Kenya Country Report FY17

Transcription

1 USAID ASSIST Prject Kenya Cuntry Reprt FY17 Cperative Agreement Number: AID-OAA-A Perfrmance Perid: Octber 1, 2016 September 29, 2017 SEPTEMBER 2017 This annual cuntry reprt was prepared by University Research C., LLC fr review by the United States Agency fr Internatinal Develpment (USAID). The USAID Applying Science t Strengthen and Imprve Systems (ASSIST) Prject is made pssible by the generus supprt f the American peple thrugh USAID.

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3 USAID ASSIST Prject Applying Science t Strengthen and Imprve Systems Kenya Cuntry Reprt FY17 Cperative Agreement Number AID-OAA-A Perfrmance Perid: Octber 1, September 29, 2017 SEPTEMBER 2017 DISCLAIMER This cuntry reprt was authred by University Research C., LLC (URC). The views expressed d nt necessarily reflect the views f the United States Agency fr Internatinal Develpment r the United States Gvernment.

4 Acknwledgements This cuntry annual reprt was prepared by University Research C., LLC (URC) fr review by the United States Agency fr Internatinal Develpment (USAID) under the USAID Applying Science t Strengthen and Imprve Systems (ASSIST) Prject, which is funded by the American peple thrugh USAID s Bureau fr Glbal Health, Office f Health Systems. The prject is managed by URC under the terms f Cperative Agreement Number AID-OAA-A URC's glbal partners fr USAID ASSIST include: EnCmpass LLC; FHI 360; Harvard T. H. Chan Schl f Public Health; HEALTHQUAL Internatinal; Initiatives Inc.; Institute fr Healthcare Imprvement; Jhns Hpkins Center fr Cmmunicatin Prgrams; and WI-HER, LLC. Fr mre infrmatin n the wrk f the USAID ASSIST Prject, please visit r write assist-inf@urc-chs.cm. Recmmended citatin USAID Applying Science t Strengthen and Imprve Systems (ASSIST) Prject Kenya Cuntry Reprt FY17. Published by the USAID ASSIST Prject. Chevy Chase, MD: University Research C., LLC (URC).

5 Table f Cntents List f Figures and Tables... i Abbreviatins...ii 1 INTRODUCTION PROGRAM OVERVIEW KEY ACTIVITIES AND ACCOMPLISHMENTS... 4 Activity 1. Cuntry wnership and institutinalizatin f QI at the natinal and cunty levels... 4 Activity 2. Pre-service curriculum develpment... 6 Activity 3. HIV care and treatment and emtct... 6 Activity 4. MNCH, reprductive health, and family planning Activity 5. Malaria case management Activity 6. OVC and child prtectin Activity 7. Assessment f quality f care in selected End Preventable Child and Maternal Deaths (EPCMD) pririty cuntries Activity 8. Imprve the quality f pint-f-care HIV testing and cunseling in Kenya (funded by the Office f HIV/AIDS) IMPROVEMENT IN KEY INDICATORS SUSTAINABILITY AND INSTITUTIONALIZATION KNOWLEDGE MANAGEMENT PRODUCTS AND ACTIVITIES GENDER INTEGRATION List f Figures and Tables Figure 1. Rad map t gvern quality using plicies and t institutinalize activities t imprve health care quality... 4 Figure 2. Percentage f mther-baby pairs wh received NACS services in a given mnth, 5 cunties, 45 (Oct 2015 May 2017)... 8 Figure 3. Prprtin f HIV-psitive pregnant wmen attending ANC n ARVs (prphylactic r HAART) in 10 (Jan 2016 May 2017)... 9 Figure 4. Percentage f HIV expsed mther-baby pairs (0-24 mnths) in active care, 45, 1 pilt and 3 scale up cunties (Jan 2013 Jun 2017) Figure 5. Prprtin f wmen giving birth in health facility with cmplete partgraph, 20 sites, Kitui, Turkana, and Migri cunties (Jan 2015-May 2017) Figure 6. Prprtin f wmen cunselled wh vluntary pted fr LARC, 6 sites, Kakamega Cunty (Feb 2016-May 2017) Figure 7. Prprtin f newbrns with initial temperature recrded 1-2 hurs after delivery, 20 sites, Kitui, Migri, and Turkana cunties (May 2016-Apr 2017) Figure 8. Prprtin f pregnant wmen screened, tested, and treated fr malaria during first ANC visit, Rng Sub-Cunty Hspital (Dec 2016-Feb 2017) Figure 9. Percentage f supprted fr malaria imprvement reprting stck-uts f either/bth Rapid Test Kits and Artemether/lumefantrine, Kakamega, Busia, and Siaya cunties (Oct 2015-May 2017) Figure 10. Percentage f HIV-psitive adlescents referred and put n care and treatment, Migri Cunty (Oct 2016-May 2017) USAID ASSIST Kenya Cuntry Reprt FY17 i

6 Figure 11. OVC caregivers with natinal hspital insurance, sex-disaggregated, Migri Cunty (Aug 2016-May 2017) Figure 12. Prprtin f caregivers taking ver respnsibility fr schl fees, 2 QI teams, Migri cunty (Sept 2013-May 2017) Figure 13. HIV testing services (HTS) prviders in 10 sites, Busia Cunty (Jan 2017) (n=136) Figure 14. HIV testing services testing pints, Busia Cunty (Jan 2017) (n=39) Figure 15. List f HTS Imprvement indicatrs selected fr data base set up (Feb 2017) Figure 16. Percentage lt t lt validatin f HIV RTKs, determine and respnse, 20 sites in Busia Cunty (Feb 2017-Jun 2017) Figure 17. Percentage f patients receiving HIV pre-test cunseling, 20 sites, Busia Cunty (Mar 2017-Jun 2017) Table 1. Prgress tward institutinalizing health care imprvement activities, 6 cunties (May Jun 2017)... 5 Table 2. Overview f ASSIST s cunty and facility supprt, Abbreviatins 3T AIDS AL AMURT ANC APHIA ART ASSIST CCC CHMT CMCC CME COE CSI DCS DHIS DHSQAR EmNC emtct FP FY HAART HEI HIV IP IPTp ISO KeMU KHQIF KMTC Test, Treat, Track Acquired immundeficiency syndrme Artemether-Lumefantrine Ananda Marga Universal Relief Team Antenatal care AIDS, Ppulatin and Health Integrated Assistance Antiretrviral therapy USAID Applying Science t Strengthen and Imprve Systems Prject Cmprehensive Care Center (fr HIV) Cunty Health Management Team Cunty malaria crdinatr Cntinuing medical educatin Centre f Excellence Child status index Department f Children s Services Kenya s Health Infrmatin System Department f Health Standards, Quality Assurance and Regulatin Emergency bstetric and newbrn care Eliminating mther-t-child transmissin f HIV Family planning Fiscal year Highly active antiretrviral therapy HIV-expsed infant Human immundeficiency virus Implementing partner Intermittent preventive treatment f malaria in pregnancy Internatinal Organizatin fr Standardizatin Kenya Methdist University Kenya HIV QI Framewrk Kenya Medical Training Centre ii USAID ASSIST Kenya Reprt FY17

