EVALUATION SERVICES AND PROGRAM SUPPORT (ESPS) APHIAPLUS IMARISHA END-OF-ACTIVITY PERFORMANCE EVALUATION AUGUST 10, 2018: THIS REPORT IS PRODUCED FOR THE UNITED STATES AGENCY FOR INTERNATIONAL DEVELOPMENT. IT WAS PREPARED BY INTERNATIONAL BUSINESS & TECHNICAL CONSULTANTS, INC. Prepared for United States Agency for International Development/Kenya C/O American Embassy United Nations Avenue, Gigiri P.O. Box 629, Village Market 00621 Nairobi, Kenya Prepared by International Business & Technical Consultants, Inc. 8618 Westwood Center Drive Suite 400 Vienna, VA 22182 USA 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. i TABLE OF CONTENTS Acknowledgements................................................................................................................................I Acronyms And Abbreviations.............................................................................................................II Glossary Of Terms................................................................................................................................IV Executive Summary................................................................................................................................1 1 Introduction .........................................................................................................................................3 2 Background...........................................................................................................................................4 3 Methodology........................................................................................................................................5 4 Findings, Conclusions, and Recommendations............................................................................9 Part Ii: Case Studies...............................................................................................................................26 Annex 1: USAID/KEA APHIAplus Imarisha ETE SOW.................................................................31 Annex 2: Methodology..........................................................................................................................52 Annex 3: Research Tools.....................................................................................................................55 Annex 4: Health Facility Capacity Assessment................................................................................242 Annex 5: Evaluation Workplan And List Of Key Informants ......................................................246 Figure 1 – % Positivity Yield in Voluntary Medical Male Circumcision................................................................................9 Figure 2 – Proportion of Pregnant Women Testing Positive at ANC ..............................................................................10 Figure 3 – ANC Clients on ART .................................................................................................................................................11 Figure 4 – % PCR Results at 8 Weeks .......................................................................................................................................11 Figure 5 – % PCR Results (at 8 Weeks) Positive.....................................................................................................................11 Figure 6 – % Initiated on Treatment...........................................................................................................................................12 Figure 7 – Assisted Delivery and Postnatal Care within 48 Hours....................................................................................14 Figure 8 – Community Unit Functionality Profile....................................................................................................................20 Figure 9 – Capacity of County and Sub-County HMT to sustain gains in health ...........................................................22 Table 1 – Antenatal HIV Testing ...................................................................................................................................................9 Table 2 – HIV Testing in Adults and Children .........................................................................................................................10 Table 3 – Adults and Child HIV Treatment..............................................................................................................................10 Table 4 – PMTCT .................................................................................................................................................11 Table 5 – Percentage of Patients on Treatment with Viral Load Suppression................................................................12 Table 6 – ANC Attendance, Assisted Delivery, and Postnatal Care within 48 Hours.................................................14 Table 7 – Vaccinations, Percentage of Children under 1 .....................................................................................................16 Table 8 – OVC School Enrollment, Attendance, and Progression.....................................................................................18 Table 9 – OVC Households Participation in Community-Based HES Groups...............................................................19 Table 10 – Number of HES Groups...........................................................................................................................................19 Table 11 – Capacity of Health Facilities.....................................................................................................................................21 Table 12 – Capacity of Health Facility to Sustain Gains in Health......................................................................................22 Table 13 – Capacity of County and Sub-County HMT to Sustain Gains in Health .......................................................23 Table 14 - Annual Work Plan Analysis.......................................................................................................................................27 Table 14 – Annual Work Plan Analysis......................................................................................................................................28 i ACKNOWLEDGEMENTS This APHIAplus Imarisha end-of-activity evaluation was a substantial undertaking that would not have been possible without the input and support of many people:  Members of multidisciplinary field teams assisted with primary data collection, data management, data analysis, and interpretation of findings.  International, national, and local implementing partners from APHIAplus Imarisha were frank and insightful in their descriptions of APHIAplus implementation issues and provided useful insights into what did and did not work during the project period 2012–2017.  National-level stakeholders helped contextualize the implementation experiences of the APHIAplus Imarisha in Turkana and Samburu Counties.  Key county and sub-county level informants (county government officials from health and other sectors, members of County and Sub-County Health Management Teams, in-charges at selected health facilities) were gracious in sharing their insights, despite competing demands on their time.  ESPS/IBTCI Kenya staff (Dr. Norbert Rakiro, ESPS Chief of Party; Martina Nicols, former ESPS Chief of Party; Paul Mwai, ESPS Monitoring and Evaluation Advisor; Charles Maina, former ESPS Monitoring and Evaluation Advisor; Dr. Maxwell Omondi, ESPS Public Health Specialist; Rosemary Were, ESPS Program Support Manager; and all ESPS administrative personnel) provided technical and administrative support to the evaluation team during all phases of the evaluation process.  IBTCI Home Office staff, we acknowledge Swati Sadaphal, ESPS Activity Director; Juan Carlos Alegre, former ESPS Activity Director; Victoria Sesay, Program Associate; Emily Miller and Ashley Rowles, former Program Associates; and Salima Mutima, Technical Advisor, who all assisted in the proposal development, evaluation process, and review of the report.  USAID/Kenya counterparts—in particular, John Bernon and Washington Omwomo, who offered guidance and support throughout the evaluation. Lastly, the authors extend heartfelt appreciation to community stakeholders, namely maternal, newborn, and child health clients; people living with HIV who are clients of comprehensive care clinics; caregivers of orphans, vulnerable children, and youth; and community health workers, all of whom contend with myriad challenges and barriers at the grassroots level as they try to effect positive change in their lives, their families, and their communities. ii ACRONYMS AND ABBREVIATIONS AIC African Inland Church AIDS Acquired Immune Deficiency Syndrome AMREF African Medical and Research Foundation ANC Antenatal Care APHIA AIDS, Population, and Health Integrated Assistance BEmONC Basic Emergency Obstetric and Neonatal Care BRHC Broad Reach Healthcare CAC Community Advisory Committee CBO Community-Based Organizations CCC Comprehensive Care Clinics CD4 Cluster of Differentiation 4 CHMT County Health Management Team CHS Community Health Strategy CHU Community Health Unit CHV Community Health Volunteer CI Confidence Interval CME Continuing Medical Education COP Chief of Party CRS Catholic Relief Services CSI Child Status Index DBS Dried Blood Spot DHIS District Health Information System (Kenya’s National Health Information System) DHS Demographic and Health Survey EBI Evidence-Based Intervention EID Early Infant Diagnosis EmONC Emergency Obstetric and Neonatal Care ESPS Evaluation Services and Program Support ET Evaluation Team ETE FBO End-Term Evaluation Faith-Based Organization FGD Focus Group Discussion GoK Government of Kenya HCW Health Care Worker HES Household Economic Strengthening HEI HIV-Exposed Infants HIV Human Immunodeficiency Virus HPN Health Population and Nutrition HRH Human Resources for Health HSS Health Systems Strengthening HSSF Health Sector Services Fund HTC HIV Testing and Counseling HTS HIV Testing Services IBTCI International Business & Technical Consultants, Inc. IGA Income-Generating Activity IP Implementing Partner KAP Knowledge, Attitudes, and Practices KDHS Kenya Demographic and Health Survey KEMSA Kenya Medical Supplies Authority KII Key Informant Interviews KMMP Kenya Mentor Mother Program iii LIP Local Implementing Partner LOL Land O’ Lakes MARPs Most-at-Risk Populations M&E Monitoring and Evaluation MM Mentor Mother MNCH Maternal, Newborn, and Child Health MoH Ministry of Health NAL Northern Arid Lands NASCOP National AIDS and STI Control Program OCA Organizational Capacity Assessment OI Opportunistic Infection OJT On-the-Job Training OLMIS OVC Longitudinal Management Information System OPH USAID Kenya Office of Population and Health OVC Orphans and Vulnerable Children PCR Polymerase Chain Reaction PEPFAR U.S. President’s Emergency Plan for AIDS Relief PITC Provider-Initiated Testing and Counseling PLHIV People Living with Human Immunodeficiency Virus PMP Performance Management Plan PMTCT Prevention of Mother-to-Child Transmission of HIV PNC Postnatal Care PSSG Patient Social Support Group QIT Quality Improvement Teams RDT Malaria Rapid Diagnostic Test RMNCH Reproductive, Maternal, Newborn and Child Health SCHMT Sub-County Health Management Team SILC Savings and Internal Lending Communities SIMS PEPFAR’s Site Improvement through Monitoring System SOP Standard Operating Procedures TOT Training of Trainers USAID/KEA United States Agency for International Development Kenya and East Africa VMMC Voluntary Medical Male Circumcision WASH Water, Sanitation, and Hygiene iv GLOSSARY OF TERMS Activity: USAID-funded program; referred to in this report as APHIAplus Imarisha Antiretroviral drugs (ARVs): Tested and approved drugs that prevent HIV (and other retroviruses) from replicating. Antiretroviral therapy (ART): Use of a combination of ARVs to achieve viral suppression. CD4: Also known as T-helper cells: A form of white blood cell that is important for immune system functioning; used to determine the stage of HIV infection. Community Health Extension Worker (CHEW): An employee of the Government of Kenya, a trained health worker who supervises the work performed by Community Health Workers assigned to a particular Community Health Unit. Community Health Strategy: A nationwide strategy adopted in 2006–2007 by the Kenyan Ministry of Health to accelerate the achievement of Millennium Development Goals 4 and 5 by extending community access to health care; community participation is a pillar of the strategy. Community Health Unit: Within Kenya’s health system, a level 1 health unit comprising about 5,000 individuals, with oversight by a Community Health Extension Worker (CHEW), supported by a cadre of Community Health Workers; fulcrum of the Community Health Strategy. Community Health Volunteer (CHV): An individual, male or female, recruited and trained to provide basic home-based and community-based health services; community mobilization and referral is a central function, with a focus on maternal and child health, community hygiene and sanitation, and family planning. Each CHW is assigned to a specific Community Health Unit and supervised by a Community Health Extension Worker; they are generally regarded as volunteers though some CHWs receive stipends. Continuing Medical Education (CME): In-service training and updating of knowledge and skills to maintain a certain standard of clinical proficiency for different cadres of health professionals. County Health Management Team (CHMT): Entity created under devolution to provide technical and management coordination and oversight of health service delivery within a particular county. Devolution: In Kenya, a political reform that transferred authority and financial responsibility from central government structures to autonomous, sub-national administrative units known as counties. Dried Blood Spot (DBS): Blood samples that are blotted and dried on filter paper; DBS samples are easy to prepare and store in resource-limited settings and have shown promise for use in Polymerase Chain Reaction (PCR) testing for diagnosis of HIV-exposed infants. End-of-activity evaluation, end-of-term evaluation and end-of-project evaluation were used interchangeably to mean evaluation of the APHIAplus Imarisha at post intervention phase. Household Economic Strengthening: Activities that link vulnerable families to economic services and/or opportunities that expand their assets and/or promote their market participation. Mentor Mothers: A peer-support approach that involves training and supporting mothers who are living with HIV to provide basic health education and psychosocial support to other HIV-infected mothers, one-on-one and in groups. Mentorship: A form of strengthening the capacity of health service providers and/or technical staff through one-to-one pairings with APHIAplus technical advisors and SCHMTs. v On-the-Job Training: Individualized training that occurs within the confines of the clinic environment to minimize service disruptions often associated with off-site training. Opportunistic Infections (OIs): Various types of infections (e.g., viral, bacterial, fungal) associated with a weakened immune system. Output-Based Aid: A form of results-based financing that aims to increase access to health services for the poorest segments of society; usually achieved through a combination of subsidies, rewards, and performance￾based incentives. Quality Improvement (QI): A series of techniques and/or methods employed to maximize high standards and performance at health service delivery sites and/or by persons involved in community-based service delivery. Skilled Delivery: When a delivery/birth event is assisted by an individual who is trained and qualified to manage both normal and complicated deliveries. Doctors, nurses, and midwives qualify as “skilled birth attendants.” Traditional birth attendants (TBAs), regardless of years of experience and/or ad hoc training or support received, are not recognized as skilled birth attendants. Sub-County Health Management Team (SCHMT): Under Kenya’s devolved governance system, the team provides coordination/oversight of community health services. In theory, it is akin to the District Health Management Team, an entity that existed before devolution. Traditional Birth Attendant (TBA): An unskilled individual, usually an elderly female, who resides within a community and has established a reputation as a source of delivery assistance when mothers deliver their babies at home; TBAs are not sanctioned delivery providers by the Government of Kenya or the World Health Organization. 1 EXECUTIVE SUMMARY The United States Agency for International Development / Kenya and East Africa (USAID/KEA) commissioned an end-of-activity evaluation in January 2018 of the APHIAplus Imarisha program, a five￾year cooperative agreement funded by USAID/KEA that started on March 1, 2012. APHIAplus Imarisha was implemented by African Medical and Research Foundation (AMREF) in collaboration with consortium partners including Catholic Relief Services (CRS), Land O’ Lakes (LOL), FHI360, Broad Reach Healthcare (BRHC), and University of Maryland working with local implementing partners (LIPs). The evaluation covered the period from March 2012 through March 2017 and was carried out targeting two counties of the program activity: Turkana and Samburu. Evaluation Services and Program Support (ESPS) received a Task Order (TO) from USAID/KEA to conduct the end-term evaluation of three of the health flagship activities noted above. The reference period for the evaluation is March 15, 2012, through March 14, 2017. The evaluation served two main purposes: (1) To learn to what extent the activities’ objectives and expected health outcomes at county, sub-county, health facility, and community levels were achieved, including effectiveness of APHIAplus model, key lessons learned and challenges; and (2) to identify implementation strategies in terms of the “what” and the “how to” that have a high likelihood of achieving sustainable health and institutional strengthening outcomes for the Northern Arid Lands (NAL) region. The evaluation utilized both qualitative methods (document review, key informant interviews, focus group discussions) and quantitative methods (household surveys and organizational capacity assessment) approaches to collect data from primary and secondary sources with a contribution analysis case study looking at both annual work plans and progress reports to understand what worked and what did not work. A total of 979 mother-child pairs, 537 orphans and vulnerable children (OVC) caregivers, 68 key informant interviews (KIIs), 38 Organizational Capacity Assessments (OCAs) (17 with health facilities, 13 with community units, 8 with CHMT) responded to the evaluation from January 18, 2018, through February 8, 2018. In addition to descriptive statistical analysis the evaluation used grounded theory analysis, comparative analysis, content and triangulation, and inferential analysis to analyze the collected data. Two validation workshops held in the two focus counties helped ground evidence that led to the development of conclusions from the validated findings and resulted in the development of the suggested relevant recommendations. The key findings of the evaluation are as follows:  Over the life of the project, HIV positivity yield at antenatal care (ANC) decreased from 5.5 percent (95 percent CI: 4.6 percent, 6.4 percent) in 2012–2013 to 3.7 percent (95 percent CI: 3.2 percent, 4.2 percent) in 2016-2017.  There was a scale-up of HIV testing among adults and children. HIV positivity yield (overall) decreased from 4.3 percent (95 percent CI: 4.0 percent, 4.6 percent) to 1.4 percent (95 percent CI: 1.38 percent, 1.45 percent).  The proportion of positive clients initiated on antiretroviral therapy (ART) increased from 52.1 percent (95 percent CI: 48.6, 55.6 percent) in 2012–2013 to 85.5 percent (95 percent CI: 83.1, 87.9 percent) in 2015–2016. Out of all clients initiated on testing HIV positive, the proportion of adults initiated on treatment increased from 46.3 percent (95 percent CI: 42.6 percent, 49.9 percent) to 83.8 percent (95 percent CI: 81.2 percent, 86.4 percent).  Among prevention of mother-to-child transmission of HIV (PMTCT) clients, the proportion on ART with viral load suppression is 58.3 percent (95 percent CI: 32 percent, 80.7 percent).  Over the life of the project, polymerase chain reaction (PCR) positive results at 8 weeks increased from none in 2012–2013 to 7.7 percent (95 percent CI: 3.1 percent, 12.3 percent) in 2016–2017. 2  There was a scale-up of PCR results at 8 weeks among children. However, PCR results positivity yield (overall) decreased from 8.9 percent (95 percent CI: 1.5 percent, 16.4 percent) in 2014 to 7.7 percent (95 percent CI: 3.1 percent, 12.3 percent) in 2016–2017.  The proportion of children initiated on ART increased from none in 2012 to 79.3 percent (95 percent CI: 64.6 percent, 94.0 percent) in 2016–2017.  Voluntary male medical circumcision (VMMC) uptake was highest among the 15- to 24-year-old clients compared with males aged 25 and above; this is due to the activity focus on teenagers and school-going children and can be attributed to the project interventions. VMMC positivity yield dropped from 2.59 percent (95 percent CI: 1.7 percent, 3.4 percent) in 2012-2013, and 0.38 percent (0.05 percent, 0.7 percent) in 2016–2017.  Coverage levels for fully vaccinated children under 1 were the lowest in Loima (2.4 percent), followed by Turkana Central (9.1 percent) and Turkana West (9.4 percent). The highest proportion of fully immunized children under 1 was in Samburu West (21.4 percent) and Samburu East (19.6 percent).  Assisted birth delivery was on average high in Samburu County, ranging from 63.5 percent in Samburu East to 74.1 percent in Samburu West, while in Turkana, skilled birth attendance varied (lowest coverage in Turkana West (47.4 percent) and the highest in Turkana Central (72.1 percent)).  Postnatal care within 48 hours after birth varied from 44.4 percent (95 percent CI: 34.6 percent, 54.7) in Turkana East to 69.6 percent (95 percent CI: 60.6 percent, 77.2 percent) in Turkana North. In Samburu, the lowest coverage was observed in Samburu East 47.9 (95 percent CI: 38.2 percent, 57.8 percent), and was highest in Samburu North 59.9 percent (95 percent CI: 51.6 - 67.5 percent).  Capacity assessment of health facilities shows varied services offered by CHV as well as gaps in quality improvement initiatives. The assessed Sub-County Health Management Team (SCHMT) had low levels of enabling environment for sustainability. The Ministry of Health (MOH) CU functionality scorecard pointed to noticeable gaps in access to equitable health services.  Testing at ANC increased over the evaluation period, from 2,397 in 2012 to 5,834 in 2017, with decreasing positivity rates (HIV positivity yield at ANC decreased from 5.5 percent (95 percent CI: 4.6 -6.4 percent) in 2012–2013, to 3.7 percent (95 percent CI: 3.2 - 4.2 percent) in 2016–2017).  The proportion of pregnant women initiated on ART also increased. The proportion of ANC clients on ART increased from 25.8 percent (95 percent CI: 18.3 percent, 33.2 percent) in 2012–2013 to 33.3 percent (95 percent CI: 27.0 percent, 39.6 percent) in 2016–2017. The increase in the number of pregnant women tested and the proportion of those initiated on ART can be credited to the program’s strategies to improve PMTCT outcomes, among them mentor mothers (MMs). These results indicate that MMs and the roles they play were positively received by clients, communities, and health care workers (HCWs). MMs were noted to be approachable and well informed on matters pertaining to PMTCT. The absorption of the MMs into the county staffing has not yet been adopted, which means the role is donor supported with no ownership from the county government.  The block grant not only provided alternative livelihoods but also increased OVC caregivers’ resilience. It has provided evidence of successes in supporting OVC household economic strengthening (HES) and made them resilient, and increased retention and progression in schools has been made possible by the partnership between OVC caregiver groups and the schools. However, reduction of provided services and number of LIPs due to funding constraints resulted in less success for the direct support to OVC to meet their immediate and critical needs. In addition, there was not a clear sustainability and exit strategy: the OVC support was not owned by the county government and was donor-dependent. In conclusion, the end-of-activity evaluation established that the activity was in line with the national and county strategies and policies that aim to address health for the marginalized NAL counties. The end￾term evaluation (ETE) further established that the activity had laid a strategic foundation in its initial years for attainment of sustainable outcomes. It was also established that the activity approaches used 3 contributed largely to the achievement of the positive outcomes witnessed. Some of the lessons learned are that partnerships and networking with local stakeholders and the community are key to increase reach, sustainability, and ownership. Specific partnership models that showed contribution to the achieved health outcome include involvement of community health volunteers (CHVs), expert patients/clients, peer volunteers, and MMs who were crucial, particularly in reaching the PMTCT outcomes. In addition, creating community demand for health services must be matched with the availability of improved services within health facilities. Further, community participation and involvement in the strengthening of health care delivery elicits grassroots acceptance creating a sense of ownership and increased utilization of health services. The evaluation strongly recommends the need for developing and implementing a joint action plan/memorandum of understanding as well as a robust exit and sustainability strategy that clearly links the phase-out of project activities to county governments’ interventions, including OVC support. This would ensure that the county governments together with other partners actively participate and take over the continued implementation of the project interventions and activities for sustaining the gains achieved by the project. Further, there is need to ensure that an integrated project like APHIAplus Imarisha takes into account all health focus areas without over-delivery on one at the expense of the other areas. Success stories should be widely shared within counties and scaled up to other counties. To address immediate food needs, small-scale vegetable and poultry farming should be considered and promoted. There is need to invest more resources and for more collaboration between stakeholders to ensure access to all immunizations especially OPV3, DTP3, and measles vaccines. VMMC needs to focus on all sexually active age groups rather than targeting only the children attending school. 1 INTRODUCTION Evaluation Purpose: The United States Agency for International Development Kenya and East Africa (USAID/KEA) commissioned an end-of-activity evaluation in January 2018 of the APHIAplus Imarisha program, a five-year cooperative agreement, to determine the extent to which the activities have met the expected health outcomes as were expressed in the five-year implementation framework. It looked at all aspects of the activity that have direct and indirect bearing on the anticipated health outcomes. The information therein will inform future direction in activity design, development, implementation, and management strategies. Audience: The primary audience for the findings of this evaluation is USAID/KEA, Health Population and Nutrition (HPN) leadership, USAID technical team, and the implementing partner (AMREF) and its consortium partners. USAID/KEA’s Office of Strategic Planning and Analysis, Office of Economic Growth, Education and Youth Office, and Democracy and Governance Office are part of the next level of primary audience for the evaluation findings. Secondary users of the evaluation findings include key stakeholders that implemented activities in national and county governments, MOH programs such as the National AIDS and STI Control Program (NASCOP), Family Health Programs, Ministry of Gender and Social Services/Department of Children Services, National Water and Sanitation Programs within the Ministry of Health, among others. Finally, the donor communities supporting health programs are also consumers of the evaluation findings. Synopsis of tasks: The end-of-project evaluation serves two main purposes: (1) to learn to what extent the activities’ objectives and expected health outcomes at county, sub-county, health facility, and community levels were achieved, including effectiveness of APHIAplus model, key lessons learned, and challenges; and (2) to identify implementation strategies in terms of the “what” and the “how to” so as to ascertain the likelihood of achieving sustainable health and institutional strengthening outcomes for the NAL region. Through a two-phase approach, the evaluation sought to respond to these objectives by answering the following key questions: 4 1. What is the current coverage/improvement status on the priority health outcomes in HIV/AIDS; Reproductive, Maternal, Newborn, and Child Health (RMNCH); Nutrition, Water, and Sanitation; and institutional/organizational capacity building? To the extent possible, determine the activity’s contribution to the observed health outcomes. 2. To what extent has the activity increased the capability of health community, health facility, and county health management teams to sustain the gains in the observed health outcomes? 3. What implementation challenges did the activity face during the implementation period and how were these challenges addressed? (This question examined successes; challenges with the primary outcomes being programmatic and management lessons learned, especially on institutional capacity building; sustainable household economic strengthening (HES) models for OVC vulnerable households; and overall sustainability of implemented strategies to guide future programming decisions). Additionally, using a case study approach, key analysis questions informed by evidence coming out of phase I were developed as well as an in-depth content analysis of the annual work plans for years 1–5 and corresponding quarterly progress/annual progress reports and documents. This was to ascertain what appeared to have worked and what did not work. 2 BACKGROUND Development Problem: The Northern Arid Lands (NAL) comprise eight counties characterized by harsh climatic conditions that are economically stagnated. The region covers about 70 percent of Kenya’s land mass with an estimated population of 4,469,174. Communities are predominantly nomadic or semi-nomadic and conservative, and the population is sparsely distributed (1 to 2 persons per sq. km). The availability and quality of health services in the NAL is poor. Barriers to health—including harmful cultural attitudes, social stigmas, limited financial resources, high illiteracy levels, and low education levels—often prevent people from accessing quality health services even where they are available. Most of the health indicators fall far below the national average. In all regions except North Eastern (67 percent), 94 percent or more of women received antenatal care from a skilled provider (Demographic Health Survey, DHS2014). Less than 90 percent of women in Garissa, Marsabit, West Pokot, and Samburu and less than 60 percent in Mandera and Wajir received antenatal care from a skilled provider; 47 percent of women in Mandera received no antenatal care at all (DHS2014). HIV prevalence varied greatly by region with a low of 2.1 percent in Eastern North region to 15.1 percent in Nyanza region; North Eastern had the lowest prevalence for both rural and urban areas at 1.5 percent and 3.6 percent respectively (KAIS 2012). USAID Kenya Response: Design and Implementation Approach: Broadly, APHIAplus Imarisha activity has a regional/county and sub-county focus, working closely with county and sub-county health management teams to support provision of integrated health services at health facilities and the community level. Specifically, these include HIV/AIDS; malaria; Family Planning/ Reproductive Health (FP/RH); Maternal, Newborn, and Child Health (MNCH); Water, Sanitation, and Hygiene (WASH); Orphans and Vulnerable Children (OVC); and other social determinants of health. These activities are implemented by a consortium of several local and international partner organizations that bring specialized expertise to contribute to the achievement of the overall goals and objectives. Specific activity design and implementation approaches are described below. In order to sustainably improve the health outcomes and create impact among the residents of the NAL, the implementing partner proposed to build on more than 30 years of development experience in the region. The African Medical and Research Foundation (AMREF) proposed to deploy a holistic program design intended to empower and strengthen health service delivery and social development structures in the region to sustainably fulfill their mandate of providing health and development services while 5 integrating their actions for synergy. This design was informed by participatory consultations with NAL health and development stakeholders through the activity jointly with stakeholders’ identified needs, gaps, and practical solutions. Using this program design, the activity set out to (i) strengthen the capacity of community to county (levels 1 to 4) health systems to deliver high-quality services, products, and information and create demand for the same; (ii) strengthen the ability of local social and economic development structures to create positive change in livelihoods, food security, education, and social protection; and (iii) through proven approaches such as the Saving and Internal Lending Communities (SILC) model by CRS and the value chain approach by Land O’ Lakes, foster multi-sectoral integration by creating practical and synergistic linkages between actions at the health system level and among social and economic development initiatives in order to improve health outcomes. Social and economic development initiatives were to have a significant impact on health in the medium and long term and form an important entry point for health development in the NAL region. In the health system, the activity proposed to strengthen the capacity of District and later County Health Management Teams (CHMTs); health facility staff and management committees; Community Health Units (CHUs) and civil society organizations (CSOs). Key target development structures for capacity strengthening included local CSOs, local cooperatives, county leadership, women’s and youth groups, livestock and other cooperatives, religious structures, cultural fora (e.g., elders’ fora), primary and ECD schools, and water management committees. Integrated actions were to include joint outreach actions on livestock and human health as well as joint MNCH and WASH actions. The activity proposed to work with government departments—Ministry of Health (MOH), Ministry of Education (MOE), Ministry of Livestock, National Drought Management Authority (NDMA), and Ministry of Public Services; Youth and Gender Affairs—CSOs, livestock and other cooperatives, schools, water management committees, and cultural structures to integrate interventions that were expected to strengthen the health system with those that were to address social health determinants. The activity was to work with the ministries of Health and Livestock at local levels to combine efforts with mobile pastoral training units to deliver integrated human health and animal health outreach, starting with areas such as Isiolo and Wajir where pastoral training units were already active. The activity was to prioritize the Annual Operating Plan (AOP) cycle and empower sub-county and county health management teams to prepare SMART plans and supervise, document, monitor, and review implementation of a multi￾sectoral approach to attain health and developmental results. End-of-Activity Performance Evaluation - Purpose: Evaluation Services and Program Support (ESPS) received a Task Order (TO) from USAID/KEA to conduct the end-term evaluation of three of the health flagship activities noted above from March 15, 2012, through March 14, 2017. The end-of-project evaluation serves two main purposes: (1) to learn to what extent the activities’ objectives and expected health outcomes at county, sub-county, health facility, and community levels were achieved, including effectiveness of APHIAplus model, key lessons learned, and challenges; and (2) to identify implementation strategies in terms of the “what” and the “how to” so as to ascertain the likelihood of achieving sustainable health and institutional strengthening outcomes for the NAL region. 3 METHODOLOGY In addressing the three key evaluation questions the evaluation team employed a nonexperimental post￾intervention design using a mixed-methods approach that used both quantitative and qualitative elements as described below. The methodology was informed by the evaluation requirement in focus counties: that is HIV (Voluntary Medical Male Circumcision; HIV testing; Elimination of Prevention of Mother to Child Transmission of HIV) in Turkana County only; and the Orphans and Vulnerable Children (OVC) program and Maternal, Newborn, and Child Health (MNCH) in both Turkana and Samburu. 6 3.1 Sources of Data: The following data sources were used for this end-term evaluation:  Document review: The document review provided the Evaluation Team with background information on activity during the life of the activity—March 2012 through March 2017. Specifically, the document review enabled the team to better understand the activity’s goals, objectives, and interventions; inform the design of the data collection tools and instruments; and determine the characteristics of both stakeholders and activity beneficiaries that were interviewed. Activity documents served as secondary data sources for trends analysis when possible. Annex 5 provides the complete list of the documents reviewed for the evaluation.  Key Informant Interviews/Panel Discussions: A cross-sectional design using qualitative methods was used to conduct key informant interviews (KIIs) and panel discussions with various stakeholders and Implementing Partners (IPs) in the NAL region and at national level. Panel discussions/KIIs were conducted with CHMT, SCHMT, LIPs, and CUs to elicit expert opinion on the implementation of the activities, outputs, outcomes, and impacts of the Activity in the NAL region.  Focus Group Discussions: The Evaluation Team conducted focus group discussions (FGDs) with the following five target groups: Maternal Newborn and Child Health (MNCH) clients; Comprehensive Care Clinics (CCC) clients, and Youths (15- to 24-year-olds) who participated in HIV prevention services (restricted to Turkana County); OVC caregivers supporting orphans and vulnerable children; and Community Health Workers (CHW).  District Health Information System (DHIS2) and the Early Infant Diagnosis/Viral Load (EID/VL) System: These were used to abstract HIV program data from the 17 counties supported by the Activity between 2015 and 2017.  Household Surveys and Observations: This evaluation included two cross-sectional household surveys targeting women of reproductive age (15- to 49-year-olds) and OVC households. The objectives of these surveys were to: (a) measure population health estimates guided by some specified key priority indicators on fourth ANC attendance; delivery under skilled attendant; immunization coverage; proportion of children who receive postnatal care (PNC) within 48 hours after birth; skilled birth attendance; family planning uptake specifically for MNCH/FP; and OVC school enrollment, attendance, and progression under OVC support; (b) assess community-based household economic strengthening initiatives; (c) assess water, sanitation, and improved hygiene; (d) assess food security and sustainable livelihoods; (e) assess adoption of health behaviors; and (f) assess barriers to accessing and utilizing health services.  Organizational Institutional Capacity Assessment: This evaluation included an organizational capacity assessment (OCA) of the county health management teams (CHMT), health facilities and community units.  Case Study: Using the priority outcomes and expected health outcomes, the Evaluation Team used a case study approach and analyzed the APHIAplus Imarisha work plans and the corresponding quarterly and annual work plans to determine what worked/not worked over the Life of the Activity. Evidence from the case studies augmented information obtained from primary data obtained during fieldwork (KIIs, FGDs, household surveys, and OCAs). Two validation workshops—one in Maralal (Samburu County), the other in Lodwar (Turkana County) — were conducted to capture stakeholders’ views on implementation strategies and discuss the findings. The validation workshops informed the conclusions of the evaluation and led to the suggested recommendations. 7 3.2 Sampling strategy Selection of health facilities: The health facilities were first stratified by county/sub-county and type of facility. The population of supported health facilities (PMTCT or PMTCT/ART sites) in FY 2015–2016. All were high-volume, as defined by facilities with ANC/PMTCT client load of >200/year for health centers/ dispensaries. The sample included 17 health facilities (eight in Turkana, and nine in Samburu). These provided sites for KIIs, FGDs, and OCAs for this evaluation (see Annex 5 – List of Health Facilities). Note: HIV data (from DHIS and EID/VL databases) for all 17 health facilities supported by the Activity in Turkana between 2015 and 2016 was included in the analysis. Selection of LIPs: All community-based organizations (CBOs) supporting OVC in the target counties supported by the Activity were included in this evaluation. Selection of community units: This was restricted to those linked to a sampled health facility. Each community unit in the sample was purposively selected based on (i) its community work with a sampled health facility, (ii) its functionality, (iii) the community unit’s catchment population, (iii) its proximity to the sampled health facility and/or CBO (in case of more than one CU) and, (iv) its geographical location to ensure a good representation of the activity’s geographic coverage. Thirty-eight OCAs (17 with HFs, 13 with CUs, 8 with CHMTs) were completed during this evaluation. Selection of FGD participants: The Evaluation Team liaised with the MNCH clinics, CCCs, CUs, and CBO in-charges to estimate the average number of clients seen per day (for facility beneficiaries), the number of OVC caregivers (for CBOs supporting OVCs), the average number of Youth (15- to 24-year olds) who participated in HIV prevention services in a month (for CBOs supporting evidence-based interventions targeting youths) and the number of community health workers supporting community work within each sampled facility. A total of 41 FGD were completed (22 in Turkana and 19 in Samburu). Sample for the household survey: A cross-sectional study design was used to estimate the priority health outcome indicators at the household level. This evaluation included two household surveys in the targeted sub-counties: (1) a household whose target population was mother-child (under 5 years) pairs; and (2) a household survey whose target population was OVC–Caregiver pairs. Within each sub-county, cluster random sampling approach with Lot Quality Assurance Sampling (LQAS) technique was used to provide sub-county-specific population health estimates and identify wards within the target sub￾counties that could be lagging behind on program targets. Stratification by wards: Within each sub-county, all wards were identified. The wards served as the primary units (distinct strata) for the survey. Stratification by wards was applied to (i) minimize sampling errors; (ii) ensure proper representation; and (iii) identify wards that are below the program coverage levels. Supervision Areas: All wards served as the LQAS supervision areas (SA) for this end-term evaluation. LQAS samples of 19, 24, and 30 were selected depending on the number of SA in each sub-county. This ensured that the final sample size per SA is sufficient for LQAS classification and estimation purposes at the county level (i.e., on aggregating LQAS sample within each county). A total of 979 for mother-child pairs and 537 OVC caregivers were interviewed. Key informants/panel discussion participants were purposively selected for this evaluation. Representatives of key institutions, government departments, and developmental partners, as well as IP/consortium members who are most informed about APHIAplus Imarisha activity were sampled. In total, 68 key informant interview (KII) sessions (9 at national level, 26 in Turkana County, and 33 in Samburu County) were conducted. 3.3 Data management and analysis Household survey data: Data collection used handheld devices (Android-enabled mobile phones) to collect the survey data. The survey questionnaire was programmed/administered electronically using 8 Survey ToGo Dooblo Software. Relative frequencies with 95 percent Wilson Score Confidence Intervals were used in analysis. The results were classified by constituencies, as well as by indicator definition. All analysis was conducted using STATA 15 (StataCorp. 2015. Stata Statistical Software: Release 14. College Station, TX: StataCorp LP). Routine program HIV data: The team downloaded District Health Information System (DHIS2), and Ministry of Health’s Early Infant Diagnosis/Viral Load (EID/VL) program data from 17 health facilities on selected priority outcome indicators (March 2012 through March 2017). In addition, the evaluation teams conducted data quality assessment to verify the accuracy of the data obtained from DHIS2. Proportions (HIV positivity yield) and 95 percent Wald Confidence Intervals were computed for each priority outcome indicator. All data analysis (graphics) were conducted using R Statistical Programming (v.3.3.3).i Qualitative data analysis relied on content and triangulation analysis, which was adopted as an analysis tool to identify key thematic areas. Triangulation from the different data sources above was used to build a coherent justification for the themes/evidence emerging from desk reviews, interviews with various target respondents, and work plan analysis. Analysis of case studies: The analysis focused on the annual work plans for years 1–5 and the corresponding quarterly progress/annual progress reports, and documents the intended interventions and implementation strategies. 3.4 Organization of fieldwork Timelines: A pre-fieldwork phase desk review (January 2–January 6, 2018) and team planning meeting (January 8–January 13, 2018) were conducted. Research training was conducted within the counties in Turkana (January 14 –January 18, 2018) and Samburu (January 18–January 22, 2018). Fieldwork was conducted from January 18, 2018, through February 8, 2018. The Activity period under review was March 2012 through March 2017. Team composition: IBTCI assembled a team of professionals to conduct the end-term evaluation in the two counties. A senior local public health expert and four local experts led the team. John Paul Oyore, BSc, MSc, PhD, a senior public health expert, served as the team leader and brought both evaluation and HIV technical expertise. He worked with four other Kenyan experts—an RMNCH specialist (Angela Nguku, BSN, MSc, MA), a social scientist (Grace Jowi-Jobita, BA, MA), a public health specialist (Philip Wambua, BSc, MPH), and a monitoring and evaluation (M&E) specialist (Nelly Yatich, BSc, MSc, PhD). Two sub-team leaders coordinated the fieldwork; 36 research assistants (RAs) collected field data and were responsible for gathering household survey data. The sub-team leaders and two capacity assessors collected qualitative data and organizational capacity assessment data. The RAs interviewed mother-child pairs and OVC caregivers while the sub-team leaders and the capacity assessors interviewed health facility staff and county health management teams and conducted FGDs with beneficiaries. ESPS recruited the RA team through the Kenya National Bureau of Statistics, selecting RAs who had prior experience in conducting national surveys and carrying out field-related data collection activities specifically in the assigned counties. 3.5 Limitations The non-experimental post-intervention design used doesn’t account for non-APHIAplus Imarisha activity influences on outcomes because there are no comparison sites or groups; casual attribution is not possible but inferential analysis and triangulation led to an attempt to establish relationship among relevant variables. On immunization, there was a possibility of recall bias for the household survey data since the data collected was based on mother’s report only. The quality of the secondary data sources from the DHIS2 data on HIV led to values of more than 100 percent as a result of poor quality data coming from health facilities. The number of household economic support (HES) groups per ward could 9 not be ascertained, especially in Turkana, thus an estimate of the proportion of HES groups per ward could not be computed. However, the number of HES groups by LIP is presented in the findings section. 4 FINDINGS, CONCLUSIONS, AND RECOMMENDATIONS PHASE I: EVALUATION QUESTIONS EVALUATION QUESTION 1: What is the current coverage/improvement status on the priority health outcomes in HIV/AIDS, RMNCH, Nutrition, Water and Sanitation, and institutional/ organizational capacity building? To the extent possible, determine the activity’s contribution to the observed health outcomes. Voluntary Medical Male Circumcision (VMMC) Figure 1 – % Positivity Yield in Voluntary Medical Male Circumcision Source: DHIS (March 2012–March 2017) VMMC activities scaled up between 2012 and 2014; however, after 2014, there was a notable drop in the number of VMMC clients. Uptake was generally low among males aged 25 and above, and highest among the 15- to 24-year-old clients. VMMC positivity yield dropped from 2.59% (95% CI: 1.7%, 3.4%) in 2012–2013 and 0.38% (0.05%, 0.7%) in 2016–2017. Only five of the sampled facilities reported on VMMC, with reporting rates ranging from 50% to 83.3%. Activity’s contribution: The APHIAplus Imarisha activity supported resuscitation of VMMC activities in Turkana through partnership with a local implementing partner, African Inland Church (AIC)–Turkana West sub-county; renovation of the theatre at AIC Lokichoggio; recruitment of a skilled VMMC team (surgeons, nurses hygiene promoters, HIV Testing and Counseling (HTC) counselor, and community mobilizers); provision of logistics for community entry; community mobilization/awareness activities (during school holidays, through VMMC champions); and post-circumcision support.ii However, there was a lack of MOH ownership of implementation at the county level—the activity implemented the services through their staff deployed by the project with minimal involvement of MOH staff. Therefore, when the activity came to an end there was a lack of continuity and the VMMC services stalled. This applied to other HIV service delivery areas. iii VMCC is considered a new practice within the Turkana community, and the use of VMMC champions aided in increasing its acceptability. iv The activity mostly targeted teenagers and the school-going population rather than more sexually active older boys and men, v as evident in the trends in Figure 1 above. HIV Testing In each program year except for 2015–2016, the HIV positive rate across all age categories was generally higher among females than males. HIV positive rates were generally higher among clients aged 25 years and above than for other age categories. Table 1 – Antenatal HIV Testing Year ANC Testing Testing HIV Positive Known HIV Positive Status Total HIV Positive (at ANC) % Positivity Yield 2012 2397 59 73 132 5.51% 2013 3501 48 99 147 4.20% 2014 5156 72 112 184 3.57% 2015 5128 80 141 221 4.31% 2016 5834 58 158 216 3.70% Source: DHIS (March 2012–March 2017) 10 Figure 2 – Proportion of Pregnant Women Testing Positive at ANC Source: DHIS (March 2012–March 2017) Over the life of the project, HIV positivity yield at ANC decreased from 5.5 percent (95% CI: 4.6%, 6.4%) in 2012–2013 to 3.7% (95% CI: 3.2%, 4.2%) in 2016–2017. There was a scale-up of HIV testing among adults and children. HIV positivity yield (overall), decreased from 4.3% (95% CI: 4.0%, 4.6%) to 1.4% (95% CI: 1.38%, 1.45%). HIV Care and Treatment The proportion of positive clients initiated on ART increased from 52.1 percent (95 percent CI: 48.6, 55.6 percent) in 2012–2013 to 85.5 percent (95 percent CI: 83.1, 87.9 percent) in 2015–2016. Table 2 – HIV Testing in Adults and Children Total Tested for HIV Total HIV Positive % Testing HIV Positive Year Overall Female Male < 15 YRS 15–24 YRS 25+ YRS < 15 YRS 15–24 YRS 25+ YRS 2012 20130 789 4.3% 4.6% 15.3% 34.0% 4.2% 13.8% 28.1% 2013 38718 1075 2.8% 5.9% 14.9% 39.2% 4.6% 5.8% 29.8% 2014 40611 817 2.0% 4.5% 13.2% 38.6% 4.8% 6.2% 32.7% 2015 36542 822 2.2% 3.2% 11.6% 35.3% 5.1% 5.1% 39.8% 2016 71004 972 1.4% 6.8% 12.7% 36.9% 5.1% 3.0% 35.5% Source: DHIS (March 2012–March 2017) Table 3 – Adults and Children HIV Treatment Total Tested for HIV HIV Positive Clients Clients Initiated on ART % Initiated on ART Year Overal l Childre n Adult s Overal l Childre n Adults Overal l Childre n Adults 2012 20130 789 69 720 411 78 333 52.1% 113.0% 46.3% 2013 38718 1075 112 963 564 90 474 52.5% 80.4% 49.2% 2014 40611 817 76 741 621 82 539 76.0% 107.9% 72.7% 2015 36542 822 68 754 703 71 632 85.5% 104.4% 83.8% 2016 71004 972 116 856 1066 142 924 109.7% 122.4% 107.9% Source: DHIS (March 2012–March 2017) Out of all clients initiated on testing HIV positive, the proportion of adults initiated on treatment increased from 46.3 percent (95 percent CI: 42.6 percent, 49.9 percent) to 83.8 percent (95 percent CI: 81.2 percent, 86.4 percent). Activity’s Contribution The activity offered regular technical assistance to HCWs through trainings, mentorships, and supervisory visits;vi and supported HTC through the deployment of short-term HIV Testing Services (HTS) lay counselors who were enrolled in the national HTS proficiency testing for quality assurance. The activity supported the CMLTs and SCMLTs to enroll and distribute the PT panels to the HTC 11 providers, conduct the HTS Direct observations assessment coupled by periodic support supervision to monitor the competency of the HTS providers and collect the PT feedback from the HTS providers.vii HTC provided outreaches (e.g., community HTC in Kalokol Division among the fisher folk and during cultural festivals such as the Tobongu Lore). viii The activity invested (coordinated and provided technical assistance) to the Turkana County Laboratory technical working group and the sub-county Medical laboratory Coordinators to conduct monthly forecasting, quantify rapid test kits, and submit the monthly reports through the rapid test kit online reporting system. This was in an effort to ensure a steady supply of rapid test kits in the county.ix Elimination of Mother-to-Child Transmission of HIV Table 4 – PMTCT Year ANC HIV Testing Testing HIV Positive Known HIV Positive Status Total HIV Positive (at ANC) ANC Positivity Yield Startin g ART % Starting on ART 2012 2397 73 59 132 5.5% 34 25.8% 2013 3501 99 48 147 4.2% 51 34.7% 2014 5156 112 72 184 3.6% 74 40.2% 2015 5128 141 80 221 4.3% 78 35.3% 2016 5834 158 58 216 3.7% 72 33.3% Source: DHIS (March 2012–March 2017) Figure 3 – ANC Clients Starting on ART Source: DHIS (March 2012–March 2017) The proportion of ANC clients starting ART increased from 25.8% (95% CI: 18.3%, 33.2%) in 2012–2013, to 33.3% (95% CI: 27.0%, 39.6%) in 2016–2017. However, the proportion of ANC clients starting ART has been gradually decreasing during the past two years, from 40.2% in 2014 to 35.3% in 2015 and down to 33.3% in year 2016. This could potentially be the result of stigma, discrimination, and nondisclosure in the NAL.1 Figure 4 – % PCR Results at 8 Weeks Source: EID/VL NASCOP System The proportion of PCR results at 8 weeks for the EID tests has progressively increased during the life of the project from none in 2012 to 45% in 2016. There has been a scale-up on the EID testing over time. Figure 5 – % PCR Results (at 8 weeks) Positive 1 IMARISHA Quarterly reports (Oct–Dec 2013, Jul–Sep 2016). 