Evaluation of the Integrated Health Project in the Democratic Republic of Congo September 2013 This publication was produced at the request of the United States Agency for International Development. It was prepared independently by International Business & Technical Consultants, Inc. (IBTCI). It was authored by Mary O’Grady, Swati Sadaphal, Jean-Lambert Mandjo, Kapil Ahmed, and Annette Bongiovanni. BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT i EVALUATION OF THE INTEGRATED HEALTH PROJECT IN THE DEMOCRATIC REPUBLIC OF CONGO September 30, 2013 AID-660-M-13-00001/GS-10f-0309P Cover Photo Credit: Annette Bongiovanni 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. BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT ii BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT iii Map of East Kasai, West Kasai, Katanga, and South Kivu provinces in the Democratic Republic of Congo, where the Integrated Health Project (IHP) is implemented. Note IHP’s nine coordination bureaus highlighted. BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT iv Table of Contents ACKNOWLEDGEMENTS .........................................................................................................................................VI ACRONYMS AND ABBREVIATIONS ....................................................................................................................... VII EXECUTIVE SUMMARY ..........................................................................................................................................XI I. EVALUATION PURPOSE AND QUESTIONS ............................................................................................................ 1 II. PROJECT BACKGROUND..................................................................................................................................... 3 III. EVALUATION METHODS AND LIMITATIONS ...................................................................................................... 6 IV. EVALUATION FINDINGS .................................................................................................................................. 13 V. CONCLUSIONS ................................................................................................................................................. 29 VI. RECOMMENDATIONS ..................................................................................................................................... 33 FIGURES AND TABLES IN THE REPORT TABLE 1: IHP FUNDING ALLOCATIONS 2011-2014 .................................................................................................................. 5 FIGURE 1: IHP RESULTS FRAMEWORK .................................................................................................................................... 6 TABLE 2: DESCRIPTION OF FACILITIES SURVEYED....................................................................................................................... 8 TABLE 3: RESPONDENT PROFILE IN THE CLIENT EXIT SURVEY ....................................................................................................... 8 TABLE 4: CLIENT INTERVIEWS BY BC, NUMBER OF FACILITY SITES, NUMBER OF COMPLETED INTERVIEWS............................................ 9 TABLE 5: NUMBER OF KEY INFORMANT INTERVIEWS BY INFORMANT PROFILE TYPE ......................................................................... 9 BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT v List of Annexes (Provided in a separate volume) ANNEX A. Scope of Work ANNEX B Key Informant Interview Guides ANNEX C. Quantitative Data Analysis Plan ANNEX D. Data Collection Sampling Procedure ANNEX E. Qualitative Data Analysis Matrix ANNEX F. Quantitative Analysis Results: Availability of MPA-PLUS Health Services ANNEX G. Quantitative Analysis Results: Quality of Health Care Services ANNEX H. Quantitative Analysis Results: Knowledge, Attitudes, and Practices ANNEX I. Client Exit Survey Questionnaire (English and French version) ANNEX J. Health Facilities Survey Questionnaire (English and French version) ANNEX K. List of Health Facilities Surveyed ANNEX L. List of Persons Interviewed ANNEX M. List of Supervisors, Data Collectors, and Interviewers ANNEX N. List of Documents Reviewed ANNEX O. List of MPA-plus Services ANNEX P. Field Implementation Plan ANNEX Q. Training Manual for Data Collection BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT vi ACKNOWLEDGEMENTS The evaluation team wishes to thank everyone in the DRC who accommodated our needs, in particular the many individuals who went out of their way amid busy schedules to provide various types of support. The team wishes to thank the Ministry of Public Health in the DRC, which provided excellent support for this evaluation at the national, provincial, district, and zone levels, including technical and administrative staff. The team also wishes to thank USAID staff members who supported this evaluation, in particular Courtney Babcock, John Bernon, Kai Beard, and Dr. Richard Matendo. Special thanks go to Dr. Patrick Piongo, Kamina District Medical Inspector, Katanga Province, whose excellent knowledge, foresight, planning assistance, and support enabled the team to conduct its evaluation activities in this large district through additional assistance from the Expanded Programme on Immunization. The team also appreciates the support of the Centre de Communication et d’Education pour la Santé et le Développement (CESD) for its administrative and logistical support throughout the study. The team would like to thank all the individual staff members at the Integrated Health Project (IHP) who provided support to make this a participatory evaluation. The team also is grateful to survey supervisors Magalie Kabale and Germaine Kawal for all their hard work and dedication to the evaluation. Finally, we are grateful to Professor Patrick Kayembe for his technical assistance and guidance. BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT vii ACRONYMS AND ABBREVIATIONS ACT Artemisinin-based combination therapy AIDS Acquired immune deficiency syndrome AMTSL Active management of third stage labor ANC Antenatal care ARI Acute respiratory infection ART Antiretroviral therapy ARV Antiretroviral AXxes USAID-funded Primary Health Care project in DRC 2006–2011 BC Bureau de Coordination (IHP Coordination Bureau) BCC Behavior change communication BCG Bacillus Calmette-Guerin vaccine CBO Community-based organization CCM Community case management CHW Community health worker C-IMCI Community-based integrated management of childhood illness CODESA Comité de Développement Sanitaire (Health Development Committee) CPA Complementary package of activities CPR Contraceptive prevalence rate CTX Co-trimoxazole DHS Demographic and health survey DOTS Directly observed treatment short-course for TB DPT Diphtheria, pertussis, tetanus DRC Democratic Republic of Congo EPI Expanded Programme on Immunization FBO Faith-based organization FGD Focus group discussion FOSACOF Fully functional service delivery point FP Family planning GAVI Global Alliance for Vaccines and Immunization GBV Gender-based violence GDRC Government of the Democratic Republic of Congo GESIS Database software for routine health information GRH General reference hospital HC Health center Hep B Hepatitis B HF Health facility HIV Human immunodeficiency virus HZ Health zone BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT viii IEC Information, education and communication IHP Integrated Health Project IMCI Integrated management of childhood illnesses IPTp Intermittent preventive treatment (of malaria) in pregnancy IR Intermediate Result IRC International Rescue Committee ITN Insecticide-treated net KAPs Knowledge, attitudes, and practices KII Key informant interview LDP Leadership Development Program LLIN Long-lasting insecticide-treated net LQAS Lot quality assurance sampling MCH Mother and child health MDR-TB Multi-drug resistant TB MSP Ministère de la Santé Publique (Ministry of Public Health) MNCH Maternal, newborn and child health MPA Minimum package of activities MSH Management Sciences for Health NGO Non-governmental organization NHDP National Health Development Plan NTD Neglected tropical disease ORS Oral rehydration salts OSC Overseas Strategic Consulting, Ltd. PEP Post-exposure prophylaxis for HIV PEPFAR President’s Emergency Plan for AIDS Relief PMI President’s Malaria Initiative PMP Performance Monitoring Plan PMTCT Prevention of mother-to-child transmission of HIV PNC Postnatal care PNDS National Health Development Plan PNLP National Malaria Control Program PNLS National AIDS Program RBF Results-based financing (see FBR) RDT Rapid diagnostic test RH Reproductive health SANRU Santé Rurale Project (USAID funding ended in 2006) SNIS National Health Information System of the DRC STI Sexually transmitted infection TB Tuberculosis TBA Traditional birth attendant BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT ix TFR Total fertility rate UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund USAID United States Agency for International Development USG United States Government Vit A Vitamin A WASH Water/sanitation/hygiene WHO World Health Organization WRA Women of reproductive age BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT x GLOSSARY General Inductive Approach Systematic procedure for analyzing qualitative data where the analysis is guided by specific objectives with a purpose of allowing findings to emerge from the frequent, dominant, or significant themes in the data. (Adapted from D.R. Thomas, American Journal of Evaluation, June 2006.) Key Informant Interview Conversation during which the informant provides information in an area that s/he knows well. This technique is used when the subject matter is complex and respondents are highly knowledgeable; when the information is highly sensitive; or when respondents are geographically diverse. Interviews can be either structured or non-structured. The technique makes use of both open- and close-ended questions and is flexible enough to follow the lead of the informant, keeping in mind the main themes to be covered. (Adapted from USAID, Monitoring and Evaluation TRM, 2006.) Lot Quality Assurance Sampling A random sampling survey methodology used to determine whether a group has achieved a given performance standard by looking at a small but statistically representative sample from that group. A lot in the IHP evaluation was the geographic area to be surveyed. (Adapted from Measure Evaluation, Carolina Population Center, University of North Carolina at Chapel Hill, 2011.) BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT xi EXECUTIVE SUMMARY EVALUATION PURPOSE International Business and Technical Consultants, Inc. (IBTCI) is pleased to present the performance evaluation report of the USAID/DRC Integrated Health Project (IHP) Cooperative Agreement #AID-OAA-A-10-00054, being implemented by Management Sciences for Health and its partners (MSH). MSH had already conducted a baseline evaluation of demand for key family health services as part of IHP (IHP Part I Baseline) in May 2011. The purpose of this evaluation is to assess the supply of health services, including quality, accessibility, and availability of key family health interventions, provided in the targeted facilities. Due to a number of factors, including inevitable changes in evaluation teams and the fact that IBTCI was hired to start this evaluation in 2013, data collection is being finalized well after two years of program implementation. This evaluation serves two purposes. First, it forms a baseline that will set up benchmarks against which achievements and effectiveness can be evaluated at the end of IHP. Second, it identifies programmatic areas that need improvement; it then forms initial conclusions and provides recommendations. This evaluation will help USAID/DRC determine the project components and aspects that are working well, understand why they are successful, and identify constraints facing the project so that any modifications and midcourse corrections that are needed can be made. An endline evaluation is scheduled for 2015. PROJECT BACKGROUND In September 2010, USAID/DRC awarded the five-year $139,767,129 Integrated Health Project, Cooperative Agreement #AID‐OAA‐A‐10‐00054, to Management Sciences for Health (MSH) and its partners, International Rescue Committee (IRC) and Overseas Strategic Consulting, Ltd (OSC, Ltd.). IHP supports the National Health Development Plan (PNDS) of the DRC. The project is designed to improve the enabling environment for, and increase the availability and use of, high-impact health services, products, and practices for family planning; (FP); maternal, newborn and child health (MNCH); nutrition; malaria; neglected tropical diseases (NTDs); tuberculosis (TB); HIV/AIDS; and water, sanitation and hygiene (WASH) in target health zones. IHP works in 80 target health zones in four provinces of the Democratic Republic of Congo (DRC): East Kasai, West Kasai, Katanga, and South Kivu. By the end of IHP’s five-year life-of-project, it is anticipated that 80% of the targeted health centers (HCs) and general reference hospitals (GRHs) will offer the minimum package of health service activities-plus (MPA-plus) and complementary package of health service activities-plus (CPA-plus) covering preventive, curative, health promotion and facility management interventions. EVALUATION QUESTIONS, METHODS, AND LIMITATIONS The evaluation team was tasked with answering the following six questions: BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT xii 1. To what extent has the project improved access to MPA-plus and CPA-plus services1 and products in targeted health zones? 2. Has the project improved the quality of key family care services in targeted health zones? 3. Have knowledge, attitudes, and practices to support health-seeking behaviors increased in targeted health zones? 4. Has health sector leadership and governance in the four targeted provinces improved? 5. What are the external factors that hamper IHP activities from delivering better results? 6. How is the IHP perceived and valued? The evaluation team employed both quantitative and qualitative methods. The quantitative method took the form of a cross-sectional survey of health facilities in 23 randomly selected health zones in IHP’s eight Bureau de Coordination (BC) in four provinces: East Kasai, West Kasai, Katanga, and South Kivu. The facility survey was employed to determine facility characteristics, accessibility, and availability of MPA-plus services, community outreach and support, and management capacity. A client exit survey was conducted to solicit women’s perspectives on the quality of care and knowledge, attitudes, and practices with regard to key family care service-seeking behaviors. The qualitative methods included document reviews and key informant interviews and was used to explain the context and reasons for project implementation bottlenecks, record perceptions regarding IHP, understand leadership and governance issues, and document determinates of service quality and utilization. Twelve facilities in each BC (three health centers and one general reference hospital in each zone and three zones in each BC) were selected randomly using lot quality assurance sampling (LQAS). Some of the sites were later changed due to insecurity or threat to survey personnel by non-state rebel groups. In some cases, some HCs that were difficult and cost prohibitive to reach were replaced with other randomly selected HCs. A total of 73 HCs and 23 GRHs (a total of 96 in eight BCs) were included in the surveys. A total of 383 client exit interviews with women of reproductive age, pregnant women, and mothers with children 0-59 months were completed. In addition, 80 semi-structured in-depth interviews were conducted with health managers and other professionals at HCs and GRHs; staff from the Ministry of Public Health (Ministère de la Santé Publique) (MSP) at the national, provincial, district, and zone levels; members of CODESAs (health development committees) and community health workers; managers and specialists working at IHP field offices; and USAID/DRC program staff. Client perspectives are not necessarily representative of the general population, as the respondents were a self-selected population of women who were already using health services. The health facilities sample is not representative of facilities located in areas of highest insecurity, as these were eliminated from the sample. Nonetheless, several of the facilities selected were in conflict settings. There is a lack of baseline information on MPA and CPA service coverage and facility client perspectives on service quality and health practices to allow for comparison with results from this evaluation. The full evaluation report describes the limitations to the study. 1 CPA-plus services were not evaluated. BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT xiii FINDINGS Current access to and availability of MPA-plus services. There are more than 50 interventions in the IHP model of integrated services package (MPA-plus), including preventive, curative and community-based services focused on family planning (FP), mother and newborn health (MNCH), nutrition, malaria, neglected tropical diseases (NTDs), tuberculosis (TB), HIV/AIDS and water, sanitation, and hygiene (WASH). (MPA builds on the MSP’s minimum package of activities.) None of the 96 facilities surveyed currently provides a full range of MPA￾plus services. However, almost all facilities surveyed provided prenatal care and family planning, and 100% of the facilities offered clinic-based integrated management of childhood illnesses (IMCI).2 About 79% of facilities had a maternity unit to provide normal delivery services and postpartum care. Twenty-one percent of facilities with labor and delivery services reported that their employees provided these services both in the facility and in the community. Fifty-eight percent of facilities reported that they must refer a case requiring emergency cesarean section; however, only 45% had written instructions to provide referrals in emergency obstetrics cases. Vitamin A during prenatal care was provided in 23% of the surveyed facilities and is one of the activities in the MPA preventive services package. As vitamin A distribution is not an IHP service component at this time, this appears to be the result of previous vitamin A campaigns. Not all health facilities are designated sites for prevention of mother-to-child transmission of HIV (PMTCT) services: Pregnant women were advised to be tested for HIV in 69% of facilities offering prenatal care. Not all health facilities are designated sites for PMTCT services. Forty￾one percent of surveyed facilities provided an HIV test for PMTCT. Out of these sites, only 59% provided anti-retrovirals (ARVs) for PMTCT and 36% offered HIV care (co-trimoxazole) to HIV-positive pregnant women. About 88% of facilities offered immunization services for children. Sixty-seven percent (55/82) did not have DTP vaccine, 66% (55/82) did not have measles vaccine, 72% (61/84) did not have BCG vaccine, and 68% (56/82) did not have polio vaccine in stock at the time of the survey. Only 60% provided growth and development monitoring of children of any age as part of preventive care. Some 93% of facilities distribute insecticide-treated nets (ITNs) for malaria prevention; all of the facilities had received ITNs from IHP only once and all had been out of stock for more than three months. Coverage for nutrition rehabilitation, blood transfusion services, HIV post-exposure prophylaxis (PEP), and gender-based violence (GBV) services was <49% across all Bureaux de Coordination except for GBV services in Bukavu (83%) and Uvira (67%). The services provided at facilities for HIV care, TB, and NTDs and sexually transmitted infections (STIs) ranged from 20 to 70%. Not all IHP-supported sites are designated sites under Centre de Santé et de Dépistage Traitement de Tuberculoses for provision of TB care and treatment. Similarly, blood transfusion and HIV/AIDS interventions are not implemented at all health facilities. 2 A decision rule was created to describe the performance of MPA-plus availability and accessibility service indicators: 0-49% was labeled as poor performance; 50-79% as improving, and ≥80% as good performance. BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT xiv Almost all facilities surveyed (>95%) provided health promotion services for condoms, exclusive breastfeeding, hygiene and sanitation, food safety, oral rehydration salts (ORS) for diarrhea, improved latrines, and malaria prevention. About 54% of key informants stated that the availability of services had not improved since IHP began implementation. About 44% said that IHP had improved the range of services available, citing FP, ITNs, PMTCT, and WASH as examples of services added since IHP started implementation. About 55% of informants stated that IHP had improved access to services, while 37% said that access to services had not changed since IHP began. Quality of key family health care services. Only 7% (0% of HCs, 26% of GRHs) of the facilities surveyed were found to have adequate minimum infrastructure3 to be functional. Twenty percent (12% of HCs, 43% of GRHs) of the surveyed facilities had the basic infrastructure components, defined as the presence of a physical room and continuous water (albeit not potable) and electricity supply sources. However, this does not imply the presence of running water or reliable electricity. The facilities were mainly staffed by cadres of nurses, community liaisons, and lay/village birth attendants. All HCs and GRHs had at least one nurse, 31% (25% of HCs, 52% of GRHs) had at least one certified birth attendant, and 64% (66% of HCs, 57% of GRHs) had at least one lay/village birth attendant. All GRHs and 13% of all HCs had at least one doctor. The MSP norm does not require HCs to be staffed by physicians. Facilities reported low supervision rates, with 48% of facilities reporting that a MSP representative supervision visit had occurred in the previous or current month of the survey. A high proportion of facilities (82%) reported delays in the delivery of medications and supplies. According to findings from the client exit survey, the overall satisfaction with the services received was 90%. Some 72% of key informants—mainly zone and facility managers—stated that service quality had improved since IHP started implementation, while 25% of informants said that service quality was about the same. Client knowledge, attitudes, and practices supporting health-seeking behaviors. Findings from the client exit survey revealed that about half of children (49%) had visited the health facility with common childhood illnesses such as diarrhea, acute respiratory infections, malaria, and fever on the day of the survey. While 86% of mothers had delivered in a health facility, this does not imply these were births attended by a skilled health professional. Traditional birth attendants (lay village midwives) (TBA) were reported to use health centers to attend deliveries. Eighty-two percent of mothers started breastfeeding their child during the first hour of birth. Some 51% of non-pregnant women reported that they practice an FP method. About 32% had received HIV counseling services; of these, 50% received HIV test results. Some 46% of women had received specific health information related to women’s health from someone in the community. Among the pregnant women who were surveyed, 86% had received prenatal care that day, 89% reported sleeping under an ITN the previous night, and 73% had received their HIV test results. Some 67% of key informants said that health￾seeking behaviors had increased based on the community health education provided in their health zones since IHP started. 3 The minimum infrastructure indicator was defined as a facility having a physical room, a source of electricity, water supply, working emergency communication equipment, access to transport, presence of a toilet, disinfectants currently in stock, and presence of a biomedical waste management system on the day of the survey. BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT xv Health sector leadership and governance. More than half of key informants stated that leadership and governance in the four targeted provinces had improved through the support of IHP. Many managers said that IHP-supplied leadership training had helped them understand the challenges they face in the health sector. Among other informants, 38% said that leadership and governance in their district or zone was unchanged since IHP’s start. Nearly 40% of informants expressed dissatisfaction with the project’s support for health zone supervision due to the low funding level for supervision and lack of IHP provision so far of motorcycles for supervisory visits. NB: At the time of this report, IHP had secured 112 motorcycles, which are ready to be delivered to its field offices. Factors hampering IHP activities from delivering better results. About 30% of key informants stated that decision making, purchasing, and planning for IHP is too centralized in Kinshasa. However, attempts at decentralization during the project’s first two years resulted in several infractions where BCs did not follow MSH’s rules and regulations, with serious implications. Based on this initial experience, IHP managers decided to limit decentralized authority. Some 25% of informants stated that IHP support is spread too broadly and the project is stretched thin trying to cover a wide array of health services and needs. Many informants described problems associated with drugs supplied by IHP, including an inadequate range of drugs, irregular deliveries, and drugs delivered that were not ordered. Geographic access affects IHP implementation as some health zones are vast; roads are very poor in most areas; and ongoing security issues in some areas due to rebel activities curtail access. Other factors hampering IHP results include the low levels of IHP funding for operations and supervision; the slow rate of IHP rehabilitation of facilities; and cultural and religious practices affecting attitudes about health care among some groups, which limit health-seeking behaviors, access to health care services, and good health outcomes. Perceptions of IHP. IHP was perceived by most CODESA members interviewed as helping to improve community health through the supply of drugs and training provided on health issues and diseases. Provincial, district, and zone managers viewed the project’s leadership training as a strength, with all IHP training described as high quality. While about 75% of informants voiced their belief that IHP is a good project, they said it also needs improvement. CONCLUSIONS AND RECOMMENDATIONS Improved access and availability of MPA-plus services Conclusion: It is unrealistic to expect 80% of IHP’s health facilities to achieve a full range of MPA-plus services by the end of the project. Both the breadth of the target population (~ 1,600 facilities in total) and the depth of MPA-plus services (some 50 activities) are overly ambitious given the health system’s existing status, logistical constraints, and implementation costs. Recommendation: USAID should convene with IHP and others to revisit project priorities and targets. The depth of the MPA-plus package should be reconsidered and tailored to fit the epidemiology and most pressing needs of the populations served. USAID should also consider the degree to which IHP supports health facilities, giving the highest priority to the MSP’s “red” facilities, which are classified as the least functional in the provision of services. Improved quality of key family services BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT xvi Conclusion: The team concluded that it is not possible at this juncture to assess the level of improvement in the quality of key family services in IHP-targeted health zones. The package of IHP activities focus on many of the key pre-determinates of quality of care based on international standards and evidence. We collected baseline client perceptions of quality as part of this evaluation. This evaluation question will be answered in the final evaluation report by comparing results of the quantitative surveys at baseline and final evaluation and triangulated with qualitative data obtained during final evaluation. Recommendation: IHP should continue to focus on improving the quality of health services by taking into account all World Health Organization’s quality elements that require health care to be effective, efficient, accessible, acceptable (patient-centered), equitable, and safe. Increased knowledge, attitudes, and practices to support health-seeking behaviors Conclusion: The team concluded that it is not possible at this juncture to assess the level of improvement in knowledge, attitudes, and practices to support health-seeking behaviors in the four IHP-targeted provinces. This evaluation question will be answered in the final evaluation report by comparing results of the quantitative surveys at baseline and final evaluation and triangulated with qualitative data obtained during final evaluation. Recommendation: As funding permits, IHP should continue CODESA trainings with a stronger emphasis on community health worker trainings and a focus on MNCH, FP, nutrition including breastfeeding, malaria, and WASH to promote health-seeking behaviors and utilization of key family health services. Improved health sector leadership and governance Conclusion: IHP has provided important training on leadership and governance that is highly regarded by participants, but this has not yet been provided in all the zones nor has it filtered down to the health center level. Lack of resources including funding is affecting regular facility supervision activities by district and zone managers. Fostering supportive relationships with provincial, district, and zone managers is a high priority for IHP supervisory area office staff. The annual operating plans of the districts and zones are supposed to be formulated jointly with IHP and other partners. That said, the perception of field staff is that the project’s own planning sometimes appears to supersede the annual operational planning carried out at the district and zone levels. Recommendation: IHP should scale up support for leadership and governance and prioritize training for health center nurses. To successfully implement this recommendation, increased funding for supervision is needed. IHP should consider its partnership approach to assess the degree to which it is service-oriented and problem-solving. This could be accomplished through greater transparency and timely communication by IHP staff about what the project can and cannot support. Factors hampering IHP from delivering better results Conclusions:  Funding for the provinces, districts, and zones is well below the real costs associated with their operations, making them ill-equipped to render the wide range of health services needed by local communities. IHP is operating in resource-constrained environments and lacks sufficient resources to fill the gaps. BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT xvii  Decision making is centralized in Kinshasa and is perceived as a barrier by field-based key informants in the field. Long delays due to centralized decision making and purchasing and protracted procurement processes are problems recognized both within and outside the project. However, weak systems for accountability make it difficult to decentralize decision making and IHP Kinshasa’s decision to re-examine this aspect of program implementation was rational.  There have been a number of logistical problems in providing the full range of IHP-supplied drugs and ensuring the regularity of IHP drug deliveries, many of which are outside the manageable control of MSH and its partners. Nevertheless, recent data suggest improvement in the supply chain.  The field perception is that IHP does not pay enough attention to the most prevalent diseases in the zones. Despite the fact that the foundation of MPA-plus is on MSP’s health priorities, zone and facility managers and community members are concerned with the prevention and treatment of the most prevalent diseases in their areas and look to IHP to address them.  Lengthy delays in promised rehabilitation of infrastructure has been a weak point for IHP. Rehabilitation is a joint effort between health facilities, the community, and IHP. IHP cannot control the timely contribution of input from health facilities and the community. It seems unlikely that IHP will be able to complete all planned rehabilitation during the life of the project.  Some cultural and religious practices in the DRC, along with gender practices and inequality, do not support positive health-seeking behaviors and may serve as an impediment to health access. Recommendations:  IHP Kinshasa should empower IHP field office staff members by allocating them more decision-making authority to support needs in the health zones more rapidly, fostering their relationships with district and zone managers.  USAID and IHP should assess if more funding could be reallocated and made available for provincial, district, and zone operations to help managers fulfill their respective roles.  In collaboration with USAID and field-based stakeholders, IHP should determine the disease priorities it is best positioned to support while continuing its focus on MNCH.  USAID should determine if rehabilitation will continue to be a priority. If so, a plan should be developed to rehabilitate the structures with the greatest need.  To help increase health-seeking behaviors, USAID and IHP should pay greater attention to the need for health education materials for CODESA members to use in outreach to community members. The education materials that are designed should address the gender practices and cultural issues that are currently hampering service utilization. How IHP is perceived and valued Conclusion: The most common perception of IHP is that it is a good project that needs improvement. The project is valued in various ways, ranging from the drugs it has supplied to the leadership training it has provided. BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT xviii Recommendation: IHP should make mid-course corrections based on the previous recommendations by weighing them as a whole against available funding and resources and redefined priorities and targets. BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT 1 I. EVALUATION PURPOSE AND QUESTIONS USAID/DRC contracted International Business and Technical Consultants, Inc. (IBTCI) in December 2012 to conduct two external evaluations of the Integrated Health Project (IHP) based in the Democratic Republic of Congo (DRC) and implemented by Management Sciences for Health (MSH) and its partners, International Rescue Committee (IRC) and Overseas Strategic Consulting Ltd (OSC). The external evaluations include a performance evaluation of the overall IHP project with baseline and endline components (this report includes the baseline for the IHP endline and a performance evaluation) and an impact evaluation including a baseline study and endline reviews of MSH’s Results-Based Financing component of IHP. The request for quotation to which IBTCI responded was issued through the U.S. General Services Administration’s Mission Oriented Business Integrated Services (MOBIS) schedule in September 2012, nearly two years into MSH’s implementation of IHP. A complete description of this evaluation’s scope of work is provided in Annex A. (NB: A midterm evaluation is no longer proposed.) While the conventional approach to a baseline evaluation of a development project is to conduct it early in a program’s life, several factors impeded this from happening. First, MSH had already conducted a baseline evaluation of demand for key family health services as part of IHP (IHP Part I Baseline) in May 2011. This study focused on knowledge, practices, and coverage of key health areas among households in targeted communities. However, as per the new Evaluation Policy, USAID/DRC decided to seek an external contractor for Phase II that focuses on the supply side of health services, including the quality, accessibility, and availability of key family health interventions provided in the targeted facilities. This is the component that IBTCI has completed and documented through this report. This performance evaluation will help USAID/DRC determine the project components and aspects that are working well, understand why they are successful, and identify constraints facing the project so that any modifications and corrections that are needed can be made. An endline evaluation is scheduled for 2015. This evaluation provides data and information on the current state of access, utilization, and delivery of quality health services at the health centers (HCs) and general reference hospitals (GRHs) in IHP health zones in Katanga, South Kivu, East Kasai, and West Kasai provinces for the following health-related priorities : (1) family planning (FP); (2) maternal, newborn, and child health (MNCH); (3) nutrition, malaria, and tuberculosis (TB); (4) HIV/AIDS; water, sanitation, and hygiene (WASH); and neglected tropical diseases (NTDs). Unlike a conventional baseline study conducted before project implementation, this evaluation goes a step further and identifies programmatic areas that need improvement. It then forms initial conclusions and provides recommendations to allow for mid-course program adjustments. The final evaluation, and to a lesser extent this performance evaluation, seeks to answer the following questions: BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT 2 1. To what extent has the project improved access to and availability of the minimum package of activities-plus/complementary package of activities-plus (MPA-plus/CPA-plus4 ) services and products in target health zones? 2. Has the project improved the quality of key family health care services in target health zones? 3. Have knowledge, attitudes, and practices to support health-seeking behaviors increased in target health zones? 4. Has health sector leadership and governance in the four target provinces improved? 5. What are the external factors that hamper IHP activities from delivering better results? 6. How is IHP perceived and valued? 4CPA-plus services were not evaluated in this study. See Annex O for list of MPA-plus services. BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT 3 II. PROJECT BACKGROUND The DRC has suffered more than 20 years of civil war and political unrest. The country currently has one of the lowest gross national incomes per capita in the world, at $190 (World Development Indicators Database: World Bank, 2011). An estimated 80% of DRC’s population of 75.5 million lives below the poverty line; half live in extreme poverty (U.S. Census Bureau, International Database, 2013). In 2013 the DRC ranked 186th and shared last place with Niger in the UNDP Human Development Report (UNDP Human Development Report, 2013). The country has suffered a long decline from relative prosperity to a complete free‐fall economy, a collapse that accelerated in the 1990s during a decade of conflict that accompanied the disintegration of former Zaire. Today stakeholders are cautiously optimistic that the DRC’s worst problems are over. Multiple donors have demonstrated renewed interest, particularly in supporting the development of the country’s health sector. Until 1990, the DRC’s health system was well known in Africa for its network of health facilities, quality of physicians, and primary health care system. This was due, in part, to significant support from USAID and faith-based entities, including Protestant and Catholic missionaries. The U.S. Government invested heavily in training health workers, including establishing a School of Public Health in Kinshasa. However, war and mismanagement led to significant backsliding in the health sector. Today, health indicators are extremely poor: Under￾5 mortality is estimated at 148 per 1,000 live births, the fifth highest rate in the world (Ministry of Planning and Macro International, 2008, Demographic and Health Survey, 2007). The 2008 estimate of maternal mortality was 670 per 100,000 live births, ranked as the 16th highest rate in the world (World Health Organization, 2011). The health sector is chronically underfunded, with per capita health expenditures amounting to U.S. $14.20 in 2007. Of this total, U.S. $1.95 comes from the government; U.S. $5.50 comes from international partners, and U.S. $6.50 comes from households (preliminary National Health Accounts estimates for 2008–2009, Ministère de la Santé Publique, Programme de la Santé, and USAID/Health Systems 20/20, 2010). National des Comptes Nationaux. With the country’s health system lacking critical financial and material resources, supply chain breakdowns are widespread, particularly in remote areas. This situation leaves a majority of the country with limited access to health care services, which are often poor in quality. Access to primary health care remains a challenge, with 70 to 80% of the population having difficult or no access to health care. Access varies widely by province and health zone, with urban areas generally better served than rural. High population growth is a serious issue, impeding economic growth and threatening to undo future prospects for gains in the social services sector. Projections of population growth indicate that DRC’s population will double by 2050 to nearly 147 million (World Development Indicators Database: World Bank, 2010). The expanding population will exert increasing pressure on the country’s resources and communities, presenting dramatic challenges to the provision and delivery of basic health services. Before 1990, USAID‐supported project areas experienced relatively high rates of family planning. In the past two decades the contraceptive prevalence rate (CPR) has fallen dramatically and the country now has one of the highest total fertility rates (TFRs) at 6.3 births per woman and one of the lowest CPRs in the world, at 5.8% (Reproductive Health at a Glance, DRC, World Bank, 2011). Against this backdrop of pressing BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT 4 social needs, the Government of DRC (GDRC) is challenged to demonstrate tangible progress in development and rebuilding basic health services. Improving the quality and use of essential health services at the national level is a key component of the GDRC’s strategy to reduce poverty; it also is an essential goal of the Ministry of Public Health (Ministère de la Santé Publique) (MSP). Several reforms are currently under way to improve health system performance. A new National Health Development Plan (Plan National de Développement Sanitaire, or PNDS; MSP, 2010a) for 2011–2015 was developed in March 2010. Its objectives are to contribute to the well-being of the Congolese people by improving their health and providing universal access to quality basic health services, particularly for vulnerable groups. The plan involves four strategies: (1) strengthening health zones; (2) supporting health zones in human resources for health; drug supply; health system financing; infrastructure rehabilitation/reconstruction; provision of equipment; and health information systems; (3) strengthening health sector governance and leadership; and (4) improving intersectoral collaboration. In September 2010, USAID/DRC awarded the five-year $139,767,129 Integrated Health Project, Cooperative Agreement #AID‐OAA‐A‐10‐00054, to Management Sciences for Health and its partners, International Rescue Committee and Overseas Strategic Consulting, Ltd. The five-year project supports the DRC’s national health plan, the PNDS). IHP is designed to improve the enabling environment for, and increase the availability and use of, high-impact health services, products, and practices for FP; MNCH; nutrition; malaria; NTDs; tuberculosis; HIV/AIDS; and WASH in target health zones. The project works in 80 target health zones and currently supports approximately 1,600 health facilities in four provinces of eastern DRC: East Kasai, West Kasai, Katanga, and South Kivu. IHP has two components. In Component 1, Services, IHP supports health zone strengthening, the first strategic focus of the PNDS. Component 1 works to strengthen health zone capacity to deliver services by addressing both the supply and demand sides of services. Under this component, there are three intermediate results (IRs): IR 1: Access to and availability of minimum package of activities plus/complementary package of activities plus (MPA-plus/CPA-plus) services in target health zones increased IR 2: Quality of MPA/CPA-plus services in target health zones increase IR 3: Knowledge, attitudes, and practices (KAP) to support health-seeking behaviors increased in target health zones Component 2, Other Health Systems, corresponds to the second PNDS strategic pillar, support for health zone strengthening and works in six priority areas: human resource development, pharmaceutical management, health finance, construction/rehabilitation of infrastructure, equipment and new technologies, and improved health system management. Under Component 2, IHP is focusing on activities that create an enabling environment for strong health zones. Component 2’s emphasis is on leadership, governance, and resource provision tied to performance, with the goal of eliminating health system bottlenecks stemming from unaligned or absent policies, especially at the provincial level. The fourth intermediate result is found under Component 2: IR 4: Health sector leadership and governance in target provinces improved BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT 5 The IHP Results Framework is provided in Figure 1 on the following page. Table 1, shown below, provides data on IHP funding streams and program elements since the inception of the project. Noteworthy is the fact that malaria and MCH funding has accounted for almost 52% of IHP’s total funding in prior years and will account for close to 60% of all resources in 2014. Yet one-third of IHP’s PMP indicators are focused on prevention of mother-to-child transmission of HIV (PMTCT) (28/85), while HIV/AIDS funding is on average 5% of the budget. This is a result of PEPFAR reporting requirements. Table 1: IHP Funding Allocations 2011-2014 Program Element 2011 2012 2013 2014 HIV/AIDS 7.0% 5.0% 5.1% 3.0% TB 12.6% 11.9% 13.5% 9.8% Malaria 16.3% 17.4% 14.2% 8.9% MCH 35.2% 32.3% 39.0% 50.6% FP/RH 15.9% 17.1% 13.8% 10.8% WASH 8.9% 10.4% 8.8% 8.6% Nutrition 4.2% 5.9% 5.6% 8.6% At the end of the five‐year IHP life of project, it is anticipated that 80% of targeted HCs and GRHs will offer MPA-plus and CPA‐plus. Many bilateral and multinational donors, faith‐based organizations (FBOs), and non-governmental organizations (NGOs) are providing support to implement MPA/CPA‐plus, as well as technical assistance for specialized health systems strengthening interventions at all levels. Under IHP, MSH and its partners are building on this investment through service delivery contracts with providers and the MSP, ensuring they receive training, medical equipment, and access to essential medicines and other health commodities. BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT 6 Figure 1: IHP Results Framework BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT 7 III. EVALUATION METHODS AND LIMITATIONS METHODOLOGY The IHP evaluation team employed both quantitative and qualitative methods. The quantitative method took the form of a cross-sectional survey of health facilities including HCs and GRHs, with client exit interviews that used structured questionnaires in the eight target BCs (IHP Coordination Bureaus). Data were collected from 23 randomly selected health zones in four provinces: East Kasai, West Kasai, Katanga, and South Kivu. Two quantitative surveys were employed to determine facility characteristics, client volume, and utilization of MPA-plus services, community outreach and support, management capacity, and client knowledge and perceptions on the quality of care and practices with regard to key health interventions. The qualitative methods included document reviews and key informant interviews. The qualitative component’s primary objective was to explain the context and reasons for project implementation bottlenecks, record perceptions regarding IHP, and document the factors that determine service quality and utilization. The primary unit of analysis of the facility survey is the BC. There are four units of analyses in the client exit survey: children 0-23 months, children 24-59 months, pregnant women, and women of reproductive age (WRA) (15-49 years). Document Review The evaluation team requested various documents from MSH and USAID, including the IHP household baseline survey conducted by MSH in 2011, DRC IHP quarterly/annual reports, training materials, and all other documents related to IHP development and implementation. The evaluation team used the collected materials to assess the coverage and content of project interventions and implementation. The document review provided a foundation for understanding and developing operational strategies for the evaluation; the survey questionnaires were used to answer baseline evaluation questions. Annex N, Sources of Information, provides a list of documents and other references used by the team. Facility Survey The lot quality assurance sampling (LQAS) method was used to select facilities for the facility survey. A facility is defined as a fixed structure where health services are provided to the communities residing in nearby areas. The facility survey focused on MPA-plus services, as they are supposed to be provided at all HCs in the 80 target zones (see Annex O for a list of MPA￾plus services). Three health zones were randomly selected in each BC. Within each of those health zones, three HCs were randomly selected. As there is only one GRH per health zone, all 24 GRHs were included in the original sample distribution (see Annex D, Data Collection Sampling Procedure). Twelve facilities (three HCs and one GRH in each zone) in each BC were selected. Seventy-three HCs and 23 GRHs (a total of 96 in eight BCs) were included for the surveys (Table 2). A structured facility questionnaire with open- and close-ended questions was used to collect information. The questionnaire included questions for data collectors to record facility observations notes on infrastructure, medications, and documentation reviews. (See Annex J, Facility Questionnaire, and Annex K, List of Surveyed Facilities.) Originally, 24 health zones had been selected (three in each BC); however, in Uvira, the Hauts-Plateaux health zone was dropped to protect our evaluation team from heightened conflict. The remaining health zones possible to select from were not included, also due to insecurity in the region. This BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT 8 resulted in a total of 23 health zones and respective GRHs. To keep the sample size, we oversampled HCs from the two selected health zones in Uvira. Annex D provides further detail on changes made to the original sample distribution. Table 2: Description of Facilities Surveyed BC No. Name of Province Name of BC Number of Health Zones/BCs Number of HCs Surveyed in Each BC Number of GRHs Surveyed in Each BC Total Health Facilities Surveyed in Each BC 1 South Kivu Bukavu 3 9 3 12 2 Katanga Kamina 3 9 3 12 3 E Kasai Kole5 3 9 3 12 4 Katanga Kolwezi 3 9 3 12 5 W Kasai Lwiza 3 9 3 12 6 E Kasai Mwene-Ditu 3 9 3 12 7 E Kasai Tshumbe 3 9 3 12 8 South Kivu Uvira 2 10 2 12 Total 4 8 23 73 23 96 Table 3: Respondent Profile in the Client Exit Survey Characteristics Number % Type of facility Health center 293 77% General reference hospital 90 23% Gender of respondents Female 383 100% Age of respondents Mean (range) age of respondent 27.3 years (14-47) Profile of women Women 15-49 years 231 60% Pregnant women 117 31% Othera 35 9% Reason for clinic visit For self 183 48% For childb 203 53% Profile of childrenc Child 0-23 months 152 75% Child 24-59 months 51 25% a: Women who did not seek care for themselves on interview day, who accompanied either a child or another woman seeking care, only completed questions assessing satisfaction with facility quality. b: Three women brought two children to receive care on the interview day. c: Interview respondents were mothers of children. 