during the World Breastfeeding Week in Wajir in August 2015. The CHVs are currently disseminating messages to OVC/ PLHIV households and general community and conducting awareness campaigns that stress on the importance of personal hygiene especially hand washing, treating water quality, community hygiene to best protect at-risk populations from cholera and similar illnesses. Education of producer groups on food and food product preservation and storage: To prolong food security throughout the year, the project through LIPs and MoA facilitated dissemination of information about new preservation, processing and storage techniques and ways to scale up their adoption by project beneficiaries. The project through LIPs continued to work closely with the 796 producer groups in crop and livestock based production linking them to extension services, available markets and funding opportunities which can serve as income generating business opportunities for the targeted groups. LIPs support supervision: To follow up on implementation of approved LIPs work plans, LIP support supervision was undertaken. The joint supervision visit by the OVC technical officer was also aimed at guiding and encouraging LIP staff to optimize their work performance, ensure integrated programming and provision of comprehensive package of services to OVC and their caregivers. LIP staff were orientated on the food security and nutrition Standard Operating Procedures to ensure quality programming and services are provided to OVC and their households. MUAC tapes for detecting undernourished OVC and Agri- nutrition linkages toolkit were shared with the LIPs.

MANDERA COUNTY During the period under review, activities such as training of 12 OVC caregivers on improved poultry keeping for nutrition and income generation, training of 16 Al-Sunnah OVC school health clubs on nutrition corners, sensitization of 500 producers groups, Nutrition and health education and VAS and deworming to 300 OVC caregivers and LIPs supportive supervision were undertaken in Mandera County. The number of people reached with the respective nutrition and food security services are summarized in table below. Table 30: Number of People Reached with Nutrition Services in Mandera County Nutrition Services Number Reached

Nutrition Counseling and Education 362

MUAC Screening 300

Referral for nutrition support and services 29

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During HTC undertaken by EPAG and RACIDA LIPs in Mandera, 350 OVC were screened for malnutrition and 29 were found to be undernourished and were referred and linked to supplementary feeding programs run by MoH. 350 OVC received Vitamin A supplementation and deworming during the exercise. Training of school health clubs on nutrition corners/gardens: To improve the health and nutrition of OVC in schools, the project trained 12 school health club members from Al-sunnah OVC centre on nutrition gardens/corners and established one kitchen garden. The objective of the training was to contribute to learning about good nutrition, incorporating nutrition into the school programs, increasing knowledge of dietary diversity and ways to ensure food security. The training also provided an avenue to combine theory and practice with children transferring skills to the community using the techniques of behavior change communications which move beyond message dissemination to supporting individuals and communities in making the transition to healthier practices. Garden-based learning has the potential of increasing the relevance and quality of children‘s education by introducing them to food and nutrition-related knowledge and skills. Through EPAG LIP, the project and MoA will continue to provide ongoing technical assistance visits to the gardens. OVC caregivers training on improved poultry keeping for nutrition and income generation: During the quarter, the project trained 12 OVC caregivers on improved poultry keeping for nutrition and income generation. The training focused on improved management practices, how to start poultry keeping, selection of the breeding stock, housing, feeding, collection of eggs, brooding, rearing chicks, poultry diseases and vaccinations and how to use income for nutrition. The caregivers received 60 poultry from RACIDA LIP funded by the APHIAplus IMARISHA project. Nutrition and Health Education: To improve household nutrition behaviors RACIDA and EPAG LIPs conducted station days for OVC and disseminated nutrition and health education messages to 350 OVC. Provision of vitamin A supplementation, deworming and linkages of 29 undernourished OVC to feeding programs. The LIPs were able to reach 350 caregivers with essential nutrition actions framework key messages. Education of producer groups on food and food product preservation and storage: To prolong food security throughout the year, the project through LIPs and MoA facilitated dissemination of information about new preservation, processing and storage technique to 500 producer groups in Mandera and ways to scale up their adoption. The project through LIPs EPAG and RACIDA continues to work closely with the 900 producer groups in crop and livestock based production linking them to extension services, available markets and funding opportunities which can serve as income generating business opportunities for the targeted group. TURKANA COUNTY During the reporting period, efforts were geared towards working with the Ministry of Agriculture to provide technical assistance to ongoing food security initiatives being undertaken by project beneficiaries. Adoption of product preservation and storage techniques was also ensured. This was majorly done through education on appropriate preservation techniques. So far 2,604 households are adopting these techniques. Provision of key nutrition services to OVC was also enhanced especially during station days. The nutrition station was revamped this year to include cooking demonstrations. The project continued to work with LIPs to ensure delivery of quality nutrition services and promotion of nutrition sensitive interventions to OVC and PLHIV households. Interventions such as small scale farming and poultry production are some of the interventions that the project continues to promote. These efforts will continue to enhance household access to food and sustainable livelihoods. The number of beneficiaries reached with the respective nutrition services are summarized in Table 31 below USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 118

Table 31: Number of People Reached with Nutrition Services in Turkana County Nutrition Services Number Reached MUAC screening 308 Referral for nutrition support and services 419 Nutrition Education 870

The key achievements realized in efforts to improve food security included: Increased food security: The project continued to work with LIPs to promote various activities to enhance access to food by project beneficiaries. Due to the efforts by the project, Kiya self-help group is expanding their farm after the MoH donated a drip irrigation system to the group. The project supported the group to install the drip irrigation system. The mother to mother support group at Kalokol Health Centre was also supported to expand their gunny-bag farms. So far, all the 15 active members of the group have received gunny bags for use at the household level. 5 of the members have successfully planted the sack gardens and now have improved access to nutritious vegetables. The 35 members of Echami group in Lokori also continued to have improved access to vegetables and income by selling their harvest in the local market. To diversify, these livelihoods, the project in the coming quarter will support a second group of 35 beneficiaries from Lokori with 450 chicks for rearing and will report on the progress of the poultry project and the expansion of the farm at Kiya. Distribution of drought tolerant seeds: Working with African Inland Church (AIC) Lokori (LIP), 35 members of the Echami farming group received various seeds for use in their farm. The seeds that were distributed include cowpeas, green grams, Sukuma wiki, watermelon, pumpkin, tomatoes and spinach. The project will provide a progress update on these efforts in the coming quarter. Nutrition education: The project continued to conduct nutrition education to caregivers on various topics. These education sessions were done during caregiver forums and station days‘ events. Due to these efforts, 870 caregivers were reached with various nutrition messages during the period. Provision of Nutrition services to OVC: the project continued to work with the 4 LIPs in the county to ensure delivery of quality nutrition services to OVC and PLHIV households. This was done through regular technical assistance and provision of regular updates to the staff. Due to these efforts, 419 OVC received nutrition counseling and referrals for relevant nutrition support. Nutrition Training for CHVs: In an effort to enhance partner skill and knowledge on Nutrition, the project trained 16 CHVs from AIC Lokori on Nutrition with a special focus on assessment, referral and nutrition education. Following the training, the trained CHVs have incorporated some doable nutrition actions such as nutrition education and counseling in their monthly work plans. OVC station days: The project continued to maximize on the station days‘ events to bring comprehensive nutrition and food security interventions to the OVC and their caregivers. This year, nutrition stations were expanded to include cooking demonstrations. This is in addition to the routine services such as Vitamin A supplementation, deworming and MUAC screening. This was done during all the station days. The report from AIC Lokori, Nakwamoru and Kalokol station days is shown in Table 32 below: Table 32: Nutrition Services Provided to OVC During OVC Station Days Events in Turkana County Vitami Reasons for Facility/Group MUAC Deworming Station day n A # Referred referral referred to

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Kalokol & 158 158 158 Nakwamoru 0 N/A N/A

Underweight AIC Lokori AIC 150 150 150 3 LOKORI MUAC below PHC Lokori 12.5

MARSABIT COUNTY During this quarter the project supported capacity building of CHVs to facilitate screening and referral of malnourished children in hard to reach areas and provision of nutrition education on food preservation and food storage techniques to OVC caregivers, supplementation of Vitamin A in ECD centers to under-fives and Nutrition and Agricultural field day in Saku Sub County, Moyale, Marsabit South and North Sub Counties. 8,202 targeted populations that included 6,140 OVC, 2,062 caregivers were reached with food security and nutrition services in Marsabit County. The numbers reached with the respective nutrition services are summarized in the table below: Table 33: Number of People Reached with Nutrition Services in Marsabit County Nutrition Services Number Reached Nutrition Counseling and education 8,202 MUAC Screening 1,232 Referral for nutrition support and services 374

Education of OVC/PLHIV households on food preservation and storage techniques: To increase food diversification among resource poor populations of Northern Arid Lands the project sensitized 5 groups of 122 OVC care givers on preservation and storage of kales, tomato jam, pawpaw jam and sorghum in Moyale, Sololo, Kalacha, Laisamis and Saku locations. A total 517 producer OVC households, health extension workers and CBOs were educated on crop- and livestock-based food product preservation, processing and storage techniques. 517 households are adopting small scale household-based production of preserved food products, mainly pawpaw jam, meat and kales in Marsabit County. The technique minimizes the growth of microorganisms during the storage period, thus promoting longer shelf life and reduced hazard from eating the food. The transfer of skills empowers families at risk of hunger with the skills, knowledge and confidence to make healthy and affordable meals. With the help of MOH Nutritionist, participants learnt how to select foods that provide various nutrients to their households. As a result OVC care givers household will embrace the new techniques to hygienically store and preserve the produce; like kales for further utilization during lean periods. Agricultural and Nutrition field days: During the quarter the project supported the LIPs in conducting Agricultural and Nutrition field day to expose households to alternative (crop/livestock) production techniques for improved food security & nutrition. A total of 133 farming caregivers and OVC caregivers participated and learnt new improved food security techniques including production, utilization of different foods, value addition and preservation among and others secondly to expose households to alternative (crop/livestock) production techniques for improved food security & Nutrition. During the field day, USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 120 communities identify affordable, acceptable, effective and sustainable practices that are already used by at-risk people and that do not conflict with local culture. Through learning what their neighbors with equally limited resources especially within the communities of Northern Arid regions are doing to prevent malnutrition, families are empowered to adopt better practices. TANA RIVER COUNTY During this reporting period, the county was generally dry with prices of essential commodities increasing on a day to day basis making food accessible to fewer households while others acquired it on credit and to a larger extent aid from relatives and friends. The county had provision of relief food and supplementary feeding for the vulnerable groups of the communities in the divisions most affected including through the Food for Assets programme. The project continued to build on partnerships by jointly coordinating activities with the County Government, the LIPs and other stakeholders to target existing OVC caregiver groups and OVC households. Livelihoods and nutrition has also built strong linkages where nutrition messaging is closely integrated into IGA training and development activities. During the quarterly review meeting, the 3 LIPs in Tana River discussed their progress in reference to their scope of work and were also capacity built on many issues including improvement of writing skills for both development and reports. A total number of 3,208 were reached with nutrition education and counseling. The numbers reached with the respective nutrition services are summarized in the table below: Table 34: Number of People Reached with Nutrition Services in Tana River County Nutrition Services Number Reached

Nutrition Counseling and education 3,208

MUAC Screening 319

Referral for nutrition support and services 51

Support supervision to LIPs: The project technical staff made visits to Caritas and Maridhiano LIPs to discuss programme issues among them reporting, communication issues, and the green house and caregivers clusters groups. The team agreed on action plans with deliverables and timelines. Follow-up visits were done to ensure implementation of agreed actions. The project also administered SIMS to KICE and they were to work on a few identified gaps to improve programming. Coordination and advocacy: Tana River LIPs quarterly review meeting was held from the 22nd to 25th July. This was a learning session and the team together with LIPs reviewed project progress, challenges and lessons learnt. The LIPs were challenged to make use of existing opportunities for synergy to improve the welfare of the communities they serve and to improve programme performance. The LIPs were also mentored on nutrition data capture and use of an issue log. A total of 16 (12M: 4F) LIP staff were mentored. The project also participated in 3 and supported 1 County Food Security Forum where discussions focused on the Kenya Food Security Steering Group /County Steering Group Long rains 2015 assessment after two days field visit to verify data that were presented in the initial CSG meeting. This forum also discussed the Food for Assets programme that was to be rolled out by the Kenya Red Cross Society and the County‘s preparedness towards the upcoming El Nino rains. Household diet diversification Nutrition Education: MoA and MOH staff oriented 34 CHVs from Caritas in Hola and Bura on nutrition topics during the Child Protection session. The lesson given centered on importance of good nutrition, diversified diet and availability of a variety of foods some of which are readily available yet they are ignored

USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 121 because of cultural tenets and ingrained ignorance. 87 caregivers were reached with nutrition education during HES beading session. The education forum focused on mainstreaming HIV in agriculture, food utilization and preservation and nutrition during illness. 895 OVC households from Caritas were also reached with nutrition education during monthly CHVs household visits. Maridhiano CHVs conducted education sessions on diet diversification at household level including nutrition from animal sourced foods and reached 2,153 people. 27 PLHIV supported by the project in Kipini were referred from community to health facility with different nutrition services offered at the Kipini Health Centre Home and Community Based Care link desk, including nutritional counseling and education. 46 caregivers also benefitted from nutritional counseling and education conducted the OVC Station Day event held in August in Kilelengwani Primary School in Kipini. PD Hearth: : Based on the data extracted from the DHIS, the project in partnership with MOH implemented 4 Hearth sessions in Dayate, Wachakone in Galole Sub County and Dalu in Tana Delta Sub County. The outcomes from the 4 Hearth sessions are summarized in the table and graph below: Table 35: Key Outcomes from the 4 PD Hearth Sessions in Tana River County

Wachakone Dayate Dalu (2 sites)

Total number of children screened 56 89 79

Total children underweight 15 23 26

Children admitted in the hearth 15 16 20

Vitamin A supplementation 9 50 48 Deworming 56 89 79 Children who gained weight- graduated 13(86%) 8(50%) 14(70%) Children who did not graduate 2 2 6 Children who dropped out of Hearth 1 6 6 Referrals 1 0 4

Number of CHWs mentored on PD Hearth 2 2 4

The graph below illustrates the outcomes from one of the sites

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Figure 82: PD Health Outcomes from One of the Sites Nutrition Sensitive Interventions Greenhouse Farming: During the month of July, the project held a community level meeting with Naghea group in Malakoteni, Garsen division in the Tana Delta sub county to discuss the progress and challenges of the greenhouse farming project. Water challenges that the group experienced have since been resolved, initial plant in the green house was uprooted and a new nursery was done for high value tomatoes. 500 seedlings were transplanted and the progress is good. Fencing has also been done and the group has planted other vegetables around the green house for household consumption. The tomatoes will be ready in December 2015 and the group expects good sales apart from household consumption as tomatoes will be off season then. They are currently weeding and pruning. Schools’ nutrition corners/kitchen Gardens: The school health kitchen garden at Rafiki primary School Hola, Galole Sub County picked up well after the project supported the fencing of the garden. The pupils planted a variety of vegetables and were doing fine except for a few challenges resulting from the dry spell and the teacher‘s strike. Follow ups have been made and the club‘s patron is working with the children to revive it. Poultry farming: Caritas Diocese of Garissa (LIP) provided an in kind grant of 40 birds to CHAO caregivers group based in Madogo, Bura Sub County. With a vibrant income generating activity and household consumption of chicken, CHAO members can live expecting great things for their households and OVC, given improved takings or financial wellbeing from the group‘s activity of poultry keeping and sales with time. The group has 48 direct beneficiaries. Maono OVC caregivers‘ group in Oda, Tarasaa division, Tana Delta Sub county with 63 benefitting household members will be receiving their birds this month and this will scale up their production since they are already producing but in small scale. Proper food handling and storage: LIPs continued to conduct household visits to follow up on households‘ adoption of food preservation technologies, 518 households are reported to be practicing food preservation techniques. Another 60 caregivers from 4 support groups (KICE) were educated on food preservation and storage during HES/Nutrition integrated training sessions.

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GARISSA COUNTY The short rains were well below average which resulted in a far below average harvest and an increase in the number of people who were food insecure. During the quarter under review, majority of households remained stressed with the areas that had the least rainfall in a crisis. Insecurity, conflict and human displacement between the pastoralists affected forage and water utilization too and had implications on food security. However, some OVC caregiver groups practiced irrigation crop production activities along River Tana where bananas, pawpaw, melon, lemon, onions and tomatoes are grown. Expansion of farms and farm infrastructure continued with support from the MoA and other NGOs. The project in partnership with the LIPs, MOA and other food security partners in the county targeted OVC households and their caregivers with integrated activities such as nutrition education with on and off farm HES activities, food distribution and health services including nutrition screening and referrals. 4 caregiver groups with a membership of 92 benefitted from poultry farming education and have started poultry production for both consumption and income generation. 62 caregivers from SIMAHO received vegetable seeds which they used for their kitchen gardens and gunny bag farming and now have access to vegetables for household consumption. The project continued to provide nutrition services among OVC and their households where 94 were screened using MUAC, 51 referred to other nutrition interventions and a total of 1585 reached with nutrition education. The numbers reached with the respective nutrition services are summarized in the table below: Table 36: Number Of People Reached with Nutrition Services in Garissa County Nutrition Services Number Reached

Nutrition Counseling and education 1,585

MUAC Screening 94

Referral for nutrition support and services 51

Capacity Building: During the quarterly review meetings, the project sensitized the 2 LIPs in Garissa on correct documentation of food security and nutrition activities and writing success stories including reports. This has led to a lot of improvement in correct data capture and subsequent report writing. The 16 LIP staff were also capacity built on use of issue log to identify, track and resolve issues that are likely to affect project implementation. Coordination and Advocacy: The project participated in 2 County Food Security Forums which discussed the worsening food security situation and the contingency plans including NGO support towards a food secure community. Discussions on the County‘s El Nino rains preparedness was also part of the agenda. The project also conducted support supervision visits to the LIPs for follow up on agreed action plans according to their scope of work, to mentor and to provide technical assistance in use of reporting tools. Household Diet Diversification

 Nutrition and health education to OVC/PLHIV households: During the quarter, the project through LIPs educated 1,585 OVC/PLHIV households on healthy dietary practices, promotion of Exclusive Breastfeeding, diet diversification at the household level, hand washing and demonstrations on Multi Storey Gardens. Targeting was done during station days and routine monthly OVC household visits. This is an effort to improve household nutrition behaviors. 236 OVC were also dewormed and supplemented with vitamin A and the data was shared with link facilities for entry into the DHIS.  Cooking demonstrations: To bridge the gap in maternal and child nutrition, to increase household dietary diversification and consumption of fruits and vegetables, the project supported 4 cooking USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 124

demonstrations to 60 OVC caregivers. This practical forum gives the caregivers an opportunity to prepare the meals, taste them and learn different ways of preparing nutrient dense foods while looking at some of the common and bad cooking practices that prevent households from consuming nutrient dense foods.

