ACCESS TO INFANT AND

MATERNAL HEALTH (AIM

HEALTH) PROJECT

REPORT ON MID TERM REVIEW

NICOLE LEE

Social & Behavioral Interventions Program

MSPH Essay

March 2015

First Reviewer: Larissa Jennings, Ph.D

Second Reviewer: Ingrid Friberg, Ph.D

i

Executive Summary

Background

World Vision Kenya (WVK) launched the Access to Infant and Maternal (AIM) Health project in 2012 at

Mutonguni Area Development Programme (ADP), which is located in the semi-arid land of western Kitui

County. This area has an estimated infant mortality rate of 39 deaths per 1,000 live births and maternal mortality

ratio of 137 deaths per 100,000 live births.

In support of Ministry of Health (MOH) initiatives, Kenya is one of five countries in which WV is implementing

the AIM Health Programme. Recognizing the unique vulnerability of women and young children, the AIM Health

project seeks to address their needs with a set of comprehensive interventions. The AIM Health Programme is a

contextualized roll-out of World Vision’s 7-11 strategy, which focuses on promoting seven key behavior change

interventions for pregnant women and eleven key interventions for infants and children below two years. The

programme activities are based on evidence-based interventions from the Lancet’s Maternal Survival and

Neonatal Survival series, as well as World Health Organization guidelines for improving maternal and newborn

health.

Methodology

AIM Health project carried out a mid-term review (MTR) between May and August 2014. The MTR used a

mixed methods approach, collecting primary quantitative data through Lot Quality Assurance Survey (LQAS) and

qualitative data. The review also included measurement of population-level outcomes in the results based

framework (RBF) of the project and modelling the impact of the project’s interventions in place of measuring

population-level mortality rates. Qualitative data was collected through in depth interviews (IDIs) and focus

group discussions (FGDs) with a range of program stakeholders. Fifteen IDIs and nine stratified FGDs were

coordinated and conducted by a trained team consisting of a graduate-level Global Health Fellow, local

facilitators, and WVK staff.

The Lives Saved (LiST) tool, a multi-cause software model of mortality, was used to make a retrospective

estimation of lives saved/deaths averted, and to project the same estimates for the remaining part of the project

and beyond. Coverage data were derived from default population-level survey sources and project

baseline/LQAS. Three projections were created for the main analyses, and a separate projection was created for

secondary analyses – which were carried out through extraction of results from LiST.

Key Findings

Program progress to date: The perceptions of health status changes in the AIM Health project area

were generally positive, but were not supported by improved quantitative data. Nutritional outcomes,

specifically, and care seeking behaviors have improved. Community members reported that some

negative traditional practices have fallen out of favor over the past few years, especially when it comes to

unskilled deliveries with Traditional Birth Attendants (TBAs) or harmful newborn care. Several new

facilities have opened in the past 2-3 years, and utilization of health services are said to have increased as

a result of the health messages and facility upgrades.

Lessons, Promising Practices and Key Success Factors: As a regional staff member put it,

“Community participation ensures ownership which later on makes the project be more sustainable.”

ii

The synergy created through AIM Health is evident through the noted community ownership and

local/national cohesion to achieve shared visions and objectives around MCHN. One manager admired

the project’s five-year duration as a best practice for lasting change.

Constraints and Challenges to Implementation: Environmental and socio-economic constraints, such

as poverty and a challenging landscape, hamper maximum intervention coverage. The AIM Health

catchment area is rural, the terrain is difficult, and there are very few reliable transportation options.

AIM Health relies on CHW-led health promotion, and many stakeholders believe minor illness

management to be a critical component left out of the intervention. District health services, in general,

are also constrained by occasionally delayed funding, supply and staff shortages, and poor infrastructure.

Management Issues and Lessons Learned: AIM Health has had limited staff, but MOH/WVK

integration and shared resources are key to successful implementation of the project. There is agreement

that strong points of the program are budget clarity and focused spending. There is an interest in

utilizing technology for monitoring and evaluation purposes at the district level, as long as it is not

heavily web-based. One important lesson learned is that activities need to be carefully planned but

flexible enough to respond to delays or environmental changes.

Impact: The LiST exercise found that the AIM Health project contributed to saving a total of 36

maternal and child lives (including stillbirths) since the project’s start, which is approximately an 8%

reduction in under five mortality and a 14% reduction in maternal mortality. There are an estimated 37

additional maternal and child lives that can be saved by achieving scaled up intervention coverage to RBF

target levels in 2015. The most important intervention to preventing maternal, neonatal and child

deaths is increased skilled birth attendance, particularly in a facility.

Recommendations

Big gains in mortality reduction can be made with increased care seeking (and treatment) for

pneumonia, increased oral rehydration solution (ORS) treatment for diarrhea, and continued increases

in skilled delivery. Project activities should focus on scaling up ICCM training in the next year to aid in

achieving end of program goals.

Accelerate advocacy efforts at the county government level and work to strengthen communication

among different levels of the community health system with the purpose of creating sustainable funding

solutions for the intervention components.

Develop and implement a communications strategy to better promote the community ambulance and

encourage utilization. Aid the DHMT in further work on transportation guidelines for health system

linkages in the sub-county.

Encourage the MOH to develop an alternative supervision model to ease the current gap. For example,

CHWs could be incentivized with task-shifting by creating an advancement opportunity for high-

performing CHWs to move into supervisory roles (with stipend) as they gain more skills.

iii

Acknowledgments

The author was based in Kitui and Nairobi (Kenya) as a Global Health Fellow with World Vision Kenya during

the time of this study. Thanks are owed to staff at the World Vision Kenya National Office and to members of the

World Vision Ireland AIM Health team, who sponsored and organized training in the Spectrum software in

Baltimore, who provided logistical support and fellowship accommodation, and assisted in the procurement of

background information and coverage data. Yvonne Tam, MHS and Ingrid Friberg, Ph.D. at Johns Hopkins

Bloomberg School of Public Health provided technical assistance on the Spectrum software and modelling

process. Study design and supervisory support was provided by Beulah Jayakumar, MD, MPH, public health

consultant. Additional feedback on earlier drafts and supervisory support was provided by Erin Jones, MPH,

World Vision International (Sustainable Health) and Larissa Jennings, Ph.D., Johns Hopkins Bloomberg School of

Public Health.

List of Acronyms

ADP – Area Development

Programme

AIDS – Acquired

Immunodeficiency Syndrome

AIM – Access to Infant and

Maternal (Health)

ANC – Antenatal Care

ARI – Acute Respiratory Infection

ARV – Anti-retroviral

CBO – Community Based

Organization

CHC – Community Health

Committee

CHEW – Community Health

Extension Worker

CHW – Community Health

Worker

CU – Community Unit

CVA – Citizen Voice and Action

DHMT – District Health

Management Team

DHS – Demographic and Health

Survey

FGD – Focus Group Discussion

HH - Household

ICCM – Integrated Community

Case Management

IDI – In-depth Interview

IPTP – Intermittent Preventive

Treatment in Pregnancy

ITN – Insecticide Treated Net

KEPH – Kenya Essential Package

for Health

KEPI – Kenya Expanded

Programme on Immunization

LiST – Lives Saved Tool

LQAS – Lot Quality Assurance

Survey

MCHN – Maternal & Child Health

and Nutrition

MDG – Millennium Development

Goals

MMR – Maternal Mortality

Ratio/Rate

MOH – Ministry of Health

MTR – Mid-term Review

NGO – Non-governmental

Organization

NMR – Neonatal Mortality Rate

OBA – Output Based Approach

ORS/ORT – Oral Rehydration

Solution/Treatment

PMTCT – Prevention of Mother-

To-Child Transmission

PNC – Postnatal Care

RBF – Results Based Framework

SBA – Skilled Birth Attendance

SD – Standard Deviation

SGA – Small for Gestational Age

TBA – Traditional Birth Attendant

TTC – Timed and Targeted

Counseling

U5MR – Under-5 Mortality Rate

UNICEF – United Nations

International Children's

Emergency Fund

USAID – United States Agency for

International Development

WASH – Water and Sanitation

Hygiene

WHO – World Health

Organization

WVI – World Vision Ireland

WVK – World Vision Kenya

iv

Contents

1.0 Background ......................................................................................................................... 1

2.0 Qualitative Study .................................................................................................................. 6

2.1 Scope, Design and Methods .................................................................................................. 6

2.2 Data Collection, Processing and Analysis ................................................................................. 6

2.3 Findings .......................................................................................................................... 7

2.4 Limitations ..................................................................................................................... 13

3.0 Impact Study ....................................................................................................................... 15

3.1 Scope, Design and Methods ................................................................................................. 15

3.2 Findings for Objective 1 (2014 Midterm) ............................................................................... 16

3.3 Findings for Objective 2 (2015 Endline) ................................................................................. 17

3.4 Mortality Findings ............................................................................................................ 18

3.5 Limitations ..................................................................................................................... 18

4.0 Conclusions & Recommendations............................................................................................. 20

5.0 Reflections on Field Practicum ................................................................................................ 22

References ........................................................................................................................... 23

Programmatic Context............................................................................................................ 25

Data Collection Summary ........................................................................................................ 27

LiST Data Collection .............................................................................................................. 29

LiST Results ......................................................................................................................... 33

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Tables and Figures

Table 1: TTC components of AIM Health......................................................................................... 2

Table 2: Qualitative Data Collection .............................................................................................. 27

Table 3: Survey Results .............................................................................................................. 27

Table 4: Demographic Data ......................................................................................................... 29

Table 5: National/Region Coverage Levels Update ............................................................................ 29

Table 6: AIM Health Indicators and Values ...................................................................................... 30

Table 7: LiST Intervention Coverage Summary ................................................................................. 32

Table 8: Deaths Averted, Neonates and Children (Midterm) ................................................................ 33

Table 9: Maternal Deaths and Stillbirths Averted (Midterm) ................................................................ 34

Table 10: Changes in Nutritional Status (Midterm) ............................................................................ 35

Table 11: Cases of Illness Averted (Midterm) ................................................................................... 36

Table 12: Deaths Averted, Neonates and Children (Endline) ................................................................ 36

Table 13: Maternal Deaths and Stillbirths Averted (Endline) ................................................................ 38

Table 14: Cases of Illness Averted (Endline) ..................................................................................... 38

Table 15: Changes in Mortality ..................................................................................................... 38

Table 16: Lives Saved, Neonates ................................................................................................... 39

Table 17: Lives Saved, Children under 5 ......................................................................................... 40

Table 18: Lives Saved, Maternal .................................................................................................... 40

Table 19: Lives Saved, Stillbirths ................................................................................................... 41

Table 20: Lives Saved Summary .................................................................................................... 42

Figure 1: Map of Kitui County ...................................................................................................... 25

Figure 2: AIM Health MTR Timeline ............................................................................................. 25

Figure 3: LiST Modelling Examples ............................................................................................... 26

Figure 4: Deaths Prevented by Cause (Midterm) ............................................................................... 34

Figure 5: Deaths Prevented by Cause (Endline) ................................................................................. 37

Figure 6: Reduction in Mortality by Intervention (Midterm) ................................................................ 39

Figure 7: Changes in Mortality, Children under 5 .............................................................................. 41

Figure 8: Changes in Mortality, Neonates ........................................................................................ 42

1

1.0 Background Health overview in Kenya

Kenya has made considerable progress in maternal and child health since the Millennium Development Goal

(MDG) targets for 2015 were first conceived. Mortality has improved, fertility has declined, and health service

utilization has increased across the country over the years1. Although improvements are being seen, Kenya is not

on track to reach those targets for 2015. Maternal and child mortality rates are still higher than expected. In

2008, Kenya’s under-5 mortality rate was 74 deaths per 1,000 live births, the infant mortality rate was 52 deaths

per 1,000 live births, and the maternal mortality ratio was 488 deaths per 100,000 live births2. Although most

women received antenatal care at some point in pregnancy (92%) and almost all infants were breastfed at birth

(97%), only three-quarters of children under five were fully vaccinated (77%) and a third of children (35%) were

stunted2. In contrast, Kitui district’s under-5 mortality rate was 86 deaths per 1,000 live births, the infant

mortality rate was 63 deaths per 1,000 live births, 64% of children were fully vaccinated, and 38% of children

were stunted in 20083. Seven out of 10 facilities in Kenya offer basic child health services and antenatal care, but

normal, assisted, vaginal delivery is only possible in three out of 10 facilities4. Between a quarter to half of

facilities regularly have basic equipment and supplies for these services, a functioning transportation system,

regular water, and/or regular electricity4. Effective and efficient programs are needed to continue to address

these issues and elevate the overall health status of children in this country.

