Final Report
End of Project Performance Evaluation for
USAID/Egypt: Improving the Performance of
Nurses in Upper Egypt
January 21, 2015 
This publication was produced at the request of the United States Agency for International Development. It
was prepared independently by Chris McDermott, Waleed El-Feky, and Dr. Madiha Said Mohamed Abdul￾Razik of Social Impact, Inc. 
ACKNOWLEDGEMENTS
The Social Impact Evaluation Team gratefully acknowledges the steady and comprehensive support of 
USAID/Egypt in carrying out the requirements for the Improved Performance of Nurses (IPN) project 
implemented in Upper Egypt between November 2009 and June 2014. The Office of Population and 
Health (OPH) at USAID/Egypt made reference and background documents available before the team 
began field work, greatly facilitating the preparation of inquiry tools, travel arrangements, contact lists, 
and identification of key issues prior to undertaking investigations in the field. The team is most 
particularly appreciative of the clear guidance and timely responses provided by Ms. Shadia Attia and Dr. 
Shahira Hussein, serving under the direction of OPH Director Dr. Nabil El-Soufi. Dr. El-Soufi was
generous with his time and shared insights on the context of IPN from his personal experience, an 
invaluable contribution to our understanding of the chronology of events and key developments. Under 
the current situation, field visits to Upper Egypt require extensive coordination and cooperation from 
the Ministry of Health and Population (MOHP). Dr. Kawther Mahmoud and Dr. Imad Ezzat, senior
MOHP officials in Cairo, were instrumental in securing the team’s access to health officials and facilities 
in the three governorates. They also shared their experiences with the IPN and ideas for improving 
future collaboration with USAID. We are most grateful for their full cooperation. Also, Dr. Abdo el￾Aswasi, former Chief of Party for the project with MSH, was most generous with his time in assisting 
with our understanding of the chronology and challenges of the project, in providing documentation, and 
facilitating access to project records and information. Finally, SI takes full responsibility for the content, 
quality, and integrity of this evaluation report, and acknowledges that any omissions, errors, or oversights 
are attributable to the SI team and no other person or agent. It has been a privilege to visit Upper Egypt 
and to learn about and give witness to the dedicated and talented nurses and other health 
officials serving the communities of Upper Egypt. 
Cover Photo: Nurses, Nurse Supervisors and the SI interviewers at Kom Ombo Health Facility, Aswan by Chris 
McDermott (October 2014).
i
ii
EVALUATION OF 
THE IMPROVING THE
PERFORMANCE OF
NURSES IN UPPER
EGYPT PROGRAM
A FINAL PERFORMANCE EVALUATION
January 21, 2015
Task Order AID-263-O-14-00033
DISCLAIMER 
The authors’ views expressed in this publication do not necessarily reflect the views of the United States 
Agency for International Development or the United States Government. 
3
CONTENTS
Executive Summary ......................................................................................................................... 1
Evaluation Purpose & Questions .................................................................................................... 5
Project Background ......................................................................................................................... 6
Evaluation Methods & Limitations ................................................................................................. 9
Findings ............................................................................................................................................ 13
Conclusions and Lessons Learned ................................................................................................ 26
Recommendations ......................................................................................................................... 30
Annexes ........................................................................................................................................... 32
Annex1: Evaluation Statement of Work (SOW) ....................................................................... 33
Annex II: Tables, Figures, and Photographs ................................................................................ 47
Annex III: Methodology and Limitations ..................................................................................... 60
Annex IV: Data Collection Instruments ...................................................................................... 74
Annex V: Sources of Information ................................................................................................. 79
Annex VI: Summary of Findings, Conclusions/Lessons Learned, and Recommendations... 90
Annex VII: Disclosure of Any Conflicts of Interest ..................................................................... 95
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ACRONYMS
ANC Antenatal Care 
AOR Agreement Officer Representative 
CLM Center of Leadership and Management 
COP Chief of Party 
ECG Electrocardiogram 
FGD Focus Group Discussion 
HQ Headquarters 
IC Infection Control 
IPN Improving the Performance of Nurses in Upper Egypt Program 
IR Intermediate Result 
KII Key Informant Interview 
LDP Leadership Development Program 
LMS Leadership, Management and Sustainability Program 
M&E Monitoring and Evaluation 
MCH Maternal and Child Health 
MOHP Ministry of Health and Population 
MSH Management Sciences for Health 
NGO Non-Governmental Organization 
NICU Neonatal intensive care unit 
NS Nurse Supervisor 
OHF Om Habibeh Foundation 
OHP Office of Health and Population (USAID) 
OJT On-the-job-training 
PHC Primary Health Care 
PHU Primary Health Care Unit 
PMP Performance Monitoring Plan 
PY Project Year 
Q1 Quarter 1 
Q2 Quarter 2 
Q3 Quarter 3 
Q4 Quarter 4 
RF Results Framework 
SAM Senior Alignment Meeting 
SI Social Impact, Inc. 
SOW Statement of Work 
TOT Training of Trainers 
USAID United States Agency for International Development 
EXECUTIVE SUMMARY
EVALUATION PURPOSE AND EVALUATION QUESTIONS
The purpose of this external, final project performance evaluation is: 
1. To review, analyze, and evaluate the effectiveness of the Improved Performance of Nurses (IPN) 
project in achieving program objectives and completing deliverables; 
2. To identify lessons learned in terms of implementation and relationships with counterparts in 
order to inform USAID future investments; 
3. To assess the sustainability of the interventions at an individual (nurses) and an institutional 
(Ministry of Health and Population [MOHP] facilities) level; and 
4. To inform a follow-on health personnel capacity development program. 
Per the Evaluation Statement of Work (SOW) in Annex 1, the evaluation of the IPN project
seeks to answer the following questions: 
1. Given the turbulent operating environment, to what extent did the IPN Program achieve its
intended goals and results? 
a. To what extent was IPN able to improve nurses’ practices and services provided in hospitals
and primary health care units in intervention governorates? 
b. To what extent was IPN able to empower nurses in intervention facilities? And how has this
impacted their performance and their ability to address their challenges? 
2. To what extent are project interventions sustainable at the level of nurses and at the level of the 
institutions? 
3. What lessons have been learned through the IPN program that can advance future efforts to
improve leadership and management skills of Egyptian health care personnel? 
PROJECT BACKGROUND
The IPN project is one of several activities contributing to the Office of Population and Health’s current 
Development Objective 4: Access to Health Services Improved, and to Intermediate Result (IR) 3, 
Management of the Health Sector Improved. The objective of the project is to improve nursing services in 
MOHP hospitals and primary health care (PHC) units in Upper Egypt, specifically, in Aswan, Luxor, and 
Qena. USAID/Egypt field support allocated to the Global Health (GH) Bureau resulted in award of a
Leader with Associate Cooperative Agreement (CA) to the Global Leadership, Management, and
Sustainability (LMS) project implemented by Management Sciences for Health (MSH). The total funding 
provided through this mechanism was US $3,626,668, and IPN activities ran from November 2009 
through June 2014. 
Project Rationale. Building the technical and management capacity of physicians, nurses, and 
paramedic staff is critical for improving the impact of health and health-related services for Egyptian 
families. Nurses, in particular, may have experienced gaps in their pre-service training (especially high 
school or diploma nurses), and may have limited on-the-job and in-service training opportunities. IPN’s
scope is intended to bring about improvements to health services in Aswan, Luxor, and Qena by 
improving the performance of nurses to lead and manage their teams to address specific, identified 
challenges and achieve measurable results in three focus areas: (1) infection control, (2) basic nursing 
2
care, (3) communication between health care providers and patients. A fourth focus area, (4) primary
health care, was added to the project under an Amendment to the CA in August 2010. 
EVALUATION DESIGN, METHODS, AND LIMITATIONS
The primary audience of the evaluation report is USAID/Egypt, especially its health team and other 
decision makers. Other important audiences include USAID’s Global Health Bureau and Middle East 
Bureau, Egypt’s MOHP, and future leadership and human resource capacity building implementing 
partners. 
This final evaluation of IPN was conducted using multiple mixed methods (both quantitative and 
qualitative techniques) to address these key evaluation questions and to test the development theory
underlying the project’s design. Methods ranged from review of secondary reports to collecting primary
data through interviews and focus groups discussions with stakeholders, principal actors, and project 
beneficiaries. As determined in consultation with USAID/Egypt, the evaluation team’s principal data
collection took place in the three governorates that IPN served during the project: Aswan, Luxor, and 
Qena. Sites were selected based on a stratified, purposive sampling method, and, on-site, all nurses or
nurse facilitators involved in LDP were invited for interviews and/or focus group discussions (FGDs) in 
order to explore in greater depth the participant’s varied experiences and views of LDP. The evaluation 
team’s specific analysis methods for the IPN evaluation were tailored for each method of data collection 
and each level or category of respondent (i.e. nurses, nurse or physician supervisors, and stakeholders). 
Data from the interview questionnaires and FGDs was processed to compile summary statistics for the 
findings, which are presented in text, tables, and graphs. The team developed its report based on the 
data collected and the team’s corresponding analysis for each evaluation question to help ensure 
evidence-based recommendations for future programming of IPN-type USAID activity. 
EVALUATION FINDINGS, CONCLUSIONS, LESSONS LEARNED, AND 
RECOMMENDATIONS
The major Findings are: 
 Despite the political turmoil and civil unrest, the project achieved or nearly achieved most of its
performance targets. Analysis of the six performance indicators from the PMP reveals IPN 
exceeded one planned outcome and achieved or nearly achieved three of its six planned 
outcomes. Two indicator targets (#1 and #5) were not met. 
 According to the MSH project reports and as confirmed through KIIs with nurse supervisors
and physician officers in charge, the LDP and refresher technical sessions led by the MOHP 
increased the capacity of nurses and promoted proper utilization of limited resources to provide 
care according to MOHP Polices and Guidelines. 
 According to both nurses and their supervisors, LDP nurses felt empowered to influence other 
staff members, e.g., in making changes to enforce patient’s rights, to do their jobs thoroughly. 
 As a basic measure of cost effectiveness, the project expended a total of $5,129 in each of the 
707 persons who participated in and benefitted directly from the LDP. Without a clear standard
for comparison, however, the team did not reach any evidence-based conclusion as to whether 
the costs are appropriate of cost-effective. In the eyes of the LDP participants, however, it’s
clear that the training was perceived as of high quality and of great professional and personal 
benefit. 
 The IPN did not achieve or maintain the critical mass of trained nurses required to sustain 
change longer than a year after the LDP training, and to produce self-sustaining transformation 
3
and/or systemic change within MOHP health services. This was particularly evident in hospitals, 
where only one or two persons from any one section or department were included in the LDP. 
Even with “in-house” follow-up trainings, the frequent staff transitions meant that the 
proportion of nurses in any department or throughout the facility were a minority of staff. This
mitigated against achieving sustained changes in the facility. 
 MSH introduced the LDP with USAID support into some 39 facilities in three UE governorates 
between 2009-2014, but the program was not formally adopted as an MOHP program – either 
at central or governorate level. Further expansion and sustainability of the leadership program 
are handicapped by perception that it is a “donor initiative” and the fact LDP has not and will 
not receive support under the MOHP recurrent budget. 
 USAID added funds for expanding LDP in two other governorates through amendments to the 
IPN over the course of the project. However, changes in the MOHP leadership and policy as
well as civil unrest made it impossible for MSH to work in these “expansion sites.” As a result, 
MSH and USAID agreed to use the incremental funding to expand the scope of the project in 
the three original governorates (Aswan, Luxor and Qena) and discontinue efforts to implement 
the LDP in the frontier or other UE governorates. 
 As a basic measure of cost –effectiveness, the project expended a total of $5,129.66 per direct 
beneficiary (LDP participants and facilitators trained). In the absence of a basis for comparison, 
the team did not reach a conclusion on the appropriateness of these costs. As noted in other 
findings, however, greater involvement and use of indigenous organizations have the potential to
reduce the average cost per beneficiary. 
Primary Conclusions are: 
 The LDP resulted in improved nurse capacity and performance, but, the small number trained 
(at any one department or hospital) during LDP, and the steady diminution of trained nurses in 
target facilities have reduced the momentum and sustainability of the project interventions. 
 Completion of the LDP is associated with success in changing participant nurses’ motivation, 
mindset, and practices in intervention facilities. The evidence points to improvements in 
infection control practices, patient communication and care, communication and problem￾solving among teams/departments, and improved ante-natal care. 
 Further expansion and sustainability of the LDP are handicapped by the MOHP’s perception that 
it is a “donor initiative” and the fact LDP has not and is not expected to receive support from 
the MOHP under its next 5-year plan or next annual recurrent budget. 
Primary Lessons Learned are: 
 Leadership training requires further development and fine-tuning in the MOHP, and USAID is
well positioned to assist in this with future programs. 
 LDP training needs to continue indefinitely (after USAID support ends) to achieve and maintain 
the “critical mass” necessary for sustaining it. 
 Multiple iterations (three major revisions) of the IPN show flexibility and commendable resolve 
by MSH and USAID to accommodate the turbulent situation in Egypt. 
The main Recommendations for USAID are: 
 During project implementation, engage with MOHP officials at the Governorate level regularly
(e.g. quarterly) to monitor activities and to maintain support for USAID activities, especially
when key changes occur (Effectiveness). 
4
 New leadership programs need to provide frequent (at least monthly) and effective (i.e., 
supervision, refresher sessions) follow-up to sustain the momentum for improvement 
(Sustainability). 
 Involve local NGOs (and Health Worker Syndicates) and gain from their experience and 
expertise in design and implementation of any future human resource development projects
(Local Ownership and Effectiveness). 
 Consider providing technical support to the nurses’ syndicate to promote leadership, 
professional growth, and improved performance of nursing through training, mentorship, and 
licensing and accreditation programs (Reinforce and Broaden Support for USAID Objectives). 
 Future programs to develop human resources should include a gender training component, 
increasing awareness of gender as a workplace and as a health services issue. 
A complete listing of Findings, Conclusions, Lessons Learned, and actionable Recommendations can be 
found starting on page 13 and also in Annex VI. 
5
EVALUATION PURPOSE &
QUESTIONS
EVALUATION PURPOSE
The purpose of this external, final project performance evaluation is as follows: 
1. To review, analyze, and evaluate the effectiveness of the Improving Performance of Nurses 
(IPN) project in achieving program objectives and completing deliverables; 
2. To identify lessons learned in terms of implementation and relationships with counterparts in 
order to inform USAID’s future investments; 
3. To assess the sustainability of the interventions at an individual (nurses) and an institutional 
(Ministry of Health and Population [MOHP] facilities) level; and 
4. To inform a follow-on health personnel capacity development program. 
The primary audience of the evaluation report is USAID/Egypt, especially its health team and other 
decision makers. Other important audiences include USAID’s Global Health (GH) Bureau and Middle 
East Bureau, Egypt’s MOHP, and future leadership and human resource capacity building implementing 
partners. USAID will address the report recommendations in future leadership and management 
capacity-building activities and share lessons learned with other stakeholders. Management Sciences for
Health (MSH) will incorporate lessons learned to improve ongoing projects and future activities in the 
area of leadership and management. The findings and recommendations will offer an opportunity to
Government of Egypt (GOE) counterparts, especially MOHP, to optimize the implementation climate 
and maximize the benefits of technical assistance. 
EVALUATION QUESTIONS
Per the Evaluation Statement of Work (SOW, available in Annex I), this evaluation of IPN seeks to
answer the following questions: 
1. Given the turbulent operating environment, to what extent did IPN achieve its intended goals
and results? 
a. To what extent was IPN able to improve nurses’ practices and services provided in 
hospitals and primary health care units in intervention governorates? 
b. To what extent was IPN able to empower nurses in intervention facilities? How has this
impacted their performance and their ability to address their challenges? 
2. To what extent are project interventions sustainable at the level of nurses and at the level of the 
institutions? 
3. What lessons have been learned through IPN that can advance future efforts to improve 
leadership and management skills of Egyptian health care personnel? 
6
PROJECT BACKGROUND
The IPN Project is one of several activities contributing to the Office of Population and Health’s current 
Development Objective 4: Access to Health Services Improved, and to Intermediate Result (IR) 3, 
Management of the Health Sector Improved. The objective of the project is to improve nursing services in 
MOHP hospitals and primary health care (PHC) units in Upper Egypt, specifically, in Aswan, Luxor, and 
Qena. USAID/Egypt awarded a Leader with Associate Cooperative Agreement (CA) to the Global 
Leadership, Management, and Sustainability (LMS) project implemented by Management Sciences for
Health (MSH) to implement IPN beginning in November 2009, and the project was amended or
modified six times before completion of activities in June 2014. The total funding provided through this
mechanism was US $3,626,668. 
Project Rationale. Building the technical and management capacity of physicians, nurses, and 
paramedic staff is critical for improving the impact of health and health-related services for Egyptian 
families. Nurses, in particular, may have experienced gaps in their pre-service training (especially high 
school or diploma nurses), and may have limited on-the-job and in-service training opportunities. 
Further, weak management systems in the MOHP are thought to augment the problems inherent in a
highly centralized “command/control” ministry, and also contribute to mismanagement of health facilities 
and sub-optimal patient outcomes, including the prevalence of nosocomial infections and other 
preventable diseases.1 Contributing to the cycle of sub-optimal patient outcomes is the low social status 
of nurses, who serve on the frontline and are often not well compensated for their labor. Relatedly, the 
perception and compensation of nurses is an issue of gender parity within the healthcare sector, 
affecting investments in additional training and professional advancement—two contributing factors to
the quality of healthcare service. 
PROJECT OVERVIEW
Mechanism. USAID/Egypt field support allocated to the GH Bureau resulted in award of a Leader with 
Associate Cooperative Agreement (CA) to the Global Leadership, Management and Sustainability (LMS) 
project implemented by MSH. The signing of the CA on November 19, 2009 marked the beginning of 
IPN. The project scope was revised several times during implementation due to changes in MOHP 
leadership and policy, as well as prolonged civic unrest. As finalized, the SOW for the IPN intends to
bring about improvements to health services in Aswan, Luxor, and Qena governorates. This was to be 
accomplished by improving the performance of nurses to lead and manage their teams to address
specific, identified challenges and achieve measurable results in three focus areas: (1) infection control, 
(2) basic nursing care, and (3) communication between health care providers and patients. An 
amendment to the CA in August 2010 added (4) primary health care as a fourth technical focus, and 
added Assiut and Sohag governorates to the project area. However, months later when political and 
security conditions deteriorated and work in Assiut and Sohag was not feasible, USAID decided to
exclude these two governorates, leaving Aswan, Luxor and Qena as the three project governorates. 
The theory of change behind LMS and MSH’s approach stipulates that nurses who completed LDP would
gain leadership skills, leading them to successfully identify and address key healthcare challenges and 
achieve measurable results in their health facilities. Further LDP activities conducted in Phase II (more 
1 For example, see World Bank, 2010, Egypt: management and service quality in primary health care facilities in the Alexandria
and Menoufia governorates (Washington, D.C.). 
7
MOHP participation) and in Phase III (MOHP lead with minimal project support) were expected to
broaden the impact of changes across districts and governorates and ensure sustainability. More 
specifically, the project’s expected results were: 
1. Nurses are aware of the MOHP standards for (a) infection control, (b) basic nursing care, (c) 
patient-provider communication, and (d) primary health care; 
2. Nurses are committed to adhering to MOHP quality assurance standards and to assessing and 
improving their performance and the health services in the hospitals according to these 
standards; and 
3. Increased local training capacity through a group of trained facilitators. This group was to
promote the methodology across districts and governorates, leading to ownership and 
sustainability of the program. 
To achieve the above results, MSH applied their Leadership and Development Program (LDP) approach 
in the IPN project to strengthen leadership and management skills of nurses and, ultimately, to improve 
health care delivery. Under IPN, the plan was to build leadership and management capacity through 
implementation of a phased Leadership Development Program (LDP) approach in the selected 
governorates. The LDP is a structured, participatory process, applied over four to six months, that 
enables nurses to face challenges, analyse root causes, design and implement effective action plans, and
achieve measurable results.2 A literature review of leadership training reveals that a number of 
observers found strong similarities to Quality Improvement (QI) and LDP, and, therefore, observations 
on successful QI activities are especially pertinent to a full understanding of the LDP approach. 
Applying these practices in the work setting is expected to produce changes in work climate, nurse 
attitudes and practice, and an enhanced capacity to respond positively to change. Although the project 
design did not include a logical framework, the LDP approach is well documented in the LMS Global 
Leadership Award and related reports. The theory of change implicit to IPN may be understood as a
cycle of intervention (LDP and follow-up) leading to organizational change. In the first LDP workshop, 
participants identified areas they wished to improve or change. This step in the process is represented in 
the top oval in Figure 1 below.3 The participants then (ovals descending clockwise) identified a specific
problem, explored solutions and benchmarks, designed interventions and expected results (targets), 
implemented in the workplace, and evaluated results (during phases 2–4 of LDP). In this
conceptualization, however, the type or mix of intervention(s), whether policy measures, change in 
operational systems or practices, and/or human resources are not specified and, thus, may be 
considered as applicable to all. 
2 Aku Kwamie, Han Van Dijk, and Irene Akua Agyepong. “Advancing the application of systems thinking in Health: realist
evaluation of the LDP Program for district manager decision-making in Ghana,” BioMed Central, June 2014. 3 “What is Organizational Development.” Web. 21 November 2014. http://www.managementguru.net/what-is-organizational￾development/
8
FIGURE 1 INTERVENTION CYCLE FOR ORGANIZATIONAL CHANGE
In Figure 1 below, the intervention cycle of organization development is conceptualized differently. In 
this simplified conceptualization, three key components of the organization are identified as access
points for intervention or change. The interventions are categorized as Human Resources/Capacity
Building, Operational systems, and Policy directives (including formative bylaws, structures, traditions 
and styles, etc.). The bi-directional arrows indicate that the process is not unidirectional, but changes in 
one category may influence other areas (feedback loops). The SI team notes the IPN project’s primary
and predominant intervention for improving nursing services and health outcomes was the LDP for
nurses and supervisors, which focuses exclusively on one of these three key aspects of organizational 
development, Human Resources/Capacity Building. 