Nutrition Sensitive Interventions

 Green House Farming: The project in partnership with the Farmers Training Centre Garissa continued to provide technical support to the greenhouse established at the Alfarouk Children Centre. The OVC based at the centre are now consuming a variety of vegetables thanks to the technical support received from the project including the purchase seeds for the green house.  Agricultural field day: The project supported one on farm field day at the Agricultural Training Center in Garissa where 30 Caregivers and 3 LIP staff from NEWS (LIP) participated. This event exposed the caregivers to ways of growing vegetables using different multistorey techniques, green house farming, fish farming, alternative food sources and improved agricultural (crop/livestock) production techniques for improved food security & nutrition among OVC households.  Poultry farming: 4 caregiver groups (92 members) have been trained by the Livelihood‘s Officer and sensitized on the benefits of poultry as a source of animal protein and for income generation. They have started on their own and are consuming the byproducts. The 2 LIPs will through their budgets give an in- kind grant to the groups to boost their product.  Distribution of drought tolerant seeds: SIMAHO (LIP) distributed vegetable seeds to 62 OVC caregivers. At least 2 households have already started selling the surplus while the others are consuming the vegetables from their kitchen gardens. This has led to increased consumption of vegetables at the household level.  Proper food handling and storage: 60 OVC caregivers from NEWS were educated on food preservation and storage. This has led to increased safe storage period of food and availability of out of season foods. At least 500 households are now adopting new preservation technologies and this has improved their food security and nutrition resilience

SAMBURU COUNTY Support to OVC households on food preservation: There was continued support to the OVC HHs on the food preservation methods. This was done through the LIPs reaching 3200 OVCs in the quarter Table 37: Number of People Reached with Nutrition Services in Isiolo County Nutrition Services Number Reached Nutrition Counseling and education 858 MUAC Screening 2483 Referrals to nutrition interventions 13 Specific community nutrition activities undertaken are summarized below Capacity building of CHVs on Community Nutrition: 795 caregivers from 16 caregiver forums and 63 CHVs were sensitized and educated on appropriate eating habits and food preservation as well as demonstrations and promotion of personal hygiene especially hand washing during the critical times. The 63 CHVs trained on MUAC (rapid assessment tool) managed to reach 2483 OVC with nutritional screening and referral services, those eligible for vitamin A and deworming were supplemented in accordance with the national guidelines and in consultation with the ministry of health. Due to that, 13 Moderate acute malnutrition cases were referred and managed in respective facilities. Further, 670 OVC households received education on best hygiene practices, especially on hand washing, fecal management and treatment of drinking

USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 125 water. This has boosted their caregiver knowledge and skills on maintenance of clean environment and the link to communicable diseases. Kitchen Garden: The LIPs with technical support from the project continued to sustainably support households to respond to their feeding needs. 50 caregivers were received kitchen garden drip irrigation kits for use to produce nutritious vegetables for household consumption with the surplus sold for income generation to meet other basic household needs. So far, 2 caregivers have gained significant income that has enabled them to provide uniforms for 4 of their OVCs. This has impacted positively on the 4 OVCs access to classes and learning.

Demonstrations on food security: During the quarter, various activities were conducted to enhance food security and nutrition of OVC households. These are elaborated below by each LIP:

SAIDIA  40 drum irrigation kits were procured for 40 households. So far, 6 irrigation kits in Maralal are functional and the households have planted mixed vegetables including kales, spinach and amaranthus; 3 drum kits in Wamba girls and 3 in Wamba boys‘ schools have been assembled. The yield from these kits will support OVCs in the two schools. The OVCs will be allowed to take home some vegetables for home consumption once week. Any profits proceeding from sale of the excess vegetables by the school will go towards supporting the OVC to offset some of their scholastic needs.  160 households and school were supported with improved poultry. By September, the hens had started laying eggs and the cocks were ready for the market, each fetching approximately KSh.700. KIBA  20 OVC households were supported with drip irrigation kits for kitchen gardens  575 rainbow roosters were distributed to 11 caregiver groups benefiting 189 households  The 184 households and one secondary school with 14 OVCs that had received 450 rainbow roosters in the previous quarter reported some remarkable outcomes; the birds are now laying eggs which are consumed by the OVC households with the excess sold to the locals at Ksh.20 per egg. Each household thereby makes an average of Kshs. 800 from these sales. So far, 316 females and 57 males are direct beneficiaries of improved poultry. SCAAP  586 males and 1257 females received information on improved poultry management in different forums. A further 100 males and 800 females were reached with messages on new farming methods  3 out of the 26 goats that were distributed in the previous quarter have kidded. This has enhanced access to milk by these households. 5 goats additional goats are expected to kid in the near future.  7 drip kits have been assembled, distributed and are being used by 7 households Caritas Maralal  77 caregivers in Sirata and 32 in Suguta Marmar were trained on food preservation, modern farming techniques during the station days  43 drum kits and 2 drip kits were installed, 7 groups (234 households) were supported with 100 chicks each Shepherds of Life (SOL)  3 caregivers‘ groups comprising of 117 households received 460 improved kienyenji chicken for rearing.

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 The 19 caregiver groups that were trained previously on drip irrigation received drum kits for drip irrigation this quarter. The kits have been assembled and are in use.  The 10 caregivers who received goats last year continued to reap benefits from the goats. Due to these efforts, 81 household members have improved access to milk and improved household social status resulting from increased number of livestock.

ISIOLO COUNTY

Specific community nutrition activities undertaken are summarized below Capacity building of CHVS on Community Nutrition: 795 caregivers from 16 caregiver forums and 63 CHVs were sensitized and educated on eating habits and food preservation as well as demonstrations and promotion of personal hygiene especially on hand washing during the critical times. The 63 CHVs trained on MUAC (rapid assessment tool) managed to reach 2,483 OVC for nutritional screening and referral services, those eligible for vitamin A and deworming were supplemented in accordance with the national guidelines and in consultation with the ministry of health. 13 Moderate acute malnutrition cases referred and managed in respective facilities. 670 OVC households educated on best hygiene practices, especially on hand washing, fecal management and treatment of drinking water, this has boosted their skills to promote clean environment and to be caution on communicable diseases. Mother to mother support groups: 45 active mother to mother support group linked to Waso dispensary, courtesy of FHK LIP through the project‘s technical support. The mothers were sensitized on TB management, hand washing, kitchen gardens and on methods of food preparation and preservation. These mothers are currently promoting nutrition interventions in Waso location. As a result of this, hand washing at critical times is being practiced in their households and neighboring ones. Kitchen Gardens: The LIPs with technical support from the APHIAplus aimed at sustainably and supporting households to respond to their feeding needs for the last 3 months, 50 caregivers were supported with kitchen garden drip irrigation kits of 300 crops that are currently supporting household to access vegetable for their consumption and small income generation at household level for other basic households needs. 2 caregivers gained significant income that has enabled them to provide uniforms for 4 of their OVCs. This has impacted positively on the 4 OVCs access to classes and learning at ease,

IR 4.3: Marginalized, Poor and Underserved Groups have Access to Education, Life Skills and Literacy Initiatives through Coordination and Integration with Education Programs Expected Outcome 4.3.1: Increased Access to Education, Life Skills and Literacy Initiatives for Highly Marginalized Children, Youth and Other Marginalized Populations The project continued to provide OVC with essential education and training services to increase school enrolment, ensure school retention and transition from one level to the other as well as to support older OVC who are out of school to acquire skills necessary for employment and engagement in activities to generate income. During this quarter, the OVC enrolled and attending school in different institutions across the 8 counties in NAL were reached with education services as follows; 1,021 OVC benefitted from secondary school fees payment, 1,861 OVC were provided with school uniforms, 386 OVC received scholastic materials, 1,274 girls were provided with sanitary towels and fees support was provided to 132 OVC to undertake vocational training courses. These achievements are attributed to direct project support as well as support through linkages with other partners like County Governments, the Constituency

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Development Fund (CDF) and the President‘s Education Bursary Fund through the Department of Children Services (DCS). A summary of achievements by county for this reporting period is shared below. GARISSA COUNTY 2,048 (1343M: 705F) OVC enrolled in the program are attending schools at different schools and different levels in the county. During this reporting period, 850 (350M: 500F) OVC participating in health clubs in 20 schools supported by APHIAplus IMARISHA were reached with life skills education. 316 (157M: 159F) were provided with scholastic materials. 53 OVC were provided with school uniforms, 8 OVC (5M: 3F) benefitted from school fees payment at Modogashe Secondary school and 3 girls enrolled for a tailoring course. During this period, the project also participated in commemoration of the International Literacy Day held in Lagdera Sub County and attended by 300 (185M: 115F) community members who were sensitized on taking active role in the education of their children.

TANA RIVER COUNTY 3,494 (1726M: 1,768F) OVC are attending school in various institutions in the county, among these, 616 (280M: 336F) OVC in ECD were paid for ECD levies, 600 of the 2,529 (1,257M: 1,272F) OVC in primary school received school uniforms, 326 (180M: 146F) OVC in secondary school were paid for secondary school fees and 23 (9M: 14F) OVC were supported to undertake vocational training courses, another 2,960 OVC benefitted from pairs of shoes. LIPs also followed up on action points raised during life skills/phase sessions conducted by SILC FAs and CHVs which saw 2 girls and 1 boy returned back to school. QI team in Kipini held dialogue sessions with children in 13 schools in Kipini to discuss poor performance in education while OVC caregivers and QI team members in Kipini discussed their role in ensuring education uptake among OVC.

ISIOLO, SAMBURU AND MARSABIT COUNTIES In Isiolo County, 5,687 OVC are enrolled in schools and were reached with various education and training services during the quarter, among these; 50 OVC received school fees while 12 OVC were supported for vocational training in areas of mechanics, tailoring and electrical while 25 were provided with tailoring machines to initiate IGAs. The project has continued to monitor the progression and performance of OVC in school with feedback showing that provision of school fees and uniforms to OVC enhances their regular attendance and performance. In Marsabit County, support to OVC on education entailed supporting 30 OVC with school fees while 640 received school uniforms enhancing regular attendance and retention in school. Continuous educational counseling was conducted during home visits to 4,789 school going OVC by CHVs.

6,621 OVC are attending school in Samburu County and 30 OVC in secondary school and 2 in vocational training were supported with school fees payment, 344 OVC were supported with school uniforms, 1,898 received tom‘s shoes while 344 adolescent girls received sanitary pads during this reporting period. The children will be retained in school, reducing absenteism and further expected to improve education performance. 412 adolescents were also reached with life skill messages during station day events. TURKANA COUNTY Out of the 4,263 OVC enrolled in school in Turkana County; 393 (168M: 225F) OVC benefitted from secondary school fees payment, 100 OVC in Lokichoggio received school uniforms, 40 OVC in Turkana Central received scholastic materials, 105 girls received sanitary pads which enabled them remain in school and prevent school absenteeism and 3 OVC were supported through vocational training courses during this USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 128 reporting period. A list of KCPE 2015 candidates was presented to respective SCCOs for support through the presidential education bursary fund.

WAJIR AND MANDERA COUNTIES

In Mandera County, 34 students in different secondary schools benefitted from secondary school fees payment worth Kshs. 184,000. Another 200 girls received sanitary towels. In Wajir County, 180 OVC in various secondary schools were paid for school fees during the quarter while 124 OVC were reached with school uniforms, 625 girls received sanitary towels and 30 OVC supported with scholastic materials.

IR 4.4 Increased Access to Safe Water, Sanitation and Improved Hygiene Expected Outcome 4.4.1: Support Exploitation of Ground Water

Expected Outcome 4.4.2: Promote and support rain water harvesting

Expected Outcome 4.4.3: Support comprehensive school heath During the year 2015, through APHIAplus IMARISHA 49,495 people (90% of 55,550 target) have gained accessed to improved drinking water supply, while 30,115 people (83% of 36,120 target) in the target counties have gained access to improved sanitation facilities as a result of USG assistance. During the same period, the project completed 69 squat holes (96% of 72 target) VIP latrines in schools and health facilities. The great contributors to the attainment of sanitation targets included use of CHVs to collect sanitation and hygiene data within the CLTS process and rigorous follow-up with the triggered villages. In the quarter under review, APHIAplus IMARISHA reached 30,522 (19,982 in Samburu; 2649 in Isiolo; 4737 in Mandera; 670 in Wajir and 2,484 in Marsabit counties) new beneficiaries with access to clean drinking water as a result of drilling and rehabilitation of 2 boreholes, 7 water pipeline extensions, construction of 7 shallow wells and installation of 4 rain water harvesting tanks in schools, health facilities and communities. To ensure the water being used for drinking and cooking is safe; APHIAplus IMARISHA procured and distributed 208,550 point of use water treatment chemicals which composed of 122,550 aqua tabs and 86,000 purr sachets to OVC households and schools to disinfect 3.3 million liters of drinking water during the reporting quarter. In the reporting quarter, APHIAplus IMARISHA conducted a self-Environmental Audit (EA) in 6 counties (Marsabit, Isiolo, Samburu, Turkana, Garissa and Tana River) to review the implementation of the Environmental Management, Mitigation and Monitoring Plan (EMMP) developed during 2014 to determine level of compliance in regard to national environmental laws. It looks at the effects of the implemented activities/projects on the biological, economic, social and physical environments. The audit covered activities which had been predicted to have low/moderate impact on the environment. A report on the EA is being finalized and will be shared separately. A summary of WASH facilities that have been developed through the project since inception is shown in the table below.

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Table 38: Number of WASH Hardware Developed Since Project Inception in The Northern Arid Lands

County Boreholes New and VIP Number Rain WSMC Pipelines Spring (New and rehabilita construc of water s/Artis extended Protecti Rehabilitat ted ted villages harvestin ans on ed) shallow triggere g trained wells d systems Garissa 21 13 Mandera 5 6 10 2 22 Wajir 2 9 29 86 7 95 3 Marsabit - 1 3 5 6 - 3 - Isiolo 2 3 18 13 4 13 1 - Turkana - 2 8 10 5 Samburu 2 2 4 11 4 43 3 1 Tana 2 31 71 15 89 River Total 6 24 99 227 56 262 10 1

In an effort to reduce incidences of water related diseases, APHIAplus IMARISHA continued supporting schools and health facilities to construct improved sanitation facilities. During the reporting quarter, 2,842 additional people accessed improved sanitation through completion of 18 door VIP latrines. Community-Led Total Sanitation (CLTS) remained our key approach to improving sanitation for OVC households in NAL. To date APHIAplus IMARISHA in collaboration with MoH has triggered 227 villages and these villages continued constructing toilets to eventually become Open Defecation Free (ODF) communities. In the reporting quarter 3,439 households in the previously triggered villages constructed toilets and installed hand washing facilities serving 19,800 people. However, the progress towards ODF has been challenging due to slow and lengthy certification process, lack of county level certifiers and high ODF target. To accelerate and fast track the ODF certification process, APHIAplus IMARISHA conducted training for 23 County level 3rd party certifiers for Wajir, Mandera, Isiolo and Samburu counties. With this batch of Certifiers at the county level, the project intends to fast-track the certification process and attainment of ODF target. Further, during the reporting year, APHIAplus IMARISHA conducted training for 16 community based artisans in Mandera on hygiene promotion, operations and maintenance of WASH facilities and sanitation marketing including making and selling of toilets slabs to encourage households upgrade and improve their sanitation facilities. Specific achievements made during the quarter by county are summarized below; 4.4.1: Support Exploitation of Ground Water During the quarter under review, insecurity continued to pose a major challenge in some of the counties, resulting in interruptions and delayed implementation of planned activities. The most affected County was Mandera, where key activities including a new borehole drilling at Dandu Community Unit and Takaba borehole rehabilitation had to be moved to Isiolo and Samburu respectively. In order not to lose on the APR targets, APHIAplus IMARISHA requested and got approval to relocate Dandu Borehole to Chumvi Yare community in Isiolo County and Takaba borehole rehabilitation to Baragoi and Wamba health facility water connections. While, Baragoi and Wamba are priority health facilities, in Chumvi Yare the project will utilize the opportunity to layer and work with PREG (formerly 952) partners on Food Security, Household Economic Strengthening (HES) and Nutrition for vulnerable households.

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WAJIR COUNTY During the reporting quarter, APHIAplus IMARISHA fully completed water pipeline extensions to Arbajahan Health Centre and Wajir County referral hospital MNCH departments. At Arbajahan, the pipeline extension was undertaken to supply water to the Health Centre about 1.3km from an existing borehole; while in Wajir referral hospital, APHIAplus IMARISHA extended water by 200m to serve MNCH department. In both facilities, the scope of works included construction and installation of elevated plastic 10m3 water tanks and plumbing works inside the facilities. Further, during the reporting period, APHIAplus IMARISHA completed, branded and handed over three (3) shallow wells; Kwa Sharif, Guyow and Marere in Leheley CU to community Water Sanitation Management Committees (WSMCs) for operation and maintenance. As a result of pipeline extensions and completion of three (3) shallow wells, 5,300 new beneficiaries in Wajir County are now accessing improved drinking water supply all the year round.

Figure 83: Elevated Plastic Water Tank at Wajir DH MNCH Department and Marere Shallow Well, Wajir County.

MANDERA COUNTY In Mandera County, APHIAplus IMARISHA completed construction/protection of five (5) shallow wells namely; El-wak DEB Primary school, Al Uteibi OVC primary school, Aluweis, Qurdoboshanan and Bulla Afya community shallow wells. Identification of the sites as well as the construction of the shallow wells was done in collaboration with the local administration, beneficiary Figure 84: El-Wak DEB Shallow Well and Training of Local Artisans on Hand communities and area Pump Installation, Mandera County. WSMCs. The scope of works included capping, construction of spillway drains, cleaning and disinfection, installation of the Afridev hand pumps and protection of the well area by fencing. As a result of these shallow wells 4,737 new beneficiaries have gained access improved drinking water supply. During the same reporting period, APHIAplus IMARISHA

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trained 16 local community based artisans on WASH technologies, particularly installation and maintenance of hand pumps, hygiene promotion and sanitation improvements. SAMBURU COUNTY During the previous quarter, APHIAplus IMARISHA completed drilling of a new borehole at Napunye community in Archers Post of Samburu County. In the reporting quarter, APHIAplus IMARISHA completed installation of a 50 m3 elevated steel water tank, solar powered water pumping system and constructed two (2) water kiosks. Further, the project supported formation of a 15 member, gender balanced Water Services Management Committee (WSMC), who will in the coming quarter be trained on integrated management of water, operations and maintenance, hygiene, Multiple Use Services (MUS), 3R (Recharge, Retention and Reuse) technique and environmental conservation and protection measures. Currently, the project is serving Rapunye and Lekipiren villages reaching 3,060 people with improved drinking water supply throughout the year. Additionally, APHIAplus IMARISHA has completed rehabilitation of Longewan community borehole in Suguta Marmar, Samburu County. The rehabilitation works included installation of a 50m3 capacity elevated steel tank, replaced diesel run pumping with a solar powered pumping system and constructed two (2) communal water access points – water kiosks to serve 3 villages, a primary and a secondary schools; a Health Center and a Police Camp. The rehabilitated borehole and water distribution network is currently serving a total population of 1,814 people and hence saving time for women to engage in productive work and children to attend school instead of helping their parents in collecting water.

Further, APHIAplus IMARISHA completed water connection from Longewan to Kao village; to Baragoi and Wamba health facilities serving communities and health facility departments. In total the three (3) water pipeline extensions are serving approximately 12,608 people. In Ngeriyoi village, APHIAplus IMARISHA completed construction of an infiltration well. The well is located between 2 earth dams and water from the dams is filtered into the well by artificial filtering layer of stones, thus improving water quality significantly. The shallow well has been installed with a hand pump and is currently providing improved drinking water supply to over 2,500 people in Ngeriyoi village in Samburu County.

Figure 85: Showing Stages in Construction of Ngeriyoi Infiltration Shallow Well, Samburu County.

ISIOLO COUNTY During the previous quarter, APHIAplus IMARISHA completed and installed Ngaremara and Alakara shallow wells with hand pumps. During the same period, the project trained 13 (7 Male, 6 Females) community based artisans to enhance their technical skills and knowledge on construction of shallow wells and promotion of sanitation and hygiene at the community level. In the reporting quarter, the project utilized these trained community own resource persons to construct and installed a hand pump on Kiwanjani shallow

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well in Ngaremara area of Isiolo County. Currently, the three (3) shallow wells are serving total population of 1,389 people with improved domestic water supply throughout the year.