12 Source: EID/VL NASCOP System Over the life of the project, PCR positive results at 8 weeks increased from none in 2012–2013 to 7.7% (95% CI: 3.1%, 12.3%) in 2016–2017. There was a scale-up of PCR results at 8 weeks among children. However, PCR results positivity yield (overall) decreased from 8.9% (95% CI: 1.5%, 16.4%) in 2014 to 7.7% (95% CI: 3.1%, 12.3%) in 2016–2017. Figure 6 – % Initiated on Treatment Source: EID/VL NASCOP System The proportion of children initiated on ART increased from none in 2012 to 79.3% (95% CI: 64.6%, 94.0%) in 2016–2017. Table 5 – Percentage of patients on treatment with viral load suppression % patients (PMTCT clients) with viral suppression Source: EID/VL NASCOP System 2012 2013 2014 2015 2016 Total VL tests done: 0 0 0 0 12 Routine VL Tests with Valid Outcomes: 0 0 0 0 12 Valid Tests > 1000 copies/ml 0 0 0 0 5 Valid Tests < 1000 copies/ml 0 0 0 0 7 Baseline VLs Non-Suppression - - - - 5 (41.7%) Suppression - - - - 7 (58.3%) Among PMTCT clients, the proportion on ART with viral load suppression is 58.3 percent (95 percent CI: 32 percent, 80.7 percent). Activity’s contribution: Dissemination of new guidelines: The activity provides technical assistance (TA) through the support of the latest national guidelines and standard operating procedures (SOPs) on HTS, ART, Kenya Mentor Mother Program (KMMP) guidelines. Whenever a new guideline was in place the activity organized dissemination and rollout activities across the county and supported in the distribution of the new guidelines and SOPs.x Mentor Mothers/Link Desk Volunteers: The activity deployed and supported mentor mothers to act as case managers in high-volume facilities. In addition, they trained eight KMMP training of trainers (TOTs) to help in the rollout mentorship of the mentor mothers in the county. Expert patients were also engaged to help educate patients in the health facilities. This was critical in ensuring adherence to and compliance with PMTCT treatment guidelines for HIV-infected pregnant women during pregnancy, delivery, and until 18–24 months postnatal. In addition, the activity also deployed link desk volunteers 13 within the supported health facilities to help support and direct patients in navigating the health facility as they reached the various points of health care provision within the facility.xi The activity trained and supported Community Health Volunteers (CHV) to sensitize the community on HTS and also conducted defaulter tracing and linked the mothers back to the health facilities.xii The activity also invested in defaulter tracing for HIV-exposed infants through trainings, deployment of expert patients, mentor mothers, and peer volunteers to ensure that they were traced and brought back to health facilities.xiii This was achieved through the activity’s support for psychosocial support groups.xiv These efforts in defaulter tracing ensured retention of HIV-infected mothers and subsequent enrollment and follow-up of their infants. The activity capacity built the Health Care Workers (HCWs) through regular trainings, mentorships, continuing medical education (CMEs), and support supervisory visits on pediatric HIV care and treatment and management of HIV-exposed infants as per the national guidelines;xv as well as on orientations, and mentorships on collection of high-quality dried blood spot (DBS) samples for early infant diagnosis (EID).xvi The activity deployed, trained, and supported adherence counselors to help address the low viral load suppression. The adherence counselors provided treatment preparation sessions in the supported health facilities. The activity also supported the dissemination of the national standard operating procedures (SOPs), sensitization and mentorship of the HCWs and CHVs on treatment preparation, and treatment literacy.xvii These efforts were key in ensuring adherence to treatment guidelines and therefore ensuring client retention into care and treatment and subsequent adherence monitoring that ultimately ensures viral load suppression targets are achieved. To further support treatment adherence, the activity provided logistical support by providing required supplies and stationaries such as airtime, mobile phones, appointment diaries to strengthen the appointment system, and fuel for motorcycles. xviii The activity supported laboratory sample networking for dry blood spot (DBS) and viral load (VL) testing to improve access to EID and VL testing. They supported sample storage, transportation, and documentation, and ensured a reasonable turnaround time for the results to get back to the facility for prompt patient management. The activity supported the printing and distribution of VL and EID results in addition to developing the facility line lists for clients due for routine and repeat VLs and EID tests. The activity also improved the skills of HCWs on DBS and VL sample collection, storage, and transportation through continuous orientations, CMEs, and on-the-job training (OJT).xix The activity supported the monitoring and evaluation function by ensuring proper documentation as per the MOH guidelines and timely and accurate facility reporting. This also included conducting data reconstruction to ensure quality data are in use for decision-making at the facility and county levels.xx The activity also provided logistical support by providing modems and airtime bundles to the MOH to facilitate timely online reporting. In addition, the activity conducted OJT on completion of the HMIS tools and registers and also supported in the distribution of the HMIS tools, registers, and Job Aids from the national/county level to the health facilities in a timely manner.xxi Conclusion  The activity supported resuscitation of VMMC activities, mainly working with AIC Lokichoggio HC through deployment of facility and community VMMC staff. This led to a notable increase in VMMC activities in 2012–2014 reporting periods.  There was lack of local ownership of implementation at the county, sub-county, and facility levels. The VMMC uptake was highest among the 15- to 24-year-old clients compared with males aged 25 and above; this is due to the activity focus on teenagers and school-going children.  Over the life of the activity, there has been an upscale of HTS among adults and children with a corresponding reduction in the HIV positivity rate. This can be attributed to deployment and regular capacity building of HTS lay counselors through trainings, mentorships and support of the HTC outreaches (e.g., Tobongu Lore). 14  VL testing has yielded valid outcomes only since 2016. The proportion of PCR/viral load suppression among PMTCT clients on ART was 58.3 percent (95 percent CI: 32 percent, 80.7 percent).  The ANC positivity rate declined from 5.5 percent to 3.7 percent. The proportion of adults (including ANC clients) and children enrolled into care and treatment increased over time, possibly as the result of continuous TA provided by the activity to HCWs (including adherence counselors) through dissemination of the new national guidelines and SOPs; deployment and support to mentor mothers, expert patients, and link desk volunteers; and support provided to the Community Health Volunteers to sensitize the community on HTS and conduct defaulter tracing in the community. Recommendations  To ensure sustainability, the programs should continue capacity building of CHMT, SCHMTS, and local MoH HCWs in service delivery as opposed to focusing capacity building on the activity deployed staff;  VMMC needs to focus on all sexually active age groups (i.e., 15- 49-year-olds) rather than targeting the school-going children.  Work closely with the county government and advocate for absorption of the deployed staff (e.g., HCWs, adherence counselors, HTS counselors, Mentor Mothers, expert patients, and CHVs) for sustained health outcomes. Maternal, Neonatal, and Child Health/Family Planning Table 6 – ANC attendance, assisted delivery, and postnatal care within 48 hours Constituency N Pregnant women with 4 or more visits Skilled birth attendance Children receiving post-natal care within 48 hours after birth Proportion 95% CI Proportion 95% CI Proportion 95% CI Turkana North 115 61.7 (52.6, 70.1) 66.1 (57.0, 74.1) 69.6 (60.6, 77.2) Turkana West 133 58.6 (50.1, 66.6) 47.4 (39.1, 55.8) 48.1 (39.8, 56.5) Turkana Central 111 51.3 (42.2, 60.4) 72.1 (63.1, 79.6) 64.9 (55.6, 73.1) Loima 85 65.9 (55.3, 75.1) 64.7 (54.1, 74.0) 65.9 (55.3, 75.1) Turkana South 95 67.4 (57.4, 76.0) 55.8 (45.8, 65.3) 53.7 (43.7, 63.4) Turkana East 90 74.4 (64.6, 82.3) 44.4 (34.6, 54.7) 44.4 (34.6, 54.7) Samburu West 112 62.5 (53.2, 70.9) 74.1 (65.3, 81.3) 58.9 (49.7, 67.6) Samburu North 142 62.0 (53.8, 69.5) 67.6 (59.5, 74.7) 59.9 (51.6, 67.5) Samburu East 96 57.3 (47.3, 66.7) 63.5 (53.6, 72.5) 47.9 (38.2, 57.8) Source: IMARISHA ETE MNCH Household Survey (2018) In Turkana County, ANC attendance among pregnant women (four or more visits) varied from 51.3 percent (95 percent CI: 42.2 percent, 60.4 percent) in Turkana Central to 74.4 percent (95 percent CI: 64.6 percent, 82.3 percent) in Turkana East; in Samburu, an even distribution was observed, with the lowest coverage in Samburu East 57.3 (95 percent CI: 47.3, 66.7 percent) and the highest in Samburu West 62.5 percent (95 percent CI: 53.2 percent, 70.9 percent). Assisted birth delivery was on average high in Samburu County, ranging from 63.5 percent in Samburu East to 74.1 percent in Samburu West; in Turkana, skilled birth attendance varied, with lowest coverage observed in Turkana West (47.4 percent) and the highest in Turkana Central (72.1 percent). Figure 7 – Assisted delivery and postnatal care within 48 hours (Source: IMARISHA ETE MNCH Household Survey (2018) Postnatal care within 48 hours after birth varied from 44.4 percent (95 percent CI: 34.6 percent, 54.7) in Turkana East to 69.6 percent (95 percent CI: 60.6 percent, 77.2 percent) in Turkana North; in Samburu, the lowest 15 coverage was observed in Samburu East 47.9 (95 percent CI: 38.2 percent, 57.8 percent) and the highest was in Samburu North 59.9 percent (95 percent CI: 51.6 percent, 67.5 percent). Activity’s Contribution APHIAplus Imarisha was mainly an HIV activity with minimal MNCH activity support.xxii The Government of Kenya (GoK) through the Ministry of Health introduced free maternity services in all public health facilities in June 2013, and services were expanded in October 2016 to include antenatal care, delivery, postnatal care, and emergency referrals for pregnancy-related conditions as well as complications dubbed Linda Mama.xxiii Samburu County: In Samburu County, the activity built the capacity of HCWs on MNCH and Basic Emergency Obstetric and Neonatal Care (BEmONC) through trainings, mentorships, and CMEs.xxiv They also supported integrated outreaches in the community that were meant to increase access and utilization of the health services in the vast county and also because of the nomadic lifestyle of the inhabitants.xxv The activity constructed and supported maternal shelters to improve skilled deliveries [e.g., Kisima HC maternal shelter, Lesidai Dispensary maternal shelter (Samburu Central) and Nachola Dispensary maternal shelter (Samburu North)]. The activity also provided supplies such as mattresses, solar lighting, and washing basins to the maternal shelters and the community provided labor.xxvi The activity also helped develop SOPs and data capture tools for the maternal shelters to standardize the practice as the service expands. It is worth noting that the fact that health facility deliveries were free of charge also encouraged many pregnant women to deliver at the health facility.xxvii The Activity trained and supported CHVs to educate mothers on the importance of skilled deliveries and to refer them to the nearest health facility for deliveries.xxviii The CHVs would also refer mothers to attend the ANC and subsequently PNC services after deliveries. To further boast skilled birth attendance, the activity provided free mother-baby packs (e.g., shawls, soap, and baby bags). xxix The activity also supported BOMA model implementation, for instance, through the support of Bendera CU.xxx In addition they implemented the UMATI concept through facilitation of the HCWs to provide services during various community forums.xxxi Turkana County: In Turkana County, APHIAplus Imarisha engaged, trained, and supported CHVs as community advocates and as referral agents to support MNCH services.xxxii This helped in community mobilization and in creating demand for MNCH services. Integrated outreaches were also supported by the activity in Turkana County to reach women in marginalized areas. xxxiii To address the supply side of service delivery, the activity built HCWs’ capacity through regular mentorships, CMEs/orientations, and trainings on Emergency Obstetric and Neonatal Care (EmONC) to improve their knowledge and skills to offer EmONC services at the supported health facilities.xxxiv This helped build the HCWs’ capacity to manage EmONC and refer as appropriate and in a timely manner. In addition, the activity supplied MNCH equipment and supplies that were done through the county.xxxv Patient social support groups (PSSGs) were also supportedxxxvi and these helped promote skilled birth deliveries. Status of Expected Health Outcomes of Fully Immunized Children Under 1 Year Table 7 shows the percentage of children under 1 who received specific vaccinations at any time before the survey, according to the mother’s report by constituency. The Kenyan immunization program considers a child to be fully vaccinated if the child has received all basic vaccinations [including BCG, three doses each of the DPT-HepB-Hib (also called pentavalent) and polio vaccines, and a vaccination against measles] and three doses of the pneumococcal vaccine (KDHS, 2014).xxxvii Coverage levels for fully vaccinated children under 1 were the lowest in Loima (2.4 percent), followed by Turkana Central (9.1 percent) and Turkana West (9.4 percent). The highest proportion of children under 1 in Samburu West (21.4 percent) and Samburu East (19.6 percent) were fully immunized. Coverage levels for fully 16 vaccinated children under 1 were identical with the coverage level for all basic immunizations in all constituencies except in Turkana South, Turkana East, and Samburu East. Table 7 – Vaccinations, percentage of children under 1-year PENTAVALENT OPV PCV % 95%CI Constituenc y n % wit h car d BCG 1 2 3 0 1 2 3 Measl es ALL basic immunization s 1 2 3 Fully vaccinated Turkana North 5 5 92. 7 92. 7 67. 3 56. 4 38. 2 58. 2 72. 7 45. 4 27. 3 36.4 10. 9 (2.7, 19.1) 70. 9 49. 1 38. 2 10. 9 (2.7, 19.1) Turkana West 6 4 87. 5 95. 3 73. 4 51. 6 43. 7 67. 2 84. 4 54. 7 46. 9 25.0 9.4 (2.2, 16.5) 78. 1 48. 4 42. 2 9.4 (2.2, 16.5) Turkana Central 4 4 97. 7 95. 4 81. 8 61. 4 45. 4 79. 5 84. 1 70. 4 54. 5 20.4 9.1 (0.5, 17.6) 84. 1 65. 9 43. 2 9.1 (0.5, 17.6) Loima 4 2 100 .0 97. 6 50. 0 40. 5 35. 7 69. 0 92. 9 71. 4 50. 0 30.9 2.4 (0.0, 7.0) 71. 4 50. 0 45. 2 2.4 (0.0, 7.0) Turkana South 3 8 89. 5 100 .0 71. 0 47. 4 39. 5 78. 9 89. 5 47. 4 42. 1 23.7 13. 2 (2.4, 23.9) 84. 2 44. 7 34. 2 10. 5 (0.7, 20.2) Turkana East 5 0 96. 0 98. 0 78. 0 66. 0 48. 0 62. 0 90. 0 68. 0 44. 0 36.0 16. 0 (5.8, 26.2) 82. 0 68. 0 46. 0 14. 0 (4.4, 23.6) Samburu West 4 2 97. 6 97. 6 76. 2 71. 4 57. 1 54. 8 83. 3 71. 4 57. 1 42.9 21. 4 (9.0, 33.8) 76. 2 73. 8 59. 5 21. 4 (9.0, 33.8) Samburu North 6 4 89. 1 96. 9 87. 5 68. 7 53. 1 67. 2 87. 5 68. 7 53. 1 26.6 10. 9 (3.2, 18.5) 79. 7 65. 6 51. 6 10. 9 (3.2, 18.5) Samburu East 4 6 95. 6 95. 6 80. 4 76. 1 50. 0 63. 0 89. 1 76. 1 52. 2 34.8 21. 7 (9.8, 33.6) 78. 3 71. 7 54. 3 19. 6 (8.1, 31.0) Source: IMARISHA ETE MNCH Household Survey (2018) In a given constituency, more children under 1 have received their first dose of the DPT vaccine than their third dose of the DPT. Differentials in coverage across constituencies showed lower proportions of children had received either their first or third DPT dose in Loima (50 percent for DPTI and 35.7 percent for DTP 3) and Turkana North (67.3 percent for first dose and 38.2 percent for the third dose of the DTP). Measles coverage fluctuated between 20.4 percent in Turkana Central and 42.9 percent in Samburu West. Activity’s contribution to children under 1 fully immunized a) Turkana County: The activity provided TA through regular mentorship, CMEs, and supportive supervisory visits to the HCWs on immunization.xxxviii In addition, It supported the county to ensure against stockout of vaccines and for proper maintenance of cold chain.xxxix Given the vastness of the county and nomadic lifestyle of the population, the activity invested in outreaches (e.g., supported FBOs and MOH facility outreaches). xl This was critical in increasing access to immunization services. They also offered targeted support to national immunization campaigns (e.g., polio campaigns). xli To improve the demand of immunization services, the activity trained and supported CHVs to be advocates of immunization. The CHVs provided health education, mobilized mothers and referred them to the health facility to seek immunization services.xlii b) Samburu County: The activity provided TA through routine mentorship, CMEs, and supportive supervisory visits to the HCWs on immunization.xliii They invested in outreaches (e.g., supported FBOs and MOH facility outreaches). xliv To increase the demand for services, the activity trained and supported CHVs to be advocates of immunization. The CHVs provided health education, mobilized mothers, and referred them to the health facility to seek immunization services.xlv Conclusion 17 APHIAplus Imarisha was heavier on HIV activity than MNCH activity support over the life of the activity in regard to resource allocation and focus outreach interventions. The activity used CHVs as advocates and referral agents for ANC, SBA, PNC, and immunization services in the community; however, the role of CHV is not institutionalized. The GOK free maternity care, coupled with activity’s provision of maternal shelters, free mother-baby packs, and awareness creation through the UMATI concept helped promote skilled birth attendance. Capacity building of the HCWs and provision of EmONC equipment and supplies improved availability to services. In addition, due to the nomadic lifestyle of the population, integrated outreaches helped improve access to ANC and PNC services; however, immunization coverage was significantly low. Recommendations  There is a need to allocate more resources toward MNCH activity support to improve and sustain MNCH indicators.  The role of the CHVs needs to be institutionalized to advocate and mobilize for the MNCH services.  Integrated outreaches should continue to be promoted to increase access to ANC, PNC, and immunization attendance.  There is a need to further investigate the reason for such a low yield for immunization services despite the implementation of integrated strategies. Furthermore, more resources and collaboration between stakeholders is needed to ensure access to all immunizations, especially OPV 3, DPT3, and measles vaccines. Orphans and Vulnerable Children OVC program outcome indicators were assessed in wards where IMARISHA implemented its OVC program (see Annex 2 – Methodology). School enrollment, attendance, and progression Table 8 below shows the status of OVC school enrollment, attendance, and progression as of February 2018. In Turkana County, Loima constituency recorded the lowest rate of OVC school attendance at 86.7 percent (95 percent CI: 70.3 percent, 94.7 percent) while Turkana West had the highest enrollment rate of 97.7 percent (95 percent CI: 84.4 percent, 95.7 percent). In Samburu County, enrollment rates were Samburu West 84.3 percent (95 percent CI: 75.0 percent, 90.6 percent); Samburu North, 84.8 percent (95 percent CI: 71.8 percent, 92.4 percent); and Samburu East, 92 percent (95 percent CI: 81.5, 96.9 percent). The lowest school attendance rate was recorded in Loima constituency at 60 percent (95 percent CI: 42.3, 75.4 percent), and highest was in Samburu North, 78.3 percent (95 percent CI: 64.4 percent, 87.7 percent). School progression rate was lowest in Turkana Central at 72.9 percent (95 percent CI: 59.0 percent, 83.4 percent) and highest in Turkana North, 93.3 percent (95 percent CI: 78.7 percent, 98.1 percent). Table 8 – OVC school enrollment, attendance, and progression Source: IMARISHA ETE OVC Household Survey (2018) Constitu ency % Enrollment % Attendance % Progression N Fem ale N Mal e Cumul ative Propo rtion 95% CI N Fem ale N Ma le Cumul ative Propo rtion 95% CI N Fem ale N Mal e Cumul ative Propo rtion 95% CI Turkana North 1 2 83. 3% 1 8 100. 0% 93.3% (78.7, 98.1) 1 2 66. 7% 1 8 77. 8% 73.3 (55.5, 85.8) 1 2 83. 3% 1 8 100. 0% 93.3% (78.7, 98.1) Turkana West 4 9 89. 8% 4 7 93.6 % 97.7% (84.4, 95.7) 4 9 65. 3% 4 7 76. 6% 70.8 (61.1, 79.0) 4 9 87. 8% 4 7 93.6 % 90.6% (83.1, 95.0) Turkana Central 2 5 84. 0% 2 3 73.9 % 79.2% (65.7, 88.3) 2 5 80. 0% 2 3 65. 2% 72.9 (59.0, 83.4) 2 5 76. 0% 2 3 69.6 % 72.9% (59.0, 83.4) Loima 1 8 88. 9% 1 2 83.3 % 86.7% (70.3, 94.7) 1 8 55. 6% 1 2 66. 7% 60.0 (42.3, 75.4) 1 8 88. 9% 1 2 83.3 % 86.7% (70.3, 94.7) 18 Turkana South 5 2 94. 2% 4 4 97.7 % 95.8% (89.8, 98.4) 5 2 71. 1% 4 4 86. 4% 78.1 (68.9, 85.2) 5 2 88. 5% 4 4 95.4 % 91.7% (84.4, 95.7) Turkana East 3 6 91. 7% 2 4 91.7 % 91.7% (81.9, 96.4) 3 6 80. 6% 2 4 66. 7% 75.0 (62.8, 84.2) 3 6 86. 1% 2 4 87.5 % 86.7% (75.8, 93.1) Samburu West 4 2 80. 9% 4 1 87.8 % 84.3% (75.0, 90.6) 4 2 71. 4% 4 1 75. 6% 73.5 (63.1, 81.8) 4 2 80. 9% 4 1 85.4 % 83.1% (73.6, 89.7) Samburu North 2 2 90. 9% 2 4 79.2 % 84.8% (71.8, 92.4) 2 2 86. 4% 2 4 70. 8% 78.3 (64.4, 87.7) 2 2 90. 9% 2 4 79.2 % 84.8% (71.8, 92.4) Samburu East 3 1 90. 3% 2 0 95.0 % 92.2% (81.5, 96.9) 3 1 80. 6% 2 0 70. 0% 76.5 (63.2, 86.0) 3 1 90. 3% 2 0 95.0 % 92.2% (81.5, 96.9) Activity Contributions There was a focus on the girl child necessitated by the low enrollment, attendance, and progression rates in the NAL region. The Activity promoted girl-friendly policies, held monthly mentoring sessions for girls, distributed sanitary towels, and supported progression of girls with comparatively lower marks to post-primary institutions.2 In Turkana County, the Activity provided education and training services to increase school enrollment, ensure school retention and transition by paying school fees to OVC in secondary schools and vocational training institutes, and by distributing school uniforms, scholastic materials, and sanitary pads. OVCs who passed KCPE were linked to Presidential Bursary fund.xlvi This helped reduce absenteeism and school dropouts. To further support retention in schools, the activity adopted AMREF’s 4 R model (Rescue, Reintegrate, Rehabilitate, and Re-socialize) to improve referral mechanisms and case management for school dropouts. xlvii The activity also supported life skills by holding OVC station days during school holidays.xlviii In Samburu County, the activity supported school fees payment to OVC and distribution of school uniforms and shoes, sanitary pads, and life skills messages during OVC station days. In collaboration with the county government, the activity supported the enrollment of OVCs in a bursary fund. xlix This was aimed at increasing OVC enrollment, retention, and progression in schools. The activity supported life skills, sexual and reproductive health, and better hygiene practices in schools through health clubs.l Household Participation in Community-Based HES Groups Table 9 – OVC Household participation in community-based HES groups Constituency Ward N Goat Rearing Poultry Production SILC Vegetable Production Animal Lodging Other None Source: IMARISHA ETE MNCH Household Survey (2018) Turkana North Lake Zone 30 0.0% 0.0% 3.0% 0.0% 0.0% 2.0% 83.3% Turkana West Lokichoggio 96 1.0% 0.0% 3.1% 2.1% 0.0% 8.3% 85.4% Turkana Central Lowdar Township 25 0.0% 0.0% 4.0% 0.0% 0.0% 0.0% 96.0% Kanamkemer 23 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 100.0% Loima Turkwel 30 0.0% 3.3% 16.7% 3.3% 0.0% 0.0% 76.7% Turkana South Kaputir 25 4.0% 0.0% 8.0% 8.0% 0.0% 8.0% 72.0% Katilu 23 0.0% 0.0% 17.4% 0.0% 0.0% 0.0% 82.6% Lobokat 24 0.0% 0.0% 8.3% 4.2% 0.0% 4.2% 83.3% Lokichar 24 0.0% 0.0% 16.7% 0.0% 0.0% 4.2% 79.2% Turkana East Katilia 30 0.0% 0.0% 6.7% 0.0% 3.3% 0.0% 90.0% Lokori/Kochodin 30 0.0% 0.0% 0.0% 0.0% 0.0% 3.3% 96.7% Samburu West Lodokejek 18 0.0% 0.0% 5.6% 0.0% 0.0% 0.0% 94.4% Suguta Marmar 19 5.3% 5.3% 21.0% 10.5% 0.0% 5.3% 52.6% Maralal 25 0.0% 0.0% 12.0% 0.0% 0.0% 0.0% 88.0% Poro 21 9.5% 0.0% 4.8% 0.0% 0.0% 4.8% 81.0% Samburu North El-Barta 25 0.0% 0.0% 4.0% 0.0% 0.0% 4.0% 92.0% Nachola 21 0.0% 0.0% 14.3% 14.3% 0.0% 0.0% 71.4% Samburu East Waso 24 0.0% 4.2% 12.5% 8.3% 0.0% 20.8% 54.2% Wamba East 24 0.0% 0.0% 11.1% 3.7% 0.0% 7.4% 77.8% 2 Year 1 Work Plan; Annual Report (2015); FGD OVC Caregiver RCEA Watoto Wazima Initiative (2018). 19 Number of Functional Household Economic Strengthening Groups within Each County Table 10 – Number of HES groups County LIP # of HES support groups Samburu CDM 6 KIBA 3 SAIDIA 4 SCAAP 11 SOL 4 Total 28 Turkana - Source: Catholic Relief Service Activity Contribution In Turkana County, the activity supported LIPs to deliver economic strengthening services with a focus on capacity building of the groups to improve household nutrition and increase income. Under SILC, the project offered training on savings and loans and linked the SILC groups with microfinance institutions. The Beneficiaries were also trained on business skills (soap making, greenhouse farming) and given irrigation kits and drought-resistant seeds. They were given rainbow roosters, dairy goats, and poultry management. li In addition, the activity also provided seed capital to business development groups.lii However, the LIP that took over from APHIAplus Imarisha reported directly to USAID and did not therefore continue with CRS-initiated activities. All HES activities ceased in 2015. After group formation and initial investments to the HES activities, no reports were made through APHIAplus Imarisha. 3 In Samburu County, the activity provided food preservation methods and trained on improved poultry management, dairy goats, and small business management.liii The activity supported livelihood activities through group activities. Groups received greenhouses, water tanks, seeds for horticultural production, chicks, goats, and grantsliv . In Samburu, the block grants were successful in the institutions where they were initiated. The OVC caregiver support groups and the OVC households learned to replicate the same initiatives to benefit the OVC in their households. 4 The activity identified 10 institutions that benefited from a block grant that helped them establish economic initiatives that provided food to the OVC household and excess products sold and the money use to pay OVC school fees and buy other scholastic materials. The institutions were to partner with OVC caregivers groups.lv The activity also provided seed capital to OVC caregivers to start small businesses.lvi Barriers mentioned by OVC caregivers during FGD include high cost of farm inputs, drought, low or no agricultural extension support, lack of markets for products, and loans defaulting under SILC.5 Possible strategies for increasing uptake include mapping and identifying viable HES initiatives to be supported until the beneficiary is stable; incorporating sustainable technical support in HES initiatives (e.g., linkages to relevant national/county government departments) and empowering LIPs; and gradually phasing out direct support to OVC when the household is economically more stable to stand on its own.6 Conclusion School enrollment and progression was generally high. In support of school enrollment, attendance, and progression, the activity invested in capacity building through school fee payments, bursary funds, vocational skills training, and life skills training (including sexual and reproductive health). The activity also provided scholastic and other needed materials (e.g., sanitary pads). 3 FGD OVC Caregivers – RCEA Watoto Wazima; FGD CHV Kanamkemer; KII CRS 4 KII – CRS; SAIDIA LIP (Samburu) 5 FGD OVC Caregivers – RCEA Watoto Wazima LIP in Turkana, SAIDIA LIP, CARITAS LIP, and KIBA LIP in Samburu 6 KII with CRS, QR3 2016 Progress Report, KII with SAIDIA LIP Manager Samburu 20 To support HES, the activity provided capacity building on SILC, small business skills, agro-business, and livestock rearing trainings. In addition, the activity procured and distributed drought-resistant seeds, dairy goats, poultry, and irrigation kits to support OVC households. The activity also provided seed capital to business development groups and block grants to schools that were a success. Recommendations  There is a need to allocate more resources to block granting because it was successful in meeting the educational and nutritional needs of the OVC in the beneficiary institutions during the life of the activity. The resources should focus on granting OVC caregiver business groups and OVC households.  To strengthen the household economics, there is need to invest in more income-generating activities (IGAs) suitable for this population to enhance their resilience.  Increase the OVC services offered beyond Education and HES per the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) OVC 2012 guidelines.  County government needs greater involvement and ownership for the sustainability of the HES initiatives, particularly the block grant.  Focus more effort on school attendance to improve/sustain school progression. EVALUATION QUESTION 2: To what extent has the activity increased the capability of health community, health facility and county health management teams to sustain the gains in the observed health outcomes? The findings below show the capacity of community units, health facilities, and CHMTs to sustain gains in the health outcomes. Community Health Unit Capacity to Sustain Health Gains: The MOH CHU functionality scorecard was adapted in this ETE to assess a CU’s performance management, resource allocation, and decision-making. Nineteen parameters (11 process indicators, five performance indicators, and three cardinal elements for basic functionality) were used to score a CU.lvii Figure 8 – Community Unit Functionality Profile Source: IMARISHA ETE: Institutional Capacity Assessment (2018) CU Functionality Score Turkana Samburu No. of CU Score 80 & Above 0 1 1 50%–79% 6 3 9 < 50% 0 3 3 Total 6 7 13 Of the sampled CUs, 3/13 were non￾functional and 9/13 were semi￾functional; only one CU (South Horr CU) was classified as functional. More than 50 percent of the sampled CUs did not have CHV kits (i.e., a kit per CHV based on content agreed upon by the project and CHMT as guided by the national policy); 8/13 (61.5 percent) did not have a chalk board (MOH 516); 11/13 (93 percent) reported that CHVs do not receive a monthly stipend of Kshs. 2000; 8/13 (61.5 percent) did not have means of transport (bicycles) available for use by CHVs; and 7/13 (54 percent) did not hold quarterly meetings to review CU work plans with minutes. The Activity identified “Expert Clients” from among the PLHIV who were contracted to work at the CCC centers. The Expert Clients were trained and remunerated to work as CHVs while a large percentage of them were not linked to the CHUs as indicated by the stakeholders in Turkana and 21 Samburu in the validation workshops and the CHVs in all FGDs. The Expert Clients took over the responsibilities of the CHVs at the facility and occasionally at the household during defaulter tracing. Health Facilities Capacity to Sustain Health Gains: Capacity of health facilities was assessed using eight parameters: governance/planning (management, planning, and financing), financing, human resources (availability of medical officers, nurse/midwife, clinical officers, counselors, nutritionists, pharmacists, lab technicians/technologists, health records officers, PH officers/technicians, CHEW), service availability (family planning, antenatal care, postnatal care, immunization, PAC, maternity, TB prevention and treatment, EID, HIV testing, HIV care and treatment, VMMC, PEP, malaria prevention and treatment, and nutrition), staff training, CHV services (FP, immunization, well-baby care, TB-DOTS, health education, HTS, and malaria prevention), quality improvement (number of supervisory visits, QI team in place, availability of guidelines for the implementation of standards, and QI meetings), and physical office space/furniture. lviii Health facilities that scored below the 25th percentile on each parameter were classified as having no capacity. The table below shows the number of health facilities in each category. Table 11 – Capacity of Health Facilities NUMBER OF HEALTH FACILITIES No Capacity Low Capacity Moderate Capacity High Capacity Governance/Planning 0 3 5 10 Financing 1 3 6 8 Human Resources 1 5 2 10 Service Availability 0 1 1 16 Staff Training 2 4 2 10 Services Offered by CHV 5 4 4 5 Quality Improvement 4 3 4 7 Physical Space (Office space/Furniture) 0 6 1 11 Scoring criteria: Score below 25th percentile – No capacity; 25th–50th percentile – Low capacity; 50th–75th percentile – Moderate capacity; Above 75th percentile – High capacity; Source: IMARISHA ETE ICA (2018) More than half of the assessed health facilities had moderate to high capacity to sustain the observed health outcomes. The table below shows individual facility scores on the assessed parameters. The assessed health facilities scored at least 50 percent on governance/planning, service availability, and existence of physical space. There were varied outcomes on financing with capacity scores ranging between 14.3 percent and 100 percent. On human resources, all except South Horr dispensary scored at least 50 percent. Staff training scores were varied, ranging from 15.8 percent and 100 percent; services offered by CHV ranged from 0 percent to 100 percent. The facilities scored between 25 percent and 100 percent on quality improvement. S/CHMT Capacity to Sustain Health Gains: The ETE assessed the County and Sub-County health management teams’ ability to sustain gains in health using three sets of nine parameters: (1) governance/policy, which included governance (demonstrated capacity to develop health strategy, implementation of the strategy, capacity to engage with the health and other relevant sectors within the county, capacity to develop health policies, and ownership of the health system), human resources (ability to recruit/deploy/retain staff; conduct performance appraisal; undertake staff capacity development based on identified need; planning for the entire health system; equitable distribution of staff), and health financing (develop evidence-based budgeting; source for sustainable budget; availability of financial policies, procedures, and compliance; and ability to monitor/ensure accountability for county finances); (2) medical products and technologies, including access to products and commodities 22 (ability to provide oversight for product and commodity management, oversight for health supply chain management, developing/adapting county-owned logistics information management, and ability to oversee quality of products); delivery of health services (develop/distribute policies, strategies, guidelines on standard of care; effectively implement policies and strategies; deliver HIV/AIDS, TB, RMNCH, Nutrition, WASH, and Malaria programs; supervise use of health delivery policies, strategies and guidelines, and standard operating procedures; and demonstrated equity strategies in service provision); and health information systems (timely linking/reporting of county data with DHIS; provision of oversight on data quality assurance; and ability to monitor/evaluate key program performance indicators, and use in planning); and (3) enabling environment for sustainability including innovations (development/adaptation of innovations; scaling up innovations; and harness impacts from the innovations); networking, linkages, collaboration and partnership (ability to hold multi-sectoral stakeholder forum; coordination of various sectors aligned to health; and implementation of stakeholders resolutions); and sustainability (ability to sustain technical competencies to deliver projects after phase-out; financial leverage; and creation of an enabling environment to sustain programs). The table below shows the individual institutional scores on the nine parameters. Table 12 –Capacity of Health Facility to Sustain Gains in Health Governance / P lanning F inancing Human Resources S ervice Availability S taff training S ervices offered by CHV QI P hysical space 4 7 4 14 19 8 4 6 Catholic Hospital Wamba 4 (100% ) 4 (57.1% ) 4 (100% ) 14 (100% ) 19 (100% ) 0 (0.0% ) 4 (100% ) 6 (100% ) S AMBURU COUNTY RE F E RRAL HOS P ITAL 4 (100% ) 2 (28.6% ) 4 (100% ) 14 (100% ) 19 (100% ) 7 (87.5% ) 3 (75.0% ) 6 (100% ) Katilu District Hospital 2 (50.0% ) 5 (71.4% ) 2 (50.0% ) 14 (100% ) 15 (78.9% ) 7 (87.5% ) 4 (100% ) 6 (100% ) Kisima Health Centre 3 (75.0% ) 5 (71.4% ) 4 (100% ) 13 (92.8% ) 16 (84.2% ) 8 (100% ) 2 (50.0% ) 6 (100% ) S uguta MarMar 4 (100% ) 5 (71.4% ) 4 (100% ) 11 (78.6% ) 15 (78.9% ) 7 (87.5% ) 3 (75.0% ) 4 (66.7% ) Lesirikan 3 (75.0% ) 3 (42.8% ) 2 (50.0% ) 12 (85.7% ) 6 (31.6% ) 4 (50.0% ) 2 (50.0% ) 3 (50.0% ) Wamba Health Centre 4 (100% ) 6 (85.7% ) 4 (100% ) 14 (100% ) 17 (89.5% ) 2 (25.0% ) 2 (50.0% ) 6 (100% ) S ereolipi Health Centre 4 (100% ) 5 (71.4% ) 4 (100% ) 14 (100% ) 16 (84.2% ) 2 (25.0% ) 1 (25.0% ) 6 (100% ) Archer's P ost Health Centre 4 (100% ) 2 (28.6% ) 4 (100% ) 12 (85.7% ) 12 (63.1% ) 3 (37.5% ) 1 (25.0% ) 3 (50.0% ) Kerio HC 3 (75.0% ) 7 (100% ) 2 (50.0% ) 14 (100% ) 6 (31.6% ) 5 (62.5% ) 4 (100% ) 3 (50.0% ) AIC Kalokol HC 4 (100% ) 7 (100% ) 4 (100% ) 13 (92.8% ) 15 (78.9% ) 2 (25.0% ) 4 (100% ) 6 (100% ) Lokichar RCE A HC 2 (50.0% ) 6 (85.7% ) 2 (50.0% ) 14 (100% ) 18 (94.7% ) 7 (87.5% ) 4 (100% ) 6 (100% ) Nakwamoru HC 2 (50.0% ) 6 (85.7% ) 3 (75.0% ) 12 (85.7% ) 5 (26.3% ) 5 (62.5% ) 1 (25.0% ) 6 (100% ) Kainuk HC 3 (75.0% ) 7 (100% ) 4 (100% ) 14 (100% ) 11 (57.9% ) 6 (75.0% ) 4 (100% ) 6 (100% ) S outh Horr GOK Dispensary 4 (100% ) 1 (14.3% ) 1 (25.0% ) 13 (92.8% ) 17 (89.5% ) 4 (50.0% ) 1 (25.0% ) 3 (50.0% ) S t. Mary's Kalokol P rimary HC 3 (75.0% ) 4 (57.1% ) 2 (50.0% ) 7 (50.0% ) 4 (21.0% ) 1 (12.5% ) 3 (75.0% ) 3 (50.0% ) Lokori P rimary Health P rogramme 4 (100% ) 6 (85.7% ) 3 (75.0% ) 11 (78.6% ) 3 (15.8% ) 6 (75.0% ) 4 (100% ) 6 (100% ) S t.P atrick 4 (100% ) 6 (85.7% ) 4 (100% ) 10 (71.4% ) 9 (47.4% ) 4 (50.0% ) 3 (75.0% ) 3 (50.0% ) Source: IMARISHA ETE Institutional Capacity Assessment (2018) Table 13 – Capacity of County and Sub-County HMT to Sustain Gains in Health Source: IMARISHA ETE Institutional Capacity Assessment (2018) Govern ane HR Health financin g Access to products & commodities Deliver y of health services Health information system Innovatio n Networking, linkages/ collaboration Sustainability Samburu North SCHMT 55.0% 50.0% 50.0% 75.0% 55.0% 70.0% 66.7% 33.3% 33.3% Samburu Central SCHMT 75.0% 54.2% 62.5% 50.0% 55.0% 65.0% 50.0% 33.3% 20.8% Samburu East SCHMT 75.0% 45.8% 56.3% 75.0% 75.0% 70.0% 58.3% 37.5% 33.3% Samburu CHMT 60.0% 62.5% 50.0% 75.0% 70.0% 70.0% 66.7% 37.5% 37.5% Turkana West SCHMT 55.0% 54.2% 56.3% 75.0% 70.0% 55.0% 25.0% 12.5% 12.5% Turkana Central SCHMT 80.0% 75.0% 68.8% 75.0% 75.0% 65.0% 75.0% 12.5% 37.5% Turkana CMHT 85.0% 79.2% 75.0% 75.0% 75.0% 85.0% 75.0% 37.5% 45.8% Turkana East SCHMT 50.0% 50.0% 50.0% 50.0% 50.0% 60.0% 33.3% 12.5% 16.7% Figure 9 – Capacity of County and Sub-County HMTs to Sustain Gains in Health 23 For governance, Samburu North SCHMT and Turkana Central SCHMT score over 80 percent; for HR, only Turkana Central SCHMT and Turkana CHMT score above 75 percent; and for health information systems, only Turkana CHMT scored above 80 percent. None of the assessed S/CHMTs scored above 80 percent on health financing, access to health products and commodities, delivery of health services, innovation, networking/linkages/collaboration, or sustainability. Conclusions  The Activity strategy for expert clients to serve as the link between the facilities and the community affected the role of CHVs within a CU.  Capacity assessment of health facilities depicts varied services offered by CHVs across the sampled health facilities as well as gaps on quality-improvement initiatives.  Low capacity exists among the S/CHMTs to develop/adapt innovations, form networks, and coordinate multi-sectoral forums on health-related issues. Recommendations  S/CHMTs should consider incorporating quality-improvement initiatives at health facilities.  Future programming or investment should focus on building the capacity of the S/CHMT to develop/adapt innovations, form networks, and coordinate multi-sectoral forums on health-related issues. EVALUATION QUESTION 3: What implementation challenges did the activity face during the implementation period and how were these challenges addressed? (This question will examine successes and challenges with the primary outcomes and is expected to be key to programmatic and management lessons learned especially on institutional capacity building, sustainable household economic strengthening (HES) models for OVC vulnerable households, and overall sustainability of implemented strategies to guide future programming decisions.) Challenges and How They Were Addressed Result 3  Vastness of the areas. This posed transportation challenges for patients seeking health services.lix This also posed a challenge in coordination of the implementation activities. The activity established and supported county offices to minimize implementation costs.  HCWs strikes. Nurse and doctor strikes happened in 2015 and 2017. This affected provision of services in the public health facilities and reduced utilization of services. This remained underutilized for a number of weeks as the situation slowly returned to normal; lx the activity deployed staff at the supported health facilities continued to offer services during this period.  Rampant insecurity.lxi The activity installed satellite-based vehicle tracking, VHF radios, and satellite phones to complement GSM networks in all its fleet of vehicles. The activity regularly updated the Team Communication tree and the emergency contact list. The activity developed project security protocols and had affirmative action favoring locals in staff recruitment. 24  High poverty levels.lxii IGA training was held for most vulnerable households with the priority focus on empowering women and girls.  Poor infrastructure and harsh terrain.lxiii The activity procured a fleet of hard-top Land Cruisers and held regular joint review and planning sessions with the MOH and other stakeholders;  Reduced funding for community health strategy. Reduced funding to CHUs affected the service delivery with many of the CUs facing attrition after the stipend previously received by CHWs was stopped. This was partially addressed by providing the CHVs with non-monetary incentives as well as supporting them to have IGAs as a form of alternative income.  Reduced funding midstream for activity implementation that led to some consortium members pulling out (e.g., FHI360, BroadReach Health Care, University of Maryland). To address this AMREF Health Africa (the Prime Partner) absorbed most of the staff that had been employed by the partners to ensure that the technical skills that they were bringing on board continued.  Inequalities that resulted from the activity focused on high-volume health facilities and some health facilities felt left out.lxiv This was due to the interest in achieving numbers (activity targets) due to donor requirements.  The activity transport refunds for the laboratory sample networking were inconsistent, which led to delays in turnaround time. lxv The Activity formed and supported the County Laboratory Technical Working Group. Result 4  Strategic changes (some initiated by the USAID/USD such as the new PEPFAR OVC guidelines for 2012) laid more emphasis on HES than focusing on the relief model. Reduced funding to CHUs affected the service delivery since the CHVs could no longer receive stipends, leading to attrition. Sustainability of Implemented Strategies Result 3  Lack of MOH ownership of implementation at the county level – The activity implemented the services through their staff deployed by the project with minimal involvement of MOH staff (e.g., VMMC was implemented through AIC with minimal involvement of the Turkana West SCHMT and the local staff). This applied to other HIV service deliverylxvi – When the activity came to an end there was lack of continuity and the VMMC services stalled.  Based on the lessons learned from the Activity, Turkana County government had a Bill in County Assembly that sought to formalize the Community Health Strategy by employing CHVs.  Sporadic shortages of rapid test kits for HIV testinglxvii – The activity established and supported Turkana County Laboratory Technical Working Group to conduct month to month forecasting and quantification of test kits and delivered five modems to the sub-county medical laboratory coordinators to aid timely submissions of reports through the rapid test kit online reporting system in Turkana.  Deployment of extra staff (HTS, adherence counselors, clinicians, nurses) and training and mentorship by the Activity built the capacity of health workers; some were absorbed by the county government and will have the skills and knowledge to continue offering the services beyond the activity period. Result 4  There was poor linkage of OVC interventions with the Ministry of Health; this was confirmed by participants in both Samburu and Turkana validation workshops.  The APHIAplus Imarisha approach of working with local implementing partners (LIPs), has not only built local capacity but also they are able to compete for funding to continue offering services, hence showing prospects for sustainability. 25  The household economic strengthening (HES) initiatives supported by the activity under the block grant ensured that the targeted beneficiary households are able to sustain the interventions and continue to take care of the OVC beyond the life of the activity. Key Programmatic Lessons Learned Result 3  County and sub-county CHMTs should be supported to provide technical assistance to low- volume and far-flung facilities.  Entrenching HTC counselors in the HTC to take care of the referral and linkage system for HIV￾positive clients ensures high enrollment in HIV care and treatment. The HTC counselors are able to walk the journey to enrollment with the client, providing the initial psychosocial support required.  Use of maternal shelters in a predominantly pastoralist community and where distance to the nearest health facility is large increases access to skilled delivery and improves both maternal and newborn outcomes (prompt management of maternal complications reduces mortality).  Linking and integrating private health facilities in the County MOH infrastructure and forums improves private health sector engagement and the expanded access to essential MNCH/FP/HIV/TB services in private health facilities. Result 4  Household economic strengthening is a blueprint for improving nutritional support for vulnerable groups in the community, which are primarily women and children. Therefore, establishment of kitchen gardens and provision of clean and safe drinking water for PLHIV and other vulnerable groups should be emphasized at all levels of project implementation.  HES and food security initiatives provide more sustainable ways to support and strengthen families. OVC caregivers undertaking viable initiatives become more empowered and self-reliant and regain their lost dignity as a result. These initiatives need to be supported by allocation of additional resources.  The quality improvement process is a key aspect in OVC programming. It encourages participation of communities in identifying and addressing children’s issues, thus promoting ownership and sustainability of program interventions. Child Status Index as a step in QI provides a clear and deeper analysis and understanding of issues and a basis to measure improvement in children’s well-being.  Agro-based and livestock-based economic initiatives can succeed in the NAL region but require sustained technical extension services form the Ministry of Agriculture staff until the beneficiaries are competent enough to work with minimum support.  Reducing direct support to OVC households in favor of household economic strengthening initiatives works best if the OVC caregiver has stabilized enough and can take over providing the OVC household with basic needs including school fee payment. Otherwise the number of OVC dropping out of school or who fail to progress in school increases. Key Management Lessons Learned  Working closely with the county government and the local health authorities is key in terms of building the local capacity and also ensuring that some of the best practices are infused, owned, and financed by the local government (e.g., the county bill that attempts to regularize the work of the CHVs as part of the Community Health Strategy, and absorption of the HCWs deployed by the Activity into the county government). Recommendations for Sustainability  Consider developing joint action plan/memorandum of understanding with CHMTs and ensure that each team is aware of what the other is doing in future activities. This will enhance active participation 26 of the CHMTs, SCHMTs, and HCWs. In the plan, document roles and responsibilities of each partner and the stakeholders and level of their mandates.  Consider the participation of the CHMTs and SCHMTs in the recruitment of staff in future activities employment and deployment of HRH that are seconded or employed to the county by USAID funds. PART II: CASE STUDIES CASE STUDY 1: ROLE OF MENTOR MOTHERS (MMs) IN ELIMINATION OF MOTHER-TO-CHILD TRANSMISON OF HIV (eMTCT) IN TURKANA COUNTY BACKGROUND AND INTRODUCTION: The prevention of mother-to-child transmission (PMTCT) of HIV has been lauded as one of the greatest public health successes in recent years, with significant reductions in the number of positive children born to HIV-positive women. Without preventive interventions, the risk of HIV transmission in utero or at birth ranges from 15 to 30 percent, increasing to 20 to 45 percent with breastfeeding. lxviii HIV prevalence in Turkana is reported to be 4.0 percent, which is lower than the national prevalence (5.9 percent). Compared to other counties, Turkana county is still lagging behind in PMTCT coverage, with a reported coverage of 46 percent in 2015, and was ranked 44th of out the 47 counties. lxix However, this was an improvement from 2013, where coverage was reported at 14 percent. Turkana County contributed 1.4 percent of the total new HIV infections among children in Kenya. lxx Many initiatives have led to the marked improvement in PMTCT in Turkana County. These include increased investments by the county government, introduction of Option B+ through Bring Back the Mothers campaign, free maternity and Beyond Zero, and partner-specific interventions (e.g., the mentor mothers program). The activity adopted a case management approach in eMTCT, where women found to be HIV infected were identified and immediately attached to a case manager at the community and facility level (as part of the KMMP) to ensure uptake of recommended interventions, follow-up of HIV-positive pregnant women to delivery, and tracking mother-baby pairs through early infant diagnosis and exit of uninfected children. These were augmented with support groups that offered health education on PMTCT and also allowed sharing of experiences from MMs as well as learning from each other THE INTERVENTION: MENTOR MOTHERS: Mentor Mothers (MMs) is a peer-based task￾shifting approach, where HIV-positive mothers are recruited and deployed to provide counseling, psychosocial support, and assistance in navigating and accessing HIV care for their HIV-positive peers (pregnant women) and their exposed or infected children. MMs are HIV-positive mothers who have successfully completed the PMTCT cascade (ANC, ART use, infant feeding counseling, and HIV-exposed infant (HEI) follow-up). This model was designed to improve ART adherence, strengthen referral linkages, and increase enrollment in care and treatment. The APHIAplus IMARISHA activity worked with MMs to improve quality of HIV and AIDS care and treatment services. Through mentorship sessions conducted by health workers, the mentor mothers were identified and trained to mentor HIV-positive pregnant women to enhance linkage to care and treatment, retention, monitoring viral load suppression, and sustained adherence counseling sessions. They were then supported to form patient social support groups (PSSG). In Turkana County, rollout of the KMMP program saw training of eight KMMP TOTs and sensitization of Turkana County CHMT/ SCHMTs on the KMMP approach in order to get administrative support for the same. Eight MMs were recruited to act as case managers in the high-volume facilities. Their role was to provide psychosocial support to the mothers and ensure follow-up of the mother￾baby pairs up to 18 months. In year 4, the activity supported recruitment of mentor mothers in eight selected high-volume facilities (Kalokol AIC, St. Mary’s PHC, Namukuse, St. Patrick’s, St. Monica, Lokichar RCEA, Katilu, and Lokori PHC) to support PMTCT uptake.lxxi The project sustained investment in the defaulter tracking system through provision of airtime for reminder phone calls, 27 provision of appointment diaries, deployment and facilitation of MMs, and provision of support for patient psychosocial support groups.lxxii Table 14 – Annual Work Plan Analysis Annual Work Plan Progress Timeline Planned Activity Achievement Mar 2012– Dec 2012 Train champions of the mother-to-mother approach (8 training sessions held) No documentation Support existing PLHIV support groups established during APHIA+ NAL No documentation Jan 2013– Dec 2013 Use MM in PMTCT support groups No documentation Form 28 PLHIV support groups and strengthen 56 PLHIV support groups Jan 2014– Dec 2014 Facilitate the adaption of the KMMP model, and engage MMs Working with CHVs who are linked to priority facilities with specific deliverables in defaulter tracing and community referrals Capacity building of MMs In partnership with the Mothers-to-Mothers project, APHIAplus Imarisha facilitated the training of 10 TOTs on the Kenya Mentor Mother Program to prepare for program rollout in priority facilities in the county in year 3 Host 96 monthly mother-to mother facility-based EBF support group meetings in 43 HFs The CHVs collaborated with TBAs and other community resource persons such as mother-to-mother support groups to refer and/or accompany pregnant mothers to the ANC Jan 2015– Dec 2015 Support MM and PLHIV support groups to augment patient retention efforts Engaged MMs to help improve follow-up and psychosocial support (in Turkana) Facilitate the formation of 8 Mother-to-Mother Support groups Trained 8 KMMP TOTs and sensitized CHMTs and SCHMTs; recruited 8 MMs; trained CHVs Place mentor mothers at all P1 facilities for support counseling/default management The project also identified MMs who will be engaged and deployed by the project to support ACT strategy implementation TA to RCEA Lokichar health center on identifying mentor mothers to assist in defaulter tracing and patient education; sensitization of Turkana County CHMT/ SCHMTs on the KMMP approach; 8 mentor mothers recruited to act as case managers in the high￾volume facilities (Kalokol AIC, St. Mary’s PHC, Namukuse, St. Patrick’s, St. Monica, Lokichar RCEA, Katilu, and Lokori PHC); 8 KMMP TOTs trained 45 CHVs/mentor mothers sensitized on pediatric ACT initiative strategy, treatment preparation, stigma and discrimination, defaulter management, and their roles and responsibilities in achieving the 90- 90-90 targets; In Turkana, 9 additional MMs were formally recruited to act as case managers Jan 2016– Dec 2016 Train CHVs and MMs Supported monthly psychosocial support groups (PSSGs) in Turkana Support KMMP, MMs, PSSGs in Turkana Sustained support to MMs in Turkana county Place mentor mothers at all supported facilities for support counseling/default management Supported CHVs in defaulter tracing through trainings and material support Support KMMP Mentor Mother PSSGs in Turkana The program will sustain support for the MMs in Turkana County to ensure that all pregnant women get tested at 1st ANC and all positive women are followed up to delivery to ensure adherence to highly active Antiretroviral Therapy (HAART). After delivery, the mentor mothers (who are the case managers) will follow up on the other baby pairs until 18 months. The project team mentored and technically supported MMs to mobilize people for HTS, linkage to care, treatment and retention, monitoring viral load suppression, and sustained adherence counseling sessions for unstable clients. 