FIGURE 1 THREE KEY FUNCTIONAL AREAS FOR ORGANIZATIONAL CHANGE
Three Components of an 
Organization: Points of 
Intervention for Change 
9
The analysis, findings, conclusions, and lessons learned during the evaluation are presented below, and 
these address the validity of the project’s theory of change (as well as the other evaluation questions) in 
terms of results obtained from IPN. 
IPN was completed on June 30, 2014, four years and nine months after its inception. During its
operation, major political and social changes occurred, which interrupted implementation in one or
more governorates and led to USAID and the MOHP renegotiation and revision of several key aspects
of the project, including the target governorates. In January 2012, political shifts in the GOE resulted in 
the MOHP declaring a formal cessation of activities with donors (and international NGOs) for nearly a
year and undoubtedly affected the willingness and ability of Egypt’s health officials and public health 
workers to participate. 
EVALUATION METHODS &
LIMITATIONS
EVALUATION METHODS
The final evaluation of the IPN project was conducted using multiple mixed methods (both quantitative 
and qualitative techniques) to address the key evaluation questions and to test the project’s underlying 
theory of change. Methods ranged from a review of secondary reports to collecting primary data
through key informant interviews (KIIs) and focus groups discussions (FGDs) with stakeholders, 
principal actors, and beneficiaries of project interventions. The team interviewed key informants in 
Cairo from October 13 to 16 and traveled in Upper Egypt from October 17 to 28, 2014, to visit project 
sites and to interview and review project activities at a convenience sample of 13 hospitals, five primary
care facilities, and four MOHP offices. Sites were chosen in conjunction with USAID/Egypt and MOHP in 
order to provide for inclusion of all types of challenges (IC, basic nursing, communication and PHC), 
geographic coverage (sites from various districts across the governorate), and the presence of at least 
two LDP-participants. In nine of the health facilities where an adequate number of LDP-trained nurses 
were available, the SI team organized FGDs. 
The evaluation team’s principal data collection took place in the three governorates that IPN served
during the project: Aswan, Luxor, and Qena. Sites were selected based on a stratified, purposive 
sampling method, and on site all the nurses or nurse facilitators involved in the LDP were invited for
interviews and/or focus group discussions. A total of sixty nurses and seventeen nurse 
supervisors/physicians in the three governorates informed the evaluation. A roster of facilities (general 
hospitals, specialty hospitals, and PHC units) where IPN participants (nurses) are working forms the 
universe from which the sample was drawn for KIIs and FGDs. In all, the team managed to visit 13 
hospitals, comprising 52 percent of the hospitals involved in the IPN, and 5 of 14 PHC units, or 26 
percent of the total in IPN. Further detail about the specific quantitative and qualitative methods used 
can be found in Annex III. 
QUANTITATIVE METHODS
Desk Review. Prior to field visits, the evaluation team reviewed all IPN related documents provided by 
USAID, MSH and IPN staff, and other stakeholders. This review included but was not limited to design 
documents, quarterly/annual reports, monitoring data, relevant assessments and evaluations, appropriate 
10
contextual data, and other information from government sources, program implementers, and 
researchers. A full list of documents reviewed by the evaluation team can be found in Annex V. 
Internal Consultations. SI also carried out consultations with USAID/Egypt officials, the primary
intended users of the evaluation of IPN, to gain their understanding of the development 
hypothesis/theory of change for the program, identify areas of consideration to be explored in the 
evaluation, and inform SI’s evaluation tools. These consultations were distinct from KIIs with USAID 
officials as part of the sample frame for discussion of IPN’s performance. 
Review of IPN Performance Targets and Actual Achievements. With the Performance 
Management Plan (PMP) developed by IPN and project reports, the evaluation team reviewed and
reported on the extent to which the project met its performance targets. Target achievement was
assessed via reported results per the PMP, and analysis included an assessment of timeliness and how 
internal project (such as changes in personnel) as well as external factors (government changes) may
have affected the results obtained. One of the PMP indicators is pre- and post-scores on the Work 
Climate Assessment (WCA) tool administered at the onset and end of LDP training. These results were 
also examined in detail. 
Health Care Facility Administrative Records Review. To assess IPN’s contribution to changes in 
infection control procedures, basic nursing care, nurse-patient communication/teamwork, and primary
health care, SI queried nurse teams about the results of their challenge and reviewed documentation 
available on the current status of the intervention. For example, at Kom Ombo Hospital in Aswan the 
team reviewed IC statistics from the past four quarters to track the rates of infection. Appropriate 
records were reviewed when available. The team also probed in interviews and FGDs to determine 
whether the “LDP challenge” approach was still being used in some fashion (explicitly or implicitly) by 
nurses to improve operations and health care delivery. 
QUALITATIVE METHODS
Individual and Key Informant Interviews
Findings gleaned from KIIs provide critical contextual data with which to gain detailed understanding of 
IPN effectiveness and to triangulate with existing quantitative data. KIIs included nurses, nurse 
supervisors, and others who had LDP training; USAID/Egypt’s Office of Population and Health, including 
Activity Managers (current and previous); IPN Technical Advisors from MSH; MOHP officials (as advised 
by USAID/Egypt) in Cairo and in three governorates; physicians and administrators at hospitals/Primary
Health Care units where IPN activities occurred; and LDP mentors from Suez Canal University. 
In most instances, two members of the evaluation team conducted KIIs, one who led the discussion (a
native Egyptian Arabic speaker), and the other who recorded observations and key responses. The team 
analyzed the results and summarized “key responses” by method (KII, FGD), current position (nurse, 
supervisor, etc.), and gender. The list of persons contacted (see Annex V) reflects gender 
considerations, to allow generation of information on women and men from different cadres, and taking 
into consideration possible gender discrimination and unequal power relations. KIIs were largely 
structured, with opportunity for comments on any aspect of IPN and related topics. Interview responses 
were not recorded verbatim but rather categorically and thematically. 
The SI team used semi-structured questionnaire guides (see Annex IV) to gather the views of 
stakeholders on the key themes of the evaluation exercise to allow adequate and uniform coverage of 
topic areas while encouraging the natural evolution and expansion of the iterative qualitative data
collection process, which the team could then adjust for each type of stakeholder based on the rationale 
for the interviewee’s selection and their level of knowledge of queried subject areas. 
11
Focus Group Discussions
FGDs are particularly useful for supplementing KIIs and quantitative data by gleaning valuable 
information from discussions among group participants. The evaluation team conducted FGDs with 
various cadres of IPN stakeholders, from a sample of facilities with IPN-trained staff, to gain an in-depth 
understanding of their experiences with project interventions. Each FGD was organized around a group 
of participants that had common characteristics of engagement with IPN, which included the type of 
intervention/benefit received and also their geographical distinctions (e.g., governorate, urban, rural). 
FGDs were held at several sites for each type of facility (e.g., general hospital, primary health care unit) 
in Aswan and Luxor. In Qena, the small number of LPN-trained nurses (usually two or three) available 
during the evaluation team’s visit prohibited the application of FGDs. Analysis of results from the 
interviews and discussions contributed a great deal to the team’s understanding of the IPN experience. 
This included both positive and negative aspects of the training and follow up, as well as verification and
amplification of identification of quantitative results, lessons learned, and assessment of future prospects
for sustaining the LDP program within the governorates. 
In some cases, the team used positive deviance assessment and appreciative inquiry in these focus 
groups. Positive deviance allows focus group participants to identify nurses or facilities that have been 
very successful to help pinpoint factors that have led to their success. Appreciative inquiry was also
employed to help determine specific factors working well for program participants and implementers, 
and whether and why they were able to leverage these functional areas to identify other ways to create 
leadership and better health outcomes in other areas. An analysis of these discussions contributed to a
greater understanding by the team about why certain nurse leadership conditions exist and how 
challenges might be addressed by USAID and other implementers. 
ANALYSIS
The evaluation team’s specific analysis methods for the IPN evaluation were tailored for each method of 
data collection and each level or category of respondent. These include organizing responses by code 
and array, and disaggregation by factors such as the type of challenges completed, health facility type, and 
geographic location. Data from questionnaires was processed using Excel, Word, and PowerPoint to
compile summary statistics from the findings, which are presented in text, tables, and graphs. Where 
similar findings were obtained across the different data collection methods, the team triangulated 
evidence and confirmed the credibility of the results in order to develop confidence in its assessments
and recommendations. As such, the team developed its findings, conclusions, recommendations, and 
lessons learned based on the data collected and the team’s corresponding analysis for each evaluation 
question to help ensure evidence-based recommendations for future programming of IPN-type USAID 
activities. Moreover, the team’s recommendations are based solely on the evidence collected, its
independent analyses, and the conclusions reached. 
LIMITATIONS
The validity of the evaluation findings may have been affected by several factors, which SI addressed 
proactively. As pointed out in the analysis section above, SI minimized the effects of bias (particularly
recall, response, and selection bias) by using multiple sources of data to triangulate answers to each 
evaluation question. The evaluation also used questions about specific examples (“anchoring responses”) 
to probe general responses more thoroughly. Finally, key informants with different “causal distances” 
12
from the activity, such as indirect beneficiaries and external experts, were interviewed, in order to
obtain different perspectives of the project’s contributions. 
Another challenge was the short timeline to conduct the evaluation, with just nine weeks from start to
completion. In Qena, a particular limitation was the long recall period since the LDP training sessions, 
and, as a result, fewer than the desired numbers of nurses (or nurse supervisors) were available for
interview and discussions. In Luxor, the four days of the team’s visit coincided with National 
Immunization Days for polio, which meant that staff from the PHC units who were committed to the 
campaign and had only limited time for meeting with the team. Despite these constraints, the team 
managed to meet LDP informants from a wide array of districts and facilities. 
A final limitation is that IPN took place when Egypt’s governance and economy were disturbed, such 
that distractions and many parallel activities may have disguised or offset IPN’s results. SI developed its 
instruments in collaboration with the USAID/Egypt Health Team to ensure the highest possible accuracy
in identifying context, trends, events, and other factors affecting IPN results and in specifying and 
measuring IPN’s results. 
THREATS TO VALIDITY
In order to ensure that data of the highest quality was collected and analyzed, the evaluation team first 
consulted with USAID/Egypt staff to determine the extent to which available data was complete and
likely to be accurate. Second, the team queried MSH former staff on a number of issues to more fully
understand performance reports. For instance, the number of pre-LDP and post-LDP participants who
took the WCA are not shown in the MSH reports, but these were obtained to compute weighted 
averages for the WCA. SI also developed its instruments in collaboration with the USAID/Egypt Health 
Team to ensure the highest possible accuracy in identifying context, trends, events, and other factors
affecting IPN results and in specifying and measuring IPN’s results. The consistent triangulation of 
quantitative and qualitative data in the analysis ensured findings drawn from best available evidence. 
Another important change occurred with the composition of Key Personnel. For personal reasons, the 
evaluation Senior Technical Advisor had to withdraw from the assignment and was quickly replaced by 
Dr. Madiha Said Mohamed Abdul Razik prior to the first week of data collection. 
REPORTING
Following the completion of fieldwork in Egypt, the evaluation team prepared and delivered a
presentation to USAID/Egypt consolidating data collected into formulation of preliminary findings, 
conclusions, and recommendations. Based on feedback from the presentation, the team drafted an 
annotated outline of the draft evaluation report consistent with the standards set forth in USAID’s
Evaluation Policy. Within two weeks of the teams’ departure from the field, SI submitted a full draft of 
this report to USAID/Egypt for review, comment, and further guidance. Further, the evaluation team will 
prepare an expanded executive summary in both English and Egyptian Arabic. 
13
FINDINGS
QUESTION 1: Given the turbulent operating environment, to what extent did IPN achieve its intended goals 
and results?
a) To what extent was IPN able to improve nurses’ practices and services provided in hospitals and 
primary health care units in intervention governorates?
b) To what extent was IPN able to empower nurses in intervention facilities? How has this impacted 
their performance and their ability to address their challenges?
QUANTITATIVE ANALYSIS
TABLE 4.1 PERFORMANCE MANAGEMENT PLAN INDICATORS FOR IPN WITH TARGETS AND RESULTS
ACHIEVED
PMP Indicator Target Result % of
Target
Status
1. Number of LDP facilitators trained 58 46 79.3% Not met
2. Number of persons completing the LDP,
by cadre (e.g., doctor, nurse, etc.)
742 661 89% Nearly achieved
3. Number of teams completing the LDP 94 88 93.6% Met4
4. Percent change in Work Climate
Assessment Score (pre- and post-test) by
type of facility
- Hospital
- PHC units
10% 
10% 
81% 
132% 
810% Exceeded
1320% 
5. Percent of teams that select a new 
challenge independently after completing
their Action Plan
60% 38.6% 64.3% Not met
6. Number (percent) of hospitals that
develop scale up plans by the end of
implementing their Action Plans
13 
(50%) 
14 
(56%) 
14/13 
(108%) 
Met
1. At a minimum, the USAID Monitoring and Evaluation (M&E) system requires a PMP to establish 
baselines and targets for projects to meet by project completion (see Table 4.1 above). 
4 The process of setting targets for performance indicators at the onset of a project sometime requires a “leap of judgment” 
due to lack of prior experience and solid evidence on which to base the projections. For this reason, the Evaluation team made
some decision rules prior to our assessment of performance. “Meeting” (met) an objective was defined as reaching between 90
to 110 percent of the target, “exceeding” it as reaching more than 110%, and, obviously, achieving less than 90% as not meeting
the target or “not met.” 
14
Despite the political turmoil and civil unrest, the project achieved or nearly achieved most of its
performance targets. Analysis of the six performance indicators from the PMP reveals the 
project exceeded one and achieved or nearly achieved three of its six planned outcomes. Two
indicator targets (#1 and #5) were not met. 
2. The first three PMP indicators provide objective evidence about the scale and pace of project 
implementation For instance, the target for the first indicator, training 58 LDP facilitators, was
not met, as only 46 (79%) were trained. Similarly, the target for the second indicator, 
completion of LDP training for 742 nurses, was not quite met, as only 661 (89%) nurses 
completed the LDP. The third indicator, on the number of teams completing the LDP, was also
nearly met. These results are unsurprising in light of the previously noted major security and 
political changes resulting in delays, disruptions and revisions to IPN activities. Due to these 
external factors, the project achieved somewhat less than expected in terms of outputs or scale 
of implementation. 
3. The fourth PMP indicator, changes in Work Climate Assessment in facilities where nurses 
received LDP training, provides some evidence of whether LDP participation is associated with 
perceived changes in nurses’ attitudes and deportment. As a “quality” indicator, the results on 
Indicator 4 say more about the degree of change experienced by the participants, and less about 
the number of health providers or facilities experiencing changes. Since only participants in LDP
completed the WCA, it was less affected by external factors which disrupted or delayed the 
extension of leadership training to planned areas. Pre and post applications of the Work 
Climate Assessment (WCA) tool showed dramatic changes in all three governorates, suggesting 
that the impact of the LDP on Egyptian nurses was positive and consistent across the 
governorates. It also indicates morale and perception of nurses on their role in providing 
health care changed considerably after 4–6 months of enrollment in the LDP. The weighted 
averages for Hospitals and PHC units are shown in the figure below. 
FIGURE 3 WEIGHTED AVERAGES OF PRE- AND POST-LDP TRAINING WORK CLIMATE ASSESSMENT SCORES FOR
HOSPITALS AND PRIMARY HEALTH CARE UNITS
4. Indicators 5 and 6 from the PMP, on the number of teams selecting a new challenge after 
completing their action plan and the percentage of hospitals developing a scale-up plan after 
implementing the initial action plan, respectively, can be understood as proxy indicators of 
sustained project activity. Per Table 4.1 above, only 64 percent of teams selected a challenge 
after completion of the first one, and the failure to achieve this indicator suggests that the 
momentum achieved during the LDP training was lost as early as one year after the completion 
of the training sessions. Some 56 percent of hospitals, or slightly more than half, continued with 
scale-up plans for continuing LDP, again suggesting that institutional sustainability is an issue. It is 
15
interesting to note that the PMP targets required only 50/60% of facilities to develop scale up 
plans and address new challenges after the formal LDP sessions had ended. This might suggest 
that even at the beginning of the project, there were indications that the follow-through 
expected (and essential) from the MOHP would be uneven and not reach all participants. In 
hindsight, USAID might have pushed for a higher percentage (e.g. 90 or even 100) to be attained 
on these “sustainability” indicators. The evaluation team observed that neither the project 
objectives nor evaluation questions (e.g., “were nurses empowered”) specifically address broad, 
sustained institutional change. Instead, the project emphasized changing nurses’ attitudes, 
knowledge and practices, which, according to the theory of change underlying the IPN, would
result in specific changes in the practice of health care in the four technical challenge areas. 
While changed behaviors and improved health care were observed in technical areas of the 
challenges, the evaluation did not find conclusive evidence that these changes have been adopted 
institutionally or on a broad scale. 
5. As Table 4.2 below illustrates, teams of nurses (usually 4 to 5 per team) working on defined 
challenges were mostly successful. For the evaluation team, the success rate for achieving 
defined challenges may be considered a proxy indicator of IPN-trained nurses’ adherence to
leadership principles and the extent to which (six months to a year after training) these were 
put in practice at their facility. 
 Overall, 88 teams addressed 91 challenges over the course of the IPN project, and 76 
(84%) of the challenges were achieved. Nurse participants and their supervisors jointly
determined challenges to be addressed as part of the LDP. 
 Basic Nursing skills were the most common technical area, comprising 39 out of 91 
(43%) of the total, and Infection Control (IC) challenges were second (30%). Provider￾patient communication was third (14%), and Primary Health Care was fourth and least, 
with just 13 percent of total challenges. 
 Rates of achieving targeted results were high. For instance, Primary health care achieved 
11 out of 12 (92%) of their targets. Achievement rates were 24 out of 27 (89%) for
Infection Control, 29 out of 39 (82%) for Basic Nursing Care, and 9 out of 13 (69%) for
patient-provider communication. 
 Interviews and FGDs with key informants suggest that the process for choosing 
challenges in the LDP varied by district/facility. In some instances, it appears that 
supervisors had the major say, while in others the challenges and targets were chosen 
through consensus discussions among participants and trainers. In Qena and Luxor, 
some participants recalled they chose “easy” targets to ensure success. However, in 
most instances participants cited the difficulty of achieving them and were proud of their
accomplishments. By governorate (not shown in table), Aswan teams had the highest 
rate of success in meeting challenges—94 percent. Qena fell in the middle, with an 82 
percent success rate, and Luxor had the lowest success rate, at 75 percent. 
 The success rate for challenges in the four technical areas ranged from 69 to 92 percent. 
Interviews and analysis of these results lead the team to conclude that all four technical 
areas were appropriate, and required considerable effort to achieve. Also, informants
felt that failure to achieve a challenge could be attributed to a) changes in personnel, b) 
failure to enlist cooperation of some colleagues, patients or supervisors, or c) overly
ambitious target setting. 
16
TABLE 4.2 LDP CHALLENGES UNDER IPN
LDP Challenges under IPN
Technical area # Challenges
Achieved?
Yes No
Infection Control 27 89% 11%
Basic Nursing 39 82% 18%
Communication 13 69% 31%
Primary HC 12 92% 8%
Total # 91
Achieved % 84% 16%
QUANTITATIVE FINDINGS
Finding 1.1 In terms of the PMP and other quantitative indicators, despite the political turmoil and civil 
unrest, the project achieved or nearly achieved most of its performance targets. The IPN met or nearly
met three of six targets on performance indicators, and exceeded on one. Two indicators (#1 and #5) 
were not met. 
QUALITATIVE ANALYSIS
The detailed analysis from KIIs, FGDs and unstructured interviews can be found organized by 
governorate below. In general, many of the key points made by respondents aligned well and indicated a
strong consensus among nurses on the benefits as well as the shortcomings of the LDP. One interesting 
observation was that Nurse Supervisors (NSs) play a critical role in motivating nurses and sustaining 
LDP gains or—if they were not involved in LDP and hold any misgivings—in playing a constraining role 
on follow-up and continuation of LDP practices. Nearly all the facility supervisors and district 
supervisors were positive about LDP and wanted to see it expanded in the future. The results of KIIs 
and FGDs across the three governorates were analyzed for common themes and patterns of responses. 
Divergent responses were also noted and checked against project documents and other sources 
(stakeholders) to assess their validity and application. The results by governorate are presented in detail 
in the sections below and within the Findings, Conclusions, and Recommendations table within Annex 
VI. The generalized results pertaining to question 1 (performance) are presented as key findings below. 
Finding 1.2 Training in the LDP improved nurses’ problem solving skills and resulted in more pro￾active deportment among nurses and with their supervisors (KIIs with nurses, NSs, and managers). 
Finding 1.3 According to the MSH project reports and as confirmed through KIIs with nurse 
supervisors and physician officers in charge, the LDP and refresher technical sessions led by MOHP 
17
increased the capacity of nurses and promoted proper utilization of limited resources to provide care 
according to MOHP Polices and Guidelines (KIIs with nurses, NSs, and managers). 
Finding 1.4 There were no standardized selection criteria for participation in the LDP. Criteria varied 
across governorates and across type of facility (hospital or PHC unit), according to the preferences of 
local MOHP officials (KIIs with stakeholders). 
Finding 1.5 According to both nurses and their supervisors, LDP nurses felt empowered to influence 
other staff members, e.g., in making changes to enforce patient’s rights, to do their jobs thoroughly
(Nurse FGDs and KIIs with all groups). 
Finding 1.6 Based on IPN’s achievements, the project’s theory of development regarding changes in 
nurses’ behavior and improved health services was at least partially validated. 
Finding 1.7 Nurses and supervisors credit LDP with changing participants, including increased 
awareness and adoption of MOHP quality standards of practice, patient-centered care, and problem 
solving approaches. 
Finding 1.8 Leadership and other MOHP programs/initiatives share many common features with 
Quality Improvement, Centers of Excellence, and other ongoing MOHP initiatives. 
