USAID AFYA HALISI QUARTERLY PROGRESS REPORT PY3 Q3 (1 APRIL – 30 JUNE 2020)

Photo 1 CME on use of Partograph and EmONC Signal functions at St. Josephs Mission Rapogi in Uriri Sub-county, . A mother taking the MUAC of her child after he was supplemented with Vitamin A at the household level in the context of COVID-19 pandemic OCTOBER 2017 Date of Submission: July 30, 2020 This publication was produced for review by the United States Agency for International Development. It wasThis prepared publication by wasDr. producedGathari Ndirangu by Afya Halisiand the for team review of byMCSP the UnitedKenya TechnicalStates Agency Advisors for International Development.

USAID KENYA AFYA HALISI PROJECT FY 2020 Q3 PROGRESS REPORT

April 1 – June 30, 2020

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

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

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

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.

Table of Contents

I. AFYA HALISI EXECUTIVE SUMMARY ...... 1

II. KEY ACHIEVEMENTS (Qualitative Impact) ...... 12

III. ACTIVITY PROGRESS (Quantitative Impact) ...... 67

IV. CONSTRAINTS AND OPPORTUNITIES ...... 67

V. PERFORMANCE MONITORING ...... 68

PROGRESS ON GENDER STRATEGY ...... 73

VII. PROGRESS ON ENVIRONMENTAL MITIGATION AND MONITORING ...... 73

VIII. PROGRESS ON LINKS TO OTHER USAID PROGRAMS ...... 74

IX. PROGRESS ON LINKS WITH GOK AGENCIES ...... 74

X. PROGRESS ON USAID FORWARD ...... 75

XI. SUSTAINABILITY AND EXIT STRATEGY ...... 76

XII. GLOBAL DEVELOPMENT ALLIANCE ...... 76

XIII. SUBSEQUENT QUARTER’S WORK PLAN ...... 76

XIV. FINANCIAL INFORMATION ...... 80

XV. ACTIVITY ADMINISTRATION ...... 81

XVII. GPS INFORMATION ...... 82

XVIII. SUCCESS STORIES ...... 82

ANNEXES & ATTACHMENTS ...... 86

USAID/KENYA & EA AFYA HALISI PROGRESS REPORT FOR Q3 FY 2020 ii

ACRONYMS AND ABBREVIATIONS

ADSE Anglican Development Services FHOK Family Health Options Kenya Eastern FIC Fully Immunized Child ANC Antenatal Care FP Family Planning AWP Annual Work Plan G-ANC Group Antenatal Care AYP Adolescent and Young People GBV Gender Based Violence AYSRH Adolescent and Youth Sexual GMP Growth Monitoring Promotion and Reproductive Health GoK Government of Kenya BEmONC Basic Emergency Obstetric and HCP Health Care Provider Newborn Care HCW Health Care Worker BFCI Baby Friendly Community HFs Health facilities Initiative HH Household BFHI Baby-friendly Hospital Initiative HINI High Impact Nutrition BTL Bilateral Tubal Ligation Intervention CBD Community based distribution HMIS Health management information CBHIS Community Based Health systems Information System HPAC Health Promotion Advisory CBO Community Based Organization Committee CEC County Executive Committee HRH Human Resource for Health CEmONC Comprehensive Emergency HRIO Health Records Information Obstetric and Newborn Care Officer CH Child Health HSS Health System Strengthening CHA Community Health Assistant iCCM Integrated Community Case CHAI Clinton Health Access Initiative Management CHC Community Health Committee ID Identification details CHEW Community Health Extension IEC Information Education and Worker Communication CHMT County Health Management IFAS Iron and folic acid Team supplementation CHU Community Health Unit IGA Income Generating Activity CHV Community Health Volunteer iHRIS Integrated Human Resource CLTS Community led total sanitation Information System CME Continuous medical education IMAM Integrated Management of Acute CMMB Catholic Medical Mission Board Malnutrition CMSG Community Mother Support IMCI Integrated Management of Group Childhood Illness COC Combined Oral Contraceptive IPC Infection prevention and control CPR Contraceptive Prevalence Rate IPV Intimate partner violence CQI Continuous Quality Inactivated poliovirus vaccine Improvement IUCD Intrauterine contraceptive device CSA Center for the Study of IYCF Infant and young child feeding Adolescence J2SR Journey to Self-Reliance CSO Civil Society Organization JOOTRH Jaramogi Oginga Odinga CYP Couple years of protection Teaching and Referral Hospital DFH Department of Family Health KCGTRH County Government DMPA Depot medroxyprogesterone Teaching and Referral Hospital acetate KDHS Kenya Demographic and Health DO2 Development Objective 2 Survey DQAs Data Quality Audits/Assessments KHIS Kenya Health Information EBF Exclusive Breastfeeding System ECD Early childhood development KEMSA Kenya Medical Supplies EMMP Environmental Mitigation and Authority Monitoring Plan KIWASH Kenya Integrated Water, EmONC Emergency Obstetric and Sanitation, and Hygiene Newborn Care KMC Kangaroo mother care EPI Expanded Program on KMET Medical and Education Immunization Trust ETAT Emergency Triage Assessment KPA Kenya Pediatric Association and Treatment KQMH Kenya Quality Model for Health FGM Female Genital Mutilation USAID/KENYA & EA AFYA HALISI PROGRESS REPORT FOR Q3 FY 2020 iii

LAPM Long-acting and permanent RMNCAH Reproductive, maternal, method newborn, child and adolescent LARC Long-acting and reversible health contraceptive RRI Rapid response initiative LCA Lwala Community Alliance SBA Skilled birth attendant or LCHV Lead CHV attendance LDHF Low-dose high frequency SBCC Social and behavior change LIPs Local implementing partners communication LOA Letter of agreement SCHMT Sub-County Health Management M2MSG Mother-to-Mother Support Team Group SDP Service delivery point MCA Member of County Assembly SGBV Sexual and gender based violence MCH Maternal and child health SGS Small group sessions mCPR Modern contraceptive SRH Sexual and reproductive health prevalence rate STI Sexually transmitted infection MEDS Mission for Essential Drugs and TA Technical assistance Supplies TBA Traditional birth attendant MEL Monitoring, evaluation and ToR Terms of reference learning TOT Training of trainers MFL Master Facility List TWG Technical working group MIYCN Maternal, infant, and young child UHC Universal health coverage nutrition UNICEF United Nations International MLM Middle Level Managers Children's Emergency Fund MNCH Maternal, newborn and child USAID United States Agency for health International Development MNH Maternal and newborn health USG United States Government MNP Multiple Micronutrient Powder VAS Vitamin A supplementation MOE Ministry of Education VSC Voluntary surgical contraception MOH Ministry of Health VSLA Village savings and loaning MOU Memorandum of Understanding activities MPDSR Maternal and Perinatal Death WASH Water, sanitation and hygiene Surveillance and Response WHO World Health Organization MR Measles Rubella WIT Work Improvement Team NHIF National Hospital Insurance Fund WRA Women of reproductive age ODF Open-defecation Free OJT On job training OPV Oral poliovirus vaccine ORS Oral rehydration salt ORT Oral rehydration therapy OVC Orphans and vulnerable children PAFP Postabortion family planning PBCC Provider based behavior change PHO Public Health Officer PIFP Provider-initiated family planning PLGHA Protecting Life in Global Health Assistance PMP Performance monitoring plan PNC Postnatal care POP Progesterone-only pill PPFP Postpartum family planning PPH Postpartum hemorrhage PPIUCD Postpartum intrauterine contraceptive device PPR Performance planning and review PSK Population Services Kenya PWD Persons living with disability PY Planning Year QIT Quality Improvement Team REC Reaching every child RED Reaching every district RH Reproductive Health RMC Respectful maternity care USAID/KENYA & EA AFYA HALISI PROGRESS REPORT FOR Q3 FY 2020 iv

I. AFYA HALISI EXECUTIVE SUMMARY

Qualitative Impact

The US Agency for International Development’s (USAID) Afya County and National Support Program (Afya Halisi) is a five-year project that is being implemented by Jhpiego as the lead partner, with PS Kenya and an additional four local implementing partners (LIPs) that were sub granted in year 3. The partners include; Anglican Development Services Eastern (ADSE), the Center for the Study of Adolescence (CSA), Kisumu Medical and Education Trust (KMET), Lwala Community Alliance (LCA). The Project works with the Kenya National Ministry of Health (MOH) and the four focus county governments of Kakamega, Kisumu, and Migori to deliver quality, integrated services in family planning, reproductive, maternal, newborn, child and adolescent health, nutrition, and water, sanitation and hygiene (FP/RMNCAHN/WASH) to those most in need. The Project is designed to strengthen the capacity of national, county and sub-county health leaders and health systems across the continuum of the household through the community to health facilities to improve efficiency of the health systems. This report highlights Afya Halisi achievements for PY3 Q3 (April 1 – June 30, 2020) period. The report also documents progress in implementation of the Health, Population and Nutrition (HPN) integrated work plan being implemented in .

During the reporting period, Afya Halisi provided support to 664 health facilities in 26 sub-counties across the four counties. In this reporting quarter, Afya Halisi expanded its geographical scope to include direct support to the whole of Butere and Lurambi sub-counties in Kakamega County. Consequently, the Project provided support to 6 out of the 12 sub-counties in the county, adding to the initial sub-counties of Khwisero, Matungu, East and Navakholo. The Project also provided support to 6 out of 7 sub- counties in Kisumu, 6 out of 8 sub-counties in Kitui and all the 8 sub-counties in Migori.

During the reporting quarter, the Project reprogrammed its intervention approaches to adapt to the national and county governments’ prevention and containment measures to slow down the spread of COVID-19 pandemic. The reprogramming was aimed at ensuring that there is continuity of essential health services to the targeted population. Due to the evolving nature of the pandemic, the Project adopted an agile and adaptive approach to its implementation strategy based on iterative learning, performance data and guidance received from USAID KEA. At county level, the Project in collaboration with the national and county governments, prioritized co-implementation of activities that do not involve large gatherings, while practicing all COVID-19 preventive measures to sustain the RMNCAHN gains while making every effort to flatten the curve. Progress on J2SR pillars

The Project continued to align its programmatic approaches, operations, and activity implementation to USAID’s Policy Framework of Journey to Self-Reliance (J2SR) that Afya Halisi has arranged into 5 pillars, with the goal of increasing national and county government’s capacity and commitment towards self- reliance. To enhance meaningful engagement and capacity of local partners towards self-reliance, the Project continued to engage the local implementing partners (LIPs) on the jointly agreed upon capacity improvement action plans. During the reporting quarter, the Project conducted a second organizational capacity assessment for KMET and LCA to assess progress and changes in the organizational capacity of the LIPs. The findings showed significant improvements in the five capacity areas that were assessed for the two LIPs. The assessment for ADSE and CSA will be conducted in the subsequent quarter. During the quarter, the Project conducted a virtual training on report writing for the LIP staff based on gaps that were identified in the submitted monthly and quarterly progress narrative reports. In addition, Afya Halisi with

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technical support from Jhpiego head office in Baltimore conducted a virtual training on proposal development and submission for the LIP staff as well as Department of Health resource mobilization team. Some of the LIPs were in the process of developing capability statements and have requested for Jhpiego’ s technical inputs. The goal of the training was to build capacity of the LIPs and Kisumu County on proposal development and position them for future opportunities that may arise.

During the reporting quarter, the Project consistently advocated its focus counties to co-finance implementation of prioritized FP/RMNCAH, nutrition and WASH activities based on an earlier agreed upon joint work plan. The Project continued to track and document the in-kind contributions and activities co-financed by the focus county governments. During the quarter under review, the counties co-financed activities amounting to US$96,239, bringing the total to US$262,837 co-financed by the focus county governments as at end of PY3 Q3 period.

Despite the persistence of COVID-19 pandemic and the HCWs industrial action in Kisumu County during the reporting quarter, the Project continued its efforts to strengthen the capacity of the County Government of Kisumu to reach out to the private sector to supplement county government efforts to deliver health services. During the reporting period, the Project supported the co-creation of a draft memorandum of understanding (MoU) for twinning of Aga Khan Hospital Kisumu (AKHK) and Kisumu County Referral Hospital (KCRH) for cross transfer of knowledge and skills on appropriate technical, clinical and management aspects of health service delivery. The Project will work with the Kisumu county health leadership to expedite signing and execution of the MoU by the two hospitals. During the quarter, the Project co-created with the Kenya Obstetrical and Gynecological Society (KOGS) and the Kisumu county government, and identified four (4) KOGS members to pilot the mentorship and coaching initiative targeting HCWs in Level 4 peripheral facilities in order to improve quality of MNCH care in peripheral health facilities. However, the planned activities were interrupted by the COVID-19 pandemic and Kisumu HCWs strike. In the next quarter, the Project will re-engage the KOGS consultants to commence the initiative. The Project worked with the Kisumu county government to develop a draft road map for domestic resource mobilization from the private sector. The road map will be finalized and launched in the subsequent quarter. In preparation for the roll out of the road map, Kisumu County Department of Health resource mobilization team were trained on proposal development including USAID processes and requirements. To enhance social accountability across all levels and amplify community voices to demand quality health products and services, during the reporting quarter, Afya Halisi focused on strengthening capacity of selected local community based organizations (CBOs) to spearhead social accountability activities at the community level. The Project also continued to empower health facility management committees to put in place mechanisms that inform community members of the services that are available at each health facility and redress mechanisms in cases of unsatisfactory service provision. In addition, community members were engaged using the community scorecard to voice their expectations of health services provided at the health facilities. To address gaps in the health system building blocks, the Project co-supported to integrate and anchor community health services into the Kitui County Health Services Bill. Once enacted into county law, it will protect the community health platform against cyclical changes in political leadership. The bill also has provisions on health services fund and health products and technologies unit. The draft bill is now with the county executive for approval and submission to the County Assembly. In Migori County, the Project co-financed and co-facilitated development of regulations to operationalize the County Health Services Act. The Migori Health Services Act provides for establishment of a health services fund which ring-fences and protects health care finances from being appropriated under different county expenditures not related to health care. The regulations were approved by the county assembly and printed by the Government printer. In addition, the Project co-financed the co-creation of regulations for

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operationalization of the Kakamega County Health Facility Fund. The fund provides for health facilities to be able to utilize facility generated resources for facility level development and service delivery. Previously, all facility generated funds have been channeled to the county revenue account, which can be channeled to other expenses outside health.

Program management activities

Revision of Year 3 work plan During the reporting quarter, Afya Halisi revised its work plan, for the six months period of April to September 2020, to include innovative and strategic shifts to achieve the Project’s year 3 targets and J2SR objectives, in the context of COVID-19 pandemic. In addition, the Project worked with the Kakamega county government and USAID implementing partners to co-create the Health, Population and Nutrition integrated work plan for the county. Afya Halisi is leading and coordinating implementation of the integrated work plan in the county, in collaboration with AMPATHPlus, MWENDO, Impact Malaria, Afya Ugavi and Tupime Kaunti. The two work plans were approved by USAID KEA and implementation is on- going.

COVID-19 response During the reporting quarter, USAID provided incremental funding of US$ 400,000 to Afya Halisi to support the Ministry of Health in implementing responsive actions to the COVID-19 pandemic at national level and in Migori, Busia and counties. Through co-creation process with USAID KEA, relevant implementing partners, national and focus county governments, Afya Halisi developed a work plan for the response, which was approved. In addition, USAID approved redirection of the Project’s funds amounting to US$ 120,000 to support COVID-19 related activities in Kisumu and Kitui counties. Afya Halisi received further guidance from USAID KEA on the need to re-do the co-creation of COVID-19 work plan to ensure the national and county governments, and other implementing partners’ contributions are included and the Project leverages and supports prioritized and impactful activities that elevate USAID’s visibility.

Weekly AMT meetings with USAID During the reporting quarter, the Project held weekly virtual meetings with USAID Activity Management Team (AMT) to review management updates; program achievements; progress on HPN integrated work plan, and COVID-19 activities; finance updates; and receive updates and guidance from USAID. In addition, the Project began to hold monthly virtual co-creation meetings between USAID and the focus county governments. During the quarter, USAID held the co-creation meetings with Kitui and Migori county health leaderships. Relocation of Kitui office During the quarter, the Project relocated the Kitui office to a smaller office in the town, which has resulted in reduction of operation costs and more funds for programming to target beneficiaries. In addition, Afya Halisi provided vehicles to KMET and CSA to facilitate field movement of the staff working for the Project.

Sub-purpose 1: Increased availability and quality delivery of FP/RMNCAH, nutrition and WASH Despite the initial disruptions in consistent continuity of services after the confirmation of COVID-19 in Kenya in March 2020, the Project co-created and co-implemented prioritized activities with the national and focus county governments to ensure minimal disruptions in provision of essential FP, RMNCAH, nutrition and WASH services. During the reporting quarter, the Project achieved a couple years protection (CYP) of 121,111, bringing the total as at end of PY3 Q3 to 378,244. This reflects an achievement of 62% against the annual target of 609,815. During the quarter, the Project supported provision of family planning services in 641 health facilities across the four supported counties, an increase by 27 facilities after the

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Project's expansion into Butere, Lurambi, and Mumias East sub-counties in Kakamega county. In the reporting period, private facilities contributed to 12% of the Project’s CYP achievement, compared to 11% in the previous quarter.

The Project supported a total of 3,045 community health workers (CHWs) to provide FP services at the community level, an achievement of 138% against the annual target of 2,200. The 55 additional CUs identified for support in Butere and Lurambi Sub-counties led to an increased number of CHVs providing FP services in Kakamega County. During the quarter, 16 more CUs began to provide CBD bringing the total number of project supported CUs providing CBD to 53. However, CUs in Kisumu County have had challenges in providing CBD with the county not fully supporting the distribution of the non-prescriptive oral contraception pills by CHVs.

The stock out of FP commodities remains a critical system-level gap in the focus counties. In the reporting period, 71% of the project supported sites reported stock-out of at least one of the five FP commodities (either of COCs or POPs, IUDs, DMPA, Male condoms, and Implants). This is higher than the 64% stock out reported in PY3 Q2 period. The FP commodity that was mostly out of stock during the reporting quarter was male condoms at 43%. During the quarter, the Project supported distribution of 7,100 male condoms to the focus counties which was a donation from DKT. The Project continued with its collaboration with Afya Ugavi to strengthen commodity security and supply chain component of the health system and advocate for the accountability of commodity management with the respective CHMTs. Specifically, Afya Halisi supported printing and distribution of FP reporting tools (Facility Contraceptives Consumption Data Report and Request form- FCDRR) while Afya Ugavi supported county level commodity TWG to review commodity data and inform actions based on performance. One key gap identified in FP commodity security is the inadequate understanding of the FCDRR tool by HCWs. In the subsequent quarter, the Project and the counties will co-finance mentorship of HCWs in specific facilities identified as having gaps.

The Project continued to support counties to strengthen emergency obstetric and newborn care functions in the supported health care facilities. At the end of PY3 Q3 period, the Project supported 149 health facilities to provide appropriate maternal and neonatal emergency care services in the four counties. This reflects an achievement of 90% against the annual target of 165. Out of these, 127 health facilities had capacity to provide seven signal functions for BEmONC and 22 health facilities had capacity to provide nine signal functions for CEmONC. The signal functions that were not met by majority of the BEmONC sites included removal of retained products due to lack of manual vacuum aspiration (MVA) kits and performance of assisted vaginal delivery due to lack of Kiwi vacuum extractor. In response to these gaps, the Project will intensify advocacy for the counties to procure the MVA kits and Kiwi.

During the reporting period, the Project reached 18,614 women to attend 4 ANC visits, bringing the total as at end of PY3 Q3 to 51,346. This reflects an achievement of 70% against the Project's annual target. The overall coverage for ANC 4 visits at the end of PY3 Q3 was 55% in the project focus counties. The non-emergency services were greatly affected by COVID-19 response measures, with some of the health facilities closing out-patients’ departments or transferring those services to other health facilities to minimize the spread of COVID-19 pandemic. In response, the Project reprogrammed its activities to respond to the COVID-19 pandemic period. A total of 24,585 births were conducted at health facilities supported by Afya Halisi across the four focus counties, bringing the total to 70,967 as at end of PY3 Q3 period. This reflects an achievement of 101% against the annual target of 70,002. The overall coverage for SBA at the end of PY3 Q3 was 71% , up from 68% as at end of SAPR 2020 period. This is above the national skilled birth attendance target of 70% for 2020. The disruptions by COVID-19 did not significantly affect skilled birth attendance coverage as concerted efforts were made by counties and stakeholders to ensure continuity of essential health services, especially for mothers and children. During the reporting quarter, the Project supported private facilities contributed to 27% of the Project’s skilled birth attendance achievement, compared to 23% in the previous quarter.

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In PY3 Q3, there were 21,820 newborns that received immediate post-natal care services in project supported health facilities. This brought the total to 62,051 newborns as at end of PY3Q3, representing an achievement of 92% against the annual target of 66,501. Considered against the 24,146 live births recorded during the reporting quarter, immediate PNC for the newborn was at 90%. The Project has achieved a considerable improvement in PNC coverage attributable to mentorship of HCWs on essential newborn care and utilization of service delivery reporting tools.

The Project reached 8,635 adolescents (10-19 years) with contraceptive services in the reporting period, bringing the total number of adolescents reached with contraceptive services in PY3 to 22,194. This represents an achievement of 72% against the annual target of 31,040. The Project's achievement during this period is attributed to adoption and implementation of a multi-sectoral and combination prevention approach; and co-planning, co-implementation and co-financing of adolescents and young person’s (AYP) interventions with MOH in the project supported counties. During the reporting quarter, implementation of project activities was affected by the COVID-19 pandemic restrictions. The Project co-created with MOH and rolled out toll free lines in Migori, Kakamega and Kitui counties to provide information on health services for adolescents and youth during COVID-19 pandemic period.

During the reporting quarter, through the Project's support, a total of 29,458 children under one year of age were fully immunized. Cumulatively, this increased the number of fully immunized children under one year over the period PY3 Q1 to Q3 to 76,323, against an annual target of 99,688 children. County level coverages were as follows, Kakamega 77%, Kisumu 83%, Migori 85% and Kitui 83%. The Project supported activities responding to emerging challenges such as floods in Kisumu and Migori counties as well as strategic shifts to ensure continuity of services in the background of an ongoing COVID-19 pandemic. In PY3 Q4, the Project will support immunization catch up activities such as targeted outreaches and door-to- door campaigns in specific wards in the context of COVID-19 restrictions. The project will also work towards convincing the counties to channel county resources towards poorly performing sub-counties that are not under direct project support. Sub-optimal performance in immunization in counties without direct project support has continued to weigh down the counties’ coverage as is the case with Kakamega County where the Project supports six out of the 12 sub-counties.

In PY3 Q3, a total of 14,707 child diarrhea cases were reported in Project supported health facilities, out of which 13,929 (95%) cases were appropriately managed with ORS and Zinc. There was a reduction in the reported diarrhea cases from 19,488 in PY3 Q2 to 14,707 in PY3 Q3, a scenario that is attributed to the reduction in clients seeking services due to the COVID-19 containment measures. There were no stock outs of ORS and Zinc co-packs reported in the quarter. The improvement in appropriate management of diarrhea cases is attributed to the IMNCI mentorship activities supported in the focus counties during the quarter.

The Project's focus in nutrition is in the counties of Migori and Kakamega. During PY3 Q3, the Project, through co-implementation with the focus counties, reached 247,379 children under five years of age with nutrition specific interventions, an achievement of 110% against the PPR target of 225,361. In the previous semesters, the Project supported Vitamin A supplementation in Early Years Education (EYE) centers. In the quarter under review, the EYE centers were closed due to the COVID-19 pandemic. The Project therefore co-planned and worked with Migori county to support Vitamin A supplementation at the household level. The household level supplementation, led to the increased coverage as CHVs were able to reach the eligible children. In addition, the Project reached 18,953 pregnant women with nutrition specific interventions at health facility and community levels bringing the total achievement to 50,336. This reflects an achievement of 91% against the project’s PPR target of 55,374. The Project co-planned and co-implemented with the county MOH team a rapid results initiative (RRI) in targeted sub counties to identify and refer ANC

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defaulters. In addition, the Project worked with the MOH teams to develop a data base of pregnant women which was used to conduct follow ups to ensure ANC attendance as scheduled. The Project strengthened the capacity of 153 health facilities to implement IMAM, an increase of 9% from 140 in PY3Q2 period. The Project’s WASH focus remains in Kakamega, Migori and Kitui counties. During the quarter, the Project worked with MOH to verify a total of 57 villages as open defecation free (ODF), enabling a total of 8,452 people to gain access to basic sanitation services. In the subsequent quarter, the Project will work with MOH in the two counties to verify villages that had been identified for CLTS follow ups. The Project supported a total of 15,069 people to gain access to basic drinking water services. This reflects an achievement to date of 133% against the annual target of 11,300. The over-achievement has been due to the Project’s support to repair five boreholes in Kitui, which are located in more populated areas, thus enabling 13,200 to gain access to basic drinking water services. During the quarter, the Project worked with MOH to support minor renovation of five doors’ latrines in the focus counties. In the subsequent quarter, the Project will focus co-support in minor repair of five additional latrines in the target counties. Sub-purpose 2: Increased care seeking and health promoting behavior for FP/RMNCAH, nutrition and WASH The COVID-19 pandemic brought in challenges that led to reduced volume of clients seeking health services in health facilities. To address these barriers, the Project made course adjustments and co-created with the focus county governments to develop guidelines and talking points that were used in various community engagement sessions. These included;  Talking points on AYSRH and SGBV for use by CHVs  Talking points on continuity of services for use by County Health Promotion Officers and other cadres attending radio and TV interviews and carrying out social mobilization using vans mounted with public address systems  Taking points on integrated COVID-19/Malaria for radio that were used during World Malaria Day  FP/RMNCAH, Nutrition and WASH Guide on household visits for CHVs  Strategy document for rollout of the Project co-supported toll-free lines christened “411 Nangos mtaani”.  Mass media strategy for Afya Halisi, which was disseminated to the focus MOH teams and co- support provided Health Promotion Officers in planning for mass media activities.  Development of messages for key health areas to address “Continuity of Services” amid the COVID-19 pandemic. The messages aim at providing correct information on COVID-19 to the public, address myths and misinformation, and create confidence in the public sector healthcare system.

During the reporting period, the Project continued to build capacity and deepen commitment of County Departments of Health and Gender in promoting gender equality and social inclusion as well as sexual and gender based violence (SGBV) prevention and response in FP/RMNCAH, Nutrition and WASH. However, COVID-19 pandemic continued to increase susceptibility of children, women, men and boys to Gender Based Violence and destabilization of related gender norms. In response, the Project co-supported the following activities targeted at mitigating cases of gender violence and strengthening health systems to adequately respond to the emerging cases; formation of the Project Gender Steering Committee, training of HCWs on IPV/SGBV prevention/response, orientation of county and sub county HMTs on gender responsive approaches, site supportive supervision and mentorship on IPV/SGBV screening, documentation and reporting, community dialogues, Gender technical working group (TWG), formation and support of Gender/GBV ward multi-sectorial boards, review of SGBV data and advocacy on data use for decision making, and sensitization of CHAs on SGBV prevention and response.

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Sub-purpose 3: Increased MOH stewardship of key health program service delivery During the reporting quarter, the Project supported the Department of Family Health to develop and disseminate guidelines and tools for continuity of essential services in the context of COVID-19 pandemic. The Project co-supported the Division of Reproductive and Maternal Health to plan for the national MPDSR taskforce meetings in addition to providing online platforms and technical assistance in convening online TWG meetings. In June 2020, the Project supported the Division of Neonatal and Child Health to develop its 2020/2021 annual work plan, a process that involved co-creation of activities in partnership with all child health stakeholders. The Project conducted a co-creation meeting with the Division of Adolescent and School Health and USAID to identify priorities for intervention in the remaining period of the year.

Quantitative Impact

At the core of Afya Halisi’s work is partnering with MOH to track and measure progress in achievement of key health outcomes that demonstrate improvements in health systems and expansion of access to quality FP/RMNCAHN and WASH services to targeted populations in the four focus counties and at national level. As at end of PY3 Q3 period, the Project cumulatively achieved 378,244 couple-years of protection (CYP). This achievement translates to 108,934 unintended pregnancies averted as shown in Figure 1 below. Migori had the highest unintended pregnancies averted at 50,988 while Kakamega, Kisumu and Kitui had a combined unintended pregnancies averted of 57,947 during the period.

Unintended pregnancies averted CYP Pregnancies Averted 64,620 Kakamega 18,611 70,184 Kisumu 20,213 66,400 Kitui 19,123 177,040 Migori 50,988

378,244 Total 108,934 Figure 1. Unintended pregnancies averted in project supported health facilities in PY3Q1-Q3

In the PY3Q1-Q3 period, the Project focus counties achieved 1st ANC visit coverage of 94 percent out of the estimated deliveries; 4th ANC visit coverage was 55 percent, lower than the national 2019/20 target of 80 percent; skilled birth attendance coverage was 71 percent, which was higher than the national 2019/20 target of 70 percent, while coverage for post-natal care within 48-hours for infants was 57 percent, lower than the national 2019/20 target of 90 percent, as shown in Table 1 below. Table 1. MNH coverage in project focus counties, PY3Q1-Q3 Indicator County/coverage Kakamega Kisumu Kitui Migori Project Estimated deliveries 48,400 30,299 27,105 35,532 141,336 Oct 2019 to June 2020 achievement 45,463 30,309 22,579 34,275 132,626 1st ANC Oct 2019 to June 2020 coverage 94% 100% 83% 96% 94% Oct 2019 to June 2020 achievement 28,026 18,025 9,373 21,725 77,149 4th ANC Oct 2019 to June 2020 coverage 58% 59% 35% 61% 55% Skilled birth Oct 2019 to June 2020 achievement 33,102 23,140 15,539 28,696 100,477 attendance Oct 2019 to June 2020 coverage 68% 76% 57% 81% 71% PNC - Oct 2019 to June 2020 achievement 20,291 21,172 13,019 26,268 80,750 infants Oct 2019 to June 2020 coverage 42% 70% 49% 74% 57%

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During the reporting period, the performance of the 1st ANC and 4th ANC coverage indicators were affected by the COVID-19 pandemic. The Project reprogrammed its activities and approaches in order to improve 4 ANC attendance. To improve the PNC coverage, the Project will continue to utilize system-level support and engagements with Kakamega and Kitui CHMTs to strengthen supportive supervision on PNC The Project tracked the average institutional maternal mortality rate (iMMR) in project supported health facilities from 2018 up to PY3 Q3. The average iMMR was 140/100,000 deliveries as at end of the reporting quarter as shown in Figure 2 , having decreased from 209/100,000 deliveries in PY3 Q2 to 175/100,000 deliveries in PY3 Q3 period. At county level, Kisumu county had the highest institutional iMMR at 239/100,000 deliveries and Kakamega had 218/100,000 deliveries in project supported delivery facilities. In Kitui, the iMMR was mainly contributed by Kitui County Referral Hospital, and by Kakamega County Government Teaching and Referral Hospital in Kakamega. The two facilities receive referrals from all the neighboring sub counties.

250 200 209 162 175 150 145 151 119 109 109 122 100 94 50 0 Year 1 Year 1 Year 1 Year 2 Year 2 Year 2 Year 2 Year 3 Year 3 Year 3 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3

MD per 100000 Deliveries 2018 2018 Average MD per 100000 Deliveries 2018

Figure 2. Institutional maternal mortality rate in project supported health facilities, 2018/2020

Afya Halisi has worked with the governments to support the implementation of interventions that target health systems and service delivery towards improving maternal and newborn health outcomes, including; training through mentorship of healthcare workers in emergency obstetric and newborn care (EmONC); quality improvement; infection prevention and control and waste disposal; technical and financial support for maternal and perinatal death review and response; procurement, distribution, and orientation on MNCH equipment and support with human resource for health (HRH) staff. However, these investments seem to yield very slow results. In Kisumu, the Project is advocating for better management of human resources to end the perennial HCW strikes, and improve the regional coordination of care and referral pathways as the county is a strategic healthcare support county for Western Kenya. In all the focus counties, the Project will put efforts in co-supporting the deployment of specialist medical personnel in high comprehensive care facilities, sustenance of supply chain for essential life-saving MNH medicines, and establishment of blood safety systems.

In the PY3Q1-Q3 period, the Project focus counties achieved DPT 3 coverage of 85 percent as shown in Table 2 below. During PY3 Q3, the emergence of COVID-19 pandemic saw the government introduce public health measures targeted at slowing down the spread of the virus. With the resultant reduction in clients seeking immunization services, Afya Halisi supported the counties to put in place measures to ensure continuity of the services across all supported counties. Specifically, the project supported mapping and tracking of immunization defaulters as well as scheduling of immunization visits in a manner that ensured compliance with public health measures for COVID-19 control. In the subsequent quarter, the Project will co-create with the focus county governments to implement immunization catch up activities such as targeted outreaches and door-to-door campaigns in specific wards with a high number of unvaccinated and under vaccinated children.