28 MENTOR MOTHERS: WHAT APPEARS TO HAVE WORKED  Sensitization of Turkana CHMT/SCHMT on the KMMP approach.  The rollout of KMMP in partnership with mothers-to-mothers projects saw the training of 10 TOT on KMMP.  Recruitment of eight mentor mothers to act as case managers in high-volume facilities (Kalokol AIC, St. Mary’s PHC, Namukuse, St. Patrick’s, St. Monica, Lokichar RCEA, Katilu and Lokori PHC).  Provided TA on identification of MMs who are to assist in providing psychosocial support to the mothers and ensure follow-up of the mother-baby pairs up to 18 months.  Working with CHV linked to priority facilities to conduct defaulter tracing, health education, and community referrals.  These observed results indicate that MMs and the roles they play were positively received by clients, communities, and HCWs. MMs were noted to be approachable and well informed on matters pertaining to PMTCT.  For communities, MMs provided a friendly, reliable alternative source of information on PMTCT. Among HCWs, MMs were available for task shifting, mainly for documentation, client counseling, and tracing. This enhanced service delivery to HIV-positive pregnant women.  This case study highlights the need for adequate training, supervision, and remuneration for mentor mothers. The available literature demonstrates the positive impact of MM interventions on PMTCT program outcomes.lxxiii MENTOR MOTHERS: WHAT APPEARS TO HAVE NOT WORKED: MMs have not yet been absorbed into the county staffing. This means the role is donor-supported with no ownership from the county government and therefore little prospect for sustainability once the donor funding ceases. CONCLUSIONS: In conclusion, well-trained and supported mentor mothers contribute to the elimination of HIV infection for infants born to HIV-positive mothers through adherence, retention to care, and treatment. There were limited MM activities especially in the first two years of implementation. Continued support to MMs is critical to ensure increased HIV testing, treatment initiation, and retention to sustain eMTCT gains. The county government has not yet demonstrated ownership of the KMMP by absorbing the skilled MMs already trained and mentored by the activity. RECOMMENDATION: There is need to advocate for the institutionalization of MMs into the county’s human resources for health. The Activity and/or donors should increase support for the MM. CASE STUDY 2: BLOCK GRANT IN SAMBURU COUNTY BACKGROUND TO THE PROBLEM: The PEPFAR OVC Guidelines of 2012 recommended eight categories or domains of interventions to reduce vulnerability of OVC: Food and Nutrition, Shelter and Care, Protection, Health, Psychosocial, Education and Life Skills, Capacity Building, and Household Economic Strengthening (HES).lxxiv,lxxv,lxxvi The project worked with local implementing partners (LIPs) to implement OVC/HCBC interventions in both Turkana and Samburu.lxxvii New PEPFAR OVC guidelines of 2012 emphasized HES more than focusing on the relief model. Therefore, to promote family strengthening and self-reliance as a sustainability strategy to transition families out of project support, there was a shift from providing other direct support to OVC to strengthening the OVC household capacity to provide basic needs to the OVC through household economic strengthening. All other interventions (education, health, nutrition, food security, shelter, and care) were linked to economic strengthening initiatives.lxxviii 29 THE CASE – BLOCK GRANT: With support from the USAID-funded APHIAplus Imarisha project, five local implementing partners (LIPs) worked with the OVC/HCBC households to implement the block grant initiative whose aim was to inculcate agribusiness skills and improved nutrition to OVCs as well as generate income toward the education and livelihood support of children from extremely vulnerable households.lxxix Ten learning institutions with the highest number of OVC were identified to benefit from the block grant for various household economic strengthening initiatives.lxxx The institutions were linked to the OVC households through the economic strengthening groups. The OVC households were already organized into three main economic strengthening initiatives: Savings and Internal Lending Communities (SILC), small business development, and livelihood opportunities (agro-based, livestock-based, and handcraft). The institutions contributed in various ways depending on the IGA identified, by giving land for cultivation and land for greenhouses, building a poultry house and goat shed, and paying the staff working in the IGAs and the teachers to give technical support. The IGAs were managed by OVC caregivers who also benefit from the training and management skills as well as income to support their household.lxxxi Table 15 – Annual Work Plan Analysis Timeline Planned Activity Achievement Mar 2012– Dec 2012 Targeted grants to assist in IGA establishment No documentation Jan 2013– Dec 2013 Support 80 LIPs/CBOs to establish livestock/agro-based enterprises and IGA demonstration sites through in-kind grants. No documentation Establish 24 IGA/Demonstration livestock/agro-based enterprises sites for the 80 LIP/CBO through in-kind grants. Jan 2014– Dec 2014 Provide matching in-kind grants to support groups identified, taken through IGA self-selection process and provided with training on enterprise development. No documentation Jan 2015– Dec 2015 Facilitate disbursement of in-kind grants to 23 beneficiary groups to expand and grow IGAs. Piloted the school block grants model and provided three schools in Samburu County with poultry and drip irrigation kits to initiate poultry projects and school gardens. Support the selected beneficiary groups in establishing and/or expanding small enterprises in poultry farming, small livestock trade, fodder establishment demonstrations, meat value addition, hides and skins, small trade and handcrafts. Jan 2016– Dec 2016 Disburse in-kind grants (drip irrigation and improved indigenous poultry) for food security, nutrition and economic strengthening. Ten learning institutions received block grant for various household economic strengthening initiatives (poultry, drip kits and a multistory garden). The block grant model started in year 4 in three secondary schools in Samburu County will be scaled up to 10 more schools that will be provided with drip irrigation kits, supplied with poultry, and trained on agribusiness to initiate school farms and poultry projects that will be used to kick-start IGAs and provide a platform for practical business development training. WHAT WORKED FOR THE BLOCK GRANT: Three drum kits provided to both Wamba Girls and Wamba Boys secondary schools are fully functional, and income from the sale of produce to be harvested from the school farms will support in the payment of school fees of the OVC enrolled in the program and attending school in the two schools.lxxxii The yield from these kits supported OVCs in the two schools. The OVCs were allowed to take home some vegetables for home consumption once a week. Any profits from sale of the excess vegetables by the school went to supporting the OVC to offset some of their scholastic needs.lxxxiii 30 Two secondary schools in Wamba and Maralal that received improved poultry benefited from poultry produce—the eggs laid were consumed at the household and the surplus sold for income.lxxxiv One secondary school with 14 OVCs that received 450 rainbow roosters reported some remarkable outcomes; the birds are laying eggs, which are consumed by the OVC households and the excess sold for revenue.lxxxv Maralal Girls Secondary School, which had eight OVC, received 100 improved indigenous chickens. The school generated a total of Kshs 16,000 net profits from the sale of 1,000 eggs. The money was used to pay school fees for the three OVC in the school. This contributed to retention in the school, and as a result, the eight OVC registered improved performance in school. Maralal Mixed Secondary School was supported with 100 improved “Kienyeji” KARI and 100 rainbow roosters. Through the sale of eggs and mature cocks, 10 OVC have been supported with school fees. As a result of the project the school also created employment for some OVC caregivers who utilize part of the salary to pay school fees for their children. Wamba Boys Secondary school was supplied with 200 birds, and they are able to sell both eggs and cocks. The income supports the needy OVC to pay for their school fees.lxxxvi Learning institutions supported under block granting models to cater for 185 OVC (83M/102F) have started to provide OVC with scholastic materials. Proceeds from the Wamba Boys poultry project have been used to pay for OVC with school fee subsidies worth Kshs 7,850 ($77.72). Other students have acquired practical skills in poultry production from the project, thus preparing them for future endeavors. lxxxvii WHAT DID NOT WORK  The direct support to OVC to meet immediate and critical needs did not work because of funding constraints and withdrawal of partners critical to success of the chosen intervention. For example, in Samburu county, the activity started by sub-granting the LIP to provide OVC services (between 3+2 and 6+1 services), but this was reduced to only education and HES- related services by 2015; in Turkana county the five LIPs were reduced to one LIP. Reduced funding affected implementation of some activities, mainly capacity building/training of beneficiary groups and administration of in-kind grants (2015 Annual Work Plan).  Upscaling successes for adoption by caregiver groups was not possible due to reduced funding as stated in the 2016 Annual Work Plan.  There is no clear sustainability and exit strategy. The OVC support was not owned by the county government and is donor-dependent. CONCLUSIONS ON BLOCK GRANT: Partnership between the OVC caregiver groups and the school where the targeted OVC were attending greatly contributed to the success of the project. Increased retention and improved performance was reported among OVCs supported in Maralal Girls Secondary School. The block grant not only provided alternative livelihood but also increased OVC caregivers’ resilience. RECOMMENDATIONS: Block grant successes should be shared widely within the county and the practice replicated as part of OVC HES support to increase their resilience, retention, and progression in school. To improve food security among OVC households, all Economic Strengthening (ES) initiatives must be looked at through a nutrition lens. Proven interventions such as small-scale vegetable and poultry farming should be promoted to address immediate food needs and the surplus sold for household income. OVC support should be owned and funded by the county governments to better address the long–term needs of OVCs. 31 ANNEX 1: USAID/KEA APHIAPLUS IMARISHA SOW RFTOP Issuance Date: March 14, 2017, Revised July 19, 2017 RFTOP Closing date: April 13, 2017 8:00 a.m. Nairobi local time SUBJECT: Request for Task Order Proposals (RFTOP) No. SOL-615-17-000010. End-of-project evaluation for the APHIAplus Imarisha Activity under AID-623-I-13-00001 Single award IDIQ. Subject to availability of funds, the Government plans to award a firm-fixed fee contract. The anticipated period of performance is on/about April 01, 2017–August 15, 2017. Any questions regarding the RFTOP’s requirements must be submitted via e-mail to Winnie Hinga, A&A Specialist, at whinga@usaid.gov and Nya Kwai Boayue, Contracting Officer, at NBoayue@usaid.gov The proposals must be received electronically on or before the closing date and time stipulated above. Proposals must be sent via e-mail to A&A Specialist, at whinga@usaid.gov and Nya Kwai Boayue, Contracting Officer, at NBoayue@usaid.gov and must conform to all requirements outlined herein. This RFTOP does not obligate the United States Government to award a contract, nor does it commit USAID to pay for any costs incurred in the preparation or submission of proposals. USAID reserves the right to award this contract without discussions and any resultant contract is subject to the availability of funds. Sincerely, Nya Kwai Boayue Contracting Officer USAID/KEA 32 SECTION B – SUPPLIES OR SERVICES AND PRICE/COSTS B.1 PURPOSE This Task Order must provide all evaluation services as described in detail in Section C. B.2 CONTRACT TYPE Firm-Fixed-Price Task Order. B.3 PRICE The total price of this Task Order is TBD. B.4 APPLICABILITY OF IDIQ All Sections from the Indefinite Delivery Indefinite Quantity (IDIQ) are hereby incorporated. If there are any discrepancies between IDIQ and the Task Order, then the Task Order shall take precedence. [End of Section B] 33 SECTION C – STATEMENT OF WORK Purpose: The purpose of this Statement of Work (SOW) is to seek services from qualified contractors to conduct an end-of-project evaluation that will seek to determine the extent to which the activities have met the expected health outcomes as were expressed in the five year implementation framework. It will look at all aspects of the activity that have direct and indirect bearing to anticipated health outcomes. This information will inform future direction in activity design, development, implementation, and management strategies. Evaluation Focus and Geographical Scope: Despite HIV/AIDS and FP/RMNCAH/Nutrition and WASH geographic targeting that have resulted into less focus in North Eastern region with an exception of Turkana county, it’s critical that USAID KEA documents key factors that have worked for and/or against the achievement of intended results, key lessons learned and key challenges. More importantly, the documentation of the well triangulated and grounded “how to” strategies from a broad-based stakeholders working in the region will provide learning platform for future programming for USAID KEA, other development partners and their respective projects. This evaluation is therefore expected to spend considerable level of efforts in the analysis of the “what” and “how to” implementation strategies that AMREF and its sub-partners used; facilitate subject matter experts’ panels discussions individually and through validation workshops, and document workshop outputs into well synthesized strategic directions for future programming. Discussions on the future “what” and “the how” program implementation strategies and their cost feasibilities will form part of this panel analysis. The geographical scope for this evaluation will be limited to Turkana and Samburu counties. A. BACKGROUND INFORMATION A.1: Evaluation Purpose: The evaluation will serve two main purposes: (1) to learn to what extent the activities’ objectives and expected health outcomes at county, sub‐county, health facilities, and community levels have been achieved, including effectiveness of APHIAplus model, key lessons learned, and challenges; and (2) to identify implementation strategies in terms of the “what” and the “how to” that have high likelihood of achieving sustainable health and institutional strengthening outcomes for the Northern Arid Lands (NAL) region. A.2: Audience and Intended Uses for the Evaluation: The primary audience for the findings of this evaluation is USAID/Kenya and East Africa, Health Population and Nutrition (HPN) leadership, and its technical team and the implementing partner – AMREF. USAID/Kenya and East Africa’s Strategic Planning and Analysis office, Office of Economic Growth, Education and Youth Office, and Democracy and Governance Office are part of the next level of primary audience for the evaluation findings. The first line secondary users of the evaluation findings will include key stakeholders that implement activities in national and county governments, national Ministry of Health programs such as National AIDS & STI Control Program, Family Health Programs, Ministry of Gender and Social Services/ Department of Children Services, National Water and Sanitation Programs within the Ministry of Health, among others. Civil Society Organizations and researchers from the local and international universities as well as research organizations will form part of the second line users of the findings. Finally, the donor community supporting health programs will also be consumers of the evaluation findings. A.2: Background Information: A.2.1: Project Description 34 USAID/Kenya and East Africa’s Health Population and Nutrition Office’s current strategic objective is to, “Reduce fertility and the risk of HIV/AIDS transmission through sustainable, integrated family planning and health services.” It directly supports the Government of Kenya’s (GOK) efforts toward reducing unintended and mistimed pregnancies, improving infant and child health, reducing HIV/AIDS transmission, and reducing the threat of infectious diseases. While APHIAplus service delivery program description was developed in line with HPN’s Implementation Framework (2010–2015), its results areas are consistent with the current Health Program Approval Document’s results. HPN’s Program Approval Document was designed to support the achievement of the Country Development and Cooperation Strategy (CDCS) Goal by contributing to DO2, Health and Human Capacity Strengthened, and more specifically by contributing to increased use of quality health services (DO2 IR 2.2) and increased Kenyan ownership of health (DO2 IR2.1). HPN’s Health PAD is contributing to CDCS’s intermediate results through strengthened county health systems and strengthened county health service delivery. The primary focus for the Kenya Health PAD will be at the county level with activities encompassing family planning and reproductive health (FP/RH); maternal, newborn and child health (MNCH); nutrition; malaria; tuberculosis (TB); water, hygiene, and sanitation (WASH); HIV/AIDS prevention, care, and treatment; and health systems strengthening (HSS). APHIAplus Imarisha activity primarily focused in these areas through an integrated model of service delivery. Specifically, it responded to social determinants of health in the technical areas of HIV and AIDS, malaria, family planning, tuberculosis, MNCH, and water and sanitation. Basic Activity Information: Activity Name Activity Number TEC Period of Performance APHIAplus AID – 623 – A – 12 – 00015 $49,985,210. March 15, 2012 to March 14, Imarisha 2017 APHIAplus Imarisha Consortium members: 1. Catholic Relief Services 2. Land O‟ Lakes Inc. (LOL) 3. University of Maryland Baltimore (UMB) 4. Family Health International (FHI360) 5. BroadReach Healthcare (BRHC) A.2.2: Problem Statement, Activity Development Hypothesis, Design and Implementation Approach: A.2.2.1: Problem Statement: The Northern Arid Lands (NAL) of Kenya comprise eight counties that are under- developed, and characterized by harsh climatic conditions. The region covers about 70 percent of Kenya’s land mass with an estimated population of 4,469,174 which is sparsely distributed (1 to 2 persons per sq. km) and predominantly nomadic or semi-nomadic and conservative communities. The availability and quality of health services in the NAL is poor. Social barriers to health including harmful cultural attitudes, social stigma, financial, education and literacy challenges often prevent people from accessing quality health services even where they are available. Most of the health indicators are far worse than the national average. In all regions except North Eastern (67 percent), 94 percent or more of women received antenatal care from a skilled provider (DHS2014). Less than 90 percent of women in Garissa, Marsabit, 35 West Pokot, and Samburu and less than 60 percent in Mandera and Wajir received ANC from a skilled provider; 47 percent of women in Mandera received no ANC at all (DHS2014). HIV prevalence varied greatly by region with a low of 2.1 percent in Eastern North region to 15.1 percent in Nyanza region; North Eastern had the lowest prevalence for both rural and urban areas at 1.5 percent and 3.6 percent respectively (KAIS 2012). A.2.2: Development Hypothesis DO2’s development hypothesis states “if health and human capacity in Kenya are sustainably strengthened, then Kenyans will be able to effectively participate in and contribute to the transformation of their governance and economy.” Besides Kenya Health PAD primarily contributing to DO2’s intermediate results focused on health; it will also contribute to initiatives that relate to education and youth to strengthen HIV/AIDS and life skills curricula and policies, and improve government capacity to provide quality gender sensitive health care and education. It also supports the implementation of the new Adolescent Sexual and Reproductive Health Policy that provides a framework for the allocation of resources toward access to information and support for a variety of services for example: contraception to reduce unwanted pregnancies; prevention programs to reduce risky behaviors leading to HIV and substance abuse; and creation of opportunities to enhance their autonomy, decision-making capabilities, and economic prospects including for vulnerable OVC households through household economic strengthening sustainable community-based models. A.2.3: Activity design and implementation approach Broadly, APHIAplus Imarisha activity has a regional/county and sub-county focus, working closely with county and sub-county health management teams to support provision of integrated health services at health facilities and the community level. Specifically these include HIV/AIDS, Malaria, FP/RH, MCH, Water, Sanitation and Hygiene, OVC and other Social Determinants of Health. These activities are a consortium of several local and international organizations that bring specific expertise to contribute to the achievement of the overall goals and objectives. Specific activity design and implementation approaches are described below: In order to sustainably improve the health outcomes and create impact among the residents of NAL, the activity proposed to build on its more than 30 years’ experience in the region. AMREF proposed to deploy a holistic program design that was meant to empower and strengthen health service delivery and social development structures in the region to sustainably fulfill their mandate of providing health and development services, while integrating their actions for synergy. This design was informed by participatory consultations with NAL health and development stakeholders, through the activity jointly with stakeholders identified needs, gaps and practical solutions. Through this program design, the activity set out to (i) strengthen the capacity of community to county (level 1 to 4) health systems to deliver high quality services, products, and information and create demand for the same; (ii) strengthen the ability of local social and economic development structures to create positive change in livelihoods, food security, education, and social protection; and (iii) through proven approaches such as the SILC model by CRS and the value chain approach by Land O’ Lakes, foster multi-sectoral integration by creating practical and synergistic linkages between actions at the health system level and among social and economic development initiatives in order to improve health outcomes. Social and economic development initiatives were to have a significant impact on health in the medium and long term, and form an important entry point for health development in the NAL region. In the health system, the activity proposed to strengthen the capacity of District and later County Health Management Teams; health facility staff and management committees; Community Health Units and civil society organizations. Key target development structures for capacity strengthening included local civil society organizations; local cooperatives; county leadership; women and youth groups; livestock and other cooperatives; religious structures; cultural fora (e.g. elders fora); primary and ECD schools and water management committees. Integrated actions were to include joint outreach actions on livestock 36 and human health as well as joint MNCH and WASH actions. The activity proposed to work with government departments (MOPHS, MOMS, MOE, Ministry of Livestock, NDMA, and MOGSD), CSOs, livestock and other cooperatives, schools, water management committees and cultural structures to integrate interventions that were expected to strengthen the health system with those that were to address social health determinants. The activity was to work with the Ministries of Health and Livestock at local levels to combine efforts with mobile pastoral training units to deliver integrated human health and animal health outreach, starting with areas such as Isiolo and Wajir where pastoral training units were already active. The activity was to prioritize the Annual Operating Plan (AOP) cycle and empower sub-county and county health management teams to prepare SMART plans and supervise, document, monitor, and review implementation of a multi-sectoral approach to attain health and developmental results. A.3: Activity Results Framework: The theory of change that was envisioned for the APHIAplus Imarisha activity was that depicted in the Results Framework below. Specifically for the USAID/Kenya and East Africa to achieve its mandated strategic goal of sustained improvement of health and well-being for all Kenyans, the APHIAplus Imarisha activity were to directly and indirectly contribute to health outcomes in results 3 and 4. Collaboration, coordination and synergy among the activities implementing all the result areas were to result in the achievement of strategic objective and in long term result in the achievement of the strategic goal as presented on the framework below: Results Framework Strategic Goal: Sustained improvement of health and well-being for all Kenyans Strategic Objective: Improved health outcomes and impact through sustainable country-led programs and partnerships Result 1: Result 2: Result 3: Result 4: Strengthened Health systems Increased use of Social determinants leadership, strengthened for quality health of health addressed management, and sustainable services, to improve well-being governance for delivery of quality products, and of targeted communities and sustained health services information populations programs Cross-Cutting Elements Whole Market Innovation Gender-Focus Youth-Focus Equity A.3.1: Program Goal: The goal of the APHIAplus Imarisha activity is improved health outcomes and impact through sustainable country-led programs and partnerships. 37 A.3.1.1: Program Results: APHIAplus Imarisha was designed to respond to Result 3 and 4 (see results framework above) of the 2010 – 2015 Implementation Framework, the Activity was to primarily support technical areas of HIV/AIDS, malaria, family planning, and tuberculosis, and, to the extent that funds are available, MNCH and nutrition, food security, water and sanitation, and selected interventions related to the social determinants of health. The Implementation Framework allowed for additional technical areas to be added should an emergency occur or additional technical priorities be identified and funding available. Over the implementation period, several shifts in strategic directions informed by changes in national HIV/AIDS, RMNCH, and/or nutrition policy/guidelines, adoption of county-level government, and changes in Ministry of Health division/departmental leadership that were not initially envisioned and may have impacted on the observations made or implementation plans developed by the APHIAplus Imarisha Activity. To the extent possible, programs in these technical areas were to be integrated in order to reduce vertical programming and avoid duplication of effort. The primary beneficiaries of the Activity under the five-year framework were to include the poor and underserved (particularly from the lowest two quintiles); vulnerable and marginalized groups; those most at risk for contracting HIV/AIDS including young women and adolescent girls, people living with HIV/AIDS (PLHA), commercial sex workers (CSWs), men who have sex with men (MSM), truck drivers, discordant couples, and substance abusers; OVC; youth; young couples and/or newlyweds; women of childbearing age and their partners; pregnant and postpartum women; newborns and children under five years of age; and those at risk by health condition, age, gender, social, and religious determinants or other circumstances. A.3.1.2: Expected Health Outcomes by IRs RESULT 3: Increased Use of Quality Health Services, Products, and Information • Improved capacity of public sector facilities to provide reliable and consistent high quality package of high-impact interventions at community, dispensary, health center, sub-county hospital and county level hospital. • Increased capacity of the CHMTs to plan and manage service delivery, including effective linkages with health activities to support drought response. • Increased number of functional community units to promote preventive health behaviors, identify and refer/manage complications • Increased availability of essential newborn care and resuscitation, nutrition, safe and clean water at point of use, and prevention and management of childhood illnesses • Expanded coverage of high-impact interventions for women and men of reproductive age, youth, vulnerable groups, MARPs, mothers, newborns and children Intermediate Result 3.2: Increased demand for an integrated package of quality high-impact interventions at community and health facility levels Expected health outcomes: • Reduced social, economic, and geographic barriers to accessing and utilizing services • Increased capacity of districts to organize appropriate communications strategy • Increased capacity of facilities to provide client-centered, humane, and dignified care • Increased capacity of community units to mobilize communities Intermediate Result 3.3: Increased adoption of healthy behaviors Expected health outcomes: • Improved appropriate health care seeking behavior • Improved home-based healthy practices with a special focus on the high-impact interventions • Improved compliance with preventive and curative protocols 38 Intermediate Result 3.4: Increased program effectiveness through innovative approaches Expected health outcomes: • Innovative approaches developed to increase the use of quality services at community and facility levels, especially among the marginalized, poor, and underserved populations • Data analysis and of best practices institutionalized • Increased coverage of services among marginalized, poor, and underserved populations RESULT 4: Social Determinants of Health Addressed to Improve the Well-Being of Targeted Communities and Populations Intermediate Result 4.1: Marginalized, poor, and underserved groups have increased access to economic security initiatives through coordination and integration with economic strengthening programs Expected health outcomes: • Marginalized, poor, and underserved groups accessing economic security initiatives • Target groups actively participating in viable economic activity Intermediate Result 4.2: Improved food security and nutrition for marginalized, poor and underserved populations Expected health outcomes: • Increase in food security, improved nutrition and sustainable livelihoods among the target groups Intermediate Result 4.3: Marginalized, poor and underserved groups have increased access to education, life skills, and literacy initiatives through coordination and integration with education programs Expected health outcomes: • Increased access to education, life skills, and literacy initiatives for highly marginalized children, youth, and other marginalized populations • Increased school preparedness; enrollment and retention in quality education marginalized, poor and underserved children and youth • Increased preparation for primary school achievement through regular participation in quality early childhood development programs • Increased completion of life skills curriculum offered through primary or secondary levels • Increased enrollment and retention in primary and secondary schools • Increased transition to post primary and/or secondary education • Reduced reliance on individual scholarships and provision of quickly expended supplies to secure educational access Intermediate Result 4.4: Increased access to safe water, sanitation, and improved hygiene Expected health outcomes: • Integration of key hygiene practices into HIV and MNCH activities at the community level • Increased access to improved water sources • Increased utilization of POU water treatment Intermediate Result 4.5: Strengthened systems, structures, and services for protection of marginalized, poor and underserved populations Expected health outcomes: • Quality protective services available to survivors of sexual assault, child maltreatment and children without adequate family care • MGCSD supported to develop policies, protocols, and guidance to support quality social services • Eligible children and families are identified and linked to available government social protection initiatives through CHWs, CSOs, volunteers, and local government representatives • Strengthened referrals between police, court, health, and social services established 39 Intermediate Result 4.6: Expanded social mobilization for health Expected health outcomes: • Improved financial, managerial, and technical capacity of indigenous organizations serving social and health needs of marginalized, poor, and underserved populations • District, sub-district, and village health committees plan and coordinate implementation of effective multi-sectoral partnerships for health • Women, youth, children, and MARP groups meaningfully participate in the design, delivery, and monitoring of interventions on their behalf • Increased social inclusion and reduced stigma and discrimination against MARPs A.3.1.3: Priority Outcome level Indicators The evaluation team will apply both quantitative and qualitative data analysis techniques. In as much as possible, the evaluation team is required to refer to and use all different sources of data including District Health Information System II (DHIS2); NASCOP’s National EID System; NASCOP’s National Viral Load System; primary data sources such as Knowledge, Attitude, Practice, and Coverage (KAPC) survey; and the Health Facility Assessment in conducting indicator level comparative analysis on current and baseline values. Using a logic model that links interventions to intermediate outcomes and then to end outcomes, analyze the observed trends and or changes in intermediate and end outcome levels through contribution analysis to try and establish what input(s)/ interventions the activity did provide and the extent to which the observed trends in intermediate and end outcomes are a result of the inputs provided by the activity. Reliable results on some indicators such as viral load suppression might not be available for all the Activity’s performance years; the evaluation team is therefore required to document such limitations. Some quantitative indicators will be analyzed for a period of five years, while some longitudinal quantitative indicators such as MTCT rate will be analyzed into cohorts of 18 months to determine the extent to which the desired outcomes were achieved. The following are the priority intermediate and end outcome level indicators the evaluation is required to study/explore: VMMC (limited to Turkana County only)  % positivity yield in VMMC  Improvement in institutional capacity to conduct VMMC HIV Testing (limited to Turkana County only)  Positivity yield disaggregated by adults, pregnant women and pediatrics  Positivity yield initiated into HIV treatment disaggregated by adults, pregnant women, and pediatrics eMTCT (limited to Turkana county only)  PCR results at 8 weeks; Proportion +ve; % PCR +ve initiated on Treatment; % patients on treatment with viral load suppression OVC program: Turkana and Samburu  Enrollment, attendance, and progression disaggregated by gender  Proportion of vulnerable OVC households actively participating in community-based household economic strengthening groups disaggregated by wards within each county  Functional household economic strengthening groups disaggregated by wards within each county MNCH and FP: (Turkana and Samburu)  % of births attended by skilled health care worker  Proportion of pregnant women with 4+ ANC visits 40  Proportion of children under 1 year fully immunized  DPT1 coverage; DPT3 Coverage; Measles Coverage  Proportion of children that receive postnatal care within 48 hours after birth Existence of established systems for program quality improvement at health facility (Turkana and Samburu)  Existence of Quality Improvement Multi-Disciplinary Committee  Use of performance measurement data to improve quality of services  Use of national guidelines/protocols by health care workers  Use of program data for developing work plans, and plan supportive supervision by health managers A.3.1.4: Existing Data Sources Primary sources of data for the priority indicators will be the Health Information System for HIV, RMNCH, and TB programs at the facility; CHMT support supervision records; and the implementing partner quarterly/annual progress reports, program records/reports generated through child status index assessments, household vulnerability assessment report and any other reports that implementing partner might have access to. Other facility-level data sources will include NASCOP’s National EID system, NASCOP’s National Viral Load System, and DHIS2. Data from various existing data sources have varied data quality limitations, with HIV/AIDS data having a relatively better quality than FP/ RMNCAH/Nutrition, and WASH data. The Contractor should therefore try as much as possible to validate data especially from health facility registers, monthly summaries, activity quarterly progress reports, and county/sub-county quarterly performance review reports through triangulation approaches. Known data limitations and their effects on the findings and conclusions should be documented in the report. USAID KEA will provide the following documents and encourage the evaluation team to gather other documents relevant to this evaluation:  Activity description documents  Annual work plans years 1–5  M & E Plans and PMPs  Kenya Health Strategic and Investment Plan 2014–2018  Kenya AIDS Strategic Plan (KASP) 2014–2019  Kenya Population Projections 2009–2030  Activity quarterly reports, annual reports  USAID Evaluation Policy Revised October 2016  Checklist for Assessing Evaluation Reports  Other technical/implementation strategy documents for every activity included as an annex B.2: Evaluation Questions The following questions are numbered in terms of priority, with a lot of interdependency and must as much as possible be answered with total empirical evidence. IBTCI is required to develop sub-questions that would add details for each main question: Phase I: Evaluation Questions (40% of LOE) 1. What is the current coverage/improvement status on the priority health outcomes in HIV/AIDS, RMNCH, Nutrition, Water and Sanitation and institutional/ organizational capacity 41 building? To the extent possible, determine the activity’s contribution to the observed health outcomes. 2. To what extent has the activity increased the capability of health community, health facility, and county health management teams to sustain the gains in the observed health outcomes? 3. What implementation challenges did the activity face during the implementation period and how were these challenges addressed? (This question will examine successes; challenges with the primary outcomes expected to be key programmatic and management lessons learned, especially on institutional capacity building; sustainable household economic strengthening models for OVC vulnerable households; and overall sustainability of implemented strategies to guide future programming decisions.) Phase II: Required Qualitative and/or Quantitative Analytic and Documentation (60% of LOE): 1) Using a Case Study approach on every yearly work plan and accompanying progress reports, develop key analysis questions informed by evidence coming out of process I: Conduct an in-depth content analysis of the annual work plans for years 1–5 and corresponding quarterly progress/annual progress reports and document: a. What appears to have worked? b. What appears not to have worked? 2) Public consultations and discussions with the development experts/organizations working in the Northern Kenya using various methods such as panel discussions, round table discussions, key informant interviews among other technically and financially feasible data collection methods and: a. Document the possible successful and unsuccessful implementation strategies around the priority health outcomes for the Northern Arid Lands (NAL) counties, and b. Validate the findings from the rigorous analytical work through stakeholders validation workshop to facilitate the development of well-grounded “the what” and “the how to” implementation strategies that are more likely to be most appropriate for the NAL region. B.3. EVALUATION DESIGN AND METHODS B.3.1: Evaluation Design The contractor is encouraged to propose innovative ways of using qualitative and quantitative approaches in similar complex evaluations that could enhance better and well‐grounded evidence especially on the possible “how to” strategies appropriate for the NAL region. However, the contractor must consider the Government’s evaluation design recommendations as stated below. Where “must” is written the contractor must include these approaches in their proposed approach. A non‐experimental evaluation design that uses pre‐ and post-analysis of project health outcomes to analyze and determine the current status of health outcomes is recommended for this evaluation with a mixed of both qualitative and quantitative methods to strengthen the rigor of the evaluation design. This must include content review/analysis of resource documents; Mini Rapid Knowledge, Attitude, Practice and Coverage (KAPC) Survey; Mini Rapid Health Facility Assessments; reviews of quantitative data from reports and data collection systems [National AIDS & STI Control Program (NASCOP) Early Infant Diagnosis (EID) system and District Health Information System2 (DHIS2)]; Focus Group Discussions; Key Informant Interviews; and records from meeting minutes held by CHMTs and various health facility management committees. A sequential mixed method design is recommended, and the contractor must sequentially use qualitative–quantitative–qualitative approaches in data collection. A sequential approach starting with qualitative may help the contractor to form foundational understanding by reviewing and analyzing available reports and guidelines, and to form preliminary guiding questions around key result areas. Quantitative approaches such as analysis from KAPC, Health Facility Assessments, and use of 42 available databases to extract quantitative values would provide the status and help in the crafting of further questions for use in the next round of qualitative analysis. This sequential approach is proven to help focus evaluations and to facilitate efficient use of LOE by the evaluation team. It may further help the Evaluation Team in grounding evidence around the key priority health outcomes. The contractor must utilize key informant interviews and focus group discussions with health care workers that provide baseline, intermediate, and end-term coverage information on knowledge, attitudes, and practices upon which to conduct trend, content analysis, and triangulation of results to determine the extent of contribution that APHIAplus Imarisha activity inputs had on the observed outcomes. A validation workshop must also be conducted for another source of local and expert opinions that would be valuable in the identification, prioritization, and validation of the “what and the “how to” strategies. The contractor must also collect data on quality improvement utilizing, at the least, the following methods: through review of records held by health facility in‐charges, meeting minutes from facility program performance review committees, focus group discussions and/or key informant interviews with members of the quality improvement committee; and health care workers on availability and use of national service delivery guidelines. B.3.2: Data Collection Methods It is generally stated in the literature that the manageable number of Focus Group Discussions (FGDs) ranges between 7 and 10 participants largely because large groups of more than 10 participants are difficult to control and they also limit each of the participants’ opportunity to actively share insights and observations. It is understood on this evaluation that the sample size for FGDs is not meant to support making any inferences neither is it to support generalization of issues into the general population. It is largely to provide insights and observations critical for grounding evidence emerging from the quantitative and from other forms of qualitative data. 1) Content Analysis of the scope of work in the agreement, national program guidelines, annual work plans and implementation strategies developed in the course of activity implementation and determine the extent to which technical strategy and national policy/guidelines documents informed work plan development and implementation. Review of the key documents such as baseline assessment reports, quarterly and annual progress reports, any mini-household survey such as LQAS reports, CSI reports, programmatic quality assessment reports, etc. conducted by the activity during the implementation period. 2) Review of quantitative data posted on the National AIDS and STI Control Program’s (NASCOP) Early Infant Diagnosis (EID) database, NASCOP’s National Viral Load database and District Health Information System 2 (DHIS2) and associated health information system primary data sources. 3) Rapid Mini Knowledge, Attitude, Practice, and Coverage Survey to measure the current status of priority health outcomes at the household level. Using Lots Quality Assurance Sampling Methodology, the Contractor should develop appropriate sampling design with the number of sampled households per Supervision Area maintained between 19 and 25. The appropriate geographic area/administrative boundaries to be used Supervision Areas should be discussed with the AMREF team to ensure that the decision makes programmatic sense. Results of LQAS will be reported at County and Project Level. Confidence Intervals will be included for all reported outcome indicators. 4) Mini Rapid Health Facility Assessment to document organizational and institutional capacity improvements that include a look into the quality improvement systems that the Activity supported and their contribution to quality service delivery in the focal counties. The Contractor will develop an appropriate sampling strategy for health facilities that ensures a good mix of health facilities based on the size of their catchment area population classified into high, medium and low population densities. Other considerations such as health facility 43 classifications of county and sub-county hospitals, health centers, and dispensaries as well as facility ownership (public, private, and faith-based) could also be used. 5) Panel Discussions with 3–5 people representing organizations that have worked in the region for a long time such UN family, Save the Children, and AMREF, among others. 6) Focus Group Discussions (FGD) with two small groups of 7–10 health facility beneficiaries (1 MNCH group and 1 CCC), one group of 7–10 OVC Care Givers attached to every sampled CBO, one group of 7–10 youths who participated in HIV prevention services supported by every sampled CBO, and one group of 7–10 Community Health Workers (CHWs) attached to every sampled CU to collect data about specific and appropriate priority outcome indicator of interest in evaluation. 7) Key Informant Interviews (KII) with (1) USAID technical staff from HIV, Family Health, Malaria, HSS, and SI teams; (2) implementing partner technical staff; (3) health facility in-charges and departmental heads; (4) county and sub-county health management team members; and (5) staff from collaborating institutions. 8) Validation Workshop. Organize two validation workshops (one in Samburu and the other in Turkana) and invite people whose background and experience and expertise covers the key thematic areas for discussions and validation. Recruit and use a facilitator with good facilitation, communication, and negotiation skills to manage the two workshops. B.3.3: Data Analysis Approaches The Contractor must propose an appropriate data analysis technique. These approaches must be informed by techniques that have more likelihood of affecting expected program outcomes such as types of program activities/interventions, level of intensity (amount of services, number of contacts/sessions held), and the length of the intervention just to mention a few. These characteristics will aid in analyzing the extent to which they affected the observed outcomes. Gender analysis (including disaggregation of results) must be incorporated in all the analytical work as much as possible. The proposed and illustrative data analysis approaches in this evaluation include: Trend analysis – Determine the overall change in key quantitative indicators over the past five years of activity implementation, comparing/plotting year by year to assess the level of the quantitative indicators using basic statistical analysis methods. Reconstructed baseline values will be required for indicators with no baseline values from implementing partners. Coverage and Effectiveness Analysis – Examination of coverage and effectiveness is critical in understanding the contribution that APHIAplus Imarisha has made toward the reductions in MTCT rates and generally toward the reductions in neonatal and infants mortality. Available evidence suggests that low coverage of programs for early infant diagnosis of HIV is one of many gaps in the EMTCT cascade contributing to lower coverage of ART and high mortality among children infected with HIV (Wettstein et al. 2012). Understanding program and/or intervention(s) coverage (for example the level as supported by the APHIAplus Imarisha) is an important factor of analysis in providing evidence on what level of contributions that APHIAplus Imarisha has made. Elimination of MTCT involves multiple program elements, ranging from primary prevention of HIV infection among women of reproductive age to prevention of unwanted pregnancies among women living with HIV to ART for women and their children (UNAIDS 2011). Therefore, an attempt to understand the extent of program coverage of such multiple program elements is suggested. Using program coverage analytical framework that is built around the four-pronged approach to PMTCT to understand coverage and effectiveness is suggested. Comparative analysis – Analyze knowledge gains and application, adopted best practices, and application among health care workers that benefited from interventions and programs supported by 44 APHIAplus Imarisha such as mentorship programs, and service delivery quality improvement programs at the facility and community levels. Grounded theory analysis – This technique will help build a well-grounded body of evidence from the insights, perceptions and observation from the participants. Summarize observations and insights from different FGD/KII groups into thematic issues/categories and test theories from the start to the end; where possible make follow-ups to support the refinement of conceptual/thematic categories. Other techniques such as ethnographic and case study analysis approaches will be used in data analysis. This analytical technique is expected to develop very substantive and evidence-based conclusions. Content and Triangulation Analysis to Develop Contribution Analysis Framework –Using a Case Study Approach, the Contractor is expected to develop questions to guide the content review and analysis of implementation strategies that the Activity used in every Annual Work Plan and results reported in quarterly and annual progress reports to determine to the extent possible the extent to which USAID KEA contributed to the observed health outcomes through the Activity. Using content analysis as an analysis tool to identify key thematic and categories for triangulation with evidence from the quantitative data from other sources of data, evaluation team is expected link implemented strategies to the observed health outcomes. This technique will help the evaluation team to better understand the technical support that was provided over time by APHIAplus Imarisha and as much as possible attempt to associate the observed health outcomes with the strategies implemented by the Activity. From the analysis of the causal logic models evaluation team should also establish if the observed health outcomes would have occurred even without the inputs/outputs from the activity. B.3.4: Sampling Strategy A mix of multi-stage, systematic and purposive sampling strategy is recommended in this evaluation. Multi-stage systematic sampling is adopted as a way of ensuring that more representation is achieved at the ward level and/or sub-county level in developing sampling frames by wards and selecting health facilities to create a more representative sample of the health facilities and CDBOs implementing OVC programs in Turkana and Samburu counties. Purposive sampling is then introduced as way of ensuring that all county and sub-county hospitals and CBOs that serve between 2000 and 3000 OVC are included in the sample. This mix will help reduce costs and reduce challenges largely associated with logistics of reaching to service delivery points. USAID KEA expects that whatever sampling designs that the Contractor proposes would ensure good representation of urban and rural populations as well as health facilities; and at a minimum would meet the rigor required to accurately estimate the values of interest in the assessment. Sampling design must ensure quality results while taking into account cost feasibility. To ensure that the breadth and depth of the APHIAplus Imarisha activity is included in the data collection process, different sampling strategies are suggested for different points of data collection as detailed below: 1. Rapid Mini Health Facility Assessment: County, sub-county, health center and dispensaries. All county and sub-county hospitals will be purposively included in the sample; while only high￾volume health centers/dispensaries (ANC/PMTCT clients – 300 per year) and dispensaries (ANC/PMTCT clients 200+ per year) are included. (AMREF to provide: List of PMTCT/ANC sites based on FY 15 and FY 16 APR that they support in Turkana and Samburu). The list from the two reporting periods will be considered since some facilities were dropped in FY 16. IBTCI team will first stratify facilities into rural and urban and then use systematic random sampling to select required sample size that includes all sub-county hospitals, health centers and dispensaries. Catchment area population for the sampled health facilities should also consider factors besides the patient volume. All county and sub-county hospitals will purposively be included in the sample. 