AIDS population and health integrated assistance [APHIA] project : report of the mid-term review

A child survival initiative in Bungoma District was added in 1997. Mid-term review covers the period 8/95-5/99. Despite a one-third decline in funding, APHIA has made notable gains in each of the major program areas. (1) Between 1983 and 1998, modern contraceptive prevalence among married women has more than tripled from 10% to 32%, one of the most rapid and sustained increases in the world. Among African countries, only South Africa and Zimbabwe have higher prevalence. Due principally to this increase in prevalence, the total fertility rate (TFR) has fallen dramatically over the past 20 years, from an estimated 8.1 to 4.7 children per woman between 1976 and 1996. This 40% decline in fertility eases the pressures of population growth on Kenya's society, economy, and environment. (2) While the HIV/AIDS epidemic is expanding, there are signs that sexual and reproductive attitudes and behavior are changing. Nearly all reproductive-age women and men have heard of AIDS; roughly 85% know at least one way of avoiding infection; and nearly 40% know at least two of the four important ways of avoiding infection. Among men, nearly 50% know that condoms can be used to avoid AIDS, up from 36% in 1993, and 90% report that they have changed their behavior to avoid AIDS, with 50% limiting sex to one partner, 20% using a condom, and 15% abstaining from sex. Among women, 77% report having changed their behavior, with 47% limiting sex to one partner, 3% using a condom, and 19% abstaining from sex. (3) There have been marked increases in revenues generated through cost-sharing activities, from under $l million in 1990 to over $8 million in 1998. This initiative has been critical to increasing the sustainability and improving the quality of public health services. It has also been a cornerstone of national health reform as it has worked to devolve authority and accountability to the district level. This initiative has also lent support to the privatization of two major hospitals and the sustainability of health NGOs through shared-risk insurance. Continued USAID investment is key to continued progress in these areas, especially given the gaps and constraints that will impede future progress. These include: the slow growth of contraceptive prevalence among women generally; the shortfalls in couple years of protection targets for USAID-funded programs; limited progress in integrating child survival, HIV/AIDS, and FP services; the slow pace of implementing health sector reforms; the health risks associated with the expansion of private health care; weaknesses in the Ministry of Health's training and supervisory system; societal denial of the socioeconomic and personal impact of the HIV/AIDS epidemic; the limited access of adolescents to reproductive health services; gaps in the delivery of basic reproductive and child health care; the lack of appreciation in Kenyan society of the importance of women and children; the slow growth of the economy; lack of reliable sources for necessary supplies and commodities; and declining support from other donors.