AFRICARE/GUINEA
MATERNAL AND CHILD HEALTH INITIATIVE
(MCHI)
MIDTERM EVALUATION
By:
Bonnie L. Kittle
Submitted by:
LTG Associates, Inc.
and
TvT Associates, Inc.
Submitted to:
The United States Agency for International Development/Guinea
Under Contract No. HRN-I-00-99-00002-00.
January 2000
MEDS
MONITORING EVALUATION & DESIGN SUPPORT
Africare/Guinea: Maternal and Child Health Initiative (MCHI) Midterm Evaluation, was prepared under
the auspices of the U.S. Agency for International Development (USAID)/Guinea under the terms of the
Monitoring, Evaluation, and Design Support (MEDS) project, Contract No. HRN-I-00-99-00002-00. The
opinions expressed herein are those of the authors and do not necessarily reflect the views of LTG
Associates, TvT Associates, or USAID.
Information about this and other MEDS publications may be obtained from:
Monitoring, Evaluation, and Design Support (MEDS) Project
1101 Vermont Avenue, N.W., Suite 900
Washington, DC 20005
Phone: (202) 898-0980
Fax: (202) 898-9397
ltg@earthlink.net
ACRONYMS AND FOREIGN TERMS
ADRA Adventist Development and Relief Agency International
AGBEF Association Guinéenne pour le Bien Être Familial
BASICS Basic Support for Institutionalizing Child Survival
BHR/PVC Bureau for Humanitarian Response/Private and Voluntary Cooperation
BSR Office of Referral Support (in French)
CA Community agent
CBD Community-based distribution (distributor)
CDD Control of diarrheal disease
COPE Client-oriented, provider efficient services
DFSI Dinguiraye Food Security Initiative
DPS Prefectoral direction or director of health (in French)
DPT Dyptheria, pertussis and tetanus vaccine
EPI Expanded programme on immunization
FAMPOP Family Planning Options Project
FY Fiscal year
GTZ German Technical Cooperation for Development
HIS Health information system
IEC Information, education and communication
IRS Regional health inspector (in French)
KPC Knowledge, practice and coverage
MCHI Maternal and Child Health Initiative
MIS Management information system
MOH Ministry of Health
NGO Nongovernmental organization
ORS/T Oral rehydration solution/therapy
OSFAM Options pour la Santé Familiale
PHC Primary health care
PNLP National Malaria Control Program (in French)
PRISM Pour Renforcer les Interventions en Santé Reproductive et MST/SIDA
PSI Population Services International
SIAC System d’information à assise communautaire
SO Strategic Objective
UNICEF United Nations Children’s Fund
USAID United States Agency for International Development

CONTENTS
ACRONYMS AND FOREIGN TERMS
EXECUTIVE SUMMARY...................................................................................................i
I. Project Description 1
A. Background ..........................................................................................................1
B. Field Procedures...................................................................................................2
II. Quality of
Programming…………………………………………………………….…………3
A. Relationship between MCHI and Other Health-Related Activities.....................3
B. Level of Access of Mothers and Children to Health Facilities and Other
Child Survival Services.......................................................................................5
C. Project Staff and Other Personnel Related to the Project.....................................5
D. Support and Supervision......................................................................................7
E. Conclusions and Recommendations Regarding Appropriateness of Support,
Supervision and Workload ..................................................................................8
Conclusions....................................................................................................8
Recommendations..........................................................................................9
III. Quality at the Community Level....................................................................................11
A. Information, Education and Communication (IEC) Messages and Means of
Communicating....................................................................................................11
B. Project Assessment of Understanding of Messages and Use of Information......13
C. Assessment of Understanding of Messages among Target Audience .................14
D. Conclusions and Recommendations....................................................................15
Conclusions....................................................................................................15
Recommendations..........................................................................................16
IV. Quality of Health Worker and Facility Services.............................................................19
A. Facility, Health Worker (MOH) and Community Agent Knowledge, Skills
and Practices Assessment.....................................................................................19
B. Quality of Service Tools Used by the Project......................................................21
C. Materials/Supplies for Each Type of Health/Worker Facility.............................23
D. The Health Information System...........................................................................25
E. Conclusions Regarding Effectiveness of Training, Support, Monitoring, and
Supervision of Service Delivery..........................................................................25
Conclusions....................................................................................................25
Recommendations..........................................................................................26
V. Capacity Building and Sustainability...............................................................................29
A. Project Plans and Progress Toward Increasing Partner Capacity........................29
B. Project SustainabilityæPlans and Progress.........................................................31
C. Conclusions and Recommendations Related to Capacity Building and
Sustainability........................................................................................................33
Conclusions....................................................................................................33
Recommendations..........................................................................................34
VI. Technical and Administrative Support...........................................................................35
A. Types and Sources of External Technical Assistance ........................................35
B. Technical and Administrative Support Received from Headquarters................36
C. Conclusions and Recommendations...................................................................36
Conclusions....................................................................................................36
Recommendation............................................................................................36
VII. Financial Expenditures..................................................................................................37
VIII. Accomplishments and Constraints................................................................................39
A. Consistency of Project Implementation with the Continuation Application.......39
B. Adherence to Project Schedule ...........................................................................41
C. Primary Achievements........................................................................................42
Addressing MalnutritionæThe Hearth Model...............................................42
Increased Access............................................................................................43
Integration and Coordination.........................................................................43
Increased Quality............................................................................................44
D. Impediments to Project Progress and Overcoming Constraints..........................44
Understaffing in Health Centers.....................................................................44
Little MOH Incentive to Support Community Activities...............................44
Health Center Quality of Care........................................................................45
Widely Dispersed Population.........................................................................45
E. Conclusions and Recommendations....................................................................46
Conclusions....................................................................................................46
Recommendations..........................................................................................46
IX. Issues Identified by the Evaluation Team, NGO or USAID.........................................47
A. Project Expenditures..............................................................................................47
B. Coordination/Collaboration between DFSI and MCHI Projects with Regard to
the Village Health Committee Strategy ...............................................................47
C. Reduced Budgetary Support..................................................................................47
D. Role of Continuation Application.........................................................................48
ANNEXES
A. Scope of Work (from USAID/Guinea) ........................................................................51
B. Questionnaires and Discussion Guides........................................................................59
C. Summary of Evaluation Field Work ............................................................................77
D. Project Indicators..........................................................................................................81
E. Supervision Form.........................................................................................................87
F. IEC Messages Promoted by MCHI (translated from French)......................................91
G. Time Line (Year 2): October 1998-September 1999 ..................................................95
H. References....................................................................................................................99
I. Evaluation Team Members.......................................................................................... 101
TABLES
1. MCHI Project-Related Personnel...................................................................................6
2. Knowledge among Mothers Living in the Project Area ..............................................15
3. MOH: Health Agents’ Knowledge Levels..................................................................20
4. Community Agents’ Knowledge Levels......................................................................20
5. Quality Assurance Instruments Used by MCHI...........................................................22
6. Supplies, Materials and Equipment provided to Community Agents..........................23
7. Supplies, Materials and Equipment provided to Health Centers, Health Posts and
Health Workers......................................................................................................24
8. Training........................................................................................................................30
9. Technical Assistance Received by MCHI....................................................................35
10. MCHI Budgetary Summary.........................................................................................37
11. Summary of Achievement of Project Outcome Indicators..........................................40
12. Year 2 Time Line .........................................................................................................94

i
EXECUTIVE SUMMARY
A. INTRODUCTION
In November 1999, the United States Agency for International Development
(USAID)/Guinea commissioned a midterm evaluation of the Maternal and Child Health
Initiative (MCHI), a child survival project being implemented by Africare/Guinea. The
four-year project began in October 1997. The purpose of the evaluation was to identify
successes as well as problems, suggest areas which need further attention, and
recommend useful actions to guide the staff through the second half of the project. (The
scope of work is provided in annex A). The following is a summary of project
achievements and recommendations.
B. PROJECT ACHIEVEMENTS
Addressing Malnutrition: The Hearth Model
Innovative Work: Capitalizing on its comparative advantage as a nongovernmental
organization (NGO), MCHI/Africare has undertaken innovative work with the Hearth
model, an approach that addresses malnutrition at the community level. Through this
method, 117 (84 percent) of the 140 children present at the second post-Hearth weighing
had been rehabilitated and mothers had begun to adopt feeding behaviors that should
prevent malnutrition from recurring.
Advocacy: As a result of Africare’s organization of a national seminar on the Hearth
model, many other NGOs and ministries have become aware of the method. It has
quickly become a potential model approach for malnutrition rehabilitation among other
NGOs, including Plan/Guinea, Adventist Development and Relief Agency International
(ADRA), and Action against Hunger.
National Application: More importantly, the Hearth model has the potential of becoming
a means for the Ministry of Health (MOH) to reduce malnutrition rates nationally. In the
fourth year of the project, Africare will work with the director of health (DPS) of Dabola
to determine how the Hearth model can be adapted so the DPS can implement it as part
of its own community-based strategy.
Increased Access
MATERNAL AND CHILD HEALTH INITIATIVE (MCHI) MIDTERM EVALUATION
ii
The MCHI project has increased access to primary health care (PHC) services by
ß promoting collaborative efforts between community agents and MOH health
workers so that more people take part in community-level health activities
conducted by health center staff, such as vaccination days;
ß training 48 community agents in nutrition, malaria control and prevention,
diarrheal disease control, reproductive health, and IEC skills;
ß implementing growth monitoring and Hearth activities to identify and
rehabilitate malnourished children;
ß constructing and renovating health posts;
ß providing motorcycles to MOH agents;
ß supporting and supervising community agents;
ß developing a referral system;
ß improving the emergency evacuation system from health posts to hospitals
through the provision of radios to health posts; and,
ß working with the United Nations Children’s Fund (UNICEF) to develop a
community-level emergency evacuation system.
Integration and Coordination
MCHI/Africare has developed an excellent working relationship with the DPS and other
organizations operating in the area and effectively coordinates its work with these
entities. For example, MCHI is:
ß working with the UNICEF/Maternity without Risk Project to develop an
emergency evacuation strategy to complement the project’s provision of
radios to health centers;
ß working with Pour Renforcer les Interventions en Santé Reproductive et
MST/SIDA (PRISM) and 13 other organizations to standardize and share
approaches to information, education and communication (IEC) in the region;
ß working with PRISM, the Association Guinéenne pour le Bien Être Familial
(AGBEF) and the National Malaria Control Program (PNLP) to standardize
the training of health agents;
ß providing information to PRISM’s community-based strategy coordinator to
standardize community-level data gathering and supervision instruments; and,
EXECUTIVE SUMMARY
iii
ß serving as a resource to other NGOs interested in initiating the Hearth model.
Increased Quality
MCHI/Africare has increased the capacity of community agents to provide quality care in
support of maternal and child health through training and support. It has developed
monitoring instruments to track inputs and outcomes and is advocating for better support
and recognition of community-level health activities.
C. RECOMMENDATIONS
1. Continue to implement the Hearth model. Help other NGOs learn about and
implement it. Work with the DPS to improve the involvement of MOH health
workers and community agents in its implementation. Develop a plan
whereby health agents begin to take more and more responsibility for different
aspects of Hearth implementation.
2. Work with the DPS to ensure that
ß health center staff members provide reports regarding all
community-level activities at semiannual monitoring meetings,
ß health agents record vaccinations on the green system
d’information à assise communautaire (SIAC) Road-to-Health
card during village-level vaccination campaigns,
ß quality of service delivery is monitored among health agents,
ß performance standards for community agents are developed and
monitored, and
ß an assessment of the quality of supervision of community agents
by health workers is carried out, a plan is developed and
implemented to improve supervision, and field agents’ supervision
responsibilities are gradually reduced.
3. Use very creative and multiple means to encourage health agents to take more
interest and responsibility in monitoring community activities. These could
include
ß sending a copy of the project’s supervision form (of community
agents) to the health agents,
ß discussing the content of the supervisory visit with the health
agent, and
MATERNAL AND CHILD HEALTH INITIATIVE (MCHI) MIDTERM EVALUATION
iv
ß inviting the health agents to a day of community agent training and
involving the two in teambuilding activities.