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Table 2. Immunization coverage in project focus counties, PY3Q1-Q3 Indicator Kakamega Kisumu Kitui Migori Project Estimated under 1 children 47,453 28,840 24,945 34,261 135,499 Oct 2019 to June 2020 achievement 39,390 25,281 19,891 32,525 117,087 DPT 1 Oct 2019 to June 2020 coverage 83% 88% 80% 95% 86% Oct 2019 to June 2020 achievement 38,602 24,226 19,355 32,567 114,750 DPT 3 Oct 2019 to June 2020 coverage 81% 84% 78% 95% 85% Oct 2019 to June 2020 achievement 36,611 23,666 21,109 29,881 111,267 Measles Oct 2019 to June 2020 coverage 77% 82% 85% 87% 82% Oct 2019 to June 2020 achievement 36,723 23,805 20,763 29,131 110,422 FIC Oct 2019 to June 2020 coverage 77% 83% 83% 85% 81%

Attribution of PY3 Q3 results

While Afya Halisi cannot claim full attribution to the results reported in this quarterly report due to the key role played by MOH in oversight and delivery of FP, RMNCAHN and WASH services at health facility and community unit levels in the four focus counties, coupled with support from other implementing partners, the Project has reported results from its supported sub-counties, health facilities and community units due to its support and contributions during the reporting period. During this period, the Project continued to work closely with MOH to co-plan, co-implement and co-review FP/RMNCAHN and WASH activities through provision of technical assistance to strengthen health systems at sub-county, county and national levels and through targeted support to project supported health facilities, community units and communities in the focus counties. During the quarter, the Project provided technical support during stakeholder engagement meetings to review focus counties’ preparedness and response plans to COVID-19 pandemic; the Project provided technical support during virtual dissemination of the national RMNH guidelines on continuity of essential health services to all the focus counties, during the COVID-19 pandemic period; the Project worked with the focus county governments to co-implement a rapid assessment on the impact of COVID-19 pandemic on provision and uptake of RMNCAH services in the focus counties; the Project worked with the county governments to roll out toll free hotlines in Kakamega, Kitui and Migori counties; the Project worked with the focus county governments to co-support the collection of the revised MOH reporting tools from the national Ministry of Health’s stores in Nairobi; the Project supported the training of LIP staff on report writing and proposal development and submission; and the Project co-supported the implementation of the quarterly EmONC assessment in Project supported facilities providing delivery services. Other system level support co-implemented by the Project during the reporting period are outlined below. In Kakamega, the Project co-financed and co-facilitated the co-creation of regulations for operationalization of Kakamega County Health Facility Fund; the Project provided leadership in the roll out of the HPN integrated service delivery model for Kakamega County; the Project co-implemented supportive supervision on integrated supply chain in the focus sub counties; the Project provided technical support during development of the Kakamega County biannual MPDSR report; the Project co-supported Kakamega County to validate its FP costed implementation plan 2020 – 2025; the Project co-supported training of members of health facility management committees on budgeting process and financial accountability; the Project co-supported the Kakamega County EPI targeted supportive supervision visits that were aimed at strengthening provision of immunization and child health services; the Project co- supported training of nurses/midwives and clinical officers on basic obstetric ultrasound; the Project co- supported the standardization of child health mentors in Kakamega County; and the Project co-supported the Kakamega County water, sanitation and hygiene (WASH) stakeholders forum.

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In Kisumu, the Project worked with the Kisumu CHMT to develop the draft road map for domestic resource mobilization from the private sector; the Project held meetings with KOGs to plan for mentorship of HCWs in peripheral facilities; the Project provided technical support during meetings with county and sub county Pharmacists aimed at strengthening supply chain activities at county and sub county levels in Kisumu; the Project provided technical support and worked with Afya Ugavi to co-support the Kisumu County TWG meeting to streamline RHMNCAH/FP commodity security; the Project provided technical support during the FP/RMNCAH and Nutrition score card review meeting at the county level; the Project provided technical support during the dissemination of the Kisumu County Family Planning Costed Implementation Plan to the new County Managers and sub county health management team (SCHMT) members; the Project provided technical support during development of the Kisumu County MPDSR biannual report; and the Project co-supported implementation of quarterly data review meetings in the focus sub counties. In Kitui, the Project co-financed and provided technical support during the drafting of the Kitui County Health Services Bill; the Project co-financed and provided technical support during the Kitui County Adolescents and Youth Multi Sectoral Forum, which was graced by the Kitui County Deputy Governor; the Project provided technical support during the virtual County HRH TWG meeting; the Project provided technical support during the Kitui County MPDSR meeting; the Project provided virtual technical support during the consolidation of the Kitui County AWP for 2020/21; the Project supported MPDSR meetings in private facilities; the Project co-implemented supportive supervision visit and onsite mentorships to CHEWs and CHVs in the focus counties, including distribution of MOH reporting tools to the CUs; the Project co-supported the training of CHVs on infection, prevention and control and universal health coverage in the county, in collaboration with Red Cross and National MOH; and the Project co-supported Specialist-led IMNCI mentorship and supervision activities. In Migori, the Project provided technical support during the Migori County data review meeting, to review performance in the county and establish impact of COVID-19; the Project co-supported the sub county data review meetings; the Project co-supported performance review of RMNCAHN and WASH indicators; the Project co-supported BFCI training for the eight Sub county Community Health Strategy focal persons; the Project conducted mentorship on EmONC clinical simulation in the focus sub counties; the Project co- supported social and behavior change (SBC) technique training for local implementing partners and MOH staff; the Project provided technical support during the County stakeholders meeting to co-create on development of Migori county nutrition factsheet and meeting to plan for roll out of COVID-19 community level activities; the Project co-supported immunization and ANC rapid results initiative in the county; and the Project co-supported inter-county health promotion technical working group meeting to review communication guidelines.

Constraints and Opportunities

Effect of COVID-19 on planned activities: During the reporting quarter, the emergence of COVID-19 pandemic saw the national and focus county governments introduce public health measures targeted at slowing down the spread of the virus. The non-emergency health services were greatly affected by the COVID-19 response measures that were put in place, with some of the health facilities closing out-patient departments or transferring those services to other health facilities to minimize the spread of COVID-19 pandemic. During the initial weeks of the reporting quarter, communal and group activities were halted with counties offering support only for emergency support. A result, the Project reprogrammed its interventions to align to the national and county governments’ regulations on prevention and management of the pandemic. The reprogramming was necessitated to ensure that there is continuity of essential health services to the targeted population. In consultation with the focus county health leaderships, the Project continued with implementation of activities that do not require large gatherings of people, while ensuring adherence to the COVID-19 prevention measures.

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Floods in Kisumu and Migori counties: During the reporting quarter, floods were experienced in parts of Nyando, Muhoroni, Nyakach and Seme sub counties in Kisumu County. The floods affected access to FP/RMNCAH and nutrition services in Komwaga, Kadhiambo, Katolo-Manyatta and Magina dispensaries in the county. In Migori, the floods were experienced in parts of Nyatike Sub County. The areas that were affected included Lwanda Konyango, Kabuto, Angugo, Nyora, Modi, Muhuru and Got Kachola wards. The Project co-implemented, with the county governments, targeted outreaches in the affected areas.

Kisumu HCWs strike: During the reporting quarter, HCWs in Kisumu went on strike to protest delays in salary payment, promotions, and re-designations. The strike affected provision of healthcare services in the county. The strike was resolved through a dispute resolution mediated by the industrial court. The effects of the strike and the public interest occasioned by the strike presented an opportunity for the county government to put in place long term measures to avert subsequent strikes. Through advocacy by Afya Halisi leadership and the County Assembly involvement, the county has initiated a process that will guarantee timely payment of salaries through bank overdrafts and also fast track the process of effecting promotions. These issues have been pending and were contributory factors to the strikes. The new CEC for Health, Prof Boaz Nyunya has identified HRH concerns as a priority issue for his attention to avoid similar situations in the future.

Transitioning of HRH staff to the county governments: During the reporting quarter, the Project provided contracts to only 70% of the HRH staff that were included in the Project's payroll. The other 30% were considered for transitioning by the county governments of Kisumu, Kitui and Migori. Due to various reasons, complete transition of the envisioned 30% of the HRH staff to the county governments’ payrolls did not take place.

Stock out of commodities: During the reporting quarter, the focus counties experienced challenges with commodity stock outs, including FP commodities. Upto 71% of the project supported sites reported stock- out of at least one of the five FP commodities (either of COCs or POPs, IUDs, DMPA, Male condoms, and Implants). This is higher than the 64% stock out reported in PY3Q2 period. The FP commodity that was mostly out of stock during the reporting quarter was male condoms at 43%. During the quarter, the Project supported distribution of 7,100 male condoms to the focus counties which was a donation from DKT. The Project continued with its collaboration with Afya Ugavi to strengthen commodity security and supply chain component of the health system and advocate for the accountability of commodity management with the respective CHMTs.

Subsequent Quarter’s Work Plan

In the subsequent quarter, the Project will co-create, co-plan, and co-implement with the national and focus county governments the following activities with strict observance of the COVID-19 prevention and containment measures;  Co-implement with the national and targeted county governments the COVID-19 response activities.  Work with Kakamega county government and USAID implementing partners to co-implement the HPN integrated work plan.  Advocate with Kitui county government and county assembly for enactment of Kitui County Health Services Bill into law.  Advocate with county governments of Kitui and Migori for operationalization of the operating theatres at Awendo, Migwani, Rongo, and Tseikuru sub county hospitals.  Co-implement the second organizational capacity assessment for ADSE and CSA.  Re-engage members of KOGS to commence mentorship and coaching of HCWs in the peripheral health facilities in Kisumu County.

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 Work with Kisumu county government to expedite re-engagement of the leaderships of Aga Khan Hospital Kisumu and Kisumu County Referral Hospital to conclude signing of the MoU and commencement of the cross-learning initiative.  Co-create with Kisumu county government to finalize and launch the county’s road map for domestic resource mobilization to leverage financial resources for health from the private sector.  Monitor outcomes of toll-free lines in Kisumu, Migori, Kakamega and co-create with the Kitui county government to launch the toll free hot line in the county.  Work with Afya Ugavi to provide targeted small group and structured mentorships on FP commodity management to HCWs.  Work with Kakamega and Migori county MOH teams to verify villages that had been identified for CLTS follow ups, for achievement of open defecation free status.  Support renovation of targeted health facilities upon receipt of approval from USAID KEA.  Co-create with focus county governments to implement immunization catch up activities in wards with high number of unvaccinated and under vaccinated children in the context of COVID-19 restrictions.  Co-support county level review and co-creation meeting for Vitamin A supplementation at household level to ensure sustainability in line with the J2SR principles.  Co-support Gender focal persons to scale up provision of comprehensive post GBV care including follow up of justice outcomes for the survivors.

II. KEY ACHIEVEMENTS (QUALITATIVE IMPACT)

Progress on Journey to Self-Reliance Pillars

Meaningful engagement with LIPs 1. Capacity building of the LIPs During the reporting quarter, the Project continued to engage the local implementing partners (LIPs) on the jointly agreed upon capacity improvement action plans. This was done through follow-up visits, training, and virtual meetings. An initial organizational capacity assessment for the LIPs showed that although their capacities were fairly good, there were gaps in areas such as cash flow analysis, internal auditing, open competition standard in procurement, tracking goods issue, performance improvement process for staff, asset disposal, risk assessment, internal and stakeholder communication, cost-share, and knowledge management. The follow up visits provided an opportunity for the Project to mentor and coach the LIPs on areas that had gaps. In addition, the Project shared requisite templates such as project charters for the LIPs to adopt and use in developing policies, guidelines, and standard operating procedures that they lacked.

Consequently, during the reporting quarter, the Project conducted a second organizational capacity assessment for KMET and LCA to assess progress and changes in the organizational capacity of the LIPs. A similar tool used during the initial organizational capacity assessment was used during the second organizational capacity assessment. The assessment focused on 5 key capacity areas: leadership and governance; finance and administration; human resource; project management and data visualization and communication. For each capacity area, availability of essential documents, implementation of processes and procedures as well as a graduation criterion were assessed. The findings showed significant improvements in the five capacity areas that were assessed for the two LIPs as shown in Figure 3 below. There was also better understanding of the Project’s technical areas and scope of implementation. The second organizational capacity assessment for ADSE and CSA will be conducted in the subsequent quarter.

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120% 97% 100% 100% 95% 91% 89% 100% 84% 82% 81% 80% 70% 60% 40% 20% 0% Leadership and Finance Human Resources Project Data visualisation Governance Management

KMET 1st Assessment KMET 2nd Assessment Lwala Community Alliance 1st Assessment Lwala Community Alliance 2nd Assessment

Figure 3. Organizational capacity assessment results for KMET and Lwala Community Alliance

During the reporting quarter, The Project conducted a virtual training on report writing for the LIP staff based on gaps that were identified in the submitted monthly and quarterly progress narrative reports. This has led to improvements in the quality of narrative reports submitted by the partners, less time spent in review of the reports and reduced turn-around time for reimbursement of funds.

2. Ability to write and submit proposals During the reporting quarter, the Project supported a virtual training on proposal development and submission for the LIP staff. The training, which was facilitated by a representative from the Jhpiego Business Unit, aimed at empowering the LIPs to effectively respond to Request for Application/Request for Proposals from potential donors through the submission of robust and quality proposals. The main areas of interest by participants included the development of capability statements, understanding a call, making the decision to apply, as well as choosing partners for a teaming agreement. The Project will continue to provide tailored support to each of the partners during proposal development and application processes. Some of the LIPs were in the process of developing capability statements and have requested for Jhpiego’s technical inputs.

3. Linkage of the LIPs with Health NGOs Network (HENNET) During the reporting quarter, the Project continued to engage the partners on the importance of HENNET membership. Through the Project’s initiative, ADSE was linked with HENNET for further consultations on membership. CSA was already a member and sits on the board of HENNET at the national level as well as being a member in , Busia, and Nairobi counties. The organization will seek to play a bigger role in Kisumu and Kakamega counties. KMET is a member in Bungoma, Kakamega and Kisumu counties and has started the process for national level membership. Lwala Community Alliance (LCA) is in the process of deciding on membership. Table 3 below summarizes progress made on the J2SR metrics.

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Table 3. Progress on Meaningful engagement with LIPs J2SR Metrics Progress Ability to write and submit Virtual training on proposal development conducted proposals Ability to attract funding To provide tailored TA during proposal development from multiple sources Capacity to provide quality LIPs already implementing health activities at the community level health services as per the LIPs have been sensitized on Afya Halisi processes and procedures scope of work Joint performance review meetings regularly take place Training has been conducted on technical thematic areas Training staff on report writing Organizational capacity assessment completed Action plans for improvement agreed upon and signed Follow up visits on the action plans complete 2nd organizational capacity assessment completed in KMET and LCA Linking partners with LIPs at different stages of membership HENNET

Strengthen coordination and stewardship of county governments to deliver services Afya Halisi’s J2SR roadmap envisions strengthening the counties’ ability to effectively coordinate and manage health programs. As per the approved J2SR roadmap, Afya Halisi Project identified three key deliverables for this objective. Details of the progress made as at end of the reporting quarter is outlined below.

1. Development and operationalization of joint work plans (JWPs) During the previous quarters, Afya Halisi worked closely with the CHMTs in the focus counties of Kakamega, Kisumu, Kitui and Migori to develop their joint work plans. The joint work plans that cover the period of FY 2020, highlight the county priorities in line with their annual work plans, and indicates funding by the government and all stakeholders. The counties committed resources for training and mentorship, supportive supervision, performance review meetings, data quality assessments, and immunization logistics including vaccine distribution. However, due to the COVID-19 pandemic, the focus county governments shifted their focus in mitigating and preventing the surge of the pandemic. The Project continued to co- create, co-plan, co-implement and co-monitor activities with the focus county governments.

2. Co-financing of prioritized activities with county governments Afya Halisi has consistently advocated its focus counties to co-finance implementation of prioritized FP/RMNCAH activities . The Project continued to track and document the in-kind contributions and activities co-financed by the focus county governments. During the quarter under review, the counties co- financed activities amounting to US$96,239, bringing the total to US$262,837 co-financed by the focus county governments as at end of PY3Q3 as shown in Table 4. The counties also conducted activities with funding from the World Bank grant on Transforming Health Systems. These activities included training and mentorship, supportive supervision, performance review meetings, and facility in-charges meetings.

 Operationalization of operating theaters in Kitui County: In Kitui County, Afya Halisi continued to advocate with the county to operationalize the two operation theaters in Tseikuru and Migwani sub-county hospitals that were renovated with funding from USAID KEA. The county government deployed 7 nurses, 2 anesthetists, and 2 doctors together with the necessary commodities and supplies to fully operationalize the theaters to provide comprehensive emergency obstetric and newborn care closer to where women live. The Project will continue to advocate for the operationalization of the theatres in the next quarter as everything is already in place.

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 Operationalization of operating theaters in Migori County: In Migori County, Afya Halisi supported the renovation of Awendo and Rongo sub county hospital operating theaters which were completed and handed over to the county. The Project will continue to advocate the county government to provide equipment and deploy the requisite staff together with commodities and supplies to operationalize the two theaters for comprehensive emergency obstetric and newborn care during the next quarter.

3. Direct funding of county governments for implementation of activities Kakamega County is a frontline USAID/KEA Prosper County that has already signed a multi-sectoral MOU with USAID/KEA and is also one of the three integration pilot counties. Following consultations with USAID KEA, Afya Halisi was advised to discontinue the process of direct funding to the County Government of Kakamega. Instead, AMPATHplus will engage in an agreement with the County Government of Kakamega on direct funding to the county government. Afya Halisi will be among the USAID implementing partners that will support implementation of the Annexes on Health and Water in the county. Table 4 below summarizes progress made on the J2SR metrics. Table 4. Progress on strengthening coordination and stewardship of county governments J2SR Metrics Progress Number of co-designed In FY 20, Afya Halisi in collaboration with other implementing partners work-plans with county supported the development of 4 county level joint work plans (Kisumu, government Migori, Kakamega, Kitui). Visibility of funds  Kisumu County committed US$ 1,155,514 for FP/RMNCAHN services, allocated to health by while Afya Halisi committed US$ 361,007; county governments and  Migori County committed US$ 1,162,556 with US$ 380,000 from Afya other implementing Halisi; Kakamega County committed US$ 1,362,666 with Afya Halisi partners committing US$ 405,192; and Kitui County committed US$ 9,707,830 (amount inclusive of recurrent costs) with the Afya Halisi committing US$ 562,301 Evidence of co-financing The Project is tracking financial and in-kind contribution by counties for by the county implementation of activities. By the end of Q3, the co-financing by the governments counties was as follows; Kisumu US$ 111,684, Kakamega US$ 66,235, Migori – US$ 51,283, and Kitui US$ 33,635. Total US$ 262,837

Engagement of private sector to leverage financial and technical resources for health Despite the persistence of COVID-19 pandemic and the healthcare workers industrial action in Kisumu County during the reporting quarter, the Project continued its efforts to strengthen the capacity of the County Government of Kisumu to reach out to the private sector to supplement county government efforts to deliver health services. The details on progress in private sector engagement as at end of PY3 Q3 are outlined below. Technical coordination, collaborative learning and adaptation 1. Twinning of public and private health facilities for exchange of technical resources During the reporting period, Project supported the co-creation of a draft memorandum of understanding (MoU) for the twinning partnership between Aga Khan Hospital Kisumu (AKHK) and Kisumu County Referral Hospital (KCRH) for the latter to be mentored on technically appropriate and contextual management and clinical aspects of health service delivery. The Project worked with the Kisumu county health leadership to facilitate a consultative meeting between the leaderships of AKHK and KCRH. During the meeting, the two facilities affirmed their intentions to partner together for exchange of technical resources as well as reviewed and refined the draft MoU. However, the MoU could not be signed by the

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leadership of the two facilities due to the need for AKHK to engage further with their governance structures and for identification of specific areas of partnership in priority health departments for both health facilities. These included Obstetrics and Gynecology; Radiology and Diagnostic Imaging; Pathology; Administration; and Support Services. Afya Halisi also supported the co-creation of a SWOT Analysis tool to aid AKHK and KCRH to identify areas of strength and weakness, which will be helpful during the twinning engagement. Due to the COVID- 19 pandemic and HCWs industrial action, KCRH was not able to conduct its SWOT Analysis in time while AKHK received the greenlight to proceed from their Board of Trustees later on and thus did not have adequate time to carry out the SWOT Analysis. The signing of the MoU between AKHK and KCRH therefore did not materialize as had been anticipated. Afya Halisi used this opportunity to co-create cross- learning tools in readiness for implementation of the exchange program between the two facilities. These tools will be useful in documenting best practices and lessons learnt from the cross-learning sessions. In the subsequent quarter, the Project will work with the County to expedite re-engagement of the leaderships of AKHK and KCRH to conclude signing of the MoU and commencement of the cross-learning sessions. 2. Harnessing technical resources from health professional associations Afya Halisi facilitated meaningful engagement between the Kisumu CHMT and local chapters of the health professional associations of Kenya Obstetrical and Gynecological Society (KOGS) and Kenya Pediatrics Association (KPA) to have these two associations play a bigger role in mentoring and coaching health care workers in both public and private sectors to improve the quality of care. In PY3Q2, Afya Halisi co-created with KOGS and the Kisumu government, and identified four (4) KOGS members to pilot the program. The Project worked with KOGS on the modalities of facilitating the members to carry out the activity. In additionally, the Project co-created with KOGS and the Kisumu county government, and identified priority facilities whose HCWs have high need for mentorship and coaching on life-saving skills. These included Ahero County Hospital, Muhoroni Sub-County Hospital, Kombewa Sub- County Hospital and Nyakach Sub-County Hospital. However, the mentorship and coaching program was not implemented due to emergence of the COVID-19 pandemic. In PY3Q3, Afya Halisi regularly engaged the KOGS representatives in Kisumu to discuss the readiness to initiate KOGS mentorship and coaching program. During this time, the Project worked with KOGS to co-create mentorship and coaching tools that will effectively guide in documentation of the mentorship and coaching initiative in the peripheral facilities. At the end of May 2020, the Project conducted a meeting with KOGS consultants where an agreement to start the mentorship and coaching initiative was reached. The Project successfully sought approval to carry out the activity from the Kisumu county government. The project also formed a WhatsApp group for easy communication with the KOGS consultants. However, a HCW industrial action in Kisumu during the reporting period led to postponement of the activity. In the subsequent quarter, the Project will re-engage the KOGS consultants to commence the mentorship and coaching of HCWs in the peripheral facilities. 3. Domestic Resource Mobilization from the Private Sector Afya Halisi has been working with the Kisumu county health leadership to develop a road map to guide the county in domestic resource mobilization from the private sector. During the reporting quarter, the Project built on previous quarter’s work that started during the two-days’ workshop with the Kisumu CHMT to come up with a roadmap. The Project utilized virtual and small group face-to-face meetings of less than 10 participants to accelerate the completion of the roadmap. Using a chapter by chapter development and review approach, the Project co-created with the county government to develop the draft road map. The chapters include; an introduction; situational analysis; resource mobilization strategies; resource mobilization implementation approach; and monitoring and evaluation framework. Afya Halisi also carried out a two-day integrated zoom training for 13 Kisumu county health management team (CHMT) members (8 male, 5 female) and 18 LIP staff (11 male, 7 female) on proposal writing and how to respond to funding opportunities. The objective of training was to introduce the CHMT to United

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States funding opportunities, impart skills on improving preparedness to respond to calls for proposals and effective response to available calls for concept and proposal applications. In the subsequent quarter, the Project will support finalization of the road map and focus on strengthening the capacity of the CHMT in developing and submitting concept notes and proposals. A summary of the progress of the J2SR metrics is presented in Table 5 below.

Table 5. Progress on Engagement of private sector to leverage resources for health J2SR Metrics Progress Pairing of Aga Khan Hospital Kisumu and Kisumu CRH for cross-learning Memorandum of Aga Khan Hospital Kisumu and Kisumu County Referral Hospital leadership understanding between engaged by AH independently for buy-in and support the twinning Aga Khan Hospital Kisumu Engagement of the county health leadership on this activity despite the frequent and Kisumu County changes in office holders Referral Hospital Draft MoU developed, reviewed and refined into a Kisumu County format AGHK and KCRH leadership meeting to deliberate on MoU contents - Agreement on most elements of the MoU except on specific areas of partnership in specified departments. MoU signing meeting deferred due to the need for Aga Khan Hospital to consult their governance structures, and due to HCWs industrial action affecting identification of specific areas of partnership in KCRH Call for the facilities’ leadership meeting once HCWs strike ends Harnessing technical resources from the professional associations County roadmap of Leadership of KOGS and KPA engaged for buy-in engagement with Meetings between KOGS and KPA and Afya Halisi conducted and county health professional associations leadership updated. KOGS agreed to pilot the mentorship and coaching program for HCWs in health facilities that have been jointly identified based on need. KOGS identified four (4) consultants to lead the first phase of mentorship and coaching and the modalities of facilitation agreed upon with Afya Halisi and the county health leadership. Mentorship and coaching program deferred as a result of COVIS-19 pandemic and HCWs industrial action. This will take off within the remaining period of this year County government, AH and KOGS will co-create formal structure for engagement with the county after generation of evidence from pilot mentorship and coaching. Resource Mobilization County roadmap for Buy-in from the County Department for Health leadership sought domestic resource Focal person for resource mobilization engaged for input into the process mobilization A resource mobilization team identified from existing CHMT (Disbanded in PY3Q2 as a result of change in leadership) A new team installed after appointment of a new CHMT and oriented 5-day workshop planned to deliver a resource mobilization roadmap but was canceled on day 2 due to COVID-19 pandemic. Zoom meetings and small group (less than 10) face-to-face meetings utilized to work on the roadmap focusing on chapter by chapter approach First draft of the Kisumu County Resource Mobilization Roadmap developed The first draft will undergo content review, editing, design, production and will be launched by the Kisumu Department of Health in PY3Q4 Implementation of the roadmap to begin in August 2020 Number of concept notes Zoom training on “Responding to calls for proposals” done. submitted to private sector Hands-on training on concept development and proposal writing to be done in players the remaining period of the year Number of concept noted Submission of concept notes and proposals to identified resource providers to be funded by private sector done in the remaining part of the year

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County forums convened To be carried out once COVID-19 situation allows meetings of more than 20 by the Kisumu County participants to be held Governor to engage private sector players

Enhance social accountability across all levels During the reporting quarter, the Project focused on strengthening capacity of selected local community based organizations to spearhead social accountability activities at the community level. The Project also continued to empower health facility management committees to put in place redress mechanisms that community members can utilize and inform community members of the services that are available at each health facility. In addition, community members were engaged using the community scorecard to voice their expectations of health services provided at the health facilities. Details of the progress made so far are outlined below;

1. Promoting citizen monitoring of facility performance During the reporting quarter, the Project supported targeted communities and health facilities on use of the community scorecard to advance social accountability, participation, transparency, and accountability in the During scorecard feedback meeting held at delivery of health services. The Project supported one Eshinutsa Health Center in Kakamega County, community and one health facility scorecard session in the discussions revealed that significant Migori as well as an interface session in Kitui. In progress had been made in addressing Kakamega, the Project supported a scorecard feedback challenges that were highlighted by the meeting held at Eshinutsa Health Center to review the community during the interface session. There action plans that were developed during the interface was consensus that staff attitude had improved leading to more clients seeking services at the meeting in PY3Q1. A total of 18 individuals (12 male, 6 facility after the interface sessions; the facility female) drawn from the facility management committee, had started to provide 24-hour services after facility in-charge, community CHA, Sub-county MOH, RH employment of 2 additional HCWs; there was coordinator, and six community members participated. provision of free laboratory services for ANC profiles and free removal of FP implants. These In Migori, the Project supported the sensitization of the services were previously being charged. CHMT on the community scorecard process reaching 28 Condom dispensers were placed at strategic participants (18 male, 10 female). In addition, one points within the facility for people to easily community and one facility session were held at Bware access as well as the facility’s gate was being Health Centre. The interface session will be held in the opened early. subsequent quarter.

In Kitui, an interface session was held at Mutito Sub-county Hospital with 17 participants (7 males, 10 females) in attendance. The community and facility teams developed a joint work plan. The work plan had short term resolutions that did not require many resources and long term resolutions that needed to be financed. The immediate actions included communicating to the community members on the ambulance services; purchase of vouchers for laboratory reagents; purchase of x-ray machine within 6 months; commodity monitoring for timely restocking; and request for mosquito nets from the sub-county.

2. Creating a critical mass of local organizations During the reporting quarter, the Project worked with the county governments to select 10 local community based organizations (CBOs) from a pool of 28 CBOs in Kakamega and in Migori, 8 CBOs were selected from the 57 CBOs that had been mapped. A criteria was developed to guide in the selection of the CBOs. The key areas that were considered included; strength in community health involvement, participation in community advocacy, financial control systems, and a record of collaboration with communities within their catchment areas. In addition, gender diversity, youth and adolescent involvement, as well as the inclusion of people living with disabilities were also considered. The selected CBOs showed great interest

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and enthusiasm in working with the communities to roll-out social accountability activities. The Project supported the training of 90 community social accountability facilitators (50 male, 40 female) on use of the community scorecard. The facilitators are expected to work with the health facility management committees to advocate for improved quality of care, promote establishment of grievance redress mechanisms at the health facilities, promote community participation in the annual budgetary process, and advocate the communities to have a collective voice and demand for better performance at health facility, ward and county government levels.

3. Strengthening oversight and accountability of facilities and hospitals During the reporting quarter, the Project continued to strengthen the capacity of health facility management committees (HFMCs) to improve their functionality and optimize service delivery. In Migori, the Project supported the training of 8 HFMCs reaching 96 committee members (41 male, 55 female). Three (3) out of the 4 HFMCs that were trained in the previous quarter had put in place grievance and redress mechanisms to enable community members to provide feedback aimed improving service delivery in the facilities. The HFMCs also tracked resource allocation during the fiscal year 2020/21 budgeting process and showed commitment to follow through the process to ensure prudent allocation of resources to their facilities. A summary of the progress on the J2SR metrics to-date is presented in Table 6 below.

Table 6. Progress on Enhancing Social Accountability J2SR metrics Progress Number of functional health • Jointly mapped out 164 health facility committees facility management • Co-facilitated and co-financed training for 19 HFMCs (Kakamega – 15, Migori- committees or hospital 4) boards as defined by • Co-financed and co-facilitated quarterly review meetings for 10 HFMCs (3 in government statutes Kakamega and 7 in Migori) Number of facilities with • 3 out of 4 HFMCs have put in place grievance and redress mechanism grievance and redress structures. Some facilities have placed suggestion boxes at strategic points mechanisms Number of facilities with • Trained community facilitators on implementation of community scorecard health facility management • At different stages in 6 facilities (1 each in Kakamega and Kitui; & 2 each in committees that develop Kisumu and Migori and utilize community • Use of community scorecard with community members completed in 4 participation tools facilities • Use of community scorecard with HCWs completed in 3 facilities • 2 interface sessions completed (Kakamega-1, Kitui -1) • 10 CBOs in Migori and 8 in Kakamega selected and capacity assessment done. • Trained 90 CBO facilitators on social accountability Number of communities • Co-facilitated participation of key community champions in Kisumu, Kakamega, actively participating in the and Migori in public participation forums for county fiscal budgets for budgetary process FY2020/21

Health systems strengthening by addressing the WHO building blocks 1. Human resources for health (HRH)

Transitioning of the contracted HRH to county government employment as per the letters of agreement The Project continued to advocate the county governments, up to the highest levels of leadership, to absorb 30% of the HRH staff into their payroll in FY 2020/21. In June 2020, the Project provided contracts to only 70% of the HRH staff that were included in the Project's payroll. The other 30% were considered for transitioning by the county governments of Kisumu, Kitui and Migori. The county governments of Kisumu and Migori absorbed 2 HRH staff each, and the other HRH staff were not considered based on the appraisal results that were done jointly with the county governments.

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Increasing efficiencies of existing HRH The Project continues to advocate with counties to regularly utilize the WHO workload indicator of staffing needs (WISN) tool for mapping of existing health care workers in all facilities to enable rationalization of existing human resource in Migori, Kisumu and Kakamega counties. The WISN tool has provided objective ways of addressing mal-deployment of HRH by improving rationalization and deployment to the appropriate service areas, and enhancing accountability and motivation of HRH. A summary of the progress of the J2SR metrics is indicated Table 7 below.

Table 7: Progress on Human resources for health J2SR Metrics Progress Evidence of absorption of In Kisumu, Kitui and Migori counties, the Project successfully conducted joint 30% of the supported HRH advocacy sessions with senior county government leadership including the CDH, staff COH, Health CEC Member, Governor, and the Chairman of the Health Committee at the County Assembly resulting in the commitment by each to absorb 30% of the HRH by July 2020. Due to various reasons, complete transition of the envisioned 30% of the HRH staff to the county governments’ payrolls did not take place. Counties utilizing the WHO The Project continued to engage the counties to implement action plans that were workload indicators of generated in collaboration with the HRH mechanism during the dissemination of staffing needs (WISN) tool the WISN assessment results. Kakamega county committed to expand use of to rationalize deployment of WISN tool to all health facilities to inform staffing norms and the rationalization staff was interrupted by the advent of the COVID-19 pandemic. Migori County has continued to expanded use of the tool to additional health facilities as a result of sustained advocacy efforts. The plan by Kitui County to conduct its WISN assessment during reporting quarter was interrupted by the COVID-19 pandemic. Afya Halisi will continue to collaborate with HRH Kenya to provide the necessary technical support during the exercise.

