USAID AND EAST AFRICA AFYA JIJINI YEAR 3 ANNUAL WORK PLAN

AUGUST 2017 This publication was produced for review by the United States Agency for International Development. It was prepared by IMA World Health. USAID KENYA Afya Jijini YEAR 3 ANNUAL WORK PLAN

Award No: AID-615-C-15-00002

Prepared for Dr. Teresa Simiyu United States Agency for International Development/Kenya and East Africa c/o American Embassy Avenue, P.O. Box 629, Village Market 00621 , Kenya

Prepared by: IMA World Health 1730 M Street N.W. • Suite 1100 Washington, DC 20036

DISCLAIMER

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

TABLE OF CONTENTS

ACRONYMS AND ABBREVIATIONS ...... ii INTRODUCTION ...... 1 AFYA JIJINI Y3 PROPOSED ACTIVITIES ...... 3 Sub-Purpose 1: Increased Access And Utilization Of Quality Hiv Services...... 3 Output 1.1: Elimination Of Mother-To-Child Transmission (Emtct) ...... 4 Output 1.2 And Output 1.3: Hiv Care, Support, And Treatment Services ...... 8 Output 1.4: Hiv Testing And Counseling (Htc), Voluntary Medical Male Circumcision (Vmmc), Gender-Sensitive Hiv Prevention, And Dreams ...... 11 Output 1.5: Tb / Hiv Co-Infection Services ...... 20 Sub-Purpose 2: Increased Access And Utilization Of Focused Maternal, Newborn, And Child Health (Mnch); Family Planning (Fp); Water, Sanitation And Hygiene (Wash); And Nutrition Services ...... 23 Output 2.1: Mnh Services ...... 24 Output 2.2: Child Health ...... 29 Output 2.3: Family Planning (Fp) ...... 31 Output 2.4: Water, Sanitation And Hygiene (Wash) ...... 33 Output 2.5: Nutrition Services ...... 36 Sub-Purpose 3: Strengthened And Functional County Health Systems ...... 40 Output 3.1: Partnerships For Governance And Strategic Planning ...... 41 Output 3.2: Human Resources For Health (Hrh) ...... 43 Output 3.3: Health Products And Technologies (Hpt) ...... 44 Output 3.4: Strategic Monitoring And Evaluation (M&E) ...... 47 Output 3.5: Quality Improvement Systems ...... 49 Annexes And Attachments ...... 54 Annex I: Year III Budget ...... Error! Bookmark not defined. Annex II: Proposed International Travel ...... Error! Bookmark not defined. Annex III: High-volume Maternity and FP Facilities ...... 56 Annex IV: Afya Jijini AYSRH Model ...... 59 Annex V: Afya Jijini Facility Champion Model ...... 60 Annex VI: Screening Tools ...... 61 Annex VII: List of Tracer Medicines and Laboratory Commodities ...... 64

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ACRONYMS AND ABBREVIATIONS

ACF Active Case Finding ADR Adverse Drug Reaction AGYW Adolescent Girls and Young Women AJSG Afya Jijini Small Grants ALHIV Adolescents Living with HIV AMSTL Active Management of Third Stage of Labor ANC Antenatal Care APOC Adolescent Package of Care ART Antiretroviral Therapy AVD Assisted Vaginal Delivery AWP Annual Work Plan AYSRH Adolescent and Youth Sexual Reproductive Health BCC Behavior Change Communications BEmONC Basic Emergency Obstetric and Newborn Care BFHI Baby-Friendly Health Initiatives BP Blood Pressure CASCO County AIDS/STI Coordinator CBD Community-based Distributors CBHIS Community-based Health Information Systems CBO Community-based Organization CCC Comprehensive Care Center CEmONC Comprehensive Emergency Obstetric and Newborn Care CF Case Finding CHA Community Health Assistant CHAK Christian Health Association of Kenya CHMT County Health Management Team CHV Community Health Volunteer CME Continuing Medical Education cMNH Community Maternal and Newborn Health CNAP County Nutrition Action Plan CNTF County Nutrition Technical Forum CoC Continuum of Care COP Chief of Party CTLC County TB/Leprosy Coordinator CWC Child Welfare Clinic DBS Dry Blood Spot DICE Drop-in Center DOTS Directly Observed Therapy, Short Course DQA Data Quality Assessment DREAMS Determined, Resilient, Empowered, AIDS-Free, Mentored, and Safe Women DRTB Drug-Resistant Tuberculosis EBF Exclusive Breastfeeding EBI Evidence-based Intervention ECD Early Childhood Development ECHO Extension for Community Healthcare Outcomes EID Early Infant Diagnosis EMR Electronic Medical Records EmONC Emergency Obstetric and Newborn Care eMTCT Elimination of Mother-to-Child Transmission EPI Expanded Program on Immunization EQA External Quality Assessment FBO Faith-based Organization FGD Focus Group Discussions FP Family Planning USAID/KENYA AFYA JIJINI YEAR 3 WORK PLAN ii

FPPAC Family Planning during Post Abortion Care FSW Female Sex Workers GBV Gender-based Violence GOK Government of Kenya GUC Grants under Contract HC Health Center HCBF Healthy Choices for a Better Future HCW Healthcare Worker HCWM Health Care Waste Management HH Household HII High-impact Interventions HINI High Impact Nutrition Interventions HEI HIV-Exposed Infant HMT Health Management Team HRD Human Resources Development HRH Human Resources for Health HRIO Health Records Information Officers HSDA Health Service Delivery Awards HSS Health Systems Strengthening HTS HIV Testing Services HVF High-volume Facility HWT Household Water Treatment Technologies ICF Intensified Case Finding IEE Initial Environmental Examination IFAS Iron and Folic Acid Supplementation iHRIS Integrated Human Resources Information System IMAM Integrated Management of Malnutrition IMCI Integrated Management of Childhood Illnesses INH Isoniazid IP Implementing Partner IPC Infection Prevention Control IPD Inpatient Department IUCD Intrauterine Contraceptive Device KCB Kenya Commercial Bank KMC Kangaroo Mother Care KP Key Populations KSG Kenya School of Governance LARC Long-acting Reversible Contraception LDP Leadership Development Program LIMS Logistic Information Management Systems LTFU Lost-to-follow-up M&E Monitoring and Evaluation MDT Multi-disciplinary Team MDR Multi-drug Resistant MEDS Mission for Essential Drugs and Supplies MHMC My Health, My Choice MIYCN Maternal Infant and Young Child Nutrition MNCH Maternal, Newborn and Child Health MNH Maternal and Newborn Health MNP Multi-nutrient Powders MOH Ministry of Health MPDSR Maternal and Perinatal Death Surveillance and Response MSM Men who have Sex with Men MSP Male Sexual Partner MSW Male Sex Workers MTC Medical Therapeutic Committee

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MUAC Mid-Upper Arm Circumference NACS Nutrition Assessment Counseling NASCOP National AIDS and STI Control Program NBU Newborn Unit NCC Nairobi City County NCD Non-Communicable Diseases NGEC National Gender and Equality Commission NHIF National Health Insurance Fund NOPE National Organization of Peer Educators OCP Oral Contraceptive Pills OJT On-the-Job Training OPD Outpatient Department ORS Oral Rehydration Solution ORT Oral Rehydration Therapy OTZ Operation Triple Zero OVC Orphans and Vulnerable Children PAC Post Abortion Care PBB Program-based Budgeting PBI Performance-based Incentives PCR Polymerase Chain Reaction PEP Post-Exposure Prophylaxis PHDP Positive Health Dignity and Prevention PHO Public Health Officer PLHIV People Living with HIV PNC Postnatal Care POC Point of Care POU Point of Use PMTCT Prevention of Mother-to-Child Transmission PPFP Postpartum Family Planning PPH Postpartum Hemorrhage PPP Public-Private Partnership PrEP Pre-exposure Prophylaxis PSSG Psychosocial Support Group PT Proficiency Testing PVC Post-Violence Care PWID People Who Inject Drugs QA/QI Quality Assurance/Quality Improvement QIT Quality Improvement Team RDQA Routine Data Quality Audit REC Reach Every Community RH Reproductive Health RMHSU Reproductive and Maternal Health Services Unit RMNCH Reproductive Maternal, Newborn, and Child Health RRI Rapid Results Initiative SASA! Start Awareness Support Action SCASCO Sub-County HIV/AIDS and STI Coordinator SCHMT Sub-County Health Management Team SCNTF Sub-County Nutrition Technical Forum SDP Service Delivery Point SGBV Sexual Gender-based Violence SMLT Sub-County Medical Laboratory Technologist SOP Standard Operating Procedure SRH Sexual Reproductive Health STI Sexually-transmitted Infection STLC Sub-County Tuberculosis and Leprosy Coordinator TA Technical Assistance

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TB Tuberculosis TOR Terms of Reference TPA Treatment Preparation Adherence TWG Technical Working Group U5 Under-five UCLTS Urban Community Lead Total Sanitation UON (UoN) VCT Voluntary Counseling and Testing VL Viral Load VMMC Voluntary Medical Male Circumcision WASH Water, Sanitation, and Hygiene WIT Work Improvement Team WRA Women of Reproductive Age

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INTRODUCTION

Afya Jijini is a three-year contract (with two option years) that contributes to USAID/Kenya’s Country Development Cooperation Strategy Sub-Intermediate Result 2.2.2 for “improved county-level institutional capacity and management of health service delivery” in Nairobi City County (NCC) The project’s purpose is to improve and increase access and utilization of quality health services in NCC through strengthened service delivery and institutional capacity of health systems. Afya Jijini seeks to achieve three main sub-purposes:

Sub-Purpose 1: Increase access and use of quality HIV services. Sub-Purpose 2: Improve access and uptake of maternal, neonatal, and child health (MNCH); family planning (FP) and reproductive health (RH); Water, Sanitation and Hygiene (WASH); and nutrition services. Sub-Purpose 3: Strengthen County and sub-county health systems.

The following priorities guided FY18 work plan development:

Overall: Afya Jijini enters Y3 having made significant strides in HIV linkage and suppression, while having a more nuanced understanding of the key barriers impacting uptake and retention in HIV and MNCH services. Y3 offers the opportunity to scale-up proven, evidence-based interventions (EBIs) grounded in project-specific guidance honed during Y2, including the MNCH assessment. emerging guidance on Pre-Exposure Prophylaxis (PrEP) and other County policies and plans developed with Afya Jijini technical assistance (TA). The program will also scale-up the Afya Jijini Small Grants Program with local entities to support sustainable, community-based efforts.

Sub-Purpose 1: The PEPFAR annual targets for Afya Jijini increased for Y3, in view of increasingly sophisticated data-driven approaches. In Y3, Afya Jijini will test at least 288,361 clients, with a focus on scaling-up testing through targeting high-yield areas/approaches (outpatient, inpatients, tuberculosis (TB) clinics, antenatal care (ANC), family and partner testing (with an emphasis on reaching men), key populations (KP), and youth). The project will identify 12,573 new HIV-positive adult clients and link them to antiretroviral therapy (ART) through a series of aggressive linkage approaches. Afya Jijini will focus in particular on improving pediatric and adolescent case finding, linkages, and retention, an area that requires dedication and innovation, given the challenges for these populations. The project will continue striving to achieve 90% retention and suppression for clients on ART. It will ensure 95% of ANC clients are offered HIV testing services (HTS) and identify 3,178 prevention of mother-to-child (PMTCT) mothers and link them to ART. Additionally, under DREAMS, the program will support adolescent girls and young women (AGYW), their sexual partners, and community members in line with the DREAMS core package, expanding to new wards in Westlands sub-county. The program will hold bi- weekly performance assessments to monitor progress towards targets and make real-time course corrections.

Sub-Purpose 2: In Y2, program activities contributed to notable strides in MNCH, FP, and service use at targeted NCC health facilities, despite observed quarter-to-quarter fluctuations due to the nurses’ and doctors’ strikes (December 2016-March 2017 and June 2017-present). These temporary “shocks” had a destabilizing effect on MNCH service delivery, particularly for maternity wards. An in-depth external evaluation of the Afya Jijini MNH portfolio in Y2 identified several challenges – particularly related to post-partum hemorrhage (PPH) management – that will be addressed in Y3. Afya Jijini will focus specifically on improving facility- and community-based family planning, post-partum family planning (PPFP), and FP during Post Abortion Care (PAC), with the aim of increasing the number of women of reproductive age (WRA) accessing modern contraceptives by 20% by the end Y3 from the baseline. The program will help the County offer improved youth-friendly services, especially for FP, with a goal of reducing teenage pregnancy among adolescent women 15-19 years. Increasing access to quality health

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services remains pivotal to increasing child survival in Nairobi City County. To achieve this, the program will implement strategies that prioritize on-demand creation, reduction of coverage barriers, as well as scale-up high impact child health interventions (HII) and provide quality service delivery towards reducing child morbidity and mortality in informal settlements in Y3. For WASH, the project will continue improving sanitation, decreasing the population’s practice of open defecation (especially in informal settlements), with an emphasis on Urban Community Lead Total Sanitation (UCLTS), and scaling-up/accelerating the number of households complying with water treatment technologies in targeted informal settlements. For nutrition, Afya Jijini will assist the County in rolling out 11 evidence- based High Impact Nutrition Interventions (HINIs) within target health facilities and catchment areas. At the community level, the project will work with community health volunteers (CHVs) and grantees to boost uptake and awareness of services across all aspects of Sub-Purpose 2.

Sub-Purpose 3: The program will continue offering TA to strengthen the County’s capacity to develop and implement plans and systems for health service delivery, focusing in particular on strengthening human resources for health (HRH) performance and quality of care. In Years 1 and 2, Afya Jijini continued to build the leadership and management capacity of County, sub-county, and facility staff; re- established critical committees (e.g. the County and sub-county commodity security committees, medicines and therapeutic committees, and work improvement teams (WITs)); supported lab networking to improve efficiency in samples collection; improved data quality through regular data quality assessments; and strengthened quality assurance/quality improvement (QA/QI) knowledge and skills through training and coaching/mentorship. Afya Jijini also coordinated with the Kenya School of Government (KSG) to provide more than 100 County and sub-county staff with leadership and management trainings. In strengthening governance, the program will support dissemination and implementation of the completed County policies and strategies, including the Nairobi City County Health Sector Strategic and Investment Plan and the Nairobi City County Health Policy. Afya Jijini will continue strengthening the annual work plan (AWP) process by ensuring linkages with program-based budgeting (PBB), improving governance by engaging with the hospital boards and health facility committees, conducting supportive supervision, covering all WHO health systems building blocks, improving performance management, as well as training plans, at the facility level, supporting coordination of all HRH activities by ensuring functionality of the HRH technical working group (TWG), providing pharmacy and laboratory management support, ensuring improved inventory management practices at the facility level, supporting laboratory sample networking, accelerating biosafety/ biosecurity activities, supporting capacity building data systems use, as well active healthcare worker HCW participation in data review and analysis, and supporting WITs’ functionality and institutionalization of QA/QI coaching within the County system through County and sub-county coaches. Ayfa Jijini will also continue providing technical and logistics support to County and sub-county stakeholder meetings, as well ensuring implementation of the newly-developed Partnership Engagement Framework through monitoring and continuous coaching of County staff.

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AFYA JIJINI Y3 PROPOSED ACTIVITIES

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

Introduction Nairobi City County (NCC) ranks among the top five leading counties contributing to the HIV burden in Kenya. While not necessarily leading in prevalence, it is home to more than 10 percent (nearly 180,000 people) of people living with HIV (PLHIV). Rapid urbanization in NCC, high levels of poverty in ever- growing informal settlements, and lingering HIV stigma and discrimination put people at increased risk of contracting HIV, particularly among key populations and young girls.

Targets In FY18, Afya Jijini will:  Test at least 288,361 clients, with a focus on scaling-up testing through targeting high-yields areas/approaches (outpatient, inpatients, tuberculosis (TB) clinics, ANC, family and partner testing, key population, and youth).  Identify 12,573 HIV-positive adult clients and link them to ART.  Identify 172 HIV-positive children and link them to ART.  Maintain 41,631 PLHIV on treatment and ensure viral load suppression for 37,468 PLHIV.  Initiate 10,587 PLHIV on ART and achieve 90% retention rates.  Ensure 95% of ANC clients are offered HIV testing and identify 3,178 prevention of mother-to- child (PMTCT) mothers and link them to ART.

Approach Afya Jijini supported NCC to scale-up HIV services in Y2 for adults and pediatrics, supporting 42 eMTCT sites, 22 high-volume care and treatment facilities, and 36 sites with TB/HIV services.  The First 90: By FY17/Q3, the project provided HIV testing services (HTS) to 217,725 clients, achieving 113% of APR target. Of these, 6,679 tested positive (67% of APR target), with an overall positivity yield of 3.1% (with higher yields among certain sub-populations).  The Second 90: From Q3, the project had initiated 54% of the APR target on treatment.  The Third 90: The project retained 81% of clients on treatment after 12 months, with 84.3% virally suppressed.

Ambitious COP17 targets and adoption of the Test and Treat strategy in July 2016 call for intensified support to NCC in scaling-up access to HIV services to achieve the 90-90-90 targets. Afya Jijini will continue working closely with the county to roll-out the new guidelines to all supported care and treatment sites, focusing on high-volume sites (sites with >500 HIV patients in HIIV care and treatment). The “Test and Treat” strategy requires an intensified focus on identifying clients testing HIV-positive and offering same-day initiation on ART.

As described in Sub-Purpose 3, the project’s Health Systems Strengthening (HSS) Team will also coach the county and sub-counties in supervision, planning, quantification of commodities, and reporting of both service delivery as well as commodity consumption for HIV. To promote sustainability, Afya Jijini will continue participating in technical working groups (TWGs), County Health Management Team (CHMT) and Sub-County Health Management Team (SCHMT) planning meetings, and donor affinity groups.

At the community level, the project will work with a grant to engage and train 30 community Mentor Mothers to strengthen the community-facility linkages and to ensure that patients are retained in USAID/KENYA AFYA JIJINI YEAR 3 WORK PLAN 3

treatment. At the site level, project UHAI TA teams will work closely with health facilities to support site-specific work plans to improve HIV integration and service delivery. Site level approaches to strengthen service delivery will include continuing medical education (CMEs), on-the-job trainings (OJTs), mentorship, support to psychosocial support groups (PSSGs), and lab networking (see Output 3.3) and, where needed, supplements to the workforce. Specific cadres, such as clinical workers in the Comprehensive Care Centers (CCCs) and HTS Counselors, will also be deployed strategically at high- volume health facilities to support scale-up of Test and Treat. The project will also integrate PMTCT services into seven new maternal and child health (MCH) clinics, as well as improve HIV-exposed infant (HEI) follow-up through defaulter tracking and HEI analysis.

OUTPUT 1.1: ELIMINATION OF MOTHER-TO-CHILD TRANSMISSION (EMTCT)

Background and Rationale Afya Jijini will provide technical support to 42 health facilities for improved eMTCT service delivery during FY18. Of these, 25 facilities serve more than 500 clients for first ANC monthly. The project will guide its FY18 approaches based upon current data trends, scaling-up evidence based approaches and addressing existing gaps, including integrated RH services provision (Prong 2), EID uptake (in line with the new guidelines), viral load uptake, and suppression and retention of the eMTCT mothers. Viral load uptake among mothers was low due to the mother’s arriving after 10am when VL sample collection ends. To address this, it was decided that DBS for VL should be collected for those who turn up after 10 am instead of rescheduling sample collection for another day as DBS samples can be kept in the facility land sent to the lab the following day. To address this, DBS for VL is now taken instead of asking the mother to reschedule her appointment. Additionally, the project will closely collaborate with Sub-Purpose 2 activities designed to increase ANC attendance, facility-based deliveries, and safe infant feeding practices, all of which will contribute to reduced risk of mother-to-child transmission of HIV. Due to the HCWs strikes Afya Jijini was not able to train HCWs on RH service provision in support of integration during Year 2, therefore the project aims work with the county team in Year 3 to carry out this training.

The project’s target was to test 53,076 women and identify 1,787 HIV positive pregnant women at first ANC visit in Year 2. As of Y2/Q3, Afya Jijini reached 41,367 pregnant women with HIV testing (78% of the annual target), linking 885 out of 907 (98.9%) of those testing HIV-positive to ART. Eligible HIV- positive pregnant or lactating women had a viral uptake of 61% (816 clients), indicating a need for increased attention to ensuring VL uptake. Of those with a VL, 604 clients (91%) achieved viral suppression. The project identified gaps in tracking mother-baby pairs throughout the PMTCT cascade, during Y2, particularly in later stages of the continuum of care (CoC)). Many MCH nurses still lack the capacity to conduct viral load testing due to lack of training, mentoring, and having been newly posted into MCH/PMTCT rotation, consequently creating challenges in ART monitoring. During Y3, Afya Jijini will work with eMTCT nurses in high-volume facilities to mentor HCWs in various service delivery points to provide quality HIV care and treatment services, including ART monitoring.

FY18 strategies will ensure that high rates of HIV testing among pregnant women continues, service quality improves, and that mother-infant pairs are followed throughout the continuum of care. The project’s supported 26 eMTCT nurses employed by the project to support high volume PMTCT sites will help improve overall delivery of eMTCT services in MCH settings, including integration of HIV services into MCH and RH services in CCC, focusing mainly on the four prongs of PMTCT. These eMTCT nurses will complement facility-based efforts by providing OJT and mentorship and also track integration efforts.

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The project will further integrate PMTCT services into seven1 new MCH departments to improve service reach and client follow-up. Facility-based Mentor Mothers will lead PSS efforts and client defaulter tracking. Improved use of data, such as QI efforts and training on HEI cohort analysis, will help health facilities identify PMTCT service delivery improvement areas. The project will also explore engagement of community-based Mentor Mothers to provide necessary PSSGs on a more frequents basis within the community and to also support tracking of mother/baby pairs throughout the eMTCT cascade. Afya Jijini intends to identify and manage Mentor Mothers at facility and community levels in partnership with small grants program sub-grantees during Y3. Afya Jijini will work with other partners (including the USAID- funded Nilinde project and COGRI) to strengthen defaulter management and referrals at community level.

Activities Identify HIV-positive pregnant women through testing and re-testing. Afya Jijini will test 69,221 pregnant women, with the aim of identifying 946 new HIV-positive pregnant women and 2,232 known positive pregnant women. In FY18, the project will continue to ensure that HIV testing for pregnant and breastfeeding women is available at all entry points, with eMTCT nurses reporting progress on a weekly basis (increasing in frequency from Y2, when it was monthly). Facility-based Mentor Mothers will educate waiting mothers in MCH about the importance of HIV testing for pregnant women. HTS counselors will be placed in high-volume facilities to support HTS, including the re-testing for women who previously had a negative test in the first trimester and to test other clients presenting at the facility for ANC, FP, CWC, and PNC. The project’s four cluster teams, called UHAI teams (translated to “life” or alive” in Kiswahili) work closely with and mentor HCW and sub-counties in Afya Jijini-supported facilities. These teams will also conduct CMEs to ensure capacity of HTS providers, sensitize HCW on syphilis testing (an emerging County priority to achieve elimination of HIV and syphilis in line with the MOH recommendation). The project will distribute IEC materials and job aids to facilities in need, as in Y2.