Figure 86: Completed Ngaremara and Alakara Shallow Wells, Isiolo County

In the previous quarter, APHIAplus IMARISHA completed developing water supply system for Naretate OVC caregivers in Kakili village in Burat location. The project is currently serving 1, 260 people including an ECD centre with improved drinking water supply and providing water for small scale irrigation e.g. kitchen and storey gardens at household level. In the reporting quarter, APHIAplus IMARISHA conducted training of 51 WSMCs (5 males and 46 female) on integrated WASH, MNCH and Nutrition, for sustainability and ownership of the projects. The participants were drawn from Naretate OVC caregivers, Alakara and Kiwanjani shallow well groups. The integrated training was facilitated by Ministries Public Health and Sanitation, Water and Irrigation, Department of Nutrition and MNCH and Ministry Agriculture and Livestock staffs. The WSMC members agreed to integrate interventions and promote sustainability of the project.

Further in Isiolo County, APHIAplus IMARISHA started the process of drilling a new borehole at Atir community in Chumvi Yare to serve 3,000 people in Atir and Mandeleo villages. Hydro geological survey has been done to map the most suitable site for drilling and environmental impact assessment (EIA) to identify and mitigate any environmental threats. Competitive bidding process to identify a contractor to drill the borehole is underway and the borehole will be drilled to maximum depth of 250metres at VES 2 grid reference 0024.572‘N; 037039.870‘E. In the coming quarters, APHIAplus IMARISHA will utilize this opportunity to work with PREG (formally 952 partners) to maximize on the impact of the project. TURKANA AND MARSABIT COUNTIES In the previous quarter, APHIAplus IMARISHA completed installation of 50m3 elevated steel tank at Elelea community in Turkana County. In the reporting quarter, the project procured, pipe, fittings and other construction materials to extend water from the elevated tank to Elelea primary school, Elelea Dispensary and two community water access points to serve estimated population of 4,565 (2,333 male and 2,231 female) people. During the next quarter, the project will facilitate formation and training of WSMC on operation & maintenance, hygiene and integrated management of water supply system including MNCH, Nutrition and HES initiative. During the training, issues of Water User Fees and its transparent management will be addressed to facilitate the WSMC to sustainably run the project and further extend water to reach more needy villages not yet served by the current water distribution network.

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In Marsabit County, APHIAplus IMARISHA completed trenching and laying of 2km water pipeline extension from Ngurunit primary to Ngurunit Secondary School. The water extension works included construction of a tank base, installation of a 10m3 plastic water tank and communal water access point outside the school compound. The solar powered borehole provides water to the primary, secondary school and 283 households (1,984 people) in Ngurunit market with improved and reliable safe water supply throughout the year.

Figure 87: The Newly Installed 50 M3 Elevated Steel Water Tank in Elelea, Turkana

4.4.2: Promote and support rain water harvesting MARSABIT COUNTY In the reporting quarter, APHIAplus IMARISHA successfully procured and installed 2plastic rain water harvesting tanks of 10,000 liter capacity in Marsabit County Referral Hospital to serve maternity and laboratory departments. The tanks were also connected to an existing Marsabit water supply system to guarantee continuous availability of water serving approximately 200 people in the facility per day.

Figure 88: Plastic Water Installed at County Referral Hospital, Marsabit County In the previous quarters, APHIAplus IMARISHA completed installation of a 10m3 plastic water tank at Mercy primary school in Laisamis Sub County. The installation works comprised of purchase and delivery of the tank, construction of concrete tank base and fixing of the guttering system. During the current reporting period, the School Management Committee (SMCs) connected the tank to an existing communal water supply network and thus providing improved drinking water supply to over 300 pupils in the primary school. In Samburu County, APHIAplus IMARISHA installed a 10m3 plastic water tank at Wamba Health Centre. USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 134

Figure 89: The 10m3 Plastic Water Tank at Mercy Girl’s Primary School in Laisamis Sub County, Marsabit County 4.4.3 Sanitation and Hygiene at Community and Facility Level In collaboration with the Ministry of Health (MoH), APHIAplus IMARISHA continued follow up visits to triggered villages so that they can became open defecation free communities. However, progress towards reaching the ODF target has been slow and challenging, partly due to the CLTS process itself and partly due to lack of County level master certifiers. In an effort to accelerate and fast track attainment of ODF target, APHIAplus IMARISHA conducted training for 23 Master Certifiers for Isiolo and Wajir regions. The two training sessions were facilitated by the National CLTS Hub and each training took three days, where the participants were exposed to CLTS protocol, tools and practical experience on the actual certification process. In Isiolo County, the team visited 2ODF claimed villages (Kiwanja Ndege A&B), while in Wajir County Lafaley and Shanta Abaq villages were visited. None of the four (4) villages could get ODF certification because there was evidence of open defecation after a transit walk in the villages. According to ODF certification, if human faeces are found in the open; then the certification process stops and the village is again declared not open defecation free, but encouraged not to despair and move on with the CLTS journey until its attains ODF. It‘s key to note here that, the CLTS process from pre-triggering, triggering, follow ups, verification, certification and post ODF is very lengthy, slow and expensive. There is high likelihood of relapses back into open defecation even after attaining ODF status without immediate post ODF interventions. This is particularly true for the NAL communities where people move with their animals in search of pasture and water or displacement due to insecurity. In the coming quarters, APHIAplus IMARISHA will utilize CHVs and trained County level certifiers in supporting the CPHOs to do follow ups and certify villages to meet ODF target. To prevent already certified ODF villages relapse back into open defecation, APHIAplus IMARISHA will in future support the trained community based artisans to promote sanitation marketing -making and selling of latrines slabs to households to improve their sanitation facilities.

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Figure 90: Showing Participants during CLTS Master Certifiers Training in Wajir and Isiolo Regions. In Isiolo and Turkana counties, APHIAplus IMARISHA is at an advanced stage in supporting County Health Management Committees (CHMCs) to construct modern incinerators at Isiolo TB Manyatta and St. Patrick‘s dispensary in Lodwar. The tenders for the works have been awarded and the contractor will shortly move to sites to start the works. The two (2) incinerators are expected to be complete by the end of December 2015. During the quarter, APHIAplus IMARISHA completed construction of 5 2-door VIP latrines at Bula Mpya primary school serving 642 pupils in Wajir County. During the same period, the project distributed 43,530Aqua tabs and 21,600 sachets of Purr to treat 1,158,600 liters of water. The water treatment chemicals were distributed to households through Community Units (CHVs), MOPHs, LIPs and WSMCs. A practical demonstration on use of the chlorine based tablets was done before distribution. In Isiolo County, 834 households have constructed toilets serving 4,170 people with improved toilet facilities. A core component of hygiene is hand washing with soap and clean water at the 4 critical times. In recognition of this, APHIAplus IMARISHA supported Isiolo County Referral Hospital maternity department and two maternal shelters (Sidai and Nachola) in Samburu with hand washing facilities to promote the culture of hand washing, especially among mothers coming to visit. Each facility got one hand washing facility. Demonstration of the same was done and mothers encouraged replicating the same at their household level.

SAMBURU COUNTY

During the reporting quarter, 1624 households in Samburu County have constructed toilets after triggering and follow up visits and hence accessing sanitation facilities for 9,744 people. Community dialogue is an event where members of community, partners, local leaders and religious leaders meet and talk about their health problems frankly and openly. To this end, APHIAplus IMARISHA supported community dialogue day at Longewani attended by 421 community members, GOK partners, CHVs and local leaders. The services offered during the day was hygiene education, immunization, family planning and growth monitoring for 92 children. During the reporting quarter, APHIAplus IMARISHA conducted community action day at Kao village, where 11 households constructed toilets after CLTS triggering and follow up visits.

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Figure 91: Demonstration on Use of a Tippy Tap For Handwashing and Community Members Constructing Latrine at Household Level, Samburu County. WAJIR COUNTY During the reporting quarter, APHIAplus IMARISHA continued monitoring of triggered villages on CLTS in collaboration with CPHOs, CHVs and Natural leaders. In Wajir County, 534 households in Sarif CU constructed toilets. This has increased access to improved toilets and hygiene practices-handwashing with soap and water for 3,204 people. At Leheley Health Centre, two doors VIP Latrines have been completed serving five hundred people. Further, in Wajir, the project supported response to cholera outbreak through hygiene promotion as well as dissemination of the Small doable actions (SDAs); which include effective personal hygiene with emphasis on handwashing with soap, household water treatment and safe storage and safe disposal of feces. A total of 2,347 household was reached with hygiene messages and also issued with aqua tabs for purification of drinking water, 623 shallow wells in Leheley and Barwaqo CUs were chlorinated; 10 water purifiers donated by Unilever were distributed to health facilities and schools to purify their drinking water.

IR 4.5: Strengthened Systems, Structures and Services for Protection of Marginalized, Poor and Underserved Populations

Provision of OVC services: The project continued to provide essential services to OVC to address their critical and prioritized needs. During the period under review, 37,408 OVC were served with essential service, 123% achievement above the USAID FY15 Country Operation Plan (30,512) targets. The services provided ensured improved food security in OVC households, increased enrolment, retention and school progression for OVC in school, access to preventive and curative health services, emotional wellbeing of OVC, availability of safe, clean shelter and environment for OVC, safety from violence and abuse and ability of households to meet OVC basic needs. To ensure sustainability, the project continues to target households with HES and other interventions geared towards family strengthening and self-reliance as a strategy to transition families out of project support. OVC Access to HIV services:

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Figure 92: Number of OVC Accessing HIV Services in NAL 9,141 OVC were counselled and tested for HIV this quarter; increasing the total number of OVC with known HIV status in the project from 64.2% in the previous quarter to 83% this quarter, this also brings the total number of OVC who accessed HIV services this financial year to 11,542 (89%) OVC against an annual target of 12,934 OVC, among these are 10,867 who were counselled and tested for HIV this year and 577 OVC living with HIV (tested for HIV in the previous years) who continued to access HIV services in various CCCs in NAL. So far 31,181 (83%) OVC of the 37,408 OVC who are active and served this quarter have known HIV status and 675 OVC are living with HIV and accessing HIV services in CCCs across counties in NAL The HTC achievements in Tana River, Marsabit, Garissa and Turkana Counties are attributed to the OVC Station Days events organized by the projects where OVC and their caregivers were mobilized to access integrated health services including Vitamin A supplementation, deworming, MUAC screening and HTC offered as one of the routine services during the events. The integration of HTC services in station days enabled the project to provide HTC services to a big number of OVC because of reduced stigma and accessibility of the services through the outreach activities. Other approaches such as door to door testing and targeted mobilization of OVC with unknown HIV status to access HTC at link health facilities were also employed in these counties to mop up OVC who could not be reached through OVC station days‘. The HIV positive children have been mobilized into 18 Kids clubs formed and linked to ART facilities across the counties, 574 OVC who are members of the clubs attend monthly meetings and receive age appropriate information on HIV and AIDS, adherence counselling and psychosocial support through engagement in play and group therapies (for older OVC) to promote positive living.

Community SIMS Assessment: The project conducted internal SIMS assessments targeting LIPs to continuously identify and address OVC programming and system gaps. Documentation and filling as well as low HTC rates were the main gaps identified and strategies were put in place to address them. For instance, the implementation of Rapid Results Initiatives in all counties with low HTC rates led to the increase of HTC rates among OVC from 64.2% in the previous quarter to 83% this quarter. This was through the use of

USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 138 effective strategies like OVC station days‘ events, door to door testing and targeted mobilization of OVC with unknown HIV status to access HTC at link health facilities.

OVC Quality Improvement: The 39 Quality Improvement teams in NAL continued to implement essential actions aimed at improving OVC service delivery through OVC Quality Improvement initiatives. QI coaches from Local Implementing Partners, Department of Children Services and APHIAplus IMARISHA also provided technical assistance (mentorship and coaching) to support QI teams to pilot improvement change ideas meant to address gaps in food security, shelter, education and legal protection. The project also trained 6 LIP staff and one Children Officer as QI coaches in Turkana County, the coaches will provide guidance to QI teams in Turkana to enable them strengthen roll out of these activities. Sustainability and Family Strengthening: Working towards sustainability through community ownership and family strengthening, 64 OVC caregiver groups were formed this quarter bringing the number of OVC caregiver groups formed this year to 227 against the annual target of 200 OVC caregivers groups. 2,761 OVC caregivers who are members of these groups are engaged in various HES activities and other initiatives to improve the capacity of the family to support their own children and promote self- reliance. So far 516 caregivers‘ groups have been initiated since program inception. A summary of achievements by county is shared below: Expected Outcomes: 4.5.1 Increased Access to Quality Protective Services to Survivors of Sexual Assault, Child Maltreatment and Children without Adequate Family Care 4.5.1.1 Provision of Essential Services to OVC

GARISSA COUNTY During the period under review, 2,451 (98%) out of the 2,500 OVC enrolled in the program in Garissa County were served with OVC services to address their critical needs. 700 OVC accessed HTC services and one OVC tested positive and was linked for HIV services at the Garissa County Referral Hospital Comprehensive Care Centre (CCC); this brings the total number of OVC tested for HIV and with known HIV status in FY 15 to 1,228 OVC, 132% achievement against the annual target of 933 OVC targeted with HTC in Garissa County this year. So far 2, 267 (91%) of the enrolled OVC have ever been tested and have their status known among these 16 OVC are living with HIV and continue to access HIV services at various CCCs in the county. Food and Nutrition: 1,875 (975M: 900F) OVC were reached with nutrition information during home visits and outreach programs. 236 OVC were also dewormed and given Vitamin A supplementation, another 25 (13M: 12F) were referred to health centers for nutrition support. Capacity building on health education with focus on healthy dietary practices, promotion of Exclusive Breastfeeding, diet diversification at the household level, hand washing and demonstrations of Multi Storey Gardens was provided to 1,585 caregivers and CHVs. Shelter and Care: CHVs provided continuous monitoring to ensure that OVC are under the care of parents, this is as a result of increased knowledge and skills acquired through child protection training conducted this quarter. 1,000 (525M: 475F) were reached with this service. 3 OVC households were also renovated and 30 mattresses were offered to needy OVC households. Child protection and legal support: 1,000 (606M: 394F) OVC were provided with child protection and legal support services. Among these, 76 OVC were issued with birth certificates this quarter, 1,350 (650M: 700F) OVC of the 2,500 OVC enrolled in the program have acquired birth certificates. The Garissa County Child Protection Working Group (CPWG) that comprises of more than 10 organizations has remained pivotal to addressing child protection issues in the county. Under the stewardship of the County Children‘s

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Coordinators office, sensitization of the members and the larger community on child rights with emphasis on education, Female Genital Mutilation and early marriages which are key in the region has been ongoing. The CPWG is currently championing and advocating for the birth registration agenda in the county. A task force was formed to spearhead the initiative and meetings were held with County Executive for Children Affairs and the Governor to discuss way forward and address challenges experienced in acquisition of birth registration certificates in the county. Health Care: Outreach programs were held by LIPs (SIMAHO) reaching out to 1,026 (350M: 676F) OVC and their households members. These included 266 (115M: 151F) OVC treated for minor illnesses, 292 (136M: 156F) OVC provided with vitamin A supplementation and 176 (76M: 100F) OVC dewormed. Community Led Total Sanitation triggering exercise was done jointly with MoH at Bulla Waberi and Tagwein in Lagdera and Daadab Sub Counties, follow up will be done in the coming quarter to encourage and monitor building of latrines. Psychosocial wellbeing: Station Days events have been the most effective avenues in enhancing PSS as well as integrated service provision for OVC. The children got a rare opportunity to play, recreate and interact closely with their peers and adults. 3 station days were done and attended by 390 (166M: 224F) OVC. The school health clubs have also played a big role in enhancing OVC psychosocial well-being through the guidance and counseling from teachers/patrons as well as peer support. Spiritual talks provided to the 400 boys at Alfarouk Children Centre have also been vital. A Kids club for HIV positive OVC was formed in Garissa Township and linked to SIMAHO health facility, a meeting was held where 15 (7M: 8F) OVC living with HIV attended to discuss issues on positive living including ART adherence and disclosure. Household economic strengthening: 664 caregivers were reached with HES services and 434 are currently engaged in HES activities, four caregiver groups comprising of 62 members (4M: 56F) were issued with tomato, Kales, Spinach and green-pepper seeds for Multi Store and kitchen gardening. Four poultry houses have been constructed and the beneficiaries trained ahead of procurement of chicks. Coordination of care/ referrals and linkages: A good networking has been fostered with the Department of Children Services, project staff and CHVs. The project participated in Area Advisory Council AAC meetings at the Sub County level and attended Garissa County CPWG meetings. Leveraging with partners enabled 50 caregivers (female) to get casual employment under the County Environmental (bush clearing) Program in Daadab and another 50 households acquired shelter materials (iron sheets and polythene/tarpaulin) through collaboration with Kenya Red Cross Society and Mentor Initiative in the same area. The project‘s collaboration with the Education Ministry and Teachers Service Commission in the county has also provided a conducive working atmosphere with teachers and pupils in the implementation of school based programs.

TANA RIVER COUNTY 4.5.1.1 Provision of Essential Services to OVC

During the period under review, 3,790 (96%) OVC in Tana River County were served with services to address their critical needs. 833 OVC were counseled and tested for HIV this quarter and 26 OVC who tested positive for HIV were linked to CCC for enrollment into care and treatment, bringing the number of OVC who accessed HTC services this year to 1,131 OVC (99%) against an annual target of 1,190 OVC. Another 100 OVC who were tested in the previous quarters and are living with HIV were monitored and continue to access HIV care and treatment services at various CCCs in Tana River County. So far 3,901 of the enrolled OVC in the program have known HIV status and among these 126 OVC are living with HIV.

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Food and Nutrition: 2,805 (1,486M: 1,319F) were reached with this service, through direct project support as well as linkages with other partners. Caregivers affiliated to Farmer Field Schools benefitted from seeds provided by the program and through linkages with Kenya Red Cross Society, Government of Kenya Special Programmes Department and Caritas Spain Livelihoods Program. CHVs conducted diet diversification education during household visits reaching 1,112 OVC households in Garsen, Tana delta Sub County. Mwangaza support group in Kipini received 14 dairy goats from Catholic Diocese of , Witu Parish Tuvumiliane Project to undertake dairy goat farming aimed at improving nutritional status and improved economy among members through consumption and sale of surplus milk.

Shelter and Care: 1,564 (788M: 776F) OVC were reached with this service during this period. Caregivers were sensitized on importance of shelter and care for OVC and resource mobilization for shelter renovation. 3 dilapidated OVC households were renovated and OVC in these households are now living in habitable environment.

Child protection and legal support: The project supported 270 OVC to acquire birth certificates and preparation of birth registration documents for 380 OVC has been made. 5 birth registration advocacy sessions were also conducted in the project sites to increase registration awareness among children. Teachers, SILC (FAs) and CHVs orientated on child protection through the program were engaged in protection activities. This includes the identification and presentation to Kipini Police Station of a case affecting a female OVC who was impregnated by an elderly man in Kipini, the OVC was taken back to school and the culprit reprimanded. 2 OVC have also been rescued from early marriage and taken back to school and other two OVC rescued from commercial sex work and re-united with their parents.