2. Healthcare financing Empanelment into NHIF, timely reimbursement of funds and improved budgeting for reimbursed funds continues to be priorities of most private health facilities as they strengthen revenue generation. Building on identified challenges in PY3Q2 which included capitation delays, reimbursement delays, protracted approval of pre-operative health services, lower allocations for cesarean sections, long periods NHIF takes to notify hospitals of any adjustments, and exclusion of some facilities in NHIF training among others, Afya Halisi co-supported sensitization of 40 health facility managers (16 male, 24 female) on the process of registration of Linda Mama, making claims, budgeting for Linda Mama and NHIF reimbursements, general financial management and when to follow up in case of delays and complication at different times. Twenty two of the managers (9 male, 13 female) were drawn from 22 private facilities in Migori County while 16 health care managers (5 male, 11 female) were from 14 private health facilities in Kisumu County. As a result of this sensitization, health facility managers were equipped with knowledge and skills leading to improved capacity to manage reimbursements claims and allocate resources appropriately. During the quarter, Afya Halisi also supported efforts to empanel private facilities into NHIF and Linda Mama. Based on an assessment that was conducted in PY3Q2, 14 private facilities in Kisumu County and 18 private facilities in Migori County neither had NHIF nor Linda Mama. During the reporting quarter, the Project followed up with Migori County NHIF Office on the status of seven (7) private health facilities that had applied for empanelment but had not received any feedback. As a result of this follow up, four (4) of the seven (7) facilities were gazzetted and signed contracts with NHIF. However, the Project experienced challenges in supporting facilities that were initiating engagements with NHIF. There was confusion in responsibility for empanelment of health facilities into NHIF between NHIF agency and the Kenya Health Professionals Oversight Authority (KHPOA) as created by Health Laws (Amendment) Act, 2019. The Project sought clarity from KHPOA where it was informed that KHPOA does the preliminary assessments

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and categorization of facilities by levels. Any facility accredited by KHPOA is entitled for NHIF accreditation but must be validated by NHIF. However, NHIF is of the opinion that KHPOA should do the preliminary assessments and validations for NHIF accreditation. In PY3Q4, Afya Halisi will continue engagements with NHIF and KHPOA. Afya Halisi will work with the County to support empanelment of facilities requiring NHIF accreditation. In Migori, the regulations to operationalize the County Health Service Act that was co-facilitated and co- financed by Afya Halisi was finalized and printed by the government printer. The Health Services Act has a section that describes the mobilization and utilization of health funds. The Project supported the County Government of Kitui through a co-creation, co-planning and co-financing process to finalize the Kitui Health Services Bill that has sections that stipulate the generation and utilization and ring-fencing of health services funds; implementation of the Community Health Strategy, including the role and utilization of CHVs; and the Health Products Technology Unit. In Kisumu, the Project co-supported the county to develop a draft road for domestic resource mobilization from the private sector. The draft road map is undergoing review and will be launched in the subsequent quarter. 3. Leadership and Governance Capacity of C/SCHMTs During the quarter, Afya Halisi continued to build on earlier advocacy initiatives directed at the MOH leadership in the four focus counties to strengthen planning and coordination for effective delivery of quality services. The Project supported the counties to lead the process of developing of joint work plans, including all implementing partners. Afya Halisi has consistently engaged the county leadership on the various advocacy agenda. The progress of the various advocacy agenda is shown in Table 8 below.

Table 8. Progress on Advocacy agenda County Advocacy Agenda Progress Kitui Reinstatement of the The Project co-facilitated and co-financed a workshop bringing community program as per the County Assembly Health Committee, the County MOH national policies and guidelines leadership and a team of lawyers (The County Assembly legal for implementation of the advisor, the Kitui County Legal Officer and a consultant lawyer) Community Health Strategy to harmonize the various clauses in the Kitui County Health and having it anchored in an Services bill. The Project supported the county to integrate appropriate county law. community health services into the Bill. Once enacted into county law, it will protect the community health platform against the cyclical changes in political leadership. The bill also has provisions on the health services fund and the Health products and technologies unit. The draft bill is now with the county executive for approval and submission to the County Assembly. Absorption of contracted Despite the county government’s commitment to absorb 30% of HRH hires by the county the HRH staff, that was not possible. However, the Project government. transitioned 30% of the HRH staff from July 2020. Migori Development of UHC In PY3Q2, through regular discussions with the Migori county implementation policy and health leadership, it became apparent that operationalizing the framework. Health Services Act was the county’s immediate priority. Consequently, the Project co-financed and co-facilitated development of regulations to operationalize the County Health Services Act that had been enacted in November 2019.The regulations were approved by the county assembly and printed by the Government printer. Kisumu Domestic resource The Project worked with the Kisumu CHMT to develop the mobilization from the private draft road map for domestic resource mobilization from the sector for health care private sector. The road map is undergoing review and will be financing. launched in the next quarter.

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County Advocacy Agenda Progress Kakamega Finalization of the The Project co-financed and co-facilitated the co-creation development of the Health Bill meetings to develop regulations for operationalization of Kakamega County Health Facility Fund.

4. Health Management Information System for Effective Use of Data During the reporting quarter, the Project collaborated with Tupime Kaunti to generate a fact sheet for Migori County that showed performance trends in key health indicators and priority actions to address the key gaps. During the previous quarter, the Project collaborated with Tupime Kaunti in generating a quarterly bulletin for Kisumu County that demonstrates progress in key FP/RMNCAH indicators and recommended responsive actions to accelerating improvement in performance. The Project co-developed ward level RMNCAH scorecards for Kisumu County. These scorecards were used during a consultative meeting between the County Health Executive, the County Assembly and members of the County Public Service Board to advocate with the Kisumu County Members of Assembly for increased resource allocation for RMNCAH services, especially for wards with low coverage performance in key FP/RMNCAH indicators.

Afya Halisi will continuously create knowledge sharing events to bring together counties to share best practices. The Project will continue to work with Tupime Kaunti and county MOH teams to develop bulletins that will show progression of county performance in key FP/RMNCAH, nutrition and WASH indicators during the COVID-19 pandemic period, and key actions required to ensure continuity in service provision.

5. Increased Access to Essential Medicines and Products During the quarter, the Project continued to advocate to the counties to prioritize their budgeting to include making payment of all unpaid KEMSA bills to minimize interruption of supplies of essential medicines, health products and technologies, including FP commodities. This advocacy initiative resulted in Kisumu county even buying essential medicines from the open market when KEMSA did not have life-saving medicines like Oxytocin in stock. The four counties are currently paying their bills to KEMSA on schedule. The Project continued to work with the counties on improving the supply chain system that has been catalyzed by the introduction of the integrated supply chain management approach, towards improvement of security of essential lifesaving commodities and supplies including those for family planning, maternal and newborn health and vaccines. However, the counties still experienced stock outs of commodities and supplies at the point of use at different times. During the quarter under review, the Project collaborated with Afya Ugavi to build the capacity of staff/pharmacists on commodity security and pharmacovigilance. The progress of the engagements with the county governments is shown in Table 9 below.

Table 9. Progress on Increased Access to Essential Medicines and Products J2SR Metrics Progress Number of facilities During the quarter under review. The Project has consistently engaged the senior county reporting zero stock- leaderships, up to the Governor level, to pay their debts to KEMSA to allow them out of essential minimize stock out of essential drugs and commodities. This advocacy has resulted in the commodities counties being able to reduce their debts to an extent they now have regular supplies of essential medicines and commodities.

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

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

Family Planning

During the reporting quarter, the Project achieved a couple years protection (CYP) of 121,111, bringing the total year-to-date CYP performance to 378,244. This reflects an achievement of 62% against the annual target of 609,815 as shown in Figure 4 below. During the quarter, the Project supported provision of family planning services in 641 health facilities across the four supported counties, an increase by 27 facilities after the Project's expansion into Butere, Lurambi, and Mumias East sub-counties in Kakamega county. At the county level, Migori achieved 79% of the county’s CYP target, Kisumu was at 58% while Kitui achieved 50% of the county’s CYP target. Kakamega added 22,515 CYP to reach 48% of the county’s annual target. Despite the initial disruptions after the confirmation of COVID-19 in Kenya in March 2020, the Project co-created and co-implemented prioritized activities to ensure minimal disruptions in family planning and other essential MNCH services. The Project supported the development and dissemination of Reproductive and Maternal, Newborn, and Family Planning services guidelines during the COVID-19 pandemic. The dissemination meetings were held through virtual platforms and small group sessions in line with COVID-19 public health protocols.

700,000 100% 600,000 79% 80% 500,000 378,24462% 400,000 58% 60% 48% 51% 300,000 40% 177,040 200,000 20% 100,000 64,620 70,184 66,400 - 0% Kakamega Kisumu Kitui Migori Project

Y3 target Y3Q1-Y3Q3 achievement % achievement

Figure 4: CYP achievement by County, PY3Q1-Q3

In PY3 Q3, the Project worked with 133 private health facilities, representing a fifth of all the supported health facilities. With the exception of the catholic affiliated facilities, the Project continued to build capacity of the SCHMTs to provide supportive supervision to the private facilities and offer expanded FP services. The private facilities have been critical in providing key services and filling in service gaps especially during disruptions in health services in the public sector due to HCWs strikes. During the quarter, the private facilities achieved a CYP of 14,139, an increase of 11% compared to the private facilities’ CYP achievement of 12,786 in PY3 Q2 period. The facilities contributed to 12% of the Project’s CYP

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achievement in the reporting period as shown in Figure 5 below. Kisumu had the highest contribution at 17%, Kitui at 14% while private facilities in Migori and Kakamega contributed to 11% and 5% respectively.

140,000 18% 17% 120,000 16% 14% 14% 100,000 11% 12% 12% 80,000 10% 60,000 8% 6% 40,000 5% 14,139 4% 20,000 1,129 3,750 2,752 6,508 2% - 0% Kakamega Kisumu Kitui Migori Project

Project Y3Q3 results Private sector Y3Q3 results % Private sector contribution

Figure 5. Private sector contribution in CYP achievement by County, PY3Q3

Specific activities in the counties are outlined in the following sub-sections.

Expanding access to high quality FP services In Kakamega, the Project supported mentorship on Long Acting Reversible Contraception (LARC) and Postpartum family planning (PPFP) in 11 health facilities, contraceptive technology updates on the administration of subcutaneous depot medroxyprogesterone acetate (DMPA-SC) to HCWs in the facilities, and voluntary surgical contraception (VSC) clinics that reached 14 clients, including 3 male vasectomy. The Project did not support outreach VSC activities during the reporting quarter in line with the national RMNCH guidelines on continuity of essential services during the COVID-19 pandemic. In Kisumu, the Project supported mentorship of 89 HCWs from 56 health facilities on PPFP while 12 outreaches were conducted to reach displaced communities affected by floods during the reporting quarter. In Kitui, the Project continued to support mentorships on PPFP with more focus on Postpartum Intrauterine Contraceptive Device (PPIUD) which requires extra mentorship and practice to establish proficiency among service providers in the county. In Migori, the county government-supported training of 40 recently recruited HCWs on family planning with the Project facilitating post-training follow up. The Project also supported 12 in-reaches in Nyatike, Kuria East and Kuria West sub-counties. The three sub-counties have the most under-served population.

FP commodity management In PY3 Q3, the Project did not conduct training on commodity management as the Project had already frontloaded training of the HCWs in commodity management and reached 595 HCWs (233 male, 362 female) in year 1 and 251 HCWs (102 male, 149 female) in year 2. During the quarter, the Project worked with the USAID supply chain systems support mechanism (Afya Ugavi) to conduct an assessment of HCWs' capacity needs on commodity management in Kitui County. In the next quarter, the Project will work with Afya Ugavi to provide targeted small group and structured mentorships to the HCWs, while adhering to the government's public health guidelines on continuity of essential health services during the COVID-19 pandemic period.

The stock out of FP commodities remains a critical system-level gap in the focus counties. In the reporting period, 71% of the project supported sites reported stock-out of at least one of the five FP commodities (either of Combined oral contraceptive or Progestogen-only pills, Intrauterine device, Depot-

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medroxyprogesterone acetate (DMPA), Male condoms, and Implants). This is higher than the 64% stock out reported in the PY3 Q2 period. At the county level, the stock out of at least one of the five FP commodities was highest in Kakamega at 87%, Kitui at 82%, Kisumu at 79%, and Migori at 42%. The FP commodity that was mostly out of stock during the reporting quarter was male condoms at 43%. During the quarter, the Project supported distribution of 7,100 male condoms to the focus counties which was a donation from DKT. The Project continued with its collaboration with Afya Ugavi to strengthen commodity security and supply chain component of the health system and advocate for the accountability of commodity management with the respective county health management teams (CHMTs). Afya Ugavi has been supporting Health Products and Technologies Units in the four counties whose mandate is to ensure consistency in-stock availability.

Immediate Post-Pregnancy Family Planning The provision of immediate PPFP is now part of essential post-partum care in health facilities with delivery and family planning services. Past USAID support with the right equipment and continuous mentorship on competency skills by the Project has resulted in increased access and reduced opportunities for FP services. In the reporting period, Afya Halisi facilitated the sub-county mentors to conduct LARC and immediate PPFP mentorship in 54 private health facilities in Migori and Kisumu counties reaching 192 HCWs.

Family Planning Advocacy The Project facilitated the development of county action plans, a process that had been disrupted following government restrictions on movement and congregated events. The Project notes the risk posed by COVID- 19 that could affect government investment in FP funds and fundamentally change women’s contraceptive use. In the reporting period, the Project facilitated virtual dissemination of the Ministry of Health guidelines on service continuity in the four counties. In the same period, Afya Halisi printed and facilitated the distribution of Kenya RMNH COVID-19 Guidelines in the four counties. The Project will collaborate with advocacy groups on safeguarding investments in family planning as the impact of COVID-19 pandemic on the economy is likely to alter government investments in healthcare. Family Planning Quality of Care In PY3 Q3, the Project co-supported the training of 183 health care workers (49 male, 134 female) in different FP/RH modules bringing the total to 376 (91 male, 285 female). This reflects an achievement of 38% of the annual target of 1,000. The Project's approach is to ensure counties have the internal capacity to conduct the training with no support from the national government, except for periodic quality assurance purposes. In Kakamega, during the reporting quarter, the Project expanded its support to the larger Lurambi, Mumias East and Butere sub-counties and supported the training of 71 HCWs in FP/RH based on identified gaps. The Project also trained 59 HCWs in Kisumu while Kitui and Migori had 41 and 12 HCWs trained. As it has been in PY3 implementation, the training is meant to fill recurrent service delivery gaps since the Project had front loaded technical training of HCWs in the first two years of implementation. In Kakamega, the FP/RH technical updates were focused on the roll-out of subcutaneous DMPA and on-site mentorship on post-partum IUD. The Project supported refresher training of HCWs on LARC in both Kitui and Kisumu while the focus in Migori was on post-pregnancy FP. Recognizing the need to maintain RH- FP services as essential services even as counties focus their efforts in the response to the COVID-19 pandemic, the Project will work with the focus county governments to reach the target through refresher training and targeted mentorships, through mentors that were developed in the first two years.

FP Compliance to USG Requirements There was no reported violation of US abortion and FP requirements in the reporting period. The Project continues to provide reminders to the local implementing partners on these provisions. Emphasis was put on the client’s right to informed choice, voluntarism, and privacy during FP mentorships, project review meetings, and on-site during support supervision.

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Maternal and Newborn Health

The Project anticipated disruptions in maternal and newborn health services following the confirmation of COVID-19 in Kenya in March 2020. The impact of containment and public health policies on COVID-19 pandemic was feared to be more pronounced in maternal and newborn health services. In the reporting period, the government instituted restrictions on travel and gatherings while health facilities that had limited infection prevention and control practices and required supplies reduced or completely ceased offering maternal and newborn services. In the reporting quarter, the Project focused on ensuring continuity of MNH services in the four focus counties. These processes involved joint-designation of care including provision of technical guidance on service continuation with the national, and focus county governments.

The specific activities in the reporting period are outlined in the following sub-sections.

Access to Essential MNH Care Even with the disruptions caused by the COVID-19 pandemic, more than 95% of women in the four counties attended at least one ANC visit, the gap remains in the timing of these visits where most of the women start ANC in second or even in the third trimester. During the initial weeks of the reporting quarter, communal and group activities were halted due to COVID-19 with counties offering support only for emergency services. During the reporting quarter, the Project reprogrammed its activities to respond to the COVID-19 pandemic period. The Project continued to focus on community initiatives for early ANC attendance and improving the quality of the first ANC visits. Some of the community activities included household visits, social-behavior change messaging, and mapping and tracking of pregnant women by CHWs.

In PY3 Q3, the Project reached 18,614 women to attend 4 ANC visits, bringing the year-to-date total to 51,346. This reflects the achievement of 70% of the Project's target as shown in Figure 6 below.

80,000 100% 70,000 88% 80% 60,000 70% 65% 50,000 62% 60% 40,000 54% 30,000 40% 20,000 20% 10,000 - 0% Kakamega Kisumu Kitui Migori Project

Y3 Target Y3Q1-Y3Q3 Achievement % Achievement

Figure 6. 4th ANC visit achievement by County, PY3Q1-Q3

The average 4th ANC coverage during the reporting period was 55%, a slight improvement from the coverage of 52% as at end of SAPR 2020 period as shown in Figure 7 below. At county level, Kakamega improved from 55% at the end of PY3 Q2 to 58%, Kisumu slightly improved from 57% to 59% in PY3 Q3 and Kitui improved from 32% to 35% in PY3 Q3. The coverage for 4 ANC visits in Migori improved by 3 percentage points to 61% in the reporting period.

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160,000 70% 140,000 61% 58% 59% 60% 55% 120,000 50% 100,000 40% 80,000 35% 30% 60,000 40,000 20% 20,000 10% - 0% Kakamega Kisumu Kitui Migori Project

Estimated deliveries 4th ANC achievement 4th ANC coverage

Figure 7. 4 ANC visit coverage by County, PY3Q1-Q3 period

The non-emergency services were greatly affected by COVID-19 response measures, with some of the health facilities closing out-patients’ departments or transferring those services to other health facilities to minimize the spread of COVID-19 pandemic. More understanding of COVID-19 preventive measures resulted in the modification of approaches to improve 4 ANC attendance. In all the counties, the Project supported community mapping of pregnant women and health promotion activities in the flood-affected areas in Kisumu and Migori counties. The Project also supported group centered care in Kakamega and Migori counties with modification on the number of participants to align to the required physical distancing amid COVID-19. In Kitui, the project supported crucial activities to ensure continuity of MNH services including support for roving laboratory technologists who went around health facilities to do ANC profiles, the orientation of HCWs on IPC, orientation of HCWs on Linda Mama healthcare financing and minor repairs of maternity shelters in two health facilities for privacy in promotion of respectful maternity care. The support for roving medical laboratory technologists in Kitui resulted in 188 pregnant women receiving essential ante-natal laboratory investigations in 9 health facilities during the reporting quarter.

During the reporting period, 24,585 births were conducted at health facilities supported by Afya Halisi across the four focus counties, bringing the total to 70,967 as at end of PY3Q3 period. This reflects an achievement of 101% against the annual target of 70,002 as shown in Figure 8 below. At the county level, Migori had the highest contribution to the performance with 9,230 births, Kisumu with 5,859, Kakamega with 5,035, and Kitui with 4,461 births with skilled care during the reporting quarter. As much as this performance indicates achievement of overall Project target, the Project continued to work with counties to increase coverage for skilled care at birth.

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80,000 140% 70,000 121% 120% 60,000 100% 101% 101% 100% 50,000 82% 80% 40,000 60% 30,000 20,000 40% 10,000 20% - 0% Kakamega Kisumu Kitui Migori Project

Y3 Target Y3Q1-Y3Q3 Achievement % Achievement

Figure 8. Skilled birth attendance performance by County, PY3Q1-Q3

Overall coverage for skilled birth attendance at the end of PY3 Q3 was 71%, up from 68% as at end of SAPR 2020 period as shown in Figure 9 below. This is above the national skilled birth attendance target of 70% for 2020. Migori consistently reported high SBA with a coverage of 81% with Kitui reporting an all-time high of 57%. Kakamega and Kisumu had SBA coverage of 68% and 76% respectively. Healthcare workers strike in Kisumu disrupted activities in the county, compounding the effects of COVID-19 on the healthcare system. The Project also effected the transition of 30% of HCWs supported by USAID in Kisumu, Kitui and Migori during the reporting quarter, albeit with difficulties.

150,000 100%

76% 81% 80% 100,000 68% 71% 57% 60% 40% 50,000 20%

0 0% Kakamega Kisumu Kitui Migori Project

Estimated deliveries SBA achievement SBA coverage

Figure 9: Skilled birth attendance coverage by County, PY3Q1-Q3

The disruptions by COVID-19 did not significantly affect skilled birth attendance coverage as concerted efforts were made by counties and stakeholders to ensure continuity of essential health services. These activities included mapping of pregnant women using the community health structures, phone call follow- up and teleconsultation services, provision of curfew passes in all the four focus counties for use by expectant pregnant mothers and taxi drivers or boda boda riders at night during the curfew hours, roll-out of the toll-free helpline in Kisumu, Kakamega and Migori counties. The toll-free lines will also be rolled out in Kitui in the PY3 Q4 period as a long term initiative to allow for phone-based consultation services, especially targeting adolescents and youth with information on sexual and reproductive health services.

In addition, during the reporting quarter, the Project trained an additional 431 HCWs on MNH, through structured on-site mentorships. This brought the total to 653 HCWs trained in MNH as at end of PY3 Q3,

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reflecting an achievement of 71% against the annual target. The Project reached 289 HCWs in Migori with different technical modules including basic Ultrasonography, helping babies breathe, and management of postpartum hemorrhage (PPH). In Kakamega, 74 HCWs were trained on ultrasound and essential newborn care using the national training modules. The Project supported skill-based mentorship sessions on newborn resuscitation, PPH, and assisted vaginal delivery in Kitui and reached 58 HCWs including staff from the private sector. In Kisumu, the Project trained 10 HCWs on the use of the ultrasound, a continuation of similar support that started in PY2.

The Project continued to facilitate capacity strengthening efforts targeted at private facilities. In the reporting period, Afya Halisi facilitated skills drills in 8 private health facilities (identified based on adverse maternal and perinatal outcomes data) in 5 sub-counties in Migori reaching 35 HCWs (13 male, 22 female) on the management of postpartum hemorrhage (PPH), helping babies’ breath (HBB) and management of severe pre-eclampsia using PPH bundles approach. In PY3 Q3, the healthcare services in Kisumu were disrupted over healthcare workers strike which affected service provision. To mitigate the effects of the industrial actions in Kisumu, the Project's supported staff continued to offer emergency services and augmented service provision in private health facilities. During the reporting quarter, the Project supported private facilities contributed to 42% of all the deliveries in Kisumu county compared to 35% in PY3 Q2 and a 27% overall contribution at project level in PY3 Q3 compared to 23% in PY3 Q2 period as shown in Figure 10 below. The COVID-19 pandemic also contributed to an increase in the contribution of the private health facilities as expectant mothers shied away from seeking skilled delivery services from public health facilities given that some of the public health facilities had been earmarked as isolation and quarantine centers for positive and suspected COVID-19 cases.

30,000 50%

25,000 42% 40% 20,000 29% 30% 15,000 27% 27% 20% 10,000 5,000 8% 10% - 0% Kakamega Kisumu Kitui Migori Project

Project Y3Q3 results Private sector Y3Q3 results % Private sector contribution

Figure 10. Private sector contribution in skilled birth attendance achievement by County, PY3Q3

Scale-up EmONC services In PY3Q3, the Project supported 149 health facilities to provide appropriate maternal and neonatal emergency care services in the four counties. This reflects an achievement of 90% against the annual target of 165. Out of these, 127 health facilities had capacity to provide seven signal functions for basic emergency obstetric and newborn care (BEmONC) and 22 health facilities could provide nine signal functions for comprehensive emergency obstetric and newborn care (CEmONC) services. The signal functions that were not met by the majority of the BEmONC sites were the removal of retained products due to lack of MVA kits and the performance of assisted vaginal delivery due to lack of vacuum extractor. The quarterly assessment on facility preparedness for emergency care offers an opportunity to change attitudes and practices, minimize risks and failures in the provision of emergency care, and improve quality of care. During the reporting quarter, Migori had 51 health facilities providing emergency maternal and neonatal services, 5 of these being comprehensive care facilities. Seven of the 48 EmONC facilities provide comprehensive emergency maternal care in Kitui, while 7 of the 24 EmONC facilities could provide

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emergency maternal care functions in Kisumu. In Kakamega, where the Project has expanded geographically, 3 of the 26 EmONC facilities can offer comprehensive emergency obstetrics and neonatal care services.

The four health facilities (Tseikuru, Migwani, Awendo and Rongo sub county hospitals) whose operating theatres were renovated by the Project and handed over to the Kitui and Migori county governments are yet to be operationalized and the Project continues with advocacy to the county governments on optimal utilization of these essential investments. The biggest challenge remains mobilization of the requisite staffing capacity while the extended focus on COVID-19 response has delayed the processes more. Due to operational challenges, both Kitui and Migori have not commenced use of the operating theatres. The Project held meetings with the two county health leaderships to identify ways of supporting this operationalization and will continue to follow up on the matter with the relevant county authorities.

In Kitui, the project supported the standardization of EmONC mentorship in the county to streamline mentorship methodologies and make it easy to measure outputs. This process had started in February 2020 but was suspended due to the COVID-19 pandemic. All the EmONC mentors in the county participated in the standardization meetings and follow up site level activities. Through the mentorship, 58 HCWs from North and Mwingi Central sub counties completed a minimum of seven-hour sessions on management of postpartum hemorrhage (PPH).

Essential Newborn Care In PY3 Q3, a total of 21,820 newborns received immediate post-natal care services in the project supported health facilities. This brought the total to 62,051 newborns as at end of PY3 Q3, representing an achievement of 92% against the annual target of 66,501. Considered against the 24,146 live births recorded during the reporting quarter, immediate PNC for the newborn was at 90%. The Project has achieved a considerable improvement in PNC coverage, which is attributable to mentorship provided to HCWs on essential newborn care and utilization of service delivery reporting tools. In the reporting quarter, PNC coverage against the expected births was highest in Migori at 74% and Kisumu at 70%. Despite improvements from the SAPR 2020 period, both Kitui and Kakamega counties were below 50%, at 49% for Kitui up from 39% and Kakamega reporting PNC coverage of 43% from a similar 39% reported at the end of PY3 Q2.

In Kitui, the Project worked closely with the county in plan and conduct ETAT drills focusing on capacity building of HCWs on newborn resuscitation. These were conducted in 12 EmONC facilities to reach 62 HCWs (19 male, 43 female) who were mentored on newborn resuscitation. The Project will continue to co-support the drills in PY3 Q4 period and the same team of HCWs will be revisited after one month for a second session on the same skill to ensure good mastery of the skill.

Table 10 below shows a comparison of PNC coverage and institutional neonatal mortality ratio in the four focus counties, for the two periods of October 2018 to June 2019, and October 2019 to June 2020.

Table 10. Comparison of PNC coverage and institutional neonatal mortality ratio in Project focus counties in October 2018 to June 2019 and October 2019 to June 2020 periods Oct 2018 to June 2019 Oct 2019 to June 2020 County PNC Institutional neonatal PNC Institutional neonatal Coverage mortality rate Coverage mortality rate Kakamega 29% 11 42% 13 Kisumu 68% 11 70% 10 Kitui 46% 8 49% 13 Migori 63% 5 74% 5

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Respectful Care The Project supported minor repairs of two maternities in 2 health facilities (Kyethani and Winzyeei health centres) in Mwingi West sub county where maternity waiting home services are offered. This was in a bid to promote respectful maternity care in the two facilities. This was combined with other strategies for promoting the uptake of skilled birth attendance services in these two facilities that usually serve marginalized populations. The Project supported community dialogues on institutional deliveries and advocacy for the uptake of skilled birth care through the engagement of local leaders. In the reporting period, 9 mothers benefited from maternity shelter services in the two facilities. In the two facilities, the number of women accessing skilled birth deliveries doubled compared to PY3 Q2 performance.

Maternal and Perinatal Death Surveillance and Response (MPDSR) In the reporting quarter, there were 43 maternal deaths and 482 perinatal deaths in project supported facilities. Due to restrictions placed on meetings, maternal and perinatal death audits didn’t happen in some of the fatalities. Only 49% of the perinatal deaths and 91% of the maternal deaths were audited during the reporting period as shown in Figure 11 below. However, the audit process has since resumed with measures put in place to avoid the risk of HCWs contracting COVID-19.

120% 100% 80% 60% 40% 20% 0%

Proportion of maternal deaths audited Proportion of perinatal deaths audited

Figure 11: Proportion of maternal and perinatal deaths audited, PY3Q3

Institutional maternal mortalities remain a gap in the four counties, despite past and present investments by USAID/KEA and other stakeholders. In the four counties, Afya Halisi has worked with the governments to support the implementation of interventions that target health systems and service delivery towards improving maternal and newborn health outcomes, including; training through mentorship of healthcare workers in emergency obstetric and newborn care (EmONC); quality improvement; infection prevention and control; technical and financial support for maternal and perinatal death review and response; procurement, distribution, and orientation on MNCH equipment and support with human resource for health (HRH) staff. However, these investments seem to yield very slow results. In addition, follow-ups and responses to findings of audits is still a challenge. In Kisumu, the Project is advocating for better management of human resources to end the perennial HCW strikes, and improve the regional coordination of care and referral pathways as the county is a strategic healthcare support county for Western Kenya. The 18 maternal deaths recorded in the whole of Kisumu County for the reporting period is the highest registered in a quarter. Other areas identified for focus which also apply to the other three counties include the deployment of specialist medical personnel in high comprehensive care facilities, sustenance of supply chain for essential MNH medicines, and establishment of blood safety systems.

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In Migori, the Project supported the development of county MPDSR report which has an action plan that will guide advocacy efforts towards system-level responses to avert preventable maternal and perinatal mortalities. In the reporting period, the county recorded 14 maternal deaths (iMMR of 152/100,000 deliveries) while Kakamega, with 11 maternal mortalities had an iMMR of 218/100000. Kitui recorded 4 maternal mortalities and an iMMR of 90/100,000 deliveries in project supported facilities.

Quality of Care During PY3 Q3, Afya Halisi co-supported the training of 36 HCWs (18 male, 18 female) on electronic Kenya Quality Model For Health (e-KQMH) in Kisumu and Migori counties. The HCWs were from 30 private facilities and were imparted with knowledge and skills on basic concepts of KQMH, 6S, Continuous Quality Improvement (CQI), Total Quality Management (TQM); and e-KQMH platform for conducting quality assessments. All participants were able to practice and use the e-platform of KQMH as this is what they will use to carry out self-assessments on quality. In Migori, Afya Halisi co-supported quality improvement (QI) mentorship in 10 private facilities, through the sub-county QI focal persons. Afya Halisi will co-support mentorship on e-KQMH and support private facilities to initiate and complete ongoing QI projects. In Kakamega, Afya Halisi conducted a re-orientation of the quality improvement teams at Kakamega County Teaching and Government Referral Hospital (KCGTRH) on KQMH. The re-orientation reached 15 HCWs (5 male, 10 female) from the maternal, newborn, and child health service delivery points.

In PY3 Q3, a total of 19,190 women giving birth received Uterotonics in the third stage of labour, bringing the total to 56,171 as at the end of the reporting quarter. This represented 78% of the 24,585 facility-based deliveries conducted under skilled care during the reporting quarter. The appropriate use of Uterotonics for the prevention and management of PPH is a life-saving intervention that has been affected by county supply chain gaps. In Kisumu and Kitui counties, prompt action to procure an emergency supply of Uterotonics was needed after facilities reported depleted stocks. The cold chain maintenance of oxytocin, the widely used uterotonic in Kenya remains a gap. However, the much anticipated national guidance on the roll-out of heat-stable Carbetocin is expected to provide an alternative to oxytocin. The Project is working with the national MOH and other stakeholders on a process to advance the use of heat-stable Carbetocin in the prevention of postpartum hemorrhage. The sessions on active management of the third stage of labour are part of the EmONC package provided during the mentorship described under the training of HCWs on maternal and newborn health.

Immunization

During the reporting quarter, the focus of immunization support was on ensuring continuity of routine immunization services in the context of COVID-19 pandemic. The raft of measures the national government instituted targeted at slowing down the spread of the disease resulted in a sudden decline in uptake of immunization services across the focus counties. Immunization data from March 2020, indicated a 30% drop in service uptake countrywide, including in Afya Halisi supported counties. In line with the government’s guidance on ensuring continuity of care during the pandemic, Afya Halisi made course adjustments in programming support for immunization. The adjusted measures included; dissemination of RMNH guidelines during COVID-19 to guide healthcare workers on how to provide essential health services in the context of the pandemic, mapping of all immunization defaulters from the permanent registers and instituting follow up through phone calls and CHVs, scheduling immunization sessions to reduce crowding and minimizing risks for transmission of the disease, ensuring availability of vaccines and supplies given the restrictions on movements. In addition, the Project supported targeted outreaches in parts of Kisumu and Migori counties where there were displaced populations as a result of the floods experienced in April 2020. In Kitui County, Afya Halisi worked with the county government to co-create and co-finance immunization rapid results initiative (RRI) targeting children who missed immunization services at the

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beginning of the pandemic in March 2020. The RRI contributed between 10% and 30% of the immunization coverage in focus sub-counties, thereby increasing the county’s coverage as at end of PY3 Q3.

