Final Evaluation The Healthy Child and Mother Project January 2015 This publication was produced at the request of the United States Agency for International Development. It was prepared independently by Kreulen, G.J., External Consultant. January 2015 Acknowledgements Many people and organizations contributed to the success of the SUSOMA evaluation. I would like to especially thank World Renew for their ongoing assistance and support, especially Nancy TenBroek, Kohima Daring, Alan Talens and Stephanie Sackett. Thanks also goes to Sukumar Ghagra (SUSOMA Project Manager), Gabriel Rozario and Prafullo Hajong (ED and Coordinator from PARI), and Apurba Ghagra, Catherine Guda and Mukarram Hossain (Director, Assistant Director, and Project Coordinator from SATHI) for arranging and facilitating details of the evaluation. All members of the final evaluation team were invaluable as each contributed of their time, talents, and experience to the collection, analysis and synthesis of evaluation data and to arriving at a mutual understanding of accomplishments, challenges, sustainability, impact, and best practices of the project. The evaluation would not be complete without the insights received from stakeholders. Thanks goes out to the 459 persons who gave inputs in 59 stakeholder interviews during the evaluation, including government officials in Netrokona, Durgapur, Kendua, and Dhaka, health care workers in upazilla and ward-level facilities, and community members who participated in the PI groups and those who were beneficiaries of MNC activities undertaken as part of this project. Appreciation goes to Stacy Saha, the RHFA coordinator, who led the RFHA and assisted with interpreting findings. Thanks also to DM Emdadul Hoque, Principal Investigator, and colleagues at ICDDR,B for the KPC and operations research study that strengthened understandings of project accomplishments and of the utility of the PI Model intervention strategy. In addition, the support provided by Umma Meena, the Bangladesh Mission Director, Meridith Crews and Kristina Gryboski from USAID, Jennifer Luna from MCSP, Aparna Jain and James Foreit from Evidence Project, and Ashley Strahley and team from EnCompass is deeply appreciated. Grace Kreulen, External Consultant Front-cover photo: People’s Institution primary group member, Sheuli Rani Borman, with her infant son, Shoristala village, Durgapur, Bangladesh (Kohima Daring, photographer). January 2015 The Healthy Child and Mother Project Final Evaluation: Reducing mortality and improving health status among mothers and newborns through building public and private partnerships in Bangladesh       Date of Draft Report: Submission: September 7, 2014       Kohima Daring – Team Leader for India and Bangladesh, World Renew Nancy TenBroek – Asia Regional Health Advisor, World Renew Stephanie Sackett – Associate Director for Grants, World Renew Alan Talens – Health Advisor, World Renew (Contact Person) Dr. Grace Kreulen -- Final Evaluation Team Leader (External Consult) and report author 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. January 2015 Contents Acronyms ............................................................................................................................................................................ 5 Executive Summary .......................................................................................................................................................... 6 Evaluation Purpose and Evaluation Questions ........................................................................................................... 8 Evaluation Purpose .................................................................................................................................................... 8 Evaluation Questions ................................................................................................................................................ 8 Project Background .......................................................................................................................................................... 9 Evaluation Methods and Limitations ........................................................................................................................... 13 Findings, Conclusions, and Recommendations ........................................................................................................ 17 Findings ...................................................................................................................................................................... 17 Conclusions .............................................................................................................................................................. 28 Recommendations ................................................................................................................................................... 33 Annexes: submitted electronically in separate files I. Not Applicable II. List of Publications and Presentations Related to the Project III. Project Management Evaluation IV. Work Plan Table V. Rapid CATCH Table VI. Final KPC Report, Revised Baseline KPC Report VII. CHW Training Matrix VIII. Evaluation Scope of Work IX. Evaluation Methods and Limitations X. Data Collection Instruments XI. Information Sources XII. Disclosure of Any Conflicts of Interest XIII. Statement of Differences XIV. Evaluation Team Members, Roles, and Their Titles XV. Final Operations Research Report XVI. Operations Research Brief XVII. Stakeholder Debrief PowerPoint Presentation XVIII. Project Data Form XIX. Optional Annexes a. Final RHFA Report with RHFA assessment baseline and endline scorecard (a1) b. Final CSSA Dashboard with component score indicators c. Peer-reviewed publications d. Report on Cost Analysis of Interventions e. Final Operations Research Qualitative and Social Capital Study Report    January 2015 ACRONYMS ADS Automated Directives System AMTSL ANC/PNC Active management of the third stage of labor Antenatal care/postnatal care CC Community Clinic (ward level) CCC Central Cooperative Committee (middle tier of PI structure, also known as Union Committee) CHT Community health trainer (SUSOMA staff) CHV Community health volunteer CHW Community health worker CSBA Community skilled birth attendant CSSA Child Survival Sustainability Assessment DDFP District Director of Family Planning DEC Development Experience Clearinghouse DTAC District Technical Advisory Committee EHF Emergency health funds ENC EPI Essential newborn care Expanded program for immunization FWC Family Welfare Center (union level) FY Fiscal Year GOB Government of Bangladesh HMIS Health ministry information system ICDDR,B International Centre for Diarrhoeal Disease Research, Bangladesh IGA Income generation activities ISP Informal service provider (village doctor) KPC Knowledge, practices, and coverage survey LAMB Lutheran Aide to Medicine in Bangladesh LQAS Lot Quality Assurance Sampling MNC/MNCH Maternal newborn care / Maternal newborn child health MOHFW Ministry of Health and Family Welfare NHD National health days NID National immunization day OR Operations Research PG Primary group (bottom tier of PI structure) PI Peoples Institution (top tier of PI structure) PICI/CCI People’s Institution Capacity Indicators/Community Capacity Indicators PPP Public-Private Partnership RD Rural Dispensary (union level) RHFA Rapid Health Facility Assessment survey SOW Scope of Work January 2015 TOT Train the trainer TTBA Trained traditional birth attendant UFPO Upazilla family planning officer UH&FPO Upazilla health and family planning officer UHC Upazila health complex USAID U.S. Agency for International Development UTAC Upazila Technical Advisory Committee WRA Women of reproductive age  January 2015 The Healthy Child and Mother Project Final Evaluation: Executive Summary This project was funded by the U.S. Agency for International Development through the Child Survival and Health Grants Program September, 2014 Evaluation, Purpose, and Evaluation Questions The overarching purpose of the evaluation is to determine the extent to which the Healthy Child and Mother Project that was implemented by World Renew and its local partners from 2009-2014 accomplished the intended results. The evaluation describes key factors that contributed to what worked or did not work and shares project learnings. The findings can be used by the government and NGOs in Bangladesh and elsewhere to inform decisions related to best strategies for enhanced maternal and newborn health care in developing communities. The evaluation answers the following questions: 1) To what extend and in what ways did project interventions contribute to improved MNC household and community behaviors and the utilization, availability and quality of health services? 2) What challenges were faced and how were they overcome? 3) What project strategies have the potential to be sustained or expanded? 4) Did the operations research provide evidence that supports attribution of results to the project innovation? Project Background Neonatal and maternal mortality in the rural districts of Bangladesh remains high, especially in remote areas where health facilities are few and critical child and maternal health indicators are consistently lower than the national average. The purpose of this project was to contribute to reducing mortality and improving health status among mothers and newborns through building public private partnerships in the Netrokona district in northern Bangladesh. The project used a maternal newborn intervention package focused on promotion of essential newborn care, appropriate care-seeking behavior and key family practices, which was intentionally integrated into the GOB C-IMCI strategy (expanded to include newborns) and delivered by a cadre of trained CHWs at household and community levels. The project innovation is the People’s Institution (PI) community mobilization model, adapted to empower the poor and marginalized to collaborate with the public health sector to promote maternal newborn health. The operations research study measured PI model effectiveness, equitability, cost-effectiveness, performance, and impact on social capital. Evaluation Design, Methods, and Limitations The final evaluation team used a comprehensive participatory approach to determine project accomplishments and challenges, the sustainability of project results, and the impact of project interventions. Quantitative and qualitative data from a variety of sources informed the evaluation. These include project Peoples Institution group member with infant son (Photographer, Kohima Daring) Key Findings: • 493 poor communities with locally lead CBO in PPP for MNC • 78% CBOs have EHFs • 1,078 trained volunteer community-based providers promoting MNC & supporting GOB health workers • CBOs managing local health clinics/making decisions for MNC with MOH officials • Active referral and EHF systems providing access to care for poor • Significant gains in intervention group versus comparison group in ANC, delivery, PNC, care￾seeking, newborn care, quality of care, POU and handwashing ⇒ 4+ ANC ⇑ 2.6 times ⇒ Inst. delivery ⇑ 2.4 times ⇒ SBA delivery ⇑ 2.4 times ⇒ NB PNC ⇑ 2.2 times FINAL EVALUATION EXECUTIVE SUMMARY  January 2015 documents and M&E/HMIS data, the OR study, KPC surveys (with a comparison group), and RHFA surveys. Stakeholder interviews were conducted over a 3-day period to gain a broader understanding of the how and why of project accomplishments. The evaluation team was limited by difficulties encountered by the operations research (OR) study team in finalizing KPC and OR data and reports. Findings and Conclusions The project effectively mobilized women and men for maternal newborn health and involvement with the health system in a strong PPP by founding the People’s Institution Model with marginalized people. A 3-tiered functional PI system was established within 2-years that served as the foundation for public private partnership development, enhanced health services, trained volunteer community-based providers, emergency health funds, and MNC gains. The project strengthened public private health system collaboration with memos of understandings, a referral system, and participatory health committee structures in which the poor are active MNC advocates with the government and government officials and health workers are meeting with them to make policies and decisions to meet community needs. Significant (p≤ gains seen from baseline to endline in the intervention group include: 4+ ANC visits increased from 5% to 14%, quality of ANC increased from 0% to 5%, institutional delivery from 8% to 19%, SBA delivery from 9% to 22%, thermal care of newborn from 10% to 45%, clean cord care from 55% to 65%, postnatal newborn care from 8% to 19%, and handwashing practices from 22% to 39%. Of these, gains in ANC visits, SBA delivery, institutional delivery, newborn and maternal PNC visits, care-seeking for ANC and PNC complications, and handwashing practices were significantly greater (p≤ in the intervention group versus the comparison group. The intervention group also had significant improvements versus the comparison group in use of clean birth kits, thermal care of the newborn, delayed bathing, quality ANC, AMTSL, and essential newborn care at delivery. In addition, the availability of weekly ANC services at health facilities increased from 60% to 90%, and 24/7 facility-based delivery services from 3% to 17%. OR findings show that in 2014 over 60% of WRA in the intervention area were active members of the PI groups and PI group members were significantly more likely to have higher levels of social capital than non group members with increases in both structural and cognitive social capital. Qualitative data supports attribution of growth in social capital and improvements in MNC to the PI model intervention. The average cost for the intervention per woman of reproductive age is USD 9.73 and per community volunteer is USD 1,045. Scaling up a similar program with a population of 1.5 million is estimated cost USD 3.6 million. Best practice for the global and Bangladesh health community to consider in promoting maternal newborn health care in marginalized communities include: 1. The PI Model delivery platform of empowerment and local governance to increase social capital of marginalized women and improve community-based MNC and health practices in partnership with MOH officials and health facilities/providers. 2. Community-supported and managed emergency health funds to promote access to care for the poor. 3. The public-private partnership (PPP) based referral system with which poor mothers and children get priority access to care. 4. A volunteer system of trained village-based health providers working in collaboration with health facility providers to promote ANC, safe deliveries, newborn care, and PNC. 5. CBO (PI) involvement in the management and operations of local clinics to increase quality of care. 6. HMIS matching meetings between PI and government providers/officials for accurate data to address MNC needs. 7. Using Theater for Development for strategic MNC messaging at the community level. 8. Grantee working through local NGO partners (civil society) to increase local organizational capacity. The SUSOMA Project in Netrokona, Bangladesh is supported by the American people through the United States Agency for International Development (USAID) through its Child Survival and Health Grants Program. The SUSOMA is managed by World Renew under Cooperative Agreement No. GHS-A-00-09-00009-00. The views expressed in this material do not necessarily reflect the views of USAID or the United States Government. For more information about SUSOMA contact www.worldrenew.net  January 2015 EVALUATION PURPOSE AND EVALUATION QUESTIONS EVALUATION PURPOSE This document presents the final performance evaluation (FE) for the Healthy Child and Mother Project (SUSOMA) funded by USAID’s Child Survival and Health Grants Program (CSHGP) GHS-A-00-09-00009- 00 that was implemented by World Renew and its local partners from September 30, 2009 to September 29, 2014 in Netrokona, Bangladesh. USAID’s CSHGP supports community-oriented projects implemented by U.S. nongovernmental organizations (NGOs) and their local partners. The purpose of this program was to contribute to reducing mortality and improving health status among mothers and newborns. USAID reviewed and approved the FE Scope of Work (SOW) and approved the final evaluator. Grace J. Kreulen, PhD, was hired with project funds as and independent consultant to serve as the FE team leader. The evaluation was conducted in a manner protective of the evaluator's independence and neutrality. The draft report was directly submitted to USAID simultaneously by the evaluator at the time it was provided to the grantee. The primary aim of the FE is to determine the extent to which the project accomplished the intended results, to describe key factors that contributed to what worked or what did not work, and to demonstrate strategies directly relevant to improving MOH policies/practices and to global learning. In addition the impact of the innovation, the People’s Institution model, was assessed as part of the operations research study. The FE provides an opportunity for all project stakeholders to take stock of accomplishments to date and to listen to the beneficiaries at all levels, including mothers and caregivers, other community members and opinion leaders, health workers, health system administrators, local partners, other organizations, and donors. The following audiences will use the FE report as a source of evidence to help inform decisions about future maternal newborn care program designs and policies, especially programs desiring to utilize public-private partnerships to enhance maternal newborn health: 1. In-country partners at national, regional, and local levels, including the GOB MOHFW and other relevant ministries, district officials and health providers, local organizations, and communities. 2. USAID (CSHGP, Global Health Bureau, USAID Mission in Bangladesh) and other CSHGP grantees. 3. The international global health community. The FE report will be posted the USAID Development Experience Clearinghouse https://dec.usaid.gov. FINAL EVALUATION QUESTIONS Primary Questions Related Sub-Questions 1. To what extent did the SUSOMA project contribute to improved MNCH-related household and community behaviors, availability and utilization of quality services? a) To what extent and in what ways did the local NGO’s (SATHI and PARI) effectively engage communities to strengthen private/public partnerships in support of MNCH? b) How did community engagement and mobilization strategies using the PI model impact public-private collaboration, allocation of resources for health (local EHF, community and facility-based care), local government capacity for facility services, and policy advocacy? c) To what extent and in what ways did the utilization of volunteer CHWs contribute to improved MNCH practices and increased coverage and utilization of ANC, assisted delivery, and post partum care? d) To what extent and in what ways were community health system enhancement strategies effective? Did the Quality Improvement System improve services at the village level? Did engaging the informal health system reduce harmful practices? What was the impact of the referral process for mothers and sick newborns? 2. What strategies and factors (both planned and unplanned) lead to achievement of key a) Was the project implemented as designed, including the incorporation of key partners outlined in the DIP? What changes were made to the implementation plan and why? b) What is the quality of the data and of the system for measuring project results? Did the  January 2015 critical results? What challenges/ barriers were faced and how were they overcome? quantitative and qualitative indicators provide useful evidence for decision-making? c) How did consideration of socioeconomic factors and gender affect implementation and outcomes? Were females and males appropriately engaged in the PI model strategy? Did the project effectively unify the socially and economically underprivileged and create opportunities and resources for MNCH not usually available to these individuals/groups? d) What synergy/integration occurred between strategies that impacted results? 3. Which project strategies have potential be sustained or expanded? What are the promising practices and lessons learned? a) What evidence is there that SATHI and PARI have become more sustainable as organizations able to support community engagement and mobilization? b) To what extent and in what ways has the project developed an enabling and learning environment to support sustainable capacity and advocacy for quality MNCH care? c) What aspects of the program can be or are being scaled-up to benefit more people and to foster lasting policy/program development? What factors influence the success of scale-up efforts? d) What resources would be required to institutionalize or scale up key intervention components (cost analysis)? 4. Did the operation research provide evidence that supports attribution of project results to the PI model? How could scale-up of the PI model impact MNCH in Bangladesh? a) What role did the OR study have in evaluating and improving the impact of the PI model on MNCH outcomes at the community level? To what extend did OR results provide evidence that the PI model of community mobilization (vs other confounding factors): 1) Promotes equity by engaging the poor and marginalized to have power to make decisions in health and care-seeking 2) Builds local capacity to identify and address community needs, provide quality services, raise social capital (SC) and contribute to desired MNCH outcomes 3) Enables the community to establish linkages with health facilities to improve quality and access to health services and to advocate for policy changes b) How were results of the OR study used for informed decision making and improvement of the PI model? PROJECT BACKGROUND PROJECT AND OR DESIGN Despite recent overall improvements, neonatal and maternal mortality in Bangladesh remain high (53/1000 live births and 194/1000 live births, respectfully), especially in remote rural areas where health facilities are few and critical child and maternal health indicators are poor and consistently lower than the national average.1 The Netrokona district in northern Bangladesh is a priority district of USAID and one of the 14 GOB low performing districts.2 The main causes of neonatal deaths are birth asphyxia, low birth weight, severe infection, and acute respiratory infection. Maternal deaths primarily occur due to hemorrhage, sepsis, and obstructed or prolonged labor.3 A skilled birth attendant attends only 26.5% of births in Netrokona.4 For the CSHGP SUSOMA5 project, World Renew worked with local partners, SATHI and PARI, in two rural sub-districts or 1 Bangladesh Demographic and Health Survey, 2011; Bangladesh Maternal Mortality and Health Care Survey, 2010, Multiple Indicator Cluster Survey, Bangladesh, 2006. 2 UNICEF, 2007 3 World Health Organization (WHO), 2005. World Health Report 2005: Make every mother and child count 4 National Institute of Population Research (NIPORT), 2011. Bangladesh maternal mortality and health care survey 2010: Summary of key findings and implications.  January 2015 upazilas in Netrokona: Kendua with 13 unions and Durgapur with 7 unions. Durgapur is close to the border of India, very remote with limited roads and electricity, and has large Garo and Hajong populations. In Kendua there is very limited access to health services. At the inception of the project, both sub￾districts had a large population of women of reproductive age (WRA), infants and children (Table 1). The total population in these two sub-districts (upazilas) is 484,920. The project benefitted 96,571 children under five and 124,313 WRA. The goal of the SUSOMA project in Bangladesh was to reduce mortality and improve health status among the most marginalized mothers and newborns in two sub-districts of Netrokona: Kendua and Durgapur. The project’s overarching objective was improved household and community MNC-related behaviors and increased utilization of quality MNC services for hard to reach families and communities. The project specifically sought to mobilize communities for MNC utilizing the People’s Institution model strategy to establish community￾based organizations and public-private partnership structures for ongoing MNC gains. The SUSOMA project devoted 100% effort to a maternal and newborn intervention package focused on promotion of essential newborn care, appropriate care-seeking behavior and key family practices that was intentionally integrated into the GOB C-IMCI strategy (expanded to include newborns) and delivered by a cadre of trained volunteer community health workers (CHVs and TTBAs) at household and community levels. The project worked closely with the GOB IMCI Program Manager in Dhaka to address the GOB’s goal of decreased maternal newborn mortality, and supported GOB priorities and strategies articulated in the National Health Policy, the National Neonatal Health Strategy, and the Maternal, Neonatal, and Child Survival Programme6. The project innovation is the People’s Institution (PI) community mobilization model, adapted to empower the poor and marginalized to interact and collaborate with informal service providers (village doctors), private providers, and the public health sector (MOHFW) to promote maternal newborn health. World Renew has 18-years of experience implementing the PI model successfully in Bangladesh to help poor communities form independent, self￾sustaining community-based organizations. World Renew contracted with ICDDR,B to conduct operations research (OR) to measure PI model effectiveness, equitability, cost-effectiveness, performance, and its impact on social capital. The PI model innovation was evaluated with a mixed method quasi-experimental operations research design that included a) quantitative appraisal of program effects utilizing baseline and endline KPC survey data, b) qualitative process documentation of SUSOMA PI model implementation, and c) measurement of social capital as it relates to participation in the PI model. The project detailed implementation plan (DIP) specified project goals, objectives, intended results, and intervention mechanisms in a manner that facilitated project implementation and evaluation. Table 2 presents the project results framework and mechanisms utilized to meet the project strategic objective. To strengthen a public/private partnership, project staff established and built capacity of 3-tiers of PI groups for management of local MNC, linkages with the public health sector, health facility collaboration, and emergency health funds. To promote MNC practices, key MNC behavior change communication 5 The project name is formed from the Bangla words Shusto Sontan O Ma, which means ‘healthy child and mother’ 6 IMCI, target high poverty areas, use informal health sector and community-based service providers, mobilize women/families/opinion leaders, establish public-community linkages. Table 1: Beneficiaries Population in Kendua and Durgapur Beneficiary Population Kendua Durgapur Total Infants 0-11 mos. 11,253 8,061 19,314 Children 12-23 mos. 11,253 8,061 19,314 Children 24-59 mos. 33,759 24,184 57,943 Children 0-59 mos. 56,265 40,306 96,571 Women 15-49 yrs. 73,312 51,001 124,313 Total Population 286,594 198,326 484,920 Source: Population Census, Netrokona. Bangladesh Bureau of Statistics and Health Demographic Surveillance. 2001  January 2015 (BCC) messages were delivered by volunteer CHWs to households, PI groups, and communities. To improve quality of care, a cadre of community-based volunteers (CHVs, TTBAs), ISPs, and MOHFW staff received C-IMCI-based training focused on ANC, safe delivery, essential newborn care actions (ENC), and PNC. Additionally, a referral system and structures to support care quality in local clinics were effectively established. To increase capacity of local NGOs, World Renew trained and mentored local implementing NGOs, PARI and SATHI, as they networked with the MOHFW and built the capacity of the four local PIs, who have become GOB licensed NGOs and are capable of continuing PI strategies for MNC. An enabling environment for MNC was strengthened both in Netrokona and nationally through public-private partnership activities, such as HMIS data collaboration, learning circles, and MNC advocacy for the marginalized. Table 2: Project Results Framework Goal/Impact To reduce mortality and improve health status among the most marginalized mothers and newborns in two sub-districts of Netrokona: Kendua and Durgapur Strategic Objective Improved household and community MNC-related behaviors and increased utilization of quality services for hard-to-reach families and communities 1 2 3 4 5 Results/ Outcomes Strengthened private (civil society)/public partnerships in support of MNC Improved MNC practices of marginalized mothers and families Increased quality of MNC services Increased NGO capacity to support People’s Institutions Enhanced enabling environment Intermediate Results/ Mechanisms 1 Increase community capacity for management of health and the health system (via PI model). 2 Establish public/private health system collaboration with mechanisms for CBO feedback on health facilities. 3 Increase community access to health services through community￾based financing scheme, the Emergency Health Fund. 1 Improve knowledge of pregnancy, childbirth and postpartum danger signs. 2 Increase coverage and utilization of quality ANC services. 3 Equitable access to delivery by skilled personnel. 4 Increase training and coaching of mothers and communities on essential newborn care actions 5 Increase promotion of key MNC– related behaviors 1 Increase engagement community￾based providers in provision quality MNC care. 2 Improve referral of mothers and newborns. 3 Decrease harmful practices of informal service providers. 4 Establish quality improvement system between public health facilities and community sectors. 5 Improve capacity of MOHFW to provide MNC services. 1 Increase capacity of NGOs to assist PIs in implementing and monitoring their own activities. 2 Strengthen capacity of local NGOs to work with MOHFW at district and national levels. 3 Develop capacity of local NGO partners to train community￾based providers in advocacy and networking with local government within the CBO (PI) model. 1 Strengthen and sustain community and local government capacity in MNC. 2 Improve ability of CBOs to advocate for local level policies that benefit the health status of the poor. 3 Establish partnerships with key services and programs to advance awareness of the MNC needs of marginalized citizen and to improve social and policy environment for MNC. USAID theme Community engagement Service delivery/equity Service delivery/quality Scale-up/ sustainability Learning/ adaptation  January 2015 PARTNERSHIPS/COLLABORATION The project was highly aligned with in-country partners at national, regional, and local levels (See Table 3). There was close collaboration with the USAID Mission in Bangladesh and project achievements contributed to the Mission’s overall health objectives. Table 3. Project Partnerships and Alignment Partner Alignment Collaboration Activities USAID Mission Bangladesh USAID Bangladesh Strategic Statement FY2007-2010 (2005), Program components 1, 2, & 4. USAID Bangladesh Country Development Cooperation Strategy FY 2011-2016 (2011), Development objective: IR 3.2, 3.3. World Renew provides quarterly updates and gets advice; works closely with Dr. Umma Meena/others; attends annual Mission partner’s meeting. MCHIP Bangladesh ACCESS family planning project, 2006-2009; MaMoni project (Save the Children in Sylhet and Habiganj, 2009-2014). SUSOMA consulted with MCHIP, focused training on 10 MaMoni low-cost, high-impact community maternal newborn interventions. MOHFW National-- National Health Plan, 2008; Maternal Health Strategy, Health and Population Sector Programme; Community￾Integrated Management of Childhood Illness (C-IMCI) strategy; IMCI Working Group; Neonatal Technical Group; endorsement of SUSOMA training materials SUSOMA results framework and training linked with GOB priorities. World Renew maintains ongoing alignment via participation in national-level groups and regular meetings with Dr Altaf, IMCI Bangladesh. Netrokona-- District and upazilla officials and health facilities, (Community Clinics, Family Welfare Centers and Upazila Hospitals); Monthly community clinic management and UTAC meetings; quarterly DTAC meetings SUSOMA facilitated the building of a strong public-private partnership with collaborative working relationships between PI groups, officials and facilities. PARI and SATHI SUSOMA implementing partners for all project activities within their respective sub-district. World Renew provided technical support for capacity of local NGOs in PI model. LAMB and Joyramkura Training Institutions for TOT of project and health facility staff; training of CHVs & TTBAs using adapted MaMoni/Saving Newborn Lives/SAVE materials Excellent collaboration in adaptation of existing training materials and in timely completion and follow-up of training programs. ICDDR,B Principal Investigator for the Operations Research study, including the KPC surveys, process documentation of PI model, and investigation of social capital and PI model. Good collaboration with project, however, partner delayed in getting KPC and OR study reports completed. Communities in project area PI groups with PPP MOUs and referral system; community-based providers and ISPs linked with health facilities; elite community members; private providers. Working together to overcome deficiencies in services and enhance MNC quality. Other NGO program affiliates Smiling Sun Franchise White Ribbon Alliance Obstetrics and Gynecological Society of Bangladesh-salter scale training GBC (Garo Baptist Convention)--MNCH care private provider in program area DSK (Dushtha Shasthya Kendra)— MNCH care private provider in program area Other NGO programs that were being implemented within the program area are: Upazila NGO Intervention focus Upazila NGO Intervention focus Kendua Durgapur BRAC Swablami Damien Fdn Red Cresent ASA Caritas Bgdesh Children’s schools Credit Leprosy control Blood work, hospital support Microfinance Integrated development/credit Durgapur BRAC DSK GBC YMCA Damien Fdn World Vision Children’s schools Health clinics Health clinics Training center Leprosy control HIV/AIDS awareness  January 2015 EVALUATION METHODS AND LIMITATIONS The 15-member final evaluation team used a participatory approach to determine project accomplishments and challenges/inputs, the sustainability of project results, lessons learned, and the impact of the project innovation on health outcomes. Both quantitative and qualitative data from varied sources were obtained and reviewed to provide a comprehensive evaluation of the project. These include 1) review of key project documents, 2) analysis of quantitative and qualitative assessment study reports, 3) cost analysis, and 4) stakeholder interviews. A more detailed description of evaluation methods and limitations is in Annex IX. Data collection instruments are in Annex X. Review of key project documents. A comprehensive review of project reports and documents was conducted to confirm project implementation and/or revision of planned activities and to understand the environment/context in which the project was conducted. A complete listing of sources of information is in Annex XI. Analysis of quantitative and qualitative assessment study reports. Multiple assessments that provided key data for interpreting the effects of the project on project outcomes were reviewed and analyzed: Operations Research Study (OR) Reports, Knowledge Practices and Coverage Survey (KPC) Reports, Rapid Health Facilities Assessment Reports (RHFA), and the Child Survival Sustainability Assessments (CSSA). The Operations Research Study was done by ICDDR,B, DM Emdadul Hoque, Principal Investigator. The stated objectives of the OR study are to: 1) Evaluate the performance of the Primary Groups and PI model in reaching marginalized and poor populations and effects on maternal, newborn and child health. 2) Assess PI model effects on MNC, care-seeking for maternal, neonatal and childhood illnesses, and on compliance with referral. 3) Assess PI model effects on quality of care and utilization of maternal, neonatal, and childhood services by health workers. 4) Measure incremental intervention costs, cost￾efficiency and equity aspects of the PI model and its ability in reaching marginalized population. 5) Undertake process evaluation of the implementation of the PI model. 6) Measure social capital. Objectives 1-4 are addressed in by the KPC study and 5-6 by the operations research study. Expanded KPC surveys were done at baseline (October 2009) and endline (July 2014) by ICDDR,B as part of the SUSOMA OR study to explore the effectiveness, equity, and cost-effectiveness of the project intervention package. A 211-item questionnaire with 4-modules indexed 1) socio-economic status and PI group involvement, 2) maternal newborn care (MNC), 3) cost of care, and 4) child health care. Respondents were women who had a birth in the one year preceding the survey for the MNC and cost modules, and mothers of children 0-2 years for the child health modules. A total of 4,079 households were surveyed at baseline (2,038 intervention group, 2,041 comparison group) and 4,502 at endline (2,206 intervention, 2,296 comparison) from a listing of over 6,800 households. Sample size was calculated using standard formulas based on normal distribution, confidence levels of 95%, 80% power, and design effect of 1.5 (to allow for clustering). Randomized cluster sampling was used in which 40 clusters were selected, 20 for the intervention group from the two-upazila intervention area (Durgapur, Kendua) and 20 for a comparison group from two nearby upazilas with usual GOB services (Barhatta, Kalmakanda). Data was analyzed with the statistical software STATA 12. Forty-three maternal newborn and child health variables were calculated for baseline and endline, in addition to the cost and equity/wealth quintile indicators. The Final KPC Report and Baseline KPC Report are in Annex VI. Two final operations research study reports were produced. The first focuses on documenting the process of implementing the PI model and measuring social capital and is herein called the Final Operations Research Qualitative and Social Capital Study Report. The qualitative process evaluation utilized nonproportional quota and snowball sampling at baseline (2011) and endline (2014) for in-depth interviews of PI group members (n=22), non-members (22), CHVs (8) and TTBAs (4). It also included focus group discussions with members (9) and non-members (8), social mapping and organizational profiling, and observations of group formation. The quantitative measurement of social capital used an adapted World Bank tool with data obtained from randomly selected samples of approximately 300 PI  January 2015 group members and non-members, all poor women of reproductive age (WRA). The baseline OR measurement of social capital occurred in 2012, halfway through the project, and the endline in 2014. Analysis of qualitative data was done manually. Quantitative data analysis used SPSS for frequencies, reliability analysis to derive a social capital scale for baseline and endline, and ANOVA for testing the association between social capital and group membership/residence. The Final Operations Research Qualitative and Social Capital Study Report is in Annex XIXe. The second OR report brings together findings from the qualitative process evaluation and measurement of social capital from the Final Operations Research Qualitative and Social Capital Study Report with the quantitative program evaluation from the KPC and RHFA reports. It seeks to address all of the OR objectives in one document utilizing the USAID OR report template and is herein called the Final Operations Research Report. It is in Annex XV. The RHFA was done at baseline (November 2009) and endline (June 2014) using existing standard tools and analysis approaches to index 12 key indicators and five optional indicators of health services delivery quality and access. The RHFA provided comparable data about MNCH services in the three levels of public health facilities in the project area (upazilla health complex (UHC) outpatient department, union family welfare center (FWC)/rural dispensary (RD), and ward community clinic (CC)) and in private/NGO clinics. Data was collected from a systematic random sample of 30 health facilities and CHWs. Data collection included a health facilities checklist, health worker interviews, child sick care observations and exit interviews of child caregivers (63 cases at baseline, 141 at endline), and CHW/CSBA assessments (13 at baseline, 20 at endline). The final RHFA report is in Annex XIXa. The CSSA is an emerging capacity monitoring tool with roots in the community mobilization work of World Renew in Bangladesh. Using selected indicators from multiple data sources, the tool is complied on a six-month basis to monitor change in community capacity to sustain health gains. The CSSA was completed seven times during the project and indexed six components of sustainability: health outcomes (10 MNC indicators), health services (8 indicators), organizational capacity (9 indicators), organizational viability (5 indicators), community capacity (5 indicators), and environment (5 indicators). Indicator data was obtained from multiple sources: LQAS and KPC data, project M&E system, HMIS data, and PICI/CCI (PI and Community Capacity Indicator self-monitoring done by PI groups). The CSSA summary dashboard and indicator information is in Annex XIXb. Cost analysis. A cost analysis was done by World Renew to determine what resources would be required to institutionalize or scale-up the intervention components. It estimates the average project cost per woman of reproductive age, and cost to support each community volunteer. The cost analysis report is available in Annex XIXd. Stakeholder Interviews. In-depth qualitative interviews were conducted with SUSOMA stakeholders to gain a broader understanding of the how and why of project accomplishments and challenges. Interviews occurred as part of the final evaluation over a 3-day period at the district health complex and SUSOMA office in Netrokona, the health complexes and partner NGO offices in Kendua and Durgapur, throughout the intervention upazilas, and in Dhaka. Stakeholders to be interviewed were categorized into 6 groups: 1) government officials, 2) SUSOMA and NGO staff, 3) government health facilities and providers, CHVs, TTBAs and ISPs, 4) PI groups (PI, CCC, PGs) at varied functional levels, 5) beneficiaries (pregnant women, mothers, husbands, in-laws), and 6) training institution directors. Interview questionnaires, developed to target each of the six stakeholder groups, were derived from the final evaluation questions and categorized using the A-C-S-I mnemonic: • Accomplishments: What results were achieved? How did interventions contribute to results? • Challenges & Inputs: What factors contributed to/detracted from critical results and why? • Sustainability: What strategies can be sustained, scaled-up, shared globally? • Impact: What evidence links project results with the PI model? More information about stakeholder interviews is in Annex IX.  January 2015 Data Quality and Use The evaluation team had an appropriate mix of information to inform the final evaluation report, however, multiple issues related to quality of the KPC data/report and operations research report existed. These are described in Annex IX and resolution of these issues is summarized below. In terms of other information, the RHFA presents valuable comparable data about the health services in the intervention area at baseline and endline, however, interpretation of some indicators is limited due to lack of clarity related to clinic staffing levels and lack of access to CHW health registers at the time of the interviews. The CSSA is a self-monitoring tool that portrays progress overtime in the development of local capacity for health from the perspective of the PI groups. It provides valuable subjective data. The stakeholder interviews conducted by the evaluation team provide insights into stakeholder and partner opinions of the importance of the project, the effectiveness of the overall project strategy, contextual factors that changed over the life of the project, sustainability, and lessons learned. Data from all sources aligned to support and explain project achievements during the data triangulation phase of the final evaluation. The Final KPC Report and a revised Baseline KPC Report were received from ICDDR,B on October 30, 2014 along with data tables of results for maternal newborn child health indicators at baseline and endline for the intervention and comparison groups, including cost and wealth quintile data. A revised baseline report with MNC and cost module data limited to women who had a birth in the one year preceding the survey was required so that data presented was comparable to the data collected for the final KPC. The final KPC report was of adequate quality to utilize in writing the final report with one exception: All data comparisons in the report are observational only. There is no statistical comparison of differences between groups from baseline to endline and between intervention and controls in these reports, such as confidence intervals, chi square tests, t-tests, or ANOVA. To better understand KPC findings and be able to apply them to analysis of project accomplishments, the final evaluator utilized the data available and computed percentage change in variables from baseline to endline as well as 95% confidence intervals.7 The external evaluator has some concern about the selected comparison group. ICDDR,B states that they selected the KPC survey comparison upazilas in Netrokona because they had “usual GOB services” (Final KPC Report, p. 20). However, during the life of the SUSOMA project, donor health projects were occurring in the comparison areas. PARI was conducting a large maternal newborn health project (EDM Switzerland funded) in four unions in Kalmakanda upazila and was working with a PI system in Barhatta in integrated programming. These activities in the comparison upazilas have the potential to confound estimation of SUSOMA program effects and must be considered in comparing intervention and comparison group findings. The Final Operations Research Qualitative and Social Capital Study Report was received from ICDDR,B on November 3, 2014. This report was of adequate quality to utilize in writing the final evaluation report. However, because this report and a summary report that followed did not meet the USAID/Evidence Project Operations Research Report guidance, World Renew contracted with Grace J. Kreulen to write a final operations research report that brought together all aspects of the operations research study. This Final Operations Research Report is in Annex XV. FINDINGS, CONCLUSIONS, AND RECOMMENDATIONS FINDINGS SUSOMA addressed the project strategic objective (SO) of improved household and community MNC behaviors and increased utilization of quality services for hard-to-reach families and communities through five intermediate results (IRs). Findings are summarized in Table 4 and presented in detail related to each IR, the OR study, and other influencing factors. Conclusions and recommendations follow presentation of findings.  7 https://www.mccallum-layton.co.uk/tools/statistic-calculators/confidence-interval-for-proportions-calculator/  January 2015 SUSOMA made good use of quantitative and qualitative data in monitoring and planning during the life of the project. This includes project MIS data directly collected in the community, data from the MOHFW HMIS, and indicator data from project assessments. The partner NGO health coordinators presented updated project data in monthly and annual progress reports based on the DIP M&E and work plan. The project management and implementation teams used these data to make informed decisions. For example, when more targeted interventions related to improving ANC and assisted deliveries were indicated, additional effort was made to track these accurately at the village level on an ongoing basis. In addition, the MOHFW HMIS data system and the project’s M&E data and reports were systematically used for decision-making in the public-private partnership (PPP). For example, maternal newborn data gathered at the village and union-level by CHVs and TTBAs were discussed with health facility providers during monthly coordination meetings at the local health center and ‘merged’ with MOHFW data at union and upazila-level matching meetings attended by the UH&FPO, UFPO, and Health officer in charge. Data was then discussed at the district level in quarterly meetings with the Civil Surgeon, Deputy Civil Surgeon, DDFP, and Guiney Specialist during which aggregate data were analyzed collaboratively for recommended action. Table 4. Summary of Inputs, activities and Outputs that Contributed to Key Outcomes Goal: To reduce mortality and improve health status among the most marginalized mothers and newborn. Strategic Objective: Improved household and community MNC behaviors and increased utilization of quality services for hard-to-reach families and communities. Inputs Activities Outputs Outcomes (*   Intermediate Result #1 (IR1): Strengthened private/public partnerships (PPP) in support of MNC 40 CHT staff TOT training Training materials Supportive supervision Mobilized, established and built capacity of Peoples Institution model in 494 villages 4 PIs, 22CCCs, and 541 PGs provide community-based management of local MNC All communities have active empowered PIs promoting MNC Formed, trained, and developed PI health sub-teams 4 PI health sub-teams formed, 126 meetings held PI health sub-teams functioning independently to promote MNC Strengthened PI-health facility collaboration and feedback Signed PI-GOB MOUs, 3,326 coordination meetings held PI groups established strong functional ties w GOB for MNC PG’s supported to establish and manage EHFs EHF save BDT 437,004/USD 5,660. EHF records kept 96% PGs have active EHF, 2,406 women & children used EHF PGs establish bank accounts and health savings accounts. All PGs have bank accounts, health savings = BDT 9,443,810 /USD121,672 PGs giving small business loans for IGA for health (unintended) Intermediate Result #2 (IR2): Improved practices of marganized mothers and families regarding MNC Monitoring, supervision BCC & IEC materials Mother health cards/registry Gov’t training in NID Established BCC-based household counseling by trained CHVs and TTBAs to promote ANC, skilled delivery/ENC, PNC. TTBAs counseled 73,966 pregnant mothers/20,147 newborns mothers, CHVs counseled 46,383 pregnant women/19,970 newborns mothers Mother of 0-11 month old: -Knowledge of pregnancy dangers increased 65% 72% -4+ ANC 5.3% 13.6%* -SBA birth 9.3% 21.9%* -Facility birth 8% 19.3%* -Newborn PN visit 7.9% 18.7%* -Mother PNC visit 8.6% 18.5%* -Contraceptive use 49%71% -No pre-lacteal feed 59.3%81.6% -Immediate BF 52.8% 77.6% -Exclusive BF 47.2%52.9%* -2+TT 86.9% 80.2% Knowledge & skill-building of PG members re MNC, PI/CHV led community MNC promotion CHV held 14,576 community group and 55,486 primary group MNC promotion meetings, PI leaders educated pregnant women in 1,083 meetings. PI participation in NHD/NID events & Theater for Development (TfD) for influencing groups 3 trained drama teams in PI system, PIs held 113 BCC drama events, PIs participated in 881 NHDs, CHVs/TTBAs assisting with  January 2015 NID 2x/year Intermediate Result #3 (IR3): Increased quality of MNC services TOT training Training materials Supportive supervision Trained community-based and informal service providers in MNC, counseling, and referrals. Supervision of CHVs/TTBAs 537 CHVs and 541 TTBAs trained to teach ANC PNC safe delivery and ENC actions, referrals, 377 ISPs trained in safe practices and referrals 1,078 trained volunteers promoting MNC in villages: -Clean cord care 54.5%65% -Clean birth kit 4.2%32%* -Thermal care 9.7%44.7%* Selection and training of Super CHVs 79 Super CHVs make weekly supervisory visits, facilitate learning, advocate with officials CHVs share best practices in monthly Super CHV meetings Networking Established SUSOMA PI referral system with health facilities & government officials with poor getting priority treatment Coordinated referrals for ANC, delivery PNC, illness care being made by CHV, TTBA, village doctor, PI Facilities w/ 1+ CHV referral/ month increased 37%80%, 5,006 MNC referrals made by CHV & TTBA, 461 by ISP Pictorial HMIS registry Facilitation and support Assisted PIs to monitor facility utilization and develop methods to improve quality of care Tracking pregnant women and newborns in local registry, 190 PG members serve on CC management committees, 30 PI managed ‘model CCs’ 100% PGs involved in clinic decision-making & advocacy, Clinic service availability increased: -ANC 4x/month 60% 90% -Institutional delivery 3% 17% Facilitation, training and support Government health worker (HW) TOT and MNC training, PI advocacy for health clinic strengthening 123 facility HWs trained in MNC/ TOT, 15 in IMCI/ETAT, HW training increased- -training child health 37%87% -training MNC 3% 37% -training CSBA 31% 43% Intermediate Result #4 (IR4): Increased NGO capacity to support People’s Institutions WR training, materials & support Capacity building of PARI/ SATHI in implementing PI model PI Training Manual published All villages in Kendua and Durgapur have established PIs Established the capacity of LAMB for community-based TOT training Joyramkura, Pari, Sathi, GOB trainers and PIs equipped to train CHVs, TTBAs, and ISPs Sustainable training mechanisms in place Lessons, supplies, funds Engagement in learning circles and exchange visits SATHI/PARI share project at NGO learning circle, visit MaMoni & PLAN-Bd NGOs linked with health NGO/government sectors PI and Super CHV participation in learning exchanges Facilitation and advocacy PI assisted to apply for registration with GOB All 4 PIs registered with GOB as social welfare agencies 4 PIs independent NGOs Intermediate Result #5 (IR5): Enhanced enabling environment Networking support Established and strengthened PI￾MOHFW HMIS system Monthly HMIS matching meetings between government officials and PI/CHV/TTBA Government MNC HMIS provides data for decision￾making/ resource allocation Advocacy training PI establish networks with government officials at national, district, & sub-district levels 712 monthly/quarterly meetings held between PI leaders and health officials for MNC 60 documented evidences of policy change that benefitted the poor Advocacy with national NGOs for MNC policies for poor WR met 30 times with WRA and Neonatal Working Team GOB official for C-IMCI supporting PI efforts for MNCH * Percentage change from baseline to endline in intervention group significantly different (p≤0.05) from comparison group.  January 2015 IR1. Strengthened public private partnerships (PPP) in support of MNC SUSOMA effectively built strong public private partnerships (PPP) with ties between the Kendua and Durgapur communities and government health officials and facilities by 1) mobilizing and empowering all 494 village communities in the intervention area to support maternal newborn health by forming a total of 541 self-help primary groups (PG), 22 union-level Central Cooperative Committees (CCC), and 4 upazila-level People’s Institutions (PI) utilizing the People’s Institution model; 2) effectively aligning and networking these PI groups and their health sub-committees with the government health system at district, upazila, union and ward levels and with national MNCH priorities; and 3) establishing active emergency health funds for care of pregnant women, newborns and mothers. Community mobilization using the PI model strategy. In the first two years of the project, staff community health trainers (CHTs) established and built the capacity of three tiers of community groups to mobilize poor marginalized community members for maternal newborn health (see Figure 1). Initially, CHTs went household to household in each village to build awareness and engage pregnant women and mothers in forming Primary Groups (PG) to address mother and newborn health concerns. CHTs trained PG members and supported them to work together to solve problems, to claim their rights, and to track group gains in capacity. The PGs selected local volunteers providers, CHVs and TTBAs, to promote maternal newborn health in their village. Of the 541 PGs established during the project, 42% are high-level/independent functioning, 38% are medium-level, and 20% are low￾level/emerging. There is at least one PG in each of the 494 villages in Kendua and Durgapur. Initially, PG formation focused exclusively on women but since midterm efforts were made to form men’s groups. Of the 541 PGs formed during the project, 22 of these are male. Stakeholder interviews confirm that poor marginalized women have become leaders and found their voice. Female leadership is accepted by husbands, in-laws and communities as fewer mothers and newborns are dying. Figure 1. PI community mobilization approach and links to the health system Once the PGs became established the CHT helped each select two representatives to form a union￾level Central Cooperative Committee (CCC). The CCCs received training and were supported to become functional. Each CCC then selected six representatives to the upazilla-level PI group. In the two upazillas covered by the project, 22 CCCs and 4 PIs are functioning. Each PI (with the CCC and PGs under it) has one trained health sub-team with a MNC-focus responsible for overseeing local MNC health “Before we did not know the problems and let people die… now we know and do” The ‘Friendship’ PG  January 2015 services through maintaining PPP networks and community mobilization. With the addition of male PGs in 2012, the 22 CCCs and 4 PIs have mixed-gender leadership and enhanced MNC advocacy potential. CHTs trained the three-tiers of PI groups in leadership, management, record keeping, register, gender, local resource mobilization, M&E, sustainability, audit, advocacy, networking, and capacity measurement. Utilizing a TOT strategy, over 40,000 community members have received PI-related training in the intervention upazilas. Aligning Public-Private Partnerships. The PGs, CCCs, and PIs have developed strong PPP networks by which they interact and collaborate with the local formal, informal and private health care systems to advocate for enhanced MNC service delivery and policy change. (See Figure 1). Active collaborative linkages formalized during the project include: • A PPP network established between PI and health facilities committed to decreasing maternal newborn deaths and illness by improving MNC health services. The PIs have signed MOUs with local government and private (GBC, DSK) facilities in which each extends to the other support and cooperation for training, education, meeting together, improving quality of services, referrals and emergency care, and maintaining maternal newborn registries. • PI’s promote maternal newborn health as they link at the upazila and district levels with government officials and serve on the Upazila and District Technical Advisory Committees that meet quarterly (UTAC) and semi-annually (DTAC). They share progress, inform officials of needs, influence strategies to meet gaps, and participate in decision-making related to MNC. • CCC’s link at the union level to the Family Welfare Centers (FWCs) and Rural Dispensaries (RDs) and participate in clinic decision-making. They have developed a common maternal newborn HMIS data format and meet monthly with the UFPO and UH&FPO in ‘HMIS matching meetings’ to sync the CHV and TTBA registries with clinic staff registries (SACMO, FWV, FWA/HA, CSBA). They do microplanning to enhance quality of services and availability of supplies and drugs to meet the need. • PG’s serve and participate in decision-making at the ward level on the 60 Community Clinic (CC) Management Committees. Community-based CHVs and TTBAs trained by the project, in conjunction with ISPs, have meet monthly (3,326 times) to coordinate MNC with government health providers (CHCP, HA, MA) and set goals/strategies for local action. These providers now have improved communication channels, work together in the clinics, share data, and jointly promote local MNC through satellite clinics, national immunization and health days (NID/NHD), and other events. Stakeholder interviews confirm that community people have become aware of and created demand for MNC services at the local health facilities and that health facility staff and government officials are working to supply those services. All PI groups have developed friendly reciprocal relationships with higher government officials, and meet quarterly for guidance and support with local elites (non-poor) who are on their PI Advisory Committees. The officials and the elites/influential expressed appreciation for the work of the CHVs/TTBAs and PIs and their desire to continue collaborating to improve MNC. Emergency health funds (EHF). To provide access to emergency MNC for the poor in their community, 520 PG groups (96%) have set up, raise funds for, and actively manage EHFs with financial records, policies, and bank accounts. In addition, groups have purchased or had donated rickshaw ambulances. A total of BDT 437,004 (USD 5,660) has been saved in project-linked EHFs and 2,406 women and children have taken interest-free loans from the funds for emergency transportation and care. The EHFs are a noted access to care enhancing accomplishment of SUSOMA. An unintended but popular development in all the PGs is health savings, which have accumulated a total of BDT 9,443,810 (USD 121,672). Loans are taken from these funds for IGA, enabling parents to better feed and protect “The biggest accomplishment of SUSOMA is the EHFs” FWV-CSBA “The PI model is excellent for motivating community people in reducing maternal newborn deaths…one of the most effective approaches to bring positive change within the community.” Government Health Workers  January 2015 the health of their families. Group members bring 2-5 taka to the weekly meetings for these funds. The EHFs are managed at the CCC level; the health savings accounts belong to and are managed by the PGs. IR2. Improved MNCH health practices To achieve improved health practices among marginalized mothers and families, the project established BCC-based counseling with all pregnant women and key stakeholders in each village. Trained CHVs and TTBAs promote ANC, safe institutional/SBA delivery, essential newborn care (ENC), kangaroo care, and PNC. Over the life of the project, these volunteer providers raised awareness and motivation for MNC though 120,349 household visits to pregnant mothers and 40,117 visits to newborn mothers. CHVs also held 14,576 educational meetings with PGs on MNC. PI leaders also taught pregnant women at 1,083 meetings and collaborated with government providers in 881 NHDs. Additionally, three trained Theater for Development (TfD) teams, which are integrated into the PI system, performed 113 community dramas to raise the awareness of MNC-related issues and overcome resistance of influencing husbands and in-laws. Stakeholder interviews confirm that these activities increased MNC awareness, health practices and utilization of health services, and created demand on the government for equitable distribution of MNC at the village level. Over time in-laws and husbands became involved in promoting MNC and facility-based deliveries. Tables 5 and 6 present data for changes in antenatal knowledge, health practices, and care utilization of women with children 0-11 months in both the intervention and comparison groups from baseline (2009) to endline (2014). Over the life of the SUSOMA project, the number of health facilities offering ANC four times a month increased 50% from 60% to 90% (Final RHFA Report), with a corresponding significant increase (p≤0.05) in the intervention group in receipt of four-or-more ANC from a medically trained provider (5.3% at baseline to 13.6% at endline). The number of women in the intervention group with three ANC increased by 46% and those with four-or-more ANC increased by157% (versus 37% and 4% gains, respectively, in the comparison group). By endline, significantly more (p≤0.05) women in the intervention group than in the comparison group had had three and four-or-more ANC visits despite being comparable at baseline. The percentage change from baseline to endline was significantly greater (p≤0.05) in the intervention vs. the comparison group. Increases in ANC visits occurred across both groups in all age, educational, and wealth quintile categories (Final KPC Report). In the intervention group all wealth quintiles at least doubled in the number of women receiving four-or-more ANC. Because the project educated and engaged both poor and elites in intervention strategies, it is not surprising that all quintiles in the intervention group saw increases. Other ANC practices also improved in the intervention group during the life of the project. 1 ANC at least 2 ANC at least 3 ANC 4+ ANC 2 TT Consumed IFA Know AN dangers 2009 intervention 10.2% 7.6% 6.5% 5.3% 86.9% 43.7% 65.2% 2014 intervention 14.6% 9.6% 9.5% 13.6% 80.2% 69.2% 72.3% 2009 Comparison 11.0% 5.6% 3.0% 5.6% 82.3% 37.1% 53.7% 2014 Comparison 16.8% 7.4% 4.1% 5.8% 77.8% 58.1% 72.4% 0.0% 20.0% 40.0% 60.0% 80.0% 100.0% Table 5. ANC practices of mothers with children age 0-11 months in intervention and comparison groups, 2009 baseline and 2014 endline KPC Survey.  January 2015 • There was a significant 58% increase (p≤0.05) from baseline to endline in the number of women in the intervention group that consumed IFA (43.7% to 69.2%). The comparison group saw similar gains (37.1% to 58.1%), however, by endline the intervention group reported significantly more (p≤0.05) IFA intake than the comparison group. This may reflect, in addition to the effectiveness of the project messaging, the RHFA documented 49% increase in the availability of IFA tablets at health facilities that occurred during the project in the intervention area (67% to 100%). • The percentage gain across time in maternal knowledge of pregnancy, delivery, postpartum and neonatal danger signs were significantly lower in the intervention than the comparison group. While knowledge of danger signs during pregnancy increased by 11% in the intervention group (65.2% to 72.3%) it increased 35% in the comparison group (53.7% to 72.4%). Likewise, knowledge of maternal danger signs during delivery was higher in the intervention group at baseline and made only small gains during the project (67.2% to 67.4%) while the comparison group saw greater gains (48.1% to 69.9%). Gains in knowledge of postpartum complications had a similar pattern. Overtime, the comparison group’s knowledge of ANC, delivery, PNC and neonatal complications became comparable to the knowledge levels in the intervention group. In addition, by the end of the project 91.7% of women in the intervention group had learned about and made preparations for the birth of their youngest child (89.6% at baseline), which was similar to the comparison group. These findings may reflect the effect of ongoing MNCH projects in the comparison upazilas and/or a knowledge ceiling effect in these populations. While the intervention group did not significantly increase in knowledge of complications over the comparison group, application of knowledge may be more effective in the intervention group. The intervention group had significantly greater (p≤0.05) improvements in care-seeking practices from a qualified provider for all reported antenatal complications (26.4% to 37.6%, 42% gain) compared to the comparison group (24.4% to 27.4%, 12% gain), as well as in care-seeking for postpartum complications (29.3% to 43.4%, 48% gain) compared to the comparison group’s decrease (30.4% to 23.1%, -24%). Care-seeking for delivery complications saw a non-significant 6.3% decline in the intervention group and a 23.7% decline in the comparison. • The percentage of women that received two tetanus toxoid injections decreased 8% in the intervention group as well as 5% in the comparison group from baseline to endline, with decreases occurring across all education and wealth quintile categories. This unexpected finding may reflect systemic issues beyond control of the project, such as the availability of tetanus toxoid and measurement timing. CSBA delivery Inst delivery PNC visit (mother) Contraceptive use No pre-lacteal feed Exclusive breast-feeding 2009 Intervention 9.3% 8.0% 8.6% 49.3% 59.3% 47.2% 2014 Intervention 21.9% 19.3% 18.5% 71.0% 81.6% 52.9% 2009 Comparison 13.0% 9.9% 11.1% 44.3% 56.5% 49.0% 2014 Comparison 15.7% 14.8% 15.2% 64.1% 78.6% 41.7% 0% 20% 40% 60% 80% Table 6. Delivery and PNC practices of mothers with children age 0-11 months in intervention and control groups, 2009 baseline and 2014 endline KPC Survey.  January 2015 Over the life of the project, there was a 500% increase the number of facilities offering 24/7 institutional delivery services (3% to 17%, Final RHFA Report) with a significant increase (p≤0.05) in institutional deliveries (8% at baseline to 19.3% at endline). While an increase in institutional deliveries occurred in both intervention and comparison groups, the 141% gain in the intervention group was significantly greater (p≤0.05) than the 49% gain in the comparison group. In addition, deliveries assisted by CSBAs,8 which are primarily skilled home deliveries, also increased significantly (p≤0.05) in the intervention group (9.3% to 21.9%, 135% gain) versus the comparison group (13% to 15.7%, 21% gain), with significantly more women in the intervention group having CSBA-assisted deliveries. Together institutional and CBSA￾assisted skilled deliveries accounted for 41.2% of all deliveries at endline in the intervention group. Examining institutional and CBSA-assisted deliveries by wealth quintiles reveals a greater increase for women in the lower poor quintiles than those in the upper richer quintiles with the greatest gains in the intervention group (see Table 7), reinforcing the effectiveness of program interventions that targeted improving equity in MNC for the poor and ultra-poor. There was a significantly greater percentage increase (p≤0.05) in the intervention group than in the comparison group in the number of newborns and mothers that received post-partum care from an appropriate trained health worker within two days after birth, with the number increasing significantly (p≤0.05) from baseline to endline in the intervention group but not in the comparison group (See Table 6). Post-partum visits to newborns in the intervention group increased 137% (10.7% at baseline to 15% at endline) and to mothers increased 135% (8.6% to 18.5%). Contraceptive use, part of project MNC messaging, increased significantly from baseline to endline in both the intervention and comparison groups, indicating that the 44% gain seen in both groups may be influenced by common factors, such as district-wide MOHFW family planning program initiatives. Improvements in post-partum visits were greatest in the lower as compared with the higher wealth quintiles with greater change in the intervention group. The lowest quintile in the intervention group had 5-fold and 7-fold gains against the highest quintiles for newborn and maternal post-partum visits, respectively, versus 4-fold gains in the comparison group. Breast-feeding practices also improved significantly (p≤0.05) from baseline to endline, both in terms of gains in the number of newborns put to breast within one hour of delivery (52.9% to 77.6%) and children 0-23 months not receiving pre-lacteal feeds (59.3% to 81.6%). Since similar gains in these indicators occurred in the comparison group, these increases in breastfeeding may be due to district￾wide breastfeeding initiatives and/or local program efforts. The intervention group experienced a  8 CSBAs are community-based government health providers (FWV, FWA, HA) with SBA training. They do many home deliveries in the area because most health facilities in the area have not been upgraded to delivery sites. 0 200 400 600 800 1000 1200 1400 lowest quintile second quintile middle quintile fourth quintile highest quintile % change Inst Delivery￾intervention group % change Inst Delivery￾comparison group % change CSBA Delivery￾intervention group % change CSBA Delivery￾comparison group Table 7. Percentage change by wealth quintile in institutional and CSBA-assisted deliveries in the intervention group from 2009 baseline to 2014 endline. “We have fewer deaths, more safe deliveries…hospital deliveries increase day by day” Jhinuk PI  January 2015 significantly greater (p≤0.05) increase in exclusive breastfeeding (47.2% to 52.9%, 12% gain), which was significantly greater than the comparison group at endline. Improvements in exclusive breastfeeding occurred relatively equally across all wealth quintiles. Because the MNC intervention was embedded in the C-IMCI framework, MNCH program effects related to ORT use, care-seeking for pneumonia, handwashing practices, and underweight children were tracked in assessing program effects. In the intervention group ORT use for diarrhea increased 15% (73.3% to 85%) while the comparison group had a significantly greater (p≤0.05) 73% increase (49.6% to 85.9%) with both groups having equivalent ORT use at endline. Appropriate care-seeking for pneumonia increased significantly (p≤0.05) in the intervention group (22.3% to 32.6, 42% gain), while there was no improvement in the comparison group. Similarly, handwashing practices in the intervention group saw a significant (p≤0.05) improvement (21.6% to 39.3%, 82% gain) while there were declines in the comparison group. Both groups saw equivalent decreases in the percentage of underweight children. Declines were 18% in the intervention group (33.3% to 27.3%) and 13% in the comparison group (36% to 31.4%). The gains in ORT use, care-seeking, and fewer underweight children in the intervention group were greatest in the lower as compared with the higher wealth quintiles. IR3. Increased quality of MNCH services SUSOMA improved the quality of maternal newborn care services through 1) training community-based health providers, 2) supervising PI-linked CHVs and TTBAs, 3) establishing an active referral system, and 4) facilitating PI monitoring and support of health facility (HF) utilization and care quality. Training community-based health providers. A total of 1,201 community-based volunteers (537 CHVs, 541 TTBAs) and 123 government facility-based providers received training and refresher training in ANC, safe delivery, PNC, ENC actions, and IMCI. Of these, 79 CHVs were trained as regional Super CHVs to oversee and strengthen CHV performance. An additional 377 ISPs received training and refresher training in IMCI and referrals to reduce harmful practice. SUSOMA supported 10 local government health workers for intensive IMCI training and six for ETAT training in HBB in Dhaka. The endline RHFA revealed that 87% of government health workers reported receiving training in child health (37% baseline), 38-40% had training in maternal newborn care/ANC (0-3% baseline), and 43% had received government CSBA training (31% baseline). The impact of this training on maternal newborn care is evidenced in the MNC gains discussed in IR2 and summarized in Tables 5 and 6 (above). The effect of training in essential newborn care actions on the quality of home delivery practices is evidenced in Table 8 (below). Significant improvements (p≤0.05) from baseline to endline in the intervention group include a 661% increase in the use of clean birth kits by women during home deliveries (4.2% to 32%), a 323% increase in thermal care (immediate drying and wrapping) after home delivery (9.7% to 40.2%), a 103% increase in delaying bathing for three days after delivery (22.7% to 46.3%), and a 19% increase in clean cord care at the time of birth (57% to 69%). With the exception of clean cord care, significant increases in these birthing practices were also seen in the comparison group; however, the percentage increases in the comparison group were lower for each behavior. Stakeholder interviews confirm attribution of these gains to project-supported training in which both government health workers and community volunteers (CHVs, TTBAs, and PG members) were empowered with greater knowledge and skills that impacted both the messaging given to women and communities (IR2) and PPP-generated improvements in quality of MNC delivery. Quality of care saw several important gains over the life of the project that, although the endline values are low, may point towards future potential for care improvement with ongoing PPP synergies. In the “The PI, CHVs and TTBAs are mobilizing the marginalized for MNC.” GBC Physician “There is increased ANC, knowledge of services, and trust.” FWA-CSBA  January 2015 intervention group, active management of the third stage of labor (AMTSL9) increased 4-fold (0.9% to 3.6%) and quality of ANC10 increased 12-fold (0.4% to 4.9%). These significant (p≤0.05) gains were not seen in the comparison group. At endline, quality of ANC was significantly greater (p≤0.05) in the intervention (4.9%) than the comparison group (1.0%). Receipt of essential newborn care11 during home delivery increased significantly (p≤0.05) in both intervention and comparison groups; however, the 14.1- fold increase in the intervention group (0.9% to 12.7%) was significantly greater (p≤0.05) than the 2.8- fold increase in the comparison group (4.8% to 13.6%). Although there was a 92% increase in prophylactic eye care in the intervention group, the fact that only 4.8% of newborns received this care at endline may reflect the lack of availability of eye ointment for CSBA-assisted home and institutional deliveries, as the RHFA found low supplies of newborn eye ointment at health facilities (33% at baseline, 27% at endline). The project may have had an impact on the small gain that was seen in prophylactic eye care, as the comparison group did not change during the project period. Training was done effectively and efficiently utilizing a TOT strategy to train 42,610 people (4,624 male/37,986 female) over the life of the project. World Renew and SUSOMA staff developed curriculum with the LAMB Training Center who conducted TOT training with SATHI and PARI health coordinators, assistant health coordinators and CHTs, government health providers (FWVs, SACMOs, MAs, CBSAs) from district, upazila and union levels, and Joyramkura trainers. These then did training and refresher training in Kendua and Durgapur for the three-tiers of PI members, CHVs, TTBAs, ISPs, and health providers. Table 8. Quality of care practices in intervention and comparison groups, 2009 baseline and 2014 endline KPC Survey. Supervision. Supportive supervision of volunteers to nurture and maintain quality was built into the project. Project MIS data show that project staff made 45,413 supervisory visits to CHVs and TTBAs. MOHFW staff that are taking over this role made an additional 6,359 supervisory visits to oversee CHV and TTBA care quality. The Super CHVs also oversee CHVs and hold monthly meetings of to facilitate ongoing learning and sharing of case studies and best practices. The RHFA demonstrated that, in government facilities, supervisory visits to health workers increased over the life of the project from 7% to 87% and supervision of CSBAs increased from 23% to 30%. Stakeholder interviews confirmed that MOHFW staff and volunteers are working together to promote quality MNC. 9 AMTSL includes administering a prophylactic uterotonic, gentle cord traction, and uterine massage after delivery of the placenta. 10 Quality ANC includes receipt of 4 or more ANC visits from medically trained providers with all necessary services (blood pressure and weight measurement, urine testing for proteinuria, blood testing) and advising about danger signs of pregnancy complications and their management. 11Essential newborn care includes thermal protection (immediate drying and wrapping), clean cord care, and immediate and exclusive breastfeeding. Clean cord care Thermal care Delayed bathing Clean birth kit Eye care Quality ANC AMTSL 2009 Intervention 54.5% 9.5% 22.7% 4.2% 2.5% 0.4% 0.9% 2014 Intervention 65.0% 40.2% 46.3% 32.0% 4.8% 4.9% 3.6% 2009 Comparison 62.3% 21.7% 34.6% 17.3% 3.1% 1.5% 1.5% 2014 Comparison 66.6% 36.6% 58.8% 29.0% 3.1% 1.0% 2.3% 0% 20% 40% 60% 80% “We have learned to solve problems” Jhinuk Society PI  January 2015 Referral system. The project established a referral system collaboratively with health facilities and government officials that gives priority status to SUSOMA referrals. Marginalized poor mothers and newborns with ‘the slip’ now ‘go to the front of the line’ at health facilities. Community and facility-based providers, trained in the referral system, meet monthly at union/FWC and ward/CC levels to coordinate referral follow-up and plan care. Stakeholder interviews verify that the referral system is well established and respected, and that patients with referral slips get priority care. The referral system is used most often CHVs, TTBAs, PI leaders, who consult by cell phone with health providers and often accompany pregnant women/ newborn mothers for emergency care. During the project 5,156 SUSOMA referrals to health facilities for ANC, delivery, PNC, and illness/emergency care were made by CHVs, TTBAs and PIs. In addition, ISPs made 461 referrals. Eighty percent of health facilities sampled in the RHFA reported receiving referrals by endline, compared with 37% at baseline (116% increase). Quality improvement of health facility care. The primary activity to improve quality of health facility care was involvement of PGs in their local community clinics (CC, FWC, RD). Initial monitoring of clinic functioning led to active involvement of PGs in clinic management committees. All PGs are now involved in clinic decision-making and advocacy with local elites. Thirty ‘Model CCs’ have developed in which the PG opens the clinic, cleans it daily, assists and holds health workers accountable, and makes improvements in the clinic (stakeholder interviews). Logistical support has been provided, such as delivery kits, delivery beds, weighing scales, and blood pressure cuffs. Since midterm, the PIs have been engaged with government on a ‘Helping Workers Thrive’ campaign, which has supported clinic personnel. PG, CCC, and PI involvement in the local health facilities has enhanced the availability of clinic health services (stakeholder interviews). At baseline there were 55 CCs of which 48 were open but RHFA data collectors found them without staff or patients. At endline, there were 60 CCs and all are open, staffed, and providing care. Stakeholders attribute these improvements to the involvement of the PGs in local clinics. The MOHFW also played an important role by instituting a new cadre of government health workers, the community health care providers (CHCP), that staff the CCs six days per week. The marked improvements that occurred over the life of the project in government health facility service availability, supplies, and quality of care in the intervention area attest to the impact of the demand created by SUSOMA for quality of care (See table 8). Table 8. MNCH Quality improvements in government health facilities, RHFA 2009 baseline and 2014 endline Child Health Summary 2009 2014 Maternal Newborn Summary 2009 2014 Availability sick care 60% 100% ANC available 4x per month 60% 90% Availability growth monitoring 7% 20% Institutional delivery available daily 3% 17% Availability essential care supplies 34% 66% Availability neonatal drugs 17% 22% Availability first line drugs 39% 63% Availability neonatal supplies 9% 22% Availability care guidelines 7% 21% Availability ANC drugs 19% 22% Staff training in CH past 12 months 37% 87% Availability ANC supplies 9% 28% Appropriate treatment/diagnosis 23% 53% CSBA supply availability 31% 43% Supervision past 6 months 7% 51% CSBA drug availability 15% 22% Facility-community collaboration 73% 90% Availability care guidelines 7% 21% Community referral 37% 67% MNC information system 14% 38% Infrastructure (latrine/water/privacy) 22% 42% Staff training MNC past 12 months 3% 53% “I triage by mobile with the PIs as to best care and give priority to SUSOMA referrals” Gynee Specialist, Sadar “Quality is increasing since SUSOMA. The PIs are improving ANC, PNC and have EHFs. We have better service in the CCs and increased CSBA deliveries. Village level motivation through the PI is encouraging mothers and children to go to clinics.” Civil Surgeon, Netrokona District MOHFW  January 2015 Available laboratory 7% 10% Available laboratory 15% 32% IR4. Increased NGO capacity to support PIs World Renew effectively built the capacity of local implementing partners PARI and SATHI through ongoing training and advisory support mechanisms. Training occurred both formally and informally throughout the project. It was all encompassing, including the TOT course on MNC and IMCI from LAMB, Learning that Lasts, Behave framework, communication, survey data collection, leadership and group management, financial records/audit, development, community capacity monitoring, sustainability, HMIS, and values formation. World Renew’s Asia Region Health Advisor and Bangladesh Team Leader visited the field frequently, kept abreast of project activities, and served on the DTAC, The Health Advisor headed the Project Management Team (PMT, an oversight body for the project), and was readily available by phone and email. To further increase capacity, after midterm SATHI and PARI coordinators and directors became more involved in SUSOMA activities and events, including project implementation team (PIT) meetings and field visits. During stakeholder interviews, these local NGOs confirmed that they had gained knowledge and skill in the PI model, EHFs, volunteerism, MNC, reporting systems, training mechanisms, survey techniques, evaluation methodology, and grant writing. Stakeholder interviews confirm that SATHI and PARI established friendly working relationships with key government officials and health-oriented local NGOs. They held over 700 meetings with district, upazilla, and union level government officials, civil servants, and elites to facilitate the MNC-focused PPP. In addition, they attended 64 upazila and district NGO coordination meetings and have become active participants in a learning circle of 18 local NGOs engaged in community development, where they presented SUSOMA project strategies and results. They participated in exchange visits with the MCHIP MaMoni project in Habiganj, and with LAMB/PLAN-Bd to learn their approach to community clinic management. During the project PARI and SATHI were instrumental in publishing a compendium of the PI model program, entitled the PI Manual, with the support of the primary author, Kohima Daring, who is a PI Model expert and the Bangladesh Team Leader for World Renew. As evidence of their increased capacity, PARI and SATHI effectively initiated, monitored, and supported community mobilization for maternal newborn health in Durgapur and Kendua. They achieved rapid uptake of the 3-tiered PI system through communication, networking, encouragement and training. As a result of their work, all villages have equipped local community leadership and established CHV/TTBA volunteers actively promoting MNCH. All four PIs have an advisory council of local elites, executive committee, development plans, data monitoring systems, and sub-committees for health, leadership/peace, justice, IGA, and networking. PI leaders have been trained in leadership role, capacity building, sustainability, capacity monitoring, and SUSOMA exit strategy planning. Learning was strengthened as exchange visits were made by PIs to other successful PIs, and the Super-CHVs made exposure visits to the partner project upazila to clarify and strengthen CHV roles, responsibilities, and supervision strategies. The PGs track capacity every six months using community capacity indicators (CCI) in the six areas of financial, management, technical, maternal newborn health, community governance, and networking. The PIs track capacity on a six-month basis using PI Capacity Indicators (PICI) on the seven areas of shared vision, leadership and management, financial capacity, resource/knowledge/skills, gender, networking, and ownership. The CSSA dashboard (Annex XIXb) summarizes the substantial growth in PI community capacity over the life of the project for six capacity components--health outcome (50% in 2009 to 95% in 2014), health services (33% to 75%), community capacity (13% to 64%), organizational capacity (15% to 70%), organizational viability (8% to 69%), and environment (2% to 77%). Figure 2 portrays the flow of capacity building that occurred during SUSOMA. ‘SUSOMA created a learning environment …staff received important trainings…seeing the change in communities inspired us” PARI & SATHI Directors/ Coordinators  January 2015 Figure 2. Flow of capacity building during the SUSOMA project from World Renew to local implementing partners to CBOs with illustrative activities. Learnings from SUSOMA are being applied by these NGOs to projects in other districts and to new grant programs. SUSOMA hosted an exchange visit from the World Renew SUJIBON project in Nilfamai district in 2012. SATHI has extended their work in rural areas and is implementing a four-year child￾centered community development project (EU/KNH Germany funded) and a one-year farming project (World Renew funded) using the same design in Atpara upaxila, Netrokona district. PARI shared its increased capacity with its PI-based integrated community development program in Barhatta and four￾year maternal newborn health program in Kalmakanda, Netrokona (EDM Switzerland funded). World Renew, with SATHI and PARI, has applied for funding to start a three-year integrated nutrition program that will build on the established PI structures in Kendua and Durgapur upazilas. World Renew enhanced the MNC capacity of LAMB training department to develop effective community-based TOT training, to support a local training institution (Joyramkura) in rolling out TOT strategies, and to follow-up in the field with health workers to assess training uptake. Joyramkura, PARI, SATHI, GOB trainers, and PI members are equipped to train PI groups, CHVs, TTBAs, drama teams, and ISPs. Sustainable training mechanisms are in place. A capstone in the ongoing growth of PIs is that all four PIs are registered with the GOB Social Welfare Department as independent NGOs. They have begun taking loans from the government department and pregnant women and widows are receiving government allowances through the PIs. IR5. Enhanced learning environment Stakeholder interviews confirmed that a highly valued strategy that fostered an enabling environment between the PIs, government officials and clinic providers was establishment of a joint community￾government MNC HMIS system with monthly PPP matching meetings during which HMIS data is complied and examined. Since the CHVs and TTBAs go house to house throughout the upazilas delivering MNC, they had an accurate count of the number of pregnant women and began collecting SUSOMA data using a standardized pictorial format. In meetings with district officials, the decision was made for the CHV, TTBA, and PIs to meet monthly with officials at the union/upazila level to merge MOHFP and SUSOMA information to arrive at a complete picture of the maternal newborn situation, allowing for more informed allocation of staff and supplies. Evidence from the RHFA coupled with stakeholder inputs link this data to the enhanced ANC and delivery services, a 3-fold increase in health facilities with all essential ANC supplies (9% to 28%), 1.35-fold increase in facilities with all essential delivery and neonatal drugs (17% to 22%), and with all ANC drugs      -Comprehensive ongoing training -Advisory support -Joint project meeting attendance -Joint field visits -Exchange visits -Friendly links with gov’t officials -Community PI model mobilization -Comprehensive ongoing TOT training -Supportive supervision for sustainability -Exchange visits -Friendly links with MOH providers -PPP MNC HMIS Indicators -# Pregnant women -delivery type -newborn sex/weight -referrals -ANC-PNC visits -maternal child deaths -abortions “LAMB has made their training systematic and organized” LAMB Training Director  January 2015 (19% to 26%). The HMIS matching meetings are evidence of the strength of the PPP and are a SUSOMA best practice. Advocacy, networking, and communication training provided to PI groups empowered PI members to effectively work with government officials for local level policies that met health needs of mothers and children. Over the course of the project, the PIs were at the table telling their story at a total of 712 meetings with government officials at district and upazila levels, including monthly meetings with the deputy commissioner, semi-annual DTAC, quarterly UTAC, and annual General Assembly meetings of the PIs, CHV/TTBAs and ISPs. They documented 60 evidences of policy change as a result of these meetings that benefitted the poor. At the SUSOMA dissemination in Netrokona, the 10 district and upazila government officials in attendance each expressed appreciation for the work of the PIs and re￾affirmed the commitment expressed during stakeholder interviews to support the PI-government PPP in the years ahead. In addition, World Renew, PARI, and SATHI established and maintained key relationships at the national level to advance MNC for marginalized citizens. Project staff met 24 times with the White Ribbon Alliance, and 6 times with the Neonatal Working Team. World Renew is a member of the National IMCI Working Group led by the GOB and UNICEF, wherein seven NGOs12 collaborate and integrate individual plans with the national yearly strategy for IMCI. In addition, World Renew has a close relationship with the national IMCI Program Manager who chairs project DTAC meetings in Netrokona and lends support to PI initiatives. Operations research study: PI group development and social capital (Quotes in this section are from the Final Operations Research Qualitative and Social Capital Study Report in Annex XIX. Italicized quotes are interview data, non-italicized quotes are report narrative descriptions.) The qualitative process evaluation of the OR report indicates that the PI groups in Kendua and Durgapur at endline are “well aware of their groups’ activities, purposes, and vision” to reduce maternal child mortality, and have developed trust, solidarity, and problem-solving capabilities. The process of group formation by NGO staff, who “provide the know-how and orient potential group members on activities and goals,” takes several months and is “arduous and requires a lot of patience...to find the right persons who…have a vision of doing well for themselves and their community.” The female groups are comprised of married WRA and, although there are no set income criteria, they decide “who is poor and who can join the group.” PG members elect their leaders, choosing educated persons that can read, write and calculate, and have the time to “run the activities of the group properly.” At endline the PGs were working on creating health guidelines, flipcharts and books to discuss during weekly meetings, during which they also deposited money, sanctioned loans, and provided emergency assistance to mothers and children. Groups have developed confidence in their emergency and health savings, “distrust over the bank has disappeared,” and they are receiving donations from upazilla Parishid chairmen, local elites, and government officials that value the PI efforts for MNC. The CHVs and TTBAs are teaching PG members and households about MNC and proper care-seeking. The CHVs confirmed the training received in surveillance, MNC, and group formation from NGO staff, stating, “we have learned a lot.” The TTBAs confirmed their work in promoting MNC and meeting with government health workers to share information and work. They report that previously, “Mothers died, babies died…now you won’t find any mother dying…none of the newborns die now…few babies are born with weight less than 3 kilo…now mothers go to the hospital as they understand that delivery at the hospital would ensure good health for the mother and baby.” The ISPs interviewed connect with the CHVs/TTBAs and have learned about MNC. They know PG members and are making SUSOMA referrals. Observations made of the CCCs and PIs confirm that these groups are functioning effectively to coordinate the work of the PGs for MNC, deliberate emergency issues, account for regular funds and EHFs, coordinate with health personnel, and prepare for independence. Group members have capacities  12 ICDDR,B, JEPIEGO, CARE, PLAN, SAVE the Children, World Renew and CONCERN Worldwide  January 2015 in MNC, record-keeping, financial management, decision-making, and team functioning and are “confident to run the PG without NGO help” in the future. Evidence given for group capabilities to work independently as an organization is: 1) Groups jointly discuss matters before making decisions. 2) Groups are continuing learning. 3) Groups help non-group community people with EHFs, welfare for the ultra-poor, and work on MNC-related community needs, such as road repairs. 4) Groups save funds, hold bank accounts, and share ideas. 5) Groups hold monthly community and annual union-level assemblies to report about PI activities and make plans. The PGs have good respectful relations with government and know that “our information influences government decisions.” They provide household￾level maternal child HMIS data, referrals, health teaching, and activate communities for EPI, satellite clinics, and NID/NHDs. The four PIs “are playing important roles in improving maternal care” in Kendua and Durgapur by motivating pregnant women and “sending patients to the hospitals and helping them to get timely care.” The PI members represent their communities at the upazilla and district-level meetings with health and family planning officials and have “created linkages with health service providers and reduced refusal of patients at the hospitals.” The OR process evaluation report concludes discussing four PI model-related changes observed in the intervention community at endline: 1) Improved referrals and service provider attitudes/behaviors toward rural poor community members. 2) Overall enhanced capacity of community people, including those who are not PG members. 3) A social movement in the intervention area with active PPP collaboration with HMIS, CHV-provider linkages, and trainings. 4) Sustainable PI groups able to make decisions and expanding activities to the wider community. They go on to say: “It is prudent not to expect radical changes in a project where all is dependent on community uptake of intervention messages, group formation, and savings. All this takes a lot of time…the most important thing is that the connection between mother and child health and overall development…has been made with success.” The Social Capital findings presented in the OR report from the household survey confirm that at in 2014 over 60% of WRA sampled in Kendua and Durgapur were active members of the SUSOMA PI groups, and that groups were becoming more heterogeneous in terms of religion, occupation, and ethnicity. When conflicts arose, people often work it out among themselves or with the help of a neighbor, although it was noted that at times problems lead to violence. Accessibility to health services increased from the 2012 baseline but was still problematic. Credit service accessibility also increased. Over 95% of informants expressed trust in others from their community in terms of lending or borrowing money to/from others. Analysis of the social capital tool data focused on the relationship between social capital and two variables--PI group membership status and residence. In 2012, there was no association between social capital and residence (mean Durgapur 6.61, Kendua 6.53) but a significant relationship (p<=0.001) between social capital and membership status (mean member 8.22, non-member 4.92). At endline there was a significant relationship (p<=0.001) between social capital and residence (mean Durgapur 9.24 and Kendua 15.80), and between social capital and membership status (mean member 15.35 and non￾member 9.99). Although different social capital scales were used at baseline and endline, these findings do suggest a relationship between engagement in PI groups and development of social capital. Challenges and other influencing factors The final evaluation examined challenges that the project faced in achieving results and other factors that may have affected project strategies. These include the initial ramping up of the PGs and volunteers, gender barriers, illiteracy, inclusion of men in the program, religious superstitions and traditional practices, inadequate public health service infrastructure and availability of ANC, institutional delivery, and PNC services, homebirths by untrained personnel, frequent transfer of key government health officials and service providers, and lack of emergency transportation systems. An unexpected occurrence that facilitated project strategies and achievements was the rapid increase in the use of cell phones to coordinate delivery and emergency care. A key factor contributing to project successes is the 18-years of experience World Renew Bangladesh has had to refine the PI Model intervention.  January 2015 Stakeholders and NGO staff related multiple initial challenges in setting up PGs and engaging community￾based health volunteers. A primary gender barrier was resistance from families/husbands and communities to forming female PGs and allowing women to serve as CHV/TTBA. This was overcome by engaging community elites in the MNC cause, BCC messaging during household visits, PG group education, and community events/drama. Many of the TTBAs and CHVs were illiterate and so picture cards and registries were used to time their teaching and track data. Initially only women’s groups were formed and it was difficult to include men in the program. Eventually men began supporting the women, even carrying pregnant women and newborns to health facilities in emergencies. The NGOs and PG members recognized that males are essential for decision-making at family and community levels and that mixed-gender CCCs and PIs would strengthen their advocacy voice with government officials. In year four, the project formed men’s PGs, initiating programs with fathers-in-law, husbands, and male health workers. Now men and women, rich and poor are working together with government to prevent maternal newborn death. Religious-based superstitions and traditional practices that were barriers to community engagement with the PI model were overcome as PG members met with religious leaders/IMAMs to explain MNC goals. Religious leaders now support the program, there are reduced superstition-based care decisions, and use of traditional healers, unskilled home births, and uninformed ISPs has decreased. PIs report that continuing communication is necessary to maintain the linkage with religious leaders. Barriers were also dealt with in relation to availability of and access to quality health services. ANC was not readily available in government health facilities initially. As PG, CCC, and PI members built PPP relationships and supported local health facilities services improved. Now both ANC and facility-based deliveries are more available from trained staff at the CC and FWC/RD levels. Adequate PNC services are also available, however, PNC utilization is increasing slowly because its value is not widely appreciated. Inadequate health facility infrastructure is also an access barrier. Initially there were not enough functional clinics or health workers. Although this has improved dramatically over the life of the project, the problem of inadequate facilities, supplies, drugs and staff continues to require advocacy by the PIs. While the government plans to enhance the number of CSBA-trained health workers they will continue to do home deliveries until the FWCs are upgraded. Institutional delivery points continue to be lacking throughout both upazilas. The PPP was challenged with frequent transfer of key government officials and workers, necessitating re-building relationships with each transfer. Transport of pregnant/ill mothers and newborns to facilities was an access problem overcome with establishment of EHF and emergency transport mechanisms coupled with the SUSOMA referral system that gave the poor person priority treatment upon arrival at the health facility. Access to care continues to be limited by poor roads that are impassible by rickshaw ambulances in rainy seasons. Because the rivers in Durgapur divide the upazila into three areas, three PIs were formed to more readily address MNC barriers. The use of cell phones by PI leaders and CHVs/TTBAs to coordinate care with doctors and health facility staff is an unexpected but welcome enhancement to the intervention strategy that occurred during the project and correlates with the rapid increase in availability of cell phones in Bangladesh since 2009. Health providers and government officials shared cell phone numbers with PI members and volunteers as they worked together to enhance maternal newborn health. A key factor that positively influenced the project was the 18-year experience of World Renew in successfully implementing the PI model in Bangladesh. Because the model is well developed, SUSOMA PIs were well equipped to collaborate with informal and public health sectors in ways that lead to stronger, sustainable health systems and communities with greater social cohesion and empowerment. While findings presented from the OR study confirm the process and utility of the PI model in mobilizing communities for health and in increasing social capital, the OR/KPC studies presented challenges, especially during the end of the project that are detailed in Annex IX of this report.  January 2015 CONCLUSIONS Upon integrating and synthesizing all project findings, the FE team arrived at the following six conclusions about the SUSOMA project. 1. SUSOMA effectively increased community capacity for maternal newborn health and involvement with the health system in a PPP by establishing the People’s Institution Model with marginalized people. A 3- tiered functional PI system was established within 2-years (rapid uptake) which served as the foundation for public private partnership development, enhanced MNC services, trained volunteer community￾based providers, and MNC gains. Primary groups (541) were established and trained in all villages in the program area (494) after which the CCC (22) and PI (4) groups were formed. The groups developed bylaws, plans, capacity monitoring systems, EHF collections, bank accounts, and capabilities in advocacy, networking and community monitoring of maternal newborn health. All are now independent NGOs with GOB registration as a Social Welfare Society. Sustainability was integrated into the PI group model in terms of financing, monitoring capacity, continuing training for groups and volunteer health workers, and establishment of a vibrant PPP between PIs and government officials and health workers. 2. SUSOMA staff developed social capital in marginalized women through ongoing monitoring and support using a slow compassionate approach that demonstrated values and modeled trust, listening, compassion, and teaching. They effectively empowered communities, initially women, with knowledge, skills, and finances via PI model mechanisms and changing social norms using group approaches that fostered development of a helping mentality and inclusive working together. They found that trust and love are foundational to caring and community. Trust was built first among a group before taka were donated and funds managed by the group. People built friendly relationships with eachother and then learned to serve their neighbors. When they formed a group and got knowledge and skill they were seen as people of worth in the community. All involved volunteered their time and resources for MNC. 3. SUSOMA effectively established public private health system collaboration, formalized with MOUs, in which the poor are active MNC advocates with the government and government officials are awakened to their needs. Multiple approaches were utilized to establish PPP relationships. These include development of friendly working relationships around a common MNC goal, common trainings, working together on NID/NHDs, communication about referrals, sharing mobile phone numbers, and an established network of joint meetings with district, upazila, union, and local officials/health workers. The PI-based CHVs and TTBAs built relationships with government health workers and provide ongoing MNC at ward and union level clinics. PI groups are actively involved in monitoring and supporting local clinics, helping clinic health workers to thrive and provide consistent quality MNC care, and networking and advocating with government officials to address gaps in services. 4. SUSOMA improved the MNC practices of marginalized mothers and families by increasing knowledge of danger signs and improving the health practices of mothers through health counseling by trained community volunteers (CHVs TTBAs). They increased the demand for 4 ANC, safe delivery, and PNC services by means of targeted BCC-based household counseling and community messaging through drama and health events. Trained ISPs were empowered to follow IMCI care guidelines and increase appropriate referrals. Specific training curriculums were utilized for CHVs, TTBAs, ISPs, and government health workers to meet project objectives. Both males and females were involved in project activities to the extent culturally possible. 5. SUSOMA increased equitable access to safe CSBA home and facility delivery by increasing demand through awareness raising and change attitudes and behaviors via house to house counseling, drama events, and engaging with influencing elites to promote ANC and institutional delivery/CSBA births. With the government they developed a new role for TTBA as an advocate to promote CSBA/facility delivery rather than doing home deliveries themselves. Key to increasing access for the poor was establishment of PI-based EHFs, emergency transportation mechanisms, and referral systems.  January 2015 6. SUSOMA strengthened the capacity of PARI and SATHI to support the PI model, promote rural MNC, and work with MOHFW at upazilla and district levels through extensive training and support. They increased the number and capacity of NGO health staff and mentored NGO management in rapid￾uptake of the PI model, working in volume, monitoring and evaluation, grant proposal writing, tool development, carrying out research, financial management, donor communication, and networking with the MOHFW at national and local levels. Sustainability of the PI model and project accomplishments Stakeholders interviews, project data and the OR study suggest that the PI model groups and PPP structures developed during SUSOMA are self-sustaining and will continue promoting MCH after the project ends. All PIs are registered with the GOB as independent NGOs and have advisory committees of local elites that provide support and guidance. All tiers of PI groups have strong skilled leaders and members that are equipped to continue the MNC work. Groups have bylaws, healthy bank accounts with EHFs and health savings, and established capacity in the six PICI areas. They are active in planning, financial management, IGA, theater for development, and advocacy. The social capital of PI members is enriched and a culture of servant leadership for their communities established. PIs are equipped to conduct trainings for new PGs, and have formed 34 PGs directly without staff assistance. They are committed to forming male primary groups and achieving gender-equality in the PI system. The PI partnership with the government is well established and characterized by networking, mutual commitment, cooperation and support. The PI groups have MOUs with health facilities and with the government and are accepted in the community and at the facility level. They are involved in decision￾making related to the management of all clinics in Kendua and Durgapur. Local resources are being mobilized by the PIs for health service improvements. The referral system is established and strengthened with marginalized women and babies now getting better treatment by referral. The DDFP recognizes the important role CHVs and TTBAs have in promoting MNC, is linking them with district family planning outreach, and plans to provide them additional training. CHVs/TTBAs are established in the community as volunteer health providers with PI supervision and the provision of mobile phones for better communication. They are motivated to continue household visits, health lessons to primary groups, meeting with government health workers, linking with health facilities and making referrals. They report needing continued training and support. The PIs are supporting the CHVs, making lists of health lessons for them to share with the community, arranging training for them, and will continue to share best practices and successes with government and their communities through established networks of relationships, meetings, and assemblies. Gains in MNC are expected to continue as PI’s continue to promote healthy mothers and babies at the grassroots level and through PPP activities. It is possible that the full impact of the PI system on maternal newborn mortality and health status may take longer to occur than can be measured during this project. Cost-Analysis of resources required to institutionalize scale-up the intervention The 5-year project intervention using the PI model with volunteer community-based providers was completed at a cost of USD 1,207,572. The average project cost per woman of reproductive age is USD 9.73 and per community volunteer (CHV/TTBA) is USD 1,045. It is estimated that a similar program three times as large could be scaled up over 4-5 years in an area with a population of 1.5 million for a cost of USD 3.6 million. The complete cost analysis is in Annex XIXd. SUSOMA’s Best Practices After integrating all evaluation findings, the evaluation team identified the following eight SUSOMA best practices for the global community to consider in promoting maternal newborn health care in marginalized communities:  January 2015 1. The delivery platform: The PI Model of empowerment and local governance that increases social capital of marginalized poor women and improves community-based MNC and health practices by coordinating with government health facilities and officials (Daring, K. The PI Manual, 2013). 2. Emergency health funds built and managed by PI groups for payment of health transport and services for the poor. 3. The PPP-based referral system established jointly and used by PI groups, CHV’s TTBA’s, ISPs and both government and private health facilities that gives priority access to the poor. 4. Matching meetings between PI and government providers focused on collaborative integration of HMIS, a more complete portrayal of maternal newborn data, and improved coverage. 5. The volunteer system of MNC and promotion of ANC, safe deliveries/births and PNC at the grassroots level by trained unpaid CHVs and TTBAs working in collaboration with health facilities providers. 6. PI involvement in the management and operations of community clinics to increase quality and availability of care. 7. Using theater for development (TfD) for MNC messaging at the community level. 8. WR working through local NGO partners (civil society) to increase local organizational capacity so that local NGOs have the structures and substructures for community development and are able to create and support the PIs, work with MOHFW officials and health facilities, train community-based providers, promote sustainable change and apply these learnings to other settings/projects. Impact The OR provides preliminary evidence that social capital can be measured in poor women engaged in PI model groups focused on improving MNC in their community. The higher social capital scale scores found in PI group members in 2012 and 2014 compared to non-members may support attribution of project results to the increase in social capital that occurred in poor women of reproductive age engaged in the PI model. Project findings support that the PI model was foundational to improving social capital of marginalized people and to achieving MNC gains. The PI model rapidly engaged the poor in all communities in intervention upazilas in a commitment to promoting maternal newborn health with a strong private￾public partnership. It empowered women socioeconomically and with decision-making leadership capacities, and actively promoted gender-based leadership as men’s groups were formed. It created a cadre of new grassroots leaders, increased communication and networking between government and PI leaders both horizontally and vertically, and increased access to government and private sector health and social services. The evaluation team appraised that involvement in the PI model brought hope and health care to the marginalized poor. Now that the PIs are GOB licensed NGOs, they can take loans from the social welfare department, secure welfare support for widows and vulnerable groups, and independently work with the government to advance community health and welfare. HMIS and project findings support that the PI model is associated with health improvements in communities. There has been a decrease in maternal and newborn deaths linked temporally with an increase in MCH service utilization and coverage, an increase in institutional and skilled deliveries, a decrease in unskilled home births, and improved practice of good health habits by pregnant women and mothers. The poor and uneducated marginalized citizens were the focus of project interventions and they benefitted the most in terms of savings, health knowledge and practices, availability of and access to health services, referrals and emergency health funds, and enhanced capacity in leadership as well as development of a common community platform for MNC and a grassroots helping mentality. “Change comes through the PI, if there is no PI there is no development or change.” PI Sukher Sandhane’s Secretary  January 2015 RECOMMENDATIONS The evaluation team made three recommendations for extending the accomplishments of the SUSOMA project (Table 9). Table 9. Final evaluation team recommendations. Finding Conclusion Recommendation Action Who Is Responsible -Strong PPPs for MNC established between GOB and PI groups. -Marginalized mothers and families have improved MNC practices. -Quality of MNC services is increasing. The PI model is associated with improved MNC health practices and higher quality of MNC. 1. That the PI model receives ongoing support by GOB and NGOs and be considered for scale-up in rural poor communities with government officials interested in improving MNC health services and outcomes. -Continued sharing of the stories and accomplishments of the PI model including the best practices and learnings. -Disseminate the PI Manual World Renew SATHI PARI GOB -The local NGOs have increased capacity to support community mobilization using the PI model. PARI and SATHI are positioned to influence support for ongoing PI development. 2. That the PI groups established in this project continue to receive ongoing support PARI and SATHI continue to engage the GOB with the established PIs for MNC gains PARI SATHI GOB World Renew USAID Donors -The OR study has the potential to explain the link between the PI intervention and program effects, and between development of social capital and PI group membership. Quality OR data analysis and reports need to be finished as planned. 