FINDINGS: GOVERNORATE LEVEL
Aswan -- Analysis
In terms of quantitative indicators (see Annex VI), the Aswan LDP met most of nearly all of its PMP
objectives and, in addition, nurse teams from Aswan met 94 percent of challenges (the highest of the 
three governorates). The quantitative results are highly consistent with the results of interviews and 
FGDs, which are summarized below. LDP participants maintain strong commitment to LDP as a relevant 
and continuing influence on their outlook and work. 
A total of 19 interviews and five FGDs were held with nurses, nurse supervisors, and stakeholders in 
Aswan Governorate at five district hospitals and three PHC units during October 19–23, 2014 (a
summary of the interviews and FGDs are found in Annex II). Another KII was conducted with Om 
Habibeh NGO, a subsidiary of Aga Khan Foundation. Key points are discussed below. 
 Nurses and supervisors interviewed in Aswan spoke repeatedly about the increased ability
among nurses to identify a work-related challenge and to organize collectively an effective team 
response. A challenge was clearly defined, with clear presentation of the root causes of the 
problem to be addressed. In addition, nurses were capable of planning a clear and scientific
methodology for undertaking their challenge and presenting evidence-based results to
demonstrate changes. Nurses reported that they learned to develop and use appropriate tools
such as showing indicators before and after intervention. These comments are indicative of a
changed mindset of the individual nurse, yet there were only a few who readily claimed changes 
had occurred in all nursing practices or the performance of the facility in general. 
 Increased self-confidence was another common benefit mentioned by respondents completing 
the LDP program. Some nurses had gained enough confidence to make presentations to facility
directors; some used Microsoft PowerPoint, while others used colorful flow diagrams or
summary tables of hospital forms to document changes measured over time in the area 
addressed by their challenge. 
 In facilities where the LDP training had taken place three or more years before, nurses had
difficulty recalling or showing evidence of their work on challenges. Respondents also reported 
18
that in 2012 when the Ministry stopped collaboration with NGOs, the lack of any material and
technical support from MSH restricted their ability to conduct observational visits or follow-up 
trainings. 
 Nurse Supervisors the team interviewed shared an impression around the strength of the LDP
program in prompting change in multiple aspects among nurses. One Nurse Supervisor even 
said, “It’s the first time we had a project dedicated for nurses.” 
 Om Habibeh Foundation (part of the Aga Khan Network) played a critical role in the early
phases of the LDP program. The primary reasons for discontinuation were due to concern 
about the limited timeline for LDP and the sustainability of the LDP program after conducting 
the training. 
 All groups credited the LDP with enhancing their skills in addressing problematic behaviors of 
their colleagues, patients or supervisors. However, a number noted they had limited success in 
changing behaviors, especially among those supervisors or colleagues who had little knowledge 
of the LDP program. In a few cases, the interaction of trained and untrained colleagues led to
fragmentation of efforts and a lack of institutional support for sustaining efforts after the training 
was complete. 
 Another critical challenge nurses faced was the issue of time, highlighting their extensive tasks 
and long work hours. The LDP was an additional burden on nurses’ work and duties inside their
respective facilities. 
 Nurses and supervisors emphasized the challenge of extended breaks between the different 
phases of the training program and the travel time to and from their homes to the training 
venue. They suggested that on-the-job training would be a better solution to the extended
travel time that negatively affected their performance either in the training or inside their
facilities. 
 All groups found that more continuous intervention was needed both in terms of quantity of 
nurses trained and quality of training given. When asked, several admitted that they were no
longer doing “challenges” per the LDP methodology. 
 Although training on technical and basic nursing skills was not formally part of LDP, it is clear
from interviews with supervisors that when gaps in skills were identified (e.g., proper 
intramuscular injections), special training classes were held that addressed these gaps, usually
with assistance from the district or governorate office. 
 The district nurse director at Aswan District also mentioned the value of continued effective 
communication through the development of a Facebook group page for nurses to exchange 
information and for her to follow-up on the work of her nurses working inside PHC units in her 
district. This is a clear example of how digital social media contributed to sustaining the level of 
communication among PHC nurses in Aswan district and including their supervisor. The page is
shown in Annex II and the link is at https://www.facebook.com/groups/222924277893721/.
Aswan – Findings
Finding 1.9 More than a year after completing the LDP, nurses are losing acquired skills, and this
underlies their recommendation for continuous refresher training. 
Finding 1.10 LDP participants maintain strong commitment to leadership and see LDP as a relevant 
and continuing influence on their outlook and work. 
Finding 1.11 Om Habibeh Foundation (Aga Khan Network) played a key role in providing a base of 
support for the project in Aswan during its start-up phase, maintains close relations with the MOHP, 
and continues to work closely with them on nurse development in the governorate. As part of the Aga 
19
Khan Network, OHF continues to work with nurse development but has a wider scope of training and a
longer time horizon than MSH. 
Luxor – Analysis
A total of 18 interviews and three FGDs were held with nurses, nurse supervisors, and stakeholders in 
Luxor Governorate at selected health facilities during October 25–28, 2014. KIIs with nurses were 
conducted in a group setting; nurse supervisors were usually interviewed individually with structured 
questions from the questionnaire. FGDs were organized at the facility following the interview sessions, 
usually with three or more nurses available in the afternoon. The number of participants at PHC units
was further reduced by competition from the National Polio Immunization days during the week of our 
visit. A summary analysis of the responses, which clusters similar responses by the number of times 
they were mentioned, and the evaluation team’s further discussion, is provided in the tables below. 
 Nurse Improvements/Benefits. Among all KII respondents, improved problem solving skills was
the most frequently cited benefit to nurses of the LDP program. As we see in the summary
notes from KIIs and from some FGDs as well, there was clear recognition and appreciation for
individual learning and change stemming from the LDP, but there was little testimony of 
sustained, broad organizational change (systemic change). 
 Nurses enthusiastically discussed the increased confidence they felt after completing the LDP. 
Some nurses showed the posters (or PowerPoint presentations) on their challenges and how 
they were met (or nearly met), and others testified that the LDP had changed their personal as
well as professional lives. When asked more about these changes, nurses talked about taking 
initiative to organize their approach, communicate their concerns with supervisors (or family
members), and look for creative solutions. 
 For supervisors and hospital directors, the changes they observed focused more on behavior
change, such as nurses reviewing lab reports and other evidence-based data to understand 
patient status and condition, and the improvements related to the challenge their team had
addressed. In Luxor, the Infection Control (IC) challenges were mentioned the most, and there 
is convergence among the various ways the team obtained information on how IC had improved 
in their facility and the statistical reports to show it. 
 Negative Aspects. Interviews with some a minority of informants revealed that not all 
supervisors and colleagues were supportive and cooperative, especially among those who had
not taken the LDP training. Among those respondents who claimed a lack of full cooperation, 
the conflict between management and nurses was the most common. In these instances. For
supervisors, on the other hand, who talked about conflict in the workplace, the lack of 
cooperation and harmony among LDP-trained and untrained nurses was their primary concern. 
Additionally, in a few hospitals, the physician directors we interviewed (e.g., at both Luxor
hospitals) were not well informed about LDP, and, with one exception (Om Kobo), were not 
actively supportive. All respondent groups (KIIs and FGDs) noted time management as an 
obstacle to fulfilling the promise of LDP, with nurses highlighting their many tasks (including 
menial as well as patient care) and long hours as issues inhibiting their ability to provide quality
services (adhering to MOHP standards). Nurse supervisors, on the other hand, emphasized the 
challenge of having adequate staffing on all three shifts, due, at least in part, to the expectation in 
Upper Egypt that married female nurses would only work the morning shift. Several noted that 
20
male nurses are in high demand because they are often willing to work long hours and take 
evening or night duty. 5
Luxor – Findings
Finding 1.12 Infection control challenges initiated by LDP were successful in Luxor and had lasting 
impact on nurses’ awareness of MOHP standards, their practice of IC procedures, and on patient 
services (in some areas). 
Finding 1.13 Continuation of promising IC activities in Luxor is impeded by the lack of communication 
and agreement between the IC department and the MOHP leadership in the Governorate. 
Finding 1.14 Among the physician directors of Luxor hospitals, knowledge and support of LDP is weak, 
and most are not familiar with the content and objectives of the leadership program. 
Qena – Analysis
A quantitative review of findings in Qena reveals that targets were nearly met in most instances. Among 
the challenges (projects) faced by nurse teams, 82 percent were completed successfully. As in the other 
governorates, the work climate assessment (WCA) showed vast improvement between the pre-LDP
and post-LDP tests. The one published study (see References) of this tool suggest that it provides 
consistent results in various settings (cultures, institutions). However, because only a few staff members
from any MOHP clinic or hospital were enrolled in LDP (and thus completed the WCA), the findings
apply to the LDP participants and not necessarily to the institution where they work. Thus, the WCA 
does not provide convincing evidence that the MOHP institutions changed as much as it does individual 
perceptions (of those institutions) changed. 
Two team members traveled to Qena project hospitals and held KIIs there during October 21–23, 
2014. In Qena, the LDP was implemented only at hospitals (and particular departments of those 
hospitals), and not in PHC health centers/clinics. Structured interviews were held with nurses and 
supervisors – and not FGDs, due to the smaller number of LDP-trained persons available at site visits in 
Qena.6 A total of eight structured interviews were held at four Qena hospitals with nurses and nurse 
supervisors with LDP experience. KIIs with nurses were conducted in a group setting, while interviews 
with nurse supervisors were usually done individually, using structured questions from the 
questionnaire. The challenge topics covered by the nurse teams included: (a) preparing patients before 
surgical operations, (b) correct steps in administration of medications to patients, and (c) routine hand 
washing. PHC units were not involved with LDP training in Qena. 
Among the primary benefits of LDP cited by nurses and supervisors, the following were salient: 
5 At the team’s meeting with policy makers in the MOHP we learned that the number of nurses assigned to work in MOHP had
been increased (males and females). This was intended to ensure adequate job allocations of staff. Additionally, the nursing
syndicate as well as NGO (Masr-El-Kheer) are working in a program for having another category of health manpower "medical
assistants", who will conduct administrative work, record keeping and retrieval. The nursing syndicate enforces policies for
making this category of "medical assistants" to be part of MOHP staff 
6 In general, six to twelve persons are considered ideal for holding FGDs. In Qena, only 2- 3 LDP-trained nurses were available
at the site visits. This is attributed to the three to four year gap between the LDP and the time of the evaluation, and the
resultant high turnover of staff. 
21
 Improved communication skills, resulting in effective nurse-patient communication 
 Improved awareness of nurses about MOHP standards and guidelines for care 
 Completing a challenge gave team members real-life experience with principles of leadership and 
setting targets, organizing, and striving for achievement. 
 Practice with developing evidence-based approaches to problem solving and presenting them 
built confidence and created enthusiasm and competition among groups, with potential to result 
in better performance. 
 Nurses and supervisors cited improved nurse-community communication as a benefit, and this
could be seen in higher immunization (e.g., tetanus) coverage among women throughout the 
four years of the LDP program. Training of Trainers (TOT) improved the personality of trainers
and added new skills in training, especially role play. 
 The MSH trainers used new (and effective) techniques in conducting the training programs in 
basic nursing care, IC, re-activation of heart and lungs, and other technical nursing care issues. 
Training in LDP was of high quality and applicable to “on the job” experiences. More of this kind 
of training would be appreciated. 
The District Nursing Director and several hospital nurse supervisors observed that the LDP was
associated with recognition for strong performance and promotions for nurses and nurse supervisors. 
The nurse supervisors involved in the LDP also claimed to have strengthened their role and 
participation in decision making in hospitals. 
Other key points taken from the interviews include: 
 LDP trained nurses serve as leaders in QI and other MOHP programs, conducting peer to peer 
sessions to extend LDP. 
 LDP led participants toward adopting new approaches to “induce change.” For example, after 
LDP the nurses prepared handmade posters with drawings showing the proper steps in hand
washing. Those posters were distributed in all departments to promote adherence to standards
for hand washing. 
 Communication with nurses throughout four workshops triggered needs for filtering manpower 
and reallocating nurses according to efficiency and effectiveness in different nursing systems at 
the governorate level. 
Interviewees also identified several shortcomings of the LDP. The key shortcomings noted were: 
 Sometimes LDP teams settled on challenges they could easily address, and thus, expended little 
effort to achieve them as opposed to taking on more difficult problems. 
 The low number (often just one) of nurses trained in a hospital department, and the high 
turnover of the trained nurses over several years, resulted in an inadequate number of trained 
nurses remaining to change the “character” of the institution. 
 Physicians did not acknowledge the “new look” of the trained nurses. The trained nurses’ role in 
insisting on compliance with the standard of practice in IC by physicians often resulted in their
resistance and disinterest. 
Qena – Findings
Finding 1.15 The LDP program in Qena started and stopped again, impeding the pace and scale of 
operations. 
22
Finding 1.16 Despite the lack of MOHP support for IPN activities during much of the project and the 
minimal follow-up of the LDP workshops, the experiences gained by nurses were positive and created
demand for further leadership and “on the job” training. 
QUESTION 2: To what extent are project interventions sustainable at the level of nurses and at the level of
the institutions?
Sustainability
The cascade training and refresher courses planned for Phase II and Phase III7 in the LDP ceased 
operations in Upper Egypt when the project ended (June 2014) or before. The team found that the 
formal “challenge-response” model of LDP did not become an established practice after LDP. It survives 
in the awareness of the LDP participant nurses and is still evident in the actual challenges (e.g., hand 
washing signs and reminders). But, it is not being practiced formally to identify new challenges and 
address them (using the 8 steps, etc.). Nurses (KIIs and FGDs) claim they are “still doing what they 
learned,” but nurse supervisors and facility managers (KIIs and Facility Records review) showed little 
evidence of new challenges being implemented. 
Interviews with senior MOHP officials in Cairo revealed observations about LDP and its relation to the 
ministry structure, strategic plan and operations. Although the MOHP has a Quality Improvement 
Directorate, the IPN and the MOHP chose to implement the project under the direction of the 
Ministry’s preventive and curative departments. The reasons for this are not clear, but it may be 
surmised that the QI department is smaller and less influential. In addition, the introduction of LDP into
25 hospitals (in three UE governorates) was a major departure from existing management practices. It 
was less novel to the preventive care sector – which has used target setting and problem solving for
decades. The principles and application of operations research (OR) that identifies challenges, focuses 
on solutions using available resources, and tests them in measured actions were not well established in 
hospital administration and management. For instance, the Ministry’s hospital performance indicators
focus on length of stay, bed census, supply of key materials, and other outputs. The practice of 
measuring and reporting on patient satisfaction and outcomes was new and untried in the hospital 
sector. Further, the LDP trained only one or at most two nurses in any hospital department. Combined 
these conditions made sustainability particularly difficult to obtain. 
 MSH introduced the LDP with USAID support into some 39 facilities in three UE governorates 
during 2009-2014, but the program was not formally adopted as an MOHP program – either at 
central or governorate level. 
 USAID added funds for expanding LDP in two other governorates through amendments to the 
IPN over the course of the project. However, changes in the MOHP leadership and policy as
well as civil unrest made it impossible for MSH to work in these “expansion sites.” As a result, 
MSH and USAID agreed to use the incremental funding to expand the scope of the project in 
the three original governorates (Aswan, Luxor and Qena) and discontinue efforts to implement 
the LDP in the frontier or other UE governorates. Key findings include: 
7 As per the explanation on pages 5-6, the LDP is implemented in three phases of training and follow-up. Phase I is
led by MSH technical staff with minimal MOHP input, Phase II depends on both MSH and MOHP technical and
facilitative expertise, and Phase III training and follow-up are conducted primarily by MOHP with minimal MSH
support. 
23
Finding 2.1 There is no MOHP department or senior-level officer with official authorization or
recognition of responsibility for leadership training at any level: national, governorate, or district. 
Finding 2.2 Some senior MOHP officials in the governorates (Aswan, Qena) are generally not familiar
with LDP and have not yet made a “home” for LDP within any department or ongoing/planned MOHP 
initiative (e.g., Quality Improvement, Centers of Excellence, Five-year Strategic Plan). 
Finding 2.3 The critical mass of trained nurses required to sustain change and produce transformation 
or systemic change within MOHP health services was not achieved and maintained. 
Finding 2.4 The head of the Nursing Syndicate expressed an interest in furthering leadership through 
developing programs it could offer to its Pial for replication in other localities.8
Finding 2.6 The principles and application of operations research (OR), which identifies challenges, 
focuses on solutions using available resources, and tests them in measured actions, were not well 
established in hospital administration and management. For instance, the Ministry’s hospital performance 
indicators focus on length of stay, bed census, supply of key materials, and other outputs. The practice 
of measuring and reporting on patient satisfaction and outcomes in LDP was new and untried in the 
hospital sector. Further, the LDP trained only one or at most two nurses in any hospital department. 
Combined these conditions made sustainability particularly difficult to obtain. 
Finding 2.7 The LDP as implemented under the IPN project shares some common features with other 
ongoing and planned MOHP programs/initiatives. In the competition for future MOHP support, LDP has
not competed successfully to either replace or influence the MOHP’s Quality Improvement Directorate, 
or the proposed Centers of Excellence, and other ongoing MOHP initiatives. 
CROSS-CUTTING ISSUE: GENDER ANALYSIS AND FINDINGS
Gender studies and analysis carried out in Egypt over the past decades have documented the strong role 
and differences in gender identity held by most Egyptians. Most nurses are female, but an increasing 
number of men are completing nursing school (especially the six-year program), and the team observed 
male nurses (and/or supervisors) in most of the facilities we visited. During KIIs, interviewers asked the 
nurses if they had experienced differences in the way male and female workers behaved, and whether 
they had observed any problems or conflicts. Responses were then further probed for evidence of 
gender inequity or experiences with words or actions in the workplace that made them uncomfortable 
or concerned. 
In many cases, female nurses at hospitals cited the particular roles they prefer male nurses to perform 
on male patients, such as managing urinary catheters, assisting in operations like hemorrhoid treatment, 
giving enemas, and other operations that can “scratch” female modesty. On the other hand, female 
nurses were more accepted in managing female patients. Female nurses also credited male nurses with 
skill in avoiding quarrels among the nursing team, carrying patients who cannot move, and expertise in 
the emergency department. Other preferred male nurse roles included giving ECG exams for men, 
8 Om Habibeh’s approach to nurse training and empowerment was not assessed by SI as it is beyond the scope of
the evaluation. But, it appears to have the full support (and participation) of local MOHP authorities and may well
merit a more in-depth assessment as part of any design work on a future health provider development project. 
24
working at reception, protecting them from difficult patients and family members, and working as a
nursing supervisor. 
Female nurses face particular socio-cultural barriers, and several volunteered complaints that they 
suffered gender discrimination from the community and from their families, who did not appreciate the 
important role of female health workers. Despite these problems, they remain positive and hopeful to
overcome these barriers and gain more satisfaction from their work in health. 
The team’s female interviewer asked all-female groups about their experience with sexual language or
innuendo from male co-workers, physicians (who are largely male), or patients. With few exceptions, 
they responded that their families and supervisors were conscientious about their dignity and would
protect them if co-workers became aggressive or acted inappropriately. Further probing yielded little or
no firm evidence of sexual harassment. Both nurses and supervisors, however, were quick to point out 
the different expectations on male and female workers based on marital status. The team learned that in 
Upper Egypt, a married female nurse is not expected to work in the late afternoon or night shift, and 
mostly works the morning shift. Men on the other hand, are more than happy to work night shifts and 
extra shifts, which supervisors appreciate. The community norms and expectations for married women 
nurses could be seen as a constraint to women’s advancement in the health workforce. Even with equal 
pay rates, men would have the advantage of earning more (longer hours) and potentially advancing faster 
(as supervisors) than their married female counterparts. Though this may well be the case, no one 
interviewed expressed dismay or great concern about this, merely noting it in passing. This underlines 
the dominance of gender-assigned roles in Upper Egyptian society and its strong influence in the 
workplace. 
The future of nursing looks quite different. Discussions with nursing directors in Aswan and Luxor
Governorates made clear that more men are attending nursing school, and that should the trend 
continue (along with high female attrition in nursing), gender parity (equal numbers of men and women) 
might be realized in a few decades. This would profoundly alter the public’s perception of nurses, and, if 
prevailing gender norms remain as they are, might easily lead to greater gender differentiation in hiring 
and promotion. The MOHP, along with universities, and nursing educational institutions need to be 
vigilant about shifting gender balance in the nurse workforce, and, at the very least, take measures to
heighten gender awareness and equality in the nursing profession. 
Finding 3.1 Extensive investigation with nurses in the three UE governorates reveals a prevailing 
opinion that nurse supervisors and facility directors are managing male and female nurses adequately in 
terms of balancing community with individual employee expectations, but female nurses will remain 
professionally and economically disadvantaged under these conditions. 
COST EFFECTIVENESS
Although	it falls outside of the three evaluation questions given explicitly for this evaluation, 
USAID/Egypt expressed an interest in the cross-cutting issue of cost-effectiveness. A review of the MSH 
budgets and the IPN project budget revealed nothing unusual or noteworthy from the perspective of 
USAID centrally managed projects. In general, and in the case of the IPN, when home office support 
and external TA and travel are involved in starting up and managing a project, costs are higher than 
when only local personnel and organizations are involved. On the other hand, the project 
documentation maintains the argument that innovation and expertise of the LDP were required to
achieve the desired results. 
It is interesting to note that none of the evaluation’s informants, even when prompted for a response, 
expressed concern over the cost of training under IPN. Some USAID informants suggested the costs 
25
were high for the level of output. However, the evaluation team does not have the analytical background 
nor comparative data base to address this concern. In the most basic analysis, the project invested an 
average of $5,129 in the 707 persons who participated and benefitted directly in the LDP. Without a
clear standard for comparison, the team could not reach any conclusion as to whether the costs were 
appropriate or cost-effective. In the eyes of the LDP participants, however, it is clear that the training 
was perceived as of high quality and of great professional and personal benefit to them. 
Finding 4.0 As a basic measure of cost effectiveness, the project expended a total of $5,129.66 per 
direct beneficiary (LDP) participants and facilitators trained). In the absence of a basis for comparison, 
the team did not reach a conclusion on the appropriateness of these costs. As noted in other findings, 
however, greater involvement and use of indigenous organizations have the potential to reduce the 
average cost per beneficiary. 
