FINAL EVALUATION - STAFH PROJECT a MIDTERM EVALUATION - CHAPS PROJECT INTERNATIONAL EYE FB?JNDATION CHIKWAWA DISTRICT, MALAWI Subrmtted by Marcle Rubardt External Consultant TABLE OF CONTENTS I. EXECUTIVE SUMMARY 5 IV SUMMARY OF RESULTS - STAF'H PROJECT 12 V SUMMARY OF PROGRESS 1 GENERAL CONCLUSIONS - CHAPS PROJECT 15 VI OBSERVATIONS, LESSONS LEARNED, RECOMMENDATIONS - SPECIFIC INTERVENTIONS 19 A COM~~ITY BASED DISTRIBLTION OF CONTRACEPTIVES (STAFH AND CHAPS) B SYNDROMIC TREATMENT OF SEXUALLY TRANSMITTED DISEASES (STAFH) C HOME BASED CARE / HV/AIDS COUNSELING (%"Am AhD CmS) D SCHOOL - BASED ACTIVITIES (STAFH) E SPECIAL TARGET GROLPS (STAFHJ 1 Trad~honal Healers / Nankungwis 2 Szrcoma Peer Edt~cators 3 Bar Girls 4 kapachrla Falls Workers and Surr ounding Villages 5 Polrtrc~ans F DRUG REVOLVI~G FUNDS (CHAPS) a G SEED DISTRIBUTIOY / COMMUNAL GMDENS (CHAPS) H WATEF~SANIT~TION ADULT LITER~CY &VD PRIM~RY EYE CARE I IYTEGR~TED MANAGEMENT OF CHILDHOOD ILL~ESS (MCI), SUPPORT FOR TRADI~IOYAL BIRTH ATTEND %TS (TBAs) VII OBSERVATIONS, LESSONS LEARNED, RECOMMENDATIONS - CROSS-CUTTING LNTERVENTIONS 27 A CAPACITY BUILDING - DISTRICT LEVEL (CHAPS) B CAPACITY BULDI~G - PERIPHERAL LE~ ELS 1 Qualzty Assurance Problem Solvrng Approach 2 Management and Supen won 3 Strengfhenmg of HSA r 4 Strengthenzng Vtllage Health Committees (VHCJ C SUPPL~ SYSTEMS D OTHER PARTNERSHIPS E IEC STRATEGI / COMMUNITY MOBILIZATIO~ VIII PROJECT MANAGEMENT 34 A PROJECT PLANNING AND MONITORING PROCESS B INTERNAL PROJEC r MGAGEMENT - IEF C TECHVICAL ASSISTANCE D IMPACT OF THE PROJECTS ON EF X CONCLUSIONS 37 APPENDICES A EvaluaQon Team ComposiQon, Schedule, and Contacts B Key Evaluation Issues (identtfied by team) C Discussion hdes for Field Vls~ts D Map of Project Area (evaluatron vlslts noted) F ResuIts of LIP Surveys Pertamg to STAFH Objectltes G STAFH Achevements Compared to Proposed Actmbes H Summary of CHAPS Achievements (4/98-9/99, by J Naisho) I Recommendabons and Lessons Learned LIST OF ABBREVIATIONS ARI CBD CPR DEHO DHMT DHO DW FP HBC HIS HIV HSA IEC IEF IMCI FCC MCH MOH NRH ORS PAC PEA Q A STAFH STD TBA TH VHC Acute Resp~ratory Illness Comrnumry Based Distribution (of contraceptives) Contraceptive Prevalence Rate Distnct Environmental Health Officer District Health Management Team Distrlct health officer Drug Revolving Fund Famly Plmng Home-Based Care Health Information System Human Immuno-deficiency Virus Health Surveillance Ass~stant Information, Education and Cornmumcation International Eye Foundation Integrated Management of Childhood Illness Interpersonal Counseling and Communication Maternal Child Health Wmstry of Health Ngabu Rural Hospital Oral Rehydration Solutlon Project Advisory Comttee Primary Education Advisor Quality Assurance (and Problem Solving process) Support to AIDS and Famly Hedth Project Sexually Transrnltted Dlsease Traditional B~rth Attendant Traditional Healer Village Health Committee I EXECUTIVE SUMMARY The evaluation covered two projects providing the final assessment for the STAFH (Integrated AIDS and Famil) Plamg) project and the rrudterrn assessment for the CHAPS (Commumt~ Health Partnershps) project The STAFH project ran from 2/96 - 9/99, whlle the CHAPS project is scheduled to run from 4/98 - 610 1 The et aluation took place from September 13 - 30, 1999, with a team that mcluded IEF staff from both projects the Maternal Chld Health (MCH) and Farmly Plannmg (FP) Coordinators from the Ministrt of Health (MOH) and an external evaluator The STAFH project was largelv a mobilization, behavior change project balanced bv an effort to assure the avaiiabili~ of semces once demand was mobilized It had a relatively narrow techcal focus on WAIDS prevention and family planning The project covered a broad svieep of the District, mcluding a vanety of target groups and a variety of partners for reachmg these groups By contrast, CHAPS works euclusi\el~ through the MOH with a focus on capac15 budding and assuring service atallability at the community level The range of potential mterventions 1s as wide as the actnities of the MOH ~tself, but the strengthening of management and support systems for these mtenent~ons prondes the framework for these ach~it~es The project desrgn outlines objectives for both the capacity b~uldmg and the actual serwce deliven mtementlons STAFH was a competentlv unplemented project that made good progress towards all of its objectl\es Highhghts of these achevements lnclude Increased contraceptwe prevalence rate (CPR) m the District as a whole and m villages m~th comnunity based distribution (CBD) of contracepbves m pamcular Increased competency of cllnlcal staff m the appropnate treatment of sexuallj transmitted diseases (STDs) and in the supermion of CBDs Increased access to FP methods - both in the cornrnuluty, and mith respect to reliable supplies at the health centers Increased depth and breadth of knomledge about AIDS and FP Points where the project fell short are due more to the gaps m the deslgn of the project particularlv regardmg unclear defimtion of objectives and lack of support systems for activrties rather than to the implementation of project actn ities themselves Sign~ficant accomplishments with respect to specific STAFH activities mclude CBDs trained and actlve in commumty distribution of pills and condoms 0 Providers trzuned and retramed in STD syndromc management Health Surverllance Assistants (HSAs) tramed m H!X/AJDS and FP, incIudmg supervision of CBDs Tradlbonal healers tramed 111 HIV/AIDS prevention and modern TP Partnershps supporting peer educators m Sucoma and home-based Lare (HBC) kolunteers and counseling at Montfort Hospital Pilot efforts m trallllng tradlt~onal mitmtlon counselors (nankungws) and educatmg pollti~ians on MVIAIDS prevenbon The fourth year no-cost extension under STAFH allomed for a seamless transition of STAFH actwities into CHAPS More lmportantlv homever, it allowed for the STAFH design to transition to the system strengthening model ln partnershp wth the Mlnlstry of Health (MOH) of CHAPS The kev activities for mcreasing FP use and access as well as those for improl ed clin~cal capacitv are now firmlt established under CHAPS For the mdterm el aluabon of CHAPS, the earl) phases of implementation for such field activities as drug revolving fimds@FWs), CBDs communal gardens and work nith .tillage health commttees (VHCs) were assessed, m add~tion to assessing the qualiB assurance/problem solwng process (QA) for improLlng servlces at the health center level Whlle specific recoxnmendabons for each interv~ntron area are elaborated m the body of the report the more generalized conclus~ons about the CHAPS process are probably moIe s~gmficant The first year of the project was frustratmg for everybody - the Dxstnct Health Management Team (DHMT) was not hnctlonlng and IEF staff had no authoriQ in the District Without MOH leadershp m the Distnct, it was extremely d~fficdt for the project to move fonvaxd Ths project demonstrates a strong sense of ownership on the part of MOH and the DHMT really 'gets it" that CHAPS 1s a participatory teem process The project has focused sigmficanth on DHMT and community le~el inputs, but has not addressed the problem of DHMT attnkon and turnover Most ail commumty level activities are well under way with concurrent efforts to address supervision and supply systems Gwen the decentralizat~on process occurnng m Malawi the CHAPS design (PVO/MOH partnershp, mixed commumty and system level intenentions and mlved process and matend inputs) uorks %ell and IS very appropnate The CHAPS objectives are appropriate for a project such as this but the three war tune frame is too short for a project nith this scope and effecting this level of change As part of the systems approach taken bv CWS, the e\duatlon team recommended significant strengthemng and expansion of the qualitv assur~~ce/problem sohing approach recent11 initiated In the D~strxct This has the potentla1 to provlde strengthening and capacity build~ng at the health center and cornmum@ levels as a balance to the efforts undemaj at the DHMT level It can also assure continuity in the face of turnox er at more semor levels Whde ths process was or~glnally conceiT ed as an approach to lrnprove health center leadtrshlp and accountability for quality servlces the team also saw ~t as a potential tool that could be adapted for communiQ mobihzat~on and orgamzahon Specific recommendations include Explore waqs to eltend the team problem solving approach to supervision of HSAs and to the HSA supervismg the co~nmunxty Strengthen the supervision and support role between the secondary supervisors at the health centers, the HS As, and the commumtv volunteers A11 health centers and Ngabu Rural Hospital need to put a management stn~cture (health center management team) in place to oversee dat to dm operations and resource allocation The biggest constramt faced by CHAPS IS the extreme shortage and turnover of human resources in the District p~cularly m leadership posihons NMe the project can uork to offset thls disadvantage through strengthening managetnent systems and policies as well as through strengthenmg the management funcbons of the Distnct Coordmators and health center level staff, it can't function m a vacuum The iarger human resource needs also need to be taken into consideration at the national level when assigmng personnel II OVERVIEW OF PROJECT DESIGN - STAFH AND CHAPS These two projects had very cbfferent designs and emphases The STAFH project focused strictly on 0 w/MDS prevenbon and fmly plmmg, wlth most of ~ts activities and obJectlves centerlng on commumty mobilmt~on and behawor change It began m Feb 1996 and was granted a fourth year no cost extension The CHAPS project 1s balanced betmeen an onentation towards District level capacitj buildmg focusing on management SF stems and resource provision and assuring dehveq of health sen Ices and unproved health at the health center and comnunitv letels Tlxs project began m April 1998 and is hnded through June 2001 The follow~ng schemat~c represents the relative emphases of each project as well as the pomts of oberlap with respect to capacitv build~ng service del~verv and corn mu nit^ mobihzationldemand creat~on SCHEMATIC REPRESENTATION OF WELATEONSHIP BETWEEN STAFH AND CHAPS PROJECTS CAPACITY BUILDING CHAPS ST AFH Svndrom~c Tx a SERVICE DELIVER5 /ACCESS CHAPS STAFH * Montfort HBC HSA tramng for FP Outreach shelters ORS d~stnbution AIDS counseling Quality murace FP provider tranlng DEMAND CWE 4TEQN/CCBMMUNITY MOBILIZATION CHAPS ST AFH OVERLAP Water comnuttees - IEC for HIV/FP 4IDS/FP Education Tram trad healers in - CBD and HSA rnobil~zat~on of Suconia peer educators Defirution of IEC clrents for FP general messages and Edzl Toto clubs Teacher education * Kapachila Falls area Man? of the STAFH activltm fell Into the areas of communit~ mobilizat~on The ong~nal RFA for the project emphasized a broad sweep of IEC and service strengthemg activities but btith the ven specific focus of HNIAIDS pretenhon and fairutt planning A banety of partners was encornaged rather than norking prlrnarlly mith the MOH As a result, STAFH included actlvities targetmg schools special groups such as bar glrls, peer educators and empIowes of Sucoina contract laborers and surroundug b~llages for the Kapachila Falls project tradmonal healers and nankungwis for village education and home based care volunteers (HBC) workmg with Montfort Hospital STAFH staff tramed and followed up all these groups in HIVIAIDS prevention as well as farndy plannmg Whlle CHAPS has a few activlties uith cornmunit\ mobilization, they fall under the general IEC strateg~es being developed by the MOH The3 cover the full range of pnman care actwties supporting the senlce delivery activlties for vrhich MOH is responsible CHAPS IS not prclung up the special target groups that were covered under STAFH With respect to increasing access to reproductive health senices, the STAFH project tramed and supported comrnumtv based drstnbutors (CBDs) for famh plann~ng HSA capabll~q to supervise CBDs as well as to distribute FP methods themselves were also covered Condom distnbut~on was emphasized through el en possible outlet These lncluded supportmg the sale of Chishango condoms through Sucoma and local grocenes and bars as well as assuring the free distribution of MOH condoms through MOH distr~bution svsterns Bv design CHAPS IS pcking up most of these actrvihes through its support of MOH service deliver) ST4FH began addressing quahb assurance in a small wa, through the tramng of FP providers 111 interpersonal communicat~on and counseling (IPCC) as well as supen~slon and support for appropriate STD treatment However thls 1s being much more comprehensively addresed through the CHAPS project as an intervention at several levels It becomes part of the capacio b~rddmg approach that wlll lead to improved sustamabilrty for the tramng and interventions introduced In adclxQon to the reproductive health service delivery, CHAPS ib also suppomng service dehven, actnities for a vanetv of other child surv~val actlvitles These mclude drug revolvmg hnds (Dm) for Improved v~llage access to malar~a and pneumoma treatment (among others) * renovaboil of the Ngabu Rural Hospital operating theater to improve access for sl~rgical contraception and Caesman sections construcbon of outreach shelters to provlde a prn ate place for FP counselmg, facd~tation of vlllage based ORS distnbut~on and implementation of a food securltr component thro~~gh seed distribution and establ~shment of communal gardens Llke with other CHAPS actlv~ties, these intenentlons are implemented b, MOH staff but resources traimng, and svsterns support are provided by the project In the project design documents, these are referred to as the "Part B" interventions The STAFH project focused less on long term capacity buddmg smce it was prrmanlq des~gned as a communlb mobilization project and the partnership w~th the MOH mas less emphasized This area Is, however strongly ernphaslzed m the CHAPS project Whde there are a significant number of activlties occurring to assure dellvery of senlces m the penphen, the capaclty bulldmg actlvities provide the framework which holds the project together These include developing management structures establislw~g systems such as supervlslon, cornurncation and 1ogistics1transport for supporhng day to dav operations, mmtaJ.~ung mformabon, and plannrg/remew activities It 1s these activitles comblned with some s~gn~ficant and jomth prioritized materm1 mputs that complement the health center and commumty level actavltres Thev glte the project a balance that is appropnate for supportmg dav to day operat~ons as well as for Increasing the sense of ownership on the part of MOH Thrs will ultlmatelv mprove the chance for susta~mng these activit~es after the end of the project In the project des~gn documents, these are referred to as the "Part A" mtervenhons The fourth year evtension for the STAFH project allowed staff to cont~nue to expand the coverage for the kev mtenentlons However more ~mportantlq, it also allowed the project to begm Lo fiinction in the capacrb bullding mode undertaken by CHAPS As such, the lme between tht two projects became a moting target as IEF s unplementat~on of STAFH actlvit~es began to roll over into act~vit~es supportmg MOH's mpleineiltat~on role 111 EVALUATION METHODOLOGY The evaluatron process nas a partic~patory one, complemented by results from several surve, s and a revlew of reports and activi5 data It was the fial evaluat~on for the STAFH proj~xt the level of partnership irnphed In a project such as this means that ssustainabiht\ filth respect ' to MOH absorpt~on and ownersh~p of the actn mes 1s not on Issue although reduced resource levels ail1 need to be planned for during the second phase of the project Secondh, the miled colnmumty and system level mterventions prov~de the glue ' that holds a vane@ of cornmunib level mterventions in place Wlthout mtervenuon to assure the svstems are in place for continued log~stlc and supervisoq support of communitv intervenDons, tramg occurs 111 a vacuum and activities fall short Eastlv the sigmficant level of matenal mputs has prowded credlb~lit~o the project and srgnlficantlv unproved the acceptabilit~ of the partnershrp m the eyes of MOH staff The CHAPS objectives ale appropr~ate for a project such as thts but the three vear t~me frame 1s too short fot a project wlth thls scope and effectmg ths level of change In spite of the s~gn~ficant delays and frustrat~ons earl\ m the project the CHAPS project IS esscilt~ally on track m the implementat~on of the~r object11 es and planned actmties However it 1s behmd schedule This is partly due to the delays in getting started but it is also due to overIv amb~tmus objectives given the depth and breadth of change expected - both in behaviors at the household le~ el and in senlce del~ven systems Particularlc the behavlor change object~ves are delayed because the community mobilrzat~on systems (IEC HSAs, VHCs, supenision etc ) have to be put in place before the mtervention can take place and behatlor change can occur Wxle a detaded report of progress against object1 des IS mcluded m the appendix, specific CHAPS project acl-uevements mclude Part A - Capacity Budd~ng D~str~ct office space renovated to accommodate IEF CHAPS staff on the hospital grounds as well as to accommodate the hospltal accounts office and to provide the hosp~tal with an arcondltioned computer room Fleet management svstem mplemented transport comrmttez established, 12 vehcles repalred policies for use of cars and motorcycles in place, 15 motorcycles and large truck procured, and motorc3cle nders traned The need for procuring and mamtamng HSA bicycles is still to be addressed and a transport officer needs to be recru~ted An accountmg computer has been purchased and use of the Quicken accounting package has been temporady mplemented A scope of work for an accountmg consultant has been finallzed and arrangement of the consultancv is m progress The IEF Systems Adwor is worlung w~th MOH accounts offke for on the job trainmg and budget rekiew Monthly MOH budget review meetlngs are taking place The storekeeper has been trained in a manual $\stem for stock control Initial cleanmg and reorganlztng of store was accomplished and htchen stores management was reorgamzed Regular DHMT meetmgs general staff ineetlngs and CHAPS Coordinators meetmgs are talmg place IEF and MOH staffjolntly developed two annual work plans whlch also lncluded a detailed rewew of progress Monthlt work plans for DRF, outreach shelter construction CBD QA, and primarc ete care act~v~ties are also developed Management team meet~ngs foi Ngabu Rural Hospital stiH need to be iinplenzented A quality assurance/problem solving process (QA) has been mtiated as a means to Improve management and supervision QA trarning of trainers was completed for a team of four tralners and tranmg has taken place at Ngabu Rural Hosp~tal and two health centers A qualitv baseline asqessment was carrred out and analvzed Job descnpt~ons for most cadres are m place and a transparent staff evaluation process is being cons~dered Superv~s~on for quality and effectmeness has not bet been considered m depth except for providing ra&os to health centers for unproved comunication Thls will be covered in depth as part of rolling out the QA problem solving process With rad~os now m place and mproved zva~lability of transport supercwion is occurring more regularh than previoush and the Dlstr~ct QA team IS using rad~os to monitor the progress of the QA teams at the health centers A team is reviewmg the HIS They have agfeed on a plan for collectmg processing and using mfom~ation A Dlstnct cost shar~ng account was opened and souIces for cost sharing fimd5 under discussion The Integration of cost sharing systems -1th re-supply for the DRFs has not yet been addressed A consuitant worked wlth a Distnct team to remew IEC actn ities m the Dlstnct and to develop posslble messages and strategies A plan for iinplementat~on std needs to be elaborated Equ~pnlent has been ordered for new Ngabu Rural Hospital theater including equipment for voluntaq surgical contracepbon (VSC) One MOH Cluucal Officer was trained in Integrated Management of Childhood Illness (IMCI) Tno Clmical Officers and one nurse uere tramed m VSC, the DlStnct AIDS Coorhator attended the international HlVIAIDS conkrence m Zarnb~a thirteen health officers were tramed m IEC, and four management staff were trmed m computers (Note the above ach~evements mere taken b) \erbal report dunng conversations w~th project and MOH staff and from q~mrterly reports The actual implementation of these actnitles was not rewewed durlng the evaluation process ) Part B - Health Intervent~ons A needs assessment was done to detennme needs for outreach shelters Th~s resulted m the orgmzation of commt~mties and the mitiat~on of construction for eight shelters Health center fmilv planning providers were trarned as secondan supervisors for CBDs Renovation of the operatmg theater at Ngabu Rural Hospltal was begun 46 CBDs were refreshed An assessment of CBD supenrsors was completed m preparation for tra~nlng CBDs as well as to identify needs for strengtheimg supervision The adult literacv curricuIum was reaewed and adapted to mclude more reprodwove health content 20 ~nstructors and 10 VHC members were tralned m the new approach 3 17 women started classes m August A DRF needs assessnxent was carried out and communrty mobilizat~on in I0 villages with non-active DRFs nas completed Trainmg of VHCslDRF volunteers for 2 vlllages mas done Soya and groundnut seed dstnbutlon was p~loted m 30 households durmg the 1998 growing season 100% of fm~ers who had a good veld of groundnuts returned the~r 12 kilograms of loan seed at the end of the season Fifteen comm~inal gardens were also piloted, wrth nine of those gardens producmg a reasonable yield A sub-contract for water and smtation is bemg lrnplemented by Concern Universal 60 teachers from 4 1 schools and 27 health workers were tralned in prxmary eye care screemg, preventwe care, and management of bas~c problems A health worker tralning needs assessment done in preparation for their tramng VI OBSERVATIONS, LESSONS LEARNED, RECOMMENDATIONS - SPECiFIC INTERVENTIONS A Comrnunrty Based D~sfrtbufron of Contracept~wes (STAFPI and CHAPS) Both projects have mnvested s~gnlficanth m this intervenhon, and the evaluation assessed it carefidlv Observat~ons All the clrents mten~etved apprecmted the u ork ot their CBD and appreciated having contracepbves available m their village Several village CBD clients ~ndzcated the\ mere usrng pllls because they were avalable m the v~llage, altho~tgh they would prefer injectable contraceptives Several CBDs mdicated that women who use Depo Provera may come to them for pills dumg the rmy season when access to the health center is more difficult and outreach achvitles are less regular The health center mdicated the) have no new cllents comg to them for p~llsmce all prefer Depo Provera The only client they hate on pills are those who had Qffic~dbes w~th the mjectron Clients feel they can help mobilzze others to use FP One cllent mentioned it 1s hard for her to make appointments for follow up at the health center, but smce the CBD 1s m her v~llage she doesn t have problems gettmg re-suppked