5 After the end of data collection, IHP changed the location of Kole’s Bureau de Coordination to Lodja. Both cities are located in Sankuru District. This change has no implications on the findings, conclusions, or recommendations herein. BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT 9 Client Exit Survey Respondents for the client survey were selected by convenience to include women of reproductive age, pregnant women, and mothers with children ages 0-59 months attending the facility. A structured questionnaire comprised of four modules with open- and closed-ended questions was used (see Annex I). To keep the interviews to less than a half hour and avoid respondent fatigue, women were not asked to complete more than two modules. There were 383 interviews completed across the eight BCs. Table 3 and 4 shows the profile of the respondents interviewed in the client exit survey. Table 4: Client Interviews by BC, Number of Facility Sites, Number of Completed Interviews BC No. Name of SA No. of Facilities Surveyed Total No. of Respondents % 1 Bukavu 12 56 15% 2 Kamina 12 30 8% 3 Kole 12 35 9% 4 Kolwezi 12 50 13% 5 Lwiza 12 51 13% 6 Mwene-Ditu 12 71 19% 7 Tshumbe 12 43 11% 8 Uvira 12 47 12% Total 96 383 Key Informant Interviews A total of 80 semi-structured in-depth interviews were conducted across all of the BCs with health managers and other professionals at health centers and general reference hospitals; staff from the MSP at national, provincial, district, and zone levels; members of CODESAs (health development committees) and community health workers (CHWs; managers and specialists working at IHP field offices; and USAID/DRC program staff (Table 5). More than 62% of key informants represented MSP. A list of interviewees is found in Annex L, List of Persons Interviewed. Table 5: Number of Key Informant Interviews by Informant Profile Type Total National/ Provincial/ District MSP Staff MSP Health Zone Managers MSP Facility Managers CODESAs IHP Staff USAID 80 10 (12.5%) 20 (25%) 20 (25%) 16(20%) 13 (16.3%) 1(1.3%) Data Collection Team The senior evaluation team members included Mary O’Grady, Team Leader, and Jean-Lambert Mandjo, Deputy Team Leader, who also served as Survey Coordinator. The team included four field supervisors: Magalie Kabale, Germaine Kawal, Valentine Ilunga, and Hubert Kinwa. See Annex M, List of Supervisors, Data Collectors, and Interviewers. For field data collection, there was a total of 64 data collectors and interviewers organized into teams of eight, with one supervisor overseeing two data collectors (focused on the facility survey) and two interviewers (focused on the client exit survey) per health zone. The field BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT 10 supervisors, assisted by the Team Leaders, conducted the recruitment of interviewers from a main pool of more than 120 trainees. For each BC, a new group of data collectors and interviewers was trained and selected so surveys could be conducted in local languages; this also facilitated mapping of remote HCs. The team selected interviewers on the basis of skills, experience in conducting surveys, familiarity with the interview locations, and knowledge of the local language/dialect of the survey sites. All selected interviewers went through a three-day practical survey training in the BC, with one day devoted to the facility survey, one day focused on the client exit survey, and the last day focused on the use of the mobile phone for data collection using Magpi software. After the training session, which included role-playing and a final test, supervisors selected the best candidates to participate as interviewers. The Team Leader or Deputy Team Leader conducted key informant interviews. Annex Q provides an English translation of the French Training Manual given to all interviewers and Annex B provides key informant interview guides for interviews with health managers and CODESA members. The project’s Field Implementation Plan is found in Annex P. Ethical Considerations Oral informed consents were administered to inform respondents of the purpose, process, potential risks, use, and confidentiality of the information and their right to refuse to participate at any time. Facility managers were interviewed in private in the HC’s consultation rooms. Clients were interviewed at a short distance from the facility but out of hearing range from health facility staff. All interviewers received training in ethical protocols to ensure that no identifying characteristics of respondents were recorded during data collection. Unique identifiers were used in place of client names. Additionally, the electronic database was kept in password-protected computers used only by the senior evaluation team members. Pilot Testing A pilot survey was conducted to test and finalize the survey methodology and data-collection instruments in 10 facility locations in the Luputa Health Zone, in the Mwene-Ditu BC, East Kasai Province. This pilot surveyed involved different HCs than those where data collection subsequently took place for the evaluation. As a result, data collection questionnaires were revised and additional training provided to the field supervisors. Data Management Prior to deployment of survey teams to the field, a logistics plan was developed. The plan focused on the organization of trips to survey areas and accommodation of and travel to interview sites. Each interviewer was provided with a phone with Magpi data-collection software. The interviewer directly entered information from survey respondents into mobile phone devices and stored it. After a supervisor provided data-quality assurance, the completed survey was sent to a centralized Magpi server using phone network connection; in this way, data entry and release of the data file occurred on the same day. The database with completed questionnaires on the Magpi server was downloaded and converted into a STATA file at the IBTCI home office at the end of data collection. This ensured fast, complete download, which was difficult to perform locally in the DRC due to erratic Internet service and power supply. The key informant interviews were conducted in French and transcribed into English for subsequent analysis. Data Quality Assurance BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT 11 During survey data collection, interviewers were continually supervised on-site by supervisors. Whenever possible, cell phones were used to ensure constant communication between interviewers and supervisors, particularly for sites that were far apart. However, given that each supervisor was responsible for overseeing two two-person teams, they were able to observe the interviewers at least every other day and ensure quality team performance. Before uploading a completed survey from a phone to the Magpi server, the supervisor performed quality checks to ensure questionnaire accuracy and completion. In situations where a telecommunications network or a charged phone was not available, interviews were conducted on paper forms and later transferred to a phone and then to the database. In Bukavu and Uvira, where security was an issue, the interviewers did not use their phones. The interviewers later transferred the information into Magpi and their supervisors double checked their entries before they were uploaded to the server. The data recording forms contained pre-coded questions. Variable names, labels, and value code and label were defined for each question in survey questionnaires while developing the Magpi database. Range checks were programmed to avoid entering spurious data entries. Additionally, 5% of all paper forms sent to the IBTCI home office were checked randomly for completeness and accuracy. Status reports on data-collection progress were sent to IBTCI home office at the end of each month. These checks included ensuring for data completeness, plausibility, and consistency. The paper forms were compared with the corresponding data entry on the Magpi database and monthly status reports. Any missing data, inconsistency, or error detected in the data were reported to the Deputy Team Leader, who in turn informed the responsible Site Supervisor to correct the information. Data Analysis STATA version 12 was used for analysis of performance indicators. A data analysis plan was created, reviewed, and decisions made about which measures and indicators would be calculated to answer each evaluation question (see Annex C, Quantitative Data Analysis Plan). Descriptive data analysis of facility clients provided information on the number and type of clients. Client’s health service access, knowledge, attitude, and practices indicators were calculated as an aggregate, including all BCs; client satisfaction indicators were disaggregated according to type of client and BC. Analysis of the facilities’ performance indicators focused on availability, accessibility, and quality of care for key MPA-plus services. Availability and accessibility of MPA-plus services indicators were labeled as poor (0-49%), improving (50-79%), or good (≥80%). Qualitative data were analyzed using a mixed method of statistical analysis combined with an inductive approach that focused on the dominant themes and frequency of specific responses to the six evaluation questions (see Annex E, Qualitative Data analysis matrix). LIMITATIONS AND CONSTRAINTS Although facility survey sites were selected randomly using LQAS, some of the sites were later changed due to insecurity or threat to survey personnel by non-state rebel groups. The remoteness and inaccessibility of some areas was the main difficulty encountered in the deployment of interviewers (see the table of replaced facilities in Annex D). The number of available 4x4 vehicles and motorbikes was extremely limited in most districts, and the rental costs for vehicles were as high as $350 per day, plus fuel. These factors led to the selection of only those sites that survey personnel could access and were fairly safe. BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT 12 Client interview data are subject to recall bias since the questions were based on self-reported health status. The client exit interviews reflect the perceptions of a self-selected population of women who were already using health services. These women are not representative of the sub-population of women who fail to seek services in the formal health sector. Interview bias was also a potential limitation of the client exit interviews, as questions were translated into local languages when clients did not speak a regional language. However, the low supervisor-to￾interviewer ratio enabled supervisors to frequently observe interviewers to ensure the consistency of translations. An insufficient number of clients from the target groups were available at some health facilities—especially the smaller facilities—on the day of the client exit survey. Phone communication was difficult in many areas due to network inaccessibility. This situation limited the ability to collect data directly onto a phone and led to the duplication of work, i.e., the collection of data on paper forms and its subsequent transfer to a phone for final uploading to the Magpi server. Due to logistics, clients were interviewed on different days of the week, which could skew the client characteristics between facilities (e.g., a survey conducted during antenatal days versus immunization days or on Saturdays, which would have different patient populations from other days of the week). Interview bias was much less of an issue for the key informant interviews, since the majority of those interviews were conducted by the two team leaders who were in close communication. Finally, the sample is not representative of facilities located in the areas of highest insecurity as they were eliminated from the sample. Nonetheless, several of the facilities selected were in conflict settings. For both facility managers and clients, “halo” bias is clearly a potential bias, whereby the respondent provides the interviewer with what they believe to be a desirable answer. Effects of limitations on results interpretations: The results of the evaluation cannot be generalized. The areas where the survey team could not collect data due to insecurity and difficult accessibility may have lower performance than the areas that were surveyed, since the team anticipates similar difficulties in reaching the communities for service provision in these areas. Similarly, the results of the client exit interviews cannot be generalized to the entire population since the perspectives of service non-users of facilities could not be ascertained. However, this perspective was already captured in the 2011 IHP Baseline Household Survey conducted by MSH. Additional actions taken to mitigate limitations: All sites for the facility survey were selected randomly during the sampling process to avoid selection bias as much as possible. To minimize client selection bias, all clients who were present at the facility at the time of the facility survey were interviewed. (No respondents refused to participate.) There was no prior communication with clients or communities regarding the day, time, or location of the survey. No incentives were provided to respondents for participation. To mitigate data-entry error when data were entered on paper before imputed into the Magpi software on cell phones, supervisors conducted a modified form of double-data entry by reviewing each questionnaire after the interviewer entered his/her data from paper. BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT 13 IV. EVALUATION FINDINGS Evaluation Question 1: To what extent has the project improved access to and availability of MPA-plus and CPA-plus services and products in the targeted health zones? OVERVIEW This question relates to USAID/DRC’s anticipation that by the end of IHP’s five‐year period of performance, 80% of targeted HCs and GRHs will offer MPA-plus and CPA‐plus to correspond to IR 1. The findings to this question are derived from an analysis of the quantitative data included in the facility survey and the relevant qualitative data from the key informant interviews (KIIs). FACILITY SURVEY FINDINGS About 83% of the surveyed health facilities are open 24 hours a day, seven days a week, except in the Kamina and Kolwezi BCs in Katanga Province, where 75% of facilities are open to this extent. The facilities provide a range of preventive, curative, and community health promotion services and products. However, none of the facilities surveyed (0/96) provided a full range of MPA-plus services (Annex F, Quantitative Analysis). The following two subsections describe the availability of services. Preventive and Curative Services Almost all of the facilities surveyed (>95%) provided prenatal care and FP services. About 79% (76/96) had a maternity unit to provide normal delivery services; all provided postpartum care. However, it was not ascertained if labor and delivery and postpartum care is delivered by traditional birth attendants (TBAs) or professional nurses. There is anecdotal information to infer that TBAs are performing these services in some settings. Twenty-one percent of facilities (16/76) with labor and delivery services reported that their employees offer these services in both the facility and the community, with the lowest coverage (0%) in Mwene-Ditu and Uvira BCs. Fifty-eight percent (44/76) of facilities reported that they must refer a case requiring emergency cesarean section; however, only 45% (34/76) had written instructions to provide referrals in emergency obstetrics cases. Fifty-eight percent (44/76) reported no maternal deaths in 2012. Pregnant women were advised to be tested for HIV in 69% (63/91) of the facilities offering prenatal care. Not all health facilities are designated sites for PMTCT services. Forty￾one percent (39/96) of surveyed facilities provided an HIV test for PMTCT. Out of these sites, only 59% of facilities (23/39) provided ARVs for PMTCT, and 36% offered HIV care (co￾trimoxazole) to HIV-positive pregnant women. One hundred percent of the facilities surveyed offer clinic-based integrated management of childhood illnesses (IMCI). About 88% (84/96) of facilities reported that they offer immunization services for children. About 79% (66/84) of facilities offering immunization services reported that they had an immunization education plan for the current year. However, limitations due to supply chain weaknesses were evident: sixty-seven percent (55/82) did not have DTP vaccine, 66% (55/82) did not have measles vaccine, 72% (61/84) did not have BCG vaccine, and 68% (56/82) did not have polio vaccine currently in stock at the time of the survey. BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT 14 About 60% (58/96) of health facilities in the sample provided growth and development monitoring of children under 5, even though growth monitoring should be a routine activity provided at HCs. In Kolwezi BC, the coverage of this service is 42%. The coverage of nutritional rehabilitation services was 40% (38/96), although it is important to note that IHP does not support nutritional rehabilitation. Vitamin A during prenatal care was provided in 23% of health facilities (21/91). According to a key informant from MSH, vitamin A distribution is not a service delivery component at this time and these distributions appear to be a remnant of previous vitamin A campaigns. Some 93% of facilities reported that they previously distributed insecticide-treated nets (ITNs) for malaria prevention, especially for pregnant women, but ITN distribution for children under 2 was low, at 57%, with the lowest coverage in Kamina and Kolwezi BCs in Katanga Province and Uvira BC in South Kivu Province (33–46%). During the period of data collection, no facility was distributing ITNs: All the facilities had received ITNs from IHP only once and all had been out of stock for more than three months. Coverage for blood transfusion services (32.3%, or 31/96), HIV post-exposure prophylaxis (PEP) (24%, or 23/96), and gender-based violence (GBV) services (32.3%, or 31/96) was low across all BCs The services provided at facilities for HIV care, NTDs, and sexually transmitted infections (STIs) ranged from 20-70%. Fifty-seven percent (55/96) of facilities surveyed provided TB treatment. According to a key informant from MSH, not all IHP sites are designated sites under Centre de Santé de Dépistage et Traitement de Tuberculoses for provision of TB treatment and care services. Similarly, not all sites are providing blood transfusion, HIV/AIDS treatment and care, PEP, and GBV services. About 91% of the facilities offered services for minor surgery. Community and Health Promotion Services Almost all facilities surveyed (>95%) provided health promotion services for condoms, exclusive breastfeeding, hygiene and sanitation, food safety, oral rehydration salts (ORS) for diarrhea, improved latrines, and malaria prevention (in the latter case, via free distribution of ITNs). However, the promotion of iodized salt and fistula prevention was lacking, with coverage of about 40%. The TB treatment sites providing coverage for TB contact tracing and monitoring of TB patients in the community was about 78% (43/55). BCs with good TB community interventions included Kamina and Kolwezi in Katanga Province and Mwene-Ditu and Tshumbe in East Kasai Province. KEY INFORMANT INTERVIEW FINDINGS The following findings are based on the team’s analysis of the key informant interviews that were conducted. The evaluation question was split into two sub-questions, with the first focused on improved availability of services and the second focused on improved access to services. About 54% of 61 informants stated that service availability had not improved during IHP implementation, while 44% said that IHP had improved the range of services available, citing FP, ITNs, PMTCT, and WASH as examples of the services added since IHP started implementation. BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT 15 About 55% of 57 informants stated that IHP had improved access to services, while some 37% of informants said that access to services was unchanged. Only 7% said that access had gone down for various reasons, one reason being that some community members access health services at other facilities due to the lower costs for services at facilities supported by donor funding or through subsidies from private companies. Evaluation Question 2: Has the project improved the quality of key family health care services in targeted health zones? OVERVIEW This question relates to IHP IR 2: Quality of MPA/CPA-plus services in target health zones increased. The findings for this question stem from analysis of the quantitative data collected using a facility survey at 96 health facilities, including 73 HCs and 23 GRHs in the four targeted provinces; a client exit survey of 383 clients at the same facilities; and qualitative data collected through interviews with 64 key informants. (See Annex G, Quantitative Analysis: Quality of Care Variables, which provides a list of variables for quality of care.) FACILITY SURVEY FINDINGS Infrastructure and Operations Information was collected using the facility survey on the availability of basic infrastructure and facility operations, including supervision, drugs and supplies, infection control, and waste management. Only 7% of facilities (7/96; 0% of HCs and 26% of GRHs) were found to have adequate minimum infrastructure to be functional. The minimum infrastructure indicator was defined as a facility having a physical room, continuous electricity source, running water supply, working emergency communication equipment, access to transport, presence of a toilet, disinfectants currently in stock, and presence of a biomedical waste management system on the day of the survey. Twenty percent (19/96; 12% of HCs and 43% of GRHs) of the surveyed facilities had the basic infrastructure components, defined as presence of a physical room and access to water (but not necessarily potable or readily available on site) and electricity supply sources (not necessarily consistent and in the case of generators, reliant on the availability of fuel). Inadequacies were mainly linked to the following: a continuous electricity supply was present in only 30% of facilities, a running water supply inside the building was present in 51% of facilities, and an emergency communication system was present in 18% of facilities. Transportation was readily available in 49% of facilities even though in many cases, the only means of transport is a bicycle. The term running water supply also includes facilities that use buckets of water with a built-in spigot; the water must be transported by hand to the facility. Staffing The health facilities surveyed were mainly staffed with cadres of nurses, community liaisons, and lay/village birth attendants. All facilities had at least one nurse, 80% had at least one community liaison, 31% (25% of HCs; 52% of GRHs) had at least one certified birth attendant, and 64% (66% of HCs; 57% of GRHs) had at least one lay/village birth attendant. More than 80% of facilities surveyed in Kole and Lwiza BCs had no certified birth attendants. Only 34% of the facilities had at least one doctor, including just 13% of the HCs (10/73), but all GRHs had at least one doctor (the MSP norm does not require a physician to be based in each HC.) Only BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT 16 34% of facilities had a lab assistant, including 20% of the HCs (15/73) and 78% of the GRHs (18/23 had at least one lab assistant). Only 3% of the HCs (2/73) had a nutritionist on staff, while 30% of GRHs (7/23) had a nutritionist employed. The gender distribution of staff was skewed toward males, but birth attendants were 100% female. These findings are in line with the cultural norm and community preference for female birth attendants at the time of delivery. Training rates were lowest for the lay birth attendants (26% trained within the past three years) compared to other staff categories. Supervision Rates Overall, 48% of facilities reported a MSP representative supervision visit had occurred in the previous or current month of the survey. The lowest supervision rates were reported in Kamina (0%) and Kolwezi (8%) BCs in Katanga Province and the Mwene-Ditu BC (8%) in East Kasai Province. Only the Tshumbe BC in East Kasai Province had a high supervision rate, at 83%. Supervision rates at both Bukavu and Kole were 67%; the rate at both Uvira and Lwiza was 75%. Medications and Supplies Procurement The predominant sources of procurement for medications and supplies are official central offices of health zones (60%), followed by international NGOs (47%) and private suppliers (29%). Very little is known about the quality of the drugs supplied by the private sector. A full 82% of facilities reported delays in the delivery of medications and supplies due to the depletion of stock at the central office of the health zone. Other reasons for delays included inadequate transportation (34%) and administrative and financial difficulties (20%). Delays in deliveries were severe for the Uvira SA in South Kivu Province and the Lwiza SA in West Kasai, where all facilities (100%) reported delays in delivery. The fewest delays were reported in the Bukavu SA in South Kivu (58%). At the time of survey, current stock-out rates for oral combination birth pills was 19% (18/96); for injectable contraceptives 9% (9/96); for intrauterine contraceptive 79% (76/96); and for condoms17% (16/96). Sterilization and Medical Waste The most effective method for medical equipment sterilization is the autoclave, but it was reported to be used in only 24% of health facilities. Most facilities reported using boiling (60%) as their sterilization method. Used needles and sharps were incinerated in 79% of health facilities. No facility reported the reuse of needles and sharps. However, during one site visit, an evaluation team member observed a nurse reuse an intravenous needle several times on the same baby. Only 35% of facilities used an incinerator for disposing of medical waste. About 47% of facilities used burial for medical waste disposal and 42% used outside burning as their method of medical waste disposal. Some 6% of facilities did not use any safe method for medical waste disposal. CLIENT EXIT SURVEY FINDINGS Client Satisfaction A client exit survey was used to collect data on the satisfaction of 383 clients (woman ages 15- 49) with the health services she or her child had just received at a health facility. A high proportion of the clients, 95%, were treated by a nurse at the health facility; only 5% were treated by a doctor. More than 95% of clients expressed satisfaction with the BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT 17 interpersonal skills of the health provider while s/he was treating the child or woman. Although the satisfaction levels regarding staff attitudes and skills were high, 48 clients (10-15%) reported that they thought another facility offered better care. Overall satisfaction with the services received was 90%; the level of satisfaction with the waiting time to see a provider was 86%; and satisfaction with the level of privacy, 92%. Eighty-eight percent of clients were satisfied with the amount of time spent with the health provider and 92% were satisfied with the attitude of the service provider toward the client. KEY INFORMANT INTERVIEW FINDINGS The evaluation team conducted informant interviews with 64 MSP district, zone, and facility managers and IHP managers who responded to the question of whether IHP had improved the quality of key family health care services. Seventy-two percent of informants stated that service quality had improved since the inception of IHP, while 25% said the quality remained unchanged. Many managers attributed the quality improvements to IHP training and drug supplies. Some informants noted that IHP’s monitoring activities have mobilized the zone managers, resulting in an improvement in the quality of care. Only 3% of informants said service quality had declined since IHP started. One reason given was a decline in the facilities’ curative indicators due to the lack of affordable lab services for patients. Another reason provided was a steady decline in facility resources over the last decade. Evaluation Question 3: Have knowledge, attitudes, and practices to support health-seeking behaviors increased in the targeted health zones? OVERVIEW This question relates to IHP IR 3: Knowledge, attitudes, and practices to support health-seeking behaviors increased in target health zones. The quantitative data (see Annex H, Quantitative Results: Knowledge, Attitudes, and Practices) contributing to the findings for this question are derived from an analysis of the 383 respondents in the client exit survey conducted at 96 facilities. The qualitative data result from an analysis of interviews with 48 informants who responded to this question in a key informant interview. CLIENT EXIT SURVEY FINDINGS On the days the client exit survey was conducted, 98% (198/203) of children 0-59 months at the health facility had visited to be treated for an illness. About 18% of children 0-23 months (n=152) received treatment for acute respiratory infections, 35% received treatment for diarrhea, and 44% received treatment for a fever. About 24% of children received a vaccination. Thirty-six percent of the children’s mothers reported they had received child nutrition information from the health care provider during the visit. Some 66% of the mothers reported that the child was weighed and11% reported that the child’s height or length was measured. Only 26% of the mothers were informed about their child’s growth by the health provider. More than two-thirds (68%) of mothers visiting the facility with a child 0-23 months reported that the child had received vitamin A in the past six months. BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT 18 Almost half (49%) of children 0-23 months visiting the facility had suffered from diarrhea in the previous two weeks. Seventy-eighty percent of their mothers had given them ORS for diarrhea and 85% of mothers continued feeding their child during diarrhea. Among the children 0-23 months visiting the facility who had experienced a fever in the previous two weeks, 80% (78/98) had received treatment to prevent malaria within 24 hours of the fever. About 80% (122/152) of all children 0-23 months visiting the facility reportedly slept under an ITN the previous night, and 80% (121/152) of their mothers knew the signs of malaria requiring immediate treatment. Some 51% of the mothers reported that they knew two danger signs of pneumonia and 20% (31/152) of the mothers had brought in the child because they thought the child might have pneumonia; 74% (23/31) of these children were treated with antibiotics. About 46% of mothers visiting the facility had attended at least four prenatal visits while pregnant with her youngest child. About 74% received a tetanus vaccine and 52% (79/152) received vitamin A. A high proportion of the mothers (86%) delivered in a health facility; 61% were examined by a health professional within three days of childbirth. Nonetheless, these figures do not necessarily imply facility births and postpartum care was provided by a professional nurse. About 29% had heard of fistula. Eighty-two percent of the mothers started breastfeeding their children during the first hour of birth. More than one-quarter, 26%, reported that the source of early breastfeeding information was a health care worker, followed by her mother (16%). Forty-one percent of the mothers reported practicing exclusive breastfeeding for her youngest child. Among the non-pregnant clients who were women of reproductive age (15-49 years) (n=231), 31% received FP counseling on the day of the interview. Half of the women (51%) reported that they practice FP, 32% received HIV counseling services, and 11% had received TB screening in the past at the facility. About 50% (117/231) reported that they had received their HIV test results. Although less than half (46%) of the women had received women’s health messages, only 3% reported that they had received SMS text messages on women’s health (in East Kasai, Kitanga, and West Kasai provinces). Among the pregnant women who were surveyed (n=117), 86% received prenatal care on the day of the interview. Fifty percent of the pregnant women reported receiving iron and folic acid; 57% received two doses of malaria prevention treatment; and 18% received TB screening. The majority of the pregnant women, 76%, were informed on the danger signs of pregnancy complications, including complications requiring immediate attention. A high proportion of the pregnant women surveyed, 89%, reported sleeping under an ITN the previous night. Some 73% (32/44) of pregnant women had received their HIV test results among those who had been tested at the same facility. About 21% of the partners of the pregnant women had been screened for HIV and these couples had received couples counseling. WASH intervention access and practice: About 44% (52/117) of pregnant women and 62% (144/231) of women of reproductive age (WRA) reported having access to a water source, 40% (47/117) of pregnant women and 39% (91/231) of WRA reported improved sanitary facility use, and about 36% (54/152) of mothers of children 0-23 months reported the use of soap for hand washing in the household. BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT 19 KEY INFORMANT INTERVIEW FINDINGS The 48 informants who responded to the question regarding health-seeking behaviors were comprised of health zone and facility managers and members of CODESAs (health committees). Some 67% of these informants believed that knowledge, attitudes, and practices to support health-seeking behaviors had increased in their health zones since IHP started, while 33% said that the health-seeking behaviors had remained the same. Many of the CODESA informants said the increase in health-seeking behaviors, including fewer people visiting traditional healers, was a direct result of the health communication outreach they had conducted in their communities, which was supported by IHP. Evaluation Question 4: Has health sector leadership and governance in the four targeted provinces improved? Under the second component of IHP—Other Health Systems—the project focuses on activities that create an enabling environment for strong health zones, with an emphasis on leadership and governance. IHP provides resources tied to performance to eliminate health system bottlenecks stemming from unaligned or absent policies, particularly at the provincial level. The findings on whether leadership and governance has improved in the four targeted provinces are the results of an analysis of qualitative data collected through key informant interviews with national, provincial, district, and health zone and facility managers in the four IHP provinces. As these informants work in management positions and receive direct support from IHP staff, they are expected to have well-informed views on leadership and governance, its status, and whether improvements have occurred as a result of IHP implementation. KEY INFORMANT INTERVIEW FINDINGS More than half of the 65 informants (55%), mostly from the MoH, stated that leadership and governance in the four targeted provinces had improved through IHP’s support. More than 40% of informants noted their appreciation for the high quality of the Leadership Development Program (LDP) training provided by IHP. Managers stated that the leadership training has helped them better understand the challenges they face in the health sector, formulate plans focusing on solutions to problems and challenges, and work together to overcome difficulties in meeting their objectives. Other informants, 37%, stated that leadership and governance in their district or zone was about the same as before IHP started. While the leadership training provided by IHP had been helpful to them, they were disappointed that it had not filtered down to the HC level. They believe nurses would benefit from LDP training, resulting in better management of HCs. Only 8% of informants stated that leadership and governance in their area had declined since IHP started. The reasons they gave included:  Insufficient IHP focus on capacity building  Lack of IHP interest in building the leadership of government authorities  IHP’s failure to establish a true partnership with government entities  IHP’s provision of inadequate funding for supervision and problems in disbursing funds BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT 20  The insufficiency of IHP resources provided per resident to solve health sector problems, hindering sector leadership and good governance Among the key informants interviewed, about 8% noted that leadership and governance is an ongoing process that requires daily attention. They said that determinations of achievements and improvements can be only be made at the end of the year, which they are working toward with hopes for success. About a third of health zone managers noted their dissatisfaction with IHP support for health zone supervision as a reason they did not think that leadership and governance has improved. Managers repeatedly described supervision as a bottleneck, since they are only able to make quarterly supervisory visits, rather than monthly visits. Nearly 40% of informants noted IHP’s inadequate funding for monthly supervisory visits, which can require long-distance travel, as well as IHP’s inability to date to provide vehicles or the promised motorbikes for these visits. (After data collection for this study, MSH reported that it is proceeding to deliver 112 motorbikes.) Some 10% of informants noted that IHP staff could have made greater efforts to organize joint supervisory visits to zones in cases where IHP field offices had an available vehicle. About 30% of informants stated that IHP should focus on improving health system management by taking into account the specific needs of the various health zones. Some informants voiced their belief that IHP does not prioritize the annual operating plans of the districts and zones, although the project is supposed to take health zone needs into account when drafting its own annual work plan. About 10% of informants stated that IHP is a very good project aligned with the PNDS in its design, but that some IHP staff members have confused their role in the field by trying to supplant MSP structures when the project should be strengthening the leadership of these structures. They remarked that the DRC is in transition and the provinces must consequently strengthen their autonomy and leadership within the health sector. Some 20% of informants stated that IHP should devote more resources to strengthening the capacity of provincial health authorities. They communicated their concerns regarding the ability of MSP staff on various levels to manage projects and mobilize resources after IHP has ended, stating that strengthening leadership in the health sector is IHP’s mission. Evaluation Question 5: What are the external factors that hamper IHP activities from delivering better results? OVERVIEW Overall, IHP encounters a wide range of contextual factors in DRC that hinder project implementation and negatively affect activities in a variety of ways, making the DRC environment a very difficult one in which to work and produce good results. These factors include decades of civil and political unrest, which continues in some provinces; the country’s large geographic size, the size of the four target provinces and their distance from the capital, Kinshasa; the fact that 80% of the population lives below the poverty line; the lack of financial and material resources in the health system and widespread supply chain breakdowns; and the population’s limited access to health care services, which are often poor in quality, especially in rural areas. It is important to note that regular electricity supply and running water are unavailable in many areas. BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT 21 KEY INFORMANT INTERVIEW FINDINGS Qualitative data collected through key informant interviews conducted during the evaluation provided a basis for the findings concerning the factors hampering IHP activities from delivering better results. Every factor hampering IHP activities mentioned by individual informants is not included in the following findings, only those that were most frequently cited. In addition, it was impractical to quantify the wide range of factors discussed by the informants. The respondents to this question were comprised as follows: 40% health zone managers, 40% hospital managers, 10% provincial and district managers, and 10% IHP and USAID staff members. IHP decision making, purchasing, and planning are too centralized in Kinshasa. Some 30% of key informants stated that IHP decision making is too centralized in Kinshasa, which is far away from the four targeted IHP provinces and where there is little understanding of needs in the field. Informants said that this factor is significant when emergency situations occur in the field—such as the cholera epidemic that occurred in Katanga earlier this year— when a district or health zone manager sought urgent support from a local IHP office to respond effectively to the crisis. Local IHP offices noted they cannot provide support unless and until IHP’s main office in Kinshasa makes the decision to provide resources. While IHP senior managers in Kinshasa acknowledged this lack of flexibility, they also voiced concerns about past issues with BC staff who did not follow MSH rules and regulations, with serious ramifications. IHP purchasing is centralized in Kinshasa, with protracted procurement processes and delays in decision making about purchasing and receiving supplies, including medications, medical equipment, and motorbikes needed for supervisory visits by district and health zone managers, as noted by informants. However, what might not be evident are the bottlenecks that are outside of IHP Kinshasa’s manageable control. About 10% of MSP staff members in the four provinces believe that IHP planning takes place in Kinshasa rather than at IHP BC supervisory offices in the field. These district and zone managers pointed to this centralization as the reason the project seems unable in their view to address on-the-ground health needs in a timely way. IHP support for health services is too broad. Some 25% of informants stated that IHP support is spread too broadly and the project is stretched thin, with IHP staff members trying to cover a wide array of health services and needs. As quoted by one of the informant: “IHP is covering too many aspects. They have too much to do to do it all properly.” Some viewed this issue as a problem in the project’s design; others saw it as mainly an implementation problem. About 10% of informants stated that there is no noticeable IHP impact on the local population because its coverage is so broad. According to 10% of informants, IHP should support fewer facilities and provide stronger support Conversely, informants in several areas noted that IHP is supposed to provide “widespread support”—that is, support for all health needs in the zones. About 10% of informants were dissatisfied with the project’s inability to meet all health needs identified in their zone, which they claimed has a negative impact on the zone’s performance results. Another objection to IHP’s real or apparent positioning in the four provinces was that the situation had reportedly prevented several zone managers from securing support from additional donors for needs IHP is supposed to, but is unable, to meet. They contended that BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT 22 some other donors will not provide funding to areas where IHP is said to be providing “widespread support.” There are problems supplying drugs. The principal benefit of IHP cited by about 50% of informants in the health sector and by CODESA members was the project’s supply of drugs. Key informants in some areas noted the lower prices of drugs supplied by IHP and, on some occasions, the project’s provision of free drugs. At the same time, informants identified several challenges with IHP-supplied drugs:  The range of drugs was seen as inadequate.  Deliveries have been irregular, especially during the project’s first two years.  Drugs have been delivered that were not ordered, and those ordered were not always delivered, including essential medications.  Some drugs had been delivered that expired in a month or two.  Supplies to keep the cold chain operational are inadequate in some zones. Regarding malaria—the disease all informants said was the most prevalent in their area—IHP does not supply the full range of medications complying with the national treatment protocol, including quinine. The lack of IHP’s ability to supply all medications needed to treat malaria was considered to be a significant project flaw by about 15% of informants. In some areas, when IHP has experienced drug delivery delays or has not supplied the full range of medications needed, informants said it has been necessary for drugs to be procured on the open market. “They give us drugs based on what they have, not on the diseases we have here.” “Irregularity of medications supplies, and the fact that what they provide does not correspond to our actual needs.” “Also, the selection of drugs is very limited and essential medications are not offered.” Sometimes malaria drugs can only be procured from non-certified vendors from other African countries, which may not contain enough active ingredients. Informants said these drugs can also be marked with false expiration dates. Other drug-delivery problems that were mentioned include the fact that deliveries during the rainy season are impossible in some areas, and that drugs are sometimes held too long at the health zone’s central supply, which results in late delivery. A few district managers commented on lengthy delays of incoming drugs in customs processing—a very lengthy delay (close to one year) could be alleviated by involving the DRC government in facilitating customs approval. Even though there is greater regularity in drug deliveries in the project’s third year and IHP has overcome some supply problems, drug supplies remain a continuing concern on all levels at MSP offices. Informants shared their concerns about a sustainable drug supply after IHP ends, even though health zone managers have authorized that 30% of drug expenses be set aside for supplies after the project’s completion. BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT 23 Geographic access and security problems affect IHP. Geographic access is the biggest challenge some districts and zones face due to the very limited or, in some areas, almost complete lack of available transportation. Supervisory visits to each health zone are supposed to be made on a monthly basis. Yet limited transportation availability, especially where health zones are large and far from district offices, means that some zones are visited only quarterly for supervisory visits, and others not at all during the rainy season. “Geographical access is our biggest challenge. We oversee 8 health zones and have only one vehicle for supervision, so health zone access is difficult.” “The obstacles to treatment are geographic in nature, because the health centers are far from the general hospital.” “We have many challenges: one is access to the remote health zones reachable only by waterways, a huge challenge!” According to informants, geographic access affects IHP in a variety of ways:  The DRC is a vast country, and distances are great between IHP’s main office in Kinshasa in the far west and the four targeted provinces.  