26
CONCLUSIONS AND LESSONS
LEARNED
QUESTION 1: PROJECT ACHIEVEMENTS AND NURSE EMPOWERMENT
The team’s independent analysis of the evidence leads to the conclusion the IPN was mostly successful 
in achieving its intended goals and results despite the political turbulence and extensive civil unrest that 
unfurled in Egypt during the life of project. The final evaluation assessment also concluded the following. 
Conclusions
1. Completion of the LDP is associated with success in changing nurses’ motivation, mindset, and 
practices in intervention facilities. The evidence points to improvements in infection control 
practices, patient communication and care, communication, and problem-solving among 
teams/departments, and improved ante-natal care. 
2. Participation in MSH’s leadership program empowered nurses to be pro-active in decision 
making, learn to assess and solve problems (e.g., address conflict) better, communicate vital 
information to peers and supervisors, set and measure performance, and share an improved 
work climate. 
3. The LDP program had a synergetic effect in raising awareness regarding MOHP guidelines on 
Infection control, basic nursing services and patient communication. 
4. LDP activities were designed and implemented with little to no synthesis (or alignment) with 
other USAID health and governance activities. The IPN did not succeed in arranging 
complementary or reinforcing activities from other projects. 
5. USAID and the MOHP could capitalize on current MOHP initiatives (or departments) to
advance LDP principles and practices. For example, greater integration with quality
improvement or infection control (as in Luxor) at MOHP would bolster the sustainability of 
leadership as practiced in LDP. 
6. The inadequate number of nurses and nurse supervisors trained and the lack of joint 
MSH/MOHP follow-up (due to withdrawal of MOHP support) prevented the IPN from achieving 
all of its performance goals. 
QUESTION 2: PROGRAM SUSTAINABILITY FOR NURSES AND INSTITUTIONS
At the level of nurses, there were indications of profound, lasting changes occurring as a result of the 
interventions implemented by MSH under IPN. Nurses interviewed, as well as their supervisors and 
officers in charge, were consistent in citing that nurses attending LDP had come away with new 
confidence, more effective, evidence-based approaches to problem solving, and heightened willingness
and ability to communicate with patients, as well as with supervisors and other nurses. Others cited
increased abilities in organization of work, time management, and planning. These skills were also partly
in evidence in nurse-patient communication and nurses’ awareness of and adherence to MOHP 
standards. The PMP indicators (5 and 6 above) show that only about half of the LDP facilities were able 
to develop a scale-up plan one year after LDP. Thus, evidence for sustainability at the institutions was
not compelling, and this suggests that the project’s gains are only partially sustainable, along with the 
conclusions reached below. 
27
Conclusions
1. LDP resulted in improved nurse capacity and performance, but the small number trained (at any 
one department or hospital) and the steady diminution in the number of trained nurses at target 
facilities reduced its momentum and sustainability. 
2. The results obtained from the evaluation’s integrated analysis of PMP, challenge, and qualitative 
(KIIs and FGDs) data lead us to question the theory of change for sustainability underlying the 
project. Specifically, the project’s emphasis (if not exclusive focus) on human resource/capacity
development of nurses without complementary interventions designed to induce and sustain 
systemic changes in operations and policy may not have been sufficient to achieve the desired 
profound, sustainable changes in nurse performance and health services. 
QUESTION 3: LESSONS LEARNED THROUGH THE IPN PROGRAM THAT CAN 
ADVANCE FUTURE EFFORTS TO IMPROVE LEADERSHIP AND MANAGEMENT 
SKILLS OF EGYPTIAN HEALTH CARE PERSONNEL
Lessons Learned
The development lessons derived from the Findings and Conclusions in the preceding sections include: 
1. To sustain a culture of effective leadership within a large organization such as the MOHP, 
USAID needs to ensure that the intervention finds a “home” within the Ministry which would
provide strong advocacy for its continuation. A number of approaches to follow-up and refresh 
leadership development have been tested and reported on in the literature. At present, the 
MOHP has some elements of leadership training incorporated into its ongoing Quality
Assurance and planned Centers of Excellence programs, but these have not fully incorporated
the lessons and experience of the LDP. 
Lesson Learned: Leadership training requires further development and fine-tuning in the 
MOHP, and USAID is well positioned to assist in this with future programs. 
Lesson Learned: Future USAID projects should include (or ensure from another partner) a
continuing component of leadership training for physicians and administrators who have 
management roles, as well as for nurses, and also ensure MOHP agreement that these will be 
part of their operational strategy and plans too. 
2. As the initial enthusiasm and the number of LDP-trained staff diminish over time, the “leadership 
mindset” becomes less widespread throughout the facility. 
Lesson Learned: LDP training needs to continue indefinitely (after USAID support ends) to
achieve and maintain the “critical mass” necessary for sustaining it. 
3. Leadership training for physicians and administrators in positions of authority, in addition to
training for nurses, could strengthen the culture of leadership and amplify the benefits of nurse 
training. To sustain LDP in the MOHP generally, USAID needs to ensure more advocates are 
trained (for a critical mass) within each and every hospital department or PHC facility. The only
way this could be feasible, given the limited funding available to donors, is for USAID to ensure 
that future programs negotiated with the MOHP are included in the Ministry’s Strategic plan and 
operational budgets. 
28
Lesson Learned: USAID should ensure that future programs negotiated with the MOHP are 
included in the Ministry’s Strategic Plan and operational budgets. 
4. A key observation of the evaluation is that agreement and shared commitment between Nurse 
Supervisors and Nurses on LDP are crucial to maintaining momentum. In addition, supervisors
who became LDP facilitators also indicated they need some small, but essential funding for
transport and logistics for follow-on activities. In some (but not all) districts, the MOHP nurse 
supervisor became the LDP facilitator and, pending the availability of MOHP funding, could carry
on leadership activities. 
Lesson Learned: MOHP nurse supervisors or locally available trainers (from NGOs or
universities) should be trained as facilitators during the project and provided continuing support 
(during and post project) as this is an essential step to sustaining gains in leadership and 
performance. 
5. Since leadership shares some common features with other ongoing and planned MOHP 
programs/initiatives, USAID might increase the return on its health sector investments through 
the design of interventions that continue key aspects of leadership training in ongoing or planned 
MOHP activities. The technical literature notes the strong similarities among quality assurance, 
total quality management and leadership training. For instance, all of these approaches 
emphasize continuous scanning to identify problems, devising, measuring and testing solutions in 
group settings. Further, the principles and application of operations research (OR), which 
identifies challenges, focuses on solutions using available resources, and tests them in measured 
actions, are also essential aspects of these programs. 
Lesson Learned: New USAID programs should attempt to “build in” leadership with the 
MOHP, rather than “build out” (as an externally branded project initiative) with expectations 
that the MOHP will adopt it by end of project. 
6. It is clear from numerous reports (see references) that the principles of OR and the LDP were 
not well established in hospital administration and management of the MOHP. As one example, 
the Ministry’s hospital performance indicators focus on length of stay, bed census, supply of key 
materials, and other outputs. The practice of measuring and reporting on patient satisfaction 
and clinical outcomes in the LDP was new and untried in the hospital sector. Thus, it was
difficult for the IPN to “bridge the gap” between ongoing MOHP practices and what was
proposed and essential under the LDP. 
Lesson Learned: USAID programs to improve health services, whether focused on access, 
effectiveness or quality of care, should include operations research (OR) as part of its technical 
approach. Creating familiarity and skill in conducting OR, would contribute to the MOHP’s
ability to improve management and make informed management decisions. 
7. A key finding of the evaluation is the LDP trained only one or at most two nurses in any hospital 
department. Thus, there was lack of critical mass at any one institution. While specific 
behaviors were changed, and compliance with several specific MOHP guidelines/standards
improved, the changes were not evidenced institution-wide. Lack of critical mass, uneven 
support for changes among the non-LDP participants, and frequent nurse turnover in Egyptian 
facilities, impeded institutional change. These conditions made sustainability particularly difficult 
to obtain. 
29
Lesson Learned: In the design of new programs, USAID needs to adopt a more strategic
approach to “scaling up” interventions that will lead to sustained, provider change. 
GENDER ANALYSIS
Conclusions
1. Gender issues are evolving rapidly as more male nurses enter the profession. 
2. The LDP training did not specifically and adequately address gender issues in the workplace, nor
did it provide gender training as part of its formal training sessions and follow-up activities. 
30
RECOMMENDATIONS
Based on the evaluation’s investigative research, resultant findings, conclusions, and lessons learned as
described above, the evaluation team developed a list of recommendations. Below, the key program 
recommendations are intended to inform any follow-on program in human capacity building (e.g., 
leadership), health services reform, or quality assurance. Recommendations for the principal 
stakeholders, USAID and the MOHP, stem from the findings, conclusions, and lessons about what is
important and crucial for success. Notably, the recommendations do not imply fault or that the 
recommendations were not followed in the design and implementation of the IPN project. Rather, they 
are intended to serve as guideposts for future activities, built on the foundation of what was
accomplished and can be distilled from the project’s experience to date. 
PROGRAMMATIC RECOMMENDATIONS
1. Follow-on activities to improve health worker performance should have impact-level 
performance measures as well as outcome and output measures. Further, organizational and 
institutional performance changes should be measured in addition to individual changes 
(Program measurement). 
2. Selection criteria for participation in leadership (or related) training should be standardized and 
consistent with a project’s development theory, that is, lead to sustained changes in organization 
and performance (Program consistency). 
3. New or extended leadership programs need to involve enough of the workforce (over time) to
reach a critical mass, whether at PHC, hospital, or governorate levels—or by health cadre— 
nurses, as well as physicians and administrators in management roles, to affect widespread
systemic change (Impact and Effectiveness). 
4. The declining influence of LDP over time suggests that the scale and duration of any future 
program should be revised to simultaneously address reinforcing changes in policy and 
operational systems in order to enhance the likelihood of systemic, sustainable change (Impact 
and Sustainability). 
5. Initiatives such as leadership training should promote linkages and harmonize efforts with other 
established Egyptian programs, such as MOHP’s Quality Improvement, Centers of Excellence, 
etc. (Effectiveness and Sustainability). 
6. Reinforce leadership by making it a cross-cutting component of all training programs, including 
technical, quality improvement, management, health reform, etc. (Sustainability). 
7. Other human resource development approaches, such as “Sustained Organizational 
Performance,” continuous quality improvement, mentorship, and peer-review for nurses merit 
further review and consideration for future activities, as they combine human resource 
interventions with policy and system change, have some foothold in Egypt, and may contribute 
to transformative and sustainable change (Examine Alternatives for Effectiveness). 
RECOMMENDATIONS FOR MOHP
1. Further integrate leadership training inside ongoing or planned MOHP in-service education 
(training) programs, or through creating a leadership center within MOHP. 
2. Make leadership training (establish a standard) a mandatory requirement for all supervisory
positions in the MOHP (nurses, physicians, pharmacists, etc.). 
3. Periodically, but at least annually, conduct anonymous employee work climate assessments to
monitor employee morale and perceptions. 
31
4. Develop nursing performance indicators for routine tasks to better monitor their performance 
and test the impact of any interventions (e.g., leadership training). 
RECOMMENDATIONS FOR USAID
1. During project implementation, engage with MOHP officials at the Governorate level frequently
to monitor activities and to maintain support for USAID activities, especially when key changes 
occur (Effectiveness). 
2. New leadership programs need to provide frequent (at least monthly) and effective (i.e., 
supervision, refresher sessions) follow-up that continue on after the external intervention to
sustain the momentum for improvement (Sustainability). 
3. Involve local NGOs and gain from their experience and expertise in design and implementation 
of any future human resource development projects (Local Ownership and Effectiveness). 
4. Consider providing technical support to the nurses’ syndicate to promote leadership, 
professional growth, and improved performance of nursing through training, mentorship, and 
licensing and accreditation programs (Reinforce and Broaden Support for USAID Objectives). 
5. Future programs to develop human resources should include a gender training component, 
increasing awareness of gender as a workplace and as a health services issue. 
32
ANNEXES
33
ANNEX1: EVALUATION STATEMENT OF WORK (SOW)
STATEMENT OF WORK (SOW)
Part (1)
End of Project Performance Evaluation of USAID/Egypt 
Improving the Performance of Nurses in Upper Egypt Program
ARTICLE I. PURPOSE
The purpose of this evaluation is to conduct an end of project performance evaluation of
Improving the Performance of Nurses in Upper Egypt Program (IPN). 
ARTICLE II. BACKGROUND
The broad human resource base of Egypt’s public health sector, including physicians, nurses and
paramedic staff, is a potential strength in terms of improving the quality of care and addressing
the needs of the growing population. One of the key factors that drive the critical gap in health
sector leadership and management is inadequately trained health sector leaders and managers. 
Health care providers and managers receive little to no training on leadership and management
before or during their service. Medical and nursing schools’ curricula in the Egyptian education
system are primarily clinical with no emphasis on enhancing the leadership and management
skills of health personnel. The Ministry of Health and Population (MOHP) employs more than
111,000 nurses. Despite their critical role in health service delivery, especially in remote areas
where they may be the only frontline providers of care, nurses—have low salaries and low social
status. This factor, coupled with a lack of authority and control, contribute to a low morale 
among nurses and, in turn, poor standards of care and low client satisfaction. 
In 2003, USAID, in collaboration with MOHP, supported the one-year pilot of the Leadership
Development Program (LDP) approach in Aswan Governorate in order to address the issue of poor
management and leadership skills among nurses. Eighty MOHP nurses from the national,
governorate and distirict levels took part in the LDP porogram. 
In 2009, USAID/Egypt, through a field support fund to the global Leadership, Management and
Sustainability (LMS) project, started the “Improving the Performance of Hospital Nurses in Upper
Egypt” to conduct activities in Aswan, Luxor and Qena Governorates. The aim of the project was to
improve nursing performance in the three areas of (1) infection control, (2) basic nursing care, and 
(3) patient provider communication. 
Management System for Health (MSH) facilitated the LDP for 107 hospital nurses in the three
intervention governorates. Consequently, this first two-year phase was extended for two additional
years. The program’s new scope expanded to inlcude a selected number of Primary Health Care
Units (PHUs). The modified program was named “Improving the Performance of Nurses in Upper
Egypt” or IPN. The new program also included two additional Upper Egypt governorates; Sohag 
34
and Assiut. The aim of this extension was to ensure that nurses in the five selected governorates, at
both the hospital and primary health care level, are trained in leadership and management. 
The expanded program started rolling out the methodology to more hospitals and initiated activities
at PHU level in Aswan, Luxor and Qena Governorates. These sites also started initiating their
sustainability activities, with greater responsibility for all aspects of implementation falling under
the responsibility of the MOHP teams. The project was also in its early stage of engaging
stakeholders in Sohag and Assiut Governorates. 
However, following the January 25 Revolution and the resulting transition led to considerable
uncertainty in the implementation environment. Government decrees in January 2012 requested
international or internationally-funded NGOs to not implement any new activities within the
public sector. This has had a significant impact on the program at PHU level. 
The project had planned to train 480 of hospital and PHC nurses in Sohag, Assuit, Aswan, Luxor
and Qena from January 2012, through the end of the project. Due to the MOHP decree, the
project limited its activities to carrying out monthly and quarterly support visits and sessions in
Aswan, Luxor and Qena Governorates (and no longer worked in Assuit and Sohag as planned).
This support has mainly been directed at hospital level, working with Steering Committees as
they implement LDPs independently, and develop plans for future replication. 
With these restrictions, the IPN project has continued to engage in discussions with the MOHP
and key individuals in the nursing sector in hopes of restarting activities. Near the end of 2012,
MOHP decided resuming the project’s activities. The MOHP initially requested to change the
intervention governorates to North and South Sinai, Mersa Matrouh and Greater Cairo. MSH
started to introduce and position activities in this new set of Governorates. Shortly thereafter, the
MOHP requested MSH to change the governorates again. The MOHP and USAID agreed that
the project would continue to intervene in Luxor, Qena and Aswan and to expand to two
additional Frontier Governorates, namely Red Sea and North Sinai. 
These suggested changes did not take place because MOHP’s key officials questioned the cost￾effectiveness of the project. After June 30 event, MOHP requested that the IPN program resume
its activities in Luxor and Aswan. Lately, USAID granted a five-month no cost extension to the
IPN to resume its activities. 
ARTICLE III. SCOPE OF WORK
Development Hypothesis
The development hypothesis underlying the IPN project is that building management and
leadership capacity of nurses, who constitute an integral part of the health system, and have little
or no preparation in management and leadership, improves their performance in providing health
services. 
35
Program Objectives
The objective of the LMS/IPN Associate Award, supported by USAID/Egypt, was to improve
health services in Aswan, Luxor, Qena, Sohag and Assiut governorates. This was to be
accomplished by improving the performance of nurses to lead and manage their teams to address
their challenges and achieve measurable results in three focus areas: (1) infection control, (2)
basic nursing care, and (3) communication between health care providers and patients the
program worked with. Nurses at all levels will successfully identify and address key health care
challenges and achieve measurable results. 
More specifically, the projects expected results were: 
i. Nurses are aware of the MOHP standards for a) infection control, b) basic nursing care, and 
c) patient-provider communication. 
ii. Nurses are committed to adhering to MOHP quality assurance standards and to assess and
improve their performance and the health services in the hospitals according to these
standards. 
iii. Increased local training capacity through a group of trained facilitators. This group was to
promote the methodology across districts and governorates, leading ownership and
sustainability of the program. 
To achieve the above results, the implementer, MSH, used their Leadership and Development
Program (LDP) approach in the IPN project, to strengthen leadership and management skills of
nurses. 
Program Approach
The LDP is a structured, participatory process, applied over four to six months, that enables
“naturally occurring teams9
” to address challenges in the workplace and achieve desired results
by applying leadership and management practices. At the core of the LDP is the conviction that
achieving measurable improvements in health outcomes is attributable to good leadership. The
LDP aims to achieve positive health outcomes by strengthening leadership practices and skills
and teamwork to improve the organization and delivery of quality health services. 
Exposure to the LDP approach enables health professionals to a) learn leadership and
management practices; b) apply these practices to bring about changes in work climate,
management systems and practices, and c) enhance the capacity of the system and the staff to
respond positively to change. All three, along with the application of best practices in clinical
medicine and public health, are critical contributors to improved health services and outcomes. 
The LDP approach invites teams at all levels of an organization to participate, acquire and
practice management and leadership skills. A key LDP principle is that leadership can be learned
at all levels. The LDP approach demystifies leadership by teaching participants to work as a team 
9 Teams that already work together on various tasks within the same organization. 
36
and apply leading and managing practices to address their day-to-day challenges. In contrast to
other leadership programs which are a one-time didactic session; the LDP is a series of four
participatory workshops, incorporating real and practical challenges with continuous coaching
support. Additionally, the LDP aims to improve the working environment, contributing to
positive change in the work climate. The Work Climate Assessment (WCA) is a tool that
measures work climate before and after the intervention of the LDP. The LDP, along with the
WCA, result in behavior change for better working relationships and conditions. 
The program uses a three-phase approach: 
Phase I: targets an initial number of nurses and facilities in a given governorate and is under
the responsibility of the project team. Phase I is implemented by the IPN project staff
members with the goal of developing local facilitation and coaching capacity. 
Phase II: targets an additional number of nurses and facilities in the governorate. Activities
are implemented jointly with MOHP teams with direct technical support from IPN staff. 
Phase II represents a shift of the activities’ logistics to MOHP. Phase II participants serve as 
a model to the local MOHP facilitators which serves the sustainability strategy. 
Phase III: is implemented by the MOHP with minimal technical support from the IPN team.
The MOHP coordinates, plans and provides logistical support for the LDPs. During this
phase the IPN technical team starts focusing on those activities that contribute to
sustainability and full transfer of the program to the participating governorates. Follow up is
provided through monthly and/or quarterly meetings. 
In each of the governorates, the following activities take place to implement the LDP: 
1. Senior Alignment Meeting for key senior-level managers from the governorate and district
levels, the participating hospitals, the MOHP, and the Directorate of Health. The meeting is
facilitated by MSH to create commitment and ownership of the program. 
2. Five-Day LDP Training of Trainers (TOT) Workshop- This workshop aims to prepare a
cadre of local trainers who have a good understanding of the methodology and can deliver
the training to local MOHP trainees. 
3. Five-Day Scanning Workshop-This workshop reinforces information on infection control,
basic nursing care, and patient-provider communication and introduces the timeline,
objectives, frameworks, and processes of the LDP. Participants identify a challenge they are
facing in their workplace. 
4. Three-Day Focusing and Planning Workshop-This workshop applies the leading and
managing practices to move from vision to action, and complete an action plan to address the
identified challenge. 
37
5. Three-Day Mobilizing and Inspiring Workshop-This workshop focuses on improving
teamwork and reinforce concepts of monitoring and evaluation as the participants continue to
implement their action plan. 
6. Monthly Coaching Meetings between Workshops during which feedback and support are
provided by peers, local facilitators, and MSH staff. During these coaching meetings, teams
have the opportunity to review their progress in facing their selected challenge with a trained
local Monitoring and Evaluation (M&E) Specialist. Nurses learn how to use the available
data to monitor, evaluate and report their progress and results. 
7. Results Presentation Meeting, involving key stakeholders from the governorate and district
levels, the participating hospitals, and senior managers from the MOHP and Health
Directorate. At these meetings, the team representatives share results achieved and make
commitments towards the sustainability and expansion of the program. 
Critical Assumptions
The successful implementation of USAID –supported IPN projects assumed that: 
 the national and governmental authorities, at all levels, realize the importance of and
maintain a strong willingness for building the leadership and management capacity of
nurses; and 
 the MOHP at the facility-level is willing to provide support and enhance an enabling
environment for trained nurses to assume their responsibilities and play an increasingly
significant role. 
A. Project Management Modifications
In August 2010, the agreement was modified to extend the initial 2 year award to 3 years, to
incorporate two additional Governorates, Assiut and Sohag. The TEC was increased from 
$2,626,688 to $3,626,668 and the name of the project was changed from “Improving the
Performance of Hospital Nurses in Upper Egypt” to “Improving the Performance of Nurses in
Upper Egypt” in order to reflect the inclusion of Primary Health Care units nurses. 