3. That the OR study be properly completed and published so that the story of successful community mobilization using the PI model can be told to the world. -Complete OR data analysis of KPC, process data, and social capital and complete reports per guidance from USAID/ Evidence Project. -Use all opportunities to publish OR model. ICDDR,B World Renew  January 2015 U.S. Agency for International Development 1300 Pennsylvania Avenue NW Washington, DC 20523  ANNEX II. LIST OF PUBLICATIONS AND PRESENTATIONS RELATED TO THE PROJECT 1. Hoque, D. E., Salam, S.S., Tenbroek, N., Karim1, M.R., Savic, M., Talens, A.T., & Arifeen S.E. (2011). Challenges to realizing universal coverage of maternal, newborn and child health interventions in high mortality districts: findings from a KPC survey in Netrokona, Bangladesh. Podium presentation at the ASCON Conference, March 16-18, Dhaka, Bangladesh. 2. Talens, A., TenBroek, N., & Nyangara, F. (2011). Addressing Health Equity in Bangladesh through Community Mobilization and Governance-the CRWRC Peoples Institution Model: A USAID Child Survival Program Operations Research. Poster presentation at the Consortium of Universities for Global Health (CUGH) and Canadian Society for International Health Conference, November 13- 14, Montreal, Canada. 3. Story, W. T., Burgard, S. A., Lori, J. R., Taleb, F., Ali, N. A., & Hoque, D.E. (2012). Husbands' involvement in delivery care utilization in rural Bangladesh: A qualitative study, BMC Pregnancy and Childbirth, 12:28. 4. Tenbroek, N., Daring, K., Kreulen, G., & Talens, A. (2012). Reducing Mortality among Mothers and Newborns through building Public-Private Partnership: Bangladesh Child Survival Project 2009-14. Netrokona District Bangladesh. Podium presentation at the Women Deliver Conference, May 28- 30, Kuala Lumpur, Malaysia. 5. Talens, A., TenBroek, N., Story, W.T. & Hoque, D.E. (2013). Closing the Gap by Design: Setting up a Maternal Newborn Health Program as if People Mattered. Podium presentation at the CORE Group Spring Meeting, May 9-13, Baltimore, MD. 6. Daring, K., TenBroek N., Sackett, S., Kreulen, G.J., & Talens, A. (2014). The People Institution Model to Close the Sustainability Gap in Child Survival Project in Bangladesh: Governance and Asset-based Capacity-Development of Civil Society Organizations. Poster presentation at the Consortium of Universities for Global Health (CUGH) Conference, Washington DC. May 7, 2014. 7. Daring, K. (2014). The People’s Institution Manual. World Renew, Bangladesh. 8. Paul, M. B. & Ghagra, S. (2014). Story directory: A collection of success stories. Child Health and Survival Program SUSOMA, World Renew Bangladesh. 9. Paul, M.B., editor (2014). MCHIP newsletters with SUSOMA stories: A collection of MCHIP news. Child Health and Survival Program SUSOMA, World Renew Bangladesh. ANNEX III. PROJECT MANAGEMENT EVALUATION The SUSOMA Project of World Renew worked with its two long-standing partner organizations, PARI and SATHI. The Project Manager (PM) is considered a staff member of World Renew, the prime grant holder, with 100% of the PM’s time devoted to the project. The World Renew staff also included a Monitoring and Evaluation Officer, Training Coordinator and a Project Accountant. This is similar to the model used in World Renew’s first USAID-funded Child Survival (CSP1) grant from (2004-2010). For the five-year period, the SUSOMA project office and staff were located in Netrokona town, close to Government health offices. This is the mid way point between the two upazilas and provided staff with easy access to the two project sites within Netrokona – Kendua and Durgapur upazila (sub district). It also allowed for good communication with the Civil Surgeon, Deputy Director Family Planning and other related health officials. The World Renew Bangladesh-based Asia Regional Health Advisor supervised the World Renew SUSOMA Project Manager. They met together monthly for supervision and planning meetings. The Manager for the first two years left after midterm to pursue her career in dentistry. A new Project Manager was hired from another World Renew partner organization. He had much experience in managing MNCH programs so the transition went smoothly. The World Renew Health Advisor and Capacity Development consultant also visited the fields regularly for training and consultation. The Project Manager (PM) in turn supervised the M&E Officer, Training Coordinator, and Project Accountant. The PM was responsible for daily oversight of operations of the project in both partner areas. The Project Directors of SATHI and PARI supervised the partner personnel in close cooperation with the SUSOMA Project Manager. The field staff were employees of the two partners and under their board approved policy system for wages, benefits and overall supervision. This model worked effectively for the five-year period. All SUSOMA, PARI and SATHI staff in the project had job descriptions that were reviewed annually. Each staff also had a performance evaluation yearly with six monthly follow up meetings. Initial communication challenges between the two partner organizations and the SUSOMA project staff were overcome through regular meetings with partner directors and close coordination and training from the World Renew consultant staff. A communication strategy was followed and ensured that all people involved had access to the same information. Throughout the five years of the project, there were various levels of coordination meeting. Each project team (SATHI and PARI) held monthly meetings at their field offices in Kendua and Durgapur. These were led by the coordinators and include all field staff. Minutes were taken and distributed to the SUSOMA Project organization as well as their respective partner organization. The next level of meeting was the Project Implementation Team (PIT) that met monthly at the Netrokona project office and included partner coordinators and assistant coordinators (the SUSOMA Project team). Partner directors and World Renew staff also frequently attended these meetings. The PIT had a clear Terms of Reference that included program updates, HMIS reports, public private partnership updates and other pertinent information. Each meeting included action items that were included in the minutes and followed up in the subsequent meeting. The meeting location alternated between the SUSOMA, SATHI and PARI offices. The Project Management Team (PMT) was a quarterly meeting for the project. Members included the World Renew Consultants, World Renew Accountant, SUSOMA staff, SATHI and PARI Directors, SATHI and PARI Coordinators and Assistant Coordinators. These meetings usually took place in Dhaka but occasionally took place in the project offices. Per the TOR, the meeting agendas included discussions on IR progress, HMIS, operations research, project plan update and DIP Gannt chart, midterm recommendation progress, and finance. Minutes were taken with clear action points. This meeting was extremely helpful to ensure coordination between the two partners and to ensure progress according to the plans. For financial management, the SUSOMA project employed a full time accountant based in Netrokona. The Assistant Coordinators in SATHI and PARI also served as bookkeepers and submitted reports through their organizations to the SUSOMA accountant who recorded the reports monthly on the quick books system. Financial statements were initially approved by the SUSOMA project manager, and then reviewed by the World Renew Consultants. The SUSOMA accountant then coordinated with the World Renew Bangladesh accountant for producing the monthly financial report. This was reported to World Renew U.S., and was also reviewed with each project. Budget spending variances were also monitored. Yearly financial audits took place and these were reviewed in country and then submitted to World Renew U.S. World Renew also submitted monthly VAT reports to U.S. Aid Bangladesh per their prescribed format. The World Renew Accountant also attended regular USAID meetings regarding VAT and financial management. Overall, the project management system and coordination with the partners ran smoothly. Adjustments made at midterm and noted in the midterm evaluation helped to strengthen each of the field offices. This included the placement of assistant coordinators and pairing experienced staff with inexperienced staff within a union for good support. The Project management at different levels of coordination ran smoothly. There was a clear staff development plan for SUSOMA and partner staff capacity. Since the midterm evaluation, no staff left the partners and one staff left SUSOMA 6 months before project end after getting a new job in a long term project. The World Renew Capacity Development Consultant and Regional Health Advisor supported the project with regular capacity building and training per the DIP. In addition, consultancy services were obtained for refresher training from Lamb Hospital. ICDDR,B carried out the final survey with independent contract staff and they took responsible for training them. Overall, management of the project went smoothly and both projects increased their capacity in carrying out MNCH programs. Annex 4: Work Plan Table Objectives/Activities Objective Met Activity Status General Activities Monitoring using LQAS (every 2 years) Changed With ICDDR, B we agreed to add a mid- term KPC and not do the LQAS. LQAS was done in year 4. Monitor sustainability using PI Sustainability Framework (every 6 months) Completed The PI Sustainability Framework training took place and indicators developed and measured 7 times total in March and September (2011-2014). Monthly Report submitted to CRWRC/World Renew Completed Monthly HMIS submitted and reviewed monthly. Monthly Staff Meetings Completed Monthly staff meetings take place at Kendua and Durgapur. The Project Implementation Team (PIT) also meets monthly in Netrokona. Minutes are circulated for all meetings. IR1 Strengthened Private (Civil Society)/Public Partnership in support of MNCH (Operation Research) Baseline assessment for OR Completed Formation of primary groups Completed 216 Primary Groups have been formed in Durgapur and 289 PGs in Kendua. Of these, 22 are male PGs formed from MTE recommendation #5. Overall the project has formed 541 groups against a plan of 495. Thirteen Community Central Committees (union level) have been formed in Kendua, and 9 in Durgapur (22 total). Four PIs have been established at the sub-district level--3 in Durgapur, and 1 in Kendua. Formation of union committees Completed Formation of People’s Institutions Completed Strengthening of primary groups, union committees and People’s Institutions Completed Establish quality improvement system Completed The QIS is developed and taking place quarterly. Results are shared with staff. Pictorial HMIS are field tested and in place monthly. Establish Emergency Health Fund Completed Out of 541primary groups, 520 (96%) have active EHF. The goal is to have 494 groups with the EHF. Design and planning of OR (Comparison and Union selection) Completed See FE Report Annex XV, XVII: OR Final Report and OR Brief. Implementation of OR Completed Quality Assessment of Health Workers (OR) Completed Formative Research (OR) Completed Data Collection on cost (OR) Completed End line assessment of OR Completed OR analysis and write-ups Completed Primary group meetings (4 visits/week) Completed These are done by CHTs (Community Health Trainer) Community Central Committee (Union) meetings (monthly) Completed Union meetings are taking place monthly. Peoples Institution meetings (Thana Federation meetings) (monthly) Completed The 4 PIs have monthly meetings. Health Sub committee (PI) meeting (monthly) Completed The 4 PIs have active health sub-committees. IR2: Improved knowledge and practices of pregnant women and families regarding MNCH Acquire BCC materials on maternal and newborn care Completed BCC flip charts obtained from Mamoni project (MCHIP), Saving Newborn Lives, GOB. Staff training on Designing for Behavior Change Completed In March 2011, four government workers and 25 project personnel were trained in the 6- day course, which included field practicum. Five staff members were trained under the previous CSHGP award. BCC Formative Research (doer/non-doer￾analysis) Completed In August 2011, formative research was done in Kendua and Durgapur for ANC visits and institutional deliveries. BCC materials Refine existing BCC materials using were refined based on findings. doer/non-doer analysis Completed Finalize BCC materials Completed Materials used by staff, CHVs and TTBAs. Coordination with the GOB, Mamoni project and SNL continued through project. Objectives/Activities Objective Met Activity Status IR3: Increased quality of MNCH Service Training of CHV and TTBA and Informal Health Providers Completed 537 CHVs, 541 TTBAs, and 377 village doctors received training and refresher training. Implement prenatal (birth preparedness TT Immunization) /delivery care (clean delivery, referral to Emergency Obstetric Care (EmOC) and post partum care (breastfeeding, thermal care, referrals) Completed SMC (Social Marketing Company) and BRAC (Bangladesh Rural Advancement Company) birth kits are being promoted. Referrals are made and records kept. CHVs and TTBAs promoted BCC MNC messages in households, communities, and Primary Groups. Drama teams also did targeted messaging to influencing groups. Supportive supervision and visit Completed Done by CHTs, Super CHVs, and now GO health workers Community Health Volunteer meeting (monthly) Completed 27 Super CHVs oversee local CHVS and facilitate ongoing sharing and learning at monthly CHV meetings. Trained Traditional Birth Attendant meeting (monthly) Completed Child Weighing (monthly) Completed MOHFW implemented activity and not under direct project control National Immunization Day Observation (2x/yr) Completed MOHFW implemented activity not under direct project control, however, the PIs, CHVs and TTBAs participate in NID. CHV and TTBA Gathering (yearly) Completed IR4: Increased capacity of local NGO for implementing People’s Institution Finalize and sign MOU with new partners Completed All PIs have MOUs with for MNC with GO and Pvt health facilities. Partners Staff Training Completed 824 staff received SUSOMA trainings. Semi Annual Learning Circles for partners Completed Learning exchange World Renew staff and partners Completed IR5: Enhanced enabling environment for MNCH Dissemination of survey results to the community and stakeholders Partially completed Midterm survey results disseminated in Netrokona, Kendua and Durgapur, and in Dhaka (ICDDR, B) with participants from USAID, UN agencies, GOB and NGOs. Final evaluation dissemination occurred in Netrokona, and Dhaka (pending completions of OR). Dissemination meetings with stakeholders (half yearly) Yes Completed Completed at the district level in Netrokona and at the sub-district level in Kendua and Durgapur. Formation and meeting of sub￾district/upazila advisory committee Completed Two upazila technical advisory committees are meeting quarterly. Terms of Reference have been completed. Formation and meeting of district advisory committee Completed The district technical advisory committee started in August 2012 with approved Terms of Reference and 6-monthly meetings. Dhaka’s IMCI Director and ICDDR, B staff attend these meetings. Quarterly progress report to Civil Surgeon Completed Civil Surgeon receives quarterly report and the Deputy Commissioner of the District receives monthly report on GOB approved format. Neonatal Working Team -IMCI meetings (quarterly) Completed The Neonatal Working Team completed its work and the IMCI annual work plan meeting was held in June 2011. World Renew has contributed to the plans and signed the document. IMCI meetings take place quarterly; World Renew is a regular member of IMCI Working Group. White Ribbon Alliance National meetings (monthly) Completed World Renew served as the acting chairperson of the Bangladesh White Ribbon Alliance (WRA) Executive Committee. Advocacy issues focus on institutional delivery and early marriage. 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COMMUNITY HEALTH WORKER TRAINING MATRIX Community Participants (CHVs, TTBA, PI and Village Doctors) Government Participants Project Staff Number Trained Over Life of Project Focus of Training Total Male Female 35 66 101 10 91 TOT on Antenatal Care, Post￾natal Care and Essential Newborn Care 46 46 5 41 Community Development Training 10 2 12 1 11 Material Development Workshop 3 10 13 1 12 Behavior Change Communication (BCC) 3 3 3 0 IMCI Clinical Management Training 6 4 10 9 1 TOT on IMCI Package 38 38 4 34 Community Capacity and Sustainability Training 5028 40 5068 507 4561 Record Keeping and Management 4783 41 4824 482 4342 Volunteerism` 4738 40 4778 478 4300 Formation of CCC and PI 377 377 377 0 Village doctor Basic Training 1 1 0 1 Learning That Last 1 1 1 0 PRA Training 6 6 1 5 ETAT Training 6 44 50 5 45 PICI and Sustainability Training 31 31 3 28 Training on LPC Survey  Community Participants (CHVs, TTBA, PI and Village Doctors) Government Participants Project Staff Number Trained Over Life of Project Focus of Training Total Male Female 29 29 3 26 CCI Monitoring Workshop 3 1 4 4 0 IMCI Clinical Management Training 5217 41 5258 526 4732 Group Bi-laws 5022 40 5062 506 4556 Leadership and Management 1 1 1 0 Water Policy and Water Resource Management 1 1 1 0 PICI and Sustainability Training 4861 40 4901 490 4411 Networking 25 25 3 22 Workshop and Audit on CCI 678 678 68 610 Several Village Level Training 27 27 3 24 Super CHV Training 42 42 4 38 Monthly Workshop on vision of PI Sustainability 139 139 14 125 Group Management Training for PI and CCC leaders 17 17 2 15 Responsibility Training for PI leaders 145 145 15 130 Sustainability Training for CCC/PI Leaders 26 26 3 23 Monthly Workshop on Group Audits and Account Keeping 26 26 3 23 Audits and Account keeping 29 29 3 26 Workshop on Advocacy 28 28 3 25 Vision Workshop of PI leaders 55 55 6 49 ANC Delivery and PNC  Community Participants (CHVs, TTBA, PI and Village Doctors) Government Participants Project Staff Number Trained Over Life of Project Focus of Training Total Male Female Training for CHCP 4 4 0 4 PI Registration Workshop 35 35 4 31 9 Design Training for Health Subcommittee and PI/CCC Leaders 16 16 2 14 Accessing Health Facilities for the Marginalized People 52 52 5 47 9 Design Training for Super CHVs 16 16 2 14 Workshop of Advocacy 28 28 3 25 Community Clinic Management orientation with PI and CCC leaders 11 6 17 2 15 Workshop on Mixed PI Formation 30 30 3 27 Theater for Development Training 4 4 3 1 IMCI Training 5 5 0 5 PI Module writing Workshop 3216 26 3242 324 2918 Audits and Account keeping for Groups 3457 26 3483 348 3135 Functions of Health Sub Committee 2998 26 3024 302 2722 Health Care to the poor 8 10 18 2 16 Rapid Health Facility Assessment Training 67 67 7 60 Management and Record Keeping  Community Participants (CHVs, TTBA, PI and Village Doctors) Government Participants Project Staff Number Trained Over Life of Project Focus of Training Total Male Female 224 224 22 202 Audit CCI and PICI 70 70 7 63 Gender and Reproductive Health 35 35 4 31 Local Resource Mobilization 69 69 7 62 Monitoring and Evaluation 16 16 2 14 Responsibility Training for PI leaders 172 172 17 155 Leadership Development 51 51 5 46 Social Leadership and Development Training 53 53 5 48 Capacity Building and Sustainability Training 27 27 3 24 Exit Strategy Plan 41,663 123 824 42,610 4,624 37,986 Total # of People Trained: 42,610 17 35 43 95 10 85 Refresher TOT ANC PNC ENC 559 559 56 503 Refresher ANC PNC ENC for TTBA 558 558 56 502 Refresher ANC PNC ENC for CHV 280 280 280 0 Village Doctor Refresher Training 30 30 3 27 Drama Refresher Training 1,444 35 43 1,522 405 1,117 Total # of Training Encounters: 44,132  Community Participants (CHVs, TTBA, PI and Village Doctors) Government Participants Project Staff Number Trained Over Life of Project Focus of Training Total Male Female  Annex VIII. Evaluation SOW Terms of Reference for GRACE KREULEN, PhD, RN Final Evaluator -External Consultant for the Child Survival Project (SUSOMA) Project in Bangladesh August 3-11, 2014 I. Introduction World Renew will hire Grace Kreulen, PhD, RN an independent consultant to conduct a final performance evaluation (FE) for the Bangladesh Child Survival (SUSOMA) project funded by USAID’s Child Survival and Health Grants Program (CSHGP) with Cooperative Agreement No. GHS-A-00-09-00009-00 (September 30, 2009 to September 29, 2014). Contact person is Alan Talens (World Renew Health Advisor address: 1700 28th Street SE Grand Rapids Michigan atalens@worldrenew.net, Phone no. (616) 224-0740 x 2150). The Child Survival Project is in Netrokona District, Bangladesh. USAID’s CSHGP supports community-oriented projects implemented by U.S. private voluntary organizations (PVOs) and nongovernmental organizations (NGOs) and their local partners. The purpose of this program is to contribute to sustained improvements in child survival and health outcomes by supporting the innovations of PVOs/NGOs and their in-country partners in reaching vulnerable populations. This document describes the Final Evaluator’s SOW for the Bangladesh Child Survival Project (SUSOMA) Final Evaluation. II. Background The SUSOMA project (derived from Bangla Shusto Sontan O Ma - Healthy Child and Mother) is a 100% maternal and newborn child health (MNCH) intervention in 2 rural sub-districts in Northern Bangladesh with a large population of poor and ethnic minorities. The goal of this project is to reduce mortality and improve health status among the most marginalized mothers and newborns which will result in improved household and community behaviors and increased utilization of maternal and newborn services through establishment of public –private collaboration called the People’s institutions, the community based organizations. III. Project Population Beneficiaries* Total Total Population 484,920 Total Neonates (0-28 days) 19,873 Infants aged 0–11 Months 19,314 Children aged <5 Years 96,571 Women of Reproductive Age (15–49 years) 124,313 Total Beneficiaries 220,884 Expected Pregnancies* 21,932 Community Health Workers or Volunteers (CHWs), Disaggregated by Sex 998 (99 m, 899 f) Health Facilities (Hospital to Sub Health Post) 74 Community-Based Structures (Peoples Institutions) 4 Source: Population Census, Netrokona, Bangladesh Bureau of Statistics and Health Demographic Surveillance, 2001 *http://www.unfpa.org/sowmy/resources/docs/country_info/profile/en_Bangladesh_SoWMy_Profile.pdf  IV. Partners World Renew partners with 2 local NGOs: SATHI and PARI, with experience in capacity development and health programing in implementing the project in the sub districts of Durgapur and Kendua respectively. The International Center for Diarrheal Disease Research, Bangladesh (ICDDR, B) is another partner; ICDDRB conducts the Operations Research part of the project- a quasi-experimental research design to test whether the strategy, the Peoples’ Institution is more effective, equitable and cost effective than currently available programs in the area. LAMB (Lutheran Aid to Medicine in Bangladesh) a local training institution is the partner responsible for the training of CHVs, TTBAs, Ministry of Health and Family Welfare and project staffs. V. Key Activities World Renew Bangladesh CSP’s level of efforts is 100% focused on maternal and newborn intervention package and integrated into the Government of Bangladesh’s (GOB) C-IMCI (Community -Integrated Management of Childhood Illness) strategy. It is expanded to include newborns, and delivered at the household level by trained traditional birth attendants and unpaid community health volunteers (CHVs). The project is introducing a best practice in a new environment, by implementing the innovative community mobilization approach: the project delivery strategy, the “People’s Institution Model”. This is unique in that it reaches the poorest and most marginalized members of the community. The community- based organizations formed within this model interact and collaborate with both the informal health care system and the public health sector in ways that lead to stronger, more sustainable health systems. An Operations Research (OR) is part of the project to test the effectiveness of delivery strategy – using the People’s Institution model. Community-based activities of the volunteer health workers (CHVs and trained TBAs) are the following: Maternal Care • Community Health Volunteers (CHVs) counsel mothers on the importance of ANC, skilled delivery, and breastfeeding. • Establishment of an emergency health fund in each sub districts. • Traditional Birth Attendants (TBAs) trained to perform clean deliveries and make referrals to skilled birth attendants and other qualified providers (health facilities). • CHVs trained to provide postnatal care. Healthy Newborn Care and Breastfeeding • CHVs trained to counsel mothers and other influencing groups on essential newborn care practices. • TBAs trained to provide essential newborn care immediately after delivery. Birth Asphyxia • CHVs counsel mothers on risk factors and preventive measures to reduce birth asphyxia. • TBAs trained on the early management of birth asphyxia and post-resuscitation referral and management. Low Birth Weight (LBW) • TBAs trained in identifying LBW neonates, kangaroo care, and breastfeeding promotion. • CHVs counsel adolescent girls and mothers to reduce known risks related to LBW. • Coordination with GOB on maternal nutrition and IFA. Neonatal Sepsis • CHVs trained to counsel mothers and other influencing groups on neonatal sepsis. • CHVs trained to manage sepsis in the home.  VI. Purpose of the Final Evaluation The purpose of USAID’s CSHGP is to contribute to advancing the health system strengthening goals of Ministries of Health toward achieving sustained improvements in child survival and health outcomes, particularly among vulnerable populations, by supporting the innovative, integrated community-oriented programming of PVOs/NGOs and their in-country partners. CSHGP cooperative agreements offer unique opportunities to demonstrate the links between specific delivery strategies and measured outcomes. The FE is intended as a performance evaluation but should be broadly accessible to various audiences including Ministries of Health (MOHs), and findings will contribute evidence relevant to global initiatives such as the Global Health Initiative and Feed the Future.1 It is important that the final evaluator consider the audiences listed below, when conducting the evaluation and writing the report. The FE provides an opportunity for all project stakeholders to take stock of accomplishments to date and to listen to the beneficiaries at all levels, including mothers and caregivers, other community members and opinion leaders, health workers, health system administrators, local partners, other organizations, and donors. The FE Report will be used by the following audiences as a source of evidence to help inform decisions about future program designs and policies: 1. In-country partners at national, regional, and local levels (e.g., MOH and other relevant ministries, district health team, local organizations, communities in project areas). 2. USAID (CSHGP, Global Health Bureau, USAID Missions), and other CSHGP grantees. 3. The international global health community. The FE report will be posted for public use at http://www.mchipngo.net and the USAID Development Experience Clearinghouse at https://dec.usaid.gov. VII. Methodology The evaluation methodology consists of a mixed-methods approach using both quantitative and qualitative data. The approach comprises both a desk review of secondary data sources and the collection of qualitative data to complement existing data. The written design of the evaluation must be further defined and specified by the final evaluator (e.g., number of key informant interviews, focus groups discussions, observations, and locations) and must be shared with project stakeholders and implementing partners for comment before the evaluation commences. World Renew will facilitate this sharing and feedback. Secondary Data: The final evaluator will review project reports (e.g., Detailed Implementation Plan (DIP); annual reports; Mid Term Evaluation knowledge, practice, and coverage baseline; and final survey and any monitoring reports) to assess the quality of quantitative and qualitative data and make assessments of project results in relation to the project design and targets set. The final evaluator will review key U.S. Government/USAID strategic documents at the global and national levels relevant to the content of project. All relevant policy and strategy documents at the national level (e.g., MOH policies and strategies) are also crucial and to be used and referenced.  %       !"$$#  #  "$$#   ##  Qualitative Data: In-depth qualitative interviews or focus group discussions may be conducted with stakeholders, including project staff, MOH, local NGOs and community-based organizations, district health teams, community- and facility-based health workers, community members, community leaders, and mothers (exit interviews). If possible, the assessment will also include observations of activities supported by the project. This will involve site visits to one or more implementation areas. It is recommended that the final evaluator randomly select communities to visit from a list provided by World Renew. However, purposive sampling may be warranted in addition to explore certain areas in more depth to investigate particular results (e.g., high or low performance or unexpected results). Limitations: The evaluation report must include a discussion of the methodological limitations of the evaluation. (Additional guidance on reporting format is provided in the CSHGP Guidelines for Final Evaluations, specifically in the Final Evaluation Report Template included therein). VIII. Evaluation Questions (updated) The final evaluator and the evaluation team will use existing data collected or compiled during the life of the project, as well as additional data collected during the evaluation to answer the following questions: Primary Evaluation Questions Related Sub-Questions 1. To what extent did the SUSOMA project contribute to improved MNCH-related household and community behaviors, availability and utilization of quality services? a) To what extent and in what ways did the local NGO’s (SATHI and PARI) effectively engage communities to strengthen private/public partnerships in support of MNCH? b) How did community engagement and mobilization strategies using the PI model impact public-private collaboration, allocation of resources for health (local EHF, community and facility-based care), local government capacity for facility services, and policy advocacy? c) To what extent and in what ways did the utilization of volunteer CHWs contribute to improved MNCH practices and increased coverage and utilization of ANC, assisted delivery, and post partum care? d) To what extent and in what ways were community health system enhancement strategies effective? Did the Quality Improvement System improve services at the village level? Did engaging the informal health system reduce harmful practices? What was the impact of the referral process for mothers and sick newborns? 2. What strategies and factors (both planned and unplanned) lead to achievement of key critical results? What challenges/ barriers were faced and how were they overcome? a) Was the project implemented as designed, including the incorporation of key partners outlined in the DIP? What changes were made to the implementation plan and why? b) What is the quality of the data and of the system for measuring project results? Did the quantitative and qualitative indicators provide useful evidence for decision-making? c) How did consideration of socioeconomic factors and gender affect implementation and outcomes? Were females and males appropriately engaged in the PI model strategy? Did the project effectively unify the socially and economically underprivileged and create opportunities and resources for MNCH not usually available to these individuals/groups? d) What synergy/integration occurred between strategies that impacted results? 3. Which project strategies have potential be sustained a) What evidence is there that SATHI and PARI have become more sustainable as organizations able to support community engagement and  or expanded? What are the promising practices and lessons learned? mobilization? b) To what extent and in what ways has the project developed an enabling and learning environment to support sustainable capacity and advocacy for quality MNCH care? c) What aspects of the program can be or are being scaled-up to benefit more people and to foster lasting policy/program development? What factors influence the success of scale-up efforts? d) What resources would be required to institutionalize or scale up key intervention components (cost analysis)? 4. Did the operation research provide evidence that supports attribution of project results to the PI model? How could scale-up of the PI model impact MNCH in Bangladesh? a) What role did the OR study have in evaluating and improving the impact of the PI model on MNCH outcomes at the community level? To what extend did OR results provide evidence that the PI model of community mobilization (vs other confounding factors): 1) Promotes equity by engaging the poor and marginalized to have power to make decisions in health and care seeking2 2) Builds local capacity to identify and address community needs, provide quality services, raise social capital (SC) and contribute to desired MNCH outcomes 3) Enables the community to establish linkages with health facilities to improve quality and access to health services and to advocate for policy changes b) How were results of the OR study used for informed decision making and improvement of the PI model? IX. Final Evaluator Characteristics and Expected Timeline The consultant will serve as the evaluation team leader and is welcome to propose additional evaluation team members to round out the evaluation team’s skill set in order to ensure adequate representation of evaluation, technical, geographic, cultural and language skills. Team members, their affiliations, and disclosure of conflicts of interest must be listed in an annex to the evaluation report. The consultant will coordinate closely with the World Renew team regarding tool finalization, evaluation methodology, timeline, and draft report finalization. Requirements: The consultant must be approved by USAID CSHGP and should meet the following minimum requirements: • Proven expertise and leadership in integrated community-oriented reproductive, maternal newborn, and child health projects conduct of evaluations (baseline, end line) using mixed methods. • Experience with design, collection, and analysis using applied research methods in a program implementation context. • Familiarity with public health system in Bangladesh. • Demonstrated ability to communicate with and lead a team of stakeholders, staff, and national experts in participatory evaluation. • Familiarity with USAID programming. • Skill or familiarity with cost analysis methods for program assessments • Excellent analytical and writing skills (English) • Signed statement explaining any conflict of interest3  &            $#  Key Tasks of the Evaluation Team Leader: • Review project documents and resources to understand the project • Refine the evaluation objectives and key questions based on the CSHGP guidelines in coordination with World Renew team and its partners. • Develop the field evaluation schedule and assessment tools. • Train enumerators and team members on objective and process of the evaluation including evaluation tools. • Lead the team to complete the collection, analysis, and synthesis of supplemental information regarding the program performance. • Interpret both quantitative and qualitative results and draw conclusions, lessons learned, and recommendations regarding project outcome. • Lead an in-country debriefing meeting with key stakeholders, with a PowerPoint slideshow deliverable, no longer than 20 slides (with USAID/Washington, DC, participation remotely, as able). • Prepare draft report in line with the CSHGP guidelines and submit to CSHGP and World Renew simultaneously on or before September 1. • Prepare and submit the final report, which is due at the USAID CSHGP GH/HIDN/NUT office on or before 90 days after the end of the project. • Timeline: Dates (2014) Activities January Send project documents (DIP, Baseline Reports (KPC and RHFA), OR data from ICDDRB, Mid Term Evaluation Report, all annual reports to consultant (done) Aug 1 and 2 (Fri and Sat) Travel August 3 (Sun) Meet with ICDDR,B in the morning and with the evaluation team in the afternoon August 4 (Mon) Meet as evaluation team in the morning to develop questions. Drive up to program area (Netrokona District in the afternoon. August 5-6 (Tues and Wed) Field interviews (3 teams - 2 regular teams + 1 rover) August 7 (Thurs) Government interviews in Dhaka Aug 8 (Sat) Writing Aug 9-10 (Sat and Sun) Team works on the evaluation findings and report sections. Aug 13 (Tue) Dissemination Aug 13 (Wed) Travel Aug 30 Submission of Report to USAID  '                    #                                #  X. Final Evaluation Report The Final Evaluation report will follow the outline in USAID CSHGP’s Guidelines for Final Evaluations (submission instructions as indicated in the guidelines.) A final report, written by the final evaluator, will be submitted directly to the CSHGP XI. Budget Expenses [Level of Effort: 100% Maternal Newborn Health ] Amount ( in USD) 1. FE consultant fee (Daily rate: $400/day); cost to include all foreseen expenses during the evaluation. $10,000 2. Cost in-country for carrying out evaluation (accommodation and local travel of evaluation team) $ 5,000 Total $ 15,000 XII. Deliverables At the conclusion of the consultancy period, the consultant is expected to complete the following deliverables: 1. Lead an in-country debriefing meeting with key stakeholders (and remote participation by USAID/Washington, DC) with a PowerPoint presentation no longer than 20 slides for distribution 2. Prepare a draft report in line with the CSHGP guidelines and submit to CSHGP and World Renew simultaneously on or before September 1, 2014. 3. Prepare and submit the final report, which is due at the USAID CSHGP GH/HIDN/NUT office on or before 90 days after the end of the project. Annex IX. Evaluation Methods and Limitations A. Prior to conducting the evaluation in Bangladesh, the evaluation team leader prepared by examining documents listed in Annex X1. B. SUSOMA Final Evaluation, Evaluation Team Schedule Dates Activities Aug 3, 4 Workshop 1 & 2: Team building, project review, final evaluation quantitative data review, develop stakeholder interview questions (Dhaka) Aug 5, 6, 7 Field visits (3 teams): Stakeholder interviews, record interview data (Netrokona) Aug 8 Day off Aug 9, 10 Compile interview data, triangulate data, interpret finding, draft conclusions and recommendations (Dhaka) Aug 11 Prep for Netrokona dissemination Aug 12 Final evaluation dissemination in Netrokona C. Final Evaluation Methodology. The evaluation team used the following participatory process over a two-week period: 1. Discuss expectations about the evaluation 2. Review evaluation principles for child survival projects and evaluation frameworks 3. Examin SUSOMA final evaluation objectives and processes and the evaluation report. 4. Receive reports from PARI and SATHI on their roles and activities in SUSOMA, reviewed evaluation results received to date (KPC, RHFA, CSSA, OR). 5. Determine final evaluation priority focus. 6. Identify key stakeholders to be interviewed, designed stakeholder questionnaires. 7. Conduct key informant interviews/focus group discussions in three teams--listened to beneficiaries, stakeholders, and partners to validate and gain greater understanding of project. 8. Process the results from each team and triangulate the information with other data previously collected (KPC, RHFA, CSSA, M&E) 9. Develop group consensus on project achievements, challenges, sustainability, lessons learned, conclusions and recommendations. 10. Dissemination: Share finalized results with key government officials, health facility providers, elites, PI leaders, CHVs, and TTBAs in Netrokona. 11. Discussed project accomplishments with USAID Mission and ICDDR,B in Dhaka. 12. CANCELED: A final dissemination is planned for late September in Dhaka upon completion of the KPC and OR reports by ICDDR,B. D. Developing stakeholder interview questions. The evaluation team used a set of guiding questions directly linked to the FE questions to develop questionnaires for each stakeholder group (see next page). The questions were summarized into the acronym ACSI, which was translated in Bengali to mean ‘to tell a story/paint a picture:’ 1. Accomplishments: What results were achieved? How did interventions contribute to results? 2. Challenges & Inputs: What factors contributed/detracted from to critical results and why? 3. Sustainability: What strategies can be sustained, scaled-up, shared globally? 4. Impact: What evidence links project results with the PI model? The Final Evaluation field interview questions by stakeholder group were translated into Bengali for interviews. The English version is in Annex X. The SUSOMA Final Evaluation Question Guide for developing stakeholder interview questions Primary Questions Guiding Sub-Questions with Probes Accomplishments A. To what extent and how did the project contribute to improved MNCH-related: a) household and community behaviors, b) equitable availability and utilization of quality services? 1. To what extent and in what ways has the local NGO’s (SATHI and PARI) engaged communities to strengthen private/public partnerships in support of MNCH? 2. How did community engagement and mobilization using the PI model impact MNCH outcomes? • In what ways did community capacity for management of health and health systems increase? • How were public-private collaboration and feedback mechanisms established? • What training & capacity building was essential to successful PI mobilization? • In what ways were resources for EHF and local capacity for facility services & policy advocacy established? 3. To what extent and in what ways has SUSOMA improved MNCH practices and equitable access to services for the marginalized at household and community levels? • In what ways did ENC actions and MNCH behaviors promoted by CHWs increase health equity? • What lead to increased maternal MNCH knowledge and practices? • What lead to increased coverage and utilization of ANC, assisted delivery, and post partum care? 4. To what extent and in what ways has SUSOMA enhanced community health system quality? • How did the Quality Improvement System improve services at the village level? • In what ways did engaging the informal health system reduce harmful practices? • What made the referral process for mothers and sick newborns effective? • In what ways was the capacity of MOHFW enhanced and structures established to ensure ongoing QOC. Challenges & Inputs B. What key strategies and factors lead to achievement of critical results? What challenges/ barriers were faced and how were they overcome? 1. How has consideration of socioeconomic factors and gender affected implementation and outcomes? • To what extent were females and males appropriately engaged in the PI model strategy? • In what ways did the project unify the socially and economically underprivileged? Who benefited the most? • How did it create opportunities and resources for MNCH not usually available to these individuals/ groups? 2. What community partners and structures are especially important for improving MNCH outcomes? 3. What specific strategies are the most effective? In what ways are they most effective? • What strategies did not work? • What unplanned activities occurred that influenced results? • What synergy/integration occurred between strategies that impacted results? 4. What challenges and barriers were faced in implementing SUSOMA and how were they overcome? 5. To what extent are project implementation and data systems effective? • Was the project implemented as designed, including the incorporation of key partners outlined in the DIP? What changes were made to the implementation plan and why? • What is the quality of the data and the system for measuring project results? Did the quantitative and qualitative indicators provide useful evidence for decision￾making? Sustainability C. Which project strategies have potential be sustained, scaled￾up or expanded? What promising practices and evidence can contribute to global learning? 1. To what extent and in what ways are SATHI and PARI more sustainable as organizations able to support community engagement and mobilization? • What are local NGOs doing differently than before? What factors enabled these changes? 2. To what extent and in what ways has the project developed a learning environment to support sustainable capacity and advocacy for quality MNCH care? What more can be done? • How has the learning been shared with decision makers at local, district, and national levels? 3. What elements of SUSOMA are most likely to be sustained after the current program ends and why? • What exit strategies are in place to maximize the likelihood that the outcomes will be sustained? • What is most critical to sustaining the PI Model innovation? 4. What aspects of the program can be or are being scaled-up to benefit more people and to foster lasting policy/program development? • To what extent have components of SUSOMA been integrated or institutionalized into the formal HCSx? What factors influence the success of scale-up efforts? • What are the best practices of SUSOMA? What one strategy would you want to share with others? 5. What resources would be required to institutionalize or scale up key intervention components (cost analysis)? Impact 4. To what extent and in what ways does the OR provide evidence for attribution of project results to the PI model? How could scale-up of the PI model impact MNCH in Bangladesh? 1. What evidence links results to the PI model? 2. How were results of the OR study used for informed decision making and improvement of the PI model? How might they be applied in other settings? 3. To what extent did OR results provide evidence that the PI model of community mobilization is more capable than comparison programs of: • Promoting equity by engaging the poor and marginalized to have power to make decisions in health and care seeking (closing the gap between lowest and highest quintiles of rich/poor) • Building local capacity to identify and address community needs, provide quality services, raise social capital, and contribute to desired MNCH outcomes • Enabling the community to establish linkages with health facilities to improve quality and access to health services and to advocate for policy change. E. Stakeholder interviews occurred as part of the final evaluation over a 3-day period at the district health complex and SUSOMA office in Netrokona, the health complexes and partner NGO offices in Kendua and Durgapur, throughout the intervention upazilas, and in Dhaka. Stakeholders to be interviewed were categorized into 7 groups: 1) government officials, 2) SUSOMA and NGO staff, 3) government health facilities and providers, CHWs (CHVs, TTBAs), and ISPs/village doctors, 4) PI groups at varied functional levels (PI, CCC, PGs), 5) beneficiaries (mothers, husbands, in-laws), 6) training institution directors, and 7) other. Three teams conducted the interviews: Team A did interviews in Kendua, Team B was in Durgapur, and the Rover Team interviewed in Netrokona, Kendua and Durgapur. The interview schedule, names of stakeholders interviewed and sites visited during the final evaluation are listed in Annex XI. For each IR, the final evaluation team identified groups and individuals to be interviewed (see table below). Summary of Stakeholders Interviewed for each IR Stakeholder Group Persons interviewed 49 Team Interviews Project IRs A B R 1 2 3 4 5 Officials Netrokona Upazila Dhaka CS, DCS, DDFP, GYN Specialist UH&FPO, UFPO, HI in charge, USSO UP Chair IMCI 4 1 1 3 1 1 1 X X X X X Implementing NGOs Sathi/Pari Staff Sathi/Pari Management 1 1 1 1 X X X X X Upazila /Ward health facilities and health workers (FWV, FWA, CSBA, SACMO, FPI, HI) FWC and CC workers and facilities Pvt HW, CHVs/TTBAs ISP/VDs 3 1 3 1 1 4 1 1 X X X X PI groups- 3-tiers PI groups/members/committees CCC PG/health groups (female=8, male=2) 1 1 4 2 1 2 1 2 X X X X X Beneficiaries Pregnant women & U2 mothers, Husbands and father/mothers-in-law 1 1 1 X X Training institutions Lamb training directors 1 X X USAID ICDDR,B Bangladesh Mission Director Operations Research Study team 1 1 During field interviews, observations were made of communities, government (FWCs/RD, CCs) and private health facilities, ‘model’ CCs with active daily PI involvement in clinic management and on the Management committee, and ‘regular’ CCs with PI members only serving on the decision-making Management Committee, low, medium and highly functional PI groups and their meetinghouses. Interview data was entered in English on a standard reporting form within one day of completion of each interview. Thereafter, the evaluation team met for two days during which it compiled interview data by stakeholder group, arrived at consensus on themes across stakeholder interviews, triangulated all data sources, interpreted findings, and drafted conclusions and recommendations. F. Stakeholder interview processing. The evaluation team processed results from stakeholder interviews and triangulated them with other data. Consensus regarding accomplishments, challenges, sustainability and impact can be found below and are reflected in this report. Consensus regarding best practices and conclusions are in the report. G. Limitations of evaluation data. The evaluation team had an appropriate mix of information to inform the final evaluation report, however, it had to deal with multiple issues related to quality of the preliminary KPC data and Operations Research reports. 1. The KPC survey report was received in preliminary form from ICDDR,B on July 23, 2014. Also received was a preliminary summary table of percentage results (without N’s or confidence intervals) for the 43 maternal newborn child health indicators at baseline and endline for the intervention and comparison groups. In reviewing the data it became clear that the maternal newborn care and cost module data was collected at baseline from women with children aged 0-23 months while the endline KPC survey sampled women with children aged 0-11 months. (This change was made without notifying World Renew.) The data provided was comparable, because ICDDR,B recomputed the baseline indicators using the 0-11 month metric, however, the reanalysis of baseline data was incomplete and without sample size and confidence intervals. ICDDR,B sent preliminary updated endline data with confidence intervals (CIs) on August 12. On August 26, 2014, World Renew held a conference call with USAID to confer with them on issues related to the KPC data and report. Extensive feedback about the KPC data and the draft KPC survey report were provided by World Renew and the lead final evaluator via email/phone calls and were discussed with the OR team at ICDDR,B on August 7, 2014 during the FE visit at which time concerns discussed included the FE finding that SUSOMA partner staff reported irregularities in the KPC data collection processes in both Kendua and Durgapur, such as erratic data collector work behavior and community member complains. ICDDR,B reported that in endline data cleaning made it necessary to re-interview a substantial number of households, which they were doing at that time. Dialogue with Dr. Emdad continued until the final updated KPC reports for baseline and endline including cost and wealth quintile data and the final complete baseline and endline indicator data was received until October 30. The final KPC report was of adequate quality to utilize in writing the final report with one exception: There were no statistical comparisons of differences between groups from baseline to endline and between intervention and controls. The endline CIs in the not-yet-finalized August 12 data were all that has been shared with World Renew, despite ongoing requests via email for statistical comparisons between baseline and end line for key summary variables and statistical comparisons of the change over time between intervention and comparison groups. All data comparisons in the Final KPC Report are observational only with the exception of computed rich to poor ratios for the wealth quintile data. There is some concern about he appropriateness of the comparison group selection. ICDDR,B states that they selected the KPC survey comparison upazilas in Netrokona because they had “usual GOB services.” However, during the life of the SUSOMA project, unacknowledged donor health projects were happening in the comparison areas. PARI was conducting a large maternal newborn health project (EDM Switzerland funded) in four unions in Kalmakanda upazila and was working with the PI system in Barhatta in integrated programming. These activities in the comparison upazilas have the potential to confound estimation of SUSOMA program effects and need to be deliberated upon in comparing intervention and comparison group outcomes. 2. The Operations Research Study report was received in draft form from ICDDR,B on July 24, 2014. Extensive feedback was given to ICDDR,B on the draft report by World Renew, USAID/Evidence Project and the lead evaluator via email, phone call, and a July 30 conference call. As part of the final evaluation, the Dr. Kreulen, Ms. Nancy TenBroek, and Dr. Alan Talens met with Dr. Shams, Dr. Emdad and the OR team at ICDDR,B on August 7 to further discuss and come to resolution of issues related to the OR study (including the KPC). The issues discussed included data quality, sampling, analysis, and the structure of the report. On August 28, 2014 a ‘revised OR report’ was received with improvements; however, multiple concerns persisted that limited interpretation of the report data. These were communicated with Dr. Emdad who sent the Final OR Qualitative and Social Capital Study Report on November 3, 2014. This report is in XIXe. The Final OR Qualitative and Social Capital Study Report was of adequate quality to utilize in writing the FE report, however, because it did not follow the USAID/Evidence Project OR Report guidance World Renew requested an additional summary report be written that brought together all aspects of the operations research study. The draft OR Final Summary Report was received from ICDDR,B on November 21. World Renew finalized this report and it is in annex XV. Concerns communicated with Dr. Emdad on the August 28 version of the revised OR report which persist into the Final OR Qualitative and Social Capital Study Report include: a. Some remaining lack of clarity in the description of sampling for the qualitative process evaluation, related to: 1) the inclusion criteria for in-depth interviews are not listed (p13), 2) the manner of selection of focus group discussion and social mapping participants is not described (p13), 3) lack of an explanation for the number of informants selected for purposive qualitative sampling or if the numbers listed are for baseline or endline/actual or real (p13), 4) how focus group and social mapping/organizational profiling participants were selected (p 13-14). b. In addition, there is confusion related to sampling that makes it difficult to understand the data presented. The table listing informant numbers for the qualitative sampling (pg13) has both PI group members and non-members for in￾depth interviews (IDI) and focus group discussions (FGD), while the narrative following report data from PI group members. c. Guidelines for informants, which must be the baseline survey tools in the annex, are included without indication if the same measurement tools were used for endline. d. The social capital findings were not updated. • Sampling for social capital measurement includes both group members and non￾members. Because the descriptive findings presented do not differentiate between members and non-members and one half of those interviewed were non-members, the influence of the PI model on components of social capital that are described may be masked. • Construction of an 18-item social capital scale at baseline and a 35-item scale at endline from the social capital data using reliability analysis to maximize Cronbach’s Alpha at each period individually prevents direct comparison of baseline and endline scores. The report appropriately separates the association between level of social capital and PI group membership status at baseline. Theory-based scale construction and/or factor analysis may be a more appropriate approach to scale construction. SUMMARY OF DATA PROCESSED BY EVALUATION TEAM A. Accomplishments 1. Well-established 3-tiered PI system (PI,CCC,PG) a) Trained skilled PI leaders and members. (1) Women’s leadership has increased b) At least 1 primary group functioning in every village in each upazilla, 22CCCs, 4 PIs c) Emergency Health Fund****(for poor people) and transportation*. EHF established which is managed, raised and used by PI for emergency MNCH needs in community. d) Health savings--IGA, GO resource utilization e) Increased awareness** and motivation* through local volunteers (CHV, TTBA) H2H visits and TfD drama team performances * (1) Increased demand for/utilization of services (2) Awareness/involvement of mothers-in-law, husbands and cooperating to promote facility-based deliveries (3) Superstition regarding MNC has decreased (4) Skilled community advocate (CHV) f) PI-CHV-TTBA-VD collaboration for MNCH g) CHVs/TTBAs* are established in the community as volunteers with PI supervision and provision of mobile phones for better communication h) Capacity building starting with PG (1) Ability to solve problems (2) Unity--Groups working together for MNC (3) People claim their rights (4) Empowerment of women, evolving inclusion of men (5) PIs beginning to form primary groups on their own i) Capacity measurement and monitoring 2. PPP established at the community level a) Engagement of all community working together (1) all aware of MNH issues and confident in communicating goals with GO health facilities and officials (2) Local elites, chairman and members support PI initiatives. Used influencing groups (chairmen, members, elite) to develop relationships with GO b) MOUs between PI and GO c) GO-PI linkage and collaboration: (1) CHV-TTBA-GOHW meeting and working together in facilities**--improved communication and relationships, good networking for NID and satellite clinics, share information and update eachother -Network developed between PI and CC, RD, FWC, GBC & DSK facilities for accessing their health services. -Community people now know what services are available in HFs so that GO staff bound to provide services -PI is doing Govt’s staffs’ duties, so they provide QOC services because people now know about quality services -PI has good network/relation with higher Govt’s officials which creates fear among union/village level staffs (2) Local data management/matching meetings established to get complete HMIS data (3) UTAC meetings where PI share progress with MNCH, inform GO officials of needs, influence strategies to meet gaps, coordinate. (4) GO officials recognizing effort of CHVs/TTBAs and PI. (5) CC mgmt/support team participation by PI, CCC, PG. d) Referral system (slip) well established and used by CHVs TTBAs** (communication slip/cell phone). e) Improved quality health services being provided (1) Training for GOB on ANC/PNC by LAMB, IMCI training (2) Increased availability of GO resources and services. (3) Matching meetings & microplanning meetings enhance quality of services and availability of supplies/drugs. CHVs listed names of pregnant mothers by walking on foot through the village and shared with HF providers to get quality services. (4) Logistical support provided to CCs (delivery kit, delivery bed, weighing scales, BP cuffs, etc) (5) Referrals and check-ups at facilities have improved. (6) PI working with all health facilities, involved in management of 23 model clinics (~1/3rd) (7) Community clinics are open/providing services-100% (95% functioning well) -- 60 clinics total 3. Training TOT design**: CHTs trained PIs in leadership, management, record keeping, register, gender, local resource mobilization, M&E, sustainability, PICI, audit, CCI, networking, advocacy: a) GO HW; H&FP workers b) TTBAs, CHV: Maternal care, ANC/PNC, community development, Sustainable development, Exchange visit to successful PIs, Attend, PI management, referral system etc. c) VD d) Primary groups, CCCs, PIs e) SATHI AND PARI staff f) TOT with Joyramkura 4. Increased health practices a) Knowledge of danger signs, health services, 4ANC+ b) Birth preparedness c) ANC/PNC increased* with better follow-up on care d) More skilled and facility-based deliveries (CHVs/TTBAs contact CSBAs (FWA, FWV, HA) for delivery e) Reduced use of traditional healers B. Challenges Encountered/Overcome 1. Health Facility Infrastructure a) Not enough workers (improving) b) Frequent transfer of GO officials and workers c) Institutional delivery not readily available throughout Upazilla d) Lack of supplies/services at baseline—improved by endline e) Disturbed communication between CC mgmt and CC support group. 2. **Religious, poverty, and gender barriers a) Overcome as PG members meet with religious leaders/IMAMs to explain MNCH goals. Need to maintain ongoing linkages. b) Difficult including men in the program, however, males are essential for decision making at family and community level. Eventually they supported the women, even carrying PM/newborn to health facilities in emergency. c) Poor were the focus of and benefitted the most from the intervention in terms of savings, health and service knowledge and practices, EHFs, skills in leadership, development of common platform for MNC and grassroots helping mentality. 3. PI system a) Initial challenges when setting up PGs (1) Illiterate TTBAs (2) Initial community acceptance of CHV/TTBA roles (3) Participation by influentials (4) Engagement of rich and poor (5) Men and women working together (6) Not valued by GO*-improving (7) Resistance from communities and families and husbands*--Not allowing women to do work as CHV/TTBA, should stay at home, MNCH messaging-overcome by H2H b) Only womens’ groups formed initially, began men’s groups in last 2 years. In Y4 formed men’s primary groups, initiating programs with fathers-in-law, husbands, and male health workers. 4. Access to quality services a) Women engaging in potentially harmful practices (1) Superstition-based care decisions (2) Home delivery by unskilled TBA (3) Going to uninformed VD or traditional healers for care b) ANC in facilities was difficult initially. Now it is more readily available from qualified staff at the CC and FWC levels c) Transport of pregnant mother to facilities—problem overcome with establishment of EHF and EmTransport systems d) PNC services available but not adequately promoted--slow increase in PNC e) Access limited by poor roads/rivers/community infrastructure 5. Staff issues a) Maintaining the following reports/ documents C. Sustainability 1. Sustainability of PI model a) PI’s forming own groups, including men’s groups b) Strong skilled PI leaders, CHVs, TTBAs c) EHFs and Health Savings Accounts for IGA established d) PI have bylaws, bank accounts, plans, self-monitoring of capacity. They are capable of planning, budgeting, microplanning, and conducting the PICI sessions. e) PI has established skills in the 6 PICI capacity areas and self-monitor. f) Partnership with GO well established (PPP) (1) PI-HF MOUs with health facilities. There is acceptance of the PI in the community and at the facility level. (2) Networking, coordination, support and advocacy channels established (3) Referral system established and strengthened with women and babies now getting better treatment by referral (4) Coordination/matching meetings occur monthly (5) Community members 100% part of management committees and decision-making group supporting community clinics 23/60 model clinics, total # PI members on clinic committees = 190 (6) DDFP linking CHVs and TTBAs with FP work and planning to provide training to them g) PIs officially registered with GOB social welfare dept h) Social capital of PI members is enriched and culture of servant leadership of their communities established i) Local resources are being mobilized for health service improvements (need examples) j) PIs are supervising CHV/ TTBA and conducting trainings k) CHV/TTBA work as volunteers for their community will continue household visits, MNC lessons to primary groups, meeting with health workers, linkage with health facilities, referrals. They report needing basic supplies and continued training and relationships with HF and gov’t. l) PI is capable of supervising the CHVs, making lists of health lessons for them to share with the community, and also in arranging training for new or replacement CHVs m) PIs equipped to conduct trainings for new primary groups, CHVs, TTBAs, and to link with other NGOs for support if needed. n) PIs/CHVs/TTBAs will continue sharing good practices and successes. o) Staff relate that most critical to sustaining the PI model are servant leadership, effective networking, financial solvency, and gender equality. 2. Gains in MNCH are expected to continue as PI’s continue to promote healthy mothers and babies at the grassroots level and through PPP and increase SBA deliveries. D. Impact: 1. PI model is a) engaging the entire community b) foundational to improving social capital c) creating a cadre of new grassroots leaders d) empowering women socioeconomically, decision-making leadership capacities e) active in promotion of gender-based leadership (men’s groups formed and forming) f) leading to commitment to MNCH by all in a strong PPP g) increasing communication and networking between GO and PI both horizontally and vertically h) increasing access to GO and private sector health and social services (other NGO’s like JTS, DSK, GBC) i) leading to the practice of good MNC health habits j) bringing hope and health care to the marginalized poor. Everyone at PI/CC/PG seems happy face! k) Once licensed can take loan from social welfare dept, get ards for widows & vulnerable groups. 2. PI model is associated with health improvements in communities a) Decreased maternal newborn deaths b) Increased MCH service utilization and coverage c) Increased institutional / skilled delivery (decreased unskilled home births) d) Improved practice of good health habits by pregnant women and mothers 3. DDFP recognizes the important role CHVs and TTBAs have in promoting MNCH ANNEX X. DATA COLLECTION INSTRUMENTS 1. KPC survey instruments from endline are in Annex Xa. The baseline survey was not made available. 2. Operations Research Survey Tools are in annex Xb. The same tools were used at both baseline and endline. 3. RHFA instrumentation is described in the RHFA report in Annex Xc. 4. CSSA component items are listed in the CSSA dashboard document Annex XIXb. 5. Stakeholder Interview Questionnaires are described below. Stakeholder Interview Questionnaires In depth qualitative interviews were conducted with SUSOMA stakeholders as part of the evaluation process to gain a greater understanding of the how and why of project accomplishments and challenges. Stakeholders interviewed included 1) government officials, 2) SUSOMA and NGO staff, 3) government health providers, CHVs, TTBAs, and ISPs/village doctors, 4) PI groups (PI, CCC, PGs), 5) beneficiaries (mothers, husbands, in-laws), 6) training institutions. Interview questionnaires targeted for each of the six stakeholder groups were derived from the final evaluation questions that were categorized using the A-C-S-I mnemonic: • Accomplishments: What results were achieved? How did interventions contribute to results? • Challenges & Inputs: What factors contributed/detracted from to critical results and why? • Sustainability: What strategies can be sustained, scaled-up, shared globally? • Impact: What evidence links project results with the PI model? As part of the interviews, observations were made of FWCs, CCs, CC Management Committees, and PI group meetinghouses. A. Questionnaire for Government officials               Accomplishments 1. To what extent has the SUSOMA project helped you to accomplish district/sub-district targets related to MNCH? How effective is the support provided by this project? 2. To what extent and in what ways have the local NGO’s (Sathi and Pari) engaged communities to strengthen private/public partnership in support of MNCH? What collaborations have occurred that were not there before the project? 3. In what ways has the project helped to engage and build capacity of local communities for health? 3. To what extend and in what ways has SUSOMA enhanced community health system quality? Especially in the following areas: • In improving the village level health services • In reducing the harmful practices of the informal health systems • In establishing referral process for mothers and sick newborns effective? Challenges and Inputs 4. In what ways did the project unify the socially and economically underprivileged? Who benefited individuals/groups? 5. To what extent were females and males appropriately engaged in the PI model strategy? 6. What community linkages and structures were established that contributed to improved MNCH outcomes? 7. What SUSOMA strategies are most effective? In what ways they are effective? 8. What challenges and barriers did you face in working with SUSOMA? How they were overcome? Sustainability 9. What elements of SUSOMA do you plan to continue? How will you do it? 10. What steps are you taking to sustain MNCH and service improvements? Impact 11. What do you see as the biggest impact of the SUSOMA project on MNCH? What SUSOMA intervention is most linked to the improved MNCH outcomes? 12. What evidence links results to the PI model? B. Questionnaire for SUSOMA and NGO staff               Achievements 1. What were the three top ways you engaged a community to strengthen private/public partnerships for health? a. How were public-private collaboration and feedback mechanisms established? b. What training and capacity building was essential to successful PI mobilization? c. In what ways were resources for EHF and local capacity for facility service & policy advocacy established? d. In what ways and how did community capacity for management of health and health systems increase? 2. To what extent has SUSOMA improved practices and access to services for the marginalized mothers and newborns? a. What strategies led to increased maternal MNCH knowledge and practices? b. What strategies led to increased coverage and utilization of ANC, assisted delivery and post partum care? c. In what ways did engaging the informal health system reduce harmful practices? 3. What made the referral process for mothers and sick newborns effective? 4. In what ways was the capacity of MOHFW enhanced and structures established to ensure ongoing QOC? Challenges & Inputs 5. To what extent were females and males appropriately engaged in the PI model strategy? 6. In what ways did the project unify the socially and economically underprivileged? Who benefited the most? 7. How did it create opportunities and resources for MNCH not usually available to these individuals / groups? 8. Did you find the monthly monitoring system helpful and how? 9. What specific strategies were the most effective? In what ways were they effective? 10. What challenges and barriers were faced in carrying out this project? Sustainability 11. What elements of SUSOMA are most likely to be sustained after the current program ends and why? 12. What is most critical to sustaining the PI model innovation? 13. What exit strategies are in place to maximize the likelihood that the outcomes will be sustained? 14. If you had one thing to share that you think is a best practice, what is it? Impact 15. What SUSOMA intervention do you think is most linked to improved health outcomes? C. Questionnaire for GOB Health Workers (FWV, CSBA, CHCP), CHWs (TTBA, CHV), ISPs (VD)               Accomplishments 1. Did you receive any training from SATHI and PARI in providing and supporting MNCH services? What are those training? How helpful were these trainings? 2. What do you think how PI is playing its role in providing and supporting MNCH services? 3. Which MNCH practices are improved due to SUSOMA interventions? and How? 4. To what extent was SUSOMA able to make these services available to the people and their families? 5. In what ways or to what extent has SUSOMA improved the quality of the health services? How? Challenges and Inputs 6. What challenges did you face implementing the project and achieving results and how did you overcome those challenges? Sustainability 7. How will the MNCH activities continue so that people continue to receive these services when this current program ends? 8. Which of your activities will be sustained when the current program will end? 9. What resources are essential for the sustainability of your activities or for your to continue doing this work? Impact 10. What do you know about the PIs involvement with the MNCH services? What has been effective? D. Questionnaire for PI, CCC and PGs               Accomplishments 1. What kind of support did Pari/Sathi extend to PIs to engage communities in strengthening partnership/good relationship with government health and family planning departments in support of MNCH? 2. How did community people engage in achieving good results of maternal newborn health (MNH) using PI model? 3. How did SUSOMA contribute to make community people aware of practicing good habits related to MNH and access to available services equally? 4. Please tell us to what extent and how the SUSOMA project support you to develop quality in community health system? Challenges and Inputs 5. How did socio-economic condition and gender affect implementation and achieving results of SUSOMA project? 6. What kind of community partners and structures are most important to improve MNH? 7. Which strategies are most effective and why do those most effective? 8. What kind of challenges and barriers did your group face in doing mother and child work and how did it overcome them? 9. Of the HMIS data are you collecting, which of it is the most helpful? Why? Sustainability 10. Upon completion of the SUSOMA project what elements or learning of the project will be most likely be ongoing or continued? 11. For the PI to expand or scale-up their work, what resources or training do you need? Impact 12. How has your PI helped your community? Tell us stories of your success. E. Questionnaire for Beneficiaries               Accomplishments 1. In your area who are working for maternal and newborn issue? Please explain what they are doing? 2. Do you have any group or Peoples Institution in your area? What they are doing? Do you have any relationship with them? Pls explain. 3. Do you know any TTBAs and CHVs? What they are doing in your area? What are the changes happened in your area as a result of their intervention? Have you received any support from any CHV/TTBA? 4. What are the maternal and newborn health knowledge you are practicing as a result of the health education you have received? 5. Have you received any consultation from any CHV/TTBA for receiving any health treatment? Where you usually go for receiving health service? Do you think currently the health facilities improved in the last five yeas on maternal and newborn issues? Pls share in which areas? 6. Do you know about emergency health fund? Have you contributed or received any support from the EHF? How it benefited you and do you think it is helpful for the community? Challenges & Input: 7. What challenges are you currently getting for receiving maternal and newborn health services from the health facilities? How you overcome the situation? who is helping you? 8. Do you think poor people from our community are receiving same type of health services? What type of health services they are getting and why? Sustainability 9. What are the changes happening n your community as a result of the involvement of the Peoples Institutions and CHVs and TTBAs? Impact 10. What type of changes will continue in maternal and newborn health if the PI and the CHVs/ TTBAs continue their activities in the community? F. Questions for Training Institutions               Accomplishments/Challenges 1. How did working with the SUSOMA project change you as an organization for training? 2. What is unique about the SUSOMA approach to training? 3. What suggestions do you have for improvement of the SUSOMA training approach? a. SUSOMA used direct training via LAMB and indirect training through Joyramkura. What do you see as the advantages / disadvantages of these approaches? Sustainability 4. What suggestions do you have for community ownership of training? Impact 5. What improvements have you made to your training have by made based on your SUSOMA experience? 1 1.1 HOUSEHOLD QUESTIONNAIRE Improving maternal, newborn, and child health through building public-private partnerships (SUSOMA) Baseline Survey for Social Capital Measurement 2012 Household Questionnaire World Renew icddr,b IMCI section of DGHS USAID 2 Lvbvi cÖkœcÎ (Household Questionnaire) mv¶vrKvi ïiæi mgq (start time of interview) N›Uv wgwbU mv¶vrKvi ‡kl nevi mgq (end time of interview) N›Uv wgwbU 1. wba©vwiZ Lvbv mbv³Kib (identification of household) 1.1. ‡Rjv (district) ..................................... 1.2. mve-‡Rjv/Dc‡Rjv (sub-district/ Upazila) ..................................... 1.3. BEwbqb: (Union) ..................................... 1.4. kni/MÖvg (city/ village) ..................................... 1.5. IqvW© (Ward) ..................................... 1.6. cvov/gnjøv (para/ moholla) ..................................... 1.7. iv¯Ív (road) ..................................... 1.8. Lvbv bv¤^vi (Household number) ..................................... 1.9 Ab¨vb¨ we¯ÍvwiZ (Others ) ..................................... 2.0. GjvKvi aib (type of the area) kni (Urban) MÖvg(Avw`evmx bq) (village/ not indigenous) Avw`evmx (indigenous) cÖZ¨šÍ AÂj (remote) mvÿvrMÖnbKvixi bvg (Interviewer) ..................................... mycvifvBRvi bvg (Supervisor) ..................................... 3 NO. QUESTIONS CODING CATEGORIES SKIP 2. evwoi ‰ewkó¨ HOUSING CHARACTERISTICS AND HOUSEHOLD ROSTER 2.1 evwoi aib(ïaygvÎ †`‡L) Type of house (observation only) GKK evwo .......................................... Individual house 1 Avw½bv mn A¯nvqx Qv`(wUb,Li)............... Open roof and patio 2 A¨vcvU©‡g›U……………………………. Apartment 3 eo evwoi GKwU iæg…………………… Room within a larger house 4 Ab¨vb¨(D‡jøL Kiæb)………..………….. Other (specify) 2.2 wbgv©b DcKib: Ni ev fe‡bi evwn‡ii †`hvj¸‡jvi Rb¨ mvavibZ wK e¨envi nq ? What construction material is used for the majority of the exterior walls of the house or building? BU/cv_i/KswK&ªU/wm‡g›U…...…. Brick/stone/concrete/cement 1 KvV…………………………………… Wood 2 wUb…………………………………… Tin 3 ‡eZ/Lo/cvUKvwV/evku……………………. Cane/straw/sticks 4 cwjw_b ……………………………… Polythene 5 ‡`qvj bvB……………………………… No walls 6 4 NO. QUESTIONS CODING CATEGORIES SKIP 2. evwoi ‰ewkó¨ HOUSING CHARACTERISTICS AND HOUSEHOLD ROSTER Ab¨vb¨(D‡jøL Kiyb) …………………….. Other (specify) 2.3 evwoi Qv‡`i DcKib wK ? What is the construction material of most of the roof of this house? KswK&ªU/wm‡g›U…………………………… Concrete/cement 1 UvBjm…………………………………. Tiles 2 avZz(`¯Ív/A¨vjgywbqvg/wUb/Ab¨vb¨)………….. Metal (zinc, aluminum, tin, etc.) 3 KvV……………………………………. Wood 4 Lo ev ZvjcvZv………………………….. Straw or thatch 5 Ab¨vb¨(D‡jøL Kiyb) …………………….. Other (specify) 2.4 evwoi †g‡Si DcKib wK ? What is the construction material of most of the floor of this house? KswK&ªU/wm‡g›U………………………….. Concrete/cement 1 UvBjm/&BU/MÖvbv&BU ……………………… Tiles, brick, granite 2 KvV ……………………………………… Wood 3 ‡iw·b g¨vU…………………………… Vinyl 4 5 NO. QUESTIONS CODING CATEGORIES SKIP 2. evwoi ‰ewkó¨ HOUSING CHARACTERISTICS AND HOUSEHOLD ROSTER gvwU/evwj…………………………….. Earth, sand 5 ‡eZ…………………………………. Cane 6 Ab¨vb¨(D‡jøL Kiyb) …………………... Other (specify) 2.5 GB evwoi KqwU iyg ïaygvÎ Nygv‡bvi Rb¨ e¨envi nq ? How many rooms are used by this household for sleeping only ............................................................wU 2.6 GB evwo‡Z †Kvb ai‡bi cvqLvbv e¨envi nq ? What type of sanitary services does this household use? cqwb®‹vkb e¨e¯nvi mv‡_ hy³……………… Connected to sewage system 1 ‡mcwUK U¨vswKi mv‡_ hy³…………………. Connected to septic tank 2 ‡jwUªb(¯øve) …………………………….. Latrine 3 bvB…………………………………….. None 4 Ab¨vb¨(D‡jøL Kiyb) …………………….. Other (specify) 2.7 mvcøv&B cvwb……………………………… Piped water system 1 wbR¯^ Kzqv ……………………………… Private well 2 6 NO. QUESTIONS CODING CATEGORIES SKIP 2. evwoi ‰ewkó¨ HOUSING CHARACTERISTICS AND HOUSEHOLD ROSTER GB evwoi cvwbi cÖv_wgK Drm wK ? What is the primary source of water for this household? miKvwi Kzqv…………………………….. Public well 3 mevi Rb¨ D¤§y³ Kj……………………… Open tap or faucet 4 ‡QvU b`x ev cyKzi………………………… River or stream 5 wUDeI‡qj……………………………… Tube well 6 Ab¨vb¨(D‡jøL Kiyb) ……………………. Other (specify) 2.8 GB evwoi gqjv-AveR©bv ‡Kv_vq ‡djv nq ? How does this household dispose of most of its garbage? miKvwi e¨e¯nvq… …..……………………. Public garbage service A ‡emiKvix e¨e¯nvq……………………… Private garbage service B ‡Lvjv hvqMvq Qz‡o †djv………………….. Throw in vacant lots C b`x/Lv‡j/ cyKz‡i †djv…….……….......… Throw in river/canal/ pond D cywo‡q ev cy‡Z †djv/M‡Z© †djv…………….. Burn and/or bury E Ab¨vb¨(D‡jøL Kiyb) ……………………. Other (specify) 7 NO. QUESTIONS CODING CATEGORIES SKIP 2. evwoi ‰ewkó¨ HOUSING CHARACTERISTICS AND HOUSEHOLD ROSTER 2.9 GB evwo‡Z wK ai‡bi Av‡jv e¨envi K‡i ? What type of lighting does this household use? we`¨yr (miKvix e¨e¯nvq) ………………… Electricity (public source) A we`¨yr (‡e-miKvixe¨e¯nvq) ………………. Electricity (private source) B ïaygvÎ †K‡ivwmb,M¨vm,‡gvgevwZ……………. Only kerosene, gas, candles C Ab¨vb¨(D‡jøL Kiyb) …………………….. Other (specify) 2.10 G&B evwowUi (gvwjKvbvÑ n‡”Q ………… Ownership pattern of this house is…… wbR¯^ gvwjKvbvaxb / cy‡iv `vg w`‡q †Kbv……… Owned (completely paid for) 1 e›&aK †`qv n‡q‡Q………………………… Owned with a mortgage 2 fvov evwo………………………………. Rented 3 ‡mevi webwg‡q †`qv(‡KvqvU©vi G _v‡K) ……… Given in exchange for services 4 `LjK…Z Rwg‡Z evmv…………………….. Squatter 5 Ab¨vb¨(D‡jøL Kiyb) …………………. Other (specify) 8 x wb‡`©kbv: cÖ_‡g Lvbv m`m¨‡`i bvg wj÷ Kiæb Ges cÖkœ wRÁvmv Kiæb 2.12-2.20 | x Lvbv : †hme m`m¨ GKB mv‡_ emevm K‡i , GKB Pzjvi ivbœv Kiv Lvevi Lvq Ges LiP enb K‡i No. 2.11:Lvbvi cÖ‡Z¨K m`m¨‡`i bvg wjLyb (Name of all the members in the household) (cÖ_‡g Lvbv cÖav‡bi bvg) bvg (Name) 2.12:Lvbv cÖav‡bi mv‡_ m¤ú©K wK ? (relationship with the household head) (‡KvW e¨envi Kiæb) (use code) ‡KvW 2.13: wj½ (sex) cyiæl...1 (Male) gwnjv... 2 (female ) 2.14: eqm (age) ermi (years ) 2.15:‰eevwnK Ae¯nv (Marital Status) weewnZ... 1 (Married) wW‡fv©mW&... 2 (divorced) weaev/wecwZœK... 3 (Widow/ widower) wewQbœ…...… 4 (seperated) AweevwnZ...…5 (Bachelor/ single) 2.16:...¯^vgx ev mͪx wK eZ©gv‡b GB Lvbvi m`m¨? hw` n¨v nq,¯^vgx ev mͪxi N‡ii b¤^i wjLyb ,bv n‡j 99wjLyb| Is “_____”’s Spouse currently a member of the household? yes, use number of spouse no, write 99 2.17: ‡ckv (‡KvW e¨envi Kiæb) (Occupat ion) ‡KvW 2.18:eZ©gv‡b PvKzwiiZ (Currently Employed) n¨v......1 (yes) bv..... 2 (no) 2.19: wkÿv (educ ation) (‡KvW e¨envi Kiæb) 2.20:KZw`b a‡i GB GjvKvq _v‡Kb (How long have you lived in this community ) ermi (years) 2.21: GLv‡b Avmvi Av‡M Avcwb †Kv_vq wQ‡jb? ‡Rjvi bvg wjLyb| (where have you been before you came here? Wtite down the name the district.) 1 2 3 4 5 6 9 7 8 9 10 11 12 13 14 15 16 10 2.12 Gi Rb¨ †KvW 2.17Gi Rb¨ †KvW 2.19 Gi Rb¨ †KvW Lvbv cÖavb ........ ... ... ... ... 01 (Household Head) PvPv/PvPx-gvgv/gvgv/gvgx..........14 (uncle/aunt) K…lK....... ..... ..... ..... .....1 (farmer) ¯^vÿiÁvbnxb/ ¯‹z‡j hvqwb..........1 (Illiterate, no schooling) ¯^vgx/¯¿x............. ... ... ... ...02 (Husband/wife) KvwRb ................. ... ... .... 15 (cousin) ‡R‡j......... ..... ..... .......2 (fisherman) ¯^vÿiÁvb m¤úbœ/ ¯‹z‡j hvqwb......2 (Literate, no schooling) ‡Q‡j/‡g‡q.......... ... ... ... .. 03 (daughter/son) Ab¨vb¨ AvZ¥xq....... ... ... ..... 16 (other relatives) e¨emvqx...... ..... ..... .......3 (business) cÖvBgvix Am¤ú~b©.....................3 (Primary incomplete) evev/gv ............. ... ... ... .. 04 (father/mother) Ab¨ evwoi wkï... ... ... ... .....17 (child from another home) Drcv`K: (producer) cÖvBgvix m¤ú~b©....................4 (Primary complete) fvB/‡evb........... ... ... ... ...05 (siblings) fvovwUqv......... ... ... ...... …18 (tenant) KvwiMi...... ..... ..... .......4 (technician) gva¨wgK Am¤ú~b©....................5 (Secondary incomplete) mr †Q‡j/mr †g‡q.. ... ... .. ..06 (step son/daughter) Ab¨vb¨..... ...... ... ............. 19 (other) wkí.......... ..... ..... .......5 (industry) gva¨wgK m¤ú~b©.......................6 (Secondary complete) mr evev/gv ......... ... ... ... 07 (step parents) †emiKvix: (non-GO/ private) KvwiMwi K‡jR...... ..... ..... ....7 (Vocational college) bvZx/bvZœx .......................08 (grand daughter/ grand son) A`ÿ....... ..... ..... ... ....6 (Unskilled) B&Dwbfvwm©wU .......... ..... .........8 (University) `v`v/`v`x-bvbv/bvbx..............09 (grandfather/grandmothe) `ÿ...... ..... ..... ......... ..7 (skilled) Ab¨vb¨ ............ ..... ..... .......9 (others) k¦ïi/kvïox........................10 (monther/father in law) miKvix : (Public) 11 †Q‡ji eD/‡g‡qi RvgvB..........11 (daughter-in-law/ son-in-law) A`ÿ.... ..... ..... ........ ...8 (Unskilled) †`ei/bb`............................12 (brother/sister-in-law) `ÿ......... . ...... ..... ......9 (Skilled) fvwZRv/fvwZwR-fvM‡b/fvMwb ...13 (nephew/niece) Ab¨vb¨...........................10 (others) 12 3. ‡R‡bvMÖvg Instruction: Try to understand: 1. Does the informant live in the same household with his/her parents? 2. How many siblings does the informant have? Are they living in the same household with the informant or in other areas? Who else is living with them? Who is living with whom? 3. Is there anyone living with them as a member of the household but not a kin? 4. Are all of them alive? 5. What type of relationship is present there? Married? Divorced? Married for more than once? wb‡`©wkKv: eyS‡Z †Póv Kiæb: 1. Z_¨`vZv wK Zvi evev-gvÕi mv‡_ GKB Lvbvq _v‡Kb? 2. Z_¨`vZvÕi KqRb fvB-‡evb Av‡Qb? Zviv wK Z_¨`vZvÕi mv‡_ GKB Lvbvq _v‡Kb ev Ab¨‡Kv_vI _v‡Kb? Ab¨ †K †K Zv‡`i mv‡_ _v‡Kb? †K Kvi mv‡_ _v‡Kb? 3. Ggb †KD wK Av‡Qb whwb GKB Lvbvq _v‡Kb wKš‘ cwiev‡ii m`m¨ bb? 4. mevB wK RxweZ? 5. wK ai‡bi m¤úK© Av‡Q mevi g‡a¨? weevwnZ? ZvjvKcÖvß? GKvwaKevi we‡q K‡i‡Qb Ggb? 13 †R‡bvMÖv‡gi cÖwZK cyi“l(male) cyiyl Z_¨`vZv (male informant) g„Z cyiyl(deceased male) gwnjv (female) gwnjv Z_¨`vZv (male informant) g„Z gwnjv (deceased male) AvBbMZ weevn b.19----R¯§ ZvwiL(date of birth) ZvjvK cÖvß d.19--- g„Z¨y ZvwiL (date of death) Z_¨`vZvi evwo‡Z emevmiZ †jvKRb Z_¨`vZvi evwoi evB‡i emevmiZ Z_¨`vZvi AvZ¥xq GB D`vniYwU Ggb GKRb ZvjvKcÖvß f`ªgwnjvÕi Ae¯’v †`Lvq, hvi Lvbvq wZbRb †Q‡j‡g‡q I GKRb bvZwb Av‡Q| GKB Lvbvq Zvi gv (whwb ¯^vgxi g„Zy¨i ci Avevi we‡q K‡i‡Qb), mrevev, mr‡evb I Zvi fvwMœ _v‡Kb| Av‡iK mr‡evb wKQzw`b Av‡M gviv †M‡Qb| Z_¨`vZvi Av‡Mi ¯^vgx Av‡iKwU RvqMvq _v‡Kb| H ¯^vgxi evox‡Z Zvi ¯¿x, †Q‡j, I Z_¨`vZvi fv†Mœ _v‡Kb| Z_¨`vZvi fvB, Zvi ¯¿x, `yB †Q‡j I i‡³i m¤úK© †bB Ggb GKwU †g‡q _v‡K| This example represents the situation of a divorced woman whose household includes her three children and granddaughter. In a household within the same community live her mother (a remarried widow); her step father, her half-sister; and her niece. Another half-sister died some time ago. The respondent’s former husband resides in another community. His household consists of his wife, their son, and the respondent’s nephew. The respondent’s brother lives with his wife two sons and child, a girl, who is not a blood relation. 14 Please, draw and describe it here. (GLv‡b Gu‡K †R‡bvMÖvg AvKyb I eY©bv Kiæb|) 15 NO. QUESTIONS CODING CATEGORIES SKIP 4. STRUCTURAL SOCIAL CAPITAL Now I would like to ask you some questions about how you feel about this village/neighborhood, and how you take part in the community activities. By community, I mean __________ [insert consensus definition from community profile]. 4.A. Organizational Density and Characteristics 4A.1 Avcwb ev Avcbvi evoxi †KD wK †Kv‡bv msMV‡bi ev Mªy‡ci m`m¨? Are you or is someone in your household a member of any groups or organizations? nu¨v .................... .................... (yes) 1 bv.................... .................... (No ) 2 4A.2 Avcwb ev Avcbvi evoxi †KD wK Gme msMV‡bi ev Mªy‡ci mwμq m`m¨? Do you consider yourself/household member to be active in the group? ‡bZv .................... .................... (Leader ) 1 Lye mwμq .................... .................... (Very Active) 2 Kg mwμq.................... .................... (Somewhat Active) 3 mwμq bq.................... .................... (Not active ) 4 4A.3 GB `j¸‡jvi g‡a¨ †KvbwU Avcbvi Lvbvq me‡P‡q ¸iæZ¡c~Y©? bvg I aiY wjLyb| (Which of these groups is the most important to your household? Write down the Name and type) `j 1 (Group 1):...................... `j 2( Group 2): ..................... `j 3 (Group 3): ..................... 4A.4 GB wZbwU wfbœ ai‡bi `‡ji m`m¨iv wK GKB †jvK? (Are the same people members of these three different groups? ) Kg wgj ............................ (Little overlap) 1 wKQz wgj............................ (Some overlap) 2 16 NO. QUESTIONS CODING CATEGORIES SKIP 4. STRUCTURAL SOCIAL CAPITAL A‡bK wgj.......................... Much overlap 3 4A.5 `‡ji AwaKvsk m`m¨ wK GKB ewa©Z cwiev‡iiI m`m¨? (Are group members mostly of the same extended family) `j 1 2 3 nu¨v (Yes)…1 bv (No)…..2 4A.6 m`m¨‡`i AwaKvskB wK GKB a‡g©i? (Are members mostly of the same religion?) nu¨v (Yes)…1 bv (No)…..2 4A.7 m`m¨‡`i AwaKvskB wK GKB wj‡½i? (Are members mostly of the same gender?) nu¨v (Yes)…1 bv (No)…..2 4A.8 m`m¨‡`i AwaKvskB wK GKB ivR‰bwZK `„wófw½ ev Zviv wK GKB ivR‰bwZK `j †_‡K G‡m‡Q? (Are members mostly of the same political viewpoint or do they belong to the same political party?) nu¨v (Yes)…1 bv (No)…..2 4A.9 m`m¨‡`i AwaKvskB wK GKB †ckvi? (Do members mostly have the same occupation?) nu¨v (Yes)…1 bv (No)…..2 4A.10 m`m¨‡`i AwaKvskB wK GKB eq‡mi? (Are members mostly from the same age group?) nu¨v (Yes)…1 bv (No)…..2 4A.10 m`m¨‡`i AwaKvskB wK GKB iKg wkwÿZ ? (Are members mostly from the same education level?) nu¨v (Yes)…1 bv (No)…..2 4A.12 1 2 3 17 NO. QUESTIONS CODING CATEGORIES SKIP 4. STRUCTURAL SOCIAL CAPITAL `j mPivPi wKfv‡e wm×všZ †bq? (How does the group usually make decisions?) ‡bZv wm×všZ †bq Ges Ab¨vb¨‡`i Rvbvq (The leader decides and informs the other group members ) 1 `‡ji m`m¨iv wK fve‡Q Zv †bZv wR‡Ám K‡i Ges Zvici wm×všZ †bq (The leader asks group members what they think and then decides ) 2 `‡ji m`m¨iv Av‡jvPbv K‡i Ges GK‡Î wm×všZ †bq (The group members hold a discussion and decide together) 3 Ab¨vb¨ (D‡jøL Kiæb) Other (specify) 4 4A.13 me©cwi,`‡ji †bZ…Z¡ KZUv Kvh©Kix? (Overall, how effective is the group’s leadership?) nu¨v (Yes) 1 bv (No) 2 18 4B.Networks and Mutual Support Organizations GLb Avwg Avcbv‡K Kwg&DwbwUi Kvh©μg I mgm¨vmg~n wb‡q wKQz cÖkœ wR‡Ám Kie. (Now I would like to ask you some questions about community functions and dealing with problems.) 19 Questions Coding Categories Skip 4B.1 hw` GB MÖvg/cvovi cÖvBgvix ¯‹zj A‡bK mgq a‡i wk¶K Qvov PjZ ,aiæb Qq gvm ev Zvi ‡ekx,ZLb Avcbvi g‡Z GB MÖvg/cvovi Kviv G‡¶‡Î GKwÎZ n‡q c`‡¶c wb‡Zb? (If the primary school of this village/neighborhood went without a teacher for a long time, say six months or more, which people in this village/neighborhood do you think would get together to take some action about) (if yes go question 4B.3) nu¨v Yes bv No MÖv‡gi/cÖwZ‡ekx‡`i †KDB GKwÎZ n‡Zvbv (No one in the village/neighborhood would get together ) 1 2 ¯’vbxq/‰cŠi miKvi (Local/municipal government) 1 2 MÖvg/cvov mwgwZ (Village/neighborhood association) 1 2 ¯&Kz‡ji wkï‡`i evev-gv (Parents of school children) 1 2 m¤ú~Y© MÖvg/cvov (The entire village/ neighborhood) 1 2 Ab¨vb¨(D‡jL Kiæb) Other (specify) 20 Questions Coding Categories Skip 4B.2 †K &D‡`¨vM wb‡Zb(‡bZvi f~wgKvq) {Who would take the initiative (act as leader)?} …………………………………………………………. 4B.2 ‡mLv‡b GKwU mgm¨v n‡jv hv m¤ú~Y© MÖvg/cvov‡K ¶wZMÖ¯Z Kij,D`vniYmiƒc(MÖv‡g:km¨ bó nIqv;kn‡i:wbh©vZb),G&B Ae¯’v‡K Avq‡Z¡ Avbvi Rb¨ Kviv GKwÎZ n‡q KvR KiZ e‡j Avcwb g‡b K‡ib? (If there were a problem that affected the entire village/neighborhood, for instance(RURAL: “crop disease”; URBAN: “violence”), who do you think would work together to deal with the situation?) (if yes, go to section 4C) nu¨v Yes bv No cÖ‡Z¨K e¨w³/Lvbv wK mZš¿fv‡e mgm¨v wb‡q KvR KiZ (Each person/household would deal with the problem individually) 1 2 cÖwZ‡ekxiv wb‡RivB Neighbors among themselves 1 2 ¯’vbxq miKvi/‡cŠi ivR‰bwZK †bZv Local government/municipal political leaders 1 2 21 Questions Coding Categories Skip mKj KwgDwbwU †bZv GK‡Î KvR KiZ All community leaders acting together 1 2 m¤ú~Y© MÖvg/cvov The entire village/ neighborhood 1 2 Ab¨vb¨(D‡jL Kiæb) Other differences (specify) 4B.4 †K D‡`¨vM wb‡Zb ? (‡bZvi f~wgKvq) (Who would take the initiative (act as leader?) .................................. 22 Questions Coding Categories Skip 4C.1 GKB MÖvg/cvovq emevmiZ e¨w³‡`i g‡a¨ cv_©K¨ _v‡K| wb‡¤œi †Kvb †Kvb †¶‡Îi cv_©K¨ Avcbvi MÖvg/cvovi †jvKRb‡K wef³ K‡i‡Q? (Differences often exist between people living in the same Village/ neighborhood. To what extent do differences such as the following tend to divide people in your village/neighborhood?) Not at all Somewhat Very Much wk¶v (Education ) 1 2 3 m¤ú`v (Wealth/ material possessions) 1 2 3 Rwg gvwjKvbv (Landholdings) 1 2 3 mvgvwRK Ae¯’vb (Social status) 1 2 3 bvix-cyiæ‡l wewfbœZv (Differences between men and women) 1 2 3 cÖR‡b¥i wewfbœZv (Differences between younger and older generations) 1 2 3 23 Questions Coding Categories Skip `xN©‡gqv`x I bZzb Awaevmx‡`i g‡a¨ wewfbœZv (Difference between long-time inhabitants and new settlers) 1 2 3 ivR‰bwZK `j (Political party affiliations) 1 2 3 ag©xq wek¦vm (Religious beliefs) 1 2 3 RvwZMZ cUf~wg (Ethnic background) Ab¨vb¨ (D‡jøL Kiyb) Others (specify) 1 2 3 4C.2 GB wewfbœZv¸‡jv wK †Kvb mgm¨v ‰Zix K‡i? (Do these differences cause problems?) n¨v......................... Yes 1 (go to question 4C.5) bv ........................... No 2 4C.3 A GB mgm¨v¸‡jv mvaviYZ wKfv‡e mvgjv‡bv nq? How are these problems usually handled? nu¨v Yes bv No †jvKRb wb‡RivB wVB K‡i People work it out between themselves 1 2 24 Questions Coding Categories Skip B cwievi/Lvbvi m`m¨iv ga¨¯’Zv K‡i Family/household members intervene 1 2 C cÖwZ‡ekxiv ga¨¯’Zv K‡i Neighbors intervene 1 2 D KwgDwbwU †bZviv ga¨¯’Zv K‡i Community leaders mediate 1 2 E agx©q †bZviv ga¨¯’Zv K‡i Religious leaders mediate 1 2 F wePviK †bZviv ga¨¯’Zv K‡i Judicial leaders mediate 1 2 4C.4 GB mgm¨v¸‡jv wK wbh©vZ‡bi w`‡K avweZ nq? Do such problems ever lead to violence? nu¨v ............ yes 1 bv ............ No 2 4C.5 Ggb †Kvb †mev e¨e¯’v Av‡Q wK ,†hLv‡b Avcwb Avcbvi Lvbvi m`m¨‡`i †mev †bqv gvbv ev mxwgZ my‡hvM i‡q‡Q? (Are there any services where you or members of your household are occasionally denied service or have limited opportunity to use?) nu¨v Yes bv No a wk¶v/¯‹zj (Education/schools) 1 2 25 Questions Coding Categories Skip b ¤^v¯’¨‡mev/wK¬wbK (Health services/clinics) 1 2 C evox evbv‡bv (Housing assistance) 1 2 D PvKzwi cÖwk¶Y/wb‡qvM (Job training/employment) 1 2 e FY (Credit) 1 2 F hvbevnb (Transportation ) 1 2 G cvwb e›Ub (Water distribution) 1 2 H ¯^v¯’¨‡mev e¨e¯’vmg~n (Sanitation services) 1 2 I K…wl (Agricultural extension) 1 2 J b¨vqwePvi/؇›Øi mgvavb (Justice/conflict resolution) 1 2 K wbivcËv/cywjk †mev (Security/police services) 1 2 4C.6 n¨v................... (Yes) 1 26 Questions Coding Categories Skip Avcwb wK g‡b K‡ib †h GB Kwg&DwbwU‡Z Av‡iv Ab¨vb¨ Lvbv i‡q‡Q hv‡`i GKB ai‡bi Amyweav i‡q‡Q? (Do you think that there are other households in this community that have such access problems?) bv ........................ (No) 2 4C. 7 Zviv wK Gme †ÿÎ †_‡K ewÂZ nb? Are they excluded from the following sectors? nu¨v Yes bv No A wk¶v/we`¨vjq.(Education/school) 1 2 B ¯^v¯n¨‡mev/wK¬wbK(Health service/clinics) 1 2 C evox evbv‡bv (Housing assistance) 1 2 D Kv‡Ri cÖwk¶b/PvKzix (Job trining/employment) 1 2 E FY (Credit) 1 2 F cvwbi e›Ub(Water distribution) 1 2 G cqwb®‹vlb e¨e¯nv(Sanitation service) 1 2 H K…wl †mev(Agricultural extension) 1 2 I b¨vq wePvi/`Ø mgvavb(Justice/conflict resolution) 1 2 J wbivcËv/bxwZ e¨e¯nv(Security/policy service) 1 2 27 Questions Coding Categories Skip 4C.8 GB ai‡bi †mevmg~n †_‡K wKQz †jvK‡K ev` †`qvi KviY¸‡jv wK wK? (What are the reasons or criteria why some people are excluded from these services?) A. Avq (Income level ) 1 2 B. ‡ckv (Occupation ) 1 2 C. mvgvwRK Ae¯’vb(RvwZ,eb©)[Social status (class, caste)] 1 2 D. eqm(Age ) 1 2 E. wj&½ (Gender) 1 2 F. RvwZ/RvwZmË¡v (Race/ethnicity) 1 2 G. fvlv (Language) 1 2 H agx©q wek¦vm (Religious beliefs) 1 2 I ivR‰bwZK ms‡hvM (Political affiliation) 1 2 J wk¶vi Afve (Lack of education) 1 2 4D.1 MZ eQ‡i, GB MÖvg/cvovi m`m¨iv wK cÖvq GKwÎZ n‡Zv Ges miKvix Kg©Pvix ev ivR‰bwZK †bZv‡`i mv‡_ †hŠ_fv‡e MÖv‡gi Dbœq‡b Av‡e`b KiZ? (In the past year, how often have members of this village/neighborhood gotten together and jointly petitioned government officials or political leaders with village development as their goal?) KL‡bv bv Never 1 GKevi Once 2 K‡qKevi A couple of times 3 evievi Frequently 4 28 Questions Coding Categories Skip 4D.2 GB KvR/GB KvR¸‡jvi †KvbwU wK mdj n‡q‡Q? (Was this action/were any of these actions successful?) nu¨v,me¸‡jv mdj n‡q‡Q… Yes, all were successful 1 wKQz mdj n‡q‡Q,wKQz nqwb Some were successful and others not 2 bv,‡KvbwU mdj nqwb No, none were successful 3 4D.3 MZ eQi Avcwb wKfv‡e GB MÖvg/cvovi Ab¨vb¨‡`i mv‡_ ‡Kvb mvaviY wel‡q m¤^‡Ü GKwÎZ n‡q‡Qb ? (How often in the past year have you joined together with others in the village/neighborhood to address a common issue?) KL‡bv bv Never 1 GKevi Once 2 K‡qKevi A couple of times 3 evievi Frequently 4 4D.4 A. weMZ wZb eQ‡i Avcwb wb‡Pi †KvbwU K‡i‡Qb wK? (In the last three years have you personally done any of the following things) nu¨v (Yes) bv (No) wbe©vP‡b †fvU ‡`qv Voted in the elections 1 2 B. ‡Kv‡bv ms¯’vq mwμq AskMÖnY Actively participated in any association 1 2 C. cÖfvekvjx †jv‡Ki mv‡_ e¨w³MZ †hvMv‡hvM Made a personal contact with influential person 1 2 D. ‡Kvb mgm¨vq MYgva¨g‡K AvMÖnx K‡i †Zvjv Made the media interested in a problem 1 2 29 Questions Coding Categories Skip E. Z_¨ cÖPv‡i mwμq AskMÖnY Actively participated in an information campaign 1 2 F. wbe©vPbx cÖPviYvq mwμq AskMÖnY Actively participated in an election campaign 1 2 G. cªwZev`x Av‡›`vj‡b AskMÖnY Taken part in a protest march or demonstration 1 2 H. wbe©vPbx cÖwZwbwai mv‡_ †hvMv‡hvM Contacted your elected representative 1 2 I. ‡Rvi`L‡ji cªwZev‡` AskMÖnY Attend to protest forceful possession 1 2 J. miKvwi ˆeVK/Awdm Taken part in government meetings/ offices 1 2 K. GjvKvi Ab¨vb¨‡`i mv‡_ mgm¨v wb‡q K_v ejv Talked with other people in your area about a problem 1 2 L. Av`vjZ ev cywjk †K mgm¨v m¤ú‡K© Rvbv‡bv Notified the court or police about a problem 1 2 M. Avw_©K ev `qvi `vb Made a monetary or in-kind donation 1 2 N. `vZv ms¯’vi †¯^”Qv‡meK Volunteered for a charitable organization 1 2 nu¨v (Yes) Bv (No) 30 Questions Coding Categories Skip 4D.5 Avcwb wK MZ wZb eQ‡i e¨w³MZfv‡e Kv‡ivi m¤§yLxb n‡q‡Qi whwb Avcbv‡K wb‡Pi †h‡KvbwU Ki‡Z e‡j‡Qb: Have you been approached by someone personally during the last three years who asked you to do any of the following: A wbe©vP‡b †fvU ‡`qv Voted in the elections 1 2 B ms¯’vq mwμq AskMÖnY Actively participated in an association 1 2 C cÖfvekvjx †jv‡Ki mv‡_ e¨w³MZ †hvMv‡hvM Made a personal contact with an influential person 1 2 D ‡Kvb mgm¨vq MYgva¨g‡K AvMÖnx K‡i †Zvjv Made the media interested in a problem 1 2 E Z_¨ cÖPv‡i mwμq AskMÖnY Actively participated in an information campaign 1 2 F wbe©vPbx cÖPviYvq mwμq AskMÖnY Actively participated in an election campaign 1 2 G cªwZev`x Av‡›`vj‡b AskMÖnY Taken part in a protest march or demonstration 1 2 H wbe©vPbx cÖwZwbwai mv‡_ †hvMv‡hvM Contacted your elected representative 1 2 I ‡Rvi`L‡ji cªwZev‡` AskMÖnY Attend to protest forceful possession 1 2 31 Questions Coding Categories Skip J miKvwi ˆeVK/Awdm Taken part in a sit-in or disruption of government meetings/ offices 1 2 K GjvKvi Ab¨vb¨‡`i mv‡_ mgm¨v wb‡q K_v ejv Talked with other people in your area about a problem 1 2 L Av`vjZ ev cywjk †K mgm¨v m¤ú‡K© Rvbv‡bv Notified the court or police about a problem 1 2 M Avw_©K ev `qvi `vb Made a monetary or in-kind donation 1 2 N `vZv ms¯’vi †¯^”Qv‡meK Volunteered for a charitable organization 1 2 4D.6 hw` GB MÖv‡g/cvovq &wKQz wm×všZ Dbœqb cÖK‡íi mv‡_ RwoZ nq,Avcwb wK g‡b K‡ib ZLb cy‡iv MÖvg/cvov‡K wK wm×všZ MÖn‡Yi Rb¨ †W‡K Avbv n‡e A_ev KwgDwbwU †bZviv wb‡RivB wm×všZ †b‡e? (If some decision related to a development project needed to be made in this village/ neighborhood, do you think the entire village/ neighborhood would be called upon to decide or would the community leaders make the decision themselves?) KwgDwbwU †bZviv wm×všZ †b‡e The community leaders would decide 1 cy‡iv MÖvg/cvov wm×všZ †b‡e The whole village/ neighborhood would be called 2 4D.7 Lye Kg.................... Very low 1 32 Questions Coding Categories Skip Avcwb GB MÖv‡gi /cvovi AskMÖn‡Yi D`¨g‡K wKfv‡e g~j¨vqb Ki‡eb? (Overall, how would you rate the spirit of participation in this village/neighborhood?) Kg........................... Low 2 ‡gvUvgywU...................... Average 3 ‡ekx.......................... High 4 Lye ‡ekx ...................... Very high 5 4D.8 Avcwb wb‡R wK g‡b K‡ib GB MÖvg/cvov †e‡P _vKvi Rb¨ A‡c¶vK…Z fv‡jv n‡j RbMb wK Zv cQ›` Ki‡e? (How much influence do you think people like yourself can have in making this village/neighborhood a better place to live?) A‡bK.................... A lot 1 wKQzUv ......................... Some 2 Lye †ekx bq...................... Not very much 3 G‡Kev‡iB bv .......................... None 4 33 5. COGNITIVE SOCIAL CAPITAL 5A. mvgvwRK eÜb (Solidarity) 34 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 35 5.A1 g‡b K‡ib,GB MÖv‡g/cvovq Kv‡iv `yf©vM¨RbK wKQz N‡U‡Q †hgb-evevi nVvr g„Zz¨| G&B Aem&_vq Zviv Kvi Kv‡Q mvnv‡h¨i Rb¨ AvmZ e‡j Avcwb g‡b K‡ib? (cÖ_g wZbwU †iKW© Kiyb|) Suppose someone in the village/neighborhood had something unfortunate happen to them, such as a father’s sudden death. Who do you think they could turn to for help in this situation? (Record first three mentioned.) 1 2 3 ‡KDB mv&nvh¨ KiZ bv……………...…….1 No one would help cwievi…………………………………2 Family cÖwZ‡ekxMY…………………………….3 Neighbors eÜziv…………………………………..4 Friends agx©q †bZv ev `j……………………….5 Religious leader or group KwgDwbwU †bZv…………………………6 Community leader e¨emvqx †bZv…………………………..7 Business leader cywjk………………………………….8 Police cvwievwiK Av`vjZ………………………9 Family court judge c„ô‡cvlK/wb‡qvMKZ©v/DcKvix……………10 Patron/employer/benefactor ivR‰bwZK †bZv………………………..11 Political leader cvi¯úwiK mnvqZv ‡`q Ggb `j †hLv‡b wZwb m`m¨ ……………………………….12 36 Mutual support group to which s/he belongs mnvqZvKvix ms¯_v †hLv‡b wZwb m`m¨ bb ……………………………………….13 Assistance organization to which s/he does not belong Ab¨vb¨( D‡jøL Kiyb) ..……….…….14 Other (specify) 37 5.A2 g‡b Kiyb Avcbvi cÖwZ‡ekx Avw_©K ÿwZi wkKvi n‡qwQj †hgb(MÖv‡g:km¨ bóÓ;kn‡i:PvKwi nviv‡bv)|GB Ae¯_vq Zv‡K Avw_©Kfv‡e †K mnvqZv KiZ e‡j Avcwb g‡b K‡ib? (&cÖ_g wZbwU †iKW© Kiyb|) Suppose your neighbor suffered an economic loss, say (RURAL: “crop failure”; URBAN “job loss”). In that situation, who do you think would assist him/her financially? (Record first three mentioned.) 1 2 3 ‡KDB mv&nvh¨ KiZ bv……………...…….1 No one would help cwievi…………………………………2 Family cÖwZ‡ekxMY…………………………….3 Neighbors eÜziv…………………………………..4 Friends agx©q †bZv ev `j……………………….5 Religious leader or group KwgDwbwU †bZv…………………………6 Community leader e¨emvqx †bZv…………………………..7 Business leader cywjk………………………………….8 Police cvwievwiK Av`vjZ………………………9 Family court judge c„ô‡cvlK/wb‡qvMKZ©v/DcKvix……………10 Patron/employer/benefactor ivR‰bwZK †bZv………………………..11 Political leader cvi¯úwiK mnvqZv ‡`q Ggb `j †hLv‡b wZwb m`m¨ ……………………………….12 Mutual support group to which s/he belongs 38 mnvqZvKvix ms¯_v †hLv‡b wZwb m`m¨ bb ……………………………………….13 Assistance organization to which s/he does not belong Ab¨vb¨( D‡jøL Kiyb) ..……….…….14 Other (specify) 5B. wek¦vm I mnvqZv (Trust and Cooperation) 39 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 5B.1 Avcwb wK g‡b K‡ib GB MÖv‡g/cvovq RbMb mvaviYZ avi †`qv I avi ‡bqvi e¨vcv‡i G‡K Aci‡K wek¦vm K‡i? Do you think that in this village/ neighborhood people generally trust one another in matters of lending and borrowing? wek¦vm K‡i Do trust 1 wek¦vm K‡i bv Do not trust 2 5B.2 Avcwb wK g‡b K‡ib, MZ K‡qK eQi a‡i GB wek¦v‡mi ai‡bi †Kvb cwieZ©b n‡q‡Q ? Do you think over the last few years this level of trust has gotten better, gotten worse, or stayed about the same? Zyjbvg~jK fv‡jv cwieZ©b n‡q‡Q Better 1 GKB The same 2 Zyjbvg~jK Lvivc cwieZ©b n‡q‡Q Worse 3 5B.3 Ab¨vb¨ MÖvgmg~n /cvovmg~†ni Zzjbvq GB MÖv‡gi/cvovi RbMb avi †`qv Ges avi †bqvi e¨vcv‡i KZUzKz G‡K Aci‡K wek¦vm K‡i? How much do the people in this area believe each other in terms of lending/ taking loan? Kg Less 1 GKB The same 2 †ekx More 3 40 5B.4 g‡b K‡ib MÖvg/cvovi KvD‡K Zv‡`i cwievimn wKQz mg‡qi Rb¨ `~‡i †h‡Z n‡jv|Kvi Dci fimv K‡i Zviv P‡j hvq (MÖv‡g:Zv‡`i km¨‡¶Z;kn‡i:Zv‡`i AvZ¥x‡qi evwo)? ( cÖ_g wZbwU †iKW© Kiyb) If someone from the village/ neighborhood had to go away for a while, along with their family. In whose charge could they leave (RURAL: “their fields”; URBAN: “their relatives’ house”)? (Record first three mentioned.) 1 2 3 cwiev‡ii Ab¨vb¨ m`m¨……………......1 Other family member cÖwZ‡ekx ………...…………………..2 Neighbor GKB D‡Ï‡k¨ MÖvg/cvovi †h †KD……….3 Anyone from the village/neighborhood for this purpose †KD bv………...………………………4 No one Ab¨vb¨( D‡jøL Kiyb) ………................. Other (specify) 41 5B.5 hw` Avcbv‡K nVvr GKw`b ev `yBw`‡bi Rb¨ `~‡i †h‡Z n‡Zv, Avcwb Avcbvi †Q‡j‡g‡qi †`Lvïbvi Rb¨ Kv‡K wVK Ki‡Zb ?(cÖ_g wZbwU †iKW© Kiyb|) If you suddenly had to go away for a day or two, whom could you count on to take care of your children? (Record first three mentioned.) ` 1 2 3 cwiev‡ii Ab¨vb¨ m`m¨…………………1 Other family member cÖwZ‡ekx ………………………………2 Neighbor GKB D‡Ï‡k¨ MÖvg/cvovi †h †KD…………3 Anyone from the village/neighborhood for this purpose ‡Kvb †Q‡j‡g‡q †bB……………………..4 Don’t have children Ab¨vb¨( D‡jøL Kiyb) …………………..4 Other (specify) 5B.6 RbMb MÖv‡gi Kj¨v‡bi †P‡q Zv‡`i cwiev‡ii Kj¨v‡Y m‡PZb _v‡K ,G wel‡q Avcbvi gZvgZ | Do you think that people in this area are more concerned about family welfare than village welfare? m¤ú~Y© fv‡e GKgZ Strongly agree 1 GKgZ agree 2 wØgZ Disagree 3 GK`gB gv‡bb bv Strongly disagree 4 5B.7 mgq w`‡e bv Will not contribute time 1 42 Avcbvi cÖwZ‡ewk †Kvb cÖ‡R± †_‡K mivmwi DcKvi cvqbv wKšZz MÖv‡gi Ab¨vbiv DcKvi cvq,†m‡¶‡G wK Avcbvi cÖwZ‡ewk H cÖ‡R‡± mgq w`‡e ? If a community project does not directly benefit your neighbor but has benefits for others in the village/neighborhood, then do you think your neighbor would contribute time for this project? mgq w`‡e Will contribute time 2 5B.8 Avcbvi cÖwZ‡ewk †Kvb cÖ‡R± †_‡K mivmwi DcKvi cvqbv wKšZz MÖv‡gi Ab¨vbiv DcKvi cvq,†m‡¶‡G wK Avcbvi cÖwZ‡ewk H cÖ‡R‡± UvKv w`‡e? If a community project does not directly benefit your neighbor but has benefits for others in the village/neighborhood, then do you think your neighbor would contribute money for this project? UvKv w`‡e bv Will not contribute money 1 UvKv w`‡e Will contribute money 2 5B.9 `qv K‡i ejyb Avcwb wK mvaviYZ wbgœwjwLZ wee„wZ¸‡jvi mv‡_ m¤§Z bvwK Am¤§Z : Do you agree or disagree: m¤ú~Y© fv‡e GKgZ strongly agree GKgZ Agree wØgZ disagree GK`gB gv‡bb bv strongly disagree A GB MÖv‡gi/cvovi AwaKvsk RbMb g~jZ mr Ges wek¦vm Kiv †h‡Z cv‡i Most people in this village/ neighborhood are basically honest and can be trusted 1 2 3 4 B RbMb memgq ïaygvÎ wbR¯^ Kj¨v‡Y AvMÖnx People are always interested only in their own welfare 1 2 3 4 C MÖv‡gi/cvovi m`m¨iv Ab¨vb¨‡`i Zzjbvq †ekx wek¦vm‡hvM¨ Members of this village/neighbor- hood are more trustworthy than others 1 2 3 4 D GB MÖv‡gi/cvovq,†h KvD‡K mZK© _vK‡ZB n‡e,bZzev †KD my‡hvM wb‡Z cv‡i In this village/ neighborhood, one has to be alert or someone is likely to take advantage of you. 1 2 3 4 43 E hw` Avcwb mgm¨vq c‡ob,Avcbv‡K memgq mn‡hvwMZv Kivi Rb¨ †KD Av‡Qb? If I have a problem, there is always someone to help me 1 2 3 4 F Avcwb MÖv‡gi/cvovi Ab¨vb¨ m`m¨‡`i gZvg‡Zi ¸iyZ¡ †`b bv I do not pay attention to the opinions of Gothers in the village/ neighborhood 1 2 3 4 I GB MÖv‡gi/cvovi AwaKvsk RbMb Avcbvi cÖ‡qvR‡b mnvqZv Ki‡Z B”QzK Most people in this village/neighborhood are willing to help if you need it. 1 2 3 4 J MZ cuvP eQ‡i GB MÖv‡gi/cvovi DbœwZ n‡q‡Q This village/neighborhood has prospered in the last five years 1 2 3 4 K Avcwb wb‡R‡K GB MÖv‡gi/cvovi m`m¨ g‡b K‡ib I feel accepted as a member of this village/ neighborhood 1 2 3 4 L MÖv‡g:hw` Avcwb GKwU k~Ki A_ev GKwU QvMj nvivb, MÖv‡gi †KD wK Zv LyuR‡Z Avcbv‡K mnvqZv Ki‡e ev Avcbv‡K †diZ w`‡e RURAL: If you lose a pig or a goat, someone in the village would help look for it or would return it to you. 1 2 3 4 99 M kn‡i: hw` Avcwb Av‡kcv‡k Avcbvi e¨vM ev Iqv‡jU †d‡j ‡`b,‡KD Zv †`L‡e Ges Avcbv‡K †diZ †`‡e URBAN: If you drop your purse or wallet in the neighborhood, someone will see it and return it to you. 1 2 3 4 99 5C. ؇›`¦i mgvavb (Conflict Resolution) 44 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 5C.1 Avcbvi g‡Z, GB MÖvg/cvov wK mvavibZ kvwšZc~Y© ev Ø›`c~Y©? In your opinion, is this village/neighborhood generally peaceful or conflictive? kvwšZc~Y© Peaceful 1 Ø›`c~Y© conflictive 2 5C.2 Ab¨vb¨ MÖvgmg~n /cvovmg~†ni Zzjbvq GB MÖv†g/cvovq wK Ø›` Kg ev †ekx? Compared with other villages/neighborhoods, is there more or less conflict in this village/neighborhood? †ekx More 1 GKB same 2 Kg Less 3 5C.3 GjvKvevmx wK mvaviY Dbœq‡bi j‡¶¨ mgq Ges UvKv †`q? Do people in this village/neighborhood contribute time and money toward common development goals? Zviv wKQzUv ev ‡ekx †`q They contribute some or a lot. 1 Zviv Lye Kg †`q ev †`q bv They contribute very little or nothing 2 5C.4 Ab¨vb¨ MÖvgmg~n /cvovmg~†ni Zzjbvq GB MÖv†g/cvovq RbMb mvaviY Dbœq‡bi j‡¶¨ KZUzKz mgq Ges UvKv †`q? Compared with other villages/neighborhoods, to what extent do people of this village/neighborhood contribute time and money toward common development goals? Kg †`q less 1 GKB iKg The same 2 ‡ekx †`q More 3 5C.5 ‡KD bv;‡jvKRb wb‡RivB K‡i No one; people work it out between themselves 1 cwievi/Lvbvi m`m¨iv Family/household members 2 45 `yÕRb e¨w³i g‡a¨ gvivZœK Ø›Ø n‡jv ,Avcbvi g‡Z †K cÖv_wgKfv‡e Ø›Ø †gUv‡Z GwM‡q Avm‡e ? Suppose two people in this village/neighborhood had a fairly serious dispute with each other. Who do you think would primarily help resolve the dispute? cÖwZ‡ekx Neighbors 3 KwgDwbwU †bZviv Community leaders 4 agx©q †bZviv Religious leaders 5 wePviK †bZviv Judicial leaders 6 Ab¨vb¨ (&D‡jøL Kiyb) Other (specify) 46 1.2 COMMUNITY QUESTIONNAIRE Improving maternal, newborn, and child health through building public-private partnerships (SUSOMA) Baseline Survey for Social Capital Measurement 2012 Community Questionnaire World Renew icddr,b IMCI section of DGHS USAID 47 Lvbvi cÖkœcÎ (Household Questionnaire) mv¶vrKvi ïiæi mgq (start time of interview) N›Uv wgwbU mv¶vrKvi ‡kl nevi mgq (end time of interview) N›Uv wgwbU 1. wba©vwiZ Lvbv mbv³Kib (identification of household) 1.1. ‡Rjv (district) ..................................... 1.2. mve-‡Rjv/Dc‡Rjv (sub-district/ Upazila) ..................................... 1.3. BEwbqb: (Union) ..................................... 1.4. kni/MÖvg (city/ village) ..................................... 1.5. IqvW© (Ward) ..................................... 1.6. cvov/gnjøv (para/ moholla) ..................................... 1.7. iv¯Ív (road) ..................................... 1.8. Lvbv bv¤^vi (Household number) ..................................... 1.9 Ab¨vb¨ we¯ÍvwiZ (Others ) ..................................... 2.0. GjvKvi aib (type of the area) kni (Urban) MÖvg(Avw`evmx bq) (village/ not indigenous) Avw`evmx (indigenous) cÖZ¨šÍ AÂj (remote) mvÿvrMÖnbKvixi bvg (Interviewer) ..................................... mycvifvBRvi bvg (Supervisor) ..................................... 48 1. B KwgDwbwUi cÖkœcÎ (Community questionnaire) 1. KwgDwbwU ‰ewkó¨ mg~n (Community Characteristics ) SL# Questions Coding Category Skip 1.1 KZ eQi GB KwgDwbwU wU Av‡Q ? How many years has the community been in existence? 20 erm‡ii †ekx ........…………………… 1 More than 2years 10 †_‡K 20 erm‡ii ch©šZ ………………2 Between 10 and 20 year 10erm‡ii Kg ..………………………… 3 Fewer than 10 years 1.2 GB KwgDwbwU‡Z KZ¸‡jv Lvbv Av‡Q? How many households are in this community? 25 Gi Kg........…………………… 1 Fewer than 25 25 †_‡K 49 ch©šZ........………….. 2 Between 25 and 49 50 ‡_‡K 99 ch©šZ........…………… 3 Between 50 and 99 100 †_‡K 249 ch©š— ........………..4 Between 100 and 249 250Gi †ekx ........……………………5 More than 250 1.3 MZ wZb erm‡ii,GB KwgDwbwU‡Z RbmsL¨vi †Kvb cwieZ©b n‡q‡Q wK ? In the last three years, the number of people living in this community has: e„w× †c‡q‡Q ………………….…1 Increased K‡g wM‡q‡Q ………………….. 2 Decreased GKB iKg Av‡Q ……….……… 3 Remained the same 49 1.4 e„w× cvIqv ,K‡g hvIqv A_ev cwieZ©‡bi `yBwU cÖavb Kvib wK wK ? What are the two main reasons for the increase, decrease, or lack of change? (a)_____________________ (b)______________________ 1.5 GB KwgDwbwU‡Z cyi“l‡`i Rb¨ A_© Dcv©R‡bi `yBwU cÖavb KvR wK wK ? What are the two principal economic activities for men in this community? (a)_____________________ (b)______________________ 1.6 GB KwgDwbwU‡Z gwnjv‡`i Rb¨ A_© Dcv©R‡bi `yBwU cÖavb KvR wK wK ? What are the two principal economic activities for women in this community? (a)_____________________ (b)______________________ 1.7 GB KwgDwbwUi emevmKvixiv hvZvqv‡Zi Rb¨ wK ai‡bi iv¯Zv e¨envi K‡i el©vKv‡j Ges ïKbv‡gŠmy‡g ? What is the main route that inhabitants use to reach this community, both during rainy season and dry season? (a) e„wói mgq (b) Liv cvKv iv¯Zv ………………………… 1 Paved road KuvPv iv¯—v ………………………… 2 Dirt road cvKv I KuvPv iv¯—v wg‡j …………… 3 Mixed paved and dirt cvwb c_ ………………….………… 4 Water ways Ab¨vb¨ (D‡j-L Ki“b) Other (specify) 50 1.8 MZ wZb erm‡ii g‡a¨, GB KwgDwbwUi cÖavb iv¯—vi †Kvb cwie©Zb n‡q‡Q wK ? Has there been any changes in the roads in this community in the last three years? DbœwZK‡i‡Q ……………………… 1 Improved Lvivc n‡q‡Q ……………….. 2 Worsened GKB iKg Av‡Q………….…... 3 Remained the same 1.9 MZ wZb erm‡ii g‡a¨,GB KwgDwbwU‡Z emZevoxi ¸bMZ gvb †Kgb n‡q‡Q ? In the last three years, the quality of housing in this community has: DbœwZK‡i‡Q ……………………… 1 Improved Lvivc n‡q‡Q ……………….. 2 Worsened GKB iKg Av‡Q………….…... 3 Remained the same 1.10 MZ wZb erm‡i GB KwgDwbwU‡Z emZevox DbœZ /Lvivc / GKB iKg _vKvi cÖavb `yBwU Kvib wK ? What are the two main reasons that housing in the community has improved/ worsened/ remained the same during the last three years? (a) _________________________________ (b) _________________________________ 1.11 MZ wZb erm‡ii g‡a¨ , GB KwgDwbwU‡Z RbM‡bi Rxeb-hvc†bi gv‡bi †Kvb cwieZ©b n‡q‡Q wK ? (PvKwii my‡hvM-myweav,wbivcËv, cwi‡ek, Avevmb) In the last three years, the overall quality of life of the people living in this community has: (consider job availability, safety and security, environment, housing, etc. DbœwZK‡i‡Q ……………………… 1 Improved Lvivc n‡q‡Q ……………….. 2 Worsened GKB iKg Av‡Q………….…... 3 Remained the same 1.12 MZ wZb erm‡i GB KwgDwbwU‡Z RbM‡bi Rxeb-hvc†bi gv‡bi cwieZ©b nIqvi cÖavb (a) _________________________________ 51 `yBwU Kvib wK ? What are the two main reasons for the overall quality of life? (b) _________________________________ 1.13 GB KwgDwbwUi AwaKvsk emevmKvix †Kgb ? (Ae¯’vi w`K †_‡K ) Overall, the level of living of this community may be characterized as: abx ........................................ 1 Wealthy m”Qj......................................... 2 Well-to-do †gvUvgywU ................................... 3 Average Mixe .................................... 4 Poor Lye Mixe................................. 5 Very poor 1.14 GB KwgDwbwUi RbMb mvavibZ: avi‡`qv Ges avi ‡bqvi e¨vcv‡i G‡K Aci‡K wek¦vm K‡i ? Do people in this community generally trust one another in matters of lending and borrowing? n¨vu ................................................ 1 Yes bv .................................................. 2 No 1.15 MZ wZb erm‡i GB wek¦v‡mi ai‡bi †Kvb cwieZ©b n‡q‡Q wK ? In the last three years, has the level of trust improved, worsened, or stayed the same? DbœwZK‡i‡Q ……………………… 1 Improved Lvivc n‡q‡Q ……………….. 2 Worsened GKB iKg Av‡Q………….…... 3 Remained the same 1.16 Ab¨ KwgDwbwUi ms‡M Zzjbv Ki‡j GB KwgDwbwUi RbMb avi ‡`qv Ges avi ‡bqvi e¨vcv‡i G‡K Aci‡K KZUv wek¦vm K‡i? Compared with other communities, how much do people in this †ekx wek¦vm K‡i............................ 1 More trust GKB iKg................................2 Same as 52 SL# Questions Coding Category Skip 2. PRINCIPAL SERVICES 2 A. Electricity 2 A.1 GB Lvbv¸‡jv‡Z memgq we`y¨r _v‡K ? Is electricity available here for households? n¨vu................................................ 1 Yes bv .................................................. 2 No 2B 2 A.2 MZ wZb erm‡ii g‡a¨ GB KwgDwbwU‡Z we`y¨r Gi †mevi Ae¯’v †Kgb wQj? In the last three years, the electrical service to this community has: DbœwZK‡i‡Q ……………………… 1 Improved Lvivc n‡q‡Q ……………….. 2 Worsened GKB iKg Av‡Q………….…... 3 community trust each other in matters of lending and borrowing? Kg wek¦vm K‡i ........................ 3 Less trust 1.17 RbMb KwgDwbwUi Kj¨v‡bi ‡P‡q wb‡Ri cwiev‡ii Kj¨v‡bi Rb¨ m‡PZb _v‡K : G‡Z Avcbvi gZ wK ? m¤ú~Y© fv‡e GKgZ............................ 1 Strongly agree GKgZ ............................................... 2 agree wØgZ................................................... 3 Disagree 53 Remained the same 2 A.3 eZ©gv‡b GB GjvKvi we`y¨‡Zi †mevi gvb †Kgb ? Currently, the quality of electrical service within the homes of community is: Lye fvj............................. 1 Very good fvj ................................... 2 Good †gvUvgywU ............................ 3 Average Lvivc................................ 4 Poor Lvivc................................. 5 Very poor 2 A.4 we`y¨r †mevi cÖavb `yBwU mgm¨v wK wK ? What are the two main problems with the electrical service? a)_______________________________ __ (b)______________________________ ___ 2B. Public Lighting 2B.1 GB GjvKvq iv¯—vq jvB‡Ui e¨e¯’v Av‡Q wK? Does this community have street lights? n¨vu................................................ 1 Yes bv .................................................. 2 No 2B.2 MZ wZb erm‡i cvewjK jvB‡Ui e¨e¯’v ‡Kgb wQj ? In the last three years, the public lighting service has: DbœwZK‡i‡Q ……………………… 1 Improved Lvivc n‡q‡Q ……………….. 2 Worsened GKB iKg Av‡Q………….…... 3 54 Remained the same 2B.3 eZ©gv‡b cvewjK jvB‡Ui gvb †Kgb ? Currently, the quality of public lighting service is: Lye fvj............................. 1 Very good fvj ................................... 2 Good †gvUvgywU ............................ 3 Average Lvivc................................ 4 Poor Lvivc................................. 5 Very poor 2B.4 GB GjvKvi cvewjK jvB‡Ui cÖavb `yBwU mgm¨v wK wK ? What are the two main problems with the public lighting in this community? (a)________________________________ (b)________________________________ 2C. Lvevi cvwb. Drinking Water 2C.1 GB GjvKvq cvB‡ci/b‡ji gva¨‡g cvwbi e¨e¯’v Av‡Q wK ? Is the community has pipe-borne water? n¨vu................................................ 1 Yes bv .................................................. 2 No 2C.2 GjvKvi †Kvb As‡k GB cvB‡ci/b‡ji gva¨‡g cvwbi e¨e¯’v Av‡Q ? What part of the community has pipe-borne water? mgMÖ KwgDwbwU…………………….....1 The entire community AwaKvsk KwgDwbwU.............................. 2 Most of the community cÖvq A‡a©K KwgDwbwU ............................ 3 55 About half the community A‡a©‡Ki Kg/Lye Aí ............................ 4 Less than half/very few 2C.3 GB GjvKv‡Z RbM‡bi Rb¨ miKvix K‡ji e¨e¯’v Av‡Q wK ? Is the community has public Standpipes? n¨vu................................................ 1 Yes bv .................................................. 2 No 2C.4 GB GjvKvi †Kvb As‡k RbM‡bi Rb¨ miKvix K‡ji e¨e¯’v Av‡Q ? What part of the community has access to public standpipes? mgMÖ KwgDwbwU…………………….....1 The entire community AwaKvsk KwgDwbwU.............................. 