Policy Environment

Vision 2030 is the country’s 20-year development blueprint with economic, social, and political pillars to propel

the nation to middle-income status5. The vision to a globally competitive and prosperous nation is anchored on

macroeconomic stability, continuity in governance reforms, and enhanced equity and wealth creation

opportunities for the poor, among other strategies. In alignment with this vision, the overall Kenya health sector

policy goal is to “attain the highest possible standard of health in a manner responsive to the needs of the

population”6. To attain universal coverage of critical services, the government is implementing programs that

focus on

o eliminating communicable conditions;

o halting and reversing the rising burden of non-communicable conditions;

o reducing the burden of violence and injuries;

o providing essential health care;

o minimizing exposure to health risk factors; and

o strengthening collaboration with other sectors.

In 2006, Kenya introduced a community health strategy to deliver basic health care services – the Kenya Essential

Package for Health (KEPH) – to 16 million Kenyans7. The purpose of the community health strategy was to

enable communities to improve and maintain a level of health that will enable them to participate fully in national

development towards the realization of Kenya’s Vision 2030. Community Units (CU) were established, each

made up of about approximately 5,000 people and 1,000 households, with 5 persons per household on average.

The CUs are served by volunteer health workers to deliver household health promotion, and are linked to district

health facilities.

The adoption of a new constitution by Kenya in 2010 introduced a rights based approach to health in service

provision and a devolved system of government, which assigned the larger portion of delivery of health services

to the counties8. With the exception of national referral services, in which the Ministry of Health Kenya (MOH)

governs tertiary hospitals that provide complex care, the governance of community and provincial facilities is left

to the counties. The government is committed to good health for all Kenyans, acknowledging that health is not

only a right but also a responsibility for all. Promotion of good health at different levels of society is the

responsibility of all individuals, families, households, and communities.

2

World Vision’s response

There are many local, national, and international health and development actors working to realize these goals in

Kenya. To support the government, World Vision develops and implements programs in some of the neediest

areas. With funding support from World Vision Ireland (WVI), World Vision Kenya (WVK) launched the Access

to Infant and Maternal (AIM) Health Programmea in 2012 at Mutonguni Area Development Programme (ADP)

to tackle these health challenges in an area with poor health outcomes. Recognizing the unique vulnerability of

women and young children, the AIM Health project seeks to address their needs with a set of comprehensive

interventions.

Kenya is one of five countries where the AIM Health Programme is currently being implemented. The first phase

of the AIM Health project—a preparatory phase for WVK staff, local communities and MOH partners termed

AIM-Prep—engaged stakeholders in a participatory approach to program implementation from 2011 to 2012.

Officially launched in 2012, the objective of AIM Health was to be actively engaged with local stakeholders in

order to increase community access to maternal and infant health care services and in turn, improve maternal and

child health. Its overall goal is to reduce both infant mortality and maternal mortality by 25% over five years.

Mutonguni ADP is situated in western Kitui County – formerly known as Kitui West District and now referred

to as Kitui West sub-county (Figure 1) – and serving a population of approximately 50,000 people. Kitui

County is located in a semi-arid region with moderately high temperature and bi-modal rainfall. The central part

of the county is characterized by hilly ridges separated by wide low lying areas and has slightly lower elevation.

The population is rapidly growing and poverty is quite high, as many families rely on sustenance farming and

livestock herding. Agriculture, though difficult, is the major backbone to the economy, and cotton is a major

industry.

AIM Health Programme

The AIM Health Programme is a contextualized roll-out of World Vision’s 7-11 strategy9, which focuses on

promoting seven key behavior change interventions for pregnant women and eleven key interventions for infants

and children below two years (Table 1). This approach is delivered at the household for behavior change

communication and community levels with Community Health Committee (CHC), Citizen Voice and Action

(CVA), and Community Health Worker (CHW) led Timed and Targeted Counselling (TTC) programming.

Table 1: TTC components of AIM Health

Pregnant women Children (0-24 months)

Adequate diet Appropriate breastfeeding

Iron/folate supplements Essential newborn care

Tetanus toxoid immunization Hand washing with soap

Malaria prevention and treatment (including IPT) Appropriate complementary feeding

Birth preparedness and healthy timing/spacing of delivery Adequate iron

De-worming Vitamin A supplementation

Access to maternal health services (antenatal care, postnatal

care, delivery by skilled birth attendant, PMTCT,

HIV/AIDS, tuberculosis, screening for STIs)

Oral rehydration therapy (ORT/zinc)

Prevention and care seeking for malaria

Full immunization for age

a For this paper, “AIM Health programme” will always be in reference to the 5-country initiative in general, and “AIM Health project” will be in reference to the Mutonguni initiative.

3

Prevention/treatment of acute respiratory infection

De-worming (+12 months)

Timed and Targeted counselling (TTC) refers to household level counselling informed by the MOH’s community

health volunteers training curriculum, which included basic health promotion and maternal and newborn care.

Community health workers (CHWs) are community-elected volunteers and are frontline agents of the Ministry.

Each CU comprises approximately 50 CHWs supervised by a Community Health Extension Worker (CHEW).

The CHWs make a series of eleven scheduled visits to households when women become pregnant, and

throughout the child’s infancy, communicating the 7-11 message sets at the most appropriate times using

effective dialogue-based counselling techniques.

The Community Health Committee (CHC) represents the collective of stakeholders in the community focused

on Maternal and Child Health and Nutrition (MCHN) outcomes. The CHC is an integrated civil structure

empowered to coordinate community activities and manage activities leading to child well-being. In Kenya, these

groups were formed independently through the MOH under the Community Health Strategy (2006), province

by province. CHCs have an important governance role in the processes that take place to improve health at the

community level, particularly regarding the CU. They have the responsibility of mobilizing communities for

involvement in health-promotive and disease prevention activities, and they are active in supporting latrine

construction in communities as well as other small projects.

Citizen Voice and Action (CVA) is an approach that aims to improve accountability from the government (both

national and local) in order to improve the delivery, quality and efficiency of public services through increased

dialogue. AIM Health helps to mobilize and train groups of community members for advocacy work. Educated,

empowered and mobilized citizens are encouraged to assess the performance of public services that are provided

in their communities. In addition to equipping CVA with the tools they need to effect change, AIM Health also

contributes to health system strengthening through activities that are aligned with MOH priorities such as

community outreaches, capacity building, and gifts-in-kind.

Evidence supporting the programme design

When it comes to ensuring infant and child survival, key interventions have been repeatedly identified as effective

at preventing particular causes of mortality. Immunization, exclusive breastfeeding, antibiotics for pneumonia,

insecticide treated nets, and ORS, among others, have been evaluated to show efficacy in a variety of settings10–12.

While acknowledging that child mortality has a complex web of determinants, Jones and colleagues (2003)

estimated that 63% of deaths could be prevented if the most effective interventions – breastfeeding or ORS for

example – were universally available13. Unfortunately, some programs package these interventions haphazardly

out of convenience or funding requirements, rather than based on anticipated synergistic effects12. Several

researchers have noted that sustained and strong community engagement, care linkages, and health education are

crucial to meeting health needs at scale11,12.

Evidence on community-based strategies to improving maternal, neonatal, and child health outcomes is rapidly

mounting. Freeman and colleagues (2012) reviewed multiple child health interventions and identified four

programmatic approaches that the most successful interventions employ, using community empowerment as an

overarching strategy: home visitation, group educational or support meetings, health care service outreach, and

community-based treatment (case management) or referral14. Researchers have also seen that community

interventions effective at reducing mortality have elements of involving communities in designing solutions,

raising awareness through health behavior change strategies such as the interpersonal contact of caregivers and

decision makers, and encouraging dialogue through community mobilization15,16. In Kenya, recent studies have

evaluated the effectiveness of their community maternal and child health programs. In one study, a three year

project that trained volunteer CHWs in rural areas to deliver health education found that knowledge of newborn

care and the proportion of women going for skilled delivery was higher among those exposed to the messages

4

than among those who were not17. In a controlled two year trial of the implementation of Kenya’s national

Community Health Strategy, another study found that antenatal care, deliveries in facilities, latrine use, measles

vaccination, and water treatment practices significantly improved in intervention sites as compared to control

sites18.

Overview of the current MTR

The AIM Health project, which is being implemented until December 2015, carried out a mid-term review

(MTR) between May and August 2014 (Figure 2). The MTR used a mixed methods approach, collecting

primary quantitative data through a Lot Quality Assurance Survey (LQAS) and qualitative data. The purpose of

the MTR was to assess the progress made in the first two full years of implementation, program quality according

to the standards for the core implementation models and make specific recommendations for how the

implementation of AIM Health can be improved, allowing for context-specific programming feedback regarding

opportunities to increase efficiency and reach of program interventions. In addition to gauging progress and

quality, a qualitative study was conducted to help identify any limitations, opportunities, and risks connected

with the AIM Health program. The review also included measurement of population-level outcomes in the

results based framework (RBF) of the project and modelling the impact of the project’s interventions in the place

of measuring population-level mortality rates, as the latter is beyond the scope of the project. The Lives Saved

Tool (LiST) was used to make a retrospective estimation of lives saved/deaths averted, and to project the same

estimates for the remaining part of the project and beyond.

Process evaluation, or implementation research, is a common and practical tool in the field of program

evaluation19. Often there is a big gap between what is described in the protocol and what is actually implemented

on the ground. If a program fails, the reason may be unclear from standard pre- and post-measurement designs.

Process evaluations measure how well a program is operating in its specific context. They can help to modify or

strengthen the intervention, make midcourse corrections, help explain why results were achieved (or not), and

provide lessons for others. Process evaluations may contain a quantitative component, but they almost always

contain a qualitative component.

Qualitative research is a set of theoretical perspectives and methods for eliciting textual data. It is a long-standing

methodology of social science with well-known data collection strategies such as interviews with key informants,

focus group discussions, and observations20. A common strategy for qualitative data analysis include the

Grounded Theory technique, and common software for analysis include Nvivo or Atlas.ti. Qualitative research is

useful in process evaluations for understanding nuances of implementation and allowing the evaluation to be

culturally responsive. LQAS is a sampling and analysis quantitative methodology for rapid population-based

surveys, adapted from industrial quality control techniques. It is an inexpensive tool for monitoring coverage and

outcomes that requires a small sample size to determine if an area is “performing” at acceptable levels or not21. A

review found that more than 800 health-related studies using LQAS had been conducted globally since the mid-

1980s22. LiST, on the other hand, is a fairly novel tool for evaluation that has been picking up steam in the past

decade.

LiST has been described as a linear, mathematical modelling software to estimate the impact of scaling up

evidence-based intervention on various population level maternal and child health outcomes23. It is one of nine

modules nested in the Spectrum software, and it requires several pieces of input data for the models –

intervention coverages, underlying health status measures, and effect estimates of interventions on cause-specific

mortality, which general come from the Child Health Epidemiology Reference Group (CHERG)24,25. The

reduction in mortality – better known as lives saved or deaths averted – caused by a particular intervention is

calculated from the increased coverage of that intervention multiplied by the effectiveness of that intervention in

reducing mortality26 (see example, Figure 3). LiST modelling is a useful alternative to lengthy, randomized

controlled trials in that it can capture rare events (e.g. maternal mortality), overcome time lags (e.g. impact of

nutrition interventions), and can be used to construct counterfactuals to prospectively or retrospectively

interpret trends.

5

Often, LiST is used for strategically planning and validating public health programs. As an example, Friberg and

colleagues (2010) estimated using LiST that if high impact intervention were scaled up to 90% by 2015 across 42

African countries, nearly four million maternal and child deaths could be averted27. Additionally, the Catalytic

Initiative used LiST to model national scale up of five high impact intervention in five countries, and found that

under-5 mortality could be reduced by at least 20% in five years28. As LiST is adopted more as a tool in the field

of international health, more evidence of its use for evaluating programs and strengthening health systems

accumulates29. In several cases, LiST has been shown to measure mortality outcomes as good as or better than

standard epidemiological measurement. Ricca and colleagues looked at numerous USAID supported projects that

implemented community-based intervention packages for children under five years, and, using LiST in

comparison to measured DHS data, found that average coverage changes exceeded DHS trends in the majority of

cases – an overall 5.8% improvement in mortality compared to 2.5% by DHS16. A World Relief project in

Mozambique compared LiST estimations of mortality to independently collected evaluation data and found

reasonably accurate estimates of decline in under-5 mortality (39% in LiST vs. 37% independently)30. The

Accelerated Child Survival Project in Ghana found similar results, with LiST estimating a 10.7% reduction in

under-5 mortality which was within the 95% confidence interval for the measured reduction of 20.6%31.

Although LiST is not perfect – the same projects also found underestimations in some aspects – it is a practical

and sound tool for program planning and evaluation activities.

6

2.0 Qualitative Study

2.1 Scope, Design and Methods The overall purpose of the qualitative study was to provide in-depth, descriptive information on the AIM Health

project to complement available quantitative data. There were five specific objectives, which revealed key themes

from varied respondent groups. The study aimed to:

1. Describe the project’s progress to date.

2. Compile lessons, promising practices and key success factors.

3. Analyze constraints and challenges to implementation of the various project models.

4. Identify management issues that help or constrain program implementation and management lessons

learned.

