Assessing Training 
Approaches and a Supportive 
Intervention for Managing 
Febrile Illness in Tanzania
Tibu Homa Performance 
Evaluation Report 
May 2017 TR-17-157
Emily Weaver, Team Leader
Milissa Markiewicz, Gideon Kwesigabo, and Joe Lugalla
EVALUATION

Assessing Training 
Approaches and a 
Supportive Intervention 
for Managing Febrile Illness 
in Tanzania
Tibu Homa Performance 
Evaluation Report 
MEASURE Evaluation 
University of North Carolina at Chapel Hill
400 Meadowmont Village Circle, 3rd Floor
Chapel Hill, NC 27517 USA
Phone: +1 919-445-9350
measure@unc.edu
www.measureevaluation.org
This publication was produced with the support of the United States Agency 
for International Development (USAID) under the terms of MEASURE 
Evaluation cooperative agreement AID-OAA-L-14-00004. MEASURE 
Evaluation is implemented by the Carolina Population Center, University of 
North Carolina at Chapel Hill in partnership with ICF International; John 
Snow, Inc.; Management Sciences for Health; Palladium; and Tulane 
University. Views expressed are not necessarily those of USAID or the United 
States government. This report was prepared independently by Emily 
Weaver, MEASURE Evaluation (team leader); Milissa Markiewicz, 
MEASURE Evaluation; and Gideon Kwesigabo and Joe Lugalla, both of 
Health and Development International Consultants. TR-17-157 
ISBN: 978-1-9433-6445-9
Emily Weaver, PhD, MEASURE Evaluation (Team Leader)
Milissa Markiewicz, MPH, MEASURE Evaluation
Gideon Kwesigabo, PhD, Health and Development International Consultants
Joe Lugalla, PhD, Health and Development International Consultants
EVALUATION
May 2017

Tibu Homa Project Performance Evaluation Report i
ABSTRACT
The United States Agency for International Development (USAID)/Tanzania established the Tibu Homa 
project to (1) increase availability and accessibility of fundamental facility-based curative and preventive 
child health services; (2) ensure sustainability of critical child health activities; and (3) increase linkages 
with the community to promote healthy behaviors and increase knowledge and use of child health 
services. Tibu Homa’s components were training for healthcare workers on integrated management of 
childhood illnesses (IMCI), quality improvement, supply chain management, and supportive supervision 
and mentorship. MEASURE Evaluation was asked to conduct a performance evaluation to estimate the 
association between (1) the training modalities and (2) supportive components implemented by the Tibu 
Homa project with quality of care (QOC). The evaluation used a retrospective, mixed-methods approach 
drawing from a cross-sectional quantitative health facility survey, qualitative and costing data collection, 
secondary time series data, and project document review. The IMCI score was the primary outcome of 
the study. Evaluation results indicate the training modality was not associated with different levels of 
QOC as measured by the IMCI score. The QOC on this measure improved significantly over the course 
of the project regardless of training modality, but dropped by the time of follow-up. One year after the 
project ended, Tibu Homa facilities had higher QOC for all cases measured by the IMCI score, and 
higher rates of correct classification and treatment for pneumonia cases than did a group of comparison 
facilities. Both Tibu Homa and comparison facilities performed well on accurate classification and 
treatment of malaria cases.
ii Tibu Homa Project Performance Evaluation Report
ACKNOWLEDGMENTS
MEASURE Evaluation thanks the United States Agency for International Development (USAID) for 
supporting this evaluation.
We also thank the following people for their support: Raz Stevenson, George Greer, Jema Bisimba, Todd 
Koppenhaver, and Moses Busiga, of USAID/Tanzania; Sigsbert Mkude, of the National Malaria Control 
Program; and Georgina Msemo, Mary Azayo, and Felix Bundala, of the Ministry of Health, Community 
Development, Gender, Elderly, and Children. We appreciate the contributions of Mwiru Sima and Daniel 
Michael, of Population Services International.
We are especially indebted to the data collection team of the Health and Development International 
Consultants for their hard work and dedication. 
Finally, our sincere thanks to the gracious people of Tanzania who participated in clinical observations, 
key informant interviews, and focus group discussions.
Cover photo: A mother and infant in Tanzania waiting to see their health provider for a well child visit.
© 2009 Virginia Lamprecht, courtesy of Photoshare
Tibu Homa Project Performance Evaluation Report iii
CONTENTS
FIGURES...................................................................................................................................................................... v
TABLES ........................................................................................................................................................................ v
EXECUTIVE SUMMARY........................................................................................................................................ 2
Supportive Supervision and Mentorship............................................................................................................. 5
Training..................................................................................................................................................................... 5
Structural Factors.................................................................................................................................................... 5
INTRODUCTION..................................................................................................................................................... 6
IMCI in Tanzania.................................................................................................................................................... 7
The Tibu Homa Project......................................................................................................................................... 8
Evaluation of Tibu Homa’s Supportive Components and Training Modalities........................................... 9
METHODS ................................................................................................................................................................ 11
Health Facility Survey...........................................................................................................................................12
Secondary Analysis Using Tibu Homa Performance Monitoring Data .......................................................13
Cost Study ..............................................................................................................................................................14
Qualitative Study: Stakeholders’ Experience of Tibu Homa .........................................................................16
Qualitative Case Study: Community Mobilization...........................................................................................16
Limitations..............................................................................................................................................................17
Challenges Encountered during Data Collection.............................................................................................17
IRB Clearance and Informed Consent..............................................................................................................17
QUALITY-OF-CARE RESULTS.......................................................................................................................... 18
The Value-Added of the Tibu Homa Project...................................................................................................18
Changes in Quality of Care during Tibu Homa ...............................................................................................29
Supply Chain Management..................................................................................................................................32
Pediatric Quality Improvement Teams .............................................................................................................33
The Marginal Cost of Implementing the Tibu Homa Supportive Components........................................35
PROJECT IMPLEMENTATION RESULTS..................................................................................................... 37
Time and Financial Cost of Training.................................................................................................................37
Adherence to the IMCI Protocol .......................................................................................................................37
Community Health Promotion...........................................................................................................................40
DISCUSSION............................................................................................................................................................ 46
Quality of Care ......................................................................................................................................................46
Supportive Supervision and Mentorship...........................................................................................................47
Supply Chain Management..................................................................................................................................48
Community Health Promotion...........................................................................................................................48
Other Findings.......................................................................................................................................................48
Limitations..............................................................................................................................................................48
iv Tibu Homa Project Performance Evaluation Report
Summary.................................................................................................................................................................49
CONCLUSIONS AND RECOMMENDATIONS ........................................................................................... 50
REFERENCES.......................................................................................................................................................... 52
APPENDIX 1. STATEMENT OF WORK......................................................................................................... 55
APPENDIX 2. DISCLOSURE OF ANY CONFLICTS OF INTEREST.................................................... 64
APPENDIX 3. EVALUATION METHODS AND LIMITATIONS........................................................... 66
APPENDIX 4. SOURCES OF INFORMATION............................................................................................. 68
APPENDIX 5. ADDITIONAL TABLES ........................................................................................................... 69
APPENDIX 6. LIST OF INDICATORS BY SOURCE................................................................................... 71
APPENDIX 7. COMPARISON OF TWO HEALTH FACILITY SURVEYS IN KIGOMA AND 
KAGERA, TANZANIA, 2012–2015.................................................................................................................... 72
APPENDIX 8. INSTRUMENTS .......................................................................................................................... 75
Quantitative Instruments.....................................................................................................................................76
Cost Study Instruments........................................................................................................................................90
Qualitative Instruments........................................................................................................................................95
Tibu Homa Project Performance Evaluation Report v
FIGURES 
Figure 1. Tibu Homa logic model ............................................................................................................................. 3
Figure 2. The IMCI model.......................................................................................................................................... 6
Figure 3. Tibu Homa logic model ............................................................................................................................. 9
Figure 4. Average IMCI scores for HCWs with and without dIMCI (Panel A) and for HCWs 
with and without any IMCI/dIMCI training (Panel B) in intervention and comparison facilities, 
April–May 2016.......................................................................................................................................................... 21
Figure 5. IMCI score over time in Phase 1 and Phase 2 facilities from start of the project.......................... 31
Figure 6. Percentage of facilities stocked with 10+ tracer first line medicines and supplies at the time 
of visit (quarterly) by project phase, April 2012–June 2016................................................................................ 33
Figure 7. Percentage of facilities collecting and using data to improve febrile illness .................................... 34
Figure 8. Quarterly trends in PQIT performance, SCM, and IMCI assessments during Tibu Homa, 
April 2012–April 2015............................................................................................................................................... 35
Figure 9. Community referral system for children with fever............................................................................. 43
Figure 10. Tibu Homa quality improvement approach to community mobilization...................................... 44
TABLES
Table 1. Summary of IMCI scores (QOC) from Tibu Homa Phase 1 and Phase 2 performance 
monitoring data and HFS intervention and comparison facilities....................................................................... 4
Table 2. Assessment tasks by healthcare workers in 2006 and 2014–2015, Tanzania Service 
Provision Assessment.................................................................................................................................................. 7
Table 3. Health facility survey training dates and sampling results by study group ........................................ 13
Table 4. Sampling results by region from Tibu Homa performance monitoring data ................................... 14
Table 5. Key inputs used to estimate the cost per child treated compliantly with Tibu Homa’s 
supportive components ............................................................................................................................................ 16
Table 6. Observed HCW and facility characteristics in facilities participating in the HFS by 
comparison and intervention groups...................................................................................................................... 19
Table 7. Case observation characteristics from comparison and intervention facilities................................. 20
Table 8. Breakdown of IMCI score in comparison and intervention facilities................................................ 22
Table 9. Quality of care summary for malaria and pneumonia cases ................................................................ 23
Table 10. Summary of incorrectly classified pneumonia cases........................................................................... 23
Table 11. Comparison of SPA and Evaluation HFS IMCI assessment results, 2006 SPA, 
2014–15 SPA, and 2015 HFS ................................................................................................................................. 24
Table 12. Factors associated with appropriate assessment (IMCI score) controlling for HCW, 
patient, and facility characteristics........................................................................................................................... 26
Table 13. Inventory of equipment and supplies in comparison and intervention facilities........................... 27
Table 14. Inventory and tracking of medications in comparison and intervention facilities......................... 28
Table 15. Case review, diagnosis, and facility characteristics at baseline, and 6-month follow-up 
SS&M visits in Phase 1 and Phase 2 Tibu Homa facilities.................................................................................. 29
vi Tibu Homa Project Performance Evaluation Report
Table 16. Performance indicators at baseline and six months of SS&M in Phase 1 and Phase 2 
Tibu Homa facilities .................................................................................................................................................. 30
Table 17. Factors associated with IMCI score over time in Tibu Homa facilities .......................................... 32
Table 18. Cost study summary................................................................................................................................. 36
Table 19. Tibu Homa community mobilization actors and roles ...................................................................... 41
Table 20. Reasons providers were unable to refer a severely ill child by group, 2015 HFS .......................... 45
Table 21. Tibu Homa evaluation research objectives, methods, key research questions/themes, 
and responsible organization.................................................................................................................................... 66
Table 22. Summary of WHO HFS Indicators ...................................................................................................... 69
Table 23. IMCI scores by HCW type ..................................................................................................................... 69
Table 24. Provider, patient, and facility characteristics for malaria and pneumonia diagnoses .................... 70
Table 25. Comparison of 2012 and 2015 HFS survey data from dispensaries in two districts in Kagera...73
Table 26. Comparison of 2012 and 2015 HFS survey data from Kagera and Kigoma Regions................... 74
Table 27. Summary of research questions, sources of information, and evaluation tools.............................75
Tibu Homa Project Performance Evaluation Report 1
ABBREVIATIONS
CHIF Community Health Insurance Fund
CHMT council health management team
CHW community health worker
CQIT community quality improvement team
CSG community social group
dIMCI distance integrated management of childhood illnesses
DMO district medical officer
FGD
GOT
focus group discussion
government of Tanzania
HCW healthcare worker
HDIC Health and Development International Consultants
HFS Health Facility Survey(s)
IMCI
IRB
integrated management of childhood illnesses
internal review board
KI/SGI key informant or small-group interview
MoHCDGE&C Ministry of Health, Community Development, Gender, Elderly & Children
MOHSW Ministry of Health and Social Welfare
mRDT malaria rapid diagnostic test
PQIT pediatric quality improvement team
PSI Population Services International
ORS oral rehydration solution
OVC orphans and vulnerable children
QI quality improvement
QOC quality of care
R/CHMT regional/council health management team
SCM supply chain management
SS&M supportive supervision and mentoring
TOT training of trainers
TZ Tanzania
U5 under five years of age
UNICEF United Nations Children’s Fund
USAID U.S. Agency for International Development
VEO village executive officer
WHO World Health Organization
2 Tibu Homa Project Performance Evaluation Report
EXECUTIVE SUMMARY
Integrated management of childhood illnesses (IMCI) is an approach to case management that includes a 
detailed algorithm for how to assess a child, classify the child’s illness, determine if referral is necessary, 
treat the child, counsel the mother, and provide follow-up care (World Health Organization [WHO], 
2014). Developed by WHO and the United Nations Children’s Fund (UNICEF), IMCI was introduced in 
Tanzania in 1996. While under-five (U5) mortality in Tanzania has declined over the past two decades, 
socioeconomic disparities in child mortality persist and are especially prominent in rural areas. The Lake 
Zone of Tanzania, which surrounds Lake Victoria, has the highest U5 mortality rate in the country. The 
chief causes of postneonatal deaths in children 1–59 months in Tanzania are estimated to be pneumonia 
(22%) and malaria (16%) (Liu, et al., 2015). Because severe febrile illness is a key symptom both of 
malaria and pneumonia, accurate diagnosis and treatment of severe febrile illness is critical to efforts to
reduce U5 mortality.
To reduce U5 morbidity and mortality owing to diseases that cause severe febrile illness, the United States
Agency for International Development (USAID) Tanzania established the Tibu Homa project (Swahili 
for “Treat Fever”) in the Lake Zone through a cooperative agreement with University Research Co., 
LLC. The goals of the project were these: (1) increase availability and accessibility of fundamental facility￾based curative and preventive child health services; (2) ensure sustainability of critical child health 
activities; and (3) increase linkages with the community to promote healthy behaviors and increase 
knowledge and use of child health services. Tibu Homa was implemented from March 2011–September 
2015. 
Tibu Homa worked with health facilities to train healthcare workers (HCWs) in IMCI. During Phase 1 of 
Tibu Homa (2011–2012), HCWs were trained on IMCI through an abbreviated three-day, in-person 
training focused on febrile illness. This was a modified version of the standard 11-day in-person IMCI 
training. Beginning in 2013 (Phase 2 of Tibu Homa), distance integrated management of childhood 
illnesses (dIMCI) replaced the in-person training as required by guidelines at that time of Tanzania’s 
Ministry of Health and Social Welfare (MOHSW)— now the Ministry of Community Development, 
Gender, Elderly, and Children (MoHCDGE&C]). 
The following additional components supported Tibu Homa’s approach:
• Quality improvement (QI): Tibu Homa provided training to HCWs on QI methods and facilitated 
the formation of pediatric quality improvement teams (PQITs) at participating health facilities.
The PQITs focused on identifying and addressing facility-level gaps in services for children.
• Supply chain management (SCM): Tibu Homa provided additional training to HCWs on SCM to 
improve inventory management and ordering of essential medicines and supplies for children.
• Tibu Homa trained members of council health management teams (CHMTs) on supportive 
supervisions and mentoring (SS&M) methods and helped CHMTs provide monthly SS&M to 
HCWs. The CHMTs are comprised of senior district health administrators who support the 
district medical officer (DMO) in the management and coordination of local health services. 
Supportive supervision and mentoring efforts had the following goals:
o Improve HCWs’ case management skills and adherence to the IMCI algorithm
o Monitor and facilitate the work of PQITs as they implemented facility-level 
improvements 
Tibu Homa Project Performance Evaluation Report 3
o Improve HCWs’ supply-chain management skills to increase the availability of essential 
medicines and equipment, such as malaria rapid diagnostic tests (mRDTs), antibiotics, 
and antimalarials
The QI interventions, HCW training on SCM, and the accompanying SS&M provided to healthcare 
workers by CHMT members are referred to as Tibu Homa’s “supportive components.” Figure 1
illustrates the Tibu Homa logic model; the shaded boxes highlight the supportive components.
Figure 1. Tibu Homa logic model
USAID/Tanzania asked the USAID-funded MEASURE Evaluation to conduct a performance evaluation 
of the association between (1) the training modalities and (2) supportive components implemented by 
Tibu Homa, with quality of care (QOC). The results are intended to inform the selection of future 
supportive interventions that may be implemented by USAID/Tanzania or the government of Tanzania
(GOT) in conjunction with dIMCI training to enhance HCW compliance with the IMCI algorithm. The 
broad objectives of the evaluation were to estimate the added value of Tibu Homa’s supportive 
components.
The evaluation uses a retrospective, mixed-methods approach. Data sources are a cross-sectional 
quantitative health facility survey, qualitative and costing data collection, secondary time series data, and 
project document review. Primary outcomes are measures of QOC, which are defined by the WHO
Health Facility Survey (HFS) and include the Index of Integrated Assessment (called the “IMCI score”);
correct classification; and correct treatment of cases observed or reviewed in patient records.
The IMCI score was the primary outcome of the study. It is a count index, between 0–10, of the number 
of assessment steps completed as required by IMCI guidelines. These steps are (1-3) checking for three 
danger signs; (4) checking for cough; (5) checking for fever; (6) asking about diarrhea; (7) weighing the 
child; (8) checking the weight against a growth chart; (9) reviewing vaccination status; and (10) checking 
palmar pallor. Results indicate the following (see also Table 1):
• Training modality (three-day, in-person IMCI versus dIMCI) was not associated with different 
levels of QOC as measured by the IMCI score. The QOC on this measure improved significantly 
over the course of the project regardless of training modality (by 77.4% in Phase 1 facilities and by 
4 Tibu Homa Project Performance Evaluation Report
84.6% in Phase 2 facilities), but had dropped by the time of follow-up during the evaluation’s
HFS. 
• Tibu Homa facilities had higher QOC for all cases measured by the IMCI score, and higher rates 
of correct classification and treatment for pneumonia cases than did comparison group facilities.
This result is amplified by the fact that Tibu Homa facilities had a vastly smaller proportion of 
trained HCWs than did comparison facilities.
• Both Tibu Homa and comparison facilities performed well on accurate classification and 
treatment of malaria cases. 
Table 1. Summary of IMCI scores (QOC) from Tibu Homa Phase 1 and Phase 2 performance monitoring 
data and HFS intervention and comparison facilities
Project/phase 
baseline
Project/phase
endline Follow-up HFS
Tibu Homa Phase 1: 3-day IMCI
 Overall
 Malaria 
 Pneumonia
5.3
5.4
5.3
8.9
9.2
9.4
--
Tibu Homa Phase 2: dIMCI
 Overall
 Malaria 
 Pneumonia
5.5
6.1
5.2
8.2
8.4
9.6
6.3
6.8
6.5
Comparison: dIMCI
 Overall
 Malaria 
 Pneumonia 
-- --
5.5
5.7
5.6
Data source (method) Performance data 
(chart review)
Performance data 
(chart review)
HFS 
(patient-provider 
observations)
Related findings indicated that:
• SS&M, as part of the Tibu Homa package, was well received by facility staff; however, SS&M was 
not continued with the same intensity after the project ended.
• Availability of tracer medications and supplies improved greatly during Tibu Homa; however,
measures of supply chain management between intervention and comparison facilities were 
generally similar, as measured at the time of the HFS.
• Health facility staff viewed PQITs favorably as a means to improve QOC in their facilities and to 
provide staff motivation based on data collected by the team.
• Many structural factors in the health system need additional support to fully leverage investments 
in IMCI training.
• The community mobilization approach was successful in disseminating salient messages about the 
importance of early care-seeking for fever.
The cost analysis estimated that the cost of a supportive supervision visit was $271 and the cost of 
training and supervision per child assessed in full compliance with the IMCI algorithm (that is, IMCI 
Tibu Homa Project Performance Evaluation Report 5
score = 10/10) was $3.52–$8.21 per visit. These costs may be viewed as prohibitive in terms of sustaining 
this important practice. 
Recommendations to improve QOC and address structural barriers to improve service provision appear
below. These recommendations draw on evaluation results and stakeholder feedback.
Supportive Supervision and Mentorship
• Expand training for CHMT members to transform the standard supervision to include clinical 
mentorship, as in the Tibu Homa approach.
• Provide regular clinical mentorship in classification and management of pneumonia, with 
emphasis on steps to check for stridor/wheezing, and determine the respiratory rate. 
• In resource-constrained settings, one or more of the following may be considered to address cost 
concerns:
o Explore cost containment strategies for SS&M visits.
o Conduct pilot check-ins via cellular technology for SS&M, by CHMT members unable 
to make monthly in-person visits.
o Explore training options for district-level staff responsible for budgeting and scheduling 
transportation for SS&M visits.
o Explore other methods of creating accountability for healthcare workers and healthcare 
management, such as the use of performance-based incentives to promote good QOC 
and attention to detail.
Training
• Continue dIMCI training with high coverage density among HCWs who manage U5 children.
Structural Factors
• Continue to emphasize the importance of referral for severely ill children and determine structural 
barriers that may be mitigated.
• Expand community health promotion.
• Investigate low-cost innovations in diagnostics for pneumonia.
• Identify funding to ensure supply of essential oral treatments and equipment.
• Support projects with potential for sustainability.
• Require development and implementation of a sustainability plan prior to project’s end.
6 Tibu Homa Project Performance Evaluation Report
INTRODUCTION
Integrated management of childhood diseases is an approach to case management developed by WHO 
and UNICEF that includes a detailed algorithm to assess a child, classify the child’s illness, determine if 
referral is necessary, treat the child, counsel the child’s mother, and provide follow-up care (WHO, 2014).
The clinical guidelines employ a syndromic approach and are designed for use in outpatient clinical 
settings with limited diagnostic tools and medications (WHO, 2005). The IMCI approach also calls for
strengthening health systems and improving community care-seeking behaviors related to child health. 
Figure 2 depicts the IMCI model in practice (Bryce, Victora, Habicht, Vaughan, & Black, 2004).
The IMCI approach was introduced in Tanzania in 1996. While U5 mortality in Tanzania has declined 
over the past two decades, socioeconomic disparities in child mortality persist and are especially 
prominent in rural areas. The Lake Zone of Tanzania, which surrounds Lake Victoria, has the highest U5
mortality rate in the country. The chief causes of postneonatal deaths in children 1–59 months in 
Tanzania are estimated to be pneumonia (22%) and malaria (16%) (Liu, et al., 2015). Because severe 
febrile illness is a key symptom both of malaria and pneumonia, accurate diagnosis and treatment of 
severe febrile illness is critical to efforts to reduce U5 mortality.
Figure 2. The IMCI model
Source: Bryce, Victora, Habicht, Vaughan, & Black (2004)
Tibu Homa Project Performance Evaluation Report 7
IMCI in Tanzania
The IMCI approach was originally introduced in Tanzania through an 11-day, in-person, in-service 
training curriculum in 1996. After its implementation, a 2004 study of IMCI in rural Tanzania found that 
child mortality was 13 percent lower in IMCI-trained facilities than in facilities in selected comparison 
districts (Armstrong, Schellenberg, 2004). A multi-country evaluation of IMCI found Tanzania to be the 
only country to have successfully implemented IMCI at scale (Bryce, Victora, Habicht, Black, & 
Scherpbier, 2005). However, these gains were not sustained, and a later assessment of IMCI in Tanzania 
found that while 86 percent of districts had carried out at least one IMCI training, national coverage was 
estimated at only 14 percent of HCWs—well below the 60 percent recommended by WHO (Prosper, 
Macha, & Borghi, 2009). The assessment attributed the low coverage in part to the high cost of in-person 
training coupled with a reduction in global aid funds for IMCI training. The assessment further 
determined that there was poor adherence to the IMCI algorithm owing to HCWs’ time constraints, poor 
follow-up supervision, frequent rotation of staff, lack of IMCI-related drugs and job aids, and poor layout 
of facilities.
Despite significant efforts, quality of care did not improve much following the training. Results from the 
2006 and 2014–2015 Service Provision Assessment Surveys in Tanzania indicate that a minority of 
healthcare workers performed the most basic tasks related to assessment using the IMCI guidelines of 
sick children (see Table 2).
Table 2. Assessment tasks completed by healthcare workers in 2006 and 2014–2015, Tanzania Service 
Provision Assessment
2006 SPA 2014–2015 
SPA
All children
 Child checked for three danger signs 11% 8%
 Child checked for the presence of diarrhea, cough, and fever 46% 46%
 Number of observations 2,272 4,961
Malaria-specific
 Child checked for three danger signs† 14% 9%
 Child checked for the presence of diarrhea, cough, and fever 53% 49%
 Number of observations 1,434 1,641
Pneumonia-specific
 Child checked for three danger signs 14% 13%
 Child checked for the presence of diarrhea, cough, and fever 46% 53%
 Number of observations 442 575
†The three danger signs are cough/difficulty breathing, diarrhea, and fever.
In order to reduce training costs and improve coverage of training for HCWs, the MOHSW rolled out
the dIMCI training modality in 2014, after the curriculum had been piloted in South Africa (2010) and 
Tanzania (2011). The dIMCI training involved a one-day, in-person orientation followed by three to four
weeks of self-study; a second one-day, in-person review meeting followed by six to eight weeks of 
additional self-study; and a final one-day, in-person synthesis meeting (WHO, 2014). One additional in￾service facility follow-up supervision visit was also prescribed for HCWs four to six weeks after 
completing the dIMCI training.
8 Tibu Homa Project Performance Evaluation Report
The Tibu Homa Project
Tibu Homa was a cooperative agreement between USAID and University Research Co., LLC to reduce 
U5 morbidity and mortality owing to severe febrile illness in the Lake Zone of Tanzania (Kagera, 
Mwanza, Mara, Geita, Shinyanga, and Simiyu regions). The project was funded from March 1, 2011–
September 30, 2015 for $23,988,103 (Award #621-A-00-11-00011-00). The Tibu Homa project (Swahili 
for “Treat Fever”) aimed to accomplish the following goals: (1) increase the availability and accessibility 
of fundamental facility-based curative and preventive child health services; (2) ensure the sustainability of 
critical child health activities; and (3) increase linkages with the community to promote healthful
behaviors and increase knowledge and use of child health services. Tibu Homa was implemented from 
March 2011–September 2015n collaboration with the MOHSW, primarily through regional and council 
health management teams (R/CHMTs). A central component of Tibu Homa was training HCWs from
selected health facilities in districts with relatively high malaria prevalence on IMCI. During Phase 1 of
Tibu Homa (2011–2012), HCWs were trained on IMCI through a three-day, in-person training focusing 
on febrile illness, which was a modified version of the standard 11-day, in-person IMCI training
mentioned above. Beginning in 2013 (Phase 2 of Tibu Homa), dIMCI replaced the in-person training.
The Supportive Components
In addition to the three-day, in-person IMCI and dIMCI training in Phase 1 and Phase 2 respectively, 
Tibu Homa worked with health facilities throughout the project to address factors associated with 
reduced adherence to the IMCI algorithm. Tibu Homa supported the following trainings to address 
specific needs:
• QI: Tibu Homa provided training to HCWs on QI methods and facilitated the formation of 
PQITs at participating health facilities. The PQITs focused on identifying and addressing facility￾level gaps in services for children, such as long waiting periods and a lack of triage systems for 
children.
• SCM: Tibu Homa provided additional training to HCWs on SCM to improve inventory 
management and ordering of essential medicines and supplies, in order to reduce stockouts of 
IMCI-related drugs and equipment.
• SS&M: To enhance mentoring of HCWs, Tibu Homa trained members of CHMTs on SS&M 
methods and facilitated CHMTs to provide monthly SS&M to HCWs. Monthly SS&M had the 
following goals:
o Improve case management skills and HCW adherence to the IMCI algorithm
o Monitor and facilitate the work of PQITs as they implemented facility-level 
improvements
o Improve SCM skills to increase availability of essential medicines and equipment, such 
as mRDTs, antibiotics, and antimalarials
The QI interventions, HCW training on SCM, and the accompanying SS&M provided to HCWs by 
CHMT members are referred to as the Tibu Homa’s “supportive components.” Figure 3 illustrates the 
Tibu Homa logic model; the shaded boxes highlight the supportive components.
Tibu Homa Project Performance Evaluation Report 9
Figure 3. Tibu Homa logic model
Community Mobilization Activities
In addition to the supportive components already described, Tibu Homa also implemented community 
mobilization activities in a small number of communities. For the purposes of this evaluation, the 
community mobilization activities are considered separate and distinct from the other supportive 
components. In both phases of Tibu Homa, community mobilization activities involved educating 
community members on the importance of taking children to a health facility within 24 hours of the 
onset of fever, and creating a community referral system to identify and track children with fever.
Evaluation of Tibu Homa’s Supportive Components and Training Modalities 
USAID/Tanzania asked the USAID-funded MEASURE Evaluation to assess the two training modalities 
used during Tibu Homa and to estimate the value added by the supportive components. This 
retrospective, mixed-methods evaluation is intended to inform future supportive interventions that may 
be implemented by USAID/Tanzania in conjunction with dIMCI training. The evaluation has seven
research questions (listed below) that are related to two main components: (1) estimating quality of care 
and (2) describing project implementation. 
Research Questions
Quality of Care
1. What is the value, i.e., marginal QOC, associated with dIMCI training and Tibu Homa’s supportive 
components versus the QOC provided in comparison facilities that received dIMCI training without 
the supportive components?
2. What factors are associated with improved QOC? Do these factors differ between Phase 1 (three-day 
IMCI plus supportive components) and Phase 2 (dIMCI plus supportive components) facilities?
3. What are the costs of the intervention components associated with improved QOC?
Inputs
CHMTs provide 
monthly SS&M to:
• HCWs to improve 
case management
• PQITs to make 
facility-level 
improvements
• HCWs to improve 
SCM
HCW receive 
dIMCI training
HCW training on 
QI and 
formation of 
PQITs
HCW training 
on SCM
Outcomes
Improved HCW 
clinical skills
Improved health 
facility systems
Increased 
availability of 
mRDTs & meds
Improved 
pediatric 
quality of 
care 
&
health 
outcomes
10 Tibu Homa Project Performance Evaluation Report
Project Implementation
4. What have been the facilities’ experiences implementing program activities?
5. What support did Tibu Homa provide to CHMTs? 
6. What program activities have been sustained?
7. What was Tibu Homa’s approach to community mobilization and how was the project successful (if 
it was) in creating referral networks for children with fever and for orphans and vulnerable children
(OVC)?
1
 