Quarterly supervision and mentorship will be conducted jointly with the SCHMT to enable them to identify gaps at county and sub county levels such as frequency of staff rotation within facilities, sub- counties, and/or county. Nurses attached to MCH and maternity from 60 facilities will be trained on the new guidelines using the NASCOP curriculum. Of these, the trainees will be drawn from 15 new private facilities that are now under the support of Afya Jijini. The Y3 training will cover new staff who are on rotation in MCH clinics and maternities, as well as more HCWs from private facilities. Thereafter, the trained nurses and HTS service providers will be linked for proficiency testing to ensure quality of HTS.

Improve services in private facilities. To strengthen service delivery within the informal settlements provided in the private clinics (a Y3 focus and key to attaining contractual outcomes), Afya Jijini will include the 15 private sites in the training, mentorship, supportive supervision, and provision of job aids and standard operating procedures (SOPs) for eMTCT. In addition, the sites will link to the community- based Mentor Mothers engaged through the Afya Jijini Small Grants Program, who will escort pregnant and lactating women to facilities for their linkage to care and treatment.

Improve eMTCT-MCH integration. Afya Jijini will integrate PMTCT services into the remaining 7 MCHs (35 sites have already been integrated of the overall 42 eMTCT sites) to improve retention of eMTCT clients and reduce transmission to infants. Afya Jijini UHAI Teams and eMTCT Nurses will provide guidance, oversight and measure progress toward integration. The project will train 60 MCH nurses in Afya Jijini supported sites including the 26 hired by Afya Jijini on fast-tracking HIV-positive clients, providing ART treatment, and monitoring and defaulter management to enable integration (using

1 AMURT, DIWOPA, FHOK, STC Casino, Jamaa Hospital, Metropolitan Hospital, and Kivuli Dispensary. USAID/KENYA AFYA JIJINI YEAR 3 WORK PLAN 5

the NASCOP ART curriculum). For the non-integrated facilities, Mentor Mothers will escort clients to the various service points to facilitate fast access to service and shorten patient waiting times. Integration efforts at all 42 PMTCT sites will be supported and sustained through OJT, CMEs, and joint mentorship and supportive supervision with the SCHMT. Monthly WITs meeting will monitor quality of care and the project will document best practices during the new quarterly eMTCT practice sharing forum.

Afya Jijini will further integrate reproductive health services into 26 high-volume CCCs during FY18 as a means of helping women prevent unintended pregnancies (Prong 2). Afya Jijini will train CCC clinicians on RH services, on service provision, commodity management and reporting, with the eMTCT nurses supporting integration of these services by mentoring CCC HCW to offer family planning services and ensure that family planning commodities are readily available at the CCCs. Mentor Mothers will track referrals for long-acting methods and PPFP. The project will also support printing and dissemination of RH job aids to all supported CCCs.

Enroll HIV-positive pregnant women on ART and achieve 90% viral load suppression. Afya Jijini’s previously-mentioned MCH training activities (referenced in 1.1.2) will improve the capacity of MCH nurses to start more patients on ART, monitor their treatment, and keep them into the CoC, improving VL suppression. UHAI teams will also hold CMEs and mentorship sessions (in partnerships with the relevant SCHMT) to strengthen capacity of facilities to appropriately monitor viral load testing uptake and suppression. WITs teams will implement follow-up actions based on data analysis and feedback, including establishment of multi-disciplinary switch teams to review those with unsuppressed viral loads and develop client action plans/switching of regimens.

Clinicians will also review progress along the eMTCT cascade, with a specific emphasis on retention in care (see Activity 1.2.5) and viral load suppression rates, during WIT meetings. As described in Output 3.3, the project will support daily viral load sample networking and reporting aiming to decrease turnaround times. Mentor Mothers have played a critical role in ensuring follow-up with clients who missed appointments, and will continue being engaged in Y3. They will continue educating and reminding clients eligible for a viral load test, using appointment diaries and defaulter tracking registers adopted by Afya Jijini to track those who have not had one (or have an unsuppressed viral load), and providing monthly progress reports. The Mentor Mothers will generate a line list of clients eligible for viral load testing on a weekly basis, then track the clients and those unreachable with the community Mentor Mothers to track them back to clinic for testing.

Identify and track HIV-exposed infants (HEI). The project will support EID services for all expected 3,178 HIV-exposed infants by ensuring EID commodities are available through supply chain TA/monitoring, holding CMEs on the new EID algorithm guidelines, and re-stocking reporting tools on a quarterly basis. The project will also review EID services during joint SCHMT-UHAI mentorship and supportive supervision, monitoring that EID is provided in all service delivery points (including CWC and OPD/IPD), per the algorithm (and offering TA when it is not). Facility Mentor Mothers will offer pre-test education at both ANC and CWC service points, targeting clients who had a negative test or were not tested before. Community Mentor Mothers will identify pregnant women with unknown status as well as HIV-exposed infants at community level and escort the identified clients to a health facility, as well as follow them up through EID and CoC.

Finally, the project’s eMTCT nurses will work with 42 facilities to better monitor HEI outcomes by conducting HEI cohort analysis. HEI cohort analysis was planned for in Y2, but was not carried out due to the HCW strike. Afya Jijini will train 120 eMTCT nurses and CCC clinicians on HEI cohort analysis, helping sites document progress and share it on the talking walls of the clinic. WIT meetings will track the elimination process on a monthly basis and developing small doable actions to address challenges.

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Increase mother-baby retention in the eMTCT cascade. Project FY17/Q3 data showed HEI retention at 41% (535 infants, defined as infants accessing a 12-month PCR) and 51% (456, defined as infants exiting HIV-negative at two years), respectively, for Year 1 and 2 review. These rates of low retention are due in part to low buy-in from HCWs due to lack in knowledge and training. To improve this, the project will continue strengthen the Mentor Mothers at facility level as a primary strategy, who will coordinate activities to retain mother/baby pairs in the eMTCT cascade. As peers, they will manage and run the PSSG groups with oversight from the respective facility and UHAI teams, manage and document the defaulter tracking process, and participate in QI initiatives that will review retention along the eMTCT cascade. Through the grants program, 30 new Community Mentor Mothers will also be trained and allocated to community-based initiatives to complement defaulter tracing and PSS at the facility level. These Community Mentor Mothers will work closely with facility-based Mentor Mothers to improve patient follow-up and treatment literacy, a new innovation for Y3. During Y2, facility-based MMs were limited in their ability to follow-up with patients due to handling high caseloads and having limited ability to track within the community, except through phone calls. To further boost retention and suppression, Afya Jijini will hold biannual HEI graduation ceremonies for those pairs who have successfully exited the program at two years, for both those with HIV-negative and HIV-positive infants who have been linked to ART. The HEI graduates will be provided with a baby pack during the ceremony consisting of a badge, a t-shirt for the baby, and a carrier bag for the mother during the ceremony.

Afya Jijini will print and distribute project-developed mother-baby pair registers and ensure availability and correct use at supported health facilities to track these cohorts. The sub-counties will monitor eMTCT retention performance during quarterly meetings. In addition, Mentor Mothers will hold a quarterly experience sharing forum, sharing data and tips and tricks for retaining mothers. Afya Jijini will work with other partners, such as Nilinde and COGRI, to leverage their existing community networks to identify and reach infants and pregnant women. This collaborative approach will better ensure that missed opportunities for HEIs and HIV-positive infants are minimized.

Boost eMTCT stakeholder collaboration. Afya Jijini will collaborate with other stakeholders (including NCC, COGRI, Nilinde, UMB, and AHF) in the 10 sub-Counties in ensuring eMTCT activities are planned, coordinated, and managed appropriately. Afya Jijini will continue supporting the quarterly eMTCT sub-county technical working groups (TWG), monthly sub-county eMTCT data review meetings, as well as holding a new quarterly sub-county best practice sharing meeting that includes invited private facilities. The collective meetings will be a platform to monitor the elimination agenda and create a platform for data sharing and lessons learnt. Afya Jijini UHAI teams will closely work with the SCASCOs to monitor the eMTCT progress and share progress on a monthly basis.

Strengthen ART linkages for HIV-positive infants. At Y2 SAPR, Afya Jijini identified 31 HIV- infected infants by DBS-PCR, with 65% linked to ART. To reach 90% linkage, UHAI teams will mentor HCWs (especially newly-rotated ones) to access EID results and fast-track all HIV-infected infants for ART. The Mentor Mothers will track and document the process in the defaulter register developed by the project and relay the information to the HCWs. The WIT will assess the linkage status to ART (including those who may have sought treatment at a different facility), as well carry out audits to define and intervene as necessary on a monthly basis. Through the data review meetings, SCASCOs will also share data on those tested and not tested from the particular facility and/or county with their counterparts to facilitate linkages.

Strengthen family-centered HIV testing and care. Mentor Mothers will generate a list for family members (including the spouse and children of the HIV-positive pregnant and breastfeeding mothers) whose status is unknown for targeted family testing and linkages to ART on a monthly basis. Testing will be carried out by HCW preferably at the facility. However, the project will facilitate planned household/community testing for those unable to attend the facility.

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Increase adolescent-friendly ANC services. Afya Jijini identified two facilities providing adolescent- friendly ANC services in Y2. Afya Jijini intends to scale-up the same in 20 high-volume health facilities, including those facilities that will receive referrals from DREAMS activities in Makuru kwa Njenga. Working with the facilities, UHAI teams will identify point persons to coordinate the services as well as train the HCWs on AYSRH and APOC. The adolescent focal HCW will oversee special monthly clinic days. S/he will be selected based upon who can most effectively interact and engage with AGYW to provide ANC services for pregnant AGYW, including health education. The same sites will hold monthly adolescent PSSGs to ensure adherence to ANC services and follow-up. Other Comments OUTPUT 1.2 AND OUTPUT 1.3: HIV CARE, SUPPORT, AND TREATMENT SERVICES

Background and Rationale In Y3, Afya Jijini will focus on achieving the Second and Third 90 by building on activities initiated and implemented in Y1 and Y2 that have worked. The project will initiate 10,587 clients on treatment, maintain 41,631 on treatment, and ensure 90% of all clients on treatment are virally suppressed. From FY17/Q2 data, Afya Jijini had initiated 35.5% of the annual targeted clients on treatment and retained 84% on treatment after 12 months (with a viral load suppression of 84%). Test and Treat was successfully rolled out, leading to 98% of all clients in care enrolled on treatment. As in Y2, linking clients to treatment will be a significant focus, given the challenges of Nairobi’s largely mobile population.

Approach Afya Jijini will implement targeted HIV interventions with demonstrated high impact, as identified in PEPFAR’s COP 2017 strategy and NCC’s HIV/AIDS Strategic Plan. Best practices learned during program implementation and from other implementing partners will be scaled up (such as providing engaging recreational/social activities at DREAMS safe spaces to encourage retention), while activities that did not improve outcomes will be reviewed and improved or potentially discarded. The project will continue to support new strategies rolled out in the past two years, like Test and Treat (including continuing to implement Test and Treat by initiating all newly diagnosed clients onto treatment either on the same day or within two weeks of diagnosis), the differentiated model of care and Operation Triple Z2 (which targets adolescents with HIV adherence and retention interventions).

Initiate new clients (10,308 adults and 279 pediatrics) on ART. Afya Jijini will train additional untrained or newly-rotated HCWs (including nurses) on the revised ART Guidelines to update them on the Test and Treat strategy. Treatment Preparation and Adherence (TPA) counselors will prepare new clients for initiation to treatment, preferably on the same day or within two weeks. TPA counselors will hold weekly treatment literacy classes with newly diagnosed clients until they are initiated on treatment; at least three adherence sessions will then be given two weeks apart; thereafter the sessions will become monthly; and then every 2-3 monthly, if the patients remain stable; and will then occur after one year, thereby following the differentiated care model. One of the three initial adherence sessions will include a group session supported by a peer educator. The project will also support quarterly meetings for peer educators and TPA Counselors to share best practices on enrolling and retaining new clients on treatment. The project will also continue to support PSSGs and adherence sessions for newly-diagnosed HIV-positive clients to foster ART uptake where treatment literacy will be emphasized. Clients who

2 Zero missed drugs, Zero missed appointments, and Zero viral load maintained. USAID/KENYA AFYA JIJINI YEAR 3 WORK PLAN 8

default on care before being initiated on treatment will be tracked using the defaulter tracing mechanism outlined below with the support of a grantee.

Support current HIV clients on treatment. Afya Jijini will support provision of quality HIV services to all patients on treatment through mentorship and OJT by UHAI teams to HCWs in CCC sites. High- volume facilities with staff shortages will be supported with clinicians and nurses to deliver quality HIV care and treatment services. In Years 1 and 2, adequate space was a major hindrance in some facilities for providing high quality services. To address this, Afya Jijini will request approval to procure and renovate a container for Jamaa Hospital to use as a comprehensive care clinic.

Support defaulter tracing for clients who miss clinical appointments: Clients in care and treatment will continue to have their clinical appointments booked and recorded in the appointment diaries by peer educators (who are supported via the small grants program during Y3). Through the support of a grantee, CHVs, peer educators, and TPAs will track clients who miss their clinical appointments through phone calls and home visits, as per the SOPs that Afya Jijini has helped the facilities develop.

Support pediatric HIV care and support services: Afya Jijini will continue to support and cascade pediatric days and clinics from the current 14 facilities to all 22 high-volume facilities. Play and art therapy, a technique to help children cope with emotional stress and thus improve adherence and retention to care, will continue being supported in high-volume facilities (HVFs) through training HCWs in the technique and providing toys needed for the therapy. The project will also continue to support psychosocial support groups for caregivers that will take place on the monthly pediatric clinic days.

Support adolescent HIV care and support services: The project will continue to support and cascade adolescent- specific clinics and days and monthly Adolescent PSSGs, from the current 17 facilities to all HVFs. These will be offered on an adolescent-friendly schedule (during school holidays and the like). The project will work with groups of adolescents living with HIV in NCC, e.g. Sauti Skika, to interact and share experiences with youths and adolescents during the youth days and during school holidays. To foster adherence and viral load suppression, the project will support un-suppressed adolescents to undergo HERO book training, which will educate them on treatment literacy and adherence. Operation Triple Zero (OTZ) will be adopted and rolled out in HVFs. After a needs assessment, the project will roll out APOC training (prior to establishment of OTZ). The project will also consider options to grant part of this activity to an organization, depending on applicants’ experience implementing such activities.

Support delivery of HIV care and treatment services targeting men: The project will support extended CCC clinic hours (evenings, weekends) targeting men, with a bundle of testing and treatment services, starting with high-volume facilities. In addition, the project will help site establish Male Wellness Clinics through expansion of services currently offered in We Men Care Clinics. The project will initially target five high- volume CCCs.

Support screening and management of opportunistic infections, STIs, non-communicable diseases and mental health conditions: Afya Jijini will support facility-based CMEs for CCC HCWs on screening and treatment of opportunistic infections, STIs, non-communicable diseases and mental health illness. Screening for hypertension and diabetes will be improved by procuring and distributing BP machines, glucometers, and weighing scales for HVF CCCs. Lastly, Afya Jijini will print and distribute SOPs on management of opportunistic, non-communicable and mental health diseases for CCC HCWs.

Differentiated Model of Care: Afya Jijini will continue to support fast track desks for stable clients in high- volume facilities. The project will support pre-packaging of dispensed drugs to be distributed by peer educators at the fast track desk in facilities with space and human resource constraints. The four HTS sites with high yields (Mary Immaculate, Samaritan, Umoja VCT, and Marura nursing home) and not offering ART in Y2 will be supported to offer ART as part of the differentiated model by distributing

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pre-packaged drugs from the main facility in Y3. Facility WITs will review DCM data on a monthly basis and recommend action, where necessary, to ensure quality of care.

Increase VL uptake and suppression among HIV clients. VL uptake for all eligible clients on ART: The project will continue to support motorcycle riders to transport VL samples to the National Reference Laboratory. Daily bleeding will be supported through roving and site-based lab technologists and by sensitizing clinicians and nurses on sample collection. For clients who come late after the samples have been collected by riders, the project will support the use of DBS to collect blood for VL testing. Viral load uptake will be monitored through a dashboard that will be updated daily by UHAI teams with data from supported facilities and motorcycle riders. The project will print and distribute VL tracking registers and sensitize clinicians and lab technologists on documentation in the registers. The point-of-care electronic medical records (EMR) systems being rolled out in all high- and middle-volume facilities (in Y2 and Y3) will generate prompts and reminders to clinicians on VL uptake for individual patients to increase reminders/uptake.

90% of all clients on ART virally-suppressed: Afya Jijini will support facility MDTs to meet biweekly to review clients with non-suppressed VL. These clients will be booked in clinics for patients with non-suppressed viral loads to access specialized services from county, project medical officers, and county-hired consultants. The clients will also be supported to meet monthly in PSSGs for adherence sessions and PSS from adherence councilors and peer educators.

Target key populations for HIV care and treatment support. Working closely with the USAID- funded LINKAGES project, Afya Jijini will continue to offer technical support to key population drop-in centers DICEs (expanding to people who inject drugs (PWID) DICEs in Year 3) on care and treatment through enhancing linkage to care, retention, and follow-up to achieve viral suppression in these vulnerable clients. The project will establish comprehensive PHDP through mentorship and OJTs to the three supported key population DICEs. Key population PLHIV tracking will be supported by Afya Jijini through airtime for KP DICEs to help track key populations linked to other facilities to confirm linkage, progress on treatment and ascertain viral load status/suppression.

Sensitization: Afya Jijini will strengthen HCW capacity in mainstream target facilities (who serve higher key population loads) to identify key populations and understand and address some of their key adherence and retention issues. Follow-up mentorship and CMEs will strengthen and assess the provision of free, high quality, and stigma-free services to these key populations (since not all key populations receive services at DICEs). The project will involve key population in CMEs and sensitizations for ownership and to encourage synergy between KP implementing partners and county facilities. The project will work toward supporting new KP support groups at the CCC in the county facilities to enhance adherence and achieve viral suppression for those who don’t want to attend a DICE. To improve county coordination, the project will support one county quarterly KP TWG and three sub-county KP stakeholder conferences. (Further collaboration with LINKAGES is described under Output 1.4).

Build M&E capacity for HIV care and treatment at multiple service levels. The project will support quarterly HIV care and treatment data review meetings at the sub-county level to review facility data and come up with county and sub-county driven solutions to identified gaps.

Improve HIV treatment stakeholder collaboration. Afya Jijini will continue to support the county and sub-county to strengthen HIV services and increase partner cooperation through TWGs, support supervision, data review meetings, in-charges, and stakeholders’ meetings. The project, together with other implementing partners (IPs) in NCC, will also support the county in celebrations commemorating important health days, like the World AIDS Day and World Health Day.

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The project will support NCC to establish and operationalize a regional county TWG that will be tasked with supporting clinical decision-making for complex HIV cases in the county. The TWG will also build the capacity and mentor HIV service providers in the county in coordination with the national office. The Secretariat of the TWG, including an extension for community health outcomes (ECHO) hub3, will be hosted at STC Casino Health Center. The project will also support the establishment of an ECHO room at STC Casino, where teleconference sessions on clinical cases and CMEs will be held.

OUTPUT 1.4: HIV TESTING AND COUNSELING (HTC), VOLUNTARY MEDICAL MALE CIRCUMCISION (VMMC), GENDER-SENSITIVE HIV PREVENTION, AND DREAMS

HTS Background and Rationale Afya Jijini supported testing for 145,748 clients by FY17/Q2, achieving 66% of the quarterly target. Yields have increased through targeted testing at the facility and community level, rising from 2.1% at the end of FY17/Q1 in Y2 to 3.8% at SAPR. Intra-facility linkage to care and treatment still remains a challenge in the highly mobile NCC, especially at referral facilities like Mbagathi and Mama Lucy Kibaki Hospitals, where clients diagnosed while admitted for treatment for other conditions opt to be initiated on treatment at their nearest treatment facility.

Approach The project will continue to pivot technical support to facilities with high yields like Mbagathi, STC Casino and facilities within Mukuru. At facility level, priority will be given to high-yield testing points, including TB clinics and inpatient departments. Technical Assistance will encourage sites to pre-screen previously tested clients at voluntary testing and counseling (VCT) and OPD, optimizing testing. Partner notification services, which have been proven to produce high yields, will be cascaded to all facilities. Family testing will be expanded to include home testing for family members who cannot access testing at the facility level.

Community testing will be focused at hotspots that have been identified through program data and through rapid results initiatives (RRIs) conducted by the project and other IPs. The project will target key populations (female sex workers (FSW), men who have sex with men (MSM), and PWIDs) with testing services at mapped out hotspots at , Langata, and Westlands. Through collaboration with LINKAGES and during joint outreaches, other KPs (MSM, male sex workers (MSW), FSW, and PWID) will be linked to care and followed-up through the HIV treatment cascade.

HTS Counselors will be responsible for tracking linkages for all new positives they test and will submit a weekly report on testing and linkage. The linkage web will be strengthened by ensuring TPA counselors are working at all supported HVFs. The project will also help sites better use linkage diaries to document intra- and inter-facility linkage to account for all new positives, as some clients were missed in Y2 who attended treatment at other sites closer to their homes.

3 Project ECHO (Extension for Community Healthcare Outcomes) is a collaborative model of medical education and care management that empowers clinicians everywhere to provide better care to more people, right where they live. The ECHO model™ does not actually “provide” care to patients. Instead, it dramatically increases access to specialty treatment by providing front-line clinicians with the knowledge and support they need to manage patients with complex conditions such as: hepatitis C, HIV, TB, chronic pain, endocrinology, behavioral health disorders, among others. It does this by engaging clinicians in a continuous learning system and partnering them with specialist mentors at an academic medical center, or hub.

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Provide strategic HTS. Increased access to targeted HIV testing at facility level: Afya Jijini will continue to support HTS counselors in all facilities to conduct targeted testing, with emphasis on sites and testing points with high yields, including the TB and inpatient departments. At the outpatient and VCT service delivery points, the project will support pre-screening of clients based on current Kenya HTS guidelines to maximize yields while reducing unnecessary re-testing. Eligibility for re-tests will be determined through the use of screening tools that were developed in line with the national HTS guidelines (see Annex VI). To reach more men with testing services, the project will support HTS counselors to conduct extended hours and weekend testing regularly.

Increased targeted testing at community level for at-risk populations: Afya Jijini will conduct quarterly review of HTS data to identify sub-counties and wards with high yields. The data will be used to identify hotspots that the project will target with HTS services, including AGYW, older men, and people living with disabilities at higher risk of HIV infection. These data will also be used to identify gaps and provide targeted testing. The project will continue to partner with USAID’s Nilinde and the NCC to test orphans and vulnerable children (OVC) through quarterly RRIs and other avenues. To maximize yields, OVCs will be screened using the Prototype Risk Screening Algorithm.

Support family testing and partner notification services: The project will print and distribute family testing registers and mentor HTS counselors on their use. Eligible family members of index clients (children below 15 years and or spouse of the index client) will be line listed and their contact details recorded in the family testing register. They will be contacted for testing at facility or home-based testing through project support and/or a grant. HCWs in all HVFs will be trained on delivery of partner notification services and will contact the sexual partner (s) of the index client, with client permission.

