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Project Name and Number AMKENI CA # 623-A-00-00019-00
REPORT FOR USAID/KENYA 
FINAL EVALUATION OF THE AMKENI PROJECT
Pinar Senlet
Nimrod Bwibo
Joseph Karanja
Joyce Olenja
Alice Mwangangi
Fredrick Ombwori
April 15, 2005
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ACKNOWLEDGEMENTS 
The consultants would like to acknowledge the support they received from the staff of
USAID/Kenya, the AMKENI Project, and the Ministry of Health in conducting this
evaluation. The team expresses special appreciation to Sheila Macharia, USAID
Reproductive Health Specialist, and Job Obwaka, AMKENI Project Director, who provided 
useful information and insights as the team progressed from gathering information to drawing
conclusions and making recommendations.
The time and assistance provided by staff of AMKENI’s international and local partners are 
greatly appreciated, including EngenderHealth, Family Health International, IntraHealth,
Program for Appropriate Technologies, Aga Khan Health Services, Cooperative League of
the USA, Family Planning Association of Kenya, and the UZIMA Foundation 
Finally, our special thanks go to those managers, service providers and community members
in the Coast and Western Provinces, who graciously allowed us time to visit their facilities
and conduct focus group discussions. 
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ACRONYMS
AIDS Acquired Immune Deficiency Syndrome
AKHS Aga Khan Health Services 
ANC Antenatal Clinic 
ARV Anti Retral Virus 
BCC Behavior Change and Communication 
BTL Bilateral Tubal Ligation 
CAI Community AID International 
CBD Community Based Distribution 
CLUSA Cooperative League of the USA
COPHIA Community Based HIV/AIDS Prevention, Care and Support
CPC Carolina Population Center 
DHC Dispensary Health Committees
DHMT District Health Management Team 
DFPID Department for International Development 
DHR Division of Reproductive Health 
EMR Extended Management Review
EOC Emergency Obstetric Care 
FHI Family Health International 
FPAK Family Planning Association of Kenya 
GOK Government of Kenya 
GTZ German Development Cooperation 
HCDC Health Center Development Committee
HIV Human Immunodeficiency Virus 
IMCI Integrated Management of Childhood Illnesses
IMPACT Implementing AIDS prevention and Care Project
IP Infection Prevention 
KEPI Kenya Expanded Program on Immunization
KDHS Kenya Demographic and Health Survey 
KMFF Kenya Music Festival Foundation 
M&E Monitoring and Evaluation 
KMTC Kenya Medical Training College
MOH Ministry of Health 
MVA Manual Vacuum Aspiration 
NASCOP National AIDS Control Program 
NGO Non-Governmental Organization
NSV No-scalpel Vasectomy
OJT On-the-Job Training 
OVC Orphans and Vulnerable Children 
PAC Post-Abortion Care 
PATH Program for Appropriate Technologies in Health 
PEPFAR President’s Emergency Plan for AIDS Relief 
PHO Public Health Officer 
PHT Public Health Technician 
PMTCT Prevention of Mother to Child Transmission 
PIA Performance Improvement Approach 
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RFA Request for Application 
RH Reproductive Health 
RH-ICC RH Inter-agency Coordinating Committee 
SP Sulphamethoxazole-pyrimithamine 
STI Sexually Transmitted Infections 
T&S Training and Supervision 
UNFPA United Nations Population Fund
USAID United Agency for International Development 
VCT Voluntary Counseling and Testing 
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TABLE OF CONTENTS 
Executive Summary 6
I. Introduction
Purpose 14
Methodology 15
II. Background
Trends in Reproductive Health, HIV/AIDS and Child Health in Kenya 16
USAID/Kenya’s RH/FP/CS/HIV/AIDS Portfolio 18
III. The AMKENI Project: Findings, Conclusions and Lessons Learned
AMKENI’s Goals, Strategies and Major Interventions 21
Coverage of Geographical Areas and Pace of Project Implementation 26
Training and Supervision 29
Service Delivery 32
Behavior Change and Communication 41
Capacity Building and Sustainability 50
Project Management 52
Monitoring and Evaluation Plan 54
Funding Sources and Allocation of Funds 59
Relations and Coordination with USAID, MOH and Other Stakeholders 61
IV. Short-term Recommendations for AMKENI 63
V. Long-term Recommendations for USAID for Future Programming 66
ANNEXES
A. Scope of Work
B. Documents Reviewed 
C. List of Contacts 
D. List of Clinical Sites Visited 
E. List of Community Focus Group Discussions 
F. Data Collection Tools
G. AMKENI Organogram 
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EXECUTIVE SUMMARY
The purpose of this evaluation is to examine the activities of USAID/Kenya’s increased use
of family planning, reproductive health, child survival, and HIV/AIDS services portfolio,
implemented through a Cooperative Agreement. The project, AMKENI is being implemented 
by a cooperative partnership of four development agencies led by EngenderHealth. The
evaluation aims to analyze:
ß The progress of AMKENI towards the achievement of specific project objectives;
ß The achievements in quality, demand for, and utilization of FP/RH/CH/HIV/AIDS
services; 
ß The achievements in national training and supervision systems; 
ß The communities’ perspectives of the project activities; 
ß The appropriateness of the strategies towards achievement of the project activities; 
ß The pace of project implementation; 
ß The impact of shifting funding mechanisms on project implementation; 
ß The degree to which systems and processes are established that lead to sustained
behavior change and increased demand for services; 
ß Overall challenges and lessons learned; and, 
ß Key areas of focus for future programming. 
The evaluation took place in early 2005 and was conducted by a core team of four
independent consultants. The evaluation methodology included review of relevant
documentation, structured interviews with key informants and stakeholders, field visits to
Project provinces, visits to clinical facilities and focus group discussions with community
members. 
Summary of Key Findings, Conclusions and Lessons Learned
ß The strategic directions of the AMKENI have evolved significantly over the life of
the project due to a number of external causes, including policy changes and
availability of additional funding sources. A mid-term evaluation conducted in 2003
led the Project revise and consolidate its strategic focus. 
ß Currently AMKENI has two overarching objectives; 1) Increasing access to and
quality of RH/FP/CS services including HIV/AIDS prevention services, and, 2)
Promoting healthier behaviors among the population and increasing demand for
services. These two objectives form the backbone of the project, aiming to link
communities and service facilities. 
ß AMKENI implements a three-pronged strategy: 1) Improving the capacity of health
facilities to provide FP/RH/CS services, including HIV/AIDS, 2) Working with
communities to promote healthier behaviors and demand for services, and 3)
Strengthening the MOH’s decentralized systems for training and supervising RH
service providers. AMKENI aims to improve service delivery, training, community
involvement and behavior change in several technical areas, implementing multiple
approaches.
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ß Linking the facilities and the communities is a powerful approach. Likewise, the
three-pronged strategy is appropriate for AMKENI to achieve its objectives and goals. 
ß As a result of numerous interventions, Project implementation has been very
comprehensive and complex. While the evaluation team understands the importance
of each technical area and related interventions, the technical focus of the project has 
been extensive and lacks prioritization.
ß Given the complexity of the project design, AMKENI has done remarkably well.
There have been substantial improvements in all project elements. Nevertheless, the
team concludes that if the project had more focus on family planning and selected
reproductive health interventions, implementation would have been smoother, faster
and the achievements would have been greater.
ß AMKENI works in the Coast and Western Provinces, targeting 10 districts. The total
population of the AMKENI-assisted districts encompasses majority of the province
populations in both provinces. It also appears that on average, AMKENI was able to 
reach a critical mass of the populations living in project districts. 
ß Majority of the AMKENI-assisted facilities are public facilities, as opposed to
privately owned or Mission facilities. The mix of public/private facilities is
appropriate for achieving the goals of the project. Similarly, AMKENI’s focus has
been on lower-level facilities such as maternity homes, dispensaries and health centers 
as opposed to hospitals. This approach is also valid and appropriate. 
ß Project components have progressed at different pace. In general, training and service 
delivery components have progressed at a higher pace compared with BCC. 
ß AMKENI formulated training and supervision (T&S) interventions with the purpose
of improving the quality of services through a combination of direct training in
specific skills and development of sustainable training and supervision systems at the
national level. 
ß AMKENI completed establishment of decentralized T&S teams in all eight provinces, 
10 target districts in Coast and Western Provinces, and 16 facilities. In addition, the
project assisted in development of national RH T&S curricula and manuals. 
ß The Project promoted implementation of earlier policy reforms allowing nurses and
clinical officers to provide implants and PAC services.
ß AMKENI worked with the provincial and district health management teams to
strengthen their service quality through the introduction of the Performance
Improvement Approach (PIA). 
ß Overall, AMKENI has trained over 3,000 trainers and service provides at all levels, in 
various courses in accordance with service delivery needs.
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ß AMKENI’s training and supervision interventions have been highly successful and
have been valued by trainees and stakeholders. However, the team is concerned that 
the National PMTCT and VCT Training manuals developed by the MOH have not
integrated family planning counseling. 
ß The team believes that AMKENI’s mandate to undertake direct training activities
both at the national level and at the provincial and district levels was not justified and 
somehow led the Project to stretch itself too thin. 
ß AMKENI has not put in place a systematic follow-up procedure to support and
evaluate the outcomes of its training efforts. 
ß Expanding existing services and establishment of new services was one of the key
elements of the service delivery component of the Project. AMKENI enhanced the
capacity of its supported facilities by training staff in specific skills and by providing
essential equipment and supplies. 
ß In 2003, AMKENI expanded its HIV/AIDS interventions when funds from the
PEPFAR track became available. The Project assisted several facilities to establish
VCT and PMTCT services. The team has observed that in some PMTCT and VCT
centers, basic family planning counseling is available. However there was no
evidence of full integration of FP with VCT and PMTCT in the facilities visited. 
ß One of the innovative approaches of AMKENI has been to facilitate outreach
activities for long-term and permanent methods, with the intention of organizing
frequent outreach activities to health centers located at a distance from district 
hospitals.
ß AMKENI interventions have contributed to increased number of family planning
acceptors. Marked improvement is especially noted for long term and permanent
methods. Increases in use of long-term and permanent methods indicate
improvements in contraceptive method mix. Total number of deliveries from all
AMKENI supported facilities have also raised significantly between 2001 and 2004. 
ß The team concludes that high input in training and supervision, equipment and
renovations, and community mobilization has lead to high quality service and to
increased utilization. There were however challenges that adversely affected family
planning utilization. In some facilities visited family planning services were not fully
integrated with other maternal and child health and HIV/AIDS services. 
ß The evaluation team has observed three system-wide issues that have been negatively
affecting service availability, quality and utilization during field trips. These
challenges are not necessarily within the mandate the AMKENI Project. However,
the team believes that they should be mentioned since they are widespread and
crosscutting challenges that will continue to have a negative impact on services in the 
future. These are contraceptive shortages, abolishment of MOH’s cost-sharing policy
and staff shortages. 
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ß In the area of BCC interventions, AMKENI implemented four approaches; 1) Family￾to-family communication: 2) Direct outreach to men, women and youth: 3) Women’s
agency, and 4) Magnification of behavior change. These interventions were
implemented through partnerships with five local implementers. 
ß The BCC component has had a positive influence on the knowledge, attitude and
behavior of individuals in project sites. This is further corroborated by the preliminary 
findings of the Household Survey and by the focus group discussions conducted by
the evaluation team. 
ß The community response to the Project has been positive and this is evident in the
level of engagement. In discussion groups, participants noted that they had benefited 
from the Project through education in FP/RH/CS and particularly on VCT and
PMTCT, contributing to behavior change in the community. 
ß The Project’s uniqueness lies in its approach of improving services at the facility level
and mobilizing communities to demand for quality services. The challenge then
becomes maintaining the balance between the two components; so that once
communities are fully mobilized and come for services, these would be in place. 
ß Multiple BCC approaches have been implemented in different sites and at varied
levels, thus it is not possible to delineate the contribution of each of the approaches
singly. The main models are Community/Women’s Agency Model (CLUSA) and
Community Participatory Model (AKHS). 
ß Overall, BCC activities have contributed to increased demand and utilization of
services. However, the implementation of several BCC strategies is labor intensive
and costly. 
ß BCC activities/messages are increasingly inclined towards HIV/AIDS and VCT/
PMTCT and it seemed much less on FP/RH the core business of the Project. BCC 
activities have gone beyond this to include other facets of health, leaning much more
towards general public health issues. 
ß The Project has been successful in capacity building both in personnel and physical
inputs. Training and skills development are sustainable and replicable. There are
certain elements, especially in BCC that are not sustainable beyond the project
particularly where there are parallel systems of personnel. 
ß AMKENI partnership formed among four international agencies works well. The
partners have mutually respectful relationship, developed around their respective
technical expertise and their strengths. 
ß AMKENI has a highly qualified, committed and hard-working staff at all levels. The 
reporting and financial systems put in place are sophisticated, and satisfies USAID’s
reporting needs. 
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ß The management style of the project is rather top-down and centralized. The Area
Managers only have administrative oversight for the staff in the area offices. The
technical staff reports directly to the respective technical advisors in Nairobi. 
ß There is some duplication in staffing. HIV/AIDS Advisor and the two HIV/AIDS
Coordinators are separated from service delivery staff. This does not help better
integration of HIV/AIDS with the other elements of the Project. 
ß AMKENI has spent substantial efforts and resources to develop its monitoring and
evaluation plan. However, the plan is too comprehensive and complicated, thus it
does not enable the Project to monitor progress on a daily and continuous basis. There 
is little evidence that the M&E is used as a management and performance
improvement tool at the field level. 
ß To date, USAID has obligated AMKENI a total of $18,913,090. The bulk of funding 
is obligated from population funds, comprising 72% of the total budget, followed by
AIDS funding at 12%. Largest line item in utilization of funds is the management
category, which used 37% of the total budget, followed by BCC activities at 19%. 
Summary of Key Recommendations 
The recommendations are presented in two categories. First, there are short-term 
recommendations for AMKENI to consider over the remaining life of the Project. Secondly, 
the team provides long-term recommendations for USAID/Kenya for future programming
purposes, specifically developed for the new five-year follow-on project. Since
USAID/Kenya is planning for a new competitive procurement within a year, these long-term 
recommendations are procurement sensitive and are omitted in the report presented to
AMKENI and its partners. . 
Short-term recommendations for AMKENI 
ß The basic thrust of the AMKENI, working with both the facilities and the
communities to create linkages and to improve service quality while increasing
demand for services is a powerful approach and should be maintained. 
ß The current three-pronged strategy implemented by AMKENI is appropriate and
should be continued with some modifications outlined below. 
ß The Project should speed up the implementation of the decentralized T&S system in
the remaining 81 facilities. 
ß AMKENI should undertake a rapid assessment and document the outcomes of its
training activities by the end of the Project.
ß By the end of the Project, AMKENI should ensure that all PMTCT and VCT
providers in Project facilities have been trained in basic family planning counseling.
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ß AMKENI should work with the newly awarded CAPACITY Project to coordinate
pre-service training activities and should transfer technical assistance in pre-service 
training to the CAPACITY Project by the time of closure. 
ß USAID and AMKENI should consider assisting MOH with vehicles to transport
supervisors by providing a vehicle to each of the AMKENI current provinces
ß AMKENI should ensure that family planning services are fully integrated with other
maternal and child health care services, PMTCT, and VCT in all target facilities by
the end of the Project. 
ß Although there is evidence that family planning method mix has improved in project
areas, additional efforts are needed to further improve method mix and to ensure
continuity of family planning use and compliance. 
ß AMKENI should work closely with the MOH and the DELIVER Project to ensure
that contraceptives are available at the facility level. 
ß AMKENI’s BCC component should place higher emphasis on FP/RH BCC messages 
and pay special attention on men and male youth as the locus of power. 
ß Given the role played by the PHOs PHTs, it is prudent that they are facilitated more 
by the Project in terms of transport. The team recommends that AMKENI provide
bicycles for the PHOs and PHTs. 
ß AMKENI should analyze the Household Survey data and disaggregate it by province 
to facilitate comparison with the end of project targets. The analysis should also
determine the most successful and cost effective BCC approach. 
ß The team recommends AMKENI to consolidate project interventions in current 10
districts within the Coast and Western Provinces over the next year. 
ß AMKENI should undertake an assessment within the current districts to analyze its
exact coverage of the populations. This analysis can be done by mapping out of the 
catchment areas of the current AMKENI-assisted facilities. Based on this analysis,
AMKENI should decide whether it is feasible to assist additional facilities within the 
current districts. 
ß If AMKENI decides to assist additional facilities, it should develop criteria for
selecting those sites. The focus of the expansion should continue to be on lower level 
facilities, particularly the most needy dispensaries. 
ß AMKENI should delegate both administrative and technical oversight responsibilities
to the Area Managers for field implementation. 
ß AMKENI should review its M&E Plan and retain those indicators only essential for
tracking performance and progress of the project. 
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Long-term recommendations for USAID/Kenya 
ß The evaluation team recommends that the follow-on project should focus on FP, PAC, 
AC, IP, PMTCT and VCT. Maternal health activities should be minimized, with
selected and targeted interventions. Child survival interventions should not be part of
the follow-on project. 
ß USAID/Kenya should coordinate closely with the new DFID-funded Safe
Motherhood Project while developing the follow-on procurement instrument. 
ß USAID/Kenya should continue collaborating with the donor community to ensure
contraceptive security.
ß USAID/Kenya may consider initiating policy level talks with the MOH to reverse the 
cost-sharing policy and/or explore alternative means of financing health care at lower 
level facilities
ß USAID/Kenya may consider fostering synergies between the follow-on Project and
the CAPACITY Project by directing emergency staffing assistance foreseen under the 
CAPACITY Project to understaffed dispensaries within the new provinces. 
ß The follow-on Project should maintain AMKENI’s approach to linking facilities and
communities. The follow-on Project should also maintain AMKENI’s three-pronged 
strategy incorporating T&S, service delivery and BCC components. 
ß The follow-on Project should not be involved in pre-service training. Pre-service 
training interventions currently implemented by AMKENI should be transferred to the
CAPACITY Project.
ß All components of the follow-on Project should focus on integrating FP/RH and
HIV/AIDS interventions at the field level. 
ß The follow-on Project should use lessons learned from AMKENI to simplify and
streamline BCC activities by implementing the most effective strategy that reflects a
hybrid of the most successful elements of the piloted BCC models. 
ß The team recommends that the BCC interventions of the follow-on Project should
focus on FP/RH themes and on men and youth. 
· AMKENI should complete and phase-out its activities in Coast and Western
Provinces by the end of the project in March 2006. The follow-on Project should 
select and move on to working in two new provinces. 
· The follow-on Project should focus on provincial, district and facility level activities
and should not include national level interventions. Similarly, the next phase should
focus on the lower level facilities, where high-level demand is obvious. 
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ß The follow-on Project should have a decentralized management structure and lean
staffing. The Project should be required to consolidate technical staffing under teams
in line with the project’s main technical components; training, service delivery and
BCC. 
ß The follow-on Project should continue AMKENI’s effective coordination with the
IMPACT Project and the current division of labor. However, the team does not
recommend sharing of staff between the two projects. 