4. Review the IEC strategy to
ß make sure that the messages are worded such that they incite action
and are entirely correct,
ß ensure that community agents know the target audience for each
message,
ß find ways to provide positive incentives for desired behavior changes,
ß ensure that each message has a visual means of communicating that is
easy to use with groups or individuals, and
ß guide the community agents in selecting audiences for group
presentations and home visits.
5. Develop a Logical Framework for the project in which
ß the indicators related to health center management capacity
building reflect the actual role and responsibilities of the project
and avoid duplication with other partners,
ß knowledge indicators are included for which baseline data are
available,
ß the indicator for malnutrition is changed from chronic to acute (or
simply malnutrition), and
ß other strategies (activities) to achieve project objectives are
outlined (for example, exclusive breastfeeding support
groups/community-based treatment of malaria).
6. Develop a detailed sustainability plan with indicators and means of
verification that focuses on continuing the benefits of the project as well as
some of the activities. This might include the formation and training of
district development committees to support the community agents,
establishing and testing other community agent (CA) support systems (such as
resupplying of oral rehydration salts and contraceptives and regular
supervision), and DPS management of the Hearth model.
EXECUTIVE SUMMARY
v

1
I. PROJECT DESCRIPTION
A. BACKGROUND
In early 1997, the Guinean Ministry of Health (MOH) requested that Africare/Guinea
expand the scope of the Dinguiraye Food Security Initiative (DFSI) to include a focus on
maternal and child health. To that end, Africare, in collaboration with different partners
(the regional health inspector [IRS], the director of health [DPS], the German Technical
Cooperation for Development [GTZ], and the Association Guinéenne pour le Bien Être
Familial [AGBEF]), developed and submitted a proposal to the United States Agency for
International Development (USAID)/Guinea. In October 1997, Africare/Guinea was
awarded a four-year grant in the amount of $2.3 million to fund the Maternal and Child
Health Initiative (MCHI). The project is being implemented in Dabola and Dinguiraye
prefectures in the Faranah region of Upper Guinea. The target populations of the project
include 42,000 children under 5 years of age and 42,000 women of reproductive age.
The MCHI project seeks to improve maternal and child health by reducing maternal and
child morbidity and mortality. This goal will be achieved by strengthening and
expanding existing government health services and strengthening communities’ capacity
to manage their own health problems.
Indicators for measuring these objectives were developed and presented in the original
proposal, but were then changed in the first continuation application to focus more on
practices rather than knowledge. (These indicators are presented in annex D of this
report.)
MCHI focuses on four interventions: nutrition, malaria prevention, control of diarrheal
disease, and reproductive health. The project also supports the MOH’s immunization
efforts.
To achieve the project’s objectives, MCHI has employed and trained a cadre of field
agents who in turn help to train and support volunteer community agents (CAs). The
CAs are village (called sector, in Guinea) residents selected by their community to
provide a number of services in support of maternal and child health. These services
include monthly growth monitoring and promotion, health education, identification and
referral of sick children to the local health center, sale of oral rehydration solution (ORS)
packets and a few types of contraceptives (not yet initiated as of the midterm evaluation),
and assistance with the Hearth model.
The Hearth model is a strategy employed by the project to rehabilitate malnourished
children and teach mothers feeding practices that will help avoid the recurrence of
malnutrition in their children. (See chapter III for details regarding the Hearth model.)
MATERNAL AND CHILD HEALTH INITIATIVE (MCHI) MIDTERM EVALUATION
2
The project also trains MOH health agents, assists with national vaccination day
campaigns, has provided six motorcycles and two-way radios to health centers and health
posts, is building and renovating health posts, and plans on supporting income-generating
activities.
B. FIELD PROCEDURES
In November 1999, USAID/Guinea commissioned an evaluation of the MCHI, a project
being implemented by Africare/Guinea in the Dabola and Dinguiraye prefectures of the
country. The scope of work of the evaluation (see annex A) called for an assessment of
the quality of programming, quality at the community level, quality of health worker and
facility services, capacity building and sustainability, technical and administrative
support, financial expenditures, and accomplishments and constraints. Other issues
identified by USAID, Africare or the evaluation team were also investigated. The
evaluation team consisted of six members and included representation from the project,
the MOH and the Prefectoral Direction (DPS): Bonnie Kittle (consultant/team leader),
Gouley Cisse (MCHI assistant coordinator), Tadiba Kourouma (MCHI assistant capacity
building coordinator, newly hired), Kadiatou Keita (midwife from MOH, Conakry),
Abdoulaye Diallo (MCHI assistant supervisor), and Etiene Wendeno (DPS head of health
center).
The evaluation was conducted in four phases: document review and initial interviews,
field work, data analysis and interpretation, and report writing. The field work consisted
of indepth interviews with project staff, partners (MOH, DPS, the United Nations
Children’s Fund (UNICEF), Pour Renforcer les Interventions en Santé Reproductive et
MST/SIDA (PRISM), Population Services International (PSI), and GTZ), health agents,
community agents, and beneficiaries (mothers) for which several instruments and
discussion guides were developed (annex B). Approximately 125 interviews were
conducted, as indicated in annex C. The evaluation team visited six health centers and
four health posts as well as six districts.
Once the information was collected, the team spent 4 days analyzing and interpreting it,
identifying findings, drawing conclusions, and developing recommendations. The most
important of these were presented to the project staff for discussion. The team was then
invited to the regional capital, Faranah, to present the results to all of the prefecture heads
of health and hospital administrators (18), who were gathered for training. Upon return to
Conakry, the team leader debriefed the USAID project officer before presenting the
results to a group assembled by the Ministry of Health.
3
II. QUALITY OF PROGRAMMING
A. RELATIONSHIP BETWEEN MCHI AND OTHER HEALTH-RELATED ACTIVITIES
MCHI staff members have excellent working relations with the DPS (the local
representative of the MOH) and the other partners of the DPS, including UNICEF, GTZ,
and the USAID–funded PRISM project. The DPS considers Africare one of its most
valued partners in the prefecture and collaboration between the two is very productive.
The MCHI staff coordinates project activities directly with the DPS and consults with
UNICEF, PRISM and GTZ to keep abreast of their initiatives and avoid duplication of
effort. In order for the excellent level of coordination to continue in the absence of the
DPS (who will be on sabbatical for most of the year 2000), a special structure needs to be
put in place.
Project staff has participated in the UNICEF–funded annual workshop on nutrition
activities, is a regular participant in the DPS’ semiannual monitoring meetings, and
serves as the secretary on the Regional Information, Education And Communication
(IEC) Working Group. In addition, Africare is represented at meetings with
USAID/Guinea’s Strategic Objective (SO) 2 team when all of USAID’s health and
population grantees meet to share information about their activities. There are no other
nongovernmental organizations (NGOs) implementing health activities in the prefecture.
When the project began, Africare inventoried prior endeavors and activities underway in
the target zone. At that point, it was decided that rather than train a different cadre of
community health agents the MCHI project would build upon the prior work of
UNICEF’s Integrated Project and the predecessor of the PRISM project, Family Planning
Options Project (FAMPOP). Both of these projects had trained community health
agents—one to combat malnutrition through growth promotion activities (system
d’information à assise communautaire [SIAC] volunteers) and the other to serve as
community-based distributors (CBDs) of contraceptives. Neither of these two types of
agents was being optimally supported when the MCHI project began and the project
encouraged community leaders to select these community volunteers for further training
and support by the project. (The project also encouraged community members to select
women for training, and now 30 percent of the community agents are female.) Africare
used the SIAC volunteer training curriculum to train them in growth monitoring and
promotion and will use the PRISM training curriculum to train them in community-based
distribution of contraceptives.
Africare is also working with UNICEF’s Maternity without Risk project to implement an
emergency evacuation system for pregnant women and children with serious illnesses.
Through the Maternity without Risk project, an Office of Referral Support (BSR) has
been established. This is a committee formed at the village (sector) level, which manages
an emergency evacuation fund. Many MCHI–trained community agents and traditional
birth attendants (trained by UNICEF) are members of the BSR and serve as the link
MATERNAL AND CHILD HEALTH INITIATIVE (MCHI) MIDTERM EVALUATION
4
between the community or individual in need and the BSR member who has the means to
contact the health center and access the ambulance.
Africare is coordinating its work on malaria prevention with the National Malaria Control
Program (PNLP). Because of the project’s focus on malaria prevention and its reputation
as a cooperative partner, the PNLP decided to make Dabola a pilot site for its mosquito
net impregnation efforts. The project supported this by facilitating the participation of
heads of four health centers in the mosquito net impregnation training that was
implemented by the PNLP with support from UNICEF. In addition, the project is helping
to train a second mosquito net impregnation unit in Dabola.
In addition to strengthening the community’s ability to address its health problems, the
project also seeks to strengthen health center staffs’ ability to provide adequate care. To
this end, the project has trained health center and health post staffs in each of the four
technical components of the project. The project’s field agents are regular visitors at the
MOH health centers in Dabola. According to the MOH employees interviewed for this
evaluation, MCHI staff (primarily field agents) visits the health centers several times a
month. These visits serve to keep the health agents informed about project activities
taking place in the sectors and to coordinate activities, such as sector vaccination days
(strategie avancé). Project field agents may also follow up on sick patients referred to
the health center for treatment and receive feedback regarding community members’
attendance at prenatal consultations, etc. Because the number of MOH personnel is
extremely limited in some health centers and visits to the field are infrequent, these visits
by field agents help to maintain contact between the health worker and the community
agent. Project staff also helps organize and implement vaccination campaigns, and the
project has provided material support to each health center as well.
Africare’s work in reproductive health in Dabola and Dinguiraye is helping the PRISM
project meet its objectives. Furthermore, with Africare working in these two prefectures,
PRISM can focus its time and resources on other parts of the region. PRISM can also
learn from the work of MCHI, particularly the community activities which PRISM has
yet to initiate. Members of the PRISM staff are working with MCHI to standardize IEC
approaches and supervision instruments. MCHI staff has helped PRISM to train health
agents in reproductive health norms and procedures and the Hearth approach may well
prove to be a model for PRISM’s child survival/nutrition component.
One area of possible duplication of effort exists. This is between the GTZ project, whose
objectives include management capacity building of the IRS and DPS in the Faranah
region, and the objective of the MCHI project, which is the same. Thus far, MCHI has
avoided duplication by not providing management training at all. Given the comparative
advantages of Africare (community development) and GTZ (institutional support), it is
preferable to divide the resources accordingly and work to complement each other’s
efforts rather than to duplicate them.
B. LEVEL OF ACCESS OF MOTHERS AND CHILDREN TO HEALTH FACILITIES AND OTHER
CHILD SURVIVAL SERVICES
II. QUALITY OF PROGRAMMING
5
The MCHI project has increased access of mothers to quality health services and
facilities by
ß training 48 community agents (many of whom are women), who provide child
survival services at the community level,
ß mobilizing community members to access MOH services being offered both
at the health center and in the community,
ß helping to improve the quality of service delivery by health agents by
establishing a referral system for sick children, and
ß facilitating emergency evacuation through the provision of radios to health
posts and working with UNICEF’s Integrated Project, as described previously.
Health agents interviewed for this evaluation all agreed that attendance at prenatal
consultations had increased since the project began and that immunization coverage had
increased due to wider participation in sector vaccination days. Training of community
agents in growth monitoring and promotion means that each child (under age 3 is
weighed once a month and their mothers receive some counseling and encouragement.
This activity was found to be strongly supported by fathers as well. Many mothers
interviewed mentioned that in addition to monthly growth monitoring, they had received
other health services, such as group health education, vaccinations, Hearth, and
hygiene/sanitation activities. The majority of mothers interviewed reported that health
conditions in their community had improved in recent years.
C. PROJECT STAFF AND OTHER PERSONNEL RELATED TO THE PROJECT
As shown in table 1, workloads of the project staff appear to be evenly distributed with
the exception of the supervisor. He is responsible not only for supervising the field
agents, but also for the health and management information systems (HIS/MIS) and the
IEC strategy. Furthermore, he plays a major role in training and implementing the Hearth
model. The project has recognized this imbalance and plans to hire a person to be
responsible for the HIS/MIS.