Some health zones in the districts are very large, especially in Katanga Province.  Roads are extremely poor in most areas where the project is implemented.  Transportation availability is severely limited in rural areas and fuel is expensive, with limited supplies of both available.  Some health zones are inaccessible during the rainy season.  There are ongoing security issues in some areas due to rebel activities, which curtail access. IHP’s lack of provision for transportation except through a limited amount of monthly funding for fuel—which is expensive and can be hard to find—is a serious issue for informants. It has a major impact on the ability of district and zone managers to supervise health facilities and address problems in a timely manner. Because supervision and strengthening of health zone management is one of IHP’s priorities, its limited support to health zones for transportation is seen by many as a prominent project weakness. IHP’s inability to date to supply motorbikes was repeatedly mentioned by informants. A few informants said access to health zones where rebel activity is occurring can be cut off for many months at a time. Such situations prevent or limit supervision and negatively affect the capacity of health facilities to deliver services to the local population. IHP funding support is too low. Health finance is a priority area of support for IHP under Component 2, Other Health Systems. The fact that IHP’s funding support is too low is recognized across the four targeted provinces and by the project’s staff and its leadership. Informant health zone managers provided various examples of the limited funding provided under the project: “IHP is supporting supervision through funding, but it’s not enough to meet the supervision needs. We need $1,350 per month, and they only give $250.” “We receive $300 monthly for operations, but we need $1,500 monthly for operations, and our biggest need is for transportation funding.” BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT 24 “IHP provides $750 a month for operations and activities at the provincial level, not nearly enough to make a difference.” About 40% of managers stated that the level of funding the IHP provides for operations and supervision prevents the fulfillment of the leadership and managerial roles expected of them and their offices. A few managers said insufficient IHP funding means that provinces seek other resources that will allow them to meet all their obligations. The team was told that some zones not included in IHP receive more substantial support from other donors to subsidize the costs of health care for community members, resulting in greater access to health care in these zones. IHP staff and leadership are aware of the funding issue, with several stating that “The resources that have been implemented (+/- $2.50 per inhabitant) are insufficient to meet expectations.” All informants stated their belief that IHP should increase the funding it provides to the various levels of the health sector to have a bigger impact—or, in some cases, any impact—on health service provision and access. IHP has differing priorities from districts and zones. About 10% of informants felt that IHP has different priorities than the districts and health zones the project was designed to support. According to some informants, IHP is too directive and has its own priorities, which some IHP staff has emphasized in lieu of district or zone priorities. According to district and zone managers: “With IHP, they direct everything and tell you what you have to do. They have different priorities, and we lose focus on what is most important.” “IHP should consult its base to understand the high-priority needs, because they bring things that we do not need; the support is top-down.” Some 15% of managers view IHP as having intervention objectives that differ from those of some of the districts and zones. This issue was considered serious enough in one district that IHP had to stop work for five months until the situation was sorted out and a more supportive relationship with the district was established. About 5% of informants stated that IHP expends a great deal of effort in family planning activities while other health problems that are important to the district seem to receive insufficient attention. A few IHP staff members noted that family planning is a high priority for USAID, which is seen as an important reason for prioritizing this intervention within IHP. “A great deal of effort is being put for the family planning activities, while other health problems that are important to the district seem not to receive sufficient attention.” While these feelings were not universal among informants, quite a few felt that IHP was not responsive enough to the priority needs identified by districts and zones. About 30% of informants commented that IHP priorities should include the provision of support and drug supplies for the most prevalent diseases in their health zone, including malaria, bronchitis, pneumonia, septicemia, diarrheal diseases, anemia, pulmonary tuberculosis, and HIV. IHP rehabilitation has been slow. Under IHP Component 2, Other Health Systems, one of the six priority areas is construction/rehabilitation of infrastructure. Rehabilitation is a joint effort involving the health facilities, communities, and IHP, with no direct control by IHP to ensure timely contributions BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT 25 from facilities or community members. About 30% of informants felt that rehabilitation of infrastructure is a weak area for IHP, with too little attention given to this aspect of the project to date. Only a few informants mentioned their thanks to IHP for the useful rehabilitation work that had been undertaken by the project at a facility. Some 10% of informants were unaware of any rehabilitation work that has been done by IHP. On the other hand, while some informants mentioned examples of rehabilitation that IHP was supporting in their zone or at a facility, several stated that the work has taken a long time to start or finish. Others said “We were told that three structures would be rehabilitated per year, and they have started on only one facility in the third project year of the three health zones targeted. People don’t think that IHP will do rehabilitation.” A number of community members in various zones reported that rehabilitation of one or more health structures had been promised by IHP and there had been a scoping visit to one or more facilities, but nothing had happened afterwards. Some informants and community members are skeptical that IHP will actually undertake rehabilitation because of the lengthy delays associated with it. A few informants commented on the low quality of the reconstruction that IHP had supported. Three IHP field offices also reported local dissatisfaction with the lack of rehabilitation progress. Social challenges affect IHP implementation. Cultural and religious practices influence beliefs about health and health care attitudes among some members of the population in the four provinces targeted by IHP. Among the social challenges that informants cited was the impact that behavioral practices have on access to health services. Gender equality is not the norm in the DRC. For example, a few informants said many women do not seek health care services unless they have permission from their husbands. The lack of gender equality also affects the attitudes of some health-care providers, who may not respect patients’ rights the way they should, as noted by an informant. Another gender-related issue mentioned to the team is that certain foods are considered to be taboo for children and pregnant women to eat in some cultures, which has a major impact on their nutritional status. As a result, malnutrition can be a problem due to local social norms even in areas where there is enough food available. A significant challenge in some cultures and areas in the DRC noted by a few informants is that having many children is considered to be a sign of wealth. They said that raising awareness on family planning and limiting births and increasing access to family planning services can be difficult when health care providers are faced with this attitude, despite the very high maternal mortality rate in the DRC (670 per 100,000 live births, World Health Organization, 2011). Religious beliefs can also present challenges to health care access. As stated by an informant “Anemic children who were previously taken to prayer rooms to be healed are now taken to the hospital. Before these educational efforts by community liaisons… some parents took their anemic children to prayer rooms with the hope of having them healed through prayer.” About 5% of informants noted that belief in the power of traditional medicine continues to block access to health care in some communities, as do revivalist churches, which can have a substantial following in communities. Another challenge mentioned in some areas was the belief that children with bloated stomachs have had spells cast on them; as a result, many parents have not BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT 26 understood the need to access treatment for these children, who actually might be suffering from intestinal worms. Evaluation Question 6: How is IHP perceived and valued? KEY INFORMANT INTERVIEW FINDINGS The following findings on how IHP is perceived and valued are derived from the key informant interview discussions conducted with district, zone, and facility managers, IHP managers, and CODESA members in the four provinces. The data are qualitative, based on opinions of and experiences with IHP. The most frequent, dominant, or significant themes arising in the responses related to how IHP is perceived and valued are described, rather than the full range of informants’ responses on their perceptions of IHP and how they value the project. Project Benefits and Strengths Some 50% of informants emphasized that a major benefit of IHP was the project’s supply of medications and some medical supplies in the four provinces, despite complaints about irregular deliveries and the limited range of medications. IHP-supplied medications have saved lives. About half of the chief physicians pointed out they would be unable to provide good care without these necessary medications. About 10% of zone managers and CODESA members commended IHP for providing drugs at minimal or no cost, “allowing the poorest of the poor to get them.” About 5% of informants lauded IHP for the improvements it has made in community health overall and specific diseases. According to one CODESA member, “The biggest benefit from the IHP support is that the health of the people has improved!” CODESA members in one zone mentioned that after IHP provided TB training to members, more people sought medications and health care for TB. Another example is that diarrheal diseases have nearly disappeared in some health areas as a result of WASH activities that IHP has supported on the community level. A district manager noted that IHP-supported WASH work is a major achievement and has strengthened community access to potable water. About 15% of informants noted IHP’s support for malaria prevention through the provision of ITNs; in addition, several health managers spoke appreciatively of IHP’s support for malaria treatment through the procurement of medications, including artemisinin-based combination therapy (ACT). Malaria, diarrheal diseases, and TB are among the most prevalent diseases in the four targeted provinces, as noted by health zone managers and CODESA informants, who appreciated IHP’s work in tackling these diseases. The multitude of trainings that IHP has provided to managers, physicians, and CODESA members was viewed as a real strength of the project. The leadership (LDP) training was praised widely by managers, who feel it has provided them with a solution orientation and has enabled greater ownership. According to one zone manager, “Before the training, we could not do deep analysis of problems and tended to blame others. But the training enabled us to take another approach. Now if we have a problem, we take ownership and try to find a solution.” BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT 27 The FOSACOF (fully functional service delivery point) training also was valued highly by 20% of managers. According to district and zone managers, the quality of services has improved at health facilities where managers and chief physicians have received FOSACOF training. Some 10% of zone managers also considered the training that IHP has provided in support of the Expanded Programme on Immunization (EPI) as exceptional. Moreover, informants viewed trainings by the project in reproductive health, FP, nutrition, and hygiene as important for CODESA members in mobilizing health-seeking behaviors among community members. Another type of IHP-provided training valued by 5% of zone and facility managers was focused on caesarean sections, important due to the extremely high maternal mortality rate in the DRC. Other aspects of IHP are valued even when difficulties have been noted. An example is the project’s support and alignment with the PNDS and its facilitation of activities important to the MSP, specifically immunization and supplying drugs. “IHP is a support and a relief for us,” explained one zone manager regarding the project’s supply of medications and medical supplies and some rehabilitation work that had been done. IHP’s field offices (BCs) are generally valued in the provinces because IHP staff members facilitate communications between government authorities and project management in Kinshasa, according to district and zone managers. Also IHP staff members understand the difficulties the zones face. One district manager’s comments about IHP exemplifies this fact: “They are technicians who have the same competencies as us, and we support health zones together.” Thus, in some areas, IHP is considered to be a true partner. Project Weaknesses and the Need for Improvement A common feeling about IHP expressed by about 75% of informants was that it is a good project that needs improvement. Many said that when the project first started, expectations for it were very high, both nationally and in the four targeted provinces. Others voiced their hope that improvements will be made during the project’s remaining two years to provide greater support to the health sector and more benefits to community members in the four provinces. Informants cited the need for improvements that include the following:  Delivering additional staff capacity building and scaling up of resources  Providing more resource support at the zone level  Giving more support to the health center managers through training  Complying with the medication support schedule  Providing direct support to hospitals  Providing community liaisons with more training and with health materials for local distribution About 40% of MSP staff expressed the feeling that IHP has not lived up to its promises regarding the range of support it would provide. About 54% of MSP staff implied that the project has had more than the normal number of problems and there have been too many delays in funding and deliveries. These occurrences have fueled a perception by about 5% of respondents that IHP staff members “are not achievers” even though they may have good intentions. A perception by about 5% was that because of the range of problems the project has BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT 28 had, IHP does not really contribute to the national health policy, though it was designed to do so. Another issue raised by about 20%, mostly CODESA members but also zone managers, was that the project has little visibility among community members despite the support it provides to CODESAs, which ranges from training to health materials in some areas. “The public does not know or sense that IHP is here,” stated one CODESA member. The team noted that very few IHP signs are posted in the areas where IHP works. Also, the lack of IHP provision of health promotional materials, project T-shirts and caps, etc., to CODESAs was noted as detrimental to project awareness and wider visibility; although one informant argued that the high visibility of IHP as a project is not a prerequisite to its ultimate success. The lack of any other donor support in some areas in the four provinces where IHP is implemented makes the project appreciated all the more by these zone managers and especially by the CODESAs, even if there is not complete satisfaction with IHP so far. About 90% of all informants, excluding IHP staff, noted that IHP will provide more support in the next two years, resulting in strengthened leadership in the health sector and better health outcomes in the communities where IHP is working. BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT 29 V. CONCLUSIONS EVALUATION QUESTION 1 To what extent has the project improved access to and availability of MPA-plus services and products in the targeted health zones? Conclusions USAID/DRC anticipated at the project’s start that 80% of the HCs in the 80 health zones targeted by IHP would offer the MPA-plus package of health services and activities by the end of the project’s fifth year. It is important to note that IHP is not funded by USAID/DRC to support all of the more than 50 MPA-plus services and activities in the 80 targeted health zones and communities. No facility among the 96 facilities surveyed in the evaluation provided a full range of MPA-plus services. This evaluation has taken place in the third year of the project, and no facility baseline existed at the project’s start to document the range of MPA-plus services that were available at that time in facilities in the 80 health zones targeted for support. Thus there are no data available to compare the MPA-plus service availability findings in this evaluation with previous data to show the extent to which IHP has improved the availability and access of MPA-plus services. It is unrealistic to expect 80% of IHP’s health facilities to achieve a full range of MPA-plus services by the end of the project. Both the breadth of the target population (~1,600 facilities in total) and the depth of the MPA-plus services (some 50 activities) are overly ambitious given the existing status of the health system, logistical constraints, and implementation costs. EVALUATION QUESTION 2 Has the project improved the quality of key family services in targeted health zones? Conclusion The package of IHP activities focuses on many of the key pre-determinates of quality of care based on international standards and evidence. The project’s efforts to improve the quality of services have been recognized by 72% of the provincial, district, and zone managers in the four targeted provinces based on its provision of training, monitoring, and drug supplies. However, according to the available data, which do not include a baseline at IHP’s start to gauge service quality—and because of the varying findings from the evaluation’s facility survey related to service quality, including the dilapidated state of health care infrastructure, the lack of essential medical equipment, and regular stock-outs of drugs—it was difficult for the team to determine whether the IHP has improved key family services across the targeted health zones. This evaluation question will be answered in the final evaluation report by comparing results of the quantitative surveys at baseline and final evaluation and triangulated with qualitative data obtained during final evaluation. BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT 30 EVALUATION QUESTION 3 Have knowledge, attitudes, and practices to support health-seeking behaviors increased in targeted health zones? Conclusion In the absence of any baseline information for comparison, the team concluded that it is not possible at this juncture to assess the level of improvement in knowledge, attitudes, and practices to support health-seeking behaviors in the four IHP-targeted provinces. The results from health-seeking behavior indicators obtained by client exit interviews and key informants, including zone and facility managers and CODESA members stating the IHP has increased health-seeking behaviors in their zones, show some evidence that IHP efforts have had a positive influence on increasing health-seeking behaviors in the targeted zones. Yet, despite the training and involvement of CODESA members and their community outreach, educational activities for health are still low. The client exit survey showed varying levels of mothers' knowledge on major childhood diseases such as malaria, diarrhea, and pneumonia. Compared to the 2007 DRC Demographic and Health Survey (DHS) data, there are relatively high levels of practices such as family planning, initiation of breastfeeding in the first hour of birth, exclusive breastfeeding until the age of 6 months, and child vaccinations before the first birthday. Baseline household survey conducted by IHP in 2011 showed lower levels of knowledge and practices for key family health interventions except for practices such as exclusive breastfeeding until the age of 6 months, child vaccinations (measles and BCG) before the first birthday, vitamin A to children age 0-23 months and mother visiting antenatal care service at least four times when pregnant with their youngest child. However, data from the sample from which data were obtained from the DHS or IHP baseline household survey is not similar enough to the current sample of women who participated in this evaluation. This evaluation question will be answered in the final evaluation report by comparing results of the quantitative surveys at baseline and final evaluation and triangulated with qualitative data obtained during final evaluation. EVALUATION QUESTION 4 Has the health sector leadership and governance in the four targeted provinces improved? Conclusions Better supervision of the 80 targeted health zones is a priority for IHP support. District and zone managers struggle to conduct monthly supervisory visits based on the low level of funds allocated for this activity, about 20% of what is needed. The lack of IHP provision of the promised motorcycles to the zones has been a serious hurdle to conducting monthly supervisory visits. Fostering supportive relationships with provincial, district, and zone managers is a high priority for IHP BC staff. IHP has provided important training on leadership and governance, which is highly regarded by participants, but it has not yet been provided to all the zones nor has it filtered down to the health center level. Lack of resources, including funding, is affecting regular facility supervision BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT 31 activities by district and zone managers. Fostering supportive relationships with provincial, district, and zone managers is a high priority for IHP supervisory area office staff. The annual operating plans of the districts and zones are supposed to be formulated jointly with IHP and other partners, but the perception of field staff is that the project’s own planning sometimes seems to supersede annual operational planning at the district and zone levels. However, in the absence of any baseline information to compare with, the team concluded that it is not possible at this juncture to assess improvement in leadership and governance from the health sector in the targeted provinces. EVALUATION QUESTION 5 What are the external factors that hamper IHP activities from delivering better results? Conclusions Implementation of IHP is fraught with challenges. Key external factors that hamper IHP activities include the following:  Funding for the provinces, districts, and zones is well below the real costs associated with their operations, making them ill-equipped to provide the wide range of health services needed by local communities. As a result, the majority of the 80 health zones in which IHP operates are poorly equipped to deliver the wide range of MPA-plus services needed by local communities. IHP is operating in resource-constrained environments and lacks sufficient resources itself to fill the gaps.  Decision making is centralized in Kinshasa and is perceived as a barrier by field-based key informants. At the local level, this centralization is an impeding factor in improving the local leadership and governance supporting health service provision in the four targeted provinces. Long delays due to centralized decision making and purchasing and protracted procurement processes are problems recognized both within and outside the project. However, weak systems for accountability make it difficult to decentralize decision making. IHP Kinshasa’s decision to re-examine this aspect of program implementation was rational.  IHP has encountered a number of logistical problems to providing the range of drugs it has committed to supplying and ensuring the regularity of drug deliveries, with many of the problems outside the manageable control of MSH and its partners. Nevertheless, recent data suggest an improvement in the functioning of the supply chain.  The perception in the field is that IHP does not pay enough attention to the most prevalent diseases in the zones. Despite the fact that the foundation of MPA-plus is the MSP’s health priorities, zone and facility managers and community members are concerned with the prevention and treatment of the most prevalent diseases in their areas and look to IHP to address them.  Lengthy delays in the promised rehabilitation of infrastructure has been a weak point for IHP. It seems unlikely that IHP will be able to complete all planned rehabilitation during its life of project. Rehabilitation is a joint effort involving the health facilities, communities, and IHP. IHP cannot control the timely contribution of input from health facilities and the community. BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT 32  Some cultural and religious beliefs in the DRC, paired with gender practices and inequality, are not supportive of positive health-seeking behaviors and may serve as an impediment to health access. EVALUATION QUESTION 6 How is the IHP perceived and valued? Conclusion IHP is an important project to the MSP and is seen as one of the largest projects in the country. The most common perception regarding IHP is that it is a good project that needs improvement. The project is valued in various ways, ranging from the drugs it has supplied to the leadership training it has provided. The multitude of trainings that IHP has provided to managers, physicians, and CODESA members was viewed as a real strength for the project. IHP’s field offices (BCs) are generally valued in the provinces as facilitators in communications between government authorities and project management in Kinshasa. BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT 33 VI. RECOMMENDATIONS Evaluation Question 1: To what extent has the project improved access to and availability of MPA-plus and CPA-plus services and products in the targeted health zones? Recommendation for USAID/DRC Revisit project priorities and targets: IHP has not been funded adequately to support the full range of MPA-plus services in the 80 targeted health zones. USAID should convene with IHP and others to revisit project priorities and targets. The depth of the MPA-plus package should be reconsidered. USAID should also consider the degree to which it supports health facility rehabilitation, giving the highest priority to the MSP’s “red” facilities classified as the least functional in the provision of services. Recommendations for IHP Strengthen evidence–based interventions to reduce maternal mortality: Based on DRC’s high maternal mortality rate, IHP BC managers with -one and HC managers should discuss the need for developing and strengthening family planning interventions, skill-building trainings for health providers attending pregnant women, and efficient referral systems for complicated or emergency obstetric cases. Health providers should be able to recognize complicated emergency obstetric conditions, provide primary-level emergency treatment, and referral to higher centers. CHWs and TBAs should be trained to help pregnant women in the community by encouraging positive health-seeking behaviors and referring women who have complications to the nearest health facility with a skilled birth attendant. Nurses should be trained and encouraged to perform deliveries in the HCs rather than lay birth attendants who are not trained. This transition is likely to take time in settings where the nurses lack obstetric skills. Improve provision of ARVs at all PMTCT sites: While not all health facilities in the 80 zones are PMTCT sites, IHP should consider providing ARVs for PMTCT and co-trimoxazole for HIV-positive pregnant women at all PMTCT sites along with HIV testing. Improve availability of routine growth and monitoring services for children under 5: IHP BC managers should discuss the relatively low rate of growth development and monitoring of children under 5 with zone managers, who should follow up with HC managers so this activity will become routine. There is a need for providers to place an increased focus on nutritional counseling for mothers of children under 5. Improve availability of nutrition rehabilitation services: IHP should improve its current level of nutrition interventions based on allocated funding. Prioritize delivering more ITNs for pregnant women and children under 2: IHP should prioritize delivering more ITNs for pregnant women and children under 2 in the targeted zones if this activity is not already under way, whether the ITNs are purchased by IHP itself or made available by other partners. Implement GBV training in all BCs: Training on GBV should be added to the IHP training curriculum for health care providers in all BCs. BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT 34 Evaluation Question 2: Has the project improved the quality of key family services in targeted health zones? Recommendation for IHP Continue focusing on the quality of key family services by applying the World Health Organization’s (WHO) standards: IHP should continue its strong focus on service quality, which may become the most important legacy of the project. IHP should continue its training programs focusing on standards of care and promote the use of service quality improvement tools based on latest WHO protocols at supported facilities.). Evaluation Question 3: Have knowledge, attitudes, and practices to support health-seeking behaviors increased in targeted health zones? Recommendation for IHP Continue community mobilization activities through CODESA: IHP should continue with CODESA capacity building and include more CHW training over the next two years, with a focus on FP, MNCH, nutrition, malaria, and WASH to promote health-seeking behaviors and support the increased use of key family health services provided by health facilities. Evaluation Question 4: Has the health sector leadership and governance in the four targeted provinces improved? Recommendations for IHP Scale-up leadership and governance support to zone offices and health centers: IHP’s support for leadership and governance should be scaled up. IHP BC office managers should suggest the types of management training that would be most beneficial to managers, based on the management problems they have observed in the field and inputs from zone managers on the management issues for which they could use more training. Providing the LDP training to more facility-based nurses should be a priority to improve leadership and governance at the HC level. Increase funding support for facility supervision: IHP should increase the monthly funding level to zones for supervision. Delivering the motorcycles to the zones needed for supervision at the earliest opportunity should be a high priority for IHP. Where transportation for supervisory visits continues to be a problem, IHP BC offices should see whether an IHP vehicle could be made available, when possible, for IHP to conduct joint supervisory visits with district or zone managers so they occur more frequently than on a quarterly basis. Ensure greater transparency and timely communication in developing district/health zone annual operational plans: IHP BC managers should make special efforts to cement positive, supportive relationships with provincial, district, and zone managers. IHP staff should embrace more of a service-oriented, problem-solving mentality through greater transparency and timely communication about what the project can and cannot support in the annual operating plans of districts and health zones. BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT 35 Evaluation Question 5. What are the external factors that hamper IHP activities from delivering better results? Recommendations for USAID/DRC Reevaluate interventions based on public health priorities: In collaboration with USAID and local stakeholders, IHP should determine which disease priorities it is best positioned to support, while continuing its special focus on maternal, newborn, and child health. Determine priority areas and support for facility rehabilitation: USAID should determine if supporting additional rehabilitation will continue to be a priority for IHP. If so, a plan should be developed to rehabilitate the highest-priority structures in the next two years. Potentially, the funding allocated for rehabilitation could be used for other project activities that may be higher priorities for IHP support. This action could help IHP address more urgent needs than rehabilitating all the facilities previously planned by the project, even if some rehabilitation work will be deemed as important to continue. Recommendations for USAID/DRC and IHP Review the feasibility of devolving some decision making including limited procurements during emergency situations: MSH and USAID/DRC should examine whether the centralization of decision making and purchasing in Kinshasa is essential. On a case￾by-case basis, consider devolving some of these functions with the necessary funds allocated to BC offices with a proven track record of adherence to MSH rules and regulations. Funding levels available for quick field access do not have to be large and could be extremely helpful in the case of emergencies, such as cholera or malaria epidemics. Allocating some decision making to IHP field offices would empower IHP staff members and enable them to support some needs in the health zones more rapidly, fostering their relationships with district and zone managers. Ensure regular supplies of drugs to facilities: IHP should work with MSP and other relevant government entities to ensure that drug deliveries continue to be regular, that drug procurement problems are solved, and that its list of drugs is reviewed for possible changes to better meet drug supply needs in the targeted zones, noting the differing needs of HCs and hospitals. USAID should provide support in obtaining clearances from the Government of DRC for the import of necessary drugs and supplies. Improve facility operations management: USAID/DRC and IHP management should assess if more IHP funding could be reallocated for provincial, district, and zone operations during the project’s last two years to help managers fulfill their respective roles in facility operations management, enable standardization of facility operations activities, and increase the overall quality of service provision. Improve availability of community education materials for CODESA members: To help increase health-seeking behaviors, USAID/DRC and IHP management should increase its attention to the need for health education materials for CODESA members to use for outreach to community members by reprinting and distributing materials developed by the MSP that are relevant to the local context and languages. BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT 36 Evaluation Question 6: How is the IHP perceived and valued? Recommendation for USAID/DRC and IHP Make mid-course corrections based on recommendations: IHP should make mid￾course corrections based on the previous recommendations by weighing the recommendations as a whole against available funding and resources and the project’s redefined priorities and targets. Insert photograph representing the project being evaluated to replace this instruction and fill this text box. Evaluation of the Integrated Health Project in the Democratic Republic of Congo Annex Volume September 2013 This publication was produced at the request of the United States Agency for International Development. It was prepared independently by International Business & Technical Consultants, Inc. (IBTCI). It was authored by Mary O’Grady, Swati Sadaphal, Jean-Lambert Mandjo, Kapil Ahmed, and Annette Bongiovanni. BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES EVALUATION OF THE INTEGRATED HEALTH PROJECT IN THE DEMOCRATIC REPUBLIC OF CONGO September 30, 2013 AID-660-M-13-00001/GS-10f-0309P Cover Photo Credit: Annette Bongiovanni 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. BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES TABLE OF CONTENTS ANNEX A. STATEMENT OF WORK 1 ANNEX B. KEY INFORMANT INTERVIEW GUIDES 8 ANNEX C. QUANTITATIVE DATA ANALYSIS PLAN 14 ANNEX D. DATA COLLECTION SAMPLING PROCEDURE 23 ANNEX E. QUALITATIVE DATA MATRIX 26 ANNEX F. QUANTITATIVE ANALYSIS RESULTS: AVAILABILITY OF MPA￾PLUS HEALTH SERVICES 34 ANNEX G. QUANTITATIVE ANALYSIS RESULTS: QUALITY OF HEALTH CARE SERVICES 42 ANNEX H. QUANTITATIVE ANALYSIS RESULTS: KNOWLEDGE, ATTITUDES, AND PRACTICES 47 ANNEX I. CLIENT EXIT SURVEY QUESTIONNAIRE 49 ANNEX J. HEALTH FACILITIES SURVEY QUESTIONNAIRE 71 ANNEX K. LIST OF HEALTH FACILITIES SURVEYED 105 ANNEX L. LIST OF PERSONS INTERVIEWED 107 ANNEX M. LIST OF SUPERVISORS, DATA COLLECTORS, AND INTERVIEWERS 109 ANNEX N. LIST OF DOCUMENTS REVIEWED 112 ANNEX O. MPA-PLUS SERVICES 113 ANNEX P. IHP FIELD IMPLEMENTATION PLAN 116 ANNEX Q. TRAINING MANUAL FOR DATA COLLECTION 122 BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 1 ANNEX A. STATEMENT OF WORK Integrated Health Project: Performance Evaluation I. Purpose In September 2010, USAID/DRC awarded the five-year $139,767,129 Integrated Health Project (IHP), Cooperative Agreement #AID‐OAA‐A‐10‐00054, to Management Sciences for Health (MSH) and its partners—International Rescue Committee and Overseas Strategic Consulting Ltd. The purpose of this solicitation is to identify a contractor to carry out multiple external evaluations of IHP. USAID/DRC intends to conduct a performance evaluation of IHP. The performance evaluation will assess whether results of the project are being achieved as planned. The evaluation responds to USAID‘s new evaluation policy released in February 2011. The design and implementation of the evaluation will be closely coordinated with USAID/DRC and MSH. II. Background and Context 1. Country Context The Democratic Republic of Congo (DRC) currently has one of the lowest gross national incomes per capita in the world ($190).1 An estimated 80 percent of the population lives below the poverty line and half live in extreme poverty. The country has suffered a long decline from relative prosperity to complete free‐fall that accelerated in the 1990s during the decade of conflict that accompanied the collapse of the former Zaire. DRC was ranked 187 out of 187 countries in the 2011 Human Development Index. Now, stakeholders are cautiously optimistic that the worst is over; recently, multiple donors have demonstrated renewed interest, particularly in supporting development of the health sector. Until 1990, DRC’s health system was well known in Africa for its network of health facilities, quality of physicians, and primary health care system. This was due, in part, to significant support from USAID and faith based entities (Protestant and Catholic missionaries). The U.S. Government invested heavily in the training of health workers, including the establishment of a School of Public Health in Kinshasa. However, war and mismanagement led to significant backsliding in the health sector. The health system now lacks financial and material resources and supply chain breakdowns are widespread, particularly in remote areas. This leaves a majority of the country with limited access to often poor quality health care services. Access to primary health care remains a challenge, with 70 to 80 percent of the population having difficult or no access to health care or who do not utilize the care available. Access varies widely by province and health zone, with urban areas generally better served than rural. High population growth impedes economic growth, and threatens to undo future gains in the social services sector. Projections of population growth indicate that the DRC’s population will more than double by the year 2050, from the current estimate of 68 million to nearly 147 1 World Development Indicators Database: World Bank, December 2011. BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 2 million.2 This expanding population will exert increased pressure on the country’s resources and communities and will present dramatic challenges to provide and deliver basic services. Before 1990, USAID‐supported project areas experienced relatively high rates of family planning. The contraceptive prevalence rate (CPR) has fallen dramatically in the two decades since, and the country now has one of the highest total fertility rates (TFRs) and one of the lowest CPRs in the world. Against this background of pressing social needs, the Government of DRC (GDRC) will be challenged to demonstrate tangible progress in development and in rebuilding basic health services. 2. Integrated Health Project 2.1 Integrated Health Project Overview The five‐year USAID‐funded IHP supports the National Health Development Program (PNDS) of the DRC. The project’s goal is to improve the enabling environment for, and increase the availability and use of, high‐impact services, products, and practices for family planning; maternal, newborn, and child health; nutrition, malaria, and tuberculosis; neglected tropical diseases; HIV; and water/sanitation/hygiene in the target health zones. The project has two components. Through IHP Component 1, Services, IHP is supporting the first strategic focus of the PNDS: health zone strengthening. Component 2, Other Health Systems, corresponds to the second PNDS strategic pillar, support for health zone strengthening in six priority areas: human resource development; pharmaceutical management; health finance; construction/rehabilitation of infrastructure; equipment and new technologies; and improved health system management. Component 1 strengthens health zones’ capacity to deliver services by addressing both the supply and demand sides of services. Under Component 2, Health Systems, IHP is focusing on activities that create the enabling environment for strong health zones, with particular emphasis on leadership and governance and the provision of resources 2 World Development Indicators Database: World Bank December 2010. BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 3 tied to performance to eliminate health system bottlenecks stemming from unaligned or absent policies, particularly at the provincial level. The project is designed to create better conditions for, and increase the availability and use of, high impact health services, products, and practices. The project works in 80 target health zones in four provinces (East Kasai, West Kasai, Katanga, and South Kivu). At the end of the five‐year IHP life of project it is anticipated that 80 percent of target health centers and general referral hospitals will offer the minimum package of health service activities‐plus and complementary package of health service activities‐plus (MPA‐plus and CPA‐ plus).3 Many bilateral and multinational donors, as well as faith‐based (FBOs) and nongovernmental organizations (NGOs), are providing support to implement MPA/CPA‐plus, as well as technical assistance for specialized health systems strengthening interventions at all levels. Under IHP, MSH builds on this investment through service delivery contracts with providers and the Ministry of Health (MOH), ensuring they receive training, medical equipment and access to essential medicines and other health commodities. 2.2 IHP Results Framework 3 The minimum package of health service activities‐plus and complementary package of services‐plus are found in Annex B. BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 4 2.3 Project Approach and Implementation The overarching technical strategy used by IHP to integrate activities across health system sectors, levels, and geography is people‐centered health systems strengthening, presented in Figure 1. At the heart of the strategy is outreach to providers, health authorities, community organizations, and families with evidence‐based techniques they can use to impact the health system in ways they experience as meaningful and sustainable. IHP builds human capacity to lead and manage for health results, whether in the public, civil society, or private sector. Two of the evidence‐based techniques scaled up under the strategy are: leadership and management training and the Fully Functional Service Delivery Point (FOSACOF) service delivery model. Figure A-1: Building People‐Centered Leadership and Management Capacity As shown in Figure 1, interactions between and among health stakeholders—the government, personnel in health sector subsystems, clients, communities—play a critical role in overall system performance and the ultimate health status of citizens. IHP tailored a Leadership Development Program (LDP) for participants with major roles in HZ strengthening: provincial planning authorities, health zone management teams, facility management teams, community organizations, patient groups, and so on. III. Existing Information The following background documents are included in the SOW as annexes: Project health zone data (Annex A) Minimum package of health service activities‐plus and complementary package (Annex B) USAID Evaluation Policy4 4http://transition.usaid.gov/evaluation/USAIDEvaluationPolicy.pdf BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 5 USAID/DRC and IHP will provide the successful contractor with a package of briefing materials upon award, including: Detailed Project Description Project quarterly and annual reports Project Performance Monitoring Plan Report on the first part of IHP’s Performance baseline survey, a population‐based study on Knowledge & Practices and Coverage of key IHP performance indicators, conducted by MSH in May 2011 (IHP Part I baseline) IV. Evaluation Rationale 1. Performance Evaluation Rationale The performance evaluation will help USAID/DRC determine what components and project aspects are working well and why, and which constraints the project faces, and to make modifications and midcourse corrections, if necessary. As part of IHP’s evaluation strategy, MSH and its partners conducted the first part of a baseline study (IHP Part I Baseline) on knowledge, practices, and coverage of key health areas in May 2011. The study used a cross‐ sectional population‐based survey to assess the health conditions of young children, their mothers, and women of reproductive age living in IHP target areas. The survey used the Lot Quality Assurance Sampling (LQAS) methodology with a parallel sampling strategy. A second baseline study (IHP Part II Baseline) of targeted facilities is required to elicit and analyze information on the provision and quality of key health services. The study will provide quantitative and qualitative baseline data on access, availability, utilization, and quality of a minimum package of activities/complementary package of activities at the health centers and general referral hospitals. USAID fully recognizes that the IHP Part II Baseline will have been collected well into project implementation and while this is not ideal, it will still offer data to compare to an end line survey. As part of the performance evaluation the contractor will carry out a baseline (facilities), mid‐term, and final evaluation according to the following schedule: IHP Performance Evaluation Schedule IHP Part I Baseline (completed) May 2011 IHP Part II Baseline December 2012 IHP Mid‐Term Evaluation June 2013 IHP Final Performance Evaluation June 2015 V. Objectives of the Evaluation 1. Performance Evaluation Objectives Mid‐term Evaluation Objective: To evaluate progress to date, identify areas in project implementation that need improvement and provide recommendations. Final Evaluation Objective: To determine the extent to which project outcomes were achieved and to inform future USAID/DRC integrated health strategy and design. BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 6 VI. Audience and Intended Uses The audience of the performance evaluation will be the USAID/DRC Mission, specifically the health team and program office, and the implementing partner. An Executive Summary and recommendations will be provided to the MOH. USAID will use the report to make changes to its current integrated health strategy and to share lessons learned with other stakeholders. The audience of the RBF impact evaluation will be the USAID/DRC Mission, specifically the health team and program office, the implementing partner, the Ministry of Health, donors involved in RBF piloting, and secondary users like NGOs and other stakeholders. USAID/DRC will use this evaluation to inform policy and learning on RBF. VII. Evaluation Questions Evaluation questions will structure the evaluation process, and USAID intends that these be aligned with the evaluations purpose and expected use. It also intends that each question be answerable with the highest quality and most credible evidence possible, given time and budget constraints. To ensure this, the total numbers of questions included in the SOWs for each evaluation will be limited. 