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I. INTRODUCTION
PURPOSE 
The purpose of this evaluation is to examine the activities of USAID/Kenya’s increased use
of family planning, reproductive health, child survival, and HIV/AIDS
(FP/RH/CS/HIV/AIDS) services portfolio, implemented through a Cooperative Agreement
with EngenderHealth. The cooperative agreement is a five-year initiative to improve
FP/RH/CS/HIV/AIDS situation in Kenya with an emphasis on increasing utilization of
facility based integrated services. The project, AMKENI is implemented by a partnership
agreement among four development agencies led by EngenderHealth. AMKENI started in
December 2000 and will run through September 2005, with a possibility of extending through
March 2006. 
The evaluation aims to analyze the following:
ß The progress of AMKENI towards the achievement of specific project objectives in
line with USAID/Kenya’s Strategic Plan;
ß The achievements in quality, demand for, and utilization of FP/RH/CS/HIV/AIDS
services; 
ß The achievements in national training and supervision systems; 
ß The communities’ perspectives of the project activities; 
ß The appropriateness of the strategies towards achievement of the project activities; 
ß The pace of project implementation given the geographical focus and expansion of
scope; 
ß The impact of shifting funding mechanisms on project implementation; 
ß The degree to which systems and processes are established that lead to sustained
behavior change and increased demand for services; 
ß Overall challenges and lessons learned; and, 
ß Key areas of focus for future programming. 
In general, the assessment analyses the impact of the following topical issues on quality,
utilization and demand for FP/RH/CS/HIV/AIDS services in project areas:
ß Service delivery: The achievements in quality, access, utilization and integration of
services.
ß Training and supervision: The development of national policies and systems for
training and supervision.
ß Behavior change and communication (BCC): The impact on demand and utilization
of services.
ß Community ownership and capacity building: Change in knowledge and attitudes,
establishment of systems and processes. 
ß Monitoring and evaluation: The efficiency of the monitoring and evaluation systems. 
ß Project management: The efficiency of administrative, programmatic and financial
management.
ß Relationships with the Ministry of Health (MOH) and other key partners. 
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The full Scope of Work for the evaluation is found in Annex A. 
METHODOLOGY
The evaluation took place in February-March 2005 and was conducted by a core team of four 
independent consultants: Pinar Senlet, an international public health consultant; Prof. Nimrod
Bwibo, a pediatrician and child health specialist; Prof. Joseph Karanja, a consultant
obstetrician and gynecologist and senior trainer in maternal health; and; Prof Joyce Olenja, a 
medical anthropologist. The core team members had complementary skills and expertise,
including experience in management, monitoring and evaluation, service delivery, training,
and BCC with regard to FP/RH/CS/HIV/AIDS. The team was accompanied and supported 
by two additional members from the MOH throughout the evaluation process: Alice
Mwangangi, a staff of Division of Reproductive Health; and Fredrick Ombwori, an
economist from the MOH. The team closely collaborated with USAID/ Kenya, AMKENI and 
the MOH while conducting the evaluation. 
The evaluation methodology included the following: 
ß Review of relevant documentation, including project studies, program reports, USAID
strategy documents, and other reports related to FP/RH/CS/HIV/AIDS in Kenya. The 
list of documents reviewed is attached in Annex B.
ß Structured interviews with key informants and stakeholders, including USAID/Kenya
staff, AMKENI partners, MOH representatives and other local implementing partners. 
The list of persons contacted is found in Annex C. 
ß Field visits to Project Provinces (Coast and Western Provinces) to interview field
stakeholders including MOH officials, implementing partners, service providers, and
field agents. 
ß Visits to clinical facilities to assess service quality, access and utilization. The team
developed and used a simple facility checklist to collect data on access and quality. 
ß Structured focus group discussions with community members to assess the extent to 
which the project has achieved its goals in behavior change and communication.
The list of sites visited, list of focus groups conducted and data collection tools are found in
Annexes D, E and F. 
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II. BACKGROUND
TRENDS IN REPRODUCTIVE HEALTH, HIV/AIDS AND CHILD HEALTH IN
KENYA 
Following several decades of many achievements and improvements in health, Kenya faced
many challenges in reproductive health, child health and HIV/AIDS over the 1990s. AIDS
epidemic became a tragedy of devastating proportion during the last decade. According to 
estimates derived from the Sentinel Surveillance System, HIV/AIDS prevalence had peaked
at around 10% for adults in the late 1990s. Since then, prevalence has been declining
gradually. The prevalence is estimated to have declined to seven percent according to Kenya 
Demographic and Health Survey 2003 (KDHS 2003), meaning that there are currently 1.1
million adults infected with HIV. Nearly two thirds of those infected are women and HIV
infection among adults in urban areas is almost twice as high in rural areas. 
Figure 1
HIV Prevalence among Adults
0
2
4
6
8
10
12
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
Percent 
Source: Adjusted from the Sentinel Surveillance System.
Since 1984, contraceptive use increased steadily in Kenya, as shown in Figure 2. The rate of 
increase slowed down in early 1990s and even more during the latter portion of the decade. 
The slowing down of the increase in contraceptive use, as documented by KDHS 2003 is in
sharp contrast with previous trends: modern contraceptive use has increased from 32 percent 
to only 33 percent between 1998 and 2003. 
Since 1993, the method mix in Kenya has been shifting towards increased use of the
injectables, while other methods use have been declining. The use of injectables has
increased dramatically from 7 percent in 1993 to 12 percent in 1998 and 15 percent in 2003, 
making it the predominant method. Over the same timeframe use of pills has declined from
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10 to 8 percent, IUDs from 4 to 3 percent, and female sterilization from 6 to 5 percent. This 
is a troublesome finding, since it may indicate problems such as inadequate access and
availability of methods other than the injectables, and perhaps increasing biases against these
methods. (See Figure 3)
Figure 2
Trends in Modern Contraceptive Use among Married Women
0
5
10
15
20
25
30
35
1984 1989 1993 1998 2003
Percent 
Source: KDHS 2003 
Figure 3
Trends in Contraceptive Method Mix
0
2
4
6
8
10
12
14
16
Pill IUD Injectables Condoms BTL
Percentage
1993
1998
2003
Source: KDHS 2003
Since 1980s, the number of women of reproductive age has more than doubled, and the size 
of the reproductive age population will continue to grow markedly in the years ahead, due to 
population momentum. Despite the remarkable growth in family planning use since the
1980s, there remains a significant unmet need for family planning in Kenya: overall 20
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percent of births are unwanted, and an additional 25 percent are mistimed, or wanted later. 
According to KDHS 2003, 25 percent of married women wish to limit or space their next
birth, but still are not using contraceptives. In addition, the survey estimates that the number 
of contraceptive users will need to grow by three percent each year, just to maintain current 
contraceptive prevalence.
Currently, the infant mortality rate is 77 and under-five mortality rate is 115 in Kenya,
meaning that one in every nine children dies before his or her fifth birthday. The KDHS
2003 and other surveys indicate a worsening of child health mortality rates during the 1990, 
reversing decades of steady improvement: The surveys indicate that under five mortality rate 
has increased by 25 percent. The increase was primarily due to expanding HIV/AIDS
epidemic, combined with malaria and other childhood diseases. Other child health indicators 
have also been worsening recently; for example, vaccination coverage (percent of children
age 12-23 months who had received the full regimen of recommended vaccines) has declined 
significantly between 1998 and 2003, from 65 to 57 percent. 
The continued growth of the reproductive age population in Kenya, coupled with increasing 
HIV prevalence and child mortality increased the demand on the health care system in Kenya 
significantly throughout the 1990s. The additional burden and the negative impact for the
health system became a major issue on the public sector health care financing since health
care resources from the Government of Kenya (GOK) were not increasing. 
USAID KENYA’S FP/RH/CS/HIV/AIDS PORTFOLIO 
In response to the worsening FP/RH/CS/HIV/AIDS situation in Kenya over the last decade, 
USAID/Kenya developed a new health and population strategy through a process
incorporating input from numerous sources in 2000. The Strategic Objective 3 was
formulated as part of the USAID/Kenya Integrated Strategic Plan for 2001-2005. The
Strategic Objective 3 is defined as “to reduce fertility and the risk of HIV/AIDS transmission 
through sustainable, integrated family planning and health services” The Results Framework 
for Strategic Objective 3 is shown in Figure 4. The framework illustrates the causal
relationships between the high level IRs and the linkages with the lower level results. Key
elements of family planning, reproductive health and child survival are integrated with
HIV/AIDS activities.
USAID/Kenya’s Strategic Plan provides detailed information on definitions of each 
intermediate result to be achieved and offers illustrative approaches to achieve each result. 
The plan also includes a comprehensive Performance Monitoring Plan on how the strategic
objective and the expected results will be monitored and evaluated. 
During the Integrated Strategic Plan development process, USAID/Kenya developed a new
emphasis, as well as a renewed commitment to family planning within the Strategic Objective 
3. The new strategy incorporated numerous directions in the areas of FP/RH/CS/HIV 
activities: 
ß A recognition of HIV/AIDS as a multisectoral crisis;
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ß Better integration of HIV/AIDS services; 
ß Integrated private sector programs in targeted geographic areas; 
ß Recognition of the need for behavior change and positive health care seeking 
behavior;
ß Giving young people priority attention; and,
ß Enhanced efforts to strengthen the policy environment and manage sector
resources.
Figure 4
USAID Results Framework for Strategic Objective 3
In accordance with the above strategic directions, USAID/Kenya issued a Request for
Application (RFA) in July 2000 to enhance its efforts to improving the health of Kenyans
through integrated family planning, reproductive health and child survival services, including
HIV/AIDS. The program included two major components: 1) family planning, reproductive 
health and child survival NGO and private sector service delivery in selected geographic
areas (with 75 percent of emphasis), and 2) Improvements in public sector FP and RH
training and supervision systems (with 25 percent emphasis). In both components, family
planning was described as the predominant focus. However, the RFA required that
“HIV/AIDS, other reproductive health and child survival activities be included as feasible 
and appropriate”. While the RFA focused on FP, it was “designed to receive child survival 
and HIV/AIDS funding to take advantage of future funding opportunities and potential
synergies and linkages.” 
The project was awarded to EngenderHealth (then AVSC International) and its partners in
December 2000. The initial estimated budget for AMKENI was $15,997,129, which
increased to $ 18,913,090 through 2004, including President’s Emergency Plan for AIDS
Relief (PEPFAR) funds. 
IR3.1.1
Policies for FP/RH/CS
services improved
IR3.1.2
Efficiency in the management
of health sector resources
improved
IR3.1.3
Quality of services in health
facilities improved
Intermediate Result 3.1
Improved enabling environment
for the provision of health services
IR3.2.1
Reduced key policy and other
contextual constraints to preventing
and mitigating the impact of HIV/AIDS
IR3.2.2
Improved knowledge and practice
of prevention behaviors
IR3.2.3
Enhanced provision of HIV/AIDS/STI
prevention, care, and support services
Intermediate Result 3.2
Increased use of proven, effective inter￾ventions to decrease risk of transmission
and mitigate the impact of HIV/AIDS
IR3.3.1
Integrated FP/RH/CS
services expanded
IR3.3.2
Improved knowledge of
and demand for FP/RH/CS
services
IR3.3.3
New and improved FP/RH/CS
programs and interventions
conducted and applied
Intermediate Result 3.3
Increased customer use of
FP/RH/CS services
Strategic Objective 3
Reduce fertility and the risk of HIV/AIDS
transmission through sustainable, integrated
family planning and health services
20
USAID/Kenya is currently in the process of revising its Results Framework and extending it 
through 2008. While the Results Framework will undergo significant revisions in response to 
PEPFAR requirements, the IRs related to FP/RH are not expected to alter substantially.
USAID/Kenya supports an array of other FP/RH/CS/HIV/AIDS projects under the Strategic 
Objectives 3. IMPACT, implemented by FHI is USAID’s flagship project for HIV/AIDS
prevention and treatment. The POLICY Project, implemented by the Futures Group
International works in the policy arena to address policy issues regarding FP/RH and
HIV/AIDS. The DELIVER Project, implemented by JSI, is a large contraceptive logistics
management project and has a mandate to distribute contraceptive supplies down to the
district level. Recently USAID has awarded another large project to improve human resource 
capacity in health sector, the CAPACITY Project. 
In addition to USAID-funded projects, other international agencies support several FP/RH
projects in Kenya. Among the most active donors are DFID, GTZ and the UNFPA. DFID 
supports a Safe Motherhood Project in the Western Province, where AMKENI is also
working. DFID has issued a new bid with a substantial budget to expand the Safe
Motherhood initiative, and the award is imminent. UNFPA supports a comprehensive FP/RH 
program implemented by the MOH, covering nine districts across the country. Two of these 
districts, Kwale and Kilifi, overlap with AMKENI targeted areas. GTZ had supported a large 
contraceptive community based distribution (CBD) project in the past, which has been scaled 
down considerably. GTZ is now considering increasing its support to CBD programs. 
21
III. THE AMKENI PROJECT: FINDINGS, CONCLUSIONS AND 
THE LESSONS LEARNED
The AMKENI project is a five-year (2001-2005) technical assistance effort aimed at 
improving the FP/RH/CS services, including HIV/AIDS status in Kenya. The project is
being implemented by a cooperative partnership of four development agencies led by
EngenderHealth. Other international implementing partners are Family Health International 
(FHI), IntraHealth International Inc., and Program for Appropriate Technology in Health
(PATH). A fifth partner, Carolina Population Center (CPC) withdrew from the consortium
two years ago. 
AMKENI aims to bring together the complementary strengths and expertise of these
organizations. EngenderHealth has strengths in service delivery systems, practical quality
improvement processes and management systems. FHI brings in expertise in integrating
HIV/AIDS and STI prevention and integration with other FP/RH/CS services. IntraHealth
has its strengths in developing performance improvement training and supervision systems in
public and private sectors. IntraHealth also contributes to the partnership in monitoring and
evaluation planning, a role it has taken on from CPC. PATH is the lead agency in developing 
behavior change communication and community mobilization interventions. 
AMKENI works with a variety of local implementing agencies. The Project’s principal
partner is the MOH and it is being implemented with the MOH at all levels. Other
implementing partners are Aga Khan Heath Services (AKHS), Cooperative League of the
USA (CLUSA) Family Planning Association of Kenya (FPAK), Community AID
International (CAI), and UZIMA Foundation (UZIMA). 
AMKENI’S GOALS, STRATEGIES AND MAJOR INTERVENTIONS 
The overall goal and strategic directions of the AMKENI have evolved significantly over the 
life of the project. The initial goal of the project was to increase use of integrated FP/RH
services with limited focus on CS and HIV/AIDS activities, while placing an emphasis on the 
development of private and NGO sector services. The project conducted an assessment of
the potential service delivery sites as an initial step. The findings of the assessment indicated 
a major change of focus in terms of public vs. private sector involvement in project
implementation. The structures of the private sector facilities which were to play a major role 
in increasing access to and quality of FP/RH/CS/HIV/AIDS in the selected provinces were 
found to be weak. Well-established private hospitals were too expensive to increase access 
for the general population. Smaller private health care structures were scattered and lacked
the required minimum quality of care standards to be involved in the activities of the Project. 
A significant policy change, which took place in the early days of AMKENI, further limited
the Project’s ability to work with the NGO sector: The reinstatement of the so-called “Gag 
Rule” in 2000 restricted the project to work with the predominant NGOs in Kenya; Marie
Stopes and FPAK. As a result, AMKENI had to revise its strategic focus to shift towards 
working mostly with the public sector. 
22
Another development, which led AMKENI to revise its strategic focus, was the availability
of PEPFAR funding. In 2003 USAID/Kenya allocated PEPFAR funding which enabled the
project greater involvement and focus in HIV/AIDS activities. AMKENI emphasized VCT
and PMTCT interventions, as they were mandated under PEPFAR. 
Finally, a mid-term evaluation, which is referred as an Extended Management Review
(EMR), was conducted in April-May 2003. The EMR was a turning point for AMKENI to 
revise and consolidate its strategic focus. The EMR called for major changes in project
design as well as significant shifts in focus areas. In summary, the EMR recommended the
project to:
ß Review the training program by determining training needs, the services/skills/sites
that require training and the optimal training format;
ß Strengthen collaboration with the MOH;
ß Place greater focus on district priorities and needs; 
ß Concentrate on aspects of HIV/AIDS that are most closely related to RH, such as
PMTCT and VCT;
ß Focus and consolidate BCC activities; and, 
ß Improve the monitoring and evaluation system. 
The evaluation team highly appreciates AMKENI’s positive response to the
recommendations of the EMR. The Project took immediate action on most of the
recommendations. As will be discussed in other sections of this report, the Project was able to
achieve greater impact over the last two years. A major change made in the project design
was to form stronger relationships with the MOH at all levels (e.g., national, provincial,
district and facility levels). The project also streamlined its operations by focusing on district 
level and graduating national level training interventions, as well as improving its monitoring
and evaluation plan. The EMR led to the formulation and implementation of the current
strategic directions and key interventions. 
Currently AMKENI has two overarching objectives: 
ß Increasing access to and quality of FP/RH/CS services including HIV/AIDS
prevention services, and, 
ß Promoting healthier behaviors among the population and increasing demand for
services.
These two objectives form the backbone of the project, aiming to link communities and
service facilities. The evaluation team believes that it is a very powerful approach and
applauds the project’s efforts for working with both the facilities and the communities in
order to improve services and increasing demand for services. 
In order to achieve the above objectives, AMKENI uses the following three strategies and
related interventions: 
1. Improving the capacity of health facilities to provide FP/RH/CS services, including 
HIV/AIDS related services through:
23
ß Training; 
ß Expanding range of services (e.g., upgrading facilities, provision of essential
equipment and supplies);
ß Strengthening supervision; and, 
ß Service outreach. 
2. Working with communities to promote healthier FP/RH/CS/HIV/AIDS behaviors and
demand for services by: 
ß Promoting preventive and health-seeking behavior;
ß Fostering community agency; and,
ß Creating a supportive environment for individual and community change. 
3. Strengthening the MOH’s decentralized systems for training and supervising RH service 
providers through 
ß Facilitating the establishment of Decentralized RH training and Supervision System;
ß Updating and strengthening the teaching skills and materials for public sector pre￾service and in-service trainers and supervisors; and, 
ß Facilitating the application of the Performance Improvement Approach (PIA). 
Within its overall strategic approach, AMKENI aims to improve service delivery and training
in several interrelated technical areas. These are summarized in Table 1 
Table 1
Interventions by Technical Elements of Service Delivery and Training 
Family planning and 
reproductive health 
o Short, long term and permanent contraception 
o Post abortion care (PAC)
o Prevention of sexually transmitted infections (STI)
o Infection prevention (IP)
Maternal health o Antenatal care (ANC)
o Safe delivery 
o Emergency obstetric care (EOC)
o Newborn care
o Prevention and treatment of malaria in pregnancy
HIV/AIDS o Voluntary counseling and testing (VCT)
o Prevention of mother to child transmission (PMTCT)
Child health o Immunization 
o Growth monitoring 
o Integrated management of childhood illnesses (IMCI)
o Vitamin A supplementation
24
In BCC, AMKENI implements four main approaches, with six local implementing partners. 