The project also plans on hiring additional field agents to take responsibility for the new
cohort of communities into which the project will be expanding during the second half of
the project. A capacity-building coordinator (to be hired) and her/his assistant will be
responsible for establishing, training and supporting district development committees and
overseeing income-generation activities.
The current organizational chart does not reflect these new hires or the project staff
operating in the Dinguiraye prefecture and should be amended.
The evaluation team assessed the knowledge of field agents and found that while their
knowledge in the area of nutrition is very strong (94 percent correct, on average), some
field agents will need to review the technical aspects of control of diarrheal disease
MATERNAL AND CHILD HEALTH INITIATIVE (MCHI) MIDTERM EVALUATION
6
(CDD), malaria and reproductive health. To their credit, however, the expectations of the
project with regard to knowledge levels are quite high, for example, case management of
a child with moderate dehydration.
Table 1: MCHI Project-Related Personnel
Title No. Organization Role
Africare Headquarters
Staff
4 Africare 5–15% Project support, technical assistance, liaison
Country Representative 1 Africare–20% Supervision, representation, program guidance
Administrator 1 Africare–40% Financial and administrative support
Project Coordinator 1 Africare–100% Project management, personnel supervision,
representation at national level, program
oversight, liaison with Africare
Conakry/Headquarters, financial oversight
Assistant Coordinator 1 Africare–100% Project management, supervision, coordination
of activities, training curriculum development
Supervisor/Trainer 1 Africare–100% Supervision of field agents, HIS data
management, development of training
curriculum for field agents, trainer,
development and oversight of IEC strategy,
implementation of Hearth model
Assistant Supervisor 1 Africare–100% Supervision of field agents, trainer of CAs
Project Administrator 1 Africare–100% Logistical coordination
Project Secretary 1 Africare–100% Secretarial work
Field Agents/Dabola 9 Africare–100% Training of community agents, supervision and
monitoring of community agents, oversight of
Hearth activities
Field Agents/
Dinguiraye
7 Africare–50% Training of community agents, supervision and
monitoring of community agents;
Supervisor, Capacity
Building
0 Africare–100% Will work to establish village development
committees, oversee income-generating
activities
Assistant Supervisor,
Capacity Building
1 Africare–100% Helping to form, train and support village
development committees, oversee income￾generating activities
HIS Coordinator 0 Africare–100% Will be responsible for the HIS/MIS system
Community Agents 48 Community
Volunteers
Carrying out of census, monthly growth
monitoring, provision of health education,
referrals to health center and follow up of
referred cases, selling of ORS packets in
sectors, carrying out of Hearth activities,
monitoring of progress of Hearth participants
Regional Health
Inspector
1 MOH Oversight and coordination of health activities
in the region, supervision of DPS, coordination
with donors/project operating at the regional
level
Director of Health,
Prefect Level
1 MOH Coordination of health activities at the prefect
level, liaison with projects/donors
Health Agents 28 MOH Provision of health services at health centers
and vaccination in sectors, supervision of
community agents
II. QUALITY OF PROGRAMMING
7
D. SUPPORT AND SUPERVISION
The project employs nine field agents in the Dabola prefecture who in turn supervise 48
community agents. The average number of community agents (CAs) per field agent is
five, but in reality, the ratio of CAs to field agents ranges from 3:1 to 8:1. The ratio
varies according to many factors: size of the area being covered both in terms of square
miles and population; distance between health centers, districts and sectors; terrain;
complexity of the community; and, experience with the project. Each field agent is
supposed to supervise each community agent once a month. This usually occurs during
the last two weeks of the month when growth-monitoring activities take place, since
supervision activities include on-the-job training and data collection. To supervise the
IEC aspects of the CA’s job, however, a second visit would be necessary. It is not clear
to what extent this is taking place since the field agents are quite involved with other
activities (training preparation and implementation, and Hearth preparation) which
require their presence outside the target communities. Furthermore, in order for capacity
building to take place at an optimal pace, field workers should have more frequent
contact (2–3 times a month) with each community agent.
The project has developed a supervision instrument to guide field agents’ efforts. This
tool (see example in annex E) collects information regarding the supplies and materials
provided to the CA, the growth monitoring activity, home visits, referrals, number of
family planning participants, and IEC activities. The aide memoire section at the end of
the sheet serves to remind the field agent to provide feedback to the CA, to write the
recommendations in the CA’s notebook, and to provide feedback to the field agent’s
supervisor.
Although the instrument is effective in collecting project data, this tool is not well suited
to assessing the community agent’s performance. To be useful in supervision, therefore,
the instrument needs to be modified to focus more on assessing the quality of service
delivery.
The project supervisor and his assistant supervise the nine field agents. Although there is
no specific schedule for supervision, both supervisors insist that they are frequently in the
field overseeing field agents’ work. Given the number of responsibilities delegated to the
supervisor (see table 1), however, it is difficult to imagine him having time to supervise
the field agents adequately, even with his assistant’s help. A very general and open-ended
supervision instrument is currently being revised to make it more specific and easy to
use. The revised supervision instrument should focus on assessing and improving the
field agent’s performance.
Although the MCHI–employed field workers assume responsibility for supervising the
community agents, in reality, this is the job of the MOH health agents, usually the person
responsible for the vaccination program. Given the restricted number of health agents
and their limited means of transportation, however, they are only expected to supervise
the CAs once a quarter. According to a study conducted by MCHI, the majority of health
agents are able to respect this schedule, although the actual content of the supervisory
visit is not clear. Because regular supervision is a key to sustaining the work of the
MATERNAL AND CHILD HEALTH INITIATIVE (MCHI) MIDTERM EVALUATION
8
community agents, the project needs to look for ways to assess and improve (if need be)
the quality of supervision provided by health agents and gradually reduce the field
agents’ supervisory responsibilities.
The project coordinator’s mechanism for supervising her senior technical staff is weekly
meetings, during which the project’s activities are discussed and determined. Although a
schedule of project activities is developed for each month, senior staff members are not
required to submit plans or reports of their own activities. As a result, there is no written
record of their work.
E. CONCLUSIONS AND RECOMMENDATIONS REGARDING APPROPRIATENESS OF SUPPORT,
SUPERVISION AND WORKLOAD
Conclusions
1. The project has significantly increased access to health services by training
community agents and mobilizing mothers to make use of the services
provided by health agents.
2. The project has strengthened the link between community agents and health
agents.
3. The project effectively coordinates its activities with those of the DPS and
other partners.
4. The MCHI enables the PRISM project to use its resources more effectively by
taking responsibility for reproductive health and community activities in two
prefectures.
5. A potential duplication of effort exists between the work of GTZ and MCHI
in management capacity building among health center staff.
6. The absence of a standard of performance for community agents hinders
effective supervision and support efforts.
7. The current monthly supervision approach focuses too much on quantity of
work (and data collection) and not enough on quality of work.
8. Monthly supervisory visits of this sort are too frequent.
9. Support visits for the sole purpose of improving service delivery are not
frequent enough.
10. Not enough is known about the quality of supervision provided by health
agents to community agents.
II. QUALITY OF PROGRAMMING
9
11. MCHI field agents and senior technical staff are not being supervised
systematically.
12. The chief supervisor is overburdened with work.
Recommendations
Relationships
1. Prior to his departure, the DPS should designate (in writing) one of his staff as
the MCHI project point person. A schedule of regular meetings should then
be established between this person and the project coordinator.
2. To avoid duplication of effort with GTZ, the MCHI project should officially
drop the indicators related to health center management capacity building (see
annex D).
Staff
3. As planned, the project coordinator should reduce the workload of the chief
supervisor by hiring a person to take charge of the HIS/MIS.
Support and Supervision
4. In collaboration with DPS and other partners, senior project staff should
develop a standard of performance for community agents.
5. The new HIS/MIS person should revise the supervision instruments (field
workers or community agents and supervisors of field agents) so that they
assess performance, not outcomes (e.g., quality of growth monitoring rather
than the number of children weighed).
6. Field agents should share completed supervision forms with health agents, and
systematically discuss results of supervision with the MOH supervisor.
7. Trainers should invite the health agents to participate in teambuilding
activities with CAs as part of the training provided by the project.
8. Field agents should use the current supervision instrument (parts I and II) to
collect data only.
9. MCHI should assess the quality of community agent supervision by health
agents and develop and implement a strategy for improving the quality of this
supervision. The involvement of project staff in CA supervision should
MATERNAL AND CHILD HEALTH INITIATIVE (MCHI) MIDTERM EVALUATION
10
gradually decrease over the life of the project and should be shifted entirely to
health agents.
10. The HIS/MIS person should reduce the frequency of data collection and
supervision visits (of community agents) to about once every two months or
once a quarter.
11. Senior project staff should reduce field agents’ involvement in activities that
take them away from their districts so that field agents are able to schedule
and routinely conduct several support visits a month per CA to help improve
their performance.
12. The MCHI supervisor and assistant should establish a regular schedule for
supervising field agents (for example, once every two months).
13. The project coordinator should require senior technical staff members to
develop their own calendar of activities and report on these regularly.
11
III. QUALITY AT THE COMMUNITY LEVEL
A. INFORMATION, EDUCATION AND COMMUNICATION (IEC) MESSAGES AND MEANS OF
COMMUNICATING
The project has defined 21 key messages, which are divided into the following
categories: breastfeeding, varied diet, hygiene, malaria, CDD, growth monitoring and
vaccinations. (The key messages are presented in annex F.) While the content of the
messages corresponds to 12 of the 16 behaviors considered essential to reducing infant
and child morbidity and mortality, 1
 there are no messages that promote the safe
motherhood/family planning behaviors being used to measure project progress (prenatal
consultations and contraception use).
In addition to missing some messages, the messages themselves are not well formulated
and need to be reworded. More specifically,
ß key messages should incite action—a few of the messages only provide
information,
ß the wording “ought to” is condescending—an imperative statement is more
effective,
ß the target audience of the message needs to be made clear in each message
(i.e., Mothers! Only give your baby breast milk until he’s 6 months old to
avoid getting diarrhea),
ß the diarrhea message about ORS is incorrect and needs to be modified, and
ß the wording of messages needs to be specific. For example, the word
“sufficient” in the varied diet message should be qualified, as should the
message regarding feeding during and after diarrhea.
The project has included several messages about hygiene. While popular among project
staff, community agents and beneficiaries, these messages are not related to the project’s
CDD objective (proper case management of diarrhea) and they have not proven to be
particularly effective in preventing diarrhea within the context of a child survival project
(with the exception of hand washing). In fact, an overemphasis of these messages has
overshadowed some of the other messages, which have a better track record in preventing
diarrhea (i.e., vaccinations and exclusive breastfeeding).
 
1
Emphasis Behaviors in Maternal and Child Health, Technical Report, BASICS, 1997.
MATERNAL AND CHILD HEALTH INITIATIVE (MCHI) MIDTERM EVALUATION
12
The community agent is the key communicator of the project’s health and nutrition
messages, which are communicated to target audiences at three different opportunities:
during monthly growth monitoring, group health education sessions, and home visits.
Prior to weighing babies once a month, most CAs will select a theme and present this to
the assembled women. Counseling while the baby is being weighed seems to be limited
to mothers of malnourished children who are advised regarding proper feeding practices
and/or referred to the health center for follow up. Once or twice a month (on average),
the community agent will assemble women on a non-growth monitoring day to hear
another message. In addition, from time to time, a community agent will visit a mother at
her home and deliver a message on an individual basis. Discussions with project staff
revealed that key messages are not targeted to any particular subgroup of mothers, but
rather are delivered generally to the entire community of mothers with the assumption
that at some point in time, this message has been, is, or will be relevant to the mother.
This approach is not the most effective. Studies have shown that mothers are most
receptive to messages when they (or their child) actually have the problem being
discussed or need the particular bit of information.
The project has provided each community agent with training and some visual aids to
help communicate the key messages. From a review of the training curriculum, the
interpersonal communication component appears to have been rather shallow. However,
since the evaluation team observed no IEC sessions, definitive conclusions could not be
drawn regarding the community agents’ IEC skills. CAs have some visual aids but some
messages (i.e., malaria prevention) lack an accompanying visual aid. A few of the images
in the flip chart used by the CAs seem to be inappropriate and not to have been pre-tested
(i.e., a picture of a purple baby).