1 Research related to research question #7 was designed by MEASURE Evaluation but carried out by Population 
Services International (PSI).
Tibu Homa Project Performance Evaluation Report 11
METHODS
A mixed-methods approach was employed to draw on several sources of data to triangulate findings 
regarding the value added by Tibu Homa’s supportive components. Table 21, in Appendix A, illustrates 
the research questions and associated methods.
The evaluation included two quantitative components. The first component estimated the differential 
QOC provided in facilities that received dIMCI training with Tibu Homa’s supportive components (that 
is, intervention facilities) versus the QOC provided in facilities that received dIMCI training without the 
supportive components (that is, comparison facilities). Primary data collection via a cross-sectional HFS 
was implemented in both intervention and comparison facilities. Quality of care was measured using
three constructs: HCW assessment, classification, and treatment of U5 children with fever. A HCW 
assessment (called the “IMCI score”) was the primary measure for QOC; it was used to triangulate with
results from the second quantitative component, as described below.
The second quantitative component involved secondary data analysis of a subsample of Tibu Homa’s
performance monitoring data. This analysis aimed to compare and contrast changes in QOC over time in 
Phase 1 versus Phase 2 Tibu Homa facilities. The main distinction between these two phases was training 
modality: three-day, in-person IMCI training in Phase 1 versus dIMCI training in Phase 2. Thus, the main 
goal of the secondary analysis was to assess whether outcomes were related to type of training modality 
(three-day, in person IMCI versus dIMCI) on QOC. During the second phase, a predetermined set of QI 
interventions were suggested to facilities during the QI training. This “change package” is also thought to 
have quickened the pace of change in outcomes in those Phase 2 facilities. The supportive components 
were implemented similarly in both phases.
A cost analysis entailed primary data collection from CHMTs and local organizations on QI, SCM 
training, and SS&M costs in order to estimate the marginal cost of implementing the project’s supportive 
components. This was measured as the cost per U5 child receiving fully compliant care at Tibu Homa 
facilities. 
Two qualitative studies complemented the quantitative analyses. The first involved key informant or
small-group interviews (KI/SGIs) with CHMT members and HCWs at health facilities. This study took 
place in four districts where Tibu Homa was implemented, to gain an understanding of the Tibu Homa 
approach, in practice. The research questions related to this component were to describe health facilities’ 
experiences implementing Tibu Homa activities, understand how Tibu Homa worked with the CHMTs,
and describe how well Tibu Homa activities have been sustained.
The second qualitative component employed a case study method to describe the community engagement
activities carried out during Phase 2 of Tibu Homa. The Phase 2 community engagement component was 
considered to be more effective by the implementing partner than the approach employed in Phase 1. 
The Phase 2 approach included outreach to active community social groups, which enabled the project to 
reach many community members. The objectives of this component were to understand how the 
community mobilization component functioned and describe how and if it was successful in creating 
community referral networks for children with fever and OVC.
The data collection team consisted of seven trained clinicians, six qualitative researchers, and five 
supervisors. Health and Development International Consultants (HDIC) trained the team in 
collaboration with MEASURE Evaluation. Data collection occurred from April 19–May 27, 2016.
12 Tibu Homa Project Performance Evaluation Report
Health Facility Survey
Data Collection
The main mode of data collection was an HFS. The WHO HFS was adapted for the evaluation and 
consisted of (1) patient-provider observations of children ages 2–59 months; (2) gold standard 
reexaminations to record the case classification from an IMCI expert; and (3) an equipment-and-supply 
checklist to determine availability of essential medicines, equipment, and materials. The WHO HFS and 
guidebook can be accessed here: 
http://www.who.int/maternal_child_adolescent/documents/9241545860/en/ (WHO, 2003).
Sampling
An estimated 42 facilities and 126 patient-provider observations for each the intervention and 
comparison groups were needed to measure a difference of two to three steps in adherence in the IMCI 
score. This sample size estimate was determined using the WHO HFS sampling guidelines provided in 
the survey manual along with Tibu Homa project data. A minimum of three patient-provider 
observations per facility was assumed.
All Phase 2 districts from Tibu Homa were included in the HFS except those in the Mara region.2A 
sample of comparison districts and health facilities was selected from Kigoma and Tabora Regions. 
HCWs in these comparison districts had received dIMCI training from another GOT partner during the 
same two-year period as Tibu Homa implemented dIMCI training, but they were not part of the Tibu 
Homa intervention.
3 Four districts were purposively selected from a sample provided by the MOHSW
based on proximity to the Lake Zone, in order to maximize the comparability of study sites, the timing of 
dIMCI training, and the feasibility of reaching the sites during data collection, which occurred during the 
rainy season.
4
Facility eligibility required at least one currently employed HCW to have received dIMCI training, but any 
HCWs attending children on the day of the survey were observed. A total of 86 facilities were surveyed 
during data collection, resulting in 440 patient-provider observations. Table 3 provides dIMCI training 
dates and sampling results by region and group. The lag between training and the HFS was shorter for 
the comparison group than for the intervention group.
 
2 Facilities in the Mara region were excluded for logistical reasons and because no health centers from 
this region participated during Phase 2.
3 HCWs in comparison facilities did not receive any additional support aside from the dIMCI training 
and one prescribed follow-up visit. The sampling frame for the comparison group was determined in 
collaboration with the MOHSW.
4 Gender was not a factor related to purposive sampling of comparison districts.
Tibu Homa Project Performance Evaluation Report 13
Table 3. Health facility survey training dates and sampling results by study group
Sample characteristics Comparison Intervention
Regions Kigoma, Tabora Kagera, Shinyanga, Simiyu
dIMCI training dates April 2014–September 2015 February 2014–May 2015
Facility type Planned Actual Planned Actual
Health centers 7 7 16 15
Average number of cases observed 3 5.0 3 5.2
Dispensaries 35 36 26 28
Average number of cases observed 3 5.5 3 4.6
Total facilities surveyed 42 43 42 43
Total cases observed 126 232 126 208
Analysis
Descriptive and bivariate statistics were generated for (1) facility, HCW, and case review characteristics;
(2) select WHO HFS indicators, including the IMCI score—the primary measure of QOC; and (3) other 
measures of QOC. Multivariate models were then used to identify characteristics and indicators 
associated with QOC. District-level fixed effects controlled for unobserved variation at the district level. 
Standard errors were adjusted for facility-level clustering, and a threshold of p≤0.05 was used to assess 
statistical significance. For small sample sizes p≤0.10 is also indicated.
The IMCI score is the main QOC outcome of these analyses; it measures the number of assessment tasks 
the clinician completed during the observation. These include checking for the three danger signs (cough,
fever, and diarrhea); weighing the child and referencing a growth chart; checking for palmar pallor; and 
reviewing vaccination status. Other measures of QOC are whether or not the case was classified correctly 
and subsequently treated correctly.
Secondary Analysis Using Tibu Homa Performance Monitoring Data
The Tibu Homa Performance Monitoring Database
Tibu Homa’s performance monitoring database was used to generate information about HCW
performance during the project. The database captures IMCI case review data from monthly supportive 
supervision visits and facility-level indicators recorded by the project, either at monthly or quarterly
intervals. See Appendix B for a list of indicators. Monthly case review data were compiled by CHMT
members with the support of Tibu Homa staff. During monthly supervision, IMCI scores were recorded
using patient records for up to five outpatient visits for U5 children with fever, including age and 
diagnosis. No inpatient or outpatient case reviews for children ages 0–1 month were used in the
evaluation. Information for facility-level performance indicators was also extracted from and maintained 
in the performance monitoring database for the duration of the project.
Sampling
MEASURE Evaluation extracted performance monitoring data from a random sample of 15 percent of 
all project facilities in Phases 1 and 2 that had received four or more months of SS&M (n=57). A total of 
4,233 outpatient case reviews for children ages 2–59 months were extracted; 71.2 percent were from 
14 Tibu Homa Project Performance Evaluation Report
Phase 1 project facilities, and 28.8 percent were from Phase 2 project facilities. Table 4 provides a 
breakdown of case reviews by region. 
Table 4. Sampling results by region from Tibu Homa performance monitoring data
Region Number of districts 
sampled
Number of case 
reviews extracted Percentage
Kagera 6/8 1,418 33.5
Mara 4/6 823 19.4
Mwanza 7/8 1,199 28.3
Shinyanga 2/2 350 8.3
Simiyu 3/3 443 10.5
Total 22/27 4,233 100.0
Analysis
Descriptive and bivariate statistics were produced from the project monitoring data and used to compare 
results between project phases and over time. Generalized estimating equation modeling with facility-level 
clustering was used to assess the time trend of the IMCI score throughout the project. A threshold of 
p≤0.05 was used to assess statistical significance. For small samples, p≤0.10 is also noted.
The primary outcome of the analyses was the IMCI score, as recorded from patient chart reviews during 
SS&M visits. Full compliance with the index of integrated assessment is also reported, which is the 
proportion of cases that had an IMCI score of 10/10.
Cost Study
The cost study aimed to provide cost data that could be used to estimate the cost of implementing the 
supportive components conducted by Tibu Homa in the future. Specifically, we estimated the marginal 
cost of implementing the supportive components (in terms of the cost per U5 child receiving fully 
compliant care). The assumption is that these supportive components would be implemented in 
conjunction with dIMCI training (see Table 5).
Data and Methods
Since Tibu Homa ended prior to its evaluation, cost data were collected from former staff, other 
implementing partner staff, and local health officials (during qualitative interviews with a former Tibu 
Homa trainer, HDIC staff, MEASURE Evaluation Tanzania associate award staff, and CHMT 
members). An interview guide was developed to estimate the basic costs elements (see Appendix E), and 
cost information was gathered on the supportive components. Interviews were conducted by MEASURE 
Evaluation in April–May, 2016 in Mwanza and Dar es Salaam. The average number of children seen per 
facility each month was obtained from MEASURE Evaluation’s HFS estimates. Noncost data were
extracted from the Tibu Homa final report and project training reports that included the percentage of 
U5 children with fever estimated to receive fully compliant care, the average number of people trained,
and trainers required per training session (Table 4). There were differences in the completeness of the 
data across respondents and in some of the data elements. Therefore, in the analysis phase, the data were
triangulated in order to come up with best estimates based on the information provided.
Tibu Homa Project Performance Evaluation Report 15
During implementation, Tibu Homa developed the training materials, supportive supervision guidelines,
and other tools needed to implement the Tibu Homa supportive components. Therefore, the 
development costs for these materials were considered “sunk costs” and did not figure in estimates of the 
costs for the GOT or an implementing partner to implement the Tibu Homa supportive components in 
the future. Specifically, the cost study determined the extra costs of implementing the Tibu Homa
supportive components. These components were the following: training HCWs in QI and SCM, training 
for R/CHMT members on SS&M, and travel costs for SS&M visits associated with the Tibu Homa
supportive components. It was assumed that all staff who might implement the supportive components
would already be employed by the implementing partner or agency. So while some task shifting may be 
expected, extra labor costs, such as salaries, were not considered, because the package would be 
implemented as part of the existing duties. Therefore, there would be no opportunity costs (that is, costs 
of implementing the supportive components instead of another task).
Analysis
The underlying theory of change is that if SS&M-trained CHMT members make monthly SS&M visits to 
facilities where HCWs have been trained on dIMCI, QI, and SCM, there will be increased adherence to 
the IMCI assessment protocol. Therefore, overall SS&M costs of a visit to a facility by a trained CHMT 
member were estimated. Specifically, the cost per child treated compliantly according to the IMCI 
algorithm was estimated as a function of: (1) the annualized training costs of HCWs in QI and SCM; (2) 
the annualized training costs of SS&M per supervisor; (3) the number of SS&M visits; (4) the cost of an
SS&M visit; and (5) the number of children assumed to be seen and treated compliantly. Training costs 
were estimated based on the information gathered during the evaluation. We used the following formula:
CC = [(CV+CT)/V] / (KxR), where:
CC = cost per child treated compliantly
CV = cost per SS&M visit
CT = average training costs for SS&M per supervisor and per HCW in QI and SCM per time 
interval
V = number of visits per year to a facility by a supervisor for SS&M
K = average number of U5 children attending a facility per month
R = compliance rate for treatment
Three important inputs that influenced the cost estimate were the frequency of SS&M visits, the number 
of children seen on average per facility, and the compliance rate. These parameters are presented in Table 
5 along with their sources. Two scenarios were considered overall and by facility type. The first scenario 
is a higher-intensity intervention that assumes that annual training and monthly SS&M visits are 
supported. The second scenario assumes training every three years and only includes the cost of eight 
SS&M visits per year. This number of SS&M visits assumes that the GOT will fund and conduct 
quarterly SS visits per GOT policy, which should already be budgeted in each district. 
16 Tibu Homa Project Performance Evaluation Report
Table 5. Key inputs used to estimate the cost per child treated compliantly with Tibu Homa’s supportive 
components
Parameter Scenario
1
Scenario 
2
Source of 
information
Training interval for CHMT members and HCWs 
(yrs.)
1 3 Assumption
Count of SS&M visits per year 
(number of times per year)
12 8 Assumption
Children under 5 seen per facility per month (#) 227 227 MEASURE 
Evaluation HFS
 Health facilities 350 350
 Dispensaries 185 185
Compliance rate (% cases assessed with 10/10 
steps of IMCI algorithm)
36 36 Tibu Homa Final 
Report, Figure 
Qualitative Study: Stakeholders’ Experience of Tibu Homa
Methods and Analysis
For this component, data were collected in four districts and eight health facilities (one dispensary and 
one health center in each district). Because of high turnover rates, health facilities were purposively 
selected in collaboration with district medical officers (DMOs) to include facilities where HCWs who
participated in Tibu Homa were still employed.5 Facilities were also selected based on good performance 
during the Tibu Homa project. Qualitative KI/SGI guides were developed by MEASURE Evaluation. 
Nine CHMT members and 18 HCWs participated in interviews.
KI/SGIs were audio-recorded and translated and transcribed into English. Both HDIC and MEASURE 
Evaluation staff analyzed the transcripts, focusing on identifying relevant themes and patterns of 
responses related to the implementation of the Tibu Homa supportive components to help explain and 
supplement quantitative findings.
Qualitative Case Study: Community Mobilization
Methods and Analysis
For the community mobilization component, which was implemented by Population Services 
International (PSI) and HDIC, data were collected in four communities in two districts of Shinyanga and 
Simiyu where Tibu Homa community mobilization activities were implemented. These communities were 
purposively selected in collaboration with DMOs who identified communities where the mobilization 
had worked well. Within each community, health facility in-charges collaborated with community leaders 
to identify community members who were involved with Tibu Homa to participate in KI/SGIs and 
focus group discussions (FGDs). A total of 140 community members participated in interviews.
Interviews and focus groups were also recorded, translated, and transcribed into English. Transcripts 
were analyzed by both HDIC and MEASURE Evaluation for each case (that is, each community)—and 
across cases—to develop an understanding of how the community outreach component was 
implemented. Any variation in implementation across communities was also noted. The analysis focused 
 
5 Selection criteria did not include gender.
Tibu Homa Project Performance Evaluation Report 17
on identifying barriers to care-seeking, and on constructing a depiction of the community referral system 
for children with fever and OVC. 
Limitations
Given the design of the evaluation, it was not possible to quantify the causal effect of the Tibu Homa
intervention on QOC. However, triangulation of evidence from various sources (such as quantitative, 
qualitative, and project data) enabled the evaluation team to validate and enrich the interpretation of 
results and synthesize findings to assess the contribution of the Tibu Homa supportive components in 
conjunction with dIMCI. 
Challenges Encountered during Data Collection
Despite inclement weather and low patient flow in many facilities, the survey team was able to observe an 
average of more than five patients per facility during the HFS. In cases where observations were inhibited 
by such factors, replacement facilities were randomly selected from those in close proximity to the 
original facility. Overall, 22 facilities out of 86 (25.6%) were replaced, owing to such barriers to 
observation, with more replacements in the comparison area (14/43, 32.6%) versus intervention areas 
(8/43, 18.6%).
IRB Clearance and Informed Consent
The Tibu Homa Project evaluation study protocol was reviewed and approved by the University of North 
Carolina’s internal review board (IRB) (study number 15-3209). The study protocol was also reviewed 
and approved by the National Institute for Medical Research (NIMR) in Tanzania. All data collection 
personnel (supervisors and interviewers) were trained in the protection of human subjects. Informed 
consent was obtained from all participants prior to their participation in the study.
18 Tibu Homa Project Performance Evaluation Report
QUALITY-OF-CARE RESULTS
The evaluation results are presented below, by research question. 
The Value-Added of the Tibu Homa Project
This section addresses research question #1: What is the value, i.e., marginal QOC, associated with 
dIMCI training and Tibu Homa’s supportive components versus the QOC provided in comparison facilities that 
received dIMCI training without the supportive components?
The HFS was the primary data source for this research question. The survey was conducted to compare 
the QOC provided in intervention facilities that received Tibu Homa’s supportive components with 
comparison facilities that did not receive the supportive components. Although intervention and 
comparison groups were selected to maximize comparability, some differences existed between the two 
samples. The main differences that may affect the interpretation of the analysis are (1) the percentage of 
staff trained in either dIMCI or IMCI and (2) the patient volume for U5 children. Higher volume facilities 
often have greater time constraints owing to workforce shortages, which limit HCWs’ ability to complete 
the relatively time-consuming IMCI protocol. Comparison facilities had both a higher percentage of 
trained staff and also a higher patient volume compared with intervention facilities (Table 6). 
Tibu Homa Project Performance Evaluation Report 19
Table 6. Observed HCW and facility characteristics in facilities participating in the HFS by comparison 
and intervention groups
Characteristics Comparison Intervention
HCW characteristics (n=45) (n=49)
HCW sex
 Sex (% male) 55.5 48.2
HCW type (% of total)
 Physician/clinical officer/assistant medical officer 65.5 52.9
 Nursing officer/enrolled nurse/public health nurse 29.3 41.4
 Medical assistant 0.0 5.8
 Other 5.2 0.0
HCW training
 Any dIMCI (e.g., Tibu Homa or other) (%) 72.5 **48.8
 Trained in 2014 (%) 18.6 **94.1
 Trained in 2015 (%) 81.4 **5.9
 Any IMCI (e.g., 11-day or abbreviated in-person training) (%) 7.4 18.8
Facility characteristics (n=43) (n=43)
Facility type (%)
Dispensary 83.7 65.1
 Health center 16.3 34.9
Accessibility of referral center
 Time to referral center (minutes) 59 52
Staffing
 60%+ staff trained in IMCI (%) 93.0 **44.2
 60%+ staff trained in dIMCI (%) 58.1 **14.0
 Number of dIMCI-trained staff present today (# staff) 2.5 2.0
 Total healthcare workers on staff managing children (any day)(#) 5.5 6.1
 Healthcare workers managing children present today (#) 2.8 3.0
 Total number of visits made by children from 2 to 59 months†
(# visits) 269 **181
Number child visits per HCW/month among HCWs managing children
 Dispensaries (# visits) 86 **42
 Health centers (# visits) 51 32
WHO HFS facility indicators
 Index of availability of injectable drugs for pre-referral
 treatment (count of drugs out of four) 2.4 **2.8
 Index of availability of essential oral treatments (count of oral 
treatments out of 8) 4.3 4.4
 Health facility received at least one supervisory visit that 
 included observation of case management during the previous 
 six months (%)
40.0 40.0
 Essential equipment and materials (count out of seven) 0.0 2.3
Facility has Tibu Homa-supported items (%)
 Have IMCI chart booklet 100.0 97.7
 Documented if patient was seen within first 24 hours onset of fever 0.0 **13.9
 Triaged and recorded severity status upon arrival (P 1-2-3) 0.0 11.6
 Documented OVC status 0.0 18.6
 Maintained patient records 67.4 76.7
** p<=0.05
†Estimate from March 2016 patient registers
20 Tibu Homa Project Performance Evaluation Report
To have a valid comparison, case and facilities characteristics in both groups need to be similar. Table 7 
provides a description of case characteristics by group, and indicates that case characteristics were similar 
in both groups for U5 children with fever. The most commonly reported symptoms were respiratory 
issues (namely fast/difficult breathing, cough, or pneumonia). The most common case classifications 
were malaria, pneumonia, cough/cold/flu, and acute watery diarrhea (see Table 7). Selected WHO HFS 
indicators are provided in Appendix A, Table 22. 
Table 7. Case observation characteristics from comparison and intervention facilities
Characteristics Comparison (n=232) Intervention (n=208)
Patient characteristics
 Age (years) 1.5 1.3
 Sex (% male) 47.0 52.4
Symptoms (%)
 Fever 100.0 100.0
 Fast/difficult breathing/cough/pneumonia 67.2 ** 79.8
 Diarrhea/vomiting 38.4 **24.0
 Other 47.8 49.0
 Ear problem 0.9 1.4
Malaria diagnostic used (%)
 mRDT† 76.3 88.9
 Microscopy 3.9 3.4
 None 19.8 7.7
Classification
 Correctly classified (%) 56.0 62.3
Gold standard diagnosis (%)
 Fever, no malaria 41.4 **72.0
 Cough/cold/flu 37.9 42.8
 Malaria 38.4 **18.4
 Diagnosed by mRDT 86.9 91.0
 Diagnosed by microscopy 10.5 9.0
 Diagnosed without diagnostic test 2.6 0.0
 Fever, malaria unlikely†† 19.0 **9.7
 Pneumonia 14.2 **20.8
 Anemia 12.5 8.2
 Acute watery diarrhea 9.1 5.8
 Malnutrition, very low weight 3.0 2.4
 Very severe febrile illness 2.6 2.4
 Dehydration 2.6 2.9
 Acute ear infection 0.8 1.9
 Dysentery 0.4 1.0
 Mastoiditis 0.4 0.0
Note: Diagnoses not mutually exclusive
†Difference not significant when assessing facilities that had mRDTs in stock
††Selected when no diagnostic test was available, but Malaria was not likely
** p<=0.05
Tibu Homa Project Performance Evaluation Report 21
Quality of Care
Quality of care was assessed in several ways. The primary outcome measure, the IMCI score, is a measure 
of how thoroughly patients were assessed according to the IMCI protocol. Average IMCI scores were 
calculated as a measure of QOC with a maximum score of ten steps completed. Then, the frequency of 
accurate classification and treatment for malaria and pneumonia cases was determined.
Observations were conducted with any HCW managing children on the day of the survey regardless of 
IMCI/dIMCI training status. Figure 4, Panel A shows the average IMCI scores in intervention and 
comparison facilities for dIMCI-trained and non-dIMCI-trained HCWs. Average IMCI scores were 
higher in intervention facilities for both trained and un-trained HCWs relative to HCWs in comparison 
facilities. Figure 4, Panel B depicts average IMCI scores in intervention and comparison facilities for 
combined IMCI/dIMCI-trained HCWs and untrained providers. The difference in the IMCI scores are 
not as large when combining IMCI and dIMCI-trained HCWs together.6
IMCI scores also did not vary 
significantly by type of HCW between or within comparison and intervention facilities for physicians and 
nurses (see Appendix A, Table 23).
Figure 4. Average IMCI scores for HCWs with and without dIMCI (Panel A) and for HCWs with and 
without any IMCI/dIMCI training (Panel B) training in intervention and comparison facilities, April–May 
2016
Panel A Panel B
Table 8 provides a snapshot of the 10 components of the IMCI score and the frequency with which these 
components (steps) were completed, on average, by HCWs during observations in comparison and 
intervention facilities. The HCWs in intervention facilities completed the steps at a greater rate than 
HCWs in comparison facilities, for 5 (of 10) components: weighing the child; checking for cough; 
checking for diarrhea; checking for fever; and vaccination status. The least frequently completed step by 
far was weighing the child, with 8.6 percent and 15.4 percent of cases weighed in comparison and 
intervention facilities, respectively.
 
