IMPROVING THE HEALTH OF MOTHERS AND CHILDREN OF RURAL JINOTEGA, NICARAGUA: An Integrated Approach in Partnership with the Public and Private Sector Providers in Coffee -Growing Areas Cooperative Agreement No. HFP-A-00-02-00026-00 MidTerm Evaluation Report Project Duration: September 30, 2002 – September 29, 2007 Submitted to: USAID/GHB/HIDN Child Survival and Health Grants Program Room 3.7.75, Ronald Reagan Building 1300 Pennsylvania Avenue Washington, DC 20523-3700 Submitted by: Project HOPE – The People-to-People Health Foundation, Inc. Millwood, Virginia 22646 Tel: (540) 837-2100 Fax: (540) 837-1813 May 2005 HQ Contact person: Field Contact Person: Bonnie Kittle Francisco Torres Director, Health of Women and Children Country Director, Project HOPE Nicaragua Prepared by: Renee Charleston, Consultant ACRONYMS AMAS MOH Health Facility Supervision System AMATE Animation, Motivation, Appropriation, Transference, Evaluation educational approach ARI Acute Respiratory Infection BCC Behavior Change and Communication BF Breastfeeding CDD Control of Diarrheal Diseases CHW Community Health Worker COPE Client-Oriented Provider Efficient (EngenderHealth) CORE Child Survival Collaborations and Resources Group CORU Community Oral Rehydration Unit CRS Catholic Relief Services CSP Child Survival Project CSHGP Child Survival Health Grant Program CSTS+ Child Survival Technical Support Project DIP Detailed Implementation Plan DPSV Life saving skills (Destrezas Para Salvar Vidas) ECMAC Community Based Distribution of Family Planning Methods EPI Expanded Program of Immunizations FP Family Planning GIK Gift-In-Kind HC Health Center HIS Health Information System HP Health Post HQ Headquarters IDRE Introduction, Development, Reflection, Evaluation educational approach IEC Information, Education and Communication IMCI Integrated Management of Childhood Illnesses KPC Knowledge, Practice, and Coverage Survey LAM Lactational Amenorrhea LQAS Lot Quality Assurance Sampling M&E Monitoring and Evaluation MCH Maternal and Child Health MMR Measles, Mumps and Rubella MOH Ministry of Health (MINSA in Spanish) MSH Management Sciences for Health NGO Non-Governmental Organization NICASALUD Network of PVOs in Nicaragua ORS Oral Rehydration Solution PCI Project Concern International PCM Pneumonia Case Management PDA Personal Digital Assistant (Handheld PC) PROCOSAN MOH integrated community health program, similar to AIN PVO Private Voluntary Organization SICO Community Information System SILAIS Sistemas Locales de Atención Integral en Salud-Departmental level of MOH TA Technical Assistance TBA Traditional Birth Attendant TQM Total Quality Management TABLE OF CONTENTS A. Summary . 1 B. Assessment of progress made in achievement of program objectives 1. Technical Approach . 3 a. General Overview . 3 b. Progress report by intervention area . 6 c. New tools or approaches . 20 2. Cross-cutting approaches . 22 a. Community Mobilization . 22 b. Communication for Behavior Change . 23 c. Capacity Building Approach . 25 i. Strengthening the PVO Organization . 25 ii. Strengthening Local Partner Organizations . 27 iii. Health Facilities/Health Worker Strengthening . 29 iv. Training . 30 d. Sustainability Strategy . 31 C. Program Management . 33 1. Planning . 33 2. Staff Training . 33 3. Supervision of Program Staff . 34 4. Human Resources and Staff Management . 34 5. Financial Management . 35 6. Logistics . 35 7. Information Management . 35 8. Technical and Administrative Support . 38 D. Conclusions and Recommendations . 39 E. Results Highlight . 43 ACTION PLAN . 44 ANNEXES A. Baseline information from the DIP B. Evaluation Team Members and their titles C. Evaluation Assessment methodology D. List of persons interviewed and contacted E. Training Results/KPC Issues F. KPC MTE Report G. Project Data Sheet H. Key Indicators A. SUMMARY Project HOPE is implementing a five-year Child Survival Project aimed at improving the health status of children under five and women of reproductive age in the Department of Jinotega, Nicaragua—with a focus on rural populations, including those working on coffee plantations. The main partners in implementation are: Ministry of Health (MOH) at the Departmental level (SILAIS), Health Centers/Posts, and private sector coffee growers. Specific program health interventions and level of effort include: maternal and newborn care (30%), nutrition/micronutrient deficiencies (13%), breastfeeding promotion (10%), control of diarrheal disease (15%), pneumonia case management (10%), immunization (7%), child spacing (10%), and HIV/AIDS/STIs (5%). The proposed interventions are being implemented in accordance with Nicaragua’s PROCOSAN initiative, a program based on community growth monitoring sessions as an opportunity for incorporating IMCI. Other