with plfk CBD volunteers are generalh hard morkmg and hke then work, although they menaoned tramg and the opportumt~ to learn more provides them mot~vation to contrnue We some other mceaives such as umbrellas boots etc were mentioned, the request for addjltronal incentives was not ovemhelmmg CBDs are generally working 2-3 aftemoonslweek Some CBDs have d~fficultt maintaming a regular supplv of contraceptives Thls usuallv seems to depend on the level of act~vltv of the supervising HSA although some CBDs seek supplies d~rectlv from the health center on the~r own mitiatne Those CBDs who were active and seemed to care about their work seemed well trmed - many were able to mentlon side effects and their management Registers were generally well mamtamed and showed signs of regular use Gola CBD - counselmg means glving the necessarv facts and informat~on so FP clrents can make a choice It seems male CBDs are able to work effectwely with both men and women They feel the> m~ght have an advantage when dealrng wlth husbands nho are difficult to convlnce of the benefits of FP There seemed to be a steady trickle (3-jlweek average) of tubal Iigatlon clients that were motivated bt CBDs The CWS project works w~th the FP Coord~nator to provlde transport for these clients One CBD was serv~ng four school girls smce ' they were shy to go to the health center One health center supemsor was concerned that the mam problem wth the CBD program was lack of supemslon and he hopes the secondan supemsor system will improve thmgs Lessons Learned 1 The long d~stances reqmred to cover several vlllages make mobilization and follow-up of cl~ents cfifficuit for CBD volunteers 2 CBD vol~lnteers do increase access to famrh plannmg and users appreciate the atailability of methods at the village level Howeter, several users md~cated thev were usmg pds because they were atailable m the village while they would prefer lnjectabie colltracephves 3 Tramed vlllage volunteers are capable of delivering essent~al family planrung llltormation and senices 4 Male CBD volunteers are able to provlde fa-nilv planning servlces to both male and female clients 5 Although important the idea of reproduct~ve goals IS still far from the understaridmg of village clients 6 CBD mob~lizat~on posltwely ~nfluences the acceptance of tubal ligahons Recommendations I Contlnue to strengthen the secondanr provider (family planrung prov~ders at the health center) role as a means to assure support for CBD actmties even if the supemsmg HSA ma) not be strong 2 Complete the CBD tralmng as planned under STAFH and CHAPS with the addition of at least 28 more CBD volunteers 3 Encourage CBD cl~ents to also be family plmmg motivators B Syndrotn~c Treatment of Sexually Pransrnrttecd D~seases (STA FH) Observations Contact tracmg appears good at Ngabu Rural Hosp~tal- over 50% of paoents in the STD register had brought partners However others say it is difficult when anonymty Isn t assured or when HSAs are not Interested in assisting with trackmg down partners Smce 5/99 STD drugs have been ~n short supplv at Makhwira HC - especlall) erythromvcln Montfort - 4 technicians and 4 nurses were tramed m 1998 for 2 weeks Health education and counselmg 1s reportedly done for STD pat~ents at Ngabu Rural Hospital Drugs seem to be effective - providers reported there were no return cl~ents at Ngabu Rural Hosprtal Trainmg has prepared the climcim to treat cases well without havmg to figure out the exact dlagnosrs Reg~sters seem to mdicate a high rate of appropnate treatment, whch was corioborated during mterc iews Lesson Cllnicms appreciated the syndromic management trainmg and recognize ~ts importance The three total meeks of syndromc management trammg (one week initiallv then tuo weeks expanded sundrom~c management trmg) seems to have been enough to achieve appropnate treatment (dmg selection and dosage) assummg correct diagnosis Prowders also understood the co~mselmng, values unpllcahons, and partner ~dentification issues that come with the problem Recornrnendabon Include review of STD drug stocks and STD registus as part of routine supenlnsion of cli~ucal pract~ce No additional verhcal trammg is recommended at this time except to replace staff lost through attrition C Home Based Care / HIV/AIDS Counselrng {STAFH and CHAPS) HBC clients appreciate the support the~r guardians recen e from the volunteers No other health workers vls~them HBC volunteers have never been provlded wth gloves or other suppl~es The program trles to stq withm the locally avdable suppl~es but some clients refuse to be seen because the ~olunteer does not have any essentral drugs such as aspinn and eve ointment Volunteers render phys~cal support to their clients such as water colle~tron and sweepmg houses Volunteers are covenng a wder area (several v~llages) and as a result tmr~sport remms a problem Transport 1s not a problem for the IBC supervlsor because IEF1STA.H suppl~ed and mamtarned the motorc5 cle The supervisor for Montfort co~msehng center counsels patients both in the hospltal and villages Hovce~er, blood testing is currently not avalable at the counseling center and she feels people are not coming for counsel~ilg because testmg is not wadable The supervlsor was trued in HBC and Care Counselmg In 1994 and 1995, and refreshed m 1999 Montfort cllmc~ans appreciate being able to refer to the HBC supervisor nhen they are d~sckarging sick pahents Lessons 1 The STAFH inputs appear sufficient to leave a sustainable HBC/counseling mtervenQon with the Montfort Hospital context Recommendat~ons 1 HBC volunteers should be provided with personal protection (e g soap and gloves) 2 CHAPS with the DHMT should identify and support a HBC committee to recommend and pilot a feasible HBC delivew model mcludlng provision of rmnunal supplies Lessons learned from the Montfort expenence should be consndered D School - Based Acf~v~t~es (STAFI$) Observat~ons Pnmary Educahon Advisors (PEAS) and Patrons were observed to have more mterest m Edzi Toto clubs than teachers Other teachers have less interest m club act~vities despite good thlngs the club is domg The club members know most of the important points of HIVIAIDS and FP but not STDs Thelr act~viles focused on AIDS and FP transmission and prevention of HW, pmia1Iq on home care and on FP mformation Teachers at Phwadzi Secondan, School felt that the least sustamable activlty is the organization of extension actwibes The man support needed 1s transport for club members The club lacks strong leadership The Mmstq of Education doesn t support the club In an1 tvaj It was suggested that other related lessons such as First Aid, tuberculosis, cancer, diabetes, deforestation and others in~ght add interest One club suggested bnnging in guest speakers Phwadzi Secondav School Patron feels that the ~ntroduction of FP boosted the group He also suggested HBC activittes could be Introduced Problems with the cascade tralmng model and the expectations for allowances make it difficult for PEAS visitnng schools to tram teachers Puplls meet on the~r own without patrons - He makes them meet but he doesn't come ' Students complamed that Edz~ Toto Clubs do the sdrne thing agam and agam Pupils requested T-shrts as ID and dmed having membership cards Thev suggested something be done for mot~rration e g incenttves transport, certificates etc Supervis~on of Edzi Toro achvihes is not usuallv included m PEA vislts Lessons 1 Ad&tion of family planning informabon increased partmpahon at the club le\el 2 Lack of Ministry of Education and District Education Office ownership for ths Anti AIDS club program makes sustamabllitv difficult 3 Involvement of the Prlrnarq Educaoon Advlsors m the Anti-AIDS club program created a potentla1 linkage for sustmabilit). Recommendat~on IEF should hold a "Change of ownership ' meetmg for all PEAS representatzves fiom health centers and DHO/DEO representatives to a Discuss hdmgs fiom the final evaluation b Gve partxipants an assignment to meet together and develop a work plan for the Anti-AIDS clubs and other school based actmtles for the commg vear and c Offer them a fixed amount of support knds per school (to be detennmed b\ the DHMT worlung from the CHAPS budget) which they could use to support their activities These funds would on14 become avalable upon submission of a proposal for achcities with a means for monitoring their unpleinentation 1 Traditional Healers I Nankungwrs Qbservatlons Most traditional hedlers reported changing their behawor as a result of what they learned regardmg HIV prevention Thev st111 remember lrnportant information eg modes of transimssion and preventive measures such as avoichng sharing razor blades and usmg a different meQcme stick for each person They were will~~lg to glve out condoms but hadn t been re-supplied after the first batch The ~mpact of the Nankungwis is difficult to assess m a village as there are sexeral of them They have both religious and tradiuonal affiliations The m -charge of Makhwlra HC thlnks there 1s need for traditional healers and commuruty to be traned on mdma as a cause of ~onvulslons He sees too maw kids dying because thev were held up w~th the tradihonal healer for too long Tradluonal healers would like health workers to visit them in order to educate them on new issues They don t know what is gomg on m the tdlage w~th health activities because they are not invohed with or vlsited by health personnel There is good collaboration between them (healers) and government (hosp~tal) compared to the past years If they hake faled to cure a certan disease, they send the patient to the hospital One refers STD chents to the kospitd aftu the? hav6 been on fus t~i-satmtm for thrrt: days w&i FIB Impr8tir;nat Tlx, chances for cure of an STD is 50150 in the case of one tra&tional healer Amther healer feels he 1s m partnership m~th ththe HSA because both are domg health related Issues The tradtt~onal healers are supervised b~ nobody apart from their chairman nho stays in the same area The tradiDonal healer in Jakobo received HIVIAIDS messages from tradtional healer comrn~ttee (e g not to share razor blades use condoms, etc ) but no explanation of reasons All treated STD cases are encouraged to brmg their partners for treatment Lesson Trahbonal healers are interested in learnmg about Western vlews of inedtcme and are w11Iing to change their behamor They are also willing to promote healthy behawors in the commurutv Recommendat~ons 0 Trad~t~onal healers should be considered as part of the cornmun~tv's health team As such regular contact bemeen them and HSAs, health comttees and MOH staff should be encouraged Traditional healers should be supplied w~th free condoms for distr~bu~on The project should cany out a smple assessment of the nankungwi intervention and apply for separate follow-on funds if the assessment shons the mtertention works well 2 Sucoma Peer Educators Ths was an intervenbon that was begun by Project Hope and taken over bv IEF under the STAFH project The initial tramg was done by Project Mope, wlde refresher trmng and superviston were subsequently promded bu IEF Trwg of 40 peer educator supenlisors out of the group of peer educators was also added bv IEF Observations As peer educators they are not doing much on counseling since thec seldom tis~t people m the~r homes A lot of people request condoms froin these volunteers Some members of the coinmunlty insult these volunteers - thev get trred of the same old comrnun~B educatlon meetings 0 All peer educators had to be employees or spouses of empluvees m order to avoid problems with mceilhk es The Sucoma Medical Officer is willing to sustan acnvities, but IS concerned that he doesn't have enough internal trained tralners and the Sucoma management doesn t support trainmg costs Sucoma co~runmcatlon betwen med~cd staff and semuf irmnagemmt acems lmatsd Lesson The requirement that the peer educators be Sucoma emplo~ees or their spouses is a significant advantage for sustainabilitv d ~ecamm~.fldaf 10~s De-emphasize the commumt~ meetmgigroup education component of their lesponsltxhtias and mmgly emplmezs the~r drstrlbuhan of condoins IEF staff should meet with the Sucoma staff who are mvoIved wath the peer edueat~r prsgrsnr to hand over STAFH achviQes and to assist with development of the nex* vear's work plan (Note thls may also include joimg the medical officer m a meetmg with senior Sucoma staff ~f he tlunks ~t would be helpful) 3 Bar Girls fie project did an assessment of the trammg program in inid- 1999 usmg a focus group of women from each of the three tradmg centers in the Dlstnct They asked about safe sex beha~lors, knowledge about AIDS and FP and impressions of the tramg done by the project The conclusioil was that knowledge lekels were hgh, people appreciated the tramng and the tramg d~dn't necessarily lead either to increased education activibes with peers or changed personal behavior Recommendatmn Although potentially an mportant mtervention, there is increclslng recogmt~on that all women/people are at nsk, and specially targeting commercial sex workers may not be the most effective use of resources for a AIDS prevention The CHAPS project should contme to assure condom availablil~tv at bottle stores and tradmg centers, but should probabh not contmue to spend resources on special tramngs for bar girls unless addmonal funds for that purpose are procured 4 Kapachila Falls Workers and Surrounding V~ilages Although a sipficant amount of effort was put into working nith the construction company on HIViAIDS prevention and fmly plannmg, verq little progress was made As a short term contractmg company thec felt little or no responsibility e~ther for thelr workers or for the area and thev were unwillmg for any achvmes to take place during work hours There was also a fair arnount of tension between labor and manageinent, wrth the project percewed as assocmted with management * An mcome generation intervention m the Kapachila v~llages was also planned to prowde an alternative to the commercial sex work avmlable with the construction workers Unfortunatelv a ftasibility review mdlcated the project wmld hale needed to make a sigmficantly larger investment than they had planned, including emplovment of a staff person for mlcro-enterprise m order for such an intervention to be successfd As a result, this was never started This decision dld not Impact the implenlentation of the other District health actlubes such as drama group support and CBD m the Kapachila area Lessons When dealing with short term coitractois, a 1s dzfficult to get management support for health acuv~ties There IS a Iumt to how much wu can work &redly wth nnrkm: r5hs am afteo dlsplacd and disenf~mehxt;td in thehe settmgs W~~l~t1hwad3i4ezg r Conhue to conslder the Kapach~la area for conmmut~ letel intementions Itke any other underscrccd ared of the Distnct * Encourage the hpregllo Company doctor to mclude and expand the partner identdicatlon and treatment component of hs STD program Provide the necessary adv~ce and traming for ths effort 5 Polrtic~ans Talung the observation that polltlcal commrtrnent in Uganda seems to have contributed s~pficantlj to the decrease of HIV transmission m that country, the project dec~ded to try norlung wth polrtmans m Chkwawa Drstrict durmg its extension phase Thlrteen polrtzcians were trained m HIV prevention and farndy planmng wrth the hope they would then mcorporate these messages m the~r work However, the @ agency's need to reman non-sectarian has made follow up complicated Recommendation Whlle political leaders are Interested in health ~ssues and are potentlal allles for health lnterventions a formal relationsh~p with them through pro\ islon of truaing IS potentiallv compl~cated IEF could support non-parban efforts at the nahonal level F Drug Revolw~ng funds (CHAPS) Observations The DRF has strong management svstems m place the VHC monltors drug stocks and nlone, (Gola) * a Drug prices are set by the VHC to be slightly less than groceq prices (Replacement cost not considered ) The MOH drug supply system for the DR.Fs IS not workmg at all In GoIa vlflage there 1s one DRF volunteer and the communitv has dlfficultres &hen he is out of the vdlage for a few days Then DRF has dlfficultles with the commumtj on the Issue of purchasing andlor complet~ng the course * of treatment The volunteers were observed to be hard fiorkmng and cooperative Sometunes thev reported meetmg Mr Gobede, the MCH Coordmator, at Chikuana for purchasmg drugs Recommendation 1 The Distnct DRF committee, wh~ch is already in place, should contmue working on a The Drug re-supply system so that ~t is funchoilal at the health center level Ths -111 need to take some hnd of cost shai-mg accountmg svstem Into account b Ways to train volunteer replacement? \\hen onginal DRF volunteers leave c The conmmty svstem for oversight and otvnersh~p of the lntenentlon d Ways to educate the comnwmtv on appropriate drug use G Seed Drstr,butron / Communal Gardens (CHAPS) Ths project has two agrlcuihlrd mntervennons for the purpose of improvmg food security It is d~stnbutlng so, and groundnut seeds to mdiv~dual farmers and IS also attempting to organize communal gardens m a order for the cornmuniQ to have a means to provide supplemental food for malnourished chddren The commumty m Pende harvested so\a m March and ate it for three months imedmtely after harvest Thev made Llkunl Phala to feed the entire farmly - not just the chldren Farmers m Gola mnbcate seed avalabil~tv (llke plgeon peas) 1s the lnam I~rmtmg factor for increasmg production a Last year they had a poor y~eld of sova beca~~se the3 planted late Desp~te low product~on from soydgroundnuts they are shll ullling to grow these crops They would also hke assistance rn ith plgeon pea seeds Farmers m Gola do not appreciate the nutrlt~onal value of plgeon peas or know how to make pomdge w~th them The comrnumty has been dwouraged beca~lse no extens~on workers have been supervising them 0 Lesson Seed distr~bution, even if w~th lmited other inputs, can be well accepted and susta~nable Recommendat~ons The seed dlstnbution should be expanded, but substitutmg other protem foods such as increased ground n~~ts or pigeon peas for soya should be considered Farmers also need to be tralned to use these m makmg porrrdge for young chldren Even though thrs is a difficult mtervention the project should select the successfully produc~ng v~llages (those where the cooperative gardening is worhng) but place a much stronger emphas~s on the goal of malnutnbon prevenbon (as contrasted to just communal production) Lessons learned should be documented and used to develop recornmendaQons for contlnuatlon of the program (or not) next year H Water/Samtation, Adult L~teracy, and Prmary Eye Care These lntervenhons were not assessed in detail during the etaluat~on Adult literacy and prmary eve care were only mtiated \%ithin the last couple of months although In both cases curr~cula have been developed and tramm truned It was felt ~t was too early to assess the effect~veness or progress of these interventions The water and smtabon component of the project IS covered bv a sub-contract to Concern International a PVO that has been worklng on nater m the Dlstr~ct for many years Whde they are me11 underway wlth their work the tune allowed for the el aluatlon did not allow for a full assessnzent of the progress on thls sub-contract Recommendat~on A couple of representatives from CHAPS (e g D~strict Env~ronn~eiltal Health Officer, IEF) should go through a s~mplified rmdtenn evaluaQon process wth Concern Un~versal to assess progress and to assure collaboration and cons~stent messages between the dfferent components of the CHAPS project at the commumty level 1 Integrated Management of Childhood Illness (IMCI), Suppot3 for Traditronal BMb Attendants (TBAs) These are mtervenOons wlth whch the project has done llttle or nothmg to date but vihch the team thought should stdl be considered Thev are a&vitles tvhlcl~ the MOH is alreadj mplementmg or undertaking so the additxon of project support to these activltles is onlv providing the same kmd of svstem support ~t 1s providing to other mterventions a Recommendatlons a Contmn~~e the process of ~mplenlenting IMCI in the Dlstnct by tramng a Chlkwana Climcal Officer as an IMCI tramer and by encouraging its mplementatlon in the Distrlct Although TBAs &d not originall) figure in the CHAPS proposal and work plan, the MOH is activel) workmg to mcrease the tralning and supenislon of TBAs m the Dlstrict With this in mmd the CHAPS project should use its resources to Add TBAs to the supervision and support structure already established to support the DRF and CBD actlvlbes in vrllages (VHCs, HSA prman, supervisors, and health center secondan supen7isors) Review 11 the cntena for selection, 21 the mechanism for repiacmg those lost through attrition and 31 the content of the curnculuin to be sure it reflects the state of the art for maximizing the effectneness of TBAs m preventmng maternal mortaliQ and promoting maternal health m the commumtv Vli OBSERVATlONS, LESSONS LEARNED, RECOMMENDATIONS - CWOSS￾CUTTING BMTERVENGIONS A Capacrty Bu~lding - DIS~PIC~ Level (CHA PSI The man activities undertaken bv the project to address this level are re-imtiation of regular management meetmgs for both ahstrat~on and budget reviem , unprovenlents on the fleet management storekeepmg and accounting systems and some effort to increase both freq~~encj and effectiveness of supemision While the specific details of these iilterventims mere not assessed during the ekaluabon the external evaluator met wth the Dlstr~ct Health Management Team (DHMT) and the IEF Scstems Advlsor and made the followmg The DHMT recowzed a wde vane6 of benefits While most of them mere matenal, the assistance from the transport and QA consultant5 the re-imtiat~on of DHILlT ad budget meetings aqd the annual plwlg meetmg were also mentioned The DHMT mentioned concern about sustainabilitv and whether there was a possibility of contmued fbnding beyond 610 1 Whde uxtiallv this meant ava~labiht). of fimds to contlnue m ith the activit~es the\ have started they also made some behavioral recommendations for sustamng the changes made (see below) The DHMT zndmted there was already a recommendation to include a Farmly Health Coordinator on the team to represent the concerns of MCH and FP in the decision making The lack of a Public Health Nurse 111 ths position m the District is the reason they are not currently represented The DHMT felt the partnership beh?ieen EEF and the MOH was generallc going well They feel listened to and supported m their efforts, although thev had several suggestions (see below) Wule they recogmze that the allu~vance issue continues to create tenslon they were aware of and accept the written Memorandum of Understanding that was developed The\. suggested it would be helpful if MOH Program Coordrnators were bnefed more thoroughlc on ~ts contents The IEF CHAPS team has pro\ ided a sense of vision and leadership that slgnificantlq helped the DHMT move forward The Sjstems Advisor has reviemed the Distnct HIS with DHMT members The general concIus~on was that the system design 1s generally all rlght and has hmited fleulbili~ due to requirements at the natlonal level However, work needs to be done to improve the qualib and comrstency of the mformation reported as well as use of the