Summary of PY3 Q3 achievements under immunization During the quarter under review, the total number of children under one year of age who were fully immunized across the project supported areas was 29,458, bringing the total to 76,292 over the period PY3Q1 to Q3. This translates to an achievement of 77% against an annual target of 99,688 and a population coverage of 81%. Performance against target and population coverages for Project supported counties are shown in Figure 12 and 13 below. Sub-optimal performance in Kisumu is attributed to poor performances in Muhoroni (46%) Kisumu East (57%) and Kisumu West (68%) sub-counties. In Muhoroni sub-county, access to immunization services remains a challenge due to poor road infrastructure during rainy season and huge facility-to-facility distances making the sub-county essentially a hard-to-reach area. In Kisumu East and Kisumu West sub-counties, some of the health facilities were not offering immunization services due to being designated as COVID-19 quarantine and isolation centers. In the subsequent quarter, the Project will support catch up immunization activities targeted at reaching the unvaccinated and under vaccinated children in the three sub-counties.

100,000 120%

80,000 100% 87% 84% 80% 60,000 77% 67% 68% 60% 40,000 40% 20,000 20% - 0% Kakamega Kisumu Kitui Migori Project

Y3 Target Y3Q1-Y3Q3 Achievement % Achievement

Figure 12. FIC performance against target in PY3Q1 – Q3 period

Specific full immunization coverages for the supported counties during PY3 Q1 - Q3 period were as follows: Kakamega 77%, Kisumu 83%, Kitui 83% and Migori 85%. The county coverages are shown in Figure 13 below. Kakamega FIC coverage is weighed down by the sub-optimal performance in Likuyani, Butere and Khwisero sub-counties. While Butere sub-county has continuously had a FIC coverage above 80%, Khwisero sub-county has a population that opts to seek services in the neighboring County due to access and level of facilities. On the other hand, Likuyani sub-county has no direct project support. In the subsequent quarter, the Project will support targeted catch up immunization activities in the poorly performing sub-counties to reach children who have been missed between October 2019 and June 2020. These activities will include targeted outreaches, door-to-door campaigns complimented by intensified defaulter tracing and referrals. Through the county health leadership, Afya Halisi will also advocate for strict observance to routine immunization services in areas where scheduling of immunization services is the norm, such is the case in some sub-counties in Kakamega County.

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160,000 100% 140,000 83% 83% 85% 81% 80% 120,000 77% 100,000 60% 80,000 60,000 40% 40,000 20% 20,000 - 0% Kakamega Kisumu Kitui Migori Project

Estimated under 1 children FIC Y3Q1-Y3Q3 achievement FIC Y3Q1-Y3Q3 for coverage Figure 13. FIC coverage in PY3Q1 – Q3 period

During the reporting quarter, private facilities achieved FIC of 4,180, which was 14% overall contribution to the project’s performance of 29,458 for the period. As compared to the Project’s performance in the previous quarter, this represents a slight increase of 2% in the proportion of children seeking and receiving immunization services in the private sector.

At the county level, the project supported activities as outlined below;

Kakamega County

Missed Opportunities for Vaccination Strengthening daily immunization in health facilities In the reporting period, the Project continued to support the CHMTs and SCHMTs to strengthen REC implementation at health facilities. Under this support, onsite mentorship during support supervision was conducted in Mumias East where a total of 12 health facilities were reached. Worth noting is that all the facilities reached had immunization micro plans developed through Afya Halisi support in PY3 Q2, but were not being followed. Six (50%) of the facilities were scheduling immunization sessions leading to missed opportunities and no clear defaulter tracing strategies. Key issues addressed during the supervision included strengthening provision of immunization services during weekends for facilities that conduct deliveries but do not offer immunization over the weekends. In addressing this gap, the SCHMT made reference to the immunization policy on routine immunization services.

EPI standards assessment Building on work done in PY3 Q2, Afya Halisi and the SCHMTs co-planned and co-implemented an EPI standards assessment in Matungu and Khwisero sub-counties reaching a total of 29 immunizing health facilities. The assessment aimed at assessing routine immunization practices, adherence to SOPs and immunization guidelines. A total of 18 standards were assessed and scored with each facility having an overall performance. Facilities that did not meet most of the standards were mainly private immunizing facilities including Fina Medical clinic and St. Angela Medical Centre in Matungu and Emalindi Mission Hospital in Khwisero Sub County. In the subsequent quarter, Afya Halisi and the two SCHMTs will co- implement measures targeted at strengthening immunization standards in these health facilities. In Matungu, the overall score was 64% with 2 facilities with the highest score (100%) and 2 facilities with the least score (83%) were mainly private facilities. In Khwisero, 2 facilities with the highest score had 94% while the least score 44% was a mission facility.

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Commodity Security Strengthening the E-chanjo LMIS platform for immunization During the reporting quarter, Afya Halisi collaborated with CHAI and the County EPI logistician to strengthen vaccine commodity security through orientation of sub-county logisticians on the LMIS for vaccines and supplies. In order to strengthen monitoring of vaccine through the platform, Afya Halisi staff were included in the e-chanjo platform. All the sub-counties are now able to utilize the e-chanjo platform for ordering and reporting of commodities.

Vaccine stock status Through the e-chanjo platform, the Project continued to co-monitor stock status of various vaccines at the County and Facility level with the purpose of raising and mitigating potential stock outs During the quarter, there were no stock outs reported at health facility level. In the same period, the regional depot received the following quantities of vaccines; 188,420 doses of BCG, 135,300 doses of DPT, 32,900 doses of IPV, 166,100 doses of OPV, 133,800 doses of PCV 10, 58,950 doses of rotavirus vaccine, 86,450 doses of MR, 106,137 doses of HPV and 144,000 doses of TD. The vaccines will cover stocks for Kakamega, , Bungoma and Busia for the next quarter.

Transition to Tetanus Diphtheria (TD) vaccine In the reporting period, most facilities consumed all the Tetanus Toxoid vaccine stocks and were successfully transitioned to Tetanus Diphtheria (TD). Through supportive supervision visits, onsite mentorship of service providers on the new vaccine was provided to ensure smooth transition.

Cold Chain Management Orientation of HCWs on Fridge Tag 2 (FT2) During PY3 Q3, Afya Halisi and the C/SCHMTs co-planned and co-implemented an orientation of HCWs on Fridge Tag 2 in Mumias East sub-county. This support was a follow up to and was guided by findings from a EPI standards assessment conducted in the sub-county during Q2. Some of the identified gaps from the assessment included poor VVM monitoring, lack of routine temperature monitoring and lack of skills in the use of the FT2. This support reached a total of 13 immunizing facilities where 13 (2 male, 11 female) healthcare workers were oriented on the use of the FT2 and cold chain maintenance.

Kisumu County

Missed Opportunities for Vaccination Ensuring continuity of services in the context of COVID-19, flooding and HCWs industrial action During the reporting quarter, restrictions occasioned by public health measures to slow down spread of COVID-19 coupled with an industrial action and flooding in parts of Nyakach and Nyando sub-counties resulted in a decline in uptake of immunization services. Through co-planning and co-implementation, Afya Halisi and the Kisumu C/SCHMT supported mapping of all pregnant women and children under one year of age to identify unvaccinated and under vaccinated children.

Following the mapping exercise, the Project partnered with the SCHMTs to institute defaulter tracing and referrals across the six supported sub-counties. The county provided phones and HCWs as well as stipends for CHWs who led the defaulter tracing drives. Afya Halisi supported the defaulter tracing drives through provision of airtime for facility phones used in follow ups. In addition, in order to respond to the emerging flooding emergencies, the Project co-planned with the Kisumu County C/SCHMTs and co-implemented targeted integrated outreaches in Nyando and Nyakach sub-counties whereby the county provided vehicles, HCWs and health commodities while Afya Halisi supported lunch allowances for the HCWs and CHVs. The national government through the National Disaster Management Authority (NDMA) and private firms in Kisumu provided relief support in the form of temporary shelters, food, clothes and drinking water. This support resulted in emergency relief for approximately 30,000 people in the two sub-counties.

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In the month of June 2020, Kisumu County experienced a HCWs industrial action emanating from a dispute on re-designation, promotion and late payment of salaries. During the strike, 14 Afya Halisi supported HCWs continued to provide essential services including immunization services, thereby mitigating effects of the HCWs strike to an extent.

EPI Standard Assessment As part of strengthening routine immunization services, in PY3 Q3, Afya Halisi and CHMT co-supported an EPI standards assessment reaching 156 health facilities across the 6 supported sub-counties. The highest facility scored an overall score of 95% and the lowest scored 35%. Some general observations included; most facilities adhered to principles of cold chain management, had updated micro plans with adequate stocks. Key gaps for improvement included documentation on Monitor charts, ledger books and tally sheets, defaulter tracking logs not updated and lack of MCH diaries. Lack of MoH 710 (Immunization summary) and lack of outreach files was also cited as a gap resulting in poor immunization data flow from outreaches. Some health facilities did not have the required vaccine trays and a number did not adhere to the multi-dose vial policy. In the next quarter, Afya Halisi will work with the CHMT to address these gaps and improve quality of services in routine immunization. Figure 14 below shows the average score of standards per sub- county.

100% 84% 88% 81% 80% 82% 78% 82% 80%

60%

40%

20%

0% Kisumu West Kisumu East Kisumu Muhoroni Nyakach Nyando Kisumu Central

Figure 14. Average score of standards per sub county in Kisumu County, PY3Q3

Commodity Security Stock outs of various antigens was experienced in the first six weeks of the quarter occasioned by stock outs at the national level. Afya Halisi continued to support vaccine stock monitoring during this period and in order to ensure vaccine availability, Afya Halisi supported redistribution of antigens within sub-counties, distribution of MoH 710 tools, ledger books and strengthened weekly physical stock updates through electronic media. The Project also supported Kisumu County to transport immunization supplies including registers, tally sheets and safety boxes from the EPI depot in during COVID-19 restrictions.

Cold Chain Management During the EPI standards assessment conducted in 156 health facilities, it was noted that most immunizing sites adhered to cold chain principles. Among facilities with gaps in cold chain, most were from the private health facilities. About forty-two (42) sites are still using RCW42 fridges which require replacement. Kisumu-East sub-county depot does not have a freezer and results in breaches in immunization cold chain. During the assessment, the SCHMTs carried out targeted onsite mentorships on reading and recording on the fridge tag 2 in select facilities. Another underlying challenge identified during the assessment is lack of toolkits for cold chain maintenance. In the next quarter, the Project will support the county to procure cold chain maintenance tool kits for the sub-counties as advocacy efforts for cold chain support through fridges continues at the county budgetary level.

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Kitui County

Missed Opportunities for Vaccination Immunization RRI A rapid assessment of RMNCAH services uptake in light of COVID-19 conducted by the Project in the reporting period indicated that immunization uptake had reduced compared to the pre-pandemic period. To counter this effect, the Project in concert with the CHMT co-created and co-implemented a rapid results initiative (RRI) for immunization through outreaches and in-reaches targeting children missed with immunization services due to COVID-19. Immunization outreaches were conducted in 73 health facilities in the six supported sub-counties. Through the RRI, 199 children received penta 1, 191 children received penta 3, 332 children received measles 1 vaccine and 609 children under one year of age attained full immunization. The Project also supported mentorship for 42 HCWs (19 male, 23 female) on various EPI aspects including vaccine forecasting, interpretation of immunization monitor charts and defaulter tracing. In Mwingi West sub-county, vaccine forecasting sheets were developed in 19 health facilities through the EPI mentorship. The mentorship is aimed at strengthening access to immunization services in these facilities. Further, the Project supported supportive supervision for EPI services in 36 facilities in 3 sub- counties (Mwingi West-16, Kitui Central-10 and Mwingi Central-10).

Commodity Security In the reporting period, the county had adequate stocks for all antigens. However, during support supervision, it was noted that some facilities had low stock levels and these were occasioned by knowledge gaps in vaccine forecasting and not due to stock out of vaccines in the sub-counties. The Project supported EPI mentorship and support supervision to strengthen commodity management for EPI.

Cold Chain Management In the quarter, the Project supported EPI mentorship in 39 health facilities (21 in Mwingi West sub-county, 13 in Mwingi North sub-county and five in Kitui South sub-county) whereby 42 HCWs (19 male, 23 female) were mentored on various aspects in EPI including management of heat and freeze excursions, arrangement of vaccines in the vaccine fridges, reading of fridge tag and documentation in the temperature monitor chart. The mentorship was aimed at strengthening cold chain maintenance and consequently improve quality and access to immunization services in these facilities. Further, the project supported redistribution, repairs and preventive maintenance of fridges in 17 facilities. This was aimed at ensuring continuity of immunization service delivery in the three facilities where these services had temporarily stalled due to lack of functional fridges. The project also supported preventive maintenance of EPI fridges in 8 facilities in Kitui South and 8 facilities in Kitui East sub-county.

Migori County Cold Chain Management During the reporting quarter, in order to address emerging gaps in routine immunization services, Afya Halisi co-planned and co-supported an EPI mentors’ review and standardization meeting. The EPI mentors were taken through a 2-day rigorous program which involved a review of operational level guidelines, and an orientation on mentorship tools. Subsequently, the mentors were supported to conduct mentorship sessions reaching 192 HCWs (58 male,134 female) in 79 health facilities. The mentorship topics included cold chain management, vaccine forecasting and quantification, and documentation of immunization service data. One of the key findings across board was failure to correctly document the immunization monitor chart, vaccines ledger books, and MCH diary. Considering most of health facilities have task- shared some non-clinical roles to clerks and CHVs like documentation and managing client flow, onsite mentorship included these cadres in addition to the HCWs.

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Commodity Security In responding to the travel restrictions occasioned by the COVID-19 pandemic and the threat on vaccines and supplies availability, Afya Halisi co-supported Migori County Health Department to transport a consignment of immunization supplies including registers, tally sheets, safety boxes, Vitamin A and vaccine carriers. The support was timely in averting a looming crisis since some facilities had an impending stock out of some antigens and other EPI supplies. Afya Halisi led advocacy efforts for allocation of resources for EPI supplies including syringes. This was informed by the competition for resources at the county level in the background of COVID-19. Through advocacy meetings with the county health leadership, resources were allocated for procurement of solo shot syringes. This guarantees availability of adequate stocks for the next 7 months. The advocacy happened in the backdrop of erratic supply of commodities which adversely affected immunization service delivery leading to poor coverage. World Immunization Week In marking the World Immunization week on April 27th to 1st May 2020, Afya Halisi supported EPI focused in-reaches across the county targeted at mopping up pockets of immunization defaulters and ensuring the county maintained an immunization coverage above 85% . The weeklong activity reached 536 children with various antigens, 127 of whom were immunization defaulters. As part of the immunization drive, the recently introduced HPV vaccine was also administered to 172 girls aged 10 years. In addition, the Project supported immunization RRIs and defaulter tracing targeted at children who had missed their appointments due to COVID-19 related restrictions and fears. A total of 718 children were reached through these supplementary immunization activities.

Child Health

During the reporting quarter, Afya Halisi programming under child health was adapted to focus on ensuring continuity of IMNCI services in the context of restrictions occasioned by COVID-19, with the aim of ensuring that critical services such as management of pneumonia, malaria and diarrhea are still available in the background of the pandemic. A rapid assessment of uptake of services during COVID-19 pandemic revealed a drastic decline in the uptake of IMNCI services. In order to ensure continuity of services, Afya Halisi and C/SCHMTs co-supported dissemination of RMNCH guidelines on continuity of care during COVID-19. Subsequently, the SCHMTs were supported to cascade the guidelines to health facilities. Over time, these efforts saw a slow resumption in uptake of IMNCI services. The Project thereafter focused on strengthening IMNCI services with management of pneumonia in the context of COVID being a center area of focus. The Project also focused on following up ETAT+ trainers and strengthening of child survival working groups.

Summary of PY3 Q3 Child health achievements During the reporting quarter, the number of cases of child diarrhea treated in USG-assisted programs across the Project supported health facilities was 14,707, bringing the total number of diarrhea cases to 52,810 as at the end of PY3 Q3. This represents an achievement of 56% against the annual target of 94,492 children, as shown in Table 11 below. During the quarter, there has been a decline in the number of children receiving treatment for diarrhea from 19,488 to 14,707 children in PY3 Q3, a situation attributed to COVID-19 restrictions and the fear of contracting the disease in health facilities. Most of the diarrhea cases during the quarter were reported in Migori county followed by Kakamega County.

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Table 11. Achievement of Diarrhea and Pneumonia cases treated against target, PY3 Q1 - Q3 County Diarrhea cases Pneumonia cases Y3 PY3Q1 PY3Q2 PY3Q3 Total % Y3 PY3Q1 PY3Q2 PY3Q3 Total % target target Kakamega 23,938 2,612 3,028 4,256 9,896 41% 5,180 737 937 684 2,358 46% Kisumu 20,473 3,521 5,440 3,131 12,092 59% 8,562 1,380 3,231 1,168 5,779 67% Kitui 25,586 7,800 5,411 3,004 16,215 63% 5,761 944 2,004 442 3,390 59% Migori 24,495 4,682 5,609 4,316 14,607 60% 15,056 2,730 4,383 2,234 9,347 62% Project 94,492 18,615 19,488 14,707 52,810 56% 34,559 5,791 10,555 4,528 20,874 60%

Of the 14,707 diarrhea cases reported, 95% (13,929) were appropriately managed with ORS and Zinc as shown in Table 12 below. Even though Kisumu county had the lowest proportion of correctly managed diarrhea cases at 84%, this is an improvement from the previous quarter’s performance of 76% which can be attributed to the IMNCI mentorship initiatives implemented in early PY3 Q3. Improved performance in Kakamega, Kitui and Migori counties is attributed to IMNCI mentorship efforts, availability of ORS and Zinc co-packs as well as improved county level coordination of child health interventions.

Table 12. Proportion of diarrhea and pneumonia cases treated appropriately in PY3 Q3 Indicator Kakamega Kisumu Kitui Migori Project Diarrhea cases 4,256 3,131 3,004 4,316 14,707 Diarrhea cases treated 4,130 2,625 2,944 4,230 13,929 Proportion treated 97% 84% 98% 98% 95% Pneumonia cases 684 1,168 442 2,234 4,528 Pneumonia cases treated 625 1040 423 2,141 4,229 Proportion treated 91% 89% 96% 96% 93%

During the reporting quarter, the number of cases of childhood pneumonia treated in USG-assisted programs across the project supported counties was, 4,528, bringing the cumulative total for PY3 to 20,874. This represents an achievement of 60% against an annual project target of 34,559 children as shown in Table 11 above. As compared to the previous quarter, the number of pneumonia cases treated in PY3 Q3 represents a decline from 10,555 in PY3 Q2 to 4,528 cases in PY3 Q3. The decline is attributed to the COVID-19 containment measures and the fear of contracting COVID-19 in health facilities especially those designated as isolation and quarantine centers. Most of the pneumonia cases were reported in Migori county followed by Kisumu county. Out of the 4,528 cases of childhood pneumonia reported during PY3Q3, 93% (4,229) were appropriately managed using antibiotics as shown in Table 12 above. Kisumu county had the lowest proportion of correctly managed pneumonia cases at 89%, with Kisumu West having the lowest proportion at 77%. Despite the decline in the total number of cases treated in PY3 Q3, the proportion of correctly managed cases improved from 86% in PY3 Q2 to 93% in PY3 Q3.This can be attributed to the investments made under IMNCI mentorships and support supervision.

Table 13 below shows the relationship between FIC coverage, PCV 3 coverage and pneumonia burden, for the two periods of October 2018 to June 2019, and October 2019 to June 2020. Pneumonia burden is comparatively high in Migori. In the subsequent quarter, the Project will aim at expanding FIC and PCV 3 coverages in order to reduce pneumonia burden in under five children especially in Kisumu and Migori Counties.

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Table 13. Comparison of FIC coverage, PCV 3 coverage and Pneumonia incidence in Project focus counties in October 2018 to June 2019 and October 2019 to June 2020 periods County Oct 2018 to June 2019 Oct 2019 to June 2020 FIC Coverage PCV 3 Pneumonia FIC PCV 3 Pneumonia Coverage burden Coverage Coverage burden Kakamega 79% 77% 1% 78% 82% 1% Kisumu 83% 81% 2% 83% 84% 3% Kitui 74% 72% 4% 84% 78% 1% Migori 80% 86% 5% 86% 96% 5%

Specific activities co-planned and co-implemented in the four focus counties are as outlined below.

Kakamega County Strengthening IMNCI Approaches Co-creation meeting with the Child Survival team During the reporting quarter, Afya Halisi held a co-creation meeting with the Child Survival team aimed at reviewing the progress of implementation of the child survival interventions as per the 2019-2020 AWP. Most of the prioritized child health activities were not on track and through Afya Halisi support, priority interventions were identified with an implementation strategy.

Standardization of Sub-county child health coordinators on IMNCI In the reporting period, Afya Halisi supported orientation of Child Health coordinators on IMNCI. The orientation focused on dissemination of the 2018 IMNCI guidelines and capacity build them on the facilitation skills. A total of 11 (6 male, 5 female) child health coordinators were reached. Key findings included low training coverage for IMNCI and poor stewardship of child health interventions. To address this, Afya Halisi will continue to strengthen co-planning and co-implementation with the County Child Health focal person and intensify IMNCI onsite mentorship.

Support for Child Survival TWG In the reporting period, Afya Halisi supported the County Child Survival TWG. A one day meeting was held where the terms of reference for the Child Survival TWG were adopted in-line with the national structure and disseminated. In addition, priority child health indicators were presented and the status of the implementation of the child health activities discussed, resulting in an action plan for PY3 Q4. IMNCI Mentorship & Support Supervision During PY3 Q3, Afya Halisi co-planned and co-supported onsite IMNCI mentorship and child health support supervision in Kakamega County. A total of 37 health facilities from Navakholo, Matungu, Butere and Mumias East were visited. The mentorship focused on strengthening care for children under 5 including appropriate history taking, classification of the danger signs, diagnosis, treatment and general ORT management. Gaps identified included poor identification and classification of the danger signs and poor utilization of the ORT register.

Assessment of the child health standards In the reporting period, Afya Halisi conducted an assessment of the child health standards aimed at evaluating the quality of care for a child 0-59 days. Ten (10) health facilities were visited in Mumias East and Navakholo sub counties. Most of the facilities weigh children 0-59 days, take temperature and ask for reasons for hospital visit. However, complete physical assessment, monitoring of respirations and identification of the danger signs were not done appropriately. Afya Halisi will use these findings to strengthen mentorship activities for IMNCI.

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Strengthening of ETAT+ In PY3 Q3, Afya Halisi conducted mapping of the ETAT+ ToTs who were previously trained in the county. A total of 11 ToTs spread across the entire county were mapped and all were found to be certified. A follow up of these ToTs will be done in the next quarter to further evaluate their skills and competency.

Kisumu County Strengthening IMNCI Approaches During the reporting quarter, Afya Halisi co-planned and co-supported IMNCI support supervision and onsite mentorship in seventy-five (75) health facilities in Kisumu county. Health facilities supported are among those that had recorded discrepancies in the correct management of both pneumonia and diarrheal diseases. The focus of mentorship was on correct diagnosis, classification and treatment of diarrhea and pneumonia and on ensuring functional ORT corners. During the same period, health facilities did not experience any stock outs of ORS and Zinc co-packs as well as Amoxicillin DT. Notable gaps recorded during the supervision included; lack of pulse oximeters and nebulizers in health facilities, lack of functional ORT corners and lack of IMNCI guidelines in private health facilities. There were also notable cases of irrational use of antibiotics. In the next quarter, Afya Halisi will co-support training of new hires on IMNCI, ETAT + and KQMH.

Kitui County Strengthen IMNCI Approaches In the reporting period, the Project continued to strengthen institutionalization of appropriate management of diarrhea and pneumonia using the current MOH guidelines for IMNCI, 2018. Afya Halisi and Kitui County Division of Neonatal and Child Health co-planned and co-implemented child health focused supervision and onsite mentorship on quality IMNCI service delivery. Child health support supervision was conducted in Kitui South and Kitui East sub-counties in the quarter and is scheduled to continue on a monthly basis to ensure all the six Afya Halisi supported sub-counties are visited within a quarter. During the quarter, twenty one (21) health facilities were supervised including all the level 4 facilities ( SCH, Ikanga SCH, SCH and Zombe SCH).

Key gaps identified included HCWs knowledge gaps on classification and treatment of diarrhea and pneumonia, lack of functional ORT corners and inadequate job aids for IMNCI. In responding to the identified gaps, the Project supported IMNCI mentorship focusing on classification and treatment of diarrhea and pneumonia in all the six Afya Halisi supported sub-counties by a pool of previously trained IMNCI TOTs. The mentorship was proceeded by mentorship standardization meetings for IMNCI mentors organized by the county’s Division of Neonatal and Child Health. Key points agreed upon included number of sessions to be conducted for each topic, minimum and maximum number of mentees per session, deliverables, scheduling of the mentorship and documentation. During the meetings, the mentors were also updated on COVID-19 guidelines for child health services and community acquired pneumonia. Eighty- five HCWs (45 male, 40 female) from 26 facilities were mentored on diarrhea and pneumonia classification and treatment.

Scale Up of ETAT+ A large proportion of neonatal deaths in Kitui County are associated with newborn asphyxia. In the county’s largest referral hospital, Kitui County Referral Hospital, out of 69 neonatal deaths reported in the newborn unit from January to May 2020, 32 of the deaths (46%) were due to newborn asphyxia. Further reports from MNH supervision and MPDSR reviews conducted in the reporting period indicated that most HCWs in the county lack knowledge and skills in newborn resuscitation. In a bid to address the gaps and promote newborn survival, Afya Halisi and the county health department co-planned and co-implemented ETAT+ drills focusing on capacity building of HCWs on newborn resuscitation. These were conducted in 12 EmONC facilities reaching a total of 62 HCWs (19 male, 43 female) were mentored on newborn

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resuscitation. The drills are ongoing and the same team of HCWs will be revisited again after one month for a second session on the same skill to ensure good mastery of the skill.

Migori County Strengthen IMNCI Approaches Afya Halisi co-supported standardization of sixteen (16) Migori county child health mentors (4 male, 12 female). These mentors were identified by the county IMNCI lead mentors who are also ToTs. The 16 mentors were picked from each sub-county and were taken through a 2-day program whose content included review of previous mentorships, overview of IMNCI and updates, an orientation on RMNCAH mentorship tool and planning. Mentors were matched with mentees from facilities within their sub-county and they were facilitated to initiate mentorship process. As a result, HCWs 87 (30 male, 57 female) from 36 facilities across the county were reached. Some of the cross-cutting issues addressed across board include; identification and classification of childhood diseases, treatment and documentation. Mentors also ensured all facilities visited had a functional ORT corner. At the same time, HCWs were sensitized on management of community acquired pneumonia in the context of COVID-19. Although it’s still early to quantify the benefits of this activity, facilities are already posting great improvement in administering treatment to children. For example, in God Jope Dispensary, where 5 HCWs were mentored, there’s judicious use of antibiotics and utilization of ORT corner which is attributed to drastic reduction of revisits and stock-out of antibiotics.

Nutrition Despite the COVID pandemic, the Project worked with the focus county governments to supplement 247,379 children aged 6-59 months with Vitamin A in Migori and Kakamega counties during the reporting quarter. This reflects an achievement of 110% of the annual target of 225,361 as shown in Table 14 below. The achievement was through household level supplementation of Vitamin A given that the early year education (EYE) centers were closed by the national government as part of the containment measures against COVID-19 pandemic. During the reporting quarter, 8,572 children with diarrhea received zinc supplementation reaching 24,503 as at end of the reporting quarter. This was an achievement of 49% against the annual target of 50,355. Within the same quarter, through the Project’s co-implementation with the focus county governments, a total of 16,333 children aged 0-23 months were reached with community level nutrition interventions bringing the total reached to-date to 57,627. This reflects an achievement of 72% of the annual target. The Project achieved all these by co-supporting community level and hospital baby friendly initiatives and strengthening High Impact Nutrition Interventions (HINI). Table 14: Achievements against targets in Nutrition indicators, PY3Q1-Q3 period Indicator County/Achievement Kakamega Migori Project Vitamin A supplementation Y3 Target 88,878 136,483 225,361 Y3Q1 - Y3Q3 Achievement 110,482 136,897 247,379 % Achievement 124% 100% 110% Children under 2 reached with Y3 Target 31,374 49,050 80,424 community-level nutrition Y3Q1 - Y3Q3 Achievement 23,036 34,591 57,627 interventions % Achievement 73% 71% 72% Pregnant women reached by Y3 Target 21,523 33,851 55,374 nutrition-specific interventions Y3Q1 - Y3Q3 Achievement 17,822 32,514 50,336 % Achievement 83% 96% 91% Individuals receiving nutrition Y3 Target 127 243 370 related professional training Y3Q1 - Y3Q3 Achievement 212 248 460 % Achievement 167% 102% 124% Health facilities with established Y3 Target 45 79 124 capacity to manage acute under- Y3Q1 - Y3Q3 Achievement 73 80 153 nutrition % Achievement 162% 101% 123%

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During the reporting period, Vitamin A coverage for Kakamega and Migori counties were at 113% and 89% respectively as shown in Table 15 below. The improved coverages were due to the Project’s co- creation efforts with the two county governments and shift of strategy to working with CHVs to supplement eligible children at household level due to the closure of EYE centers as well as the reluctance of mothers to take their children for Vitamin A services in health facilities due to the fear of contracting COVID-19. Table 15. Nutrition coverage in project focus counties, PY3Q1-Q3 period Intervention Indicator Kakamega Migori Breastfeeding IBF Estimated live births 48,198 35,500 coverage Babies IBF within an hour of birth 29,893 28,046 % initiated on IBF 62% 79% EBF Children < 6 months weighed 183,950 150,201 Exclusive breastfeeding 0-<6 months 141,495 137,536 % EBF 77% 92% Micronutrient Children Children < five who received VAS 237,812 141,946 supplementation supplemented Population 6 - 59 months 209,702 159,004 coverage with Vitamin A % supplemented with Vitamin A 113% 89% ANC Women receiving IFAS 110,074 58,595 supplemented Total ANC attendance 155,809 112,393 with IFAS % combined IFAS 71% 52% Growth Underweight Children < five underweight 8,789 4,470 monitoring children Total children < five weighed 583,570 458,961 % children < five underweight 2% 1%

The county specific activities are detailed below;

Improve micronutrient supplementation Kakamega County During the quarter under review, the Project worked with the county government to support Vitamin A supplementation reaching 110,482 eligible children. This translated to an achievement of 124% of the annual target. Given the closure of EYE centers and schools by the national government due to the COVID- 19 pandemic, the Malezi bora campaign that aims at accelerating supplementation of Vitamin A was delayed and could not proceed in April 2020 as had earlier been planned. The activity proceeded in June 2020 with guidance from the county government. The Hellen Keller international (HKI) supported the county level co-creation meeting with Afya Halisi and the county government to plan for co- implementation and co-monitoring of the Vitamin A supplementation exercise at the household level due to the COVID-19 pandemic. The Project supported the co-implementation of Vitamin A supplementation in the six focus sub counties while HKI supported the other six sub counties in Kakamega County. In addition, HKI also supported with personal protective equipment and supplies for use by CHVs that included; face masks, sanitizers, waste disposal bags and scissors for all the twelve sub counties in the county. The Project supported the CHVs to conduct household level supplementation while adhering to the COVID-19 guidelines. In addition, the Project supported the county, sub county teams and community health assistants (CHAs) to conduct supportive supervision for the exercise in the six focus sub counties. The Project integrated deworming and screening of mid-upper arm circumference (MUAC) for malnourished during the exercise. As a result, a total of 61,944 children were dewormed, which was five times more than the 13,072 children that were dewormed in the previous quarter. The major challenge experienced was inadequate stocks of dewormers, resulting into some children not being dewormed. In the subsequent quarter, the Project will co-support a county level review and co-creation meeting for Vitamin A supplementation to ensure sustainability in line with the Journey to Self-Reliance principles.

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Migori County During the quarter, the Project reached 136,897 children with Vitamin A supplementation, translating to an achievement of 100% of the annual target. Similar to Kakamega, the children were reached at household level through supplementation by the CHVs. The actual supplementation was done by the children’s mothers under close supervision of the CHVs to minimize contact due to COVID-19. Mother led MUAC was also integrated to identify malnourished children. However, there was no significant difference in the number of malnourished children as the proportions (1% for moderate malnutrition and 0.18% for severe malnutrition) were similar to the previous quarter. In contrast, a total of 30,255 children A mother supplementing her child at were dewormed, almost twice double than the 16,452 household level with Vitamin A under children that were dewormed in the previous quarter. During supervision of a CHV in Kisembe village in Navakholo Sub County in Kakamega the quarter, the Project also co-supported integrated outreaches that contributed to the Vitamin A coverage performance in the county.