2. Rapid Mini Knowledge, Attitude, Practice, and Coverage Survey: A representative sample of households with women of reproductive age (15–49 years) is recommended, preferably developed using Lots Quality Assurance Sampling Methodology. Appropriate designation of 45 Supervision Areas is required and should be determined in consultation with AMREF team. Sample size of 19–25 per Supervision Area is recommended and the reported results are expected to include confidence intervals. 3. Community Based Organizations (CBOs) supporting Orphans and Vulnerable Children (OVC) will purposively be selected based on (1) number of years implementing OVC program, (2) total number of OVC that it supports, and (3) geographical location to ensure good representation of the Activity’s catchment area. APHIAplus Imarisha will provide a detailed list of CBOs in each ward from which a suitable sample of CBOs will be obtained. Systematic random sampling method will be used in the selection of OVC households to participate in the data collection processes as determined most appropriate by IBTCI. (AMREF and RCEA/Watoto Wazima Initiative teams to provide: List of CBOs and the wards they cover with OVC activity.) 4. Collaborating/partner institutions/county MOH program representatives. These partners will be selected based on the length of time in months/years that it has been closely working with the Activity. Those that worked with the activity for a period of 2–3 years will be accorded high priority in the selection process. AMREF team to provide a list of collaborating/partner institutions/MOH representatives for every focal county (Turkana and Samburu). IBTCI will make determination on the level of efforts after consulting with AMREF Activity team. Respondents from the collaborating/partner institutions will be selected using a purposive sampling method and will be guided by the potential number of key respondents with relevant knowledge about the Activity performance on thematic areas of interest. 5. IBTCI is required to use its technical judgment on the right mix of respondents for Focus Group Discussions (FGD), Panel Discussions, Round Table Discussions (RTD), Key Informant Interviews (KII) sessions and validation workshop participants. Targeted respondents should include but not be limited to women with children under five years, people living with HIV, youths 15–24 years, OVC, and OVC Caregivers. B.3.5: Synthesis of Conclusions and Recommendations on Future Implementation Strategies The Contractor must develop strategies that would ensure that for every key finding, explanations are sought from key sources to better present it and also contribute to the development of substantive conclusions. These follow up data collection strategies (Key Informant Interviews, Subject Matter Expert Consultations, Panel Discussions, Focus Group Discussions) should narrow down to specific factors both external and internal that might have contributed to the observed results. Guided analysis at this stage is expected to result in well-synthesized conclusions upon which recommendations are developed. The contractor must develop 3–5 key recommendations on the “what” and the “how to” strategies for every evaluation question, that are well‐thought out, action‐oriented, and practically possible to implement. Recommendations are required around thematic areas of sustainability, promising implementation strategies for scale- up, institutional/organizational strengthening and management, and coordination/ collaboration and partnerships among other areas that will come up. B.3.6: Threats to validity The Contractor must guard against any possible threats to validity of findings, conclusions and recommendations drawn from the qualitative and quantitative methods. Any conclusion drawn from the qualitative and quantitative data sources must be supported by well‐grounded body of evidence that is triangulated and confirmed. The Contractor must adhere to USAID’s “Checklist for Reducing Threats to Validity for Qualitative Methods.” B.3.8. Limitations to the Proposed Evaluation Design and Methodology The known data limitations are twofold: data quality and availability from the national health information system. Given that the public health sector still relies on the paper-based system (except for a few high-volume sites that use electronic medical systems) to collect, collate, and report data, data are always incomplete (especially longitudinal data) and do not reflect the actual outputs. Availability of health records at health 46 facilities is a major limitation, especially for the records that cover earlier periods going back to 2010. Recall bias from health care workers is another major limitation, especially in situations where facilities have gone through staff transitions. Contribution analysis is based on the activity’s theory of change and determination of the actual inputs, activities, and outputs that are directly linked to correspond to the every priority outcome indicator could prove challenging. The validity and reliability of the used baseline data on selected indicators from various data sources is another potential limitation. IBTCI is expected to propose ways through which such limitations will be addressed and/or minimized to the extent possible. Evaluation Management and Participation: USAID KEA through the designated Contracting Officer’s Representative (COR) will provide technical direction within the scope of work. The contractor shall be responsible for arranging all focus group discussions, roundtable discussions, panel discussions, Key Informant Interviews (KII), and validation workshops and for booking meeting places. The Evaluation Team must include the following skill sets (Team leader; Public Health evaluation expertise; Reproductive, Maternal, and Child Health Evaluation expertise; social scientist expertise; M&E expertise; and facilitation skills). IBTCI must arranging all domestic travel and hotel arrangements for the selected county health executives listed below. Format of Final Evaluation Report IBTCI is responsible for ensuring that the final evaluation report meets all quality criteria listed in Appendix 1 of USAID’s Evaluation Policy. The final evaluation report shall have a maximum of 30 pages: 1. Executive Summary—concisely states the most salient findings and recommendations (2pg) 2. Table of Contents (1pg) 3. Introduction—purpose, audience, and synopsis of task (1pg) 4. Background—brief overview of development problem, USAID project strategy and activities implemented to address the problem, and purpose of the evaluation (3pg) 5. Methodology—brief description of the evaluation methods, detailed presentation on the analytical methods used including data triangulation analytical processes, description of data limitations, impact of any on drawn conclusions/recommendations, constraints, and gaps (3pg) 6. Key Findings/Conclusions/Recommendations—organized by Part I and Part II (11–30pg) 7. Annexes —including the full evaluation SOW, a summary of the evaluation methods used and data collection schedules and instruments. Annexes will also include interview lists and tables that are succinct, pertinent, and readable; references to bibliographical documentation consulted; and focus group discussion notes and/or transcripts. The first section should focus on achievements on the expected health outcomes, key lessons learned, and challenges, and the second section must focus on outputs of the analytical work that documents what worked and what didn’t work, to demonstrate as part of Contribution Analysis Framework what has been USAID KEA’s contribution to the observed health outcomes. The analytical work should present the “what” and the “how to” implementation strategies with high likelihood of achieving sustainable results in the NAL region. The “what” and the “how to” strategies are expected to inform programs/activity designs by multiple development partners and other civil society organization that program interventions in the NAL region for the final evaluation report as outlined in Section F. USAID Evaluation Policy standards must be met by the offeror throughout the contract. [End of Section C] 47 48 SECTION F – DELIVERIES OR PERFORMANCE F.1 INCORPORATION OF IDIQ CLAUSES The clauses included in the IDIQ are hereby incorporated by reference. F.2 PERIOD OF PERFORMANCE The period of performance will be on/about October 15, 2017 (October 23, 2017)–January 15, 2018. (February 28, 2018) Note: In the original issuance the POP was 4.5 months from April 1, 2017 to August 13, 2018; ESPS aims to start on October 23 after the October 17 Kenyan Election (see illustrative work plan, Annex 11) and to end about February 28, 2018. F.3 PLACE OF PERFORMANCE The place of performance is Kenya (Turkana and Samburu counties.) F.4 DELIVERABLES All reports are subject to approval by the Contracting Officer’s Representative (COR). Updates shall be provided to the COR on all Task Order deliverables, and discussions will be held upon USAID request, between the Chief of Party and COR on progress and implementation issues. All reports shall be submitted electronically using Microsoft Word, Excel, PowerPoint software, or any other USG SIMS reporting system. All reports shall comply with the standards at Section C.3.2 of the IDIQ AID-623- I-13-00001. All products produced by the Contractor and submitted to USAID shall: ● Be written in proper American English with correct spelling and grammar ● Be written in Plain English, as defined at http://www.plainlanguage.gov/ ● Be submitted on time ● Be accurate, with all data substantiated 49 TASKS AND DELIVEABLES: A. In Briefing/Team Planning Meeting: Contractor to propose dates. B. Work plan: The evaluation team will provide a detailed work plan to USAID KEA before commencing the evaluation. The work plan will outline how the evaluation will be undertaken, the evaluation design and methods to be used considering the evaluation questions and the data collection and analysis plan for every main question. The work plan will also include detailed data collection instruments, including FGD and KII questionnaire guides. The work plan must be approved by USAID KEA before commencing field work. C. Briefings: The Evaluation team will provide regular in‐country briefs to USAID/Kenya and East Africa on progress and discuss problems and issues on a bi‐weekly basis via email communications and/or meeting to brief USAID KEA on the fieldwork progress, any implementation challenges and how they are being addressed, A mid‐term briefing must be held at the mid‐point of data collection process on the progress made by mid‐point and include any data collection challenges that would require USAID KEA’s attention. D. In‐Country Presentation: The contractor must make an in‐country PowerPoint presentation with handouts to USAID Kenya and East Africa on the main preliminary findings at the end of the evaluation. E. Draft Evaluation Report: Acceptance of the draft report by USAID/Kenya and East Africa will be contingent upon the report adequately fulfilling the scope of work and addressing major important areas of inquiry outlined in the SOW. The format of the draft and report must contain the required format and content as indicated the statement of work. F. Final Evaluation Report. Upon final approval of the content by USAID/Kenya and East Africa, IBTCI will have the report edited and formatted. The final report must be submitted both electronically and in hard copy. Four hard copies of the report will be provided to USAID/Kenya and East Africa. In addition, all the raw data will be submitted to USAID on CD labeled “APHIAplus Imarisha Data” for future reference. Once USAID approves the final report, IBTCI must load the report to the Development Experience Clearinghouse (DEC). 50 F.5 KEY PERSONNEL Team Leader (TL): The TL must be a senior local (Health/Population/Nutrition/HIV‐AIDS Analyst) expert in public health with strong program management and team leadership experience, especially managing evaluation teams in developing countries. S/he will have overall responsibility for fulfilling the requirements of this SOW. S/he must have a master’s degree and experience in program management, team leadership, and evaluation. Ten years and above of extensive international experience related to health programs and at least seven years in evaluating donor funded activities is required. S/he will have experience in leading evaluation teams, and drafting high-quality evaluation reports. IBTCI will present to USAID for review a copy of the last three evaluation reports that he/she wrote and a reference for each. S/he will ensure that each technical area expert leads a well-guided process of developing substantive conclusions and recommendations on the “what” and the “how to” strategies. Other Key Personnel The other key personnel must process the following skills: Senior Local Expert (Health/Population/Nutrition/HIV‐AIDS Analyst), a clinician with a master’s degree in Public Health, International Development, Social Science, or a closely related field is required. S/he will have significant work experience in HIV/AIDS programing especially in HIV care and treatment and HIV/TB program areas. Experience in participatory evaluation methodologies, design, and end-of-program evaluations with 6–8 years’ experience in conducting NGO/CBO/FBO level research in Sub‐Sahara Africa is highly desirable. S/he will take full responsibility for leading evaluation of HIV/AIDS programs at the facility and community, while working with the other two team members. S/he will have strong demonstrated experience in the use of social science qualitative research methods in the collection and analysis of data. S/he will provide technical area leadership in the data collection, analysis of key findings, development of substantive and evidence-based conclusions and action-oriented and practical recommendations, and on facilitating technical discussions geared toward developing implementing strategies on a broad range of development programs. A senior local expert (Health/Population/Nutrition/HIV/AIDS Analyst), a Reproductive Health, Maternal Newborn and Child Health (RMNCH) expert with a master’s degree in Public Health or International Development is required. S/he will have significant work experience in RMNCH programming areas. Experience in participatory evaluation methodologies, design, and end-of-program evaluations with between 6 and 8 years’ experience in conducting NGO/CBO/FBO level research in Sub‐Sahara Africa is highly desirable. S/he will be responsible for leading other members of the team in evaluating RH/MNCH/Nutrition components of the APHIAplus activities. S/he will have strong demonstrated experience in the use of social science qualitative research methods in the collection and analysis of data. S/he will provide technical area leadership in the data collection, analysis of key findings, development of substantive and evidence based conclusions and action‐oriented and practical recommendations, and on facilitating technical discussions geared toward developing implementing strategies on a broad range of development programs. Senior local (Social Scientist/Other Technical Advisor) with strong understanding of OVC, especially in the development, evolution and transitioning of community‐based household economic strengthening models in Sub‐Saharan Africa. S/he will have a master’s degree in public health, agriculture, nutrition, anthropology, social work/sociology and/or any other related field with a working experience in participatory evaluation methodologies, design, and implementation of program evaluations with 5–6 years in Sub‐Saharan Africa is highly desirable. S/he will have requisite skills and experience in evaluating nutrition and livelihoods, and must have extensive experience using a range of sound social science research methods and analysis. S/he will provide technical area leadership in the data collection, analysis of key findings, development of substantive and evidence-based conclusions and action‐oriented and practical recommendations and on facilitating technical discussions geared toward developing implementing strategies on a broad range of development programs. 51 Senior local (Monitoring and Evaluation or Research Specialist) with a master degree in public health, statistics and/or information management. S/he will have significant M&E, Research work experience in integrated HIV/AIDS, MNCH/FP/Nutrition/Malaria programming, with at least 7–10 years’ experience. Experience in a wide range of evaluation methodologies, qualitative and quantitative data analysis techniques that include ability to triangulate findings from different methods. Proof of participation in end-of-program evaluation. Other personnel: Validation Workshop Facilitator (1): This person must have the ability to facilitate a Validation Workshop. Experience facilitating meetings/workshops where participants are expected to contribute to and develop consensus on technical program implementation strategies. Research Assistants (36): Must be local junior professionals with past experience in conducting national and/or county-level cross-sectional household surveys. Preference should be given to those who have participated in household surveys organized and conducted by Kenya National Bureau of Statistics (KNBS). As the majority of the Research Assistants with experience from KNBS may not meet the labor qualifications for local junior professionals, IBTCI will require a blanket waiver to USAID Contracting Officer in order to expedite the recruitment process and be responsive to USAID expected time frame for conducting the overall evaluation. [End of Section F] 52 ANNEX 2: METHODOLOGY The evaluation team used both quantitative and qualitative methods to gather data to answer the three key evaluation questions. The evaluation team conducted a document review and household surveys; gathered data from the District Health Information System (DHIS2); conducted organizational capacity assessments; performed qualitative research that included key informant interviews, focus groups, panel discussions, and developed a case study—performing quality control through triangulating information from multiple sources. Data sources and quality control A document review enabled the team to better understand the activity’s goals, objectives, and interventions; inform the design of the data collection tools and instruments; and determine the characteristics of both stakeholders and activity beneficiaries that were interviewed. Qualitative methods included KIIs and panel discussions with various stakeholders and IPs in the NAL region and at national level. Panel discussions/KII were conducted with CHMTs, SCHMTs, LIPs, and CUs to elicit expert opinion on the implementation of the activities, outputs, outcomes, and impacts of APHIAplus Imarisha in NAL region. In addition, the team conducted focused group discussions (FGDs) with five target groups: Maternal Neonatal and Child Health (MNCH) clients; Comprehensive Care Clinic (CCC) clients; youth (15–24 years) who participated in HIV prevention services in Turkana County; caregivers supporting orphans and vulnerable children; and community health workers (CHWs). Household surveys and observations queried women of reproductive age (15 – 49 years) and OVC households. These two surveys measured population health according to key priority indicators on: a) Fourth ANC attendance, delivery under skilled attendant, immunization coverage, proportion of infants receiving postnatal care within 48 hours after birth, skilled birth attendance, family planning uptake specifically for MNCH/FP; OVC school enrollment, attendance, progression under OVC support b) Community-based household economic strengthening initiatives c) Water, sanitation and improved hygiene d) Food security and sustainable livelihoods e) Adoption of health behaviors f) Access barriers to accessing and utilizing health services The evaluation included organizational capacity assessments (OCA) of the County Health Management Teams (CHMT), health facilities, and community units. Data Quality Assessment This evaluation used routine program data (source: DHIS2) to assess the activity’s performance on priority indicators relating to HIV testing, treatment, HIV-exposed infants (HEI), and antenatal care (ANC) attendance. Data on infant testing using Polymerase Chain Reaction (PCR) was obtained from the National AIDS & STIs Control Program (NASCOP) – Early Infant Diagnosis (EID) database. 53 Case Study Using the priority outcomes and expected health outcomes, the evaluation team used a case study approach, analyzing APHIAplus Imarisha work plans and the corresponding quarterly and annual work plans to determine what worked and what did not during the activity. Evidence from the case studies augmented information from primary data obtained during fieldwork (KII, FGD, household surveys and OCA). Validation Workshops The team conducted validation workshops in Maralal (Samburu County) and Lodwar (Turkana County) to elicit stakeholders’ views on implementation strategies and findings. Sampling strategy Key informants/panel discussion participants included representatives of key institutions, government departments, and developmental partners as well as implementing partners The health facilities were stratified by county/sub-county and type of facility. The team selected a sample of 24 facilities distributed across three counties. All are high-volume, as defined by an ANC/PMTCT client load of more than 200/year. The evaluation included all community-based organizations supporting OVC in the project. All community units selected had links to a sampled health facility and were functioning. The team also considered the following criteria: i) the unit’s catchment population ii) proximity to the sampled health facility and/or CBO (in case of more than one CU) iii) geographical location, to ensure broad of geographic coverage Focus group members The Evaluation Team liaised with the MNCH clinics, CCCs, CUs, and CBO in-charges to estimate the average number of clients seen per day (for facility beneficiaries), the number of OVC caregivers (for CBOs supporting OVCs), the average number of Youth (15-24) that participated in HIV prevention services in a month (for CBO supporting evidence-based interventions targeting youths) and the number of community health workers supporting community work within each sampled facility. Focus group discussions with youths (15–24 years) and CCC clients were restricted to Turkana County. For the household survey, a cross-sectional study design was used to estimate priority health outcome indicators at the household level, among mother-child pairs, with children under five, and among OVC-caregiver pairs. Lot Quality Assurance Sampling: Within each sub-county, cluster random sampling approach with Lot Quality Assurance Sampling (LQAS) technique was used to provide sub-county-specific population health estimates and to identify wards within the target sub-counties that could be lagging behind on program targets. 54 Stratification by wards: Within each sub-county, wards served as the primary units (distinct strata) for the survey. Stratification by wards was applied to minimize sampling errors, ensure proper representation, and identify wards that are below the program coverage levels. Supervision Areas: All wards served as the LQAS supervision areas (SA) for this end-term evaluation. LQAS samples of 19, 24, and 30 were selected depending on the number of SA in each sub-county. This ensured that the final sample size per SA is sufficient enough for LQAS classification and estimation purposes at the county level (i.e., on aggregating LQAS sample within each county). Data management and analysis Household survey data Data collectors used Android-enabled mobile phones. The survey questionnaire was programmed and administered electronically using Survey To Go Dooblo Software. Routine program HIV data The evaluation team used the District Health Information System (DHIS2) to download health facility data on selected outcome indicators (March 2012 through March 2017). In addition, teams conducted data quality assessment and discussed any discrepancies with the implementing partner responsible for that health facility. The final dataset for each health facility was shared with the IP and sent to the M&E specialist. Qualitative data Triangulation from the different data sources helped back up qualitative information from the desk reviews, interviews, and work plan analysis. Contribution Analysis – Case Study We developed a logic model for contribution analysis to help draw conclusions about APHIAplus Imarisha’s contribution to the expected health outcomes. We analyzed the five annual work plans, quarterly progress reports and other, documents to discern intended interventions, implementation strategies, gaps in outputs and the observed health outcomes in a particular case. 55 ANNEX 3: RESEARCH TOOLS Contents _Toc519813032 TOOL 1: 56 TOOL 2: HOUSEHOLD INTERVIEW WITH OVC CAREGIVERS 82 TOOL 3: KEY INFORMANT INTERVIEW QUESTIONNAIRE 109 TOOL 4: KEY INFORMANTS INTERVIEW, USAID HPN STAFF (MNCH TEAM); USAID SI TEAM 122 TOOL 5: PANEL DISCUSSION GUIDE WITH ORGANISATIONS WORKING IN TURKANA AND SAMBURU 128 TOOL 6:KEY INFORMANT INTERVIEW GUIDE— 130 NATIONAL-LEVEL GOK 130 TOOL 7: KEY INFORMANT INTERVIEW QUESTIONNAIRE 135 - CHMT-SCHMT-HW - 135 TOOL 8: FOCUS GROUP DISCUSSION GUIDE - MNCH CLIENTS141 TOOL 9: FOCUS GROUP DISCUSSION WITH OVC CAREGIVERS 143 TOOL 10: GUIDE FOR FGDS WITH COMMUNITY HEALTH WORKERS (CHWS) 148 TOOL 11 - FGD CCC BENEFICIARIES 154 TOOL 12 GUIDE FOR FGDS WITH YOUTH SERVED BY LIPS 162 TOOL 13: LIST OF DOCUMENTS TO VERIFY DURING ORGANIZATIONAL CAPACITY ASSESSMENT (OCA) 172 TOOL 14: ORGANIZATIONAL CAPACITY ASSSESSMENT TOOL FOR COUNTY/SUB-COUNTY HEALTH MANAGEMENT TEAMS 174 TOOL 15: HEALTH FACILITY CAPACITY ASSESSMENT TOOL 191 TOOL 16: COMMUNITY UNIT CAPACITY ASSESSMENT 200 TOOL 17: ORGANIZATIONAL CAPACITY ASSSESSMENT 202 56 TOOL 1: KNOWLEDGE, PRACTICES, AND COVERAGE (KPC) SURVEY FOR MATERNAL, NEWBORN, CHILD HEALTH & NUTRITION (MNCHN) IN TURKANA AND SAMBURU COUNTIES (28 pages) Identification County 1. Samburu 2. Turkana Sub-County Ward Community Unit Name Household Number Village Name Name of Mother Name of Interviewer Interview date ___/___/____ day/month/year For Supervisor Day Name of STL Month Year 57 Consent Page INFORMED CONSENT Hello. My name is……………………………………………….. and I am here on behalf of IBTCI/USAID. We are conducting an evaluation of the just concluded AMREF led APHIA Imarisha project. I would like to ask you about your health and the health of your youngest child under the age of five. This information will help (MoH and USAID) to plan health services and assess whether it is meeting its goals to improve women and children’s health in this community. The interview will take about 40 minutes to complete. Whatever information you provide will be kept strictly confidential. Participation in this interview is voluntary and you can choose not to answer any individual question or all of the questions. You can stop the survey at any time. You will not be penalized in any way for refusing to participate; however, we hope that you will participate in this survey since your views are important. Are you willing to participate in this survey? At this time, do you want to ask me anything about the survey? Signature of interviewee: __________________________________________________ Date: ____________________ RESPONDENT AGREES TO BE INTERVIEWED ................................ RESPONDENT DOES NOT AGREE TO BE INTERVIEWE ............................................................................................................................. D................................ 1 ............................................................................ INSTRUCTIONS: (1) ALL QUESTIONS ARE TO BE ADDRESSED TO MOTHERS WITH A CHILD LESS THAN 59 MONTHS OF AGE. (2) ASK FOR OFFICIAL DOCUMENTATION REGARDING CHILD (MOTHER AND CHILD BOOKLET) 58 SECTION 1: DEMOGRAPHICS 101 In what month and year were you born? …………./……………..(MM/YYYY) Don’t Know 99 102 Confirm that respondent is aged between 15 and 49 years Yes No 1 2 If “2” End Interview 103 How long have you been living continuously in this village? More than 9 months Less than 9 months 1 2 104 What is the highest level of schooling you attended? None /never went to school Nursery/pre-unit/ kindergarten Primary (no certificate/incomplete) Primary (Certificate /complete) Secondary/A level (no cert/incomplete) Secondary/’A’ level (Certificate /complete) College/Tertiary (no certificate/incomplete) College/Tertiary (Certificate /complete) Other (specify)………………………… 0 1 2 3 4 5 6 7 88 105 What is your religion? Catholic Protestant/ Pentecostal Muslim Traditional No religion Other (specify)………………………………….….. 1 2 3 4 5 88 106 What is your marital status currently? Single and not in a regular relationship Single but with a regular partner Married, monogamous Married, polygamous Divorced/Separated Widowed Other (specify)……………………………………… 1 2 3 4 5 6 88 107 What is your MAIN occupation? [DO NOT READ LIST. CIRCLE Unemployed, looking for work Unemployed, not looking for work 1 2 59 ONLY ONE RESPONSE] Informal micro trading (e.g. hawker, kiosks) Formal trading (with business permit) Employed professional (skilled labor) Employed (unskilled labor) Student Other (specify)…………………….. 3 4 5 6 7 88 108 Who is the MAIN breadwinner in your household? Myself Partner Parent Other relative (specify)…………..……………… 1 2 3 88 IF “1” Skip to 110 109 What is the MAIN occupation of the MAIN breadwinner in your household? [DO NOT READ LIST. CIRCLE ONLY ONE RESPONSE] Unemployed, looking for work Unemployed, not looking for work Informal micro trading (e.g. hawker, kiosks) Formal trading (with business permit) Employed professional (skilled labor) Employed (unskilled labor) Student Other (specify)…………………….. 1 2 3 4 5 6 7 88 110 From all the sources of income, what is your average household income per month? Kshs…………………….. 111 What is the total number of people who normally live with you in this household? ……………Adults, ……………Children 112 Who is the head of the household? RECORD THE GENDER & WHETHER ADULT OR CHILD Adult male Adult female Male child Female child Other (specify)………………………. 1 2 3 4 88 SECTION 2: FERTILITY 201 During the last FIVE years, how many children have you given birth to? ………………. children 201 What is the age of your last born child? 60 ..……………….Months ……..…………….Years 202 At the time you became pregnant [with NAME)], did you intend to become pregnant then, or did you want to wait until later, or did you not want to have any (more) children? Wanted to be pregnant then Wanted to wait until later Did not want any (more) children 1 2 3 203 Do you intend to have (more) children in future? Yes No Not decided 1 2 99 204 How long would you like to wait before having (another) child? ……….…………….Months ……………………….. Years 205 What is your desired number of children? [………………………………] SECTION 3: FAMILY PLANNING 301 Which ways or methods have you heard about that a couple can use to delay or avoid a pregnancy? [FOR METHODS NOT MENTIONED SPONTANEOUSLY, ASK: Have you ever heard of (METHOD)?] Tubal ligation Vasectomy Pill IUD Injectable Implants Condom Female condom Lactational amenorrhea method (LAM) Rhythm method Cycle beads Withdrawal Emergency contraception Other (specify…………………………………………. 1 2 3 4 5 6 7 8 9 10 11 12 13 88 302 Do you know of a place where you can obtain any of the family planning/child spacing methods you have heard about? Yes No 1 2 IF “2” Skip to 304 303 Where is that? Any other place? [CIRCLE ALL MENTIONED] Public health facility Private health facility FBO/NGO facility 1 2 3 61 Chemist/pharmacy/shop CHV Other (specify)……………………….. 4 5 88 304 Have you at any time, wished to delay pregnancy or space your births? Yes No 1 2 IF “2” Skip to 308 305 When you wished to delay pregnancy or space your births did you use any method? Yes No 1 2 IF “2” Skip to 307 306 Which method did you use? [DO NOT READ OPTIONS] Tubal Ligation Vasectomy Pill IUCD Injectables Implants Condom Female condom Lactational amenorrhea method (LAM) Rhythm method Cycle beads Withdrawal Emergency contraception Other (specify…………………………………………. 1 2 3 4 5 6 7 8 9 10 11 12 13 88 307 What made you not to use any method? Any other reason? [PROBE WITHOUT READING OPTIONS. CIRCLE ALL MENTIONED SPONATANEOUSLY] I didn’t know of any method I didn’t know where to get method My preferred method was not available Could not afford the cost Not allowed by our culture Not allowed by my religion Fear of side effects Fear of embarrassment/ stigma Partner refused Other (specify)…………………………………… I don’t know 1 2 3 4 5 6 7 8 9 88 99 308 Are you and your partner currently doing something or using any method to delay or avoid getting pregnant? Yes No 1 2 IF “2” Skip to 401 62 309 Which method are you and/or your partner currently using? [ASK ANY OTHER?] [CIRCLE ALL MENTIONED] Tubal Ligation Vasectomy Pill IUD Injectables Implants Condom Female condom Lactational amenorrhea method (LAM) Rhythm method Cycle beads Withdrawal Emergency contraception Other (specify………………………………………. 1 2 3 4 5 6 7 8 9 10 11 12 13 88 310 Does your husband/partner know that you are using a method of family planning? Yes No 1 2 311 Would you say that using family planning is mainly your decision, mainly your husband’s/partner’s decision, or did you both decide together? My decision My husband’s decision We decided together Decision of other people Other (specify)……………………. 1 2 3 4 88 SECTION 4: ANTENATAL CARE 401 During your pregnancy with (NAME), did you receive any antenatal checkups? Yes No 1 2 IF No Skip to 419 402 How many times did you receive antenatal care checkups before you gave birth? ……………………. Times 403 How many months pregnant were you when you FIRST received antenatal care? ……………………….Months 404 Where did you receive the antenatal care services? MOH health facility Private health facility FBO/NGO health facility At home by CHV At home by TBA 1 2 3 4 5 63 Don’t Know Other (specify)………………………… 88 405 The last time you went for antenatal care, who examined you? [PROBE: WAS IT A MALE OF FEMALE HEALTH PROVIDER?] Male Female 1 2 406 Would you have preferred being examined by a male or female health provider? Male Female I am fine with any/ no preference 1 2 3 407 During the last visit to the ANC clinic did the provider talk to you about any signs of complications (danger signs) that should warn you of problems with the pregnancy? Yes No Don’t know 1 2 99 408 Please tell me any signs of pregnancy complications (danger signs) that you know of. [ASK ALL RESPONDENTS EVEN THOSE WHO ANSWER NO/DON’T KNOW IN QUESTION E7. DON’T READ CHOICES. PROBE BY ASKING ANYTHING ELSE? CIRCLE ALL MENTIONED] Vaginal bleeding Fever Swollen face or hands Tiredness or breathlessness Headache or blurred vision Convulsions Baby stops moving/reduced fetal movement Water breaking/Gush of fluid from vagina Other (specify………………………………………… Don’t know 1 2 3 4 5 6 7 8 88 99 409 What should a pregnant woman do if she experienced any of the danger/ warning signs? [DO NOT READ ANSWERS. PROBE BY ASKING WHAT ELSE?] Seek care at a facility Seek the help of a TBA Decrease activity Take bed rest Change diet Prayers Other [specify)……………………. 1 2 3 4 5 6 88 410 Now, tell me whether you received the following services as part of your ANC services? [READ CHOICES AND CIRCLE ALL CHOICES THAT GET A YES ANSWER] Advice about breastfeeding Tetanus injection (in the arm) Iron folate tablets Were you weighed? Was your blood pressure measured? Did you give a urine sample? Did you give blood sample? 1 2 3 4 5 6 7 64 Medicine to prevent malaria Bed net/ mosquito net 8 9 411 During your pregnancy with (NAME), how many times did you receive an injection in the arm to prevent tetanus? Once Twice Three times More than 3 times Never/was not injected Don’t know/ can’t remember 1 2 3 4 5 99 412 During any of the antenatal visits for (NAME) were you given any information about babies getting HIV from their mother? Yes No Don’t know 1 2 99 413 During any of the antenatal visits for (NAME) were you given any information about things that you can do to prevent transmitting HIV to a baby? Yes No Don’t know 1 2 99 414 Were you offered a test for HIV as part of your antenatal care? Yes No Don’t know 1 2 99 415 I don’t want to know the results, but were you tested for HIV as part of your antenatal care Yes No Don’t know 1 2 99 If No or Don’t Know, Skip to 420 416 Where was the test done? MOH health facility Private health facility FBO/NGO health facility At home by CHW At home by TBA Other (specify)………………………… 1 2 3 4 5 6 88 417 I don’t want to know the results, but did you get the results of the test? Yes No Don’t know 1 2 99 418 All women are supposed to receive counseling after being tested. After you were tested, did you receive Yes No 1 2 65 counseling? Don’t know 99 419 Why did you not attend/ receive Antenatal care services? [MULTIPLE ANSWERS POSSIBLE. CIRCLE ALL MENTIONED] ANC not important Lack of transport Long distance High cost of care I was okay all through Spouse refused Other (specify)………………………… 1 2 3 4 5 6 88 420 During your pregnancy with (NAME), did you take any drug for intestinal worms? Yes No Don’t know 1 2 99 421 During your pregnancy with (NAME), did you take any drugs to prevent you from getting malaria? Yes No Don’t know 1 2 99 422 During your pregnancy with (NAME), did you sleep under a mosquito net? Yes No Don’t know 1 2 99 423 During your pregnancy with (NAME), did you know the date that the baby was expected to arrive? Yes No 1 2 424 During your pregnancy with (NAME) did anyone discuss things you should have in preparation for the delivery? Yes No Don’t know 1 2 99 425 Please tell me any things you know of that you should have in preparation for your delivery. [ASK ALL, EVEN THOSE WHO ANSWERED NO/DON’T KNOW IN QUESTION ABOVE. CIRCLE ALL RESPONSES. PROBE BY ASKING ANYTHING ELSE?] Emergency transport Money Disinfectant Sterile blade/scissors to cut cord Baby cloths and toiletries Other (specify)……………………….. Don’t know 1 2 3 4 5 88 99 426 Did you have money set aside for the delivery? Yes, enough Yes, but not enough No Can’t remember 1 2 3 99 427 During the last visit to the ANC clinic did the provider talk to you about Yes No 1 2 66 where you plan to deliver your baby? Don’t know 99 428 Where did you deliver (NAME)? At public health facility At private health facility At FBO/NGO health facility At home Other (specify………………………… 1 2 3 4 88 If they delivered at home skip to 430 429 For what reasons did/do you prefer to deliver in a health facility? Safer to deliver there Skilled care from health workers Health facility is near Recommended by relative Services are free Other (specify)………………………… 1 2 3 4 5 88 Skip to 431 430 For what reasons did you deliver at home? I did not have money for the health facility I prefer to deliver at home High transport costs Health facility was too far Do not trust/like health facility Better care at home To attend to my other children Recommended by relative Other (specify)………………………… 1 2 3 4 5 6 7 8 88 431 When you were pregnant with (NAME), who made the final decision on where you would give birth? Myself My husband/Partner My mother/mother in law Other relative Other (specify)………………………… 1 2 3 4 88 SECTION 5: CARE DURING DELIVERY 501 During your pregnancy with (NAME), where did you deliver? At home GOK/MOH health facility (Name…………………………..… Private health facility (Name……………………...… FBO/NGO health facility (Name…………………… Other specify (……………..………………………..……… 1 2 3 4 88 502 Why didn’t you deliver in a health facility? Baby came abruptly 1 67 DO NOT READ THE RESPONSES BUT CIRCLE THE RESPONDENTS ANSWERS EVEN WHEN MORE THAN 1 Any other reason? Cost at health facility unaffordable Facility closed at time of delivery Didn’t have means of transportation Health Facility too far Don’t trust facility/Poor quality service No privacy at health facility Husband/family did not allow Not necessary Not customary Religion doesn’t allow TBA services better Other (specify)…………………………………………. 2 3 4 5 6 7 8 9 10 11 12 88 503 During your last birth with (NAME) who assisted with delivery? Doctor/Nurse/Clinical officer Community Midwife Traditional Birth Attendant (TBA) Relative/ friend/neighbor Other (specify…………..………………. 1 2 3 88 504 Between the times you went for delivery but before the baby was born, were you offered an HIV test? Yes No Don’t know 1 2 99 505 I don’t want to know the results, but were you tested for HIV at that time? Yes No Don’t know 1 2 99 If NO skip to 508 506 Where was the test done? MOH health facility Private health facility FBO/NGO health facility Private clinic At home by CHW At home by TBA Other (specify)………………………… 1 2 3 4 5 6 88 507 I don’t want to know the results, but did you get the results of the test? Yes No Don’t know 1 2 99 508 At any point during labor and delivery of (NAME) were you mistreated in any way? Yes No 1 2 If NO, SKIP to 601 68 509 What exactly happened? (DO NOT READ, CIRCLE ALL THAT APPLY, PROMPT FOR ANY MORE) Confidentiality breached Privacy breached Abused verbally Abused physically Left unattended Detained because couldn’t pay Procedures done without consent Other (specify)…………………………………………… 1 2 3 4 5 6 7 88 SECTION 6: POSTNATAL CARE- MATERNAL & NEWBORN 601 After birth of (NAME), did any health care provider check on your health? Yes No Don’t know 1 2 99 If “2” or “99” Skip to 607 602 Who checked on your health at that time? Doctor/Nurse/Midwife/clinician TBA CHW Other (specify…………………………………. 1 2 3 88 603 How long after delivery of (NAME) did your first check take place? ……………………Hours ……………………………Days …………………..Months 604 How many times after delivery of (NAME) did you get checked? ………………………….Times 605 During the postnatal checkup/ visit were you advised on danger signs to look out for baby (NAME)? Yes No Don’t know 1 2 99 606 Which are the danger signs you should look out for baby (NAME)? [ASK ALL RESPONDENTS EVEN THOSE WHO ANSWER NO/DON’T KNOW IN QUESTION 706] Difficulty breathing/ rapid breathing Difficulty feeding/ poor suckling High or low temperature/fever Skin color change/ Jaundice Abnormal crying Vomiting Diarrhea/ dehydration Other (specify………………….……………………….. 1 2 3 4 5 6 7 88 607 After birth of baby (NAME), did any health care provider check on his/her Yes 1 If “2” or “99” Skip to 612 69 health? No Don’t know 2 99 608 Who checked on (NAME) health at that time? Doctor/Nurse/Midwife/clinician TBA CHW Other (specify…………………………………. 1 2 3 88 609 How long after delivery did baby (NAME) first check take place? ……………………Hours ……………………………Days …………………..Months 610 How many times after delivery did baby (NAME) get checked? ……………………….Times 611 During the first two months after delivery of baby (NAME), did you receive a vitamin A dose looking like this? [SHOW VITAMIN A CAPSULE] Yes No I don’t know 1 2 99 612 When baby (NAME) was newly born tell me how you cared for the umbilical cord. [DO NOT READ CHOICES, PROBE WITH WHAT ELSE AND CIRCLE ALL MENTIONED] Applied Vaseline/ jelly/lotion Applied baby powder Applied methylated spirit Cleaned with water Kept cord dry Kept cord covered Chlorhexidine/ tube gel given at health facility Traditional remedies (herbs, ash, oil etc.) Other (specify……………………………… 1 2 3 4 5 6 7 8 88 613 During the last visit to the ANC clinic did the provider give you advice on the importance of exclusively breastfeeding—that is, about giving your baby nothing apart from breast milk? Yes No I don’t know If No or Don’t Know, Skip to 615 1 2 99 614 For how many months did the provider recommend that you exclusively breastfeed, that is, that you do not give your baby liquid or food in addition to your breast milk? ………………… Months 70 615 Did you ever breastfeed baby (NAME) Yes No 1 2 If No Skip to 701 616 How long after delivery of (NAME) did you breastfeed? ……………………Hours ……………………………Days …………………..Don’t know If within ONE HOUR Skip to 618 617 Why was the baby not put on breast within 1 hour? Mother was unwell Taboo Breast not producing milk Colostrum not good for baby Other (specify………………………… I don’t know 1 2 3 4 88 99 618 Did you ever exclusively breastfeed (NAME) —that is, giving (NAME) nothing apart from breast milk? Yes No 1 2 IF No, Skip to 620 619 For how many months did you exclusively breastfeed? ……………………………Months If 6 months or more, skip to 701 620 Why didn’t you exclusively breastfeed for 6 months? [ASK WHAT ELSE, CIRCLE ALL MENTIONED] Breast milk not enough I was too busy/ was working Did not know importance I was advised by relative I was advised by friend Other (specify……………………………………… 1 2 3 4 5 88 SECTION 7: CHILD HEALTH & NUTRITION 701 Do you have a mother child booklet indicating vaccinations for (NAME) IF YES: May I see it please? Yes No 1 2 702 Since birth, has (NAME) received any of the following immunizations? [IF CARD IS AVAILABLE CHECK AND CIRCLE APPROPRIATELY]. [IF CARD NOT AVAILABLE, ASK THE MOTHER AND DESCRIBE VACCINATON FOR BCG Birth Polio (Polio 0) Polio 1 Polio 2 Polio 3 Pentavalent 1 YES NO NOT DUE 1 2 99 1 2 99 1 2 99 1 2 99 1 2 99 71 CLARITY THEN CIRCLE APPROPRIATELY) Pentavalent 2 Pentavalent 3 Measles Pneumococcal Vaccine (PCV) 10 1 PCV10 2 PCV10 3 Rotavirus Other (specify) 1 2 99 1 2 99 1 2 99 1 2 99 1 2 99 1 2 99 1 2 99 1 2 99 …………………………. 703 [IF THE CARD INDICATES SOME VACCINATION WERE NOT GIVEN OR [IF ANY OF THE ANSWERS TO QUESTIONS ABOVE IS NO ASK THE MOTHER THE FOLLOWING QUESTION]. I see your baby (NAME) is not up-to￾date with his/her immunization. Can you tell me why? [MULTIPLE ANSWERS POSSIBLE. DON’T READ ANSWER. CIRCLE ALL MENTIONED] Cannot afford to pay cost/expensive Unaware of need for immunization Unaware of need for completing all doses Not aware of place or time of immunization Time of immunization inconvenient Health facility too far Vaccinator absent Vaccine not available Mother too busy/sick Long waiting time on the queue Unpleasant treatment by health worker Fear of side effects Child ill Other (specify)………………………………………. I don’t know/ no reason 1 2 3 4 5 6 7 8 9 10 11 12 13 88 99 704 Has (NAME) been dewormed in the last six months? Yes No Don’t know 1 2 99 If “1” or “99” skip to 706 705 Why has (NAME) not been dewormed in the last 6 months? [MULTIPLE ANSWERS POSSIBLE. DON’T READ ANSWER. CIRCLE ALL MENTIONED] No need Didn’t know it is necessary Cannot afford I don’t have time/busy No reason Others (specify…………………………………………… … 1 2 3 4 5 88 72 706 Has (NAME) been sick for the last 2 Months? Yes No 1 2 If “2” skip to 901 707 What type of illness did s/he have Tick as many symptoms and signs as apply. PROBE ANYTHING ELSE Fever Hot body Weakness Cough Rapid/difficult breathing Headache Loss of appetite Vomiting Diarrhoea Convulsions Loss of consciousness or coma Diarrhea Joint pains Yellow eyes Catarrh (running nose Failure to drink or breastfeed Other (Specify)……………………………………… Don’t know 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 88 99 708 Did you seek advice or treatment from any source when (NAME) was sick? Yes No Don’t know 1 2 99 709 Where did you seek advice or treatment? Government health facility Private clinic FBO/NGO health facility CHV TBA Traditional healer Religious healer/Prayers Bought medicine from shop/chemist Others (specify……………………………………… 1 2 3 4 5 6 7 8 88 710 After you noticed signs and symptoms of sickness in (NAME) how long did you take before first seeking advice or treatment? Sought advise/treatment immediately Within 3 hours 3-12 hours 12-24 hours 2-3 days More than 3 days Other (specify…………………………………………. 1 2 3 4 5 6 88 SECTION 8: MANAGEMENT OF DIARRHOEA 801 Has (NAME) had diarrhea in the last 2 weeks? Yes No Don’t Know 1 2 99 If 2 or 99 Skip to 809 73 802 What was (NAME) given to treat the diarrhea? Anything else? If answer pill or syrup, show local packaging for zinc and task if the child received this medicine RECORD ALL MENTIONED NOTHING FLUID FROM ORS PACKET HOME-MADE FLUID PILL OR SYRUP, ZINC PILL OR SYRUP, NOT ZINC INJECTION IV (INTRAVENOUS) HOME REMEDIES/HERBAL MEDICINES OTHER (SPECIFY) A B C D E F G H I 803 Who provided the remedy/treatment? CHV Health facility/Health worker Pharmacy Others Specify 1 2 3 4 804 Did a CHV visit NAME at home while he/she was sick? Yes No Don’t Know 1 2 99 805 How long after providing the treatment did the CHW visit you? Same day Next day 2 days later 3 days later 4 days later 5 or more days later Don’t know 1 2 3 4 5 6 7 806 When (NAME) had diarrhea, did you breastfeed him/her less than usual, about the same amount, or more LESS SAME MORE CHILD NOT BREASTFED DON’T KNOW 1 2 3 4 5 807 When (NAME) had diarrhea, was he/she offered less than usual to DRINK, about the same amount, or more than usual to drink? LESS SAME MORE CHILD NOT BREASTFED DON’T KNOW 1 2 3 4 5 808 When (NAME) had diarrhea, was he/she offered less than usual to EAT, about the same amount, or more than LESS SAME 1 2 74 usual to eat? MORE CHILD NOT BREASTFED DON’T KNOW 3 4 5 809 Have you heard of ORS? IF YES, ASK MOTHER TO DESCRIBE ORS PREPARATION FOR YOU If no, circle 3 (never heard of ORS) once mother has provided a description, record whether she described ORS preparation correctly or incorrectly circle 1 [correctly] if the mother mentioned the following: USE 1 LITER OF CLEAN DRINKING WATER (1 LITER=3 SODA BOTTLES) USE THE ENTIRE PACKET DISSOLVE THE POWDER FULLY DESCRIBED CORRECTLY DESCRIBED INCORRECTLY NEVER HEARD OF ORS 1 2 3 SECTION 9: MANAGEMENT OF ARI/PNEUMONIA 901 Has (Name) had an illness with a cough that comes from the chest at any time in the last two weeks? Yes No Don’t Know 1 2 99 If 2 or 99, skip to 1001 902 When (Name) had an illness with a cough, did he/she have trouble breathing or breathe faster than usual with short, fast breaths? Probe for in drawing of the chest while (NAME) was breathing? Yes No Don’t Know 1 2 99 903 Did you seek advice or treatment for the cough/fast breathing/chest in drawing for (NAME)? Yes No Don’t Know 1 2 99 904 How long after you noticed (NAME’s) cough and fast breathing did you seek treatment? Same day Next day 2 days later 3 days later 1 2 3 4 905 Who gave you advice or treatment of (NAME)? Anyone else? RECORD ALL MENTIONED CHV Health facility/Health worker Pharmacy Others 1 2 3 4 75 Specify 906 Did the CHV visit (NAME) at home after providing treatment? Yes No Don’t Know 1 2 99 907 How long after providing the treatment did the CHV visit you? Same day Next day 2 days later 3 days later 4 days later 5 or more days later Don’t know 1 2 3 4 5 6 7 Section 10: WATER AND SANITATION 1001 What is the MAIN source of drinking water for members of this household? (CHECK ONE) PIPED WATER INTO HOMESTEAD PIPED WATER INTO YARD/PLOT/BUILDING PUBLIC TAP/STANDPIPE TUBEWELL/BOREHOLE PROTECTED DUG WELL UNPROTECTED DUG WELL PROTECTED SPRING UNPROTECTED SPRING RAIN WATER COLLECTION CART WITH SMALL TANK/DRUM TANKER TRUCK BOTTLED / SACHET WATER SURFACE WATER (RIVER/STREAM/ETC) EARTH PAN OTHER __________________________________ 96 (SPECIFY) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 1002 Do you treat your water in any way to make it safe for drinking? YES NO 1 2 If NO, skip to 1004 1003 If yes, what do you USUALLY do to the water to make it safer to drink? LET IT STAND AND SETTLE/ 1 76 Anything else? ONLY CHECK MORE THAN ONE RESPONSE IF SEVERAL METHODS ARE USUALLY USED TOGETHER, FOR EXAMPLE, CLOTH FILTRATION AND CHLORINE. SEDIMENTATION STRAIN IT THROUGH CLOTH BOILINGC ADD BLEACH/ CHLORINE(PUR/ AQUATAB) WATER FILTER (CERAMIC, SAND, COMPOSITE) SOLAR DISINFECTION OTHER __________________________________ X (SPECIFY) DON’T KNOW 2 3 4 5 6 7 8 9 99 1004 Do you know the times when it is important to wash hands? IF FOR WASHING MY OR MY CHILDREN’S HANDS IS MENTIONED, PROBE WHAT WAS THE OCCASION, BUT DO NOT READ THE ANSWERS. (DO NOT READ THE ANSWERS, ASK RESPONDENT TO BE SPECIFIC. ENCOURAGE “WHAT ELSE” UNTIL NOTHING FURTHER IS MENTIONED AND CIRCLE ALL THAT APPLY) BEFORE PREPARING FOOD BEFORE EATING BEFORE FEEDING CHILD AFTER CLEANING CHILD’S BOTTOMS AFTER USING THE TOILET AFTER EATING AFTER CLEANINGG AFTER TOUCHING SOMETHING STICKY, OILY, SMELLY OTHER (SPECIFY) 1 2 3 4 5 6 7 8 9 10 1005 Can you show me where you usually wash your hands and what you use to wash hands? ASK TO SEE AND OBSERVE INSIDE/NEAR LATRINE/TOILET FACILITY INSIDE/NEAR KITCHEN/COOKING PLACE ELSEWHERE IN YARD OUTSIDE YARD NO SPECIFIC PLACE NO PERMISSION TO SEE 1 2 3 4 5 6 1006 OBSERVATION ONLY: IS THERE SOAP OR DETERGENT OR LOCALLY USED CLEANSING AGENT? THIS ITEM SHOULD BE EITHER IN PLACE OR BROUGHT BY THE INTERVIEWEE WITHIN ONE MINUTE. IF THE ITEM IS NOT PRESENT WITHIN ONE MINUTE CHECK NONE, EVEN IF BROUGHT OUT LATER SOAP DETERGENT ASH MUD/SAND NONE OTHER (SPECIFY) 1 2 3 4 5 6 1007 Do you have soap in your household? YES NO 1 2 If NO skip to 1009 77 1008 When you used soap today or yesterday, what did you use it for? IF FOR WASHING MY OR MY CHILDREN’S HANDS IS MENTIONED, PROBE WHAT WAS THE OCCASION, BUT DO NOT READ THE ANSWERS. (DO NOT READ THE ANSWERS, ASK TO BE SPECIFIC, ENCOURAGE “WHAT ELSE” UNTIL NOTHING FURTHER IS MENTIONED AND CHECK ALL THAT APPLY) WASHING CLOTHS WASHING MY BODY WASHING MY CHILDREN WASHING CHILD’S BOTTOMS WASHING MY CHILDREN’S HANDS WASHING HANDS AFTER DEFECATING WASHING HANDS AFTER CLEANING CHILD WASHING HANDS BEFORE FEEDING CHILD WASHING HANDS BEFORE PREPARING FOOD WASHING HANDS BEFORE EATING OTHER _________________________________ X (SPECIFY) 1 2 3 4 5 6 7 8 9 10 11 1009 The last time [NAME] passed stool, where did he/she defecate? USED LATRINE/TOILET USED POTTY USED WASHABLE DIAPERS USED DISPOSABLE DIAPERS WENT IN HOUSE/YARD WENT OUTSIDE THE HOUSE TO THE BUSH HIS/HER CLOTHS OTHERS (SPECIFY 1 2 3 4 5 6 7 8 1010 The last time (NAME) passed stools, where was the stools disposed of? (IF “WASHED OR RINSED AWAY”, PROBE WHERE THE WASTE WATER WAS DISPOSED OF. IF “DISPOSED”, PROBE WHERE IT WAS DISPOSED OFF SPECIFICALLY. DROPPED INTO TOILET FACILITY RINSED/WASHED AWAY WATER DISCARDED INTO TOILET FACILITY WATER DISCARDED INTO SINK OR TUB CONNECTED TO DRAINAGE SYSTEM WATER DISCARDED OUTSIDE DISPOSED INTO SOLID WASTE/TRASH SOME WHERE IN YARD OUTSIDE HOUSE BURIED DID NOTHING/LEFT IT THERE OTHER (SPECIFY) DON’T KNOW 1 2 3 4 5 6 7 8 9 10 11 99 78 1011 How do you store your drinking water? IN CONTAINERS (BUCKET, JERRY CAN, BOTTLE, DRUM, POT ETC.) ROOF TANK OR CISTERN NO WATER STORED OBSERVATIONS OF STORAGE CONTAINER, TOILET FACILITY AND PLACE FOR HANDWASHING ARE BEST DONE AT THE END OF THE INTERVIEW. PLACE QUESTIONS AND OBSERVATIONS 12- 14 AT THE END OF THE QUESTIONNAIRE. 