Support HTS for PWID and other key populations: Afya Jijini will conduct HTS and linkage services for PWIDs within Dagoretti, Langata, and Westlands. The project will adopt a peer-led system where it will engage recovering addicts from the Kenya Network of People who use Drugs to do hotspot mapping and zoning and to identify peer educators who will help to identify and mobilize their peers for HTS possibly through a grant depending on applicants’ expertise. The peer educators will mobilize their peers in the hotspots (injecting dens) and accompany the engaged HTS counsellors in the HTS outreaches. The health facilities near the dens will be identified for strengthening and integration to provide PWID- sensitive services. Afya Jijini will set up safe testing spaces for the PWIDs using tents and chairs in the identified health facilities in collaboration with the sub-counties (to be branded agnostically so as to reduce identification of PWIDs and maintain confidentiality). PWIDs who are HIV-positive will be linked to the nearest facility of choice or DICE for care and treatment.

Engage community mobilizers. The project will engage 10 community mobilizers to conduct outreaches in hard-to-reach places. Mobilization strategies for HTS outreaches will include snowballing, using the community health strategy, and moonlighting4.

4Snowballing: this is where one person is identified and asked to bring another person with similar characteristics in for testing. This approach applies to PWIDs and SWs, as well as older men. Some considerations need to be taken into account, such as incentives for the individual who is referring fellow clients (for example, could consider reimbursement based on the number of people referred).

Community health strategy: this involves using CHVs who are allocated a certain number of households within a community unit. Because the CHVs know the information of those within their households, it is possible to have targeted mobilization using this strategy. The CHVs can go door-to-door in those households that have clients with the desired characteristics. This has been successful in other activities, such as the recent OVC RRI. In this strategy, we would need to work closely with the Sub-County Community Strategy Coordinator and the Community Health Assistants. A mobilization fee should also be paid to the CHVs. The project can also plug in to community activities, such as action and dialogue days, to distribute information.

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Sensitization: Health care workers in identified health facilities will be sensitized and their capacity built to enable them provide comprehensive HIV prevention free of stigma and discrimination. Training will be conducted for the staff on Ministry of Health (MOH) tools that will be used to capture data for monitoring purposes. The project will sensitize law enforcement officers in areas of coverage to help reduce stigma, discrimination, and criminalization of PWIDs.

Collaboration: Afya Jijini will collaborate with other implementing partners (including Nocet, MDM, and Kanco) to support harm reduction, including a needle and syringe program, referral for Methadone, screening for Hepatitis B and C, Hepatitis B vaccination, provision of information, educational, and communication (IEC) materials, TB screening and treatment, nutritional support, reproductive health services, PrEP, and screening of NCDs. The project will engage addiction counselors who will offer health education, psychosocial support for PWIDs and their families. The project will participate and support implementing partner’s forums and work in partnership to develop a PWID Nairobi documentary, potentially through a grant. The project will work with sub-counties to capture PWID data and provide joint supervision with UHAI teams. HIV self-testing: The project will implement HIV self-testing in line with the national guidelines. HIV self- testing service delivery channels will complement existing HTS testing models, including:

• At the facility level: eligible clients will be offered an opportunity to self-test for HIV while waiting for other services, such as MNCH. They will also be provided with a self-test kit to take home for use on themselves, or share with their sexual partners. • At the community level: HIV self-testing will be offered to targeted groups, such as youth and adolescents, as well as men and their sexual partners.

HCWs, peer educators, and CHVs will be sensitized so that they can provide health education on self- testing to eligible clients.

Link >90% of all newly-diagnosed patients to HIV care and treatment. Newly-diagnosed clients enrolled into care: Afya Jijini will continue to support the testing and linkage web through peer educators and HTS counselors who will escort all newly-diagnosed patients to CCC for enrollment to care. Linkage diaries will be printed and distributed and linkage officers identified among the HTS counselors in all high-volume facilities to ensure all newly-diagnosed HIV-positive patients are enrolled in care. HTS counselors will be trained/mentored on use of new ART tools to collect accurate contact and locator information to enable tracking of those who default before enrollment. Clients who opt to be enrolled in other facilities will be referred using the county facility directory and referral forms and tracked on a weekly basis through phone calls to ensure linkage, which will be documented in the linkage register.

Internal HTS quality assurance (QA) strengthened: Lot-based validation will be conducted for every new lot of HIV RTKs. Joint supervision undertaken with the CHMT and SCHMT will enhance quality of HIV testing and results, as has been successful in past years. Counselor supervisors will conduct observed practice with all HTS counselors’ semi-annually and provide face-to-face feedback. To monitor client feedback, Afya Jijini will also implement a system to conduct exit interviews on a periodic basis for all facilities providing HTS. Counselors support supervision will be conducted monthly at the sub-county level to monitor provider burnout and enhance quality of counseling at all the supported facilities.

Moonlighting: this involves setting up testing areas in places that have been frequented by the target group of people: for example in bars. This can be used to target men who frequent bars and can have good yields.

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External HTS QA measures improved: Afya Jijini will support distribution of PT panels and dissemination of results, as it did in Y2. UHAI teams (in collaboration with the sub-county medical laboratory technologists - SCMLTs) will provide corrective action to HTS providers with unsatisfactory PT results. The project will continue to support monthly debrief and update sessions at sub-county for HTS counselors. Annual refresher workshops will be held for all HTS providers.

Scale up of PrEP services: The project will sensitize HCWs on PrEP at all 22 project-supported HVFs in line with the recently launched national guidelines. Through the Commodity and Supplies Chain Advisor, the project will strengthen supply chain management system for PrEP. Job aids and SOPs on PrEP will be printed and distributed to all HVFs.

Scale-up of condom promotion and contraception use: The project will continue to improve condom promotion and distribution through sub-county and facility-based CMEs on condom efficacy as well as through printing and distributing condom tracking tools. Afya Jijini will also procure penile and vaginal models and distribute them to supported HTS sites.

Support HIV stigma reduction efforts: Building on work from Y2, the UHAI teams will refresh HCW on stigma reduction and mitigation through CME to focus on role plays and case studies discussions. Stigma reduction and mitigation job aids will be printed and distributed to all HVFs. PSSG activities as described under Outputs 1.1 and 1.2 will support disclosure of HIV status as a means of stigma reduction.

Support Facility-Based VMMC. Afya Jijini will help sites provide VMMC services, including HTS and STI treatment, to 6,224 clients in Year 3. The project will support three dedicated teams to support all mapped out facilities offering VMMC services (namely North Health Center, , Biafra, and Mukuru Health Centers, Mbagathi Hospital, and Jericho health center) through RRIs. The project will also collaborate with the County to conduct RRIs during school holidays, targeting boys and men ages 10 to 49, receiving consent for all patients under 18 years of age in accordance with PEPFAR guidelines.

Local mobilizers will reach clients in informal settlements around Korogocho, Mathare North, and Biafra, which all have non-circumcising communities. Mukuru Health Center is a DREAMS facility and Mbagathi District Hospital will also act as a referral center for adverse events. The mobilizers will target men from non-circumcising communities, based on the FGD conducted by Afya Jijini in Year 2. These FGDs will help inform the mobilizers on the barriers and motivating factors for seeking VMMC services. The mobilizers will also use messages crafted from the FGDs to carry out health talks at the facility and work with CHAs to replicate them at within communities. The mobilizers will also collaborate with the SASA! activities by targeting the young men and men at their convening areas. In addition, the mobilizers will work with expert clients (VMMC beneficiaries) to engage with communities, using their testimonies to encourage other men to take up the service. The program will also help facilities inform men of the free service by distributing leaflets and posters to the communities.

The project will continue supporting dedicated teams to conduct targeted outreaches at hard-to-reach areas with limited resource settings, providing them with equipment, commodities, and consumables to conduct both daytime and moonlight outreaches, with the support of a grant. The project will also use a targeted approach to mobilize clients from non-circumcising communities, including adolescent and youth, through learning institutions, churches, and through engaging satisfied clients to testify on the procedure and its benefits.

At the facility level (Mbagathi, Jericho, and Mathare North), dedicated teams will collaborate with County staff to offer continuous VMMC services and also rotate to other facilities when the need arises. The project will also conduct VMMC training for facility staff with the aim of building capacity and ownership of the services provided by the County.

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To ensure compliance, Afya Jijini and the County AIDS/STI Coordinator (CASCO) will conduct joint supportive supervision to strengthen the quality of services and ensure that facility teams are able to manage adverse events and have a structured referral system in place for severe adverse reactions.

Additionally, the project will support two TWGs for all stakeholders to support County teams in coordinating partners’ activities on implementation and mapping out communities with non- circumcising citizens.

GENDER-SENSITIVE HIV-PREVENTION SERVICES

Reach 3,422 AGYW and community members with gender norms messaging (DREAMS): Afya Jijini’s FY16 Gender Analysis recommended that the project employ SBCC strategies to change gender norms among community leaders and mentors, such as parents, religious leaders, and community leaders, enlisting their support to strengthen and sustain key program HIV prevention messages. To that end, under the DREAMS program in Y3, Afya Jijini will work with a grantee to roll out the Start Awareness Support Action (SASA!) evidence-based intervention (EBI) to reach 3,422 AGYW () and 3,213 AGYW (Westlands), their male sexual partners, men and boys, and women and girls with strategic behavior change messages aimed at addressing the existing negative gender norms. SASA! will address two key objectives: support the AGYW and community members to understand the existing gender norms and their impact in their lives and communities, as well as establish a clear link between the existing gender norms and HIV prevention, treatment, care, and support.

Three clinics offer comprehensive PRC services. The project supported 3 facilities in Year 2 to offer gender-based violence (GBV) services. Human Resources and the community were both receptive, however the facilities were not able to offer comprehensive services and therefore referral was done to other facilities. Documentation was also a challenge owing to shortage of reporting tools and some staff not trained in sexual gender-based violence (SGBV) reporting. The project will continue to support three GBV clinics to offer comprehensive services, including Post-Exposure Prophylaxis (PEP), emergency contraception, Hepatitis B vaccination, STI screening and treatment, and psychosocial support at three strategic health facilities with high survivor volumes (Mukuru Health Center, a DREAMS site; Maternity Hospital; and Health Center). In Year 3, there will be deliberate effort to ensure that the clinics are child-friendly to encourage uptake, enhanced through engagement of the children survivors in play art therapy. SGBV reporting tools will also be availed, as well as periodic training HCWs on SGBV reporting.

Strengthen the community gender norms program in East and Westlands Sub-Counties (DREAMS) through training and sensitization. DREAMS AGYW’s male sexual partners are mainly men aged 20-35 years who are teachers, boda boda operators, and religious leaders, according to the recent male sexual partner characterization in Mukuru kwa Njenga. The project will work towards reaching 784 MSP with gender norms messages by working with the SASA! Advocates to organize targeted outreaches to male sexual partners (MSPs), refer MSPs for service uptake, and provide bio medical services (including HTS, ART, and VMMC) on site during the outreaches. In Westlands, the outreaches will be preceded by the MSP characterization.

Conduct PSSGs for HIV-positive women, discordant couples, men only groups, and male-only adolescent groups and post- test clubs. Age and gender-specific psychosocial support groups – as described under 1.2 and 1.3 - will continue to be supported in the Afya Jijini health facilities to target HIV positive women, discordant couples, men only groups, adolescent groups, and post-test clubs. This is largely because the project recognizes that these groups experience unique challenges and peer groups help encourage sharing of

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challenges. Specifically, the support groups will address these challenges including build the clients’ capacity in treatment literacy, importance of adherence among others.

Identification of men for TB and HIV testing through Cough Monitors. Men are an under-served TB population according to the most recent prevalence survey and project data. As such, the project will specially emphasize them in Y3 as an under-served population. Targeted active case finding will also be implemented, through targeted outreaches in informal settlements, identifying suspected TB patients using contract tracing. Suspected TB patients will be escorted to the link health facilities for further testing and treatment.

Improve HIV prevention among adolescents and young people. To improve HIV care and support services delivery to clients aged 15-24 years, Afya Jijini will continue to support the roll out the Positive Health Dignity and Prevention (PHDP) interventions among 15-24 years old adolescents and young people, targeting 17 project-supported high-volume facilities to reach a total of 2,923 adolescents and young people. This constitutes 80% of the adolescents and young people living with HIV in the 17 Afya Jijini supported sites.

DREAMS

Background and Rationale In Years 1 and 2, Afya Jijini’s DREAMS activity focused on nine villages in Mukuru kwa Njenga in Embakasi East sub-county: Wapewape, Vietnam, Riara, Kware, Sisal, Milimani, Zone 48, MCC/AA, and Moto Moto. The project’s activities cover all prescribed DREAMS core intervention areas, including “Empower Adolescent Girls and Young Women (AGYW),” “Risk Reduction for Sexual Partners,” “Strengthening Families,” and “Community Mobilization for Social Norm Change,” as well as cross- cutting DREAMS activities (such as communications, M&E, and coordination). Afya Jijini engages a number of technical and community-based facilitators to implement activities, including field assistants, DREAMS mentors, EBI facilitators, combined socio-economic approaches facilitators, community mobilizers, and SASA! advocates.

In Year 2, the project continued to implement activities to reach a total of 3,514 with OVC_SERV (the indicator includes Social Asset Building, Parenting/Caregiver Programs, Cash Transfers and Education Subsidy) and 1,378 with PP_PREV (the indicator includes School-Based HIV & Violence Prevention, Condom Promotion & Provision, Increase Contraceptive Method Mix, Combination Socioeconomic Approaches).

In Year 3, in addition to ensuring maintenance of 7,183 AGYWs in Mukuru kwa Njenga Afya Jijini will be expanding to four wards in Westlands (Kangemi, Parklands, Mountain View, and Karura) that cover 36 villages to reach 3,231 AGYWs with 18,451 services. Among other activities, the project will strengthen and/or establish linkages with County facilities (including the MMM clinic and Mukuru Health Center for GBV and PrEP, and Mama Lucy Kibaki Hospital for PrEP sample processing) for referrals, as well as newly identified link facilities for the expansion to Westlands. The project will also work with the grantee to deliver priority population prevention services, including the school health component and gender norms interventions in Mukuru Kwa Njenga.

In Mukuru Kwa Njenga, Afya Jijini will ensure that project-supported safe spaces are fully operational, including access to vital staff such as HTS counselors and trauma counselors. There will also be targeted mobilization and service provision for the AGYW’s MSPs for VMMC, HTS, and ART services. Gender norms and GBV activities will be rapidly scaled-up, both by engaging a grantee to ramp up use of SASA! advocates in GBV prevention, and by continuing to implement PP_PREV-related activities to ensure new AGYW are effectively reached and linked to appropriate Sexual Reproductive Health (SRH)/FP and HTS services. In order to meet the saturation targets in Mukuru kwa Njenga for DREAMS recipients by age group remain the same in Year 3, there will be more focus on graduating the AGYW who transition USAID/KENYA AFYA JIJINI YEAR 3 WORK PLAN 16

from vulnerable to less or no vulnerability while at the same time replacing those who graduate with new girls who meet the vulnerability status.

The project’s target in Year 3 is to provide a total 18,451 services to enrolled AGYWs in Westlands. Afya Jijini will work with the Nilinde project’s partners in the wards where both projects are implementing activities to leverage OVC_SERV-related activities. The project will coordinate with USAID to convene a meeting with these partners to identify areas of synergy and leveraging in order to harmonize the targets in relevant areas. Afya Jijini will also provide PP_PREV-related interventions to cover the targets for both Embakasi East and Westlands sub-counties.

Empower AGYW (Core Area 1). The interventions in this core technical service area focus on empowering AGYW to reduce their risk of violence and consequently decrease their risk of HIV infection. This intervention package includes: increased consistent use and availability of condoms, PrEP, violence prevention and post-violence care, HTS, contraceptive method mixes, and social asset building. In Year 3, the project will implement best practices from Years 1 and 2 to enrich the quality of services provided to the AGYW in Mukuru kwa Njenga and in the areas the project is expanding to in Westlands by working in partnership with link facilities to provide adolescent youth-friendly sexual reproductive health (AYSRH) and FP services. In support of these activities, the project will work with a grantee to roll out the EBIs that target AGYW between the ages of 10-17 years old. Additionally, condom promotion and distribution will be carried out at the safe spaces by mentors and Community-based Distributors (CBDs).

To increase the contraceptive mixes, the RH/FP providers will provide contraceptive counseling at target health facilities and in project-supported safe spaces to reach 2,586 AGYWs in Mukuru kwa Njenga and 1,270 in Westlands. Additionally, CBDs will reach AGYW with contraceptive method mixes at these safe spaces. One major lesson learned from the Mukuru kwa Njenga experience was that uptake of offered services was higher in these safe spaces than the link facilities. Therefore, in addition to focusing provision of these types of services in safe spaces in Year 3, Afya Jijini will strengthen the working relationship between HCW and AGYW by organizing periodic visits to safe spaces and health facilities. The project will also strengthen effective referrals and linkages to facilities for AGYW through the peer escort system.

The project will continue to provide PrEP interventions to AGYW 18-24 years old who meet the criteria, as appropriate. Afya Jijini will work with the County and Westlands and Embakasi East sub-counties to execute two PrEP site assessments to identify suitable community facilities to be used by AGYWs for PrEP. The project will also conduct quarterly PrEP support supervision for S/CHMTs in Westlands and Embakasi East Sub-Counties. Afya Jijini will also continue to conduct community sensitization on PrEP to increase acceptability, and will conduct monthly support group meetings with the AGYWs on PrEP. Sample networking will be leveraged through UHAI teams in both saturation and expansion areas of implementation. The project will identify link facilities in Westlands, and will train HCWs and implementation teams on this intervention. The project will conduct monthly community stakeholders’ engagement forums to increase community awareness to support the intervention. Additionally, violence prevention and post-violence care activities to address both acute and chronic cases of violence will be strengthened in the saturation area (Mukuru kwa Njenga) and established in the expansion area (Westlands). The Project will also renovate 2 containers at Mukuru HC to be used to provide integrated HIV prevention and reproductive health services including strengthening PrEP services to the AGYW more so in the DREAMS project.

The project will continue to support the provision of GBV services to AGYW by engaging trained GBV/trauma counselors to rove around the safe spaces, providing post-GBV/trauma counseling support services and ensuring effective referrals of acute and chronic cases to link facilities for further care. Afya Jijini will also identify and train adolescent and youth/GBV champions (AYSRH champions) at

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link facilities to serve as a link between AGYW and other facility staff. In addition to strengthening this model, which is being implementing in Mukuru kwa Njenga, the project will establish a similar model in Westlands. In Mukuru kwa Njenga AGYW with a post-violence history formed support groups, serving as a safe haven for them to discuss their pains, challenges, how they have managed to overcome these hurdles. This approach serves as a best practice that the project will expand in Mukuru kwa Njenga and scale up in Westlands. The project will also continue supporting cross-cutting GBV activities, such as continuing to engage the GBV counselors to create community creation towards GBV prevention and strengthening referrals to other medico-legal services. Lastly, the project will identify GBV partners in Westlands while strengthening collaboration with rescue shelters in Mukuru kwa Njenga to ensure protection for abused AGYW.

AGYW will be tested for HIV at the project’s safe spaces by a roving counselor and link facilities. For example, HTS counselors will be deployed during Social Assets Building sessions that are held at safe spaces and during other DREAMS activities, including community integrated outreaches, to reach all the enrolled and replaced AGYW in Mukuru kwa Njenga while reaching 80% of the enrolled AGYW in Westlands. Linkages and tracking of HIV-positive AGYW, including pregnant AGYW, to appropriate care and treatment services will continue (related to output 1.1). The project will also follow-up work with AGYW on PrEP for ongoing risk assessments and appropriate action at facilities.

Afya Jijini will continue scaling-up the Social Assets Building interventions to reach saturation of AGYW in Mukuru kwa Njenga (3,161), by increasing the number of safe spaces (many of which are donated spaces from the community) from 15 to 30 to adequately reach vulnerable AGYW. The project will also continue intensified support and OJT for DREAMS mentors. In Westlands, the project will identify and set up safe spaces and will reach 1,551 AGYW with Social Asset Building sessions at these safe spaces. These youth-friendly sessions will incorporate fun-filled activities, like dancing, while also offering biomedical services (HTS and PVC services).

Interventions to reduce risk of/among AGYW sex partners (including through the Afya Jijini Small Grants (AJSG) program for the Community Mobilization for Norms Change activities). These interventions aim to characterize and target “typical” sexual partners of AGYW with appropriate HIV interventions. MSP characterization in Mukuru kwa Njenga indicated that boda boda riders and other men in the public transport sector, religious leaders, and teachers between the ages of 20-35 are the most common MSPs to AGYW. The project and grantee(s) will continue working with 15 trained community mobilizers and 25 SASA! advocates to conduct community mobilization outreaches and forums on GBV and gender norms change. The project will also continue mobilizing and linking MSPs to targeted HTS, ART, and VMMC services, as well as promoting and providing condoms to MSPs at the community level in order to reduce their sexual risk. The AJSP program will engage select community- based organization(s) (CBOs) to build awareness of community norms and reduce risk among sexual partners through a number of EBIs, including SASA! In the new program area, Afya Jijini and the grantee(s) will identify, recruit, and train community mobilizers and SASA! advocates while adhering to intervention guidelines.

Strengthening families. The most effective social protection approaches for promoting healthy practices and decreasing risk of violence among AGYW have been those that use both economic and social approaches. Afya Jijini will therefore continue strengthening AGYW families economically and building their capacity to provide positive parenting in both Mukuru kwa Njenga (including for the parents/caregivers of newly-enrolled AGYW) and Westlands. The project will work with newly trained and existing FMP facilitators to deliver this intervention in the 36 villages in Westlands.

The project will continue providing unconditional cash transfers (UCT) to reach all 603 vulnerable AGYW in Mukuru kwa Njenga. The project will identify and profile AGYW families who are ready for exit and will replace those who graduate with newly identified and eligible AGYW for UCT. In

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Westlands, this intervention will reach 557 AGYW households. Afya Jijini will hold monthly feedback meetings with the AGYW and their heads of household to discuss progress made, contribute/provide feedback, and to identify areas that can be strengthened. The UCT intervention’s criteria includes: AGYW mothers with no source of income; AGYW in child-headed households; AGYW living with critically sick parent(s)/caregivers; and AGYW living with elderly caregivers. Cash transfers will continue being provided on a rolling basis through Kenya Commercial Bank (KCB). Verification with the Government of Kenya (GOK) Single Registry will be done prior to roll-out to avoid duplication. Beyond disbursement, the project will work with the KCB 2Jiajiri project to identify and recruit AGYW into the program for Year 2018 lot benefits, as well link the AGYW to their mentorship programs. Other public- private partnerships (PPPs) will also be explored, including with YADEN and SIDAREC (for services such as loans and day-care services).

The project will also continue improving access to education and reducing drop-out rates among 1,289 in Mukuru kwa Njenga and 1,190 newly-identified AGYW in Westlands by providing education subsidies that cover primary, secondary, and other short courses. The project-formed multi-sectorial economic strengthening component committee (comprised of representatives from the Ministry of Education, Ministry of Social Services, Children’s Department, AGYW representatives, religious leaders, and CBO representatives) will continuously select AGYW to ensure the most-deserving cases are identified and benefit from this intervention. AGYW ages 15-24 years old and out-of-school will continue being identified for vocational training, which will be offered through Vocational Training Institutions identified within the areas of jurisdiction. Linkages for industrial attachment/apprenticeship will also be done through PPPs with institutions such as foundations, companies and local industries within the project areas in Mukuru kwa Njenga and Westlands. Retention mechanisms (such as sending SMS reminders and including fun activities in sessions) will be applied to improve retention of AGYW ages 18-24 who are often the heads of household and look to the project to help them acquire sources of income for their dependants. The project will work with other stakeholders to enhance linkages to employment and income generating opportunities within and outside of the project implementation areas.