A very positive activity of the project is the feedback session that the community agent
holds every trimester with the communities he/she serves. During this presentation to the
district leaders and community members, the CA reports on the activities he/she has
carried out during the past quarter. The CA also reports on the number of cases referred,
the number of children weighed, and the number malnourished. This activity reinforces
the fact that the CA is not only accountable to the project, but more importantly, he/she is
accountable to the community in which he/she works. The practice of providing
feedback is very important and will pave the way for the formation of district
development committees, whose task it will be to support the CA.
When the project initiated the Hearth model to rehabilitate malnourished babies, it
created two other mechanisms for influencing child feeding practices: the maman
lumiere, or the mother of light, and modeled behavior for appropriate feeding. The
maman lumiere is a model mother because, in the absence of extraordinary means, she is
able to maintain her baby in good health. This woman is selected by the project following
a home visit that includes a questionnaire to determine positive feeding and health
practices, a 24–hour diet recall, and observation.
The maman lumiere serves as a practical model for participants in Hearth activities. She
participates in a 4–day training session to learn the key messages of the project and how
III. QUALITY AT THE COMMUNITY LEVEL
13
to communicate these to other mothers. When mothers come to the Hearth training each
morning for 12 days, the maman lumiere, along with the CA and project staff,
communicate the key messages to the Hearth participants. A study of Africare’s
implementation of the Hearth model suggests that the maman lumiere often becomes a
resource mother in her community who reinforces the key messages (particularly the ones
on hygiene and feeding) even after the Hearth training is finished. Further study of this
unintended effect would be useful.
Thus far, it appears that the most effective means of changing mothers’ behaviors has
been through the Hearth activities. Not only do the participating mothers hear the key
messages repeatedly and from various sources during a significantly long period of time
(12 consecutive days), but they practice many of the messages as well—food hygiene,
hand washing, varied diet, portion size, persistence in feeding, breastfeeding, etc. The
practices are reinforced by community leaders, husbands, health agents, and everyone
associated with the project, and are rewarded (and therefore reinforced) in most cases by
visible positive changes in the child’s behavior. Even before weight gain is assessed, the
majority of participants in the Hearth training report that their once lethargic baby
became lively and happy as a result of the feeding.
B. PROJECT ASSESSMENT OF UNDERSTANDING OF MESSAGES AND USE OF INFORMATION
The project does not systematically assess understanding of key messages or levels of
knowledge and practices. The closest the project comes to following up in this regard are
periodic visits to Hearth participants’ homes to see if the mothers are continuing to follow
the feeding practices promoted during the Hearth training. However, these efforts pertain
to a very small percentage of the target population, are not systematic, and do not
produce data that are used to make future decisions. The project collects data on the
number of ORS packets sold by the community agent, but thus far, these data have not
been used to track changes in diarrheal disease case management. Health centers collect
data on the number of prenatal consultations provided and children vaccinated, and
project staff participate in semiannual monitoring activities during which these data are
compared to the previous reporting period. The project does not take particular note of
this information, however, in part because the MOH uses a reporting formula (effective
coverage, adequate coverage) that does not meet the needs of the project.
The project may be less inclined to track knowledge because at the time of the continuing
application (July 1998), all but one of the knowledge indicators were changed to practice
indicators (see annex D). Changes in knowledge levels are important indicators (and
usually precede changes in practice), especially when related to practices that are
particularly difficult to affect, such as infant feeding. The project should consider
reinserting the knowledge indicators for which they have gathered baseline data.
The practice that the project does track systematically is growth monitoring. Each
month, the field agents check the number of children under age 3 that were weighed, the
number malnourished, and to what degree. These results do not correspond to the
project’s child nutrition indicator, however, because the indicator relates to chronic
malnutrition (stunting), which is measured by height for age, while the project uses
MATERNAL AND CHILD HEALTH INITIATIVE (MCHI) MIDTERM EVALUATION
14
weight for age, which measures acute malnutrition. In addition, the way the census was
taken (registering women/children who came to a central registration spot) does not allow
the project to know with certainty the percentage of the population’s children under age
3 who are registered and being weighed and therefore, the percentage that is
malnourished.
C. ASSESSMENT OF UNDERSTANDING OF MESSAGES AMONG TARGET AUDIENCE
The evaluation team interviewed a total of 68 mothers of children less than 2 years of
age. Among other things, the team sought to determine the extent to which mothers
understood the primary messages of the project (see annex F). As table 2 shows, the vast
majority of mothers demonstrated an understanding of the breastfeeding messages. The
weakest point in the varied diet section concerns the number of meals a baby requires.
Three quarters of the mothers could name two ways to prevent diarrhea and at least one
appropriate diarrhea case management technique. Half of the mothers interviewed knew
what causes malaria and could cite one way to avoid getting the disease (compared with
only 37 percent among health workers). The message about seeking help for a child with
a fever was familiar to the majority of mothers. Mothers’ knowledge regarding the
vaccination schedules for pregnant women are particularly weak.
These results reflect the fact that the project has focused much of its attention thus far on
nutrition, and that the nutrition messages have been reinforced by the Hearth training.
The CAs received training in nutrition in October 1998, a year before the evaluation, and
training in malaria in July 1999, only three months prior to the evaluation. With time,
mothers are likely to absorb the other messages with equal efficiency.
Table 2: Knowledge among Mothers Living in the Project Area
(n = 68)
Component/Question Correct Responses
Breastfeeding
1. What should a mother first give to her newborn after his birth? 58 (85%)
2. Do you know about colostrum? (yes) 64 (94%)
3. Why is it important? 56 (83%)
Varied Diet
4. When should a mother start to feed her child other foods in addition to
breast milk?
50 (73%)
5. As of 6 months of age, what should a baby eat? 58 (85%)
6. As of 6 months of age, how many meals does a baby need to have each
day?
41 (61%)
Diarrhea
III. QUALITY AT THE COMMUNITY LEVEL
15
7. What should a mother do to avoid getting diarrhea? 51 (75%)
8. What should you do for a child with diarrhea? 50 (73%)
Malaria
9. What causes malaria? 35 (51%)
10. How can you protect yourself against malaria? 36 (52%)
11. What should you do if your child gets a fever? 52 (77%
Vaccinations
12. Why should you vaccinate your child? 67 (98%)
13. At what age should a child be completely vaccinated? 35 (51%)
14. How many times does a pregnant women need to be vaccinated? 26 (39%)
D. CONCLUSIONS AND RECOMMENDATIONS
Conclusions
1. The project has promoted the sense of ownership by institutionalizing
feedback sessions to the community. This activity has also set the stage for
the establishment of community development committees.
2. The content of the key messages corresponds to the key behaviors considered
essential to reducing infant and child morbidity and mortality.
3. The list of key messages is incomplete. Messages regarding the need for
prenatal consultations and contraceptives are missing.
4. The Hearth model is probably the project’s most effective behavior change
strategy because it includes most, if not all, of the elements that most
effectively promote behavior change.
5. The non-targeting of IEC messages has compromised the effectiveness of the
IEC strategy.
6. The project’s current means of influencing mothers’ behaviors are quite
limited (CAs communicating messages, providing products and Hearth
activities), and, on its own, may not result in significant changes in behavior.
7. Some maman lumieres have become positive change agents in their
communities who also reinforce the key messages of the project.
8. The project does not systematically assess mothers’ knowledge levels or track
other intermediary indicators related to practices (sales of ORS).
9. The project uses its growth monitoring activities, primarily to identify
malnourished children for inclusion in Hearth activities. It is not being used
to its fullest potential, such as targeting health education messages.
Recommendations
MATERNAL AND CHILD HEALTH INITIATIVE (MCHI) MIDTERM EVALUATION
16
1. Develop key messages that specifically promote prenatal consultations and the
use of contraceptives.
2. Review the list of key messages and reword these to address the specific
issues identified previously. Identify the primary target audience for each
message and use the messages to communicate the ideas.
3. Help CAs target their IEC efforts by establishing general criteria for group
education sessions and home visits. Focus less on hygiene and more on case
management and other means of preventing diarrhea (i.e., exclusive
breastfeeding, measles vaccination). Use the growth monitoring activity as a
means of identifying the messages mothers need to hear.
4. When district development committees are formed, provide technical training
to them so they can reinforce the key messages of the project.
5. Conduct research on the impact of the Hearth training (both of the maman
lumiere and of the participants) on non–Hearth participants.
6. Consider developing other strategies for promoting desired behavior change.
For example, to encourage and support immediate and exclusive
breastfeeding, the project could pilot test the formation of breastfeeding
support groups, as described by Wellstart.
7. Revise the current list of indicators to include knowledge indicators for which
there are baseline data.
8. Change the indicator related to malnutrition from chronic malnutrition to
acute malnutrition (or simply malnutrition).
9. As part of a comprehensive IEC strategy, identify ways to provide positive
reinforcement to mothers/communities that adopt desired behaviors or
practices, for example, a certain percentage of children under 3 years with
normal weight for the quarter or a certain percentage of new mothers who
exclusively breastfeed their infants.
III. QUALITY AT THE COMMUNITY LEVEL
17
18
IV. QUALITY OF HEALTH WORKER AND FACILITY
SERVICES
A. FACILITY, HEALTH WORKER (MOH) AND COMMUNITY AGENT KNOWLEDGE,
SKILLS AND PRACTICES ASSESSMENT
The project trains and supports two types of health workers: the community agent, a
community volunteer, who provides some basic preventive services and health education;
and, the health agent (also referred to as a health worker), an MOH employee based in a
health center or health post, who provides a variety of health care services.
To improve access and quality of service delivery, the project trains both health agents
and community agents in the four technical areas of the project. The cascade approach is
used, whereby field agents and MOH health workers are initially trained. Following their
training, the community agents are trained. Unfortunately, the ministry’s health workers,
once trained, do not help train the community agents. Rather, the project’s field agents
train them, with MOH personnel being involved only sporadically and for certain parts of
a course. Apparently, the health workers are so overworked that they do not have time to
participate in the CA training.
The project has designed and conducted three courses for MOH agents and six courses
for community agents, as shown in table 8 in chapter V. Pre- and posttests are
systematically administered and serve to assess the participants’ levels of knowledge
following the training event. In all cases, the posttest scores were higher than pretest
scores. To assess the trainees’ retained knowledge in the subjects in which training was
received, the evaluation team administered its own questionnaire, the results of which are
shown in tables 3 and 4.
Table 3 indicates that many of the health agents did not retain the information provided
during the training. Out of 15 questions, only 7 were answered correctly by more than
half of the health agents. This poor showing probably reflects the lack of reinforcement
(or use) of the information following the training, rather than on the quality of the
training, since posttest scores were reasonably high. Furthermore, while project field
workers continue to reinforce the lessons of the training among the community agents,
this is not done (nor is it an appropriate role for field agents) among the health workers.
Table 3: MOH Health Agents’ Knowledge Levels
Component/Question Number of Correct
Responses
IV. QUALITY OF HEALTH WORKER AND FACILITY SERVICES
19
Component/Question Number of Correct
Responses
Nutrition (n = 6)
1. What is the advantage of vitamin A? 4
2. What advice would you give to a pregnant woman about feeding her
newborn?
6
3. What actions should a mother take to assure the health of her baby? 4
4. Why should a baby begin to eat at age 6 months? 3
Diarrhea (n = 6)
1. What are the signs of (moderate) dehydration in a child? 2
2. How do you treat a child with moderate dehydration? 0
3. What advice should a community worker give to a mother about taking care
of a child with diarrhea?
3
Malaria (n = 8)
1. What are the signs of serious malaria? 2
2. What is the treatment for serious malaria? 8
3. What can you do to prevent getting malaria? 3
4. Why is it particularly serious when a pregnant woman gets malaria? 6
Reproductive Health/Family Planning (n = 4)
1. What are the signs of a sexually transmitted disease? 2
2. What advice should you give to a patient you think has HIV/AIDS? 0
3. What advice would you give a woman if she forgot to take her pill the night
before?