6
IMCI training was provided at an earlier period than was dIMCI.
6.7 6.0 6.0
4.27
0.0
2.0
4.0
6.0
8.0
10.0
dIMCI no dIMCI
IMCI Score
Intervention Comparison
6.7 5.9 5.8 4.6
0.0
2.0
4.0
6.0
8.0
10.0
IMCI/dIMCI no IMCI/dIMCI
IMCI Score
Intervention Comparison
22 Tibu Homa Project Performance Evaluation Report
Table 8. Breakdown of IMCI score in comparison and intervention facilities
Component Comparison Intervention
Checked for 3 danger signs 26.7 **16.8
 Can drink/breastfeed 49.1 57.2
 Vomits everything 46.6 41.3
 Convulsions 56.0 57.2
Checked for cough, diarrhea, and fever 51.3 **74.5
 Cough 89.7 **98.1
 Diarrhea 67.7 **81.3
 Fever 81.9 **90.9
Weighed and weight checked against growth 
chart 8.6 **15.4
Vaccination status 53.4 **71.2
Palmar pallor 42.7 48.1
** p<=0.05
Table 9 provides a summary of QOC in intervention and comparison facilities for two priority diagnoses:
malaria and pneumonia. Most malaria cases were accurately classified and treated; mRDTs were almost 
universally conducted. For pneumonia cases, disparities exist with regard to QOC. A higher percentage of 
pneumonia cases were correctly classified in intervention versus comparison facilities. Of those correctly 
classified (though the number of cases is small), a higher percentage were also treated correctly in 
intervention facilities. First- and second-line drugs to treat pneumonia, specifically amoxicillin and 
cotrimoxazole, were available in one-third of facilities where patients were incorrectly treated, meaning 
that appropriate treatments were available for those cases, but not prescribed. Most incorrectly classified 
pneumonia cases were assigned a classification of respiratory infection (see Table 10). One main indicator 
in the differential diagnosis of pneumonia and respiratory infection is the respiratory rate. Anecdotal 
evidence from the HFS indicates that, although most HCWs had a device for counting the respiratory 
rate, taking time to set up the stopwatch on their (nonsmart) cell phones was a barrier owing to the time 
required.
Tibu Homa Project Performance Evaluation Report 23
Table 9. Quality of care summary for malaria and pneumonia cases
Indicator Comparison Intervention
Malaria 
(n=89)
Pneumonia /
severe pneumonia 
(n=33)
Malaria 
(n=38)
Pneumonia / severe 
pneumonia (n=42)
IMCI score 5.6 5.7 **6.7 *6.5
Received diagnostic test (%) 89/89 (100%) -- 37/38 (97.4%) --
Correctly classified, n (%) 89/89 (100%) 9/33 (27.3%) 38/38 (100%) 20/42 (47.6%)
 Correctly treated, n (%) 77/89 (86.5%) 4/9 (44.4%) 36/38 (94.7%) 17/20 (85.0%)
 Among incorrectly 
treated, appropriate drugs 
available, n (%)†
4/12 (33.3%) 3/5 (60.0%) 2/2 (100.0%) 1/3 (33.3%)
†Includes 1st and 2nd line drugs
Difference between comparison and intervention facilities significant at: **p≤0.05; *p≤0.10
Table 10. Summary of incorrectly classified pneumonia cases*
 Group Number
 Comparison
Total cases pneumonia / severe pneumonia 33
 Incorrectly classified 22/33 (66.7%)
 Incorrectly treated (%) 14/33 (42.4%)
 Average IMCI score 5.2
 Facility has watch or timing device (%)** 58.3
 Misclassification assigned***
9 respiratory infections
5 malaria
1 acute watery diarrhea
1 bacterial infection
 Intervention
Total cases pneumonia / severe pneumonia 42
 Incorrectly classified (%) 22/42 (52.4%)
 Incorrectly treated (%) 11/42 (26.2%)
 Average IMCI score 6.6 
 Facility has watch or timing device (%)** 63.6
 Misclassification assigned*** 
7 respiratory infections
2 urinary tract infections
1 intestinal worms
1 tonsillitis
1 bronchial asthma
*Three cases of pneumonia misdiagnosed as severe pneumonia, and four cases of severe pneumonia misdiagnosed 
as nonsevere are not counted toward misclassification statistics.
** The primary method for diagnosing pneumonia includes counting breaths per minute for which a timing device is 
generally used.
***Other accurate classifications also may have been assigned and are not counted here.
24 Tibu Homa Project Performance Evaluation Report
Table 11 below provides summary results of IMCI assessment steps completed over time using SPA and 
HFS data. The SPA observed providers assessing children presenting with any ailment, while the 
evaluation HFS only observed providers assessing children presenting with fever. The SPA data from 
2006 and 2014–2015 show few changes in the completeness of assessments for all children, including 
those with malaria and pneumonia. Providers observed in the evaluation’s HFS, during the same general 
time period as the 2014–2015 SPA, completed a higher percentage of assessment steps for all measures 
except for the following: checking three danger signs among children with malaria in the comparison 
facilities and among children with pneumonia in intervention facilities. In general, providers in the 
evaluation sample completed a greater percentage of assessment tasks (significance not tested), with a 
higher percentage of children in intervention facilities checked for the presence of diarrhea, cough, and 
fever and a lower percentage of children in intervention facilities checked for three danger signs.
Table 11. Comparison of SPA and Evaluation HFS IMCI assessment results, 2006 SPA, 2014–2015 SPA, and 
2015 HFS
SPA Evaluation HFS†
2006 2014–2015 Comparison
2015
Intervention
2015
All children
 Child checked for three danger signs (%) 11 8 27 17
 Child checked for the presence of diarrhea, 
 cough, and fever (%)
46 46 51 75
 Number of observations 2,272 4,961 232 208
Malaria-specific
 Child checked for three danger signs†
(%) 14 9 28 16
 Child checked for the presence of diarrhea, 
 cough, and fever (%)
53 49 47 82
 Number of observations 1,434 1,641 89 38
Pneumonia-specific
 Child checked for three danger signs (%) 14 13 33 12
 Child checked for the presence of diarrhea, 
 cough, and fever (%)
46 53 61 79
 Number of observations 442 575 33 42
†The SPA observed children with any/all symptoms, while the HFS observed children with fever.
Table 12 provides results from four separate multivariate linear regression models that identify factors 
associated with the IMCI score. The models are adjusted for HCW, patient, and facility characteristics,
and they employ district fixed effects. Standard errors are adjusted for facility-level clustering. Because of 
key differences in patient volume between the intervention and comparison groups, the analysis also 
controls for the number of children seen per month in each facility. The coefficient of interest varies for 
each model.
Model 1 provides results from the sample of both treatment and comparison facility observations, and 
the coefficient of interest is “intervention facility,” which shows the differential IMCI score associated 
with cases observed in intervention group facilities. Cases observed in intervention facilities received 
more thorough assessment than cases observed in comparison facilities. Specifically, cases observed in 
intervention facilities had, on average, IMCI scores that were two steps higher (out of 10) relative to the 
Tibu Homa Project Performance Evaluation Report 25
comparison group facilities, after adjusting for other factors (p<0.05). This model also shows that other 
predictors of a higher IMCI score are that the HCW had received dIMCI training (1.08 steps higher, 
p<0.05) and that the patient tested positive for malaria (0.64 steps higher) (Table 12, Model 1). If the 
provider under observation referenced the IMCI chart booklet during the patient visit, it was generally 
associated with a lower IMCI score (1.1 step lower score, p<0.05). Patient age, gender, health facility 
characteristics, and health facility volume were not significantly related to IMCI scores.
Model 2 includes an additional interaction term between “intervention facility” and “HCW trained in 
dIMCI.” This allows the effect of dIMCI training on IMCI score to vary by study group (intervention
versus comparison group). The interaction term was not predictive of a higher IMCI score (Table 12, 
Model 2). This observation is important, because it strengthens the assumption that differences in 
outcomes across study groups were not due to differences in the dIMCI training itself (or its effects); 
differences were likely due to other factors, including those influenced by Tibu Homa.
In this model, dIMCI training and being seen in an intervention group facility were both independently 
and significantly associated with higher IMCI scores, with notably stronger effects than in Model 1. Being 
observed in the intervention group was associated with 2.53 more assessment steps completed (p<0.05).
Having received dIMCI training in both intervention and comparison groups was associated with 1.69 
more assessment steps completed (p<0.05).
Models 3 and 4, respectively, provide results of models that test for factors associated with IMCI scores 
for comparison and intervention groups separately. Modeling the results separately provides an 
opportunity to examine whether there may be some effects in one group or another that are not captured 
in the combined models (such as, the effects are averaged or washed out by the larger and more diverse 
sample). These stratified analyses show that observing an HCW who had received dIMCI training 
resulted in consistently higher scores in both groups, independently. Other factors varied by group (Table 
12, Models 3 and 4). These models do show some different predictors of IMCI score. In the comparison 
group (Model 3), HCW characteristics were significantly associated with the IMCI score, which is 
consistent with Models 1 and 2. The major difference in this model is that facility volume, specifically 
100–150 children per month, shows a large and negative effect on the IMCI score. Further investigation 
of this result reveals that there were just two facilities in the comparison group sample with this patient
volume, and that HCWs observed in both facilities completed few assessment steps, specifically an 
average 2.5 assessment steps per patient-provider interaction observed. Thus, this result is not of practical 
significance. The outcome of a clinical malaria test was not a predictor of IMCI scores in comparison 
facilities, indicating that the significance of this characteristic on IMCI score was driven by the results of 
observations in the intervention group for Models 1 and 2.
Model 4 provides results from this analysis in intervention facilities, only. The results indicate the 
following: (1) assessments completed by HCWs trained in dIMCI were associated with slightly higher 
IMCI scores than HCWs who did not receive training (0.72 more assessment steps completed, p<0.05);
(2) older children were also associated with fewer assessment scores completed (0.25 fewer assessment 
steps completed per month in age of the patient, p<0.05); (3) a lab-confirmed malaria diagnosis was 
associated with 1.09 more assessment steps completed (p<0.05); and (4) having an IMCI chart book was 
associated with 1.52 more assessment steps completed (p<0.10). Contrary to Models 1–3, the HCW 
referencing the IMCI chart was not associated with the IMCI score, indicating that the significance of this 
effect is mainly driven by the results of observations completed in comparison facilities in the other 
models. 
26 Tibu Homa Project Performance Evaluation Report
Table 12. Factors associated with appropriate assessment (IMCI score) controlling for HCW, patient, and 
facility characteristics, 2015 HFS
Model 1 Model 2 Model 3 Model 4
Characteristic All
(n=439)
All
(n=439)
Comparison
(n=232)
Intervention
(n=208)
Intervention facility (versus comparison) **1.99 **2.53 -- --
Intervention facility * HCW trained in dIMCI -- -1.14 -- --
HCW characteristics
 HCW trained in dIMCI (versus not trained in dIMCI) **1.08 **1.69 **1.86 **0.72
 HCW referenced IMCI chart (versus did not 
reference) **-1.10 **-1.10 **-1.14 -0.46
Patient characteristics
 Patient age in years -0.11 -0.11 -0.03 **-0.25
 Patient is male 0.03 0.06 0.16 -0.01
 Patient has lab-confirmed positive malaria 
diagnosis (versus negative diagnosis) **0.64 **0.59 0.48 **1.09
Facility characteristics
 Facility is health center (versus dispensary) 0.61 0.45 0.30 0.54
 Facility has working baby scale 0.44 0.49 0.39 1.86
 Facility has microscope -0.27 -0.11 0.05 -0.19
 Facility has IMCI chart book 1.20 1.44 0.00 *1.52
Facility volume of children age 2-59 months in one month (March 2016)
 100-150 children (versus 0–99 children) -0.85 -0.79 **-3.56 -0.49
 150-200 children (“ “) 0.14 0.08 -0.07 -0.55
 200-325 children (“ “) 0.06 0.05 -0.35 0.37
 325+ children (“ “) 0.87 0.98 0.86 0.53
* p<=0.10; ** p<=0.05; *** p<=0.001
Stratified analysis for malaria and pneumonia diagnoses also showed that dIMCI training was associated 
with higher IMCI scores for those cases independently (Appendix A, Table 24). 
Supply Chain Management
Few differences were noted in comparison and intervention groups with regard to the facilities’
equipment and supplies. A greater percentage of intervention facilities had baby scales and were recording 
the use of an mRDT in the patient register. Notably lacking in less than half of all facilities were a 
microscope and supplies to mix oral rehydration solution (ORS). Less than one-fifth of facilities in both 
groups had a designated triage area, and transportation for referrals. About two-thirds of facilities in both 
groups had a clean source of water. See Table 13.
Tibu Homa Project Performance Evaluation Report 27
Table 13. Inventory of equipment and supplies in comparison and intervention facilities, 2015 HFS
Item Comparison 
(%)
Intervention
(%)
Equipment and supplies
 mRDTs 95.4 93.0
 Baby scale 88.4 *97.7
 Timing device 62.8 72.1
 Supplies to mix ORS 32.6 30.2
 Microscope 30.2 46.5
Materials
 Patient register 100 100
 Patient register for U5 children 2.3 7.0
 Stock cards/drug book 90.7 83.7
 Child vaccination cards 93.0 *100.0
 Mothers’ counseling cards 86.1 79.1
 Recording mRDT status 69.8 *93.0
Infrastructure
 Refrigerator 90.7 97.7
 If no refrigerator, ice packs and cold boxes 100 75.0
 Sterilizer, cooker, stove 86.1 81.4
 Electricity 81.4 81.4
 Clean water source 65.1 67.4
 Transport for referral 18.6 27.9
 Designated triage area 18.6 14.0
Number of facilities 43 43
* p<=0.10; ** p<=0.05
Table 14 provides information about medicines available and stockout documentation in facilities on the 
day of the visit. The first-line treatment for malaria was more available in intervention facilities (95.4%) 
than in comparison facilities (65.1%). Just over half of all facilities had amoxicillin, the first-line drug for 
pneumonia. Record-keeping for drug stockouts was relatively high for medications related to IMCI 
treatment and also generally similar across comparison and intervention facilities. Drugs for pediatric 
HIV treatment were infrequently available and less frequently tracked in stockout forms. 
28 Tibu Homa Project Performance Evaluation Report
Table 14. Inventory and tracking of medications in comparison and intervention facilities, 2015 HFS
Comparison Intervention Comparison Intervention
Drug In stock (%) If stocked out,
reflected in stockout form (%)
Oral rehydration solution (ORS) 95.4 93.0 100 100
Pneumonia
Amoxicillin Syrup/Tablets 55.8 54.5 88.9 78.9
Erythromycin 39.5 44.2 100 91.7
Cotrimoxazole antibiotic 
tablets/syrup 67.4 67.4 100 92.9
Dysentery
Zinc 83.7 81.4 100 87.5
Cotrimoxazole antibiotic 
tablets/syrup (dysentery) 65.1 62.8 100 87.5
Metronidazole tablets/syrup 32.6 34.9 100 *89.3
Another antibiotic 
recommended for dysentery 41.9 41.9 100 *88.5
Malaria
Artemether-Lumefantrine 65.1 **95.4 93.3 100
Dihydroartemisinin plus 
Piperaquine (DPQ) 4.7 0.0 9.8 2.3
Quinine tablets 11.6 **37.21 57.9 53.6
Another antimalarial 51.2 53.5 4.8 5.0
HIV
Ped Combivir (60mg/3TC 30mg) 25.6 37.2 9.4 7.1
Ped Ducvir N (AZT 60 mg/3TC 
30mg/NVP 50mg) 34.9 51.2 3.6 13.6
Triomune Baby (c4t 6mg/3TC 
30mg/NVP 50mg) 7.0 18.6 0.0 0.0
Efaverenz (200mg) 34.9 *53.5 7.1 0.0
Triomune Junior (c4T 12mg/ 3TC 
30mg/ NVP 100mg) 4.7 **18.6 4.9 0.0
Other
Vitamin A 69.8 **88.4 92.3 50.0
Iron 88.4 93.0 60.0 100
Paracetamol/aspirin 93.0 93.0 66.7 100
Mebendazol/albendazole 74.4 81.4 81.8 100
Tetracycline eye ointment 67.4 60.5 92.9 70.6
Gentian violet 2.3 9.3 14.3 5.0
Other vitamins 41.9 32.6 48.0 **10.0
Number of facilities 43 43 43 43
 * p<=0.10; ** p<=0.05
Tibu Homa Project Performance Evaluation Report 29
Changes in Quality of Care during Tibu Homa
This section addresses research question #2: What factors are associated with improved QOC? Do these 
factors differ between Phase 1 (three-day IMCI plus supportive components) and Phase 2 (dIMCI plus supportive 
components) facilities?
Project performance-monitoring data provide information about changes in IMCI scores and compliance 
rates in Phase 1 (three-day IMCI training) and Phase 2 (dIMCI training) districts during Tibu Homa. The 
primary purpose of the analyses was to assess time trends over the course of the project and compare 
outcomes across the two different training modalities used by Tibu Homa. One additional difference 
between Phase 1 and Phase 2 was the QI implementation process: in Phase 1, QI approaches were tested 
and proven (or disproven). The most effective QI interventions were suggested for facilities participating 
during Phase 2. However, these QI efforts are likely to have small indirect effects on the main outcome 
here (IMCI score).
7 These data derive from case reviews completed by CHMT members and Tibu Homa
staff reviewing patient records during SS&M visits. 
Facility characteristics, case characteristics, and quality of care should be similar to make comparisons
between Phase 1 and Phase 2 based on training modality. Table 12 shows the results of a comparison of 
these characteristics for Phase 1 and Phase 2 facilities engaged in the project. We found that HCWs’ 
IMCI scores and full compliance rates were not statistically different at baseline for facilities in Phase 1
and Phase 2. Yet, some contextual differences are important for interpreting the results that follow. First, 
the Phase 1 facilities began the project two years earlier than Phase 2 facilities, and thus, in most cases 
participated for a longer period in the project (10 months versus 5.5 months participation in Phase 1 and
Phase 2 facilities and districts, respectively). Second, Phase 1 districts and facilities were selected by the 
project based on having relatively high malaria prevalence, and thus the share of malaria cases was 
significantly higher in Phase 1 facilities (64.8%) compared with Phase 2 (35.5% ), while the share of other 
illnesses were higher in Phase 2 facilities (46.3%) compared to Phase I (28.9%). There was also a higher 
proportion of dispensaries in the Phase 2 sample. Except for these differences, Phase 1 and Phase 2 cases
were very similar based on case review characteristics at the first (baseline) visit (Table 15).
Table 15. Case review, diagnosis, and facility characteristics at baseline and 6-month follow-up SS&M 
visits in Phase 1 and Phase 2 Tibu Homa facilities, Tibu Homa performance monitoring data
 
7 QI interventions were mainly focused on patient flow and supply chain, and would be expected to 
indirectly improve quality of care and/or availability of necessary equipment and/or supplies.
Characteristics Baseline† Six months
Case review characteristics Phase 1 Phase 2 Phase 1 Phase 2
IMCI full compliance (%)†† 1.4 1.7 27.8 29.9
IMCI score 5.3 5.5 7.5 **7.4
Male (%) 50.7 52.5 51.3 51.9
Diagnosis
Malaria (%) 64.8 **35.5 54.1 **40.5
Pneumonia (%) 17.6 14.0 13.7 14.1
Diarrhea (%) 5.6 14.9 10.0 **13.5
Other (%) 28.9 **46.3 33.8 **41.9
Facility characteristics
Dispensary (%) 62.0 **91.7 60.9 **87.0
Health center (%) 38.0 **8.3 39.1 **13.0
# months in Tibu Homa 0.0 0.0 10.0 **5.5
# Cases 142 121 3,045 1,189
30 Tibu Homa Project Performance Evaluation Report
†Characteristics at first SS&M visit where facility had retained patient records
††Full compliance is defined as the percentage of cases that were assessed with all 10/10 steps in the IMCI algorithm.
**p≤0.05 for differences between Phase 1 and Phase 2 cases; reviewed at baseline and again at six months
Because very few facilities received more than six months of SS&M during Phase 2 of Tibu Homa, we 
present results comparing indicators across the two training modalities at their first month of SS&M 
(baseline) and at the 6-month SS&M visit (Table 16). Few indicators varied across project phases with 
regard to the project’s performance indicators; this suggests that training modality (and QI approach)
were not significant influences on these indicators. At baseline, Phase 2 facilities had a higher percentage 
of IMCI-trained staff and had received an SS&M visit in the previous month more frequently than Phase 
1 facilities. After six months of receiving SS&M, Phase 2 facilities also had a higher percentage of U5 
children who were tested for malaria by lab diagnostic (mRDT or microscopy), but fewer (lab-confirmed)
positive malaria diagnoses.
Table 16. Performance indicators at baseline and six months of SS&M in Phase 1 and Phase 2 Tibu Homa 
facilities, Tibu Homa performance monitoring data
Performance indicators
Baseline Month 6
Phase 
1
Phase 
2
Phase 
1
Phase 
2
Children U5 w/ fever attending facilities seen by skilled provider 
w/in 24 hours of onset of fever (%) 34.5 38.7 48.3 56.0
Children U5 w/ fever tested w/ lab (mRDT or microscopy) (%) 76.5 83.1 68.0 **95.1
Children U5 w/ fever w/ lab-confirmed malaria (mRDT or 
microscopy) (%) 54.6 49.4 57.0 **31.9
Children U5 w/ lab-confirmed malaria who received treatment 
w/ antimalarial (%) 89.7 95.5 90.4 95.3
Eligible OVC provided with a minimum of one CORE care 
service in the last month (#) 3.2 6.0 6.5 1.5
Tracer medications in stock today (#) 15.1 10.4 15.9 14.2
Health facilities reporting no stockout of key commodities
during the reporting period (proportion)
0.70 0.53 0.60 0.46
Health facilities collecting and using data to improve 
management of febrile illnesses (proportion) 0.47 0.60 0.60 0.55
Health facilities with at least 60% of healthcare workers 
managing children trained in IMCI (proportion) 0.32 **0.68 0.37 **0.62
Staff who received a supervisory visit during reporting period 
(%) 59.5 **84.5 51.7 51.5
# Facilities 30 27 30 11
†Characteristics at first SS&M visit 
**Difference between Phase 1 and Phase 2 indicator is significant at p≤0.05 at baseline and at the 6-month SS&M 
visit
Quality of Care Scores
Scores in both phases of Tibu Homa began at about 5/10 steps completed and improved over time to 
above 8/10 steps (Figure 5). In the first six months of the case review data collection (project months 0–
5 for Phase 1 and 14–19 for Phase 2), Phase 1 facilities improved an average of 0.43 steps per month; 
Phase 2 facilities improved an average of 0.58 steps per month. During months 6–11 of supportive 
Tibu Homa Project Performance Evaluation Report 31
supervision, Phase 1 facilities continued to improve at a slower rate (0.17 steps per month average 
improvement), while Phase 2 facilities leveled off (0.01 steps per month improvement). 
Figure 5. IMCI score over time in Phase 1 and Phase 2 facilities from start of the project, Tibu Homa 
performance monitoring data
Table 17 provides information about factors associated with changes in IMCI scores, adjusting for project 
phase (training modality), case characteristics, facility characteristics, and time. Factors associated with 
higher IMCI scores are malaria, diarrhea, and pneumonia diagnoses (compared to all other diagnoses), 
number of months receiving SS&M, and being seen in a dispensary compared to a health facility. The 
percentage of children with fever seen within 24 hours of onset and the percentage of lab-confirmed 
positive malaria cases were also associated with IMCI scores, although with very small effect sizes.
0 2 4 6 8
10
 IMCI Score
0 6 12 18 24 30
Number of months since THP inception
Phase_1 Phase_2
IMCI score
32 Tibu Homa Project Performance Evaluation Report
Table 17. Factors associated with IMCI score over time in Tibu Homa facilities, Tibu Homa performance 
monitoring data
Variable Coefficient
Training modality
dIMCI (versus in-person 3-day IMCI training) 0.53
Sex
Female 0.02
Diagnosis
Malaria diagnosis (versus other diagnosis) ***0.62
Diarrhea diagnosis (versus other diagnosis) ***0.56
Pneumonia diagnosis (versus other diagnosis) **0.44
Months receiving SS&M (#) **0.11
Months since Tibu Homa began (#) 0.02
Facility type
Dispensary (versus health center) ***1.16
Facility-level project indicators
Children U5 with fever seen within 24 hours of onset (%) **0.01
Children U5 with fever with lab-confirmed positive malaria diagnosis (%) ***-0.01
≥ 60% HCWs trained in IMCI/dIMCI 0.44
Tracer medicines in stock (#) 0.00
Proportion HFs reporting no stockout of key commodities 0.11
Facility is collecting and using data to improve case management 0.33
**p≤0.05; ***p≤0.001
IMCI scores for malaria and pneumonia diagnoses were also examined separately. Pneumonia cases’ 
IMCI scores saw the greatest improvement during Tibu Homa, rising from 5.3 and 5.2 at baseline to 6.5
and 7.6 after six months, and with an overall average of 8.0 and 8.4 steps completed in Phase 1 and Phase 
2 facilities, respectively. Pneumonia cases in Phase 2 facilities had higher IMCI scores at six months and 
overall compared with pneumonia cases in Phase 1 facilities.
Supply Chain Management
Participating facilities’ SCM staff received specialized training in managing commodities and logistics. 
They also received SS&M to monitor the management of the facilities’ inventory tracking and ordering 
systems. Both training and SS&M were meant to serve as vehicles for improving availability of medicines 
and supplies in the facilities. The PQITs may also have tracked some of the SCM data, enabling
improvements through that mechanism as well. 
Figure 6 shows improvements made in the availability of medicines and diagnostics over the course of the 
program. Availability in facilities in both phases of Tibu Homa increased during the project to more than
90 percent of facilities having 10+ tracer first-line medicines and supplies. Assessing stockouts for 
specific medicines and supplies is not possible with program data. No practical difference existed in the 
Tibu Homa Project Performance Evaluation Report 33
rate of improvement over time between Phase 1 and Phase 2 facilities in the first six months of entering 
the program.
8
 
Figure 6. Percentage of facilities stocked with 10+ tracer first-line medicines and supplies at the time of 
visit (quarterly) by project phase, Tibu Homa performance monitoring data April 2012–June 2016
Pediatric Quality Improvement Teams
Program data included one indicator related to performance of PQITs: the percentage of facilities
collecting and using data to improve management of febrile illness. The PQITs were the main vehicles 
for collecting and using data in facilities to improve febrile illness during the project. The time trend of 
this indicator is displayed in Figure 7 separately for Phase 1 and Phase 2 facilities. During Phase 1, 
facilities identified and tested improvements through the PQITs. In Phase 2, Tibu Homa staff developed 
a list of most successful improvements made by PQITs during Phase 1 and provided it to the facilities 
involved in Phase 2 as suggested options for improvement. Phase 2 facilities could choose to follow the 
information provided to them based on learning during Phase 1, or they could identify and test their own 
improvements.
 
8 A comparison is made between the two phases during the first six months of their respective program 
participation because Phase 1 lasted much longer than Phase 2. Phase 1 facilities had, on average, a 
greater number of tracer items at baseline and at six months, but the difference in the rate of 
improvement was less than 0.01 medicines per quarter in Phase 1 versus Phase 2 facilities.
0
10
20
30
40
50
60
70
80
90
100
Apr-12 Jul-12 Oct-12 Jan-13 Apr-13 Jul-13 Oct-13 Jan-14 Apr-14 Jul-14 Oct-14 Jan-15 Apr-15
Percent
Quarter
Phase 1 Phase 2
34 Tibu Homa Project Performance Evaluation Report
Figure 7. Percentage of facilities collecting and using data to improve febrile illness, Tibu Homa 
performance monitoring data
Typical PQIT activities were: improving patient flow; implementing a triage system; collecting additional 
data on the time of onset of fever, mRDT results, and OVC status; introducing job aids; and improving 
record keeping and data management. Because many of these PQIT-related activities were designed to 
support improvements in QOC, it is informative to visualize whether the indicator shown in Figure 7
(percentage of facilities collecting and using data to improve febrile illness) trends with improvements in 
other areas. Figure 8 shows trends of PQIT performance, as measured by this indicator; supply chain 
management (the percentage of facilities with 10+ tracer items in stock); and QOC, or IMCI (the average 
percentage of IMCI steps completed in Phase 1 and Phase 2 facilities). Although there is a strong upward 
time trend for these indicators, no clear pattern emerges between PQIT performance and SCM, or PQIT 
performance and IMCI score. Because the Tibu Homa project was consistently implemented across 
facilities, it is not possible to parse the individual contribution of PQITs.
0
10
20
30
40
50
60
70
80
90
100
Apr-13 Jul-13 Oct-13 Jan-14 Apr-14 Jul-14 Oct-14 Jan-15 Apr-15
Percent
Quarter
Phase 1 Phase 2
Tibu Homa Project Performance Evaluation Report 35
Figure 8. Quarterly trends in PQIT performance, SCM, and IMCI assessments during Tibu Homa, April 
2012–April 2015
The Marginal Cost of Implementing the Tibu Homa Supportive Components
This section addresses research question #3: What are the costs of the intervention components associated 
with improved QOC?
Table 18 summarizes results from the cost study. It shows cost estimates per child receiving a full 
assessment (compliant with the IMCI Index of Integrated Assessment where the IMCI score is 10/10). It 
also shows costs where SS&M was provided and training was based on the Tibu Homa approach
(“supportive components”). These two costs per child treated compliantly were calculated for 
dispensaries and health centers, and for an overall average of all facilities. The first cost was simply the 
cost per child treated compliantly for SS&M visits. For Scenario 1, this amounted to 8,140 TZ shillings 
per child for annual trainings and monthly SS&M (1 USD = 21,844.4804 TZS). The estimate for Scenario 
2 is 7,695 TZ shillings for training every three years and eight SS&M visits per year. The second estimate 
added the costs of training to the costs for SS&M. Estimates that include supervisor and HCW training 
costs (exclusive of dIMCI training) are more than double the estimated cost per child: 17,964 TZ shillings 
for annual trainings and monthly SS&M (Scenario 1) and 10,970 TZ shillings for training every three
years and eight SS&M visits per year (Scenario 2). Because the average number of children seen is higher 
in health facilities than in dispensaries, the package costs less per compliantly treated child in health 
facilities.
0
10
20
30
40
50
60
70
80
90
100
Percent
Quarter
Phase 1 - SCM Phase 1 - PQIT Phase 1 - IMCI
Phase 2 - SCM Phase 2 - PQIT Phase 2 - IMCI
36 Tibu Homa Project Performance Evaluation Report
Table 18. Cost study summary
Item Scenario 1* Scenario 2**
TZS USD*** TZS USD***
Cost per SS&M visit 592,500 $270.74 592,500 $270.74
Training costs
Average cost per TOT participant 872,800 $398.82 872,800 $398.82
Average cost per HCW participant 802,800 $366.83 802,800 $366.83
Average cost per supervision participant 868,800 $396.99 868,800 $396.99
Annualized overall SS&M training cost per supervisor 872,898 $398.86 290,966 $132.95
Average cost per compliant child in dispensaries
For SS&M 9,989 $4.56 9,943 $4.54
For SS&M + training 22,043 $10.07 13,461 $6.15
Average cost per compliant child in health centers
For SS&M 5,280 $2.41 4,991 $2.28
For SS&M + training 11,651 $5.32 7,115 $3.25
Average cost per compliant child in all facilities
For SS&M 8,140 $3.72 7,695 $3.52
For SS&M + training 17,964 $8.21 10,970 $5.01
* Assumes annual training and support for monthly SS&M
** Assumes training every 3 years and 8 additional SS&M visits above the quarterly visits already in place
*** Exchange rate: 1 USD = 21,844.4804 TZS
Tibu Homa Project Performance Evaluation Report 37
PROJECT IMPLEMENTATION RESULTS
In this section, we summarize results from research question #s 4-7: 
4. What have been the facilities’ experiences implementing program activities?
5. What support did Tibu Homa provide to CHMTs? 
6. Among phase one facility clusters, how well have program activities been sustained?
What was Tibu Homa’s approach to community mobilization and how (and if) was the 
project successful in creating referral networks for children with fever and for orphans 
and vulnerable children (OVC)?
9
Tibu Homa was designed to address many known barriers to successful implementation of the IMCI 
approach in Tanzania. This section summarizes strategies that were identified through our project 
document review and KI/SGIs with CHMT members and HCWs.
Time and Financial Cost of Training
The original 11-day IMCI training was challenging because of the cost per HCW and the time spent away 
from patient care (Ahmed, Mitchell, & Hedt, 2010; Goga & Muhe, 2011; WHO, 2014). The Tibu Homa
project reduced the IMCI training time in Phase 1 to three in-person days, and converted to the three-day
dIMCI training during Phase 2. Tibu Homa also embedded the expectation that trained HCWs would 
return to their posts and train their colleagues on IMCI guidelines. 
Funding cuts and early project completion stymied Tibu Homa’s initial plan to train more HCWs per 
facility. While some PQIT improvements resulted in time efficiencies, Tibu Homa was not designed to 
address workforce shortages. Frequent staff transfers and turnover resulted in a reduction of IMCI￾trained staff, sometimes leaving a facility with no IMCI-skilled staff. Transferring staff also limited the 
ability of trained HCWs to practice IMCI skills (Goga & Muhe, 2011; Prosper, Macha, & Borghi, 2009).
Adherence to the IMCI Protocol
Studies have found that adherence to the IMCI protocol has been inadequate because of poor 
supervision, inadequate HCW motivation, reluctance to refer severely ill patients, lack of required drugs, 
and inconvenient facility layout (Kiplagat, Musto, Mwizamholya, & Morona, 2014; Prosper, et al., 2009; 
Leonard, Masatu, & Vialou, 2007; Walter, et al.,, 2009). We found that Tibu Homa’s approach sought to
address many of these problem areas. Some of these activities are noted in this section, and highlighted 
with quotes from study participants.
Supervision
Tibu Homa provided training on SS&M for R/CHMT members. The project also provided resources and 
support to conduct monthly SS&M that covered case management for IMCI. Qualitative respondents 
described their understanding of SS&M as a way to identify challenges and solutions:
 