The project is providing a platform for 2,547 AGYW to benefit from financial savings programs through financial capability and entrepreneurship trainings, linkages to microfinance institutions, the formation of savings and table banking groups to build a culture of saving, and linkages to national government funding programs including Uwezo Fund, Youth Enterprise Development Fund, and other like-minded PPP products such as the KCB Foundation’s 2jiajiri (which the project will continue working with in Year 3), the Youth in Arts CBO, and DREAMS Innovation Challenge partners. The project will continue supporting AGYW reached with financial capability sessions to graduate as entrepreneurs through helping them access micro-financing facilities, mentoring them on savings and self-employment, and linking them to income opportunities to decrease their vulnerability.

Interventions to mobilize communities for change SASA! Afya Jijini will implement school-based and community mobilization interventions aimed at educating AGYW, young men, and mobilizing communities about HIV prevention through the Afya Jijini Small Grants (AJSG) program. Under the school-based HIV prevention activity, the project and grantee(s) will continue to implement the Healthy Choices for a Better Future (HCBF) EBI, targeting 2,834 10-14-year-old AGYW in Mukuru and 1,430 AGYW in Westlands.

The project will continue to reach all schools with school management sensitization forums, community- school sensitization, and linkages to DREAMS activities, while also conducting mapping, sensitizing school heads, and training teachers in newly identified schools in Westlands. In-school counseling sessions will continue in the 56 identified schools in Mukuru kwa Njenga, as well as initiating these sessions in identified schools in the expansion area. The project will periodically organize sports for social change activities to create a platform to provide and/or refer AGYW to biomedical services (HTS, PrEP,

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etc.), while adhering to parental consent guidelines. This activity will happen annually in the DREAMS intervention areas.

Community Mobilization/Norms Change activities provide an essential support framework for HIV prevention programs, as well as serve as a platform to engage boys and men and the community in addressing negative social norms that increase AGYW’s risk of contracting HIV. The project will engage grantee(s) to roll out these activities to reach at least 10% of community (3,422) members in Mukuru kwa Njenga and 3,159 community members in the wards of Westlands.

Cross-Cutting DREAMS Activities M&E: Afya Jijini will continue providing mentorship and refresher trainings to HCWs and volunteers on DREAMS reporting tools in Mukuru kwa Njenga to enhance the quality of reporting, while identifying, training, and mentoring field teams while setting up DREAMS activities in Westlands in Year 3. To improve data quality, the project will conduct conducting routine data quality audits (RDQAs) at the safe spaces and holding monthly DREAMS data quality review meetings. The project will also build the capacity of HCWs, mentors, and EBI facilitators to deliver and report on quality programs through on- site mentorship and weekly supportive supervision.

Communications: Afya Jijini will collaborate with the USAID-funded Health Communication and Marketing Program to develop and produce BCC messages IEC materials.

Coordination: The project will organize quarterly review meetings for the DREAMS Advisory Committee (including sub-committees), organize periodic cross-learning exchange visits for staff and volunteers based on need, participate in planning and review meetings both internally and with other DREAMS implementers, as requested by USAID, and organize for weekly supportive supervision at all levels.

Expansion Plan: The project will conduct initial entry meetings and engage relevant stakeholders, facilitate girl roster mapping, work with community gatekeepers to identify safe spaces in the churches, social halls and schools, and engage enumerators and staff needed to implement DREAMS activities in the 36 villages in Westlands. All-inclusive community advisory committee members will be identified in coordination with the local administration and County and sub-county representatives in Westlands to provide the project with feedback as implementation begins and progresses over time.

OUTPUT 1.5: TB / HIV CO-INFECTION SERVICES

Background and Rationale The recently completed Kenya TB prevalence survey shows that 40% of TB cases in Kenya go undetected and untreated. Most TB cases presenting with respiratory symptoms also go undiagnosed at health facilities. The project will use these findings to guide its TB detection and diagnosis approaches in Year 3. Building upon what worked well in Year 2, the project will continue to use cough monitors at priority TB facilities to screen for TB at all service delivery points and to identify new TB cases who were also tested for HIV. In addition, the project will continue strengthening facilities’ use of presumptive TB registers, which were first embraced by cough monitors and later by HCWs. Presumptive TB registers have been critical in following-up with all suspects until they are ruled to be either positive or negative. The project will also address continuing challenges, including active case finding (ACF) and ensuring the appropriate use of GeneXpert and pediatric diagnoses.

Afya Jijini will strengthen TB/HIV co-infection services to improve overall screening coverage and frequency, accuracy of diagnosis via GeneXpert, infection prevention control (IPC), and pediatric TB interventions, addressing gaps and challenges observed in the previous year (such as inaccurate documentation in TB4 registers, which led to missing out on capturing complete data). As of Y2 Q3, the

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project had helped facilities identify a total of 3,222 TB cases. Of these, 1,968 tested for HIV, 715 tested positive, and all were linked to HAART. Intensify TB Case Finding at Facilities Active case finding (ACF): Finding the “missing cases”: In Year 2 Afya Jijini supported cough monitors to screen for TB at all service delivery points, including outpatient departments (OPD), CCC, MNCH facilities, and inpatient wards for 31 of the 36 Level 3 facilities. The project identified the use of cough monitors as a best practice since most cases of TB/HIV co-infected cases were detected at OPDs and CCCs (where they are screened at every visit). The project will therefore continue to implement this approach in Year 3, including scaling-up use of cough monitors at the five remaining TB sites.

Facility ACF and low hanging fruits: In Year 3 Afya Jijini will ensure that early detection of TB cases is a permanent and routine activity carried out at all service delivery points (SDPs) of all health facilities with enhanced facility ownership. The project will accomplish this by working in collaboration with the CTLC and STLCs to offer CMEs and OJTs to HCWs to build their capacity to suspect, screen, and diagnose TB using the new revised TB diagnostic algorithms.

In Year 2 the project provided TA and mentorship to encourage cough monitors to utilize presumptive TB register (use to document and follow-up with all suspects). However, they initially perceived this as extra work, so in Year 3 they will be sensitized on the presumptive registers, including covering the benefits of maintaining these registers. Afya Jijini will also support HCWs to identify barriers in using the presumptive registers at different points of care. The project will conduct joint supportive supervision visits with the STLCs to follow-up on this activity. The project will also continue rolling out the presumptive registers at all service delivery points for the HCWs to use, including mentoring and sensitizing lab workers on TB screening and GeneXpert testing to diagnose walk-in patients at the labs. The target of new TB cases to be reached in Year 3 is 5,028 cases with documented results.

Strengthen community TB awareness, identification and linkage to diagnosis and treatment. Afya Jijini will work with the CTLC and STLCs to develop simple TB awareness messages for communities, which will be disseminated through health talks at churches, informal schools, and social places to enable the population to detect the signs and symptoms of TB and to seek early treatment. The project will support STLCs and facilities to conduct targeted case finding and outreaches at the community level, especially with high indexes of suspicion. For example, the project will focus on men’s social places, informal settlements, informal work places, and industries in order to reach men (who are historically under-diagnosed/don’t present for treatment) and other vulnerable populations.

Afya Jijini will continue building the capacity of CHVs through cough monitors sensitizations and updates on TB. These activities will enable them to conduct contact tracing at households and to offer community DOTs and structured defaulter tracing under the supervision of the TB clinicians.

Improve IPT provision. In Year 3 Afya Jijini will continue collaborating with SCASCOs and STLCs to offer mentorship and sensitizations on INH therapy among PLHIV to 68 HCWs. Clinicians and sub- county health teams (STLCs and SCASCOs) will sample clients’ files at CCCs during clinical discussions to identify missed opportunities through data and feedback given to clinicians in order to address barriers and gaps. TB/HIV WITs from 36 facilities will meet on a quarterly basis to monitor progress on INH initiation for both PLHIV and under-fives with positive contacts. To support the INH supply chain, the project will also collaborate with county pharmacist to train and mentor HCWs on the new ordering and supply management tools introduced at KEMSA to ensure adequate stocks and supply are maintained.

Strengthen IPC at facilities. Afya Jijini will continue working with STLCs to conduct semiannual facility assessments on the IPC plans, including re-evaluating the already-existing plans and ensuring they are utilized at all 36 facilities. Sensitization on the IPC plans will also be conducted for the existing WIT members to strengthen HCWs ability to adopt the IPC measures and routinely adhere to and implement

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environmental, administrative, and individual measures. Since HCWs are the most exposed to TB and DRTB, Afya Jijini will also support the STLCs to conduct semiannual screening of facility staff at all 36 facilities.

Boost TB/HIV integration and provision of immediate ART for TB clients. Afya Jijini will collaborate with STLCs to sensitize 61 HTS counselors at project-supported facilities to routinely screen for TB during HTS sessions. The HTS counselors will also be offered TA and mentorship to address weak referral linkages for TB diagnostic centers that only diagnose TB so that patients can be tested for HIV and screened for TB on-site. Additionally, the project will work with STLCs to sensitize 50 TB clinicians on the new ART guidelines and the newly-revised TB guidelines. For ease of integration of TB services to CCC at Mama Lucy Kibaki Hospital, the project will renovate a container at the Hospital therefore facilitating relocation of TB/HIV services which are being offered under a staircase.

Strengthen pediatric TB diagnosis and treatment. Afya Jijini will ensure that HCWs use all possible measures to ensure diagnosis of childhood TB, including by collaborating with STLCs to sensitize 248 HCWs (mainly from OPDs) on clinical diagnosing TB among pediatric patients. The project will also support STLCs to offer OJTs to at all project-supported TB facilities on Nasogastric and Nasopharyngeal aspirate for GeneXpert. 180 HCWs will be trained including MNCH, in nasogastric and nasopharyngeal aspirate for GeneXpert and clinical screening. Afya Jijini will work with STLCs and facilities to conduct targeted TB screening and IPC at schools with open TB cases. Intensified case finding (ICF) in primary and secondary schools, children’s home, daycare centers, and colleges will also be conducted in collaboration with HCWs and STLCs.

The project will continue engaging CHVs to conduct contact tracing at households with pediatric cases of TB to identify transmission from adults to children in communities. Afya Jijini will also sensitize 60 nutritionists and nurses at MNCH facilities on TB screening among pediatrics. HTS counselors conducting routine testing will be sensitized on ACF at pediatric units in OPDs and IPDs. The project will also train 120 HCWs on the new pediatric formulation and dosing. Additionally, job aids and IEC materials will be distributed at facilities.

Multi-drug resistant (MDR)-TB strengthening. The project will continue supporting PMDT clinical meetings in five sub-counties to ensure continuous mentorship for HCWs during client reviews and case discussions. Bi-monthly routine screenings for HCWs with GeneXpert will be conducted at the 36 TB facilities. Afya Jijini will sensitize OPD clinicians to ensure that they embrace GeneXpert testing as the first test for all relapse and retreatment cases. The project will support STLCs to train 68 TB clinicians on the new 9-month (short course) MDR regimen which will be rolled out beginning in July 2017. Additionally, for all clients on the DRTB regimen who are recommended to be on DOTs, Afya Jijini will work with STLCs and TB nurses to facilitate CHVs in administering DOTs at the household level.

Strengthen county TB coordination. Afya Jijini will continue to support the CTLC to conduct monthly operations meetings for STLCs and UHAI teams to use data for decision-making, address identified challenges and gaps, and exchange best practices. The project will continue supporting monthly joint supportive supervision with SMLTs, STLCs, SCASCOs, and sub-county pharmacists to offer TA and mentorship to HCWs working at the 36 TB facilities. Quarterly monthly data review meetings will be conducted for facilities to review data and set targets based on performance. The project and STLCs will also support facilities to have talking walls on the TB cascade and outcomes. Additionally, the project will continue printing registers as requested by STLCs. Coordination of the monthly operation meetings for STLCs, SMLTs and the CTLC will also be done in collaboration with the USAID-funded TB ARC to enable the CTLC to coordinate all activities across the sub-counties.

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SUB-PURPOSE 2: INCREASED ACCESS AND UTILIZATION OF FOCUSED MATERNAL, NEWBORN, AND CHILD HEALTH (MNCH); FAMILY PLANNING (FP); WATER, SANITATION AND HYGIENE (WASH); AND NUTRITION SERVICES

Introduction Sub-Purpose 2 focuses on ensuring that 58% of the population in informal settlements have access to quality MNCH, FP, WASH, and nutrition services. In Nairobi City County, maternal, neonatal and under-five (U5) mortality remain major burdens, and therefore require a structured and well-coordinated multi-sectoral response. The evolving context (including increasing labor unrest and HCWs’ industrial actions), as well as data and evidence-based best practices, drive the project’s Y3 approaches.

Hard-to-reach informal settlements are most affected with the three delays5 that impact MCH outcomes across the continuum of care. The project baseline further details the statistics across outputs and will help guide activities in Y3. A major focus in Y3 will be helping NCC understand and align the national FP modern CPR to the newly adopted FP2020 goals. In recognition of these new goals, the project will help NCC raise its CPR from 61% to 66% by 2030, with a focus on increasing adolescents (15-19 years) and youth CPR for any contraceptive method from 40% to 50% by 2020 and to 55% by 2025. The project will help the county offer improved youth-sensitive services, especially for FP, with a goal of reducing teenage pregnancy among adolescent girls from 18% to 12% by 2020 and 10% by 2025.

Approach Project activities in Y2 contributed to notable strides in MNCH, FP, and service use at targeted NCC health facilities (and toward contractual outcomes). These achievements were made despite observed quarter-to-quarter fluctuations due to a number of externalities, such as the extended nurses’ and doctors’ strikes (in late 2016 and early 2017, respectively). These temporary “shocks” had a destabilizing effect on MNCH service delivery, particularly for maternity wards.

During Y2, Afya Jijini has been instrumental in providing hands-on assistance and technical support to targeted health facilities. Noteworthy is the project’s contribution to demand creation for MNCH, FP, WASH, and nutrition services; skills building of service providers; procuring basic equipment/supplies; scaling-up and rolling out high-impact, low-cost interventions (e.g., Kangaroo Mother Care (KMC)), and instituting quality improvement and Maternal and Perinatal Death Surveillance and Response (MPDSR) processes. The project will continue to use the same model (mentorship/OJT) for strengthening HCW capacity, as MNH is highly-skilled and requires continuous reinforcement. Although the number of reported maternal and neonatal deaths in targeted facilities have been on a downward path since the project’s inception, examination of the cause structure of maternal mortality suggests the need for redoubled efforts to prevent and treat postpartum hemorrhage (PPH), which accounts for the overwhelming majority of reported maternal deaths in NCC. 2014/2015 KDHS data, which show that 39.9% of girls are already pregnant by age 19, also suggested the need for special attention on adolescent mothers to address their sub-optimal care seeking during pregnancy, postnatal care (PNC), as well as their elevated risks of outcomes such as pre-term birth, low birthweight in their babies and other maternal complications.

5 Delay in decision to seek care, delay in reaching care, and delay in receiving adequate healthcare. USAID/KENYA AFYA JIJINI YEAR 3 WORK PLAN 23

An in-depth external evaluation of the Afya Jijini MNH portfolio in Y2 identified several challenges – particularly related to PPH management – that will be addressed in Y3. These challenges included: functional verbal autopsies were not in place in communities, minimal integration from ANC, FP and HIV, a lack of male involvement during ANC visits, and demotivated HCWs (leading to their unwillingness to implement their skills in managing mothers in labor, delivery and postnatal). Afya Jijini plans on addressing these challenges by operationalizing verbal autopsies, exploring integrated ANC- WASH, ANC-FP, and ANC-HIV IEC/BCC messaging and activities to attract and engage males, and supporting recognition mechanisms to address HCW morale and performance issues in maternity wards. Afya Jijini will focus specifically on improving facility- and community-based family planning, post- partum family planning (PPFP), and Family Planning during Post Abortion Care (FPPAC), with the aim of increasing the number of women of reproductive age (WRA) accessing modern contraceptives by 20% by the end Y3 from the baseline of 78,189 CYPs to 125,102 CYPs by Y3. To do this, Afya Jijini will center efforts on youth across all aspects of Sub-Purpose 2, as described below.

OUTPUT 2.1: MNH SERVICES

Approach Afya Jijini utilized DHIS2 data (October 2014-September 2015) to establish baseline values for contract indicators. The data showed that 72% of pregnant women (69,017) completed the recommended 4+ ANC visits in NCC. In response, during Y2 the program sensitized HCWs on the importance of advocating for encouraging pregnant mothers to seek care early in their pregnancy to ensure that the 4+ visits were spaced throughout pregnancy, and hence improve the quality of care received. The lack of AVD and MVA kits as well as inadequate HCW competency to perform AVD has hindered supported sites from performing all required EmONC signal functions. During Y3, the program will utilize these lessons learned and findings from the EmONC assessment (to be finalized in Y2Q4) to inform its technical support to facilities and HCWs and increase the 4th ANC coverage by 50% from the baseline. The program will also support EmONC sites (such as Mutuini sub- District Hospital) to upgrade to CeMONC sites, increasing the number of facilities offering CEmONC signal functions from (baseline) 9% to 40%.

Prior to Afya Jijini, 89,764 (73%) of newborns in NCC were reached with postnatal care (PNC) and 65,813 pregnant women accessed skilled deliveries (DHIS2, Oct. 2014-Sept. 2015). The program aims to increase this by 3% to 76% by strengthening community-facility linkages. Through continued mentorship, OJTs and responsive CMEs informed by MPSDR committees, the project aims to reduce reported cases of maternal mortality at targeted facilities by 40% by the end of Y3, from a baseline of 86.6/100,000 live births. The project will further continue efforts to increase reviews of maternal deaths from a baseline of 64% to 70%.

These data illustrate the need for both community-level behavior change interventions (demand creation) and facility-based mentorship, focusing on adolescents and youth, to ensure clients receive respectful and quality care. During Y3, the project will target eight maternities that contribute to 85% of NCC’s deliveries (see Annex 3), primarily within informal settlements of the 10 sub-counties, to maximize impact. To continue reducing maternal and infant deaths, the focus will be on scaling up EmONC, including the correct use of the partograph, AVD, AMSTL and newborn resuscitation, as well correct use of chlorhexidine (in line with the new policy) and use of antibiotics to reduce maternal and newborn complication and deaths.

Strengthen County and sub-county MNH service quality and coordination. Afya Jijini will continue supporting quarterly County and sub-county MNCH TWGs for coordinated service delivery and sharing of MNH best practices with other key county MNH implementers. The project will focus on supporting 30 maternities (see Annex 3) to achieve EmONC compliance (currently working with 26 maternities), scaling up standardized EmONC approaches in line with other counties. The project will work jointly USAID/KENYA AFYA JIJINI YEAR 3 WORK PLAN 24

with the County/sub-county and facility teams who will assess these project-supported high-volume maternities (HVM) for EmONC preparedness through an initial annual assessment, followed by weekly SIMs, while addressing notable gaps (high turnover of staff, commodity security, and a lack of basic equipment) by engaging facility-based champions to mentor new staff and advocating to the County and sub-counties for more equipment and commodities. In lower volume maternities, the project will facilitate monthly SIMS and interventions to address gaps.

The various strikes that occurred during Y2 compromised the quality of care in supported facilities. This was further exacerbated by the shortage of midwives and frequent staff turnover. As a response to these challenges, and with an aim of improving the quality of service delivery, Afya Jijini will discuss strategic financing and resource allocation of MNH supplies, consumables, and HCWs for facilities (linking to SP 3.1 and 3.2) with the county and stakeholders. Additionally, the project will continue advocating for procurement and supply chain management of essential drugs (e.g. Oxytocin, magnesium Sulphate (MgSO4) and iron, folate and iron- folic acid supplementation (IFAS), Chlorhexidine, sphygmomanometers, fetoscopes/Doppler monitors, Ambu bags, and masks, and other essential drugs) to ensure availability at service points in targeted health facilities and reduce deaths, a key barrier identified during the program review preventing progress toward contractual outcomes. ). The program will also work with sites and sub-counties to better forecast their budgetary needs for these items (Output 3.3).

The program will continue mapping and engaging more private and faith-based maternities. Afya Jijini will also build their capacity on EmONC signal functions through mentorship, OJT and CMEs, and distribute basic equipment (e.g. BP machines, Ambu bags, IPC and MUAC tapes) as needed. The program will also support MNH program managers/focal persons from the county/sub-county to conduct quarterly joint supportive supervision, offer mentorship/OJTs to HCWs and provide program updates. Quarterly county and sub-county stakeholders’ meetings will be supported for synergy and coordination of activities to avoid duplication.

At the facility level, the project will further train a total of 90 mentors/"champions” for specific high- impact interventions (HII) and processes in the 30 EmONC focal maternities (see Annex 5) for the facility champion model). These 90 HCWs will then mentor other HCWs in their respective facilities in these areas. The NCC County Health Management Team (CHMT) will thus be supported to establish a pool of roving MNCH mentors/"champions" for specific HII and processes (e.g., newborn resuscitation, KMC, PPFP, IPC, and MPDSR). The project will continue engaging the WITs to monitor resuscitations through process indicators. The project will continue advocating for nurse hiring plans, which the CHMT has slated to start in late 2017.

The program will further support MNCH and FP focal persons to attend and participate in respective TWGs and ad-hoc MNCH, FP forums at County and sub-county levels. Afya Jijini will continue to support monitoring the availability of a pool of functional ambulances in the county (those that belong to the County health department or to partners). The program will utilize available ambulances to enhance referrals for pregnant women through the referral system bi-monthly task force meetings (a serious challenge identified during the baseline and Y2 MNCH review).

Boost ANC attendance (uptake and completion of 4+ visits). In Y3, Afya Jijini will focus on 30 high- volume facilities (HVF) – and their catchment areas - that contribute to 80% of ANC attendance. In order to continue improving NCC’s 4th ANC attendance (currently at 62% as of Year 2 Q2) the project will focus on prevention of maternal complications with discussion around danger signs.

The project will center on the community for early identification and referral of pregnant women to encourage completion of the 4th ANC visits and timely management of maternal complications. The 50 already-trained CHVs (some of whom are AGYW) will conduct monthly door-to-door household visits

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to track pregnant women from the five target informal settlements and refer them early for comprehensive ANC, identify those who are prone to high risk deliveries (adolescents, older women, and multipara), promote linkage to PMTCT, and follow-up for missed appointments. They will be equipped with IEC materials that contain MNCH messages focusing on increasing ANC and PNC services uptake, to be delivered at public forums (such as chiefs baraza’s and water drawing points). The project will also adopt, print, and distribute already-existing IEC/BCC materials to project-supported sites. Through the Afya Jijini Small Grants (AJSG) Program, the project will further strengthen linkages to ANCs by working with CBOs to identify 500-1,000 pregnant women (including those not currently accessing ANC in the informal settlements) where they will be working and refer/escort/follow them for comprehensive MNH services at the nearest health facility. They will also help to identify the 11% of pregnant women who do not benefit from skilled deliveries.

The project will work with 10 HVFs per sub-county to hold bi-monthly data reviews and subsequently help them effectively monitor and improve ANC coverage. In the 30 targeted facilities, the project will help sites adopt and institutionalize a tool that will help HCWs enhance screening for anemia, STIs (particularly syphilis), HIV infection, and/or symptoms of stress, S/GBV, or domestic violence. During Y3, the project will conduct quarterly exit interviews and FGDs in eight HVFs to identify barriers to providing client-orientated, effective ANC and establish solutions to ensure that women return after their first ANC visit (linked to Output 3.5 and based on a suggestion from the Y2 program review). Findings of the exit interviews, FGDs, MPDSR and verbal autopsies will be discussed during bi-weekly ANC WIT meetings and recommendations will be executed accordingly.