5. Help clarify the probable mechanisms behind observed quantitative changes.

This qualitative study covered all stakeholders from communities and health facilities who participated in the

program, MOH partners, AIM project staff, and ADP/region/national office staff who have provided technical

or managerial support to the project. Fifteen IDIs were planned and conducted in English among community and

MOH partners, and WVK staff. Nine stratified FGDs were planned and conducted in the local language,

Kikamba, among beneficiaries, community groups, and CHWs.

IDIs and FGDs among key stakeholders were conducted by a trained team consisting of the author and local

facilitators, and these were coordinated by WVK staff. ADP staff hired local personnel to carry out FGDs in the

community. The facilitators both held Kenyan university degrees. The Fellow is a current U.S. graduate student

in public health trained in qualitative research methodology and analysis. A half-day training was conducted with

the facilitators on FGD methodology, facilitation skills, and the content of the guides.

The MTR consultant developed semi-structured interview and discussion guides. The tools were finalized

incorporating input from the evaluation team, including AIM Health staff and key technical staff from WVI and

the Global Centre. Interview and discussion guide topics focused on themes identified above, with neutral and

open lines of questioning. Probes were used to explore other relevant themes that emerged during the

discussions and interviews. Study participants were purposively sampled from among the 10 community units.

The FGD participants were identified, recruited, and introduced to the team by MOH staff with the support of

AIM Health staff. The IDI participants were identified by the MTR consultant and were asked to join the study by

AIM Health staff. All logistics of the data collection were planned, overseen, and made possible by WVK staff.

No ethical approval from an institutional review board was sought or obtained for this study. Evaluative studies of

public health programs are not typically considered human subjects research, and are thus not subject to peer

review.

2.2 Data Collection, Processing and Analysis Over the course of four weeks, nine FGDs and fifteen IDIs were conducted (Table 2). Verbal informed consent

was obtained from all study participants prior to interviews and discussions. A digital voice recorder was used to

record all IDIs and FGDs with consent from all participants. Face-to-face (mostly) in-depth interviews were

carried out at MOH/health facilities, and with staff at ADP, project, region and national levels in and around the

ADP area. The FGDs were carried out by a team of three consisting of gender appropriate local facilitators and

note-takers, and the Fellow. Each FGD called for eight to ten members in each discussion. FGDs were held with

CHWs, mothers of children under two and at least one older child, husbands or male partners, CHC and CVA

working group members across six different community units.

The main ideas and observations were reviewed between the Fellow and facilitators following each FGD. Notes

of the FGDs were written up into reports by the FGD facilitators. All FGDs and IDIs were transcribed and

7

translated to English where possible. Notes and transcripts from the IDIs and FGDs were collated and checked

for quality, in preparation for analysis. Additionally, secondary data in the form of project documents and

manuals, quantitative data from LQAS and prior reports were reviewed.

Data management for coding and analysis was aided by the use of computer software programs – Dedoose (web-

based)b and Microsoft Excel 2013. Analytic memos were used to organize and document the processes. A

combined approach was used to code the qualitative data, enabling codes to be developed both deductively from

pre-defined themes and inductively from the views of the participants. The process started with examining the

complete data set and developing a preliminary codebook based on the study objectives. After coding a few

transcripts, the codebook was revised with additional focused codes and categories that emerged. The transcripts

were checked against the revised codebook for meaning and overlaps, and then the codes were applied to the

remaining transcripts. The process of refining and applying the codebook was repeated until no new codes were

generated. The central themes were identified from clustering of codes.

All of the coded data were retrieved and sorted by codes and informant using Excel. The data were then charted

in a matrix, summarizing each theme by category of informant and noting exemplary quotes. When organizing

themes, the analyst frequently reviewed findings with other AIM Health Fellows for additional validation.

Thematic analysis was guided by the FrameWork approach32. Analysis began with reviewing the matrix and

making connections within and between informants and themes, noting contradictions and outliers.

Interpretations of possible relationships were noted in analytic memos, and possible explanations for what was

happening were developed to guide findings.

2.3 Findings Program Progress to Date

Changes in health status/outcomes

In the last few years, all stakeholders have noted changes in the health status of pregnant women and infants

under two years, mentioning each of the targeted 7-11 interventions/behaviors at least once. Markedly,

informants report that although peaking seasonally, cases of diarrhea and pneumonia are becoming harder to find.

Although it is perceived that latrine coverage, sanitation behaviors and ORS treatment have increased, survey

results show that both diarrhea and pneumonia prevalence among children under five have increased to

approximately 20% (from 15% and 12% respectively) and that ORS treatment, access to safe water, and hand

washing have all decreased since the project started (Table 3).

Members of the community also reveal that there have been reductions in diseases and that many children have

been immunized. According to the LQAS results, coverage of full immunization had dropped 30% (although no

significance testing or analysis of variance was done). Facility staff say the community is experiencing reduced

maternal, neonatal, and child deaths that could be related to increased recognition of danger signs, health care

seeking and skilled deliveries. There is a common view that women are increasingly accepting family planning to

space their children. LQAS results support this by showing improved completion of antenatal care, skilled birth

attendance, and postnatal care.

Informants relay that severe cases of malnutrition have been decreasing, and that many mothers are practicing

exclusive breastfeeding, with six months being the ideal duration. Survey data show that stunting and

underweight in children have been reduced (from 47% to 38% and from 20% to 12%, respectively), in addition

to improvements in early initiation of and exclusive breastfeeding (up to 71% and 91%, respectively). Mothers

and fathers report being more informed about complementary infant feeding and balanced diets for children and

pregnant women, which are supported by improved estimates of diverse diets.

b Dedoose Version 5.0.11, web application for managing, analyzing, and presenting qualitative and mixed method research data (2014). Los Angeles, CA: SocioCultural Research Consultants, LLC (www.dedoose.com).

8

Most stakeholders view AIM Health as a success for its contribution in delivering behavior change communication

at the household level and supporting health service improvements along with the MOH. The program works to

increase knowledge and change attitudes around specific behaviors, which fuels the uptake and adoption of these

behaviors leading to changes in health status overall.

Perceptions

AIM Health has had positive reception in the sub-county. The communities are supporting the CHWs in their

work and hold them in high regard. The perception of the health services varies from community to community,

but people are accepting the need to seek services from facilities instead of relying solely on each other or advice

from traditional healers. Community members report that some negative traditional practices have fallen out of

favor over the past few years, especially when it comes to unskilled deliveries with Traditional Birth Attendants

(TBAs) or harmful newborn care. According to informants, practices that are no longer acceptable include

putting soot on the cord stumps, rubbing ash mixtures on gums, feeding glucose and water to newborns, or

allowing women to eat soil for iron. A father in Musengo put it this way when describing changes seen in the

community, “Where there is no sickness, there is happiness.”

Demand/utilization of services

An apparent perception of change in utilization of services pertains specifically to childbirth. Many pregnant

women are gradually seeking antenatal care (ANC) earlier and more often, but facility staff note that fewer

women actually complete the fourth ANC visit. It is reported that more women are choosing to deliver in health

facilities due to counselling, birth planning, and the help of output based approach (OBA) vouchers for safe

motherhood – a government sponsored maternal health service financing intervention in place since 200533–35.

Health care seeking behavior has increased among the target population, particularly in regards to completing

scheduled immunizations and growth monitoring for children. “Defaulters” – described as people who either

refuse or delay immunizations for children – are traced and community members use social pressure and

mobilization to ensure that children are immunized. Some facilities even have queues due to increased demand.

Informants reveal that families have reduced their use of herbs, borrowing medicines from neighbors and buying

medicines from shops.

Health service accessibility and quality

Several new government and NGO health facilities have opened in the last few years in the AIM Health project

area to increase access to services for the target population. Currently, the MOH conducts door-to-door

immunization campaigns and, with facilitation from AIM Health, conducts monthly outreach services to the more

remote villages that are hard to reach. Community members report that the quality of services has been

enhanced with a noticeable improvement of attitudes by health workers. WVK also supported in provision of

KEPI (Kenya Expanded Programme for Immunization) equipment and acquisition of delivery packs to the

facilities. An example is given by a District Officer:

“Like you go in a place I have to reach, like Usiani. They’ll tell you at least there’s something good going on

because they have stayed there for a long period of time without any health facility. That facility was opened I

think one and half years ago. At least something is being done, so they say thank you because they’re seeing the

services there. They are able to access some of the services which are being provided by the Ministry. The

outreaches which have been supported by World Vision, hard to reach areas, they are really appreciating that.”

Status of women and children in household

Both husbands/male partners and mothers agree that AIM Health has contributed to playing a part in elevating

the status of women in the household. They say that, because of the counselling, men are more supportive of

wives throughout pregnancy by making efforts to accompany wives on ANC visits and for delivery. Women are

not made to work as much while pregnant or immediately after childbirth. One example was given that women

were no longer seen as slaves or beaten for secretly practicing family planning.

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It was reported that other behavior influencers, like mother-in-laws, are accepting better practices – particularly

the avoidance of early complementary infant feeding – and husbands are learning to become champions for

nutrition and exclusive breastfeeding. One facility staff describes the change,

“If we counsel the mothers alone we encounter some problems because if you tell the mother she’s supposed to

take an extra meal, who is the provider? It’s the husband. So, if the husband is not there, he will not understand

why this woman is eating so much. But when the husband is there, he’ll be like, ‘You didn’t take your snack. You

didn’t take your porridge.’ He’ll be reminding.”

Intervention coverage and maintaining implementation standards

As far as maintaining minimum standards in project model implementation, AIM Health covers 10 CUs but at

least one sub-location does not have the minimum number of CHWs as specified by the project plan (50). CHWs

reported being responsible for 20 households of pregnant women and mothers of children under two in his/her

village, though the proposal called for a maximum of 15 per CHW. The CHWs also report visiting four or five

households each day.

The CHWs are diligent about completing all of the scheduled TTC visits, but the rainy seasons (in April and

October) can create additional adversities to overcome in order to visit each household. During the visits, the

CHWs report that they share targeted health messages to households using the counselling cards, check clinical

cards, refer women and children for services, and follow-up on referrals and births. Supervision of CHWs should

occur once per month, but constraints (discussed below) inhibit regular supervision.

Extent of support by Community Health Committees (CHC)/Citizen Voice and Action (CVA)

The CHCs report that they help to monitor progress of the CHWs, and play a role in problem solving and

conflict resolution for the CHWs. The CHCs have sensitized the community to activities related to AIM Health

and have led community dialogues and forums. CHCs are described as key for providing an appropriate and

supportive social environment for the work of CHWs and CHEWs. Some CHWs admit that the CHC has not

been that helpful for them. There seems to be tension in some areas regarding the method by which CHC

members were selected. Still, the CHC does try to support, encourage, and motivate the CHWs. They have

catered trainings for them and have also provided incentives in the form of goats, seeds, and flour.

CVA is noted as operating as a link for different groups in the community. They mostly involve themselves in

development projects and county budgeting. They have formed an umbrella CBO (community based

organization) for the CUs, and help get them registered as self-help groups. They are described by CHWs as the

force that advocates on the communities’ behalf and create awareness for their rights to health and health care.

Lessons, Promising Practices and Key Success Factors

What works: “Synergy”

The AIM Health program has been lauded at all levels for its strong design, especially for imbedding a

participatory preparation phase. The interventions were well planned, and funding was appropriately allocated.

One manager admired the project’s five-year duration as a best practice for lasting change. The programme has

allowed for novel solutions to emerge out of implementation. Prominent examples include arranging table-

banking among the CUs, acquiring a new community ambulance, and facilitating the deployment of Integrated

Community Case Management (ICCM) training to further the skills of CHWs.

Informants mention that a key practice of this program is that of community empowerment. AIM Health is

recognized as strategically working with MOH and other stakeholders to engage communities in taking

ownership of both its problems and the solutions for them. As a regional staff member put it, “Community

participation ensures ownership which later on makes the project be more sustainable.” The community-based

monitoring and data collection is also acknowledged as a best practice for programs such as AIM Health. The

communities report being aware of what is available to them in terms of health care, and are encouraging others

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to take advantage of them. Other stakeholders suggest that the engagement on health also radiates to other facets

of well-being tangentially.

Another key practice is the indirect health system strengthening. WVK has demonstrated strong partnership with

the MOH. AIM Health is described as “harmonious”, allowing for all levels of partners to pool resources and

work together for the well-being of the area. The seamless integration of AIM Health into the existing MOH

strategy and structures provides a foundation for sustainability. WVK and the Ministry collaborated on

developing the TTC training manual, and as a result, the Ministry has taken up the TTC concept in other areas.