7 KQMH LARC MCH MEACL&SP MIP MLSS&S MNCH MOH NACS NASCOP NHIF NPA NVP OPD OVC PHFS PITC PLHIV PMI PMTCT POC PSS PT Q QI QIT QM-TWG RDT RH RMNCAH RMNCH RTK SCH SOP TA TWG USAID USG VSLA WIT Kenya Quality Mdel fr Health Lng-acting reversible cntraceptives Maternal and child health Ministry f East African Cmmunity, Labr, and Scial Prtectin Malaria in pregnancy Ministry f Labr, Scial Security and Services Maternal, newbrn, and child health Ministry f Health Nutritin assessment, cunseling, and supprt thrugh Natinal AIDS & STI Cntrl Prgram Natinal Hspital Insurance Fund Natinal Plan f Actin Nevirapine Outpatient Department Orphans and vulnerable children Partnership fr HIV-Free Survival Prvider-initiated testing and cunseling Peple living with HIV President s Malaria Initiative Preventin f mther-t-child transmissin f HIV Pint f care Psychscial supprt Prficiency Testing Quarter Quality imprvement Quality imprvement team Quality Management Technical Wrking Grup Rapid diagnstic test Reprductive health Reprductive, maternal, newbrn, child, and adlescent health Reprductive, maternal, newbrn, and child health Rapid test kits Sub-cunty hspital Standard perating prcedure Technical assistance Technical wrking grup United States Agency fr Internatinal Develpment United States Gvernment Vluntary Savings and Lan Assciatin Wrk imprvement team USAID ASSIST Kenya Cuntry Reprt FY17 iii

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9 1 Intrductin Since Octber 2012, the USAID Applying Science t Strengthen and Imprve Systems (ASSIST) Prject in Kenya has fcused n supprting the Ministry f Health (MOH) and the Ministry f East African Cmmunity, Labr, and Scial Prtectin (MEACL&SP) t build leadership fr quality imprvement (QI) at bth the natinal and cunty levels. Majr achievements in this area have been the develpment and peratinalizatin f varius QI natinal level guidelines, standards, and framewrks as well as supprting their peratinalizatin. The prject cncentrated n pling natinal and cunty level resurces t enhance crdinatin, thrugh a cmprehensive plan that was explicit abut what needed t be imprved, hw imprvements wuld ccur, and what targets wuld be achieved. Fiscal year (FY) 17 being the final prject year, ASSIST fcused n establishing supprt platfrms fr spread f QI activities at bth natinal and sub-natinal levels. During FY17, mst f the health service delivery activities in the cunties that ASSIST prvided supprt t were affected by the health wrkers industrial strike. This was wrsened by a natinal strike (called fr by different unins) that crippled health services beginning in late Nvember Sme f the activities affected by this impasse were QI learning sessins, trainings, and n-site mentrships. As f September 2017, nly sme health care wrkers have resumed duties, and prtracted negtiatins are still nging between the nurses unin and varius gvernment rganizatins. This situatin is likely t upset the gains made in pushing the QI mmentum at the service delivery level, since the mrale f the health care wrkers has been severely hit by numerus issues plaguing the management f health care in the cuntry. ASSIST s wrk in Kenya in FY17 encmpassed eight activities, five f which were entirely Missinfunded, ne which was c-funded by the Office f Health Systems and Office f HIV/AIDS as Crss- Bureau Supprt, anther funded by the Office f Health Systems, and ne which was funded by the Office f HIV/AIDS. ASSIST s wrk in FY17 was als respnsive t directins frm USAID Kenya cncerning the supprt prvided t cunties. There was insistence that fcus be put n establishing functinal QI structures at natinal and sub-natinal levels. Hwever, direct supprt fr facility-level implementatin is key in prviding learning and lessns n mdalities fr applicatin f QI methdlgies. In this case, ASSIST cntinued t supprt selected but the fcus was n getting ther USAID service delivery mechanisms t align their implementatin wrk t the natinal QI framewrks as ASSIST supprt ends in September ASSIST planned in its final year wrk plan t transitin all activities at the end f the third quarter with the last quarter left fr prject clse-ut. The transitin plans included: Putting tgether learning materials fr knwledge sharing and learning; Cnducting meetings with stakehlders n the prject s transitin plans and hw bth gvernment and nn-gvernment rganizatins can cntinue prviding supprt fr quality imprvement; Prviding a cst analysis t the cunties; and Structural supprt t ensure gvernance and plicy directin. USAID ASSIST Kenya Cuntry Reprt FY17 1

10 Scale f USAID ASSIST s Wrk in Kenya MH, MLSS&S, NASCOP, 9 IPs, 4 tertiary training institutins 14 (direct) ut f 47 cunties 145 (direct) 199 cmmunities 315 QI teams 600,000 ut f 2.4M OVC 150,084 ut f 1.6M PLHIV 1.7M ut f 5.1M malaria cases 2 Prgram Overview What are we trying t accmplish? At what scale? 1. Cuntry wnership and institutinalizatin f QI at the natinal and cunty levels Develp institutinal structures fr quality at natinal and cunty level thrugh harmnizatin and institutinalizatin f key quality f care appraches and incrprate them int ne M&E framewrk in Kenya Prmte a quality management system supprted by all technical departments Natinal and cunty level Natinal Supprt select cunties t ensure imprvement is sustained and institutinalized at natinal level and in the 7 cunties 7 cunties: Migri, Kakamega, Kisumu, Kwale, Taita Taveta, Turkana, and Busia 2. Pre-service curriculum develpment (c-funded by the Office f Health Systems and Office f HIV/AIDS as a Crss-Bureau activity) Integrate QI cncepts int cre pre-service training curricula in 3 select tertiary training institutins and develp medical training institutins faculty and health prfessinal imprvement cmpetencies t cntribute t better perfrmance and health utcmes Natinal: 3 tertiary training institutins: Kenya Methdist University (KeMU), Mi University, and Kenya Medical Training Centre (KMTC) 3. HIV care and treatment and eliminatin f mther-t-child transmissin f HIV (emtct) Supprt MOH thrugh Natinal AIDS & STI Cntrl Prgram (NASCOP) and cunty gvernments t apply QI techniques t strengthen and imprve the PMTCT cntinuum f care; t identify, enrll, and retain mre HIV infected pregnant and breastfeeding wmen and their HIV-expsed infants Natinal 5 cunties: Busia, Kakamega, Uasin Gishu, Kwale, and Turkana 2 USAID ASSIST Kenya Reprt FY17