Health care: The project through the CHVs and health club patrons in schools conducted health education sessions to OVC and caregivers, this was done in schools, at household level and during Kids clubs meetings. 3,208 OVC were also reached with nutrition counseling and education. Deworming, Vitamin A supplementation and HTC services were also provided to OVC and their caregivers during OVC station days, health action days and door to door visits, to scale up uptake of these services. As a result; 833 OVC were counseled and tested for HIV this quarter; 26 OVC tested positive for HIV and were linked to CCCs for ART services, 319 OVC were reached with MUAC screening, Vitamin A supplementation and deworming and 51 referred for nutritional support and services. The project assisted 6 OVC to access health referral services in Kijabe Hospital, Kenyatta National hospital, Malindi Sub-County Referral Hospital and Hola County Referral Hospital.

A community triggering exercise was done at, Kibaoni B village in Kipini, Tana Delta Sub County (which had only 3 latrines in existence) with an aim of adopting good sanitation practices through latrine construction and use and reducing open defecation methods. 390 community members (150M: 240F) participated in the exercise. A follow-up visit to Kibaoni A village found out that 6 latrines have been constructed as a result of the triggering. Jigger awareness and treatment campaigns were also conducted in Kipini where 139 OVC were treated. Psychosocial Wellbeing: 2,713 (1,418M: 1,295F) were reached with psychosocial and counseling services provided to OVC during station days and Kids clubs meeting sessions in Tarasaa, Kipini, Hola, and Bura. 2 Kids clubs (in Kipini and Bura) received play materials donated by Team and Team International and refreshments offered by Witu Catholic Parish. There are 5 active Kids clubs in Tana River County established and supported by the project and 88 (42M: 44F) OVC who are members of the clubs attended the monthly psychosocial wellbeing in Bura , Hola, Kipini, Tarasaa and Garsen health facilities. One of the established kids clubs in Kipini, Tana River County has integrated ART services during monthly Kids club meetings and children who are accompanied by their caregivers receive their medication, adherence counseling and all the necessary tests (CD4 counts), nutritional screening (MUAC), deworming and vitamin A supplementation by USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 141 the HCWs who attend these meetings. 640 OVC caregivers who are members of the 52 OVC caregiver groups continued to receive PSS during meetings and are actively engaged in HES activities.

Household Economic Strengthening: 52 OVC caregiver groups are in existence in Tana River County and 640 OVC caregivers who are members of these groups are involved in HES activities. The 52 OVC caregivers‘ groups are involved as follows; 3 groups in FFS, 27 groups in SILC, 6 groups in farming and 16 are IGA groups. Coordination of care/referrals and linkages: To enhance coordination and referrals a meeting was held with the Tana Delta Sub County Public Health Officer where interventions to improve sanitation and hygiene in Tana Delta were discussed. The project also participated in an Area Advisory Council (AAC) meeting in Galole Sub-County

ISIOLO REGION 4.5.1.1 Provision of Essential Services to OVC During the period under review, 20,436 OVC were served with OVC services to address their critical needs. 3,457 OVC were counseled and tested for HIV this quarter and 6 OVC who tested positive for HIV were linked to CCC for enrollment into care and treatment, bringing the number of OVC who accessed HTC services this year to 4,627 OVC (91%) against an annual target of 5,092 OVC, another 247 OVC who were tested in the previous quarters and living with HIV were regularly monitored and continued to access HIV care and treatment services at various CCCs in Marsabit, Isiolo and Samburu Counties. So far 15,643 of the enrolled OVC in the program have known HIV status and among these 253 OVC are living with HIV. ISIOLO COUNTY Food Security and Nutrition: The quarter aimed at supporting households to respond to their feeding needs. 50 caregivers were supported with kitchen garden drip irrigation kits that are supporting household production of nutritious vegetables for consumption and small income generation at household level. 2 caregivers have reported having gained significant income that has enabled them to provide uniforms to four of their OVC. 123 caregivers from 9 caregiver forums were sensitized on eating habits and food preservation as well as demonstrations on personal hygiene. 1,270 OVC were reached out with nutritional screening and referral services, provided with vitamin A and dewormed. One case of acute malnutrition was referred to Garbatula Sub County Hospital and successfully managed. Shelter and Care: To address regular attendance and high performance in school, 960 OVC were provided with TOM‘s shoe. The impact of TOMs shoe have been reported to include enhancing OVC self – esteem and increasing leaner interests in attending school. Continuous visits to 2,886 households by 147 CHVs that were re-oriented on OVC care and support ensured that the 5,379 OVC were assessed and the caregivers sensitized on OVC care and support. Child Protection: 147 CHVs sensitized on child protection during CHV orientation visits reached out to 2,886 caregivers with various child protection issues including child labor and FGM rampant in the area. Efforts on acquisition of birth certificates led to 22 OVC receiving their birth certificates and caregivers orientated on the significance of birth certificates registration in claiming of property rights. Health: 2,886 households were reached with water purifying agents (PUR and aqua tabs) and promotive health care information. 11 OVC living with HIV continued to receive adherence support and referrals for health care by CHVs. The 11 OVC together with additional 4 others were enrolled for 1 year NHIF for subsidized medical care.

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Psychosocial Well-Being: Psychosocial support was offered to 5,379 OVC through home visits by CHVs. 2,886 caregivers also benefited from sensitization on PSS needs of OVC through their regular monthly forums. This has been key in addressing the emotional needs of the OVC. Household Economic Strengthening: The quarter focused on enabling households to be self-reliant and in preparation of the clusters and forums for exit. During the quarter, 13 caregiver groups of 675 members that had been trained on IGA management were supported to establish rainbow rooster poultry project, a dual purpose breed significant for egg laying and high quality meet. The forums were provided with trainings on poultry management and introduced to the market model of extension and egg sale. The cocks will be sold for meat while the hens will be kept for production of eggs for sale. Further, 7 caregiver forums made of 209 caregivers were trained on business management and supported with goats enterprise projects. The groups were linked with the Ministry of Livestock who will provide further training and other service as need arises. The project facilitated 4 groups affilitated to Pastoralists Women for Health and Education (PWHE) to develop livestock trade business plans as they planned to expand their business. Through PWHE, the groups were supported with goats and sheep worth KShs. 250,000. Each live animal gives an average profit margin of KShs. 400. Part of the proceeds go to members to take care of their household needs and the remainder into their group business expansion. In preparation of the predicted El-nino rains, most groups had prepared their farms for crop production. APHIAplus IMARISHA linked the groups to the Ministry of Agriculture for support with seeds. The groups face challenges such as pests and diseases, and APHIAplus IMARISHA linked them to Amiran Kenya to train them on crop protection. 3 SILC groups based in Garba Tulla have continued to receive technical support from the SILC FA. The groups had saved a total of Kshs.15, 000. Twenty two self-help groups are actively engaged in SILC and have a savings of Kshs.255, 900 another Sixteen caregivers groups comprised of 350 (34M: 316F) had merry-go- round activities and were contributing Kshs.194, 040 per month. The groups do poultry farming, livestock trade, crop farming and small businesses. Through women‘s ‗Uwezo‘ fund, Rwalo and Pathfinder Caregivers Groups benefited with loans of Kshs.50, 000 and Kshs.100, 000 respectively. The groups lend the money to its members with interest. By the time of reporting, the groups had started repaying the loan to ‗Uwezo‘ fund. Emejeng caregivers group benefitted from ‗Njaa Marufuku Kenya‖ project which is run under the Ministry of Agriculture. Table 39: Isiolo County Caregivers Groups which Have Been Linked for Funding

Name of Group M F Financial Institution / Type of Fund Amount (KShs.) Rwalo 0 23 Uwezo Fund 50,000 Pathfinder 0 15 Uwezo Fund 100,000 Emejeng Caregiver Group 8 6 Njaa marufuku Kenya 150,000

Tupendane and Mungaano FFS remained active in the reporting quarter. Tupendane FFS continued with their merry-go-round and table banking activities. The active members are 25 and they make a monthly contribution of Kshs.200 through table banking and KShs.300 weekly in the merry-go-round. The members use the money to boost their own individual businesses and take care of immediate household needs. Most of the members undertake farming as a business. They also lease out their water pumps at a rate of Kshs.200 per day. On a good month, they make an average of Kshs.2400 which is given to members as a loan. MARSABIT COUNTY

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Food and Nutrition: During the quarter, 1,232 OVC benefitted from MUAC screening, deworming and vitamin A supplementation with 5 cases of acute malnutrition referred and managed at Marsabit County hospital. 6 households were supported with drip irrigation kits supporting household food production. Shelter and Care: The project aimed at enhancing the shelter of most vulnerable OVC. 7 HIV positive OVC had their households renovated. 168 CHVs oriented on care and support to OVC reached out to the 1,578 caregivers with sensitization on OVC care during regular monthly caregiver forum meetings. Child Protection: 19 OVC benefited from birth registration while 1,578 caregivers were reached with awareness creation on rights of children with emphasis on legal rights and protection of children from child labor, FGM and early marriage. The caregiver forums continued to provide avenues for identification of abuse cases and for dialogue amongst the caregivers on child protection. Engagement of provincial administration in some of the forums has enhanced cooperation in pursuing of reported cases. Health Care: 340 OVC were supported with sanitary pads while 173 adolescent OVC were provided with health talks. The CHVs continued providing home visits to assess progress and support families to monitor the health of the OVC and adopt promotive health care behaviors such as hand washing and personal hygiene management. Psychosocial Well-Being: The CHV orientation provided them with increased information on PSS which they utilized and reached out to the caregivers and 6,987 OVC during regular home visits. PSS provision enabled the caregivers to explore various issues affecting the OVC well-being. Household Economic Strengthening: 8,516 beneficiaries (the OVC and the caregivers) were reached with HES support ranging from poultry farming, supply of drip irrigation kits, SILC initiatives and new technology farming methods. 5,664 OVC caregivers are currently engaged in IGAs and are able to meet other basic needs. 420 HIV positive caregivers and OVC are benefitting out of these initiatives. The initiatives have relieved the burden at the household level, enabled payment for medication and access to good nutrition. Monitoring of 1,950 improved poultry (Rainbow roosters) distributed to 795 OVC households in the previous quarter continued throughout the quarter 5,565 OVC will be benefitting from the poultry projects once they are mature. SAMBURU COUNTY Food and Nutrition: During the quarter under review 1,936 caregivers taking care of 5,808 OVC were reached with messages on dietary practices by CHVs during the monthly home visits. 33 new households have established their own kitchen gardens which they have utilized in meeting households food requirements and nutritional support. 157 caregivers taking care of 561 OVC that had initiated kitchen gardens in the previous quarter continued to maintain their kitchen gardens. 58 drum kits and high value vegetable seedlings were distributed and installed to 38 OVC households with the aim of improving nutritional status of the children and other family members. MUAC assessment and Vitamin A supplementation for 860 OVC was done during station day events. 4 malnourished cases were identified and referrals for nutritional support to Longewan dispensary and Wamba sub-county hospital done. Meanwhile CHVs continued to monitor the health status of the OVC and 1,812 OVC were dewormed. This will improve their health status, ability to learn better and improved performance in school. Shelter and Care: 2 OVC households were renovated while 168 OVC caregivers were reached with messages on child rights. 50 OVC households were supported with solar-powered lamps which have more reliable source of energy. This will benefit children from reduced exposure to kerosene toxic fumes, reduced

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T e risk of burns and reduced respiratory diseases. It will also improve school performance due to prolonged reading hours at household level. Child Protection: The project works toward the goal of developing appropriate strategies for preventing and responding to child abuse, exploitation, violence, and family issues affecting the well-being of the children, integrating child protection activities and supporting communities to prevent and respond to child protection issues. 296 OVC were supported to acquire birth certificates which will help them access other legal documents like national Identity cards in future and access family property. Health Care: During the quarter under review, 2,364 OVC were tested, 10 new cases were identified and linked with the nearest health facilities for care and treatment. 10 OVC households with 51 beneficiaries were supported to register for NHIF medical scheme. The family members will be able to access medical care and treatment and improve the quality of life. Through SAIDIA, a child (male) aged five was diagnosed with cardiac failure was referred to KNH for specialized treatment. The child was treated and now is in good health and attending school. Psychosocial Well-Being: The project ensured that PSS interventions were prioritized to build on existing resources and place and maintain children in stable and affectionate environments through parents and family support approaches, peer and social group interventions, mentorship through the trained CHVs and community caregiver forums through the partners. 7,538 OVC were visited by CHVs and served on need based. 28 caregiver forums continued to meet on monthly basis where they discuss PSS issues. 148 CHVs were orientated on OVC PEPFAR programming and new reporting tools. Realignment of children served by the project was completed and the missing documents required for OVC documentation availed to the LIPs. Household Economic Strengthening: 8,516 beneficiaries (the OVC and the caregivers) were reached with support ranging from poultry, drip kits, through SILC initiatives and new technology farming methods. 5,664 OVC caregivers are currently engaged in IGAs and are able to meet other basic needs. Monitoring of 1,950 improved poultry (Rainbow roosters) distributed to 795 OVC households in the previous quarter continued throughout the quarter and 5,565 OVC will be benefitting from this initiative. 80 drip kits were distributed to beneficiaries through LIPs and households have planted vegetables and benefitting from the proceeds. This has helped in addressing food insecurity among OVC households.

Coordination and referrals: Across the three counties of Isiolo, Marsabit and Samburu, the project has continued to work with GoK for enhanced coordination, harmonization and linkages. Ministry of Agriculture has continued to provide agricultural trainings on horticulture and livestock rearing while the MoH has supported health and nutritional activities in the counties. They have in particular supported HTC exercise, nutritional assessments and roll out of PD hearths. Children‘s department has continued to provide guidance on child protection and in supporting the roll out of QI activities, birth certificate processing and taking up of legal referral cases. Collaboration with other partners such as World Vision and Catholic Diocese of Marsabit has led to linkage of needy cases to access their services. The enhanced coordination has improved on the quality of care and support to OVC and has led to increased leveraging of resources and standardization of services being offered.

TURKANA COUNTY During the period under review, 4,244 (96%) of the 4,440 OVC enrolled in the program in Turkana County were served with OVC services to address their critical needs. 1,473 OVC were counseled and tested for HIV this quarter, this brings the total OVC tested this year to 1,694 (124%) against this years‘ annual target of 1,367 OVC. Another 263 OVC living with HIV were supported to access care and treatment services at

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CCCs and other HIV services at the household level, so far 3,577 (80%) OVC have known HIV status in Turkana County. Food and Nutrition: During the quarter, 491 (248M: 243F) OVC received nutritional counseling and referrals. Green vegetable harvests from Lokori OVC caregivers‘ farm group is ongoing, this irrigation farm supports 35 caregivers and 85 OVC with fresh vegetables for household consumption and income from sale of surplus vegetables. Shelter and Care: 121 (51M: 70F) OVC received bed sheets and 2 dilapidated houses for 2 OVC households were renovated. 2,200 OVC received pairs of shoes (TOM‘s shoes) distributed during station days and at household level. Child Protection: 85 CHVs were trained on child protection to increase their awareness and knowledge. Subsequently the CHVs sensitized 875 OVC caregivers on child rights, child abuse and protection. This has increased awareness among the caregivers and increased responsibility towards the care of OVC. 62 (35M: 32F) OVC also received their birth certificates. 82 girls (Std 8 and form1 -4) were taken through a holiday program that aimed at giving girls knowledge, awareness and information on their rights and how to protect themselves against HIV, early pregnancy and avoiding and not accepting early marriages. LIPs are now active members of the child protection networks within their respective sub-counties. The networks share, discuss and advocate for child protection issues and support partner organizations working and implementing OVC and children projects.

Health Care: 468 (206M: 262F) OVC received continuous health education on HIV/AIDS. 113 OVC were referred and supported to access health care services for minor ailments while CHVs continued to provide health care education to caregivers leading to increased awareness on disease prevention for communicable diseases. This also included nutrition education as part of the prevention of illnesses through balance diet. Another 1,471 OVC were counseled and tested for HIV conducted during station days‘ events Psychosocial Well-Being: 3,525 OVC (1,765M: 1,760F) received psychosocial support services conducted by CHVs during their monthly visit to OVC households. Messages delivered included child rights and protection, nutrition education and the role of the caregiver in the care and support of the children under their care. Four Kids clubs for HIV positive children were also formed to assist in ART adherence and positive living through peer support; the Kids clubs are linked to St. Monica and St. Catherine in Lodwar and Lokori Health Centre (Keekori) in Lokori with a total membership of 89 OVC. The kids clubs have held their first meetings which are hailed as eye opener for disclosure from their peers and psychological support. Household Economic Strengthening: 9 OVC caregiver groups are actively engaged in economic strengthening activities. These groups are engaged in green house farming (3), irrigation farming, poultry, and handcrafts. A further 350 members are members in SILC groups initiated by Diocese of Lodwar (DOL) and SILC FAs. 7 SILC groups have been formed and have started saving. 14 caregiver forums were formed bringing the total number of caregiver forums in Turkana County to 39. These groups meet once a month where they discuss issues related to their roles in OVC care and support and child protection and rights. They are also engaged in various HES activities to increase their level of income and promote self-reliance.

Coordination of care/referral and linkages: LIP staff attended Sub-County Gender and Children Protection Networks. This is meant to increase advocacy for support and protection of OVC (especially the USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 146 girl child) against early pregnancy, early marriage, abuse and exploitation. Sub County Children Officers (SCCOs) also conducted support supervision to all the 4 LIPs in Turkana County. This has opened up the chance for close linkage and support from the SCCOs. Involvement and participation of the County Children‘s Department in the retraining of QI teams made other Government Officers take keen interest in the QI team activities.

WAJIR AND MANDERA COUNTIES 4.5.1.1 Provision of Essential Services to OVC During the period under review, 6,444 (89%) out of the 7,238 OVC enrolled in the program in Wajir Region were served with OVC services to address their critical needs. A total of 2,678 OVC were reached with HTC services this quarter, out of the tested OVC one (1) child tested positive for HIV and the family is currently undergoing counseling with a view to support the child access care and treatment. This brings the total number of OVC who accessed HTC services this year to 2,862 (66%) against an annual target of 4,352. Cumulatively, 5,791 out of 7,238 OVC (80%) have known HIV status and among these 23 OVC (Wajir - 20, Mandera- 3) are living with HIV and are accessing care and treatment at various CCCs in Wajir and Mandera Counties. Food and Nutrition: As part of continuous program to boost the food and nutritional support for OVC, 40 OVC households received food items in Mandera County; these highly vulnerable OVC households were identified through the monthly assessment conducted by CHVs and reached with assorted food items such as rice, maize flour, wheat flour, sugar, tea leaves and cooking oil. Another 845 OVC in Wajir County were linked with food distribution programmes undertaken by other agencies within the county and received food support. 79 clients/OVC caregivers were referred for nutritional support while 60 OVC households were reached with nutritional and health messages and information on food preservation and storage techniques during the quarter. 20 OVC households were also reached with breast feeding messages through the CHVs. Shelter and Care: Shelter and Care is one of the most basic requirements of essential human needs, it is integral in the lives of OVC as well as their guardian. To ensure OVC live in safe, dry and adequate; shelter renovation for 17 highly vulnerable OVC households in Bute, Buna, Korondille, Eldas, Griftu and Wagalla Locations was done while 300 institutions based OVC in Wajir County received bed sheets. A further 14 OVC households were supported with ‗dhuful‘ – raw material for the construction of traditional Somali houses.