The project will work with facilities to coordinate PSSGs for pregnant women, including adolescent women and their partners, in order to prepare them emotionally and physically for birth and care of their baby. The project will work with County/sub-counties and facilities to develop and roll-out a model of male engagement and other gatekeepers on optimal ANC care-seeking during the three trimesters of pregnancy. Working closely with the CHVs, the project will facilitate door-to-door men and couples counseling in the community to reach them with information on FP, EBF, and the importance of early and routine ANC attendance and skilled birth deliveries in the five informal settlements.

Afya Jijini will improve early ANC uptake and completion among AGYW in Y3, a population who require intense focus to achieve the ANC 4+ contract indicator. The project will train and mentor 24 HCWs from the eight HVFs with high burdens of teenage/adolescent pregnancies on the AYSRH (see Annex 4) package. The trainees will mentor and provide OJTs to other HCWs to be able to provide an integrated AYSRH ANC package to ensure continuum of care. Project UHAI teams will mentor a further 150 HCWs on how to counsel mothers on the importance of early ANC (within the first trimester) and completing 4+ ANC visits in 30 maternities for enhanced early clinic attendance.

UHAI teams, the project’s cluster teams that work with Afya Jijini supported facilities and sub-counties, will also ensure that facilities hold monthly CMEs on recognition and management of pregnancy-related complications, including pre-eclampsia and anemia, during ANC visits. Facility-level HCWs will be coached on improved ANC/MNH commodity management to ensure availability of supplies and reagents (e.g. ANC profile reagents, syphilis and HIV testing kits, and essential drugs and equipment) for effective ANC services.

Increase safe deliveries within NCC. Afya Jijini will continue working with the County to implement a dual, linked community-facility approach to increasing safe deliveries in NCC. At the community level, the approach seeks to promote ANC uptake, reduce home deliveries, and promote facility delivery, while at the facility level the project will address major drivers to poor MNH outcomes: proper skills and respectful care.

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Afya Jijini will continue working with 50 CHVs who will support integration and scale-up of community interventions, focusing on counseling family members on caring for pregnant women, especially during the critical last trimester of pregnancy. During the chief’s barazas and other community gatherings, community administrators in the three6 sub-counties with higher burdens of maternal mortality will be engaged to support identification and mobilization of transport means for the community to facility referrals to address "first and second delays." CHVs in these three sub-counties will refer pregnant women to facilities and strengthen the community-facility interface by working with community gatekeepers to devise affordable and sustainable referral mechanisms (especially at night due to insecurity issues) to address the "first and second delays," and will facilitate community verbal autopsies for maternal and infant deaths. Male champions working as CHVs will promote partner involvement in five informal settlements by reaching out to and encouraging men to support their pregnant women in using facility-based ANC and delivery services.

To boost quality of services and provider skills, Afya Jijini will facilitate quarterly support supervision for the County and sub-counties to the eight high-volume maternities (HVM). Following bi-weekly WIT meeting, the project will support mentorship/OJT of 40 HCWs from the eight HVMs on management of PPH and high blood pressure, including when to refer in case of complications, as well as other identified problem areas.

The 30 targeted maternities will carry out a monthly inventory on preparedness for the seven BEmONC signal functions through the USAID-developed sampling tool. Afya Jijini will train 40 new or previously untrained HCWs from the eight focal HVMs with competency-based EmONC training. The project will partner with Pumwani maternity Hospital for provision of training package that include the conference package and a venue for skill based training within the hospital for cost effectiveness. Mentorship/OJTs by facility champions will complement the training with mentorship and skills evaluation for safe deliveries. Previously-trained HCWs will also receive an annual refresher through OJT, as well as mentorship and CMEs by UHAI teams and sub-county supportive supervision visits.

The project will introduce a new practice in Y3 designed to improve client satisfaction and respectful care based on experiences and challenges faced in the first two years of implementation (including HCW strikes). Afya Jijini will build off of its activities related to exit interviews by training and mentoring more HCWs to do more exit interviews in Year 3. It will conduct quarterly quality of care surveys through client exit interviews as an ongoing goal-oriented performance improvement approach in the eight HVMs. The project will further support and strengthen the provision of Respectful Maternity Care (RMC) services in the eight HVMs by incorporating those components within QI processes and CMEs.

The project will coordinate with the County to facilitate introduction and institution of a recognition award system to recognize outstanding performers to boost morale and performance for HCWs on maternity wards (linked to Sub-purpose 3 and Output 3.1) and provide a semi-annual recognition award to the best performing maternity. To strengthen the County referral system, Afya Jijini will work closely with the County referral coordinator to support three7 major referral facilities through advocacy at the county level and the formation of a facility-based QIT (Output 3.5).

Improve uptake and provision of PNC at target health facilities for mothers and newborns. In Years 1 and 2, the project supported the County, sub-counties and facilities to form MPDSR committees, with all maternal deaths reviewed and action points implemented. However, most maternal and neonatal deaths still happen during the PNC period. As such, Afya Jijini will focus more on this critical phase

6 Kamukunji, Langata, and Embakasi West. 7 Mama Lucy Kibaki Hospital, Pumwani Maternity, and Mbagathi Hospital.

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during Y3. The project aims continue supporting newborn examination within the first 48 hours, ultimately reducing reported cases of newborn deaths in targeted health facilities from the baseline (baseline:128/1,000 live births) and increase perinatal death reviews from 31% at baseline to 70% at targeted health facilities. To do this, sites and sub-counties will strengthen HCW capacity to educate mothers on the four8 critical targeted postnatal care (PNC) periods so they can identify post-delivery complications early and manage them promptly. CHVs will track postnatal mothers, counsel them on FP (including PPFP) and HIV testing, and refer them to facilities for services in informal settlements (linked to Output 1.1 and 2.3). CHVs will deliver evidence-based messaging through community events, household visits, and facility health talks that promote the benefits and critical nature of PNC.

During Y3, CHVs will map home deliveries in the five informal settlements to reach the most vulnerable with the following services. They will refer and/or accompany the pairs within 48 hours after delivery for postnatal assessment and immunization. Mentor Mothers will education HIV-infected mothers on postpartum danger signs (detection of sepsis, PPH, headaches that warrant checkup, etc.), IYCF, and maternal nutrition in 30 maternities at facility and community levels. CHVs will be linked with maternity HCWs to promote immediate and exclusive breastfeeding, clean cord care (e.g. use of chlorhexidine), neonate thermal care (e.g. KMC at home), early detection of newborn danger signs or illnesses at community level, and offer prompt/accompanied referrals to the nearest health facility. CHVs will also promote a free maternity and child care program (Linda Mama) and NHIF during their visits, leveraging the opportunity to expand care. Through the AJSP program, 50 CHVs in the five informal settlements and facilities will use a post-delivery tracking system for mothers to ensure that recently-delivered mothers are not lost-to-follow up (LTFU) for timely PNC. The project will also consider engaging a community organization through a grant to pilot a mobile platform to monitor mothers for follow-up.

At the facility level, UHAI teams will mentor HCWs in eight maternities on routine checks for vaginal bleeding, uterine contraction, fundal height, temperature, and heart rate during the first 48 hours post- delivery. The project will further train 40 HCWs drawn from these eight maternities on presumptive antibiotic therapy for high-risk babies and newborn resuscitation, as well as PPFP (an area that needs increased attention). CMEs that promote EBF and skin-to-skin contact within one hour after delivery will be held. In addition, post-training follow-up for those trained in KMC, MIYCN, and mentored on PPFP in Y2 will be completed. Linked to Output 1.1, Afya Jijini will assess PNC-eMTCT integration services in the 30 maternities and develop solutions to address identified gaps. It will also provide HCWs with mentorship and OJT on integration of postnatal services with other MNCH services (immunization and FP) in eight HVMs. The project will work with these HVMs to provide integrated AYSRH PNC that targets adolescent mothers with their unique needs. Facility champions will mentor HCWs to ensure that newborns are assessed for any danger signs at the appropriate intervals, to that they are immunized against preventable diseases, and that they are treated for any infections during the targeted postnatal visits, as per national guidelines. To reduce congestion in NBUs (and hence neonatal sepsis), the project will collaborate with key stakeholders and support roll-out of KMC services to four additional maternities in Y3 through capacity building, using a mentorship/OJT model.

Afya Jijini will additionally continue distributing job aides and IEC materials to promote immediate and exclusive breastfeeding for 6 months, KMC, cord care (e.g. use of Chlorhexidine) and neonate thermal care in the 30 maternities, as need arises, to improve quality of care. Bi-weekly WIT meetings will monitor PNC process indicators as part of their facility monitoring. At the County level, quarterly TWGs will discuss and plan for addressing unmet FP needs among postnatal mothers through advocacy on improving the IUCD and other LARC commodities and their availability in the delivery room and postnatal settings.

8 First 48 hours post-delivery, Day 3 (48–72 hours), between days 7-14 after birth, and six weeks after birth.

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Strengthen County maternal and perinatal death review surveillance and response (MPDSR). Afya Jijini’s Y3 MPDSR work continue aiming to increase maternal death reviews, similar to the infant death review referenced above. Afya Jijini will work closely with the County and sub-county MPDSR committees to hold quarterly meetings and follow-up on action points. In Y3, the project will emphasize facility participation (especially large referral sites) at the sub-county level. At facility level, MPDSR will be integrated into the bi-weekly WIT meetings as part of quality improvement monitoring in the eight HVMs, with action points developed following reviews. The project will further also help facilities coordinate quarterly inter-facility MPDSR forums to discuss and promote joint MNCH data reviews, problem analysis, and coordinated actions between facilities in NCC. The project will disseminate 400 MPDSR notification booklets and 100 MPDSR guidelines to 30 maternities to facilitate accurate and timely notifications and strengthen the review reporting system.

During Y3, the project will train cMNH CHVs to conduct verbal autopsies as a complementary activity to facility MPDSR around the eight HVMs, with priority given to neonatal deaths as a means of ensuring an increase in skilled birth deliveries (leading to a decrease in maternal mortalities), and in Langata and Kamukunji. Working with sites, CHVs will conduct relevant community mobilization and responsive actions in the community.

Scale-up gender-sensitive approaches to MNH. CHVs will encourage clients to attend MNCH services with their partners. Technical support will be provided for the S/CHMTs, facilities, and the community to review and develop a responsive "We Men Care" model that appropriately engages and enables male partners of pregnant women to improve their knowledge on how to support their pregnant women throughout the continuum of care. The project will further adopt, print, and distribute gender- sensitive IEC materials on MNCH, FP, and RH. For the high-volume ANC sites, the project will explore and facilitate integrating ANC-WASH, ANC-FP, and ANC-HIV IEC/BCC through messaging and services delivery focusing on activities that attract and engage males who accompany their female partners to ANC (nutritional assessment, BP checking, prostate cancer screening, among others).

OUTPUT 2.2: CHILD HEALTH

Approach Increasing access to quality health services remains pivotal to increasing child survival in Nairobi City County. To achieve this, the project will implement Y3 strategies that prioritize on-demand creation, reduction of coverage barriers to accessing healthcare services, as well as scale-up high impact child health interventions (HII) and provide quality service delivery towards reducing child morbidity and mortality. Focus will be targeted to facilities within the five largest informal settlements.

Strengthen County and sub-county planning and supportive supervision for child health. In Y3, Afya Jijini will continue working to improve the quality of service delivery, including ensuring timely and accurate documentation of child health activities. The project will offer technical support during the quarterly joint supportive supervision visits conducted with the County and sub-county child health program managers/focal persons, focusing on cold chain maintenance of vaccines (a persistent challenge identified in Y2). The project will also work with the County and sub-counties in planning and carrying out select immunization campaigns, as need arises. Additional activities include facilitating quarterly micro-planning meetings for EPI at the County and sub-county levels in an effort to reach every

USAID/KENYA AFYA JIJINI YEAR 3 WORK PLAN 29

community (REC) with full immunization coverage9. The project’s aim by the end of Y3 is to continue supporting NCC with immunizations in informal settlements, with an increased focus on pastoralists through targeted, integrated outreaches where there are no nearby facilities. Sub-counties will carry out monthly data review meetings on child health indicators, as well as sensitize HCWs on immunization data management and how to carry out DQAs.

Improve facility child health service provision. Afya Jijini will continue strengthening facility-level diarrhea identification and management in children under five, working with sites to improve monitoring and reporting of diarrhea cases and the outcomes of case management in five informal settlements and at 30 project-supported sites. Afya Jijini will partner and collaborate with other implementing partners in the county to ensure that all the facilities are oriented with updated guidelines on ORS and use of Amoxicillin DT for treatment of pneumonia The project will train 150 HCWs drawn from 30 high- volume child welfare clinics (CWC) on integrated management of childhood illnesses (IMCI), as well as covering the new guidelines, pneumonia management, and ensuring a holistic approach to addressing the major child killers10 in NCC. The trained HCWs will cascade the knowledge to their colleagues and other facilities through mentorship, OJT, and CMEs. The facilities will display weekly dashboards to monitor ORT use and outcomes, and HCWs will be mentored on commodity management (including reporting) to ensure availability of ORS and Zinc stock in the 30 project-supported facilities (linked to Output 3.3).

The project will continue working with 28 WASH champions (linked to Output 2.4) and 50 CHVs to monitor children with diarrhea in five informal settlements, provide ORT to simple cases in the community, educate the parents on preparing ORS, refer them to the nearest facility, and follow-up with them on the outcome. The project will also train 120 HCWs from 30 HVF with updates on EPI. Facilities will provide education to the community on the immunization schedule and hold quarterly community-facility meetings on immunization.

Afya Jijini will support facilities to develop a health talk schedule for health promotion on personal hygiene for mother-baby pairs, dangers signs of pneumonia, dehydration, and malnutrition; MIYCN; and HEI follow-up. Intensified facility defaulter tracing will be conducted for immunization re-visits in 30 facilities. The project will print and distribute relevant IEC materials on child health to 30 health facilities. Afya Jijini-supported public, private and faith-based facilities will be mentored through CMEs and OJT. The program will also provide training where needed to keep the HCWs updated on the current guidelines and policies.

Strengthen knowledge and uptake of infant and child health services at the household and community level. There is clear evidence that the way children are cared for at home and in their immediate environment makes a big difference to their chances of survival. A number of key practices in the home and community have been identified which are crucial to improving child health and development. These practices include ways of preventing illness through improved feeding and care, as well as advice on how to treat children at home if they become ill, and on when children need to be taken to the health facility for expert attention. Applying these practices more widely is at the core of improving children’s health and development.

The project will focus on activities that improve health messaging, service delivery, and documentation of child health activities at the community level as per the national community strategy guidelines. Through

9 Communities will include Somali communities, which have historically lower coverage based on reports from Kamukunji and Starehe, which showed that coverage for polio campaigns was very low, with some instances of zero dose vaccinations. 10 Pneumonia, diarrhea diseases, birth asphyxia, neonatal sepsis, and prematurity.

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the CHVs, the project will further continue working in the five11 targeted informal settlements with under-fives receiving preventive services and link them to facilities for immunization, Vitamin A, deworming, and growth monitoring, as required. The project will continue supporting monthly community surveys in five informal settlements to identify children under one year who are not fully immunized and refer them to facilities for services. CHVs will also identify children with disabilities, and the project will facilitate monthly outreaches in Starehe and Kamukunji and offer them individualized12 services, as they previously have been under-served. The project will support quarterly meetings for community dialogue days on child health and household visits will be conducted by CHVs to deliver health messages on the importance of breastfeeding up to two years, complementary feeding to infants, growth monitoring, management of diarrhea with ORT, and how to identify signs of pneumonia, dehydration, and any other childhood illnesses and what to do once they are identified.

OUTPUT 2.3: FAMILY PLANNING (FP)

Approach In Y3, Afya Jijini will ramp up FP efforts to ensure that NCC achieves a contractual target for modern CPR (20% increase from baseline) while concurrently contributing to the newly-adopted FP2020 commitments (described in the introduction). The project will zero-in on the high birth rates among AGYW in target informal settlements, building on successful approaches with DREAMS girls and targeting girls ages 15-19 who have unique needs (timing for offering services, confidentiality, and privacy).

Strengthen County and sub-county FP coordination and service delivery. The project will support the County’s quarterly RH TWG meetings where issues affecting uptake of FP services, commodity security, and reporting rates, including advocacy for budget line items for FP commodities, will be discussed. The project will support and participate in joint quarterly supportive supervision visits to provide on-site technical assistance with sub-counties on FP issues, including integration and youth- sensitive services.

Afya Jijini will support FP service strengthening by increasing access to and use of quality FP services at the County and sub-county levels, particularly focusing on populations with high unmet need; improve the quality of FP services, including counseling (a current weakness); and enhance the capacity and competency of HCWs. The project will work with other DREAMS implementing partners and AYSRH implementers in the County to increase access of FP services for adolescents through discussions held in the County/sub-county stakeholders’ meetings and joint work planning sessions. It will further coordinate and collaborate with the USAID-funded PACE and HP+ projects to leverage those efforts at the County level.

Improve access to and quality of facility-based FP services. There is still need to improve FP services in NCC. In response, the project will work with high-volume maternities to initiate PPFP counseling during the ANC visits (for IUCD, implants, exclusive breastfeeding and BTL), and to document those who consent in the mother-child booklet to follow-up with them during and after labor. This service will be given to clients who seek PAC services in outpatient and in gynecologists’ wards.

Many women who commence contraception discontinue use within 12 months. The discontinuation rate for oral contraceptive pills (OCP) is usualy higher than long acting and reversible contraceptive (LARCs) due in part to poor quality of care in services delivery (including counseling). As a result of challenges in

11 Makadara, Embakasi West, Embakasi East, , and Ruaraka. 12 Immunization, Vitamin A, deworming, growth monitoring, and physiotherapy. USAID/KENYA AFYA JIJINI YEAR 3 WORK PLAN 31

quality of care, there has been low utilization of FP services, non-compliance, and high rates unintended pregnancies among certain sub-populations and age strata (including adolescents (15-19), people living with disabilities, and pastoralists).

Afya Jijini will improve the quality of care in FP service delivery points to reduce unmet need among women of reproductive age (WRA). Data tends show high rates of teenage pregnancy in Kamukunji and Ruaraka sub-counties indicating geographic areas of focus for Y3. In Y3, the project will focus on FP commodity management, an area identified for improvement in Y2, providing mentorship on monitoring stock outs on a weekly basis and stock status on a monthly basis to ensure commodity security. Redistribution will be carried out when necessary (link to Output 3.3). The project will provide quarterly CMEs on FP compliance at in-charges meetings. Facility champions will provide bi-weekly mentorship, OJTs, and CMEs to build the capacity of 90 HCWs to provide FP services in 30 HVFs (see Annex 3). The project will also sensitize HCWs on USG Compliance testing of service providers and follow-up. The project will utilize facilities at Mama Lucy Kibaki Hospital and Decentralized Training Centre for family planning and post abortion care trainings. FP-CCC integration will be strengthened in 26 high-volume CCC sites through weekly mentorship/OJT and CMEs (link to Output 1.1).

These target facilities will carry out quarterly FGDs focusing on PNC mothers, including adolescent clients (10-14, 15-19, and 20-24), to identify myths and misconceptions that hinder access to contraceptives. The project will work with the County to adapt messages to address them based on findings from the Gender Analysis and the FGDs. For example, the Gender Analysis found that many young women are reluctant to take oral contraceptives as they fear gaining weight, while male partners are reluctant to support them because they too think they will gain weight and the men will have to fund the purchase of new clothes. The messages will be delivered during household visits, chiefs’ barazas, and during MNCH outreach campaigns. Opportunities for Continuous Learning and Adaptation (CLA) will also be explored to demystify misconceptions. The project will assist FBOs in supporting WRA to access appropriate FP methods, including cycle beads, in project-supported FBO and Catholic facilities through the AJSP program in Y3. In HVMs, the project’s UHAI teams will sensitize HCWs on integrating FP and counseling in various service delivery points. The project will also train 125 HCWs from project- supported sites on LARC, especially IUCD uptake, which has been low in NCC as compared to other counties.

Community-based distributors (CBDs) offer FP services in target informal settlements. CBDs will continue delivering youth-sensitive FP messages, information, and distributing oral contraceptives and condoms at the community level in DREAMS sub-counties (linked to Output 1.4). CHVs will counsel clients on all FP methods, provide them with pills and condoms, conduct integrated outreaches to the communities, and refer or escort them to facilities for LARC methods. The CBDs will be linked to facilities for FP re-stocking through the facility CHAs, who will provide commodity supplies, supportive supervision, and will support reporting. HCWs will be sensitized on AYSRH service delivery, especially uptake of PPFP and FPPAC, to reach adolescent mothers (ages 10-14, 15-19, and 20-24) with FP methods in eight HVFs. Over time, the uptake of FPPAC services among AYGW has improved. In Y3, the project will expand the services to HVFs as this was only being done in 3 HVFs in Y2 (i.e, MLKH, Mbagathi, and Pumwani). During the CHV monthly household surveys (for pregnancies and PNC), CHVs will identify mothers of reproductive age and not on FP, counsel them, and refer them to facilities as needed (or provide FP if they are CBDs). FP services will be provided during integrated outreaches and health days at the community level. WRA, adolescents, and youth (ages 10-14, 15-19, and 20-24) will be mobilized through CBDs for uptake of FP methods during WCD celebrations.

Offer gender-sensitive FP approaches. During Y3, the project will focus on integrating CHVs into male detached spaces to improve male involvement in delivering messages on FP at service delivery to adolescents, youth, and young women with their partners. The project will further design/adopt gender- sensitive IEC materials on FP and AYSRH for health talks at community and facility levels and use them

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through the engaged CHVs at facility and community levels.

OUTPUT 2.4: WATER, SANITATION AND HYGIENE (WASH)

Approach In Year 3 Afya Jijini will build on lessons learned and successes in implementing WASH activities in Years 1 and 2. The project will continue improving sanitation, decreasing the population’s practice of open defecation (especially in informal settlements) with an emphasis on Urban Community Lead Total Sanitation (UCLTS) and scaling-up/accelerating the number of households complying with water treatment technologies in targeted informal settlements. In year 2 of the project county management and coordination activities resulted in establishment of TWGs and appointment of WASH focal persons at SC level. In year 3 the project will enhance other areas that need specific attentions to be strengthened to achieve wholesome outcome for the county and more so in informal settlements. An example is that AJ will support in establishing a sustainable HCW referral system at facilities through the joint effort of ward/SC administrators and the public health departments, this effort has worked in Y2 in specific areas and will support the county to roll out and leverage on other structures in the devolved system to achieve this.

The project will focus on improving facility and community-based WASH interventions critical to improving gains in maternal health and child survival, such as the reduction of under-five mortality. Facility-level interventions include ensuring that all facilities have IPC mechanisms, functional ORT corners, available essential commodities (such as zinc and ORS), and clean running water; and assessing the status of sanitation facilities and health care waste segregation and referral systems. At community level the project will ensure proper hand washing facilities at all SDPs. Community level interventions include distributing household level information on water treatment, buildingb uilding strong linkages for community-facility approaches through deployed and trained CHVs, and community dialogue and conversation forums (including clean-up days and community led total sanitation approaches).