information Lessons Improvement of the transport system has positivelc impacted morale and supervision at all levels of the Distnct r The deslgn for CHAPS provides a coherent focused frarnenork for whatever intenenbons were/are pnontized in the Distrlct By contrast STAFH b\ deslgn had a more narrou technical focus for ~ts Interventions that resulted in more of a l~st of interventions wth less concern for the svstem relationshps between them The MOH s direct mvoheinent in the development of the CHAPS work plans, budgets, and budget decisions has led to a sign~ficantlv different sense of ownership with the CHAPS project than with other PVO projects Recommendat~ons Followmg are suggestions that came from the DHMT members themselves, but supported by evaluator Continue to emphas~ze the ~mplementation and enforcement of pol~cies and s% stems even when individual personnel change, as a means to mamtam actmhes whch have been mihated c In order to mantam newly mioated actihlties, specific plans for their contmuaaon should be included durmg the development of annual and quarterlv work plans - not only plans for new actlvlt~es It mould be more helpful for all ths JEF CHAPS staff to have oFices m Chlk~awa so the) would be more accessible to each other 0 They would like to continue to be mohed with selection of CHAPS staff when people are hired from outs~de The3 are also mterested to knom the qualifications of the techcal staff nith whom they are workulg B Capacrty Buridmg - Periphetal Leveis Recommendatnon LUthough the CHAPS project has put a lot of energy mto capacl6 building of the DHMT, the cons~derable turnover of staff maks it difficult to establ~sh inst~tutional memory at that Icvevel The project should balance these efforts nit11 strengthenmng and capacity bmldmg at the health center and community levels for Increased sustamabilib There are aiready spec~fic intervenQons m progress to addless ths but the evaluator felt it uas miportant to elaborate the overarchmg recommendation emphasizrng the need to address capac~ty buildxng activities at all levels Actwities are underway to address supervision and supply systems at the health center and community levels, as well as to strengthen the roles of the HSAs and the VHCs A ke) strate@ to do this is the ~mplementation of a yuahty assurance/problem solving process that empowers personnel at each level to idenbfv thelr problems and constramts and to nork collectwely to resolve them 1 Quality Assurance 1 Problem Salvmg Approach Thib is also an u~tervent~oi~ that is still m its earl) phases, but is ce~ltral enough to the overall project goals that the evaluation team did a prelminan, assessment Two health centers where staff had been tra~ned in the process were s~s~ted and two members of the training team at the D~strlct lekel were inten ~eued Observations Cbapananga Health workers ' nork as a team md hold staff meetings nom as a result OF their QA traning" but the) had a difficult bme definmg quality semces They reported working together to repalr thex stenliz~ng stove, and they are meeting together to identifj and hscuss problems e "The benefits of QA is it allows staff to identifq problems and their solutions before seeknig external assistance' Ngabu Rural Hosp~tal They don t see health center reports as they are sent directly to the D~stnct lks makes it difficult 0 to support the health centers m their catchment area At Ngabu Rural Hospital tlle QA process is not going well because the members are too bus) wth other activities People are absent (norkshops) so ~t is hard to get together for a meetmg There is no proper coordination between departments at the hospital - e g no planning for transport use Staff don't see themselves as a team responsible for managmg their health center They w111 need follow-up and remforcement of problem solvlng process Thev had a tendency to slip back into the pattern of expectmg external solutions of the~r problems QA Trmmg Team The team reported a very thorough trajnmg process whereby they were first tramed in the process then supemsed while they facilitated a tramng and finall) carried out tramng on their own By the third tune through they felt confident in the process While they ~ndicated they are prepared to provide follo u up supervision to the health centers that were tramed m the QA process, thev maj not be so clear on the next steps necessary to keep the process movmg fonvard Thev m~tdly had a difficult bme maglung hot\ the process might be applied at the commumt~ letel - particularl~ since it imphes sdch a large scale However when offered the suggeshon that HSAs rmght be tramed to unplement the process they seemed to thmk the adaptabon to achieve th~s would be qute feasible Lesson The thorough plamg and tramlng for the implementation of ths process means the qual~ty asssurance team feels well tramed and competent in trammg health center staff and in pushg the process forward a Recommendat~on Tlxs IS a promising process that IS recommended tor expanslo11 at the health center and even commun~tv Level Honever, solid follow up should be emphas~zed and remforced for the QA core team so they are clear on their support role and for the health centers and communm committees by the QA core team and staff supervisors 2 Management and Supervos~on Obse~ vatbons The in -charge of Makhnira Health Center complains that manv staff members are sent to 11.1s area without receiwng any trmmg In addltion he is mterested m KBC and %odd l~ke to recelve tramlng 111 Care Counseling The in- charge of Makhwira Health Center clams that the health center management team (MA, Nurse, HA) meets about every other month The last meetmg was July 19, 1999 but the next meeting has not yet been scheduled In general, health center staff don't see themselves as managers Makhwira Health Center doesn t get supemsion support for a&nimstration md management - onlv the DHO wslts and his vislts are generally onented towards technical issues and troubleshootmg 0 The in- charge of Makhwira Health Center states that transport is not the main reason why he is not malung so many supervlslon visits, rather he is too bust at the health center Rout~ne visits by DHO unproted soon after CHAPS came into the Distnct Health Assistant was concerned that he can't supervise HSAs on CBD ~f he hasn t also been tramed on CBD The FP Coordinator felt the Interpersonal counselmg tralning has made a sigmficant difference both m her ability to assist staff technicallv with fmlt planning counseling, but also in her abilit.ci to effecbvely supervise and manage her staff Recommendations 1 Supervisors need to be tramed m the responsibilities of then subordinates (CBD, QA, etc) 2 All health centers and Ngabu Rural Hospital need to put a management stru~ture (health center management team) m place to oversee day to day operations and resource allocation (e g transport, outreach activ~ties, supervision reportmg etc ) CHAF'SIDistnct MOH should assist with ths process 3 Relnfor~e relatxonshxps between secondaq supervisors (health center staff) and vlliage volunteers (for CBD DRF etc ) partxcularly when there ma\ be difficultxes in gettmg supphes mto the hands of the volunteers 3 Strengthening of HSAs The HSA is a key lrnk betmeen those who are xnvolved wth comrnun~ty le~ el activities and their supporting health center In areas where there were strong HSAs, communxty actxvities seemed to be going well and volunteers felt good abo~~t their work In areas where the HSA was not strong the etaluation team found reports of supply stock outs at the coinm~~iuty level, frustrated volunteers, and limted activities actually occumng Obsesvatmns 9 The HS 4 m Pende v~llage is not aware of health activ~tw in his village Many problems in the vxllage appear to be due to the lack of supervlsion by the HSA e The Daus~ HSA refers clxents with normal Depo-Provera side effects to the health center even when thev should be managed at the vdlage level e The HS 4 m Mchacha shows that an HS 4 s work in a village need not depend on an active VHC - he works &rectly with volunteers 9 HS 4 has problems m keeping hls bicycle m runnmg condition as the hospital rarely gives spare parts e HSA is only bemg supemsed during normal under-fi$e outreach once a month Hence the outstandmg problems are not sorted properlv Lessons 1 HSA supervisxon of CBDs m the current svstem depends too strong13 on the qualitv of the individual HSA 2 Transfer of HSAs make it necessarv to plan for regular tralning svsterns (even if it is on the job trammg) for speclal HSA programs (such as CBD, water maxntenance, DRF etc ) to assure contxnued supervxslon of these programs by mcomng replacements Recommendations 1 Explore ways to exqend the qualitv assurance / team problem solvlng approach to supervlsion of HSAs and to the HSA supei-vasmg the communxty 2 As CHAPS act11 ihes are dependmg on effectn e HSAs, the problem of HSA transport (bicycle hstnbution and mamtenmce system) needs to be urgently addressed 3 Smce HSAs are cnlcxal for the success of coimunltj activities an effort should be made to pull ueak ones to posts where they can be supervised, and fired if necessary 4 Strengtt-ien~ng V~llage Health Commrttees (VHC) Observations Gola and Mwla - The VHC encourages mothers to attend both ante-natal and under fi\e climcs (mobilization) They also motmite dl people to go to the DRF and mothers to go to CBD and communities to go to communal gardens One CBD (Makh~lla) has d~fficultv mobxlizmg older women and men and thought the VHC m~ght be able to help w~th inob~lizabon Members poulted out clearly that CBD, DRF and gardens were for their own benefit (Gola) 9 There is need to provlde refresher course to those who were tramed m 1997 m order to boost their morale It was obsemed the conmttee was only supervised once (Dausi) There is also a need to replace the drop out members as there IS no system to address attnaon VHC members in Mchacha said thev supervise the CBD/DRF volunteer regularly but they dldn t seem clear on what supervision meant The NJ alugwe VKC is distorted and falling apart - 'the Village Headman (W) is a dictator In Lazo, the VHM was not represented at all Volunteers are not represented on the VHCs The HSA in Mchacha thrnks VHCs do not understand their role as responsible for health activities in their wllage a Members of the Outreach Shelter Committee appear to be corfused regardmg their role and the overlap wth the VHC Thev complam about "too l~ttle sand and too man) supervisors' - Dlstnct and health center supervisors are confusing the budder, the commumty and the HSA on the plan for the shelter a Recommendations I VHCs need tranmg includlng implementation of a sq stem for training replacements when attr~tion occurs a All PHC actrvltles occurrmg in their particular village (CBD Dm, water, gardens, growth momtomg, etc ) b How to provrde overs~ght and support to tillage volunteers a c How to orgamze regular conunumty meetmgs on health in order to Increase general cornmunib partmpabon and ownershp 2 Train and work with all Distrnct HSAs to apply the problem soivmg process (as initiated under the qualiq assurance interventron for CHAPS) m organizmg and trmmg VHCs 3 Select 10-20 tery active VHCs to focus on strengtheqmg the commurutpNHC/HSA/health center relationslups and collaborabon through more active implementation and supervision of the problem solvmg process Document the experience and lessons learned e C Supply systems Obsei vatxons Both the HSA and m-charge for Makhwira Health Center say there are never any problems with contraceptlves supplies but the CBD from Machacha sa~s she often does not get enough contraceptites from HSA @ The FP log~stic lnformatlon system has decreased contraceptwe stock outs at Ngabu Rural Hospital The m-charge of Makhwlra Health Center reports that he gets contraceptives soon after he sends his FP reports and the same IS true for vaccmes Condoms are not adequate at the HC The staff feel that they are onlv supplied for FP and not for casual use Sucoma - The STAFH project asslsted in transporting supplies from the MOH m Chkwawa The Sucoma Matron is concerned that the STD/FP equipment she requested (through IEF to be procured by JSL'STAFH) was never received and the now the project is endmg Lessons * The recently mtroduced contraceptwe logistic system (CDLMIS) made a difference m contraceptne avadability In the periphery The sphthng of condom dlstnbufion responsibility between family plmng and AIDS sections has resulted m problems with condom availabil~t~ at the health center level and belm Recomn~endations The perceptzon of adequate supply at the health center and communitv lek els needs to be considered nhen distnbutmg contraceptwes (If providers perceive their supplies to be feu they sometlme under - dlstnbute supplles to cllents or bolunteers - even if then actual supphes are adequate ) CHAPS should provlde the FPISTD equipment that was identified as needed but not supplied by the JSUSTAFH project CHAPS should facilitate problem solvlng between the FP and AIDS Coordinators at the District letel for efficient condom &stnbution Advocacy for changmg the system at the national ievel should also be considered D Other Partnershrps The MOH 1s the pnmq partnedlead plajer for the CWS project However both Sucoma and Montfort Hosp~tal were unportant partners under the STAFH project As significant health service providers m the Drstnct they also need to be considered under CHAPS Observat~ons * The Montfort Medcal Officer did not seem to realize that STAFH hnds mere pajmg the counselor - he thought Montfort was paymg her The Montfort inotorcvcle is regularly mamtained bj STAFH Montfort feels awk~mrd usmg MOH HSAs and HC staff to support their comn1umQ activities There seems to be conhsion oFer the health del~verj asea and the role of MOH for supervlsion and follow-up in that area Sucoma management dlcln t know the project was endmg although there are mulhple reasons (staff turnover, misunderstanding, mdependence) whj the phase over process mav not have been clear to evenrbody Lessons a Early in the STAFH project, the project adtison conmiittee (PAC), whlch was made up of MOH IEF Montfort and Sucoma provided a forum for addressing program implementation and management in general The dissol~~t~on of tlus group maj have led to a loss of clarity regarding specific project activibes and the plans for handover among these partmpants * Montfort Hospital s responsibility for the recru~tment and pajmnent of the HBC supervisor even though it was with STAFH fimds, Improved their ownerslup of the HBC program Recommendntums 4 Do formal handover including wntten letters and meetmg with management to assure details (e g payment of HBC supermsor salan, contmued condom supplj etc) are not dropped 111 the process of phaslng out (see also speclfic recommendation for Sucoma peer educators) Review and strengthen the role of the Distnct Health Technical Coordinating Comrmttee (DHTCC) or other District structures to assure a forum for cornmumcation and problem solving of techn~cal as well as management and supervlsion issues for all heaith players in the D~strict E IEC Strategy / Communrty Mobrlrzatmn The STAFH project was prmanly an IEC project, focusing on a xariety of target groups with focused messages around HIVIAIDS prevention and fmly planning Drama groups, competihons wall murals peer education, videos, and discussion groups were a11 used to convev these messages More m l111e with ~ts approach to strengthenmg systems, thz CWS project IS taking a Distnct wide focus to defimg an overall IEC strategy It lilcludes specific behatioral messages that reflect the project 0bjeCtIves but is also trying to provide staff wth a more effective framework for their health educatiort activit~es Lessons There has been an mcrease m the depth and breadth of people s knowledge about HIV transmission and familv plmng slnce the mception of the project that mav ha\ e been encouraged bj the wide \ ariety of IEC actmities that occurred throughout the D~stnct @ The knowledge changes (parhcularly for FP) were greater in the CBD killages than In the Distnct as a whole This might Indicate that the individual peer counselmng mode mav be more effective than a generalized IEC campzugn, or at least effective as an eenhancer of such a campagn Recommendation Although the IEC consultant outlmed a comprehensive llst of potential target groups and IEC strategies, the a messages and activltnes should be pnor~tmzed to a few key messages and strategies - keeping in man$ that €ht fialc"ll 1a'dpXt hr~~ to bc, fbc; %ts=ofFst~fin urfht: Ete,i@&L f6b $GkWsibf Ch&E& $\ ~ndlvrtludils ~~4~b~6 raa conmunlties Vlll PROJECT MANAGEMENT Both projects werelare generdlt well managed .M ith respect to resources personnel, planning, lnformat~on monltomg and teclmcd support A Project Plannrng and M~mfor~ng Process The STAFH project was large11 desgned bv IEF stdf with mput from the MOH and the Project Ad\ ison Cornnuttee (MOH, Montfort Hospital, Sucoma and IEF) The colnnuttee served as s forum for ccordmatmg activlt~es and exchangmg ideas The nature of the des~gn was qulte concrete w~th a clear outlme of actnines to be completed As a result, although staff went through the process of developing an ~mplementabon plan, ~t was ne, er finallzed nor did it become a document that was used as a management tool Addrtionally, whde quarterly reports were done the project did not follow an annual reporting or renew process When questioned, staff drd not report missmg the implementahon plan wth respect to keeplng track of project delwerables However it 1s llkely that the lack of this document affected the abtlm of staff to share the project with others, and rt certaml\ made ~t more difficult for the el aluator (or others) to assess rts status It is also open to &scussion whether the project activities might have had more coherence ~f thev were implemented m the context of an overall mork plan Momtonng for the STAFH project mas by survey, and bq monthh actn ity reports that mere tracked bj Project Coordmators Baselme swvehs were done in the Kapachila Falls area, an schools, and In CBD villages A final chld sumval survey carned out in August, 1996 also contributed sigmficant baselme rnformat~on Fmd survevs were done in the CBD villages and m schools The baselme surveF for CHAPS also conmbuted to an esbmate for some fmal STAFH mdicators for the Dlstnct as a whole The project effect~vely used simple informal assessments to detemme program strengths, weaknesses and contextual informat1011 This information was then used to plan training and make program decisions Examples of assessments carrled out include CBD Supemsors - Trammg needs assessment and review of constramts pnor to refresher training Peer educators - bar glrl focus groups to remew Jsnowledge and practices pnor to refresher traimng NanLungw initlatlon advisors - assessment of practices roles and AIDS/FBknowledge pnor to mihatmg mterventlon z Trachtiond healers - tramng needs assessment prior to refresher tralning These assessments were simple and d~d not take a lot of tune and resources but they protided good mnformation on whlch to base subsequent project act~vities A disadvantage hometer to the limited emphasis on fonnal~zing these assessments 1s the lack of access~bilitt of the information to others - e~ther for use bv other IEF staff, or bv other projects m the country In contrast to STAFH, the CHAPS project has been planned extensively from the begmmg In a particlpatov way with the MOH Several people cited the value of the annual rexlew and work plan development process statlng they had learned a lot about program plamng and management bv golng through ~t In addit~on to the quant~tative basellne survet carried out m October 1998, the project carried out a baselme qualiQ assessment tv~th techcal assistance from Umversitv Research Corporation (URC) This assessment mcluded a vanety of measures for health facdities as well as techcal competency m order to prov~de a basellne for many of the health center level capacity building lnterventrons that are proposed under CHAPS With respect to the capacity buildmg interventions at the Distnct level the Systems advisor carned out a prelimnary remew, with the specialized consultants dong more in-depth assessment as part of developmg an mtervention pl A However, because ths kind of capacit) buddmg is a nem arza of focus there are not yet e~ther elaborated tools or defined ind~cators fo~ progress for many of these activities In Leepmg with its commitment to puttmg MOH in the lead mplementauon position the project has not developed an mforrnabon system beyond that already util~zed bq the MOH It is focusmg instead on lmprovlng the quality and flow of mformabon withln that system Project Coordmators track activltles on a monthlv basis and ths prov~des mformation for the Project Manager to momtor progress Wh~le m principle th~should be adequate the evaluator is concerned that there arc: some key performance mdicators that mav fall between the cracks unless ad&tlonal effort is made to track them or at least to pull the spec~fic mformation OLI~ of the MOH informahon system Examples of these mght be 75% of acti~it~es on the work plans are completed, health center stock levels of essentral drugs or traclung of supervision activities Recommendatron Project staff should revien the avadable information relatwe to the specific perfomance ~ndlcators listed in the proposal log frame to be sure thev are monitoring the necessarv ~nfonnation for measuring project progress B Internal Project Management - IEF EF as an organlzatlon has the baslc structures in place for effective management fiese lnclude job descriptions, annual staff evaluaQons performance revlew durmg the first three months of employment, generation of monthly finance expen&tures agamst projectlolls and efficient procul ement As a result, project staff is generally free to focus thelr effort on project mplementation The evaluator met formally with both project managers, the Countrv Director, and rhe CHAPS Systems Advisor to assess their mew of project management In addition, she was available thro~ghout the evaluation for rnformal comments from more junior staff Following are some of her observations Observat~ons Wrth the emphas~s on MOH capaciQ build~ng IEF staff (QA PM) are concerned that the1 too need staff development rf they are to be effective advisors Staff appreciate the open, partmpatorv management style practiced at IEF They feel listened to and supported The Systems Advisor has the double role of project abnistrator and counterpart for MOH admrnlstration and finance This is a b~g job He likes bemg involved and really working with systems - gettmg hs hands d~rty and not just worlung them out theoretically Everyone feels there has been good support from both Blantyre and US offices in loglstm procurement, finance tracking, admnistrafion etc Spendmg for both projects was on track and consistent wlth budget projections Recommendat~on 0 IEF sho~~ld tryto assure tram opportunit~es for IEF adv~sors to complement traning received by MOH counterparts m order to assure the~r contmued credibilitv Everyone needs to be sure both the IEF management and the MOH Systems Advlsor components of the Systems Advisor's job are adequatelv addressed Delegat~ng some of the dav to day errands he does (for