1012 IF IN CONTAINERS, may I see the containers, please? YES NO 1 2 If NO skip to 1101 1013 WHAT TYPE OF CONTAINERS ARE THESE? (OBSERVE AND CHECK ALL THAT APPLY) Narrow mouthed: opening is 3 cm or less (interviewers use template) NARROW MOUTHED WIDE MOUTHED OF BOTH TYPES 1 2 3 1014 ARE THE CONTAINERS COVERED? (OBSERVE AND CHECK) ALL ARE SOME ARE NONE ARE 1 2 3 SECTION 11: ACCESS & UTILIZATION OF HEALTH SERVICES 1101 What is the name of the health facility that you visit MOST for services in the last 6 months? [WRITE DOWN NAME OF FACILITY] …………………………………………………… ……………….. 1102 What were the reasons why you chose to go to [NAME OF FACILITY] and not another place? Referred there by health provider 1 Recommended by partner/ friend/ relative 2 Drugs/services are always available 3 Providers are always available 4 Providers are always friendly 5 Services are affordable/ free 6 Facility is nearby/ distance is short 7 Facility is the only one available 8 Did not know any other place 9 Other (specify)……………………….. 88 1103 The last time that you visited Were you satisfied, somewhat satisfied or not satisfied at all with the services you Satisfied 1 79 received at the facility? Somewhat satisfied Not satisfied at all 2 3 1104 Would you recommend a relative or friend to come to this facility for the services you received? Yes No Don’t know/ Not sure 1 2 99 1105 Are there CHVs in this village? Yes No Don’t know 1 2 99 If “2” or “99” skip to 1201 1106 What services do the CHVs provide to residents of this village? [MULTIPLE ANSWERS POSSIBLE. DON’T READ ANSWER. CIRCLE ALL MENTIONED] Health education/counseling Treatment/ caring for the sick Promotion of health services Referral Others (specify)…………………………………………… … 1 2 3 4 88 1107 Has a CHV visited you or your household in the last 3 months? Yes No Don’t know 1 2 99 IF NO skip to 1201 1108 During that visit what services did the CHV provide to you/your household? Health education/counseling Treatment/ caring for the sick Promotion of health services Referral Others (specify)…………………………………………. 1 2 3 4 88 1109 How would you rate the services you or your household received from the CHV- very poor, poor, good, or excellent? Very poor Poor Good Excellent 1 2 3 4 SECTION 12: HEALTH EDUCATION AND INFORMATION 1201 In the last 3 months, have you heard or read any educative messages about the following? [READ CHOICES & CIRCLE ANSWERS APPROPRIATELY] Family planning Antenatal care Giving birth Postnatal care Child health Immunization Nutrition Yes No 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 80 HIV Malaria WASH NONE 1 2 1 2 1 2 If None skip to 1203 1202 [ONLY ASK THOSE WHO HAVE HAD AT LEAST ONE MESSAGE] From what sources did you hear or read about the messages? MULTIPLE RESPONSES POSSIBLE. PROBE: WHAT OTHER SOURCE? Radio TV Newspaper Internet Billboard/ posters/wall chart Hospital / health center staff Community health Volunteer Imam/mosque/ religious leader NGO/CBO/ women group Husband/ relatives Friends Others (specify)……………………………….. 1 2 3 4 5 6 7 8 9 10 11 88 1203 What source/method of passing health messages would be the most effective to reach women like you in this village? [MULTIPLE RESPONSES POSSIBLE. CIRCLE ALL MENTIONED] Radio TV Newspaper Internet Billboard/ posters/wall chart Hospital / health center staff Community health worker Imam/mosque/ religious leader NGO/CBO/ women group Husband/ relatives Friends Others (specify) ……………………………………….. 1 2 3 4 5 6 7 8 9 10 11 88 SECTION 13: USE OF LLITNs MOSQUITO NETS 1301 Do you have any bed nets in your household? Yes No Don’t know 1 2 99 IF 2 or 99 skip to 1401 1302 Who slept under a bed net last night? Children under 5 1 81 [Circle all mentioned] Husband Wife Baby All Children Other specify…………………………. 2 3 4 5 88 SECTION 14: RESPECT, DIGNITY, EQUITY AND EMOTIONAL SUPPORT 1401 Are you always treated with appropriate respect by nurses/doctors at government health facilities when you or NAME go for any service? Always Sometimes Not at all I have not attended 1 2 3 4 Thank you for taking your time to take part in this interview 82 TOOL 2: HOUSEHOLD INTERVIEW WITH OVC CAREGIVERS (31 pages) IDENTIFICATION DATA 001. QUESTIONNAIRE IDENTIFICATION NUMBER 002. COUNTY 003. SUB-COUNTY 004. WARD 005. TYPE OF LOCATION 1=Urban 2=Rural 006. HOUSEHOLD NUMBER 007. CAREGIVER’S SEX 1=Male 2=Female 008. CAREGIVER’S AGE 1= under 18years 2=18-49years 3=50 years and above INTERVIEW LOG INTERVIEWER COMMENTS Interview Comment Codes 1 = Interview completed 2 = Respondent refused to be interviewed 3 = Respondent started the interview but did not complete it 4 = Multiple attempts made but respondent was not available to be interviewed 5 = Respondent not capable of giving consent to be interviewed (e.g., mentally ill, too sick, drunk, etc.) 6 = Others (specify) 009. INTERVIEWER CODE 010. DATE INTERVIEW COMPLETED (day/month/year) 011. START TIME OF INTERVIEW [__|__|:[____] CHECKED BY SUB-TEAM LEADER: Signature _______________________ Date _______________ 83 Comments 84 Section 1: OVC Households Status No. Questions Coding Categories QUESTIONS 12-14 ARE BASED ON DIRECT OBSERVATION. DO NOT READ THESE QUESTIONS ALOUD TO THE RESPONDENT. 012. MAIN MATERIAL OF THE ROOF 1 = No roof 2 = Thatch/palm leaf 3 = Plastic/Polythene sheet 4 = Wood planks 5 = Cardboard 6 = Metal/iron sheets 7 = Asbestos 8 = Cement 66= Other (specify): ________________________________ 99 = NOT OBSERVED 013. MAIN MATERIAL OF THE FLOOR 1 = Earth/sand/dung 2 = Wood planks 3 = Parquet or polished wood 4 = Vinyl (PVC) 5 = Ceramic /terrazzo tiles 6 = Concrete cement 66= Other (specify): _______________________________ 99 = NOT OBSERVED 014. MAIN MATERIAL OF THE EXTERIOR WALLS 1 = No walls 2 = Cane/palm/trunks 3 = Mud 4 = Bamboo 5 = Stone with mud 6 = Plywood 7 = Cardboard 8 = Cartons/polythene 9 = Wood 10 = Cement 11 = Stone with cement 12= Bricks 13= Iron sheets 66=Other (specify): _______________________________ 99=NOT OBSERVED APHIAPlus Imarisha End-of-Activity Evaluation, 2018 85 No. Questions Coding Categories 015. My first set of questions will help us to get a better understanding of your household. To start, how many people under the age of 18 years live in this household? _______ _______ UNDER 18 YEARS 016. How many people over the age of 18 live in this household? _______ ________ OVER 18 YEARS 017. Does your household have (a)….? ASK RESPONDENT ABOUT EACH ITEM (A TO J), READING EACH ITEM ALOUD AND RECORDINGA YES OR NO RESPONSE FOR EACH. Yes No a) Electricity 1 2 b) Solar panel 1 2 c) Radio 1 2 d) Television 1 2 e) Mobile telephone 1 2 f) Fixed-line telephone 1 2 g) Refrigerator 1 2 h) Sewing machine 1 2 i) Plough 1 2 j) Grain grinder 1 2 018. Does your household have a….? ASK RESPONDENT ABOUT OWNERSHIP OF EACH ITEM (A TO F), READING EACH ITEM ALOUD AND RECORDING A YES OR NO RESPONSE FOR EACH. Yes No a) Bicycle 1 2 b) Animal-drawn cart 1 2 c) Motorcycle 1 2 d) Vehicle 1 2 e) Boat with a motor 1 2 f) Canoe 1 2 019. Does your household own this structure (house, flat, shack), do you pay rent, or do you live here without paying rent? 1 = Owns, 2 = Pays rent/lease, 3 = No rent with consent of owner 4 = no rent, 5 = squatting 98 = I don’t know 020. Does your household own any land? 1=Yes 2=NoSKIP TO Q.21 021. Approximately how much land does your household own? RECORD THE AMOUNT AND SELECT THE MEASUREMENT UNIT MENTIONED BY THE RESPONDENT (I.E., ACRES, HECTARES, FEET). ______ acres / hectares /feet(INDICATE UNITS) 022. What is the main source of drinking water used by your household? 1 = PIPED INTO DWELLING 2 = PIPED TO COMPOUND/PLOT 3 = PUBLIC TAP/STAND PIPE APHIAPlus Imarisha End-of-Activity Evaluation, 2018 86 4 = BOREHOLE 5 = PROTECTED WELL 6 = UNPROTECTED WELL 7 = PROTECTED SPRING 8 = UNPROTECTED SPRING 9 = RAINWATER 10 = TANKER TRUCK 11 = WATER VENDOR 12 = SURFACE WATER (E.G., RIVER/DAM/LAKE/POND/STREA M/ CANAL/ IRRIGATION CHANNEL) 13 = OTHER __________________________ _ (SPECIFY) 023. What do you usually do to make the water safer to drink? KEEP ASKING ‘Anything else?’ UNTIL THE RESPONDENT HAS NO MORE RESPONSES FOR THIS QUESTION. RECORD ALL MENTIONED. A = DO NOTHING B = BOIL C = ADD BLEACH/CHLORINE D = STRAIN THROUGH A CLOTH E = USE WATER FILTER (CERAMIC/ SAND/COMPOSITE/ETC.) F = SOLAR DISINFECTION G = LET IT STAND AND SETTLE H= OTHER__________________ (SPECIFY) Z = DON’T KNOW 024. What kind of toilet facility do most members of your household use? 1=FLUSH TO PIPED SEWER SYSTEM 2= FLUSH TO SEPTIC TANK 3 = FLUSH TO PIT LATRINE 4 = FLUSH TO SOMEWHERE ELSE (E.G., RIVER) 5= FLUSH, DON’T KNOW WHERE 6=VENTILATED IMPROVED PIT LATRINE 7 = PIT LATRINE WITH SLAB 8 = PIT LATRINE WITHOUT APHIAPlus Imarisha End-of-Activity Evaluation, 2018 87 SLAB/OPENPIT 9 = COMPOSTING TOILET 10 = BUCKET TOILET 11= HANGING TOILET/HANGING LATRINE 12 = NO FACILITY/BUSH/FIELD 96 = OTHER (SPECIFY) _________________________ 025. How many of each of the following animals does this household own? ASK RESPONDENT ABOUT OWNERSHIP OF EACH ITEM (A TO J), READING EACH ITEM ALOUD AND RECORDING A NUMBER FOR EACH ANIMAL. IF NONE ENTER ‘000’. IF UNKNOWN ENTER 998. a) Traditional cattle ___ ___ ___ b) Dairy cattle ___ ___ ___ c) Beef cattle ___ ___ ___ d) Donkeys or mules ___ ___ ___ e) Goats ___ ___ ___ f) Sheep ___ ___ ___ g) Pigs ___ ___ ___ h) Chickens ___ ___ ___ i) Camels ___ ___ ___ j) Other poultry ___ ___ ___ k) Other livestock ___ ___ ___ Section 2: OVC Households access to money to meet basic needs No. Questions Coding Categories 026. I would now like to ask some questions about your household’s expenses. Roughly how much is your household’s monthly income? IF RESPONDENT IS UNSURE, ENCOURAGE HER/HIM TO GIVE AN ESTIMATE. IF S/HE STILL DOESN’T KNOW, SELECT DON’T KNOW. _____ _____ _____ , _____ _____ _____ KSH ☐ DON’T KNOW 027. What are the sources of income for this household? (IF NO INCOME REPORTED IN Q23, SELECT ‘A’ (NO INCOME REPORTED) AND SKIP TO Q.26. IF INCOME WAS REPORTED IN Q23, SELET ALL RESPONSES THAT APPLY. KEEP ASKING ‘Anything else?’ UNTIL THERE ARE NO MORE SOURCES TO RECORD.) A = NO INCOME REPORTED SKIP TO Q.31 B = Agriculture C = Self-employed, not related to agriculture (Describe work (e.g., ‘shop owner’) in the space provided: _________________________________________________) D = Informal employment (e.g., domestic work, jua kali, etc.) E = Formal employment F = Government cash transfers G = Money/support from friends or relatives H= OTHER (Specify) APHIAPlus Imarisha End-of-Activity Evaluation, 2018 88 Z = DON’T KNOW 028. About how much do you spend each month on the following: READ EACH OF THE FOLLOWING ITEMS ALOUD AND RECORD THE AMOUNT SPENT PER MONTH. (a) Food? (b) Rent/housing? (c) Health care/medical bills? (d) School fees/education? (e) Clothing? (f) Transport/fares? (g) Entertainment? (h) Other items or issues? IF RESPONDENT DOESN’T KNOW AMOUNT SPENT FOR A PARTICULAR ITEM, ENCOURAGE HER/HIM TO TRY AND ESTIMATE THE AMOUNT. IF S/HE STILL DOESN’T KNOW, SELECT ‘DON’T KNOW’ FOR THAT ITEM. (a) Food: _____ _____ _____ , _____ _____ _____ KSH ☐ DON’T KNOW (b) Rent/housing: ____ ____ ____ , ____ ____ ____ KSH ☐ DON’T KNOW (c) Health care/medical bills: ___ ___ ___ , ___ ___ ___KSH ☐ DON’T KNOW (d) School fees/education: ___ ___ ___ , ___ ___ ___ KSH ☐ DON’T KNOW (e) Clothing: ___ ___ ___ , ___ ___ ___ KSH ☐ DON’T KNOW (f) Transport/fares: ___ ___ ___ , ___ ___ ___ KSH ☐ DON’T KNOW (g) Entertainment: ___ ___ ___ , ___ ___ ___ KSH ☐ DON’T KNOW (h) Other items: ___ ___ ___ , ___ ___ ___ KSH APHIAPlus Imarisha End-of-Activity Evaluation, 2018 89 (Specify: _______________________________________________) 029. Who usually decides how the income you earn will be used 1 = you, 2 = your husband/partner, or 3 = you and your husband/partner jointly 98=I don’t Know 030. Is your household able to save any money? 1=Yes 2=No 031. Do you or any member of your household participate in any income￾generating activities? (DO NOT PROMPT RESPONDENT. CIRCLE ALL MENTIONED. KEEP ASKING ‘Anything else?’ UNTIL THE RESPONDENT HAS MENTIONED ALL ACTIVITIES IN WHICH THE HOUSEHOLD PARTICIPATES.) A=Food stuff (cooked, raw, grains) B= Second-hand items C= Other petty trading D= Retail /whole sale shop (grocery) E = Unprocessed milk products F = Butchery/Fish selling G = Other animal products H= Phone shop/repair/phone transfer/Mpesa I = Tailoring J= Crafts /carpentry K= Brewing/brewery L= Transport M= Mechanic N = Electronics repair O =Haircutting/salon P =Agricultural processing Q =Restaurant/ bar/lodging/hotel R= NO PARTICIPATION IN INCOME-GENERATING ACTIVITIES S =Other (specify)__________________________ Z=Don’t Know Section 3: Food Security & Nutrition 032. I would now like to ask you some questions about your household’s food. During the last month (four weeks), was your household able to pay for food expenses? 1=Yes 2=No 98=Don’t Know APHIAPlus Imarisha End-of-Activity Evaluation, 2018 90 033. During the last four weeks, how did your household get food to eat? DO NOT READ THE LIST OF RESPONSES TO THE RESPONDENT. MULTIPLE RESPONSES ALLOWED. KEEP ASKING ‘Anything else?’ A=Crops from the farm B=Livestock outputs C=Livestock Sale D=Employed on a Farm E=Employed doing household chores F=Employed in the private sector G=Employed by the government H=Own business/retailing/selling food I=Rental income (house, equipment, animals) J=Money given by friends or family /donors K=Only relied on food donation L=Other (specify):__________________________________________ Z=Don’t Know 034. Has the amount your household spends on food changed over the past year? 1=Yes 2=No SKIP TO Q.31 98=Don’t Know SKIP TO Q.31 035. Why? MULTIPLE RESPONSES ALLOWED. RECORD ALL MENTIONED. KEEP ASKING ‘Any other reasons?’ UNTIL THE RESPONDENT MENTIONS NO OTHER REASONS. A=Stopped receiving food donations/food support B=Reduced household food stores C=More disposable income D=Food prices went up E=More people live in household now F=Fewer people live in household now G=Harvest produced food; no need to buy H=Received food support I=Food prices went down J=Other: _______________________ Z=Don’t Know 036. Are you aware of what foods a household should eat on a daily basis to have a balanced diet? If YES, can you please tell me what those foods are? IF RESPONDENT IS NOT AWARE (ANSWERS ‘NO’ CIRCLE A (DOES A=DOES NOT KNOW B= DAIRY PRODUCTS C = FRUITS D = GRAINS (e.g., ugali, maize, rice) E= LEGUMES (e.g., beans, green grams) F = VEGETABLES G = MEAT/CHICKEN/FISH H = OTHER (Specify) _______________________ APHIAPlus Imarisha End-of-Activity Evaluation, 2018 91 NOT KNOW). MULTIPLE RESPONSES ALLOWED. RECORD ALL MENTIONED. ALL TYPES OF MEAT (SEAFOOD, MUTTON, RED MEAT, CHICKEN, ETC.) ARE CODED IN THE SAME CATEGORY (CATEGORY G) 037. Are you aware of any extension services from the Ministry of Agriculture and other ministries such as fisheries and livestock? 1=Yes 2=NoSKIP TO Q54 98=Don’t KnowSKIP TO Q54 038. Has your household received any of those services? 1=Yes 2=No 98=Don’t Know 039. Are there any children from this household who are benefiting from feeding programs in school? 1=Yes 2=No 98=Don’t Know Section 4: Household Management of shocks & Unexpected Financial Occurrences 040. Did your household incur any unexpected household expenses in the last 12 months? IF RESPONDENT NEEDS EXAMPLES OF WHAT YOU MEAN BY ‘UNEXPECTED HOUSEHOLD EXPENSE,’ YOU CAN MENTION ‘house repair’ or ‘urgent medical treatment.’ 1=Yes 2=NoSKIP TO Q.34 98=Don’t Know SKIP TO Q.34 041. Was your household able to pay for these expenses? 1=Yes 2=No 98=Don’t Know 042. Thinking about the last time you had an unexpected household expense, how did you cover the costs? DO NOT READ RESPONSES ALOUD. CIRCLE ALL THAT APPLY. KEEP ASKING ‘Anything else?’ A=Crops from the farm B=Livestock outputs C=Livestock Sale D=Employed on a Farm E=Employed doing household chores F=Employed in the private sector G=Employed by the government H=Own business/retailing/selling food I=Rental income (house, equipment, animals) J=Money given by friends or family /donors K=Government cash transfer L=Other (specify) _________________________________________ APHIAPlus Imarisha End-of-Activity Evaluation, 2018 92 Z=Don’t Know 043. Has the amount your household spends on healthcare changed over the last year (12 months)? 1=Yes 2=No SKIP TO Q.39 3=Don’t knowSKIP TO Q.39 044. Why did the amount you spend on healthcare change? MULTIPLE RESPONSES ALLOWED. RECORD ALL MENTIONED. A=Household member was sick B=Household member pregnant/had baby C=Had to buy drugs D=Routine check-ups E=Household member had an accident F=Other_________________________________________ Z=Don’t Know 045. Did your household incur any school￾related expenses in the last 12 months? 1=Yes 2=No SKIP TO Q.46 98=Don’t KnowSKIP TO Q.46 046. Was your household able to pay for these expenses? 1=Yes 2=No 98=Don’t Know 047. What are the main ways that your household pays school-related expenses? (CIRCLE ALL THAT APPLY. KEEP ASKING ‘Anything else?’) A=Crops from the farm B=Livestock outputs C=Livestock Sale D=School fees support from LIP E =School fee support from Government (CDF, bursaries, etc.) F=Employed on a Farm G=Employed doing household chores H=Employed in the private sector I=Employed by the government J=Own business/retailing/selling food K=Rental income (house, equipment, animals) L=Money given by friends or family /donors M=Other (specify) _________________________________________________ N=Don’t Know 048. Has the amount your household spends on education changed over the last year (12 months)? 1=Yes 2=No SKIP TO Q.47 98=Don’t KnowSKIP TO Q.47 049. Why did the amount you spend on education change? MULTIPLE RESPONSES ALLOWED. RECORD ALL MENTIONED. IF RESPONDENT MENTIONS NUMBER OF SCHOOL-GOING MEMBERS INCREASED (RESPONSE D), PROCEED TO Q46. FOR ALL OTHER RESPONSES, PROCEED TO Q47. A=School fees increasedSKIP TO Q.46 B=School requirements, such as: uniforms, school booksSKIP TO Q.46 C=PTA costs or transportation costs increasedSKIP TO Q.46 D=Number of school going members in the household increased E=Withdrawal of previous supportSKIP TO Q.46 F=School fees reduced, add other support receivedSKIP TO Q.46 G=PTA costs or transportation costs reducedSKIP TO Q.46 H=Number of school going members in the household reducedSKIP TO Q.46 I=Support from government/other agencies SKIP TO Q.46 J=Other: ________________________SKIP TO Q.46 Z=Don’t KnowSKIP TO Q.46 050. ONLY ASK IF RESPONSE TO 1 = Because children living in the household got older (of school-going APHIAPlus Imarisha End-of-Activity Evaluation, 2018 93 Q45 WAS D: Why did the number of school-going members in your household increase? age) 2 = Because brought additional children into the household 3 = OTHER (Specify): __________________________________________________ 051. Approximately how much money did your household spend on making improvements (e.g., home repairs, new furniture) to your home in the last 12 months? IF THE HOUSEHOLD SPENT MONEY ON IMPROVEMENTS, WRITE THE AMOUNT IN THE SPACE PROVIDED) _________________[Kshs] ☐NO MONEY SPENTQ.48 052. How did you pay for those home improvements? (CIRCLE ALL MENTIONED. KEEP ASKING ‘Anything else?’) A = Household savings/salary B = Government cash transfer C = Loan D = Profits from business E = OTHERS (Specify) ______________________________ Section 5: Health 053. Where do members of your household usually go for health care? (CIRCLE ONLY ONE) IF RESPONDENT MENTIONS ‘PRIVATE HEALTH FACILITY,’ PROBE WITH THE FOLLOWING QUESTION: “Do you have to pay fees to receive care at that facility, or do you get the services for free?”). IF FREE, SELECT RESPONSE #3. IF THE HOUSEHOLD HAS TO PAY A FEE, SELECT RESPONSE #4 1= NO WHERE 2=Public health facility: 2a=Name_____________________ 3=Private health facility—free/waived fees 4=Private health facility—pays fees 5= Chemist/pharmacy 6=Religious leaders 7=Traditional healers 8=Other (Specify) ___________________________________________ 98=Don’t Know 054. What are the main ways that your household pays for health care? MULTIPLE RESPONSES ALLOWED. CIRCLE ALL MENTIONED. KEEP ASKING ‘Anything else?’ UNTIL THE RESPONDENTS STOPS MENTIONING WAYS. A = DOES NOT SEEK HEALTH CARE B= CANNOT PAY FOR HEALTH CARE C = NHIF D = Medical Insurance E = Personal/household funds F = Health fee waivers G = OTHER (Specify) _________________________________________________ 055. How can a household reduce health care costs? CIRCLE ALL MENTIONED. DO A=NHIF B=Fee waivers C=Free medical care APHIAPlus Imarisha End-of-Activity Evaluation, 2018 94 NOT PROMPT. KEEP ASKING ‘Anything else?’ D=Private health insurance E=Others (specify) ___________________ Z=Don’t Know 056. How can a household prevent malaria? CIRCLE ALL MENTIONED. DO NOT PROMPT. KEEP ASKING ‘Anything else?’ A= Sleep under/use mosquito nets B= Insecticide spray C=Mosquito repellent D=Clearing bushes E=Draining/no standing water F=Other (specify) _____________________ Z=Don’t Know Section 6: Caregivers involvement in family strengthening activities No. Questions Coding Categories Household income and property 057. I would now like to ask your opinion on a few different topics. What business/income-generating activities Have you been most active with? DO NOT READ RESPONSES ALOUD. CIRCLE ALL THAT APPLY. KEEP ASKING ‘Anything else?’ IF THE RESPONDENT PROVIDES ONE RESPONSE ONLY THEN SKIP TO Q.51 A=Food stuff (cooked, raw, grains) B= Second-hand items C= Other petty trading D= Retail /whole sale shop (grocery) E= unprocessed Milk products F= Butchery/Fish selling G= Other animal products H= Phone shop/repair/phone transfer/Mpesa I= Tailoring J= Crafts /carpentry K= Brewing/brewery L= Transport M= Mechanic N= Electronics repair O=Haircutting/salon P=Agricultural processing Q=Restaurant/ bar/lodging/hotel R=Other (specify) Z=Don’t Know SKIP TO Q.50 058. Which one brings the most income to this household? SINGLE RESPONSE (CIRCLE ONLY ONE) 1 =Food stuff (cooked, raw, grains) 2 =Second-hand items 3 = Other petty trading 4 = Retail /whole sale shop (grocery) 5 = Unprocessed Milk products 6 = Butchery/Fish selling 7 = Other animal products 8 = Phone shop/repair/phone transfer/ Mpesa 9 = Tailoring 10 = Crafts /carpentry 11 = Brewing/brewery 12 = Transport 13 = Mechanic APHIAPlus Imarisha End-of-Activity Evaluation, 2018 95 14 = Electronics repair 15 =Haircutting/salon 16 =Agricultural processing 17 =Restaurant/ bar/lodging/hotel 18 =Other (Specify): ___________________ ___________________________________ 98=Don’t Know 059. Has your small business adopted formal business practices? (Select all that apply) 1=Yes, I have registered my small business with the local authority and government 2=Yes, I have opened a bank account for my small business 3=Yes, I am paying tax for my small business 4=Yes, my small business is using written contracts 5=Yes, my small business is submitting tenders for business opportunities 6=No, my small business has not adopted any formal business practice 98 = Don’t know 060. What are the biggest obstacles facing your business? (Select all that apply) 1 = Low demand for product 2 = Lack of access to market 3 = Strong competition 4 = Stigma issues 5 = Lack of skills / knowledge 6 = Lack of finance 7 = Government interference 8 = Taxation 9 = Corruption 10=Other 98=Don’t know 061. Do you currently belong to any informal business/development/credit/support groups such as SILC, PLHIV, OVC caregiver support group etc.? (Select one) 1=Yes 2=No 98=Don’t Know 062. If yes, which are the support groups, 1 = PLHIV Support Group 2 = OVC caregiver support group 3 = Youth group 4 = Business Development group 5 = Other, specify__________________ 98= I Don’t know 063. How long have you been a member of the support group? (Select one) 1 = 1-6 months 2 = 7-12 months 3 = Over one year 064. Which Household economic strengthening initiatives is your group actively participating in? 1 = Vegetable production 2 = Sale of water 3 = Poultry production and sale of eggs 4 = Fresh milk production 5 = Ghee production APHIAPlus Imarisha End-of-Activity Evaluation, 2018 96 6 = Harvesting natural grass and selling 7 = Bee keeping 8 = Saving and internal loaning (SILC) 9 = Goat rearing 10=Animal lodge 98=I don’t know 065. Do you think being part of a business/savings/support group is important to your financial stability and future growth? (Select one) 1 = Yes, very important 2 = Yes, somewhat important 3 = No, not very important 4 = I don’t know yet 066. Has this feeling changed over the past year? (Select one) 1 = Yes, the group is more important to me now 2 = No, the group is less important to me now 3 = About the same 4 = I don’t know yet 067. Compared to last year, do you feel more in control of your economic future? (Select one) 1 = Yes, I am a lot more in control of my economic future now 2 = Yes, I am a little more in control of my economic future now 3 = I feel about the same as last year 4 = No, I am a little less in control of my economic future 5 = No, I am a lot less in control of my economic future 6 = I don’t know Section 7: Child Protection No. Questions Coding Categories 068. Are you aware of any of child rights? 1=Yes 2=NoSKIP TO Q64 98=Don’t KnowSKIP TO Q64 069. What are those rights? (DO NOT PROMPT, BUT KEEP ASKING ‘Anything else?’ CIRCLE ALL MENTIONED.) A=Right to protection B=Right to education C=Right to shelter D=Right to health E=Right to participation F=Right to food G=Right to clothing H=Others (Specify_______________) Z=Don’t Know 070. I just have two more questions. Do you believe that physical punishment is a good way of disciplining or controlling a 1=YesEND 2=No APHIAPlus Imarisha End-of-Activity Evaluation, 2018 97 child at home or in school? 98=Don’t Know 071. How do you discipline your child? A = Talk to the child B = Refuse/deny food C = Lock child outside of the house D = OTHERS (specify): _______________________________________ ______ 072. Where can household members access legal protection services when needed? CIRCLE ALL MENTIONED. DO NOT PROMPT. KEEP ASKING ‘Anything else?’ A=Police B=Children’s department C=Teacher D=Religious leader E=Relative F=NGO/CBO/FBO G=Paralegals H=Chief I=Lawyer J=Others (specify)___________________________ Z=Don’t Know The Caregiver is to provide information on the Oldest OVC (5-17yrs) in the Household No. Questions Coding Categories 010. Record / Confirm Child’s Name “What is the child’s name?” 011. Record / Confirm Child’s Sex Female Male 1 2 012. “In what month and year were NAME born?” Month [____] Year [__|__|____] 013. “How old is {NAME}?” [____] years 014. What kinds of services should a 5- 17 year old receive? (DO NOT READ THE A =appropriate family/household based care B =appropriate housing/shelter C =received all immunization as per the schedule APHIAPlus Imarisha End-of-Activity Evaluation, 2018 98 RESPONSES ALOUD. HOWEVER, KEEP ASKING ‘Anything else?’ UNTIL THE RESPONDENT CANNOT NAME ANY MORE SERVICES. RECORD ALL MENTIONED.) D =health care E =receives proper nutrition/food secure F =has birth certificate G =appropriate clothing H =access to early childhood development I =receives psychosocial support when appropriate J =caregiver receives information on OVC care K=education L =Others (Specify________________) Z =Don’t Know SECTION 3: CHILD EDUCATION No. Question Coding Category 015. “Has NAME ever been to school?” Yes No 1 2SKIP TO Q23 016. Is {NAME} enrolled in school now? Yes No 1SKIP TO Q24 2 017. Why does {NAME} NOT go to school? DO NOT READ RESPONSES ALOUD. MULTIPLE RESPONSES ALLOWED. RECORD ALL MENTIONED. KEEP ASKING ‘Any other reason?’ UNTIL THE RESPONDENT CAN MENTION NO OTHER REASONS. No money for school materials, transport……….. T{NAME} is too sick to attend school ……………..…………. School is too far away /no school …………………… {NAME} has to work …………………………………………… ……. have to care for household members …………….. I do not want {NAME} to go to school …………………………………………… …………………. {NAME} doesn’t like school …………………………………………… School was not in session ………………………………… Other: ………………………………… DON’T KNOW ………………………………………… ASKIP TO Q29 BSKIP TO Q29 CSKIP TO Q29 DSKIP TO Q29 ESKIP TO Q29 FSKIP TO Q29 GSKIP TO Q29 HSKIP TO Q29 ISKIP TO Q29 ZSKIP TO Q29 APHIAPlus Imarisha End-of-Activity Evaluation, 2018 99 018. What class/form is {NAME} in now? FIRST, CIRCLE THE CORRECT CODE NEXT TO THE CURRENT LEVEL OF SCHOOLING (I.E., PRE￾PRIMARY=1, PRIMARY=2, SECONDARY=3). THEN,USE THE SPACE PROVIDED NEXT TO THE RESPONSE TO WRITE THE SPECIFIC CLASS/FORM THE CHILD IS CURRENTLY IN. 1……. PRE-PRIMARY (1-3) [________] 2………PRIMARY (Class 1-8) [________] 3………SECONDARY (Form 1-4) [________] 8…….. DON’T KNOW 019. During the last school week, did {NAME} miss any school days for any reason? Yes No 1 2SKIP TO Q27 020. Why did {NAME} miss school days during the last school week? DO NOT READ RESPONSES ALOUD. MULTIPLE RESPONSES ALLOWED. KEEP ASKING ‘Anything else?’ RECORD ALL MENTIONED. A = No money for school materials, transport… B = I am too sick to attend school… C = School is too far away / no school… D = I have to work… E = I have to care for household members… F = School was not in session… G = I don’t like school… H = Parent/guardian does not want me to go to school… I = Other: ______________________ 021. During the last school term, how often did you {NAME} miss school? READ RESPONSES ALOUD TO THE RESPONDENT AND CIRCLE ONLY ONE ANSWER. 1 = Never…SKIP TO Q.2 2 = Occasionally (Maximum Once A Month)… 3 = Often (Two Or More Times A Month)… 8 = Don’t Know… APHIAPlus Imarisha End-of-Activity Evaluation, 2018 100 022. What were the main reasons why {NAME} miss school last term? DO NOT READ RESPONSES ALOUD. MULTIPLE RESPONSES ALLOWED. KEEP ASKING ‘Anything else?’ RECORD ALL MENTIONED. No money for school materials, transport… Was too sick to attend school… School is too far away / no school… I had to work… I had to care for household members… School was not in session… I don’t like school… Parent/guardian does not want me to go to school… Other: ___________________________ A B C D E F G H I 023. IF CHILD HAS NEVER BEEN ENROLLED IN SCHOOL, CIRCLE 3, AND PROCEED TO Q.33. OTHERWISE ASK THE FOLLOWING: Was {NAME} enrolled in school during the previous school year? 1 = Yes 2 = NoSKIP TO Q31 3 = Never Enrolled In SchoolSKIP TO Q32 024. What class/form was {NAME} in the previous school year? FIRST, CIRCLE THE CORRECT CODE NEXT TO THE APPROPRIATE LEVEL OF SCHOOLING (I.E., PRE-PRIMARY=1, PRIMARY=2, SECONDARY=3). THEN, USE THE SPACE PROVIDED NEXT TO THE RESPONSE TO WRITE THE SPECIFIC CLASS/FORM THE CHILD WAS IN LAST YEAR. 1……. PRE-PRIMARY (1-3) [________] 2………PRIMARY (Class 1-8) [________] 3………SECONDARY (Form 1-4) [________] 8…….. DON’T KNOW 025. What is the highest class/form that you {NAME} have completed? 1……. PRE-PRIMARY (1-3) [________] 2………PRIMARY (Class 1-8) [________] 3………SECONDARY (Form 1-4) [________] 8…….. DON’T KNOW APHIAPlus Imarisha End-of-Activity Evaluation, 2018 101 026. How many school aged children living in your home go to school currently? (Enter # of each) 1 = (#) Male Children in School________________________ 2 = (#) Female Children in school_______________________ 3 = (#) Male Children not attending School________________ 4 = (#) Female Children not attending School ______________ 073. Has the number of school aged (5-17) children living in your home going to school changed from a year ago? (Select one) 1 = We don’t have child between5-17 2 = Yes, more children are attending school(#M____ #F____) 3 = Yes, less children are attending school(#M____ #F____) 4 = No change 074. For school aged (5-17) children not receiving education, please note primary reasons for them not attending. (Select all that apply) 1 = Household responsibilities(including child care) 2 = Household labor or farming/IGA 3 = School fees, uniforms, etc., too expensive 4 = No access to formal education 5 = Too ill / sick to attend 6 = Other, specify____________________ 027. Have you received any type of educational assistance? (Select all that apply) 1 = Books 2 = Educational Materials (paper, pencils, etc.) 3 = Financial support / School Fees 4 = Food Support 5 = Tutoring 6 = School uniform 7 = Solar lamps 8 = No, we do not receive educational assistance 9 = Other, specify __________________________ 028. If yes, who provides this assistance? (Select all that apply) 1 = Government 2 = Relatives/friend 3 = NGO/CBO 4 = Religious Organization /Institution 5 = Other, specify _____________________________ 029. Has {NAME} received any life skills training? 1 = Yes 2 = No 8 = Don’t know 030. Has {NAME} been to any vocational institution? 1 = Yes 2 = No 075. What vocational or technical skills has {NAME} acquired? MULTIPLE RESPONSES ALLOWED. CIRCLE ALL MENTIONED.KEEP ASKING ‘Anything else?’ UNTIL NO OTHER SKILLS ARE MENTIONED. A = Carpentry B = Masonry C = Mechanics D = Cosmetology E = Tailoring F = Customer care G = Plumbing H = Electrician I = Others specify__________________________ APHIAPlus Imarisha End-of-Activity Evaluation, 2018 102 SECTION 4: FOOD CONSUMPTION 034. Now I would like to ask you about liquids or foods {NAME} ate yesterday during the day or at night. Did you drink or eat any of the following? READ EACH OF THE ITEMS LISTED IN A-Z OUT LOUD TO THE RESPONDENT. RECORD YES OR NO FOR EACH. YES NO DK A) Plain Water 1 2 8 B) Milk 1 2 8 C) Tea Or Coffee 1 2 8 D) Other Liquids 1 2 8 E) Porridge/Gruel 1 2 8 F) Grains ............................... 1 2 8 G) Red/Yellow Vegetables 1 2 8 H) Roots, Tubers 1 2 8 I) Green/Leafy Vegetables 1 2 8 J) Mango, Pawpaw, Guava 1 2 8 K) Other Fruits 1 2 8 L) Meat, Chicken, Fish, Eggs 1 2 8 M) Beans, Pulses 1 2 8 N) Sour Milk, Cheese 1 2 8 O) Other Foods 1 2 8 Z) Nothing To Eat 1 2 8 035. Were the foods and liquids that {NAME} ate yesterday the kinds of things that he/she normally eat? 1 = Yes 2 = No 8 = Don’t know 036. In the past four weeks, did {NAME} have any problems getting enough food to eat? 1 = Yes 2 = No 8 = Don’t know SECTION 6: LEGAL PROTECTION No Questions Coding Categories 037. Which of the following apply to {NAME}’s situation? 1 = Mother and Father alive 2 = Mother alive, Father deserted (or survival unknown) 3 = Mother alive, Father deceased 4 = Father alive, Mother deserted (or survival unknown) 5 = Father alive, Mother deceased 6 = Both Mother and Father deceased APHIAPlus Imarisha End-of-Activity Evaluation, 2018 103 I have come to the end of my questions. Is there anything you would like to add or ask us? Thank you for participating in this interview! 076. END TIME [__|__|:[____] CHECKED BY TEAM LEADER: Signature _______________________ Date _______________ Comments SECTION 1: BACKGROUND INFORMATION AS A REMINDER: IF THE CHILD IS AGE 5–9 YEARS, INTERVIEW THE CHILD’S CAREGIVER. IF THE CHILD IS AGE 10–17 YEARS, INTERVIEW THE CHILD DIRECTLY, BUT THE CAREGIVER MUST GIVE CONSENT FOR THE CHILD TO BE INTERVIEWED. No. Questions Coding Categories 038. what is the relationship between you and this child Do not read responses. Record one primary response only. 1 = Biological mother 2 = Biological father 3 = Sister and/or brother 4 = Aunt and/or uncle 5 = Grandmother and/or Grandfather 6 = Other relative 7 = Neighbor 8 = Friend 9 = No one/self 10=Other: __________________ 039. Does {NAME} have a birth certificate? 1 = Yes 2 = No END 8 = Don’t know END 040. Could you please show me the birth certificate? 1 = Seen / confirmed 2 = Not seen / not confirmed APHIAPlus Imarisha End-of-Activity Evaluation, 2018 104 033. Record / Confirm Child’s Name What is your name? 034. Record / Confirm Child’s Sex Female Male 1 2 035. In what month and year were you born? Month [____] Year [__|__|____] 036. How old were you at your last birthday? [____] years 037. What kinds of services should a 5- 17 year old receive? (DO NOT READ THE RESPONSES ALOUD. HOWEVER, KEEP ASKING ‘Anything else?’ UNTIL THE RESPONDENT CANNOT NAME ANY MORE SERVICES. RECORD ALL MENTIONED.) A =appropriate family/household based care B =appropriate housing/shelter C =received all immunization as per the schedule D =health care E =receives proper nutrition/food secure F =has birth certificate G =appropriate clothing H =access to early childhood development I =receives psychosocial support when appropriate J =caregiver receives information on OVC care K=education L =Others (Specify________________) Z =Don’t Know SECTION 2: HIV TESTING No. Question Coding Categories 038. I would now like to change the topic again to discuss some other issues. Have you ever heard of HIV, the virus that causes AIDS? FOR 5-12 YEARS OLD, POSE Qs 17-19 TO THE CAREGIVER Yes 1 No 2SKIP TO Q.21 Don’t know 8SKIP TO Q.21 039. Do you know your HIV status? Yes 1 No 2 Don’t know 8 040. ***SKIP THIS QUESTION IF THE CHILD DIRECTLY ANSWERED Q.18*** Yes 1 No 2 Don’t know 8 APHIAPlus Imarisha End-of-Activity Evaluation, 2018 105 Do you know the HIV status of [NAME]? 041. Has {NAME} ever been tested for HIV but you did not receive his/her test results? SECTION 3: CHILD EDUCATION No. Question Coding Category 042. Have you ever been enrolled in school? Yes No 1 2SKIP TO Q23 043. Are you enrolled in school now? Yes No 1SKIP TO Q24 2 044. Why do you NOT go to school? DO NOT READ RESPONSES ALOUD. MULTIPLE RESPONSES ALLOWED. RECORD ALL MENTIONED. KEEP ASKING ‘Any other reason?’ UNTIL THE RESPONDENT CAN MENTION NO OTHER REASONS. No money for school materials, transport……….. I am too sick to attend school ……………..…………. School is too far away /no school …………………… I have to work …………………………………………… ……. I have to care for household members …………….. Parent/guardian does not want me to go to school …………………………………………… …………………. I don’t like school …………………………………………… School was not in session ………………………………… Other: ………………………………… DON’T KNOW ………………………………………… ASKIP TO Q29 BSKIP TO Q29 CSKIP TO Q29 DSKIP TO Q29 ESKIP TO Q29 FSKIP TO Q29 GSKIP TO Q29 HSKIP TO Q29 ISKIP TO Q29 ZSKIP TO Q29 APHIAPlus Imarisha End-of-Activity Evaluation, 2018 106 045. What class/form are you in now? FIRST, CIRCLE THE CORRECT CODE NEXT TO THE CURRENT LEVEL OF SCHOOLING (I.E., PRE￾PRIMARY=1, PRIMARY=2, SECONDARY=3). THEN,USE THE SPACE PROVIDED NEXT TO THE RESPONSE TO WRITE THE SPECIFIC CLASS/FORM THE CHILD IS CURRENTLY IN. 1……. PRE-PRIMARY (1-3) [________] 2………PRIMARY (Class 1-8) [________] 3………SECONDARY (Form 1-4) [________] 8…….. DON’T KNOW 046. During the last school week, did you miss any school days for any reason? Yes No 1 2SKIP TO Q27 047. Why did you miss school days during the last school week? DO NOT READ RESPONSES ALOUD. MULTIPLE RESPONSES ALLOWED. KEEP ASKING ‘Anything else?’ RECORD ALL MENTIONED. A = No money for school materials, transport… B = I am too sick to attend school… C = School is too far away / no school… D = I have to work… E = I have to care for household members… F = School was not in session… G = I don’t like school… H = Parent/guardian does not want me to go to school… I = Other: ______________________ 048. During the last school term, how often did you {NAME} miss school? READ RESPONSES ALOUD TO THE RESPONDENT AND CIRCLE ONLY ONE ANSWER. 1 = Never…SKIP TO Q.2 2 = Occasionally (Maximum Once A Month)… 3 = Often (Two Or More Times A Month)… 8 = Don’t Know… APHIAPlus Imarisha End-of-Activity Evaluation, 2018 107 049. What were the main reasons why you missed school last term? DO NOT READ RESPONSES ALOUD. MULTIPLE RESPONSES ALLOWED. KEEP ASKING ‘Anything else?’ RECORD ALL MENTIONED. No money for school materials, transport… Was too sick to attend school… School is too far away / no school… I had to work… I had to care for household members… School was not in session… I don’t like school… Parent/guardian does not want me to go to school… Other: ___________________________ A B C D E F G H I 050. IF CHILD HAS NEVER BEEN ENROLLED IN SCHOOL, CIRCLE 3, AND PROCEED TO Q.33. OTHERWISE ASK THE FOLLOWING: Were you enrolled in school during the previous school year? 1 = Yes 2 = NoSKIP TO Q31 3 = Never Enrolled In SchoolSKIP TO Q32 052. What is the highest class/form that you {NAME} have completed? 1……. PRE-PRIMARY (1-3) [________] 2………PRIMARY (Class 1-8) [________] 3………SECONDARY (Form 1-4) [________] 8…….. DON’T KNOW 053. Have you received any type of educational assistance? (Select all that apply) 1 = Books 2 = Educational Materials (paper, pencils, etc.) 3 = Financial support / School Fees 4 = Food Support 5 = Tutoring 6 = School uniform 7 = Solar lamps 8 = No, we do not receive educational assistance 9 = Other, specify __________________________ 054. If yes, who provides this assistance? (Select all that apply) 1 = Government 2 = Relatives/friend 3 = NGO/CBO 4 = Religious Organization /Institution 5 = Other, specify _____________________________ 055. Have you received any life skills training? 1 = Yes 2 = No 8 = Don’t know APHIAPlus Imarisha End-of-Activity Evaluation, 2018 108 I have come to the end of my questions. Is there anything you would like to add or ask us? Thank you for participating in this interview! 041. END TIME [__|__|:[____] 056. Have you been to any vocational institution? 1 = Yes 2 = No 077. What vocational or technical skills have you acquired? MULTIPLE RESPONSES ALLOWED. CIRCLE ALL MENTIONED.KEEP ASKING ‘Anything else?’ UNTIL NO OTHER SKILLS ARE MENTIONED. A = Carpentry B = Masonry C = Mechanics D = Cosmetology E = Tailoring F = Customer care G = Plumbing H = Electrician I = Others specify__________________________ APHIAPlus Imarisha End-of-Activity Evaluation, 2018 109 TOOL 3: KEY INFORMANT INTERVIEW QUESTIONNAIRE - IMPLEMENTING-PARTNER TECHNICAL STAFF - RECORD NO. DATE: 2018 (dd) (mm) (yyyy) ACTIVITY: 1… Imarisha A….. APHIAPlus Implementing Partner—PRIME B….. APHIAPlus Implementing Partner—SUB C…. OTHER (Specify): NAME OF KEY INFORMANT POSITION AGENCY 1. 2. 3. 4. 5. READ INFORMED CONSENT STATEMENT (see separate sheet) TICK THIS BOX ONCE YOU HAVE DONE THE FOLLOWING: I read the Informed Consent Statement and have obtained the respondent’s informed consent. RECORD START TIME OF INTERVIEW (HH:MM) ___________ ___________: ___________ ___________ APHIAPlus Imarisha End-of-Activity Evaluation, 2018 110 N O. QUESTION RESPONSES The Local Context/Local Operating Environment 1. Thank you for agreeing to meet with me today. To start, for how long have you been serving in your current position? RESPONDENT 1 RESPONSE: RESPONDENT 2 RESPONSE: RESPONDENT 3 RESPONSE: RESPONDENT 4 RESPONSE: RESPONDENT 5 RESPONSE: Evaluation Question One What is the current coverage/improvement status on the priority health outcomes in HIV/AIDS, RMNCAH, Nutrition, Water and Sanitation and institutional/organizational capacity building and to the extent possible, determine the activity’s contribution to the observed health outcomes? 2. Based on the activity’s theory of change, what have been the actual inputs of the activity at the county, sub-county, health facility and community levels on coverage of high impact interventions More Specifically what did the Imarisha do regarding i. HIV/AIDS ii. MARPS iii. FP/RMNCH iv. Nutrition v. WASH vi. Economic Strengthening vii. OVC Care APHIAPlus Imarisha End-of-Activity Evaluation, 2018 111 N O. QUESTION RESPONSES Contributions of the APHIAPlus Activity 3. In your opinion, what was the most important contribution of APHIAPlus to the county’s health goals and priorities? How have these activity inputs led to the observed health outcomes? Probe for i. HIV/AIDS ii. MARPS iii. FP/RMNCH iv. Nutrition and food security v. WASH vi. Household Economic Strengthening vii. OVC Support 4. What is the projects contribution to the OVC component Probe for a. Supporting Transition to post primary and Secondary education b. promoting reliance on individual scholarships and provision of supplies to secure educational access c. Probe for roles of livestock and other cooperatives, religious structures, water management committees, schools 5. How did the Imarisha identify and link eligible children and families to available government social protection initiatives Achievement of expected health outcomes by intermediate results been achieved, if not why APHIAPlus Imarisha End-of-Activity Evaluation, 2018 112 N O. QUESTION RESPONSES 6. R3: Increased Use of Quality Health Services, Products and Information 7. IR 3.1: increased availability of an integrated package of quality high impact interventions at community and health 8. IR3.2 Increased demand for an integrated package of quality high-impact interventions at community and health facility levels. 9. IR 3.3 Increased adoption of healthy behaviors 10. IR 3.4: Increased program effectiveness through innovative approaches 11. R4: Social Determinants of Health Addressed to Improve the Well-Being of Targeted Communities and Populations 12. IR 4.1Marginalized, poor and underserved groups have increased access to economic security initiatives through coordination and integration with economic strengthening APHIAPlus Imarisha End-of-Activity Evaluation, 2018 113 N O. QUESTION RESPONSES 13. IR 4.2 Improved food security and nutrition for marginalized, poor and underserved populations 14. IR 4.3: increased access to education, life skills, and literacy initiatives through coordination and integration with education programs 15. IR4.4: Increased access to safe water, sanitation and improved hygiene APHIAPlus Imarisha End-of-Activity Evaluation, 2018 114 N O. QUESTION RESPONSES 16. IR 4.5: Strengthened systems, structures and services for protection of marginalized, poor and underserved populations 17. IR 4.6: Expanded social mobilization for health 18. How did the APHIAplus integration model work for and/or against the achievement of results in each of the key service delivery program areas (PROBE FOR Contribution of their model to HIV/AIDS, RMNCH, Nutrition, Water and sanitation, and institutional/organizational capacity building); APHIAPlus Imarisha End-of-Activity Evaluation, 2018 115 N O. QUESTION RESPONSES 19. How did synergies, collaboration or coordination between different program areas and/or between different USG activities contribute if any, to the observed health outcomes? 20. What other service delivery support systems/structures has the activity initiated and/or strengthened at the county, sub-county, facility, and community levels? Probe for Service delivery systems at a) County b) Sub-County c) Facility d) Community Evaluation Question two: What extent has the activity increased the capability of health community, health facility and county health management teams to sustain the gains in the observed health outcomes? 21. How effective was the capacity building (financial, managerial and technical capacity) to ensure sustainability to provide high quality package of services? Probe for technical, Managerial and Technical capacity of a. county/health facility management teams, b. health care workers, c. CUs and local d. CBOs/NGOs APHIAPlus Imarisha End-of-Activity Evaluation, 2018 116 N O. QUESTION RESPONSES 22. What are your thoughts on the partnership model adopted by your APHIAPlus Activity? PROBES: WHAT “WORKED?” WHAT DIDN’T “WORK?” ALSO PROBE ON: PROJECT STRUCTURES, E.G., TECHNICAL COMMITTEES, MANAGEMENT MEETINGS—DID THEY OCCUR REGULARLY? WERE THEY EFFECTIVE? HOW DID THEY ADVANCE COORDINATION WITHIN THE PARTNERSHIP? HOW DID THEY ENSURE QUALITY? 23. (a) What were your experiences with regards to coordination and collaboration with other USG funded projects? (b) What would you recommend regarding rationalization and national mechanisms? (c) What are key considerations for future programming? APHIAPlus Imarisha End-of-Activity Evaluation, 2018 117 N O. QUESTION RESPONSES 24. What support did the Imarisha provide to MGCSD to develop policies, protocols and guidance to support quality social services; Explain and Provide evidence 25. What are the established systems for program quality improvement at health facilities? Explain and Provide evidence 26. In your opinion, What are the weakest systems/structures at facility, community and administrative levels that might hamper the continuation and sustainability of the achieved health outcomes Provide examples 27. How did Imarisha Support the development of capacity of functional community units to promote preventive health behaviors, identify, refer cases? Probe for capacity to a. Identify cases b. Refer cases INTEGRATION 28. How did APHIAplus contribute to broader integration efforts within the country? PROBE ON:  INTEGRATED SERVICE DELIVERY FOR CLIENTS IN HEALTH FACILITIES  SYSTEMS INTEGRATION (E.G., EXTENT TO WHICH DIFFERENT TECHNICAL PROGRAM MANAGERS (E.G., FROM FAMILY PLANNING, HIV) ENGAGED IN JOINT PLANNING AND IMPLEMENTATION.  INTER-SECTORAL LINKAGES APHIAPlus Imarisha End-of-Activity Evaluation, 2018 118 N O. QUESTION RESPONSES (E.G., BETWEEN HEALTH AND EDUCATION; LINKAGES TO SOCIAL PROTECTION) 29. Have there been any unintended or unexpected consequences from the APHIAPlus integration approach? Please describe. These could be positive or negative. 30. (a) Are there particular issues (programs) for which integration was easy? Please explain. (b) Are there particular issues (program areas) for which integration was difficult? Please explain. Evaluation KEY QUESTION 3: What implementation challenges besides security did the activity face during the implementation period? IMPLEMENTATION CHALLENGES 31. In your opinion, what have been the key implementation challenges of APHIAPlus? PROBE: HOW DID NATIONAL MECHANISMS (E.G., FOR TRAINING, DRUGS) CONTRIBUTE TO THE ABOVE IMPLEMENTATION CHALLENGES? APHIAPlus Imarisha End-of-Activity Evaluation, 2018 119 N O. QUESTION RESPONSES 32. Are there any aspects of the APHIAPlus program design that contributed to those implementation challenges? Please describe. PROBE ON: -PARTNERSHIP MODEL -APPROACH TO CAPACITY BUILDING -HOW WELL THE RATIONALIZATION PROCESS WORKED? 33. Are there any aspects of the APHIAPlus program design that helped to minimize implementation challenges? Please describe. 34. Were there any coordination and collaboration challenges between the activity and its key collaborating institutions did the activity face and how did these challenges affect the achievement of expected outcomes? 35. What suggestions do you have for addressing the design shortfalls if any? INNOVATION 36. Innovations were supposed to be an important aspect of APHIAPlus. Can you please expound on the specific ways innovations were introduced to: (a) overcome known barriers and/or implementation challenges? (b) Accelerate or amplify project achievements? APHIAPlus Imarisha End-of-Activity Evaluation, 2018 120 N O. QUESTION RESPONSES Can you share any documentation (e.g., operations research reports, facility performance reviews) on the effectiveness of those innovations? 37. Were there any innovations that were part of the original program design but were NOT implemented? Why? Lessons learned 38. Are there any lessons learned from APHIAPlus regarding the role of evidence-based innovations in addressing: (a) Social determinants of health? (b) Service integration? (c) Service quality? (d) Sustainability? SUSTAINABILITY 39. APHIAPlus had proposed a number of approaches to ensure sustainability of outcomes. Which of those approaches were actually implemented? PROBE ON:  AMREF ORGANIZATIONAL DEVELOPMENT & STRENGTHENING MODEL,  LOL AND CRS LIVELIHOODS MODELS,  PROBLEM SOLVING TOOLS FOR PUBLIC SERVICE PROVIDERS,  LINKAGE TO NATIONAL MECHANISMS E.G. FANIKISHA  EMPOWERMENT OF LOCAL HEALTH & DEVELOPMENT:  STRENGTHENING CAPACITY OF HEALTH SYSTEMS FROM APHIAPlus Imarisha End-of-Activity Evaluation, 2018 121 N O. QUESTION RESPONSES COMMUNITY TO DISTRICT LEVELS TO DELIVER QUALITY SERVICES  FOSTERING MULTI-SECTOR INTEGRATION MODELS SUCH AS SILC AND VALUE CHAIN ADDITION TO CREATE POSITIVE CHANGE  PHASED PROJECT IMPLEMENTATION: 40. How has the withdrawal of Activity’s support to CHWs been addressed 41. APHIAPlus is ended in December of this year 2017 PROBE: PLEASE COMMENT ON WHICH PROGRAM RESULTS ARE LIKELY TO BE SUSTAINED AFTER THE PROGRAM CLOSES. WHY? PROBE ON STRUCTURES/MECHANISMS THAT MIGHT HAVE BEEN INTRODUCED VIA APHIAPLUS (E.G., TECHNICAL COMMITTEES, REVIEW MEETINGS). WHAT ARE THE PROSPECTS FOR SUSTAINING THOSE STRUCTURES/MECHANISMS AFTER APHIAPLUS? SCALE UP 42. What strategies or features of APHIAPlus show promise in being scaled up to other parts of the country? Why? 43. What implementation models can be replicated in other geographic locations of the country outside NAL region? Give specific Examples 44. What are your recommendations for strategic and programmatic design of future activities in the NAL region 45. What would you recommend for quality improvement at health facilities as well as use of national guidelines and protocols by Health workers APHIAPlus Imarisha End-of-Activity Evaluation, 2018 122 TOOL 4: KEY INFORMANTS INTERVIEW, USAID HPN STAFF (MNCH TEAM); USAID SI TEAM RECORD NO. DATE: 2018 (dd) (mm) (yyyy) TYPE(S) OF RESPONDENT(S) PARTICIPATING IN THE INTERVIEW: A… … USAID HPN staff (MNCH Team) USAID –SI Team Name of the KII respondent Designation/T itle Length of service in that designation Agency 6. 7. 8. 9. 10. READ INFORMED CONSENT STATEMENT (see separate sheet) Yes TICK THIS BOX ONCE YOU HAVE DONE THE FOLLOWING: I read the Informed Consent Statement and have obtained the respondent’s informed consent. RECORD START TIME OF INTERVIEW (HH:MM) ______________ APHIAPlus Imarisha End-of-Activity Evaluation, 2018 123 No . Question Targeted Respondent Responses The APHIAplus Imarisha Design 46. The APHIAplus Imarisha Activity Aimed to achieve sustainable country-led (and now county-led) actions, partnerships with the Ministries of Health, and engaging key stakeholders, the program is addressing two results of USAID’s five year Strategic Framework, what are your opinions about this approach?, (Probe: what are some strengths and weaknesses of this approach) . 47. How has the country led approach contributed to the achievement of the observed health outcomes? 48. As part of the five year implementation framework, USAID also designed national health system related activities, the APHIAplus activities were to coordinate and collaborate with these national mechanisms to address health systems related challenges at service delivery level. What worked well in this approach, what did not work well? what were the challenges?, how did this contribute to the achievement of the observed health outcomes, how did this hinder achievement of the expected health outcomes, what are your recommendations on how those challenges could be addressed? (Additional probes: Role of each of the national mechanism, when the mechanism started, interventions implemented in collaboration with each APHIAplus Imarisha} APHIAPlus Imarisha End-of-Activity Evaluation, 2018 124 No . Question Targeted Respondent Responses 49. In addition to the “health related result areas”, APHIAplus Imarisha design included result 4 that focused on “social determinants of health addressed to improve the well-being of the targeted communities and populations”, in your opinion how has this worked?, do you think this result area has been effectively implemented?, how well did the activities link/integrate this result area with the other result area?, what challenges did the activities experience in the implementation of this result area?, what improvements do you think could be made on the design and implementation of this result area? 50. The APHIAplus Imarisha activity focused on technical areas of HIV and AIDS, Malaria, Family Planning and TB, MNCH, WASH, OVC and Social Determinants. In your opinion, how effective has the APHIAplus Imarisha activity been in addressing each of the technical areas?,{Probe on adequacy of activities that APHIAplus Imarisha implemented in each of the specific technical areas based on the respondent category,} 51. Who are the key development partners/programs supporting the specific technical area?, how well have the activities synergized with/collaborated with the other development partners supporting this technical area, how well has this worked?, what has been the challenges in coordinating and synergizing with other development players?, how did this coordination on lack of it affect the implementation of the three activities, what would be your suggestions for improving this? { Probe: Activity coordination with other USG and USAID programs/initiatives including CDC,PMI among others, activity coordination with other development partners such as GF for HIV, TB and Malaria, probe for coordination at the facility level } APHIAPlus Imarisha End-of-Activity Evaluation, 2018 125 No . Question Targeted Respondent Responses 52. A key strategic pillar of the APHIAplus Imarisha model was integration of the focus technical areas to reduce vertical programming and avoid duplication effect. In your opinion did this work? What worked well and what did not work well and why? How could integration be strengthened? How did integration contribute to the observed health outcomes? {Probe: probe on joint planning, integrated service delivery at point of service, referral, data sharing, joint supervision, etc.