At the local level, capacity building has been vital to ensuring the continuum of care promoted by the program.

AIM Health, by facilitating training of CHWs and CHEWs on MOH standards and guidelines as well as the

occasional procurement of supplies, strengthens the quality of health facilities in the project area.

National learning

National level participants declare that AIM is contributing to learning throughout WVK and the MOH. For

example, the data being collected locally is used at the county level for advocacy and planning purposes.

Inclusive trainings and documentation allow lessons to be shared and applied across WVK ADPs AIM Health is

heralded for aligning with Kenya Health Policy priorities and complementing MOH strategy on health,

particularly relating to objectives 4 (Provide essential health care) and 6 (Strengthen collaboration with other

sectors). The project is also expected to contribute to long-term conversations pertaining to Kenya’s Vision 2030

Social Pillar as well as global 2015 MDG 4 and 5.

Gaps remaining

There were very few critiques towards the AIM Health program. AIM Health relies on CHW-led health

promotion, and many stakeholders believe minor illness management to be a critical component left out of the

intervention. The current CHW supervision structure is inadequate for the scope of the intervention. Whether

being a design flaw or constraint on the MOH side, the CHWs are in need of sufficient monitoring and feedback

of their work. Moreover, the community believes that AIM Health is not doing its due diligence for peripheral

target groups, such as disabled children, men, and adolescent mothers. Although a communications strategy was

implemented, engagement for these populations is perceived as a continued need.

Potential for sustainability

There are spillover effects of the AIM Health project intervention. This is evidenced by benefits of AIM Health

being seen even by those in areas the project is not covering, and those communities are demanding a similar

intervention. As one MOH representative explains, community-based care is already a “government obligation”,

in which AIM is a temporary gap-fill, and there is agreement that it should be extended. In WVK, scale-up is

desired and, already, ADPs have been identified for replicating the AIM Health strategy.

The community groups and supervision of CHWs by MOH will continue, but additional measures need to be

taken to ensure changes will last. Proper funding is a major challenge to sustaining the progress made thus far.

An MOH representative suggests that,

“You have to engage the county governments and bring them on board so that they can continue…so that they can

also safeguard some money, resources for continuing to expand coverage even in the other areas. We should talk

to the county government to continue strongly the areas where you are and then also think about moving to other

areas.”

Constraints and Challenges to Implementation

Coverage issues

Stakeholders identified several environmental constraints that have affected intervention coverage. Foremost is

the issue of distance. The AIM Health catchment area is rural, the terrain is difficult, and there are very few

reliable transportation options. The households that CHWs are required to visit can be very spread out, and they

11

sometimes cover distances up to and over five kilometers. Pregnant women struggle to deliver with skilled birth

attendants at health facilities and families struggle to follow through on referrals to the better-equipped hospitals.

Although the county government has purchased three community ambulances this year (with plans of more to

come), the issue of poverty has also constrained coverage as families have competing demands for their limited

income. Some families cannot afford the cost of transportation, or perceive facility costs to be too burdensome to

follow through on referrals – especially among the persons living with disabilities. At a more basic level, some

households cannot afford the necessities promoted through TTC for behavior change such as additional food for a

balanced diet or soap for hand washing. CHWs and project staff must often deal with people expecting material

support when visiting homes. Sometimes negative attitudes and beliefs can get in the way of implementation. For

example, the Kavanokie are a known religious sect that refuses modern medicine. CHWs also say they deal with

uncooperative people and women who hide their pregnancy from them.

Additional gaps in coverage are due to small failures in implementation. The CVA working groups are not

particularly recognized by the communities or the government – who declare that they were never introduced –

and they say they lack advocacy tools. CHWs have not been utilized fully in all areas, specifically in the Katutu

sub-location where at least three CHWs are no longer working. Fathers and CHC members in that area remark

that CHWs are not visible in the villages and they prefer to stay near the dispensary and market.

CHW motivation

For many CHWs, volunteering can be a burden as they strain to cover large areas, on top of tending to personal

responsibilities and problems. They, and other stakeholders, have expressed basic needs to do their work that

have not been fulfilled. Most prominent is a CHW kit with simple medicines, first aid, and preventive

commodities. There is also a strong demand for training to handle minor ailments, ideally, or a TTC refresher, at

minimum.

Every stakeholder discussed incentivizing CHWs as a way to motivate them, chiefly in the form of monetary

recompense. Currently, there is debate over a 2,000 Kenya shillings (KES) per month stipend recently

recommended by the government. While AIM project staff and CHC/CVA groups are making the CHWs aware

of this recommendation and advocating for its initiation by government officials, the MOH say that the

recommendation was essentially to align disparate NGO schemes. They note that even if they were to take this

on, they could not afford it because there are too many CHWs. A district official highlighted that,

“In fact, there’s a proposal that they be paid like 2,000 in a month from the government. Because now it’s kind of

disturbing their brain, ‘oh we are supposed to be given money.’ …They knew even when they were doing the

recruitment that this is a volunteer job and when you’re doing the recruitment you have to pass that message very

clear that you’re coming here. What you want? You want to serve the community and you want to assist them to

the various issues of health. But when that thing came like they expected the national government wanted to pay

them. So they are waiting. When are they going to start being paid? It’s distorting their minds, they start thinking

in terms of payment. And when they were being recruited, the issue of payment was not mentioned and they

accepted volunteer.”

A suggestion was made that AIM Health work with the MOH towards a more formal scheme of recognition or

appreciation for the CHWs before the project ends.

Monitoring and supervision issues

Some CHWs raise concerns that either 1) they have no referral forms or 2) the current referral forms are

inadequate. On top of distance issues, this makes following up on cases hard at times. The referral forms are an

important component of monitoring the project utilization, along with CHW registers. CHWs bring their

registers to CHEWs at the end of the month so they can be compiled into a report. A district official commented

that the self-selection of CHWs skews toward the less educated, which may affect the quality of information

being collected. A CHEW acknowledged possible lapses in data quality saying, “You are not sure whether this

information is true because you’ve not gone there.”

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Everyone directly involved with project implementation agree that each CHEW has too many CHWs to account

for and supervise. CHEWs typically have a full clinical load and other MOH responsibilities, leaving almost no

time for adequate supervision of each and every CHW. One CHW mentioned going almost a year without being

visited, and others declared that CHC supervision was scant as well. In addition to similar distance and

transportation issues, a lack of appropriate tools was reported to hinder supervision visits.

Health service issues

Despite the decentralization of governance, health service delivery has been slow partly due to challenges in

securing adequate funding from the Line Ministries. Most of the health facilities in the project area are second tier

level of care dispensaries for primary care services and often do not have the capacity to support increased

demand for services. As a district officer notes,

“We talk of delivery in the facility, but the facilities they don’t have even a room where a mother can deliver.

There are some facilities that don’t even have a delivery bed. We find that it’s just a couch that they just went to

buy at the market for examining patients. So in case a mother comes possibly in second stage, she’ll just be lying

there.”

District health workers and beneficiaries raised concerns of limited services and poor infrastructure, such as a lack

of electricity, running water, and fences for security. Facilities are in need of equipment to be up to standards,

principally for maternity and lab services. Sometimes funding is delayed, causing shortages in supplies and drug

stock outs.

Health care is also hampered by restricted working hours, leaving many people without options late at night, or

when the only staff are gone for training, meetings, or are sick themselves. Health facilities are understaffed, and

those there are overworked or may not be up to date on medical skills. Monthly outreaches, or the provision of

health care services in the communities, can be expensive in terms of time by taking personnel away from the

facility.

Management Issues and Lessons Learned

Workload, monitoring and supervision

AIM Health has a single project manager and project officer. The staff are spread thin with the many moving

pieces of AIM and other projects being managed. The program requires considerable coordination with a

multitude of stakeholders, which can be taxing. Fortunately, they are significantly supported by other staff at the

ADP, region, and national levels.

While MOH officials provide monitoring and supervision support in the sub-county, there are issues in securing

enough trained personnel to conduct the visits. Until recently, supervision was conducted haphazardly due to the

lack of a standard checklist. WVK has assisted the Ministry in providing the needed monitoring tools in the sub-

county.

Data collection, reporting and use

According to a district officer, there has been a substantial improvement in data quality due to training CHWs

and CUs in data management. Reporting is streamlined, which allows the data to be shared between all

stakeholders, but regional staff note that the flow of information is problematic at times. There is an interest in

utilizing technology for monitoring and evaluation purposes, as long as it is not heavily web-based. There is need

for a dedicated and local M&E officer for AIM Health, as WVK staff have expressed dissatisfaction with the

evaluation design thus far.

Logistics, procurement and administration

Although it can take up to one month or more, the WVK procurement process is clear, and the online system has

made approvals easier. A procurement committee that includes community members ensures fairness in the

process. Respondents described the process of procuring supplies as starting with creating a purchase requisition

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form online to be approved by management at the appropriate levels, “floating” price quotations to different

vendors, then awarding contracts by committee. One lesson learned concerning procurement is that the process

must be initiated early to account for possible delays like unreliable vendors. Although there is shared

administration and supportive integration at the ADP between projects, logistics must be carefully planned due to

limited availability of vehicles.

Line-management

AIM Health has stayed close to budget thus far, but there is a discrepancy between financial managers on

approximately how much the project has overspent. This could be due to managing spending across the different

fiscal periods that WVK and the donor have. There is agreement that strong points of the program are budget

clarity and focused spending.

When it comes to line-management, notable challenges are the inherent field realities of a community-based

program and balancing conflicting expectations. The time frame for planned activities may change rapidly with

shifting priorities of partners. Multiple stakeholders acknowledge that limited resources sometimes hinder AIM

from addressing more pressing needs. For example, the community may expect more out of the project than the

design allows for, like tangible facility improvements or health worker skills training.

Funding and reporting

Monthly financial reporting is centralized and feedback is constantly given to mitigate snags and support progress.

At times, the flow of funds is slow, but communication keeps implementation moving along. No difficulties are

found in managing the grant requirements or complying with donor expectations. The AIM team appreciates the

technical support given by WVI.

Bottlenecks and recommendations

A few bottlenecks were identified related to management and implementation. Staff turnover at WVK and staff

shortages within the Ministry impede successful completion of activities, procurement, monitoring, and

supervision. For a five-year grant, there is agreement that the program planning and budgeting has been too rigid,

overall, to meet on-the-ground needs as they arise.

“But you know when you come to the ground, things are different. Things are changing and you have to change

with the times. Yes, you’ve done TTC in the community and the household, good. But then now when they go to

the health facility they need to get equally good care, but they cannot get good care if capacity isn’t built. Five

years ago, or seven years ago, you plan for this, but in these seven years, things change. So that is where we have a

little bit of difficulty.” – AIM Project Manager

2.4 Limitations There were small challenges in executing the original protocol fully. First, the FGD training was shorter than

planned due to the late arrival of one facilitator, but the bulk of the time was spent ensuring adequate translation

of the discussion guides into the local language. Although two weeks of data collection were planned, there were

difficulties in scheduling interview or discussion time for dozens of participants. Community members were

sometimes hard to contact and mobilize due to land preparation and other home duties. One FGD had to be

rescheduled due to miscommunication concerning the start time. Both WVK and MOH staff were busy with

other work commitments and some informants were not located in the program area, therefore delaying

interviews further. Two interviews had to be completed over the phone, which resulted in muffled recordings

that were difficult to transcribe. An additional barrier encountered was fatigue with research by both FGD and

IDI participants associated with AIM Health in Mutonguni. WVK conducted a documentation exercise in

February, covering similar topics and utilizing many of the same participants. Many participants were noticeably

silent in FGDs, despite prodding from facilitators. Direct translation from the local language to English, or

verbatim transcription, of the FGDs were not possible due to limited time and only having one person to work

on them. In spite of these challenges, staff and participants alike did their best to make the data collection process

as smooth as possible. Finally, regarding analysis, internet connectivity obstructed coding progress initially, but

14

all data was downloaded for offline use afterwards. The analyst attempted to reconcile partial transcriptions with

corroboration from other sources, such as reading project documents, speaking with project managers or

searching online for additional information.

15

3.0 Impact Study

3.1 Scope, Design and Methods The overall purpose of the LiST exercise was to strengthen the evidence base of the AIM Health Programme.

Specific objectives were to:

1. Estimate the likely impact of the first half of the project (2012-’14) in terms of deaths averted and

lives saved using population-level coverage estimates obtained at baseline and at mid-term.

2. Project the probable future impact of the second half of the project (2015) with the current suite of

interventions, based on baseline and mid-term coverage estimates and establishing a temporal trend.

Protocol

The analyst attended an eight week training on the Spectrum software and conducting analyses with the LiST

module at Johns Hopkins University Bloomberg School of Public Health (JHSPH) prior to the MTR, followed by

additional refresher trainings during the MTR. The data collection and analyses were carried out over a four

week period between August and September 2014. No ethical approval was sought due to the lack of collecting

primary, human-subjects data.