Strengthened capacity for Baby Friendly Hospital Initiative (BFHI) Kakamega county During the quarter under review, the focus sub counties in Kakamega county conducted their own self assessments. In previous quarter, the county government conducted the assessments and the findings showed that Navakholo and Matungu sub county hospitals achieved 47% and 54% respectively. Both hospitals improved from their last assessment and were at 61% and 64% respectively. The gaps noted stem from referrals from the peripheral facilities that neither implement Baby Friendly Hospital Initiative (BFHI) nor Baby Friendly Community (BFCI). Other challenges included interrupted skin to skin contact, some mothers still not expressing breast milk, inadequate knowledge at household level and knowledge gap due to new staff and staff transfers. In the subsequent quarter, the Project will support updates for HCWs, follow ups at household level to ensure messaging, conduct exit interviews to inform BFCI review meetings and scale up Butere sub county hospital to implement BFHI.

Migori county During the reporting quarter, the county conducted follow up visits to seven BFHI hospitals. These included Migori County Referral Hospital, and Kegonga, Kehancha, Karungu, Awendo, Rongo and Uriri sub county hospitals. The county team provided mentorships to HCWs in the hospitals based on gaps they had identified during their self-assessment and developed joint action plans to guide implementation of the recommendations. The challenge that was noted was provision of inadequate information to mothers, while the transfer of trained HCWs and new staff deployment led to capacity gaps in implementing hospitals. Two of the sub county hospitals, Uriri and Kuria East sub county hospitals, conducted their self-assessment during the reporting quarter and scored 74% and 76% respectively. The other remaining hospitals will conduct their self-assessments in the subsequent quarter.

Strengthened capacity for High Impact Nutrition Interventions (HINI) including IMAM Kakamega county During the reporting quarter, the Project co-supported mentorship of HCWs on high impact nutrition interventions (HINI) and integrated management of acute malnutrition (IMAM) in both private and public health facilities. A total of 44 facilities were reached (Mumias East 12, Navakholo 14, Lurambi 5, Khwisero Matungu 13). It was noted that IMAM commodities were out of stock in most facilities. The Project advocated the county government to procure the commodities.

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In Butere sub county, the Project conducted baseline assessment for all the facilities to determine the gaps in implementation. The major gap noted across the health facilities was inadequate knowledge among the HCWs on the Breastmilk Substitutes Regulation and Control Act, micronutrient supplementation at community level and complementary feeding that all scored below 50% as shown in Figure 15 below. In the subsequent quarter, the Project will support the county to conduct mentorship and sensitize the sub county health management teams of Butere, Lurambi and Mumias East, after which they will conduct mentorship of HCWs in targeted health facilities.

100% 77% 80% 74% 63% 64% 68% 60% 52% 50% 51% 44% 42% 40% 23% 20%

0%

Figure 15. Butere sub county HINI baseline assessment results as at May 2020

In addition, the Project will work with the county MOH and Weights and Measures Department to standardize and repair weighing scales to ensure correct weights are given and documented for children.

Migori county During the quarter under review, the Project supported HINI mentorship in 96 facilities in the county. Though Vitamin A and Iron and Folic Acid (IFA) had been out of stock, the county procured some stock of IFA and also received Vitamin A from national level for supplementation to pregnant women and children respectively. During the mentorships, it was noted that there was inadequate knowledge among the newly recruited HCWs due to transfer of HCWs that were initially trained. In addition, there were inadequate and faulty anthropometric equipment, and inadequate reporting tools i.e. MOH 734. However, the county received a supply of the reporting tools from the national level. In the subsequent quarter, the Project will work with the maintenance department to repair and standardize all the weighing scales. In addition, the Project will integrate mother led MUAC in community units (CUs) A mother taking the MUAC of her child implementing BFCI and co-support its implementation in areas after he was supplemented with with high cases of malnutrition. Vitamin A at the household level

Linkages with other partners and stakeholders Due to the COVID-19 pandemic, some organizations slowed down implementation of activities at the community level in response to the prevention and containment measures that were announced by the national government. In Kakamega County, the Project worked with Hellen Keller International (HKI) and

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the county government to co-create, co-implement and co-monitor the provision of Vitamin A supplementation at the household through the community health volunteers.

In Migori county, the Project worked with a local CBO called Three way care. The Project worked with the CBO to train mother to mother support groups (M2MSGs) in community units and health facilities implementing BFCI on soap making in Nyatike, Uriri, Suna East, Suna West, Kuria East and Kuria West sub counties. The training on soap making was targeted as an income generating activity (IGA) for the M2MSGs given the increased demands for soap during the COVID-19 pandemic period. As a result of the training, some of the trained groups are making and have successfully sold the soap as an IGA. In addition, the Project worked with Community Mobilization Kangeso M2MSGs setting up a home Against Desertification (CMAD) in Rongo sub county in garden Migori County to support establishment of kitchen gardens in Ngere and Kochola M2MSGs. One of the mothers gave her kitchen garden for the group learning process and CMAD gave seeds for local traditional vegetables and taught the mothers how to prepare the garden. In the subsequent quarter, the Project will collaborate with CMAD and the county government to make follow ups on the gardens and scale up the initiative in other M2MSGs.

WASH During the reporting quarter, the Project continued to support various water, sanitation and hygiene (WASH) interventions both in the community and health facilities across the three focus counties of Kisumu, Kakamega and Kitui. These included following up villages for Community Led Total Sanitation (CLTS) in Kakamega and Migori counties; building capacity for WASH in communities and health facilities; improving sanitation in facilities through minor repair works; and increasing access to basic water services.

The Project’s WASH performance by county as at end of PY3 Q3 period is shown in Table 16 below. Table 16. WASH Performance by County, PY3Q1-Q3 Indicator County/Achievement Kakamega Kitui Migori Project Villages verified as ODF Y3 Target 42 32 74 Y3Q1-Y3Q3 Achievement 34 23 57 % Achievement 81% 72% 77% People gaining access to safely Y3 Target 5,573 7,711 13,284 managed sanitation service Y3Q1-Y3Q3 Achievement 2,004 6,448 8,452 % Achievement 36% 84% 64% People gaining access to safely Y3 Target 4,300 3,200 3,800 11,300 managed drinking water services Y3Q1-Y3Q3 Achievement 673 13,200 1,196 15,069 % Achievement 16% 413% 31% 133% Individuals trained to implement Y3 Target 315 263 210 788 improved sanitation methods Y3Q1-Y3Q3 Achievement 235 237 839 1,311 % Achievement 75% 90% 400% 166% Basic sanitation facilities provided Y3 Target 3 3 4 10 in institutional settings as a result Y3Q1-Y3Q3 Achievement 2 0 3 5 of USG assistance % Achievement 67% 0% 75% 50%

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WASH at Healthcare facilities During the reporting quarter the Project worked with MOH in the focus counties to support minor renovation of 5 doors latrines in supported health facilities. This reflects an achievement of 50% against the annual target of 10. This support followed the joint assessments on WASH that was conducted in healthcare facilities during PY3Q1 and PY3Q2. The achievement of the target was slowed down by the counties focusing more on access to basic water activities during the reporting quarter due to COVID-19 pandemic. In Migori County, the Project supported minor repair of 3 doors latrines at the maternity unit (2 door for use by mothers and 1 door for maternity staff) at Rongo Sub County Hospital in order to improve access to proper sanitation and hygiene. The Project procured materials for the minor repairs which included water connection and plumbing parts. In addition, the Project supported the fixing and connection of water in the maternity unit.

Latrine repaired at maternity unit and water sink installed and connected to water source at Rongo Sub County Hospital

In Kakamega, the Project worked with MOH to support minor repair of 2 doors latrines in two health facilities in Navakholo sub county. In the subsequent quarter, the Project will focus co-support in minor repair of five additional latrines in the target counties in order to achieve the annual target of 10 healthcare facilities.

Latrines supported with minor repairs at Navakholo Sub County and Kharanda Health Center in Navakholo Sub County, Kakamega County

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Output 1.2: Strengthened delivery of targeted FP/RMNCAH, nutrition and WASH services at community level, including effective referral to mobile and/or static facilities Activity 1.2.1. Strengthen Community Health Platform Capacity building of CHVs in MNH Due to the COVID-19 pandemic, it became necessary for CHVs to monitor pregnant women and newborns closely due to the fear of seeking services in health facilities. During the reporting quarter, to ensure strengthened capacity of the CHVs, the Project supported refresher training to 686 CHVs (212 male, 474 female) on community MNH. At county level, the Project trained 441 CHVs in Kitui, 170 in Migori, and 75 in Kakamega. This brought the total number of CHVs trained on community MNH to 1,542 (444 male, 1,098 female), achievement of 117% against the annual target of 1,320. The Project did not conduct training of CHVs on community MNH in Kisumu as the Project had supported training for 681 CHVs (176 male, 505 female) in the county at the end of PY3 Q2. The refresher training was necessitated by the need for enhanced infection prevention and control in the wake of the COVID-19 pandemic. The training also focused on ANC, danger signs in pregnancy, skilled birth attendance, individual birth plan, and postnatal care. The Project's support for the training is need-based although the Project will purpose to reach all the CHVs with updates, particularly on infection prevention and control with the evolving nature of the COVID-19 pandemic. In addition, continued mentorship will be provided to CHVs to improve referrals for skilled birth attendance, early initiation, and continuity of antenatal care, immunization, and postnatal care services.

Capacity building of CHVs in Family Planning During the reporting quarter, the Project supported the training of 104 CHVs (36 male, 68 female) on the Family Planning technical module. At county level, the Project supported the training of 64 CHVs (20 male, 44 female) in Kakamega while 40 CHVs (16 male, 24 female) were trained in Migori. The training equipped the CHVs to provide adequate and quality information on various family planning methods including counseling techniques and referral systems. The CHVs were empowered to identify the side effects of the various family planning methods and the importance of referring clients to health facilities.

Supportive Supervision for Improved Quality of Services During the reporting quarter, the Project facilitated S/CHMTs, CHEWs, and CHAs to provide enhanced supportive supervision to 77 CUs reaching 576 CHVs (153 male, 423 female). The supportive supervision focused on CU performance, reporting and utilization of generated information, CHV and CHC motivation, community/facility referral, financing and sustainability as well as CU functionality. At the household level, the focus was on the quality of services provided by CHVs, feedback from community members, and CHVs’ level of engagement. The supervision was also important in revealing the challenges CHVs face during their day to day duties, especially during the COVID-19 pandemic period.

In Kakamega, the Project supported supervision to 37 CUs in Butere and Lurambi sub-counties reaching 347 CHVs (80 male, 267 female). The findings revealed inadequate reporting tools, lack of CHV desks in some facilities, inadequate dialogue sessions, and training; low understanding of indicators; and incomplete referrals. The Project will work with the county MOH team to strengthen these gaps. In Kitui, the Project supported supervision to 27 CUs reaching 63 CHVs (20 male, 43 female) at the household level. The need for household mapping was established and the Project will work jointly with MOH to support household mapping in the subsequent quarter. The IEC materials for use during household visits were also discussed.

In Migori, the Project supported supportive supervision to 13 CUs reaching 166 CHVs (53 male, 113 female). A follow-up support supervision to 5 CUs in Uriri Sub-County revealed that there was an improvement made by the CHVs in provision of MNH massages at the household level. Besides, supervision was also provided to two CUs previously trained on Integrated Community Case Management

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(iCCM). It was revealed that the CHVs had adequate knowledge of iCCM, were able to competently assess, classify, treat, and refer children for treatment. In addition, documentation of iCCM was also good. The challenges included availability of old MUAC tapes, faulty timers, commodities, and supplies.

CU Sustainability and CHV Retention The Project continued to support the strengthening of village savings and loan association (VSLA) activities in order to assist vulnerable and poor communities to save and lend money among themselves with no external liabilities. The eight CUs that were previously trained on VSLA continued to mobilize resources for their income-generating activities. Two CUs in Migori had mobilized up to Ksh. 345,340 between April and June 2020. During the reporting quarter, the Project supported the training of 200 CHVs in 17 additional CUs on VSLA bringing the total to 25 CUs that are implementing VSLA. The training was aimed at equipping the CHVs with financial management and entrepreneurial skills. The Project in collaboration with MOH will monitor progress of the groups and provide them with relevant linkages for sustainability purposes. VSLA will also be included as an agenda during monthly review meetings for the trained CUs. In Kakamega, 116 CHVs (28 male, 88 female) from 10 CUs were trained while in Migori, 84 CHVs (28 male, 56 female) from 7 CUs were trained. The CUs were selected based on their already identified initiatives and willingness to expand their savings and income generation. In Kitui, the Project worked with UNICEF to co-support sensitization of 89 CHVs (38 male, 51 female) on entrepreneurship. UNICEF provided them with 200 sanitation products, that consisted of 100 Sato pans, 50 Sato stools, and 50 Sato Flex, which they were to sell to generate income for their groups and at the same time, improve the sanitation standards in their communities. Household Visits Covering All Thematic Areas During the quarter, the Project continued to support CHVs to visit households in line with the guidelines of implementing community activities in the context of COVID-19. The CHVs wear masks during such visits while ensuring social distancing and regular hand washing as well as the use of sanitizers. They communicate with the members of the household outside the house while having minimum touch as possible. The number of households visited was 151,225, representing 63% of the total households compared to 182,110 households that were visited in PY3Q2, that represented 69% of the total households. The reduction in the proportion of households visited are attributed to the containment measures that were put by the national and focus county governments in response to COVID-19 pandemic. As COVID-19 cases increase, it is expected that the proportion of households visited will decrease as engagements will shift to be telephone-based.

At county level, the Project supported the CHVs in Kakamega County to visit 25,353 (72%) households; in Kisumu the CHVs visited 34,616 (62%) households; in Kitui, they visited 35,734 (49%) households; and in Migori, a total of 21,925 (66%) households were visited.

During the reporting quarter, the household visits were more targeted to prioritize households with pregnant women, newborns, lactating mothers, and sick community members. Close monitoring was also done for community members most vulnerable to COVID-19 including those who are above 60 years and those with underlying conditions. To empower pregnant women to have skilled birth attendance, messaging on health insurance was incorporated in the routine household visits. Figure 16 below provides a summary of the mothers tracked and mapped in PY3 Q1-Q3.

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14771 13902

11,897

9,149

7860

7,439

4,054

3,347 2,497

Y3 Q 1 Y3 Q 2 Y3 Q 3

Mapped mothers Mothers with birth plans Mothers registered for Linda Mama

Figure 16. Mapping and tracking of pregnant mothers in PY3Q1-Q3

In Kisumu County, the Project in collaboration with the CHMT co-created an online database for mapped pregnant women. The database enables the CHAs to continuously update the information and use it for tracking and following up pregnant women to ensure they attend ANC visits and deliver at the health facility. It has made it easy for CHVs and health workers to identify home deliveries and make referrals as soon as possible. Besides, the information has been used to identify defaulters and refer them for missed services. In addition, based on information from the database, a total of 6,700 curfew passes were printed and provided to CHVs for distribution to pregnant women seeking health services during the curfew hours.

Community Dialogue Sessions for all Thematic Areas During the reporting quarter, the Project supported 79 targeted dialogue sessions reaching 1,123 community members (224 male, 899 female). At county level, 39 dialogue sessions were held in Kakamega, 10 in Kitui and 30 in Migori. The sessions targeted wards with low population coverage performance in various FP, RMNCAH and nutrition indicators. The CHAs and lead CHVs engaged participants to generate as much information as possible. Every session generated action plans for community members and expectations for the follow on sessions. Out of the 1,123 community members reached, 17% received FP messages, 68% received ANC services and skilled birth attendance, 13% received child health services, and 2% received AYSRH services.

In Kakamega, during the sessions, it was noted that cultural norms and traditions such as the need to bury the placenta in a banana plantation to increase fertility, delivering at home to allow in-laws perform rituals and the belief that planning for an unborn baby brings bad omen were some of the reasons why women deliver at home.

In addition, in Kakamega, the Project supported 3 joint dialogue sessions with the Ministry of Health, Ministry of Interior, birth companions, and community members to address challenges in access to health services due to the curfew put in place as part of the containment measures to mitigate the COVID- 19 pandemic. The sessions reached a total of 70 participants (32 male, 38 female). The community Multi-sectoral actors attending MNH dialogue reported that there was increased cases of home session in Kakamega deliveries due to the curfew restrictions. As a way forward, curfew passes were provided to birth companions to enable them to accompany pregnant mothers

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seeking health services at night. In Khwisero sub county, the Medical Officer of Health designated three ambulances for use to transport mothers seeking MNH services at night. In Matungu sub county, the Chiefs assigned two motorbike riders per village to operate during curfew hours for transporting pregnant mothers in labor to the health facility. The motorbike riders were also provided with curfew passes.

In Kitui, a total of 10 targeted dialogue sessions were supported held reaching 135 community members (45 male, 90 female) with MNH, FP, child health, and AYSRH messages. The session with Kavonokya leaders revealed their perception of good health and practices which included living according to the Bible commands, personal hygiene, prayer before consuming water and food. For example, they have different prayer requirements for various diseases, with simple diseases only requiring a personal prayer and the more serious ones need prayers by church leaders for prolonged periods. The Project will build on their best practices during future engagements on behavior change.

In Migori, the Project supported 30 dialogue sessions, reaching 411 participants (97 male, 314 female). The participants included TBAs, pregnant mothers, men, and adolescents. A dialogue session was held with 24 re-designated TBAs in Bware Health Centre to discuss their experience as birth companions. Since the sensitization in March 2020, they had accompanied 23 women for skilled birth attendance. The facility continued to provide allowances when they accompanied women for skilled birth attendance. They started a savings scheme to mobilize resources for sustainability. In addition, the Project engaged 124 Boda Boda riders (116 male, 8 female) from whom RMNCAH champions were selected and will engage other riders with information on FP AYSRH and GBV. Out of these meetings, the base leaders were selected to lead in the sensitization of other Boda Boda members to participate in condom distribution and submit reports to respective CHAs. The CHAs will liaise with Boda Boda bases, reinforce messaging, and collate reports for CUs. Four Boda Boda bases also agreed to offer free services to women and children during referrals.

Male only dialogue Due to the critical role played by men in decision making on issues of maternal and child health, the Project supported 7 men-only sessions reaching 91 participants in Migori. A tota of 15 champions were identified to work together with respective CHAs, create awareness and promote uptake of FP, and RMNCAH services. During the discussions, the men understood how they had been a hindrance to women in accessing health services due to culture and ignorance. Consequently, they agreed to support their spouse and create awareness among other men.

Activity 1.2.2. Support Community Health Service Delivery

Conduct Integrated Outreaches, including for Hard-to-Reach Populations During the reporting quarter, the Project supported 24 outreaches/in-reaches in Kakamega while 8 in reaches were conducted in Migori targeting the hard to reach areas with low immunization, FP, and MNCH coverage. The outreaches were conducted with adherence to COVID-19 guidelines and CHVs mobilized community members to participate in the outreaches. Table 17 below provides a summary of the people reached with the outreach services in PY3 Q3. Table 17. People reached with outreaches services, PY3Q3 Service Kakamega Migori 1. Immunization 678 308 2. Family planning 308 150 3. ANC 257 76 4. Vitamin A Supplementation 1193 279 5. Deworming 419 221 6. Information and Education 1,879 586

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Notably, out of the 1,150 children who were weighed during the outreaches in Kakamega; 6 were underweight (5 with moderate malnutrition and 1 with severe malnutrition) while in Migori, out of the 450 children who were weighed; 12 were found to be underweight, (3 wasted and 3 with moderate malnutrition). All these children were linked with the sub-county nutritionist for follow ups. Other services provided included malaria vaccination to 11 children.

Community maternal and perinatal death surveillance and response During the reporting quarter, three (3) maternal deaths in Kitui County and 15 perinatal deaths (Kisumu – 11, Migori - 4) were reported. In Kisumu, out of the 11 perinatal deaths that were reported, three verbal autopsies were conducted. Some of the causes of home perinatal deaths included hypothermia, hemorrhage due to cord not being well clumped at home, sepsis due to removal of plastic teeth by herbalist and asphyxia. In Kitui, a verbal autopsy for one maternal death revealed that she had died possibly of puerperal sepsis after declining a laparotomy following a presumptive diagnosis of intestinal obstruction. She had been discharged from the hospital following a cesarean section. Action plans to address possible risk factors contributing to the death included providing feedback to healthcare workers on the importance of good communication to clients; involvement of birth companions in decision making on options for the client; the CHVs to continue visiting pregnant mothers and referring them for ANC, SBA, PNC, and danger signs. In Migori, there were four neonatal deaths and the verbal autopsies showed that the causes were late commencement of ANC, religious beliefs (husband’s religion did not support hospital services), unskilled delivery, and delay in reaching the hospital when labor had started. There was an agreement to hold dialogue sessions in the relevant villages and strengthen household visits as well as the Chief holding further discussions with the community members on religious beliefs and importance of seeking health services. Integrated Community Case Management (iCCM) rollout During the reporting quarter, the Project scaled up integrated community case management (iCCM) in 2 CUs in Migori. The CUs were selected based on distance from the nearest health facility, inconsistent 24- hour service at the link facilities, and pneumonia and diarrhoea burden among under five children. The Project supported a 5-day rigorous training of 21 CHVs (8 male, 13 female) and 5 CHAs (1 male, 4 female) on iCCM which also included visits to health facilities for practical sessions. All the participants demonstrated a good understanding of iCCM and were provided with stopwatches, MUAC tapes, and patient recording forms after the training. Due to commodity stock-outs, only a few CHVs were provided with oral rehydration solution (ORS). The health facilities committed to provide the CHVs with necessary commodities.

Community-based distribution (CBD) of FP commodities During the reporting quarter, the Project supported a total of 3,045 CHVs to continue providing family planning services to community members. At county level, there were 865 CHVs in Kakamega, 861 in Kisumu, 934 in Kitui and 385 CHVs in Migori. The CHVs reached 67,404 community members with family planning counseling and key messages at the community level as shown in Table 18 below. In addition, 16 more CUs began to provide community based distribution of FP commodities, bringing the total to 53 project supported CUs involved in community based distribution of family planning commodities. The CHVs distributed 415 circles of pills during the reporting quarter. However, CUs in Kisumu faced challenges from the county government and were not able to distribute FP commodities during the reporting quarter. In Kakamega and Migori, an additional 104 CHVs (36 male, 68 4 female) were sensitized and began distribution of FP commodities. They consisted of 64 CHVs in Kakamega and 40 in Migori. They were provided with reporting tools and will be reviewing performance monthly. This is expected to increase access to family planning services to community members in hard to reach areas in the two counties.

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Table 18. Family planning services provided by CHVs in PY3Q3 County CHVs providing FP Clients that received FP CUs involved in messages counseling and messages CBD Kakamega 865 24,812 10 Kisumu 861 198 24 Kitui 934 31,569 0 Migori 385 10,825 19 Total 3,045 67,404 53

Strengthen Community-Facility Linkages, Referral Mechanisms, and Accountability During the quarter under review, the Project continued to support the strengthening of CHV desks to improve community-facility linkages. The CHVs on duty at the desks coordinate defaulter tracing and referrals as well as share tasks at the link facility. The CHV desks have enhanced collaboration between the communities and the link facilities, and have enabled the CHVs to interact with clients as they come to the facilities. Further, the CHV desks have enabled registration of ANC mothers to the Linda Mama program. In addition, during the reporting quarter, the Project supported the convening of CU monthly reporting and feedback CHV link desk at Navakholo sub-county meetings at the health facilities to interrogate and hospital; CHVs supporting in taking weight and triangulate data from the community with that of the height of mothers and babies at MCH link facility. Continuous mentoring on CBHIS reporting tools was provided during the meetings to address any data quality gaps..

During the reporting period, the Project supported a total of 3,045 CHVs (788 male, 2257 female) to attend monthly review meetings, an improvement from 2,249 CHVs that were reported in PY3Q2 period. The 55 additional CUs identified for support in Butere and Lurambi sub counties in Kakamega county led to an increased number of CHVs providing FP services during the reporting quarter. In Kakamega, the Project supported 89 CUs to hold monthly review meetings that were attended by a total of 865 CHVs (81 male, 256 female) to discuss data generated during household visits. In Kisumu, the Project supported the 60 CUs to hold review meetings to review monthly data with a total of 861 CHVs (140 male, 721 female) in attendance. In Kitui, 94 CUs were supported to revive the link desks and develop a monthly duty roster for CHVs to manage the desk. The desks have improved the coordination of defaulter tracing and referrals for ANC and immunization. During the monthly review meetings, 934 (279 male, 655 female) CHVs participated. In addition, 29 traditional birth attendants (TBAs) were supported to hold quarterly review meetings in Mwingi West and Kitui South sub counties. In Migori, the Project supported 32 CUs to convene monthly review meetings that were attended by a total of 385 CHVs (136 male, 249 female).

Strengthen Use of Community Based Health Information System for Decision Making During the quarter, the Project supported the distribution of 1,440 copies of community based health information system (CBHIS) reporting tools to enhance data collection and reporting. In addition, the Project supported mentorship of 353 CHVs (146 male, 207 female) in Migori and 368 CHVs (85 male, 283 female) in Kakamega on CBHIS reporting tools and interpretation of the indicators. In Kitui, the Project

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supported data quality assessment in 6 CUs across the county. The assessment revealed gaps in CHVs’ understanding of key indicators and reporting, availability of necessary tools, as well as the need for household mapping to update the CU household data. The Project will continue to support continuous mentorship and coaching for CHVs to improve the quality of reporting. In addition, the Project will strengthen use of “talking walls” that visualize performance trends in key indicators to enable CHVs to continuously interact with and use the community data for decision making. DQA exercise in Kasyala CU in Kitui Central Sub County in Kitui County Output 1.3: Strengthened county health systems for delivery of FP/RMNCAH, nutrition and WASH services Activity 1.3.1. Improve Leadership and Governance Capacity of CHMTs and SCHMTs

Development and operationalization of joint work plans (JWPs) During the previous quarters, Afya Halisi worked closely with the CHMTs in the focus counties of Kakamega, Kisumu, Kitui and Migori to develop their joint work plans. The joint work plans that cover the period of FY 2020, highlight the county priorities in line with their annual work plans, and indicates funding by the government and all stakeholders. The counties committed resources for training and mentorship, supportive supervision, performance review meetings, data quality assessments, and immunization logistics including vaccine distribution. However, due to the COVID-19 pandemic, the focus county governments shifted their focus in mitigating and preventing the surge of the pandemic. The Project continued to co- create, co-plan, co-finance, co-implement and co-monitor activities with the focus county governments.

Activity 1.3.2. Strengthen Health Workforce

Transitioning of the contracted HRH to county governments The Project continued to advocate the county governments, up to the highest levels of leadership, to absorb 30% of the HRH staff into their payroll in FY 2020/21. In June 2020, the Project provided contracts to only 70% of the HRH staff that were included in the Project's payroll. The other 30% were considered for transitioning by the county governments of Kisumu, Kitui and Migori. The county governments of Kisumu and Migori absorbed 2 HRH staff each, and the other HRH staff were not considered based on the appraisal results that were done jointly with the county governments.

Activity 1.3.3. Health Management Information Systems (HMIS) for Effective Use of Data

Details for this section are included in the Performance Monitoring section of the report.

Activity 1.3.4. Access to Essential Medicines and Other Health Commodities

Percent of SDPs that report a stock out of any FP commodity The stock out of FP commodities remains a critical system-level gap in the focus counties. In the reporting period, 71% of the project supported sites reported stock-out of at least one of the five FP commodities (either of COCs or POPs, IUDs, DMPA, Male condoms, and Implants) as shown in Table 19 below. This is higher than the 64% stock out reported in PY3Q2 period. The FP commodity that was mostly out of stock during the reporting quarter was male condoms at 43%. During the quarter, the Project supported

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distribution of 7,100 male condoms to the focus counties which was a donation from DKT. The Project continued with its collaboration with Afya Ugavi to strengthen commodity security and supply chain component of the health system and advocate for the accountability of commodity management with the respective CHMTs. Afya Ugavi has been supporting Health Products and Technologies Units in the four counties whose mandate is to ensure consistency in-stock availability.

Table 19. FP commodity stock out rates in project supported health facilities, PY3Q1-Q3 Indicator/County Kakamega Kisumu Kitui Migori Project Percent of SDPs that report Y3Q1 81% 83% 90% 81% 85% a stock out Y3Q2 59% 53% 70% 67% 64% Y3Q3 87% 79% 82% 42% 71% Average stock out rate Y3Q1 49% 63% 32% 53% 46% (Injectables as proxy) Y3Q2 48% 40% 21% 36% 32% Y3Q3 29% 44% 13% 11% 21%

Average FP commodity stock out rate The injectable DMPA is seldom stocked out in facilities in the country. In PY3Q3, 131 facilities (21%) experienced a stock out of Injectables during the reporting quarter as shown in Table 19 above. This is a slight improvement from 32% stock out reported in PY3Q2 period. The counties received stocks in February/March 2020 and this resulted in an improvement in the availability of the commodity. Kisumu county had the highest stock-out of DMPA at 45% percent and the Project identified distribution gaps. The Project worked with the sub counties in Kisumu County to support redistribution of the commodity to health facilities that had a stock out.

Capacity strengthening on commodity management In PY3Q3, the Project did not conduct training on commodity management as the Project had already frontloaded training of the HCWs in commodity management and reached 595 HCWs in year 1 and 251 HCWs in year 2. During the quarter, the Project worked with the USAID supply chain systems support mechanism (Afya Ugavi) to conduct an assessment of HCWs' capacity needs on commodity management in Kitui County. In the next quarter, the Project will work with Afya Ugavi to provide targeted small group and structured mentorships to the HCWs, while adhering to the government's public health guidelines on continuity of essential health services during the COVID-19 pandemic period.

Activity 1.3.5. Health Care Financing

During the reporting quarter, the Project co-supported sensitization of 40 health facility managers (16 male, 24 female) on the process of registration of Linda Mama, making claims, budgeting for Linda Mama and NHIF reimbursements, general financial management and when to follow up in case of delays and complication at different times. Twenty two of the managers (9 male, 13 female) were drawn from 22 private facilities in Migori County while 16 health care managers (5 male, 11 female) were from 14 private health facilities in Kisumu County. As a result of this sensitization, health facility managers were equipped with knowledge and skills leading to improved capacity to manage reimbursements claims and allocate resources appropriately. During the quarter, Afya Halisi also supported efforts to empanel private facilities into NHIF and Linda Mama. Based on an assessment that was conducted in PY3Q2, 14 private facilities in Kisumu County and 18 private facilities in Migori County did not have NHIF and Linda Mama. During the reporting quarter, the Project followed up with Migori County NHIF Office on the status of seven (7) private health facilities who had applied for empanelment but had not received any feedback. As a result of this follow up, four (4) of the 7 facilities were gazzetted and signed contracts with NHIF. However, the Project experienced challenges in supporting facilities that were initiating engagements with NHIF. There was confusion in

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responsibility for empanelment of health facilities into NHIF between NHIF agency and the Kenya Health Professionals Oversight Authority (KHPOA) as created by Health Laws (Amendment) Act, 2019. In PY3Q4, Afya Halisi will continue engagements with NHIF and KHPOA. Afya Halisi will work with the County to support empanelment of facilities requiring NHIF accreditation. In Migori, the regulations to operationalize the County Health Service Act that was co-facilitated and co- financed by Afya Halisi was finalized and printed by the government printer. The Health Services Act has a section that describes the mobilization and utilization of health funds. The Project supported the County Government of Kitui through a co-creation, co-planning and co-financing process to finalize the Kitui Health Services Bill that has sections that stipulate the generation and utilization and ring-fencing of health services funds; implementation of the Community Health Strategy, including the role and utilization of CHVs; and the Health Products Technology Unit. In Kisumu, the Project co-supported the county to develop a draft road map for domestic resource mobilization from the private sector. The draft road map is undergoing review and will be launched in the subsequent quarter.

Sub-purpose 2: Increased care seeking and health promoting behavior for FP/RMNCAH, nutrition and WASH

Output 2.1: Increased knowledge of and demand for FP/RMNCAH, nutrition and WASH services Activity 2.1.1 Identify and Support Context-Specific Strategies for Healthy Behaviors

Cascading SBC Strategies In Migori, during the reporting period, the Project supported a 3-day training on social and behavior change (SBC) for 21 (12 male, 9 female) MOH officers and 6 LIP staff (3 male, 3 female). The participants included 4 Health Promotion Officers, 12 sub county Community Health Strategy Focal Persons from all the focus sub counties and three staff each from Lwala Community Alliance and KMET. In addition, the Project supported the training of 42 CHVs (13 male, 29 female) and 2 female CHAs in Migori on community maternal and newborn health and SBC facilitation techniques.

In Kakamega, the Project worked with MOH to support the training of 10 female HCWs and 40 CHVs (11 male, 29 female) in Matungu Sub County on Counselling for Choice (C4C). The training was aimed at building the capacity of the HCWs and CHVs to better guide clients while making choices on contraception methods and dealing with the side effects thereby promoting client satisfaction. In addition, the Project supported the training of 17 HCWs (7 male, 10 female) in Lurambi Sub County and 23 HCWs (10 male, 13 female) in Butere Sub County on social and behaviour change. The two sub counties were added for the Project’s support during the reporting period, and the training on SBC had been identified as a need.