These approaches are: 
1. Family-to-family communication; 
2. Direct outreach to men, women and youth; 
3. Women’s agency; and, 
4. Magnification of behavior change. 
Table 2 summarizes the approaches used in BCC interventions in collaboration with the local
implementing partners, in both the Coast and Western Provinces. A full description of these 
approaches is found under the section on BCC.
Table 2
AMKENI BCC Implementing Partners and Approaches
Implementing 
partner
Coast Western Approach 
1
Approach 
2
Approach 
3
Approach 
4
MOH X X X X X X
AKHS X X X X
CAI X X X X
CLUSA X X X X X
FPAK X X X
UZIMA X X X
Conclusions and Lessons Learned 
The evaluation team believes that the above three-pronged strategy is appropriate for
AMKENI to achieve its objectives and goals. The project was successful in revising and
streamlining its strategic directions over the course of implementation and in incorporating
lessons learned. The evaluation team, however, has some concerns regarding the broadness
of some of the interventions: The two interventions outlined under Strategic Objective 2
“fostering community agency” and “creating a supportive environment for individual and
community change” are defined too broadly. While the team recognizes the importance and 
potential impact of both interventions, these are too far-reaching and ambitious to be
implemented under a RH project. Secondly, the team also believes that the inclusion of pre￾service training intervention under the Strategic Objective 3 is over ambitious. Pre-service 
training in FP/RH/CS/HIV/AIDS requires substantial inputs and will lead the project to
spread its resources too thinly. 
As a result of numerous interventions summarized in Tables 1 and 2, project implementation
has been very comprehensive and complex. While the evaluation team understands the
importance of each technical area and related interventions, the technical focus of the project 
looks too extensive and lacks prioritization.
The multiplicity of project interventions has stemmed from both design and implementation
issues. The RFA issued by USAID was comprehensive and somewhat ambiguous; the RFA
required focus on FP/RH but at the same time it allowed flexibility for implementation of
25
HIV/AIDS, child health, maternal health and malaria-related activities. Over the course of the 
project, USAID was able to allocate significant additional funding for HIV/AIDS, but CS
funding remained very limited, about 2% of the overall project funding. Thus the project was 
able to undertake some child survival interventions, all were successful, but they were few
and scattered. 
The team acknowledges that the term reproductive health encompasses a broad array of
elements, which are somehow differently defined by individual organizations. RH needs in
each country may also greatly vary. In order to avoid confusion, throughout this report, the 
term FP/RH is used in line with the way it is defined in the current RFA issued by
USAID/Kenya in this report. 
While describing the FP/RH focus of the Project, RFA required an overall emphasis on
family planning, and other RH priority areas were defined as PAC, STI prevention and
treatment, HIV/AIDS prevention, and antenatal care. The team has found that although this
focus is still a strong part of the training interventions; the overall emphasis of the project has 
shifted towards maternity services throughout the project. Improving maternity services have
been absorbing a significant portion of the resources, especially in terms of renovations and
equipment donations. Implementation of HIV/AIDS prevention activities has been the recent 
focus within the project, due to availability of substantial PEPFAR funding. 
With that said, the team does not necessarily disapprove expanding the concept of FP/RH. In 
particular, the team would like to note that the expansion of AMKENI’s mandate has taken
place with the approval of USAID/Kenya. The team points out to the fact that the way the 
Project is currently being implemented is significantly different from the original design. 
Another underlying cause, which led AMKENI to diversify interventions and stretch itself
far, is the project’s responsiveness to the needs of the local partners, especially the MOH, and 
the communities. The team interviewed numerous individuals throughout this evaluation,
including MOH officers at all levels and community leaders and volunteers. FP/RH may not 
be perceived as a high priority need for stakeholders, especially the communities. Thus,
AMKENI’s dilemma has been responding to and meeting the needs of the stakeholders and 
beneficiaries while keeping a focus on its mandate and core business. The evaluation team
appreciates AMKENI’s high level of responsiveness to community needs and sees this as
strength. At the same time, however, this has become a challenge for the Project by diverting 
the Project resources and efforts away from its core business. 
Given the complexity of the project design, AMKENI has done remarkably well in all of the 
above areas. There have been substantial advancements and improvements in all project
elements and this report provides ample evidence regarding these findings. Nevertheless, it is 
the conclusion of the team that if the project had more focus on family planning and selected 
reproductive health interventions, implementation would have been smoother, faster and the
achievements would have been greater in this area. As will be discussed in detail in further 
sections of this report, the team has found evidence of significant improvements in quality
and utilization of FP/RH services. However, the team has also found ample evidence that
there is a much greater unmet need in provision of FP/RH services and information, which
the Project was not able to adequately address. 
26
COVERAGE OF GEOGRAPHICAL AREAS AND PACE OF IMPLEMENTATION 
Geographic and population coverage 
AMKENI works in the Coast and Western Provinces targeting 10 districts. In Coast, the
project is working in four of the total seven districts, and in Western AMKENI is active in six 
of the total eight districts. In these districts the Project targets 97 health facilities. Once the 
project districts were identified, the project undertook a facility assessment in each district to 
determine facility selection, in collaboration with the MOH. The facility assessments
examined the availability of minimum quality standards at each site in order to be included in
project activities. A short list of 30 to 40 facilities in each district was presented to the MOH 
and MOH identified 12 target facilities in each district. MOH’s selection criterion was to
include those sites with low service utilization rates. 
Table 3 provides a breakdown of AMKENI supported facilities by province, district and
facility type. Total populations of the provinces and districts are provided to understand
population coverage of the project. 
Table 3
Breakdown of Facilities by Province, District and Facility Type
Province/
Population*
District/
Population*
Facility type Total
Public Private Mission 
Coast 2,927,273 Kilifi 640,593 9 2 1 12
Kwale 566,886 11 1 12
Mombasa 808,221 6 6 12
Malindi 338,077 11 1 12
Subtotal 2,353,777 37 10 1 48
Western 3,885,290 Bungoma 1,096486 8 2 2 2
B-Mumias 539,671 3 2 5
Kakamega. 749,861 3 1 1 5
Busia . 442,692 10 1 1 12
Lugari 268,320 1 1 2
Vihiga 595,180 12 1 13
Subtotal 3,692,210 37 8 4 49
Total 6,812,563 6,045,987 74 18 5 97
*Source: Population Projections for 2005; 1999 Kenya Population and Housing Census.
As can be seen in the table above, the total population of the AMKENI-assisted districts 
encompasses the majority of the total province populations in both Coast and the Western 
Provinces. Overall, ten districts assisted by AMKENI make up close to 89 percent of the 
total province populations. This percentage is higher in the Western Province (95%)
compared with the Coast (80%). 
27
The team attempted to estimate the population coverage of AMKENI interventions within the 
project districts by assessing the catchment areas of the AMKENI assisted facilities. It
appears that on average, AMKENI was able to reach a critical mass of the populations living 
in project districts: 50 percent of the populations living in AMKENI-assisted districts have
been reached by AMKENI (See Figure 5). This ratio is significantly higher in Coast, (59%), 
compared with the Western Province (47%). It should be noted that these figures represent 
coverage of training and services delivery activities. 
Figure 5 
AMKENI Population Coverage in Coast and Western Provinces
6.8
6.0
3.0
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
Total population of
the provinces 
AMKENI districts'
population 
AMKENI facilities'
catchment area
population 
million 
Facility Types and Levels 
AMKENI works with several levels and types of health facilities within both private and
public sectors. Table 4 provides a breakdown of facilities by type and level. 
Table 4
Breakdown of AMKENI-assisted facilities by facility type and level
Facility Level Facility Type
Public Private Mission
Total
Dispensary/Clinic 24 5 1 30
Health Center 37 0 2 39
Hospital 13 2 2 17
Nursing/Maternity 0 11 0 11
Total 74 18 5 97
28
As seen in Table 4, AMKENI activities have been geared towards working with the public
sector. 74 percent of the total AMKENI-assisted facilities are public facilities, as opposed to 
privately owned or Mission facilities. Similarly, AMKENI’s focus has been on lower-level 
facilities such as maternity homes, dispensaries and health centers as opposed to hospitals. 
Within the Kenyan health service delivery networks, demand for services and service
utilization significantly increases at the lower level health facilities. The health centers, and
particularly the dispensaries have considerably higher client loads per staff compared with
hospitals. 
Pace of implementation 
The team has observed that project components have progressed at different pace. In general, 
training and service delivery components have progressed at a higher pace compared with
BCC. Particularly in the West, BCC interventions have been highly intensive, requiring more 
resources and time. As will be discussed later in this report, the team estimates that the BCC 
activities have reached to about 20% of the target district populations. 
Conclusions and Lessons Learned 
The team concludes that AMKENI has already reached out to the majority of the Province 
populations. The districts that are left out have low population density and are hard to reach
areas. The catchment areas of the existing AMKENI-assisted facilities also have high
coverage but more data and further analysis is needed to determine the exact coverage of the 
Project. 
The team believes that the mix of public/private facilities is appropriate for achieving the
goals of the project. A review of the initial site assessment and the team’s observations in the 
field confirmed that the project resources had to be shifted towards public sector in order to 
achieve higher impact. 
The team believes that AMKENI’s approach to direct more resources to working with the
lower level facilities rather than the hospitals was valid and appropriate. However, the
resources required for upgrading hospitals and training their staff were probably higher than
the assistance required for health centers and dispensaries. Thus, the project might have 
invested more for the hospitals although the number of hospitals is fewer than the health
centers and dispensaries. 
The team had detailed discussions with the AMKENI and MOH staff at the field regarding
their views on future programming. AMKENI and MOH staff is keen on expanding the
project activities province-wide in both Coast and Western Provinces to include other
districts where AMKENI has not been active yet. In addition, many think that AMKENI
should work in other facilities that have not benefited from the project over the last four
years. The team does not believe such an over-reaching perspective is strategic or feasible. 
The 10 districts covered by AMKENI so far comprise over 80 percent of the total population 
of the two provinces. The remaining districts are small, with fewer inhabitants and most
importantly, are hard to reach areas. The resources required to reach these districts will be 
too high and the approach will not be cost effective. 
29
TRAINING AND SUPERVISION 
The AMKENI goal of a sustainable increase in the quality of, demand for and utilization of
integrated FP/RH/CS services including HIV/AIDS at the community level required well
trained and supervised staff. In this regard, AMKENI formulated Training and Supervision
(T&S) interventions with the purpose to improve the quality of services in the public sector
through a combination of direct training in specific skills and development of sustainable
training and supervision systems at the national level.
The T&S component implemented four main interventions:
Assistance in development of sustainable training and supervision systems and
development of national level training materials:
Following change from the original mandate and also as a result of EMR, AMKENI worked 
with the MOH to consolidate existing training and supervision sub-systems into one
Decentralized RH Training and Supervision System. The activities also included
development of several national T&S curricula and manuals. Achievements included: 
ß Establishment of decentralized RH T&S System. At the time of this evaluation,
AMKENI had completed training in clinical training skills and facilitative supervision
of all eight provincial teams nationwide, all 10 target district teams in Coast and
Western provinces, and 16 facility-based teams in Bungoma and Malindi districts.
Overall, 200 supervisors have been trained nationally. A recent evaluation of the
decentralized T&S system has found that the system is in place and operational. The 
evaluation also concluded that the system has potential for national replication.
ß Development of national RH T&S curricula and manuals. These activities led to
development of several national level training materials including: 
ÿ National Reproductive Health Curriculum including manuals for the trainers and
trainees, which is currently awaiting pre-testing;
ÿ National Facilitative Supervision Manuals for supervisors of the RH services;
ÿ National Guidelines for Integration of FP in VCT is currently under development;
ÿ In addition to the above, AMKENI participated in development of national
materials for training in VCT and PMTCT. 
Assistance for revision of policies affecting availability of RH services: 
AMKENI assisted the MOH’s Division of Reproductive Health (DRH) and other
stakeholders to review and revise policies affecting the availability of trained service
providers. These interventions included promotion of implementation of earlier policy
reforms allowing nurses and clinical officers to provided implants and PAC services, and 
advocacy for policy change to allow nurses and clinical officers to provide bilateral tubal
ligation (BTL) and no-scalpel vasectomy (NSV). Achievements included the following: 
ß 417 nurses and clinical officers were trained in Norplant insertions and removals; 
30
ß 101 nurses and clinical officers are trained in provision of PAC services; and, 
ß A concept paper advocating for policy change to allow nurses and clinical officers to 
provide BTL and NSV services was prepared and presented to the MOH, but was 
rejected. 
Improving performance of trainers and service providers: 
AMKENI worked with the provincial and district health management teams and other
training institutions to strengthen their service quality through the introduction of the
Performance Improvement Approach (PIA). The goal was to improve performance of
trainers and service providers through training and supervision in FP/RH/CS and HIV/AIDS
skills. The PIA training resulted in a total of 422 participants trained including MOH Heads
of Departments, Kenya Medical Training College (KMTC) heads of departments and other
staff, MOH provincial heads from Western and Coast, and many staff from MOH health
facilities. 
The training of MOH staff in PIA helped adoption of the principles of PIA, ownership of the 
process, and identification of additional trainees and long-term support to trainees in district
health facilities. The facility level training in PIA helped identify areas for improvement
such as infection prevention, provision of wider range of contraceptive methods, improved
morale, client congestion and better immunization rates. 
Training of trainers and services providers in FP/RH/CS and HIV/AIDS 
Up to now, AMKENI has trained a total of 3239 trainers and service provides at all levels, in 
various courses in accordance with service delivery needs, including clinical skills,
contraceptive technology, facilitative supervision, VCT, PMTCT, on the job training
methodology (OJT), and PAC. Table 5 presents a summary of skills training and number of 
personnel trained. 
In addition to the above, AMKENI supported pre-service training by upgrading technical
skills pre-service tutors in medical colleges nationwide. A total of 250 participants from 18
colleges countrywide have been trained.
Conclusions and Lessons Learned 
AMKENI’s training and supervision interventions have been highly successful have been
valued by trainees and stakeholders interviewed by the evaluation team. At the time of the
evaluation, the project had reached 85 percent of its direct training targets. The Project is not 
planning to expand its training activities until June 2005, except for additional training
required for replaced or retired trainees. The Project is aiming to continue to assist the MOH 
to improve the functionality of the Decentralized RH T&S System. 
Overall, the Project has assisted in development of high quality training materials. The team
observed that the materials have been widely distributed, and are being used to improve
quality of services at the field. The team also observed that the decentralized teams are doing 
a commendable job of supportive supervision and on-the job training. An issue regarding
31
supervision is at times, inadequate commitment of the MOH supervisors and means of
transport. MOH sometimes is not able to provide vehicles to its supervisors.
Table 5
FP/RH/CS and HIV/AIDS Skills Training 
Skills Numbers Trained Nationwide
Clinical Skills Training 241
Contraceptive Technology Update 244
Facilitative Supervision 304
FP Counseling 203
IMCI 91
Infection Prevention 229
IUD Insertion and Removal 171
Norplant Insertion and Removal 526
On-the Job-Training Methodology 60
Post-abortion Care 102
PIA Training and Orientation 422
PMTCT 171
STI Syndromic Management 199
STI/HIV/AIDS Counseling 53
VCT 223
Total 3,239
The team is concerned that the National PMTCT and VCT Training manuals developed by
the MOH in 2003 have not integrated family planning counseling. AMKENI is currently
helping in the development of materials for integration of family planning counseling in
VCT. The team observed only a few VCT counselors who have been trained in FP and
providing FP counseling to VCT clients. Yet, there are no efforts to incorporate FP
counseling within PMTCT. 
The team believes that AMKENI’s mandate to undertake direct training activities both at the 
national level and at the provincial and district levels was not justified and somehow led the 
Project to stretch itself too thin. The Project was not able to follow-up on the outcomes of the 
national level training activities. For example, AMKENI trained 526 trainers and service
providers in Norplant insertions and removals nationwide. The evaluation team was not able 
to assess the impact of national level training activities. 
Finally, the team has observed that AMKENI has not put in place a systematic follow-up 
procedure to support and evaluate the outcomes of its training efforts at the provincial and
district levels. The Project probably relies on the MOH supervision system for the follow-up 
on the trainees; however, the team does not think that this is sufficient. One would expect
that, as a project incorporating a large training component, AMKENI would have established 
an internal system to follow-up on trainees, not only to assess the results of training efforts 
but also to provide further on-the job support.
32
SERVICE DELIVERY 
The overall goal of AMKENI is to establish a sustainable increase in the quality of, demand 
for, and access to and utilization of integrated FP/RH/CS services, including HIV/AIDS. The 
service delivery component comprises of several technical elements, depicted in Table 1. To
achieve its service delivery goal, AMKENI identified specific objectives:
ß To expand the range of FP/RH/CS and HIV/AIDS services offered at target facilities 
and the coverage of these services through outreach;
ß To institutionalize services at target facilities;
ß To improve the service environment of target facilities through facility renovation and
equipment supply;
ß To enhance the quality of services available at target facilities; and,
ß To promote client input and participation at target facilities.
The team has analyzed AMKENI’s achievements in services delivery under two broad
categories: 
ß Expansion of service availability and improvements in quality; and, 
ß Increased access to and utilization of services. 
Expansion of service availability and improvements in quality
Expansion of services and quality improvement encompassed a wide range of interventions,
including training, expanding existing services, establishment of new services, service
outreach activities, facility renovations and provision of equipment and expendable supplies. 
Skills training to improve service availability and quality are discussed in detail in the 
previous section. Thus in this section we will focus on other interventions.
Expanding existing services and establishment of new services: Family planning and selected 
reproductive health interventions was one of the key elements of the service delivery 
component of AMKENI. At baseline, most of the facilities could only offer short term
methods such as pills, injection and condoms and even for these the numbers of clients were 
low. AMKENI strengthened the facilities to empower them to offer as many methods as
possible with an emphasis on long term and permanent methods. The Project enhanced the
capacity of its supported facilities by training in specific skills and by providing essential
equipment and supplies. The Project trained doctor/nurse teams, and equipped theatres or
minor theatres for procedures. Relevant equipment for family planning was also supplied to
many AMKENI supported sites. (See Table 5 for numbers of service providers trained in
FP/RH and Table 9 for equipment provided for FP/RH services). 
In Kenya, until recently, only doctors were allowed to provide the surgical element of PAC. 
To date, AMKENI has nationally trained 102 nurse/midwives and clinical officers to perform
Manual Vacuum Aspiration (MVA) for uterine evacuation. The team was able to see
instances where AMKENI has trained clinical offices or nurses, renovated and equipped
procedure rooms or minor theatres making PAC services available and accessible nearer the 
communities. The training of nurses and clinical officers in PAC and implant insertion and
33
removal, for example, made these services available in health centers and dispensaries for the 
first time. As seen in Figure 6, there was marked increase especially in the number of
facilities that could provide IUDs, implants, vasectomy, BTL, and PAC. 