4
4. Having stopped Depo-Provera, how long afterward does fertility return? 3
Table 4: Community Agents’ Knowledge Levels
(n=16)
Component/Question Number of Correct
Responses
Nutrition
1. Why do you weigh babies? 15
2. How can you distinguish between a well nourished and a malnourished child? 16
3. What is the importance of colostrum for a baby? 15
4. At what age should a baby receive foods in addition to breast milk? 15
5. What steps should be followed to ensure proper feeding of a child? 13
Diarrhea
1. What measures can be taken to avoid getting diarrhea? 9
2. What should a mother do to care for a child with diarrhea? 10
Malaria
1. What are the signs of malaria that require an urgent referral? 10
2. What should a CA do for a child with malaria? 15
3. Malaria is more dangerous among which groups? 13
4. What measures can you take to protect yourself against malaria? 13
Interpersonal Communication
1. What are the qualities of a good message? 11
2. What are the qualities of a good communicator? 12
3. What are some obstacles to good communication? 5
The community agents revealed higher levels of retained understanding of the project
messages (content of the training) than did the health agents, presumably because they
use the information more often and are supported more regularly. Their understanding of
MATERNAL AND CHILD HEALTH INITIATIVE (MCHI) MIDTERM EVALUATION
20
the key nutrition messages is greater than the other two technical components and there is
particular need to reinforce the diarrheal disease messages.
During each training course, information about interpersonal communication is reviewed.
Knowledge about interpersonal communication and the ability to communicate
effectively are two very different things, however; when it comes to behavior change
communication, the trainers would do well to focus more on performance than on
knowledge and to devise ways to assess CAs’ abilities to organize and execute group
health education sessions as well as one-on-one events.
B. QUALITY OF SERVICE TOOLS USED BY THE PROJECT
As table 5 shows, the project has developed a vast array of instruments and tools to
monitor project inputs and outcomes and to assess quality of service. This attention to
tracking mechanisms may be a result of the project being considered performance-based
by USAID/Guinea. This means that each year’s funding is based on the performance of
the project, which is different from other funding mechanisms. According to the
USAID/Guinea project officer, MCHI’s performance each year is determined by the
extent to which the project’s schedule of activities has been implemented and certain
process indicators achieved for the year.
A review of the instruments cited below revealed the following:
ß In a few instances, data (for example, numbers of malnourished children) are
being gathered by several different sources/instruments;
ß The tool used to supervise community agents focuses more on outcomes
(numbers of IEC sessions, number of children weighed) than on performance
(quality of IEC sessions, quality of growth monitoring and counseling);
ß The original tool used to supervise field agents (which is being revised) is too
open ended;
ß There appears to be no standard protocol for classifying or using the referral
forms once they reach the health center;
ß Some community agents are not recording deaths or referrals in their registers;
ß Field agents’ advice to community agents about how to set up and complete
the register differs resulting in variances in data collection instruments;
ß Health agents are not recording vaccinations on the green SIAC Road-to￾Health cards; and,
ß None of the tools/instruments relate to the supervision of technical (senior
staff).
Table 5: Quality Assurance Instruments Used by MCHI
IV. QUALITY OF HEALTH WORKER AND FACILITY SERVICES
21
Name of Instrument Used by Purpose
Growth Monitoring Register Community Agents A register of names of children under 3
years of age; record of family information
and monthly weight; also contains
information about Hearth participants and
cases referred to the health center
Monthly Report Form Community Agents Completed by CA and used by field
agents and MOH health agents to monitor
the work of CAs
24–hour Recall Form Field Agents Collect information regarding child
feeding (and other information) habits
among positive deviant mothers in
preparation for the Hearth training
Hearth Guide Field Agents and
Community Agents
Describes the steps necessary to carry out
the Africare/Guinea Hearth strategy
Growth Monitoring Census Community Agents Form used to register children under 3
years of age who will participate in
growth monitoring activities
Schedule of Activities for the Health
Center
Community Agents
and Health Agents
Completed by the CA, used to help MOH
health agents know and follow what
activities the CAs are carrying out each
week so the health center can coordinate
its activities with those of the CA
Evaluation Form—Nutrition Trainees Used to evaluated a training event
Referral Register Community Agent Forms completed by the CAs and given to
children who need to receive medical
attention at the health center; forms kept
by health center staff
Community Chart (tableau
communautaire)
Community Agent Large Road-to-Health chart that is used
by CA to summarize the monthly
weighing so that mothers and other
community members can see the
nutritional status of the children weighed
that day
Road-to-Health Form Community Agents Used to track weight gain of children;
also serves as the vaccination card
Organizational Chart of the Project All Staff Used to indicate the hierarchy among
project staff and who supervises whom
Community Agent Supervision
Form
Field Agents Used to supervise CAs each month
Supervision Schedule Supervisor and
Assistant Supervisor
In the process of being revised; used to
guide and track supervision of field agents
Motorcycle Use Form Field Agents Used to track use of motorcycles
Job Descriptions All Staff Written by each staff member to guide
them in their work; determine position in
hierarchy and understand supervision
responsibilities
Activity Planning Chart Field Agents Planning form used by supervisors to
monitor the monthly activities of field
agents; posted in the health centers so
health workers can know when certain
activities are planned
MATERNAL AND CHILD HEALTH INITIATIVE (MCHI) MIDTERM EVALUATION
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Name of Instrument Used by Purpose
Market Survey Field Agents and
Technical Staff
Inventory of what is available in the
market and the prices; used to develop
recipes for the Hearth training
Hearth Activity Form Field Agents Used to track the daily activities of the
Hearth model (presence of children,
weight, etc.)
Pre- and Posttests Trainers Used to assess levels of knowledge
achieved by trainees following a training
event
ORS Space Assessment Field Agents One-time tool, used to assess the space
put aside to treat dehydrated kids
C. MATERIALS /SUPPLIES FOR EACH TYPE OF HEALTH WORKER/FACILITY
Tables 6 and 7 list the supplies, materials and equipment provided to the community
agents and health centers.
Table 6: Supplies, Materials and Equipment Provided to Community Agents
Communities/Community Agents
Bicycle
Boots
Raincoat
Backpack
Community register (large ledger)
Several notebooks and ruler, pens, pencils, etc.
Monthly report forms
Referral forms (with copies)
Scale with halter
Supply of Road-to-Health forms
Community growth board
Posters on vitamin A, breastfeeding, and ORS
Brochures on CDD
ORS packets (150–250 packets)
UNICEF–produced flip chart (boite à image), visual aids on
diarrhea prevention and case management
Community agents provided the items listed above to communities for use. Bicycles are
required for getting around to each of the communities covered by the CA because, in
Guinea, populations are not grouped in villages as much as they are dispersed over a
sometimes large geographic area. That is also why a backpack, raincoat and boots were
considered essential. Each month the field agents take stock of the equipment, supplies
and materials as part of the supervisory visit and replenish supplies as necessary.
The CA has all of the reporting forms and instruments he/she needs but lacks some visual
aids. Given the need to cover several communities and not working from a central point,
posters are not the most effective visual aid. Rather, community agents need more
portable aids, such as the boite à image. Similarly, the community growth board is not
easily portable. As mentioned previously, some key messages are not accompanied by
visual aids.
IV. QUALITY OF HEALTH WORKER AND FACILITY SERVICES
23
Table 7: Supplies, Materials and Equipment
Provided to Health Centers, Health Posts and Health Workers
Health Facilities/Health Agents
Six Motorcycles
Four Two-way Radios
Posters:
ß Breastfeeding
ß Vitamin A
ß Conceptual Framework of Malnutrition
ß CDD Case Management
Documents:
ß Hearth Model
ß Steps in the Hearth Model
ß Training Module on Feeding and Nutrition (Food
and Agriculture Organization [FAO], UNICEF)
ß CDD Training Module
ß Malaria Control Training Module
ß Contraceptive Technology (AGBEF)
ß Management and Quality of Services (AGBEF)
ß IEC Training Module
ß CA Service Delivery Training Guide (AGBEF)
ß Designing by Dialogue (USAID, SARA)
The motorcycles were provided to those health centers where transportation was a serious
constraint. They enable the expanded program on immunization (EPI) health agent to
conduct regular vaccination campaigns in the communities and to supervise community
agents more regularly. The posters were provided to health centers and were visible
during the evaluation site visits. The health workers who participated in the training
events organized by the project received the documents noted above. The provision of
the training modules is noteworthy in that the health agents would then be able
(presumably) to provide the same training to other health agents, thereby increasing the
number of trained MOH personnel.
According to the project proposal, the DPS was expected to receive mopeds (mobylettes)
as well. Since their transportation needs had already been met, the project provided a
photocopier, a much needed and appreciated piece of equipment.
D. THE HEALTH INFORMATION SYSTEM
The project does not use the MOH health information system, in part because it does not
analyze information in a way that would be useful to the project. Furthermore, since the
MOH does not have nutrition or community activity indicators, it does not collect this
information. This is a major constraint to the project, as the MOH’s information system
does not provide an incentive to health agents to support nutrition or community
activities. Given the performance-based nature of the project, MCHI regularly collects
information regarding outcomes and activity completion and this is reported to
USAID/Guinea each year in its annual report. As mentioned above, the only impact
MATERNAL AND CHILD HEALTH INITIATIVE (MCHI) MIDTERM EVALUATION
24
indicator that the project reports on consistently is malnutrition; the rest will be assessed
during the final knowledge, practice and coverage (KPC) survey.
E. CONCLUSIONS REGARDING EFFECTIVENESS OF TRAINING, SUPPORT, MONITORING,
AND SUPERVISION OF SERVICE DELIVERY
Conclusions
1. The project has developed a very comprehensive management and health
information system. Instruments for the most part are simple and easy to use.
2. The project’s information system has helped bridge the gap between health
center staff and community agents. Most health agents coordinate their
activities with those of the CAs by making use of the monthly work plan.
3. There is some duplicative collection of information.
4. The supervision tools (CA and field workers) are more effective in collecting
outcomes than in assessing or promoting improved quality of performance.
5. Referral forms are not classified or used in a standard fashion.
6. The MOH provides little incentive to support nutrition or community-level
activities.
7. The project will have a difficult time assessing vaccination coverage because
the health agents are not recording vaccinations on the Road-to-Health card.
8. The project’s provision of equipment and supplies to community agents has
been appropriate, with the exception of the quantity and type of visual aids.
9. The project’s tracking of outcomes is appropriate for its performance-based
funding mechanism.
Recommendations
1. When the new information systems position is filled, senior staff should take
the opportunity to thoroughly review the MIS/HIS, putting particular
emphasis on value and use of information gathered, and scale back data
gathering, wherever possible.
2. The new HIS person should revise the CA supervision form to focus more
attention on quality of service delivery. This might require the development of
separate instruments (such as checklists) to periodically assess implementation
of specific activities (growth monitoring, IEC sessions, home visits, etc.).
IV. QUALITY OF HEALTH WORKER AND FACILITY SERVICES
25
3. The new HIS person should revise field agents’ monthly reports to focus on
CAs’ performance rather than on growth monitoring statistics.
4. Provide crayons to CAs so they can color the Road-to-Health charts, which
will make it easier for mothers to understand the card.
5. The project should not create more visual aids, but rather it should research
(through the Africare network in West Africa, for example) for which health
messages visual aids have already been developed and either adopt or adapt
these to the Guinean culture.
6. In consultation with the head of the health center, develop a protocol for filing
and use of the reference forms.
7. The project should request the DPS to require heads of subprefecture health
centers working in the project area to report on community activities, either in
a separate report (for which the project could help develop a format) and/or
orally at semiannual CTPS meetings.
8. Request the DPS to require health agents to record vaccinations on the Road￾to-Health card. Explain to health agents why this is important and support
compliance during community-level vaccination campaigns.
9. Senior staff members should prepare and submit to the coordinator brief
reports of their work (how they spent their time) every two months. These
should focus on their individual tasks, such as the number of field workers
supervised.
10. All staff, including senior staff, should prepare monthly work plans that
identify such things as field trips and their purpose and CA contacts and the
content.