9 Detailed results regarding Tibu Homa’s community mobilization activities have been provided 
separately by PSI.
38 Tibu Homa Project Performance Evaluation Report
You observe what a person is doing and through that, you can identify gaps and correct them. 
—CHMT member
You sit with HCWs and pass through the challenges they have and discuss the way forward and later 
put in an action plan. —CHMT member
HCWs also reported very positive experiences with SS&M: 
With only distance learning, I was not yet competent, but with supportive supervision, I continued 
gaining experience. —HCW 
Distance learning takes some time. We differ in rates of understanding…whenever supportive 
supervision comes, it continues to build him and gives him confidence. —HCW
Motivation
Regular SS&M was designed to motivate HCWs to adhere to the protocol. The SS&M also served as an 
accountability mechanism. The CHMTs charted IMCI compliance levels and reported that setting goals 
and tracking progress motivated HCWs. The HCWs reported they were motivated to achieve goals as a 
result of this process. 
They had graphs which they affixed to the wall…for self-assessment…and when he or she looks at the 
graph, it motivates him or her if the graph is low to make it high. —HCW
At the end of the day, they tell us that your health centre has scored so and so marks. That means we 
get motivated – now we have 80 marks, let us take care so we do not lose performance. —HCW
It gives us the spirit to work even harder. —HCW
Facility-Level Inefficiencies
The PQITs identified structural and system-level gaps in services for children. With the support of Tibu 
Homa staff and SS&M provided by council health management teams, PQITs identified and 
implemented improvements during the project. Common facility-level improvements reported by 
respondents were as follows:
• Restructuring patient flow to reduce wait time at the lab by administering mRDTs in the 
consultation room
• Implementing a triage system
• Working with community leaders to create a community referral system for children with fever 
(see previous section on Community Mobilization)
• Collecting data on time of onset of fever, mRDT results, and OVC status
• Enhancing well-child clinic visits by including education about early care-seeking for children with fever
• Introducing job aids, such as IMCI flow charts
• Improving record keeping and data management
The CHMT members and HCWs reported that PQITs were an effective means for problem solving, and 
had a team-building effect. They also reported that CHMTs helped PQITs set goals and monitor 
progress.
Tibu Homa Project Performance Evaluation Report 39
This is the team that evaluates the functioning of the facility. It evaluates the weaknesses; it also 
evaluates our progress…It is the only team that solves problems at the facility.—HCW
We were documenting progress, so if we come this month and observe something and try to correct it, the 
next month we will observe to what extent has the situation changed.—CHMT member
If you have quality improvement, there must be indicators which you set and at the end you want to 
evaluate yourself … That is a very important thing in delivering services…It is better that 
HCWs…set their indicators and they will know at the end of the day what they have achieved.
—CHMT member
Early Care-Seeking
The importance of early care-seeking was promoted both through SS&M and community engagement
activities. Health promotion also was conducted at health facilities while patients waited. Although Tibu 
Homa supported referral systems at both facility and community levels, lack of transport and financing 
were persistent barriers.
Lack of Medicines
Lack of medicines was addressed through SCM training and SS&M for appropriate facility staff to track
medicines and ensure timely ordering. Project staff also communicated with the Medical Stores 
Department to advocate for needed drugs and promote redistribution of drugs within districts where 
shortages existed or where drugs were reaching expiration. The Community Health Fund was promoted
in several communities to raise resources for purchasing drugs in the private sector when needed.
Healthcare workers reported positive experiences with SS&M in building their skills in SCM:
We were recording our mRDT uses…we were able to identify our needs using the same forms. —HCW
We had forms to fill daily. Therefore, we actually knew what we had to order the day of ordering. —HCW
We are buying medicine according to the needs of the facility contrary to past days. —HCW
Tibu Homa activities did not focus on strengthening the capacity of the Medical Stores Department, the 
sole source of medicines to public facilities in the Lake Zone. Thus, even with high SCM performance in 
facilities, timely supplies of essential medicines were not guaranteed. 
Sustainability
Sustainability for Tibu Homa hinges on financial resources for SS&M, and on conducting SS&M in a way 
that continues to work with HCWs in clinical mentorship that holds the facility and HCWs accountable.
In addition, transport is a major challenge (insufficient fuel and vehicles).
The problem is, when the supportive supervision comes from the district, it depends on car transport. Whenever 
there is no fuel, they cannot make it.
Respondents report that SS&M is currently less comprehensive, and there is less focus on IMCI.
40 Tibu Homa Project Performance Evaluation Report
Supervision on IMCI has decreased.
We are still doing supportive supervision but what I should say is that what we do now is the routine supervision 
that is done in all other places because it is dictated by the availability of resources from the government…it is no 
longer as deep, comprehensive, and serious as during the project.
Community Health Promotion
A main component of IMCI is improving family and community health-seeking behaviors. Tibu Homa 
staff reported that the community mobilization activities implemented in Maswa District (Simiyu Region) 
and Kishapu District (Shinyanga Region) were highly effective in promoting early care-seeking because 
they incorporated outreach to active community social groups (CSGs) and traditional healers. In their 
final project report, Tibu Homa reported that the percentage of children under five identified with fever 
that were taken to a health facility within 24 hours of onset increased from 46% in March 2015 to 80% in 
June 2014 in Maswa District, and from 67% in July 2014 to 91% in June 2015 in Kishapu District 
(USAID & URC, 2015).
Community mobilization results derive mainly from qualitative data collection and are supplemented with 
information from Tibu Homa’s performance monitoring data and the 2015 HFS. The primary purpose of 
exploring Tibu Homa’s community mobilization approach is to describe the approach and to draw out 
lessons learned and to identify any successful strategies used to promote early care-seeking behavior for 
children under five with fever.
Roles of Various Actors
The findings of this qualitative component of the evaluation revealed that the main actors involved in 
implementing Tibu Homa activities at the community level were local leaders – elected or appointed 
officials – and volunteer community health workers (CHWs). These individuals educated community 
members and traditional healers on the importance of early care-seeking for children with fever and 
created a system for referring such children when identified in the community. Table 16 describes
the roles of the various actors.
Tibu Homa Project Performance Evaluation Report 41
Table 19. Tibu Homa community mobilization actors and roles, focus group and KII discussions
Tibu Homa 
role
Position in the 
community
Role in community mobilization
Community 
coach
Elected or 
appointed 
political leaders 
such as village 
and hamlet 
chairpersons, 
village 
executive 
officers (VEOs)
• Oversaw the implementation of the community 
component in their jurisdiction
• Convened village and hamlet meetings to promote 
early care seeking
• Delivered early care-seeking messages at churches 
and mosques
• Identified CHWs to work on the project
• Sometimes assisted CHWs by attending meetings of 
CSGs to promote early care-seeking, by visiting 
households and by meeting with traditional healers
• Formed and often served on the CQIT
CHW Community 
volunteers
• Visited households to identify and refer children with 
fever; kept data on referrals
• Identified OVC, referred if fever detected
• Conducted outreach to traditional healers
• Conducted outreach at CSG meetings
• Formed art/drama/dance groups to promote early 
care seeking
Supervisor of 
CHW
VEOs • Monitored and assisted CHWs
• Aggregated data collected by CHWs, CSGs, and 
traditional healers on a monthly basis
• Analyzed the data for trends (increases or 
decreases in percent of children seen in 24 hours of 
onset of fever, and in number of U5 deaths)
Community 
quality 
improvement 
team (CQIT) 
member
Same as 
community 
coaches
• Overlapped with community coaches; did not 
have a clearly defined separate role
• Supposed to verify/approve the monthly data, but 
VEOs usually did this
Community 
social group 
(CSG) 
member
Community 
members of 
existing savings 
groups or 
income￾generating 
groups
• Belonged to CSGs with 15–30 members; most were 
mixed male/female groups though some were all￾female
• Involved in income-generating activities or savings 
and lending
• Agreed to be visited by CHWs and community 
coaches for sensitization on early care seeking
• Agreed to gather monthly data on number of 
members’ children with fever and number taken to 
a health facility within 24 hours
• Encouraged by Tibu Homa to have a system for 
assisting members’ children with fever with funds for 
transport
Traditional 
healer
Traditional 
healers
• Were mostly male
• Usually saw about 5 children per week, fewer since 
Tibu Homa
• Usually saw children brought for convulsions 
(“degedege”) or worms (“mchango”)
• Agreed to be visited by CHWs and community 
coaches and to be sensitized on importance of 
referring children with fever to a health facility
• Agreed to gather monthly data on number of 
children with fever brought for care and number 
referred to a health facility
42 Tibu Homa Project Performance Evaluation Report
We saw little variation in how Tibu Homa community mobilization activities were implemented across 
communities. There were some differences regarding the degree of involvement of community coaches 
and supervisors of CHWs in assisting CHWs with their work.
Early Care-Seeking Messages Delivered
The CHWs, community coaches, and supervisors worked together to educate the community on the 
importance of early care-seeking for children with fever. Tibu Homa messages were delivered at hamlet 
and village meetings convened by chairpersons, at monthly meetings of CSGs, and at churches and 
mosques. This information was also delivered through visits to households and traditional healers. In 
addition, CHWs formed art/drama/dance groups to promote early care-seeking.
Key informants and focus group participants readily recounted the main messages delivered by Tibu 
Homa. What follows are four primary messages and direct quotations from interviews and focus groups:
• Caregivers should take children with fever to a heath facility within 24 hours of onset of fever. 
This was reported repeatedly (and enthusiastically) by respondents of all types. When a child suffers 
from fever in 24 hours, we must rush them to a health centre! —CSG member
• Community members and caregivers should recognize the early signs of malaria and the 
consequences of not getting timely care. Those symptoms…you find a child loses appetite, becoming weak, 
high temperature, vomiting…these were symptoms we were told. —CSG member. You can lose a child for no 
reason. —CSG member
• Caregivers should not get medicine directly from pharmacies or visit a traditional healer; they 
should visit a health facility to determine the cause of fever. In case of high temperature, one should rush 
to the hospital for diagnosis and treatment and not use herbs. —CSG member. You need to take him/her to 
hospital to test so that you know the specific illness he/she suffers from. —CSG member
• Caregivers should share this information with their families and neighbors to educate them on the 
importance of early care-seeking.
Traditional healers from KIIs/SGIs reported receiving similar messages regarding the urgency of getting 
children checked by a health facility before receiving treatment. Here are a few examples:
• If there is fever, I will not take them [children] in. I tell them to go the hospital. —Traditional healer
• They told us if we observe these symptoms then we should immediately refer them to the hospital, then if they fail to 
treat them, they can return to us. —Traditional healer
• They told us that when you treat a person without being checked, there is the possibility of treating a disease the 
person is not suffering from and you can find yourself accelerating the disease or even causing death. —Traditional 
healer
Community Referral for Children with Fever and OVC
Tibu Homa established a community referral system for children with fever. The intention was to refer 
OVC for care and support (in addition to treatment). However, respondents reported there were no 
special services for OVC, so they were folded into the system for referring all children with fever. Figure 
9 shows how the referral system should work when fully functional. In practice, respondents reported
variations across communities regarding the degree of data collection. Moreover, even though all 
Tibu Homa Project Performance Evaluation Report 43
communities identified and referred children, only two of the four communities in the study reported 
they used referral forms; the other two relied on verbal referrals. The two that relied on verbal referrals
collected data but used informal notebooks books to track referrals along with health facility registers. All 
communities reported that they continued to identify and refer children after Tibu Homa ended. 
However, only one community reported they were still using referral forms. None was still compiling and 
analyzing data.
Figure 9. Community referral system for children with fever, focus group and KII discussions
Putting It All Together
When we examined the roles of the actors, messages, and community referral systems, a quality 
improvement approach to community mobilization emerged (see Figure 10; note that the box at the 
bottom right reproduces Figure 9, above, and is readable there). Village leaders and CHWs conducted 
outreach; the community was educated on the importance of early care-seeking for children with fever;
children were referred and tracked; data were analyzed to track progress; and efforts were stepped up as 
needed. 
44 Tibu Homa Project Performance Evaluation Report
Figure 10. Tibu Homa quality improvement approach to community mobilization, focus group and KII 
discussions 
Barriers to Care-Seeking
Study participants were asked to describe ongoing barriers to care-seeking. While some barriers to care￾seeking were addressed by community mobilization activities, gaps remain related to quality of service at 
health facilities, perceptions of the Community Health Insurance Fund (CHIF), distance to health 
facilities, and poverty. Barriers are grouped in the following six categories, highlighted with examples and 
quotes from study participants:
• Issues with quality of service at health facilities 
o Medicines are stocked out or clients are told to pay for medicine. She goes to the dispensary 
and she will not get medication….she is told no medication; go and buy from a pharmacy…now she 
finds it is better to go buy directly from the pharmacy. —CSG member. 
o At the health center, there is no medication, and even if there is medication, she is told to pay…the 
parent feels even if I go to the health center it is a nuisance…better to go buy from a pharmacy. —
CSG member
o Customer service can be poor. The mother is confused…to be cross-examined why a child has no 
[child health] card…she decides to avoid and go for traditional medicine [or to] pharmacies to buy 
maybe Panadol… —CSG member
o Hours of service are limited. You find there are no service providers…some time you go there at 
3:00 or 4:00 pm when they are closed and you don’t find them…now you decide to go help yourself and 
go to the pharmacy. —CSG member
Tibu Homa Project Performance Evaluation Report 45
o There can be a language barrier. When you go there, you find a nurse from Dodoma who does not
know Sukuma, when she asks what the child is sick from, they do not understand one another. —CHW
• Perceptions of the Community Health Insurance Fund and consequences of having no insurance
o If you do not participate in the CHIF, you will not get care. He/she goes to the hospital and
is told, do you have insurance? No…she abuses you and abuses you and tells you I do not treat you, go
home.—CSG member
o Medicines are reserved for those participating in the CHIF. Most people have no health
insurance, so when you go to the hospital, you are told that the available medicine is for those who are
members, so you will have to buy. —CSG member
• Lack of health-related knowledge
o Some community members believe that convulsions (degedege) are a sign of being
bewitched (kurogwa).
o Some may not be able to identify early signs and symptoms of malaria, or they are not
aware of the danger of delaying care.
• Preference for traditional healers
o Community members may believe that convulsions mean one is bewitched.
o Traditional healers speak Sukuma.
o Traditional healers accept payment in-kind, are more affordable, and will accept
alternative payments. Maize or a bowl or cup of millet. —CSG member
• Distance to health facility
o Ten kilometers is considered far.
o Communities have poor roads in general, and impassable roads during rainy season.
• Poverty
o Community members lack funds to buy medicine (if there is a stockout or are told to
buy medicine).
o Community members lack funds for transport.
The Health Facility Survey collected information about barriers to completing onward referrals that also 
reflect ongoing barriers with referral networks. Table 20 shows reasons given about why providers were 
unable to refer a severely ill child. Financial constraints and transport were cited most often.
Table 20. Reasons providers were unable to refer a severely ill child by group, 2015 HFS
Reason reported* Comparison Intervention
Financial constraints 17/19 (89.5%) 8/13 (61.5%)
Transport 1/19 (5.3%) 4/13 (30.8%)
Prefer traditional healer 1/19 (5.3%) 1/13 (7.7%)
Parental beliefs 1/19 (5.3%) 0/13 (0%)
Total responses 19/43 (44.1%) 13/43 (30.2%)
Note: Multiple responses permitted
46 Tibu Homa Project Performance Evaluation Report
DISCUSSION
The IMCI approach was designed to address major causes of mortality at community, health facility, and 
health system levels (Gera, Shah, Garner, Richardson, & Sachdev, 2016). Tibu Homa was implemented to 
enhance the use of IMCI in the Lake Zone for a four-year period: 2011–2015. Evaluation of the project 
across two phases has revealed improvements in QOC for U5 children in Tibu Homa facilities, and has 
demonstrated the success of the Tibu Homa training and SS&M approach. However, most 
improvements were not sustained one year after the project ended. The evaluation also identified ongoing 
barriers to healthcare access and IMCI implementation. 
Quality of Care
To reduce morbidity and mortality among U5 children, QOC must be improved. Tibu Homa has shown 
that increasing the proportion of IMCI-trained staff, and providing SS&M and SCM on a regular basis,
are associated with improved QOC for U5 children. Providing additional training on the differential 
diagnosis of pneumonia and upper respiratory infection (URI), and improving availability of essential 
supplies, diagnostics, and equipment, could also improve QOC. 
The three-day IMCI or dIMCI training packages combined with the Tibu Homa supportive components
were associated with significant improvement in QOC for measures assessed during the project. (There 
were no significant differences between using in-person IMCI or dIMCI.) The abbreviated three-day 
training is an appealing alternative for countries that can’t afford to saturate their healthcare workforce 
with the full 11-day IMCI training (Goga & Muhe, 2011). While dIMCI may be less costly than the 
conventional 11-day IMCI training, little research has been done to assess the use or cost effectiveness of 
dIMCI over the longer training (Mushi, et al., 2011). Research on this topic is forthcoming in Tanzania.
Evidence from the evaluation HFS shows that one year after Tibu Homa, diagnosis and treatment for 
malaria were highly accurate and effective. Malaria outcomes were similar in both intervention and 
comparison facilities, suggesting that dIMCI training and the availability and use of mRDTs may be 
enough to produce meaningful change. This finding refutes previous research that highlighted over
diagnosis of malaria due to factors outside of the treatment guidelines (such as patient expectations and
cultural norms) (Chandler, et al., 2008; Mosha, et al., 2010). The role of dIMCI is uncertain in influencing 
malaria outcomes observed. Perhaps due to mRDTs, children with malaria are receiving a higher standard 
of care in Tibu Homa facilities than those with pneumonia. At the same time, about one-quarter to one￾third of children who do not need an antibiotic still receive a prescription.
Real change is still needed for diagnosing and treating children with pneumonia. Most misdiagnosed 
pneumonia cases were mistaken for URIs. Although diagnosis and treatment outcomes were better in 
intervention facilities than in comparison facilities, further improvements are needed in both groups. 
Pneumonia is the greatest cause of death among children under five years of age (WHO, 2014). The lack 
of diagnostics in health facilities and dispensaries requires HCWs to assess these children thoroughly.
Other research suggests that HCWs may know the proper assessment steps for pneumonia but fail to 
conduct them (Lange, Mwisongo, & Mæstad, 2013). Similar findings were observed in neighboring 
countries, where good-quality IMCI pneumonia case management (determined by counting the 
respiratory rate) was completed in only 16 percent of the children. This resulted in incorrect classification 
of 70 percent of children with pneumonia (Bjornstad, et al., 2013). Not counting the respiratory rate in 
both intervention and comparison facilities may have been because of large caseloads, providers 
Tibu Homa Project Performance Evaluation Report 47
disregarding the importance of counting, and/or a lack of timing devices. Those who counted used cell 
phones with stop-watch applications. One intervention in Tanzania that provided additional training and 
supervision for respiratory illness resulted in worse treatment outcomes (Osterholt, et al., 2006). Any 
future targeting in this area should be closely monitored for effectiveness and unintended consequences.
Tibu Homa facilities were at a disadvantage when comparing some outcomes with the comparison 
facilities that may have resulted in underestimation of the project effects. One reason is that a much 
smaller percentage of HCWs in intervention facilities had been trained, and were trained for a longer time 
in advance of the survey. Both of these factors could disadvantage project facilities’ outcomes and risk an 
underestimation of the project’s association with QOC. However, many outcomes in Tibu Homa 
facilities were generally better than in comparison facilities, suggesting that the project improved QOC, 
and that the higher QOC was maintained over one year later compared with comparison group facilities
despite these factors. 
Supportive Supervision and Mentorship
The IMCI scores in facilities receiving dIMCI rose over the course of Tibu Homa; facilities participating 
up to 15 months achieved average scores of 8/10 steps completed. One year later, the scores had 
dropped to 6.3/10 in a sample of these intervention facilities surveyed, highlighting the importance of 
SS&M in maintaining QOC. The study’s qualitative research also suggests that regular SS&M is an 
important component in maintaining QOC after training occurs. However, the cost study reveals how 
cost-intensive SS&M can be. While SS&M was provided monthly during Tibu Homa, only 40 percent of 
intervention and comparison facilities had received a supervision visit in the six months before the HFS. 
The importance of regular, quality supervision is well-documented. Supervision can reinforce IMCI skills, 
stimulate HCW motivation, and enhance accountability (Armstrong Schellenberg, 2004; Steinhardt, et al., 
2015; Pariyo, Gouws, Bryce, & Burnham, 2005; Prosper, et al., 2009; Kwesigabo, et al., 2012). Identifying 
sustainable methods for providing this service is paramount to the success of this strategy.
Findings of the association between SS&M and improved QOC in the Tibu Homa intervention are 
supported by other work in Tanzania. Research by the Tanzania IMCI multi-country Evaluation Health 
Facility Survey group showed that, in rural Tanzania, supervisory visits were associated with higher IMCI 
scores even if the facility was visited only once every six months (Bjornstad, et al., 2013; Goga & Muhe,
2011). These findings imply that there could be a relationship between the frequency of supervision and 
improvement in quality of care up to a particular optimum level that is yet to be determined in the 
Tanzanian setting. In the case of Tibu Homa, IMCI scores improved significantly for the first 5–6 
months of SS&M, but improvement was slower after that. Testing an intervention with five to six months 
of intensive monthly SS&M may be a good starting point to determine minimum levels of SS&M 
required to improve QOC. Implementation of such an intervention requires that at least one member of 
the R/CHMT be trained in SS&M for IMCI, and that the necessary time, transport, and human resource 
be made available. Since SS&M within Tibu Homa used existing structures, it is possible that the visits
will continue being implemented where resources exist. 
The SS&M also supported on-the-job training using logistic mentors to focus on improving 
quantification and correct forecasting of medicines and supplies. Supply-chain management activities
contributed to improving case management, by ensuring increased availability of medicines and supplies 
at the facility level. Performance monitoring data showed an improvement in the availability of 
commodities in Tibu Homa-supported facilities. However, Tibu Homa indicators are difficult to attribute 
to the project given the numerous external factors that also affect availability of medicines and supplies.
48 Tibu Homa Project Performance Evaluation Report
Supply Chain Management
Lack of basic equipment and supplies are critical for providing high QOC and for enabling HCWs to 
follow IMCI guidelines. Other than being able to prescribe medicines that are available in the immediate 
facility, HCWs should administer the first dose of medication at the facility. This gets the child on a path 
to wellness and provides an example for the caregiver to follow at home. Basic equipment needed to 
administer some therapies and treatments was rarely available in all facilities surveyed. In the future, a 
SCM module will be integrated into the dIMCI curriculum that may support better management and 
supply of necessary items. 
Community Health Promotion
Health systems are complex networks that depend heavily on supply- and demand-side factors to produce 
healthy outcomes. Care-seeking behavior is one aspect of the demand-side of the health system addressed 
by Tibu Homa. The project’s strategy to promote early care seeking for U5 children with fever seems to 
have left relevant institutionalized messages in communities. Community health workers, traditional 
healers, and others are poised to get children into facilities for treatment. However, when QOC in 
facilities does not live up to clients’ expectations, or essential medicines are not available, the gains in 
health promotion activities may be lost (Leonard, Mliga, & Mariam, 2002). Structural barriers (such as 
lack of supplies, equipment, workforce shortages, and transport to facilitate referrals) work against 
improving supply factors in the healthcare system. This longstanding problem needs long-term solutions
(Kwesigabo, et al., 2012). During Tibu Homa, HCWs had higher IMCI scores when managing children 
who were brought within 24 hours’ onset of fever. This finding aligns with the continuum of care that
exists when (1) a child falls sick with fever; (2) the child is immediately brought to a health facility; and (3) 
the child will receive good-quality care, and the illness will be managed well.
Other Findings
Based on results from the evaluation’s HFS, more education is needed for providers in terms of referral 
for severe cases. Both groups of facilities only referred severe cases for 2/29 children. The gap of 
providing referral for severe cases has been observed in other studies, and to some extent may be related 
to providers’ beliefs that the cases can be managed locally (Walter, et al., 2009; USAID, 2012). 
Other Tibu Homa factors that may have had an impact on QOC but could not be measured 
independently for the evaluation were reduced waiting time by improving the patient flow in facilities; 
introduction of triage systems; new job aids and flowcharts available for patient care; and improvement of 
record keeping and data management, and the use of data in decision making.
Limitations
This study has used numerous sources of data to triangulate findings and provide evidence about the 
programmatic approaches used during the Tibu Homa project. However, due to data limitations, it was
not possible to quantify the causal effect of the Tibu Homa intervention on QOC. 
A comparison of quality of care was made between Tibu Homa facilities and non-Tibu Homa facilities 
one year after the project ended. The comparison group of facilities was selected in collaboration with 
stakeholders and was based on dIMCI training dates and geographic location. Other facility 
characteristics were adjusted in multivariate models to mitigate remaining differences between 
Tibu Homa Project Performance Evaluation Report 49
comparison and intervention facilities’ quality of care. However, unobserved and/or unmeasured 
differences at facility, patient, or provider-levels may exist that were not captured in the analysis. Further, 
the main outcome measure, the IMCI score, was measured using patient-provider observations. This is a 
strong method but is known to be subject to bias due to a potential for the Hawthorne effect.10 None￾the-less, the Hawthorne effect would result in an over-estimation of quality of care using patient-provider
observations (as compared to quality of care provided in a typical setting that are not observed). Any 
Hawthorn effect, however, is expected to effect both comparison and intervention facilities in the same 
way and should not influence the difference in average IMCI scores between groups.
Although multivariate models were adjusted for the gender of the patient, sample size did not allow for 
disaggregated gender analyses. Where adjusted, gender was not a significant factor related to quality of 
care received.
The program collected a wealth performance monitoring data that were based on patient chart 
abstraction. These data were used in a time series analysis to understand how quality of care changed over 
the course of the Tibu Homa project. Although there were a large number of observations available to 
measure these changes, few covariates were available for analysis from the database that are able explain 
changes in the outcome trends. Given the significant efforts of the Tibu Homa project to improve quality 
of care, it is likely much of the changes observed were associated with project activities. 
Summary
This retrospective evaluation draws on several sources of data to generate insights into the effects of Tibu 
Homa and its sustainability one year later. Results are generalizable to facilities that received dIMCI in the 
Lake Zone, and may be adapted for use in other areas. At the time of the evaluation’s HFS, QOC was 
better in Tibu Homa facilities than in comparison facilities on several observed measures in unadjusted 
and adjusted analyses. Although it is not possible to assign this higher QOC to Tibu Homa activities
owing to the post-only assessment, these results are encouraging and are supported by other sources of 
data. All indications suggest that the effect of Tibu Homa on QOC may be underestimated when 
compared with comparison facilities in Kigoma and Tabora. Time-series data available from performance 
monitoring suggest that QOC increased significantly during the project from a baseline level similar to 
the comparison districts’ QOC at the time of the evaluation’s HFS. These baseline levels in both sources 
of data, albeit at different points in time and regions, are consistent and comparable in terms of staff
having received training but negligible follow-up or SS&M. A consistent body of evidence shows that 
provider training is not sufficient to improve QOC, but follow-up supervision and clinical mentorship are 
viewed as financially prohibitive (Goga & Muhe, 2011; Pariyo, Gouws, Bryce, & Burnham, 2005).
 
10 The Hawthorne effect occurs when participants in a study alter their behavior because they are 
under observation (Lance P, Guilkey D, Hattori A, Angeles G, 2014).
50 Tibu Homa Project Performance Evaluation Report
CONCLUSIONS AND RECOMMENDATIONS
Based on this evaluation, we offer the following conclusions and recommendations.
• Tibu Homa’s approach was associated with improved QOC both during the project and one year 
after the project ended. The facilities visited preferred SS&M to standard supervision, and 
evidence suggests it is effective in improving clinical practice. This aspect of the Tibu Homa
approach is a high-cost intervention that may not be reasonably sustained by the GOT without 
outside funding, especially if it is to be provided monthly. Recommendation: Expand training 
for CHMT members to transform the standard supervision to include clinical mentorship
(such as the Tibu Homa approach) that aligns with GOT’s new guidelines for clinical 
mentorship.
Owing to lack of funding, regularly scheduled SS&M visits are not likely to occur reliably in the 
near future. The following may be alternative approaches to funding regular SS&M in this context: 
o Identify external sources for supporting the current guidelines: one SS&M visit per 
quarter per facility with a longer-term goal of increasing the number of visits. This 
support should include reliable sources of funding for fuel and transportation.
11
o Explore cost containment strategies for SS&M visits.
o Pilot CHMT check-ins via cellular technology for SS&M where in-person visits are not 
possible.
o Explore other methods of accountability in the health system to ensure HCWs’ and 
CHMT members’ incentives are aligned with producing good quality of care, such as 
performance-based incentives.
• Results suggest that dIMCI training and mRDTs were sufficient for appropriate management of 
malaria cases. However, during Tibu Homa, only a small proportion of HCWs were trained per 
facility, and many were transferred. Although assessment for pneumonia improved the most over 
the course of Tibu Homa, accurate classification and treatment of pneumonia need more 
improvement in intervention and comparison facilities. Recommendation: For HCWs who
manage children, use high-coverage dIMCI training or preservice training followed by 
refresher trainings that are conducted via dIMCI. This approach may be sustainable and 
cost-effective. Continue supplementing dIMCI training with additional opportunities for 
clinical mentorship through SS&M and regular facility staff meetings, and consider 
additional support for improving differential diagnosis of pneumonia and appropriate 
referral.
o Investigate innovations in diagnostics for pneumonia that may be appropriate in 
Tanzania.
o Ensure that low-cost timing devices are available at all times.
o Conduct regular clinical mentorship focused on accurate classification and treatment of 
pneumonia, emphasizing that HCWs check for stridor/wheezing and count the 
respiratory rate.
 