11 What are we trying t accmplish? 4. Maternal, newbrn, and child health/reprductive health Enhance cunty and sub-cunty capacity t apply QI techniques t imprve the quality f MNCH and FP services in Kenya At what scale? Natinal 5 cunties: Kilifi, Migri, Kakamega, Kitui, and Turkana Indirect supprt fr all the 10 USAID MNCH/FP fcus cunties 5. Malaria case management: Reduce malaria mrtality and mrbidity thrugh case detectin and management Prvide technical supprt fr natinal malaria M&E and case management technical wrking grup, and the respective subcmmittees: diagnstics, cmmdities, and training sub-cmmittee Supprt select malaria endemic cunties in malaria case management with a fcus t the general ppulatin and malaria in pregnancy Natinal 5 cunties: Kakamega, Siaya, Busia, Migri, and Hma Bay 6. OVC and child prtectin (cunty level): Strengthen systems within the natinal and cunty gvernments t supprt the institutinalizatin f QI in child prtectin and OVC t imprve the welfare f children Enhance the capacity f the MEACL&SP, the Natinal Cuncil fr Children s Services, and Department f Children Services t identify and address pririty imprvement issues in child prtectin and OVC Enhance capacity f the implementing partners and imprvement teams t prmte the welfare f vulnerable children and husehlds thrugh the mainstreaming f imprvement science methdlgies at the pint f service delivery Natinal 7 cunties: Nark, Mmbasa, Uasin Gishu, Kilifi, Migri, Embu, and Nakuru 7. Assessment f quality f care in selected End Preventable Child and Maternal Deaths (EPCMD) pririty cuntries Develp a survey tlkit and assess the quality f essential reprductive, maternal, newbrn, and child health (RMNCH) care in selected EPCMD cuntries. Kenya, Uganda, Zambia 8. Imprve the quality f pint-f-care HIV testing and cunseling in Kenya (funded by the Office f HIV/AIDS) Imprve the prcess f care s that patients are mre likely t receive crrect test results frm pint f care (POC) rapid HIV tests Cnduct a pre- and pst-test evaluatin Imprvement Activity 9 public health care and ne teaching & referral hspital in Busia Cunty, Kenya Crss-cutting Activity USAID ASSIST Kenya Cuntry Reprt FY17 3

12 3 Key Activities and Accmplishments Activity 1. Cuntry wnership and institutinalizatin f QI at the natinal and cunty levels BACKGROUND This activity has been a key part f ASSIST supprt fr the Ministry f Health since 2015, with cnsiderable supprt t the MOH t develp a guideline review handbk in 2016 and review the Kenya Quality Mdel fr Health (KQMH) standards and indicatrs. Since USAID s assistance t the natinal MOH was suspended earlier this year, ASSIST has fcused all QI institutinalizatin assistance n the cunty level. In quarter (Q)3, ASSIST s effrts fcused n cntinued t supprt six cunties (Kisumu, Busia, Kwale, Taita Taveta, Kakamega, and Migri) t define institutinal rles and relatins t gvern quality and share lessns n gverning quality using plicies and strategies and defining rles. Our assistance included supprting cunty level Quality Management (QM) Technical Wrking Grup meetings and cnducting a handver f all knwledge and guidance prducts develped by ASSIST t cunty-level authrities fr nging applicatin. KEY ACCOMPLISHMENTS AND RESULTS Develp institutinal structures fr quality at natinal level Supprted the MOH in drafting sustainability plan fr ISO certificatin after being ISOcertified in 2016 (Oct and Nv 2016). Held a meeting with MOH t agree n rad map fr finalizing the Kenya Health Quality Imprvement Plicy (Dec 2016) (Figure 1). Figure 1. Rad map t gvern quality using plicies and t institutinalize activities t imprve health care quality Cnduct SitAn (Mar 2014) Thughtful cnversatin n institutinal rles and structures t gvern quality in healthcare. (Feb 2013) Validate findings f SitAn (Jun 2014) Plicy visining and strategic actin planning (Sep 2014) Draft Health Imprvement Plicy in place, waiting t be signed Design plicy paper t institutinalise QI at cunty level (Apr 2016) Identify gaps and define rles and relatinships t gvern quality in six cunties (Apr Jun 2017) Cnvened a 5-day meeting with MOH and stakehlders t cnslidate final feedback n the Kenya Health Quality Imprvement Plicy (Mar 2017). Supprted a half-day natinal quality management technical wrking grup (QM-TWG) meeting (Mar 2017). Supprted the MOH t finalize the KQMH standards and indicatrs (Feb-April 2017). 4 USAID ASSIST Kenya Reprt FY17

13 Technical Wrking Grup Meetings Supprted ne-day Technical Wrking Grup meetings fr Busia and Kisumu cunties (Nv 2016, April 28, March 28, 2017). Organized 1-day QM-TWG meeting fr Kisumu (Mar 2017). Held ne-day intrductry meeting with the Kakamega Cunty Health Management Team (Nv 2016) n gverning quality using plicies and strategies and defining institutinal rles and relatins fr quality. Held three-day meeting with Busia, Kwale, Taita Taveta, and Kisumu cunties n lessns learned n gverning quality using plicies and strategies and institutinalizing activities t imprve health care quality (May 2017). Held meeting with Kakamega, Migri Cunty n institutinalizing activities t imprve health care quality and develped a wrk plan (Jun 2017). ASSIST supprted meetings t discuss transitin f QI supprt t cunty and USAID mechanisms where ASSIST shared gains as well as knwledge management prducts and the reprductive, maternal, newbrn, child, and adlescent health (RMNCAH) assessments (Aug 2017). Develped scre card depicting prgress twards defining rles and relatinships t gvern quality (May Jun 2017). Table 1 is a summary f prgress made twards institutinalizing activities t imprve health care quality in the six cunties based n a scale f 1 (lwest) t 4 (highest). All six cunties had designated a QI pint persn and were implementing activities t prtect the rights f patients including rights charters, exit interviews, and surveys. All cunties had facility-based imprvement teams. Kisumu and Busia have included QI activities in their annual wrk plans. Table 1. Prgress tward institutinalizing health care imprvement activities, 6 cunties (May Jun 2017) Package f interventins implemented Busia Kisumu Kwale Taita Kakamega Migri QI Unit with a persn, rgangram, budget, TWG and wrk plan Nn-state actrs invlved in pursuit f patient centeredness care. Mechanism fr licensure, certificatin and accreditatin Cunty-level plicies, strategies, legislative framewrks t anchr quality activities. Mechanism t cllate and disseminate guidelines Identified respnsibility fr funding QI initiatives Cunty Assembly-Health Executive engagement Training and frmatin f facility QITs and WITs 2/4 2.5/4 1.5/4 1.5/4 1/4 ¼ USAID ASSIST Kenya Cuntry Reprt FY17 5