Figure 6 
AMKENI Supported Facilities by FP/RH Services Provided
0
20
40
60
80
100
120
PAC
Maternity care 
Pills 
Injectables 
Norplant
IUD
Tubal ligations 
# of facilities 
Baseline (2001) 
2004
Infection prevention practices were integrated in all service delivery interventions as well as
in waste disposal. AMKENI trained staff in infection prevention and ensured availability of
bleach for decontamination. The Project also provided sterilizers, autoclaves, and assisted in
setting up incinerators, and placenta pits.
AMKENI improved antenatal care by providing training for staff, equipment and supplies to 
health facilities, and laboratory tests. The equipment included weighing scales and
examination couches. Health workers in health centers and dispensaries were trained in EOC 
to enable them to conduct appropriate antenatal care. During antenatal care pregnant women 
were given Sulphamethoxazole-pyrimithamine (SP) for malaria prophylaxis, tetanus toxoid
immunization to prevent neonatal tetanus and Vitamin A to improve the immunity status of
the newborn child. 
Many AMKENI facilities were empowered to conduct normal and complicated deliveries.
This was achieved through provision of EOC training, providing delivery beds and delivery
packs and renovation of maternity units. Some facilities were enabled to conduct complicated 
deliveries such as caesarean sections. The number of facilities capable of conducting
deliveries was increased by 22%. The evaluation team visited several facilities that were
assisted by AMKENI to establish or improve maternity care and confirmed that in fact
training, supply of equipment, renovations and even assistance in building of maternity units
were done. 
In 2003, AMKENI expanded its HIV/AIDS interventions in its project activities when funds 
from the PEPFAR track became available. In the original RFA, USAID had shown that the 
34
expanding epidemic threat of HIV/AIDS in Kenya was escalating as shown by prevalence
rates reported elsewhere in this report. AMKENI response by including HIV/AIDS in its
activities appears justified even at that late period of inclusion and even though other USAID 
funded organizations are carrying out such activities.
Figure 7
Maternity Services Capabilities of Facilities before and after AMKENI Interventions
0
10
20
30
40
50
60
70
80
90
100
Normal
delivery
Removal of
retained
placenta
Blood
transfusion
Cesarean
section 
# of faciities 
2001
2004
AMKENI, in collaboration with the MOH, identified sites in the project districts where it was 
feasible to introduce additional VCT centers. Where a room was available AMKENI
renovated it for VCT; where there was none, the Project assisted the community to establish
one. VCT services are supported by National AIDS Control Program (NASCOP), which
supplies test kits and supports training of staff. The VCT centers are stocked with the
required laboratory and test kits. The team found that the VCT centers are utilized well by
the communities; in many facilities, the demand had surpassed the available services.
However, in a number of facilities the availability of HIV test kits ran short of supply,
frustrating the clients.
AMKENI has also established PMTCT services, which counsel antenatal clients, test for
HIV, and distribute Niverapine as well. Table 6 shows selected activities undertaken by
AMKENI to support HIV/AIDS activities. The team has observed that in some PMTCT and 
VCT centers, basic family planning counseling is available. However there was no evidence 
of full integration of FP with VCT and PMTCT in the facilities visited. 
So far, AMKENI has established 43 new VCT sites and 37 new PMTCT sites, in addition to 
the sites that were previously established in AMKENI-targeted facilities. Currently 73 of the 
97 AMKENI supported sites are providing VCT services and 75 are providing PMTCT. 
Although AMKENI has not established all these sites, the Project continues to provide
support to all facilities. 20 of VCT sites are included in operations research to evaluate the 
implementation of FP and VCT integration. The results will provide input for the
35
development of training modules to include in the VCT and PMTCT curricula. PMTCT and 
VCT services and clients are shown in Tables 7 and 8. 
In the early phases of AMKENI, child survival interventions were included among the main
areas of project focus. As the high child hood mortality would influence utilization rates of
FP services, it would have been expected AMKENI would strengthen child survival in order 
to uplift the acceptability of FP which formed major emphasis in its project. But AMKENI
had four scattered areas of child survival strategies addressed i.e., safe delivery,
immunization, support for growth monitoring and IMCI. Even then the funding for CS was
very low at only 2% of the project funding.
Table 6
Selected Activities related to HIV/AIDS
Activity Number*
Staff trained in IP 110
Staff trained in VCT 140
Staff trained in PMTCT 123
Health facilities received PMTCT whole site orientation 45
*Figures only include staff from the 97 AMKENI-supported facilities
Table 7
VCT Services
Number
Health facilities offering VCT services 73
VCT services initiated with AMKENI support 37
Total VCT clients counseled and tested 46,959*
Monthly average July-Sept 2004 4,672*
*Figures include clients served at all VCT sites since 2002. 
Table 8
PMTCT Services
Number
Health facilities offering PMTCT services 75
PMTCT services initiated with AMKENI support 43
Total ANC clients counseled and tested 21,509*
ANC clients testing positive 1,595*
ANC clients received Niverapine 451*
*Figures include clients served at all PMTCT sites since 2002. 
AMKENI has strengthened safe child birth by improving safe motherhood through improved
maternity services – has renovated, even helped in building maternity units and equipped
them with delivery beds, baby incubators resuscitation equipment for the newborn and the
newborn weighing scales. The team found that other collaborators including MOH also
strengthened this area of early childcare. In the strategy of immunization, AMKENI assisted 
36
in advocacy and awareness through health messages in songs and drama. AMKENI also
implemented a small project in Kilifi District with funding from Bill and Melinda Gates
Foundation, using child-to-child communication to improve immunization coverage. In
immunization the team found that the Kenya Expanded Program on Immunization (KEPI) of
the MOH was very strong on the ground both in the Coast Province and Western Province. 
The team found that AMKENI supported growth monitoring by providing children weighing
scales in many health facilities. Although AMKENI participated in conducting some training
in IMCI, this was minimal. In various health facilities, particularly in Western province, the 
staff expressed their need for more IMCI training, stating that the four days’ lectures in IMCI 
they were given were inadequate. 
Out-reach activities: One of the innovative approaches of AMKENI has been to facilitate 
outreach activities for long-term and permanent methods, in collaboration with the MOH. 
The intention was to organize frequent outreach activities, especially for BTL, in health
centers located at a distance from district hospitals in an effort to make services more
accessible to the communities. AMKENI facilitated training for nurse/doctor teams from
supported hospitals and helped to put in place a schedule for provision of BTLs in these
facilities. The team has observed that outreach activities are now being conducted
successfully in many health centers, and has contributed substantially to increasing access to
BTL services. Additionally, AMKENI has supported integrated and comprehensive VCT
outreach services. 
Facility renovations and provision of equipment: AMKENI’s provided substantial resources 
to improve the service environment at the target facilities through facility renovations,
provision of essential equipment and expendable supplies. Minor renovations were
conducted in selected health facilities to improve procedures in terms of space,
confidentiality and quality, for example for implant and IUD insertions, and PAC and
maternity services. There were also assistance to upgrade small district hospitals and health
centers to help to provide more comprehensive services. Throughout the life of the Project 
37 health facilities received funding for renovations. AMKENI provided comprehensive list
of essential equipment to the health facilities. A complete list is found in Table 9.
AMKENI also realized the need for safe disposal of all waste materials from the service
delivery areas, and embarked on construction of incinerators. So far 20 such structures have 
been constructed within the Project districts. Infection prevention measures through the
supply and use of chlorine were started in clinical areas. Roof water catchments or bore hole 
were effected in some health facilities; water tanks and necessary plumbing were provided by
the project. Finally, AMKENI supplied necessary laboratory equipment and expendables to
enable laboratory technicians perform biochemical analysis and hemoglobin estimation.
Increased access to and utilization of services 
Overall, the team found that AMKENI interventions have contributed to increased number of
family planning acceptors. Marked improvement is especially noted for long term and
permanent methods. Increases in use of long-term and permanent methods indicate
improvements in contraceptive method mix, which is heavily skewed toward injectable use in
Kenya. Changes in family planning acceptance for both short term and long-term and
permanent methods are found in Table 10. 
37
Table 9
Equipment Provided by AMKENI to Supported Facilities by September 2004 
# Description of item # Description of item
8 Absorber machine 4 Operating lamp
8 Anesthetic machine 39 Operating table 
137 Angle poise lamp 21 Oxygen concentrator 
44 Baby incubator 34 Oxygen flowmeter 
86 Baby Resuscitator 256 Scales 
7 Bench 103 Screen 
102 BP machine 14 Signboard 
19 Cabinet 124 Sterilizer-autoclave 
3 Caesarean section set 118 Sterilizer-boiling 
94 Chair 271 Sterilizer-drums 
85 Cheatle jars 7 Sterilizer-steam 
119 Cheatle forceps 79 Suction machine 
160 Delivery set 4 Table 
82 Delivery bed 97 Torches
224 Drip stand 4 Trocars
115 Endotracheal tube 341 Trolley 
85 Examination couch 22 Vacuum extractor
24 Fridge 25 Vasectomy set 
28 Instrument container 1 Video machine 
1 Lantern 1 Water pump
60 Laryngoscope 1 Water tank 
35 Minilap set 
Table 10
Trends in Family Planning Acceptance 
Method acceptors Baseline 
(2001)
2004 Percent change 
Short-term methods 127,740 173,606 +36
Long term & permanent 
methods
2,335 3,758 +61
Total Acceptors 130,075 177,364 +36
It should be noted that in Table 10, figures for short-term methods might be inflated due to 
the definition of family planning acceptance used by AMKENI. The Project reports family
planning acceptance for short-term methods as the sum of new users and continuous users
annually. Although the trend would be the same, the figures would have been lower for both 
years if the correct definition were used. 
38
Total number of deliveries from all AMKENI supported facilities have also risen
significantly between 2001 and 2004. The trend of reported deliveries as indicated in Figure 
8 shows remarkable improvement. 
Figure 8
Annual Number of Deliveries From All AMKENI Supported Facilities 
0
5,000
10,000
15,000
20,000
25,000
2001 2002 2003 2004
Normal 
Complicated 
There were however discrepancies between ANC attendance and deliveries in health
facilities. This finding is reflected in KDHS 2003, which reports skilled personnel assist only
42 percent of deliveries. 
A few maternal deaths were reported in some health facilities. Some of them from outside the 
catchment areas of the facilities, may not have attended ANC. The deaths, therefore, do not 
necessarily reflect on the quality of service of those facilities. Rather than staff calculating
maternal mortality ratios, the team advised them to conduct maternal death reviews to find
avoidable factors for each case as lesson for future. 
By 2005, 65 facilities were offering PAC services, depicted in Table 11. It should be noted 
that only one half year of PAC data is available for 2002, so the reported value of 661 clients 
in 2002 should be multiplied by two to estimate an annual number. The total number of
clients served could be estimated to have increased by 42 percent from 2002 to 2004. 
Table 11
Trends in PAC Services
2002* 2003 2004
# of PAC clients 661 1,641 1,880
# of facilities providing PAC services 43 62 65
Only one half year of PAC data is available for 2002. 
39
Conclusions and Lessons Learned 
High input in training and supervision, equipment and renovations for family planning has
lead to high quality service and to increased utilization. Training, supervision and family
planning service delivery are generally well integrated. Frequent stock outs, shortage of staff
in health centers and dispensaries and lack of integration in some facilities are adversely
affecting utilization. The project has too many service delivery components, and risks losing
focus from family planning and selected reproductive health services.
There were, however, challenges that adversely affected family planning utilization. In some
facilities visited family planning services were not fully integrated with other maternal and
child health HIV/AIDS services. Facility client flow arrangements adversely affected the
utilization. For example, in one case, family planning clients had to queue with a large
number of sick children and adults to get served while another section of the facility has
spacious rooms serving only a few PMTCT or VCT clients. In another facility, FP clients are 
first seen in the antenatal room next to the overall maternal and child health and HIV/AIDS 
services and then walk across the compound to receive an IUD or an implant. They then walk 
back to the clinic to complete the documentation. Although everything else was in place in
terms of trained staff, equipment and supplies, the situations cited lead to client
dissatisfaction and cause reduced utilization. 
The HIV/AIDS component of AMKENI is doing well and has implemented some HIV/AIDS 
activities in collaboration with NASCOP and COPHIA and IMPACT Projects. However
they have not integrated fully with family planning services and other service delivery
elements. In child survival, AMKENI’s assistance has been valuable, however, the Project
has played little role as it’s funding was minimal. VCT services are very popular and
AMKENI is beginning to consolidate and integrate the service with FP and other RH
services. As noted previously, the team has not observed any efforts to incorporate family
planning counseling into PMTCT. 
The evaluation team has observed three main issues that have been negatively affecting
FP/RH/CS and HIV/AIDS service availability, quality and utilization during field trips. 
These challenges are not necessarily within the mandate the AMKENI Project. However, the 
team believes that they should be mentioned here since they are crosscutting challenges that 
will continue to have a negative impact on services in the future. 
ß Contraceptive and HIV test kit shortages: Frequent stock outs of contraceptive
commodities are hampering utilization, skewing the method mix and adversely
affecting clients’ choices. In a number of facilities the team visited the method mix
was erratic and differed month-to-month depending on what methods were available. 
The team learnt that stock outs stem from two factors; first there has been frequent
nationwide stock outs due to donor dependency and secondly, local stock outs occur 
due to logistical issues between the district MOH and facilities. The team was
informed by the Head of Reproductive Health Division that there are no contraceptive 
shortages nationwide at the time of this evaluation. We were also informed that
USAID-funded DELIVER Project distributes contraceptive commodities to the
district level and has trained district MOH staff in logistics management. However,
during field trips the team observed that only two of the facilities visited had all
40
contraceptives available. Facility level stock outs seem to stem from the fact that staff 
often does not prepare their returns on time and therefore cannot obtain supplies. 
Lack of transportation may also play a role in contraceptive stock outs. Similarly, the 
team was informed by NASCOP that currently they do have adequate stocks of HIV
test kits, however, availability of test kits at the facility level was inconsistent, as
frequent shortages occurred. 
ß Abolishment of MOH’s cost-sharing policy: Cost sharing was started in Kenya to
enable facilities supplement the Government efforts in financing health care. With
cost sharing funds, government health facilities were able to employ supplementary
staff, both clinical and support, purchase drugs not provided by the MOH, purchase
non-pharmaceutical supplies, hire transport for emergency referrals, and provide
essential laboratory tests. In mid 2004, the Minister of Health abolished cost sharing
in government health centers and dispensaries. The new policy sets a low fixed
payment base for attendance at government health centers and dispensaries and
eliminates community contributions and other charges. This is the single most
important development that has seriously affected access and quality of services in
AMKENI supported facilities. The policy has been erroneously equated to free
services and the initial reaction to the directive was a sudden upsurge of client load,
mainly minor curative services, that was overwhelming to the few staff at the
facilities. The result was that preventive services e.g., FP/RH, VCT and PMTCT
tended to be relegated to the back seat. Our observation in the areas we visited is that 
both staff and members of the communities are demoralized and their stamina to
continue supporting development is eroded. The policy change is also having a
serious detrimental effect on quality of services since the facilities are now lacking the 
funds to hire additional staff and purchase essential commodities and supplies. Our
most important finding is that communities would like to have the policy reversed
since they are willing to pay affordable fees for better quality services, as they were in 
the past. 
ß Staff shortages: Finally, shortages of staff adversely affect service availability, access 
and quality. Staff shortages are particularly an issue at the lower level facilities, e.g., 
health centers and dispensaries. The team has observed dispensaries serving more
than 100 clients a day with only one or two nurses. Abolishment of the cost sharing 
policy has limited the facilities’ ability to hire additional staff, while MOH is not able 
to assign more service providers to these short-staffed sites. 
BEHAVIOR CHANGE AND COMMUNICATION 
The strategic objectives of the BCC component focus on helping individuals and
communities to better understand and act upon their FP/RH/CS and HIV/AIDS needs.
AMKENI uses a variety of partners and approaches to reach men, women and youth in
communities served by target facilities. The Project also works with community groups and
structures, helping to create an environment that supports positive change. In phase one of the 
project BCC activities were conducted in the field by several local implementing partners, 
including AKHS, CAI, CLUSA, FPAK, Kenya Music Festival Foundation (KMFF), UZIMA
41
Foundation and World Relief. However, in phase two the operating partners remain AKHS,
FPAK, CLUSA, CAI and UZIMA. 
The project has a strong focus on linking communities and services using variety of
complementary strategies of community mobilization and sensitization. BCC’s three key
objectives continue to focus on increasing individual/community knowledge and `agency’
with regards to their health –in terms of both preventive and appropriate health seeking
behavior. Specifically, the strategy seeks to: 
ß Promoting preventive and health-seeking behavior
ß Fostering community agency
ß Creating a supportive environment for individual and community change 
BCC Approaches 
A summary of the different approaches that AMKENI uses in its work with communities is
presented below.
ß Family-to Family Communication: The concept of family-to-family communication
includes interactions between individual members of a family unit (e.g. parents and 
their children), as well as between separate families (e.g. two families that live in the 
same village). AMKENI works with a core group of “peer families” to explore
relationships and health issues, and to discuss health enhancing family values and
behaviors. As participating family members acquire skills, discuss real-life situations,
re-define roles and seek health solutions, their insights are shared with other interested 
families and community members through family-to-family peer education, linkages 
with community structures and groups, larger “family bazaars”.
ß Direct outreach to men, women and youth: In addition to working with family units, 
AMKENI continues to reach out to individual family members- men, women and
youth- to raise the same issues of family relationships and health, as well as
addressing the specific health needs of each target audience. Individuals have health
concerns that may best and most quickly be addressed through focused activities.
Therefore, AMKENI uses established networks/channels to reach discrete audiences
including men at work places, youth in clubs and women in community groups.
ß Women’s agency: Women’s agency is a term that describes the involvement of
women as pro-active agents of change. A cornerstone of AMKENI’s approach, 
greater participation of women in health related decision making and utilization, helps
create sustainable impact at the community level. The goal of fostering women’s
agency involves working with the community as a whole to create a supportive
environment for women’s agency. In addition to this, AMKENI conducts specific
activities with women, both individually and through women’s organizations, which
strengthen their skills/roles as advocates and decision-makers in health.
ß Magnification of behavior change: New health norms and behaviors are emerging
that should be shared beyond the family, village, workplace, church, school or group 
to let the larger community know that change has begun. Through its implementing
42
partners and networks, AMKENI works to identify desirable behavior change as it
happens and magnify it quickly and effectively to a larger audience. Activities for
magnification include providing health messages (via a range of discussion groups),
linking to drama outreach activities, creating materials, and using community forums
(e.g. family bazaars, barazas).
Following the EMR, AMKENI revised its BCC workplan that incorporated three key areas; 
consolidating geographic and programmatic scope, strengthening MOH participation at all
levels, and monitoring changes in knowledge, attitudes and behavior. This plan also included
new activities addressing VCT and PMTCT. A significant change in the implementation of
BCC was the involvement of Public Health Officers (PHOs) and Public Health Technicians 
(PHTs) in community activities. 