} Strategic Shifts 53. What were the key strategic shifts that happened during the APHIAplus Imarisha implementation period, how did this affect the APHIAplus Imarisha design and implementation? How did APHIAplus Imarisha adapt into those strategic shifts? What other modifications/adjustments do you the activities should have made given the emerging scenarios? {Probe for: policies, technical guidelines, devolution, changes in MoH leadership and management at national and county level, PEPFAR blueprint, budget cuts/ rationalization, new program such as the Beyond Zero Campaign, epidemiological changes} Implementation Challenges and Management 54. What are some key implementation challenges that affected implementation of the activities? how were those challenges addressed?, how responsive were the implementing partners in addressing the challenges?, How did USAID support the partners in addressing the challenges?, what are your opinions on how those challenges could have been better addressed , how did those challenges impact the on the attained of the expected health outcomes {Probe: Partner related challenges, USAID related challenges, Ministry of health and Government/ policy related challenges, health systems related challenges, other challenges) Innovation APHIAPlus Imarisha End-of-Activity Evaluation, 2018 126 No . Question Targeted Respondent Responses 55. (a) Were there any features of APHIAplus Imarisha that you consider to be particularly innovative? (b) Compared to the strategies implemented by other local actors, how innovative was APHIAplus Imarisha’ strategies and approaches? 56. The activity proposed to work with government departments (MOPHS, MOMS, MOE, Ministry of Livestock, NDMA, and MOGSD), CSOs, livestock and other cooperatives, schools, water management committees and cultural structures to integrate interventions that were expected to strengthen the health system with those that were to address social health determinants. To what extent was this done Sustainability 57. AMREF proposed to deploy a holistic program design that was meant to empower and strengthen health service delivery and social development structures in the region to sustainably fulfill their mandate . To what extent do you think this has been achieved? Probe for (i) strengthen the capacity of community to county (level 1 to 4) health systems to deliver high quality services, products, and information and create demand for the same; (ii) strengthen the ability of local social and economic development structures to create positive change in livelihoods, food security, education, and social protection; and (iii) Use of proven approaches such as the SILC model by CRS and the value chain approach by Land O’ . APHIAPlus Imarisha End-of-Activity Evaluation, 2018 127 No . Question Targeted Respondent Responses Lakes, Recommendations/ Interventions for Scale UP 58. What strategies or features of APHIAplus Imarisha show promise in being scaled up to other parts of the country? Why? What is required to accelerate scale up? (PROBE on operations research evidence, costing, etc. Also probe on criteria for determining where (e.g., in which other counties to scale up effective APHIAplus Imarisha interventions) 59. Based on lessons learned, policy changes, new priorities and gaps identified during the activity implementation, what would your suggestions for follow on activity? (Probe for new technical areas, new interventions etc.) APHIAPlus Imarisha End-of-Activity Evaluation, 2018 128 TOOL 5: PANEL DISCUSSION GUIDE WITH ORGANISATIONS WORKING IN TURKANA AND SAMBURU (2 pages) Organisation Name of the representative and designation Thematic area Discussion issues a. Intervention focus of participating organizations working in the region a. What are your specific intervention focus in the technical areas of: HIV/AIDS, RMNCAH, WASH, nutrition, food security, HES and institutional capacity building b. Which approaches/strategies do you use to deliver your interventions (through CHWs, mentorship at facility level, etc.)? c. What is your geographical coverage? Do you cover the entire county or some specific counties/sub￾counties? d. How long have you worked in the county? b. Partner organisation’s involvement with APHIAplus IMARISHA program a. Did you collaborate with APHIAplus response? b. What were the areas of collaboration? c. Do you think the collaboration was adequate? d. How do you think the collaboration could have been improved? c. Opinions on APHIAplus IMARISHA program design a. What are your views on the effectiveness if of the APHIAplus IMARISHA program design and approaches o County led approach o Working in a consortium o Integrated approach including the multi-sectoral response o Capacity building approaches b. What are your suggestions on how the design of the program could be better addressed? d. Opinions on whether the APHIAplus IMARISHA addressed the priority needs around HIV/AIDS, RMNCAH, Nutrition, WASH and social determinants a. What are the priority needs around HIV/AIDS, RMNCAH, nutrition, WASH, food security and institutional strengthening in the county? b. Do you think APHIAplus IMARISHA addressed the priority needs around those technical areas? c. What other priority areas do you think should have been included around the technical areas: HIV/AIDS, APHIAPlus Imarisha End-of-Activity Evaluation, 2018 129 Thematic area Discussion issues RMNCAH, nutrition, WASH, food security and institutional strengthening in the county e. Impact of APHIAplus IMARISHA in improving health and institutional strengthening outcomes a. In your opinion how would you rate APHIAplus IMARISHA on achievement of the planned health and institutional outcomes? b. In which areas would rate APHIAplus IMARISHA as having performed the best? c. Which was the weakest area of performance? f. Recommendations on the what and how for future programming in the technical areas of HIV/AIDS, RMNCAH, Nutrition and social determinants a. Based on your experience in this county, what innovative strategies do you recommend for sustainable health and institutional strengthening outcomes in each of the technical areas targeted by APHIAplus IMARISHA b. What are you suggestions on the ‘how’ of implementing the proposed strategies g. Any other comments Any other suggestions on what should be done differently to improve health and institutional strengthening outcomes APHIAPlus Imarisha End-of-Activity Evaluation, 2018 130 TOOL 6:KEY INFORMANT INTERVIEW GUIDE— NATIONAL-LEVEL GOK (6 pages) RECORD NO. DATE: (dd) (mm) (yyyy) TYPE(S) OF RESPONDENT(S) PARTICIPATING IN THE INTERVIEW: A… … National Level GOK Name of the KII respondent Designation/T itle Length of service in that designation Agency 11. 12. 13. 14. 15. READ INFORMED CONSENT STATEMENT (see separate sheet) Yes TICK THIS BOX ONCE YOU HAVE DONE THE FOLLOWING: I read the Informed Consent Statement and have obtained the respondent’s informed consent. RECORD START TIME OF INTERVIEW (HH:MM) -----------: _------------ APHIAPlus Imarisha End-of-Activity Evaluation, 2018 131 No . Question Targeted Respondent Responses The APHIAplus Design 60. Are you familiar with the APHIAplus project? Describe how the project started after March 2012: What type of support was delivered by the APHIA plus project? More Specifically what did the Imarisha do regarding viii. HIV/AIDS ix. MARPS x. FP/RMNCH xi. Nutrition xii. WASH xiii. Economic Strengthening xiv. OVC Care 61. APHIAplus was supposed to center on “sustainable country led programs and partnerships.”, How has this worked?, (Probe: how well APHIAplus involved the Ministry of health at national and county levels in “leading” the implementation of the program?, how well did the program fit in the national priorities and policies, 62. APHIAplus Imarisha was to strengthen the capacity of District and later County Health Management Teams; health facility staff and management committees; Community Health Units for Increased use of quality health services, products and information. To what extent has this been done? 63. The activity was to prioritize the Annual Operating Plan (AOP) cycle and empower sub-county and county health management teams to prepare SMART plans and supervise, document, monitor and review implementation of a multi-sectoral approach to attain health and developmental results? To what extent has this been done? 64. In addition to the “health-related result areas,” APHIAplus design included result 4 that focused on “social determinants of health addressed to improve the well-being of the targeted communities and population.” In your APHIAPlus Imarisha End-of-Activity Evaluation, 2018 132 No . Question Targeted Respondent Responses opinion how has this worked? To what extent was this achieved? 65. The APHIAplus activity focused on technical areas of HIV and AIDS, Malaria, Family Planning and TB, MNCH, WASH, OVC and Social Determinants. In your opinion, how effective have the three APHIAplus activities been in addressing each of the technical areas?,{Probe on adequacy of activities that APHIAplus implemented in each of the specific technical areas based on the respondent category} USAID, MoH departments, development partners (CDC) 66. How has the situation of {mention specific technical area} changed over time since inception of the activities under evaluation in 2012{Probe for: national and the regions of focus}, in your opinion what has been the contribution of the activities to the observed health outcomes, what have been the inputs from the activities that have contributed to the observed changes {Probe for: inputs of the three activities at national if any and at regional level} 67. Who are the key development partners/programs supporting NAL in the technical areas supported by Imarisha?, how well have the activities synergized with/collaborated with the other development partners supporting this technical area APHIAPlus Imarisha End-of-Activity Evaluation, 2018 133 No . Question Targeted Respondent Responses 68. A key strategic pillar of the APHIAplus model was integration of the focus technical areas to reduce vertical programming and avoid duplication effect. In your opinion did this work? What worked well and what did not work well and why? How could integration be strengthened? How did integration contribute to the observed health outcomes? {Probe: probe on joint planning, integrated service delivery at point of service, referral, data sharing, joint supervision, etc.} Strategic Shifts 69. What were the key strategic shifts that happened during the APHIAplus implementation period, how did this affect the APHIAplus design and implementation?, {Probe for: policies, technical guidelines, devolution, changes in MoH leadership and management at national and county level, PEPFAR blueprint, budget cuts/rationalization, new program such as the Beyond Zero Campaign, epidemiological changes} Implementation Challenges and Management 70. What are some key implementation challenges that affected implementation of the activities? How were those challenges addressed? Innovation 71. Were there any features of APHIAplus that you consider to be particularly innovative? Probe for a. Performance Based Financing for DHMTs b. Output-based approaches for HCW & CHW c. Provider-defined quality approaches d. Web-based learning e. Institutionalizing data analysis & use f. Specialist Clinical Outreaches g. Support for equipment maintenance APHIAPlus Imarisha End-of-Activity Evaluation, 2018 134 No . Question Targeted Respondent Responses Sustainability 72. The APHIAplus activity designed various strategies for ensuring sustainability Interventions for Scale UP 73. What strategies or features of APHIAplus show promise in being scaled up to other parts of the country? Why? What is required to accelerate scale up? (PROBE on operations research evidence, costing, etc. Also probe on criteria for determining where (e.g., in which other counties to scale up effective APHIAplus interventions) USAID, MoH departments, IPs at national level, development partners As above-I cannot mention any 74. Based on lessons learned, policy changes, new priorities and gaps identified during the activity implementation, what would your suggestions for follow on activity? (Probe for new technical areas, new interventions etc.) APHIAPlus Imarisha End-of-Activity Evaluation, 2018 135 TOOL 7: KEY INFORMANT INTERVIEW QUESTIONNAIRE - CHMT-SCHMT-HW - (26 pages) RECORD NO. Respondent name Designation Length of service in C/SCHT/Facility 16. 17. 18. 19. 20. READ INFORMED CONSENT STATEMENT (see separate sheet) TICK THIS BOX ONCE YOU HAVE DONE THE FOLLOWING: I read the Informed Consent Statement and have obtained the respondent’s informed consent. RECORD START TIME OF INTERVIEW (HH:MM) ___________ ___________: ___________ ___________ APHIAPlus Imarisha End-of-Activity Evaluation, 2018 136 N O. QUESTION RESPONSES 75. As part of understanding the local context, we would like to understand the organisations that have been and or are working in this county in the technical areas of HIV/AIDS, RMNCAH, nutrition, food security, household economic strengthening and education. Probes Probe on the names of the organisations, the length of time they have been in the county, the type of support they provide specifically on the AI technical areas and the geographical spread of the interventions Probe on whether AI is considered among the main partners/or the leading partner in the AI specific intervention areas, the uniqueness of the AI support in terms of coverage and breadth of the technical intervention areas APHIAPlus Imarisha End-of-Activity Evaluation, 2018 137 N O. QUESTION RESPONSES 76. What are some changes in health care delivery that have happened since 2013 and how has these impacted on health service delivery? Probes How did devolution impact on the delivery of health care services with special focus on the AI intervention areas? How did APHIAplus Imarisha support the health facilities/health workers to adjust to impact of devolution? What are some shifts in strategic direction including changes in policies/guidelines that have happened since March 2012 and how did these impacted on service delivery with special focus on the AI technical areas?, how did AI support the health facilities/health workers to adjust to those changes? 77. Please describe to me the changes in coverage /status of the priority health outcomes in HIV/AIDS, RMNCAH, nutrition, WASH and institutional capacity building Probes Probe on changes in by the priority health outcome indicators APHIAPlus Imarisha End-of-Activity Evaluation, 2018 138 N O. QUESTION RESPONSES 78. Please describe to me the contribution of APHIAplus Imarisha in improving coverage/status on the priority health outcomes in HIV/AIDS, RMNCAH, Nutrition, WASH and capacity building of health workers and health facilities. What has been the contribution by other partners if any? Probe Probe by IRs and identify the specific interventions by APHIAplus IMARISHA for each IR Did the interventions work? How effective were the various interventions implemented 79. How is the delivery of health services in this county? Are the services delivered in an integrated manner? What was the contribution of APHIAplus in ensuring that services are provided in an integrated approach? Probes How well did the activity integrate the various APHIAplus IMARISHA technical areas? (Extent to which different technical program areas are integrated such as FP and HIV/AIDS, MNCH and PMTCT, engagement in joint planning by different technical areas) Inter-sectoral linkages (e.g., livestock interventions as an entry point for health interventions) What challenges 80. (a) Were there any features of APHIAPlus IMARISHA that you consider to be particularly innovative? If not mentioned cite examples of the AI promised innovations by County (b) How well did those innovations work? Were they successful? (c)Were there any mechanisms for ensuring the documentation and dissemination of the innovations? Have the innovations in your opinion been taken up by other partners APHIAPlus Imarisha End-of-Activity Evaluation, 2018 139 N O. QUESTION RESPONSES including the county government? If not, why? 81. APHIAplus IMARISHA promised to strengthen capacity of community to county health systems to deliver high quality services, products and information, in your opinion do you think this happened? Probes Probe on the implementation of the promised capacity building interventions for all the levels: CHMT, SCHMT, Health facilities, CU, health workers, were these implemented? How effective were the approaches used in building at the various levels? 82. In your opinion, were the key implementation successes of APHIAPlus IMARISHA? Probes Probe for successes around the AI design of county led, partnership model, integration, capacity building models, coordination, collaboration and partnership with other institutions, working with national mechanisms 83. In your opinion, what were the implementation challenges of APHIAPlus IMARISHA? Probes Probe for challenges resulting from AI design of county led, partnership model, integration, capacity building models, collaboration and partnership, working with national mechanisms, devolution, shifts in strategic direction including government policies and programs 84. What approaches did the program use to address the implementation challenges? APHIAPlus Imarisha End-of-Activity Evaluation, 2018 140 N O. QUESTION RESPONSES 85. What would you say were the lessons learned in the implementation of APHIAplus program? Probes Probe on lessons learned from the implementation of various interventions, capacity building approaches used, the innovations implemented 86. What do you think should have been done differently to ensure increased use of quality health services, products and information in this county? Probes What should have been done differently in the design of the program In building capacity of the county, CHMT, SCHMT, health facilities, health workers APHIAPlus Imarisha End-of-Activity Evaluation, 2018 141 TOOL 8: FOCUS GROUP DISCUSSION GUIDE - MNCH CLIENTS DATE: 2018 (dd) (mm) (yyyy) ACTIVITY: 1… SAMBURU 2… TURKANA COUNTY NAME: FACILITY TYPE: 1... FACILITY NAME: GROUP COMPOSITION:  Total number of participants:  (AGE) Number of FGD participants who are: o Age 15-19 years: o Age 20-24 years: o Age 25-49 years:  (MARITAL STATUS)Number of participants who are: o Currently married: o Not currently married:  OTHER GENERAL OBSERVATIONS FROM FACILITATOR: Thank you for meeting with me today. I am interested in better understanding the availability and utilization of maternal, new born and child health services in this health facility for the clients like you and I will be asking a few questions about your experiences and about your community. When answering the questions, please be as honest as possible. APHIAPlus Imarisha End-of-Activity Evaluation, 2018 142 Everyone has an opinion. It is okay if someone says something that the other people in the group don’t agree with. I am interested in hearing from everyone, so let’s be respectful, even if we don’t agree with something being said. Because I don’t want to miss anything we discuss, I will be taping our discussion. Also, I will give each of you a nametag with a number written on it. Before you say something, please say the number that I assign you. That will help me keep track of everything everyone say 1. Changes in FP/MNCH health care services in the community (a) How have the health care services of mothers, new-borns and children (Antenatal, intrapartum, and postpartum care; FP; PMTCT; neonatal care; child health services) changed over the last 5 years in this community? 2. Support provided by APHIAplus Imarisha project  Are you aware of any organizations that have been working in your community to address the health of mothers and children in your community? If yes, name some (Probe for knowledge on APHIAplus Imarisha project and other organizations working in the locality)  How has the APHIAplus Imarisha project contributed to improving the health of mothers and children in this community? 3. Access to FP/MNCH  Are FP/MNCH services accessible to women and children in this community? Has the access changed over the last 5 years?  In Your opinion, what factors made it easier for you to access these services over those years?  In your opinion, what made it difficult for some women to access these services over these years? (Probe for: Economic, Geographical and Socio- Cultural barriers) 4. Availability and utilization of high impact interventions for FP/MNCH/Malaria APHIAPlus Imarisha End-of-Activity Evaluation, 2018 143 (for: FP services, antenatal care services, postnatal care for mothers, postnatal care for children, malaria prevention and treatment, ort, zinc, ITNs, childhood diseases (pneumonia, diarrhoea, fever, malaria, chest / respiratory diseases, measles etc.), HIV, TB)  What role(s) have community health volunteers played in ensuring availability of the above services in your community?  How has the utilization of these services improved over the last five years? In your opinion, what contributed to the improvement in the utilization of these services? 5. Client treatment at health facilities I am interested in getting your views on the treatment of women and children when they access health services in this health facility.  How would you describe the way they are treated at the health facilities in terms of privacy, confidentiality, and consent before receiving a service, dignified care, denial of care, discrimination?)  How important are those factors when people are deciding whether or not to seek health care?  Over the past 5 years, have you seen any changes in this health facility in regards to the way health service providers treat? What changes? TOOL 9: Focus Group Discussion with OVC Caregivers (N=10 participants maximum) APHIAPlus Imarisha End-of-Activity Evaluation, 2018 144 DATE: 2018 (dd) (mm) (yyyy) COUNTY NAME: NAME OF LIP: ]] GROUP COMPOSITION:  Total number of participants:  (GENDER) Number of FGD participants who are: o Female: o Male:  {AGE} Number of FGD participants who are: o Age 15-19 years: o Age 20-24 years: o Age 25-49 years: o Age 50 or older:  {MARITAL STATUS} Number of FGD participants who are: o Currently married: o Not currently married:  {RELATION TO CHILD} Number of FGD participants who are: o Grandparents of OVC: o Siblings of OVC: o Other relative of OVC: o Non-biological custodian of OVC (e.g., “foster parent”): o Parent Thank you for meeting with me today. We are interested in better understanding the situation affecting orphans and vulnerable children, as well as their caregivers, and I will be asking a few questions about your experiences. When answering the questions, please be as honest as possible. Everyone has an opinion. It is okay if someone says something that the other people in the group don’t agree with. I am interested in hearing from everyone, so let’s be respectful, even if we don’t agree with something being said. Because I don’t want to miss anything we discuss, I will be taping our discussion. Also, I will give each of you a piece of paper with a number written on it. Before you say something, please raise your sheet of paper, and I will call on you so that you can share your thoughts with the group. APHIAPlus Imarisha End-of-Activity Evaluation, 2018 145 1. Please describe the economic status of your household. How does this affect your ability to provide for the orphans and vulnerable children under your care? Probes: a) What HES related support have you received from APHIAplus IMARISHA? b) Are there other organizations providing HES support. c) Can you describe the situation before the support and after in terms of the well-being of the OVC.(how the HES support improved access & utilization of health, education, social protection for the OVC) d) Are the benefits to (effects on) your household long lasting or just short-term? Please describe. e) How will you sustain the benefits of HES? (probe for evidence) f) What are some of the challenges in accessing and utilizing the HES services? g) What can be done differently to maximize access and utilization of HES services h) Transition: linkages to GOK, other organizations. APHIAPlus Imarisha End-of-Activity Evaluation, 2018 146 2. Please describe how the OVC in your care access Education and Life Skills Programs? Probes: a) What Education and life skills related services have you received from APHIAplus IMARISHA? b) Are there other organizations providing similar services. c) Can you describe the situation before the support and after in terms of school enrollment, retention, progression and ability to cope with life challenges (life skills) d) Are the benefits to the OVC long lasting or just short-term? Please describe. e) What are some of the challenges in you and the OVC have experienced in accessing and utilizing these services? f) What is the extent of reliance on individual scholarships and provision of quickly expended supplies to secure educational access? g) How will the OVC continue accessing the services provided by APHIAplus IMARISHA after the project ends? h) What can be done differently to maximize access and utilization of Education and other life skills services(probe: enrollment, retention, progression) i) Transition: linkages to GOK, other organizations. APHIAPlus IMARISHA End-of-Activity Evaluation, 2018 147 3. Please describe the key issues related with social protection of OVC and their families? (Violence, abuse, Sexual Assault, Child Maltreatment and Children without Adequate Family Care, FGM, early marriage, Birth Registration, Shelter, Psychosocial support) Probes: a) How do these issues differ between the older and younger OVC. b) Did APHIAplus IMARISHA address some of these issues? List the issues. c) Which issues were they not able to address? a) Are there other organizations supporting the OVC and their families to address these issues? List the Organizations and the support they provide. b) Can you describe the situation before the support and after in terms of c) What are some of the challenges you and the OVC have experienced in accessing and utilizing these services? d) What resources exist at the community level to ensure the protection of OVC and their families? Explain. e) How will the OVC continue accessing the services provided by APHIAplus IMARISHA after the project ends? f) What can be done differently to maximize access and utilization of social protection initiatives? g) Transition: How did the APHIAplus IMARISHA identify and link eligible children and families to available government social protection initiatives through CHWs, CSOs, volunteers and local government representatives? APHIAPlus IMARISHA End-of-Activity Evaluation, 2018 148 Tool 10: Guide for FGDs with Community Health Workers (CHWs) (N=10 participants maximum) DATE: 2018 (dd) (mm) (yyyy) COUNTY NAME: NAME OF COMMUNITY UNIT: Total number of CHWs in the CU ]] GROUP COMPOSITION:  Total number of participants:  (GENDER) Number of FGD participants who are: o Female: o Male:  {AGE} Number of FGD participants who are: o Age 15-19 years: o Age 20-24 years: o Age 25-49 years: o Age 50 or older: Thank you for meeting with me today. We are evaluating a program called APHIAplus IMARISHA that was implemented in your community by AMREF together with other partners from 2013 up to end of last year. We understand the program worked with you and we are interested in getting your experiences and opinions about the program. We will therefore like to ask you some questions. When answering the questions, please be as honest as possible. Everyone has an opinion. It is okay if someone says something that the other people in the group don’t agree with. I am interested in hearing from everyone, so let’s be respectful, even if we don’t agree with something being said. Because I don’t want to miss anything we discuss, I will be taping our discussion. Also, I will give each of you a piece of paper with a number written on it. Before you say something, please raise your sheet of paper, and I will call on you so that you can share your thoughts with the group. APHIAPlus IMARISHA End-of-Activity Evaluation, 2018 149 1. Just as a start; let me briefly understand the common health issues in this community? What are your roles as CHWs in addressing those problems? a. NOTE: THE FIRST PART OF THIS QUESTION IS AN ICE BREAKER QUESTION; PROBE TO UNDERSTAND WHETHER PROBLEMS APHIAPLUS IMARISHA TECHNICAL AREAS ARE MENTIONED b. IF NOT MENTIONED PROBE TO UNDERSTAND THE ROLE OF CHWS IN THE FOLLOWING AREAS o HEALTH PROMOTION WITH FOCUS ON THE APHIAPLUS IMARISHA TECHNICAL AREAS oREFERRALS OF CLIENTS TO THE HEALTH FACILITY FOR HIV, TB, MNCH, MALARIA o DEFAULTER TRACING FOR HIV AND TB CASES oEXTEND TO WHICH CHWS SERVE AS A LINK BETWEEN COMMUNITIES AND HEALTH FACILITIES TO ENSURE CONTINUUM OF CARE c. HOW DO YOU ENSURE DELIVERY OF SERVICES (PROBE FURTHER BY TECHNICAL AREAS) IN AN INTEGRATED APPROACH, WHAT CHALLENGES DO YOU EXPERIENCE IN DELIVERY OF INTEGRATED SERVICES? APHIAPlus IMARISHA End-of-Activity Evaluation, 2018 150 2. I would like to understand the support that APHIAPLUS IMARISHA provided in ensuring that CHWs like you are able to effectively perform their roles? Probes o Have you worked/partnered/received any support from APHIAplus IMARISHA? o What has been the role of APHIAplus in ensuring the CHWs undertake their roles as described earlier- Health promotion, referral of clients, defaulter tracing, serving as a link between communities and health facilities o Probe to get specific role of APHIAPLUS in mobilisation, establishment of the community units and other structures, training of the community health workers, provision of allowances, provision of other materials including reporting tools, supportive supervision o Are there other organisations providing similar support to your community health unit? If yes, which organisations and what support are they providing? APHIAPlus IMARISHA End-of-Activity Evaluation, 2018 151 3. What approaches/strategies do you use in ensuring access to services at community and facility level? Have any innovative approaches been developed? How have these worked? Probes o How do the CHWs ensure delivery of services in an integrated manner, how do you integrate the various technical areas (Probe further by the technical areas) o Probe for the promised innovations at community level including: Ngadakarin Bamocha model, Mhealth o What lessons have you learned in the implementation of the various approaches/strategies- probe further by the strategies/approaches that were utilised APHIAPlus IMARISHA End-of-Activity Evaluation, 2018 152 4. We are now going to discuss the success factors as well the challenges that you have faced in your work as CHWs?, What do you think has worked very well in the work in the roles that you undertake as CHWs? Probes o What roles do you think you have done very well and what would you say have been the factors that have contributed to this success What challenges do you face in carrying out your work? How have your or AMREF/County Government addressed those challenges? Probes o Probe for challenges related to supportive supervision, training and mentorship, referrals, weak linkage, reporting tools, attrition, motivation including stipends and other allowances APHIAPlus Imarisha End-of-Activity Evaluation, 2018 153 Last updated on January 202018 5. We would like to discuss the ability of your CU to ensure continuity of services that you provide even at the end of the APHIAPLUS program? Probes o How would you rate your ability to continue providing services even after the end of the program? (If no responses probe by type services offered by CHWs), what are/would be the facilitating factors for sustaining the interventions, what would be the constraining factors to ensuring continuity of services? o What are some of the things that you have done as a CU unit to ensure sustainability of interventions even without the support of the program? o What support did APHIAplus provide to ensure that as a CU you can continue to provide services even after the end of the program period?, did that work, if yes why?, if it did not work, what are the reasons why it did not work o Is the CU involved in any economic strengthening interventions for purposes of ensuring sustainability? How has this impacted on the delivery of services by the CU? o What are your suggestions on what should have been done better to ensure sustainability/continuity of services after the end of APHIAplus Imarisha APHIAPlus Imarisha End-of-Activity Evaluation, 2018 154 Last updated on January 202018 TOOL 11 - FGD CCC Beneficiaries (N=10 participants maximum) DATE: 2018 (dd) (mm) (yyyy) ACTIVITY: 1… TURKANA 2… SAMBURU COUNTY NAME: Comprehensive Care Clinic (CCC) FACILITY NAME: GROUP COMPOSITION:  Total number of participants:  (GENDER) Number of FGD participants who are: o Female: o Male:  (AGE) Number of FGD participants who are: o Age 15-19 years: o Age 20-24 years: o Age 25-49 years: o Age 50 and older:  (MARITAL STATUS) Number of participants who are: o Currently married: o Not currently married:  OTHER OBSERVATIONS FROM FACILITATOR: Facility type 01=HOSPITAL 02=HEALTH CENTRE 03=DISPENSARY04=CLINIC APHIAPlus Imarisha End-of-Activity Evaluation, 2018 155 Last updated on January 202018 05=NURSING HOME 88=OTHER (SPECIFY)_______________________ Type of sector (Managing Authority/Ownership) 01=GOVERNMENT/PUBLIC 02=NGO/PRIVATE NOT-FOR-PROFIT 03=PRIVATE -FOR-PROFIT 04=FAITH-BASED/MISSION/CHURCH 88=OTHER (SPECIFY)_______________________ Thank you for meeting with me today. We are interested in better understanding the situation affecting CCC beneficiaries like you and I will be asking a few questions about your experiences and about your community. When answering the questions, please be as honest as possible. Everyone has an opinion. It is okay if someone says something that the other people in the group don’t agree with. I am interested in hearing from everyone, so let’s be respectful, even if we don’t agree with something being said. Because I don’t want to miss anything we discuss, I will be taping our discussion. Also, I will give each of you a piece of paper with a number written on it. Before you say something, please raise your sheet of paper, and I will call on you so that you can share your thoughts with the group. APHIAPlus Imarisha End-of-Activity Evaluation, 2018 156 Last updated on January 202018 5. WHAT HIV-RELATED SERVICES HAVE YOU RECEIVED IN THE PAST FROM THIS FACILITY? PROBES:  SERVICES: HIV COUNSELING AND TESTING, PMTCT, ADHERENCE COUNSELING, ANTIRETROVIRAL THERAPY (ART), CANCER SCREENING, CD4, CONDOMS/FAMILY PLANNING, COUPLES COUNSELING, GENERAL MEDICAL CARE, NUTRITION COUNSELING/SUPPORT, PEDIATRIC HIV CARE, PRE-EXPOSURE PROPHYLAXIS, POST-EXPOSURE PROPHYLAXIS, PREVENTIVE TREATMENT—SEPTRIN, PREVENTIVE TREATMENT, MALARIA, TUBERCULOSIS (TB) SCREENING, VIRAL LOAD, EID, CHILD IMMUNIZATION, POSTNATAL CARE, GBV, VMMC OTHER (SPECIFY)________________________  HOW HAVE THE SERVICES CHANGED OVER THE PAST FIVE YEARS?  OVER THE PAST FIVE YEARS, HAVE YOU SEEN CHANGES IN BEING ABLE TO GET DIFFERENT TYPES OF SERVICES WHEN YOU COME TO A CCC OR HAVE CONTACT WITH A HEALTH WORKER? PLEASE EXPLAIN.  WHAT/WHO WOULD YOU CONTRIBUTE THESE CHANGES TO? HAVE YOU HEARD OF APHIA PLUS IMARISHA? WHAT CONTRIBUTION HAVE THEY PLAYED IN BRINGING ABOUT THESE CHANGES? APHIAPlus Imarisha End-of-Activity Evaluation, 2018 157 Last updated on January 202018 6. WERE YOU REFERRED BY ANYONE TO THIS HEALTH FACILITY FOR THE SERVICES YOU HAVE RECEIVED? PROBES:  ROLE OF CHWS AND LINKAGE VOLUNTEERS  ARE THERE LINK DESKS AND VOLUNTEERS BASED AT THIS HEALTH FACILITY TO REFER PLHIV TO OTHER SERVICES WITHIN THE FACILITY?  HAVE YOU EVER USED THE SERVICES PROVIDED BY THOSE DESKS/VOLUNTEERS? APHIAPlus Imarisha End-of-Activity Evaluation, 2018 158 Last updated on January 202018 7. WHAT COMMUNITY-BASED SERVICES ARE AVAILABLE TO INDIVIDUALS LIKE YOU? PROBES: o HOW HAVE THE TYPES OF SERVICES CHANGED IN RECENT YEARS? HOW OR WHY DID THOSE CHANGES HAPPEN? o WHAT CHANGES HAVE OCCURRED IN ACCESS TO INFORMATION THAT CAN HELP YOU MAKE HEALTH DECISIONS? o WHAT COMMUNITY RESOURCES EXIST TO SUPPORT INDIVIDUALS LIKE YOU IN SEEKING CARE AND LIVING HEALTHY LIVES? o WHAT ROLE(S) DO COMMUNITY HEALTH WORKERS PLAY IN THE ABOVE? o HAVE YOU EVER BEEN LINKED TO RECEIVE THESE SERVICES? APHIAPlus Imarisha End-of-Activity Evaluation, 2018 159 Last updated on January 202018 8. WHAT CHALLENGES HAVE YOU EXPERIENCED IN SEEKING SERVICES AT THIS CCC? PROBES: o NOT EVERYONE COMES TO A HEALTH FACILITY, WHAT FACTORS MAKE IT DIFFICULT FOR SOME PLHIV IN YOUR COMMUNITY TO SEEK SERVICES? o WHAT CHALLENGES DID YOU HAVE TO OVERCOME TO SEEK SERVICES AT THIS CCC? o ARE CERTAIN TYPES OF HIV SERVICES MORE DIFFICULT TO ACCESS THAN OTHERS?  PROBE ON: PREVENTION (PRIMARY AND SECONDARY), TESTING, TREATMENT, CARE & SUPPORT APHIAPlus Imarisha End-of-Activity Evaluation, 2018 160 Last updated on January 202018 9. I AM INTERESTED IN GETTING YOUR VIEWS ON THE WAY COMMUNITY MEMBERS ARE HANDLED WHEN THEY ACCESS HIV SERVICES. HOW WOULD YOU DESCRIBE THE QUALITY OF HIV SERVICES IN TERMS OF: PROBES: o Privacy (audio and visual) o Confidentiality? o Treating clients and community members with respect when communicating or interacting with them? o HOW DO THE ABOVE VARY FOR DIFFERENT TYPES OF HEALTH SERVICES SUCH AS: HIV/TB? FAMILY PLANNING? MATERNAL, NEWBORN, AND CHILD HEALTH? MALARIA? o HOW IMPORTANT ARE THOSE FACTORS WHEN PEOPLE ARE DECIDING WHETHER OR NOT TO SEEK HEALTH CARE? APHIAPlus Imarisha End-of-Activity Evaluation, 2018 161 Last updated on January 202018 10. WHAT NEEDS TO BE IN PLACE TO ENSURE THAT HIGH-QUALITY SERVICES ARE ALWAYS AVAILABLE? PROBES: o WHAT ARE YOUR VIEWS ON HEALTH WORKERS (AVAILABILITY, SKILLS, ATTITUDES)? o WHAT ARE YOUR VIEWS ON THE AVAILABILITY OF MEDICINES AND SUPPLIES? o WHAT ARE YOUR VIEW ON SERVICE PROVISION TIMES? o WHAT OTHER FACTORS AFFECT QUALITY? o HOW GOOD ARE THE LINKAGES AND REFERRAL BETWEEN DIFFERENT TYPES OF SERVICES AND DIFFERENT TYPES OF SERVICE PROVIDERS? HOW CAN THOSE LINKAGES AND REFERRALS BE IMPROVED? APHIAPlus Imarisha End-of-Activity Evaluation, 2018 162 Last updated on January 202018 Tool 12 Guide for FGDs with Youth served by LIPs (Target number=7 youth participants [10 is the absolute maximum]) DATE: 2018 (dd) (mm) (yyyy) NAME OF COUNTY 1… TURKANA 2… SAMBURU NAME OF LIP: GROUP COMPOSITION:  Total number of participants:  (GENDER) Number of FGD participants who are: o Female: o Male:  {AGE} Number of FGD participants who are: o Age 15-19 years: o Age 20-24 years:  {MARITAL STATUS} Number of FGD participants who are: o Currently married: o Not currently married:  {EDUCATIONAL STATUS} Number of FGD participants who are: o Currently in school: o Currently out of school: Thank you for meeting with me today. We are interested in better understanding the situation affecting youth like you, and I will be asking a few questions about your experiences and about your community. When answering the questions, please be as honest as possible. APHIAPlus Imarisha End-of-Activity Evaluation, 2018 163 Last updated on January 202018 Everyone has an opinion. It is okay if someone says something that the other people in the group don’t agree with. I am interested in hearing from everyone, so let’s be respectful, even if we don’t agree with something being said. Because I don’t want to miss anything we discuss, I will be taping our discussion. Also, I will give each of you a nametag with a number written on it. Before you say something, please say the number that I assign you. That will help me keep track of everything everyone says. APHIAPlus Imarisha End-of-Activity Evaluation, 2018 164 Last updated on January 202018 11. How youth friendly are HIV and sexual and reproductive health services in this location? PROBES: o HOW DO YOU DEFINE YOUTH FRIENDLY? o HOW ACCESSIBLE ARE THE SERVICES?  PROBE FOR FACTORS AFFECTING FEMALES. o HOW SATISFIED ARE YOU WITH SERVICES AVAILABLE AT HEALTH FACILITIES? o HOW SHOULD SERVICES BE PACKAGED (DELIVERED) TO HELP MORE YOUTH ACCESS THE SERVICES? o HOW SHOULD THE SERVICES BE PACKAGED (DELIVERED TO IMPROVE THE QUALITY OF THE SERVICES)?  ARE THERE ANY SERVICES THAT COULD BE INTEGRATED (JOINED TOGETHER) TO MAKE IT MORE CONVENIENT FOR YOUTH TO ACCESS THOSE SERVICES? WHICH ONES?  HAVE YOU EVER GONE TO A HEALTH FACILITY OR AN ORGANIZATION TO RECEIVE A SERVICE AND BEEN OFFERED ADDITIONAL SERVICES? DID YOU ACCEPT THE ADDITIONAL SERVICES? HOW DID YOU FEEL ABOUT BEING OFFERED (PROVIDED) THOSE ADDITIONAL SERVICES? o WHAT COULD BE DONE TO INCREASE AVAILABILITY OF THE SERVICES? APHIAPlus Imarisha End-of-Activity Evaluation, 2018 165 Last updated on January 202018 (page left intentionally blank for facilitator notes) APHIAPlus Imarisha End-of-Activity Evaluation, 2018 166 Last updated on January 202018 12. What should be done to specifically encourage young women to access the available sexual and reproductive health services? PROBES: o Who are the key players in helping young women access those services? o What is the best way to deliver those services? o Are there any special circumstances or conditions faced by some young women that need to be taken into account? Which specific types of young women? o What about the attitudes of health workers? APHIAPlus Imarisha End-of-Activity Evaluation, 2018 167 Last updated on January 202018 (page left intentionally blank for facilitator notes) APHIAPlus Imarisha End-of-Activity Evaluation, 2018 168 Last updated on January 202018 13. What should be done to specifically encourage young men to access the available sexual and reproductive health services? PROBES: o Who are the key players in helping young men access those services? (Include access and uptake of VMMC services) o What is the best way to deliver those services? o Are there any special circumstances or conditions faced by some young men that need to be taken into account? Which specific types of young men? APHIAPlus Imarisha End-of-Activity Evaluation, 2018 169 Last updated on January 202018 (page left intentionally blank for facilitator notes) APHIAPlus Imarisha End-of-Activity Evaluation, 2018 170 14. What innovations exist to address the HIV prevention, testing, treatment, and care needs of youth? PROBES: o HOW DO YOU DEFINE INNOVATIVE? o HOW RELEVANT ARE THE INNOVATIONS TO THE NEEDS OF YOUTH? o HOW USEFUL ARE THEY IN HELPING YOUTH REDUCE HIV RISKS AND ACCESS VARIOUS TYPES OF TESTING, COUNSELING, TREATMENT AND CARE SERVICES? o WHICH INNOVATIONS HAVE BEEN MOST EFFECTIVE? WHY? o WHICH INNOVATIONS HAVE NOT BEEN EFFECTIVE? WHY? (page left intentionally blank for facilitator notes) 15. Please describe the specific APHIAPlus Imarisha activities you have participated in or been exposed to. PROBES: o IN YOUR COMMUNITY, WHAT ARE SOME OF THE APHIAPLUS-SUPPORTED ACTIVITIES INVOLVING YOUTH?  PROBE FURTHER ON: o BCC o PEER EDUCATION o WHAT ARE SOME OF THE CHANGES AMONG YOUTH ASSOCIATED WITH THE ABOVE ACTIVITIES?  ADDITIONAL PROBES: o HOW HAVE THOSE ACTIVITIES AFFECTED YOUR KNOWLEDGE OF DIFFERENT HIV-RELATED ISSUES? o HOW HAVE THOSE ACTIVITIES AFFECTED YOUR ATTITUDES ON HIV AND SEXUAL AND REPRODUCTIVE HEALTH? o HAVE YOU CHANGED ANY OF YOUR BEHAVIOURS OR PRACTICES AS A RESULT OF THOSE ACTIVITIES? HOW? o THE APHIAPLUS PROJECT CAME TO AN END LATE LAST YEAR. WHAT CAN BE DONE TO CONTINUE ACTIVITIES AND SUSTAIN OUTCOMES IN THE FUTURE?  WHO ARE THE KEY PLAYERS IN THOSE FUTURE EFFORTS?  HOW WOULD YOU DESCRIBE THEIR ABILITY TO MEET THE NEEDS OF YOUNG PEOPLE LIKE YOU? (page left intentionally blank for facilitator notes) 16. Describe other legal economic activities that youth are engaged in? PROBES: o ARE YOUTH ABLE TO MAINTAIN EMPLOYMENT OR GENERATE A STEADY INCOME FROM THESE ACTIVITIES? o WHAT ARE THE CHALLENGES THAT YOUTH FACE WHILE SEEKING THESE OPPORTUNITIES? o HOW DO THESE CHALLENGES VARY FOR MALE AND FEMALE YOUTH? APHIAPlus Imarisha End-of-Activity Evaluation, 2018 171 17. What have you been able to do differently as a result of support received from APHIAplus Imarisha in this area? PROBES: o ACCESS TO AVAILABLE SRH SERVICES FOR THE YOUTH o ADOPTION OF HEALTHY BEHAVIOURS o WHICH OTHER LOCAL IMPLEMENTING PARTNERS ARE WORKING ON SIMILAR PROJECTS IN THIS AREA? 18. What kinds of services are available for household economic strengthening for the youth? PROBES: o ARE THE LOCAL IMPLEMENTING PARTNERS TARGETING THE YOUTH WITH THESE SERVICES? o HOW ARE THE YOUTH UTILISING THESE SERVICES? o HOW HAS THIS TRANSLATED TO IMPROVED UTILIZATION OF OTHER SERVICES PROVIDED BY IMARISHA LIKE SRH AND HIV/AIDS? o WHAT CHALLENGES DO YOU FACE AS YOUTH IN ACCESSING THESE SERVICES APHIAPlus Imarisha End-of-Activity Evaluation, 2018 172 TOOL 13: LIST OF DOCUMENTS TO VERIFY DURING ORGANIZATIONAL CAPACITY ASSESSMENT (OCA) HF 1. Minutes of the last meeting 2. Strategic plan/ operational plans 3. Policy and guideline documents 4. List of essentials drugs 5. MHFL No 6. Service chatter 7. Financial documents 8. Organizational chart 9. List of trainees by training type 10. List of essential drug 11. Job Aids 12. List of CHV linked to the facility Local Implementing Partners 1. OVC school enrollment by gender 2. OVC school attendance by gender 3. OVC school progression by gender 4. Proportion of vulnerable OVC households actively participating in community-based household economic strengthening (HES) groups by wards 5. Percentage of functional HES groups by wards 6. Audited accounts report/ Financial report 7. Registration certificate for the LIP Community Unit 1. Copy of Registers 513, 514, 515, 516 2. Training list by trainees 3. Referral form 4. Drug kit list 5. Minutes of the last meeting 6. List of the CHV County Health Management Team 1. County Integrated Development plan 2. Health Strategic Plan 3. Implementation plan 4. National documents (policies/guidelines) 5. Communication strategy 6. M&E strategy APHIAPlus Imarisha End-of-Activity Evaluation, 2018 173 7. RH strategy 8. Youth Friendly services 9. Budget 10. Partnership Code of Conduct exists 11. The 2014 National HRH norms, standards and guidelines for conditions of employment, work standards and development of the health work force for staffing of each level of the health 12. Human Resource Information System 13. Staff appraisal performance 14. Training list by trainees 15. Data quality assessment protocol forms 16. disease surveillance forms 17. Commodity Security Committee’s Terms of Reference (TORs) APHIAPlus Imarisha End-of-Activity Evaluation, 2018 174 TOOL 14: ORGANIZATIONAL CAPACITY ASSSESSMENT TOOL FOR COUNTY/SUB-COUNTY HEALTH MANAGEMENT TEAMS (15 pages) A. COUNTY NAME B. SUB-COUNTY NAME C. NAME OF CAPACITY ASSESSOR D. DATE(S) CAPACITY ASSESSMENT CONDUCTED E. REVIEW/APPROVAL BY SUB￾TEAM LEADER (STL):  SUB-TEAM LEADER’S NAME:  DATE REVIEWED:  SUB-TEAM LEADER’S SIGNATURE: The objective of this tool will be to assist the evaluation team in assessing the critical elements within the County and Sub-County Health Departments that the activity undertook for effective county health management, and identifying those areas that need further strengthening or further development. This OCA tool is divided into two sections: APHIAPlus Imarisha End-of-Activity Evaluation, 2018 175 SECTION 1: GENERAL CAPABILITY ASSESSMENT ITEM STATUS AT THE TIME OF THE CAPACITY ASSESSMENT REMARKS 1 Needs urgent attention 2 Needs improvement 3 Good but require some support 4 No need for additional training A. GOVERNANCE AND LEADERSHIP 1. Has the CHMT demonstrated the capacity to develop health and development strategy in the county from CIDP 2. Has the CHMT demonstrated the capacity to implement the County Health Strategy? 3. Has the CHMT demonstrated the capacity to engage with the health and other relevant sector actors sector in the county 4. Has the CHMT demonstrated the capacity to develop health policies in the county 5. Has the CHMT demonstrated the capacity for ownership of the health system in the county? ADDITIONAL NOTES ON GOVERNANCE: B. HUMAN RESOURCE 6. Has the County/Sub-County health department team shown the ability to recruit, deploy, retain and motivate staff in the APHIAPlus Imarisha End-of-Activity Evaluation, 2018 176 ITEM STATUS AT THE TIME OF THE CAPACITY ASSESSMENT REMARKS 1 Needs urgent attention 2 Needs improvement 3 Good but require some support 4 No need for additional training various departments in the county 7. Has the County/Sub-County health department team shown the ability to conduct professional development for its staff 8. Has the County/Sub-County health department team shown the ability to conduct performance appraisal for its staff? 9. Has the County/Sub-County health department team shown the ability to undertake staff capacity development based on identified need? 10. Has the County/Sub-County health department team shown the ability to plan for the entire health system? 11. Has the County/Sub-County health department team demonstrate the ability to equitably distribute staff across the county? ADDITIONAL NOTES ON HUMAN RESOURCE C. COUNTY HEALTH FINANCING APHIAPlus Imarisha End-of-Activity Evaluation, 2018 177 ITEM STATUS AT THE TIME OF THE CAPACITY ASSESSMENT REMARKS 1 Needs urgent attention 2 Needs improvement 3 Good but require some support 4 No need for additional training 12. Does the County/Sub-County health department team demonstrate the capacity to develop evidence based budget and allocate it to key departments for the county? 13. Has the County/Sub-County health department team shown the ability to source for sustainable budget? 14. Does the County Health Management Department have Financial Policies Procedures and compliance 15. Has the County/Sub-County health department team shown the ability to monitor and ensure accountability for the county finances? ADDITIONAL NOTES ON COUNTY HEALTH FINANCING D. ACCESS TO PRODUCTS AND COMMODITIES 16. Does the CHMT have the capacity to provide oversight for product and commodity management in the county? 17. Does the CHMT have the capacity to provide oversight APHIAPlus Imarisha End-of-Activity Evaluation, 2018 178 ITEM STATUS AT THE TIME OF THE CAPACITY ASSESSMENT REMARKS 1 Needs urgent attention 2 Needs improvement 3 Good but require some support 4 No need for additional training for the county health supply chain health management 18. Does the CHMT have the capacity to develop and/or adapt the County owned Logistics information management 19. Does the CHMT have the oversight ability of the quality of these products? ADDITIONAL NOTES ON PRODUCTS AND COMMODITIES E. DELIVERY OF HEALTH SERVICES 20. Has the CHMT demonstrated the capacity to develop and distribute policies, strategies, guidelines on standards of care and services 21. Has the CHMT/SCHMT demonstrated capacity to effectively implement policies and strategies 22. Has the CHMT demonstrated the capacity deliver HIV/AIDs, TB, RMNCH, Nutrition WATSAN and Malaria programs? 23. Has the CHMT demonstrated APHIAPlus Imarisha End-of-Activity Evaluation, 2018 179 ITEM STATUS AT THE TIME OF THE CAPACITY ASSESSMENT REMARKS 1 Needs urgent attention 2 Needs improvement 3 Good but require some support 4 No need for additional training the capacity to supervise the use of health service delivery policies, strategies and guidelines and SOPs? 24. Has the CHMT demonstrated equity strategies in service provision? ADDITIONAL NOTES ON ADMINISTRATION AND HUMAN RESOURCES: F. COUNTY HEALTH INFORMATION SYSTEMS 25. Does the CHMT have the capacity to link and report county data with the DHIS on time? 26. Does the CHMT have the capacity to provide oversight on data quality assurance? 27. Does the CHMT have the ability to monitor and evaluate key program performance indicators and use this for planning purposes? G. UNIVERSAL HEALTH ACCESS 28. Has the CHMT demonstrated the capacity to link health (FP/RMNCH/HIV/AIDs/TB, Malaria, Nutrition, water and sanitation) to the other social APHIAPlus Imarisha End-of-Activity Evaluation, 2018 180 ITEM STATUS AT THE TIME OF THE CAPACITY ASSESSMENT REMARKS 1 Needs urgent attention 2 Needs improvement 3 Good but require some support 4 No need for additional training determinants of health 29. Has the CHMT demonstrated the capacity to and bring the other sectors to dialogue on these social determinants of health? H. INNOVATION 30. Has the CHMT demonstrated to develop/adapt innovations? 31. Has the CHMT demonstrated to the ability scale innovations in the county? 32. Has the CHMT demonstrated the ability to harness impacts from these innovations? I. Networking, Linkages, collaboration and Partnership building 33. Has the CHMT demonstrated capacity to hold multi-sectoral stakeholder forum 34. Has the CHMT demonstrated capacity to coordinate the various sectors aligned to health 35. Has the CHMT demonstrated capacity to implement the stakeholders resolutions Additional notes from Networking, Linkages collaboration and partnership APHIAPlus Imarisha End-of-Activity Evaluation, 2018 181 ITEM STATUS AT THE TIME OF THE CAPACITY ASSESSMENT REMARKS 1 Needs urgent attention 2 Needs improvement 3 Good but require some support 4 No need for additional training J. SUSTAINABILITY 36. Has the CHMT demonstrated the capacity to sustain their technically competence to deliver the project after its phase out? 37. Has the CHMT demonstrated the capacity to source for resources to continue finance the programs? 38. Has the CHMT demonstrated the capacity to continuously create enabling environment to sustain the programs Additional notes on sustainability 182 SECTION 2: TECHNICAL CAPACITY STATUS ASSESMENT S/N DESCRIPTION RESPONSES (Circle as appropriate) Remarks 1 Needs urgent attention 2 Needs improv ement 3 Good but require some support 4 No need for additional training A. GOVERNANCE AND LEADERSHIP 1. aThere is a communication plan, and protocols are clearly established to guide the plan. bMore than 50% of key county staff are aware of the internal communication plan and protocols AND evidence exists of use the plan and protocols more than once a year. 2. aEvidence of coordination framework that maps out different stakeholders working in the health sector bRegular coordination meetings are held between the county and different health actors where key stakeholders have opportunity to present and review health priorities and their contributions toward health goals. cAll different health actors are fully involved in annual sector performance reviews, county health annual work plan development and in policy development affecting the county APHIAPlus Imarisha End-of-Activity Evaluation, 2018 183 population and health services (Partnership Code of Conduct exists). d County health leadership receives regular performance updates in the form of reports from all different health actors. 