In Kitui, the Project supported virtual mentorship sessions on SBC for 5 LIP staff. The sessions focused on introduction to SBC, theories/modules guiding SBC work, and guidelines to conducting effective outreaches. In Kisumu, the Project supported the training of 14 HCWs (4 male, 10 female) and 22 CHVs (3 male, 19 female) from Kobura ward in Nyando Sub County on Education Through Learning (ETL) and Counselling for Choice (C4C) techniques.

In addition, the Project sourced for, contracted and on-boarded an online learning platform service provider, Tech Care for All (TC4A). The service provider runs the medicallearninghub.com. The two SBC modules on C4C and ETL were completed and forwarded to the service provider for adaptation and uploading to the online learning platform for use in online training of HCWs and other cadres. Ten Project staff will test the platform in the subsequent quarter, before its roll out.

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Adaptation of Available/National Materials to Context During the period under review, the Project supported the focus counties through the inter-county virtual meeting forums to revise the now defunct National Health Communication Guidelines (NHCG) and adapt them to county context to address emerging communication priorities such as the need for guidelines for Health Emergency, Disaster and Risk Communication and how to implement an effective social media intervention. During the Health Promotion Advisory Council (HPAC) meetings, the county teams shared progress and challenges in reviewing the health communication guidelines. All the county teams submitted their reviews, which were consolidated into “draft zero”. In the subsequent quarter, the Project will co- create with the county HPAC teams to review the document and contextualize it to the county needs. During the reporting period, the Project supported in collation of information, education and communication (IEC) materials in all the health areas and uploaded them to a sharable G-drive to support in learning. During the period under review, Afya Halisi worked with Kisumu county government to co-plan for the establishment, operationalization and launch of the Kisumu Emergency Communication Center (ECC). The Project supported in development of marketing materials (artworks for e-flyers) and the protocols to guide the personnel working at the ECC.

Activity 2.1.2 Create Demand for Services

Small Group Sessions In Kitui, the Project supported a dialogue session on maternal and newborn health with 20 members ( 17 male, 3 female) of Kavonokya sect in Mwingi West Sub County. During the sessions, social and religious barriers to uptake of health services were identified. The Project supported dissemination of health messaging to the sect members. In addition, the Project supported a dialogue session on AYSRH with 10 female adolescents where issues of teen pregnancies and menstrual hygiene were discussed. The Project also supported re-orientation of 20 traditional birth attendants (TBAs) in Kakululo Dispensary in Mwingi South Sub County.

Community Engagement and Mobilization Activities The COVID-19 pandemic came with challenges that led to reduced volume of clients seeking health services in health facilities. To address these barriers, the Project co-created with the focus county governments to develop innovative ways of reaching community members with correct health information and ensure continuity of essential RMNCAH and nutrition services. The Project co-supported the drafting of guidelines and talking points that were used in various community engagement sessions. These included;  Talking points on AYSRH and SGBV for use by CHVs  Talking points on continuity of services for use by County Health Promotion Officers and other cadres attending radio and TV interviews and carrying out social mobilization using vans mounted with public address systems  Taking points on integrated COVID-19/Malaria for radio that were used during World Malaria Day  FP/RMNCAH, Nutrition and WASH Guide on household visits for CHVs  Strategy document for rollout of the Project co-supported toll-free lines christened “411 Nangos mtaani”.  Mass media strategy for Afya Halisi, which was disseminated to the focus MOH teams and co- support provided Health Promotion Officers in planning for mass media activities.  Development of messages for key health areas to address “Continuity of Services” amid the COVID-19 pandemic. The messages aim at providing correct information on COVID-19 to the public, address myths and misinformation, and create confidence in the public sector healthcare system.

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Afya Halisi continued to support Health Promotion Officers in the focus counties to operationalize catalytic technologies, including revamping their social media pages. In the month of June 2020, the Project provided technical assistance to the counties on use of social media as a tool of change. The Project supported development of content which was shared on various platforms such as E-poster, videos and existing county screens. There were also follow-up sessions on how to build followers and maintaining their interest on the pages. Throughout the reporting period, relevant health information were uploaded in the platforms to provide ample updates on various health services. Strengthen Community Referrals, Linkages and Defaulter Tracing During the reporting quarter, the Project supported the CHVs to trace and refer for services a total of 2,350 defaulters in comparison to 2,200 defaulters that were traced in PY3 Q2 and 612 in PY3Q1 as shown in Figure 17 below. The CHVs followed up to ensure referred defaulters received the missed services. In Kakamega, 518 defaulters (ANC - 121, immunization - 385, PNC - 12) were traced and referred for services while in Kisumu, 301 (ANC- 74, immunization - 212, PNC - 15) were traced and referred for services. In Kitui, 738 defaulters (ANC - 263, immunization- 442, PNC - 33) were traced and referred for services, and in Migori, 533 defaulters (ANC - 236, immunization - 496 and PNC - 61) were traced and referred for services. The Project supported HRIOs to follow up and ensure that HCWs updated registers once the defaulters were identified.

2500 2350 2220 2000 1535 1500 1212

1000 612 650 694 445 500 358 167 121 0 0 Y3Q1 Y3Q2 Y3Q3

ANC PNC Immunization Total

Figure 17. Defaulter tracing outcomes in focus counties, PY3 Q1- Q3

Activity 2.1.3 Optimize all Contacts with the Health Care System

Improvement of SBC Quality During the reporting quarter, the Project supported mentorships of 105 HCWs (64 male, 41 female) and 101 CHVs (75 male, 36 female) on social and behaviour change quality assurance/quality improvement (SBC QA/QI), mentorship and supportive supervision to enable them provide meaningful supportive supervision sessions and enhance the quality of social and behaviour change sessions with clients for improved uptake of health services. The HCW mentees will cascade the skills to community health assistants (CHAs) and community health extension workers Health care workers during the sensitization on SBC QA/QI tool

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(CHEWs) at the ward levels. The SBC QA/QI tool was also disseminated and the mentees were expected to scale up its use in the subsequent quarter.

In order to improve the quality of community dialogue sessions, the Project facilitated support supervision visits that reached 95 CHVs (40 male, 55 female) in Migori. The supportive supervision sessions were conducted at household level and during small/mini-group discussions. The CHVs were assessed during the dialogue sessions and were provided with feedback on facilitation quality indicators that included; preparation, choice of venue, salutation and introduction, building rapport/trust, probing skills, reflective listening, mastery of health area knowledge, call to action, action-planning with clients and post-session duties including linkages and referrals.

Facilitate/Support Quarterly SBC review meetings During the quarter under review, the Project supported four inter-county virtual Health Promotion Advisory Council (HPAC) meetings. The virtual meetings were necessitated by the need to ensure continuity of priority activities of the committees despite the challenges brought about by the COVID-19 pandemic. During the inter-county meetings the following; the HPAC terms of reference were finalized; county briefs focusing on COVID-19 prevention and promotion activities were discussed, and provided a rich learning platform for the participants; online learning platforms for SBC were demonstrated; and mass and social media support as a strategy for promoting health messaging and continuity of services was discussed.

In addition, the Project supported an in-person HPAC meeting in Kitui. The participants reviewed key health area messages for use in community and media activities. The messages will be useful in ensuring continuity of essential health services in health facilities which had been negatively affected by the COVID- 19 pandemic. Output 2.2: Improved gender norms and sociocultural practices During the reporting period, the Project continued to build capacity and deepen commitment of County Departments of Health and Gender in promoting gender equality and social inclusion as well as sexual and gender based violence (SGBV) prevention and response in FP/RMNCAH, Nutrition and WASH. However, COVID-19 pandemic continued to increase susceptibility of children, women, men and boys to Gender Based Violence and destabilization of related gender norms. In response, the Project co-supported the following activities targeted at mitigating cases of gender violence and strengthening health systems to adequately respond to the emerging cases; formation of the Project Gender Steering Committee, training of HCWs on IPV/SGBV prevention/response, orientation of county and sub county HMTs on gender responsive approaches, site supportive supervision and mentorship on IPV/SGBV screening, documentation and reporting, community dialogues, Gender technical working group (TWG), formation and support of Gender/GBV ward multi-sectorial boards, review of SGBV data and advocacy on data use for decision making, and sensitization of CHAs on SGBV prevention and response.

Activity 2.2.1. Implement County Specific Gender Integration Strategies

Strengthening of Gender TWGs In Kisumu, the Project supported the Gender Technical Working Group under the leadership of Gender Directors to sensitize the team on gender sensitive planning. The Gender TWG reviewed the performance of the last quarter and developed action plans for the subsequent quarter and the priority was to mark out all stakeholders aimed at stream lining gender integration and SGBV prevention/response to avoid duplication and maximize on resources, dissemination of SGBV policy and Gender Policy Development fast tracking. In Kitui, 12 health facilities identified gender focal persons and they are in the process of forming facility level gender committee to enhance gender integration and SGBV prevention/response.

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Commemoration of the Day of the African Child In Kakamega and Migori counties, the Project participated in virtual celebrations of the Day of the African Child through Gender and Child Protection Technical Working Groups. The theme of the commemoration was "Access to a Child-Friendly Justice System in Africa". The teams agreed to enhance justice access for child survivors of Sexual Gender Based through a multi-sectorial approach.

Project Gender Steering Committee During the quarter the, the Project established Project Gender Steering team to support in gender integration, SGBV prevention/response and social inclusion in the focus counties as well as project level thematic areas.

Activity 2.2.2. Utilize community platforms to promote positive gender and sociocultural norms and practices, including equitable decision-making

Set Up Community Gender Multi-Sectoral Advisory Boards During the reporting quarter, the Project supported the Gender focal persons and Reproductive Health Coordinators to strengthen a total of 27 Community Gender Multi-Sectorial Advisory Boards aimed at promoting and addressing gender based inequities that limit access and utilization of FP, RMNCAH and nutrition services, and strengthen GBV prevention and response especially in identification, referral and linkage of SGBV survivors for post GBV Care.

Targeted Small Group Sessions The Project worked with MOH to hold community level dialogues sessions in Kakamega and Migori to discuss gender norms that promote uptake and utilization of FP, RMNCAH, nutrition and WASH services. During the dialogue sessions, gender myths and misconceptions were clarified. The sessions also provided an opportunity to discuss GBV prevention and response at the community level.

Activity 2.2.3. Build capacity of HCWs, CHVs and champions to discuss gender norms and sociocultural beliefs and provide gender responsive services

Build the Capacity of County and Sub-county Mentors on GBV First-line Response During the quarter under review, the Project worked with the Gender Focal Persons in Migori and Kitui counties to build the capacity of 73 HCWs (32 male, 41 female) as county and sub county mentors aimed at equipping them with knowledge, skills and attitudes on IPV/GBV as first line responders. In Kakamega, the Project supported the training of 14 HCWs (2 male, 12 female) in Lurambi sub County on management of SGBV among children and adolescent survivors. In Kisumu, the Project worked with MOH to sensitize 11 private sector representatives (5 male, 6 female) on gender integration and SGBV response with the aim of strengthening referral and linkage of survivors.

Gender Transformative Programming of LIPs and S/CHMTS The project also continued to build the capacity of local implementing partners on gender integration, social inclusion and SGBV prevention and response, to enable them carry out targeted advocacy on social inclusion, gender responsive care, gender based violence and eradication of harmful socio-cultural practices that impede access to FP/RMNCAH and nutrition services.

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In Kakamega, the Project worked with the Kakamega County Gender Focal Person to orient 12 C/SCHMTs (6 male, 9 female) on gender sensitive approaches to FP/RMNCAH/Nutrition/WASH that were aimed at enhancing gender sensitive planning and budgeting.

Develop/print GBV IEC, Service Delivery Algorithms and Data Tools The Project supported the distribution of GBV - LIVES flipbooks in Migori and Kitui counties to act as a reference guide to healthcare providers in GBV service provision. GBV LIVES flip book Activity 2.2.5. Strengthen GBV response and prevention mechanisms in schools, health facilities and community

In PY3 Q1, the Project worked with MOH to identify health facilities for targeted support on GBV in Kakamega and Kisumu counties. Based on the co-creation efforts, the Project and MOH identified 18 health facilities (14 in Kisumu and 4 in Kakamega) to offer comprehensive post rape care services. The trained CHV chaperones working closely with community and GBV actors continued to identify, refer and link survivors of SGBV to health facilities. Table 20 below shows the GBV survivors provided with services to-date in Y3.

Table 20. Post GBV services in targeted health facilities in Kakamega and Kisumu in PY3Q1-Q3 Kisumu Kakamega Total Post GBV services PY3Q1 PY3Q2 PY3Q3 Total PY3Q1 PY3Q2 PY3Q3 Total No of rape survivors 528 369 158 1,055 81 79 91 251 1,306 No presenting within 88 73 89 250 56 59 75 190 440 72hrs No initiated on PEP 76 72 79 227 46 36 55 137 364 No tested for HIV 497 364 158 1019 81 73 91 245 1,264

In Kisumu, there has been a steady decrease in documented rape survivors in the targeted health facilities from 528 in PY3 Q1 to 158 in PY3 Q3. This could be attributed to the fear among the rape survivors to seek services in health facilities due to the COVID-19 pandemic. In Kakamega, the rape survivors marginally increased from 81 in PY3 Q1 to 91 in PY3 Q3 period. The increase can be attributed to COVID- 19 pandemic which has led to increased vulnerability to gender based violence as a result of destabilization of the social norms compounded by curfew, restriction of movements and economic challenges. In the subsequent quarter, the Project aims to intensify awareness creation on SGBV at the community level, support the Gender focal persons to scale up provision of comprehensive post GBV care including follow up of justice outcome for the survivors. The Project will also work with MOH to enhance efforts to ensure comprehensive care of all survivors, including follow up on PEP completion and HIV testing using the trained case chaperones, and ensuring timely, complete and accurate reporting of the data.

Identify and Train CHVs as Case Chaperone’s for Survivors The Project worked with MOH to conduct sensitization of 15 CHAs (3 male, 12 female) to promote strengthening of community health strategy to address gender norms that hinder access and utilization of services as well as enhancing GBV prevention and response through awareness creation, identification of survivors, referral and linkage for post GBV Care services.

Creation of Friendly and Safe Waiting Bays for Child Adolescent Survivors of VAC In PY3Q2 period, the Project, in collaboration with the Kisumu and Kakamega county MOH teams, identified space at Ahero Sub County Hospital and Kakamega County Government Teaching and Referral

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Hospital (KCGTRH) for renovation as Gender Based Violence and Recovery Centers (GBVRC). During the reporting quarter, the Project submitted a request for approval of renovation of the centers to USAID KEA. In the subsequent quarter, the Project will support renovation of the centers once it gets approval from USAID KEA.

Strengthen County, and Sub-county Level GBV Focused M&E Approaches During the reporting quarter, the Project supported the orientation of 39 HRIOs and Gender Focal Persons (18 male, 21 female) on management of GBV data, including documentation and uploading of data in the Kenya Health Information System. In addition, the Project supported dissemination of IPV screening and reporting tools and well as SGBV documentation and reporting tools in supported health facilities in Kakamega, Migori, Kisumu and Kitui Counties. In addition, in Kakamega and Kisumu counties, the Project supported onsite mentorship of 100 HCWs (44 male, 56 female) on IPV screening, SGBV documentation and reporting. In the subsequent quarter, the Project will continue to work with the County Gender Focal persons and CHRIOs to mentor HCWs on use of GBV and IPV reporting tools.

Output 2.3: Increased practice of key nutrition and WASH behaviors in target communities Activity 2.3.1. Promote and support key nutrition and WASH behaviors in target communities

Baby Friendly Community Initiative The Project co-implemented an assessment of the BFCI CUs in Navakholo and Khwisero sub counties to track progress and identify gaps. The Project also supported orientation of sub county Community Focal Persons, Community Health Assistants (CHAs) and facility CHEWs on BFCI. In addition, the Project co- financed the cascading of the training on BFCI to CHVs in Khwisero, Navakholo, Uriri, Awendo, Nyatike, Kuria West and Kuria East sub counties. This led to an additional 11 CUs implementing BFCI in Kakamega County bringing the total to 61 CUs while in Migori an additional 13 CUs were trained bringing the total to 66 CUs implementing BFCI.

Kakamega County During the reporting quarter, the Project reached 8,366 children aged 0-23 months through community level nutrition interventions in the county. The under two children were reached through BFCI CUs, BFHI CUs and other project supported CUs during household visits conducted by CHVs and during mother to mother support group (M2MSG) meetings. The Project also co-planned and co-financed BFCI trainings with the county MOH teams. In addition, the Project supported monthly review meetings where BFCI data was integrated and discussed. In Kakamega, the Project supported training of community health assistants (CHAs) on BFCI since a BFCI assessment in Navakholo sub county in capacity gap had been created when some CHAs Kakamega County were transferred out. In addition, the Project scaled up BFCI implementation by training CHVs in additional 11 CUs bringing to total 61 CUs implementing BFCI in the county. Due to COVID-19 containment measures, a separate training was organized for community mother support groups (CMSGs) to ensure adherence to social distancing. In the subsequent

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quarter, the Project will scale up implementation of BFCI in the additional sub counties (Butere, Lurambi and Mumias East) in Kakamega.

100% 83% 80% 68% 61% 63% 60% 53% 50% 50% 38% 39% 40% 33% 25% 20% 13% 13% 13% 13%

0% Navakholo SCH Ematia Dispensary Bushiri RDHC Kharanda H/C Butingo Dispensary

Baseline 2018 Self-assessment 2019 County assessment 2020

Figure 18. Progress on BFCI implementation in Navakholo sub county in Kakamega, 2018 -2020

Figure 18 above shows progress made by health facilities in Navakholo sub county on implementation of BFCI. Based on the county assessment that was done during the reporting quarter, there was great improvement and follow ups will be done in the high performing facilities in the subsequent quarter. The main challenge has been frequent transfers of CHAs from the high performing health facilities. To address this, the Project will work with the sub county teams to provide onsite mentorships in health facilities with newly recruited HCWs. Migori county During the quarter under review, the Project reached 7,967 children through community level nutrition interventions. The Project scaled up implementation of BFCI to 68 CUs in the county, from 53 in the previous quarter. This was done through training of the sub county Community Health Strategy focal persons, CHAs, CHVs and CMSGs. The key community members that were trained as CMSG included: Chief, lead mother, CHC representative, youth leader, religious leader, community CHA, facility chairman, CHV representative, traditional birth attendants (TBAs) and village elders. The trainings were conducted while observing all the COVID-19 guidelines. The Project also worked with the sub county teams to co- support mentorship of HCWs in CUs implementing BFCI in readiness for the self-assessment that will conducted in the subsequent quarter.

Activity 2.3.2. Improve Water Sanitation and Hygiene Practices

Scale Community–Led Total Sanitation (CLTS) Approach During the reporting quarter, the Project continued to implementing WASH activities in the community through CLTS in Kakamega, Kitui and Migori counties. The activities ranged from triggering, follow-up, monitoring, open defecation free (ODF) verification, certification and post-ODF activities.

During the quarter, the Project worked with the county MOH teams and supported verification of 57 villages as open defecation free. This reflected an achievement of 77% against the annual target of 74. In Kakamega, the Project worked with sub county WASH Coordinators and Public Health Officers to support verification of 34 villages in Khwisero, Matungu and Navakholo sub counties. In Migori, the Project supported follow up of a total of 113 villages based on the CLTS protocol. Consequently, during the reporting period, 23 villages in Kuria East sub county were verified as ODF against an overall target of 36 villages. Follow up in the remaining villages will continue in the subsequent quarter. In Kitui, the Project

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does not support CLTS follow up villages since the county is open defecation free. The Project's focus is not only on villages attaining ODF status but that those same villages retain ODF status beyond the life of the project. To achieve this, the Project in PY3Q3 trained PHOs on sanitation marketing. The PHOs cascaded the training to CHVs in order to increase coverage for sanitation marketing.

The CLTS interventions were implemented in the background of heavy rains that pounded most areas in Migori and Kakamega counties from the period of September 2019 to June 2020 that resulted in villages in the flood prone areas such as Nyatike relapsing to open defecation.

As a result of the CLTS support, the Project enabled a total of 7,733 people (3,791 male, 3,942 female) to gain access to basic sanitation services during the reporting, bringing the total to 8,452 (4,137 male, 4,315 female). This represented an achievement of 64% of the annual target of 13,284. The Project worked with MOH to prioritize wards that had low latrine coverage, had challenges with soil formation and other barriers to access to basic sanitation and scaling up the sanitation ladder. The achievement of the target was initially slowed down at the beginning of the quarter due to national government restrictions that were put in place on gathering of people to mitigate the spread of COVID-19 pandemic. In the next quarter, the Project will work with MOH to support additional households to access a basic sanitation service, especially in villages that had been identified for CLTS follow ups and targeted for verification in Kakamega and Migori counties.

Support Post ODF Activities for Sustainability In order to improve the sanitation ladder at household level, the Project supported the training on Sanitation Marketing for PHOs, artisans and CHVs in Kakamega, Kitui and Migori counties. During the reporting quarter, the Project worked with MOH to train 1,299 individuals (595 male, 704 female) on sanitation marketing (SanMark). This reflects an achievement of 166% against the annual target of 788. The over- achievement was due to the Project's focus on onsite training of the individuals on sanitation marketing. At the county level, the Project supported the training of 235 individuals in Kakamega, 827 in Migori and 237 individuals in Kitui.

The training on sanitation marketing was aimed at equipping the PHOs, artisans and CHVs with skills to enable them help communities to climb the sanitation ladder through sustainable, affordable and acceptable sanitation options for households and communities. The approach employed local technologies that helped communities adopt sanitation facilities such as latrines that are permanent and that can help them sustain ODF status. The slogan in such a case has been “choo bora” translated as “good latrine” instead of “bora choo” (just a latrine).

As an outcome of the training in sanitation marketing, the PHOs in Migori in collaboration with local artisans embarked on demand creation strategies in their respective communities They engaged community members on the importance of sanitation uptake and associated benefits as well as demonstrations on improved sanitation hardware options that are locally available, such as Sato pans and Sato stools. In the subsequent, the Project will support the PHOs to conduct follow ups that have constructed improved latrines as a result of the SanMark approach.

Increase Access to Safe Water through Spring Protection During the reporting period, the Project supported a total of 15,069 people (6,866 male, 8,203 female) to gain access to basic drinking water services. This reflects an achievement to date of 133% against the annual target of 11,300. The over-achievement was due to the Project’s support to repair five boreholes in Kitui, which are located in more populated areas, thus enabling 13,200 to gain access to basic drinking water services as shown in Table 21 below. The boreholes were carefully selected to be within the priority sub counties with a focus on high diarrhea burden locations.

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Table 21. Boreholes supported with minor renovations in Kitui County No Name of the borehole Sub County Ward Beneficiary population 1 Mwangea borehole Mwingi North Tseikeru 2,500 2 Kasaini borehole Tseikeru 3,700 3 Kasaala borehole Kitui South Ikutha 2,300 4 Katanu borehole Mutha 1,700 5 Uae borehole Mutomo 3,000 13,200

In Kakamega, the Project reached 673 people, and 1,196 people in Migori were reached to gain access to basic drinking water services, through rehabilitation of four water springs. The Project worked together with the county water departments and the community conducted assessments, and held co-creation meetings and consultations on community contributions, community mobilization of local resources, and provision of unskilled labor by the community members for rehabilitation of the water springs.

Activity 2.3.3 Support County WASH and Nutrition forums and link with partner projects

Strengthen coordination of WASH partners During the reporting quarter, the Project co-supported the Kakamega County WASH coordination forum that brought together WASH implementing partners and the water and health department officers responsible for WASH. The key agenda for the meeting was the introduction of new WASH partners in the county, receive feedback from the sub county teams and partners, and explore areas of synergy by partners. Sub-purpose 3: Increased MOH stewardship of key health program service delivery

Output 3.1: Strengthened coordination, M&E capacity Activity 3.1.2. Build M&E capacity and strengthen strategic information for evidence- based policy planning Engagement with new Head of Department of Family Health The Project leadership held a meeting with the new Head of Department of Family Health to articulate the project’s support to the Department, and share challenges that have been encountered. The Head affirmed his support for Afya Halisi Project and provided a roadmap that would unlock some of the challenges that had been faced which included inadequate coordination of activities between the various Divisions and pending revision of guidelines that were long overdue.

Rapid Assessment on the impact of COVID-19 on essential services At the onset of the COVID-19 pandemic, Afya Halisi conducted a rapid assessment to document the impact of COVID-19 pandemic on the provision and uptake of RMNCAH services. The purpose of the assessment was to document the impact of the pandemic on RMNCAH services; identification of potential areas for intervention to mitigate any negative consequences; identification of services that have been negatively impacted for future mop-up activities; and dissemination of the findings to the county governments, donors and other players. The assessment was done using two methodologies that included review of facility data on select key performance indicators, and interviews with key participants, ranging from health care workers, CHVs, community members, and adolescents. The findings were disseminated in national forums and an action plan developed on how to ensure continuity of services. The findings were also incorporated in the guidelines that the various programs developed on continuity of health services.

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Division of Reproductive and Maternal Health TWG Meeting During the reporting quarter, the Project supported DRMH to convene technical working group meetings for the M&E and MNH Programs. Afya Halisi participated in these discussions and provided online platform, zoom account, for the meetings. In all these meetings, Afya Halisi supported MOH to prepare and present the performance review of the RMNCAH indicators which led to actions that were aimed at improving the overall performance of the indicators. Some of the actions agreed upon included; routine DQA to review data on teen pregnancy; finalization of guidelines for essential services; strengthen coordination with the Division of Community Health to leverage on the community health strategy for continuity of RH services during the COVID-19 pandemic period.

Division of Neonatal and Child Health M&E TWG Meeting Afya Halisi provided technical support during the Division of Neonatal and Child Health M&E meeting. The forum was aimed at sharing performance of key neonatal and child health indicators for the quarter; updates on children infected with COVID-19; updates on the printing and roll out of the revised MOH reporting tools, and partner updates on M&E plans and activities. There was notable decline in outpatient department (OPD) attendance, pneumonia and diarrhea cases in March 2020; and decline in Vitamin A performance – normally there is a spike in May due to the Malezi Bora activities. Training of HCWs on the revised MOH reporting tools was postponed to a later date due to COVID-19 pandemic. The Health Information System (HIS) was to upgrade and customize the new tools in KHIS by July-August 2020.

Output 3.2: Strengthened capacity to develop evidence-based policies, strategies and guidelines Activity 3.2.1. Provide technical support for the development, review and dissemination of national policies, guidelines and technical briefs

Development of guidelines for continuity of RMNH/FP care and services in the background of COVID- 19 pandemic Afya Halisi provided technical support during virtual technical discussions with DRMH and partners to develop and finalize guidelines for continuity of RMNH/FP services during the COVID-19 pandemic period. The guidelines were shared nationally to guide HCWs to effectively manage the COVID-19 pandemic while maintaining continuity of essential health care services. The Project supported printing of 1,000 copies of the guidelines for the four focus counties.

Development of guidelines for provision of GBV services during COVID-19 pandemic period Afya Halisi provided technical support during virtual technical discussions that had been convened by the SRH program within the Division of Reproductive and Maternal Health. The engagement forums were co- supported by the various SRH implementing partners, which culminated in the development of guidelines for GBV services during the COVID-19 pandemic period.

Development of the national EmONC package Afya Halisi provided technical support in review of the materials for the development of the national emergency obstetric and newborn care (EmONC) package, which re-commenced after being postponed due to the COVID-19 pandemic. Part of the materials for development of the EmONC package was shared by the consultant for review. The plan is to have the Department of Family Health team to review the full materials by early July 2020.

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Lessons Learned Key lessons learned during the reporting quarter included;  The launch of toll free hot lines need to ensure county buy-in for sustainability; intensified marketing to increase the number of calls received and issues addressed; on board top most county leadership from the onset as it increases media coverage; and avoiding paying allowances to service providers that are handling the lines as this is not sustainable.  The use of online platforms such as Zoom, Google Meet and other videoconferencing tools, have proved to be nimble and cost effective, especially for regular and urgent virtual meetings and trainings and technical updates, in the context of the COVID-19 prevention and containment measures.  Mapping of pregnant women and under five children has enhanced defaulter tracing and referral for services. The creation of a database of the mothers with their mobile phone numbers has made longitudinal follow up, defaulter tracing and reminder volleys to be done effectively.  The formation and strengthening of GBV multi-sectoral boards at ward level has created a platform for prompt follow up of GBV cases. Through the WhatsApp platform, the members update each other and link the victims for services, and inform the authorities.

III. ACTIVITY PROGRESS (Quantitative Impact) This section has been included as an attachment.

IV. CONSTRAINTS AND OPPORTUNITIES

Effect of COVID-19 on planned activities: During the reporting quarter, the emergence of COVID-19 pandemic saw the national and focus county governments introduce public health measures targeted at slowing down the spread of the virus. The non-emergency health services were greatly affected by the COVID-19 response measures that were put in place, with some of the health facilities closing out-patient departments or transferring those services to other health facilities to minimize the spread of COVID-19 pandemic. During the initial weeks of the reporting quarter, communal and group activities were halted with counties offering support only for emergency support. A result, the Project reprogrammed its interventions to align to the national and county governments’ regulations on prevention and management of the pandemic. The reprogramming was necessitated to ensure that there is continuity of essential health services to the targeted population. In consultation with the focus county health leaderships, the Project continued with implementation of activities that do not require large gatherings of people, while ensuring adherence to the COVID-19 prevention measures.

Floods in Kisumu and Migori counties: During the reporting quarter, floods were experienced in parts of Nyando, Muhoroni, Nyakach and Seme sub counties in Kisumu County. The floods affected access to FP/RMNCAH and nutrition services in Komwaga, Kadhiambo, Katolo-Manyatta and Magina dispensaries in the county. In Migori, the floods were experienced in parts of Nyatike Sub County. The areas that were affected included Lwanda Konyango, Kabuto, Angugo, Nyora, Modi, Muhuru and Got Kachola wards. The Project co-implemented, with the county governments, targeted outreaches in the affected areas.

Kisumu HCWs strike: During the reporting quarter, HCWs in Kisumu went on strike to protest delays in salary payment, promotions, and re-designations. The strike affected provision of healthcare services in the county. The strike was resolved through a dispute resolution mediated by the industrial court. The effects of the strike and the public interest occasioned by the strike presented an opportunity for the county government to put in place long term measures to avert subsequent strikes. Through advocacy by Afya

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Halisi leadership and the County Assembly involvement, the county has initiated a process that will guarantee timely payment of salaries through bank overdrafts and also fast track the process of effecting promotions. These issues have been pending and were contributory factors to the strikes. The new CEC for Health, Prof Boaz Nyunya has identified HRH concerns as a priority issue for his attention to avoid similar situations in the future.

Transitioning of HRH staff to the county governments: During the reporting quarter, the Project provided contracts to only 70% of the HRH staff that were included in the Project's payroll. The other 30% were considered for transitioning by the county governments of Kisumu, Kitui and Migori. Due to various reasons, complete transition of the envisioned 30% of the HRH staff to the county governments’ payrolls did not take place.

Stock out of commodities: During the reporting quarter, the focus counties experienced challenges with commodity stock outs, including FP commodities. Upto 71% of the project supported sites reported stock- out of at least one of the five FP commodities (either of COCs or POPs, IUDs, DMPA, Male condoms, and Implants). This is higher than the 64% stock out reported in PY3Q2 period. The FP commodity that was mostly out of stock during the reporting quarter was male condoms at 43%. During the quarter, the Project supported distribution of 7,100 male condoms to the focus counties which was a donation from DKT. The Project continued with its collaboration with Afya Ugavi to strengthen commodity security and supply chain component of the health system and advocate for the accountability of commodity management with the respective CHMTs.

V. PERFORMANCE MONITORING

Strengthen HMIS and MEL systems for MOH and local implementing partners

Onsite mentorships on MOH reporting tools

During the quarter under review, the Project co-supported targeted onsite mentorship sessions focusing on documentation of data on adolescents (10-19 years) presenting with pregnancy (ANC) and Babies who received postnatal care within two days of childbirth, reaching a total of 79 HCWs in Kisumu (32 male, 47 female), while in Kakamega 56 HCWs (21 male, 35 Female) were reached. Across the two counties, 94 health facilities benefited from the onsite mentorship sessions. The mentorship sessions were conducted by respective SCHRIOs, Sub county RH coordinators and Ward data mentors in five sub counties in Kisumu and three sub counties in Kakamega. In addition, Afya Halisi worked with the Kakamega CHMT team led by GBV focal person and CHRIO, to co-support onsite mentorship of 111 healthcare workers (49 male, 62 female) on screening of clients for Intimate Partner Violence (IPV), data management and reporting.

In Kisumu, the Project co-supported a sensitization workshop of 25 SGBV focal persons (10 male, 15 female) in 14 health facilities across the six sub counties on Sexual and Gender Based Violence (GBV) tools. The team was sensitized on Sexual Gender Based Violence Register (MOH 365), Sexual Gender Based Violence Summary Form (MOH 364), Post Rape Care (PRC) Form (MOH Kitui East HMIS mentor providing onsite 363) and IPV screening and summary tools. The data mentorship at Kinakoni Dispensary collection and validation plan was developed and the

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HCWs were provided with copies of SGBV monthly summary reports to update SGBV data for the period of April-June 2020. Data quality and timely reporting was emphasized during the workshop.