2 Most of the community cÖvq A‡a©K KwgDwbwU ............................ 3 About half the community A‡a©‡Ki Kg/Lye Aí ............................ 4 Less than half/very few 2C.5 MZ wZb erm‡i Lvevi cvwbi e¨e¯’v †Kgb wQj? In the last three years, potable water service has been: DbœwZK‡i‡Q ……………………… 1 Improved Lvivc n‡q‡Q ……………….. 2 Worsened GKB iKg Av‡Q………….…... 3 Remained the same 2C.6 eZ©gv‡b Lvevi cvwbi e¨e¯’v †Kgb ? Lye fvj............................. 1 Very good fvj ................................... 2 Good †gvUvgywU ............................ 3 Average 56 Lvivc................................ 4 Poor Lvivc................................. 5 Very poor 2C.7 Lvevi cvwbi `yBwU cÖavb mgm¨v wK wK ? What are the two main problems with the drinkable water service? (a)________________________________ (b)________________________________ 2D. evox‡Z †Uwj‡dv‡bi e¨e¯’v Home Telephone Service 2D.1 GB GjvKvi evox¸‡jv‡Z †Uwj‡dv‡bi e¨e¯’v Av‡Q wK ? Is the home telephone service available in this community? n¨vu................................................ 1 Yes bv .................................................. 2 No 2E 2D.2 GB GjvKv‡Z KZUzKz As‡k GB †Uwj‡dv‡bi e¨e¯’v Av‡Q ? What fraction of the community has home telephone service? mgMÖ KwgDwbwU…………………….....1 The entire community AwaKvsk KwgDwbwU.............................. 2 Most of the community cÖvq A‡a©K KwgDwbwU ............................ 3 About half the community A‡a©‡Ki Kg/Lye Aí ............................ 4 Less than half/very few 57 2D.3 eZ©gv‡b evox‡Z †Uwj‡dv‡bi Ae¯’v ‡Kgb? Currently, the home telephone service is: Lye fvj............................. 1 Very good fvj ................................... 2 Good †gvUvgywU ............................ 3 Average Lvivc................................ 4 Poor Lvivc................................. 5 Very poor 2E. †hvMv‡hvM e¨e¯’v Communication Services 2E.1 GB GjvKv‡Z miKvix/cvewjK †Uwj‡dv‡bi e¨e¯’v Av‡Q wK ? Does this community have public telephones? n¨vu................................................ 1 Yes bv .................................................. 2 No 2E.3 2E.2 GB GjvKv‡Z miKvix/cvewjK †Uwj‡dv‡bi msL¨v KZ? How many public telephones are in this community? _________________ Uv (Number) 2E.4 2E.3 GB GjvKvq wbKUZg miKvix/cvewjK †Uwj‡dv‡bi `~iZ¡ KZ? What is the distance from this `~iZ¡ (cv‡q †n‡U KZmgqjv‡M) Distance (in walking minutes) _________________ 58 community to the nearest public telephone? 2E.4 MZ wZb erm‡i GB GjvKvq miKvix/cvewjK †Uwj‡dv‡bi †mevi gvb †Kgb wQj? In the last three years, what was the scodition of public telephone in this community? DbœwZK‡i‡Q ……………………… 1 Improved Lvivc n‡q‡Q ……………….. 2 Worsened GKB iKg Av‡Q………….…... 3 Remained the same 2E.5 eZ©gv‡b GB GjvKvq miKvix/cvewjK †Uwj‡dv‡bi †mevi gvb †Kgb? Currently, the condition for telephone service in this community: Lye fvj............................. 1 Very good fvj ................................... 2 Good †gvUvgywU ............................ 3 Average Lvivc................................ 4 Poor Lvivc................................. 5 Very poor 2E.6 GB GjvKvq miKvix/cvewjK †Uwj‡dv‡bi †mevi cÖavb `yBwU mgm¨v wK wK ? What are the two main problems with the public telephone service in this community? a)________________________________ (b)________________________________ 2E.7 GB GjvKvq †cvóAwdm Av‡Q wK? Is there a post office in this n¨vu................................................ 1 Yes 2E.9 59 community? bv .................................................. 2 No 2E.8 GB GjvKvq wbKUZg ‡cvóAwd‡mi `~iZ¡ KZ? What is the distance from this community to the nearest post office? `~iZ¡ (cv‡q †n‡U KZ mgq jv‡M Distance (in walking minutes) __________________ 2E.9 MZ wZb erm‡i GB GjvKvi ‡cvóAwd‡mi †mevi Ae¯’v †Kgb n‡q‡Q? In the last three years, what was the condition of post office? DbœwZK‡i‡Q ……………………… 1 Improved Lvivc n‡q‡Q ……………….. 2 Worsened GKB iKg Av‡Q………….…... 3 Remained the same 2E.1 0 eZ©gv‡b GB GjvKvi ‡cvóAwd‡mi Ae¯’v †Kgb ? What is the current situation in the post office? Lye fvj............................. 1 Very good fvj ................................... 2 Good †gvUvgywU ............................ 3 Average Lvivc................................ 4 Poor Lvivc................................. 5 Very poor 2E.1 1 GB GjvKvi ‡cvóAwd‡mi cÖavb `yBwU mgm¨v wK ? What are the two main problems with the mail service in this a)________________________________ (b)________________________________ 60 community? 2E.1 2 GB GjvKvq cvewjK B›Uvi‡bU mvwf†mi e¨e¯’v Av‡Q wK ? Is there a public internet service in this community? n¨vu................................................ 1 Yes bv .................................................. 2 No 2E.15 2E.1 3 GB GjvKvi ‡Kvb As‡k cvewjK B›Uvi‡bU mvwf©‡mi e¨e¯’v Av‡Q ? What fraction of the community has access to public Internet service? mgMÖ KwgDwbwU…………………….....1 The entire community AwaKvsk KwgDwbwU.............................. 2 Most of the community cÖvq A‡a©K KwgDwbwU ............................ 3 About half the community A‡a©‡Ki Kg/Lye Aí ............................ 4 Less than half/very few 2E.1 4 †Kv_vq memgq cvewjK B›Uvi‡bU mvwf©m cvIqv hvq? Where are public Internet access services available? ¯’vbxq ¯‹zj ....................... ..... ..... ..... 1 Local school jvB‡eªix ..................................... ..... .... 2 Library KwgDwbwU ‡m›Uvi ..... ..... ..... ..........3 Community center ‡Uªwbs †m›Uvi .................. ..... ..... 4 Training center B›Uvi‡bU K¨v‡d ...................... 5 Internet café Ab¨vb¨ (D‡j- L Ki“b)............ 6 Other (specify) 2F 61 2E.1 5 GB GjvKvq wbKUZg cvewjK B›Uvi‡bU mvwf©‡mi `~iZ¡ KZ ? What is the distance from this community to the nearest public Internet access service? `~iZ¡ (cv‡q †n‡U KZ mgq jv‡M) Distance (in walking minutes) __________________ 2F. cqtwb®‹vkb e¨e¯’v Sewage 2F.1 GB GjvKvq miKvix cqtwb®‹vkb e¨e¯’v e¨e¯’v Pvjy Av‡Q wK ? Is there a public internet service in this community? n¨vu................................................ 1 Yes bv .................................................. 2 No `~iZ¡ (cv‡q †n‡U KZ mgq jv‡M) ) Distance (in walking minutes) __________________ [ ] 2 (go to question 2F.6 2F.6 2F.2 GB GjvKvi ‡Kvb As‡k miKvix cqtwb®‹vkb e¨e¯’v Av‡Q ? What fraction of the community is served by a public sewage system? mgMÖ KwgDwbwU…………………….....1 The entire community AwaKvsk KwgDwbwU.............................. 2 Most of the community 62 cÖvq A‡a©K KwgDwbwU ............................ 3 About half the community A‡a©‡Ki Kg/Lye Aí ............................ 4 Less than half/very few 2F.3 MZ wZb erm‡i GB GjvKvi miKvix cqtwb®‹vkb e¨e¯’v ‡Kgb wQj ? In the last three years, what was the condition for public sewage system? DbœwZK‡i‡Q ……………………… 1 Improved Lvivc n‡q‡Q ……………….. 2 Worsened GKB iKg Av‡Q………….…... 3 Remained the same 2F.4 eZ©gv‡b GB GjvKvi miKvix cqtwb®‹vkb e¨e¯’v ‡Kgb ? Currently, what is the condition for public sewage system? Lye fvj............................. 1 Very good fvj ................................... 2 Good †gvUvgywU ............................ 3 Average Lvivc................................ 4 Poor Lvivc................................. 5 Very poor 2F.5 GB GjvKvi miKvix cqtwb®‹vkb e¨e¯’vi cÖavb `yBwU mgm¨v wK ? What are the two main problems with the public sewage system in this community? (a) ________________________________ (b) ________________________________ 2F.6 GB GjvKvq cqtwb®‹vk‡bi Rb¨ ch©vß †Wªb Av‡Q ,hvi Øviv AwZwi³ cvwb ,eb¨v Ges e„wó cÖwZ‡iva Kiv hvq ? n¨vu................................................ 1 Yes 63 Do the streets of this community have sufficient sewers and drains to handle excess water and prevent flooding when it rains? bv .................................................. 2 No 2F.7 GB GjvKv‡Z cqtwb®‹vkb e¨e¯’vi Rb¨ Ab¨ Avi wK e¨e¯’v Av‡Q ? What other sewage and waste water systems are used in this community? Yes No a. cvqLvbv(Latrine) 1 2 b. ‡mcwUK U¨vb&K(Septic tanks) 1 2 c. b`x A_ev mgy`ª(River or sea) 1 2 d. Ab¨vb¨ (D‡j- L Ki“b) Other (specify) 2G. gqjv Ave©Rbv msMÖn Garbage Collection 2G.1 GB KwgDwbwU‡Z AveR©bv msMÖ‡ni e¨e¯’v Av‡Q wK ? Is there any garbage collection system in this community? n¨vu................................................ 1 Yes bv .................................................. 2 No 2G.3 2G.2 GB GjvKvi †Kvb As‡k AveR©bv msMÖ‡ni e¨e¯’v Av‡Q ? What fraction of the community is served by a garbage collection service? mgMÖ KwgDwbwU…………………….....1 The entire community AwaKvsk KwgDwbwU.............................. 2 Most of the community 64 cÖvq A‡a©K KwgDwbwU ............................ 3 About half the community A‡a©‡Ki Kg/Lye Aí ............................ 4 Less than half/very few 2G.3 MZ wZb erm‡ii g‡a¨ GB GjvKvi AveR©bv †djvi e¨e¯’v †Kgb wQj? In the last three years, how was the system for garbage collection? DbœwZK‡i‡Q ……………………… 1 Improved Lvivc n‡q‡Q ……………….. 2 Worsened GKB iKg Av‡Q………….…... 3 Remained the same 2G.4 †hevox‡Z AveR©bv msMÖ‡ni †mev MÖnb K‡i bv, Zviv AveR©bv wK K‡i ? In the homes that do not receive garbage collection service, what is the main solid waste disposal method? cywo‡q †d‡j .................................... 1 Burn it wb‡Ri RvqMvq †d‡j ……………........ 2 Throw on own lot A‡b¨i RvqMvq †d‡j............................. 3 Throw on others’ lots b`x/mgy`ª/cyKz‡i †d‡j .......................... 4 Throw into river/sea/ pond cy‡Zu iv‡L….................................... 5 Bury it Ab¨vb¨ (D‡j-L Ki“b) ............. Other (specify) 65 2H. cvewjK gv‡K©U Public Market 2H.1 GB KwgDwbwU‡Z †Kvb cvewjK gv‡K©U Av‡Q wK ? Does this community have a public market? n¨vu................................................ 1 Yes bv .................................................. 2 No 2H.5 2H.2 KwgDwbwU †_‡K wbKUZg gv‡K©†U †n‡U †h‡Z KZ¶b jv‡M : The walking distance from the community to the nearest market is: `~iZ¡ (‡nu‡U †h‡Z KZ mgq jv‡M) Distance (in walking minutes) ____________ 21 2H.3 KwgDwbwUi KZ Rb gv©‡K‡U hvq? How many people in the community use the market? mgMÖ KwgDwbwU…………………….....1 The entire community AwaKvsk KwgDwbwU.............................. 2 Most of the community cÖvq A‡a©K KwgDwbwU ............................ 3 About half the community A‡a©‡Ki Kg/Lye Aí ............................ 4 Less than half/very few 2H.4 gv‡K©U K‡e †Lvjv _v‡K : The market is open: cÖ‡Z¨Kw`b ………........................... 1 Every day mßv‡ni wKQyw`b ............................. 2 Some days of the week cÖwZ mßv‡ni 1 w`b.......................... 3 One day per week Ab¨vb¨ (D‡j-L Ki“b ).................... 4 Other (specify) 66 2H.5 MZ 3 erm‡i GB gv‡K©‡Ui gvb I †mevi Ae¯’v †Kgb n‡q‡Q ? In the last three years, what has been the situation of this market? DbœwZK‡i‡Q ……………………… 1 Improved Lvivc n‡q‡Q ……………….. 2 Worsened GKB iKg Av‡Q………….…... 3 Remained the same 2I. hvbevnb (Transportation) 2I.1 GB KwgDwbwU‡Z wK cvewjK cwien‡bi e¨e¯’v Av‡Q ? Is this community served by a public transport system? n¨vu................................................ 1 Yes bv .................................................. 2 No 21.2 2I.2 cvewjK cwien‡bi gva¨‡g wbKUeZx© KwgDwbwU‡Z hvIqvi Rb¨ nvUvi `~iZ¡ KZUzKz: The walking distance to the nearest community with public transportation is: `~iZ¡ (nvU‡Z KZ wgwbU jv‡M ? ) Distance (in walking minutes) ____________ 21.5 2I.3 cvewjK cwienb mn‡R cvIqv hvq (Is public transportation is available easily?) cÖ‡Z¨Kw`b ………........................... 1 Every day mßv‡ni wKQyw`b ............................. 2 Some days of the week cÖwZ mßv‡ni 1 w`b.......................... 3 67 One day per week Ab¨vb¨ (D‡j-L Ki“b ).................... 4 Other (specify) 2I.4 Kviv cvewjK cwienb e¨envi K‡i Public transportation is used by whom? mgMÖ KwgDwbwU…………………….....1 The entire community AwaKvsk KwgDwbwU.............................. 2 Most of the community cÖvq A‡a©K KwgDwbwU ............................ 3 About half the community A‡a©‡Ki Kg/Lye Aí ............................ 4 Less than half/very few 2I.5 MZ 3 erm‡i cvewjK cwien‡bi gvb I †mevi Ae¯’v †Kgb n‡q‡Q ? In the last three years, was there any changes in quality of public transport? DbœwZK‡i‡Q ……………………… 1 Improved Lvivc n‡q‡Q ……………….. 2 Worsened GKB iKg Av‡Q………….…... 3 Remained the same 2I.6 GB KwgDwbwUi cvewjK cwienb‡K DbœZ Kivi Rb¨ cÖavb 2 wU cwieZ©b wK n‡Z cv‡i ? What two main changes can be made to improve public transportation to this community? (a)___________________________ (b____________________________ 2I.7 GB KwgDwbwUi ‡jvKRb cv‡ki KwgDwbwU†Z hvIqvi Rb¨ Avi †Kvb ai‡bi hvbevnb e¨envi K‡i (me‡P‡q ¸i“Z¡c~Y© 2wU bvg wjLyb). (a) (b) 68 What other types of transportation do people in this community use to go to neighboring communities? (List the two most important ones). ‡n‡U(Walking) 1 mvB‡K‡j (Bicycle) 2 ‡Nvovq(Horse) 3 Mvox‡Z (Car) 4 Ab¨vb¨ D‡j- L Ki“b(Other (specify) 2J. we‡bv`b (Recreation) 2J.1 GB GjvKv‡Z wK †Ljvi gvV Ges we‡bv`‡bi RvqMv Av‡Q ? Does this community have sports fields or recreational areas? n¨vu................................................ 1 Yes bv .................................................. 2 No 2J.3 2J.2 MZ 3 erm‡i GB GjvKvi †Ljvi gvV Ges we‡bv`‡bi RvqMv¸‡jvi Ae¯’v †Kgb n‡q‡Q ? In the last three years, the condition of the sports fields and recreational areas has: DbœwZK‡i‡Q ……………………… 1 Improved Lvivc n‡q‡Q ……………….. 2 Worsened GKB iKg Av‡Q………….…... 3 Remained the same 2J.3 GB KwgDwbwU‡Z wK wkï‡`i Rb¨ Avjv`v †Ljvi gvV Av‡Q ? Does this community have separate children’s play areas? n¨vu................................................ 1 Yes bv .................................................. 2 No 2K 2J.4 MZ 3 erm‡i wkï‡`i GB †Ljvi gv‡Vi Ae¯’v †Kgb n‡q‡Q ? DbœwZK‡i‡Q ……………………… 1 69 In the last three years, the condition of these children’s play areas has: Improved Lvivc n‡q‡Q ……………….. 2 Worsened GKB iKg Av‡Q………….…... 3 Remained the same 2K. wbivcIv (Security) 2K.1 GB KwgDwbwUi wK wbivcIv ev cywjk †mevi e¨e¯’v Av‡Q ? Does this community have a security or police force? n¨vu................................................ 1 Yes bv .................................................. 2 No Sec tion-3 2K.2 GB ‡mevUv Kviv †`q ? This service is provided by cywjk /Avbmvi ............................... 1 The police GjvKvevmx ................................... 2 The community cÖvB‡fU †Kv¤úvbx ……….............. 3 A private company 2K.3 GB wbivcIv ‡mevUv GjvKvi †Kvb As‡k †`Iqv nq ? This security service is provided to: mgMÖ KwgDwbwU…………………….....1 The entire community AwaKvsk KwgDwbwU.............................. 2 Most of the community cÖvq A‡a©K KwgDwbwU ............................ 3 About half the community A‡a©‡Ki Kg/Lye Aí ............................ 4 Less than half/very few 2K.4 MZ 3 erm‡i wbivcIv ‡mevi gvb †Kgb n‡q‡Q ? In DbœwZK‡i‡Q ……………………… 1 70 the last three years, the quality of the security service has: Improved Lvivc n‡q‡Q ……………….. 2 Worsened GKB iKg Av‡Q………….…... 3 Remained the same 3.kªg Awfevmb.( LABOR MIGRATION) 3.1 GB KwgDwbwUi m`m¨iv wK KvR Kivi Rb¨ erm‡ii wKQy mgq Ab¨ ¯’v‡b hvq ? Are there members of this community who go to other places to work during certain periods of the year? n¨vu................................................ 1 Yes bv .................................................. 2 No 3.6 3.2 GB KwgDwbwUi m`m¨†`i g‡a¨ Kviv Kv‡Ri Rb¨ Ab¨¯’v‡b †ewk hvq ? Do more women than men leave to work? Do more men than women leave to work? Or equal numbers of women and men? cyi“‡li †P‡q gwnjviv †ewk..................... 1 More women than men gwnjv‡`i †P‡q cyi“‡liv †ewk ................ 2 More men than women mgvb msL¨K ..................................... 3 Equal numbers 3.3 cÖv_wgKfv‡e Kv‡Ri Rb¨ Zviv †Kv_vq hvq ? Where do they go to work primarily? GB A‡ji kn‡i ................................... 1 To a city in this region Ab¨ A‡ji kn‡i................................ 2 To a city in another region we‡`‡ki kn‡i .............................. 3 To a city in another country 71 GB A‡ji MÖv‡g ............................. 4 To a rural area in this region Ab¨ A‡ji MÖv‡g ........................... 5 To a rural area in another region we‡`‡ki MÖv‡g ................................ 6 To a rural area in another country 3.4 gwnjviv gyjZ: wK wK Kv‡Ri Rb¨ hvq ?(2wU †ckv wjLyb ) What are the two principal jobs women leave for? (a) _____________________________ (b) _____________________________ 3.5 cyi“liv gyjZ: wK wK Kv‡Ri Rb¨ hvq ?(2wU †ckv wjLyb ) What are the two principal jobs men leave for? (a) _____________________________ (b) _____________________________ 3.6 Ab¨ KwgDwbwUi †jvKRb wK GB KwgDwbwU‡Z KvR Ki‡Z Av‡m ? Are there people from other communities who come to work in this community? n¨vu................................................ 1 Yes bv .................................................. 2 No Sec tion- 4 3.7 Zviv †Kvb 2wU Kv‡Ri Rb¨ g~jZ GB KwgDwbwU‡Z Av‡m ? What are the two principal jobs they come for? (a) _____________________________ (b) _____________________________ 72 4. wk¶v (EDUCATION) 4A. wcÖ¯‹zj(Preschool) NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 4A.1 GB KwgDwbwU‡Z wK miKvix wcÖ¯‹zj Av‡Q ? Does this community have a public preschool? n¨vu................................................ 1 Yes bv .................................................. 2 No 4A.3 Sec tion￾4B 4A.2 me‡P‡q Kv‡Qi miKvix wcÖ¯‹zjwU KwgDwbwU †_‡K KZ `~‡i ? How far from the community is the nearest public preschool? `~iZ¡ (‡n‡U †h‡Z KZ wgwbU jv‡M ) Distance (in walking minutes) _______________________ 4A.3 GB GjvKvq †QvU ev”Pv†`i Rb¨ ch©vß cwigvb wcÖ¯‹zj Av‡Q wK ? Is the number of preschools in this community sufficient to serve the number of young children in the community? n¨vu................................................ 1 Yes bv .................................................. 2 No 2 4A.4 GB GjvKvq †QvU wkï‡`i Rb¨ wcÖ-¯‹z‡j ch©vß cwigvb wk¶K Av‡Q wK ? Is the number of teachers in these preschools sufficient for the number of children? n¨vu................................................ 1 Yes bv .................................................. 2 No 4A.5 wcÖ¯‹zjwUi AeKvVv‡gv †Kgb ? What is the physical condition of the preschool is? Lye fvj............................. 1 Very good fvj ................................... 2 73 Good †gvUvgywU ............................ 3 Average Lvivc................................ 4 Poor Lvivc................................. 5 Very poor 4A.6 †QvU wkï†`i g‡a¨ KZ kZvsk miKvix wcÖ¯‹zj¸‡jv‡Z hvq ? What percentage of young children attends public preschools? mKj wkï(All children)……………….. 1 AwaKvsk wkï(Most children)………….. 2 cÖvq A‡a©K wkï(About half of the children) .................................. 3 A‡a©‡Ki Kg(Less than half)…………….. 4 LyeB Kg / †KDbv (Very few/none)……….. 5 4A.7 GB KwgDwbwUi cvewjK wcÖ¯‹zj¸‡jv‡Z †QvU wkï‡`i Abycw¯nwZ cÖavb 2 wU KviY wK wK ? What are the two principal reasons that young children from this community do not attend public preschool? (a) ____________________________ (b) ____________________________ 4B.cÖv_wgK we`¨vjq(Primary School) NO QUESTIONS AND FILTERS CODING CATEGORIES SKIP 4B.1 GB GjvKvq †Kvb miKvix cÖvBgvix ¯‹zj Av‡Q wK? Does this community have a public primary school? n¨vu................................................ 1 Yes bv .................................................. 2 No 4b.3 4B.2 me‡P‡q Kv‡Qi miKvix cÖvBgvix ¯‹zjwU KwgDwbwU †_‡K KZ `~‡i? `~iZ¡ (‡n‡U †h‡Z KZ wgwbU jv‡M ) Distance (in walking minutes) _______________________ 74 How far from the community is the nearest public primary school? 4B.3 GB GjvKvq ¯‹zjMvgx wkï†`i Rb¨ ch©vß msL¨K cÖvBgvix ¯‹zj Av‡Q wK ? Is the number of primary schools in this community sufficient to serve the number of school-age children in the community? n¨vu................................................ 1 Yes bv .................................................. 2 No 4B.4 GB ¯‹z‡ji QvG/QvGx‡`i Rb¨ ch©vß msL¨K wk¶K Av‡Q wK? Is the number of teachers in these schools sufficient for the number of students? n¨vu................................................ 1 Yes bv .................................................. 2 No 4B.5 cÖvBgvix ¯‹zjwUi AeKvVv‡gv †Kgb ? What is the physical condition of the primary school ? Lye fvj............................. 1 Very good fvj ................................... 2 Good †gvUvgywU ............................ 3 Average Lvivc................................ 4 Poor Lvivc................................. 5 Very poor 4B.6 ¯‹zj Mvgx wkï†`i g‡a¨ KZ kZvsk miKvix cÖvBgvix ¯‹z‡j Dcw¯nZ _v‡K ? What percentage of eligible school-age children attends public primary schools? mKj wkï(All children)……………….. 1 AwaKvsk wkï(Most children)………….. 2 cÖvq A‡a©K wkï(About half of the children).. 3 A‡a©‡Ki Kg(Less than half)…………….... 4 LyeB Kg / †KDbv(Very few/none)……….. 5 4B.7 GB GjvKvq ,¯‹zj Mvgx wkï‡`i cvewjK cÖvBgvix ¯‹z‡j Abycw¯nwZi cÖavb 2 wU KviY wK 75 wK ? What are the two principal reasons that school-age children from this community do not attend public primary school? (a) ____________________________ (b) ____________________________ 4C. gva¨wgK ¯‹zj NO QUESTIONS AND FILTERS CODING CATEGORIES SKIP 4C.1 GB KwgDwbwU‡Z wK ‡Kvb miKvix gva¨wgK ¯‹zj Av‡Q ? Does this community have a public secondary school? n¨vu................................................ 1 Yes bv .................................................. 2 No 4C.3 4C.2 me‡P‡q Kv‡Qi miKvix gva¨wgK ¯‹zjwU GjvKv †_‡K KZ `~‡i ? How far from the community is the nearest public secondary school? `~iZ¡ (‡n‡U †h‡Z KZ wgwbU jv‡M ) Distance (in walking minutes) _______________________ 4C.3 GB GjvKvq gva¨wgK ¯‹z‡ji ¯‹zjMvgx QvG/QvGx‡`i Rb¨ ch©vß msL¨K gva¨wgK ¯‹zj Av‡Q wK ? Is the number of secondary schools in this community sufficient to accommodate the number of secondary-school-age students in the community? n¨vu................................................ 1 Yes bv .................................................. 2 No 4C.4 GB gva¨wgK ¯‹z‡j QvG/QvGx‡`i Rb¨ ch©vß msL¨K wk¶K Av‡Q wK ? Is the number of teachers in the secondary schools sufficient for the number of students? n¨vu ................................................ 1 Yes bv .................................................. 2 No 4C.5 gva¨wgK ¯‹z‡ji KvVv‡gvMZ Ae¯’&v †Kgb ? What is the physical condition of the secondary school ? Lye fvj............................. 1 Very good fvj ................................... 2 Good 76 †gvUvgywU ............................ 3 Average Lvivc................................ 4 Poor Lvivc................................. 5 Very poor 4C.6 QvG/QvGx‡`i KZ kZvsk miKvix gva¨wgK ¯‹z‡j Dcw¯nZ _v‡K ? What percentages of secondary-school-age children attend public secondary schools? mKj wkï(All children)……………….. 1 AwaKvsk wkï(Most children)………….. 2 cÖvq A‡a©K wkï(About half of the children).. 3 A‡a©‡Ki Kg(Less than half)…………….. 4 LyeB Kg / †KDbv(Very few/none)……….. 5 Sec tion￾4D 4C.7 GB GjvKvi miKvix gva¨wgK¯‹z‡ji QvG/QvGx‡`i Abycw¯nwZi cÖavb 2 wU KviY wK wK ? What are the two principal reasons the secondary-school-age children from thisCommunity does not attend public secondary school? (a) ____________________________ (b) ____________________________ 4D. eq¯‹wk¶v (Grown-up Education) NO QUESTIONS AND FILTERS CODING CATEGORIES SKIP 4D.1 GB GjvKv‡Z eq¯‹wk¶vi †Kvb e¨e¯’v Av‡Q wK ? Is there an grown-up literacy campaign or program for the community? n¨vu................................................ 1 Yes bv .................................................. 2 No 4D.2 GB GjvKvq PvKzwii Rb¨ ‡Kvb cÖwk¶‡bi †cÖvMÖvg Av‡Q wK ? Are there job training programs for this community? n¨vu................................................ 1 Yes bv .................................................. 2 77 No 5. ¯^v¯’¨( HEALTH) NO QUESTIONS AND FILTERS CODING CATEGORIES S KI P 5.1 GB KwgDwbwU‡Z 6 ermi eq‡mi bx‡P wkï‡`i Amy¯’ nIqvi cÖavb 3 wU ¯^v¯’¨ mgm¨v wK wK ? What are the three principal health problems affecting children under six years of age in this community? (a) ___________________________ (b) ___________________________ (c)___________________________ 5.2 GB KwgDwbwU‡Z cÖvß eq¯‹ cyi“l‡`i Amy¯’ nIqvi cÖavb 2 wU ¯^v¯’¨ mgm¨v wK wK ? What are the two principal health problems affecting adult men in this community? (a) ___________________________ (b) ___________________________ 5.3 GB KwgDwbwU‡Z cÖvß eq¯‹ gwnjv‡`i Amy¯’ nIqvi cÖavb 2 wU ¯^v¯’¨ mgm¨v wK wK ? What are the two principal health problems affecting adult women in this community? (a) ___________________________ (b) ___________________________ 5.4 GB KwgDwbwU‡Z gv‡q‡`i Amy¯’ nIqvi cÖavb 2 wU ¯^v¯’¨ mgm¨v wK wK ? What are the two principal health problems affecting maternal health in this community? (a) ___________________________ (b)____________________________ 78 5.5 GB KwgDwbwU‡Z wkï‡`i Amy¯’ nIqvi cÖavb 2 wU ¯^v¯’¨ mgm¨v wK wK ? What are the two principal health problems affecting child health in this community? (a) ___________________________ (b) ___________________________ 5.6 GB GjvKv‡Z †Kvb ¯^v¯’¨ wK¬wbK ev nvmcvZvj Av‡Q Kx ? Does this community have a health clinic or hospital? n¨vu ................................................ 1 Yes bv .................................................. 2 No 5. 8 5.7 me‡P‡q Kv‡Qi ¯^v¯’¨ wK¬wbK ev nvmcvZvj GjvKv †_‡K KZ `~‡i ?How far is the nearest public health clinic or hospital? `~iZ¡ (‡n‡U †h‡Z KZ wgwbU jv‡M ) Distance (in walking minutes) ___________________________ 5.8 ¯^v¯’¨ wK¬wbK ev nvmcvZ†j wK memgq ..............Av‡Q/bvB ? Does the health clinic or hospital regularly have sufficient: ch©vß (Suffie nt) Ach©vß (Insufficient) bvB (no ne) 1 2 3 79 a. Ri“ix Jla Basic medicines b.hb&¿cvwZ Equipment/instruments 1 2 3 c. †ivMxi kh¨v Patient beds 1 2 3 d.G¨v¤^y‡jÝ Ambulances 1 2 3 e. wPwKrmK Physicians 1 2 3 f. bvm Nurses 1 2 3 g.Ab¨vb¨ Kgx© ( D‡jøL Ki“b) Other health staff 5.9 GB KwgDwbwU‡Z wK †Kvb cwievi cwiKíbv †cÖvMvg Av‡Q ? Does this community have a family planning program? n¨vu ................................................ 1 Yes bv .................................................. 2 No Sec tion￾6 5.10 ‡K GB †cÖvMvg ev¯Íevqb K‡i ? Who offers the program? miKvi ........................................... 1 Government GbwRI........................................... 2 NGO †emiKvix........................................ 3 Private facility 80 Ab¨vb¨( D‡jøL Ki“b ) .................. 4 (Other (specify) 5.11 GB GjvKvi †jvKRb Zv‡`i wPwKrmvi Rb¨ wK †Kvb e¨w³ ev cÖwZôv‡bi Kv‡Q †jvb K‡i ? Do the people of this community receive loans or credits from individuals or institutions for health expenditure? n¨vu ................................................ 1 Yes bv .................................................. 2 No 5.12 GB GjvKvi †jvKRb Zv‡`i wPwKrmvi Rb¨ wK Ab¨ A‡ji e¨w³ ev cÖwZôv‡bi Kv‡Q †jvb K‡i ? Do the people of this community receive loans or credits from individuals or institutions for health expenditure from outside this region? n¨vu ................................................ 1 Yes bv .................................................. 2 No 6.cwi‡ekMZ welq (ENVIRONMENTAL ISSUES) NO QUESTIONS AND FILTERS CODING CATEGORIES SKIP 6.1 GB KwDwbwU‡Z wK .............................Av‡Q ? Does this community have: a.AveR©bv †djvi RvqMv ‡hBUv b`x Ges Kzqv‡K `ywlZ K‡i (Garbage dumping that contaminates rivers or wells) nu¨v (Yes) bv(No) 1 2 b. AveR©bv †djvi RvqMv †hUv mvMi †K `~wlZ K‡i (Garbage dumping that contaminates the ocean) 1 2 81 c. Ae¨eüZ wRwbm cG †djvi RvqMv (Junk yards or scrap heaps) 1 2 d. e× Rjvkq / cvwb e×Zv(Standing water or stagnant pools) 1 2 e. KmvBLvbvi gqjv ‡djvi cvewjK †c- m (Slaughterhouses that dump waste in public places) 1 2 f.eR©¨ †Z‡ji gva¨‡g (Mechanics who dump waste oil in soil or water) 1 2 g. `~wlZ KviLvbv (Polluting industries) 1 2 h. eb cwi®‹vi Kiv ev ‡cvov‡bv (Clear-cutting or forest burns) 1 2 i. Lbb (Mining) 1 2 j. Ab¨vb¨ (D‡j- L¨ Ki“b)(Other (specify) 1 2 6.2 mvgwMÖK fv‡e GB GjvKvi cwi‡ekMZ Aeš’v †Kgb ? How is the overall Lye fvj............................. 1 Very good 82 environment in this area? fvj ................................... 2 Good †gvUvgywU ............................ 3 Average Lvivc................................ 4 Poor Lvivc................................. 5 Very poor 6.3 MZ wZb eQ‡i GB KwgDwbwUi cwi‡ekMZ Ae¯’v ‡Kgb n‡q‡Q ? What changes have been happened in this community in terms of environment? DbœwZK‡i‡Q ……………………… 1 Improved Lvivc n‡q‡Q ……………….. 2 Worsened GKB iKg Av‡Q………….…... 3 Remained the same 6.4 g~jZ: wK wK c`‡¶c †bqv †h‡Z cv‡i (2Uv Myi“Z¡c~b© welq) ? What are the two main actions that could be taken to improve the environmental conditions in this community? (a) ___________________________ (b) ___________________________ 7.K…wl (ïay MÖvgxY GjvKvi ) AGRICULTURE (only in rural areas) NO QUESTIONS AND FILTERS CODING CATEGORIES SKIP 7.1 GB GjvKvi †Kvb cÖavb 3wU K…wlKvR Ges Mevw`cï cvj‡bi Rb¨ c`‡¶cD‡`¨vM ? What are the three principal agricultural or livestock activities undertaken in this community? a) ___________________________ (b) ___________________________ (c)___________________________ 83 7.2 GB GjvKvi †jvKRb mvavibZ Zv‡`i Drcvw`Z cb¨ Ges Mevw` cï †Kv_vq wewμ K‡i ? (¸i“Z¡ Abyhvqx cÖavb 3 wU †KvW Ki“b) Where do the inhabitants of this community generally sell their livestock and produce? (List up to three venues by order of importance.) 1 2 3 GjvKvi gv‡K©U(Community market) …………… 1 Av‡k cv‡ki evRv‡i(Market in neighboring areas) …………… 2 ¯’vbxq ga¨mZ¡‡fvMx/`vjvj/)¯’vbxq e¨cvix(Domestic iddlemen …………… 3 ißvwb KviK(Exporters) …………… 4 miKvix cÖwZôvb(Public institutions) …………… 5 mgevq(Cooperatives) …………… 6 ¯’vbxq †`vKvb(Local stores and shops) …………… 7 ïaygvG wbR‡`i Rb¨ evB‡i wewμi Rb¨ bq( Only self-consumption/no outside sales) …………… 8 Ab¨vb¨ (D‡j- L¨ Ki“b) Other (specify) …………… 7.4 7.3 GjvKvi ‡jvKRb Zv‡`i cb¨ †c‡Z Ges jvf Ki‡Z wK ai‡bi mgm¨vi †gvKv‡ejv Ki‡Z nq?(2 wU ¸i“Z¡c~Y© mgm¨v wjLyb) What are the two most important problems facing members of this community for getting their products to the market and earning a profit? a) ___________________________ (b) ___________________________ 7.4 GB K…wl k&ªwgK/Drcv`K †Kvb ai‡bi cªhyw³MZ mvnvh¨ cvq Kx ? Do the agricultural n¨vu................................................ 1 Yes 84 workers/producers in this community receive technical assistance? bv .................................................. 2 No 7.6 7.5 cªhyw³MZ cÖavb mnvqZvKvixi †K? (hvPvBiæb:miKvix/‡emiKvix) Who is the main provider of this technical assistance?(Probe whether the institution is public or private.) ...................................................... 7.6 GB GjvKvi wK †Kvb cÖKv‡ii K…wl mgevq Av‡Q ? Does this community have any type of agricultural cooperative? n¨vu................................................ 1 Yes bv .................................................. 2 No 7.9 7.7 GB GjvKvi †Kvb cÖwZôvb ev e¨w³(nq GB GjvKvi A_ev KvQvKvwQ )Kx K…wl Drcv`‡bi Rb¨ †jvb Fb †`q ? Does this community have any institution or person (either in the community or nearby) that provides credit and loans to agricultural producers? n¨vu................................................ 1 Yes bv .................................................. 2 No 7.8 GB GjvKvi K…wl Drcv`‡bi Rb¨ †jvb ev Fb †`q GiKg wZbwU cÖavb e¨w³ ev cÖwZôv‡bi bvg D‡jøL Ki“b ? What are the three main persons or institutions that provide credit or loans to agricultural producers in this community? A B C miKvix e¨vsK(National banks) ............. 1 K…wl /Dbœqbe¨sK(Agricultural/development banks) ............. 2 ‡emiKvix e¨vsK(Private banks) ............. 3 K…wl Fb BDwbqb/mgevq(Agricultural credit unions or cooperatives) e¨vw³( Private individuals) ............. 4 5 85 icÍvwb KviK(Export businesses) ............. 6 c¨vwKs e¨emvqx(Packing businesses) ............. 7 Drcv`K mwgwZ(Producer associations) ............. 8 ¸`vg KviK/ga¨mZ¡‡fvMx(Warehouses or middlemen) ............. 9 Ab¨vb¨ (D‡j- L¨ Ki“b) Other (specify) ............. 10 7.9 GB GjvKvi K…wl Drcv`Kiv Ab¨ GjvKvi e¨w³ ev cÖwZôvb †_‡K †jvb ev Fb †bq Kx ? Do the agricultural producers of this community receive loans or credits from individuals or institutions in other cities or regions? n¨vu................................................ 1 Yes bv .................................................. 2 No 7.10 GB GjvKvi Drcv`K‡`i KZ kZvsk Drcv`K Zv‡`i Kv‡Ri Rb¨ †jvb ev Fb †bq? What percentage of the agricultural producers in this community use loans or credits to support their activities? ............................................. 7.11 Fb †bqvi Rb¨ Drcv`K ‡kÖbxi cÖavb 2wU mgm¨v Kx ? What are the two principal problems facing the agricultural producers of this community in terms of receiving loans and credits? a) ___________________________ (b) ___________________________ 7.12 MZ 3 eQ‡ii dm‡ji/Drcv`‡bi Ae¯nv †Kgb ? What was the condition of crop production here, in last three years? DbœwZK‡i‡Q ……………………… 1 Improved Lvivc n‡q‡Q ……………….. 2 Worsened GKB iKg Av‡Q………….…... 3 Remained the same 86 7.13 MZ 3 eQ‡ii GB GjvKvi K…wl/cï cb¨ we‡μi Ae¯nv †Kgb ? What was the condition of selling crops/ animals here, in last three years? DbœwZK‡i‡Q ……………………… 1 Improved Lvivc n‡q‡Q ……………….. 2 Worsened GKB iKg Av‡Q………….…... 3 Remained the same 8.GjvKvi mnvqZv (COMMUNITY SUPPORT) QUESTIONS AND FILTERS CODING CATEGORIES SKIP 8.1 GB GjvKv‡Z ..........ms¯’v¸‡jvi Aw¯ÍZ¡ Av‡Q ? nu¨v (Yes) bv (No) GjvKvi Dbœqb KwgwU( Community development committee) 1 2 mgevq(grm,K…wl,n¯Í wkí) Cooperative (fishing, agriculture, crafts) 1 2 wcZv /gvZv-wkÿK mwgwZ Parent-teacher association 1 2 mv¯’¨ KwgwU Health committee 1 2 hye MÖæc Youth group 1 2 ‡Ljvi `j Sports group 1 2 mvs¯‹…wZK †Mvôx Cultural group 1 2 bvMwiK †Mvôx Civic group 1 2 Ab¨vb¨(D‡jøL Kiæb) Other 1 2 87 (specify) 8.2 GB GjvKv wfwËK ms¯nv¸‡jv‡K ‡Kvb e¨w³ ev cÖwZôvb mgyn mvnvh¨ ev mg_©b K‡i _v‡K ? Which persons or organizations help or support these community based organizations? nu¨v (Yes) bv (No) bv (No) (K)¯nvbxq miKviLocal government 1 2 2 (L)RvZxq miKvi National government 1 2 2 (M)ivRbxwZex` Politicians 1 2 2 (N)ag©xq cÖwZôvb Religious organizations 1 2 2 (D)¯‹zj/wkÿK School/teachers 1 2 2 (E)GbwRI Nongovernmental organizations 1 2 2 (P)e¨emvqx Mª~cv Business group 1 2 2 (Q)mvwfm© K¬vev Service club 1 2 2 R)Mb¨gvb¨ bvMwiK Prosperous citizens 1 2 2 (S)GjvKvi mKj †jvK The community as a whole 1 2 8.3 GB GjvKvi †jvKRb wgwUs Ges mgv‡e‡ki Rb¨ ........... e¨envi K‡i ? What buildings do people in this community regularly use for meetings and gatherings? nu¨v (Yes) bv (No) 88 (K)KwgDwbwU †m›Uvi Community center 1 2 (L)wbR¯^ evwo Personal homes 1 2 (M)ivR‰bwZK ‡bZv‡`i evwo Homes of political leaders 1 2 (N)¯nvbxq †bZvi evwo Homes of other local leaders 1 2 (D)MxR©v/agx©q feb Churches or religious buildings 1 2 (E)mv¯n¨ ‡K›`ª /¯‹zj Health center/school 1 2 (P)miKvix feb Government buildings 1 2 (Q)e¨emv/evwbwR¨K feb Business/commercial buildings 1 2 (R) Ab¨vb¨(D‡j- L Ki“b ) Other (specify) 1 2 8.4 GjvKvi mgm¨v mgvav‡b Kviv †ekx Ask MÖnb K‡i ? Which members of the community participate most in solving the issues facing the community? K)wj½ Øviv (By gender) cyiyl(Men).......................................................... 1 gwnjv (Women)................................................. 2 DfqB mgvb(Men and women equally )............ 3 89 ‡KD bv(Neither participate)............................... 4 L)eqm Øviv By age hyeK I wK‡kvi (Youth and adolescents)........... 1 cÖvß eq¯‹(Adults)............................................ 2 eq¯‹ e¨w³(Older persons)................................ 3 hyeK,cÖvß eq¯‹ I eq¯‹ e¨w³ (Youth, adults, and elders equally)....................................... 4 ‡KD bv(None participate ).............................. 5 M)Kg©ms¯nv‡bi Øviv By employment status kÖwgKiv (Workers)......................................... 1 ‡eKvi A_ev kÖwgK-bv(Unemployed or non-workers).......................................... 2 bv DfqB(Workers and non-workers Equally)................................. 3 ‡KD bv (Neither participate)........................ 4 8.5 MZ 3 eQ‡i GjvKvevmx Zv‡`i cÖ‡qvRb ev mgm¨v †gvKv‡ejvq GKwGZ n‡q‡Q Kx ? In the last three years, has the community organized to address a need or problem? n¨vu ................................................ 1 Yes bv .................................................. 2 No 8.8 90 8.6 wK welq¸‡jv GB mg‡q KwgDwbwU msMwVZ K‡iwQ‡jv ? Around what issue(s) did the community organize? a) ___________________________ (b) ___________________________ 8.7 D‡`¨vM wK mdj n‡qwQj ? Was/were the initiative(s) successful? nu¨v (Yes) bv (No) eZ©gvb (K) D‡`¨vM #1 (L) D‡`¨vM #2 1 1 2 2 3 3 8.8 Ggb †Kvb 2 Uv mgm¨v ev Pvwn`v hv Avcbviv ,GKvKvevmx mgvavb Ki‡Z Pvb ? What are the two main problems or needs that community members feel must be addressed or solved? (a) ___________________________ (b) ___________________________ 8.9 GB KwgDwbwUi wbw`ó© †Kvb mnvqZv gyjyK †Kvb †cÖvMÖvg Av‡Q wK ? Are there any specific assistance programs to this community? n¨vu ................................................ 1 Yes bv .................................................. 2 No 8.11 8.10 †Kvb 2Uv †cÖvMÖvg Ges cÖwZôvb GjvKvevm †K mnvqZv K‡i ? What are the two main programs and the institutions that support them? K).‡cÖvMÖvg/cÖwZôvb Program......................... L)…cÖvMÖvg/cÖcwZôvb. Program................................. 91 8.11 GB KwgDwbwU‡Z †Kvb ai‡bi mgm¨v Av‡Q ?hw` n¨vu nq ,Kviv †ekx ¶wZMÖ¯Í ev SzwKc~b© `j(eqm Øviv,wj½ Øviv,Kvó Øviv ,ÿy`ª MÖæc Øviv,Ab¨vb¨) Do any of the following problems exist in this community? If yes, who is the most affected or at￾risk group (by age, gender, caste, ethnic group, etc.)? nu¨v (Yes) bv (No) ‡ekx ¶wZMÖ¯Í `j (K) Pzwi Burglaries 1 2 ............................... (L) WvKvwZ. Robberies 1 2 ............................... (M) AvNvZ. Assaults 1 2 ............................... (N) M¨vs Gangs 1 2 ............................... (P) wnsmv –we‡iva Vandalism 1 2 ............................... (Q) Gj‡Kvn‡ji Ace¨envi Alcohol abuse 1 2 ............................... (R) Wªv‡Mi vce¨envi Substance (drug) abuse 1 2 ............................... (S) Aí eq‡m Mf©eZx nIqv Teen pregnancy 1 2 ............................... (T) gvZ… g„Zz¨ Maternal Death 1 2 ............................... (U) wkï g„Zz¨ Child Death 1 2 ............................... (V) beRvZ‡Ki g„Zz¨ Neonatal Death 1 2 ............................... (W) Nb Nb ¯^v¯n¨ mgm¨v 1 2 ............................... (X) cvwievwiK mwnmsmZv 1 2 ............................... 92 93 1.3 SOCIAL MAPPING Improving maternal, newborn, and child health through building public-private partnerships (SUSOMA) Baseline Survey for Social Capital Measurement 2012 Guideline for community profile and asset mapping (social mapping) World Renew icddr,b IMCI section of DGHS USAID 94 Lvbvi cÖkœcÎ (Household Questionnaire) ïiæi mgq (start time) N›Uv wgwbU ‡kl nevi mgq (end time) N›Uv wgwbU 1. wba©vwiZ Lvbv mbv³Kib (identification of household) 1.1. ‡Rjv (district) ..................................... 1.2. mve-‡Rjv/Dc‡Rjv (sub-district/ Upazila) ..................................... 1.3. BEwbqb: (Union) ..................................... 1.4. kni/MÖvg (city/ village) ..................................... 1.5. IqvW© (Ward) ..................................... 1.6. cvov/gnjøv (para/ moholla) ..................................... 1.7. iv¯Ív (road) ..................................... 1.8. Lvbv bv¤^vi (Household number) ..................................... 1.9 Ab¨vb¨ we¯ÍvwiZ (Others ) ..................................... 2.0. GjvKvi aib (type of the area) kni (Urban) MÖvg(Avw`evmx bq) (village/ not indigenous) Avw`evmx (indigenous) cÖZ¨šÍ AÂj (remote) mvÿvrMÖnbKvixi bvg (Interviewer) ..................................... mycvifvBRvi bvg (Supervisor) ..................................... 95 1.1 Community profile and asset mapping (Social Mapping) KwgDwbwUi †jvKRb Zv‡`i KwgDwbwU‡Z we`¨gvb MÖvg/emwZ/Drcv`b Kvh©vejx/m¤ú` I †mevmg~n m¤ú‡K© ej‡e Ges KvM‡R gvK©vi wKsev gvwU‡Z KvwV/aviv‡jv wKQz w`‡q Zv Gu‡K †`Lv‡e| (The community people will talk about their existing area of the village, community, productive activities, resources and facilities and will draw them in the paper with marker or in the earth with stick or something sharp. ) K. GB GjvKv wU KZUzKz ch©šÍ we¯Í„Z? (a. Can you tell us about the boundary of this area?) AvbygvwbK RbmsL¨v KZ? (What is the population number?) Awfevmb nq wK? Kviv †ekx K‡i? (Have there been any cases of migration? Within which category?) KZw`b Av‡M ‡_‡K GB GjvKvwUi / †jvKvj‡qi ïiæ n‡q‡Q? (How many years has this community established?) Gi RbmsL¨v wK K‡g‡Q/ †e‡o‡Q? (Has the population been increased or decreased after that?) L. †Kv_vq †Kv_vq Av‡Q... .. .. .. .. .. ? (Where is/ are….?) 1.¯‹zj(cÖvBgvix/gva¨wgK/K‡jR/BDwbfvwm©wU/Ab¨vb¨ wk¶v cÖwZôvb) (1. schools- primary, secondary, college, university/ others) 2.¯^v¯’¨‡mevmg~n (cÖvwZôvwbK/ AcÖvwZôvwbK) (2. Health services- formal/ informal) 3.cvwb (Lvj/b`x/cyKzi) (3. Water – canal/ river/ ponds ) o e¨env‡ii Ges Lvevi cvwbi Drm (Sources for everyday usages and edible water) 96 o gvQ Pvl (fish farming) o Ab¨vb¨ (others) 4.AveR©bv †djvi RvqMv (4. waste and garbage disposal sites) 5.we`y¨r (Zvi/LuywU) (5. Electricity- cables/ poles) 6.miKvwi †Uwj‡dvb (6. Public Telephone service) 7.cÖavb moKmg~n (7. Main roads) 8.hvbevnb (cÖavbZ wK ai‡bi hvbevnb e¨envi Kiv nq) (8. Transports- types of transports usually used) 9.weμq‡K›`ª/nvU-evRvi/evwbwR¨K ¯’vcbvmg~n (wgj-KjKviLvbv Av‡Q wKbv) (9. Sales centre/ haat/ bazar/ commercial points or trade centres- presence of industries) 10.agx©q ¸iyZ¡c~Y© ¯’vbmg~n (gmwR`/gw›`i /wMR©v/gvRvi/ Ab¨vb¨) (10. Places of worship/ importance- mosque, temple, church, mazar and others) 11.mvs¯‹„wZK Ges we‡bv`‡bi ¯’vbmg~n (‡gjv/hvÎv/bvUK) (11. Cultural and recreational areas- Mela/ Jatra/ drama) 12.Awbivc` ev Kg wbivc` ¯’vbmg~n (wec`RbK RvqMv) (12. Less secured and insecured areas- places with danges) 13.‡mP e¨e¯’vmg~n (Irrigation systems) 1.2mgwóMZ KvR I mvgvwRK eÜb (Collective Action & Solidarity ) 97 K. MÖvg/cvovi mgm¨v mgvavb I Rxebgv‡bi Dbœqb n‡q‡Q -Ggb †Kv‡bv NUbv m¤ú‡K© ejyb|(MZ wZb eQ‡ii) ( wk¶v,¯^v¯’¨,miKvwi †mevmg~n,hvZvqvZ,iv¯Zv,FY,we‡bv`b I mvs¯‹…wZK Dcv`vbmg~n,wbivcËv,wkïi hZœ,‡mP,evRvi,e¨emvq,K…wl †mev) - (mKj †kÖYxi Rb¨)| (In the last three years, has there been any evidence of improvement or solution to any problem taken place in this area? Probe: – education, health, public services, communication, roads, loan, recreation and cultural elements, security, child care, irrigation, market, business, and agriculture- discuss on all these issues for all classes of people.) L. wk¶v,¯^v¯’¨,miKvwi †mevmg~n,hvZvqvZ, iv¯Zv,FY,we‡bv`b I mvs¯‹…wZK Dcv`vbmg~n,wbivcËv,wkïi hZœ,‡mP,evRvi,e¨emvq,K…wl †mevmg~‡n Zv‡`i my‡hvM-myweav| (hvPvB Kiyb: mKj †kÖYxi Rb¨)| (Education, health, public services, communication, roads, loan, recreation and cultural elements, security, child care, irrigation, market, business, and agriculture- discuss access to all these for all classes of people.) M. KwgDwbwUi †jvKRb/¯’vbxq miKvi/Ab¨vb¨ msMVbmg~n MÖvg/cvovi mgm¨v mgvavb I Rxebgv‡bi Dbœq‡b †Kv‡bv f~wgKv cvjb K‡i wKbv? (Does the community people/ local government/ other organizations play any role for the community development/ creating any solution?) wK wK mvov Av‡m? (What kind of responses are there?) wK wK evav Av‡m? (What kind of resistances are there?) (hvPvB Kiyb: ‡bZ…Z¡, cÖwZ‡iv‡ai Drmmg~n,djvdj n‡Z †K DcK…Z n‡q‡Q ev †K ¶wZMÖ¯’ n‡q‡Q ,d‡jv-Av‡ci aiY hv D‡`¨v‡gi `iyY msNwUZ n‡q‡Q, cÖ‡Póv‡K wUwK‡q ivLvi †KŠkj) (Probe: leadership, sources of resistance, who benefitted or suffered, follow-up based of efforts, mechanisms to carry on the actions) N. Dbœq‡bi †¶‡Î †Kv‡bv e¨_©Zvi NUbv Av‡Q wK? Kvibmg~n wK wK? GB e¨_©Zv ‡Kvb Dcv‡q mdj Ki‡Z cv‡i? (hvPvB Kiyb: mgwóMZ Kv‡R evav, ¯’vbxq miKv‡ii f~wgKv AbymÜvb, GjvKvi msMVb¸‡jv, cÖfvekvjx cÖwZôvbmg~n, Ges KwgDwbwUi ga¨Kvi m¤úK ©Av‡jvPbv,cÖwZwbwaZ¡Kvix msMVb,¯’vYxq miKvi,Ab¨vb¨ mykxj mgv‡Ri gvbyl) (Is there any evidences of failure while acting for development? What are the reasons? What can be done to make this a success? Probe- resistance in collective activities, explore role of local government, discussion on relationship among organizations in the community, influential organizations, community; representative organizations, local government and civil society.) 98 1.3 GjvKvi cwiPvjbv Ges wm×všZ MÖnY (Community governance and Decision-making) K. GB GjvKvi g~j †bZv Kviv? (cÖvwZôvwbK/ AcÖvwZôvwbK DfqB) wKfv‡e Zviv †bZv n‡jb? wKfv‡e Zviv wbe©vwPZ nb? †bZviv wKfv‡e wm×vš— †bb? (Who are the main leaders? – probe- formal and informal) How do they become leaders? How were they selected? How do they take decisions?) 1.4 GjvKvi cÖwZôvbmg~‡ni ZvwjKv K. GB MÖvg/cvovq Kg©iZ `j,msMVb A_ev ms¯’vi ZvwjKv Kiyb (Make a list of the active groups, organizations or institutions) (¸iyZ¡ Abyhvqx `j¸‡jvi ZvwjKv- cÖvwZôvwbK/ AcÖvwZôvwbK/ K…wlwfwËK/ FYwfwËK/ ag©wfwËK/ we‡bv`bwfwËK/ m¦v¯’¨wfwËK / wk¶vwfwËK/ c`gh©v`v) (Create this list on the basis of importance- formal/ informal/agricultural/ micro-credit/ religious/ recreational/ health/education/ status) L. ‡Kvb `j¸‡jv KwgDwbwU m`m¨‡`i g½‡ji Rb¨ me‡P‡q ‡ekx KvR K‡i K‡i? (Which groups play most active roles for the wellbeing of the members of the community?) M. GB `j ev msMVb wKfv‡e ïiy n‡qwQj(miKvwi D‡`¨vM, miKvwi A_©vqb, GbwRI A_©vqb,mvaviY RbM‡bi D‡`¨vM)? (How did these groups or organizations get initiated? Effort from the government, financial help from the government or NGO, effort from the general people) N. Zviv wKfv‡e †bZv‡`i evQvB K‡i (wbe©vPb,wb‡qvM,DËivwaKvi m~‡Î)?GB †bZ„‡Z¡i ¯’vqxZ¡ †Kgb (evievi ev nVvr cwiewZ©Z,m¦vfvweK wbq‡g cwiewZ©Z)? (How do they select leaders- election, recruitment or inheritance? How stable is this leadership- (frequent changes/ normal changes)?) O. GB `j ev msMVb¸‡jv‡Z wKfv‡e wm×vš— †bqv nq? (How are decisions made within these groups or organizations?) 1.5 msMVb¸‡jv Ges GjvKvi g‡a¨ m¤úK© (Relationships between the organizations/ institutions and the community ) 99 ‡fbwPÎ: msMV‡bi ¸iyZ¡ m¤ú‡K© Zv‡`i aviYv †`Lvi Rb¨ wZbwU wfbœ AvKv‡ii ‡Mvj KvMR e¨envi Kiyb | (Ven Diagram: Please, use three paper circles to understand community people’s perception regarding institute.) K. ¸iyZ¡ Abyhvqx msMVb¸‡jvi ZvwjKv Kiyb| (Create a list of the institutions according to their importance.) L. ‡jvKRb †Kvb msMVb¸‡jv‡Z †ekx hvq? (Which institutions are used most/ most accesible by the community people?) M. ‡Kvb msMVb¸‡jv GK‡Î KvR K‡i?Zviv wKfv‡e GK‡Î KvR K‡i? (Which institutes are working together? How do they do so?) N. Ggb †Kv‡bv msMVb Av‡Q wK †h¸‡jv GKwU Av‡iKwUi wec‡¶ KvR K‡i (cÖwZ‡hvwMZv A_ev †Kv‡bv ai‡bi Øš^)? ‡KvbwU Ges †Kb? (Are there institutions who are rival to one another? (completing with each other or have any kind of conflict of interest?) Which are those and why do they do so?) O. Ggb †Kvb msMVb Av‡Q hviv GKB iKg m¤ú` ‡fvM K‡i? (Are there any institutions which have same type of resources?) 100 1.4 ORGANIZATIONAL PROFILE Improving maternal, newborn, and child health through building public-private partnerships (SUSOMA) Baseline Survey for Social Capital Measurement 2012 Organizational Profile Scoresheet World Renew icddr,b IMCI section of DGHS USAID 101 Lvbvi cÖkœcÎ (Household Questionnaire) mv¶vrKvi ïiæi mgq (start time of interview) N›Uv wgwbU mv¶vrKvi ‡kl nevi mgq (end time of interview) N›Uv wgwbU 1. wba©vwiZ Lvbv mbv³Kib (identification of household) 1.1. ‡Rjv (district) ..................................... 1.2. mve-‡Rjv/Dc‡Rjv (sub-district/ Upazila) ..................................... 1.3. BEwbqb: (Union) ..................................... 1.4. kni/MÖvg (city/ village) ..................................... 1.5. IqvW© (Ward) ..................................... 1.6. cvov/gnjøv (para/ moholla) ..................................... 1.7. iv¯Ív (road) ..................................... 1.8. Lvbv bv¤^vi (Household number) ..................................... 1.9 Ab¨vb¨ we¯ÍvwiZ (Others ) ..................................... 2.0. GjvKvi aib (type of the area) kni (Urban) MÖvg(Avw`evmx bq) (village/ not indigenous) Avw`evmx (indigenous) cÖZ¨šÍ AÂj (remote) mvÿvrMÖnbKvixi bvg (Interviewer) ..................................... mycvifvBRvi bvg (Supervisor) ..................................... 102 1 †bZ…Z¡( LEADERSHIP) 1A. Rotation NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 1A.1 msMVbwUi †bZ…Z¡ wK wbqwgZ cwieZ©b nq? Does the organization’s leadership change regularly? nu¨v ................................ 1 (Yes) bv ..................................2 (No) 1A.2 †bZviv hZUzKz mgq Zv‡`i c‡` _v‡Kb Zv wK AwfÁZv AR©b I †bZ…‡Z¡i Kvh©vejx †kLvi Rb¨h‡_ô? Is the amount of time the leaders remain in their position sufficient for acquiring experience and learning leadership functions? nu¨v .................................1 (Yes) bv ...................................2 (No) 1A.3 mdj †bZv‡K cybivq wbe©vPb Kivi †Kvb m¤¢vebv Av‡Q wK? Is there the possibility of reelecting successful leaders? nu¨v .................................1 (Yes) bv ..................................2 (No) B. Density/Availability NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 1B.1 msMVbwUi g‡a¨ KZRb gvbyl †hvM¨ †bZv nIqvi gZ `¶Zv Ges ¸Yv¸Y AR©b K‡i‡Q? How many people within the organization have acquired the capability and qualities to be effective leaders? †KD bv………………………….1 (No one possesses these qualities) Aí msL¨K(1-3 R‡bi g‡a¨ ……….2 Few (1 to3) wKQy msLK(4-6R‡bi g‡a¨)……..…3 103 Some (4 to6) A‡b‡K (6R‡bi †ewk) …………. 4 Many (more than 6) 1B.2 KZRb †bZ…‡Z¡i c‡`i Rb¨ AvMÖnx ? How many are put forward for leadership tasks? ïaygvÎ wKQz msL¨K………………1 Only a few `‡ji g‡a¨ cÖv_©x mxwgZ wKš‘ ch©vß ..2 Candidates is limited but adequate KLbB cÖv_©xi Afve nq bv ………. 3 Never lack of candidates 1B.3 GB msMV‡bi cÖv³b †bZvi AskMÖnY wK iKg ? How amenable are former leaders to continued participation in the organization? msMVbwU bZzb; cÖv³b †bZv †bB …1 There are no previous leaders; the organization is new ‡Kvb AskMÖnYB wQjbv …………. 2 Almost no participation by former leaders wKQzUv AskMÖnY wQj………………3 Some participation by former leaders mwμq AskMÖnY wQj…………….4 Active participation by former leaders C.ˆewPÎZv/wewfbœZv (Diversity/Heterogeneity) NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 1C.1 †bZviv wK Aí wKQy `j ev cwievi †_‡K Av‡m A_ev GjvKvi 1Uv e„nËi `j †_‡K Av‡m? †bZv wK KwgDwbwUi g‡a¨ GKwU e„nr `j‡K Zz‡j ai‡Z cv‡i ? Do the leaders tend to come from a few groups or families that are always the same, or do the leaders represent a wider circle among the community? Aí msLK `j †_‡K Av‡m …………1 From few groups wewfbœ `j †_‡K Av‡m ……………2 From various groups within the community cÖvq me `j †_‡K Av‡m ……….…..3 104 From almost all the groups within the community 1C.2 eZ©gv‡b Avcbv‡`i `vwqZ¡-KZ©e¨ cvjb Ki‡Z cv‡i Ggb KZRb †bZv Av‡Qb ? How many leaders do you have now for carrying out responsibilities? ÑÑÑÑÑÑÑÑÑÑÑÑÑÑÑÑ 1C.3 GB msMV‡bi KZ kZvsk gwnjv †bZ„‡Z¡i `vwq‡Z¡ Av‡Q? What percentage of those that occupy leadership positions within the organization are women? ÑÑÑÑÑÑÑÑÑÑÑÑÑÑÑÑ(msL¨v Ges %) 1D.†bZ…‡Z¡i ¸Yv¸Y Ges `¶Zv mg~n(Leadership Quality and Skills) NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 1D1 Avcwb GB msMV‡bi †bZ…‡Z¡i gvb‡K wKfv‡e g~j¨vqb Ki‡eb †hgb￾In general, how would you characterize the quality of leadership in this organization in terms of… Lye fv‡jv Excellent fv‡jv Good ch©vß Adequate ch©vß bq Deficient wk¶v/cÖwk¶Y Education/training 1 2 3 4 mwμqZv/j¶¨ Dynamism/vision 1 2 3 4 †ckvavix/`¶Zv Professionalism/skills 1 2 3 4 mZZv/¯^”QZv Honesty/ transparency 1 2 3 4 105 2. PARTICIPATION 2A.Frequency of Meetings NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 2A.1 msMVbwUi m`m¨‡`i mvÿvr Gi msL¨v ......... Uhe frequency with which the organization meets… … … †e‡o‡Q(Greater)………………………………………..1 K‡g‡M‡Q(Less)…………………………………………2 GKB iKg Av‡Q(The same)…………………………..3 2B. (Participation in Decision making) 2B.1 MZ eQi me‡P‡q ¸iæZ¡c~b© †Kvb `ywU wm`¦všÍ †bqv n‡qwQj ? What have been the two most important decisions made in the past year? wm×všÍ #1. (Decision # 1)............................................... wm×všÍ #2(Decision # 2)................................................ 2B.2 GB wm×všÍ ¸‡jv m¤ú‡K© †f‡e ejyb ,wb‡Pi †Kvb wel‡q wmØvšÍ †bqv n‡q‡Q ? (wm×vš—‡K †KvW Kiæb # 1 cÖ_g ,Zvici wm×všÍ # 2 Gfv‡e Pvwj‡q hvb) Thinking about these decisions, did any of the following take place? (Code decision # 1 first, then continue with decision # 2.) nu¨v(Yes) bv(No) 106 wm×všÍ #1 (Decision # 1) K.c~©e n‡Z Z_¨ cªPvi a. Prior dissemination of information 1 2 L.‡Lvjv‡gjv Av‡jvPbvi myweav b. opportunity for informal discussion 1 2 M.me©mvavi‡bi mv‡_ civgk c. Consultation with grassroots 1 2 N.e„nr cwim‡i weZK©,wecÿxq gZvgZ Ges gy³ Av‡jvPbv d. widespread debate, opposing opinions and frank discussion 1 2 O.djvdj cÖKvk e. dissemination of results 1 2 wm×všÍ #2 (Decision # 2) K. c~©e n‡Z Z_¨ cªPvi a. Prior dissemination of information 1 2 L.‡Lvjv‡gjv Av‡jvPbvi myweav b. opportunity for informal discussion 1 2 M.me©mvavi‡bi mv‡_ civgk c. Consultation with grassroots 1 2 N.e„nr cwim‡i weZK©,wecÿxq gZvgZ Ges gy³ Av‡jvPbv d. widespread debate, opposing opinions and frank discussion 1 2 O.djvdj cÖKvk e. dissemination of results 1 2 2C.AšÍf~w³ Kib (Inclusiveness) NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 107 2C.1 MZ 3wU wgwUs‡q gwnjv, hyeK Ges Mixe‡`i Ask MÖnY †Kgb wQj? In the last three meetings, what has been the level of participation of women, of youth, and of the poorest groups? mwK&ªq †gvUvgywU †KDbv (Active) (Moderate) (Little/None) a.gwnjv (Women) 1 2 3 b.hyeK (Youth) 1 2 3 c.`wi`ª (Poor) 1 2 3 2C.2 weMZ wgwUs¸‡jvi mv‡_ Zzjbv Ki‡j GB Ask MÖn‡Yi cwigvY †e‡o‡Q / K‡g‡Q bvwK GKB Av‡Q? In comparison with earlier meetings, was this level of participation more, less, or the same? ‡e‡o‡Q K‡g‡Q GKB iKg (More) (Less) (Same) a.gwnjv (Women) 1 2 3 b.hyeK (Youth) 1 2 3 c.`wi`ª (Poor) 1 2 3 2C.3 cÖK…Z c‡¶ msMVbwU m`m¨‡`i †K KZUzKz Zz‡j ai‡Z cv‡i? To what degree does the organization truly represent its members? Lye fvjfv‡e (Highly representative)………………..….1 ‡gvUvgywU (Somewhat representative )………………….2 wKQyUv (Slightly representative)………………………3 G‡Kev‡iB bv (Not representative at all)………………...4 2C.4 GB KwgDwbwUi KZ kZvsk gvbyl g‡b K‡i †h Zviv msMVbwUi gva¨‡g DcK…Z n‡”Q ev Zv‡`i Pvwn`v Zz‡j aiv n‡”Q ? What percentage of the population in this community feels included as beneficiaries of the organization or feels its interests are represented by the organization? 25% Gi Kg(Less than 25% )…………………………..1 25% †_‡K 50% g‡a¨( Between 25 % and 50%)…………2 51% ‡_‡K 75% g‡a¨ (Between 51% and 75%)…………3 75% Gi †ekx (More than 75%)…………………………4 3. ORGANIZATIONAL CULTURE NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 3.1 msMVbwUi KZRb m`m¨ msMVbwUi wbqgvejx, g~j¨‡eva Ges KvR m¤ú‡K© Rv‡b? How many members know the procedures, norms, and tasks of the organization? †ewkifvM m`m¨………………………….….1 The majority of members 108 wKQz msL¨K m`m¨……………..……………...2 Some members Aí msL¨K m`m¨ …..………………………..3 Few members 3.2 msMVbwU m`m¨‡`i g‡a¨ †h mgm¨v nq Zv †gvKv‡ejv Ki‡Z wK B”QzK? How willing is the organization to confront problems with its members? LyeB B”QzK ……………….………………...1 Very willing KLbI KLbI B”QzK………………………….2 Sometimes willing ¶gZv ‡bB………………………………..…3 Little capacity 3.3 Riyix †¶‡Î Rwigvbv Ges ewn®‹vi Kiv hvq , GiKg †Kvb wb‡`©wkKv Ges wbqgvejx Av‡Q wK? For serious cases, do guidelines or rules exist to sanction, fine, or expel the transgressor? nu¨v ........................................................1 Yes bv ........................................................2 No 109 4.Organizational Capacity & Sustainability 110 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 4A. we‡kl `¶Zv mg~n-------------------- †Kgb ? (Specific Capacities) 4A.1 GB msMV‡bi mvg_©......( What is the organization’s capacity to…) Lye fv‡jv Excellent fv‡jv Good ch©vß Adequate ch©vß bq Deficient cÖ‡hvR¨ bq not applicable K. we‡klvwqZ KvR ( †hgb- FY,cÖwk¶Y, evwbwR¨KiY) a. Carry out its specialized tasks (e.g., credit, training, and commercialization)? 1 2 3 4 99 L. ZË¡veavqb ev we‡klvwqZ civgk©`vZv Ges Kg©xi mv‡_ †hvMv‡hvM b. Supervise and contract specialized consultants or staff? 1 2 3 4 99 M. e¨vsK, `vZv ms¯’v Ges miKv‡ii Rb¨ Avw_©K cÖwZ‡e`b cÖ¯‘Z Kiv c. Prepare financial reports for banks, donors, or government? 1 2 3 4 99 N.msMVb‡K cÖfvweZ Ki‡e Ggb wel‡q mgqgZ cwieZ©b Kiv (`ªe¨g~j¨ e„wØ , miKvi cwieZ©b) d. Respond in a timely fashion to changes that affect the organization (e.g., price fluctuations, change of government)? 1 2 3 4 99 O. fwel¨‡Zi we‡kl cwiKíbv MÖnY Kiv e. Develop specific plans for the future 1 2 3 4 99 P. `„wó Av‡ivc Kiv Ges AwfÁZv †_‡K Ávb jvf Kiv(cÖvwZôvwbK avibv ‰Zix Kiv) f. Reflect upon and learn from experience (build an institutional memory)? 1 2 3 4 99 111 Q. Ab¨vb¨ msMVb Ges mvgvwRK e¨w³‡`i mv‡_ mgm¨v Ges `›Ø mgvavb g. Resolve problems or conflicts with other organizations or social actors? 1 2 3 4 99 R.msMV‡bi Avf¨š—ixb `›Ø I mgm¨v‡K mgvavb Kiv| h. Resolve problems or conflicts within the organization? 1 2 3 4 99 4B.Collective Action and Formulation of Demands NO. QUESTIONS AND FILTERS CODING CATEGORIES SKI P 4B.1 GB msMVbwUi wK Ggb †Kvb wbw`©ó cÖwμqv Av‡Q hvi gva¨‡g m`m¨‡`i Pvwn`v‡K fvjfv‡e mbv³ Ki‡Z cv‡i ? Does the organization have clearly defined processes for identifying the common needs and priorities of its members? nu¨v .................................1 (Yes) bv ...................................2 (No) 4B.2 MZ wZb eQ‡i m`m¨iv Zv‡`i Pvwn`v c~i‡bi Rb¨ †Kvb AvbyôvwbK Av‡e`b K‡i‡Qb wK ? In the last three years, have there been petitions or other formal expressions of demand by the membership? nu¨v .................................1 (Yes) bv ...................................2 (No) 4B.3 m`m¨‡`i Rb¨ wK AbvbyóvwbK †Kvb Dcvq Av‡Q †hLv‡b Zviv wb‡R‡`i `vex cÖKvk Ki‡Z cvi‡e? Have there been informal ways for members to express their demands? nu¨v .................................1 (Yes) bv ..................................2 112 (No) 4B.4 wKfv‡e msMVbwUi Zv‡`i `vex mg~n‡K Zz‡j a‡i? In what way has the organization addressed these demands? me© m¤§wZ‡Z `vex D‡V Av‡m…………………..…1 Promotes demands of common interest mvaviY welq wPwýZ Kivi †Póv Kiv nq ………….2 Tries to identify common elements GKUvi ci GKUv `vex‡K μgvbymv‡i mvRv‡bv nq …3 Tries to process them one by one †Kvb `vex bvB …………………………………4 There were no demands 113 1.5 IDI AND FGD GUIDELINES Improving maternal, newborn, and child health through building public-private partnerships (SUSOMA) Baseline Survey for Social Capital Measurement 2012 In-depth Interview and Focus Group Discussion World Renew icddr,b IMCI section of DGHS USAID 114 1.1 msMV‡bi bvg (Organization’s Name) _______________________________ 1.2 msMV‡bi aib (Organization’sType) ______________________________ 1.3 m`m¨c` (Membership) ______________________________ 1.4 Ae¯’vb (Location) ______________________________ 1.5 †bZv‡`i bvg (Name of leaders) ______________________________ 2. ‡bZ…Z¡ welqK mv¶vrKvi MvBW (Leadership Interview guide) 2.K. DrcwË Ges Dbœqb (Ogigin and development) 2.K.1 Avcbvi msMVb wKfv‡e ˆZix n‡qwQj †m m¤ú‡K© Avgv‡`i GKUz ejyb ? ˆZixi Rb¨ me©waK `vwq‡Z¡ †K wQ‡jb ? ( D`vnib miKv‡ii wb‡`©k, GjvKvi wm×všZ, evB‡ii GbwRI-I civgk©) (Please, tell us about how your organization was created? Who was the most responsible person for this? Example- by the permission of government and the area or with advice from external NGO.) 2.K.2 GB msMV‡bi Kvh©μg wK Av‡Q? (Are there any activities of this organization? What are they?) 2.K.3 wK Dcv‡q msMV‡bi KvVv‡gv Ges D‡Ï‡k¨i cwieZ©b n‡q‡Q ? Avcbvi msMV‡bi AvR‡Ki cÖavb D‡Ïk¨ wK ? (How does organization’s structure and purpose get changed? What are the main purposes of your organizations currently/) 2.K.4 GB msMV‡bi Dbœq‡bi Rb¨ evB‡i †_‡K ai‡bi mvnvh¨ †c‡q‡Qb ? (Have you got any external help for development purpose of the organization?) 2.L . m`m¨c` (Membership) 2.L.1 Avcbvi msMV‡bi mv‡_ RwoZ e¨w³‡`i m¤ú‡K© wK Avgv‡`i ej‡Z cv‡ib ? Zviv wKfv‡e RwoZ n‡q‡Q ?GjvKvi me †jvK wK RwoZ ?hw` bv nq,†Kb GjvKvi wKQy m`m¨ RwoZ nq bvB ? (Can you tell about the people involved with your organization? How did they get involved? Are all the people in this area involved with this? If no, why are some members not involved?) 2.L.2 †Kb gvbyl ‡hvM w`‡q msMVb G KvR Ki‡Z B”QyK?( Kg©KZ©v/†bZv/†ev‡W©i m`m¨) gvbyl‡K 115 mšZó‡i‡L msMV‡bi KvR Pvjy ivLv wK KwVb? Zv‡`i wK ai‡bi Aby‡iva/`vex †bZ…Z¡ Ges msMV‡bi Rb¨ ? (Why do some people join or are willing to join this organization as members, leaders or board members? How hard it is to make people satisfied and work side by side? What kind of request/ demand do they have for leadership and institution?) 2.L.3 GB msMV‡bi mwμq m`m¨iv wK GjvKvi Ab¨ msMV‡bi m`m¨ ? †Kb Avcwb ej‡Z cv‡ib ? (Are active members of these institution also members of other organization in this community? Do you know why?) 2M. cÖvwZôvwbK `¶Zv (Institutional Capacity) 2 M.1 Avcwb wKfv‡e GB cÖwZôv‡bi †bZ…‡Z¡i gvb‡K wPwüZ Ki‡ eb ? (hvPvB Ki“b: ¯’vwqZ¡ ,†bZv‡`i msL¨v /cÖvc¨Zv ,ˆewPG¨Zv/†bZv‡`i wewfbœZv, †bZv‡`i gvb I `¶Zv , †bZv I Kgx© Ges GjvKvevmxi ms‡M m¤úK©?) (How would you characterize the quality of leadership of this organization, probe: stability, number of leaders/availability, diversity/heterogeneity of leadership, quality and skills of leaders, relationship of leaders to staff and to the community) 2M.2 Avcwb GB cÖwZôv‡bi AskMÖnbKvixi gvb‡K wKfv‡e wPwüZ Ki‡eb ? (hvPvB Ki“b: wgwUs G Dcw¯’wZ - msMV‡b / Ab¨vb¨ msMV‡b , msMV‡bi wm×všÍ MÖn‡b AskMÖnY , ev g~j msMV‡bi mv‡_ civgk© cÖwμqv , weZK© , mZZv, wm×všÍ MÖnb cÖwμqvi djvdj cÖPvi , GB msMV‡b KvR K‡i Ges `vwqZ¡c‡` Avmxb Ggb gwnjv ,hyeK ,`wi`ª †jv‡Ki msL¨v, GB GjvKvi †Kvb `j wK GB msMVb †_‡K wb‡R‡`i wew”Qbœ g‡b K‡i , msMV‡b wK GivB AskMÖnY K‡i hviv GKUz Mb¨gvb¨ cwiev‡ii, GB Mb¨gvb¨iv wK `qvjy , mnvqZvKvix, Ges n¯Í‡¶cKvix ev ¶wZKviK) (How would you characterize the quality of participation in this organization? Probe: attendance at meetings- internally and externally to the organization, participation in decision making within the organization, debate, honesty, dissemination of the results of the decision making process, the number of women, young people, poor people who work in the organization and who occupy positions of responsibility in the organization, whether any groups within the community feel excluded from the organization? What groups are they? the level of participation of more prosperous families (elites) in the organization, whether elites are sympathetic, supportive, interfering, adversarial, or negative influences.) 2M.3 Avcwb GB cÖwZôv‡bi mvsMVwbK ms¯‹…wZ‡K wKfv‡e wPwüZ Ki‡eb ? ((‡cÖve : c×wZ I bxwZ, c×wZi Kvh©KvwiZv Ges bxwZ Ávb Ges m¤cÖ`v‡qi g‡a¨ Ø›Ø, Ges Ø›‡Øi aiY ) 116 (How would you characterize the organizational culture of this organization? Probe: procedures and policies, effectiveness of these procedures, ethics, conflict within community and type of conflict. ) 2M.4 Avcwb GB cÖwZôv‡bi mvsMVwbK m¶gZv ‡K wKfv‡e wPwüZ Ki‡eb ? (cÖve : we‡kl Kvh©μg ( †hgb: F„Y ,evwbwR¨K Kib ) Kvh©`kx© Ges civgk©`vZv Pzw³e× Kiv , e¨vsK, `vZv Ges miKv‡ii Avw_©K cÖwZ‡e`b cÖ¯ZzwZ, cwieZ©‡bi cwiw¯’wZ‡Z cÖwZwμqv ( †hgb :`vg IVvbvgv , miKvi cwieZ©b ) (How would you characterize the organizational capacity of this organization? Probe: specialized activities- credit, commercialization; supervising and consultants, crating financial statements for bank, donor and government, response to changing circumstances- price fluctuation, change in government) 2.N. cÖvwZôvwbK ms‡hvM (Institutional Linkages) 2 N.1 Avcwb wKfv‡e Ab¨ GjvKvi msMV‡bi ms‡M Avcbvi msMV‡bi m¤úK© wPwüZ Ki‡eb ? Avcwb KLb Zv‡`i ms‡M mn‡hvMxZv/ms‡hvM ¯’vc‡bi cÖ‡qvRb g‡b Ki‡eb ? (What kind of relationship do you have with other organizations in your community? When do you feel the need to establish collaboration with them?) 2 N.2 Avcbvi wK evB‡ii MÖvg/cvovi msMV‡bi ms‡M ms‡hvM Av‡Q ?†KvbwUi ms‡M ? ms‡hv‡Mi cÖK…wZ wK ? (Do you have links with organizations external to this community? Which one? What kind of link do you have?) 2 N.3 Avcwb wK Ab¨ †Kvb msMV‡bi Õ†cÖvMÖvgÕ Ges ÕKvh©μgÕ m¤ú‡K© h‡_ó AewnZ g‡b K‡ib ? Avcbvi Z‡_¨i m~Î wK? (Do you feel that you are well aware of ‘programmes’ of other organizations? From where did you get information?) 2 N.4 Avcwb Ab¨ msMV‡bi ms‡M KvR Ki‡Z Ki‡Z GKwU cvi¯úwiK jvfRbK j‡¶¨ †cŠuQv‡bvi †Póv K‡i‡Qb ?(wRÁvmv Ki“b ,†Kvb Kvh©μ‡gi Rb¨) GUv wK GB MÖvg/cvovi msMV‡bi g‡a¨ mvavib †KŠkj ? †Kb A_ev †Kb bq? (Have you tried to get mutual benefit while working with other organization? For which activity? Is that generally present as a common strategy in this community? Why? Why not?) 2 N.5 miKv‡ii ms‡M Avcbvi m¤úK© eb©bv Ki“b ? miKv‡ii mnvqZv †c‡Z Avcwb †Póv K‡iwQ‡jb ? Avcbvi AwfÁZv wK wQj ?Avcwb wK Lyu‡R †c‡q‡Qb ,miKv‡ii †Kvb ¯—‡i AwaKvsk mn‡hvMx (¯’vbxq, †Rjv, RvZxq) ?Avcbvi msMV‡b miKvi we‡kl Aby‡iva K‡i‡Qb ? 117 (What is your relationship with government? Have you tried to get help from the government? What was your experience? Have you explored in which level does government help most? – local, district, national? Has the government made particular requests of your organization?) 2 N.6 miKv‡ii †Kvb †cÖvMÖv‡gi mv‡_ Avcbvi msMV‡bi ms‡hvM Av‡Q ? miKv‡ii †Kvb †cÖvMÖv‡gi mv‡_ Avcbvi msMV‡bi mv‡_ RwoZ? (Is your organization linked to any government program? Which government program(s) is your organization involved with?) 2 N.7 Avcwb g‡b K‡ib miKv‡ii †cÖvMÖvg /Kvh©μg h‡_ó ? Avcbvi Z‡_¨i m~Î wK? (Do you think that government’s activities are enough? What is the reference of your information?) 2 N.8Avcwb wK miKvi‡K BbcyU w`‡Z †Póv K‡i‡Qb ? cwiw¯’wZUv wK wQj ?djvdj wK n‡n‡Q ? (Have tried to provide input to government? What was the situation? Result?) 2 N.9 miKv‡ii wewfbœ Dbœqb –cwiKíbv cÖbqb cÖwμqvi †Kvb AskMÖn‡b Avcbvi msMVb†K Avgš¿b Rvbv‡bv n‡q‡Q ? (Have you ever been asked to join any government programme to create development plan?) 2 N.10 mvavibZ: Avcwb wKfv‡e †Rjv ch©v‡q miKv‡ii mx×všZ‡K Avcbvi msMV‡bicÖK…Z cÖfve gyj¨vqb Ki‡eb ? (In general, how do you assess your organization’s actual influence on government decision making at the district level?) 3. m`m¨‡`i B›UviwfD MvBW (Members Interview Guide) 3 G. msMV‡bi BwZnvm Ges KvVv‡gv (Organizational History and Structure) 3.G.1. GB `j wKfv‡e ïi“ n‡qwQj ? (Tell us, how did this groups start?) 3.G.2 Kviv `‡ji †bZv n‡q‡Q ? GLb `‡ji †bZv †K ? wKfv‡e Ges †Kb wba©vixZ mg‡q †bZ…Z¡ cwiewZ©Z n‡qwQj ? †bZ…‡Z¡i ¸bvejx wK wK ? (Who have been the leaders? Who is the leader now? How and why there were changes in leadership overtime? What qualities a leader must have?) 118 3.G.3 †Kb Avcwb GB `‡ji m`m¨ nIqvi wm×všÍ wb‡qwQ‡jb ? GB `‡ji m`m¨ n‡q Avcwb wK ai‡bi myweav ‡c‡q‡Qb ? (What does make you the leader of this group? What facilities did you receive?) 3.G4 wKfv‡e GB `‡ji †bZv wbev©wPZ nq ? wKfv‡e wm×všÍ ‡bqv nq? Avcbvi g‡Z , GB msMVb Avcbvi gZvgZ‡K wewfbœ RvqMvq Ges miKv‡ii Kv‡Q KZUzKz Zz‡j ai‡Z cv‡i ? (How are the leaders get selected? How the decision is taken? Do you think, this group can represent your concerns to the external world and the government?) 3.G.5 wKQy gvbyl †Kb GB `‡ji m`m¨ bq ? (Why some people have not been the members of this group?) 3.G.6 Avcwb wK g‡b K‡ib GB `j (MÖ“c) miKvix/ †emiKvix cÖwZôv‡bi cwie‡Z© cy‡ivcywi ev AvswkKfv‡e KvR Kivi R‡b¨ h‡_ô ? (DO you think that, this organization can complement or replace the government offices / private partially?) 3G.7 `j‡K Av‡iv †ewk Kvh©Ki Kivi Rb¨ Avcbviv wK Ki‡eb ? (What would you do to make this organization more effective?) 3we. cÖvwZôvwbK `¶Zv (Institutional Capacity) 3we.1 Avcwb wKfv‡e GB cÖwZôv‡bi †bZ…‡Z¡i gvb‡K wPwüZ Ki‡ eb ? (hvPvB Ki“b: ¯’vwqZ¡ ,†bZv‡`i msL¨v /cÖvc¨Zv ,ˆewPG¨Zv/†bZv‡`i wewfbœZv, †bZv‡`i gvb I `¶Zv , †bZv I Kgx© Ges GjvKvevmxi ms‡M m¤úK©?) (How would you characterize the quality of leadership of this organization, probe: stability, number of leaders/availability, diversity/heterogeneity of leadership, quality and skills of leaders, relationship of leaders to staff and to the community) 3we.2 Avcwb GB cÖwZôv‡bi AskMÖnbKvixi gvb‡K wKfv‡e wPwüZ Ki‡eb ? (hvPvB Ki“b: wgwUs G Dcw¯’wZ - msMV‡b / Ab¨vb¨ msMV‡b , msMV‡bi wm×všÍ MÖn‡b AskMÖnY , ev g~j msMV‡bi mv‡_ civgk© cÖwμqv , weZK© , mZZv, wm×všÍ MÖnb cÖwμqvi djvdj cÖPvi , GB msMV‡b KvR K‡i Ges `vwqZ¡c‡` Avmxb Ggb gwnjv ,hyeK ,`wi`ª †jv‡Ki msL¨v, GB GjvKvi †Kvb `j wK GB msMVb †_‡K wb‡R‡`i wew”Qbœ g‡b K‡i , msMV‡b wK GivB AskMÖnY K‡i hviv GKUz Mb¨gvb¨ cwiev‡ii, GB Mb¨gvb¨iv wK `qvjy , mnvqZvKvix, Ges n¯Í‡¶cKvix ev ¶wZKviK) 119 (How would you characterize the quality of participation in this organization? Probe: attendance at meetings- internally and externally to the organization, participation in decision making within the organization, debate, honesty, dissemination of the results of the decision making process, the number of women, young people, poor people who work in the organization and who occupy positions of responsibility in the organization, whether any groups within the community feel excluded from the organization? What groups are they? the level of participation of more prosperous families (elites) in the organization, whether elites are sympathetic, supportive, interfering, adversarial, or negative influences.) 3we.3 Avcwb GB cÖwZôv‡bi mvsMVwbK ms¯‹…wZ‡K wKfv‡e wPwüZ Ki‡eb ? ((‡cÖve : c×wZ I bxwZ, c×wZi Kvh©KvwiZv Ges bxwZ Ávb Ges m¤cÖ`v‡qi g‡a¨ Ø›Ø, Ges Ø›‡Øi aiY ) (How would you characterize the organizational culture of this organization? Probe: procedures and policies, effectiveness of these procedures, ethics, conflict within community and type of conflict. ) 3we.4 Avcwb GB cÖwZôv‡bi mvsMVwbK m¶gZv ‡K wKfv‡e wPwüZ Ki‡eb ? (cÖve : we‡kl Kvh©μg ( †hgb: F„Y ,evwbwR¨K Kib ) Kvh©`kx© Ges civgk©`vZv Pzw³e× Kiv , e¨vsK, `vZv Ges miKv‡ii Avw_©K cÖwZ‡e`b cÖ¯ZzwZ, cwieZ©‡bi cwiw¯’wZ‡Z cÖwZwμqv ( †hgb :`vg IVvbvgv , miKvi cwieZ©b ) (How would you characterize the organizational capacity of this organization? Probe: specialized activities- credit, commercialization; supervising and consultants, crating financial statements for bank, donor and government, response to changing circumstances- price fluctuation, change in government) 4. B›UviwfD MvBW: m`m¨ bq (Nonmembers Interview Guide) 4G MÖ“c #1: m`m¨ bq wKš‘ m`m¨ n‡Z Pvq (Group #1: Nonmembers who want to be members) 4.G.1 Avcwb wK g‡b K‡ib, hviv `‡ji m`m¨ bq Zviv GB msMVb †_‡K DcK„Z nq ? (Do you think that those who are non-members get benefitted from these groups?) 4.G.2 †Kb wKQy gvbyl GB `‡ji m`m¨ bq ? Avcwb †Kb m`m¨ bb ? (Why are some people not members of this organization? Why are you not a member?) 4.G.3 Avcbvi g‡Z , GB msMVb GjvKvi Ab¨vb¨ msMV‡bi mv‡_ KZUv fvimvg¨ i¶v ev cÖwZ‡hvMxZv Ki‡Z K‡i ? 120 (How far do you think this organization complements or competes with other community organizations?) 4.G.4 miKv‡ii mv‡_ `‡ji m¤ú©‡Ki welqUv‡K Avcwb wKfv‡e †`‡Lb ?( D`vnib miƒc GB m¤ú©K i¶vi †¶‡Î AvZ¥xqZvi m¤ú©K A_ev `jMZ ms‡hvM wK †Kv‡bv fywgKv cvjb K‡i) (What is your view about how the organization deals with government? (For example, does kinship or party affiliation play a role in determining the relationship?) 4.G.5 MÖv‡g/ cvovq KvR K‡i Ggb Ab¨vb¨ msMV‡bi mv‡_ GB msMV‡b i m¤ú©‡Ki welqUv‡K Avcwb wKfv‡e †`‡Lb ? (What is your view about how the organization deals with other organizations that work in the village/neighborhood?) 4we MÖ“c #2: m`m¨ bq wKš‘ m`m¨ n‡Z Pvq bv 4. we.1 Avcwb wK g‡b K‡ib, hviv `‡ji m`m¨ bq Zviv GB msMVb †_‡K DcK„Z nq ? (Do you think that those who are non-members get benefitted from these groups?) 4. we.2 †Kb wKQy gvbyl GB `‡ji m`m¨ bq ? Avcwb †Kb m`m¨ bb ? (Why are some people not members of this organization? Why are you not a member?) 4. we.3 Avcbvi g‡Z , GB msMVb GjvKvi Ab¨vb¨ msMV‡bi mv‡_ KZUv fvimvg¨ i¶v ev cÖwZ‡hvMxZv Ki‡Z K‡i ? (How far do you think this organization complements or competes with other community organizations?) 4. we.4 miKv‡ii mv‡_ `‡ji m¤ú©‡Ki welqUv‡K Avcwb wKfv‡e †`‡Lb ?( D`vnib miƒc GB m¤ú©K i¶vi †¶‡Î AvZ¥xqZvi m¤ú©K A_ev `jMZ ms‡hvM wK †Kv‡bv fywgKv cvjb K‡i) (What is your view about how the organization deals with government? (For example, does kinship or party affiliation play a role in determining the relationship?) 4. we.5 MÖv‡g/ cvovq KvR K‡i Ggb Ab¨vb¨ msMV‡bi mv‡_ GB msMV‡b i m¤ú©‡Ki welqUv‡K Avcwb wKfv‡e †`‡Lb ? (What is your view about how the organization deals with other organizations that work in the village/neighborhood?) 121 1.6 PROCESS OF CONDUCTING SOCIAL MAPPING 122 1.7 PROCESS OF CONDUCTING VENN DIAGRAM Rapid Health Facility Assessment (R-HFA) December 12, 2007 Survey Forms for core Maternal, Neonatal, and Child Health (MNCH) services at the primary level Health Facility Assessment: Directions for Users page 2 of 51 BRIEF INSTRUCTIONS FOR USE OF THE RAPID HEALTH FACILITY ASSESSMENT (R-HFA) What is the Rapid Health Facility Assessment (R-HFA)? This is a rapid assessment tool, designed specifically to aid managers assess the quality of and access to child health services at the "primary level," namely, the first level facilities. The core questions collect information on 12 key indicators of quality and access. There are also 7 optional indicators the can be collected with supplemental questions that are indicated by being highlighted in a yellow background. If these optional indicators are not desired, please delete the highlighted questions. On the other hand, if in-depth information is desired about a subject like vaccinations or growth monitoring, then project managers may want to add additional questions to supplement the information obtained in this R-HFA. What is the R-HFA based on? The R-HFA methodology is based, to a great extent, on the BASICS Integrated Health Facility Assessment (IHFA). The IHFA was developed in the late 1990s and is available online: http://www.basics.org/publications/pubs/hfa/ The indicators in the R-HFA have been formulated to conform to recent work by the International Health Facility Assessment Assessment Netwrork (IHFAN), hosted by WHO and which includes many technical agencies. An important contribution of IHFAN was to standardize health facility indicators. About half the R-HFA indicators come from an evolving standard survey drafted by the IHFAN for agencies doing national level health facility surveys. The IHFAN indicators were supplemented with indicators adapted from the Service Provision Assessment (SPA) tool of the DHS. The SPA is described on the MEASURE / Evaluation web site: http://www.cpc.unc.edu/measure/publications/html/ms-02-09-tool06.html Some indicators and elements of the methodology also come from the IMCI-based Health Facilities Survey (HFS) tool of the World Health Organization. It is quite similar to the BASICS Integrated Health Facility Assessment tool. The WHO tool and manual is available at WHO's website: http://www.who.int/child-adolescent-health/publications/IMCI/HFS.htm The source of each of the questions for the R-HFA is indicated in the right margin of each of the tools (this is placed outside the print range so as not to clutter the forms). Health Facility Assessment: Directions for Users page 3 of 51 How should one sample the Health Facilities to be assessed with the R-HFA? Which facilities should be assessed? Managers will need to make a decision about whether to include private for-profit, faith-based and/or NGO facilities among the facilities assessed. The general advice on whether or not to include a facility is to think about whether a facility is programmatically important. One should ask oneself if the program will be working directly with or trying to influence the practices in a particular facility. If so, then assessing it is probably a good idea, and it ought to be included in the sampling frame or census. Sampling First Level Health Facilities This instrument is designed to give usable data at a district level where typically one finds15-30 health facilities at the primary level. These are facilities that do not receive referrals. In cases where there is a small number of facilities and due to the rapid nature of the survey, it can be applied without sampling facilities but rather as a census. However, in most circumstances you can reduce the amount of work that needs to be carried out by sampling facilities. We recommend that you use a quality assurance approach to determine the sample size. Lot Quality Assurance Sampling (LQAS) has been used to carry out Health Facility Assessments with good results. It is a rapid and accurate method to judge whether a predetermined performance standard has been reached. There are several steps to use LQAS. The first step is to establish the performance standard. For this example, we assume that at least 80% of health facilities in a district must be of adequate quality or function well for a given performance indicator. If more than 20% are dysfunctional, then you assume there is a chronic problem in the district and that the problem must be corrected throughout the district. If fewer than 20% of health facilities are judged to be problematic then you can assume that problems in the indicator can be corrected through recurrent supervision and that they are not a priority. The second step is to determine the sample size. Typical LQAS district level samples use a simple random sample of 19 Health Facilities. This sample size is determined using binomial probabilities. It is better than 90% specific in identifying Health Facilities that function up to the performance standard and better than 90% sensitive for districts in which 50% or less are of adequate quality. Additional information about LQAS and training materials can be found in Valadez, J.J., B. Weiss, C. Leburg and R. Davis (2002), Assessing Community Health Programs: A Trainer’s Guide, London: Teaching Aids At Low Costs (TALC). A more rapid approach than using binomial probabilities is to use the hypergeometric – which in large populations will result in sample sizes similar to those calculated with binomials. However, in small universes of health facilities (say, less than 100), it is well worth the effort to use this calculation. There are a number software available to carry out the calculation, such as: http://henrylu.netfirms.com/hyper1/Apllet.html As an example, let us assume that a district has 30 Health Facilities; assuming the performance standards presented in step one, a sample of 13 health facilities would be required -- six fewer than using binomials. The third step is to choose a statistically determined decision rule to test the hypothesis that at least 80% of the health facilities in the district are of adequate quality. Using the above software, the resulting decision rule is that no more than 4 health facilities in the sample of 13 can exhibit a problem vis a vis a particular indicator for a district to pass the 80% standard. Hence, once the fifth health facility fails then the district is judged to be below the standard. With n=13 and DR=4, this design is 96% specific for districts with 80% of health facilities performing adequately. It is 93% sensitive for districts in which 50% of the health facilities fail. Health Facility Assessment: Directions for Users page 4 of 51 Different sample sizes will result in universes of different sizes. For example, a district with 20 Health facilities will require a sample of 10 and use a decision rule of 3. Using a census instead of a sample Since districts tend to have small universes of, say, N=30, one could carry out a census of all relevant facilities in the program area. These can all be assessed intensively in a three week period at baseline and again at the end of an intervention, or every 3-5 years. It does require considerably more work and expense, but it is feasible. Alternate sampling procedures In addition to LQAS approaches, one may also want to stratify by health facility type when possible. That is, if there are several large hospital outpatient departments and many smaller health facilities, it may be desirable to use a stratification scheme that ensures that at least some of the hospital OPDs are included in the sample. This will give a more valid picture of primary care service provision in the area than if the hospital OPDs were not to be included in the analysis. For a fuller explanation of a stratification scheme by type, see the the BASICS IHFA tool. http://www.basics.org/publications/pubs/hfa/hfa_chap4.htm#5 This sampling procedure is also explained in more detail in Chapter 2 of the WHO HFS manual: http://www.who.int/child-adolescent-health/publications/IMCI/HFS.htm Health Facility Assessment: Directions for Users page 5 of 51 Using a “Rolling Census” for Monitoring and Supervision This assessment tool was designed to be rapid enough that it can even be included in normal supervision used to monitor progress on an ongoing basis. During ongoing program implementation, a subset of the indicators can be used to track key performance benchmarks. Indicators #4 through #9 (inclusive) are the most useful and feasible for monitoring. They can be tracked annually by doing a "rolling census." For example, if there are 24 facilities in a district, then two facilities per month could be assessed during routine supervisory visits, and over the course of the year, all 24 would be assessed at least once. The data aggregated over that year from this “rolling census” of all primary level facilities in the district could then be analyzed as if they had been collected at the same time and the indicators would be "the score for the district primary health facilities within the last year." Managers could also carry out “rolling sampling”. The principle is the same as for a “rolling census” except that fewer health facilities need to be measured. Should an LQAS sample of 13 be needed, then one randomly selected health facility would need to be visited each month in the year. As soon as the fifth problematic health facility is detected (assuming an 80% performance standard), the sampling could stop and the district-wide problem ameliorated. Similarly, as soon as the ninth successful health facility is detected the sampling could also stop since the district automatically passes. Sampling for Clinical Cases Observed and Exit Interviews Conducted in First Level Health Facilities This set of observations should be made with the most experienced clinician in treatment of sick children. While there are different sampling schemes for obtaining random samples of cases to observe in each clinic, for the purposes of this rapid assessment, we recommend observing six consecutive cases that fit the criteria (child 1-59 months whose reason for visit is any or all of the following: fever, diarrhea, cough with rapid/difficult breathing). We are assuming that the sequencing of the patients that come to a clinician is not biased and can be treated as a simple random sample. The manager should ensure that we have no reason to suspect that the clinic is biasing the presentation of the patients by allowing the wealthiest or most politically powerful to be seen first. Also, we would not want to observe only the sickest patients or only those who live closest to the health facility because of the way the sample was chosen. In this simple random sample of cases we are looking to see if treatment of 5 of the 6 observed cases adhere to the norms. If so, then the HF is given a passing score for this indicator. The indicators that depend on observation of cases are #10 (assessment) and #11 (treatment). The caretakers interviewed should be those whose children’s care was observed. The exit interview collects the data needed for the calculation of indicator #12 (counseling). Health Facility Assessment: Directions for Users page 6 of 51 This sampling design also uses LQAS principles. The 6:1 design (a sample of 6 and 1 failure permitted) is 97% specific for identifying clinicians providing appropriate services 95% of the time. In this design we assume that clinicians should have a conservative performance standard; at least 95% of the time, they must provide adequate care to patients. The benefit of using a design with such a high level of specificity is that one can be quite certain that all or almost all of the health facilities identified as problematic do have performance problems. Very few (only 3%) of those with have reach the standard of care are incorrectly classified as having below standard performance. Explanation of the instruments in the R-HFA The short instruments of the R-HFA are included as worksheets in this Excel file, each with its own tab. The following conventions are used in these instruments: -- Questions that the interviewer asks to a respondent are in regular type like this. -- INSTRUCTIONS TO THE INTERVIEWER ARE IN CAPITALS LIKE THIS. -- Questions for optional indicators are in yellow background like this. If these indicators are not desired, these questions can be deleted with no change in numbering or flow resulting. DHO-PLANNING. This form is used for planning the survey and calculating the "Geographic Access" indicator. This form is applied initially in the planning stage for the R-HFA. Project staff approach the District Health Officer (DHO). This assists in improving partnership. There are three tables to fill out: a. line listing of all eligible facilities that could be assessed b. line listing of all community health workers that could be assessed (if your assessment will include community workers) c. line listing of all communities in the project area, wit a notation on whether they have year-round access to services. There are detailed instructions on how to determine "year-round access" in the instruction manual. There are five (5) instruments in the R-HFA. These are called "modules:" MODULE 1. Observation of Clinical Care for 6 consecutive sick children. The health worker with the most experience seeing children who is present and available is observed providing treatment. This is a brief checklist to assure that assessment, treatment, and health worker communication follow a standard protocol. It may need to be modified to the fit context. MODULE 2. Exit Interview for Caretakers of the same six consecutive sick children There are questions to determine if the caretaker understands the treatment given. There are optional questions on satisfaction with care. MODULE 3. Health Facility Checklist The facility supervisor (in small facilities, this will be the same health worker as is observed) can accompany the interviewer to walk around the facility and observe the infrastructure, equipment, supplies, and drugs available on the day of the assessment. The health worker can clarify any questions that arise. Health Facility Assessment: Directions for Users page 7 of 51 MODULE 4. Health Worker Interview & Record Review The health worker with the most experience seeing children who is present and available is interviewed. Some of the answers are verified by review of records. MODULE 5. Community Health Worker Form (WHERE APPLICABLE) In health systems that employ CHWs a sample of them can be assessed. This form has simplified elements of the HW Interview & Record Review as well as the HF Checklist. It can be used to calculate the half of the indicators that are relevant to CHWs (#5,6,7,8,9,11). How is the R-HFA implemented? One facility can be assessed by a team of two people (if not assessing CHWs) or three people (if assessing CHWs) in one morning. One person observes clinicians providing care to patients while the other interviewer carries out the Exit Interviews. Once this is finished, one can carry out the interview while the other examines the supplies, drugs and information system. However, if the facility is large then a third person could examine the supplies, drugs and information system while the other two interviewers are carrying out the interviews. In cases where CHWs are assessed, the third interviewer should specialize in locating and assesing them. The team can then move in the afternoon to the next facility to be assessed, so that the work can start first thing the next morning. In this way, one team can assess 5-6 facilities in a week. In an urban environment where travel times are not as long between facilities, it may even be possible to assess two facilities in a single day. This is likely to be unusual in most circumstances. If it is planned to assess two facilities in a day, then the team should verify that there are sufficient patients seen in a typical afternoon session at the second health facility that six sick child cases can be observed. The total number of assessors depends on the sampling approach or census selected. If 13 facilities will be assessed, then only 2 teams of two or three assessors each (4 to 6 total assessors) will be needed to assess the entire district. In this case, a single trainer can feasibly train all assessors in one district. Regardless of the choice of sampling strategy, the number of assessors will be a manageable number for two trainers to handle in an intensive three or four day training. Ideally, the interviewers/observers should be experienced health workers, preferably from the Ministry of Health. If they cannot all be HW, then one member of each team should be so (and should be the supervisor of the team). Data entry should occur in the evenings on the days of data collection. The data cleaning and preliminary analysis should be done within a few days of completion of the survey. The Excel data entry and analysis program (in the zip package on the CSTS web site) facilitate very rapid analysis. If each supervisor transcribes his/her own data for 4-6 facilities into the Excel sheets, then the HFA team leader can simply cut and paste all data into the same sheet and the tables and indicators are automatically calculated. Data can be validated by visually inspecting 20% of it for accuracy. If done this way, the team will have a clean and initially analyzed data set only 1-2 days after finishing data collection. That means that the entire process of implementation of this R-HFA (i.e., training, data collection, and initial analysis) should take about two to three weeks, with data ready at that point for feedback and planning purposes at the district level. Health Facility Assessment: Directions for Users page 8 of 51 Country adaptation of the R-HFA When adapting these generic R-HFA forms for application in a specific country context, there should be a national level consultation with knowledgeable counterparts to introduce them to the forms. During this consultation, several adaptations need to occur. In particular the following needs to happen: 1. Determine in what Districts malaria is holoendemic. In these Districts, Intermttent Presumptive Treatment (IPT) will be the norm for all pregnant women. In Districts where IPT is not the norm, then the IPT component of Indicators 5c (Essential Drugs) and 11c (Treatment for ANC) should be eliminated 2. The country norm for first line drugs for malaria, pneumonia, dysentery and neonatal sepsis need to be specified and put into the following questions: 106A First line antimalarial 106B First line oral antibiotic for pneumonia 106D First line oral antibiotic for dysentery 313NEO First line antibiotic for neonatal sepsis 314.02 First line oral antibiotic for pneumonia 314.03 First line oral antibiotic for dysentery 314.04 First line antimalarial 314.08 First line antibiotic for newborn sepsis 314.09 First line antibiotic for newborn eye infections 411.A2 First line antimalarial 411.B2 First line oral antibiotic for pneumonia 3. Determine the benchmarks that will be used for a “passing score” for a HF for the following indicators: 2. % clinical staff present (in other places, this has been 100%) 3. Infrastructure (There are 7 items. Many first level facilities will not have all these, like emergency transport) 4. Supplies (The default is all. This is 5 for the child) 5. Drugs (the default is all. This is 5 for the child) 10. Assessment tasks performed by HW (the default is all 4 tasks) You can use this link to US Census Bureau site to get national figure for crude birth rate at the national level: http://www.census.gov/ipc/www/idb/summaries.html A. LIST OF FIRST LEVEL HEALTH FACILITIES CODE Picked for sample? Name of health facility Type of facility 1 = Hospital OPD 2 = Health Center 3 = Health Post 4 = Private Office 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 Estimated crude birth rate in project area (per 1,000 population) DHO INTERVIEW (listing of HF, CHWs, and communities) CODE Picked for sample ? Name of authorized CHW 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 B. LIST OF AUTHORIZED CHWs CODE Picked for sample ? Name of authorized CHW 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 DHO INTERVIEW (listing of HF, CHWs, and communities) Population of communities with access 0 Total population 0 C. LIST OF COMMUNITIES CODE Name of community Name of nearest facility Name of nearest authorized CHW Population of community WITH access Population of community WITHOUT access 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 If no access, give reason DHO MODULE QUESTIONNAIRE (Questions to be addressed to the District Health Officer or other knowledgeable respondent at District Health Office) # a Does a District Helath Management Team (or an equivalent structure) exist? YES NO b Does the DHMT have authority to make decisions on health plans? YES NO c Personnel postings? YES NO d What level of authority does the District have to use its budget to pay staff? FULL AUTHORITY NO AUTHORITY e What level of authority for the purchase of drugs? FULL AUTHORITY NO AUTHORITY f What level authority to purchase other supplies (e.g., linen, stationery, cleaning materials)? FULL AUTHORITY NO AUTHORITY g What level of authority for spending on the repair of equipment? FULL AUTHORITY NO AUTHORITY h What level of authority to spend on the Maintanence of buildings? FULL AUTHORITY NO AUTHORITY i And what level of authority to spend on the maintanence of vehicles? FULL AUTHORITY NO AUTHORITY j Does the DHMT have guidelines for its functioning? YES NO k Do DHMT members have job descriptions? ALL HAVE NONE l How many meetings has the DHMT had in the last 12 months? YES, 4 or more YES, 2 or 3 YES, one NONE m Is there a written record of the last DHMT meeting? If so, can I see the record? YES, interviewer saw NO a Is there a District Health Plan that covers the current date? YES NO b Write in the dates covered by the District Health Plan c Who was involved in development of the District Helath Plan? (CIRCLE ALL THAT APPLY) National MOH District MOH Technical Agencies Local NGOs d What fraction of facilities in the District have health plans? ALL MORE THAN HALF LESS THAN HALF NONE e Is the plan being implemented? YES NO f Is implementation of the plan on target (i.e., up-to date)? YES, COMPLETELY NO g If not, why not? h Does the District Health Plan include a plan for monitoring and evaluation of its implementation? YES NO i If yes, who is responsible? National MOH District MOH a How does the DHMT communicate with most health centers in the District? TELEPHONE/RADIO IN FACILITY TELEPHONE/RADIO NEAR FACILITY MESSENGER MAIL b How does the DHMT communicate with most health posts in the District? TELEPHONE/RADIO IN FACILITY TELEPHONE/RADIO NEAR FACILITY MESSENGER MAIL c How many functioning vehicles are there for use per District supervisor? AT LEAST 1 PER SUPERVISOR NONE d Is there fuel today for the vehicles used for supervision? YES for all NO, no fuel in any vehicle e Does the District have a vehicle maintanence plan with budget? YES, WITH ADEQUATE BUDGET YES, BUT INADEQUATE BUDGET YES, BUT NO BUDGET NO PLAN f Does the District have a standard list of equipment that all primary level health facilities should have? YES NO g Does the District have an inventory of equipment in health facilities? YES NO h If yes, when was this last updated? WITHIN LAST 12 MO MORE THAN 12 MONTHS AGO i Does District use a written system for control of stock of medications in health facilities? YES NO j If yes, ask to see the ledger book OBSERVED NOT OBSERVED k If observed, check date of last entry WITHIN LAST 3 MONTHS MORE THAN 3 MO. AGO QUESTIONS CIRCLE ONE BEST ANSWER ADDITIONAL COMMENTS Structure & Administration of DHMT SOME AUTHORITY SOME AUTHORITY SOME AUTHORITY SOME AUTHORITY Dates of plan: YES, PARTIALLY Planning Answer: Other (please specify): Resources Others (please specify): SOME AUTHORITY SOME AUTHORITY SOME HAVE YES, but did not see LESS THAN 1 PER SUPERVISOR YES for some # MIN. No attainment 1. informal activity only 2. start of formal activity 3. some/fair progress 4. good progress 5. excellent progress MAX. complete attainment 0 points 10 points 30 points 50 points 70 points 90 points 100 points a Does DHMT keep accounts of money that can be presented on demand? No accounts are kept No records of money are kept. Records kept of money received and spent but it is difficult to know how much money is held at any one time as there is no systematic process for keeping records up to date Records kept of money received and spent. There is a systematic process for keeping recods up to date but it is not always followed Accounts are kept up-to-date and balances and statements are prepared at the end of the year, but there are inaccuracies or there is incomplete recordkeeping. Accounts are always kept up-to-date and balances and statements are prepared at the end of the year Balances and statements are prepared quarterly. At the end of the year, they are presented to external stakholders for approval b Does DHMT have a bank account to hold its funds? DHMT has no bank account. It manages its funds in cash Someone's personal account is used for any funds A bank account is registered in DHMT's name, but only one person's signature required A bank account is registered in the DHMT's name which requires dual or specific authorized check signatories. No other financial safeguards are in place. A manual or computerized record of all payments (cashbook) is kept and compared with all bank statements. This record is not well kept and/or not up to date. A manual or computerized record of all payments (cashbook) is kept and compared with all bank statements. This record is probably accurate but has not been audited within the last two years. A manual or computerized record of all payments (cashbook) is kept and compared with all bank statements. This record has been confirmed as complete and accurate by an audit within the last two years. c Does DHMT maintain supporting receipts and invoices for every expenditure? Receipts and invoices are only asked for when claiming money to justify expenses There is no requirement for keping receipts or invoices. Receipts and invoices are needed to justify expenses sometimes but rarely kept on file Receipts and invoices are needed to justify any use of money and these are kept on file but are rarely reviewed by anyone Receipts and invoices are needed to justify any use of money and these are kept on file and are reviewed about half the time. Receipts and invoices are needed to justify any use of money and these are kept on file and usually (but not always) reviewed All receipts/invoices and other supporting documents are filed for three years and are regularly reviewed by an authorized person d Does DHMT prepare, monitor, and review the budget? Budgets are prepared for every proposal but are not used for anything else Budgets are not prepared, except possibly as required by a donor. Budgets are prepared to decide how much to spend on all project and organizational costs, to ensure that there is enough money for all future plans Budgets are presented annually for approval to a representative group of members Every six months budgets are compared to money already spent and planned cash flow, to make sure there will be enough cash to keep the organization running Quarterly budgets are compared to money already spent and planned cash flow, to make sure there will be enough cash to keep the organization running. Every month budgets are compared to money already spent and planned cash flow, to make sure there will be enough cash to keep the organization running a Does DHMT have relations with NGOs implementing health activities in the District? The MOH works in isolation. There is no knowledge of the strategies or work of other organizations, like NGOs There is knowledge of other organizations' work and informal internal discussions, mainly when planning projects and with an eye not to duplicate services. There is knowledge of other organizations' work and efforts not to duplicate programming. Additionally, there have been discussions at least once in the last two years with another organization about collaboration of some kind. There is sometimes consultation with the management of other organizations in area, especially in the planning stages. There may sometimes be joint activities. When planning projects there is sometimes internal discussion as well as consultation with others to ensure no duplication and there has been at least one instance in last two years of joint activities with another organization. When planning projects there is always internal discussion as well as consultation with others to ensure no duplication and activities are often done jointly with other organizations. Have effective partnerships working together, sharing resources or referring clients to other NGO, private, or community organizations b What is the extent and nature of the DHMT's relations with central Ministry of Health? DHMT has no meetings or relations with government agencies, in particular the Ministry of Health. DHMT has some knowledge of relevant government health policies and plans. Members sometimes informally discuss these matters and how the District should work within these parameters. DHMT has knowledge of relevant government health policies and plans. Members discuss these matters and how the they should work within these parameters. Once in the last two years someone has met with the central MOH to discuss plans and/or policies. A Member of the DHMT has met at least once in the last two years with national MOH authorities Representative(s) of DHMT meet but not regularly with national MOH DHMT has regular meetings with central MOH authorities and knowledge of their plans/policies. DHMT has regular (at least twice a year) meetings with central MOH authorities. Have detailed knowledge of their plans and policies. Have done joint planning and/or evidence￾based advocacy with them at least once in last two years. c Does DHMT have relations with technical agencies (e.g., UN agencies, large NGOs, local universities, others that offer technical assistance) and knows where it can get technical assistance when needed? DHMT has no contacts or knowledge of the activities or competencies of technical agencies in the country. At least one representative of DHMT has some knowledge about technical competencies of some agencies, but they are not sure who they would contact if help was needed in a technical area like doing a baseline survey. Organization has contact, but not on a regular basis, with technical agencies. Has some knowledge of where to find assistance on technical topics in which it needs help, but either depends on an outside donor to make the contact or has experienced problems getting the required assistance more often than not. DHMT has contacts at tehcnical agencies and technical staff attend events at least several times a year either for information exchange or training. Managers also are aware of the technical agencies. But there is either usually dependence on an outside donor for contact or there have been problems in acquiring needed quality assistance on their own. DHMT has contacts at technical agencies and technical staff attend events at least several times a year either for information exchange or training. Managers also are aware of the technical agencies. DHMT shares repsonsibility for getting assistance with outside donors. DHMT usually knows where it can turn to for outside assistance but no ongoing formal relationship with outside technical agencies (like a local university or a UN agency) DHMT has ongoing realtionship or partnership with at least one technical agency, preferably local (e.g., national university) for needed technical assistance. For any type of technical assistance (e.g., baseline study, research analysis, or training for specialized area), DHMT members know specific orgainzations and individuals they can consult. Budget Management Coordination QUESTION CIRCLE BEST ANSWER (Read answers to respondent) HF Face Sheet Write a circle around the correct option response or fill in the information requested. QUESTIONNAIRE IDENTIFICATION NUMBER (For Office Use Only) ___ ___ ___ 001 Province / District Name 002 Facility Name 003 Facility Code 004 Date of assessment (dd / mm / yyyy) 005 Facility Type Hospital Affiliated Health Center / Outpatient Department 1 Health Center....2 Health Post / Dispensary .. 3 Office (private doctor, walk-in surgery) .4 006 Managing Authority Government / Public.. 1 Private Non-profit (NGO, faith-based, mission, community) 2 Private For-profit 3 007 Facility GPS Geographic Coordinates (optional) Latitude. Lat: Longitude .. Long: 008 Assessment Result Code Completed all forms  1 Partially completed forms...2 No respondent available / facility closed 3 Refused.. 4 009 Supervisor Check (circle all appropriate codes) Clinical observation form complete (6 sick children) A Exit interview of caretakers of sick children complete (6 caretakers) B Health facility checklist complete.. C Health worker interview & record review complete.D Community Health Worker form(s) complete E N/A Comments from Supervisor (Note anything unusual about data collection or interesting qualitative findings:) HF FACE SHEET - RAPID HEALTH FACILITY ASSESSMENT Consent Name of interviewer: ___________________________ Name of interviewee: ___________________________ Title of interviewee (HW, Exiting Patient, etc): ____________ Date: ___________________________ Name of interviewer: ___________________________ Title of interviewee (HW, Exiting Patient, etc): ____________ Title of interviewee: ___________________________ Date: ___________________________ Name of interviewer: ___________________________ Name of interviewee: ___________________________ Title of interviewee (HW, Exiting Patient, etc): ____________ Date: ___________________________ Name of interviewer: ___________________________ Name of interviewee: ___________________________ Title of interviewee (HW, Exiting Patient, etc): ____________ Date: ___________________________ INFORMED CONSENT - RAPID HEALTH FACILITY AS Facility Code: In FOR HW ONLY: We are asking for your help to ensure that the information appropriate person to provide the information, we would appreciate your int You may refuse to answer any question or choose to stop the interview at a proceed? YES NO Hello. My name is_________. We are here on behalf of the Ministry of Hea like to explain the survey. You / Your facility was selected to participate in this study. We will be asking patient names from the registers will be reviewed, recorded, or shared. The for planning service improvement or further studies of health services. The your name nor the name of this health facility will be provided, and any repo facility cannot be identified. Your name and all information that you give me Consent Name of interviewer: ___________________________ Name of interviewee: ___________________________ Title of interviewee (HW, Exiting Patient, etc): ____________ Date: ___________________________ Name of interviewer: ___________________________ Title of interviewee (HW, Exiting Patient, etc): ____________ Title of interviewee: ___________________________ Date: ___________________________ Name of interviewer: ___________________________ Name of interviewee: ___________________________ Title of interviewee (HW, Exiting Patient, etc): ____________ Date: ___________________________ Name of interviewer: ___________________________ Name of interviewee: ___________________________ Title of interviewee (HW, Exiting Patient, etc): ____________ Date: ___________________________ SSESSMENT (one form for each data collector in each facility) nterviewer Code: n we collect is accurate. If there are questions for which someone else is the most troducing us to that person. any time. Do you have any questions about the survey? Do I have your agreement to alth (MOH) to assist the government to know more about its health services. I would g you questions about various health services and will ask to see patient registers. No e information may be used by the MOH and organizations supporting health services data collected may also be provided to researchers for analyses; however, neither orts that use rhis facility's data will only present information in aggregate so that the e will be kept strictly confidential. Clinical Observations page 23 of 51 Facility Code: Interviewer Code: READ CONSENT FORM TO HEALTH WORKER. READ CONSENT FROM TO THE CHOSEN CARETAKERS BEFORE THEY ENTER THE CONSULTATION ROOM. OBSERVE SIX CONSECUTIVE ELIGIBLE CLINICAL CASES. ELIGIBLE CASES ARE THOSE THAT ARE SICK CHILDREN, 1-59 MONTHS OF AGE. THEY SHOULD BE SEEN FOR ANY ONE (OR A COMBINATION) OF THE THREE FOLLOWING REASONS: MALARIA OR FEVER, ARI OR RAPID OR DIFFICULT BREATHING, DIARRHEA. THERE IS A SEPARATE COLUMN FOR EACH OF THE FIVE CASES OBSERVED. FOR EACH QUESTION, CIRCLE YES, NO, OR NOT APPLICABLE. CODING CLASSIFICATION NO. QUESTIONS CASE 1 CASE 2 CASE 3 CASE 4 CASE 5 100 RECORD THE EXACT TIME THAT THE CARETAKER ENTERS THE EXAMINATION ROON TIME: TIME: TIME: TIME: TIME: 100A WHAT TYPE OF HEALTH WORKER EXAMINED THE CHILD? Doctor Nurse Other Doctor Nurse Other Doctor Nurse Other Doctor Nurse Other Doctor Nurse Other 101 AGE OF CHILD (IN COMPLETED MONTHS - 1 TO 59) 102 REASON FOR VISIT (CIRCLE ALL THAT APPLY) (SHOULD ONLY BE FOR CASES WITH FEVER/MALARIA, COUGH/RAPID OR DIFFICULT BREATHING, AND/OR DIARRHEA) cough / breathing problem fever / malaria diarrhea cough / breathing problem fever / malaria diarrhea cough / breathing problem fever / malaria diarrhea cough / breathing problem fever / malaria diarrhea cough / breathing problem fever / malaria diarrhea 103 DOES THE HEALTH WORKER. A. ASK ABOUT THE ABILITY TO FEED OR BREASTFEED? Y N Y N Y N Y N Y N B. ASK WHETHER THE CHILD VOMITS EVERYTHING? Y N Y N Y N Y N Y N C. ASK ABOUT THE PRESENCE OF CONVULSIONS? Y N Y N Y N Y N Y N 104 DOES THE HEALTH WORKER A. CHECK NUTRITIONAL STATUS ON CHILD HEALTH CARD? Y N Y N Y N Y N Y N porikkha B. CHECK VACCINATIONS ON CHILD HEALTH CARD? porikkha Y N YN YN YN YN 105 DOES THE HEALTH WORKER CLASSIFY THE CHILD AS HAVING A. FEVER OR MALARIA? Y N Y N Y N Y N Y N B. PNEUMONIA OR FAST / DIFFICULT BREATHING? Y N Y N Y N Y N Y N C. DIARRHEA WITHOUT BLOOD? Y N Y N Y N Y N Y N D. DIARRHEA WITH BLOOD? Y N YN YN YN YN MODULE 1: CLINICAL OBSERVATION OF SIX CONSECUTIVE SICK CHILDREN Clinical Observations page 24 of 51 106 DOES THE HEALTH WORKER PRESCRIBE A. FIRST LINE ANTIMALARIAL? Y N NA Y N NA Y N NA Y N NA Y N NA B. FIRST LINE ANTIBIOTIC FOR PNEUMONIA? Y N NA Y N NA Y N NA Y N NA Y N NA C. ORS (or IV fluids - only in case of severe dehydration)? Y N NA Y N NA Y N NA Y N NA Y N NA D. FIRST LINE ANTIBIOTIC FOR DIARRHEA WITH BLOOD? Y N NA Y N NA Y N NA Y N NA Y N NA E. OTHER ANTIBIOTIC? Y N NA Y N NA Y N NA Y N NA Y N NA 107 DOES HEALTH WORKER EXPLAIN TO CARETAKER HOW TO GIVE A. FIRST LINE ANTIMALARIAL? Y N NA Y N NA Y N NA Y N NA Y N NA B. FIRST LINE ANTIBIOTIC FOR PNEUMONIA? Y N NA Y N NA Y N NA Y N NA Y N NA C. ORS (or IV fluids - only in case of severe dehydration)? Y N NA Y N NA Y N NA Y N NA Y N NA D. FIRST LINE ANTIBIOTIC FOR DIARRHEA WITH BLOOD? Y N NA Y N NA Y N NA Y N NA Y N NA E. OTHER ANTIBIOTIC? Y N NA Y N NA Y N NA Y N NA Y N NA SPECIFY: ___________ ___________ ___________ ___________ ___________ 108 RECORD THE EXACT TIME THAT THE CONSULTATION ENDS TIME: TIME: TIME: TIME: TIME: Supervisor Recode for Indicator #11 (HW performance - treatment): Does classification (Q.105) match the medication prescibed (Q.106)? CASE 1 CASE 2 CASE 3 CASE 4 CASE 5 A. malaria or fever / first line antimalarial Match Match Match Match MatchNot match B. pneumonia or difficult breathing / first line antibiotic for pneumonia Match Match Match Match MatchNot match C. diarrhea without blood / ORS but no antibiotic Match Match Match Match MatchNot match D. diarrhea with blood / first line antibiotic for dysentery Match Match Match Match MatchNot match INDICATOR #11 (numerator = all match) All match All match All match All match All match Not all match NOTE ANY QUALITATIVE OBSERVATIONS HERE: Not match Not all match Not all match Not all match Not match Not match Not match Not all match Not match Not match Not match Not match Not match Not match Not match Not match Not match Not match Not match Not match Clinical Observations page 25 of 51 CASE 6 TIME: Doctor Nurse Other cough / breathing problem fever / malaria diarrhea YN YN YN YN YN YN YN YN YN Y N NA Y N NA Y N NA Y N NA Y N NA Y N NA Y N NA Clinical Observations page 26 of 51 Y N NA Y N NA Y N NA ___________ TIME: CASE 6 Match Match Match MatchAll match Not all match Not match Not match Not match Not match Exit Interview Page 27 of 51 Facility Code: Interviewer Code: OBTAIN INFORMED CONSENT FROM EACH CARETAKER IF THE SUPERVISOR HAS NOT ALREADY DONE SO. CODING CLASSIFICATION (PUT CASE CODE AT TOP OF EACH COLUMN) NO. QUESTIONS CASE 1 CASE 2 CASE 3 CASE 4 CASE 5 200 What illness(es) did the health worker tell you your child had? cough / breathing problem fever / malaria diarrhea Don't Know cough / breathing problem fever / malaria diarrhea Don't Know cough / breathing problem fever / malaria diarrhea Don't Know cough / breathing problem fever / malaria diarrhea Don't Know cough / breathing problem fever / malaria diarrhea Don't Know 201 Did the health worker give you or prescribe any YES. 1 YES. 1 YES. 1 YES. 1 YES.1 medicines today? NO (end interview) 2 NO (end interview) 2 NO (end interview) 2 NO (end interview) 2 NO (end interview) 2 202 ONLY ASK ABOUT THE MEDICATIONS FROM YOUR LIST (I.E., ORS, FIRST LINE MED FOR MALARIA, FIRST LINE MED FOR PNEUMONIA, FIRST LINE MED FOR DYSENTERY) 01 WRITE NAME OF MEDICATION 1 Med name: Med name: Med name: Med name: Med name: a. How much will you give each time? Amount: Amount: Amount: Amount: Amount: b. How many times a day will you give it? #times/day: #times/day: #times/day: #times/day: #times/day: c. For how many days will you give it? #days: #days: #days: #days: #days: 02 WRITE NAME OF MEDICATION 2 Med name: Med name: Med name: Med name: Med name: a. How much will you give each time? Amount: Amount: Amount: Amount: Amount: b. How many times a day will you give it? #times/day: #times/day: #times/day: #times/day: #times/day: c. For how many days will you give it? #days: #days: #days: #days: #days: 03 WRITE NAME OF MEDICATION 3 Med name: Med name: Med name: Med name: Med name: a. How much will you give each time? Amount: Amount: Amount: Amount: Amount: b. How many times a day will you give it? #times/day: #times/day: #times/day: #times/day: #times/day: c. For how many days will you give it? #days: #days: #days: #days: #days: Thank you for participating. We will use this information to help improve health services in this area. CASE 1 CASE 2 CASE 3 CASE 4 CASE 5 Is the caretaker's description of medication dose, MED1 Correct Not Corr. frequency, and duration correct (Q.202)? MED2 Correct Not Corr. MED3 Correct Not Corr. All correct Not all correct NOTE ANY QUALITATIVE OBSERVATIONS HERE: Supervisor Recode for Indicator #12 (HW performance - counseling) Indicator #12 (numerator = all correct) All correct Not all correct All correct Not all correct Correct Not Corr. Correct Not Corr. All correct Not all correct All correct Not all correct Not Corr. Correct Not Corr. Correct Not Corr. Correct Not Corr. Correct Not Corr. Correct Not Corr. Correct Not Corr. MODULE 2: EXIT INTERVIEW (CARETAKERS OF SIX OBSERVED SICK CHILDREN) Can you please show me the medications or prescriptions given to you by the health worker? 2," AND "MEDICINE 3.") ASK HER ABOUT THE AMOUNT TO BE GIVEN EACH TIME, THE NUMBER OF TIMES A DAY TO GIVE IT, AND THE NUMBER OF DAYS IT IS TO BE GIVEN. ASK THE MOTHER TO SHOW YOU EACH MEDICINE OR PRESCRIPTION GIVEN TO HER. THEN WRITE DOWN THE NAME OF EACH MEDICINE BELOW (UNDER "MEDICINE 1," "MED. Correct Not Corr. Correct Not Corr. MEDICATION 1 MEDICATION 2 MEDICATION 3 Correct Not Corr. Correct Exit Interview Page 28 of 51 CASE 6 cough / breathing problem fever / malaria diarrhea Don't Know YES.1 NO (end interview) 2 Med name: Amount: #times/day: #days: Med name: Amount: #times/day: #days: Med name: Amount: #times/day: #days: CASE 6 All correct Not all correct Correct Not Corr. Correct Not Corr. Correct Not Corr. Health Facitity Checklist page 29 of 51 Facility Code: Interviewer Code: OBTAIN INFORMED CONSENT NO. QUESTIONS CODING CLASSIFICATION OBSERVE TO SEE IF EACH OF THE FOLLOWING STRUCTURES EXISTS IN THE FACILITY. IF IT DOES EXIST, ASK TO BE SHOWN IT SO YOU CAN INSPECT IT 301 Does this facility have overnight or inpatient beds? YES  1 NO  2 302 Is there 24-hour staff coverage? YES, 24-HOUR DUTY ROSTER OR STAFF LIVE ONSITE .1 IF YES, ASK TO SEE A DUTY ROSTER FOR OVERNIGHT STAFFING NO DUTY ROSTER NOR STAFF LIVE ONSITE .. 2 IF STAFF LIVE ON SITE, MARK "1." 303 Does this facility have a working phone or shortwave radio that is YES, OBSERVED ONSITE OR WITHIN 5 MINUTES WALK .. 1 available at all times client services are offered? YES, REPORTED ONSITE OR WITHIN 5 MINUTES WALK .2 COUNT AS RESPONSE "3" IF HW HAS A CELL PHONE THAT PAY PHONE OR HW CELL PHONE  3 FUNCTIONS IN THE FACILITY NO .4 304 Does this facility have a functional ambulance or other vehicle YES, OBSERVED FUNCTIONING AND WITH FUEL .. 1 on site for emergency transport for clients? YES, REPORTED FUNCTIONING AND WITH FUEL .. 2 IF YES, ASSESS IF VEHICLE IS FUNCTIONING & THERE IS FUEL VEHICLE BUT NO FUEL .3 ACCEPT REPORTED RESPONSE NO VEHICLE .. 4 305 Does this facility have electricity functioning now? YES, OBSERVED  1 COUNT AS "YES, OBSERVED" IF ELECTRICITY IS OBVIOUSLY NO  2 RUNNING OR IF YOU CAN TURN ON AN ELECTRICAL SWITCH AND GET ELECTRICITY 306 Does this facility have a back-up or standby generator for electricity? YES OBSERVED FUNCTIONING AND WITH FUEL  1 IF YES, ASSESS IF THE GENERATOR IS FUNCTIONING AND YES OBSERVED FUNCTIONING AND BUT NO FUEL .. 2 FUEL IS AVAILABLE. ACCEPT REPORTED RESPONSE YES, REPORTED FUNCTIONING AND WITH FUEL .. 3 YES, REPORTED FUNCTIONING BUT NO FUEL  4 NO .5 307 Is there a toilet or latrine that is available for clients' to use? YES  1 THIS TOILET OR LATRINE MUST BE FOR THE USE OF CLIENTS, NO  2 NOT JUST HEALTH FACILITY STAFF 308 ASK TO SEE THE TOILET OR LATRINE AND INDICATE THE TYPE FLUSH / POUR FLUSH:  1 VENTILATED IMPROVED PIT LATRINE (VIP)  2 IF THERE ARE MULTIPLE TOILET FACILITIES, CIRCLE THE SIMPLE PIT LATRINE .3 RESPONSE THAT CORRESPONDS TO THE HIGHEST QUALITY COMPOSTING TOILET .4 TYPE. THIS IS THE TYPE WITH THE LOWEST NUMBER. OPEN PIT  5 BUCKET  6 HANGING TOILET / LATRINE  7 OTHER ______________________  8 MODULE 3: HEALTH FACILITY CHECKLIST (INFRASTRUCTURE, EQUIPMENT, SUPPLIES, DRUGS) Health Facitity Checklist page 30 of 51 309 IS THE TOILET OR LATRINE USABLE? YES  1 TO BE UNUSABLE, THE LATRINE IS NOT SIMPLY DIRTY, BUT NOT NO  2 IN FUNCTIONING CONDITION (THAT IS, CANNOT BE USED) UNABLE TO OBSERVE 3 310 Does the health facility have water available today? YES  1 NO  2 311 Could you please tell me where the health facility is getting PIPED INTO FACILITY  1 water for hand washing today. PIPED ONTO FACILITY GROUNDS .. 2 WATER CAN BE EITHER ON SITE OR WITHIN 500m OF THE SITE PUBLIC STANDPIPE .. 3 TUBE WELL / BOREHOLE ON GROUNDS .. 4 IF THERE ARE MULTIPLE WATER SOURCES, PLEASE CIRCLE PROTECTED DUG WELL ON GROUNDS  5 THE ONE RESPONSE THAT CORRESPONDS TO THE MOST BOTTLED WATER  6 COMMONLY USED WATER SOURCE. RAINWATER, SURFACE WATER, OR TANKER TRUCK .7 OTHER _____________________________ .. 