1. IHP Performance Evaluation Questions The mid‐term and the final performance evaluation will focus on verifying the theory of change underlying IHP’s results framework. The following illustrative questions may lead the evaluation: ‐ To what extent has the project improved access to and availability of MPA‐plus and CPA‐plus services and products in targeted health zones? ‐ Has the project improved the quality of key family health care services in targeted health zones? ‐ Have knowledge, attitudes, and practices to support health‐seeking behaviors increased in targeted health zones? ‐ Has the health sector leadership and governance in the four targeted provinces improved? ‐ What are the external factors that hamper IHP activities from delivering better results? ‐ How is IHP perceived and valued? VIII. Evaluation Design and Methodology USAID/DRC will provide the contractor with a statement of work for each evaluation component (baseline, mid‐term, and final) conducted under this contract but the contractor will design the methodology, sampling frames, and data collection instruments in consultation with USAID/DRC staff, implementing partners and country counterparts. Illustrative designs are set forth in Section J – Attachments. For the two baseline evaluations a SOW will be provided immediately after award of the contract and will require a collaborative effort between USAID and the contractor due to time sensitivities. The SOWs for all mid‐term and final evaluations will be provided at least four months prior to the start of each evaluation component. The contractor will be responsible for managing the evaluation and data collection in the field, working directly with program implementers, verifying data quality, and preparing clean data sets, for analysis. BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 7 1. Evaluation Design Performance Evaluation will include participatory methodologies to be built in at key stages for measuring potential behavior change, and for learning. Both quantitative and qualitative methods will be used. Questions will need to be answered around all key outcomes/results of IHP with particular focus on changes at the household level; why, how and under what circumstances/conditions change occurs. Case studies and targeted studies may also be considered to test the hypotheses and provide more in‐depth understanding of the process of change, particularly at household level. USAID recognizes that the Baseline Part II (facilities baseline) is being collected well after implementation of the IHP project has begun. The final evaluation will note that the baseline for the facilities component was collected later in implementation. 2. Data Collection Methods Data collection methods will neither completely be prescribed by USAID/DRC nor completely left up to the contractor to propose. USAID encourages a collaborative approach to their development. The following steps for developing the SOW for the evaluation are envisaged: a) USAID will provide a first draft of the evaluation SOW to the contractor. b) Within 15 working days, the contractor will provide comments to the SOW and propose the detailed methodology for data collection and data analysis. c) USAID conducts an internal peer review of the SOW and methodology and provides final comments to the contractor (within five working days) d) The contractor finalizes the SOW and methodology and submits to USAID for final approval (within five working days) e) USAID provides final approval of the SOW (within three working days). BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 8 ANNEX B. KEY INFORMANT INTERVIEW GUIDES 1. GUIDE TO INTERVIEWING CODESA/COMMUNITY HEALTH WORKERS After introductions and an explanation of the evaluation, including confidentiality and oral informed consent from all participants, the following questions and issues should be discussed using a conversational style: 1. Has the range of health services available at the health center supporting this community increased since IHP started working here? If so, please describe which services have been added that IHP has supported. 2. What are the biggest health-related needs for health services in this community? 3. Are the members of this community using these important health services more than they did before IHP started? If not, why not? Is there greater awareness in the community of these services? 4. Has IHP provided training to community health workers since the project started? 5. Has IHP provided training to community-based organizations or community members since the project started? If so, on which issues or skills? 6. To which types of community-based organizations or community members has the training been provided by IHP? 7. If no training has been provided in this community or to the local community health workers, do you know of plans by IHP to provide training? If so, when is training planned and what type of training? 8. In your opinion, has the quality of the services provided at the health center increased? Do you know if IHP has played a role in strengthening the quality of the services provided there? If so, do you know how it has done this? 9. Do you provide a range of health education to individual community members through your community outreach? If so, on which health topics? 10. How do you conduct this health education and information outreach and how often? Can you please give me one or more examples? 11. In your opinion, is there enough of a focus on prevention in the health education that you provide, or is it mostly focused on health treatment for an illness? 12. Do you give any printed materials to community members about specific illnesses, pregnancy, vaccinations, etc.? If so, please tell me about them/show me a few. Are some/more printed materials needed and, if so, specifically on which topics? BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 9 13. Has this community formulated a community action plan on health issues? 14. As part of your work, do you regularly make referrals to the community health center or to the nearest hospital? Which illnesses or issues do you make most of your referrals for? 15. Do you know if the work being done on community health education in this community has resulted in many more individuals and families seeking health care services? If so, please describe some successful examples. If not, can you explain what the impediments are? 16. Which health-seeking behaviors do you feel should be targeted as the highest priorities for this community in the future? 17. Based on your experience, is there a need for health care management training in this area for the health care providers at the local health center or nearest hospital that you as community workers and beneficiaries think IHP should consider providing in the future? If so, what are the needs? 18. Do you exchange communications or share information with any IHP staff? If so, how often? Do you meet with any IHP staff on a regular basis? If so, how frequently? 19. In many countries and communities there are structural or external factors that inhibit the range, frequency, and quality of health care service provision. What are the main inhibiting factors or constraints that you encounter regarding health care service provision by health care providers here? 20. What are the main inhibiting factors or constraints regarding access to these health services encountered by community members? 21. What is your overall feeling about IHP? Do you think IHP is a valuable additional project supporting health care provision in this area? From your point of view, what are the project’s principal strengths? 22. Based on your experience, are there any weaknesses that you can identify about IHP’s work so far in this area? If so, what are they? 23. Do you have suggestions for improvements to IHP’s work? If so, what are they? 24. Is your organization or your community receiving other donor support for health care service provision or access? If so, from which donors? BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 10 25. If other donor funds are providing support locally, which health services or health topics are being supported by the other donors? Thank you very much! BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 11 2. GUIDE TO INTERVIEWING HEALTH CARE FACILITIES/DISTRICT/HEALTH ZONE MANAGERS After introductions and an explanation of the evaluation, including confidentiality and oral informed consent, that emphasizes that this interview and discussion is part of the IHP evaluation, the following questions and issues should be discussed using a conversational style: 1. Has the range of health services available at the health center/hospital/health zone increased since IHP started working here? If so, please describe which services have been added. If no services have been added, why do you think the service range has not increased? 2. What are the biggest needs for health services in this health center/hospital/health zone? Since IHP started working here, has the use of these important services increased? 3. Are community members accessing these important health services more than they did before? Is there greater awareness in the community of these services? If not, why not? 4. Has IHP provided training to health care providers at this facility since the project started? If so, for which services or issues and for which levels of health care workers has training been provided? If no training has been provided, do you know of plans by IHP to provide training? If so, when is training planned and what type? 5. In your opinion, has the quality of the services provided here increased? Has IHP played a role in strengthening the quality of the services provided here? If so, how has it done this? 6. Do you have any suggestions for additional needs regarding raising the level of service quality that IHP may be able to help provide within the next year or two? 7. Do the health care workers here provide health education as part of their discussions with individual patients? If so, how do they do this? Can you please give me an example? 8. In your opinion, is there enough of a focus on prevention in the health education that is provided by health workers, or is it mostly focused on health treatment for an illness? 9. Are there any printed materials available to give to patients regarding specific illnesses, pregnancy, vaccinations, etc.? If so, please tell me about them/show me a few. Are some/more printed materials needed? If so, specifically on which topics? 10. Is community outreach on health care taking place in communities in the surrounding area? If so, who is providing it? Is IHP involved in or supporting this community health education provision? Can you please describe the types of activities for me? 11. Do you know if the communities have formulated community action plans on health issues? BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 12 12. Has work community health education in communities resulted in more individuals and families seeking health care services? If so, please describe some successful examples. If not, can you explain what the impediments are? 13. Which health-seeking behaviors do you feel should be targeted by IHP as the highest priorities for community health education in the future? 14. Has IHP provided specific types of management training to facility, zone, or district managers in this area? If so, has IHP provided training on strategic, action, or operational planning? 15. Has IHP provided leadership or supervision training? If so, when? Was it helpful? If it was, can you give me an example of how it helped you or others? 16. Has IHP provided any other types of management training? If so, what has the training covered? 17. Are there other needs for health care management training in this area that you think IHP should consider providing in the future? If so, what are they? 18. How often do you meet with IHP staff? Are there regular meetings set up by you or IHP to share information and conduct joint planning? How closely involved is IHP in the planning taking place here on an annual, quarterly, or monthly basis? 19. Can you please describe the types of communications you exchange with IHP and on which topics or issues? 20. Has IHP increased or helped increase access to any other community health needs you manage in your health management position? If so, which ones? 21. In many countries and communities there are structural or external factors that inhibit the range, frequency, and quality of health care service provision. What are the main inhibiting factors or constraints that you encounter here regarding health care service provision that IHP is also encountering in its support for health services? 22. What is your overall feeling about IHP? Do you think IHP is a valuable additional project supporting health care provision in this area? What are the project’s principal strengths? 23. Are there any weaknesses that you can identify about IHP’s work so far in this area? If so, what are they? 24. Do you have suggestions for improvements to IHP’s work? If so, what are they? BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 13 25. Are you receiving other donor funding in this area for health care service provision? If so, which other donors are providing funds and for which services or topics specifically? Thank you very much! BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 14 ANNEX C. QUANTITATIVE DATA ANALYSIS PLAN IHP impact evaluation data analysis Quantitative surveys Descriptive data analysis Facility survey: Compare baseline and final evaluation survey data % differences in availability of key MPA-plus services at facilities % differences in accessibility of key MPA-plus services at facilities % difference in quality of health services: facility infrastructure, staff, and maternal health, family planning, child health interventions Test of significance: Availability, accessibility and quality of MPA-plus services: change from baseline vs final Client exit interviews: Compare baseline and final evaluation survey data % differences in client knowledge on key MPA-plus services % differences in client practices on access to key MPA-plus services % difference in client perception on quality of health services Test of significance: Client knowledge, practices and client perception on MPA-plus services: change from baseline vs final Qualitative interviews 1. Assess perception of informants from start of IHP to end of IHP with regards to the access and availability of MPA-plus and CPA-plus services, quality of main family health services, knowledge, attitudes, practices, and positive behaviors related to health in the target health zones. BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 15 2. Assess perception of informants on leadership and governance in the health sector improved in the target provinces, the external factors impeding IHP activities and which impede achieving the best possible results and the overall perception of IHP and its reputation? BASELINE EVALUATION DATA ANLYSIS PLAN Table C-1: Facility Survey Evaluation Questions Assessment Domains Source of Data (Quantitative) Modules Data Analysis Availability of key family health care services minimum package of activities/complementary package of activities plus (MPA/CPA-plus) Assess range and type of services provision including preventive care, curative, water/sanitation/hygiene (WASH) services and products MPA+ services: should be provided at all HCs CPA+ services: should be provided by all GRHs. (This is a limitation since as of mid￾March MSH did not have data on CPA-Plus. The facility questionnaire used for the survey didn't incorporate CPA-Plus.) Facility survey: HCs and GRHs Module 3 questions Module 4 questions Percentage of facilities (HC and GRH) offering full range of MPA+), by health HZ, SA, province IHP MPA-Plus Preventive Module no./Question no. Growth and development monitoring for children under 5 Module 3, PREV38b Prenatal counseling Module 3, PREV2 Vitamin A for pregnant women Module 3, PREV7 PMTCT counselling Module 3, PREV11 HIV testing for pregnant women Module 3, PREV12 Antiretroviral prophylaxis for HIV prevention Module 3, PREV16, 17 HIV + pregnant given co￾trimoxazole Module 3, PREV15b Postnatal care Module 3, PREV27 BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 16 Evaluation Questions Assessment Domains Source of Data (Quantitative) Modules Data Analysis FP counseling Module 3, PREV33 Immunization for children Module 3, PREV38a Children born to HIV+ given co-trimoxazole Module 3, PREV15d Distribution of ITNs Module 3, PREV 69 HIV information Module 3, PREV64 Infection prevention and blood safety Module 4, SC19 Curative Clinic-based IMCI Module 4 SC1 Normal labor Module 3 PREV 20 Referral for emergency obstetrics Module 3 PREV 24, 25 ITN for pregnant women and children under 5 Module 3, PREV 70 Care and treatment of HIV Module 4 SC18 Care and treatment of TB Module 4 SC10 Care and treatment of NTDs Module 4 SC22 Blood transfusions Module 4 SC20 Nutritional rehabilitation Module 4 SC25 Minor surgery Module 4 SC23 STI treatment and referrals Module 3, PREV55 PEP Module 3, PREV68 Handle GBV/rape Module 3, PREV67 BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 17 Evaluation Questions Assessment Domains Source of Data (Quantitative) Modules Data Analysis Availability of community or health promotion interventions to improve accessibility to key family health care services Assess community-based support and outreach with respect to information, communication, and delivery of key family health care services Facility survey: HCs and GRHs Module 4: SC26-34 Module1: IG4,5 Module 3 PREV22 Module 3 PREV40 Module 4 SC12, 13 questions Module 3 PREV71 Module 10 % of the health centers surveyed providing health promotion/information on: condom use; hygiene and sanitation; exclusive breastfeeding; food hygiene/food safety; oral rehydration for diarrhea; and, fistula prevention) type of facility, location of HF, HZ, SA, province % of facilities open 24 hours a day, type of facility, location of HF, HZ, SA, province % of facilities open 7 days a week, type of facility, location of HF, HZ, SA, province By: type of facility, location of HF, HZ, SA, province  % facility offering labor and delivery services in community  % facility with vaccine education plan  % facility offering TB contact tracing, monitoring in community  % of the health centers surveyed distributing ITNs free of charge  % of facility offering growth monitoring with growth-monitoring IEC materials: BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 18 Evaluation Questions Assessment Domains Source of Data (Quantitative) Modules Data Analysis Quality of key family health care services provision General quality of health facility Derive quality score by combining quality of health facility variables Health facility infrastructure, equipment, communication, transport, waste management Facility survey Module 1 questions combine Q IG: 3, 8, 11, 13, 14, 16, 17,19, 22, 25 % of facility with adequate infrastructure to be functional now (presence of waiting room, electricity, running water, source of water, equipment work, transport, emergency communication, toilets, disinfectant, waste disposal) Derive quality score on health facility infrastructure Compare by type of facility, location of HF, HZ, SA, province Staff characteristics Staff training and skills Module 2 questions: SP 1-7 Type of staff: number (%), gender, training status: by type of health facility, HZ, SA, province Characteristics of staff: type of staff, number (%), gender, training status: by type of health facility, HZ, SA, province % health workers with specific skills (FP, HIV, STI, IMCI, PMTCT) by type of facility, HZ, SA Infection control practices Module 1: IG 21, 23- 24, 25 Module 6: EM 1-2 Top three methods for decontamination of medical equipment, by type of facility, location, HZ, SA, province Top three methods of sterilization of medical equipment, by type of facility ,location, HZ, SA, province Top three methods of sharp waste disposal, by type of facility Top three methods of waste disposal, by type of facility, location, HZ, SA, province Facility supervision Module 5: SU1-2 Facility supervision rate: number and % of facilities with at least once a month supervision visit, by type, location, HZ, SA, province BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 19 Evaluation Questions Assessment Domains Source of Data (Quantitative) Modules Data Analysis Essential drugs, supply management, and monitoring systems Module 6: EM5-6 % of health facilities experiencing delivery delays for medications and supplies, by type, location, HZ, SA, province Top three reasons why medications and supplies are delivered delayed, by type of facility, location, HZ, SA, province Top three source of procurement, by type of facility, location, HZ, SA, province Quality of FP services: whether quality of FP services is adequate in facilities offering FP services Similar analysis for vaccination service, STI, PMTCT, maternal health, IMCI Module 1, PREV 33 Module 1, PREV 36 Module 1, PREV 34 Module 2 SP3 Module 1, IG 1 Module 6 EM7 Module 8 Module 6: EM8, EM9 Module 10 Module 7 % of facility adequate for providing FP services among those offering FP  Does this facility offer FP? How many consultations offered in last 12 months?  % of facility offering FP 7 days a week  % of facility offering FP 30 days a month  Presence of trained staff in FP: presence of sign board  % of facility offering contraceptive: source of procurement  % of facility offering different methods have currently available method in stock, experienced shortage of method  % of facility with procurement delay of contraceptives: causes of delays  % of facility offering FP with FP IEC materials  % of facility offering FP contraceptives with proper storage of contraceptives Service utilization of key family health care services minimum package of Review utilization of maternal, newborn, and child health Facility survey: HCs and GRHs Module 3, PREV51 Calculate service utilization rates: % of children receiving DTP1 last 12 months/population of under 12 months in catchment area for 2012 BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 20 Evaluation Questions Assessment Domains Source of Data (Quantitative) Modules Data Analysis activities/complementary package of activities plus (MPA/CPA-plus) Multivariate analysis: Calculate service utilization rate for HF: % of children receiving DTP1 last 12 months/population of less than 12 months in catchment area Difference in service utilization rate for HF by quality of care scores, type, location of HF, HZ, province Client interview: Module 1, Q30,31 Module 4, Q12, 13 % of pregnant women reporting having slept under an insecticide-treated net the night/pregnant women reported receiving ITN % of children aged 0-23 months slept under an insecticide-treated net the night before the child’s mother brought him/her to a health center/mother reporting ITN at home % of clients receiving a given procedure or intervention (including frequency of visits, consultations, referrals, treatments) and demographic characteristics (i.e., age and place of residence) for the following health services: women of reproductive age (15-49), pregnant women, mothers and their children aged 0-23 months Client Perspectives Client access to health facility and available MPA and CPA–plus services, resources, and service health seeking practices Assess client’s health-seeking reason for current visit and practices in the past Assess services available to clients by health facility/providers in current visit and past visits Client Exit Survey: Module 1: child <23 months Q6, 7: Current health seeking Table questions Q1-2: Health education by provider child nutrition Q8-18: Client access to facility growth monitoring and immunization services Q27-28: Client access to malaria prevention interventions Q35-39: Client access to pre/postnatal interventions Module 1, 2, 3, 4: Q on current reason for clinic visit, services received this visit Module 1, 3, 4: Q on access to qualified health providers, child, maternal health services, infant nutrition education, immunization (questions on services￾child health, family planning, WASH, N and % of client (infants, child, women 15-49, pregnant) receiving various types of care/services, current and past: by type of facility, location of facility, age of respondent, HZ, SA, province Client health-seeking and utilization practices: by age, location of facility, HZ, SA, age of respondent % of health center clients surveyed with access to prevention, curative, health education interventions under MPA and CPA-plus BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 21 Q41-45: Client access to WASH interventions Module 2 Child 24-59 months Q1-3: Current health seeking Module 3 Women 15-49 Q1-2: Current health seeking Table questions Q3: Health education by provider FP Q5: Client access to TB screening Q6-7: Client access to HIV prevention interventions Q8: Client access to referral services Q10-11: Client access to health education messages Q12-13: Client access to WASH interventions Module 4 Pregnant Women 15-49 Q1-2: Current health seeking Table questions Q3: Access to prenatal service Q4: Client access to Fe folic acid to prevent anemia Q5: Client access to TB screening Q5-9: Client access to HIV prevention interventions Q10: Client access to HIV care and support interventions Q11: Client access to malaria prevention interventions Q14-15: Client access to health education messages Q16:17: Client access to WASH interventions maternal health, TB, HIV- received in current visit and in the past, e.g., having their weight checked, testing for presence of cough, diarrhea, and fever Module 1, 3, 4: Q on access and utilization of available services child immunization, breast feeding, malaria, fever, danger signs, pneumonia, diarrhea, pre-natal , antenatal, alternate health providers Module 1, 3, 4: Q on access and utilization of availability of resource: ITN, soap, sanitary facilities, safe water BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 22 Client perceptions of services provided by health facility Assess client satisfaction with key family health care services Client perceptions of staff skills and knowledge with interpersonal counseling skills of providers, perceived provider-client quality of interaction Client perceptions of tests and treatment for their children (0- 23, 24-59 months); on current visit and past visits Client perceptions of treatment received from staff (in all areas, including family planning clients) Client perceptions of waiting time, appointment schedules, privacy Client Exit Survey: Module 1: Child<23 months Q8-14: Satisfaction with nurse provider Q15-21: Satisfaction with physician provider Q22-23: Alternate care available if not satisfied. Module 2: Child 24-59 months Q4-10: Satisfaction with nurse provider Q11-17: Satisfaction with physician provider Q18-19: Alternate care available if not satisfied. Module 3: Women 15-49 Q14-19: Satisfaction with nurse provider Q20-25: Satisfaction with physician provider Q26: Alternate care available if not satisfied. Module 4: Pregnant Q17-22: Satisfaction with nurse provider Q23-28: Satisfaction with physician provider Q29: Alternate care available if not satisfied. Overall satisfaction with facility services: Q1-5 Module 1, 2, 3, 4 (client satisfaction questions: Likert Scale, interpersonal skills of providers, quality and availability of provider) Calculate overall satisfaction with services received on current visit using by combining indicators  Index of satisfaction with facility management and infrastructure  Index of satisfaction related to trust in providers  Index of satisfaction with nurse services  Index of satisfaction with physician services  Index of satisfaction with service providers: nurse vs. doctor Client satisfaction on availability of services during current visit and past: by type of facility, location of facility, age of respondent, HZ, SA, province % of mothers visiting a health facility to have her child ages 0-23 months treated who were surveyed were very satisfied/ somewhat satisfied/neutral/somewhat unsatisfied/very unsatisfied % of mothers visiting a health facility to have her child ages 23-59 months treated who were surveyed were very satisfied/ somewhat satisfied/neutral/somewhat unsatisfied/very unsatisfied % of women 15-49 treated who were surveyed were very satisfied/somewhat satisfied/neutral/somewhat unsatisfied/ very unsatisfied % of pregnant women treated who were surveyed were very satisfied/somewhat BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 23 satisfied/neutral/somewhat unsatisfied/ very unsatisfied % clients surveyed reported total satisfaction, partial, non-satisfaction with the quality of health services offered Client knowledge and practice on key health topics Assess client’s knowledge on key heath issues affecting women and children Assess client’s source of information on key family health care services Assess client’s participation in community interventions and resources provided by facility on key family health care services Client Exit interview Module 1: Child <23 months Table questions Q3- 7: Client’s child nutrition practice and knowledge Q19: Knowledge of common childhood illnesses: pneumonia Q20-26: Client health-seeking practices for childhood illnesses Q30-31: Client practice for malaria prevention Q32, 33: Knowledge of common childhood illnesses: malaria Q34: Client practice of prenatal care Q40: knowledge of fistula Module 3: Women 15-49 Q4: Client practice of FP Q9: Client participation in community facility coordination Module 4: Pregnant Q12-13: Client practice of malaria prevention Q18-19: Client knowledge of pregnancy complications Module 1,3, 4: Q on knowledge of health topics and source of information: child immunization, breast feeding, danger signs, malaria, fever, pneumonia, diarrhea, fistula, maternal health, WASH Module 1,3,4: Q on knowledge of availability of services: child immunization, breast feeding, malaria, fever, danger signs, pneumonia, diarrhea, pre-natal, antenatal Calculate overall knowledge of key health topics and availability of services % of clients with knowledge by type of information, source of information, HZ, SA, age of respondent % of clients adopting/practicing health intervention: by type of service, HZ, SA, age of respondent % of pregnant women surveyed reporting having received at least two doses of malaria-prevention treatment at a health center during pregnancy % of pregnant women surveyed reporting having received information from service providers on the danger signs that may occur during pregnancy % of women ages 15-49, including pregnant women, surveyed reported having participated in a health coordination meeting in her community BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 23 ANNEX D. DATA COLLECTION SAMPLING PROCEDURE Overview The overall goal of the IHP is for 80% of all health facilities to be functioning with a minimum package of activities-plus (MPA-plus) and for 80% of all general reference hospitals (GRHs) to be functioning with a complementary package of activities-plus (CPA-plus). The IHP evaluation is a cross-sectional study of the health centers (HCs) and GRHs and community outreach and support in the sampled health zones (HZ) over the four provinces of East Kasai, West Kasai, Katanga, and South Kivu. The study employed both quantitative and qualitative methods. While the quantitative method provided information on facility characteristics or attributes, the primary objective of the qualitative component was to describe the context and enabling factors or barriers to the utilization and quality of MPA/CPA-plus services and perceptions regarding IHP. Sampling Method The lot quality assurance sampling (LQAS) method is applied under the assumption of randomness on the occurrence of cases (disease condition), unimmunized children (defectives), etc. The IHP survey used the LQAS methodology, which is a cost-effective, robust approach to obtain information from a representative sample of communities and households located in the targeted health zones of the project. The IHP evaluation team administered the survey across eight “lots” or supervision areas, which reflect almost the same IHP implementation structure of the eight IHP coordination offices located in the project target areas. Units and Sampling Frames The sampling frame is a list of health zones, health centers, and villages with their population sizes for each supervision area. The sampling units for this study include HCs and GRHs in these locations. In the first stage, the sampling frame consists of a list of health zones for each supervision area. In the second stage, a list was developed of health centers corresponding to the health zones as the point of reference. Sampling Procedure For the selection of the sample, the LQAS sampling framework originally included a random selection of approximately 19 sites (health facilities) for interviews in each supervision area, for a total of 152 sites that could be surveyed for the entire area covered by the project. The sample size was determined with a precision level of 92% and 95% confidence intervals. Later due to resource constraints, it was decided to determine three HZs from each supervision area and nine HCs including one GRH from each HZ. This constituted a total of 72 sample health facilities and equal distribution among eight HZs. Due to the lower statistical significance with a sample size of 72 health facilities, an additional 24 (one for each HZ) health facilities were proposed to be included to confirm an acceptable confidence level of approximately 90% over a total of (72+24) 96 facilities. During data collection, a change was made due to rebel activity in one supervision area to include 73 HS and 23 GRHs, still totaling 96 facilities, as shown in Table 1. See Table 2 for a complete list of the health zones and health centers that were substituted BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 24 to various reasons during data collection. However, intervention areas corresponding to each supervision area were excluded during the sample determination. Table D-1: IHP Sample Size by SA, HZ, and Number of Health Centers Sl. No Supervision Areas Sample HZ No of GRH to Be Surveyed Sample HC Total Health Facility (GRH+HC) Additional HC 1 Lwiza 3 3 6 (6+3)=9 3 2 Mwene-Ditu 3 3 6 (6+3)=9 3 3 Kole 3 3 6 (6+3)=9 3 4 Tshumbe 3 3 6 (6+3)=9 3 5 Kolwezi 3 3 6 (6+3)=9 3 6 Kamina 3 3 6 (6+3)=9 3 7 Bukavu 3 3 6 (6+3)=9 3 8 Uvira 2 2 6 (6+4)=10 2 Total 23 23 48 73 23 Process for Sample Selection For the selection of interview sites, the process of drawing the sample was done supervision area by supervision area. Then the selection process followed a random procedure for systematic sampling of units. Moreover, the selection of interview sites used the following steps: List the supervision area, health zone, and health center with its population size. Select 3 HZs randomly from each supervision area. Determine the number of health facilities as the sample based from each HZ. The selection of HC followed a random process, but in some cases was systematic. Include one GRH for interview with the selected HC for each HZ. List the name of each selected HC to identify the exact sample facilities corresponding to each health zone under the respective supervision area. Table D-2: Changes Made to Sampled Health Zones and Health Centers During Data Collection Province Supervision Area Comments and Changes East Kasai Mwene Ditu No changes made. Kole Tshudi Loto Health Zone replaced Vangakete which was no longer under the management of the Kole Supervision Area. Tshumbe No changes made. West Kasai Luiza The Mutoto HZ which is no longer supported by IHP was replaced by Dibaya HZ. In Dekese Health Zone, Bololo Health Center was changed to Isandja Health Center. Katanga Kolwezi In Dilala Health Zone, the Kanina Health Center was randomly selected to replace Bilende Health Center, which didn't exist. In Lubudi Health Zone, because of inaccessibility, Dilenge and Kalonga Health Centers, were replaced by Lubudi 1 and Mukabe 2. BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 25 Province Supervision Area Comments and Changes Kamina Kinkondja Health Zone replaced Mulongo Health Zone, which was not accessible due to insecurity and would have required travel by boat and bicycle. South Kivu Bukavu Two of the 3 health zones were not accessible for security reasons, and a new sample was drawn, which included: Bagira-Kasha, Mwenga and Kaniola Health Zones. In Kaniola Health Zone, the Culwe Health Center was not accessible was replaced by Izege Health Center. Uvira Hauts-Plateaux Health Zone was removed from the sample for reasons of insecurity and inaccessibility. Since no other HZ was available, the number of facilities to visit was increased in the remaining Health Zones: Lemera and Rusizi. Client Exit Survey Upon arrival at the health facility, two interviewers screened women departing the health facility to determine if they were of reproductive age (15-49 years) and available for and agreed to be surveyed. Client exit interviews were initiated at the health centers in the morning to survey the most women possible. The majority of clients seek care between 0800-1200 Monday through Saturday. Saturdays were included in the sample to the degree possible since women seeking care on Saturdays are likely to have different characteristics than women seeking care during weekdays (e.g., formally employed). Key Informant Interviews Key informant interviews were conducted as part of the qualitative methodology in each of the provinces, districts, and health zones. The sample for the key informants included the following: Ministry of Health managers at provincial, district, zone, and facility levels in the four provinces Ministry of Health managers Members of CODESAs (health development committees) in the targeted zones IHP field and headquarters staff members BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 26 ANNEX E. QUALITATIVE DATA MATRIX Evaluation question Location Increase Same Decrease N/A Service Availability Increase Bena Dibele Zone, East Kasai X Bena Dibele Hospital, EK X Bena Dibele CODESA, EK X Djalo Ndjeka Zone, EK X Djalo Ndjeka Hospital X East Kasaï (EK) Province X Kanda Zone, EK X Kanda Hospital, EK X Katako Kombe Zone, EK X Katako Kombe CODESA, EK X Kole Zone, EK X Kole Hospital, EK X Kole IHP, EK X Luputa Zone, EK X Luputa Hospital, EK X Luputa Administration, EK X Luputa CODESA, EK X Mbuji-Mayi District, EK X Mwene-Ditu Zone, EK X Mwene-Ditu District, EK X Mwene-Ditu Hospital, EK X Mwene-Ditu CODESA, EK X Mwene-Ditu IHP, EK X Ototo Hospital, EK X Ototo CODESA, EK X Sankuru District, EK X Sankuru District, EK-2 X Tshudi Loto Hospital, EK X Tshumbe IHP, EK X Dilala Zone, Katanga X Dilala Hospital, Katanga X Dilala CODESA, Katanga X Kamina District, Kitanga X Kamina IHP, Kitanga X Katanga Province X Kayamba Zone, Kitanga X Kayamba Hospital, Kitanga X Kayamba CODESA, Kitanga X Kinkondja Zone/Hospital, Kitanga X Kinkondja CODESA, Kitanga X Kitenge Zone, Katanga X Kitenge Hospital, Katanga X Kitenge CODESA, Katanga X Kolwezi District, Katanga X Kolwezi IHP, Katanga X Lubudi Zone/Hospital, Katanga X Lubudi CODESA, Katanga X Manika Hospital, Katanga X Manika Zone, Katanga X Manika CODESA, Katanga X Bagira-Kasha Zone, South Kivu X BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 27 Bagira-Kasha Zone, South Kivu-2 X Bagira Hospital, South Kivu X Bagira CODESA, South Kivu X Lemera Zone, South Kivu X Bukavu IHP, South Kivu X Kaniola Zone, South Kivu X Kaniola CODESA, South Kivu X Lemera Hospital, South Kivu X Lemera CODESA, South Kivu X Mwenga Zone, South Kivu X Mwenga CODESA, South Kivu X Ruzizi Hospital, South Kivu X Ruzizi CODESA, South Kivu X South Kivu Province X South Kivu Province-2 X Uvira IHP, South Kivu X Bulape Zone, West Kasai X Dekese Zone, WK X Dekese Hospital, WK X Dekese CODESA, WK X Kananga IHP, WK X West Kasai Province X Kinshasa IHP X Kinshasa IHP X Kinshasa IHP X Kinshasa IHP X Kinshasa IHP X MOH Kinshasa X USAID/DRC X Total n=80 responses=61 27/61 (44%) 33/61 (54%) 1/61 (1.6%) 19 Service Access Increase Bena Dibele Zone, EK X Bena Dibele Hospital, EK X Bena Dibele CODESA, EK X Djalo Ndjeka Zone, EK X Djalo Ndjeka Hospital, EK X East Kasai (EK) Province X Kanda Kanda Zone, EK X Kanda Kanda Hospital, EK X Katako Kombe Zone, EK X Katako Kombe CODESA, EK X Kole Zone, EK X Kole Hospital X Kole IHP, EK X Luputa Zone, EK X Luputa Hospital, EK X Luputa Administration, EK X Luputa CODESA, EK X Mwene-Ditu Zone, EK X Mbuji-Mayi District, EK X Mwene-Ditu District, EK X Mwene-Ditu Hospital, EK X Mwene-Ditu CODESA, EK X Mwene-Ditu IHP, EK X BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 28 Ototo Hospital, EK X Ototo CODESA, EK X Sankuru District, EK X Sankuru District-2 X Tshudi Loto Hospital, EK X Tshumbe IHP, EK X Dilala Zone, Katanga X Dilala Hospital, Katanga X Dilala CODESA, Katanga X Kamina District, Kitanga X Kamina IHP, Kitanga X Katanga Province X Kayamba Zone, Kitanga X Kayamba Hospital, Kitanga X Kayamba CODESA, Kitanga X Kinkondja Zone/Hospital, Kitanga X Kinkondja CODESA, Kitanga X Kitenge Zone, Katanga X Kitenge Hospital, Katanga X Kitenge CODESA, Katanga X Kolwezi District, Katanga X Kolwezi IHP, Katanga X Lubudi Zone/Hospital, Katanga X Lubudi CODESA, Katanga X Manika Hospital, Katanga X Manika Zone, Katanga X Manika CODESA, Katanga X Bagira-Kasha Zone, South Kivu X Bagira-Kasha Zone, South Kivu-2 X Bagira Hospital, South Kivu X Bagira CODESA, South Kivu X Bukavu IHP, South Kivu X Kaniola Zone, South Kivu X Kaniola CODESA, South Kivu X Lemera Zone, South Kivu X Lemera Hospital, South Kivu X Lemera CODESA, South Kivu X Mwenga Zone, South Kivu X Mwenga CODESA, South Kivu X Ruzizi Hospital, South Kivu X Ruzizi CODESA, South Kivu X South Kivu Province X South Kivu Province-2 X Uvira IHP, South Kivu X Bulape Zone, West Kasai X Dekese Zone, WK X Dekese Hospital, WK X Dekese CODESA, WK X Kananga IHP, WK X West Kasai Province X Kinshasa IHP X Kinshasa IHP X Kinshasa IHP X Kinshasa IHP X Kinshasa IHP X BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 29 MOH Kinshasa X USAID/DRC X Total n=80 responses=57 32/57 (56%) 21/57 (37%) 4/57 (7%) 23 Service Quality Improvement Bena Dibele Zone, EK X Bena Dibele Hospital, EK X Bena Dibele CODESA, EK X Djalo Ndjeka Zone, EK X Djalo Ndjeka Hospital, EK X East Kasai (EK) Province X Kanda Kanda Zone, EK X Kanda Kanda Hospital, EK X Katako Kombe Zone, EK X Katako Kombe CODESA, EK X Kole Zone, EK X Kole Hospital X Kole IHP, EK X Luputa Zone, EK X Luputa Hospital, EK X Luputa Administration, EK X Luputa CODESA, EK X Mbuji-Mayi District, EK X Mwene-Ditu Zone, EK X Mwene-Ditu District, EK X Mwene-Ditu Hospital, EK X Mwene-Ditu CODESA, EK X Mwene-Ditu IHP, EK X Ototo Hospital, EK X Ototo CODESA, EK X Sankuru District, EK X Sankuru District, EK-2 X Tshudi Loto Hospital, EK X Tshumbe IHP, EK X Dilala Zone, Katanga X Dilala Hospital, Katanga X Dilala CODESA, Katanga X Kamina District, Kitanga X Kamina IHP, Kitanga X Katanga Province X Kayamba Zone, Kitanga X Kayamba Hospital, Kitanga X Kayamba CODESA, Kitanga X Kinkondja Zone/Hospital, Kitanga X Kinkondja CODESA, Kitanga X Kitenge Zone, Katanga X Kitenge Hospital, Katanga X Kitenge CODESA, Katanga X Kolwezi District, Katanga X Kolwezi IHP, Katanga X Lubudi Zone/Hospital, Katanga X Lubudi CODESA, Katanga X Manika Zone, Katanga X Manika Hospital, Katanga X Manika CODESA, Katanga X BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 30 Bagira-Kasha Zone, South Kivu X Bagira-Kasha Zone, South Kivu-2 X Bagira Hospital, South Kivu X Bagira CODESA, South Kivu X Bukavu IHP, South Kivu X Kaniola Zone, South Kivu X Kaniola CODESA, South Kivu X Lemera Zone, South Kivu X Lemera Hospital, South Kivu X Lemera CODESA, South Kivu X Mwenga Zone, South Kivu X Mwenga CODESA, South Kivu X Ruzizi Hospital, South Kivu X Ruzizi CODESA, South Kivu X South Kivu Province X South Kivu Province-2 X Uvira IHP, South Kivu X Bulape Zone, West Kasai X Dekese Zone, WK X Dekese Hospital, WK X Dekese CODESA, WK X Kananga IHP, WK X West Kasai Province X Kinshasa IHP X Kinshasa IHP X Kinshasa IHP X Kinshasa IHP X Kinshasa IHP X MOH Kinshasa X USAID/DRC X Total n=80 responses=65 47/65 (72%) 16/65 (25%) 2/65 (3%) 15 Health-seeking Behavior Increase Bena Dibele Zone, EK X Bena Dibele Hospital, EK X Bena Dibele CODESA, EK X Djalo Ndjeka Zone, EK X Djalo Ndjeka Hospital X East Kasai Province X X Kanda Kanda Zone, EK X Kanda Kanda Hospital, EK X Katako Kombe Zone, EK X Katako Kombe CODESA, EK X Kole Zone, EK X Kole Hospital X Kole IHP, EK X Luputa Zone, EK X Luputa Hospital, EK X Luputa Administration, EK X Luputa CODESA, EK X Mbuji-Mayi District, EK X Mwene-Ditu Zone, EK X Mwene-Ditu District, EK X Mwene-Ditu Hospital, EK X Mwene-Ditu CODESA, EK X BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 31 Mwene-Ditu IHP, EK X Ototo Hospital, EK X Ototo CODESA, EK X Sankuru District, EK X Sankuru District, EK-2 X Tshumbe IHP, EK X Tshudi Loto Hospital, EK X Dilala Zone, Katanga X Dilala Hospital, Katanga X Dilala CODESA, Katanga X Kamina District, Kitanga X Kamina IHP, Kitanga X Katanga Province X Kayamba Zone, Kitanga X Kayamba Hospital, Kitanga X Kayamba CODESA, Kitanga X Kinkondja Zone/Hospital, Kitanga X Kinkondja CODESA, Kitanga X Kitenge Zone, Katanga X Kitenge Hospital, Katanga X Kitenge CODESA, Katanga X Kolwezi District, Katanga X Kolwezi IHP, Katanga X Lubudi Zone/Hospital, Katanga X Lubudi CODESA, Katanga X Manika Hospital, Katanga X Manika Zone, Katanga X Manika CODESA, Katanga X Lemera Zone, South Kivu X Lemera Hospital, South Kivu X Lemera CODESA X Ruzizi Hospital, South Kivu X Ruzizi CODESA, South Kivu X South Kivu Province X South Kivu Province-2 X Uvira IHP, South Kivu X Bagira-Kasha Zone, South Kivu X Bagira Hospital X Bagira-Kasha Zone, South Kivu X Bagira CODESA, South Kivu X Bukavu IHP, South Kivu X Mwenga Zone, South Kivu X Mwenga CODESA, South Kivu X Kaniola Zone, South Kivu X Kaniola CODESA, South Kivu X Bulape Zone, West Kasai X Dekese Zone, WK X Dekese Hospital, WK X Dekese CODESA, WK X Kananga IHP, WK X West Kasai Province X Kinshasa IHP X Kinshasa IHP X Kinshasa IHP X Kinshasa IHP X BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 32 Kinshasa IHP X MOH Kinshasa X USAID/DRC X Total n=80 responses=47 32/47 (68%) 16/47 (34%) 0/47 33 Leadership/Gov. Improvement Bena Dibele Zone, EK X Bena Dibele Hospital, EK X Bena Dibele CODESA, EK X Djalo Ndjeka Zone, EK X Djalo Ndjeka Hospital, EK X East Kasai (EK) Province X Kanda Kanda Zone, EK X Kanda Kanda Hospital, EK X Katako Kombe Zone, EK X Katako Kombe CODESA, EK X Kole Zone, EK X Kole Hospital, EK X Kole IHP, EK X Luputa Zone, EK X Luputa Hospital, EK X Luputa Administration, EK X Luputa CODESA, EK X Mbuji-Mayi District, EK X Mwene-Ditu Zone, EK X Mwene-Ditu District, EK X Mwene-Ditu Hospital, EK X Mwene-Ditu CODESA, EK X Mwene-Ditu IHP, EK X Ototo Hospital, EK X Ototo CODESA, EK X Sankuru District, EK X Sankuru District, EK-2 X Tshudi Loto Hospital, EK X Tshumbe IHP, EK X Dilala Zone, Katanga X Dilala Hospital, Katanga X Dilala CODESA, Katanga X Kamina District, Kitanga X Kamina IHP, Kitanga X Katanga Province X Kayamba Zone, Kitanga X Kayamba Hospital, Kitanga X Kayamba CODESA, Kitanga X Kinkondja Zone/Hospital, Kitanga X Kinkondja CODESA, Kitanga X Kitenge Zone, Katanga X Kitenge Hospital, Katanga X Kitenge CODESA, Katanga X Kolwezi District, Katanga X Kolwezi IHP, Katanga X Lubudi Zone/Hospital, Katanga X Lubudi CODESA, Katanga X Manika Zone, Katanga X Manika Hospital, Katanga X BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 33 Manika CODESA, Katanga X Bagira-Kasha Zone, South Kivu X Bagira-Kasha Zone, South Kivu-2 X Bagira Codesa, South Kivu X Bagira Codesa, South Kivu X Bukavu IHP, South Kivu X Kaniola Zone, South Kivu X Kaniola CODESA, South Kivu X Lemera Zone, South Kivu X Lemera Hospital, South Kivu X Lemera CODESA, South Kivu X Mwenga Zone, South Kivu X Mwenga CODESA, South Kivu X Ruzizi Hospital, South Kivu X Ruzizi CODESA, South Kivu X South Kivu Province X South Kivu Province-2 X Uvira IHP, South Kivu X Bulape Zone, West Kasai X Dekese Zone, WK X Dekese Hospital, WK X Dekese CODESA, WK X Kananga IHP, WK X West Kasai Province X Kinshasa IHP X Kinshasa IHP X Kinshasa IHP X Kinshasa IHP X Kinshasa IHP X MOH Kinshasa X USAID/DRC X Total n=80 responses=65 36/65 (55%) 24/65 (37%) 5/65 (8%) 15 BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 34 ANNEX F. QUANTITATIVE ANALYSIS RESULTS: AVAILABILITY OF MPA-PLUS HEALTH SERVICES Table F-1: Availability of Preventive and Curative Services (Source: Facility Survey) Availability of MPA-Plus Services: Preventive and Curative Services (color codes- red: 0-49%, yellow: 50-79%, green: >=80%) Total (N=96) Bukavu (N=12) Kamina (N=12) Kole (N=12) Kolwezi (N=12) Lwiza (N=12) Mwene-ditu (N=12) Tshumbe (N=12) Uvira (N=12) N % n % n % n % n % n % n % n % n % Facility offers prenatal care 91 95% 11 92% 12 100% 12 100% 12 100% 11 92% 11 92% 12 100% 10 83% Women receive Vit A during PNC 21 23% 4 36% 2 17% 0 0% 4 33% 4 36% 2 18% 0 0% 5 50% Pregnant women advised to be tested for HIV 63 69% 11 100% 7 58% 9 75% 12 100% 7 64% 6 55% 4 33% 7 70% Routinely offers HIV test for PMTCT 39 41% 9 75% 1 8% 6 50% 9 75% 4 33% 4 33% 2 17% 4 33% Give ARV for PMTCT prevention 23 59% 5 56% 1 100% 2 33% 7 78% 0 0% 4 100% 1 50% 3 75% Offers CTX to HIV+ pregnant women 14 36% 2 22% 1 100% 0 0% 3 25% 3 75% 1 25% 1 50% 2 50% Offers CTX child born to HIV + women 8 21% 1 11% 1 100% 0 0% 2 17% 1 25% 1 25% 0 0% 2 50% Facility offers normal labor services, has maternity unit 76 79% 10 100% 12 100% 6 50% 11 92% 10 83% 11 92% 7 58% 9 75% Offers postpartum care 76 100% 10 100% 12 100% 6 100% 11 100% 10 100% 11 100% 7 100% 9 100% Referrals for emergency obstetrics 34 45% 5 50% 5 42% 0 0% 4 36% 4 40% 4 36% 5 71% 7 78% BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 35 Availability of MPA-Plus Services: Preventive and Curative Services (color codes- red: 0-49%, yellow: 50-79%, green: >=80%) Total (N=96) Bukavu (N=12) Kamina (N=12) Kole (N=12) Kolwezi (N=12) Lwiza (N=12) Mwene-ditu (N=12) Tshumbe (N=12) Uvira (N=12) N % n % n % n % n % n % n % n % n % Facility offers FP services 94 98% 10 83% 12 100% 12 100% 12 100% 12 100% 12 100% 12 100% 12 100% Immunization for children 84 88% 11 92% 10 83% 11 92% 12 100% 10 83% 11 92% 10 83% 9 75% Growth and development monitoring of children under 5 58 60% 11 92% 8 67% 7 58% 5 42% 6 50% 6 50% 9 75% 6 50% Offers clinic￾based IMCI 96 100% 12 100% 12 100% 12 100% 12 100% 12 100% 12 100% 12 100% 12 100% Distributes ITN for malaria prevention 89 93% 11 92% 10 83% 12 100% 11 92% 11 92% 11 92% 11 92% 12 100% ITN for pregnant women 87 98% 11 100% 10 100% 12 100% 10 91% 11 100% 11 100% 10 91% 12 100% ITN for children under 2 51 57% 7 64% 4 40% 7 58% 4 36% 10 91% 7 64% 8 73% 4 33% Offers nutritional rehabilitations 38 40% 8 67% 0 0% 1 8% 7 58% 4 33% 7 58% 5 42% 6 50% HIV care and treatment 26 27% 6 50% 2 17% 2 17% 4 33% 4 33% 2 17% 2 17% 4 33% TB care and treatment 55 57% 7 58% 9 75% 7 58% 7 58% 10 83% 6 50% 5 42% 4 33% NTD care and treatment 68 71% 10 83% 9 75% 8 67% 6 50% 11 92% 4 33% 9 75% 11 92% Offers blood transfusions 31 32% 2 17% 4 33% 3 25% 6 50% 5 42% 4 33% 4 33% 3 25% Offers minor surgery 87 91% 11 92% 11 92% 11 92% 10 83% 12 100% 11 92% 11 92% 10 83% BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 36 Availability of MPA-Plus Services: Preventive and Curative Services (color codes- red: 0-49%, yellow: 50-79%, green: >=80%) Total (N=96) Bukavu (N=12) Kamina (N=12) Kole (N=12) Kolwezi (N=12) Lwiza (N=12) Mwene-ditu (N=12) Tshumbe (N=12) Uvira (N=12) N % n % n % n % n % n % n % n % n % Offers STI treatment and referrals 68 71% 12 100% 5 42% 10 83% 10 83% 8 67% 8 67% 8 67% 7 58% Facility offers PEP 23 24% 8 67% 0 0% 2 17% 2 17% 0 0% 1 8% 1 8% 9 75% Facility handles GBV/rape cases 31 32% 10 83% 2 17% 1 8% 2 17% 3 25% 1 8% 4 33% 8 67% Gives HIV/AIDS information to public 38 40% 8 67% 2 17% 6 50% 8 67% 5 42% 4 33% 1 8% 4 33% Infection prevention and blood safety (has blood transfusion written instructions) 33 34% 2 17% 5 42% 3 25% 7 58% 5 42% 4 33% 4 33% 3 25% BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 37 Table F-2: Availability of Community and Health Promotion Services (Source: Facility Survey) Availability of Community or Health Promotion Services (color codes- red: 0-49%, yellow: 50-79%, green: >=80%) Total (N=96) Bukavu (N=12) Kamina (N=12) Kole (N=12) Kolwezi (N=12) Lwiza (N=12) Mwene￾ditu (N=12) Tshumbe (N=12) Uvira (N=12) N % n % n % n % n % n % n % n % n % Condom promotion 92 96% 11 92% 12 100% 12 100% 12 100% 10 83% 12 100% 12 100% 11 92% Hygiene and sanitation promotion 90 94% 11 92% 11 92% 12 100% 12 100% 12 100% 11 92% 9 75% 12 100% Exclusive breastfeeding promotion 94 98% 12 100% 11 92% 11 92% 12 100% 12 100% 12 100% 12 100% 12 100% Food hygiene and safety promotion 89 93% 12 100% 11 92% 11 92% 11 92% 10 83% 12 100% 10 83% 12 100% Iodized salt consumption promotion 41 43% 8 67% 5 42% 1 8% 8 67% 3 25% 4 33% 5 42% 7 58% Improvement of latrines promotion 78 81% 9 75% 11 92% 9 75% 11 92% 10 83% 10 83% 9 75% 9 75% ORS in diarrhea promotion 92 96% 12 100% 12 100% 12 100% 11 92% 11 92% 12 100% 11 92% 11 92% Fistula prevention promotion 39 41% 8 67% 6 50% 3 25% 4 33% 3 25% 6 50% 4 33% 5 42% Facility providing immunization has vaccine education plan 66 79% 10 91% 8 80% 7 64% 9 75% 10 100% 7 64% 8 80% 7 78% Facility provides labor and delivery services both in HF and community 16 21% 5 50% 1 8% 2 33% 2 18% 3 30% 0 0% 3 43% 0 0% Facility distributes ITN free of cost 89 100% 11 100% 10 100% 12 100% 11 100% 11 100% 11 100% 11 100% 12 100% Facility offers monitoring of TB patients in community 43 78% 4 57% 8 89% 4 57% 6 86% 7 70% 6 100% 5 100% 3 75% Facility does TB contact tracing 42 76% 4 57% 8 89% 5 71% 5 71% 7 70% 5 83% 5 100% 3 75% BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 38 Table F-3: Accessibility of MPA-plus Health Services (Source: Facility Survey) Accessibility of Health Services (color codes- red: 0-49%, yellow: 50-79%, green: >=80%) Total (N=96) Bukavu (N=12) Kamina (N=12) Kole (N=12) Kolwezi (N=12) Lwiza (N=12) Mwene￾ditu (N=12) Tshumbe (N=12) Uvira (N=12) N % n % n % n % n % n % n % n % n % Facilities open 7 days a week 83 86% 11 92% 9 75% 10 83% 10 83% 10 83% 11 92% 12 100% 10 83% Open 24 hours and 7 days a week 80 83% 10 83% 9 75% 10 83% 9 75% 10 83% 10 83% 12 100% 10 83% Table F-4: Access to MPA-plus Health Services for Children 0-23 months (Source: Client Exit Survey) Client Profile: Child 0-23 months, Respondent: Mother of the Child N=152 % Child sick today? Yes 148 97% No 4 3% Type of care received today Vaccination 24 16% Nutrition 3 2% Vit A 0 0% ARI treatment 28 18% Diarrhea treatment 53 35% Malaria 0 0% Fever 67 44% Other 63 41% Health education/information received from health provider today Education about child nutrition 54 36% Education about exclusive breastfeeding 39 26% Feeding solid food/semi-solid/broth 3 times per day 34 22% Received other nutrition information 18 12% Services and health education received by child at health facility Child received a dose of Vit A in past 6 months 103 68% BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 39 Client Profile: Child 0-23 months, Respondent: Mother of the Child N=152 % Child was weighed 100 66% Child height or length measured 17 11% Mother informed about child's growth 39 26% Mother has child's vaccination card with her 41 27% Child received BCG before first birthday 124 82% Child received OPV before first birthday 97 64% Child received 3 doses of DPT before first birthday 86 57% Prenatal and delivery services received by mother while pregnant with youngest child Number of prenatal visit : None 8 5% Number of prenatal visit : Between 1 to 3 66 43% Number of prenatal visit : At least 4 70 46% Mother received 2 shots of tetanus vaccine 113 74% Received Vit A within 2 months of childbirth 79 52% Assisted by a qualified medical professional during childbirth 127 84% Mother delivered child in a health facility 131 86% Mother examined by a qualified medical professional within 3 days of childbirth 93 61% Women heard of fistula 44 29% WASH intervention access and use Has access to potable water source 88 58% Use appropriate method to treat potable 40 26% Use improved sanitary facility other than public facilities 62 41% Has soap and water for washing hands 54 36% Soap available at household 93 61% BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 40 Table F-5a: Access to MPA-plus Health Services for Children 24-59 Months (Source: Client Exit Survey) Client Profile: Child 24-59 Months, Respondent: Mother of the Child N=51 % Child sick today? Yes 50 98% No 1 2% Type of care received today Vaccination 0 0% Vit A 6 12% ARI treatment 0 0% Diarrhea treatment 0 0% Malaria 0 0% Fever 26 52% TB treatment 1 Other 28 55% Table F-5b. Access to MPA-plus Health Services for Women 15-49 Years (Source: Client Exit Survey) Women 15-49 Years N=231 % Type of care received at facility FP advice 71 31% TB screening last year 25 11% HIV counselling 73 32% Received HIV test results 116.5 50% Woman practices FP 118 51% Woman was referred to this facility by other facility 16 7% Health information access Women participated in health coordination meeting in community 70 30% Received health info specific for women/girl 107 46% Received SMS text health messages 7 3% WASH intervention access and use Have access to source of potable water 144 62% Improved sanitary facilities 91 39% Nurse treated woman today 137 59% BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 41 Table F-6: Access to MPA-plus Health Services for Pregnant Women (Source: Client Exit Survey) Pregnant Woman N=117 % Seeking care today? Yes 115 98% No 2 2% Type of care received today Prenatal care 101 86% Type of care received in past Iron/folic acid 59 50% TB screening last year 21 18% HIV counselling 44 38% Received HIV test results 31 26% Received HIV test results among those tested at the HC 32 73% Partner screen and received results 24 21% Couples counselling 28 24% Taking CTX 28 24% 2 doses of malaria prevention 67 57% Have access to health information Received health info specific for women/girl 57 49% Received SMS text health messages 4 3% Informed of danger signs 86 74% Informed about complication requiring immediate attention 89 76% WASH intervention access and use Have access to source of potable water 52 44% Improved sanitary facilities 47 40% Behavior: usage of ITN Use ITN 97 83% Used last night among those who use ITNs 86 89% Nurse treated woman today 110 94% BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 42 ANNEX G. QUANTITATIVE ANALYSIS RESULTS: QUALITY OF HEALTH CARE SERVICES Table G-1: Facility Infrastructure (Source: Facility Survey) Quality of Care Provision Facility Infrastructure for Facility Functionality Total (N=96) Bukavu (N=12) Kamina (N=12) Kole (N=12) Kolwezi (N=12) Lwiza (N=12) Mwene￾ditu (N=12) Tshumbe (N=12) Uvira (N=12) N % n % n % n % n % n % n % n % n % Waiting room present 83 86% 12 100% 10 83% 9 75% 11 92% 10 83% 11 92% 8 67% 12 100% Continuous supply of electricity present 30 31% 5 42% 3 25% 3 25% 6 50% 4 33% 4 33% 1 8% 4 33% Continuous water inside building present 49 51% 9 75% 5 42% 3 25% 7 58% 4 33% 10 83% 2 17% 9 75% Has emergency communication system 17 18% 3 25% 0 0% 0 0% 4 33% 5 42% 2 17% 0 0% 3 25% Has access to transportation at all times 47 49% 6 50% 4 33% 6 50% 4 33% 6 50% 9 75% 6 50% 6 50% Toilets present 88 92% 11 92% 9 75% 11 92% 11 92% 12 100% 11 92% 11 92% 12 100% Disinfectant currently in stock 76 79% 11 92% 11 92% 3 25% 10 83% 10 83% 12 100% 8 67% 11 92% Bio-medical waste disposal present 96 100% 12 100% 12 100% 12 100% 12 100% 12 100% 12 100% 12 100% 12 100% Names of facilities with adequate infrastructure (all 8 components shown above) Supervision Area 1 Burhiba Bukavu 2 HGR Bulape Lwiza 3 HGR Dilala Kolwezi 4 HGR Lemera Uvira 5 HGR Mwene-ditu Mwene-ditu 6 HGR Mwenga Bukavu 7 HGR Ruzizi Uvira BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 43 Table G-2: Staff Characteristics (Source: Facility Survey) Staff Characteristics (All SA) N=96 % % Male % Female Range Received Training in Past 3 Years Has at least one doctor 33 34% 94% 6% 1 to 15 73% Has at least one nurse A1 69 72% 87% 13% 1 to 30 72% Has at least one nurse A2 84 88% 77% 23% 1 to 36 74% Has at least one nurse A3 55 57% 65% 35% 1 to 11 51% Has at least one certified birth assistant 30 31% 0% 100% 1 to 4 77% Has at least one lay/village birth assistant 61 64% 0% 100% 1 to 8 26% Has at least one community liaison 77 80% 95% 5% 1 to 112 66% Has at least one lab technician 33 34% 94% 6% 1 to 4 79% Has at least one nutritionist 9 9% 67% 33% 1 to 3 67% Has at least one physiotherapist 3 3% 67% 33% 1 33% Has at least one other staff 77 80% 17% Table G-3: Facility Supervision and Management (Source: Facility Survey) Total (N=96) Bukavu (N=12) Kamina (N=12) Kole (N=12) Kolwezi (N=12) Lwiza (N=12) Mwene-ditu (N=12) Tshumbe (N=12) Uvira (N=12) N % n % n % n % n % n % n % n % n % Facility Supervision and Management MOH representative visits the facilities at least once in a month 46 48% 8 67% 0 0% 8 67% 1 8% 9 75% 1 8% 10 83% 9 75% Drugs and Supplies Management Source of procurement Central Office of health zone 58 60% 12 100% 0 0% 11 92% 0 0% 12 100% 0 0% 11 92% 12 100% International supplier/NGO 45 47% 5 42% 12 100% 2 17% 11 92% 2 17% 2 17% 1 8% 1 8% Private supplier 28 29% 3 25% 2 17% 0 0% 7 58% 2 17% 10 83% 0 0% 4 33% Facility experience delivery delays for medications and supplies 79 82% 7 58% 9 75% 10 83% 8 67% 12 100% 11 92% 10 83% 12 100% Central storage depleted 48 61% 5 71% 2 22% 8 80% 3 38% 9 75% 10 91% 8 80% 3 25% Inadequate transportation 27 34% 3 43% 5 56% 2 20% 3 38% 6 50% 0 0% 3 30% 5 42% Administrative difficulties 16 20% 2 29% 2 22% 1 10% 3 38% 3 25% 1 9% 0 0% 4 33% Financial problems 16 20% 3 43% 1 11% 0 0% 1 13% 1 8% 1 9% 2 20% 7 58% Facility experience delivery delays for contraceptives 42 44% 3 25% 6 50% 6 50% 6 50% 7 58% 9 75% 3 25% 2 17% Central storage depleted 22 52% 1 33% 4 67% 5 83% 3 50% 1 14% 7 78% 1 33% 0 0% Inadequate transportation 14 33% 2 67% 3 50% 1 17% 2 33% 3 43% 0 0% 1 33% 2 100% Administrative difficulties 10 24% 2 67% 0 0% 0 0% 0 0% 4 57% 2 22% 1 33% 0 0% BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 44 Total (N=96) Bukavu (N=12) Kamina (N=12) Kole (N=12) Kolwezi (N=12) Lwiza (N=12) Mwene-ditu (N=12) Tshumbe (N=12) Uvira (N=12) N % n % n % n % n % n % n % n % n % Infection Control and Waste Management Facility's method for sharps and contaminated syringes disposal By incineration 76 79% 11 92% 8 67% 10 83% 10 83% 10 83% 11 92% 6 50% 11 92% By septic pit 22 23% 3 25% 3 25% 2 17% 2 17% 5 42% 1 8% 4 33% 3 25% By special pit 10 10% 4 33% 1 8% 0 0% 0 0% 2 17% 0 0% 2 17% 0 0% Reuse 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% Facility's method for sterilization of medical equipment Boiling 58 60% 7 58% 7 58% 10 83% 4 33% 11 92% 8 67% 5 42% 6 50% Autoclave 23 24% 1 8% 4 33% 1 8% 3 25% 1 8% 3 25% 7 58% 3 25% Dry heat 15 16% 4 33% 1 8% 1 8% 5 42% 0 0% 1 8% 0 0% 3 25% Facility's method for waste disposal Burial 45 47% 5 42% 6 50% 5 42% 6 50% 8 67% 7 58% 6 50% 2 17% Outdoor incineration 40 42% 2 17% 8 67% 4 33% 7 58% 4 33% 8 67% 6 50% 1 8% Incineration in an Incinerator 34 35% 9 75% 1 8% 2 17% 6 50% 3 25% 2 17% 1 8% 10 83% Thrown outside 6 6% 0 0% 1 8% 2 17% 1 8% 1 8% 0 0% 1 8% 0 0% Table G-4: Overall Satisfaction with Services Received at Health Facilities (Source: Client Exit Survey) Overall Satisfaction: All Clients (N=383) Satisfied Not Satisfied Not sure n % n % n % With service received 346 90% 20 5% 11 3% With waiting time to see service provider 331 86% 41 11% 13 3% With the level of privacy in the examination room 351 92% 22 6% 12 3% With the amount of time service provider spent with the client 338 88% 30 8% 15 4% With the attitude of service provider toward the client 353 92% 21 5% 5 1% BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 45 Table G-5: Women 15-49 Satisfaction with Services Received at Health Facilities (Source: Client Exit Survey) Women 15-49 Years N=231 % Type of Care Received at Facility FP advice 71 31% TB screening last year 25 11% HIV counselling 73 32% Received HIV test results 116.5 50% Woman practices FP 118 51% Woman was referred to this facility by other facility 16 7% Nurse treated woman today 137 59% Woman satisfaction by interpersonal skills of nurse Showed respect 133 97% Responded to concerns 129 94% Would like to be treated again 128 93% Woman satisfaction level with quality of care provided by nurse Very satisfied 81 59% Somewhat satisfied 49 36% Neutral 4 3% Somewhat unsatisfied 2 1% Unsatisfied 1 1% Doctor treated woman today 10 4% Woman satisfied by interpersonal skills of doctor Showed respect 10 100% Responded to concerns 10 100% Would like to be treated again 10 100% Woman satisfaction level with quality of care provided by doctor Very satisfied 6 60% Somewhat satisfied 4 40% Woman thinks other health centers offer better quality of care 31 13% Women not seen by nurse or doctor today 84 36% BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 46 Table G-6: Pregnant Women’s Satisfaction with Services Received at Health Facilities (Source: Client Exit Survey) Pregnant Woman N=117 % Yes 115 98% No 2 2% Prenatal care 101 86% Nurse treated woman today 110 94% Woman satisfaction by interpersonal skills of nurse Showed respect 109 99% Responded to concerns 106 96% Would like to be treated again 107 97% Woman satisfaction level with quality of care provided by nurse Very satisfied 75 68% Somewhat satisfied 29 26% Neutral 2 2% Somewhat unsatisfied 4 4% Unsatisfied 0 0% Doctor treated woman today 7 6% Woman satisfied by interpersonal skills of doctor Showed respect 5 71% Responded to concerns 5 71% Would like to be treated again 5 71% Woman satisfaction level with quality of care provided by doctor Very satisfied 5 71% Somewhat satisfied 1 14% Woman thinks other health centers offer better quality of care 17 15% BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 47 ANNEX H. QUANTITATIVE ANALYSIS RESULTS: KNOWLEDGE, ATTITUDES, AND PRACTICES Table H-1: Client Profile: Child 0-23 Months (Based on Client Exit Survey) (Respondent = mother of the child) Client Profile: Child 0-23 Months, Respondent: Mother of the Child N=152 % Child sick today? Yes 148 97% No 4 3% Type of care received today Vaccination 24 16% Nutrition 3 2% Vit A 0 0% ARI treatment 28 18% Diarrhea treatment 53 35% Malaria 0 0% Fever 67 44% Other 63 41% Mother started breastfeeding during first hour of birth Yes 124 82% Source of early breastfeeding information (multiple responses apply) Hospital nurse 25 16% Hospital doctor 4 3% TBA 10 7% Mother 24 16% Mother-in-law 7 5% Husband 0 0% Other family member 7 5% Friend 7 5% Other sources 27 18% Child nutrition practices Mother exclusively breast-fed baby 63 41% Mother also gave the child mixed food 78 51% Child ate solid food/semi-solid food/broth at least 3 meals yesterday 54 36% Mother’s knowledge and practice for child pneumonia Mother knows two danger signs of child pneumonia 77 51% Mother bought child to HC in last 2 weeks due to suspected child pneumonia 31 20% Mother thought child has pneumonia, treated with antibiotics 27 18% Mother already has child treated for pneumonia by someone else before coming to HC 15 10% Source of consultation for pneumonia prior to coming at the health facility Family member 7 47% Friend/neighbor 2 13% Traditional healer 3 20% Traditional midwife 1 7% CHC 2 13% Informal health worker 4 27% Other 4 27% Mother’s knowledge and practice for child diarrhea Child had diarrhea in the past 2 weeks 74 49% Mother gave ORS for diarrhea 58 78% BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 48 Client Profile: Child 0-23 Months, Respondent: Mother of the Child N=152 % Mother continued feeding the child during diarrhea 63 85% Mother bought child today for diarrhea treatment 49 66% Mother’s knowledge and practice for child fever or malaria Child had fever in past 2 weeks 98 64% Child received malaria treatment within 24 hours of fever 78 80% Child slept under ITN in 2012 94 62% Child slept under ITN last night 122 80% Mother knows sign/symptoms of malaria requiring treatment right away 121 80% Mother knows sign/symptoms of malaria: fever 111 73% Mother knows sign/symptoms of malaria: Headache 25 16% Mother knows sign/symptoms of malaria: other 65 43% BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 49 ANNEX I. CLIENT EXIT SURVEY QUESTIONNAIRE English Version For female clients: Module 1: Mothers with a child 0-23 months Module 2: Mothers with a child 24-59 months Module 3: Women ages 15-49 Module 4: Pregnant women Table I-1: Client Exit Survey Questionnaire N° Question: N° Question: 01. GPS location : 02. Interviewer's code: /____________/ 03. Name of health facility _________________ 04. Facility code/____________/ 05. Name of supervision area 06. Supervision area code 07. Name of health zone 08. Health zone code 09. Woman's name: ________________________ 010. Woman's age:/___________/ 011. Type of facility:  Health center  General Referring Hospital 1 2 012. Province name and code  West Kasai  East Kasai  Katanga  South Kivu 1 2 3 4 013. Name and code of supervisor /_________ / 014. Urban/rural:  Urban  Semi-urban  Rural 1 2 3 015. Date: /____ /_____/________/ 016. Time: /_____o'clock :_______/ minutes 1. Instructions for interviewers: If the woman has two children ages 0-23 months and both of them were seen today, complete this questionnaire for the younger of the two children 0-23 months that was seen. Instructions for interviewer: Always introduce yourself and state the purpose of this interview. Hello, my name is ____________________. My colleagues and I are working on a project to support health care services in your area. I would like to interview you about the health services that you and/or your child received today. 2. Screening questions: a. Did you come to the health center today for care for this child, or for yourself? b. For this child Yes/no (If yes, eligible for module 1 or 2; go to question 3) c. For myself Yes/no (If yes, eligible for module 3 and/or 4; go to question 4) 3. How old was your child on his/her last birthday? (Instruction: record the age in months) /____/___/ 1. If between 0 and 23 months => Go to module 1 2. If between 24 and 59 months => Go to module 2 3. If older than 60 months (Verify if the response to question 2 is no 2 Stop the interview) 4. How old were you on your last birthday? /___/____/ BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 50 1. If under 15 years (Go to question 5) 2. If between 15 and 49 years => Go to module 3 3. If older than 50 years (Stop the interview) 5. Are you pregnant at this time? 1. Yes => Go to module 4 2. No Informed consent for the interviewer: This study will help identify the range of health services offered in community health centers and hospitals. It will also help focus the project's efforts to provide high-quality health services in the future. We are very interested in hearing your comments about access to the health services that you, your child, or your children received today. Your opinion is very important, because it will help improve and strengthen health services and the public's well-being. We would now like to interview you; the interview will take about 30 minutes. We ask for your consent to discuss your experience about access to the health services today at this health center. The information that you provide will not be directly linked to your name or your responses in our report. We encourage you to share your point of view and your suggestions for improvement for the Integrated Health Project/Prosani's work over the next three years. However, your participation in this interview is completely voluntary. If you choose not to participate, you will lose absolutely nothing. You can also refuse to respond to specific questions if you don't have enough information to answer them or if you think they are too personal. In addition, you can end the interview at any time. Now, please tell me if you have any objection to participating in this interview and if you have any questions before we get started. You can also ask questions or ask for clarification about the questions as we go along. Thank you very much for taking the time to talk to us. Instructions for interviewer: If the woman refuses the interview, please speak to the supervisor. If she agrees, please begin with the following questions: Module 1: Child 0-23 Months 1. Is your child sick today? YES NO 2. What type of care did your child receive today? (Check all responses that apply) a. Vaccination b. Nutrition (for example nursing, or introduction to solid food) c. Vitamin A (Note: Some mothers think that Vitamin A is a vaccine; we need to determine how to establish the difference without encouraging them toward a certain response) d. Treatment for a respiratory illness e. Treatment for diarrhea f. Treatment for malaria g. Treatment for fever h. Other: …………………………………………………. 3. Did a nurse treat your child? YES NO If no, go to question 15 4. Did the nurse treat you with respect and dignity? YES NO 5. Did the nurse treat your child with respect and dignity? YES NO 6. Did the nurse respond to all of your concerns? YES NO 7. Do you have any questions that you would like to ask the nurse? YES NO 8. Are you satisfied with the quality of care that the nurse provided to you today? (Instructions for interviewer: Read the possible responses to the woman before she responds) BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 51  VERY SATISFIED  SOMEWHAT SATISFIED  NEUTRAL  SOMEWHAT UNSATISFIED  VERY UNSATISFIED 9. Would you like this nurse to treat your child again? YES NO 10. Did a doctor treat your child today? YES NO If no, go to question 22 11. Did the doctor treat you with respect and dignity? YES NO 12. Did the doctor treat your child with respect and dignity? YES NO 13. Did the doctor respond to all of your concerns? YES NO 14. Do you have any questions that you would like to ask the doctor? YES NO 15. Are you satisfied with the quality of care that the doctor provided to your child today? (Instructions for interviewer: Read the possible responses to the woman before she responds)  VERY SATISFIED  SOMEWHAT SATISFIED  NEUTRAL  SOMEWHAT UNSATISFIED  VERY UNSATISFIED 16. Would you like this doctor to treat your child again? YES NO 17. Do you think that there are other health centers that could offer your child a better quality of care? YES NO If no, go to question 1 in the table below 18. If yes, what is the name of that center? _________________________________ Table I-2: Client Exit Survey Questionnaire: Module 1 Question: Response: Yes (1) Response: No (0) Response: I don't know (99) Child's care card (booklet) Infant nutrition: 1. Did the nurse or doctor talk to you today about your child's nutrition? (If no, go to Q3) 1 0 99 N/A 2. What did he/she tell you about the child's nutrition? Instructions for interviewer: Do not give the mother any suggestions, and check all of the responses that apply:  I should exclusively breastfeed my baby until 6 months of age.  My child should eat solid food, semi-solid food, or broth 3 times per day.  Other ……………………….  Other……………………….. 1 1 0 0 99 99 3. Did you start breastfeeding your baby during the first hour after birth? 4. If yes to Q3, who told you that it was important to breastfeed your baby during the first hour after birth? Instructions for interviewer: Do not give the respondent any suggestions, and check all of the responses that the respondent gives: • Health center nurse • Hospital nurse • Hospital doctor • Traditional midwife • Mother • Mother in law • Husband • Other family member BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 52 Question: Response: Yes (1) Response: No (0) Response: I don't know (99) Child's care card (booklet) • Friend • Other 5. Do you exclusively breastfeed your baby with your milk? If yes, go to question 8 6. Do you also give the child mixed food? 7. Did your child eat solid food, semi-solid food, or broth for at least three meals yesterday? 8. Did your child receive a dose of vitamin A in the past 6 months? 9. Was your child weighed? 10. Was your child's height or length measured? If no, go to question 11. 11. Were you informed about your baby's growth? Vaccination coverage for children 0-23 months. Instructions for interviewer: Ask the respondent to show you her child's care card (booklet) and check the status of the vaccinations that are recorded. Check the box in the last column only if the vaccine is recorded on the child's care card (booklet). 12. Do you have your child's vaccination card with you? If yes, go to question 11 and check the Vaccination Card column. 13. Did your child receive the BCG (TB) vaccine before his/her 1st birthday? 14. Did your child receive all 3 doses of the OPV (polio) vaccine before his/her 1st birthday? 15. Did your child receive all 3 doses of the DTP (diphtheria/tetanus/pertussis) vaccine before his/her 1st birthday? 16. Was your child vaccinated against measles before his/her 1st birthday? 17. Did your child receive all 3 doses of the hepatitis B vaccine before his/her 1st birthday? 18. Was your child vaccinated against yellow fever before his/her 1st birthday? 19. Do you know the two danger signs that indicate that your child has pneumonia? 20. Did you bring your child to the health center because, in the past 2 weeks, you thought that he/she might have pneumonia (rapid and labored breathing)? 21. If, in the past 2 weeks, you brought your child to the health center because you thought that he/she might have pneumonia, was he/she treated with antibiotics? 22. Did you already have your child treated for pneumonia by someone else before you came to the health center today? If no, go to Q24. 23. If yes to Q20: Who did you consult for that care? Instructions for interviewer: Do not suggest anything to the respondent, and check all care providers that she mentions:  Family member  Friend/neighbor  Traditional healer  Traditional midwife  Community health worker  Informal health worker N/A N/A N/A BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 53 Question: Response: Yes (1) Response: No (0) Response: I don't know (99) Child's care card (booklet)  Other 24. Did your child have diarrhea in the past 2 weeks? If no, go to question 27 25. Did you give him/her ORS or the recommended liquids? 26. Did you continue feeding the child while he/she had diarrhea? 27. Did you bring your child to the health center today to have him/her treated for diarrhea? 28. Did your child have a fever in the past two weeks? If no, go to question 29. 29. If yes, did the child receive a malaria prevention treatment within 24 hours after the symptoms began? 30. Did your child sleep under an insecticide￾treated mosquito net in 2012? 31. Did your child sleep under an insecticide￾treated mosquito net last night? 32. Do you know the signs and symptoms of malaria that indicate that your child needs treatment right away? If no, go to question 30 33. What are these signs or symptoms?  fever  headache  Other……………………….. 34. How many prenatal visits did you have while you were pregnant with your youngest child? /____/ 35. Did you receive at least 2 tetanus vaccinations while you were pregnant with your youngest child? 36. Did you receive a dose of vitamin A within 2 months after the birth of your youngest child? 37. Were you assisted by a qualified medical professional during the birth of your youngest child? 38. Did you give birth to your youngest child in a medical facility? 39. Were you examined by a qualified medical professional within 3 days after the birth of your youngest child? 40. Have you heard of fistulas? 41. Do you have access to a source of potable water? 42. Does your household use appropriate methods for treating potable water? 43. Does your household use improved sanitary facilities other than the public facilities? 44. At your house, do you have soap and water in a specific place for washing hands? 45. At your house, do you have soap for the members of your household? Check the response to question 2 (Check if the mother is eligible) Module 2: Mother with a child 24-59 months 1. How old is this child? /______/ (age range 24-50 months) 2. Was your child treated today? 3. What type of care did your child receive today? (Check all that apply) BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 54 a. Vaccination b. Vitamin A (Note: Some mothers may think that Vitamin A is a vaccine; we must determine how to differentiate without suggesting a response) c. Treatment for a presumed case of pneumonia or a respiratory illness d. Treatment for diarrhea e. Treatment for malaria f. Treatment for tuberculosis (TB) g. Treatment for fever h. Other 4. Did a nurse treat your child? YES NO If no, go to question 11 5. Did the nurse treat you with respect and dignity? YES NO 6. Did the nurse treat your child with respect and dignity? YES NO 7. Did the nurse respond to all of your concerns? YES NO 8. Do you have any questions that you would like to ask the nurse? YES NO 9. Are you satisfied with the quality of care that the nurse gave your child today? (Instructions for interviewer: Read the possible responses to the woman before she responds)  VERY SATISFIED  SOMEWHAT SATISFIED  NEUTRAL  SOMEWHAT UNSATISFIED  VERY UNSATISFIED 10. Would you like this nurse to treat your child again? YES NO 11. Did a doctor treat your child today? YES NO 12. Did the doctor treat you with respect? YES NO 13. Did the doctor treat your child with respect? YES NO 14. Did the doctor respond to all of your concerns? YES NO 15. Do you have any questions for the doctor? YES NO 16. Are you satisfied with the quality of care that the doctor gave your child today? (Instructions for interviewer: Read the possible responses to the woman before she responds)  VERY SATISFIED  SOMEWHAT SATISFIED  NEUTRAL  SOMEWHAT UNSATISFIED  VERY UNSATISFIED 17. Would you like this doctor to treat your child again? YES NO 18. Do you think that there are other health centers that could offer your child a better quality of care? YES NO 19. If yes, what is the name of that center? _____________________________ Check the response to question 2 (Check if the mother is eligible) Module 3: Women ages 15-49 1. Did you come here to be treated? YES NO 2. How old are you? (age range 15-49) BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 55 BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 56 Table I-3: Client Exit Survey Questionnaire: Module 3 Question: Response: Yes (1) Response: No (0) Response: I don't know (99) Did you receive advice about family planning today? 3. Do you practice family planning? 5. Were you screened for tuberculosis last year? 6. Did you receive HIV counseling and screening at this health center? If no, go to question 8 7. Did you receive the results of your HIV test? 8. Did anyone at this center transfer you to another medical facility for health services? 9. Have you participated in health coordination meetings in your community? 10. Have you received specific health information from anyone in your community that was meant specifically for you as a woman/girl? 11. Have you received health messages on your cell phone via SMS text message? 12. Do you have access to a source of potable water? 13. Do you have improved sanitary facilities at your house? 14. Did a nurse treat you? YES NO If no, go to question 20 15. Did the nurse treat you with respect? YES NO 16. Did the nurse respond to all of your concerns? YES NO 17. Do you have any questions that you would like to ask the nurse? YES NO 18. Are you satisfied with the quality of care that the nurse provided to you today? YES NO (Instructions for interviewer: Read the possible responses to the woman before she responds)  VERY SATISFIED  SOMEWHAT SATISFIED  NEUTRAL  SOMEWHAT UNSATISFIED  VERY UNSATISFIED 19. Would you like this nurse to treat you again? YES NO 20. Did a doctor treat you today? YES NO 21. Did the doctor treat you with respect? YES NO 22. Did the doctor respond to all of your concerns? YES NO 23. Do you have any questions for the doctor? YES NO 24. Are you satisfied with the quality of care that the doctor gave you today? YES NO (Instructions for interviewer: Read the possible responses to the woman before she responds)  VERY SATISFIED  SOMEWHAT SATISFIED  NEUTRAL  SOMEWHAT UNSATISFIED  VERY UNSATISFIED 25. Would you like this doctor to treat you again? YES NO 26. Do you think that there are other health centers that could offer you a better quality of care? YES NO Module 4: Pregnant Women 1. Did you come here today to seek treatment for yourself? 2. How old are you? /______/ (age range 15-49) BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 57 BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 58 Table I-4: Client Exit Survey Questionnaire: Module 4 Question: Yes (1) No (0) Don't know (99) 3. Did you receive prenatal care at the health center today? 4 Did you receive iron and folic acid supplements? 4. Were you screened for tuberculosis last year? 5. Did you receive HIV counseling and screening at this health center? 6. Did you receive the results of your HIV test? 7. Has your partner or husband been screened for HIV and has he received the results? 8. Have you and your partner had couples' counseling and have you been screened for HIV? 9. Are you taking co-trimoxazole (CTX)? 10. Have you received at least two doses of malaria prevention treatment at this health center during your pregnancy? 11. Do you use an insecticide-treated mosquito net? 12. Instructions for interviewer: If she answers yes, ask if she used an insecticide-treated net last night? 13. Have you participated in health coordination meetings in your community? 14. Have you received specific health information from anyone in your community that was meant specifically for you as a woman/girl? 15. Have you received health messages on your cell phone via SMS text message? 16 Do you have access to a source of potable water? 17. Do you have improved sanitary facilities in your house? 18. Have you received information from service providers, and have you discussed with them the danger signs that might occur during pregnancy? For example bleeding, severe headaches, dizziness, abdominal pain, contractions, decrease in fetal movement, etc. 19. Were you informed about complications that require immediate medical attention? 20. Did a nurse treat you? YES NO If no, go to question 23 21. Did the nurse treat you with respect? YES NO 22. Did the nurse respond to all of your concerns? YES NO 23. Do you have any questions that you would like to ask the nurse? YES NO 24. Are you satisfied with the quality of care that the nurse provided to you today? Instructions for interviewer: Read the possible responses to the women before she responds.  VERY SATISFIED  SOMEWHAT SATISFIED  NEUTRAL  SOMEWHAT UNSATISFIED  VERY UNSATISFIED BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 59 25. Would you like this nurse to treat you again? YES NO 26. Did a doctor treat you today? YES NO 27. Did the doctor treat you with respect? YES NO 28. Did the doctor respond to all of your concerns? YES NO 29. Do you have any questions for the doctor? YES NO 30. Are you satisfied with the quality of care that the nurse or doctor gave you today? Instructions for interviewer: Read the possible responses to the women before she responds.  VERY SATISFIED  SOMEWHAT SATISFIED  NEUTRAL  SOMEWHAT UNSATISFIED  VERY UNSATISFIED 31. Would you like this doctor to treat you again? YES NO 32. Do you think that there are other health centers that could offer you a better quality of care? YES NO I am thinking of general questions to evaluate the quality of health care services offered to the target population. These questions are for all respondents. # Questions Satisfied Not satisfied Not sure 1. Please evaluate your overall satisfaction with the service that you received? 2. Are you satisfied with the amount of time that you waited to see the health care provider? 3. Are you satisfied with the level of privacy in the examination room? 4. Are you satisfied with the amount of time that the health care provider spent with you? 5. Are you satisfied with the health care provider's attitude toward you? BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 60 French Version: Client Exit Interview Questionnaire Pour clients de sexe féminin:  Module 1. Mère avec un enfant de 0-23 mois  Module 2. Mère avec un enfant de 24-59 mois  Module 3. Femme âgée de 15-49  Module 4. Femme enceinte Table I-5: Client Exit Survey Questionnaire (français) N° QUESTION N° QUESTION 017. GPS Location : 018. Code de l’enquêteur: /____________/ 019. Nom de la structure sanitaire _________________ 020. Code de la structure :/____________/ 021. Nom de l’Aire de Supervision 022. Code de l’Aire de Supervision 023. Nom de la Zone de santé 024. Code de la Zone de santé 025. Nom de la femme : ________________________ 026. Age de la femme : /___________/ 027. Type de structure :  Centre de santé  Hôpital Général de Référence 1 2 028. Nom et code de la Province  Kasaï Occidental  Kasaï Oriental  Katanga  Sud-Kivu 1 2 3 4 029. Nom et code du superviseur : /_________/ 030. Urbain/Rural :  Urbain  Semi-urbain  Rural 1 2 3 031. Date : /____ /_____/________/ 032. Heure : /_____H:_______/ Minutes 1. Indication aux Enquêteurs: Si la femme a deux enfants âgés de 0-23 mois et si les deux enfants ont reçu des soins aujourd'hui, remplissez ce questionnaire pour le plus jeune des deux enfants de 0-23 mois ayant reçu des soins. Indications à l'enquêteur : A toutes les femmes, présentez-vous et donnez le but de cette entrevue. Bonjour, je m’appelle ______________. Mes collègues et moi travaillons pour le projet qui appuie les services de soins de santé dans votre contré. Je voudrais m’entretenir avec à propos des services de santé que vous / ou votre enfant avez reçus aujourd'hui. 2. Questions de Dépistage: a. Etes-vous venu au centre aujourd'hui pour obtenir des soins pour cet enfant ou pour vous-même ? b. Pour cet enfant Oui /Non (Si oui éligible pour module 1 ou 2 alors poser la question 3) c. Pour moi-même Oui / Non (Si oui éligible pour le module 3 et/ou4 alors posez la question 4) 3. Quel âge avait votre enfant avait à son dernier anniversaire? (Indication : complétez l'âge en mois) /____/___/ 1. Si entre 0 et 23 mois => Administrer le module 1 2. Si entre 24 et 59 mois => Administrer le module 2 3. Si 60 mois et plus (Vérifier si non à la réponse 2 de la question 2 Arrêter l’interview) 4. Quel âge aviez-vous à votre dernier anniversaire? /___/____/ BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 61 1. Si moins de 15 ans (Posez la question 5) 2. Si entre 15 et 49 ans => Administrer le module 3 3. Si 60 ans et plus (Arrêter l’interview) 5. Etes-vous actuellement enceinte ? 19. Oui => Administrer le module 4 20. Non Consentement éclairé pour l'enquêteur : Cette étude servira à déterminer la gamme de services de santé fournis dans les centres de santé communautaires et les hôpitaux. Elle va aussi servir à orienter les efforts du projet en vue de la fourniture des services de santé de haute qualité à l'avenir. Nous sommes très intéressés à écouter vos observations sur l’accession aux soins de santé que vous / votre enfant / vos enfants avez reçus aujourd’hui. Votre opinion est très importante, car il aidera à améliorer et à renforcer les services de santé et le bien-être de toute la population. Nous aimerions mener avec vous maintenant une interview qui prendra environ 30 minutes. Nous demandons votre consentement pour discuter de votre expérience sur l’accession aux services de santé aujourd'hui à ce centre de santé. Les informations que vous allez nous fournir ne seront pas liées personnellement à votre nom, à vos réponses, ni dans notre rapport. Nous vous encourageons à partager vos points de vue et vos suggestions pour améliorer les trois prochaines années de la mise en œuvre du PROSANI. Cependant, votre participation à cette interview est entièrement volontaire. Si vous optez de ne pas participer, vous ne perdez absolument rien. Vous pouvez également refuser de répondre à des questions spécifiques, si vous n'avez pas suffisamment d'informations pour y répondre, ou si vous les trouvez trop sensibles. En outre, vous pouvez à tout moment, mettre fin à cette interview. Veuillez me dire dès maintenant si vous avez une quelconque objection à participer à cette interview et si vous avez des questions avant que nous ne puissions commencer? Vous pouvez également poser des questions ou demander des éclaircissements sur des questions au fur et à que nous avançons. Merci beaucoup d'avoir pris le temps de parler avec nous. Indication pour l'enquêteur: si la femme refuse l'entrevue, veuillez-vous référer au superviseur. Si elle accepte, veuillez commencer avec les questions suivantes: BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 62 Module 1 : Enfant de 0 à 23 mois 1. Votre enfant est-il malade aujourd'hui? OUI NON 2. Quel type de soin votre enfant a-t-il reçu aujourd’hui ? (Cochez toutes les réponses qui s'appliquent) a. Vaccination b. Nutrition (par exemple, l'allaitement, l'introduction d'aliments) c. La vitamine A (NB: Certaines mères pourraient supposer que la vitamine A est un vaccin, nous devons voir comment arriver à établir la différence sans les pousser vers une réponse quelconque) d. Traitement des maladies respiratoires e. Traitement de la diarrhée f. Traitement de la malaria g. Traitement de la fièvre h. Autre: …………………………………………………. 3. Est-ce que c'est un (e) infirmier(e) qui a administré des soins à votre enfant? OUI NON Si non, passez à la question 15 4. Est-ce que l'infirmier(e) vous a traitée avec respect et dignité ? OUI NON 5. Est-ce que l'infirmier(e) a traité votre enfant avec respect et dignité ? OUI NON 6. Est-ce que l'infirmière a répondu à toutes vos préoccupations? OUI NON 7. Avez-vous des questions que vous aimeriez poser à l'infirmièr(e) ? OUI NON 8. Etes-vous satisfait de la qualité des soins que l’infirmièr(e) vous a administré aujourd'hui? (Instruction pour l’enquêteur : Lisez les réponses possibles à la femme avant qu'elle ne réponde)  TRES SATISFAITE  ASSEZ SATISFAITE  NEUTRE  PLUTOT INSATISFAITE  TRES INSATISFAITE 9. Aimeriez-vous que cet(te) infirmièr(e)puisse encore prendre soin de votre enfant? OUI NON 10. Est-ce que c’est un médecin qui a pris soins de votre enfant? OUI NON Sinon, allez à la question 22 11. Est-ce que le médecin vous a traité avec respect et dignité? OUI NON 12. Est-ce que le médecin a traité votre enfant avec respect et dignité ? OUI NON 13. Est-ce que le médecin a répondu à toutes vos préoccupations? OUI NON 14. Avez-vous des questions que vous aimeriez poser au médecin? OUI NON 15. Etes-vous satisfaite de la qualité des soins que le médecin a administré à votre enfant aujourd’hui? (Instruction pour l’enquêteur : Lisez les réponses possibles à la femme avant qu'elle ne réponde)  TRES SATISFAITE  ASSEZ SATISFAITE  NEUTRE  PLUTOT INSATISFAITE  TRES INSATISFAITE 16. Aimeriez-vous que ce médecin puisse soigner encore votre enfant? OUI NON 17. Pensez-vous qu’il y a d’autres centres de santé qui pourraient offrir à votre enfant une meilleure qualité des soins? OUI NON Sinon, allez à la question 1 du tableau ci￾dessous 18. Si oui, quel est le nom de ce centre? _________________________________ BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 63 Table I-6: Client Exit Survey Questionnaire: Module 1 (français) Question: Réponse: Oui (1) Répo nse: Non (0) Réponse: Je ne sais pas (99) Fiche de soin de l’enfant (Carnet) Nutrition du nourrisson: 1. Est-ce que l'infirmière ou docteur vous a dit (parlé) aujourd'hui sur la nutrition de votre enfant? (Si non, allez à la Q3) 1 0 99 n/a 2. Qu'est-ce qu'elle/ il vous a dit sur l'alimentation de l'enfant? Indication pour l’Enquêteur: Ne rien souffler à la mère et cochez toutes les réponses qui s’appliquent.  Allaiter exclusivement mon bébé jusqu'à 6 mois d’âge  Mon enfant doit prendre des aliments solides, semi￾solides ou de bouillie 3 fois par jour  Autre ……………………….  Autre……………………….. 1 1 0 0 99 99 3. Avez-vous commencé à allaiter votre bébé durant la première heure après sa naissance? 4. Si oui à la Q ° 3, qui vous aurait dit qu’il était important d'allaiter votre bébé durant la première heure après sa naissance? Indication pour Enquêteur Ne rien souffler au répondant et cochez toutes les catégories indiquées par le répondant : • Infirmière du centre de Santé • Infirmière à l’hôpital • Médecin à l'hôpital • Accoucheuse traditionnelle • Mère • Belle-mère • Mari • Autre membre de la famille • Ami • Autre 5. Vous ne nourrissez exclusivement votre bébé qu’avec le lait maternel? Si oui, passez à la question 8 6. Est- ce que vous lui donnez aussi des aliments mélanges? 7. Votre enfant a-t-il mangé des aliments solides, semi-solides, des aliments ou bouillie, au moins 3 repas hier? 8. Votre enfant a reçu une dose de vitamine A durant les 6 derniers mois? 9. Est-ce le poids e de votre enfant a été mesurée? 10. Est-ce la taille de votre enfant a été mesurée? si non, passez à la question 11 11. Avez-vous été informé de l'état de croissance de votre bébé? C0uverture vaccinale des enfants de 0-23 mois Indication pour Enquêteur: Demandez à l'enquêtée de vous montrer la fiche des soins de son enfant (carnet) et examinez le statut vaccinal indiquant les vaccinations enregistrées. Ne cochez la case dans la dernière colonne que si le vaccin a été enregistré dans la fiche des soins (carnet) de l'enfant. 12. Avez –vous la carte de vaccination de votre enfant sur vous ? Si oui allez à la question 11 et remplissez la colonne (Carte vaccination) BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 64 13. Est-ce que votre enfant a reçu le vaccin BCG (TB) avant son 1er anniversaire? 14. Est-ce que votre enfant a reçu toutes les 3 doses du vaccin VPO (poliomyélite) avant son 1er anniversaire? 15. Est-ce que votre enfant a reçu toutes les 3 doses du vaccin DTC (diphtérie / tétanos / coqueluche) avant son 1er anniversaire? 16. Est-ce que votre enfant était vacciné contre la rougeole avant son 1er anniversaire? 17. Est-ce que votre enfant a reçu toutes les 3 doses du vaccin contre l'hépatite B avant son 1er anniversaire? 18. Est-ce que votre enfant était vacciné contre la contre la fièvre jaune avant son 1er anniversaire? 19. Connaissez-vous les 2 signes de danger indiquant que votre enfant a la pneumonie? 20. 21. Avez-vous amené votre enfant au centre de santé parce qu'au cours des 2 dernières semaines vous pensiez qu’il pouvait avoir la pneumonie (respiration rapide et difficile)? 22. Si au cours des 2 dernières semaines, vous avez amené votre enfant au centre de santé, pensant qu’il pourrait avoir la pneumonie, était-il traité avec un antibiotique? 23. Aviez-vous déjà fait soigner votre enfant pour un cas de pneumonie par quelqu’un d’autre avant de venir au centre de santé aujourd’hui? Si non allez à q24 23. Si oui à q20: Qui avez-vous consulté pour les soins? Indication pour enquêteur: Ne rien suggérer au répondant et cochez tous les fournisseurs de soins (le personnel soignant) qu'elle indique :  Membre de famille  Ami / voisin  Guérisseur traditionnel  Accoucheuse traditionnelle  Relais communautaire  Relais prestataires  Autre n/a n/a n/a 24 Est-ce votre enfant avait la diarrhée au cours des 2 dernières semaines? Si non, allez à la question 27 24. Est-ce que vous lui aviez donné le SRO ou les liquides recommandés? 25. Est-ce que vous avez continué à le nourrir pendant qu’il avait la diarrhée? 26. Est-ce que vous avez amené votre enfant au centre de santé aujourd'hui pour le faire traiter contre la diarrhée? 27. Est-ce que votre enfant a fait de la fièvre au cours des deux dernières semaines ?, Si non allez à question 29 28. Si Oui, a-t-il reçu un traitement contre la malaria dans les 24 heures après la constatation des symptômes? 29. Est-ce que votre enfant a dormi sous une moustiquaire imprégnée d'insecticide, ou une moustiquaire traitée à l'insecticide, au cours de l’année 2012? 30. Est-ce que votre enfant a dormi sous une moustiquaire imprégnée d'insecticide la nuit dernière? 28. Connaissez-vous les signes / symptômes de la malaria indiquant que vous devez rapidement faire soigner votre enfant? Si non, allez à la question 30. 31. Quels sont ces signes ou symptômes ?  