In Kitui, the Project co-supported sensitization of 14 HMIS mentors through a virtual workshop. Consequently, the Project co-supported a total of 107 healthcare workers (43 male, 64 female) in 48 facilities in Kitui East and Mwingi Central sub counties to be reached through onsite mentorship on HMIS reporting tools. The Project also co-financed all the focus counties to collect the revised MOH reporting tools from national stores in Nairobi.

In Migori, the Project co-supported sub county MOH teams to conduct mentorship sessions to 72 HCWs (23 male, 49 female) in targeted 18 health facilities in Awendo and Uriri sub counties to address identified data quality gaps. The health facilities reached were identified a result of DQA that was conducted in PY3Q2 as part of follow up of the data quality improvement plan. The Project plans to continue working with the sub county MOH teams to support targeted onsite mentorship to HCWs and CHVs in high volume health facilities, and link CUs, on use of the MOH reporting tools to improve data capture and foster data use for decision-making.

Strengthen capacity of MOH and LIPs in planning, budgeting and monitoring

Development of annual work plans During the quarter under review, the Project co-supported consolidation of the annual work plans (AWPs) for 2020/2021 in Mwingi North, Mwingi Central, Kitui South and Kitui East sub counties. The AWPs will guide the county and sub county MOH teams to plan and monitor accomplishments during the financial year.

Strengthen use of data and information for action

Sub-county data review meetings

During the quarter under review, the Project co- financed and co-supported FP/RMNCAH, nutrition and WASH performance quarterly review meetings in five sub-counties in Kisumu county, reaching a total of 120 HCWs (87 male, 73 female). In Kakamega, the Project co- supported data review meetings in three sub counties, reaching 202 HCWs (69 male, 103 female). A total of 162 project supported health facilities were involved in the review meetings. During the meetings, the sub county and facility RMNCAH score card performance was reviewed as well as data extract from the Kenya Health Information System (KHIS). Afya Halisi printed copies of January to March 2020 score-card to act Ahero Sub county performance review meeting as points of reference during the review meetings. for January to March 2020 period. All the strategies to improve performance were developed, consolidated and uploaded in the RMNCAH.org tracker for follow-up. Due to the prevailing COVID-19 situation, the performance review meetings were held with a smaller number of participants, in larger halls and extended days to accommodate supported facilities whilst ensuring that the COVID-19 prevention measures were adhered to as required.

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In Kitui, the Project co-supported a quarterly performance review meeting in Mwingi North Sub County that targeted three wards. A total of 13 health facility in-charges participated in the performance review meeting, which looked at performance for the period October 2019 to May 2020. In addition, Afya Halisi collaborated with the SCHMT and Catholic Medical Mission Board (CMMB) to conduct the quarterly performance review meeting for Kitui South Sub County. CMMB supported six ward Public Health Officers and the SCHMT provided support for hall hire and fees for the Facilitators.

In Migori, the Project supported sub county data review meeting in all the eight focus sub counties. The data reviews were conducted at the sub county level as part of limiting the number of participants in line with the national government measures on containment of COVID-19 pandemic. The meetings were attended by 111 SCHMT members (69 male, 42 female). During the meeting, it was noted there was reduced outpatient attendance that affected MNH services. In addition, stock out of commodities such as iron and folic acid supplementation (IFA) and measles antigen was noted. The action points included printing of curfew passes and distribution to all the delivery sites, redistribution of IFA, increased outreaches in the affected wards and continuous health promotion at the community level to dispel the fears by the community members on COVID-19 pandemic, hence increase access and demand for health services. Strengthen data quality Conduct quarterly data quality assessments During the reporting period, the Project co-supported routine data quality assessment on RMNCAH indicators in three sub counties of Kisumu and two in Kakamega County, reaching 22 and 21 health facilities in Kisumu and Kakamega respectively. The data that was assessed was for January to March 2020 data. The indicators that were assessed included; 1st ANC, adolescents (10-19 years) presenting for pregnancy, PNC within 48 hours - infants, FP clients issued Implants, FIC under one year, Diarrhea cases in under five children, Vitamin A supplementation at 6- 59 months and infants breastfed within one hour. The Project co-created and coordinated with the sub county health facilities to support development of data quality implementation plan (DQIP) for every facility to strengthen data management and reporting system. Figure 1. below shows the RDQA findings for Migori County. RDQA findings for Migori County, PY3Q3 In Migori, the Project co-supported routine DQA in the eight sub counties reaching 80 health facilities. The exercise, which was led by the sub county HMTs, aimed to identify data quality gaps in PY3Q2 period. The Indicators assessed included Penta 3, FIC, Vitamin A, 1st ANC, 4th ANC, deliveries, Adolescent pregnancy and Family planning. The exercise also involved assessment of the existence of MOH reporting tools and storage of registers, use of the Partographs and functionality of MPDSR. One dimension of data quality that stood at 100% was timeliness in reporting of data. An action plan was drawn which included having a functional facility quality improvement team as well as departmental work improvement team to address data quality gaps instantly. In addition, the Project will work with the sub county MOH teams to provide targeted mentorships on data capture and distribute data management SOPs to sites that reported to be missing them.

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In Kitui County, the Project worked jointly with the sub county MOH teams to improve data quality by conducting targeted routine data quality assessment in thirty two (32) health facilities in Mwingi North, Kitui South, Kitui Central and Kitui East sub counties. The indicators that were assessed included; First ANC visit, number of adolescents (10-19 years) presenting with pregnancy, Babies receiving PNC within 48 hours, and skilled birth attendants. The gaps identified were over reporting and under reporting in adolescents presenting with pregnancy and First ANC, and incompleteness of PNC registers. The gaps identified were addressed immediately, and a work plan was drawn with specific timelines, on when they needed to be addressed. Furthermore, the Project co-planned and supported follow ups of data quality improvement plans in 8 health facilities in Mwingi West Sub County. The findings showed that at least 80% of DQA action points had been implemented which included availing and updating of talking walls, and addressing the over-reporting of adolescents (10-19 years) presenting with pregnancy. In addition, a total of 10 healthcare providers (4 male, 6 female) in eight health facilities were mentored on documentation of FP/RMNCAH indicators.

In addition, in Kitui County, there has been a remarkable improvement of reporting rates for Community Health Extension Worker Summary (MOH 515) in KHIS, from an average of 17% in October 2019 to an average of 70% in April 2020 in project supported sub counties. This prompted the county to work with Afya Halisi to conduct a data quality assessment of the CU data. The Project co-created with the county to randomly select 12 CUs in each of the six supported sub counties. The indicators that were assessed included; Pregnant women referred for skilled delivery, Pregnant women referred for ANC, Number of newborns visited within 48 Hours, Defaulters referred for Immunization. During this exercise, 60 HCWs (36 male, 34 female), and 12 CHVs (4 male, 8 female) were mentored on documentation and reporting of the community data.

Conduct validation of data reported in KHIS to address data quality gaps

In Kitui, during the reporting quarter, the Project co-supported validation of monthly reports entered in the Kenya Health Information System (KHIS). The Project also worked with the SCHMTs through the Sub County HRIO to check on arithmetic errors, completeness, reporting of similar indicator in different datasets and timeliness of reports. Corrections were made on the spot and facility in charges were also reached via phone calls to make corrections at the health facility level.

In Migori, the Project, in liaison with the sub county HRIOs, co-supported verification and follow up of data discrepancies identified in monthly data reported in KHIS. The Project worked with the sub county HRIOs to make corrections in KHIS during the reporting quarter.

As a result of these support, the reporting rates was 100% for most of the main MOH monthly reports in PY3Q3 as shown in Figure 19 below.

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100 80 60 40 20 0 MOH 705 A MOH 710 MOH 711 FCCRR

Kakamega Kisumu Kitui Migori Figure 19. Reporting rate for main summary reports by County for April to June 2020

Health facility capacity and Community functionality assessments in additional sub counties in Kakamega County

Health facility capacity assessment Afya Halisi co-created and co-implemented a health facility capacity assessment in three additional sub counties of Butere, Lurambi and Mumias East in Kakamega County. A total of 46 health facilities were assessed. The data was collected using REDCAp mobile application platform to enhance quality and real- time data transmission. The assessment focused on staffing, commodity and supplies, equipment, documentation, competence and skills of HCWs as well as data tools. The data cleaning has been done, including preliminary findings on equipment availability to inform targeted support to the health facilities.

Community Units Functionality Assessment Afya Halisi co-created and co-implemented a Community Unit functionality assessment in 104 CUs across six project supported sub counties in Kakamega County. The assessment encompassed a follow up assessment of 34 CUs in Navakholo and Khwisero sub counties that were assessed in Year 2 and a baseline assessment for 70 CUs in Butere, Lurambi, Mumias East and Matungu sub counties that were added in Year 3, as part of the Project’s expansion to additional sub counties in Kakamega County. The findings showed that 43% of the CUs were non-functional, 56% semi functional while 1% were functional. The findings will inform key areas for co-implementation with the county and sub county MOH teams to strengthen capacity of the CUs, CHVs and CHAs to provide tailored community health services to the target population.

Implement project learning agenda

Afya Halisi is implementing an AYSRH learning agenda in Matungu county, Kholera ward and Nyando sub-county, Kobura ward that aims at determining the Effectiveness of a Combined Approach towards Improving Utilization of Adolescent Sexual Reproductive Health Services in Kisumu and Kakamega Counties. This study was set up with specific interventions to help in enhancing access and utilization of responsive SRH services to adolescents between the age of 15-19 years to effectively address the AYSRH issues. During the reporting quarter, community, facility and multi-sectoral level interventions took place as indicated below; Community based Interventions The study supported a total of 10 young mother’s sessions reaching 218 young mothers. Out of these, 40 young mothers received FP services, others received immunization services for their babies and nutritional counselling. Community dialogues were also conducted as a way of reaching out to the community with

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information on ASRH information. Two (2) community dialogue sessions were conducted in Kholera ward and Kobura ward where a total of 52 (25 male, 27 female) community leaders attended the sessions. Afya Halisi partnered with Organization of African Youth who facilitated a skills-building session for the youth in Kobura ward in Kisumu county. A total of 100 adolescents (14 male, 86 female) were reached and trained in soap making. The Project supported the C4C training of 60 CHVs (12 male, 48 female) and 4 CHAs (1 male, 3 female) spread across two intervention sites of Kholera and Kobura wards.

Facility based Interventions The study supported adolescent in-reaches and weekend clinics to enable the adolescents get services. Of the 299 (36 male, 263 female) adolescents who attended the in-reaches, 117 new clients received FP services and 46 revisit clients also took up FP methods while another 44 received condoms. Afya Halisi supported one weekend clinic session in Kholera ward, where 89 adolescents attended the session. Twenty one (21) new clients received FP services, and 14 male adolescents took male condoms with them. A total of 25 HCWs (4 male, 21 female) HCWs in Kobura and Kholera wards were trained on the importance of proper communication and counselling during provision of FP services.

PROGRESS ON GENDER STRATEGY

During the reporting period, the Project continued to build capacity and deepen commitment of County Departments of Health and Gender in promoting gender equality and social inclusion as well as sexual and gender based violence (SGBV) prevention and response in FP/RMNCAH, Nutrition and WASH. However, COVID-19 pandemic continued to increase susceptibility of children, women, men and boys to Gender Based Violence and destabilization of related gender norms. In response, the Project co-supported the following activities targeted at mitigating cases of gender violence and strengthening health systems to adequately respond to the emerging cases; formation of the Project Gender Steering Committee, training of HCWs on IPV/SGBV prevention/response, orientation of county and sub county HMTs on gender responsive approaches, site supportive supervision and mentorship on IPV/SGBV screening, documentation and reporting, community dialogues, Gender technical working group (TWG), formation and support of Gender/GBV ward multi-sectorial boards, review of SGBV data and advocacy on data use for decision making, and sensitization of CHAs on SGBV prevention and response.

VII. PROGRESS ON ENVIRONMENTAL MITIGATION AND MONITORING

Afya Halisi, working with the Ministry of Health (MoH) and focusing on the four focus counties of Kitui, Migori, Kakamega and Kisumu, aims to deliver quality, integrated services in the areas of FP/RMNCAH, Nutrition, and WASH with the goal to reduce preventable maternal and neonatal deaths. In Year 3, the Project will support minor physical repairs and renovation to enhance patient privacy and dignity, conduct field monitoring and assessments and support and/or participate in numerous activities jointly with the county and national governments that have the potential to have adverse effects on the environment. As in the previous years, the project has purposed to ensure that all environmental mitigation measures and conditions are implemented in Year 3 and the remaining life of the project. In the reporting quarter, Kenya continued to respond to the COVID-19 pandemic, with an upsurge of the positive cases being reported during the reporting period. The Ministry of Health continued to urge Kenyans to prevent the spread of the disease by cleaning of hands often, using soap and water, or an alcohol-based hand rub; maintaining social distancing; wearing a mask; avoiding to touch the eyes, nose or mouth; covering the nose and mouth with the bent elbow or a tissue when coughing or sneezing; staying at home when feeling unwell; and if one has

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a fever, cough and difficulty breathing, then seeking medical attention. All amendments to the EMMP will be undertaken as required with guidance from the relevant Bureau Environment Officer.

VIII. PROGRESS ON LINKS TO OTHER USAID PROGRAMS Table 22. Linkage with other mechanisms Implementing Area of collaboration partner Afya Ugavi Implementation of HPN integrated work plan in Kakamega County, and implementation of the integrated supply chain model which is a subset of the larger HPN integrated work plan. Tupime Kaunti Implementation of the HPN integrated work plan for Kakamega; development of bi-annual MPDSR reports for Kakamega and Kisumu; review of Kakamega and Migori FP county costed implementation plans Impact Malaria Implementation of integrated HPN work plan in Kakamega County. The two projects are jointly implementing group ANC model targeted at improving early ANC, ANC 4 and IPTp 3 uptake. MWENDO Implementation of integrated HPN work plan in Kakamega. Specifically the two projects are collaborating on implementation of the AYSRH and OVC components. CHAI Implementation of IMNCI mentorship in Migori County as well as in the roll out of e-chanjo which is a vaccines Logistics Management Information System (LMIS) in Kakamega at the sub- county level. AMPATHPlus Implementation of Integrated work plan implementation. The two mechanisms are collaborating in PMTCT, FP/HIV integration and HTS/SBA integration. Afya Ugavi County commodity stakeholder meetings and county data review meeting in Kitui, Kisumu, Kakamega and Kisumu; Integrated Supply chain field visit in Kitui; and county level quarterly commodity TWG meeting in Kisumu and Kakamega; Commodity management training in Kitui Living Goods Support in community health services Kisumu, WASH stakeholder forum in Kakamega to review county WASH (CLTS) data management and reporting Options Consultancy Support the preparation of county MPDSR report in Kitui Services Kenya Red Cross Support for IPC training for CHVs in Kitui UNFPA Collaborated on the dissemination of revised MPDSR tools and development of county MPDSR report UNICEF County support for delayed Malezi Bora campaigns in Kitui; County support for WASH commodities coordination in Migori and Kakamega. USAID HRH Kenya County HRH TWG and health workforce council meetings in Kitui Mechanism

IX. PROGRESS ON LINKS WITH GOK AGENCIES The Project continued to engage the state and semi-autonomous government agencies in the implementation of activities. These included;  Ministry of Health: Collaboration with the county and sub-county MOH teams in the implementation of health services in the focus counties.  County Executive for Health: Collaborated with County Executive Committee Members for Health and Chief Officers for Health in launch of toll-free hotlines for adolescents seeking services during COVID-19 pandemic period.  Ministry of Interior: Collaboration with County Commissioners and Chiefs in dissemination of COVID-19 related materials such as risk reduction information, and distribution of curfew passes to boda boda riders and pregnant women requiring services during curfew hours.

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 County Assembly: On-going discussions on the road map for the enactment of the Kitui Health Services Bill. The Project also collaborated with the Kakamega County Assembly in the development and review of the regulations for the Kakamega County FIF Bill.  Ministry of Water: Collaboration with the county governments in areas dealing with borehole repair and spring water development.  National Vaccines and Immunization Program (NVIP): Advocated for immunization supplies at national level and delivery of these essentials to the supported counties.  KEMSA and MEDS: KEMSA continued to avail essential RH-MNH commodities to the counties based on the pull system.  National Hospital Insurance Fund: Strengthening NHIF, KCHIC and Linda mama enrollments.  Ministry of Youth (National Council): Supported in mobilizing youth for dialogue sessions.  KMTC: Worked with Kitui MTC to participate in youth education forums.

X. PROGRESS ON USAID FORWARD During the reporting quarter, the Project continued to engage the local implementing partners (LIPs) on the jointly agreed upon capacity improvement action plans. The Project conducted a second organizational capacity assessment for KMET and LCA, which showed significant improvements in the five capacity areas that were assessed for the two LIPs. The second organizational capacity assessment for ADSE and CSA will be conducted in the subsequent quarter. The Project also conducted a virtual training on report writing for the LIP staff based on gaps that were identified in the submitted progress narrative reports. In addition, the Project also supported a virtual training on proposal development and submission for the LIP staff. Table 23 below shows the status of engagements with the LIPs during the reporting period.

Table 23. Status of engagements with the LIPs Meaningful engagement with LIPs Milestone ADSE CSA KMET LCA Current work- strengths Food security, AYSRH including RMNCAHN Community WASH, HIV/AIDS interventions health environmental interventions conservation and climate change Geographical scope Eastern Kenya Counties across Kakamega, Kisumu, Rongo Sub- Kenya Migori and other County, Migori counties across County Kenya Signing sub-agreement Completed Completed Completed Completed Work plan submission Submitted Submitted Submitted Submitted Recruitment process Completed Completed Completed Completed Initial organizational Completed Completed Completed Completed capacity assessment Orientation on Afya Halisi Completed Completed Completed Completed processes and procedures Orientation on Afya Halisi Completed Completed Completed Completed Technical Areas Follow-up visit Completed Completed Completed Completed 2nd organizational capacity Scheduled for July TBD Completed Completed assessment 2020 Quarter 2 performance Completed Completed Completed for Scheduled for review Kakamega July 2020

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XI. SUSTAINABILITY AND EXIT STRATEGY The Project has instituted system-level mechanism to ensure sustainability. Many of these are on an on- going basis. Key among these is the engagement of local implementing partners that took up the implementation of community-based activities in the four counties. Through combined efforts from Project inception through the reporting period, supported counties have the requisite capacity to conduct RMNCH training with minimal support from the national MOH. Through community participation, the Project facilitated county government and community contributions in rehabilitation of water springs so as to foster ownership which is a critical in the sustainability of water infrastructure. A key outcome of the county level joint work plans is increased county funding of FP/RMNCAH activities. Some of the activities funded by county governments through the World Bank grant on Transforming Health Systems include training and mentorship, supportive supervision, performance review meetings, and facility in-charges meetings. As at end of PY3 Q3 period, the four counties had allocated US$262,837 for direct activity implementation. Migori and Kitui counties committed to operationalize the renovated surgical operation theatres through deployment of staff, purchase of essential supplies and improved referral services.

XII. GLOBAL DEVELOPMENT ALLIANCE

Not Applicable

XIII. SUBSEQUENT QUARTER’S WORK PLAN

Table 24. Subsequent Quarter’s Work plan Planned Actions from Previous Quarter Action Status this Explanations for Deviation Quarter Management/J2SR activities LIP organizational capacity assessment follow up visits Done No deviation LIP quarterly performance review meetings In progress Completed for 2 out of 4 LIPs Bi-annual organizational capacity assessment In progress Completed in KMET and LCA Training LIPs on proposal development and submission Done No deviation Linking LIPs to HENNET In progress Partners at different stages Co-creation meetings with counties on COVID-19 Ongoing Nil deviation response Development and roll out of Kakamega integrated work Completed, implementation Nil deviation plan on-going Support engagement between CHMT and Local On course Nil deviation professional associations (KPA/KOGS) to strengthen RMNCAH services CHMT training on resource mobilization strategies Completed Nil deviation Train CHMT to write concept notes and proposals Ongoing Nil deviation Sub-purpose 1: Increased availability and quality delivery of FP/RMNCAH, nutrition and WASH services Output 1.1.: Strengthened FP/RMNCAH, nutrition and WASH service delivery at health facilities, including referral from lower level facilities and communities. Family Planning Establish and Support onsite mentorship for VSC On course Nil deviation, activities limited to facility level due to COVID Dissemination of RMNH COVID-19 Guidelines Done virtually for all counties Nil deviation Roll out of CBD - Community DMPA Rolled out in Kakamega Rolled out in Kakamega Roll out of SC - DMPA in health facilities Rolled out in Kakamega Rolled out in Kakamega Post training follow ups of C4C ToTs Not done Awaits validation by MOH

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Mentorship on LARC and PPFP On-going Nil deviation Develop/Review of FP CIPs Process completed in Process not yet initiated in Kisumu, and Kakamega Kitui, to be done in Q4 Support TWGs On course Nil deviation Quarterly support supervision Done in each of the 3 Nil deviation quarters, to continue in Q4 AYSRH Primary Prevention Interventions Support School Health Intervention Not Completed School closure since march 2020 due to Covid-19 pandemic Improving Adolescent and Youth Responsive Services Completed Nil deviation Support AYSRH Dialogue with Parents, and Key Completed Nil deviation Behavioral Influencers Secondary Prevention Interventions Improve Access to Quality Services to Pregnant and Completed across all Nil deviation Postnatal Adolescents counties. Support Targeted In-reach and Outreach Services for Completed across all Nil deviation Hard-to-Reach Adolescent Populations counties. Support Linkage to Safety Nets, Economic Strengthening On Going across the 4 Linkage to KYEOP, TVET, Opportunities and Return to School Counties DREAMS Project System Level Interventions Supporting County and Sub County AYSRH Completed across all Nil Deviation Coordination Forums counties. MNH Update 3 mentors per sub county on current MNH On-going process Nil deviation recommendations Dissemination of RMNH COVID-19 Guidelines Completed Nil deviation Conduct skill drills in select CEmONC sites Done in all the counties Nil deviation Institutionalize BeMONC assessment Done for all the counties Nil deviations EmONC Mentorship Ongoing Nil deviation Support provision of KMC beds Not done, the activity Counties taken up the deferred from the work plan responsibility Support privacy and improve service delivery points Renovation of maternity Service delivery and (RMC) waiting homes in Kitui sustainability guiding the process Support roving lab technician to provide ANC profiling Started in Kitui county in Q2, Nil deviation in select facilities-Kitui County ongoing support Support establishment of additional maternal shelters Needs assessment done in Nil deviation Kitui and four facilities Facilitate County and sub county level MPDSR Done jointly supported Nil deviation committee meetings UNFPA, MDTF (Options Consultancy Ltd) Support follow up of MPDSR action plans Ongoing activity Nil deviation Support Biannual Inter-county Technical learning forums Not done in Q2 Change of structure Restrictions on movement Sensitization of HCWs on KQMH e-tool Done in Migori, Kisumu and Nil deviation Kakamega. Kitui in Q1 County QI learning forums (cost-share with CH) Activity earmarked for Q3/Q4 Nil deviation Support county referral strategy meeting Done in Kisumu and Migori Nil deviation Follow-on training/mentorship on ultra-sound Done in Kakamega and Migori Planned in Kitui and K in Q4 Strengthen provision of RMNCH services for private Ongoing process Nil deviation sector

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Service orientation on Group ANC - select 5 facilities Started in Migori and Kitui, re- Likely to be deviations with strategized due to COVID-19. further inputs on the strategies. Procure relevant equipment for 5 CEmONC health Equipment distributed directly Nil deviation facilities in Kitui to facilities Child Health and Immunization Immunization defaulter tracing Done across all supported Nil deviation counties due to COVID-19 Support targeted outreaches and in reaches Supported in Kisumu, Kitui Nil deviation and Migori counties Support EPI micro planning Done in additional sub- Nil deviation counties in Kakamega County Facilitate EPI mentors to conduct EPI mentorships Done across all counties Nil deviation Support Biomedical engineers to mentor Lab Techs on Done in Migori, Kitui, Kisumu Activity supported but cold chain maintenance counties redesigned Procure tool kits Not done Pending, awaiting a needs assessment for the tool kit. Facilitate IMNCI mentors to provide IMNCI mentorship Done in Kitui, Kisumu, Nil deviation to targeted health facilities Kakamega and Migori counties Facilitate ETAT+ mentors/Tots to cascade ETAT+ Done in Kitui and Kakamega Nil deviation training to targeted health facilities Counties Scale up iCCM in additional CUs by training additional Not Done. Activity implemented through CHVs on ICCM LIPs at community level Nutrition HINI/IMAM mentorship On course Nil deviation BFHI assessment On course Nil deviation HINI/IMAM baseline assessment On course Nil deviation Vitamin A supplementation On course Done at household level instead of EYE centers WASH Support WASH Stakeholders forums in Kitui, Kakamega On course Nil deviation and Kakamega Training of PHOs and CHVs on Sanitation Marketing in On course Nil deviation Kitui, Kakamega, and Migori Repair sanitation facilities in identified health facilities in On course Nil deviation Kitui Whole site orientation on hygiene and waste On course Nil deviation management in Kitui, Kakamega, and Migori. Output 1.2: Strengthened delivery of targeted FP/RMNCAH, nutrition and WASH services at community level, including effective referral to mobile and/or static facilities Engagement on reorganizing CHS in Kitui County On-going Awaiting discussion by the County Assembly Scale up VSLA On-going 17 more CUs trained and started VSLA Support community dialogue sessions Done No deviation Strengthen community verbal autopsies Done Verbal autopsies being done in the community Outreaches in hard to reach areas Done Done according to need Train additional CHVs in CBD On-going 16 more CUs trained on CBD and began distribution of FP Roll out iCCM On-going 2 CUs trained on iCCM; began distribution of commodities Monthly facility/community data review meetings Done No deviation

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Targeted onsite mentorships to CUs and CHAs on use Done No deviation of CBHIS Output 2.1: Increased knowledge of and demand for FP/RMNCAH, nutrition and WASH services 2.1.1 Identify & Support context-specific strategies for healthy behaviors Coordination – Facilitate/support quarterly SBC Review Partially done (in Kitui) and No deviation Meetings (HPACs) Inter county virtual meetings Conduct Materials Review/Adaptation Workshop On going TWGs to have physical meetings and explore materials. Remapping of Health Promotion/SBC Partners in Done, 4 county databases Nil Deviation Counties using SDH lenses updated Standardize Quality Assurance parameters for SBC Done: Tool developed, now Nil Deviation interventions under pilot 2.1.2 Create demand for services Review & contextualize guidelines for doing outreaches Done Nil deviation. Training LIPs/MOH in relevant SBC modules On-going(Migori finalized) Planned trainings in Kitui, Kakamega and Kisumu. Provide TA during implementation of demand creation On-going Nil Deviation activities Output 2.2: Improved gender norms and sociocultural practices Implement GBV first line response (IPV and LIVES) Done IPV mentors trained in 4 mentorship package Counties IPV screening rolled out within FP/RMNCAH service Completed Follow up and Mentorship in delivery points Q4 Conduct community dialogues on harmful practices Completed Nil deviation Set up multi sectoral community gender advisory boards Done Follow ups and mentorship in at ward level Q4 Conduct community scorecard and critical reflection On going Finalize in Q4 processes on quality of RMNCAH/nutrition and WASH Train county/sub county mentors on GBV first line Done 250 providers trained- response (LIVES) Mentorships in Q4 Capacity build county and SCHMT HRIOs on GBV Done Mentorship to continue reporting in KHIS-10 facilities Reprint and disseminate IPV, VAC job aids, and IEC Done Scale up of dissemination and materials distribution in Q4 Establish /support Kakamega county gender/GBV TWGs Done Technical support of TWGs in Kisumu ad Kakamega Creation of friendly and safe waiting bays for child Completed Ahero County Hospital and adolescent survivors of VAC KCGTRH Roll out school gender and GBV prevention/response Not done School Suspension due to activities in Kakamega county (Good schools toolkit) COVID-19 Sensitize students on GBV prevention in schools(step 2 Not done School Suspension due to and 3 of the good schools) COVID-19 Safe spaces branded (walls, toilets) Not done due to COVID-19 To be done in Q3 Output 2.3: Increased practice of key nutrition and WASH behaviors in target communities Nutrition BFCI assessment On course Nil deviation BFCI reviews On course Nil deviation BFCI training On course Nil deviation Training of individuals on BFCI On course Nil deviation Linkages established with partners On course Some partners were not available due to COVID-19 WASH CLTS interventions On course Nil deviation

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Post ODF sensitization and monitoring On course Nil deviation Protection of identified springs On course Nil deviation Water quality tests at community water points for On course Nil deviation identified springs Sub-purpose 3: Increased MOH stewardship of key health program service delivery Output 3.1: Strengthened coordination, M&E capacity Facilitate HMIS mentors to provide onsite mentorship to Ongoing Nil deviation HCWs and CHVs in high volume health facilities on use of the revised MOH reporting tools Print revised MOH registers and reporting tools Done Nil deviation Support workshops for generation of County Ongoing Nil deviation information products (Bulletins, Factsheets, scorecards ) Identify and develop HMIS mentors to mentor HCWs Done Nil deviation on registers and reporting tools Conduct quarterly data review meetings at sub-county Done Nil deviation levels. Strengthen use of KHIS and CBHIS Ongoing Nil deviation Conduct quarterly CHV data review meetings Ongoing Nil deviation Conduct quarterly data quality assessments. Ongoing Nil deviation Data corrections with SCHRIOs Ongoing Nil deviation Strengthen capacity of MoH systems, structures and Ongoing Nil deviation personnel on data collection and use Implementation of learning activities Ongoing Nil deviation Provide airtime support to SC/HRIOs in project Successfully transitioned to In line with J2SR supported sub-counties for use in KHIS2. county government

XIV. FINANCIAL INFORMATION

Cash Flow Report and Financial Projections (Pipeline Expenditure Rate)

Actual Expenses expenditure 40,000,000 quarter April-June 2020 Actual Expenses expenditure 35,000,000 quarter Jan -March 2020 30,000,000 Actual Expenses expenditure 25,000,000 quarter October -December 2019 20,000,000 Actual expenditures FY 1 & 2 15,000,000 (October 2017-September 2019) Obligations 10,000,000 5,000,000 0 Obligations Expenditures

Figure 20. Obligations vs. Current and Projected Expenditures - $Millions

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Table 25. Budget Details T.E.C: $66,336,770 Cumulative Obligations: $35,072,942 Cumulative Actual Expenditures: $28,682,302

Budget Line Year 1-2 1st Quarter 2nd Quarter 3rd Quarter Actual Actual Actual Actual Expenditures Expenditures Expenditures Expenditures Personnel 3,901,830.27 402,589.58 416,082 432,251.74 Fringe Benefits 1,460,444.52 135,721.43 138,695 190,956.73 Travel, Transportation & Per Diem and 3,613,617.98 200,043.54 334,672 354,291.33 Misc Equipment 397,129.43 - 0 - Supplies 793,573.19 7,448.12 10,943 48,799.69 Contractual 7,935,270.50 798,283.62 368,776 683,443.96 Construction - - 0 - Other Direct Costs 2,447,108.27 189,087.01 156,216 234,296.00 Total Direct Costs 20,548,974.16 1,733,173.30 $1,425,383 1,944,039.45 Total Indirect Costs 2,346,465.42 181,811.60 $225,403 277,051.20 Total Estimated Costs 22,895,439.58 $1,914,985 $1,650,787 2,221,090.65

Table 26. Budget Notes Salary and wages Salaries and wages are in line with Jhpiego’s Human Resource policies. Fringe Benefits Calculated as per Awards conditions and prevailing Jhpiego approved NICRA rates. Travel Travel costs are in relation to Project staff. Participant travel is generally charged to Programmatic Costs. Equipment Equipment costs relate to procurement of project vehicles, copiers and a generator, this will be procured fully by end of the third quarter Contractual The contractual are consistent with agreements signed with the Partners Other Direct Costs Other direct costs include programmatic activities aligned to the detailed implementation plan and general office operating costs. Total Indirect Costs Calculated as per award conditions. Total Estimated Cost Total of all costs

XV. ACTIVITY ADMINISTRATION

The Project staff at the Kitui office moved to a smaller office which has resulted in reduction of operation costs and released more funds for programming to target beneficiaries. In addition, Afya Halisi provided vehicles to KMET and CSA to facilitate field movement of the staff working for the Project.

Personnel

There were no changes in the key personnel during the reporting period.

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Contract, Award or Cooperative Agreement Modifications and Amendments

USAID provided incremental funding of US$ 400,000 to Afya Halisi to support the Ministry of Health in implementing responsive actions to the COVID-19 pandemic.

XVII. GPS INFORMATION

Refer to attachment.