The modelling process began with verifying coverage data from default sources and project baseline/LQAS. AIM

Health interventions and indicators were mapped to LiST interventions and indicators for comparison. The

decision for inclusion in final models was largely based on: degree of match between AIM Health indicator and

LiST indicators, and completeness of indicators (at least 2 time points). A baseline projection was created

adjusting national demographic, mortality, and coverage values to ADP levels. Additional change projections

were created through input of data for the relevant years. Analysis was carried out through extraction of results,

such as deaths, from the LiST software.

LiST Specifications

Projections were created with Spectrum version 5.0736. The base year of coverage and first year of intervention

were 2011 (the unifying year for sourcing data). The Mutonguni ADP AIM Health project area population was

49,055 in 2011 and population adjustments were made to align to that value. Other demographic data for the

ADP area (sourced and LiST derived) are listed in Table 4. Most default data were from the Kenya

Demographic and Health Survey 2008-2009. Other baseline coverage values, more specific to the region, were

updated from various sources (Table 5). Baseline mortality and fertility rates were sourced from Multiple

Indicator Cluster Survey 2008 (Kitui District) estimates.

When indicators had multiple potential source values, inclusion as the baseline was prioritized by relation to

project area (project/regional values chosen over national values) and year (more recent values chosen over older

values). For indicators where data was unavailable or unreliable, no coverage (0%) was assumed. These indicators

were not included in the analysis and did not have any effect on the results because coverage was not artificially

inflated to an observed percent.

HIV treatment coverages (PMTCT/ARV) were flattened from 2011 onward to eliminate any effects since the

project did not specifically focus on HIV treatment and the decision was made to not include it in the analyses. As

part of a sensitivity analysis, a projection was made without flattening these estimates and no additional lives were

saved. Vaccination coverage was not used in the models at all (flattened from 2011 onward). The analyst could

not verify the project data quality, as the indicator was listed as “percent fully immunized” without specification

of which immunizations constituted full immunization and multiple values were present in the baseline report for

individual immunization coverages. National immunization coverage (WHO/UNICEF and MOH estimates)

actually dropped in the project years.

Coverage Information

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Three scenarios were created for the main analyses. These scenarios used values for the included AIM Health

interventions (Table 6) based on the above criteria. Table 7 lists a summary of the magnitude of changes in

intervention coverages. Midterm values moved between 1 and 31 percentage points from baseline (12.7 on

average). Endline values were scaled up between 2 and 66 percentage points (21.7 on average) from midterm

(interventions with values above 90% were held constant). Midterm and endline target values were sourced from

the AIM Health Programme RBF. Most interventions were population-level outcome indicators, but others were

listed as output indicators. The output indicator target values, which were among the population visited by

CHWs, were included because they were at a realistic level of increase from the baseline values.

AIM_baseline-point: AIM Health baseline coverage (2011) entered for the selected interventions; a

counterfactual scenario of no change in coverage for any year.

AIM_midterm-point: AIM Health LQAS coverage (2014) entered; a scenario of linear change from

2011 to 2014.

AIM_endline-targets: AIM Health endline (2015) target coverage entered; a scenario of expected

change from 2011 baseline and 2014 midterm values until the end of the program.

An additional scenario was created as secondary analyses:

AIM_midterm-targets: AIM Health MTR (2014) target coverage entered for those interventions which

did not meet targeted values (i.e. improved water source, ORS, Vitamin A supplementation, and ITN);

all others entered as the 2014 point value.

Table 7: LiST Intervention Coverage Summary

Intervention 2011 (%) 2014 (%) Change between 2011-2014 (%)

2015 (%) Change between 2014-2015 (%)

Antenatal care 43.5 58 14.5 70 12

Skilled birth attendance (facility births)

54 76 22 86 10

Postnatal care 20 30 10 32 2

Exclusive breastfeeding 83 91 8 91* 0*

Complementary feeding 50 65 15 80 15

Vitamin A supplementation

69 80 11 90 10

Improved water source 50 19 -31 85 66

Improved sanitation 91 90 -1 90* 0*

ITN ownership 70.5 71 0.5 95 24

ORS for diarrhea 55 46 -9 80 34

Case management for pneumonia

55 73 18 95 22

** = Indicator value for 2014 met or exceeded 2015 target values

3.2 Findings for Objective 1 (2014 Midterm) Deaths avertedc in children under 5

Table 8d (see Annexure) reveals that 14 total deaths were averted in all children under 5 years of age in 2014.

Ten of those deaths averted (71%) are specifically in children under one month of age. A total of 27 deaths in

c Deaths averted attribute reduction in mortality due to specific causes by each intervention. It does not assume that individuals are at risk of dying of multiple causes. d In tables on deaths/cases averted, negative numbers signify an increase in deaths due to a particular cause or intervention instead of the expected decrease in deaths. When deaths are broken down by cause or intervention, the numbers may not

17

children under 5 were averted during the project implementation period (2011-2014). In the neonates, increased

coverage of labor and delivery management (skilled birth attendance) prevented 40% of deaths, which would

have been caused by neonatal asphyxia. In children 1-59 months, increased coverage of oral antibiotics (case

management for pneumonia) prevented 36% of deaths, which would have been caused by pneumonia. Figure 4

shows what causes of death were averted in children under 5. A third of deaths averted were deaths which would

have otherwise been caused by pneumonia (n=5). The next two greatest deaths averted by cause were neonatal

asphyxia (n=5, 29%) and neonatal prematurity (n=4, 25%).

Maternal & stillborn deaths averted

Table 9 shows that one maternal death was averted, but that one death is actually made up of partial deaths due

to specific causes. Three intrapartum stillbirths were averted due to increased coverage of labor and delivery

management.

Nutritional status

Table 10 reveals stunting and wasting distributions for children of different age groups as calculated by LiST and

as calculated from the LQAS results both in 2011 and 2014. Although LQAS showed a 10% decrease in stunting

overall, LiST modelled a change in stunting status that was not more than a 2% decrease per age group. Wasting

status and birth outcomes (pre-term and term small for gestational age) were unchanged with changes in

intervention coverage.

Morbidity

Table 11 shows that although breastfeeding and vitamin A prevented over 1,132 cases of diarrhea, many more

cases were added due to decreased coverage of certain WASH (Water and Sanitation Hygiene) interventions in

2014. There is a net -366 cases of diarrhea averted – in other words, this is an additional 366 cases of diarrhea

due to intervention coverage changes. This result is consistent with LQAS findings of a 5 percentage point

increase in diarrhea prevalence over baseline values. Incidence of pneumonia increased in older children, but

LiST only modelled 4 additional cases which is not consistent with the 9 percentage point increase in suspected

acute respiratory illness (ARI) prevalence over baseline values.

3.3 Findings for Objective 2 (2015 Endline) Deaths averted in children under 5

Table 12 reveals that 31 total additional deaths will be averted in all children under 5 years of age if end of

program targets are met for 2015. Fourteen of those deaths averted (45%) will be specifically in children under

one month of age. Figure 5 shows what causes of death will be averted in children under 5. Pneumonia has the

greatest share of deaths averted by cause (n=11, 36%), followed by neonatal asphyxia (n=6, 21%) and neonatal

prematurity (n=5, 17%), and diarrhea (n=4, 14%).

In neonates, increased coverage of labor and delivery management will prevent 5 neonatal asphyxia deaths.

Increased coverage of antenatal corticosteroids will prevent 3 neonatal prematurity deaths. In children 1-59

months, increased coverage of ORS treatment and improved water source will prevent 3 and 1 deaths,

respectively, which would otherwise be caused by diarrhea.

Maternal & stillborn deaths averted

Four intrapartum stillbirths will be averted due to increased coverage of labor and delivery management, and 1

additional antepartum stillbirth will be averted due to increased coverage of syphilis detection (antenatal care) as

shown in Table 13. One additional maternal death will be averted with 2015 level coverages.

always sum up to the total because of rounding and/or fraction values. Only whole numbers were reported due to the ambiguousness of 0.3 of a life saved.

18

Morbidity

Table 14 shows that the expected increase in vitamin A coverage prevents the greatest number of cases of

diarrhea (2,023 cases), followed by improved water source coverage (1,534 cases). Approximately half of

diarrhea cases averted will occur in children between 24-59 months of age. There will be a net 2,992 cases of

diarrhea averted in children under 5 if 2015 targets are met. Cases of pneumonia will continue to occur at similar

rates in older children, with a net -10 cases averted in 2015.

3.4 Mortality Findings Mortality rates

Table 15 shows the modelled trend of different mortality rates for the project area. The intervention coverage

changes led to an 8% reductione for both the stillbirth and under-five mortality rates for 2014. They also led to a

13% reduction in the neonatal mortality rate and a 14% reduction in the maternal mortality rate for 2014.

In 2015, the intervention coverage changes will potentially lead to an 18% reduction in the under-five mortality

rates, a 12% reduction in the stillbirth rate, a 20% reduction in the neonatal mortality rate, and a 20% reduction

in the maternal mortality rate.

Figure 6 shows that (aggregated) components of skilled birth attendance contributed the most to mortality

reduction, followed by oral antibiotics for case management of pneumonia.

Deaths

Tables 16-19 make a comparison of total deaths and cause of death distribution for the 2014 scenario and the

2015 scenario. The lives savedf are approximately the same as deaths averted presented above. A secondary

analysis of MTR target values reveals that an additional 4 deaths would have been prevented in children under 5

(18 deaths averted total) if targets had been met for all interventions

Figure 7 is a graphical representation of Table 17, and Figure 8 is a graphical representation of Table 16.

Both show the trend in total deaths over the project implementation period comparing a scenario of expected no

change in coverage to a scenario that modelled AIM Health measured changes in coverage.

3.5 Limitations A decision was made early on in the analysis process to not include vaccination coverage, but a sensitivity analysis

was conducted. Had national immunization coverage been left as is (declining over the project period), 2

additional lives would have been saved for a less than 1% additional mortality reduction.

Every indicator measured in LQAS was not included in the analyses for LiST. Some indicators only had mid-term

values and no baseline values. Some indicators had both but had differences in how they were measured (e.g.

IPTp). Some indicators were not compatible enough with LiST definitions (i.e. reported hand-washing behavior).

Breastfeeding promotion was used instead of breastfeeding behavior because inadequate data was available for the

other required categories (exclusive vs. predominant vs. partial breastfeeding).

LiST makes special assumptions about antenatal care and delivery care as both are interventions that actually

represent several individual component interventions. Antenatal care components can be manually changed, but

some are calculated from the coverage of antenatal care and are scaled up or down in relation to antenatal care in

total (e.g. syphilis detection). The same goes for delivery care, or skilled birth attendance, with the additional

e Mortality reductions are interpreted as the percent change between comparison and intervention scenarios in the year of interest. f Lives saved takes into account that an individual can be at risk of dying from multiple causes, so is calculated by subtracting the total number of expected deaths in the intervention change scenario from the total deaths of the scenario depicting no intervention coverage changes.

19

assumptions that some component interventions are only at higher levels of health facilities and certain

percentages of women have access to the higher level facilities.

The impact modelled is only as valid as the quality and accuracy of its data inputs. Although LQAS is a sufficient

tool for judging program quality, it is not always a sufficient tool for precise population-level estimation due to its

small sample size requirements.

Finally, these results are also limited by the parameters of the comparison projection. The assumption made was

that with the AIM Health project in this area, the coverage values for all indicators would remain the same

throughout the years. An alternative analysis could have been made with the assumption that coverage may have

changed naturally (possibly using MOH data), and then comparing that to the evaluation results. The analysis as

presented does not take into account the potential contribution of other projects in the area. The impact cannot

be attributed to AIM Health conclusively without additional analyses.

20

4.0 Conclusions & Recommendations

Overall, the perceptions of health status changes in the AIM Health project area were positive, but are not

supported by mid-term quantitative data. Nutritional outcomes, specifically, and care seeking behaviors have

improved. Utilization of health services seems to have increased as a result of the health messages and facility

upgrades. There appeared to be widespread support for the AIM-MOH partnered interventions permeating

throughout the community.

AIM Health is well integrated into MOH strategy to strengthen the community health system. Participants note it

has been successful program at engaging the community and setting a foundation for sustainability. The synergy

created through AIM Health is evident through the noted community ownership and local/national cohesion to

achieve shared visions and objectives around MCHN.

Environmental and socio-economic constraints hamper maximum intervention coverage – primarily poverty and

a challenging landscape. Health services are also constrained by occasionally delayed funding, supply and staff

shortages, and poor infrastructure. The current CHW supervision structure is unsustainable, and CVA members

and CHWs report a need for tools to carry out their work.

