Bolivia CS-16 Final Evaluation

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Bolivia CS-16 Final Evaluation Wawa Sana Mobilizing Communities and Health Services for Community-Based IMCI: Testing Innovative Approaches for Rural Bolivia Bolivia CS-16 Final Evaluation Cooperative Agreement No.: FAO-A-00-00-00010-00 September 30, 2000 – September 30, 2004 Submitted to USAID/GH/HIDN/NUT/CSHGP December 31, 2004 Mobilizing Communities and Health Services for Community-Based IMCI: Testing Innovative Approaches for Rural Bolivia TABLE OF CONTENTS I. Executive Summary 1 II. Assessment of Results and Impact of the Program 4 A. Results: Summary Chart 5 B. Results: Technical Approach 14 1. Project Overview 14 2. Progress by Intervention Area 16 C. Results: Cross-cutting approaches 23 1. Community Mobilization and Communication for Behavior 23 Change: Wawa Sana’s three innovative approaches to improve child health (a) Community-Based Integrated Management of Childhood Illness 24 (b) SECI 28 (c) Hearth/Positive Deviance Inquiry 33 (d) Radio Programs 38 (e) Partnerships 38 2. Capacity Building Approach 41 (a) Strengthening the PVO Organization 41 (b) Strengthening Local Partner Organizations 47 (c) Strengthening Local Government and Communities 50 (d) Health Facilities Strengthening 51 (e) Strengthening Health Worker Performance 52 (f) Training 53 Bolivia CS-16, Final Evaluation Report, Save the Children, December 2004 i 3. Sustainability Strategy 57 III. Program Management 60 A. Planning 60 B. Staff Training 61 C. Supervision of Program Staff 61 D. Human Resources and Staff Management 62 E. Financial Management 63 F. Logistics 64 G. Information Management 64 H. Technical and Administrative Support 66 I. Management Lessons Learned 66 IV. Conclusions and Recommendations 68 V. Results Highlight 73 ATTACHMENTS A. Evaluation Team Members and their titles 75 B. Evaluation Assessment methodology 76 C. List of persons interviewed and contacted 153 D. Diskette or CD with electronic copy of the report in MS WORD 2000 E. Special reports 156 F. Project Data Sheet form – updated version 179 Bolivia CS-16, Final Evaluation Report, Save the Children, December 2004 ii Glossary of Acronyms APROSAR The Association of Rural Health Promoters (CS-16 partner NGO) (Asociación de Promotores de Salud del area Rural) ARI Acute Respiratory Infections BASICS Basic Support for Institutionalizing Child Survival (USAID Project) BCC Behavior Change Communication BHR/PVC USAID’s Bureau for Humanitarian Response, Office of Private and Voluntary Cooperation CAI/TAI Information Analysis Committee (Comite de Analisis de Información/Taller de Analisis de Información) CB-IMCI Community-Based Integrated Management of Childhood Illnesses CDD Control of Diarrheal Disease CORE The Child Survival Collaborations and Resources Group CS Child Survival CS-16 Child Survival-16 (SC’s Wawa Sana project described in this FE, supported through the 16th cycle BHR/PVC CS funding) CSTS Child Survival Technical Support Project, Macro International DD Diarrheal Disease DHS Demographic and Health Survey DILOS Directorio Local de Salud DIP Detailed Implementation Plan DPT3 Diphtheria-Pertussis-Tetanus immunization, 3rd dose EPI Expanded Program on Immunization FE Final Evaluation FO Field Office (country office of Save the Children/US) H/PD The Hearth model using the Positive Deviance approach HIPC World Bank indicators for “Heavily Indebted Poor Countries” used by the Bolivian MOH IMCI Integrated Management of Childhood Illnesses IR Intermediate Result ISA Institutional Strengths Assessment Bolivia CS-16, Final Evaluation Report, Save the Children, December 2004 iii KPC Knowledge, Practice, and Coverage survey LAC Latin America/Caribbean Region LINKAGES USAID initiative for improving breastfeeding M&E Monitoring and Evaluation MOH Ministry of Health MTE Midterm Evaluation NGO Non-Governmental Organization OH Office of Health of Save the Children ORS Oral Rehydration Solution PAHO Pan American Health Organization PCM Pneumonia Case Management PD Positive Deviance/Positive Deviant PDQ Partnership Defined Quality PLAN PLAN International POA Plan Operativo Anual (Annual Operational Plan) PROCOSI PVO Integrated Health Network (in Bolivia) (Programa de Coordinación de Salud Integral) PVO Private Voluntary Organization RHD Rural Health District SC Save the Children/US SC/B Save the Children/US Bolivia Field Office SC/HQ Save the Children/US Headquarters SECI Community Epidemiology Surveillance System/Integrated Community Epidemiological System (Sistema Epidemiologico Comunitario Integral) SEDES Ministry of Health departmental level in Oruro SNIS National Health Information System (of the Bolivian MOH) (Sistema Nacional de Información en Salud) SUMI New financial assistance basic care package providing free coverage in Bolivia TA Technical Assistance Wawa Sana “Healthy