both the project and MOW to others leawng h~m free to focus on the svstems management would help C Technrcal kssrstance Because of the capacitv building and ad\ison nature of CHAPS with its focus on strengthening management systems, the project has depended fairly heady on outside technical assistance A lot of this has come through the umbrella agreement uith URC that was arranged at the begmmg of the project Others have come independently URC on Quality Assurance - 9 Ms Lqnette MaIianga came a total of five tmes wlth a duration vanmg from 3- 10 davs to assist with the baselme assessment and trallllng m the quality assurance/problem sohing process Ms Jolee Reinke came once for 5 days to assist with QA tranmg Ms Mellma Mchombo came once for 5 days to assist with QA tramng URC on Fleet Management - recruited Mr Tobias Harwa from Zxnbabwe to develop fleet management plan Mr Gilbert Mwakanenla, Adult Literacv Consultant - cane froin L~longwe to assist with adaptaaon of and tralmng for ad~dt literacy curr~culum Mr Daud~ Nturibi IEC Specialist - Came from Narobi to revlew and develop IEC messages and strategies with D~strlcteam Mr Precious Givah, Plannutg Specialist - Came from Malawi Institute for Management In L~longwe and assisted with workshop for the development of the annual work plan URC mas hired by all the CHAPS projects to provide a framework and technical assistance for the management tralnmng con~ponent of these projects This has been an mnokative, although relatively expensive mput, and mdications from staff are that some elements have been more helpful than others Recommendation Evaluate the costs and benefits associated with the teclwcal support model offered by URC to detemne if th~s kmd of assistance model is helpfbl as PVOs mo\e touard mcreased systems support and adwsorv roles D lmpact of the Projects on lEF The STAFH project provlded the opportunity for IEF to apply its chld survival exyenence m the Dlstnct to the more technrcally focused intementions of HIFIAIDS preveiihon and fmdy planning They were able to expand and strengthen then CBD mterventlons as well as raise the general profile and awareness regardmg reproductive health both mternallj as well as m the District Implementabon of the CHAPS project has entailed a shft m role for IEF from one of doing direct mplementat~on of programs to one of advismg They are now working in partnershp to assist MOH in lmprovmg health in the D~stnct The techmcal assistance brought in to support this new role has posit~tely affected the way the agency Iias carned out the planrung and management of thxs project - both internallv and m relation to the MOH It is hoped that this perspective mi11 be n~aintamed with the turnover of project leadershp to the STAFH Project Manager IX SUSTAINABILITY IMPLICATIONS With respect to the STAFH project, the fourth year extension allomed for more lmted and priorlt~zed a actn it~es W~th the CHAPS project m place the contlnuatton of those mterventions tvhlch contribute to the larger D~str~ct %ision for health 1s possible As such, some actwltles are bemg phased out, some are bang phased over to other partners such as Montfort Hosp~tal and Sucoma, and those which fit m w~th the MOH vislon for health m the D~str~ct w~ll continue to be supported by MOH under CHAPS Suztamabillty wth respect to CHAPS enta~ls two elements resources - both financial and human and a ownership Wlth respect to resources, the current actrtlt~es have all been planned with consideration to the resource constrants of the MOH, but real~stically they hate also benefited from the additional resources of CHAPS Some level of the current actlvlt~es would be sustamable \n ithout outs~de resources but they ~ould not lnclude the level of tramng and support the) are currently receiving With respect to ownership, the design of the CHAPS project with the MOH as the prima9 implementer of m all actmt~es, essent~ally makes th~s a non-lssue As a result, m spite of the ending of the STAFH project and the general need to consider sustamabrlity dunng an etaluatlon process the issue of sustamabillty m this evaluat~on tended to slide mto the background X CONCLUSIONS In conclus~on, the STAFH project was a hell executed project targeting most of Chkwawa Dibtrlct wtth a rride bar1et-c of interventions des~gned to improve awareness and lead to changmg behat iors w~th respect to AIDS pretentlon and farmlv planning utlhzation The a\allabil~Q of funding under the CHAPS project allow for the conmuation of some actn lties - partlcularh those contr~butlng to unproved access for fam~ly plammg It was certalnlv the feeling of all parties consulted that the CHAPS design is workmg ven well in Malam1 at thls tme It provrdes a framework for strengtheiung svstems mhde at the same trine mplementmng actwlhes designed to Improve health at the household level The Distr~ct focus is large enough to make a slgnlficant difference 111 health as me11 as to have some ~nlpact on nat~onal policj whle at the same tune it is small enough to get something done The true partnership undertaken m th~s projecl has led to a significant level of ownership on the part of MOH for the project achvltles and mtervent~ons It has also led to an effectwe balance between insbtut~onal capaclty budding and commumty level mplementanon of mterventions such that the comm~mty level actn~t~es areoccurring m the context of sustainable support svstems APPENDIX A Evaluation Team Compos~tion, Schedule, and Contacts EVALU 4TION TEAM Marc~e Rubardt Team Leader Chnstme Wltte EF Countrv D~rector Joyce Nasho, CHAPS Project Manager Tome Mpetheya STAFH Project Manager Mercy kampinda bIOH FP Coordinator Nelson Gobede MOH MCH Coordinator Sun 12 Sept Mon 13 Sept Tues 14 Sept Wed 15 Sept Thus 16 Sept Fri 17 Sept Mon 20 Sept Tues 21 Sept Wed 22 Sept Thurs 23 Sept Fn 24 Sept EVALUATION SCHEDULE AND PERSONS CONTACTED Awivc Blcqre Met wlth core e3aludbon team Joyce Naisho IEF CWS Project Mandger Tome Mtepheya IEF STAFH Project Manager Christine Witte IEF Counlw Dlrectot Mercy Kampmda, MOH IT Coordmator - Ch~kwawa Nelson Gobede MOH MCH Coorchnator - Chlkwawa Reviewed project progress to date Met wth expanded evaluafion team includmg George Meksem IEF CHAPS QA/Traning adasor Elton Chrum~a, IEF STAFH FP Coor&nator Paul Clubisa IEF STAFH Asst HIVIAIDS Coordmator Defined evaluduon issues, outlined schedule Met with Dr Esther Ratsma outgoing Dlstnct Hedith Officer Chlkwawa Finali~ed latemew tools and evaluat~on schedule Fleld vlsits - Matengambin Chambuluka and Pava vlliages Konzere Primary School Ngabu Rural Hospital Field vls~ts - Pende and Dausi villages Field vislts - Makhula Nguleti and Mchacha viIlages Phmbi f runary School Makhhwira Health Center F~eld mslts - Chlpakuza and Thomu villages Montfort Counseling center and Montfort MandgenIent Sucoma - peer educators and clients Sucoma Health Center and Sucoma management Fleld t isits - Gola and Mvula villages Chapananga Health Center Phwadz~ Secondary School Orgamzation of obsenahons Develop Recommendatioz~s Develop Recornmendat~ons Meet wth 2 QA team members Mr Mulenga and Mrs Ch~kopa Meet wlth DHMT Mr Chinkonde Acting DHO Mr Chunga - DEHO (on studv leave) Mr Mulenga Achng DEHO Mr Semu, D~stnct IEC Officer Mrs Phin ClerWAdln~nistrdtion Sat /Sun 25-26 Sept Complete recommendatlons Rev~ew numbers and accompiishments re activities completed and survey results related to obJechves Mon 27 Sept Finalize recomrnendatlons Presentatmn to results to Chkwawa Dlstnct representatlves from Distnct Commsioner, Distrrct Educauon Office DHMT Sucoma DEF staff Tues 28 Sept Presentation of results to USAID - Mevson Nylrongo and Kalinde Chndehu Wed 29 Sept CHAPS quarterly meehng Presentation of results Thurs IFn 30 Sept If Oct Travel home APPENDIX B Key Evaluation Isues (~dentified by tern) CBD￾how does the comrnuntty benefit from the CBD client satisfachon with the smce what kind of support do thev get from the project/MOH and the commumtt (not just allowances but also supervision, supplies etc what conseaints do they expenence - are there ways the project could ImnproL e to dlmimsh these a * Home-based Care What role does the HE3C volunteer have m the conm1~111t3 (what nlodel makes sense for delivery of HBC what to do about luts or supplies (gloves, pan meQcines soap etc ) what constra~nts do they face and how might the project address these (improve) the impact of HBC in the comrnumty, what is the connectton of the commumts level wlth the hosp~tal level (referrals follow up etc ) Is it feasible? Counseling and Testmg - What is the quality of counseling for FP STD, HIV? How do vou tram for or achleve good Interactwe counseling? STD svndromc management How well is it done m reality (check post tests for knowledge treatment repter for practice) What 1s the commumtv perceptlon of the need to seek treatment at the health center (survey) How IS partner idenBficafion orl lung What are problems Are there creahve approaches to erlcouragmng partner partIclpauon NankungwdTradmonal Healers What 1s their perception / the communltIes perceptlon (including \out11 and parents) of their role m the comrnumty - do people llsten to them dnd follow what they saj Do the healers appreciate what they learn - does ~t make a Werence e What role does the cornmmtv play in supportmg the health actlvit~es? Schools / Edzi Toto Clubs What next? What is the level of apprecratlon of the shtdents and the teachers Comrnerc~al sex workers - what IS the effectweness, what next Sucoma peer educators - what next? Kapachla - what next7 Food sewb model - comrnumty gardens and subsldi7ed crops Is ~t dolng what ~t s supposed to IEC - has been covered by the recent consultant v~t Condom clstnbutton - PSI CSW MOH QA process politicians - what next partnershps the number and breadth of the CHAPS ~ntervenaons COMMUNITY QUESTIONNAIRE HEALTH COMMITTEE - (Group) What health activibes are occurring in your commu~uty~ Prompt FPICBD? Health education? DRF? Condom &stnbution7 Water and Sarutabon? - what specific actlvitles m each of these areas and bv whom7 How are these actmtles going on? - What 1s workmg well7 Wht? What isn't working so well? Why not? (strengths and constramts) Whdt do vou do to support these actmtles? (health cornnuttee role) How do you know what needs to be done? What are difficulues jou find in malung sure these amvmes happen and can continue' (Whose actmtles are they?) How has the project/MOH supported or helped wth these activit~es in your commumt~ 7 When was ihe last Ume someone from the projectfMOH vlslted here to see how the work was going? What dld YOU discuss7 What health education actn lties have taken place here in the village^ (all IEC activltles - not just health talks What have you learned? What dctwihes do you see as most effectwe for helpmg people understand about health and ways they can improve then health? Hate \ou or fnends of yours recened speclfic services m the comrnunitv? (such as CBD HBC health education, drugs fiom DRF, samtation acti.i.ibes home vislt etc ) What was yourltheir expenence Was 11 helpful? - If so, what was helpful? Are there things you w~sh had been done differently - If so what7 Are vou doing anythng &fferently as a result of th~s project? (has behallor changed?) After the project finishes what are ways you can think of to encourage these people to contmue promQng services in the village? (sustamability) Were tradlhonal healers (or nankunms - Paiva) in your con~mwty trained by the project? Do tou know what that trxmng was? What, d? anythmg have you noticed they are domg d~ffeiently as d result of that trsumng? (Palva - Hon do vou feel about nankunw~s passmg on th~s kind of information to your children? - Do your children listen or do an*ng d~fferent ds a result of ~t?) If you need condonls here in the vlllage, n here can you go to find them? Are they alwavs there HEALTH CENTEWNRH MEDICAL ASSISTANTATURSE (Climcal Officer at Ngabu? 1 What experience have you had with the MOH efforts to assess and Improve qualm of serwces in your facilitv7 What kmds of components do you thnk contribute to good qualit, senlces? (what are the elements of quality what is the defimtion of qualitv) How are waj s you see that you can impro~~e the quality of semce at your facility? 2 What tramng have ~ou had recent11 In FP? What do vou know about what the CBDs xe doing? Hou many CBDs do )ou have m your area? What contact have you had with them? What do you see as the benefits of havlng CBDs? What are some of the hfficultles you see with working with CBDs9 0 3 What tralnlng did you have in STD treatment? Describe what vou do when someone comes to vou with symptoms of an STD Do vou feel comfortable in the way you are able to treat STDs? Why or why not? What do you do to ~denhfv partners of STD patients? How well 1s ths worlung) What are your difficulties with tius? May we review vour STD regster to see what patients you hate seen in the last two months and how they ha~e been treated (copy Diagnos~s treatment and doses for each patient in last tu o months) What kinds of thmgs do you discuss mth lour FP pabents7 Your STD patlentsq Any IlIV patients? What are the concerns these pabents bnng up wth you? (counseling) 1 What do you find most saQsfying about vow job? Why? What do you find most d~fficult about vour job7 Why 7 5 What support ha~e you had from the project/MOH over the past 6 months (superv~slon supphes trailung etc ) Are there wavs th~support could be improved' What are ways you prov~de support to volunteers in the field? What do you need to do ths better? 6 How do vour supplles and drugs systems work? Have IOU had am stock outs In STD drugs family planrung supplies or condoms m the past six months? If ves do J ou knon why 7 How do .cou account for FP supplies andlor condoms that are given to others (CBD TH etc) to dstrlbute7 WARD ATTENDANT/CLEANER Kha~ananga HC1 1 Whdt traimng &d you receive from the project/MOH? Are you dolng anythmg Merent at your uork as a result of ths training? What? SCHOOLS PEAS, TEACHERS, PATRONS, STUDENTS 1 What do .cou see as the main benefits that Edzi Toto clubs have to offer? What are the most successful a actnmes vour club has done? Can jou descnbe how thmgs have changed (~f thev have) as a result of some of these activrtles7 What are other thngs the club might do? What are some of the effectne health ducation actwities7 (dthe murals are part of the school - How have the murals been usedlmade a difference? ) What difficulties do you find in doing your actn ities? What are ways the project could better fac~l~tate these activltles? COMMUNITY VOLUNTF -RS (CBD, HBC, DRF, (GMV, TBA, )Water and sanitaQon Sucoma peer educators) 1 What lunds of thmgs do vou do as a volunteer? How often? What do ,ou llke best about your job9 Why7 2 What is going well in your job7 Why? What do you find difficult 7 Why? 3 How has the project/MOH facilitated your doing your job? What could be done to help you as a volunteer Hou about the community or the health committee? 1 Is what is expected of ?on reasonable? Is there a reasonable dmount of work? Do you feel competent in doing what you are expected to do7 How have things changed in the comrnufulv with respect to (FP/HEC/Drug awlabill&/Water and Smtation etc ) How are things different as a result of vour uork 7 (man to man village - Gola) CBDs - What 1s vour success wdh reachmg men' To what do vou attribute the success or chfficul~, 7) CBD,HBC CLIENTS Ask questlons #6 and #5 from health comrmttee list NANKUNGWI/TRADITIONAL HEALER 1 What is your role wlth respect to health In this cornmunlty~ When are vou consulted? How do jou Influence peoples achons or beha~iors with respect to their health? Do you feel people listen to and follow uhat you saj Why or why not? What lund of trainmg chd jou receive from the project? What mas helpful about it? What do vou ulsh might have been done differently? Are you mlsslng lnformatlon you uish you had? What? Are vou doing anythmg Werently (either In your own hfe or with vow clients) as a result of what \ou learned in traimng7 What? Nankungwl Youth - Ask health commttee questlons # 5 and #6 &dJ 1 What are the actmties in the cornmum5 that take most of your tlme7 Which ones are going the best? Why? Whch ones are you havlng the most dficultv wrth7 Whv? What do you llke best about your job? Whv7 2 What kind of support from the projectlMOH have you had to do your job7 (training supervision trmsport supplies etc ) How drd it help you? What more could be done to help you do your job better 3 What do you see as the strengths of vour '~olunteers/comrnittees~ (all cadres) Of their programs? - (CBD HBC DRF Water etc ) Are the wa~ s these acti\l&es could be carried out more effectrvelq in the commi~nities~ What kind of tralrung and other support has this intervenuon received from the STAFH project (tramng supplies reimbursements transport etc ) How did it help your program? Are lhere was it could have been 1mproved7 PEAS - has the project had an impact on the capdcitv of the MOE to address the problem of teen pregnancj and HIV In what wav7 TEACHERS - Descnbe how if in any my the training on the AIDS curriculum influenced what vou do in the class room W~th the end of the STAFH project what kmd of inputs mill be needed to continue the Edzl Toto actlvitles Do you have any ideas where thls support mght come from7 What? ('IEACHERSIPEAS) Have YOU had any tratung regardmg pnman eye care? What is the benefit of this tra1mng7 Do you see this as an Important problem that teachers should be addressing? Wh? or u hy not? MISC INTERVIEWS POLITICIAN 1 What traimng d~d you receive from IEF/STAFH regardng HTV/AIDS pre%entionl Did vou learn anlvthmg new or Merent from what you knew alread17 Are you doing dnvthing different as a result of your contact w~th EF7 2 Do YOU have suggestions of what role NGOs mght plaj in adwcatmg for health issues (AIDS pre%ennon HBC safe motherhood etc ) through the political system? Volunleers - (peer educators HBC volunteers) - see t olunteer questmns under comrnuruty Health staff - See quesuons under health center Management Staff what has been the benefit you hake seen to worlung with the IEF STAFH project 7 How hds vour orgamzanon capaaty increased (If it has) as a result of th~s collaboration (tralmng new programs personnel etc ) What difficult~es have vou experienced with ths partnership' Why do jou thmk this was 7 Knowing what ne know now are there ways these could have been allevldted or better addressed (lessons learned) Are there ways the project could better hake helped you overcome the constramts and cl§fxulhes jou experience In implementmg famly plannlng and AIDS preventions inten entions? How do you plan to contmue the actnrtles that have been supported b, the project' What difficult~es do you foresee in domg ths? FOOD SECURITY Communal Garden - Pmc~pants 1 Explain to us how vou have the garden set up who does the work M ho keeps track of the inputs and outputs, who supemses etc? Whose garden is it7 2 What do vou see as the benefit to ha\ lng a garden hke ths? Is th~s the best wav to reach thls benefit 7 3 What dlacult~es do you encounter m managng a garden hke this 7 Is there a better way to do ~t 7 4 What actuallv happened to the food that was harvested last year? Sold' Eaten? B\ whom? Is thls what was supposed to happen If not, nhy d~d ~tget allocated the way ~t did? SoytGroundnut Farmers 1 What convmced you to plant soy/groundnuts') 2 What has been your experience w~th ths crop' Dld you get a good hanest? Whv or n h~ not 7 What did vou do mth the harvest - eat 1t7 Sell 1t7 To whom? 3 Do you expect to contrnue plantmg 1t3 Why or whv not? PROJECT MANAGEMENT (IEF AND MOWCWS) Human resource management - personnel polmes staff development plan annual appraisals supemeon (checklists') etc (EF staff progress on CHAPSMOH) Planrung process - pmclpatory use of data dyncmu~, ownerslup (both projects) F~nanclal reporhng awareness of expenltures aganst budget Increase m EF capacity as a result of project(s) Ways to measure change m cclpacitv KIS mstem Lessons learned APPENDIX C Discussion Guides for Field Vis~ts CBMMUMZTY QUESTIONNAIRE HEALTH COMMfTTEE - (Group) What health activibes are occumng m your commun~ty~ Prompt FP/CBD? Health educatron? DRF? Condom distnbutlon? Water and Smtauon? - what speclfic actlwtles In each of these areas and by whom 7 How are these actlvihes gomg on? - What is worlung well? Why? What Isn t workmg so well? Wh, not? (strengths and constrams) What do you do to support these actlv~hes? (health conmttee role) How do you know a hat needs to be done? What are d~fficulaes you find in makmg sure these actmities happen and can contmue? (Whose actlmtles are they?) How has the project/MOH supported or helped with these actnltles in your cormnunit4 When was the last tlme someone from the project/MOH vlsited here to see how the work was golng7 What did YOU discuss7 What health education actavifies have taken place here in the mllage? (all IEC aLtwities - not just health talks What have you learned? What actwlues do you see as most effecuve for helping people understand about health and ways they can Improve their health? Have you or fnends of yours recerved specific services In the commumty? (such ds CBD HBC health educaoon drugs from DRF, samtation actiwtles home visrt etc ) What was your/their expenence Was it helpful? - If so, what was helpful? Are there tlmgs you wlsh had been done Qfferently? - If so what? Are YOU doing anythmg daerenth as a result of th~s project? (has behamor changed?) After the project fimshes what are ways you can thrnk of to encourage these people to contmue provld~ng semces in the village? (sustainabihty) Were tradihonal healers (or nankungwis Paiva) in your commuwtj traned bj the project7 Do you know what that traimng was? What if anvthmg hme vou noticed they xe domg differently as a result of that tra~mng? (Pa~.ca - How do you feel about nankunwis passing on th~s kind of information to your chddren? - Do your chddren Wen or do anythmg different as a result of it?) Ifvou need condoms here m the village where can jou go to find them? Are the, dlud~s there' COMMUNITY VOLUNTELAS (CBD, HBC. DRF. (GMV, TBA )Water and samtation Sucoma Deer educators) What hnds of thmgs do you do as a volunteers Hon often? What do ) ou like best about vour job 7 Whv" What is going well in your job7 Why? What do YOU find difficult? Whv7 How has the project/MOH facilitated your doing your job? What could be done to help you as a volunteer? How about the community or the health conmttee? 