MATERNAL AND CHILD HEALTH INITIATIVE (MCHI) MIDTERM EVALUATION
26
27
V. CAPACITY BUILDING AND SUSTAINABILITY
A. PROJECT PLANS AND PROGRESS TOWARD INCREASING PARTNER CAPACITY
The project did not begin with a detailed capacity building strategy that identified desired
performance or training needs. Rather, building on the projects that had preceded it
(UNICEF’s Integrated Project and Family Planning Options Project [FAMPOP]); MCHI
set out to train community agents in each of the four technical areas of the project, as well
as growth monitoring. Following the cascade approach to training, the health agents and
field workers were trained first and then the community agents were trained. None of the
agents’ training needs were assessed in advance, however, or based on an analysis of
desired performance. The project planned to conduct a training needs assessment of the
health agents, but was discouraged from doing so by USAID, as another USAID grantee,
PRISM (with Population Council), was due to conduct a nationwide assessment, which
was thought to produce results useful to the project. As a result, the health agent training
was based more on the project’s needs than on the health agents’ particular needs.
During the first half of the project, Africare focused primarily on developing capacity at
the community level, more specifically on the community agent. While MCHI provided
training to both health agents and community agents, as shown in table 8, the field agents
were able to follow up on the training with regular field visits which helped the CAs put
into practice what they had learned. The absence of this follow-up support for health
agents resulted in many of them forgetting what they had learned, as shown in table 3. In
fairness to the project, however, the most appropriate means of following up on the
training is not particularly evident. The field agents, most of whom are not official health
care providers, are not suited for this task. The MCHI doctors on staff, while capable, do
not have the time or authority necessary to provide this kind of support to health agents.
MOH capacity building was one of the original objectives of the project. The project
proposal included as one of its objectives, “to strengthen and expand existing government
health services,” and proposed to measure this by the following indicators:
ß 90 percent of health personnel will have participated in MCHI–sponsored
training courses,
ß 80 percent of health personnel will appropriately treat and/or refer childhood
illnesses (diarrhea, malaria, and malnutrition),
ß Six new health posts will be constructed,
ß 80 percent of health facilities will have functioning cost recovery systems, and
ß 90 percent of health facilities will be submitting accurate monthly reports on
time.
MATERNAL AND CHILD HEALTH INITIATIVE (MCHI) MIDTERM EVALUATION
28
Table 8: Training
TOPIC DATE
LENGTH
(in days) TRAINEES No.
Training of Trainers 7/20–24/98 5 Africare Staff: MCHI, DFSI 9*
Nutrition 7/28-1/98 5 Field Agents 9
Assistant Supervisor 1
MOH Agents 6
Community Agents:
Dabola: 1st group CA 16
Malaria/Nutrition Retraining 7/27-30/99 4
Dinguiraye 1
Nutrition/Communication 6/7-12/99 6 Community Agents:
Dabola: 2nd group 35
Diarrheal Disease Case
Management
6/14-16/99 3 Community Agents:
Dabola: 2nd group 35
Malaria Control and CA: Dabola 35
Nutrition Retraining
10/4-7/99 4
CA: Dinguiraye 10
Field Agents 9
Assistant Supervisor 1
MOH Agents: Dabola 9
Diarrheal Disease Control 1/12-16/99 5
MOH Agents: Dinguiraye 2
MOH Agents 9
Field Agents: Dabola 9
Field Agents: Dinguiraye 8
Malaria Control 7/5-9/99 5
Assistant Supervisor 1
Reproductive Health Field Agents: Dabola 9
Field Agents: Dinguiraye 8
9/13-16/99 4
Assistant Supervisors 2
Reproductive Health 9/13-22/99 8** MOH Agents 4
11 Courses 55
* At least 9 individuals were trained.
**4 days in common with field agent reproductive health training
The continuation application makes no mention of these indicators, but cites the
following as the project’s newly adopted indicators for MOH strengthening and
expanding:
ß number of new health posts constructed,
ß number of health posts renovated, and
ß number of health centers with adequately functioning cold chain equipment
(subsequently dropped following baseline data survey).
Since there was no written communication between USAID/Guinea and Africare about
these changes, it is not clear whether the changes were officially recognized, as they
would have been as part of a Detailed Implementation Plan under the Bureau for
Humanitarian Response/Private and Voluntary Cooperation (BHR/PVC). Discussions
with the USAID project officer seem to indicate that the continuation application and any
changes it contains becomes the base document and therefore, it appears that MCHI is
V. CAPACITY BUILDING AND SUSTAINABILITY
29
not required to use the indicators presented in the proposal to measure MOH
strengthening efforts.
Given this and the fact that the present indicators relate to expansion rather than
strengthening, the project should consider rephrasing the objective to reflect this
(eliminate the word strengthen and leave expand). However, the project is supporting
and strengthening the DPS’ capacity in other ways (strengthening the link between health
agent and community activities; increasing knowledge about malaria, CDD, nutrition,
etc.) and it may want to revise its indicators to more accurately reflect these efforts.
B. PROJECT SUSTAINABILITY¾PLANS AND PROGRESS
The project’s sustainability plan outlined in the proposal envisioned project activities and
benefits being sustained through two means: community support of community agents’
activities and MOH support of community activities. The first approach relies on the
formation, training and support of community- and district-level development committees
that will “lead the community mobilizing, organizing and coordinating development
activities,” some of which presumably would include health activities. The proposal also
suggests that at least some of these committees or the health center would find the means
and motivation to pay the community agent a small stipend. Income-generating activities
are also mentioned in the sustainability section of the proposal, but the link between these
activities and sustained primary health care (PHC) activities is not clear. And, finally, it
is assumed that the profit from the sale of certain commodities, ORS packets and
contraceptives, would “serve as a sustainable financial motivation to continuing
community agents’ efforts.”
Thus far, the project has not established any development committees. The idea was
considered but it was decided to establish the community agents and investigate the
presence of indigenous groupings before forming the committees. Although most projects
do form the committees first, MCHI seems not to have suffered from having done it the
other way. For example, despite the fact that communities do not provide direct support
to their CA, the community agents interviewed for the evaluation seemed very satisfied
with their work and well supported by the project. This leads one to speculate that
community members may be more inclined to support the CA by serving on and
supporting a community development committee, now that they have experienced the
benefits of the community agent’s work. Having completed the research, the project
plans on establishing committees during the second half of the project and has designated
two staff positions to take responsibility for this activity.
The project has taken steps to initiate income-generating activities. Rather than
implement this component themselves, however, MCHI decided to identify a local NGO
with income-generating experience and subcontract the implementation of this
component to them. To this end, a study of local NGOs was conducted recently, the
results of which are being reviewed. While this is the most intelligent way of handling
this component, the link between the main objectives of this project and this component
are vague at best. Furthermore, with the addition of the time and energy intensive Hearth
MATERNAL AND CHILD HEALTH INITIATIVE (MCHI) MIDTERM EVALUATION
30
activities and the establishment of community development committees, it is doubtful
that the project will have the time necessary to oversee the implementation of this
component. Income-generating activities require specific expertise and a significant
amount of time. It is doubtful that the project will benefit from any input into this
component, and it is possible that energy expended (even under a subcontract) may
detract from other activities that are directly related to achieving the objectives.
With regard to profits from the sale of commodities, it is too early to know how much
income this will generate. The project had just provided each CA with a supply of ORS
packets (which will be resupplied through the MOH) and the sale of contraceptives had
not yet begun. If experience from other projects holds true for MCHI, however, it is
unlikely that these sales will generate enough income to form the primary motivation of
the community agents.
The project proposal cites the MOH’s commitment to primary health care and continued
support of the community agents as positive indicators of sustainability. While this
commitment may exist in theory, it is visible to only a small degree in practice. To truly
demonstrate this commitment, the MOH will need to develop national nutrition indicators
and acknowledge the importance of community-level activities by holding health agents
accountable for these. While waiting for a national commitment, in Dabola, the DPS has
already taken steps to reinforce the staff of health centers by initiating the recruitment of
a cadre of health agents who (he says) will be responsible for community-level activities.
If the schedule holds, these agents should be in place within the next year. The
deployment of these health agents is essential to activity sustainability, since regular
supervision and support have been found to be the key to sustained quality performance.2
The placement of additional health agents in late 2000 allows the project to concentrate
on training the new agents to supervise and support the community agents during the last
year of the project.
Thus far, the project has been operating without a detailed sustainability plan. In fact, the
plan most often referred to by project staff and the DPS is the continuation of project
activities by the DPS and his staff. This notion, however, is not accompanied by specific
strategies and detailed plans. A sustainability plan needs to be developed and executed
deliberately if activities and benefits are to be continued following the project.
C. CONCLUSIONS AND RECOMMENDATIONS RELATED TO CAPACITY BUILDING AND
SUSTAINABILITY
Conclusions
1. Training has been provided based more on the objectives of the project than
on an analysis of the training needs of the community agents and health agents
relative to a universal standard of performance.
 
2
Sustaining Health Worker Performance in Burkina Faso, Technical Report, BASICS 1997, and
Sustainability of a Community-Based Mother-to-Mother Support Project in the Peri-Urban Areas of
Guatemala City, Technical Report, BASICS and La Leche League, 1997.
V. CAPACITY BUILDING AND SUSTAINABILITY
31
2. The performance assessment conducted by PRISM is only marginally useful
to the project.
3. The project staff’s (field agents and technical staff) ability to influence
changes in (MOH) health agent performance is very limited.
4. MCHI is not being held accountable by USAID for three of the original
indicators related to MOH strengthening. At present, the project has no
appropriate indicators for measuring its MOH strengthening efforts.
5. Progress toward achieving sustainability cannot be measured or assured in the
absence of a detailed sustainability plan. Although the sustainability plan
outlined in the proposal calls for the DPS to take over responsibility for the
activities initiated by the project, without an analysis of capacity-building
needs and a plan to increase capacity, there is no assurance that health workers
will have the skills and knowledge needed to take over at the project’s end.
6. Until the MOH demonstrates a commitment to nutrition and community
activities by setting measurable indicators for these and additional health
agents are recruited, hired and deployed, the ability of the MOH to become
more effectively involved in supporting community activities and eventually
assuming responsibility for these, will be seriously impaired.
7. The fourth year of the project will focus on implementing the exit strategy
(i.e., training MOH staff to support community activities).
8. Although efforts to transfer responsibility of the current activities have a good
chance of succeeding if additional health agents are deployed, the need for
additional support from Africare will still be likely to expand activities to
include maternal nutrition and additional reproductive health activities.
9. The delay in forming development committees has prevented the project thus
far from securing tangible support for community agents from the
communities.
Recommendations
1. Use the standards of performance for community agents to determine further
training needs.
2. In collaboration with the DPS, develop a detailed sustainability strategy that
includes objectives, indicators and a monitoring plan and begin to implement
it as soon as possible. As part of this plan, develop a capacity-building plan,
which can also be monitored.
MATERNAL AND CHILD HEALTH INITIATIVE (MCHI) MIDTERM EVALUATION
32
3. As part of this plan, work with the DPS to define a more substantial role for
health agents and to increase their understanding of and ability to execute the
Hearth model and quality of supervision of CAs.
4. As part of the continuation application, USAID should require a detailed
capacity-building strategy, sustainability table and a logical framework.
5. Africare should begin to develop a follow-on project proposal no later than
March 2000 for submission to BHR/PVC in December 2000.
6. Work with the DPS to add a quality of service delivery assessment to the
semiannual monitoring exercise. This could be an observation of service
delivery using the client-oriented, provider efficient services (COPE) or Basic
Support for Institutionalizing Child Survival project (BASICS) observation
instruments (or the ones used by the Population Council).
7. Review and revise project objectives and indicators related to MOH
strengthening efforts to better reflect the project’s efforts and capabilities.
8. When work with the development committees begins, community support of
the CA should be one of the first subjects of discussion.
33
VI. TECHNICAL AND ADMINISTRATIVE SUPPORT
A. TYPES AND SOURCES OF EXTERNAL TECHNICAL ASSISTANCE
Table 9 shows the types of technical assistance that the MCHI has received, including the
provider, technical area of assistance, and dates and benefits of assistance.