14 Activity 2. Pre-service curriculum develpment BACKGROUND During Q1 f FY17, USAID ASSIST supprted three medical training institutins t upgrade their training curriculum t include QI units as part f their training. An assessment f bth faculty and students was dne t measure the knwledge, gaps and attitudes f respndents twards QI. The three medical training institutins assessed included Kenya Methdist University (KeMU), Mi University, and Kenya Medical Training Cllege (KMTC). The findings f the assessment were then used by these institutins t adpt quality imprvement principles in the KQMH int the students curricula. Funz Kenya, a USAID-funded training mechanism, was als invlved. KEY ACCOMPLISHMENTS AND RESULTS Held meetings with stakehlders (3 training institutins, USAID FunzKenya Prject, and the MOH) n embedding QI curriculum int pre-service health curses at institutins f higher learning (Oct-Nv 2016). ASSIST supprted the MOH t cnduct a pre-service QI assessment with three medical institutins in Kenya. Thrugh initial cnversatins with the institutins, it became clear that QI was nt taught as a tpic and therefre a systematic review f all curricula fr QI was necessary. In ttal, 316 faculty respndents were assessed. The majrity f respndents stated that there is need fr the integratin f QI cntent int curricula. Faculty respndents at KeMU were unanimus abut the need fr integratin as well as a majrity at KMTC (90%) and at Mi University (92.5%). Student respndents in all the training institutins reflected the same need fr integratin (KeMU 93.7%, KMTC 98%, 100% Mi University) (Mar 2017). A reprt n a Staff and Student Survey n Perceptins f the Integratin f Quality Imprvement int Pre-service Training at Three Medical Training Institutins in Kenya was finalized in March Cmpleted all deliverables fr USAID, including the survey reprt, a faculty self-study guide, the quality imprvement mdule utline, and a lessns learned reprt. The prducts were apprved by the Office f HIV/AIDS in July and by the Office f Health Systems in September. Activity 3. HIV care and treatment and emtct BACKGROUND During FY17, ASSIST supprted emtct imprvement wrk in sites in fur cunties: 16 sites in Kwale Cunty (the riginal demnstratin sites) and then scaled up in tw stages: first t 11 sites in Kakamega Cunty, and then later t 10 sites in Busia and 11 sites in Uasin Gishu cunties. Integratin f emtct int MNCH services ensured HIV-expsed mther-baby pairs were seen in the emtct clinic. Client flw was mdified as a result f integratin, and this led t reduced waiting time. Task shifting was intrduced t use mentr mthers and cmmunity health vlunteers t assist in dcumentatin in emtct clinics. Data cleaning exercises were carried ut which imprved the quality f data reprted. Staff rtatin was embraced in mst, ensuring the emtct clinic was well cvered. HIV-expsed infant (HEI) graduatin days have mtivated mthers t bring their children t the emtct clinic and enhanced dcumentatin f retentin data. Uasin Gishu s gd perfrmance can be attributed t the presence f an implementing partner wh has been in the regin fr a lng time. KEY ACCOMPLISHMENTS AND RESULTS Supprted MOH and Kwale Cunty t cnduct HIV-expsed infant chrt analysis and data validatin in Kwale Cunty (Oct 2016). Prvided supprt fr cunty-level HIV TWG meetings in Kwale, Uasin Gishu, and Kakamega cunties (Oct 2016, Nv 2016 and Feb 2017). Cnducted QI rientatin f MOH peer caches fr scale-up f PHFS t 12 new in Kwale Cunty (Nv 2016). ASSIST prvided supprt fr quarterly caches meetings in Kwale 6 USAID ASSIST Kenya Reprt FY17

15 (Nv 2016), Uasin Gishu (Oct 2016, Jan 2017 and Mar 2017), Kakamega (Oct 2016 and Feb 2017), Turkana (Nv 2016), and Busia cunties (Dec 2016). Prvided supprt fr facility-level QI caching visits t all 54 in Kwale, Uasin Gishu, Kakamega, and Busia cunties (Oct Feb 2017). Prvided supprt fr QI cntinuus medical educatin (CME) in Kwale, Turkana, Busia, Kakamega, and Uasin Gishu cunties (Oct 2016 t Feb 2017). Cnducted wrk imprvement teams (WITs) functinality assessment Uasin Gishu, Busia, Kakamega, and Kwale cunties (Nv 2016 and Feb 2017). Cnducted data validatin in Turkana (Jan 2017), Kakamega (March 2017), Uasin Gishu and Busia cunties (May 2017). In Kakamega, fur indicatrs were validated in fur. The variance between reprted and validated data was belw 5% fr all the indicatrs. In Turkana Cunty, fur indicatrs were validated frm five, with the health wrkers strike affecting indicatrs. The variance between reprted and validated data was abut 40%. The were mentred n data quality. Cnducted learning sessins fr Busia and Kakamega cunties (Feb 2017). Results: Nutritin assessment, cunseling, and supprt (NACS) is an imprtant aspect in ensuring better patient utcmes in HIV treatment. Hwever, this cmpnent is nt ften given the utmst fcus. Where this is prvided, the assessment is either given t the baby r mther and is mainly based n clinical presentatin. The Gvernment f Kenya has issued guidelines n the need t have nutritinal assessment and categrizatin as a standard measure at all clinic encunters. As shwn in Figure 2, this service is still reaching bth babies and mthers during clinic visits. Teams have been testing changes t ensure they reach the desired 100% perfrmance. This includes task shifting the assessment duty t vlunteers; changing the triage prcess t allw fr assessment befre visits t the clinician; and prviding standard perating prcedures (SOPs) n nutritin assessment and categrizatin. This assures that mther-baby pairs underg nutritin assessment and categrizatin t spur apprpriate remedial and supprt. Facilities ptimized NACS by ensuring that the Nutritin and MCH departments integrated s that all services were available in ne area. Facilities intrduced weekly review meetings t mnitr hw well the change ideas were wrking in imprving the nutritinal services f mther-baby pairs in MCH. USAID ASSIST Kenya Cuntry Reprt FY17 7

16 Figure 2. Percentage f mther-baby pairs wh received NACS services in a given mnth, 5 cunties, 45 (Oct 2015 May 2017) As per the new ART guidelines, the pregnant wman shuld be given prphylaxis fr herself and the infant upn diagnsis f HIV. Wmen wh are knwn t be HIV+ shuld cntinue with ARVs and similarly be given prphylaxis fr the infant upn becming pregnant. While infant prphylaxis cverage has been ding well and sustained at abut 100% acrss, ASSIST supprt has led t marked imprvements in issuance f prphylactic ARVs t the mther. As shwn in Figure 3, health have enhanced cverage f maternal prphylaxis thrugh health talks targeting HIV services in ANC. Dcumentatin has imprved due t task shifting where mentr mthers and cmmunity health vlunteers have assisted in dcumentatin in the emtct clinic. Data cleaning exercises and data review meetings held acrss have enhanced the quality f emtct data reprted. Much as the ANC register is used t cllect data n prphylaxis issued, the use f ART registers specific fr emtct clients has acted as supplementary dcumentatin t capture maternal prphylaxis issued. 8 USAID ASSIST Kenya Reprt FY17

17 Figure 3. Prprtin f HIV-psitive pregnant wmen attending ANC n ARVs (prphylactic r HAART) in 10 (Jan 2016 May 2017) 100% 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% 400 Integratin f Task shifting by mentr mthers Staff reshuffles Jan-16 Mar-16 May-16 Jul-16 Sep-16 Nv-16 Jan-17 Mar-17 May-17 Denminatr: Number f HIV psitive pregnant wmen attending ANC Jan-16 Mar-16 May-16 Jul-16 Sep-16 Nv-16 Jan-17 Mar-17 May-17 ASSIST supprt fr care and imprvement has cntinued at bth facility and cunty levels. As shwn in Figure 4, and as required by Kenya s new ART guidelines, HIV-expsed mtherbaby pairs shuld be fllwed up in the emtct clinic fr tw years. Imprvement in this area has been enhanced by integratin f emtct int MNCH services leading t emtct-specific initiatives such as emtct psychscial supprt grups, task shifting where mentr mthers and cmmunity health vlunteers are invlved in defaulter tracing activities, use f defaulter tracing registers fr emtct clients, and specific emtct days. Other change ideas changes tested ver time include: linking care at delivery r first pst-natal cntact; having ne case file fr bth mther and baby until cnfirmatin f baby s HIV status (in case psitive, the case file remains same); individualized client visit timed t cincide with child welfare clinic/immunizatin schedules; and inviting ther cunties t learning frums n successful strategies in retentin f mther-baby pairs. Facilities nw have active imprvement teams. Even thugh the wrk was hampered with incessant natinal health wrker strikes frm Dec 2016 March 2017, the gains have been maintained. USAID ASSIST Kenya Cuntry Reprt FY17 9