1s what is expected of you reasonable Is there a reasonable amount of nark? Do vou feel competent in doing what vou are expected to do? How have things changed in the conununiQ nith respect to (FP/HBC/Drug availabilily/~dter and Samtation etc ) How are hngs bfferent as a result of your work" (man to man village - Golaf CBDs - What is your success w~th reachmg men7 To what do vou atvlbute the success or d1Eculty7) CBD,WBC CLIENTS Ask questions #6 and #5 from health comttee list NANKUNGWIITRADITIONAL HEALER 1 What 1s your role with respect to health In ~s comrnuility 1 When are vod consulted? How do you influence peoples' acbons or behav~ors mth respect to thew health? Do vou feel people listen to and follow what you say7 Why or whv not? What lund of trairung &d you receive from the project? What was helpfbl about it7 What do you v,ish mght have been done Merenth7 Are you mssing informaQon vou wish YOU hdd? What 7 Are you doing anythmg Merently (either in your own Iae or wlth your clients) as a result of what you learned in tramng? What? Nankungw Youth - Ask health comttee questmns # 5 and #6 &A 1 What are the actnines in the communi6 that take most of vour time? Whlch ones are going the best) Whv? Mch ones are you having the most dlfi3cult-v n1th7 Why7 What do vou lrke best about vour job? Whv? 2 What lund of support from the projecWH have you had to do vow job? (training supervision transport supplles etc ) How did ~t help you? Whan more could be done to help you do vour job better 7 3 What do vou see as the strengths of vow ~olunteers/commttees~ (all cadres) Of their programs? - (CBD HBC DRF, Water etc ) Are the ways these actwihes could be camed OLI~ more effectwelv In the conunufllhes7 HEALTH CENTEWNRB: MEDICAL ASSISTANTNJME IClinical Officer at Naabu)) What experience have you had with the MOH efforts to assess and rmprote quality of semces In your faality? What hnds of components do you think contribute to good qualitv services7 (what are the elements of quality, what is the defimfion of qualitv) How are ways IOU see that you can Improve the quality of service at your facil~ty? What tramng have you had recently in FP? What do you know about what the CBDs are doing9 Ho* maw CBDs do you have In your area? What contact have you had with them? What do you see as the benefits of havmg CBDs7 What are some of the dlfficultaes you see with worlung with CBDs? What trainmg did YOU have in STD treatment? Describe what you do when someone comes to F ou with symptoms of an STD Do you feel comfortable in the way you are able to treat STDs7 Whv or whv not? What do you do to identlfy partners of STD patients? How well IS this norlung7 What are your dficultles with this7 May we review tour STD regster to see what paQents you have seen in the last two months and how they have been treated (copy Diagnosis treatment and doses for each patient in last two months) What kinds of things do you discuss with vour FP patients Your STD patients' Any HIV pdhents? What are the concerns these pabents bnng up with you? (counselmng) What do you find most sat@mg about your job? Why? What do you find most difficult about your job? Wh?? What support have T ou had from the projectrMOH mer the past 6 months (supervision supplies traimng etc ) Are there ways th~support could be improved7 What are ways you provide support to T, olunteers in the field? What do you need to do this better 7 How do your supplies and drugs %stems work? Have you had an? stock outs m STD drugs family plamng supplles or condoms in me past six months' If yes do you know why7 How do vou account for FP supplies andfor condoms that are gwen to others (CBD TH etc) to distribute? WARD ATTENDANT/CLEANER (Chanananna HC) 1 What tra~ning did you receive from the project/MOH? Are you doing anythmg dfierent at your work as a result of this training 7 What7 SCHOOLS PEAS. TEACHERS. PATRONS, STUDENTS 1 What do you see as the man benefits that Edzi Toto clubs haxe to offer? What are the most successful acbvvmes vour club has done7 Can you descnbe how things have changed (dthey have) as a result of some of these actwities7 What are other hngs the club mght do" What are some of the effectlve health educdtion actinues? (if the murals are part of the school - How have the murals been used/nlade a Werence7 ) What mculhes do you find m doing your actmties? What are ways the project could better facilitate these actwines? COMMUNITY VOLUNTEF LS (CBD, HBC, DRF, tGMV TBA. )Water and sanmtron, Sucoma peer educators) 1 What kmds of things do sou do as a volunteer? How often' What do you like best about your job? why7 What is going well In lour joo? Why'? What do you find difficult? Why? How has the projecUMOH fac~l~tated your doing )our job? What could be done to help you as a volunteer' How about the commurutv or the health commttee? Is what 1s expected of you reasonable7 Is there a reasonable amount of uork? Do IOU feel competent in doing what vou are expected to do? How have things changed m the commwty w~th respect to (FP/HBC/Drug availabilitv/Water and Sanrtat~on etc ) How are tlungs dfierent as a result of your work? (man to man v~llage - Gola) CBDs - What 1s your success wlth reachmg men' To what do you ambute the success or d1.ffhlty7) a CBD,HBC CLIENTS Ask quesQons #6 and #5 from health committee list NANKUNGWI/TRADITIONAL HEALER 1 What is your role wth respect to health in th~s community? When are you consulted' How do vou ~nfluence peoples actxons or behar, lors u xth respect to their health? Do sou feel people listen to and follow what you say? Whv or wh? not? What lund of trairung did you recelb e from the project? What was helpful about it7 What do vou wish mght have been done dBerentlv? Are you missmg informat~on YOU wish you had? What? Are you domg anythmg Merently (either in your own life or with j our clients) as a result of n hat F ou learned m tramng7 What? Nankungw Youth - Ask health committee quebQons # 5 and #6 =A 1 What are the actiwQes m the commwtr, that take most of your t~me? Which ones are going the best? Why? Whch ones are vou havmg the most difficulty 1v1th7 Wh\? What do you llke best about your job7 Why? 2 What lund of support from the project/MOH hate vou had to do \our job? (training superclsion transport supplies etc ) How &d it help you? What more could be done to help you do jour job better7 3 What do you see as the strengths of your volunteers/comttees? (all cadres) Of their progran~s? (CSD, HBC, DRF, Water etc ) Are the ways these actrvitles could be caned out more effectively tn the conunumhes? What lund of traimng and other support has this intervenbon received from the STAFH project (traning supplies reimbursements transport etc ) How did it help your program' Are there ways it could have been improved? PEAS - has the project had an impact on the capacitv of the MOE to address the problem of teen pregnancy and MV? In what way? TEACHERS - Descnbe how din any way the traimng on the AIDS cumculum influenced what vou do in the class room W~th the end of the STAFH project what lund of inputs will be needed to continue the Edzi Toto achvities Do you have any ideas where this support mght come from? What? (TEACHERSPEAS) Have you had any tramng regardmg pnmary eye care7 What is the benefit of tlus trarmg? Do you see tlus as an important problem that teachers should be addressing? Why or why not MISC INTERVIEWS POLITICIAN 1 What tramng Qd you receive from IEFISTAFH regardng HIVIAIDS prevenhon' Did you learn anythmg new or Merent from what you knew already? Are you doing anythmg different as a result of your contact with IEF? 2 Do you have suggesbons of what role NGOs mght play in advocating for health issues (AIDS prevenhon HBC, safe motherhood etc ) through the polit~cal system? Volunteers - (peer educators, HBC volunteers) - see volunteer quesbons under commmtv Health staff - See queshons under health center Management Staff what has been the benefit you have seen to worlung with the IEF STAFH project) How has your organizaQon capacity increased (If it has) as a result of tlus collaborabon (traimng new programs personnel etc ) What mculties have you experienced wth thls partnerslup? Why do you think this was? Knowing what we know now are there ways these could have been alleviated or better addressed (lessons learned) Are there ways the project could better have helped you overcome the constraints and difficulties vou eyenence in implementing family planning and AIDS preventions interventions 7 Hon do kou plan to continue the activities that have been supported by the project' What difficulties do you foresee in domg this 7 FOOD SECURITY Communal Garden - Participants 1 Explain to us how vou have the garden set up u ho does the work who keeps track of the Inputs and outputs who supervises etc' Whose garden is it7 2 What do you see as the benefit to ha~mg a garden llke this9 Is ths the best way to reach ths benefit? 3 What dficulbes do you encounter in managing a garden like thsp Is there a brtter wa) to do 1t7 4 What dctuallv happened to the food that was harvested last year' Sold? Eaten' BY whom? Is this whdt was supposed to happen If not why did it get allocated the way it did? Soy/Groundnut Farmers 1 What conmnced you to plant soylgroundnuts 7 2 What has been your experience wlth ths crop? Did ~ou geta good harvest' Why or whq not? What Id vou do wth the harvest - eat 1t7 Sell ~t? To whom? 3 Do you expect to continue planting it7 Why or wh\ not7 PROJECT MANAGEMENT (EF AW MOWCHAPS) Human resource management - personnel polmes staff development plan annual appraisals supermion (checklists?) etc (IEF staff progress on CHAPSIMOH) Plamng process - partxipatory use of data d-vnam~c ownershp (both projects) Financial reporting awareness of expendtures against budget Increase in IEF capacity as a result of project(s) Ways to measure change m capacitv HIS system Lessons learned APPENDIX D Map of Project Area (evaluatmn visits noted) APPENDIX E Evaluation Observations EVALUATION OBSERVATIONS NOTE The followmg observahons reflect contnbuQons from all evaluation part~cipants They are essenhally the raw data the team worked for the development of recommendat~ons and have not been eutens~vely eated SCHOOLS It was also observed that PEAS and Patrons were on the great demand of refresher courses The murals are not used very much by pupils or teachers in class when dmussing about HrVf AIDS and FP Issues The club feels it has not benefited much from the project The club feels the Patron is a contnbutlng factor to their falure of actmhes Female members are shy to conmbute ~deas The club members know most of the important polnts of HIVIADS and FP and not STDs Their actlvlhes focused much on AIDS and FP e g Mode of transmssion of HIVfAIDS a PrevenQon measures of HIVfAIDS Parhally, home care Importance of FP and polnts of FP OBSERVATION OF PEAS TEACHERS AND PATRONS Teachers are interested m lemng FP/STD/I-D[V/AIDS acbvlttes to have more knowledge PEAS and Patrons were observed to have more interest wth EDZI TOT0 CLUBS as compared to teachers When asked about other thmgs to be mcluded in clubs the WMaster as well as teachers were observed to request IEF to include 'Malana dsease ~n the program Patrons were mterested m Edz~ Toto before they were chosen by master Other teachers have less Interest ~n club achntles desplte good tlungs the club is doing The~r support to club patron is inadequate that makes clubfpatron not to tlunk of sustamng abil~ty It's a one man operation and In addmon to that the school has the problem of under staff It s drfficult to measure the behavlor change but it s there indnectlv They re companng these days to the past They mdicate drop outs and evpulsion due to pregnanaes are not happenmg as it used to Teachers at Phwadzi Secondary School felt that the least sustamable achvlty is the orgmzation of eutenslon actlvlhes The man support needed 1s transport for Edzl Club members The club lacks strong leadershp The MOE doesn't support the club in any wav In Pnmary Schools club actmhes wll be a b~t sustamable wth problems due to lack of thugs whch can motlvate them Other related lessons added to boost the club members morale could be Fmt Ad TB Cancer Diabetes, Deforestahon and others Phwadz~ Secondary School Patron feels that the mntroduchon of FP boosted the group Patrons m Phwadzi Secondary School suggested HBC actlvlhes could be introduced Problems w~th the cascade tramng model due to evpectahons for allowances make ~t d~fficult for PEAS vlsiQng schools to tram teachersThs could also be due to IEF not traimng deputies as promsed Pupils meet on their own wthout patrons - He makes them meet but he doesn t come Edz~ Toto Clubs do the same fhmg again and agam Pup~ls requested T-shirts as ID deny havmg membersh~p cards 0 0 0 0 0 0 0 e - DRF 0 a 0 0 0 a 0 e a * Students msinterpret rhe name of club, thus other students think that members of the club have AIDS Somethmg has to be done for motnation e g ~ncentlves transport cemficates etc Jmor Pnmary Schools do not have EDZI TOT0 - maybe more attcntron goes to Semor Prman Schools Patrons Qd not remember to menuon zone compehtIon even though they were number one (Pbmb~) Compeat~on pnzes wers for benefit of school Students apprecidte prves as an Incentive Toto clubs also know pllls and condoms for FP They ment~oned as oi&ng teen pregnanm as a means to prevent mortality - body not read) (mamage grls 15/18 y~s boys 2 1 yrs) Supervision of Ed~i Toto not usually mcluded in PEA visits No system for bnefing other teachers after tralmng (no allowance) PEAS sav they do not have transport for supemslon even though they have motom cles DRF has strong systems VHC measures stocks md monq Drug pnces set bj VHC to be slightly less than grocerv prxes (Replacement cost not considered ) MOH drug supply for DRF not worlung at a11 Makhula had 2 false st- (stolen money) but VHC recommended new drug stock Farmers in Gola sad that thls DRF usualh onh has Aspinn and Fansidar It was observed that the DRPi In both villages are verv active and cooperatn e Above all ~t was noted that they have enough drugs such as aspmn bdctr~m TEO fansidar and albenclazole Farmers in Gola would llke to have more than one DRF vol~mteer as thev often find it hard to get drugs nhen he is away All farmers (10) reported uslng the DRF indicated medicme for the DRF can be purchased by themselves at Chpiku En Gola v~llage there is one DRF tolunteer and commun1t)- has problem when he has gone out to the mllage for a few days Their DRF has Qfficulbes w~th the commuiuQ on the Issue of compleung the course of treatments People don't respect volunteer - thnk he 1s steahng money Gola DRF dfiiculty geIhng people to buj the full course of drugs It was noted that there was a long dela~ in recelr mg the drugs when the). purchdsed an order at Ngabu Rural Hospltal They were obsen ed to be hard worlung and cooperatmg Sometrmes they reported meetlng Mr Gobede at Clukwawa for purchasmg drugs It was observed that the volunteers were of importance to the~r community because of sen ices they rendered HC CAPACITY 0 In charge of Makhwm HC compla~ns that manj staff members are sent to hrs ai-ea without having received any training In charge of Makhwlra HC would hke to recen e traimng m care counsellmg Last time he got on HIVIAIDS was In 1992 In charge of Makhwira HC clams that HC management team (MA Nurse HA) meets about every other month Last meetmg was Jul) 19 1999 but the next meetlng has not been scheduled 1 et 0 3 clients referred to the HC were not assisted It seems bs jumors are unrulj as he kept conlpla~rung about them 0 (Ngabu Rural Hospital) CHAPS/STAFH has really assisted in perfornung then work well -Tr mng (STDs OBD USC DA) e -Transport -Renovabons a Makhmra HC don t get supervision support tn admmstraaon and management e g Full DHMT support a In charge of Makhw~ra HC states that transport 1s not the man reason why he is not maklng so many supervision vls~ts rather he is too busv at the HC Health centers don't see themselves as managers Makhawira NRH Sucoma - 10 FP provlders trained in IPPC and 7 m FP logtstlcs management - CBD CBD VOLUNTEERS He doesn t do a follou up on client who choose other methods e g Deco Dausi village CBDs were both hard worlung and proved to hke their work Thev said they needed some more tramng to refresh them Dausi CBD- One is using p~lls but the other is using natural FP (I feel she 1s on tradit~onal method) He feels refresher courses are the only remedv for problems e g CBDs report nstem CBD- Even though ver, elderly but seems dedicated and knows mhat she is supposed to do Works 3 days ~n a week The CBDA in Makhula v~llage nas observed to be a ded~cated and alert Abo~e all she mas observed to be a good motmator He has managed LO counsel 4 men on condoms as their method of contraception She acts as TBA as well (gathered from the VHC) Her main problem n h~ch she kept mentionmg is that she inadequdte supply of contraceptwes It seems the CBDA under reports (improper use of talh sheet) that s whv she gets in adequate supply of contraceptmes He has too many activltles le CBD DRF and VHC whch can e~entually lead to poor performance People don t like foam Prefer Depo but use pills because of local availabilrty Depo users tn to comince them on benefits of Depo CBDs in Pende were selected by the heddman who called them to h~s hut and told them that the3 are volunteers Thev were not told what they were volunteenng for Refresher courses seems to him ds d mohvaQon in CBD uorks as dllowances recexved was cited as an encouragement CBD Gola knew side effects & management / adv~ce to give Knew admce for mssed pills includmg need for using condoms as backup CBD want incentives such as T-shrt umbrella also refresher course Cola CBD thtnks a male CBD is more effectne smce he can speak strong11 and convlnce people in cult areas The are some new developments ~n fmly planning whch should be covered dunng refresher Registers generally well mntaned and well used (to keep records of when people had appointments) First person in Makhula register was CBD herself CBD serving 4 school girls because they xe too shy to go to HC Needed coachmg to gne both plls and condoms to school girls for protection as well as contraception - dldn t seem to knom much at MV prevention CBD CLlENTS 0 Client doesn t know what to do in case of mssed ptlls (espec~allv 2) The chents were satisfied and their CBD even though some were after depo e Sometimes was no possible for her to fulfil HC appointment dates but slnce the CBD rs at eas) reach there is no r oblem m gettmg re-supply of p~lls a CBD Clrents- Hs been on lofer for 4 years It was fiarther obsened that the client motwated his In-law who 1s currently usmg farmly plmng @~lls) Eght out of mne farmers in Gala report learrung FP messages from the~r CBD The nmth person was a vew old man SUPERVISOR/COMMUNITY SUPPORT Support from the programme Tramg on DRF CBD comrnmcation garden and so5 a ut~lizatlon CIler~ts can help mobtlze others CBD feels commitment to her cllents can continue wlthout allowance but does fee1 need for continued learnmg In charge of Makhwm HC tbnks the man problem with the CBD IS lack of superctsion by the HSAs Hopes that the secondarv supervrsion w111 improve things The commmty is not prepared to asstst alth CBDA in cultlvatmg hdher garden on any other plece of work but they are wllmg to thank the services through token gfts Observed to lack contraceptlves In some months of the year Observed to be supemsed mostly bq MOH HSA rather than an IEF member who goes there on11 once a month (Chapananga) Health Asststant was noz onented on CBD/FP and cant supelwse HSAsICBD on these actmtles He gets supervlsron frequently slnce he 1s near with hs supertlsor Supemslon of Malcula 1s a problem because the supervisor (HSA) was transferred to Chlkwawd Distnct Hospital and secondar) supervisor (MA) too bun HSA knows the actwties wh~ch are tak~ng place in hs catchment area as he was able to list them all CBDs should only be assigned to one vlllage as they have other thrngs to do to support thelr famrlles CBDs m Pende appreciate the referral blsrts by the IEF Volunteer mentroned that supemson vlslts from CMwawa prov~de s~g~cant mowatlon NRH has two good motorcycles grounded nhlch could be used In the field act11 ities Transport orgamzation k erv poor No transport for 2 CBD supervisors Gola CBD covers 3 vlllages - &stance 1s a sigmficme constrant (transport) SUPPLY SYSTEMS The new reporhng svstem for FP allows NRH to have adequate supplles of contraceptnes CBDs m Pende and Fakolo wllages have few cllents and compld~n about long penods of stock outs 4 Both HSA and HC ~n-charge for Makuwlrd HC say there are ne\a any problems alth contraceptlves supplres but the CBDA of Machacha says she often does not get enough contraceptives from HSA o Sucoma eqmpment for FPlSTD not a\allable (was supposed to come f?om JSPtSTAFH) a The Chapananga HC members reported to hake enough contracept~ves but thev ran short of condoms In Mav June and July last year It was reported that they were stuck at Kukoma Health Center e The FP loglstic ~nformatlon wstem has assisted In easing stock outs of FP nlethods at Ngabu W Necessaq condoms were out of stock 6 out of the last 12 months hence fen rnen uslng condoms regularly In-charge of Makh ,ira reports that he gets contraceptives soon after he sends hls FP reports The same is true for vaccines o HSA in Mchacha lkes M4E - he mahes up hs own forms as there 1s a shortage of forms o Condoms are not adequate at the HC The staff feel that they are onlv supplied for FP and not for casual use 0 Chapananga HC complamed of stock outs - condoms Gentamycin and Ervthromvcln - lt wdsn t clear why - They stated Chlkvr:awa pharmacy had no antibiot~cs in August there was some problem with eupiratIon7) Condoms went to Kukoma WC They don t get enough condoms for both FP and AIDS prevenhon 0 Sucoma - STAFH project assists in transportaoon of supplies 0 Matron concerned that STD/FP equlpnlent requested was never honored (JSI/STAFH)& project alreadj ending Sucoma - logst~c tralmng asslsted with decreasing stock outs HSA - ROLE 1 CAPACITY HSA in Pende village 1s not aware of health acuvltles in hls village Many problems in the village appear to be due to the lack of supervision by the HSA Dausi HSA refers clients with normal Depo side effects to HC The HSA had a few problems compilmg reports from the CBD HSAs sad they hked their sanitmon activmes but commumtles 1 is~ted didn t have adequate pit latrines HSA in Mchacha shows that HSA work wlth the village does not dBer whether there is an active VHC or not - he works Qrectlv wlth volunteers He seems to know hs job descnphon well HSA was able to answer what he does, but he knew hls job lacked gwdance from hls supervisors HSA has problems in keeping hls bicycle in rumng condihon as the hospital rarelv gives spare Parts HSA of Mchacha was last vmed bv hs supervisor (HA) on August 17 1999 HSA - Gola The HSA IS a hard worker even though there are down falls In other achvltles conducted in that area The HSA has been assigned more work to be done in his area Hence others such as the Ul5 c111ucs are not doing as well due to lack of superviston HSA is only bemg supemsed dunng normal u/5 outreach once a month Hence the outstanding problems are not sorted properh while made other actwities not to move nell PEER EDUCATION As peer educators they are not doing much on conseliing since thw seldomlv visit people in their homes e A lot of people request condoms from these volunteers Peers feel the traiiungs they have had has benefited them and more people are saved from HIV bv use of condoms and unwanted pregnancies by use of FP Some members of the commuruty insult these volunteers - get wed of the same old comrnunifi educahon meetmgs Peer Educators - These peer educators are comrnltted to their work because they combme their paid job with their health actwhes All peer educators had to be employees or spouses of employees in order to avo~d problems wth inceilhves TB NANKUNGWI Wllhng to glve out condoms but ddn t get resupplied after the first batch Impact of Nankunf vls can not be assessed In a vdlage as there are several of them They have both rehgous and rdditronal affiliauons In charge of Makhwlra HC thlnks there is need for THs and community to be tramed on malma as a cause of convulsions as he sees too manv luds dying because they were held up at the TH for too long TH Dausi w~lling to hstnbute free condoms especially to )oung men for protection against HIV/AIDS and STDs Trahhonal healers ask that health workers should vls~t her In order to educdte her on new Issues They requested refresher course to remnd then1 on the mformatlon they learned He doesn t know what is gomg on In the vlllage and health activities because he 1s not lnvolved or vlsited by health personal TH in Jakobo recelved MV/AIDS messages from TH commlttee (~e do not share razor blades prevent condoms) but no exylanabon why Says she would llke to learn more abou HIV/AIDS He refers STD clients to the hosp~tal after they have been on hs treatment for three da~s and no Improvement There 1s a good colabordtron between them (healers) and government (hospital) compared to the past years lfthey have faled to cure cemn hsease thej do send the paDent to the hosp~tal They do work together with others eg VHC TBAs CBDs DRF and HSA though these others are not supervmng them The tra&bonal healers are superv~sed by nobody apart from their charman who sta) s In the same area On HIV/AIDS, the trahtiondl healers sull remember some of the Important points eg mode of transrmsslon On thls one the mentioned sexual Intercourse Prebentlve measures menboned included avoid~ng sharmg razor blades and uslng a suck per person to appk medicme He feels he 1s in partnershlp w~th the HSA because both are dolng health related Issues All treated STD cdses are encouraged to bnng their partners for treatment He cited Kulowa Kufa as one of the cultural behavlor promoting the spread of HIVI AIDS TH Makhda was able to mentlon all toplcs covered lrunal tralnlng HIVJALDS, Farmly palnrung, STDs and Pr~mary Eye Care Patrents refered are wdling to go to the hedlth facllitV for further management after seelng the TH TradrUonal healer Makhula remembered some modern famllv planning methods mentroned some common STDs and some common eye problems STD patients are treated for three days and If not better referred to a health centre TH were supplied with condoms dunng their mQaI trarrung Smce then no suppIy They are urllllng to distribute them to the co~~m~un.