AIM Health has had limited staff, but MOH/WVK integration and shared resources is key to successful

implementation of the project. Although grant compliance is satisfactory, participants share that funding has been

slow and the budget has been strict. One important lesson learned is that activities need to be carefully planned

but flexible enough to respond to delays or environmental changes.

The LiST exercise found that the AIM Health project contributed to saving a total of 36 maternal and child lives

(including stillbirths) since the project’s start, including 17 in 2014 alone (Table 20). There is an estimated 37

additional maternal and child lives that can be saved by achieving scaled up intervention coverage to RBF target

levels in 2015. The most important intervention to preventing maternal, neonatal and child deaths is increased

skilled birth attendance, particularly in a facility. Although the components (e.g. clean birth practices, neonatal

resuscitation) are what make the most impact, management of births by skilled health professionals is one of the

premiere ways to ensure child survival.

Table 20: Lives Saved Summary

Lives Saved Summary

Children under 5 years*

Children under 1 month

Maternal Stillbirths Total

2012 5 (3) 1 1 7

2013 9 (7) 1 2 12

2014 13 (10) 1 3 17

2015 31 (15) 1 5 37

Total 58 (35) 4 11 73**

*Inclusive of children under one month **Total until 2014 only: 36

() Not counted in Total column

Although at first glance these numbers seem low, they translate to an 8% reduction in under five mortality and a

14% reduction in maternal mortality. Scaled up coverage for 2015 will fall short of achieving the current RBF

targets of a 25% reduction in both under-five and maternal mortality, but the LiST analysis suggests that an

approximately 20% reduction may be achieved in both groups. The mortality impact modelled by LiST is actually

determined by several factors: intervention coverage (quality and change), intervention effectiveness, baseline

cause of death profile, and population.

The results of this exercise reflect some cautions. First, the project area population is slightly lower than

recommended for use of LiST (50,000), and even with such a high mortality rate, the absolute numbers of deaths

21

will be low. LiST estimated that pneumonia is the biggest killer of children under 5 in this area, so large

reductions in mortality would most likely be achieved with interventions focused on preventing and treating

pneumonia37. Although the choices of interventions for AIM Health are effective, some very effective

interventions had steep drops and others had high baseline values, leaving little room for improvement.

Although the biggest deficit to overcome in the next year is access to improved water source, WASH is not an

important component of the AIM Health strategy. The 2015 analysis shows that big gains can be made with

increased care seeking (and treatment) for pneumonia, increased ORS treatment for diarrhea, and continued

increases in skilled delivery. At the time of the MTR, ICCM training was beginning for MOH partners in the

project area. It is recommended that project activities focus on scaling up this intervention in the next year to aid

in achieving end of program goals. In order to increase program efficiency, reach and to realize its full potential

for sustainability, it is also recommended that the Mutonguni AIM Health project focus on the following key

aspects during the remaining year:

Accelerate advocacy efforts at the county government level and work to strengthen communication

among different levels of the community health system with the purpose of creating sustainable

funding solutions for the intervention components.

Develop and implement a communications strategy to better promote the community ambulance.

Encourage the DHMT to further work on transportation guidelines for health system linkages in the

sub-county.

Continue working with the MOH to further motivate CHW performance with training needs

assessment, refresher and ICCM trainings, procurement of or supply chain management for CHW

kits, and procurement of bicycles for transportation.

As the DHMT continues to develop CHW performance appraisal guidelines, encourage the MOH

in developing an alternative supervision model to ease the current gap. A case for task-shifting as

incentivization could be made, such as creating an advancement opportunity for high-performing

CHWs to move into supervisory roles (with stipend) as they gain more skills. Also strongly

consider the prior recommendation made to combine CHWs and CHEWs supervision with the

outreach strategy for immunization.

CVAs need to be revitalized with the support and tools they need. AIM Health should support

experiential learning visits to similar groups in nearby areas, have CVA groups introduced at

community dialogues/forums, and aid in securing an interface meeting with government

stakeholders.

22

5.0 Reflections on Field Practicum From June to September of 2014, I undertook my master’s field practicum in Kenya. I was engaged as a Global

Health Fellow, along with three other of my classmates, with World Vision – a Christian humanitarian

organization dedicated to improving the lives of children, families, and their communities worldwide. My role

was to conduct an evaluation of one of their health programs in Kenya, primarily focusing on a qualitative study

and impact modelling study. I was also to work with national office staff on implementing LiST as a monitoring

and evaluation tool for their health projects, but that portion of the fellowship had to be canceled due to

scheduling conflicts. I chose to work in Kenya because I had been there once before as a volunteer and wanted to

more fully immerse myself in that context. The fellowship began with a week-long training and orientation

session in the U.S. (Washington, D.C. and Baltimore, MD) before departing to Nairobi, Kenya.

I spent the remainder of June in a training workshop on LiST, and being introduced to World Vision Kenya staff

in the national office and at the ADP. Once all of the fellows were situated, the head consultant on this mid-term

evaluation started sharing the evaluation protocol and instruments to be used with us. Although I did not develop

any of these instruments out right, I was able to provide input during revisions. Data collection started in July,

and I was immediately responsible for putting my graduate training to use by organizing a training of my own

with the hired focus group discussion moderators. I pulled together the resources I had and attempted to make it

an interactive session, but time constraints left us to focus on the essentials only. The ADP staff were really

diligent about getting me to the scheduled interviews and making sure I had the chance to experience other

projects being implemented in the area. As predicted in my classes, it soon became clear that data collection

would take slightly longer than expected, but I was prepared to work intensely on the analysis and write-up in

August.

I constantly reflected on why I felt “this” wasn’t right or “that” could be done better when developing my report

and recommendations, being careful to avoid the cultural barrier scapegoat. As Mark Nichter put it, “Cultural

barrier explanations are commonly based on (mis-) representations of culture as monolithic and the “local” as

both stagnant and somehow juxtaposed to the modern.”g I had to understand that things were done in a manner

that best reflects the complex reality in which health programs are situated. For this practicum, some challenges I

faced was that the quality of data to use for this evaluation (both collected by myself and by others) was poor at

times. Also, I learned a lot about Grounded Theory in my Qualitative Research series, but when faced time

constraints to conduct an analysis of my data, I opted to use the less well known FrameWork Approach.

Although English was the primary language between staff/interviewees and I, sometimes there

miscommunications where one party did not fully understand the meaning of what the other party was saying.

I really enjoyed my time in Kenya, and I am grateful for the opportunity. Although the security situation was

shaky during my time there (because of terrorist attacks on the coast), I met so many wonderful people, tried

new foods, and even got to explore Kitui county and Nairobi. When I pursued this fellowship, I sought a field

experience with an international NGO that tied together knowledge I had gained from the spectrum of my first

year courses. Through experiential learning and professional mentorship, I hoped to intimately improve my skills

in designing and evaluating behavior change interventions.

With this practicum, I learned how to manage expectations from multiple parties, as well as communicate

effectively with my superiors at different levels. I also felt that I was learning the intricacies of managing a large

project: from collection to analysis and changes in the protocol in between. I was able to understand on the

ground realities that surround health programs in Kenya. Overall, I wholeheartedly believe I achieved my

practicum goals, and I am excited to apply this experience to the next phase of my career.

g Nichter, M. (2008). Global health: Why cultural perceptions, social representations, and biopolitics matter. University of Arizona Press.

23

6.0 Annexure

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Changing Environment. Nairobi, Kenya; 2009:41–66. Available at: http://na.unep.net/atlas/datlas/sites/default/files/unepsiouxfalls/atlasbook_1135/Kenya_Screen_Chapter2.pdf.

2. Kenya National Bureau of Statistics, ICF Macro. Kenya Demographic and Health Survey 2008-09.; 2008. 3. Kenya National Bureau of Statistics. Kitui District Multiple Indicator Cluster Survey 2008.; 2009. 4. National Coordinating Agency for Population and Development, Ministry of Medical Services, Ministry of Public

Health and Sanitation, Kenya National Bureau of Statistics, ICF Macro. Kenya Service Provision Assessment Survey 2010.; 2011.

5. Government of the Republic of Kenya. Kenya Vision 2030.; 2007. Available at: http://www.vision2030.go.ke/cms/vds/Popular_Version.pdf.

6. Republic of Kenya. Health Sector Strategic and Investment Plan July 2012-June 2017. Ministry of Medical Services and Ministry of Public Health Sanitation; 2013.

7. Kenya Ministry of Health. Taking the Kenya Essential Package for Health to the Community: A Strategy for the Delivery of Level One Services.; 2006.

8. Ministry of Medical Services, Ministry of Public Health and Sanitation. Kenya Health Policy 2012-2030. 9. World Vision International. 7-11 Start-up Field Guide.; 2010. 10. Bhutta Z a, Darmstadt GL, Hasan BS, Haws RA. Community-based interventions for improving perinatal and

neonatal health outcomes in developing countries: A review of the evidence. Pediatrics. 2005;115(2):519–617. doi:10.1542/peds.2004-1441.

11. Darmstadt GL, Bhutta ZA, Cousens S, Adam T, Walker N, De Bernis L. Evidence-based, cost-effective interventions: How many newborn babies can we save? Lancet. 2005;365:977–988. doi:10.1016/S0140-6736(05)71088-6.

12. Haws RA, Thomas AL, Bhutta ZA, Darmstadt GL. Impact of packaged interventions on neonatal health: A review of the evidence. Health Policy Plan. 2007;22:193–215. doi:10.1093/heapol/czm009.

13. Jones G, Steketee RW, Black RE, Bhutta Z a., Morris SS. How many child deaths can we prevent this year? Lancet. 2003;362:65–71. doi:10.1016/S0140-6736(03)13811-1.

14. Freeman P, Perry HB, Gupta SK, Rassekh B. Accelerating progress in achieving the millennium development goal for children through community-based approaches. Glob Public Health. 2012;7(February 2015):400–419. doi:10.1080/17441690903330305.

15. Marston C, Renedo A, McGowan CR, Portela A. Effects of community participation on improving uptake of skilled care for maternal and newborn health: A systematic review. PLoS One. 2013;8(2):e55012. doi:10.1371/journal.pone.0055012.

16. Ricca J, Kureshy N, LeBan K, Prosnitz D, Ryan L. Community-based intervention packages facilitated by NGOs demonstrate plausible evidence for child mortality impact. Health Policy Plan. 2014;29(2):204–16. doi:10.1093/heapol/czt005.

17. Adam MB, Dillmann M, Chen M, et al. Improving maternal and newborn health: Effectiveness of a community health worker program in rural Kenya. PLoS One. 2014;9(8):e104027. doi:10.1371/journal.pone.0104027.

18. Olayo R, Wafula C, Aseyo E, Loum C, Kaseje D. A quasi-experimental assessment of the effectiveness of the Community Health Strategy on health outcomes in Kenya. BMC Health Serv Res. 2014;14(Suppl 1):S3. doi:10.1186/1472-6963-14-S1-S3.

19. Peters DH, Tran NT, Adam T. Implementation Research in Health: A Practical Guide. World Health Organization; 2013. Available at: http://who.int/alliance-hpsr/alliancehpsr_irpguide.pdf.

20. Onwuegbuzie AJ, Leech NL, Collins KMT. Innovative Data Collection Strategies in Qualitative Research. Qual Rep. 2010;15(3):696–726.

21. Rhoda D a., Fernandez S a., Fitch DJ, Lemeshow S. LQAS: User beware. Int J Epidemiol. 2010;39:60–68. doi:10.1093/ije/dyn366.

22. Robertson SE, Valadez JJ. Global review of health care surveys using lot quality assurance sampling (LQAS), 1984-2004. Soc Sci Med. 2006;63:1648–1660. doi:10.1016/j.socscimed.2006.04.011.

23. Walker N, Tam Y, Friberg IK. Overview of the Lives Saved Tool ( LiST ). BMC Public Health. 2013;13(Suppl 3):S1. doi:10.1186/1471-2458-13-S3-S1.

24. Walker N, Fischer-Walker C, Bryce J, Bahl R, Cousens S. Standards for CHERG reviews of intervention effects on child survival. Int J Epidemiol. 2010;39:i21–i31. doi:10.1093/ije/dyq036.

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25. Stover J, McKinnon R, Winfrey B. Spectrum: A model platform for linking maternal and child survival interventions with AIDS, family planning and demographic projections. Int J Epidemiol. 2010;39:i7–i10. doi:10.1093/ije/dyq016.

26. Winfrey W, Mckinnon R, Stover J. Methods used in the Lives Saved Tool ( LiST ). BMC Public Health. 2011;11(Suppl 3):S32. doi:10.1186/1471-2458-11-S3-S32.

27. Friberg IK, Kinney M V, Lawn JE, et al. Sub-Saharan Africa’s mothers, newborns, and children: How many lives could be saved with targeted health interventions? PLoS Med. 2010;7(6):e1000295. doi:10.1371/journal.pmed.1000295.