3. aThe county primary health care system at community level is over 50% funded by county government , with input from the implementing partners b Leadership and ownership of the county primary health care system at community level is held by the county (CHEWs) over 50%, with significant input from development partners for health and implementing partners. c Functionality of community units is over 50% per the reporting rates (MOH515) d Annual accountability platform for reviewing committed funding against results achieved at community level in place. Human Resource 4. aThe county develops standard job descriptions for health workers b Harmonized pay system exists (pay structure) c HR policy for staff attraction and recruitment in place. d Incentives for staff retention are in place and effective. APHIAPlus Imarisha End-of-Activity Evaluation, 2018 184 e Working conditions attractive and safe, financial and non-financial incentives for rural and hard to reach places are made more attractive and HRH wellness and welfare improved 5. a The 2014 National HRH norms, standards and guidelines for conditions of employment, work standards and development of the health work force for staffing of each level of the health system exists. b A system has been developed to track staffing levels and needs, c HRIS monthly updated (upon exit and recruitment). d Staffing data on needs by staffing cadre is being used to advocate for resources to meet staffing gaps. 6. a Policies, guidelines or system at the county on staff performance appraisals at all levels of health care management and delivery exists b Staff performance appraisals are conducted as scheduled in the guidelines. c Supervisor performance monitoring is in place d System exists for rewards and sanctions based on performance. 7. a System for coordinating in-service training for HRH exists, county APHIAPlus Imarisha End-of-Activity Evaluation, 2018 185 coordinates all trainings including those conducted by vertical programs and implementing partners b Training needs assessments conducted and coordinated by the county c Training schedules are fully coordinated/ communicated to all relevant stakeholders d Assessments of the impact of trainings to improve service delivery is conducted annually and feedback used during performance appraisals Health information 8. a County health department has the national health information system policy and strategy bMentorship program on correct use of HIS forms institutionalized in at least 75% of sub-counties and/or facilities. c Data collection tools systems for all key components are readily available: i source registers ii birth/death registration, iii reporting forms, iv data quality assessment protocol forms, APHIAPlus Imarisha End-of-Activity Evaluation, 2018 186 v disease surveillance forms d Sub-counties, facilities and community units have adequate supply 9. a County-wide single data collection systems (DHIS2, vital statistics, and disease surveillance) exist; data are routinely collected using standard data collection forms. b County department of health receives timely and complete reports from at least 75% of health facilities (public, private and faith based) i)MOH 731 (HIV) ii)MOH 515 (Community) iii)MOH 710 (Immunization) c County department of health receives accurate reports from more than 75% of health facilities (public, private and faith based) d Health performance data reviewed regularly and regular feedback provided to all health facilities on data accuracy. 10. a One Single County preferred Electronic Health Information System platforms (databases) exist at the county for the various components of the HIS, b Data are routinely extracted (at least annually) for use. c Integration of information from other health management systems (i.e., service statistics, financial, human resource, logistics information, and physical assets data systems) is evident. d County Data Management Guidelines exist including policy on health/research data sharing policy. APHIAPlus Imarisha End-of-Activity Evaluation, 2018 187 11. a The county analyses available HIS data quarterly and distributes reports containing these analyses to key members of the CHMT, Sub-county HMT, health facilities, county assembly health committee and other state and non-state actors. b Presentations and discussions of data are part of the county health performance review meetings. c The county can identify at least two examples of how data have been integrated into a decision-making process including rational budgeting in the past year. Policy and planning framework (that details national development goals, national health sector priority goals, county health priority goals, county budgetary and donor allocations, and county health development outcomes) exists. ACCESS TO PRODUCTS AND COMMODITIES 12. aA Commodity Security unit/team exists within the county health department representing key service areas and including a community liaison in its membership b Commodity Security Committee’s Terms of Reference (TORs) have been documented, are current (within 2 years) and adopted to guide operationalization and implementation of the CS Committee’s mandate. c The County Commodity Security Committee structure has been adopted, operationalized and implemented at the sub-county level for all the sub-counties in the county. d Supply chain performance statistics are maintained at county, sub￾county and facility levels and reflect improving trends overtime. 13.a The county has capacity to estimate commodity needs, and develop a supply plan, b County requires no external technical assistance to estimate commodity needs, APHIAPlus Imarisha End-of-Activity Evaluation, 2018 188 c County has capacity to fully procure or source (i.e. buy or secure donations of) essential commodities, d Health commodity procurement done at least once annually 14.a The county uses a Health Commodities’ LMIS that includes at least two of the four following components: stock keeping record, consumption/usage register, transaction record, and has system for distributing/resupplying these records. b Most staff have been trained in use of the LMIS c Stock on hand within the system and consumption/usage for the past reporting period demonstrates reporting rates of at least 75% from the sub-counties. 15.a County has a plan for routine DQA exits, DQA of LMIS data conducted semi annually b Data Quality Improvement Plan for LMIS data developed for every DQA and implemented c The county/sub-county warehouse and health facility store is adequate – meets all four criteria (i.e. large enough, regularly cleaned, dry, well organized) with all special needs storage areas clearly designated with correct signage, d County warehouse has an established re-order and stocking plan, including the use of protocols (such as first expiry, first out), job aides (such as SOP for emergency procurements) e Re-distribution/dispatching/dispensing to sub-counties follows a consistent schedule and/or record maintenance. APHIAPlus Imarisha End-of-Activity Evaluation, 2018 189 f Stock-control records such as stock cards and bin cards are well maintained COUNTY HEALTH FINANCING 16. a The county health budget is developed annually, with input from county health department and other key sectors. b Estimated actual county health expenditures are systematically calculated on an annual basis as part of budget formulation process c Program, surveys and surveillance data used as justification for budget requests d County health budget is at least between 30% - 40% of the overall county government budget. 190 Section three 1. What successes/innovations have you experienced in implementing the county health strategic plan with partners in terms of: Governance and leadership 2) Health personnel, 3) Services delivery((HIV/AIDS, TB/HIV, RMNCH, Malaria, Nutrition, Water and Sanitation, 4) Health products and commodities, 5) Health Financing and budgeting, 6, Health information, 7,Social determinants and 8.Networking, linkages collaboration and partnership building 2. Explain the capacity of the county/sub-county is able to sustain the good things/innovation and scale them up after the project IMARISHA by USIAD has ended 3. Describe the training the county teams have gone through since 2012 -2017 and how the trainings have helped the county achieve the planned activities( who went for the training and how many by cadres) 4. What challenges have you experienced in implementing the county health strategic plan with partners in terms of: Governance and leadership 2) Health personnel, 3) Services delivery((HIV/AIDS, TB/HIV, RMNCH, Malaria, Nutrition, Water and Sanitation, 4) Health products and commodities, 5) Health Financing and budgeting, Health information Social determinants and 8.Networking, linkages collaboration and partnership building 5. What must be done different in the new design of the USAID project that will be sustained and transform the health situation in your county APHIAPlus Imarisha End-of-Activity Evaluation, 2018 191 Facility MFL No. NO. TOOL 15: HEALTH FACILITY CAPACITY ASSESSMENT TOOL NAME OF CAPACITY ASSESSOR DATE(S) CAPACITY ASSESSMENT CONDUCTED REVIEW/APPROVAL BY SUB-TEAM LEADER (STL): SUB-TEAM LEADER’S NAME: DATE REVIEWED: SUB-TEAM LEADER’S SIGNATURE: 1.0 BACKGROUND FACILITY IDENTIFICATION County Sub-county Ward Facility name: ___________________________________________ Indicate Codes Facility type 01=HOSPITAL 02=HEALTH CENTRE 03=DISPENSARY04=CLINIC 05=NURSING HOME 88=OTHER (SPECIFY)_______________________ [___|___] Type of sector (Managing Authority/Ownership) 01=GOVERNMENT/PUBLIC 02=NGO/PRIVATE NOT-FOR-PROFIT 03=PRIVATE -FOR-PROFIT 04=FAITH-BASED/MISSION/CHURCH 88=OTHER (SPECIFY)_______________________ [___|___] Urban/Rural URBAN ……………………………………………………………………..1 RURAL …………………………………………..…………………………2 [___|___] Facility Services OUT-PATIENT ……………………………………………………………………1 IN-PATIENT ………………………….…………………………………………….2 BOTH ………………………….…………………………………………………….3 [___|___] 2.0 GOVERNANCE, MANAGEMENT AND PLANNING QUESTIONS CODING REMARKS APHIAPlus Imarisha End-of-Activity Evaluation, 2018 192 CATEGORIES 2.1 Does the health facility have an organizational chart with all key staff positions? 1=Yes 2=No 2.2 Does the health facility have a board/health facility management committee? 1=Yes 2=No 2.4 Does the health facility have a current, written strategic plan? 1=Yes 2=No 2.5 Does the health facility have a current annual work plan? 1=Yes 2=No 2.6 Does the health facility have regular Management meetings in this facility? 1=Yes 2=No 2.7 Does the health facility have minutes from these meetings? 1=Yes 2=No 3.0 FINANCING QUESTIONS CODING CATEGORIES REMARKS 3.1 Does the health facility have a written finance policy and procedures and applied? 1=Yes 2=No 3.2 Has the health facility ever received international donor funding (e.g., Global Fund, USAID, DFID, any UN agencies, sub-grants from international NGOs, etc.)? 1=Yes 2=No LIST ALL DONORS 3.3 Besides the APHIAplus Imarisha project, are there other active donor projects? 1=Yes 2=No 3.4 Does the health facility receive any in-kind support (e.g., office space or equipment, materials, supplies)? 1=Yes 2=No 3.5 Has the health facility undergone annual financial audit? 1=Yes 2=No 3.6 Does the health facility maintain income/funding and expenditure records? 1=Yes 2=No 3.7 Does the health facility produce financial reports for donors? 1=Yes 2=No 1=Yes 2=No APHIAPlus Imarisha End-of-Activity Evaluation, 2018 193 4.0 SERVICES QUESTIONS CODING CATEGORIES REMARKS 4.1 Does this facility have the following units? 4.1.1 MNCH unit 4.1.2 Labour wards 4.1.3 TB clinic 4.1.4 CCC 4.1.5 Lab 4.1.6 Malaria unit 4.1.7 Nutrition unit 4.1.8 Water and Sanitation 1=Yes 1=Yes 1=Yes 1=Yes 1=Yes 1=Yes 1=Yes 1=Yes 2=No 2=No 2=No 2=No 2=No 2=No 2=No 2=No 4.2 Does this facility offer the following services? 4.2.1 FP 4.2.2 ANC 4.2.3 PNC 4.2.3 Immunization 4.2.4 Post Abortion Care (PAC) 4.2.5 Maternity 4.2.6 TB prevention and treatment 4.2.7 EID 4.2.8 HIV Testing 4.2.9 HIV Care and Treatment 4.2.10 VMMC 4.2.11 PEP 4.2.12 Malaria prevention and treatment 4.2.13 Nutrition 1=Yes 1=Yes 1=Yes 1=Yes 1=Yes 1=Yes 1=Yes 1=Yes 1=Yes 1=Yes 1=Yes 1=Yes 1=Yes 1=Yes 2=No 2=No 2=No 2=No 2=No 2=No 2=No 2=No 2=No 2=No 2=No 2=No 2=No 2=No 4.3 Are there policy and guideline documents for the above service areas? (Confirm physically if the documents listed below are available) 4.3.1 FP 4.32 ANC 4.3.3 PNC 4.3.3 Immunization 4.3.4 Post Abortion Care (PAC) 4.3.5 Maternity 4.3.6 TB prevention and treatment 4.3.7 EID 4.3.8 HIV Testing 4.3.9 HIV Care and Treatment 4.3.10 VMMC 4.3.11 PEP 4.3.12 Malaria prevention and treatment 4.3.13 Nutrition 1=Yes 1=Yes 1=Yes 1=Yes 1=Yes 1=Yes 1=Yes 1=Yes 1=Yes 1=Yes 1=Yes 1=Yes 1=Yes 1=Yes 1=Yes 1=Yes 2=No 2=No 2=No 2=No 2=No 2=No 2=No 2=No 2=No 2=No 2=No 2=No 2=No 2=No 2=No 2=No 4.4 Are there Job aids (Confirm physically APHIAPlus Imarisha End-of-Activity Evaluation, 2018 194 if the job aids listed below are available (i.e., laminated charts, wall charts, posters, leaflets, etc. appropriately displayed in a visible location) 4.4.1 FP 4.4.2 ANC 4.4.3 PNC 4.4.3 Immunization 4.4.4 Post Abortion Care (PAC) 4.4.5 Maternity 4.4.6 TB prevention and treatment 4.4.7 EID 4.4.8 HIV Testing 4.4.9 HIV Care and Treatment 4.4.10 VMMC 4.4.11 PEP 4.4.12 Malaria prevention and treatment 4.4.13 Nutrition 1=Yes 1=Yes 1=Yes 1=Yes 1=Yes 1=Yes 1=Yes 1=Yes 1=Yes 1=Yes 1=Yes 1=Yes 1=Yes 1=Yes 1=Yes 1=Yes 1=Yes 2=No 2=No 2=No 2=No 2=No 2=No 2=No 2=No 2=No 2=No 2=No 2=No 2=No 2=No 2=No 2=No 2=No 5.0 STAFFING 5.1 What is the total number of staff currently working in the MNCH, CCC, VMMC and TB services? (All doctors, nurses and clinical officers including medical officer and clinical officer interns and qualified nurses undergoing post￾basic training) [-----------] 5.2. Does the Department currently have any unfilled/vacant staff positions? [Y] [N] . If Yes, how many? ------------ - 5.3 Length the gaps have remained unfilled------------------------------------------------------------------- 5.3 Indicate the NUMBER of staff working in the following service delivery points within the Health facility (excluding students) STAFF FP/MNCH CCC TB MALARIA a)Medical officers (General practitioners) [___|___]___] [___|___]___] [___|___]___] [___|___]___] b)Medical officers (Specialists) [___|___]___] [___|___]___] [___|___]___] [___|___]___] c)Nurse/Midwife [___|___]___] [___|___]___] [___|___]___] [___|___]___] d)Clinical officers [___|___]___] [___|___]___] [___|___]___] [___|___]___] e)Counselors [___|___]___] [___|___]___] [___|___]___] [___|___]___] f)Nutritionists [___|___]___] [___|___]___] [___|___]___] [___|___]___] g)Pharmacists/ Pharm techs [___|___]___] [___|___]___] [___|___]___] [___|___]___] APHIAPlus Imarisha End-of-Activity Evaluation, 2018 195 h)Lab technicians/ Technologists [___|___]___] [___|___]___] [___|___]___] [___|___]___] i)Health records officers [___|___]___] [___|___]___] [___|___]___] [___|___]___] j)Public Health officers/technicians [___|___]___] [___|___]___] [___|___]___] [___|___]___] k)CHEWs affiliated with facility [___|___]___] [___|___]___] [___|___]___] [___|___]___] l)CUs affiliated with facility [___|___]___] [___|___]___] [___|___]___] [___|___]___] 6.0: TRAINING 6.1 Please indicate the total number of staff currently working in the MNCH, CCC and TB units at this facility who have undertaken the relevant training course in the past 12 months? [--------] Additional training: Do you have any staff trained on the following areas? [1] Trained [2] None trained On job training Mentorship Orientation / workshop / seminar Facility CMEs Any trained Staff? No. Trained No. Trained No. Trained No. Trained a)HTS [1] [2] b)ART [1] [2] c)PMTCT [1] [2] d)APOC [1] [2] e)TB [1] [2] f)VMMC [1] [2] g)PEP [1] [2] h)Management of puerperal sepsis [1] [2] i)Active management of third stage of labor [1] [2] j)Management of pre-eclampsia / eclampsia [1] [2] k)Manual removal of the placenta [1] [2] l)Post abortion care [1] [2] m)Assisted vaginal delivery (vacuum extraction) [1] [2] n)Newborn resuscitation/ Essential newborn care / Helping Babies Breathe (HBB) [1] [2] o)Family planning [1] [2] p)Targeted Postpartum Care for the mother [1] [2] q)Kangaroo mother care (KMC) [1] [2] r)Chlorhexidine cord care [1] [2] s)Nutrition [1] [2] APHIAPlus Imarisha End-of-Activity Evaluation, 2018 196 7.0 COMMUNITY HEALTH VOLUNTEERS 7.1 Are there any Community Health Volunteers affiliated with this facility? [Y] [N] 7.2 What type of services do Community Health Volunteers (CHV) associated with your facility offer? Tick as MENTIONED). Family Planning, Immunization, Well-Baby Care, TB DOTS, Health Education, o HTS, Malaria Prevention, Other (Specify) ---------------------------------- ------------------ 7.3 How many CHVs have been trained to offer the above services? [All] [Most] [Some] [None 10.0 INTEGRATION OF SERVICES OFFERRED 10.1 Does this facility offer any of the following client service in any of the location in this facility? Confirm by checking service provision in each service delivery point. [FOR EACH SERVICE, ‘Y’ FOR ‘YES’ OR ‘N’ FOR ‘NO’ AS APPROPRIATE] Available at MCH/FP unit Available at Maternity Unit Available in the VCT / CCC/ART clinic Available in the YFC clinic Available in the OPD clinic a) Family planning services b) Services for the prevention of mother-to-child transmission of HIV (PMTCT) c) Adolescent health services d) HIV counseling and testing services e) HIV & AIDS care and support services, including treatment of opportunistic infections and provisions of palliative care f) Nutrition Services g) VMMC Services 11.0. QUALITY IMPROVEMENT 11.1 What quality improvement initiatives have been put in place? APHIAPlus Imarisha End-of-Activity Evaluation, 2018 197 1. How many times in the last 6 months has a supervisor come to the FP/MNCH, CCC, and TB units for supervisory purposes? 2. Is there a Quality improvement team in place 3. Are there guidelines for the implementation for the standards 4. Has a QI meeting taken place in the quarterly scheduled in the past one year? 5. What QI topics have been addressed in the past? ____________________________________________________________________ _________ _______________ __ [Y] [N] [Y] [N] 12.0 Hygiene and sanitation Confirm availability of the following through inspections MNCH CCC TB Running water [Y] [N] [Y] [N] [Y] [N] Soap [Y] [N] [Y] [N] [Y] [N] Disposable Paper Towels [Y] [N] [Y] [N] [Y] [N] Individual reusable hand towels [Y] [N] [Y] [N] [Y] [N] Alcohol hand rub/sanitizer [Y] [N] [Y] [N] [Y] [N] Masks [Y] [N] [Y] [N] [Y] [N] 13.0 How does the facility dispose of waste (Tick all that apply) Waste Pit [ ] Placenta Pit/macerator [ ] Functional Incinerator [ ] Burning [ ] Others (specify) [ ] 14.0 Sources of power: Indicate the source(s) of power at this facility (Please select ALL that are available and FULLY FUNCTIONAL) a. Solar power [ ] b. National grid (KPLC) [ ] c. Generator [ ] d. Other (Specify) [ ] e. None f. Is the source of power reliable for use always [ ] 15.0 Does the Department have a physical office space equipped with office furniture? Related to earlier Equipment MNCH CCC TB 15.1 Office space [Y] [N] [Y] [N] [Y] [N] 15.2 Furniture [Y] [N] [Y] [N] [Y] [N] APHIAPlus Imarisha End-of-Activity Evaluation, 2018 198 16.0 Communication 16.1What communication methods are in place in the facility among staff and by departments? (circle all that apply) [Internet] [Phone] [Social Media Groups] [Others (specify______________________________)] 17.0 Innovation 17.1 Are the any new innovations that have been generated by the facility? [Y] [N] 17.2 If Yes, list the innovations ________________________________________________________ __________________________________________________________________________________ 17. 3 Have the staff been trained on the new innovations? [Y] [N] 17.4 Have the innovations been used to improve services in the facility? [Y] [N] 17.5 Can these innovations be scaled up? [Y] [N] 17.6 If Yes, please explain ______________________________________________________________________ ______________________________________________________________________________ ______________ 18 Sustainability: 18.1 Does the facility have the relevant technical competency to continue offering the services [Y] [N] 18.2Is there continuous capacity building [Y] [N] 18.3 Does the facility have realistic and sustainable budget informed by sound revenue forecasting methods including use of past experience/expenses, development partners for health contributions and projections? [Y] [N] 18.4 All key stakeholders are involved (including county health department, sub-county health administrators, public participation, and as necessary, development partners for health and implementing partners) [Y] [N] 18.5 Is it able to generate financial resources to continue operating beyond the life of the project [Y] [N] 18.6 The facility has improving financial trends toward sustainability [Y] [N] Score: How would you score the facility in the following areas: Area Score (%) not 1 to 5 (Best?) Governance and Planning Financing Services Staffing Training Community Health Volunteers APHIAPlus Imarisha End-of-Activity Evaluation, 2018 199 Equipment Drugs Integration of Services Quality Improvement Hygiene and Sanitation Waste Disposal Physical Space Communication Innovation Sustainability Overall Score Key  80% and above = Fully functional (F)  50%–79% = Functional (SF)  49% and below = Semi-Functional (NF) APHIAPlus Imarisha End-of-Activity Evaluation, 2018 200 TOOL 16: COMMUNITY UNIT CAPACITY ASSESSMENT - COMMUNITY HEALTH EXTENSION WORKERS (CHEW) QUESTIONNAIRE - DATE OF ASSESSMENT ________________________________ Assessors Name _________________ County: ________________________________ Constituency: ________________________________ Ward: ________________________________ Name of the Community Unit: ________________________________ Master Community Unit List Code (MCULCODE) _________________ Name of Link Health Facility________________________________ Number of villages served _________________________________ Estimated number of households in each village: Village 1_______Village 2_______ Village 3______ CU Catchment Population ________________________________ CU Supported by USG Yes________________No_______________________ CU FUNCTIONALITY PROFILE￾No. Parameter Standard/norm Scoring instructions Scores Process Indicators 1. CHEWs recruited and trained There are two CHEWs attached to the unit and have undergone 5 days orientation on Community Strategy and support supervision Yes=1 No=0 2. CHC recruited and trained The CHC members (7, 9, 11 or 13 based on population) recruited and have undergone 7 days basic training.(Recruitment and training followed national guidelines) Yes=1 No=0 3. CHVs recruited and trained CHVS recruited from local community based on population density and have undergone 10 days basic training (Phase 1=5 and Phase 2=5) Yes=1 No=0 4. Technical Updates for CHVs CHVs provided with technical updates (HIV, TB, Malaria) at least once every 6 months Yes-1 No=0 5. CHVs supplied with CHV kits A kit per CHV based on content agreed upon by the project and CHMT, guided by the national policy Yes=1 No=0 6. Tools are Available and in use The MoH 513, 514, 515, community treatment and tracking register, AL RDT register for CHV are available and updated properly. Yes=1 No=0 7. CU supplied with a chalk board (MOH 516) A chalk board (MOH 516) is available and updated Yes=1 No=0 8. CHVs supplied with referral booklets A referral booklet per CHVs Yes=1 No=0 9. Reporting CHVs receiving stipend (KES. 2000) or other forms of motivation CHVs in a CU reporting (using MOH 514)receive 1a monthly stipend of KSHS.2000 based on performance or received seed money and have established an IGA Yes=1 No=0 APHIAPlus Imarisha End-of-Activity Evaluation, 2018 201 Key  80% and above = Functional (F)  50%–79% = Semi-Functional (SF)  49% and below = Non-Functional (NF) Functionality will be determined by dividing the “yes” totals by the 19 variables*100. NB: The three (3) cardinal elements (17, 18, 19) MUST all be fulfilled for a for a CU with≥80% Rates: 4 No need for additional training 3 Good, but requires some support 2 Needs improvement 1 Needs urgent attention Rating score Rating Description Rating % Comments 4 No need for additional training 80 and above 3 Good, but requires some support 60–79 2 Needs improvement 50–59 1 Needs urgent attention 1–49 of their choice 10. Means of transport available at the CU for use by CHVs CU has at least 10 bicycles for use by CHVs as a means of transport. Yes=1 No=0 11. Supervision of CU by CHMT Supervision of CU by CHMT (at least once every six months) Yes=1 No=0 Performance Indictors 12. Plan of action available at the CU CU has a plan of action (check wall or file) Yes=1 N0=0 13. CHCs holding quarterly meetings CHCs/CHVs holding quarterly meetings to review CU work plan with minutes (check minutes in file) Yes=2 No=0 14. CHVs holding monthly feedback meetings CHVs holding monthly data review/feedback meetings (check minutes in file) Yes=1 No=0 15. Discuss existence of a sustainability initiative Discussions held with CHEW, CHC, & CHVs (check reports in the file) Yes=1 No=0 16. Semi Annual Household Mapping CU conducts household mapping semi-annually (MOH 513 and 516 updated) Yes-1 No=0 Cardinal Elements for Basic Functionality 17. CHVS Reporting Rate CHVs reporting rate is over 80% in the CU while the CHEW is reporting at 100% Yes=1 No=0 18. Quarterly community dialogues Dialogues taking place (check reports from the file) Yes=1 No=0 19. Health Action Days Takes place each month (check reports from the file) Yes=1 No=0 Total Score out of 19 Percentage (%) Score Functionality Categorization Rating Score APHIAPlus Imarisha End-of-Activity Evaluation, 2018 202 TOOL 17: ORGANIZATIONAL CAPACITY ASSSESSMENT - LOCAL IMPLEMENTING PARTNERS (LIPs) - F. NAME OF CAPACITY ASSESSOR G. DATE(S) CAPACITY ASSESSMENT CONDUCTED H. REVIEW/APPROVAL BY SUB-TEAM LEADER (STL):  SUB-TEAM LEADER’S NAME:  DATE REVIEWED:  SUB-TEAM LEADER’S SIGNATURE: APHIAPlus Imarisha End-of-Activity Evaluation, 2018 203 ABOUT THIS TOOL This Organizational Capacity Assessment Tool (OCAT) has been adapted for use with community-based organizations (CBOs) and faith-based organizations (FBOs) who have been selected as local implementing partners (LIPs) for the USAID/Kenya East Africa-funded APHIAplus IMARISHA Project in Turkana and Samburu. The tool, which is aligned with the service delivery areas and minimum standards outlined in the Government of Kenya’s Minimum Service Standards for Orphans and Vulnerable Children (OVC) Programs, provides a rapid assessment of general institutional development issues and in-depth assessment of the program areas outlined in Kenya’s minimum service package for OVC. To elucidate USAID and APHIAplus Imarisha implementing partners on key reasons why LIPs have not adopted particular service standards, the OCAT documents the following gaps for each OVC program area: “Know” = Organization is not aware/knowledgeable of the service standard/strategy “Staff” = Organization has insufficient staff to implement the service/strategy “Train” = Organization has staff but they are not trained in the service/strategy “Fund” = Organization has insufficient funds (or suboptimal resource allocation) to implement the service/strategy The OCAT will also generate data related to the following APHIAplus IMARISHA project performance indicators: 8. OVC school enrollment by gender 9. OVC school attendance by gender 10. OVC school progression by gender 11. Proportion of vulnerable OVC households actively participating in community-based household economic strengthening (HES) groups by wards 12. Percentage of functional HES groups by wards 13. Improved financial, managerial and technical capacity of indigenous organizations serving social and health needs of marginalized, poor and underserved populations APHIAPlus Imarisha End-of-Activity Evaluation, 2018 204 The Annex includes an illustrative list of other indicators that will be gleaned from the APHIAplus IMARISHA OCAT and presented in the Evaluation report. APHIAPlus Imarisha End-of-Activity Evaluation, 2018 205 Contents ABOUT THIS TOOL 203 CHECKLIST OF KEY DOCUMENTS TO FACILITATE COMPLETING THE OCAT 205 I. ORGANIZATIONAL PROFILE 206 II. GENERAL ASSESSMENT OF INSTITUTIONAL DEVELOPMENT 209 III. ASSESSMENT OF TECHNICAL CAPACITY 216 A. FOOD SECURITY AND NUTRITION 216 B. EDUCATION AND VOCATIONAL TRAINING 219 C. HEALTH 221 D. PSYCHOSOCIAL SUPPORT 224 E. CHILD PROTECTION 227 F. HOUSEHOLD ECONOMIC STRENGTHENING (HES) AND LINKAGES 230 G. SHELTER AND CARE 232 H. COORDINATION OF CARE 236 I. MONITORING, EVALUATION AND KNOWLEDGE MANAGEMENT 238 I. KNOWLEDGE MANAGEMENT/LEARNING 239 CHECKLIST, KEY DOCUMENTS TO FACILITATE COMPLETING THE OCAT The OCAT is not based solely on verbally reported information; it requires verifying evidence. Assessors are advised to request each organization to organize any existing documents such as the following to facilitate the assessment process. Organizing those documents in advance of the assessment visit is strongly encouraged.  Vision statement, mission statement  Organizational chart or description of the staffing patterns  Recent board meeting minutes  Strategic plan  Work plan/plans  Monitoring and Evaluation (M&E) Plan  Quarterly budgets for the past one year  Recent audit report  Organization’s financial policies and procedures manual  Financial report and financial monitoring tools  Procurement policies, plans, and files; payment vouchers; approvals  Progress technical reports: quarterly/annual 1. Evaluation reports 2. Donor feedback on reports APHIAPlus Imarisha End-of-Activity Evaluation, 2018 206 I. ORGANIZATIONAL PROFILE 1. Name of the organization 2. Year of registration 3. County of operation 4. Type of organization(Circle One) 1. 2. 3. 4. 5. 6. Non-governmental organization (NGO) Community-based organization (CBO) Faith-based organization (FBO) PLWHA support group Self-help group/Association Other (specify)_____________________________ 5. Total number of sub￾counties covered by the organization (including but not limited to those covered by the APHIAplus Imarisha project) 6. Total number of wards covered by the organization (including but not limited to those covered by the APHIAplus Imarisha project) 7. Total number of wards where the organization will be implementing APHIAplus Imarisha project activities 8. Number of vulnerable households served by the organization in the past APHIAPlus Imarisha End-of-Activity Evaluation, 2018 207 12 months 9. Number of orphans and vulnerable children (OVC) served by the organization in the past 12 months 10. Forms of OVC support provided by the organization (Circle all that apply) A. Food & nutrition B. Health C. Education & vocational training D. Psychosocial support E. Shelter & care F. Child protection G. Household economic strengthening H. Coordination of care I. Capacity building J. OTHER (Specify): _______________________________________________ 11. Total operating budget (in KSH) for the current financial year {SPECIFY Start and End month for the organization’s financial year, e.g., July 2015-June 2016} 12. Total number of FULL￾TIME staff working for the organization 13. Total number of PART￾TIME staff working for the organization 14. Total number of VOLUNTEERS working for the organization 15. Total number of staff whose salaries were supported using APHIAplus IMARISHA project funds 16. CONTACT DETAILS FOR THE ORGANIZATION: a. Name of primary point of contact: APHIAPlus Imarisha End-of-Activity Evaluation, 2018 208 b. Position of primary point of contact: c. Organization’s physical address: d. Organization’s mailing address: e. Telephone number(s): f. Email address: g. Website/URL: APHIAPlus Imarisha End-of-Activity Evaluation, 2018 209 II. GENERAL ASSESSMENT OF INSTITUTIONAL DEVELOPMENT ITEM STATUS AT THE END-OF￾PROJECT CAPACITY ASSESSMENT REMARKS (0) NO (Does not exist) (1) YES, but not seen/verified (2) YES, seen/verified (9) NOT APPLICABLE K. GOVERNANCE, LEADERSHIP AND MANAGEMENT 39. Does the organization have an organizational chart with all key staff positions reflecting the mandate for OVC support? 40. Does the organization have written strategy with clear vision and mission statements? 41. Does the organization have a written constitution or bylaws? 42. Does the organization have an effective management structure in place? 43. Does the organization have a board/executive committee? APHIAPlus Imarisha End-of-Activity Evaluation, 2018 210 ITEM STATUS AT THE END-OF￾PROJECT CAPACITY ASSESSMENT REMARKS (0) NO (Does not exist) (1) YES, but not seen/verified (2) YES, seen/verified (9) NOT APPLICABLE 44. Does the organization have clear policies that guide the management and interrelationship between the different internal governance organs i.e. staff, management, Board and target OVCs? ADDITIONAL NOTES ON GOVERNANCE, LEADERSHIP AND MANAGEMENT: L. PLANNING 45. Does the organization have a current, written strategic plan? 46. Does the organization have a current annual work plan? 47. Is the annual work plan costed and effectively implemented?? APHIAPlus Imarisha End-of-Activity Evaluation, 2018 211 ITEM STATUS AT THE END-OF￾PROJECT CAPACITY ASSESSMENT REMARKS (0) NO (Does not exist) (1) YES, but not seen/verified (2) YES, seen/verified (9) NOT APPLICABLE ADDITIONAL NOTES ON PLANNING: M.FINANCE 48. Does the organization have a full-time Finance Manager/Officer? 49. Does the organization have at least one bank account registered in the organization’s name? 50. Does the organization have a written finance policy and procedures? 51. Has the organization ever received international donor funding (e.g., Global Fund, USAID, DFID, any UN agencies, sub-grants from international NGOs, etc.)? 52. Does the organization receive any in￾kind support (e.g., office space or equipment, materials, supplies)? 53. Has the organization undergone APHIAPlus Imarisha End-of-Activity Evaluation, 2018 212 ITEM STATUS AT THE END-OF￾PROJECT CAPACITY ASSESSMENT REMARKS (0) NO (Does not exist) (1) YES, but not seen/verified (2) YES, seen/verified (9) NOT APPLICABLE routine financial audit in the last two years? 54. Does the organization maintain income/funding and expenditure records? 55. Does the organization have a written procurement policy and procedures? 56. Is there more than 1 category of signatories with clear authorization and limits? ADDITIONAL NOTES ON FINANCE: N. GRANTS MANAGEMENT 57. Does the organization develop and submit proposals for funding? 58. Has the organization received funding for at least one successful proposal in the last two years? APHIAPlus Imarisha End-of-Activity Evaluation, 2018 213 ITEM STATUS AT THE END-OF￾PROJECT CAPACITY ASSESSMENT REMARKS (0) NO (Does not exist) (1) YES, but not seen/verified (2) YES, seen/verified (9) NOT APPLICABLE 59. Does the organization produce financial reports for donors? 60. Besides the APHIAplus Imarisha project, are there other active donor projects? 61. Record details on all active projects, including APHIAplus Imarisha in the space provided. Project description Donor Project start/ end dates Budget (specify KSH or USD) APHIAPlus Imarisha End-of-Activity Evaluation, 2018 214 ITEM STATUS AT THE END-OF￾PROJECT CAPACITY ASSESSMENT REMARKS (0) NO (Does not exist) (1) YES, but not seen/verified (2) YES, seen/verified (9) NOT APPLICABLE ADDITIONAL NOTES ON GRANTS MANAGEMENT: E. ADMINISTRATION AND HUMAN RESOURCES 62. Does the organization have its own child protection policy? 63. Does the organization have a written Human Resource (HR) manual/policy? 64. Does the organization have written job descriptions for all positions? 65. Does the organization currently have any unfilled/vacant staff positions in the organogram? 66. Does the organization have a physical office space equipped with office facilities?? 67. Does the organization have at least one working computer and printer? 68. Does the organization have reliable power supply in any one week? APHIAPlus Imarisha End-of-Activity Evaluation, 2018 215 ITEM STATUS AT THE END-OF￾PROJECT CAPACITY ASSESSMENT REMARKS (0) NO (Does not exist) (1) YES, but not seen/verified (2) YES, seen/verified (9) NOT APPLICABLE 69. Do all key positions within the organization have capacity to communicate regularly? ADDITIONAL NOTES ON ADMINISTRATION AND HUMAN RESOURCES: APHIAPlus Imarisha End-of-Activity Evaluation, 2018 216 III. ASSESSMENT OF TECHNICAL CAPACITY A. Food security and Nutrition The following are used in the table to highlight key reasons why the LIP is not pursuing particular service standards: Know = Organization is not aware/knowledgeable of the service/strategy Staff = Organization has insufficient staff to implement this service/strategy Train = Organization has staff but they are not trained in this service/strategy Fund = Organization has insufficient funds (or suboptimal resource allocation) to implement the service/strategy KENYAN SERVICE STANDARD KEY STRATEGIES STATUS AT TIME OF ASSESSMENT YES IF YES, verifying evidence NO IF NO, why? Know Staff Train Fund 1. Does the organization conduct on-going assessment of the target community’s food and nutrition needs? a. Organizing forums to discuss and gauge the community’s food and nutrition needs b. Mobilizing and sensitizing the community on the importance of proper food and nutrition c. Conducting on-going household needs assessments from a representative sampling of households d. Establishing feedback mechanisms within the community to monitor the community’s needs APHIAPlus Imarisha End-of-Activity Evaluation, 2018 217 KENYAN SERVICE STANDARD KEY STRATEGIES STATUS AT TIME OF ASSESSMENT YES IF YES, verifying evidence NO IF NO, why? Know Staff Train Fund 2. Does the organization conduct mapping and linking of stakeholders and resources available for food and nutrition support? a. Conducting mapping 3. Does the organization promote knowledge on nutrition for OVC, their households, and the community? a. Establishing mechanisms to promote good nutritional practices among OVC and their families b. Educating and creating community awareness on nutrition through use of media, public meetings, and information sessions, etc. 4. Does the organization provide targeted food and nutrition interventions for OVCs and their households? a. Providing food support for OVC households without access to adequate food supplies b. Enabling OVC households to access micronutrient supplementation c. Creating linkages and referrals systems for OVC requiring specialized or emergency food and nutrition support 5. Does the organization aid in increasing access to nutritious food by OVC and their households? a. Encouraging OVC and their households to diversify food production b. Linking OVC and their households to livelihoods? programs c. Building OVC and their household capacity on proper food production, food budgeting, storage, and APHIAPlus Imarisha End-of-Activity Evaluation, 2018 218 KENYAN SERVICE STANDARD KEY STRATEGIES STATUS AT TIME OF ASSESSMENT YES IF YES, verifying evidence NO IF NO, why? Know Staff Train Fund preservation APHIAPlus Imarisha End-of-Activity Evaluation, 2018 219 B. Education and Vocational Training The following are used in the table to highlight key reasons why the LIP is not pursuing particular service standards: Know = Organization is not aware/knowledgeable of the service/strategy Staff = Organization has insufficient staff to implement this service/strategy Train = Organization has staff but they are not trained in this service/strategy Fund = Organization has insufficient funds (or suboptimal resource allocation) to implement the service/strategy KENYAN SERVICE STANDARD KEY STRATEGIES STATUS AT TIME OF ASSESSMENT YES IF YES, verifying evidence NO IF NO, why? Know Staff Train Fund 1. Which of the following forms of OVC education support does your organization offer? a. Ensuring a safe school environment and completion of primary education b. Promoting access to early childhood development (ECD) programs c. Creating child-friendly and HIV/AIDS non-discrimination and gender-sensitive learning spaces d. Strengthening community￾school relationships e. The transition for girls from APHIAPlus Imarisha End-of-Activity Evaluation, 2018 220 KENYAN SERVICE STANDARD KEY STRATEGIES STATUS AT TIME OF ASSESSMENT YES IF YES, verifying evidence NO IF NO, why? Know Staff Train Fund primary to secondary school f. Market-driven vocational training 2. Does the organization develop and implement appropriate mechanisms that address educational barriers? a. Holding community forums with stakeholders to identify OVC who do not attend school and document reasons for non￾attendance/drop out b. Collecting data on household and other barriers to education c. Conducting site visits to schools to monitor OVC attendance 3. Does the organization ensure non￾discriminatory, comprehensive education and training to OVCs? a. Visiting schools to monitor age￾and gender appropriateness of efforts that promote educational progress of OVC b. Develop written agreements with participating schools and institutions creating clear roles and responsibilities in provision of education and training support for OVCs c. Involving OVCs, caregivers and other stakeholders in conducting a market assessment to inform vocational training opportunities for OVCs d. Establishing referral mechanisms to ensure APHIAPlus Imarisha End-of-Activity Evaluation, 2018 221 KENYAN SERVICE STANDARD KEY STRATEGIES STATUS AT TIME OF ASSESSMENT YES IF YES, verifying evidence NO IF NO, why? Know Staff Train Fund appropriate, comprehensive and continued educational and vocational support to OVC 4. Does the organization mobilize and sensitize the community, especially key stakeholders, to support age-appropriate education and training for OVCs? a. Encouraging education and training institutions to enhance their support for continuity of education for OVC b. Holding meetings with community members to create awareness of the educational needs and rights of OVC c. Discuss the importance of education with OVC and the members of their households, especially caregivers, and emphasis the importance of educating both boys and girls equally C. Health The following are used in the table to highlight key reasons why the LIP is not pursuing particular service standards: Know = Organization is not aware/knowledgeable of the service/strategy Staff = Organization has insufficient staff to implement this service/strategy Train = Organization has staff but they are not trained in this service/strategy APHIAPlus Imarisha End-of-Activity Evaluation, 2018 222 Fund = Organization has insufficient funds (or suboptimal resource allocation) to implement the service/strategy KENYAN SERVICE STANDARD KEY STRATEGIES STATUS AT TIME OF ASSESSMENT YES IF YES, verifying evidence NO IF NO, why? Know Staff Train Fund 1. Does the organization aid in assessing the health needs, services and costs for OVCs and their households? a. Identifying common health problems in the community b. Developing an assessment tool and using it to identify and assess the health needs of OVC and their households 2. Does the organization enhance access to HIV prevention, treatment, care and support for OVC through the following? a. Training service providers on HIV prevention, behavior change communication, life skills and adolescent sexual reproductive health b. Promoting HIV counseling and testing for OVC, in partnership with the Ministry of Health c. Formation of age-specific peer clubs d. Providing treatment literacy and ART adherence support interventions to community health workers, caregivers and HIV+ OVCs APHIAPlus Imarisha End-of-Activity Evaluation, 2018 223 KENYAN SERVICE STANDARD KEY STRATEGIES STATUS AT TIME OF ASSESSMENT YES IF YES, verifying evidence NO IF NO, why? Know Staff Train Fund e. Formation of HIV support groups f. Collaborating with other HIV prevention programs to create age￾specific messages g. Identifying HIV-positive OVCs and OVC at risk of HIV and linking them to appropriate care and treatment services 3. Does the organization aid in prevention of childhood illness in OVC, as per the Kenya Essential Package for Health (KEPH)? a. Educating and sensitizing parents, caregivers, and older OVCs on health prevention/promotion needs of OVC b. Sensitizing CHVs and OVC committee members on the health prevention/promotion needs of OVCs 4. Does the organization enhance access to appropriate curative services for OVC and their households through a. Training community health workers and caregivers on addressing curative health needs of OVCs b. Referring sexually abused children to the MOH or other appropriate APHIAPlus Imarisha End-of-Activity Evaluation, 2018 224 KENYAN SERVICE STANDARD KEY STRATEGIES STATUS AT TIME OF ASSESSMENT YES IF YES, verifying evidence NO IF NO, why? Know Staff Train Fund service providers for clinical and psychosocial management and follow-up to ensure service is provided 5. Does the organization promote safe water, hygiene and sanitation practices in their target communities and in OVC households a. Conducting household assessments to determine the current access to safe water and sanitation practices b. Conducting community education on use of safe practices, including handwashing with soap, use of latrines, boiling drinking water and proper waste disposal c. Creating access points to safe and clean water for OVC and their households d. Discuss with the girl OVCs and their caregivers about proper female hygiene during menstruation D. Psychosocial Support APHIAPlus Imarisha End-of-Activity Evaluation, 2018 225 The following are used in the table to highlight key reasons why the LIP is not pursuing particular service standards: Know = Organization is not aware/knowledgeable of the service standard/strategy Staff = Organization has insufficient staff to implement this service/strategy Train = Organization has staff but they are not trained in this service/strategy Fund = Organization has insufficient funds (or suboptimal resource allocation) to implement the service/strategy KENYAN SERVICE STANDARD KEY STRATEGIES STATUS AT TIME OF ASSESSMENT YES IF YES, verifying evidence NO IF NO, why? Know Staff Train Fund 1. Does the organization conduct community mobilization and sensitization activities to create awareness of psychosocial needs of OVC and their households through the following? a. Participating in community forums, including national and international days, to inform the community on Psychosocial Support Services (PSS) for care on OVC b. Providing guidance to community health workers, service providers and caregivers on provision of PSS to OVC c. Conducting participatory PSS awareness and education sessions for the community, particularly in schools, clinics and other places frequented by OVC APHIAPlus Imarisha End-of-Activity Evaluation, 2018 226 KENYAN SERVICE STANDARD KEY STRATEGIES STATUS AT TIME OF ASSESSMENT YES IF YES, verifying evidence NO IF NO, why? Know Staff Train Fund 2. Does the organization build the capacity of OVC to recognize, understand, meet and obtain their PSS needs through the following? a. Providing platforms for OVCs to express their needs and ideas, and documenting their responses in order to find relevant support services b. Distributing information and ensuring OVC know where and how to access PSS services c. Formation of peer PSS groups through schools or community 3. Does the organization strengthen community and household capacities to provide PSS to OVC and their caregivers? a. Conducting PSS needs assessments among community PSS providers to identify gaps and determining training needs b. Creating an inventory of current PSS providers which could be useful in working with OVC c. Providing on-going support and mentorship for caregivers and home visitors engaged in provision of PSS APHIAPlus Imarisha End-of-Activity Evaluation, 2018 227 E. Child Protection The following are used in the table to highlight key reasons why the LIP is not pursuing particular service standards: Know = Organization is not aware/knowledgeable of the service standard/strategy Staff = Organization has insufficient staff to implement this service/strategy Train = Organization has staff but they are not trained in this service/strategy Fund = Organization has insufficient funds (or suboptimal resource allocation) to implement the service/strategy ***NOTE TO ASSESSORS: A number of child protection linkages are explored in the HES and Linkages section of this tool. As a result, they are not included in the following table on child protection. KENYAN SERVICE STANDARD KEY STRATEGIES STATUS AT TIME OF ASSESSMENT YES IF YES, verifying evidence NO IF NO, why? Know Staff Train Fund 1. What is the organization’s capacity to educate OVC, caregivers and the target communities on child rights, responsibilities and child protection? a. Educating caregivers and stakeholders on their roles in child protection. b. Holding forums to sensitize the community and OVC on gender￾based violence prevention and what action to take if GBV is observed or suspected. APHIAPlus Imarisha End-of-Activity Evaluation, 2018 228 KENYAN SERVICE STANDARD KEY STRATEGIES STATUS AT TIME OF ASSESSMENT YES IF YES, verifying evidence NO IF NO, why? Know Staff Train Fund c. Training children and stakeholders on child rights. 2. What is the organization’s capacity to strengthen the capacity of households and local community structures to enhance OVC protection and maximize utilization of available resources? a. Facilitating alternative family care for OVC in need of care and protection (safe places etc.). b. Training caregivers on how to recognize signs of abuse. c. Educating the caregivers on their roles in holding protection services accountable to children. d. Training members of existing community structures such as AAC, Volunteer Children’s Officers in identifying, reporting and investigating child rights abuses. e. Knowledge of Child Helpline services for reporting cases of child abuse. 3. What is the organization’s capacity to support the OVC and caregivers to participate in matters affecting them? a. Ensuring children know how to report an abuse and find protection services. b. Establishing mechanisms, such as children advisory groups, to support children’s participation in protection. c. Disseminating national guidelines on child participation through forums and community events. APHIAPlus Imarisha End-of-Activity Evaluation, 2018 229 KENYAN SERVICE STANDARD KEY STRATEGIES STATUS AT TIME OF ASSESSMENT YES IF YES, verifying evidence NO IF NO, why? Know Staff Train Fund 4. What is the organization’s capacity to strengthen partnerships and linkages to ensure case management, law enforcement and appropriate referrals and monitoring systems? a. Keeping track of existing child protection service providers at points of service delivery. 5. What is the organization’s capacity to support OVC with special needs e.g. disability? a. Link OVCs with special needs to social safety nets. b. Link OVCs with special needs to rehabilitative/reintegration services. c. Provide and linkage for services/support to address their disability needs. 6. What is the organization’s capacity to support highly vulnerable OVC households to benefit from social support services? 