In April 2013, USAID amended MSH agreement to extend the period through end of November
2013, at no additional cost. The Ministry requested that the program be implemented in a new set
of Governorates - Red Sea, Luxor, Aswan and Qena - where the MOHP will be applying the new
Health Insurance System. USAID added North Sinai to this set of Governorates as North Sinai is
a priority governorate for the mission. Consequently, MSH agreement was amended to substitute
Assiut and Sohag Governorates with Red Sea and North Sinai Governorates. 
In September 2013, the agreement was modified to extend the project through the end of April
2014, at no additional cost. Following the July 2013 change in government the MOHP has
requested the project to resume activities in Luxor and Aswan Governorates. Accordingly, MSH
agreement was amended to implement the training activities in Luxor and Aswan. 
38
B. Relevant Documentation
The evaluation team should consult a broad range of background documents apart from project
documents provided by USAID/Egypt, MSH headquarters and IPN staff. These may include
documents that relate to health systems strengthening, leadership and management capacity
building, legacy review of 30 years of investment in Egypt
(http://www.ghtechproject.com/files/Egypt_Health_and_Population_Legacy_Review.pdf) , and a
gender assessment of the USAID/Egypt health portfolio completed in 2010
(http://www.healthpolicyinitiative.com/Publications/Documents/1410_1_Egypt_Gender_Assess
ment_Final_FINAL_acc.pdf).
The team may also find the MSH website useful as well as background information on the state
of the Egyptian health care system. USAID and IPN team will provide the evaluation team with
soft copies of a package of briefing materials, including: 
 Project’s agreement and amendments 
 Project quarterly reports, annual and ad-hoc work plans and review document
developed as part of routine monitoring. 
 Budget information 
 Gender Analysis 
 Project’s Performance Monitoring Plan 
I. Evaluation Rationale
A. Purpose
The USAID/Egypt Mission is planning to conduct a performance evaluation of its IPN project.
The purpose of this evaluation is to: 
1. Review, analyze, and evaluate the effectiveness of the IPN project in achieving program
objectives and completing deliverables. 
2. Identify lessons learned in terms of implementation and relationships with counterparts in
order to inform USAID future investments; and 
3. Assess the sustainability of the interventions at an individual (nurses) and an institutional
(MOHP facilities) level. 
4. Inform a follow-on health personnel capacity development program. 
The life of the current USAID activity is scheduled to come to an end in April 2014. Findings
and recommendations of this evaluation will guide the design and the implementation of the new
activity. 
B. Audience and Intended Uses
The audience of the evaluation report will be the USAID/Egypt Mission, specifically the health
team, the Global Health Bureau, the Middle East Bureau, the MOHP and the future
implementing partner of leadership and management capacity building activities. 
39
USAID/Egypt will review and share the executive summary, expanded executive summary, final
report, and recommendations (see IV. A. Deliverables) with the MOHP, other donors in Egypt
working on leadership and management capacity building, and the general public via the
Development Education Clearinghouse (DEC). 
USAID will address the report recommendations in future leadership and management capacity
building activities and share lessons learned with other stakeholders. MSH will incorporate
lessons learned to improve future activities in the area of leadership and management. The
findings and recommendations will offer an opportunity to GOE counterparts, especially MOHP,
to optimize the implementation climate and maximize the benefits from technical assistance. 
C. Evaluation Questions
The evaluation will answer the following questions: 
1. Given the turbulent operating environment, to what extent did the IPN Program achieve
its intended goals and results? 
c. To what extent was IPN able to improve nurses’ practices and services provided in 
hospitals and primary health care units in intervention governorates? 
d. To what extent was IPN able to empower nurses in intervention facilities? And how
has this impacted their performance and their ability to address their challenges? 
2. To what extent are project interventions sustainable at the level of nurses and at the level
of the institutions? 
3. What lessons have been learned through the IPN program that can advance future efforts
to improve leadership and management skills of Egyptian health care personnel? 
4. Evaluation Design and Methodology
A. Evaluation Design
This is a performance evaluation and is intended to focus on how IPN has been implemented,
what it has achieved, and whether expected results have occurred according to the project design
and in relation to the development hypothesis. The evaluation will focus on identifying lessons
learned that will guide future USAID investments. The evaluation will also assess the
sustainability of the interventions at an individual (nurses) and an institutional (MOHP facilities)
level. Evaluators will use a mix of quantitative and qualitative data collection and analysis
methods to generate answers, and will use USAID Evaluation Policy
(http://www.oecd.org/derec/unitedstates/USAID_Evaluation_Guidelines.pdf) as a guideline in
the evaluation design. 
40
B. Data Collection Methods
The evaluation team should develop data collection tools that are consistent with the evaluation
questions to ensure high quality analysis. The evaluation team is required to share data
collection tools with the USAID Evaluation Program Manager for review, feedback and/or
discussion with sufficient time for USAID’s review before they are applied in the field. 
The external evaluation team will start work on a paper review of all, but not limited to, 
resources cited in the “Relevant Documentation” section above prior to arriving in Egypt. The
local evaluation team members should complete the paper review prior to the external evaluation
team’s arrival. 
These tools may include a combination of the following: 
• Desk review of relevant documentation, (e.g., quarterly reports, output from the
project monitoring system, other OHP, MOHP, etc.); 
• Site visits to IPN intervention facilities; 
• Key informants interviews; 
• Focus group discussions with IPN, MOHP, training beneficiaries, and other
counterparts and stakeholders. 
Interviews 
Key Informant Interviews will include, but may not be limited to: 
 USAID/Egypt Health Team – including Activity Manager 
 MOHP staff 
 IPN staff 
 Participants of IPN training programs 
 Others 
The evaluation team will provide a more detailed explanation of the proposed methodology for
collecting the data. 
The Evaluation Team may be accompanied by a staff member from USAID/Egypt, as
appropriate, to observe interviews and field visits. A list of interviewees and key stakeholders
will be provided by USAID prior to the assignment’s inception. 
C. Data Quality Standards
The evaluation team shall ensure that the data they will collect clearly and adequately represents
answers to the evaluation questions, is sufficiently precise to present a fair picture of
performance, and is at an appropriate level of details. 
D. Data Analysis Methods
Prior to the start of data collection, the evaluation team will develop and present, for
USAID/Egypt review and approval, a data analysis plan that details how focus groups and key 
41
informant interviews will be transcribed and analyzed; what procedures will be used to analyze
qualitative and quantitative data from key informant and other stakeholder interviews; and how
the evaluation will weigh and integrate qualitative data from these sources with quantitative data
from performance indicators and project performance monitoring records to reach conclusions
about the effectiveness and efficiency of IPN activities conducted by MSH. 
The Mission expects the evaluation team to present strong quantitative and qualitative analysis,
within data limitations, that clearly addresses key issues found in the research questions. The
Mission is looking for new, creative suggestions regarding this evaluation, and it is anticipated
that the implementer will provide a more detailed explanation of the proposed methodology for
carrying out the work. 
The evaluators should consider a range of possible methods and approaches for collecting and
analyzing the information required to assess the evaluation objectives, and the findings should be
supported by data from a range of methods. The methodology will be discussed with and
approved by USAID/Egypt Activity Manager and the Evaluation Program Manager prior to
implementation. 
E. Methodological Strengths and Limitations
Key informant interviews and focus group discussions are suggested as a primary data source for
this evaluation. It is anticipated that some interviews may be conducted in the presence of at
least one or more outside observers, including project and USAID staff, and that interview
responses could be affected by the presence of these observers. 
USAID expects that all issues affecting validity be discussed and documented in the evaluation
planning stage – including measures to minimize precision and validity issues Measures to
mitigate these issues will be addressed with all team members and USAID team in the
implementation phase and detailed in the final report. 
5. Evaluation Products
A. Deliverables
Work Plan: During the team planning meeting the evaluation team will discuss the detailed work
plan, which will include the methodologies to be used in the evaluation, timeline, and detailed
Gantt chart. The work plan will be submitted to both the IPN AOTR and the USAID Evaluation
Program Manager for approval no later than the sixth day of work. 
Methodology Plan: A written detailed methodology and data analysis plan (evaluation design,
data analysis steps and detail, operational work plan, see sections III. C and D) will be prepared
by the team and discussed with USAID during the planning meeting. 
List of Interviewees and Schedule: USAID will provide the evaluation team prior to the team’s
arrival in Egypt with a stakeholder analysis that includes an initial list of interviewees, from
which the evaluation team can work to create a more comprehensive list. Prior to starting data 
42
collection, the evaluation team will provide USAID with a list of interviewees and a schedule for
conducting the interviews. The Evaluation Team will continue to share updated lists of
interviewees and schedules as meetings/interviews take place and informants are added to/deleted 
from the schedule. 
Data collection tools: Prior to starting fieldwork, the evaluation team will share the data
collection tools with the USAID Evaluation Program Manager for review, feedback and/or
discussion and approval. 
In-briefing and Mid-term brief with USAID: The evaluation team is expected to schedule and
facilitate an in-briefing and mid-term briefing with USAID. At the in-brief, the partner should
have the list of interviewees and schedule prepared, along with the detailed Gantt chart that maps
out the evaluation through the report drafting, feedback and final submission periods. At the
mid-term brief, the partner should provide USAID with a comprehensive status update on
progress, challenges, and changes in scheduling/timeline. In addition, to facilitate a smooth
implementation of the data collection and analysis phases, the evaluation team will be expected 
to coordinate and communicate with the Mission’s POC on evaluation team ongoing basis. 
Discussion of Preliminary Draft Evaluation Report: The team will submit a rough draft of the
report to the USAID Evaluation Program Manager, who will provide preliminary comments
prior to final Mission debriefing. This will facilitate preparation of a more final draft report that
will be left with the Mission upon the evaluation team’s departure. 
Debriefing with USAID: The team will present the major findings of the evaluation to
USAID/Egypt through a PowerPoint presentation after submission of the draft report and before
the team’s departure from country. The debriefing will include a discussion of methodology,
findings, achievements and issues as well as any conclusions, and recommendations. The team
will consider USAID/Egypt comments and revise the draft report accordingly, as appropriate. 
Debriefing with Partners: The team will present the major finding of the evaluation to USAID
partners (as appropriate and as defined by USAID) through a PowerPoint presentation prior to
the team’s departure from country. The debriefing will include a discussion of achievements and
activities only, with no recommendations for possible modifications to project approaches,
results, or activities. The team will consider partner comments and revise the draft report
accordingly, as appropriate. 
Draft Evaluation Report: A draft report of the findings and recommendations should be
submitted to the USAID Evaluation Program Manager prior to the team leader’s departure from
Egypt. The written report should clearly describe findings, conclusions, and recommendations.
USAID will provide comment on the draft report within two weeks of submission. 
Final Report: The team will submit a final report that incorporates the team responses to
Mission comments and suggestions no later than five days after USAID/Egypt provides written
comments on the team’s draft evaluation report (see above). If USAID/Egypt determines that its
comments on the first draft have not been satisfactorily addressed, it will provide further
feedback for the team to address within five days. The evaluation report will be deemed final 
43
only with USAID/Egypt’s approval. The format will include an executive summary, table of
contents, methodology, findings, and actionable recommendations. The report will be submitted
in English, electronically. The report will be disseminated within USAID and to stakeholders
according to the dissemination plan developed by USAID. 
Expanded Executive Summary: The team will submit an expanded executive summary to
accompany the final report that will include a background summary on the evaluation purpose
and methodology, and an overview of the main data points, findings, conclusions, and
recommendations. The expanded executive summary should be easy to read for wide
distribution to local audiences and the partner is encouraged to look for creative presentation
styles, formatting and means of dissemination. The expanded executive summary will be
submitted in English and Egyptian Arabic, in hard copy (50 copies) and electronically. The
report will be disseminated within USAID and to stakeholders according to the dissemination
plan. 
Data Sets: All data instruments, data sets, presentations, meeting notes and final report for this
evaluation will be presented to USAID on a flash drive to the Evaluation Program Manager. All
data on the flash drive will be in an unlocked, editable format. 
A two-day team planning meeting will be held in Egypt before the evaluation begins. This
meeting will allow USAID to present the team with the purpose, expectations, and agenda of the
assignment. In addition, the team will: 
 Clarify team members' roles and responsibilities; 
 Establish a team atmosphere, share individual working styles, and agree on
procedures for resolving differences of opinion; 
 Review and develop final evaluation questions (work out realistic expectations of the
team during meetings with MOHP and USAID); 
 Review and finalize the assignment timeline and share with USAID; 
 Present data collection methods, instruments, tools, and guidelines (materials should
be developed prior to this meeting); 
 Review and clarify any logistical and administrative procedures for the assignment; 
 Develop a preliminary draft outline of the team's report; and, 
 Assign drafting responsibilities for the final report. 
B. Evaluation report requirements
The format for the evaluation report is as follows: 
1. Executive Summary—concisely state the most significant findings and
recommendations (2 pp); 
2. Table of Contents (1 pp); 
3. Introduction—purpose, audience, and summary of task (1 pp); 
44
4. Background—brief overview of IPN project in Egypt, USAID project strategy and
activities implemented in response to the problem, brief description of IPN, purpose of
the evaluation (2 pp); 
5. Methodology—describe evaluation methods, including threats to validity, constraints
and gaps (1 pp); 
6. Findings/Conclusions/Recommendations—for each evaluation question, the report will
state findings, conclusions and recommendations in clearly demarcated sub-sections;, 
also clear distinctions will be made between findings, conclusions, and recommendations
(15–20 pp);
7. Challenges—provide a list of key technical and/or administrative challenges, if any (1–2
pp); 
8. Future Directions (2–3 pp); 
9. References (including bibliographical documentation, meetings, interviews and focus
group discussions); 
10. Annexes—annexes that document evaluation scope of work, evaluation methods and
limitations, copies of the actual data collection tools, documents reviewed, schedules,
interview lists and tables— should be concise, relevant and readable. Annexes should
also include a disclosure of any conflict of interest by evaluation team members. 
The final report will be reviewed using the Checklist for Assessing USAID Evaluation Reports
(http://www.usaid.gov/policy/evalweb/evaluation_resources.html). 
The final evaluation report will conform to the Criteria to Ensure the Quality of the Evaluation
Report found in Appendix I of the USAID Evaluation Policy. The Evaluation Program Manager
will determine if the criteria are met. This evaluation will not conclude until the Evaluation
Program Manager has confirmed, in writing, that the report has met all of the quality criteria. 
The final version of the evaluation report will be submitted to USAID/Egypt electronically. The
report format should be restricted to Microsoft products and 12-point type font should be used
throughout the body of the report, with page margins 1” top/bottom and left/right. The report
should not exceed 30 pages, excluding references and annexes. 
V. Team Composition
USAID encourages the participation of local experts on evaluation teams. MOHP staff is also
encouraged to participate on evaluation teams, as are implementing partners or other stakeholders 
when their participation would be beneficial for skill development and not present a 
conflict of interest nor a threat to validity, or their engagement in the evaluation would help to
ensure the use of evaluation results within USAID. All attempts should be made for the team to
be comprised of male and female members. Team members will be required to provide a written
disclosure of conflicts of interest (per USAID Evaluation Policy). 
The evaluation team will be composed of four members- a team leader, two consultants one of
them is a local specialist, and a local logistic coordinator. The evaluation team must have in one
or more team member(s) the following experience: 
45
 Human resources capacity building in a developing country; 
 Implementing and evaluating USAID health programs; 
 Demonstrated experience in Egypt; 
 Egyptian Arabic fluency; and 
 Demonstrated quantitative and qualitative data analysis skills. 
It is desirable to have in one or more team member(s) the following qualifications: 
 Implementation of USAID-funded health system strengthening programs; 
 Monitoring and Evaluation experience; 
 Human resources management experience; and 
 Implementation of leadership and management programs preferably the LDP approach. 
Offerors may comprise their team as they see appropriate, so long as all experience the team
must have that mentioned above is represented by an appropriate number of team members. All
other factors being equal, maximizing a team’s ability to fulfill more qualifications in the
“desirable” criteria might enhance an application. 
Team Leader: a senior consultant with extensive experience in leading and conducting USAID
health program evaluations. S/he should have an MPH or related post graduate degree in public
health. S/he should have at least 10 years senior level experience in at least one of the
qualifications mentioned above that the evaluation team must have. Excellent oral and written
skills are required. The Team Leader should also have experience in leading evaluation teams
and preparing high quality documents.
The Team Leader will: 
 Finalize and negotiate with USAID/Egypt the evaluation work plan; 
 Establish evaluation team roles, responsibilities, and tasks; 
 Facilitate the Team Planning Meeting (TPM) 
 Ensure that the logistics arrangements in the field are complete; 
 Manage team coordination meetings in-country and ensure that team members are
working to schedule; 
 Coordinate the process of assembling individual input/findings for the evaluation report
and finalizing the evaluation report; 
- Lead the preparation and presentation of key evaluation findings and recommendations to
USAID/Egypt team prior to departing Egypt. 
Local Consultant:
The local technical specialist is expected to be fluent/professionally proficient in spoken Egyptian 
Arabic. S/he should have an excellent understanding of the Egyptian public health 
system. S/he should also have a proven experience in conducting evaluations/assessments and
drafting high quality reports. The local specialist will assist the team to better understand
different cultural and social issues related to the sector of nurses in Egypt. S/he will also assist in 
46
communications and interviews with local stakeholders. S/he will participate in different
Evaluation activities and may be assigned specific tasks by the Team Leader as appropriate. 
Local Logistics Coordinator: 
The Logistics Coordinator should be a local staff member for handling the travel related logistics
and providing administrative support to the technical team members. The Logistics Coordinator
will also be responsible for setting up meetings with USAID and stakeholders. 
Required qualifications include: 
 Demonstrated: ability to be resourceful and to successfully execute complex logistical
coordination; ability to multi-task, work well in stressful environments and perform tasks
independently with minimal supervision. 
 Capacity for effective time management and flexibility. 
 Must be able to interact effectively with a broad range of internal and external partners,
including international organizations and host country government officials. 
 Must be fluent in both English and Arabic. 
 Proven ability to communicate clearly, concisely and effectively both orally and in writing. 
VI. Evaluation Management
A. Logistics
USAID will provide overall direction to the evaluation team, identify key documents, and assist
in facilitating a work plan. USAID will assist in arranging meetings with key stakeholders
identified by USAID prior to the initiation of field work. The evaluation team is responsible for
arranging other meetings as identified during the course of this evaluation and advising USAID/
Egypt prior to each of those meetings. 
The evaluation team is also responsible for arranging transportation as needed for site visits in
and around Cairo and other governorates. USAID can assist with hotel arrangements if necessary
but the evaluation team will be responsible for arranging its own work/office space, computers,
internet access, printing, and photocopying. The evaluation team is also responsible for procuring 
and paying for translation services for interviews, reports and any other evaluation 
related task. Evaluation team members will be required to make their own lodging and travel
payments. USAID personnel will be made available to the team for consultations regarding
sources and technical issues, before and during the evaluation process. 
B. Scheduling
Work is to be carried out over a period of approximately 13 weeks starting July 1, 2014. 
47
ANNEX II: TABLES, FIGURES, AND PHOTOGRAPHS
The following tables, figures, and photographs are from the WCA Assessment10 and the three
governorates (Aswan, Luxor, and Qena). 
Table 1.1 WCA Questions table 1. Standardized factor loadings for the final eight WCA
items, by level of analysis. 
Title Individual
Level
Work Group 
Level
1. We feel our work is important.a 0.62 0.82 
2. We strive to achieve successful outcomes.a 0.67 0.90 
3. We have a plan which guides our activities.b 0.47 0.73 
4. We pay attention to how well we are working together.a 0.51 0.77 
5. We understand each other’s capabilities.b 0.49 0.79 
6. We seek to understand the needs of our clients.b 0.66 0.93 
7. We understand the relevance of the job of each member in our 
group.a 0.54 0.92 
8. We take pride in our work.b 0.61 0.93 
Notes: a Additional items included in the model 
b Original WCA items 
10 Perry Cary, Nancy LeMay, Greg Rodway, Allison Tracy and Joan Galer. “Validating a work group climate assessment tool for
improving the performance of public health organizations.” Human Resources for Health 3:10, 2005. 
48
Table 1.2 Success in Completing Challenges by LDP teams in 3 governorates 
Governorate Aswan Luxor Qena Total IPN
Technical area
Total # 
challenges Achieved? Total # challenges Achieved? Total # challenges Achieved? Total # challenges Achieved? Yes No Yes No Yes No Yes No
IC 10 9 1 12 11 1 5 4 1
91 76 15 BNC 12 11 1 16 12 4 11 9 2 PPC 3 3 9 5 4 1 1
PHC services 9 9 3 2 1
Achieved % 94% 75% 82% 84%
Overall, the 88 teams addressed 91 challenges over the course of the IPN project. 76 of them achieved their goal or 91 percent.
Aswan teams had the highest rate of success at 94 percent. Basic nursing skills were the most common technical focus area, 
comprising 43 percent of the total. IC challenges were second (30 percent of total), provider-patient communication third with 14 
percent, and PHC fourth with 14 percent. 
Table 1.3 Illustrative Distribution of Technical Focus Areas 
Technical Area Percent of Total
Basic Nursing Skills 43%
IC 30%
Provider-Patient Communication 14%
PHC 13%
Total # Challenges 100%
Table 1.4 PMP Indicators Analysis 
PMP indicators Target Result % of Target Status
1. Number of LDP facilitators
trained
58 46 79.3% Not met
2. Number of persons
completing the LDP, by cadre
(e.g. doctor, nurse, etc.)