~tv The chances of STD cure 1s 50/50 in hls case as d TH Requested for refresher course to rermnd them what they have forgotten and new mfornlatlon Changed then practlce ie one razor blade per patient No more ~n~echons from local people No more appl~cationfor local trop~cal drugs to the cornea Patrents wlth blurred vision one refered to health facillty He 1s loolung for hture tramng with much enlphas~s on HIV/AIDS & prlnlaw eye care Mentmned some slgns & smptoms of a client wlth STDs (GC Svphlls) TH and health center staff in Mchacha consider then relanonshp as d partnershlp since they bothe deal wlth health SUPERVISION /MANAGEMENT The secondary supervisor from the HC in asslstlng me too on top of the pnmary supemsor What to do when trairung of supemsors 1s wanted ' but supelvrsor staff 1s too weak (e g HSA) Rouune v~sits by DHO rmproved soon after CHAPS came Into the Dlstnct GARDENS I FARMERS e 114 of germnated soya seeds is destroyed by worms and grasshoppers whle 113 of groundnuts is destroyed from moisture They harvest soya m March and feed on it for three months After that ey are left with notlung They make Lhm Phala to feed the enbre famly - not just the kids Farmers in Gola say that their mam hrnrfing factor to Increase production is seed (llked seeds of pigeon peas) e Despite low producuon from soya/groundnuts they are stdl w~llmg to grow these crops and would also llke assistance with plgeon peas seeds Farmers in Gola do not appreciate the nutnbon value of plgeon peas and how to make L~kun~ Phala wth pigeon peas e The commumtv has been &scouraged because no extension workers has been supervising them Last year they had a poor veld of soya because they planted late 0 Client produced 3 bags peanuts (seeds not from project) and plans to sell 50% Doest1 t know about adding peanuts to phala but does add to rehsh COMMUNAL GARDEN o Garden imput gwen to Pende vlllage all went to the headman Some vlllages considered the commumtv garden 'the chers property o People of Pende mllage did not appear to have a clear and realistic plcture of how many people benefit from the commumty garden Soya and maze will be unlized to feed children and e~en parents to 470 faml~es from a field of one hectare Most men are not talung part in communal garden HBCI COUNSELLING BC VOLUNTEER HBC volunteer has never been provided with condoms / gloves New the disease affect~ng people - volunteer renders ph5 sical support to her clients le water collection and sweeping houses of pts Volunteers covenng a wder area as a result transport remams a problem They require an ldentttv such ds a badge or umform They should be gwen protective wears such as aprons gloves and masks just to protect themselves They requre bicycles as an incenlme but also to ease their problem of transport Had a wide area to cover but lacks transport Some clients refuse to be seen because the kolunteer does not have any essential drugs as aspirin eye ointment HBC SUPERVISOR Transport is not a problem to her because of the IEF stafh motor blke she mas gven but her volunteers have a problem of this issue Monfort counselling centre WBC supervisor counsels pauent both m hosp~tal and village Blood testing IS not avalable at the counselling centre Monfort supervisor may be undercounting her clients HI3C supervisor feels people are not coming for counseling because testmg not available She was tramed m HBC are care counselhng in 1994 and 1995 Refreshed in 1999 Adv~ce for expanding HBC model Build on exlang programs Keep ~t ample and basic usmg exlsting resources Volunteers mav be easier for MF to recrult than for govt She needs more support from the MOHP on terms of supervision and material support ie stationen and spare parts for her motorcycle Follow up of patlents some bmes is a problem because it is a problem to iden* homes HBC emphas~s on the use of local avalable resources In comrnumtles and household of patzent No coordinafion between Chkwawa dlocese HBC programs and Monfort hospital despite Monfort being a Cathollc inst~tut~on She is worlung in 60 vlllages but has 32 volunteers from 30 villages HBC volunteers have no supplies, medcal officer acknowledges &s may be sometlung they should consider Need to assess cost In charge of Makhwra HC thmks one HBCIvillage would be good but supemslon of that many volunteers would exceed hs HC s supemsory capacity HBC volunteer supervisor makes follow up of her 32 volunteer in 30 villages eveiv month MF chmcians appreciate being able to refer to HBC nhen they are discharging sick patients She gets other support from AcQon Ad HBC CLIENT 0 JBC Volunteer has assisted me to improve my health though I am sick No health worker asslang me exclu&ng the HBC volunteers I am gemng a good support from rnh guardians because of the HBC volunteers advises Vislted several times by volunteers appreciates the volunteers' support She lacks money to pay Monfort hosprtal for medrcal services V~lla~e Halth Comttees Cmes out home hygiene disease surve~llance and Under five shelter construction Observations from Gola and Mvula - WC encourages mothers to attend both ante-natal and under five clinics (mobilizat~on) Members pomted out clearly that CBD DRF and gardens were for theu own benefit (Gola) There 1s need to prowde refresher course to those who were waned in 1997 in order to boost thelr morale It was observed the comrmttee was oniv superv~sed once (Dausi) Suggestion to integrate the TH Into village health activities - get HSA and VHC recogrution Farmers in Gola see the HSA as one of their own - see lum as a partner with the VHC (they thmk the MCH coordmator (who visits regularlv) is the supewsor VHC members in Mchacha sad they superme the CBD/DRF volunteer regularly But they didn t seem clear on what supemisson meant VHC in Gola and Mvula encourage mother to concentrate on FP methods in order to save their hves and have a better hfe for their children and themsehes Lazo VHC presented themselves and the water comnuttee (recently tramed by Concern) but had no representation from the Village Headman Daus~ comttee secretary seemed to take a leadersh~p role - mght be better uhllzed even though he Isn t the chalrman CBD has dficulty mobilizing older women, and men - she thought the VHC might be able to help wth mobihzaQon (Makula) Nqalugwe VHC is &stoned and falllng apart - VHM is a dmator VHC in Pende is not well ofgan~zed and does not asslst the CBD CBDs in Pende have been without contraceptives for 6 mos There is need to replace the drop out members of the VHC (Dausi) - no mechanism to address amtlon Volunteers are not represented on the VHCs HSA In Mchacha thnks VHCs do not understand their role as responsrble for hedth activities in the~r village Community Health Cente Committee IS not funct~oning for Chapananga HC Thev need latnnes and there u no way to mobil~ze self help for that task e The VHC motivates ill people to go to the DRF and mothers to go to CBD and cornrnunraes to go to communal gardens Protect comttee - Sub-C~fnrmttee for Outreach Shelter - Mchacha Members were open (males) while females were unable to speak Questions meant for WC comttee were wrongly forwarded to project comttee Members of the outreach shelter project committee appear to be confused regarding ths role and the overlap w~th the VHC Outreach shelter commttee members for Mchacha cornplans about too l~ttle sand and too man! supemsors ' v Role of Project Comttee - Provision of cheap labor for collecuon of sand bncks and water for construction Under five shelter gemng assistance with cement, window and door frames k7ehcle to assist in collecuon of bncks and sand D1stm.3 and HC supervisors confusing the builder communlQ and HSA on the plan for the shelter IEC Strateees Teachers have recommended drama as the best dnd most reliable wav to teach others because ~t tackles the real situauon - what IS acutally happemng in a dav to day llfe Peers expressed that use of films and visual aids would help more in educating the communitv Thw also requested bringng Chewa videos for commumty educat~on - suggested the local priest has a video machme Gola CBD - counselmg means gving the necessarv facts and infonnatlon so FP clients can make d choice Ways of impartmg knowledge for Edzi Toto groups include drama lecture questions dnd ansners guest speakers, video shows A FP client managed to mouvate four of her friends Pupils request exchange visits and guest speakers e g from the MOH Two messages on the murals are a supplement to materlal already m their s3lIabus * The murals assist teachers and puplls as a discussion polnt for 4IDS and FP Polltlc~ans Pohtician suggested he could asslst in gathermg people together while the NGO could assist wth bssenunatlng informaoon and transport (staff) concern that NGO affllatlon with politicians could be taken wrongiv Sustamablhty Farmers in Cola sav they intend to contmue farming sovd and groundnuts even though the, dld not have a good harvest thls year Suggested sustainab~llty for the E T club In the hture rmght be through a communal garden or other IGA v Sustdmab~litv of the clubs w~ll obvious1,r go down smce thev re used to gettlng something from EF e g evchange visits, competluons, and regular supervision * HSA collaborates wth other exchange workers m hs area (Gola) DRF IS also keepmg goats to support shortfalls but d~fficult because the person keeping the goats hds become employed and not keeplng them well * Gola - the commuruty can contmue with actmues when the project ends because they now have then own seeds and goats to support the DRF Partnersh~ps Sucoma - there are m~~tlpIe reasons (st& turnover rmsunderstandmg independence) wh) the phase over process may not be clear to everybody Sucoma management didn't know the project was ending, was concerned about continuing training and gemng suppl~es regularlv from MOH Sucoma is willing to sustam actltiQes but is concerned because the Sucoma management doesn t support tramng costs and they feel they don t have enough internal tramed trainers Sucoma cornmumcatton between me&cal stafTand senror management seems lim~ted Sucoma reports no MOH supervision of FP or STD Montfort - the HBC supervisor didn t know here status upon the phasing out of STAFH Montfort was concerned there was no memorandum of understanding - the level of collaborat~on was impIred but not defined Montfort was concerned that colIaboratton meetlngs with STAFH had fallen off since 1997 The Montfort motorcycle 1s regularlv mamtained by STAFH (the supervisor saldlv also pa~d b\ STAFH -but the Montfort medm1 officer d~dn t realize it) 0 Montfort feels awkward using MOH HSAs and HC staff to support the~r comrnumtv activltles - confusion over the health dellverv area and what is the role of MOH tn that area Quality Assurance Makuwira - the in charge reqmres information on QA since he ddn t know anvtlung about it (HA has not been tramed, but one of the QA team 1s at lus HC) The FP Coordinator is concerned the numbers from their registers aren t reflected in then monthlr reports Chapananga - health workers work as a team and hold staff meetmgs now as a result of their QA mmng People off to an exceIlent start at Chapananga, but had a dacult tlme definlng quality services Chapananga sited thev worked together to repar their sterilizer stove, and the^ are meeting together to identlfy and discuss problems They will need flu and re~nforcement of problem solving process The benefits of QA is it allows staff to identlfl problems and thelr solutions before seelung evternal dssistance NRH doesn t see HC reports as they are sent directly to the Dlstnct At NRH the QA process 1s not gomg well because the members are too buq with other activities People are absent (workshops) so ~t is hard to get together for a meetmg There is no proper coordinahon between departments at NRH - e g no planmng for transport use Sydrom~c Management of STD Sucoma refresher course for svndromic management IS a pnoritv for contmulng dcbvmes Problem that Sucoma doesn t seem to treat maw patients - it may be a problem ofconfiden~l~l~tv in the compm chmc Sucoma - partner tracmg is dlfFicult because patients deny the proxlrmlr of the partners One health center lost thew partner stdmp - doesn t know how to do partner tracing now M~ntf~fl senserned th91 10n STB pta /ma ad fsw rslwt~, F to tho^ target pupd~Tnun Contact Wacmng appears good at NEW - over SO% had brought partners Smce 5/99 STD drugs have been m short supplv at Makuwra HC - espec~allj ervthromvcln Makuwlra claim he and the nurse Jre tmng to find dprtners but returns dre low and HSAs not interested In assistmg wth traclung down partners Montfort - 4 techc~ans and 4 nurses Lr~id m 1998 f~r 2 weeks Health edusabon and comsellng done for Sm pts At Drugs seem to be effectwe - no return chents at NRH T~annn~ has prqmd the cl~nlwm la treclt cases dl wathaut ha\ ~ng tohgurc out thc euda diagnosis & 0 Palha religious groups take a role In advlang youth on HIV/AIDS Water - commmty &dn t partlclpate In slung the borehole Commwty needs a hand with spare parts - hasn t had them since they ere tramed 3 teachers had eve traimng - PEAS knew nothmg about lt Commumty nurse wrote proposal to mtroduce CBD at Montfort, but not clear where that u not* The nurse is transferred HC does 10 depo cl~entslmo at Gola Gola CBD has 34 active pill cl~ents Chapananga - all new FP cl~ents start wth Depo - onlj on pills If Depo drdn t work out There appears to be a d~screpancj between the number of actual cl~ents and the expected number at Makuw~ra Orphan care and youth actrvlnes are add~tlonal concerns not currently addressed bv Montfort APPENDIX F Results of KAP Surveys Pertaming to STAFH Objectives STAFH Project Final Evaluabon Key Project Objectives a 1 Increase the contraceptwe prevalence rate bv 50% bv EOP Indicators measured a 1) Women reporbng us~ng acontracepbve at the bme of the survey (CBD villages) a 2) Interviewees reported use of contracepbve at the bme of the survey (District-wide) 0 * from survey for CS mid-term evaluabon, July 1996 " from CHAPS baseline survey, October, 1998 Baseline (N=232) 24 % [C I 17% - 33%] b 2) Intewiewees who do not plan to have a chld in the next two years reported use of contracepbve at the bme of the survey (District-wlde) EOP (N=207) 41 % [CI 31% -51%] Baselme (N=594) Increase from Baseline to EOP +70% 1 * from survey for CS mid-term evaluabon, July 1996 " from CHAPS baselrne survey, October, 1998 EOP (N=289) Increase from Baseline to EOP 29% [CI 23% -35%] 2 40 villapes have at least one CBD for FP methods Increase from Baseline to EOP EOP (N=242) r Indicator # villages with at least one CBD 66 total # of CBDs acbve at EOP 93 a 36% [CI 28% -46%] Baseline (N=490) +24% 3 In villages wlt CBDs, mcrease to 50% the level of mem/women, 15-49 years, who have received FP information from a CBD Indicator a I) Percentage of all current contracepbve users who give "CBD as the source of thelr current method used (CBD-villages) b 1) Percentage of current users of the Pill or Condoms for FP who gwe the CBD as their source of contracepbve at EOP (CBD-villages) Baseline (N=56) 0% EOP (N=84) 25 % [C I 13% - 4l%] Contraceptwe [CI 22% -81%] Increase from Baseline to EOP N/A Condom 4 75% of all climcal staff having adequate knowledge about AIDS, FP and STDs Women Indicator # health center staff having adequate knowledge about AIDS, FP and STDs Men Pill i 20/31= 65% [C I 37% - 85%] 0% Post training tests (average score) 87% 54 % 11/21 = 52% 5 75% of the health centers that have adequate drug supplies correctly manage STD cases Indicator # STD cases correctly managed at health centers 413/469 = 88 % Sample analyzed records from 7 health centers for 2 - 3 months (1 e Jun - Aug, 99) 6 Increase to 50% che proporbon of men/women, 15-49 years, who know 1) modes of transmlsslon of HIV 2) methods of HN/AIDS prevenbon 3) correct condom use 4) four or more methods of family planrung Note 1) and 2) address the same issue as a person who knows how to get HW/AIDS knows what to do to prevent infechon wlth HW 3) is very difficult to measure and the project did not attempt to do so Indicators a 1) Intewlewees who could correctly rdenhfy AIDS (open quesbon) (CBD villages) a 2) Tntervlewees who had ever heard of AIDS (district-wide) BASE LINE I EOP I BASE LINE I EOP** I Women I Women I Men I Women ( Men 1 * from survey for CS mid-term evaluabon, July 1996 ** from CHAPS baseline survey, October, 1998 Men b 1) Interwewees who knew what AIDS is and who knew at least one correct way of gettrng AIDS (CBD villages) I BASE LINE I EOP 1 Women Men Women 88 % Men 99% Women 98 % Men 98 % b 2) Interv~ewees w o had heard of AIDS and who knew at least one correct way of getbng AIDS (district-w~de) I BASE LINE* EOP** * from survey for CS mld-term evaluatron, July 1996 ** from CHAPS baseline survey, October, 1998 c 1 Interv~ewees who knew what AIDS is and who had at least one misconcepbon about how to get AIDS (CBD-villages) Women N/D Men N/D Women 85 % Men 96 % BASE LINE I ( Decrease from Baseline to EOP In CBD vdlages I EOP Women (N=284) 17% [CI 11% -24%] - - - c 2) Interv~ewees who had at least one misconceptron about how to get AIDS Men (N=73) 20% [C I 7% - 36%] Women Men 5 7-fold decrease (-470%) 3 3-fold decrease (-230%) * from survey for CS m~d-term evaluation, July 1996 " from CHAPS baseline survey, October, 1998 Women (N=200) 3% [C I 1% - 9%] d 1) Interviewees named methods of modern FP (CBD villages) Men (N=173) 6% [C I 2% - 14%] BASE LINE EOP** Women N/D Women (N=218) 4% [C I 1% -lo%] Men N/D Men (N=266) 3% [C I 1% - 8%] [ # FP methods I BASE LINE EOP I at least one 1 74% 1 85% 1 77% 11 90% 1 82% 1 86% 1 known II 11 women I Men I Total at least two at least three at least four # FP methods known -- 62% 24 % 7% 58 % 23% 8% at least one at least two at least three d 2) Interviewees named methods of modern FP (D~str~ct-wlde) Increase from Baselme to EOP 59% 24 % 8% + 21% + 50% +140% I I I I at least one at least two Women Total at least four FP methods I BASELINE I at least three N/D 87% 56 % 23 % Men - 3% + 27% + 95% EOP ** * from survey for CS m~d-term evaluatron, July 1996 ** from CHAPS baselme survey, October, 1998 + 11% + 42% +116% +187% ppp 79 % 47% 15% +114% I +150% 84 % 52% 20 % 7 80% of adolesce ,ts partmpatmg - in anh-AIDS clubs know 1) modes of transmission of HIV 2) methods of HN/AIDS prevention 3) correct condom use 4) four or more methods of famdy planrung Note I) and 2) address the same issue as a person who knows how to get HN/AIDS knows what to do to prevent infecbon wlth HIV 3) is very difficult to measure and the project did not attempt to do so a) Students who could correctly idenhfv AIDS Note as overall levels were above target, no breakdown by membership in EDZI TOT0 clubs was done BASE LINE EOP 7 b) Students who could name at least one correct wav of gethng AIDS (Note as overall levels were above target, no breakdown by membershp in EDZI TOT0 clubs was done) # I BASE LINE I EOP I I Girls I Boys I Glr 1s I Boys I I c 1) Students who have at least one misconception about how to get AIDS G~rls 96 % BASE LINE EOP~ Boys 92% Girls 99% Boys 99% c 2) Students having ever belonged to an EDZI TOTO Club who know what AIDS is and who have at least one mlsconceptron about how to get AIDS Girls N/D Boys N/D Glrls (N=188) 10% [C I 5% - IS%] Bovs (N=192) 7% [C I 3% - 14%] BASE LLqE d) Students who named modern methods of FP EOP I Glrls # FP ~~~~O~S~BASELINE 8 Increase to 50% the number of - proshtutes emplo~ed at commercial centers reporhng use of condoms dur~na last sexual act N/D Boys EOP known at least one at least two at least three at least four Gids 1 N/D N/D N/D N/D Boys Total TOT0 Club 99% 90 % 71 % 33 % Girls 97% 83% 57% 23% Boys 98% 84% 63% 25% Total 98 % 83% 60 % 24 % 9 Increase by 2E % the proporbon of men/women, 15-49 years, reportmg use of condoms during their last sexual act Indicators a 1) Reported having ever used a condom (CBD v~llages) BASE LINE EOP I I Women I Men I Women I Men I I [CI 7%-20x1 1 [CI 15%-46%] / [CI 6%-21%] I [CI 31%-52%] 1 I I Increase from Baselme to EOP m CBD wllages I I Women I 0% I a 2) Reported havlng ever used a condom (Distr~ct-wide) Note hs quesbon was not asked in the CHAPS baseline survey, see below for variatton Men a 2 1) Reported know~ng that condoms prevent the spread of HN/AIDS (District-wide) +46 % BASE LINE " from CHAPS baseline survey, October, 1998 EOP I Women Men Women Men a 2 2) Reported havir 3 ever used a condom to avoid gethng or transmithng HIV/ AIDS (District-wlde) b 1) Reported using a condom during last sexual act with regular partner (CBD villages) Note of those who reported having ever used a condom (see 9 a above) BASE LINE c 1) Reported usmg a condom during last sexual act with non-regular partner (CBD villages) 0 Note of those who reported having ever used a condom (see 9 a above) AND excluding those who gave "no non-regular partner" as reason for not having used a condom, those who responded "don't know" were included in the denominator a " from CHAPS baseline survey, October, 1998 Women N/D EOP 0 