MOH programs being implemented include community-based family planning, Maternal Newborn Care; and the newly introduced supervisory system for health facilities. Key strategies include: § building the service-delivery capacity of health facilities and improving the quality of care; § strengthening cooperation among public, private and community stakeholders; § empowering consumers, particularly women, to take greater responsibility for personal and family health maintenance decisions; § improving timely care- seeking behaviors, through recognition of danger signs, system of referral and counter-referral, and the formation of emergency committees; § improving the knowledge and skills at the community level by strengthening the work of Brigadistas and TBAs and strengthening of the Community Information System. The target population includes the entire population of Jinotega department due to the project focus on strengthening the SILAIS and all health units within the department. The population includes 62,451 children under five and 67,461 women of reproductive age (129,912 total beneficiaries). The MOH and CSP selected 80 priority communities where the project provides more direct support, but all HC/HP staff has been involved in institutional strengthening activities The main accomplishments during the first half of the project were: § Support to ongoing or newly introduced MOH programs in child health, maternal health, quality improvement, and family planning; § Provision of logistical support (transportation), materials, and medicines; § Monthly or bimonthly meetings as linkage between MOH and community; § Improved access to health services, by working in isolated communities § Training for Brigadistas, TBAs, community committees and MOH staff; 368 Brigadistas had attended at least one training event and 234 TBAs had attended at least one training event § A KPC Survey was conducted as part of the mid term evaluation and showed an increase in vaccination coverage, use of modern family planning methods, improved knowledge of prevention of HIV/AIDS and improved care seeking during diarrhea; § Committees for emergency transportation during obstetrical emergencies have been formed in 63 communities with 104 committee members trained in the formation of emergency 1 brigades, collecting funds to help cover medical emergencies, recognition of danger signs, etc. § PROCOSAN has been implemented in 76 priority communities, selected by the MOH. § Community based child spacing has been established in 36 of the 80 priority communities, plus an additional 22 communities selected by the CSP and MOH (total 58), with trained counselors who distribute some contraceptive methods in the communities. Project records show there are 49 counselors in the 80 priority communities and 27 counselors in other communities. § The CSP is supporting, through training, materials and supervision, the implementation of the official national MOH program for Maternal Newborn Care in 58 of the 80 priority communities plus five additional communities § A qualitative study was carried out by HOPE/MOH on maternal preferences for home vs. institutional birth. § The Humanitarian Assistance Program provided donations of pharmaceutical products. The national donation level during the life of this project has been 9.5 million dollars, 2.77 million of that going to Jinotega The project however has some weaknesses which need to be addressed: § No monitoring of process indicators; § Deviation from M&E plan due to misunderstanding of the use of some instruments and introduction of SIGHOPE; § Lack of follow-up on the CSTS Sustainability Framework and HOPE Nicaragua Institutional Assessment. § Greater emphasis on the use of information for decision making Priority Recommendations § The institutional assessment for HOPE Nicaragua should be revived and the original work plan reviewed, implemented and monitored. § An institutional assessment should also be conducted with SILAIS to identify specific actions for capacity building based on the needs of SILAIS. § Develop a sustainability plan based on the work started with the CSSA model, including planning with communities, based on the use of local resources for problem solving. § Strengthen analytical abilities in the communities, Brigadistas, TBAs, MOH and HOPE staff. The CSP staff and partners will develop a revised work plan as part of the MTE process according to the following schedule. June 1 – 10 - MTE report and Chapters A& E of the DIP translated into Spanish; - Develop guides regarding work to be done by CSP and partners in preparation for writing the work plan and revised DIP June 13 – July 15 - CSP team follows guides to study the MTE recommendations and begin writing work plan and revised DIP - Develops