8 312 Can you please show me where children are seen for treatment VISUAL AND AUDITORY PRIVACY  1 INSPECT FOR AUDITORY AND VISUAL PRIVACY. VISUAL BUT NOT AUDITORY PRIVACY .2 MARK AS "BOTH" IF THERE IS A DOOR THAT CAN CLOSE VISUAL NOR AUDITORY PRIVACY .3 MARK AS "VISUAL" IF THERE IS A DRAPE OR CURTAIN IN THE CHILD CONSULTATION AREA, CHECK WHETHER EACH OF THE ITEMS BELOW IS EITHER IN THE ROOM WHERE THE SERVICE IS GIVEN OR IN AN ADJACENT ROOM. 313 ITEMS FOR SICK (a) AVAILABILITY (b) FUNCTIONING CHILD CONSULTATIONS OBSERVED REPORTED, NOT DON'T YES NO DON'T NOT SEEN AVAILABLE KNOW KNOW 01 Optional (for Infection Control):1 b 2 b 3 9 1 2 9 Electric autoclave or dry heat sterilizer 02 Refrigerator for storing vaccines 1 b 2 b 3 9 1 2 9 03 Infant scale that is 1 b 2 b 3 9 1 2 9 accessible 04 Adult (standing) scale that is 1 b 2 b 3 9 1 2 9 accessible 05 Timer or watch with second hand 1 b 2 b 3 9 1 2 9 06 Jar or pitcher for oral 1 2 3 9 rehydration solution (ORS) 07 Cup and spoon for oral rehydration 1 2 3 9 IN THE DELIVERY ROOM/NURSERY CONSULTATION AREA, CHECK WHETHER EACH OF THE ITEMS BELOW IS EITHER IN THE ROOM WHERE THE SERVICE IS GIVEN OR IN AN ADJACENT ROOM. 313NEO ITEMS FOR DELIVERY AND IMMEDIATE (a) AVAILABILITY (b) FUNCTIONING NEWBORN CARE OBSERVED REPORTED, NOT DON'T YES NO DON'T NOT SEEN AVAILABLE KNOW KNOW 01 Optional (for Infection Control):1 b 2 b 3 9 1 2 9 Electric autoclave or dry heat sterilizer 02 Neonatal resuscitation device (tube & mask or bag and mask) 1 b 2 b 3 9 1 2 9 03 Infant scale that is accessible 1 b 2 b 3 9 1 2 9 04 Vacuum extractor (for deliveries) 1 b 2 b 3 9 1 2 9 05 Baby wraps (e.g. blankets) 1 b 2 b 3 9 06 Partograph (at least one blank one) 1 b 2 b 3 9 Health Facitity Checklist page 31 of 51 313ANC IN THE ANC CONSULTATION AREA, CHECK WHETHER EACH OF THE ITEMS BELOW IS EITHER IN THE ROOM WHERE THE SERVICE IS GIVEN OR IN AN ADJACENT ROOM. ITEMS FOR ANC (a) AVAILABILITY (b) FUNCTIONING CONSULTATIONS OBSERVED REPORTED, NOT DON'T YES NO DON'T NOT SEEN AVAILABLE KNOW KNOW 01 Optional (for Infection Control):1 b 2 b 3 9 1 2 9 Electric autoclave or dry heat sterilizer 02 Refrigerator or cold box for storing tetanus toxoid vaccines 1 b 2 b 3 9 1 2 9 03 Blood Pressure Machine 1 b 2 b 3 9 1 2 9 04 Hemoglobin reagents 1 b 2 b 3 9 05 Syphilis testing kit 1 2 3 9 06 Malaria testing supplies 1 2 3 9 07 Albustix for testing for protein 1 2 3 9 ASK TO SEE THE FOLLOWING DRUGS AND SUPPLIES. IF THE ITEM IS LOCATED IN A DIFFERENT PART OF THE FACILITY, GO THERE TO OBSERVE IT. IF YOU ARE UNABLE TO SEE AN ITEM, ASK IF IT IS AVAILABLE AND THE EXPIRATION DATES HAVE NOT PASSED. FOR EACH ITEM, CIRCLE THE APPROPRIATE CODE. 314 CHILD DRUGS AND (a) AVAILABLE TODAY (b) (OPTIONAL) TREATMENTS OUT OF STOCK OBSERVED AND AVAILABLE NOT OBSERVED IN LAST 6 MONTHS AVAILABLE AVAILABLE AVAILABLE REPORTED NOT AVAIL- NEVER ALL AT LEAST BUT NONE AVAILABLE, ABLE TODAY / AVAIL- YES NO DON'T VALID ONE VALID VALID NOT SEEN DON'T KNOW ABLE KNOW 01 ORS packets 1 b 2 b 3 4 5 6 1 2 9 02 First line oral drug for child pneumonia 1 2 b 3 4 5 6 1 2 9 03 First line oral drug for child dysentery 1 b 2 b 3 4 5 6 1 2 9 (bloody diarrhea) 04 First line oral antimalarial 1 b 2 b 3 4 5 6 1 2 9 05 Vitamin A 1 b 2 b 3 4 5 6 1 2 9 06 Optional: Insecticide Treated Net (ITN) 1 b 2 b 3 4 5 6 1 2 9 ASK TO SEE THE FOLLOWING DRUGS AND SUPPLIES. IF THE ITEM IS LOCATED IN A DIFFERENT PART OF THE FACILITY, GO THERE TO OBSERVE IT. IF YOU ARE UNABLE TO SEE AN ITEM, ASK IF IT IS AVAILABLE. FOR EACH ITEM, CIRCLE THE APPROPRIATE CODE. 314NEO NEWBORN & DELIVERY DRUGS AND (a) AVAILABLE TODAY (b) (OPTIONAL) TREATMENTS OUT OF STOCK OBSERVED AND AVAILABLE NOT OBSERVED IN LAST 6 MONTHS AVAILABLE AVAILABLE AVAILABLE REPORTED NOT AVAIL- NEVER ALL AT LEAST BUT NONE AVAILABLE, ABLE TODAY / AVAIL- YES NO DON'T VALID ONE VALID VALID NOT SEEN DON'T KNOW ABLE KNOW 01 Antibiotics for newborn infections (except eye) 1 2 3 4 5 6 1 2 9 02 Antibiotics for newborn eye infections 1 2 3 4 5 6 1 2 9 03 Oxytocin 1 2 3 4 5 6 1 2 9 04 Niveripin (in high HIV prevalence settings) 1 2 3 4 5 6 1 2 9 Health Facitity Checklist page 32 of 51 ASK TO SEE THE FOLLOWING DRUGS AND SUPPLIES. IF THE ITEM IS LOCATED IN A DIFFERENT PART OF THE FACILITY, GO THERE TO OBSERVE IT. IF YOU ARE UNABLE TO SEE AN ITEM, ASK IF IT IS AVAILABLE. FOR EACH ITEM, CIRCLE THE APPROPRIATE CODE. 314ANC ANC DRUGS AND (a) AVAILABLE TODAY (b) (OPTIONAL) TREATMENTS OUT OF STOCK OBSERVED AND AVAILABLE NOT OBSERVED IN LAST 6 MONTHS AVAILABLE AVAILABLE AVAILABLE REPORTED NOT AVAIL- NEVER ALL AT LEAST BUT NONE AVAILABLE, ABLE TODAY / AVAIL- YES NO DON'T VALID ONE VALID VALID NOT SEEN DON'T KNOW ABLE KNOW 01 Tetanus toxoid vaccines 1 b 2 b 3 4 5 6 1 2 9 02 Iron/folic acid 1 b 2 b 3 4 5 6 1 2 9 03 First line oral antimalarial for IPT 1 b 2 b 3 4 5 6 1 2 9 04 Insecticide Treated Net (ITN) 1 b 2 b 3 4 5 6 1 2 9 Opt CHILD IMMUNIZATIONS AVAILABLE AVAILABLE AVAILABLE REPORTED NOT AVAIL- NEVER ALL AT LEAST BUT NONE AVAILABLE, ABLE TODAY / AVAIL- YES NO DON'T 314A VALID ONE VALID VALID NOT SEEN DON'T KNOW ABLE KNOW 01 BCG vaccine 1 b 2 b 3 4 5 6 1 2 9 02 OPV (Polio) vaccine 1 b 2 b 3 4 5 6 1 2 9 03 DPT or Pentavalent vaccine 1 b 2 b 3 4 5 6 1 2 9 04 Measles or MMR vaccine 1 b 2 b 3 4 5 6 1 2 9 Opt ASK TO SEE THE FOLLOWING OBSERVED AND REPORTED, NOT DON'T 314B GUIDELINES IN PATIENT AREA NOT SEEN AVAILABLE KNOW 01 Sick child care 1 2 3 9 02 Immunization 1 2 3 9 03 Delivery 1 2 3 9 04 Antenatal Care 1 2 3 9 05 Postnatal care for new mothers 1 2 3 9 06 Newborn Care 1 2 3 9 07 Other: P-MTCT 1 2 3 9 Opt ITEMS FOR INFECTION (a) AVAILABILITY 314C CONTROL OBSERVED REPORTED, NOT DON'T NOT SEEN AVAILABLE KNOW 01 Chlorine-based disinfectant 1 2 3 9 02 Latex gloves (clean or sterile) 1 2 3 9 03 Sharps container 1 2 3 9 04 At least one 5 ml syringe in sterile 1 2 3 9 packet 05 At least one 19 or 21 gauge needle 1 2 3 9 in sterile packet (may be with syringe) 06 Hand washing soap (bar or liquid) 1 2 3 9 Health Facitity Checklist page 33 of 51 Opt Now I would like to ask you a few questions about the waste disposal i. SHARPS ii. INF. WASTE 314D practices for sharp items such as needles or blades, including filled sharps INCINERATOR - HIGH TEMPERATURE (2 CHAMBER)  1 .1 containers, and for infected waste, such as bandages and intravenous tubes. INCINERATOR - ONE CHAMBER, DRUM OR BRICK .. 2 .. 2 Can you please tell me what is the final disposal process for filled sharps boxes BURN AND BURY .. 3  3 and for infected waste? BURY BUT NOT BURN .. 4 .4 PUT IN COVERED PIT (MAY BE LATRINE) .. 5 .. 5 BURN (IN GROUND OR PIT), BUT NOT BURY .. 6  6 OPEN TO AIR (NO BURN OR BURY) .. 7  7 STORE AND REMOVE OFFSITE (MAY BE BURNED PRIOR) .. 8 .. 8 NEVER HAVE ITEMS . 9 .. 9 Opt ASK TO SEE THE PLACE USED TO DISPOSE OF SHARPS AND i. SHARPS ii. INF. WASTE 314E INFECTIOUS WASTE. INDICATE IF THE SITE IS PROTECTED AND IF YES, PROTECTED AND WASTE IS VISIBLE .. 1 .1 THERE IS EXPOSED WASTE OR NOT. YES, PROTECTED AND NO WASTE VISIBLE .2  2 "PROTECTED" IS DEFINED AS: INSIDE A LOCKED FENCE OR ROOM NO, NOT PROTECTED AND WASTE VISIBLE .. 3 .3 OR A PIT OR TRASH BIN WITH A LID (E.G., COVERED PIT LATRINE) NO, NOT PROTECTED AND NO WASTE VISIBLE  4 .4 SUCH THAT UNAUTHORIZED PERSONS CANNOT EASILY GAIN SITE NOT OBSERVED .. 5 .5 ACCESS Malaria ASK TO SEE THE RECORD SYSTEM FOR ORDERING AND ACCEPTING DELIVERY OF DRUGS AND SUPPLIES. IF YOU ARE NOT ABLE Opt TO SEE THE RECORDS THEN ASK FOR THE FOLLOWING INFORMATION. REVIEW THE FIRST LINE ANTI-MALARIAL (ACT) 314F OBSERVED NOT OBSERVED 01 Review the date of the most recent order of DATE IS anti-malarial / ACT and tell me the date please. DATE IS IN MORE THAN DATE IS IN DATE IS LAST 3 MO. 3 MO. NO DATE LAST 3 MO. MORE THAN NO DATE (1) (2) (3) (4) (5) (6) 02 Review the quantity of the most recent delivery . DELIVERY DELIVERY DOES QUANTITY DELIVERY DELIVERY DOES QUANTITY Is this amount the same as the quantity ordered? AGREES WITH NOT AGREE IN ORDER AGREES WITH NOT AGREE IN ORDER ORDER WITH ORDER MISSING ORDER WITH ORDER MISSING (1) (2) (3) (4) (5) (6) 03 Does the Balance as recorded in the Records NO NO Agree with the quantity in the Stores/Pharmacy YES DOES NOT YES DOES NOT (CARRY OUT A HAND COUNT IF POSSIBLE OR AGREE AGREE AGREE AGREE ASK YOUR INFORMANT TO DO SO) (1) (2) (4) (5) 04 Have any of the First Line Anti-Malarials / ACT NO DATE NO DATE passed their expiration date? YES NO VISIBLE YES NO VISIBLE (1) (2) (3) (4) (5) (6) 05 Does this Health Facility have a plan to dispose of expired Drugs? YES NO IF THE RESPONSE IS YES THEN ASK APPROPRIATE APPROPRIATE What is that plan? PLAN EXISTS PLAN DOES DID NOT NOT EXIST KNOW (1) (2) (3) 06 Please show me where or how expired drugs are APPROPRIATE NO APPROPRIATE COULD NOT destroyed? PLAN IN USE PLAN IN USE OBSERVE (1) (2) (3) REVIEW ENTRIES ABOUT ITN / LLIN 314G OBSERVED NOT OBSERVED 01 Review the date of the most recent order of DATE IS IN DATE IS DATE IS IN DATE IS ITN / LLIN and tell me the date please. LAST 3 MO. MORE THAN NO DATE LAST 3 MO. MORE THAN NO DATE 3 MO. (1) (2) (3) (4) (5) (6) 02 Review the quantity of the most recent delivery . DELIVERY DELIVERY DOES QUANTITY DELIVERY DELIVERY DOES QUANTITY Is this amount the same as the quantity ordered? AGREES WITH NOT AGREE IN ORDER AGREES WITH NOT AGREE IN ORDER ORDER WITH ORDER MISSING ORDER WITH ORDER MISSING (1) (2) (3) (4) (5) (6) 03 Does the Balance as recorded in the Records NO NO Agree with the quantity in the Stores? YES DOES NOT YES DOES NOT (CARRY OUT A HAND COUNT IF POSSIBLE OR AGREE AGREE AGREE AGREE ASK YOUR INFORMANT TO DO SO) (1) (2) (4) (5) NOTE ANY QUALITATIVE OBSERVATIONS HERE: Health Facitity Checklist page 34 of 51 GO TO 310 Health Facitity Checklist page 35 of 51 312 Health Facitity Checklist page 36 of 51 Health Facitity Checklist page 37 of 51 Health Facitity Checklist page 38 of 51 Health Worker Interview Page 19 of 51 Facility Code: Interviewer Code: SPEAK TO THE MOST EXPERIENCED HEALTH WORKER INVOLVED IN MANAGEMENT OF CURATIVE CHILD HEALTH SERVICES. IT IS BEST TO APPLY THIS FORM AFTER PATIENT SESSIONS HAVE FINISHED. OBTAIN INFORMED CONSENT, IF YOU HAVE NOT ALREADY DONE SO. NO. QUESTIONS CODING CLASSIFICATION GO TO 401 For each of the following services, please tell me whether the service is offered by your facility, and if so, how many days per month the service is provided either at the facility or as outreach services. FOR THE PURPOSES OF THIS QUESTION, A MONTH IS EQUIVALENT TO FOUR WORK WEEKS. 01 Consultation or curative services for sick children A. # OF DAYS PER MONTH IN FACILITY IF NONE, WRITE "00" IF ALL WEEKDAYS, WRITE "20" B. # DAYS PER MONTH IN OUTREACH LOCATIONS IF ALL DAYS including weekends, WRITE "30" IF ONE TIME PER WEEK, WRITE "4" 02 Routine immunizations for children A. # OF DAYS PER MONTH IN FACILITY IF NONE, WRITE "00" IF ALL WEEKDAYS, WRITE "20" B. # DAYS PER MONTH IN OUTREACH LOCATIONS IF ALL DAYS including weekends, WRITE "30" IF ONE TIME PER WEEK, WRITE "4" 03 Growth monitoring & promotion - where a healthy child is routinely A. # OF DAYS PER MONTH IN FACILITY weighed, has weight charted on growth chart, feeding advice given IF NONE, WRITE "00" IF ALL WEEKDAYS, WRITE "20" B. # DAYS PER MONTH IN OUTREACH LOCATIONS IF ALL DAYS including weekends, WRITE "30" IF ONE TIME PER WEEK, WRITE "4" 04 Antenatal care A. # OF DAYS PER MONTH IN FACILITY IF NONE, WRITE "00" IF ALL WEEKDAYS, WRITE "20" B. # DAYS PER MONTH IN OUTREACH LOCATIONS IF ALL DAYS including weekends, WRITE "30" IF ONE TIME PER WEEK, WRITE "4" 05 Normal delivery services A. # OF DAYS PER MONTH IN FACILITY IF NONE, WRITE "00" IF ALL WEEKDAYS, WRITE "20" B. # DAYS PER MONTH IN OUTREACH LOCATIONS IF ALL DAYS including weekends, WRITE "30" IF ONE TIME PER WEEK, WRITE "4" MODULE 4: HEALTH WORKER INTERVIEW & RECORD REVIEW Health Worker Interview Page 20 of 51 NO. QUESTIONS CODING CLASSIFICATION GO TO 402 Now I would like to ask you about the health personnel that work in this facility. I will read the type of health worker and for each one I would like you to tell me the number sanctioned by the Ministry of Health to work in this facility and the ones who are here today. JOB OF HEALTH WORKER A. # WORKERS SANCTIONED B. # WORKERS WHO ARE TO WORK IN THIS FACILITY PRESENT TODAY (FULL OR PART-TIME) 01 DOCTOR 02 REGISTERED / CERTIFIED NURSE 03 REGISTERED / CERTIFIED MIDWIFE 04 OTHER CLINICAL CARE STAFF (CLINICAL OFFICER, ETC.) 05 PHARMACIST 06 LABORATORY TECHNICIAN 07 ALL OTHER ASSIGNED STAFF (for instance, clerical staff, cleaning staff, etc.) 403 During the past three years have you received any pre-service or in-service training on subjects YES  1 related to maternal, child, or newborn health or illness? NO  2 405 Health Worker Interview Page 21 of 51 NO. QUESTIONS CODING CLASSIFICATION GO TO 404 Did you receive the training in any topic related to YES, IN YES, IN NO TRAINING the following topics that I will read? PAST PAST 2-3 WITHIN PAST IF YES, THEN ASK: 12 MONTHS YEARS 3 YEARS When was your most recent training? READ THE LIST 01 Immunizations 12 3 02 Treatment of pneumonia or Acute Respiratory Infections 1 2 3 03 Diarrhea treatment 12 3 04 Malaria treatment for children 12 3 04b IF YES ASK: Did this training include treatment with ACTs? YES, in last 12 months YES, in last 2-3 years NO (1) (2) (3) 05 Malaria prevention / Use of ITNs 1 2 3 06 IPT for pregnant women 12 3 07 Nutrition (for instance, complementary feeding, micronutrients) 1 2 3 08 Breastfeeding 12 3 09 Integrated Management of Childhood Illness (IMCI) 1 2 3 10 Newborn care 12 3 11 Postnatal care for new mothers 12 3 12 Antenatal care topics (like STI controil, nutrition in pregnancy) 1 2 3 13 Infection prevention and control 12 3 14 Active management of the third stage of labor (AMTSL) 1 2 3 15 Referral protocols for obstetric and newborn emergencies 1 2 3 405 Now I would like to ask you some questions about YES, IN THE PAST 3 MONTHS . 1 specifically speaking about supervision from a supervisor YES, IN THE PAST 4-6 MONTHS  2 outside the facility. YES, IN THE PAST 7-12 MONTHS  3 407 a. Do you receive technical support or supervision YES, MORE THAN 12 MONTHS AGO  4 407 in your work? NO SUPERVISION  5407 b. IF YES, ASK: When was the most recent time? 406 The last time you were personally supervised, did DON'T your supervisor do any of the following? READ THE LIST: YES NO KNOW 01 Deliver supplies DELIVERED SUPPLIES 1 2 9 02 Check your records or reports CHECKED RECORD 1 2 9 03 Observe your work OBSERVED 1 2 9 04 Provide any feedback (either positive or negative) GAVE FEEDBACK 1 2 9 on your performance 05 Provide any comment that you were GAVE PRAISE 1 2 9 doing your work well 06 Provide updates on administrative or technical GAVE UPDATES 1 2 9 issues related to your work 07 Discuss problems you have encountered DISCUSSED PROBLEMS 1 2 9 08 Checked drug supply CHECKED DRUG SUPPLY 1 2 9 Health Worker Interview Page 22 of 51 NO. QUESTIONS CODING CLASSIFICATION GO TO Opt Is there a mechanism that this health facility uses YES .1 406A to elicit community participation? NO  2 406D DON'T KNOW  9 406D Opt Please tell me how the health facility elicits community COMMUNITY REPRESENTATIVE ON MANAGEMENT COMMITTEE A 406B participation. MEETINGS WITH CHWs AND/OR TBAs .B CIRCLE ALL THAT APPLY PATIENT SATISFACTION SURVEYS .. C OTHER (SPECIFY):  D Opt Can you please tell me if the facility uses the DISCUSS AT MANAGEMENT COMMITTEE MEETINGS A 406C information it has gotten from community HEALTH WORKER REPORTS A CHANGE IN PRACTICE B participation? OTHER USE OF INFORMATION _________________________ C NO USE OF INFORMATION REPORTED / DON'T KNOW D Opt When was the last time that this health facility received IN LAST MONTH  1 406D a referral from a CHW? 1 - 3 MONTHS AGO  2 4 - 12 MONTHS AGO  3 OVER A YEAR AGO  4 NEVER  5 Health Worker Interview Page 23 of 51 NO. QUESTIONS CODING CLASSIFICATION GO TO ASK THE HEALTH WORKER TO IDENTIFY PATIENT CONSULTATION REGISTER FOR THE HEALTH FACILITY. DO NOT INCLUDE INPATIENT RECORDS. USE THE REGISTER TO ANSWER THE QUESTIONS BELOW. 407 Is there a sick child consultation register? OBSERVED REGISTER  1 IF YES, ASK TO SEE THE REGISTER REPORTED, NOT SEEN 2 412ANC NO REGISTER  3 412ANC 408 DOES THE REGISTER CONTAIN COMPLETE INFORMATION ON AGE, DIAGNOSIS, TREATMENT FOR EVERY CASE LISTED IN AGE INFORMATION COMPLETE .A DIAGNOSIS OR SYMPTOM INFORMATION COMPLETE .. B LAST 3 MONTHS? TREATMENT INFORMATION COMPLETE .. C CIRCLE ALL THAT APPLY. NONE OF ABOVE COMPLETE .. D FOR INSTANCE,FOR AN AGE TO BE COUNTED AS COMPLETE EVERY PATIENT MUST HAVE THEIR AGE WRITTEN. THE SAME APPLIES FOR DIAGNOIS AND TREATMENT. 409 HOW RECENT IS THE DATE OF THE MOST RECENT ENTRY? WITHIN THE PAST 7 DAYS  1 MORE THAN 7 DAYS OLD  2 410 RECORD THE NUMBER OF SICK CHILDREN NUMBER CHILDREN (0 - 59 months old) BELOW 5 YEARS OF AGE (0 - 59 months age) WHO RECEIVED CONSULTATION SERVICES DURING THE IF NONE, THEN WRITE "00" IN THE BOX 412ANC PAST THREE COMPLETE CALENDAR MONTHS REVIEW ENTRIES IN THE SICK CHILD REGISTER (ONLY THE ENTRIES FOR CHILDREN U5 IF ADULT AND U5 REGISTERS COMBINED) NOTE ALL THE CASES OF FEVER/MALARIA, PNEUMONIA/FAST OR DIFFICULT BREATHING, AND DIARRHEA OR CASES WITH A COMBINATION OF DIAGNOSES THAT INCLUDE ANY OF THESE THREE. REVIEW ALL CASES FROM THE FIRST TO THE LAST DAY OF THE LAST COMPLETED CALENDAR MONTH 411 REVIEW OF SICK CHILD REGISTER 01 MALARIA OR FEVER A1. NO. OF MALARIA A2 NO. MALARIA CASES IN REGISTER CASES TREATED OF CHILDREN U5 WITH 1ST LINE MALARIAL 02 PNEUMONIA / RAPID OR DIFFICULT BREATHING B1 NO. OF PNEUMONIA B2 NO. PNEUMONIA CASES IN REGISTER CASES TREATED OF CHILDREN U5 WITH 1ST LINE PNEUMONIA MED 03 DIARRHEA WITHOUT BLOOD C1. NO. OF DIARRHEA C2 NO. DIARRHEA CASES IN REGISTER CASES TREATED OF CHILDREN U5 WITH ORS & NO ANTIBIOTIC Health Worker Interview Page 24 of 51 NO. QUESTIONS CODING CLASSIFICATION GO TO 412ANC Is there an ANC consultation register? OBSERVED REGISTER  1 REPORTED, NOT SEEN 2 416 NO REGISTER  3416 413ANC DOES THE REGISTER CONTAIN COMPLETE INFORMATION ON DATE OF DELIVERY/CONFINEMENT, TT, AND BLOOD DATE OF DELIVERY INFORMATION COMPLETE .A PRESSURE FOR PREGNANT WOMEN LISTED TT INFORMATION COMPLETE OR HAS LIFE TIME IMMUNITY .. B IN THE LAST 3 MONTHS? BLOOD PRESSURE INFORMATION COMPLETE .. C CIRCLE ALL THAT APPLY NONE OF ABOVE COMPLETE  D TO BE COUNTED AS COMPLETE, THERE CAN BE NO BLANKS FOR THAT COLUMN 414ANC HOW RECENT IS THE DATE OF THE MOST RECENT ENTRY? WITHIN THE PAST 7 DAYS  1 MORE THAN 7 DAYS OLD  2 415ANC RECORD THE NUMBER OF PREGNANT WOMEN WHO RECEIVED NUMBER .. CONSULTATION SERVICES DURING THE PAST THREE COMPLETE CALENDAR MONTHS IF NONE, THEN WRITE "00" IN THE BOX 415NEO Is there a delivery register? OBSERVED REGISTER  1 REPORTED, NOT SEEN 2 416 NO REGISTER  3416 415.1NEO HOW RECENT IS THE DATE OF THE MOST RECENT ENTRY? WITHIN THE PAST 30 DAYS  1 MORE THAN 30 DAYS OLD  2 415.2NEO RECORD THE NUMBER OF DELIVERIES PERFORMED NUMBER .. DURING THE PAST THREE COMPLETE CALENDAR MONTHS IF NONE, THEN WRITE "00" IN THE BOX 416 Can you please show me a copy of the latest monthly service LATEST REPORT SEEN AND LESS THAN 3 MONTHS OLD  1 report that you sent to the District Health Office? LATEST REPORT SEEN AND OLDER THAN 3 MONTHS OLD  2 EXAMINE THE REPORT REPORT SAID TO BE LESS THAN 3 MONTHS, NOT OBSERVED  3 REPORT SAID TO BE MORE THAN 3 MONTHS, NOT OBSERVED .. 4 NO REPORT .5 417 LOOK FOR EVIDENCE OF USE OF SERVICE DATA Can you tell me if you have a wall chart or graphs or have WALL CHART SUMMARIZING MSR DATA .A had a meeting among the health facility staff to discuss the GRAPH SUMMARIZING MSR DATA .B monthly service report (MSR) data within the last 3 months? MEETING TO DISCUSS MSR DATA IN IN LAST 3 MO.  C OTHER: SPECIFY .D CIRCLE ALL THAT APPLY NONE OF THE ABOVE .. E 417A ASK TO SEE THE IMMUNIZATION REGISTER. optional RECORD THE NUMBER OF CHILDREN IMMUNIZED NUMBER  IN THE LAST THREE MONTHS IF NONE, WRITE "00" DON'T KNOW  999 417B ASK TO SEE THE GROWTH MONITORING REGISTER optional RECORD THE NUMBER OF CHILDREN SEEN NUMBER  FOR GROWTH MONITORING IN THE LAST 3 MONTHS IF NONE, WRITE "00" DON'T KNOW  999 417C For each of the following diagnostic tests, please tell me if this facility can conduct the test and has all items so it can be done today, optional or if the facility has a system for having the test conducted elsewhere but getting results returned for follow up by this facility. YES, CAN BE YES, OBSERVED TEST NOT CONDUCTED SYSTEM FOR AVAIL￾DIAGNOSTIC TEST ONSITE TODAY TEST OUTSIDE ABLE 01 Complete blood count 1 23 02 Anemia (hemoglobinhematocrit, or litmus paper) 1 23 03 Malaria (rapid test or microscopy) 1 23 04 Urine glucose (dipstix or benedicts test) 1 23 05 Urine protein (dipstix or acetic acid) 1 23 06 HIV (rapid, ELISA, or Western Blott) 1 23 07 AFB for TB 1 23 08 Syphilis (VDRL or RPR) 1 23 NOTE ANY QUALITATIVE OBSERVATIONS HERE: 5 CHW Form Start CHW Code: Interviewer Code: Time: OBTAIN INFOMRMED CONSENT NO. QUESTIONS CODING CLASSIFICATION GO TO 501 What services do you provide for children? HEALTH EDUCATION  A READ THE LIST GROWTH MONITORING  B CIRCLE ALL THAT APPLY VACCINATION OR MOBILIZATION FOR VACCINATION .. C REFERRAL OF SICK CHILDREN D TREAT DIARRHEA  E TREAT PNEUMONIA  F TREAT MALARIA  G PROVIDE OR SELL ITNs .H OTHER (SPECIFY) ___________________  I 502 During the past three years have you received any pre-service or in-service training on subjects YES  1 related to child health or illness? NO  2 504 503 I will read a list of training topics in child health. For each topic YES, IN YES, IN NO TRAINING I would like you to tell me if you have received any training PAST 1 PAST 2-3 WITHIN PAST in that topic. IF YES, ASK: When was the most recent training? YEAR YEARS 3 YEARS 01 Immunizations 1 23 02 Treatment of pneumonia or Acute Respiratory Infections 1 2 3 03 Diarrhea treatment 1 23 04 Malaria treatment 1 23 04b IF YES ASK: Did this training include treatment with ACTs? YES, in last 12 months YES, in last 2-3 years NO (1) (2) (3) 05 Malaria prevention / Use ITNs 1 2 3 06 IPT for pregnant women 1 23 07 Nutrition (for instance, complementary feeding, micronutrients) 1 2 3 08 Breastfeeding 1 23 09 Community Integrated Management of Childhood Illness (C-IMCI) 1 2 3 10 Newborn care 1 23 11 Postnatal care for the mother 1 2 3 12 Antenatal case 1 23 504 Now I would like to ask you some questions about YES, IN THE PAST 3 MONTHS  1 supervision you have personally received. YES, IN THE PAST 4-6 MONTHS  2 Have you received any technical support or supervision YES, IN THE PAST 7-12 MONTHS  3 507 in your work? YES, MORE THAN 12 MONTHS AGO  4 507 IF YES, ASK: When was the most recent time? NO SUPERVISION  5 507 505 The last time you were personally supervised, did DON'T your supervisor do any of the following? YES NO KNOW 01 Deliver supplies DELIVERED SUPPLIES 1 2 9 02 Check your records or reports CHECKED RECORDS 1 2 9 03 Observe your work OBSERVED WORK 1 2 9 04 Provide any feedback (either positive or negative) FEEDBACK 1 2 9 on your performance 05 Provide any comments that you were GAVE PRAISE 1 2 9 doing your work well 06 Provide updates on administrative or technical GAVE UPDATES 1 2 9 issues related to your work 07 Discuss problems you have encountered DISCUSSED PROBLEMS 1 2 9 MODULE 5: COMMUNITY HEALTH WORKER FORM (INTERVIEW, RECORD REVIEW, AND CHECKLIST) 5 CHW Form ASK THE CHW TO SHOW YOU THEIR PATIENT REGISTER OR BOOK. USE THE INFORMATION IN THE REGISTER OR BOOK TO ANSWER THE QUESTIONS BELOW. 506 Do you treat sick children, inder 5 years old? TREAT SICK CHILDREN  1 DO NOT TREAT SICK CHILDREN  2 513 507 Is there a patient register or book that has information OBSERVED REGISTER 1 on children under 5? YES, REPORTED, NOT SEEN  2 513 IF YES, ASK TO SEE THE REGISTER. NO REGISTER  3 513 508 DOES THE REGISTER OR BOOK HAVE A PLACE TO AGE INCLUDED .A INDICATE AGE, CLASSIFICATION, DIAGNOSIS OR CLASSIFICATION INCLUDED  B AND/OR THE TREATMENT FOR THE CHILDREN SEEN? TREATMENT INCLUDED .C CIRCLE ALL THAT APPLY NONE OF ABOVE INCLUDED  D 509 DOES THE REGISTER CONTAIN COMPLETE INFORMATION AGE COMPLETE A ON AGE, DIAGNOSIS, AND/OR TREATMENT? DIAGNOSIS OR MAJOR SYMPTOM COMPLETE B TO BE COMPLETE, THERE CANNOT BE ANY BLANKS FOR TREATMENT COMPLETE C ENTRIES IN THE PAST 3 MONTHS. NONE OF ABOVE INCLUDED  D CIRCLE ALL THAT APPLY 510 HOW RECENT IS THE DATE OF THE MOST WITHIN THE PAST 30 DAYS  1 RECENT ENTRY IN THE REGISTER? MORE THAN 30 DAYS OLD  2 511 RECORD THE NUMBER OF SICK CHILDREN, NUMBER  BELOW 5 YEARS OF AGE, WHO RECEIVED CONSULTATION SERVICES DURING THE IF NO CASES, WRITE "00" in BOX AND SKIP TO Q. 514 513 PAST 3 COMPLETE CALENDAR MONTHS REVIEW THE ENTRY IN THE PATIENT REGISTER (ONLY THE ENTRIES FOR CHILDREN U5). NOTE ALL THE CASES OF FEVER/MALARIA, DIARRHEA PNEUMONIA/FAST OR DIFFICULT BREATHING, OR CASES WITH A COMBINATION OF DIAGNOSES THAT INCLUDE ANY OF THESE THREE REVIEW ALL CASES FOR THE LAST 3 COMPLETE CALENDAR MONTHS 512 REVIEW OF SICK CHILD CASES IN REGISTER.. 01 A. MALARIA OR FEVER A1 NO. OF MALARIA A2 NO. CASES CASES IN REGISTER TREATED WITH FIRST LINE MALARIAL 02 B. PNEUMONIA / RAPID DIFFICULT B1 NO. OF PNEUMONIA B2 NO. CASES BREATHING CASES IN REGISTER TREATED WITH FIRST LINE ANTIBIOTIC 03 C. DIARRHEA C1 NO. OF DIARRHEA C2 NO. CASES CASES IN REGISTER TREATED WITH ORS BUT NO ANTIBIOTIC Opt ASK TO SEE THE IMMUNIZATION REGISTER. 512A RECORD THE NUMBER OF CHILDREN IMMUNIZED NUMBER  IN THE LAST THREE CALENDAR MONTHS DON"T KNOW  ## Opt ASK TO SEE THE GROWTH MONITORING REGISTER 512B RECORD THE NUMBER OF CHILDREN SEEN NUMBER  FOR GROWTH MONITORING IN THE LAST THREE CALENDAR MONTHS DON'T KNOW  ## CHECK WHETHER EACH OF THE ITEMS BELOW IS IN THE POSSESSION OF THE CHW. ASK HIM/HER TO SHOW YOU. 513 ITEMS FOR SICK (a) AVAILABILITY (b) FUNCTIONING CHILD CONSULTATIONS OBSERVED REPORTED, NOT DON'T YES NO DON'T NOT SEEN AVAILABLE KNOW KNOW 01 Timer for counting breaths or CHW has watch with 1 b 2 b 3 9 1 2 9 second hand 02 CHW Training Manual 123 9 ASK TO SEE THE FOLLOWING DRUGS AND TREATMENTS. FOR EACH ITEM, CIRCLE THE APPROPRIATE CODE. 514 CHILD DRUGS AND TREATMENTS (a) AVAILABILITY OF MEDICINES OBSERVED AVAILABLE NOT OBSERVED ALL AT LEAST AVAILABLE REPORTED NOT AVAIL- NEVER VALID ONE VALID BUT NONE AVAILABLE, ABLE TODAY / AVAILABLE VALID NOT SEEN DON'T KNOW 01 ORS packets 1 2 34 5 6 02 First line antibiotic for pneumonia 1 2 3 4 5 6 03 First line anti-malarial 1 2 3 4 5 6 04 Other medicine ____________________________ 1 2 3 4 5 6 05 Other medicine ____________________________ 1 2 3 4 5 6 NOTE ANY QUALITATIVE OBSERVATIONS HERE: End Time: Core Indicators page 27 of 51 INDICATORS WITH AN ASTERISK (*) ARE STANDARD INTERNATIONAL HEALTH FACILITY ASSMENT NETWORK (IHFAN) INDICATORS Area of Analysis Indic. # Domain Indicator Instrument Denominator Reference OVERALL Geographic Access to Curative Services % population with year-round geographic access (within 5 km. or one hour) to an authorized provider of curative child health services DHO Interview Target population JHU Pneumonia Care Assessment Tool (JHU tool outlines procedure for pneumonia care, but this procedure has been generalized to any curative child care) 1 CHILD Service Availability Child* % HF that offer three basic child health services (growth monitoring, immunization, sick child care) HW Interview All HF IHFAN Services Offered Indicator for child services only / Component of SPA Indicator 2.1 1 ANC Service Avaialabilty ANC* % HF that offer four basic antenatal care services (malaria treatment (IPT), tetanus toxoid (TT), and testing for anemia and syphilis) HW Interview All HF 2 Staffing* % HF with all clinical staff presetn in surveyed HF on the day of the survey HW Interview All HF IHFAN Staffing Indicator 3 Infrastructure* % HF with all essentail infrastructure on day of the survey (power, improved water source, functional latrine for clients, communication equipment, emergency transport, overnight beds, setting allowing auditory and visual privacy) HF Checklist All HF IHFAN Infrastructure Indicator 4 CHILD Supplies Child* % HF with all 5 essential supplies to support child health in HF on day of the survey (accessible and working scale for child, accessible and working scale for infant, timing device for diagnosis of pneumonia, spoon/cup/jug to administer ORS, ITNs) HF Checklist All HF IHFAN Supplies Indicator - only for child health supplies 4 NEO Supplies Newborn* % HF All 4 essential supplies to support newborn health in HF on day of the survey (resuscitation device, weighing scale, antibiotics and baby wraps) HF Checklist All HF 4 ANC Supplies ANC* % HF with all 7 essential supplies to support antenatal care in HF on day of the survey (blood pressure machine, tetanus toxoid vaccine, hemoglobin reagents, syphilis testing kit, and albastix for protein) HF Checklist All HF 5 CHILD Drugs Child* % HF with all 5 first line medications for child health on day of the survey (ORS, oral antibiotic for pneumonia, first line oral antibiotic for dysentery, first line anti-malarial, vitamin A) HF Checklist All HF 5 NEO Drugs Newborn* % HF with the first line medication for newborn sepsis on day of the survey HF Checklist All HF 5 ANC Drugs ANC* % HF with all 3 essential ANC medications on day of survey (iron, folic acid, antimalarial for IPT) HF Checklist All HF CORE INDICATOR DEFINITIONS - RAPID HEALTH FACILITY ASSESSMENT ACCESS INPUTS IHFAN Treatments Indicator - only for treatments specific to health area Core Indicators page 28 of 51 6 CHILD Information System (Child and Newborn)* % HF that maintain up-to-date records of sick U5 children (age, diagnosis, treatment) and have report in last 3 months and evidence of data use HW Interview (record review) All HF IHFAN Health Service Statistics Indicator 6 ANC Information System (ANC)* % HF that maintain up-to-date records of antenatal care (TT, iron/folate, expected date of delivery) HW Interview (record review) All HF 7 CHILD Training in Child Health % HF in which interviewed HW reported receiving in-service or pre￾service training in maternal, child or neonatal health in last 12 months HW interview All HF Component of SPA Indicator 1.4 7 NEO Training in Maternal Neonatal Care % HF in which interviewed HW reported receiving in-service or pre-service training in child health in last 12 months HW Interview All HF 8 Supervision % HF that received external supervision at least once in the last 3 months (supervision included one or more of the following: checked records or reports, observed work, provided feedback, gave praise, provided updates, discussed problems, OR checked drug supply)) HW interview All HF Component of SPA Indicator 1.4 9 CHILD Utilization of Curative Services % HF with > 1.0 sick child visits in the last 12 month per U5 childen in catchment area HW interview (record review) Number of U5 children in HF catchment area Based on WHO standard Utilization indicator 9 ANC Utilization of ANC Services % HF with > 2.0 ANC visits per estimated number of births in catchment area in last 12 months HW Interview (record review) Number of births in HF catchment area 10 CHILD HW Performance (Assessment) % HF in which all 5 key assessment tasks are made by HW (check presence of general danger signs, assess feeding practices, assess nutritional status, check vaccination status) (benchmark 5 of 6 clinical observations) Clinical Observation All HF Several Components of SPA Indicator 2.5 11 CHILD HW Performance (Treatment of Sick Child) % HF in which treatment is appropriate to diagnosis for child with malaria, pneumonia, or diarrhea (benchmark: 5 of the 6 clinical observations) Clinical Observation All HF WHO HFS Core Indicator #7 12 CHILD HW Performance (Counseling for Sick Child) % HF in which the caretaker whose child was prescribed an antibiotic, antimalarial, or ORS, can correctly describe how to administer all drugs (benchmark: 5 of the 6 caretakers interviewed) Exit interview - child All HF WHO HFS Core Indicator #11 PROCESSES PERFORMANCE Optional Indic Area of Analysis Indic. # Domain Indicator Instrument Denominator Reference Opt2 Availability of Immunizations % HF with all nationally-mandated vaccines in stock on day of survey HF Checklist All HF WHO HFS / BASICS IHFA Opt3 Availability of Guidelines % HF with all nationally-mandated guidelines for care of children available and accessible on day of survey HF Checklist All HF IHFAN Indicator #4 Opt4 Infection Control % HF with all infection control supplies and equipment available on day of survey HF checklist All HF IHFAN Indicator #2 Opt5 HF-Community Coordination % HF that have routine community participation in management meetings (with evidence through notes) OR have a system for eliciting client opinion and evidence that client feedback is HW interview (record review) All HF Component of SPA Indicator 1.5 Opt6 Community Referral % HF that received at least one referral from CHW in the last month HW interview (record review) All HF  Opt7 Malaria - ACT Logistics % HF with adequate logistics compliance for ACTs HF Checklist All HF World Bank Malaria Booster Initiative Opt8 Malaria - ITN/LLIN Logistics % HF with adequate logistics compliance for ITNs/LLINs HF Checklist All HF World Bank Malaria Booster Initiative Opt9 Laboratory Facilities % HF with adequate laboratory facilities on site or able to send out HW interview All HF IHFAN Indicator #7 PERFORMANCE Opt10 Utilization of Child Preventive Services # annualized encounters for children per U5 population in HF catchment area: a. for vaccination b. for growth monitoring and promotion HW interview (record review) All HF  OPTIONAL INDICATOR DEFINITIONS - RAPID HEALTH FACILITY ASSESSMENT INPUTS PROCESSES Tabulation Plan page 30 of 51 Area of Analysis Indic. # Domain Indicator Data Element(s) for Numerator Data Element(s) for Denominator Notes OVERALL Geographic Access % population with year-round geographic access (within 5 km. or one hour) to an authorized provider of curative child health services Sum of populations of villages/neighborhoods that have year-round access to curative child health services (DHO Form, sum of column J figures where column K = YES) Total population in project area (DHO form - sum of all column J figures) 1 CHILD Service Availability* % HF that offer ALL three basic child health services (growth monitoring, immunization, sick child care) # HF with 3 basic child health services (Q.401/ 01A+B > 30 AND Q.401/02A+B > 4 AND Q.401/03A+B > 4) # HF surveyed 1 ANC Service Availability ANC* % HF that offer ANC # HF with ANC at least 4 days per month (Q401 04 > 4) # HF surveyed 2 Staffing* % staff in HF who provide clinical services were working (either in HF or in outreach activities) on the day of the survey # clinical care staff present on day of survey (Q.402A, boxes 01+02+03+04) # sanctioned staff working in HFsurveyed (Q.402B, boxes 01+02+03+04) this is the index value form of this indicator 3 Infrastructure* % essential infrastructure in HF on day of the survey (power; improved water source; functional latrine for clients; communication equipment; emergency transport; overnight beds; setting allowing auditory and visual privacy) # Overnight beds (Q.301=1 AND 302=1); Communication (Q.303=1,2,or 3); Transport (Q.304=1 or 2); Electricity (Q.305 = 1 OR Q.306 = 1 or 3); Usable latrine (Q.307 = 1 AND Q.308 = 1,2,3, or 4 AND 309 = 1); Water from improved source (Q.310 =1 AND 311 = 1,2,3,4,5, or 6); Auditory and visual privacy (Q.312 = 1) # HF surveyed x 7 infrastructure items this is the index value form of this indicator 4 CHILD Supplies* % essential supplies to support child health in HF on day of the survey (accessible and working scale for child, accessible and working scale for infant, timing device for diagnosis of pneumonia, spoon/cup/jug to administer ORS) # essential supplies available in surveyed HF (Items 02-07 for which Q.313a = 1 or 2); items 02 - 05 are also functioning (Q.313b = 1 for all items 02 - 05) # HF surveyed this is the index value form of this indicator 4 NEO Supplies Neonatal % of 4 essential supplies to support newborn health in HF/CHW on day of the survey (resuscitation device, weighing scale, antibiotics and baby wraps) # essential neonatal supplies available in surveyed HF (Items 01-04 for which Q.313NEOa = 1 or 2); items 01 - 03 are also functioning (Q.313NEOb = 1 for all items 01 - 03) # HF surveyed x 4 essential items this is the index value form of this indicator 4 ANC Supplies ANC % of 5 essential supplies to support antenatal care in HF on day of the survey (blood pressure machine, tetanus toxoid vaccine, hemoglobin reagents, syphilis testing kit, and albastix for protein) # essential ANC supplies in HF on day of survey (Item 01-07 for which Q.313ANCa = 1 or 2; items 1 and 2 are also functioning (Q.313ANCb = 1 for items 01 and 02) # HF surveyed x 7 essential items this is the index value form of this indicator 5 CHILD Drugs* % of first line medications for child health in HF on day of the survey (ORS, oral antibiotic for pneumonia, first line oral antibiotic for dysentery, first line antiamalarial, vitamin A) # first line child drugs available and at least one valid (not expired)in HF on day of survey (Q.314, 01 - 05 all = 1 or 2) # HF surveyed x 5 essential drugs this is the index value form of this indicator 5 NEO Drugs Neonatal % of first line medications in HF on day of survey (for newborn sepsis and eye infections) # of first line medications for newborns on day of the survey (Q.314NEO 01 and 02 = 1 or 2) # HF surveyed x 2 essential drugs this is the index value form of this indicator 5 ANC Drugs ANC % of 3 essential ANC medications in surveyed HF on day of survey (iron, folic acid, antimalarial for IPT) # of first line ANC medications in facility of day of survey (Q.314ANC 01 - 04 = 1 or 2) # HF surveyed x 3 essetial drugs this is the index value form of this indicator 6 CHILD Information System* % HF that maintain up-to-date records of sick U5 children (age, diagnosis, treatment) and for HF: have report in last 3 months and evidence of data use # HF in which all 3 data elements (age, diagnosis, treatment) are all complete in sick child register (Q.409 = A,B,C all circled) AND in which last entry is within last 7 days (Q.410 = 1) AND report written in last 3 months (Q.411 = 1 or 3) AND there is evidence of data use (Q.412 = A, B, or C) # HF surveyed 6 ANC Information System ANC % HF that maintain up-to-date records of antenatal care (TT, blood pressure, expected date of delivery) # HF in which all 3 data elements (TT status, Iron/folate, EDD) are all complete in ANC register (Q.411 = A,B,C all circled) AND in which last entry is within last 7 days (Q.410 = 1) # HF surveyed 7 CHILD Training in Child Health % HF in which interviewed HW reported receiving in￾service or pre-service training in child health in last 12 months # HF in which interviewed HW received training in at least one child health topic in last 12 months (Q.404, 01 - 09 at least one response = 1) # HF surveyed SPA indicator is "at least 50% HW trained in." but in order to make this more feasible, this instrument only asks about the interviewee. 7 NEO Training in Maternal￾Neonatal Care % HF in which interviewed HW reported receiving in￾service or pre-service training in maternal neonatal care in last 12 months # HF in which interviewed HW received training in at least one child health topic in last 12 months (Q.404, 10 - 12 at least one response = 1) # HF surveyed SPA indicator is "at least 50% HW trained in." but in order to make this more feasible, this instrument only asks about the interviewee. 8 Supervision % HF that received external supervision at least once in the last 3 months (supervision included one or more of the following: checked records or reports, observed work, provided feedback, gave praise, provided updates, discussed problems)) # HF receiving supervision in last 6 months that included more than just delivering supplies (Q.406 = 1 and Q.407, 02 - 08, at least one response = 1) # HF surveyed TABULATION PLAN - CORE INDICATORS ACCESS INPUTS PROCESSES Tabulation Plan page 31 of 51 Area of Analysis Indic. # Domain Indicator Data Element(s) for Numerator Data Element(s) for Denominator Notes 9 CHILD Utilization of Curative Services Annualized rate of clinical encounters for sick children per U5 population # clinical encounters with sick childen under 5 in last three complete calendar months (Q.413 x 4) # children in catchment area (Q.400B or form DHO or from Census data ) 1. Can get this data from routine HIS, but this is here as a validation check. 2. "Sick children" is chosen to give comparable data across different projects and health systems; however, the project may want to collect data on utilization of other types of services as well (e.g., growth monitoring vaccination) These are included as optional 9 ANC Utilization of ANC Services % HF with > 2.0 ANC visits per estimated number of births in catchment area in last 12 months # ANC visits in last three complete calendar months (Q.413ANC) x 4 # annual births estimated for catchment area (apply national birth rate to catchment area population (DHO Form total popn.) 10 CHILD HW Performance (Assessment) % of four key assessment tasks are made by HW (check presence of general danger signs, assess feeding practices, assess nutritional status, check vaccination status) # key assessment tasks complete (Number of answers = "Y" for Q.103A,B,C AND Q.104A,B,C) # sick child clinical encounters observed in all HF x 4 assessment tasks this is the index value form of this indicator 11 CHILD HW Performance (Treatment) % HF clinical encounters in which treatment is appropriate to diagnosis (for encounters in which at least one of the presenting problems was fever, breathing problem, or diarrhea) (from record review for CHW / from Clinical Obs. for HF) # sick child clinical encounters in which treatment was correct (Supervisor recode - Indicator #11 = 1 on Clinical Obs. Form) HF: # sick child clinical encounters observed in all HF 12 CHILD HW Performance (Counseling) % HF clinical encounters in which the caretaker whose child was prescribed an antibiotic, antimalarial, or ORS, can correctly describe how to administer all prescribed drugs # clinical encounters in which antibiotic, antimalarial, or ORS prescribed in which caretaker correctly describes the dose, frequency and duration of medication administration for ALL prescribed medications (Supervisor Recode - Indicator #12 = Y on Exit Interview Form ) # sick child clinical encounters observed in which antibiotic, antimalarial, or ORS prescribed (Q.201 = 1) Area of Analysis Indic. # Domain Indicator Numerator Denominator Notes Opt1 Availability of Immunizations % HF with all nationally-mandated vaccines in stock on day of survey # HF with all nationally-mandated vaccines on day of survey (Q.314A, 01 - 04 all = 1 or 2) # HF surveyed Opt2 Availability of Guidelines % HF with all nationally-mandated guidelines for care of children available and accessible on day of survey # HF with all nationally-mandated guidelines on day of survey (Q.314B, 01 - 05 all = 1) # HF surveyed Opt3 Infection Control % HF with all infection control supplies and equipment on day of survey # HF with all infection control supplies and equipment on day of survey, including all supplies available (Q.314c, all items 01 - 06 = 1 or 2) AND waste disposal for sharps and infectious waste is adequate (Q.314D-i = 1-6 AND Q314D-ii = 1-6 AND 314E-i = 1 or 2 AND 314E-ii = 1 or 2) # HF surveyed Opt4 HF-Community Coordination % HF with routine community participation in management meetings (with evidence through notes) OR have a system for eliciting client opinion, and evidence that client feedback is reviewed # HF that have routine community participation (Q.407B = A, B, or C) AND evidence that feedback is reviewed (Q.407C = A or B) # HF surveyed Opt5 Community Referral % HF that received at least one referral from CHW in the last month # HF receiving at least one referral from a CHW in the last month (Q.407F = 1) # HF surveyed Opt6 ACT Logistics % HF with adequate logistics compliance for ACTs # HF that have ordered ACTs in last 3 months, stock card agrees with hand count of ACTs; no ACTs have passed expiry date; and have aapropriate plan for ACT disposal (Q.314F 01-06 all = 1) # HF surveyed Opt7 ITN/LLIN Logistics % HF with adequate logistics compliance for ITNs/LLINs # HF with ITN/LLIN order in the last 3 months; delivery agrees with order; count agrees with order (Q.314G 01-03 all = 1) # HF surveyed Opt8 Laboratory % HF with adequate basic laboratory facilities on site or ability to send out # HF with supplies to do eight basic laboratory tests or to send out (CBC, H/H, malaria RDT, urine glucose, urine proterin, HIV rapid test, AFB stain, syphilis testing) (Q417C 01-08 all = 1 or 2) # HF surveyed IHFAN laboratory indicator PERFORM ANCE Opt9 Utilization of Preventive Services Annualized rate of encounter for children for immunization / growth monitoring per U5 population in project area # encounters with children for immunization / growth monitoring in last 3 complete months (for immunization: Q.414A, sum answers for all HF / for growth monitoring: Q.414B, sum of answers for all HF) x 4 # U5 children in project area PROCESSES TABULATION PLAN - OPTIONAL INDICATORS INPUTS TABULATION PLAN - CORE INDICATORS (continued) PERFORMANCE ANNEX XI. SOURCES OF INFORMATION Documents reviewed 1. SUSOMA Detailed Implementation Plan (DIP) and annexes, including PRA 2. SUSOMA First, Second and Fourth Annual Reports including LQAS 3. SUSOMA Midterm Evaluation Report and annexes 4. SUSOMA Baseline and endline RHFA 5. SUSOMA OR study proposal, social capital measurement report, annual report updates 6. SUSOMA KPC baseline, midline, and endline reports 7. SUSOMA RHFA baseline and endline reports 8. SUSOMA index computation for CSSA dashboard # 2, 3, 5, 7 9. SUSOMA M&E cumulative, MOHFW HMIS cumulative data 10. Project Implementation Team monthly reports. 11. LAMB and Joyramkura Training Reports 12. SUSOMA MCHIP Newsletters with SUSOMA stories. Compiled by Mitra Bardhan Paul, Training Coordinator, SUSOMA 13. SUSOMA Story Directory: A collection of success stories. Written by Mitra Bardhan, Paul, Training Coordinator, SUSOMA, Edited by Sukumar Ghagra, Project Manager, SUSOMA. 14. CORE Group (2009). Community-based Integrated Management of Childhood Illness Policy Guidance. 15. WHO (2014). WHO recommendation on community mobilization through facilitated participatory learning and action cycles for maternal newborn health. 16. Story, W.T. (2014). Social capital and maternal and child health in low- and middle-income countries: Evidence from India. CORE Group Webinar, June 30, 2014. 17. USAID (2011). USAID Evaluation Policy: Evaluation-Learning from Experience. 18. Mridha, M.K., Anwar, I., & Koblinsky, M. (2009). Public-sector maternal health programmes and services in rural Bangladesh. Journal of Health and Population Nutrition, 27(2), 124-136. 19. WHO (2014). Success factors for women’s and children’s health: Brief update on Bangladesh multi-stakeholder review. 20. SUSOMA publications and presentations listed in Annex 11. Individual and Group Stakeholder Interviews (n=459 persons) and Sites Visited during Final Evaluation Field Visits Stakeholder Interview Schedule for Team A (Kendua: 17 interviews, 218 persons) Date Site Person/Group Interviewed # 5 August 14 Mujafforpur (Shalpa Durga) Doel Primary Group (Female) 21 Muzafforpur (Amlipara ) Muzafforpur CC Samorthan Health group (Male) CC Management Committee group 17 9 Muzafforpur Union Parisad Md. Azizul Islam, UP Chairman 1 Kandhiura Union Parishad Kandhiura CCC group 36 Shandhikona Gonda , FWC Madhumathi Primary Group (female group formed by PI rep.) SACMO & FWV 20 2 Kendua Upazila Health Complex Dr, Abdul Kaddush, UH& FPO 1 Kendua Upazila Health Complex Mr, Abdus Salam, HI In Charge, Mr, Kamal Hossain, UFPO 2 Social welfare Office, Kendua Ms, Mirza Nijuara, USSO, 1 7 August 14 Dolpa Influencing group (Husband and mother-in-law) 19 Asuzia Union Parisad 17 CHVs & 15 TTBA group 32 SATHI SUSOMA Office CHT Staff group 23 PI office, Kendua, PI Office, Kendua Sukher Sandhane PI Executive Committee group, PI Health Sub-Committee group (12F/1M) 13 Schedule for Team B (Durgapur: 14 interviews, 150 persons) Date Site Person/Group Interviewed # 5 August 14 Dakhinail Joba Primary Group (low-level) 10 Birisiri Shishir CCC group (16F/1M) 17 Upazilla Health Complex GO health worker group (HI, FWV,FPI, SACMO) 11 Chondigorh and Durgapur Union Parishad Chairman and member 1 Chalk Lengura CSBA group 4 6 August 14 Soristola, Kakorgora Union Sharishaful Primary Group (high-level) 13 Nogua, Kakorgora CHCP interview, visit PI-linked Model CC 4 Luxmipur CHV and TTBA group 22 Birisiri Union Parishad HIRA Society PI meeting group 18 PARI SUSOMA PARI SUSOMA staff group 13 7 August 14 Madhobpur Mukta Society PI Management Committee group 10 Madhobpur Influencing group (Husband, mothers, and mother In-laws) 15 PARI SUSOMA Office Village Doctors group 10 8 August 14 SATHI offices, Dhaka Ms Smita Hazda Mun, LAMB Training Center, Director Ms. Sara Mallick, LAMB Training Center, Technical Support Officer 2 Stakeholder Interview Schedule for Rover Team (Netrokona, Kendua, Durgapur, Dhaka: 17 interviews, 86 persons) Date Site Person/Group Interviewed # 5 August 14 SUSOMA office, Netrokona Breakfast, visit office Netrokona Family Planning Office, Netrokona Golam Mohammad Azam, DDFP with Dr. Bijon Kanti Sarker, DCS 2 CS Office, Netrokona Dr. Shahid Uddin Ahmed, CS 1 Sadar Hospital, Netrakona Dr. Ranjon Karmoker, Gyn. Specialist 1 Kendua Sathi Susoma Office, Kendua Lunch, visit office Dobagati, Chirang (3rd Ward) CC management, elites, Parishad Chair, FWA, CHCP, CSBA, TTBA, CHV, Super CHV group 22 6 August 14 Durgapur Birisiri GBC Nirsjal Chisik, Medical Officer; Dr. Malory, Healthcare Board Medical Director CHT SUSOMA PARI 2 1 UHC-Durgapur UH&FPO--out of office due to illness, unable to interview 0 UHC-Durgapur Mahdi Hasan Khan, UFPO 1 Nayapara Model CC visit, interview with CHCP, FHA-CSBA, CC donor/management committee member, PI leader/CC management committee member 5 PARI SUSOMA Office Lunch, visit office Chondigorh FWC visit, interview with FWV-CSBA Male PI group member, CHVs 1 3 Fanda Jhinuk PI Meeting group (Hi-level) 22 7 August 14 Dhaka ICDDR’B Office, Dhaka Meeting with ICDDR’B Operations Research Team: Sr. Shams El Arifeen, PI 5 10 August 14 ICDDR’B Office Dr. Altaf, Program Manager, IMCI, DGHS 1 11 August 14 USAID Mission Dhaka, Bangladesh Dr. Umma Meena 1 12 August 14 Netrokona Netrakona District Health Complex EPI Dissemination meeting, observation of speeches of government officials, PI leaders, CHV, and SATHI, PARI, World Renew leaders Stakeholder meetings held by Dr. Grace Kreulen: 4 meetings, 1 interview-5 persons Site Person/Group Interviewed # 30 July 14 Conference Call Jain Aparna & James Foreit, Evidence Project, Kristina Gryboski, USAID, Dr. Emdad, ICDDR,B, Dr. Alan Talans, World Renew--OR report discussion 4 8 August 14 SATHI offices, Dhaka PARI & SATHI management staff group 5 25 August 14 Skype call Stacy Saha, LAMB MIS & Research Director, RHFA coordinator 1 26 August 14 Conference Call Meridith Crews, USAID, Kristina Gryboski, USAID, Jennifer Luna, MCSP, Dr. Alan Talens--KPC data discussion 3 Note: Permission was obtained to use the names of individuals listed above in this report. The names of health workers, beneficiaries and SUSOMA program participants are not listed to protect their privacy. ANNEX XII. DISCLOSURE OF ANY CONFLICTS OF INTEREST Name Grace J. Kreulen Title Independent Consultant Organization Story Consulting Evaluation Position √ Team Leader  Team Member Evaluation Award Number (Contract or other instrument) None USAID Project(s) Evaluated (Include project name(s), implementer name(s) and award number(s), if applicable) Bangladesh Child Survival Project (SUSOMA Healthy Child and Mother) Implemented by World Renew (in partnership with SATHI and PARI) Cooperative Agreement No. GHS-A-00-09-00009-00 I have real or potential conflicts of interest to disclose.  Yes √ No If yes answered above, I disclose the following facts: Real or potential conflicts of interest may include, but are not limited to the following: 1. Close family member who is an employee of the USAID operating unit managing the project(s) being evaluated or the implementing organization(s) whose project(s) are being evaluated 2. Financial interest that is direct, or is significant though indirect, in the implementing organization(s) whose projects are being evaluated or in the outcome of the evaluation 3. Current or previous direct or significant though indirect experience with the project(s) being evaluated, including involvement in the project design or previous iterations of the project Not Applicable 4. Current or previous work experience or seeking employment with the USAID operating unit managing the evaluation or the implementing organization(s) whose project(s) are being evaluated 5. Current or previous work experience with an organization that may be seen as an industry competitor with the implementing organization(s) whose project(s) are being evaluated 6. Preconceived ideas toward individuals, groups, organizations, or objectives of the particular projects and organizations being evaluated that could bias the evaluation I certify (1) that I have completed this disclosure form fully and to the best of my ability and (2) that I will update this disclosure form promptly if relevant circumstances change. If I gain access to proprietary information of other companies, then I agree to protect their information from unauthorized use or disclosure for as long as it remains proprietary and refrain from using the information for any purpose other than that for which it was furnished. Signature √ Date√ January 6, 2014 ANNEX XIII. STATEMENT OF DIFFERENCES Date: December 13, 2014 at 1:31:13 AM EST From: Nancy Tenbroek To: Grace Kreulen World Renew has reviewed the FE report written by Dr. Grace Kreulen and we have no objection to the report. The report is an accurate reflection of the Susoma project. -- Nancy TenBroek Development Consultant World Renew Bangladesh Annex XIV. Evaluation Team Members, Roles and Titles Evaluation Team Member Name Title Role 1. Ms. Grace Kreulen, PhD, MSN, BSN, RN Independent consultant FE Team Leader Rover Team 2. Ms. Kohima Daring Country Consultant Team B leader 3. Ms. Nancy Ten Broek Development Consultant Rover Team 4. Mr. Alan Talens Backstop, World Renew Team B 5. Mr. Dayal Chandra Paul Executive Director, Supoth Team A leader 6. Mr. Gabriel Rozario Executive Director, Pari Team A note taker 7. Mr. Apurba Ghagra Director, Sathi Team B note taker 8. Ms. Catherine Guda Assistant Director, Sathi Team B note taker 9. Ms. Shagota Chisim Capacity Developmt Manager, WR Team A note taker 10. Mr. Mukarram Hussein Musa Coordinator, Susoma Sathi Team A 11. Mr. Prafullo Hajong Coordinator, Susoma Pari Team B 12. Mr. Shukumar Ghagra Project Manager, Susoma Rover Team 13. Mr. Mitra Bardhan Paul SUSOMA Training Coordinator Team A 14. Mr. David Kreulen, PhD Visitor Rover Team, visitor 15. Ms. Kim Visitor Team A, visitor January 2015 1 Building Public-Private Partnership to improve maternal, newborn, and child health in Bangladesh Operations Research Final Report Center for Child and Adolescent Health (CCAH), icddr,b: DM Emdadul Hoque Associate Scientist, Project Coordinator Nabeel Ashraf Ali Assistant Scientist Fahmida Taleb Research Investigator Shumona Sharmin Salam Senior Research Investigator Shams El Arifeen Senior Scientist and Director World Renew Nancy TenBroek Asia Regional Health Advisor Kohima Daring Team Leader for India and Bangladesh Stephanie Sackett Associate Director for Grants Alan Talens Health Advisor Grace J. Kreulen Lead Program Evaluator, Consultant William Story Consultant Lutheran Aid to Medicine in Bangladesh (LAMB) Ms. Stacy Saha RHFA Coordinator January 2015 The SUSOMA Project in Durgapur and Kendua sub-district of Netrokona district, Bangladesh is supported by the American people through the United States Agency for International Development (USAID) through its Child Survival and Health Grants Program. The SUSOMA Project is managed by World Renew, formerly known as Christian Reformed World Relief Committee (CRWRC), in collaboration with GOB and icddr,b under Cooperative Agreement No. GHS-A-00-09-00009-00. The views expressed in this material do not necessarily reflect the views of USAID or the United States Government. January 2015 2 Acknowledgements The SUSOMA Operations Research study was conceptualized by World Renew in conjunction with icddr,b and USAID. The study was conducted by DM Emdadul Hoque and his team at icddr,b. Icddr,b carried out all aspects of the study, from the concept paper to data collection and analysis to writing multiple reports, including the baseline and final KPC and Operations Research Qualitative and Social Capital Study reports. This report brings together the KPC and OR data from the icddr,b reports, the health facilities assessment conducted by Stacy Saha from the RHFA report, World Renew’s Peoples’ Institution model intervention strategy developed by Kohima Daring and Nancy TenBroek, William Story’s expertise in social capital research, and USAID/Evidence Project guidance provided by Aparna Jain and James Foreit. As primary author, I express my appreciation to each of these whose contributions enabled the writing of this integrative Final Operations Research Report that showcases the utility of the People’s Institution model intervention in promoting MNC practices and utilization among poor and marginalized women in rural Bangladesh. Grace Kreulen January 2015 3 Table of Contents  ############################################################################################################################+  ####################################################################################################################################################, ############################################################################################################################################, !" ######################################################################################- ###################################################################################################################################################(, %  #####################################################################################################). ! ###############################################################################################################################*'       ########################################################################*( ############################################################################################################################################*)  #$ "  " !########################################################**  #   ########################################################################################################################*/ January 2015 4 List of Abbreviations ANC Antenatal Care AMTSL Active Management of the Third Stage BDHS Bangladesh Demographic and Health Survey CBO Community Based Organization CC Community Clinic (Ward level) CCC / UC Central Coordinating Committee / Union Committee CCAH Center for Child and Adolescent Health CHT Community Health Trainer CHV Community Health Volunteers CSBA Community Skilled Birth Attendant (health providers (FWV, FWA, HA) with SBA training) DGHS Directorate General of Health Services DGFP Directorate General of Family Planning EHF Emergency Health Funds ENC Essential Newborn Care FWA Family Welfare Assistant FWC Family Welfare Centre FWV Family Welfare Visitor GOB Government of Bangladesh HA Health Assistant HIV/AIDS Human Immunodeficiency Virus/ Acquired Immune Deficiency Syndrome HMIS Health Ministry Information System Icddr,b International Centre for Diarrhoeal Disease Research, Bangladesh IGA Income Generating Activities IMCI Integrated Management of Childhood Illness KPC Knowledge, Practice and Coverage survey MA Medical Assistant MIS Program Management Information System MOHFW Ministry of Health and Family Welfare MOU Memo of Understanding MMR Maternal Mortality Ratio MNC/MNCH Maternal Newborn Care/Maternal Newborn and Child Health NGO Non-Government Organizations NHP National Health Policy NNHS National Neonatal Health Strategy PG Primary group OR Operations Research PI Peoples’ Institution PNC Post Natal Care PPP Public Private Partnership PHSD Public Health Sciences Division RHFA Rapid Health Facilities Assessment SACMO Sub-Assistant Community Medical Officer SC Social Capital SES Socio Economic Status TTBA Trained Traditional Birth Attendant World Renew The international NGO formerly known as CRWRC January 2015 5 Abstract Objective. This Operations Research (OR) study examines an innovative approach to community mobilization of poor marginalized populations that seeks to engage communities in planning and action to mobilize resources for maternal newborn care (MNC). The study aims to document Peoples’ Institution (PI) model group formation, examine the development of social capital in PI model group members, and determine the impact of the PI model on health outcomes. Methods. The study used a mixed-method approach including baseline and endline qualitative process evaluation, investigation of social capital, health facilities assessment, and quantitative program evaluation with an intervention and control group. Respondents included 5,373 women of reproductive age (15-45 years old) and 30 health facilities randomly selected from Netrokona district, Bangladesh. Results. Perspectives on PI model group formation, goals, activities, savings, training, capacity development, and involvement in promoting MNC were documented as was the development of structural and cognitive social capital by group members. Membership in a group was associated with higher levels of social capital (p≤0.001) at project year 3 and 5. There was a significantly greater percentage increase (p≤0.05) in the intervention than in the comparison group in receipt of four or more antenatal care (ANC) visits, institutional delivery, delivery by a skilled birth attendant, postnatal care (PNC), exclusive breastfeeding, care-seeking for ANC/PNC complications and pneumonia, quality ANC, active management of the third stage of labor (AMTSL), and essential newborn care. Discussion. The study confirmed that the PI model can be effectively established in rural underserved upazilas in Bangladesh to increase the social capital of poor marginalized women and empower them to work with government officials and health providers to improve household and community MNC practices and increase utilization of quality health services in hard-to-reach families and communities. The PI model intervention strengthened public-private partnerships thereby enhancing access to resources for marginalized families. It improved the MNC practices of poor mothers and families, increased the quality of MNC health services in their communities, and established an upazila-wide enabling environment to strengthen and sustain MNC gains. Introduction A major barrier to reducing maternal and neonatal mortality around the world is the lack of quality accessible maternal newborn health services. This is especially true in developing countries with poor and marginalized populations where maternal newborn care (MNC) service delivery platforms are underdeveloped. In Bangladesh the high maternal and neonatal mortality rates are decreasing, however, the neonatal mortality rate is slower in its decline (52 in 1994, 32 in 2010) than the maternal mortality rate (322 in 2001, 194 in 2010) (Streatfield, et al. 2011, BMMS, 2010). Newborn deaths now account for two-thirds of all under-five deaths (39% in 1991, 60% in 2010). Among neonates death results from serious infections (24%), birth asphyxia (21%), pneumonia (13%), and pre-term birth (11%) (BDHS 2013, NIPORT 2011). For maternal deaths, about 64% are a result of direct obstetric causes such as prolonged labor, hemorrhage, eclampsia and abortion (BMMS 2010). Disparities in death rates exist between rich and poor economic quintiles and in factors that contribute to health, such as the adequacy of antenatal care, skilled attendance at birth, and postnatal care (BDHS, 2011). Rural poor areas in Bangladesh generally experience higher rates of neonatal and maternal mortality and poorer intervention coverage (BMMS, 2010). Within this context, World Renew implemented the SUSOMA* USAID-funded Child Survival and Health * SUSOMA is formed from the Bangla words Shustho Shishu o Shustho Ma, which means ‘healthy child and mother.’ January 2015 6 Grants Program from 2009 to 2014. The project targeted 124,313 women of reproductive age (WRA) and 19,314 infants 0-11 months in the Kendua and Durgapur sub-districts of Netrokona, Bangladesh. The Netrokona district in northern Bangladesh is rural, poor, one of the 14 Government of Bangladesh (GOB) low performing districts, and a priority district of USAID (UNICEF, 2009). The goal of the project intervention was to reduce mortality and improve health status among marginalized mothers and newborns through improved household and community MNC-related behaviors and increased utilization of quality MNC services. The project specifically sought to build social capital of the poorest households and mobilize communities for MNC utilizing the PI model intervention to establish community-based organizations and public-private partnership structures for ongoing MNC gains. The effectiveness of community-based interventions that target improving MNC in poor and disadvantaged populations has not been established. While community-based strategies to enhance MNCH have been developed and had success in achieving program objectives, the mechanisms of change are now beginning to be understood (WHO, 2014). Reducing inequalities in health outcomes requires monitoring and addressing multiple factors contributing to inequity in the specific geographical area, including economic, geographic, ethnic, and health system influences (Mulholland, et al, 2008). Over the last 18 years, World Renew has developed the innovative PI model approach to engage communities to form independent, self-sustaining community-based organizations (CBOs) that promote MNCH. The empowered CBOs have the capacity and social capital to establish linkages with public (clinics/officials) and informal (village doctors) health sectors that strengthen health services and MNCH gains. This operations research study examines mechanisms of establishing the PI model within a community and explores the relationship between the PI model intervention, the development of individual social capital, and the achievement of MNC health gains. The selection of remote upazilas (sub-districts) in Netrokona district with high levels of poverty and maternal/neonatal mortality was done in consultation with the GOB to serve as a representative area for testing the innovative PI model approach and for obtaining data for informed decision-making relative to scale-up of the PI model to other areas with similar contexts. The project sought to reduce inequity in health outcomes by addressing multiple factors contributing to inequity in the geographical area, including economic and health system influences. A conceptual framework serves as the basis for the PI model as a social capital enhancing intervention. Social capital is seen as a broad term including social relationships, networks, and values that facilitate collective action for mutual benefit. It includes the ability to access resources through social relationships. Two types of social capital are structural and cognitive. Structural social capital focuses on what people ‘do,’ their actions and behaviors such as civic participation and involvement in social networks. Cognitive social capital focuses on what people ‘feel,’ their attitudes and perceptions such as social trust and reciprocity (Story, 2013). The PI model intervention intentionally works to increase social capital in poor, marginalized populations by building cognitive social capital in terms of social trust, social cohesion, and collective action. It works to increase structural social capital in terms of organizational involvement in PI groups and bridging links to networks of government officials, health providers, and elites/influential individuals in the community. Social capital is a useful concept to study in global public health because it provides a conceptual basis for assessing the impact of community-based health programs. Social capital has been linked to lower levels of mortality, better health and healthy behaviors (Story, 2014). Studying the linkage between the PI model, social capital and improved health outcomes will provide greater understanding of the mechanisms of change in populations engaged in PI model community development and action to enhance MNH. This OR study focused on three areas, each with associated research questions: 1. PI model group formation. How do PI model primary groups (PGs) form? How do PI model approaches engage poor and marginalized women of reproductive age (WRA) and promote January 2015 7 MNC practices? 2. Social capital in PI model implementation. What is the degree of implementation of the PI model? What are the structural and cognitive social capital characteristics of intervention group PG members? Is membership in a PI associated with higher levels of social capital in the intervention group at endline when compared with non-member levels of social capital? Is an increase in social capital linked with improved health outcomes? 3. PI model and health outcomes. Is the PI model more capable than the status quo of 1) increasing care-seeking and utilization of MNC services, 2) increasing maternal newborn heatlh practices 3) increasing quality and availability of MNC health services, 4) creating more equitable MNC and health outcomes, and 5) reducing and creating equity in costs? Study Design, Methods and Intervention Study design. The study questions were addressed using a mixed-method approach with four components: 1. Qualitative process evaluation with intervention-group only baseline and endline interviews. 2. Investigation of social capital with intervention-group only pretest-posttest measurement (Social Capital survey) 3. Quantitative program evaluation with a quasi-experimental pretest-posttest, intervention￾comparison group design (KPC study). 4. Health facilities assessment with an intervention area only pretest-postest design (RHFA). Study duration, timeline. The total study duration was 48 months (4 years). The qualitative process evaluation data collection occurred in three phases: a) formative visits to intervention upazilas in June, August and November 2011 at the start of intervention implementation, b) visits for baseline process evaluation interviews and focus group discussions (FDGs) in January and June 2012, 7 and 12 months after the intervention began, and c) visits for endline process evaluation interviews and FGDs in March-April and July 2014 at the end of the intervention implementation period. The investigation of social capital baseline data collection occurred over 2-months (October to November 2012) during the second year of intervention implementation, and endline measures over 1- month (28 March to 15 April 2014) at the end of the intervention period. For the quantitative program evaluation, the baseline KPC survey data collection took 3-months (17 February to 06 May 2010) and was followed by the implementation of the intervention that lasted 39- months (July 2011 to September 2014). The endline KPC survey data collection occurred during the end of the intervention period and took 4-months (06 March to 25 June, 2014). For the health facilities assessment, the RHFA occurred over 1-month in November 2009 prior to the start of the intervention, and at endline in June 2014 at the end of the intervention period. Study participants, sampling, ethics. Participants were women of reproductive age (WRA, 15- 45 years old) from Netrokona district, Bangladesh. For the qualitative process evaluation, participants were 81 PI group members and non-members, community-health volunteers, and managers and coordinators from the two local implementing NGOs. Non-random purposive quota and snowball sampling was used for selecting interview participants. For the investigation of social capital, participants were 300 PI group members and non-members. Equal numbers of members and non-members were randomly selected from villages that were randomly selected from a list of villages in each of the intervention upazilas. Inclusion criteria for the qualitative process evaluation and investigation of social capital were being a married WRA and lower socioeconomic status (non-elite). For the quantitative program evaluation, the respondents in the intervention group consisted of 2,500 mothers of children 0- 2 years from 494 villages in the 20 unions of the intervention upazilas (Kendua and Durgapur), and the respondents in the comparison group consisted of 2,500 mothers of children 0-2 years from the 15 January 2015 8 unions of two nearby upazilas with usual GOB services (Kalmakanda and Barhatta). Randomized cluster sampling was used in which 40 clusters were selected (20 intervention, 20 comparison). For the health facilities assessment, data regarding MNCH services in the intervention area was obtained from health facilities and health workers using systematic random sampling. Additional information about sampling is in Annex A. Ethical approval for this study, including the process for getting informed consent from study participants, was obtained from the Research Review Committee and Ethical Review committee of icddr,b. The exception to this was RHFA carried out by LAMB for which permission and consultation was obtained from the Civil Surgeon and Deputy Director of Family Planning in Netrokona district. Data collection and analysis methods. Information about data collection methods and endline sample size are summarized in Table 1. Additional information about these methods is in Annex A. Table 1. Summary of Data Collection Methods Analysis. In order to determine whether the change in each KPC survey variable over time was significantly different in the intervention area compared to the comparison area, the percentage change was calculated from baseline to endline along with the 95% confidence interval for each variable. The percentage change in the intervention area was considered significantly different from the comparison area if the confidence intervals did not overlap (Knezevic, 2008). The percentage change was calculated using the following formula: 100 1 12 ∗⎟ ⎟ ⎠ ⎞ ⎜ ⎜ ⎝ ⎛ − = p pp PChange where p1 is the proportion at baseline and p2 is the proportion at endline. The percentage change demonstrates the difference in proportions from baseline to endline relative to the starting value at baseline. The 95% confidence interval was calculated using the following formulas: 95% confidence interval = PChange ± .1 96∗ SE − pp 12 and the standard error using: Data collection method When administered Sampling approach Respondents Sample size (endline) Baseline Endline Intervention Group Comparison Group Qualitative Process Evaluation Observations 2011/12 2014 PG and CC formation, CHV training 4 -- In-Depth Interviews (IDI) 2012 2014 Purposive quota sampling (with snowball) PI group members, WRA, low SES Group non-members, WRA, low SES CHVs TTBAs 22 22 4 8 -- Focus Group Discussion (FGD) 2011 2014 PI group members Group non-members 9 8 -- NGO interview 2011 2014 SATHI & PARI managers SATHI & PARI coordinators 2 6 -- Qualitative Social Capital (SC) Investigation SC Survey -Household questionnaire 2012 2014 Random selection of 45 villages and of 2 respondents/village PG members, WRA, low SES Group non-members, WRA, low SES 150 150 -- Quantitative Program Evaluation KPC Survey 2010 2014 Randomized cluster sampling (40 clusters) Mothers of children 0-2 years of age 2500 2500 RHFA 2009 2014 Systematic random sampling of facilities 30 -- January 2015 9 () () ⎟ ⎟ ⎟ ⎠ ⎞ ⎜ ⎜ ⎜ ⎝ ⎛ − + ∗ ⎟ ⎟ ⎠ ⎞ ⎜ ⎜ ⎝ ⎛ − − = ∗ deff n p p deff n p SE pp p 2 2 2 1 1 1 1 1 12 where n1 is the baseline sample size, n2 is the endline sample size, and deff is the design effect. The design effect accounts for the bias introduced by using cluster sampling instead of simple random sampling during data collection. Although the design effect varies for different variables, a conservative estimate for cluster sampling is two (CORE Group, 2004). By adding the design effect to the equation above, the standard error is larger and the confidence interval is wider; therefore, estimates for statistical significance between intervention and comparison areas more conservative than estimates that do not include the design effect. No comparison data was collected for the Social Capital Investigation or the RHFA, so statistical assessment of change was not possible for these variables. In order to determine whether changes in health outcomes over time were creating more equitable health outcomes, a wealth index was constructed from data collected on ownership of household durable goods, dwelling characteristics, sources of drinking water and sanitation facilities. Households were ranked according to their total ‘wealth’ score, and then divided into quintiles from the lowest (poorest) to the highest (richest). Health outcome data was analyzed by wealth quintile and the ratio of rich (upper quintile) to poor (lower quintile) computed for the rapid CATCH variables. To determine whether the change in the rich-to-poor ratio overtime was significantly different in the intervention area compared to the comparison area, the percentage change was calculated along with the 95% confidence intervals for each variable. Intervention impact model. Factors considered in studying the intervention are categorized into five areas presented in the intervention impact model depicted in Figure 1. The context includes individual and community-level factors present at baseline within which the intervention was established. The quantitative program evaluation and health facilities assessment included variables that measured context. The intervention strategies comprise the independent variable, the PI model intervention, and include approaches used to affect change in MNC, such as community mobilization and training, EHFs, MNC referral system, and the PPP. Process outputs are factors that indicate the degree and mechanisms of PI model implementation and include PI group formation, inclusion of marginalized people in groups, utilization of EHFs and referrals, and size/functioning of the PPP network. The qualitative process evaluation and project M&E indicators inform the process outputs. Intervention outcomes are the dependent variables and include intermediate indicators of intervention effects such as utilization, practices, service availability, quality of care, equity, social capital and cost. The quantitative program evaluation, investigation of social capital, and health facilities assessment inform intervention outcomes. Impact factors are effects beyond the scope of this study that the project aims to influence in the long term, including changes in maternal and neonatal mortality and morbidity. Intervention strategies. The SUSOMA program intervention platform being examined as the independent variable (IV) in this OR study is the People’s Institution (PI) model. The PI model approach was used to mobilize marginalized populations and to train and empower them to establish independent, self-sustaining community-based organizations (PI groups) to promote maternal newborn health and social change. The PI groups supported a cadre of trained community health volunteer MNC providers, developed emergency health funds and referral mechanisms for MNC, and established public-private partnership structures for ongoing MNCH gains. The intervention group upazilas received the PI model intervention. The comparison group upazilas had usual GOB services and did not receive the intervention. January 2015 10 Figure 1. Intervention Impact Model In the first two years of the project, project staff community health trainers (CHTs) built social capital as they mobilized poor marginalized community members for maternal newborn health and established the three tiers of PI model community groups (see Figure 2). Initially, CHTs went household to household in all villages in the district to build awareness and engage pregnant women and mothers in forming groups, called Primary Groups (PGs), to address mother and newborn health concerns. PGs are PI Model groups that function at the village level. CHTs trained PG members and supported them to work together to solve problems, to claim their rights, and to track group gains in capacity. The PGs selected local volunteer providers, community health volunteers (CHVs) and trained traditional birth attendants (TTBAs) to promote maternal newborn health in their village. Beginning in 2012, men’s PGs were formed to promote the involvement of husbands and males in MNC-related decision-making at family and community levels and to strengthen PI advocacy with the government. Because many of the women in the initial PGs were illiterate, they linked with elites in the higher wealth quintiles to assist them in running their organization, and eventually formed advisory groups of supportive influential persons. Once the PGs became established, the CHT helped each select two representatives to form a union￾level Central Cooperative Committee (CCC). The CCC representatives received training and were supported to make and carryout plans for enhancing union-level MNCH. Each CCC then selected six representatives to join the upazilla-level PI group, which received additional training and support. Each PI (with the CCC and PGs under it) has one trained health sub-team that is responsible for overseeing local MNC health services through maintaining public-private partnership (PPP) networks. The project established three tiers of CBOs utilizing the PI model: 541 PGs (22 male), 22 CCCs, and 4 PIs. Utilizing a training of trainers strategy, CHTs trained each of these tiers in leadership, management, record keeping, gender, local resource mobilization, monitoring and evaluation, sustainability, auditing, advocacy, networking, and capacity measurement. January 2015 11 Figure 2. PI community mobilization approach and links to the health system The PGs, CCCs, and PIs were assisted to develop PPP networks by which they collaborate with the local formal, informal and private health care systems to advocate for enhanced MNC service delivery and policy change. The PIs signed MOUs with local government and private (Garo Baptist Convention (GBC), Dushtha Shasthya Kendra (DSK)) facilities in which each extends to the other support and cooperation for training, education, meetings, improving quality of services, referrals and emergency care, and maintaining maternal newborn registries. The PI’s promote maternal newborn health as they link at the upazila and district levels with government officials and serve on the Upazila and District Technical Advisory Committees that meet quarterly (UTAC) and semi-annually (DTAC). They share progress, inform officials of needs, influence strategies to meet gaps, and participate in decision-making related to MNC. The CCC’s link at the union level to government officials and participate in decision￾making within the Family Welfare Centers (FWCs) and Rural Dispensaries (RDs). Over the course of the project they jointly developed a community maternal newborn Health Ministry Information System (HMIS) data collection form. They instituted monthly HMIS data matching meetings with the Upazila Family Planning Officer (UFPO) and Upazila Health and Family Planning Officer (UH&FPO) to sync CHV and TTBA registries with clinic staff registries and make plans to promote availability of MNC services and availability of supplies and drugs to meet local needs. The PG’s promote and coordinate MNC at the village level. PG members serve and participate in decision-making at the ward level on the 60 Community Clinic (CC) Management Committees. Community-based CHVs, TTBAs, and Independent Service Providers (ISPs) trained by the project meet monthly to coordinate local MNC with government health workers† and set goals/strategies for local action. To provide access to emergency MNC for the poor in their community, PG groups were assisted to set up, raise funds for, and actively manage emergency health funds (EHFs) in collaboration with their union CCC. The EHFs have financial records, lending policies, and bank accounts. In addition, groups purchased or had rickshaw ambulances donated to them. An unintended but popular development in all the PGs were the health savings from which loans were taken for income generating activities (IGA) that enable parents to better feed and protect the health of their families. Group members bring 2-5 taka to † Sub-assistant Community Medical Officer (SACMO), Family Welfare Visitor (FWV), Family Welfare Assistant (FWA), Health Assistant (HA), Community Skilled Birth Attendant (CSBA), Community Health Care Provider (CHCP), Medical Assistant (MA) January 2015 12 the weekly meetings for these funds. The health savings accounts belong to and are managed by the PGs. To improve MNC practices the intervention established BCC-based maternal newborn counseling done by PI volunteers with all pregnant women and key stakeholders in each village. The trained CHVs and TTBAs were responsible for promoting ANC, safe institutional/community skilled birth attendant (CSBA) delivery, essential newborn care (ENC), and PNC during household visits to pregnant and newborn mothers in their villages. They also held educational meetings with the PI groups in their community. Additionally, Theater for Development (TfD) teams were trained and integrated into the PI system to perform community dramas to raise awareness of MNC-related issues and counter the resistance to proper MNC of influencing husbands and in-laws. To increase quality of MNC services the project intervention 1) trained community-based health providers, 2) supervised PI-linked CHVs and TTBAs, 3) established an active referral system, and 4) facilitated PI monitoring and support of health facility (HF) utilization and care quality. A total of 1,201 community-based volunteers (537 CHVs, 541 TTBAs) and 123 government facility-based providers received training and refresher training in ANC, safe delivery, PNC, ENC actions, and integrated management of childhood illness (IMCI). Of these, 79 CHVs were trained as regional Super CHVs to oversee and strengthen CHV performance (CRWRC, 2009). An additional 377 ISPs received training and refresher training in IMCI and referrals to reduce harmful practice. The project equipped 101 government providers (FWVs, SACMOs, MAs, CBSAs) as trainers and supported 10 local government health workers for intensive IMCI training and six for Emergency Triad Assessment and Treatment (ETAT) training in Dhaka. Supportive supervision of community volunteers to nurture and maintain quality was built into the project with project staff initially making supervisory visits to CHVs and TTBAs and then turning the role of overseeing CHV and TTBA care quality to MOHFW staff. Beginning in 2012, the role of Super CHV was developed to support local networks of CHVs and hold monthly meetings to facilitate ongoing learning, sharing of case studies, and best practices. The primary activity to improve health facility utilization and quality of care was involvement of PGs in their local community clinics. Initial monitoring of clinic functioning by PGs led to the active involvement of PGs in clinic management committees. All PGs are now involved in clinic decision-making and advocacy along with the local elites. In thirty ‘Model CCs’ the PG opens the clinic, cleans it daily, assists and holds health workers accountable, and makes improvements in the clinic. PGs have advocated for logistical support and received delivery kits, delivery beds, weighing scales, and blood pressure cuffs. In 2012, the project assisted the PIs to work with the government on a ‘Helping Workers Thrive’ campaign, which has provided support and encouragement to clinic personnel. To assess if the intervention was being implemented as planned, the OR team relied on monitoring of intervention implementation done systematically throughout the project utilizing multiple techniques established in the SUSOMA Project workplan, M&E plan, and HMIS. This includes quantitative and qualitative project data collected in the community and from field visits, data from training events and meetings, data from the MOHFW HMIS, and data from project qualitative and quantitative assessments. Following every training, follow-up and supportive supervision was provided to all participants to ensure actions taken were congruent with intervention strategies. The CHVs and TTBAs were observed by CHTs and later by MOH workers to be sure they were following BCC counseling and referral guidelines and adjustments/retraining were done as needed. The CHTs had close relationships with the PGs, CCCs and PIs and slowly ‘weaned’ them from oversight as they demonstrated the ability to report monthly data and function independently. Once data was submitted to the M&E officer it was reviewed and disseminated in monthly and annual progress reports. These reports were discussed at monthly Project Implementation Team and quarterly Project Management Team meetings and adjustments were made when indicated to stay focused on project aims. The project monitored the intervention activities in the intervention area. The comparison area did not receive a project intervention and was not January 2015 13 monitored during the study. Although the OR team did not participate in intervention monitoring, it did train data collectors and monitor all data collection and analysis processes for both intervention and comparison groups to ensure integrity of the data. Process output measurement. Process output indicator measures that indexed how and the degree to which the PI model intervention was implemented are presented in Table 2. Table 2. Process output measures Variable category How measured Collection method PI model intervention implementation processes • Demonstration of PI model group formation, CHV/TTBA trainings and roles • Group member reports about PI model PG, CCC, and PI group formation, leadership, goals and activities, EHFs, CHW training and roles, linkages, capacity and involvement in MNC • Group non-member reports about purposes of PI groups, CHV roles, impact of PI model groups on their community • NGO leader reports about group formation, mobilization strategies, group functioning, leadership and linkages, involvement in MNC, barriers to MNC Observation, IDIs, FGDs, interviews Outcome variables and measurement. Outcome variables that indexed intermediate PI model intervention effects are presented in Table 3. Table 3. Study outcome variables, indicators, and data collection method Variable category Variable name Indicator Collection method Social capital Structural social capital Cognitive social capital Level of social capital • Structural social capital survey indices for decision-making, leadership, political and social networks, conflict, and access to services • Cognitive social capital indices for solidarity, trust, cooperation, and conflict resolution • Social capital scale score SC household survey Utilization of health care services ANC SBA delivery Institutional delivery PNC-newborn PNC-maternal • Percentage of mothers of children age 0-11 months who had four or more antenatal visits when they were pregnant with the youngest child. • Percentage of children age 0-11 months whose births were attended by skilled personnel • Percentage of children age 0-11 months whose births took place at institution/health facility • Percentage newborn of age 0-11 months who received a post-partum visit from an appropriate trained health worker within two days after birth (LB) • Percentage of mother of children age 0-11 months who received a post-natal visit from an appropriate trained health worker within two days after birth KPC Care-seeking • Percentage of children age 0-23 months with chest-related cough and fast and/ or difficult breathing in the last two weeks who were taken to an appropriate health provider • Percentage of mothers of children age 0-11 months who sought care from a medically trained provider for complications during pregnancy, delivery, and after delivery for births in the year preceding the survey KPC Practices Contraceptive use Exclusive breastfeeding Immediate breastfeeding No pre-lacteal feeds Use of clean birth kits Thermal care newborn • Percentage of mothers of children age 0-23 months using modern contraception • Percentage of children age 0-5 months who were exclusively breast fed • Percentage of children age 0-23 months put to breast within 1 hour of delivery • Percentage of children age 0-23 months who did not receive pre-lacteal feeds • Percentage of women of children age 0-11 months who used a clean delivery kit during the birth of their youngest child (HOME Delivery only) • Percentage of children age 0-11 months who were dried immediately KPC January 2015 14 Variable category Variable name Indicator Collection method Immediate wrapping ORT use Point-of-use water Handwashing practices after birth (HOME Delivery only before the placenta was delivered)(LB) • Percentage of children age 0-11 months wrapped with a cloth or blanket immediately after birth before placenta delivered (HOME Delivery LB only) • Percentage of children age 0-23 months with diarrhea in the last 2- weeks who received oral rehydration solution (ORS) or recommended home fluids • Percentage of households of children age 0-23 months that treat water • Percentage of mothers of children age 0-23 months who live in households with soap at the place for hand washing Service availability ANC services Institutional delivery • Percentage facilities with ANC services 4+ times/month • Annualized number ANC visits/facility/year • Percentage facilities with 24/7 delivery services RHFA Clinic availability Sick child care Growth monitoring Laboratory services • Number of CCs, FWCs and RDs open and functional • Percentage facilities that offer sick child care • Annualized number of sick child visits/facility/year • Percentage facilities that offer growth monitoring • Percentage facilities with available MNC and child laboratory services RHFA Supply/drug availability Guideline availability • Percentage facilities with all essential child care supplies/drugs • Percentage facilities with ANC supplies and drugs • Percentage facilities with neonatal supplies and drugs • Percentage facilities with available care guidelines • Percentage facilities with MNC information systems RHFA MNC referrals • Number referrals made by CHVs, TTBAs, and ISPs • Percentage facilities with community referrals MIS RHFA Community health volunteer & informal health services • Number CHV and TTBA visits • Number community presentations about MNC • Number ISPs collaborating with CHVs and HFs MIS Quality of health care services Quality antenatal care • Percentage of mothers of children aged 0-11 months who had 4+ ANC visits from medically trained providers with all necessary services (blood pressure and weight measurement, urine testing for proteinuria, blood testing) and advising about danger signs of pregnancy complications and their management KPC Quality delivery care • Percentage of mothers of children 0-11 months who received AMTSL (active management of the third stage of labor with administration of a prophylactic uterotonic, gentle cord traction, uterine massage after delivery of the placenta) KPC Essential newborn care coverage • Percentage of children age 0-11 months who received all 3 ENC elements (essential newborn care includes thermal protection immediately after birth, clean cord care, immediate/exclusive breastfeeding) KPC Infection control Infrastructure • Percentage of facilities with soap for handwashing • Percentage of facilities with gloves • Percentage of facilities with client latrine, safe water, and visual/auditory privacy RHRA Facility-community collaboration • Percentage of facilities having at least one method for community participation (facility management committees and/or engagement with CHWs/TTBAs) and at least one way to incorporate information received (community discussions and/or changing health worker behavior) RHRA IMCI-based staff training • Percentage facilities with staff training in MNC / child health in past 12 months • Appropriate child diagnosis/treatment during illness visit RHFA Health Equity Rich-to-poor ratio • The ratio of community members surveyed in the lowest versus the highest wealth quintile for intervention outcome indicators (health equity gap indices) KPC Cost of care Out-of-pocket cost • Out-of-pocket cost incurred by mothers for transport, hotel, KPC January 2015 15 Variable category Variable name Indicator Collection method incurred in securing care consultation, diagnostic, and drug costs in securing antenatal, delivery, and postnatal care for a pregnancy in the year preceding data collection as well as care for pregnancy complications and illnesses in their under two children Results Intervention monitoring results. The SUSOMA project utilized the PI model intervention to establish the capacity of the poor and marginalized to work for improved MNH in multiple ways. They mobilized the poorest village residents and helped them to establish the PI model system across each of the 494 villages in Durgapur and Kendua upazilas, including 4 People’s Institutions (PIs) with health sub￾teams, 22 union-level Community Central Committees (CCC), and 541 village-level Primary Groups (PGs) that together are providing community-based management of MNC. By the end of the project, 42% of the PGs formed were high-level/independent functioning, 38% medium-level, 20% low￾level/emerging, and 96% had active EHFs that had been used by 2,406 women and children to access care. The project trained and supported over 40,000 community PI members in the intervention upazilas. The PI groups are registered GOB social welfare agencies and have established functional PPPs with GOB health officials and workers with MOUs and regular meetings to promote equitable, quality MNC (4,038 meetings held during the project). All PGs are involved in decision-making on their local clinic management committees and 30 clinics are PI-managed. PI groups were helped to establish a PPP￾based MNC referral system in which the poor receive priority treatment (5,467 referrals made to health facilities by CHVs, TTBAs, and ISPs). During the life of the project, facilities receiving referrals increased from 37% to 80% (RHFA). The project provided training, supportive supervision, and refresher training in ANC, safe delivery, PNC, ENC actions, and IMCI to 1,201 community-based volunteers (537 CHVs, 541 TTBAs) and 123 government facility-based providers. An additional 377 ISPs were trained in IMCI. CHVs and health officials/workers met monthly to coordinate care and match HMIS data. The PI-based CHVs and TTBAs visited every household in the intervention upazilas and provided counseling to over 120,000 pregnant women and 40,000 newborn mothers. The CHVs held 15,659 community MNH promotion events and 55,486 MCH teaching sessions with PG members. Three PI-based Theater for Development teams performed 113 BCC drama events to raise awareness and overcome resistance to MNC utilization. The PI groups assisted with 881 National Health/Immunization Days. During the project, the Peoples Institution Manual (Daring, 2014) was published which has standardized PI model implementation and training practices. Demographic characteristics and equivalence of groups. Comparison of household and population data from the KPC surveys, obtained from the intervention upazilas and two comparison upazilas in Netrokona District, revealed that both groups (WRA with a child <2 years old) were similar in age, marital status, religion and ethnic status (Table 4). Fewer respondents in the intervention group did not have any formal education, however, across both groups more younger than older women had completed primary school or higher. They were equivalent in household size, access to electricity, improved drinking water, and household possessions. At baseline the intervention group had better access to improved sanitation and more owned their homestead than the comparison group, however, both groups were equivalent in sanitation and homestead ownership by endline. Fewer of the households in the intervention than the comparison group were in the poorest wealth quintile and more were in the richest quintile, although the differences were less marked in 2014. January 2015 16 Table 4: Respondent demographic characteristics intervention and comparison group, 2010 and 2014 (KPC Survey) Indicators Intervention Comparison 2010 2014 2010 2014 Mean age in years (SD) 27.5 (±5.08) 27.3 (±5.07) 27.5 (±5.09) 26.7 (±5.04) Currently married 99.4% 99.8% 99.4% 99.7% No formal education 32.6% 24.7% 44.6% 27.5% Islamic religion 95% 95.7% 88.4% 91.5% Hajong, Garo or other ethnic minority 2.7% 1.1% 2.7% 0.7% Mean size of households (SD) 5.4 (±2.05) 5.5 (±2.1) 5.6(±2.19) 5.3 (±2.0) Percentage of HHs with electricity 20.8 43.1 20.2 43.8 Percentage of HHs with improved source of drinking water 98.5 97.8 97.2 98.6 Percentage of HHs with improved toilet facility 73.1 76.2 62.5 78.2 Land ownership status Homestead 77.5 89.8 73.0 90.1 Other cultivable land 47.5 45.7 37.6 50.0 Neither 18.1 7.9 23.1 8.4 Wealth status Lowest 16.6 19.0 23.6 20.9 Second 19.9 19.0 20.1 20.9 Middle 21.2 20.1 18.7 19.9 Fourth 20.5 21.3 19.6 18.7 Highest 21.9 20.5 18.1 19.5 Main findings. Results will be reported in three stages: First, by examining the dynamics of PI model group formation utilizing qualitative process evaluation data; second, by exploring the role of social capital in PI model implementation utilizing data from the investigation of social capital; and, third, by evaluating whether the PI model is more capable than the status quo of increasing care-seeking, utilization, MNC quality, and equity with reduced personal costs utilizing KPC survey and RHFA data. Composite results are presented for the intervention area. For the sake of clarity in understanding findings, differences between upazilas are not considered here, however, they can be found in the cited reports. The dynamics of PI model group formation are presented by examining the research question in light of the qualitative process evaluation data from group members, non-members, and implementing NGO leaders. Information presented below is drawn from the qualitative research findings found in the 2014 icddr,b Final Operations Research Qualitative and Social Capital Study Report (SUSOMA Final Evaluation Report, Annex XIXe). Major findings of the qualitative process evaluation are summarized in Annex B. How do PI model PGs form and how do they engage poor and marginalized WRA and promote MNC practices? Data related to PGs is presented first, followed by CCCs and PIs and then promotion of MNC. Primary Groups (PG) PG formation. NGO staff and community health trainers (CHT) were the primary “external” element in the basic scheme of building a People’s Institution (Figure 3). The CHT spends months talking to people in the community, expressing the need and utility of forming a Primary Group (PG), explaining the vision to women and men, and mobilizing group formation, selection of leaders, and planning activities for the group. The process was arduous and required a lot of patience. The initial activity of group formation was finding the right persons who were motivated enough to deposit a nominal amount of money weekly and had a vision of doing well for themselves as well as the community. One of the CHTs in Kendua reported that she worked for three months and was able to identify 13 potential members. January 2015 17 NGO staff provided the organizational know-how and oriented the potential group members on the activities, goals, and objectives of forming the group. PG membership criteria and leadership. Group members indicated that membership criteria included being a married female of reproductive age (15-49 years). Groups indicated that they decided who was poor and could join the group, income was not mentioned as a criterion. Groups were comprised primarily of uneducated poor women who could not write their names, so groups intentionally included educated ‘elite’ members who could read, write and calculate money deposits to serve in leadership roles. Groups stated, “she can read and write and understand all… she helps us to understand things and keeps linkage with everyone in our society.” Overtime, education became a criterion for the selection of the president, cashier and secretary. Figure 3. The process of PG formation as related by informants PG trust and social cohesion. The development of trust and unity of vision (social cohesion) among members was reported as important for groups to function, especially related to management of EHFs and health savings bank accounts. Initially saving money was a technical problem, the women did not know how to do it and did not trust each other or the banks, but eventually they and their husbands developed confidence in savings and were reaping benefits. Mistrust was also initially present related to uncertainty about the NGO intent in setting up groups, lack of clarity about PG’s objectives and plans, confusion about individual roles and responsibilities. Jointly working through these conflicts as they emerged helped strengthen group bonds. By endline, groups demonstrated trust and the ability to resolve problems that they arose, understood that groups function for their own benefit, and showed commitment to working together for positive community change. PG goals and activities/EHF and savings. Primary groups stated their main task was to reduce maternal and child mortality in their area. Most of the PGs had regular weekly meetings that were facilitated by the PG leader. Initially, groups developed mechanisms for collecting regular deposits and calculating the deposited amount, and decided financial matters such as providing loans, how to collect and distribute EHF money, and where to spend money. As groups matured, they worked on creating health guidelines, flipcharts, and books that they discussed during their weekly meetings. The PGs engaged with union￾level CCCs, and although all PGs were able to talk knowledgably about the CCC, involvement with CCCs was not uniform across all groups. Savings was the most important motivation to PG members. Each deposited BDT 2 (USD .03) per week for the EHF and BDT 5-10 (USD .03-.13) per week for the group health savings account. The poor women earned taka for these deposits by selling vegetables grown in their yard, sewing, poultry, or accumulating a handful of rice every day. They were required to deposit funds to the EHF weekly to remain in the group and were expected to deposit to the health savings account as well. Upon approval of the group, members who deposited to the saving account could take a zero to .04% loan from their PG for IGA, such as rickshaw van, shop, nursery, poultry, animals, pond or land property, to enhance the welfare of their families. Loans from the EHF were interest free and for all mothers and children from the community requiring emergency care. The cashier kept the financial records for the group. A PG member explained the mechanisms of using EHFs and linking with government hospitals, “Each of us ' !!  ! ' !$!"!%! !#!! #!   !!   !   !& &!!  !%! !! !!  !"!"!#! $! "#    !  January 2015 18 gives 2 taka which constitute 50 taka per month… we deposit this money in the emergency fund. If the pregnant mother faces any trouble, if the newborn is in bad health, we take them to the hospital with this money. We call the van or person to accompany her. We have the referral slip with us and write the name of the patient and her husband’s name on it. We take that with us and show that to the doctor. Then, they find that this patient is from SUSOMA and provide emergency treatment. They help us, otherwise, they don’t.” CHV/TTBA training and roles. The CHVs received training in MNC in batches of 16-22 participants from the implementing NGO staff. Attendance and compliance to this training was high. A CHV related that at her 5-day training she learned how to counsel the pregnant mother regarding diet and activity, complications and ANC, weighing and wrapping newborns, breastfeeding, handwashing, identifying danger signs, referrals, and maintaining MNC registries. CHVs also received training on PG formation. A PG related that a CHV contributed to their group coming together by telling them, “You should form a PG and deposit 10 taka or 5 taka. This is to keep our health better. If we have money, that money will be used for the pregnant mother to take her (to the hospital).’ This is the reason for our creating this group.” TTBAs also received MNC training and maintained linkages with the health system. They visited households and delivered MNC health promotion to all the mothers in the catchment area. They encouraged 4 ANC checkups, identified danger signs of pregnant mother, sent mothers to the hospital for any danger sign, and enhanced patients’ communication with the doctor. One TTBA related, “After training now I can understand easily what is good and what will be bad for a patient, and if I see any problem I say to them, ‘take her to the hospital’, they listen to me.” TTBAs also identified neonatal danger signs, encouraged giving colostrum to the newborn, and assisted health personnel with MNC. TTBAs found that their lives had changed since they joined the groups in terms of knowledge, relationships with people and new linkages with elites and government officials, who respected them and met regularly with them. One of the TTBAs stated that there are changes in the society as well after commencing the PI groups, “Mothers died, babies died previously…any woman might have 5 to 10 children… nowadays they have 2 or 3… the mother in labor died before as soon as she delivered… now you won’t find any mother dying even if you search thoroughly… none of the newborns die now…very few babies are born with weight less than 3 kilo… mothers go to the hospital as they understand that delivery at hospital would ensure good health for the mother and the baby… isn’t that a change that happen after they got the message?” ISP training and roles. The PGs and CHV/TTBAs engaged with ISPs (village doctors). Many ISPs were trained by the project; however, most in the qualitative process evaluation sample were not. One ISP had a good connection with the CHT, CHV/ TTBA, knew PG members from the same locality and was willing to help people in need. Another ISP trained by the project stated that he had referred nearly 100 patients with MNH problems to the district hospital in Netrokona. All ISPs said that the CHT visited and informed them about MNH regularly and also provided referral slips. One advised that more programs on awareness building should be initiated to get a good result on MNH and to include the religious leaders in disseminating information after Jumma (Islamic Friday prayers). PG linkages with government. Since the beginning PGs were highly appreciated by local leaders and the support PGs received from others encouraged group members to further concentrate on their activities. The PGs met monthly with their implementing NGO and government health staff at the union level. At these meetings they shared about group activities and discussed MCH, nutrition and food practices. PG members helped the GOB by informing communities about health clinics, assisting with immunizations and hand washing programs, sharing pregnant mother and newborn HMIS lists, and providing health facility referrals and support. Government health staff invited PG leaders to join in meetings with elites where information provided by the PGs influenced decision-making and plan development of the GOB. A PG related, “In upazila and district level we are respected, our list and our information helps the government.” PGs received donations from government officials and elites of blood pressure machines and scales for the clinics, and contributions to EHFs and a clinic management fund. PG Capacity. During the project, members developed knowledge and skills in MCH, what to do in emergencies, management and leadership of a group, financial management, record keeping, and group processes. Most members gained capacity to work independently over the years and confidence to run January 2015 19 the PG without NGO assistance, saying, “Yes, we are capable, we can.” As groups, they were committed to helping communities with EHFs, were becoming more knowledgeable on MNC topics, were praised by family members and community people, and were satisfied with their activities saying, “This is not mere wastage of time… we are helping the pregnant mothers and the children… this is our reason to be happy.” They reported that collectively groups were able to have discussions and make decisions, learn and share ideas, and save and help others. They expressed wanting to share about their activities and ideas at meetings with community people, “We need to share about our group activities with community peoples, we need to arrange a large monthly meeting…” PG non-member perspective. Non-members reported that, although the groups were engaged in monetary matters, they also dealt with issues of MNCH emergencies, health education, compilation of information on pregnant mothers, identification and their regular health check-ups, and other health needs. They indicated that the CHV provided regular visits to the mothers and provided booklets to the mothers so that they can take better care for their health. They stated that due to this group the general consciousness regarding maternal health had increased in their community. Central Coordinating Committee (CCC) and Peoples’ Institution (PI) CCC formation. Data from NGO leaders and PGs indicated that, as groups developed the CHT proposed that all PGs elect two representatives to form the union-level CCC. A meeting was held, officers elected, and BDT 10 deposited by each member. The monthly meeting observed by the qualitative research team opened with recitation from the Holy Qur’an, introductions and sign-in, calculation of money deposited, discussion of MNC health topics, and reports by the health, communication, leadership and finance sub-teams. The CHT was present to assist the president in learning their role and to help facilitate group process. Resolutions made were recorded and only passed if all members agreed. Planning for community service, such as purchase of emergency vans, began in the CCC. PI formation and leadership. The PIs formed after the CCCs were established, when up to five representatives from each of the CCCs from all the ‘feeder’ unions came together for the election of officers. The PI, which is the top level in the PI model, worked to reduce maternal newborn deaths, monitored activities of the PGs, provided special assistance for high risk situations, and deposited BDT 10 in PI savings. The qualitative research team noted that in the PI they observed, “none of the PI members are now poor,” but most were illiterate and all were less than 50 years of age. Committee secretaries were elected based on their qualifications, all members participated in the meeting, and decisions were made when all members agreed. The group had a bank account and was preparing for sustainability. The four PIs active at endline had good linkages with the public health system and other local government offices. They were buying land for their offices. They reported being confident that they would be able to continue without the NGO cooperation. Leadership development was one of the primary outcomes of the PI model. PI leadership criteria focused on being committed and having time to accomplish activities, being trustworthy and of good character. Leaders were volunteers trained to manage groups of 15-20 members, to lead discussions and solve problems. Although members of the groups were poor and illiterate, by learning to take care of group property and manage group activities they became more confident, honest, responsible and knowledgeable, and were taking over from the rich as community leaders. Motivation for the voluntary work was 3-fold: to get respect from other community members, fulfill one’s responsibility to society, and please God with their good will. Mobilization strategies. Members from the community formed the women’s PGs and men’s PGs (which were added in year 3 of the 5-year project), the CCC was developed from the participation of two representatives from all the PGs, and representatives from CCC formed the PI. Strategies used by the implementing NGOs to mobilize PI groups included: a) helping them make a strategic plan and set targets, b) developing a list of all possible trainings, sign community people up and provide the training, c) networking with local government to learn more about the on-going activities, improve health facility access, create lists of facilities, stakeholders and local resources, and apply for registration as a GOB January 2015 20 social service agency. Each PI was subdivided into several committees, such as, health committee, education committee, and financial committee that focused on management of different activities, namely, how to manage health-related emergencies, educational arrangements for poor, to whom loans should be given, and how to manage financial activities. The PI coordinated capacity building efforts of the PI model groups and provided direction to the committees. A NGO manager explained that their goal with the PIs was to ensure the empowerment of women and the increase in social capital and reduction in poverty among the poor. CCC/PI group functioning. The CCC and PI met monthly, each with 20 participants, 11 which were members of the steering committee. NGO participation in the groups was for financial decision-making, leadership development and measurement of capacity. The PIs were taught to measure their capacity in human resources, financial stability, leadership management, networking, legality, and gender equity with a 6-indicator PI Capacity Indicator scale (PICI). The PGs used a brief Organization Capacity Indicator tool (OCI). Collective actions of the community members were done for societal good. PI model groups worked for road and bridge construction, health emergencies, donation of warm clothes and food during winter, and worked against early marriage. An NGO staff gave an example of their initiative, stating, “suppose, one of the roads is broken… everyone was thinking that government will reconstruct the road… however, members from our CCC found that this would not be carried on… the community start collecting 2 taka from everyone to create a small bridge made of bamboo to cross this river… they dig the soil and put in the road…” PI linkages with government. After successful formation of the PIs good relationships were established between PI groups and local GOB/NGO officials, who gave donations from them several times, including: The Ministry of Child and Women’s Affairs donated a total of BDT 900,000 (USD 11,800) to a PI from which a member can take a loan of BDT 10,000 (USD 128). The implementing NGOs donated decoration sets for event management (plates, glass, spoon, mike and so on) worth a total of BDT 412,000 (USD 5,301) that they can use for earning money. Promotion of MNC Involvement in MNC. NGO leaders and PI model group members indicated that the four PIs were playing important roles in improving maternal care and reducing maternal and newborn deaths by assisting in sending patients to the hospitals and helping them to get timely care through improved connections with local elites, as depicted in Figure 4. These benefits were accessible to all community members. Figure 4. PI model group’s involvement in maternal newborn health care-seeking The PI members reported getting directly involved in helping mothers and newborns with accessing emergency care. They gave an example of the PI president going to a home to convince the mother-in￾law that bleeding in the seventh month of pregnancy was abnormal and required hospital care. The PIs directly taught families the importance of getting care when maternal and newborn danger signs were present, gave families referrals to insure they will be seen when they get to the health facility, and gave them interest free loan from the EHFs to pay for the care. The loan was repaid in small installments over a long period of time. When problems arose with access, such as being denied care at the regional (&!  !  !!   %  "  )& !#! ! !    % *& !!  !%   ! +&"! "!$! ! # # ! "  ,& "!   ! January 2015 21 hospital, the PI president called the resident medical officer who then provided care. PI members also explained that their quarterly meetings at the district level with MOHFW service providers created linkages and helped in reducing the refusal of patients. These PPP meetings were explained by NGO staff: “Two representatives from each PI join the Upazila Technical Meeting where other participants are upazila health and family planning officer (chairperson), UFPO (co-chairperson), the NGO health coordinator (secretary) and other respectable guests. Here the PI members represent their community. They also have regular meeting with the chairmen. In the district level, the PI members and the CHVs join the meeting. The public health staff didn’t give them any value before, however, it is different now. They are well respected there.” Barriers to MNC. The challenges community and NGO informants faced in seeking health care from public health services early in the project and the status at the end of the project when the PI model groups were formed and functioning are presented in Table 5. Table 5. Comparison of reported barriers in healthcare seeking 2011-2012 versus 2014 (Qualitative Process Evaluation) Barrier 2011-12 2014 Knowledge health problems Present in one, absent in other upazila. Improved. Inability to make care￾seeking decisions Present in almost all areas. Present in small scale. Health care provider behavior and availability Not always welcoming, some did not care for patients with severe cases, absent health care providers even during duty time. Mostly welcoming. Strong connection established between the health service providers and the PI leadershis. Distance to care and lack of transportation Worked as a demotivating factor and very few went to hospital. Use emergency fund to take to the hospital whatever the distance is. Cost of treatment (BDT 20) People borrow (with interest) from different sources or sell properties, very few uses emergency fund. Emergency fund used by members and non-members to get health care. Money provided as loan without interest and paid back in small installments over long period. Communication with CC Absent Present. Communication with elites Present in upazila with early PI groups, present in small scale in other upazila. Interpersonal and working relationships established with local elites and public health service providers. Family member’s disapproval Present in almost all areas. Present in small scale. Exploration of the degree of change in social capital in PI model implementation is presented by examining data from the investigation of social capital. Information presented below is a summary of findings from the investigation of social capital found in the 2014 icddr,b Final Operations Research Qualitative And Social Capital Study Report (SUSOMA Final Evaluation Report, Annex XIXe, pg. 57-86). Data from this intervention-group only sample provide results that inform the social capital related research questions (Table 6). Table 6: Summary social capital investigation indicators, 2012 and 2014 (Social Capital Survey) Social Capital Indicator 2012 n=335 2014 n=310 Degree of PI Model implementation Member of any group or organization PI model group most important group to their household Function as a leader in their group 65.4% 62.5% 10.5% 63.9% 74.8% 19.2% Structural social capital Leadership/decision-making: -group leaders effective -leaders make decisions with group input -group members hold discussion and decide together 96% 12.3% 74.9% 98.5% 36.9% 59.6% January 2015 22 Social Capital Indicator 2012 n=335 2014 n=310 Social support/political networks: Who would work together to deal with a village-level problem? -each household individually -neighbors among themselves -municipal leaders -entire village Who would decide on a village-level development project -community leaders -whole village Collective action -joined with others to address a common issue -success when jointly petition officials with development goals -made personal contact with an influential person (advocacy) -actively participated in an election campaign 20.6% 6.3% 33.7% 29.2% 38.5% 61.5% 45.9% 43.2% 44.2% 35.5% 88.1% 9.0% 6.5% 8.1% 23.6% 76.5% 63.6% 87.6% 51% 43.2% Community-level conflict: -differences in community likely to cause trouble -problems likely to lead to violence -problems worked-out by the people themselves -problems worked-out with help of neighbors -problems worked-out with help of community leaders 13.7% 30.4% 32.6% 37% 76.1% 31% 56.3% 68.8% 62.5% 36.5% Service access: -denied or limited access to health services -denied or limited access to credit -denied or limited access to justice/conflict resolution 19.4% 17.3% 26.6% 45.5% 44.5% 40.3% Cognitive social capital Solidarity in time of personal crisis: -turn to family for assistance -turn to neighbors for assistance 33.8% 43.6% 90.3% 5.5% Trust: -trust eachother in lending and borrowing -believe interpersonal level of trust has gotten better last few years -believe that most village people are basically honest & trustworthy 93.1% 39.7% 37% 95.5% 52.3% 52.3% Conflict resolution: -believe their community is peaceful -believe their community has less conflict than other communities -believes neighbors will help resolve interpersonal disputes that occur 89.8% 73.4% 58.2% 96.1% 73.2% 59.4% Social capital scale score (2012 and 2014 scales not comparable) Mean non-member social capital scale score Mean member social capital scale score Relationship between social capital and membership status in 2012 & 2014 4.9 8.22 p≤0.01 10.0 15.35 p≤0.01 What is the degree of implementation of the PI model? In 2014, two-thirds of household social capital questionnaire respondents indicated that they were members of a group, one-fifth considered themselves to be group leaders, and three-quarters reported that the PI model groups were the most important group for their household. Over time groups were increasingly heterogeneous in terms of religion (83.6% Muslim in 2012 vs. 70.7% in 2014), gender (93.6% vs. 90.9% female), political perspective (17.8% vs. 14.7% with same viewpoint), occupation (68.5 vs. 33.3 with same occupation), and educational level (13.2% vs. 11.1% from same level). What are the structural social capital characteristics of intervention group PG members? PI group members overwhelmingly considered their leaders to be effective. By 2014, one-third relied on their leaders to decide issues while two-thirds related holding group discussions and deciding matters together. In terms of collective action, respondents expressed decreased reliance on municipal leaders to work out village￾level problems and increasingly thought the whole village would be called to make a decision on a village-level development project. They reported greater joining together with others to address a common issue and more success when they jointly petitioned officials. In addition, respondents increasingly voted in elections (88.5% to 92.3%), made a personal contact with an influential person January 2015 23 (44.2% to 51%), actively participated in an election campaign (35.5% to 43.2%), talked with other people in their area (51.3% to 56.1%) and made a monetary donation (59.7% to 61.9%). They considered the spirit of participation in their village to be moderately to very high (78% in 2012, 50% in 2014). Assessment of sources of conflict in the intervention communities reveals that throughout the intervention period 50% or more of the issues that divided villages were attributed to differences in education, wealth, landholdings, and social status. By 2014, additional differences were acknowledged that included gender (29% to 62%), age (38.2% to 63.2%), political party affiliation (68.9% to 79.4), religious beliefs (10.8% to 58.9%) and ethnic background (8.9% to 59.4%). The differences experienced were viewed as more likely to cause trouble and lead to violence, which was increasingly worked out between themselves with the help of others. By 2014, respondents reported that individuals, households and community members more often were denied or had limited opportunity to use the following services: health services (19.4% to 45.5%), job training and employment (14.9% to 26.5%), credit (17.3% to 44.5%), agricultural extension (18.5% to 30%), and justice/conflict resolution (26.6% to 40.3%). What are the cognitive social capital characteristics of intervention group PG members? In dealing with a crisis, such a father’s sudden death, the respondents increasingly indicated villagers would turn to family for help with less importance placed over time on neighbors for assistance. The same trend was reported for getting help for an economic loss, such as a crop failure, that required financial assistance (family 33.4% to 84.9%, neighbors 33.1% to 10.7%). Over 95% of informants in 2012 and 2014 indicated that they trusted each other in lending and borrowing, and the level of trust had gotten better during this time period. A greater percentage over time agreed that most people in the village were basically honest and trustworthy. Respondents believed their communities were peaceful and had less conflict than others. When serious conflicts emerged between two people, they consistently indicated reliance on neighbors to help resolve the dispute as opposed to the persons working it out among themselves (4.9% to 7.4%). Is membership in a PI associated with higher levels of social capital at endline when compared with non-member levels of social capital in the intervention group? Analysis of the social capital scales created from the social capital tool, which differed in 2012 and 2104, focused on the relationship between social capital and PI group membership status. There was a significant relationship (p<=0.001) between social capital and group membership status in 2012 (mean member 8.22, non-member 4.92) and also in 2014 (mean member 15.35 and non-member 9.99). Is an increase in social capital linked with improved health outcomes? Because the social capital study utilized intervention group only data drawn from different baseline and endline population samples, there is no quantitative comparison to examine the link between increased capital and outcomes. Exploration of whether the PI model is more capable than the status quo of increasing health outcomes and health equity is assessed through analysis of intervention and comparison group KPC survey data found in the baseline and final KPC Reports (SUSOMA Final Evaluation Report, Annex VI) with significance tests of the change between groups from 2010 to 2014. The intervention group only RHFA data from 2009 and 2014 (SUSOMA Final Evaluation Report, Annex XIXa) provides additional information regarding these variables. The research questions are answered below, with data presented in tables 7, 8, and 9. The percentage change and confidence interval data for all variables is in Annex B. Is the PI model more capable than the status quo of increasing care-seeking and utilization of MNC services? (Table 7). Between 2010 and 2014, there was a significantly greater percentage increase (p≤0.05) in the intervention than in the comparison group in receipt of four or more ANC visits from a medically trained provider, institutional deliveries, and in deliveries assisted by CSBAs, which are primarily skilled home deliveries. By endline, institutional and CBSA-assisted skilled deliveries accounted for 41% of all deliveries in the intervention group and 30% in the comparison group. There was a significantly greater percentage increase (p≤0.05) in the intervention group than in the comparison group in the number of newborns and mothers that received post-partum care from an appropriate trained health worker January 2015 24 within two days after birth, in care-seeking from a qualified provider for all reported antenatal and postpartum complications, and in appropriate care-seeking for pneumonia. Care-seeking for delivery complications saw a decline in both the intervention and comparison groups. Is the PI model more capable than the status quo of increasing MNH practices? (Table 7). Although the use of a modern contraceptive by mothers increased significantly (p≤0.05) in both groups between 2010 and 2014, there was no difference between groups in the percentage change during this period. Data regarding delivery practices indicate reported high levels of clean cord cutting (≤95%) in both intervention and comparison areas in both 2010 and 2014. During this period, there was a significantly greater percentage increase (p≤0.05) in the intervention group in use of clean birth kits by women during home deliveries, in thermal care /immediate drying and wrapping of the newborn, and in delayed bathing. Table 7: Percentage change in utilization, care-seeking, MNCH practices, intervention vs. comparison groups, 2010 to 2014 (KPC Survey) Indicator value Indicators Intervention Comparison p ≤0.05 2010 2014 % change 2010 2014 % change * % % % % Antenatal care 5.3 13.6 157% 5.6 5.8 3% * Tetanus toxoid 86.9 80.2 -7.7% 82.3 77.8 -5.5% Skilled birth attendant 9.3 21.5 136% 12.9 15.6 2% * Institutional delivery 8.0 19.3 143% 9.9 14.8 49% * PNC-newborn 7.9 18.7 132% 10.7 15.0 39.2% * PNC-maternal 8.6 18.5 114% 11.1 15.2 36.3% * Contraceptive use 49.3 71.0 44% 44.3 64.1 44.6% Exclusive breastfeeding 47.2 52.9 12% 49.0 41.7 -14.8% * ORT use 73.7 85.0 15.3% 49.6 85.9 73.1% * Point of use (POU) 1.8 4.6 163% 5.7 9.7 71.6% * Hand washing practices 21.6 39.3 82.2% 31.6 15.7 -50.3% * Care-seeking for: -pneumonia 22.3 32.6 46.2% 18.5 16.8 -9.4% * -ANC complications 26.4 37.6 42.4% 24.4 27.4 12.3% * -delivery complications 43.0 40.0 -6.3 29.5 22.5 -23.7% -PNC complications 29.3 43.4 48.1% 30.4 23.1 -24% * Clean cord cutting 98.4 94.6 -3.8 95.8 96.2 4.1% Use of clean birth kit 4.2 32.0 663% 17.3 29 67.5% * Thermal care newborn 9.5 40.2 334% 21.7 36.6 68.9% * Delayed bathing 22.7 46.3 104% 34.6 58.8 70.1% * Immediate breastfeeding 52.8 77.6 46.9% 53.0 76.4 44.1% No pre-lacteal feeds 59.3 81.6 37.6% 56.5 79.5 40.8% Quality of ANC 0.4 4.9 1116% 1.5 1.0 -36.2% * AMTSL 0.9 3.6 300% 1.5 2.3 53.3% * Essential newborn care 0.9 12.7 1315% 4.8 13.6 183% * Data regarding breastfeeding show a significantly greater percentage increase (p≤0.05) in the intervention versus the comparison group in exclusive breastfeeding of infants 0-5 months with comparable gains across groups in immediate breast-feeding after birth and in children age 0-23 months January 2015 25 not receiving pre-lacteal feeds. While ORT use for diarrhea increased significantly (p≤0.05) in both groups between 2010 and 2014 the increase in the comparison group during this period was significantly greater than that in the intervention group. In addition, there was a significantly greater percentage increase (p≤0.05) the intervention group compared with the comparison group in the number of households with children age 0-23 months that treat water effectively and in households with soap at the place for handwashing. Is the PI model more capable than the status quo of increasing the quality and availability of MNC health services? This question is answered with data from the 2010 and 2014 KPC surveys (Table 7) and the intervention-group only 2009 and 2014 RHFA (Tables 8). Quality of maternal newborn care (Table 8). Significantly greater percentage increases (p≤0.05) occurred in the intervention versus the comparison group in terms of quality of ANC, active management of the third stage of labor (AMTSL), and receipt of essential newborn care (ENC) during home delivery. Changes in the comparison group were significantly less for each of these indicators. Availability of maternal neonatal and child health care in the intervention area (Table 8). From 2009 to 2014, the number of facilities in the intervention area offering greater maternal newborn and child services availability increased 28%. In 2009 there were 55 Community Clinics (CCs) at the ward level of which 48 were open but which RHFA data collectors found without staff or patients. In 2014, there were 60 CCs, all of which were open, staffed, and providing care. In addition, 27 FWC and RDs (20 at baseline) were operating at the union level. Table 8. Percentage change in MNC and child health service and quality in health facilities, intervention area, 2009 and 2014 (RHFA) Sevice and quality indicator 2009 2014 % change Service and quality indicator 2009 2014 % change Number of clinics open 68 87 28% Community health worker referral 38% 80% 111% ANC available 4+x per month 60% 90% 50% Availability neonatal drugs 17% 22% 29% Institutional delivery available daily 3% 17% 467% Availability neonatal supplies 9% 22% 144% Availability of sick care 60% 100% 67% Availability ANC drugs 19% 22% 16% Availability of growth monitoring 7% 20% 186% Availability ANC supplies 9% 28% 211% Appropriate child diagnosis/treatment 23% 53% 130% Availability essential child care supplies 34% 66% 94% Annualized number of ANC visits/ facility 51 236 363% Availability first line child health drugs 39% 63% 62% Annualized number U5 sick child visits visits/facility 508 606 19% MNC information system 14% 38% 171% Staff training MNC past 12 months 3% 53% 1667% Available MNC laboratory 15% 32% 113% Staff training in child health past 12 months 37% 87% 135% Available child health laboratory 7% 10% 43% Staff supervision in past 12 months 7% 51% 629% Infection control-gloves 30% 60% 100% Availability care guidelines 7% 21% 200% Infection control-soap for handwashing 57% 93% 63% Facility-community collaboration 73% 90% 23% Infrastructure (latrine/water/privacy) 13% 27% 108% Between 2009 and 2014, facilities offering ANC service at least four times per month increased 50%. There was a 95% increase in the average ANC days per month per facility (10 to 19.5 days), and the annualized number of ANC visits increased 363%. In 2009, daily delivery services were only offered by an Upazila Health Complex (UHC) and this increased by 2014 to include two HWCs, one CC, and a private clinic (467% change). Facilities offering under-5 sick child care had a 67% increase, growth monitoring a 186% increase, and children receiving appropriate diagnosis/treatment a 130% increase. The annualized number of sick child visits increased 19%. January 2015 26 During the same period, there was an 1667% increase in the numbers of staff trained in MNC in the past 12 months, a 135% increase in staff trained in child health, a 200% gain in the availability of care guidelines in clinics, a 629% improvement in supportive supervision of health workers, and a 111% increase in facilities that received referrals from community health workers. In addition, facility￾community collaboration levels saw a 23% improvement by endline, with 90% of facilities having management committee meeting discussions (70% baseline), 77% engaging with the CHW/TTBA (57% baseline), and 53% changing health worker behavior based on community feedback (60% baseline). Table 8 also depicts improvements that occurred between 2009 and 2014 in availability of neonatal, ANC, and child health drugs and supplies, MNC information systems, laboratory services, hand soap and gloves, and in the facility infrastructure. Is the PI model more capable than the status quo of creating more equitable MNC and health outcomes? This question is addressed with a comparison of health equity between the highest and lowest wealth quintiles in the intervention versus comparison groups utilizing rich-to-poor ratio‡ data from relevant 2010 and 2014 KPC survey rapid CATCH variables (Table 9). The wealth quintile data is in Annex B. Table 9. Percentage change in rich-to-poor ratio for outcome indicators, intervention and comparison groups, 2010 to 2014 (KPC Survey) Rich to poor ratio Indicators Intervention Comparison p ≤0.05 2010 2014 % change 2010 2014 % change * % % % % Antenatal care 3.0 3.6 20% 33.7 3.7 -89% * Skilled birth attendant 12.9 3.4 -73.6% 7.2 2.9 148% * Institutional delivery 23.6 3.6 -84.7% 13.5 2.9 -78.5% PNC-newborn 23.8 5.1 -78.5% 9.1 2.2 -56.8% * PNC-maternal 24.4 3.6 -85.2% 11.2 2.8 -75% * Contraceptive use 1.3 1.2 -7.7% 2.0 1.2 -40% * Exclusive breastfeeding 0.9 1.1 22.2% 0.8 0.9 12.5% * ORT use 1.3 1.0 23.1% 0.8 1.2 50% * Point of use (POU) 1.4 1.3 -7.1% 2.2 3.4 54.5% * Hand washing practices 2.3 2.5 8.7% 2.7 3.9 44.4% * Care-seeking for pneumonia 1.7 1.9 11.8% 2.2 1.1 -50% * Significant (p≤0.05) variations were present in the rich-to-poor ratios between the intervention and comparison areas that illuminate changes in equity that occurred between 2010 and 2014. There was a significantly greater percentage decrease (p≤0.05) in the intervention versus the comparison group in the rich-to-poor ratio for births attended by a skilled birth attendant, newborn and maternal post￾partum visits, and households that treat water effectively (POU). In addition, the equity gap for ORT use and appropriate handwashing practices increased at a slower rate in the intervention than the comparison group. The equity gap in the intervention group decreased the most for institutional delivery (-84.7% change), however, the decrease was non-significant because of substantial decreases that also occurred in the comparison group (-78.5% change). Although the rich-to-poor ratio for current contraceptive use decreased somewhat in the intervention group, there was a significantly greater (p≤0.05) reduction in the comparison group. The rich-to-poor ‡ A decrease in the rich-to-poor ratio indicates a decrease in disparity between the highest and lowest wealth quintiles and an increase in equity for the variable under consideration. January 2015 27 ratio for four or more ANC and care-seeking for pneumonia increased in the intervention group, while there was a significant reduction (p≤0.05) in the comparison group for these indicators. The rich-to￾poor ratio increase for exclusive breastfeeding in the intervention group was double that in the comparison group. In the intervention group, increases in ANC visits occurred in all age, educational, and wealth quintile categories (Final KPC Report, Annex 3). All wealth quintiles at least doubled in the number of women receiving four-or-more ANC. For institutional and CSBA-assisted deliveries, there were greater increases for women in the lower poor quintiles than those in the upper richer quintiles with the greatest gains in the intervention group. Improvements in post-partum visits were greatest in the lower as compared with the higher wealth quintiles with greater change in the intervention group. The lowest quintile in the intervention group had 5-fold and 7-fold gains against the highest quintiles for newborn and maternal post-partum visits, respectively, versus 4-fold gains in the comparison group. Is the PI model more capable than the status quo in reducing and creating equity in MNC cost? Exploration of MNC costs and equity in health expenditures considers data from the 2010 and 2014 KPC surveys related to direct out-of-pocket (OOP) expenditures incurred by mothers in securing antenatal, delivery, and postnatal care for a pregnancy in the year preceding data collection, as well as care for pregnancy complications and illnesses in their children under the age of two. Table 10 presents the data in USD (US Dollars), Annex B presents the data in BDT (Bangladesh Taka). Table 10: Percentage change in household out-of-pocket expenditures and rich-to-poor ratio for ANC, delivery, PNC, maternal complications and childhood illness, intervention and comparison groups, 2010 and 2014 (KPC Survey SUSOMA Final Evaluation Report, Annex VI) Average out-of-pocket expense USD ($) Rich to poor ratio Type Intervention Comparison p ≤0.05 Intervention Comparison p ≤0.05 2010 2014 % 2010 2014 % * 2010 2014 % 2010 2014 % * change change % % change % % change Antenatal care $12 $14.88 21.6% $14.30 $14.01 -2.0% * 6.4 4.8 -25% 7.4 2.5 -66.2% * Institutional delivery $114.34 $149.13 30.4% $59.58 $139.21 134% * 3.3 1.6 -51.5% 2.7 1.8 -33.3% Home delivery $12.56 $15.57 24% $10.28 $12.87 25.2% na* 1.5 1.0 2.5 150% Postnatal care $8.66 $8.42 -2.8% $10.80 $9.15 -15.3% * 0.8 1.7 113% 10.6 0.7 -93.4% * Complications $8.08 $4.64 -42.6% $22.66 $5.54 -75.5% * 2.1 2.4 14.3% 6.6 1.6 -75.8% * U2 child illness $1.51 $1.94 28.5% $1.85 $1.73 -6.5% * 1.3 1.5 15.4% 1.4 2.0 42.9% * * Numbers not enough to make any comparisons Significant (p≤0.05) variations were present between the intervention and comparison areas for OOP expenditures between 2010 and 2014. Reported OOP costs that increased significantly more in the intervention then the comparison group were for antenatal care and care for childhood illness for children under the age of two. OOP costs that had significantly less change in the intervention versus January 2015 28 the comparison group included expenditures for institutional delivery, postnatal care, and care for complications. In the intervention group, reported expenditures for all MNC increased slightly or stayed the same, except for care for complications that was cut in half. In the comparison group, reported expenditures for institutional delivery increased markedly while those for complications decreased markedly while the remaining costs increased slightly or stayed the same. Significant (p≤0.05) variations were also present between the intervention and comparison areas in the rich-to-poor ratio, or equity gap, for OOP expenditures. Although the rich-to-poor ratio for ANC costs decreased in the intervention group, there were significantly greater (p≤0.05) decreases in the control group. While the rich-to-poor ratio increased for postnatal and complication care expenses in the intervention group, it decreased and had a significantly greater (p≤0.05) change in the control group. The equity gap for institutional delivery saw a greater but non-significant decrease in the intervention versus comparison group. The equity gap for care-seeking for childhood illnesses remained similar in intervention areas but increased in comparison areas. Discussion/Recommendations Main conclusions. The study confirmed that the PI model can be systematically and effectively established in poor rural underserved upazilas in Bangladesh to increase the social capital of poor marginalized women and empower them to work with government officials and health providers to improve household and community MNC and increase utilization of quality health services in hard-to￾reach families and communities. The PI model intervention strengthened public-private partnerships thereby enhancing access to resources for marginalized households. It improved the MNC practices of poor mothers and families, increased the quality of MNCH services in their communities, and established an upazila-wide enabling environment to strengthen and sustain MNC gains. Brief summary of evidence supporting main conclusions. PI model groups were effectively formed at the ward, union, and upazilla level by grassroots mobilization efforts of the implementing NGO who motivated the poor and marginalized women of reproductive age to form groups, establish trust, elect leaders, engage in group savings, and work together for MNCH. They trained and supported over 40,000 community members in 567 PI model groups (PGs, CCCs, PIs) to promote MNC practices in the community, and establish emergency health funds (EHFs) and health savings accounts. The groups were supported to form public-private partnerships in which PI group members worked together with government officials and local health providers to improve MNC and promote health. The groups had functioning joint referral and HMIS systems. A cadre of community health volunteers received MNC and IMCI training and promoted health knowledge and practices at household, community, and group levels in collaboration with local government health workers and ISPs/village doctors, who were also trained. In the process, the poor assumed community leadership roles alongside the rich. The PI groups assisted in sending patients to hospitals and helped them get timely care for complications via EHF loans, a referral system, and collaboration with established networks of health providers. They brought problems and needs of the people to their monthly/quarterly meetings with government health officials for mutual solution and action. PI model groups were established in all villages in the intervention upazilas. Two-thirds of WRA in the social capital investigation sample were members of a group. Group mobilization focused on increasing the social capital in its members to facilitate group action for MNC. Reports from those engaged in PI model groups from 2012 to 2014, demonstrated enhanced structural social capital via involvement in PI model groups, group leadership, and decision-making. Their increased reliance on personal problem￾solving abilities and in village-wide decision-making speaks to PI model empowerment of individual and group-level decision-making. PI group members were more likely to join together to work out problems with the help of others, such as government officials, health providers, and elites. Their increased petitioning of officials, contacting of influential persons, and participating in election campaigns speaks to the PI model emphasis on advocacy skill development. The finding that PI model group members January 2015 29 reported more problems accessing services generally may reflect a heightened awareness of their rights to services as well as the possibility that it may take greater than a two-year measurement window for perceptions of access to improve, despite the MNC improvements seen in the project period. Reports from PI group members also demonstrated cognitive social capital in terms of a stronger sense family solidarity in times of personal crisis, established levels of group trust in financial matters and overall, and the belief that their overall peaceful community was able to resolve interpersonal conflicts by themselves. The finding that members of PI groups had significantly (p≤.001) higher levels of social capital than non-members in both 2012 and 2014 indicates that involvement in a PI group can lead to enhanced social cohesion, networking and values that facilitate collective action for community health benefits. The PI model intervention shows promise of being more capable than existing approaches in increasing utilization of ANC, delivery, and PNC services and care-seeking for ANC/PNC complications and pneumonia. The PI model led to significantly better MNCH practices than the status quo in terms of greater levels of exclusive breastfeeding, use of clean birth kits, thermal care of the newborn, delayed bathing, safe drinking water and handwashing. Quality of MNC also had significant gains with the PI model versus the status quo in quality of ANC, delivery care (AMSTL) and essential newborn care. The finding that the intervention group had significantly greater gains than the comparison group’s status quo in each of these areas points to the utility of the total package of the PI model intervention in achieving greater MNC outcomes. The outcomes in which the intervention group had fewer or no gains than the status quo may reflect the effect of ongoing MNCH projects in the comparison upazilas, and/or a ceiling effect for these outcomes in these populations. ORT use increased statistically more in the comparison area, however, both groups were equivalent by endline. Immediate breastfeeding, no pre-lacteal feeds and contraceptive use increased equally to approximately 75% in both groups, and over 95% of all deliveries already practiced clean cord cutting at baseline. Although it is not clear why care-seeking for delivery complications declined in both groups, the intervention group decline was four times less than that in the comparison group. Although quality of care outcome values remain low, the fact that care quality improved significantly with the PI model over the status quo between 2010 and 2014 may point toward the potential for further care improvement with ongoing PI model PPP synergies. This conclusion is supported by gains in MNC and child health service and quality that occurred in the intervention area health facilities during PI model implementation, such as more open and functioning clinics, greater use of referrals, more available MNCH services from trained supported skilled providers, greater availability of drugs/ supplies/guidelines and laboratory services, and improved infection control practices and infrastructure. The impact of the PI model intervention on OOP cost of care was variable and appears to be impacted by multiple factors. While MNC costs for most services increased in both PI model intervention and status quo groups, the finding that costs for institutional delivery, postnatal care, and care for complications had significantly less increase than the comparison group may reflect the intervention focus on preventive practices and appropriate early care-seeking for complications as well as the effect of the PI referral network and EHFs on cost efficiencies for this population. The significant increase in ANC costs associated with the PI model versus the status quo was due to the fact of a 363% increase in ANC visits/facility with many women making more ANC visits in the intervention area. Expenditures for home deliveries were markedly less than cost for institutional deliveries, and increased equally across groups indicating that home deliveries may have been more stable and manageable in terms of costs. The equity gap or ratio of costs of care for the lowest and highest wealth quintiles for ANC costs and institutional delivery decreased by a 25% and 50%, respectively, in the intervention group. However, because these decreases were not significantly greater than the status quo, the effect of the PI model on equity related to costs of care cannot be established and warrants further study. The significant increase in cost for child illness in the PI model versus the status quo may be a positive finding reflecting improved access to needed care made possible by the EHF mechanisms. Although the equity gap January 2015 30 increased for child illness costs, this may reflect the costs of increased care-seeking that were incurred in the poor intervention population and is significantly less than the broadening of the equity gap seen in the comparison group. The PI model intervention showed promise of effectively narrowing the MNC equity gap. Involvement in the PI model groups and activities was associated with a significant reduction in health inequity versus the status quo. The equity gap narrowed as significantly more women in the lowest wealth quintile in the PI model area had SBA-attended births, newborn and maternal postpartum visits, and clean water than in the comparison area. The PI model area saw a lesser increase in inequities for ORT use and handwashing practices than the status quo due to PI model community-based health counseling. Despite the significant gains in four or more ANC visits associated with the PI model versus the status quo, the ANC equity gap for the PI model area did not narrow appreciably because the project engaged the whole community, both poor and wealthy elites, in intervention strategies and saw at least a doubling in ANC visits across all wealth quintiles. Similar gains were seen in care-seeking for pneumonia across wealth quintiles. The finding that the equity gap for institutional deliveries decreased substantially and equally for both the PI model and status quo does not diminish this PI model achievement, but points to possible influence of complementary district-wide initiatives promoting institutional deliveries. That the equity gap for contraceptive use and exclusive breastfeeding improved less in the PI model versus the status quo points to the need for addition efforts to promote these practices with poor and ultrapoor women in the PI model communities. Mechanisms of the intervention that specifically contributed to the significant MNC gains associated with the PI model included: a) the established autonomously functioning 3-levels of PI groups that worked closely with government officials and health providers at ward, union, upazilla and district levels to monitor and advocate for equitable MNC for all; b) the cadre of trained community health workers (CHVs/TTBAs) delivering MNC at household and community levels and linking with trained ISPs and government/private health workers with referrals to promote ANC, safe delivery, PNC, and care for complications and childhood illnesses; and c) the availability of funds, transportation and advocacy in every village for emergency care. Study Limitations • A limitation of this operations research is that it used different samples for the KPC and social capital studies and did not collect comparison data for the social capital study. Also, it was not possible to determine if there was a significant improvement in social capital scale scores from baseline to endline because, although the same data collection tools were use, different scales were constructed for each time period. • This comprehensive mixed method study investigates the effects of a complex intervention in a remote rural area of Bangladesh. It was susceptible to difficulties from the beginning and may have been under-resourced. The study’s coordinator/principle investigator moved from Bangladesh to Australia during year four of the project. • The timing of the baseline qualitative evaluation study and social capital study was delayed such that the findings were not available until year three and four of the five year program. Interpretation of findings must take this into consideration. In addition, data from the endline assessments, which all occurred at project end, were not finalized until after the program final evaluation occurred. • OOP costs were calculated by the total amount of money spent on the service instead of the cost per service (where the number of visits were used as the denominator). In the data presented, an increase in care use results in an increase in OOP costs. It might be better to calculate OOP costs by dividing the cost of care by the number of visits for each service. January 2015 31 Implications and Program Recommendations Based on these findings and conclusions, the following recommendations are made: 1. That the PI model intervention receives ongoing support by GOB and NGOs and be consider for scale-up among marginalized communities with low health outcomes in Bangladesh that have government officials interested in improving MNC health services and outcomes. 2. That the duration of PI model intervention be longer than 5-years to sustain MNC behavior change and care-seeking from the formal health care sector. Although the project was able to achieve rapid uptake of the model in 2-years and achieve independently functioning PI groups by year five, incorporation of support mechanisms for group and PPP structures beyond 5-years could increase sustainability of the model and health gains. 3. That learnings from the PI model intervention be applied to the Community Clinic Support Groups of the GOB MOHFW that are actively working in the whole country in improving child and maternal health activities. 4. That continuing research and scholarship be conducted to enhance the impact and sustainability of the PI model in various settings. 5. That the international global health community adapt relevant PI model approaches to promoting MNC in their specific contexts. January 2015 32 References BMMS (2010). Bangladesh Maternal Mortality and Health Care Survey 2010: Summary of Key Findings and Implications, available at http://www.cpc.unc.edu/measure/publications/tr-12-87. CORE group Monitoring and Evaluaton Working Group (2004). Knowledge, Practice, Coverage Survey Training Curriculum. CORE Group: Washington, DC. Accessed January 2015 at http://www.coregroup.org/resources/core-tools/242-knowledge-practice-coverage-kpc-survey-training￾curriculum-. CRWRC (2009). Final Evaluation, USAID Child Survival Project, Bangladesh, 2004-2009 (No. GHS-A-00-04-00010- 00 Knezevic, A. (2008). StatNews # 73: Overlapping confidence intervals and statistical significance. Cornell University: Ithica, NY. Accessed January 2014 at http://cscu.cornell.edu/news/statnews/stnews73.pdf. Mulholland, E.K., Smith, L., Carneiro, I., Becher, H., & Lehmann, D. (2008). Equity and child- survival strategies. Bulletin of the World Health Organization, 86: 399-407. Accessed January 2014 at http://www.who.int/bulletin/volumes/86/5/07-044545.pdf BDHS (2013). Bangladesh Demographic and Health Survey 2011. National Institute of Population Research and Training, Dhaka Bangladesh, accessed January 2014 at http://dhsprogram.com/pubs/pdf/FR265/FR265.pdf. NIPORT (2011). National Institute of Population Research and Training. Causes of death in children under five, Bangladesh Demographic Health Survey 2011, accessed January 2014 at http://www.niport.gov.bd/wp-content/uploads/publication/1377161290-BDHS-2011-causes-of￾deaths.pdf. Streatfield, P.K., Arifeen, S.E., Ahmed, A., Measure Evaluation, Jamil, K. & USAID, Bangladesh, (2011). Bangladesh Maternal Mortality and Health Care Survey 2010: Summary of Key Findings and Implications. Dhaka: icddr,b. Story, W.T. (2014). Social capital and the utilization of maternal and child health services in India: A multilevel analysis. Health & Place, 28, 73-84. Story, W.T. (2013). Social capital and health in the least developed countries: A critical review of the literature and implications for a future research agenda. Global Public Health, 8(9), 983-999. UNICEF 2009, Maternal and Neonatal Health in Bangladesh, accessed at www.unicef.org/bangladesh/Maternal_and_Neonatal_Health.pdf. World Health Organization (2104). WHO recommendation on community mobilization through facilitated participatory learning and action cycles with women’s groups for maternal and newborn health. Accessed January 2014 at http://www.who.int/maternal_child_adolescent/documents/community-mobilization-maternal￾newborn/en. January 2015 33 Annex A. Methods-Sampling, Data Collection, Analysis Qualitative Process Evaluation (Source: Final Operations Research Qualitative And Social Capital Study Report, SUSOMA Final Evaluation Report Annex XIXe) Methods. This section of the study explored and documented the dynamics of PGs, representation of marginalized in the PGs and its activities, nature of care seeking for maternal, neonatal and childhood illness and nature of community support system through a combination of several qualitative methods, namely, in-depth interview (IDI), Focus Group Discussion (FGD) and observation of events. The study was implemented in both Durgapur and Kendua. Participatory approaches, such as, social mapping were also used for identifying local resources, disenfranchised people, health care facilities visited and preferences. All the information was collected after getting participants’ informed consent. Sample. Procedure for qualitative sampling for process evaluation followed the standard purposive approach with in-depth interviews with member of PGs (22), non-members (22), TTBA (4), CHV (8); social mapping (11); organizational proofing (8); FGD with member (9), non-member (8); observation of CHV training (4), PG (4) and CC formation (4); in-depth interviews with implementing NGO managers and coordinators (8). Interview guidelines and tools. A set of tools was developed for extracting desired information that were pretested and used for data collection. These consisted of a guideline for social mapping (conducted in selected sites), guideline for IDI and FGD (conducted with selected individuals and in selected sites) and organization profiling (administered to key-informants). Data Collection, Entry, and Analysis. The research team visited randomly selected intervention areas for several times during the implementation period for data collection. First level visits for formative research were made as follows: Durgapur, June 2011 and November 2011; Kendua, August 2011 and November 2011. Second level visits were held in Durgapur and Kendua, January 2012; Kendua, June 2012; and third level visits took place in Durgapur and Kendua in March-April 2014; Netrokona and Dhaka: 30th June to 3rd July 2014. All the interviews and FGDs were transcribed. All observations and social mapping were reported as soon as the team returned from field. We performed content analysis of the qualitative data with a code list prepared and agreed on by the research team. Investigation of Social Capital (Source: Final Operations Research Qualitative And Social Capital Study Report, SUSOMA Final Evaluation Report Annex XIXe) Methods. A social capital measurement survey was done at baseline and endline. Sample. The sampling techniques were the same for both baseline and endline social capital measurement. Inclusion criteria for the participants are, married women of reproductive age; reproductive age set in between 15-45; non-elite (belongs to lower socio-economic strata). Sample size was 300 to 360 from two sub-districts (i.e. Kendua and Durgapur) where 75 are members and 75 are non-members from both of the areas. 40 to 45 villages were randomly selected from a complete list of villages in the sub-districts; 2 members were randomly selected from each village; randomness was decided through spinning bottles. Survey Questionnaire. Questionnaires were primarily an adaptation of the World Bank tools which were pretested in Amalpur in April 2012 and revised based on our findings from pretesting and interviews with various managers of the NGOs related to mature PIs. The same set of questionnaires were used in both the baseline and endline survey. The survey set used in the investigation of social capital consisted of a Household questionnaire (survey) and a Community questionnaire (administered to key￾informants). Data Collection, Entry, and Analysis. The social capital surveys were carried out from October to November 2012 (baseline) and from March to April, 2014 (endline). A total of 15 data collectors were recruited and trained to collect the SC survey data from 335 households during baseline and 310 during January 2015 34 endline using the household questionnaire. The community questionnaire was administered by field research officers (4) to 12 community elites during baseline and eight during endline. All the information was collected following participants’ informed consent. Two field supervisors, who reported to two field research officers, monitored the data collection process and quality assurance of data. The Data Management Services System (DMSS) from icddr,b safeguarded entry of the data. After all these procedures, data was analyzed using STATA. The following steps were followed for the development of the scale: 1. Recode dichotomous variables 2. Check for successful recoding 3. Reliability analysis – 1st round 4. Interpret the first round of reliability analysis 5. Reliability analysis – 2nd round (with reduced number of variables; during the baseline, this was 17 variables, while during the endline it was 35 variables) 6. Interpret the second round of reliability analysis 7. Create social capital scale and create bar charts At the final stage a total of 17 variables were selected to construct the baseline social capital scale, while a total of 35 variables were selected to construct the endline social capital scale. To apply the scale, we examined the association between the social capital scale score and membership status. For more detail about scale development and testing is in the Final Operations Research Qualitative And Social Capital Study Report, SUSOMA Final Evaluation Report, Annex XIXe. KPC survey sampling and data collection methods (Primary source: Final KPC Report, SUSOMA Final Evaluation Annex VI)) Methods. A pre-post quasi-experimental study design was used for the study in order to explore the effectiveness, equity and cost-effectiveness of the intervention package. A total forty clusters were selected for the study. Twenty clusters were from the two intervention upazilas, while the other 20 clusters were selected from two nearby upazilas with usual GOB services as comparison areas. Indicator and respondents. The key indicators measured in the baseline, midline and endline KPC survey are provided below in Table A-1. The lists of indicators were prepared on the basis of rapid CATCH indicators. The measurement of these indicators required a population of under-2 children and women who had a birth outcome in the previous one year. Table A-1. Sample size calculation for KPC survey Indicator Denominat or (target) Recall period Proportion in the comparison /baseline Proportion in the intervention/ endline Sample required for specific category per union/cluster (assuming 20% refusal) # of HHs required per union/cluster to provide the required sample % of newborn dried & wrapped by warm cloth immediately (-0-4 min) Ch 0-5 months last birth 4% 20% 4 76 % of newborn boys & girls received delayed bathing by 72 hours Ch 0-5 months last birth 16% 25% 25 529 Exclusive breastfeeding Ch 0-5 months Previou s day 57% 71% 18 378 % of pregnant women who received at least 4 ANC services Mothers children age 0-11 months last birth 5% 20% 5 48 January 2015 35 Indicator Denominat or (target) Recall period Proportion in the comparison /baseline Proportion in the intervention/ endline Sample required for specific category per union/cluster (assuming 20% refusal) # of HHs required per union/cluster to provide the required sample % of pregnant women received at least 2 doses of Tetanus Toxoid Mothers children age 0-11 months last birth 70% 80% 29 287 Skilled attendant at delivery? Mothers children age 0-11 months last birth 13% 20% 35 346 % of mothers and newborns who received postnatal care within 2 days of delivery Mothers children age 0-11 months last birth 15% 25% 20 203 Vitamin A supplementation 9-23m 6m 66% 85% 8 66 Measles vaccine coverage Ch 12-23 months 50% 75% 6 57 ORS for diarrhea Ch 0-23 mos with diarrhoea last 2 wk 2 wks 64% 85% 80 under-2 children (7 children with diarrhoea) 378 % of children 0-23 months with suspected pneumonia taken for treatment to health facility/ medically trained provider Ch 0-23m with fast breathing last 2 wk 2 wks 25% 50% 96 under-2 children (5 child with suspected pneumonia) 454 Recommended homemade fluid for diarrhea Ch 0-23 mos with diarrhoea last 2 wk 2 wks 12% 40% 27 126 % of <5 years old children <- 2 z weight for age Ch 0-23m 31% 25% 83 391 Current contraceptive use among mother of young children Mothers children age 0-23 months 48% 57% 44 210 Access to Immunization service (% of children aged 12- 23 months received DPT1) Ch 12-23 months 92% 97% 38 363 Health System Performance regarding Immunization Service (% of children aged 12- 23 months received DPT3) Ch 12-23 months 80% 88% 34 318 % of HH of children Ch 0-23m that treat water effectively Ch 0-23m 1% 3% 44 210 Sample size. Standard formulas (Betty 2003) had been used to estimate the required sample size based on the normal distribution, confidence levels of 95%, 80% power, and a design effect of 1.5 (to allow for clustering) for both baseline and endline surveys. Rapid CATCH indicators (and questionnaire) and the module on maternal and newborn care guided selection of indicators for the sample size calculation. Annex-1 shows the sample requirements according to selected indicators. The largest sample size required for each cluster was 96 under-2 children for the primary indicator of care seeking for suspected pneumonia. The largest sample required for the maternal and newborn care indicators was 50 women who had a birth outcome one year preceding the survey. January 2015 36 Selection of village and households from upazila. The selection process consisted of two stages in both the surveys. In the first stage, 4-9 villages were selected from each cluster using Probability proportionate to sampling (PPS) to get 750-900 households (HHs). Next a census was done to map and list the HHs of the selected villages. In each selected village a sketch map was drawn indicating boundary, landmark and Bari locations. All HHs and all women who had a birth outcome (live birth or still birth) two years preceding the survey were enumerated and listed. In the second stage sampling was done according to the following steps: Step 1: First, 125 women with pregnancy outcomes two years preceding the survey were drawn from the list randomly for collecting information on child health, morbidity, nutrition, ITN, HIV/AIDS, family planning etc. using a computer designed program . One hundred and twenty five women were selected to attain the required number (96) of under-2 children for the sample. Step 2: Then, 60 women who had a pregnancy outcome one year preceding the survey were randomly selected from the 125 women for maternal and newborn care measurement. Step 3: Next, 30 women were randomly selected from the 60 women selected in step 2 for maternal costing who had a birth outcome one year preceding the survey. Finally, based on the random sampling technique, a list of HHs by village was provided to the supervisor for conducting the survey. The list contained detailed information on which module needed to be used for which selected women. Data collection. A household survey questionnaire consisting of four modules (HH information; Maternal and newborn information; cost of maternal care; and child health, morbidity, nutrition) was used to collect the required information both at baseline and endline. The baseline tools are provided in the SUSOMA Final Evaluation Report Annex X. Trained data collectors collected the data. The baseline KPC survey was conducted in 2009. The endline survey was conducted in 2014. The respondents for the survey were women who had a birth (live/still) in the one year preceding the survey and mothers of children aged 0-2 years. A total of 4,502 households were surveyed during baseline and endline respectively. Quality assurance. The quality of data collection was maintained by trained field supervisors through spot￾checking, cross checking, consistency checking and editing. Each day, field supervisor accompanied three or four data collectors for part of their workday and observed some interviews. The field supervisor reviewed completed questionnaires. Any errors, discrepancies and other problems were discussed and resolved at the end of each day and at weekly meetings. This sometimes resulted in a re-visit to the household. Field supervisors or data collectors to check the correctness of the information collected revisited a random sample of 5% of households interviewed. Any discrepancies were resolved with the original data collectors and supervisors. Data entry and analysis. In both baseline & endline survey, SQL server 2008 was used for data entry and the interface was designed by Visual Basic. Data was analyzed with the statistical software STATA 12. Descriptive analysis has been done to present the findings on keys indicators and cost information. In order to determine whether changes in intermediate health outcomes over time were creating more equity, a wealth index was constructed from data collected on ownership of household durable goods, dwelling characteristics, sources of drinking water and sanitation facilities. Households were ranked according to their total ‘wealth’ score, and then divided into quintiles from the lowest (poorest) to the highest (richest). Health outcome data was analyzed by wealth quintile and the ratio of rich (upper quintile) to poor (lower quintile) computed for the rapid CATCH variables (Annex B. Table B-2). All costs were presented in taka (BDT) with conversion to USD in report tables (Annex B. Table B-3). Direct cost was used to reflect out of pocket expenditure for the maternal and child illness. Direct costs refer to household expenditures related to seeking treatment (medical expenses such as January 2015 37 physician’s fee, drug cost, cost of hospital stay both for patient and accompanied person) along with non-medical expenses such as transport costs. In order to determine whether the change in each variable, including rich-to-poor ratio data, over time was significantly different in the intervention area compared to the comparison area, the percentage change was calculated from baseline to endline along with the 95% confidence interval for each variable (Annex B. Table B-4). The percentage change in the intervention area was considered significantly different from the comparison area if the confidence intervals did not overlap (Knezevic, 2008). The percentage change was calculated using the following formula: x 100 where p1 is the proportion at baseline and p2 is the proportion at endline. The percentage change demonstrates the difference in proportions from baseline to endline relative to the starting value at baseline. The 95% confidence interval was calculated using the following formulas: 95% confidence interval = and where n1 is the baseline sample size, n2 is the endline sample size, and deff is the design effect. The design effect accounts for the bias introduced by using cluster sampling instead of simple random sampling during data collection. Although the design effect varies for different variables, a conservative estimate for cluster sampling is two (CORE Group, 2004). By adding the design effect to the equation above, the standard error is larger and the confidence interval is wider. Therefore, the estimates for statistical significance between the intervention area and comparison area more conservative than estimates that do not include the design effect. Rapid Health Facility Assessment (Source: Final RHFA Report, SUSOMA Final Evaluation Report Annex XIXa) Methods. Baseline and endline Rapid Health Facility Assessments (RHFA) were carried out in Durgapur and Kendua Upazillas of Netrakona District in November 2009 and June 2014 by World Renew and LAMB to assess the maternal, newborn and child health services (MNCH) in the 3 levels of Health Facilities in the project area (district hospital, first level and community- based) in the areas of staffing (qualifications, training, supervision); health infrastructure (facilities, medicines, supplies); and health worker performance regarding management of childhood illnesses. Sampling. Sampling was done to determine the health facilities to be assessed; the number of clinical cases /exit interviews to be observed and the Community Health workers to be interviewed. Health Facilities: The sampling frame included all health facilities that provided primary care (not just referral) for childhood illnesses. Sampling was done on a sample proportionate to size basis to ensure balanced sampling from the different levels of health facility. Once the sample size was determined the sample was chosen using systematic random sampling. Information about the sample frame and sample size is in Table A-2. 1 12 p pp PChange − = PChange ± .1 96∗ SE − pp 12 () () ⎟ ⎟ ⎟ ⎠ ⎞ ⎜ ⎜ ⎜ ⎝ ⎛ − + ∗ ⎟ ⎟ ⎠ ⎞ ⎜ ⎜ ⎝ ⎛ − − = ∗ deff n p p deff n p SE pp p 2 2 2 1 1 1 1 1 12 January 2015 38 Table A-2. Sampling for Health Facilities and Population estimates Baseline Endline Level Type of facility included Sampling frame Percent of total Final Sample Size Sampling frame Percent of total Final Sample Size 1 UHC OPD 2 2.7 1 2 2.3 1 2 FWC / RD 20 27.4 8 21 24.4 7 3 Community Clinic 48 65.8 20 60 69.8 21 4 Private / NGO 3 4.1 1 3 3.5 1 Total 73 100 30 86 100 30 Clinical observations/Exit Interviews: Six clinical observations/ exit interviews were targeted for each facility (30 x 6= 180 cases). The first six children who attended the clinic and presented with fever/malaria, diarrhoea (with or without blood) and/or pneumonia / difficulty breathing were chosen for observation. Community Health Workers: A systematic random sample of 13 out of a total of 40 Community Health Workers (33%) was chosen from the sampling frame provided by the government authorities at baseline and 20 out of 60 (33%) at endline. Data collection tools and techniques. The survey instrument was based on the Rapid Health Facility Assessment tool developed by a team at MEASURE Evaluation. The tool was designed to provide valid data on indicators of health service quality and access that would be comparable across child survival programs in different countries. Adaptation of the questionnaire was done in consultation with World Renew (CSP, Health Specialist) before the baseline survey, retaining the optional questions that were appropriate for the context. The RHFA used five modules to collect data on health service delivery access and quality through exit interview of caregivers, Health facility checklist to check availability of logistics and infrastructure, health worker (including community health worker) interview to elicit information on their training, supervision and record keeping. The data collection teams consisted of two members: one supervisor who did the clinical observation on child illness assessments and health worker interviews as well as checking all forms for completeness at the end of each day; and one field investigator who did the exit interviews with the child’s care giver, the health facility check lists and community health worker interviews January 2015 39 Annex B. Data Tables Table B-1. Summary of major endline findings regarding the dynamics of PI model formation (Final Operations Research Quantitative and Social Capital Study Report, October 2014). Perception, knowledge and practice regarding the PI model groups and activities Perception of PGs Knowledge levels regarding goals and aims of PGs differed at the beginning but at endline PGs in both intervention sub-districts were well aware of their group’s activities, purposes, and vision. Selection of PG members Criteria to select the members of a PG, though were set by the programme, not always followed and the group members included those whom they found to serve group’s purposes better [such as educated elites]. Capacity of leaders of PGs Leadership rests on the more educated as it did in the beginning. Groups make careful decisions in their leaders. They want someone who is presentable, articulate, and able to provide the time essential to leading an organization. Trust among PG members Most of the PG members have learned to trust themselves or at least know how to resolve if problems related to trusting arises. Management of groups Group management has become more diversified over the years. Initially it was limited to saving money, while now it includes providing loans, taking on small income generating projects, and ensuring health benefits to members and non-members. Management of financial activities Banking was problematic in the beginning. Over the years, people have started to reap the benefits of the system and have started to have faith banks. Engagement with CCCs CCCs are formed out of representatives from the PGs, but not all PGs are equally aware of it. The awareness has increased over time, but still is lacking in some places. Engagement of ISPs (village doctors) Orientation of the village doctors seemed slow to pick up. Most of our informants at baseline were among those who didn’t receive the orientation. However, we did find out many of them were oriented on SUSOMA activities and things that were expected of them. Problems in forming PGs Formations of groups have become stable over time and the questions and doubts about the groups have lessened. Impact of PI model on health equity Utilization of Savings Focus on ensuring money for the emergency funds seem to have increased over the years. People are involved in various income generating activities in order to pay their dues, which they take almost religiously. Planning Planning is being diversified. Every passing year people gain more confidence in their abilities and now think about innovative ways to earn and save more money for both emergency health needs and also their own sustainability. Linkage with social elites Support of the social elites has been noteworthy in these communities throughout the years. The elites are properly motivated in helping in people with health needs. Engagement of NGOs Over the years, PGs have become confident in engaging with other groups and the parent NGO, but not yet with NGOs or other organizations beyond the reach of the program. Engagement of GOB There has been active collaboration between the government health system and PGs – especially the TTBAs who are a part of the PGs in their respective areas. The extent of collaboration has only gotten better over time and the PGs have also received both respect and monetary assistance from the government. TTBA’s linkages A linkage between the TTBAs and health system is encouraging. Pregnant women and mothers in need are being referred and attempts at better care is ensured. Building capacity: CHV Training of CHVs is crucial to their activities and also for their confidence to work in the community. This has been provided to the CHVs adequately, though frequent refreshers may be required. Capacity building: individual Group members are becoming confident and claim they might be able to continue without the assistance of the NGOs who helped them form the groups initially and have been guiding them ever since. They discussed increased capacity in terms of their ability to manage group finances and plan what to do in the future, as well as their increased knowledge of mother child health and what to do during times of need. Capacity building: group The PGs unanimously valued their capacity to help the community, especially with regard to emergency medical needs, i.e. pregnant women needing assistance during delivery. They mentioned that their capacity to share ideas during the group meetings helps the community at large and the group members in specific. While some confusion over the selection and election aspects of PI formation remains, people are more inclined toward election rather than selection, which the see as more empowering. PI- improving SES The PIs report making progress in terms of improving the SES of the members and diversifying the savings mechanism and income generating activities. Impact of PI groups on referral and health care-seeking January 2015 40 Health care seeking Initially, the activities of the groups were limited to savings and then it expanded to certain other activities, like some income generating activities and helping group members in emergencies. People have started to know about their health related activities where even the non-group members are also becoming aware. Table B-2. Percentage distribution by wealth quintile, intervention and comparison, 2010 and 2014 (KPC Survey) Indicators Time Intervention Quintiles Comparison Quintiles Rich-to-poor Ratio t low 2nd 3rd 4th high t low 2nd 3rd 4th high Intervention Comparison Antenatal Care Baseline 3.3 4.9 3.3 4.7 9.7 0.6 0.8 1.4 4.9 20.6 3.0 33.7 Endline 7.1 11.2 7.6 14.0 25.7 3.4 3.5 5.3 3.9 12.5 3.6 3.7 Tetanus Toxoid Baseline 79.5 88.5 85.5 87.3 91.5 71.3 80.5 83.9 85.9 91.1 1.2 1.3 Endline 75.0 84.0 77.1 81.1 82.9 77.7 75.7 74.2 83.1 79. 1.1 1.0 Skilled Birth Attendant Baseline 1.6 4.2 6.6 10.7 21.2 4.3 5.3 11.2 14.1 30.8 12.9 7.2 Endline 12.5 15.2 13.9 22.0 42.1 10.1 11.1 15.9 11.5 29.0 3.4 2.9 Institutional delivery Baseline 0.8 3.0 4.6 10.1 19.4 1.8 3.8 7.7 12.0 24.7 23.6 13.5 Endline 10.7 15.2 11.1 17.7 38.8 9.5 9.7 14.6 11.5 27.6 3.6 2.9 Post-Partum Visit Newborn Baseline 0.8 3.7 3.4 10.3 19.8 3.1 3.9 8.6 10.9 27.9 23.8 9.1 Endline 7.6 12.7 11.4 17.7 38.8 11.5 10.1 14.1 12.5 25.7 5.1 2.2 Maternal Baseline 0.8 3.6 5.9 10.7 20.0 2.4 4.5 9.1 12.7 27.4 24.4 11.2 Endline 9.8 15.2 11.1 18.3 34.9 10.1 11.1 13.9 11.5 28.3 3.6 2.8 Contraceptive Use Baseline 42.9 45.5 48.4 50.9 55.4 30.2 44.5 41.6 48.4 59.5 1.3 2.0 Endline 64.9 71.9 68.6 70.7 77.5 56.9 62.9 64.0 66.0 71.0 1.2 1.2 Exclusive breastfeeding Baseline 31.4 29.5 30.4 30.1 29.6 32.3 28.5 30.9 30.4 27.1 0.9 0.8 Endline 50.9 46.6 48.5 52.5 58.3 44.2 41.9 38.0 43.1 38.5 1.1 0.9 ORT use Baseline 60.0 80.0 74.2 73.9 80.0 52.8 41.7 54.2 54.5 44.8 1.3 0.8 Endline 84.9 79.3 85.7 90.0 87.0 77.8 90.6 90.9 77.8 91.3 1.0 1.2 Care Seeking￾Pneumonia Baseline 18.2 15.4 17.4 26.9 30.3 7 25.8 21.2 26.5 15.6 1.7 2.2 Endline 21.7 47.4 30.0 25.0 41.2 12.2 16.7 14.3 25.6 13.0 1.9 1.1 January 2015 41 Point of Use -POU Baseline 1.4 1.1 2.3 1.8 2.0 3.7 5.1 5.1 6.7 8.2 1.4 2.2 Endline 4.1 4.8 3.8 5.2 5.1 5.2 5.3 9.1 11.6 17.7 1.3 3.4 Appropriate Hand washing Practices Baseline 16.3 15.9 17.7 18.7 36.9 19.5 26.6 26.5 37.2 52.1 2.3 2.7 Endline 23.4 32.7 32.9 43.5 59.3 8.2 8.0 15.5 15.5 31.7 2.5 3.9 Table B-3. Percentage change in household out-of-pocket expenditures and rich-to-poor ratio for ANC, delivery, PNC, maternal complications and childhood illness, intervention and comparison groups (KPC 2010 and 2014) Average out-of-pocket expense BDT (t )/USD ($) Rich to poor ratio A Type of expense Intervention Comparison p ≤0.05 Intervention Comparison p ≤0.05 2010 2014 % 2010 2014 % * 2010 2014 % 2010 2014 % * change change % % change % % change Antenatal care (n) 156 240 143 208 156 240 156 240 t952.8 $12.24 t1157.6 $14.88 21.6% t1112. $14.30 t1090.3 $14.01 -2.0% * 6.4 4.8 -25% 7.4 2.5 -66.2% * Institution al delivery (n) 28 68 40 50 40 50 40 50 t8897.1 $114.3 4 t11603. 9$149.1 3 30.4% t4636.3 $59.58 t10832.4 $139.21 134% * 3.3 1.6 -51.5% 2.7 1.8 -33.3% Home delivery (n) 375 267 341 309 341 309 341 309 t977.1 $12.56 t211.7 $15.57 24% t800.3 $10.28 t1001.7 $12.87 25.2% na* 1.5 1.0 2.5 150% Postnatal care (n) 41 80 46 52 46 52 46 52 t673.7 $8.66 t657.2 $8.42 -2.8% t840.0 $10.80 t712.0 $9.15 -15.3% * 0.8 1.7 113% 10.6 0.7 -93.4% * Complic￾ations (n) 68 93 80 74 80 74 80 74 t628.6 $8.08 t361.1 $4.64 -42.6% t762.9 $22.66 t431.1 $5.54 -75.5% * 2.1 2.4 14.3% 6.6 1.6 -75.8% * U2 child illness n) 960 899 906 935 960 899 906 935 t117.7 $1.51 t150.9 $1.94 28.5% t144.1 $1.85 t134.8 $1.73 -6.5% * 1.3 1.5 15.4% 1.4 2.0 42.9% * January 2015 42 Table B-4. Results of percentage change and confidence interval analysis (KPC Data) Variable name Area Endline % Baseline % Endline (n) Baseline (n) % change 95% CI Lower 95% CI Upper Antenatal Care (4+) Intervention 13.63 5.31 697 753 156.58 1.5233 1.6084 Comparison 5.79 5.63 725 728 2.86 -0.0051 0.06238 Tetanus Toxoid Intervention 80.20 86.85 697 753 -7.66 -0.1306 -0.02259 Comparison 77.79 82.28 725 728 -5.45 -0.1126 0.00351 Skilled Birth Attendant Intervention 21.95 9.30 697 753 136.13 1.3089 1.41375 Comparison 15.72 13.05 725 728 20.50 0.1540 0.25597 Institutional Delivery Intervention 19.37 7.97 697 753 143.08 1.3811 1.48047 Comparison 14.76 9.89 725 728 49.23 0.4446 0.53994 Post-Partum Visit Newborn Intervention 18.54 7.97 669 740 132.47 1.2748 1.37470 Comparison 14.89 10.69 712 711 39.28 0.3438 0.44176 Post-Partum Visit Mother Intervention 18.51 8.63 697 753 114.41 1.0944 1.19374 Comparison 15.17 11.13 725 728 36.36 0.3146 0.41271 Contraceptive Use Intervention 70.96 49.28 1670 1806 43.99 0.3950 0.48474 Comparison 64.08 44.33 1846 1771 44.58 0.4007 0.49082 Exclusive Breast- feeding Intervention 52.86 47.21 384 502 11.97 0.0259 0.21356 Comparison 41.72 48.99 441 494 -14.83 -0.2384 -0.05816 Infant and Young Child Feeding Intervention 25.25 31.74 1303 1314 -20.44 -0.2532 -0.15559 Comparison 23.95 36.59 1432 1290 -34.54 -0.3939 -0.29679 Vitamin A Supplement Intervention 82.35 72.07 1303 1314 14.26 0.0975 0.18772 Comparison 83.94 65.19 1432 1290 28.75 0.2420 0.33307 Immunization (Measles) Intervention 69.78 95.07 877 893 -26.60 -0.3134 -0.21856 Comparison 70.28 85.88 979 921 -18.17 -0.2332 -0.13026 (DTP1/Penta1) Intervention 88.60 94.51 877 893 -6.26 -0.0991 -0.02610 Comparison 92.85 90.55 979 921 2.54 -0.0098 0.06049 (DTP3/Penta3) Intervention 76.28 90.82 877 893 -16.00 -0.2080 -0.11206 Comparison 72.01 83.50 979 921 -13.75 -0.1898 -0.08528 Treatment of Fever Intervention 0.71 0.80 1686 749 -11.15 -0.1222 -0.10084 Comparison 0.21 0.14 1873 715 52.70 0.5221 0.53184 ORT Use Intervention 84.96 73.68 133 114 15.31 0.0101 0.29606 Comparison 85.92 49.63 142 135 73.11 0.5870 0.87527 Care Seeking￾Pneumonia Intervention 32.63 22.31 95 130 46.28 0.2954 0.63019 Comparison 16.77 18.50 167 173 -9.36 -0.2081 0.02096 Point of Use (POU) Intervention 4.63 1.76 1686 1816 162.54 1.6089 1.64201 Comparison 9.72 5.66 1873 1784 71.64 0.6921 0.74064 Handwashing Practices Intervention 39.32 21.59 1686 1816 82.17 0.7793 0.86420 Comparison 15.70 31.61 1873 1784 -50.35 -0.5419 -0.46510 Child Sleeps Under ITN Intervention 8.36 5.89 1686 1816 41.94 0.3952 0.44353 Comparison 6.67 2.58 1873 1784 158.83 1.5692 1.60734 Underweight Intervention 27.27 33.26 1665 1816 -18.02 -0.2232 -0.13711 Comparison 31.42 36.03 1865 1779 -12.80 -0.1714 -0.08456 Clean Cord Cutting Intervention 94.68 98.40 526 683 -3.78 -0.0681 -0.00762 Comparison 96.19 95.80 604 643 0.41 -0.0267 0.03486 Thermal Care Intervention 40.24 9.50 246 368 323.62 3.1397 3.33267 Comparison 36.64 21.70 292 378 68.87 0.5909 0.78644 Delayed Bathing Intervention 46.34 22.70 669 740 104.13 0.9729 1.10971 January 2015 43 Variable name Area Endline % Baseline % Endline (n) Baseline (n) % change 95% CI Lower 95% CI Upper Comparison 58.85 34.60 712 711 70.08 0.6297 0.77194 Immediate Breast-feeding Intervention 77.58 52.80 1686 1816 46.93 0.4263 0.51230 Comparison 76.39 53.00 1872 1784 44.13 0.3987 0.48388 Knowledge Timing/Spacing of Pregnancies Intervention 48.10 54.90 1686 1816 -12.38 -0.1706 -0.07708 Comparison 59.74 55.30 1873 1784 8.04 0.0351 0.12565 Knowledge Risk Birth-Pregnancy Intervals<24 mo Intervention 49.41 37.30 1686 1816 32.46 0.2784 0.37072 Comparison 46.88 17.40 1873 1784 169.41 1.6536 1.73456 Quality Antenatal Care Intervention 4.86 0.40 473 713 1115.64 11.1283 11.18463 Comparison 0.96 1.50 418 687 -36.20 -0.3805 -0.34362 Iron Tablets for Pregnant Women Intervention 69.15 43.70 697 753 58.25 0.5127 0.65219 Comparison 58.07 37.10 725 728 56.52 0.4942 0.63622 Knowledge of Danger Signs During Pregnancy Intervention 72.31 65.20 697 753 10.90 0.0418 0.17630 Comparison 72.41 53.70 725 728 34.85 0.2796 0.41734 Knowledge of Danger Signs During Delivery Intervention 67.43 67.20 697 753 0.35 -0.0649 0.07179 Comparison 69.93 48.10 725 728 45.39 0.3841 0.52360 Knowledge of Post-Partum Danger Signs Intervention 67.00 63.20 697 753 6.01 -0.0092 0.12951 Comparison 69.24 45.70 725 728 51.51 0.4453 0.58496 Knowledge of Neonatal Danger Signs Intervention 74.46 78.20 697 740 -4.78 -0.1100 0.01438 Comparison 84.83 67.40 725 711 25.86 0.1974 0.31971 Clean Birth Kit Intervention 32.04 4.20 543 683 662.96 6.5701 6.68902 Comparison 28.97 17.30 611 643 67.45 0.6090 0.74006 Essential Newborn Care Intervention 12.74 0.90 526 683 1315.29 13.1114 13.19446 Comparison 13.58 4.80 604 643 182.84 1.7832 1.87352 Cord Care Intervention 65.02 54.60 669 740 19.09 0.1189 0.26290 Comparison 66.57 62.30 712 711 6.86 -0.0017 0.13887 Feeding Colostrum Intervention 97.03 96.80 1686 1816 0.24 -0.0138 0.01861 Comparison 98.18 97.20 1872 1784 1.01 -0.0037 0.02392 Pre-Lacteal Feeds Intervention 81.61 59.30 1686 1816 37.63 0.3350 0.41757 Comparison 79.54 56.50 1872 1784 40.78 0.3662 0.44935 Prophylactic Eye Care Intervention 4.78 2.50 669 740 91.33 0.8854 0.94116 Comparison 3.09 3.10 712 711 -0.33 -0.0287 0.02219 Birth Prepared￾ness Intervention 91.68 89.60 697 753 2.32 -0.0191 0.06553 Comparison 94.76 88.60 725 728 6.95 0.0296 0.10941 AMTSL Intervention 3.60 0.90 753 697 300.00 2.9787 3.02127 Comparison 2.30 1.50 728 725 53.33 0.5135 0.55318 Careseeking for any ANC complication Intervention 37.60 26.40 202 182 42.42 0.2934 0.55511 Comparison 27.40 24.40 190 209 12.30 0.0012 0.24471 Careseeking any delivery complication Intervention 40.20 42.90 112 84 -6.29 -0.2602 0.13429 Comparison 22.50 29.50 111 105 -23.73 -0.4025 -0.07210 Careseeking for any postpartum complication Intervention 43.40 29.30 76 75 48.12 0.2666 0.69583 Comparison 23.10 30.40 65 79 -24.01 -0.4440 -0.03623 Careseeking from health Intervention 5.00 2.20 202 182 127.27 1.2206 1.32483 Comparison 3.20 1.40 190 209 128.57 1.2438 1.32767 January 2015 44 Variable name Area Endline % Baseline % Endline (n) Baseline (n) % change 95% CI Lower 95% CI Upper worker ANC period Average OOP expense for ANC ($) Intervention 1.49 1.22 240 156 21.57 0.1831 0.24832 Comparison 1.40 1.43 208 143 -2.03 -0.0559 0.01532 Average OOP expense for institutional delivery ($) Intervention 14.91 11.43 68 28 30.43 0.0990 0.50951 Comparison 13.92 5.96 50 40 133.65 1.1657 1.50733 Average OOP expense for home delivery ($) Intervention 1.56 1.26 267 375 23.96 0.2133 0.26602 Comparison 1.29 1.03 309 341 25.19 0.2286 0.27529 Average OOP expense for PNC ($) Intervention 0.84 0.87 80 41 -2.77 -0.0768 0.02138 Comparison 0.92 1.08 52 46 -15.28 -0.2087 -0.09689 Average OOP expense for complications ($) Intervention 0.46 0.81 93 68 -42.57 -0.4616 -0.38987 Comparison 0.55 2.27 74 80 -75.55 -0.8075 -0.70356 Average OOP expense for childhood illness ($) Intervention 0.19 0.15 899 960 28.48 0.2794 0.29012 Comparison 0.17 0.19 935 906 -6.49 -0.0703 -0.05940 Rich-to-poor ratio-expense for ANC Intervention 4.80 6.40 240 156 -25.00 -0.3164 -0.18357 Comparison 2.50 7.40 208 143 -66.22 -0.7299 -0.59447 Rich-to-poor ratio - institutional delivery expense Intervention 1.60 3.30 68 28 -51.52 -0.6178 -0.41251 Comparison 1.80 2.70 50 40 -33.33 -0.4214 -0.24523 Rich-to-poor ratio - home delivery expense Intervention 1.50 267 375 Comparison 2.50 1.00 309 341 150.00 1.4712 1.52879 Rich-to-poor ratio-PNC expense Intervention 1.70 0.80 80 41 112.50 1.0694 1.18061 Comparison 0.70 10.60 52 46 -93.40 -1.0638 -0.80414 Rich-to-poor ratio - care complications expense Intervention 2.40 2.10 93 68 14.29 0.0776 0.20811 Comparison 1.60 6.60 74 80 -75.76 -0.8445 -0.67066 Rich-to-poor ratio - expense childhood illness Intervention 1.50 1.30 899 960 15.38 0.1387 0.16898 Comparison 2.00 1.40 935 906 42.86 0.4119 0.44525 Rich-to-poor ratio -Antenatal Care (4+) Intervention 3.60 3.00 697 753 20.00 0.1739 0.22607 Comparison 3.70 33.70 725 728 -89.02 -0.9425 -0.83790 Rich-to-poor ratio - Tetanus Toxoid Intervention 1.10 1.20 697 753 -8.33 -0.0989 -0.06781 Comparison 1.00 1.30 725 728 -23.08 -0.2463 -0.21527 Rich-to-poor ratio - Skilled Birth Attendant Intervention 3.40 12.90 697 753 -73.64 -0.7753 -0.69759 Comparison 7.20 2.90 725 728 148.28 1.4511 1.51446 Rich-to-poor ratio - Institutional Delivery Intervention 3.60 23.60 697 753 -84.75 -0.8946 -0.80032 Comparison 2.90 13.50 725 728 -78.52 -0.8243 -0.74606 January 2015 45 Variable name Area Endline % Baseline % Endline (n) Baseline (n) % change 95% CI Lower 95% CI Upper Rich-to-poor ratio - Post￾Partum Visit (Newborn) Intervention 5.10 23.80 669 740 -78.57 -0.8351 -0.73633 Comparison 2.20 5.10 712 711 -56.86 -0.5961 -0.54115 Rich-to-poor ratio - Post￾Partum Visit (Mother) Intervention 3.60 24.40 697 753 -85.25 -0.9000 -0.80487 Comparison 2.80 11.20 725 728 -75.00 -0.7866 -0.71342 Rich-to-poor ratio - Contra￾ceptive Use Intervention 1.20 1.30 1670 1806 -7.69 -0.0874 -0.06648 Comparison 1.20 2.00 1846 1771 -40.00 -0.4116 -0.38841 Rich-to-poor ratio - Exclusive Breastfeeding Intervention 1.10 0.90 384 502 22.22 0.2034 0.24104 Comparison 0.90 0.80 441 494 12.50 0.1083 0.14170 Rich-to-poor ratio - ORT Use Intervention 1.00 1.30 133 114 -23.08 -0.2687 -0.19287 Comparison 1.20 0.80 142 135 50.00 0.4669 0.53306 Rich-to-poor ratio - Care Seeking for Pneumonia Intervention 1.90 1.70 95 130 11.76 0.0677 0.16760 Comparison 1.10 2.20 167 173 -50.00 -0.5382 -0.46184 Rich-to-poor ratio - Point of Use (POU) Intervention 1.30 1.40 1686 1816 -7.14 -0.0822 -0.06062 Comparison 3.40 2.20 1873 1784 54.55 0.5304 0.56053 Rich-to-poor ratio - Handwashing Practices Intervention 2.50 2.30 1686 1816 8.70 0.0726 0.10131 Comparison 3.90 2.70 1873 1784 44.44 0.4281 0.46078      maintains the Building Public- Private Partnership to Improve Maternal Newborn and Child Health in Bangladesh The high proportion of newborn and maternal mortality in Netrokona District is due to lack of accessible quality maternal newborn services and underdeveloped health care delivery platforms. The Peoples Institution (PI) model is an approach to community mobilization of poor marginalized populations that seeks to engage communities in planning and action to mobilize resources for maternal and newborn care (MNC). This Operations Research (OR) study examines the PI model as an intervention delivery platform and documents PI model strategies, outcomes and effectiveness. This project was funded by the U.S. Agency for International Development through the Child Survival and Health Grants Program February 2015 Background Netrokona is a resource-poor district with marginalized populations and one of 14 lowest performing districts in Bangladesh. Disparities in death rates exist between the rich and poor in factors that contribute to health such as adequacy of antenatal care, skilled attendance at birth and post-natal care. Within this context World Renew, in partnership with local NGOs SATHI and PARI, implemented the USAID–funded child survival project (2009-2014) targeting 124,313 women of reproductive age and 19,314 infants 0-11 months in two upazilas (sub-districts) of Netrokona. The goal of the project was to reduce mortality and improve health status among poor mothers and newborns in vulnerable communities by building the social capital of the poorest households and mobilizing communities for maternal newborn care (MNC). World Renew utilized the PI model intervention to establish community-based organizations (CBOs) and public￾private partnership (PPP) structures for ongoing MNC gains. The PI model CBOs served as grassroots governance bodies to oversee MNC promotion, direct resources to those who need them most, and promote equity. The project addressed economic and health system factors that contributed to inequality. Icddr,b (International Center for Diarrheal Disease Control, Bangladesh) was the local partner that conducted the Operations Research study, which included the KPC study. The Health Facility Assessment was conducted by LAMB (Lutheran Aid to Medicine, Bangladesh). Intervention Design and Implementation The PI model intervention was used to mobilize marginalized populations in Kendua and Durgapur upazilas of Netrokona and train and empower them to establish independent self-sustaining PI groups (CBOs) to promote MNC. These PI groups supported a cadre of trained community health volunteers, developed emergency health funds (EHF) and MNC referral mechanism, and established public-private partnerships (PPP) with health facilities and government officials. The entry point to the PI is membership in the village-level primary group (PG) (Figure 1). With support from the project’s community health trainers (CHTs), PGs worked together to solve problems, claimed their rights, and tracked group gains in their capacity building efforts. The PGs selected Community Health Volunteer (CHVs) and Traditional Birth Attendants (TTBAs) who were trained and supported to promote MNC in their villages. Once the PGs were established, each selected two representatives to form the union￾level Central Cooperative Committee (CCC) to coordinate MNC-related activities of the PGs. Each CCC then selected six representatives to form the upazila-level PI. Each PI has a trained health sub-team that oversees upazila-level MNC services and maintains e           1. The People Institution (PI) model can be systematically established in poor rural underserved upazilas (sub districts) in Bangladesh to increase the social capital of poor marginalized women and empower them to work with government officials and health providers to improve household and community maternal and newborn care and increase utilization of quality health services in hard to reach families and communities. 2. The PI model intervention strengthened public-private partnerships enhancing access to resources for marginalized households. 3. The PI model improved the maternal newborn care practices of poor mothers and families, increased the quality and availability of MNCH services in their communities, and established an upazila-wide enabling environment to strengthen and sustain MNC gains. Significantly greater percentage increases (p≤0.05) in the intervention versus comparison group: • 4+ ANC • Institutional & SBA delivery • PNC-newborn & maternal • Care-seeking (complications/ARI) • Exclusive breastfeeding • Quality of MNC services !#    !!"!%"!#&  $!""% !  !! %!            PPP linkages with health officials and facilities . Using a Training of Trainers (TOT) strategy, the project CHTs trained each PI model group (PG, CCC and PIs) in the area of leadership, governance, record-keeping, gender, M&E, sustainability, advocacy, networking and capacity. The primary activity to improve health facility utilization and quality care is the involvement of PG and PI members with their corresponding level health facility (PGs with Community Clinics, CCCs with Union Health and Family Welfare Centers/Rural Dispensaries, and PIs with the Upazila Health Complex) through membership on the health facility management committees and involvement in decision-making, advocacy and policy making on behalf of their communities. PI groups participate in clinic operations, assist in the daily opening and cleaning of facilities, and provide safety and logistic support to local facilities. The intervention upazilas received the PI model intervention while comparison upazilas received usual government services. Methodology The Operations Research (OR) focused on 3 areas, each with associated research questions: 1. PI model group formation: How do PI primary groups form? How do PI model approaches engage poor and marginalized women of reproductive age (WRA) and promote MNC practices? 2. Social capital in the PI model: What is the degree of implementation of the PI model? What are the structural and cognitive social capital characteristics of intervention group PG members? Is membership in a PI associated with higher levels of social capital at endline when compared with non-member levels of social capital? 3. PI model and health outcomes: Is the PI model more capable than the status quo in 1) increasing care-seeking and utilization of MNC services, 2) increasing maternal-newborn health practices 3) increasing quality and availability of MNC health services 4) creating more equitable MNC and health outcomes and 5) reducing and creating equity in costs? Study questions were addressed using mixed-method design with 4 components: 1. Qualitative process evaluation with intervention group only baseline and endline interviews. 2. Investigation of social capital with intervention group only pretest-posttest measurement (Social Capital survey). 3. Quantitative program evaluation with quasi-experimental pretest-posttest, intervention comparison group design (KPC study). 4. Health facilities assessment with an intervention area only pretest-posttest design (RHFA). Participants were women of reproductive age (15 to 45 years old) from Netrokona District. For the qualitative process evaluation interviews, participants were 81 PI group members and non-members, CHVs/TTBAs, and lead staff from the local implementing NGOs selected with random purposive quota and snowball sampling. For the social capital investigation survey, participants were 300 PI group members and non-members randomly selected from a list of villages in each of the intervention upazilas. Inclusion criteria for the qualitative process evaluation and investigation of social capital were being a married WRA and lower socio-economic status (non-elite). For the quantitative program evaluation KPC survey, respondents in the intervention group consisted of 2,500 mothers of children 0-2 years from the 20 unions of the intervention upazilas and respondents in the comparison group were 2,500 mothers of children 0-2 years from the 15 unions of nearby upazilas with usual government services (Kalmakanda and Barhata). Randomized cluster sampling was used in which 40 clusters were selected (20 intervention and 20 comparison). For the health facility assessment, data regarding MNCH services in the intervention area were obtained from 30 facilities and health workers using systematic random sampling. Ethical approval for the study was obtained from the Research Review Committee and the Ethical Review Committee of icddr,b and from LAMB. Findings PI model group formation. The process of PI model group formation, capacity building, and involvement in promoting MNC was documented in OR reports. The development of trust and unity of vision (social cohesion) among members was reported as important for PI groups to function, select leaders, make decisions, and manage Emergency Health Funds (EHFs) and health savings accounts. By endline the PI groups demonstrated trust and the ability to resolve problems that arose, showed commitment to working together to overcome barriers to MNC, and had established strong referral systems and PPP linkages with health officials and facilities. Figure1. PI Community Mobilization Approach      Social capital in PI model implementation. Analysis of social capital scales created from the social capital tool, which differed from 2012 to 2014, showed significant association (p<0.001) between social capital and PI group membership status at year 3 and 5 of the project. Enhanced structural social capital was evidenced by involvement in groups (65% in 2012 to 64% in 2014) and group leadership (11% to 19%), and in greater joining together to address common issues (46% to 64%) and work out conflicts (33% to 69%). Enhanced cognitive social capital was evidenced by greater household resourcefulness in time of personal crisis (34% to 90%) and interpersonal levels of trust (40% to 52%). PI model and health outcomes. The KPC study documented significantly greater percentage increases (p≤0.05) over the duration of the project in the intervention versus the comparison group in receipt of 4 or more ANC visits from medically trained providers (157% in intervention versus 3% in comparison), institutional deliveries (143% versus 49%), deliveries assisted by skilled birth attendants (136% versus 2%), postpartum care of mothers (114% versus 36%) and newborns (132% versus 39%), and care-seeking from a qualified provider for ANC complications (42% versus 12%), postpartum complications (48% versus -24%) and pneumonia (46% versus -9%). Additionally, significant percentage increases (p≤0.05) were seen in the intervention compared with the comparison group in use of clean birth kits during home deliveries (663% versus 68%), thermal care of the newborn (334% versus 69%), delayed bathing (104% versus 70%), and exclusive breastfeeding (12% versus -15%). The percentage improvement in quality of ANC, active management of the third stage of labor (AMTSL), and provision of essential newborn care was also significantly greater in the intervention versus the comparison group. There was a significantly greater percentage reduction in the equity gap (rich-to-poor ratio) in the intervention versus the comparison group for births attended by a SBA, PNC for mother and newborn, and households that treat water effectively. Out of pocket costs for all MNC increased slightly or stayed the same in the intervention group, except for a 50% decrease in care for complications, while costs for institutional delivery in the comparison group increased markedly. The RHFA documented that MNC service availability increased in the intervention area, with ANC services increasing 50%, institutional deliveries 467%, sick child care 67%, laboratory services 113%, and MNCH supplies and drugs 16% to 211%. Conclusions and Limitations The study confirms that the PI model can be systematically and effectively established in poor rural underserved upazilas in Bangladesh to increase the social capital of poor marginalized women and empower them to work with government officials and health providers to improve household and community MNC and increase utilization of quality health services in hard-to reach families and communities. The PI model intervention strengthened public-private partnerships thereby enhancing access to resources for marginalized households. It improved the MNC practices of poor mothers and families, increased the quality of MNC services in their communities, and established an upazila-wide enabling environment to strengthen and sustain MNC gains. The PI model shows promise of being more capable than existing approaches in increasing utilization of MNC services, care-seeking for complications and pneumonia, health practices, and quality and equity in care. The finding that the intervention group had significantly greater gains than the comparison group in each of these areas points to the utility of the total package of the PI model intervention in achieving greater MNC outcomes. A limitation of this study is that it used different samples for the KPC and social capital studies, did not collect comparison data for the social capital study, and constructed different social capital scales with 2012 and 2014 data. Recommendations and Use of Findings These are the recommendations made based on the findings: 1. That the PI model intervention receives ongoing support by Government of Bangladesh (GOB) and NGOs and be considered for scale-up among marginalized communities with low health outcomes in Bangladesh that are interested in improving MNC health services and outcomes. 2. That the duration of PI model intervention be longer than 5-years to sustain MNC behavior change and care-seeking from the formal health care sector. Although the project was able to achieve rapid uptake of the model in 2-years and achieve independently functioning PI groups by year five, incorporation of support mechanisms for group and public￾private partnership structures beyond 5-years could increase sustainability of the model and health gains. 3. That learnings from the PI model intervention be applied to the Community Clinic Support Groups of the GOB MOHFW that are actively working in the whole country in improving child and maternal health activities. 4. That continuing research and scholarship be conducted to enhance the impact and sustainability of the PI model in various settings. 5. That the international global health community adapt relevant PI model approaches to promoting MNC in their specific contexts. The World Renew Healthy Mother Healthy Child (SUSOMA) Project in Netrokona District in Bangladesh is supported by the American people through the United States Agency for International Development (USAID) through its Child Survival and Health Grants Program. The SUSOMA project is managed by World Renew] under Cooperative Agreement No.   The views expressed in this material do not necessarily reflect the views of USAID or the United States Government.      SUSOMA Child Survival Project Final Evaluation Netrokona Dissemination August 12, 2014   $""&!$"#% Agenda of Presentation:  Project Overview  Evaluation Methodology  Assessment Results  Field Visit Findings  Conclusions & Recommendations Goal: To reduce mortality and improve health status among marginalized mothers and newborns Strategic Objective: Improved household and community MNCH behaviors and increased utilization of quality services     USAID CSHGP 2009-2014 Kendua & Durgapur Sub-districts Netrokona District Population: 529,602 Kendua: 304,729; Durgapur: 224,873 ~135,767 women age 15-49 ~105,469 children age 0-5 Project Area Profile SUSOMA C-IMCI Results Framework Overview Improved knowledge and practices Increased NGO capacity to support PI Strengthened Public Private Partnerships Increased quality of services Enhanced Enabling Environment SUSOMA C-IMCI Results Framework Overview Improved knowledge and practices Increased NGO capacity to support PI Strengthened Public Private Partnerships Increased quality of services • People’s Institution • GO-PI linkages • Emergency Funds Community￾based MNCH education Enhanced Enabling Environment • Training • Referrals • Track HF utilization • HMIS • Resources • Advocacy • PARI SATHI • Learning exchanges • PI GOB registration People’s Institution (PI) Model 4 541 22 CCC PG People’s Institution (PI) 1. World Renew/PARI/SATHI established capacity of the 3-tier PI system through activation, training & support, guidance • ~ 50% of families reached in each village • Active Emergency Health Funds and Health Savings 2. Volunteers promoted MNC through monthly household counseling, referral, group teaching, community dramas & events • 537 CHV and 541 TTBA volunteer trained providers in villages 3. Extensive trainings of community health providers in collaboration with LAMB and Joyramkura • 44,132 training event participants GO health workers (158); partner staff (867) Village Doctors, CHVs TTBAs, and PI leaders (43,107); 4. PI members advocated for quality improvement of MNC • PI’s active in management of 90% Community Clinics • Monthly HMIS ‘matching meetings’ to track MNCH  Sub-district Profiles Population Health Facilities Upazilla Health Complex Union FWC/RD Community Clinic Private NGO facilities PI Model Groups # villages 505 # primary groups 541 # union groups (CCC) 22 # People’s Institution 4 Durgapur 245,000 1 7 25 4 216 214 9 3 Kendua 305,000 1 13 30 0 289 326 13 1 Agenda of Presentation:  Project Overview  Evaluation Methodology  Assessment Results  Field Visit Findings  Conclusions & Recommendations Evaluation Principles Evaluations are joint activities: Participatory evaluations encourage problem analysis and solution development by project staff and partners (and not just by an external evaluator) 1. Monitoring – day to day implementation progress  How fast are we going? Are we using the strategies? 2. Midterm Evaluation -- program improvement  Are we going in the right direction? Do we need to make adjustments to get to our goals? 3. Final Evaluation -- documenting accomplishments and lessons learned  Have we arrived? What did we learn? What will continue? Final Evaluation (FE) Objectives (from June 2013 CSHGP FE Guidelines) 1. Provide overview of project goals, objectives, key intervention strategies implemented 2. Determine the extent to which the project accomplished the results and present evidence of these accomplishments. 3. Describe key factors that contributed to what worked or did not work regarding of some or all aspects of the program. 4. Demonstrate how the project contributed to learning and evidence to improve MOH policies and practices and global learning about community-oriented health programing. 5. Provide a record of results obtained and the processes by which they were achieved, so that USAID . . . help others understand what should be done to reproduce these results. Accomplishments – What results were achieved and how? Challenges – What worked or did not work and why? Sustainability - What can be sustained, scaled-up, shared? Impact – What evidence links results with the PI model? (Operations Research by icddr,b) Evaluation Focus Used to examine attainment of SUSOMA program objectives The Evaluation Team The SUSOMA Final Evaluation Team FE Schedule 3, 4 Aug Workshop 1 & 2, Dhaka Project review, quatitative data review, develop field questions 5, 6, 7 Aug Field interviews, Netrakona (Teams A, B, C) 7 Aug Visit with irddc,b, Dhaka (Team C) 8 Aug Day off (Teams A & B return Dhaka) 9, 10 Aug Workshops 3 & 4 Compile all findings, triangulate data, draw conclusions 12 Aug Final evaluation dissemination, Netrokona Evaluation Team Activities 1. Review endline quantitative & qualitative data 2. Agree on evaluation activities, key stakeholders & questions 3. Conduct field interviews & compile information 4. Discuss findings considering all evaluation data 5. Develop conclusions and recommendations 6. Present findings to partners 7. Compile written report for granting agency (USAID) Agenda of Presentation:  Project Overview  Evaluation Methodology  Assessment Results  KPC Survey  Health Services Delivery Assessment  Child Survival Sustainability Assessment  Field Visit Findings  Conclusions & Recommendations KPC Survey Knowledge Practices and Coverage Survey Durgapur and Kendua populations KPC: 43 items related to antenatal care, delivery, postnatal care, neonatal health, nutrition and breastfeeding, child health Sample: 679 mothers of children less than 1 year of age obtained by cluster sampling Interviews: Baseline – 2009 Endline – 2014 KPC Results: Antenatal Care Visits 0 0.05 0.1 0.15 0.2 0.25 0.3 0.35 0.4 0.45 0.5 at least 1 at least 2 at least 3 4 or more Baseline Endline KPC Results: Antenatal Practices 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 4+ ANC visits 2 TT vaccinations Took Iron tablets Knows ANC danger signs Birth preparation Baseline Endline KPC Results: Delivery + Newborn Practices 0% 10% 20% 30% 40% 50% 60% 70% 80% Skilled birth attendant Institutional delivery Clean delivery kit (HD) Thermal Care (HD) Immediate BF Delayed bathing Baseline Endline KPC Results: Postnatal + Child Care Practices 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% PNC visit Modern FP Exclusive BF ARI Care ORT use Baseline Endline Health Facility Assessment Baseline 2009 Endline 2014 All essential infrastructure present 13% 27% Adequate basic laboratory services 3% 30% External supervision w/in last 3 months 7% 57% Child: Quality assessments performed 18% 13% all essential supplies available 13% 23% ORS available 43% 77% sick child care 60% 100% MNC: ANC at least once a week 60% 90% Delivery services all days 3% 17% ANC supplies: BP Cuff 33% 100% Neonatal drugs: antibiotics 13% 33% ANC drugs: Iron Folate 67% 100% Up-to-date records of ANC & deliveries 14% 38% HF random sample: UHC (2) , FWC/RD (7), CC (21), Pvt (1) facilities 95 75 64 77 70 69 95 72 53 69 54 64 95 69 46 59 50 60 60 64 40 55 48 58 60 61 37 49 42 52 50 38 16 21 17 33 50 33 13 15 2 8 0 10 20 30 40 50 60 70 80 90 100 Health Outcome Health Services Community Capacity Ecological, human, economic,political and policy environment Organizational Capacity Organizational Viability CSSA April,14 CSSA October,13 CSSA April,13 CSSA October,12 CSSA April,12 SUSOMA PI Sustainability Assessment CSSA October,11 BaselineIndices Operations Research Study DM Emdadul Hoque, PI, ICDDR,B Objectives 1. To evaluate the performance of PI model groups in reaching marginalized and poor populations 2. To assess PI model effects on MNCH, care-seeking for illnesses, and compliance with referral, quality of care and utilization of services 3. To describe the process of PI group formation in model implementation 4. To assess the effect of social capital on PI outcomes. Methods:  Qualitative process evaluation of PI model implementation  Investigation of social capital as it relates to the PI model  Quantitative comparison of program effects from baseline to endline. Findings: Report pending Preliminary analysis indicates significant increases in social capital in primary group members vs. nonmembers Agenda of Presentation:  Project Overview  Evaluation Methodology  Assessment Results  Field Visit Findings  Conclusions & Recommendations Stakeholder Interviews Stakeholder group Government Officials 9 persons GO health workers 9 groups CHV, TTBA, Village Doctor 5 groups Community Clinic, Pvt Clinic 8 groups Pis, CCCs, Primary Groups 14 groups Mothers, Husbands, In-laws 4 groups SUSOMA and NGO staff 4 groups Findings from Field Interviews Accomplishments:  Well-established PI groups actively working for the community  Well integrated government provider – community linkages  Extensive training and capacity building occurred  Emergency health funds and referrals improving access to care Challenges:  Health facility infrastructure  Initial lack of trust and hesitancy to get involved in PI group  Initially only women in PI groups, now men’s groups forming Sustainability:  PI will continue to promote MNCH at grassroots level and with the Government health facilities  CHV and TTBA work for their communities will continue Impact:  The PI model is associated with improved MNCH in communities Agenda of Presentation:  Project Overview  Evaluation Methodology  Assessment Results  Field Visit Findings  Conclusions & Recommendations Commendations 1. Commend government officials on a well functioning partnership with community-based People’s Institutions to promote MNCH 2. World Renew and PARI & SATHI created well￾balanced trained dedicated project teams that effectively established the PI Model in Kendua and Durgapur Key Conclusions 1. SUSOMA increased community capacity for MNCH and involvement with the health system by establishing the PI model with marginalized people. 2. SUSOMA effectively established public-private health system collaboration in which the poor are active with government facilities and government officials are awakened to their needs 3. Access to quality MNCH services for the poor was increased by establishment of emergency health funds, a special referral system with priority care status, and the public-private partnership. 4. The MNCH practices of marginalized mothers and families have improved Key Conclusions 5. The Pis helped to increase access to safe and facility-based delivery by increasing awareness of mothers, creating demand, networking and advocacy with influencing others, training CSBAs, and providing emergency health funds. 6. SUSOMA integrated sustainability into the PI group model in terms of financing, monitoring capacity, continuing trainings for groups and volunteer workers, fostering of public-private networks between PI members, GO officials, and health workers. 7. SUSOMA strengthened the capacity of PARI and SATHI to support the PI model, promote rural MNCH, and work with MOHFW at upazilla and district levels. SUSOMA Best Practices 1. The PI Model of empowerment and local governance to increase social capital of marginalized poor women and improve MNC health status of the community 2. Emergency health funds built and managed by PI groups for payment of health transport and services 3. SUSOMA’s referral system established jointly with government health facilities 4. Matching meetings between PI and GO providers focused on integrating HMIS to include MNCH field data. 5. PI involvement in the management and upkeep of Community Clinics 6. Volunteer system of MNCH promotion utilizing community-based CHVs and TTBAs Recommendations  That the success of the SUSOMA PI model be actively shared with others and considered for scale-up in other settings.  That there be continuing engagement between PARI, SATHI, government and the PI groups to promote sustainability of project achievements.  That the PI Manual compiled during the SUSOMA project be translated into English for wider dissemination. The People’s Institution Manual Child Survival and Health Grants Program Project Summary Dec-11-2014 Christian Reformed World Relief Committee (Bangladesh) General Project Information Cooperative Agreement Number: GHS-A-00-09-00009 WORLDRENEW Headquarters Technical Backstop: Alan Talens WORLDRENEW Headquarters Technical Backstop Backup: Stephanie Sackett Field Program Manager: Sukumar Ghagra Midterm Evaluator: Franklin Baer Final Evaluator: Grace Kruelen Headquarter Financial Contact: Stephanie Sackett Project Dates: 9/30/2009 - 9/29/2014 (FY2009) Project Type: Innovation USAID Mission Contact: Sukumar Sarker Project Web Site: www.crwrc.org Field Program Manager Name: Sukumar Ghagra Address: Bangladesh Phone: Fax: E-mail: sgsupoth@gmail.com Skype Name: Alternate Field Contact Name: Nancy TenBroek (Regional Health Advisor (Asia)) Address: Baridhara DOHS Baridhara DOHS Dhaka 1000 Bangladesh Phone: 011 (88) 02 8419171 Fax: 011 (88 )02 8419171 E-mail: ntenbroek@crwrc.org Skype Name: nancy-tb Grant Funding Information USAID Funding: $1,428,543 PVO Match: $496,422 General Project Description CRWRC, a 2009 Innovation category grantee, is implementing the SUSOMA (Shusto Sontan O Ma, Bangla words which mean "healthy child and mother") Project in in two rural sub-districts of northern Bangladesh where a large population of poor and ethnic minorities live. The project goal is to reduce mortality and improve health status among the most marginalized mothers and newborns. Household and community behaviors will be improved and utilization of maternal and newborn care (MNC) services will be increased through establishment of a public-private collaboration -- the People’s Institution. The People’s Institution model is an innovative community mobilization and empowerment strategy that can be used to reach the poorest and most marginalized members of a community. The community organizations formed within this model interact and collaborate with both the formal and informal health care systems in ways that lead to stronger, more sustainable systems. CRWRC is implementing the project in partnership with two local nongovernmental organizations, PARI and SATHI, and will be integrated into the Government of Bangladesh’s Community Integrated Management of Childhood Illness (C-IMCI) strategy, which has been expanded to include newborns. Community health volunteers (CHVs) and trained traditional birth attendants (TTBAs) will help caretakers improve their knowledge and health behaviors, particularly related to MNC, and increase demand for quality services through linkages with health facilties, which will result in better access to health services. Project Location Latitude: 24.89 Longitude: 90.73 Project Location Types: Rural Levels of Intervention: Health Center Health Post Level Home Community Province(s): -- District(s): Netrokona District Sub-District(s): Durgapur, and Kendua Sub-Districts Operations Research Information OR Project Title: Building Public-Private Partnerships to Improve Maternal, Newborn and Child Health in Bangladesh Cost of OR Activities: $265,000 Research Partner(s): Government of Bangladesh (GOB), International Center for Diarrheal Disease Research, Bangladesh (ICDDR,B), University of Michigan OR Project Description: CRWRC is partnering with the International Center for Diarrheal Disease Research, Bangladesh (ICDDR,B) and indirectly with University of Michigan and the Goverment of Bangladesh to conduct operations research (OR) to test whether the People’s Institution model is more effective, equitable, and cost-effective than currently available programs in the area. The OR will use a quasi-experimental design composed of three phases: (1) formative research, (2) evaluative research, and (3) qualitative process documentation. The study will evaluate the effectiveness of the People's Institution model on increaseing caretakers' knowledge, household practices, and care-seeking behavior. Included in the parameters to be measured are social constructs such as social capital and social mobilization, which contribute to empowerment of the poor and disenfranchised. The OR will also explore equity, attitudes and accountability of the community, and the cost-effectiveness of the model. Partners SATHI (Sustainable Association for Taking Human Development Initiatives. (Subgrantee) $433,540 PARI (Participatory Action for Rural Innovation) (Subgrantee) $297,671 ICDDR,B (International Center for Diarrheal Research,Bangladesh) (Subgrantee) $219,998 Government of Bangladesh (Collaborating Partner) $0 Strategies Social and Behavioral Change Strategies: Community Mobilization Group interventions Interpersonal Communication Social Marketing Mass media and small media Health Services Access Strategies: Emergency Transport Planning/Financing Addressing social barriers (i.e. gender, socio-cultural, etc) Community-based health insurance scheme/Community financing mechanisms Implementation with a sub-population that the government has identified as poor and underserved Implementation in a geographic area that the government has identified as poor and underserved Health Systems Strengthening: Quality Assurance Conducting capacity assessment of local partners Supportive Supervision Developing/Helping to develop job aids Providing feedback on health worker performance Monitoring CHW adherence with evidence-based guidelines Referral-counterreferral system development for CHWs Community role in supervision of CHWs Community role in recruitment of CHWs Coordinating existing HMIS with community level data Community input on quality improvement Strategies for Enabling Environment: Advocacy for revisions to national guidelines/protocols Stakeholder engagement and policy dialogue (local/state or national) Advocacy for policy change or resource mobilization Building capacity of communities/CBOs to advocate to leaders for health Tools/Methodologies: BEHAVE Framework Sustainability Framework (CSSA) Rapid Health Facility Assessment LQAS Participatory Rapid/Rural Appraisal MAMAN Framework Lives Saved Calculator Capacity Building Local Partners: Local Non-Government Organization (NGO) Traditional Healers Health CBOs Other CBOs Government sanctioned CHWs Non-government sanctioned CHWs TBAs Private Providers (Other Non-TBA) Interventions & Components Maternal & Newborn Care (100%) - Recognition of Danger signs - Newborn Care - Post partum Care - Integation. with Iron & Folic Acid - Normal Delivery Care - Birth Plans - Emergency Transport - Neonatal Vitamin A - Kangaroo Mother Care (skin to skin care) IMCI Integration CHW Training HF Training Operational Plan Indicators Number of People Trained in Maternal/Newborn Health Gender Year Target Actual Female 2010 230 Female 2010 343 Male 2010 38 Male 2010 26 Female 2011 1281 Female 2011 1159 Male 2011 129 Male 2011 142 Female 2012 1330 Female 2012 1632 Male 2012 54 Male 2012 148 Female 2013 1245 Female 2013 2441 Male 2013 414 Male 2013 138 Number of People Trained in Child Health & Nutrition Gender Year Target Actual Female 2010 0 Female 2010 0 Male 2010 0 Male 2010 0 Female 2011 0 Female 2011 0 Male 2011 0 Male 2011 0 Female 2012 0 Female 2012 0 Male 2012 0 Male 2012 0 Female 2013 0 Female 2013 0 Male 2013 0 Male 2013 0 Number of People Trained in Malaria Treatment or Prevention Gender Year Target Actual Female 2010 0 Female 2010 0 Male 2010 0 Male 2010 0 Female 2011 0 Female 2011 0 Male 2011 0 Male 2011 0 Female 2012 0 Female 2012 0 Male 2012 0 Male 2012 0 Female 2013 0 Female 2013 0 Male 2013 0 Male 2013 0 Locations & Sub-Areas Total Population: 484,920 Target Beneficiaries Bangladesh - WorldRenew - FY2009 Children 0-59 months 96,571 Women 15-49 years 124,313 Beneficiaries Total 220,884 Rapid Catch Indicators: DIP Submission Sample Type: 30 Cluster Indicator Numerator Denominator Percentage Confidence Interval Percentage of mothers with children age 0-23 months who received at least two Tetanus toxoid vaccinations before the birth of their youngest child 648 753 86.1% 3.5 Percentage of children age 0-23 months whose births were attended by skilled personnel 70 753 9.3% 2.9 Percentage of children age 0-5 months who were exclusively breastfed during the last 24 hours 237 502 47.2% 6.2 Percentage of children age 6-23 months who received a dose of Vitamin A in the last 6 months: card verified or mother’s recall 942 1314 71.7% 3.4 Percentage of children age 12-23 months who received a measles vaccination 849 893 95.1% 2.0 Percentage of children age 12-23 months who received DTP1 according to the vaccination card or mother’s recall by the time of the survey 844 893 94.5% 2.1 Percentage of children age 12-23 months who received DTP3 according to the vaccination card or mother’s recall by the time of the survey 811 893 90.8% 2.7 Percentage of children age 0-23 months with a febrile episode during the last two weeks who were treated with an effective anti-malarial drug within 24 hours after the fever began 6 749 0.8% 0.9 Percentage of children age 0-23 months with diarrhea in the last two weeks who received oral rehydration solution (ORS) and/or recommended home fluids 84 114 73.7% 11.4 Percentage of children age 0-23 months with chest-related cough and fast and/or difficult breathing in the last two weeks who were taken to an appropriate health provider 29 130 22.3% 10.1 Percentage of households of children age 0-23 months that treat water effectively 32 1816 1.8% 0.9 Percentage of mothers of children age 0- 23 months who live in households with soap at the place for hand washing 392 1816 21.6% 2.7 Percentage of children age 0-23 months who slept under an insecticide-treated bednet (in malaria risk areas, where bednet use is effective) the previous night 107 1816 5.9% 1.5 Percentage of children 0-23 months who are underweight (-2 SD for the median weight for age, according to the WHO/NCHS reference population) 605 1816 33.3% 3.1 Percentage of infants and young children age 6-23 months fed according to a minimum of appropriate feeding practices 417 1314 31.7% 3.6 Percentage of mothers of children age 0- 23 months who had four or more antenatal visits when they were pregnant with the youngest child 40 753 5.3% 2.3 Percentage of mothers of children age 0- 23 months who are using a modern contraceptive method 890 1806 49.3% 3.3 Percentage of children age 0-23 months who received a post-natal visit from an appropriately trained health worker within two days after birth 59 740 8.0% 2.8 Rapid Catch Indicators: Mid-term Sample Type: 30 Cluster Indicator Numerator Denominator Percentage Confidence Interval Percentage of mothers with children age 0-23 months who received at least two Tetanus toxoid vaccinations before the birth of their youngest child 534 582 91.8% 3.2 Percentage of children age 0-23 months whose births were attended by skilled personnel 76 582 13.1% 3.9 Percentage of children age 0-5 months who were exclusively breastfed during the last 24 hours 115 194 59.3% 9.8 Percentage of children age 6-23 months who received a dose of Vitamin A in the last 6 months: card verified or mother’s recall 252 301 83.7% 5.9 Percentage of children age 12-23 months who received a measles vaccination 185 233 79.4% 7.3 Percentage of children age 12-23 months who received DTP1 according to the vaccination card or mother’s recall by the time of the survey 228 233 97.9% 2.6 Percentage of children age 12-23 months who received DTP3 according to the vaccination card or mother’s recall by the time of the survey 198 233 85.0% 6.5 Percentage of children age 0-23 months with a febrile episode during the last two weeks who were treated with an effective anti-malarial drug within 24 hours after the fever began 0 324 0.0% 0.0 Percentage of children age 0-23 months with diarrhea in the last two weeks who received oral rehydration solution (ORS) and/or recommended home fluids 48 57 84.2% 13.4 Percentage of children age 0-23 months with chest-related cough and fast and/or difficult breathing in the last two weeks who were taken to an appropriate health provider 15 52 28.8% 17.4 Percentage of households of children age 0-23 months that treat water effectively 12 582 2.1% 1.6 Percentage of mothers of children age 0- 23 months who live in households with soap at the place for hand washing 326 582 56.0% 5.7 Percentage of children age 0-23 months who slept under an insecticide-treated bednet (in malaria risk areas, where bednet use is effective) the previous night 112 582 19.2% 4.5 Percentage of children 0-23 months who are underweight (-2 SD for the median weight for age, according to the WHO/NCHS reference population) 197 582 33.8% 5.4 Percentage of infants and young children age 6-23 months fed according to a minimum of appropriate feeding practices 347 379 91.6% 4.0 Percentage of mothers of children age 0- 23 months who had four or more antenatal visits when they were pregnant with the youngest child 65 582 11.2% 3.6 Percentage of mothers of children age 0- 23 months who are using a modern contraceptive method 334 579 57.7% 5.7 Percentage of children age 0-23 months who received a post-natal visit from an appropriately trained health worker within two days after birth 67 582 11.5% 3.7 Rapid Catch Indicators: Final Evaluation Sample Type: 30 Cluster Indicator Numerator Denominator Percentage Confidence Interval Percentage of mothers with children age 0-23 months who received at least two Tetanus toxoid vaccinations before the birth of their youngest child 629 697 90.2% 3.1 Percentage of children age 0-23 months whose births were attended by skilled personnel 153 697 22.0% 4.3 Percentage of children age 0-5 months who were exclusively breastfed during the last 24 hours 156 305 51.1% 7.9 Percentage of children age 6-23 months who received a dose of Vitamin A in the last 6 months: card verified or mother’s recall 510 662 77.0% 4.5 Percentage of children age 12-23 months who received a measles vaccination 187 304 61.5% 7.7 Percentage of children age 12-23 months who received DTP1 according to the vaccination card or mother’s recall by the time of the survey 263 304 86.5% 5.4 Percentage of children age 12-23 months who received DTP3 according to the vaccination card or mother’s recall by the time of the survey 222 304 73.0% 7.1 Percentage of children age 0-23 months with a febrile episode during the last two weeks who were treated with an effective anti-malarial drug within 24 hours after the fever began 8 377 2.1% 2.1 Percentage of children age 0-23 months with diarrhea in the last two weeks who received oral rehydration solution (ORS) and/or recommended home fluids 60 67 89.6% 10.4 Percentage of children age 0-23 months with chest-related cough and fast and/or difficult breathing in the last two weeks who were taken to an appropriate health provider 19 57 33.3% 17.3 Percentage of households of children age 0-23 months that treat water effectively 78 1686 4.6% 1.4 Percentage of mothers of children age 0- 23 months who live in households with soap at the place for hand washing 663 1686 39.3% 3.3 Percentage of children age 0-23 months who slept under an insecticide-treated bednet (in malaria risk areas, where bednet use is effective) the previous night 69 967 7.1% 2.3 Percentage of children 0-23 months who are underweight (-2 SD for the median weight for age, according to the WHO/NCHS reference population) 257 954 26.9% 4.0 Percentage of infants and young children age 6-23 months fed according to a minimum of appropriate feeding practices 133 662 20.1% 4.3 Percentage of mothers of children age 0- 23 months who had four or more antenatal visits when they were pregnant with the youngest child 95 697 13.6% 3.6 Percentage of mothers of children age 0- 23 months who are using a modern contraceptive method 1185 1670 71.0% 3.1 Percentage of children age 0-23 months who received a post-natal visit from an appropriately trained health worker within two days after birth 124 669 18.5% 4.2 Rapid Catch Indicator Comments Rapid CATCH 2008 Indicators were used in this KPC. At baseline 20 clusters (unions) were sampled in the two intervention areas and another 20 unions were sampled in the two comparison upzilas. Only results from the intervention area were entered into the data form. See the KPC report in the final DIP for the results in the comparison area. At midterm 30 clusters (villages) were sampled in the two intervention areas; a survey was not conducted in the comparison upzilas. Endline Data for the following indicators: Antenatal Care, Tetanus Toxoid, Skilled Birth Attendants, Post-Partum Visit, skilled Birth Attendant and Current Contraceptive Use among Mothers of Young Children were obtained from samples of respondents of mothers of children age 0-11 months instead of mothers of 0-23 months. Baseline data recalculated for appropriate comparison. (USAID informed of these changes) 1 Health Services Delivery Assessment Durgapur and Kendua Unions, Netrakona District Comparing Endline (June 2014) to Baseline (November 2009) Using the Rapid Health Facility Assessment (R-HFA) For core maternal, neonatal and child health (MNCH) services at the primary level District Health and Family Welfare Department, Netrakona; Child Survival Program, USAID World Renew, LAMB 2 Table of Contents 1 Introduction 1.1. Background 1.2. Purpose of the Rapid Health Facilities Assessment 1.3. Outcomes from the RHFA 1.4. Durgapur and Kendua Health Systems 1.5. Facilities 1.5.1. Upazilla Health Complex (UHC) 1.5.2. Rural dispensaries (RD) 1.5.3. Union Health and Family Welfare Centers (UHFWC) 1.5.4. Community Clinics (CC) 1.6. Staff: 1.6.1. Medical Doctors 1.6.2. Senior Nurses 1.6.3. Medical Assistants / Sub-Assistant Community Medical Officers (SACMOs) 1.6.4. Family Welfare Visitors (FWV’s) 1.6.5. Community Skilled Birth Attendants (CSBA’s) 1.6.6. Community Health Care Providers (CHCP’s): 1.7. Integrated Management of Childhood Illness (IMCI) in Bangladesh: 2. Methodology 2.1. Introduction 2.2. Instruments and their Adaptation 2.3. Training and Teams 2.4. Data Collection 2.4.1. Clinical Observation 2.4.2. Exit Interviews 2.4.3. Health Facility Check List 2.4.4. Health Worker Interview 2.4.5. Community Health Worker Interview 2.5. Sampling 2.5.1. Health Facilities 2.5.2. Clinical observations / Exit Interviews 2.5.3. Community Health Workers 2.6. Population Estimates for Utilization Rates 2.7. Informed Consent and Confidentiality 2.8. Data Checking, Entry and Analysis 2.9. Initial feedback 3. Results 3.0 Intro: Core Indicators 3.1. Access to Health Care 3.1.1. Geographic Access 3.1.2. Service Availability for Children 3.1.3. Availability of ANC services 3.1.4. Availabilitiy of Delivery Sercvices 3.2. Inputs 3.2.1. Indicator 2: Staffing 3 3.2.2. Indicator 3: Infrastructure 3.2.3. Indicator 4: Supplies 3.2.3.1. Supplies Child Care 3.2.3.2. Supplies- Maternal and Newborn Care 3.2.3.3. Supplies- ANC 3.2.4. Indicator 5: Drugs 3.2.4.1. Drugs for Childhood Illnesses 3.2.4.2. Drugs for Maternal Newborn Care 3.2.4.3. Drugs for ANC 3.2.5. Optional Indicator 2: Availability of Guidelines 3.2.6. Optional Indicator 3: Infection Control 3.3. Processes 3.3.1. Indicator 6: Information Systems 3.3.1.1. Information System- Child 3.3.1.2. Information System- MNC 3.3.2. Indicator 7: Training 3.3.2.1. Training- Child Health 3.3.2.2. Training- Maternal-Neonatal Care 3.3.3. Indicator 8: Supervision 3.3.4. Optional Indicator 4: HF Community Coordination 3.3.5. Optional Indicator 5: Community Referrals 3.3.6. Optional Indicator 8: Laboratory Facilities 3.4. Performance 3.4.1. Indicator 9: Utilization of Services 3.4.1.1. Utilization of Child Curative Services 3.4.1.2. Utilization of ANC Services 3.4.2. Indicator 10: Health Worker Performance 3.4.2.1. Child Assessment 3.4.2.2. Child Treatment 3.4.2.3. Child Counseling 3.5. Community Skilled Birth Attendants (CSBA’s) 3.5.1. Indicator 4: CHW Supplies 3.5.2. Indicator 5: CHW Drugs 3.5.3. Indicator 6: Adequate Information System 3.5.4. Indicator 6: Adequate Training 3.5.5. Indicator 8: Adequate Supervision 3.5.6. Health Facility based Child Health Services 4. Discussion 4.1. Health Facility based Child Health Services 4.2. Health Facility based Maternal Neonatal Services 4.3. Community Health Worker Health Services 4.4. Additional Comments: Malaria 5. Conclusion 4 List of Tables and Figures Table 1: Health Facilities in Durgapur and Kendua Upazilas Table 2.1 Health Staff by Directorate, Total Posts and Posts Currently Filled (2009) Table 2.2 Health Staff by Directorate, Total Posts and Posts Currently Filled (2014) Table 3: Sampling for Health Facilities and Population estimates Table 4: Sampling Targets and Final Sample Table 5: Population estimates for Under Five and ANC utilization analysis 2009 and 2014 Table 6: List of Key Data Variables/ Key Indicators to be reported Table 7: Optional Indicators Included in R-HFA Assessment Table 8: Supplies for Child Care, Maternal and Newborn Care and Antenatal Care, 2009 and 2014 Table 9: Percent of HW who had training on child health topics in the last three years Table 10 Under-five assessment and treatment indicators: baseline and endline Table 11: Caretaker interview information Figure 1: Indicator 1: Service Availability for Children: Figure 2: Proportion of infrastructure items available at all Health Facilities: Nov. 2011 and June 2014. Figure 3: Childhood Illnesses- Percent of facilities with drugs in stock when surveyed Figure 4: Drugs for MNC care; endline compared to baseline Figure 5: Proportion of facilities with select infection control supplies and equipment Figure 6: Proportion of HF with various elements of an Information System Figure 7: Proportion of child assessment tasks completed by task. Figure 8: Child Health Services Reported by CSBA’s, n=13 baseline; n=20 endline Figure 9: Pre-service or In-Service Training Received by CSBA’s in the last 12 months Figure 10.1; 10.2: Balanced Score Card: Health Facility, Child Health Figure 11.1; 11.2: Balanced Score Card: Health Facility, Maternal Newborn Health Figure 12.1; 12.2: Balanced Score Card, Community Health Worker 5 1. Introduction 1.1. Background: World Renew implemented a USAID-funded five-year Child Survival Program for Netrokona (sub-districts of Durgapur and Kendua.), a remote northern district with high newborn and maternal mortality (1). The project’s goal was to reduce mortality among the most marginalized mothers and newborns by building sustainable public-private partnerships with the community organizations (People’s Institutions) that can mobilize poor families to access quality maternal and newborn health services. The Strategic objectives of the project included: • Strengthen public-private partnerships with the peoples institutions for maternal and newborn health • Improve utilization of quality maternal and newborn care services, and • Enhance the enabling environment for maternal and newborn health. World Renew focused all its efforts on a maternal and newborn intervention package, using the government’s integrated strategy for childhood illness (Community IMCI) that was expanded to include maternal and newborns. The project, implemented with 2 local partners PARI and SATHI, provided community- based services and health promotion delivered at the household level by trained traditional birth attendants (TTBAs) and unpaid Community Health Volunteers (CHVs).