As of Y2/Q3, Afya Jijini has reached 75,938 households with point-of-use water treatment products and over 200, 000 households with information on water treatment technologies. In Y3, the project aims to double this intervention in other areas by supporting the County to increase the manpower and skills needed to ensure that WASH interventions are scaled up in a quality manner across sub-counties and facilities. Interventions will also aim to reduce diarrheal prevalence among under-fives.

County-level WASH support. Afya Jijini will work with stakeholders to conduct two WASH-related assessments in Y3: a baseline assessment for urban WASH indicators and operational research, including solid waste management, latrine coverage, and hygiene standards and practices; and a WASH assessment of early childhood development (ECD) and daycare centers that were not assessed in Year 2. Need for these assessments was identified based on the initial WASH assessments completed in Year 1 and joint planning with stakeholders (including the County, KIWASH, and Synergy). These assessments will guide planning for targeted UCLTS interventions and increase the percentage of households in target areas that practice correct point of use (POU) water treatment.13

13 Such as chlorination (chemical disinfection), Flocculent/Disinfectant (physio-chemical disinfection), Filtration (physical removal), Solar disinfection (UV/heat disinfection) and Boiling (disinfection via heat) USAID/KENYA AFYA JIJINI YEAR 3 WORK PLAN 33

The project will continue participating in and providing support to the County WASH TWG to ensure that it meets annual objectives, such as advocating for the provision of piped water in informal settlements through the Maji Safi initiative. Afya Jijini will also help the County to fully operationalize the three new TWGs on school wash, hygiene promotion, and urban sanitation, which were identified in Year 1 by the WASH TWG as a need to better coordinate and improve in these areas. The project will also advocate for key County WASH staff to participate in relevant inter-agency coordination conferences and fora, as appropriate, to learn from and gain best practices from other counties. The project will also continue working with the County taskforce to develop a long-term solution to address the sporadic outbreaks of cholera and AWD.

Afya Jijini will support NCC to hold mobilization activities and outreaches through relevant World Health Days, including the Global Handwashing Day and World Toilet Day, in the densely populated informal settlements, targeting children under five.

In response to identifying reporting of WASH activities into DHIS2 as a weakness in Years 1 and 2, the project will support the County to strengthen this component through training public health officers (PHOs) on WASH reporting tools and printing the tools, as required. Afya Jijini will also provide OJTs and mentorship to WASH focal persons and Community Health Assistants (CHAs) on sub-county level data collection and reporting to improve collection of community-based data. DQAs will also be applied to achieve results in reporting. These activities will be geared toward strengthening county-level WASH- related decision-making.

Sub-county and facility-level WASH support. Afya Jijini will support sub-counties by sensitizing HCWs and developing plans to address infection prevention and control (IPC) challenges that were identified during quarterly supportive supervision visits, specific audits, and observation during UHAI team facility visits. The project will also sensitize HCWs at high-volume facilities on Health Care Waste Management (HCWM) and infection prevention and control (IPC), using the findings from the Year 1 HCWM plan assessment and the lessons learned in Year 2 (such as that capacity building on HC increased the IPC improvements, whereas HCWM are still challenges in Y2 due to the logistic involvements). Additionally, based on the findings from the Year 1 facility WASH assessment, the project will continue supporting facilities to develop and/or operationalize WASH improvement plans to ensure that all facilities are properly equipped with clean water, handwashing stations, safe latrines, waste segregation, and proper waste disposal. The project will also train HCWs on operationalizing the HCWM strategies and plans that were developed in Y2 at the sub-county level. The project will also advocate for the County to establish sustainable approaches of waste referrals. In Year 3 the project will support the sub-counties to procure targeted IEC and SOPs on handwashing, waste segregation, safe water, and sanitation materials. These materials will be distributed to project-supported HVFs, institutions, as well as for use during community outreach activities in the targeted informal settlements. Afya Jijini will also help the sub-counties disseminate WASH policy guidelines and practical guidance on WASH activities at the sub-county level.

Afya Jijini will participate in and support the SCHMTs to undertake observational audits and supportive supervision to increase coordination and oversee facility-level WASH activities (including handwashing at service delivery points), observe the status of facilities implementing IPC plans, and monitor waste segregation.

Afya Jijini will continue supporting 28 WASH champions to oversee ORT corners to reduce diarrhea- related morbidity and mortality in children under five. These champions will continue ensuring availability of required equipment (apparatuses), supplies, and commodities at the ORT corner; availability of IEC materials at both the ORT corner and health facility; giving health education to parents and caregivers; demonstrating handwashing, mixing and administering ORS; and conduct daily monitoring of WASH activities at the ORT corner and health facility. In addition, the project will

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monitor the stock flow of essential commodities for diarrheal management (ORS and zinc), especially during supportive supervision, and assist with redistributing or liaising with other partners (e.g. CHAI, which the project partnered with in Year 2) to increase availability, in order to address periodic stock outs of these commodities in the County.

The project will also procure and distribute other supplies, such as bins and bin liners, and advocate for equipment14 through other partners according to the HCWM referral plans and reported needs. The supplies will be distributed to all project-supported high-volume facilities.

Afya Jijini will support 40 PHOs and other HCWs from the 10 sub-counties in relevant topics (UCLTS, water storage, and quality improvements) to build their capacity to implement WASH activities, including improving proper sanitation and water treatment technologies at household levels. The project will also offer didactic trainings, CMEs/OJTs and mentorship on UCLTS and water quality monitoring on an as- needed basis. These trainings will help the facility-based HCWs to integrate WASH activities, such as handwashing and waste management, during service provision.

Support community-based WASH activities. To increase the percentage of households in target areas practicing correct use of recommended household water treatment technologies (HWT), the community will be educated on the significance of treating water at the household (HH) level through simple techniques such as disinfecting water by boiling, chlorination, and filtration. The project will procure and distribute POU water treatment products to public water points, HHs in triggered villages, and to parents who brought their children in for diarrhea management at facility ORT corners. The project will also sensitize children’s caretakers on initiating ORS at the HH level before reaching a facility. Some of the water treatment products, such as aqua tabs, will be distributed to the 27 triggered villages, high-volume ECDs and daycare centers, and project-supported HVFs.

Afya Jijini will support the County to monitor water quality through water sampling and testing at public water points in targeted informal settlements by procuring rapid test kits for water sampling. The project will also train the County to conduct quarterly monitoring of water quality in informal settlements, schools, ECDs, community water points, and sampled households. Afya Jijini will also provide targeted communities with chlorine powder to treat water. This chlorine water will be distributed through the sub- County health offices.

Afya Jijini will coordinate with sub-counties, KIWASH, and PSK to support communities to develop an effective communication strategy, including evidenced-based WASH messages, to ensure that residents have easy access to information about sanitation and hygiene. These messages will be developed to target specific populations, such as the schools and daycare centers as well as general community members. The project will procure and distribute IEC materials on water quality to reinforce key messages to community members in the informal settlements on the importance of treating water. Community dialogue forums will be held to discuss how more community involvement can lead to improved WASH and to come up with their own strategies on improving sanitation and hygiene. Afya Jijini will also support NCC to hold mobilization activities and outreaches to raise awareness on water safety.

The project will support sub-counties to conduct clean-up activities at targeted communities to improve the WASH conditions for community members. These activities include ensuring a clean environment by preventing open defecation and inappropriate disposal of waste materials. The project will help identify and train community sanitation champions in target informal settlements to enforce proper sanitation in communities and link those in need to nearby facilities, support CHVs to undertake WASH activities in

14 Heavy duty gloves, shredders, macerators, waste transfer trolleys, and personal protective equipment USAID/KENYA AFYA JIJINI YEAR 3 WORK PLAN 35

ECDs and primary schools, and hold monthly review meetings at ECDs.

Afya Jijini will support NCC with procuring handwashing facilities to improve handwashing practices in the communities. The handwashing facilities will be distributed to project-supported high-volume facilities, selected high-volume ECDs and daycares, and at public points in the triggered villages. Implement and scale up UCLTS in NCC’s informal settlements. During the first two years of implementation, triggered villages have been followed up with post triggering monitoring sessions and outcomes were tracked (i.e. positive change on open defecation and community behavioral change). Afya Jijini will therefore continue supporting the CHMT to conduct supportive supervision visits on UCLTS for these triggered villages to monitor any improvements and/or achievements, thereby confirming evidence of open defecation reduction. The County team will also provide TA on UCLTS to other community members of the public workforce (i.e. chiefs, and sub-county and ward administrators).

In Year 3, Afya Jijini will trigger an additional 10 villages, since this strategy is proven to be successful in tackling open defecation in informal settlements. The process is expected to be much easier and less costly than in Years 1 and 2 since the project will leverage on experience gained in the previous two years.

Afya Jijini will also support post-triggering meetings in triggered villages and schools (ECDs and daycares). The post-triggering activities will mainly involve community members to continually maintain clean villages. The project will support continuous post-triggering follow-ups organized by natural leaders in their respective triggered villages, and major focus will be in ensuring that everyone in the community has a designated sanitation facility and that there is no evidence of open defecation in the community. Afya Jijini will also support advocacy for the provision of sanitation blocks that are suited for informal settlements, as the project continues collaborating with Sanergy15 to provide cheap and sustainable sanitation facilities in informal settlements. CHVs will be trained on UCLTS, thereby supporting them to conduct triggering sessions. These CHVs will be “Ambassadors of Change” in the communities and will mobilize and spearhead all triggering activities at the villages, as well as disseminate IEC materials.

The project will help CHVs and other key leaders in targeted informal settlements (mainly in and around triggered villages) hold quarterly forums. The CHVs will assist with addressing WASH-related diseases and risks and discuss effective strategies to conduct WASH activities at the community level, such as community dialogue and clean-up days, health talks on signs and symptoms and home management, and referral of diarrhea-related illnesses to facilities, among other public health messaging.

OUTPUT 2.5: NUTRITION SERVICES

Approach During Year 3, the project will continue strengthening and supporting NCC’s health department and nutrition stakeholders to improve coordination, planning, and advocacy activities in line with the National Nutrition Policy (Vision 2030, the approved National Nutrition Action Plan 2012, the County Implementation Plan 2013-2017, and the County Nutrition Action Plan). Coordination has been an area that needs continued support given the multi-sectoral nature of nutrition.

In addition, the project will assist the County in rolling out 11 evidence-based High Impact Nutrition Interventions (HINI) within target health facilities and catchment areas, attempting to cover the majority of the estimated 555,748 under-fives in NCC (Kenya National Bureau of Statistics(KNBS) 2015). Afya Jijini will strengthen County and sub-county coordination and planning meetings for 187 integrated

15 Sanergy is a franchise/marked-based company that provides affordable, use-friendly sanitation blocks and latrines in informal settlements. USAID/KENYA AFYA JIJINI YEAR 3 WORK PLAN 36

management of malnutrition (IMAM) sites, 32 CCCs, and 29 maternities and their catchment areas. These meetings will cover activities targeting improvements in health systems by strengthening the capacity of HCWs and deployed CHVs on preventing and treating malnutrition and improving the socio- cultural care practices that impact children’s nutrition through an ECDs model approach and outreach activities as, described below.

County-level nutrition support. In order to effectively coordinate multi-sectorial planning and programming for improved nutrition, the project has adapted and supported County and Sub-County Nutrition Technical Forums (S/CNTFs) over the past two years. These forums involve other stakeholders, including the Ministries of Agriculture, Education, and the Children’s Department to increase advocacy on multi-sectorial issues and increase the likelihood of success at County and sub- county levels. The forums serve as a primary coordination platform to set clear mandates and responsibilities for nutrition stakeholders at different levels, advocate and mobilize financial and human resources, establish partnership activities at all levels, hold and document regular joint planning, and review meetings in line with the County’s annual nutrition planned activities. In Year 3 the project will work with the CNTF to help participants advocate for high impact interventions like conduct more regular active case findings of malnourished cases emphasize multi-sectoral participation, which have lapsed or happened irregularly in the past.

Afya Jijini will continue supporting the County and sub-counties to host Malezi Bora weeks and World Breastfeeding week, building on its success from the previous years, which increased uptake of basic services (including immunizations, growth monitoring, uptake of Vitamin A, deworming, and HINI activities) through outreaches in informal settlements. The project will support these events by organizing planning meetings, providing IEC materials (including banners and T-shirts, and distributing nutrition commodities, reporting tools), and working with sub-counties to provide supportive supervision during these events. Post-event coverage (PEC) will be conducted after Malezi Bora activities to validate coverage of those activities and document lesson learned and results to indicate success in terms of coverage and sustainability.

Facility-based nutrition strengthening activities. To ensure effective provision of preventive and therapeutic nutrition services for vulnerable urban populations at facilities, Afya Jijini will focus on the effective16 delivery of preventive and therapeutic nutrition services. Nutrition services will be prioritized based on Kenya’s High Impact Nutrition Interventions (HINI) and will focus on the first 1,000 days, from conception to a child’s second birthday, as this is the most critical period in which to respond with direct nutrition interventions. This approach can be achieved by strengthening the capacity of existing service providers from both public and private facilities that are situated within or peripherally to informal settlements and by focusing more on the following service areas:

Capacity build (training) of HCWs: Based on lessons learned in Year 2, including staff turnover in most public facilities and a low level of information on most HINI-related activities (early initiation, EBF, CF, and maternal nutrition), Afya Jijini will target both in-patient and out-patient health facility staff, as well as facilities with maternal and child health (MCH) departments. The project will employ a range of capacity building strategies, including recommended specific nutrition module trainings, OJTs, mentorship, and sensitization targeting specific HINI topics, as needs arise. Those HCWs trained (including nurses, clinical officers, medical officers, nutritionists, and PHOs) will then promote and strengthen integration of nutrition screening into other departments (such as MCH, pediatric outpatient, CCC, and TB clinics) to address co-existence of other co-morbidities in malnourished patients, as well as optimizing messages

16 ‘Effective’ in this context considers coverage and targeting, as well as integration with other health and social protection services. USAID/KENYA AFYA JIJINI YEAR 3 WORK PLAN 37

and modeling of nutrition in ECDs. In addition, the project will provide anthropometric and reporting tools to facilities that reported needs.

Encourage quarterly nutrition supportive supervision and improve reporting: The project will work with the S/CHMTs to provide supportive supervision to facilities on the HINI package, especially to the 183 sites with IMAM capability. Afya Jijini will also help plan for and disseminate nutrition guidelines for the County, and will print and disseminate nutrition IEC materials to facilities lacking them. One of the key challenges of working in informal settlements is the lack of data (or non-exceptional nutrition data) with which to guide programmers. In response to observations during Year 2, which found low reporting rates of indicators related to nutrition, the Sub-Purpose 3 team will conduct Data Quality Assessments (DQAs), sensitization, and will build the capacity of HRIOs on the importance of uploading this data into DHIS2 in a timely manner (see sub-purpose 3 or more details). The project will keep in mind that different informal settlements’ environment and needs will vary widely and will enhance equitable and timely targeted responses to the area’s most in need of particular attention. For example, finding highly severe acute malnourished cases as an outcome of ACF is an indicator that the area needs more attention and a wider integrated approach for the community.

Strengthening Nutrition Assessment and Counseling (NACS) services: Afya Jijini will continue with strengthening NACS provision (availability and quality) at target CCCs and ANCs. In the third year, the main focus will be referral and ensuring any malnourished HIV + person receive the recommended food by prescription and follow up and documentation are in place. UHAI teams and the nutrition Technical persons will provide on-the-job training and mentorship on NACS for clinicians at CCCs. The project will also strengthen the quality of anthropometric measurements and categorization of PLHIV through continued provision of OJT and coaching to CCC clinicians. Afya Jijini will collaborate with the USAID-funded Nutrition and Health Plus (NHP+) project to disseminate registers, summary tools, and anthropometric tools (BMI wheels, scales, etc.) and work with the SCHMTs to provide supportive supervision to CCCs and assess their NACS services (including conducting quarterly checks on nutrition data MOH 407 A&B). in addition the project will liaise with Nilinde OVC projects to have this HH to receive nutrition focused interventions besides the testing and HIV care approaches including growth monitoring at these HH through the deployed CHVs in the communities with OVC households.

Further strengthening facility HINI provision: The project support the county to continue scale up of the Government adopted package of 12 high impact nutrition interventions, focusing on infant feeding, micronutrient supplementation and management of acute malnutrition. The interventions include: support and promotion of exclusive breastfeeding, complementary feeding, vitamin A and zinc supplementation, iron folate supplements for pregnant women, deworming and improved hygiene practices. This is aimed to reduce the stunting that recent SMART survey conducted by the county with the support of CWW and TA by Afya jijini conducted May,2017, indicated in informal settlement varying stunting rate from 27.7% in Kayole in Soweto Slums in Embakasi West at 20.0% at Kiambio/Majengo in Kamakunji sub-counties. These interventions are proven to be efficient in preventing and addressing malnutrition and mortality in children and have the potential to reduce stunting if implemented fully and at scale. Targeted trainings on the significance of maternal nutrition will be conducted, the training will ensure that HCWs assess all pregnant women at ANC clinics and offer micronutrient supplementation to pregnant and breastfeeding women and children. During Y3, Afya Jijini will ensure that all HCWs nutritionally assess every pregnant woman at each ANC visit and provide ongoing nutritional counseling and required recommended micronutrients supplements (IFAS).

Afya Jijini will continue the established quarterly supportive supervision visits to strengthen monitoring and mentorship for the critical HINI interventions, using checklists and other tools. Other HINI-related activities to be undertaken in Year 3 include: continuing dissemination of IEC materials and job aides on HINI, training and scaling-up community health strategies and community mechanisms (BCC, Mother- to-Mother support groups, EBF outreach, community dialogue days, strengthening growth monitoring of

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children below 5 years at all levels through the ECDs/day care model, and ensuring that targeted sites provide complementary HINI interventions (i.e. deworming, handwashing, safe water, ORS/Zinc) at facilities). The project will also train and mentor HCWs on HINI and its full implementation through promoting good nutrition practices, supply management, and reporting. Mentoring will take the form of bi-weekly OJTs and quarterly reviews.

Strengthen IMAM at priority health facilities: Afya Jijini will partner with the County to continue building the capacity of staff at IMAM sites through OJT/mentorship and refresher trainings at sites in all sub- counties, and will ensure that all 183 IMAM sites have needed IMAM equipment and supplies. As part of the training, the project will emphasize client counseling aimed at improving IYCF practices (dietary diversity, and EBF) as a key prevention component. The project will also coodinate with the USAID- funded national nutrition mechanism, NHP+, to help sub-counties improve nutritional outcomes in facilities (especially among PLHIV, including children under five and breastfeeding women) by distributing resources and materials (including anthropometric tools, reporting tools, policies, and guidelines) and strengthening the supply of FBP that NHP+ distributes. WITs will reinforce nutrition QI standards by reviewing outpatient therapeutic cards and registers of children admitted with acute malnutrition on a quarterly basis, tracking patient outcomes, and suggesting health facility change ideas. SCHMTs will conduct quarterly supportive supervision visits to their IMAM sites to find gaps and develop action plans.

Improving maternal nutrition (see also Output 2.1): The maternal nutrition intervention will focus on the 1,000 days between pregnancy and a child’s second birthday as the most critical period to ensure optimum physical and cognitive development. In Year 3 Afya Jijini will improve maternal nutrition through several strategies, including by ensuring that all targeted pregnant women get nutrition assessments using well- calibrated anthropometric tools, building the capacity of ANC staff (with a focus on HCWs at HVFs) on maternal and child health and nutrition by providing training and OJT/mentorship on areas of MIYCN. In addition, the project will support stock monitoring of IFAS and other essential multiple micronutrient supplementation, as well as availability of food assistance and fortified/specialized food products (CSB+, Super cereal Plus, RUTF, RUSF, etc.).

The project will also promote optimal breastfeeding practices and food diversity knowledge through quarterly community conversations and forums for seven sub-counties and during project outreach activities (including mass screening, ACF, de-worming campaigns etc.), and will disseminate IEC materials on MIYCN to improve community knowledge on better nutrition and lead to more baby- friendly communities. The project also plans to train CHVs and HCWs on MIYCN and provide them with job aides and SOPs.

In Year 2, the County formed County committees and all sub-counties were sensitized on BFHI. The project selected Pumwani Hospital to serve as a Center of Excellence for these activities since it is following the ten core steps of BFHI. In year 3 this will be scaled up to other facilities, thus ensuring follow-up and monitoring of BFHI activities in to the County Nutrition Action Plan (CNAP).

Community-based nutrition support activities. The project will work with the County to ensure that all children ages 6-59 months receive Vitamin A dosing through Malezi Bora campaigns at targeted health facilities. To minimize the effect of micronutrient deficiencies, the project will continue monitoring the stock of key elements (including zinc, Vitamin A and fortified food) at facility levels.

The project will train and support lead CHVs, identified and trained in the last two years of the project, to promote nutrition messaging and relevant community HINI actvities. In Year 3, Afya Jijini will continue working with CHVs to support the community-linked aspects of the intervention package. Afya Jijini will further train/refresh 60 CHVs on maternal and child nutrition, and engage the CHVs to support child health nutrition at the community level through the ECD model. In Year 1, Afya Jijini, mapped and

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recorded 2,710 ECDs and daycare centers, with nearly 120,000 children enrolled, and began using these ECDs as entry points for health services (with a focus on WASH and nutrition), targeting both the children and the surrounding catchment communities. In Year 3, the project will sustain the ECD model for nutrition services (ACF, growth monitoring, and deworming) and WASH activities (UCLTS, distribution of water treatment tablets, and targeted clean-up days), as needed. The CHVs will also help the project target households with under-five children and enable messaging (social behavior change and education) of caretakers in a convenient location.

The project will continue focusing on implementing community-level SBCC activities that were started in Year 2 that help target households develop a plan for improved nutrition across a number of comprehensive dimensions: maternal nutrition, dietary diversity, EBF, IYCF, education to promote complementary feeding, etc. For example, CHVs will help communities/villages form EBF support groups, as well as help women seek support and tips to proceed with EBF when it becomes challenging. In addition, during quarterly community conversation forums and nutrition weeks CHVs will sensitize the community members who will act as agents of change on the issues that affect them on health seeking behavior and nutrition demand barriers. For example, the sub-county, ward, and provisional administrators will participate in nutrition SBCC activities so it becomes the norm for them to discuss issues related to good nutrition in their daily community activities. CHVs will organize social mobilization activities leading up to deworming campaigns, and will help distribute and administer Vitamin A and dewormers. CHVs will also conduct quarterly malnutrition ACF and outreach activities in the community and follow-up on acute malnutrition cases, linking those identified to livelihood support and safety nets.

Working in conjunction with the Ministry of Agriculture within sub-counties, and as part of community outreach activities, the project will focus on community cooking/nutrition demonstrations (recipe) in the targeted informal settlements. These demonstrations emphasize promotion of good dietary practices and will be carried out as a core activity during Malezi Bora weeks. The baseline assessment and other project observations show that uptake of optimal breastfeeding practices, IFAS among pregnant women, multi- nutrient powders (MNPs), and the use of zinc within diarrhea management requires additional focus. The project will therefore reinforce focus during community conversation/ outreach activities and disseminate IEC materials at public areas. The project will also closely coordinate with the USAID- funded Nilinde project, with Afya Jijini reaching and supporting OVC households in GMP and strengthening referrals and linkages to facilities, while Nilinde will continue to strengthen household economies for particular family members.