Table 9: Technical Assistance Received by MCHI
Person or Institution
Technical Area of
Assistance Dates Benefits
Ms. Waverly Rennie ß Facilitated
training of trainers
ß Facilitated
training in
nutrition/commun
ication
July 1998
July 1998
ß Teambuilding between MCHI and
DFSI staff
ß Staff learned about appropriate and
effective training facilitation and
communication techniques
ß Improved knowledge of health
facility staff in nutrition
Dr. Hassane Fadiga
(DPS)
Dr. Djenabou Barry
(DPS)
Assisted with training
of field agents and
MOH staff in CDD
January 1999 ß Improved skills of MOH staff
related to CDD
ß Trained MCHI field agents in CDD
Dr. Fode Konate
(MOH Institute of
Nutrition)
Provided technical
advice regarding the
Hearth model
March 1999 ß Helped the project identify simpler
and less expensive recipes,
promoted Hearth approach among
MOH officials
Dr. Boubacar Diallo
(MOH/NMCP)
Dr. Louis Destephen
(Donka Hospital)
Assisted with training
of MOH/HC staff and
project field agents in
malaria control
July 1999 ß Improved skills of MOH and
project staff related to malaria
Mr. Jean Gozaka
Kourouma and
Ms.Hadja Binta Barry
(AGBEF)
Assisted with training
of MOH and MCHI
project staff
September
1999
ß Improved skills of MOH and project
staff related to reproductive health,
particularly family planning
Dr. Grethchen
Berggren
Ms. Waverly Rennie
Helped facilitate
national workshop and
provided technical
assistance on the
MCHI Hearth
approach
October 1999 · Strong advocacy at national,
regional and prefectoral levels for
MCHI Hearth approach
· Documented feeding behavioral
changes among Hearth participants
and impressions of husbands
· Provided suggestions on improving
the approach
· Pretested the video on MCHI
Hearth approach
B. TECHNICAL AND ADMINISTRATIVE SUPPORT RECEIVED FROM HEADQUARTERS
MATERNAL AND CHILD HEALTH INITIATIVE (MCHI) MIDTERM EVALUATION
34
Technical and administrative support from Africare/Headquarters has been adequate, and
the project appears not to have faced any constraints in receiving technical assistance in a
timely manner. Technical support has been provided by Africare’s health program
manager through three visits to the project since its inception. The most recent visit was
to attend the national workshop on the Hearth model in October 1999. Africare’s West
Africa regional director also visited the project in July 1999. He is planning another visit
shortly to help orient the new MCHI project coordinator. In addition to visits from the
headquarters’ staff, the project is guided by the country director and the administrator
who see project staff either in Dabola or in Conakry at least once a month.
In hindsight, it may have benefited the project to receive technical assistance to help
develop an IEC strategy and an HIS/MIS system. These are two very specialized areas
with which NGO project staff often need assistance. At this point in time, however, it is
not clear who should have identified this need or if it appeared as a need at the time at all.
The project could use technical assistance to develop its sustainability plan and may need
assistance if it proceeds with the income-generation component. An outside consultant
will be engaged to lead the final evaluation but will probably be hired by USAID directly.
C. CONCLUSIONS AND RECOMMENDATIONS
Conclusions
1. Technical assistance was provided in a timely manner and was considered
beneficial.
2. The project would have benefited from technical assistance in the
development of an IEC strategy and a health information system.
Recommendation
Technical assistance should be procured to help project staff and DPS develop a
comprehensive sustainability plan.
35
VII. FINANCIAL EXPENDITURES
Table 10 outlines the project’s budgetary situation at the time of the midterm evaluation.
Table 10: MCHI Budgetary Summary
Item
Amount in
Dollars
Approved Project Budget 2,358,370
Expenditures through July 1999 942,035
Estimated Expenditures, August-Sept. 1999 108,179
Balance as of October 1, 1999 1,308,156
Proposed Expenditures Fiscal Year (FY) 2000-01 1,308,156
Anticipated Balance 0
Africare/Guinea maintains very comprehensive and understandable budget summaries
and analyses, which are accompanied by a detailed budget narrative. Budget adjustments
are signaled to USAID/Guinea each year in the annual report. At a monthly average
expenditure rate of between $45,000-$65, 000, the project is expected to spend the
remaining $1.3 million of its budget.
MATERNAL AND CHILD HEALTH INITIATIVE (MCHI) MIDTERM EVALUATION
36
37
VIII. ACCOMPLISHMENTS AND CONSTRAINTS
A. CONSISTENCY OF PROJECT IMPLEMENTATION WITH THE CONTINUATION APPLICATION
It is assumed that the continuation application is similar to a Detailed Implementation
Plan and similar to those prepared by BHR/PVC-funded child survival grantees. The
continuation application, however, is not similar to the Detailed Implementation Plan. It
is more similar to an annual report and does not set forth a narrative plan for project
implementation. Therefore, it is not possible to assess the extent to which the project is
consistent with the continuation application except perhaps to compare the work plan for
the second year with what actually took place. This was provided in MCHI’s annual
report to USAID and appears here in annex G.
Neither the proposal nor the continuation application mentions the nutritional Hearth as a
strategy to address malnutrition. This activity was added at the end of FY 1997, and the
first Hearth activity was conducted in the first quarter of FY 1998 (December 1998).
Because the project did not have a malnutrition indicator, it did not identify a specific
strategy for addressing malnutrition. The project coordinator introduced this approach
with assistance from a technical assistant who had prior experience with the Hearth
model. Interestingly enough, this strategy may prove to be the most important
contribution to improving health among Guinean children.
Project staff did not expect to become involved with mosquito-net impregnation and
distribution. However, when the project coordinator approached the National Malaria
Control Program (PLNP) team regarding training, Africare was identified as a welcome
collaborator, and the PLNP decided to train a mosquito-net impregnation and distribution
unit in Dabola with assistance from the project. Through its involvement, the project may
help the development community answer some questions regarding the implementation
of impregnated bed nets as a strategy to control malaria. In the area of malaria case
management, the project’s current intervention is limited to referral, because, unlike its
neighbors, Guinea’s MOH has not yet approved the treatment of malaria by community
health workers. Given Africare’s comparative advantage as an innovator, the prevalence
of malaria and the difficulties associated with referrals, the ministry might want to
consider piloting community-based case management of malaria through the MCHI.
Table 11 shows the extent of achievement of the project’s outcome indicators, the basis
upon which USAID judges performance (in addition to the work plan). Without the
benefit of a Logical Framework, it is difficult to tell if these are the most appropriate
outcome indicators. What is certain is that the means of verification (training post-test)
of some of the indicators is not particularly valid since knowledge is expected to be high
immediately after a training event. A more meaningful indicator would be related to
practices and could be assessed by field agents during supervisory visits.
Table 11: Summary of Achievement of Project Outcome Indicators
MATERNAL AND CHILD HEALTH INITIATIVE (MCHI) MIDTERM EVALUATION
38
Component Activity
Expected
Year 2
Achievement
Actual Year 2
Achievement Comments
1. Number of Hearths
created
80 20
2. Percentage of
community health
workers who know how
to accurately weigh and
interpret the weight on
the community board
90% 81% Achievement
assessed at time of
posttest
3. Percentage of
community health
agents who understand
the principle of
frequency, adequacy,
density, and utilization
(FADU)
90% 76% Achievement
assessed at time of
posttest
Nutrition
4. Number of community
health agents trained in
nutrition
47 48 Would be more
meaningful if this
indicator related to a
particular score on a
training posttest
5. Percentage of health
center staff accurately
able to cite the
appropriate case
management for
diarrhea
70% 86% Achievement
assessed at time of
posttest
Control of
Diarrheal
Disease
6. Percentage of
community agents who
cite continued/frequent
feeding/breastfeeding as
an important message to
give to mothers whose
children have diarrhea
90% To be
determined
Component Activity
Expected
Year 2
Achievement
Actual Year 2
Achievement Comments
Malaria 7. Number of insecticide￾treated bed nets sold
To be
determined
To be
determined
VIII. ACCOMPLISHMENTS AND CONSTRAINTS
39
8. Number of women’s
groups promoting and
distributing
impregnated bed nets
3 1
9. Number of community
agents trained in
malaria control
47 48
10. Percentage of
community agents who
know the advantages
of family planning in
relation to maternal
and child health
80% To be
determined
Project is waiting for
PRISM to complete
the reproductive
health training
curriculum before
training the CAs
11. Number of new
acceptors of modern
contraception
328 To be
determined
Component has not
yet begun
12. Couple years of
protection
To be
determined
To be
determined
Contraception
distribution will
begin only after CAs
have been trained
Reproductive
Health
13. Percentage of districts
covered by community
agents trained by the
project
70% 40% Project expects
coverage of 60% of
Dabola by project’s
end.
14. Number of new health
posts constructed
1 0 Construction
underway
15. Number of health posts
renovated
1 0 Renovations
underway
MOH
Expansion
and
Strengthen￾ing
16. Percentage of health
centers with
adequately functioning
cold chain equipment
Indicator eliminated
because baseline data
indicated that cold
chain equipment had
already been
provided and was
functioning well
B. ADHERENCE TO PROJECT SCHEDULE
As the work plan displayed in annex G indicates, there are a few activities that were not
carried out when originally scheduled. These include the organization of community
development committees, construction/renovation of health posts, provision of cold chain
equipment, and implementation of income-generating activities. As mentioned
previously, the project deliberately delayed creation of village health committees until it
could better understand the extent to which other such committees already exist in the
target areas. While thought to be essential to continued support of the community agent,
the delay in creating these committees seems not to have hindered the project thus far.
The construction of health posts, which was supposed to begin in December 1998, was
delayed by about 10 months while the exact location was negotiated, community
participation generated, and the legalities of construction were met. The baseline data
MATERNAL AND CHILD HEALTH INITIATIVE (MCHI) MIDTERM EVALUATION
40
survey conducted of the health centers revealed that cold chain equipment was available
and functioning, so this activity was eliminated from the project plan. Implementation of
income-generation activities has been delayed for several reasons: project staff has been
very occupied with Hearth activities and the national workshop held in October, project
staff wanted to study potential partners and their ongoing activities before proceeding,
and additional staff was needed to handle this and the community development
committee aspects of the project (it was decided to wait until that person was hired before
proceeding further). Training events have also been rescheduled to accommodate
workloads.
The project has also been involved with activities that were not originally programmed
but which have enhanced the project and its contribution to primary health care in
Dabola. These include Hearth activities and the national Hearth workshop, field worker
assistance on national vaccination days, participation in the Regional IEC Working
Group; and participation in the semiannual MOH monitoring activities.
C. PRIMARY ACHIEVEMENTS
Addressing Malnutrition¾The Hearth Model
Innovative Work: Capitalizing on its comparative advantage as an NGO, MCHI/Africare
has undertaken innovative work with the Hearth model, an approach that addresses
malnutrition at the community level. Through this method, 84 percent of the 140 children
present at the second post-Hearth weighing had been rehabilitated and mothers had
begun to adopt feeding behaviors that should prevent malnutrition from recurring.
Advocacy: As a result of Africare’s organization of a national seminar on the Hearth
model, many other NGOs and ministries have become aware of the method and it has
quickly become a potential model approach for malnutrition recuperation among other
NGOs, such as Plan/Guinea, Adventist Development and Relief Agency International
(ADRA), and Action against Hunger.
National Application: More importantly, the Hearth model has the potential of becoming
a means for the MOH to reduce malnutrition rates nationally. In the fourth year of the
project, Africare will work with the DPS of Dabola to determine how the Hearth model
can be adapted so the DPS can implement it as part of its own community-based strategy.
Increased Access
The MCHI project has increased access to PHC services by
ß promoting collaborative efforts between community agents and MOH health
workers so that more people take part in community-level health activities
conducted by health center staff, such as vaccination days;
ß training 48 community agents in nutrition, malaria control and prevention,
diarrheal disease control, reproductive health, and IEC skills;
VIII. ACCOMPLISHMENTS AND CONSTRAINTS
41
ß implementing growth monitoring and Hearth activities to identify and
rehabilitate malnourished children;
ß constructing and renovating health posts;
ß providing motorcycles to MOH agents;
ß supporting and supervising community agents;
ß developing a referral system;
ß improving the emergency evacuation system from health posts to hospitals
through the provision of radios to health posts; and,
ß working with UNICEF to develop a community-level emergency evacuation
system.