Men N/D Women (N=253) 8% [C 1 4% - 14%] Men (N=295) 16% [C I 10% - 23%] I Men +110% I BASE LINE * e EOP Women 0% EOP Women Women (N=42) 31 % [C I 14% - 55%f Men 0% Women (N=5) 60 % BASE LINE Increase from Baselme to EOP in CBD villages + 50% Men (N=74) 61 % [C I 43% - 76%] Men (N=45) 84 % Women (N=49) 24 % Men (N=44) 40 % c 2) Reported usm a condom during last sexual act with non-regular partner (District -wide) Note of those who reported havzng had casual sex during the last 12 months BASE LINE I EOP * ** from CHAPS baseline survey, October, 1998 10 Increase by 50% condom drstribuhon to men/women, 15 - 49 wars I Indicator Women Men ff condoms dlstrzbuted In project area PSI Women Supplzer SUCOMA IEF(M0HP) Men 1996 299,268 S TOTAL 1997 N/A 1999 (Jan - Aug) [prorated for 12 1998 233,352 400,968 To 222,486 382,032 48,000 1 68,200 612,320 180,000 months] 160,200 [240,300] 80,200 774,232 -- 1,Oi 77,652 [I 16,4781 -18 14,210 302,982 [393,877] 21 2,09 -- APPENDIX G STAFH Ach~evements compared to Proposed Activities STAFH ACHIEVEMENTS JNITIAL TARGET Condoms d~stnbuted &roughout project area by PSI MOH CBDs trddmonal healers peer educators and vlllage health commttees Iden* indmdual or agency to become official Clushango distributor HSAs and 120 CBDs wll be traned in AIDS educahon and FP promotion Tram cllmc staff in STD management and HIV prevenhon counseling using standard MOH protocol BDDED TARGET WITH EXTENSTION Rema~rung CBDs to be tramed under CHAPS after supervlslon and supply systems have been strengthened - Tram remairung 69 new HSAs for a new target of 134 total HSAs traned in FP promohon and AIDS prevenhon Train 2 sta£f members per health center (total of 44 includ~ng 22 newly trained) in expanded tramng for syndromic management Assessment of tramng quality to be considered Condoms distributed :hroughout dsmct by PSI - th~s bstnbubon svstem 1s probably nore sustanable than developmg m mdependent persodagency for Chshango distnbution - Some condom shortages at health center level due to :ofision m ordermg between :ondoms for FP and condoms for AIDS prevenhon - CBDs distribute condoms regularly THs distnbuted once but are lnte~ested in confinumg VHCs not well developed under tfus project - Sucoma peer educators each distributing up to 2 cartons of Chshango /month - 65 HSAs rece~ved irutial traning in FP promofion and HIVIAIDS educauon as well as refresher trainlng whch also included reporking issues - 32 HSAs (those m CBD areas) received additional trai~ung In CBD management and supervision - STAFH tramed 73 CBDs to make a total of 93 CBDs m the d~stnct It has prov~ded ongomg refresher and supervision for all 93 CBDs These are worlung in a total of 66 villages (about 10% of the Dismct) selected in clusters of undersen ed areas - 15 Add~tional HSAs trained for HIVEP under the extension phase The one vear extension was short to catch all 69 new HSAs - 44 clln~c staff representing all one each from 1 1 health centers and 3 hospitals received mfial 1 week traning - 45 chnical staff representmg at least two from each HC- maJon6 but not all had been prev~oush tramed- rece~ved expanded 2 Nurses from all D~stnct health centers except Montfort wlII be trained in FP provlsxon and use of the hom~onal check list BLM wiII provide TA to health centers on quality assurance for FP sen Ices 1 individuals to be tramed tn Sucoma 2 MOH) Montfort also prowdlng free STD treatment in splte of betng paying hospital Eqmp teachers at every pnman and secondary school In the Dlstrlct to inmate anti-AIDS clubs Strengthen Montfort counsehng center (Montfort was to) Recnut and train an additional 80 HBC volunteers beyond the 30 already tramed bv IEF Distr~ct MOH tak CHAPS w~ll caw out quahb assurance exercles including FP and STD treatment servlces to be carried out under CHAPS Extend co\erage to new schools in Distrrct to lnclude total of 157 schools (1 33 prrrnan 3 secondary 6 pnvate and IS d~stant educauon centers) -- Same week tralmng in syndromic management and HIV prevenbon - STD tramng assessment camed out In Feb In all Dlstrict HCs - Dlstnct MOH talung lead on FP provider trainmg includ~ng use of hormonal check list - Trained 13 FP providers in ~nterpersonal commumcatlon and counselmg slulls (IPCC) - Tratned 30 HSAs (in addittona to those trained as CBD sueprv~sors)as core FP providers able to adrnlmster the hormona1 check list and dtstnbute pills - Project trained 18 health center and hospltal nurses representing 100% of health facilities as secondary supen isors for managlng CBDs QA assessment camed out in 11/98 and inltidtlon of pamcipatory QA process at health center level undenva under CHAPS 2 clinical officers and 1 nurse traned In VSC techniques for both men and women Montfort receivmg STD drugs from MOH and grov~ding free STD treatment - 132 actite anb-AIDS clubs out of 157 schools - 264 headmasters and patrons tramed in 132 schools 3 92 teachers In 13 1 schools trained in teachng AIDS curnculurn - AII 12 PEAS trained as tramers for supervising and supporting anti-AIDS clubs - 150 patrons from 75 schools tramed In FP messages and wdj s to introduce them In the am￾AIDS clubs - Center renovated - mane? provided to Montfort to pav salan of HBC/counseling supervisor - 32 HBC volunteers tra~ned and refreshed and worlung in a Tram dnd support peer educators for AIDS educatron and condom drstnbuhon actrvines a Kapachm Falls cornmumty educahon and mobilizahon efforts m IGAs and AIDS preventlon Emplovee HIV/AU)S education 0 and condom distnbut~on program for lmpregiloat Kapachrla Falls Special health educat~on targehng bar grls ~ormahv~research to detemne role of tradihonal adkisors (nankungws) m sex educahon and mhatlon of educaQon program to target voung women through these advlsors a No ~mhal plan to tram tradihonal healers In proposal? IEC Canzpalgn for AIDS prevention and FP promotion to mclude drama groups, vldeo shows sports achvares music events etc Dropped out because IGA mterventlon because mcro￾enterprise perspective to IGAs was beyond the scope of STAFH Dropped out due to tenslon between Group Flt e management dnd staff Worlung elzv~ronment d~d not allom for effective occupanonal health mtervention Had not been done at tme of extension but kept as intervention Plan to tram 400 new trahtmnal healers dunng extension project Explore mvolving them in condom d~stnburton approximately 60 d~fferent v~llages They cared for a total of 240 pabents and registered 1665 orphans Ad&bonal volunteers not trained due to lack of Montfort mobilization - 514 peer educators and a sub group of 40 peer educators supervisors were refreshed and supemsed - Sucoma supenasor ~ndlcates there are currentlj approx~matelv 120 acme peer educators Project trained 6 CBDs and supported 2 drama groups In the area as part of their general Distnct-side efforts Tramed 1 nurse at Impreg110 m svndromlc management for STDs IEC amvibes were llmlted to employees dunng off-hours and to canlp resrdents These actmtles were poorly attended due to the worlung atmosphere - I62 bar girls originalh tramed as peer educators w~th emphas~s on negohatlon for safe sex condom use and seehng treatment for STDs - 48 bar girls (mostly new ones) were tramed under the evtenslon phase - Qual~tative assessment done on role attitudes and practxes of nankungw is - 28 1 naps ineastern bank area of the distnct tramed In AIDS pre% entlon and FP - 633 tradlhonal healers ~nltiall) tramed In HV prevention under shdc survrval and refreshed (with the addtion of FP and eye care)under STAFH - 150 additional new trahbondl healers trained under STAFH (tlme ran short In one jear to tram all 400) Mulhple LEC actlvitles ~nclud~ng drama groups compehtions Chlshango iught rnuslc shows etc - 150 murals deplctmg AIDS preventlon and famlly plannlng Tram VHCs and TBAs in addition to CBDs and traditional healers 1n comrnumQ based educauon for AIDS prevention and FP promoQon MISC ADDITIONAL ACTIVITIES a Not done under STAFH because these are weak struchlres and reqwre more inputs than were available under the project CHAPS will pick up the VHCs as part of overall community strengthening of health activ~hes Tram 11 political leaders as traners for AIDS prevention in order for them to conduct educational sessions in their areas messages have been palnted on walls of 25 schools TBAs st111 to be discussed - 13 political leaders tralned but no apparent follow on activities have occurred - Project continues to pursue partmpatorv intervenuons such as Stepprng Stones gender traimng and Care Counseling tmmng to encourage beha lor change - Prlntlng of FP cards and Larmnated hormonal check hsts to assist with Distnct supplles - Tramed all 19 homecraft workers in FP motnabon and HIV prevention - Trained18 HSAs In man to man" (some of these were already CBD supervisors or FP pro\ iders) APPENDIX H Summary of CHAPS Achievements Apnl 1998 - September 1999 (prepared by Joyce Naisho, CHAPS PM) CHIKWAWA DISTRICT CHAPS SUMMARY IREPORT FROM APHL 1998 TO SEPTEMBER 1999 PRlEYARED TIN SEPTBMBER 1999 BY JOYCE NAISHO 1 CAPACITY BUILDING t 1 2 Office alloca,wn for CHAPS I DHI, Accounts and CHAPS Planned Activity 1 Ploject staff recruited Progress hs quarter Project secretary hired Training/QA Advxsor, Community Hedlth, DRF, PEC and Adult L~teracy Coordinators and other project support staff h~red Project office complete and occupied Not applicable (N/A) Progress pnor to this quarter Project Manager, System Advisoi, 1 Purchase any add~tlonal furiuture required 2 All Coordinators and supervisors wll move to the former STAFH office Plans for Oetober/Dec 1999 Two extra guards to be hired Remarks Some members of staff from STAF H project wxll be trimsferred to CHAPS These ale the HIVIAIDS FP supervisors and support staff N B these were not or~gmndly budgeted but project funds could adequately ~ater for therr expenses List has already been prepared Planned Actlvrty 3 CHAPS Project fleet mechanic Progress this quarter 1 One foul wheel double cabin pickup 2 Four motorcycles Remarks 1 To be used for short errdnds 2 Mi F Chola takes the general management for all IEF CHAPS fleet Progress prior to this quarter 1 Vehicle and motorcycles In good shape The vehicle is legularly serv~ced at Toyota motors 2 All riders have been taught on dddy, weekly & monthly checks, and ail motorcycles are servxed at 5tansfield motors or by the Hospltal 3 The accounting system for all mlnistrles may change once the policy for decentrdllzatlon 1s started Plans for October/lPec 1999 Project wdl need two office blcycles These were not planned for before but found necessary later Planned Act~v~ty 4 Project Management Progress ths quarter 1 IEF CHAPS Project Coordinators meeting 2 E,xpanded DHMT meetings 3 Expanded goveinment and CHAPS budget rneetlngs 4 Hosp~tal general staff meeting 5 Ngabu Rulal Hospltal Health Management meeting - - - -- Progress pnor to th~s quarter 1 All coordinators meet with the Ploject manager monthly to d~scusslons either technical and/or admin~stration 2 MOHP & CHAPS Project Issues are d~scussed In ths meeting held regularly once d month 3a Once or twice a month governed by tlme the HQ sent in funds fo~ the district expenditure 3b CHAPS budget held every SIX months 4 Once every three months for staff welfare and dlsseminat~on of new government pollcles and/or circulars 5 No regular meeting\ have been planned at NRH yet Plans for October/Dec 1999 - 1 75% of all the tlmes and dates set for numbers 1,2 3 and 4 have been successfully carrled out 5 NRH wlli need to be assisted to pldn for regular monthly meetings for them to begin seeing themselves as d cohes~ve team Remarks 1 Although most of these rneetlngs have been held regularly the CHAPS Project Manager will need to keep remmding the DHL' -d the hospital administrator Assist in drawing the agenda that w111 rnclude project and generdl distri~t lssues -- -- Planned Act~v~ty -- - 5 Accounting System improved dnd computerized Progress th~s quarter 1 Discussions wlth URC continued and a ievised scope of work sent to Partnership for Health Reform Project (PHR) This project have now taken the task for financial management for all CHAP5 Projects 2 Chikwawa expanded CHAPS team expressed the need for the rA to be available in the next quarter 3 The second computer has been ordered Progress prior to this quarter 1 The first accounting computer purchased 2 The accountmg pa~kage that IEF for ~ts accounts was installed rhis facilitates CHAPS Project accounts reporting system 3 Internal needs assessment for the government accounting system was done 4 Results discussed duling QA meeting/workshop in May 1999 These gap in the findmgs was used to develop the scope of work fo~ TA done 5 On job training for the Accounts clerk started and is being continued Plans for BctoberIDec 1999 1 Follow-up the purchase of the second accounting computer 2 Continue d~scussion with URC to put pressure on PHR for the accounts TA 3 Chola to develop a plan for training and on job training to be continued 4 PHR and QAP supplemental questions for financial management for CHAPS quality assessment to be completed and sent to Q AP Remarks Planned Activity 6 Stock control improved and computerized 7 Deta~led implementation plan (DIP), annual and monthly plans exist Progress th~s quarter 1 Manual system was for stock control, was d~scussed by the management The store keeper was trained for stores and he, under the DHO's supervision started cleanmg and reorgan~slng stores 1 Monthly plans for CBD program 2 Monthiy plans for DRFs program 3 Monthly plans for outreach shelters constructxons 4 Plans for pr unary eye cdre survey and tralning 5 Plans for Quality Assurance by the QA Core Team 6 Traimng Plans for various areas e g VSC, laboratory, adult literacy, etc Progress pnor to th~s quarter 1 Kitchen stores managerncnt reorgdnlsed Two different staff members were assigned to ieceive and supply Items for the day use 1 Detailed Irnplementat~on Plan m place 2 Annual for Apr~l 1998 to March 1999 exist and most activities planned were carried out withm the year 3 Annual plan for Apr~l 1999 to March 2000 exist and activities are stdl being implemented 4 Program managers and coordmators use the annual plans to draw out monthly plans These help management In budgetmg Plans for Octuber/Dec 1999 1 Close supervision for these two section need to be continued 2 A second store keeper has been posted to the Dlstnct Follow-up needed 1 Planned activities to be continued 2 Budgeting for pldnned actlvlties Remarks 1 The DHMT had leaded not to :omputenzed its ;toch control system It was thought that it might be too zomplex 1 Some activities may flow mto next planned This should be considered when plans for Aprll 2000 to Maich 2001 will be developed - - Planned Actlvrty 1 Progress thls quarter 2 Drscuss~on and plamlng for retrainmg for Chlkwawa Distr~ct Hospital motorcycles rlders - 8 Government vehicle management plan exists and is implemented 3 Continue the monthly transport committee meetings 1 Contmued repairs and regular service for all vehicles and motorcycles 4 Site fol veh~cle reparr shade hdve been identified dnd plans have been drawn Progress prior to this quarter 1 PIans for getting technical assistant for the fleet management were developed TA procured and fleet management plans developed 2 Flfteen motorcycles ordered and received 3 Four tone track purchased and in fu~: use Plans for October/Dec 1999 1 Shade for repalring vehicles at the hospital to be built 2 Re~nforcement of the plans laid down for fleet management This could well be done through discussions and regular meetings by the transport Lornmittee Remarks 1 The current cost for vehicle mamtenance is extremely hlgh This is because of the age of the vehicles and lack of rnam,, .: Ice before the start of the project 2 Continue support for fleet (momtor mplementation for pldn, use of the supplementary fuel) Planned Act~vity 9 Personnel management plan including a QA plans exists and ts Implemented Progress thls quarter 1 Four staff members tmwned as QA Tratners and Coachng 2 QA Teams trad in HW, Gaga HIC and Chapanmga HIC Progress prlor to th~s quarter 1 Former DNO, DHI and late Ms Jamu were trained in QA Dlstrict education Officer, Current DHI and MCH Coordmdtor, the CHAPS Trammgl QA Advisor and the CHAPS Project Manager were tralned in QA too 2 Quality Assurance assessment was carried out The report was written, recommendations drawn, prlorlties set and interventions started Plans for OctoberIDec 1999 1 Dtscussions held with QAP to help train replacements 2 Contmue support for QA Core Team 3 QA Core Team conttnue tramng health centre QA teams 4 Train supervisors, Implement and monitor supervisory system 5 Train mcomng CHAPS Project Manager and TraimngIQA Advisor in QA Remarks 1 Most of those trained in QA have been transferred Therefore need to tram others 2 Q A tralning strategy LV De extended to the HSA level 2 Middle level management to be strengthen as advtsed after the mid term evaluation Planned Actwty 9b Staff development Progress this quarter 1 Clinical officer completed IMCI traimng 2 Two climcaI officers fimshed VSC theory and are doxng practicals One Registered Nurse completed VSC support tralning and is undergomg practical traimng 3 Mr K Chikonde, Semor CO and Acting DHO has had an o~~entatron HTVIAIDS m Zambia 4 Thlrteen health officers from Chlkwawa dlstnct Hospital, Ngabu Rural Hospital, IEF MICAH and CHAPS had a two week training In IEC The tralning covered the process for IEC and development for the Dlstrlct Progress prlor to this quarter 1 Mr Mgeni, Accounts Ass~stant on job computer traimng cont~nuing 2 Mrs Y Uzarnba and MIS Harawa on job computer tramng conilnumg 3 Mr Semu tralned on spreadsheet 4 Electrician trained on radio maintenance Plans for October/Dec 1999 Remarks Planned Activity 10 HIS exist that satisfies the information needs at all level of MOHP and the conlmunities 11 Cost shar~ng plan is deveioped and unplemented 12 Distiict IEC IS developed and successfully implemented, w~th emphasis on cornmuruty education Progress this quarter 1 HIS workshop carried out and a plan for collecting, processing, reporting and using the health information was set 2 A planned foi monitormg HIS was set 3 Information for writing the 1998 District Annual report was collected analysed and the report completed 2 Dlstrict cost sharmg account opened -- 1 Competent IEC consultant to be ldentlfied 2 Some IEC materials availdble : g for FP, HIVIAIDS, TB Bilharzia, Health Education Calenders and Nutrition posters wlth messages collected Progress prior to th~s quarter 1 All HSA reportmg forms collected for review 2 Data for developing the five years D~strict planned collected and a plan developed in collaboration wlth the national plannxng unit -- -- -- - 1 Discuss~ons for ways of raising funds for cost sharrng discussed at DHMT 2 Preparation for cost sharing carried out (application and d~scussions with headquarters done) -- 1 IEC needs assessment to be carried out The results were then used to develop the scope of work for the IEC TA Plans for October/Dec 1999 1 Posslble review of the HSA reportmg forms 2 Contrnue assisting the District in collecting all the activity data 1 Develop the plans discussed for raising cost shai mg funds 1 Complete the IEC report 2 Develop any necessary IEC materials 3 Put Into practice the plans developed Remarks 1 This was one of :he very weak Ireas A lot will still need to be clone to unprove the recording system 1 Private ward not yet possible It was found to be too demanding The Distrlct mlght not adequately manage Plans for OctoberlDec 1999 Remarks 1 Follow-up on equipment ordered through IEF USA - -- Planned Actrv~ty 13 Health facilities and equipment have been assessed and improved wlth focus on NRH Progress thls qua1 ter 1 IEF USA office orgamsing for shipment 2 Eight VCS kits added to the orlginal equipment orders Progress prlor to th~s quarter 1 Theatre equipment for NIRW and CDH ordered 2 IEF USA office received quotations that were then approved by DHMT PROJECT INTERVENTIONS Objectwe 1 Increase Access to Reproductwe Health Objectm 2 Increase HIVIAIDS Awareness and Prevention through Condom Bromot~on and Female Adult Literacy 1 Provision of centers for reproductive health care services -- -- 1 Construct~on and/or renovation for eight outreach shelters started - - 1 Report for needs assessment available 1 Needs assessment for outreach for seventeen outreach centres carried out 2 Constructions are at different stages for the different shelters 1 Contmue and complete renovat~on/buildmg for the elght completed shelters 3 The costs for the renovation are shared between the commumty and the project 3 Providing tuba1 hgation and vasectomy at NRH and CDH 2 Increasmg of famlly 1 Four Family plamng providers trained in IEC I 2 Three FP providers trained as trainers for CBDAs and HSA wpervsion plann~ng providers at the health centres level 1 Staff for VCS are still undergoing practical tralning at BLM These are done twice a week 1 MOHP has posted four commumty nurses with FP trainmg to Distr~ct One is based at CDH and three at HICs 2 Seventeen Famlly plamng providers tramed for CBD program 1 Regular follow up for FP prov~ders needed 1 Two COs and one SRN had theory and some practical training in VSC 2 Trainmg on supervlston for FP providers 1 The three staff members to complete the traintng and exammed by Prof Lema (BLM will arrange and inform on date for exammatron) 3 See other needs from QA assessment report - 1 SRN or Community Nui se from NRH to be trained in VSC 2 Anaesthetist for NRH hospital to be identified and 4 Enabling NRH to handle minor surgeries including caesai ian sections -- - - 5 Increasing the number of CBDAs 1 Renovation of formei stores, kitchen and laundry for theatre started on 15th September 1999 2 Eight VSC kits added to 01 iginal equipment list IEF USA office is organizing for equipment shipment 1 Forty six (46) CBDAs and 14 primary supervisors had refresher training 2 Needs assessment carried out two days prior to CBDAs refresher course Combined findings i e HSAs and CBDAs identified problems were then used to determine refresher courses content 1 NRH visited, state of buildings checked, and ~dentify one suitable for a theatre 2 Committee for renovation set 3 Current kitchenlstore earmarked for renovation 4 Plans for new stores, kitchen and laundry drawn 5 Search for quotations cariied out and two contractors identrfied 1 Needs assessment for primary supervisors was carried out The report was used to b~idge the missing gaps on CBD 1 Close supervision for construction for DHO and PM at least once eve1 y two weeks 2 DHI to visit work once a week 1 The CBD program in Eastern Bank and Chikwawa has unique problems Therefore focus group discussions in 10 villages in these areas will be carried out 2 This FGD will give direction for appropr late intervention 1 Malnoui ished children had no place for feeding, therefore a space for them will be provided at the renovated structure 1 The additional CBDAs will be trained in Dec 19991Mar 2000 quarter 6 Offering Norplant at CDH and NRH -- - - 7 Empowermg women in negotiation skills through adult literacy 1 Searched and reviewed six ava~lable training adult literacy ti aining materials 2 Six supervisors trained in LePSA method 3 Twenty instructors (20) trained on Learner-centred, Problem Posing, Self