SUB-PURPOSE 3: STRENGTHENED AND FUNCTIONAL COUNTY HEALTH SYSTEMS

Introduction High populations in capital cities, especially considering the density of informal settlements, remain unique challenges for Nairobi City County (NCC) to achieve quality healthcare services for all of its residents. Additionally, the challenges of devolution and HCWs unrest, as demonstrated in Year 2 of the project, continue to affect health service delivery. Nairobi City County, just like many other counties, continues to require broad-based health systems support and strengthening if improved health outcomes are to be achieved. Afya Jijini will therefore continue helping NCC build a robust health system that is able to respond to healthcare needs of NCC residents by strengthening its leadership and governance structures, stakeholder coordination, human resource management systems, laboratory and commodities systems, and improving information systems.

Approach Improved health outcomes in NCC require quality service delivery in communities and at health facilities, which in turn need strong county, sub-county, and facility, and community-level leadership and

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management of resources, supplies, technical guidance, and training. Building on the achievements of Years 1 and 2 (including finalizing and launching the NCC health policy, health strategic plan, and partnership engagement framework; updating the iHRIS system and performance management systems; re-establishing the commodity security committees at the county and sub-county levels; strengthening the laboratory networking system; and forming work improvement teams (WITS)) Afya Jijini will continue to support each level of NCC’s health system—county, sub-county, facility, and community—to strengthen the role each must play in strengthening the county’s health system.

County and sub-county level. Afya Jijini will continue building the capacity of the CHMT and SCHMTs in leadership and management through training, coaching, and mentorship. In Years 1 and 2 the project coordinated with the Kenya School of Government (KSG) to provide more than 100 County and sub- county staff with leadership and management training. In strengthening governance, the project will support dissemination and implementation of the completed county policies and strategies, including the Nairobi City County Health Sector Strategic and Investment Plan and the Nairobi City County Health Policy. The project will also continue supporting key TWGs in human resources for health (HRH), commodity management, quality improvement, County monitoring and evaluation (M&E), and laboratory systems strengthening to ensure quality delivery of services. Working with the CHMT and SCHMTs, the project will also ensure that performance monitoring of the 2017/2018 Annual Work Plan (AWP) is carried out by providing integrated supportive supervision and rolling out performance appraisals to improve accountability. Since stakeholder coordination is key to leveraging available resources and improving efficiencies, the project will continue providing technical and logistics support to County and sub-county stakeholder meetings as well ensuring implementation that the newly- developed Partnership Engagement Framework is implemented by working with implementing partners to share their plans with the County and reporting on their achievements on a quarterly basis.

Facility Level. Afya Jijini will continue strengthening HRH (performance management, staff motivation, and skills building), commodity management (inventory management, forecasting etc.), laboratory services, and quality assurance (with a focus on HIV care and treatment-related outcomes) activities at the facility level. The project will also support development of strategic plans for the County’s referral facilities and build the capacity of selected health facility committees in efforts to continue strengthening health facilities’ governance capabilities.

At the national level, the project will continue to support the CHMT members to participate in national TWGs, especially related to HIV, MNH, improving devolution, and human resource (HR) planning, among other priority areas, as allowed.

OUTPUT 3.1: PARTNERSHIPS FOR GOVERNANCE AND STRATEGIC PLANNING

Background and Rationale Devolution has caused many challenges for NCC’s health sector, including frequent HCW strikes due to issues of motivation and remuneration, as well as supply chain and financial management challenges. Afya Jijijni will continue working with the CHMT and SCHMTs to better manage, deliver, and report on health services in the devolved context and in compliance with international guidelines and GOK policies. Year 3 will focus on: disseminating and implementing newly-developed key County documents (i.e. the health policy, health strategic plan, and partnership engagement framework), strengthening performance monitoring of AWP implementation, continuing to build leadership and management capacity, strengthening governance structures (i.e. facility management committees), and strengthening supportive supervision by improving feedback and follow-up processes.

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Strengthen County and sub-county-level leadership and governance. In Years 1 and 2 Afya Jijini helped the County develop the new NCC HIV/AIDS Strategic Plan, County Health Policy, County Health Strategic and Investment Plan, and the Partnership and Engement Framework. The project also supported the county to develop a new “bottom up” (by engaging the community, facilities, and sub- counties) approach to developing its AWP. As a result of project support, the sub-counties developed sub-county-specific AWPs for the first time since devolution. In Year 3 the project will help disseminate these key county documents to various levels, and will ensure that are understood and are used as reference documents for decision-making. Afya Jijini will facilitate quarterly meetings with the Department of Health Policy, Planning, and Research to monitor implementation of the AWP, strategic plan, and other plans. The project will also continue working with the county to conduct performance reviews in order to monitor AWP implementation and will assist with developing the 2018/2019 AWP. Afya Jijini will also support the sub-counties to hold semi-annual performance reviews of all relevant plans and strategies mentioned and the county M&E plan. In order to further institutionalize the AWP process, and based on lessons learned during development of the 2016/2017 and 2017/2018 AWPs, the project will help the County develop perfomance review and AWP guidelines during Year 3.

Strengthen stakeholder coordination and support: Afya Jijini will work with the county to disseminate the finalized Partnership Engagement Framework at the sub-county and the county referral facility levels in order to continue supporting the County with coordinating stakeholders for improved service delivery and reduced duplication of services. Afya Jijini will support semi-annual County health stakeholder meetings17 as a coordination mechanism, and quarterly meetings at the sub-county level, according to the framework. The projet will also work closely with the new county partnership coordinator to monitor adherence to the framework.

Provide TA in program-based budgeting: Working with the USAID-funded HPP+ project, Afya Jijini will help the county link annual work planning (2018/2019) to the MTEF (2014/2015-2019/2020) to ensure that county plans are linked to available resources.

Supportive supervision: In Years 1 and 2 the project provided TA and logistics support to the County to revise, pre-test, and finalize the integrated supportive supervision tools for the sub-county, primary health facilities, and county referral facilities. In Year 3, the project will continue supporting the County to conduct quarterly supportive supervision visits at the sub-county and facility levels. The project will ensure that supervision reports and action plans are completed for areas identified with weakness and in need of interventions. This activity will also be linked to performance monitoring.

Leadership and governance training; In Yeas 1 and 2, Afya Jijini supported the County in rolling out leadership and governance training for 79 CHMT and SCHMT members through the Kenya School of Government (KSG), resulting in improved coordination of processes and development of better quality documents (e.g. the improved “bottom up” AWP process for 2017/2018). In Year 3 the project will focus on providing this training to an additional 50 participants drawn from SCHMT members that were previously unable to access the training and hospital management team (HMT) members from four county referral facilities, thereby ensuring leadership and governance is infused through all levels of healthcare management in NCC.

Strengthened facility level leadership and governance. In Years 1 and 2 Afya Jijini provided TA and logistics support in conducting perfomance reviews and developing the AWP 2016/2017 and 2017/2018. Additionally, facilities like Pumwani Maternity Hospital were able to have their first-ever AWP

17 The county forums include more than 100 invitees from government ministries, NGOs (international and local), universities (international and local), the private sector, and faith communities. A full list of participants can be shared upon request. USAID/KENYA AFYA JIJINI YEAR 3 WORK PLAN 42

(2017/2018). The project also provided technical and logistics support in rolloing out the roles and responsibilities guidelines for health facility committees for 20 level three facilities.

Planning and perfomance review: In Year 3 Afya Jijini will continue providing technical support in conducting perfomance reviews and developing the AWP (2018/2019) for other country referral facilities. In addition, the project will help finalize the strategic plans for the two referral facilities (see above) and develop an additional strategic plan for Mbagathi Hospital. In acknowledgement of the role that faith- based and private sector facilities play in providing service delivery in the County, particularly in informal settlements and during HCW strikes, the project will put more emhasis on strengethening systems in these facilities in Year 3. This will involve providing technical and logistics support for St. Mary’s Hospital to develop a strategic plan and AWP, including establishing a performance monitoring platform.

Governance support: The project will provide sensitization meetings to the HMT and hospital boards of County referral facilities so that they understand the NCC health policy, strategic plan, and partnership engagement framework. Afya Jijini will also continue to rollout the roles and responsibilities guidelines to additional 20 level 3 facilities to ensure that committees settle in their roles and provide leadership and accountability.

OUTPUT 3.2: HUMAN RESOURCES FOR HEALTH (HRH)

Background and Rationale With 80% of health functions now devolved to County governments, a robust and very effective health delivery system at the county level is paramount in order to achieve a transformational approach to delivering health services, as articulated in the NCC Health Sector Strategic and Investment Plan 2013/2014-2018/2019. The biggest barrier for NCC to accomplish its health goals is the coordination and management of the current health workforce. To help address these challenges, and in response to a need identified during the County’s supportive supervision visits, Afya Jijini focused on improving the human resources management system at the County, sub-county, and facility levels through setting up and strengthening the coordination and management mechanisms in Year 2. These improved coordination and management mechanisms ensure that HRH issues are well articulated at the sub-county and facility levels and that appropriate solutions for each level of management are prescribed, implemented, and/or recommended for decision-making at the County level, as necessary.

Strengthen the Health Workforce Coordination Committees at the county, sub-county and facility levels. In response to NCC receiving an increased number of donor-funded projects that offer different levels of HRH support, including the USAID-funded HRH Kenya, Healthstrat, and Afya Jijini projects, UNICEF, and JICA, more emphasis will be placed on coordinating and harmonizing these activities to ensure greater and more sustainable impact. Based on a recommendation from a recent County supportive supervision visit, Afya Jijini helped establish three key HRH coordination groups at the County, sub-county, and facility levels in Year 2, including development and disseminating their TORs. In Year 3, Afya Jijini will work with the County HR Office to ensure that these coordination groups hold quarterly meetings with HRH implementing partners’ participation and progress toward meeting their goals/implementation plans. Afya Jijini will work with the County to strengthen HRH coordination, reduce duplication of efforts, and create greater efficiencies in harmonization and management of HRH interventions (including Staff Performance Appraisals, iHRIS upate and utilization for decision-making, HRH supoportvie supervision, training coordination and management, development of training plans for County Hospitals, JD roll out, and a Rewards and Recognition program for health facilities).

Improve workforce planning to ensure adequate number and skill mix of health workers at facility level. In response to the HRH audit report conducted in Year 2, Afya Jijini will work with the County to implement the following activities: redistribute staff, update the Integrated Human Resources USAID/KENYA AFYA JIJINI YEAR 3 WORK PLAN 43

Information System (iHRIS), and build HMTs’ capacity in HRH data use for decision-making. The project will ensure quarterly updating of the iHRIS through staff returns that the sub-counties and facilities submit on a monthly basis and by developing HRH dashboards at all levels of service delivery. The project will collaborate with the HRH Kenya program to conduct quarterly HRH data quality assurance checks to ensure accuracy and credibility. The County will be able to use the iHRIS to monitor retention, turnover, and vacancy rates, with information building up for an annual HRH report. In Years 1 and 2 the project helped the County develop 68 HCWs’ leadership and management skills through the Leadership and Development (LDP) program. As a result, facilities with trained HCWs saw improvements in various service delivery areas. In year 3 the project will aim to reach 60 new participants with the LDP. The participants will be drawn from levels 3 & 4 health facilities to participate in a 6- month long training program which aims at improving service delivery in PEPFAR program areas.

The project proposes to hire 166 temporary staff in project-participating sites. They will particularly be hired to support program areas where the County has little or no staff attached to the areas. A mix cadre of staff will be hired to support HIV/AIDS service delivery (to include Clinician Officers, PMTC Nurses, Peer Educators, Mentor Mothers, Pharmaceutical and Laboratory Technologists, HTS Counselors, and Cough Monitors). The staff will be deployed in facilities identified as needing extra workforce to implement these services.

Training and development activities for HCWs will be implemented on a continuous basis throughout the project period. The trainings planned include OJT, site-based trainings for smaller groups of HCWs, and outsourced training venues (such as accredited training institutions). Trainings will be conducted by accredited providers and curriculum sourced from the MOH departments and Afya Jijini technical staff. The specific trainings will be planned under Sub Purposes 1, 2 and 3.

Assist health facilities to develop an HRH management system. In Years 1 and 2 Afya Jijini conducted HRM capacity assessments and an HRH audit at the County, sub-county, and facility levels. These two activities revealed gaps in HRM and Human Resources Development (HRD). In Year 3 the project will address these gaps by strengthening the HRH advisory committee to supervise and address HRH issues, developing a facility-based training plan (targeting four referral facilities), providing technical support for performance contract reviews that are linked to a staff appraisal system, supporting quarterly HRH supportive supervision visits, and use data to advocate to the HRH Advisory Committee on filling HRH gaps within the County. The project will continue supporting CHVs’ performance improvement and management by ensuring regular supportive supervision visits are conducted, supporting development of supportive supervision guidelines for the County, and documenting case studies on CHV work.

OUTPUT 3.3: HEALTH PRODUCTS AND TECHNOLOGIES (HPT)

Background and Rationale Afya Jijini used several strategies designed to improve commodity availability and reporting, including improving coordination and joint planning, leveraging multiple projects (such as University of Maryland and Pact Endeleza) to support use of WebADT; the Bill and Melinda Gates Foundation-funded InSupply project to improve FP and vaccine commodity reporting; the Clinton Health Access Initiative (CHAI) to support online Lab commodities reporting platforms; and KEMSA to support capacity building of the county on commodity management), implementing on-site sub-county and health facility mentoring, and establishing electronic reporting systems to better forecast and track commodities in Year 2. Afya Jijini also supported the County to have a functional county health commodities security committee. In addition, the project helped establish a sub-county health commodities security committee in every sub-

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county. Sensitization of laboratory staff on utilizing electronic platforms (DHIS2) was successfully carried out in Year 2. In Year 3 the project will focus on enhancing data use for decision-making.

The project supported NCC to quantify rapid test kits requirements and generate facility-specific orders based on drawing rights allocated to the County by NASCOP. The project revived and trained facility- based Medicine and Therapeutic Committees (MTCs) in six county referral facilities. The committees meet regularly to discuss medicine-related issues. In Year 2, Afya Jijini also continued working with the County to achieve the third 90 by supporting sample laboratory networking for viral load testing, networking EID DBS samples, CD4 and sputum samples (for GeneXpert TB diagnosis), leading to improved turnaround times. Additionally, the project conducted biosafety and biosecurity training for 60 laboratory staff.

During the past year Afya Jijini collaborated with other USAID and donor-funded HPT projects (e.g. Insupply, KEMSA, CHAI, and University of Maryland), including initiating quarterly laboratory stakeholder meeting and securing support from other partners to convene the meetings. This will continue in Year 3.

County and sub-county level HPT strengthening. In Years 1 and 2 the project reviewed the TORs for the County Commodity Security Committee, which were approved by County leadership. As a result, this committee was re-established and has been meeting to address County supply chain issues. In addition, the project spearheaded the formation of sub-county commodity TWGs with clear TORs. In Year 3 the project will work with the commodity security committees on the following priority areas: improving commodity management systems, supporting commodity security, improving commodity information systems coverage to ensure timely reporting and quantification based on consumption data, and supporting pharmaceutical services/medication management (especially for reporting adverse drug reaction (ADR) events). Afya Jijini will ensure that the County Commodity Security TWG and the sub- county TWGs continue meeting to improve the County’s commodity and supply chain management, data management and reporting. In particular, the project will support the sub-county commodity management committees to meet on a quarterly basis and conduct supportive supervision to address commodity issues. The project will work with the County to monitor commodity stock status of tracer commodities every month and hold quarterly data reviews. The key findings will be compiled and shared with USAID and relevant national programs on a quarterly basis. Urgent findings requiring immediate intervention by USAID will be reported whenever they arise. See Annex VII for the proposed list of tracer commodities that was finalized in consultation with the Commodity TWG team.

The project will also ensure that County activities align with national activities by supporting the County to participate in quarterly national-level activities related to commodity security (such as national ART, FP, and laboratory commodity quantification), as allowed.

County and sub-county level HPT strengthening (inventory management and commodity security). In Years 1 and 2 the project trained and provided facility-based CMEs to more than 120 HCWs on commodity management, with a focus on pharmacovigilance. In addition, the project initiated the 5S approach to improve storage and inventory management at the facility level. In Year 3, the project will provide at least an additional 30 HCWs with training, OJTs and CME to improve planning, forecasting, quantification, storage of commodities, and inventory management for both laboratories and pharmacies at facilities. The project will work with the County to quantify commodity requirements, which will assist in lobbying for resource allocation for health commodities in NCC. Afya Jijini will work with supply chain pharmacists and laboratory officers to continue implementing the 5S approach to improve the work environment and storage practices in additional high-volume facilities. The project will also continue supporting facilities to dispose of expired commodities to free up additional storage space, and will continue supporting implementation of proper commodity quantification and forecasting to

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mitigate additional expiries and redistribution of commodities to prevent stock-outs at facilities. Additionally, the project will ensure commodity management SOPs and job aides are available at facilities.

County and sub-county level HPT strengthening (information systems). In Years 1 and 2 Afya Jijini supported facilities utilize existing platforms for commodity reporting (e.g. HCMP, LMIS, and migrating commodity reporting in DHIS2). In Year 3 the project will continue supporting the County, sub- counties, and facilities to use DHIS2 and continue scaling-up use of EMR (such as ADT and IQ care) for commodity reporting. The project will also support facility-based commodity data audits and reviews to enhance accountability of health commodities. In addition, Afya Jijini will sensitize HCWs on logistic information management systems (LIMS). County and sub-county level HPT strengthening (patient safety). In Years 1 and 2 Afya Jijini helped establish six Medical Therapeutic Committees (MTC) (four county referral facilities and two faith-based referral facilities) to strengthen pharmacovigilance, patient safety, and supply chain management best practices. In Year 3, Afya Jijini will continue prioritizing patient safety interventions by setting up, scaling- up, and reinforcing pharmacovigilance systems (including protocols). These systems will monitor and track ADRs, medication error reporting, and poor quality medicine reporting in all high-volume facilities. The project will continue supporting the existing MTCs at the four county referral hospitals and two faith-based referral facilities so they can serve as models for other sites. The project will also set up and strengthen MTCs in four additional high-volume facilities. The project will train 30 members of these MTCs in patient safety to ensure that they are well-grounded ensure that patient safety is prioritized at all sub-county commodity management committee meetings. The project will also continue providing facility-based mentorship on ADRs, medicine recording and reporting to ensure patient safety, and will distribute IEC tools, job aides, and protocols on pharmacovigilance to reinforce best practices.

County and Sub-County Level HPT Strengthening (QA). In Year 2 Afya Jijini collaborated with the KEMSA Medical Commodities Program to collect expired ARVs. The project also disseminated pharmacy reference materials to high-volume facilities. In Year 3, the project will hold biannual best practice sharing forums. The project will also integrate ART pharmacies into OPD pharmacies in 10 facilities for sustainability. Additionally, the project will enhance collaboration with the pharmacy and poisons board to improve pharmacovigilance reporting by holding joint facility-based CMEs and feedback sessions.

Collaborate with related USAID and donor HPT projects. Afya Jijini will continue working closely with other donor-funded supply chain projects, such as the InSupply, Kenya Supply Chain Systems Strengthening (KSCSS), and KEMSA commodity projects. Activities will include joint planning and collaboration meetings to develop a collaboration and sustainability plan for scaling their activities down to the sub-county and facility levels, meeting with other partners working with HPT in NCC, and organizing regular meetings with Palladium on implementing the IQ care supply chain module.

Implement the Environmental Monitoring and Mitigation Plan (EMMP). Afya Jijini will build off of the trainings provided to 60 laboratory staff in Year 2 on biosafety/biosecurity by providing 1-day refresher trainings as well as conducting additional 5-day biosafety/security trainings to medical laboratory technologists. In Year 3 the project will also conduct biosafety/biosecurity supportive supervision visits to monitor adherence to biosafety standards. The project will disseminate biosafety guidelines and policies in addition to adapting SOPs to each facility. Afya Jijini will also support KEMRI or NPHLS certification of biosafety cabinets at high-volume laboratories. Additionally, the project will procure infection control and waste management commodities, such as lab coats, gloves, waste bins, and bin linners.

Strengthen laboratory systems management. In Year 2, Afya Jijini continued working with the County to achieve the third 90 by supporting sample laboratory networking for VL testing, EID DBS samples, and sputum samples (for GeneXpert TB diagnosis and CD4 samples). This approach decreased turn-

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around times by ensuring that samples reach testing laboratories the same day as sample collection, and that results are immediately submitted to facilities. In Year 3, the project will strengthen the lab referral network by engaging a low-cost courier service to provide additional sample networking riders. To improve the efficency of sample networking, Afya Jijini will continue supporting high-volume facilities with labs that can act as centrally-located sample handling and processing hubs for other facilities. This approach will significantly improve sample flow, minimize sample losses by reducing sample rejection, and provide more timely results to clients and clinicians. The project will train phlebotomists and laboratory technologists on VL sample management. Turn around time and specimen rejection will be tracked. In addition, the project will monitor testing interruptions within the lab networks.

Afya Jijini will continue to conduct supportive supervision and mentorship at facility laboratories to ensure they implement quality management systems as per SIMS laboratory quality essentials. The project will disseminate laboratory policies and guidelines at County and facility levels. Supportive supervision will continue to ensure implementation of these policies and guidelines at high-volume facilities. Medical laboratory technologists will also be trained on SOP development.

In Years 1 and 2 the project provided technical and logistical support for submitting proficiency testing (PT) results to the National HIV reference laboratory. In Year 3, the project will enroll high-volume facilities on External Quality Assessments (EQA), provide biannual EQA corrective actions, and support a semiannual EQA performance sharing forum, which will focus on TB and HIV. The project will also help the County to ensure that lab registers, SOPs, and job aides are available in high-volume laboratories.

Afya Jijini will support three County referral facilities and two faith-based facilities to implement best practices in blood transfusion (e.g. by setting up hospital transfusion committees, a system to sustain cold chain, and SOPs on blood safety procedures).

In Years 1 and 2 Afya Jijini participated in the quarterly laboratory TWG to discuss laboratory issues. The key outcomes from the TWG meeting included the provision of facility-level mentorship to implement laboratory quality management systems and to strengthen the capacity of the SCMLTs to use DHIS2 in reporting. These activities will continue to be supported in Year 3. As part of M&E activities to monitor quality outcomes and continous quality improvement, the project will support quarterly meetings of the SCMLTS and biannual laboratory incharges meetings for sharing best practices.

OUTPUT 3.4: STRATEGIC MONITORING AND EVALUATION (M&E)

Background and Rationale Afya Jijini strengthens data collection, analysis, and use as part of its mandate to foster strong, accountable health systems. As of quarter 3 of Year 2, the project trained 164 health management team members on the new HIV tools, conducted program-level RDQA in partnership with the sub-county HRIOs (which has improved facility-level data ownership accuracy), strengthened data use at the facility and sub-county levels by introducing performance trackers and supporting data review sharing forums, and helped transition six facilities to EMR at POC (five facilities were EMR POC ready). In Year 3 the project will focus on strategic scale-up of electronic medical records (EMR) at point-of-care (POC) in an additional 10. The project will also building HCWs’ capacity through OJTs, CMEs, and mentorship on M&E topics (such as indicators definitions, DDIUs, data analysis, and presentations among others).