fièvre  maux de tête BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 65  Autre………………………… 32. Combien des visites prénatales avez-vous effectuées pendant que vous étiez enceinte de votre dernier né? /____/ 33. Avez-vous reçu au moins 2 vaccins contre le tétanos pendant que vous étiez enceinte de votre dernier né? 34. Avez-vous reçu une dose de vitamine A dans les 2 mois qui suivaient la naissance de votre dernier né? 35. Avez-vous été assistée par un personnel médical qualifié pendant l’accouchement de votre dernier né? 36. Avez-vous donné naissance à votre dernier né dans un établissement médical? 37. Avez-vous été examinée par un personnel médical qualifié dans les 3 jours qui suivaient la naissance de votre dernier né? 38. Avez-vous déjà entendu parler de la fistule? 39. Avez-vous accès à une source d'eau potable ? 40. Est-ce que votre ménage utilise des méthodes appropriées de traitement d'eau potable? 41. Votre ménage utilise-t-il des installations sanitaires améliorées autres que les installations communes ? 42. Il y a-t-il chez vous à la maison de l’eau et du savon dans un emplacement spécifique de lavage des mains? 43. Il y a-t-il quelque part chez vous à la maison du savon pour les membres de votre ménage ? Rentrer au contrôle pour vérifier la question 2 (Vérifier si la mère est éligible) BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 66 Module 2 : Mère avec un enfant de 24-59 mois 1. Cet enfant a quel âge ? /______/ (tranche d’âge de 24-59 mois) 2. Votre enfant-il était soigné aujourd’hui ? 3. Quel type de soins votre enfant a-t-il reçu aujourd'hui? (Cochez tout ce qui s'applique) a. Vaccination b. Vitamine A (NB: Certaines mères pourraient supposer que la vitamine A est un vaccin, nous devons savoir comment différencier ceci sans souffler des réponses) c. Traitement d’un cas présumé de pneumonie les ou d’une maladie respiratoire d. Traitement de la diarrhée e. Traitement de la malaria f. Traitement de la tuberculose (TB) g. Traitement de la fièvre h. Autre 4. Est-ce qu'un(e ) infirmièr(e) a administré des soins à votre enfant? OUI NON Si non, allez à la question 11 5. Est-ce que l'infirmière vous a traitée avec respect et dignité ? OUI NON 6. Est-que l'infirmière a traité votre enfant avec respect et dignité ? OUI NON 7. Est-que l'infirmière a répondu à toutes vos préoccupations? OUI NON 8. Avez-vous des questions que vous aimeriez poser à l'infirmière? OUI NON 9. Etes-vous satisfaite de la qualité des soins que l’infirmière a administré à votre enfant aujourd'hui? (Instruction pour l’enquêteur : Lisez les réponses possibles à la femme avant qu'elle ne réponde)  TRES SATISFAITE  ASSEZ SATISFAITE  NEUTRE  PLUTOT INSATISFAITE  TRES INSATISFAITE 10. Aimeriez-vous que cette infirmière puisse encore prendre soin de votre enfant? OUI NON 11. Est-ce que c’est un médecin qui a pris soins de votre enfant? OUI NON 12. Est-ce que le médecin vous a traitée avec respect? OUI NON 13. Est-ce que le médecin a traité votre enfant avec respect? OUI NON 14. Est-ce que le médecin a répondu à toutes vos préoccupations? OUI NON 15. Avez-vous des questions que vous aimeriez poser au médecin? OUI NON 16. Etes-vous satisfaite de la qualité des soins que l’infirmière a administre à votre enfant aujourd’hui? (Instruction pour l’enquêteur : Lisez les réponses possibles à la femme avant qu'elle ne réponde)  TRES SATISFAITE  ASSEZ SATISFAITE  NEUTRE  PLUTOT INSATISFAITE  TRES INSATISFAITE  17. Aimeriez-vous que ce médecin puisse soigner votre enfant? OUI NON 18. Pensez-vous qu’il y a d’autres centres de santé qui pourraient offrir à votre enfant une meilleure qualité des soins? OUI NON 19. Si oui, quel est le nom de ce centre? _____________________________ BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 67 Rentrer au contrôle pour vérifier la question 2 (Vérifier si la mère est éligible) BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 68 Module 3 : Femme agée de 15-49 1. Etes-vous venu vous faire soigner ? OUI NON 2. Quel âge avez-vous? (tranche d’âge 15-49) Table I-7: Client Exit Survey Questionnaire: Module 3 (français) Question: Répons e: Oui (1) Réponse: Non (0) Réponse: Je ne sais pas (99) 3. Avez-vous reçu des conseils sur la planification familiale aujourd'hui? 4. Est-ce que vous pratiquez la planification familiale? 5. Avez-vous été soumise à un dépistage de la tuberculose l’an dernier? 6. Avez-vous reçu le counseling et le dépistage du VIH à ce centre de santé ? si non, passez à la question 8 7. Avez-vous reçu les résultats de votre test de VIH? 8. Quelqu'un dans ce centre vous-t-il transféré vers une autre formation médicale pour les services de santé 9. Avez-vous participé à des réunions de coordination de la santé dans votre communauté? 10. Avez-vous reçu de la part de quelqu’un dans votre communauté des informations spécifiques de santé, adressées à vous en tant que femme/jeune fille? 11. Avez-vous reçu des messages de santé par SMS sur votre téléphone portable? 12. Avez-vous accès à une source d'eau potable ? 13. Avez-vous des installations sanitaires améliorées chez vous à la maison? 14. Est-ce que c’est une infirmière qui vous a administré des soins? OUI NON Si non, allez à la question 20 15. Est-ce que l'infirmière vous a traitée avec respect? OUI NON 16. Est-ce que l'infirmière a répondu à toutes vos préoccupations? OUI NON 17. Avez-vous des questions que vous aimeriez poser à l'infirmière? OUI NON 18. Etes-vous satisfaite de la qualité des soins que l’infirmière vous a administré aujourd'hui? OUI NON (Instruction pour l’enquêteur : Lisez les réponses possibles à la femme avant qu'elle ne réponde)  TRES SATISFAITE  ASSEZ SATISFAITE  NEUTRE  PLUTOT INSATISFAITE  TRES INSATISFAITE 19. Aimeriez-vous que cette infirmière puisse encore prendre soin de vous? OUI NON 20. Est-ce que c’est un médecin qui a pris soins de vous? OUI NON 21. Est-ce que le médecin vous a traité avec respect? OUI NON 22. Est-ce que le médecin a répondu à toutes vos préoccupations? OUI NON 23. Avez-vous des questions que vous aimeriez poser au médecin? OUI NON 24. Etes-vous satisfaite de la qualité des soins que le médecin vous a administrés aujourd’hui? OUI NON (Instruction pour l’enquêteur : Lisez les réponses possibles à la femme avant qu'elle ne réponde)  TRES SATISFAITE  ASSEZ SATISFAITE BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 69  NEUTRE  PLUTOT INSATISFAITE  TRES INSATISFAITE 25. Aimeriez-vous que ce médecin puisse encore vous soigner? OUI NON 26. Pensez-vous qu’il y a d’autres centres de santé qui pourraient vous offrir une meilleure qualité des soins? OUI NON Module 4: Femme enceinte 1. Etes-vous venu aujourd’hui pour vous faire soigner vous-même? 2. Quel âge avez-vous? /______/ (Tranche d’âge 15-49) Table I-8: Client Exit Survey Questionnaire: Module 4 (français) Question: Oui (1) Non (0) Ne sait pas (99) 3. Avez-vous reçu des soins prénatals aujourd'hui au centre de santé? 4. Avez-vous reçu un complément de fer et d’acide folique? 4. Avez-vous fait le dépistage de la tuberculose l’an dernier? 5. Avez-vous reçu le counseling et le dépistage du VIH à ce centre de santé ? 6. Avez-vous reçu les résultats de votre test du VIH? 7. Votre partenaire ou votre mari a-t-il été soumis au dépistage de VIH et a-t-il reçu le résultat? 8. Avez-vous suivi, votre partenaire et vous, le counseling pour couples et avez￾vous été soumis au dépistage de VIH? 9. Est-ce que vous recevez le traitement par le co-trimoxazole (CTX)? 10. Avez-vous reçu au moins deux doses de traitement préventif contre la malaria au centre de santé pendant votre grossesse? 11. Est-ce que vous utilisez une moustiquaire imprégnée d'insecticide? 12. Indication pour l'enquêteur : Si elle répond oui, demandez si elle a utilisé une moustiquaire imprégnée la nuit dernière? 13. Avez-vous participé à des réunions de coordination de la santé dans votre communauté? 14. Avez-vous reçu de la part de quelqu’un dans votre communauté, des informations spécifiques de santé spécialement adressée à vous en tant que femme / jeune fille ? 15. Avez-vous reçu des messages de santé par SMS sur votre téléphone portable? 16. Avez-vous accès à une source d'eau potable ? 17. Avez-vous des installations sanitaires améliorées dans votre maison? 18. Avez-vous été informé des fournisseurs des services et avez-vous discuté avec eux les signes de danger qui peuvent survenir pendant la grossesse. Par exemple, des saignements, des maux de tête sévères, des vertiges, des douleurs abdominales, des contractions, diminution des mouvements fœtaux, etc. 19. Etiez-vous informé des complications qui nécessitent une consultation médicale? 20. Est-ce que c’est une infirmière qui vous a administré des soins? OUI NON (Si non, passez à la question 23) 21. Est-ce que l'infirmière vous a traitée avec respect ? OUI NON 22. Est-ce que l'infirmière a répondu à toutes vos préoccupations ? OUI NON 23. Avez-vous des questions que vous aimeriez poser à l'infirmière ? OUI NON 24. Etes-vous satisfaite de la qualité des soins que l’infirmière vous a administrée aujourd'hui? (Indication pour l’enquêteur : Lisez les réponses possibles à la femme avant qu'elle ne réponde) BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 70  TRES SATISFAITE  ASSEZ SATISFAITE  NEUTRE  PLUTOT INSATISFAITE  TRES INSATISFAITE 25. Aimeriez-vous que cette infirmière puisse encore prendre soin de vous ? OUI NON 26. Est-ce que c’est un médecin qui a pris soins de vous ? OUI NON 27. Est-ce que le médecin vous a traité avec respect OUI NON ? 28. Est-ce que le médecin a répondu à toutes vos préoccupations OUI NON ? 29. Avez-vous des questions que vous aimeriez poser au médecin OUI NON ? 30. Etes-vous satisfaite de la qualité des soins que l’infirmière ou le médecin vous a administré aujourd’hui ? (Indication pour l’enquêteur : Lisez les réponses possibles à la femme avant qu'elle ne réponde)  TRES SATISFAITE  ASSEZ SATISFAITE  NEUTRE  PLUTOT INSATISFAITE  TRES INSATISFAIT 31. Aimeriez-vous que ce médecin puisse encore vous soigner ? OUI NON 32. Pensez-vous qu’il y a d’autres centres de santé qui pourraient vous offrir une meilleure qualité des soins ? OUI NON Je pense à des questions d'ordre général pour évaluer la qualité des services (soins de santé) offerts à la population cible. Ces questions, sont à posées à tous les répondants: # Questions Satisfaite Pas Satisfaite Incertaine 1. Veuillez évaluer votre satisfaction globale à l'égard du service que vous avez reçu? 2. Etes-vous satisfaite du temps d’attente avant de voir le fournisseur de services de santé? 3. Etes-vous satisfaite des conditions d’intimité dans la salle de consultation ? 4. Etes-vous satisfaite du temps que vous réserve le fournisseur des soins de santé? 5. Etes-vous satisfaite de l’attitude du fournisseur des services de santé à votre égard ? BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 71 ANNEX J. HEALTH FACILITIES SURVEY QUESTIONNAIRE English Version: Baseline Evaluation Table J-1: Questionnaire: Availability of Services and Equipment N° Question: N° Question: 033. GPS location : 034. Data collector code: 035. Name of health structure _________________ 036. Facility code /____________/ 037. Name of supervision area 038. Supervision area code 039. Name of health zone 040. Health zone Code 041. Type of facility:  Health center  General Referring Hospital (GHR) 1 2 042. Province name and code  West Kasai  East Kasai  Katanga  South Kivu 1 2 3 4 043. Name and code of Supervisor 044. Urban/Rural:  Urban  Semi-urban  Rural 1 2 3 045. Respondent's professional category:  Physician  State Registered Nurse  State Registered Midwife Health Technician  Technical Health Agent  Physician in training/volunteer physician  Other trainee/volunteer  Other (specify): _________________ 1 2 3 4 5 6 7 046. Date and time of survey  Date: /____ /____/______/  Time: /_____o'clock :_______/ minutes Guide to the survey on availability of services and equipment Locate the Head Nurse and the Health Center Director/ Head Physician of the General Hospital, and introduce yourself as follows: Hello. My name is ____________________. I represent IBTCI/CESD, a research organization working with USAID in cooperation with the Ministry of Health. We are conducting a survey on health facilities supported by USAID through MSH/IHP (Prosani), with the goal of identifying ways to improve services. We would like to interview you about the situation at this facility, and the availability of services and equipment. Be assured that our conversation will remain strictly confidential, and you will not be identified in any way. At any time, you may choose to stop the interview or refuse to answer a question. May I proceed? Yes... No… If no, go to the end of the questionnaire. BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 72 Table J-2: Module 1: General Information (IG) on the Health Facility N° QUESTIONS CODE IG1. Simply observe and note Do you see a sign or poster showing the availability of the following services (circle all appropriate responses)? A) Family planning services. B) Infant health services C) Prenatal care D) STI/AIDS consultations E) Prices for services If prices are NOT posted: Skip to IG3 Yes, Yes, No OUTSIDE INSIDE 1 2 0 1 2 0 1 2 0 1 2 0 1 2 0 IG2. If yes, what is the posted price for:  Initial visit forms  Malaria case  Diarrhea case  Prenatal consultation  Childbirth  Family planning  Other (specify): __________________________  Other (specify): __________________________  Other (specify): __________________________  Other (specify): __________________________ /______________/ FC /______________/ FC /______________/ FC /______________/ FC /______________/ FC /______________/ FC /______________/ FC /______________/ FC /______________/ FC /______________/ FC /______________/ FC /______________/ FC IG3. Is there a waiting room for patients? Yes No 1 2 IG4. How many days is this facility open to outpatients? (Outpatients are those who are receiving preventive or curative care and going home the same day). Number of days per week Number of days per month Don't know /______/ days /______/ days 98 IG5. Does this center provide care 24 hours per day? Yes No 1 2 IG6. At what time do outpatient care hours begin? /________ / IG7. At what time do outpatient care hours end? /________ / IG8. Do you have a continuous electricity source in the building? Yes No If no, go to IG11 1 2 IG9. If yes, is it: A generator A solar panel SNEL (public electricity) Other (specify): _____________________ 1 2 3 4 IG10. Do you have electricity today? Yes 1 BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 73 N° QUESTIONS CODE No 2 IG11. Do you have a continuous water supply inside the building? Yes No If no, go to IG14 1 2 IG12. If yes, is it: A water hole An improved well REGIDESO (public water supply) A rainwater cistern Other (specify): 1 2 3 4 5 IG13. Do you have running water today? Yes No 1 2 IG14. Does the facility have an emergency communications system? Yes No If no, go to IG17 1 2 IG15. If yes, is it: A telephone Radiotelephone Motorola/VHF radio Internet A short wave radio Other (specify): 1 2 3 4 5 6 IG16. Does this equipment work? Yes No 1 2 IG17. Does the facility have access to a transportation method at all times? Yes No If no, go to IG19 1 2 IG18. What type of transportation method does the facility have at this time? A motorcycle A vehicle A bicycle Other (specify): 1 2 3 4 IG19. Are there toilets? Yes No 1 If no, go to IG21 IG20. If yes, what type of toilet/shower? Septic pit latrines Pit toilet Other (specify): 1 2 3 IG21. What disinfectant(s) is/are used in the health facility? Cyteal (chlorhexidine - gluconate) Dakin’s solution Bleach (sodium hypochlorite/chlorine solution/JIK solution) Denatured alcohol 1 2 3 4 BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 74 N° QUESTIONS CODE Other (specify): _________________ 5 IG22. Do you currently have disinfectants in stock? Yes No 1 2 IG23. What procedure is used to decontaminate medical equipment after initial use? Soak in a disinfectant solution, then brush and scrub with soap and water Scrub with soap and water, then soak in a disinfectant solution Only scrub with soap and water Only soak in a disinfectant solution Clean with soap and water Equipment is never decontaminated Equipment is never reused Other (specify): ________________________________________________ 1 2 3 4 5 6 7 8 IG24. What procedure is used to sterilize the medical equipment before it is reused? Dry heat sterilization (Poupinel) Autoclave Boiling Steam sterilization Chemical method Other (specify): _____________________________ 1 2 3 4 5 6 IG25. Are there procedures for disposing of biomedical waste? Yes No Don't know 1 2 98 IG26. How does the facility dispose of waste? Incineration in an incinerator Outdoor incineration Burial Thrown outside Other (specify): ___________________________ 1 2 3 4 5 IG27. Data collector's comments IG28. Supervisor's comments Table J-3: Module 2: Personnel Statistics (SP) Professional Categories SP1: Number of available personnel currently working Number: Don't know=98; Not determined=99 a) Physicians b) Nurses A1 c) Nurses A2 d) Nurses A3 e) Certified birth assistants f) Lay midwives/Village birth assistants g) Community liaisons h) Laboratory technicians i) Nutritionists j) Physiotherapists BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 75 Professional Categories SP1: Number of available personnel currently working Number: Don't know=98; Not determined=99 k) Other (specify) : ___________________________ Other (specify): ___________________________ Other (specify): ___________________________ Category SP2 : Sex: What services does (NAME) provide? SP7: Has (Category) received training during the previous 3 years? SP3. Family planning SP4. Prenatal/ postnatal care SP5. Child health SP6. STI/AIDS a) Physicians M....1 F….2 Yes....1 No...2 Yes....1 No...2 Yes....1 No...2 Yes....1 No...2 Yes....1 No...2 [ to b)] b) Nurses A1 M....1 F….2 Yes....1 No...2 Yes....1 No...2 Yes....1 No...2 Yes....1 No...2 Yes....1 No...2 [ to b)] c) Nurses A2 M....1 F….2 Yes....1 No...2 Yes....1 No...2 Yes....1 No...2 Yes....1 No...2 Yes....1 No...2 [to d)] d) Nurses A3 M....1 F….2 Yes....1 No...2 Yes....1 No...2 Yes....1 No...2 Yes....1 No...2 Yes....1 No...2 [to e)] e) Certified birth assistants M....1 F….2 Yes....1 No...2 Yes....1 No...2 Yes....1 No...2 Yes....1 No...2 Yes....1 No...2 [to f)] f) Lay midwives/Village birth assistants M....1 F….2 Yes....1 No...2 Yes....1 No...2 Yes....1 No...2 Yes....1 No...2 Yes....1 No...2 [to g)] g) Community liaisons M....1 F….2 Yes....1 No...2 Yes....1 No...2 Yes....1 No...2 Yes....1 No...2 Yes....1 No...2 [to h)] h) Laboratory technicians M....1 F….2 Yes....1 No...2 Yes....1 No...2 Yes....1 No...2 Yes....1 No...2 Yes....1 No...2 [to i)] i) Nutritionists M....1 F….2 Yes....1 No...2 Yes....1 No...2 Yes....1 No...2 Yes....1 No...2 Yes....1 Non...2 [to j)] j) Physiotherapists M....1 F….2 Yes....1 No...2 Yes....1 No...2 Yes....1 No...2 Yes....1 No...2 Yes....1 No...2 [to i)] k) Other (specify) : ___________________________ M....1 F….2 Yes....1 No...2 Yes....1 No...2 Yes....1 No...2 Yes....1 No...2 Yes....1 Non...2 [to j)] Other (specify): ___________________________ M....1 F….2 Yes....1 No...2 Yes....1 No...2 Yes....1 No...2 Yes....1 No...2 Yes....1 No...2 [to i)] Other (specify): ___________________________ M....1 F….2 Yes....1 No...2 Yes....1 No...2 Yes....1 No...2 Yes....1 No...2 Yes....1 Non...2 [to j)] Table J-4: Module 3: Preventive Care (PREV) N° QUESTIONS CODES PREV1. How many outpatients (total) were seen at this facility in the past 12 months? (Total for the past 12 months for which data are available.) Number Don't know /_______ / 98 PNC PREV2. Does this facility offer prenatal consultations (PNC)? Yes No 1 2 [Go to Prev20] PREV3. How many days per week are PNC patients seen at this facility? Number per week Number per month Don't know /_______ / /_______ / 98 BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 76 N° QUESTIONS CODES PREV4. How many prenatal consultations were given at this health center in 2012? Number Don't know /_______ / 98 PREV5. In the past 6 months, how many meetings did this health facility hold with traditional birth assistants? Number Don't know /_______ / 98 PREV6. Throughout 2012, did you routinely prescribe iron and folic acid? Interviewer: verify written records. If there are no written records, ask the director. Record the responses, noting whether or not you verified the written records. Yes No Don't know 1 2 98 PREV7. Do pregnant women receive Vitamin A during prenatal consultations? Yes No 1 2 PREV8. Do women who come to the health facility for prenatal care receive prenatal or maternal health cards? If no, go to PREV10 Yes No 1 2 PREV9. Where is the maternal health card kept once it has been issued to the mother? It is given to the mother so that she can bring it to the next visit. 1 It is kept at the health facility. 2 One copy is given to the mother and the other copy is kept at the hospital. 3 Other (specify): __________________________ 4 PREV10. Can you show me the cards belonging to specific patients? Seen Not seen 1 2 PMTCT PREV11. During prenatal consultations, are women advised to be tested for HIV for PMTCT purposes? If no, go to PREV20 Yes No 1 2 PREV12. Does the center routinely offer the HIV test to pregnant women to prevent mother to child transmission? Yes No 1 2 PREV13. Does the center have personnel trained in PMTCT? Yes No 1 2 PREV14. How many pregnant women were screened for HIV in 2012? Number Don't know /__________/ 98 PREV15. What services does the center offer to pregnant women who test positive for HIV, and to their babies? Referred to the General Hospital for treatment. 1 Given co-trimoxazole. 2 Given family planning advice. 3 Children born to HIV-positive mothers given co-trimoxazole. 4 Given nutritional advice. 5 Other (specify): 6 PREV16. How many women who tested positive for HIV were given ARVs to prevent transmission of HIV to their babies? Number Don't know /__________/ 98 PREV17. How many babies born to HIV-positive mothers received anti-retroviral treatments for HIV prevention at birth? Number Don't know /__________/ 98 PREV18. Were the partners/husbands of pregnant women who Yes 1 BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 77 N° QUESTIONS CODES tested positive for HIV asked to be tested? No 2 PREV19. How many partners/husbands of women who tested positive for HIV agreed to be tested? Number Don't know /__________/ 98 CHILDBIRTH AND POSTPARTUM PREV20. Does this facility have a maternity unit? Yes No 1 2 PREV21. Is the maternity unit open 24 hours per day? Yes No 1 2 PREV22. Do the health facility's employees offer labor and delivery services in the health facility, in the community, or both? Only in the health facility. 1 Only in the community 2 In both the health facility and the community. 3 PREV23. How many deliveries did this facility's personnel attend in 2012? Number Don't know /__________/ 98 PREV24. Is the health facility capable of managing emergency caesareans? They can be managed now 1 They can usually be managed, but not now 2 They must be transferred 3 PREV25. For health centers, do you have written instructions that pregnant women can refer to in the event of obstetric complications? Yes No 1 2 [Go to Prev27] PREV26. If yes, how many women were referred to the general hospital for obstetric complications in 2012? Number Don't know /__________/ 98 PREV27. Does this health facility offer postpartum care? Yes No 1 2 PREV28.Are the postpartum services offered only at specific times, during outpatient consultation hours, or both? Only at specific times 1 During outpatient consultation hours 2 Both at specific times and during outpatient consultation hours 3 PREV29. In 2012, on how many days were women allowed to have postpartum care? Number Don't know /__________/ 98 PREV30. What postpartum care is given to women? 1 2 3 4 5 PREV31. In 2012, how many clinical information sessions did the health facility have for postpartum clients? Number Don't know /__________/ 98 PREV32. In 2012, how many maternal deaths did the health facility have? Interviewer: verify written records. Number Don't know /__________/ 98 FAMILY PLANNING PREV33. Does this facility offer family planning services? (Family planning includes methods and advice for spacing or limiting births). Yes No 1 2 PREV34. How many days per week are family planning services available? Number of days per week Number of days per month Don't know /__________/ /__________/ 98 PREV35. How many family planning consultations took place at this health center in the past 12 months? Number Don't know /__________/ 98 PREV36. What family planning methods are given to women at this health center? Oral contraceptives 1 Condoms 2 BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 78 N° QUESTIONS CODES Injections 3 IUD 4 Cycle beads 5 Natural lactation method 6 Other (specify): _____________________ 7 CHILD HEALTH CARE PREV37. What types of child health care does this facility offer? (Preventive and curative infant care included.) Note all types of care Curative care 1 Preventive care 2 Health promotion care 3 PREV38. What types of preventive care does your facility offer? Immunizations 1 Growth and weight gain tracking 2 Other (specify): 3 PREV39. How many days do you offer preventive care for children? Number per week Number per month Don't know /__________/ /__________/ 98 PREV40. Is there a vaccine education plan in place for this year? Yes No 1 2 PREV41. How many of the following storage methods does this site have for vaccine storage? Refrigerator with a refrigerated section 1 Ice chest 2 Freezer 3 Vaccine carrier 4 Ice packs 5 None 6 PREV42.Are temperature variations recorded? Interviewer: If yes, ask to see these. Yes, seen 1 Yes, not seen 2 No 3 PREV43. In the past 7 days, on how many days was the temperature recorded? Number Don't know /__________/ 98 PREV44. In the past 7 days, how many times was the temperature recorded, in total? Number Don't know /__________/ 98 PREV45. In the past 7 days, on how many days did you record temperatures above 80C or below 20C? Number Don't know /__________/ 98 PREV46. Does every child who starts the vaccination program receive a vaccination card? Yes No 1 2 PREV47. Where are the vaccination cards kept after the vaccination program starts? They are given to the parent or guardian so that he/she can bring them to the next visit 1 They are kept at the health facility 2 One copy is given to the parent and the other copy is kept at the hospital. 3 Other (specify): ______________________________ 4 PREV48. Can you show me the cards belonging to specific patients? Seen Not seen 1 2 PREV49. Does this facility have a child vaccination unit? Yes No 1 2 PREV50. How many days per week are vaccination services available? Number Don't know /__________/ 98 PREV51. How many children received a first diphtheria/tetanus/pertussis (DTP1) vaccine in this health center in 2012? Number Don't know /__________/ 98 PREV52. In 2012, how many children received the full vaccination? Number Don't know /__________/ 98 PREV53. How many consultations for sick children took How many children 0-11 /_______ / BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 79 N° QUESTIONS CODES place in this facility in the past 12 months? months How many children 12-23 months /_______ / How many children 24-59 months /_______ / How many children 0-24 months /_______ / How many children 0-59 months /_______ / PREV54. How many preventive care visits for children took place in this facility in the past 12 months? How many children 0-11 months /_______ / How many children 12-23 months /_______ / How many children 24-59 months /_______ / How many children 0-24 months /_______ / How many children 0-59 months /_______ / STIs PREV55. Does this facility offer sexually transmitted infection (STI) consultations? If no, go to PREV69 Yes No 1 2 PREV56. How many days are STI consultations available? Number per week Number per month Don't know /_______ / /_______ / 98 PREV57. What protocol does the center use for managing STIs? Etiologic method 1 Syndrome approach 2 Other (specify) __________________ 3 Don't know 98 PREV58. Did the center have a shortage of STI medications in 2012? Yes No Don't know 1 2 98 PREV59. Does the center currently have medications for managing STIs? Yes No Don't know 1 2 98 PREV60. How many STI consultations took place in the center in 2012? Number Don't know /_______ / 98 HIV AIDS PREV61. Does this facility offer HIV/AIDS consultation services? Yes No 1 2 [Go to Prev67] PREV62. How many days are HIV/AIDS consultations available? Number per week Number per month Don't know /_______ / /_______ / 98 PREV63. How many HIV/AIDS consultations took place at this health center in the past 12 months? Number Don't know /_______ / 98 PREV64. Is HIV/AIDS prevention information given to the public? Yes No Don't know 1 2 98 PREV65. If yes, what information? Information about prevention Information about management Information about decreasing 1 2 3 BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 80 N° QUESTIONS CODES the effects of the disease PREV66. What media are used? Posters Leaflets Video messages Audio messages Information provided during prenatal consultations and preschool health visits Community education activities Other (specify): __________________________ 1 2 3 4 5 6 7 PREV67. Does the facility have written instructions for handling rape and other gender-based violence? Yes No Don't know 1 2 98 PREV68. Does the facility have PEP (post￾exposure prophylaxis) kits? Yes No Don't know 1 2 98 MALARIA PREVENTION PREV69. Does the health facility have a malaria-prevention program involving distribution of insecticide-treated mosquito nets? Yes No 1 2 PREV70. If yes, to whom are the insecticide-treated mosquito nets distributed? To pregnant women To women with children 0-23 months Other (specify): _________________ 1 2 3 PREV71.Are the insecticide-treated mosquito nets distributed for free, or sold? Distributed for free Sold 1 2 PREV72.Are the insecticide-treated mosquito nets currently in stock? Yes No 1 2 BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 81 Table J-5: Module 4: Curative Care (SC) N° QUESTIONS CODES MALARIA, ARIs and HIV/AIDS SC1. Does this facility offer care/treatment for children with the following diseases? Malaria Yes No Don't know 1 2 98 Acute Respiratory Infections Yes No Don't know 1 2 98 HIV/AIDS Yes No Don't know 1 2 98 SC2. How many days is treatment offered to sick children? Number per week Number per month Don't know /_______ / /_______ / 98 SC3. Does the facility have a written protocol for treating childhood diseases? Yes No Don't know 1 2 98 SC4. If yes, verify that the document exists Exists, and is posted Exists, and is not posted 1 2 SC5. Have the personnel assigned to these treatments been trained in IMCI? Yes No Don't know 1 2 98 SC6. Does the facility have the required medications and supplies in stock? Yes No Don't know 1 2 98 SC7. Are the medications to treat these diseases provided to children within the facility itself, or do the parents have to obtain them from an outside pharmacy? They must be obtained from the facility's pharmacy They must be obtained outside the center It depends on the parents Don't know 1 2 3 98 SC8. Does the cost of treatment for these diseases include the consultation and medications? Yes No Don't know 1 2 98 SC9. How many consultations for sick children took place in this facility in the past 12 months? How many children 0-11 months /_______ / How many children 12-23 months /_______ / How many children 24-59 months /_______ / How many children 0-24 months /_______ / How many children 0-59 months /_______ / CHRONIC DISEASES SC10. What tuberculosis-related services does this health facility offer? Interviewer: A Tuberculosis Room is a space in the health facility where people who have tuberculosis can be seen and treated. If none, go to SC15 Only services related to diagnosis 1 Only services related to treatment 2 Both diagnosis and treatment services 3 none 4 SC11. Is there a room reserved for tuberculosis patients in the health facility? Interviewer: A Tuberculosis Room is a space in the health facility where people who have tuberculosis can be seen and treated. Yes No 1 2 BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 82 N° QUESTIONS CODES SC12. Are people diagnosed with tuberculosis monitored at the community level? Yes No 1 2 SC13. Are people in contact with tuberculosis patients asked to be tested? Yes No 1 2 SC14. Is there a tuberculosis registry? If yes, ask to see it. Yes No 1 2 SC15. Does the center have the document listing the Standards and procedures for reproductive health services, adopted in 1997? Yes No 1 2 [Go to SC17] SC16. May I see a copy of this document? Seen Not seen 1 2 SC17. How are people who test positive for HIV managed and treated? The general hospital physician writes a prescription The facility only renews a prescription written by the doctor Nothing is done for these patients The facility does not do testing Other (specify): ___________________________________________ 1 2 3 4 5 SC18. Does the facility have written instructions for HIV testing, and for managing patients living with HIV? Yes No 1 2 SC19. Does the facility have written instructions for blood transfusions? If no, go to SC21 Yes No 1 2 SC20. Does the facility do blood transfusions? Yes No 1 2 SC21. If no, what does the facility do if a child or a pregnant woman needs a blood transfusion? Transfer the patient to the General Hospital Transfer the patient to another medical facility Don't know 1 2 98 SC22. Does the facility have written instructions for managing cases of the following diseases? : Leprosy Trypanosomiasis Lymphatic filariasis Onchocerciasis Schistosomiasis Verminosis 1 2 3 4 5 6 SC23. Does the facility perform minor surgery? Yes No 1 2 SC24. How many minor surgeries did you perform in 2012? Number Don't know /_______ / 98 SC25. Does the facility perform nutritional rehabilitation? Yes No 1 2 HEALTH PROMOTION ACTIVITIES SC26. Does the facility perform the following health promotion activities? SC27. Promoting the use of condoms Yes No Don't know SC28. Hygiene and sanitation Yes No Don't know SC29. Exclusive breastfeeding of children for the first six months of life Yes No Don't know SC30. Food hygiene/food safety Yes No BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 83 N° QUESTIONS CODES Don't know SC31. Consumption of iodized salt Yes No Don't know SC32. Improvement of latrines Yes No Don't know SC33. Promotion of oral rehydration for diarrhea in children Yes No Don't know SC34. Information on fistula prevention Yes No Don't know Table J-6: Module 5: Supervision (SUP) N° Question: Responses Code SU1. A supervision visit is a visit from a Ministry of Health representative who comes to observe the facility in order to help personnel improve services. When was your facility's last supervision visit? Last month During the last three months During the last six months More than six months ago Never [Go to module 6] Don't know [Go to module 6] This month 1 2 3 4 5 6 7 SU2. What took place during this supervision visit? CIRCLE ALL RESPONSES MENTIONED. ASK QUESTIONS. Anything else? Review of files/reports Meetings Inspection/delivery of equipment Observation of patient consultations Discussion of problems Discussion about personnel Other________________________ Nothing Don't know 1 2 3 4 5 6 7 8 98 Table J-7: Module 6: Equipment and Materials (EM) I would like to ask you a few questions about this facility's equipment and materials: N° Question: Responses Code EM1. What method is most often used for high-level disinfection or sterilization of medical equipment and supplies? Hot plate Steam sterilizer (steamer) Chlorhexidine Bleach Other None Don't know 1 2 3 4 5 6 98 EM2. How do you dispose of your contaminated syringes and sharps? (CIRCLE ALL RESPONSES MENTIONED) Incineration Burial Trash Reuse 1 2 3 4 BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 84 N° Question: Responses Code Septic pit Special pit Other____________________ Don't know 5 98 EM3. When did you last inventory your medications, equipment, and supplies? Month . . . . . . . Year. . . . . . Don't know /_________ / /__________/ 98 EM4. Where does your facility generally obtain medications and supplies? Government supplier Private supplier International supplier/NGO Central Office for the health zone Other____________________ Don't know 1 2 3 4 5 98 EM5. Do you sometimes experience delivery delays for medications and supplies? Yes No 1 2 [EM7] EM6. What is the most frequent cause of delivery delays for medications and supplies? Inadequate transportation Fuel shortage Administrative difficulties Shortage of personnel Financial problems Central storage location depleted Other ___________________ Don't know 1 2 3 4 5 6 7 98 EM7. Where does your facility generally procure or receive contraceptives? Government supplier Private supplier International supplier/NGO Central Office for the health zone Other____________________ Don't know 1 2 3 4 5 98 EM8. Do you sometimes experience delivery delays for contraceptives? Yes No 1 2 [Go to module 7] EM9. What is the most frequent cause of delivery or collection delays for contraceptives? Inadequate transportation Fuel shortage Administrative difficulties Shortage of personnel Financial problems Central storage location depleted Other ___________________ Don't know 1 2 3 4 5 6 7 98 BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 85 Table J-8: Module 7: Inventory of Supplies and Medications for Reproductive Health ASK QUESTION No. 530 FOR EVERY ITEM. IF IT IS NOT AVAILABLE, GO TO THE NEXT ITEM ITEM 530 Do you have an inventory card for (item)? 531 Is (item) stored according to expiration date? 532 Are the (items) protected from rain, sun, harmful temperatures, rats and other animals and harmful insects? a) Contraceptives Yes....1 No…..2 [Go to b)] Yes ....1 No…...2 Yes ....1 No…...2 b) Medications for treating STIs Yes....1 No…..2 [Go to c)] Yes ....1 No......2 Yes ....1 No.......2 c) Vaccines Yes....1 No.....2 [Go to d)] Yes ....1 No......2 Yes ....1 No.......2 d) Other medications Yes....1 No…..2 Yes ....1 No…...2 Yes ....1 No…...2 ASK QUESTION No. 530 FOR EVERY ITEM. IF IT IS NOT AVAILABLE, GO TO THE NEXT ITEM ITEM 530 Do you have an inventory card for (item)? 531 Is (item) stored according to expiration date? 532 Are the (items) protected from rain, sun, harmful temperatures, rats and other animals and harmful insects? a) Contraceptives Yes....1 No......2 [Go to b)] Yes ....1 No…...2 Yes ....1 No.......2 b) Medications for treating STIs Yes....1 No…..2 [Go to c)] Yes ....1 No.......2 Yes ....1 No.......2 c) Vaccines Yes....1 No…..2 [Go to d)] Yes ....1 No…...2 Yes ....1 No…...2 d) Other medications Yes....1 No…..2 Yes ....1 No…...2 Yes ....1 No…...2 BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 86 Table J-9: Module 8: Availability of Family Planning Methods and Vaccines Now I would like to ask you a few questions about the family planning methods and vaccines that are available at this facility. After these questions, I will need to see your inventory of contraceptives and vaccines. ASK QUESTION No. 533 FOR EACH FAMILY PLANNING METHOD OR VACCINE. IF IT IS NOT AVAILABLE, GO TO THE NEXT METHOD OR VACCINE. METHOD/VACCINE 533 Is (method/vaccine) currently available in this facility? 534 Have you had a shortage of (method/vaccine) or were you unable to offer it during the past 6 months? 535 VERIFY THROUGH VISUAL INSPECTION: DID YOU SEE TWO UNEXPIRED UNITS OF (METHOD/VACCINE)? a) Combination birth control pill (Lo￾femenal) Yes....1 No…..2 [Go to b)] Yes ....1 No.......2 Seen .........1 Not seen....2 b) Progesterone-only birth control pill (Ovrette) Yes....1 No…..2 [Go to c)] Yes ....1 No…...2 Seen .........1 Not seen....2 c) Injection (Depo-provera) Yes....1 No…..2 [Go to d)] Yes ....1 No…...2 Seen .........1 Not seen....2 d) IUD kit Yes....1 No…..2 [Go to e)] Yes ....1 No…...2 Seen .........1 Not seen....2 e) Spermicide Yes....1 No…..2 [Go to f)] Yes ....1 No…...2 Seen .........1 Not seen....2 f) Condom Yes....1 No…..2 [Go to g)] Yes ....1 No.......2 Seen .........1 Not seen....2 g) BCG vaccine Yes....1 No.....2 [Go to h)] Yes ....1 No.......2 Seen .........1 Not seen....2 h) Polio vaccine (OPV) Yes....1 No.....2 [Go to i)] Yes ....1 No…...2 Seen .........1 Not seen....2 i) DTP vaccine Yes....1 No…..2 [Go to j)] Yes ....1 No……2 Seen .........1 Not seen....2 Measles vaccine Yes....1 No…..2 Yes ....1 No...,,,.2 Seen .........1 Not seen....2 Table J-10: Module 10: Availability of IEC Materials Do you currently have educational materials on family planning, maternal and infant health and STIs/AIDS? SERVICE 601 Image box 602 Brochures 603 Posters a) Family planning Yes.............1 No...............2 Yes.............1 No...............2 Yes.............1 No...............2 b) Prenatal/postnatal care Yes.............1 No...............2 Yes.............1 No...............2 Yes.............1 No...............2 c) Safe motherhood (childbirth) Yes.............1 No...............2 Yes.............1 No...............2 Yes.............1 No...............2 d) Prevention/treatment of HIV/AIDS Yes.............1 No...............2 Yes.............1 No...............2 Yes.............1 No...............2 e) Prevention/treatment of other STIs Yes.............1 No...............2 Yes.............1 No...............2 Yes.............1 No...............2 f) Maternal nutrition Yes.............1 No...............2 Yes.............1 No...............2 Yes.............1 No...............2 g) Monitoring children's nutrition and weight Yes.............1 No...............2 Yes.............1 No...............2 Yes.............1 No...............2 BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 87 h) Breastfeeding Yes.............1 No...............2 Yes.............1 No...............2 Yes.............1 No...............2 i) Prevention of diarrheal illnesses Yes.............1 No...............2 Yes.............1 No...............2 Yes.............1 No...............2 j) Acute respiratory infections Yes.............1 No...............2 Yes.............1 No...............2 Yes.............1 No...............2 k) Malaria Yes.............1 No...............2 Yes.............1 No...............2 Yes.............1 No...............2 l) Vaccination Yes.............1 No...............2 Yes.............1 No...............2 Yes.............1 No...............2 m) Vitamin A Yes.............1 No...............2 Yes.............1 No...............2 Yes.............1 No...............2 n) Adolescent reproductive health Yes.............1 No...............2 Yes.............1 No...............2 Yes.............1 No...............2 n) Men's reproductive health Yes.............1 No...............2 Yes.............1 No...............2 Yes.............1 No...............2 During the interview, the respondent consulted written records and reports: All the time 1 Sometimes 2 Rarely or never 3 Final result of the survey on availability of services and equipment  Complete  Partially complete  Refused  Authorized respondent not found  Facility not found  Other (specify): ___________________ 1 2 3 4 5 6 Interviewer's comments: Supervisor's comments Time completed: /____ /____/______/ BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 88 French Version: Health Facility Survey Questionnaire QUESTIONNAIRE DISPONIBILITE DES SERVICES ET EQUIPEMENT Table J-11: Health Facility Survey Questionnaire (français) N° QUESTION N° QUESTION 047. GPS Location : 048. Code du « data collector »: 049. Nom de la structure sanitaire _________________ 050. Code de la structure :/____________/ 051. Nom de l’Aire de Supervision 052. Code de l’Aire de Supervision 053. Nom de la Zone de santé 054. Code de la Zone de santé 055. Type de structure :  Centre de santé  Hôpital Général de Référence 1 2 056. Nom et code de la Province  Kasaï Occidental  Kasaï Oriental  Katanga  Sud-Kivu 1 2 3 4 057. Nom et code du superviseur : 058. Urbain/Rural :  Urbain  Semi-urbain  Rural 1 2 3 059. Catégorie professionnelle du répondant:  Médecin  Infirmier d'état  Sage-femme d'état Technicien de santé  Agent technique de santé  Médecin stagiaire/bénévole  Autre stagiaire/bénévole  Autre (préciser) : _________________ 1 2 3 4 5 6 7 060. Date et Heure de l’enquête  Date : /____ /____/______/  Heure : /_____H:_______/ Minutes Guide pour l’enquête sur la disponibilité des services et équipement Trouver l’Infirmier Titulaire et Chef du centre de santé ou le Médecin Directeur du HGR et se présenter comme suit : Bonjour. Je m’appelle ____________. Je représente IBTCI/CESD une organisation de recherche qui travaille avec l’USAID en collaboration avec le Ministère de la Santé. Nous menons une enquête dans les établissements de santé appuyés par l’USAID à travers MSH/PROSANI dans le but d’identifier les moyens d’améliorer la prestation des services. Nous aimerions nous entretenir avec vous sur la situation de cet établissement et la disponibilité des services et équipement. Soyez assuré que notre conversation demeurera strictement confidentielle et qu’il sera impossible de vous identifier. Vous pouvez, à tout moment, choisir d’interrompre l’entrevue ou refuser de répondre à une question. Puis-je continuer ? Oui…. Non… Si NON, aller à la fin du questionnaire Table J-12: Module 1 : Informtions Generales sur la Formation Sanitaire (IG) N° QUESTIONS CODE IG29. Observer seulement et note Voyez-vous une pancarte ou une affiche indiquant la disponibilité des services suivants (encercler toutes les réponses appropriées) : A) Services de planification familiale B) Services de santé infantile C) Consultations prénatales D) Consultations pour les IST/SIDA Oui, Oui, Non A L’EXTERIEUR A L’INTERIEUR 1 2 0 1 2 0 1 2 0 BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 89 N° QUESTIONS CODE E) Les tarifs pour les services 1 2 0 IG30. Si tarif NON affiché? Allez à IG3 1 2 0 IG31. Si OUI, quel prix est marquée pour:  La fiche à la première visite  Cas malaria  Cas diarrhée  Consultation prénatale  Accouchement  Planification familiale  Autres (préciser) : __________________________  Autres (préciser) : __________________________  Autres (préciser) : __________________________  Autres (préciser) : __________________________ /______________/ FC /______________/ FC /______________/ FC /______________/ FC /______________/ FC /______________/ FC /______________/ FC /______________/ FC /______________/ FC /______________/ FC /______________/ FC /______________/ FC IG32. Y a-t-il une salle d'attente pour les patients ? Oui Non 1 2 IG33. Combien de jours cet établissement est-il ouvert aux patients externes ? (Les patients externes sont ceux qui reçoivent des soins préventifs ou curatifs qui rentrent chez eux le même jour.) Nombre de jours par semaine Nombre de jour par mois Ne sait pas /______/ jours /______/ jours 98 IG34. Est-ce que ce centre fournit des soins à toute heure? c.