(2) 1.2. Purpose of the Rapid Health Facilities Assessment (RHFA): As part of the setup of the child survival program in Durgapur and Kendua the baseline assessment was done to evaluate the maternal, newborn and child health services (MNCH) in the 3 levels of Health Facilities in the project area (district hospital, first level and community- based) in the areas of staffing (qualifications, training, supervision); health infrastructure (facilities, medicines, supplies); and health worker performance regarding management of childhood illnesses. (2) The endline RHFA was done to assess progress in each of these areas at the end of child survival project. 1.3. Outcomes from the RHFA: 1.3.1. Provide a baseline and endline on staffing, infrastructure and knowledge and practices of health workers regarding IMCI for the three levels of health facility in Durgapur and Kendua Unions, to measure improvements achieved during the project period. 1.3.2. Develop the capacity of the survey team (both Pari and Government Health Staff) to conduct a health facilities assessment and understand the value of the information collected. 1.4. Durgapur and Kendua Health Systems: Government Health services in Netrakona district are ultimately under the jurisdiction of the Civil Surgeon (CS, health) and Deputy Director (DD, family planning). Each Upazilla (sub-district) has an Upazilla 6 Health Complex (UHC) and a mixture of Union Health and Family Welfare Centers (FWC), Rural Dispensaries (RD), and Community Clinics (CC) (see table 1 below). Durgapur also has a number of private/NGO clinics. Actual staffing of Government facilities is generally less than the allotted posts, due to both overall health worker shifts to Urban areas and the remoteness of Netrakona district, in particular (Table 2, below). Table 1. Health Facilities in Durgapur and Kendua Upazilas (update) UNIT TYPE Upazilla Health Complex FamilyWelfare Center Rural Dispensary Community Clinic (open) Private Clinic/ UPAZILLA NGO Durgapur 2009 1 6 1 25 (18) 4 2014 1 6 1 25 (25) 3 Kendua 2009 1 4 9 30 (30) 0 2014 1 8 5 35 (35) 0 Total 2009 2 10 10 55 (48) 4 2014 2 12 15 60 (60) 3 Table 2.1 Health Staff by Directorate, Total Posts and Posts Currently Filled (2009) Directorate Type of Staff Durgapur Kendua Total posts Posts filled Total posts Posts filled Health Medical Doctors (health complex and sub-health center) 9 3 8 6 Medical Officer( Union Level) New￾Created 6 6 13 2 Dental Surgeon 1 0 1 0 Nursing Staff (health complex) 11 5 10 3 Medical Assistant (Health complex/sub￾HC) 3 3 15 9 Medical Assistant (Union) 6 3 2 1 Technologists (lab, pharmacy, Leprosy etc) 11 10 20 20 Support staff (accounts, stores, guards, drivers, ayahs, etc) 29 19 40 34 Health Inspector/Assistant 11 9 17 16 Health Assistant 40 24 60 31 Total 124 82 186 122 Family Planning Doctors 4 3 6 5 Family Welfare Visitor 7 7 13 12 Family Welfare Assistant 38 33 unk 59 Family Planning Assistant 7 3 -- -- SACMO (Medical Asst.) 5 1 5 3 Community Skilled Birth Attendants unk 23 unk 37 Pharmacist 5 2 0 0 Support staff 18 11 unk unk Total 107* 83 120* 116 7 Table 2.2 Health Staff by Directorate, Total Posts and Posts Currently Filled (2014) Directorate Type of staff Durgapur Kendua Total post Post filled Total post Post filled Health Medical Doctors(Health complex and sub-health center 16 4 8 6 Medical Officer( Union Level) New￾Created 6 3 13 3 Dental Surgeon 1 0 1 1 Nursing Staff (health complex) 16 11 14 8 Medical Assistant (Health complex/sub￾HC) 3 3 2 2 Medical Assistant (Union) 6 6 13 11 Community Health Care Provider(CHCP) CC level 25 25 38 35 Technologists (lab, pharmacy, Leprosy etc) 9 8 20 9 Support staff (accounts, stores, guards, drivers, ayahs, etc) 29 19 40 34 Health Inspector/Assistant 11 9 17 10 Health Assistant 40 40 60 50 total 162 128 226 169 FAMILY PLANNING Family Planning Doctors 5 0 2 1 Family Welfare Visitor 13 9 16 16 Family Welfare Assistant 38 35 74 62 Family Planning Assistant 7 3 3 3 SACMO (Medical Asst.) 5 2 4 4 Community Skilled Birth Attendants Unk* 22 Unk* 21 Pharmacist 5 2 1 0 Support staff 18 8 19 16 total 113 81 140 123 * Where the total number of posts for the position was unknown, the number of staff posted was used in the total. Therefore the total presented may underestimate the actual total. 1.5. Facilities: 1.5.1. Upazilla Health Complex (UHC): There is one UHC per Upazilla. These are administered by the Upazilla Health and Family Planning Officer (UHFPO) and are staffed by doctors, nurses, technologists and support staff according to the number of beds (officially 31 or 50) (3). In line with the government’s commitment to implement Integrated Management of Childhood Illness (IMCI) protocols, UHC’s are being set up with IMCI corners where medical assistants or Senior Nurses with IMCI training treat under-five children. All UHC’s have facilities for normal deliveries and a number have been upgraded to deliver Emergency Obstetric Care 8 (EmOC), including cesarean sections. The catchment area for an UHC is normally .2-.45 million people (4). 1.5.2. Rural Dispensaries (RD): Rural Dispensaries operate at the Union level and serve a population of 20-30,000. Along with the UHC they operate under the Health Services wing of the Ministry of Health and Family Welfare (MOHFW). Staff postings at RD’s include Medical Officers, Medical Assistants (sub-assistant medical officers or SACMO’s) and Pharmacists. 1.5.3. Union Health and Family Welfare Centers (UHFWC): UHFWC’s also operate at the Union level and serve a population of 20-30,000. They operate under the Family Planning wing of the MOHFW. They have a post for a medical officer but are normally staffed by Medical Assistants and Family Welfare Visitors (FWV’s). Medical Assistants and FWV’s are targeted to get IMCI training by the government, but not all have received it. UHFWC’s were originally built with a room in which to do normal deliveries, however only a few ‘upgraded’ facilities are currently doing deliveries. Community Clinics (CC): Each CC was envisioned to provide basic health care to a population of 6,000 families. Although many buildings were constructed in the 1990’s most were closed, or were used for purposed other than health. The current government has been committed to re-opening community clinics since 2009 and staffing them with Female Welfare Assistants (FWA’s), Female Health Assistants (HA’s) trained as community skilled birth attendants (CSBA’s) and Community Health Care Providers (CHCP’s). The CHCP is a new cadre of health care provider, developed specifically to work at Community Clinics. The first training started in April of 2012 (5). 1.6. Staff: 1.6.1. Medical Doctors: Most doctors are posted to hospitals, though there are posts for medical officers down to the union level. 1.6.2. Senior Nurses: Female senior nurses traditionally have had a 3 year training in general nursing with an additional year in normal obstetrics. The government nursing curriculum has been updated and a three year general diploma in nursing is now the standard. In 2010 a 6 month advanced midwifery certificate course was launched for diploma midwives to expand their skills as nurse-midwives. In addition, a direct entry three year diploma in midwifery course was launched in December of 2012 (6). Diploma nurses are mainly posted to hospitals (district, upazilla and municipality 50 bed). They perform normal deliveries, and some have had extra training in emergency obstetric care and/or IMCI 9 1.6.3. Medical Assistants/ Sub-Assistant Community Medical Officers (SACMO’s): MA’s have a three year medical training and are posted to UHC outpatient clinics, and Rural Dispensaries. SACMO’s are posted to Upazilla Health and Family Welfare Centers. Many have been trained in IMCI and run under-five clinics. 1.6.4. Family Welfare Visitors: FWV’s work under the Directorate of Family Planning. They have an 18 month training that includes family planning and normal delivery. They are targeted to receive IMCI training. FWV’s are posted to Maternal Child Welfare Centers (MCWC’s), Family Planning Clinics at UHC’s, and FWC’s. They are also the supervisors of the new Community Skilled Birth Attendant cadre. None have been trained since 1995. (7) 1.6.5. Community Skilled Birth Attendants (CSBA’s): Female Welfare Assistants (FP Directorate) and Female Health Assistants (Health Directorate) are given 6 month’s training in antenatal (ANC), normal delivery and post natal (PNC) care to function as skilled delivery attendants in the home. CSBA’s also carry on their normal responsibilities as FWA’s and HA’s and provide health education and family planning services at Community Clinics and in the home. FWA’s were meant to visit homes one every two months. (7) The CSBA was considered the community health worker for purposes of the RHFA. 1.6.6. Community Health Care Providers (CHCP’s): CHCP’s receive 12 weeks of pre￾service training (six weeks theoretical and 6 weeks practical)(MOHFW website, 2012). 237 CHCP’s had been trained in Netrakona Upazilla by the end of the third phase (16 May, 2014) (5). In addition, CHCP’s have received a three day community IMCI course to increase their skill in treating under-five children. 1.7. The WHO has been instrumental in developing the IMCI strategy which encompasses a range of interventions to prevent and manage major childhood illness (ARI (mostly pneumonia), diarrhea, measles, malaria, or malnutrition) both in health facilities and in the home. Implementation of the IMCI strategy involves the following three components: • Improvements in the case management skills of health staff through the provision of locally adapted guidelines on integrated management of childhood illness and activities to promote their use. • Improvements in the health system required for effective management of childhood illness. • Improvements in family and community practices. 10 The Government of Bangladesh decided to pilot the IMCI strategy in 1998. After adaptation of the generic guidelines, implementation started in 2001 in three upazillas, and plans made for rapid scaling up after an evaluation of the program in 2003. (8) 2. Methodology 2.1. Introduction: A Rapid Health Facility Assessment (R-HFA) was carried out in Durgapur and Kendua Upazillas of Netrakona District in November 2009 and June 2014. Staff from CRWRC Child Survival Project (CSP) and partner organization, Pari, initially approached the Civil Surgeon of Netrakona for his permission and cooperation in conducting the RHFA in facilities under his authority. In addition, the DD Family Planning was consulted as some of the staff to be interviewed is under his authority. Dates for the survey workers’ training and data collection were set in consultation with these local authorities to ensure maximum cooperation from the health facility staff. Authorities were aware of the period of time over which the survey would be conducted, but were not told which facility would be assessed on which day, to enable the survey to be conducted under as normal day to day conditions as possible. 2.2. Instruments and their Adaptation: The survey instrument was based on the Rapid Health Facility Assessment tool developed by a team at MEASURE Evaluation. The tool was designed to provide valid data on indicators of health service quality and access that would be comparable across child survival programs in different countries (9). The principal investigator and World Renew’s Regional Health Advisor for Asia were briefed by the developer of the tool during an ‘e-lluminate’ session online before the baseline survey, as well as following the suggestions given in the detailed instruction manual. Adaptation of the questionnaire was done in consultation with World Renew (CSP, Health Specialist) before the baseline survey, retaining the optional questions that were appropriate for the context. As the survey team had previous experience collecting data using collection forms written in English, only the consent form and exit interviews were planned to be translated ahead of the training for the baseline survey. In the end, the data collectors found the English of the survey forms more difficult than anticipated, and translation was done as the forms were reviewed during training. The clinical observation, exit interview, health worker interview and community health worker interview (modules 1, 2, 4 and 5) were translated into Bengali by a World Renew staff before the endline survey and back translated by an outside source. Piloting of the translated forms took place during training. 11 2.3. Training and Teams: For both the baseline and endline a three day’s training was conducted at the Pari office in Durgapur with the assistance of World Renew, Pari and LAMB. There were 6 supervisors and 7 field investigator at the baseline and 7 supervisors and 7 field investigators at the endline training. The supervisors were mainly government health staff (MA’s and FWV’s) who had IMCI training. The field staff was mainly community supervisors and field workers from Pari, some of whom had previously been involved in data collection for knowledge practice and capacity (KPC) surveys. On the first two days of the training the questionnaires the first four modules (Clinical Observation, Exit interview, Health facility check list and Health Worker Interview) were reviewed, meanings clarified, notes taken in Bengali (baseline) and practiced using role plays. The third day the supervisors and field investigators were divided into teams and went to health facilities to practice the first four questionnaires in an actual setting. After the field practice, questions were clarified and translations revised. The community health worker interview (module 5) was also reviewed and teams for the respective unions were given the forms they would need for data collection in the facilities they had been assigned. The World Renew CSP staff, along with the principal investigator also acted as field supervisors for the field practice sessions and during the first two days of the actual data collection of the baseline. In addition for the endline a monitoring and evaluation officer from LAMB assisted with field supervision as well as overseeing data entry for all six days of the survey. Since the government staff was from the area where the survey was being conducted care was taken not to assign them to survey their own facility. The original plan was to assign government health staff from Kendua to assess facilities in Durgapur and vice versa. Lack of suitable housing for the survey team in Kendua, however, made this impractical, and so government HW’s stayed in his/her own home and came to a designated center each morning to travel to the health facility to be assessed that day with their team. This means that government staff was sometimes interviewing staff that they knew personally, not an ideal situation. They were cautioned not to give any ‘tips’ to HF staff and CHW’s that were to be interviewed, such as day of interview (so that they would make sure to show up) or what information would be collected. 2.4. Data collection: The RHFA used five modules to collect data on health service delivery access and quality. The data collection teams consisted of two members: one supervisor who did the clinical observation on child illness assessments and health worker interviews as well as checking all forms for completeness at the end of each day; and 12 one field investigator who did the exit interviews with the child’s care giver, the health facility check lists and community health worker interviews. Information collected for each module included the following: 2.4.1. Clinical Observation: The primary health worker doing clinical care for sick children was observed during consultations. Adherence to IMCI guidelines for diagnosis, treatment and explanation of treatment prescribed for three major illnesses of childhood (fever, diarrhea with and without blood and pneumonia) was assessed. 2.4.2. Exit Interviews: This assessed what the care giver understood the diagnosis to be, what medicines had been given and what the caregiver understood the treatment dosage and schedule to be (quality of counseling by health worker) 2.4.3. Health Facility Check List: The check list covered availability of essential infrastructure, equipment, supplies and drugs necessary to care for newborns, pregnant and delivering mothers and children under five. 2.4.4. Health Worker Interview: Information was collected from the health worker who was the primary person seeing under-five children in the facility regarding initial education, recent in-service education / relevant training, and supervision of their work. Information was also collected from registers regarding antenatal, delivery and under-five consultations for fever/ diarrhea/ pneumonia in the last three months. 2.4.5. Community Health Worker Interview: This brief questionnaire focused on services provided by the CHW, training received in the last three years, type of supervision provided by their supervisor, any register information maintained and treatment given to ill children. 2.5. Sampling: Sampling was done to determine 1. Which health facilities would be assessed; 2. Which clinical cases /exit interviews would be observed and 3. Which Community Health workers would be interviewed. Different sampling methods were used for each group as follows: 2.5.1. Health Facilities: The sampling frame included all health facilities which provided primary care (not just referral) for childhood illnesses. Four categories of facility were targeted for sampling in the instructions: hospital OPD, health center, health post and private office. In the Bangladesh context these translated to 1. Outpatient Department of Upazilla Health Complexes; 2. Upazilla Health and Family Welfare Centers and Rural Dispensaries; 3. Community Clinics and 4. Private / NGO clinics. Only Community Clinics which were determined to be open 13 and functioning by the relevant government authority were included in the sampling frame. The total number of facilities eligible for sampling at baseline was 73 and at endline, 86. According to the guidelines given in the instructions a sample of 28 would give a 95% confidence interval of +/- 15% for indicators which have Health Facility as the denominator. Since we had six to seven teams of two and five days in which to complete the survey it was decided to sample 30 facilities. Sampling was done on a sample proportionate to size basis to ensure balanced sampling from the different levels of health facility (see table 3 below). At least one facility was sampled from each category. Once the sample size was determined the sample was chosen using systematic random sampling. Table 3: Sampling for Health Facilities and Population estimates Baseline Endline Facility Level Type of facility included Samp￾ling frame Percent of total Final Sample Size Samp￾ling frame Percent of total Final Sample Size 1 UHC OPD 2 2.7 1 2 2.3 1 2 FWC / RD 20 27.4 8 21 24.4 7 3 Community Clinic 48 65.8 20 60 69.8 21 4 Private / NGO 3 4.1 1 3 3.5 1 total 73 100 30 86 100 30 2.5.2. Clinical observations/ Exit Interviews: Six clinical observations/ exit interviews were targeted for each facility (30 x 6= 180 cases). As per the manual the first six children who attended the clinic and presented with fever/malaria, diarrhea (with or without blood) and/or pneumonia / difficulty breathing were chosen for observation. In general health facilities opened after 10 am and there were a number of facilities who had less than 6 eligible patients to interview. In addition, one facility did not open the day of the survey visit at baseline. Overall 63 out of an anticipated 180 child assessments and exit interviews were observed (35%) at baseline and 141 (78%) at endline (see table 4, below). 14 Table 4: Sampling Targets and Final Sample Target Targeted Final sample baseline Final sample endline Number of health facilities 30 29 30 Facilities with under-five sick children the day of the survey 30 17 30 Child Observations (6/facility x 30 facilities) 180 63 141 ARI cases observed Na 42 83 Fever / malaria observed Na 34 34 Diarrhea observed Na 19 40 Health Worker Interviews 30 29 30 CHW interviews 13 (baseline) 20 (endline) 13 20 2.5.3. Community Health Workers: A systematic random sample of 13 out of a total of 40 Community Health Workers (33%) was chosen from the sampling frame provided by the government authorities at baseline and 20 out of 60 (33%) at endline. 2.6. Population Estimates for Utilization Rates: Current population of the catchment area for each health facility was not available. Therefore standard government of Bangladesh figures for the expected catchment area of each type of facility were used (see table 5, below). This was compared with total population figures for Durgapur and Kendua Upazillas from the 2001 census (baseline) and 2011 census (endline), upgraded by estimated population growth rates/year. (10, 11) Since less than ½ of functioning health facilities in the two upazillas were sampled (30/73 for baseline and 30/86 at endline, see table 1, above) and the catchment area of some of the facilities overlap (Durgapur UHC and most of the clinics in the same union as well as the private clinic) we would expect the utilization rates to be artificially low. Table 5: Population estimates for Under Five and ANC utilization analysis 2009 and 2014 Facility/ Area Governme nt estimate of catchment population Population estimate from 2001 census, upgraded for 2009* Estimated Under￾fives/ catchment area for 2009@ Estimated deliveries/ catchment area for 2009! Population estimate from 2011 census, upgraded for 2014* Estimated Under￾fives/ catchment area for 2014@ Estimated deliveries/ catchment area for 2014! UHC .2-.45 million 22,000 5772 24800 4100 UHFWC/ RD 20-30,000 2,200 577 2480 424 15 CC 6000 660 173 744 136 Total for HF sample areas using GoB estimate 514,000 (2009) 466,000 (2014) 56,540 14,834 60,264 10,348 Durgapur/ Kendua Upazillas (total) 540,136 59,415 15,588 543,682 67417 11145 *minimum GoB catchment area estimates used; @based on 11% of population for 2009 and 12.4% for 2014 (2011 figure); ! based on birth rate for 2009 of 28.86/1000 population and for 2014 the 2011 figure of 20.5 births/1000 population was used. 2.7. Informed Consent and Confidentiality: The consent form was translated into Bengali and piloted during the training period. The supervisor was responsible to obtain the consent from the health worker observed/interviewed and each caregiver interviewed. Interviews were conducted as much as possible in quiet areas, away from other observers. In some facilities, however, there was no secluded area in which to conduct the exit interviews. All answers, however, were kept confidential once recorded. 2.8. Data checking, Entry and Analysis: All forms were checked for completeness by the team supervisor each day. In addition, the Principal Investigator reviewed all forms before data entry to double check for completeness as well as check the supervisors’ assessment of health worker performance for treatment and counseling (on modules one and two). All forms were transported to the CSP Dhaka office where data entry was done by the CSP statistician for the baseline. For the endline assessment data was entered each evening by two data entry assistants. Data from all the forms was entered directly into the Exel package formulated by the creators of the tool. A random selection of forms was visually checked with data entered into the excel spreadsheet. In addition all data from modules 1 and 2 were double checked against entry to ensure accuracy. 2.9. Initial feedback: Although data collectors are encouraged to give initial feedback to health care workers before leaving the facility in the R-HRA instructions, this did not seem appropriate for this survey. Since each team included non-government and non￾medical personnel it was felt that any feedback on areas for improvement might not have been well accepted. Therefore feedback was limited to thanking all participants and giving positive comments on tasks that were being done well. 3. Results 3.0 Intro-: Core Indicators: Twelve key indicators are calculated from the data collected by the R-HFA. The indicators focus on four key areas of health service 16 delivery: Access; Inputs; Processes and Performance. A summary of the indicators is given in Table 6, below (see Appendix for details): Table 6: List of Key Data Variables/ Key Indicators to be reported (reference- Rapid Health Facility Assessment Data Entry & Analysis Forms) Area # Domain Indicator Access 1 Service Availability % HF that offer three basic child health services Inputs 2 Staffing % staff in HF who provide clinical services working on the day of the survey 3 Infrastructure % essential infrastructure in HF to support child preventive / curative care available on the day of the survey 4 Supplies % essential supplies in HF to support child preventive / curative care available on the day of the survey 5 Drugs % first line medications for child services available in HF/ CHW on the day of the survey 6 Information System % HF / CHW that maintain up-to-date and complete records of sick U5 children (age, diagnosis, treatment) AND show evidence of data use 7 Training % HF / CHW where interviewed HW reports received in-service or pre-service education in child health in last 12 mo. 8 Supervision % HF / CHW that received external supervision at least once in the last 6 months Performance 9 Utilization # clinical encounters (annualized / CHW/HF) for sick children per U5 population in project area OR % HF with adequate population service coverage 10 HW Performance: Assessment % clinical encounters in HF in which ALL essential assessment tasks were made by HW for sick child 11 HW Performance: Treatment % clinical encounters (HW/CHW) in which treatment was appropriate to diagnosis for malaria, pneumonia, and/or diarrhea 12 HW Performance: Counseling % clinical encounters in HF in which the caretaker whose child was prescribed an antibiotic, anti-malarial, or ORS can correctly describe how to administer ALL prescribed drugs Ten additional ‘optional indicators’ are included in the data collection / analysis format. These 10 focus on additional aspects of inputs, processes and performance which are also important for quality health service delivery, but may not applicable to the country / area of assessment, or how health services are provided. Of the optional indicators, numbers 2,3 (inputs) and 4,5, 8 (processes) were included for this assessment (see table 7 , below). Optional indicators 1 (availability of immunizations) and 9a (utilization of immunization services) were not appropriate for the facilities assessed, since the Expanded Program on Immunization (EPI) is still a vertical program. Although some of 17 the facilities assessed were able to report EPI data for their area, this did not accurately cover all EPI activity. In addition, government indicators in Bangladesh are based on children less than 12 months of age. Optional Indicators 6 (Malaria Drug (ACT) Logistics and 7 (ITN/LLN logistics) were not included since only one of the two target upazillas is considered a high risk malaria area. Table 7: Optional Indicators Included in R-HFA Assessment Area # Domain Indicator Inputs Opt 2 Availability of guidelines % HF with all nationally-mandated immunizations in stock on day of survey Opt 3 Infection Control % HF with all infection control supplies and equipment on day of survey Processes Opt 4 HF-Community Coordination % HF with routine community participation in management meetings OR have a system for eliciting client opinion, AND evidence that client feedback is reviewed Opt 5 Community Referral % HF that received at least one referral from CHV in the last month Opt 8 Laboratory % HF with adequate basic laboratory services on site or ability to send out Rapid Health Facility Assessment Data Entry & Analysis Forms: Optional Indicators Reporting on results of the HFA will be organized by indicator, looking first at the health facilities and then Community Health Workers and comparing endline to baseline results. 3.1 Indicator 1: Access to Health Care 3.1.1 Geographic Access: This indicator measures the proportion of the population with year-round geographic access (within 5 km. or one hour) to an authorized provider of curative child health services. Since neither GPS equipment nor detailed maps delineating the catchment area of each facility were available for Durgapur and Kendua unions, geographic access was not calculated for this report. 3.1.2 Service Availability for Children: This indicator measures the proportion of Health Centers that offer the three basic child health services, growth monitoring, immunization and sick child care. The proportion of facilities offering sick child care went from 60% at baseline to 100% at endline, a laudable improvement. Availability of immunization services at a facility increased to 97% at endline . Immunization is still a vertical program provided by specialized teams of health workers. Using this system Bangladesh has been able to achieve quite high levels of 18 immunization coverage (76% of children received all basic vaccinations by one year of age, (12) but it means that most health centers are involved in immunization days through outreach clinics rather than immunization days administered and reported on by the facility staff. The Bangladesh government is committed to improving child health through implementation of the Integrated Management of Childhood Illness package developed by the WHO. Despite the emphasis in IMCI on taking every opportunity to weight children and plot their growth, growth monitoring was rarely available, with only 7% of facilities providing this service at baseline and 20% at endline (see figure 1, below). Figure 1: Service Availability for Children: Sick child care; Immunization; Growth Monitoring. Days/month/facility available and % of HF providing the service . 3.1.3 Availabilitiy of ANC services: At baseline 60% of facilities offered Antenatal Check-up services at > 4 times per month, averaging 10 days/ month/facility. This increased to 90% of facilities offering ANC check-up services at endline, averaging 19.5 days/month/facility. 3.1.4 Availability of Delivery Services: Only one out of 30 (3%) facilities, the Upazilla Health Complex, offered delivery services every day at baseline, which increased to 5 out of 30 (17%) at endline. The facilities offering delivery services at endline included two Upazilla Health and Family 19 Welfare Centers and one Community Clinic as well at the Upazilla Health Complex and private clinic. 3.2 Inputs: 3.2.1 Indicator 2: Staffing An impressive 80% of facilities had all of their clinical staff present on the day of the survey at baseline. In 7 of the 30 facilities, however, there was no clinical staff posted. At the FWC and CC level a clinic is sometimes run by a pharmacist or lab technician who sees patients as well as gives out medicines / does lab tests. Small facilities, such as CC’s, where only one or two clinical staff are posted were more likely to have all staff present, compared to the UHC and Private clinic which had 75% and 70% of clinical staff present on the day of the survey, respectively. At endline 4/30 (14.7%) facilities had all of their clinical staff present. There are a couple of possible reasons for the large discrepancy between the baseline and endline data for staffing. One reason could be that more posts have been created for clinical staff at facilities, but many of those posts are yet to be filled, or not all staff show up every day. Whereas there were no clinical staff at many of the community clinics at baseline, by endline there were 1-4 clinical staff (mainly CSBA’s and CHCP’s) posted to each of the clinics, although only one or 2 staff were often present at the time of the survey. Another possibility is that in the endline survey data collectors recorded the number of government sanctioned posts as the total sanctioned posts and at the baseline the number of posts actually filled was used as the denominator. For example, for the Upazilla Health Complex there are 16 actual posts for doctors but only 4 of those posts are currently filled, On the day of the survey there were three medical officers present. On the survey form the data collector had originally entered 23 as the sanctioned posts for doctors (the total number for the Upazilla Health Complex, union level health facilities and a dental surgeon for the upazilla). 3.2.2 Indicator 3: Infrastructure Although the infrastructure section of the questionnaire collected information on a number of variables, three main data were used to calculate the indicator: a useable client latrine; water from a protected water source on or near grounds; and auditory and visual privacy. 20 Using these standards, only 13% of facilities surveyed had all essential infrastructure (latrine, water, privacy) at baseline and the average proportion of infrastructure items present per HF was 22%. At endline 27% had all three and the average proportion present per HF was 42%. Figure 2, below, shows availability of all basic infrastructure items assessed. The most commonly available item, clean water, was present in less than 50% of facilities at baseline but increased to 83% at endline. About 45% of facilities had a latrine which was working and available for client use at baseline and that nearly doubled by the end of project (83%). Less than one in 5 facilities assessed provided both audio and visual privacy to their clients during assessment at baseline and one in three at endline. Many more facilities had the potential for auditory and visual privacy (consultancy rooms with doors that closed) than actually enforced a one patient at a time rule. Even where there was a separate room for consultations, several children and their caretakers were often lined up on the same bench as the child being seen, or crowded in the doorway. The other infrastructure item that made a significant increase during the period of the child survival project was availability of emergency communication (from 23 to 97%). This is due largely to individual health care providers having a personal mobile phone which they can use to make emergency calls. 21 Figure 2: Proportion of infrastructure items available at all Health Facilities: November 2011 and June 2014. 3.2.3 Indicator 4: Supplies 3.2.3.1 Supplies- Child Care: Only 13% of facilities assessed had all essential supplies necessary to care for sick children (infant scale; scale for children/adults; timer or watch, pitcher and cup/spoon for ORS) at baseline which had increased modestly to 23% at endline. None of the individual items were available in even 50% of the facilities at baseline but all items except a means of timing infant respirations was available on over 50% of facilities at endline (see Table 8, below). The nurse running the IMCI corner at the Upazilla Health Complex showed us several government issued respiration timers, still in the box, which had never worked. This severely limits the ability of caregivers to follow the IMCI protocols for sick children, even if they have had the training. In addition 17% had a functioning autoclave and 7% a functioning refrigerator at baseline, increasing to 20% and 13% respectively by end of project. 3.2.3.2 Supplies- Maternal and Newborn Care: Not unexpectedly, with only 2 of the facilities reporting deliveries in the last 3 months, only 3% of facilities had all of the essential supplies for delivery and neonatal care at baseline (see individual items, below). The private facility was the only one with all essential supplies. Availability of essential supplies has increased as more 22 facilities are open for deliveries. The biggest improvement is in the availability of a working infant scale (57%, up from 13%). 3.2.3.3 Supplies- ANC: Even though 60% of facilities provided ANC at least 4 days per month and 90% at endline, only 3% (the private clinic) had all the essential supplies. The most common item, a functioning blood pressure cuff, was only available in 33% of facilities at baseline, but increased to 100% at endline (see list below). The next most commonly available item at endline was hemoglobin testing reagents (27%). Table 8: Supplies for Child Care, Maternal and Newborn Care and Antenatal Care 2009 and 2014 Supply Item- Available, Functioning, Seen by data collector % Supplies for Child Care 2009 2014 Has functioning and accessible infant scale 27 73 Has functioning and accessible scale for children/adults 37 90 Has functioning timer or watch 47 40 Has pitcher for ORS 30 73 Has cup or spoon for ORS 30 53 Supplies for Maternal and Newborn Care Has functioning neonatal resuscitation equipment 13 20 Has functioning and accessible infant scale 13 57 Has functioning vacuum extractor 3 3 Has neonatal wraps for warming 10 33 Has partographs 3 3 Supplies for Antenatal Care Has functioning refrigerator 7 10 Has functioning blood pressure equipment 33 100 Has hemoglobin testing reagents 3 27 Has syphilis testing kits 3 7 Has malaria test kits 3 10 Has urine albumin test strips 3 13 3.2.4 Indicator 5: Drugs 3.2.4.1 Drugs for Childhood Illnesses: Overall drugs to treat childhood illnesses were more available at endline compared to baseline (see figure 3 below). Cotrimoxizole (first line drug for pneumonia and bloody diarrhea) was available in 63% of facilities at baseline and 90% of facilities at endline. ORS, the preferred treatment for non-bloody diarrhea was only available in 43% of facilities at baseline, but increased to 77% at endline. First line 23 malarials were available at fewer facilities at endline compared to baseline. Staff explained that they normally do not treat malaria but sent patients for a malaria test if they have malarial pattern fever. Figure 3: Childhood Illnesses- Percent of facilities with drugs in stock when surveyed: baseline compared to endline. Note: Cotrimozizole is first line antibiotic for both pneumonia and bloody diarrhea 3.2.4.2 Drugs for MNC Care: A much larger proportion of facilities had the antibiotics for newborn sepsis/pneumonia at endline (33%) compared to baseline (13%), however 2/3 of facilities were still without these essential drugs (see figure 4, below). Oxytocin, for preventing and treating post-partum hemorrhage was only available at one of the sampled facilities at baseline and 2 of five facilities which do deliveries at endline. Neonatal eye ointment was less available at endline compared to baseline. 24 Figure 4: Drugs for MNC care; endline compared to baseline 3.2.4.3 Drugs for ANC: Tetanus toxoid is generally given as part of the government vaccination program and is not stored in facilities without a proper cold chain (below UHC level) therefore the low levels of availability is not surprising (7% baseline; 3% endline). Iron/folate tablets were available in 67% of facilities at baseline but had increased to 100% at endline. ITN’s are sometimes distributed by private/NGO programs in Durgapur, but IPT is not currently being used, even in high risk malaria areas. 3.2.5 Optional Indicator 2: Availability of Guidelines: None of the facilities had all of the guidelines for patient care at baseline or endline. At endline facilities had, on average, 21% of the seven guidelines listed, up from 7% at baseline. The most common guideline available at endline was for ANC (33%; 0% at baseline) followed by sick child care (30%; 23% at baseline), maternal post-partum care (27%; 0% at baseline) and neonatal care (23%; 7% at baseline). Only two facilities were able to show guidelines for delivery care (0 at baseline) and immunizations (3 at baseline). One SacMO stated that he received IMCI guidelines during training but they were at home, and he didn’t need to refer to them during patient consultations. In contrast, the nurse seeing under-five children at the Upazilla Health Complex in Durgapur had a copy of the guidelines on her table and referred to them regularly when prescribing treatment. 25 3.2.6 Optional Indicator 3: Infection Control: Overall availability of supplies for infection control was better at endline compared to baseline (see figure 5, below). More facilities had soap, sterile needles and syringes, sharps containers and gloves. Chlorine was less available at endline, with only 17% of facilities able to show they had supplies compared to 40% at baseline. Figure 5: Proportion of facilities with select infection control supplies and equipment: endline compared to baseline 3.3 Processes 3.3.1 Indicator 6: Information Systems 3.3.1.1 Information System- Child: Having all information elements is described as: 1. Up-to-date records of sick U5 children (age, diagnosis, treatment for all children seen); 2. Service report submitted in last three months; AND 3.) at least one evidence of data use. During the project period service delivery reporting was switched from manual counting and form fill-up to computerized reporting. Monthly reports are now required to be submitted by every facility. Evidence of data being used also increased at endline, especially in wall charts (from 7 to 23%) and in discussions (from 10 to 53%). 26 Figure 6: Proportion of HF with various elements of an Information System: endline vs. baseline 3.3.1.2 Information System- MNC: Complete MNC information was defined as; 1.) Having an ANC register with complete information (EDD, TT, BP); 2.) Last ANC register entry within 7 days AND 3.) A delivery register with last entry within 30 days. None of the facilities met the criteria for this indicator at baseline. When only the criteria for ANC information was included only three facilities (10%) met the criteria. At endline 7% of facilities me the entire MNC indicator criteria, 63% had complete information on BP and 73% had an ANC entry within the last seven days. 3.3.2 Indicator 7: Training 3.3.2.1 Training- Child Health: 37% of the health workers interviewed had had training in a child health topic in the last 12 months at baseline. Nine of the health workers (30%) had had recent training on immunization, two (7%) on nutrition and one each (3%) on malaria management, and IMCI. At endline 87% of health workers interviewed had had training on a child health topic in the last 12 months. 37% had had training on immunization, diarrhea case management and pneumonia case management. 27% had had training on malaria case management. 27 23% of those interviewed at endline had had IMCI training in the past 12 months compared to only 3% of those interviewed at baseline. Table 9: Percent of HW who had training on child health topics in the past 12 months: baseline and endline Training baseline endline Immunization 30 37 Pneumonia mgmt 0 37 Diarrhea mgmt 0 37 Malaria mgmt 3 27 ITN use 0 7 Nutrition 7 17 BF promotion 0 33 IMCI 3 23 3.3.2.2 Training- Maternal -Neonatal Care: Only 3 % of HW’s interviewed reported receiving in-service or pre-service training in maternal neonatal care in last 12 months at baseline. One person reported training in infection control. At endline, however, 37% reported recent training in neonatal care; 47% in post natal care; 40% ANC training; 20% in infection control; 7% in the active management of third stage of labor and 23% in OB/neonatal emergencies and referrals. 3.3.3 Indicator 8: Supervision Supervision of health workers is an area of concern in Bangladesh. This data bears out the low levels of supportive supervision received by health care workers at primary care centers. Only 7% of HW interviewed reported receiving external supervision which included more than just delivering supplies in the previous three months at baseline. 30% reported a supervisory visit to deliver supplies. One person (3%) reported a supervisor checking drug supplies, discussing problems, and providing feed-back. At endline 87% of health workers reported a supervisory visit from their supervisor: 37% for delivering supplies/ checking reports/ observing their work; 27% received feedback on their work during the visit; 7% received technical supervision/ updates/ discussed problems; and 17% had drug supplies checked. 28 3.3.4 Optional Indicator 4: HF Community Coordination: 73% of facilities had at least one method for community participation AND at least one way to incorporate information at baseline. This had increased to 90% at endline. The most common method of community participation was community participation in HF management committee meetings (70% baseline; 83% endline) followed by engagement of CHW’s/TTBA’s (57% baseline; 77% endline). The most common mechanism for incorporating the information was via community discussions (70% baseline; 90% endline) and by changing health worker behavior (60% baseline; 53% endline). 3.3.5 Optional Indicator 5: Community Referrals: At least one referral from a Community Health Worker in the last month was reported by 38% of facilities at baseline and 80% at endline. 3.3.6 Optional Indicator 8: Laboratory Facilities: As expected availability of all basic maternal-child laboratory services was only available at 3% of facilities at baseline and endline (private clinic). Only two of the facilities had laboratory facilities of any kind available on site, the private clinic and the UHC. Community clinics are not intended to do any laboratory exams onsite. At endline a greater proportion of the facilities had the ability to at least send out for testing of glucose (27%); urine dip stick (17%) and CBC (10%). On average 10% of the laboratory services listed were available at each of the facilities at endline. This would increase to over 30% if the community clinics were excluded from the calculation. 3.4 Performance 3.4.1 Indicator 9: Utilization of Services: As noted in the methodology section, using government estimates of catchment area for the various levels of health facility may overestimate the actual population served, and consequently underestimate service utilization. 3.4.1.1 Utilization of Child Curative Services: Out of 30 facilities in the sample, one was closed on the day of the survey and another 5 had no child visits in the last three months, or were unable to show a child health register at baseline. Only 7 out of the remaining 25 (7/30=23%) of health facilities met the standard of at least 1 sick child visit/under-five child in the catchment area in the previous year. Using the total number of under five children estimated from 29 the catchment figures as the denominator, this averaged to 0.26 sick child visit/under five child/year for all areas. If we use the number of under five children based on half of the population estimate as the denominator (to adjust for proportion of Health Facilities surveyed and take into account for possible overlapping of service areas), the average visit per under-five child is 0.52/ child/year. Overall, the annualized figure for child visits for all facilities surveyed was 15,248, or an average of 508 visit/ facility/ year. At endline all 30 facilities were open on the day they were surveyed and all had under-five child visits in the last three months, however four facilities did not have an under-five register available as it was locked in a cabinet (the person holding the key was absent or at a satellite clinic that day). Only 5/30 (17%) of individual facilities met the standard of at least 1 sick child visit/under-five child in the catchment area in the previous year. Using the total number of under five children estimated from the catchment figures as the denominator, this averaged to 0.27 sick child visit/under five child/year for all areas- surprisingly similar to the baseline results. If we use the number of under five children based on half of the population estimate as the denominator (to adjust for proportion of Health Facilities surveyed and take into account for possible overlapping of service areas), the average visit per under-five child is 0.54/ child/year. Overall, the annualized figure for child visits for all facilities surveyed was 18,188 (nearly 3000 more than baseline), or an average of 606 visit/ facility/ year (nearly 100 visits/facility/year more than baseline). 3.4.1.2 Utilization of ANC Services: In addition to the one facility that was closed on the day of the survey, another 25 were unable to show an antenatal register, or had no ANC visits in the last three months at baseline. Of the 4 facilities that were giving ANC, only 1, (1/30=3%) the private clinic, met the criteria for the indicator of at least 2 ANC visits/ antenatal woman/year. Using the adjusted population figures (1/2 of estimated deliveries using 2009 population estimate for the two Upazillas as 30 denominator) the overall ANC service utilization rate for the survey area was 0.2 visits/ antenatal woman/year. . Overall the annualized number of antenatal visits for the survey area for the two unions was 1,528 or 51 visits/facility/year. At endline the figures for ANC were much improved. While 6 of 30 facilities could not show an active ANC register, 5 of 30 (17%) met the criteria of at least 2 ANC visits/ antenatal woman/year. Using the adjusted population figures (estimated deliveries for ½ the population using 2014 population estimate for the two Upazillas as denominator) the overall ANC service utilization rate for the survey area was 1.3 visits/ antenatal woman/year, over 6 times the figure at the 2009 baseline. Overall the annualized number of antenatal visits for the survey area for the two unions was 7088, or 236visits/facility/year. 3.4.2 Indicator 10: Health Worker Performance: 3.4.2.1 Child Assessment: Strong emphasis is placed on systematic assessment of children in IMCI. The assessment methods used are not high-tech nor time consuming, but enable health workers to make accurate diagnosis of the primary illness a large proportion of the time, as well as assess overall health and well-being of the child. The health workers observed in the survey did not do well, overall, in regards to following assessment protocols. In only 2 facilities (7%) were all 5 assessment tasks done 80% or more of the time at baseline and endline. Looking at individual assessment tasks asking about breast feeding was most common, followed by asking about vomiting and checking on vaccinations. Completion of assessment tasks was much lower at endline compared to baseline (see figure 7, below) 31 Figure 7: Proportion of child assessment tasks completed by task. N=63 at baseline; N= 141 at endline 3.4.2.2 Child treatment: There were 8/17 (47%) facilities at baseline and 1630 (53%) at endline (where under-five children with one of the three targeted symptom groups were seen on the day of the survey) in which treatment was according to the protocol at least 80% of the time (see table 10, below). Looking at individuals, all treatment matched the protocol for 35 children (56%) at baseline and 78% at endline. When data from the registers for the last three months was analyzed, the proportion of facilities with correct treatment of 80% or more of children was 40% at baseline and 50% at endline. Looking at individual cases, the figure increased to 68% overall (78% at endline) of children being treated according to prototol. Table 10 Under-five assessment and treatment indicators: baseline and endline Under five assessment indicators baseline endline Indicator #10 % patients in a facility for whom all 5 assessment tasks were done at least 80% of time 7% 7% Indicator #11 % sick children in HF for whom all treatments were according to protocol at least 80% of time 43% 53% Alternative Indicator #11 Number of HF in which > 80% sick children treated by protocol 40% 60% Alternative Indicator #11 index value - % sick children treated by protocol (average per HF) 66% 78% For comparison to Indicator #12 % caretaker in a facility counseled about drugs by HW 47% 47% Indicator #12 % caretakers who can correctly state how to administer all prescribed drugs 32% 36% 32 3.4.2.3 v Exit interview of caretakers: 53 caretakers were interviewed at baseline and 141 at endline (see table 11, below). Of those interviewed only 32% at baseline and 36% at endline were able to correctly state how to take all medicines prescribed (medicine; amount per dose; times per day to be taken and how many days). IMCI guidelines were used as the standard for correct dosage, therefore this indicator is a measure of correct prescribing as well as correct explanation to and understanding by the caretaker. It is noted that a full course of medication is often not given by health care workers to ensure that drug supplies will last the month. Therefore if a caretaker was given 2 days of co-trimoxizole for ARI or bloody diarrhea (correct course, five days) and s/he stated 2 days was how long the medicine was to be given, it would be counted as incorrect. Table 11: Caretaker interview information Exit interview summary baseline endline Exit Interviews Number of caretakers interviewed 63 141 Number of ARI cases identified by caretaker 40 84 Number of malaria/fever cases identified by caretaker 29 40 Number of diarrhea cases identified by caretaker 19 37 Number of caretakers who did not know diagnosis 3 4 Number of cases for which at least one drug prescribed 45 140 3.5 Community Skilled Birth Attendants (CSBA’s) Community Skilled Birth Attendants were interviewed as the community health worker for the RHFA. As well as being available for home deliveries and Antenatal care, the CSBA’s provide a number of services for children (see Figure 8, below). All reported doing health education and referring sick children, 92% said they mobilized children for immunization (100% endline). Around 50% of CSBA’s reported treating diarrhea and pneumonia at baseline and over 90% said they treated diarrhea at endline. Growth monitoring was mentioned by less than 10% at baseline, increasing to 20% at endline. Following are the results from the CHW interviews which apply to the Core indicators, above. 33 Figure 8: Child Health Services Reported by CSBA’s, n=13 baseline; n=20 endline 3.5.1 Indicator 4: CHW Supplies- 23% of the CSBA’s interviewed at baseline and 0% of those interviewed at endline had adequate supplies, defined as both a CSBA manual and a functioning timer. Although 46% of CSBA’s at baseline reported that they treat pneumonia, only 31% of them had either a functioning timer or a watch with a second hand. Overall 62% were able to show their CSBA manual. 85% reported having a CSBA manual at endline, but none had a timer. 3.5.2 Indicator 5: CHW Drugs- Only 15% of the CSBA’s met the criteria for adequate drugs at baseline (ORS, Cotrimoxizole, anti-malarial), even though 54% reported treating under five children. None of the CSBA’s interviewed at endline had antimalarials, but 40% had cotrimoxizole and 20% had ORS in stock. This indicator was hard to assess as CSBA’s were sometimes interviewed at home and not at the community clinic where they work. 3.5.3 Indicator 6: Adequate Information System: None of the CSBA’s met the criteria for complete and up to date register at baseline. 31% of CSBA’s were able to show a child health register, but only 8% (2 CSBA’s) had registers with complete information on age, diagnosis and 34 treatment. At endline only 15% of CSBA’s were able to show their registers (most were interviewed at home), but all had complete information. 2/3 of the registers had entries within the last 7 days. 3.5.4 Indicator 6: Adequate Training: CSBA’s fared slightly better than other health workers assessed in terms of recent training. 46% had had at least one training in child health in the last year and 31% had had at least one training in maternal newborn care at baseline. At endline 50% of CSBA’s had at least one child health related training, but only 5% had at least one maternal health related training in the previous 12 months. 3.5.5 Indicator 8: Adequate Supervision- Although 85% of CSBA’s reported a visit by their supervisor in the last three months at baseline, only 23% (3 of 13) met the criteria for adequate supervision (a visit within 3 months that included more than just delivery of supplies). At endline 75% of CSBA’s reported a supervisory visit in the last three months, and 30% met the criteria for adequate supervision. Figure 9: Pre-service or In-Service Training Received by CSBA’s in the last 12 months 3.5.6 Indicator 11: Correct Treatment of Child Illness: Overall 53% of ARI and diarrhea cases treated by CSBA’s were according to the IMCI protocols at baseline. Looking at the indicator by health worker, however, only 15% (2) of CSBA’s treated over 80% of cases according to the 35 protocol. At endline assessment 43% of cases treated by the CSBA’s interviewed were according to IMCI protocol. This may give an unbalanced picture, however, as only CSBA’s who had their registers with them were included in this assessment. 4.0 Discussion: Results of the survey have been compiled onto graphs to give an ‘at a glance’ view of how facilities did overall in inputs, processes and provision of services. These are presented as Balanced Scorecards of Health Facility Child Health services, Health Facility Maternal Neonatal services and Community Health Worker services. Arrows have been added to draw attention to areas which are below 50% of the minimum standard. Red arrows indicate areas of specific concern- where standards are extremely low and/or improvement in standards could result in saving the lives of many mothers and children 4.1 Health Facility based Child Health Services: Baseline; The striking feature of this score card (see figure 10.1 below) is that only three out of 16 indicators met the targets set as minimum standards for primary care of children under five. The proportion of posted staff present on the day of the survey was reasonably high, and efforts of facility staff to engage with the community was also a strong point, It is encouraging that on average HF’s had 60% of essential information system elements in place, (including complete register data on under-fives, quarterly reports and use of reported data for dissemination), but this was still well below the standard of 80%. Endline; Although there is still room for improvement impressive strides have been made to improve child health services in the two target Upazillas. Child consultation supplies and drugs needed to treat IMCI illnesses increased over the 50% mark at endline. Treatment according to protocol is still under 50% so this is a crucial area for improvement. Part of the reason for the low score in this area is the practice at some facilities of giving only 2 or 3 days of medication per child so that monthly supplies do not run out before the end of the month. Another practice that may have affected treatment results is to use second line antibiotics in preference to first line antibiotics when they get close to their expiration date to avoid wastage. It is noted here that the national IMCI guidelines were updated in 2012 to include Amoxicillin as drug of choice for pneumonia, but there is still no procurement or supply in the public sector (14). The government medical assistants who took part in the survey confirmed that they have received no updates instructing them to change to amoxicillin, nor drug supplies in their facility (13). Although the government can be applauded for increasing the number of posts for clinical staff at community clinics, actual staffing levels were still low in practice. Utilization of clinics will continue to improve as people in the community are 36 confident that competent caregivers will be available at the clinics. In addition, one staff at a Upazilla Health and Family Welfare Center complained that with the current emphasis on Community Clinics, other health facilities are suffering for both staff and supplies. One reason for the low scores on patient assessment could be related to the fact that CHCP’s who see patients at Community Clinics only have a three day training. In addition, other staff who received IMCI training more than three years ago may have become complacent regarding asking all the assessment questions. The government of Bangladesh is already committed to rolling out IMCI across the country and much progress has been made. Further improvement of basic infrastructure (timers, scales and ORS cups and spoons), basic drugs (ORS, cotrimoxizole, antimalarials), and basic training (on the IMCI protocols), would go a long way to improving performance outcomes for treatment of childhood illness above the 80% benchmark. Figure 10.1: Balanced Score Card: Health Facility, Child Health- Baseline 37 Figure 10.2 Balanced Score Card: Health Facility, Child Health- Endline 4.2 Health Facility based Maternal Neonatal Services: Baseline; Apart from staffing and HF-Community coordination, mentioned above, only one MNC specific indicator, availability of ANC services, was met in over half of facilities. Although 60% of HF’s had ANC services available at least 4 days a month, the infrastructure, supplies, drugs, training and guidelines to support the service were sadly lacking at baseline (see figure 11.1, below). Providing basic ANC is neither expensive nor technologically intensive, but requires political will and good supervision, as well as provision of essential inputs. .One reason for the poor results in delivery and newborn care was that only the UHC and private clinic were set up to do deliveries Endline; Even though there were improvements in infrastructure, supplies and drugs for maternal and neonatal health- there is still much room for improvement. The increase in availability of ANC to over 90% was an important benchmark, but if essential supplies and drugs are missing there will be less impact from those visits on maternal and neonatal health. The upgrading of some FWC’s and Community Clinics to provide delivery care is a big step in the right direction to provide skilled 38 delivery care for more women in rural areas. The improvements in supervision of health care workers should also continue to bear fruit in improved patient care. Figure 11.1: Balanced Score Card: Health Facility, Maternal Newborn Health: baseline Figure 11.2 Balanced Score Card: Health Facility, Maternal Newborn Health: endline 39 4.3 Community Health Worker Health Services: Baseline; CHW’s / CSBA’s are the level of health worker surveyed which the CSP is most likely to engage with on a regular basis since they work at the household level in communities. At baseline CHW’s scored highest in the balanced scorecard on performance, with 53% of individuals cared for by CHW’s for diarrhea and ARI being treated according to protocol (see figure 12.1, below). Comparing this to treatment of the same conditions in health facilities (register data), the figures were 83% for ARI and 93% for diarrhea cases. Their poor performance compared to HF staff at baseline may due to relative inexperience in seeing patients, training received, or the particular sample of CHW’s who were interviewed. CHW’s also lacked supplies (the indicator only required a CHW manual and timer for counting respirations as ‘adequate supplies’), drugs, adherence to an information system and active supervision. The government has set up a system of supervision whereby FWV’s at the union level oversee the work of CSBA’s. This is complicated from the offset, since those trained as CSBA’s (HA’s and FWA’s) are hired by two different directorates in the health ministry (health and family planning). In addition, FWV’s have their own responsibilities as health workers in facilities as well as their supervisory role. One way of helping this situation might be to increase the role of the community committees associated with the community clinics and /or the peoples’ institution, in keeping both the CSBA’s and those who supervise them accountable to the needs of the community they serve. The fact that this is a new cadre of worker may have something to do with the relatively higher level of recent pre-service or in-service education. Never the less, levels of performance indicate additional training with follow-up clinical supervision is still needed. Endline; Improvements were seen in availability of supplies and drugs available to the CSBA’s, but numbers are still low. This may be partly explained by the fact that many of the CSBA’s were interviewed at home, and so these numbers may be artificially low. There was also some improvement in the quality of supervision given CSBA’s, but this is an area for ongoing input. It is concerning that the proportion of CSBA treatment that was according to protocol actually decreased. Again, this may be partially due to the fact that not all CSBA’s had access to their register at the time of interview. Also, since a new cadre of health worker, the Community Health Care Provider, has been introduced to provide under-five care at community clinics CSBA’s may be seeing less patients and losing their skills. 40 4.4 Additional Comments: Malaria; The indicators for malaria were removed from the balanced score card since the two upazillas surveyed are under different protocols. Durgapur Upazilla is a high risk area for malaria and Kendua is not. Even so, there seemed to be a lot of variance regarding how health workers in Durgapur managed cases of fever. According to IMCI protocol (and verified by GoB IMCI staff in the ministry of health) all children with fever should be considered cases of malaria and treated with the appropriate dose of chloroquine. Due to limited availability of malaria drugs in the government facilities and confusion regarding IMCI protocol, the MA staffing the IMCI corner at the UHC stated he only considers children with fever not associated with diarrhea or ARI to be a possible case of malaria. These children are sent for a malaria blood test, and only those who are positive are treated. The proportion of children with fever who are positive for malaria is very small. Not all health facilities have malaria testing, and hardly any have current stocks of chloroquine. In some centers, at baseline, an NGO was present during the clinic and provided malaria testing using a new quick test that doesn’t require a microscope. This was not observed at endline. Figure 12.1: Balanced Score Card, Community Health Worker; baseline 41 Figure 12.2: Balanced Score Card, Community Health Worker; endline 5.0 Conclusion: Significant improvements were seen between the baseline and endline assessments. The most striking were the increase in numbers of children being seen at both community clinics and upazilla health and family welfare centers- and the corresponding increase in the infrastructure and medicines to support those visits. The increase in ANC and delivery services also have the potential to improve health outcomes for women and their children. The increase in supervision of health care staff increases the potential for sustaining and increasing improvements in health care, as does improved relationships between facilities and the communities that they serve. The decrease in assessment of children according to IMCI guidelines is concerning. Increased patient load and inadequate staffing may be contributing to this finding as well as inadequate refresher training and supervision. The frequent prescribing of less than a full course of antibiotics for children is a concerning finding which needs to be addressed by the Government. If they are unable to maintain adequate drug supplies to meet the demand for child treatment then a decision has to be made whether it is better to provide a full course of treatment for less children or only partially treat all children. Neither is a satisfactory solution. 42 References 1. Rahman A, Miah H, Rahman F. Enabling individual, family and community to improve maternal and neonatal health in Netrakona district: baseline survey. Unpublished internal document: PARI Development Trust; 2009. 2. Tenbroek NL. Statement of Work, Rapid Health Facility Assessment, Bangladesh Child Survival Program II. Nov 2009. 3. Directorate General of Health Services. Upazila Health Complexes in Bangladesh (online) 2010, cited August, 2014 from 10 http://app.dghs.gov.bd/inst_info/other/uhc.php 4. Bangladesh to create new community clinics. (online). 2009 cited Dec. 3; [1]. Available from; VSO Today:http://www.vsointernational.org/news/19069959/bangladesh-to￾create-new-community-clinics 5. Ministry of Health and Family Welfare, Bangladesh. Revitilization of Community Health Care Initiatives in Bangladesh (Community Clinic Project); CHCP training. 2012. Accessed 7 August, 2014 from http://www.communityclinic.gov.bd/chcpTrain.php. 1 page 6. WHO. Bangladesh expands training of midwives to improve maternal and neonatal health http://www.who.int/features/2014/midwifes-bangladesh/en/. June 2014, 1 page. 7. Mridha MK, Anwar I, Koblinsy M. Public-sector Maternal Health Programmes and Services for Rural Bangladesh. J HEALTH POPUL NUTR 2009 Apr;27(2):124-138. 8. WHO-Bangladesh, Integrated Management of Childhood Illness (IMCI). 2010 cited 28 Feb; [3]. Available from; http://www.whoban.org/imci.html 9. Ricca J, Fapohunda B. Rapid Health Facility Assessment (R-HFA):What is it? Should I use it? 2009 PP presentation. Macro International, MEASURE Evaluation. 10. Bangladesh- Population Growth Rate. 2010 cited Feb 28, 2010; [2]. Available from; indexmundi.com http://www.indexmundi.com/g/g.aspx?c=bg&v=24 11. Bangladesh Bureau of Statistics. 2011 Population Census Report, 2012. Accessed 3 August, 2014 from 203.112.218.66/RptPopCen.aspx?page=%2fPageReportLists .aspx%3fPARENTKEY%3d41.  National Institute of Population Research and Training (NIPORT), Mitra and Associates, and Macro International. 2009. Bangladesh Demographic and Health Survey 2007. 43 Dhaka, Bangladesh and Calverton, Maryland, USA: National Institute of Population Research and Training, Mitra and Associates, and Macro International. 13. ICDDR, B. Improving Access To Diarrhoea And Pneumonia Treatment In Bangladesh, An Update. Accessed 9 August, 2014 from http://ccmcentral.com/wp-content/uploads/2014/05/Improving￾access-to-DP-treatment-Bangladesh_icddr-b-DP-Working￾Group_2014.pdf#?1#?1#WebrootPlugIn#?. 22 January 2014, p. 7. HF Child Health Balanced Score Card Area of Analysis Baseline Endline Service Availability--Child 7% 20% Staffing 83% 43; Infrastructure 22% 42% Supplies - Child 34% 66% Drugs - Child 39% 63% Availability of Guidelines 7% 21% Infection Control 36% 38% Information System - Child 60% 5/; Training - Child Health 37% 87% Supervision 7% 57% HF-Community Coordination 73% 90% Community Referral 37% 80% Laboratory 6% 10% Assessment 18% 02; Treatment 23% 53% Counseling 0% /; HF Maternal Newborn Health Balanced Score Card Area of Analysis Baseline Endline Service Availability - ANC 60% 90% Service Availability - Deliveries 3% 17% Staffing 83% 43; Infrastructure 22% 31; Supplies - Neonatal 9% 22% Supplies - ANC 9% 28% Drugs - Neonatal 17% 22% Drugs - ANC 19% 26% Availability of Guidelines 7% 21% Infection Control 36% 38% Information System - MNC 14% 38% Training - Maternal-Neonatal Care 3% 53% Supervision 7% 57% HF-Community Coordination 73% 90% Laboratory 15% 32% CHW Balanced Score Card Area of Analysis Baseline Endline Supplies 31% 43% Drugs 15% 22% Information System 23% 03; Training in Child Health 46% 50% Training in MNC 31% 4; Supervision 23% 30% PERF ORM ANCE CHW Performance (Treatment) 53% 32; * did not have health register for evidence bc interviewed at home PROCESSES INPUTS PROCESSES ACCESS INPUTS PROCESSES PERFORMAN CE ACCESS INPUTS 1-10% 11-20% 21%  0%  $ "" $" ) " $ ""   "" /; 0/; 1/; 2/; 3/; 4/; 5/; '!!# "'#  "% *#$ " "  '!"(#   " " #  /; 0/; 1/; 2/; 3/; 4/; 5/; 6/; 7/; 8/; 0//; "(($*,  "(($*, $ "#$"'$'" '!!#,  $ '!!#,  "'#,  $ "'#,  ($* '# %  $"   "% *#$, ", $", '!"(#  , '$*  "$ "* #  /; 0/; 1/; 2/; 3/; 4/; 5/; 6/; 7/; 8/; 0//; $ "#$"'$'" '!!#, "'#, ($*  %  $"   "% *#$, ", $ '!"(#  , '$*  '$*""  "$ "* ####$ "$$  '# #  no Component CSSA April,14 CSSA October,13 CSSA April,13 CSSA October,12 CSSA April,12 CSSA October,11 BaselineIndices 1 Health Outcome 95 95 95 60 60 50 50 2 Health Services 75 72 69 64 61 38 33 5 Community Capacity 64 53 46 40 37 16 13 6 Ecological, human, economic,political and policy environment 77 69 59 55 49 21 2 3 Organizational Capacity 70 54 50 48 42 17 15 4 Organizational Viability 69 64 60 58 52 33 8 Dimension Indices (average) 1 Health & Health Services 62 2 Local Organization 53 3 Community & Environment 48 0- /- ., // /( .0                                                               !  !  $ $$  !    "    !  "    !       !% &   $),   $)+  $)+   $)*  $)*   $))  Component 1: Health Outcomes % of Target % Achievement as of April, 2014        5- "$&")%$)# 8% 31.1% 4 6- "$&"#%$)  "# 15% 21.15% 586 7- "$$"#"%*'$ 85% 92.5% 54< 8- "$$"#"'$#$'"## ")- 70% 81.3% 55: 9- "$ "$$"#'"&8$# &#$%" ") 15% 23.1% 59: :- "$'"'#$"%#'$5%"- 70% 77.8% 555 ;- $"#'$#$6 $#$"&")- 80% 77.7% =; <- $"#&'$#$6"##$- 80% 88.1% 554 =- "$$"#.$#'"&&#$#'$86)#$"&")- 40% 23.1% 9< 54- "$$''$"$'$- 100% 68.0% 94 Component 2: Health Services Target % Achievement as of April, 2014        5- "$$%""##$"'"## 100% 80% <4 6- &#$544%# "$ 100% 40% 84 7- &#$$$"#$#$6$# "$ 100% 93% =6 8- &#$59#$) 100% 100% 544 9- &#$59#$) 100% 100% 544 :- "$$"#&#$)# "$#$:$#- 100% 100% 544 ;- $'$.#$:$ 100% 53% 96 <- "$$"#""#$.#$:$- 100% 38% 7; Component 3: Organizational Capacity Target % Achievement as of April, 2014        5- # #'"'"%")"&'###") 100% 61% :5 6- #"#$"$ 100% 100% 544 7-)$"%")0$)1 100% 79% ;= 8-""!% "$%$#""#$"  100% 68% 64 9-"#"$$'" "$ $")'$$""*$ 100% 78% ;; :- #&#")&") #9"# 100% 72% ;6 ;- #%"# #'# $) 100% 78% ;; <- #$"# ")%$#)#$ 100% 83% <6  %"&& %#$$)####$0 1  =- " "#$$&#&#$$%$$ "")"% #!%"$") 100% 59% 9= Component 4: Organization Viability Target % Achievement as of April, 2014        5- (%$&$$#''"$ #$) "$$$- 100% 63% :7 6-  $%$)#$ "" 100% 78% ;< 7- #$" """"% "#$ 100% 58% 9< 8- #''%$ .  $#"&# 100% 79% ;= 9-"#"%$$)"%"$"#)#$ 100% 64% :8 Component 5: Community Capacity Target % Achievement as of April, 2014        5-"#$"% #"#&#)$#&# 100% 79% ;< 6-"% #'"# $ $$#$) 100% 73% ;7 7-"% #&$"')/'#'$)' 100% 63% :7 8-)&#"##"# ))"$"% "$ $") "##- 100% 53% 96 9-"% #"# " ")'"$$ ###%"#$%$$""  100% 54% 98 Component 6:Ecological, human, economic,political and policy environment Target % Achievement as of April, 2014        5-%$)  &$"#$" 100% 76% ;9 6-%$)  &&$"%%$)# 100% 100% 544 7-##$&#% ## 100% 70% := 8-%$)  '"&"$#$)") 100% 56% 9: 9- "#$$$'$$ "###$:$- 100% 85% <8 $,$$#"%#$#""&")$""$$"$&$-$$$$$#"#$ "#$-  $"#&$#""$$"$++ "$&"#%$)  "#-"$$"$#59@ &$#65-59@-$$#')$##"#586- Achieving Universal Coverage of Maternal, Newborn and Child Health through Building Public-private Partnerships in a High-mortality District: Findings from a Baseline Survey in Netrokona, Bangladesh Dewan Md. Emdadul Hoque Shumona Sharmin Salam Muntasirur Rahman Nancy Tenbroek Helen Rema Rezaul Karim Michael Savic Alan Theodore Talens Shams El Arifeen Background • Bangladesh has experienced significant progress in reducing maternal, child and infant mortality • Deaths during the neonatal period are high and contribute to 57 percent of child deaths (BDHS 2007) • Interventions to reduce maternal, child and neonatal deaths exist but the impact of these are limited by poor coverage and quality. • Improving maternal, newborn and child health requires a continuum of care addressing both women and children Background Christian Reformed World Relief Committee (CRWRC) ƒ SUSOMA - 5 year child survival project from 2009 • Innovative “People’s Institution” model • Independent, self-sustaining Community based organization • Sustainable public-private partnerships ƒ Durgapur and Kendua upazila of Netrokona district Objective Explore the baseline coverage of selected maternal, newborn and child-health indicators in the study area to help plan implementation of interventions Methods Study area: • Intervention – Durgapur, Kendua • Comparison - Barhatta, Kalmakanda Study design: • Quasi-experimental • 20 clusters from each areas Study population: Women (15-49 years) with a birth outcome in 2 years preceding the survey Sample size: 2,499 women from each areas (95% CI, 80% power, design effect 1.5) Survey period: February to April 2010 Findings on key coverage indicators Household and respondent characteristics Intervention (n= 2,038) % Comparison (n=2,041) % Mean size of households 5.4 5.6 Electricity available 21 20 Improved source of drinking water 99 97 Improved toilet facility* 73 62 Wealth quintile Poorest* Richest 17 22 24 18 Women with no education* 33 45 *p<0.000 Antenatal care a Qualified doctor, nurse/midwife, paramedic, family welfare visitor, community skilled birth attendant *Source: Bangladesh maternal mortality and health care survey 2010 30 43 21 26 24 27 56 5 8 3 6 4 7 26 Intervention Durgapur Kendua Comparison Barhatta Kalmakanda National* Any ANC from medically trained provider 4 + ANC from medically trained provider Percent distribution of women who had a live/still birth in 2 years preceding the survey by area and upazila and received any and 4+ ANC from medically trained providersa Antenatal care 15 14 59 68 Intervention Comparison No education Secondary+ 22 16 44 50 Intervention Comparison Poorest Quintile Richest Quintile Richest 2 times higher use than the poorest Richest 3 times higher use than the poorest 4 times higher for women with 10+ education 5 times higher for women with 10+ education Percent distribution of any ANC from medically trained providersa, by women education and wealth quintile a Qualified doctor, nurse/midwife, paramedic, family welfare visitor, community skilled birth attendant TT immunization Percentage distribution of women aged 15-49 who had a live/still birth in 2 years preceding the survey received at least two Tetanus Toxoid (TT) injections in their life time. 88 94 83 84 87 82 Intervention Durgapur Kendua Comparison Barhatta Kalmakanda Iron folic acid Percentage distribution of women aged 15-49 who had a live/still birth in 2 years preceding the survey who consumed Iron folic acid during last pregnancy by area and upazila 43 52 37 38 38 37 18 24 14 15 18 13 Intervention Durgapur Kendua Comparison Barhatta Kalmakanda Consumed Iron-folic acid tablet Consumed Iron-folic acid for 3 or more months Delivery care Percent distribution of deliveries conducted by skilled attendantsa for birth outcomes (live /still) among women aged 15-49 who had a live birth or still birth in 2 years preceding the survey by area and upazila 9 9 10 12 13 12 27 Intervention Durgapur Kendua Comparison Barhatta Kalmakanda National* a Qualified doctor, nurse/midwife, paramedic, family welfare visitor, community skilled birth attendant *Source: Bangladesh maternal mortality and health care survey 2010 6 4 7 6 6 5 10 2 4 1 3 4 2 13 Intervention Durgapur Kendua Comparison Barhatta Kalmakanda National Public Private/NGO 8 8 9 10 7 23 Among women aged 15-49 who had a live birth or still birth in 2 years preceding the survey, percent distribution of facility (public and private/NGO) based deliveries by area and upazila Delivery care 8 *Source: Bangladesh maternal mortality and health care survey 2010 Delivery care Percentage of women age 15-49 delivered by skilled attendants in the 2 years preceding the survey by women education and wealth quintile 3 5 34 44 Intervention Comparison No education Secondary+ 9 times higher for women with 10+ education 2 4 20 30 Intervention Comparison Poorest Quintile Richest Quintile Richest 9 times higher use than the poorest Richest 7 times higher use than the poorest 10 times higher for women with 10+ education Postnatal care for mother a Qualified doctor, nurse/midwife, paramedic, family welfare visitor, community skilled birth attendant *Source: Bangladesh maternal mortality and health care survey 2010 12 14 10 13 11 14 32 8 8 8 10 10 9 23 Intervention Durgapur Kendua Comparison Barhatta Kalmakanda National* Any provider Medically trained provider Among women aged 15-49 who had a live/still birth in 2 years preceding the survey, percent distribution of women who received PNC within 2 days of delivery from any provider and medically trained providera, by area, upazila Maternal complications 22 11 9 32 28 14 9 37 Pregnancy Delivery Post delivery At any time in the pregnancy period Intervention Comparison Percentage of women age 15-49 who reported any complication during pregnancy, during delivery and after delivery for all live or still births in the two years preceding the survey Care-seeking for reported complications among women who had a complication for all birth (live/still) in the 2 years preceding the survey Maternal complications Care-seeking for maternal complications Antenatal period (n=533) % During delivery (n=269) % After delivery (n=195) % Did not seek care 47 39 31 Sought care from medically trained providera 25 34 30 Sought care from other unqualified provider 26 26 36 a Qualified doctor, nurse/midwife, paramedic, family welfare visitor, community skilled birth attendant, MA/SACMO 22 17 52 67 Intervention Comparison No education Secondary+ 2 times higher for women with 10+ education 14 17 42 45 Intervention Comparison Poorest Quintile Richest Quintile Richest 3 times higher use than the poorest Maternal complications Care-seeking from medically trained providersa for reported complications by education and wealth quintile 4 times higher for women with 10+ education Richest 3 times higher use than the poorest a Qualified doctor, nurse/midwife, paramedic, family welfare visitor, community skilled birth attendant, MA/SACMO Essential newborn care Intervention % (n) Comparison % (n) Immediate drying* (home delivery) 10 (964) 21 (950) Immediate wrapping * (home delivery) 10 (964) 20 (950) Thermal care* (Immediate drying and wrapping) (home delivery) 9 (964) 19 (950) Delayed bathing* (> 3 days) 9 (1,043) 18 (1,035) Initiated breastfeeding within 1 hour of birth 53 (1,816) 53 (1,784) Percent distribution of essential newborn cares in children aged 0-23 months by study area *p<0.000 Nutrition Nutritional status of children age 0-23 weight for age by study area Number of children <-2z weight for age % <-3z weight for age % Mean Z￾score (SD) Intervention 1,816 33 11 -1.5 Comparison 1,779 36 12 -1.6 National* 5,312 41 12 -1.7 *Source: BDHS 2007 Nutrition 47 87 49 84 43 74 Exclusive breastfeeding among children 0-5 month age Complementary feeding among children 6-9 month age Intervention Comparison National* Levels of key feeding indicators among children in intervention and comparison areas *Source: BDHS 2007 0 20 40 60 80 100 1 2 3 4 5 6 7 8 9 10 11 12 Exclusive BF Complementary feeding Percentage of infants exclusively breastfed and percentage receiving complementary feeding (based on last 24 hrs feeding) by age of the child Nutrition Child immunization 95 91 91 95 84 86 97 91 83 DPT1/Penta1 DPT3/Penta3 Measles Intervention Comparison National* Percent distribution of children age 12-23 months who received specific vaccines at any time before the survey (according to vaccination card or mothers‘ report) by area *Source: BDHS 2007 Child morbidity Intervention % (n) Comparison % (n) National* % Suspected pneumonia in last 2 weeks* 7 (1,816) 10 (1,784) 5 Care sought from medically trained providera for suspected pneumonia 22 (130) 19 (173) 37 Diarrhoea in last 2 weeks 6 (1,816) 8 (1,784) 10 Use of ORT for diarrhoeab 74 (114) 50 (135) 81 Prevalence of two weeks morbidity of under 2 children and care -seeking by study area a Qualified doctor, nurse/midwife, paramedic, family welfare visitor, MA/SACMO *Source: BDHS 2007 bP<0.005 Conclusion • Higher than national coverage was found for exclusive breastfeeding, early initiation of breastfeeding, measles immunization • Lower coverage was found for maternal indicators such as antenatal care, delivery, postnatal care and child health. • We observed strong socio-economic inequities by education and wealth for most health interventions. Recommendation • Learning from the interventions that have reached a high coverage in such high mortality areas, e.g. immunization and childhood feeding, will be important to improve the coverage of other interventions. • The programme should focus on ensuring availability of services at facilities and that referral links work. • Focus is needed on increasing community awareness, and motivation for care-seeking • The programme should invest in increasing the understanding and capacity of community leadership in leading the community to better health and holding the health workers and health system accountable. Limitations • Purposive selection of intervention and comparison areas • Recall bias • Information on contextual factors such as road network, functionality of health systems etc. that may have effect on the indicators have not been taken into account Thank you Addressing Health Inequity in Bangladesh through Community Mobilization and Governance: A Child Survival Program Operations Research (OR). Alan Talens1 , Nancy TenBroek2 , and Florence Nyangara3 Background: Netrokona district is populated by marginalized tribal groups with unmet health needs. For greatest impact effective interventions has to reach the poor communities. Methods: The project’s4 delivery strategy is community mobilization and governance using the Peoples Institution (PI) model. The primary groups elect representatives to the PIs which become self-governing bodies and serve as linkage to government health system. The PIs create the community- based healthcare, providing services to the unreachable groups. The OR will analyze the strategy’s effectiveness in inequity-reduction and the factors influencing coverage. A quasi-experimental design is used to compare intervention and comparison groups, each stratified into 5 wealth quintiles. To show that interventions are reaching the poor, final evaluation should demonstrate health-outcome improvements in lowest quintile in intervention group. Results: Antenatal visit coverage in the lowest quintile (LQ) is 1.9% and in the highest quintile (HQ) 13.3%. In the LQ only 4% of deliveries are by skilled birth-attendants and in the HQ, 25%; In LQ, only 8% of mothers received iron –folic acid for 3+ months and in the highest quintile 31.8%. In LQ immunizations are relatively lower: DPT1 -87.5%, DPT3-80.8%, measles￾83.3% while in HQ it is 94.3% DPT1, 89.7% DPT2, and 93.7% measles. In LQ 7.7% of children 0-23 had diarrhea in the last 2 weeks while in HQ only 6.7 %, and in LQ 50% received ORS vs. in the HQ, 55%. Amongst those with pneumonia, in the LQ 10% sought care from medically trained providers compared to those in HQ, 23%. Conclusion: There are inequities in coverage of most interventions by wealth ranking in Netrokona, Bangladesh. Baseline KPC showed that more has to be done to improve coverage levels of child health interventions among the poor. The PI using community participation, representation and governance to create community-based healthcare and universal coverage could be a feasible equalization model in reducing inequities and improving health in underserved communities. Presentation Preference: Oral Grouping of Abstract: Innovations and interventions to advance global health equity Name of corresponding author: Alan Talens (atalens@crwrc.org)   Christian Reformed World Relief Committee (CRWRC) - 2850 Kalamazoo Avenue, Grand Rapids, Michigan  Christian Reformed World Relief Committee (CRWRC) - 49560 Lane 3 Road 266 Baridhara DOHS Dhaka, Bangladesh  Maternal and Child Health Integration Program (MCHIP)-1776 Massachusetts Avenue, NW Suite 300, Washington, DC 20036           R E S EARCH AR TIC L E Open Access Husbands’ involvement in delivery care utilization in rural Bangladesh: A qualitative study William T Story1*, Sarah A Burgard2† , Jody R Lori3† , Fahmida Taleb4† , Nabeel Ashraf Ali4† and DM Emdadul Hoque4† Abstract Background: A primary cause of high maternal mortality in Bangladesh is lack of access to professional delivery care. Examining the role of the family, particularly the husband, during pregnancy and childbirth is important to understanding women’s access to and utilization of professional maternal health services that can prevent maternal mortality. This qualitative study examines husbands’ involvement during childbirth and professional delivery care utilization in a rural sub-district of Netrokona district, Bangladesh. Methods: Using purposive sampling, ten households utilizing a skilled attendant during the birth of the youngest child were selected and matched with ten households utilizing an untrained traditional birth attendant, or dhatri. Households were selected based on a set of inclusion criteria, such as approximate household income, ethnicity, and distance to the nearest hospital. Twenty semi-structured interviews were conducted in Bangla with husbands in these households in June 2010. Interviews were transcribed, translated into English, and analyzed using NVivo 9.0. Results: By purposefully selecting households that differed on the type of provider utilized during delivery, common themes–high costs, poor transportation, and long distances to health facilities–were eliminated as sufficient barriers to the utilization of professional delivery care. Divergent themes, namely husbands’ social support and perceived social norms, were identified as underlying factors associated with delivery care utilization. We found that husbands whose wives utilized professional delivery care provided emotional, instrumental and informational support to their wives during delivery and believed that medical intervention was necessary. By contrast, husbands whose wives utilized an untrained dhatri at home were uninvolved during delivery and believed childbirth should take place at home according to local traditions. Conclusions: This study provides novel evidence about male involvement during childbirth in rural Bangladesh. These findings have important implications for program planners, who should pursue culturally sensitive ways to involve husbands in maternal health interventions and assess the effectiveness of education strategies targeted at husbands. Background In Bangladesh, rates of maternal mortality–the death of women during pregnancy, childbirth, or in the 42 days after delivery–are on the decline, but remain very high (194 maternal deaths per 100,000 live births) [1]. The majority of maternal deaths and disabilities occur suddenly and unpredictably between the third trimester and the first week after the end of pregnancy due to hemorrhage, sepsis, and obstructed or prolonged labor [2]. The fact that most deaths occur during childbirth or are the result of an event during childbirth emphasizes the need for every woman to have access to skilled health profes￾sionals–such as a doctor, a nurse or a midwife–and ade￾quate health facilities [2]. However, only 27% of all births in Bangladesh are assisted by skilled professionals and only 23% of births take place in a health facility [1]. Women and their families face socioeconomic and cul￾tural barriers to seeking professional delivery care, such as high costs, long distances to health facilities, lack of knowledge about danger signs during pregnancy, and a tradition of using untrained local practitioners during * Correspondence: wstory@umich.edu † Contributed equally 1 Department of Health Management and Policy, University of Michigan, 48109-2029 Ann Arbor, MI, USA Full list of author information is available at the end of the article Story et al. BMC Pregnancy and Childbirth 2012, 12:28 http://www.biomedcentral.com/1471-2393/12/28 © 2012 Story et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. delivery [3]. Two important determinants of care-seeking behavior particularly important in rural Bangladesh are social norms and family dynamics. Cultural norms and beliefs have been shown to delay and sometimes stop women from seeking professional care during childbirth [4]. Some women in Bangladesh do not believe profes￾sional medical workers are the best option to manage delivery-related complications [5]. This may be related to the concepts of purity and shame, which keep them away from hospitals and male doctors. Notions of purity are often juxtaposed with pollution in South Asian societies. In the north Indian context, the afterbirth is perceived to be the most severe pollution of all, even worse than defe￾cation or death. There is a similar understanding of child￾birth in Bangladesh, such that the person attending the birth must undergo purification after delivering the baby [6]. The mother and newborn are perceived to be in a state of ritual impurity immediately after the birth. In order to prevent other household members from becom￾ing polluted, the birthing woman is confined to a separate room designated for childbirth for seven to nine days fol￾lowing the delivery [7]. Because of the shame and impurity associated with childbirth, women prefer not be in a public space during delivery. Another possible barrier to profes￾sional delivery care is the institution of parda (or purdah) in Muslim culture, which makes a strict separation between men and women and often limits female mobility. Since most doctors in Bangladesh are male, women do not want them to be present during delivery [6]. Family dynamics present another barrier to delivery care in rural Bangladesh. Many individuals in a woman’s social network play a role in decisions about reproductive health care utilization, especially when acute problems arise [4,5,8]. Parkhurst and colleagues [5] describe deci￾sions about professional delivery care being made at a crisis point, when a woman’s home labor is perceived to be progressing poorly. Close family members in the household, including mothers-in-law and other female in-laws, often give opinions on how to proceed. The same pattern of behavior during pregnancy and child￾birth is also found in Nepal, where older women have decision-making authority, especially the mother-in-law [9]. However, the husband is also a possible family mem￾ber who may influence the decision to seek professional delivery care. It has been suggested that better spousal communication may improve women’s maternal health care-seeking behaviors [9,10]. Therefore, husbands’ atti￾tudes and beliefs can play a key role in overcoming access barriers to maternal health care in Bangladesh, or conver￾sely, act as barriers themselves [11]. The husband’s role during pregnancy and childbirth The influence of men in decision-making has been seen in studies of family planning, sexually transmitted infections and HIV, abortion, and infertility. However, there is a relative scarcity of information on men’s intentions and practices as they relate to pregnancy and childbirth, especially in South Asia [12]. Some have sug￾gested that male partners act as obstacles when it comes to safe delivery care [13]. However, male involvement during pregnancy and childbirth can lead to positive birth outcomes for the mother and child as well as a healthier marital relationship. A husband’s positive involvement can take many forms, including transport￾ing his wife to a qualified provider, providing household money to make that visit, giving helpful informational support during pregnancy, and offering emotional sup￾port during labor and childbirth [14]. In South Asia, it has been suggested that women who receive their husbands’ approval [15] and women whose husbands are concerned about pregnancy complications [8,16] are more likely to use reproductive health ser￾vices. However, men are not always encouraged to be involved during pregnancy and childbirth in the South Asian context. For example, men in Nepal are typically discouraged from involvement with pregnancy and childbirth [17,18]. Mullany [18] found that some hus￾bands were interested in supporting pregnancy health, but their lack of knowledge about maternal health posed a significant obstacle to becoming positively involved. Other barriers to the husband’s involvement included embarrassment in learning about pregnancy health, work obligations, hospital’s restrictions on the husband’s entrance into most areas of the hospital, and communi￾cation barriers between husbands and wives [18]. It has also been reported that there is a significantly higher probability of male involvement in pregnancy health when men and women made household decisions together [19]. In India, men are traditionally the gate￾keepers to health care; however, they know little about pregnancy and childbirth [20]. Chattopadhyay [20] found that men’s knowledge about reproductive health and their presence during antenatal care visits were associated with the use of professional delivery care. The studies from Nepal and India suggest that male involvement during pregnancy and childbirth is an important aspect to maternal health care utilization. In Bangladesh, men often make decisions about women’s health care because women are structurally and culturally dependent on men due to their limited mobi￾lity and limited educational and economic opportunities [6,11]. This means that even though men may be dis￾couraged from being involved in matters of pregnancy and childbirth, as is the case in the region, their beliefs and perceptions might influence where and how their wives give birth. This study was designed to provide novel evidence about male involvement during childbirth in rural Bangladesh. Story et al. BMC Pregnancy and Childbirth 2012, 12:28 http://www.biomedcentral.com/1471-2393/12/28 Page 2 of 12 Study aims This study contributes to the literature on childbirth by examining the husband’s role during childbirth from the male perspective. Specifically, this paper aims to (1) bet￾ter understand the common barriers to delivery care, (2) explore the underlying social factors associated with delivery care utilization, and (3) examine how husbands’ involvement during pregnancy and childbirth is asso￾ciated with the use of professional delivery services. Methods Setting A rural sub-district–Durgapur–in the Netrokona district of Bangladesh was selected for this study based on the population’s vulnerability to poor health outcomes. Dur￾gapur is a flood-prone area with a population of 198,326 [21]. Durgapur has high rates of poverty, low levels of lit￾eracy, poor infrastructure, and limited access to health facilities (approximately one first-level facility per 21,000 people). Durgapur is close to the border with India and has a large number of ethnic families–including Garo, Koch and Hajong–who are often overlooked when healthcare resources are distributed. Sample selection The sampling frame included 10 villages in Durgapur that were selected based on three criteria: (1) the village provided some ethnic diversity to the sample, (2) the vil￾lage was outside of a five kilometer radius of the nearest health facility, and (3) the village was relatively easy to access given the weather and road conditions. Each vil￾lage had an approximate population of 1,000. From these 10 villages, 24 households were selected for inclusion in the study using non-proportional quota sampling. First, a total of 12 households that utilized a skilled birth atten￾dant during the birth of the youngest child were selected. This sample was further divided based on the type of skilled birth attendant utilized during childbirth. Skilled birth attendants are typically defined as an accredited health professional, such as a doctor, nurse, or midwife [22]; however, it is extremely difficult to travel to the hos￾pital to find a skilled birth attendant in most rural areas in Bangladesh. Therefore, another type of skilled birth attendant, known as a community-based skilled birth attendant (CSBA), is often used for home deliveries. A CSBA is community-based female fieldworker who has received six months of training in midwifery skills and the identification of maternal danger signs for referral [23]. Our sample included six households that used a doctor, nurse or midwife at a hospital and six households that used a CSBA at home. Each of these 12 households was matched with a household that utilized an untrained dhatri (a common term for a traditional birth attendant) during the birth of the youngest child. A dhatri is usually an older, non-literate woman who has learned her skills through more experienced dhatris [24]. The dhatris used by study subjects had received no formal training on childbirth practices. Households were selected based on a set of inclusion criteria, including age of the youngest child (less than one year), age of the mother (18 to 49 years), approximate household income (less than 3,200 Taka [39 USD] per month), and distance to the nearest health facility with at least one doctor, nurse, or midwife on staff (between five to ten kilometers). The sample was selected by first identifying six women who delivered at one of three local health facilities in Durgapur–two private and one public–using a hospital registry. Next, six women who delivered at home with the help of a CSBA were identified by contacting the CSBAs who worked in the 10 villages in our sampling frame. The interview team visited the household of each woman to determine whether or not she and her hus￾band met the inclusion criteria for the study before start￾ing the interview. Once households utilizing a skilled birth attendant were identified, the interview team went house-to-house to select a household from the same vil￾lage that met the inclusion criteria, but had used a dhatri. Due to misidentification of two birth attendants, two pairs of households were dropped from the final analysis. The final sample is depicted in Table 1. Data collection Semi-structured interviews were conducted with both hus￾bands and wives over two weeks in June 2010. Four inter￾viewers (two women and two men) with a background in anthropology and experience in qualitative interviewing were recruited for data collection. All interviewers received two days of training on all of the documents for the inter￾views (oral script, pre-screening questions, consent form, code sheet, and the questionnaires). All research materials were translated into Bangla. Upon arrival in the field, a pilot test was conducted with two couples (two husbands and two wives) and necessary changes were made. Table 1 Matched Sample (n = 20) Skilled Birth Attendant (n) Untrained Dhatri (n) Location of delivery Hospital (6) Home (6) Home (4) Home (4) Story et al. BMC Pregnancy and Childbirth 2012, 12:28 http://www.biomedcentral.com/1471-2393/12/28 Page 3 of 12 This paper focuses on the data collected from the interviews with the husbands. Each husband-interview consisted of a ten-question household demographic survey and a 14-question semi-structured interview. All interviews were conducted in Bangla and took place in the couple’s home away from family members and other distractions. Interviewers were gender matched with respondents. The husband was interviewed at the same time as his wife, but they were interviewed sepa￾rately and could not hear or see one another. Inter￾views with husbands lasted between 40 and 90 minutes (53 minutes on average). The interviewer received writ￾ten consent to interview and tape record each respon￾dent. The Principle Investigator (PI) was present during half of the interviews with the husbands and supplemented the interviews with field notes describing methodological, theoretical and personal observations during the data collection period. This study was approved by the University of Michigan Internal Review Board (HUM00038924) and the International Center for Diarrheal Disease Research, Bangladesh (ICDDR, B) Ethics Review Board. Data analysis Respondents were de-identified using a numerical code. Interviews were transcribed, translated into English, and analyzed using NVivo 9.0. A combination of open and axial coding was used to identify the properties and dimensions of each major category, or theme [25]. When possible, in vivo codes–words which were used by respondents–were used for coding purposes. In vivo codes are an important part of sociological research because they pinpoint the meaning of certain ideas or experiences from the respondent’s perspective [26]. Intercoder reliability was used to evaluate the validity of the coding categories: two investigators (one Bangladeshi and one American) used the code categories developed by the PI to independently code sections from eight interviews. The average percent agreement among the three coders was 79%. Results The demographic, socioeconomic, and geographic char￾acteristics of the ten husbands whose youngest child was delivered by a skilled birth attendant (doctor, nurse, midwife, or CSBA) were compared to the characteristics of the ten husbands whose youngest child was delivered by an untrained dhatri (Table 2). Due to the small sam￾ple size, tests for statistical significance across the groups are not very informative, so they are not pre￾sented. We display the raw count data and make general observations about differences across the two groups. A larger proportion of households using a skilled birth attendant had only one child and these households appeared to have a higher monthly income per family member compared to households that used an untrained dhatri. The higher monthly income per family member may simply be a reflection of the smaller family size among households using a skilled birth attendant. Each husband’s interview was coded in two ways: (1) themes that were similar across all respondents, or com￾mon themes, and (2) themes that differed according to the type of provider utilized during childbirth, or diver￾gent themes. We first present three common themes, or barriers, related to delivery care before presenting the underlying, divergent factors related to delivery care, including husbands’ provision of social support and per￾ception of social norms related to childbirth. Common themes The interviews with husbands revealed a number of common themes related to the decision about whether or not to seek professional delivery care. Each theme was found in each of the interviews, irrespective of the type of provider. Poor transportation Each household in the sample was at least five kilo￾meters away from the nearest health facility equipped to perform deliveries. The condition of roads and availabil￾ity and cost of local transportation were mentioned as barriers to hospital-based deliveries. There are only 18 kilometers of pucca roads (good quality, black-topped roads) in all of Durgapur. The remaining roads are dirt, which turn into mud during the rainy season. Nine hus￾bands mentioned the condition of the roads as a major barrier to using health facilities. Everything depends on transportation. People don’t go [to the hospital] very often since they need to hire three to four boats [to cross the rivers]. Also, the con￾dition of the road is very poor. If the pregnant woman travels by rickshaw or motorcycle or push car, then she may get hurt and face more problems.- 26-year old husband, CSBA home delivery Local transportation is often perceived as too expen￾sive and hard to find. Types of transportation available in Durgapur include (from most to least expensive) the tempo (a small three-wheeled motorized vehicle), motor￾cycle, boat, rickshaw, push cart, and walking. Many families need to use more than one form of transporta￾tion when traveling to the hospital, especially during the rainy season. Lack of money Another major barrier to utilizing professional health services are direct costs–such as the cost of Story et al. BMC Pregnancy and Childbirth 2012, 12:28 http://www.biomedcentral.com/1471-2393/12/28 Page 4 of 12 transportation, medicine, and hospital fees–and indirect costs–such as opportunity costs related to leaving household responsibilities and taking time away from work. The costs associated with the utilization of profes￾sional delivery care are often equated to the cost of sell￾ing one’s land or forfeiting one’s livelihood. It’s a money matter. [People in our village] can’t go [to the hospital] due to the scarcity of money. So if we can solve it in the village, if Allah wants it like this, we don’t need to go. So we delay the matter and observe the [birthing] situation. Then, if the problem is serious, we go to the clinic. But it’s almost like Table 2 Sociodemographic characteristics of men interviewed (n = 20) Characteristic Skilled Birth Attendant (n) Untrained Dhatri (n) Age of respondent (years) 20-29 5 4 30-39 5 3 40 + 0 3 Age of youngest child (months) <1 1 0 1-5 8 6 6+ 1 4 Number of children 15 0 >1 5 10 Child deaths None 7 6 1-2 3 4 Education None 2 5 Class 1-4 5 2 Class 5-9 3 3 Occupation Agricultural laborer 7 6 Other 3 4 Ethnicity Bengali 8 8 Garo 1 1 Hajong 1 1 Religion Muslim 7 7 Hindu 2 2 Christian 1 1 Approximate monthly income per household (Taka and USD) 1,000-2,499 [12-31 USD] 4 4 2,500-3,200 [32-39 USD] 6 6 Approximate monthly income per family member (Taka and USD) 250-649 [3-8 USD] 4 8 650-1,100 [9-13 USD] 6 2 Distance to closest health facility (km) 5-6.9 7 6 7-10 3 4 Story et al. BMC Pregnancy and Childbirth 2012, 12:28 http://www.biomedcentral.com/1471-2393/12/28 Page 5 of 12 solving the problem by selling your land. - 43-year old husband, dhatri home delivery The danger of childbirth The perception that one is not susceptible to complica￾tions during childbirth could act as a barrier to the utili￾zation of professional delivery care, but childbirth was perceived as risky by all of the husbands interviewed. Most agreed that complications could arise during deliv￾ery, but this belief did not always lead to the utilization of a skilled birth attendant during delivery. Definitely [childbirth] is dangerous. After conceiving a baby it becomes dangerous. There is tension that anything can happen at any time. There is tension about whether the baby will be born healthy or not.- 25-year old husband, hospital delivery To me, it is a risky thing.... Both mother and child can die. Sometimes it is seen that the baby dies and the mother is alive. Again, it is seen that the mother dies and the baby is alive. If it is normally done, then it is done. But, if not then there is a lot of suffering. - 28- year old husband, dhatri home delivery Divergent themes: social support and perceived social norms There were many themes identified through the open coding process that provided insight into the unique role of husbands during childbirth, in addition to the themes above that showed similarity across respondents. How￾ever, our goal was to focus on themes that (1) differed between husbands whose wives utilized a skilled birth attendant and those whose wives utilized an untrained dhatri, and (2) were grounded in sociological and psy￾chosocial theories related to health care utilization. The two themes that met these two criteria were social sup￾port during labor and delivery and perceived social norms related to delivery. Social support Social support is the term used to describe the functional content of social relationships. Social support differs from other functions of social relationships because it is consciously provided by the sender and is intended to be helpful to the receiver. This distinguishes it from other forms of social influence that are intentionally negative or passively experienced by the receiver. Social support often attempts to influence the behaviors of the receiver in a caring, trusting, and respectful context [27]. Social support can be categorized into four broad types of sup￾portive behaviors: emotional support, instrumental sup￾port, informational support, and appraisal support. We draw upon the first three categories of social support– emotional, instrumental, and informational–to describe the type of support provided by husbands to their wives during childbirth. However, there were also situations where the husband did not provide any of these types of support to his wife during the labor and delivery period. Emotional support/involvement Emotional support involves the provision of empathy, love, trust and caring [27]. However, in order for emotional support to have a positive influence it must be perceived as helpful by the recipient [28]. The majority of husbands whose wives utilized professional delivery care exhibited some level of emotional involvement with their wives dur￾ing pregnancy and childbirth. However, a husband’s emo￾tional involvement was not always perceived as supportive by his wife. Therefore, we will refer to this theme as emo￾tional involvement. Emotional involvement was often found in the form of prayer, which is a way of expressing love or caring when the husband is not physically present. However, emotional stress, such as worry and tension, was also coded as emotional involvement. A husband’s stress during labor and delivery showed a level of emotional investment that often led to other supportive behaviors. The tension and worry usually arose from the husband’s perception that his wife was at risk for a complication dur￾ing delivery or a previous experience with the death of a child or family member during delivery. In my mind I felt there were some problems. I was worried. I thought I should go [to see her] earlier. I wanted to observe what happened. I could be present on the spot. I am her husband and she is my wife. That is why I was interested to come [home] early; otherwise I would come the next morning. - 26-year old husband, CSBA home delivery How could I sleep! The light was on and I was awake for the whole night.... At first I was not thinking about the hospital, but later, when I was tense, I took her [to the hospital] the next day. - 35-year old hus￾band, hospital delivery Instrumental support Instrumental support involves the provision of tangible assistance that directly helps a person in need [27]. Hus￾bands whose wives utilized professional delivery care, and those that utilized an untrained dhatri, each pro￾vided some level of instrumental support. However, the type of instrumental support differed depending on whether the delivery took place in a hospital or at home. In all cases the husband typically provided instrumental support to his wife once she started the first stage of labor. Husbands whose wives delivered at a hospital often Story et al. BMC Pregnancy and Childbirth 2012, 12:28 http://www.biomedcentral.com/1471-2393/12/28 Page 6 of 12 arranged transportation and collected money for the hos￾pital fees. Husbands whose wives delivered at home pro￾vided support by calling the birth attendant or going to the birth attendant’s home to inform her of the impend￾ing delivery. Husbands whose wives delivered at home often knew the birth attendant personally (i.e., she was a family member or an acquaintance from the village). Yes, I called. I went there to call chachi (father’s brother’s wife) saying, ‘Chachi, I have a problem. The placenta is not removed.’ Then she asked, ‘Why? What is the problem? Was there not any dhatri in your home? No dhatri?’ I said that the dhatri was there and [she] asked [me] to bring you here. Then she said, ‘You go, I am coming.’ When I saw that she was late, then I went to her again. - 31-year old husband, CSBA home delivery Some husbands were able to arrange resources to pay for the transportation and hospital fees. Although public hospitals are free of charge, the majority of the respon￾dents preferred the private fee-for-service health facilities. There were two exceptional cases where a husband saved money to pay for an ambulance and where a husband used his land as collateral to repay a loan for hospital fees. Typically, the husband collected money from neigh￾bors and relatives during the first stage of labor. Husbands whose wives needed to travel to the hospital for delivery were also involved in coordinating or pro￾viding the transportation. She has a younger brother. Though we rented a thela￾gari (push car), her brother and I pulled it to take her to the hospital. We admitted her in the hospital and I was there all the time. - 31-year old husband, hospital delivery Additionally, husbands prepared food for their wives and other visitors as well as purchased medicine for their wives. I explained the whole situation [to the village doctor] that my wife could not deliver the baby in spite of severe pain. Then he suggested some medicine and I brought the medicine for her. - 32-year old husband, dhatri home delivery Informational support Informational support involves the provision of advice and suggestions that a person can use to address a problem [27]. Informational support was typically provided by hus￾bands whose wives utilized professional delivery care at home or at the hospital. In our context, informational sup￾port refers to the active provision of information from the husband to his wife. The husband provided his opinion about the type of provider his wife should use during delivery and in some cases he made the final decision about the type of provider. Some husbands in our study planned in advance to go to the hospital or to call a CSBA when the labor pains started. However, most husbands asserted their opinion when they perceived the labor to be progressing poorly. I said to my wife, ‘If you have doubt in your mind and if you face trouble, then you can be admitted to the hospital...’ She said, ‘You pray for me and keep faith in Allah.’ My intention was to take her to the hospital if she faced any trouble. - 26-year old hus￾band, CSBA home delivery ... after [my wife was in labor] the whole night, in the morning at 8 am, I said [the delivery] will not work at home. We have to go to the doctor. Then, in a hurry, I called the [push car] and then took her to the hospital. By the blessing of Allah I found the doc￾tor when we reached [the hospital]. - 35-year old husband, hospital delivery Uninvolved during childbirth Not all of the husbands were involved in providing social support during the delivery of their youngest child. Hus￾bands whose wives utilized an untrained dhatri at home were typically not involved in any aspect of the labor and delivery process. Husbands who were uninvolved did not necessarily make a conscious decision to be absent dur￾ing childbirth. Many factors could have contributed to a husband’s absence, including his wife’s lack of knowledge about the labor process or a general lack of communica￾tion between spouses. Lack of involvement appeared in three different forms: (1) the husband’s passive agree￾ment with his wife’s decision with no input of his own; (2) the lack of communication between the husband and wife during pregnancy, such that the husband was una￾ware of the timing of the delivery; and (3) the husband’s belief that his presence was not necessary once labor started and female family members took control. When they tell me to bring [the dhatri], I have to bring her. I have to consider her a good nurse. - 43- year old husband, dhatri home delivery I: Were you there when the pain started? R: No, I went for work.... Later the news reached me that the baby [was born]. I: Why did you go away? Didn’t you know that the baby would be born that day? Story et al. BMC Pregnancy and Childbirth 2012, 12:28 http://www.biomedcentral.com/1471-2393/12/28 Page 7 of 12 R: We don’t know about this a lot. The woman knows about this matter. (Laugh)” - 48-year old hus￾band, dhatri home delivery R: I didn’t have to do anything. I called my younger sister. Then my older sister came and after her arri￾val the delivery was over within half an hour. I: Didn’t you hear about when the labor started? R: I didn’t know that it was time to deliver. I went to the marketplace. - 28-year old husband, dhatri home delivery Perceived social norms The second divergent theme on which we focused was the husband’s perception of social norms related to child￾birth. Social norms can influence the type of support a husband provides his wife during delivery. According to Lewis and colleagues [29], social norms are “... expecta￾tions held by social groups that dictate appropriate beha￾vior and are thought of as rules or standards that guide behavior” (p. 254). In Bangladesh, perceived social norms of the husband are important to his wife because of their close social relationship and because of his decision-mak￾ing power within the household. There are many social norms related to childbirth in Bangladesh; however, this study focuses on one in particular–the medicalization of childbirth. Medicalization of Childbirth The medicalization of childbirth refers to the redefining of physiological reproductive processes as biomedical problems that can be treated by the medical profession [30]. This view differs from the traditional view in Ban￾gladesh, in which childbirth is perceived as a natural process that should be experienced at home according to local customs [6]. In many Western countries the medicalization of childbirth is often associated with unnecessary biomedical interventions. However, the idealization of “natural childbirth” can often lead to major complications for women in developing countries who do not have access to emergency obstetric care. Therefore, in the context of this study, the medicaliza￾tion of childbirth refers to a contemporary view, which holds that timely access to professional medical care is necessary to prevent the primary causes of maternal mortality in the event of problems during delivery. The concept of medicalization is particularly relevant in Bangladesh, a country with a history of medical plur￾alism. In rural Bangladesh, indigenous medical traditions exist parallel to contemporary, allopathic medical sys￾tems. Deciding which type of provider to use during a medical emergency is a complex process, which requires the input of many influential individuals [31]. For the purpose of this study, the perception of medicalization of childbirth among the husbands emerges in the con￾trast between old day and modern age thinking. These in vivo codes–terms taken from or derived directly from the language of the informant–came from an interview with a husband whose wife delivered at home with the assistance of a trained CSBA. I: What if the delivery is done at home? R: I suppose home is preferred by the elderly people of old day. In this consideration, it is better not to keep the expectant [mother] at home. I: What are the problems that can be faced at home? R: It is not possible to do everything at home. Women who are ignorant and not up-to-date think that the delivery is always done normally. It is foolish if we don’t keep pace with the modern age. In present cir￾cumstances, it is better to contact the doctor. A nurse is needed to stay beside the patient all the time in order to look after her meals and medicine. - 26-year old husband, CSBA home delivery Husbands who were coded as “old day” along the medicalization spectrum mentioned expectations of “normal” or “natural” deliveries at home. They also described traditional practices during childbirth and their reluctance to involve a doctor. Many of these hus￾bands described the pressure from other family mem￾bers, including their wives, for a home delivery. The majority of husbands whose wives utilized an untrained dhatri at home displayed old day thinking. I: Which [place] do you prefer most [for delivery]; at home or at the hospital? R: If [my wife] is comfortable at home, then at home. I don’t find any logic in communicating with a doc￾tor. If she is well at home, then home is better. - 43- year old husband, dhatri home delivery I: Why did you apply telpora (sacred oil)? R: Telpora was at home. After applying it, pain develops and [the delivery] won’t be hard. I: How did you come to know [that you should use telpora]? R: Kabiraj (traditional practitioner) told me. He was my grandfather and he told me to [use telpora] like this, and then the baby will be born. - 32-year old husband, dhatri home delivery Husbands who were coded as “modern age” men￾tioned the importance of going to the hospital for deliv￾ery, technology at the hospital, and consulting a doctor during pregnancy. One respondent was a migrant laborer who traveled to the capital city for work and brought modern ideologies back to his village. Others had close social connections to trained health providers Story et al. BMC Pregnancy and Childbirth 2012, 12:28 http://www.biomedcentral.com/1471-2393/12/28 Page 8 of 12 or to non-governmental organizations, which promoted a biomedical approach to delivery care. The majority of husbands whose wives utilized professional delivery care displayed modern age thinking. I: Aren’t nuns and dhatris doing [deliveries] as well? R: No, they are from old time. Now time has chan￾ged. We are not in the old era now. Now the trained people are doing their jobs.... Suppose, if the patient’s condition became complicated, [the family would] carry them to the hospital. And doing delivery by the nurse is better. - 35-year old husband, CSBA home delivery Everything can be found [in the hospital]. Nothing can be found in the village. In the hospital, they gave medicine to the baby. Can they do that in the vil￾lage? - 35-year old husband, hospital delivery Discussion The majority of the literature on the utilization of pro￾fessional delivery care in low-income countries focuses on the barriers encountered by women [32]. However, the role of the family, in particular the husband, during pregnancy and childbirth is important to the under￾standing of women’s utilization of professional maternal health services [8,14-20]. This study was designed to look beyond the common barriers to the use of profes￾sional delivery care in Bangladesh and examine the underlying factors related to husbands’ involvement (or lack of involvement) in delivery care utilization. In order to examine the underlying factors, we purpo￾sefully selected households that differed by the type of provider utilized during delivery. Therefore, the themes and characteristics that were common across all respon￾dents, and did not vary with the type of provider utilized during delivery, were eliminated as sufficient barriers to the utilization of professional delivery care [33]. The find￾ings revealed three such themes common across house￾holds: (1) poor transportation, (2) lack of money, and (3) the perceived danger of childbirth. Although these have been shown to be necessary barriers to the utilization of professional delivery care [32], we suggest that they are not sufficient. In addition, we designed the sample so that socioeconomic and geographic characteristics were common among households that utilized professional delivery care and those that did not. Although many of these characteristics (e.g., income, education, and dis￾tance to the health facility) have been shown to be corre￾lated with the utilization of professional delivery services [2,3,32,34], they are not sufficient to explain the type of provider utilized during delivery among our respondents. Our findings suggest that husbands’ provision of social support to their wives and perceived social norms vary systematically with the type of provider, which implies that these factors are important to understanding deliv￾ery care utilization in Bangladesh. In order to better understand husbands’ social support and perceived social norms, these two factors were used as the axes of our analysis (Table 3). The two ends of the axis of social support were involved (which included emotional, instrumental, and informational support) and unin￾volved. Perceived social norms were divided into two categories based on husbands’ perceptions of the medi￾calization of childbirth: old day and modern age think￾ing. These two categories were not mutually exclusive; that is, some husbands displayed examples of old day and modern age thinking in the same interview. Based on the analysis, husbands whose wives utilized a skilled birth attendant were more involved and modern age thinkers. That is, these husbands provided emotional, instrumental and informational support to their wives during delivery and believed medical intervention was necessary during childbirth. On the other hand, hus￾bands whose wives utilized an untrained dhatri at home were generally uninvolved and old day thinkers. That is, these husbands were uninvolved during delivery and believed childbirth should take place at home according to local traditions. There was no distinguishable pattern for husbands who were uninvolved and modern age thinkers or husbands who were involved and old age thinkers. We identified two potential rival hypotheses that may explain the variation in the type of delivery care utilized: (1) women whose deliveries appear to be normal are more likely to stay home, while women whose deliveries appear to be progressing poorly are more likely to go to a hospital, and (2) women who only have one child are more likely to use professional delivery care, while women who have more than one child are more likely to stay home. In order to determine if the first rival hypothesis was true, we examined the differences between women who delivered at home with a CSBA to women who delivered at home with an untrained dhatri. This analysis allowed us to eliminate the potential effect of complications among women who delivered at a hos￾pital. That is, women who delivered at home with a CSBA and women who delivered at home with an untrained dhatri encountered similar levels of perceived and actual complications. We found similar coding Table 3 The axes of social support and perceived social norms Social Support Involved Uninvolved Social Norms Modern Age Skilled Birth Attendant Inconclusive Old Day Inconclusive Dhatri Story et al. BMC Pregnancy and Childbirth 2012, 12:28 http://www.biomedcentral.com/1471-2393/12/28 Page 9 of 12 patterns on the two axes of analysis (social support and perceived social norms) when husbands whose wives utilized professional delivery care at a hospital were excluded from the analysis. The second potential rival hypothesis originated from the fact that parity differed substantially by the type of provider utilized during childbirth (Table 2). This asso￾ciation may be due to the fact that the first birth can be more difficult for a woman who has no previous delivery experience. It has been shown in South Asia that a high value is often placed on the first pregnancy and the woman’s family helps her get the best care possible [35]. Although this is certainly a plausible explanation for some of the differences between the two groups, the same coding patterns existed when husbands of unipar￾ous women were excluded from the analysis. The results from this study provide a new way to con￾ceptualize a husband’s involvement in his wife’s decision to seek professional delivery care in rural Bangladesh. Lewis and colleagues [29] explain how influence and communication between interacting partners can affect each other’s motives, preferences, behaviors, and health outcomes. Specifically, our study suggests that a hus￾band’s social support and social norms are associated with his wife’s use of delivery care. Rozario [6] explains how the husband is often responsible for making deci￾sions about health care during childbirth in Bangladesh. Since social norms become more salient when the recei￾ver of social influence is motivated to maintain a rela￾tionship with the sender of social influence [36], women are likely to be receptive to their husbands’ beliefs and opinions about delivery care. These findings are sup￾ported by previous studies that suggest male involvement in pregnancy and childbirth and good spousal communi￾cation are associated with increased use of maternal health services [8-10,18-20]. This study was not designed to account for all of the factors involved in the decision-making process, nor was it designed to account for the perspective of everyone in a woman’s social network. Moreover, our view of the social processes explored in this study was based solely on the husband’s report. Future qualitative research should explore the role of broader social networks, including other key family members and other influential people, in the decision-making process during childbirth. It should also consider comparing husbands’ and wives’ perspectives when making decisions about the use of pro￾fessional delivery care. Furthermore, while this study pro￾vides a comparative picture of husbands’ involvement during childbirth, it was not designed to infer a causal association between husbands’ involvement and the use of professional delivery care. Since we used retrospective accounts it is difficult to determine whether husbands’ beliefs and opinions about childbirth were formed prior to the delivery of their youngest child or afterward. Limitations While this study provides novel information and rich detail, an important limitation is the potential endogeneity of husbands’ involvement in the decision to utilize profes￾sional delivery care. There could be a reverse causality problem, such that husbands were more likely to be involved because their wives utilized professional delivery care, rather than the reverse association that forms the focus of our analysis and interpretation. In order to address this potential endogeneity problem, future qualita￾tive studies could use a prospective study design to follow husbands and wives during pregnancy and delivery to bet￾ter understand the timing of events related to the hus￾band’s level of involvement. Additionally, the short fieldwork period did not allow for time to follow-up with the participants to clarify any misunderstandings. In parti￾cular, the sample size was reduced due to misunderstand￾ings about who actually delivered the child. Furthermore, the qualitative methods that we used when talking to hus￾bands did not allow us to capture details about personal, psychological, and temperamental differences that may have an impact on husbands’ involvement during preg￾nancy and childbirth. Finally, we could not eliminate potential sources of measurement error, such as inter￾viewer effects and retrieval failure. Possible interviewer effects include the respondent answering a question with information that he believes the interviewer desires to hear, or what he thinks is “correct.” Retrieval failure occurs when the events were never coded in the respondent’s memory due to the lack of significance of the event or because the respondent was not present during the events in question. Conclusions The findings presented in this paper suggest that the level of social support provided by the husband to his wife and the husband’s perception of social norms related medical intervention during childbirth are both asso￾ciated with the type of provider utilized during childbirth. The husband’s perception of social norms related to pro￾fessional care is important to the type of advice and sup￾port he will give his wife during pregnancy and childbirth, which has important implications for the development of future maternal health interventions. Areas of fruitful future research include the further elucidation of the types of social support provided by the husband and the critical social norms related to childbirth in Bangladesh. This and future research could be used to create valid and reliable measures to assess the quantitative impact of social support and social Story et al. BMC Pregnancy and Childbirth 2012, 12:28 http://www.biomedcentral.com/1471-2393/12/28 Page 10 of 12 norms on the utilization of professional maternal health services using a more representative sample. These find￾ings may also be useful to program planners, who should pursue culturally sensitive ways to involve the husband in maternal health interventions and assess the effectiveness of education strategies targeted at husbands. Acknowledgements The author would like to thank the University of Michigan Center for Global Health for their generous financial support for this study. The author would like to extend his gratitude to Dr. Frederick Wherry of the University of Michigan for his guidance and support; fellow doctoral student Jody Platt for her help validating codes; ICDDR, B for coordinating the project and providing technical assistance throughout the research process; the Christian Reformed World Relief Committee (CRWRC) and PARI Development Trust for their support in the field; Ms. Helen Rema for interpretation and her tireless effort to help the data collection run smoothly; and the interview team (S.M. Murshid Hasan, Md. Hafizar Rahman Numan, Sabrina Darain, and Nurun Nahan Khanam) for their help collecting data and transcribing the interviews. Author details 1 Department of Health Management and Policy, University of Michigan, 48109-2029 Ann Arbor, MI, USA. 2 Department of Sociology, University of Michigan, 48109-1382 Ann Arbor, MI, USA. 3 School of Nursing, University of Michigan, 48109-5482 Ann Arbor, MI, USA. 4 International Center for Diarrheal Disease Research in Bangladesh, GPO Box 128, Dhaka 1000, Bangladesh. Authors’ contributions WTS designed the study, participated in data collection, and drafted the manuscript. SAB and JRL contributed to the study design and critically revised the manuscript. FT and NAA led the data collection process and made revisions to the manuscript. DMEH facilitated ethical approval, coordinated field visits, and made revisions to the manuscript. All authors read and approved the final manuscrpit. Competing interests The authors declare that they have no competing interests. Received: 30 August 2011 Accepted: 11 April 2012 Published: 11 April 2012 References 1. 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BMC Pregnancy and Childbirth 2012, 12:28 http://www.biomedcentral.com/1471-2393/12/28 Page 11 of 12 34. Streatfield PK, Koehlmoos TP, Alam N, Mridha MK: Mainstreaming nutrition in maternal, newborn and child health: barriers to seeking services from existing maternal, newborn, child health programs. Matern Child Nutr 2008, 4(Suppl 1):237-255. 35. Navaneetham K, Dharmalingam A: Utilization of maternal health care services in Southern India. Soc Sci Med 2002, 55:1849-1869. 36. Cialdini RB, Trost MB: Social influence: Social norms, conformity, and compliance. In Handbook of social psychology. Edited by: Gilbert DT, Fiske ST, Lindzey G. Boston: McGraw-Hill; 1999:151-192. Pre-publication history The pre-publication history for this paper can be accessed here: http://www.biomedcentral.com/1471-2393/12/28/prepub doi:10.1186/1471-2393-12-28 Cite this article as: Story et al.: Husbands’ involvement in delivery care utilization in rural Bangladesh: A qualitative study. BMC Pregnancy and Childbirth 2012 12:28. Submit your next manuscript to BioMed Central and take full advantage of: • Convenient online submission • Thorough peer review • No space constraints or color figure charges • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit Story et al. BMC Pregnancy and Childbirth 2012, 12:28 http://www.biomedcentral.com/1471-2393/12/28 Page 12 of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• $#"'#&5 $" (#&&'&*6!$" • *#$ ' "'(()(#"!"#!!)"(- "'"#&! -+ & "' • (&"("'"$&#&!"-     • #"(")) " "'(  * '#( ('-'(!' • &(!,3"&#$  "'(()(#"2 Closing the Gap by Design: Setting up a Maternal Newborn Program as if People Mattered. Alan Talens1 , Nancy TenBroek2 , Will Story3 , Emdad Hoque 4 Presented at the CORE Group Spring Meeting in Baltimore MD on May 12, 2011 The pursuit of equity in CRWRC program stems out of the strategic theme of the organization: Relief and Development under the justice umbrella. Health, pregnancy and safe delivery are basic human rights akin to the right of life, security and equal opportunity. CRWRC has included equity in the design of its maternal and newborn program and used community mobilization with Community-IMCI (Integrated Management of Childhood Illness) as the equity strategy. Netrokona district in Northern Bangladesh is populated by marginalized tribal groups with unmet health needs. There is high population of ethnic minorities (Garos, Hajongs) in the 2 sub districts covered by the project. The local partners (SATHI and PARI) helped in identifying the disadvantaged groups who are the poorest in the district. These places also have high burden of disease with social, cultural and linguistic differences affect their access to health services. Qualitative methods were used to determine underlying conditions (barrier for ANC visits, socio-cultural beliefs and barriers etc.) Secondary data showed problems in maternal/newborn health in the district showing decline in under-5 mortality in the last 2 decades but neonatal morality remained high. The community mobilization strategy has narrowed the equity gap by empowering isolated groups who otherwise would not have coverage. For greatest impact effective interventions has to reach the poor communities. Community-based health program is a feasible way to provide health services “at the doorsteps” of people who does not normally have health care. Central to the mobilization strategy is the model for building community capacity and the venue for the community participation is the Peoples Institution. It is also the governance piece of the community mobilization. Primary groups (self-help groups) elect representatives to the PIs which become self-governing bodies and serve as linkage to government health system. The PIs also create the community- based healthcare, providing services to the unreachable groups. For the quantitative equity analysis there are 2 study arms, the intervention and the control groups. To document equity the interventions had reached the poor, it must show significant change in the health outcomes among the poor compared to the well of in the intervention area and no significant change with the poor in the control arm. There were inequities in the coverage of most interventions by wealth ranking in the district. Baseline KPC (Knowledge, Practice and Coverage) showed that more has to be done to improve coverage levels of child health interventions among the poor. The PI using community participation, representation and governance to create community-based healthcare and universal coverage could be a feasible equalization model in reducing inequities and improving health in underserved communities. Alan Talens- Presenter at the Concurrent Session on Equity  Christian Reformed World Relief Committee (CRWRC) - 2850 Kalamazoo Avenue, Grand Rapids, Michigan CRWRC-Bangladesh - 49560 Lane 3 Road 266 Baridhara DOHS Dhaka, Bangladesh  University of Michigan School of Public Health  ICDDR,B (International Center for Diarrheal Disease, Bangladesh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ignificant improvements occurred in health outcomes that reached/surpassed national averages: delivery by skilled birth attendants increased from 21% to 95% (DHS 29%); the proportion of mothers receiving four prenatal visits increased from 6% to 86% (DHS 21%) and two-doses of TT increased from 62% to 98% (DHS 90%); and mothers’ knowledge of pregnancy danger signs rose from 31% to 100% (DHS 50%). Infant and young child feeding practices improved from 14% to 80% (DHS 81%) and complete immunization rates from 32% to 96% (DHS 82%). The CSSA-based sustainability indicators tracked by PIs showed marked improvement: health outcome increased 45%, health services 79%, community capacity 54%, enabling environment 85%, organizational capacity 78%, and organizational viability 60%. " &%'%%!!'$!' &+0% "&+0' '% ""$&( #'$+ ! %&$&% && !' &+ $% ( & "&+ &! (!" & "&+ &!  &+- "$!$&,   %!( &$ !)  & ($+ "$!%/  (!" "&+ ! &$'&% &!   "$!$ !&  "$!(&!'&!%&&$*"&&!%'%&  !($&/  ! !. $/    % 4 3 5- & (%!$ ! !$  )- "$!(% &  %'""!$&&!  "$!$% && '%#'& !' &+0%""$!/% !$ $! $!'"  !0$!!' &+&!$ $!'"/ SUSOMA Project Intervention Cost Analysis What resources would be required to institutionalize or scale up key intervention components? This project was completed at a cost of $1,207, 572, after excluding costs for Operations Research and for travel to CORE Group meetings. The costs for the final quarter of the project were not included in the analysis, although an attempt was made to estimate the costs of the final evaluation and KPC survey. The project area includes a total population of 485,000 people, including 124,000 women 15-49 years of age and 97,000 children 0-5 years of age. The average cost per woman of reproductive age was $9.73 for this project. The project involved organizing and building the capacity of four People’s Institutions (community based organizations/federations of self help groups) and 22 Central Committees. 516 self help groups for men and women (known as primary groups) were formed at the village level: 302 in Kendua and 214 in Durgapur. There were 584 CHVs (356 Kendua and 228 Durgapur) and 570 TTBAs (348 in Kendua and 222 in Durgapur) recruited and trained under this program for a total of 1,154 community volunteers. The volunteers are supported by 40 Community Health Trainers, who are supervised by two Health Coordinators and two Assistant Coordinators. Each CHT is responsible for around 29 volunteers on average. Project cost per community volunteer is: $1,045. If you wanted to scale up the program you could estimate the cost based on this unit cost. For example, a program three times as large as this one would have: • 120 Community Health Trainers • Supporting 3,460 volunteers • At a cost of $3.6 million over 4-5 years • The population served would include at least 370,000 women of reproductive age… or a geographic area with a population of close to 1.5 million people. It may be possible to do the project for a lower cost than this, since there would be some economies of scale achieved during project scale up. However, travel and monitoring costs would probably increase at a greater rate since the project area would be large and monitoring would be more complex. The cost of reaching a large number of people is lower per unit in Bangladesh than it is in other parts of the world because of population density. See project cost break down and pie chart on next page and an excel spreadsheet with additional cost data details in the following pages. The project costs broke down this way:  " "* - $$," ) !!! ! /01%,.2  .4&28 !  .4,%34-  ./&/8  # 12%1,1 0&38 !! # -5%.15 -&28 "!'! %"! %$  -&/8 -1%220 )' ( 42%-3.  3&-8 ) !  ! -4.%3-.  -1&-8   ! -.,%/55  -,&,8 ! ! ' ( -,,%,10  4&/8 -%.,2%13. "$ $ $#$ 49< "$"# # 45< "( 6< $"%"( 4< !' $ .$"#,  '$"#,*#/ 3< 0. "#/ 7< "0 $" ""#$# 36<  #$# 32< "$#$# . / 8<      SUSOMA Project Intervention Cost Analysis, August 2014 )( )) )* )+ ),  Program Personnel  Technical Backstop at HQ (Salary)  =>4>D> ><4>AD  ==4<>E  C4A=D  E4=@4EDA >=4B=A  >A4?AC  ><4=BC  =A4=?E  )(/#*.+  Capacity Dev. Specialist (Salary) D4< E4BC< A4@DB >4A@A +-#0,.  5$, 0!+'*9(0(57*!&8 @4@ED C4=@= E4=@@ C4>@C @4EEA ++#(*-  Maternal & Newborn Health Specialist (contract) B4>>D B4B@= >4 =<4E<@ =?4??C =<4>?B C4BCB -(#.+-  *'", &*7*!&8 =4 7?== >@E ?@A 01+  Health Coordinator (Salary) ?4BC? @4DAD @4D>D A4?<> @4> >@> >@? BE< ><< )#0(/  Health Coordinator (Salary) ?4BBC >4@CD ?4=A< ?4BCA ?4=@< ).#))(  $, ''*!&,'*7*!&8 ?@D @>> >?> )#((*  Assistant Coordinator (Salary) =4@>< ?4<@< >4D=A >4=>> =4CC> ))#).1  ++!+,&,''*!&,'*7*!&8 ==B >C? >>= ==? /*+  Assistant Coordinator (Salary) ?4<@= >4E== ?44@ED ))#-()  ++!+,&,''*!&,'*7*!&8 A= =B =BC .-*  14 Community Health Trainers (Salaries)  =B4CCB ==4C  =@4=CE  /.#(-.  =@'%%/&!,2$, *!&*+7*!&8 ABC =E> C<> >4=?C D= +#./1  26 Comm Health Trainers (Salaries)  >B4A=< ==4=E@  >C4@B?  >B4B>=  )*/#11.  >B'%%/&!,2$, *!&*+7*!&8 CE< >4=CD ?4>?B =4<=> /#*). Subtotal Personnel                   Travel/Fuel  Per diem for project personnel =4  >4=A=  ECB  .#-,/  Supervisory visits to project sites  =4?E< C=E  >4ADC  >4BED  =4@?A  0#0*1  Travel to trainings and meetings  =4=B@ B4C?? =AD  @?D  =4ECB  =4A>>  .#0*/  Vehicle maintenance/repair  =DB A>  AD@  A<@  =E?  )#-)1  Vehicle maintenance/repair  >CE =>=  >D?  >EE  =CC  )#)-1  Vehicle maintenance/repair  >A< @?<  >@=  @EA  >>D  )#.,,  Vehicle fuel (mileage)  =4D@B @AB  >4<@E  =4D>E  =4?AE  /#-+1  Vehicle fuel  AC= @EA  *#)0+  Vehicle fuel  >EC ==C  ?C@  ?B?  )#+-.  International Travel  ?A> ==4ABB  >4<><  A4<@?  >CD  )1#*-1 Subtotal Travel                   Equipment  Motorbikes (3 @ $1,600) ?4?D= +#+0)  Motorbike (2 @ $1,600 ea.) =4C?A )#/+-  Motorbikes (2 @ $1,600 ea.) =4C>B )#**.  Bicycles (26 @ $ 110) =4DE? @B )#1+1  Computers/Printers (2 @ ($1,250)  === D?  )#/+/  Computers/Printers (1 comp. with printer) B@C .,/  Computers/Printers (1 comp. with printer)  >C AE=  .)0  Mobile Phones ( 2 @ $150 ea.) =BB )..  Mobile Phones (2 @ $150 ea.)  EB =D@  *0(  Digital Camera (1 @ $450 ea.)  =CC >A  B4C?D  ).#(-/  9!*7*!&8 DD @>? -))  KPC (estimate) A4<<< A4<<< A4<<< )-#(((  RHFA Consultant >4=<< *#)((  KPC Methods training for staff ?4CBE +#/.1  Baseline RHFA staff training >4>=A *)-  LQAS Training for project staff =4>=E >AD )#,//  Annual surveillance of health outcomes =4=B@ )#).,  Evaluation (est. for Y5) @4=BC =<4<<< ),#)./  Baseline Enumerators B4D>E .#0*1  Baseline Enumerators E4@== >DA 1#.1.  Dissemination  >A ?E=  =4<>D  =4>C@  A?  *#//)  Dissemination  B@C B?D  E?=  >B<  *#,/.  Monitoring =4>@A @>E DAA *#-*1  Monitoring =4=BC =4><> B4?=@  ?4B4C>E EBB /#/.*  TOT on Mat/Newborn Care (govt) =4>A )#+*-  Curriculum Dev using Dialogue Ed ?D= +0)  Designing for Behavior Change >4DBD *#0.0  Training for private health providers ?4@=E =4@@= ,#0.(  Behavior Change Comm materials A4=@@ B4EEA @4E =4DB? =4BC< =4E@A 1#)1)  Learning Circle  @ED @?B  1+,  Training of TBAs B4@@= A4D>A >4EDD )-#*-,  Training of TBAs C4C? @4?@< ).#./*  Training of CHVs  C4=?D ><  =4@B<  @4=BC  )*#/0-  Training of CHVs D4=CB A4=EA A4ABC )0#1+0  Monthly meetings with CHVs/TBAs  >4@  ?4<=@  C44A>B  )-#-11  Monthly meetings with CHVs/TBAs  E@A ?@  B4===  C4??D  >4B<=  )/#(*1  Exposure Visit of Staff/Service Providers  =4B  )#*((  Theatre for Development =4@A@ =AE )#.)+  Husband, Father, MIL meetings  =B ED@  )#((( Subtotal Trainings & Meetings                   Office Operating Costs  Office rent ?4=D? =4CE< @4C=A ?4 D  CAD  ,#,(-  Office rent  =4>>< DE<  =4>?C  =4?D>  =4<@E  -#//0  Office utilities  ABA @A=  >BA  @  ??D  @?<  >CC  @ED  >AD  )#-//  Office telecommunications  B>? A=D  AD=  ABC  A>@  AC>  ?E=  *#).+  Office telecommunications  A?> =><  A?=  B@=  AD?  *#,(/  Office Supplies =4D>A =4CBC =4A== =4BDD DE> /#.0+  Office Supplies >4=BE ?4EA@ DC= =4AB B4@@C =4 AE> )(#-*0  Office Furniture =4DDC 7?DC8 )#-((  Office Furniture =4?EC >B< )#.-/  Finance Manager (Salary) 302 =4>ED =4C@C >4EE A4DAE -1,  Accountant (Salary) >4@<= >4>C> >4AE@ >4D=? >4??C )*#,)/  '/&,&,7*!&8 ?CD =>? >D? =B< 1,,  Office Caretaker (Salary)  CA< BB?  CCC  =4=@D  EBA  ,#+(+  !*,#*7*!&8 EE ?B ==< B> +(/  !*,#* =< ?C ,/  !*,#* >> ?> -, Subtotal Office Costs                   NICRA     ><4DBD =C4E?=  ?D4D?<  @4CE>  =C4B??  )((#(-,  **0#+.( *.-#,-/ *0.#+,* *,0#0/) )//#-,* )#*(.#-/* SUSOMA Project Intervention Cost Analysis, August 2014        B<4=E?  &!$#+,'(7=8 CC4B?= B5@H =C4@?D !$,7>8 =CB4=?@ =@5BH =B? '$$2 !*(*'",+,'* E=4>B= C5BH ?A4D@B ''*9++,''*'**,&*+7@8 BA4D?@  A5AH ??4<>A '%%/&!,2$, *!&*+7@<8 >=@4E@C =C5DH =E4D>C A=5EH A<4B?A >4ADB =C4?>< DE? >>4DC< =4D ==4=BE C>? ==4A<= BA> CB4C4EEB C4>=B       !$    !$/$I '$*0$'+,+ A>4=D? >4EB>  @5?H =4B@A  !$ !&,&&6(!* @4?>> <5@H  #+,'(*0$,'!$ B4A@C =E4>AE =5BH D4D>E B5?H =@4>EA B4D>C  #     =4A=E       " =4=AE =4B@@ C4A?E >4=D? =4?AB =E4>AE          ','*!#+ D4BBC ?4?D= <5CH  !2$+ =4C?A ?4=BA <5?H  '%(/,*+9*!&,*+ ?4AA= ?4<<> <5>H  '!$ '&+ =4>>B  <5D< ?D@       =B45EH A== *!&!&'& 9'*+, D4E4=BC >5@H >4=<< &&/$+/*0!$$&9 '&!,'*!& B4BC< <5BH ?4CBE !++%!&,!'& A4>@C <5@H >4>H ?BE C5=H =4DAB >=A =4@CC =4=B@ =@4=BC B4D>E E4BEB >4CC= >4@CB >4A>E >4ECC        SUSOMA Project Intervention Cost Analysis, August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roject Intervention Cost Analysis, August 2014 *'",%&%&,&, &!$+, ?@A4<>B >D5BH ''*!&,'*+&+ >D<4CD= >?5?H '$*0$ AB4AAE =5BH %$$)/!(%&,7%','*!#+4'%(/,*+4!2$+8 =A4BB@ =5?H 97!&$(*+'&&$8 DB4=C> C5=H *!&!&9, **'*%'+,+ =D>4C=> =A5=H !$!'+,+ =><4?EE =<5 *'",%&%&, &, &!$+, >EH ''*!&,'*+& + >?H '$*0$ AH &,*&-'&$*0$ >H %$$)/!(%&, 7%','*!#+4 '%(/,*+4!2$+8 =H 97!&$(*+'&&$8 CH *!&!&9, * *'*%'+,+ =AH !$ '+,+ =5MR U>5 Mortality Rate VD Village doctors 7 Acknowledgement We would like to acknowledge the willing participation of all study informants who gave their time for us to learn from them. We would also like to acknowledge the support of the NGO managers from both SATHI and PARI working in Kendua and Durgapur respectively. The support we received from the senior management of World Renew1 , namely Nancy Tenbroek, needs a special mention – she accommodated all of our requirements in and outside of the field without any hesitation. Last but not the least; we would like to acknowledge the financial support from USAID. Contributors to this report Fahmida Taleb Research Investigator, icddr,b Al-Mahmud Ovi Research Officer, icddr,b Nabila Chowdhury Research Officer, icddr,b Sabrina Darain Research Officer, icddr,b Nurun Nahar Khanm Research Officer, icddr,b Hafizur Rahman Numan Research Officer, icddr,b Murshedara Begum Research Officer, icddr,b Nabeel Ashraf Ali Assistant Scientist, icddr,b DM Emdadul Hoque Associate Scientist and Project Coordinator, icddr,b Shams El Arifeen Senior Scientist and Director, Center for Child and Adolescent Health CCAH, icddr,b  1 World Renew, formerly known as CRWRC, is an international NGO 8 Executive Summary Social capital (SC) refers significantly to networks of social relationships which contribute in sustainable development. It is apparent from many studies that social capital act to stick the community members together and to fulfill societal needs. Social capital study helps to see the benefits from trust, mutuality, increase in knowledge, and assistance to each other that eventually increase rate of success in achieving individual and shared goals in terms of education, health, communication and so on through effective function of social institutions. On the other hand, society that lacks social capital may collapse in the long run. The World Renew, an international NGO, has implemented SUSOMA project in two upazilas in Netrokona district. This organization, with the help of two renowned local NGOs- PARI Development Trust and SATHI, has worked to improve social capital index of the very poor and marginalized population of these areas with an intervention of People’s Institution (PI) model and intended to reduce maternal and child death with alignment with GoB’s attempt to achieve MDG- 4 and 5. It is noteworthy that though Bangladesh has been able to achieve significant progress in reduction of under –five (U>5MR) and maternal mortality rates (MMR), this country has yet to achieve greater success with its current rate of MMR (194 per hundred thousand live births) and NMR of (32 per thousand live births) (BMMS 2010; BDHS 2011). Antenatal care, skilled attendance at birth, and postnatal care service coverage for different economic quintiles indicate gross disparity in Bangladesh (BDHS 2011). PI model of SUSOMA is especially aimed to see five intermediate results (IRs) in improvement of public-private partnership in support of Maternal, Neonatal and Child Health (MNCH) strategy of GoB, improve related knowledge and practices of pregnant women and family, increased quality of MNCH services, increased capacity of local NGOs for implementing People’s Institution and enhanced enabling environment for MNCH (Policy Environment) which are most appropriate for the context of Bangladesh. This report aims to reveal impact of Peoples Institutions (PI) model that is targeted to increase social capital, on achieving success in ensuring maternal and child health in two upazila in Netrokona District in Bangladesh. Researchers from Centre for Child and Adolescent Health from icddr,b, Bangladesh has conducted the baseline and endline of KPC survey and formative research in two intervention areas of SUSOMA project in Netrokona in 2010 and 2014 respectively. As a part of the formative research, the aim of operation research was identified in meetings with stakeholders. A team of researchers visited these two areas for several times during the implementation period and collected data using qualitative methods of in-depth interview (IDI), focus group discussion (FGD) and observation. For the social capital measurement survey, tools were adapted from World Health Organization’s (WHO) tools to measure social capital and same set of questionnaires were administered in both baseline (2010) and endline survey (2014) among the members and non-members of groups following PI model using a cluster random sampling method. This report has two major segments of findings. The first segment has focused on findings from qualitative research and the second segment presents on results from social capital measurement survey. This study finds changes that occur in the intervention areas as a result of implementing Peoples Institutions (PI) models of SUSOMA project. All the members and almost all the non-members are well aware of the idea of forming social group to save money and use that for communal benefit, such as, spending for maternal and neonatal patients, building roads or buying vans to transport patients to the hospital. Leadership qualities were building up in the intervention areas. Some of the groups were disbanding; however, many of them got reformed again after solving their problem. Many of the groups had problem in investing their savings as they were not interested to do anything that would go against 9 their religious beliefs. Members of the groups were ready to help any mother and child in need of health care despite of their religion, identity or membership to groups and they seemed to understand the importance of timely treatment from the facility. TTBAs are working within their best for creating awareness to the mothers, family members and the decision makers on significance of referral to facilities than treatment by informal providers after observing any danger signs. The level of confidence of the PI members has increased up to such a level that they are now able to solve their own problems, can communicate with social elites as well as the people from formal institutes and are achieving trust from them as a result of their improving performance in managing groups, money, health care and non-health related tasks and so on. Another most significant feature of PI model is that it has been able to create effective linkage among community people, local elites, formal health system as well as informal health care providers. The social capital measurement survey found that PI members are significant from the non-members in terms of decision making processes, their networks and mutual support, their ideas about the sources and areas of conflicts, their understanding of access to services, levels of solidarity, trust, and cooperation. They are more confident in conflict resolution, on understanding intensity of problems that can occur in their community and individual level. As, it has been stated earlier, social capital ensures social sustainability and development for generations, the PI model should be a continuous process in achieving maternal and neonatal health success. We recommend that this kind of program should be scaled up in more areas with lower status in social capital index in Bangladesh, especially among the marginalized population that lacks trust, solidarity and access to information. It is evident from this study that increase in social capital by expanding monetary capacity can bring change in people’s behavior and practices. Therefore, this research report recommend that learning from PI model can be applied to Community Clinic Support Groups (CSG) that are actively working in the whole country on the same field of improving child and maternal health activities as World Renew does. : Introduction Bangladesh has experienced significant progress in reducing under-five and maternal mortality rates but maternal (194 per hundred thousand live births) and neonatal (32 per thousand live births) mortality still remains high. (BMMS 2010; BDHS 2011) The Demographic and Health Survey (BDHS) data on antenatal care, skilled attendance at birth, and postnatal care strongly indicate gross disparity in service coverage for different economic quintiles. (NIPORT 2009) Reduction of neonatal deaths requires continuum of care addressing pregnant women and newborns as well as reaching the poor and marginalized population. Community based interventions, specially targeting the poor and disadvantaged population has the potential to have substantial impact on maternal and newborn health. World Renew, an international NGO, has developed an innovative approach called the People’s Institution (PI) model, and plans to use this model to implement a package of evidence based interventions in partnership with NGOs in Netrokona, a district in Northern Bangladesh. This document elaborates a quasi-experimental operations research design composed of Knowledge, Practice and Coverage (KPC) surveys, formative research, and process documentation to evaluate the effectiveness of the PI model on caretaker knowledge, home care, and care seeking behavior. The proposed research is not a straightforward evaluation of the program, but an operations research geared toward providing evidenced-based support for what works and what may need improvements. In this document we also describe measures of social constructs, such as Social Capital (SC), since the People’s Institution is designed to raise SC among the marginalized populations that would contribute in significant improvements in desired areas of maternal and newborn health, i.e. ability of PI model in engaging poor and disadvantaged populations through empowering them to get quality health care services. In addition the research also explored attitude and accountability of community people, and cost￾efficiency of the innovation (PI model). Process of project implementation has been documented through in-depth qualitative exploration with all the relevant stakeholders. Addressing maternal, neonatal and child health concerns through community-based strategies have been tried at various levels and have shown to be successful in achieving their objectives. However, most of the interventions have been input-intensive, hence less sustainable in the long run, though it may be necessary and required in certain contexts. The PI model is clearly a much needed innovation in this regard, given the fact that it relies on community participation, planning, and action, which in turn attempts to utilize community resources. World Renew has 18 years of experience in implementing this model successfully in Bangladesh to help the poor communities form independent, self-sustaining community-based organizations (CBOs). The formed CBOs are well positioned to interact and collaborate with the informal health care system (village doctors) and the public health sector (clinics) in ways that may lead to stronger, more sustainable health systems, and communities with greater social cohesion and sense of empowerment. However, the success and its potential to be taken to scale are yet to be measured. The government of Bangladesh (GoB) has prioritized maternal and neonatal health, which is reflected in its national health policies and guidelines. World Renew’s project is designed in line with what GoBs prioritized so that it can directly support the objectives and strategies of the government as articulated in the National Health Policy (NHP), the National Neonatal Health Strategy (NNHS), and the Maternal, Neonatal and Child Survival (MNCS) Programme. ; The selection of a poor, remote, and rural area like Durgapur and Kendua upazila of Netrokona district with high levels of poverty and maternal and neonatal mortality was done with consultation with GoB so that it would serve as a representative area to test an innovative approach that could be implemented at scale if shown to be successful and effective. This model can then be recommended for other countries with similar contexts. The project by World Renew seeks to contribute in community capacity development, involve the local government, and strengthen the health system through establishing linkages between the community and the government sector. The PI model will work as the bridging agent in achieving this end. This innovative approach to public-private partnership to achieve greater health outcomes will also address gender disparities and inequities by ensuring women-friendly services and identification and targeting of poor households with the help of local NGOs. Intervention Design Netrokona has been identified as one of the low performing areas in terms of health status by GoB. Within this context, World Renew will focus on a package of MNCH interventions, which will be integrated into the GoB strategy (expanded to include newborns) and delivered at the household level by trained traditional birth attendants (TTBAs) and unpaid Community Health Volunteers (CHVs). The project will prioritize high poverty areas and marginalized population and will involve and empower them in meeting their health needs. In the following diagram the results framework for the scope of World Renew interventions are presented in the light of intermediate results (IRs). We provide a brief description of activities addressing each one of these IRs below the diagram. Under the SUSOMA2 results framework as shown below, the stated goal and strategic objective are addressed through five intermediate results. These are then collaborated through the planned activities addressing each one of the IRs separately. Briefly, the planned activities, in conjunction with specific IRs, are as follows:  2 SUSOMA is the name World Renew adopted for their program on maternal, newborn, and child health that incorporates the PI model. SUSOMA Results Framework GOAL: To reduce mortality and improve health status among the most marginalized mothers and newborns in two sub-districts of Netrokona: Kendua and Durgapur Strategic objective: Improved household and community behaviors and increased utilization of MNH services through private/public collaboration between People.s Institutions (community-based organizations) and the public health t IR1 Strengthened private (civil society)/public partnerships in support of MNCH IR2: Improved knowledge and practices of mothers and families regarding MNCH IR3: Increased quality of MNCH services IR4: Increased capacity of local NGOs for implementing Peoples Institutions IR5: Enhanced enabling environment 32 3- Strengthen public-private partnership in support of MNCH All of the activities taken under the IRs as described below will inform IR 1. This specifically refers to increased linkages between the public health system and the community; Established mechanism for community feedback on health facilities through the community-based organizations (PIs); Increased community access to health services through community based financing scheme – the Emergency Health Fund. 4- Improved Knowledge and practice of pregnant women and families regarding MNCH Improved knowledge of danger signs in pregnancy, childbirth and postpartum periods.; Increased coverage and utilization of quality ANC services ; Increased access to delivery by skilled personnel., Increased coverage of home-based post-partum care for mothers and newborns ; Increased essential newborn care actions; Increased promotion of key behaviors related to MNCH 5- Increased quality of MNCH services Enhanced community-based provision of care; Improved referral of mothers and sick newborns by community- based (TTBAs and CHVs) and informal health providers.; Decreased harmful practices of community based and informal health providers; Established Quality Improvement System between public health facilities and community-based and informal health sector; Improved capacity of MOHFW to provide MNCH service at the union, sub-district and district levels; 6- Increased capacity of local NGOs for implementing People’s Institution Increased capacity of NGOs to assist PIs in implementing and monitoring their own activities; Strengthened capacity of local NGO to work with MOHFW at district and national level; Developed capabilities of local NGO partners to train community-based providers in advocacy and networking with local government within the PI model 7- Enhanced enabling environment for MNCH (Policy Environment) Strengthened and sustained local government capacity in MNCH; Improved ability of People’s Institutions to advocate for local level policies that benefit the health status of the poor ; Formed partnership with other services and programs (e.g. White Ribbon Alliance etc) to advance awareness of MNCH to improve social and policy environment World Renew seeks to achieve all of the above through their “innovation” The People’s Institution Model (PI), which is a community-based organization, composed of several smaller women’s and men’s groups called Primary Groups. The PI model organizes and mobilizes communities for health and social change and the goal is to become an independent, self-sustaining organization to have a lasting impact on the health of their members and the broader community through: Building local capacity to identify and address community needs Helping the poorest and marginalized populations have power to make decisions Mobilizing local resources for health and establishing resource management systems Motivating communities to advocate for policy changes to respond to their needs; and Establishing and strengthening linkages between communities and health facilities to improve quality, availability, and access to health services. 33 Study design AND methods Objectives Overall study objectives of the operations research are: 1) To evaluate the performance of the Primary Groups of the People’s Institution model in reaching marginalized and poor populations and effects on maternal, newborn and child health 2) To assess programme (PI model) effects on care-seeking for maternal, neonatal and childhood illness, and compliance with referral 3) To assess programme (PI model) effects on quality of care and utilization of maternal, neonatal and childhood services by health workers 4) To measure incremental intervention costs, cost-efficiency and equity aspects of the People’s Institution model, its ability in reaching marginalized population 5) To undertake process evaluation of the implementation of the model 6) To measure Social Capital Scope of this report Objectives 1-4 are described and documented in the Knowledge, Attitude, and Practice Survey report, which is provided separately, while the current report focuses on the fifth and sixth objectives, which is, to measure social capital in Kendua and Durgapur and to qualitatively understand the process of implementation of various components of the interventions. In order to do that, we are present findings from both the process learning/evaluation and measurement of social capital that were conducted at various points in time and provide a combined discussion to inform the objectives as stated. Study sites Study sites are Durgapur and Kendua, two sub-districts (upazilas) in the district of Netrokona in Northern Bangladesh. World Renew has extensive presence in the communities of these two upazilas and currently implementing a community-based participatory intervention program called SUSOMA. The total population in these two upazilas is 445,310 according to the census conducted in 2001. Netrokona has been identified by the Government of Bangladesh as one of 14 low performing districts with high child mortality (UNICEF, 2007). Kendua and Durgapur are two upazilas where the project was implemented in 13 and 7 unions respectively. According to the census carried out in 1991, Kendua has a population of 265,628 and Durgapur has a population of 169,135. To account for secular trends and effects of other existing programs and factors, all vital indicators from World Renew programme compared with concurrent measures from an appropriate comparison area from Netrokona district. Netrokona has a total of 10 upazilas and a similar maternal, neonatal and child survival (MNCS) programme is being implemented by GoB and UNICEF in 6 other upazilas of Netrokona, leaving only two 34 other upazilas without such programmes. Therefore, the required population for comparison is selected from these two upazilas. Durgapur is remote with limited roads and electricity. It is close to the border with India, and has a large ethnic population including 850 ethnic families from the Garo, Koch and Hajong communities. In Kendua, there is also very limited access to health services. The Bangladesh Demographic and Health Survey (BDHS) 2007 data on antenatal care, skilled attendance at birth, and postnatal care strongly indicate gross disparity in service coverage for different economic quintiles. Operations research The operations research has been divided into three separate parts as follows: Part 1: “Formative and qualitative process evaluation and learning,” tries to understand qualitatively the various dimensions of the program as it gets implemented. Part 2: “Investigation of social capital,” where we tried to measure a social construct, namely Social Capital, as it relates to the People’s Institution model. Part 3: “Quantitative program evaluation” where we addressed to measure program-level indicators at the baseline and end-line and compared the two to see if there has been an increase (or decrease) as a result of the program. The current report however, reports on parts one and two. Part three, which is basically the KPC survey, forms the rest of the total package of report from icddr,b, and to be submitted along with this report. Part 1: Qualitative process evaluation and learning Specific objectives of this report are as follows: / To explore perception, knowledge and practice around PI model / To reveal impact of PI intervention on achieving health equity / To explore the changed pattern of referral of maternal and neonatal cases to the formal health care facilities / To present changes in social capital among PG members and non-members This report is generated from our formative research and process evaluation activities that include compilation and review of implementation documents, compilation and analysis of regular program monitoring data, in-depth interviews, and focus group discussions or group meetings. Participants of the in-depth and focus group discussions include: mothers and fathers of children under two years of age; senior females (female decision makers with regard to maternal and neonatal health care) from households of the same mothers; and health care providers (i.e. government facility based providers, TBAs, CHVs, village doctors). We also conducted interviews of senior managers of NGOs involved in implementing the interventions in the field in order to understand the programmatic perspectives. Along with assessing the baseline situation with regard to maternal and neonatal care practices and behaviors in the community, the work looks into the processes involved in implementing the interventions, including the process of forming the PGs (primary groups), UCs (union committees), and the PIs (people’s institutions). 35 Sampling for qualitative exploration Procedure for qualitative sampling for formative research, process learning, and measurement of social capital followed the standard purposive approach. Table: Informants for qualitative process learning Tool Type Kendua Durgapur IDI Member 10 12 Non-member 10 12 TTBA 2 2 CHV 4 4 Social mapping 6 5 Organizational profiling 4 4 Focus Group Discussion Member 4 5 Non-member 4 4 Observation CHV training, PG and CC formation 2 2 Managers Sathi and Pari 4 4 Methods and Guidelines Separate guidelines for each type of informants were developed and employed. We used same guideline in the baseline and endline. Samples of these guidelines for each of the informants have been provided in the annex section of this report. In-depth interviews: Informants were Female and male members of PGs, UCs, and PIs, health care providers (CHVs and TTBAs). Primary objectives of the in-depth interviews were to address the functioning and performance of the PCs, UCs, and PIs. These interviews also addressed members’ concerns and the challenges they faced during the implementation of the programme. Health providers were also interviewed to understand their perception of the groups, their case management, and their relationship with their clients. In addition to the above, we interviewed managers of the implementing NGOs in order to learn of their programmatic experiences of implementing the program in the communities. In order to address objectives 5 and 6 above, we selected women of lower socioeconomic status. We used no proportional quota sampling. We visited the household of each woman to determine whether or not she met the inclusion criteria, sought permission to interview, and then interviewed her. In cases where we didn’t find a woman through our preferred method, we resorted to snowballing. In terms of selecting our informants, we tried to make it heterogeneous in terms of age, ethnicity, number of children, and education. On average, interviews lasted around 90 minutes each. 36 Focus group discussions: Participants of FGDs were both members and non-members of groups. The primary objectives of these FGDs were similar to that of individual interviews, but the focus was more on the societal-level opinions and perceptions. Observation: Events to observe include the formation of groups; client-provider relationship; and CHV training session/s. The primary objectives were to observe how groups are formed, how providers interact with their clients, and participants’ learning dynamics during training sessions. In case when we failed to observe, we tried to gather the information through “retrospective” interviews with the concerned families and providers. Participatory exercise/s (social mapping and Venn diagram): Participants for the participatory exercises were the people in the community. Primary objectives of these exercises were to identify local resources; to identify poor and disenfranchised people; health care facilities visited and preferences. Part 2: Investigation of social capital There were two different approaches to investigate Social Capital for this program: - #1: Measurement of the degree of implementation of an approach intended to increase social capital: People’s Institution Model. If there is a high score, social capital should be high, but this needs to be confirmed. - #2: Measurement of social capital – two types: structural and cognitive social capital We have prepared the questionnaires needed to measure social capital in the community, which was primarily an adaptation of the World Bank tool for the task. However, that document/s was revised in the light of the formative research, which also included site visits to observe people’s institutions around the country that are not part of the formal evaluation but are instructive as far as learning goes. We also conducted in-depth interviews of various managers of the NGOs related to mature PIs that we visited in order to contextualize the questionnaire. Sampling for quantitative measurement of social capital The sampling techniques were the same for both baseline and endline social capital measurement. Inclusion criteria • Married women of reproductive age • Reproductive age set in between 15-45 • Non-elite (belongs to lower socio-economic strata) Sample/informants • 300 to 360 from TWO sub-districts (i.e. Kendua and Durgapur) • Kendua 150-180 37 o 75 members (40 to 45 villages randomly selected from a complete list of villages in the sub-districts; 2 members randomly selected from each village; randomness decided through spinning bottles) o 75 non-members (40 to 45 villages randomly selected from a complete list of villages in the sub-districts; 2 non-members selected through snow-balling from each village) o All (member and non-members) to be females o All informants should belong to a lower socio-economic strata of the neighborhood • Durgapur 150-180 o Informants were selected in exactly the same way as described above for Kendua sub￾districts above. Tools The following tools were employed for the exercise of measuring social capital, once during the baseline and then at the endline: • Household questionnaire (survey) • Community questionnaire (administered to key-informants) • Social mapping (conducted in selected sites) • IDI and FGD (conducted with selected individuals and in selected sites) • Organization profiling (administered to key-informants)    In this section we provide an update on all of our field-trips related to data collection. The trips noted here refer to all the three parts of the operations research (i.e. formative, investigation of social capital, and quantitative program evaluation). 1. KPC (baseline): Data collection between 17 February and 06 May 2010 2. KPC (MT-Rapid catch): Data collection between 01 May and 05 May 2012 3. KPC (Endline): 5th March to 25th June 2014 (training and data collection) The KPC surveys were conducted as a part of the third component of the study. The baseline and endline surveys were conducted for evaluation purposes, while the rapid-catch survey was conducted as a rapid assessment to see if the interventions were being implemented as planned. 4. 1st visit: Durgapur, June 2011 and November 2011; Kendua, August 2011 and November 2011 5. 2nd visit: Durgapur and Kendua, January 2012; Kendua, June 2012; Jamalpur, April 2012 6. 3rd visit: Durgapur and Kendua March-April 2014; Netrokona and Dhaka: 30th June to 3rd July 2014 7. Social capital measurement (baseline): 23rd October to 12th November 2012 8. Social capital measurement (endline): 28th March to 15th April, 2014 For formative research component of the OR, we made several trips to the field. In addition to the formative research, we also collected data for process documentation and collected relevant information for the measurement of social capital. 38 Dissemination of study findings So far, results of the study have been presented in two separate dissemination seminars to make the results more widely available. The first dissemination seminar was held in February 2012, where all the relevant stakeholders were invited. A detailed presentation was made on behalf of the study team. The presentation was primarily on the baseline KPC survey results, which generated a lot of fruitful discussions. The second seminar was arranged upon completion of formative research and the first phase of process documentation. It was conducted within the organizational framework with only the relevant NGO managers and other field-level staff. The objective of this dissemination was to inform the implementing organizations of the early findings so that relevant changes can be made if found to be necessary. This seminar took place in July 2012. Findings: from qualitative research Section 1: Major findings at a glance In this section, we tried to present the major findings of the operational research on the basis of changes occurred in 5 years of programme implementation by PARI Development trust and SATHI among the study participants from Kendua and Durgapur. Table: Major findings from qualitative research Themes Subthemes Changes Perception, Knowledge and practice regarding Programme Perception of PGs Knowledge levels regarding goals and aims of PG differed at the beginning which leveled out in endline in both the sub-districts. Selection of PG members Criteria to select the members of a PG, though were set by the programme, not always followed and the group members included those whom they found to serve group’s purposes better. Capacity of leaders of PGs Leadership rests on the more educated as it did in the beginning. They took careful decisions in terms of electing their leaders. Also, it was clear that they wanted someone who is presentable and articulate, more importantly – they wanted to ensure that the person will be able to provide the time that was essential to lead an organization. Trust among the PG members Most of the PG members have learned to trust themselves or at least know how to resolve if problems related to trusting arises. Management of groups Group management has become more diversified over the years. Initially it was limited to saving money, while now it includes providing loans, taking on small income generating projects, and 39 ensuring health benefits to members and non￾members. Management of financial activities Banking was a problematic issue in the beginning. Over the years, people have started to reap the benefits of the system and have started to have faith banks. Engagement with UCs UCs are formed out of representatives from the PGs, but not all PGs are equally aware of it. The awareness has increased over time, but still is lacking in some places. Engagement of village doctors Orientation of the village doctors seemed slow to pick up. Most of our informants were among those who didn’t receive the orientation. However, we did find out many of them were oriented on SUSOMA activities and things that were expected of them. Problems in forming PGs Formations of groups have become stable over time and the questions and doubts about the groups have lessened. Impact of PI on health equity Utilization of Savings Focus on ensuring money for the emergency funds seem to have increased over the years. People are involved in various income generating activities in order to pay their dues, which they take almost religiously. Planning Planning is being diversifies. Every passing year people are gaining more confidence in their abilities and now thinking about innovative ways to earn and save more money for both emergency health needs and also their own sustainability. Linkage with social elites Supports of the social elites have been noteworthy in these communities throughout the years. The elites are properly motivated in helping in people with health needs. Engagement of NGOs Over the years, PGs have become confident in engaging with other groups and the parent NGO, but not with NGOs or any other organizations beyond the reach of the program yet. Engagement of GO There has been active collaboration between the government health system and PGs – especially the TTBAs who are also a part of various PGs in their respective areas. The extent of collaboration has only gotten better over time and the PGs have also received both moral and monetary assistance from the government. 3: TTBA’s linkages A linkage between the TTBAs and health system is encouraging. Pregnant and mothers in need are being referred and attempts at better care is ensured. Building capacity: CHV Training of CHVs is crucial to their activities and also for their confidence to work in the community. This has been provided to the CHVs adequately, though refreshers may more frequently be required. Capacity building: individual Group members are becoming confident and claim that they might be able to continue without the assistance of the NGOs who helped them form the groups initially and have been guiding them ever since. They mentioned about their increased capacity in terms of management of the finances and also in terms of planning what to do in the future. They were also sure to mention their increased knowledge in terms of health concerns and what to do during times of need. Capacity building: group At the group level, the unanimous opinion was that of being able to help the community, especially with regard to emergency medical needs, i.e. pregnant women needing assistance during delivery. They were also sure to mention the sharing of ideas that place during the group meetings that helps the community at large, and the group members in specific. People’s institutions￾improvement in SES The confusion over the selection and election aspects of PI formation remains, though it seems people are inclined toward election rather than selection, which is more empowering. The progresses made within the PIs have been encouraging in terms of improving the SES of the members and diversifying the savings mechanism and income generating activities. Impact of PI on Health care seeking Health care seeking Initially, the activities of the groups were limited to savings and then it expanded to certain other activities, like some income generating activities and helping group members in emergencies. However, with the SUSOMA activities taking ground, people have started to know about their health related activities where even the non-group members are also becoming aware. PI’s linkage with the health system PIs are increasingly becoming linked with the health system and are successfully referring patients to the 3; hospitals. They are also taking active part in non￾health development work, which is also helping the community at large. 42 Section 2: Perception, Knowledge and practice regarding Programme Findings presented in this section are the results of in-depth interviews, focus group discussions, and observations that we have conducted with the relevant stakeholders in Durgapur and Kendua from Netrokona district in 2010-12 and 2014. From our several field trips to both of the areas we have seen improved access to natural resources, capacity building at individual and group level, improved communication and support skills, and level of trust. Populations of Netrokona, as many other districts of Bangladesh, have less access to transport, roads and electricity. The condition of sanitation has been improved after GOB interventions in Netrokona. Drinking water situation is not even good in Netrokona as the water has iron component more than other areas. People have to collect drinking water from tubewells far away. In 2012, we found that recreational activities are present in Netrokona, However, people from upper SES go there till midnight and this is open after that for the poor people to play Hauji. In both baseline and endline we found that Netrokona is not quite suitable for agriculture. The soil of Netrokona is not as fertile and arable. Education and health are accessible to all in both of the districts. This present study says that most of the community members’ access to most of the natural resources is limited which is due to political leaders’ acquisition over lands, fields, river or ponds or other water bodies, as one of the implementing agency staff stated. Though group members got advocacy to reduce this problem, due to risk associated with life, they are not that much interested to act against this. A payment of 20 taka need to be made to access health services from any public hospital. However, almost all of the public health service providers and family planning personals stayed in Netrokona sadar, so, they are not accessible in time of need which influences the health care seeking of mothers in the starting of program intervention which changed over time. Again, remoteness of some of the areas and poor transport system can create difficulty for pregnant mothers. There is an NGO managed hospital named GBC which provides reproductive health care and delivery facilities with charge for services. In the baseline, in some areas of Netrokona, social security status and community support system were not satisfactory. Ethnic minorities and women were the most vulnerable to this kind of events, such as, rape, hijack. However, these problems are not present in areas with good roads and transportation system. The local leaders took bribe for mediating any disputes. In the endline, we found the situation improved in the intervention areas. In the endline, we found that after the formation of PI and their success, there has been good relationship established between the group members and local GOB officials. PIs have got good amount of donations from them several times. The ministry of Child and Women’s affairs have donated a total of 350000BDT to the PI in Kendua and they would further receive 550000 from them. However, the members would be able to take a loan upto 10000 BDT from this donation. The implementing agency from the same upazila also provided them with decoration sets for event management (plates, glass, spoon, mike and so on) worth 287000 BDT which they can use for earning money. In Durgapur, all the three PIs got donation from PARI in the form of decoration sets for event management worth 125000 BDT. We also found that members of PIs have good connections with local elites, local health care providers (TTBAs, CHVs). A good level of confidence is also observed among the members of PG, UC and PI in both of the upazila in Netrokona. 43 Perceptions of PRIMARY GROUP (pg) at Village Level: In what follows, we provide a description of what we observed and discovered with regard to primary groups over the years of our explorations in Durgapur and Kendua. This includes findings from initial stages of PG development to their current form. In the baseline we found that PGormation is relatively a newer phenomenon for the people in Kendua than the people in Durgapur, since People’s Institution has been formed in Durgapur even before SUSOMA began its activities in the vicinity. Therefore, it was expected that people in Durgapur would know more about the PGs and are able to relay their understanding to us better. On the other hand, though people from Kendua are new to this, they are eager in terms of taking up group activities and have been relentlessly working toward achieving all that can be achieved via group formation and related activities. This is how participants from Kendua stated their perceptions regarding PGs during our initial exploration: • A local village doctor stated that these groups are teams of females. He was not able to detail out the activities and purposes of the groups, but the fact that it was women’s group struck him as most noticeable. • According to husbands interviewed, these groups were a “collective” or a “cooperative” as they have observed other NGOs form in other places. • Members of the PGs, TTBAs, and the CHVs who were associated with the groups were better able to articulate their ideas. According to them, it was a place to deposit money and use that for the development of their families. They also stated that the deposited money was to help the pregnant mother (referring to SUSOMA) • The TTBAs mentioned that they have good connection with the PGs since they join their weekly meetings. In some of the cases, they are the members of PGs. Some of the TTBAs said that they have been given training on maternal health and delivery care. In one instance, the TTBA said that this group helped her to establish good connection with the community, which helped her get in touch with pregnant women. This is how she was able to perform 17 deliveries over a period of only one month. • A person, who is not a member of any group, mentioned that these groups were different from other NGOs in terms of spending money. According to her, other NGOs spend their time and money on microcredit, while these groups save money to improve the health condition of mothers and their children. She said, “They took me to the UHC. They gave me money too… SATHI groups work with us wholeheartedly…” There were negative perceptions about the PGs as well from both Durgapur and Kendua, • A non-member suggested that the NGO (SATHI in Kendua) w take the money with them. According to her, there are evidences that some other NGOs took money from the people in their villages and ran away with them. • There were standard criticisms of PG activities and their related NGO – something that just about all the NGOs face here in Bangladesh from a number of conservative Muslim groups. For 44 instance – one person suggested that the Shomiti lends money on interest which is contrary to their religious beliefs (Durgapur). • A lot of our informants from both Durgapur and Kendua mentioned that they do not know what the futures of these groups are. Being uncertain of their future makes them uncomfortable to join. • During the initial stages, almost all of the participants in Kendua, including the husbands of the female members, members of SUSOMA, TTBAs, and the village doctors were unacquainted with the activities, roles and responsibilities, UC/CCC and their future plan with the savings. • Though the CHTs are in charge of forming the PGs, they are not well aware of the UCs or PIs. Their knowledge is often limited to the role and activities of the PGs. Most of the members in Kendua in the initial stages did not know much about the election process of PG. Many of them did not have any idea about the activities of PG, other members of PG, CHT’s contribution, NGOs involvement and purpose, positions held by members, UC/CCC. In addition, many of the PGs in Durgapur do not have a bank account to deposit their money. However, since our initial exploration, a lot of changes occurred in the field. Data from endline survey found that members of PGs in Kendua are comparable to the PG members in Durgapur and are well aware of their groups’ activities, purposes, and vision. A lot of this has been captured in the endline survey intended to measure the Social Capital. In 2014, our findings present that three People’s Institutions (PIs) are formed in Durgapur and one in Kendua. Two of the PIs in Durgapur were formed as a part of general PIs of PARI who joined SUSOMA later on and started working on maternal and child health issues, especially on reducing child and maternal mortality. In Kendua, their only PI was formed as a part of SUSOMA from two representatives from each of 45 PGs and have a steering committee of 13 members. Process of Formation of groups According to the participants of this study, Community Health Trainer (CHT) was the primary “external” element in the basic scheme of building a People’s Institution and especially so as it relates to the formation of primary groups (PGs) in the community. A CHT has to spend months in a community talking to people, expressing the need and utility of forming a group, and explaining the vision of such groups to women and men in the community. The process seemed arduous and required a lot of patience. One of the CHTs in Kendua who formed the group we observed reported that she worked for three whole months and was able to identify 13 potential members. The initial activity of group formation was thus finding the right persons who would be motivated enough to deposit a nominal amount on a regular interval (usually per week) and who would have a vision of doing well for themselves as well as the community. NGO staff working on the matter was instrumental in this regard. They provide the organizational know￾how and orient the potential group members on the activities, goals, and objectives of forming the group. During initial meetings when the would-be group members were not so certain about entire ordeal, this can and did have a negative impact. People started to question their motives and were hard-pressed to keep their enthusiasm intact. It is the basic principle of forming these groups that the leaders would be elected and the groups would pick their own. It was this principle that guided the meeting that we observed. Names of people were 45 called out while the participants voiced their opinion on each. Despite this democratic process, often groups cannot form the first time they meet. There is always that chance incident where people do not see eye to eye and end up having a brawl instead. The meeting that we observed ended up on such a negative note. In this case it was two of the members who happened to be the wives of the same person started to fight with each other. The CHT had to exclude them and fix another date for a follow up session. The meeting concluded with money being returned to each member and with a conciliatory note from the CHT that these types of events were common. One of the group members in Kendua shared her experience of group formation as she recalled: “Four years ago, one day the CHT di came to our village and was looking for a local TBA. The CHT di came from Shathi office. She organized the first meeting with us. She gathered several local married women and discussed about women’s health group activities. Few local women also helped her to call other women. She introduced us to the idea of a group. Our (current) cashier and president also helped her to conduct and arrange the meeting. The first day was introductory, while it was fixed that we will have weekly meetings. The following week we discussed the possible benefits of the group and other activities of the organization. It was during the third week when it was formally formed, leaders selected, and a name for the group given. In broad strokes, the process of forming a PG can be expressed as follows: Flow chart: Process of PG formation in Kendua and Durgapur according to informants In Durgapur, one of the group members stated that they heard from others about PG and called the CHT to help them form one. The CHT came to them and gave a demonstration on how and why to form a group. All of the interested members agreed and finally they could form it. This was a retrospective interview, thus lacked the immediacy of the findings from Kendua. Nevertheless, the process seemed smoother, though they also informed us about brawls that have taken place there as well. The process of PG formation remains more or less the same over the years in both of the upazila as the study reveals. ""  $" #  $$$ .# "$%     "%  .##("% )$ '$*! ! $  %($$ " #(" $# #$%    !"# $   #$,, !"%!$# % *$ !"%!$#$ $"# "%! "'$'" %(%#)$#'!"(#  "   #$# 46 Selection criteria of PG members According to the participants in Kendua, the following were the specific requirements of being a member. All the members that we talked to in this particular FGD in baseline, were of the same opinion, indicating that they were informed about the matter in a uniform manner (relating to a female group): • Married female • Reproductive age which ranges from 15-49. • Local girls were excluded from the selection criteria (this was reported, but later we found out that this specific criterion related to unmarried women, since once they get married they might leave the community and not remain a member of the group any longer) • Income was not stated as a criterion • Education was not mentioned as a point In Durgapur, the PG members stated the following criteria for suitable members: • Women who are potential mothers (married and within the reproductive age). Therefore, doors were closed for widows and/or divorcees and unmarried women. • No limit on income, such as less or more than 3000 taka. They explained that a rickshaw puller may earn up to 6000 taka, but, he and his family may still be poor since he has to feed a lot of family members with that income. Therefore, the community would decide who is poor and who can join the group. On the other hand, there are people who have no source of income and have a family to feed. Like a woman mentioned, “Suppose, a woman’s husband does not earn anything and he is physically disable. She may have children or get pregnant again… this male cannot even earn for himself… how can he arrange food for that pregnant mother? These people can be called absolute poor, since the pregnant mother cannot even work as a maid in someone else’s home…” Though education was not mentioned as a criterion, they felt it was better if members had some education. However, the reality is, most of the members do not even know how to write their names. General members of a PG decide/choose their leaders. They decide as to what qualities they would like in their leaders. For instance, if it is a cashier they are trying to decide on, then they might look for someone who knows how to count and do some calculations at the least. In another instance, the president of the PG was selected on the basis of education and capacity to create linkage with others in the society. One of the CHVs from Kendua shared, “(she can make us) understand something after she would learn them… she can read and write and understand which is better or not… she can understand all those… she has the capacity to keep linkage with everyone in our society… she has the capacity.” In Durgapur, one of the cashiers of a PG was removed from her position as she could not calculate the money deposited to her properly. Therefore, she proposed to other members to select another cashier instead of her. The PG members sat together and selected another. The previous cashier was selected on the basis of her promptness in other activities and was given 6 months to make up her problem. 47 In addition to the points mentioned above, we also noticed there were several members who clearly were far older than being within the bounds of reproductive age. In Durgapur, members stated that there are some women who would like to be members now – women those who were not interest in the initial stages of group formation activity. However, “it is not possible to take new members now. They weren’t members before as they didn’t understand the benefit before.” The selection criteria of the PG members remain more or less the same during the end line as it did during the initial stages. In other words, PGs often “bend” the rules in order to best serve the interests of their respective PGs. Leaders Capacity The leaders are elected by general members of the PG. The general members decide the quality they want to see in their leaders. The female leaders in the team are the matobbors from the area or from influential families and educated enough to calculate. As for example, they think that, a cashier should be educated enough to calculate the monitory estimations. “We are not educated, but, she is. Therefore, we made her cashier in our team.” As mentioned in the earlier section, education becomes a criterion for the selection of a leader since people believe she would know things better and then would be able to make the rest of the members understand accordingly. A PG member form Kendua shared her experience about changes, or lack of it, in leadership and qualities a leader should have, “The group was leading by the community women who are attached to the group since last 4 years, still now there is no change in leadership. We have a president, vice president, cashier, assistant cashier, secretary, assistant secretary, another post that we call office sectary and an assistant secretary. At the very beginning, the members selected the leaders in front of the SATHI staff when the group was formed. All the members think that there leaders are capable, intelligent, educated, they also understand the financial transaction for that they select them as their leaders and still now they are doing well for that we did not need to change leadership.” A PG member from Durgapur also said the same, “It is running quite well for the last 3 years. There was no need to make any changes in leadership. But, we have it in our mind that we will change this in the near future. ” The participatory approach is what makes these PGs unique and different from other groups formed by other NGOs. Often people selected as leaders themselves talk about their inabilities to perform their tasks as expected and request to resign and have someone else replace her. They seem to understand well that it is not about holding a position, rather it is about being able to run the activities of the group properly that matters. The incident of the cashier mentioned above is one such example. Similarly as we saw in case of criteria of PG members, not much variation was observed over the years with regard to leadership qualities that the members deemed important in their leaders. 48 Interviews to inform the leadership qualities as understood within the PIs were all conducted during the end line exploration. For obvious reasons, there were no such leaders made or produced in the initial stages. In 2014, participants from both Durgapur and Kendua said that they prefer someone who can talk and give time to activities. One of the members from Durgapur said, “Though many of our members have good leadership qualities, such as, skills of writing, reading and calculating our money, but they failed to provide time to our activities. Therefore, we want someone who is able to give us time. ” According to almost all managers, it takes at least 5 years to make an effective leader from a general community member. “To be a leader, one must have willingness to do so. She must be able to talk and must have family support… they should be able to comply with rules and regulations, with other people in the community and they should be capable of managing members of their groups. One of the managers from Kendua said, “Good thing is that, anyone can challenge leaders if they don’t perform well. Many of the leaders were changed in last 3 years whenever they failed or low-performed.” “Commitment is the most precious to be a leader.” “We have wide range of leaders here in kendua.” One of the representatives from implementation agency stated how the program is designed to develop leadership, “There is executive committee in each PG, which is 3-members, or 5-members or 7 –members committee. We have president, secretary and cashier in each of the committee. They are trained on what they do, how to and work on as their position demands so that they can lead 15-20 members group. In all of the three structures (PG, CC and PI), we provide them help to develop capacities of leaders.” Other qualities that are must for leadership or selection of leaders are: • “Must know how to manage team member and their problems”. • “Must have the characters that one can respect” • “Trustworthy” • “Can explain issues and come to a possible solution” • “Can talk, not someone who has qualities, but utter a few words in a day” In 2014, in both Durgapur and Kendua, PIs have members who passed SSC and are family members of social elites, such as, wife of Homeopath doctors. However, one of the PI leader said, 49 “At first, I was not willing to be a member of the group. But, if I would not join, none would! None trusted them (implementing agency) at that time” Presence of Trust Data from 2011 and 2012, our early explorations into the communities and the activities of the PGs, show that some of the participants, such as the TTBAs, knew how the PGs can help the mothers in the community. However, they didn’t know how they themselves would be helped through it. In 2012, one of the members of PG in Durgapur quite eloquently mentioned the importance of trust in a group. She even went as far as saying that it should be a selection criterion: “Unity should be present among members. The members must have love and respect for each other. We should help each other in any danger/ emergency. This is what we need for formation of a PG. ” Lack of vision, lack of a concrete goal to which one can look forward to be essentially a problem in these group activities. In one instance in Kendua, a group was on the verge of being broken since 8 of its members were leaving. All of these 8 members were interested to withdraw their money from the PG while other members denied giving it back to them. This resulted into a conflict and the members wanting to leave were saying that Grameen Bank was going to come and take all their money – which is why they wanted to disband. Though this was a source of conflict, in time, it became a cohesive force in order to keep the group together. It worked as a bond. Consequently, most of the members returned and rejoined the group. Many a time groups that have been formed could not sustain and disbanded due to the issue related to trust of various kinds – from individual to institutional. A member of a primary group in Kendua stated that they lost interest to continue with the group because they could not trust the bank with their money. Their previous experience with NGO in financial activities was not satisfactory as those NGOs left with their money. They lost their enthusiasm in saving money for themselves and the community as soon as they were told to deposit them in the bank. In some of the cases, the members stopped believing other members of the PG due to their proximity with the NGO staffs or on the issue of supporting to keep the money in bank. In one instance, a CHV who had initiated a group did not deposit the group’s money since she was in a crisis. This created dissonance in the group and the group got disbanded. However, later on she wanted to come back to the group, but other members could not trust her any longer. However, when we went in for the last stage of exploration in the endline, we were met with changed circumstances. Most of the members, including the TTBAs, knew what to expect from the groups and how these groups were working for a positive change in the community. Trust seemed to have been built in many of the groups, or at least they had figured out how to resolve problems arising from not having much trust amongst them. A negative experience of a PG was shared by a manager where one group managed to save up to 100,000 BDT and had no bank account. The cashier who was in charge of the money spent part of it (4000-5000 BDT) which destroyed trust of the group members. However, the members managed to solve the problem and the group is still sustaining. 4: Urban-rural differences of PI It has been shared by the implementing NGOs that, in the urban areas of Dhaka, the development of PI is two tier, namely the primary groups and the PI. However, this is formed through a three tier system in the rural areas, namely primary groups, UC/CCC and PI. Selection criteria for urban PI/ PG members are also different from those in the rural areas as most of the people are migratory in nature here. Migration of any group member creates difficulty in the stability of the group. Therefore, the followings are the criteria: • Age ranges from 15-49 years for female members and 18-55 years for male members • Income > BDT 3000 / month • Resident in a particular area for at least 2 years, however, in some areas this criteria reduced to 1 year • Distinct male and female groups • Illiterates and female gets priority to be a member All of the slums were categorized into 4 categories according to their performance and facilities they got, namely A, B, C, and D. PGs in urban slums can allow 15-25 persons. The PI is formed by 2 members from each PGs. All of the sub groups are interlinked. They have different activity based sub committees on health, education, income and so on. The health committee focus on identification of pregnant mothers, checking weight of children and mother on a monthly basis, assurance of vaccination of pregnant mother and delivered mother, supervision of the TBAs and the CHVs working with them, referral to health facilities. One of the staff from SATHI stated the process of referral, “Each of the subcommittee of health has CHVs and TBAs working under them. The CSBA refer the mother. But, no one will accept if the CSBA refers. Therefore, referral linkage needs to be made. The subcommittee of health talks with and develops a MOU with any upper level staff or manager in health facilities to create linkage (to ensure special care and treatment free of cost)… the CSBA and the TBA start to refer them to the facility and that PG greet/ thanks the manager for in their meeting in once in every three months.” The capacity of the PGs is measured in every 6 months based on a scale called Community Capacity Indicator and the PIs capacity is assessed with People’s Institution Capacity Indicator. This helps to create a plan for next 6 months and assess the present status of any PI or PG. The process of choosing a leader is selection in the urban areas as many members do not have good communication among themselves due to slum environment, job type, shifting of income generation works and overall migratory nature. However, if there are more people competing for leadership position, the NGO invite them for election through confidential ballots. The old PI members are more concerned with the position of leadership than the newer PIs as they found this as a platform to join or attend city corporation power structure or a door to the political power. Leadership development in urban areas is one of the prime outcomes, as different NGO staffs agreed. Changes have been occurred in selection of leaders in the community level in the villages. This changes has been described by one of the NGO worker, 4; “Those who are rich, were the leaders in the community before. Nowadays, they have started to live at home and the poor people have been in the leadership positions.” The community people have started to belief in connection with their community. They said that all of the members of the groups were poor and illiterate. However, they have learned to take care of their groups’ property and manage groups’ activity. This made them more confident, honest, responsible and expert. One of the NGO stated that this is NGOs one major contribution that leadership has been created, “For management of money, they said, ‘how can we keep this amount of money?’ they have opened their own account… its’ not us but the groups found that they can take responsibility of their own children… the cashier was the poor most… they asked if he took the money… we said, ‘this is all your money. Won’t you find out if he does so?’… therefore, that person felt better and can dream if he has money…’’ “If somebody takes any challenge, he will get success” Leaders are selected by the team members. These people are trained in many skills and are attached to primary groups. They work voluntarily for the society within the health committee and others within primary groups. The NGO staff explained the leaders’ selection, “They consider the skill (of the leader) more than. Whenever, they select somebody as leader, they scrutinize the expertise of the person… they are skilled in selecting skilled person…” The motivations for these voluntary works are three fold: • It helps to get respect from other members of the community. • This is the responsibility of the person to the society and • The God would be satisfied upon the person for his/ her good will. Their humanitarian qualities are the most significant resource of the community. This also contributed to women empowerment. One of the NGO staff from PARI stated, “If the women have to take money from their husband to make the savings of the group, the husband will say, ‘you better leave this group’. These women has been given chance to do poultry or provided with (fruit) plant, lemon tree or guava tree. Their families are getting nutrition from these and they are selling them. Thus they are saving money.” Women empowerment is another feature of PI that strengthens its possibility for sustaining. In the urban areas, many of the women were under veil when they joined and later they learned to participate actively in the meetings and negotiation of disputes and even in elections. A leader cannot be selected more than twice for the position of chairman or secretary to a committee in Jamalpur. This is little different in Nokla, where members of a meeting decide who would facilitate the next meeting though they have chairman, secretary and cashier selected for 2 years. This helps in leadership development as all of the members get the chance to handle situation. In general, the committee gets changed in every two years. In the new committee, four of the members out of nine are new and other old members get changes after their two years stay in the committee. All the members go through trainings. However, one of the NGO staff said, 52 “This is a process that everyone will get training during election…everyone will have leadership training and will have to complete this. (But)… not everyone will be the leader after getting this training.” In some rare situations, leadership fails for the following reasons: • The new leader may not be interested to work. • They may not give importance too activities of the PGs. • Isolation from friends and family due to workload and mingling with other people from political sphere can change a leader’s mind set and turn him into a greedy person. • In some cases. The leader can develop some bad habits and forget his motivation. One NGO worker stated a case from Melandoho, Jamalpur, “we make a person named X to compete as a (UP) member. He got more vote than the chairman. Everyone in this village welcomed him, (and they said,) ‘we are with you in any kind of problem. Never get scared and talk confidently’…But, after he has been a member, he started to be habituated as other members, such as, playing cards. He had some loan from PGs. He did not even pay them and forget the community as other traditional (UP) members.” After deciding the leaders, the NGOs task is to find out the gaps of him or her and make it up through trainings. One of the NGO workers added, “after the leader is decided, we give him training support. We have discussion with him and find out his deficits and then we work on it. (We tell him), ‘it is not that you would talk (only), (but) everyone should be given the chance to talk’… this is your responsibility to make others to participate’. We stay with them and let them how to work with others.” Management of groups From the baseline, we found the CHV/ CHT as the person responsible to install the PG and along with the NGO staff she also contributes in developing leadership in the PG. During the observation of PG meeting by research team, it has been seen that the leaders (i.e. president, cashier and secretary) are from influential families, such as, wife of the local political leader and so on. In most cases, they are popular among the members. However, in endline these groups are in their advance stage and more matured state of being, the PGs are working on creating health guidelines, flipcharts, and books which they discuss during their weekly meetings. As a group member suggested, their main task is “to reduce maternal and child mortality in their area.” In summary, the activities of the PGs in Kendua are: • Weekly meeting • Depositing money • Sanctioning loan to group members for emergencies • Working on guideline and health related flip charts and books in weekly meeting The PG’s activities in Durgapur are as below: 53 • Weekly meeting • Depositing money • Sanctioning loan to group members • Helping in emergencies o Family members Pregnant women who are members of PG Management of savings In 2011 and 2012, the members of PG in Kendua have a fixed amount of money to deposit in group’s fund which was 5 taka per week for the newly formed PG and 10 taka for older PGs. They also have a fund called emergency fund for that the members pay 2 taka per week. If the members fail to provide the money for any week, they deposit twice amount in the following week. This savings is considered as the most significant motivation to the members of PG. In 2014, the members in both Durgapur and Kendua said that they must deposit money for emergency fund, even if they are not able to provide the money for regular fund. The poor women in Durgapur arrange their weekly deposits from various activities that are otherwise also income generating and/or related to their own savings. The activities are (but are not limited to): • Selling vegetables from the small gardens they have at their house, • Depositing handful rice every day, • Sewing, • Poultry According to our informants, in Kendua things are also similar where they manage their deposits through the following activities: • Husbandry • Selling vegetables grown in the yard • Poultry Management of financial activities In 2012, the husbands’ of the female members in Kendua and Durgapur knew about PG that, this is a place for saving money gradually. However, they did not know to whom this money was being deposited and what would be done with it once there was a handsome amount saved. In the initial stages, this activity was not as smooth since there were a lot of confusions over it. Many women did not even know who they were giving their money too, which often made them nervous. During the initial stages saving money was a technical problem – they did not know how to do it – whether to have it with one specific person or to have it deposited in a bank. A lot of people in Kendua did not trust the bank but many also didn’t trust their group members to be entrusted with all the money. In endline, people are starting to reap the benefits of it already. Even the husbands know where the money is going and how it is being used. This is a positive change since during the initial stages we heard of many husbands becoming a barrier to continue saving money on a regular basis. 54 Over time, their distrust over the bank has disappeared and people are now okay with idea that it is safe to keep the money there. All the members can take loan from the PGs. In Kendua, the members can pay back the loan without interest within time. If they need extra time, they have to pay very little amount of interest with the capital. On the other hand, in Durgapur, the members have to pay back a very little amount of interest if they take any loan, which is very little compared to other NGOs. As for example, “We have to give (interest of) 4 taka for each 100 taka… In other villages and in our villages, they give (loan) on interest on monthly basis or on weekly basis. Suppose, you have to pay 75 taka for 1000 taka weekly which comes to 300taka per month. But, it is 4 to 5 taka for the money we save and it is our money, not someone else’s money.” Taking ‘interest’ has been considered as “sin” among the Muslim members of the PGs. Therefore, it also created crisis in financial management in some groups. It is a constant dilemma that the PGs have to deal with, especially within the more conservative segments of the population. However, this behavioral aspect is also changing and people are becoming more accepting of the idea. For giving money to any members, all the members of the PG have to agree on this issue and this has to be passed in the meeting. They do not have any written minutes of the meeting, the cashier keep record of the money given to the members. PARI staff from Durgapur said, “Nowadays the PG members can make their own decision on financial issues. They generally keep the money in three separate ways. One part of it is kept in the bank, another is in the form of loan to others and third part is in cash for handling crisis.” The following financial decisions are taken in the weekly meeting: • Issues of providing loan and to whom this loan would be given, • where to spend the money, • how to collect money for emergency fund • who should get financial support from the fund Groups disbanded or collapsing Our study is not designed to capture the extent (quantitative) to which the PGs are collapsing at any given point in time, but judging from the reports of our informants, it seemed concerning during the initial stages. The reasons we identified in baseline were as follows: Mistrust among the group members: As pointed out elsewhere, social cohesion has been lacking in Kendua, though it is changing. We also observed this in Durgapur though on a lesser extent. This makes trusting other members difficult for the people, since they are not too aware of the other’s intentions and do not know what, if any, good would come out of it. 55 Mistrusting the NGOs (previous experience): Right across the field sites, especially in Durgapur, the role of NGOs is sketchy. People are not too sure as to why they are assisting them to form groups. In the presence of this uncertainty, people make up stories and they start to gain grounds over time. Lack of clarity regarding PG’s objectives: Not knowing what the objectives are is a major concern, since that alone can guide people in the right direction and not know them can simply destroy an association. However, this is changing since by now people have become confident about the purposes of forming the groups and are taking active interests in all matters pertaining to the groups. Lack of future plan (with regard to the money saved): We observed that a few PGs lacked any future plans, which dismayed the members and they withdrew, or wanted to, since they couldn’t see what would come out of this involvement. Confusion regarding personal roles and responsibilities: Just like the objectives, people do not seem to be too aware of all of their individual responsibilities. However, as they became aware of these roles and responsibilities, the situation also has started to change in this regard. Interest on principal amount is problematic in certain Muslim communities since Islam is against the provision of interest in their banking systems. In one instance, a group became inactive over an issue relating to providing assistance from their emergency fund to a pregnant mother for her delivery. This woman and her family was unable to return the money to the group after her delivery since they were poor. When the group members contacted the NGO regarding this matter, they suggested that it was okay since it came out of the emergency fund and was not something from which they would generate income. However, this explanation was not comforting for the members and they became uninterested to give their weekly dues. Soon it became inactive due to lack of interest and regular activity. In the endline, we found changes over the years of implementing the program. Trust within the groups have increased; group members are less weary of the NGOs; members now understand why the NGOs are assisting them to form groups; and above all – group members themselves know why they are forming groups and that it is for their own benefits and not of someone else’s. The rate at which the groups were collapsing seem to have slowed down now and the groups have become stable over time. When asked about groups collapsing, one of the representatives of the implementing agency stated, “I believe that not all the groups can sustain. There are so many groups. Therefore, it is natural that some of them would get broken.” Communication with NGOs and decision making Though in the very starting, we found that many of the groups were in dark about their responsibilities and were unable to make any decision alone, thus, highly depended on implementing NGOs. One of the members in Kendua said, “We don’t understand this yet. Tell us more about it. Let us understand.” They stated that they need help from the CHT, CHV and NGOs in taking any decisions. There are no PGs or PIs working with complete independence. However, in the end line, we found the changed situation in 56 Durgapur and Kendua. In 2014, most of the PG members from Kendua said that they have communication with SATHI, but it has been SATHI only, not any other NGOs. They communicate with other PGs in the union level monthly meetings and ask government health staff to join. One of the members said, “We communicate with other groups like us (Other sathi groups), when we attend the monthly meeting we just share with them about our activities; about the group works, investment types etc. In Upazila Sathi monthly meeting we all attend and we also share and talk about groups development, government peoples also present there”. “We do not try to communicate with other organization for our own demand or anything else.” PGs seemed to have gained the capacity to work more independently over the years but they are still not ready, according to them, to operate completely without assistance. Engagement with UCs During the baseline, most of the participants in Kendua informed that they have never heard about UCs, which includes the female members, their husbands, village doctors and CHVs. Only one village doctor, CHV and the TTBA could tell about UC, but they failed to elaborate on it.. The CHV said that, cashier form UC came to meet them and they do not know more about it. During the end line however, participants were able to talk about UC or CCC in greater details and that it was in fact composed of representatives from several of the PGs like that of their own. However, the awareness still is not of the same level within all of the groups and not all of the groups get to interact and participate in forming UCs on an equal level. Some of the participants from Durgapur heard about the UC or CCC, but could not meet anyone from UC. One of the group members said that they were told that they would have to join the UC. Engagement with Village doctors Baseline information on the village doctors suggests that they were not oriented on SUSOMA. Since the baseline, many village doctors have been trained, though most of the village doctors in our sample were not. One of the village doctors said he had good connection with the CHT and the CHV/ TTBA as she came to his work station regularly and told him about maternal and neonatal health. This village doctor also knew the members of PG as they are from the same locality and was willing to help the people in need. All of the village doctors from Kendua know that SATHI is an NGO that works for reducing maternal and neonatal death. The village doctor, who has been oriented with the SATHI, stated that he already referred nearly one hundred patients with maternal and neonatal health problem to the district hospital in Netrokona. All of them said that the CHT visits and inform about maternal and neonatal health regularly and also provides referral slip. One of the village doctor advised that more programs on awareness building should be initiated here to get good result on maternal and neonatal health and include the religious leaders in disseminating information after Jumma. 