AMKENI also made efforts to consolidate its programmatic scope by focusing on partners
and interventions that had performed well, thus engaging AKHS, CAI, CLUSA, FPAK and
UZIMA. Although interventions such as Peer Family and Gender Based Violence continued
in phase one districts they were not extended to phase two districts. During the fourth quarter, 
and with community networks active in all districts, the BCC strategy focused on supporting
these networks and monitoring their activities. 
Implementing partners
The engagement of implementing partners was based on the project’s broad mandate of
addressing different audiences as well as broad areas of FP/RH/CS including HIV/AIDS.
Table 2 in the previous section of this report summarizes the approaches used in BCC
interventions in collaboration with the local implementing partners, in both the Coast and
Western Provinces. 
ß CLUSA: BCC efforts under women’s agency target all segments of the community￾men, women youth and school children in Western Kenya. CLUSA in Western has a 
focus at the village/community level building up to the facility level. Although there
is support at the facility level, capacity building in management was not done to the
emphasis of AKHS in Coast province. 
ß Aga Khan Health Services (AKHS): The approach under AKHS aimed to increase 
community participation in managing and utilizing rural health facilities and to
provide platforms for increased women’s agency in advocacy and decision making in
reproductive health at the individual level. The main thrust is on capacity building at
the facility level with supportive activities at the community level that contribute to
demand creation and increased service utilization. This was only implemented in
selected health facilities in Coast Province.
ß Family Planning Association of Kenya (FPAK): FPAK’s approach is to increase
young people’s ability to understand HIV/AIDS and related reproductive health
issues. In addition, the purpose is to enhance their ability to take health action and to 
support community outreach activities by established youth groups using traditional
media. FPAK works in Coast Province only. 
43
ß Community Aid International (CAI): CAI set to reach men in the community via
formal and informal sector workplaces or groups or both, with health information
activities. CAI works in both provinces but more prominent in Coast Province where 
there is a larger array of established workplaces.
ß UZIMA Foundation: Much like FPAK, UZIMA focuses on increasing young people’s 
ability to understand HIV/AIDS and related reproductive health issues. It also strives
to enhance their ability to take health action and to support community outreach
activities by established youth groups using traditional media. UZIMA works in
Western Province only.
BCC progress and achievements to date 
Table 12
BCC Inputs and progress through 2004
Activity Number
# of field agents trained 1,300
# of men and women reached 1,000,000
# of villages worked with 400
# of women group members reached 16,000
# of men reached at worksites 50,000
# of youth groups reached 450
# of primary schools reached 49
# of peer families reached 148
# of PHO/PHTs trained 185
# of small grants to groups 19
Table 12 depicts the overall BCC inputs and progress through the end of 2004. The BCC 
component has continued to monitor its activities using tools that focus on changes in
knowledge, attitude and behavior. From the evaluation team’s discussions with project
personnel, the MOH and community members, it is evident that the project has had a positive 
influence on the knowledge, attitude and behavior of individuals in project sites. This is
further corroborated by the preliminary findings of the Household Survey undertaken at the
end of 2004. These are presented selectively in Figure 9 to demonstrate the effect of BCC 
activities in the community. Figure 9 compares the findings from AMKENI intervention
areas with findings from control areas where AMKENI did not work. Selected indicators
shown in this figure are: 
ß Indicator 1: Percentage of women knowing of key RH issues 
ß Indicator 2: Percentage of women using a FP method 
ß Indicator 3: Percentage of non-users intending to use a FP method 
ß Indicator 4: Percentage of women knowing about 3 STDs 
ß Indicator 5: Percentage of women knowing use of condoms for dual protection 
ß Indicator 6: Percentage of women who talked to husbands about condom use
44
Figure 9
Knowledge and Behavior in Intervention and Control Areas
0
10
20
30
40
50
60
70
80
90
Ind. 1 Ind. 2 Ind. 3 Ind. 4 Ind. 5 Ind. 6
percentage 
AMKENI +
AMKENI -
Depending on whether a community has been exposed to the full complement of BCC
interventions and the community response in terms of participation (high or low), utilization
data at the health facility from 2000 to 2004 has been analyzed and compared to baseline.
The general observation is that those with full intervention record significant changes in the
pattern of FP acceptors by quarter. This trend is corroborated by the group discussions which 
pointed to the fact that through BCC activities, service utilization at all levels has improved 
including for FP. The figure below illustrates the community /facility interaction in selected
facilities. 
Figure 10
Service Utilization in Selected BCC Intervention Facilities
0
100
200
300
400
500
600
700
800
900
Jibana Kizingo Lenga Mgamboni
percent increase in services 
Total
utilization* 
FP utilization 
*Total number of clients served by the clinic.
45
Another strategy to expand access to services used by AMKENI was through outreach, which 
also offers opportunity for mobilization of other services. Outreach activities are largely
integrated with other services. An outreach provided opportunity for registration of VCT,
BTL and attendance of ANC. The field facilitators and animators under the BCC component 
used this as an opportunity to communicate relevant health messages. The evaluation team
had an opportunity to witness one of the outreach activities held at Mihuu Dispensary in
Bungoma District. The numbers seeking both curative and preventive services were
overwhelming and a majority had to be referred. 
Although it is difficult to come up with actual number of people reached by BCC messages 
the catchment population of a given facility is estimated as the potential population reached.
Estimates of populations reached by BCC messages are 1,000,000 people, or about 20% of
the target population. During the project period 400 villages were earmarked and reached.
However, through replication with minimum project input, the Project estimates that 500
additional villages have been reached with BCC messages; an indication that the messages
are valued by the community beyond the project sites. 
Community perspectives, involvement and concerns 
The community response to the project has been positive and this is evident in the level of
engagement. In the selected discussion groups participants noted that they had benefited from
the Project through education in FP/RH/CS and particularly on VCT and PMTCT,
contributing to behavior change in the community. ANC attendance has improved greatly and 
mothers are urged to go early enough to take advantage of PMTCT services. Though
traditional birth attendants (TBAs) are still used widely, their role is slowly changing, playing
a greater role in referral. In Kwale and Malindi Districts, for example, the team was informed 
that TBAs often accompany mothers to the health facility for delivery. At Gongoni
Dispensary the community was satisfied with the health facility and suggested that it be
upgraded to health center status. In Nangina Dispensary community members applauded the
provision of services that incorporated privacy and confidentiality especially with regard to
VCT. 
A key aspect of the project has been harnessing community resources and facilitating the
linkage between the community and the health facility. Concurrently, the inputs in the
adjacent health facilities have in tandem led to changes in the community perception of the
health facilities. In Chwele, for example, it was stated that the communities now feel that they
own the facility. The community is involved in decision-making and an example was given
where through the influence of community representatives, the costs of male circumcision
was adjusted from Kenya shillings 700 to 200. 
The Project’s uniqueness lies in its approach of improving services at the facility level and
mobilizing communities to demand for quality services. The challenge then becomes
maintaining the balance between the two components; so that once communities are fully
mobilized and come for services, these would be in place. Community concerns were
therefore centered on services that they expected but were not in place at the time they need 
to access them. These included availability of appropriate FP methods, VCT kits and ARVs. 
46
The community and service delivery components are dependent on each other in the sense
that the performance of one is a mirror reflection of the other. In the discussion groups it was 
evident that community mobilization and demand creation has taken place. However, the
bigger challenge is at the health facility where constraints range from staff shortage to
negative staff attitude in some facilities and shortage of supplies, affecting the quality of
service. In all the sample communities visited, their overall perception of the services was
that there had been tremendous improvement over the project period. It was only in one
specific facility in Western Province that there were complains of poor quality services
attributed to negative provider attitude. This is of concern given that the project has invested 
in a range of trainings that incorporated quality of care.
Conclusions and Lessons Learned 
In the BCC component, the project employed a multiplicity of approaches and these have
borne fruits. Because these approaches are employed in different sites and at varied levels, it 
is not possible to delineate the contribution of each of the approaches singly. The Project
fully appreciates this and notes that one of the challenges of having such a complex approach
is that it becomes difficult to isolate the impact that any one intervention or package of
interventions is having on the uptake of RH services. However, two of the implementing
partners stand out because of their larger scope of work, namely CLUSA and AKHS. In
describing the intensity of BCC involvement either of these implementing partners had to be
present as the core around which other partners rallied. The main models are
Community/Women’s Agency Model (CLUSA) and Community Participatory Model
(AKHS) implemented in the Western and Coast provinces respectively. Other implementing
partners played a supportive role in bringing specific approaches based on their experience in 
the relevant fields. The youth drama groups were particularly resourceful in community
mobilization and transfer of health messages. Below is a detailed description of the two main
models. Diagrammatic illustrations of both models are shown in Figures 11 and 12. 
ß CLUSA Community/Women Agency Model: Using the participatory approach the
process of community mobilization entails various steps around existing community
structures, the village health committees if they already exist or new ones are formed. 
The composition reflects a gender balance, a man and a woman from each village.
From the project side, the facilitators are trained in a number of skills, which they in
turn pass on to the volunteer animators and PHOs and PHTs who work with
communities as mobilizers. The facilitators take the community through problem
identification, analysis and ranking. Animators and the Village Health Committees
develop comprehensive action plans, which often go beyond reproductive health and 
family planning issues to incorporate poverty alleviation, water and sanitation. The
sub-location health coordinating committees are formed by representatives from the
Village Health Committees and constitute the bridge between the health facility and
the community. 
ß Community Participatory Model (AKHS): This is a modification of the community
participation approach used by AKHS in its primary health care projects over the
years. A key aspect is the strengthening of management systems at the facility level, 
working its way back to the community level. Through the health facility they work
with the PHOs/PHTs who in turn work with the Village Health Committees and
47
community health workers/community resource persons who are linked to the facility.
At the community level they assist in the formation of village health committees and
building capacity through training as well as defining roles, responsibilities,
processes, planning and information/management systems. Management and financial
skills are key ingredients in capacity building at the facility level.
Figure 11
The CLUSA Model in the Western Province 
AMKENI Project
Health Center / Dispensaries
Health Center / Dispensary Health Committees
Women's Agency Coordinator
(CLUSA)
Communities
Animators
Field Facilitators
Lead Animators
Sublocation Management Managemenet Committees
Youth Drama
Groups
PHOs and PHTs
Village Health Committes
48
Figure 12
The AKHS Model in Coast Province
AMKENI Project
Health Center / Dispensaries
Health Center / Dispensary Health Committees
BCC Coordinator
Communities
Community Health Workers
PHOs
PHTS
Aga Khan Health Services
Village Health Committees
The team believes that AMKENI should have revisited the methodological approaches earlier 
during the course of the Project with the view of coming up with a hybrid model that has
optimum effect and uniformly implementing this model in the project sites. This implies,
taking the two main models (AKHS and CLUSA), teasing out what works best and
combining into a hybrid BCC model. An interesting observation is the analysis undertaken by
the project based on whether the intervention is “full” or “basic” and whether the attendant
response or community engagement is “high’ or ‘low’. If high community response were the 
prerequisite for change then one would analyze all the models, isolating what produces this
result as a key ingredient in the hybrid model. This means scaling down the approaches and 
keep those that still would achieve optimal results with less intensity and resources.
There is a need for a uniform and comprehensive approach that can be documented for
replication. At this stage, the Project is in a position to look at the activities against the inputs 
49
and come up with estimation of the costs of each of the models. This is important given the 
fact that in all the reports for BCC, resource constraints were raised as an issue. The
evaluation team envisages that an intervention that focuses on the community, encompassing
selected interventions with the PHOs and PHTs playing a major role as facilitators would
facilitate sustainability. The incorporation of PHOs and PHTs has greatly boosted the
implementation of the BCC component. This cadre of health providers has a wider mandate 
and covers a larger area. PHOs/PHTs are a crucial part of a structural continuum that links 
communities to MOH. It is acknowledged that they are often transferred and this applies to 
all other cadre of service providers and therefore the issue of sustainability would have to be 
applied across the board to all facets of the project. PHT/PHO activities are still constrained 
by transport. The evaluation team feels that besides the emphasis on the development and 
training of animators to replace the project facilitators, the PHOs/PHTs deserve more support. 
This issue was also pointed out at the EMR 2003.
Overall, BCC activities have contributed to increased demand and utilization of services.
However, the implementation of several BCC strategies is labor intensive and costly. In
discussions with the BCC coordinators, it was acknowledged that inasmuch as the approach
has mobilized the community for services; it was also noted to be labor intensive as well as 
requiring a lot of resources. In terms of resource allocation, BCC component has the largest 
share of the budget compared to other components. Acknowledging the contribution of
communities makes it even more resource and labor intensive. 
BCC activities/messages are increasingly inclined towards HIV/AIDS and VCT/ PMTCT and 
it seemed much less on FP/RH the core business of the Project. This focus at the community 
level has to be seen in the context of programmatic shifts with the entry of PEPFAR funds. 
This is the push effect of the Project but also is indicative of the priority needs of the
community. 
On the ground, the team observed BCC activities have gone beyond this to include other
facets of health. Granted that communities may apply the skills gained at their own will and 
extend to other community priority areas beyond FP/RH and health in general, but the Project 
needs to aggressively push for behaviors that address the core of their mandate. Currently, in
this Project we see a lot more than FP/RH and in some instances it may lean much more 
towards general public health issues, such as the focus on water, sanitation, malaria and
typhoid fever, which are real priority areas in most communities. The dilemma in a
participatory approach is that the project may be community-needs driven and these may not 
always be in tandem with the original project strategic objectives. The question is how does 
one maintain the balance between addressing community identified needs and at the same
time steer the community to focus on the core business of the Project. 
In sum, the team concludes that the main lessons learned from the BCC component of
AMKENI are: 
ß A comprehensive approach in community mobilization, BCC interventions and
concomitant improvement of services at the facility level make a difference by
contributing to demand creation and increased service utilization.
50
ß The selection of facilities has to go hand in hand with catchment area analysis so that 
community mobilization for use of services is appropriately linked to availability of
services within reach of the community to avoid frustration. 
ß Outreach services continue to provide services as a stopgap measure to communities
that have no access to such services, averting unnecessary referral.
ß The project strategic objective may not always be in tandem with community priority
needs and in responding to this one may inadvertently focus less on the project
mandate. 
ß A successful community mobilization intervention is likely to trigger replication of
the activities in adjacent communities and beyond with minimum support from the
project. This is a good measure of the impact of the BCC strategy and the project as a 
whole.
CAPACITY BUILDING AND SUSTAINABILITY 
Capacity building is one of the major outcomes of the AMKENI project. This has been
implemented at all levels; the national, provincial, district, facility and the community. The
technical input for the Decentralized RH T&S Teams and the production of relevant training
materials have ensured that nationally these teams will support future trainings and
supervision long after the project. 
To enhance service delivery, the project has supported the DHMTs to strengthen their
capacity in training, management, monitoring and supervision. In collaboration with the
DHMTs the Project has worked to strengthen the role of the Health Center Development
Committees (HCDCs), Dispensary Health Committees (DHCs) and Village Health
Committees in order to enlist community involvement and promote service utilization at the
facility level. In the discussions with these groups it was evident that one of their lasting
benefits from the project is relevant skills that have enabled them to perform better towards 
ensuring quality care to community members. 
The decision to build capacity of existing community groups and structures in some measure 
ensures that these groups can sustain the activities and would use these skills to attract other 
partners. Financial management and record keeping among the HCDCs and communication
and counseling skills among the animators were cited. One of the key observations of the
team was the Project has enriched the skills of the local implementers not only technically but 
also in community mobilization. For example, in three community discussions in Western
Kenya field health workers and women network members acclaimed that “We are
AMKENI”, an indication of high level of ownership and that given the skills acquired they
would be able to push the AMKENI agenda forward after the project.
The incorporation of PHOs and PHTs in Project activities at the community level no doubt 
ensures that long after the project certain activities are fully entrenched given that this cadre
51
of health providers are part of the MOH structure that operates up to the village level. PHOs 
and PHTs are new entrants in the Project, brought in after the EMR. 
In discussions with the local implementing partners, it was evident that although they came in
as experts in their own fields, they have over time benefited from the interaction with
AMKENI. This interaction has enabled them address their own goals in other projects. The 
local implementers stated that they have been able to transfer the newly acquired skills to
other regions where they work. They have also noted that this partnership has also enabled 
them to acquire visibility at the community level.
Physical inputs and institutional buildings are sustainable and it will be the onus of the MOH
to address the issue of maintenance as the project exits. The skills in training are not only
sustainable but also have the potential of a multiplier effect. The strategy of the on-the-job 
training is certainly a move in the right direction in terms of creating critical mass of trained
staff. The approach of strengthening the existing structures both at the community and facility
levels has concretized the ethic of ownership and this is critical for sustainability. In Western
Province the animators have formed a local organization to be able to provide service to the 
community long after the project. However, they would have to be backstopped by a cadre 
such as the PHOs/PHTs. This is why strengthening the latter is so important.
Conclusions and Lessons learned 
In conclusion, the evaluation team feels that the project has done a good job in capacity
building both in personnel and physical inputs. Training and skills development are
sustainable and replicable. The behavior change created and subsequent replication may be
an aspect that stays on depending on the continued availability and quality of services at the 
facility level. There are certain elements, especially in BCC that are not sustainable beyond
the project particularly where there are parallel systems of personnel for example the field
facilitators who are part of the project. Sustainability of the infrastructure is fragile, however, 
where there is strong community involvement and ample management at the facility level
these should be sustained though not at the level of the project. The embrace of cost sharing
by the community has been one way towards sustainability of services through community
support. Thus the removal of cost sharing has thrown into disarray the ethic of community
ownership that has taken a lot of effort to build. It is for this reason that the project needs to 
discuss and start working on an exit strategy where by the MOH begins to take over some of 
the activities.
PROJECT MANAGEMENT 
The AMKENI partnership
AMKENI has a formal partnership among four organizations with complementary expertise
and is governed by a jointly developed Management Agreement. The Management
Agreement sets the following roles and responsibilities in the partnership: 
ß The partners: The partners have full and equal participation in the Management
Committee and in providing overall strategic direction and setting the decision-
52
making framework for the project. Each partner has a lead role in one or more of the 
critical competencies required by the project. Because the partners also have
overlapping strengths, they have worked among themselves to clarify lead roles. 
EngenderHealth is the lead in FP/RH services, client counseling and post-abortion 
care, while FHI is responsible for HIV/AIDS and STI prevention. IntraHealth leads
the activities in performance improvement and supervision, training, and monitoring
and evaluation. PATH has the responsibility to lead behavior change communication, 
child health activities, and serving the youth. 
ß The Management Committee: The overall management of the project rests with a
Management Committee, which originally consisted of one senior representative from
each of the partner organizations, and the Project Director. Each partner has
appointed a senior member who resides in Kenya to represent the organization and
make commitments to the project. On further discussions, USAID/Kenya CTO, and 
the MOH Head of Division of Reproductive Health are now included as members of
the committee. The Management Committee has the overall responsibility for project 
performance, including review and confirmation of annual resource allocation,
workplan and performance review. The committee provides oversight and strategic
directions to the project team. The committee meets on a quarterly basis, and when
necessary, additional meetings are also conducted. 