Figure 93: An Improved Shelter Under Construction in Wajir County

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Figure 94: An Renovated Shelter in Wajir County

Child Protection and legal support: Station days were conducted in Wajir County where 895 (516M: 379F) children were sensitized on their basic rights, how and where to report cases of child torture, rape, molestation, early marriages and child labour. Further the project supported the Department of Children Services to form and train of 2 Locational Area Advisory Committees with a membership of 30 members to promote, protect, safeguard and champion the rights and interests of children at all levels. Health Care: In Wajir County, 240 pupils from 6 schools were mobilized into health clubs. This is expected to improve access to good health and hygiene education among children in the schools that also have OVC. A further, 250 adolescent OVC girls in various schools received monthly sanitary towels to promote menstrual hygiene among the girls. Another 600 OVC (210M: 390F) were reached with health education and hygiene promotion messages such as hand washing and brushing teeth among others. 60 OVC were provided with vitamin A supplementation and 10 PLHIV referred to hospital for CD4 count and treatment. 12 Station Days events were conducted in Mandera County reaching out to 1,166 OVC with HTC services another 19 Station Days events were conducted in Wajir County where 1,512 OVC were counselled and tested for HIV.

Psychosocial Well-Being: In Mandera County, 20 PLHIV/OVC caregivers participated in monthly group therapy meetings facilitated by the project to enhance their psychosocial needs. Important health and nutritional messages to enhance positive living among the PLHIV were disseminated.

In Wajir County, OVC caregiver group meetings were held with 136 OVC caregiver groups reaching out to 1,248 OVC caregivers with psychosocial care and support and information on child protection. 19 station days were conducted across various OVC sites through collaboration with other stakeholders such as OVC caregivers, community members, locational chief and CHVs. Children and caregivers interacted and shared experiences. Post Test Club meetings for 80 PLHIV/OVC caregivers were also conducted with clients counselled against chewing of miraa and smoking of cigarettes. Information on stigma reduction and disclosure among couples were also provided to the clients, discussions on psychosocial needs for clients, drug adherence and prevention of Opportunistic Infections (OIs) among PLHIV were also held. Household Economic Strengthening: The project through LIPs, mobilized OVC caregivers into groups for the purposes of linking them with economic strengthening initiatives as well as other family strengthening activities. A total of 136 caregivers group with total membership of 1,248 OVC caregivers were formed in different locations in Wajir and Mandera Counties. Poultry distribution among OVC caregivers was one of the major household economic strengthening initiatives undertaken by LIPs in the region to boost food security and livelihood among OVC households. In Wajir County, 91 OVC caregivers received poultry benefitting 106 OVC. The poultry farming is expected to boost the nutrition status and economically strengthen the OVC households through consumption and sale of eggs and other chicken products. A further 236 OVC household at Tarbaj, Habaswein, Abakore and USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 148

Kutulo Locations were mobilized and formed into economic strengthening groups. 20 highly vulnerable OVC households benefitted from dairy goats issued by the project while 3 OVC households were supported with shade nets. As part of continuous efforts to enhance care givers‘ capacity to effectively manage the OVC and guarantee sustainability of the same in Mandera County, OVC households were supported to establish multi-storey garden, 15 OVC caregivers benefitted from the poultry for joint poultry farming targeting the group of caregivers and a kitchen garden was established at Al-Uteibi Children Center. This is expected to boost food and nutritional intake of the OVC in this institution. Three (3) OVC caregiver groups consisting of 15 members each were also trained on IGA management.

Coordination of care/referrals and linkages: APHIAplus IMARISHA facilitated GOK led OVC stakeholders joint planning and review meeting across 7 sub-counties and undertook joint support supervision with LIP staff and SCCOs in Wajir and Mandera Counties. The project also supported formation and training of 2 Local Area Advisory Committees (LAAC) with membership of 30 members in Matho and Walensituto Locations in Wajir County. Project staff also participated in 4 AAC meetings and 2 Constituency Social Assistance Committee (CSAC) meetings in Wajir and 3 AAC meetings in Mandera to deliberate on up scaling of GOK OVC cash transfer and social protection services for marginalized, poor and underserved households. They also participated in a stock taking forum on budgeting for children and social protection programs organized by Kenya Alliance for Advancement of Children (KAAC)

OVC QUALITY IMPROVEMENT

GARISSA COUNTY The 3 QI teams in Garissa County continue to implement essential actions to address service delivery gaps in nutrition, shelter and care, child protection and education domains. Efforts to address child protection issues are still ongoing and the issue of low uptake of birth registration identified by Daadab QI team has been taken up by the Garissa County CPWG after the QI team CSI findings results were presented to the CPWG by the project. The CPWG has appointed a task force which has held lobbying meetings with county registrar‘s office and County Government to address the birth registration gaps identified. The County Civil Registration office has now intensified OVC birth registration efforts through integration of their services in OVC station days, 51 OVC acquired birth certificates this quarter as a result of these initiatives.

The challenges of malnutrition and food security are continuously being addressed through referrals and agronomy trainings (provision of seeds, establishment of MSGs) for CHVs and caregivers. As a result 55 malnourished OVC were referred for supplementary feeding. The establishment of a greenhouse as a demonstration site has also enabled caregivers to adopt multi storey gardens (MSGs) and kitchen gardens at their homes. The QI team in Daadab Location adopted door to door community sensitization on education to address school absenteeism as a root cause of poor education performance. QI data on 40 OVC shows a remarkable improvement in school attendance with a drop in absenteeism from an average of 12 days per month in the month of April to an average of 2 to 0 days in August.

TANA RIVER COUNTY The 5 QI teams in Tana River County continue to address service delivery gaps related to shelter and care, education and performance, food security and nutrition and growth.

2 QI teams conducted end line Child Status Index survey and analysis to measure change realized through the QI initiatives. 31% improvement on food security among households was noted, it is attributed to

USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 149 linkages to food aid, provision of seeds and training of caregivers on food preservation techniques. Nevertheless, sustained food availability has not yet been achieved. However there was no improvement on shelter and care due to weak resource mobilization strategies, retrogressive cultural practices, and harsh weather affecting structures, end line CSI findings have informed planning for continuous QI processes.

Another QI team in Kipini in Tana Delta Sub County is implementing essential actions to address poor education performance among OVC. The strategies include dialogue with children, caregivers and Ministry of Education officials. The QI team collected school performance data from class 4 to 8 which will be used to measure change at the end of the implementation cycle. They also held 13 dialogue sessions in primary and secondary schools and 5 sessions with caregivers to sensitive them on importance of education and jointly discuss issues of poor performance and actions to address them.

2 QI teams in Bura and Makere Locations in Tana North and Galole Sub Counties are implementing essential actions aimed at addressing poor nutrition and growth and food insecurity respectively as follows: mobilization of caregivers in villages into SILC groups, sensitization of all care givers on the importance of farming, communication of early warnings to farmers through the Ministry of Agriculture, promotion and adoption of gunny bag farming and kitchen gardening and ensuring that OVC caregivers in the villages engage in economic strengthening activities such as SILC and FFS. The team also worked jointly with MoA to prepare farmers on possibility of flooding due to predicted El Niño rains, distributed seeds to caregivers and orientated caregivers on food preservation techniques. Caregivers in QI sites have been organized into HES groups and are participating in HES activities such as SILC.

ISIOLO, SAMBURU & MARSABIT COUNTIES 16 QI teams continued with implementation of interventions based on the analysis of data collected during the quarter. The domains of focus include food and nutrition for 13 QI teams, legal support for 1 team and 2 for education. The QI team undertaking food and nutrition have supported households to establish 10 multi – storey gardens, 3 open drip irrigation systems and linkage to other partners for food support. 78 OVC households were oriented on food preservation. To address legal protection issues related to birth certificates, the QI team in Baragoi, Samburu Sub County developed a two months (August and Sep) work plan to address the identified needs. Main activities undertaken to address the gaps were; assisting the caregivers in completion of the birth certificates registration forms, educating all CHVs on completion of the birth certificates registration forms to be able to support caregivers, working closely with chief to ensure recommendations for children whose parents lack vital documents are done. Currently 43 OVC have been issued with birth registration certificates and copies sent to LIP for filing, 23 CHVs have been mobilized and supported completion of 210 birth certificate registration forms and shared with LIP office for processing. TURKANA COUNTY There are 5 QI teams in Turkana County. The teams have done the baseline CSI survey and the findings will inform development of work plans to implement change ideas and improve service delivery. 8 QI team coaches were also trained during this quarter while mentorship will be intensified in the coming quarter to support QI teams to implement change ideas and track quality improvement changes.

WAJIR AND MANDERA COUNTIES 10 QI teams in Mandera and Wajir Counties continue to support LIPs in improvement of quality in service provision to OVC. The QI teams continue to work with LIPs to address gaps in food security, health, shelter and care and educational performance by addressing barriers to HES, shelter and care, good health for OVC households and poor performance in education.

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HES & Food Security - to address barriers to HES in Wajir and Mandera, QI teams have supported LIPs in mobilization and formation of OVC caregivers into groups, sensitized caregivers on available micro- finance opportunities in their areas such as UWEZO funds, County Revolving Fund, Women Enterprise Funds, establishment of small scale projects among vulnerable households such as poultry keeping and goats rearing. 136 OVC caregivers groups have so far been formed with a membership of 1,248 OVC caregivers who are engaged in various HES activities.

Education – poor commitment to education by pupils, children sent to herd animals during school terms, household chores by girls, girls missing classes during their menses, poor parental responsibilities towards education of their children, clan clashes among neighboring communities, chronic teachers strike, insecurity leading to mass exodus of key non-local teachers, poverty and laxity by school administration were identified as the root causes of poor performance. The QI teams are addressing some of the underlying root causes of poor educational performance through caregivers sensitization on the importance of education for both boys and girls and parental roles and responsibilities in the education of their children, advocating for the County Government to recruit more teachers to fill in the gap left by non-local teachers, bursary support for students from poor family backgrounds, advocate the County Government to sponsor form four graduates interested in pursuing teaching careers, supporting IGA initiatives for caregivers and engaging in peace building and reconciliation initiatives among warring clans. 4.5.1.2 Capacity Building of LIP Staff and Volunteers The key capacity building activities planned for this quarter included orientation of LIP staff and CHVs on key donor and GoK children guidelines and policies including the PEPFAR OVC guidelines, Minimum service standards for OVC programs in Kenya and Child protection guidelines. Orientation of LIP staff and CHVs on OVC programming Standard Operation Procedures and sensitization of LIP staff and CHVs on child health and nutrition, it also includes mentorship sessions to LIPs to address gaps identified during routine support supervision exercises, Site Improvement for Monitoring System assessments and routine data quality audits. A summary of key interventions carried out in NAL to build the capacity of LIP staff and CHVs per county is shared below:

GARISSA AND TANA RIVER COUNTIES The key interventions carried out in Garissa and Tana River Counties to build the capacity of LIP staff and CHVs include:  Orientation of 183 CHVs (28M: 9F) on key OVC guidelines: child protection guidelines, child participation, PEPFAR OVC guidelines and Minimum Quality Service Standards  Orientation on resource mobilization to 5 LIP staff in Maridhiano. This is expected to improve on resource availability in Maridhiano. The LIP developed two fundraising proposals during the quarter  Orientation on Nutrition to 146 CHVs, the lesson given centered on nutrition, importance of good nutrition, balanced diet and availability of a variety of foods  Orientation of LIPs on OVC programming SOPs, SIMS and the code of conduct for engaging with OVC.

ISIOLO, SAMBURU AND MARSABIT COUNTIES The key interventions carried out in Isiolo, Samburu and Marsabit County to build the capacity of LIP staff and CHVs included:

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 Continuous mentorship and support supervision for technical guidance to LIP for effective programming.  Capacity building of LIP staff on knowledge management, sustainability and leadership and governance done.  Orientation of 501 CHV on children guidelines and other OVC programming aspects

TURKANA COUNTY The key interventions carried out in Turkana County to build the capacity of LIP staff and CHVs include:  Mentorship of LIP staff on caregiver group formation, developing capacity building plans for the caregiver forums, documentation and filing, linkages and understanding of SOPs.  Capacity building of LIP staff on how to facilitate child protection and nutrition sessions to CHVs during their CHV monthly meetings

WAJIR AND MANDERA COUNTIES The key interventions carried out in Wajir and Mandera Counties to build the capacity of LIP staff and CHVs included:  Provision of technical assistance to 5 LIPs in Wajir and Mandera Counties on: - OVC filling, reporting, station days, support supervision to CHVs and OVC households, SIMS and SOPs to guide in the smooth implementation of project activities - Mentorship to CHVs on how to household visit, filling of form 1A and general services delivery to OVC - Orientation of 30 CHVs in Wajir on OVC/HCBC programming, child rights and protection

4.5.1.3 Strengthening Government/ Community structures and systems to provide care and support to OVC and PLHIV The key interventions carried out in NAL Counties to strengthen government and community structures to support OVC and HCBC clients included: GARISSA COUNTY  Participation in sub county AAC meetings  Participation in the Child Protection working group meetings  Establishment and training of 4 care giver groups with a membership of 68 (female) on poultry farming

TANA RIVER COUNTY  Vulnerability assessment was done to Umoja , Waljabesno caregiver group and Mwelekeo support group to acquire baseline data before interventions to measure progress over time  Organizational Development Systems Strengthening to measure changes made to LIPs in Tana River as a result of capacity building during program implementation in NAL was done.  Finance review meetings held with LIPs to review progress in adoption of finance and procurement procedures. Key concerns such as prior approval of budgets, taxation, supportive documents, disallowed costs and conflicts of interests among others were raised and actions taken to make corrections.  A mock Site Improvement for Monitoring System tool was administered to KICE LIP. Notable were gaps in filing system and inadequate filling space, lack of MoU with local health facility, lack of Terms of Reference (TOR) for CHVs completion of mandatory documents in OVC files, documentation on

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procedures for establishing sustainable barriers to education, supporting vulnerable girls among others. An action plan was developed and project staff are addressing the gaps.  Mentorship to 6 QI teams in Tana River County to ensure that they provide direction for quality OVC programming  6 (3M: 3F) Adherence Support Workers manning CCC desks in Galole Sub-County benefitted from mentorship by CASCO

ISIOLO, SAMBURU AND MARSABIT COUNTIES  Joint support supervision with GoK to LIPs, CHVs and OVC household to strengthen capacity of service providers in providing quality SDH services to OVC and their caregivers.  Accelerated mentorship of the caregiver forums to facilitate mentorships and joint IGA establishment for OVC support

TURKANA COUNTY  Involved DCOs in the resolution in matters that affecting children  Involved of government officers, agriculture & Civil Registrar, in supporting and providing technical support to Greenhouse groups and issuance of birth certificates respectively

WAJIR AND MANDERA COUNTIES  Supported DCS in formation and training of 2 Location Area Advisory Councils (LAAC) with support from the LIPs  Conducted SILC training for 3 LIP staff and 7 SILC FAs in jointly with livelihood Technical Officer  Conducted business development training and CHVs orientation on child protection issues for 30 CHVs

4.5.1.4 Home and Community Based Care Services

During the period under review, 6,123 out of the 6,609 targeted PLHIV in the HCBC program were reached with HCBC services. The number reached with different HCBC services and outcomes are summarized in Table 40 below. Table 40: Number of Clients Reached with HCBC Services in NAL Indicator Number Number of HBC clients enrolled (current) 3 Number of HBC clients served 6123 Number of HBC Clients on ARV 5429 Number of HBC Clients on HIV care (Prophylaxis) 5490 Number of referrals for VCT 243 Number of referrals for CCC 148 Number of HBC Clients on TB drugs. 51 Number of referrals for FP/RH 19

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Number of referrals for Nutrition 139 Number of referrals for PMTCT 50 Number of referrals for Support group 211 Number of Clients referred for Treatment 91 Number of Clients in Support groups 4665 Number of clients benefiting from Agriculture 3419 No of clients benefiting / linked for legal support 0 No of clients benefiting from economic strengthening initiatives 2717 Number of clients received Nutrition education 5591 Number of clients received hygiene education 5488 Number of HBC Clients receiving counseling/psychosocial support 5296 Number of HBC Clients on nutritional support 475 Number. of ARVs clients dropped out 18 Number of Condoms distributed 960 Number of Clients who died 2

The existing structures to support PLHIV include 231 CHVs, 2,475 caregivers and 58 PLHIV support groups. TURKANA COUNTY During this quarter 899 clients were served. 3 were newly enrolled through station days‘ events. Among these 472 are in support groups and 89 benefited from Agriculture. Referrals for TB screening and CD4 count at Lodwar District Hospital was provided to 5 PLHIV with adherence counseling provided to 594 clients. Regular home visits to 569 clients were also conducted. 8 PLHIV clients were referred and linked to support groups while 594 received nutrition education and support.

TANA RIVER COUNTY 673 HCBC clients are on ARVs and one client was put on TB treatment. 694 clients benefitted from nutritional and hygiene education and 105 from psychosocial support. No client defaulted treatment during the quarter. The services were enabled through 18 trained and supported Adherence Support Workers attached to high level health facilities, home visits and referrals were also done by the 146 trained CHVs with support from HCWs attached to link facilities in the program sites.

IR 4.6 Expanded Social Mobilization for Health Expected Outcome 4.6.1: Increased Social Inclusion and Reduced Stigma and Discrimination of MARPs

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Expected Outcome 4.6.2: Decrease in Unplanned Pregnancy and HIV risk, Infant and Child Mortality and Child Abuse and Neglect The achievements and activities have been discussed in I R 3.2 and 3.3

LESSONS LEARNED During the period under review, some key lessons learned include:

HIV Testing and Counseling  The scale up of the HIV testing and Counseling has been very effective during organized community events through the County government. All clients who test HIV positive are offered opportunity for linkage via referral forms and follow up by expert clients.  Routine HIV testing for all the newly detected cases of TB is critical in the management of HIV/TB co infection management. This is followed up with monthly HIV/TB integration meeting where all new cases detected in the period are discussed and managed appropriately.

Care and Treatment  CD4 into Care Cascade through the sample networking system has ensured that patients who have attained counts of <500 cells and thus qualify for Anti-retroviral therapy are mopped up in line with the current guidelines.  Enhancement of cross boarder relationships has been undertaken in Moyale through cross border meeting to establish common areas of concerns, collaborations and areas of leveraging. In particular the project plans to come up with definitive and practical solutions including sharing defaulter list and engaging case managers on either side of the border and exchange of best practices in HIV/TB/RH programing. Other opportunities identified are use of community strategy approach to map physical address of patient and the need to leverage on partners- for instance IGAD who have shown great interest in cross border activities, IRAPP (IGAD Regional HIV/AIDS Partnership Program (IRAPP) Support Project.  With Gene Xpert technology available in a number of facilities, focus remains on the HCWs to use the Gene Xpert for MTB diagnosis and MDR-TB surveillance. TB/HIV meetings are held on a monthly basis to review the optimal utilization of the service. Sputum specimens have as a result been successfully incorporated into the existing sample networking/referral network in the counties.

MNCH  To improve client uptake of Family Planning, it‘s important during the training to emphasize the need for the trained CHVs and CHEWs to act as ambassadors in their communities where they will initiate counseling and refer clients to the facilities for the service.  Integration between MNCH, WASH & Nutrition department is key to success outcomes. Integrating MNCH activities into WASH during the training of community health volunteers is vital for successful integration. An integrated package of MCH/FP, Nutrition and WASH are now been used during the training.  Engagement of religious leaders through their association was seen to have impact and improve outcomes. Through this forum, leaders are able to understand their role in the community on issues of family planning and other health issues affecting the community as they remain a strong link and a source of demand creation.  Culturally acceptable maternal shelters are a cost-effective approach that addresses the three delays that contribute to negative maternal and neonatal outcomes namely, delay in seeking care, delay in reaching USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 155

care and delay in receiving appropriate health care. This approach bridges the gap between the communities and the health systems and creates synergies that lead to improved maternal and neonatal outcomes.  Following the success of the maternal shelter in Kisima Model Health Centre, the County Government of Samburu has embraced this as a best practice in maternal health and promoted the concept in 3 additional facilities. A draft SOP has been developed to guide HCWs in the operationalization of maternal shelters. Laboratory Services  Emphasis on proper reporting is key to commodity management and support to care and treatment for the management of CD4 testing, turnaround time for sample networking results and achievement of suppression rates.