18 Figure 4. Percentage f HIV expsed mther-baby pairs (0-24 mnths) in active care, 45, 1 pilt and 3 scale up cunties (Jan 2013 Jun 2017) % f HIV expsed mther- baby pairs (0-24 mnths) in active care in 4 cunties in % 90% 80% 70% 60% 50% 40% 30% 20% Kwale- Pilt Kakamega- Scale up Busia- Scale Up Uasin Gishu- Scale Up 10% Began CQI in Kwale 0% J/13 A/13 J/13 O/13 J/14 A/14 J/14 O/14 J/15 A/15 J/15 O/15 J/16 A/16 J/16 O/16 J/17 A/17 Number f mther-baby pairs seen Scale up 1: Kakamega Scale up 2 in Uasin Gishu & Busia Change Ideas Integratin f HIV services int MCH Enhanced health talks targeting HIV service at the ANC Psychscial supprt grups HEI graduatin days Bring-back the wmen and children campaign t mp up missed pprtunities Hme visit by clinician fr psitive mthers Intrductin f mentr mthers t 0 J/13 A/13 J/13 O/13 J/14 A/14 J/14 O/14 J/15 A/15 J/15 O/15 J/16 A/16 J/16 O/16 J/17 A/17 USAID Applying Science t Strengthen and Imprve Systems SPREAD OF IMPROVEMENT During FY14 and FY15, ASSIST, supprted by NASCOP, develped the Kenya HIV QI Framewrk (KHQIF) and training package. ASSIST embarked n a massive effrt t build capacity f cunty MOH persnnel and USAID and sme CDC implementing partners t build cmpetencies fr QI implementatin. A ttal f 32 cunties were trained. Pst-training fllw-up was verseen by NASCOP and MOH-DHSQAR supprted by the IPs. ASSIST cntinued t prvide technical assistance t seven APHIA Plus IPs. During FY15 and FY16, ASSIST fcused n direct QI implementatin supprt fr HIV care and treatment fr the general ppulatin and emtct in fur select pririty cunties (Nairbi, Kakamega, Kwale, and Isil) with APHIA Plus IPs replicating the same in ther cunties that they supprt. The prject wrked initially in a ttal f 34 in the fur cunties. Nairbi and Isil cunties were able t establish QI infrastructures with designated persns t crdinate QI in the cunties. Frm initial implementatin in ne sub-cunty in Nairbi Cunty, the cunty, with supprt frm ASSIST, was able t scale up t seven f the nine sub-cunties in Nairbi. The Partnership fr HIV-Free Survival (PHFS) initiative in Kenya was launched in Kwale Cunty in September 2013 with 16 ; the PHFS wrk has since been scaled up t an additinal 12 within the cunty. The prject dcumented PHFS best practices in the frm f a guidance package that can be used t infrm imprvement acrss the PMTCT cascade. In FY17, PHFS best practices are being replicated in the ther fur ASSIST fcus cunties: Kakamega, Busia, Turkana, and Uasin Gishu. Spread has als been aided by the facility-level caching by MOH QI caches wh have served as pllinatin agents with transfer f change ideas t beynd the ASSIST-supprted centres f excellence (COEs). Learning sessins prvided an pprtunity fr intra- and inter-cunty learning fr MOH staff. This resulted in seeding and develpment f change ideas within their wn. During this final year, as part f the prject transitin plans, cunties were supprted t develp realistic scale-up plans t supprt QI implementatin beynd the ASSIST-supprted COEs. Activity 4. MNCH, reprductive health, and family planning BACKGROUND ASSIST aimed t supprt effective, sustainable QI appraches t address challenges affecting effective patient-centered service delivery, recgnizing that newbrn and maternal health and survival 10 USAID ASSIST Kenya Reprt FY17

19 are clsely linked. ASSIST s strategy was t apply a systems apprach t QI by prviding technical assistance t cunty gvernments t imprve and strengthen RMNCH services in Kenya. In Kenya, the strategy fcused n a sample f cunties with a spectrum f selected that were develped as centers f learning. In these centers, QI was applied t generate change ideas that culd be scaled up acrss the system. Althugh with different levels f interactins ver the implementatin perid, the cunties that were directly invlved in the RMNCH wrk beynd a QI training were: Nairbi, Nakuru, Meru, Isil, Kakamega, Kilifi, Kitui, Kwale, Migri, Taita Taveta, and Turkana. At scale, ASSIST s supprt has influenced QI in the fllwing different ways ver the prject s life span: - Direct supprt At least 45 annually receiving direct QI technical guidance with different imprvement initiatives in RMNCH. - Indirect supprt - All the USAID-supprted health service delivery mechanisms received indirect supprt frm ASSIST, thrugh change packages disseminated and by attending learning sessins that supprted the spread f effective changes. - Systems supprt 35 cunties either trained r sensitized n QI under the Kenya Quality Mdel fr Health. - Systems mnitring Revisin f mnitring tls t include RMNCH prcess f care indicatrs at bth natinal and cunty levels. T prvide guidance t the cunties and imprvement teams, ASSIST shared a dcument listing imprvement aims and 14 natinal imprvement indicatrs. Cunties and were free t select frm this list as per their respective pririty. Table 2 shws a summary f ASSIST s implementatin schedule fr QI in RMNCH frm 2013 t Table 2. Overview f ASSIST s cunty and facility supprt, Year Cunty (number f receiving direct cntinuus ASSIST QI supprt) 2013 Kwale (16 ) Isil (8 ) Kitui (12 ) Nairbi (10 ) Migri (15 ) Meru (15 ) Nakuru (10 ) 2014 Minimal facility level supprt, fcused mre n natinal scale-up 2015 Kitui (12 ) Kakamega (10 ) Taita Taveta (8 ) Isil (8 ) Nairbi (10 ) 2016 Turkana (10 ) Taita Taveta (10 ) Kakamega (8 ) Migri (8 ) Kitui (10 ) 2017 Turkana (10 ) Kilifi (7 ) Kakamega (9 ) Migri (8 ) Kitui (13 ) Cmments Training cnducted fr the seven cunties and initial setting up f imprvement teams. All fcused n either/r HIV/AIDS and RMNCH prgrams. Scale up f QI thrugh jint, multi-agency trainings and rientatin t 35 cunties acrss the cuntry. Fcused narrwed t MNCH prgram areas/indicatrs, Nairbi QI activity supprt handed ver t the USAID service delivery mechanism. Fcus narrwed t USAID s RMNCH fcus cunties, Isil, Taita Taveta and Nairbi replaced with Migri, Turkana and Kilifi. Transitin perid and further supprt in setting up cunty QI structures and USAID s service delivery mechanisms. USAID ASSIST Kenya Cuntry Reprt FY17 11