7. What is the organization’s capacity to promote positive a. Sensitize parents/caregivers on positive parenting. APHIAPlus Imarisha End-of-Activity Evaluation, 2018 230 KENYAN SERVICE STANDARD KEY STRATEGIES STATUS AT TIME OF ASSESSMENT YES IF YES, verifying evidence NO IF NO, why? Know Staff Train Fund parental/family care and child stimulation? b. Organize fun/play days for OVC F. Household Economic Strengthening (HES) and Linkages Name the main household economic strengthening (HES) strategies that are implemented by the organization (can include multiple responses); specify the geographic coverage Household Economic Strengthening (HES) ⧠ No ⧠ Yes If yes, note the no. of wards Link with other service providers Direct support 1. Linkages with Government Service Sector The organization provides linkage to the following: a. To government OVC Cash Transfer Program (OVC-CT) b. To National Hospital Insurance Fund (NHIF) (Share M.O.U, enrolled nos.) c. To social safety net programs such as Local Authorities Trust Fund/CDF APHIAPlus Imarisha End-of-Activity Evaluation, 2018 231 d. Youth Empowerment Centers 2. Provide One-time Asset Transfer (i.e., pregnant goats for milk, hens for eggs) 3. Savings Groups Plus (SG+) for youth and adults (SILC, VSL, SACCOs, table banking, self-managed financial services including savings and loans, micro-insurance, and Most Vulnerable Children Funds) 4. Support Self-help Groups 5. OVC Linkages to Health Services a. Track referrals of OVCs and/or their household members to health facilities b. Monitor/follow up status of those referrals to ensure continuum of care 6. OVC Linkages to Food and Nutrition a. Training in agribusiness, value addition, and linkages to markets b. Form producer market groups or link with micro-consignment opportunities c. Promote family-focused approach to health and nutrition through linkages to ECD and school-based feeding 7. OVC Linkages to Education &Vocational Training a. Community-Based Enterprise Development training—Basic financial literacy) b. Collaboration with existing education and training resources to create opportunities for OVC 8. OVC Linkages to Child Protection a. Assist with birth registration and legal identity cards b. Strengthening the linkage between the formal and the informal child protection systems c. Networking with other child protection organizations APHIAPlus Imarisha End-of-Activity Evaluation, 2018 232 G. Shelter and Care The following are used in the table to highlight key reasons why the LIP is not pursuing particular service standards: Know = Organization is not aware/knowledgeable of the service standard/strategy Staff = Organization has insufficient staff to implement this service/strategy Train = Organization has staff but they are not trained in this service/strategy Fund = Organization has insufficient funds (or suboptimal resource allocation) to implement the service/strategy KENYAN SERVICE KEY STRATEGIES STATUS AT TIME OF ASSESSMENT d. Linking with Department of Children’s Services to ensure grassroots implementation of child safeguarding policies e. Facilitate succession planning(e.g., inheritance, will writing) f. Are any of the organization’s staff members of the local Area Advisory Council (AAC)? g. Link with the legal protection mechanisms for OVCs through the provision of legal services 9. OVC Linkages to Psychosocial Support Services (PSS) a. Connect child-headed households with role models/mentors (home visit) b. Making referrals and follow ups on all PSS services c. Others specify: ______________________ APHIAPlus Imarisha End-of-Activity Evaluation, 2018 233 STANDARD YES IF YES, verifying evidence NO IF NO, why? Know Staff Train Fund 1. What is the organization’s capacity to conduct household needs assessments to determine and support appropriate community shelter and care initiatives for OVC households? a. Identifying knowledge, skills and attitude gaps related to shelter and care provision for OVC households b. Periodically monitoring progress on improved shelter and care in identified households 2. What is the organization’s capacity to link stakeholders to resources available to support OVC shelter and care? a. Keeping an inventory of services and resources to provide shelter and care support to OVCs and their families b. Hold and participate in consultative meetings with stakeholders to determine mechanisms and procedures for providing OVC shelter and care APHIAPlus Imarisha End-of-Activity Evaluation, 2018 234 KENYAN SERVICE STANDARD KEY STRATEGIES STATUS AT TIME OF ASSESSMENT YES IF YES, verifying evidence NO IF NO, why? Know Staff Train Fund 3. What is the organization’s capacity to sensitize the community and households on the importance of OVC receiving regular and loving care from adults? a. Holding community sensitization meetings to reduce stigmatization of OVC b. Conducting regular monitoring of OVC family/living environment to ensure the OVCs are being properly cared for and protected. c. Facilitating after￾care services that enable OVC to be integrated into the community 4. What is the organization’s capacity to facilitate community and stakeholders implementation of shelter initiatives to support OVC households? a. Provide training on basic skills to construct and maintain shelters to child needs standards b. Train OVC and APHIAPlus Imarisha End-of-Activity Evaluation, 2018 235 KENYAN SERVICE STANDARD KEY STRATEGIES STATUS AT TIME OF ASSESSMENT YES IF YES, verifying evidence NO IF NO, why? Know Staff Train Fund caregivers with knowledge and skills on the needs of OVC regarding shelter, including safe structure, clean toilet facilities c. Establish linkages with income￾generating activities, religious organizations and community groups to help maintain shelter for OVC d. Mobilize community members to commit funds and/or support for the renovation of needy OVC households APHIAPlus Imarisha End-of-Activity Evaluation, 2018 236 H. Coordination of Care The following are used in the table to highlight key reasons why the LIP is not pursuing particular service standards: Know = Organization is not aware/knowledgeable of the service standard/strategy Staff = Organization has insufficient staff to implement this service/strategy Train = Organization has staff but they are not trained in this service/strategy Fund = Organization has insufficient funds (or suboptimal resource allocation) to implement the service/strategy APHIAPlus Imarisha End-of-Activity Evaluation, 2018 237 KENYAN SERVICE STANDARD KEY STRATEGIES STATUS AT TIME OF ASSESSMENT YES IF YES, verifying evidence NO IF NO, why? Know Staff Train Fund 1. What is the organization’s capacity to Establish and maintain national directory of service providers for the care of the OVC informed by local level database? a. Conduct local mapping of OVC services and service providers b. Ensure that the local database maintained by the organization is linked with county/national databases of all OVC services and service providers c. Update service and service provider databases as needed d. Participate in formal key forums for OVC welfare 2. What is the organization’s capacity to Establish and strengthen new coordination units for the integration and harmonization of OVC service provision at all levels to avoid duplication and encourage APHIAPlus Imarisha End-of-Activity Evaluation, 2018 238 I. Monitoring, Evaluation and Knowledge Management KENYAN SERVICE STANDARD CORE ASPECT OF CAPACITY YES NO COMMENTS M & E Focal Person 1. Does the organization have human resources for M&E? a. There is at least one staff person responsible for M&E. b. There are written job descriptions for all M&E staff. c. M&E staff have training or formal education in M&E(or M&E related disciplines such as statistics, information systems) d. The organization has a clear plan to strengthen the M&E capacity of its staff. e. There is M&E-related, in-service training and mentoring of staff M&E Plan 2. Does the organization have a monitoring and evaluation plan? a. The organization has a written M&E plan. b. The M&E plan is linked to the organization’s strategic plan. c. The M&E plan includes measurable OVC-related indicators. Data Collection and Data Management 3. Does the a. The organization has data collection tools to capture OVC data. b. The organization has standard reporting formats to summarize and present OVC data. prudent utilization of resources? APHIAPlus Imarisha End-of-Activity Evaluation, 2018 239 KENYAN SERVICE STANDARD CORE ASPECT OF CAPACITY YES NO COMMENTS organization collect routine data as stipulated in the M&E plan? c. The organization has documented data flow between implementation level and management level. d. The Organisation has OVC based and led M&E and Learning. Evaluation 4. Does the Organization evaluate its OVC activities? a. The organization’s OVC program activities have been evaluated within the past two years b. Through linkages/partnerships with other entities, the organization has access to evaluation expertise, when needed. c. The organization has presented findings or results from its programs at meetings of key stakeholders, conferences or forum for dissemination within the past two years. Data Quality Assurance 5. Does the organization conduct Supervision data quality assessment or audit? a. There are mechanisms to check the accuracy of the organization’s OVC data. b. Routine supervision of program activities includes data review. I. Knowledge Management/Learning SERVICE STANDARD CORE ASPECT OF CAPACITY YES NO COMMENT APHIAPlus Imarisha End-of-Activity Evaluation, 2018 240 1. Does the organization use a database to support its implementation and M&E of OVC activities? a. The organization maintains an OVC Longitudinal Management Information System (OLMIS) database. b. IF YES: Does the organization’s OLMIS link to the county/national OLMIS database? c. The organization maintains a Child Protection Management Information System (CPMIS) database. d. IF YES: Does the organization’s CPMIS link to the county/national CPMIS database? 2. Does the organization have capacity related to data reporting and use? a. Does the organization produce program reports? b. IF YES: Does the organization produce those reports at least on a quarterly basis? c. Who are the recipients of your OVC reports?  Ministry of Labour and Social Services  Ministry of Health  Ministry of Education  Children’s Department/MOGSD  Other Government ministries (Specify in remarks column)  Donors (international or local) c. Does the organization receive feedback on any of the reports submitted to the above entities? 3. Does the organization have the capacity to identify and document learning and promising/best practices? a. Has the organization ever written a case study or documented a success story on a particular OVC or OVC caregiver/household (or group of OVCs/OVC households)? b. Does the organization share its learning or best practices with other CBOs/FBOs? APHIAPlus Imarisha End-of-Activity Evaluation, 2018 241 (Specify forum in remarks column) 4. How is the organization using its evidence to improve and/or inform its work? a. What information or data does the organization use to target OVCs and their households in the community? b. How does the organization use data to improve its existing work (interventions)?  Number/percentage of LIPs with a written M&E plan that includes measurable OVC-related indicators  Number/percentage of LIPs that produce OVC program reports at least quarterly  Number/percentage of LIPs with demonstrated use of evidence to inform their OVC targeting, intervention design, and/or program improvement APHIAPlus Imarisha End-of-Activity Evaluation, 2018 242 ANNEX 4: HEALTH FACILITY CAPACITY ASSESSMENT SERVICE AVAILABILITY Hospital Health Centre Dispensary Service Availability Family Planning 3 (100%) 9 (81.8%) 2 (66.7%) Antenatal Care 3 (100%) 11 (100%) 2 (66.7%) Postnatal Care 3 (100%) 11 (100%) 2 (66.7%) Immunization 3 (100%) 11 (100%) 2 (66.7%) Post Abortion Care (PAC) 3 (100%) 9 (81.8%) 1 (33.3%) Maternity 3 (100%) 11 (100%) 1 (33.3%) TB Prevention & Treatment 3 (100%) 11 (100%) 3 (100%) EID 3 (100%) 11 (100%) 3 (100%) HIV Testing 3 (100%) 11 (100%) 3 (100%) HIV Care & Treatment 3 (100%) 10 (90.9%) 3 (100%) VMMC 3 (100%) 6 (54.5%) 0 (0.0%) Post-Exposure Prophylaxis (PEP) 3 (100%) 11 (100%) 3 (100%) Malaria Prevention & Treatment 3 (100%) 11 (100%) 3 (100%) Nutrition 3 (100%) 11 (100%) 3 (100%) AVAILABILITY OF POLICY AND GUIDELINES ON Hospital Health Centre Dispensary Family Planning 3 (100%) 9 (81.8%) 1 (33.3%) Antenatal Care 3 (100%) 10 (90.9%) 2 (66.7%) Postnatal Care 2 (66.7%) 7 (63.6%) 2 (66.7%) Immunization 3 (100%) 10 (90.9%) 2 (66.7%) Post Abortion Care (PAC) 2 (66.7%) 7 (63.6%) 1 (33.3%) Maternity 3 (100%) 10 (90.9%) 1 (33.3%) TB Prevention & Treatment 3 (100%) 11 (100%) 3 (100%) EID 3 (100%) 8 (72.7%) 3 (100%) HIV Testing 3 (100%) 11 (100%) 3 (100%) HIV Care & Treatment 3 (100%) 9 (81.8%) 3 (100%) VMMC 2 (66.7%) 5 (45.4%) 0 (0.0%) Post-Exposure Prophylaxis (PEP) 3 (100%) 10 (90.9%) 2 (66.7%) Malaria Prevention & Treatment 3 (100%) 10 (90.9%) 3 (100%) Nutrition 3 (100%) 11 (100%) 3 (100%) APHIAPlus Imarisha End-of-Activity Evaluation, 2018 243 AVAILABILITY OF JOB AIDS ON Hospital Health Centre Dispensary Family Planning 3 (100%) 10 (90.9%) 1 (33.3%) Antenatal Care 3 (100%) 10 (90.9%) 1 (33.3%) Postnatal Care 2 (66.7%) 8 (72.7%) 1 (33.3%) Immunization 2 (66.7%) 10 (90.9%) 2 (66.7%) Post Abortion Care (PAC) 2 (66.7%) 8 (72.7%) 0 (0.0%) Maternity 3 (100%) 10 (90.9%) 0 (0.0%) TB Prevention & Treatment 3 (100%) 10 (90.9%) 1 (33.3%) EID 2 (66.7%) 9 (81.8%) 0 (0.0%) HIV Testing 3 (100%) 10 (90.9%) 2 (66.7%) HIV Care & Treatment 2 (66.7%) 6 (54.5%) 2 (66.7%) VMMC 2 (66.7%) 6 (54.5%) 0 (0.0%) Post-Exposure Prophylaxis (PEP) 2 (66.7%) 9 (81.8%) 2 (66.7%) Malaria Prevention & Treatment 3 (100%) 11 (100%) 2 (66.7%) Nutrition 3 (100%) 11 (100%) 3 (100%) APHIAPlus Imarisha End-of-Activity Evaluation, 2018 244 STAFF TRAINING Hospital Health Centre Dispensary Training HTS 3 (100%) 7 (63.6%) 3 (100%) ART 3 (100%) 6 (54.5%) 3 (100%) PMTCT 3 (100%) 5 (45.4%) 1 (33.3%) APOC 2 (66.7%) 1 (9.1%) 0 (0.0%) TB 3 (100%) 4 (36.4%) 1 (33.3%) VMMC 2 (66.7%) 2 (18.2%) 0 (0.0%) PEP 3 (100%) 8 (72.7%) 2 (66.7%) Management of puerperal sepsis 3 (100%) 7 (63.6%) 1 (33.3%) Active management of third stage of labor 3 (100%) 7 (63.6%) 1 (33.3%) Management of pre-eclampsia/eclampsia 3 (100%) 8 (72.7%) 1 (33.3%) Manual removal of the placenta 3 (100%) 8 (72.7%) 1 (33.3%) Post abortion care 3 (100%) 7 (63.6%) 1 (33.3%) Assisted vaginal delivery (vacuum extraction) 3 (100%) 8 (72.7%) 1 (33.3%) Newborn resuscitation/ Essential newborn care/ Helping Babies Breathe (HBB) 3 (100%) 8 (72.7%) 1 (33.3%) Family Planning 3 (100%) 8 (72.7%) 1 (33.3%) Targeted Postpartum Care for the mother 2 (66.7%) 6 (54.5%) 1 (33.3%) Kangaroo mother care (KMC) 3 (100%) 8 (72.7%) 1 (33.3%) Chlorhexidine cord care 2 (66.7%) 7 (63.6%) 1 (33.3%) Nutrition 3 (100%) 8 (72.7%) 3 (100%) APHIAPlus Imarisha End-of-Activity Evaluation, 2018 245 QUALITY IMPROVEMENT Hospital Health Centre Dispensary Average number of times (in the last 6 months) a supervisor has come to the FP/MNCH, CCC, and TB units for supervision 1.7 2.3 4 QI team in place 3 (100%) 6 (54.5%) 2 (66.7%) Availability of guidelines for the implementation of QI standards 3 (100%) 8 (72.7%) 2 (66.7%) QI meeting taken place in the quarterly scheduled in the last one year 3 (100%) 6 (54.5%) 2 (66.7%) APHIAPlus Imarisha End-of-Activity Evaluation, 2018 246 ANNEX 5: EVALUATION WORKPLAN AND LIST OF KEY INFORMANTS Theory of change for APHIAplus Imarisha Impact Sustained improvement of health and well-being for all Kenyans Outcomes Increased use of quality health services, products and information. Social determinants of health addressed Intermediate Results Inte grate d prim ary healt h care syste m Imp rove d hom e￾base d healt h prac tices Perfor mance incent ives for comm unity and facility worke rs Institution alized culture of data analysis and use for decision making and continuou s quality improvem ent Increa sed access to incom e￾genera ting opport unities Impr oved hous ehol d nutri tion beha viors & food secur ity Impr oved pupil enrol lmen t and scho ol reten tion Increa sed access to safe water, and impro ved sanitat ion and hygien e Outputs Strengthened coordination and synergy Strengthe ning GOK authoritie s to coordinat e health and develop ment activities Coordina tion with USAID partners under the national APHIApl us support mechanis ms Coord ination with other USG agenci es and develo pment partne rs Coordi nation with govern ment agencie s at the nationa l and local levels Strengt hening coordi nation with other imple mentin g partner s and comm unities Strengt hening Gover nment to coordi nate health and develo pment Coordi nation among the consort ium partner s Improved health outcomes and impact through sustainable country-led programs and partnerships Interventions Provide TA and material support based on the expressed needs of SCHMTs , CHMTs and others Leadership, Managemen t, Governance ; HRH; Communica tion; SCM; HIS Institutional Strengthenin g for CSO; Training; QI PREG Annual operatio nal plannin g; stakehol der forums; support supervis ion; TWGs; ICCs CSOs; NGOs, CBOs CHMTs ; SCHM Ts, FMTS; AACs; CACCS AMRE F, Land O’ Lakes; CRS; UMB APHIAPlus Imarisha End-of-Activity Evaluation, 2018 247 List of intermediate results for Results 3 and 4 of USAID Kenya Implementation framework RESULT 3: Increased Use of Quality Health Services, Products and Information Intermediate Result 3.1: Increased availability of an integrated package of quality high-impact interventions at community and health facility levels Expected health outcomes:  Improved capacity of public sector facilities to provide reliable and consistent high quality package of high impact interventions at community, dispensary, health center and district hospital levels  Increased capacity of the DHMTs to plan and manage service delivery; Strengthened capacity to record, report, and use data for decision making  Increased capacity of functional community units to promote preventive health behaviors, identify, refer/manage complications  Increased availability of HIV/AIDS treatment services at points of contact for PLHA with health system, e.g., rural facilities, TB clinics  Increased availability of malaria prevention and treatment services, including IPT, ITNs, ACTs and rapid diagnostic tests (RDTs); screening and treatment for TB  Increased availability of FP services in public and private sector facilities and in communities  Increased availability and capacity of functional skilled birth attendants in public and private sectors and in health facilities and communities  Increased availability of essential newborn care and resuscitation, nutrition, safe and clean water at point of use, and prevention and management of childhood illnesses  Expanded coverage of high impact interventions for women and men of reproductive age, youth, vulnerable groups, MARPs, mothers, newborns, and children Intermediate Result 3.2: Increased demand for an integrated package of quality high-impact interventions at community and health facility levels Expected health outcomes:  Reduced social, economic, and geographic barriers to accessing and utilizing services  Increased capacity of facilities to provide client-centered, humane and dignified care  Increased capacity of community units to mobilize communities Intermediate Result 3.3: Increased adoption of healthy behaviors Expected health outcomes:  Improved appropriate health care seeking behavior  Improved home-based healthy practices with a special focus on the high impact interventions  Improved compliance with preventive and curative protocols Intermediate Result 3.4: Increased program effectiveness through innovative approaches Expected health outcomes:  Innovative approaches developed to increase the use of quality services at community and facility levels, especially among the marginalized, poor, and underserved populations  Data analysis and of best practices institutionalized APHIAPlus Imarisha End-of-Activity Evaluation, 2018 248  Increased coverage of services among marginalized, poor, and underserved populations RESULT 4: Social Determinants of Health Addressed to Improve the Well-Being of Targeted Communities and Populations Intermediate Result 4.1: Marginalized, poor and underserved groups have increased access to economic security initiatives through coordination and integration with economic strengthening programs Expected health outcomes:  Increased economic security among target groups of marginalized, poor and underserved populations  Established partnership programs with multi-sectoral partners to expand jobs and other sustained economic opportunities for target groups  Target groups linked to local market potential for revenue and sustainability  Investments in programs aimed at achieving sustainable livelihoods for the poor are maximized and coordinated Intermediate Result 4.2: Improved food security and nutrition for marginalized, poor and underserved populations Expected health outcomes:  Increased ability to utilize food and increase production of macro and micro nutrients.  Successful transitioned from therapeutic nutritional interventions to programs that improve long term food security Intermediate Result 4.3: Marginalized, poor and underserved groups have increased access to education, life skills, and literacy initiatives through coordination and integration with education programs Expected health outcomes:  Increased school preparedness; enrollment and retention in quality education marginalized, poor and underserved children and youth  Increased preparation for primary school achievement through regular participation in quality early childhood development programs  Increased completion of life skills curriculum offered through primary or secondary levels  Increased enrollment and retention in primary and secondary schools  Increased transition to post primary and/or secondary education  Reduced reliance on individual scholarships and provision of quickly expended supplies to secure educational access Intermediate Result 4.4: Increased access to safe water, sanitation and improved hygiene Expected health outcomes:  Integration of key hygiene practices into HIV and MNCH activities at the community level  Increased access to improved water sources  Increased utilization of POU water treatment Intermediate Result 4.5: Strengthened systems, structures and services for protection of marginalized, poor and underserved populations Expected health outcomes:  Quality protective services available to survivors of sexual assault, child maltreatment and children without adequate family care  MGCSD supported to develop policies, protocols and guidance to support quality social services APHIAPlus Imarisha End-of-Activity Evaluation, 2018 249  Eligible children and families are identified and linked to available government social protection initiatives through CHWs, CSOs, volunteers and local government representatives  Strengthened referrals between police, court, health and social services established Intermediate Result 4.6: Expanded social mobilization for health Expected health outcomes:  Improved financial, managerial and technical capacity of indigenous organizations serving social and health needs of marginalized, poor and underserved populations  District, sub-district and village health committees plan and coordinate implementation of effective multi￾sectoral partnerships for health  Women, youth, child and MARPs groups meaningfully participate in the design, delivery and monitoring of interventions on their behalf  Increased social inclusion and reduced stigma and discrimination of MARPs APHIAPlus Imarisha End-of-Activity Evaluation, 2018 250 Map of Evaluation Sites APHIAPlus Imarisha End-of-Activity Evaluation, 2018 251 List of documents included in the program review 1. RFTOP FINAL Imarisha SOW for End-of-Activity Evaluation for APHIAplus Imarisha Activity March 14, 2017 2. AID-623-A-12-00015 signed Signed Cooperative Agreement No.: AID-623-A-12-00015 3. MODIFICATION #1 Supplement No. 1 of Grant and Cooperative Agreement No.: AID-623-A-12-00015 4. EXECUTED MODIFICATION Modification of Assistance #02 5. Mod 3 - signed Modification of Assistance #03 6. Mod #4. signed Modification of Assistance #04 7. Signed Mod 05_AID-623-A-12-00015_APHIAplus NAL Modification of Assistance #05 8. Mod 06 doc Modification of Assistance #06 9. AID-623-A-12-00015-07-Signed by AO Modification of Assistance #07 10. AID-623-A-12-00015-08_Signed by AO Modification of Assistance #08 11. Signed Mod #09_APHIA Imarisha Modification of Assistance #09 12. Signed APHIA Imarisha Mod #10 Modification of Assistance #10 13. Modification -AID-623-A-12-00015 - SIGNED Modification of Assistance #11 14. AID-623-A-12-00015 - MOD #12 Modification of Assistance #12 15. Fully Executed Modification #13 Modification of Assistance #13 16. Signed Mod Modification of Assistance #14 17. 1. APHIAplus IMARISHA Quarter One Report - 31 07 2012 Quarterly report APRIL - JUNE 2012 18. 2. APHIAplus IMARISHA Quarter 2 Progress Report Jul - Sept 2012 Submitted 31 10 Quarterly report JULY - SEPTEMBER 2012 19. 3. APHIAplus IMARISHA Q 1 (Oct - Dec 2012) report 31 01 2013 Quarterly report OCTOBER - DECEMBER 2012 20. 4. APHIAplus IMARISHA Q 2 (Jan - March 2013) report Quarterly report JANUARY – MARCH 2013 21. 5. APHIAplus IMARISHA Q 3 (Apr - June 2013) report - July 2013 Quarterly report APRIL - JUNE 2013 22. 6. APHIAplus IMARISHA Q 4 (July - Sept 2013) report Quarterly report JULY - SEPTEMBER 2013 23. 7. APHIAplus IMARISHA Quarterly Report Oct-Dec 2013 - 15th Feb 2014 Quarterly report OCTOBER - DECEMBER 2013 24. 8. Jan-Mar 2014 Quarterly Report 2 5 2014 Quarterly report JANUARY – MARCH 2014 25. 9. APHIAplus IMARISHA April - Jun 2014 Quarterly Report - 8th July 2014 Quarterly report APRIL - JUNE 2014 26. 10. APHIAplus IMARISHA Quarterly Report July- Sept 2014 Quarterly report JULY - SEPTEMBER 2014 27. 11. APHIAplus IMARISHA Quarterly Report- Quarterly report 28. 12. APHIAplus IMARISHA Quarterly Report- January to March 2015-updated July 2015 Quarterly report JANUARY – MARCH 2015 29. 13. APHIAplus IMARISHA Quarterly Report-April - June 2015-31st July 2015 - updated Quarterly report APRIL - JUNE 2015 30. 14. APHIAplus IMARISHA Quarterly Report- July- September 2015 Quarterly report JULY - SEPTEMBER 2015 31. 15. APHIAplus IMARISHA Quarterly Report-Oct-Dec 2015 30_1 Quarterly report OCTOBER - DECEMBER 2015 32. 16. APHIAplus IMARISHA Quarterly Report-Jan-Mar 2016 Quarterly report APHIAPlus Imarisha End-of-Activity Evaluation, 2018 252 JANUARY – MARCH 2016 33. 17. APHIAplus IMARISHA Quarterly Report-Apr-Jun 2016- 31st July 2016 Quarterly report APRIL - JUNE 2016 34. 18. APHIAplus IMARISHA Quarterly Report- July-Sept 2016 Quarterly report JULY - SEPTEMBER 2016 35. APHIAplus IMARISHA ME PLAN-11.07.2012 APHIAplus IMARISHA Zone 5 – Northern Arid Lands Monitoring and Evaluation Plan Submitted July 13, 2012 36. 1 APHIAplus IMARISHA Year1 work plan - 18 07 2012 Zone 5 – Northern Arid Lands Year 1 Work Plan March – December 2012 37. 2 APHIAplus IMARISHA - Year 2 Work plan highlighted responses to questions raised 13.3.2013 Year 2 Work Plan January – December 2013 38. 2. APHIAplus IMARISHA - Year 2 Work plan approved - Feb 21 2013 Year 2 Work Plan January – December 2013 SUBMITTED: FEBRUARY 21, 2013 39. 3 APHIAplus IMARISHA- Year 3 Work plan - 9th April 2014 Year 3 Work Plan January – December 2014 40. 4 APHIAplus IMARISHA Year 4 Revised Work plan 16.3.15 FINAL Year 4 Work Plan January – December 2015 41. 5 APHIAplus IMARISHA- Year 5 Work plan - submitted 7th December 2015 Year 5 Work Plan January – March 2017 42. 5. APHIAplus IMARISHA- Year 5 Work plan Revised 2.2.2016 Revised Year 5 Work Plan January – December 2016 43. 6 IMARISHA Cost Extension Work plan 2017_ Revised 27.2.2017 Cost Extension Work-Plan January 1, 2017 – December 31, 2017 44. APHIAplus IMARISHA MTR Report - Final- August 2015 MID TERM EVALUATION REPORT MAY 2015 45. APHIAplusIMARISHAAnnualReport2015- updated17thNovember2015 USAID KENYA APHIAPLUS IMARISHA FY 2015 PERFORMANCE REPORT 01 July – 30 September 2015 46. Evaluation Report Review Checklist _November 30 2016 EVALUATION REPORT AND REVIEW TEMPLATE 47. KENYA AIDS STRATEGIC FRAMEWORK(KASF) KENYA AIDS STRATEGIC FRAMEWORK 2014/2015 - 2018/2019 48. KHSSP Ministry of Health October 2014 KENYA HEALTH SECTOR STRATEGIC AND INVESTMENT PLAN (KHSSP) JULY 2014 – JUNE 2018 49. POPULATION ACTIVITYIONS_1-3-2012 2009 Kenya Population and Housing Census Analytical Report on Population Activitiess Volume XIV, March 2012 50. USAID Evaluation Policy Updated October 2016 USAID EVALUATION POLICY Learning from Experience JANUARY 2011 UPDATED OCTOBER 2016 51. OVC CBO_GARISSA COUNTY GARISSA INFORMATION FOR THE UPCOMING EVALUATION APHIAPlus Imarisha End-of-Activity Evaluation, 2018 253 52. OVC CBOs_ Evaluation 2. List of CBOs supporting OVC program in the Community Based Organizations (CBOs) supporting Orphans and Vulnerable Children (OVC) No of OVC supported by Watoto Wazima Initiative in Turkana County per Ward 53. TX_CURRENT and PMTCT_STAT DATA PMTCT Statistics APHIAPlus Imarisha End-of-Activity Evaluation, 2018 254 National-Level Key Informants Designation Name Contact Location Country Director - AMREF Kenya Dr. Meshack Ndirangu Phone: 020 699 4623 Meshack.Ndirangu@Amref.org AMREF HQ, Lang’ata RD. Opposite Wilson Airport COP - APHIAplus Imarisha Dr. Mores Loolpapit Mores.Loolpapit@Amref.org AMREF Kenya Country Office Wilson Airport M&E - Advisor APHIAplus Imarisha Emmanuel Musombi emmanuel.musombi@amref.org AMREF Kenya Country Office Wilson Airport Country Representative Catholic Relief Services (CRS) Lane F. Bunkers Phone: 020 4210000 Lbunkers@ke.earo.crs.org Karuna Close, off Waiyaki behind Lion Place Program Manager Catholic Relief Services Timon Mainga Cell: 254 735 803021 Timon.Mainga@crs.org Karuna Close, off Waiyaki behind Lion Place Country Director Save the Children Fund Francis Woods Tel +254 20 4444006 /1028/ 1032/ 1031 Francis.Woods@savethechildren.org Matundu Close, Off School Lane, Westlands Country Director - FHI360 Dr. Masden Solomon Cell:+254 722 521361 pmwarogo@fhi360.org; Chancery building, 2nd floor, Valley Rd Chief of Party Population Services Kenya Anthony S. Okoth cell: +254 706 161612 aokoth@pskenya.org Jumuia Place,Wing B, Ground Flr, Lenana Road The Principal Secretary State Department of Agriculture Ministry of Agriculture, Livestock & Fisheries Adija Barasa, Focal Point Person 0727 581013 DIRECT 0722 521 361 E-mail: psagriculture@kilimo.go.ke Telephone: +254-20- 2718870/0727581013 KILIMO HOUSE 4TH FLOOR ROOM 3A Country Representative BroadReach Healthcare (BRHC) Joseph Ondigi Cell: 0715 209802; Phone: +254 20 7603602 Skype: nyamweya.ondigi jondigi@brhc.com 4th Floor, 9 West Building Ring Road Parklands/Lower Kabete Road Westlands Catholic Diocese* Kenya Conference of Catholic Bishops Jacinta Mutegi Tel: 0722 758249 jmutegi@catholicchurch.or.ke kccb@catholicchurch.or.ke Waiyaki Way, Westlands Waumini House FANIKISHA ACTIVITY Chistine Kiecha 0723 997328 ckiecha@msh.org cc: Dr. Joseph Mukoko 0722 779337 jmukoko@msh.org 9th Floor, ACK Garden Bishops Road, Community Area Opp. NSSF KEMSA Martin Mwenda 0721 248221 KEMSA APHIAPlus Imarisha End-of-Activity Evaluation, 2018 255 email;martin.mwenda@kemsa.co.ke Embakasi,opposite coca cola deport Director Strategy National Hospital Insurance Fund (NHIF) Nicodemus Odongo Direct: 0712 362911 254 20 2722527 Secretary - 0722 758249 9th Floor NHIF Building Community Area Principal Secretary State Department of Public Services Youth Dev. Ministry of Public Service, Youth Dr. Muinde, Youth Director Rose Mwongera Tel. 254 20 2227411 Ext 22483 0722 413 773 0722 875 887 rkmwongera@yahoo.com rkmwongera@gmail.com KENCOM 3RD FLOOR ROOM 313 Nutrition Specialist Ann Robins UNICEF Telephone: +254 20 762 2407 ext 24334 Mobile: 0729659507 Email: arobins@unicef.org UNICEF office UN Gigiri, UN Complex, UN Avenue Chief of Party Land O’ Lakes (LOL) Titianne Donde Tel: 0722 564563 t.donde@gmail.com titanne.donde@idd.landolakes.com Land O’Lakes, Inc. International Development Block A, 2nd floor, Peponi Plaza, off Peponi Road, Westlands University of Maryland, Baltimore Prof. Sylvia Ojoo 0735 800040 E-mail: sojoo@mgic.umaryland.edu Maryland Global Initiatives Corporation – Kenya 6th Floor, K-Rep Centre, Wood Avenue, Kilimani The Director of Primary Education Ministry Of Education, Science and Technology H. S. Abdi Tel: 0722 931 854 Email: abdihabat@hotmail.com 2nd Floor, Jogoo House Harambee Avenue Director of Medical Services Ministry of Health Dr. Jackson Kioko 707931940; 750803144; 720 908707 kiokojack@yahoo.com dmskenya@gmail.com Afya House Community Area Chief Executive Officer, SUPKEM Kenya Mr. Latiif Shabaan Phone: 254-20 243109; 216963; 216965 ncep@supkem.or.ke lanshab@yahoo.com Njugu lane, Islamia House, 2nd & 3rd Floor APHIAPlus Imarisha End-of-Activity Evaluation, 2018 256 Turkana County Key Informants INSTITUTION TARGET NAME CONTACT Ministry of Health County Health Director (CHD) Dr. Joseph Epem Esekon 254 729477000 epem.esekon@gmail.com Ministry of Health SCMOH Dr. Ongaki Dominic 728994223 CBO - Watoto Wazima Initiative Chief Executive Officer Coordinator Reformed Church of East Africa (RCEA) Josephine Biwott Tel;0774943900 Elelea Health Centre NO In-Charge Vincent Tel: 0704456023 Email: Kerio Health Centre Clinical Officer In-Charge Alex Natapar Tel: 0717480485 Kerio Health Centre In-Charge CCC John Maluki Tel: 0729723198 St. Patrick’s Kanamkemer Dispensary Nursing Officer in Charge Sr. Florence Wafula Phone: 0721299909 Email: Kalokol AIC Health Centre Hospital Administrator In-Charge Daniel Eripon Phone: 0722397707 Kalokol AIC Health Centre In-Charge CCC Momanyi Alfred Tel: 0711943679 St. Mary’s Kalokol Primary Health Care in Charge Sr. Joannina Karega Tel: 0724 463645 Kalokol Community Unit CHEW Kalokol AIC HC CHEW i/c, Kalokol CU Magreat Asuguru Tel No:07215364812 Lokichar (RCEA) Health Centre In-Charge Florence Musumba Tel: 0727 905240 Lokichar Community Unit CHEW Lokichar CU Alice Ekal Tel: 0714140269 Katilu District Hospital In-Charge Dr. Wilson Munai Tel: 0727 910746 Katilu District Hospital In-Charge MNCH James Inyangala Tel: 0729 792 809 Katilu Community Unit CHEW i/c Katilu CU Sarah Cheruto Tel No: 711211148 Kainuk Health Centre Nursing Officer in Charge Lydia Singoe Tel: 0716 899064 Nakululumaint Community Unit CHEW i/c/ Nakululumaint CU Moses Eyanae Tel No: 0711987649 Kainuk Health Centre In-Charge MNCH Lydia Singoe Tel: 0716 899064 Nakwamoru Health Centre Nursing Officer in Charge Elizabeth Wanjoyi Tel: 0725 903 146 Nakwamoru Health Centre In-Charge CCC Jonathan Tel: 0723 144 613 Nakwamoru Community Unit CHEW i/c Nakwamoru CU Alex Lopungurei Tel: 0705105507 SC-HMT Sub-County MOH Dr. David Moru Tel: 0717 234955 Lokori Primary Health Care Program In-Charge Sr. Seline Mbuli Phone: 0705 639 915 Email: Lokori Primary Health Care Program In-Charge CCC Beatrice Mwale Tel: 0711257735 Lokori Community Unit CHEW i/c Lokori CU Mildred Arot Tel No: 0713069255 SC-HMT Sub-County MOH Ewalan Warrance Tel: 0712582858 SC-HMT Turkana North/West Sub-County MOH Collins Odegi Otima Collins Odegi Otima Sub-County Health Records Officer 0725 205077 odegicollinsotima@gmail.co m SC-HMT Sub-County MOH John Ateyo Tel: 0706806970 APHIAPlus Imarisha End-of-Activity Evaluation, 2018 257 Samburu County Key Informants INSTITUTION TARGET NAME CONTACT Ministry of Health County Health Director (CHD) Dr. Martin Thuranira 0722 423038 martinthuranira@yahoo.com Ministry of Health Sub-County MOH Dr. Philip Leturuju 0725 056415 pleturuju@gmail.com County Devolved Government CEC - Health Chief Officer Health Peter Jerina Lolmodoni Lydia Letinina Tel:+254721976627 Tel:0721898333 SAMBURU AID IN AFRICA (SAIDIA) - CBO Activity Director Mr. Sammy Lenanyokie Mobile: 0724 934220.Email: saidia@africaonline.co.ke.Web site: www.saidiakenya.org Loikas Community Unit CHW I/C Loikas Community Unit CHW Malaral Dist Hospital Maria Ntrono Lodokiyia, +254 720 454 131 Serian Radio Station Presenter Nick Lenyakopiro Tel: 0720145826 Maralal District Hospital In-Charge Maralal District Hospital Dr. Nato Robert Tel: 065-2623; 0708775325 moh@samburu.rvp-moh.go.ke robertnato04@gmail.com Maralal District Hospital MNCH Beneficiaries Evaline Nchalion Lenaigwanai +254 720 595 777 nchalioneva@gmail.com Catholic Diocese of Maralal (CBO) Bishop, Maralal Diocese Fr. Virgilio Pante Tel: +254-065-62056; 065062030; +254-065-62056 info@maralaltholic.org Kisima Dispensary In-Charge Jacqueline Lengees Tel: 0720-096303 Kisima Dispensary MNCH Beneficiaries Jacqueline Lengees Tel: 0720-096304 Kisima Community Unit CHW Kisima Community Unit CHW Kisima Dispensary Jennifer Wasenti Letrok Edna Kwamboka 0728 478 043 0721 624423 KIBA Child Development Organization (CBO) Activity Manager Mr. Charles Lekaken Lekushula Mobile no. 0707695872.E-Mail Address: Kibacdo@Yahoo.Com/lekaken7@g mail.com Suguta Marmar Health Centre In-Charge Antonella Leakono Tel: 0714427390 Suguta Marmar Health Centre MNCH Beneficiaries Antonella Leakono Tel: 0714427391 Suguta Marmar CU CHW H/Centre John Lenanyiarra \ Tel: 0711307198 Suguta Campaign Against AIDs Program (SCAAP) CBO Activity Coordinator Mr. Stephen Olesororo Mobile +254-712277039.E￾mail:stephenolesororo@gmail.com/s caap2@gmail.com Catholic Diocese of Maralal (CBO) Bishop, Maralal Diocese Fr. Virgilio Pante Tel: +254-065-62056; 065062030; +254-065-62056 info@maralaltholic.org Ministry of Health Sub-County Health MOH Peter Zablon Lodokiyiaa Tel: +254720598220 email: peterlodokiyiaa@yahoo.com Shepherds of Life (CBO) Activity Director Mr. James Wachieni Tel: +254-720-974311 sherpherdsoflife@yahoo.com, APHIAPlus Imarisha End-of-Activity Evaluation, 2018 258 info@solkenya.org Ldergesi Community Unit CHEW - Community CHEW - Facility Ngariya Lenayasa Jospine Lolchuraki Tel: 0700-706566 Tel: 0723-750687 Archers Post Health Centre In-Charge Margaret Lekoome Tel: 0723-427338 Archers Post Health Centre MNCH Beneficiaries Margaret Lekoome Tel: 0723-427339 Sereolip Health Centre Nursing Officer In￾charge Henry Lantaaya Tel: 0720 547098 Catholic Hospital - Wamba In-Charge Jelisa Leloki Tel: 0720-284803 Email: chwmanagement@live.com Catholic Hospital - Wamba MNCH Beneficiaries Jeneta Lelesit Tel: 0720-284803 Email: chwmanagement@live.com Wamba Health Centre In-Charge Bernadetta Lorunguya Tel: 0720733565 Wamba Health Centre I/C MNCH Bernadetta Lorunguya Tel: 0720733566 Shepherds of Life (CBO) Activity Director James Wachieni Phone: + (254) 720 974 311.Email: info@solkenya.org. Website www.solkenya.org Ministry of Health Sub-County Health MOH Dr. Ezra Lekenit Tel: +254725149593 email:leruanya@gmail.com Baragoi Sub-District Hospital I/C MNCH Margaret Nabei Tel: 0723971536 email:margaretnabei@yahoo.com Bendera Community Unit CHW I/C Steve Letipila Tel: 0723292706 email:letipilas@yahoo.com Catholic Diocese of Maralal (CBO) Bishop, Maralal Diocese Fr. Virgilio Pante Tel: +254-065-62056; 065062030; +254-065-62056 info@maralaltholic.org South Horr Dispensary In-Charge Micheal Lenkaak Tel: 0726-017364 OR RADIOCALL email: michaellenkak@gmail.com South Horr Community Unit CHEW Michael Lekarato Tel: 0718371908 Lesirikan Health Centre In-Charge Mathew Lekeren Tel: 0726-310623 OR RADIOCALL. Email: lekerenmathew@gmail.com Lesirikan Community Unit CHEW Stephen Lealmusia Tel: 0716142147 Catholic Diocese of Maralal (CBO) Bishop, Maralal Diocese Fr. Virgilio Pante Tel: +254-065-62056; 065062030; +254-065-62056 info@maralaltholic.org APHIAPlus Imarisha End-of-Activity Evaluation, 2018 259 List of USAID priority indicators for APHIAplus Imarisha activity DATA FROM DQA /DHIS VMMC (limited to Turkana County only) % positivity yield in VMMC Improvement in institutional capacity to conduct VMMC HIV Testing (limited to Turkana County only) Positivity yield disaggregated by adults, pregnant women and pediatrics % positivity yield initiated into HIV treatment disaggregated by adults, pregnant women and pediatrics eMTCT (limited to Turkana county only) % PCR results at 8 weeks; Proportion +ve; % PCR +ve initiated on Treatment; % patients on treatment with viral load suppression; DATA FROM HOUSEHOLD SURVEY OVC program: Turkana, Samburu and Garissa % enrollment, attendance and progression disaggregated by gender % proportion of vulnerable OVC households actively participating in community‐based household economic strengthening groups disaggregated by wards within each county % functional household economic strengthening groups disaggregated by wards within each county MNCH and FP: (Turkana, Samburu and Garissa) % of births attended by skilled health care worker Proportion of pregnant women with 4+ ANC visits Proportion of children under 1 year fully immunized DPT1 coverage; DPT3 Coverage; Measles Coverage Existence of established systems for program quality improvement at health facility (Turkana, Samburu and Garissa) Existence of Quality Improvement Multi‐Disciplinary Committee Use of performance measurement data to improve quality of services Use of national guidelines/protocols by health care workers Use of program data for developing work plans, plan supportive supervision by health managers APHIAPlus Imarisha End-of-Activity Evaluation, 2018 260 Complete List of Evaluation Team Members Name Designation 1. Dr. John Paul Oyore Team leader 2. Dr. Nelly Yatich M & E expert 3. Phillip Wambua Public health expert 4. Angela Nguku RMNCH Expert 5. Grace Jowi Jobita Social Scientist 6 Njoroge Kimani Capacity Assessor – Turkana 7. Salmon Owii Capacity Assessor – Samburu 8. Jackson Musembi Sub-Team Leader – Turkana 9. Peter Sangoro Sub-Team Leader – Samburu APHIAPlus Imarisha End-of-Activity Evaluation, 2018 261 IMARISHA EVALUATION WORK PLAN DATE ACTIVITY TEAMS PRE-FIELDWORK IN NAIROBI AND COUNTIES Tues Jan 2 – Fri Jan 5, 2018 Document Review All key personnel Mon Jan 8 – Sat Jan 13 Team Planning Meeting, Nairobi TL, KP, STL, CA Thu Jan 11, 2018 Submit In-Brief PPT with Work Plan TL, KP, STL, CA Fri Jan 12, 2018 In-Brief at USAID TL, KP, M&E and ESPS Team Sat Jan 13, 2017 Travel to Turkana for training TL, KP, STL(Turkana), M&E, CA (Turkana) Mon Jan 15 – Wed Jan 17 Training in Turkana - mobile data collection TL, KP, STL(Turkana), M&E, CA (Turkana) Thu Jan 18 Travel to Samburu for training TL, KP(RMNCH), STL(Samburu), M&E, CA (Samburu) Fri Jan 19 – Mon Jan 22 Training in Samburu - mobile data collection TL, KP(RMNCH), STL(Samburu), M&E, CA (Samburu) FIELDWORK IN TURKANA AND SAMBURU (simultaneously) Tue Jan 23 Travel to assigned counties (TL to Nairobi) PHE, SS, RMNCH, STLs and CAs Wed Jan 24 – Tue Feb 13 Field work in Samburu/travel PHE, STL and CA Wed Jan 24 – Tue Feb 13 Field work in Turkana/travel RMNCH, STL and CA FIELDWORK IN NAIROBI (simultaneously) Wed Jan 24 – Tue Feb 13 Conduct, KIIs, Panel discussions and FGD TL ANALYSIS Wed Feb 14 – Mon Feb 26 Data Analysis (Home & together in Nairobi) M&E PHE, SS, RMNCH and STLs Tues Feb 27 Preparation USAID/IBTCI Mid-brief meeting ESPS, TL, M&E, PHE, SS, RMNCH,CA Wed Feb 28 Submit Mid-Brief PPT to USAID ESPS, TL, M&E, PHE, SS, RMNCH Thu Mar 1 USAID/IBTCI Mid-Brief meeting ESPS, TL, KP, M&E Fri Feb 23 – Thu Mar 15 Case Study – Analysis of work plans & project documents & Validation Workshop preparation – 18 days over period at IBTCI offices TL, M&E PHE, SS, RMNCH, Feb 27-Mar 10th Evaluation Team work together at IBTCI offices TL, M&E, PHE, SS, RMNCH,CA APHIAPlus Imarisha End-of-Activity Evaluation, 2018 262 VALIDATION WORKSHOPS Fri-Sat Mar 16- 17, 2018 Travel to Maralal, Samburu TL, M&E PHE, SS, RMNCH, , WF Mon Mar 19, 2018 Validation Workshop: Samburu TL and all Tues Mar 20, 2018 Travel to Lodwar, Turkana TL, M&E PHE, SS, RMNCH, , WF Wed Mar 21, 2018 Validation Workshop: Turkana TL and all Thu Mar 22, 2018 Team travel to home counties – TL to Nairobi for Out-Brief TL, M&E PHE, SS, RMNCH, , WF POST FIELDWORK Fri Mar 23, 2018 Out-Brief at USAID TL, KP, M&E, ESPS Mon Mar 26 – Tues Apr 10 Report Writing – 12 days over this period TL, Key Personnel and M&E Tues Apr 10 Submit draft report to IBTCI TL Wed Apr 11 – Mon Apr16 IBTCI Review IBTCI/ESPS Tue Apr 17 Submit draft report to USAID IBTCI Tue Apr 17 – Fri Apr 27 USAID review USAID Mon Apr 30 – Thu May 3 Respond to comments & finalise report Team Fri May 4 Submit FINAL report to USAID IBTCI TABLE 2: DELIVERABLE DATES PHASE DELIVERABLE DATE Pre-Fieldwork In-Brief to USAID FridayJanuary12, 2018 Analysis Mid-Brief to USAID Thursday February 22, 2018 Validation Workshop Validation Workshop: Samburu Monday March 19, 2018 Validation Workshop Validation Workshop: Turkana Wednesday March 21, 2018 Post Fieldwork Out-Brief with USAID Friday March 23, 2018 Post Fieldwork IBTCI submits draft report to USAID Tuesday April 17, 2018 Post Fieldwork IBTCI submits FINAL report to USAID Friday May 4, 2018 APHIAPlus Imarisha End-of-Activity Evaluation, 2018 263 QUALITY ASSURANCE PLAN The aim of the APHIAplus IMARISHA End of activity evaluation was to; o Determine the extent to which the activities have met the expected health outcomes o Look at aspects of the activity that have direct and indirect bearing on anticipated health outcomes. o Inform future direction in activity design, development, implementation and management strategies The following steps were taken in each stage of the evaluation process for quality assurance. PRE-FIELD WORK Recruitment – Experienced and seasoned Research Assistants (coming from Samburu and Turkana counties) were recruited from KNBS.  Document review - An evaluation matrix was developed and each evaluation team member focused on their area of expertise and responded to the evaluation questions and centered on the priority indicators.  TPM – Team planning meeting was held to review the methodology and the review/finalize data collection tools o Tools development - The household survey tools used in data collection borrowed heavily from the KNBS household survey tool to ensure comparability and also because these questions have been pretested and proven before.  Training – RAs were trained in Turkana and Samburu counties before the data collection process commenced. This was a 5-day training. FIELDWORK  Use of CHWs to guide the RAs to the households – this ensured the correct households were sampled and visited by the RAs during data collection process.  Use of tablets for quantitative data collection – Hand-held devices (Android-enabled mobile phones) were used to collect the survey data. The survey questionnaire was programmed/administered electronically using Survey ToGo Dooblo Software. The database had data entry screens with skip patterns and data/value ranges programmed into it. This ensured that the data is consistent at the point of interview. At the end of each day, the Evaluation Team came together to debrief on key issues related to the tools/instruments, review completed surveys and upload the day’s surveys onto a remote server. There was very close supervision of enumerators during data collection. o Qualitative Data - Paper-based tools were used as both FGDs and KII/Panel discussion interview guides. The evaluation team used audio recorders in each interview/discussion session that were submitted to ESPS on a daily basis for transcription. The transcripts were then sent back to the evaluation team member who conducted the interview/discussion for review. Transcripts were further cross-referenced with field notes and areas of digression highlighted and discussed.  Sub-Team Leaders – overseeing the research assistants o The Sub-Team Leaders held daily field team meetings – to assess data collection progress towards target, review compliance to the protocol/methodology, identify and address emerging challenges  They also did random checks on the data collection process  Central QA – this was managed by the ICT Programmer, Data Manager, and M/E Expert o The ICT Programmer did daily checks on data streaming in from the field – checking for anomalies and flagging back to the field team on a daily basis  Validation of findings - To validate the findings, two validation workshops - one in Maralal (Samburu County), the other in Lodwar (Turkana county) - were held to discuss the findings and also capture stakeholders’ views on implementation strategies adopted in the implementation of APHIAplus IMARISHA project. The County health authorities and the IPs were invited and participated Post-field work  Data analysis by the M/E expert  Data analysis by the ESPS Snr M/E Advisor, and Public Health Specialist APHIAPlus Imarisha End-of-Activity Evaluation, 2018 264 CHALLENGES EXPERIENCED AND MITIGATION MEASURES TAKEN. Despite the steps taken by the evaluation team for quality assurance, the following challenges were experienced and mitigation measures taken as noted for each challenge. Challenges/Limitations Mitigation Measures Pockets of Insecurity in data collection sites  Liaising with the locals and mapping out the movement timings in some areas  Moving with Security personnel in some areas Uncooperative respondents mainly due to overdependence of beneficiaries on stipends from CSOs hence refusal to cooperate during interviews  Taking comprehensive notes to those who refused to be tape recorded  Paying stipends to respondents  Working within their proposed schedules even when they postpone several times Language Barrier (Some Research Assistants not locals)  Distributing the RAs to areas where they can be of maximum use e.g. near market centres where Swahili is spoken  Pairing of RAs with local RAs Vastness of project area  Moving to different sites as different times Listing of non-beneficiaries in the evaluation  Concentrating on project beneficiary sites Lack of data in some health facilities  Use OF DHIS data Delay in getting subscribers  Outside Scope of evaluators Transport delays hence delaying data collection  Outside scope of evaluation team. Liaised with the office for quick fixes End Notes i R Core Team (2017). R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. https://www.R-project.org/. ii IMARISHA Quarterly Report, Oct–Dec 2013, QR Apr–Jun 2014, QR Jul–Sep 2015, Annual Report 2015, QR Apr–Jul 2016; KII – AMREF, SCHMT–Turkana West (2018), HF–In-charge Nakwamoru (2018); FGD – LIP, Youth Kalokol RCEA (2018); LIP–Youth Turkana Central (2018), CCC – Nakwamuru HC. iii KII – Turkana West SCHMT, KII – Turkana East SCHMT, KII – Kerio Delta HC. iv Quarterly Report April–June 2014, Quarterly Report July–Sept 2015, Annual Report 2015, KII – AMREF, KII – Turkana West SCHMT, FGD CCC–Nakwamuru HC v Annual Report 2016, Annual Report 2015, KII – SCHMT Turkana North and KII – SCHMT Turkana West. APHIAPlus Imarisha End-of-Activity Evaluation, 2018 265 vi KII – St. Mary’s HC, KII – Kainuk HC, KII – AIC Kalokol HC, KII – Turkana South SCHMT, Annual Report 2016. vii Annual Report 2016, Annual Report 2015, Quarterly Report July–Sept 2015, Quarterly Report July–Sept 2014, KII – Turkana East SCHMT, KII – Turkana South SCHMT, KII – Nakwamoru HC, KII – St. Patrick Dispensary, KII – St. Mary’s HC, KII – Kainuk HC, KII – AIC Kalokol HC viiiAnnual Report 2015, Quarterly Report July–Sept 2015 ix Annual Report 2015, Quarterly Report April–June 2014, KII – AIC Kalokol HC, x Annual Report 2016, Annual Report 2015, KII – Turkana South SCHMT, KII – CHMT Turkana, KII – St. Mary’s HC. xi Annual Report 2016, Quarterly Report July–Sept 2015, Quarterly Report April–June 2014, Quarterly Report July–Sept 2014, KII – Turkana South SCHMT, KII – St. Patrick Dispensary, KII – St. Mary’s HC, FGD CCC Katilu Hospital, FGD CCC AIC Kalokol, FGD CCC Kainuk HC, FGD CCC Nakwamoru HC. xii Quarterly Report July–Sept 2015, FGD CCC AIC Kalokol, FGD CCC Katilu Hospital, FGD Nakwamoru HC, FGD CCC St. Patrick Dispensary, FGD CCC St. Mary’s Dispensary, FGD CCC Kainuk HC, KII – CHMT Turkana. xiii Annual Report 2015, Quarterly Report July–Sept 2015, KII – St. Mary’s HC, KII – Turkana South SCHMT, KII – St. Patrick Dispensary, KII – St. Mary’s HC, FGD – CCC Katilu Hospital, FGD – CCC AIC Kalokol, FGD – CCC Kainuk HC, FGD – CCC Nakwamoru HC. xiv Annual Report 2016, Quarterly Report July–Sept 2015, KII – AIC Kalokol HC, KII – St. Patrick Dispensary, FGD – CCC Kainuk HC, FGD – CCC St. Patrick Dispensary, FGD – CCC Nakwamoru HC, FGD – CCC Katilu HC, FGD – CCC AIC Kalokol HC. xv Quarterly Report July–Sept 2015, Annual Report 2015, Annual Report 2016, Quarterly Report April–June 2014, KII – Turkana East SCHMT, KII – Turkana South SCHMT, KII – CHMT Turkana, KII – Nakwamoru HC, KII – Kerio Delta HC, KII – St. Patrick Dispensary, KII – Kainuk HC, KII – AMREF. xvi Quarterly Report Jan–March 2014, Quarterly Report July–Sept 2014, KII – Turkana East SCHMT, KII – AIC Kalokol HC, KII – Kainuk HC, KII – St. Mary’s Dispensary. xvii Annual Report 2016, Annual Report 2015, Quarterly Report July–Sept 2015. xviii Quarterly Report April–June 2014, Quarterly Report Jan–March 2014, Quarterly Report July–Sept 2015, Annual Report 2016, KII – St. Mary’s Dispensary, KII – Kainuk HC. xix Annual Report 2015, Annual Report 2016, Quarterly Report April–June 2014, Quarterly Report July–Sept 2014, Quarterly Report Jan–March 2014, Quarterly Report Oct–Dec 2013, KII – AMREF, KII – Nakwamoru HC, KII – Kerio Delta HC, KII – St. Patrick Dispensary, KII – AIC Kalokol HC. xx Quarterly Report July–Sept 2015, Quarterly Report Jan–March 2014, Quarterly Report Oct–Dec 2013, Quarterly Report July–Sept 2013, Quarterly Report Jan–March 2013, KII – Kerio Delta HC, KII – St. Patrick Dispensary, KII – Kainuk HC. xxi Annual Report 2016, Annual Report 2015, Quarterly Report April–June 2014, KII – AMREF. xxii KII – AMREF, KII – CHMT Turkana, KII – Turkana West, KII – Turkana South SCHMT, KII – Turkana North SCHMT, KII – Nakwamoru HF, KII – Kerio Delta HF, KII – Kainuk HF. xxiii Chuma, Jane, and Thomas Maina. 2013. Free Maternal Care and Removal of User Fees at Primary-Level Facilities in Kenya: Monitoring the Implementation and Impact—Baseline Report. Washington, DC: Health Policy Project, Futures Group; http://www.nhif.or.ke/healthinsurance/lindamamaServices APHIAPlus Imarisha End-of-Activity Evaluation, 2018 266 xxiv KII – Maralal SCHMT, KII – AMREF, Annual Report–2016, Annual Report 2015, Quarterly Report Jan–March 2014. xxv KII – Samburu Central CHMT, KII – Baragoi SCHMT, Quarterly Report July–Sept 2014. xxvi KII – SCHMT Baragoi, Quarterly Report July–Sept 2014, Quarterly Report April–June 2014, Annual Report 2015, Quarterly Report July–Sept 2015. xxvii FGD MNCH – Maralal, FGD MNCH – Wamba HC. xxviii Annual Report 2016, Quarterly Report July–Sept 2014, FGD MNCH – Maralal, FGD MNCH – Sereolepi, FGD MNCH – Wamba HC, FGD MNCH – Wamba Mission Hospital, FGD MNCH – Lesirikan Samburu West, FGD MNCH – Baragoi SDH, FGD MNCH – Kisima HC xxix FGD MNCH – Wamba HC, FGD MNCH – Wamba Mission Hospital, FGD MNCH – Baragoi SDH. xxx Annual Report 2016, Annual Report 2015, Quarterly Report July–Sept 2015, KII – AMREF, KII – SCHMT Baragoi, KII – Samburu Central CHMT Panel Discussions, KII – Samburu Central CHMT Panel Discussions, KII – SCHMT Baragoi, FGD MNCH – Wamba HC. xxxi Quarterly Report July–Sept 2014, Quarterly Report July–Sept 2015, KII – SCHMT Baragoi, KII – AMREF. xxxii Annual Report 2016, Quarterly Report July–Sept 2015, Quarterly Report July–Sept 2014, Quarterly Report Jan–March 2014, KII – Turkana East SCHMT, FGD MNCH – Nakwamoru HF, FGD MNCH – Kainuk HC, FGD MNCH –Turkana Central. xxxiii KII – SCHMT Turkana South, KII – AIC Kalokol HC. xxxiv Quarterly Report July–Sept 2015, KII – FHI360, KIIs – BroadReach, KII – AMREF. xxxv KII – Turkana North SCHMT, KII – Turkana West SCHMT. xxxvi Annual Report 2016, Quarterly Report July–Dec 2013, KII – St. Patrick Dispensary, Turkana Central. xxxvii Kenya Expanded Programme on Immunization Revised 2012. xxxviii Annual Report 2016, Quarterly Report Jan–March 2014, Quarterly Report July–Sept 2014, Quarterly Report Oct–Dec 2013, FGD MNCH – Kainuk HC Turkana South, FGD MNCH – Nakwamoru HC, Turkana South, FGD MNCH – Katilu HC, Turkana South. xxxix Annual Report 2015, Quarterly Report July–Sept 2015. xl Annual Report 2016, Annual Report 2015, Quarterly Report July–Sept 2015, Quarterly Report Jan–March 2014, Quarterly Report July–Sept 2014, Quarterly Report April–June 2014. xli Quarterly Report July–Sept 2015, Quarterly Report July–Sept 2013. xlii Annual Report 2016, Quarterly Report April–June 2014, FGD – MNCH Katilu HC Turkana South, xliii Annual Report 2016, Quarterly Report Jan–March 2014, Quarterly Report July–Sept 2014, Quarterly Report Oct–Dec 2013. xliv Annual Report 2016, Annual Report 2015, Quarterly Report July–Sept 2015, Quarterly Report Jan–March 2014, Quarterly Report July–Sept 2014, Quarterly Report April–June 2014. xlv Annual Report 2016, Quarterly Report April–June 2014, FGD MNCH – Lesirikan Samburu West, FGD MNCH – Baragoi SDH. xlvi Annual Report 2015; FGD – OVC Caregivers, LIP-RCEA Watoto Wazima Initiative, Turkana. APHIAPlus Imarisha End-of-Activity Evaluation, 2018 267 xlvii FGD – OVC Caregivers, LIP-RCEA Watoto Wazima Initiative, Turkana. xlviii KII – Watoto Wazima Initiative, LIP Turkana; FGD – OVC Caregivers – Watoto Wazima Initiative. xlix Annual Report 2015; FGD – OVC Caregivers, SAIDIA Samburu; FGD – OVC Caregivers, Shepherds of Life, Samburu; KII – KIBA, LIP Samburu. l KII – SAIDIA, LIP, Samburu. li Annual Report 2015; FGD – CHV Nakwamoru CU, Kaptir HC, Kaptir Ward, Turkana; FGD – CHV Kanamkemer CU St. Patrick Dispensary, Lodwar Township Ward, Turkana. lii Annual Report 2015; FGD – CHV Nakwamoru CU, Kaptir HC, Kaptir Ward, Turkana; FGD – CHV Kanamkemer CU St. Patrick Dispensary, Lodwar Township Ward, Turkana. liii Annual Report 2015. liv KII – SAIDIA LIP, Samburu; FGD – OVC CARITAS, Samburu, Annual Report 2015. lvAnnual Report 2015; Annual Report 2016; KII – SAIDIA LIP, Samburu; KII – CRS; CRS Kenya Program 2017: Improving Access to Health Services for OVC: Success stories from APHIAplus Project in Rift Valley and Northern Arid Land of Kenya. lvi FGD Caregivers – CARITAS, Samburu; Annual Report 2015; KII – CRS. lvii Community Health Extension Worker (CHEW) Questionnaire. lviii Annex 4: Health Facility Capacity Assessment. lix KII – Turkana East SCHMT; KII – Nakwamoru HC; KII – Kerio delta HC; KII – AIC Kalokol HC; KII – St. Patrick Dispensary; Quarterly Report Oct–Dec 2012; FGD – MNCH Kainuk HC; FGD – MNCH Katilu HC; KII – AMREF. lx KII – CHMT Turkana; KII – AIC Kalokol; Quarterly Report Oct–Dec 2013; KII – AMREF. lxi KII – Nakwamoru HC; KII – Kainuk HC; Quarterly Report July–Sept 2015; Quarterly Report Oct–Dec 2013; Quarterly Report Oct–Dec 2012; FGD MNCH Kainuk HC; KII – AMREF. lxii Quarterly Report Oct–Dec 2012. lxiii Quarterly Report Oct–Dec 2012. lxiv KII – Turkana East SCHMT. lxv KII – Turkana South SCHMT, KII – Kainuk HC, KII – St. Patrick Dispensary, KII – AMREF. lxvi KII – Turkana West SCHMT, KII – Turkana East SCHMT, KII – Kerio Delta HC. lxvii Annual Report 2015, Annual Report 2016, KII – AMREF. lxviii Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission [3 May 2014]. lxix Kenya HIV County Profiles 2016. lxx Ibid. lxxi Quarterly Report July–Sept 2015, page 74. lxxii KII with AMREF. APHIAPlus Imarisha End-of-Activity Evaluation, 2018 268 lxxiiiShroufi A, Mafara E, Saint-Sauveur JF, et al. Mother to mother (M2M) peer support for women in prevention of mother to child transmission (PMTCT) programmes: A qualitative study. PLoS One.2013;8:e64717. lxxiv Ibid. lxxvAPHIAplus IMARISHA Monitoring & Evaluation Plan 2012, page 16. lxxvi US PEPFAR Guidelines for Orphans and Vulnerable Children Programming 2012, page 16. lxxviiAPHIAplus IMARISHA Quarter 1, Year 1 Progress Report, page 10, 23, 24. lxxviiiAPHIAplus IMARISHA Cost Extension Work Plan 2017, page 46. lxxix KII with SAIDIA LIP in Samburu. lxxx Ibid. lxxxiAPHIAplus IMARISHA Quarter 4, 2015 Progress Report, page 87. lxxxiiAPHIAplus IMARISHA Annual Progress Report 2015, page 107. lxxxiiiAPHIAplus IMARISHA Annual Progress Report 2015, page 124. lxxxivAPHIAplus IMARISHA Annual Progress Report 2015, page 108. lxxxvAPHIAplus IMARISHA Annual Progress Report 2015, page 124. lxxxvi APR 2016, page 101. lxxxvii APR 2016, page 85.