11 One DMO visited by the evaluation team had worked with four local NGOs to gain agreement for 
each to cover transportation for SS&M for one quarter per year, thus spreading the cost burden.
Tibu Homa Project Performance Evaluation Report 51
• Health centers provide a higher level of care and are a back-up for many dispensaries when 
referral is needed or medications are out-of-stock. During Tibu Homa, IMCI scores were lower in 
health centers than in dispensaries. This suggests that thorough assessment is possible even where 
resources are limited. Health centers may have more time constraints because of generally higher 
patient-to-HCW ratios, thus hindering HCWs’ ability to spend enough time with each patient. 
Further research could shed light on potential factors creating this disparity. Comparison facilities 
with higher staff-to-patient ratios also had lower QOC measures regardless of facility type. 
Further, facility type was not a significant predictor of QOC when adjusted for facility volume in 
the multivariate model. Completion of the IMCI protocol is known to be more time-consuming 
than standard practice, creating barriers at times for providers who are overwhelmed with patients 
(Prosper, et al., 2009). Recommendation: Explore this topic further to shed light on which
factors related to facility type and patient volume are most important for improving QOC.
Assess whether IMCI training could be tailored to differing challenges and settings (such 
as high- and low-volume facilities, or dispensaries and health centers).
• Creating and maintaining demand from caregivers seeking medical advice for their children is 
highly influenced by perceived QOC in facilities (Leonard, Mliga, & Mariam, 2002). Tibu Homa’s 
community promotion activities increased referrals for fever and institutionalized salient messages 
about care-seeking behavior. However, without good QOC in health facilities, these advances may 
quickly diminish. Caregivers whose children do not get the care they need at local facilities 
(because of inadequate assessment, misclassification, treatment, or medicines) may not return.
This emphasizes the importance of strengthening the supply and demand sides of the healthcare 
systems to achieve greatest impact. Recommendation: Continue to emphasize the 
importance of community-level referral for severely ill children and determine which 
structural barriers may be mitigated for HCWs and clients. Perception of HCWs about
QOC at their referral facility is also an important component to consider. A more 
streamlined health promotion approach may attain similar results to the Tibu Homa 
Project while providing a simpler working approach.
• Appropriate referral for severe cases from health facilities to higher levels of care is another area 
in need of support. Our HFS found that only 2/29 cases that needed referral were actually 
referred to a higher level of care. Many structural factors may inhibit referral for these cases. For 
example, only 23.3 percent of facilities had transportation for referral at the time of the HFS. 
Recommendation: Similar to the above community-level referral recommendation, 
additional exploration may help determine which, if any, structural barriers may be 
mitigated both for HCWs and clients.
• Almost all facilities lacked basic equipment and essential supplies, which can greatly impact QOC. 
Recommendation: Continue to identify funding to procure essential supplies, diagnostics, 
and equipment, focusing on purchases for diagnosis and treatment of pneumonia and 
diarrhea that have the greatest potential for improving child health outcomes. One 
possibility would be to form a coordinated effort by CHMTs through the Community 
Health Fund and/or other funding initiatives such as the Tanzania Social Action Fund 
that focus on vulnerable children.
52 Tibu Homa Project Performance Evaluation Report
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Tibu Homa Project Performance Evaluation Report 55
APPENDIX 1. STATEMENT OF WORK
56 Tibu Homa Project Performance Evaluation Report
MEASURE Evaluation Phase IV
TANZANIA Tibu Homa Evaluation SOW (non AA)
July 2015 – September 2016
April 20, 2017 update
Approved
Carolina Population Center
University of North Carolina at Chapel Hill
400 Meadowmont Village Circle, 3rd Floor
Chapel Hill, NC 27517 USA
TEL: 919-445-9350 FAX: 919-445-9353
 http://www.cpc.unc.edu/measure
Tibu Homa Project Performance Evaluation Report 57
ACTIVITY CODE: 4TZ-001
TITLE: TANZANIA TIBU HOMA EVALUATION
ACTIVITY LEAD: WEAVER, EMILY
START AND END DATES: August 2015-April 2017
PRIMARY RESULT/INPUT: Result 4: Increased Capacity for Rigorous Evaluation
Introduction 
While under-five mortality in Tanzania has declined over the past decade, socio-economic disparities 
in child mortality persist and are especially prominent in rural areas. The highest under-five mortality 
rates are found in the Southern and Lake Zones of Tanzania where malaria, pneumonia, diarrhea, 
HIV/AIDS and neonatal conditions accounted for over 80% of childhood deaths.12. Severe febrile 
illness is a symptom of malaria, pneumonia, and diarrhea, and thus, accurate diagnosis and 
treatment of severe febrile illness is critical.
To reduce under-five morbidity and mortality due to severe febrile illness, URC’s Tibu Homa Project 
was awarded a 5-year Cooperative Agreement in the Lake Zone to: 
1. Increase availability of and accessibility to fundamental facility-based curative and 
preventive child health services;
2. Ensure sustainability of critical child health activities; and
3. Increase linkages within the community to promote healthy behaviors thereby 
increasing knowledge and use of child health services.
The project implemented activities to achieve each objective, some of which varied by geography 
and year of implementation. The initial phase of the project covered the Mwanza, Kagera, and Mara 
regions (phase 1), and in the last year of the project the approach was tailored and expanded into an 
additional three regions, Shinyanga, Simiyu and Geita (phase 2). The project was also implemented 
in a variety of facility types offering differing quality of care, as measured by the project’s baseline 
and performance indicators.
MEASURE Evaluation Phase IV 
The primary objective of MEASURE Evaluation is to enable countries to strengthen their systems to 
generate high quality health information to support for decision making at local, national, and global 
levels. MEASURE Evaluation applies a systems approach to achieve this objective in a sustainable 
way. One application of this approach is to increase capacity for rigorous evaluation. MEASURE 
Evaluation’s results framework reflects the overarching implementation strategy whereby the 
project works through distinct activities to achieve results. Achievements in the four result areas 
shown below contribute to the overall project objective. In this SOW, Measure Evaluation will focus 
on Result Area 4. 
 
12 2007–2008 Tanzania HIV/AIDS and Malaria Indicator Survey
58 Tibu Homa Project Performance Evaluation Report
Result 1: Strengthened collection, analysis and use of routine health data;
Result 2: Improved country-level capacity to manage health information systems, resources and 
staff;
Result 3: Methods, tools and approaches improved and applied to address health information 
challenges and gaps;
Result 4: Increased capacity for rigorous evaluation.
Background for this Scope of Work
Tibu Homa Project Evaluation
MEASURE Evaluation was contacted by USAID/Tanzania to conduct an independent evaluation of 
the Tibu Homa Project. The purpose of the evaluation is to learn to what extent the project’s goals 
and objectives have been achieved and to provide guidance to the Government of Tanzania and 
USAID/Tanzania. Of particular interest is whether a tailored approach used in the last year of the 
project was effective in achieving the project’s stated outcomes. Information about best practices in 
child health programming and results of the evaluation will be used for the purpose of scaling up 
child health services. 
Objectives
The overall objectives for this SOW are:
1. To rigorously contrast and compare factors associated with improved quality of care in Tibu 
Homa Project facilities; examine sustainability of the project’s activities, identify pathways of 
change related to improved quality of care; and assess how to best improve the approach to 
strengthening pediatric care using IMCI together with quality improvement in future USAID 
programming. 
2. To support strengthening of the MOHSW RCHS capacity to participate in, evaluate, and use 
data from project evaluations through a rapid capacity assessment and targeted capacity 
building strategy developed in collaboration with the MOHSW RCHS (if desired by MOHSW 
RCHS staff). 
Tibu Homa Project Performance Evaluation Report 59
Evaluation of pediatric quality of care in facilities participating in the 
Tibu Homa Project
Activity Leader: Emily Weaver (Principal Investigator)
Other Staff: Milissa Markiewicz (Project Manager), Scott Moreland (Costing 
Analyst), Ann Fitzgerald (Country Portfolio Manager)
Senior Technical Advisor: Heidi Reynolds
Objective: To design and implement a research protocol that identifies and compares factors 
associated with improved quality of care in both phases of the Tibu Homa Project. 
Year 1 Work Plan
Summary: 
We propose that the following primary research goals be addressed through a mixed methods 
approach:
1. Compare and contrast factors that are associated with improved QOC in phase 1 versus 
phase 2 Tibu Homa facilities. 
2. Among phase 1 facilities, assess how well project activities have been sustained.
3. Capture the facilities’ experiences implementing the project’s activities.
4. Assess the costs of the change model components that are associated with improved QOC 
through the Tibu Homa Project.
The research questions are motivated by the desire to understand whether the project worked, 
overall and differentially, in phase 1 and phase 2 facilities, and to understand the factors that affect 
performance. Quantitative findings will measure differences in quality of care between phase 1 and 
phase 2 Tibu Homa facilities; the qualitative investigation will explore the experiences with the 
project at the facility level to identify pathways of change. This mixed methods approach provides an 
opportunity to use qualitative research to contextualize the quantitative results and enrich 
interpretation of the evaluation findings.
The proposed mixed methods evaluation will use a cross-sectional design to compare performance 
across phase 1 and phase 2 facility clusters, using both quantitative and qualitative methods. We will 
assess the factors associated with improved quality of care for each phase. An additional component 
of the study will evaluate the cost of intervention components that are found to be associated with 
improved QOC. 
Year 1 Work Plan Narrative
Summary: The evaluation process will be divided into three phases: (1) preparation, (2) data 
collection and (3) data analysis and dissemination.
Preparation Phase:
Prior to finalizing the evaluation design, a two-week visit to Tanzania will be conducted to (1) consult 
with key informants to gather information and feedback about Tibu Homa that will be used as input 
into the design of the new project; and (2) to gather information for design of the evaluation, data 
collection instruments, sampling plan, data collection procedures, and analysis. Two evaluation team 
members will travel to Dar es Salaam and the Lake Region to meet with key informants and conduct 
site visits.
60 Tibu Homa Project Performance Evaluation Report
MEASURE Evaluation will elaborate a more detailed plan for this visit, to include a timeline of 
meetings and transit. URC and USAID will be consulted to help identify key informants and to 
facilitate meetings. A preliminary list of key informants is shown in Table 2, by visit objective.
Discussion guides, to be developed and finalized in collaboration with USAID, will seek to identify 
successful project components and inform recommendations moving forward. The community 
component of the intervention will be addressed during this visit. USAID and MOHSW input will be 
critical in development of the discussion guides. Preliminary results will be shared with USAID prior 
to the team’s departure from Tanzania. A report of findings and recommendations originating from 
key informant consultations will be provided six weeks after the conclusion of the visit.
Preparation:
Task 1.1: Gather information for evaluation design 
Task 1.2: Key informant consultations conducted to obtain programmatic feedback to inform 
USAID mission project planning and MOHSW. 
Task 1.3: Develop data collection instruments and enumerator manuals/interview guides and 
obtain IRB approval
Task 1.4 Conduct rapid capacity building assessment of MOHSW counterparts (if desired by 
MOHSW staff)
Data Collection:
Task 1.5 Train data collection team, pre-test and update the questionnaires, finalize 
instruments, implement and supervise data collection and data entry.
Task 1.6 Clean/archive data and documentation 
Data Analysis and Dissemination
Task 1.7 Perform data analysis and prepare draft report
Task 1.8 Stakeholder review through dissemination meeting
Task 1.9 Finalize report
Tibu Homa Project Performance Evaluation Report 61
Proposed Timelines and Deliverables 
Table 1. 
*Includes time for transcription and translation.
+Comments on the draft report were received from USAID/Tanzania on an ongoing basis through April 2017. 
The report was finalized in May 2017.
Activities Responsible 
Person/Entity
2015 2016
Deliverable July￾Sept Oct –
Dec
Jan￾Mar
Apr￾Jun
Jul￾Sep
1.1 Gather information for 
evaluation design onsite
MEASURE 
Evaluation X
Finalized protocol 
developed and submitted 
to USAID/MOHSW 
1.2 Key informant consultations 
conducted to obtain programmatic 
feedback to inform USAID mission 
project planning and MOHSW.
MEASURE 
Evaluation X X
Preliminary debrief and 
brief report of findings 
submitted to USAID 
1.3 Conduct rapid capacity building 
needs assessment of MOHSW 
counterparts as desired by the 
MOHSW
MEASURE 
Evaluation X
1.4 Develop data collection 
instruments and enumerator 
manuals/interview guides, and 
obtain IRB approval
MEASURE 
Evaluation X
Quantitative and 
Qualitative Data 
Collection instruments 
designed; IRB approval 
obtained
1.5 Subcontracting MEASURE 
Evaluation X
1.6 Train data collection team, pre￾test and update the questionnaires, 
finalize instruments, implement and 
supervise data collection and data 
entry.
MEASURE 
Evaluation and 
Subcontractor
X
1.7 Clean/archive data and 
documentation 
Subcontractor X
1.8 Perform data analysis and 
prepare draft report 
MEASURE 
Evaluation X X
 Draft Evaluation Report 
submitted to USAID
1.9 Obtain Stakeholder review and 
input on report. Conduct 
Dissemination Meeting - Tanzania
MEASURE 
Evaluation, 
MOHSW, USAID
X
1.10 Finalize Report MEASURE 
Evaluation X X Approved Final Report+ 
62 Tibu Homa Project Performance Evaluation Report
Budget Summary 
Budget Narrative
All costs are budgeted with the assumption of start date of July 1, 2015 and an end date of 
August 31, 2016. The estimated cost of the evaluation based on the assumptions outlined in 
the scope of work is $400,988. 
Staffing Plan and Management Plan 
Name Role/Title Technical/Managerial Focus
Country based staff
There will be no project staff based in-country on this activity. A local subcontractor will be hired.
US-based Advisors 
Emily Weaver Activity lead Evaluation 
Heidi Reynolds Senior Technical advisor Evaluation 
Milissa Markiewicz Project Manager Field Operations
Scott Moreland Costing analyst Costing
Ann Fitzgerald Country Portfolio Manager Management Oversight
Emily Weaver, MA, PhD. Activity Lead and Evaluation Specialist. Dr. Weaver will serve as PI for the 
Tibu Homa evaluation, responsible for the evaluation design, implementation, analysis, and report 
writing. Dr. Weaver is a Research Associate for the MEASURE Evaluation project based at the 
Carolina Population Center and an adjunct assistant professor in the Department of Health Policy 
and Management at the University of North Carolina. Dr. Weaver has worked for over 10 years in 
research and evaluation of public health programs with expertise in maternal, newborn and child 
health. Dr. Weaver recently led an evaluation of an emergency obstetric program in Argentina and at 
MEASURE is currently working on an impact evaluation of an integrated agricultural value chain and 
nutrition intervention in Malawi. Dr. Weaver is also building technical capacity in impact evaluation 
and in measurement of maternal mortality using various data platforms in Africa and Asia. Dr. 
Weaver’s methodological expertise spans quantitative, qualitative and mixed methods evaluation 
designs.
Heidi Reynolds, PhD, MPH. Senior Technical Advisor. Dr. Reynolds will serve as a Senior Technical 
Advisor for the evaluation, advising Dr. Weaver on design and analysis. She is the Director for 
Evaluation for the MEASURE Evaluation project based at the Carolina Population Center and an 
adjunct assistant professor in the Department of Maternal and Child Health at the University of 
North Carolina. As Director for Evaluation, Dr. Reynolds provides direction and technical oversight to 
the project’s health areas and evaluation portfolios and leads the project's Learning Agenda that is 
designed to generate evidence about how to strengthen HIS. Her areas of expertise include 
evaluation, health services research, and integration. Recent work includes evaluations of 
organizational networks for health service integration in Ethiopia and of HIV prevention programs 
for key populations in Ghana. She has worked professionally in Cote d’Ivoire, Ethiopia, Ghana, Haiti, 
Tibu Homa Project Performance Evaluation Report 63
Kenya, Senegal, Uganda, and Zambia. Dr. Reynolds earned a PhD in Maternal and Child Health and 
an MPH in Health Behavior and Health Education from UNC.
Milissa Markiewicz, MIA, MPH, PMP. Project Manager. Ms. Markiewicz will provide project 
management, logistic, and qualitative research support to the evaluation. Ms. Markiewicz is 
currently a Research Associate at UNC’s Carolina Population Center (CPC), and serves as CPC’s 
project manager for Feed the Future FEEDBACK. In this role, she supports an impact evaluation in 
Zambia focused on gender and agriculture by managing logistics, monitoring deliverables and 
budgets, conducting qualitative research and analysis, and drafting reports. She previously served as 
project manager/research associate for UNC’s Southeastern Region of the Network for Public Health 
Law where she conducted qualitative research on governance of local public health departments, 
and on national and state public health accreditation. Prior to joining UNC, she served as a program 
director at the Terry Sanford Institute of Public Policy at Duke University where she was part of the 
research team that examined poverty and health in Uganda and in North Carolina. Ms. Markiewicz 
worked in Uganda for over three years as an academic director and special projects coordinator for 
the School for International Training. 
Scott Moreland, PhD, Costing Analyst. Dr. Moreland will lead the costing component of the 
evaluation. Dr. Moreland earned his PhD in Economics from Duke University and has been a 
technical director and health economist with the Palladium Group (formerly Futures Group) since 
1995. Prior to joining Palladium, he served as a senior economist at RTI International for 10 years.
Ann Fitzgerald MPH, Country Portfolio Manager. Ms. Fitzgerald will provide management support 
to the MEASURE Evaluation team implementing this work. She will monitor compliance with the 
MEASURE Evaluation Phase IV Agreement conditions and approved work plan deliverables. Ms. 
Fitzgerald has more than 25 years of experience in public health. Prior to coming to MEASURE 
Evaluation, she led prevention, policy and capacity building projects in Southern Africa and Latin 
America focused on HIV/AIDS, MCH and SBCC. 
64 Tibu Homa Project Performance Evaluation Report
APPENDIX 2. DISCLOSURE OF ANY CONFLICTS OF INTEREST 
Name Emily Weaver
Title Research Associate
Organization University of North Carolina
Evaluation Position? X Team Leader Team member
Evaluation Award Number
(contract or other instrument)
MEASURE Evaluation
USAID Project(s) Evaluated
(Include project name(s), 
implementer name(s) and award 
number(s), if applicable)
Tibu Homa Project, URC
I have real or potential conflicts 
of interest to disclose.
 Yes X No
If yes answered above, I 
disclose the following facts:
Real or potential conflicts of interest may 
include, but are not limited to:
1. Close family member who is an 
employee of the USAID operating unit 
managing the project(s) being evaluated 
or the implementing organization(s) 
whose project(s) are being evaluated.
2. Financial interest that is direct, or is 
significant though indirect, in the 
implementing organization(s) whose 
projects are being evaluated or in the 
outcome of the evaluation.
3. Current or previous direct or significant 
though indirect experience with the 
project(s) being evaluated, including 
involvement in the project design or 
previous iterations of the project.
4. Current or previous work experience or 
seeking employment with the USAID 
operating unit managing the evaluation 
or the implementing organization(s) 
whose project(s) are being evaluated.
5. Current or previous work experience 
with an organization that may be seen 
as an industry competitor with the 
implementing organization(s) whose 
project(s) are being evaluated.
6. Preconceived ideas toward individuals, 
groups, organizations, or objectives of 
the particular projects and organizations 
being evaluated that could bias the 
evaluation. 
I certify (1) that I have completed this disclosure form fully and to the best of my ability and (2) that I will 
update this disclosure form promptly if relevant circumstances change. If I gain access to proprietary 
information of other companies, then I agree to protect their information from unauthorized use or disclosure 
for as long as it remains proprietary and refrain from using the information for any purpose other than that for 
which it was furnished.
Signature
Date
April 20, 2017
Tibu Homa Project Performance Evaluation Report 65
Name Milissa Markiewicz
Title Research Associate
Organization University of North Carolina
Evaluation Position? Team Leader X Team member
Evaluation Award Number
(contract or other instrument)
MEASURE Evaluation
USAID Project(s) Evaluated
(Include project name(s), 
implementer name(s) and award 
number(s), if applicable)
Tibu Homa Project, URC
I have real or potential conflicts 
of interest to disclose.
 Yes X No
If yes answered above, I 
disclose the following facts:
Real or potential conflicts of interest may 
include, but are not limited to:
7. Close family member who is an 
employee of the USAID operating unit 
managing the project(s) being evaluated 
or the implementing organization(s) 
whose project(s) are being evaluated.
8. Financial interest that is direct, or is 
significant though indirect, in the 
implementing organization(s) whose 
projects are being evaluated or in the 
outcome of the evaluation.
9. Current or previous direct or significant 
though indirect experience with the 
project(s) being evaluated, including 
involvement in the project design or 
previous iterations of the project.
10. Current or previous work 
experience or seeking employment with 
the USAID operating unit managing the 
evaluation or the implementing 
organization(s) whose project(s) are 
being evaluated.
11. Current or previous work 
experience with an organization that 
may be seen as an industry competitor 
with the implementing organization(s) 
whose project(s) are being evaluated.
12. Preconceived ideas toward 
individuals, groups, organizations, or 
objectives of the particular projects and 
organizations being evaluated that could 
bias the evaluation. 
I certify (1) that I have completed this disclosure form fully and to the best of my ability and (2) that I will 
update this disclosure form promptly if relevant circumstances change. If I gain access to proprietary 
information of other companies, then I agree to protect their information from unauthorized use or disclosure 
for as long as it remains proprietary and refrain from using the information for any purpose other than that for 
which it was furnished.
Signature
Date
April 20, 2017
66 Tibu Homa Project Performance Evaluation Report
APPENDIX 3. EVALUATION METHODS AND LIMITATIONS 
Table 21. Tibu Homa evaluation research questions, sources of information, key research questions/themes, and responsible organization 
Primary research questions Source of information (method) Secondary research questions/themes Org.
QUALITY OF CARE
What is the value associated with dIMCI 
training and Tibu Homa’s supportive 
components versus the QOC provided in 
comparison facilities that received dIMCI 
training without the supportive components?
Health facility survey (HFS) with
primary data collection
(Quantitative, cross-sectional 
bivariate and multivariate analysis)
• What factors are associated with improved QOC as 
measured by HCW performance using the IMCI algorithm? 
• Do these factors differ between intervention and 
comparison facilities?
• Do these factors differ by diagnosis (such as malaria, 
pneumonia)?
MEASURE Evaluation
What factors are associated with improved 
QOC? Do these factors differ between Phase 
1 (three-day IMCI plus supportive 
components) and Phase 2 (dIMCI plus
supportive components) facilities?
Tibu Homa project data
(Quantitative, secondary bivariate 
and multivariate time series 
analysis)
• Compare and contrast changes in QOC in Phase 1 versus 
Phase 2 Tibu Homa facilities over time for U5 children with 
fever.
• Compare and contrast changes in QOC in Phase 1 versus 
Phase 2 Tibu Homa facilities over time for malaria and 
pneumonia diagnoses. 
What are the costs of the supportive
intervention components associated with 
improved QOC?
Cost data (Cost study) • What is the marginal cost of implementing the supportive 
components as measured by the cost per U5 child with 
fever receiving fully compliant care?
PROJECT IMPLEMENTATION
What have been the facilities’ experiences 
implementing program activities?
Key informant/small group 
interviews (KI/SGIs) with CHMT 
members and HCWs (Qualitative)
• In what ways has Tibu Homa affected QOC? 
• What are the pathways through which Tibu Homa activities 
affected QOC (such as IMCI training, QI, SCM, SS&M)?
• What are barriers and facilitators for improving targeted 
outcomes?
What support did Tibu Homa provide to 
CHMTs?
KI/SGIs with CHMT members and 
HCWs (Qualitative)
• What were the experiences of the CHMT members in 
supporting improvements in QOC, QI, and SCM?
What program activities have been 
sustained?
KI/SGIs with CHMT members and 
HCWs (Qualitative)
• Which Tibu Homa activities are still in place? 
• Does involvement of CHMTs contribute to sustainability of 
project activities? 
Tibu Homa Project Performance Evaluation Report 67
Primary research questions Source of information (method) Secondary research questions/themes Org.
What was Tibu Homa’s approach to 
community mobilization and how was the 
project successful (if it was) in creating 
referral networks for children with fever and 
for orphans and vulnerable children (OVC)?
Focus group discussions (FGDs) and 
KI/SGIs with key actors involved in 
community mobilization
(Qualitative)
• Describe the approach to community mobilization.
• How were existing active community groups identified and 
engaged in health promotion?
• What health promotion activities were conducted? 
• Were community referral networks successfully created? 
PSI
68 Tibu Homa Project Performance Evaluation Report
APPENDIX 4. SOURCES OF INFORMATION
Document review: MEASURE Evaluation is in the process of reviewing the project’s
documentation and other key reports. These include the Health Office’s program description, 
URC’s approved proposal and Program Management Plan, URC’s annual work plans, M&E plan 
and data, quarterly and annual progress reports, data quality reports and program internal 
analyses reports. A number of technical reports will also be reviewed, such as Tibu Homa’s 
“Change Package: Improving health facility diagnosis and treatment of children under five years 
of age with severe febrile illness.” MEASURE will also consult National documents that guided 
program implementation such as National guidelines for IMCI and for management of Malaria.
Secondary data analysis: The evaluation team will use the project’s baseline study and 
performance monitoring data to help develop the evaluation design and sampling strategy. In 
addition, MEASURE will explore the feasibility of a secondary analysis of data from the study 
sponsored by USAID under Tibu Homa “Magnitude, Major Causes and Factors Associated with 
Hospital Deaths among Children under Five Years of Age in the Lake Zone of Tanzania.”
Key informant interviews: The evaluation team will consult with key informants during an 
initial visit prior to the start of field work. Formal key informant interviews will be conducted 
during the data collection period and may include interviews with district-level representatives, 
in-charges at health facilities, and healthcare providers. Key informant interviews with higher 
level stakeholders may be considered as necessary. Qualitative tools will be developed and 
translated into Swahili in the form of semi-structured interview guides. Interviews will be 
conducted in Swahili, audio-recorded, and transcribed. The interviews will then be translated 
into English and analyzed by MEASURE Evaluation staff. Building capacity of in-country staff 
will be maximized by engaging the MOHSW in assisting with interpretation of qualitative 
findings. This will also ensure that the results are contextualized from the Tanzanian perspective. 
Facility survey: The purpose of the facility survey will assess: (1) health provider performance 
related to differential diagnosis and treatment through direct observation; (2) health provider 
knowledge though provider surveys; and (3) availability of effective medicines and diagnostics, 
and the frequency of HMT visits through in-charge surveys. A detailed plan for the facility 
survey will be developed as the evaluation plan becomes formalized and provided for USAID’s 
approval prior to beginning field work. 
Capacity building assessment: A rapid assessment will be conducted with USAID and the 
MOHSW to determine priority areas of capacity building for the MOHSW. A feasible capacity 
building component will then be integrated into the evaluation. A capacity building trip is 
planned for collaborative work on the evaluation analysis that may be revised pending results of 
the rapid assessment. 
Tibu Homa Project Performance Evaluation Report 69
APPENDIX 5. ADDITIONAL TABLES
Table 22. Summary of WHO HFS Indicators
Indicator Comparison Intervention
Patient care indicators
Child is correctly classified (%) 56.0 62.3
Child needing referral is referred†
(%) 13.3 0.0
Child with malaria correctly treated (%) 96.2 94.7
Child with non-severe pneumonia correctly treated (%) 57.1 71.4
Nonurgent children who need an antibiotic get the correct
Antibiotic (%) **42.7 32.8
Nonurgent children not needing an antibiotic who don't get one (%) 31.0 25.7
Total number of observations 232 208
Facility indicators
Availability of equipment and commodities
Index of availability of essential oral treatments 5.9 **6.3
Index of availability of injectable drugs for prereferral
treatment 2.2 2.4
Health facility has essential equipment and materials (%) 0.0 2.3
Support and training
Health facility received at least one supervisory visit that
included observation of case management during the
previous six months (%)
40.0 40.0
Health facilities with at least 60% of workers managing children
trained in dIMCI (%) **58.1 14.0
Health facilities with at least 60% of workers managing children
trained in IMCI or dIMCI (%) **93.0 44.2
Number of facilities 43 43
** p<=0.05
†Cell sizes too small to conduct reliable significance test.
Table 23. IMCI scores by HCW type, 2015 HFS
HCW characteristics Comparison
(n=45)
Intervention
(n=49)
HCW type
 Physician/clinical officer/assistant medical officer 5.5 6.5
 Nursing officer/enrolled nurse/public health nurse 5.7 6.5
 Medical assistant NA 5.2
 Other 4.5 NA
Total 5.5 ***6.3
* p<=0.10; ** p<=0.05; *** p<=0.001
70 Tibu Homa Project Performance Evaluation Report
Table 24. Provider, patient, and facility characteristics for malaria and pneumonia diagnoses, 2015 HFS
Characteristics Malaria Pneumonia
Tibu Homa facility *1.85 3.07
HCW characteristics
 Provider trained in dIMCI *1.35 *1.66
 Provider referenced IMCI chart **-1.25 0.65
Patient characteristics
 Patient age in years -0.05 0.09
 Patient is male 0.22 0.52
Facility characteristics
 Facility is health center 0.00 1.10
 Facility has working baby scale 1.25 -0.05
 Facility has microscope -0.27 -0.72
 Facility has IMCI chart book 1.06 0.65
Facility volume of children 2-59 months (March 2016)
 100–150 children -0.48 -0.78
 150–200 children 1.58 0.64
 200–325 children 0.61 -1.03
 325+ children **2.57 1.86
Number of observations 127 66
* p≤0.10; **p≤0.05;
Tibu Homa Project Performance Evaluation Report 71
APPENDIX 6. LIST OF INDICATORS BY SOURCE 
Tibu Homa Performance Management Database, Project Indicators
• Percent U5s with fever attending facilities and seen by skilled provider within 24 hours
• Percent U5s with fever tested with lab
• Percent U5s with fever with lab-confirmed malaria
• Percent U5s with lab-confirmed malaria who received antimalarial
• Number of eligible OVC provided with 1+ CORE serve, last month
• Number of tracer meds in stock today
• Quarterly: percent of health facilities reporting no stockout of key commodities
• Quarterly: proportion of HFs collecting and using data to improve management of febrile illness
• Quarterly: proportion of HFs with at least 60% of HCWs managing children trained in IMCI
• Percent of staff received SS in last month
• Percent U5s with fever who received antimalarial after testing 
WHO Health Facility Survey, Key Indicators
Service Provision
• Child checked for three general danger signs
• Child checked for the presence of cough, diarrhea, and fever
• Child weight checked against a growth chart.
• Child vaccination status checked
• Index of integrated assessment (IMCI score)
Classification
• Child is correctly classified 
• Child with pneumonia correctly classified
• Child with malaria correctly classified
Treatment
• Child with pneumonia correctly treated
• Child with malaria correctly treated
• Child needing an oral antibiotic and/or an antimalarial is prescribed the drug correctly
• Child not needing antibiotic leaves the facility without antibiotic.
• Child needing referral is referred
Health Facility Preparedness
• Health facility received at least one supervisory visit that included observation of case 
management during the previous six months
• Index of availability of essential oral treatments
• Index of availability of injectable drugs for pre-referral treatment
• Health facilities with at least 60% of workers managing children trained in IMCI
• Health facility has essential equipment and materials
72 Tibu Homa Project Performance Evaluation Report
APPENDIX 7. COMPARISON OF TWO HEALTH FACILITY 
SURVEYS IN KIGOMA AND KAGERA, TANZANIA, 2012–2015
Two HFS have been conducted in Tanzania in the Lake Zone and nearby regions during a three-year 
period (2012–2015) with funding from USAID. A 2012 study, the Tanzania Assessment of Community 
Services for Childhood Illness (ADDO study) was conducted by the Maternal Child Survival Program. 
This survey included a representative sample of dispensaries and Accredited Drug Dispensing Outlets 
(ADDOs) in rural areas of Kagera, Kigoma, and Mtwara Regions in Tanzania. In 2015, MEASURE 
Evaluation conducted a HFS in health centers and dispensaries as part of an evaluation of the Tibu 
Homa project. The evaluation surveyed districts in Kagera, Shinyanga, Simiyu, Kigoma, and Tabora. 
These two HFS were both conducted in dispensaries in Kagera and Kigoma Regions. The purpose of this 
document is to summarize and synthesize results from these two sources of data to learn what trends 
have occurred with regard to quality of care for U5 children over the three-year period in dispensaries in 
Kagera and Kigoma.
To interpret and compare results from these surveys, one must understand how the samples were 
designed. The ADDO study randomly sampled dispensaries within each selected district, with the 
purpose of generating a regionally representative sample of rural facility-level data. Thus, when aggregated 
at the regional level, the ADDO data from 2012 can be considered representative of rural areas in these 
regions. In Kagera, sampled districts included Bukoba Rural, Chato, Missenyi, and Muleba. In Kigoma, 
sampled districts included Kasulu and Kigoma Rural. Patient-provider interactions (cases) were observed
for U5 children with diarrhea, fever, or cough/difficult breathing.
The Tibu Homa evaluation of 2015 HFS data should be interpreted with more caveats. The Tibu Homa 
HFS randomly sampled dispensaries from all three Tibu Homa Project regions (including Kagera) and 
two comparison regions (including Kigoma). In Tibu Homa project regions, all Phase 2 project districts8
were selected and then a random sample of dispensaries was drawn from them. This resulted in the 
selection of two districts in Kagera: Missenyi and Bukoba Rural. In Kagera, this sample is partially 
representative of dispensaries that participated in Tibu Homa.13 In the Tibu Homa HFS comparison 
regions, districts most geographically proximate to the Lake Zone were purposefully selected. The two 
districts in Kigoma that were selected were Kikonko and Kobondo. In Kigoma, the sample is 
representative of dispensaries where healthcare workers had received dIMCI training in selected districts. 
Cases for U5 children with fever were observed.
It is possible to make direct comparisons between dispensaries in two districts in Kagera in 2012 and 
2015: Missenyi and Bukoba Rural. It also is possible to make aggregate comparisons between the 
Kigoma and Kagera Regions over time, acknowledging that the data are drawn from only partially 
overlapping samples of districts.
Table 25 compares a subset of indicators available at the district level in both survey years for dispensaries 
in Bukoba Rural and Missenyi. In general, availability of oral treatments declined slightly between 2012 
and 2015, including essential oral treatments, and first-line pneumonia and antimalarial drugs. However, 
availability of basic equipment for child health services and availability of pre-referral injectable drugs 
increased. At the patient level, the percentage of children checked for three danger signs increased 
 