XVIII. SUCCESS STORIES

Success story 1. A Nurse with a Passion for the Youth Working to ensure that adolescent and young people have access to sexual and reproductive health services Kakamega County, Kenya- Located majestically in the rural areas of Navakholo Sub County in Kakamega County, is the Sisokhe Dispensary, it is a little more than a large house on a hill where clean winds blow, its rocky roadways are bordered by green lawns and the buildings in the hospital are made of corrugated iron sheets. This is where 38-year-old Jacquie Wikhala, works as the nursing officer in charge of the facility and an adolescent mobiliser. Outside her office, are some adolescent mothers waiting for service, she greats them warmly and welcomes them to the clinic. This is what Jacquie is known for – her passion for adolescent and youth. Jacquie knew that she always wanted to be a nurse but her family did not have money and therefore she ran away from home at an early age to seek a better future. “My family was very poor – we did not have money for our basic needs and I could not go to school so I ran away from home,” she narrates. She landed in the hands of a teacher, who took her in as her house help and at the same time supported her education until she finished her high school education. Her guardian was keen to have Jacquie pursue a career in education but Jacquie’s love for nursing saw her apply for a nursing diploma at Kenya Medical Training College (KMTC) behind her foster mums back. “As fate would have it, they accepted me into the college,” she chuckles proudly. Jacquie’s passion for working with young people started even before she was a nurse – a passion she has now brought to her job. “ There are a lot of young people who visit the clinic with a need for sexual reproductive health services,” Jacquie says. “ I make sure to make time to talk to them about the options available to them and ensure they get the services they need,” she says. Kakamega has a youthful population with children and youth below the age of 15 accounting for about half (47%) of the total population. According to Kenya Health Information System data for January 2020- May 2020, 6,686 adolescent girls between 10-19 years presented with pregnancy, which represents 25% of all pregnant women in Kakamega County; this is higher than the national average of 23%. The numbers could loosely be translated to mean HIV infections, school dropouts, early marriages, medical complications, high rates of abortion alongside other negative consequences. The USAID funded Afya Halisi project works in Kakamega County, through co-planning, co- implementation and co-monitoring with the county government, to ensure that adolescents have access to high quality services by building the capacity of health care providers like Jacquie to be more responsive to their needs. The project has been supporting youth trainings, in reaches, outreaches and community

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dialogues as a means to create demand and ease access of services including family planning, HIV testing and counselling and providing general information on reproductive health and sexuality. Adolescents, Youth and Sexual Reproductive Health (AYSRH) has been prioritized globally to ensure that adolescents have access to these health services. However, adolescents underutilize these services due to a number of factors that are at play including healthcare provider attitude and privacy concerns in health facilities. However, the Kakamega county government, through co-financing and co-implementation with Afya Halisi is changing this through regular training of health care providers, community dialogues and recently, the launch of a toll-free line for AYSRH services to ensure continuity of service amidst the COVID 19 pandemic. Jacquie wants all adolescents in her community to passionately fight for their dreams the same way she did to hers. “I don’t look at it on the basis of whether I am supported or not, I love my work and I am passionate about young people. Nursing is a calling and when I do it, I do it for God and God’s reward is greater,” she concludes. Success story 2. Giving Babies the Right Start Through Exclusive Breastfeeding The Afya Halisi led Baby Friendly Community Initiative is educating adolescent mothers on the benefits of early initiation and exclusive breastfeeding Peres’s story Kakamega County, Kenya - On the lush hilltop of Mukangu B village in Navakholo sub-county in Kakamega County, stands the grass thatched hut belonging to 78-year-old Beatrice Nasimiyu. “Welcome home,” she says smiling from cheek to cheek while putting her papyrus basket full of farm produce down to embrace us. Inside the hut is her 17-year-old grand-daughter Peres Mwoka and her 1-year-old son. Peres conceived in 2018, at the time, she had just joined high school and was excited about being among one of the few girls in her village to make it that far. The pregnancy devastated her and her mother became hostile. Her immediate thoughts were to procure an abortion. However, her grandmother, Beatrice, and Inviolata Ileko Wanjala, a community health volunteer(CHV) would hear none of it. She was immediately enrolled into antenatal care after having been advised by the CHV to visit the health facility. After 9 months, she gave birth to a beautiful bouncing baby boy at Navakholo Sub-county hospital. She was supported to initiate breastfeeding within an hour of delivery. She was also taught about the benefits of exclusive breastfeeding (EBF) which includes increasing the immunity of the child, it is a complete food for the baby and also increases the baby’s intelligence quotient (IQ). The World Health Organization estimates that around 220,000 children could be saved every year with exclusive breastfeeding.1 Babies who breastfeed exclusively for the first 6 months, have fewer ear infections, respiratory illnesses and bouts of diarrhea. They also have fewer hospitalizations and trips to the doctor. 2 The USAID funded Afya Halisi project, is working to ensure that infants and children survive given the high under five mortality rates in Western region second only to Nyanza region. Early initiation of breastfeeding and exclusive breastfeeding play a critical role in reducing under five mortalities. As such, the project implemented the Baby Friendly Community Initiatives (BFCI). Implementation started

1 https://www.healthynewbornnetwork.org/blog/the-importance-of-exclusive-breastfeeding 2 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6492465/

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by training of health facility staff including the community health assistants (CHA) who supervise the CHVs. Subsequently, CHV trainings were conducted in respective villages. The trainings consisted of exclusive breastfeeding, early initiation of breastfeeding, expressing of breast milk, maternal nutrition and complementary feeding in addition to child stimulation and development. Inviolata (CHV) was thus able to support Peres, based on the knowledge and skills she received from the BFCI trainings. Two months after giving birth, Peres was able to return to school and still managed to provide breast milk for her baby. “I was taught on hand expression of breastmilk and how to hygienically store it,” Peres says. “I would wake up every morning at 5 am to express breastmilk. I would leave the milk for my grandmother to feed my baby while I was in school and I would purpose to return home early after my classes to breastfeed him,’ she says as she cradles her jovial son. Peres is now in form two and her son is almost 2 years. Her grandmother is still helping her raise her son. She is happy that she did not have to choose between her child and her education. Her grandmother has been her pillar through her challenges allowing her to chase her dreams. In school, she has become a champion and advocate for exclusive breastfeeding; creating awareness on its benefits amongst her peers who have children like her. Beatrice on the other hand could not be more delighted to offer her granddaughter support. “My granddaughter has big dreams, you never know what she is going to be in the near future; that’s why I help her look after her child, so I keep going for these mother-mother support group targeted for the community so that her baby stays healthy and she can continue studying,’ Beatrice concludes. Success story 3. Making Soap while Educating Adolescents and Youth of Kholera Ward on Sexual and Reproductive Health Kakamega County, Kenya- 23-year-old, John Fanuel is a youth champion at Harambee estate at Kholera Ward in Matungu Sub county in Kakamega County. But besides that, he is also a business man who sells soap to members of his community, a business that is now peaking due to the COVID 19 pandemic which requires regular hand washing as a precautionary measure. His idea of selling soap came to him after attending a youth funded training supported by United States Agency for International Development (USAID) funded Afya Halisi project. Afya Halisi is working with adolescents and young people to ensure they are reached with sexual and reproductive health (SRH) information and services. In order to connect with the young people, Afya Halisi has incorporated life skills, self-awareness and income generating sessions as part of the sexual and reproductive health sessions. It was during a similar session held during the World Youth Day that Fanuel first encountered Afya Halisi. “There was a health talk and afterwards we were taught on how to make soap,” Fanuel recalls. This is what sparked his interest in starting his own soap making business. After the event, he started attending the youth meetings and was eventually nominated to be a youth champion. Kholera ward is experiencing a spark in teenage pregnancies and low utilization of family planning services among adolescents. To ensure that young people have information on SRH including family planning, Afya Halisi is working with youth champions like Fanuel to share information and mobilize youth that may require SRH services to visit the health facilities – a strategy that has paid off. “My work entails talking to the young people on matters regarding HIV, sexually transmitted infections and family planning. At the same time, I connect young people to health facilities for these services“, Fanuel says. “Since I started my work as a youth champion, I have seen a lot of behavioral changes among the adolescents and youth in my area; some of them come to my home to pick up condoms, an indication that they are taking precaution during sex.” Fanuel adds. His soap making business is not only a source of income but has also become a source of inspiration for other young people. He has since educated other youths that he interacts with, to start their own income generating ventures including selling firewood to

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the locals and frying foods for sale. From his soap business, Fanuel can make a profit of around Kshs.1,000 (approximately US $9) per sale, an amount he is contented with. However, he notes that there are still some challenges in reaching adolescents and young people. The first one is convincing the young male adolescent to come for the services and trainings at the health facilities. “Most of the young men/boys are hustling and trying to earn some money,” Fanuel notes. “Convincing them to leave their engagements to seek health services or to be trained without some form of reimbursement is a big challenge,” he affirms. Another challenge he faces is from parents of the adolescents. For most parents; the perception of family planning is still negative as most of them associate it with immorality and therefore discourage Fanuel from speaking with their children. But Fanuel is not discouraged, he wants to see his community develop, he wants to see less girls get pregnant. “Unwanted pregnancies are a hindrance to development, that’s how children end up being street children and girls forced into prostitution. I want it to be different for girls and children in my community,” he concludes.

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ANNEXES & ATTACHMENTS

Annex 1: Afya Halisi - From Commitment to Action: Framework for Action by Migori, Kisumu and Kakamega on Adolescents and Youth Sensitive Services Strengthen adolescent and youth-friendly services at health facility

Afya Halisi remained cognizant that adolescent and youth issues extend beyond health to socio-economic, thus continued to focus on not only utilization of a multi-sectoral approach but also a combination prevention approach, including rights-based, evidence-informed, and community-owned interventions, prioritized to meet the current health needs of adolescents and youths and their surrounding communities.

During the reporting quarter, implementation of Project activities was affected by the COVID-19 pandemic restrictions. A result, the Project reprogrammed its interventions to align to the national government's regulations on prevention and management of the pandemic. The reprogramming was necessitated to ensure that there is continuity of essential health services to the targeted population.

During the quarter under review, the Project co-planned, co-financed and co-implemented high impact AYSRH activities with the S/CHMTs and AYSRH coordinators in the four focus counties. The focus was on increasing access to AYSRH information and services through primary prevention, secondary prevention and system level interventions. Table 27 below shows the Project’s performance as at end of PY3 Q3 period.

Table 27. Adolescents (10-19 years) FP uptake and presenting with pregnancy – PY3Q1-Q3 County Adolescents (10-19 years) FP uptake Adolescents (10-19 years) presenting with pregnancy PPR Y3Q1 Y3Q2 Y3Q3 Total % PPR Y3Q1 Y3Q2 Y3Q3 Total % Target Target Kakamega 4,413 844 583 1235 2662 60% 7,549 1,202 1,070 1,753 4,025 53% Kisumu 5,748 1,327 986 2,022 4,335 75% 6,244 1,448 1,631 1,170 4,249 68% Kitui 3,450 765 682 784 2,231 65% 6,164 1,475 1,409 1,210 4,094 66% Migori 17,429 4,620 3,753 4,594 12,967 74% 10,224 2,158 2,646 2,475 7,279 71% Project 31,040 7,556 6,004 8,635 22,195 72% 30,181 6,283 6,756 6,608 19,647 65%

During the reporting period, the Project reached 8,635 adolescents with FP services, bringing the total to- date in PY3 to 22,195. This reflects an achievement of 72% against the annual target of 31,040. In addition, during the reporting period, the Project reached 6,608 pregnant adolescents with ANC services, bringing the total to-date in PY3 to 19,647. This reflects an achievement of 65% against the annual target of 30,181.

During the reporting quarter, due to the COVID-19 pandemic, the Project co-created with the focus county governments and shifted its support to focus on activities that involved small group sessions. The Project continued to provide technical support and guidance to MOH and the local implementing partners to implement primary, secondary and system level interventions aimed at increased availability and access to quality services for adolescents and youth. The closure of schools due to the COVID-19 pandemic directly affected planned school health interventions.

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The adolescent burden of pregnancy was at 20% of the 32,745 first ANC visits in project supported health facilities during the reporting quarter. The highest adolescent burden was reported in Kakamega and Migori, both at 22%, Kitui at 21% and Kisumu had the lowest burden at 15%. On average, there has been a decline in the adolescent burden of pregnancy in the Project focus counties from 29% in 2018 to 22% in the first six months of 2020 as shown in Figure 21 below.

40% 36% 31% 30% 30% 31% 29% 27% 30% 25% 25% 22% 21% 21% 20% 22% 20% 17%

10%

0% Kakamega Migori Kitui Kisumu Project

2018 2019 2020

Figure 21. Adolescent burden of pregnancy by County, 2018 to 2020

The county specific primary and secondary preventions, and systems level activities that were implemented in PY3 Q3 in the four focus counties, to address the above challenges facing adolescents, were as detailed below.

Primary Prevention Interventions The primary prevention interventions were aimed at delaying sexual debut, preventing early and unwanted pregnancies and prevention of sexual abuse among adolescents and youth. The activities were implemented at facility and community level and sought to expand access to comprehensive SRH information and services to the adolescents and youths. The activities also targeted key behavioral influencers to the adolescents including the parents, guardians, boda boda riders and community leaders.

Improving access to Adolescent Responsive sexual reproductive health service and information The Project continued to provide technical support and guidance to MOH and local implementing partners to ensure SRH services for adolescents are provided in a supportive environment, improve reproductive health knowledge, attitudes, skills and behaviors, and increase utilization of health and related services.

Training of HCWs in AYSRH During the reporting quarter in Migori, the Project supported the training of 25 HCWs (15 male, 10 female) from 25 health facilities in AYSRH. In line with the COVID-19 guidelines, the training was done in two sessions consisting of13 and 12 participants respectively. Through the County Adolescent Coordinator and Sub County Coordinators, the trained HCWs will track all pregnant adolescents, increase uptake of comprehensive sexual reproductive health services among youth and adolescents, develop innovative contextualized ways of reaching to adolescents and create a safe and free environment for young people at the health facilities.

Targeted in reaches and outreaches In order to enhance access to SRH services for adolescents, the Project supported the MOH to conduct adolescent targeted sessions during the reporting quarter. In Kisumu, the Project supported 57 in-reaches in the focus sub counties, reaching 1,378 adolescents with FP services, and a further 108 with ANC services. In Kakamega, the Project supported 50 in-reaches in the focus sub counties, reaching 780 adolescents and

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young people with contraceptive services, and a further 310 received ANC services. In Migori, the Project supported 41 in-reaches in the focus sub counties, reaching 1,418 adolescents with contraceptive services, and 1,192 children with immunization services.

Dialogue sessions with adolescents and key behavioral influencers In Kisumu, the Project supported MOH to conduct 17 sessions with parents, boda boda riders and community opinion leaders reaching 387 individuals (145 male, 242 female). The aim of the sessions was to enable the influencers to act as role models and shape young people’s perception of gender roles and influence the choices that they make about their own sexual behavior. In Kakamega, the Project supported MOH to conduct 23 sessions with parents, community leaders and stakeholders, reaching 437 individuals (190 male, 247 female). In Migori, the Project supported 8 sessions with key behavioral influencers, reaching 128 (92 male, 36 female). The dialogue sessions resolved to set up children’s’ desk at the Police Stations to handle defilement cases; Chiefs to map all pregnant adolescents in their locality and link them to services, including children services; routine dialogue with parents during Chiefs’ baraza sessions; and enhance comprehensive sexuality information to adolescents in order to improve their decision making ability. Enhancing Prevention Initiatives - Boda Boda as Condom Outlet During the reporting quarter, the Project targeted sub counties and wards with high burden of teen pregnancies in the focus counties and used boda boda shades as male condom outlets, and supported sensitization of the riders on correct use of male condoms. The intervention is targeted towards male sexual partners of adolescents girls and young women. In Migori, the Project supported sensitization of 20 boda boda riders on correct use of condoms and distributed 10,287 male condoms to the riders. In Kitui, the Project supported sensitization of 48 boda boda riders in Kitui East and Kitui South sub counties, and distributed 14,200 male condoms to the riders.

Use of Digital Platform (Facebook and Twitter) – Club Tubonge The Project supported youth champions to harness the digital space, in an initiative dubbed as ‘Club Tubonge’. The virtual platform provides a strong organic channel to raise awareness and for adolescents and youth to start real conversations on SRH issues, leading to linkage to services, especially during the COVID-19 pandemic period.

During the reporting period, the Project set up six WhatsApp groups that reached 1,361 adolescents and young people, and included sessions with HCWs on a weekly basis.

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County Based Toll Free Lines During the reporting quarter, the Project co-created with the focus county governments to set up county based toll free lines that provided a platform for adolescents and young persons to access comprehensive information regarding their sexual and reproductive health needs as well as linkage for those in need of services in health service delivery points. The intervention was in response to the fear among adolescents and youth to access services in health facilities due to the COVID-19 pandemic. The toll free lines provided an opportunity for the adolescents and youth to speak to a healthcare provider at the point of need, and to express themselves without fear of breakage of confidentiality.

During the reporting quarter, the Project, in collaboration with the county governments, launched the toll free lines in Kakamega and Migori counties. The Project procured five phones for use by healthcare providers in each of the counties. In Kakamega, the county government co- financed additional 13 phones, to make the total to 18 phones, and in Migori, the county already had two phones supported through UNFPA, bringing the total to seven phones. In Kitui, the Project was co-planning with the county government to launch the toll free line in the subsequent quarter. In Kisumu, the county government had set up a COVID-19 call center.

Migori was the first focus county to roll out the intervention, in June 2020, and the county had received a total of 144 calls from the toll free lines during the reporting period. Table 28 below shows the breakdown of the callers by age and the areas of information inquiry.

Table 28. Migori County Toll free line Callers by age and areas of concern in PY3Q3 Age Number of Areas of concern callers 10 to 14 23 Menstrual hygiene issues, changes taking place during adolescent stage and how years to handle them, and how to avoid negative peer pressure 15 to 19 77 Contraceptive use-their accessibility, how they work and side effects, if they can years access abortion services for unwanted pregnancies and post abortion care for adolescents who have attempted abortion, how a positive adolescent girl can protect their unborn children, masturbation, sexually transmitted infections, medical and legal support for adolescents who have undergone sexual violations 20 to 24 18 Contraceptive access and side effects, sexual violence, access to abortion years services, sexually transmitted infections Above 25 26 Health issues and aid for different things such as mosquito nets years Total 144

Lessons learnt on launch of toll free hot lines included the need to ensure county buy-in for sustainability; intensify marketing to increase the number of calls received and issues addressed; on board top most county leadership from the onset as it increases media coverage; and avoiding paying allowances to service providers that are handling the lines as this is not sustainable.

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Secondary Prevention Interventions Improve Access to Quality Services to Pregnant and Postnatal Adolescents In Kisumu, during the reporting quarter, the Project supported the strengthening of 63 young mothers’ clubs across the focus sub counties, reaching a total of 984 young mothers, that consisted of 370 pregnant and 614 lactating young women. Out of these, 225 received contraceptive services to prevent repeat pregnancies, while 15 who were newly identified pregnant adolescents were linked to ANC services.

In Kakamega, the Project supported strengthening of 37 young mothers’ clubs in the focus sub counties, reaching a total of 815 young mothers, that consisted of 262 pregnant and 15 lactating young women. Out of these, 263 received contraceptive services to prevent repeat pregnancies.

In Migori, the Project supported strengthening of 31 young mother’s clubs, reaching 683 young mothers’ clubs that consisted of 283 pregnant and 400 lactating young women. Out of these, six adolescent mothers delivered and received postpartum family planning services. In Kitui, the Project supported 13 young mothers’ clubs, reaching 212 pregnant and 156 lactating mothers. Out of these, 126 received ANC services, 13 received FP services and 13 children received immunization services.

Linkage to safety nets and socio-economic empowerment opportunities During the reporting quarter, the Project partnered with Paint a Smile Community Based Organization (CBO) in Kakamega, and Organization of African Youth to build the capacity of adolescents and young people on socio-economic empowerment opportunities. In Kisumu, the Project supported the training of 166 adolescents and young people (5 male, 161 female) in soap and mat making. In Kakamega, the Project supported the training of 134 adolescents and youth (14 male, 120 female) in soap making, while two groups from Bushiri in Navakholo Sub County and Mulwanda in Khwisero Sub County were trained on Savings and Internal Lending Communities (SILC). In Migori, six school adolescents in Kuria West Sub County were linked to the Kenya Youth Employment and Opportunities Program (KYEOP), 50 adolescent and youth from Nyatike Sub County were trained in soap making, and four groups in Kuria East Sub County were trained in kitchen gardening and poultry keeping.

Linkage to Health Insurance Schemes (Linda Mama and UHC) During the reporting quarter, the Project continued to ensure that pregnant adolescents and infants have access to quality and affordable health services. In Kisumu, the Project supported linkage of 36 adolescent mothers to NHIF. In Kakamega, the Project supported 107 adolescent mothers to be linked to Linda Mama.

System Level Interventions The system level interventions were aimed at strengthening the GOK structures and line ministries in delivering and coordinating multi sectoral adolescents and youth services.

During the reporting period, the project supported the following system level interventions:

County Multi Sectoral Forum In Kitui, the Project supported the County Multi Sectoral Forum that brought together representatives from national and county government ministries and departments to evaluate previous efforts on adolescents and youth services, identify gaps and redesign strategies to reach the adolescents. The forum was attended by the Deputy Governor for Kitui County, who reiterated the county’s support and commitment to reduce the adolescent pregnancy burden in the county and empower adolescents and young people. Among the key decisions arrived at during the meeting included the need for intensified focus and support in Mwingi North and Kitui South sub counties that had the highest burden of teenage pregnancies.

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In Migori, the Project co-supported the AYSRH County Taskforce meeting, that brought together partners and players in the adolescent field, to evaluate strategies and ways of supporting AYSRH activities, especially during the COVID-19 pandemic period.

County AYSRH Supportive Supervision In Kitui, the Project supported supportive supervision visits on AYSRH services in 39 health facilities in Kitui Central, Mwingi West, Mwingi Central and Mwingi North sub counties. The key recommendations from the visit included the need for formation of additional young mothers’ clubs to increase access to AYSRH information and services for adolescent and young mothers and mentorship of the HCWs on AYSRH to enhance quality of care.

Partnership with other USAID Implementing Partners The Project continued to strengthen structural interventions that invest in adolescent girls’ and young women’s human capital and provide alternatives to marriage and motherhood. In addition, the Project strengthened collaboration and linkages with other USAID implementing partners, that included Afya Ziwani on DREAMS interventions and MWENDO Project on OVC interventions, in order to promote young women’s economic empowerment, aimed at reducing their vulnerability to transactional sex and early pregnancies.

In Kisumu, the Project worked with Afya Ziwani to offer contraceptive services to adolescent girls and young women that are enrolled in the project, and Afya Ziwani provided trainer of trainees to train young mothers on financial literacy and socio-economic empowerment. In addition, Afya Halisi collaborated with Afya Ziwani during the celebration of the World Menstrual Hygiene day. During the event, Afya Halisi supported delivery of AYSRH health talks and Afya Ziwani provided sanitary towels to the adolescent girls and young women.

In Migori, Afya Halisi provided contraceptive services to sexually active adolescent girls and young women in the DREAMS safe spaces in Awendo, Uriri, Kuria East and Kuria West sub counties. In addition, through referral and linkage, 21 girls from Isibania young mums in Kuria West Sub County and 20 girls from Kuria East Sub County were enrolled into the Afya Ziwani DREAMS project. The girls will be taken through economic empowerment sessions and those out of school will be provided with start off capital to establish economic ventures.

In Kakamega, the Project collaborated with the MWENDO in household economic strengthening initiatives that involved training of young mothers clubs on Savings and Internal Lending Communities (SILC). MWENDO supported through provision of Facilitators to train the groups in Bushiri in Navakholo Sub County and Mulwanda in Khwisero Sub County..

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Annex I1: Schedule of Future Events

The scheduled activities for Quarter 4 of FY2020 are included in Table 29 below. Table 29. Schedule of upcoming events in PY3Q4 Date Location Activity July 2020 Kakamega, Kisumu , Kitui , World Population Day Migori August 2020 Kisumu Launch of the road map for Kisumu County Domestic Resource Mobilization from the Private Sector August 2020 TBD Quarterly review Meeting with USAID August 2020 TBD PY2 Work planning & Budget retreat September Kakamega, Kisumu , Kitui , World Contraception Day 2020 Migori

Annex III. List of Deliverable Products

 Rapid Assessment on the of Effect of COVID-19 on Essential RMNCAH Services: Perspectives from four Kenya Counties as at April 2020

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Annex IV. Afya Halisi PY3Q3 summary performance

Table 30. Afya Halisi Year 3 Quarter 3 summary performance Indicator FY20 Y3Q1 Y3Q2 Y3Q3 Y3Q4 Total % target Achievement FP/RH HL.CUST FP 14.0 Number of Health 270 0 0 0 0 0% Workers trained in commodity management through USG supported programs CUST Number of men 101 0 0 0 0 0% CUST Number of women 169 0 0 0 0 0% HL.CUST FP 15.0 Total number of Health 1,000 0 193 183 376 38% Workers trained in FP/RH through in- service training CUST Number of men 381 0 42 49 91 24% CUST Number of women 619 0 151 134 285 46% HL.CUST FP 16.0 Percent of USG- 13% 85% 64% 71% 71% 71% assisted service delivery points (SDPs) that experience a stock out at any time during the reporting period of a contraceptive method that the SDP is expected to provide CUST Denominator 664 610 608 641 641 CUST Numerator 86 520 391 456 456 HL.7.1-3 Average stock out rate of 15% 46% 32% 21% 21% 21% contraceptive commodities at Family Planning (FP) service delivery points (Injectables) CUST Denominator 664 603 601 630 630 CUST Numerator 100 278 192 131 131 HL.7.1-1 Couple Years protection in USG 609,815 139,855 117,278 121,111 378,244 62% supported programs HL.7.1-1-a Urban HL.7.1-1-b Rural 609,815 139,855 117,278 121,111 378,244 62% HL.7.1-2 Percent of USG-assisted service 100% 96% 96% 97% 96% 96% delivery sites providing family planning counseling and/or services HL.7.1-2-a Numerator 664 610 608 641 641 HL.7.1-2-b Denominator 664 633 633 664 664 HL.7.2-2 Number of USG-assisted 2,200 2,074 2,249 3,045 3,045 138% community health workers (CHWs) providing Family Planning (FP) information, referrals, and/or services during the year HL.7.2-2-a Number of men 835 603 582 748 748 90% HL.7.2-2-b Number of women 1,365 1471 1,470 2,297 2,297 168% HL. CUST FP 18.0 Total adolescent 31,040 7,556 6,003 8,635 22,194 72% clients (10-19) receiving FP services Maternal Health

HL.CUST MCH 6.0 Number of USG- 165 139 134 149 149 90% supported facilities that provide appropriate life-saving maternity care (this

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will be defined as seven signal functions for BEmONC and nine signal functions for CEmONC) BEmONC 143 119 114 127 127 89% CEmONC 22 20 20 22 22 100% Number of women who attended at least 27,476 32,915 32,745 93,136 one ANC visit during the latest pregnancy HL.CUST MCH 7.0 Number of women 73,686 15,676 17,056 18,614 51,346 70% who received at least 4 ANC visits during the latest pregnancy HL.CUST MCH 8.0 Total number of 1,320 0 856 686 1,542 117% Community Health Workers (CHWs) trained in maternal and/or newborn health through USG supported programs. CUST Number of Female 500 0 624 474 1098 220% CUST Number of Male 820 0 232 212 444 54% HL.CUST MCH 9.0 Number of Health 926 75 147 431 653 71% care workers trained in maternal and/or newborn health care through USG supported programs CUST Number of Female 354 48 85 225 358 101% CUST Number of Male 572 27 62 206 295 52% HL.6.2-1 Number of women giving birth 70,002 18,126 18,855 19,190 56,171 80% who received uterotonics in the third stage of labor (or immediately after birth) through USG-supported programs HL.CUST MCH 10.0 Number of births in 70,002 22,906 23,476 24,585 70,967 101% a given year attended by a skilled birth attendant (SBA) such as doctor, nurse, or midwife HL. CUST MCH 17.0 Total adolescent 30,181 6,283 6,756 6,608 19,647 65% clients (10-19) receiving ANC Child Health

Number of children who received DPT1 27,014 25,860 28,115 80,989 by 12 months of age in USG-assisted programs HL.CUST MCH 4.0 Number of children 99,688 25,407 26,559 27,254 79,220 79% who received DPT3 by 12 months of age in USG-assisted programs HL.CUST MCH 5.0 Children who 99,688 24,094 22,923 29,847 76,864 received measles vaccine by the time they were 12 months of age HL.CUST MCH 11.0 Number of children 99,688 23,916 22,949 29,458 76,323 77% under one fully immunized HL.6.3-2 Number of newborns who 66,501 19,471 20,760 21,820 62,051 93% received postnatal care within two days of childbirth in USG-supported programs HL.6.6-2 Number of cases of childhood 34,559 5,791 10,555 4,528 20,874 60% pneumonia treated in USG-assisted programs HL.6.6-1 Number of cases of child 94,492 18,615 19,488 14,707 52,810 56% diarrhea treated in USG-assisted programs Nutrition

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HL.9-1 Number of children under five (0- 225,361 198,902 32,536 247,379 247,379 110% 59 months) reached by nutrition-specific interventions through USG-supported programs HL.9-1-a Number of children whose 55,374 14,067 17,316 18,953 50,336 91% parents/caretakers received behavior change communication interventions that promote essential infant and young child feeding behaviors HL.9-1-b Number of children 6 - 59 225,361 198,902 32,536 247,379 247,379 110% months who received vitamin A supplementation in the past 6 months HL.9-1-c Number of children under five 50,355 7,294 8,637 8,572 24,503 49% who received zinc supplementation during an episode of diarrhea HL.9-1-d Number of children under five who received Multiple Micronutrient Powder (MNP) supplementation HL.9-1-e Number of children under five who received treatment for severe acute malnutrition HL.9-1-f Number of children under five who were admitted for treatment of moderate acute malnutrition HL.9-1-g Number of children under five who received direct food assistance

HL.9-1-h Number of male children under 110,427 97,373 15,943 121,216 121,216 110% five reached by USG-supported nutrition programs HL.9-1-i Number of female children under 114,934 101,347 16,593 126,163 126,163 110% five reached by USG-supported nutrition programs HL.9-2 Number of children under two (0- 80,424 22,029 19,265 16,333 57,627 72% 23 months) reached with community-level nutrition interventions through USG- supported programs HL.9-2-a Number of male children under 39,407 10,796 9,436 8,003 28,235 72% two (0-23 months) reached with community-level nutrition interventions through USG-supported programs

HL.9-2-b Number of female children 41,017 11,233 9,829 8,330 29,392 72% under two (0-23 months) reached with community-level nutrition interventions through USG-supported programs

HL.9-3 Number of pregnant women 55,374 14,067 17,316 18,953 50,336 91% reached by nutrition-specific interventions through USG-supported programs HL.9-3-a Number of women receiving 55,374 14,067 17,316 18,953 50,336 91% iron and folic acid supplementation HL.9-3-b Number of women receiving 55,374 14,067 17,316 18,953 50,336 91% counseling on maternal and/or child nutrition

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HL.9-3-c Number of women receiving calcium supplementation HL.9-3-d Number of women receiving multiple micronutrient supplementation HL.9-3-e Number of women receiving direct food assistance of fortified/specialized food product HL.9-3-f Number of women < 19 years of 14,673 6,270 3,716 6,608 16,594 113% age HL.9-3-g Number of women > or = 19 40,701 7,757 13,601 12,345 33,703 83% years of age HL.9-4 Number of individuals receiving 370 0 0 460 460 124% nutrition-related professional training through USG-supported programs HL.9-4-a Number of non-degree seeking 370 0 0 460 460 124% trainees HL.9-4-b Number of degree seeking trainees HL.9-4-c Number of new degree seeking trainees HL.9-4-d Number of continuing degree seeking trainees HL.9-4-e Number of men 115 0 0 174 174 151% HL.9-4-f Number of women 255 0 0 286 286 112%

HL. CUST N1.0 Number of health 124 127 140 153 153 123% facilities with established capacity to manage acute under-nutrition HL. CUST N2.0 Number of Children 3,025 2,196 2,648 7,869 under five who are underweight HL. CUST 2.0-a Male 1,184 1,098 988 3,270 HL. CUST 2.0-b Female 1,841 1,098 1,660 4,599 HL. CUST N3.0 Total Number of children 281,692 0 0% under five years HL. CUST 3.0-a Male 138,031 0 0% HL. CUST 3.0-b Female 143,661 0 0% WASH Number of people gaining access to a 13,284 0 719 7,733 8,452 64% basic sanitation service as a result of USG assistance Male 6,376 0 346 3,791 4,137 65% Female 6,908 0 373 3,942 4,315 62% Urban Rural 13,284 0 719 7,733 8,452 64% Number of communities verified as “open 74 0 0 57 57 77% defecation free” as a result of USG assistance Number of individuals trained to 788 0 12 1,299 1,311 166% implement improved sanitation methods Male 378 0 8 595 603 160% Female 410 0 4 704 708 173% HL.81.1 Number of people gaining access 11,300 0 0 15,069 15,069 133% to basic drinking water services as a result of USG assistance

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HL.8.1-1.a Number of Men 5,424 0 0 6,866 6,866 127% HL.8.1-1.b Number of Women 5,876 0 0 8,203 8,203 140% HL.8.1-1.c Urban HL.8.1-1.d Rural 11,300 0 0 15,069 15,069 133% HL.8.2-4 Number of basic sanitation 10 0 0 5 5 50% facilities provided in institutional settings as a result of USG assistance Institution Type (School/Health 10 0 0 5 5 50% Facility) School Health Facility 10 0 0 5 5 50%

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