742 661 89% Nearly
achieved
3. Number of teams completing
the LDP
94 88 93.6% Nearly
achieved
4. Percent change in Work
Climate Assessment Score
Hospital
PHC units
10% 
10% 
81% 
132% 
810% 
1320% 
Exceeded
5. Percent of teams that select a
new challenge independently
after completing their Action
Plan
60% 38.6% 64.3% Not met
6. Number (percent) of 13 14 14/13 Met
hospitals that develop scale
up plans by the end of (50%) (56%) (108%) 
implementing their Action
Plans
50
Aswan
Table 2.1 Summary of Key Points from Aswan KIIs, Nurses Response (n=18) 
Benefits Challenges Follow up &
Impact Recommendations
Problem solving Low number of
target trainees 
Great impact on
work and even
personal lives 
All facility staff
involvement 
Increased self confidence 
“I am a manager in my workplace”
Focus on
nurses only 
Little follow up
especially with
older trainees 
Focus more on
raising nursing skills 
presentation skills Travelling time
to training site 
Little
involvement
from higher level 
Inclusion of managers
at facility, district and
directorate levels 
Showing results based on 
evidence 
High staff
turnover   
Organized work based on clear 
SMART objectives 
Turbulent
situation in
Egypt 
  
Table 2.2 Summary of Key Points during KII for Nurse Supervisors and MOHP supervisors
(n=8) 
Benefits Challenges Follow up &
Impact Recommendations
Identifying and 
addressing work
related problems 
Physicians not
involved 
Great impact on
individual nurses only 
Retrain facility teams
Nurses are more 
organized 
Follow up from
higher level 
“A candle light is
fading”
Include doctors and dept.
teams 
Collect, read and 
analyze data 
Time between
training workshops 
Not enough
supervisors trained 
Need continuity & follow
up 
Increased skills in 
IC, Basic Nursing
services, Patient
communication
and Patient safety 
Lack of support for
changes 
Facebook page for
nurses 
Train entire departments
or all staff at a facility 
51
Table 2.3 Summary of Key Points during FGD with Nurses (average n=5) in Aswan 
Benefits Challenges Follow up &
Impact Recommendations
Problem solving Weak management
support 
Great impact on
nurses 
Train more nurses, entire
department 
Teamwork Lack of follow-up Encouraging problem
solving approach 
Need more continuity –
management support 
Increased skills in 
IC, Basic Nursing
services, Patient
communication
and Patient safety 
Trained nurses
conflict with
untrained, young vs
old 
Update new
physicians and nurses
involvement for those
who were not in LDP 
Train physicians 
Luxor
Tables 2.4 - 2.6: Summary of Luxor Analysis, Key Results of KII and FGD 
Table 2.4 Luxor Nurses KII Responses summarized on LDP 
KII Nurses Response (n=12) 
Improvements or
Benefits
Challenges or
Negatives
Follow up &
Impact Recommendations
Problem solving Lack of cooperation
from management 
Impact fading,
forgetting 
Should train
physicians and entire
department 
Self-confidence Too few trained 
Some learned IC
measures, others
didn't 
Redo training at
hospital for all 
Organizational,
planning skills 
Work & training =
long hours 
Continuous learning
needs more
resources 
Focus more on skills
than knowledge 
Presentation skills 
(communication with
managers, patients) 
Married nurses - am
schedule only Blocked by physicians Need more continuity 
& follow up to sustain 
Evidence-based 
analysis, e.g. using lab
results 
Untrained nurses not
cooperating with LDP 
Supervisors should
support LDP more 
Time management 
Work and training
overlap and make
difficulties 
Rely on other cadres
to do some tasks 
52
Table 2.5 Nurse Supervisors’ responses from KII 
KII for Nurse Supervisors, MOHP Directors, and Physician Response (n=6) 
Improvements or
Benefits to Nurses
Challenges or
Negatives Follow up & Impact Recommendations
Problem solving Untrained nurses not
cooperating with LDP Not enough trained Retrain hospital teams 
More organized 
Physicians non￾compliant & don't
listen 
Older nurses not
learning from younger
ones 
Include doctor and
role of doctor 
Use & respect data Conflict among
hospitals 
Married nurses all on
am shift 
Need continuity &
follow up 
IC improved NA Fragments facility More in-depth on
statistics, rates, etc. 
Table 2.6 Responses from Nurses in Focus Group discussions 
FGD Responses on LDP and Current Situation (n=13)
Improved/Benefits Negatives Supervision & Follow
up Sustained Impact
Problem solving Management support &
follow up weak NS supportive Train more nurses,
entire department 
Teamwork & nurse
communication 
Time conflicts - long
hours plus training 
Encouraging problem
solving approach 
Need more
continuity –
management support 
Nurse-patient
Communication 
Trained nurses conflict
with untrained, young
vs old 
Work hours - no time
for nurse training 
Time frame for
Behavior Change is
longer 
Take Initiative to
solve problems 
Not all supervisors
trained 
Train physicians - get
them behind the LDP 
53
Qena
Table 2.7 Summary of key findings from KII with nurses, nurse supervisors and the MOHP
governorate in Qena. Nurses n=10 
KII Nurses Response (n=12)
Improvements or
Benefits
Challenges or
Negatives Follow up & Impact Recommendations
Satisfaction with
meeting challenges 
End of project resulted
in loss of nurses'
enthusiasm to continue
their activities. 
Lost momentum for
sustainability as
trained groups
become dispersed 
Train more nurses at
every facility 
Success story on 
"Preparation of the
patients before
surgical operation" 
Physicians did not
acknowledge the "new
look" of trained nurses 
All trained nurses in
Disha hospital left the
hospital due to
marriage or transfer 
Train every nurse in
the department; train
nurse supervisors 
Interact with other
nurses and exchange
of experience. 
LDP documents were
lost when moved to a
new hospital (Queft) 
LDP induced changes
and reallocation of
nurses according to
their effectiveness 
Became aware of
WHO-MOHP 
standards of Practice
(SOP) 
Married nurses –
terminated or
transferred to other
areas 
Challenge result: 10
points for proper
administration of
medications –
reached 100% then 
faded to 10% 
Use organized 
objective method to
assess & report on
performance. 
  
More interactive 
communication with
nurse supervisors
and management 
Work and training
overlap and make
difficulties 
LDP grads became
supervisors 
54
Table 2.8 Qena Summary of Nurse Supervisors and Governorate Director KII Responses
Nurse Supervisors and Governorate Director, n=4 
KII Supervisors Response (n=3)
Improvements or
Benefits
Challenges or
Negatives Follow up & Impact Recommendations
Improved 
communication skills
resulting in effective
nurse-patient
communication, 
Only 1 nurse trained in
LDP per department 
Presentations by
nurses in 4th LDP
workshop added to
their confidence 
Success story for
"Preparation of the
patients before
surgical operation" 
Focus on building
capacity of nurse
leaders was not enough
to have a critical mass 
Political issues
clogged scaling up of
the MSH 
Organizational,
planning skills 
Physiciansturnover
high so loss of
awareness of LDP 
LDP added new skills
in training especially
role play 
Inadequate support
from the health
directorates 
Health directorate &
district not following
up with LDP
challenges 
Need an LDP focal
point in Qena 
Peer education and 
chance to learn from
each other 
No fund to support the
projects within
hospitals 
MOHP should provide
funds for new
challenges and LDP 
Time management 
Work and training
overlap and make
difficulties 
Rely on other cadres
to do some tasks 
55
Figure 2.1 Facebook page update posted by Nurses at Al Seel PHU, Aswan 
The screen shot above is from the Facebook group page was shot at “Al-Seel” PHU as the
evaluation team completed their visit. The large poster hanging on the wall shows the challenge
addressed at the PHC unit and the root cause analysis done by nurses to address their
problem. 
56
Figure 2.2 Facebook page from Aswan Nurses.
https://www.facebook.com/groups/222924277893721
57
Figure 2.3. Flow chart on Challenge and Plan for Meeting it from Aswan Nurses. 
58
Figure 2.4. Nurses and Supervisor at Dao Rawo Hospital (Aswan) in interview session with
Dr. Madiha Said. 
59
Figure 2.5. Nurses, Governorate Nursing Director and Nurse Supervisor after a Focus Group
Discussion at Kom Ombo Hospital (Aswan) with three team members. 
60
ANNEX III: METHODOLOGY AND LIMITATIONS
EVALUATION METHODOLOGY
This final performance evaluation was intended to determine the effectiveness of the IPN project
in improving the performance of nurses to lead and manage their teams in addressing challenges
in rendering quality health care and to achieve measurable, sustainable results. The evaluation
tested the IPN theory of change (that improvement in nurse leadership and management skills
leads to measureable results in infection control, basic nursing care, and communication between
health care providers and patients) and provided a detailed analysis of the essential factors of
IPN’s performance. The evaluation also determined the extent to which planned deliverables
were completed, the perceptions of key informants and stakeholders on the effectiveness and
impact of the project’s interventions, the sustainability of the effectiveness achieved at the
individual nurse and MOHP facilities levels, provided lessons learned in USAID implementation
and partnerships with counterparts, and suggested guidance for follow-on health and human
resource and/or institutional capacity development programs. 
The PMP developed for the IPN relies primarily on process and output level indicators. This
evaluation first addressed the outputs, answering the questions pertaining to whether planned
activities were carried out. The evaluation also reviewed other quantitative and qualitative data
to determine the potential impact and sustainability of those completed activities. The team
explored in depth the evidence behind those intended outcomes, the reasons behind outcomes
that were not achieved and enabling factors for those that were, as well as unintended results.
In this context, the evaluation team answered the aforementioned, key evaluation questions. 
Social Impact’s evaluation methodology combined a comprehensive, rigorous analysis of existing
quantitative data with customized qualitative techniques designed to elicit primary data from a
wide range of counterparts, partners, beneficiaries and other stakeholders. This mixed-method
approach allowed for the triangulation of complementary data to elucidate linkages between
project inputs, outputs, and outcomes. 
The evaluation team analyzed quantitative and qualitative data in the context of the IPN results
framework to investigate the extent to which evaluation findings substantiate the logic underlying
the project’s development hypothesis, including the sustainability of interventions at the PHC unit
and hospital level. Specifically, the team used: 1) secondary data and existing project information,
such as quarterly and annual reports and other technical reports, project and health facility
databases; and 2) primary data collected through detailed KIIs, group interviews, and focus group
discussions FGDs. 
The evaluation team recognizes that health care provider knowledge, attitude and behaviors are
inexorably linked to gender norms in Egypt. In order for nurses to be “empowered” to initiate
and sustain key behaviors, they (female nurses) must negotiate and come to terms with gender
barriers to women – who in many instances are not expected to challenge men, and workplace
norms regarding the role and status of physicians and nurses. KIIs and FGD addressed awareness
of these issues and solicit observations on the interplay between gender roles and key IPN
outcomes. In acknowledgment of the critical role gender plays in the achievement of IPN 
61
objectives, as well as the extent to which the project’s activities have influenced broader gender
considerations, the SI team employed customized gender-focused qualitative inquiry. 
Specifically, qualitative interview guides for key informants and focus group participants included
questions designed to elicit information on perceptions of gender roles with respect to key
behavior changes sought by IPN. The evaluation used this data in conjunction with other
completed gender analysis to present a detailed picture of IPN’s performance framed within the
context of delicate cultural nuances. It should be noted that due to the predominance of female
nurses and the less than five male nurses available as KIIs during the evaluation, statistical analysis
and presentation of sex-disaggregated data was not feasible. 
The SI team met with the USAID Mission team during the week of October 12th and finalized
plans for data collection from site visits (including administrative record review), structured and
unstructured key informant interviews, and focus group discussions (FGD). Illustratively, the data
collection methods and the calendar for the two teams (two members of the evaluation team on
each) are shown in the table below within the data collection methodology section. 
DATA COLLECTION METHODOLOGY
Mixed Method
The final evaluation of the IPN project was evaluated using mixed methods (both quantitative and
qualitative techniques) to address the key evaluation questions and the sub-questions, ranging
from review of secondary reports to collecting primary data through interviews and focus groups
discussions with stakeholders, principal actors, and beneficiaries of project interventions. Site
visits were conducted and include direct observations at a sample of primary care and hospital
facilities as well as follow up with the trainees as a result of the training, technical assistance, and
resources they received from the activity. 
To address each of the key evaluation questions, the evaluation team relied on a variety of data
sources and data collection methods. The Data Collection and Analysis Matrix in Table 1 below
is organized around each of the evaluation’s key questions and provides a description of data
collection methods to be used. The three data collection instruments (nurse KII, stakeholder KII
and FGD discussion questions) are presented in Annex 5 and reveal the tools which guided the
collection of data from participant (nurse) KII, stakeholder KII, and FGDs with nurses, other
providers, and possibly patients. 
The main data collection instruments are as follows: 
(a) Desk Review of Documents. The e-library consists of project documents, including
strategic documents (proposals), past evaluations, work plans, various reports (baseline
assessment, quarterly and annual), operational documents, partners reports and other related
M&E documents. The evaluation team assessed the extent to which this secondary data could 
62
be used to answer the evaluation questions and then identify data gaps which needed to be
addressed as primary data collection during the field visit. 
(b) Collection and review of secondary data in the field. In addition to the desk review
before the field visit, the evaluation team gathered additional documents from stakeholders
and partners in the field. From these, they extracted the quantitative and qualitative secondary
data which served as the key sources of information for this evaluation including country level
performance data for the various interventions in which IPN was engaged. An assessment of
data constraints were also documented and the evaluation team mitigated where possible. 
(c) Site visits. Sites were selected in order to assess the performance of the project
interventions using selection criteria that represent the geographical regions, the types of
facility (e.g., specialty hospital), the training and position of participants, and gather
perspectives from a wide range of stakeholders in order to fill data gaps identified by the
evaluation team as well as any gaps in IPN’s programming. 
Table 1: Key Evaluation Questions, Data Collection Methods, and Schedule
Data Collection Method Evaluation Question 
the Data Informs
Week 
(Sunday)
Team 1 
Location
Team 2 
Location
Desk review of
documents and project 
performance data
Questions 1, 3 28-Sep Remote Remote
In-country consultations
with USAID staff (and 
IPN implementers)
Questions 2, 3 12-Oct Cairo Cairo
Key informant interview
(KII) with stakeholders
Questions 1, 2, 3 13-Oct Cairo Cairo
KII continued 19-Oct Aswan, Qena
Focus group discussions
(FGD)
Questions 1, 2, 3 19-24 Oct
26-28 Oct 
Aswan, 
Luxor 
Qena
Structured group
discussions
Questions 1, 2, 3 19-23 Oct
25-28 Oct 
Aswan, 
Luxor 
Qena
Structured and
unstructured site 
observations
Questions 1, 2 19-23-Oct
25-28 Oct 
Aswan, 
Luxor 
Qena
Luxor 
Hospital and primary
health care facility (PHC) 
administrative record 
review
Question 1 19-23-Oct
25-28 Oct 
22 Nov 
Aswan, 
Luxor, 
Ismaleya 
Qena,
Luxor 
Ismaleya 
SI’s multi-level evaluation approach is important to understand the multiple phenomena present
in the implementation of IPN, and to capture the perspectives of people experiencing IPN from
different vantage points, including, for example, direct participants and outside observers. It
helped mitigate the bias inherent in any one specific research method, support sound analyses, 
63
and draw accurate conclusions11. Furthermore, the iterative nature of data collection allowed one
method to inform improvements to the relevance of the next data collection tool to be employed. 
The evaluation team’s principal data collection will took place in the three governorates that IPN
served most fully during the project—Aswan, Luxor, and Qena—as determined in conjunction
with USAID/Egypt. The evaluation team used a stratified, purposive sampling method to select
participants for interviews and focus groups and sites to visit. 
Sites were chosen in conjunction with USAID/Egypt and MOHP in order to provide for inclusion
of all types of challenges (IC, basic nursing, communication and PHC), geographic coverage (sites
dispersed across the governorate), and the presence of at least two LDP-participants. In health
facilities where an adequate number of LDP-trained nurses are available, the SI team also
organized a FGD in addition to KIIs. 
A roster of facilities (general hospitals, specialty hospitals and PHC units) where IPN participants
(nurses) are working formed the universe from which our sample will be drawn for unstructured
group interviews, structured KIIs and FGDs. 
Quantitative Methods
Desk Review
Prior to undertaking field visits, the evaluation team reviewed all IPN related documents provided
by USAID, MSH and IPN staff, and other stakeholders. This review includes, but is not limited to
design documents, quarterly/annual reports, monitoring data, relevant assessments and
evaluations, appropriate contextual data, and other information from government sources,
program implementers, and researchers. SI also incorporated experiences and documented
findings related to health systems strengthening, leadership and management capacity building,
and other aspects of relevant development assistance in Egypt. SI also reviewed, as they were
available, notes or recordings from prior Leadership Development Program (LDP) workshops
regarding participants’ workplace challenge action plans and nurse experiences with enacting
them. While these experiences were also explored through other primary data collection
methods, workshop records were invaluable resources to capture a wide range of successes and
challenges experienced through the program. 
The team organized and analyzed these data as a first iteration toward answering the principal
evaluation questions. Monitoring data and quarterly reports, e.g. performance monitoring
reports, were particularly useful in benchmarking responses to the first evaluation question
(understanding the extent to which IPN achieved its intended goals). These evaluation questions
were addressed by the SI team through its internal consultations, key informant interviews,
discussion and focus groups, and site visits. As such, gaps in data or areas for further exploration
were highlighted during this document review phase. 
11 Bamberger, Michael. (2013). A Mixed Methods Approach to Evaluation. Social Impact Concept Note
Series. Available at: http://www.socialimpact.com/press-releases/MME613.pdf
64
Internal Consultations
SI carried out consultations with USAID primary intended users of the evaluation of IPN in Egypt
to gain their understanding of the development hypothesis/theory of change for the program,
identify areas of consideration to be explored in the evaluation, and inform SI’s evaluation tools.
These consultations did not duplicate KIIs in the event that USAID officials were part of the
sample frame for discussion of the IPN project performance. 
Review of IPN Performance Targets and Actual Achievements
With the Performance Management Plan (PMP) developed by the Mission and project reporting,
the evaluation team reviewed and reported on the extent to which the project results met its
performance targets. Targets were assessed via reported results per the PMP, and analysis
included an assessment of timeliness, and how internal project (such as changes in personnel) as
well as external factors (government changes) may have affected the results obtained. 
Hospital and Primary Health Care Facility (PHC) Administrative Record Review
To assess the contribution of the IPN program to changes in infection control procedures, basic
nursing care, and patient communication, SI worked with the USAID/Egypt Health Team to identify
reliable indicators within health facility records that could contribute to determining the
achievement of this evaluation objective. Site visits allowed the evaluation team to review a sample
of administrative records to validate data found in project reports and/or key information
interviews, as well as to make pertinent observations of facility and staff performance. SI consulted
the administrative records at selected facilities for these indicators to identify and compare
indicator values before IPN began with those available after extended IPN activities. A performance
evaluation design, in absence of a rigorous counterfactual, cannot attribute changes in factors like
nosocomial infections, provider hand washing, or patient care procedures to the program.
However, these records provided valuable triangulation and validation of qualitative results to
provide a more robust assessment of program effectiveness. 
Qualitative Methods
Individual and Key Informant Interviews
Key informants constituted a principal source of data for this evaluation. Findings gleaned from key
informant interviews provided critical contextual data with which to gain detailed understanding of
IPN effectiveness, as well as to triangulate with existing quantitative data. Key Informant Interviews
include, but were not limited to: 
 USAID/Egypt Health Team – including Activity Managers (current and previous) 
 IPN Technical Advisors from MSH 
 District and Facility MOHP officials involved with patient care and PHC. 
 Global Health Officers familiar with IPN (as available) 
 MOHP Officials (as advised by the Mission) in Cairo (Central Ministry) and governorates 
65
 MOHP Facilitators for LDP training; Nurse and Nurse Supervisor participants; LDP
mentors from the University (i.e. , Suez Canal) 
 PHU Officers in Charge, Physicians working in units where IPN activities occurred 
KIIs generally involved two evaluation team members, one who led discussion and the other to
record observations and key responses. The results of interviews were summarized by a coding
process to record the respondent’s type of facility, job title, gender and age group. It is the usual
practice in Egypt to obtain the consent of the officer in charge or department head to hold
interviews, and conduct them at the health facility or office of the interviewee (although alternative
arrangements can be made if necessary), and, based on the semi-structured interview guide, last
between 45 minutes to one hour. 
The evaluation team initiated its inquiry in each governorate with a courtesy meeting arranged at
the Health Directorate and meeting with responsible officials (usually MOHP). The evaluation
team explained the purpose of the visit and the objective of the evaluation, and made sure the
MOHP letter (in Arabic) sanctioning this work for USAID was received at the governorate. The
team then shared the proposed plan for facility visits and the schedule of KII and FGDs, soliciting
suggestions and endorsement from the officials. For example, the local officials advised if one of
our informants at a facility is away on training or leave, and perhaps suggested a different schedule
to ensure success in locating and interviewing key informants. Once a consensus was reached, the
SI team initiated its field visits promptly, usually starting with a nearby facility on the same day. 
To reach all three of the governorates and to ensure the team covered at least six facilities in each,
the SI team, at times, sent two persons out as a team to one set of facilities, and two others to a
different location. One person from the team, who was a native Arabic speaker at facility visits,
conducted the interview and the second person took notes on the appropriate data collection
instrument. When feasible, interviews were conducted in English, though translation was offered
if requested. KIIs were largely structured, with opportunity for comments on any aspect of the
IPN and related topics. Interview responses were not recorded verbatim, but were categorical
and thematic. A summary of the direct multiple choice questions are presented in frequency tables,
showing responses by category of worker, and facility. Separate gender tables were not warranted
due to insufficient male nurses to provide a meaningful presentation. 
The SI team used a semi-structured questionnaire guide to gather the views of the stakeholders on
the key themes of the evaluation exercise to allow adequate and uniform coverage of topic areas
while encouraging the natural evolution and expansion of the iterative qualitative data collection
process. The guide was designed with universal questions that elicit detailed description for the
relevant evaluation questions, and the team tailored the questions to each type of stakeholder using
the rationale for selecting the interviewee and knowledge of their context. 
While the evaluation team conducted some interviews in English, the inclusion of local Egyptian
specialists on the evaluation team allowed interviews to be conducted in Arabic when necessary.
The review of program data, in consultation with USAID/Egypt, informed the selection of
participants for key informant interviews and the protocols for these interviews. 