28. Bryce J, Friberg IK, Kraushaar D, et al. LiST as a catalyst in program planning: experiences from Burkina Faso , Ghana and Malawi. Int J Epidemiol. 2010;39:i40–i47. doi:10.1093/ije/dyq020.

29. Komatsu R, Korenromp EL, Low-Beer D, et al. Lives saved by Global Fund-supported HIV/AIDS, tuberculosis and malaria programs: estimation approach and results between 2003 and end-2007. BMC Infect Dis. 2010.

30. Ricca J, Prosnitz D, Perry H, et al. Comparing estimates of child mortality reduction modelled in LiST with pregnancy history survey data for a community-based NGO project in Mozambique. BMC Public Health. 2011;11(Suppl 3(S35). doi:10.1186/1471-2458-11-S3-S35.

31. Hazel E, Gilroy K, Friberg I, Black RE, Bryce J, Jones G. Comparing modelled to measured mortality reductions: applying the Lives Saved Tool to evaluation data from the Accelerated Child Survival Programme in West Africa. Int J Epidemiol. 2010;39:i32–39. doi:10.1093/ije/dyq019.

32. Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol. 2013;13(1):117. doi:10.1186/1471-2288-13-117.

33. Bellows NM. Vouchers for reproductive health care services in Kenya and Uganda: Approaches supported by financial cooperation.; 2012.

34. Janisch CP, Albrecht M, Wolfschuetz A, Kundu F, Klein S. Vouchers for health: A demand side output-based aid approach to reproductive health services in Kenya. Glob Public Heal Heal. 2010;5(6):578–594. doi:10.1080/17441690903436573.

35. Arur A, Gitonga N, O’Hanlon B, Kundu F, Senkaali M, Ssemujju R. Insights from innovation: Lessons from designing and implementing FamilyPlanning/Reproductive Health Voucher Programs in Kenya and Uganda. Bethesday, MD: Abt Associates; 2009.

36. Plosky WD, Stover J, Winfrey B. The Lives Saved Tool: A Computer Program for Making Child Survival Projections. USAID; 2011. Available at: http://www.jhsph.edu/research/centers-and-institutes/institute-for-international-programs/_documents/manuals/list_manual.pdf.

37. Liu L, Johnson HL, Cousens S, et al. Global, regional, and national causes of child mortality: An updated systematic analysis for 2010 with time trends since 2000. Lancet. 2012;379(12):2151–2161. doi:10.1016/S0140-6736(12)60560-1.

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Programmatic Context Figure 1: Map of Kitui County

Source: http://www.kitui.go.ke/

Figure 2: AIM Health MTR Timeline

26

Figure 3: LiST Modelling Examples

Key: Cause of death; Disease specific treatments; Risk factors; Disease specific preventions; Distant factors

27

Data Collection Summary

Table 2: Qualitative Data Collection

Respondent Category Location/Community Date

Focus Group Discussions

Mothers Kivani (N=9) July 8

Kiseveni (N=5) July 14

Husbands/male partners Musengo (N=10) July 10

Katutu (N=8) July 15

CHWs Mithini (N=10) July 10

Mutanda (N=7) July 11

COMM Kauwi (N=7) July 8

Katutu (N=7) July 11

CVA Katutu (N=4) July 15

In-Depth Interviews

PHU/HP in-charge Kivani July 3

District Medical Officer Kauwi July 17

District M&E officer Kauwi July 4

District Hospital (senior clinical person) Kauwi July 4

Liaison/Point person within DHMT Kauwi July 9

Local Council/District Chairman Mithini July 16

AIM Project Officer Kitui July 23

ADP Manager Mutonguni July 24

AIM Project Manager Kitui July 24

Base/regional manager Mutonguni July 22

National Technical Coordinator Kitui July 24

WV M&E officer - Base/region Nanyuki July 29

Grant Finance Manager – Base/region Mutonguni July 22

Grant Finance Manager – National Nairobi July 24

National MOH point person Kitui July 23

Table 3: Survey Results

Indicator 2011 Baseline Survey (%) 2014 LQAS (%)

6-59m stunted 47.4 38

6-23m underweight 20 12

0-23m initiated on breastmilk within 1 hour 43.6 71

0-5m exclusively breastfed 83.1 91

6-59 with adequate iron intake 71.9 53

6-23m minimum meal frequency 50 77

6-23m diverse diet 50 79

PW with adequate iron intake (iron-rich food) 64.7 67

PW who took diverse diet 50 90

PW took iron previous day 72.2 46

6-59m vitamin A supplement past 6m 69.2 80

12-59m fully immunized 92.6 64

0-59m with ARI 12 21

0-59m with fever 30.7 49

0-59m with diarrhea 15.3 20

0-59m with ARI taken to facility in 24h 50 73

0-59m with diarrhea given ORT 54.7 46

0-59m with fever taken to facility in 24h 58.2 43

28

0-59m slept under LLIN 70.5 71

caregivers knowing 3 MTCT 84.2 4

HH with unrestricted access to safe water 50.4 19

HH with access to sufficient water 50.4 46

HH with access to improved sanitation 91 90

caregivers washing hands 2/4 times 87.6 69

0-59m birth attended by SBA 53.6 76

mothers of children 0-59m who had 4 ANC 43.5 58

mothers of children 0-59m who had 3 PNC 20 30

caregivers with intent to use spacing 51.6 77

0-59m with birth certificates 18.5 16

29

LiST Data Collection

Table 4: Demographic Data

Demographic Information Value Source of data & year Comments

Population (ADP) 49,055 AIM Health Baseline (2011)

Women of reproductive age 23.9% 11,722

Spectrum/DemProj (2011)

Children under 5 17.1% 8,366

Spectrum/DemProj (2011)

Sex ratio at birth 103 Spectrum/DemProj (2011) Males to females

Total Fertility Rate (TFR) 4.81 Spectrum/DemProj (2011) Recalculated as trend from MICS (2008) TFR of 5.1 for Kitui District

Crude birth rate 37.6 Spectrum/DemProj (2011) Per 1000 population

Annual # of births 1,843 Spectrum/DemProj (2011)

Poverty 63.7% Kenya Integrated Household Budget Survey (2005-2006)

Kitui District – Population living below poverty line of 1,562 KES per month

Average household size 4 Kenya DHS (2008)

Table 5: National/Region Coverage Levels Update

(Only including indicators which differed from Spectrum/LiST defaults)

Indicator LiST Default Coverage (%)

Updated Coverage (%)

Source of updated data & year

Comments (proxy indicators, other)

Postnatal care (thermal and clean practices)

6.9% 15.5% Kenya DHS (2008-2009)

Recalculated to reflect the LiST definition as specified in LiST.

Iron folate supplementation

0% 2.5% Kenya DHS (2008-2009)

IPTp 0% 25.4% Kenya MIS (2010)

Policy recommendation in place, but not for project area.

Tetanus toxoid vaccination

73% 15.5% Kitui District MICS (2008)

Water connection in the home

20.2% 12.6 WHO/UNICEF Joint Monitoring Programme (2012)

IPTp 25.4% 57.8% AIM Health (2011)

Hygienic disposal of children's stools

78.4% 49.2% MICS (2008)

Zinc - for treatment of diarrhea

0% 0.9% DHS (2008-2009)

Antimalarials - Artemesinin compounds for malaria

10.6% 12.7% MICS (2008)

30

Table 6: AIM Health Indicators and Values

Indicator in LiST

Indicator in AIM Baseline/ other sources

2011 Baseline Value (%, n, 95% CI)

2014 LQAS Value (%, n, 95% CI)

Target for MTR (%)

Target for 2015 (%)

Any departure from LiST definitions

Assumptions, quality of indicator, and source of information

Antenatal care % of pregnant women with at least 4 antenatal care visits

% mothers of children 0-59m who had 4 ANC

43.5% 58%, 128, [65.6, 50.4]

56.6% 69.6% Population difference (mothers vs. pregnant women)

The postnatal and antenatal visits were subject to recall bias (source: baseline report.

Skilled birth attendance % of children born with a skilled attendant present, including doctors, nurses, or midwives, in a facility or at home.

% 0-59m births attended by SBA

53.6%, [57.8, 49.4]

76%, 128, [82.8, 69.2]

69.7% 85.7%

Facility delivery % of infants delivered in a facility

% 0-59m births attended by SBA

53.6%, [57.8, 49.4]

76%, 128, [82.8, 69.2]

69.7% 85.7% The baseline reported SBA and facility deliveries as equal under the assumption that all SBA were in facilities.

Promotion of breastfeeding % of mothers of children 0-11 months of age exposed to a breastfeeding promotion message

% 0-5m exclusively breastfed the day prior to interview

83.1%, [92.2, 74]

91%, 252, [94, 88]

70% 80% LiST recommends using “% of 1-5 month old children exclusively breastfed” as an appropriate indicator.

Clean postnatal practices % of infants with a postnatal health contact/visit within 2 days of birth

% mothers of children 0-59m who had 3 PNC within the first week of birth, with an SBA

20% 30%, 128, [37, 23]

26% 32% The postnatal and antenatal visits were subject to recall bias (source: baseline report.

Complementary feeding--education only

% 6-23m minimum acceptable

50% 65%, 504, [69, 61]

60% 80% LiST uses % of children 6-23 months of age

Baseline did not include value for “minimum

31

% of mothers intensively counseled on the importance of continued breast feeding after 6 months and appropriate complementary feeding practices

diet receiving all 3 age-appropriate IYCF practices, or % of children 6-9 months of age breastfed and receiving complementary foods.

acceptable diet”, just “minimum meal frequency” and diet diversity separately. Because both were equal, an assumption was made that “acceptable diet” would also be equal.

Vitamin A supplementation % of children 6-59 months of age receiving 2 doses of Vitamin A during the last 12 months

% 6-59m vitamin A supplement in the past 6 months (at least 1 dose)

69.2%, [73.3, 64.7]

80%, 772, [82, 78]

85% 90% Clinic cards were often not filled in by health facility staff – vitamin A information was often missing (source: baseline report). LiST recommends using 1 dose in past 6 months if necessary.

Improved water source % of households having an improved water source within 30 minutes

% HH with unrestricted access to safe water

50.4%, [55.3, 45.5]

19%, 128, [24, 14]

75% 85%

Improved sanitation - Utilization of latrines or toilets % of households using an improved sanitation facility

% HH with access to improved sanitation

91% 90%, 128, [95, 85]

75% 85% Slight difference in indicator meaning between “using” and “access”

ITN/IRS - Ownership of insecticide treated nets (ITN/LLIN) or household protected with indoor residual spraying % of households owning at least 1 insecticide treated bed net or protected by indoor residual

% 0-59m slept under LLIN

70.5%, [75.1, 69.5]

71%, 254, [76, 66]

90% 95% LiST acknowledges that "children sleeping under an ITN" is an acceptable substitute, but the estimate will be conservative.

32

spraying

Thermal care % of infants with a postnatal health contact/visit within 2 days of birth

% mothers of children 0-59m who had 3 PNC within the first week of birth, with an SBA

20% 30%, 128, [37, 23]

26% 32% The postnatal and antenatal visits were subject to recall bias (source: baseline report.

ORS - oral rehydration solution % of children with suspected diarrhea treated with oral rehydration solution, including sachets or pre-mixed solutions

% 0-59m with diarrhea given ORS

54.7%, [66, 43.4]

46%, 204, [52, 40]

60% 80% LiST does not consider ORS made using home-available solutions as acceptable, but survey did include these

Oral antibiotics: case management of pneumonia in children % of children 1-59 months with suspected pneumonia or ARI treated with antibiotics

% 0-59m with ARI taken to facility in 24h

54.7%, [66.9, 42.5]

73%, 97, [81, 65]

70% 95% LiST recommends care seeking for suspected pneumonia as a more appropriate indicator

Table 7: LiST Intervention Coverage Summary

Intervention 2011 (%) 2014 (%) Change between 2011-2014 (%)

2015 (%) Change between 2011-2014 (%)

Antenatal care 43.5 58 14.5 70 12

Skilled birth attendance (facility births)

54 76 22 86 10

Postnatal care 20 30 10 32 2

Exclusive breastfeeding 83 91 8 91* 0*

Complementary feeding 50 65 15 80 15

Vitamin A supplementation

69 80 11 90 10

Improved water source 50 19 -31 85 66

Improved sanitation 91 90 -1 90* 0*

ITN ownership 70.5 71 0.5 95 24

ORS for diarrhea 55 46 -9 80 34

Case management for pneumonia

55 73 18 95 22

* = Indicator value for 2014 met or exceeded 2015 target values

33

LiST Results

Table 8: Deaths Averted, Neonates and Children (Midterm)

Neonates (0-1m) Total (0-60m)

Deaths averted in 2014 Deaths averted in 2014

Total: 10 14**

By Cause:

*NN Sepsis NN Asphyxia NN Prematurity

2 5 4

NN Sepsis NN Asphyxia NN Prematurity Diarrhea Pneumonia

2 5 4

-2 5

By Intervention:

Clean birth practices Immediate assessment and stimulation Labor and delivery management Neonatal resuscitation Antenatal corticosteroids for preterm labor Clean postnatal practices

1 1 4 1 2

1

Improved water source ORS Oral antibiotics Clean birth practices Immediate assessment and stimulation Labor and delivery management Neonatal resuscitation Antenatal corticosteroids for preterm labor Clean postnatal practices

-1 -1 5 1 1 4 1 2

1

By Intervention by cause:

NN Sepsis Clean postnatal practices Clean birth practices NN Asphyxia Labor and delivery management Neonatal resuscitation NN Prematurity Antenatal corticosteroids for preterm labor Labor and delivery management

1 1 4 1

2

1

Diarrhea ORS Pneumonia Oral antibiotics NN Sepsis Clean postnatal practices Clean birth practices NN Asphyxia Labor and delivery management Neonatal resuscitation NN Prematurity Antenatal corticosteroids for preterm labor Labor and delivery management

-1

5

1 1

4 1

2

1

*NN = neonatal

** = Inclusive of neonates (0-1m)

34

Figure 4: Deaths Prevented by Cause (Midterm)

*Other includes: NN Diarrhea, NN Pneumonia, NN Tetanus, NN Congenital Anomalies, Diarrhea, Meningitis,

Measles, Malaria, Pertussis, AIDS, Injury, and other unspecified diseases.