20 KEY ACCOMPLISHMENTS AND RESULTS Cnducted 5 KQMH trainings in Kilifi, Migri, Baring, Nakuru, and Makueni cunties (Q2- Q4). C-supprted training n Emergency Obstetric and Newbrn Care (EmONC) in Kitui Cunty (Q3). Cntinuus supprt fr QI caching at five cunties (Kakamega, Kitui, Kilifi, Migri, and Turkana) (Q1-Q4). Held cnsultative meetings with the new USAID RMNCH/FP service delivery mechanism n hw t supprt QI in service delivery (Nv 2016). The tw new mechanisms Afya Uzazi and Afya Timiza were awarded in September 2016 t supprt RMNCAH/FP activities in Turkana and Samburu cunties (Afya Timiza) and Nakuru and Baring cunties (fr Afya Uzazi). ASSIST cntinued t supprt Afya Timiza and Afya Uzazi thrugh trainings and frmatin f wrk imprvement teams (Q2-Q4). Prvided supprt fr pre-testing f quality f care standards by the Ministry f Health and prvide technical supprt in the review f the Kenya Quality Mdel fr Health (Q1-Q4). At the time f submissin f this reprt, the Ministry f Health and ther stakehlders (GIZ) were putting the final preparatin fr the launch f the revised KQMH cre standards. ASSIST has supprted this prcess since March Supprted exchange learning fr the WIT at Kakamega Cunty Referral Hspital (Nv 2016) t attend a cnference n cnvulsive disrders amng children in Bungma Cunty. Prvide lgistical and technical supprt fr tw cunty QI harvest sessins in Kakamega and Kitui cunties (Q2-Q3). Cnducted three data quality audits and data validatin in Kakamega Cunty (Q1-Q3). Supprted six cntinuus benchmarking visits as part f learning sessins different cunties (Q2-Q3). Dcumented best practices in imprving RMNCH in Isil Cunty (Q1) and the entire ASSIST implementatin perid (Q4). Handver f QI wrk in tw cunties (Isil and Taita Taveta) t cunty health management teams (Q4). The handver prcess fr Taita Taveta Cunty was finalized in Q4 as part f transitin prcesses with presentatin t each cunty f QI change package dcuments. Results: Intrapartum Care: Mnitring f Labr. In Kitui, 12 increased the percentage f wmen giving birth with a cmplete partgraph frm 31% in January 2015 t 90% in May Als in Kitui, the 12 sites increased the percentage f deliveries fr which xytcin was delivered within ne minute f delivery frm 42% in April 2015 t 82% in January In Turkana, the percentage f deliveries with cmplete partgraphs increased frm 13% in April 2016 t 84% in May In Migri, partgraph use increased frm 6% in July 2015 at ne site t 91% by May 2017 in six sites (Figure 5). 12 USAID ASSIST Kenya Reprt FY17

21 Figure 5. Prprtin f wmen giving birth in health facility with cmplete partgraph, 20 sites, Kitui, Turkana, and Migri cunties (Jan 2015-May 2017) 48-hur pstpartum lng-acting and reversible cntraceptives results in fur in Kakamega Cunty. Pst-natal FP is ne f the key strategies that can help t imprve the cntraceptive prevalence rate. After the revisin f the 2015 medical eligibility criteria n the use f lng-acting reversible cntraceptives (LARC), fur in Kakamega Cunty (Matungu, Iguhu, Butere, and Likuyani cunty hspitals) decided t use the PDSA cycle t imprve the uptake f LARC fr wmen wh desired FP. Figure 6 is an illustratin f hw the wrk imprvement teams (WITs) were able t track their indicatrs as they tested their change ideas. The biggest win teams have had is the integratin f MCH services in ne rm and change f client flw t facilitate access t desired FP services. USAID ASSIST Kenya Cuntry Reprt FY17 13

22 Figure 6. Prprtin f wmen cunselled wh vluntary pted fr LARC, 6 sites, Kakamega Cunty (Feb 2016-May 2017) Imprved recrding f initial temperature (1-2 hurs after delivery) in in Kitui, Turkana, and Migri cunties frm May 2016 Feb Nenatal deaths due t nenatal sepsis can be eliminated thrugh early diagnsis and treatment f nenatal sepsis. Kenya is ne f the cuntries that still has a nenatal death rate abve 30/1000 live births. Initial temperature is vital in diagnsis f nenatal sepsis; hwever, the recrding f initial temperature is a practice that has been neglected. Measuring temperature helps identify early signs f nenatal infectin. In the three cunties, there wasn t any measurement f baby s initial temperature within 1-2 hurs after delivery. Change ideas included; a) Daily review f maternity files t identify pssible missed pprtunities; b) Maternity file mdificatin-inclusin f a rw t recrd baby s temperature in the mther s file; c) Prvide maternity with digital thermmeters by APHIA Plus service delivery mechanism; d) Mentrship n dcumentatin thrugh cntinuus medical educatin, n-the jb training, and caching. Figure 7 illustrates the prgress in taking nenates temperature ver time. 14 USAID ASSIST Kenya Reprt FY17

23 Figure 7. Prprtin f newbrns with initial temperature recrded 1-2 hurs after delivery, 20 sites, Kitui, Migri, and Turkana cunties (May 2016-Apr 2017) SPREAD OF IMPROVEMENT The fcus in the final year f ASSIST was t cnslidate the gains made in the past fur years, prepare the cunties fr spread f the imprvement wrk, and strengthen the structures that will supprt quality management. In the final year f the prject, there were realignments t fit the USAID pririties fr RM/MNCH/FP supprt in Kenya. This meant that tw cunties were drpped frm the list f ASSIST s direct supprt, and tw cunties added in line with USAID s cuntry fcus. ASSIST wrked with service delivery partners implementing RH/MNCH activities in 10 USAID pririty cunties. ASSIST had direct presence in five cunties; Kitui, Kakamega, Migri, Turkana, and Kilifi where ASSIST aided QI activities in 56. The ther five RH/MNCH pririty cunties were Nakuru, Baring, Samburu, Kisumu, and Nairbi s infrmal settlements where ASSIST ffered need-based supprt as per demanded by the respective implementing service delivery mechanisms. The 10 USAID fcus cunties are at different levels in quality management. Sme have established cuntylevel QI supprt structures (e.g., a QI crdinatr/fficer r department with QI deliverables) while thers have active QI teams with gd results in maternal, newbrn, and family planning care prcesses. Spread f QI will be determined by the cunties and implementing partners readiness t invest in tracking imprvements in prcess gaps in extra. Key activities t supprt spread f the imprvement wrk included: Supprted cunties, sub-cunties, and t establish structures n quality management with jint mnitring f functinality QI teams; Assisted in the disseminatin f natinal MNCH QI related guidelines and plicy, which included the revised Kenya Cre Health Quality Standards althugh the final dcument had nt been finalized by the time f writing this reprt; Cntinued t supprt QI training and establishing f functinal QI teams at facility level fr the new USAID service delivery mechanism (i.e., Afya Uzazi and Afya Timiza); and Guide cunty learning frums t infrm spread f prcess imprvements in MNCH/FP prcesses f care. USAID ASSIST Kenya Cuntry Reprt FY17 15