57 In Durgapur, all the village doctors interviewed have stated that they know about PG, and UC. One of them said, “They (members) meet regularly on Monday… they (only female members) are given advice on maternal and neonatal care….it is good if they can really save money. ” Village doctors from Durgapur also stated that they have regular contact with the PG members through meetings. One of the village doctor also said that this communication make it easier for the mothers to get care from themselves and their children. Problems in forming PG Challenges of having members: In Kendua, many of the non-group members said that they have not been the members of groups for the following reasons: • They were not present in this area when these groups are formed, later they migrated here from other places. • The money has to be paid in every week. Even though the amount is low, they are not able to deposit this on a regular basis. • Some of them are nervous that what other people would think if they fail to deposit the money even for a week. • Some of the participants said that they do not like the idea of shomitee./ group/ dol • Some of the women have not got permission from their family members to join this though had willingness to do so. • Religion has been a barrier in some cases as one of the participant said, “She is a Maulana’s wife.” • Some thought this would deal with interest (profit), which is not allowed in their religion or unethical. “they collected money first, then it becomes an amount like 10000, 20000, 25000. Now they are investing them with interest. It’s not possible for me to live on interest. This is the main reason. ” • One stated that she doesn’t have any child, which is why she found this investment as useless. • Some thought that they would not be able to allocate time after doing household works, child rearing and so on. According to the informants, the followings are the drawbacks of forming a PG: Feeling of insecurity to get the deposited money back: One of the PG in Kendua was formed with 20 people and 9 of them left due to this reason. “Many of the members were scared that their savings will be taken by other. We will not get them back. Therefore, many of the people left.” As most of the female members of PG migrated from different areas, they are not rich and lack strong communication among themselves. 58 “They (local people) are living here on the government’s allocated land. Their husbands may have a shop, or engaged in small business…they have too many children to have any surplus from their income…” Personal conflict among the members: One of the PG get broken on the same day of formation due to personal conflict of two wives of the same person. Absence of the NGO staffs from the initial stage: Some of the female members of the PG in Kendua said that some people do not trust these PGs as no “officers” or NGO staffs were there from the early stage. Some of the members said, “Many people say, ‘officers do not come (here) … no signatures from the officers are here.’” No paper works: As there are no papers, or slips came from organizational level, people have less faith in PG formation or deposition of money in Kendua. People from different background: Many of the people in Kendua have migrated from different areas in Bangladesh. Therefore, they have different types of motivations and cannot comply with the PG formation processes. They are less confident about depositing money. The CHV from Kendua explained, “People (living here) came from different cluster villages, or districts or other places.” Policy of ‘interest’ sharing in the form of profit: The Muslim community living in the do not prefer the scope of getting ‘interest’ as this is forbidden in the religion. Therefore, they are not interested to form a group. Most of the challenges and concerns mentioned above were found during the baseline exploration as is expected since forming of groups were taking place at that point in time. Over time, things have become more stable and people are more understanding of the purposes of the groups and the need to be in the groups over a long period of time. 59 Section 3: Impact of Social Capital on social determinants of Health Equity In this section, we presented our findings that showed how increase in social capital might have impacted the indicators of health equity, i.e. access to health and health care in Durgapur and Kendua in Netrokona. As discussed earlier, population from these two upazila did not have full access to government health services during baseline due to their financial capacity, transportation cost and availability and also social injustice of not having the health care providers providing good care. Their absence in the health care facilities also hindered contributed in this regard. However, results from endline showed that this situation has improved with increased number of health service providers in health care facilities, greater linkages have been established and communication between local health care providers (CHV, TTBA, VD) and the public health care providers has improved. Influence of elites in terms of making the health care professional be more responsive to the needs of the people has increased as well. Understanding health equity Though it is not clear if people understand health equity as a concept, the activities of the PGs prove that they save and work toward ensuring that most of the members have access to the health fund. From the baseline, we found that all the PGs have their emergency fund to help the pregnant mothers in which they are committed to save 2 taka per week. In some of the areas, such as Kendua, they call this as lillah fund. If the members fail to provide the money for any week, they deposit twice that amount in the following week. This savings is considered as the most significant motivation to the members of PG. Many of the groups helped pregnant mothers for delivery or a pregnant mother’s family member to get treatment. Though these assistances came from the emergency fund, mothers can also get help from the regular funds as loan which has to be returned within a given time with or without any interest depending on the rules agreed upon among the group members of specific PGs. To carry on with the activities, most of the PGs have regular weekly meetings that are facilitated by the PG leaders to collect the regular deposits, calculating the deposited amount, and discussing financial and other emergency issues. In case of a crisis or health related needs, they can call immediate meetings to make financial arrangements if required. We found the PG members to carry out this tradition even in our Endline. PGs are working on creating health guidelines, flipcharts, and books which they discuss during their weekly meetings. As a group member suggested, their main task is “to reduce maternal and child mortality in their area.” This emergency help is not limited to the group members but also to any mother of the locality. In 2014, the members in both Durgapur and Kendua said that they must deposit money for emergency fund, even if they are not able to provide the money for regular fund. Prioritizing health In the baseline we found that, though the PGs think that their financial capacity is not yet up to the standard to make massive plans, they are hopeful to do some activities which would reduce their problems with finance, health, and any other kind of difficulties. Their money would be used for any kind of income generation activities only if they can deposit a good amount. Some of the group members have already invested the money. This money can be given to the members as loan. Their future plans was associated with cattle farming, invest on rice cultivation/ share cropping, use for marriage ceremony of their children, use in case of need/ difficulties/ emergencies, keep the money in Bank, buy a pond and 5: start fish farming, provide the money as loan to the members of the PG with or without interest and lastly for the wellbeing of family members, especially for their children. Just opposite to what we had when PGs planned during the initial stages of the program, in 2014 we found most of the members interviewed agreed that they prefer to use the emergency fund for the mothers and children who have to be taken to the hospital. This directly related to the interventions focused on health concerns and activities of SUSOMA. Most of the members of the groups and PI are highly motivated to spend the money for maternal and child health emergencies which implies that they understand the concept of getting health care. One of the member from kendua said, “Isn’t it good if we spend for our mothers and children when they will need emergency health care! Suppose, the mother needs to deliver in the hospital, then, we should take her immediately. This is our main task (responsibility).” However, one of the PG members from Durgapur said, “We are aiming to save some money in the bank, such as 500 or 1000 taka per month. If the bank, then, provides us with loan, we will use the money to buy power tiller. If we rent that to other people, we will be able to earn more money.” Improved Communication with Elites Since the beginning PGs have been highly appreciated by the local leaders. In fact, the support they are receiving is acting as an active encouragement of the members of the groups to further concentrate on their activities. In Kendua, PGs have received donation in many format, such as, • Many of the chairmen have provided BP machine and weight machine to CHVs so that they can do check-ups properly. • The UP chairman also provided 20 kg flour and 20 kg rice for the emergency health fund of one PG. • Village primary school teachers also managed to donate money • In general most of the money is collected from the villagers. From our findings in Endline, we found that support of the social elites persisted over the years. We found the active involvement of the elites in transporting, counseling and referring the patients to the health care providers, donating for the wellbeing of the PGs and supporting them in many other ways. In Kendua, we found that the seniors of that area said that they found all the groups as very useful. Most of the members said that they have got donations in the form of cash money, warm clothes for extreme poor, weight machines for mothers, rice, flour, edible oil and so on from the community, local government and local leaders where the social elites influences the decision on receiving them smoothly. Linkage with local health care providers Baseline information also showed that the village doctors as not oriented on SUSOMA, however, they knew that the PGs are small groups that save money. Since the baseline, many village doctors have been trained, though most of the village doctors in our sample were not. It eh endline, we found that many of the village doctors are acting actively in the referral of maternal health patients to the formal health care facilities. One of the village doctors said he had good connection 5; with the CHT and the CHV/ TTBA as she came to his work station regularly and told him about maternal and neonatal health. This village doctor also knew the members of PG as they are from the same locality and was willing to help the people in need. All of the village doctors from Kendua know that SATHI is an NGO that works for reducing maternal and neonatal death. The village doctor, who has been oriented with the SATHI, stated that he already referred nearly one hundred patients with maternal and neonatal health problem to the district hospital in Netrokona. All of them said that the CHT visits and inform about maternal and neonatal health regularly and also provides referral slip. One of the village doctor advised that more programs on awareness building should be initiated here to get good result on maternal and neonatal health and include the religious leaders in disseminating information after Jumma prayer. In Durgapur, all the village doctors interviewed have stated that they know about PG, and UC. One of them said, “They (members) meet regularly on Monday… they (only female members) are given advice on maternal and neonatal care….it is good if they can really save money. ” Village doctors from Durgapur also stated that they have regular contact with the PG members through meetings. One of the village doctor also said that this communication make it easier for the mothers to get care from themselves and their children. Engagement of GO In the endline, we have found that there is active engagement between the GO and the PG members on ensuring health care. In our baseline study, we could not get such information. The PG members meet the GO health officials in the monthly meetings in Union level. One of the PG member form Kendua said, “Each of the PG has representatives who are TTBA. The TTBA refers patients to UHC’s FWA and request her to provide support to our patient. In most of the cases, we talk over the phone to upazila health complex DAI (FWA) about patients’ situation. We do not try to get help from government directly but we try to receive help from health facilities according to our demand. ” PG members help the GOB in many ways, such as, informing the community about EPI and sending the list of new pregnant mothers and so on. The government health staffs also invited them to join some of the meetings other social elites where information provided by PGs influenced decision making and plan development of GOB. One of the PG members from Kendua said, “We are not involved directly in government programs but in EPI sessions we support them, our TTBA and CHV also support them, our TTBA also sent pregnant mothers and newborn list to government health officials. We inform the community when the EPI sessions start. Directly our group was not involved with government works/program. We just support government in hand wash and EPI programs.CHT (name)di inform us about government program.” “In upazila and district level we are respected, our list and our information helps government… and in district level meeting CHT (name)di represented us. She told us that our information influence government decision.” 62 Members of Durgapur also join meeting with GOB health staffs and other local elites. They shared their experience, “We have good relations with government. We have meeting with chairman, member, school teachers, leaders from the community and PARI staffs, all of these people. Sometimes this is weekly or monthly. However, it doesn’t occur in every month. PARI discusses about maternal and child health. The GOB health staffs provided medicine. They talk about nutrition and food practices. Members (UP) also provide speech. However, they didn’t ask for any help from government, but it is possible to ask for. We are not attached to any government program. The government doesn’t even invite us in their programs. But, we invite them.” “In EPI, the CHVs help if the government health staffs ask for help. The PG members also assist in EPI. Representatives from clinic and hospital work together and have meetings. Information collected by PG are provided to the hospital even if the members fail to join the meeting.” “In the district level, we don’t get any value. The government staffs always say that “you are doing well,” but, they don’t provide us with any help in developing plans or development activities.” In Durgapur, one of the PG group members is also a member to the community clinic management group. “The government already donated 50000 BDT in community clinic management fund. PARI invites these community clinic groups in their programs also.” Capacity building of CHV In our baseline study, we observed CHV training that they get from the NGO office (SATHI and PARI). This took place in batches. These batches consist of around 16-22 participants. They are trained by the NGO staff from Netrokona and Mymensingh offices. Attendance and compliance to this training is high. The contents of the training include the following: Pregnancy and newborn surveillance: • Listing of all newly married women • Listing of pregnant woman • Listing of recently delivered women During pregnancy: • Danger signs of pregnant mothers • Vaccine for the pregnant mothers • Activities of a pregnant mother • Do’s and Don’ts during pregnancy (ANC, not lifting heavy loads, danger signs, rest during pregnancy, having nutritious and adequate amount of food, Post-delivery and Neonatal care: • How to wrap t a newborn from 15th -28th day of its life • Weighing newborns • Benefits of breastfeeding; hand washing In the endline, we found that the CHVs have been able to remember much from what they learnt from their training and have been able to apply them in real time situation. One CHV from Durgapur states, 63 “I received the CHV training 4 years ago when the group started. it was a 5-day long training in SUSOMA sathi office in Kendua upazila of netrokona district. (CHT) apa,(name) Vhai and other trainers trained us. I received training on pregnant mother and new born. They taught us on how to counsel pregnant mother. They also trained us on health education, food practices, hand washing, how to take weight of newborn, how to take care of babies. We were given some logistics to do these works. In those days, they talked about Sustho Shishu o Ma. We learned how to identify danger signs, newborn wrapping, weight measurement, what to do after identification of danger signs, breastfeeding, hand washing and so on. About pregnant mother, they trained us on danger signs. We learned that mothers can’t lift heavy things during pregnancy, they should have 4 ANC. They taught us food practices, what to do in case of any complications in pregnancy period, how to refer and where to refer, I have the referral slips, and sometime I refer them in the government health facilities. I also do a list of pregnant, newborns, recently delivered women, babies under 28 days and provide this to my supervisor (CHT). ” CHV from Durgapur also emphasized on her communication with the public health facilities, as she said, “I communicate with government health facility when I identify any complications in pregnant mothers; I communicate with FWV and FWA apa in FWC. Sometimes, I go with mother and talk with them (FWV). Sometimes, I talk with them over phone. Doctors respect us and also help us.” One of the CHVs from Kendua shared her experience and told the importance of the training: “We have learned a lot. We will be able to use them in action. If anybody delivers a baby in the neighborhood or anyone from our relatives, we will be able to use our knowledge to make them understand more or provide them with advices or educate them on these issues.” One of the task of the CHV is to help community people to form PG and to motivate them to create and emergency fund that would be used for the wellbeing of pregnant mothers and child of the community. The members of a particular team shared their experience with the CHV’s contribution in formation of the team, “She told, ‘you should form a PG. you should deposit 10 taka or 5 taka. If you deposit this money, that will be good for you. This is to keep our health better. If we deposit, that will bring profit for us. If we have money, that money will be used for the pregnant mother to take her (to the hospital).’ This is the reason for our creating this group.” In the baseline, most of the informants’ perception regarding public health facilities was negative due to its being ineffective even in the working hour, health care providers’ bad behavior or their absence. One of the CHV has shared her experience that she assisted a 8-months pregnant mother with advice and let her to the hospital which helped her to get the opportunity for safe delivery from the hospital. She said that they are not hindered from the community to do their duty; however, most of the public health centers remain closed generally. Therefore, community people cannot get timely care from there. Public health facilities, especially at the union levels, most often remain closed during the time when women are in fact free from their daily chores. This is a finding that stands true through the country. 64 Our endline survey states that the CHVs have the capacity to counsel the mother on many of the maternal and neonatal health related issues in both Durgapur and Kendua. They do household visits and identify the mothers and counsel them on healthy lifestyle and getting proper care. However, during a meeting with CHT in Kendua in our baseline survey, the CHT complained that the CHVs have not done the household visits properly as they could find very few women as pregnant which is not possible. In the endline, we found that the FWV seems to be happy as the pregnancy identification of CHV and sharing of that data helps the government information system in an excellent way. In the endline, we found TTBA visits households and perform health promotion activities to all the mothers in the catchment area while in the baseline some of them preferred home delivery over facility delivery and felt capable of handling any kind of maternal complications. One of the TTBA from Durgapur said during the end line, “I haven’t referred any mother to the hospital… I don’t do that without any approval from the doctor. If the doctor from DSK find any problem after doing check-ups for 4 times and ultrasound, only then he refer the patient. In two of the cases, the mother had delivery at home. The hospital staffs were called, but they came late and the delivery had taken place already. ” Our baseline study found TTBAs activities as following: • Work on maternal and neonatal health promotion • Encourage to have 4 ANC checkups, send patient to the hospital, enhance patients’ communication with the doctor • Trained to identify danger signs of pregnant mother (severe headache, bleeding, edema, severe pain during labor, convulsion, delay in plasma …., other organs of baby coming out earlier) and send her to hospital in case of presence of any, i.e. they would send the pregnant mother to hospital for foul smelling urination. • “After training now I can understand easily what is good and what will be bad for patient.. if I see any problem , I say to them, ‘take her to the hospital’, they listen to me. Isn’t this a change?” (TTBA, Kendua) One of the TTBAs we interviewed in endline in Durgapur said that she has referred at least 20 pregnant mothers to the hospital, out of which 5 had c-section and 15 had normal delivery in the hospital. She said that, “The baby was too big in the womb that is why I send her to the hospital. If we do this delivery at home, there could be pressure in brain. If the doctor suggests that there are problems after doing ultrasound, we send these mothers to the hospital. ” The TTBA also does the following: • Identify neonatal danger signs (if the umbilical cord does not dry up, infections, cold, breathing problems) • Encourage to provide colostrum to the baby • Assist hospital/ government staffs to be informed about pregnant mothers and present during delivery 65 • Their target group include mothers and their family members including mother-in-law and the unmarried • They also encourage other members to save more One of the TTBA who is a member of a group in Durgapur for last 4 years said, “If any mother/ pregnant mother need any money during her pregnancy, if she doesn’t have any money, the groups provide her with money as loan. This money is given as loan without interest and the mother has to pay it back when possible. This mother can be a member or not.” Much of the TTBA activities remain the same over the years as our endline study reveals. During the baseline, TBAs were just being trained. Therefore, there was not much to report on them. However, over time, TBAs have been trained and as it has been documented, they have been maintaining linkages with the health system steadily. In the end line, TTBAs said that they had meetings with government health staffs on a regular basis. On these meetings they share information on, “If someone gets pregnant, if mothers have any danger signs present or if the ultrasound report is not good.” They said that as a member of PARI, they meet with GOB health workers and the local elites. The GOB health workers respect them. One of the TTBA said, “How is it that they don’t respect us. We go to them with patients. If they don’t respect us, if they won’t provide quality care, why would we go there? Could we go to them if they don’t respect us? ” TTBAs found that their life has been changed since they joined these groups in terms of knowledge, relationships with people and new linkages with elites and government officials. One of the TTBAs states that there are changes in the society as well after commencing groups, “Mothers died, babies died previously…any woman might have 10, 5 , 7 or 8 children… nowadays they have 2 at best or 3. Isn’t this a change? The mother in labor died before as soon as she delivers… Now you won’t find any mother dying even if you search thoroughly… none of the newborns die now…very few babies are born with weight less than 3 kilo … Mothers go to the hospital as they understand that delivery at hospital would ensure good health for the mother and the baby… isn’t the change that happen after they got the message?” Confidence building at individual and group level During the baseline, several members said that they will be able to use the money that they are saving for their family’s well-being through the benefits from several investments. However, that was still in the planning stage. One of the female members said, “We have created this PG…if I die; my child will be able to get back the money after 5 years and will say that his/her mother left this money for him/her.” 66 However, they are not yet certain if they can take all types of decision by themselves. They thought that they are in the learning stage yet and will gain more knowledge from the CHVs. One of the PG members said, “We are learning from her (CHV). We have to learn for her more.” In the endline, we found that people are becoming more and more confident over the passing years. In Kendua, most of the participants said that they are benefitted as they learned about maternal and child health besides management of a group through leadership qualities and are more conscious now. They learned about the following: • Danger signs • Vaccination • Health care during and after pregnancy • Health check-ups • Record keeping • Monitory management • Team management One of the PG group said that they are confident that they would be able to run alone even if the support from SATHI is taken out. One of the members said boldly, “Yes now we think that we can work as an organization”. “We think that now our organization/group can replace the government offices / private completely.” “Yes we are capable we can” “We can work individually” One of the PG of Durgapur said that it is not possible to run alone without help of others. She states, “This group cannot work alone without assistance from government or at NGO level as if they didn’t help us, we couldn’t do what we have done yet. They are the partner of our success. ” The president of a PG in Durgapur said, “If PARI won’t help us in this way, we would not be successful in saving mothers and babies. I heard that they are taking out their support in next October. So, we are trying to get ready to work alone. ” Some members in Durgapur said that, the president of the PG was also invited to get training on managing PG. The capacities are developed at individual level in the following areas: • Development of knowledge about maternal and child health 67 • Managerial capacity • In some instances, decision-making capacity • Confident to run the PG without NGOs help in some areas We found that the PG members are not only thinking about their family’s wellbeing but also interested to help their community people, especially the pregnant mothers. One of the female member presented in a FGD said, “Suppose, anyone is in danger and we give her the money. After she is rescued from the suffering… and she gives back the money to us… None of the members give us any profit… but give back the capital money.” They said that they are becoming more knowledgeable from day by day from the discussion with CHVs, especially on the maternal health. However, they know little or nothing about neonatal health. In Kendua, the CHVs have regular meeting with the CHT where a lottery takes place. Each of the members selects a topic and tells others on the topic which increases their knowledge. Most of the CHVs can tell something on these topics. The learning included the following, “the pregnant mothers…if they suffer from fever, they need to go to the hospital… what happened if they suffer from headache, abdominal pain, fever, convulsion, bleeding… you know, if these symptoms are seen, the mothers need to be taken to hospital. We have learned all of these things… ” The members in Durgapur stated that they are satisfied as their activities helped the rural women, “This is not mere wastage of time…but, we are helping…we are helping the pregnant mothers and the children. This is our reason to be happy.” Members’ activities are also praised by their family members and the community people. One of the female members said, “I took an amount of 1500 taka…for my sick husband…He has some chest disease… So, I took 1500 taka from here as I could not manage it at that moment… This money was used for curing my husband…My husband praised me for this…everyone does so… ” The capacities are developed at group level in the following areas: • Tendency to join group discussion in taking any decision • Learning from CHVs/ CHT/ and other programme partners • Inclined to help the community people • Collective savings • Collection sharing of ideas Members from Kendua said that dissemination on groups’ activities would bring success, “We need to share about our group activities with community peoples, we need to arrange a large monthly meeting with community people in each and every month, and we need group works for that.” 68 Members from Durgapur set an example of collective sharing of thought, “with 30 taka from each, the members arranged annual meeting where they not only shared their ideas but also accommodate entertainment for children and refreshment for the attendees. ” One of the staff from PARI Development Trust expressed, “Everyone deposits 2 taka per week in this lillah fund. In general, this fund may not seem to be necessary, but, sometimes people may need an surgery and may have to go to Mymensingh (for further treatment). Then, they have to pay a lot of money for that. Suppose, there are 2-4 thousands taka has been deposited in this fund. They donate this money. None has to return this. They say, ‘we give alms to the beggar in a small amount which is not really that much helpful. They (save the money and) donate warm clothes during winter and also give them semai, sugar, saree and lungi.” The PIs in Netrokona are highly motivated to work in reducing maternal and neonatal death. The PI leaders and the members took this task seriously. “I was in the primary group first… then I went to the UC and then I got elected in the PI (she smiled)…I am happy to be here, as all the activities that are carried on here are the most important for the community people.” Examples of activities of PI members would make this much clear: • The PI in Kendua successfully helped a mother with complications. This mother has several cases of child death. Therefore, the PI president identified her as a ‘risky’ case and took her to the hospital in Netrokona. She was later referred to Mymensing Medical College. The PI president collected the money from the emergency fund and helped in c-section. Therefore, the mother’s life was saved. • There is a central committee in PI that is responsible for monitoring activities of PGs on neonatal and maternal health issues and others. • Each of the PG submit 10 taka to the PIs and this money is deposited to the bank account • The PI members meet regularly to discuss on the PG activities and updates. They also call for suggestions from others. The PI observed in Durgapur had the following special features: • None of the PI members are poor now • All of the members’ decision would ensure the future plan of the PI or at individual level. • In case of providing loan from the emergency fund, the members call a meeting and disburse the money as soon as possible. At the same time, they ensure follow-up of the patients. • The PI invested money on ventures that helps to carry the patients to the hospital, such as, van. • The PI is well aware of the step down of NGO after a certain period. They are not yet confident, but, they are getting prepared to do so. In Durgapur, two of the PIs were old as they were formed under another programme and another one is a new PI. All of the PIs were found active. Both of the old PIs have good linkage with the public health system, and other local government offices. One of those PIs has the plan to buy land and develop an 69 office there. Another old PI has already bought their land. Both of the old PIs are confident that they would be able to continue without the NGO cooperation. 6: Section 4: Social Capital and Health Care Seeking In this section, we would share our findings on impact of increase in social capital and change in health care seeking behavior. During our formative study, we found that most of the informants are unaware of services available in the public health service facilities and have negative ideas regarding these facilities. They used to see the village doctors and the traditional birth attendants for maternal and child health problems. However, at 2014, it seems that the community people have increased faith on formal health care and trying to seek care from these places. Health care seeking Behavior and practices During the baseline, the PG members said that they have learned about maternal health from NGO staff, but, they are not informed about child or neonatal health. However, in the endline, we found the group members stating that they now have learned about both maternal and neonatal/child health from the CHT, FWV and CHVs. The TTBA, who have well communication with PGs, said that this initiative would be helpful for all the mothers in this locality as this would not only help in health related emergency, but also for income generating activities. One of the PG members from kendua said that the CHVs have given them information on what to do in emergencies, such as, if any pregnant mother falls in any type of problem or if anybody suffered from any danger signs and where to take the sick person. “She (CHV) told us where to go if anybody becomes pregnant and suffers from headache and fever.” After three years of intervention in Kendua, the non-members started to know that these groups also care for health of mothers and babies. The women of Meladahar village who are not members of any groups or NGO activities found that these group is different than other NGOs (i.e. ASHA, BRAC, PADAKKHEP, SAS, CMC) working there whose activities are ‘‘ merely exchange of money (depositing money weekly ad getting loan)’’. Though the group is also engaged in monetary matters it also deals with issues of maternal and child health emergency, health education, compilation of information on pregnant mothers, identification and their regular health check-ups, and other health needs. The CHV provides regular visit to the mothers, provide booklets to the mothers so that they can take better care for their health. They stated that due to this group the general consciousness regarding maternal health has increased. One of the women who is not a member of the group said, “This women’s group is totally different. They work with their own members. They find out what is the expected date of delivery, date to vaccinate… they work on these issues. They also provide booklets. They give four times checkup…they tell us how to take care of the baby… how to provide care… the pregnant mother shouldn’t do hard work… They (group) also work with the government hospital. ” In Durgapur, one of the group members described the mechanism of using their savings and linkage with public hospitals, “We deposits money in the form that each of us gives 2 taka which constitute 50 taka per month. We also go for seasonal money collection twice a year. We deposit this money in the emergency fund. If someone gets sick, if the pregnant mothers faces any trouble of if the newborn are in bad health, we send them to the hospital with this money. We take the pregnant mothers. We help her. 6; We call the van or person to accompany her. We have referral slip with us. We write the name of the patient and her husband’s name on it. We take that with us and show that to the doctor. Then, they find that this patient is from PARI and provide emergency treatment. They help us. Otherwise, they won’t.” Referral linkage with health system In 2011, we did not find many cases of referred pregnant mothers to the facility for delivery. However, in 2014, we found three active PIs in Durgapur (namely, Hira, Mukta and Jhinuk) and one in Kendua (Shukher Shondhane society) both of which are playing important roles in improving maternal care, including referral. In Durgapur, participants from all three PIs confirmed that they assisted in sending patients to the hospitals and helping them to get timely care through improved connection with local elites. One of the Managers (Durgapur) explained that their organizations goal is to ensure empowerment of women and PIs are aimed to increase social capital among the poor and reduce poverty. These two are interconnected, as he describes, “Two things work here. One is increase in capital (in term of money) and another is increase in capacity to boost in capital. The jovial natures they have… that means, when we initiate the process to develop a group, we say that e will not only think about money, but, being grouped means making relationships, i.e. making sisterhood, in which she will cry for me when I am in trouble and I will smile when she would be happy. The most significant result of being grouped is the development of solidarity.” The PI members do not only save and use the money for further investment or help the mother and child in danger to get timely treatment, they also work on any community need, such as, if there is a broken road, they reconstruct it, said PARI manager. The emergency fund helped 216 patients in Durgapur which acted as a factor in reduction of maternal and neonatal death. Their activities can be described with the following chart: Flow Chart 1: PI’s involvement in ensuring health care  "%  ##%   $" $"$ $  $"## *#" '! "#  %(%    $"#,$ # "#  "* $ $"$  ' #!$* "##!"#$ '"$"  '% )$ !'$#"( !" ("#$ #'"  " #'" $" "  $ 72 One of the PI members from Durgapur stated how they helped a mother who suffered from a danger sign in her seventh and half months of pregnancy. She articulated in the following way, “She was bleeding a lot. It was seventh and half month of pregnancy. Her mother-in-law and father-in-law decided that she should stay at home as bleeding is natural during delivery. They thought this is her time to deliver the baby. So, we went there. We talked and talked. They (mother-in-law and father-in-law) refused to take her to the hospital. Then, our president went there and made them to understand the situation. She took her (mother in bleeding) to the hospital where she got treatment and come back home. She (mother) didn’t deliver there (hospital) on her seventh and a half months, but later on ninth months. But, her mother-in-law and father￾in-law thought it was time to deliver and that’s why she doesn’t have to take to the hospital!” To help this mother, they provided loan of 1500 BDT for her treatment. As this is to save this mother and her child, they keep it as interest free and to be provided back in small installment over a long period. According to them, money is another de- motivating factor in getting treatment. They stated some challenges in sending patient to the hospital. They are: • Some of the family members disapprove to send the patient to the hospital. • Some of the parents of newborn or children under five years do not understand or underestimate the danger signs. In one of the cases was of delivery of triplet where the PI of Kendua sent the mother to the Mymensing Medical College Hospital and helped her with a loan of 2000 BDT. The mother had history of her four children to die just after delivery, therefore, she requested for c-section and delivered three healthy kids- one girl and two baby boys. However, after returning home from hospital, the daughter got infected with Pneumonia and die later. The mother and family could not identify that the daughter is suffering from this disease. Another case was of a Hazong mother, where baby’s organs other than head were coming out first during delivery. The mother of the pregnant mother begged to one of the manager, “I don’t need any son-in-law, but, save my daughter. If my daughter survives, she will have babies.” The PI in that area provided a 2000-taka-loan to the mother and sent her to the hospital where she got treatment and come round. • Sometimes, the doctor in the hospital denied to provide care in past after they send patient there. One of the PI member states that, “We send a delivery case to Mymensingh (Mymensing Medical College Hospital) once. Then the doctors disallowed to provide any treatment to her. Then our president calls over the RMO (residential medical officer). He helped afterwards. ” She also said that the meeting they have at district level public health service providers (both health services and family planning officials) once in three months, has created linkage with the health services and helped in reducing this kind of refusal f patients from hospitals. SATHI staff explained linkage with GO and PI in the following way, “Two representatives from each PI join the Upazila Technical Meeting where other participants are upazila health and family planning officer (chairperson),UFPO (co-chairperson), PARI 73 health coordinator (secretary) and others are the respectable guests. Here the PI members represent their community. They also have regular meeting with chairmen. In the district level, the PI members and the CHVs join the meeting. The public health staffs didn’t give them any value before, however, it is different now. They are well respected there.” Challenges in continuing PI’S tasks To run the activities of PI in improving maternal and child health care cadres of dedicated community members are needed. They have to be highly motivated and should motivate others. However, the way to organize the groups was not always smooth. Implementation agencies found the following challenges: • Lack of support from family or community for the female members act as a big issue as all the members are female and they need help from their family to continue work. “local religious leaders posed a lot of problems in making the women to work outside their home. We also had to manage husbands and the mothers-in-law.” • Some of the PG members tried to invest the money on interest which is as much as 10 taka per 100 taka. Many members disagreed and many of the groups broke down or about to broke. Therefore, PARI has to go and counsel the PGs not to do that or make the interest much less. • In the initial stage, PARI has to provide help in every decision making. No, almost all the groups are capable of decision making, even the financial ones. • There were many NGOs working here before PARI started working here, whose main activities were based on providing loan to applicants and PARI as aimed to empower the local poor with their own money. Therefore, PARI had to motivate them to save money and use that money for investment rather getting loan on interest that is not easy to pay back in a lifetime. • In the initial stage, the retention of CHT was higher as they lacked support from their family as well as the community. • Training of the CHV is generally 5 day-long. During this period she has to stay far from home, which is not approved or taken very well by the family members. • The time provided (2009-14) is not really enough to ensure sustainable leadership in community. • Male participation is necessary which is at its minimum level. • Collection of seasonal donation is not always approved by the family members as this is not good￾looking if women go from house to house to collect money, paddy, rice and so on. • Formation of PGs is not uniform. Sometimes they improvise the rules and bend the inclusion criteria for membership. • Though there are challenges, managers are hopeful about the future sustainability of PI model as one of them said, “The present PI leadership trends make me to believe that they will sustain for a longer period. However, in the initial stage, we may have to suffer a bit. The good thing is as we tried our best to build capacity and teach them on how to keep on working. They have started to show us their best. Some already build sustainability fund by themselves. My experience says if people are trained well, they can work better. ” (manager, durgapur) One of the PARI staff shared the experience, 74 “There are some families that don’t allow women to work outside. As for example, we had been to a…para. Three PI leaders were with us. We work there until 8 pm. Then, one of the leader’s husband was angry. Will he allow her to work again? ” “PI will survive, I believe. Because, there are some leaders who are unique and they have a dream now that they will work for the society and community. ” (manager, kendua) Table: Challenges in health seeking from public health services found in 2011-12 and 2014 Challenges 2011-12 2014 Durgapur Kendua Durgapur Kendua People’s Knowledge on danger signs, health problems Present Absent Improved Improved Health care Providers Behavior Not always welcoming Some did not care for even patients with severe cases. Sent to hospital in rare cases Many who visited by themselves to the hospital complained regarding absence of health care providers even during duty time. Mostly welcomed Strong connection established between the health service providers and the PI leaderships. Mostly welcomed Strong connection established between the health service providers and the PI leaderships. Distance Worked as a demotivating factor, used van, boat as transportation to go to hospitals Very few went to hospital Use emergency fund to take to the hospital whatever the distance is. Use emergency fund to take to the hospital whatever the distance is. Cost of treatment People borrow (with interest) from different sources, sell properties and some uses emergency fund Very few uses emergency fund Emergency fund is there for members and non-members to get health care Money is provided in form of loan without interest in small Emergency fund is there for members and non-members to get health care Money is provided in form of loan without interest in small 75 installment over a longer period. installment over a longer period. Communication with elites Present. Absent or present in small scale. Improved through tri￾monthly meeting with local elites, public health service providers and inter￾personal relationships with them. Improved through tri￾monthly meeting with local elites, public health service providers and inter-personal relationships with them. Inability to decision making Present in some areas. Present in almost everywhere. Present in small scale. Present in small scale. Family member’s disapproval Present in some areas. Present in almost everywhere. Present in small scale. Present in small scale. Communication with Community Clinic Absent Absent Present Present 76 Discussion: Impact of social capital in health equity and referral In both of the upazilas, we have seen changes over time in terms of health equity and referral of maternal and neonatal cases to formal health care facilities. It is evident from studies that health equity exists where the all the members from the community has equal opportunities to be healthy, which is, undoubtedly connected to factors such as socio-economic status, ethnic identity, religious identity, gender, sexual identity and physical fitness or disability. Ensuring health equity is influenced by distribution of social determinants of health, i.e. level of education, housing, transportation system, employment opportunities, social security and access to public health systems. Changes in any of the social determinants of health can cause changes in health equity. We can discuss the health equity situation of Kendua and Durgapur in terms of four issues, such as, the role of the public health service practitioners, capacity building of the community people in terms of achieving health equity, presence of actions as social movement and its sustainability. Our exploration shows that there had been ample changes in public health service providers’ attitudes and professional behaviors towards the rural community members of the Netrokona. We found that many of the neonatal and maternal cases were never referred to the health care facilities because of predicted nature of the health care behavior. The most general complain against them was related to their absence in the hospital during working hour and neglecting the patients after arrival to the facility. Distance, transportation and financial problems were other factors. However, later we found public health care professionals effectively using health care resources. The local and informal health care providers who were not interested to refer any patient were more eagerly communicating with the formal health care providers in any kind of need which results into a better health outcome for women and child in the community. Capacity building among the community people is another excellent outcome that we found in the intervention area. Organizational experience suggests that it takes around 2 to 3 three years before one can observe some of the expected changes in the community. Perception of groups has clearly changed over time. Initial apprehension is just about all gone and has become replaced with confidence in the groups, its activities, and vision. Even the non-members are now able to talk about the things these SUSOMA women’s groups are doing. The vision that it relates to a collective action for the good of all in the community seemed to be lacking in the initial stages. However, this is not the case anymore. This was more pronounced in Kendua than in Durgapur, but the differences are all but gone now. If we look into the matter with a probing set of eyes, we saw that the activities in Kendua were limited to savings and sanctioning loans, with no vision of development, while there are some added activities in Durgapur to make it a bit different. However, there have been positive changes. Regularizing weekly meetings, discussing financial matters, deliberating emergency issues, accounting for regular and emergency funds, and working on creating maternal and child health related materials is what management of PGs is all about now. In their mature state of being, these activities run smoothly as the members see clearly the benefits that are being reaped from their activities. People those who have been in the PGs for some time, feel an ownership in this. The cadre of informal health care providers, i. e., TTBA, TBA and VD who seemed to be the first health care seeking contact for any mother or neonate in danger, has become more powerful agent in referring. Community members of this area are getting empowered with an increase in their savings and are thinking of improving the community as well, through better transportation system, better economy with businesses like poultry, farming, animal husbandry and so on. With improved 77 financial capacities, the members as well as non-members of PIs are concentrating on getting better health care. We found that there had been changes in knowledge regarding health, danger signs and information on where and how to get good health care. The emergency fund, unquestionably, have great influence in creating the confidence to face maternal and neonatal health disasters and the capacity to think about the community together. The group leaders have to show their performance in cash management, decision making and management of the group members which also made them courageous. A linkage with social elites is crucial for visibility and support. However, this should be actively sought and not passively received, which still is the case with many of the PGs. We found that the capacity of the PG members is enthusiastically used in manifold activities that are creating a social movement in the intervention area, where they are actively collaborating with the government in several of their programs, i.e. EPI, hand-washing, maintaining pregnancy register. Participation in their programs was also observed and heard about. This is going a long way in soliciting governmental support and acknowledgement. Regular training of the CHVs is essential for their development with regard to their skills in identifying maternal childhood danger signs. This also helps them in their referral chain and consequent linkage with the public health facilities. Regular training of the CHVs on PG formation and health related matters are making them confident in managing cases in the community. However, their management is mostly related to counseling and referral. The referral part of their activity is often hampered due to non-functioning public health facilities, which the PGs are also trying to work with. They are trying to hold the providers accountable and motivate them to provide services regularly. TTBAs are proved as an asset to the program. They work as linkages to the health facilities and also provide training and knowledge to the groups of which they are often a part of. Initially the village doctors were not trained and they did not know much about SUSOMA activities with regard to maternal and child/neonatal care that were being implemented through its activities. However, since then many of the VDs have been oriented and they have come to find out about the activities. It is difficult groups to work with, since they are well set in their ways, however being able to include them in PG activities are benefiting the cause of SUSOMA. Besides conducting their regular activities of identification of danger signs, counseling, and referral, CHVs also take active part in raising awareness regarding mothers’ and children health issues with the communities they live in. They take initiatives to establish linkages with the government health care providers as well. All of these activities is also helping spread the word of their groups and even the non-members are getting to know about them. One of the major issues the programme should think about is based on its sustainability as there have been several issues related to disbanding and groups collapsing. However, over the years, they have been able to minimize the issues and the collapse is less heard of than before. However, as manager of the NGOs suggested, it is natural to expect that some of the groups simply wouldn’t sustain for whatever reason. Initial days of unsure and nervous members are long gone it seems. These days most of the PG members appeared confident, able to talk about their activities, and confident that they were able to sustain even without the intervention from the NGOs. This most certainly relates to the interventions of the program of forming groups and discussing and implementing activities together. Just as in the case of individual, the groups are also becoming more and more confident. They are venturing to take their own decisions and also wanting to expand their activities into the wider community. They are planning on trying to involve people from the community in general into some of their activities. Light of hope seems 78 to be shining slowly but surely. It is only prudent not to expect radical changes in a project like SUSOMA, where all is dependent on community uptake of intervention messages, group formation, savings, and development. All of this takes a lot of time – more time than time-bound research projects can offer! The most important thing, as we look at it, is the connection between mother and child health and overall development. And this connection has been made with success as our report details out. As people realize the connections between saving money, gaining knowledge on maternal and child health concerns, and times of need and danger, the more they feel the need to be a part of the groups. The more it starts to act as safety nets for them. This is also expressed in their activities and enthusiasm. 79 Findings: Assessment of Social capital All of the findings that we present here are from the surveys conducted at the baseline and endline phases of the OR to measure social capital based on the tools adapted from the World Bank package of tools for the same purpose. In this regards we would like to mention that when we conducted our initial interviews in 2012, the project, known as SUSOMA, was still only in its formative stage where the Primary Groups were being formed. In terms of processes being unfolded on the ground, Durgapur has been farther ahead than Kendua, which spoke for a number of differences between the two field sites. In addition, unlike Kendua, in Durgapur there has been older People’s Institutions (PIs) already in existence at the time of introducing the project in the area. In other words, people in the community in Durgapur are relatively more aware and oriented to the activities of PIs. Capacity building, which is related to all the integrated activities of the project, ensued once the groups were formed and they became regular in their meetings and savings activities. Experience of implementing People’s Institutions around the country makes it clear that organizations like the People’s Institutions take a lot of time to gain grounds and before it starts to bear fruits. Organizational experience suggests that it takes around 2 to 3 three years before one can observe some of the expected changes in the community. In fact, when we conducted the endline interviews and observations in 2014, managers still suggested that the time was not ripe yet. Contextual factors (descriptive statistics and qualitative findings) Here we present our findings, presented in tabular comparative format from the household questionnaire (n=335 during baseline and 310 during endline). Wherever necessary and relevant, we would be sharing qualitative insights into the issues discussed. Structural social capital Table 1: Organizational density and characteristics Item Baseline Endline Durgapur n (%) Kendua n (%) Both n (%) Durgapur n (%) Kendua n (%) Both n (%) Are you or is someone in your household a member of any groups or organizations? (yes) 114 (71.2) 105 (60) 219(65.4) 99(66.9) 99(61.1) 198(63.9) Do you consider yourself/household member to be active in the group? Leader 8 (7.0) 15 (14.3) 23 (10.5) 20(20.0) 18(18.2) 38(19.2) Very active 66 (57.9) 80 (76.2) 146 (66.7) 37(37.4) 58(58.6) 95(48.0) Which of these groups is the most important to your 7: Item Baseline Endline Durgapur n (%) Kendua n (%) Both n (%) Durgapur n (%) Kendua n (%) Both n (%) household? ASA 11 (9.6) 13 12.4) 24 (11.0) 5(5.1) 6(6.1) 11(5.6) Grameen Bank 9 (7.9) 16 15.2) 25 (11.4) 0(0.0) 0(0.0) 0(0.0) BRAC 5 (4.4) 3 (2.9) 8 (3.6) 4(4.0) 6(6.1) 10(5.1) DSK 12 (10.5) 0 (0.00) 12 (5.5) 7(7.1) 1(1.0) 8(4.0) PARI (SUSOMA) 66 (57.9) 0 (0.00) 66 (30.1) 72(72.7) 1(1.0) 73(36.9) SATHI (SUSOMA) 0 (0.00) 71 (67.6) 71 (32.4) 1(1.0) 74(74.8) 75(37.9) Are group members mostly of the same extended family? (yes) 27 (23.7) 15 (14.3) 42 (19.2) 39(39.4) 8(8.1) 47(23.7) Are members mostly of the same religion? (yes) 97 (85.1) 86(81.9) 183 83.6) 72(72.7) 68(68.7) 140(70.7) Are members mostly of the same gender? (yes) 104 (91.2) 101(96.2) 205 93.6) 92(93.0) 88(88.9) 180(90.9) Are members mostly of the same political viewpoint or do they belong to the same political party? (yes) 21 (18.4) 18 (17.1) 39 (17.8) 16(16.2) 13(13.1) 29(14.7) Do members mostly have the same occupation? (yes) 63 (55.3) 87 (82.9) 150 68.5) 25(25.2) 41(41.4) 66(33.3) Are members mostly from the same age group? (yes) 23 (20.2) 10 (9.5) 33 (15.1) 3(3.0) 19(19.0) 22(11.1) Are members mostly from the same education level? (yes) 24 (21.0) 5 (4.8) 29 (13.2) 10(10.1) 12(12.1) 22(11.1) Most of the people, irrespective of them being members of any Primary Groups belonging to the People’s Institution of SUSOMA, belong to at least one group/organization, though the trend is a bit higher in Durgapur than in Kendua (D: 71%; K:60%). The trend remains consistent over the years as the endline suggests (D: 67%; K:61%). This difference in sub-district level is understandable since PIs have been formed in Durgapur much earlier than in Kendua. Among the informants, during the baseline survey, a substantial majority in Kendua (90%) said that they are in fact very active or are leaders in these groups/organizations that they are a part of. The overall trend remained similar during endline, though proportion of people considering themselves as leaders increased substantially (D: 20%; K:18% during endline as opposed to D: 7%; K:14% during baseline) with a similar decrease in active participation. 7; Active participation/being a leader was considerably higher among the people in Kendua, than in Durgapur during the baseline and the trend remained similar during the endline (D: 65%; K:90% during baseline and D: 57%; K:77% during endline). In Durgapur, people have been exposed to more NGO activities than in Kendua. It is believed that this aspect of social context has a lot to do with how people respond to new initiatives. In Kendua, after overcoming the initial hurdles of forming groups, people are coming together actively, while people are reluctant in Durgapur, though in some places the intervention has become stable in terms activities and regular meetings. Among the groups mentioned, PARI in Durgapur (baseline: 58%; endline: 73%) and SATHI in Kendua (baseline: 68%; endline: 75%) were most prominent. ASA and DSK in Durgapur (10% and 11% in baseline and 5% and 7% in endline) and Grameen and ASA in Kendua (15% and 12% during baseline) were also quite popular, though much less than PARI and SATHI. Interestingly, Grameen seems to have seized its activities in both Durgapur and Kendua since no one mentioned them during baseline. There were several others NGOs working in the area, but they were considerably smaller in their membership in these communities. In terms of group composition, we observed interesting changes during the endline. It seems, people of differing backgrounds, including religion, occupation, and political views are joining the groups, making them more heterogeneous than what we found during the baseline. In terms of religion (Islam) and occupation, the composition was homogeneous during baseline, but not so during endline. In terms of religion, overwhelming majority were Muslims during the baseline survey (D: 85%; K:82%). These proportions decreased significantly when we asked them about it during the endline survey (D: 73%; K:69%). A similar trend with a greater increase heterogeneity was observed during endline with regard to occupation (D: 55%; K:82% same occupation during baseline as compared to same occupation during endline - D: 25%; K:41%). Heterogeneity is much greater in terms of other categories such as political affiliation, age group, and educational level. Table 2: Decision-making and leadership Item Baseline Endline Durgapur n (%) Kendua n (%) Both n (%) Durgapur n (%) Kendua n (%) Both n (%) How does the group usually make decisions? 82 Item Baseline Endline Durgapur n (%) Kendua n (%) Both n (%) Durgapur n (%) Kendua n (%) Both n (%) The leader decides and informs the other group members 19 (16.7) 8 (7.6) 27 (12.3) 50(50.5) 23(23.2) 73(36.9) The leader asks group members what they think and then decides 16 (13.2) 7 (6.7) 22 (10.0) 0(0.0) 3(3.0) 73(36.9) The group members hold a discussion and decide together 74 (64.9) 90 (85.7) 164 74.9) 45(45.5) 73(73.7) 118(59.6) Overall, how effective is the group’s leadership? (yes) 108 (94.7) 104(99.0) 212(96.0) 97(98.0) 98(99.0) 195(98.5) With regard to decision-making within the groups, trends remain the same during the endline as found during baseline. A much greater participation was observed among the people in Kendua, where in most cases group members discussed and came upon a decision together (86% in baseline and 74% in endline). Participation was also good in Durgapur (65% in baseline and 46% in endline), but still considerably less than Kendua. The point to be noted here is that there has been a noticeable decline in participation in both sub-districts, but the decline in Durgapur has been striking – about 20% decline. It should be noted that in 17% of cases in baseline and 50% of cases in endline, group leaders in Durgapur single handedly made decision, while this percentage was much less in Kendua (8% and 23%). However, almost all informants from both of the sub-districts mentioned that the leadership extremely effective. Table 3: Networks and mutual support Item Baseline Endline Durgapur n (%) Kendua n (%) Both n (%) Durgapur n (%) Kendua n (%) Both n (%) If the primary school of this village/neighborhood went without a teacher for a long time, say six months or more, which people in this village/neighborhood do you think would get together to take some action about 83 Item Baseline Endline Durgapur n (%) Kendua n (%) Both n (%) Durgapur n (%) Kendua n (%) Both n (%) No one in the village/neighborhood would get together (yes) 7 (4.4) 4 (2.3) 11 (3.3) 143(96.6) 122(75.3) 265(85.5) Local/municipal government 21 (13.1) 22(12.6) 43(12.8) 2(1.3) 36(22.2) 38(12.3) Village/neighborhood association 5 (3.1) 0 (0.00) 5 (1.5) 3(2.0) 36(22.2) 39(12.6) Parents of school children 27 (16.9) 23(13.1) 50(14.9) 3(2.0) 38(23.5) 41(13.2) The entire village/ neighborhood 74 (46.2) 107(61.1) 181(54.0) 2(1.3) 40(24.7) 42(13.6) Who would take the initiative (act as leader)? Chairman 9 (5.9) 18 (10.5) 27 (8.3) 0(0.0) 4(10.0) 4(8.9) Member 20 (13.1) 18 (10.5) 38 (11.7) 0(0.0) 14(35.0) 14(31.1) Village leader/Matobbor 30 (19.6) 93 (54.4) 123(38.0) 3(60.0) 19(47.5) 22(48.9) Children’s fathers 11 (7.2) 0 (0.00) 11 (3.4) 0(0.0) 0(0.0) 0(0.0) Head or assistant head teacher 13 (8.5) 1 (0.5) 14 (4.3) 0(0.0) 2(5.0) 2(4.4) School committee’s head 52 (34.0) 38 (22.2) 90 (27.8) 1(20.0) 1(2.5) 2(4.4) If there were a problem that affected the entire village/neighborhood, for Instance (i.e. “crop disease”), who do you think would work together to deal with the situation? Each person/household would deal with the problem individually (yes) 37 (23.1) 32 (18.3) 69 (20.6) 132(89.2) 141(87.0) 273(88.1) Neighbors among themselves (yes) 13 (8.1) 8 (4.6) 21 (6.3) 12(8.1) 16(9.9) 28(9.0) Local government/municipal political leaders 60 (37.5) 53 (30.3) 113(33.7) 8(5.4) 12(7.4) 20(6.5) All community leaders acting together 19 (11.9) 9 (5.1) 28 (8.4) 6(4.1) 13(8.0) 19(6.1) The entire village/ neighborhood 29 (18.1) 69 (39.4) 98 (29.2) 8(5.4) 17(10.5) 25(8.1) Who would take the initiative (act as leader)? Chairman 40 (32.5) 35 (24.5) 75 (28.2) 3(18.8) 1(4.8) 4(10.8) Member 33 (26.8) 31 (31.7) 64 (24.1) 2(12.5) 7(33.3) 9(24.3) Village leader/Matobbor 18 (14.6) 67 (46.8) 85 (31.9) 9(56.3) 10(47.6) 19(51.4) School committee’s head 7 (5.7) 0 (0.00) 7 (2.6) 0(0.0) 0(0.0) 0(0.0) 84 In order to investigate into the social networks and support that existed within the communities, a couple of different hypothetical scenarios were presented to the informants. For instance, they were asked if the neighborhood school didn’t have a teacher for a long time, then who do they think would take action in that regard. Responses show a dramatic reversal of roles in the community. Over the years people seem to have becomes more realistic and much less expecting of others getting together for a cause. During the baseline the most likely group would have been basically the entire village/community, though this response was more prominent in case of Kendua (61%) than Durgapur (46%). However, during the endline an overwhelming majority suggested that there really wouldn’t be anyone getting together to address a cause (D; 97%; K: 75%). Interestingly, despite a large majority suggesting that no one would come forward, a substantial proportion in Kendua suggested (22%-25%) that others like the municipal corporation, a local organization, parents of school children, or the entire village would respond to such a need. This was all but absent in Durgapur. During the baseline, in terms of leadership, people in Durgapur were divided with the head of the school committee coming on top (34%), with the village leader/matobbor and member of the union parishad coming in next (20% and 13% respectively). The situation in Kendua seemed markedly different, where most of the informants suggested that it would be village leader/matobbor first (54%) and only then the school committee’s head (22%) and members and/or chairman of union parishad (both at 11%). The situation observed during the endline was markedly different. It was primarily the matobbor (D: 60%; K: 48%), with hardly any mention of the school committee’s head as in baseline. When they were asked about problems relating to agriculture (i.e. pest-epidemic) during the baseline survey, people in Kendua thought that it would concern the entire village, hence it would be all of them who would get together to solve the problem (39%), while people in Durgapur relied more on the local government (38%) than they did on the community at large (18%). In terms of leadership, people in Durgapur thought that it would be chairman of the UP who would take the lead (33%), while in Kendua people thought that it would be the community leader/matobbor who would lead (47%). However, things took a drastically individualistic turn during the endline survey where overwhelming majority suggested that it would be the individual families owning up to the problem and solving it on their own (D: 89%; K: 87%). It should be mentioned here (as it has been mentioned earlier, that over time people have figured out that though it is optimistic to expect that people would get together and work toward a common goal, but it is also unrealistic. Again, previous experiences with other activities might have a lot to do with this. Table 4: Sources of conflicts Item Baseline Endline Durgapur n (%) Kendua n (%) Both n (%) Durgapur n (%) Kendua n (%) Both n (%) To what extent do differences such as the tend to divide people in your village/neighborhood? Education Somewhat 64 (40.0) 90(51.4) 154(46.0) 65(43.9) 77(47.5) 142(45.8) Very much 27 (16.7) 15 (8.6) 42 (12.5) 6(14.) 14(8.6) 20(6.1) 85 Item Baseline Endline Durgapur n (%) Kendua n (%) Both n (%) Durgapur n (%) Kendua n (%) Both n (%) Wealth/material possession Somewhat 88 (55.0) 105(60.0) 193(57.6) 83(56.1) 94(58.2) 177(57.1) Very much 19 (11.9) 26 (14.9) 45 (13.4) 29 (19.6) 10(6.2) 39(12.6) Landholdings Somewhat 85 (53.1) 82 (46.9) 167 49.8) 92(62.2) 59(36.4) 151(48.7) Very much 28 (17.5) 32 (18.3) 60 (17.9) 21(14.2) 32(19.8) 53(17.1) Social status Somewhat 78 (48.7) 61 (34.9) 139(41.5) 86(58.1) 74(45.7) 160(51.6) Very much 21 (13.1) 19 (10.9) 40 (11.9) 12(8.1) 37(22.4) 49(15.8) Gender differences Somewhat 31 (19.4) 51 (29.1) 82 (24.5) 67(45.3) 86(53.1) 153(49.4) Very much 9 (5.6) 6 (3.4) 15 94.9) 11(7.4) 28(17.3) 39(12.6) Differences in age Somewhat 34 (21.2) 71 (40.6) 105 (31.3) 85(57.4) 80(49.4) 165(53.2) Very much 7 (4.4) 16 (9.1) 23 (6.9) 5(3.4) 26(16.1) 31(10.0) Length of stay Somewhat 25 (15. 6) 42 (24.0) 67 (20.0) 62(41.9) 50(30.9) 112(36.1) Very much 4 (2.5) 1 (0.6) 5 (1.5) 1(0.7) 5(3.1) 6(1.9) Political party affiliation Somewhat 78 (48.7) 93 (53.1) 171 (51.0) 82(55.4) 99(61.1) 181(58.4) Very much 46 (28.7) 14 (8.0) 60 (17.9) 30(20.3) 35(21.6) 65(21.0) Religious beliefs Somewhat 10 (6.2) 20 (11.4) 30 (9.0) 61(41.2) 42(25.9) 103(33.2) Very much 4 (2.5) 2 (1.1) 6 (1.8) 25(16.9) 54(33.3) 79(25.5) Ethnic background Somewhat 11 (6.9) 16 (9.1) 27 (8.1) 81(54.7) 96(59.3) 177(57.1) Very much 1 (0.6) 1 (0.6) 2 (0.6) 3(2.0) 4(2.5) 7(2.3) In order to understand and investigate further into structural social capital, we looked into the sources of conflicts in the communities where the study was conducted, namely Durgapur and Kendua sub-districts of Netrokona district. Differences between people are only natural and normal in a society. However, often these differences become the sources of conflicts. This is why we asked whether several of the otherwise known areas of differences ever became a source of conflicts for our informants. The baseline survey seemed to suggest that in Durgapur the following areas were “somewhat” or “very much” the places where conflicts might have owed its origin: Education (57%), wealth or material 86 possession (67%), landholdings (71%), social status (62%), gender differences (25%), age (24%), length of stay (19%), political party affiliation (78%), religious beliefs (9%), ethnic background (8%). In Kendua during baseline, we observed a very similar picture. Here the prime areas of conflicts were: Education (60%), material possession (75%), landholdings (65%), social status (45%), gender differences (32%), age differences (50%), length of stay (25%), political party affiliation (61%), religious beliefs (12%), and ethnic background (10%). However, there seems to be interesting changes observed during the endline. In both sub-districts, gender differences (D: 45%; K:53%), differences in religious background (D: 41%; K: 26%), and ethnicity (D: 55%; K: 59%) came out as much more of a significant sources of conflict than they were before. Table 5: Areas of conflicts and problems Item Baseline Endline Durgapur n (%) Kendua n (%) Both n (%) Durgapur n (%) Kendua n (%) Both n (%) Do these differences cause problems? (yes) 33 (20.6) 13 (7.4) 46 (13.7) 33(22.3) 63(38.9) 96(31.0) How these problems are usually handled? People work it out between themselves (yes) 6 (18.2) 9 (69.2) 15 32.6) 31(93.9) 35(55.6) 66(68.8) Family/household members intervene (yes) 12 (36.4) 5 (38.5) 17 37.0) 20 (60.6) 40(63.5) 60(62.5) Neighbors intervene (yes) 25 (75.8) 4 (30.8) 29 63.0) 27(81.8) 56(88.9) 83(86.5) Community leaders mediate (yes) 29 (87.9) 6 (46.1) 35(76.1) 7(21.2) 28(44.4) 35(36.5) Religious leaders mediate (yes) 17 (51.5) 1 (7.7) 18 (39.1) 8(24.2) 22(34.9) 30(31.3) Judicial leaders mediate (yes) 25 (75.8) 3 (23.1) 28 (60.9) 18(54.6) 51(81.0) 69(71.9) Do such problems ever lead to violence? (yes) 9 (27.3) 5 (38.5) 14 (30.4) 19(57.6) 35(55.6) 54(56.3) Though there are areas of differences in the communities, it is not necessary that the differences would always lead to problems and/or violence. That is why it was important to ask the question directly to know if these differences ever did lead to problems and/or violence. Quite a substantial proportion of Durgapur inhabitants (21%) reported that it did lead to troubles, while only a minority in Kendua (7%) reported that to be the case. However, that was during the baseline, which changed substantially for the people in Kendua where 39% of informants suggested that it did lead to conflicts during the endline (the proportion remained the same in Durgapur during endline). When the differences did lead to troubles, Durgapur inhabitants during baseline reported, it was the community leaders (87%), neighbors (76%) and judicial leaders (76%) who mediated. On the other hand, in Kendua, it was the people involved who worked it out amongst themselves (69%), followed by the 87 community leaders (46%). With regard to endline survey results, things changed in favor of the neighbors who, according to the informants, played the most noticeable role in mitigating a conflict (D: 82%; K: 89%). Interestingly, a huge majority (94%) in Durgapur suggested that people worked it out amongst themselves, which was a nominal 18% during baseline. When asked if these problems ever lead to violence, most of the informants responded in the negative during the baseline survey. However, things changed quite a bit at the endline, where 58% and 56% respectively in Durgapur and Kendua said yes they did lead to violence. Table 6: Access to services Item Baseline Endline Durgapur n (%) Kendua n (%) Both n (%) Durgapur n (%) Kendua n (%) Both n (%) Are there any services where you or members of your household are occasionally denied service or have limited opportunity to use? Health services/clinics 40 (25.0) 25 (14.3) 65 (19.4) 47(31.8) 94(58.0) 141(45.5) Job training/employment 39 (24.4) 11 (6.3) 50 (14.9) 46(31.1) 36(22.2) 82(26.5) Credit 39 (24.4) 19 (10.9) 58 (17.3) 49(33.1) 89(54.9) 138(44.5) Agricultural extension 48 (30.0) 14 (8.0) 62 (18.5) 41(27.7) 52(32.1) 93(30.0) Justice/conflict resolution 43 (26.9) 46(26.3) 89 (26.6) 67(45.3) 106(65.4) 173(44.2) Do you think that there are other households in this community that have such access problems? (yes) 70(43.7) 10(5.7) 80(23.9) 44(29.7) 81(50.0) 125(40.3) Accessibility is an important variable in terms of structural social capital. Therefore, we asked about services that informants and/or their household members are occasionally denied services. According to the informants from Durgapur during baseline, agricultural extension (30%), justice (27%), health services (25%)credit (24%), and job training and employment (24%) were the principle areas where they faces issues with accessibility. On the other hand, informants from Kendua reported that they faced issues at justice (26%) and health services (14%) primarily. However, during the endline, access to legal services (D: 45%; K: 65%), health services (D: 32%; K: 58%), and credit services (D: 33%; K: 55%) became more prominent. Interestingly, during both baseline and endline, people in Kendua mentioned health services as an area where they have problems in terms of accessibility. Interestingly, when asked about households other than informants’ own and if they faced similar issues with regard to any of those same services during the baseline survey, 44% in Durgapur suggested in the affirmative, while only 6% in Kendua confirmed the same. The proportion for Kendua increased by many folds and reached 50% during the endline survey. 88 Table 7: Collective action Item Baseline Endline Durgapur n (%) Kendua n (%) Both n (%) Durgapur n (%) Kendua n (%) Both n (%) How often have members of this village got together/petitioned officials with development goals? Never 67(41.9) 30(17.1) 97(29.0) 75(50.7) 25(15.4) 100(32.3) Once 51(31.9) 34(19.4) 85(25.4) 39(50.7) 28(17.3) 67(21.6) A couple of times 39(24.4) 108(61.7) 147(43.9) 29(19.6) 98(60.5) 127(41.0) Frequently 3(1.9) 3(1.7) 6(1.8) 5(3.4) 11(6.8) 16(5.2) Was this action/were any of these actions successful? Yes, all were successful 5 (5.4) 34 (23.4) 39 (16.4) 10(13.7) 16(11.7) 26(12.4) Some were successful 32 (34.4) 39 (26.9) 71 (26.8) 47(64.4) 111(81.0) 158(75.2) No, none were successful 56 (60.2) 72 (49.7) 128(53.8) 16(21.9) 10(7.3) 26(12.4) How often in the past year have you joined together with others to address a common issue? Never 84 (52.5) 97 (55.4) 181(54.0) 91(61.5) 22(13.6) 113(36.5) Once 22 (13.7) 31 (17.7) 53 (15.8) 29(19.6) 38(23.5) 67(21.6) A couple of times 49 (30.6) 42 (24.0) 91 (27.1) 27(18.2) 86(53.1) 113(36.5) Frequently 5 (3.1) 5 (2.9) 10 (3.0) 1(0.7) 16(9.9) 17(5.5) In the last three years have you personally done any of the following things 89 Item Baseline Endline Durgapur n (%) Kendua n (%) Both n (%) Durgapur n (%) Kendua n (%) Both n (%) Voted in the elections (yes) 132 (82.5) 156(89.1) 288(86.0) 131(88.5) 155(95.7) 286(92.3) Actively participated in any association (yes) 93 (58.1) 95 (54.3) 188(56.1) 68(46.0) 106(65.4) 174(56.1) Made a personal contact w/ influential person 81 (50.6) 67 (38.3) 148(44.2) 40(27.0) 118(72.8) 158(51.0) Actively participated in an election campaign 60 (37.5) 59 (33.7) 119(35.5) 44(29.7) 90(55.6) 134(43.2) Contacted your elected representative 100 (62.5) 102(58.3) 202(60.3) 62(41.9) 112(69.1) 174(56.1) Talked with other people in your area 86 (53.7) 86 (49.1) 172(51.3) 62(41.9) 112(69.1) 174(56.1) Made a monetary or in-kind donation 87 (54.4) 113(64.6) 200(59.7) 63(42.6) 129(79.6) 192(61.9) If some decision related to a development project needed to be made, do you think the entire village/ neighborhood would be called upon to decide or only the community leaders will decide? The community leaders would decide 106 (66.2) 23 (13.1) 129(38.5) 49(33.1) 24(14.8) 73(23.6) The whole village would be called 54 (33.7) 152(86.9) 206(61.5) 99(66.9) 138(85.2) 237(76.5) Overall, how would you rate the spirit of participation in this village/neighborhood? High 66 (41.2) 82 (46.9) 148(44.2) 43(29.1) 58(35.8) 101(32.6) Very high 62 (38.7) 50 (28.6) 112(33.4) 24(16.2) 30(18.5) 54(17.4) How much influence do you think people like yourself can have in making this village a better place to live? 143 (89.4) 167(95.4) 310(92.5) 144(97.3) 112(69.1) 256(82.6) In terms of collective action, the data on the two sub-districts yielded very intriguing results. 42% of Durgapur informants reported that they never got together and jointly petitioned government officials or political leaders to initiate and/or take up a developmental project, while 62% of the Kendua informants suggested that they have done it at least a couple of times during the baseline. The trend remained similar during the endline when 61% of Kendua residents suggested that they have done it a couple of times while majority in Durgapur suggested that they never did it. In addition, during the baseline, around 23% of Kendua informants reported that their action has always been successful in this regard (as opposed to only 5% in Durgapur). During the endline, 81% in Kendua suggested some of their actions were successful, while around 64% of Durgapur residents suggested the same. 8: During the baseline survey when we asked about getting together to address a common concern, both Durgapur and Kendua informants reported in a similar fashion: in Durgapur 45% reported getting together at least once and 42% in Kendua reported the same in order to address a common concern. However, in both the sub-districts, around half of the informants reported not getting together ever for such a cause (D: 53%; K: 55%). However, when we asked the same during endline survey, the data yielded results that portrayed the sub-districts in accordance with other data, which was 62% of informants in Durgapur said that they never got together to address a common concern, as opposed to only 14% in Kendua. In Kendua, around 53% informants said they got together at a couple of times with only 18% in Durgapur to address a common concern. On an individual level, it seemed people were more inclined toward taking actions and participating in activities that had collective value both in Durgapur and in Kendua. It was the most apparent when it came to political processes such as voting; 83% in Durgapur and 89% in Kendua reported that they voted for their candidates in the last local and/or national elections. As reported earlier, they again reported that they took active part in their associations (D: 58%; K: 54%). They also reported that they kept personal contacts with influential persons (D: 50%; K: 38%) and their elected representatives (D: 62%; K: 58%). A substantial proportion of the informants also reported that they actively participated in election campaigns (D: 38%; K: 34%). Talking to other people about the issue (D: 54%; K: 49%) and/or making a donation was another area where they excelled (D: 54%; K: 49.1%). Overall, the trends remained pretty similar during the endline survey, though marked differences were noticed between the people in the informants in two sub-districts in terms of specific actions like participating in an association (D: 46%; K: 65%), making contacts with influential persons (D: 27%; K: 73%), participating in an election campaign (D: 30%; K: 56%), contacting the elected representative (D: 42%; K: 69%), and making donations (D: 43%; K: 80%). When the informants were asked about if they think the entire village would be called upon if a new developmental project was to be taken up, Durgapur responded in a negative way (34%), while Kendua was extremely positive (87%). According to the informants in Durgapur, it was going to be only the leaders who would decide (66% as opposed to 13% in Kendua). During the endline survey however, the proportions remained the same for Kendua while it improved for Durgapur (entire village being called 67% and community leaders would decide 33.1%). 8; Cognitive social capital Table 8: Solidarity Item Baseline Endline Durgapur n (%) Kendua n (%) Both n (%) Durgapur n (%) Kendua n (%) Both n (%) Suppose someone in the village/neighborhood had something unfortunate happen to them, such as a father’s sudden death. Who do you think they could turn to for help in this situation? No one 1 (0.6) 28 (16.0) 29 (8.7) 4(2.7) 5(3.1) 9(2.9) Family 43 (26.9) 87 (49.7) 130(38.8) 140(94.6) 140(86.4) 280(90.3) Neighbors 96 (60.0) 50 (28.6) 146(43.6) 2(1.4) 15(9.3) 17(5.5) Suppose your neighbor suffered an economic loss, say (i.e. “crop failure”). In that situation, who do you think would assist him/her financially? No one 9 (5.6) 30 (17.1) 39 (11.6) 5(3.4) 7(4.3) 12(3.9) Family 19 (11.9) 93 (53.1) 112(33.4) 134(90.5) 128(78.6) 262(84.5) Neighbors 70 (43.7) 41 (23.4) 111(33.1) 7(4.7) 26(16.1) 33(10.7) Community leaders 25 (15.6) 3 (1.7) 28 (8.4) 1(0.7) 0(0.0) 1(0.3) In terms of trying to understand “cognitive social capital,” we investigated into aspects related to solidarity, trust, mutual cooperation, and conflict resolution as indicators. Table 8 describes the data on solidarity. Reliance on family came out as the most prominent trend in Kendua when it came to seeking help during a crisis/unfortunate event. 50% of the informants reported that they would rather turn to their families than their neighbors (29). A reverse trend was observed in Durgapur, where 60% reported that they would rather turn to the neighbors. A similar preference for the family over neighbors and vice versa was observed when asked about the same thing, but from the opposite angle (i.e. who do you think would help?). This seemed to confirm that the responses were not due to chances. Reliance on neighbors is a good indicator of solidarity in a society. During the endline survey, this trend of trusting the family over anyone else was confirmed by overwhelming majority (D: 95%; K: 86%). A similar pattern was observed when asked about the neighbor’s loss and what they would do during an economic crisis of their own. 92 Table 9: Trust and cooperation Item Baseline Endline Durgapur n (%) Kendua n (%) Both n (%) Durgapur n (%) Kendua n (%) Both n (%) Do people trust each other in lending/borrowing? (yes) 142 (88.7) 170(97.1) 312(93.1) 142(96.0) 154(95.1) 296(95.5) Do you think over the last few years this level of trust has gotten better, worse, or same? Better 53 (33.1) 80 (45.7) 133(39.7) 65(43.9) 97(59.9) 162(52.3) Gotten worse 41 (25.6) 20(11.40) 61 (18.2) 0(0.0) 0(0.0) 0(0.0) In comparison to the other places, how much do the people here believe each other? (borrowing/lending) More 71 (44.4) 128(73.1) 199(59.4) 24(16.2) 72(44.4) 96(31.0) If someone from the village goes away for a while, who would they leave their fields with? Neighbor 17 (10.6) 16 (9.1) 33 (9.8) 4(2.7) 12(7.4) 16(5.2) If you suddenly had to go away for a day or two, whom could you leave your children with? Other family member 107 (66.9) 162(92.6) 269(80.3) 146(98.7) 146(90.1) 292(94.2) Neighbor 14 (8.7) 7 (4.0) 21 (6.3) 1(0.7) 14(8.6) 15(4.8) Other relatives 33 (20.6) 3 (1.7) 36 (10.7) 0(0.0) 0(0.0) 0(0.0) Do you think that people in this area are more concerned about family welfare than village welfare? Strongly agree 141 (88.1) 43(24.6) 184(54.9) 113(76.4) 69(42.6) 182(58.7) If a community project does not directly benefit your neighbor, do you think your neighbor would give time? 93 (58.1) 148(84.6) 241(71.9) 98(66.2) 103(63.6) 109(35.2) If a community project does not directly benefit your neighbor, do you think your neighbor would give money 60 (37.5) 136(77.7) 196(58.5) 30(20.3) 111(68.5) 141(45.5) Do you agree or disagree to the following Most people in this village/ neighborhood are basically honest and can be trusted Strongly agree 44 (27.5) 70 (40.0) 114(34.0) 49(33.1) 55(34.0) 104(33.6) Agree 49 (30.6) 75 (42.9) 124(37.0) 72(48.7) 90(55.6) 162(52.3) People are always interested only in their own welfare Strongly agree 132 (82.5) 43 (24.6) 175(52.2) 115(77.7) 50(30.9) 165(53.2) In this village/ neighborhood, one has to be alert or someone is likely to take advantage of you. Strongly agree 121 (75.6) 26 (14.9) 147(43.9) 57(38.5) 53(32.7) 110(35.5) 93 Trust becomes apparent when it comes to lending and borrowing money to/from others. Informants from both sub-district reported that they do trust others in their communities in terms of lending money to or borrowing from them (D: 89%; K:97%). The proportions remain similar during the endline (D: 96%; K: 95%). Only a minority thought that this situation has gotten worse over the years (D: 26%; K: 11%), while a substantial proportion thought it has gotten better (D: 33%; K: 46%). Interestingly, no one in either of the sub-districts thought that it has gotten worse during the endline. During the baseline, they also thought and reported that their communities are more trustworthy than others when it came to lending/borrowing money (D: 44%; K: 73%). However, proportions in this regard waned substantially during the endline (D: 16%; K: 44%). Though inhabitants of both sites reported high level of trust amongst themselves, this didn’t translate into trusting them (people other than their own family members) with their land/property – only an insignificant minority reported that they might leave their fields in the custody of their neighbors (D: 11%; K: 9% during baseline and D: 3%; K: 7% during endline). When it came to entrusting their children with someone while they were gone for a few days, it was overwhelmingly other family members or other relatives (D: 88%; K: 95% during baseline and D: 99%; K: 90%), and hardly ever anyone beyond the folds of their families. When directly asked to compare family welfare with that of village welfare, it became clear as to where people stood in terms of their allegiance, and we observed that 88% of the Durgapur inhabitants sided with family, while only 25% from Kendua sided with the family in this regard. During the endline survey, the proportions were D: 76%; K: 43%. Similarly, 58% of the informants from Durgapur reported that they think their neighbor would give time to a project even if it didn’t directly benefit them, while this was around 85% for people in Kendua (the proportions were D: 66%; K: 64% during the endline survey). In terms of giving money in a similar situation the percentage was 38% and 78% respectively (the proportions were D: 20%; K: 69% during the endline survey). In terms of thinking if the villagers were generally honest and trusting, 59% in Durgapur and 83% in Kendua reported that they either agreed or strongly agreed that to be the case (the proportions were D: 82%; K: 90% during the endline survey). Regarding self-centered welfare, 83% informants in Durgapur reported that was really the case, though only 25% agreed in Kendua (the proportions were D: 78%; K: 31% during the endline survey). It seemed the sense of “community” was lacking in Durgapur during baseline, but that may not be the case anymore. When asked if one needs to be alert so that they are not taken advantage of, 76% informants in Durgapur reported affirmatively, while only 15% agreed in Kendua during baseline, while the proportions were D: 39%; K: 33% during the endline survey. 94 Table 10: Conflict resolution Item Baseline Endline Durgapur n (%) Kendua n (%) Both n (%) Durgapur n (%) Kendua n (%) Both n (%) In your opinion, is this village generally peaceful? 134 (83.7) 167(95.4) 301(89.8) 146(98.7) 152(93.8) 298(96.1) Compared with other villages, is there more or less conflict here? Less 98 (61.2) 148(84.6) 246(73.4) 127(85.8) 100(61.7) 227(73.2) Suppose two people in this village/neighborhood had a fairly serious dispute with each other. Who do you think would primarily help resolve the dispute? No one – they will work it out themselves 15 (9.4) 0 (0.0) 15 (4.9) 20(13.5) 3(1.9) 23(7.4) Neighbors 92 (57.5) 103(58.9) 195(58.2) 101(68.2) 83(51.2) 184(59.4) In terms of considering if the communities were peaceful, informants in both sub-districts mentioned that they are and their responses remained consistent over the years (D: 83%; K: 95% during baseline and D: 99%; K: 94% during endline). They also thought that their communities were comparatively more peaceful than the other ones around (D: 61%; K: 85% during baseline and D: 88%; K: 62% during endline). However, if there was a conflict, most of the people in both sub-districts thought that it would be their neighbors who would come to resolve their conflicts (D: 58%; K: 59% during baseline and D: 68%; K: 51% during endline). Social capital As mentioned earlier, formative research was carried out to understand the current situation in the two sub-districts that we worked in, namely, Durgapur and Kendua of Netrokona District. The formative research also allowed us to adapt the WB Tool to measure Social Capital and make it culturally relevant to our context. The revised tool was then administered into the community. In what follows, we provide a comparative set of two analyses, one from the baseline data, and the other from the endline data. Development of scale The first stage of analysis of social capital was the development of a scale that can then be used to measure differing levels of social capital and how that fares with other relevant variables, i.e. membership in a community group or residence in a specific area. We followed the exact same procedure to analyze both baseline and endline data. The following steps were taken in the development of the scale (we include the findings both the surveys in here): 1. Recoded dichotomous variables 2. Check for successful recoding 3. Reliability analysis – 1st round 4. Interpret the first round of reliability analysis 5. Reliability analysis – 2nd round (with reduced number of variables; during the baseline, this was 17 variables, while during the endline it was 35 variables) 6. Interpret the second round of reliability analysis 95 7. Create social capital scale and create bar charts Recoding dichotomous variables First of all, only those variables were used that had a response from the entire sample of informants. The same set of variables was used for the analyses of both the surveys. In order to recode the dataset, we recoded the variables that were coded 1=Yes and 2=No into 1=Yes and 0=No. For this, we recoded the following 50 (fifty) variables: • Are you or is someone in your household a member of any groups or organizations? • If the primary school of this village/neighborhood went without a teacher for a long time, say six months or more, which people in this village/neighborhood do you think would get together to take some action about o No one in the village/neighborhood would get together o No one in the village/neighborhood would get together o Local/municipal government o Village/neighborhood association o Parents of school children o The entire village/ neighborhood • Are there any services where you or members of your household are occasionally denied service or have limited opportunity to use? o Education/schools o Health services/clinics o Housing assistance o Job training/employment o Credit o Transportation o Water distribution o Sanitation services o Agricultural extension o Justice/conflict resolution o Security/police services • In the last three years have you personally done any of the following things o Voted in the elections o Actively participated in any association o Made a personal contact with influential person o Made the media interested in a problem o Actively participated in an information campaign o Actively participated in an election campaign o Taken part in a protest march or demonstration o Contacted your elected representative o Attend to protest forceful possession o Taken part in government meetings/ offices o Talked with other people in your area about a problem 96 o Notified the court or police about a problem o Made a monetary or in-kind donation o Volunteered for a charitable organization • Have you been approached by someone personally during the last three years who asked you to do any of the following o Voted in the elections o Actively participated in any association o Made a personal contact with influential person o Made the media interested in a problem o Actively participated in an information campaign o Actively participated in an election campaign o Taken part in a protest march or demonstration o Contacted your elected representative o Attend to protest forceful possession o Taken part in government meetings/ offices o Talked with other people in your area about a problem o Notified the court or police about a problem o Made a monetary or in-kind donation o Volunteered for a charitable organization • If some decision related to a development project needed to be made in this village/neighborhood, do you think the entire village/ neighborhood would be called upon to decide or would the community leaders make the decision themselves? • Do you think that in this village/ neighborhood people generally trust one another in matters of lending and borrowing? • If a community project does not directly benefit your neighbor but has benefits for others in the village/neighborhood, then do you think your neighbor would contribute time for this project? • In your opinion, is this village/neighborhood generally peaceful or conflictive? • Do people in this village/neighborhood contribute time and money toward common development goals? Checking recoding was successful In order to check if the recoding was successful, we ran frequency tables for the entire set of variables (i.e. variables that were recorded in previous step.) Please look at the frequency tables from both the surveys in the annex. First round of reliability analysis Once the frequency tables were generated, a reliability test was conducted in the following way: RELIABILITY /VARIABLES=[all the recoded variables] /SCALE('ALL VARIABLES') ALL /MODEL=ALPHA /STATISTICS=SCALE /SUMMARY=TOTAL. Interpreting first round of reliability analysis First of all, we present the BASELINE interpretation of the reliability analysis. 97 Scale: ALL VARIABLES Case Processing Summary N % Cases Valid 334 100.0 Excludeda 0 .0 Total 334 100.0 a. Listwise deletion based on all variables in the procedure. Reliability Statistics Cronbach's Alpha N of Items .761 50 The following table shows the item to total statistics of just the first variable from the baseline data, but it was done for all of the variables (50). Please refer to the complete item￾total statistics in the annex section of the report. Item-Total Statistics Scale Mean if Item Deleted Scale Variance if Item Deleted Corrected Item￾Total Correlation Cronbach's Alpha if Item Deleted x4a1 15.8743 29.378 .309 .754 Scale Statistics Mean Variance Std. Deviation N of Items 16.5299 31.199 5.58559 50 Now, here we present the ENDLINE analysis of the reliability analysis. Scale: ALL VARIABLES Case Processing Summary N % Cases Valid 310 100.0 Excludeda 0 .0 Total 310 100.0 a. Listwise deletion based on all variables in the procedure. 98 Reliability Statistics Cronbach's Alpha N of Items .900 50 The following table shows the item to total statistics of just the first variable from the endline data, but it was done for all of the variables (50). Please refer to the complete list in the annex section of the report. Item-Total Statistics Scale Mean if Item Deleted Scale Variance if Item Deleted Corrected Item￾Total Correlation Cronbach's Alpha if Item Deleted x4a1 20.6968 79.325 .249 .899 Scale Statistics Mean Variance Std. Deviation N of Items 21.3355 81.693 9.03841 50 Once the reliability analyses were complete, we proceeded to conduct the second round of reliability analysis as described in the following section in order to create the additive index/scale. Second round of reliability analysis with reduced set of variables For the second round of reliability analysis, we reduced the number of variables with the following stipulations: Variables were deleted if: • Item to total (the entire scale) correlation was negative • Item to total correlation was positive, but was less than 0.3 • Cronbach’s alpha increased (i.e. improved or was > 0.761 during the baseline and > 0.9 during the endline) when the item was deleted For reliability, we did the following (as expressed earlier for all variables) RELIABILITY /VARIABLES=[reduced set of 18 variables for baseline and 37 variables for the endline] /SCALE('ALL VARIABLES') ALL /MODEL=ALPHA /STATISTICS=SCALE /SUMMARY=TOTAL. Interpreting second round of reliability analysis Second round of reliability analysis during the BASELINE was interpreted in the following manner: Reliability Scale: ALL VARIABLES Case Processing Summary N % Cases Valid 334 100.0 99 Excludeda 0 .0 Total 334 100.0 a. Listwise deletion based on all variables in the procedure. Reliability Statistics Cronbach's Alpha N of Items .791 18 The table showing the item to total statistics of all 18 variables can be located in the annex below the table for item to total statistics of all 50 variables (baseline). Variables that had item to total correlation less than 0.3 were deleted (=x4d5k), leaving a total of 17 variables to compute social capital measure at the final stage. Similarly, the second round of reliability analysis during the ENDLINE was interpreted in the following manner: Scale: ALL VARIABLES Case Processing Summary N % Cases Valid 310 100.0 Excludeda 0 .0 Total 310 100.0 a. Listwise deletion based on all variables in the procedure. Reliability Statistics Cronbach's Alpha N of Items .918 37 The table showing the item to total statistics of all 37 variables can be located at the bottom of the table for item to total statistics of 50 variables (endline) in the annex section. Just as it was done during baseline, we deleted the variables that had item to total correlation less than 0.3 (=x4c5h, x4c5i), leaving us with a total of 35 variables to compute social capital measure at the final stage. Creating social capital scale and creating barcharts At the final stage, as per the analyses above, a total of seventeen (17) variables were selected to construct the baseline social capital scale, while a total of thirty-five (35) variables were selected to construct the 9: endline social capital scale. In order to do construct the scale, the following was done (in SPSS as in other cases): Here the first set of analysis provides the social capital scale as obtained from the baseline data. COMPUTE Soc_cap= x4a1 + x4d4b + x4d4e + x4d4f + x4d4h + x4d4i + x4d4j + x4d4k + x4d4n + x4d5b + x4d5c + x4d5e + x4d5f + x4d5g + x4d5h + x4d5i + x4d5k + x4d5n. EXECUTE. FREQUENCIES VARIABLES=Soc_cap / BARCHART FREQ /ORDER=ANALYSIS (The computed Social Capital Scale can be found in the annex section of this report). Similarly, now we provide the social capital scale as obtained from the endline data: COMPUTE Soc_cap=x4b1b + x4b1c + x4b1d + x4b1e + x4c5a + x4c5b + x4c5e + x4c5f + x4c5g + x4d4b + x4d4c + x4d4d + x4d4e + x4d4f + x4d4g + x4d4h + x4d4i + x4d4j + x4d4k + x4d4l + x4d4m + x4d4n + x4d5b + x4d5c + x4d5d + x4d5e + x4d5f + x4d5g + x4d5h + x4d5i + x4d5j + x4d5k + x4 d5l + x4d5m + x4d5n. EXECUTE. FREQUENCIES VARIABLES=Soc_cap /BARCHART FREQ /ORDER=ANALYSIS. (The computed Social Capital Scale can be found in the annex section of this report). 9; Measurement of social capital Baseline analysis of social capital In order to apply the social capital scale, we look for associations between the social capital scale and other independent variables of interest. For the present, we have considered two such variables, a. Membership status, and b. Area of residence (Durgapur or Kendua sub-districts). First we looked at any possible associations with social capital and residence of the informants. MEANS TABLES=Soc_cap BY upz Soc_cap * Upz Report Soc_cap Upz Mean N Std. Deviation 18 6.6063 160 3.29684 47 6.5345 174 4.08811 Total 6.5689 334 3.72473 ANOVA Table Sum of Squares df Mean Square F Sig. Soc_cap * Upz Between Groups (Combined) .429 1 .429 .031 .861 Within Groups 4619.487 332 13.914 Total 4619.916 333 Measures of Association Eta Eta Squared Soc_cap * Upz .010 .000 Then we looked into any possible association between social capital scale and their membership status (whether or not members of PARI or SATHI). Soc_cap * Memtype1 Report Soc_cap Memtype1 Mean N Std. Deviation Member 8.2216 167 3.49940 NonMember 4.9162 167 3.17637 Total 6.5689 334 3.72473 :2 ANOVA Table Sum of Squares df Mean Square F Sig. Soc_cap * Memtype1 Between Groups (Combined) 912.287 1 912.287 81.691 .000 Within Groups 3707.629 332 11.168 Total 4619.916 333 Measures of Association Eta Eta Squared Soc_cap * Memtype1 .444 .197 Endline analysis of social capital Similarly, in order to apply the social capital scale, we look for associations between the social capital scale and other independent variables of interest during the endline as well. We have considered two such variables, a. Membership status, and b. Area of residence (Durgapur or Kendua sub-districts). First we looked at any possible associations with social capital and residence of the informants. Soc_cap * Upz Report Soc_cap Upz Mean N Std. Deviation 18 9.2432 148 6.63799 47 15.7963 162 8.06968 Total 12.6677 310 8.10186 ANOVA Table Sum of Squares df Mean Square F Sig Soc_cap * Upz Between Groups (Combined) 3321.256 1 3321.25 6 60.31 0 .000 Within Groups 16961.521 308 55.070 Total 20282.777 309 :3 Measures of Association Eta Eta Squared Soc_cap * Upz .405 .164 Then we looked into any possible association between social capital scale and their membership status (whether or not members of PARI or SATHI), just as we did during baseline. Soc_cap * Memtypa1 Report Soc_cap Memtypa 1 Mean N Std. Deviation Member 15.348 4 155 7.58895 Non￾member 9.9871 155 7.72329 Total 12.667 7 310 8.10186 ANOVA Table Sum of Squares df Mean Square F Sig. Soc_cap * Memtypa1 Between Groups (Combined) 2227.616 1 2227.616 38.001 .000 Within Groups 18055.16 1 308 58.621 Total 20282.77 7 309 Measures of Association Eta Eta Squared Soc_cap * Memtypa1 .331 .110 :4 DISCUSSION: Social capital Measurement Structural social capital Organizational density and characteristics Membership status of people conforms to the fact that PIs have been formed in Durgapur much earlier than in Kendua, though the difference is closing rapidly. However, in terms of active participation or being a leader is concerned, Kendua is far ahead indicating their interest in forming groups and working together. Interestingly, it was higher in Durgapur during the initial stages, but due to people being substantially more active in Kendua, as observed during baseline, the overall situation has changed. Data on Social Capital also indicates to the same. In Durgapur and Kendua, SATHI and PARI are ubiquitous in terms of membership and popularity and people are often very critical about other NGOs and their activities. All the other NGOs are pretty negligible with respect to them. What needs to be kept in mind is that the NGO activities have been historically extensive in Durgapur and people have formed entrenched beliefs regarding their work. One thing to note here that PARI only works in Durgapur and SATHI only works in Kendua – therefore their presence in the area is mutually exclusive. This is programmatic strategy from SUSOMA project, of which these NGOs are a part of. The groups were primarily homogeneous during our initial exploration, except with regard to political participation and age. Interestingly, most of the people belonged to the same occupation (agriculture) in Kendua than in Durgapur. This might be an indication of Kendua being a relatively newer community, where occupational diversity hasn’t really flourished as much as it has in Durgapur. It is now clear that the word is spreading and more and more people from differing backgrounds are joining the groups. Heterogeneity is on the rise. Decision-making and leadership Participatory approaches are markedly more prominent in Kendua than in Durgapur. People in Kendua fall back on groups’ decision more than relying on the leaders, which is much less among the groups in Durgapur. Moreover, the tendency to rely on the leaders is increasing at a faster pace in Durgapur. Networks and mutual support People seem to have become more realistic and do not expect much from local organizations. They seem to believe no one would come to address an issue such as a problem with the local school. However, this problem was less acute among the people in Kendua than in Durgapur. This trend was observed during the baseline exploration that the role of the entire community came out as more prominent in Kendua than in Durgapur. In Durgapur, reliance is more on the elected representatives than general community members, while it is a bit reversed in Kendua. The village matobbor is the one traditional source of help – more so than any other individual and/or organization in the communities. As suggested earlier, the endline survey saw people becoming more reliant on themselves rather than others in the village. This could be treated as people becoming more realistic and not that things have dramatically changed within the communities. :5 Sources of conflicts During the baseline, Political party affiliation played the pivotal role in Durgapur where conflicts originated, closely followed by disputes over landholdings, material possessions, social status, and education. On the other hand, people were categorical in terms of their denial about ethnic background, religious beliefs, length of stay, age, and gender differences playing any role at all in giving rise to any conflict/s. Interestingly, gender differences, religious background, and ethnicity, things that were not mentioned in our earlier exploration, came out as prominent sources of conflict during the endline. Areas of conflicts and problems We reported during the baseline that it seemed from the responses of the informants that differences led to troubles only in Durgapur, and that was largely not the case in Kendua. And, even if the differences led to troubles in Kendua, involved people were able to resolve the issue themselves, unlike people in Durgapur where community leaders, neighbors, and judicial leaders had to step in. During the endline we observed that quite a bit seems to be saying different things about people in Kendua – we observed differences in several areas in Kendua, unlike Durgapur. This might be suggestive of the fact that Durgapur is a more stable population, while people in Kendua are only recently becoming stable. However, we are not certain as to why this is the case. The role of neighbors must be acknowledged here – it is mostly the neighbors that come forward when there is a conflict. However, family members and judicial members also play a significant role. Judging from the endline results, sources of conflict needs to be addressed properly since most of the people suggested that they lead to conflicts that result in violence. Access to services During the baseline, we reported that in both Durgapur and Kendua, justice and health services were mentioned as places where people faced issues related to accessibility. In addition, agricultural extension was also mentioned in Durgapur. These are important areas where having problems related to access can and may result into disasters for the people, especially the poor and the marginalized. Quite similarly, accessing justice, health, and credit services have come out to be the most prominent areas where people have problems during the endline as well. In addition, it should be mentioned that people in Kendua seem to have a particular problem with health services. It is either about them not getting the required services or them being relatively more aware of what they need and what they do not have with regard to health, indicating that SUSOMA is working well in that area. These results are troubling since this is a major pathway through which social capital may be perceived to operate in order to increase health outcomes. Collective action As other data reflecting on group dynamics suggest, people in Kendua are more inclined toward taking group actions than people in Durgapur. We believe that the difference is due to deeply entrenched values and cultural practices where people are well set in their ways in Durgapur with regard to how they would address a certain issue. It is a reflection of those values and practices, i.e. they are more dependent on leaders than getting together to stand up for something. :6 As suggested elsewhere, people in Kendua more often than people in Durgapur get together to address common concerns. This is yet another arena where it indicates Kendua residents’ higher social capital, where there is more confidence in group dynamics and collective action than in Durgapur. Political processes were highlighted (i.e. voting in elections, taking part in campaigns, keeping contact with elected representatives) in terms of individual involvement having collective impacts. Individual level differences were not as pronounced during the baseline survey as it became during the endline with regard to maintaining social ties with influential people, participating in political processes, and making donations. Kendua seems far ahead on this than Durgapur. In a more matured state of being, we believe, the community groups are having an impact in that they are making people more self-reliant and confident in their groups and people in general rather than relying on the leaders. Conversely, the distrust regarding leaders is showing more and more each year. Cognitive social capital Solidarity Crisis and dealing with crisis, either one one’s own or of a neighbor, the responses clearly indicated informants’ choice of family. The importance that was placed on neighbors earlier in the project seems to have diminished entirely. During the baseline exploration we saw people in Durgapur would rather rely on leaders to decide on important issues including their developmental projects. We also saw the same people would rather rely on their neighbors over their family members in times of crisis for monetary or any other kind of support. This has decidedly changed over time. Trust and cooperation Surveys indicate that people in both the sub-districts remain trusting of each other, though they do not seem to think as highly of their own communities when compared to others. This, we believe, is a result of mobility and interaction, which has increased over the years. More specifically, trusting one’s own family was of much higher value than any other category of people. It seems, people in Kendua are more likely to value the welfare of the village over the value of their own families than the people in Durgapur, where the allegiance clearly is with their families or the individual themselves first. It might be safe to hypothesize here that newly formed communities are more hopeful in their initial stages till their expectations are not crushed and/or frustrated. Conflict resolution It can generally be stated the most of the respondents in both of the sub-districts believe that their communities are peaceful and that they can rely on their neighbors in times of conflicts. However, when it came to actual disputes, though in most cases there would be neighbors intervening, for some of the cases in Durgapur it was suggested that it would be the person in conflict themselves resolving the disputes. This, we believe, is an indication of somewhat “individualistic” stance of the people in Durgapur. :7 Measure of social capital Baseline measure According to our analysis, the computed cronbach’s alpha came out to be .791 when computed against 18 variables. After that, one further variable was dropped and an additive social capital scale was created. After this, we looked at the association between social capital scale and residence of the informants. This yielded a difference of means not statistically significant (means Durgapur 6.6063 and Kendua 6.5345, significance: p value .861). When we looked at the association between social capital scale and membership status of the informants (i.e. if they were members or not of PARI or SATHI), it yielded a difference of means that came out to be statistically significant (means Member 8.2216 and Non-member 4.9162; significance: p value .000). Endline measure According to our analysis during the endline, the computed cronbach’s alpha came out to be .918 when computed against 37 variables. After that, two further variables were dropped and an additive social capital scale was created. After this, we looked at the association between social capital scale and residence of the informants. This yielded a difference of means that was statistically significant (means Durgapur 9.2432 and Kendua 15.7963, significance: p value .000). When we looked at the association between social capital scale and membership status of the informants (i.e. if they were members or not of PARI or SATHI), it yielded a difference of means that also came out to be statistically significant (means Member 15.3484 and Non-member 9.9871; significance: p value .000). These analyses conform to the descriptive statistics, which also indicated that there should be a significant difference between the social capital means in two different groups, i.e. members and non-members, and also in between people belonging to two different sub-districts, i.e. Durgapur and Kendua. We believe that both the communities have become more or less stable and that the differences that we see now in terms of Kendua having more social capital than Durgapur is indicative of real differences as we have noted in our discussion section. This is a preliminary set of analysis of social capital, while several other analyses are possible. Conclusion and Utilization of results It is evident from the social capital measurement survey that the differences between social capital measures of the members and non-members, it is clear that the members are different from the non￾members in terms of decision making processes, their networks and mutual support, their ideas about the sources and areas of conflicts, their understanding of access to services, levels of solidarity, trust, and cooperation they feel, and how they resolve conflicts. These are what makes up for their social capital measure and makes it better for the members than the non-members. The qualitative data also supports that all the members and almost all the non-members are well aware of the idea of forming social group to save money and use that for communal benefit, such as, spending for maternal and neonatal patients, building roads or buying van to transport patients to the hospital. :8 Leadership qualities were building up in the intervention areas. Some of the groups were disbanding, however, many of them got reformed again after solving their problem. Many of the groups had problem in investing their savings as they were not interested to do anything that would go against their religious beliefs. Members of the groups were ready to help any mother and child in need of health care despite of their religion, identity or membership to groups and they seemed to understand the importance of timely treatment from the facility. TTBAs are working within their best for awaring the mothers, family members and the decision makers on significance of referral to facilities than treatment by informal providers after observing any danger signs. The level of confidence of the PI members has increased upto such a level that they are now able to solve their own problems, can communicate with social elites as well as the people from formal institutes and are achieving trust from them as a result of their improving performance in managing groups, money, health care and non-health related tasks and so on. This result would recommend scaling up this PI model in different areas of Bangladesh, especially among the marginalized people who have low health outcome. At the same time, we also think that five years is not enough to change the behavior. Therefore, to sustain the behavior change in getting formal health care for maternal and neonatal health, the duration of PI model intervention should be longer. We also recommend that learning from PI model can be applied to Community Clinic Support Group (CSG) members who are actively working in the whole country on the same field of improving child and maternal health activities as World Renew does.