ß Managing Partner: As the managing partner, EngenderHealth is the recipient under
the Cooperative Agreement, and is the primary contact point with USAID, and for all
invoicing and financial reporting to USAID. 
ß Project Director and Project Staff: According to the Management Agreement, the 
Management Committee delegates full responsibility to the Project Director for
managing and overseeing AMKENI. He has the authority to make staffing and key
decisions in consultation with the partners, and in accordance with the ground rules 
and principles stated in the Management Agreement. The partners have seconded
their staff to AMKENI to enable the project to work as a unified team. The project 
staff has their primary identity to AMKENI and secondary identity to the organization
that employs them. However, they maintain a link with their home institutions to
have a two-way exchange of lessons learned and technical information between the
project and the home institutions. 
Project offices and staffing 
AMKENI has a main office in Nairobi to manage the project’s operations. Office space is 
shared with EngenderHealth’s Regional Office in Nairobi, thus achieving efficiencies and
cost savings in use of space and administrative and support functions. The Nairobi Office
houses the Project Director and the senior staff. The project has two field offices, one in
Mombassa, Coast Province, and one in Kakamega, Western Province. The field offices house 
the Area Managers, technical staff and support staff. These offices are the primary 
implementation stations for activities in the focus districts. 
AMKENI staffing plan is presented in Attachment G. In Nairobi Office, there is an
Operations Manager and Monitoring and Evaluation Advisor, in addition to five senior
53
technical advisors, all reporting directly to the Project Director. The technical advisors
include Training and Supervision, Policy and Systems, Service Delivery, HIV/AIDS, and the
Behavior Change and Communication. Each senior advisor oversees the activities of the
Coordinators placed in the field offices in their respective areas of expertise. There are four 
coordinators in each field office, coordinating the activities in training and supervision,
service delivery, HIV/AIDS, and behavior change and communication. In the Western 
Province office, there is an additional Women’s Agency Coordinator, and eight Field
Facilitators reporting to her. The HIV/AIDS Coordinators in both field offices are shared
with the IMPACT Project, working 50% of their time for AMKENI, and the rest for
IMPACT. The technical staff at area offices reports administratively to the Area Managers. 
In total, the Project employs close to 50 staff. All staff has job descriptions, clearly outlining
their roles and responsibilities. 
Project Reporting 
AMKENI prepares annual workplans including proposed activities, which are first discussed
with the Management Committee, and then presented to USAID. While preparing the
workplan, the project actively consults with USAID, other partners, and the home offices of 
the AMKENI partners. The Project prepares and submits detailed reports to USAID on a 
quarterly basis. The quarterly reports include an overview of project implementation and
discusses achievements for the report period, implementation challenges and issues, and
planned activities for the next quarter. The reports also present monitoring and evaluation
status, expenditure statements and pipeline analyses. 
Financial Management
The Project provides quarterly financial reports to USAID. The Nairobi Office serves as the 
focus for all projects financial operations. Nairobi Office receives financial reports from the
provinces and consolidates the information for reports to USAID. The partners send
quarterly financial reports to the Nairobi Office, where they are reviewed and approved, and 
then the partner expenses are reimbursed. All accounting, and disbursement functions are
done at the Nairobi Office. 
Subagreements with expenditures over $300,000 require audits performed by independent
auditors. Independent auditors also perform an audit at the end of each fiscal year confirming 
adequacy of systems implemented. A final audit is planned for next year to review
expenditures for the entire project to confirm the end-of the project status. 
Conclusions and Lessons Learned
In general terms, the AMKENI partnership formed among four international agencies works
well. The partners have mutually respectful relationship, developed around their respective
technical expertise and their strengths. The partners bring in complementary expertise and
strengths, enabling the project to benefit from synergies, and helps to avoid duplications. 
Identifying a lead agency for each of the technical components has clarified the partners’ key
roles. All agencies have seconded staff to AMKENI, thus allowing the project to work as a 
unified team. 
54
The team had ample observations on how the project staff works together, as well as with
local implementing partners and the communities. Thus the team concludes that AMKENI 
has a highly qualified, committed and hard-working staff at all levels. The reporting and
financial systems put in place are sophisticated, and satisfies USAID’s reporting needs. 
The team has concerns, however, about the management style of the project, which is rather 
top-down and centralized. This style is reflected in the flow of authority between the Nairobi
and the Area Offices. The Area Managers only have administrative oversight for the staff in
the area offices. The technical staff reports directly to the respective technical advisors in
Nairobi. This structure does not allow decentralization of technical and administrative
responsibilities and authority to the field offices, where the actual project implementation is
taking place. 
Finally, the team has observed some duplication in staffing. AMKENI made a decision a few 
years ago to de-link the HIV/AIDS Advisor and the two HIV/AIDS Coordinators from
service delivery staff. The team does not think that this was a justified decision. Placing 
HIV/AIDS advisor and coordinators along with the Service Delivery Advisor and
Coordinators creates parallel systems within the project and does not help better integration
of HIV/AIDS activities with the other elements of the Project. Sharing the time of
HIV/AIDS Coordinators with the IMPACT Project is also not rational. IMPACT Project has 
a much broader mandate in HIV/AIDS, thus expecting the coordinators to split their time
equally between the two projects does not seem realistic. 
MONITORING AND EVALUATION PLAN 
The Project had formulated and submitted an M&E Plan as part of its initial workplan in
2001. As project implementation got underway, the staff decided that the initial plan is not
meeting the Project’s and USAID’s needs and a decision was made to revise the plan. Prior 
to revising the M&E Plan, the Project developed a results framework and building upon this 
developed a causal model. The revised M&E Plan included 195 indicators and their
definitions as well as data sources and frequency of data collection for each indicator. The 
plan also had end-of the project target for each indicator. 
In 2003, the EMR recommended to streamline and repackage the M&E plan. Thus the
Project revised its M&E plan for a second time, and the process resulted in this final M&E 
Plan, which the evaluation team reviewed. The final plan reduced the number of indicators to 
114, while the results framework and the causal model were not modified. Figures 13 and 14 
show the project results framework and the causal model. The indicators were selected with
the intention to serve project monitoring and evaluation in terms of activities supported
(process indicators), the products of these indicators (output indicators), the consequences of
these products (outcome indicators) and how these consequences are reflected in improving
health (impact indicators). Impact indicators such as total fertility rate and HIV prevalence
are not included in the plan, although they pertain to AMKENI’s strategic objective. These
impact indicators are subject to many other factors beyond those controlled by AMKENI. 
Majority of the indicators selected are process indicators, followed by output indicators. 
55
The revised M&E indicators include 21 of the USAID indicators, contributing to five sub
I.Rs of the USAID/Kenya results framework. These sub-IRs are: 
IR1.3.2: Training and supervision for RH improved (2 indicators)
IR2.2.3: Effective community outreach programs carried out (1 indicator) 
IR2.3.3: Enhanced provision of HIV/AIDS prevention (10 indicators)
IR3.1 Integrated FP/RH/CS services expanded (2 indicators) 
IR3.2: Improved knowledge and demand for FP/RH/CS services (3 indicators) 
IR3.2.1: Effective community outreach and interpersonal communications programs
conducted (3 indicators) 
AMKENI uses a computerized database system containing data from the provinces, using the 
ACCESS software. This system, called AmoS, combines service utilization data, trainee data 
equipment data and community interventions. Before AMoS was created, data was entered 
on multiple excel worksheets, which led to data-entry errors. These problems are now
minimized with one complete data set and standard reports and graphs are easily compiled. 
With improved management of information the Project has been able to produce newsletters, 
a brochure, a summary sheet and maps showing the location of the intervention facilities. 
Such presentations of AMKENI’s efforts and results have helped the Project share its
experiences more broadly. 
The data entry and editing for AMoS is done in Nairobi, not at the Area Offices. The Area 
Offices collect data from the facilities and the local implementers and send them to the
Nairobi office in paper form. This decision was made because of the high workload of the 
field offices, although it is recognized that this is not the ideal situation. Editing and
correcting the data at the Nairobi Office is cumbersome and takes a lot of efforts and time. 
The data is computerized in a week and sent to the Area Offices for corrections, and also that 
the Area Offices can produce their own tables and reports. Final data is usually compiled in
six to eight weeks and is incorporated into the Quarterly Management Report. Then the
quarterly reports are distributed to USAID, the MOH, consortium partners and the Area
Offices. 
The team observed that data collection from the facilities follows different procedures in the
Coast and Western Provinces. In the Coast, there is a functional MOH reporting system
developed through the assistance of the AKHS. AKHS has helped the MOH to develop a 
simple data collection tool, which is used throughout the province; however, some data
needed by AMKENI are not included in these forms (e.g., PAC attendance). Thus AMKENI 
Area Office in Mombassa completes AMKENI forms and sends them to the District MOH
office when the AKHS forms are sent. Data collection in the Western Province is more
complicated since there is no such system in the province. The Area Office requires the
facilities to report them every month, but when the reports are late, the staff needs to visit the 
individual facilities to collect data. 
Conclusions and Lessons Learned 
The team fully recognizes and appreciates the efforts that have gone into the monitoring and 
evaluation component of the project. In fact, the team has received much detailed and well-
56
organized information about each project facility, as well as the overall inputs and the outputs 
of the Project. 
The problem with AMKENI’s M&E system is that it is too comprehensive and complicated. 
The issue begins with the AMKENI Results Framework; which is exhaustive and complex.
For example, the framework has 17 lower-level IRs, which leads to a large number of
indicators. Although the number of indicators has been reduced from 194 to 114, this
number is still excessive. It is not possible to monitor project progress on a daily basis using 
all the indicators, which is stated as the intention in the revised monitoring and evaluation
plan. The team has observed that only a small portion of these indicators is used at the
central level for overall project monitoring. However, we observed little evidence that the
M&E is used as a management and performance improvement tool at the field level. 
The evaluation team attempted to comprehend why the M&E plan got so complicated and
complex. One explanation is that the project started off “thinking too big” and did not
receive adequate management and technical assistance to develop a functional M&E plan. 
Once the M&E had started so complex, the Project was not able to simplify its M&E plan. 
The team observed that the technical teams want to include all of their activities reflected in
the M&E so that their contribution to the project achievements would be recognized, which is
not a purpose of an M&E plan. The team also witnessed that the staff viewed the M&E plan 
as an USAID requirement. While the M&E plan is a requirement by USAID, many AMKENI 
staff fail to understand that the primary purpose of an M&E plan is to use it as a management 
tool to track and improve performance within the project. 
57
Figure 13
AMKENI Results Framework
IR-2. Healthierbehavior at individual, family and community 
levels
IR-1. Increased utilization of quality, integrated FP/RH/CS 
services
IR 1.2.2 Increased “agency”
taking action to preserve health
IR 1.1 Increased Quality 
and Accessibility of 
integrated FP/RH/CS 
service delivery
IR 1.2 Increased 
demand for high quality 
FP/RH/CS services
Strategic Objective: To improve the reproductive health of the people of 
Kenya
IR 1.1.1 Improved clinical 
skills among public and 
private providers
IR 1.1.7 Improved systems
for training and supervision
1.1.6 Improved FP/RH/CS 
policies and standards
IR 1.1.2 Improved 
resources management in 
service delivery facilities
IR 1.1.5 Enhanced 
community input into 
facility governance
IR 1.1.4 Continuous 
quality improvement
activity at service facilities
IR 1.1.3 Improved service 
delivery environment at 
health care facilities
IR 1.2.1Increased 
knowledge of how to 
preserve health
IR 1.2.1.1 Increased 
understanding of 
FP/RH/CS
IR 1.2.1.2 Increased 
awareness of the quality 
and availability of 
FP/RH/CS services
IR 1.2.1.3 Increased 
understanding of ways 
in which individuals and 
communities can 
influence the delivery of 
quality FP/RH/CS 
services
IR 1.2.2.1 Increased ability to 
analyze FP/RH/CS problems and 
determine solutions
IR 1.2.2.2 Increased ability to 
discuss and negotiate health 
behaviors
IR 1.2.2.3 Enhanced community 
and provider support for health 
action by individuals/communities
IR 1.2.2.4 Increased advocacy for 
FP/RH/CS by individuals and 
communities
IR 1.2.2.5 Increased 
individual/community 
participation in influencing 
FP/RH/CS service delivery
58
Figure 14
AMKENI Causal Model
TECHNICAL OUTPUT
 
 SUB IR s 
 
IR s
 
SO
SD,HIV,T&SS…………
…...….…………………
……… ….
SD,…………..…………
…...….…………………
…………… SD,HIV,………….……
……………...….………
……………………. SD, HIV,BCC… ……... 
SD,T&SS………………
……………………….…
….....…...
BCC………….……………………
……...
BCC,HIV,SD……………………..
…….
BCC,HIV,…………………………
………. 
T&SS,HIV,……………
…...
T&SS,…………… ……
…...
BCC,SD………………………
………….……………...…...
BCC……………………………
………………………...…...
BCC……………………………
…………...……………...…...
CLINICAL SKILLS
MANAGEMENT
ENVIRONMENT
QUALITY IMPROVEMENT
QI
CLIENT INPUT
POLICIES
SYSTEMS
ISSUES
K/SERVIC ES
K/AGENCY
ANALITICAL ABILITY
NEGOTIATION
PROVIDER SUPPORT
ADVOCACY
GOVERNANCE
IR1.1
QUALITY & 
ACCESS
IR1.2
DEMAND
IR 1.2.1
KNOWLEDGE
IR1.2.2
AGENCY
IR1
UTILIZATION
IR2
BEHAVIOR
SO
HEALTH
BCC……………………
………………….……
………...…... BCC,SD………………
…………………..……
59
FUNDING SOURCES AND ALLOCATION OF FUNDS 
To date, USAID has obligated AMKENI a total of $18,913,090, using funding from several 
sources. The bulk of funding is obligated from population funds, comprising 72% of the total
budget, followed by AIDS funding at 12%. Other funding sources make up a small portion
of the total budget. Child survival funding is 2% of the total obligation and the project
received one-time obligation from malaria funds, comprising 3% of the budget. PEPFAR
funds became available in 2003, through which the project received $657,400. (See Table 13)
Table 13
Breakdown of USAID Obligations by Source 
Funding
Source
2001 2002 2003 2004 Total %
Population 3,057,000 4,228,690 2,647,000 3,589,000 13,521,690 72
AIDS 22,000 1,848,000 283,000 2,153,000 12
Child survival 271,000 50,000 100,000 421,000 2
OVC 100,000 100,000 1
Other health 50,000 50,000 -
Malaria 650,000 650,000 3
PMCT 960,000 400,000 1,360,000 7
PEPFAR 657,400 657,400 4
Total 3,400,000 6,826,690 3,940,000 4,746,400 18,913,090 100
Table 14 presents utilization of project funds by AMKENI. The financial system of the
Project does not allow a breakdown of expenses by funding categories since funding sources 
are not known when workplans are made and sometimes even when expenses have occurred. 
It is not a requirement by USAID to track funds in this way and AMKENI does not do this 
tracking. 
Nevertheless, the evaluation team attempted to present the breakdown of utilization of funds
in terms of program elements. Largest line item is the management category, which used
37% of the total budget, followed by BCC activities at 19%. M&E costs comprise 4% of the 
total budget. Service delivery and training expenses amount to 10% and 15% of the budget, 
respectively. Management line item includes the overhead, office set up and running
expenses, purchase, running and maintenance of vehicles, salaries and benefits for the
management and support staff. Service delivery expenses consist of costs of clinical skills
training, supervision, training materials and salaries of technical staff. BCC line item covers 
the costs of subagreements with the local implementing partners. 
Table 14
Utilization of Funds by AMKENI
Total %
Management 6,947,899 37
M&E (CPC and IntraHealth) 814,250 4
Service Delivery 1,969,908 10
60
Equipment & Renovations 1,289,292 7
BCC (PATH) 3,614,291 19
Training (IntraHealth) 2,837,762 15
HIV/AIDS (FHI) 1,439,688 8
Total 18,913,090 100
The following table illustrates the utilization of project funds by project elements and
activities. 
Table 15
Utilization of Funds by Project Elements and Activities
Funding source Utilization by project elements and activities 
Population Family planning, particularly long-term and permanent 
methods, RH counseling, quality improvement, IP, 
facilitative supervision, equipment and renovations, PAC, 
development of training materials
HIV/AIDS Establishment of VCT and PMTCT centers, training of 
service providers, training in IP, provision of water, setting 
up incinerators, equipment, and integration of FP to VCT
Child survival Training and provision of equipment for newborn care, 
immunization, IMCI training
OVC Youth activities to promote behavior change 
Malaria Prevention and treatment of malaria in pregnancy, promotion 
of ITN use
PMCT Community activities, training, renovations and furniture
PEPFAR Training fro PMTCT and VCT, prevention of opportunistic 
infections, development of training materials, renovations for 
clean water
Under its agreement with USAID, AMKENI is responsible for providing approximately
$800,000 in cost share funds. Over the course of its four years to date, several partners and 
stakeholders have helped share the cost of implementing the Project. The major partners
have been the MOH and community members, who contributed in kind. The MOH provided 
facilitators for the training workshops at no cost to the project and its contribution is
estimated about $152,952. The community volunteers (e.g., animators and youth group
members) gave their time and effort at no cost to the Project; with AMKENI only meeting
transport and refreshment costs incurred in conducting project activities. AMKENI estimates 
that the value of contributions of community volunteers amounts approximately to $379,792. 
61
In addition to in-kind contributions, AMKENI raised funds from non-USAID sources to
support its activities. (See Table 16) 
Table 16
Summary of Cost Share Obligations
Contributions in kind Contributors and Activities USD
MOH-Training facilitation 152,952
Community volunteer services 379,792
Contributions in cash 
from non-USAID sources 
Tides Foundation-NSV 100,000
SIDA-PAC 29,456
Marie Stopes-IP - 3,602
UNICEF-Cope for Child 25,168
CLUSA-Women Agency 20,000
Gates Foundation-Child-to-child 65,000
Hewlett Foundation-Youth pharmacy 65,069
Collins Bullett Foundation- Staff time 15,000
UNC-Office rental 6,662
Total 862,701
RELATIONS AND COORDINATION WITH USAID, MOH AND OTHER 
STAKEHOLDERS
AMKENI has been able to establish excellent working relationships with the MOH since the 
EMR in 2003. A major concern raised by the EMR was the inadequate coordination with the 
MOH in project implementation. The Project succeeded to significantly improve its relation
with the MOH over the last few years. The evaluation team was impressed to observe that 
MOH staff is closely involved in project implementation at all levels. The team also observed 
a high level of ownership of the project by the MOH, which is applaudable. The Head of
Reproductive Health Division has recently became a member of the Project Management
Committee. The team believes that this was another positive step taken by the Project to
strengthen its collaboration with the MOH. 
AMKENI maintains a satisfactory relationship with USAID/Kenya. USAID/Kenya is content
with the Project’s responsiveness and the team observed that the USAID/CTO is closely
involved with project implementation. The CTO maintains daily contact with the Project,
providing feedback and direction. The team was also impressed to observe a high level of
ownership of the Project by communities throughout the field trips. 
