USAID/Madagascar Outcome Monitoring Survey in the MAHEFA Areas April 2015 This publication was produced at the request of the United States Agency for International Development. It was prepared independently by Agence CAPSULE. PERFORMANCE EVALUATION: USAID/MADAGASCAR OUTCOME MONITORING SURVEY IN THE MAHEFA AREAS PREPARED BY AGENCE CAPSULE [APRIL 7, 2015] DISCLAIMER The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government. ACKNOWLEGMENTS Our grateful thanks go to: • Vololontsoa Raharimalala and Jean-Claude Randrianarisoa for their continued support and assistance to Agence CAPSULE‘s team in conducting the study, • Dr Onja Rahamefy for her technical and expertise assistance, • Daniel Andriatsimba for his contribution to geographical mapping, • All the local authorities and health responsibles in the MAHEFA intervention zones: DIANA, SAVA, SOFIA, Boeny, Melaky and Menabe. Last and not the least, our many thanks go to the administrative team led by Eugenio Raniriharinosy and all the surveyors and supervisors who provided us great assistance, enabling us to successfully carry out the survey. In short, we would like to express our most sincere and deepest gratitude to all those who, directly or indirectly, contributed to the accomplishment of this survey. ―This report is made possible by the generous support of United States Agency for International Development (USAID), under terms of Cooperative Agreement No. SOL-687-14-000005. The contents are the responsibility of Agence CAPSULE and do not necessarily reflect the views of USAID or the United States Government.‖ ACRONYM LIST ANC: Antenatal Care BCC: Behaviour Change Communication CALC: Calculation CHV: Community Health Volunteer COR: Contracting Officer‘s Representative COSAN: Comité de Santé CPR: Contraceptive Prevalence Rate CSB: Basic Health Center (Public) CU0-6: Child between 0 - 6 months CU1: Children under one year of age CU5: Children under 5 years of age CU6-23: Child between 6 - 23 months of age CU6-59: Child between 6 - 59 months of age DEF: DEFINITION OR CLUES FP/RH: Family Planning / Reproductive Health GPS: Global Positioning System GMP: Growth Monitoring and Promotion HH: Household HPN: Health, Population and Nutrition IPC: Interpersonal communication IPTP: Intermittent Preventive Therapy for Pregnant IRS: Indoor Residual Spraying ITN: Insecticide-Treated Net JSI: John Snow, Inc KMS: Kaominina Mendrika Salama LAPM: Long-Acting Permanent Method MCPR: Modern Contraceptive Prevalence Rate MDG: Millennium Development Goals MM: Measurement Method MUAC: Mid-Upper Arm Circumference (MUAC) tapes NGO: Non-Governmental Organization OMS: Outcome Monitoring Survey POS: Point of Sales PPS: Probability Proportional to Size RS: Random Start SI: Sample Interval STI: Sexually Transmitted Infection VIP: Ventilated Improved Pit latrine WRA: Woman of Reproductive Age TABLE OF CONTENT EXECUTIVE SUMMARY……………………………………………………………………..1 INTRODUCTION…………………………………………………………………………...….3 PROJECT BACKGROUND …………………………………………………………………..3 PURPOSE-OBJECTIVES OF THE SURVEY…………………………………….…………3 METHODOLOGY –LIMITATION ………………….…………………………………….....4 GLOBAL RESULTS…………………………………………………………………………...8 TABLE 1: HOUSEHOLD INDICATORS………………………………………………..8 TABLE 2: WRA INDICATORS…………………………………………………………..17 TABLE 3: CARETAKER INDICATORS ……………………………………………….24 TABLE 4: CHV INDICATORS ………………………………….……………………….34 TABLE 5: POS INDICATORS……………………………………………………………39 ANNEX …………………………………………………………………...………………….. 44 A. RESULTS OF THE MAIN KEY INDICATORS ………...…………..…………...…......45 B. ANNEX B : Location and map of sites visited during the survey……………………….65 C. ANNEX C : Detailed methodologies and limitations…………………………...……….70 D. ANNEX D - INDICATOR LEVEL IN REGIONS AND DISTRICTS ….………...........93 D.1. HH INDICATORS……………………………………………………….…………….93 D.2. WRA INDICATORS…………………………...………………………………….....105 D.3. CARETAKERS INDICATORS………………………...…………………………..113 D.4. CHV INDICATORS………………………………………………………………….144 D.5. POS INDICATORS………………………………………………………………….151 E. ANNEX E: Data collection instruments………………………………………...……….166 E.1. HH Questionnaire……………………………………………………………..…….166 E.2. WRA Questionnaire …………………………………………………………..…. 192 E.3. CARETAKER Questionnaire ……………………………………………………….213 E.4. CHV Questionnaire………………………………………………….………………237 E.5. POS Questionnaire……………………………………………………………….