BCC/ VMMC/ Prevention Activities ● An ongoing deliberate volunteer succession planning led by the County government can address some volunteer retention challenges. ● Sustained technical support supervision to LIPs and peer educators results in effective program implementation ● During outreaches for VMMC it is important to reside in the area more than 1 week to ensure all the circumcised clients have been reviewed, this plays a crucial role in enhancing acceptability of the service by the community. ● Utilization of VMMC champions has played an important role in mobilization of the community and enhanced uptake of the service. ● It is important to continuously engage with the community, sharing key messages and de-banking myths and misperceptions of the service to maintain community confidence in the VMMC.

HES:  Ownership, sustainability and continuity of IGA activities with beneficiary groups can be fast tracked by layering approach with the PREG partners.  It is important to integrate attitude change approaches into planning to address dependency syndrome and encourage vulnerable groups on the road to self-sufficiency.  SILC, table banking and merry go round activities are key to empowering women as it inculcates the culture of making savings for vulnerable households and gives the confidence to venture into formal financial institutions for loans.  IGA groups with trained Agricultural field agents were successful in increasing productivity and profits because the agents bridged the gap between the GoK Ministry of Agriculture staff and IGA group to fast track the adoption of new technology.

Food Security and Nutrition ● Continuous follow up and technical support to both LIPs and some ministries is key in achieving the deliverables. Indeed, working with the LIPs is an effective way of cascading interventions at the community level as they have a wider and deeper reach in the communities. ● National maternal and child health focus days such as Malezi Bora and the World Breastfeeding weeks provide opportunities for improved coverage of Vitamin A, MUAC screening and deworming. ● The project will continue to support nutrition support supervision since it‘s an opportunity for supervisors to experience the challenges faced by health facilities and HCWs and collaborate to identify practical strategies to address them.

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OVC Programming  Linkages with other partners like County Governments, the Constituency Development Fund (CDF) and the President‘s Education Bursary Fund through the Department of Children Services (DCS) enabled the project to reach out to more OVC with school fees payment than what had been planned.  The Garissa County Child Protection Working Group (CPWG) that comprises of more than 10 organizations has remained pivotal to addressing child protection issues in the county.  Station Days events have been the most effective avenues in enhancing psychosocial support and provision of integrated health services such as HTC, Vitamin A supplementation, MUAC screening, deworming and general medical screening for OVC.

WASH  Open Defecation Free (ODF) is about Hygiene Behavior Change by all individuals in the village/ households and it‘s not just a mere presence of a latrine at household level. The ODF certification process is lengthy and costly too and may not be a realistic way of gauging Health Behavior Change at community level. ODF can only be sustained with very rigorous follow-up and including after declaration of ODF status, if communities are to move up the sanitation ladder and accrue health benefits of WASH activities.

Strategic Information  One key lesson learned is that facility based monthly data review meetings are a cost-effective approach that includes many health workers in data review. This has helped to create data ownership and home grown solutions to address data quality gaps through the involvement of the service providers. The project will scale up this lesson learned in Isiolo County to the other 7 counties in NAL.

III. ACTIVITY PROGRESS (QUANTITATIVE IMPACT)

The quantitative achievements are enumerated in detail in the attached Performance Data Table.

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IV. CONSTRAINTS AND OPPORTUNITIES

Some of the constraints and opportunities experienced by the project over the reporting period include: ● Insecurity: Sporadic episodes of insecurity continued in parts of NAL especially affecting the parts of Mandera, Wajir, Garissa, Turkana, Isiolo and Samburu Counties. The effect of this was disruption and delayed implementation of planned activities in the affected areas such as limited access to Longewan and Archers posts WASH sites when tension was high between the Samburu and Turkana communities. Early in the year this also significantly affected implementation of WASH activities in Mandera and the project sought approval to transfer some of the planned activities to calmer areas. Access to parts of Turkana South and East was also limited for periods of time due to clashes between the Pokot and Turkana. The project continued to take a position of cautious and limited implementation of activities limiting essential activities to the major towns and areas that were peaceful. However efforts by the local and national leaders through ―Peace Caravans‖ and celebrations such as the Tobong‘u Lore in Turkana, urging communities to avoid inter-clan and inter-tribal clashes seem to be bearing fruit. ● During this reporting period the counties advertised new positions for HCWs following the departure of others in response to insecurity in the previous quarters. This ameliorated the situation somewhat even though the more rural and perceived insecure areas continued to have facilities manned by CHVs and patient attendants as HCWs feared working there. Overall, however, the security situation is perceived to be improving in most parts of North Eastern Kenya which was most affected. New tensions, however, seem to be emerging as communities position themselves for the 2017 elections. Supply Chain Management  Short supply of ART DARs for ARV/OI BCC ● High attrition of volunteers such as trained youth out of school peer educators, trained cPwP facilitators and in some key populations due to migration and high financial expectations resulting in over reliance on the few available ones affected BCC activity implementation. For example only 15 out of the 20 trained FSW peer educators in Tana River were active during the reporting period despite the heavy need for the EBI. The project used the technical assistance visits to offer updates and psychologically motivate the volunteers through public praise and appreciation of work done. The nationwide teachers union strike coupled with teacher inadequacy, transfers and competing school academic priorities affected the implementation of the school Life Skills Education in Turkana with the project receiving data for only early July 2015. Before the onset of the strike, the project worked with the available teachers and reminded them to mentor colleagues to assist in this process. Some of the children living with HIV reported that their treatment buddies forget to remind them to take medication as needed. Alcoholism and drug addiction cases were on the increase among ART clients as reported by support groups and this were key barriers to ART adherence. The project is using the cPwP facilitators with technical backstopping from the health workers to emphasize on the importance of adherence during the support group meetings VMMC ● Flooding of rivers (due to increased rainfall) made roads in some parts of Turkana muddy and impassable for periods of time leading to suspension of outreach activities until the situation improved. HES USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 158

 Drought and inconsistent water supply was a major limitation for agro-based activities. The volume of rivers reduced significantly, this forced some beneficiary groups to reduce land under canal irrigation.  Limited number of technical resource persons for the vast sub-counties continued to be a constraint. All GoK technical staff are based in county headquarters which poses a challenge to mount timely interventions on cases of pest attack and control for IGA groups located in remote parts of the county. The project is facilitating the training of field agents from each agro-based groups to enhance the linkage with technical staff from the ministry of agriculture. Food Security and Nutrition  PD Hearth: High expectations from mothers in the PD Hearth programme, food insecure households, absenteeism by some mothers, dropping out of children from Hearth and time management by the mothers affected implementation of the PD Hearth. Additionally, some caregivers opted to drop out of the hearth sessions as they preferred to engage in Income Generating Activities instead of participating in the hearth sessions.  Persistent drought in Samburu County adversely affected the nutrition and food security situation in the County with situation in some parts of the County currently classified as acute and others as severe such as in Samburu East.  Technical assistance from Ministry of Agriculture: Reliance on the MoA for continued technical assistance and follow up on beneficiary activities continued to be affected by inconsistence availability of the MoA staff across the Counties. Due to this, some of the projects like the pro-agro initiatives that require weekly or bi-weekly follow –ups were affected.  Receptiveness of the community to new ideas: presence of strong mother to mother support groups with basic knowledge on child health, presence of strong community structures, existence of Complementary Public Health and Development Programs and greater commitment of the County Ministry of Health contributed to the success of some of the project‘s initiatives such as PD Hearth.  Beneficiary groups are increasingly warming up to agricultural based IGAs. This is evidenced by the successful implementation of the same with groups such as Kiya in Turkana County. With the poor Nutrition situation in NAL, this provides an opportunity for the project to contribute to the collective efforts of addressing food insecurity in NAL. OVC Programming  Insecurity in Mandera County made it difficult for LIPs to hold Station Days events to reach out to more OVC and their households with HTC services. As a result only 1,161 (47%) OVC out of the 2,505 targeted to be tested this year were reached with HTC services. WASH ● Communities easily relapse back to open defecation status, where no immediate and elaborate post ODF plans are not in place. This scenario is even more complicated in NAL due to people nomadic nature of life style and insecurity.

Strategic Information  Delayed response to identified data quality gaps due to staff shortage, staff attrition, new staff with low competencies on HIS, lack of EMR and shortage of reporting tools

V. PERFORMANCE MONITORING

During the period under review, performance monitoring activities supported by the project focused on strengthening Health Information Systems across the eight counties in NAL by addressing data quality gaps identifying through data verification, Routine Data Quality Audits (RDQA), data review meetings and Site USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 159

Improvement Monitoring System (SIMS). The key data quality improvement activities facilitated by the project included data reconstruction, electronic medical records, data quality assessments and mentorship. TANA RIVER COUNTY OJT/ Mentorship: APHIAplus IMARISHA staff in collaboration with SCHMTs continued to provide mentorship to HCWs in health facilities on HMIS tools. Data Review meeting: The project supported a data review meeting in Galole sub-county which attracted the attendance of CHMTs, Sub-county HMTS and facility in-charges from all health facilities in the sub- county. Data for the year 2014/2015 was reviewed; issues were raised by facility in-charges concerning their facilities performance. Some of the main concerns noted were the low technical capacity of the newly recruited county staff to complete HMIS tools. This project is addressing this through targeted mentorship on the relevant tools. EMR Support: The project staff provided support in management and proper reporting of the EMR at Hola CRH, Madogo HC Garsen HC and Ngao DH. The staffs appreciate the system which has simplified client management at the CCC as well as reporting. Support was also provided on real-time back-up of daily records. ISIOLO COUNTY Electronic Medical Record (EMR): APHIAplus IMARISHA continued to support Isiolo CRH staff to maintain the use of the EMR system installed the facility. The support included continuous mentorship, report generation support, continuous data cleaning and system configuration and upgrade. Some of the outcomes of the strengthened EMR system include: ● Timeliness in reporting: all the required reports are available on time because of ease of generating data from IQ care. ● Data Accuracy: the EMR system is able to generate more accurate and reliable reports due to continuous data cleaning support provided by the team. ● Defaulter tracing: Defaulter tracing has been made easier. Through the IQ care the hospital is able to identify defaulters and put measures for follow up. This has improved appointment management and the number of clients currently active has steadily been increasing. ● Patient monitoring: The EMR is able to generate cohort analysis report, CD4 and Viral Load access, number of patients on each regimen and other anthropometric measures for patient monitoring. Table 41 is a sample of report generated from IQ care.

Table 41: Number of Active Patients on Type of Regimen by the End of the Reporting Period

Age Group (Years) Regimen Total 0-1 2-4 5-14 Adults(>14) AZT - 3TC - NVP 5 49 274 328 AZT - 3TC - EFV 1 10 17 28 AZT - 3TC - LPV/r 12 12 ABC - 3TC - LPV/r 1 1 TDF-3TC-NVP 3 392 395 TDF-3TC-EFV 1 247 248 TDF-3TC-LPV/r 1 10 11

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Other regimens 2 10 55 19 86 Total 2 16 119 972 1109

Routine Data Quality Audit (RDQA) - A multidisciplinary team comprising of project staff and SCHMT conducted RDQA in health facilities in the county. Some of the main gaps identified were variances between reported data and data in source documents, incomplete source document, and shortages of reporting tools. The project continued to provide technical support to the facility staffs in completing the registers and reporting tools, continuous mentorship on correct completion of the source document and data management procedures. The project also continued to reproduce MOH register and reporting tools to address the shortage of tools. Monthly facility department‘s staff meeting was also initiated as a result of RDQA action plan to improve on quality of service and quality data. Figure 95 below shows data and reporting verification chart extracted from RDQA tool.

Figure 95: Data and Reporting Verifications in Isiolo County Referral Hospital

OVC Longitudinal Management Information System (OLMIS): During the period under review, the project staff continued to provide mentorship to the LIP staff on the use of OLMIS and reporting using the

USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 161 system. Through this initiative the LIPs are able to track the OVC reporting rate and generate various reports depending on the need. Table 42: Sample of PEPFAR Summary Report from OLMIS for FH-K LIP

Table 43: Sample of PEPFAR Essential Services Report from OLMIS for FH-K LIP

GARISSA COUNTY Routine Data Quality Audit: APHIAplus IMARISHA staff in collaboration with SCHMT members conducted RDQA at two facilities (Iftin SCH and SIMAHO) to verify the quality of reported data and assess the ability of data management system to collect and report quality data. The common data quality gap identified was the variance between reported data and data contained in source documents. This was attributed to limited understanding of data management procedures (data collection tools, analysis/aggregation, interpretation and presentation of results) by HCWs. The project facilitated the facility to update all source documents and conduct data reconstruction of missing data in patient files. The HCWs were also re-oriented by the project staff on data management procedures.

WAJIR COUNTY

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Data review meetings: facilitated Wajir County Referral Hospital to conduct data review meetings. The aim was to improve data quality, inter-departmental linkage and coordination in regard to HIV, TB and MNCH integration. This was a one day meeting that has enabled departmental in-charges to deliberate the performance of each department and encourage the Hospital management team to adopt the culture of data use for decision making to improve service delivery. Some of the action points agreed on to enhance data quality include:  Data discrepancies in the areas of HIV/TB and MNCH to be addressed through OJT and Data Quality Audit.  OPAHA LIP to fast track the Lost to Follow Up clients and be brought back to care.  PMTCT for Wajir County Referral Hospital data uploading into the DHIS to be addressed.  HIV Exposed Infant (HEI) due for PCR to be followed up with OPAHA together with CCC in charge. Data reconstruction at Habaswein CCC: APHIAplus IMARISHA facilitated health facility management team for Habaswein District Hospital to conduct data reconstruction at the comprehensive care clinic (CCCs). It was necessary to have data reconstruction in the facility as there were inaccuracies in the reported data for HIV care and treatment. During the exercise, the team established that:  The existing data in patients‘ files, registers and reporting tools was incomplete and not consistent across the different tools and service delivery points (CCC, pharmacy and lab).  The data filing conventions were not consistent across the data collection tools (PRE-ART, ART, TB SCREENING CARDS, DAILY ACTIVITY REGISTER and PATIENTS BLUE CARD)  The patient files were not updated Through the data reconstruction process  It was established that the number of client on care and on ART was more than what was previously reported.  All patient records from HIV care clinic, laboratory, and pharmacy were accessed and a list of all clients ever enrolled in HIV care and those transferred-in at the two clinic were developed  The filing and numbering system was set-up by arranging the list of clients ever enrolled in HIV care in the clinics in chronological order and allocated unique patient IDs  The current status of client was determined (Lost to Follow-up, Deceased, Active in Pre-ART, Trans-Out, Started ART)  Data on patient profile and care and treatment was extracted to HIV care cards  the Pre-ART and ART registers were updated accordingly with information in patient files  Facility reports with accurate data were generated following completion of reconstruction

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Mentorship of Health Care Worker on HMIS: The project staff provided continuous mentorship to Health care worker at Wajir county Referral Hospital (2 new employed HRIOs, 4 Staffs at the CCCs and 1 staffs at the MNCHs). The mentorship was aimed at improving data management at the facility. Six (6) staffs from other priority facilities were also given OJT during the quarter; the continuous mentorship has seen the staffs improve the data management process especially in Wajir County Referral Hospital which has seen complete data being reported in the DHIS by 3th of very month and records updated. HIS system support: The Wajir County facilities were supported to reproduce copies of HMIS tool especially MOH 711A and the logistics to distribute the tools through the SCHRIO. This was aimed at improving quality of data and reporting rate for the sub-county which has shortage of tools. The monthly airtime provided to the CHRIO & SCHRIO in the county and for uploading data in the DHIS 2 has realized improved reporting rates as illustrated in Figure below, inviting them to APHIA plus IMARISHA office to upload data into the DHIS when

Figure 96: Comparison of Month on Month MOH 711A Reporting Rate for 2014 and 2015.

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MARSABIT COUNTY Data Reconstruction: During the period under review, data reconstruction was undertaken at Loiyangalani Health Centre. This was because of the inaccuracy in the reported data for HIV care and treatment. During the exercise the following gaps were Identified:-  All registers are not filled well.  Knowledge gap of the health care workers on how to fill registers and reporting tools.  80% of Client files were missing Blue Cards and ICF Cards The immediate outputs and outcome after the data reconstruction were as follows:-  All patient records from HIV care clinic, laboratory, and pharmacy were accessed and a list of all clients ever enrolled in HIV care and those transferred-in at the clinic were developed  Both the Pre-ART and ART registers were updated accordingly with information in patient files and the current status of clients determined (Lost to Follow-up, Deceased, Active in Pre-ART, Trans- Out, Started ART)  OJT/Mentorship on reporting tools and registers was done for the Staffs and the staffs gained knowledge on how to fill the registers and reporting tools.  Facility reports with accurate data were generated following completion of reconstruction

Before Data Reconstruction Before Data Reconstruction After Data Reconstruction

FigureAfter Data97: ART Reconstruction Data Before. and After Data Reconstruction

During the visit the following tools were also delivered to the facility:-ART registers, Mother and Child Booklets, Blue cards (MOH 254) and ICF cards. HEI Cohort Analysis: To improve quality of care of the HEIs, the project technical staff conducted HEI Cohort Analysis at Loiyangalani Health Centre to assess the outcomes. The main challenge encountered was USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 165 improper documentation of the HEI register and HEI Cards. The output of the analysis is as shown in the table below. Actions taken after this exercise included; updating both the HEI Register and HEI cards, reconstructing the HEI register, pairing of Mother and baby files and Orientation of the MCH staffs on HEI registers and HEI cards. After implementing this action points a repeat of HEI Cohort Analysis of May 2014 was done and the result is as summarized in the table below.

Table 44: HEI Outcomes Before and After Data Reconstruction at Loiyangalani Health Centre

Birth Month/Year: Birth Month/Year: Sep/2014 May/2014 No. % No. % Total in Cohort 1 100% 1 100% Mothers Received Prophylaxis 0 0% 1 100% Infants tested with PCR at age of 6-8 Weeks 0 0% 1 100% Infant Received ARV at 0-6 weeks 0 0% 1 100% No in care after 9 months 0 0% 0 0%

MANDERA COUNTY Data Reconstruction: Data reconstruction in the comprehensive care centers (CCCs) of Rhamu and Elwak District Hospital was done and all the relevant files/registers, HMIS reporting tools and DHIS were updated. Mentorship: six (6) HCWs in two high volume facilities in Banisa and Mandera west sub counties were mentored on HMIS tools. Two Lay counselors recruited and posted to Mandera West Sub county hospital by the project was also mentored on HCT reporting/defaulter tracing. SAMBURU COUNTY OVC Longitudinal Management Information System (OLMIS): As a result of a five day training of LIP staff on OLMIS last quarter, all LIPs in the county are using the system for reporting. This has replaced the manual system that was quite labor intensive and time consuming on part of the LIP staff in compiling reports. LIPs are going to embark on cleaning of the databases to ensure the reports are close to reality as possible. Electronic Medical Record (EMR): APHIAplus IMARISHA supported staff at Samburu CRH (Maralal) to maintain use of the EMR system installed at Samburu CRH (Maralal). The support included training of CCC staff on IQ-Care in collaboration with futures group and mentorship of the same staff on usage of the IQ- Care system at the facility level. Situation before: Before the EMR installation and operationalization, the reports generated were inaccurate because of the manual collation of reports for the large number of active clients on care and treatment. This would also result in late reporting, difficulty in identification and management of defaulters and inconsistencies in numbers reached versus number of clients dispensed with drugs at the pharmacy.