-à-d. 24 heures sur 24? Oui Non 1 2 IG35. À quel moment de la journée commencez-vous les soins aux malades externes? /________ / IG36. À quelle heure prennent fin les soins aux malades externes? /________ / IG37. Avez-vous une source d’électricité en permanence dans l’établissement ? Oui Non Si non, allez à IG11 1 2 IG38. Si oui laquelle ? Groupe électrogène Panneau solaire SNEL Autre (spécifier) : _____________________ 1 2 3 4 IG39. Avez-vous de l’électricité aujourd’hui ? Oui Non 1 2 IG40. Avez-vous de l’eau en permanence dans l’enceinte de l’établissement ? Oui Non 1 2 BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 90 N° QUESTIONS CODE Si non, allez à IG14 IG41. Si OUI, quelle en est la source ? Forage Puits aménagé REGIDESO Citerne d’eau de pluie Autre (spécifier) :__________________________ 1 2 3 4 5 IG42. Avez-vous de l’eau courante aujourd’hui ? Oui Non 1 2 IG43. L’établissement dispose –t-il d’un moyen de communication pour les cas d’urgence ? Oui Non Si non, allez à IG17 1 2 IG44. Si OUI, lequel ? Téléphone Phonie Motorola/radio VHF Internet Radio à onde courte Autre (spécifier) _________________________ 1 2 3 4 5 6 IG45. Ces appareils sont-ils fonctionnels ? Oui Non 1 2 IG46. L’établissement a-t-il accès à un moyen de transport en tout temps ? Oui Non Si non, allez à IG19 1 2 IG47. Quels types de moyen de transport dispose l’établissement actuellement ? Moto Véhicule Vélo Autre (spécifier) _____________________________ 1 2 3 4 IG48. Existence des toilettes Oui Non 1 2 si Non aller à IG21 IG49. Si oui, quel type de toilette/douche ? Latrines à fosse septique Fosse arabe Autre (spécifier) _____________________________ 1 2 3 IG50. Quel(s) désinfectant(s) sont utilisés dans la formation sanitaire? Cytéal (Chlorhexidine - gluconate) Dakin Eau de javel (Hypochlorite de Sodium/Chlorine solution/JIK solution) Alcool dénaturé AUTRE A PRÉCISER : _________________ 1 2 3 4 5 IG51. Avez-vous des désinfectants actuellement en stock ? Oui 1 BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 91 N° QUESTIONS CODE Non 2 IG52. Quelle est la procédure utilisée pour décontaminer les équipements médicaux après l'utilisation initiale? Imbibés dans une solution désinfectante, puis brossés et frottés avec du savon + eau Brossés avec du savon et de l'eau, puis trempés dans une solution désinfectante Brossés uniquement avec du savon et de l'eau Trempé seulement dans une solution désinfectante Nettoyés avec de l'eau et du savon Equipements jamais décontaminés Equipements jamais réutilisés Autre (préciser) : ________________________________________________ 1 2 3 4 5 6 7 8 IG53. Quelle est la procédure utilisée pour la stérilisation de l'équipement médical avant réutilisation? Stérilisation en chaleur sèche (poupinel) En autoclave Ebullition Stérilisation à la vapeur Méthode chimique Autre (préciser): _____________________________ 1 2 3 4 5 6 IG54. Y a-t-il des dispositions prévues pour l'élimination des déchets bio médicaux? Oui Non Ne sait pas 1 2 98 IG55. Comment se fait l’évacuation des déchets dans l’établissement ? Incinération dans l’incinérateur Incinération dans la nature Enfouissement Jetés dans la nature Autre (spécifier) : ___________________________ 1 2 3 4 5 IG56. Commentaires de data Collector IG57. Commentaires du superviseur Table J-13: Module 2: Statistiques sur le Personnel (SP) CATÉGORIESPROFESSIONNELLES SP1 :. Nombre disponible en fonction actuellement Nombre; Ne sait pas=98; Non établi=99 a) Médecins b) Infirmiers A1 c) Infirmiers A2 d) Infirmiers A3 e) Accoucheuse diplômée f) Matrones / accoucheuses villageoises g) Relais communautaire h) Technicien de laboratoire i) Nutritionniste j) Kinésithérapeute k) Autre (spécifier) : ___________________________ Autre (spécifier) : ___________________________ BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 92 Autre (spécifier) : ___________________________ Catégorie SP2 : Sexe Quels services sont assurés par (NOM) ? SP7 : Est-ce que (Catégorie) a reçu une formation durant les 3 dernières années ? SP3. Planning familial SP4. Soins prénatals/ postnatals SP5. Santé de l'enfant SP6. IST/SIDA a) Médecins M....1 F….2 Oui....1 Non...2 Oui....1 Non...2 Oui....1 Non...2 Oui....1 Non...2 Oui....1 Non...2 [ à b)] b) Infirmiers A1 M....1 F….2 Oui....1 Non...2 Oui....1 Non...2 Oui....1 Non...2 Oui....1 Non...2 Oui....1 Non...2 [ à b)] c) Infirmiers A2 M....1 F….2 Oui....1 Non...2 Oui....1 Non...2 Oui....1 Non...2 Oui....1 Non...2 Oui....1 Non...2 [à d)] d) Infirmiers A3 M....1 F….2 Oui....1 Non...2 Oui....1 Non...2 Oui....1 Non...2 Oui....1 Non...2 Oui....1 Non...2 [à e)] e) Accoucheuse diplômée M....1 F….2 Oui....1 Non...2 Oui....1 Non...2 Oui....1 Non...2 Oui....1 Non...2 Oui....1 Non...2 [à f)] f) Matrones / accoucheuses villageoises M....1 F….2 Oui....1 Non...2 Oui....1 Non...2 Oui....1 Non...2 Oui....1 Non...2 Oui....1 Non...2 [à g)] g) Relais communautaire M....1 F….2 Oui....1 Non...2 Oui....1 Non...2 Oui....1 Non...2 Oui....1 Non...2 Oui....1 Non...2 [à h)] h) Technicien de laboratoire M....1 F….2 Oui....1 Non...2 Oui....1 Non...2 Oui....1 Non...2 Oui....1 Non...2 Oui....1 Non...2 [à i)] i) Nutritionniste M....1 F….2 Oui....1 Non...2 Oui....1 Non...2 Oui....1 Non...2 Oui....1 Non...2 Oui....1 Non...2 [à j)] j) Kinésithérapeute M....1 F….2 Oui....1 Non...2 Oui....1 Non...2 Oui....1 Non...2 Oui....1 Non...2 Oui....1 Non...2 [à i)] k) Autre (spécifier) : ___________________________ M....1 F….2 Oui....1 Non...2 Oui....1 Non...2 Oui....1 Non...2 Oui....1 Non...2 Oui....1 Non...2 [à j)] Autre (spécifier) : ___________________________ M....1 F….2 Oui....1 Non...2 Oui....1 Non...2 Oui....1 Non...2 Oui....1 Non...2 Oui....1 Non...2 [à i)] Autre (spécifier) : ___________________________ M....1 F….2 Oui....1 Non...2 Oui....1 Non...2 Oui....1 Non...2 Oui....1 Non...2 Oui....1 Non...2 [à j)] BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 93 Table J-13: Module 3: Soins Preventifs (PREV) N° QUESTIONS CODES PREV73. Combien de patients externes (au total) ont été reçus dans cet établissement les 12 derniers mois ? (Le nombre pour les 12 derniers mois pour lesquels les données sont disponibles.) Nombre Ne sait pas /_______ / 98 CPN PREV74. Cet établissement offre-t-il des consultations prénatales (CPN) ? Oui Non 1 2 [Passer à Prev20] PREV75. Combien de jours par semaine les clientes CPN sont￾elles reçues dans l’établissement ? Nombre par semaine Nombre par mois Ne sait pas /_______ / /_______ / 98 PREV76. Combien de consultations prénatales y’avait-il dans ce centre de santé en 2012 ? Nombre Ne sait pas /_______ / 98 PREV77.Pendant les 6 derniers mois, combien de réunions est ce que la formation sanitaire a tenu avec les accoucheurs (ses) traditionnel (les)? Nombre Ne sait pas /_______ / 98 PREV78. Durant toute l'année 2012, avez-vous prescrit du fer et de l'acide folique de façon systématique? Enquêteur : vérifier les registres. S'il n'y a pas de registres, demandez au responsable. Inscrire les réponses en tenant compte du fait que vous avez consulté les registres ou non. Oui Non Ne sait pas 1 2 98 PREV79. Les femmes enceintes en CPN reçoivent-elles le Vitamine A? Oui Non 1 2 PREV80. Les femmes qui viennent à la formation sanitaire pour les soins prénataux reçoivent-elles des carnets de santé prénatale ou maternelle? Si non, passez à PREV10 Oui Non 1 2 PREV81. Où est gardée la carte de santé maternelle une fois qu'elle a été délivrée à la mère? Remise à la mère afin qu'elle l'apporte à la prochaine visite 1 Gardée au sein de la formation sanitaire 2 Un exemplaire est remis à la mère et l'autre gardé à l'hôpital 3 Autre, précisez: __________________________ 4 PREV82.Pouvez-vous me montrer des cartes qui appartiennent à des patients précis? Vu Pas vu 1 2 PMTCT PREV83. Les femmes reçues en CPN sont-elles conseillées pour le test VIH en vue de la PTME? Si non, passez à PREV 20 Oui Non 1 2 PREV84. Le centre propose-t-il de manière systématique le test VIH aux femmes enceintes pour la prévention du VIH de la mère à l'enfant? Oui Non 1 2 PREV85. Le Centre dispose-t-il du personnel formé pour la PTME? Oui Non 1 2 BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 94 N° QUESTIONS CODES PREV86. Combien de femmes enceintes ont été dépistées pour le VIH en 2012? Nombre Ne sait pas /__________/ 98 PREV87. Quels services le Centre propose-t￾il aux femmes enceintes dépistées séropositives au VIH et à leurs bébés? Référées pour traitement à l'HGR 1 Reçoivent du cotrimoxazole 2 Conseils de planification familiale 3 Cotrimoxazole pour les enfants nés de mères séropositives 4 Conseils nutritionnels 5 Autres (préciser) __________________________ 6 PREV88. Combien de femmes dépistées séropositives ont reçu les ARV pour la prévention de la transmission du VIH à leurs bébés? Nombre Ne sait pas /__________/ 98 PREV89. Combien de bébés nés de mères séropositives ont-t-ils reçu un traitement antirétroviral pour la prévention du VIH à la naissance? Nombre Ne sait pas /__________/ 98 PREV90. Les partenaires/maris des femmes enceintes dépistées sont-ils invités à se dépistés? Oui Non 1 2 PREV91. Combien de partenaires/maris des femmes dépistées ont-ils acceptés et ont fait également le dépistage? Nombre Ne sait pas /__________/ 98 ACCOUCHEMENT ET POSTPARTUM PREV92. Cet établissement dispose-t-il d’une maternité ? Oui Non 1 2 PREV93. Le service de maternité fonctionne –t-il 24 heures sur 24 heures ? Oui Non 1 2 PREV94. Le personnel de la formation sanitaire offre les services liés à l'accouchement au sein de la formation sanitaire, seulement dans la communauté ou bien dans les deux cas? Exclusivement au sein de la formation sanitaire 1 Seulement dans la communauté 2 A la fois dans la formation sanitaire et dans la communauté 3 PREV95. Combien d’accouchements ont été assistés par le personnel de cet établissement en 2012 ? Nombre Ne sait pas /__________/ 98 PREV96.Est-ce que cette formation sanitaire dispose des capacités de gérer des césariennes d'urgence? Peut être géré aujourd'hui 1 Habituellement, mais pas maintenant 2 Doit être transféré 3 PREV97.Si Centre de santé, disposez-vous des instructions écrites pour la référence des femmes enceintes en cas des complications obstétricales ? Oui Non 1 2 [Passer à Prev27 PREV98.Si oui, combien de femmes ont-elles été référées à l’HGR suites à des complications obstétricales en 2012? Nombre Ne sait pas /__________/ 98 PREV99. Cette formation sanitaire offre-t-elle des soins post￾partum? Oui Non 1 2 PREV100.Les services liés aux soins post￾partum sont-ils offerts exclusivement à des heures spécifiques, pendant les heures de consultations de malades externes, ou à la fois à des heures précises et pendant les heures de consultations externes? Seulement à des heures précises 1 Heures de consultations externes 2 A la fois à des heures spécifiques et à des heures de consultations externes 3 BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 95 N° QUESTIONS CODES PREV101.En 2012, pendant combien de jours les femmes ont-elles eu droit aux soins post-partum? Nombre Ne sait pas /__________/ 98 PREV102.Quels soins post partum sont-ils donnés aux femmes? 1 2 3 4 5 PREV103.En 2012, la formation sanitaire a tenu combien de sessions cliniques de sensibilisation aux clients en post￾partum? Nombre Ne sait pas /__________/ 98 PREV104.En 2012, la formation sanitaire a enregistré combien de cas de décès maternels? Enquêteur : vérifier les registres. Nombre Ne sait pas /__________/ 98 PLANIFICATION FAMILIALE PREV105.Cet établissement offre-t-il des services de planification familiale ? (La planification familiale inclut les méthodes et conseils d’espacement ou de limitation des naissances.) Oui Non 1 2 PREV106.Combien de jours par semaine les services de planification familiale sont-ils disponibles ? Nombre de jour par semaine Nombre de jour par mois Ne sait pas /__________/ /__________/ 98 PREV107.Combien de consultations de planification familiale y’avait-il dans ce centre de santé durant les 12 derniers mois ? Nombre Ne sait pas /__________/ 98 PREV108.Quelles méthodes de planification familiale sont dispensées aux femmes dans le CS ? Pilules 1 Préservatifs 2 Injections 3 DIU 4 Méthode de collier du cycle 5 Méthode naturelle de l’allaitement 6 Autres (spécifier) : _____________________ 7 SOINS AUX ENFANTS PREV109.Cet établissement offre quels types de soins de santé aux enfants ? (Les soins infantiles préventifs et curatifs, y compris.) Notez tous les types de soins Soins curatifs 1 Soins préventifs 2 Soins promotionnels 3 PREV110.Quels types de soins préventifs votre établissement propose-t-il ? Vaccination 1 Suivi de la croissance et prise de poids 2 Autre (spécifier) _____________________ 3 PREV111.Combien de jours offrez-vous les soins préventifs aux enfants? Nombre par semaine Nombre par mois Ne sait pas /__________/ /__________/ 98 PREV112.Y a-t-il un plan de sensibilisation à la vaccination pour l'année en cours? Oui Non 1 2 PREV113.Combien de méthodes de stockage parmi les suivantes que ce site possède pour stocker les vaccins? Réfrigérateur avec partie réfrigérante 1 Glacière 2 Congélateur 3 Porte-vaccins 4 Accumulateur de froid 5 Aucune 6 BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 96 N° QUESTIONS CODES PREV114.Est-ce que les variations de température sont enregistrées? ENQUÊTEUR : SI OUI, DEMANDEZ A VOIR Oui et vu 1 Oui et pas vu 2 Non 3 PREV115.Pendant les 7 derniers jours, pendant combien de jours la température a-t-elle été consignée? Nombre Ne sait pas /__________/ 98 PREV116.Au cours des 7 derniers jours, combien de fois au total est ce que la température a été consignée ? Nombre Ne sait pas /__________/ 98 PREV117.Au cours des 7 derniers jours, combien de jours avez￾vous consigné des températures au-delà de 80C ou en dessous de 20C? Nombre Ne sait pas /__________/ 98 PREV118.Est-ce que chaque enfant qui commence son calendrier de vaccination reçoit une carte de vaccination? Oui Non 1 2 PREV119.Où sont gardées les cartes de vaccination après le début du calendrier de vaccination? Remis au parent ou son substitut pour qu'il/elle l'apporte à la prochaine visite 1 Gardé à la formation sanitaire 2 Un exemplaire est remis au parent et l'autre gardé à l'hôpital 3 Autre (spécifier): ______________________________ 4 PREV120.Pouvez-vous me montrer des cartes qui appartiennent à des patients précis? Vu Pas vu 1 2 PREV121.Cet établissement a-t-il un service de vaccination pour les enfants? Oui Non 1 2 PREV122.Combien de jours par semaine les services de vaccination sont-ils disponibles ? Nombre Ne sait pas /__________/ 98 PREV123.Combien d’enfants ont reçu une première vaccination contre la diphtérie / tétanos / coqueluche (DTCoq 1) dans ce centre de santé durant l’année 2012 ? Nombre Ne sait pas /__________/ 98 PREV124.En 2012, combien d'enfants ont-ils reçus la vaccination complète? Nombre Ne sait pas /__________/ 98 PREV125.Combien de consultations pour les enfants malades y’avait-il dans cet établissement durant les 12 derniers mois ? Combien d’enfants de 0-11 mois /_______ / Combien d’enfants de 12-23 mois /_______ / Combien d’enfants de 24-59 mois /_______ / Combien d’enfants de 0- 24mois /_______ / Combien d’enfants de 0-59 mois /_______ / PREV126.Combien de consultations infantiles préventives y’avait-il dans cet établissement durant les 12 derniers mois ? Combien d’enfants de 0-11 mois /_______ / Combien d’enfants de 12-23 mois /_______ / Combien d’enfants de 24-59 mois /_______ / Combien d’enfants de 0- 24mois /_______ / Combien d’enfants de 0-59 mois /_______ / IST PREV127.Cet établissement offre-t-il des services de consultation sur les infections sexuellement transmissibles (IST) ? Oui Non 1 2 BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 97 N° QUESTIONS CODES Si non, passez à PREV 69 PREV128.Combien de jours les services de consultation sur les IST sont-ils disponibles ? Nombre par semaine Nombre par mois Ne sait pas /_______/ /_______/ 98 PREV129.Quel protocole le Centre utilise-t-il pour la prise en charge des IST Méthode étiologique 1 Approche syndromique 2 Autre (spécifier) __________________ 3 Ne sait pas 98 PREV130.Le Centre a-t-il connu une rupture de stock des médicaments IST au cours de l’année 2012? Oui Non Ne sait pas 1 2 98 PREV131.Le Centre dispose-t-il actuellement des médicaments pour la prise en charge des ISTs? Oui Non Ne sait pas 1 2 98 PREV132.Combien de consultations sur les IST y’avait-il dans ce centre de santé en 2012 ? Nombre Ne sait pas. /_______ / 98 VIH SIDA PREV133.Cet établissement offre-t-il des services de consultation sur le VIH/SIDA ? Oui Non 1 2 [Passer à PREV67 PREV134.Combien de jours les services de consultation sur le VIH/SIDA sont-ils disponibles ? Nombre par semaine Nombre par mois Ne sait pas /_______ / /_______/ 98 PREV135.Combien de consultations sur le VIH/SIDA y’avait-il dans ce centre de santé durant les 12 derniers mois ? Nombre Ne sait pas. /_______ / 98 PREV136.Des informations sur la prévention du VIH/SIDA sont-ils données à la population ? Oui Non Ne sait pas 1 2 98 PREV137.Si OUI, quelles informations ? Sur la prévention Sur la prise en charge Sur l’atténuation de l’impact 1 2 3 PREV138.Quels supports sont-ils utilisés ? Affiches Dépliants Projection vidéo Messages audio Sensibilisation lors des séances CPN, CPS Activités de sensibilisation dans la communauté Autre (spécifier) : __________________________ 1 2 3 4 5 6 7 PREV139.L’établissement dispose-t-il des instructions écrites pour la prise en charge des cas de viols ou autres violences basées sur le genre? Oui Non Ne sait pas 1 2 98 PREV140.L’établissement dispose-t-il des kits PEP (prophylaxie post exposition) ? Oui Non Ne sait pas 1 2 98 PREVENTION DU PALUDISME PREV141.Un programme de prévention du paludisme par la distribution de moustiquaires imprégnées d’insecticide est-il mis en place dans la structure de santé ? Oui Non 1 2 PREV142.Si OUI, les moustiquaires imprégnées d’insecticide sont distribués à qui ? Femme enceinte Femme avec enfant de 0 à 23 mois 1 2 BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 98 N° QUESTIONS CODES Autre (spécifier) : _________________ 3 PREV143.Les moustiquaires imprégnées d’insecticide sont distribuées gratuitement ou vendues ? Distribuées gratuitement Vendues 1 2 PREV144.Les moustiquaires imprégnées d’insecticide sont actuellement en stock ? Oui Non 1 2 Table J-14: Module 4: Soin Curatifs (SC) N° QUESTIONS CODES MALARIA, IRA ET VIH/SIDA SC35. Cet établissement offre-t-il des soins/traitement aux enfants souffrant des maladies suivantes ? Malaria Oui Non Ne sait pas 1 2 98 Infections respiratoires aigués Oui Non Ne sait pas 1 2 98 VIH/SIDA Oui Non Ne sait pas 1 2 98 SC36. Combien de jours les services de traitement des maladies de l’enfant sont-ils offerts ? Nombre de jours par semaine Nombre par mois Ne sait pas /_______/ /_______/ 98 SC37. L’établissement dispose-t-il de protocole écrit sur le traitement des maladies de l’enfant ? Oui Non Ne sait pas 1 2 98 SC38. Si OUI, vérifier que le document existe Existe et Affiché Existe et Non affiché 1 2 SC39. Le personnel affecté à ces soins ont-ils été formés en PCIME ? Oui Non Ne sait pas 1 2 98 SC40. L’établissement dispose-t-il des médicaments et intrants nécessaires en stock ? Oui Non Ne sait pas 1 2 98 SC41. Les médicaments pour le traitement de ces maladies sont-ils fournis aux enfants au sein même de l’établissement ou les parents doivent les chercher ailleurs dans les pharmacies externes ? Dans la pharmacie de l’établissement obligatoirement Doivent se procurer en dehors du centre Cela dépend des parents Ne sait pas 1 2 3 98 SC42. Le tarif pour le traitement de ces maladies inclut-il la consultation et les médicaments ? Oui Non Ne sait pas 1 2 98 SC43. Combien de consultations pour les enfants malades y’avait-il dans cet établissement durant Combien d’enfants de 0-11 mois /_______ / Combien d’enfants de 12-23 mois /_______ / Combien d’enfants de 24-59 mois /_______ / BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 99 N° QUESTIONS CODES les 12 derniers mois ? Combien d’enfants de 0-24 mois /_______ / Combien d’enfants de 0-59 mois /_______ / MALADIES CHRONIQUES SC44. Quels sont les services liés à la tuberculose qu'offre cette formation sanitaire? ENQUÊTEUR : LE COIN TUBERCULOSE EST UN ENDROIT DANS LA FORMATION SANITAIRE OÙ LES MALADES ATTEINTS DE TUBERCULOSE SONT CONSULTÉS ET TRAITÉS. Si aucun, passez à SC 15 Seulement des services relatifs au diagnostique 1 Seulement des services liés au traitement 2 A la fois des services de diagnostic et de traitement 3 Aucun 4 SC45. Y-a-t-il un coin réservé à la tuberculose dans la formation sanitaire? ENQUÊTEUR : ENQUÊTEUR : LE COIN TUBERCULOSE EST UN ENDROIT DANS LA FORMATION SANITAIRE OÙ LES MALADES ATTEINTS DE TUBERCULOSE SONT CONSULTÉS ET TRAITÉS. Oui Non 1 2 SC46. Les personnes diagnostiquées de la tuberculose sont-ils suivies au niveau de la communauté Oui Non 1 2 SC47. Les contacts des personnes atteintes de tuberculose sont￾ils invités à se faire dépistés? Oui Non 1 2 SC48. Existe-t-il un registre tuberculose? SI OUI, DEMANDEZ À VOIR. Oui Non 1 2 SC49. Le centre dispose-t-il du document énonçant les Normes et procédures de services en santé de la reproduction, adopté en 1997 ? Oui Non 1 2 [Passer à SC17] SC50. Puis-je voir un exemplaire de ce document ? Vu Pas vu 1 2 SC51. Comment se fait la prise en charge des personnes dépistées VIH positives ? La prescription est faite par le médecin au niveau du HGR L’établissement ne fait que renouveler la prescription faite par le médecin Rien n’est fait pour les malades L’établissement ne fait pas de dépistage Autre (spécifier) : ___________________________________________ 1 2 3 4 5 SC52. Existe-t-il au niveau de l’établissement des instructions écrites concernant le dépistage et la prise en charge des personnes vivant avec le VIH ? Oui Non 1 2 SC53. L’établissement dispose-t-il des instructions écrites sur la transfusion sanguine ? Si non passez à SC21 Oui Non 1 2 SC54. La transfusion sanguine se fait-il au niveau de l’établissement ? Oui Non 1 2 SC55. Si NON, que fait l’établissement dans le cas où un enfant ou une femme enceinte avait besoin de transfusion sanguine ? Transférer à l’HGR Transférer dans une autre formation médicale Ne sait pas 1 2 98 SC56. L’établissement dispose-t-il des instructions écrites pour la prise en charge des cas des maladies suivantes ? : Lèpre Trypanosomiase Filariose lymphatique Onchocercose 1 2 3 4 BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 100 N° QUESTIONS CODES Schistosomiase Verminose 5 6 SC57. L’établissement effectue-t-il la petite chirurgie ? Oui Non 1 2 SC58. Combien de cas de petite chirurgie avez-vous effectués au cours de l’année 2012 ? Nombre Ne sait pas. /_______ / 98 SC59. L’établissement effectue-t-il la réhabilitation nutritionnelle ? Oui Non 1 2 ACTIVITES PROMOTIONNELLES SC60. L’établissement effectue-t-il les activités promotionnelles suivantes ? SC61. Promotion de l’utilisation du préservatif Oui Non Ne sait pas SC62. Hygiène et assainissement Oui Non Ne sait pas SC63. Allaitement maternel exclusif des enfants au cours des 6 premiers mois après la naissance Oui Non Ne sait pas SC64. Hygiène alimentaire Oui Non Ne sait pas SC65. Consommation du sel iodé Oui Non Ne sait pas SC66. Amélioration des latrines Oui Non Ne sait pas SC67. Promotion de la réhydratation oral pour les cas de diarrhée chez les enfants Oui Non Ne sait pas SC68. Information sur la prévention des fistules Oui Non Ne sait pas Table J-15: Module 5: Supervision (SUP) N° Question Réponses Code SU3. Une visite de supervision est une visite d’un représentant du ministère de la Santé venant observer ce qui se passe dans l’établissement afin d’aider son personnel à améliorer ses services. Quand a eu lieu la dernière visite de supervision de votre établissement ? Le mois passé Durant les 3 derniers mois Durant les 6 derniers mois Il y a plus de 6 mois Aucune visite de contrôle [Passer au module 6] Ne sait pas [Passer au module 6] Le mois en cours 1 2 3 4 5 6 7 SU4. Que s’est-il passé durant cette visite de supervision ? ENTOURER TOUTES LES REPONSES + MENTIONNEES. SONDER : D’autres choses ? Examen des dossiers/rapports Réunions Contrôle/apport d’équipement Observation de consultations Discussion de problèmes Discussion sur le personnel Autre________________________ 1 2 3 4 5 6 7 BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 101 N° Question Réponses Code Rien Ne sait pas 8 98 Table J-16: Module 6: Équipement et Materiél (EM) J’aimerais vous poser quelques questions sur les équipements et matériels dans cet établissement. N° Question Réponses Code EM10. Quelle est la méthode le plus souvent employée pour la désinfection de haut niveau ou la stérilisation de l’équipement et du matériel médical ? Plaque chauffante Stérilisateur à vapeur (cocote à vapeur) Chlorhexidine Eau de javel Autre Aucune Ne sait pas 1 2 3 4 5 6 98 EM11. Comment vous débarrassez-vous de vos seringues et objets tranchants contaminés ? (ENTOURER TOUTES LES REPONSES MENTIONNEES) Incinération Ensevelissement Poubelle Réutilisation Fosse septique Fosse spéciale Autre____________________ Ne sait pas 1 2 3 4 5 98 EM12. Quand avez-vous procédé à votre dernier inventaire de médicaments, d’équipement ou de matériels ? Mois. . . . . . . . Année . . . . . . Ne sait pas /_________ / /__________/ 98 EM13. Où votre établissement se procure-t-il généralement ses médicaments et matériels ? Fournisseur d’état Fournisseur privé Fournisseur international/ONG Bureau Central ZS Autre____________________ Ne sait pas 1 2 3 4 5 98 EM14. Souffrez-vous parfois de retards de livraison des médicaments et matériels ? Oui Non 1 2 [EM7] EM15. Quelle est la cause la plus courante des retards de livraison des médicaments et matériels ? Transports inadéquats Insuffisance de carburant Difficultés administratives Insuffisance de personnel Problèmes financiers Stocks centraux épuisés Autre___________________ Ne sait pas 1 2 3 4 5 6 7 98 EM16. Où votre établissement se procure-t-il ou reçoit-t-il généralement les contraceptifs ? Fournisseur d’état Fournisseur privé Fournisseur international/ONG Bureau Central ZS Autre____________________ Ne sait pas 1 2 3 4 5 98 BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 102 EM17. Souffrez-vous parfois de retards de livraison des contraceptifs ? Oui Non 1 2 [Passer module 7] EM18. Quelle est la cause la plus courante des retards de collecte ou livraison des contraceptifs ? Transports inadéquats Insuffisance de carburant Difficultés administratives Insuffisance de personnel Problèmes financiers Stocks centraux épuisés Autre_____________________________ Ne sait pas 1 2 3 4 5 6 7 98 Table J-17: Module 7: Inventaire des Materiéls et Médicaments pour la Santé Réproductive POSER LA QUESTION N° 530 POUR CHAQUE PRODUIT. S’IL N’EST PAS DISPONIBLE, PASSER AU PRODUIT SUIVANT. PRODUIT 530. Avez-vous une fiche d’inventaire de (PRODUIT) ? 531. Les (PRODUIT) sont-ils stockés en fonction de leur date limite d’utilisation ? 532. Les (PRODUIT) sont-ils stockés à l’abri de la pluie, du soleil, des températures néfastes, des rats et autres animaux et insectes nuisibles ? a) Contraceptifs Oui....1 Non...2 [ Passer à b)] Oui ....1 Non....2 Oui ....1 Non....2 b) Médicaments pour le traitement des IST Oui....1 Non...2 [ Passer à c)] Oui ....1 Non....2 Oui ....1 Non....2 c) Vaccins Oui....1 Non...2 [Passer à d)] Oui ....1 Non....2 Oui ....1 Non....2 d) Autres médicaments Oui....1 Non...2 Oui ....1 Non....2 Oui ....1 Non....2 Table J-18: Module 8: Disponibilité des Méthodes de PF et des Vaccins J’aimerais maintenant vous poser quelques questions sur les méthodes de planification familiale et les vaccins disponibles dans cet établissement. Après ces questions, il me faudra voir vos stocks des contraceptifs et vaccins. POSER LA QUESTION N° 533 POUR CHAQUE METHODE DE PF OU VACCIN. S’IL N’EST PAS DISPONIBLE, PASSER A LA METHODE OU AU VACCIN SUIVANT. METHODE/VACCIN 533. Est-ce que le (METHODE/VACCIN) est actuellement disponible dans l’établissement ? 534. Avez-vous souffert d’une rupture de stock de (METHODE/VACCIN) ou étiez-vous incapable de l’offrir durant les 6 derniers mois ? 535. VERIFIER PAR INSPECTION VISUELLE : DEUX UNITÉS DE (METHODE/VACCIN) NON PÉRIMÉES OBSERVÉES ? a) Pilule combinée (Lo-femenal) Oui....1 Non...2 [Passer à b)] Oui ....1 Non....2 Vu ........1 Pas vu....2 b) Pilule à la progestérone seulement (Ovrette) Oui....1 Non...2 [Passer à c)] Oui ....1 Non....2 Vu .........1 Pas vu....2 BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 103 c) Injection (Depo-provera) Oui....1 Non...2 [Passer à d)] Oui ....1 Non....2 Vu .........1 Pas vu....2 d) Kit DIU Oui....1 Non...2 [Passer à e)] Oui ....1 Non....2 Vu .........1 Pas vu....2 e) Spermicide Oui....1 Non...2 [Passer à f)] Oui ....1 Non....2 Vu .........1 Pas vu....2 f) Préservatif Oui....1 Non...2 [Passer à g)] Oui ....1 Non....2 Vu .........1 Pas vu....2 g) Vaccination BCG Oui....1 Non...2 [Passer à h)] Oui ....1 Non....2 Vu .........1 Pas vu....2 h) Vaccination antipoliomyélitique (OPV) Oui....1 Non...2 [Passer à i)] Oui ....1 Non....2 Vu .........1 Pas vu....2 i) Vaccination DTCoq Oui....1 Non...2 [Passer à j)] Oui ....1 Non....2 Vu .........1 Pas vu....2 j) Vaccination contre la rougeole Oui....1 Non...2 Oui ....1 Non....2 Vu …......1 Pas vu....2 Table J-19: Module 10: Disponibilité des Materiéls IEC Disposez-vous actuellement des matériels éducatifs sur la planification familiale, la santé maternelle et infantile, et les IST/SIDA ? SERVICE 601. Boite à images 602. Dépliants 603. Affiches murales a) Planification familiale Oui.............1 Non............2 Oui.............1 Non............2 Oui.............1 Non............2 b) Soins prénatals/postnatals Oui.............1 Non............2 Oui.............1 Non............2 Oui.............1 Non............2 c) Maternité sans risque (accouchement) Oui.............1 Non............2 Oui.............1 Non............2 Oui.............1 Non............2 d) Prévention/traitement du VIH/SIDA Oui.............1 Non............2 Oui.............1 Non............2 Oui.............1 Non............2 e) Prévention/traitement des autres IST Oui.............1 Non............2 Oui.............1 Non............2 Oui.............1 Non............2 f) Nutrition de la mère Oui.............1 Non............2 Oui.............1 Non............2 Oui.............1 Non............2 g) Surveillance nutritionnelle et pondérale de l’enfant Oui.............1 Non............2 Oui.............1 Non............2 Oui.............1 Non............2 h) Allaitement maternel Oui.............1 Non............2 Oui.............1 Non............2 Oui.............1 Non............2 i) Lutte contre les maladies diarrhéiques Oui.............1 Non............2 Oui.............1 Non............2 Oui.............1 Non............2 j) Infections respiratoires aiguës Oui.............1 Non............2 Oui.............1 Non............2 Oui.............1 Non............2 k) Paludisme Oui.............1 Non............2 Oui.............1 Non............2 Oui.............1 Non............2 l) Vaccination Oui.............1 Non............2 Oui.............1 Non............2 Oui.............1 Non............2 m) Vitamine A Oui.............1 Non............2 Oui.............1 Non............2 Oui.............1 Non............2 n) Santé reproductive des adolescents Oui.............1 Non............2 Oui.............1 Non............2 Oui.............1 Non............2 o) Santé reproductive des hommes Oui.............1 Non............2 Oui.............1 Non............2 Oui.............1 Non............2 Pendant l’interview, le répondant consultait les registres et rapports : Tout le temps 1 BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 104 Parfois 2 Rarement ou jamais 3 Résultat final de l’enquête sur la disponibilité des services et équipement :  Complète  Partiellement complète  Refus  Enquêté compétent non trouvé  Structure non trouvée  Autre (préciser) : ___________________ 1 2 3 4 5 6 Commentaires de l’enquêteur : Commentaires du superviseur : Heure de la fin : /____/______/ BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 105 ANNEX K. LIST OF HEALTH FACILITIES SURVEYED Province Supervision Area Health Zone Facility East Kasai Kole Bena Dibele Kabondo HC Lukibu HC Lobilo HC Dibele GRH East Kasai Kole Kole Ishenga HC Niene HC Wongo HC Kole GRH East Kasai Kole Tshudi Loto Loto HC Okala HC Tshudi HC Tshudi Loto GRH East Kasai Mwene-Ditu Kanda Kanda Bakua Bowa HC Kapangu HC Mutembue HC Kanda Kanda GRH East Kasai Mwene-Ditu Luputa Kamkindu HC Kamukungu HC Kasha HC Luputa GRH East Kasai Mwene-Ditu Mwene-Ditu Cindundu HC Katabaie HC Mandam HC Mwene-Ditu GRH East Kasai Tshumbe Djalo Ndjeka Longonya HC Lonya HC Ndjeke Losele HC Djalo GRH East Kasai Tshumbe Katako Kombe Lotahe HC Omeka HC Pamahamba HC Katako GRH East Kasai Tshumbe Ototo Diwoko HC Dolo HC Ekolo HC Ototo GRH Katanga Kamina Kayamba Kisao HC Lwamba Sakania HC Nsulu Olawa HC Kayamba GRH Katanga Kamina Kinkondja Kibila HC Mangi HC Kimpamba HC Kinkondja GRH Katanga Kamina Kitenge Kansele HC Lulenge HC Makwidi HC Kitenge GRH Katanga Kolwezi Dilala Kanina HC Luilu HC Noa HC BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 106 Province Supervision Area Health Zone Facility Dilala GRH Katanga Kolwezi Lubudi Boyofwe HC Lubudi HC Mukabe HC Lubudi GRH Katanga Kolwezi Manika Kasulo HC Kizito HC Polymoderne HC Manika GRH South Kivu Bukavu Bagira Bagira HC Ciguri HC Burhiba HC Bagira-Kasha GRH South Kivu Bukavu Kaniola Cagala HC Izege HC Kaniola HC Kaniola GRH South Kivu Bukavu Mwenga Kalambi HC Kalole HC Kitagana HC Mwenga GRH South Kivu Uvira Lemera Bushuju HC Bwegera HC Luvungi HC Mirungu HC Mubere HC Lemera GRH South Kivu Uvira Rusizi Luberizi HC Luhito HC Rusabagi HC Sange Etat HC Rusizi GRH West Kasai Lwiza Bulape Bambalaie HC Bangombe HC Bukuek HC Bulape GRH West Kasai Lwiza Dekese Dumba HC Isandja HC Isolu HC Dekese GRH West Kasai Lwiza Dibaya Bena Bitende HC Kaulu HC Mupoyi HC Dibayi GRH BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 107 ANNEX L. LIST OF PERSONS INTERVIEWED East Kasaï Province: Dr. Jules Alonga, Director, Kole General Referral Hospital Bena Dibele CODESA Dr. Didace Demba, IHP Technical Advisor, Mwene￾Ditu Mr. Floribert Ditshengo, Luputa Territorial Administrator Djalo Ndjeka CODESA Mr. Thom’s Mayebu Djeke, Community Organizer, Kole Health Zone Dr. Felicien Ilunga, Medical Director, Luputa General Referral Hospital Mr. Joseph Lowendo Iwoko, Supervising Nurse, Kole Health Zone Dr. Joseph Kalombo, Cabinet Minister, Ministry of Public Health and Human Rights Dr. Teddy Kasadi, Manager, Luputa Health Zone Dr. Judex Kasongo, Manager, Kanda Kanda Health Zone Katako Kombe CODESA Dr. Adrien Longendo, Manager, Katako Kombe Health Zone, Luputa CODESA Dr. Daniel Longonya Lushima, Manager, Bena Dibele Health Zone Dr. Gaston Lutongo Paluku, World Health Organization, Sankuru District Dr. Tshikala Malaba, Chief Physician, Sankuru District Dr. Freddy Mbuse, IHP Kole Dr. Jean MPeti Okolongo, Manager, Djalo Ndjeka Health Zone Mr. Deryck Mpoyo Ngoyi, Administrator, Luputa General Referral Hospital Dr. Jean-Pierre Mubakinayi, Medical Director, Kanda Kanda General Referral Hospital Dr. Emery Mukena, Acting Provincial Medical Inspector Dr. Marcellin Munkonkole, Chief Physician, Tshudi Loto General Referral Hospital Dr. Jean-Claude Musasa, Manager, Mwene-Ditu Health Zone Dr. Benoit-Joseph Mwanba-N’Fundji, District Medical Inspector, Mwene-Ditu Mwene-Ditu CODESA Dr. Jordi Ngimbi, Medical Director, Mwene-Ditu General Referral Hospital Dr. Joseph Ngolo, Chief Physician, Ototo General Referral Hospital Dr. Pierre Nguwa, Chief Physician, Bena Dibele General Referral Hospital Mr. Okelenge Ntikala, Administrator, Kole Health Zone Dr. Michel Omanyondo, Chief Physician, Djalo Ndjeka General Referral Hospital Ototo CODESA Dr. Thérèse Riu, Chief Physician, Kole General Referral Hospital Dr. Guy Bilulu Suama, Manager, Kole Health Zone Tshudi Loto CODESA Dr. Gary Wakigana, Coordination Director, IHP Tshumbe South Kivu Province: Bagira-Kasha CODESA Mr. Jean-Marie Banyamuluma, Nurse, Chiguri Health Center, Bagira-Kasha Health Zone Dr. Janvier Barhobagaya, IHP, Bukavu Dr. Julien Baruku Amani, Chief Physician, Bagira General Referral Hospital Mr. Clovis Buhemere, Nurse, Bagira Health Center, Bagira-Kasha Health Zone Dr. Manou Burole, Provincial Medical Inspector Dr. Nzigo Busomere John, Manager, Lemera Health Zone Kaniola CODESA Lemera CODESA Dr. Daniel Longonya Lushima, Manager, Mwenga Health Zone, Dr. Freddy Maneno, Medical Director, Lemera General Referral Hospital Mr. Janvier Mirindi, Nurse, Buriba Health Center, Bagira-Kasha Health Zone BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 108 South Kivu Province: Dr. Jean-Jacques Mapiana, IHP, Uvira Dr. Aristide Mudekereza, Manager, Kaniola Health Zone Mwenga CODESA Dr. Mwanza Nangunia, Minister of Health Dr. Ghyslain Ndungu, Medical Director, Ruzizi General Referral Hospital Ruzizi CODESA Dr. Pinpin Shamavu, Manager, Bagira-Kasha Health Zone West Kasaï Province: Dekese CODESA Dr. Jean Kanoa, IHP Coordinator, Kananga Dr. Dieudonne Kateta, Medical Director, Dekese General Referral Hospital Dr. Hapo Mobali, Manager, Dekese Health Zone Dr. Edmond Mulamba Kandolo, Provincial Medical Inspector Dr. Tshianza Patcho, Manager, Bulape Health Zone Kinshasa: Dr. Ousmane Faye, Chief of Party, IHP Dr. Mukengeshayi Kupa, Acting Secretary General, Ministry of Health Dr. Delmond Kyanza, RBF Technical Advisor, IHP Dr. Richard Matendo, Agreement Officer’s Representative (AOR), IHP, USAID/DRC Mr. Alidor Mbuyamba, Technical Advisor, Monitoring and Evaluation, IHP Mr. Tchim Tabaro, Deputy Chief of Party, IHP Dr. Philippe Tshiteta, MSH Country Director Kitanga Province: Dr. Adamo Fumie, IHP Office Director, Kolwezi Dr. Faustin Bushabo, Director of Capacity Building, IHP, Kamina Dilala CODESA Dr. Opondo Feruzi, Medical Director, Dilala General Referral Hospital Dr. Robert Kabesya, Manager, Lubudi Health Zone, Medical Director, Lubudi General Referral Hospital Mr. Georges Kakes, Deputy Manager, Manika Health Zone Dr. Jacques Kibamba Kangombe, District Medical Inspector, Kolwezi Dr. Jean-Marie Kafwembe, Acting Provincial Medical Inspector, Kitanga Dr. Claude Kasonga, Manager, Kitenge Health Zone Kayamba CODESA Kinkondja CODESA Kitenge CODESA Lubudi CODESA Mr. Alain Makachunga, Administrator, Kitenge Health Zone Manika CODESA Dr. Everest Mpoyo Numbi, Medical Director, Kitenge General Referral Hospital Dr. Thierry Mwandwe, Medical Director, Manika General Referral Hospital Dr. Patrick Nduwa, Manager, Dilala Health Zone Dr. Amide Ngongo Kitenge, Manager, Kayamba Health Zone Dr. Jean-Marc Ngoy, Manager, Kinkondja Health Zone, Medical Director, Kinkondja General Referral Hospital Dr. Van Ngoy Kilonda, Medical Director, Kayamba General Referral Hospital Dr. Patrick Piongo, District Medical Inspector, Kamina Dr. Doudou Tubaya, Acting Office Director, IHP, BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 109 ANNEX M. LIST OF SUPERVISORS, DATA COLLECTORS, AND INTERVIEWERS Table M-1: Names of Supervisors Province Supervision Area # First Names Last Names East Kasai Mwene Ditu 1 Germaine Kawal 2 Magalie Kabale Kole 1 Germaine Kawal 2 Magalie Kabale 3 Valentine Ilunga Tsumbe 1 Germaine Kawal 2 Magalie Kabale 3 Valentine Ilunga West Kasai Luiza 1 Germaine Kawal 2 Hubert Kinua 3 Magalie Kabale 4 Valentine Ilunga Katanga Kolwezi 1 Germaine Kawal 2 Magalie Kabale Kamina 1 Germaine Kawal 2 Magalie Kabale South Kivu Bukavu 1 Magalie Kabale 2 Valentine Ilunga Uvira 1 Germaine Kawal 2 Hubert Kinua Table M-2: Names of Interviewers and Data Collectors Province Supervision Area # First Names Last Names East Kasai Mwene Ditu 1 A. Mwamba Munyonga 2 Anaclet Kadiata 3 Annie Ndaya 4 Boniface Tshibanda 5 Joceline Bulungu 6 Moise Tshibangu 7 Placide Kibambe 8 Richard Muzang Kole 1 Boniface Shotshe Kandolo 2 Cécile Ngoie 3 Gilbert Onyikola Shekoshinde 4 Gustave Omanga Osako 5 Isabelle Wungudi BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 110 Province Supervision Area # First Names Last Names 6 Jeanne Danga 7 Jean-Pierre Djamba Lokombe 8 Marlene Mbolo Djonga 9 Moise Wembi Ndjeka 10 Papy Anyeme Djonga 11 Pierre Otshudi Kasongo Tshumbe 1 Boniface Shotshe Kandolo 2 Cécile Ngoie 3 Gilbert Onyikola Shekoshinde 4 Gustave Omanga Osako 5 Isabelle Wungudi 6 Jeanne Danga 7 Jean-Pierre Djamba Lokombe 8 Marlene Mbolo Djonga 9 Moise Wembi Ndjeka 10 Papy Anyeme Djonga 11 Pierre Otshudi Kasongo West Kasai Luiza 1 Adolphe Kamangu 2 Antoine Shoko lopepe 3 Charles Kasongo Muitshilua 4 Francis Tshiola 5 Franck Lokale 6 Jacques Kabongo 7 Jean-J Ndaye Mukendi 8 Jonas Mukenge 9 Lambert Djanya Epenge 10 Marcel Lopeto Danga 11 Martin Kanku 12 Mbombo Mukendi 13 Ngadi kabuanga 14 Odette Kwete Kwete 15 Pierre Bakamana 16 Sam Tshiasuma Katanga Kamina 1 Bruce Kavul 2 Hardy Yava Tshihiri 3 Joel Mputu Lobombo 4 Junior Nsikuetu Matondo 5 Sonya Mwema 6 Thierry Kamand-A-Tshikuz Kolwezi 1 Bruce Kavul 2 Hardy Yava Tshihiri BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 111 Province Supervision Area # First Names Last Names 3 Joel Mputu Lobombo 4 Junior Nsikuetu Matondo 5 Kasongo Kayembe 6 Ngandu Ilunga 7 Sonya Mwema 8 Thierry Kamand-A-Tshikuz South Kivu Bukavu 1 Antoine Igilima 2 Biatoto Chala 3 Blondy Mweze 4 Huges Barhalengehwa 5 Linda Burume 6 Malema Kasongo 7 Serge Barhacikubagirwa 8 Tabaro Gatakata Uvira 1 Balthazar Alanga 2 Blandine Kongolo 3 Françoise Ngongo 4 Gervais Muhoya Nikungwa 5 Gildard Mutambala 6 Jacques Alona Ramazani 7 Juste Muluneoderwa 8 Steven Kamwanga BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 112 ANNEX N. LIST OF DOCUMENTS REVIEWED 2013 Human Development Report, United Nations Development Programme Congolese Pygmies’ Access to Healthcare: Barriers to Healthcare Access for Pygmies in Three Health Districts in South Kivu, DRC, June 2013 Disponsibilité des Medicaments MSH Prosani à la Cadmeko au 01 Avril 2013 DRC Demographic and Health Survey 2007: Key Findings, Macro International, Inc. DRC/Integrated Health Project – Performance Monitoring Plan, March 1, 2012 Health Systems 20/20 Final Project Report, 2012 IHP Minimum Package of Health Service Activities‐plus and Complementary Package of Health Service Activities-plus List Integrated Community Case Management of Childhood Illness: Documentation of Best Practices and Bottlenecks to Program Implementation in the DRC, MCHIP, 2012 Integrated Health Project (IHP) Baseline Final Report, August 2011 Integrated Health Project (IHP) Quarterly Report, Year 1: Quarter 2 (January–March 2011) Integrated Health Project (IHP) Quarterly Report, Year 1: Quarter 3 (April–June 2011) Integrated Health Project (IHP) Quarterly Report, Year 1: Quarter 4 (July–September 2011) Integrated Health Project (IHP) Quarterly Report, Year 2: Quarter 1 (October–December 2011) Integrated Health Project (IHP) Quarterly Report, Year 2: Quarter 2: (January–March 2012) Integrated Health Project (IHP) Quarterly Report, Year 2: Quarter 3 (April–June 2012) Integrated Health Project (IHP) Quarterly Report, Year 2: Quarter 4 (July l–September 2012) Integrated Health Project (IHP) Revised Quarterly Report, Year 1 (October l–December 2010) International Database, United States Census Bureau, 2013 Plan National de Development Sanitaire (PNDS) (National Health Development Plan); MOH, 2010a President’s Malaria Initiative, Democratic Republic of Congo Country Profile, 2013 Stratégie de Renforcement du Système de Santé (SRSS), MOH, 2010b Surviving the First Day: State of the World’s Mothers 2013, Save the Children USA BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 113 ANNEX O. MPA-PLUS SERVICES 1. IHP MPA-Plus (The MPA-Plus is to be provided at all health centers in the 80 targeted health zones) General service availability questions: Facility Survey: IG 4, 5, 6, 7. Related questions: Facility Survey: SPa, b, c, d. Preventative Activities Growth and development monitoring for children under 5: Client Exit Survey: 9, 10, 11. Prenatal counseling: Facility Survey: PREV 2, PREV 27 PMTCT, including counseling, HIV testing, antiretroviral prophylaxis, FP counseling, and co￾trimoxazole, nutrition counseling, and referrals for treatment, if indicated: Facility Survey: PREV 11, 12, 13; Client Exit Survey: Module 4: 9. Co-trimoxazole for exposed infants: FP counseling and services (condoms, orals, injectables, intrauterine devices, standard day method cycle beads, lactational amenorrhea method (LAM) and referrals for long-acting and permanent methods): Facility Survey: PREV 33; 7a; 8a, b, c, d, e, f. Postnatal counseling: Facility Survey: PREV 2, PREV 27. Immunizations: BCG (tuberculosis), OPV (polio), DPTHepB-Hib (diphteria, pertussis, tetanus, hepatitis B, Haemophilus influenza type B), VAR (measles): Facility Survey: PREV 49; 7c; 8g, h, I, j; Client Exit Survey: Module 1: 34 Universal precautions for infection prevention and blood safety: Facility Survey: EM1, 2. Distribution of IPTp and LLINs: Facility Survey: PREV69, 72 HIV information: Facility Survey: PREV61, 62, 63, 64, 65, 66; Client Exit Survey: Module 3: 6, 7; Module 4: 5, 6, 7, 8. Vitamin A, other micronutrient supplementation: Facility Survey: PREV 7; Client Exit Survey: Module 1: 8, 34. Curative Activities Clinic-based IMCI including treatment of malaria and acute respiratory infection (ARI), diarrhea: Facility Survey: PREV37, SC1, SC6 Testing and treatment of chronic diseases, including NTDs: Facility Survey: SC10; Client Exit Survey: Module 3: 5, 6, 7. HIV/AIDS: PMTCT and blood transfusion testing, monitoring patients on antiretroviral therapy who have been diagnosed at GHR, management of opportunistic infections (co-trimoxazole) and related nutritional support devices. TB: sputum collection and forwarding to diagnostic and treatment centers; TB treatment Diagnosis and treatment (referrals as indicated) for other NTDs: leprosy, trypanosomiasis, lymphatic filariasis, hookworm, roundworm, whipworm, shistosomiasis, onchocerciasis) Other curative care not elsewhere cited BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 114 Nutritional rehabilitation Minor surgery Normal labor and delivery services including practice of active management of third stage labor (AMTSL), availability of oxycontin, and newborn care kits: Facility Survey: PREV20-30. IPTp for pregnant women and children under 5: Facility Survey: PREV70 STI syndromic treatment and referrals: -Facility Survey: PREV55, 57, 59; 7a Post-exposure prophylaxis (PEP) and appropriate counseling for victims of S/GBV: Facility Survey: PREV67, 68. Acute respiratory infection treatment Promotional Activities Condom use for dual protection Environmental sanitation Exclusive breastfeeding Healthy eating and food handling Use of iodized salt Improved latrines Oral rehydration therapy and diarrheal disease control Fistula awareness and prevention Management/Administrative Activities Increase availability of essential services to underserved populations (e.g., increase coverage) Management of resources (human, material, financial) Continuous health personnel training Training and mentoring of (community) outreach workers (meetings, site visits) Linkages with and referrals from private health providers in the health zones (if such exist) Management of health information Management of pharmaceutical information Community Activities Community-based IMCI (c-IMCI) including early recognition and referral for danger signs Disease surveillance: TB, NTDs, etc. Food safety and food handling Potable water improvements: spring and well capping, improved water distribution systems, community water treatment Disease control: use of LLITNs, tsetse control, environmental sanitation, etc. Community-based information-education-communication and distribution of FP commodities: standard day method cycle beads, orals, condoms, and referrals for other methods Community awareness and prevention S/GBV Vegetable gardens, fish farming, livestock production BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 115 2. IHP CPA-plus (the CPA-plus is to be provided at all general reference hospitals in the 80 targeted HZ) The CPA includes the full MPA-plus as well as standard preventative, curative, and promotional activities associated with internal medicine, surgery, obstetrics and gynecology, and pediatrics. In addition, the CPA includes management activities (hospital health information management, management of resources, applied research and training/mentoring health zone personnel. Specialized services in the CPA-plus would include:  Long acting and permanent methods of contraception (implants, tubal ligation, vasectomy)  Fistula repair  Post-abortion care (PAC)  Blood screening, storage, and collection at selected hospitals, and maintenance of a “living blood bank” at others  Multi-drug resistance (MDR) TB sputum collection and forwarding to Kinshasa or Lubumbashi labs; treatment and follow-up  PMTCT-plus, to include provision and monitoring of ARV prophylaxis to HIV-infected women and exposed infants  TB-HIV co-infection screening and treatment (entry point is PMTCT) Laboratory Testing and Analyses Parasites (including rapid diagnostic tests and microscopy for malaria) HIV (with PMTCT as point of entry) TB microscopy Blood (hematology) Bacterial Biochemical Medical Imaging Radiography Echography Equipment Sterilization Cleansing followed by disinfection, sterilization with autoclave or hot water Rehabilitation Physiotherapy BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 116 ANNEX P. IHP FIELD IMPLEMENTATION PLAN LEGEND JL: Jean-Lambert Mandjo (IHP Specialist) GK: Germaine Kawal (Supervisor) MOG: Mary O'Grady (Team Leader) MK: Magalie Kabale (Supervisor) Yellow indicates a flight to another province HK: Kinwa (Interpreter) HK: Hubert Kinwa VI: Valentine Ilunga District Health Manager = MID Health Zone Manager = MCZ Provincial Health Manager = MIP General Reference Hospital = GRH Health Center = HC JL Team MOG Team Day Date Supervision Area Health Zone Activities Team Members MWENE￾DITU SA Arrival MOG, JL, MK, GK, 4 Interviewers & Data Collectors Contact with Authorities 22 - 23 April HZ Luputa Data collection 23 April 25 April & 03 May HZ Mwene Ditu Data collection 02 - 03 May HZ Kanda Kanda Data collection 04 -06 May LUBUMBASH I Lubumbashi Arrival to Lubumbashi and contact with authorities MOG, JL, MK, GK & HK Tue 07 May KOLWEZI SA Arrival MOG, JL, MK, GK, HK & 8 Interviewers & Data Collectors Wed - Fri 08-10 May Contact with authorities MOG & JL Training I & DC MOG, JL, MK, GK, HK & 8 Interviewers & Data Collectors Sat 11 May HZ Manika Data collection MOG, JL, MK, GK, HK & 8 Interviewers & Data Collectors Mon 13 May HZ Dilala Data collection MOG, JL, MK, GK, HK & 8 Interviewers & Data Collectors BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 117 HZ Lubudi Departure to Lubudi MOG, JL, MK, GK, HK & 8 Interviewers & Data Collectors Tue 14 May Arrival to Lubudi and contact with authorities MOG, JL, MK, GK & HK Wed 15 May Data collection MOG, JL, MK, GK, HK & 8 Interviewers & Data Collectors Thu 16 May KAMINA SA Departure and arrival to Kamina MOG, JL, MK, GK, HK & 8 Interviewers & Data Collectors Arrival and contact with authorities MOG, JL, MK, GK & HK Fri 17 May HZ Kitenge Departure to Kitenge and contact with authorities MOG, JL, MK, GK, HK & 8 Interviewers & Data Collectors Arrival and contact with authorities MOG, JL, MK, GK & HK Sat 18 May Data collection MOG, JL, MK, GK, HK & 8 Interviewers & Data Collectors Sun 19 May HZ Kayamba Departure to Kayamba and contact with authorities MOG, JL, MK, GK, HK & 8 Interviewers & Data Collectors Arrival and contact with authorities MOG, JL, MK, GK & HK Mon 20 May Data collection MOG, JL, MK, GK, HK & 8 Interviewers & Data Collectors Tue-Thu 21 - 23 May HZ Kinkondja Departure to Mulongo MOG, JL, MK, GK, HK & 8 Interviewers & Data Collectors Arrival and contact with authorities MOG, JL, MK, GK & HK Data collection MOG, JL, MK, GK, HK & 8 Interviewers & Data Collectors Fri 26 May Kolwezi Arrival to Kolwezi from Kinkondja MOG, JL, MK, GK, HK & 8 Interviewers & Data Collectors Sat 27 May Arrival to Lubumbashi from Kolwezi MOG, JL, MK, GK & HK BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 118 Thu 30 May Kinshasa Arrival to Kinshasa from Lubumbashi MOG, JL, MK, GK & HK Tue 04 June Departure to RSA. END OF THE FIELD ACTIVITIES MOG Tue 04 June Bukavu Departure and arrival to Bukavu JL, MK, GK & HK Wed-Sat 05-08 June Bukavu Meeting with authorities MK & HK Training I&DC JL, MK & HK Mon-Tue 10-11 June BUKAVU Mwenga Departure and arrival to Mwenga TL + 2 Sup & 8 Interviewers & Data Collectors Contact with authorities TL + 2 Sup Data collection TL + 2 Sup & 8 Interviewers & Data Collectors Wed 12 June Kaniola Departure and arrival to Kaniola TL + 2 Sup & 8 Interviewers & Data Collectors Contact with authorities TL + 2 Sup Data collection TL + 2 Sup & 8 Interviewers & Data Collectors Thu 13 June Bukavu Arrival to Bukavu from Kaniola TL + 2 Sup & 8 Interviewers & Data Collectors Thu 14 June Bagira Departure and arrival to Bagira TL + 2 Sup & 8 Interviewers & Data Collectors Contact with authorities TL + 2 Sup Data collection TL + 2 Sup & 8 Interviewers & Data Collectors Thu-Fri 06 -07 June UVIRA Uvira Departure and arrival to Uvira TL + 2 Sup & 8 Interviewers & Data Collectors Meeting with authorities JL & GK Sat-Mon 08-10 June Training I&DC JL & GK Tue-Fri 11-14 June Lemera Departure and arrival to Lemera TL + 2 Sup & 8 Interviewers & Data Collectors Contact with authorities TL + 2 Sup Data collection TL + 2 Sup & 8 Interviewers & Data Collectors BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 119 Tue-Fri 11-14 June Ruzizi Departure and arrival to Ruzizi TL + 2 Sup & 8 Interviewers & Data Collectors Contact