AMKENI coordinates closely with the IMPACT Project, USAID’s flagship project for the
prevention and treatment of HIV/AIDS. The areas rightly selected for AMKENI’s support
are PMTCT and VCT, while IMPACT implements a much broader range of activities. 
62
Population Council, with funding from DFID implements a Safe Motherhood Project in the
Western Province. The mandates of the Safe Motherhood Project and AMKENI are almost 
similar, except that the Safe Motherhood Project does not have a community component and 
unlike AMKENI, the Project works province–wide, covering all districts. The two projects 
coordinate at central level through the RH Inter-agency Coordinating Committee (RH-ICC) 
where both AMKENI and Population Council are members. Their activities are also
coordinated at the provincial and district levels and the team did not observe any duplications 
of effort. 
UNFPA supports the implementation of a comprehensive FP/RH program through the MOH
in Kenya. The project works in 9 selected districts in the Coast, Eastern, Central and Rift 
Valley Provinces. The only districts AMKENI and UNFPA overlap are Kilifi and Kwale. 
The efforts of UNFPA and AMKENI are coordinated through the district stakeholders’
forums, and there were no duplications. 
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VI. SHORT-TERM RECOMMENDATIONS FOR AMKENI
The recommendations outlined under this section are for AMKENI to consider over the
remaining life of the Project. The team believes that these specific recommendations are
realistic and appropriate for AMKENI to undertake over the next year to consolidate gains of 
the project and achieve a smooth close-up of the ongoing interventions. 
ß The basic thrust of the AMKENI, working with both the facilities and the
communities to create linkages and to improve service quality while increasing
demand for services is a powerful approach. This approach should be maintained
over the last year of the project. 
ß The current three-pronged strategy implemented by AMKENI is appropriate and
should be continued with some modifications. The project should streamline its
interventions outlined under the Strategic Objective 2 over the next year by focusing
on 1) promotion of healthier behaviors in FP/RH/HIV/AIDS, and; 2) increasing
demand for FP/RH/HIV/AIDS services. 
ß So far, AMKENI has completed decentralized T&S system pilot interventions for 16 
facility–based teams. The project should speed up and accomplish the
implementation of the decentralized T&S system in the remaining 81 facilities. 
ß AMKENI should undertake a rapid assessment and document the outcomes of its
training activities by the end of the Project.
ß By the end of the project, AMKENI should ensure that all PMTCT and VCT
providers in Project facilities have been trained in basic family planning counseling.
ß AMKENI should work with the newly awarded CAPACITY Project to coordinate
pre-service training activities. AMKENI should prepare to transfer technical
assistance in pre-service training to the CAPACITY project by the time of closure. 
ß USAID and AMKENI should consider assisting MOH with vehicles to transport
supervisors by providing a vehicle to each of the AMKENI current provinces
ß AMKENI should ensure that family planning services are fully integrated with other
maternal and child health care services, PMTCT, and VCT in all target facilities by
the end of the Project. This includes a careful assessment of how services are
organized in each facility and provision of technical assistance to the facility 
management and staff as needed. An analysis of patient flow in facilities might
provide useful information to increase access to family planning services. 
ß Although there is evidence that family planning method mix has improved in project
areas, additional efforts are needed to further improve method mix and to ensure
continuity of family planning use and compliance. 
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ß AMKENI should work closely with the MOH, and the DELIVER Project to ensure 
that family planning commodities are available at the facility level. AMKENI should 
encourage facilities to report to the Districts on utilization of contraceptives so that
facilities receive contraceptives before stock-outs occur. AMKENI should also work 
with the DELIVER Project to follow-up on District staff trained in contraceptive
logistics by the DELIVER Project. 
ß AMKENI should continue working with AKHS to provide input and feedback to the 
report AKHS has been preparing on the impact of abolishment of cost-sharing policy 
on service availability, quality and utilization. 
ß AMKENI’s BCC component should pay special attention on men and male youth as 
the locus of power. This is particularly critical for Coast Province where although
women use contraceptives, this is to a large extent done secretly.
ß AMKENI should place higher emphasis on FP/RH BCC messages. 
ß Given the role played by the PHOs PHTs, it is prudent that they are facilitated much
more by the Project in terms of transport. This is a small but valuable sacrifice to
make alongside the heavy equipment supplied by the Project. The team recommends 
that AMKENI provide bicycles for the PHOs and PHTs. 
ß AMKENI should analyze the Household Survey data and disaggregate it by province 
to facilitate comparison with the end of project targets, some of which were province 
specific. The analysis should also determine the most successful and cost effective
BCC approach. 
ß The team recommends AMKENI to consolidate project interventions in current 10
districts within the Coast and Western Provinces over the next year. It is not realistic 
for the Project to extend to other districts or provinces over a one-year timeline. 
ß AMKENI should undertake an assessment within the current districts to analyze its
exact coverage of the populations. This analysis can be done by mapping out of the 
catchment areas of the current AMKENI-assisted facilities. Based on this analysis,
AMKENI should decide whether it is feasible to assist additional facilities within the
current districts. AMKENI should consider its remaining resources and the timeline
when deciding to expand to additional facilities.
ß If AMKENI decides to assist additional facilities, it should develop criteria for
selecting those sites. The Project should consider 1) the catchment areas of the
existing facilities and additional eligible facilities; 2) needs of each facility in terms of
training, facility upgrades, equipment and linkages with the communities; and, 3)
willingness of the facility management to improve quality and service utilization. The
focus of the expansion should continue to be on lower level facilities, particularly the 
most needy dispensaries. 
65
ß AMKENI should delegate both administrative and technical oversight responsibilities
to the Area Managers for field implementation. In this transition, technical advisors 
should work with and provide technical support to the Area Managers. 
ß AMKENI should review its M&E Plan and retain those indicators only essential for
tracking performance and progress of the Project. This task should be delegated to 
the M&E Advisor, with support from the Project Director. While revising the
indicators, the Project should maintain those 21 indicators, which contribute to the
M&E Plan of USAID/Kenya. Given the short period of time left for project
implementation, the team does not recommend AMKENI to revise its Results
Framework. 
ß Once a short list of indicators is developed, AMKENI should require the Area Offices 
to electronically enter the data into the database. The M&E Advisor should work
with the Area Offices to train them on how to use the database. 
ß AMKENI should revise the definition it has been using for family planning
acceptance and adopt the international definition. Data collected so far needs to be
readjusted accordingly. 
66
V. LONG-TERM RECOMMENDATIONS FOR USAID/KENYA FOR 
FUTURE PROGRAMMING
The recommendations provided in this section are for USAID/Kenya for future programming
purposes, specifically developed for the new five-year follow-on project. The evaluation
team has based these recommendations on lessons learned from AMKENI, its achievements 
and challenges, as well as observations on the broader Kenyan health context. Since
USAID/Kenya is planning for a new competitive procurement within a year, these
recommendations should be considered procurement sensitive. 
ß The team recommends that the follow-on project should focus on selected
reproductive health issues with special emphasis on family planning, VCT and
PMTCT. Other focus areas may include PAC, ANC, and IP. Maternal health activities 
should be minimized, with selected and targeted interventions. 
ß The team recommends that child survival interventions should not be part of the
follow-on project. The needs for improving child health are great and multifaceted,
and should be the mandate of other large-scale projects. 
ß The team recommends that USAID/Kenya should coordinate closely with the new
DFID-funded Safe Motherhood Project while developing the follow-on procurement
instrument. At the time of this evaluation, the Safe Motherhood Project was about to 
be awarded.
ß The team also recommends that USAID/Kenya should continue collaborating with the 
donor community to ensure contraceptive security, since contraceptive shortages are
severely impeding service availability and quality. Coordination efforts among
donors should focus not only on availability of contraceptives at the central level but
also at the district and facility levels. 
ß USAID/Kenya may consider initiating policy level talks with the MOH to reverse the 
cost-sharing policy and/or explore alternative means of financing health care at lower
level facilities. As discussed in detail throughout this report, the abolishment of cost￾sharing policy has had a significant negative impact on service availability, quality
and utilization. AMKENI and AKHS would provide additional information on the
impact of the change of MOH’s policy to assist USAID/Kenya’s advocacy. 
ß USAID/Kenya may consider fostering synergies between the follow-on Project and
the CAPACITY Project by directing emergency staffing assistance foreseen under the 
CAPACITY Project to understaffed dispensaries within the new provinces. 
ß The follow-on Project should maintain AMKENI’s approach to linking facilities and
communities. This has been a unique approach pursued by AMKENI and the team
has documented ample evidence that the approach has been highly successful. 
ß The team also recommends that the follow-on Project should maintain AMKENI’s
overall three-pronged strategy incorporating T&S, service delivery and BCC
67
components. The following specific recommendations provide directions to modify
and refine AMKENI’s strategic approaches. 
ß The follow-on Project should not be involved in pre-service training. Pre-service 
training interventions currently implemented by AMKENI should be transferred to the 
CAPACITY Project, which has a crosscutting mandate in human resource capacity
building. The transfer should be cautious and gradual, however, in order to avoid
interruption of ongoing pre-service activities of AMKENI. 
ß All components of the follow-on Project should focus on integrating FP/RH and
HIV/AIDS interventions at the field level. 
ß The follow-on Project should use lessons learned from AMKENI to simplify and
streamline BCC activities by implementing the most effective strategy that reflects a
hybrid of the most successful elements of the piloted BCC models. The best scenario 
is where there is a community participatory model as the umbrella that engages the
whole community and different audiences. This would further be integrated with
community (VHCs) and MOH (PHO/PHT) structures to ensure effectiveness and
future sustainability. The revised model would then be implemented uniformly in the
project sites. For ease of implementation, coordination and monitoring progress, it
would be more feasible to work with 1-2 local implementing partners. 
ß The team recommends that the BCC interventions of the follow-on Project should
focus on FP/RH themes and on men and youth. 
· The team recommends that AMKENI should complete and phase-out its activities in
Coast and Western Provinces by the end of the Project in March 2006. The follow-on 
Project should select and move on to working in two new provinces. Subject to
discussions with USAID, MOH and other stakeholders, the team recommends
considering the Eastern and Nyanza Provinces for the next phase. 
ß The follow-on Project should focus on provincial, district and facility level activities
and should not include national level interventions. Similarly, the next phase should
focus on improving public sector services, specifically at the lower level facilities,
where high-level demand is obvious. 
ß In line with the lessons learned from AMKENI, the follow-on Project should have a 
decentralized management structure. The overall authority and responsibility of
overseeing project implementation should be delegated to the Project Director.
Consequently, the Project Director should delegate the administrative and technical
oversight of the field implementation to the Area Managers. The role of the senior 
technical staff should be providing technical assistance and support. 
ß One of the lessons learned from AMKENI is that the creation of separate HIV/AID
staffing has not helped integration of HIV/AIDS and other services at the field level. 
Similarly, separation of senior staff overseeing policy and systems in training and
staff responsible for training activities has had little value. The follow-on Project
68
should be required to consolidate technical staffing under teams in line with the
project’s main technical components; training, service delivery and BCC. 
ß The follow-on Project should continue AMKENI’s effective coordination with the
IMPACT Project and the current division of labor. With that said, the team does not 
recommend sharing of staff between the two projects. Sharing of field staff between
AMKENI and IMPACT may have had merits, however, the team is concerned that
fifty-fifty sharing of staff time between the two projects is not practicable. IMPACT
has a much larger mandate in HIV/AIDS compared to AMKENI and it is not realistic 
to expect staff to allocate equal time and efforts to both projects. 
69
ANNEXES
A. SCOPE OF WORK 
External Evaluation of USAID/Kenya’s RH/FP/CS Portfolio
1. INTRODUCTION
USAID/Kenya’s health sector strategic objective (SO3) 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 efforts towards reducing unintended and
mistimed pregnancies, improving infant and child health, reducing HIV/AIDS transmission,
and reducing the threat of infectious diseases.
In 2000 the mission designed a reproductive health strategy in line with its Intermediate
Result 3: Increased use of family planning, other reproductive health services, and child
health services. Under this approach emphasis was placed on improved quality and demand
for reproductive health services. Thereafter the Cooperative Agreement with EngenderHealth
was developed to implement this strategy.
BASIC PROJECT INFORMATION
Project Name and Number AMKENI CA#623-A-00-00019-00
Initial Total Estimated Amount $ 15,997,129 
Increased Total estimated cost $ 18,913,090
(expanded SOW to include PEPFAR)
Obligations to date $ 14,166,690
2. BACKGROUND
The EngenderHealth Cooperative Agreement is a five year initiative to promote improved
reproductive health and child health in Kenya with an emphasis on increasing utilization of
facility based integrated family planning/ reproductive health/ child survival/ HIV
(FP/RH/CS/HIV) services. The project, called AMKENI is implemented by a partnership
agreement of development organizations led by EngenderHealth. They include Family Health
International (FHI), the Program for Appropriate Technology in Health (PATH),
International Training for Health (INTRAH), and the Carolina Population Center (CPC). 
Local partners include the Aga Khan Health Services (AKHS), Community Aid International
(CAI), and the Cooperative League of the U.S.A (CLUSA), Family Planning Association of
Kenya (FPAK), the Kenya Music Festival Foundation (KMFF), the UZIMA Foundation and 
World Relief.
AMKENI started in December 2000 and will run through September 2005. The project works 
with local NGOs, faith based organizations, private sector partners, provincial and district
authorities and teams, and with various departments within the Ministry of Health.
70
AMKENI seeks to achieve a sustainable increase in the quality of, the demand for and the
utilization of integrated FP/RH/CS/HIV/AIDS services at the community level. This goal is
being achieved through two complimentary approaches:
· working directly with the central level of the Ministry of Health, specifically the
Division of Reproductive Health, to strengthen and reform its systems for managing
FP/RH/CS training and supervision, and
· working in ten target districts in Coast and Western Provinces, in partnership with the 
Ministry of Health and local partners, to improve the quality of FP/RH/CS/HIV/AIDS 
services in ninety-six target facilities, and to increase the community’s demands for
these services. 
The project activities aimed at accomplishing this goal are grouped into four broad
categories: service delivery, HIV/AIDS, training and supervision, and Behavior Change
Communication (BCC) activities. 
3. EXTERNAL EVALUATION SCOPE OF WORK
i. Objectives
The evaluation team will examine activities in USAID/Kenya’s increased use of family
planning, integrated reproductive health, and child survival services portfolio to assess the
following:
· the progress of the AMKENI project towards the achievement of specific project
objectives and USAID/Kenya’s Intermediate Result 3;
· the impact on quality, demand and utilization of services;
· the impact on national training and supervision systems;
· the communities (in project areas) perspective of the impact of the project;
· the pace of project implementation given the geographical focus and expansions of
scope, and any general changes in area of emphasis and changes in specific activities 
necessary to successfully carry out project objectives;
· the appropriateness of the strategies towards achievement of the project objectives;
· the impact of shifting funding mechanisms i.e. PMCT and later PEPFAR;
· the current and potential role of this portfolio of activities to developing sustainable
community demand and utilization of services;
· overall challenges and lessons learned; and 
· Key areas of future focus for the portfolio, the value, cost and potential for expansion
into longer-term, more comprehensive activities and the actions necessary to realize
this.
· The degree to which the project has enabled communities and individuals identify
health problems, seek solutions and move towards more health behavior including
seeking services;
· The degree to which systems and processes are established that lead to sustained
behavior change and increased demand for services.
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ii. Participants, critical skills, and audience for the evaluation
Team Members:
The review team will consist of the following persons with specific expertise and experience:
· Team Leader: with senior program management experience particularly with regard to
health sector reform, FP/RH/CS and HIV service delivery, financial systems and M&E.
Should have excellent writing skills.
· Two Consultants: experience in M&E, service delivery, and training with regard to
FP/RH/HIV/AIDS/CS.
· Two Consultants: experience in behavior change communication (BCC).
· Ministry of Health Representatives: including Division of Reproductive Health,
NASCOP, Coast and Western Province PMO and DHMT. 
· USAID and project staff
Prior to commencing the evaluation the team will meet with USAID, MOH and AMKENI 
staff and management team to clarify the scope of the evaluation and to finalize the
schedule of activities. 
· USAID/Kenya (OPH, controllers office, PDA)
· MOH
· AMKENI partners
iii. Key Informants
· Project representatives
· MOH personnel
· Other Cooperating Agencies
· USAID staff
· Other donors, as appropriate
· Intended beneficiaries
iv. Issues to be addressed by the team
Topical Issues
The evaluation will include, but not be limited to, an assessment of the impact of this project 
on quality, utilization and demand for FP/RH/HIV/CS services in Coast and Western
Province
Service Delivery – quality, access, utilization, integration
Training and Supervision – Impact on National Policy and systems for training and
supervision; training linked to service delivery; performance improvement approach
BCC – impact on demand and utilization of services. 
72
Change in knowledge and attitudes; community ownership and capacity building;
establishment of systems and processes for increasing agency; steps community has taken to
address their health problems
HIV Services – quality, access, utilization, linkages, and community support
Monitoring and Evaluation Systems – efficiency, and evolution during the life of the project
Project Management – Administrative and financial management of the Nairobi, Western and 
Coast offices.
Relationships with MOH and other vital partners
Process Issues
The team will assess issues related to the process of implementation of project activities
Achievement of goals and objectives
The evaluation team will assess and comment on the extent to which the project has:
· met stated goals and objectives;
· involved the MOH
· addressed the integrated district workplans formulated by the DHMT 
· developed sustainable systems with the MOH and beneficiary communities
· developed and implemented appropriate monitoring and evaluation tools to track
progress towards stated goals and objectives;
· developed capacity of partner organizations;
· acted upon/implemented recommendations from the mid term evaluation; and
· responded to changed environment for FP/RH/HIV/AIDS
The evaluation team will also make recommendations concerning appropriate strategies for
scale up of integrated RH/FP/HIV/CS activities. 
Reporting:
While the primary objective is to assess programmatic effectiveness, the team will also assess 
the degree to which the project has complied with USAID reporting requirements.
4. Specific activities
Activities to be conducted by the team will include, but not be limited to:
· Initial conference with USAID/Kenya staff, AMKENI partners and MOH
representatives during which the team will present a proposed schedule for
undertaking the evaluation for input and finalization; 
73
· Review of relevant documentation (including project studies, status reports,
evaluations, USAID strategy documents, and other reports related to FP/RH/CS/HIV
in Kenya).
· Meetings with project partners and staff ;
· Site visits and meetings with MOH officials and other stakeholders including project
staff, BCC implementing partners, service providers, PMO, DHMT, field agents; 
· Structured interviews conducted with a representative sample of community members
in Coast and Western Province to assess their satisfaction with the project in question 
and to secure recommendations for future program direction/project improvement;
and
· Dissemination meeting during which the team will present the first draft of the
evaluation report, highlighting key findings and recommendations and receive
clarification/input from stakeholders.
5. Report and recommendations for future program direction
The team leader will submit a draft report to USAID prior to the post-evaluation debriefing. 
