CATHOLIC RELIEF SERVICES CAMBODIA PROGRAM CRS/BATTAMBANG COMMUNITY-BASED PRIMARY HEALTH CARE CHILD SURVIVAL PROJECT Award No. HFP-A-00-01-00042-00 OCTOBER 1, 2001 – SEPTEMBER 30, 2006 Midterm Evaluation Report (June 14 -25, 2004) External Evaluator, Della Dash Submitted to USAID ABREVIATIONS AIDS Acquired Immunodeficiency Deficiency Syndrome ARI Acute Respiratory Infection CBPHCP Community-Based Primary Health Care Program CDD Control of Diarrheal Disease C-IMCI Community Integrated Management of Childhood Illnesses CMCF Co-Management and Co-Financing Committee (now HCMC) COCOM Coordination Committee (Provincial) CRS Catholic Relief Services CS Community Health Structures DIP Detailed Implementation Plan DOTS Direct Observation Treatment Short Course GOC Government of Cambodia HC Health Center HCMC Health Center Management Committee (formerly CMCF) HE Health Education HIS Health Information System HIV Human Immunodeficiency Virus IEC Information, Education, Communication IMCI Integrated Management of Childhood Illness IR Intermediate Results IRCM Intermediate Results – Community Mothers IRCS Intermediate Results – Community Structures IRHC Intermediate Results – Health Center IRCHC Intermediate Results – Community and Health Center IRCHCODCRS Intermediate Results – Community, Health Center, Operational Districts and Catholic Relief Services IROD Intermediate Results Operational Districts KPC Knowledge, Practice and Coverage Survey KM Key Mother LQAS Lot Quality Assurance Sampling MCH Maternal and Child Health M&E Monitoring and Evaluation MIS Management Information System MOH Ministry of Health MPA Minimum Package of Activities ND New Districts NIP National Immunization Program NGO Non-Governmental Organization OCA Organizational Capacity Assessment OD Operational District OPD Out Patient Department ORS Oral Rehydration Solution ORT Oral Rehydration Therapy CRS / Battambang Community-Based Primary Health Care Child Survival Project Midterm Evaluation Report June 14 – 25, 2004 PHD Provincial Health Department PRA Participatory Rural Appraisal PQSD Program Quality and Support Department PVO Private Voluntary Organization SCM Standard Case Management TA Technical Assistance TT Tetanus Toxoid TB Tuberculosis TBA Traditional Birth Attendants TOT Training of Trainers USAID United States Agency for International Development USCC United States Catholic Conference VDC Village Development Committee VHC Village Health Committee VHV Village Health Volunteer VR Village Register WHO World Health Organization CRS / Battambang Community-Based Primary Health Care Child Survival Project Midterm Evaluation Report June 14 – 25, 2004 TABLE OF CONTENTS A. EXECUTIVE SUMMARY ..................................................................................................2 B. ASSESSMENT OF PROGRESS MADE TOWARD PROGRAM OBJECTIVES ......................4 1. TECHNICAL APPROACH........................................................................................................................................4 2. CROSS-CUTTING APPROACHES .......................................................................................................................35 a. Community Mobilization .......................................................................................................................35 b. Communication for Behavior Change ............................................................................................36 c. Capacity Building Approach ...............................................................................................................45 d. Sustainability Strategy...........................................................................................................................48 C. PROGRAM MANAGEMENT............................................................................................. 50 1. PLANNING ..............................................................................................................................................................50 2. STAFF TRAINING ..................................................................................................................................................52 3. SUPERVISION OF PROGRAM STAFF.................................................................................................................55 4. HUMAN RESOURCES AND STAFF MANAGEMENT..........................................................................................57 5. FINANCIAL MANAGEMENT ..................................................................................................................................58 6. LOGISTICS .............................................................................................................................................................59 7. INFORMATION MANAGEMENT ............................................................................................................................60 8. TECHNICAL AND ADMINISTRATIVE SUPPORT.................................................................................................61 D. OTHER ISSUES IDENTIFIED BY THE TEAM ................................................................... 62 E. CONCLUSIONS AND RECOMMENDATIONS ................................................................... 64 F. RESULTS HIGHLIGHT..................................................................................................... 70 ANNEXES ........................................................................................................................... 72 CRS / Battambang Community-Based Primary Health Care Child Survival Project Midterm Evaluation Report June 14 – 25, 2004 A. Executive Summary The goal of the five-year Child Survival project is to reduce morbidity and mortality in mothers and children by improving the capacity of communities and the health care system to manage and sustain primary health care. The total population of the four districts is 154,147, of which 40,078 are women of reproductive age and 21,272 are children under five years of age. The total number of expected births during the life of project is estimated at 14,640. The project is addressing the principal causes of child morbidity and mortality through Prevention of Immunizable Diseases (25%), Improved Case Management of Acute Respiratory Illness (20%), Improved Control of Diarrheal Diseases (30%), and Improved Control of Malaria (25%). To date, the main accomplishments of the program include successfully implementing IMCI at the health centers in Bovel District; successfully implementing case management in Samphov Loun Operational District, with training and implementation of IMCI about to begin imminently; successfully developing the community structures used to implement the program; and beginning the processes necessary for localization. The overall progress made in achieving program objectives to date revolves around IMCI and improving management at the health center level, and community health education and mobilization through community structures for increasing utilization and improving behavior change at the community level. The project is using IMCI to strengthen health worker performance. Observation checklists, pre and post testing, and supervision are being used to appropriately and cost-effectively assess performance, which has been very effective. Assessment results have guided additional training and supervision in order to continue increasing quality of care in health facilities, and to bridge the gaps between performance standards and actual performance. IMCI is working well in the health centers in Bovel District in terms of assessment, classification and treatment. Once counseling has been strengthened, Bovel District could be used as a living university to capitalize on hard won success and ensure future sustainability of quality health services. The community component of this program is built on a foundation of community structures. VHV and HCMC are mandated by the Government of Cambodia (GOC), and established in the project areas with the assistance of this child survival project. TBA are independent private practitioners that are accepted by the government. VHC, established with the assistance of the child survival project and CRS, have been accepted by the government as a sub-committee of the VDC, and thereby recognized by the Ministry of Rural Development as a village development structure. To date most of these structures have now been established, and are working on various levels of governance issues including bylaws and other management topics. 2 CRS / Battambang Community-Based Primary Health Care Child Survival Project Midterm Evaluation Report June 14 – 25, 2004 The project is following the work plan in the DIP very closely, and almost all activities are on schedule as planned, including the very extensive training plan. The main constraints, problems and areas in need of further attention include a weak referral system, the counseling component of IMCI in Bovel District, the development of IMCI in Samphov Loun Operational District, the challenges of establishing a new local NGO, and the behavior change strategy which has been identified as the weakest component of this program. The management information system also continues to be problematic. The CRS staff is very committed, hard-working, loyal and open to learning and growing. They have all increased their capacity considerably since the inception of the program, and will continue to do so for the remaining life