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Current Situation: The HCWs can now manage all the clients‘ data with ease including, capture of triage details, clinical and lab details and being able to print reports. Moving forward, the clinicians, lab and pharmacy will be entering the data directly into the system. Outcome ● Timeliness in reporting: all the required reports are available on time since it is less strenuous and involving to generate reports. ● Data Accuracy: the EMR system is able to generate more accurate and reliable reports. ● Patient monitoring: The EMR is able to generate cohort analysis report, all the MOH reports, clients‘ anthropometric and many more.

TURKANA COUNTY Data Review meeting: During the period under review, the project facilitated a data review meeting in Turkana South aimed at discussing performance, rectify under reporting of HTC data and capacity building of reporting through MOH 731. The shortage of tools in the county was mentioned as one of the key contributing factor to poor data quality and low reporting rate. The tools most affected are Immunization tally sheets, MOH 105 and MOH 711. The project intervened by reproducing and distribution the tools to 18 facilities in Turkana south. It was also noted that most health facilities that conduct Vitamin A supplementation outreaches and mass campaigns do not incorporate Vitamin A supplementation data in their monthly EPI reports. This was duly corrected at the meeting resulted in improving Vitamin A coverage for Lokichar sub-county Mentorship: The project M & E team addressed data quality issues by providing TA to the VMMC teams on documenting and reporting of post-surgery adverse events. Seven (4 Male; 3 Female) staff were mentored. The project in this current quarter is seeking to fill the filing gap identified in Lokichar by providing a cabinet for safe and secure storage of client files. Health workers (23 15 m 8 f) in Turkana south were mentored on MOH 711 and MOH 731 reporting. The health workers undertook reporting exercises on MOH 731 and reporting inaccuracies were cleared It is been noted that most health workers prefer to report HTC under MOH 731 and overlook 711 data sets. Routine Data Quality Audit: During the period under review, APHIAplus IMARISHA in collaboration with I-TECH undertook RDQA for EMR at St Patrick‘s dispensary and the findings are summarized in Figure below. The team is continuously working to improve the documentation and accuracy in entering data into the EMR system. There has been an improvement in the aggregate numbers between EMR and manual reporting systems and efforts are being made to ensure that this continues to improve.

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Figure 98: Findings of Routine Data Quality Audit of the EMR system in St. Patrick’s Kanamkemer

VI. PROGRESS ON GENDER STRATEGY

 To help prevent violence against women, the project supported the SASA! training for five days at Lodwar Lodge, Lodwar Town from 14th to 18th September 2015 targeting 26 fisher folk (14 males; 12 females) drawn from Eliye Springs, Namukuse, Kalokol and Long‘ech along Lake Turkana. The aim of the training was to create awareness to help the community members, leaders, service providers, and all partners to explore the implications of men‘s use of power over women and the community‘s silence about this. It was noted that subsequently, this violence contributed significantly to HIV infection and hindered access to HIV Prevention services. The project collaborated with NASCOP who availed two national master trainers. At the end of the training, participants produced work plans which the project will use to monitor and support awareness raising activities aimed at increasing access to HTC, care and treatment linkage and community support activities. The trainers used the ‗Raising Voices‘ SASA! Activist Kit‘ which is uniquely designed to address a core driver of violence against women and HIV; the imbalance of power between women and men, girls and boys. The tool kit enables communities rethink and reshape social norms. SASA! looks at power, both its positive and negative uses, shifting away from

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the traditional focus on gender towards the heart of the problem. It involves everyone in the community and helps them reflect on their own lives and relationships before trying to influence others  Towards increasing capacity of facilities to provide client – centered, humane and dignified care, the project supported a seven day TOT Stigma and Discrimination Elimination training for 25 participants (9 males; 17 females) from 28/9/2015 to 4/10/2015 in Marsabit Town. The aim was to equip participants (selected health facility staff , community members and project staff drawn from Isiolo, Samburu and Marsabit Counties ) with knowledge, skills and positive attitudes to provide non stigmatizing services to increase access and adherence to ART  The project continued to use the draft Standard Operating Procedure (SOP) that identifies and supports HIV Prevention among girls and an SOP that guides program on gender mainstreaming as well as the Communication for Development (C4D) strategy (2014-18) for the counties, to reach adult men, women and children (both boys and girls) in all its facility and community activities. The project continued to synergize with the DANIDA funded SRHR project to mobilize and sensitize religious leaders and cultural custodians to increase male involvement in advocating for the rights of women and children for HIV prevention, MNCH, FP and other service areas. The project also continued to link the outreach groups of PLWHIV, OVC care takers and men groups to participate in SILC group‘s activities to empower women and vulnerable men to meet their basic needs such as food, shelter, clothing, medication, transport and payment of school fees for their children in school  The project participated in the Quarterly Health Promotion Advocacy Committee (HPAC) meetings in Tana River and Isiolo to monitor child rights violations and to address any gender issues that affected access and utilization of health information and products to its project beneficiaries (key populations, people living with HIV, youth in and out of school).  Further, the project used the respective EBI curricula that integrate gender norms messages to address barriers to accessing HIV prevention services (behavioral, biomedical and structural interventions) to reach both males and females across ages in its interventions. During the quarter, the project‘s BCC community based volunteers reached 11,275 people (4,630 males; 6,645 females) using evidence informed behavioral Interventions (EBIs) and distributed 40,408 condoms (40,405 male; 3 female) to their peers and general community. The composition of those reached was 3,791 Key populations (421 males; 3,370 females), 7,116 youth out of school (4,004 males; 3,112 females), 136 youth in school (71 males; 65 females) and 232 young people (134 males; 98 females) with RESPECT K Intervention aimed at increasing HTC and adherence to care and treatment

VII. PROGRESS ON ENVIRONMENTAL MITIGATION AND MONITORING

During the period under review, the effects of the APHIAplus IMARISHA implemented activities /projects on the biological, economic, social and physical environments are outlined as follows: ● Small-scale irrigation agriculture: The project linked the beneficiary IGA and FFS groups engaged in greenhouse and small scale irrigation farming to the Ministry of Agriculture for technical support. There were no environmental risks observed as a result of these agriculture activities. During the FFS training, the farmer groups were encouraged to establish tree nurseries with focus on fodder trees, fruit trees and other environmental friendly trees as a mitigation for farming methods that could cause erosion and siltation of water bodies.

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VIII. PROGRESS ON LINKS TO OTHER USAID PROGRAMS

During the reporting period under review, APHIAplus IMARISHA collaborated with other USAID- supported programs as shown below. LINKAGE WITH NATIONAL MECHANISMS AND OTHER PARTNERS Table 45 APHIAplus IMARISHA Collaboration with other USAID Programs Other USAID programs Activities Maternal and Child Survival ● Participated in a USAID-funded Partners forum to share best Programme practices in MNCH in Kitui, 21st to 25th September 2015. ● Learning included a mix of technical presentations, plenary discussions and field visits. Nutrition & HIV Program (NHP) ● Redistribution of FBP commodities and nutrition service registers in Turkana County ● Met with NHPplus team to understand their new mandate and how APHIAs can contribute to the same TB ARC ● Participated in a quarterly PEPFAR funded TB/HIV Implementing Partners Meetings on 7 August in Nairobi. ● Participated in a 4-day National Tuberculosis and Lung Diseases Review workshop in County 21st – 24th September 2015. REGAL-IR, REGAL-AG and AHADI ● Participated in PREG Joint Work-Planning and Events Planning (PREG Partners) meetings in August and September 2015. ● REGAL-AG supported fodder and pasture production enterprises in Marsabit County. ● SIDAI (REGAL- IR) continued to train and provide animal health services to APHIAplus IMARISHA beneficiaries on poultry and small ruminants in Isiolo County. ● Trained groups sourced quality animal drugs and extension service from SIDAI. ● In Turkana County, APHIAplus IMARISHA linked 2 IGA groups engaged in handcraft to REGAL-IR- for support on expansion of their IGAs. ● Met with AHADI project to discuss potential areas of collaboration and common interest URC/ASSIST ● Continued Quality Improvement initiatives for OVC across NAL and in health facilities in Isiolo County FUNZO Kenya ● In partnership with FUNZO Kenya supported training of a total of 131 HCWs in Isiolo, Samburu, Mandera, and Marsabit Counties on LARC and FP. A top down cascade strategy was applied whereby 5 HCWs were trained as TOTs in long acting reversible contraceptive (LARC) and thereafter these TOTs trained an additional 30 HCWs. ● In collaboration with FUNZO Kenya and additional 59 HCWs drawn from the main ART sites and satellites were trained on the updated guidelines on HIV care and treatment (the Rapid Advise 2014) in Samburu, Marsabit and Isiolo Counties.

● In Turkana County FUNZO trained 28 HCWs on PMTCT and

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25 on FP.

APHIAplus HCM ● Participated in Health Promotion Advocacy Committees (HPAC) in Isiolo and Tana River Counties during the reporting period. Clinton Health Access Initiatives ● Jointly participated in a dissemination of MNCH baseline survey (CHAI) to facility in-charges and S/CHMTs in Samburu County and supported them to develop sub-county action plans. ● Jointly also worked with them on IMCI training of HCWs, OJT, mentorship and CMEs focused on scale up of ORS/Zn in the County MEASURE Evaluation (PIMA) ● Technical support in the conducting of the BEmONC midterm assessment and analysis of data WELTEL ● Continued engagement with WELTEL to conduct the SMS project in enhancement of treatment adherence Isiolo County Futures Group  Participated in EMR and IQCare training by Futures Group in Meru.

IX. PROGRESS ON LINKS WITH GOK AGENCIES

During the reporting period under review, APHIAplus IMARISHA‘s efforts to link project activities with the Kenyan Government agencies at both national and county are summarize in the table below:

Table 46: APHIAplus IMARISHA Collaboration with GoK Agencies Ministry/Government Agency Activities Ministry of Agriculture, livestock ● Training of beneficiary groups on agro based enterprises, viable IGAs, and business development skills ● Technical support on establishment of one IGA/demonstration agro-based enterprise site for the LIPs on agro-based enterprises with focus on fodder trees, fruit and other environmentally- friendly tree sites in Garissa County. ● Provision of technical support on management of greenhouses. ● Capacity building and providing technical support on caregiver groups with agricultural and livestock farming across counties. ● Joint visit to beneficiary groups and provision of guidance on establishment of poultry farming. Capacity assessment for groups to ascertain their management level in Garissa County. Ministry of Health ● Provided HTC services, Vitamin A supplementation and treatment ● Continued to participate in County Nutrition forums ● Collaborated with health to provide quality integrated health services responsive to the key populations, youth in school and youth out of school ● Distribution of HMIS tools to facilities from NASCOP ● Attending the M&E TWG spearheaded by CHRIO. ● Attended County Quarterly Review Meetings ● Support Supervision and Technical Assistance done jointly ● Participated in County Health Stakeholder forums Ministry of Education School health clubs and Life Skills Education

Ministry of Water, Agriculture and ● Supporting and participating in WESCOORD meetings. USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 171

Irrigation ● WSMCC training on O&M, MUS, Hygiene and MNCH services ● Follow-up on completion of WASH hardware in the focus counties Department of Children Services  Child Protection Advocacy, AAC meetings, joint support supervision, QI activities, Child protection mapping Department of Social Service Office  Registration of beneficiary groups and training on group dynamics and leadership Police and Judiciary  Legal Issues Civil registration department  Birth registration for OVC. KEMSA  Supply of commodities e.g. ARVs, FP commodities, test kits

X. PROGRESS ON USAID FORWARD

During the period under reviewing the project made the following achievement in progress towards USAID forward: a) Monitoring and on-site mentorship by Grants Officers was done on Compliance and Financial Management to all the 23 funded LIPs. b) Review meetings were held for all the LIPs and this provided an opportunity to revisit the performance of the LIPs, in addition to providing them those who are implementing care and treatment interventions with a more focused technical training to ensure they clearly understood the project objectives. c) The project‘s Grants Officers attended a workshop on New Regulations Update: USAID Grants & Cooperative Agreements conducted by InsideNGO. The training provided updates and an orientation on major revisions on 2 CFR 200 and the standard provisions both for US and non-us organizations. d) During this period the project also conducted an Organizational Development and Systems Strengthening (ODSS) analysis for all the LIPs in order to measure the level of organizational capacity in the following areas: Project Design and Management, Leadership, Governance and Strategy, Financial Management, Administration and Human Resources, Networking and Advocacy, Technical Capacity, Knowledge Management, Sustainability, Monitoring and Evaluation. The results of the assessment will be used to focus on the areas which require more support and will inform capacity building plans for the LIPs.

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Figure 99: Organizational Development and Systems Strengthening Score by LIP Some of the LIPs found to need overall more targeted and focused attention include:  A.I.C Lokori Health Centre  Kipini Integrated Community Enterprise  Maridhiano Community Based Organization  Tumaini Kanamkemer Self Help Group  Organization of People Affected by HIV & AIDS (OPAHA) As shown in the table below areas that need particular attention include M&E and project design and management. Areas found to be particularly good included Leadership, Governance and Strategy as well as Financial Management.

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Figure 100: Overall Organizational Development and Systems Strengthening Ranking By Thematic Area/ Element e) During this period, the project also shared the Revised USAID standard provisions with the LIPs through a modification, to recognize the major revisions in the standard provisions. f) There was also capacity building of LIPs on financial reporting and use of quick books, hence at least nine LIPs are now able to keep financial records and do financial reports through QuickBooks.

Table 47: List of Local Implementing Partners Funded During The Quarter

No Name of Local Implementing Partner (LIP) County Intervention Areas

1 Caritas Diocese of Garissa Tana River OVC/HCBC

2 Maridhiano Community Based Organization Tana River OVC

3 Kipini Integrated Community Enterprise Tana River OVC

4 Culture Information and Pastoralist Development (CIPAD) Marsabit OVC

5 Food for the hungry, Kenya (FH, Kenya) Marsabit OVC/HCBC

6 Samburu Aid in Africa (SAIDIA) Samburu MNCH

7 Shepherds of life (SOL) Samburu OVC

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8 Suguta Campaign against AIDs Programme (SCAAP) Samburu OVC

9 Catholic Diocese of Maralal Samburu OVC/HCBC

10 KIBA Child development organization Samburu OVC

11 Catholic Diocese of Lodwar Lodwar OVC/HCBC/ HIV Care & Treatment

12 AIC Lokichoggio Health centre Lodwar OVC/VMMC

13 AIC Lokori Health Centre Lodwar OVC

14 Tumaini Kanamkemer Self Help Group Lodwar OVC

15 AIC Kalokol Health Centre Lodwar HIV Care & Treatment

16 Pastoralist Women For Health and Education Isiolo OVC

17 Wajir South Association (WASDA) Wajir OVC

18 Strategies for northern development (SND) Wajir OVC

19 Organization of People Affected by HIV & AIDs Wajir OVC/HCBC

20 Rural Agencies for Community Dev. And Assistance Mandera OVC

21 Emergency pastoral assistance group of Kenya (EPAGK) Mandera OVC

22 North Eastern Welfare Society (NEWS) Garissa OVC

23 Sisters Maternity Home (SIMAHO) Garissa OVC

XI. SUSTAINABILITY AND EXIT STRATEGY

The project‘s key strategy to ensure a proper exit and sustainability beyond close out has been to work with and through relevant line ministries at County level. By doing so, we continue to ensure that the project activities are well aligned and integrated with County Development Plans by working closely with the appointed County Officers, including the relevant County Executive Committee members. In the current quarter, the project finalized discussions with counties where MOUs were pending and agreed on a mechanisms for mutual accountability – essentially monitoring visits and meetings between the technical teams and meetings at higher level as necessary. The County Officers continue to be briefed on new developments in the project and to participate in the project activities including mentorship and OJT for HCWs. We also continue to hold joint review meetings on a quarterly basis to review progress vis-à-vis targets set in the plans. Such review meetings form the basis for learning and building on achievements. LIPs will also contribute to the review meetings to ensure their active participation in the process and their effective contribution to sustainability efforts.

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Furthermore, the APHIAplus IMARISHA field staff continue to expend effort in developing a network of qualified community-based trainers. These individuals will remain behind long after project close-out. Over the coming quarters, APHIAplus IMARISHA staff will continue to work with these individuals to strengthen their technical skills and transition them to a fee-for-service business model. We will continue to work and collaborate with other partners and leverage on each other‘s resources so that we can have a lasting impact in the region.

XII. GLOBAL DEVELOPMENT ALLIANCE (IF APPLICABLE)

Not Applicable.

XIII. SUBSEQUENT QUARTER’S WORK PLAN

CARE AND TREATMENT Mentorship to HCWs on the HII on HIV AIDS that includes: ● Provision of job aids and SOPs ● Facilitation for the CHMT and sub CHMT to provide support to the facilities ● Sustain mentorship on implementation of the rapid advice. ● Strengthen the 4 prong approach to e-MTCT ● Strengthening HEI management and introduction of HEI cohort analysis ● Targeted community interventions to improve health outcomes in HIV/AIDS- HIV prevention, retention in care, linkage to care and treatment, defaulter tracing ● Placement and payment of performance based stipend to expert clients at the CCCs to support community-facility based linkages and activities ● Support outreaches for provision of services to far off communities ● Support implementation of ACT strategy in Turkana Sensitization on the Adolescent toolkit.