Build County capacity to monitor and evaluate priority health service delivery areas effectively. As the County moves towards digitizing health records in HIV services delivery, Afya Jijini will advocate that the County begin using a service agreements model for maintenance of computers and information

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and communications technology (ICT). Similary the project will help the County M&E TWG in rolling- out the NCC M&E Plan (once completed) and ensure routine performance reviews through: semi-annual DQAs, supportive supervision, quartely data review meetings, scaling up the service performance dashboard for each technical area, conducting CMEs, and timely reporting through DHIS2. The project will continue collaborating with other implementing partners (such as Palladium Group, PIMA, and UON) and other stakeholders to promote joint information sharing forums. These forums will be utilized as platforms for identifying challenges/gaps and their solutions, sharing best practices, and networking. The project will also continue supporting sub-county teams to upload data into DHIS2 on a monthly basis.

Afya Jijini will continue building the capacity of S/CHMTs in data quality, new tools, and National HIS platforms (including COPBAR). The project will also conduct sensitization and orientation meetings on using EMR, and IQCare specifically, for the County and sub-county HRIOs so they can mentor and offer OJTs to facilities on how to use IQCare.

Improve facility-level data collection and use. Collaborate with partners (Palladium Group) to scale-up the IQCare system to incorporate all modules: The project will strategically scale-up and strengthen use of the EMR system in care and treatment facilities in Year 3. In Years 1 and 2 the project collaborated with Palladium Group and the CHMT to transition 5 facilities (Ngaira, St. Francis, Mukuru Health Center, Westlands, and Mukuru Reuben) to POC. In Year 3 the project will continue working with Palladium Group to have all the modules activated (PMTCT, HTS, TB, and nutrition). An SMS platform will be also activated to facilitate defaulter tracing by sending reminders to patients on their appointment dates. An SMS platform for defaulter tracing that was established and tested in Year 2 (at St. Francis Hospital) will be be rolled to all the other project- supported HIV care and treatment sites.

Support high volume facilities in filling and storage of Patient records: In year 3 the project will work closely with the county health Management and facility management in identifying the most appropriate patient charts filling and storage system with all the safety measures in place. The team will employ quality improvement 5s strategy (sort, straighten, shine, standardise, and sustain) in filling at high volume sites.

Develop and implement a service performance dashboard to inform/facilitate decision-making: In Year 3 Afya Jijini will scale up use of performance dashboards/trackers to facilities’ WITs for decision-making. The dashboards will capture data at maternities, MNCH facilities, HIV care and treatent clinics, PMTCT clinic, and TB clinics. The indicators will mainly focus on quality of service delivery, identify missed opportunities using various cascades, and inform on coverage. This dashboard will form the basic tool used during WITs’ data review forums.

Capacity building of HCWs on skills to stregthen M&E technical areas: The UHAI teams will continue providing regular mentorship, CMEs, and OJTs on using data tools, reporting, data quality, and creating demand for data use at facilityies in Year 3. These topics will be guided by the National HIV Guidelines and National DQA Protocol. Other areas that will be strengthened include collaboration with Palladium Group and UON on using DHIS2, IQCare, and IQtools.

Support routine M&E acitvities: The project will continue supporting County, sub-county, and facility monthly routine activities, distributing data capture tools, supporting facility and sub-county level internet connectivity, providing ICT support to facilities through the project’s ICT/M&E assistants, and offering daily health records support to facility by the project’s M&E assistants with the aim of improving quality of data and reporting. Afya Jijini will collaborate with the sub-county HRIOs to continue engaging sub- county data entry volunteers to assist with updating routine monthly data into DHIS2. At the facility level the M&E assistants who are attached to high-volume facilities will continue enhancing the quality of data

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by assessing completeness, accuracy, and precision before data is submitted to the next level or updated into DHIS2.

Support quarterly sub-county DQA and RDQA at health facilities: The project will engage the UHAI teams, M&E officers and and M&E assistants to help high-volume facilities organize monthly RDQA and quarterly/semi-annual DQAs, in collaboration with the County and sub-counties HRIOs. This process will ensure that facility-level data meet all data quality dimensions before being uploaded into DHIS2.

Strengthen and integrate community-based health information systems (CBHIS). Afya Jijini will work with the County to distribute community tools and, where necessary, photocopies of the tools. The project will work with CHVs, including training them on data collection and reporting in Year 3. The project will oversee 9 community units entering data is uploaded into DHIS2 and updated on the facility- level chalkboards. In Year 2, the project trained 50 CHVs on reportable RMNCH indicators and supported development of data collection tools for nutrition and WASH activities. Key deliverables under community activities included; reaching a total of 690 ECDs with WASH activities, sensitizing 28 CHVs on tools for mapping triggered villages utilizing Nyumba Kumi, and sensitizing CHVs on growth monitoring data collection and referral tools. These sensitisation forums improved community-level DHIS2 reporting as well as improved referrals of RMNCH clients from community to facility. In Year 3, Afya Jijini will continue mentoring facility CHVs, Mentor Mothers, and peer educators on CBHIS to optimize reporting to DHIS2, including through supportive supervison (see output 3.2). The project will also synchronize CBHIS reporting with affiliated catchment facilities to continue strengthening and integrating community health information systems with other key health service delivery data platforms (for HIV, FP, MNCH, TB, WASH, and nutrition) at the facility level.

OUTPUT 3.5: QUALITY IMPROVEMENT SYSTEMS

Background and Rationale During Year 1, the project focused on sustaining and expanding the gains made by the USAID-funded ASSIST project in implementing the Kenya Quality Model for Health in NCC. In Year 2 the project continued supporting the existing QI structures at the County, sub-county and facility levels, with an emphasis on the sub-county and facility levels. The county QA/QI unit, led by the county QI focal person, is responsible for planning, implementation and evaluation of QI activities in the county, as well as supervision of sub-county QI teams and focal persons. This unit is currently functional and has been institutionalized within the CHMT. The county QI focal person works very closely with the sub county QI focal persons who are responsible for implementing QI at the Sub-County level and supervision of QI activities at the facility level. The sub-county QI teams are currently in place and supervising implementation of QI at the facility level. Each facility has a QI focal person who reports to the sub- county QI focal persons, in addition to a team leader being in charge of each departmental-level WIT. Facility level QI structures are in place in the majority of the facilities, with varying degrees of functionality in different facilities and different service delivery areas.

In Year 3, Afya Jijini will focus on institutionalizing QA/QI structures at the facility level by supporting each facility to develop and implement an annual QA/QI work plan, monthly performance data review, identify gaps, and implement QI projects to address identified gaps. The project will also support the county, sub-county and facility QI focal persons to plan, implement and evaluate QI activities at the various levels.

Strengthen County level QI coordination and processes. In Years 1 and 2, Afya Jijini supported the County QA/QI unit to develop and implement annual County QA/QI work plans, as well as coordinate sub-county QA/QI teams and stakeholders through the QA/QI TWG. Furthermore, the project supported the County to develop a Health Service Delivery Awards (HSDA) mechanism aimed at USAID/KENYA AFYA JIJINI YEAR 3 WORK PLAN 49

recognizing and awarding health facilities based on their performance on key priority service delivery indicators. In Year 3, Afya Jijini will continue supporting the County QA/QI unit to conduct strategic planning, coordination, implementation, and evaluation of QA/QI activities. To achieve this, the project will provide technical and logistical support to the quarterly County QA/QI TWG, quarterly QI coordination meetings with sub-county QI focal persons, and quarterly supportive supervision of sub- counties and priority facilities. The project will also support the County to conduct a QA/QI assessment of health facilities for the annual HSDA in the County, as well as continue to support the QA/QI unit and the HSDA taskforce to operationalize performance-based incentives (PBI) using the HSDA platform. The best performing facilities will receive certificates of recognition and commendation from the CHMT during the awards ceremony. To facilitate learning among sub-counties, the project will also support biannual QA/QI best practice sharing forums at the County level.

Strengthen sub-county level QI coordination and processes. In Years 1 and 2, Afya Jijini supported sub-county QI focal persons to coordinate QA/QI activities, notably supportive supervision, coaching, and best practice sharing forums. In Year 3, the project will continue supporting the 10 sub-county QI focal persons and SCHMTs to coordinate implementation of QA/QI activities at the sub-county and facility levels. The project will provide technical and logistical support for quarterly sub-county quality improvement team (QIT) and coaches’ meetings, as well as facility coaching and mentorship by the sub- county QA/QI focal persons. The project will also support quarterly best practice sharing and collaborative learning sessions at the sub-county.

Strengthen facility-level QI processes and initiatives. In Years 1 and 2, Afya Jijini supported the formation of 103 facility WITs. However, some gaps remain at the facility level, such as inconsistent performance reviews and regular QIT/WIT meetings. In Year 3, Afya Jijini will continue supporting facility level QITs to develop annual QA/QI work plans aimed at ensuring functional and structured QA/QI activities in addition to providing technical support during meetings. The project’s UHAI teams will also support facilities to ensure that data for key priority indicators are displayed on the walls and reviewed by the WITs on a monthly basis, and that identified gaps addressed. The project will also support 40 facilities to conduct 5S and process mapping to improve the work environment and patient flow, and will support 22 high-volume HIV care and treatment facilities to conduct biannual reviews of the Kenya HIV Quality Improvement Framework quality indicators.

Furthermore, Afya Jijini will continue building the QI capacity of health care managers and HCWs through providing TA for QI CMEs during sub-county and facility in-charges meetings and by supporting QI best practice sharing forums. The project will also train 60 HCWs on QA/QI using the Kenya Quality Model for Health curriculum.

Scale-up community level QA/QI. Afya Jijini will initiate QA/QI activities with selected grantees supporting community services during Year 3 in an effort to improve the quality of services being provided. This will be achieved through sensitizing the grantees on community QI, as well as facilitating the linkage between community and facility WITs. The project will also work in close collaboration with other USAID-funded projects implementing QI at the community level, particularly the SQALE project which aims to creating effective linkages between the community and Afya Jijini-supported facilities.

III. Gender

In addition to the gender activities under Sub-purpose 1, Afya Jijini will also carry out the following gender-related activities for Sub-purposes 2 and 3 in Year 3:

Sub Purpose 2: Improve uptake and access of gender-sensitive MNCH, RH/FP, Nutrition and WASH services

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HCW capacity built on SGBV management. The project will provide OJT and CMEs to on SGBV screening and management for HCWs conducting routine MNCH services. The support will build their capacity on Sexual Violence Case Management, including the legal aspects and making appropriate referrals. The project team will adapt messages from the National Guidelines in Sexual Violence Management, including the legal aspects as well as the National Guidelines of Provision of Adolescent Youth-Friendly Services for these trainings as a means of improving HCWs’ attitudes on the provision of youth-friendly MNCH, child health, and FP services. The trainings will also aim to encourage HCWs to also be proactive in GBV screening, as well as SGBV case management and referrals for medico-legal services.

DREAMS girls’ capacity built to improve sexual safety and negotiation skills. The key objectives of My Health, My Choice EBI is to raise awareness of the AGYW on reduction of sexual risks, as well as build their negotiation skills for safer sex. Through My Health, My Choice (MHMC) and Social Assets Building (DREAMS), the project will conduct sessions in the designated safe spaces to meet the two objectives. Condom efficacy education will also be carried to reduce the AGYW’s sexual risk. Afya Jijini rolled out the MHMC EBI in Mukuru kwa Njenga in Years 1 and 2 by training EBI facilitators and conducting EBI waves targeting adolescents ages 13-17 years old. In Year 3, Afya Jijini will also engage a grantee(s) to help with these activities.

DREAMS guidance and counseling teachers and We Men Care CHVs attend refresher trainings. Guidance and Counseling teachers as well as the We Men Care Male Champions will attend refresher trainings on GBV screening as well as the referral pathways. These trainings will equip the two cadres to be key in GBV screening of AGYW and men at the school and health facilities, respectively, as well as making referrals for the comprehensive GBV package of care.

Support the county to ensure schools have menstrual-hygiene friendly sanitation facilities. Girls, AGYW, and women disproportionately miss out on economic and school opportunities due to poor sanitation and toilet facilities, particular in schools. Starting from primary school, girls may miss, on average, three days of school per month due to the lack of sanitary napkins and appropriate toilet facilities that allow them to manage their menstrual hygiene with dignity and respect.

To improve on the girls’ dignity and provision of the menstrual hygiene-friendly sanitation facilities, Afya Jijini will advocate for provision of adequate sanitation facilities both at the school and community through the relevant forums. The project will also work towards educating the girls on the importance of menstrual hygiene and correct use of sanitation facilities through DREAMS in the safe spaces. Afya Jijini will also participate in the School Health and Urban Sanitation TWGs to advocate for the provision of menstrual hygiene-friendly sanitation facilities.

Sub-Purpose 3: Strengthen county health systems to support gender-sensitive health initiatives

Monthly and quarterly national TWGs attended. Afya Jijini, represented by the Youth and Gender Advisor, will actively participate in national TWGs including the National Gender and Equality Commission (NGEC) on a monthly basis and Reproductive and Maternal Health Services Unit (RMHSU) on a quarterly basis. During these meetings, Afya Jijini will participate in the review of relevant policies as well as dissemination of the relevant policy documents. The project will also participate in the Sexual Reproductive Health TWG at the national level. Afya Jijini will participate in these fora once the ban to participate in national-level activities has been lifted by USAID.

Quarterly County GBV TWG meetings attended. Nairobi City County boasts of an active GBV Technical Working Group whose formation was supported by Afya Jijini during their first year of implementation. In Y3, Afya Jijini will continue strengthening of the TWG through continuous education on SGBV prevention and response, as well as dissemination of relevant police documents and guidelines on a quarterly basis.

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Quarterly Sub-County GBV TWG meetings attended. Afya Jijini will continue working closely with the Sub- County’s GBV Focal Persons to ensure improved GBV services provision coordination in three sub- counties: Embakasi East, Kamukunji and Westlands Sub-Counties.

Joint and integrated supportive supervision visits conducted addressing gender. Supportive supervision will also be conducted in selected sites on a quarterly basis to address client flow and GBV integration, referral pathways, and SGBV reporting. County and Sub-County officials, as well as Afya Jijini staff will conduct supportive supervision in selected sites. Reports will be prepared and shared and action points followed upon by the County Gender and Psychosocial Coordinator, working closely with the project Youth and Gender Advisor.

SGBV IEC materials developed, printed, and distributed. Strategic Behavior Change Communication is key in addressing GBV. To this end, the project will support the development, reproduction, dissemination of SGBV materials to promote positive behavior change in NCC. This will include: SGBV Guidelines/SOPs, referral directories and GBV Reporting Tools and distribution to selected sites.

Transport network for GBV samples enhanced. Complete referral pathways in sexual violence has been a major challenge in NCC. To ensure effective transport network for the GBV samples, Afya Jijini will provide trainings to non-clinical staff and work closely with the County leadership and the law enforcement officials to ensure timely GBV evidence collection, adequate evidence storage, and seamless transportation of the samples to the Government Chemist for analysis.

Men, women, boys, and girls supported to participate in relevant national and international commemorations. Equal participation of men and boys, women and girls is key. Previously, boys and women have been easier to mobilize because men are usually engaged in (mainly) casual labor and are therefore not readily available to participate in such events, while girls rarely get the opportunity to participate from their guardians. Afya Jijini will mobilize men by sharing the importance of their participation in these events, and mobilize the girls by working with their guardians. In this way, the program will support men and boys, women and girls to attend relevant national and international commemorations: Malezi Bora, World Menstruation Day, The Day of the African Child, World Breastfeeding Week, 16 Days of Activism Against GBV, International Youth Week, International Day for Elimination of Violence against Women, and UN International Day of Persons with Disabilities.

Non-clinical staff trained on clinical management of SGBV. In the implementation year, Afya Jijini will train 75 non-clinical staff in Clinical Management of SGBV including legal aspects of SGBV in 3 sub-counties- Kamukunji; Embakasi East and Westlands. The non-clinical staff to be trained will include but not be limited to: customer care staff, security staff, liaison staff, hospitality staff, CHVs, Community Super Mobilizers, the Duty Bearers, and GBV Defenders. The training will take 3 days using the provided curriculum, and will be rolled out in collaboration with the County and Sub County GBV Focal Persons.

Adolescents Living with HIV (ALHIV) represented in county relevant forums. Nairobi City County led by the Deputy County Director convenes quarterly ALHIV forums that bring together various stakeholders and ALHIV to share best practices, challenges and joint work planning for improved adolescent HIV services coordination. Afya Jijini will actively participate in these quarterly forums represented by the Youth and Gender Advisor.

One project GBV dashboard maintained to inform decision-making. The dashboard, which is currently under development, will inform the project on the GBV status for purposes of utilization of data for decision making. Key indicators captured will be: SGBV cases presenting within 72 hours, SGBV rape survivors seen, SGBV rape cases initiated PEP, SGBV rape cases completed PEP, SGBV Rape survivors pregnant four weeks after exposure, SGBV Rape survivors sero-converting three months after exposure, number

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of SGBV cases reported to the police, number of SGBV survivors with disabilities, and number of SGBV cases with completed PRC forms.

GBV best practices and case studies documented and disseminated. Periodically, Afya Jijini will share best practices and case studies in the quarterly TWG meetings and the GBV Case Study Forums organized in Embakasi East Sub-County.

County and sub-county teams trained on SGBV reporting. In collaboration with the County and other GBV implementing partners, Afya Jijini will participate in the organizing and the training of the County and Sub- County officials in SGBV reporting in the DHIS2. The training participants will include: County and Sub-County Gender and Psychosocial Support Focal Persons and Health Records and Information Officers, as well as the Medical Social Workers. During these trainings, SGBV reporting tools will also be disseminated and distributed for the health facilities utilization. From these, County GBV data will be reviewed and action plans drawn and implemented.

Increase awareness on SMS Platform 21094. Afya Jijini will endeavor to create awareness at the facilities and community level on the existing SMS GBV reporting platforms, including 21094 and 1195. This will be completed by disseminating IEC materials to target beneficiaries, including the DREAMS AGYW.

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ANNEXES AND ATTACHMENTS

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Annex III: High-volume Maternity and FP Facilities

Afya Jijini Y3 Eight High-Volume Focal Maternities No. Sub-County Facility 1. Langata St Mary's Mission Hospital 2. Langata Mbagathi District Hospital 3. Embakasi West Mama Lucy Kibaki Hospital 4. Kamukunji Pumwani Maternity Hospital 5. Dagoretti Mutuini Sub-County Hospital 6. Kasarani St. Francis Hospital 7. Makadara Jamaa Hospital 8. Makadara Metropolitan Hospital

Afya Jijini Y3 30 High-Volume ANC and Maternities No. Sub-County Facility 1. Dagoretti Maria Immaculate Health Center 2. Dagoretti Coptic Hospital (Ngong Road) 3. Dagoretti Waithaka Health Center 4. Dagoretti Riruta Health Center 5. Embakasi East Mukuru MMM Clinic 6. Embakasi East Mukuru Health Center 7. Embakasi East Mama Lucy Kibaki Hospital 8. Embakasi East DIWOPA Health Center 9. Embakasi West Kayole I Health Center 10. Embakasi West Kayole II Sub-District Hospital 11. Embakasi West Umoja Health Center 12. Kamukunji Eastleigh Health Center 13. Kasarani St Francis Community Hospital 14. Kasarani II Health Center 15. Kasarani Dandora I Health Center 16. Kasarani Brother Andre Clinic 17. Langata St Mary's Mission Hospital 18. Langata Langata Health Center 19. Langata Mbagathi Hospital

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20. Langata Ngong Road Health Center 21. Makadara Bahati Health Center 22. Makadara Lunga Lunga Health Center 23. Ruaraka Kahawa West Health Center 24. Ruaraka Marura Nursing Home 25. Ruaraka Mathare North Health Center 26. Ruaraka St. John Hospital 27. Ruaraka Babadogo Health Center 28. Starehe Ngara Health Center (City Council of Nairobi) 29. Westlands Kangemi Health Center 30. Westlands Westlands Health Center

Afya Jijini Y3 30 High-Volume FP Facilities No. Sub-County Facility 1. Dagoretti Riruta health center 2. Dagoretti Waithaka health center 3. Embakasi East Sub County Mukuru health center 4. Embakasi East Sub County Embakasi health center 5. Embakasi East Soweto Kayole PHC 6. Embakasi West Kayole I Health Center 7. Embakasi West Mama Lucy Kibaki Hospital 8. Embakasi West Kayole Hospital 9. Embakasi West Kayole II Sub-County Hospital 10. Embakasi West Umoja Health Center 11. Kamukunji Pumwani Maternity Hospital 12. Kamukunji Eastleigh Health Center 13. Kasarani Kasarani Health Center 14. Kasarani Dandora I Health Center 15. Kasarani Dandora II Health Center 16. Kasarani Health Center 17. Langata Family Care Medical Center and Maternity 18. Langata Ngong Road Health Center 19. Langata Langata Health Center 20. Makadara Lunga Lunga Health Center 21. Makadara Bahati Health Center 22. Ruaraka Kahawa West Health Center 23. Ruaraka Dispensary 24. Ruaraka Mathare North Health Center 25. Ruaraka Babadogo Health Center 26. Ruaraka Korogocho Health Center 27. Starehe Family Health Options Phoenix 28. Starehe Ngara Health Center 29. Westlands Kangemi Health Center USAID/KENYA AFYA JIJINI YEAR 2 WORK PLAN 57

30. Westlands Westlands Health Center

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Annex IV: Afya Jijini AYSRH Model

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Annex V: Afya Jijini Facility Champion Model

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ANNEX VII: List of Tracer Medicines and Laboratory Commodities

LIST OF TRACER MEDICINES N0. ITEM

Cap Amoxicillin 250mg 1. Syr Amoxicillin 125mg/5ml or Amoxicillin Dispersible tablet 2. Tab Cotrimoxazole 480mg or 960 mg 3. Cotrimoxazole Suspension 240 mg/5ml 4. Tab Albendazole 400mg or Mebendazole 200 mg 5. Susp Metronidazole 200mg / 5ml 6. Inj Gentamycin 7. Inj Benzylpenicillin 8. Inj Adrenaline 1mg/ml 9. Inj Hydrocortisone 100mg 10. ORS 500ML/satchet 11. Zinc Sulphate tablets 12. 1% Tetracycline eye ointment 13. Inj. Oxytocin 14. Inj. Insulin (MIXTARD) 15. Tab. Enalapril 16. Inj. Suxamethonium 17. Iron and Folic Acid 18. Magnesium Sulphate Inj 19. Zinc Sulphate tablets 20. TB Patient Packs 21. R/H/Z 75/50/150 mg Tablets 22. R/H 75/50 tablets 23. Pyridoxine 50mg 24. Isoniazid 300mg tablets 25. Isoniazid 100mg tablets 26. TDF/3TC/EFV FDC 27.

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N0. ITEM

AZT/3TC FDC 28. TDF/FTC FDC 29. Abacavir /Lamivudine (ABC/3TC) FDC 30. Zidovudine Liquid 31. Nevirapine Suspension 10mg/5ml 32. Combined Oral Contraceptive 33. Progestin Only Pills 34. Medroxyprogesterone Inj 35. Condoms (Male) 36. Ready-to-Use Therapeutic Foods (RUTF) RUTF 37. Ready-to Use Supplementary Food - RUSF 38.

LIST OF TRACER LABORATORY COMMODITIES

Laboratory Commodities 1. HIV Rapid test Kits -Screening 2. HIV Rapid test Kits -confirmatory 3. GeneXpert Cartridges 4. CD4 Reagents 5. TB Microscopy Reagents

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