Table 9: Maternal Deaths and Stillbirths Averted (Midterm)

Maternal Stillbirths

Deaths averted in 2014 Stillbirths averted in 2014

Total: 1 3

By Cause:

Zero (fractions) Intrapartum 3

By Intervention:

Labor and delivery management 3

By Intervention by cause: Intrapartum Labor and delivery management

3

35

Table 10: Changes in Nutritional Status (Midterm)

Per LiST Per Project Data

2011 2014 2011 (baseline) 2014 (LQAS)

Stunting: > -1 SD* -1 < -2 SD -2 < -3 SD < -3 > -1 SD -1 < -2 SD -2 < -3 SD < -3 SD > -1 SD -1 < -2 SD -2 < -3 SD < -3 SD

6-11m stunted (<-2SD): 26.6% 50.9% 22.4% 15.0% 11.6%

6-11m stunted (<-2SD): 25.6% 51.6% 22.8% 14.5% 11.1%

6-59m stunted (<-2Z): 47.4%

6-59m stunted (<-2Z): 38% 6-11m (<-2Z): 17.4% 6-11m (-2<-3Z): 8.7% 6-11m (<-3Z): 8.7%

12-23m stunted (<-2SD): 44.1% 30.3% 25.6% 25.7% 18.4%

12-23m stunted (<-2SD): 42.3% 31.2% 26.4% 24.7% 17.6%

12-23m (<-2Z): 36.4% 12-23m (-2<-3Z): 22.8% 12-23m (<-3Z): 13.6%

24-59m stunted (<-2SD): 38.6% 30.9% 31.6% 23.3% 14.3%

24-59m stunted (<-2SD): 37.2% 31.0% 31.7% 23.1% 14.1%

24-59m (<-2Z): 46.9% 24-59m (-2<-3Z): 33.6% 24-59m (<-3Z): 13.3%

Wasting > -1 SD -1 < -2 SD -2 < -3 SD < -3 SD > -1 SD -1 < -2 SD -2 < -3 SD < -3 SD

6-11m wasted (<-2SD): 10.9% 71.7% 17.5% 9.7% 1.2%

No change 6-59m wasted (<-2Z): N/A

6-59m wasted (<-2Z): 3% 6-11m (<-2Z): 4.5% 6-11m (<-3Z): 0%

12-23m wasted (<-2SD): 5.1% 81.6% 13.3% 3.6% 1.5%

12-23m (<-2Z): 3.6% 12-23m (<-3Z): 0%

36

> -1 SD -1 < -2 SD -2 < -3 SD < -3 SD

24-59m wasted (<-2SD): 5.9% 79.0% 15.2% 4.2% 1.7%

24-59m (<-2Z): 1.8% 24-59m (<-3Z): 0%

Preterm SGA**

1.98 No change

Term SGA 13.51 No change

Table 11: Cases of Illness Averted (Midterm)

Year: 2014 Diarrhea Pneumonia Meningitis

<1m 5 0 0

1-23m -252 -2 0

24-59m -158 -2 0

Total (0-60m) By intervention

Improved water source Improved sanitation Vitamin A supplementation Breastfeeding

-1,372 -126

1,077 55

<1m by intervention Breastfeeding 5

Table 12: Deaths Averted, Neonates and Children (Endline)

Neonates (0-1m) Total (0-60m)

Deaths averted in 2015 Deaths averted in 2015

Total: 14 31**

By Cause:

*NN Sepsis NN Asphyxia NN Prematurity

2 6 5

Diarrhea Pneumonia Malaria NN Sepsis NN Asphyxia NN Prematurity

4 11

1 2 6 5

By Intervention:

Clean birth practices Immediate assessment and stimulation Labor and delivery management Neonatal resuscitation Antenatal corticosteroids for preterm labor Clean postnatal practices Thermal care

1 1

6 1 3

1 1

Improved water source ORS Oral antibiotics Appropriate complementary feeding ITN/IRS Clean birth practices Immediate assessment and stimulation Labor and delivery management Neonatal resuscitation Antenatal corticosteroids for preterm labor Clean postnatal practices Thermal care

1 4

11 1 1 1 1

6 1 3

1 1

By Diarrhea

37

Intervention by cause:

NN Sepsis Clean postnatal practices Clean birth practices NN Asphyxia Labor and delivery management Neonatal resuscitation NN Prematurity Corticosteroids for preterm labor Labor and delivery management Thermal care

1 1

5 1

3 1 1

ORS Improved water source Pneumonia Oral antibiotics Malaria ITN/IRS NN Sepsis Clean postnatal practices Clean birth practices NN Asphyxia Labor and delivery management Neonatal resuscitation NN Prematurity Corticosteroids for preterm labor Labor and delivery management Thermal care

3 1

11

1

1 1

5 1

3 1 1

*NN = neonatal

** = Inclusive of neonates (0-1m)

Figure 5: Deaths Prevented by Cause (Endline)

*Other includes: NN Diarrhea, NN Pneumonia, NN Tetanus, NN Congenital Anomalies, Diarrhea, Meningitis,

Measles, Malaria, Pertussis, AIDS, Injury, and other unspecified diseases.

38

Table 13: Maternal Deaths and Stillbirths Averted (Endline)

Maternal Stillbirths

Deaths averted in 2015 Stillbirths averted in 2015

Total: 1 4

By Cause:

Zero (fractions Intrapartum Antepartum

4 1

By Intervention:

Labor and delivery management Syphilis detection and treatment

4 1

By Intervention by cause:

Intrapartum Labor and delivery management Antepartum Syphilis detection and treatment

4

1

Table 14: Cases of Illness Averted (Endline)

Year: 2015 Diarrhea Pneumonia Meningitis

<1m 6 0 0

1-23m 1700 -4 0

24-59m 1682 -6 0

Total (0-60m) By intervention

Improved water source Improved sanitation Vitamin A supplementation Breastfeeding

1,534 -617

2,023 52

<1m by intervention Breastfeeding 5

Table 15: Changes in Mortality

2011 2014 (LiST projected from baseline)

2014 (LiST projected with project values)

2015 (LiST projected from baseline)

2015 (LiST projected with target values)

MMR (ratio) 56.6 (360) 53.5 (360) 45.9 (309) 52.5 (360) 42.1 (288)

NMR 36.6 36.6 31.3 36.6 29.1

U5MR 87.8 87.2 80.2 87.1 71.3

Stillbirth rate 19.4 19.4 17.8 19.4 17.1

39

Figure 6: Reduction in Mortality by Intervention (Midterm)

Table 16: Lives Saved, Neonates

Neonates (0-1m)

Deaths in 2014 in no-change scenario (A)

Deaths in 2014 in midterm scenario (B)

Lives Saved (A-B)

Deaths in 2015 in no-change scenario (C)

Deaths in 2015 in endline scenario (D)

Lives Saved (C-D)

Total: 70 60 10 71 56 15

By Cause:

Diarrhea 1 Sepsis 13 Pneumonia 3 Asphyxia 18 Prematurity 25 Tetanus 1 Congenital anomalies 5 Other 4

Diarrhea 1 Sepsis 12 Pneumonia 3 Asphyxia 13 Prematurity 21 Tetanus 1 Congenital anomalies 5 Other 4

Sepsis 1 Asphyxia 5 Prematurity 4

Diarrhea 1 Sepsis 14 Pneumonia 3 Asphyxia 18 Prematurity 25 Tetanus 1 Congenital anomalies 5 Other 4

Diarrhea 0 Sepsis 11 Pneumonia 3 Asphyxia 12 Prematurity 20 Tetanus 1 Congenital anomalies 5 Other 4

Diarrhea 1 Sepsis 3 Asphyxia 6 Prematurity 5

Comments:

14.3% reduction in mortality. 21.1% reduction in mortality.

40

Table 17: Lives Saved, Children under 5

Total (0-60m)*

Deaths in 2014 in no-change scenario (A)

Deaths in 2014 in midterm scenario (B)

Lives Saved (A-B)

Deaths in 2015 in no-change scenario (C)

Deaths in 2015 in endline scenario (D)

Lives Saved (C-D)

Total: 165 152 13 167 136 31

By Cause:

Diarrhea 8 Pneumonia 24 Meningitis 4 Measles 0 Malaria 4 Pertussis 1 AIDS 5 Injury 9 Other 40

Diarrhea 10 Pneumonia 19 Meningitis 4 Measles 0 Malaria 4 Pertussis 1 AIDS 5 Injury 9 Other 40

Diarrhea -2 Pneumonia 5

Diarrhea 8 Pneumonia 24 Meningitis 4 Measles 0 Malaria 4 Pertussis 1 AIDS 4 Injury 10 Other 41

Diarrhea 4 Pneumonia 13 Meningitis 4 Measles 0 Malaria 3 Pertussis 1 AIDS 4 Injury 10 Other 41

Diarrhea 4 Pneumonia 11

Comments:

7.9% reduction in mortality. If all MTR targets had been met 18 deaths would have been averted (4 additional in children 1-59 months).

18.6% reduction in mortality.

* = Inclusive of neonates (0-1m)

Table 18: Lives Saved, Maternal

Maternal

Deaths in 2014 in no-change scenario (A)

Deaths in 2014 in midterm scenario (B)

Lives Saved (A-B)

Deaths in 2015 in no-change scenario (C)

Deaths in 2015 in endline scenario (D)

Lives Saved (C-D)

Total: 7 6 1 7 6 1

By Cause:

Antepartum hemorrhage 1 Postpartum hemorrhage 2 Hypertensive diseases of pregnancy 1 Sepsis 1 Other indirect 2

Antepartum hemorrhage 1 Postpartum hemorrhage 1 Hypertensive diseases of pregnancy 1 Sepsis 1 Other indirect 2

Postpartum hemorrhage 1

Antepartum hemorrhage 1 Postpartum hemorrhage 2 Hypertensive diseases of pregnancy 1 Sepsis 1 Other indirect 2

Antepartum hemorrhage 1 Postpartum hemorrhage 1 Hypertensive diseases of pregnancy 1 Sepsis 1 Other indirect 2

Postpartum hemorrhage 1

Comments:

14.3% reduction in mortality. 14.3% reduction in mortality.

41

Table 19: Lives Saved, Stillbirths

Stillbirths

Deaths in 2014 in no-change scenario (A)

Deaths in 2014 in midterm scenario (B)

Lives Saved (A-B)

Deaths in 2015 in no-change scenario (C)

Deaths in 2015 in endline scenario (D)

Lives Saved (C-D)

Total: 37 34 3 38 33 5

By Cause:

Antepartum 21 Intrapartum 16

Antepartum 21 Intrapartum 13

Intrapartum 3

Antepartum 22 Intrapartum 16

Antepartum 21 Intrapartum 12

Antepartum 1 Intrapartum 4

Comments

8.1% reduction in mortality. 13.2% reduction in mortality.

Figure 7: Changes in Mortality, Children under 5

42

Figure 8: Changes in Mortality, Neonates

Table 20: Lives Saved Summary

Lives Saved Summary

Children under 5 years*

Children under 1 month

Maternal Stillbirths Total

2012 5 (3) 1 1 7

2013 9 (7) 1 2 12

2014 13 (10) 1 3 17

2015 31 (15) 1 5 37

Total 58 (35) 4 11 73**

*Inclusive of children under one month

**Total up until 2014 only: 36