The final report will be submitted no later than 14 days from the date of the final debrief to 
USAID. The document will be organized as follows:
I. Executive Summary
II. Background
III. Summary of key findings and conclusions
IV. Recommendations for future directions
V. Annexes
a. Scope of Work
b. Evaluation Team Members
c. List of Interviewees
d. Methodology
e. Questionnaire tools
The report will include the following information:
· Review methodology 
· Project accomplishments to date: Brief description of progress on each component;
notable successes/failures/challenges; attention to cross cutting program issues such
as demand creation and increasing access to services; increase in quality, demand and 
utilization of services; Monitoring and Evaluation (M&E) activities. 
· Project organization and management: prime/sub contractor relationships;
strengths/weaknesses; staff skill and mix; communication/relationship with partners,
MOH; timeliness and quality of reporting. 
· Financial analysis: (Total Budget) obligations to date and cost of each program
component
· Issues and recommendations: problems/challenges their causes recommended actions;
potential problems/challenges; suggested cooperative agreement amendments; future
direction. 
· Upon acceptance by USAID the Team Leader will submit one report in four bound 
copies and an electronic copy on a 3.5” diskette in MS word. 
74
6. References
The management team will review all project documentation, including but not limited to the
following:
a) USAID/Kenya APHIA project document.
b) USAID RFA prior to the AMKENI project.
c) USAID PEPFAR strategy for Kenya
d) Proposal by EngenderHealth led consortium.
e) AMKENI cooperative agreement and subsequent modifications.
f) AMKENI PEPFAR proposals (PMCT, VCT and SI and non ART HIV services)
g) Sub-agreements between EngenderHealth and its core partners and local partners.
h) All MOU’s between AMKENI and other CAs, other projects, target facilities.
i) The project’s initial 18-month work plan; Year two 12-month work plan; Year three 12-
month work plan; Workplan and budget for Year 3 and 4; M&E plan; Behavior Change 
and Communication (BCC) Strategy; PMCT proposal; 2005 PEPFAR proposal.
j) AMKENI quarterly reports to USAID through December 2004.
k) Mid term evaluation report
l) Preliminary reports from Household survey; documentation of the decentralized
supervision system; documentation of the AMKENI model linking “demand” with quality
services and healthier behavior.
These materials will be made available to the review team members two weeks prior to the 
start of the review in hard copies and electronically.
7. Proposed schedule
It is anticipated that the evaluation can be completed in nine weeks. The evaluation will
begin on January 24th 2005 and end no later than March 11th 2004 in terms of meetings, 
document reviews, interviews, fieldwork, draft report writing, and debriefings with USAID
and dissemination to stakeholders. The Team Leader will provide a final report to USAID no 
later than Monday March 28th 2005.
A six-day workweek will be authorized for this management review. The Team Leader will
coordinate preparation of the final schedule of meetings and field trips. The Team leader will
ensure that the schedule, as agreed with USAID and AMKENI is adhered to.
The evaluation will take place over nine weeks beginning January 24th 2005, and will 
include:
· A desk review of materials 6 days
· Team briefing and orientation 1 day
· Site visits (Coast and Western Province) and interviews 15 days
· Prepare draft report 8 days
· Dissemination to USAID, MOH and stakeholders 6 days
· Completion of written report 18 days
· Presentation to USAID in March 28th 2005
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8. Logistics and Support
All funding and logistical support for the evaluation team namely the Team Leader, two
Service Delivery Consultants and two BCC Consultants, will be provided through POPTECH 
from the USAID/K Field Support. Activities that will be included in the budget include
recruitment of the Team Leader and Consultants, their travel into and out of the country,
payment of the Team Leader and four Consultants for a six-day work week, support for all 
expenses related to the management review and logistical support. This logistical support
includes per diem, communication costs, supplies and/or fixed other direct costs (except local
travel). POPTECH will meet the costs for stationery, computers for local consultants, and
supplies. POPTECH will also meet the costs for publication and dissemination of the draft
and final reports. The Mission will meet the expenses for the Ministry of Health
Representatives, the costs for the local travel of the evaluation team, which includes air
flights, and ground transportation. The mission will organize and meet the expenses related to 
the stakeholders meeting. The mission will provide logistical support in terms of office space 
and meeting facilities for the team.
9. Relationships
The team leader will report directly to the Senior RH/FP advisor in Office of
Population and Health USAID/Kenya and work closely with the CTO and other
relevant USAID officers.
10. Completion of deliverables
The contract will be considered successfully completed when the Team Leader
submits to USAID/Kenya the final report document.
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B. LIST OF CONTACTS 
USAID/Kenya 
Sheila Macharia, Reproductive Health Specialist, Office of Population and Health (OPH)
Michael Strong, Senior Program Manager, OPH 
Janet Paz Castillo Chief, OPH
Crispus Kamanga, Project Management Specialist (M&E) OPH
Bedan Gichanga, Health Systems Specialist, OPH
Joseph Ondigi, Senior Finance Specialist, Controllers Office
Stephen Ragama, Program Development and Analysis
MOH
Nairobi
James Nyikal, Director of Medical Services
Ambrose Misore, Head of Department of Preventive and Promotive Health Services 
Josephine Kibaru, Head of Division of Reproductive Health 
Anne Wamae, Head of Division of Child Health 
Coast Province 
Anderson Kahindi, Provincial Medical Officer
Ben Kinara, Provincial Health Administration Officer 
Alice Menza, Provincial Nursing Officer 
David Wanjalla, District Medical Officer, Mombasa 
Alice Kadilo, District Public Health Nurse, Mombasa
Mwakangalu Dickson, Medical Superintendent, Kilifi DMOH
Julius Jillo, District Health Education Officer, Kilifi
Anisa Omar, District Medical Officer, Malindi
Esther Mwema, Hospital Matron, Malindi DMOH
Edward Mumbo, District Public Health Nurse, Kwale
David Baya, District Health Education Officer, Kwale
Western Province 
Janet Wasiche, Provincial Obstetric and Gynecologist 
Judith Sitti, Deputy Provincial Nursing Officer
Zablon Kebeya, Provincial Public Health Officer
Asconi Oca, Provincial AIDS and STDs Coordinator
Dr. Shikanga, DMOH, Kakamega 
Monica Ongowo, DNO, Kakamega 
Carolyn Obiero, DPHN, Kakamega
Dr. Wasike, DMOH, Bungoma
Innocent Sifuna, PHO, Bungoma
Ruth Odongo, DPHN, Bungoma
Alice Selete, DPHN, Busia
77
Simon Danda, DHEO, Busia
Mirasi Tom, DHNO, Busia
J. Mukabi, DMOH, Busia
AMKENI 
Nairobi Team 
Job Obwaka, Project Director 
Chris Oyoo, Service Delivery Advisor
Joel Rakwar, HIV/AIDS-RH Advisor
Linda Archer, Monitoring and Evaluation Advisor
Anjala Kanasethasan, BCC Advisor
Emma Njonjo, Learning and Performance Advisor 
Karanja wa Mbugua, Policy and Systems Advisor
Mbugua Kang’ethe, Operations Manager, Finance and Administration 
Joyce Isiaho, Project Administrator
Emah Macharia, Monitoring and Evaluation Assistant 
Coast Province Team 
Feddis Mumba, Area Manager
George Avosa, Training and Supervision Coordinator
Patience Ziroh , Service delivery Coordinator 
Frank Mwangemi, HIV/AIDS Coordinator (50% )
George Kaggwa, BCC Coordinator 
James Musyoki, Assistant BCC Coordinator 
Western Province Team 
Moses Lukhando, Area Manager
Kennedy Odera, BCC Coordinator 
Eunice Okoth, Training and Supervision Coordinator
Cornelius Kondo, Service Delivery Coordinator 
Allan Gohole , HIV/AIDS Coordinator
Joyce Wafula, Women’s Agency Coordinator
EngenderHealth 
David Adriance, Regional Director for East and South Africa
Family Health International (FHI) 
Ndugga Maggwa, Regional Director 
IntraHealth International 
Mary Wieczynski Furnival, Regional Director
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Alix Grubel, Kenya Country Director
PATH 
Rikka Trangsrud, Country Director
Michelle Folsom, Regional Director 
The POLICY Project
Colette Aloo-Obunga, FP/RH Coordinator 
Population Council 
Charlotte Warren, Program Associate 
NASCOP
Mary Wangai, Deputy Head, in charge of ARV
Pauline Mwololo, Program Officer
Aga Khan Health Services, Kenya 
Salim Sohani, Director of Community Health Department
Swafiya Salim, Financial Management Specialist
CLUSA
Joyce Wafula, Women’s Agency Coordinator 
Family Planning Association of Kenya
Linus Etyang, Program Director 
Juma Mwatsefu, Project Manager
Community Aid International 
Joseph Kwaka, Program Coordinator 
UZIMA Foundation 
Malesi Kinaro, Executive Director 
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C. DOCUMENTS REVIEWED 
USAID/Kenya. Integrated Strategic Plan 2001-2005.
United States Mission to Kenya. October 28, 2004. Five Year Strategy for the President’s 
Emergency Plan for AIDS Relief: Strong networks for a Sustained Response. 
USAID/REDSO/ESA. July 5, 2000. Request for Application for a Cooperative Agreement. 
AVSC International. September 18, 2000. Technical Application for a Cooperative
Agreement for the Delivery of Family Planning, Reproductive Health and Child Survival 
Services in Kenya: RFA 623-00-A-020. 
USAID/REDSO/ESA. December 19, 2000. Award No. 623-A-00-01-00019-00, Delivery of 
Family Planning, Reproductive Health, and Child Survival Services in Kenya. 
USAID/REDSO/ESA. (eight documents dated between 2001 and 2004). Amendments to
Award No. 623-A-00-01-00019-00. 
EngenderHealth. July 1, 2003. Award of Subagreement to U.S. Organization IntraHealth.
EngenderHealth. January 1, 2001. Award of Subagreement to U.S. Organization Family 
Health International (FHI). 
EngenderHealth. December 19, 2000. Award of Subagreement to U.S. Organization
Program for Appropriate Technologies (PATH). 
EngenderHealth. January 1, 2001. Award of Subagreement to U.S. Organization University 
of North Carolina. 
EngenderHealth. May 2001. AMKENI Initial Workplan and Budget (January 1, 2001-June 
30, 2002). 
EngenderHealth. May 2001. AMKENI Year 2 Workplan and Budget (July 1, 2002-June 30, 
2003). 
USAID/Kenya and MOH/Kenya. July 2004. Improving Reproductive Health Services in
Kenya: AMKENI Project Summary.
USAID/Kenya. July 2003. Expanded Management Review of AMKENI Project.
AMKENI Project. January 29, 2004. Monitoring and Evaluation Plan (Revised January 
2004). 
AMKENI Project. April 2000-October 2004. Quarterly Reports Q1-Q15. 
AMKENI Project. January 2005. Profiles. 
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AMKENI Project. No Date. The AMKENI Experience.
Kenya Central Bureau of Statistics, Ministry of Health and ORC Macro. 1999. Kenya 
Demographic and Health Survey 1998. 
Kenya Central Bureau of Statistics, Ministry of Health and ORC Macro. 2004. Kenya 
Demographic and Health Survey 2003. 
Ministry of Health. 2003. Training Curriculum on the prevention of Mother to Child
Transmission of HIV/AIDS, Kenya. 
Ministry of Health. 2003. Kenya National Manual for Training Counselors in Voluntary
Counseling and Testing for HIV, Kenya.
Ministry of Health. 1997. Family Planning and Reproductive Health Policy Guidelines and 
Standards for Service Providers. 
Ministry of Health, USAID/Kenya and the AMKENI Project. 2005. Coast Success Stories.
Ministry of Health, USAID/Kenya and the AMKENI Project. Coast Update. (Several issues 
of the newsletter).
Aga Khan Health Services, Mombassa. Policy Briefs, 1-4. 
Aga Khan Health Services, Mombassa. Training Curriculum for Community and Facility 
Committees. 
Mati, JKG, and Mwangi JN. Kenya, March 2005. Effectiveness of Decentralized
Reproductive Health Training and Supervision System on Service Delivery in Kenya. 
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D. LIST OF CLINICAL SITES VISITED 
Coast Province 
Jocham Private Hospital, Mombasa
Saint Luke’s Hospital, Kaloleni, Kilifi
MOH Dispensary, Gongoni, Malindi
MOH Dispensary, Diani, Kwale 
Western Province 
MOH Sub-District Hospital, Malava, Kakamega
MOH Health Center, Chwele, Bungoma
Lugugu Friends Mission Hospital, Bungoma
MOH Dispensary, Nangina, Busia
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E. LIST OF COMMUNITY FOCUS GROUP DISCUSSIONS 
Western Province
Women network, Malava, Kakamega District
Health Center Development Committee at Chwele Health Centre, Bungoma District
Animators, Chwele, Bungoma District
Community groups (Village health members and peer families) Mihuu, Bungoma District
Men group, Nangina Dispensary, Busia District
Youth group, Nangina, Busia District
Coast Province
Community group at JOCHAM private hospital, Mombasa District
Community group (Peer families and youth) at Kaloleni Mission Hospital, Kilifi District.
Community group(VHCs, PHT, TBAs) at Gongoni Dispensary, Malindi District
Community group (TBAs,DHCs,Youth and PHO/PHTs)
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F. DATA COLLECTION TOOLS 
FACILITY ASSESSMENT FORM (Section I) 
PROVINCE:
DISTRICT:
HEALTH FACILITY NAME: hospital/health center/dispensary
GoK/NGO/MISSION/PRIVATE 
A. GENERAL IMPRESSION:
1. Cleanliness of the facility: clean/dirty
2. Status of the buildings: well maintained/dilapidated
3. Status of the compound: well kept/neglected 
4. Water available: YES/NO; Source: PIPED/BOREHOLE/RAIN/SPRING/OTHER
5. ENERGY SOURCE: electricity/solar/generatr/paraffin/charcoal/firewood
6. IEC material displayed: yes/no 
7. Relevant Policies, Guidelines, protocols, job aids available and accessible: YES/NO 
8. Opening Hours: from------to--------DAILY/MON to FRI. Clients have to arrive by-----
- (time) in order to be served.
B. FAMILY PLANNING:
How much of the following commodities are currently available?
Amount 
PILLS
Injectables
IMPLANTS (norplant/jadelle)
IUCDs
C. ANC DRUGS AVAILABILITY: 
YES NO
Folic acid
Ferrous sulphate
SP
Quinine 
Tetanus toxoid
Niverapine
Vaccines
Anticonvulsants 
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ANC EQUIPMENT AVAILABILITY 
Cards/registers
Examination couch
BP machine
Weight scale/height scale (adult stethoscope)
Stethoscope
Fetoscope 
D. MATERNITY STATIONERY & EQUIPMENT AVAILABILITY: 
yes no
Baby scale
Adult weighing machine
BP machine
Fetoscope
Stethoscope
Delivery couch
Oxygen source
Ambu bag baby/adult
Suction machine
Baby resuscitaire 
Emergency resuscitation
Delivery sets
Incubators
Examination lamp
Ward & delivery registers, partograms
MATERNITY (OTHERS) 
Expendables supplies: syringres, needles, gauze, gloves, ADEQUATE/INADEQUATE
Incinerator facility ,, ,,
Telephone service,, ,,
E. CHILD SURVIVAL
1. Is cold chain well maintained? YES/NO
2. Is charting done? YES/NO
ANTIGENS CURRENTLY AVAILABLE
Number of Doses 
BCG
POLIO
DPT
MEASLES
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F. PROCEDURE ROOM
1. Infection prevention measures in place: YES/NO
2. Relevant equipment available and functional YES/NO 
F. VCT and PMTCT
1. Is space adequate? YES/NO
2. Is privacy maintained? YES/NO
G. AVAILABILITY OF TRAINED STAFF
TRAINING COURSE NO. OF STAFF
FP Technology Update
FP Counselling
IUD insertion/removal
Implant insertion/removal
Tubal ligation
VCT
PMTCT
PAC/MVA
EOC
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FACILITY ASSESSMENT FORM (Section II)
PROVINCE: DISTRICT: GoK/NGO/PRIVATE/MISSION
A. STAFFING
STAFF ESTABLISHMENT NUMBER AVAILABLE
Doctors (obgyn)
Doctors (MOs)
Clinical officers
Nurses/midwives
PHOs/PHTs
Lab techs
Support staff
B. FAMILY PLANNING
2002 2003 2004
PILLS: number of clients served
INJECTABLES: number of clients served
IMPLANTS: number of insertions/removal
BT/L: number of procedures
Vasectomy: number of procedures 
C. ANTENATAL CLINIC
2002 2003 2004
Number of clients served
Number of clients given 2 doses SP for IPT
Number of ITNs given out
Number of clients given Tetanus Toxoid
D. MATERNITY
The following services were performed/given at least once in the last three months:
Yes No 
Parenteral (injection) antibiotics
Parenteral (injection) oxytocics
Parenteral (injection) sedatives/anticonvulsants 
How many of the following services/procedures were performed/provided in the last three 
years?
2002 2003 2004
Normal deliveries
Complicated deliveries
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Manual removal of placenta
Blood transfusion
Caesarean section 
Evacuation by MVA or D&C
E. CHILD SURVIVAL
2002 2003 2004
Number of children who have completed immunization 
(BCG, polio, DPT, measles)
Resuscitation of newborn
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GUIDE QUESTIONS FOR THE BCC COMPONENT
Introduction
As key players and members of the community the team would like to receive from you
views of the AMKENI project covering activities, achievements, challenges and what you
would like to see in the future.
A. Health Center Development Committees
What are your views on the AMKENI project? Achievements so far?
As a committee how has the project influenced you to serve the community better? (probe for 
skills/capacity building, management)
What aspects of the project are you involved in? Are there any links you have forged with the 
community? What are these?
Specifically what are the indications of community participation in this project?
What are the constraints?
What would you like to see? From MOH, AMKENI project and the community?
B. Village Health Committees
What are your views on the AMKENI project? Achievements so far?
As a committee how has the project influenced you to serve the community better? (Probe for 
skills/capacity building, management)
What aspects of the project are you involved in? 
What is the community response?
Specifically what are the indications of community participation in this project?
What are the factors that influence utilization of services in your community?
What are the constraints?
What would you like to see? From MOH, AMKENI project and the community?
C. Women/Men/Youth
What are your views on the AMKENI project? Achievements so far?
In what ways has the project influenced your behaviour, attitude and practice towards your 
health and family? (Probe for decision-making and health seeking behaviour? Are there any
notable changes in health seeking as a result of the project? 
What are the factors that influence utilization of services in your community? (Probe for
access, provide attitude, service quality and waiting time)
What are the constraints?
What would you like to see? From MOH, AMKENI project and the community?
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AMKENI Project Organogram
Technical Responsibilities
Area Manager - Coast Area Manager - Western
Finance & Administration
SD - Coast
SD - Western
Service Delivery Advisor
BCC - Coast BCC- Western
Field Facilitators
Women's Agency
BCC Advisor Policy&Sytems Advisor
T&S - Coast T&S - Western
Learning &Performance Advisor M & E Advisor
HIV/AIDS - Coast HIV/AIDS - Western
HIV/AIDS Advisor
Project Director
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