66
The SI team carried out KIIs covering a sample of key participants, stakeholders, and geographic
sites in which IPN operated. The evaluation team worked with USAID and others to construct
an appropriate purposive sample frame of institutions related to IPN activities (e.g., USAID/Egypt,
USAID/Egypt Health Team, MOHP, MSH headquarters, governorate based health facilities, the
IPN project, etc.) and individual respondents related to or with knowledge of IPN activities (e.g.,
staff in the above institutions, other participants in IPN training programs, patients affected by
IPN, and others).Working in collaboration with USAID/Egypt, SI ensured the highest possible
degree of representation in terms of gender, geographic distribution, and staff position for the
samples selected for data collection. The composition of discussion and focus groups ensured the
representation of women at all levels in order to address gender specific issues. Individual
interviews were particularly valuable to capture highly specific or personal views that one might
feel less comfortable sharing in a group, while KIIs enabled the team to learn more about broader
groups of stakeholders. 
Individuals or nurse teams noted by stakeholders to have been very successful or unsuccessful
were purposively sought to provide insight to contributing factors. In addition, SI sought to sample
individual LDP participants and conduct qualitative interviews with nurses, trainers, and health
facility administrators and patients with whom the nurses interacted. These interviews assessed
whether the program contributed towards proactive problem-solving and leadership activities by
the nurse; whether this resulted in changes in health outcomes; the nurse’s personal feelings of
self-efficacy to lead and enact changes in her workplace; and whether her workplace and trainer
provided the necessary support for this change, among other things. These qualitative interviews
were complemented by health facility site observations and administrative record review. To the
extent this approach provided seminal data and findings for IPN, we included mini-technical case
studies in our report as text boxes. 
Working collaboratively with USAID, MSH and other stakeholders, SI developed a structured
questionnaire for the KIIs with a mix of open-ended and closed questions to balance comparability
and the need for interviewees being able to speak freely about their experiences with the different
project components. Our KII instrument was tailored for each key informant category and to
frame in-depth discussions aimed at gleaning qualitative information on topics such as perceptions
of how IPN has contributed to changes in nosocomial infection control, basic care, and patient
communication (evaluation question 1); opinions about which factors of an enabling environment
for future sustainability exist (evaluation question 2); and personal lessons learned based on
experiences implementing or benefiting from the IPN program (evaluation question 3). All were
addressed at the institutional, local and governorate levels. Special attention was also given to the
influence of Egypt’s political events and related IPN program changes on the outcomes of the
program. SI pilot tested the KII protocol to ensure validity and clarity of the tool prior to full
roll-out and did the same with all other tools developed for the IPN evaluation. 
67
Focus Group Discussions
FGDs are particularly useful for supplementing KIIs and quantitative data by gleaning valuable
information from discussions among group participants. The evaluation team conducted FGDs
with various cadres of IPN stakeholders, from a sample of facilities where IPN trained staff NP
to gain an in-depth understanding of their experiences with project interventions, and any large
grouping that occur within its operations (i.e. health workers, MOHP officers, others as identified
by the evaluation team). Each FGD consisted of a group of participants that had common
characteristics of their engagement with IPN – type of intervention/benefit received and also
taking into consideration balanced views by geographical distinction (e.g., governorate, urban,
rural). 
In addition to the individual KIIs, the evaluation team arranged FGDs to probe key questions and
elicit open discussion of items that are more complex and merit in-depth discussion. FGDs were
held at several sites for each type of facility (e.g., general hospital, primary health care unit). Once
again, the FGD responses were not recorded verbatim, but analyzed for important messages, key
controversies (if any) and common themes across groups (facilities, position, governorates).
Analysis of the results contributed to the team’s understanding of the IPN experience, positive
and needing improvement, as well as to verify and amplify KII results, identify lessons learned and
assess future prospects for sustaining the LDP program within their respective governorates. 
Where possible, the FGDs were formed with the ideal number of participants in mind--between
6 and 12 persons--which allows for a wide discussion of opinion without over-crowding. During
the FGDs, the convening member of the team began by using discussion questions to introduce
relevant themes and topics, but also encouraged participants to elaborate on key points that they
make so that depth can be achieved in the responses. The team member ascertained that opinions
are representative of the whole group and encouraged wide participation, rather than relying on
answers of the most vocal. 
Findings from FGDs provided insight into perceptions of the ways in which IPN managed
effectively, as well as how IPN activities have influenced behavior change among nurses and other
cadres of health workers. FGDs are subject to biases similar to those common to KIIs (i.e. recall
bias and subjectivity), and have the added challenge of being dominated by the most powerful
voices in a group. Power dynamics between individuals based on status and sex was a key
consideration for the evaluation team when constructing and moderating focus groups. Sex￾disaggregated focus groups, namely among groups of community beneficiaries, may be used in
order to mitigate challenges of this kind. 
Data from FGDs was transcribed and coded using summary tables, which lends itself to rapid and
efficient analysis and reporting for short-term field evaluations. Focus groups helped the team
gain insight into the same topics as KIIs, but with the added benefit of hearing discussants converse
about common or divergent experiences and opinions. By triangulating focus group findings with
findings from other methods, the team increased confidence in the validity of their conclusions. 
68
FGD targets were Nurse Supervisors who also may have been LDP facilitators, and LDP training
participants. We planned several FGDs in each of the three Governorates to be visited. These
consisted of at least three FGDs with LDP trainers, and three with nurses trained by LDP
(participants in the IPN program). . The FGDs with nurses and LDPs helped elucidate the
effectiveness of IPN’s workshops supported by the project, how they have helped improve
service quality, and provided more in-depth opinions about empowerment and factors
contributing to or inhibiting success in achieving positive health changes through program
participation. These FGDs also informed the team of the effectiveness and the acceptability of
the IPN approach. In some cases, we used positive deviance assessment and appreciative inquiry
in these focus groups. Positive deviance allowed focus group participants to identify nurses or
facilities that have been very successful to help pinpoint factors that have led to their success.
Appreciative inquiry helped determine specific factors working well for program participants and
implementers and why, and then to leverage these functional areas to allow nurses to identify
ways to create leadership and better health outcomes in other areas. These discussions can help
USAID and other implementers to understand why certain nurse leadership conditions exist and
how challenges might be addressed. 
Structured Group Discussions
To complement our FGDs, SI will carried out structured discussions with groups selected from
facility managers, service providers and other stakeholders affected by IPN activities in
governorate MOHP offices, hospitals, health facilities and other institutions. The evaluation team
aimed to understand from them whether or not the IPN activities were effective in achieving
measurable results in 1) the three substantive focus areas specified by the project, 2) enhancing
nurse leadership, and 3) whether nurse empowerment occurred. These group interviews were
particularly useful in understanding community perspectives regarding any changes in health
outcomes in the specific facilities as well as elements which might contribute to or mitigate against
sustainability of outcomes. 
Site Visits: Structured and Unstructured Site Observations
As pointed out above, our evaluation team visited at least twenty selected sites in Aswan, Luxor,
and Qena and visit mentors at Suez Canal University in Ismaleya governorate. The evaluation
team carried out structured and unstructured site observations of IPN program activities at sites
in these governorates, using observation checklists and appropriate coding techniques, questions
and analytical methods to guide our work during these visits. At sites in which nurse teams
implemented a challenge and planned to address it, questions specific to the type of plan (e.g.,
infection control) were included. 
Site visits also presented the opportunity to glean information directly from community
beneficiaries; consenting patients may be asked about key provider behaviors, e.g., hand washing,
explaining treatments clearly, etc. 
Selection included factors such as: 
 Duration and level of project support: Areas of relatively recent IPN engagement and
areas of more long-term engagement. Facilities receiving support of longer than average 
69
duration provided more useful insights on the project’s effectiveness, while a sample
including newer sites allowed closer examination of the effectiveness of recently applied
tools or approaches. 
 Demographic representativeness of beneficiary population socio-economic status: Sites
were chosen based on known characteristics of target population (e.g. areas with higher￾than-average rates of poverty/malnutrition). 
 Performance of the individual health facility: A selection of both high performing and low
performing facilities helped to understand factors contributing to success and barriers to
achievement. 
 Logistical convenience: ease of traveling, location of the facility, security considerations,
etc. 
 Areas of success and areas of difficulty and/or challenge 
 Areas outside of the program area identified as having high vulnerability 
 Budget for the evaluation exercise 
ANALYSIS PLAN
The evaluation team’s specific analysis methods for the IPN evaluation were, for each method of
data collection and each level or category of respondent, to organize (code and array), and
disaggregate (separate by gender, by type of factors such as governorate, health facility type and
size, and potentially other factors such as type of individual, etc.), and review the data for
clustering, grouping, and validity. The evaluation team then triangulated data, using information
from different sources and levels independently and in parallel to address the evaluation
questions. The evaluation team compared findings, one to one, across each data collection
method (KII, focus group, secondary data, etc.), each form of data (qualitative, quantitative), each
source of data (nurses, MSH staff, MOHP staff, etc.), and each level of data (facility, local
geographic area, governorate, national) or type of respondent (IPN participant, patient, visitor).
Then we combined all data (findings) for each evaluation question and sub-question and compared
and contrasted the data/findings from different data collection methods and sources for each
question, settling on appropriate findings and conclusions for each one. 
Our team carried out analysis on a rolling basis to examine, understand, test, and synthesize the
data, and to produce clear findings, conclusions and recommendations regarding IPN. By starting
the analysis while in the field, the team was able to identify areas where data do not align and
collect further data to understand any differences. 
Based on the data and corresponding analysis, the team developed findings, conclusions,
recommendations, and lessons learned for future programming of IPN type USAID activity overall
and for each evaluation question. Our recommendations were based solely on the conclusions
we reached. In addition, and in accord with USAID policy, the SI team integrated into its analysis
considerations of gender roles and inequalities as they affected IPN effectiveness, as well as to
how IPN may itself have influenced gender statuses and relationships. 
70
Limitations on the Evaluation Methodology
The validity of the evaluation findings was affected by several factors, which SI addressed
proactively. As pointed out in the analysis section above, we combatted bias (particularly recall,
response, and selection bias) by using multiple sources of data to triangulate answers to each
evaluation question. The evaluation team also used questions about specific examples (‘anchoring
responses’) to probe general responses more thoroughly. Finally, the evaluation team included as
respondents key informants with different ‘causal distances’ from the activity such as indirect
beneficiaries and external experts who could provide evidence from different perspectives. 
Another challenge was the short timeline to conduct the evaluation, with just nine weeks from
start to completion. In our work plan, SI frontloaded much of the initial document review so the
in-country Team Planning Meetings (TPMs) could be used to finalize the instruments and sampling
plan, in coordination with USAID/Egypt and others. This evaluation was also undertaken right at
the end of the IPN project, which allowed our team to use our KIIs and FGDs to prompt
respondents about past events compared to using other methods such as closed-ended
questionnaires. 
A final challenge was that IPN took place when Egypt’s governance and economy were
disturbed, such that distractions and many parallel activities may have disguised or offset IPN’s
results. SI developed its instruments in collaboration with the USAID/Egypt Health Team to
ensure the highest possible accuracy in identifying context, trends, events, and other factors
affecting IPN results and in specifying and measuring IPN’s results. The team also included
documentation from other agencies and partners in our initial document review and took other
activities into account when developing instruments and sampling. 
Table 2: Mapping Selection Criteria for Sites Visits
Region/
Governorate
Intervention % Nurses
Affected
Performance
(High, med, low)
Duration of
engagement
Aswan LDP 12-15% High/Low 2010-2014 
Luxor LDP 15%+ High/Low 2011-2014 
Qena LDP 12-15% High/Low 2011-2014 
LDP – 14-22 weeks of Training and On-Site Coaching (IPN annual report) 
INDEPENDENT ANALYSES OF DATA SETS
The evaluation team’s initial desk based review identified the sources of data expected to be
available and continued to assess this information as it was received during the evaluation period.
Using a Data Summary template, the content of the KIIs and FGDs responses were assigned into 
71
categories based on the evaluation themes/questions. The categories were then analyzed for
frequency of responses from stakeholders in order to identify the main messages. Once this was
done, the primary qualitative information was compared with the secondary quantitative
information to interrogate, corroborate and expand on the findings from the secondary sources
and then draw conclusions. This process was ongoing during the evaluation so that key themes
in the responses could be extrapolated for the production of the preliminary findings and
recommendations at the end of the field visit. 
As proposed, SI employed triangulation and complementarity methods as per Stern et al, 2012,
using definitions to check and clean the data collected. Secondly, information for each sub
question was gathered and used to remove outliers, irregularities and subjective responses, fill
information gaps, and determine the reliability of the data contributing to the recommendations.
Where similar findings were obtained across the different data collection methods, the team
could confirm the credibility of the results and demonstrate the confidence it has in the eventual
assessments and recommendations. Any findings that the team came across, but which have not
been corroborated through the triangulation or complementarity methods (such as suggestions
from single sources for future programs) contain a note describing that the data is from a single
source and the reason for its inclusion. However, to avoid this, the evaluation team made every
effort to reinforce the reliability of the information, and performed further document review. 
SI used multi-methods - including tables, graphs, photos, network maps, diagrams, and case
studies - to display the data behind the findings in evaluation report. Summary narratives for each
interview were used to outline the salient issues and each was linked to existing secondary data.
During the evaluation, the summary narrative was used to identify new questions that require
further exploration and these were added into the evaluation plan. Recurring themes/ideas were
coded in broad categories to facilitate drawing conclusions. 
Data from the questionnaire was processed using Microsoft Excel, PowerPoint and SPSS statistical
package to compile summary statistics from the findings, which have been presented in tables and
graphs. The team also used existing graphs, maps, and diagrams to process the newly collected
information so that the findings could be displayed in the geographical coverage of the IPN
operations. Tables have been used to summarize the number of beneficiaries (targets groups)
and stratified by gender, age groups, and activity in the targeted geographical areas. When
possible, photos depict actual project sites with beneficiaries and other activities. The
recommendations in the evaluation report were based on the measured achievements of the IPN
program and be linked where appropriate. 
DATA COLLECTION AND ANALYSIS MATRIX
Key Evaluation Question and Sub￾Questions Methods Data Source
Impact
1. Given the turbulent operating
environment, to what extent did the IPN 
Program achieve its intended goals and 
results? Thematic area: Evidence of 
improved health services in Aswan, Luxor, 
Qena, Sohag and Assiut governorates. 
Review of facility reports and 
survey data for trend analysis 
before 2009 to present 
Egypt DHS, SPA
(2004) 
Outcome
1 a) To what extent was IPN able to
improve nurses’ practices and services 
provided in hospitals and primary health 
care units in intervention governorates? 
Quantitative: review
facility/governorate reports on 
# infections, fatality rates in 
neonatal wards, project 
reports; Qualitative: KII, 
FGDs, group interviews, site 
visits including record review 
and observation 
Facility reports
(MIS), IPN Project 
reports, special 
studies 
Outcome
1 b) To what extent was IPN able to
empower nurses in intervention facilities? 
And how has this impacted their 
performance and their ability to address 
their challenges? 
Outcome
How did nurse/health care facility perform
with respect to: 1) infection control 
procedures; 2) documenting patient 
records; 3) communication with patients; 
4) communication among team 
Quantitative: review
facility/governorate reports on 
# infections, fatality rates in 
neonatal wards, project 
reports; Qualitative: KII, 
FGDs, group interviews, site 
visits including record review 
and observation. 
Facility reports
(MIS), IPN Project 
reports, special 
studies 
Outcome
To what extent are practices promoted
under IPN being sustained? 
Quantitative: review
facility/governorate reports on 
# infections, fatality rates in 
neonatal wards, project 
reports; Qualitative: KII, 
FGDs, group interviews, site 
visits including record review 
and observation. 
Output 1
Changes in nurse/provider knowledge of
MOHP standards for a) infection control, 
b) basic nursing care, and c) patient￾provider communication. 
Quantitative: review
facility/governorate reports on 
# infections, fatality rates in 
neonatal wards, project 
reports; Qualitative: KII, 
FGDs, group interviews, site 
visits including record review 
and observation 
MSH Project Data,
Project Reports, 
Special surveys 
73
Output 2
Nurses committed to adhering to MOHP
quality assurance standards and to assess 
and improve their performance and the 
health services in the hospitals according 
to these standards. 
Review of Project and MOHP 
records (governorate, site 
visits); KII, FGD and 
interviews 
Output 3
Increased local training capacity through a
group of trained facilitators 
Review of Project and MOHP 
records (governorate, site 
visits); KII, FGD and 
interviews 
Project Reports,
site visits 
Process/Activitie 
s
Number of persons completing Leadership
and Development Program (LDP) 
Review of Project records, site 
visits review of facility records 
and Personnel Department 
reports. 
Project Reports,
site visits 
Inputs
Assessment of training quality by
participants and stakeholders, and lessons 
for future interventions 
Review of Project and MOHP 
records (governorate, site 
visits); KII, FGD and 
interviews 
Project Reports,
site visits 
NOTES: List of facilitates (by type) where IPN participants are working will be survey universe for
KII and FGD involving nurses and other health providers 
ANNEX IV: DATA COLLECTION INSTRUMENTS
QUESTIONNAIRE TO GUIDE KEY INFORMANT INTERVIEWS WITH NURSES AND NURSE SUPERVISORS
Questionnaire ‐ Nurses Team 1 Team 2 (circle)
Date
Responder
Code
Facility
Code Interviewer Code
Interview Date:
Challenge Addressed :
Q
# Question
Reply Yes
No DK Key Points
Infection Control (IC)
1 In the past two years, have you received specific
training on IC? If No, then go to
Q 5
2 If YES, was the training under the IPN project? If No, then go to
Q
7
How many hours/days of training did you
3 receive? indicate hours or days by year
What were the best or most positive things
4 about this training?
What were the aspects of training that were not
5 positive?
Was the training the right duration? In the sit‐ 
6 down learning? In the practical follow on?
75
Would you have any suggestions for improving
7 the training offered in IC?
Were there changes in practices that came about
8 as the result of IPN training?
a. Is there any evidence that IC has improved in
your unit/facility since the IPN traning? b. If so,
9 what is the source of this evidence?
10 Were you involved as an IPN Trainer of Trainers? If YES< then complete questions on sheet 2
11 Men and women may approach work differently.
Tell me about your experiences, and have you observed
differences? Any problems?
KEY INFORMANT INTERVIEW (KII) QUESTIONS FOR STAKEHOLDERS
Project IPN Evaluation Team 1 Team 2 (circle)
Date of Interview:
Responder
Code Facility Code Interviewer Code
Q # Question
Short Reply
Yes No DK Key Points
(IC)
Infection Control 1 Since you became a TOT for nurses, how many training sessions have you completed? Respond by year 2010 2011 2012 2013 2014 What were the main changes brought about by 2 the training?
76
Once the Training was completed, was further
assistance provided to the training participants?
3 Please give us some Examples?
What were the best or most positive things
4 about being a TOT?
What do you think are the major obstacles in
5 adhering to MOHP IC standards?
Did the IPN training lead you to make changes in
IC, can you provide any examples of specific
6 changes made?
Compared with before the training, do you feel
greater ability to affect changes to meet IC
7 standards?
Since the IPN Project ended, how many nurse
8 trainings have you held?
Would you have any suggestions for additional
9 actions to improve IC practices?
10
Men and women may approach work
differently. Tell me about your experiences, and
have you observed differences? Any problems?
FOCUS GROUP DISCUSSION (FGD) QUESTIONS
Focus Group Discussion (FGD) Questions
Governorate: District: Facility/Town 
Number of FGD participants: START: END: 
1. Please raise your hand to show what kind of
challenge you addressed following your 
training (MSH, IPN)? 
A. IC 
B. BNS 
C. Patient provider Communication 
D. Teamwork – team communication 
E. Other 
Tally totals for each category:
A B C D E
2. What were the best or most positive things
about this training? 
3. What were the aspects of training that
were not positive or need improvement? 
78
4. Was the training the right duration? In the
sit-down learning sessions? 
5. Was the supervisor supportive of your plan
to address a challenge and make 
improvements? If so, how? 
6. If they were not supportive, what did they
do? Please give an example 
7. Do you feel the training has changed the
way nursing is practiced in your facility? Do
you believe that the changes will continue 
into the future? 
8. If there was a new training program, would
you have any suggestions for improving the 
training offered? 
For instance, do you see a need to have more 
technical training (e.g., on IC, nursing care, 
PHU, M&E, etc.) as well as leadership and 
management training? Other improvements? 
79
ANNEX V: SOURCES OF INFORMATION
DOCUMENTS REVIEWED OR REFERENCED 
PROJECT DOCUMENTS AND REPORTS
 Improving the Performance of Nurses (IPN) Implementation Plan (Revised).
December 16, 2013. 
 Improving the Performance of Nurses in Upper Egypt Program (IPN), Draft Revised
Workplan: March 1, 2012 – November 30, 2013. 
 Improving the Performance of Nurses in Upper Egypt Program (IPN), Workplan
Addendum for a Two-Month No Cost Extension, May- June 2014. 
 Improving Work Climate Saves Cardiac Patients in Qena Hospitals. 
 IPN Implementation Geographical Areas. 
 Michael Bamberger, The Mixed Methods Approach to Evaluation, Social Impact,
Number 1 June 2013. 
 Michael Quinn Patton, Utilization Focused Evaluation (U-FE) CHECKLIST, January
2002. 
 MSH. Improving the Performance of Nurses in Upper Egypt Program (IPN), Final
Report November 2009 - June 2014. 
 MSH. Leadership & Management Development Program (LDP) LDP Teams
Sustainability Results, Phase III LDP 2010-2013. 
 MSH. Leadership, Management and Sustainability Report 2005-2010. 
 MSH. Leadership can be Learned, But How is it Measured, Occasional Papers No. 8
(2008) 
 Project Monitoring Plan (PMP): IPN Project, October 1, 2009 to April 30, 2014. 
 Qena Quality Teams Sustainability Plan. 
 Success Stories from Luxor, Egypt: Armant Fever Hospital Team Success Story. 
 USAID. Action Memorandum. April 30, 2013. 
 USAID. C-18: Checklist for Assessing USAID Evaluation Reports 2011. 
 USAID. Egypt Health and Population Legacy Review: Volume 1. March 2011. 