….246 1. EXECUTIVE SUMMARY This report provides key results of the FY 2014 outcome monitoring survey (OMS) conducted in the USAID-funded community health care project that is being implemented by the MAHEFA project in the following regions: DIANA, SAVA, SOFIA, Boeny, Melaky and Menabe. A baseline survey of the MAHEFA project on key health outcome indicators was carried out in 2012. The results of that survey showed a low level of critical child health indicators such as the percentage of fully immunized children before age one (19%), the percentage of children between 6-59 months of age receiving vitamine A during the last six months (11.4%) and poor access to improved drinking water source and sanitation. Although a low percentage of women were exposed to family planning messages (12.9%), contraceptive rate was 26.9%. A proportion of 33.2% of women were seen at Antenatal Care (ANC) at least four times during their pregnancy, and a higher percentage, almost the half of birth was attended by skilled healthcare providers such as a doctor, a nurse or a midwife. Summary of findings of the 2014 OMS: I.A. MATERNAL HEALTH AND FAMILY PLANNING From the onset of the project to the end of September 20141, the proportion of women seen at ANC at least four times during their pregnancy has significantly increased, from 33.2% to 67.3%. The percentage of birth attended by skilled health providers has also increased, from 49.9% to 77.7%. Modern contraceptive prevalence rate (MCPR) has increased from 26.9% to 41.3%. The percentage of Women of Reproductive Age (WRA) who were exposed to family planning Information-Education-Communication/Behavioral Communication Change Communication (IEC/BCC) messages also increased from 12.9% to 80.3%. Among them, 48.4% received the messages from Community Health Volunteers (CHVs), the remaining has heard messages through other channels such as other healthcare providers (56.3%), television (10.9%), newspapers, posters and books (1.1%). The above data indicated evidences of effective mass and Interpersonal Communication (IPC) through CHVs that rose general awareness of Family Planning (FP) among women. However, there is a need to strength IPC through CHVs in order to individually identify and satisfy the unmet need for FP, reported by 30.6% of women (DHS 2008: 19%). I.B. WATER, SANITATION AND DIARRHEAL DISEASE The results showed a significant increase of the percentage of households having access to improved drinking water source, from 46.8% to 65.2%. Although 24.8% of the interviewed 1 USAID Fiscal Year is from October 01 to September 30. Outcome Monitoring Survey in the MAHEFA Areas - 1 - households reported practice of effective water treatment, it was observed that only 1.6% did it correctly for water boiling; the correct use is close to zero for other techniques such as Sur‘eau. The proportion of households having access to private and improved sanitation facilities has increased from 3.1% in 2012, to 9.8% in 2014. But open defecation was still reported by 39.9% of the households in 2014. An increase in the diarrhea prevalence was reported among children under five of age (CU5), from 5.5% at baseline to 10.3% in 2014. I. C. NUTRITION The percentage of children under six months of age (CU6) exclusively breastfed in the past 24 hours was high: 95.9%. About 39% of Children under two of age (CU2) were weighted during Growth Monitoring and Promotion (GMP) in the last two months. Respectively, 0.5%, 1.7% and 97.8% of the measured children were in the red, yellow, green Mid-Upper Arm Circumference (MUAC) zones. However, moderate and severe hunger was experienced by 6.7% of the surveyed households. I.D. MALARIA The percentage of households with at least one Insecticide Treated Net (ITN) was at 82.9%. At baseline, the overall ITN coverage was significantly higher, 91.8%. However, the percentages of women and CU5 who slept under ITN and/or in a house sprayed with IRS the previous night were of 52.5% and 67.9%, respectively. Malaria prevalence was low, 0.3%. A proportion of 8.2% of children with fever were treated by CHVs. I.E. HEALTH SYSTEM There were 4.5% of households that reported having access to the MAHEFA innovative transportation system, but only 0.3% has used it. Besides, 0.1% reported membership of health mutual promoted by MAHEFA. I. F. COMMUNITY HEALTH VOLUNTEERS A proportion of 36.1% of CHVs are certified on Family Planning 4 and 22.9% are polyvalent, with three or more qualifications (PF4, IEC/Counseling, and Sexually Transmitted Infections, Child Health or others). The percentage of CHVs providing counseling on Family Planning/Reproductive Health (FP/RH) and Sexually Transmitted Infections (STIs) was 46.9%. Although the majority of CHVs (91.5%) reported no stock-out of injectable contraceptives, it was found that 42.2% experienced stock-outs of Oral Rehydration Solution (ORS) and/or Zinc supplements. Although an increase in diarrhea prevalence among CU5 was found. Overall, the results of this survey highlight better status for several maternal and child health indicators. Outcome Monitoring Survey in the MAHEFA Areas - 2