LAB ● Establishment of Lab TWGs in the 8 counties for maintenance and sustainability of quality lab services ● Routine sample networking ● Routine TA and mentorship ● Support distribution and collection of PT panels in the 8 counties

HCSM ● Support operations of 4 county commodity management committees: Commodity DQAs and Monthly meetings ● Operationalization of MTCs in the 8 county referral hospitals ● Support and scale up use of electronic inventory management software

QI ● Scale up QI in the project with a focus on the priority facilities ● Hold QI follow up meeting with WITs in high volume facilities in Turkana County and set the QI agenda for the year USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 176

MNCH ● Provide mentorship to HCWs in 80 HFs on the HIIs on MNCH ● Place 8 mentor mothers in 8 high volume facilities in Turkana County ● Provide TA for integration on eMTCT services in MNCH using the current guidelines. ● Facilitate formation of 8 Mother to mother Support groups ● Train TBAs to refer / accompany mothers to health facilities for MNCH/Delivery ● Support regular integrated MNCH outreaches in hard to reach areas ● Orient and facilitate DMs to provide MNCH services in communities ● Train 30 HCWs in BEmONC in Isiolo ● Scale up BEmONC in Isiolo County using assessment results and action plans ● Sustain BEmONC activities in Wajir, Mandera and Samburu using assessment results and action plans ● Targeted community interventions to improve health outcomes in MNCH- e.g. ANC attendance, skilled birth ● Placement and payment of performance based stipend to CHVs at the MCH clinics to follow up all pregnant women at their facility and the community ● Continue to support use of maternal shelters, provision of emergency transport where possible to pregnant women, utilization of free maternity services ● Continue to pilot use of ORS and Zinc for diarrhea management in Samburu

RH/FP ● Mentorship to HCW on how to counsel HIV +ve women and couples about health benefits of child spacing ● Pilot training of CHVs as CBDs of FP in collaboration with the counties ● Orient HCWs in 111 facilities on integration of FP/HIV activities ● Orient HCW on use of SDM and distribute cycle beads to 111 health facilities ● Continue working with religious leaders to promote child spacing ● Continue mentorship of CHVs to improve documentation of referral to the facility and other community interventions

ORS/ZN Scale-up  Continue with training of HCWs on IMCI  Further share MNCH baseline assessment findings, sensitize HCWs on health talks & on the IMCI mobile app  Continue capacity building through mentorship, OJT and CMEs and include private health facilities for them to also utilize ORS/ Zn in the treatment of diarrhea  Facilitate transfer of commodities (ORS and Zn) to Samburu County  Through CHAI, receive and distribute ORT corner equipments, demand generation and other IEC materials  Conduct site based assessment of participants on progress of implementation of their action plans  Initiate assessment for training on community IMCI  Document best practices and cases  Integrate WASH and IMCI teams to create synergies in programming for better outcomes

PREVENTION

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● Work with LIPs to technically support 270 Trained Key populations (250 FSW and 20 MSM) to conduct monthly peer education sessions to 32,400 key populations in Turkana, Tana River, Isiolo, Marsabit and Samburu Counties ● Monthly HTC for key populations, family testing of index clients, linkage to care and treatment and follow up of PLWHIV on care and treatment ● Work with LIPs to support the 26 fisher folk facilitators trained on Project SASA! to reach 1,152 peers with appropriate gender norms and comprehensive HIV prevention package along the fisher community of Lake Turkana ● Provide logistics for 210 PLHIV facilitators (Turkana, 80, Tana River, 30, Isiolo, 40, Marsabit, 30, Samburu, 30) to reach 15,120 PLHIV with cPwP minimum package ● Support the functionality of all the PLWHIV support groups in the ART facility catchment areas in NAL ● Support the TOTs to address HIV related Stigma and Discrimination at facility and community levels for increased uptake of ART services

VMMC ● Support 4 dedicated teams providing VMMC services- both static and outreach ● Continue demand creation for VMMC activities in Turkana ensuring that they are culturally appropriate and sensitive to local contextual issues ● Continue to work with Film Aid/ HCM and Turkana VMMC taskforce to specifically come up with demand creation strategies for older boys and men ● Support HIV/TB/VMMC Taskforce meetings, including support supervision and quality assurance visits to field teams ● Participate in the National VMMC Taskforce meeting as appropriate ● Support accelerated activities in November and December due to expected increased demand of services. This will include working over weekends and where appropriate, undertaking moonlight activities. ● Identify VMMC champions in all locations and utilize them in community mobilization.

ECONOMIC STRENGTHENING ● Mentorship and support to LIPs/ CBOs on Enterprise Development and linkages for sustainability ● Facilitate Mentorship of existing groups in enterprise development to grow and expand their IGAs and SILC with focus on engagement of women in the value chains ● Facilitate LIPs/CBOs in organizing more vulnerable households (OVC and PLHIV) into IGA/business-focused groups through a self-selection process and training in enterprise development ● Facilitate LIP/CBOs to train groups in livestock-based enterprise development and economic strengthening with focus on engagement of women in the value chains ● Expand IGA/demonstration livestock/ agro-based enterprise sites for LIPs/CBOs ● Facilitate LIPs/CBOs to expand IGA demonstration sites on agro-based enterprises with focus on fodder trees, fruit and other environmentally-friendly tree sites ● Facilitate LIPs/CBOs to conduct peer to peer exchange visits for groups engaged in IGA ● Facilitate the LIPs to mentor & link target groups (SILC, IGA, and other target groups) to existing microfinance providers and lending institutions ● Mentor CHWs in business development and IGA management ● Facilitate training for IGA groups on value addition and quality improvement of handcraft ● Collaboration with County Governments and other USAID funded programs to synergize our inputs

NUTRITION AND FOOD SECURITY

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● Continue to strengthen documentation of Nutrition services in patient files ● Conduct routine SIMS at our priority one facilities ● Conduct OJT, mentorship and TA at various facilities ● Contribute to nutrition support supervision in all Counties ● Conduct 8 EBF support group meetings ● Support commemoration of Malezi Bora week in November 2015 ● Procure and distribute 900 chicks to beneficiary groups in Turkana and Tana River Counties ● Distribute 14 drip irrigation systems to beneficiary groups in Tana River and Garissa Counties ● Facilitate Agricultural and Nutrition field days to expose households to alternative (crop/livestock) production techniques for improved food security & nutrition ● Train 8 school health clubs on nutrition corners/gardens ● Facilitate CHWs to conduct cooking demonstrations ● Support supervision to LIPs ● Support the commemoration of World Food day- October 16th 2015 ● Facilitate LIPs to educate 8,000 OVC/HCBC HH on food preservation , storage techniques and healthy dietary practices ● Capacity building of 69 CHVs and 4 LIPs staff from Isiolo County on MUAC, key Nutrition indicators and food preservation

OVC ● Strengthening of families to provide for their children‘s needs through targeted HES and food security initiatives ● Direct support for OVC to meet immediate and critical needs ● Continue to mentor and coach LIP staff on OVC QI, OLMIS, OVC data management and filing ● Conduct joint support supervision visits to LIPs ● Orient LIPs and volunteers on program Standard Operating Procedures ● Disseminate CSI findings to LIPs and CHVs and roll out improvement activities to address service delivery gaps

WASH Samburu County  Completion of Longewan to Kao water pipeline extension – completion of 2 water kiosks and branding  Completion of Napunye Borehole – Completion of 2 water kiosks and branding  Finalize water connections to Baragoi and Wamba – Branding  Training of WSMC for Napunye borehole, Archers Post. Isiolo County  Drilling of a new borehole at Atir village in Chumvi Yare – installation of 50m3 water tank, solar pumping system, construction of 2 water kiosks and training of WSMC members.  Construction of modern incinerator at TB Manyatta. Turkana County  Completion of Elelea water extension to primary school, dispensary and community access points.  Construct modern incinerator at St. Patrick Dispensary in Lodwar. Mandera and Wajir counties  Support RACIDA in installation of 2 plastic water tanks in Mandera.  Continue completion of 6 2-door VIP latrines in institutional setting.

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 Support counties in celebrating GHD and WTD celebrations.  Branding of WASH outputs – VIP latrines and 4 wells in Mandera. All Counties  Continue follow ups and certification of ODF claimed villages

GRANTS MANAGEMENT  Monitoring and mentorship of the Local Implementing Partners by the Grants team with the technical officers and M & E Officers.  Sub-awards budget allocation per each LIP and request for approval from USAID.  Scope of Work (SOW) and target setting for 2016 for all the LIPs.  Transition and close out for the Turkana County LIPs and ensure OVC programming is transitioned to RCEA.  Review meeting with all the LIPs in order to review the period July-September 2015.  Training on governance and financial compliance.

MONITORING & EVALUATION  Facilitate facility level data review meetings  Data reconstructions for Wajir CRH.  Continuous mentorship for Health Care Worker on HMIS  Installation of ART Dispensing Tool (ADT) at the Marsabit CRH, Moyale DH, Sololo Mission Hospital and Laisamis Mission Hospital.  Conduct RDQA at both facility and community.  Install EMR and train HCWs in Marsabit County Referral Hospital

XIV. FINANCIAL INFORMATION

The expenditure burn rate against the current obligated amount for the quarter ending 30th September 2015 was at 85%. Personnel, administration and general project running costs were spent according to the tight budget. Activity costs have maintained normal and are expected to be maintained as per the work plan. Cash call downs to USAID have been made monthly and funds were received regularly. To continue enhancing and improving efficiency in operations, the Compliance Officer and Finance Manager have continued to make various field visits to further orient staff on various internal control requirements and ensuring compliance to rules and regulations in place. In addition the regional fields Accountants have been making regular field trips to offer continuous technical assistance to the field staff on processes and procedures with the aim of enhancing support to the field teams.

Cash Flow Report and Financial Projections (Pipeline Burn-Rate) CHART 1: OBLIGATIONS VS. CURRENT AND PROJECTED EXPENDITURES

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TABLE 3: BUDGET DETAILS

T.E.C.: $49,985,210 Cum Oblig: $46,726,493 Cum Expenditure: $39,644,741 Apr-June July-Sept 2015 Oct-Dec 2015 Jan-Mar 2016 2016 Obligation Actual Projected Projected Projected Expenditures Expenditures Expenditures Expenditures Total: 46,726,493 2,798,266 2,078,837 2,113,632 1,770,093 Direct Cost 1,233,073 1,053,414 1,148,816 1,032,794 Sub-Awardees 1,358,407 848,765 772,160 564,099 Indirect Cost 206,786 176,658 192,656 173,200

* When applicable.

Budget notes (List assumptions, major changes, estimations, or issues intended to provide a better understanding of the numbers.)

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BUDGET NOTES

Direct Costs are expected to be as high as in Q3 as project implementation has been at the pick towards achieving APR. Direct Cost Expenditure is expected to reduce in Q1 in preparation of YR5 work plan and further reduce in Q2 as the project awaits YR5 Work plan approval.

Sub-Awards are expected to be as high as in Q3 as project implementation has been at the pick towards achieving the APR Sub- .Expenditure is expected to reduce in Q1 in preparation of YR5 work plan an further reduce in Q2 as the project awaits YR5 Awardees Work plan approval.

Indirect Cost Indirect are at the NICRA rate of 16.77% on direct cost except on Vehicles and equipment more than $ 5,000

TABLE 4: NEW SUB-AWARD DETAILS

Total Amount in the approved budget for sub-awards: $ 23,583,265

Total Amount sub-awarded to date: $ 14,509,434.55

DO Title: Name of Sub-Awardee: FAMILY HEALTH INTERNATIONAL Activity Title: APHIAPLUS IMARISHA Agreement Performance Period: 15TH MARCH 2012 to 30TH SEPTEMBER 2014 Agreement Amount (Total Estimated Cost): $ 3,640,062 Geographic Locations for Implementation: NORTHERN & ARID LANDS IN KENYA Activity Description: (One concise paragraph)

DO Title:

Name of Sub-Awardee: BROADREACH HEALTH CARE Activity Title: APHIAPLUS IMARISHA Agreement Performance Period: 15TH MARCH 2012 to 14TH MARCH 2017 Agreement Amount (Total Estimated Cost): $ 4,672,354 Geographic Locations for Implementation: NORTHERN & ARID LANDS IN KENYA

Activity Description: (One concise paragraph)

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DO Title:

Name of Sub-Awardee: LAND O' LAKES Activity Title: APHIAPLUS IMARISHA Agreement Performance Period: 15TH MARCH 2012 to 30TH MARCH 2015 Agreement Amount (Total Estimated Cost): $ 4,409,721 Geographic Locations for Implementation: NORTHERN & ARID LANDS IN KENYA Activity Description: (One concise paragraph)

DO Title:

Name of Sub-Awardee: CATHOLIC RELIEF SERVICES Activity Title: APHIAPLUS IMARISHA Agreement Performance Period: 15TH MARCH 2012 to 14TH MARCH 2017 Agreement Amount (Total Estimated Cost): $ 7,051,655 Geographic Locations for Implementation: NORTHERN & ARID LANDS IN KENYA Activity Description: (One concise paragraph)

DO Title:

Name of Sub-Awardee: UNIVERSITY OF MARYLAND,BALTIMORE Activity Title: APHIAPLUS IMARISHA Agreement Performance Period: 15TH MARCH 2012 to 14TH MARCH 2017 Agreement Amount (Total Estimated Cost): $ 3,809,473 Geographic Locations for Implementation: NORTHERN & ARID LANDS IN KENYA Activity Description: (One concise paragraph)

XV. ACTIVITY ADMINISTRATION

Personnel

Two personnel left the project during the quarter namely: the monitoring and evaluation officer in Samburu and the grants officer in Isiolo. The recruitment for these two positions is currently ongoing.

USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 183

Contract, Award or Cooperative Agreement Modifications and Amendments

There are no modifications or amendments

XVI. FOR ANNUAL REPORTS ONLY

A. Budget Disaggregated by County

Obligation 3rd Quarter 4th Quarter 1st Quarter 2nd Quarter

Total: $ $ 2,798,266 $ 2,078,837 $ 2,113,632 $ 1,770,093 ISIOLO COUNTY $ 478,837 $ 355,729 $ 361,683 $ 302,897 MARSABIT COUNTY $ 168,756 $ 125,369 $ 127,467 $ 106,749

SAMBURU COUNTY $ 154,390 $ 114,697 $ 116,617 $ 97,662

WAJIR COUNTY $ 287,149 $ 213,323 $ 216,894 $ 181,641

MANDERA COUNTY $ 164,337 $ 122,086 $ 124,130 $ 103,954

GARISSA COUNTY $ 242,439 $ 180,109 $ 183,123 $ 153,359

TANA RIVER COUNTY $ 183,649 $ 136,433 $ 138,717 $ 116,170

TURKANA COUNTY $ 328,478 $ 244,027 $ 248,111 $ 207,785

NAIROBI COUNTY $ 790,231 $ 587,064 $ 596,891 $ 499,875

B. Budget Disaggregated by Earmarks (Earmarks for 2014/5 funds shown below; new should be added if/when appropriate.)

Obligation Q1 Q2 Q3 Q4

PERPFAR $ 900,000.00

POPULATION $ 799,885.00 $ 3,500,000.00 $ 2,000,00.00

NUTRITION $ 600,000.00 $ 191.715.00

MCH $ 282,869.00 $ 1,230,000.00 $ 700,000.00

WASH $ 1,000,000.00

Note: Each year the COR/AOR should be consulted regarding which earmarks are applicable to the activity, and the amounts.

USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 184

C. Sub-Awards

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

ISIOLO,MARSABIT,SAMBURU,WAJIR AMREF FAMILY HEALTH INTERNATIONAL 15TH MARCH 2014 14TH MARCH 2017 $3,648,716 30TH SEPT 2014 ,MANDERA,GARISSA,TANA RIVER & TURKANA ISIOLO,MARSABIT,SAMBURU,WAJIR AMREF BROADREACH HEALTH CARE 15TH MARCH 2014 14TH MARCH 2017 $2,092,657 31ST DEC 2014 ,MANDERA,GARISSA,TANA RIVER & TURKANA ISIOLO,MARSABIT,SAMBURU,WAJIR AMREF LAND O' LAKES 15TH MARCH 2014 14TH MARCH 2017 $2,070,752 31ST DEC 2014 ,MANDERA,GARISSA,TANA RIVER & TURKANA ISIOLO,MARSABIT,SAMBURU,WAJIR AMREF CATHOLIC RELIEF SERVICES 15TH MARCH 2014 14TH MARCH 2017 $4,244,042 30TH SEPT 2014 ,MANDERA,GARISSA,TANA RIVER & TURKANA ISIOLO,MARSABIT,SAMBURU,WAJIR AMREF UNIVERSITY OF MARYLAND,BALTIMORE 15TH MARCH 2014 14TH MARCH 2017 $3,642,865 30TH JUNE 2015 ,MANDERA,GARISSA,TANA RIVER & TURKANA

D. List of Deliverables The Environmental Audit report is being finalized and will be shared with USAID once completed.

E. Summary of Non-USG Funding There is no specific non-USG funding for the project but cost share activities are derived from DANIDA, EU-MNCH, Outreach and WelTel.

F. Type of Accounting System Used During Reporting Period The accounting system in use is Sun Systems version 10.1

XVII. GPS INFORMATION

The GPS information for new sites developed in year 4 is attached separately

USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 185

XVIII. BENEFICIARY STORY

Improving Financial Management in Health Facilities through the Use of Cash Registers in NAL Region

In Kenya, the introduction of user fees was the first reform in the health sector. As part of health sector reforms, cost sharing in public health facilities was meant to improve the provision of quality health care services. Funds generated from user fees would supplement government‘s diminishing resources allocated to health care services. This would ensure continued provision of health care services through the supply of drugs and medical equipment, as well as in maintaining and expanding health facilities. Cost sharing is well established in the Ministry of Health (MOH) system, and the revenue collected is critical as government support is reduced and decision making is decentralized. The challenge for each institution and for the MOH as a whole is to make the program work effectively by reducing fraud and using increased revenue to improve services. User training on the cash register system at Garissa Provincial General Hospital The private health sector, including faith based health facilities is estimated to contribute approximately 40% of the national health delivery network. They compliment the government‘s efforts in health care provision especially to the poor and the marginalized. Despite their significant contribution, their performance has been constrained by a number of factors which include inadequate sustainable financial management systems. According to a Site Capacity Assessment (SCA) carried out during the inception of the APHIAplus IMARISHA project in public and private (private not-for-profit and private for profit) facilities, Isiolo and Garissa Counties demonstrated a huge gap in financial management. Kenya‘s health reform policies have consistently called for a greater role for the private sector in meeting the health needs of Kenyans, which would offset the burden of the public sector in providing curative services.

While the challenge of running an effective health system is not limited to resource-poor settings, those with fewer resources face even greater obstacles. The manner in which the money flows through the system can also pose a greater challenge to the delivery of services than overall financing. Basic information about cost of care is lacking and financial accountability is often not measured or even expected. Embezzlement often involves user-fee revenues collected from the sale of drugs or diagnostic tests, and registration fees paid by patients. While sufficient resources for health continues to be a challenge in the country and requires

USAID/KENYA APHIAPLUS IMARISHA ANNUAL PROGRAMME REPORT FOR FY 2015 186 sustained external assistance, changing internal incentives for cost-effectiveness and promoting financial discipline are steps that can be taken immediately to achieve greater impact from current funds within the sector.

APHIAplus IMARISHA has successfully piloted the implementation of the use of cash registers to enhance revenue collection, financial planning and management at Garissa Provincial General Hospital (public) and Wamba Mission Hospital (FBO) in Samburu County. The project installed Electronic Cash Registers in the two health facilities. The support included the provision of networking of the cash points to the administration and finance offices, provision of both hardware and software materials and training of users. The project provided continuous mentorship to the health facility staff on utilization of cash register data for decision making. The computerized cash management system is meant to address the issue of cash leakages and poor financial management. The system has improved financial management through enhancing revenue collection, reporting and reducing cash leakages. The use of the networked system provides real-time data for the departmental financial reporting and it is easily monitored to prevent any cash leakages. During the period of piloting, a marked improvement was noted in the hospital departmental revenue collection and departmental budgetary planning. “The installation of the electronic networked cash register system marks a watershed in the financial management of the hospital. I can now access financial transactions and reports from the comfort of my seat.” Dr Mohamed Musa (Medical Superintendent, Garissa Provincial General Hospital).

The real value of cash registers can be measured by improved patient services and quality of care, which have been very evident at Garissa Provincial General Hospital and Wamba Mission Hospital. As a result of the use of cash registers, revenue collection from patient fees in the two health facilities has increased by 30 – 50% over a one-year period of the pilot. The major portion of the revenue increase was due to improved efficiency in collection—primarily less fraud and more complete capture of patient charges. There is enhanced ability to carry out real-time financial analysis of the revenues hence improved accountability. The quality of care has improved through reduced billing time from the previous 15-30 minutes to almost 5 minutes, which translates to a 66% reduction of the turnaround time spent at the billing points. The queues for treatment are also shorter and more orderly. There is a marked improvement in department financial planning, budgeting and decision making with the availability of daily, weekly and monthly revenue collection figures per department. The networked system allows the hospital administrators to closely monitor revenue collection from their offices. The use of the networked system provides real-time data for the departmental financial reporting and is easily monitored to prevent any cash leakages. As a result of the success of the pilot cash registers, Garissa CHMT has procured and installed the same model at Bura, Daadab, and Masalani Sub- County hospital.

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