80
 USAID. Evaluation: Learning from Experience, USAID Evaluation Policy January 2011 
 USAID Evaluation Policy, Answers to Frequently Asked Questions (FAQs), Issue 1,
March 25, 2011. 
 USAID. Federal Financial Report: Leadership, Management, and Sustainability - Egypt.
June 20, 2014. 
 USAID Health Policy Initiative. Gender Assessment of the USAID/Egypt Health
Program. August 2010. 
 USAID. Leadership, Management and Sustainability (LMS) Project under Leader
Award No.: GPO-A-00-05-00024-00. Cooperative Agreement No.: 263-A-00-09-
00059-00. November 18, 2009. 
 USAID. Modification 1 of Award Number 263-A-00-09-00059-00. July 18, 2010. 
 USAID. Modification 2 of Award Number 263-A-00-09-00059-00. August 15, 2010. 
 USAID. Modification 3 of Award Number 263-A-00-09-00059-00. September 20,
2011. 
 USAID. Modification 4 of Award Number 263-A-00-09-00059-00. May 28, 2013. 
 USAID. Modification 6 of Award Number 263-A-00-09-00059-00. April 16, 2014. 
 USAID. Success Story: Coach Inspires Nurses in Aswan Hospitals to Extraordinary
Improvements in Healthcare. 
 USAID/Egypt. Success Story: Aswan Chest Hospital Nurses Maintain Infection
Control Standards and Supplies. 
 USAID/Egypt. Success Story: Nurse Teams Exceed Their Target in Providing Quality
Service in Armant District Hospital. 
 USAID/Egypt. Success Story: Egypt’s Improving Performance of Nurses Project
Helps Cardiac Patients in Qena General Hospital. 
 USAID, MSH. Gender Analysis Final Report for Improving the Performance of
Nurses (IPN) Program in Upper Egypt (Aswan, Qena, and Luxor Governorates).
April 2012. 
 USAID, MSH. Success Story: Nurse Teams Improving Time-Out Procedures in
Patient Files in Luxor International Hospital. 
 USAID, MSH. Success Story: Nurses Take Initiative to Sustain the Improving 
81
Performance of Nurses Project in Luxor International Hospital. 
 USAID, MSH. IPN Team in El Bayadia District Hospital Succeed in Reducing
Neonatal Sepsis. 
 USAID, MSH. Success Story: Arabic Version of “Managers Who Lead” Handbook for
Improving Health Services Now Available. 
 USAID, MSH. Improving the Performance of Nurses in Upper Egypt (IPN) Program,
Quarterly Progress Report: October 2011 – December 2011. January 10, 2011. 
 USAID, MSH. Improving the Performance of Nurses in Upper Egypt (IPN) Program,
Quarterly Progress Report: January 2012 – March 2012. April 12, 2012. 
 USAID, MSH. Improving the Performance of Nurses in Upper Egypt (IPN) Program,
Quarterly Progress Report: April 2012 – June 2012. July 10, 2012. 
 USAID, MSH. Improving the Performance of Nurses in Upper Egypt (IPN) Program,
Quarterly Progress Report: October 2012 – December 2012. January 10, 2013. 
 USAID, MSH. Improving the Performance of Nurses in Upper Egypt (IPN) Program,
Quarterly Progress Report: January 2013 – March 2013. April 10, 2013. 
 USAID, MSH. Improving the Performance of Nurses in Upper Egypt (IPN) Program,
Quarterly Progress Report: April 2013 – June 2013. July 10, 2013. 
 USAID, MSH. Improving the Performance of Nurses in Upper Egypt (IPN) Program,
Quarterly Progress Report: July 2013 – September 2013. October 10, 2013. 
 USAID, MSH. Improving the Performance of Nurses in Upper Egypt (IPN) Program,
Quarterly Progress Report: October 2013 – December 2013. January 10, 2014. 
 USAID, MSH. Improving the Performance of Nurses in Upper Egypt (IPN) Program,
Quarterly Progress Report: January 2014 – March 2014. April 10, 2014. 
 USAID, MSH. Improving the Performance of Nurses in Upper Egypt (IPN) Program,
Quarterly Progress Report: April 2014 – June 2014. July 10, 2014. 
 USAID, MSH, Ministry of Health. Leadership & Management Development Program
(LDP): LDP Team Results, 2010-2011. August 2012. 
 USAID, Om Habibeh Foundation, MSH. Improving the Performance of Hospital
Nurses in Upper Egypt Project, PY1 Q2 Quarterly Report, November 2009-March
2010. 
82
 USAID, Om Habibeh Foundation, MSH. Improving the Performance of Hospital
Nurses in Upper Egypt Project, PY1 Q3 Quarterly Report, April-June 2010. 
 USAID, Om Habibeh Foundation, MSH. Improving the Performance of Nurses in
Upper Egypt (IPN) Program, Quarterly Progress Report: July 2010 -September 2010.
October 9, 2010. 
 USAID, Om Habibeh Foundation, MSH. Improving the Performance of Nurses in
Upper Egypt (IPN) Program, Quarterly Progress Report: October 2010 -December
2010. January 10, 2011. 
 USAID, Om Habibeh Foundation, MSH. Improving the Performance of Nurses in
Upper Egypt (IPN) Program, Quarterly Progress Report: January 2011 - March
2011. April 10, 2011. 
 USAID, Om Habibeh Foundation, MSH. Improving the Performance of Nurses in
Upper Egypt (IPN) Program, Quarterly Progress Report: April 2011 - June 2011.
September 30, 2011. 
 USAID, Om Habibeh Foundation, MSH. Improving the Performance of Nurses in
Upper Egypt (IPN) Program, Quarterly Progress Report: July 2011 – September
2011. October 10, 2011. 
 “We are the Ones Who Makes Changes Happen.” Nurse in Al Sabaeyya Hospital in
Asewan. 
REFERENCES
 Aku Kwamie., Han Van Dijk., Irene Akua Agyepong. “Advancing the application of
systems thinking in Health: realist evaluation of the LDP Program for district
manager decision-making in Ghana”, BioMed Central June 2014 
 El Zanaty & Associates, The DHS Program ICF International, “Egypt Demographic
and Health Survey 2014 – Main Findings”. 
 Erna Tichlaar, Olga Riklikienne, Karen Hollan, “Empowering the Nursing Profession
through Mentorship”, Handbook 2: Guidance for Program Teach
UMMARY OF FINDINGS, CONCLUSIONS/LESSONS LEARNED, AND RECOMMENDATIONS
operating environment, to what extent did the IPN Program achieve its intended goals and results?
to improve nurses’ practices and services provided in hospitals and primary health care units in intervention governorates?
to empower nurses in intervention facilities? And how has this impacted their performance and their ability to address their
Conclusions and Lessons Learned Programmatic Recommendations
turmoil	and	civil	unrest,	the	IPN	 THE	IPN	Project	nearly	met	its	goals	and	objectives.	 Follow‐on	Activities	to	improve	health	
eved	 most	 of	 its		performance
mance	indicators	from	the	PMP	
Political	turbulence	and	civil	unrest	resulted	in	impaired
pace	and	scope	of	project	activities.	
worker	performance	should	have
impact‐level	performance	measures	as	
and	achieved	or	nearly	achieved	 well	as	outcome	(output)	measures.	
s.	 Two	indicators	 (#1	and	#5)	 Further,	organizational	and
institutional	performance	changes
should	be	measured	as	well	as
individual	changes.	 (Program
measurement)	
DP		improved		nurses’		problem	 Selection	criteria	for	participation	in	
e	pro‐active	deportment	among
rs	 (KIIs	 with	 nurses,	 NSs,	 and	
Completion	of	the	LDP	is	associated	with	success	in
changing	nurses’	motivation,	mindset,	and	practices	in
intervention	facilities.	The	evidence	points	to
improvements	in	infection	control	practices,	patient
communication	and	care,	communication,	and	problem‐
solving	among	teams/departments,	and	improved	ante‐
natal	care.	
leadership	(or	related)	training	should
be	standardized	and	consistent	with
project’s	development	theory	(i.e.	lead
to	sustained	changes	in	organization
and	performance).	(Program
consistency)	
chnical	sessions	led	by	MOHP	 LDP	resulted	in	improved	nurse	capacity	and	
and	promoted	proper	 performance,	but	the	small	number	trained	(at	any	one	
provide	care	according	to	 department	or	hospital)	and	the	steady	diminution	in	the	
Is	with	nurses,	NSs,	and	 number	of	trained	nurses	at	target	facilities	reduced	its	 The	evidence	points	to	improvements	
ardized	selection	criteria	for
varied	across	governorates	and
PHC	unit),	according	to	the	
ls	(KIIs	with	stakeholders).	
momentum	and	sustainability.	
LDP	activities	were	designed	and	implemented	with	little
to	no	synthesis	(or	alignment)	with	other	USAID	health
and	governance	activities.	The	IPN	did	not	succeed	in
arranging	complementary	or	reinforcing	activities	from
other	projects.	
in	infection	control	practices,	patient
communication	and	care,
communication	and	problem‐solving
among	teams/departments,	and
improved	ante‐natal	care.	
91
Finding 1.5 LDP	nurses	feel	empowered	to	influence	other	staff
members,	e.g.,	in	making	changes	to	enforce	patient’s	rights,	to
do	their	jobs	thoroughly	(Nurse	FGDs	and	KIIs	with	all	groups).
Participation	 in	 MSH’s	 leadership	 program	 empowered
nurses	to	be	pro‐active	in	decision	making,	learn	to	assess
and	 solve	 problems	 (address	 conflict)	 better,
communicate	vital	information	to	peers	and	supervisors,
set	 and	 measure	 performance,	 and	 share	 an	 improved
work	climate.	
Reinforce	leadership	through	making	it
a	cross‐cutting	component	of	all
training	programs,	including	technical,
quality	improvement,	management,
health	reform,	etc.	
Finding 1.6 Based	on	IPN’s	achievements,	the	project’s	theory	of
development	regarding	changes	in	nurses’	behavior	and
improved	health	services	was	at	least	partially	validated.
Nurse	supervisors	(NS)	play	a	critical	role	in	motivating
nurses	and	sustaining	LDP	gains.	
Finding 1.7 Nurses	and	supervisors	credit	LDP	with	changing
participants,	including	increased	awareness	and	adoption	of
MOHP	quality	standards	of	practice,	patient‐centered	care,	and
problem	solving	approaches.	
Agreement	 and	 shared	 commitment	 between	 Nurse
Supervisors	and	Nurses	on	LDP	is	crucial	to	momentum.
Thus,	 a	 lesson	learned	 is	 that	 ensuring	 the	involvement
and	 ongoing	 commitment	 of	 nurse	 supervisors	 at	 the
facility/department,	 ideally	 before	 training	 begins,	 is	 an
essential	 step	 to	 sustaining	 gains	 in	 leadership	 and
performance.	 This	 could	 be	 done	 by	 involving	 nurse
supervisors	in	pre‐training	activities	or	 training	 them	as
LDP	facilitators	 for	 follow‐up	activities,	as	was	done	in	a
number	of	instances	(but	not	all).	
Finding 1.8 Leadership	and	other	MOHP	programs/initiatives
share	many	common	features	with	Quality	Improvement,
Centers	of	Excellence,	and	other	ongoing	MOHP	initiatives.	
Other	human	resource	development	approaches,	such	as
“Sustained	 Organizational	 Performance,”	 continuous
quality	 improvement,	 mentorship	 and	 peer‐review	 for
nurses	merit	further	consideration	for	future	activities,	as
they	combine	human	resource	interventions	with	policy
and	system	change,	have	some	foothold	in	Egypt,	and	may
contribute	 to	 transformative	 and	 sustainable	 change.
(Examine	Alternatives	for	Effectiveness)	
Involve	local	NGOs	in	design	and
implementation	of	any	future	human
resource	development	projects	and	gain
from	their	experience	and	expertise.
(Local	Ownership	and	Effectiveness)	
Findings	 ‐	Aswan Conclusions and Lessons Learned Recommendations For MOHP
Finding 1.9 More	than	a	year	after	completing	the	LDP,	nurses
are	losing	acquired	skills,	and	this	underlies	their
recommendation	for	continuous	refresher	training.
As	the	initial	enthusiasm	and	the	number	of	LDP‐trained
staff	diminish	over	time,	the	“leadership	mindset”
becomes	less	widespread	throughout	the	facility.	A
lesson	learned	is	that	LDP	training	needs	to	cover	all	or
nearly	all	of	the	staff	in	a	department/facility	and	should
continue	indefinitely	to	achieve	and	maintain	“critical
mass”	for	sustaining	it.	
Further	integrate	leadership	training
inside	ongoing	or	planned	MOHP	in‐
service	education	(training)	programs,
or	through	creating	a	leadership	center
Finding 1.10 LDP	participants	maintain	strong	commitment	to within	the	MOHP.	
leadership	and	see	LDP	as	a	relevant	and	continuing	influence
on	their	outlook	and	work.	
92
Finding 1.11 Om	 Habibeh	 Foundation	 (Aga	 Khan	 Network)
played	a	key	role	in	providing	a	base	of	support	for	the	project	in
Aswan	 during	its	 start‐up	 phase,	maintains	 close	 relations	with
the	 MOHP,	 and	 continues	 to	 work	 closely	 with	 them	 on	 nurse
development	 in	 the	 governorate.	 As	 part	 of	 the	 Aga	 Khan
Network,	 OHF	 continues	 to	 work	 with	 nurse	 development,	 but
has	a	wider	scope	of	training	and	a	longer	time	horizon	than	MSH.	
NGOs	and	indigenous	organizations	could	innovate	and
reinforce	leadership	in	the	MOHP.	
Periodically,	but	at	least	annually,
conduct	anonymous	employee	work
climate	assessments	to	monitor
employee	morale	and	perceptions.	
Findings – Luxor Conclusions and Lessons Learned
Finding 1.12 Infection	control	challenges	initiated	by	LDP	were
successful	in	Luxor	and	had	lasting	impact	on	nurses’	awareness
of	 MOHP	 standards,	 their	 practice	 of	 IC	 procedures,	 and	 on
patient	services	(in	some	areas).	 USAID	and	 the	MOHP	could	 capitalize	on	current	MOHP
initiatives	 (or	 departments)	 to	 advance	 LDP	 principles
and	 practices.	 For	 example,	 greater	 integration	 with
quality	improvement	or	infection	control	(as	in	Luxor)	at
MOHP	 would	 bolster	 the	 sustainability	 of	 leadership	 as
practiced	in	LDP.	
Finding 1.13 Continuation	of	promising	IC	activities	in	Luxor	is
impeded	by	 the	lack	of	communication	and	agreement	between
the	IC	department	and	the	MOHP	leadership	in	the	Governorate.	
Finding 1.14 Among	 the	physician	directors	of	Luxor	hospitals,
knowledge	and	support	of	LDP	is	weak,	and	most	are	not	familiar
with	the	content	and	objectives	of	the	leadership	program.	
Findings	‐	Qena Conclusions and Lessons Learned Recommendations ForUSAID
Finding 1.15 The	LDP	program	in	Qena	started	and	stopped
again,	impeding	the	pace	and	scale	of	operations.	
The	inadequate	number	of	nurses	and	nurse	supervisors
trained	and	the	lack	of	joint	MSH/MOHP	follow‐up	(due
to	withdrawal	of	MOHP	support)	prevented	the	IPN	from
achieving	all	of	its	performance	goals.	 Engage	with	MOHP	officials	at	the
Governorate	level	frequently	(e.g.,
quarterly)	to	monitor	activities	and	to
maintain	support	for	USAID	activities;
especially	when	key	changes	occur.	
Finding 1.16 Despite	the	lack	of	MOHP	support	for	IPN
activities	during	much	of	the	project	and	the	minimal	follow‐up
of	the	LDP	workshops	in	Qena,	the	experiences	gained	by	nurses
were	positive	and	created	demand	for	further	leadership	and
“on	the	job”	training.	
Multiple	iterations	(three	major	revisions)	of	LDP	show
flexibility	and	commendable	resolve	by	MSH	(and	USAID)	
to	accommodate	the	turbulent	situation	in	Egypt.	
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Question 2. To what extent are project interventionssustainable at the level of nurses and at the level of the institutions?
Findings	 Conclusions and Lessons	Learned Recommendations
Finding 2.1 There	 is	 no	 MOHP	 department	 or	 senior‐level	 officer	 with
official	authorization	or	recognition	of	responsibility	for	leadership	training
at	any	level:	national,	governorate,	or	district.	
To	sustain	leadership	within	a	large	organization
such	as	the	MOHP,	the	intervention	needs	to	find	a
“home”	 with	 strong	 advocacy.	 At	 the	 facility,
district	 and	 governorate	 level,	 training	 of
physicians	 and	 administrators	 in	 positions	 of
authority	could	strengthen	leadership	and	amplify
the	 benefits	 of	 nurse	 training.	 To	 sustain	 LDP	in
the	MOHP	 generally,	more	 advocates	 are	 needed
(for	 a	 critical	 mass)	 at	 all	 levels	 of	 the	 MOHP.
Future	 projects	 should	 include	 (or	 ensure	 from
another	 partner)	 a	 component	 of	 leadership
training	 for	 physicians	 and	 administrators	 in
management	roles	as	well	as	for	nurses.	
Initiatives	such	as	leadership
training	should	promote	linkages
and	harmonize	efforts	with	other
established	Egyptian	programs,
such	as	(MOHP)	Quality	
Improvement,	Centers	of	Excellence,
etc.	 (Effectiveness;	Sustainability).	
Finding 2.2 Some	senior	MOHP	officials	in	the	governorates	(Aswan,	Qena)
are	generally	not	familiar	with	LDP	and	have	not	yet	made	a	“home”	for	LDP
within	 any	 department	 or	 ongoing/planned	 MOHP	 initiative	 (e.g.,	 Quality
Improvement,	Centers	of	Excellence,	Five‐year	Strategic	Plan).	
New	 or	 extended	 	 leadership	 programs	 need	 to
involve	 enough	 of	 the	 workforce	 (over	 time)	 to
reach	a	critical	mass,	whether	at	PHC,	hospital	or
governorate	 levels	 –	 or	 by	 health	 cadre,	 e.g.,
physicians	as	well	as	nurses,	to	affect	widespread
systemic	change.	(Impact	and	Effectiveness)	
Consider	providing	technical
support	to	the	nurses’	syndicate	to
promote	leadership,	professional
growth	and	improved	performance
of	nursing	through	training,
mentorship,	license	and
accreditation	programs.	(Reinforce
and	Broaden	Support	for	USAID
Objectives)	
Finding 2.3 The	critical	mass	of	trained	nurses	required	to	sustain	change
and	produce	transformation	or	systemic	change	within	MOHP	health
services	was	not	achieved	and	maintained.	
The	declining	influence	of	LDP	over
time	suggests	the	scale	and	duration
of	any	future	program	be	revised	to
simultaneously	address	reinforcing
changes	in	policy	and	operational
systems	(per	Figure	2)	in	order	to
enhance	the	likelihood	of	systemic,
sustainable	change.	(Impact	and
Sustainability)	
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Finding 2.4 The	head	of	the	Nursing	Syndicate	expressed	an	interest	in
furthering	leadership	through	developing	programs	it	could	offer	to	its
members	and	sustain	over	time.	
A	number	of	approaches	to	follow‐up	and	refresh
leadership	development	have	been	tested	and
reported	on	in	the	literature.	 The	lesson	learned
is	that	this	crucial	function	needs	further
development	and	fine‐testing	in	Egypt,	and	within
the	MOHP	
New	leadership	programs	need	to
provide	for	more	frequent
(monthly)	and	effective	follow	up	to
sustain	the	momentum	for
improvement.	(Sustainability)	
Finding 2.5 The	Om	Habibeh	Foundation	(OHF)	continues	to	work	closely
with	the	MOHP	on	nurse	development	in	the	governorate.	 Future	activities
to	strengthen	human	resources	in	health	would	benefit	from	an	in‐depth
analysis	of	the	OHF	approach	and	its	results.	
Finding 2.6 The	LDP	as	implemented	under	the	IPN	project	shares	some
common	features	with	other	ongoing	and	planned	MOHP
programs/initiatives.	 In	the	competition	for	future	MOHP	support,	LDP
has	not	competed	successfully	to	either	replace	or	influence	the	MOHP’s
Quality	Improvement	Directorate,	or	the	proposed	Centers	of	Excellence,
and	other	ongoing	MOHP	initiatives	
Finding 2.7 The	LDP	as	implemented	under	the	IPN	project	shares	some
common	features	with	other	ongoing	and	planned	MOHP
programs/initiatives.	 In	the	competition	for	future	MOHP	support,	LDP
has	not	competed	successfully	to	either	replace	or	influence	the	MOHP’s
Quality	Improvement	Directorate,	or	the	proposed	Centers	of	Excellence,
and	other	ongoing	MOHP	initiatives	
Findings	‐	Gender	 Conclusions and Lessons	Learned Recommendations
Finding 3.1 Extensive	investigation	with	nurses	in	the	three	UE
governorates	reveals	a	prevailing	opinion	that	nurse	supervisors	and
facility	directors	are	managing	male	and	female	nurses	adequately	in	terms
of	balancing	community	with	individual	employee	expectations,	but	female
nurses	will	remain	professionally	and	economically	disadvantaged	under
these	conditions.	
1.	Gender	issues	are	evolving	rapidly	as	more
male	nurses	enter	the	profession.	
Future	programs	to	develop	human
resources	should	include	a	gender
component,	increasing	awareness	of
gender	in	the	workplace	and	as	a
health	services	issue. 
2.	The	LDP	training	did	not	specifically	and
adequately	address	gender	issues	in	the
workplace	and	provide	gender	training	as	part	of
its	formal	training	sessions	and	follow‐up
activities.	
Finding 4.0 As	a	basic	measure	of	cost	–effectiveness,	the	project	expended
a	total	of	$5,129.66	per	direct	beneficiary	(LDP	participants	and	facilitators
trained).	In	the	absence	of	a	basis	for	comparison,	the	team	did	not	reach	a
conclusion	on	the	appropriateness	of	these	costs.	 As	noted	in	other	findings,
however,	greater	involvement	and	use	of	indigenous	organizations	have	the
potential	to	reduce	the	average	cost	per	beneficiary.	
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