24 Activity 5. Malaria case management BACKGROUND In three high malaria burden cunties (Kakamega, Busia, and Siaya), ASSIST supprted 25 QI teams and wrk imprvement teams t imprve bth malaria diagnsis and case management, as well as t imprve stck management f rapid diagnstic test kits and medicines fr malaria. Supprt fr malaria in pregnancy began this fiscal year in Hma Bay and Migri cunties. KEY ACCOMPLISHMENTS AND RESULTS Malaria case management fr the general ppulatin Prvided supprt fr cunty-level malaria technical wrking grup meetings in Busia and Kakamega cunties (Oct and Nv 2016 respectively) during which cunty and sub-cunty malaria crdinatrs reviewed the strategic directin f malaria prgramming in the cunties. Prvided supprt fr cmmdity management and data quality in Kakamega, Busia, Siaya, Migri, and Hma Bay cunties (Feb 23-24, 2017). During this tw-day meeting, malaria cunty crdinatrs, cunty lgisticians, cunty labratry crdinatrs, cunty pharmacists, and cunty directrs f health came tgether t discuss the cmmn rt causes f perennial stck-uts f malaria cmmdities, as well as the discrepancies between primary surce dcuments and the DHIS data. Prvided supprt fr facility-level QI caching t supprt imprvement activities (Q1-2). There was a general imprvement in understanding f malaria case management guidelines and implementatin f QI change ideas within the COEs. Facilitated quarterly sub-cunty level QI CMEs in all the 25 sub-cunties in Kakamega, Busia, and Siaya cunties (Nv 2016 Q1 and Feb 2017 Q2). Health wrkers cnvened t discuss malaria indicatr perfrmance and relevant imprvement pprtunities within their specific sub-cunties. Cnducted tw runds f data validatin in the 12 COEs in Kakamega Cunty (Oct 2016 and Mar 2017). There was imprvement in cmpleteness and accuracy f malaria reprting in DHIS 2. Supprted cunty-based learning sessins in March 2017 fr Kakamega and fr Busia and Siaya cunties in May During these sessins, imprvement teams tgether with President s Malaria Initiative (PMI) partners in the regin cnvened and shared change cncepts t imprve malaria case management. Representatives f the natinal malaria cntrl prgram utilized these fra t fster the latest natinal malaria guideline. Dcumented and disseminated experiences and change cncepts fr imprving malaria case management and preventin in July Malaria in pregnancy (MIP) MIP wrk begun in Migri and Hma Bay cunties fr facility and cach selectin and QI training (Oct 2016). Rng Sub-Cunty Hspital (SCH) was ne f the 12 high-vlume MIP in Migri Cunty selected by the Cunty Health Management Team (CHMT). After training, the caches sensitized health care wrkers in their and sub-cunty health management teams t get buy-in (Nv 2016). Selectin f WITs and baseline assessments were dne in Dec 2016, but wrk stalled due t natinal health wrkers strike. The use f glden cascade has shwn prmising results in ensuring all first ANC visits are screened fr malaria, and this is underging intense dcumentatin fr wider sharing (Figure 8). Dcumentatin f an imprvement case study in Migri Cunty n the glden cascade fcused n screening, testing, and treatment f malaria in pregnancy. 16 USAID ASSIST Kenya Reprt FY17

25 Figure 8. Prprtin f pregnant wmen screened, tested, and treated fr malaria during first ANC visit, Rng Sub-Cunty Hspital (Dec 2016-Feb 2017) Reducing stck-uts f malaria cmmdities When this wrk began in August 2015, it was recgnized that many sites had disparate stck-uts. In fact, 30% f the had a median f 28 days f stck-uts a mnth f these essential cmmdities. WhatsApp grups were then frmed in each f the cunties t track cmmdity status acrss the 25 sub-cunties in September and Octber Infrmatin regarding cmmdity status wuld be sent n the platfrm every mnth, including ad hc requests frm fellw sub cunty malaria crdinatrs t their clleagues, t help them mitigate shrtages in their sub cunties by redistributin. Activity n the WhatsApp platfrm triggered subcunty and cunty-wide redistributins in the three mnths that fllwed. Further, the varius WITs tested changes such as: testing all suspected malaria cases at night and during weekends; reserving mrdts fr dd hurs when labratries were clsed; and nly issuing ACTs t clients with cnfirmed malaria. The median stck-ut days f ACTs and m-rdts drpped frm 28 t less than 5 days between Octber 2015 and Nvember 2016, and as seen in Figure 9, the percentage f sites reprting stck-ut has remained lw since then. In ne regin, the cunty malaria crdinatr (CMCC) utilized WhatsApp platfrm t mnitr stcks weekly thrugh sub-cunty reprting. ASSIST integrated mnthly transprt schedules with the CMCC (wh at the time lacked means t visit the ) and by supprting her managed t internally redistribute stck based n need. The practice is nging, thugh the cunty was supplied cmmdities in Octber Supprted quarterly caches review meetings in Hma Bay and Migri cunties in January, March, April, and June 2017 in which MIP imprvement prjects and change ideas were reviewed and teams exchanged changes that were leading t imprvements in their. Supprted the develpment f a harmnized malaria supervisin tl t be used by all PMI partners in the regin during site visit, in which quality imprvement was imbedded as a key area t be assessed and supprted by all partners in the regin. USAID ASSIST Kenya Cuntry Reprt FY17 17

26 Figure 9. Percentage f supprted fr malaria imprvement reprting stck-uts f either/bth Rapid Test Kits and Artemether/lumefantrine, Kakamega, Busia, and Siaya cunties (Oct 2015-May 2017) SPREAD OF IMPROVEMENT Since FY16, ASSIST had been supprting three fcus cunties n malaria QI implementatin: Busia, Siaya and Kakamega. With the successes in the 25 COEs acrss the three cunties, the change ideas have been cascaded t ther within the cunties thrugh the sub-cunty level CMEs, and learning sessins. The prject has in this final year spread t tw additinal cunties Hmabay and Migri -- with a fcus n malaria in pregnancy. Change ideas that have been successful in the initial three cunties were replicated in Hmabay and Migri. As part f the prject transitin plans, cunties were supprted t develp scale-up plans. Activity 6. OVC and child prtectin BACKGROUND ASSIST wrked with the natinal, cunty gvernments, and USAID service delivery partners t institutinalize QI at the pint f service delivery. ASSIST s fcus was t wrk with nine USG partners in five cunties t cnslidate QI interventins in HIV care and treatment, husehld ecnmic strengthening, and child prtectin. KEY ACCOMPLISHMENTS AND RESULTS Natinal level ASSIST supprted disseminatin f the Natinal Psychscial Supprt (PSS) guidelines t 47 cunty crdinatrs f children services (Nv 2016). The crdinatrs wh had been trained n PSS fr vulnerable children will use the guideline t ensure OVC implementing partners are using the guidelines t prvide services t vulnerable children. Supprted PSS training in Nakuru Cunty in April 2017 (10 males 14 females attended). Disseminated f the natinal PSS guidelines and the simplified versin t USAID OVC implementing partners (Dec 2016). 18 USAID ASSIST Kenya Reprt FY17