with authorities TL + 2 Sup Data collection TL + 2 Sup & 8 Interviewers & Data Collectors Sat 15 June BUKAVU Bukavu Arrival to Bukavu from Uvira TL + 4 Sup & 8 Interviewers & Data Collectors Sun 16 June Departure and arrival to Goma from Bukavu 2 TL, 3 Sup & HK Mon 17 June Departure and arrival to Lodja from Goma Mon 17 June LODJA Lodja Meeting with authorities JL + 4 Sup Tue - Thu 18 - 20 June Training I&DC JL + 4 Sup Fri 21 June Logistical arrangement Sat-Tue 22-25 June KOLE SA Kole Departure and arrival to Kole 2 Sup & 8 Interviewers & Data Collectors Meeting with authorities 2 Sup Data collection 2 Sup & 8 Interviewers & Data Collectors Sat-Sat 22-29 June Dekese Departure and arrival to Dekese from Kole 2 Sup & 8 Interviewers & Data Collectors Meeting with authorities JL + 4 Sup Data collection 2 Sup & 8 Interviewers & Data Collectors Departure and arrival to Kole from Dekese 2 Sup & 8 Interviewers & Data Collectors Sat-Tue 22-25 June Dibele Departure and arrival to Dibele from Kole 2 Sup & 8 Interviewers & Data Collectors Meeting with authorities 2 Sup Data collection 2 Sup & 8 Interviewers & Data Collectors Wed 03 July Departure and arrival to JL + 2 Sup BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 120 Tshumbe from Lodja Thu 04 July Departure and arrival to Kinshasa from Lodja. END OF THE FIELD ACTIVITIES 2 Sup Wed-Fri 26-28 June TSHUMBE SA Tshumbe Meeting with authorities JL + 2 Sup Wed-Fri 26-28 June Katako Kombe Departure and arrival to Katako￾Kombe JL + 2 Sup & 8 Interviewers & Data Collectors Meeting with authorities JL + 2 Sup Data collection JL + 2 Sup & 8 Interviewers & Data Collectors Wed-Fri 26-28 June Djalo Djeka Departure and arrival to Djalo￾Djeka JL + 2 Sup & 8 Interviewers & Data Collectors Meeting with authorities JL + 2 Sup Data collection JL + 2 Sup & 8 Interviewers & Data Collectors Wed-Fri 26-28 June Ototo Departure and arrival to Ototo JL + 2 Sup & 8 Interviewers & Data Collectors Meeting with authorities JL + 2 Sup Data collection JL + 2 Sup & 8 Interviewers & Data Collectors Fri 28 June LODJA Departure and arrival to Lodja Tue 02 July Departure and Arrival to Kinshasa END OF THE FIELD ACTIVITIES JL Thu 04 July Departure and Arrival to Kananga 3 Sup Thu 04 July LWIZA SA Kananga Meeting with authorities 3 Sup Fri-Mon 05-08 July Training I&DC 3 Sup wed-Sat 10-13 July Dibaya Departure and arrival to Mutoto 1 Sup & 8 Interviewers & Data Collectors BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 121 Meeting with authorities 1 Sup & 8 Interviewers & Data Collectors Data collection 1 Sup & 8 Interviewers & Data Collectors wed-Sun 10-14 July Bulape Departure and arrival to Bulape 2 Sup & 8 Interviewers & Data Collectors Meeting with authorities 2 Sup & 8 Interviewers & Data Collectors Data collection 2 Sup & 8 Interviewers & Data Collectors Mon 15 July Departure and arrival to Kinshasa from Kananga. END OF THE FIELD ACTIVITIES 3 Sup & 8 Interviewers & Data Collectors * Mary O'Grady and Hubert Kinwa will leave field on June 4, 2013. MK will conduct Tchumbe Supervision Area visits without them. ^ Jean Lambert Mandjo will leave the field on July 1, 2013. GK & MK will conduct Luiza Supervision Area without him ** When working in Lodja and Tshumbe, JL who will conducted the Team in Lodja will travel to Tshumbe to supervise the Tshumbe team. BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 122 Annex Q. Training Manual for Data Collection (English Translation) I. OVERVIEW OF THE INTEGRATED HEALTH PROJECT (IHP) AND THIS EVALUATION The Integrated Health Project (IHP in English, PROSANI in French) is five-year project, financed by the United States Agency for International Development (USAID) in support of the DRC's National Health Development Plan (NHDP). The project's objective is to create and support an environment conducive to the supply of healthcare services, products, and practices in the 80 targeted health zones located in the four provinces of Kasai Occidental, Kasai Oriental, Katanga, and Sud-Kivu. The IHP project was begun in October 2010 and completed at the end of September 2015. This project is supported by the Management Sciences for Health (MSH) consortium and its partners (International Rescue Committee and Overseas Strategic Consulting Ltd) in the amount of $139,767,129. The IHP has two components. Component 1 corresponds to the first strategic pillar on which the DRC's National Health Plan is focused. Specific emphasis is given to strengthening health zone capacity to be able to supply healthcare services such as family planning, maternal, neonatal, child health, nutrition, malaria, tuberculosis, neglected tropical disease, HIV/AIDS, water, sanitation, and hygiene by focusing on the services offered as well as the demand for these services. The objectives of Component 1 are: 1) improve access and availability of the main healthcare services within the minimum package of activities and the complementary package of activities-plus, (MPA-plus/CPA-plus); 2) improve the quality of MPA-Plus/CPA-Plus services; and 3) improve the knowledge and practices that lead toward behavior that encourages good health. In July 2011, within the IHP evaluation strategy framework, the NGO Management Science for Heath (MSH) and its partners conducted the first part of the baseline household survey on knowledge, practices, and coverage in the main health zones. Component 2 of the project corresponds to the second strategic pillar within the DRC's National Health Plan’s six priority areas: development of human resources; drug management; healthcare funding; infrastructure construction/repairs; equipment and new technologies; and improved health system management. The expected result for this component is improved leadership and improved governance as well as improved resource supply. The baseline evaluation and impact evaluation of the IHP program's RBF component will provide a large volume of statistical data that will permit the measurement of the baseline and impact of the RBF interventions. To achieve statistically significant results, all of the sites selected (health areas and villages) must be included in the two evaluations. USAID has contracted with IBTCI and its partners to conduct an IHP performance evaluation and an impact evaluation for the Results-Based Financing (RBF) pilot project, which will be implemented by IHP in some of the health zones. BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 123 The recipients (or audience) of this IHP performance evaluation are the USAID Mission in DRC and the implementing entity (MSH and partners). USAID will use the results to modify its current integrated health strategy and share lessons learned with other partners and implementing entities. An executive summary with recommendations will be provided to the Ministry of Health. II. OBJECTIVES AND EVALUATION QUESTIONS The goal of this study is to establish units of measure that will serve as the basis for evaluating IHP achievements and efficiency. The study will provide data and information on the actual status of access, use and the priority health services offered as well as the quality of services offered in health centers and general reference hospitals within the zones included in IHP. The following priority healthcare services are: 1) family planning, maternal health, neonatal health, child health; 3) nutrition, malaria. and tuberculosis; 4) HIV/AIDS; and water, sanitation and hygiene. The evaluation is specifically focusing on the following objectives: Documenting data on the availability and use of the main family health services: the minimum package of activities (MPA-plus) and the complementary package of activities-plus (CPA-Plus) at health centers (HCs) and at reference general hospitals (RGHs) for (female) patients of childbearing age (15-49 years), for children aged 0-23 months, children aged 24-59 months, and for pregnant women, within four provinces: Kasaï Orientale, Kasaï Occidentale, Katanga, and Sud Kivu; Evaluating the quality (including patient satisfaction) of the main health services offered: 1. Documenting data on the availability and use of the main family health services: the minimum package of activities (MPA-plus) and the complementary package of activities￾plus (CPA-Plus) at health centers (HCs) and at reference general hospitals (RGHs) 2. Evaluating system management and planning capacity for health service offerings in the targeted health zones in four provinces 3. Evaluating obstacles and bottlenecks (including beliefs, fears and perception) within the framework of using information services, educational services and communication services (SIEC) 4. Evaluating community support and information awareness, communication and supply of main family health services offered 5. Using performance indicators to identify IHP supervision areas that perform well and those that perform poorly A. Questions Related to the IHP Performance Evaluation The performance evaluation will allow USAID/DRC to determine which project components and aspects are successful and why they are successful, and what challenges the project faces, to allow for modifications or corrections to be made at the project’s mid-term. BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 124 To respond to the evaluation objectives above, USAID/DRC has come up with specific questions for each of the two evaluations. The quantitative surveys (for which you are responsible for collecting information) will provide responses to the numerous evaluation questions, but not to all of the questions. Team leaders and experts will conduct a survey of key informants to obtain responses to certain of the evaluation questions that are the most important for a qualitative evaluation. Furthermore, to contribute to the qualitative component, certain supervisors will be invited to facilitate focus groups with members of civil society organizations, health service providers, and/or women of childbearing age, and mothers of young children who are the direct beneficiaries of the IHP. The six following questions were specifically designed for the IHP Performance Evaluation: 1. To what extent has the project improved the access and availability of MPA-plus and CPA-plus services in the target health zones? 2. Has the project improved the quality of main family health services in the target zones? 3. Definition of the indicator for the use of curative services. Has there been an improvement in the knowledge, attitudes, practices, and positive behaviors related to health in the target health zones? 4. Have leadership and governance in the health sector improved in the target provinces? 5. What are the external factors impeding IHP activities and which impede achieving the best possible results? 6. What is the perception of IHP and what is its reputation? B. Evaluation of Results-Based Financing Component The RBF component of IHP has not yet been launched. IHP project staff are waiting for RBF baseline data to be collected before implementing it. The RBF component is a pilot project for a new intervention that will provide financial incentives to the health zones, to Ministry of Health offices, and to healthcare establishments (hospitals and health centers). These financial incentives will be awarded every quarter and based on the performance of participating health zones, the Ministry of Health management team, and the participating health facilities. There are specific indicators and related objectives that they should achieve. Health zone managers and civil society organizations involved in IHP will evaluate data quality every quarter to verify the reliability and validity of the results shared by the healthcare establishments and health zone managers. There are no further RBF-related interventions. There are eight RBF health zones that must pursue the same goals and objectives as all other IHP health zones. The only difference is that RBF health zones will receive a monetary reward for performing well. If the RBF intervention is considered a success, USAID plans to extend this intervention to the other health zones. The RBF impact evaluation will contribute to USAID and the Ministry of Health understanding of what works with regard to RBF and its effectiveness in increasing the quantity and quality of healthcare services. BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 125 The specific evaluation questions for the RBF component of the intervention are as follows: 1. s there qualitative and quantitative proof of change regarding services provided by health centers that are attributable to RBF? 2. What differences have resulted from the RBF component of the intervention? 3. Does the RBF model merit being expanded to other health zones? 4. What are the costs related to possible replication of the RBF model? 5. Were the expected results achieved? 6. Do the results vary from one group to another? 7. What are the factors that contributed to limiting the expected results or the constraints that limited the expected results? 8. What are the unexpected consequences of this intervention? I. TRAINING OVERVIEW  The general objective of the training workshop is to provide supervisors, data collectors. and interviewers with the skills required to conduct the surveys in an efficient and reliable manner.  Training is an important part of the survey preparation; it ensures the accuracy and reliability with which data collection is carried out, the data entry procedures, the data analysis and the precise nature of the survey results. This is why all personnel involved in data collection, supervision, or data entry must be trained to ensure the reliability and precision of data collection, filling out data collection forms, and transferring data using an appropriate method.  Training also promotes awareness among survey personnel on the importance of generating quality data. Group training allows for a common understanding of the terms and definitions used in the survey, as well as for procedures used during data collection via different survey tools and different approaches. The specific objectives of the training are:  Understanding the context and the basis for the IHP performance evaluation and the RBF impact evaluation  Discussing the general data collection process within the IHP framework  Encouraging participants to become familiar with the data collection tools  Applying the required techniques and efficient use of the tools  Developing and understanding the field implementation plan  Clarifying logistical challenges related to field work The trainer's pre-workshop responsibilities BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 126  Most important, become familiarized with all aspects of the survey methodology; this requires detailed study of the survey manual and its tools; organize training-related logistics, including pilot survey data collection  Plan the training schedule and the manner in which each session will be organized; confirm that there is logistical support and transportation available for the pilot survey location  Organize meals and refreshments for the training and lodging as needed for participants who do not reside in the area II. ROLE OF INTERVIEWER AND DATA COLLECTOR A. Interviewer Responsibilities The survey will be based on interviews with healthcare personnel, mothers of children 0 to 23 months, mothers of children aged between 24 to 59 months, and pregnant women:  Interviews with mothers after consultations  Interviews with healthcare personnel about equipment and supplies in the facility, essential drugs, etc.  Interviews with mothers of children aged 0 to 23 months within the household. It is important to note that the scientific value of the information collected during these surveys depends in large part on the interviewer's skill. The role of the interviewer is key to the success of this project. For that reason, the interviewer must:  Follow exactly the instructions on completing the questionnaire  Conduct interviews only with the individuals targeted by the survey. Do not change the way questions are asked  Provide context for the survey so that questions are well understood and do not suggest responses when it is not required  Ask all questions in the order in which they are provided on the questionnaire  Use clear, simple, and concise language and do not ask superfluous questions when unnecessary B. How to Conduct an Interview An interview engages an individual's memory. Therefore, it is important to be tactful and to ask questions clearly and in an unambiguous fashion. To be able to conduct an interview well is an art; it is not solely a technical process. The interview should be made as interesting and as positive an experience as possible. a) Establishing a rapport with the respondent 1) Make a good first impression BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 127  Make the respondent feel at ease when you meet him or her for the first time. Choosing your words wisely can make all the difference.  The physical appearance of the interviewer should inspire confidence in the individual being surveyed (well dressed, be able to present mission orders (if needed), polite language and attitude, etc.)  Smile (if needed) at the beginning of the interview and begin by saying, "Hello," and then introduce yourself. 2) Positively address the topic at hand 3) Emphasize the confidential nature of the responses 4) Reply to questions in a clear and unambiguous manner 5) Know how to deal with a situation when faced with resistance b) Tips for conducting a successful interview  Remain neutral during the interview  Never suggest answers to the respondent  Do not change the text or the order of the questions  Treat hesitant respondents tactfully  Do not rush the interview  Do not let the respondent distract you Do not fall into the trap of responding in detail to questions asked by a talkative respondent. Instead politely ask him or her to continue the interview and agree to address the other issues after it is complete. C. Qualities of a Good Interviewer a) Ethical Qualities  To perform his/her work, the interviewer must be a strong professional to avoid the following: o Filling out the questionnaires him/herself with assumed responses, specifically when the interviewer is not able to find the individual to be interviewed and doesn't want to make the effort; o Filling out the questionnaire haphazardly when responses should be written down with precision; o Suggesting responses to individuals who are indecisive to save time or to slant survey results to reflect his or her personal opinion. b) Social Qualities With a natural and confident manner, the interviewer should be courteous, appropriately dressed, and tactful. S/he should also strive to be friendly and straightforward and not give the person being interviewed the unpleasant impression that he or she is being interrogated; rather, the interview should be a friendly conversation. The interviewer should avoid showing any boredom or annoyance. BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 128 BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 129 c) Technical Criteria  There are four technical criteria: o Sufficient knowledge of the survey methodology to be able to respond to certain questions or objections that the individuals being interviewed may express. o A thorough understanding of how to ask questions. o Sufficient knowledge of the survey subject matter and its purpose. o The interviewer should be familiar with all terms and be able to explain them properly, if needed, and should also be sufficiently knowledgeable about the purpose of the survey to be able to explain it to the individuals being surveyed. D. Expected Behavior of Interviewers and Data Collectors All field personal are expected to diligently collect high-quality information and do so in quantities that are sufficient to avoid compromising the technical aspects of this study. For example, when data is of poor quality, such results will not be used in the study. If we collect less data than expected, we will not be able to achieve statistically significant data. Therefore, we ask that you pay specific attention to these types of details. Each day, collect as much data as possible. Honesty: We understand that, from time to time, you will make mistakes and that is normal. However, we do expect you to provide transparency. Inform your supervisor of any mistakes that have been made. Your supervisor will be able to help you resolve the problem. In summary, honesty is required. If we find out that you are not honest, you may be removed from the team and we will replace you with someone else. Honesty also applies to the data that you collect. For example, if you tell your supervisor that you are collecting data in the village that has been assigned to you, but in reality, you collect data in a different village, we will find out because you are required to activate the GPS locator for each questionnaire. If we discover that you have been dishonest, you will receive a warning from your supervisor. Completeness: There will be situations where you will be unable to complete the survey questionnaire. In this case, you should record the information that you have collected. But you must return to that location as soon as possible to complete data collection. In the space provided for comments, please note the reason for the interruption. If you cannot fully fill out the questionnaire, note as well the efforts that you have taken to try and complete the questionnaire and also note why the questionnaire was not fully completed. The interviewers and data collectors who repeatedly provide incomplete responses will receive a warning from their supervisor. The supervisor will offer advice on how to be more efficient. Respect: For our team, treating everyone with respect is crucially important. You must be respectful to your supervisor. If you disagree with your supervisor’s advice, you are welcome to express your opinions and suggestions. However, if you cannot come to an agreement with your supervisor on a specific question, you must abide by your supervisor’s decision. If you do not respect your supervisor's guidance, you will receive a warning. Even if rare, it is possible that BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 130 unresolved problems may exist between you and you supervisor. If you firmly believe that an issue merits attention and that your supervisor is not taking the required steps, you are welcome to bring this issue to the attention of the field coordinator or experts. However, we ask that you try to resolve the problem at the supervisory level and not bring the question to a higher level except when you think that it is absolutely necessary to do so. Respecting our respondents is crucial. You represent our institutions and we want you to display a professional attitude. The survey questionnaire cannot be administered without having read the informed consent to the patient and without having received the patient’s voluntary consent. A respondent is free to refuse to participate in the study for any reason. The respondent is also free to terminate an interview when it is ongoing. Every time that a respondent refuses to participate or asks that an ongoing interview be terminated, you are asked to clearly explain the reasons for this in your notes and to do so in French. If a respondent complains about a lack of respect that you have shown, you will receive a warning. Termination: Any interviewer or individual collecting data who has received three warnings will be asked to leave the team and will be replaced by another interviewer or data collector. III. THE IMPORTANCE OF QUALITY DATA A. Why is the quality of the data important? It is normal to have issues when collecting and entering data. Validating and cleaning up data is indeed a long process, but it is essential for reliable results. We would like to bring to your attention the following fundamental reasons why we encourage recording high-quality data:  We need reliable and valid data to support evaluation conclusions as well as the recommendations that we formulate. These recommendations may result in modifications being made to IHP interventions and its related work plan. If we base our recommendations on inaccurate data, this could cause cost overruns, and not only in financial terms; it could also result in Congolese citizens not receiving the quality health care that they need and to which they have a right.  Our detractors and opponents will look for weaknesses in the survey methodology and results. If we have poor quality data, our results will be rejected and we will lose credibility with USAID and our colleagues.  The results will be accessible to the public on the Internet and can be used by others, to, for example, make international comparisons or in new research. If we report inaccurate data, this could affect other researchers and, even, possibly, the beneficiaries of international aid in the DRC and other countries.  Future policy decisions may depend on the information generated from these surveys. If the policy is based on erroneous conclusions and recommendations, Congolese citizens may be deprived of quality health care. BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 131 B. Problems Related to Data Collection Incorrect costs of services provided:  Health facilities should provide a list showing the costs of each type of service provided. The costs should be decided on in collaboration with the district-level government and with the CODESA. Considering that the cost of services is generally a sensitive subject, we ask that you verify the data that you collect from other sources using triangulation. When there are discrepancies, please note them in writing, in French, in your survey tools in the section reserved for comments.  Unreadable or incomplete data collection forms, or both:  Since our data will be gathered with cell phones using MAGPI software, this problem should be limited. However, we must still be able to read your notes. We require, therefore, that all information be written in French. Numeric data entry errors:  Incorrect numbers and other data may be incorrectly entered on the questionnaire. Again, MAGPI will prevent certain errors, but not all (for example, incorrect numbers as responses, extra or missing zeros, etc.). Please verify your work and specifically when entering numbers in the survey tools. Translation from French to local languages:  MAGPI tools are only programed in French. The three survey tools will be translated into three local languages (Swahili, Tshiluba, and Lingala), but only on paper. You should read the questions to the respondent in the local language, unless the respondent speaks French fluently. You will enter their responses directly into MAGPI during the interview. C. Data Entry Errors Errors committed during data collection must be verified and corrected or omitted from the results. The quality of data is more important than the quantity of data. No purpose is served by having a large volume of data that is of poor quality. In certain surveys, a lot of erroneous or unreliable data had to be excluded from analysis. Sometimes, new data collection was required. Unreliable data compromises overall survey results and is a waste of precious resources in terms of the time and effort spent to collect data that could not be used. The problems related to data that are currently seen in surveys are attributable to several issues:  Supervisors, data collectors, and interviewers have been insufficiently or poorly trained.  Field work has not been properly carried out (inadequate supervision, lack of attention to detail by data collectors or by interviewers, lack of quality control before submitting filled out forms, lack of understanding instructions, etc.).  The data was not verified at each step in the survey process.  A data verification function was not used or suspect values were not verified.  Human error. Problems related to data can, therefore, be avoided. To do so: BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 132  Carefully study the interviewer's manual and tools at each stage and carefully follow instructions.  Choose an individual who is capable and reliable and make sure that this individual has been well-trained in survey methodology.  Encourage personnel to openly communicate uncertainties related to survey procedures or suspect data.  Verify data collection forms for accuracy and completeness after each data collection visit, at the end of each day of working in the field, and before entering data.  Conduct random testing on data entered into the tools (to identify unusual or outlying results that require verification). D. Quality Control To guarantee quality data, supervisors will conduct random evaluations of data quality. Every day, the supervisor will set a goal of re-interviewing 5% of the total data gathered during the day. For example, the supervisor will randomly select households and health facilities to re￾administer some sections of the questionnaire. Each time, the supervisor will select different sections. The supervisor will compare his/her results with the results that were gathered by the interviewer and data collectors. If data collectors or interviewers are claiming to collect data that, in reality, is not being collected, and/or if it is discovered that the data collection has many errors, the data collectors or interviewers will receive a warning. IV. SAMPLE SELECTION A. IHP Performance Evaluation The following studies will be carried out:  Collection of program data and results from health care facilities (HC and RGH)  Exit survey questionnaires to (female) consumers of services: women bringing children between 0 to 59 months for care or who have come for care for themselves  Interviews and focus groups with key informants: MPH, MSH, stakeholders, CODESA, community leaders, etc. (in progress)  Surveys at the health service level (in progress) Sampling Plan For operational reasons, the MPH has regrouped the 80 health zones into eight supervision areas.  Within each supervision area, three health zones have been randomly selected.  Within each health zone selected, three health centers were randomly selected (preset number). Only the health center and all the randomly selected health centers will be surveyed. BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 133 In each health center there will be:  Collection of program data and results from health care facilities (HC and RGH)  Exit survey questionnaires to (female) consumers of services: women bringing children between 0 to 59 months for care or who have come for care for themselves, according to the following order of priority: o Module 1: Women with children aged 0 to 23 months o Module 2: Women with children aged 24 to 59 months o Module 3: Women of childbearing age (15 to 49 years) o Module 4: Pregnant women  Each woman will only be questioned on two of the modules, at most. Within each health zone selected at the provincial level, interviews and focus groups will be organized with key informants: MPH, MSH, stakeholders, CODESA, community leaders, etc. B. RBF Impact Evaluation Three types of survey will be organized:  Household surveys  Interviews and focus groups with key informants: MPH, MSH, stakeholders, CODESA, community leaders, etc.  Collection of program data and results from healthcare facilities (HC and RGH) Sampling Plan Only RBF health zones are relevant (zones where the intervention is). In addition to these 8 health zones programmed for RBF, there will be 8 additional health zones selected near to the health zones where intervention is occurring (comparison zones). Selecting households to survey: The methodology has four (4) stages: 1. For each health zone where intervention is occurring, also choose a Health Zone for comparison. (completed) 2. For each of the 16 health zones involved, choose the villages in which the survey will be organized: random selection that takes into account each village's demographic weight. (completed) 3. For each village selected, randomly select the first household to be surveyed. (to be completed in the field) 4. Within each household, identify if the eligible individuals (women with children aged 0 to 23 months) are present. (to be completed in the field) The protocol for selecting households and individuals to be surveyed has two stages: 1) the selection of the first household, and the selection of the eligible individual. BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 134 Selecting the 1st household: 1st Scenario: If the list of all village households is available: Assign a number to each household Calculate the SAMPLING INTERVAL (number of households to be surveyed divided by the number of total households) Choose the first household at random Follow the sampling interval to identify other households 2nd Scenario: If the number of households in the village is fewer than 19 (our sample per village): All eligible households where a mother resides with children between 0 to 23 months will be surveyed 3rd Scenario: If the village has too many households and it is difficult to count them: Quickly estimate the number of households Subdivide the village into sections so that each section has about the same number of households Randomly select a section and follow the instructions outlined in Scenario 1 Selecting the individuals to be surveyed within the selected households Once a household has been selected:  Ask if a child between 0 to 23 months lives there with his/her mother. If Yes, this household has been selected as the first one in the survey; the number of eligible individuals are then counted and the interview process is begun with the mother of the youngest child aged 0 to 23 months.  If the household does not have a child between 0 to 23 months residing with his/her mother, the household that is closest to the one initially selected is contacted next. In this new household, the same question is asked. If an eligible individual is present, the interview is begun, or, again, the closest household is contacted. This process is continued until an eligible first household is found.  Once the first eligible household has been found and the interview completed, the interviewer returns to the first household selected at random to apply interval sampling and identify the second household. In the second household, the eligible person will be located and the process will proceed as with the first household. The process will continue until the entire defined sample has been completed.  If all the village's households are visited and a sample is not obtained (the predetermined number of households), the closest village is to be visited next and the sampling interval continued by beginning with the first household (the household closest to the previous village).  If two children are eligible within the same household, priority will be given to the mother with the youngest child. Then, the interviewer will ask questions about the other child by using the appropriate questionnaire. BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 135 V. DATA COLLECTION TOOLS A. Questionnaire Types 1. Health Facility Data Collection Questionnaires: Health Centers and GRH This tool is for health facility data collectors, and specifically in health centers and general reference hospitals. It will also be used to evaluate both IHP performance and RBF impact. Within this questionnaire, there are the following modules: Module 1: General information about the health facility (GI) Module 2: Personnel statistics (PS) Module 3: Preventive care (PREV) Module 4: Curative care (CC) Module 5: Supervision (sup) Module 6: Equipment and materials (EM) Module 7: Inventory of materials and medication for reproductive health Module 8: Availability of family planning methods and vaccines Module 9: Availability of materials (IEC) When this tool is being used, the data collectors will ask questions of the Head Nurse or designated representative. For certain information, the use of documentation is required (NHIS report, inventories, etc.) or even direct observation (for example, displayed tariffs). 2. Women’s Health Center Exit Questionnaire This questionnaire is for the interview with health service clients, and specifically, women who have come in with their children for care or who have come in to receive care themselves. This questionnaire will be used to evaluate IHP performance. Within this questionnaire, there are the following modules: For female clients: Module 1. Mothers with children between 0 to 23 Months Module 2. Mothers with children between 24 to 59 Months Module 3. Women between 15 to 49 Years Module 4. Pregnant women The interviewer must read the woman the information on informed consent and receive her consent before beginning the interview. At times, the interviewer will need to consult certain documents such as a child's vaccination card or a woman's PNC card. BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 136 It is important that the interviewer put the woman at ease and avoid her being influenced by health center personnel. Although the target of several categories, and even though a woman may be eligible for several modules and perhaps even all of them, a woman can only be interviewed on two of the modules, at most. 3. Household Questionnaire This questionnaire is used to evaluate RBF impact and for interviewing mothers of children between 0 to 23 months within households. The women surveyed are those who have been found in eligible households, selected at random with strict adherence to the methodology described above. Within this questionnaire, there are the following modules. The interviewer must read the woman the information on informed consent and receive her consent before beginning the interview. It is important for the interviewer to put the woman at ease. This questionnaire is subdivided into the three follow sections. The first section is for mothers of children between 0 to 23 months (modules 1 to 12). The second section is for mothers of children between 24 to 59 months (modules 13 to 14). The third section is for all of the mothers (module 15). Within this questionnaire, there are the following modules: Module 1: Household residents Module 2: Water and sanitation Module 3: Contraception Module 4: HIV/AIDS Module 5: Maternal health Module 6: Disease symptoms Module 7: Contact with healthcare services Module 8: Vitamin A supplements Module 9: Initial breastfeeding Module 10: Insecticide-treated nets Module 11: Treatment of diarrhea Module 12: Treatment of suspected pneumonia Module 13: Treatment of malaria Module 14: Responding mother's behavior regarding children's health Module 15: Perception of healthcare quality The interviewer must read the woman the information on informed consent and receive her consent before beginning the interview. It is important that the interviewer put the woman at ease and avoid her being influenced by health center personnel. BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 137 B. Instructions for Filling Out Questionnaires 1. Asking Questions It is important to ask each question exactly as it is written in the questionnaire. It is for this reason that when you ask the question, you should confirm that the person being interviewed heard the question clearly and had no difficulties understanding. At times, you will need to repeat the question to be sure that the person being interviewed has understood. In such cases, do not paraphrase the question—repeat it as written. If after having repeated the question, the respondent still does not understand, ask the question again in a different way. When you change the way you ask the question, however, be careful to not change its original meaning. In some cases, you will need to probe, asking additional questions to obtain a complete response. If that is the case, be careful that your probing is "neutral" and does not suggest any particular response. Such probing requires a significant amount of tact and diplomacy and will be one of the more challenging aspects of your work. 2. Recording Responses There are two types of questions: (a) closed questions (coded), for which a set of responses are defined in advance and are assigned a code and (b) open questions, the questions for which the responses are not defined in advance. a. Closed Questions (Coded Questions) In the questionnaire, there is a list of responses to coded questions. To record the response given, you will simply need to circle the number (code) that corresponds to the response. Example: GI1. Have arrangements been made for the disposal of biomedical waste? Yes No Don't know 1 2 98 If no arrangements have been made for the disposal of biomedical waste, "click NO" There are questions for which multiple responses are possible. In such cases, all responses given by the respondent must be circled. PREV145. What types of health care services does this facility provide to children? (preventive and curative pediatric care included) Note all types of care provided. Curative care 1 Preventive care 2 Promotional care 3 If the center offers more than one type of care, "click all responses given." b. Open Questions (Not Coded) The responses to certain questions cannot be predefined. To record the responses to this type of question, you must write the response in the space provided, rather than circling a given BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 138 code. In general, the response will be a number that you will note down (for example, the age of the individual being surveyed, a quantity, etc.) or a date; sometimes it will be a sentence that the respondent has uttered. However, in other cases, you must write the response exactly as it was given to you. Be careful to write the responses exactly as given, do not modify terms and do not excessively summarize. Example: PREV146. In 2012, how many days a week is postpartum care available to women? Number Don't know /__________/ 98 c. Mixed questions (coded and not coded) Some questions contain set responses as well as space to write responses that do not correspond to any of the predefined responses. Example: HC2 When have you come into contact with this (these) individual(s)?  When the individual(s) was/were conducting a routine community visit  During a health awareness campaign  During a visit where future activities were announced  When I left the health center for services  Other (specify) __________________________________  A  B  C  D  X VI. DATA COLLECTION VIA CELL PHONE USING MAGPIE SOFTWARE This part of the module allows the interviewer to:  Turn on the telephone  Open MAGPI  Open the relevant questionnaire  Navigate within the questionnaire and enter data  Save the filled out questionnaire as "incomplete"  Close MAGPI  Turn off the telephone Introduction to the Cell Phone Version of Magpie MAGPI is a data collection software application. Installed on an enabled phone, the software allows interviewers and data collectors to directly enter data they have collected onto the phone and send it to a website. From the website, the expert in charge of data management and statistical analysis can directly and electronically access the questionnaire that was uploaded and stored on the phone. The phone uses the ANDROID operating system, making it possible to use Magpie. With its touch screen, the phone is easy to use. BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 139 MAGPI mobile allows users to upload forms onto the mobile phone. Once the forms have been uploaded to the phone, the data that has been gathered via the forms can be sent to the server for analysis. If you would like to see forms that have previously been uploaded, you may touch "Enter New Data" on the main screen after connecting to Magpie. Starting the Magpie Software To connect, follow the steps below: 1. Turn on your phone (pay close attention to the demo) 2. Click on the "Menu" tab 3. Swipe your finger from right to the left until you reach the Magpieicon and then tap it. 4. Once Magpie has been activated, the application will show a new page with the following buttons: a. Enter New Data b. Review Saved Data c. Send Completed Data d. Manage Files e. Export Data Once the phone has been activated, it is important to update the date and time it displays. Data Collection with Magpie Via Cell Phone To enter responses to the questionnaire, follow the steps below:  On the main screen, select or press the "Enter New Data" button. A list of questionnaires that have already been uploaded to the cell phone will be displayed on screen.  Select the questionnaire for which you would like to enter data and touch the questionnaire or the menu button. Select either the Health Exit Survey or the Health Facility Survey (HFS) DRC 2013  The screen will open and show the title of the selected questionnaire  Follow the on-screen instructions (swipe your finger horizontally) and the first question of the selected questionnaire will open. Please note:  Responses cannot be entered for etiquette questions,  Some questions are marked as required and the user cannot proceed to the next question without entering a response for them. If you attempt to proceed to the next question without responding to the required questions, the following message will appear: "Sorry, but this response is required." BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 140 When you have finished filling out all the questions on the form, a screen will display the following button options: a) Record Incomplete Data: This filled-out questionnaire cannot be sent to the server and can only be viewed in the «Incomplete» tab that is displayed after clicking on the "Review recorded data" button on the main screen. b) Record Complete Data: This filled-out questionnaire can be sent to the server and can be viewed in the «Complete» tab that is displayed after clicking on the "Review recorded data" button on the main screen. The interviewer should always save incomplete data. The interviewer can then go back to previously entered data and complete it. Only the supervisor can mark data as "complete." Closing Magpie At any time during data entry, the user can close Magpie and choose to save or not save the data that has already been entered. Carefully review the available options before closing the questionnaire. At any question within the questionnaire, the following menu options can be displayed:  Save and Exit: When this option is selected, a dialog box will open to confirm that you wish to record your data as "complete" or "incomplete" and wish to then exit that page within the questionnaire.  Delete a Response: Deletes all data entered for the question, unselects the field or the button that was selected in the question, or resets the question to the current date.  Go To: Jumps to the first question when it is selected; displays all of the questions within the form and from these questions, you can select the question which you would like to read or skip. This feature also allows you to jump to the end of the questionnaire. When doing so, on screen, you will have the option to save as "incomplete" or "complete." When exiting, Magpie must be closed and, to preserve the phone’s battery, the phone should be turned off. The interviewer should not use the phone’s other features or the other features in Magpie; the phone should only be used to access questionnaires. VII. LOGISTICS a. Cell phone battery life: Cell phone use such as airplane mode to preserve battery life, other steps related to cell phone use, paper, navigating between screens; backing up data. Each team will also receive a set of solar chargers for recharging the phones. b. Supplies: (in plastic bags): Plastic bags will be supplied to all interviewers to be used to protect cell phones, paper questionnaires, etc. c. Site visit schedule: Each team member will receive a schedule of sites to be visited. This will include health zones, health facilities (hospitals and health zones). With regard to the RBF evaluation, the villages selected for the household survey will also be included on this schedule. The expert will schedule field visits in conjunction with the supervisors and the BASELINE FOR EVALUATION OF THE INTEGRATED HEALTH PROJECT—ANNEXES 141 interviewers. To do so, they should be assisted by the relevant health zone manager or MSH manager d. Transportation: A means of transportation will be made available to all evaluation team members. This is to ensure that everyone is on time when arriving at survey locations and, also, that everyone can leave the locations on time. These methods of transportation will depend on the specific field conditions. e. Lodging and meals: When the interviewers are required to spend the night away from their normal place of residence, a lodging allowance will be provided. The amount of this allowance is set by the CESD and is affected field conditions. A per diem will also be provided to each interviewer for daily meals when he/she works outside his/her normal place of residence. f. Salary: A salary will be provided to each interviewer on a pro rata basis according to the actual number of days worked. A day worked is one when the interviewer collected data. Travel days or rest days are not considered to be work days and will not be paid. g. Safety: interviewers must remain aware of the security situation. Supervisors must be notified of any information or event related to security and, in conjunction with the expert, take any necessary measures. Describe here what should happen in the event of an unexpected situation, including individual safety concerns [sic]. If a village or site where a survey is to take place is not accessible, the interviewer should inform the supervisor so that appropriate measures can be taken. Figure 1: Field Evaluation Team Mary O’Grady, IHP Team Leader Magalie Kabale IHP Supervisor (1) Facility Data Collectors (2) Client Exit Interviewers (2) Jean Lambert Mandjo, IHP Expert IHP Supervisor (1) Facility Data Collectors (2) Client Exit Interviewers (2) Zephyrin Kayinda, RBF Expert Eric Murphy Ngango, Study Coordinator Pascal Bukasa, Field Coordinator RBF Supervisors (6) Household Interviewers (20) Facility Data Collectors (6)