13 Because sampling in Tibu Homa facilities was not stratified by region, but sampled from the whole, we 
cannot say that the data from Kagera are representative of all Tibu Homa Phase 2 facilities or of those 
districts themselves.
Tibu Homa Project Performance Evaluation Report 73
dramatically from 18.2 percent to 88.0 percent. The percentage of children whose vaccination status was 
checked was 63.6 percent in 2012 and 68.0 percent in 2015.
Table 25. Comparison of 2012 and 2015 HFS survey data from dispensaries in two districts in Kagera
2012 
(ADDO Study)
2015 
(THP Evaluation)
Facility-level (n=18 facilities) (n=7 facilities)
Number of essential orals treatments available (out of 9) 6.5 5.0
First-line pneumonia drug available (%) 50.0 42.9
First-line antimalarial drug available (%) 83.3 76.0
Basic equipment required for child health services (%) 38.9 85.7
Number of pre-referral injectables available (out of 5) 3.0 4.4
Patient-level (n=55 cases) (n=25 cases)
Three danger signs checked (%) 18.2 88.0
Vaccine status checked (%) 63.6 68.0
Note: The following definitions were used per the 2012 ADDO study to maximize comparability: Number of essential 
oral treatments includes ORS, zinc, iron, vitamin A, mebendazole, paracetamol, and first-line drugs for pneumonia, 
malaria, and dysentery. Basic equipment for child health services includes an accessible and working child
weighing scale, timing device for diagnosis of pneumonia, and vaccination cards. The first-line drug measured in 
2012 was cotrimoxazole and in 2015 was amoxicillin. Facilities selected in 2012 were designed to be representative 
at the district level. Facilities selected in 2015 were not randomly sampled. 
Sources: 2012 Tanzania Assessment of Community Services for Childhood Illness; 2015 Tibu Homa Evaluation
Table 26 compares indicators of QOC for cases observed in two samples of facilities in Kigoma and 
Kagera Regions in 2012 and 2015. Again, 2012 estimates can be considered representative of rural 
dispensaries in these regions, whereas the 2015 estimates are drawn from a subset of randomly selected 
Tibu Homa Project dispensaries in Kagera, and a random sample of dispensaries where healthcare 
workers had received dIMCI training in two districts.
The last column of Table 26 provides unadjusted difference in differences (DID) estimates—meaning 
that it is a naïve calculation of the DID of the indicators over time within regions. For example, the 
percentage of children checked for three danger signs in Kigoma increased from 6.4 percent to 45.1
percent between 2012 and 2015; an increase of 38.7 percentage points. In Kagera, the percentage of 
children checked for three danger signs increased from 15.3 percent to 88.0 percent, an increase of 72.7 
percentage points. The difference in differences for these estimates is 34.0 percentage points (72.7-38.7). 
Specifically, in Kagera, where the Tibu Homa project was operating, the percentage of children checked 
for three danger signs increased 34 percentage points more than the increase of the same in Kigoma.
These results do not directly attribute change to the Tibu Homa Project, but give a simplistic comparison 
of the difference in changes that occurred in these two regions. Assessment of U5 children improved 
more in Kagera (in Tibu Homa districts) than in Kigoma (districts without Tibu Homa support) for 
children being checked for three danger signs; presence of diarrhea, cough, and fever; weighed and 
checked against a growth chart; and also slightly for vaccination status. The sample of disease-specific 
treatment indicators is very small, and thus comparison is limited for these indicators. Nonetheless, a 
comparison was possible for children with pneumonia, where the increase in percentage of children 
correctly treated was 41.7 percentage points greater in Kagera than in Kigoma.
74 Tibu Homa Project Performance Evaluation Report
Table 26. Comparison of 2012 and 2015 HFS survey data from Kagera and Kigoma Regions
Kigoma Kagera
Indicator 2012 2015 2012 2015 DID
Child checked for three danger signs (%) 6.4 45.1 15.3 88.0 34.0
Child checked for the presence of diarrhea, cough, and fever (%) 17.2 57.3 20.6 76.0 15.3
Child weight checked against a Road to Health chart (%) 10.7 1.2 43.2 60.0 26.3
Child vaccination status checked (%) 21.5 53.7 60.5 100 7.4
Child is correctly classified (%) 24.7 51.2 22.1 64.0 15.4
Child with pneumonia correctly treated* (%) 44.4 75.0 27.7 100.0 41.7
Child with diarrhea correctly treated with ORS and zinc** (%) 7.8 NA 5.4 NA NA
Child with malaria correctly treated*** (%) 60.5 94.5 71.4 NA NA
Child needing referral is referred (%) 0.0 0.0 7.6 0.0 NA
Number of cases observed 93 82 104 25
*Four cases of pneumonia in Kagera and eight cases in Kigoma in the 2015 survey
**There were no cases of diarrhea in Kagera or Kigoma in the 2015 survey
*** There were zero cases of malaria in Kagera and 22 cases in Kigoma in the 2015 survey
Sources: 2012 Tanzania Assessment of Community Services for Childhood Illness; 2015 Tibu Homa Evaluation
Tibu Homa Project Performance Evaluation Report 75
APPENDIX 8. INSTRUMENTS
Table 27. Summary of research questions, sources of information, and evaluation tools
Primary research questions Source of information Evaluation tools
What is the value associated with 
dIMCI training and Tibu Homa’s 
supportive components versus the 
QOC provided in comparison 
facilities that received dIMCI training 
without the supportive components?
Health facility observation 
and check-list
WHO Health Facility Survey
(HFS) (modified)
What factors are associated with 
improved QOC? Do these factors 
differ between Phase 1 (three-day 
IMCI plus supportive components) 
and Phase 2 (dIMCI plus supportive 
components) facilities?
Tibu Homa project data Tibu Homa Performance 
Monitoring database
What are the costs of the supportive
intervention components associated 
with improved QOC?
Cost data (Cost study)
Key informant/small-group 
interviews (KI/SGIs) with 
CHMT members (Qualitative)
Cost study instruments
KI/SGI Guide for R/CHMT 
Members
What have been the facilities’ 
experiences implementing program 
activities?
KI/SGIs with CHMT members 
and HCWs (Qualitative)
KI/SGI Guide for:
- Health Care Workers
- R/CHMT Members
What support did Tibu Homa provide 
to CHMTs?
KI/SGIs with CHMT members 
(Qualitative)
KI/SGI Guide for R/CHMT 
Members
What program activities have been 
sustained?
KI/SGIs with CHMT members 
and HCWs (Qualitative)
Health facility observation 
and check-list
KI/SGI guides for:
- Health Care Workers
- R/CHMT Members
WHO HFS(modified)
What was Tibu Homa’s approach to 
community mobilization and how 
(and if) was the project successful in 
creating referral networks for children 
with fever and for orphans and 
vulnerable children (OVC)?
Focus group discussions 
(FGDs) and KI/SGIs with key 
actors involved in 
community mobilization
FGD guides for:
- CQIT Members
- Community Social Group 
 Members
- Community Coaches
KI/SGI guides for:
- Traditional Healers
- Community Health Workers
- CHW Supervisor
76 Tibu Homa Project Performance Evaluation Report
Quantitative Instruments
HFS Observation Checklist—Child (2 Months–59 Months)
District: _________________________ Date: _____/_____/________
 
Facility Name ____________________ Facility Code ____________ 
Facility type: 1. Health center
 2. Dispensary 
Surveyor ID: ___________
Health worker: Name ________________ ID _________ Sex: 1. Male 2. Female
 
Type
1. Physician/Clinical Officer/Assistant Medical Officer 
2. Nursing Officer/Enrolled Nurse/PHN/Nurse Midwife 
3. Medical Assist 
4. Other
Trained:
1. IMCI
2. dIMCI
3. Other IMCI
4. None
Month training began (mm/yyyy) 
1. IMCI Month training began (mm/yy) ____ /____
2. dIMCI Month training began (mm/yy) ____ /____
3. Other IMCI Month training began (mm/yy) ____ /____
Child’s: Name ________________ ID: _________ Sex: 1. Male 2. Female
 Birth date (dd/mm/yy): ____/____/______ Age in months: ________
Child’s arrival time at facility: ____hours____ minutes 
Begin timing the observation now. Time:____ hours ____ min. Waiting time: ________ minutes
Tibu Homa Project Performance Evaluation Report 77
Assessment Module
Record what you hear or see.
A3. Does the health worker or another staff, weigh the child today?
1. Yes
2. No
8. Doesn’t know
A4. Does the health worker or another staff, check the temperature of the child? 
1. Yes
2. No
A5. What reasons does the caretaker give for bringing the child to the health facility? Circle all 
signs mentioned.
a. Diarrhea/vomiting 1. mentioned 2. not mentioned
 b. Fever/malaria 1. mentioned 2. not mentioned
c. Fast/difficult breathing/cough/pneumonia 1. mentioned 2. not mentioned
d. Ear problem 1. mentioned 2. not mentioned
e. Well-child visit 1. mentioned 2. not mentioned
f. Other 1. mentioned 2. not mentioned
 specify ____________________________
g. None given 1. mentioned 2. not mentioned
A6. Does health worker ask whether the child is able to drink or breastfeed?
1. Yes
2. No
A7. Does health worker ask whether the child vomits everything?
1. Yes
2. No
A8. Does health worker ask whether the child has convulsions?
1. Yes
2. No
A9. Is the child visibly awake (e.g., playing, smiling, crying with energy)?
1. Yes Skip to question # A11
2. No
A10. If child not visibly awake, does health worker check for lethargy or unconsciousness (try 
to wake up the child)?
1. Yes
2. No
A11. Does health worker ask about cough or difficult breathing?
1. Yes
2. No
78 Tibu Homa Project Performance Evaluation Report
A11a. If child brought in for cough or difficulty breathing, does health worker check respiration 
rate or for chest in drawing?
1. Yes
2. No
A12. Does health worker ask about diarrhea (number of days, severity)?
1. Yes
2. No
A12a. If child brought in for diarrhea, does the health worker ask about blood in the stools?
1. Yes
2. No
A12b. If child brought in for diarrhea, does the health worker check for dehydration (sunken 
eyes, drinks eagerly, irritability)?
1. Yes
2. No
A12c. If child brought in for diarrhea, does the health worker ask about duration of diarrhea (14 
days or more)?
1. Yes
2. No
A13. Does health worker ask/feel for fever (or refer to temperature if taken previously)?
1. Yes
2. No
A13a. If child brought in for fever and malaria is suspected, does health worker administer a 
rapid diagnostic test (mRDT) or order a lab blood test (microscopy) to confirm malaria? 
1. Yes 
2. No
 If yes, circle one: mRDT microscopy (blood slide)
A13b. Results
1. Positive
2. Negative 
A14. Does health worker check for visible severe wasting?
1. Yes
2. No
3. Don’t know
A15. Does health worker look for palmar pallor?
1. Yes
2. No
3. Don’t know
A16. Does health worker look for oedema of both feet?
1. Yes
2. No
3. Don’t know
Tibu Homa Project Performance Evaluation Report 79
A17. Does health worker check child’s weight against a growth chart?
1. Yes
2. No
A18. Does the health worker ask for and check the child’s vaccination card?
1. Yes
2. No Skip to question # A20
A19. Does the caretaker have the child’s vaccination card?
1. Yes Skip to question # A21
2. No
A20. Does the health worker ask the caretaker the following questions?
 a. Has your child been given an injection in the shoulder 
 against tuberculosis (BGG)? 1. Yes 2. No
b. Has your child been given drops against polio? 1. Yes 2. No
c. Has your child been given injection against DTP? 1. Yes 2. No
d. Has your child been given an injection in the arm against measles? 1. Yes 2. No
e. Has your child ever been given vitamin A capsules? 1. Yes 2. No
A21. Does health worker ask about breastfeeding?
1. Yes
2. No
A22. Does health worker ask whether the child takes any other foods/fluids?
1. Yes
2. No
A23. Does health worker ask whether feeding changed during illness?
1. Yes
2. No
A24. Does health worker ask about possible “other problems”?
1. Yes
2. No
A25. Does health worker ask about HIV status or check child’s card for HIV status?
1. Yes
2. No
80 Tibu Homa Project Performance Evaluation Report
Classification Module 
C1. Does health worker give one or more classifications for the child?
1. Yes 
2. No  Skip to Treatment Module 
Record all classifications given in the table below: 
To be completed by supervisor: ID_____
 
C05. One or more danger signs 1 2
C10.Severe pneumonia/very severe disease 1 2
C11.Pneumonia 1 2
C12.No pneumonia 1 2
C20.a Severe dehydration 1 2
 b Some dehydration 1 2
 c No dehydration 1 2
C21.Severe persistent diarrhea 1 2
C22.Persistent diarrhea 1 2
C23.Dysentery 1 2
C30.Very severe febrile disease 1 2
C31.Malaria 1 2
C32. Fever, malaria unlikely 1 2
C33. Fever, no malaria – 1 2
C34.Severe complicated measles 1 2
C35.Measles with eye/mouth complications 1 2
C36.Measles 1 2
C40.Mastoiditis 1 2
C41.Acute ear infection 1 2
C42.Chronic ear infection 1 2
C43. No ear infection 1 2
C50.a Severe malnutrition 1 2
b Severe anaemia ‘ 1 2
C51.a Anaemia 1 2
b Very low weight 1 2
C52. No anaemia and not very low weight 1 2 
C60. Other (specify)____________________ 1 2
C61. Other (specify)_____________________ 1 2
Based on the re-examination of the 
child (instrument 3A) circle surveyor 
classifications
105. One or more danger signs
Severe/very severe Pneumonia
111. Pneumonia
112. No pneumonia
120. a Severe dehydration
 b Some dehydration
 c No dehydration
121. Severe persistent diarrhea
122. Persistent diarrhea
123 Dysentery
130. Very severe febrile disease
131. Malaria
132. Fever, malaria unlikely
133. Fever, no malaria
134. Severe complicated measles
135. Measles with eye/mouth complication
136. Measles
140. Mastoiditis
141. Acute ear infection
142. Chronic ear infection
143. No ear infection
150. a Severe malnutrition
 b Severe anaemia
151. a Anaemia
 b Very low weight
152. No anaemia and not very low weight
160. 
Other(specify)__________________
161. 
Other(specify)__________________
165. Follow-up visit required in ____days
170. Malaria risk: 
 1. high, 
 2. low, 
 3. No risk
Tibu Homa Project Performance Evaluation Report 81
Treatment Module
T1. Does health worker administer or prescribe injection(s)?
1. Yes
2. No Skip to question # T3
T2. If yes, record all injections given:
a. Antimalarial 1. Yes 2. No
b. Antibiotic 1. Yes 2. No
c. Other injection: specify: _____________________ 1. Yes 2. No
d. Unknown type 1. Yes 2. No
T3. Does the health worker administer or prescribe ORS?
1. Yes
2. No Skip to question # T5
T4. If yes health worker administer ORS at the facility?
1. Yes
2. No 
 8. Don’t know
T5. Does the health worker prescribe immediate referral for the child?
 1. Yes
 2. No Skip to question # T6
T5a Does the caretaker accept referral for the child?
 1. Yes Record time at the end of the questionnaire.
 2. No
T6. Does the health worker administer or prescribe oral treatment?
 1. Yes
 2. No Skip to Communication Module, question # CM5
T7. Record all oral treatment given or prescribed:
a. ORS 1. Yes 2. No
b. Zinc 1. Yes 2. No
c. Cotrimoxazole antibiotic tablets/syrup for dysentery 1. Yes 2. No
d. Metronidazole tablets/syrup 1. Yes 2. No
e. Any other antidiarrheal/antimotility drug 1. Yes 2. No
 Specify: ______________________________
f. Recommended antimalarial tablets/syrup (ACT) 1. Yes 2. No
 Circle one: 
 1) Artemether-Lumefantrine
 2) Dihydroartemisinin plus Piperaquine (DPQ)
g. Other antimalarial tablet/syrup 1. Yes 2. No
 Circle one: 
 3) Artesunate IM/rectal
 4) Quinine IM
 5) Other, specify: ______________________________
82 Tibu Homa Project Performance Evaluation Report
h. Paracetamol/aspirin 1. Yes 2.No
i. Cotrimoxazole antibiotic tablets/syrup for pneumonia 1. Yes 2.No
j. Other antibiotic tablets/syrup 
 Specify________________________________ 1. Yes 2.No
k. Vitamin A 1. Yes 2.No
l. Multi-vitamins 1. Yes 2.No
m. Other vitamins 1. Yes 2. No
 Specify: ______________________________
n. Mebendazole 1. Yes 2. No
o. Iron tablets/syrup 1. Yes 2. No
p. Tablets/syrup, unknown type 1. Yes 2. No
q. Others specify: ______________________________ 1. Yes 2. No
T8. Does the oral treatment prescribed by the health worker include an antibiotic?
1. Yes
2. No Skip to question T10
T9. If the oral treatment includes an antibiotic, record what health worker says:
 Second antibiotic: 
a. Name: __________________ f. Name: _________________
 b. Formulation: ______________ g. Formulation:____________
 c. Amount each time:_________ h. Amount each time:_______
 d. Number of times per day:____ i. # times per day:__________
 e. Total days:_______________ j. Total days:_____________
T10. Does the oral treatment prescribed by the health worker include an antimalarial?
1. Yes
2. No Skip to Communication Module
T11. If the oral treatment includes an antimalarial, record what health worker says:
Second antimalarial: 
a. Name: ___________________ f. Name: _________________
 b. Formulation: ______________ g. Formulation:____________
 c. Amount each time:_________ h. Amount each time:_______
 d. Number of times per day:____ i. # times per day:__________
 e. Total days:_______________ j. Total days:_____________
Tibu Homa Project Performance Evaluation Report 83
COMMUNICATION MODULE
CM1. Does the health worker EXPLAIN how to administer oral treatment? 
a. antibiotic 1. Yes 2. No 3. NA
b. antimalarial 1. Yes 2. No 3. NA
c. ORS 1. Yes 2. No 3. NA
d. Zinc 1. Yes 2. No 3. NA
CM2. Does the health worker DEMONSTRATE how to administer the oral treatment? 
a. antibiotic 1. Yes 2. No 3. NA
b. antimalarial 1. Yes 2. No 3. NA
c. ORS 1. Yes 2. No 3. NA
d. Zinc 1. Yes 2. No 3. NA
CM3. Does the health worker ask an open-ended question to VERIFY the caretakers’ 
comprehension of how to administer the oral treatment? 
a. antibiotic 1. Yes 2. No 3. NA
b. antimalarial 1. Yes 2. No 3. NA
c. ORS 1. Yes 2. No 3. NA
d. Zinc 1. Yes 2. No 3. NA
CM4. Does the health worker give or ask the mother to give the first dose of the oral drug at the 
facility? 
a. antibiotic 1. Yes 2. No 3. NA
b. antimalarial 1. Yes 2. No 3. NA
CM5. Does the health worker prescribe and explain when to return for a follow-up visit? 
1. Yes
2. No Skip to question # CM7
CM6. In how many days does the health worker ask the caretaker to come back?
1. Two days
2. Five days
3. 14 days
4. 30 days
5. Other: ____ days
CM7. Does the health worker explain the need to give more liquid or breastmilk at home? 
 1. Yes 
 2. No
CM8. Does the health worker explain the need to continue feeding or breastfeeding at home?
1. Yes 
 2. No
CM9. Does the health worker give correct age-specific advice on the frequency of feeding/BF? 
 1. Yes 
 2. No
84 Tibu Homa Project Performance Evaluation Report
CM10. Does the health worker tell the caretaker to bring the child back immediately for the 
following signs? Tick all that apply.
a. Child is not able to drink or breastfeed 1. Yes 2. No 
b. Child becomes sicker (unconscious, lethargic) 1. Yes 2. No 
c. Child develops a fever 1. Yes 2. No 
d. Child develops fast breathing 1. Yes 2. No 
e. Child develops difficult breathing 1. Yes 2. No 
f. Child develops blood in the stool 1. Yes 2. No 
g. Child drinking poorly 1. Yes 2. No
h. Child vomits everything 1. Yes 2. No
i. Other, specify ___________________________ 1. Yes 2. No
CM11. Did the health worker ask at least one question about the mother’s health (ask about her 
own health, access to family planning or vaccination status)?
 1. Yes 
 2. No
CM12. Did the health worker use the IMCI chart booklet at any time during the management of the 
child?
 1. Yes 
 2. No
 3. Don’t know
Check the time of the observation as the caretaker leaves: Time:____ hours _____ min. 
Total observation time: ________ minutes ( From observation time excluding child’s arrival time)
 