27 Supprted the Department f Children s Services (DCS) (research and planning sectin) t hld a stakehlders frum (Mar 2017). After this meeting, DCS cnslidated all relevant child prtectin research in ne prtal fr ease in access and reference. Supprted Department f Children s Services cntinued implementatin f findings frm the strategy review reprt that was supprted by ASSIST (2016/17) (Oct 2016 Mar 2017). The findings included priritizatin f DCS staff training needs; redeplyment f 83 staff t the cunties and sub-cunties and emplyment f new staff; realignment f DCS sectins based n the Natinal Plan f Actin (NPA), ; inclusin f specific utcmes t staff perfrmance cntracts; imprvement f child prtectin structures in Uasin, Gishu, and Kilifi cunties and Ganze sub-cunty (helping t establish technical wrking grups with clear term f reference and pririty areas). Supprted NPA review meeting fr the Department f Children s Services (Dec 2016). The meeting brught tgether representatives f the DCS at natinal and cunty levels and ther key stakehlders in child prtectin. Cunty level imprvement wrk ASSIST supprted QI training fr 21 (14-male, 7-female) child prtectin TWG members fr Kilifi Cunty (Nv 2016). The TWG members develped a child prtectin rad map that is in line with the NPA. Five sub-cunty area advisry cuncil meetings held in Kilifi Cunty: Kalleni (10-M, 6-F), Rabai (11-M, 5-F), Kilifi Suth (10-M, 10-F), and Malindi and Ganze (13-M, 9-F) (Jan 2017). The area advisry cuncils safeguard the rights, welfare, and interests f children at sub-cunty and cunty levels. In May 2017, ASSIST supprted QI training fr 42 (18 male 24 female) child prtectin technical wrking grup fr Malindi Sub Cunty. QI team functinality assessment carried ut fr teams in Nark and Migri cunties (Dec 2016). QI team site visit fr NILINDE prgram in Nairbi (Feb 2017). QI training fr the USAID NILINDE Prject and SDP staff in Nairbi and Cast (Nv 2016, Jan 2017, and May 2017). Supprted AMURT learning sessin that brught tgether 13 QITs (April 2017). The challenges faced, and changes ideas tested are listed belw. Challenges (frm rt cause analysis) Inadequate referral frms Unclear respnsibilities as t wh shuld refer and fllw up HIV-psitive vulnerable children N clear mechanisms t track referrals Nn-adherence t referral Implemented change ideas Get adequate referral frms Ensure timely and prper dcumentatin Hld awareness days t identify thse nt linked t care and treatment The QI team struggled with dcumentatin f effective referrals f HIV-psitive children. They instituted the abve change ideas and have cntinued t track the effectiveness f referral thrugh prper dcumentatin and fllw-up. A referral pint persn acts as a link between the QI team and the health. Results: The QI team in Migri Cunty sught t imprve referrals t ensure HIV care, supprt, and treatment f adlescents and children thrugh cllabratin with key health service prviders in Migri Cunty. Between Octber 2016 and May 2017, the percentage f USAID ASSIST Kenya Cuntry Reprt FY17 19

28 Percentage f HIV +ve adlescent OVC vulnerable children referred and put n care and treatment increased frm 11% t 54% (Figure 10). Figure 10. Percentage f HIV-psitive adlescents referred and put n care and treatment, Migri Cunty (Oct 2016-May 2017) 100 # f HIV +ve adlescents effectively referred and put n care and treatment # f HIV +ve adlescent OVC intrductin f linkage fcal persn Oct-16 Nv-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May % f HIV +ve adlescents effectively referred and put n care and treatment # f Sites Reprting Thrugh caregivers invlvement in Village Saving and Lan Assciatins (VSLA) in Migri Cunty, they have been able t supprt members f their husehlds in accessing health care. T enhance the number f VSLA members making Natinal Health Insurance Fund (NHIF) mnthly cntributins, the team intrduced a new change idea mandating all VSLA members t priritize NHIF cntributins t cater fr the health services fr OVC, as illustrated in Figure USAID ASSIST Kenya Reprt FY17

29 Figure 11. OVC caregivers with natinal hspital insurance, sex-disaggregated, Migri Cunty (Aug 2016-May 2017) Percentage Number %f female caregivers in VSLA with NHIF Data validatin Initiatin f change idea Aug 16 Sep 16 Oct 16 Nv 16 Dec 16 Jan 17 Feb 17 Mar 17 Apr 17 May 17 Ttal # f Caregivers in VSLA with NHIF Cver Number f caregiver in VSLA with NHIF in Migri between 2013 t N f VSLA grup member Aug 16 Sep 16 Oct 16 Nv 16 Dec 16 Jan 17 Feb 17 Mar 17 Apr 17 May 17 Objective Supprt QIT t track and reprt VSLA members able t meet needs f their children as identified thrugh CSI assessment Change Ideas 1. Mandate new VSLA grup member t cntribute t NHIF 2. Enhance dcumentatin in VSLA thrugh tracking NHIF cntributin by members f VSLA by gender In Migri Cunty, the implementing partner, APHIA Plus, has been prviding schl fees t families based n vulnerability assessments t ensure children can g t schl despite financial barriers, a pririty OVC prgramming area under PEPFAR 3.0. Their prgram includes invlvement in village savings and lan assciatins fr supprted families. ASSIST develped the Watan initiative t further strengthen this wrk. In the Watan initiative, small grups f apprximately five families cme tgether t save mney. ASSIST als linked vulnerable families t financial literacy prgrams t strengthen their financial management skills fr financial independence. As a result, the percentage f vulnerable families wh are cvering schl fees themselves has increased frm 15% in September 2013 in 2013 t 86% in May 2017 (Figure 12). A shrt vide abut the Watan Initiative is viewable at: USAID ASSIST Kenya Cuntry Reprt FY17 21

30 Figure 12. Prprtin f caregivers taking ver respnsibility fr schl fees, 2 QI teams, Migri cunty (Sept 2013-May 2017) SPREAD OF IMPROVEMENT Dcumented and shared best practices thrugh ebulletins and with the DCS, USAID, and natinal OVC IPs. Activity 7. Assessment f quality f care in selected End Preventable Child and Maternal Deaths (EPCMD) pririty cuntries BACKGROUND In cllabratin with WHO and, ASSIST develped survey prtcls and tls t assess the quality f essential RMNCH services in three pririty EPCMD cuntries (Kenya, Uganda, third cuntry TBD) based n WHO Standards f Maternal and Newbrn Care and ther internatinally recgnized standards f care and measurement framewrks. The tls are fcused n identifying gaps in care prcesses at the time f childbirth and supprting system functins at the facility level. Tls have been tested at a small scale in Uganda and Kenya and were then finalized based n the pre-test results. The final assessment tls and study prtcl underwent institutinal review bard (IRB) apprval by URC in the U.S. and natinally (in Uganda and Kenya). KEY ACCOMPLISHMENTS AND RESULTS Develped list f indicatrs t assess RMNCH practices (Oct-Nv 2016). Fr assessing maternal and newbrn care practices, the tl was based n WHO indicatrs using a Delphi prcess t select WHO Quality f Care Maternal Newbrn Health Framewrk and Essential Newbrn Actin Plan measures. Cnducted extensive desk review f literature, including evidence-based clinical guidelines and recmmendatins and available assessment tls t develp/revise study prtcl and questinnaires (Nv 2016-Jan 2017). Initiated regular cmmunicatin with USAID ASSIST field ffices t infrm lcal key stakehlders abut the assessment and advance rganizatinal planning f field activities (Nv 2016). 22 USAID ASSIST Kenya Reprt FY17