discovery, Act~on planning (LePSA) method of teaching 4 Ten VHC members from the 20 villages where the women were selected for adult literacy have been trained in the new approach for adult literacy 4 317 women started literacy classes In August 1 Coordinating committee set (Members from MOHPICHAPS, MOWA&Y and MOE) 2 All manuals, curricula collected 2 Supplementary mate1 ials for family planning and HIVIAIDS developed 3 Stationery, blackboards & chalk purchased and d~stributed to all instructors 1 The ongoing classes will complete in May 2000, therefole these classes will zontinue till then 2 Adult literacy instructors will be trained as traineis (TOTS) in Family planning and HIVIAIDS in October 1999 1 Awaitmg MOHP policy foi Norplant at district level 1 Progress so far is good Strong team from MOHP, MOWY&CD and CHAPS 2 Classes take 10 months * 0 Objectwe 3 Increase the Partic~pation of Community Membeis In the care for AIDS Patients 2 Malawi study on AIDS and HBC literature reviewed 1 P~omotlng Home Base Care (HBC) 1 Explore means and ways for HBC 1 A workmg committee was set (members from IEF STAFH Pi oject and MOHPKHAPS) Objectwe 4 Increase Access to Drugs for Community-Based Tleatment of Malaria, ARI & Diarrhea Object~ve 5 Increase Access to and Acceptance of ORT, D~arrhea Prevention and Excluswe Breastfeedmg Messages 1 Reviewing and mapping out the current DRFs - - -- 1 Regularization of the supply of ORS to GMVs 1 Community awareness has been ralsed in ten (10) vlllages with non-active DRFs 2 Communities in these vlllages were asslsted with guidelines for selectmg volunteers for DRF management tr arnrng 1 Nothlng thls quarter -- 1 Needs assessment carried out 2 Map for existing DRFs prepared 3 Plans for DRFs activities developed 1 L~st of actlve and non-active GMVs established There are --- active and --- non-active GMVs 2 ORS has not been available at CMS - 1 Ten (lo) members from each of the first 8 non-active DRFs will be trained in October 1999 1 HBC is still a grey area, nothlng much was done (Note some suggestions from mld term evaluation) 1 Cont~nue support foi GMVs 2 Providlng IEC using relevant materials 1 Relevant IEC materials for D~arrhea prevention and Exclusive BIF were include m the master IEC plan 1 Assist in procurement or development of the planned IEC messages a a Objective 6 Improve Access and Acceptance to Consumption and Prese~ vat~on of Pi otem, 011 and Micronutrient Rich Foods 1 Increasing the numbei of farmers growing protein, oil and 1111~1 onuti lent i ich toods 1 Thirty two percentage of farmers grew groundnuts, 61 % grew sorghum, only 3 4% had soya and 50% grew plgeon peas (Baseline survey results) 2 Plans for 1999 season have been developed 3 75 % of farmers and household who were involved in either rndrvidual or communal farms have been ti ained on soya utilization 1 Baseline survey carried out 2 Data entry and analysis completed 3 30 household in Gola area issued with groundnuts and soya seeds October 1998 4 100% yield for cassava 5 20% yield for soya 6 Soya seeds and groundnuts have already been purchased for 1999 season 7 In iesponse to MOHP nutrition unit, 15 communal gaidens were set Nine were successful 8 All the farmers who harvested had a good groundnuts harvest returned 12kgs each This will be distributed to other farmers interested in growing groundnuts 1 Finalize report gectlves 6 Increase A 1 Expanding and providing training to T~aditional Healers (THs) on pi iinai y eye sei vices 2 Increasing the number of schools screening primary one entries and any other children transferring to the school 3 Ch~kwawa cataract & trachoma su~ vey * a ccess to and Acceptance of Preventive Eye Care Services in the Community 1 No baseline done 2 No training done yet and so supervisory plan yet 1 No teachers trained during this period 2 Fifteen health (15) workers trained in July 1999 1 Completed in AugustISept 1999 Data entry complete 1 S~xty (41) teachers tramed in from 25% of 130 schools a basic eye problems b Theu role for preventwe care for pup~ls c Techmques rn vision screenmg and low vlsion 2 Twenty seven (27) health workers trained in AprdIMay 1999 1 This was found not to be necessary 2 Training to be planned for next quarter 1 Although not In the origmal plan ~t was found necessary to tlaln health worhers In preventlve eye care espec~ally from H/C They w~ll be the TH supervisors 2 Before tralnlng a need assessment was done with the follow~ng find~ngs, 72% heard about PEC but only 32% tiained Less than 20% knew of s&s for trachoma and corneal ulce~ Most d~d not know Vit A dosages 3 Tra~nrng was then done 1 This was not in the original plan but was found to cover the baselme that was planned for THs, school teachers and pupils Result will be used for PEC and rehabilitation foi cataiact blindness and any other necessary intervention APPENDIX I Recornrnendatrons and Lessons Learned RECOMMENDATIONS AND LESSONS LEARNED INTERVENTION SPECIFIC RECOMMENDATIONS SCHOOL PROGRAM (STAFH) Lessons 1 Addltlon of farmlv plamng information has Increased partmpatlon at the club level 2 Lack of Mmstry of Educatlon and Dlstnct Educatlon Offlce ownerslup for the Ant1 AIDS club program makes sustanabtlity mcult 3 Involvement of the Peer Educatlon Adwsors (PEA) in the Antl-AIDS club program created a potential linkage for sustamability Recommendation IEF should hold a Change of ownershlp ' meetlng for all PEAS representahves from health centers and DHOIDEO representatives to a Dlscuss findmgs from the final evaluahon b To gwe parhclpants an assignment to meet together and develop a work plan for the Anti￾AIDS clubs and other school based actlwhes for the comng year and c To offer them a fixed amount of support funds per school (to be detemned bv the DHMT worlung from the CHAPS budget) wluch they could use to support then actlvltles These funds would only become avalable upon submssion of a proposal for actlvitles wlth a means for monltonng thelr implementation COMMUNITY BASED DISTRIBUTORS FOR CONTRACEPTIVES (STAFH, CHAPS) Lessons 1 Long Qstances reqwred to cover several vlllages make mobllizatlon and follow-up of clients difficult for CBD volunteers 2 CBD volunteers do increase access to farmly plmng Avalabillty of methods at the klllage level 1s appreciated by users However several users inlcated they were uslng pllls because they were avalable in the vlllage wlule they would prefer Depo Provera 3 Traned vlllage volunteers are capable of delivering essentlal farmly plamng ~nformation and semces 1 Male CBD volunteers are able to prowde farmly plamng semces to both male and female cllents 5 Although Important the Idea of reproductwe goals 1s shll far from the understandmg of village cllents 6 CBD mobilizahon positlvely influences the acceptance of tuba1 hgatlons RecommendaQons 1 The perceptron of adequate supply at the health center and commumty levels needs to be considered when dlstnbuhng contraceptlves (If providers perceive their supplies to be few they sometime under -dlstnbute suppl~es to cllents - even If their actual supplles are adequate ) 2 Continue to strengthen the secondary prov~der (famlly planmng providers at the health center) role as a means to assure support for CBD actwitles even rf the supemsing HSA may not be strong 3 Complete the CBD tralmng as planned under STAFH and CHAPS mth the additlon of at least 28 more CBD volunteers 1 Encourage CBD clients to also be famllv plamng motivators HOME-BASED CARE / HN-AIDS COUNSELING (STAFH, CHAPS) Lessons 1 The STAFH Inputs appear sufficient to leave a sustainable HBC/counsellng mterventlon wthin the Montfort Hospltal contevt 2 Montfort Hospltal s responsibility for the recruitment and payment of the HBC supervisor even though it was with STAFH funds improved their ownershlp of the HBC program Recommenddions 1 HBC volunteers should be prov~ded with personal protection (e g soap and gloves) 2 CHAPS wth the DHMT should ~denhfy and support a HBC committee to recommend and pilot a feasible HBC dellvery model lncludlng provlslon of mmmal supphes Lessons learned from the Montfort evpenence should be cons~dered SYNDROMIC MANAGEMENT FOR STD TREATMENT (STAFH) Lesson Cl~n~c~ans apprec~ated the syndrom~c management training and recogmze its importance The three totdl weeks of svndrormc management tralrung (one week ~mhally then two weeks evpanded sundromc management tramng) seems to have been enough to acheve appropnate treatment (drug select~on and dosage) assuming correct diagnos~s Prov~ders also understood the counselmg value and partner idnetrlicatlon Issues that come wth the problem Recommendation Include revlew of STD drug stocks and STD regsters as part of routme supemslon of clinical practlce No adhtlonal tramng recommended at hs hme evcept to replace staff lost through atvltlon TRADITIONAL HEALER TRAINING (STAFH, CHAPS - eye care) Lesson Trabhonal healers are mterested in learungabout Western mews of medmne and are urlllmg to change the~r behavlor They are also wlhng to promote healthy behav~ors m the commmty Recommendations 1 Tradltlonal healers should be considered as part of the commmty s health team As such reguldr contact between them and HSAs health comrmttees and MOH staff should be encouraged 2 Trabhonal healers should be supphed with free condoms for &stnbuUon NANKUNGWI TRADITIONAL ADVISOR TRAINING (STAFH) Recommendation Cam out a simple assessment of the nankungul mtervenhon Apply for separate follow-on funds If detemned that ~t d~d work well PEER EDUCATORS - SUCOMA (STAFH) Lesson The reqwrement that the peer educators be Sucoma employees or the~r spouses is a s~gmficant advantage for sustanab~lity Recommendations 1 De-emphaaze the commumty meehngfgroup educahon component of their respons~bilities and strongly emphasize thelr d~stnbuuon of condoms 2 IEF staff should meet wlth the Sucoma staff who are mvolved with the peer educator program to hand over STAFH actmtles and to assist w~th development of the nevt year s work plan (Note th~s mdv also includejolrung the medlcal officer In a meeting w~th se~uor Sucoma staff if he thinks it would be helpful) POLITICIAN EDUCATION (STAFH) Recommendation Wh~le pollhcal leaders are interested in health issues and are potential allies for health interventions d formal relationship w~th them through provision of tranlng 1s potenhally compl~cated IEF could support non-partlsan efforts at the natlondl level DRUG REVOLVING FUNDS (CHAPS) Recommendation 1 The DRF committee should contmue worlung on a The Drug resupply system so that ~t 1s funct~onal at the health center level Th~s will need to take some lund of cost shanng accounhng system Into account b Ways to tram volunteer replacements when ongnal DRF volunteers leave c The commmty system for overs~ght and ownership of the mntervenhon d Ways to educate the commumty on appropnate drug use SEED DISTRIBUTION (CHAPS) Lesson Seed hstnbuhon even If wmth lmmted other inputs can be well accepted and susta~nable Recornmendatlon The seed d~stnbuQon should be expanded but subshtuhng other protein foods such as increased ground nuts or pigeon peas for soya should be cons~dered Farmers also need to be tramed to use these In making pomdge for young chldren COMMUNAL GARDENS (CEIAPS) Recornmendatlon Even though th~s ISa difficult intervenoon the project should select the successfully producing v~llages (those where the cooperahve gardemng IS worlung) but place a much stronger emphaas on the goal of malnutnhon prevenbon (as contrasted to just communal produchon) Lessons learned should be documented and used to develop recommendahons for contlnuaQon of the program (or not) next year SPECIFIC INTERVENTIONS - not addressed in depth durinz the evaluation WATER AND SANITATION (CHAPS) Recornmendabon A couple of representahves from CHAPS (e g DHT IEF) should go through a s~mpllfied mdterm evaluahon process wth Concern U~uversal to assess progress and to assure collaboration and consistent messages between the different components of the CHAPS project at the community level PEER EDUCATION FOR COMMERCIAL SEX WORKERS (STAFH) Recornmendatlon Although potenoally an Important mntervenhon, there is increasing recogmhon that all womedpeople are at nsk and specially targetmg commercial sex workers may not be the most effective use of resources for AIDS prevenoon The CHAPS project should conhnue to assure condom ava~lablility at bottle stores and tradmng centers but should probably not contmue to spend resources on special tralmngs for bar girls unless addltlonal funds for that purpose are procured ADULT LITERACY, TRAINING OF TRADITIONAL HEALERS AND TEACHERS IN PRIMARY EYE CARE AND SCREENING (CHAPS) Too earlv m these mtervenhons to assess or make recommendatlons INCOME GENERATION AND HEALTH EDUCATION ACTIVITIES FOR KAPACHILA FALLS Recornmendatlon 1 Continue to consmder the Kapachmla area for community level interventions l~ke mv other undersened area of the Distnct 2 Encourage the Escom doctor to include and expand the partner identification and treatment component of lus STD program Probide the necessary ddv~ce md training for this effort WORK BASED AIDS PREVENTION INTERVENTION WITH KAPACHILA FALLS PROJECT Lessons When dealing with short term contractors ~t 1s difficult to get management support for health activltles There 1s a limt to how much you can work dnectly wth workers who are often d~splaced and dlsenfranchsed in these settmgs ADDITIONAL CHAPS INTERVENTIONS IMCI Contmue the process of ~mplementmg IMCI In the D~stncthrough the traimng of the Ch~kwawa cl~n~cal officer as an MCI trmner and encouragng its implementabon in the Distnct TBAs Although this Id not ongnally figure in the CHAPS proposal and work plan the MOH IS activelv workmg to increase the tra~ung and supemslon of TBAs in the Distnct With th~s In rmnd the CHAPS project should use its resources to Add TBAs to the supemsion and support structure already being establ~shed to support the DRF and CBD achxhes in vlllages (VHCs HSA pnmary supervisors and health center secondary supemsors) Revlew 11 the cntena for selection 21 the mechamsm for replacmg those lost through attntlon and 31 the content of the cumculum to be sure it reflects the state of the art for maxlnuvng the effectweness of TBAs in preventmg maternal mortalitv and promoting maternal health in the commwty CROSS-CUTTING ISSUES MANAGEMENT AND SUPERVISION Lesson Improvement of the transport system has posltlvely lmpacted morale and supemsion at all levels of the D~smct Recommendations 1 Supemsors need to be tramed In the respons~bilitles of their subordmates (CBD QA etc) 2 All health centers and Ngabu Rural Hospital need to put a management structure (health center management team) in place to oversee day to day operations and resource allocabon (e g transport outreach actlvlhes supervision repomng etc ) CHAPS/Distnct MOH should asslst with ths process 3 Reinforce relatlonshps between secondary supervisors (health center staff) and \Illage volunteers (for CBD DRF etc ) pmcularly when there may be d~fflcult~es in gettmg supphes Into the hands of the volunteers SUPPLY SYSTEMS Lessons 1 The recently introduced contraceptive log~stic system (CDLMIS) made a difference in contraceptive avalability in the penphery 2 The splitt~ng of condom dstnbubon responsibility between farmly planning and AIDS sectlons has resulted m problems wth condom avalabil~ty at the health center level and below Recommendat~ons 1 CHAPS should provide the FPISTD equipment that was identified as needed but not supplied bv the JSIISTAFH project 2 CHAPS should facilitate problem solving between the FP and AIDS Coordinators at the Distnct le%el for efficient condom distnbunon Advocacy for chamgn the system at the national level should also be considered CAPACITY BUILDING Recommendation Although the CHAPS project has put a lot of energy Into capaclty building of the DHMT the considerable turnover of staff makes it mcult to establish instttunonal memory at that level The project should balance these efforts with strengthemng and capacity bmlQng at the health center and communltv levels for mcreased sustanabihty More specfic recommendabons have been outlined in the secnons on HSAs and management and supemsion OTHER PARTNERSHIPS Lesson Earlv in the STAFH project the project advlsory coattee (PAC) which was made up of MOH IEF Montfort and Sucoma provided a forum for address~ng program implementation and management in general The dmolubon of th~s group may have led to a loss of clan@ regarding specific project activities and the plans for handover among these pmcipants Recommendd~ons 1 Do formal handover ~ncludmg wntten letter and meetmg with management to assure details (e g payment of HBC supemsor salary contmued condom supply etc) are not dropped in the process of phaang out (see also specific recommendation for Sucoma peer educators) 2 Review and strengthen the role of the Distnct Health Techcal Coordmating Committee (DHTCC) or other Distnct structures to assure a forum for cornmumcation and problem solving of technical as well as management and supervision issues for all health players in the Distnct QUALITY ASSURANCE INTERVENTION Lesson The thorough plmng and tramng for the implementabon of th~s process means the quality asssurance team feels well tmned and competent in trarnng health center staff and in pushng the process forward Recommendation Ths is a promsmg process being recommended for expansion at the health center and even communitv level However solid follow up is should be emphasized and reinforced for the QA core team so they are clear on their support role and for the health centers and commmty committees by the QA core team and staff supemsors HSA ROLE Lessons 1 HSA supervision of CBDs in the current system depends too strongly on the qual~ty of the indiv~dual HSA 2 Transfer of HSAs makes it necessary to plan for regular trainlng systems (even if it is on the job traimng) for specla1 HSA programs (such as CBD water maintenance DRF etc ) to assure continued supervision of these programs by incomng replacements Recommendations 1 Explore ways to extend the team problem solving approach to supemsion of HSAs and to the HSA supervising the commmty 2 As CHAPS activlties are extended to the health center level and HSAs the problem of HSA transport (bicycle distnbution and mamtenance system) needs to be urgently addressed 3 Since HSAs are cruc~al for the success of community activities as effort should be made to pull weak ones to posts where they can be supervised and fired If necessary VILLAGE HEALTH COMMITTEES Recommendat~ons 1 VHCs need tramng includmg implementabon of a system for trmung replacements when attrition occurs a All PHC actmbes occumng in their particular village (CBD DRF water gardens growth momtonng etc ) b How to prowde oversight and support to village volunteers c How to orgmze regular commwty meebngs on health in order to increase general community pmcipabon and ownershp 2 Tram and work with all Distnct HSAs to apply the problem solving process (as initiated under the qualitv assurance intervention for CHAPS) in orgamzing and traning VHCs 3 Select 10-20 verv actwe VHCs to focus on strengthemng the commu~llty/VHC/HSA/health center relahonslups and collabora~on through more active implementabon and supervision of the problem solwng process Document the evpenence and lessons learned IEC STRATEGY Lessons 1 There has been an increase in the depth and breadth of people s knowledge about HIV transmission and farmly plmng since the incepbon of the project whch may have been encouraged by the wide vanety of IEC actmbes whch occurred throughout the Distnct 2 The knowledge changes (parbcularly for FP) were greater in the CBD wllages than in the Distnct as a whole, whch indicates that the indmdual peer counseling mode may be more effectlve or at least effectlve as an enhancer of a generalized IEC campagn Recommendd~on Although the IEC consultant outlined a very comprehensive l~st of potenbal target groups and IEC strateges the messages and achvities should be pnonbzed to a few key messages and strategies - keeping m mnd that the final impact has to be the absorption of the messages for behawor change by individuals and farmlies in the commmhes CROSS - CUTTING INTERVENTIONS - not assessed m detad, but seem to be on track. HIS ACCOUNTING SYSTEM AND STOCK CONTROL - MOH FLEET MANAGEMENT PROJECT MANAGEMENT Lessons The MOH s drect involvement in the development of the CHAPS work plans budgets and budget decis~ons has led to a sign~ficantly different sense of ownershp with the CHAPS project than with other NGO projects The design for CWS prowdes a coherent focused framework for whatever interventions werelare pnontized in the Distnct By contrast STAFH by design had a more narrow techmcal focus for its interventions that threrefore resulted m more of a list of interventions wth less system rela~onships between them Given the decentralization process occurring in Malawi the CHAPS design (PVOMOH partnerslup mved community dnd system level interventions and mixed process and matenal inputs)' works verv well Following are suggestions that came from the DHMT members themselves but the evaluator agrees with them They see emphasis on the ~mplementatlon and continued enforcement of poliaes and systems even when individual personnel change as a means to maintam actlvlhes whch have been ~nitiated In order to mamtam newly lmtlated actlvitles speclfic plans for their continuation should be included dunng the development of annual and quarterly work plans In addihon to planning for new actlvities It would be more helpfbl for all the IEF CHAPS staff to have offices in Chhvawa so they would be more accesstble to each other Thev would llke to contmue to be involved w~th select~on of CHAPS staff when people are hred from outside Thev are also Interested to know the quallficahons of the techcal staff wlth whom they are worlung Although in the general plan for the DHMT the absence of a Famlv Health Coordinator in C&vawa should not preclude representation for FP MCH and cornmume level actlvities on the DHMT by more than the DEHI Other Recornmendatlons - Internal Project Management Project staff should review the avadable information relatlve to the speclfic performance mdicators llsted in the proposal log frame to be sure they are morutonng the necessary informat~on to measure project progress IEF should try to assure tramng opporturutles for IEF advisors to complement tralmng received by MOH counterparts m order to assure their contmued credb~lit-y Everyone needs to be sure both the IEF management and the MOH Systems Advlsor components of the Systems Advlsor s job are adequately addressed Delegatlng some of the day to day errands he does (for both the project and MOH) to others leavlng lum free to focus on the systems management would help Evaluate the costs and benefits assoc~ated wth the techcal support model offered by URC to detemne If tlus lund of assistance model is helpful as PVOs move toward increased svstems support and advlsory roles REVIEW OF OBJECTIVES CHAPS objectlves may be valid, but the tlme frames are probably too ambihous Three years is a totally unrealistic tlme frame for a project \nth the scope and svstem onentation of th~s one The rolllng over of STAFH into CHAPS and the inherent sustainab~litv of the CHAPS design means specific sustainability recomrnendatlons were not seen as necessary at th~s tlme