Child.” Sana is Spanish for “healthy.” Wawa is Aymara and Quechua for “child.” WHO World health Organization Bolivia CS-16, Final Evaluation Report, Save the Children, December 2004 iv I. Executive Summary The “Wawa Sana” (healthy child) Project, a four-year Child Survival-16 Program to mobilize communities and health services for Community-Based Integrated Management of Childhood Illness (CB-IMCI) by testing innovative approaches to improve child health in rural Bolivia, was funded from September 30, 2000 through September 30, 2004 through a $1 million “New Program” grant from USAID/BHR/PVC, and matched by a $1 million cost-share from Save the Children. The Wawa Sana Project aimed to: (1) document the feasibility and results of implementing innovative approaches to strengthen community capacity to identify and effectively address priority child health needs, and; (2) partner with the Ministry of Health (MOH) and non-governmental organizations (NGOs) at the district-level to strengthen their capacity to support community activities and to implement innovative culturally acceptable approaches to child survival. The CS-16 site covered 445 communities with a total population of 104,500, including 13,500 children under five, in three Rural Health Districts1 of Oruro Department on Bolivia’s Altiplano. The Program addressed high under-five mortality in this site, estimated at 109 deaths per 1,000 live births, associated with pneumonia, diarrhea, malnutrition, and immunizable diseases; in a population with low use of health services and health information, and health services which did not meet the needs of the population. SC worked with the site’s three MOH Rural Health Districts (RHDs), a Bolivian NGO, APROSAR, local governments, and communities to implement four child survival interventions: 1) Nutrition and micronutrients (30% of estimated intervention-specific project effort); 2) Pneumonia case management (30%), 3) Control of diarrheal disease (20%), and, 4) Immunization (20%). SC implemented these four interventions through three innovative approaches to child survival in Bolivia: § Community-Based-IMCI (CB-IMCI), focused on training and supporting volunteer Rural Health Promoters to provide selected child survival services in their communities, utilizing PAHO CB-IMCI materials recently adapted for Bolivia, while supporting concurrent MOH implementation of clinical integrated management of childhood illness (IMCI) at health facilities; § The Hearth model using a Positive Deviance approach (H/PD) to sustainable community- based rehabilitation and prevention of malnutrition in children under five; § Expansion of the Community Epidemiology Surveillance System (SECI), developed and pilot-tested by SC/Bolivia in 1997-98 to promote joint collection, analysis, and use of health information by health providers and communities to address local health needs. 1 During the course of CS-16, Bolivia changed the health administrative structure in the project area from three districts (District 1: Huanuni, District III: Challapata, and District V: Eucaliptus, to two “Networks” (Redes). They are called Red Azanake and Red Norte. SC/B staff worked in former districts III and V, while APROSAR’s work was concentrated in District I. Bolivia CS-16, Final Evaluation Report, Save the Children, December 2004 1 Wawa Sana Project Goals included: · A sustained improvement in nutrition status of 6 to 35 month old children in H/PD communities; · A sustained reduction in under-five mortality in the three health districts; and, · Innovative CS-16 approaches to inform policy and improve programming in other areas of Bolivia. Wawa Sana aimed to achieve the following results: · Improved capacity of APROSAR and the three rural health districts to support community activities and implement innovative, culturally acceptable child survival approaches; · Improved capacity of communities in the three health districts to identify and effectively address priority health needs of children under five; · Increased use of key health services and improved child survival practices at the household level in the three health districts; and · Uptake of successful innovative approaches by other organizations in Bolivia. These Results were to be achieved through the CS-16 Intermediate Results of: · Demonstrated SC/Bolivia capacity in CB-IMCI, SECI, and H/PD, capacity building of CS-16 partners, and advocacy; · Documented feasibility and results of implementing innovative CS-16 approaches; · Increased availability of selected child survival services in the three health districts; · Improved quality of selected CS services in the program site; and · Increased caretaker knowledge and awareness of selected child survival issues. Accomplishments Over the last four years, in the midst of a rapidly
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