END OF OBSERVATION
The surveyor may need to ask the health worker about the diagnosis made and the treatment given during the consultation, but 
only if these two components were not stated during the consultation. The surveyor must complete this form before the next child 
observation.
Tibu Homa Project Performance Evaluation Report 85
SUPERVISOR CODING
Indicator Formula Codes
A Does the child need a follow-up 
visit?
Based on re-examination (page 5, 
question 165)
(1) 
Yes
(2) 
No
B If antibiotics were prescribed 
(whatever the reason) were they 
prescribed correctly?
YES in T8 and CORRECT for T9c, 
d and e and h, i , and j if 2 antibiotics
(1) 
Yes
(2) 
No
(8) NA
(no AB)
C If antimalarials were prescribed 
(whatever the reason) were they 
prescribed correctly?
YES in T10 and CORRECT in 
T11c, d and e and h, i , and j if 2 
antimalarials 
(1) 
Yes
(2) 
No
(8) NA
(no AM)
D If the child was referred (whatever 
the reason) did the child receive an 
appropriate pre-referral treatment?
YES in T5a and appropriate pre￾referral treatment in T2 and/or T3 
(1) 
Yes
(2) 
No
(8) NA
(child not 
referred)
Equipment and Supply Checklist
Date:___/___/______
District: ______________________ Surveyor ID: ___________
Facility name: _________________ Facility Code:__________ 
Facility type: 1. Health center 
 2. Dispensary
Discuss with the head of facility to determine the number of health workers who usually have child case￾management responsibilities:
Table 1. Characteristics of healthcare workers with case management responsibilities for 
children
Category
# HCWs 
assigned 
to 
facility
# HCWs assigned 
to facility who 
usually manage 
children
# HCWs usually 
managing 
children present 
today
# HCWs usually 
managing 
children dIMCI￾trained
# trained in 
dIMCI 
present 
today
Physician, Clinical 
officer, Assistant 
Medical officer
Nurse Officer, 
Enrolled Nurse, 
Public Health 
Nurse, Nurse 
Midwife
Medical Assistant
Others
Total
86 Tibu Homa Project Performance Evaluation Report
Equipment and Supplies Module
Ask health worker to show you around the facility. Look and touch to complete the following questions.
E1. Does this facility have the following equipment and materials? (Circle if yes)
a. Patient register
b. Patient register for children under 5 (separate from adults)
c. Accessible and working baby scale
d. Working watch/timing device available to every health worker managing children
e. Supplies to mix ORS, cups and spoons
f. Source of clean water
g. Microscope
h. Stock cards/drug logbook
i. Patient records
a. If yes, are they in use? 1. Yes 2. No
j. Child vaccination cards
k. Mothers’ counselling cards
l. IMCI chart booklet
m. Accessible means of transportation for patients requiring referral
n. Other job aids? Specify __________________________________
E1a. Patient register or HMIS contains (circle):
P 1-2-3 Fever began last 24 hours OVC mRDT test
E3. Does the facility have a functional sterilizer, cooker or stove?
1. Yes 
2. No
E4. Does the facility have a functioning fridge?
1. Yes Skip to #E7
2. No
E5. Does the facility have ice packs and cold boxes?
1. Yes 
2. No
E7. Does the facility have electricity?
1. Yes 
2. No
E8. Does the facility have a designated area for patient triage?
1. Yes 
2. No
Tibu Homa Project Performance Evaluation Report 87
Availability of Drugs Module
Check the drug stocks. Answer whether the drugs are in-stock based on what you see (second column). 
Then check whether the stock-out form is accurate based on the drugs in stock identified (third column).
D1. Does the facility have the following drugs available the day of visit (circle)?
Name In stock? If no, reflected in 
stock-out form?
a.ORS
Pneumonia:
b.Amoxicillin Syrup 
c.Erythromycin 
d.Cotrimoxazole antibiotic tablets/syrup 
e.Amoxicillin tablet
Dysentery
f. Zinc
g.Cotrimoxazole antibiotic tablets/syrup (dysentery) -
Recommended antibiotic for dysentery
h. Metronidazole tablets/syrup
i. Ciprofloxacin tablets 
Malaria
j. Artemether-Lumefantrine (first-line recommended)
a. 6 tablets
b. 12 tablets
c. other
k. Dihydroartemisinin plus Piperaquine (DPQ) (second-line 
recommended antimalarial)
l. Quinine tablets
m. Another antimalarial
HIV
p.Ped Combivir (60mg/3TC 30mg)
q.Ped Ducvir N (AZT 60 mg/3TC 30mg/NVP 50mg)
r. Triomune Baby (d4T 6mg/3TC 30mg/NVP 50mg)
s. Efaverenz (200mg)
t. Triomune Junior (d4T 12mg/ 3TC 30mg/ NVP 100mg)
Other
u. Vitamin A
v. Iron
w. Paracetamol/aspirin
x. Mebendazol/albendazole
y. Tetracycline eye ointment
z. Gentian violet
aa. Other vitamins
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
1. Y 2. N
D1a. Does the facility have mRDTs on the day of the visit?
1. Yes
2. No How long has the facility been out of stock in the past month? Days ___________
3. Don’t know
D2. Does the facility have the following injectable drugs available the day of the visit (circle if yes)?
a. Chloramplenicol Injection (Recommended intramuscular antibiotic for children)
b. Artesunate IM/rectal (Pre-referral treatment and first-line treatment for severe malaria)
c. Quinine IM (Pre-referral treatment and second-line treatment for severe malaria)
d. Benzylpenicillin IM
e. Gentamycin IM
f. Sterile water for injection
g. Recommended IV fluid for severe dehydration
1. Ringer Lactate Solution
2. Normal saline
88 Tibu Homa Project Performance Evaluation Report
Facility Services Module
Ask the following questions to the health worker who has been observed during case management. If 
there are several health workers who have been observed managing cases in the same facility, discuss the 
following questions with all of them and try to reach a consensus for each question. Add comments on 
the back of the form if you have any problems.
S1. How many days per week is the facility open? Days/week ____________
S2. How many days per week are child health services provided? Days/week ____________
S5. How many times during the last six months did the facility receive a supervisory visit? 
Times ______ If 0 time, skip to question #S8
a. How many visits recorded in the visitor log? Visits _________________
S6. How many of these supervisory visits were follow-up visits to health workers 
who have recently been trained in IMCI/dIMCI? Visits _________________
Ask the health worker question S7 based on the most recent supervisory visit that was not an IMCI 
follow-up visit:
S7. Did the supervisor observe case management of a sick child the last time he/she visited the 
facility?
1. Yes
2. No
8. Don’t know
S8. Where do you refer severely-ill children?
1. Hospital, specify _______________
2. Private physician_______________
3. Other, specify _________________
S9. How long does it take for the patient to get to the referral center/physician 
using the most common local transport? 
Hours_______
S10. Have you ever wanted to refer a very severely-ill child but been unable to do so?
1. Yes Why? ___________________________________________________
2. No
S11. If you had to refer 10 children to the hospital, how many of them do you think 
will end up going to the hospital? 
Number ________
Tibu Homa Project Performance Evaluation Report 89
Facility Records Module
Ask the health worker responsible for records to help you identify records for all visits to the health facility. 
Do not include inpatient records. Use these records to answer the questions below. Use summarized 
records from March, 2016 (MTUHA Book 5)
R1. What is the total number of visits to the health facility for outpatient services 
during the previous month? No of visits ______
R2. How many of these visits were made by children from 0 up to 59 months? 
Visits by children under 5:_______
R3. How many of these child visits were made by female children: Visits: _____
R4. How many of these visits were made by children between the ages of 0-2 months? 
Visits by children 0 day-28 days: ______
Comments
1. ______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
2. ______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
3. ______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
90 Tibu Homa Project Performance Evaluation Report
Cost Study Instruments
Marginal Costs Associated with Implementing the 
Tibu Homa Project Supportive Components
Purpose
The ultimate purpose of the costing component of the evaluation is to estimate the costs of scaling up the 
Tibu Homa Project (Tibu Homa) dIMCI intervention were the Government of Tanzania to do so. We 
will estimate the marginal cost of implementing the supportive components as measured by the cost per 
child under five years of age receiving fully compliant care compared to the stand-alone dIMCI approach.
We will identify all resources used to implement and carry out the intervention, the amount used of the 
resources, and the unit costs of the resources to estimate this outcome. 
Cost Data
The Tibu Homa project is over and had developed the various training materials, supportive supervision 
guidelines, and other tools to implement the Tibu Homa dIMCI, so these are sunk costs and will not 
figure in the costs for the GOT or other IP of implementing the Tibu Homa supportive components. 
Therefore, the cost study will determine the extra costs of implementing the Tibu Homa dIMCI 
approach, and include only labor costs associated with extra time and resources allocated to implementing 
the supportive components will be counted (e.g., training of health care workers, training for R/CHMT 
members on supportive supervision, and travel costs for supportive supervision associated with the Tibu 
Homa supportive components). Interviews with people who have access to financial records will provide 
most of the costing information. 
Type of Cost Data
Type Source options
Training Costs IP options similar to URC
1) MEASURE AA
2) HDIC
3) Tibu Homa staff
4) EGPAF
5) PSI
Training of trainers
Training manual and other materials
Financial costs of training
Training of HCWs
Financial costs
Training of Supervisors
Financial costs
Supportive Supervision Costs 1) District-level KII 
Interviews
Summary of Supportive Supervision activities
Transportation costs
Other supervision costs
Tibu Homa Project Performance Evaluation Report 91
Data Collection
Note that other than the tables provided to document the respective costs, you will have to take notes of 
the information you gain and make these notes available so that we can correctly interpret the costing 
information. 
Questionnaire Guide
The information for the data collection forms will be generated from your discussions with the project 
manager(s) and finance person/people. If some information provided in the forms is not relevant, 
simply indicate “n/a” (for “not applicable”). Provide any needed explanations. Finally, it is not expected 
that all rows will be filled in. The question numbers in the questionnaire map to the column numbers in 
the tables.
Form 1A-B
For all trainings conducted for implementing the Tibu Homa supportive components (i.e., TOT training, 
HCW training, training in SS (e.g., supervision)), obtain information requested only as applicable. Not all 
fields must be filled in. Costs may or may not differ by training type (e.g., TOT/HCW/Supervisors). You 
may ask this up front and then just collect one set of information for all if applicable.
Form 2. Personnel
Fill in Form 2 for all additional personnel who would work to implement the Tibu Homa training (e.g., 
TOT, QI, SCM, and Supervision). Do not neglect support personnel (e.g., those people whose efforts 
are concentrated in preparation and planning). Names and salaries and benefits for a specific person are 
not needed. Job titles and salaries and benefits for a typical person in the same position are sufficient. We 
will use this information to budget for a contractor hired to plan and carry out the trainings.
Personnel will probably include: 
• Organizational employees (e.g., contractors) who:
- Printed training manuals, curricula, etc.
- Prepared for, assisted in, participated in, or conducted trainings
For organizational employees get their job title, whether internationally or locally based, total hours of 
effort, annual number of work days, salaries, and benefits. 
Don’t forget support staff such as those people who arrange food, lodging, venues, make copies, etc. 
Support staff includes drivers if the drivers are employed specifically for the purpose of planning or 
conducting the training by the organization. (Drivers that are hired for specific transportation events are 
handled like consultants (e.g., transporting participants to and from the training). 
92 Tibu Homa Project Performance Evaluation Report
Basic Information
Please record the names and contact information 
of people interviewed (give enough information so 
that you can follow up to fill in gaps or clarify 
responses as necessary):
Tibu Homa Project Performance Evaluation Report 93
Questionnaire
1. What is the typical venue cost for [TOT | HCWs | Supervision] training?
2. What are typical audio-video rental costs for [TOT | HCWs | Supervision] training?
3. What are typical supplies required to conduct each training (e.g., supplies the trainers use) for 
[TOT | HCWs | Supervision] training?
4. What are typical supplies provided to each participant who attends a [TOT | HCWs | 
Supervision] training?
5. What is the current per diem for [TOTs | HCWs | Supervisors] who attend a training?
6. What would you budget for lodging costs per person to implement/attend the [TOT | HCWs | 
Supervision] training?
7. What are the typical food costs to conduct the [TOT | HCWs | Supervision] training (provide 
units (e.g., daily, per/person)?
8. What is the typical trainer salary cost per day to conduct the [TOT | HCWs | Supervision] 
training (please obtain the gross salary)?
Form 1A. Financial costs: Training
Training 1.Venu
e costs
2. Audio￾video 
rental 
costs
3. Fixed 
Supply 
costs1
4. Variable 
supply costs 
(based on # 
participants) 2
5. Per 
diem/
day
6. Lodging 
costs
7. Food 
costs3
8. Trainer 
salary cost per 
person per 
day (gross)
TOT
HCWs
Super￾vision
1Fixed supplies might include training supplies such as pens, paper, notebooks, folders, markers, flipcharts, bottled 
water, DVDs, etc. for the TRAINERS.
2 Variable supplies might include supplies such as pens, paper, notebooks, folders, markers, flipcharts, bottled 
water, DVDs, etc. that each participant receives.
3DO NOT count lodging costs if lodging is paid for by participants’ or trainers’ per diem.
4e.g., Snacks, Breakfast, Lunch, Dinner. DO NOT include costs paid for by participants’ or trainers’ per diem.
9-13.1.1. What is the typical cost of a (9) driver | (10) rental car | (11) fuel cost | (12) public transport 
cost | (13) air fare for participants and trainers to attend the [TOT | HCWs | Supervision] 
training, if applicable?
14. What other costs are typically incurred to conduct a [TOT | HCWs | Supervision] training?
Form 1B. Financial costs: Transportation costs to training session for 
participants and trainers1, 2
Training
9.Driver daily rate
(incl. salary & per 
diem)
10.Car 
Rental daily
11.Fuel 
cost 
daily
12.Public 
Transport 
daily
13.Air fare 
(round trip) 14.Other
TOT
 -Trainer
 -Participant
HCWs
 -Trainer
 -Participant
Supervision
 -Trainer
 -Participant
1DO NOT count transportation costs if transportation is paid for by participant’s or trainers’ per diem; 
2Cars and drivers are only those who are hired out. Organizational cars and employees are in Form 2.
94 Tibu Homa Project Performance Evaluation Report
Form 2. List of personnel including organization or MOHSW staff, trainers, 
organizational supervisors, and support staff1
Personnel Job Title 
(or consultant) Duties performed
Based 
internationally 
or locally
Total 
hours of 
effort
# days 
worked 
per year
Salary 
(Annual)
Benefits
(Annual)2
Training 
organizer/event 
planner
Organizing venue, 
inviting participants, 
paying per diems, 
making reservations, 
ordering food, 
attending event??
Support staff for 
planning
Making copies of 
training materials, 
etc.
Trainers (e.g., 
consultants)
Conduct training for 
TOT/HCWs/SS
MEASURE will 
determine this.
Organizational 
mentors to support 
SS&M
Participate in SS and 
mentor CHMT 
members in 
providing supportive 
supervision as 
intended during 
introductory period
Others not specified
1Support staff may carry out duties such as copying and booking hotels and conference venues. They also include 
drivers that are employed by the organization. Costs for drivers that are hired out are in the respective forms. 
2Benefits include housing allowance, medical allowance, etc.
Tibu Homa Project Performance Evaluation Report 95
Qualitative Instruments
Key Informant/Small Group Interview Guide for Health Care Workers 
(HCWs)
Tibu Homa Project Evaluation
Instructions: This guide is intended for use with a single HCW or a small group of up to three 
HCWs (ideally the health facility In-Charge, a PQIT member trained by Tibu Homa, and lab 
tech/other HCW trained on SCM by Tibu Homa). After obtaining consent from each 
respondent using the consent form, record the information in the chart below for each 
respondent. Then begin recording the interview. Record the interview start and stop time.
Name of Interviewer
Date of Interview
Length of Interview
(Record stop and start time)
Start time:
Stop time:
Name of Health Facility
Type of Health Facility
(Health Center or Dispensary)
Location of Health Facility
(District and Region)
District:
Region:
Position of Respondent(s)
(In-Charge, HCW, Lab Tech, Other: 
specify)
Respondent 1:
Respondent 2:
Respondent 3:
Age of Respondent(s)
Respondent 1:
Respondent 2:
Respondent 3:
Sex of Respondent(s)
Respondent 1:
Respondent 2:
Respondent 3:
Education 
(Highest Grade Completed)
Respondent 1:
Respondent 2:
Respondent 3:
Length of Time at Current Facility
(Estimate in Years and Months)
Respondent 1:
Respondent 2:
Respondent 3:
96 Tibu Homa Project Performance Evaluation Report
I. dIMCI and Implementation of IMCI 
First I would like to ask you about your experience with dIMCI and implementing the IMCI 
algorithm.
1. How many HCWs at this health facility (including yourselves) participated in dIMCI 
training?
2. Were any HCWs (who were not formally trained) at this health facility trained on IMCI 
by HCWs who completed dIMCI? If yes:
a) Please describe the process for training others.
b) Were there any challenges? If so, what were they and how were they addressed?
3. What has been your experience implementing the IMCI algorithm? Please describe. 
Probe for:
a) What do you see as the value of IMCI and using mRDTs to diagnose febrile 
illnesses?
b) Have you had any challenges using the IMCI protocol and/or using mRDTs to 
diagnose febrile illnesses? If yes, please describe.
4. Next I want to ask you to describe any Supportive Supervision and Mentoring (SS&M) 
received during Tibu Homa from your R/CHMT and/or Tibu Homa staff related to 
case management—that is, correct implementation of the IMCI algorithm. Probe for:
a) Frequency of SS&M; details of how SS&M in case management was carried out.
b) In what ways was SS&M in case management helpful?
c) How could the SS&M in case management have been more helpful?
5. Now I want to ask you to describe any SS&M currently being received from your 
R/CHMT related to case management. Please highlight any differences from the SS&M 
received during the Tibu Homa Project. Probe for: 
a) Frequency of SS&M; details of how SS&M in case management is carried out 
(Probe for any change from Tibu Homa).
b) How helpful is the S&M in case management currently being received? (Probe 
for any change from Tibu Homa).
c) How could the SS&M in case management have been more helpful?
6. Overall, to what extent do you feel that SS&M in case management has improved your 
ability to implement the IMCI algorithm correctly? Probes:
a) In other words, if you only had dIMCI—without SS&M in case management—
do you think you would be able to implement the IMCI algorithm with the same 
degree of compliance? Why or why not?
7. In your opinion, to what extent do you feel that SS&M in case management has 
contributed to improvement of the quality of care that this health facility is able provide 
to children with fever? Why do you think that? How do you know? 
a) Which specific aspects of SS&M in case management were most important for 
improving quality of care?
II. Quality Improvement (QI) and Pediatric Quality Improvement Teams 
(PQITs)
Next I would like to ask you about your PQIT.
Tibu Homa Project Performance Evaluation Report 97
8. How many HCWs at this health facility (including yourselves) received Quality 
Improvement (QI) training through Tibu Homa?
9. Did your health facility establish a PQIT? If yes, please tell me about the activities carried 
out by your PQIT. 
a) What improvements were implemented during Tibu Homa?
b) What documentation did you use to track PQIT activities and improvements? 
c) Which specific improvements, if any, are still in place? Please describe.
d) Which specific improvements, if any, are no longer in place? Why?
10. Were there improvements identified by your PQIT that could not be implemented? If 
yes, please describe them. Why couldn’t they be implemented?
11. Next I would like you to describe any SS&M your PQIT received from R/CHMTs 
and/or Tibu Homa staff during Tibu Homa. Probe for:
a) Frequency of SS&M; details of how SS&M for PQITs was carried out.
b) How helpful was the SS&M your PQIT received?
c) How could the SS&M your PQIT received been more helpful?
12. Is your PQIT still functioning? If no, why not? If yes, probe for:
a) Current members, frequency of meetings, documentation. 
b) Examples of improvements implemented post-Tibu Homa.
13. If yes to #Q12, Is your PQIT currently receiving SS&M from your R/CHMT? If yes, 
probe for: 
a) Frequency of SS&M and how SS&M for the PQIT is carried out (Probe for any 
change from Tibu Homa).
b) How helpful is the SS&M your PQIT is currently receiving? (Probe for any 
change from Tibu Homa). 
c) How could current SS&M be more helpful to your PQIT?
14. In your opinion, to what extent have PQIT activities improved the quality of care 
provided to children with fever at this health facility? Please describe.
a) Which specific activities were most important for improving quality of care at 
this health facility? Why do you think that?
III. Supply Chain Management (SCM)
Next I would like to ask about SCM—that is, how you manage and order your essential 
medicines and diagnostics.
15. How many HCWs at this health facility (including yourselves) received SCM training 
through Tibu Homa?
16. Next I would like you to describe any SS&M received from your R/CHMT and/or Tibu 
Homa staff related to SCM during Tibu Homa—that is, mentoring on managing the 
health facility’s inventory of essential medicines and diagnostics for febrile illnesses and 
correct use of ordering forms? Probe for:
a) Frequency of SS&M; details of how SS&M for SCM was carried out.
b) How helpful was the SS&M in SCM received?
c) How could the SS&M in SCM been more helpful?
98 Tibu Homa Project Performance Evaluation Report
17. Next I would like you to describe any SS&M currently being received from your 
R/CHMT related to SCM. Please highlight any differences from the SS&M received 
during Tibu Homa. Probe for: 
a) Frequency of SS&M; details of how SS&M for SCM is carried out. (Probe for any 
change from Tibu Homa). 
b) How helpful is the SS&M for SCM currently being received? (Probe for any 
change from Tibu Homa). 
c) How could SS&M for SCM be improved? What additional support do you need?
18. Overall, do you feel that SCM training and mentoring has improved HCWs’ skills in 
SCM at this health facility? Why or why not?
19. Overall, do you feel that the SCM training and mentoring has resulted in reduced stock￾outs of essential medicines and diagnostics related to febrile illness in children, including 
mRDTs at this health facility? Probes: 
a) In other words, if your health facility had not received SCM training and 
mentoring—do you think you would have more stock-outs than you do now? 
b) Why or why not?
20. In your opinion, did SCM training and mentoring lead to improvement in the quality of 
care provided to children with fever at this facility? Why or why not?
a) Which specific aspects of SCM training and SS&M are/were most important for 
improving quality of care of children with fever?
IV. Importance of Tibu Homa Project Components
As we wrap up, I would like to ask your opinion about which aspects of the Tibu Homa Project 
have had the greatest impact on improving care for children with fever.
21. Now, let us assume that other health facilities in Tanzania will receive dIMCI. We would 
like to hear your opinion about which aspects of the additional support provided by 
Tibu Homa you think would be most important for HCWs at those facilities to receive. 
By additional support I mean:
a) SS&M in case management
b) QI training, formation of PQITs, and related SS&M
c) SCM training and related SS&M. 
Please rank the additional support in order of importance with regard to their importance in 
improving health facilities’ ability to provide quality care to children with fever:
Additional Support Rank 
(1=Most Important; 3 = Least important)
SS&M in case management for HCWs
QI training for HCWs, formation of PQITs, 
and SS&M for PQITs
SCM training and SS&M in SCM for HCWs
22. Why did you rank the components the way you did? Probe for:
a) Why did you rank XX number 1? 
Tibu Homa Project Performance Evaluation Report 99
b) XX number 2? 
c) And XX number 3?
Thank you for your participation. Is there anything else you would like to tell me about your 
experience as HCW with Tibu Homa that I have not asked about? Do you have any other 
questions for me?
100 Tibu Homa Project Performance Evaluation Report
Key Informant/Small Group Interview Guide for R/CHMT Members
Tibu Homa Project Evaluation
Instructions: This guide is intended for use with a single R/CHMT member or a small group of 
up to three members (i.e., the DMO, District Malaria/IMCI Focal Person and District Pharmacist 
who participated in Tibu Homa). After obtaining consent from each respondent using the consent 
form, record the information in the chart below for each respondent. Then begin recording the 
interview. Record the interview start and stop time.
Name of Interviewer
Date of Interview
Length of Interview
(Record stop and start time)
Start time:
Stop time:
District
Position of Respondent(s)
(Malaria/IMCI Focal Person, 
Pharmacist, Other: specify)
Respondent 1:
Respondent 2:
Respondent 3:
Age of Respondent(s)
Respondent 1:
Respondent 2:
Respondent 3:
Sex of Respondent(s)
Respondent 1:
Respondent 2:
Respondent 3:
Education 
(Highest Grade Completed)
Respondent 1:
Respondent 2:
Respondent 3:
Length of Time on Current R/CHMT
(Estimate in Years and Months)
Respondent 1:
Respondent 2:
Respondent 3:
V. Training and Support Provided by Tibu Homa
First, I would like to ask about the training you and/or your R/CHMT received from Tibu Homa 
in Supportive Supervision & Mentoring (SS&M).
1. Did you receive training from Tibu Homa on SS&M? If yes, please describe. Probe for:
a. Length of training
Tibu Homa Project Performance Evaluation Report 101
b. Topics covered 
c. Number and position of R/CHMT members trained
2. Please describe what you understand SS&M to be? Probes:
a. If someone unfamiliar with SS&M asked you to define it, how would you respond? 
b. In what ways, if any, is SS&M different from more traditional forms of 
supervision? Is it different from the SS&M you performed prior to Tibu Homa?
3. During Tibu Homa, was there any additional support that you or your R/CHMT received 
from the project related to SS&M? Probe for:
a. Did Tibu Homa assist with transport/fuel for SS&M visits?
b. Did Tibu Homa staff accompany R/CHMT members on SS&M visits?
c. What other support did Tibu Homa provide to R/CHMTs related to SS&M?
VI. Supportive Supervision and Mentoring
Next I would like to ask you about the SS&M you and/or your R/CHMT provided to HCWs. I 
would like to discuss separately SS&M related to 1) case management, 2) QI/PQITs, and 3) supply 
chain management (SCM). 
Case Management/IMCI
First I would like to ask about the SS&M you provided to HCWs to improve IMCI compliance.
4. Please describe the SS&M you and/or your R/CHMT provided during Tibu Homa to 
HCWs related to case management. Probe for:
a. Frequency of SS&M; details of how SS&M in case management was carried out; 
did you use a checklist?
b. How helpful do you think SS&M was in improving case management?
c. Did you or your R/CHMT encounter any challenges in providing SS&M in case 
management? If yes, please describe.
5. Please describe the SS&M, if any, you or your R/CHMT currently provide to HCWs 
related specifically to case management. Please highlight any differences from SS&M 
provided during Tibu Homa. Probe for: 
a. Frequency of SS&M; details of how SS&M in case management is currently carried 
out. (Probe for any change since Tibu Homa support ended). Do you still use the 
Tibu Homa checklist (if used prior)?
b. What challenges, if any, are you and/or your R/CHMT currently encountering in 
providing SS&M in case management?
c. Are there aspects of Tibu Homa’s approach to supporting case management that 
you would like to continue but are not able? Please explain.
6. In your opinion, to what extent do you feel that SS&M in case management improved 
HCWs’ clinical skills? Probes:
102 Tibu Homa Project Performance Evaluation Report
a. In other words, if HCWs received dIMCI training—without SS&M in case 
management—do you think they would have the same level of clinical skill? Why 
or why not?
b. Do you think they would be complying with the IMCI algorithm to the degree that 
they currently are? Why or why not?
7. Are there health facilities in your district that did not participate in Tibu Homa? If yes:
a. Do you notice any difference in HCW’s clinical skills in case management in Tibu 
Homa versus non-Tibu Homa health facilities? If yes, please describe.
b. Do you notice any difference in levels of IMCI compliance in Tibu Homa versus 
non-Tibu Homa health facilities? If yes, please describe.
Quality Improvement (QI) and Pediatric Quality Improvement Teams (PQITs)
Next I would like to ask about how you and/or your R/CHMT supported PQITs.
8. Please describe the SS&M you and/or your R/CHMT provided during Tibu Homa to 
PQITs related to identifying gaps and implementing facility-level improvements to 
improve care to children with fever. Probe for:
a. Frequency of SS&M; details of how SS&M to PQITs was carried out. Was any 
documentation reviewed/collected?
b. How effective do you think SS&M was in supporting PQITs to implement 
improvements? Please describe.
c. Did you and/or your R/CHMT encounter any challenges in providing SS&M to 
PQITs? If yes, please describe.
9. Do any of the Tibu Homa health facilities you currently support still have functioning 
PQITs? If yes, probe for:
a. What proportion of health facilities would you estimate still have functioning 
PQITs?
b. In your opinion, why do some health facilities still have functional PQITs while 
others do not?
c. What are some examples of activities currently being carried out by PQITs?
d. Are there aspects of Tibu Homa’s approach to supporting PQITs that you would 
like to continue but are not able? Please explain.
10. Do you and/or your R/CHMT currently provide SS&M to functioning PQITs? If yes, 
please describe. Please highlight any differences from SS&M provided during Tibu Homa. 
Probe for: 
a. Frequency of SS&M; details of how SS&M to PQITs is currently carried out (Probe 
for any change from Tibu Homa). Is any documentation reviewed/collected?
b. What challenges, if any, are you or your R/CHMT currently encountering in 
providing SS&M to PQITs?
Tibu Homa Project Performance Evaluation Report 103
Supply Chain Management
Next I would like to ask about logistical mentoring related to SCM—that is, mentoring on 
managing health facility’s inventory of essential medicines and diagnostics for febrile illnesses and 
correct use of ordering forms.
11. Please describe the SS&M you and/or your R/CHMT provided during Tibu Homa 
related to SCM. Probe for:
a. Frequency of SS&M; who (position/title) at health facilities SS&M was provided 
to; details of how SS&M for SCM was carried out. Was any documentation 
reviewed/collected?
b. How helpful do you think SS&M was in building HCWs skills in SCM?
c. Did you and/or your R/CHMT encounter any challenges in providing SS&M for 
SCM? If yes, please describe.
12. Please describe the SS&M, if any, you and/or your R/CHMT currently provide related 
to SCM. Please highlight any differences from SS&M provided during Tibu Homa. Probe 
for: 
a. Frequency of SS&M; details of how SS&M for SCM is currently carried out. (Probe 
for any change from Tibu Homa). Is any documentation reviewed/collected?
b. What challenges, if any, are you and/or your R/CHMT currently encountering in 
providing SS&M related to SCM? Please describe.
c. Are there aspects of Tibu Homa’s approach to supporting SCM that you would 
like to continue but are not able? Please explain.
13. Overall, do you feel that SS&M in SCM provided to HCWs has improved their skills in 
SCM? Probes:
a. In other words, if these HCWs had not received SS&M related to SCM, do you 
think they would be able to manage their inventories of medicines and diagnostics 
with the same degree of skill that they are now? Why or why not?
14. (SKIP if respondent answered no to Q#4). 
a. Do you notice any difference in HCW’s skills in SCM in Tibu Homa versus non￾Tibu Homa health facilities? If yes, please describe.
b. Do you notice any differences in frequency of stock-outs in Tibu Homa versus 
non-Tibu Homa health facilities? If yes, how do you know? Please describe the 
differences.
Other
15. Did your R/CHMT undertake any special initiatives during or as a result of Tibu Homa 
(e.g., assisting HCWs with building health facilities’ Community Health Funds [CHF], 
advocating for additional transportation resources, etc.)? If yes, please explain. Are these 
activities ongoing? 
104 Tibu Homa Project Performance Evaluation Report
VII. Importance of Tibu Homa Project Components
Finally, I would like to ask your opinion about which aspects of the Tibu Homa Project have had 
the greatest impact on improving care for children with fever.
16. Now, let us assume that other health facilities in Tanzania will receive dIMCI. We would 
like to hear your opinion about which aspects of the additional support provided by 
Tibu Homa you think it would be most important for HCWs at those facilities to receive. 
By additional support I mean:
a. SS&M in case management
b. QI training, formation of PQITs, and related SS&M
c. SCM training and related SS&M
Please rank the additional support in order of importance with regard to their importance in 
improving health facilities’ ability to provide quality care to children with fever:
Additional Support Rank 
(1=Most Important; 3 = Least important)
SS&M in case management for HCWs
QI training for HCWs, formation of PQITs, 
and SS&M for PQITs
SCM training and SS&M in SCM for HCWs
17. Why did you rank the additional support the way you did? Probe for:
a. Why did you rank XX number 1? 
b. XX number 2? 
c. And XX number 3?
Thank you for your participation. Is there anything else you would like to tell me about your 
experience with Tibu Homa that I have not asked about? Do you have any other questions for 
me?
Tibu Homa Project Performance Evaluation Report 105
Focus Group Interview Guide for CQIT Members
Tibu Homa Project Evaluation
Instructions: This guide is intended for use with a focus group of up to 10 CQIT members from 
different CQITs. After obtaining consent from each respondent using the consent form, record 
the age, sex, education level, primary occupation, length of time serving on a CQIT specifically 
for TBH, and the name or location of the CQIT for each participant. Then begin recording the 
interview. Record the interview start and stop time.
Name of Interviewer
Date of Interview
Length of Interview
(Record stop and start time)
Start time:
Stop time:
Age of Respondent(s)
Respondent 1: Respondent 6: 
Respondent 2: Respondent 7:
Respondent 3: Respondent 8:
Respondent 4: Respondent 9:
Respondent 5: Respondent 10:
Sex of Respondent(s)
Respondent 1: Respondent 6: 
Respondent 2: Respondent 7:
Respondent 3: Respondent 8:
Respondent 4: Respondent 9:
Respondent 5: Respondent 10:
Highest Grade Completed
Respondent 1: Respondent 6: 
Respondent 2: Respondent 7:
Respondent 3: Respondent 8:
Respondent 4: Respondent 9:
Respondent 5: Respondent 10:
Primary Occupation
Respondent 1: Respondent 6: 
Respondent 2: Respondent 7:
Respondent 3: Respondent 8:
Respondent 4: Respondent 9:
Respondent 5: Respondent 10:
Length of Time Working with THP
(Estimate in Months)
Respondent 1: Respondent 6: 
Respondent 2: Respondent 7:
Respondent 3: Respondent 8:
Respondent 4: Respondent 9:
Respondent 5: Respondent 10:
106 Tibu Homa Project Performance Evaluation Report
Name of CQIT or Name of 
Village/Hamlet of the CQIT
Respondent 1:
Respondent 2:
Respondent 3:
Respondent 4:
Respondent 5:
Respondent 6:
Respondent 7:
Respondent 8:
Respondent 9:
Respondent 10:
Name of Community
I. Background information
First I would like to ask you a little about how you became involved with the Tibu Homa Project.
1. What is your role in the community? (Note: not necessarily same as occupation)
2. Please describe how you got involved with Tibu Homa as a CQIT member. What is/was 
your role on the CQIT?
3. Why were you motivated/interested in joining a CQIT? What were your responsibilities? 
What benefits, if any, did you receive due to your involvement? (e.g., compensation, per 
diem, other)
II. Training and Supervision Received
I would like to ask you about any training or supervision you received as part of your work for 
the Tibu Homa Project.
4. Did you receive any training to prepare you for your work with the Tibu Homa Project? 
If yes, please describe the training. Probe for:
a. Length of training and topics covered. 
b. What were the most useful aspects of the training?
c. Do you have any suggestions for how the training could be improved?
5. Did you receive supervision related to your work for Tibu Homa? If yes, probe for:
a. Who provided the supervision (position, organization); frequency of supervision.
b. What happened during a typical supervision meeting/visit?
c. Did you find the supervision useful/valuable? Please describe.
d. Do you have any suggestions for how supervision could be improved?
Tibu Homa Project Performance Evaluation Report 107
6. If no to Q5, Please describe any interaction your CQIT had with a Community Coach.
III. Activities of the CQIT
Next I would like to ask about your CQIT and the activities it carried out to promote child health.
7. Please describe your CQIT. What was the composition of the CQIT you belonged to? 
Probe for:
a. Number of members, positions of members, etc. 
b. Frequency, location, and format of meetings. 
8. How did your CQIT identify gaps and test solutions to promote early health care-seeking 
behavior for children with fever? Please describe.
a. What specific gaps were identified?
b. What specific solutions proved effective?
c. How were solutions implemented? Please give a few specific examples.
d. Please describe any challenges your CQIT faced in identifying gaps and testing 
solutions.
9. Did your CQIT work with CHWs and/or CSGs to promote child health? If yes, please 
describe. Probe for:
a. How CQITs and CHWs interacted.
b. How CQITs and CSGs interacted.
10. Did your CQIT carry out activities to raise awareness among traditional healers about the 
need to refer children with fever to a health facility? If yes, please describe. Probe for:
a. What messages were provided? Were any materials (e.g., posters, other) used?
b. How did your CQIT interact with traditional healers (e.g., visited them, invited 
them to meetings, other means?
c. What activities/messages were most effective in raising awareness?
d. What activities/messages were least effective?
11. Did your CQIT carry our any activities to directly identify and refer children with fever to 
a local health facility? If yes, please describe. Probe for: 
a. How children with fever were identified.
b. Where they were referred.
c. How referrals were tracked.
d. In your opinion, was the process of identifying and referring children with fever 
effective in improving the health of children with fever in your community? Why 
do you think that? 
108 Tibu Homa Project Performance Evaluation Report
12. If yes to #Q11: Was there anything challenging about identifying children with fever and 
referring them for care? 
a. If yes, please describe.
b. What strategies/approaches were effective in addressing these challenges? Please 
describe.
13. Did your CQIT carry out any activities to identify and refer orphans and vulnerable 
children (OVCs) in the community? If yes, please describe the identification and referral 
process. Probe for:
a. Definition of OVCs. 
b. How OVCs were identified.
c. Where they were referred. For what services?
d. How referrals were tracked.
e. In your opinion, was this process of identifying and referring OVCs effective in 
improving the health of OVCs in your community? Why do you think that?
14. If yes to #Q13: Was there anything challenging about identifying OVCs and referring them 
for services? 
a. If yes, please describe.
b. What strategies/approaches were effective in addressing these challenges? Please 
describe.
IV. Other Work for Tibu Homa
I would also like to learn about any other work you did for Tibu Homa to promote child health.
15. Did your CQIT carry out any other activities for Tibu Homa to promote child health? 
Probe for:
a. Visiting individual households.
b. Distributing Information, Education and Communication (IEC) materials.
c. Holding/participating in community events.
d. Other.
16. Now that Tibu Homa is no longer operating, does your CQIT carry out activities to 
promote child health? If yes, please describe any specific activities that are ongoing. If no, 
why not?
V. Data Collection
17. Did you collect any data on behalf of Tibu Homa (or the health facilities you worked with)? 
If yes: 
a. What data did you collect?
Tibu Homa Project Performance Evaluation Report 109
b. How was the data shared with Tibu Homa (or the health facilities you worked 
with)?
c. Do you still collect this data now that Tibu Homa has ended?
VI. Lessons Learned
Finally, I would like to ask your opinion on a few things. 
18. In your opinion, what are the main factors that contribute to delays in early health care￾seeking behaviors for children with fever in this community?
19. How effective do you think you and your CQIT(s)/community was in addressing these 
factors? Probe for:
a. Activities that were most effective.
b. Activities that were least effective.
c. Is there anything about your CQITs work that would you change in the future to 
make it more effective in addressing these factors?
Thank you for your participation. Is there anything else you would like to tell me about your 
CQIT’s work that I have not asked about? Do you have any other questions for me?
110 Tibu Homa Project Performance Evaluation Report
Focus Group Discussion Guide for Community Social Group (CSG) Members
Tibu Homa Project Evaluation
Instructions: This guide is intended for use with a focus group of up to 10 CSG members. After 
obtaining consent from each respondent using the consent form, record the age, sex, education 
level, primary occupation, length of time as a member of the CSG, and type or name of the CSG 
for each participant. Then begin recording the interview. Record the interview start and stop time.
Name of Interviewer
Date of Interview
Length of Interview
(Record stop and start time)
Start time:
Stop time:
Age of Respondent(s)
Respondent 1: Respondent 6:
Respondent 2: Respondent 7:
Respondent 3: Respondent 8:
Respondent 4: Respondent 9:
Respondent 5: Respondent 10:
Sex of Respondent(s)
Respondent 1: Respondent 6:
Respondent 2: Respondent 7:
Respondent 3: Respondent 8:
Respondent 4: Respondent 9:
Respondent 5: Respondent 10:
Highest Grade Completed
Respondent 1: Respondent 6:
Respondent 2: Respondent 7:
Respondent 3: Respondent 8:
Respondent 4: Respondent 9:
Respondent 5: Respondent 10:
Primary occupation
Respondent 1: Respondent 6:
Respondent 2: Respondent 7:
Respondent 3: Respondent 8:
Respondent 4: Respondent 9:
Respondent 5: Respondent 10:
Length of Time as Member of 
CSG
(Estimate in Years/Months)
Respondent 1: Respondent 6:
Respondent 2: Respondent 7:
Respondent 3: Respondent 8:
Respondent 4: Respondent 9:
Respondent 5: Respondent 10:
Tibu Homa Project Performance Evaluation Report 111
Type/Name of CSG
Respondent 1: 
Respondent 2: 
Respondent 3: 
Respondent 4: 
Respondent 5: 
Respondent 6: 
Respondent 7: 
Respondent 8: 
Respondent 9:
Respondent 10:
Name of Community
I. Community Social Group Background
First I would like to ask you about the Community Social Group(s) that you belong to.
1. Please tell me a little bit about your CSG. Probes:
a. What activities is your group involved with?
b. Please describe the membership (female/male/mixed, approximate number of 
members). 
c. Please describe the frequency, location, and format of meetings. 
d. What is the leadership structure? 
e. How do people become members?
II. Interaction with the Tibu Homa Project
Next I would like to ask about any interaction you may have had with the Tibu Homa Project. 
Tibu Homa was a project that encouraged caregivers of young children with fever in this 
community to take them to a health facility within 24 hours of onset of fever. Tibu Homa worked 
through Community Coaches, Community Quality Improvement Teams (CQITs) and 
Community Health Workers (CHWs).
2. Did your CSG interact with a CHW, Community Coach, or CQIT member? If yes, who 
did they interact with?
3. Did the [CHW/Community Coach/CQIT member]:
a. Explain the early signs and symptoms of fever in children?
b. Encourage taking children with fever to a health facility within 24 hours of onset 
of fever?
c. Explain the dangers of not taking a child with fever to a health facility with 24 
hours of onset of fever?
112 Tibu Homa Project Performance Evaluation Report
d. Provide any educational materials on children with fever?
4. Please describe the ways your CSG interacted with the [CHW/Community Coach/CQIT 
member]. For example:
a. Did the [CHW/Community Coach/CQIT member] attend regular meetings of 
your CSG? If yes, probe for:
i. How often?
ii. What did the [CHW/Community Coach/CQIT member] discuss at 
meetings?
b. Did the [CHW/Community Coach/CQIT member] or Tibu Homa Project 
organize special meetings for community members to discuss children’s health? If 
yes: probe for:
i. How often were meetings held?
ii. What was discussed at meetings?
c. In what other ways did the [CHW/Community Coach/CQIT member] interact 
with your CSG? Please describe.
5. Did you discuss these messages/interactions with your family or other community 
members after the CSG meeting(s)? Please describe.
6. Did you change your beliefs about treatment for your own children based on your 
interactions with the Tibu Homa [CHW/Community Coach/CQIT member]? If yes, in 
what way? If no, why not?
III. Data Collection
7. Did your CSG collect any information on children with fever? If yes, probe for:
a. What information was collected?
b. Who collected it?
c. How was it collected?
d. What was done with the information? (If given to hamlet chairperson, what did 
that person do with it?)
e. Do you still collect this data now that Tibu Homa has ended?
8. Did your CSG collect any information on orphans and vulnerable children (OVCs)? If yes 
probe for: 
a. What information was collected?
b. Who collected it?
c. How was it collected?
d. What was done with the information? (If given to hamlet chairperson, what did
they do with it?)
e. Do you still collect this data now that Tibu Homa has ended?
Tibu Homa Project Performance Evaluation Report 113
IV. Health Care-Seeking for Children with Fever
Now I would like to ask your opinion about some things related to health care for children with 
fever.
9. Please tell me what you think about taking young children with fever to a health facility 
within 24 hours onset of fever. Is it necessary? Unnecessary? Why or why not?
10. What are the mains reasons that caregivers of children with fever do NOT take them to a 
health facility within 24 hours of onset of fever?
11. What are the main reasons that caregivers of children with fever take them to traditional 
healers instead of health facilities for care?
12. What are the main reasons that caregivers of children with fever buy medicines from 
pharmacies and/or local herbs for home treatment rather than take them to a health facility 
for care?
Thank you for your participation. Is there anything else you would like to tell me about your 
experience with the Tibu Homa Project? Do you have any other questions for me?
114 Tibu Homa Project Performance Evaluation Report
Focus Group Discussion Guide for Community Coaches
Tibu Homa Project Evaluation
Instructions: This guide is intended for use with a focus group of up to 10 Community Coaches. 
After obtaining consent from each respondent using the consent form, record the age, sex, 
education level, primary occupation, and the length of time serving as a Community Coach 
specifically for Tibu Homa for each participant. Then begin recording the interview. Record the 
interview start and stop time.
Name of Interviewer
Date of Interview
Length of Interview
(Record stop and start time)
Start time:
Stop time:
Age of Respondent(s)
Respondent 1: Respondent 6: 
Respondent 2: Respondent 7:
Respondent 3: Respondent 8:
Respondent 4: Respondent 9:
Respondent 5: Respondent 10:
Sex of Respondent(s)
Respondent 1: Respondent 6: 
Respondent 2: Respondent 7:
Respondent 3: Respondent 8:
Respondent 4: Respondent 9:
Respondent 5: Respondent 10:
Highest Grade Completed
Respondent 1: Respondent 6: 
Respondent 2: Respondent 7:
Respondent 3: Respondent 8:
Respondent 4: Respondent 9:
Respondent 5: Respondent 10:
Primary occupation 
Respondent 1: Respondent 6: 
Respondent 2: Respondent 7:
Respondent 3: Respondent 8:
Respondent 4: Respondent 9:
Respondent 5: Respondent 10:
Length of Time Working with THP
(Estimate in Months)
Respondent 1: Respondent 6: 
Respondent 2: Respondent 7:
Respondent 3: Respondent 8:
Respondent 4: Respondent 9:
Respondent 5: Respondent 10:
Tibu Homa Project Performance Evaluation Report 115
Name of Community
I. Background information
First, I would like to ask how you became involved with the Tibu Homa Project.
1. What is your role in the community? (Note: not necessarily same as occupation)
2. How did you learn about the Tibu Homa Project?
3. Please describe how you got involved with Tibu Homa as a Community Coach. 
4. Why were you motivated/interested in becoming a Community Coach? 
5. What benefits, if any, did you receive due to your involvement? (e.g., 
compensation, benefits, other)
II. Training and Supervision Received
Now I would like to ask you about any training or supervision you received as part of your work 
for the Tibu Homa Project.
III. Did you receive any training to prepare you for your work with Tibu Homa Project? If yes, 
please describe the training. 
1. Probe for length of training and topics covered. Who attended? 
2. What were the most useful aspects of the training?
3. Do you have any suggestions for how the training could be improved?
4. Did you receive supervision related to your work for Tibu Homa? If yes, probe 
for:
a.Who provided the supervision (position, organization); frequency of 
supervision.
b.What happened during a typical supervision meeting/visit?
c.Did you find the supervision useful/valuable? Please describe.
d.Do you have any suggestions for how supervision could be improved?
IV. Community Quality Improvement Teams (CQITs)
Next I would like to ask about your work as a Community Coach supporting CQITs as they 
carried out activities to promote child health, and also about the work carried out by the 
CQIT(s).
1. What were your responsibilities for Tibu Homa as a Community Coach?
a. How did you coach CQIT(s)? Were you a leader? Facilitator?
b. How many CQITs did you support?
c. What did you do specifically? How often?
2. How did you support your CQIT(s) to identify gaps and test solutions to 
promote early health care-seeking behavior for children with fever? Please 
describe. Probes:
116 Tibu Homa Project Performance Evaluation Report
a. What did CQITs do? How often did they meet? How did they identify 
issues in the community related to treatment of children under five with 
fever?
b. What are examples of some specific gaps were identified?
c. What are examples of some specific solutions proved effective? 
d. What are some examples of solutions that did not work?
3. Did your CQIT(s) work with Community Health Workers (CHWs) and/or 
Community Social Groups (CSGs) to promote child health? If yes, please 
describe. Probe for:
a. How CQITs and CHWs interacted. What were your responsibilities, if 
any, related to CHWs?
b. How CQITs and CSGs interacted. What were your responsibilities, if 
any, related to CSGs?
4. Did your CQIT carry out activities to raise awareness among traditional healers 
about the need to refer children with fever to a health facility? If yes, please 
describe. Probe for:
a. What health messages were shared with traditional healers?
b. What activities/messages were most effective in raising awareness?
c. What activities/messages were least effective?
d. What barriers did you/your CQIT face with regard to promoting 
awareness among traditional healers? (e.g., were they receptive?)
5. Did your CQIT(s) carry out any activities to directly identify and refer children 
with fever to a local health facility? If yes, please describe. Probe for: 
a. How children with fever were identified. 
b. Where they were referred.
c. How referrals were tracked.
d. What was your role in this activity, if any?
e. In your opinion, did these activities improve the health of children with 
fever? Why do you think that?
6. If yes to #Q8: Was there anything challenging about identifying children with 
fever and referring them for care? 
a. If yes, please describe. (Probe: What barriers, if any, exist with regard to 
families accepting referrals and seeking treatment?)
b. What strategies/approaches were effective in addressing these challenges? 
Please describe.
7. Did your CQIT carry out any activities to identify and refer orphans and 
vulnerable children (OVCs) for services? If yes, please describe. Probe for:
a. Definition of OVCs. 
b. How OVCs were identified.
c. Where they were referred.
d. How referrals were tracked.
e. What was your role in this activity, if any?
Tibu Homa Project Performance Evaluation Report 117
f. In your opinion, did these activities improve the health and social well￾being of OVCs? Why do you think that? 
8. If yes to #Q10: Was there anything challenging about identifying OVCs and 
referring them for services? 
a. If yes, please describe.
b. What strategies/approaches were effective in addressing these challenges? 
Please describe.
V. Other Work for Tibu Homa
I would also like to learn about any other work your CQIT(s) did for Tibu Homa to promote 
child health.
1. Did your CQIT(s) carry out any other activities for Tibu Homa to promote child 
health? Probe for:
a. Visiting individual households.
b. Distributing Information, Education and Communication (IEC) 
materials.
c. Holding/participating in community events?
d. Other?
2. Now that Tibu Homa is no longer operating, do you or your CQIT(s) carry out 
activities to promote child health? If yes, please describe any specific activities 
that are ongoing. If no, why not?
VI. Data Collection
1. Did you collect any data on behalf of Tibu Homa (or the health facilities you 
worked with)? If yes:
a. What data did you collect?
b. How was data shared with Tibu Homa (or the health facilities you 
worked with)?
c. Do you still collect this data now that THP has ended?
VII. Lessons Learned/Program Effects
Finally, I would like to ask your opinion on a few things. 
1. In your opinion, what are the main factors that contribute to delays in early 
health care-seeking behaviors for children with fever in this community?
2. How effective do you think you/your CQIT(s) was in addressing these factors? 
Probe for:
a.Activities that were most effective.
b.Activities that were least effective.
118 Tibu Homa Project Performance Evaluation Report
c.Is there anything about you/your CQITs work that would you change in 
the future to make it more effective in addressing these factors?
Thank you for your participation. Is there anything else you would like to tell me about your 
work supporting CQITs that I have not asked about? Do you have any other questions for me?
Tibu Homa Project Performance Evaluation Report 119
Key Informant/Small Group Interview Guide for Traditional Healers
Tibu Homa Project Evaluation
Instructions: This guide is intended for use with a single traditional healer or a small group of up 
to three traditional healers. After obtaining consent from each respondent using the consent form, 
record the age, sex, education level, and the length of time serving as a traditional healer in the 
community for each participant. Then begin recording the interview. Record the interview start 
and stop time.
Name of Interviewer
Date of Interview
Length of Interview
(Record stop and start time)
Start time:
Stop time:
Age of Respondent(s)
Respondent 1:
Respondent 2:
Respondent 3:
Sex of Respondent(s)
Respondent 1:
Respondent 2:
Respondent 3:
Highest Grade Completed
Respondent 1:
Respondent 2:
Respondent 3:
Length of Time as Traditional Healer
(Estimate in Years/Months)
Respondent 1:
Respondent 2:
Respondent 3:
Name of Community
I. Background Information
First I would like to ask you about how you became a traditional healer.
1. What is your role in the community, if any, other than a traditional healer? 
2. Why did you become a traditional healer? What do you like about it? What are the 
challenges of this occupation?
3. Please tell me about the process to become a traditional healer in this community. Did 
you receive/complete any training or an apprenticeship? 
II. Work as a Traditional Healer
Next I would like to ask you about your work as a traditional healer.
120 Tibu Homa Project Performance Evaluation Report
4. Please tell me about your work as a traditional healer. On a typical day:
a. What do you do?
b. How many clients do you see?
c. How many children do you see?
d. What types of ailments are most common for children who come to you?
5. How many young children with fever do you see on a typical day/week? 
a. How do you determine if a child has fever?
b. How do you normally treat a child with fever?
III. Interaction with Tibu Homa Project
Next I would like to ask about any interaction you may have had with the Tibu Homa Project. 
Tibu Homa was a project that encouraged caregivers of young children with fever to take them 
to a health facility within 24 hours of onset of fever.
6. Did you ever interact with a Community Health Worker (CHW) or other community 
member who:
a. Explained the early signs and symptoms of fever in children?
b. Encouraged you to refer children with fever to a health facility?
c. Explained the dangers of not referring a child with fever to a health facility?
d. Provided any educational materials on children with fever?
7. If yes to Q6, Please describe your interaction with the CHW or community member. Probe 
for:
a. Who the person was (CHW, or other – specify: role/position in community).
b. How they interacted with the CHW or community member. (Were they visited by 
them? Invited to a meeting? Other?)
c. Frequency of visits/meetings or other means of interaction.
8. Please tell me what you think about referring young children with fever to a health facility. 
Is it necessary? Unnecessary? Why or why not?
9. Did your interaction with a Tibu Homa CHW or community member change your opinion 
about referring children with fever to a health facility? Why or why not?
10. If a child with fever is brought to you for care, would you treat them yourself or refer them 
for care? Please elaborate on your decision to either treat or refer. 
a. If you would refer the child, where do/would you refer them?
Thank you for your participation. Is there anything else you would like to tell me about your work 
treating children with fever? Do you have any other questions for me?
Tibu Homa Project Performance Evaluation Report 121
Key Informant/Small Group Interview Guide for Community Health Workers
Tibu Homa Project Evaluation
Instructions: This guide is intended for use with a single CHW or a small group of up to three 
CHWs. After obtaining consent from each respondent using the consent form, record the age, 
sex, education level, and the length of time serving as a CHW specifically for THP for each 
participant. Then begin recording the interview. Record the interview start and stop time.
Name of Interviewer
Date of Interview
Length of Interview
(Record stop and start time)
Start time:
Stop time:
Age of Respondent(s)
Respondent 1:
Respondent 2:
Respondent 3:
Sex of Respondent(s)
Respondent 1:
Respondent 2:
Respondent 3:
Education 
(Highest Grade Completed)
Respondent 1:
Respondent 2:
Respondent 3:
Length of Time as a CHW for THP
(Estimate in Months)
Respondent 1:
Respondent 2:
Respondent 3:
Name of Community
I. CHW Background Information
First I would like to ask how you became involved with the Tibu Homa Project.
1. How did you learn about Tibu Homa?
2. Please describe how you got involved with Tibu Homa. 
122 Tibu Homa Project Performance Evaluation Report
3. Why were you motivated/interested in working with Tibu Homa? What were your 
responsibilities for the project? What benefits, if any, did you receive due to your 
involvement? (e.g., compensation, benefits, other)
4. Were you involved in any other projects at that time?
II. Community Background Information
5. What are typical care-seeking patterns for children in your community? (Probes: Under 
what circumstances do parents treat at home? Go to traditional healer? Go to a health 
facility?)
III. Training and Supervision Received
Next I would like to ask you about any training or supervision you received as part of your work 
for Tibu Homa.
6. Did you receive any training from Tibu Homa to prepare you to serve as a CHW for the 
project? If yes, please describe the training. 
a. Probe for length of training and topics covered. 
b. What were the most useful aspects of the training?
c. Do you have any suggestions for how the training could be improved?
7. Did you receive supervision related to your work as a CHW for Tibu Homa? If yes, 
probe for:
a. Who provided the supervision (position, organization); frequency of supervision.
b. What happened during a typical supervision meeting/visit?
c. Did you find the supervision useful/valuable? Please describe.
d. Do you have any suggestions for how supervision could be improved?
IV. Work with Community Social Groups (CSGs)
Next I would like to ask about your work with CSGs for Tibu Homa.
8. Please describe how you worked with CSGs to promote child health. Probe for: 
a. Number of CSGs engaged, types of CSGs, composition of CSGs, frequency of 
engagement (weekly, monthly, etc.).
b. How CSGs were engaged (e.g., through monthly meetings, other means).
c. Health promotion messages delivered to CSGs. (e.g., importance of taking 
children with fever for care within 24 hours, other messages).
9. Did your work with CSGs include identifying and referring children with fever to a local 
health facility? If yes, please describe. Probe for: 
a. How children with fever were identified.
b. Where they were referred.
Tibu Homa Project Performance Evaluation Report 123
c. How referrals were tracked.
d. In your opinion, was this process effective in improving health for children with 
fever? Why or why not? If not, what suggestions do you have for improving the 
referral process?
10. If yes to #Q9: Was there anything challenging about identifying children with fever and 
referring them for care? If yes:
a. Please describe.
b. What strategies/approaches were effective to address these challenges? Please 
describe.
11. Did your work with CSGs and/or in the community for Tiby Homa include identifying 
and referring orphans and vulnerable children (OVCs) for services? If yes, please 
describe. Probe for:
a. Definition of OVCs. 
b. How OVCs were identified (e.g., through NGOs, village leaders)
c. How referrals were tracked (Where they were referred and how referrals were 
documented. What services were they referred for? What was done with the 
documentation?)
d. In your opinion, was this process effective in improving health for OVCs? Why 
or why not? If not, what suggestions do you have for improving the referral 
process?
12. If yes to #Q11: Was there anything challenging about identifying OVCs and referring 
them for services? If yes:
a. Please describe.
b. What strategies/approaches were effective in addressing this challenge? Please 
describe.
13. Now that Tibu Homa is no longer operating, do you still work with CSGs to promote 
child health? If yes, please describe any specific activities that are ongoing. If no, why 
not?
V. Work with Community Quality Improvement Teams (CQITs)
Next I would like to ask about the CQITs established by Tibu Homa.
14. As a CHW for Tibu Homa, did you work with or were you a member of a CQIT(s) 
established by the project? If yes:
a. Please describe how you as a CHW worked together with CQIT(s), if at all. 
Probe for: 
i. Frequency of interaction
ii. Nature of relationship
124 Tibu Homa Project Performance Evaluation Report
iii. If CHW collaborated with more than one CQIT, was there any variation 
among CQITs?
b. What was the purpose of your work as a CHW with CQITs? In your opinion was 
this purpose achieved? Why or why not?
VI. Other Work for Tibu Homa
I would also like to learn about any other work you did for Tibu Homa to promote child health.
15. Did you do any other work for Tibu Homa to promote child health? Probe for:
a. Visiting individual households.
b. Organizing/attending community events to promote early-care seeking.
c. Working with traditional healers to increase awareness of the need to refer 
children with fever to a health facility.
d. Distributing Information, Education and Communication (IEC) materials in the 
community.
e. Other.
VII. Data Collection
16. Did you collect any data on behalf of Tibu Homa (or the health facilities you worked 
with)? If yes: 
a. What data did you collect?
b. How was the data shared with Tibu Homa (or the health facilities you worked 
with)?
c. Do you still collect this data now that Tibu Homa has ended?
VIII. Lessons Learned
Finally, I would like to ask your opinion on a few things. 
In your opinion, what are the main factors that contribute to delays in early health care-seeking 
for children with fever in this community?
17. To what extent do you think your work with Tibu Homa successfully addressed these 
factors? Probe for:
a. Activities that were most effective. 
b. Activities that were least effective. 
c. Is there anything about your work for Tibu Homa that would you change in the 
future to make it more effective in addressing these factors?
18. To what extent do you think your work with Tibu Homa improved linkages/connections 
between the community and health facilities? Please elaborate. Probe for:
a. Linking/connecting children with fever.
Tibu Homa Project Performance Evaluation Report 125
b. Linking/connecting OVCs.
Thank you for your participation. Is there anything else you would like to tell me about your 
experience as a CHW with Tibu Homa that I have not asked about? Do you have any other 
questions for me?
126 Tibu Homa Project Performance Evaluation Report
Key Informant/Small Group Interview Guide for CHW Supervisor
Tibu Homa Project Evaluation
Instructions: This guide is intended for use with a single CHW supervisor or a small group of up 
to three CHW supervisors. After obtaining consent from each respondent using the consent 
form, record the age, sex, education level, primary occupation, and the length of time serving as 
a CHW supervisor specifically for Tibu Homa for each participant. Then begin recording the 
interview. Record the interview start and stop time.
Name of Interviewer
Date of Interview
Length of Interview
(Record stop and start time)
Start time:
Stop time:
Age of Respondent(s)
Respondent 1: 
Respondent 2: 
Respondent 3: 
Sex of Respondent(s)
Respondent 1: 
Respondent 2: 
Respondent 3: 
Highest Grade Completed
Respondent 1: 
Respondent 2: 
Respondent 3: 
Primary occupation 
Respondent 1: 
Respondent 2: 
Respondent 3: 
Length of Time Working with THP
(Estimate in Months)
Respondent 1: 
Respondent 2: 
Respondent 3: 
Name of Community
Tibu Homa Project Performance Evaluation Report 127
I. Background Information
First I would like to ask how you became involved with the Tibu Homa Project.
1. How did you learn about the Tibu Homa Project?
a. Please describe how you got involved with Tibu Homa as a supervisor of a 
Community Health Worker (CHW). 
b. Why were you motivated/interested in supervising CHWs? 
c. What benefits, if any, did you receive due to your involvement? (e.g., 
compensation, per diem, other)
II. Training and Supervision Received
Now I would like to ask you about any training or supervision you received as part of your work 
for the Tibu Homa Project.
2. Did you receive any training to prepare you for your work with Tibu Homa Project? 
If yes, please describe the training. Probe for:
a. Length of training and topics covered. Who attended? 
b. What were the most useful aspects of the training?
c. Do you have any suggestions for how the training could be improved?
3. Did you receive supervision related to your work for Tibu Homa supervising CHWs 
and/or promoting health in the community? If yes, probe for:
a. Who provided the supervision (position, organization); frequency of 
supervision?
b. What happened during a typical supervision meeting/visit?
c. Did you find the supervision useful/valuable? Please describe.
d. Do you have any suggestions for how supervision could be improved?
III. Activities Carried Out by CHW Supervisors
Next I would like to ask about your work supervising CHWs as they carried out activities to 
promote child health through Community Social Groups (CSGs) and by other means through 
the Tibu Homa project.
4. What were your responsibilities for Tibu Homa as a CHW supervisor? Probes:
a. How many CHWs did you supervise?
b. What did you do specifically? How often?
128 Tibu Homa Project Performance Evaluation Report
c. Please describe how CHWs worked with CSGs to promote child health. 
Probes:
i. What did CHWs do? 
ii. How did you support their work with CSGs?
iii. How did you help them to resolve any challenges encountered?
iv. Do you think the work carried out with CSGs was effective in promoting 
health of children in this community (e.g., creating awareness of the need 
to take children with fever to a health facility for care with 24 hours of 
onset of fever)? Why or why not? Please describe.
5. Did you or the CHW(s) you supervised work with Tibu Homa Community Quality 
Improvement Teams (CQITs) and/or Community Coaches to promote child health? 
If yes, please describe. Probe for:
a. How CQITs and CHWs interacted. 
b. How Community Coaches and CHWs interacted. 
c. How did you support CHWs interactions with CQITs and/or Community 
Coaches?
6. Did the CHW(s) you supervised carry out activities to raise awareness among 
traditional healers about the need to refer children with fever to a health facility? If 
yes, please describe. Probe for:
a. What health messages were shared with traditional healers?
b. What activities/messages were most effective in raising awareness?
c. What activities/messages were least effective?
7. What barriers did CHWs face with regard to promoting awareness among traditional 
healers (e.g., were they receptive?) and how did you support them in addressing any 
barriers? 
8. Did the CHW(s) you supervised carry out any activities to directly identify and refer 
children with fever to a local health facility? If yes, please describe. Probe for: 
• How children with fever were identified. 
• Where they were referred.
• How referrals were tracked.
9. What was your role in this activity, if any?
10. Please describe anything challenging about identifying children with fever and 
referring them for care? (Probe: What barriers, if any, exist with regard to families 
accepting referrals and seeking treatment?)
a. What strategies/approaches were effective in addressing these challenges? 
Please describe.
Tibu Homa Project Performance Evaluation Report 129
11. In your opinion, did these activities improve the health of children with fever in this 
community? Why do you think that?
12. Did the CHW you supervised carry out any activities to identify and refer orphans 
and vulnerable children (OVCs) for services? If yes, please describe. Probe for:
a. Definition of OVCs. 
b. How OVCs were identified.
c. Where they were referred.
d. How referrals were tracked.
13. What was your role in this activity, if any?
14. Please describe anything challenging about identifying and referring OVCs for care? 
(Probe: What barriers, if any, exist with regard to families accepting referrals and 
seeking treatment?)
a. What strategies/approaches were effective in addressing these challenges? 
Please describe.
15. In your opinion, did these activities improve the health and social well-being of 
OVCs in this community? Why do you think that? 
16. Did you or the CHW(s) you supervised carry out any other activities for Tibu Homa 
to promote child health? Probe for:
a. Visiting individual households.
b. Distributing Information, Education and Communication (IEC) materials.
c. Holding/participating in community events?
d. Other?
17. Now that Tibu Homa is no longer operating, are you and/or the CHW(s) you 
supervised continuing to carry out activities to promote child health? If yes, please 
describe any specific activities that are ongoing. If no, why not?
IV. Data Collection
18. Did you or the CHW(s) you supervised collect any data on behalf of Tibu Homa (or 
the health facilities you/they worked with)? If yes:
a. What data did you collect?
b. Who was the data shared with? How was it shared? 
c. Do you or the CHW(s) you supervised still collect this data now that THP 
has ended? 
V. Lessons Learned
Finally, I would like to ask your opinion about care-seeking in this community and using CHWs 
to help address delays in care-seeking for children. 
130 Tibu Homa Project Performance Evaluation Report
19. In your opinion, what are the main factors that contribute to delays in early health 
care-seeking behaviors for children with fever in this community?
20. How effective do you think the activities you and the CHW(s) you supervised were 
in addressing these factors? Probe for:
a. Activities that were most effective.
b. Activities that were least effective.
c. Is there anything about your work or the work of the CHW(s) you 
supervised that would you change in the future to make it more effective in 
addressing these factors? Please elaborate.
Thank you for your participation. Is there anything else you would like to tell me about your 
work supervising CHWs that I have not asked about? Do you have any other questions for me?
This publication was produced with the support of the United States Agency for International 
Development (USAID) under the terms of MEASURE Evaluation cooperative agreement AID-OAA-L-14-
00004. MEASURE Evaluation is implemented by the Carolina Population Center, University of North 
Carolina at Chapel Hill in partnership with ICF International; John Snow, Inc.; Management Sciences for 
Health; Palladium; and Tulane University. Views expressed are not necessarily those of USAID or the 
United States government. This report was prepared independently by Emily Weaver, MEASURE 
Evaluation (team leader); Milissa Markiewicz, MEASURE Evaluation; and Gideon Kwesigabo and 
Joe Lugalla, both of Health and Development International Consultants. TR-17-157 
MEASURE Evaluation
University of North Carolina at Chapel Hill
400 Meadowmont Village Circle, 3rd Floor
Chapel Hill, North Carolina 27517
Phone: +1-919-445-9359 • measure@unc.edu
www.measureevaluation.org