Integration and Coordination
MCHI/Africare has developed an excellent working relationship with the DPS and other
organizations operating in the area and effectively coordinates its work with these
entities. For example, MCHI is:
ß working with the UNICEF/Maternity without Risk Project to develop an
emergency evacuation strategy to complement the project’s provision of
radios to the health centers;
ß working with PRISM and 13 other organizations to standardize and share
approaches to IEC in the region;
ß working with PRISM, AGBEF and PNLP to standardize the training of health
agents;
ß providing information to PRISM’s community-based strategy coordinator to
standardize community-level data gathering and supervision instruments; and,
ß serving as a resource to other NGOs interested in initiating the Hearth model.
Increased Quality
MCHI/Africare has increased the capacity of community agents to provide quality care in
support of maternal and child health through training and support. It has developed
monitoring instruments to track inputs and outcomes, and are advocating for better
support and recognition of community-level health activities.
MATERNAL AND CHILD HEALTH INITIATIVE (MCHI) MIDTERM EVALUATION
42
D. IMPEDIMENTS TO PROJECT PROGRESS AND OVERCOMING CONSTRAINTS
Understaffing in Health Centers
At present, most of the health centers are understaffed. The person most often
responsible for community activities is also responsible for the vaccination program and
this person is particularly busy. Health agents have little time to dedicate to supporting
community agents, such as providing supervision as well as formal and on-the-job
training.
To address this, the field workers visit the health centers several times a month, on
average, and have developed other mechanisms to keep the health agents informed about
community activities. The project has also provided six motorcycles to health centers to
facilitate access. In the long term, the problem will be solved when additional staff is
recruited (a process that the DPS has already set in motion) and assigned responsibility
for community activities.
Little MOH Incentive to Support Community Activities
Not only is staff limited but the MOH does not provide any incentives to health agents to
support community activities. No data or other information is collected related to
community agents’ work. As a result, health agents understand that the MOH/DPS is not
particularly interested in these activities.
UNICEF has been supporting the advocacy efforts of the MOH’s nutrition unit so that
nutrition indicators will be included among the others used by the Ministry of Health and
progress is apparently being made. Until then and to place more importance on
community activities, the Dabola DPS should require all heads of health centers to collect
and report on community activities during the semiannual monitoring meetings.
Health Center Quality of Care
While the PRISM/Population Council report clearly indicated the lack of quality of care
in health centers, given its current staffing pattern, other than training, the project has no
mechanism through which it can directly affect on the quality of service delivery at the
health-center level.
Because both PRISM and GTZ are focusing on improving quality of service delivery, and
given the already overburdened workload of project staff, MCHI has placed less
emphasis on improving the quality of care provided by health center staff than at the
community level, where Africare’s comparative advantage lies. During the second half
of the project, MCHI would do well to leave the majority of this responsibility to PRISM
and GTZ. Should the DPS implement the COPE approach (a self-assessment of quality of
care), which appears likely, then the doctors employed by the project might be useful in
helping to train heads of health centers in the execution of this approach.
Widely Dispersed Population
VIII. ACCOMPLISHMENTS AND CONSTRAINTS
43
The population of Dabola is widely dispersed and does not live in concentrated
population centers (villages) as in much of West Africa. This means that one community
agent has to travel to several different locations, which can be many kilometers apart, to
reach her/his target groups. For example, to weigh all of the children under age 3 in
her/his target area, each community agent needs to spend up to five mornings per month.
There may only be 15-20 children in any one community. This is very time consuming.
This dispersion also makes it difficult for one community agent to provide other services,
such as ORS packets and timely health education. The Hearth model is also affected by
this phenomenon, making it necessary to identify a maman lumiere who lives more or
less equidistant (and not more than 2-3 km) from the participants. This is a major
logistical challenge.
To address this situation, the project has provided bicycles to each community agent and
has tried to define target areas taking the terrain, population location, and other factors
into consideration. The project also recognizes the extra strain this places on the
community agents and provides substantial support and encouragement to them.
E. CONCLUSIONS AND RECOMMENDATIONS
Conclusions
1. The continuation application is not a substitute for a Detailed Implementation
Plan and is not useful in determining consistency of project implementation.
2. The second year annual report contains much of the information required to be
reported on in this midterm evaluation.
3. For the most part, the project is being implemented on schedule. The
formation of community committees and the implementation of income￾generating activities are the two components that are quite behind schedule.
There may not be enough time to execute the income-generation component
satisfactorily.
4. The project’s most important achievement is the successful pilot testing of the
Hearth model.
5. The most serious constraint to the project is the MOH’s limited official
recognition of the importance of community-based activities.
Recommendations
MATERNAL AND CHILD HEALTH INITIATIVE (MCHI) MIDTERM EVALUATION
44
1. Project staff needs to develop a complete Logical Framework for the project,
identify the outcome indicators, and use these to monitor and report on project
performance.
2. USAID should require grantees to develop a Detailed Implementation Plan
once the baseline data have been collected. Alternatively, the format of the
continuation application could be changed so that it looks less like an annual
report and more like a Detailed Implementation Plan.
3. In years when there is a project evaluation, USAID should not require the
project to write an annual report.
4. Project staff should continue to implement the Hearth model, always looking
for ways to more effectively and meaningfully incorporate the health agents
into the program. Also, the staff should continue to share lessons learned with
partners and other NGOs trying the approach.
5. Project staff should ask the DPS to require the heads of health centers to
collect and report on community activities taking place in their subprefecture.
45
IX. ISSUES IDENTIFIED BY THE EVALUATION TEAM, NGO
OR USAID
A. PROJECT EXPENDITURES
USAID raised the issue of whether the project could spend all of its money. As discussed
in chapter VII, at its current expenditure rate of $45,000-$65,000 per month, the project
will definitely spend its entire grant.
B. COORDINATION/COLLABORATION BETWEEN DFSI AND MCHI PROJECTS WITH
REGARD TO THE VILLAGE HEALTH COMMITTEE STRATEGY
USAID is concerned that MCHI will have difficulty merging the Dabola approach
(initially no community committees) with that of the DFSI/Dinguiraye approach where
the project started out establishing committees. In as much as MCHI/Dabola has now
decided to form development committees, this is not a problem. In fact, MCHI could
benefit from the lessons learned in the DFSI project with regard to the formation of
committees and use these lessons to improve the approach and increase support for the
community agent.
C. REDUCED BUDGETARY SUPPORT
Africare is concerned that there could be a USAID budgetary shortage. The evaluation
team discussed this issue with the project staff and came up with the following
suggestions on how reduced budgetary support could be handled:
ß Do not train a third cohort of community agents in Dabolaæconcentrate on
current activities;
ß Do not implement the bed net impregnation component and do not import
mosquito nets; and,
ß Do not implement the income-generation component.
None of these scenarios is particularly helpful without knowing exactly how much money
USAID would withhold from the project. Since costs are integrated into line items,
Africare would have to do a specific analysis to determine the financial impact of each
scenario.
D. ROLE OF CONTINUATION APPLICATION
The format of the continuation application is presented in the grant agreement with
Africare (pages 8-9) and stipulates that changes to the original proposal should be
presented in the continuation application. However, it was difficult to determine the
MATERNAL AND CHILD HEALTH INITIATIVE (MCHI) MIDTERM EVALUATION
46
precise role of the continuation application as this is a rather new concept in project
funding. The scope of work used the term “continuation application” as if it were the
same as a Detailed Implementation Plan, a document required by the BHR/PVC-funded
child survival grant that describes the project in great detail and clearly takes the place of
the proposal, once approved. The continuation application, however, does not provide
the same degree of detailed activity description, explanation and justification for changes
as a Detailed Implementation Plan, and therefore was not useful in the assessment of such
things as outcome indicators, sustainability or consistency of approach.
The main issue is that there is no single project document that clearly describes and
justifies the project’s current approach and implementation of such activities as the
Hearth and mosquito-net impregnation. The absence of this document is a major
impairment to project implementation and support efforts.
ANNEXES
A: Scope of Work (from USAID/Guinea) ........................................................................51
B: Questionnaires and Discussion Guides........................................................................59
C: Summary of Evaluation and Field Work......................................................................77
D: Project Indicators..........................................................................................................81
E: Supervision Form..........................................................................................................87
F: IEC Message Promoted by MCHI (Translated from the French).................................91
G: Timeline (Year 2): October 1998–September 1999......................................................95
H: References....................................................................................................................99
 I: Evaluation Team Members.........................................................................................101

ANNEX A
SCOPE OF WORK
(from USAID/GUINEA)
MATERNAL AND CHILD HEALTH INITIATIVE (MCHI) MIDTERM EVALUATION
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1.1 Background
USAID/Guinea’s health program currently targets the public and private sector. Under
the public sector activity, a four years Community Based Maternal and Child Health
grant was awarded to Africare in September 30, 1997 to cover the prefectures of Dabola
and Dinguiraye in Haute Guinea. The implementation of the grant activities will start in
Dabola first and then will move to Dinguiraye during the last 2 years of the grant. As a
requirement under the grant agreement, USAID/Guinea will conduct a mid-term (MT)
evaluation and hence seeks assistance in analyzing the current status of the community
based Maternal and Child Health (MCH) initiative in terms of achievement of proposed
results.
Specific objective of the MCH initiative is to reduce maternal and child morbidity and
mortality in the prefectures of Dabola and Dinguiraye through nutrition improvement,
diarrhea disease control, malaria control and safe motherhood/family planning. The
project targets 46,000 children under 5 years and 46,000 women of reproductive age
under the two prefectures.
The proposed activity contributes directly to the Mission’s health objective “increased
utilization of FP/MCH and STI/AIDS prevention services and products” and four
intermediate results notably Increased Access, Improved Quality and enhanced demand
for FP/MCH and STI/AIDS prevention products and services and more effective
response among donors and community organizations, NGOs in addressing critical health
constraints. The activity equally meets the expressed desire of Guinea’s Ministry of
Health to work in the area of maternal and child health in those two prefectures
characterized by high maternal and child mortality rates.
This MT evaluation will cover activities implemented in Dabola from September 97 to
September 99. The total population in Dabola is 110,975 and the project targets 23,000
children under 5 and 23,000 women of reproductive age. Dabola has 6 health centers and
4 health post integrated in the EPI/PHC/ED program as well as FP. There is also one
hospital in Dabola. As a community based activity, the project works with community
health agents, village leaders and elders, existing community organizations and religious
leaders to implement its maternal and child health interventions. Collaboration with
other USAID programs, the MOH and other donor’s activities in the area is also an
important aspect of this activity.
Existing Performance Information Sources
1. Activity Proposal
2. Quarterly Reports
3. Baseline quantitative and qualitative studies
4. Grant Continuation application
ANNEXES
51
5. USAID/Guinea Strategic Plan
6. USAID RA’s
7. USAID 1998 & 1999 PRA reports
8. SO2 strategic Framework and revised indicators
9. MOH and other Donors/partners in the area
10. Beneficiaries/the population
11. Other documents as required
1.2 Purpose
The purpose of the mid-term evaluation is to identify what is working well, identify
barriers to achievement of goals and objectives, review expenditure levels of the past two
years of project, suggest areas which need further attention and recommend useful
actions to guide the staff through the last half of the project. The evaluation should
equally assess the extent to which field project implementation is in accordance with the
continuation application. Any substantial changes in the project’s beneficiary
population, interventions, objectives, site or principal partners, since the time of the work
plan and the reasons for these modifications should be described.
USAID/Guinea will use information provided to make budget and program decisions
needed for future planning. The evaluation results are needed by December 30, 1999.
1.3 Description of the Contractor’s Services
The Contractor’s task is described in A through H below:
A. QUALITY OF PROGRAMMING
Describe the relationship of this project to other health-related activities in the
project area (including those of this and other PVOs, NGOs, private and
traditional health providers, government and donors). Discuss the role of the
project in relation to the area’s health facilities and referral care sites, and linkages
between these facilities and the communities served by the project. Briefly
discuss any duplication of effort or services.
Comment on the level of access of mothers and children to the health facilities
associated with the project, and to other project-related providers of child survival
services including community health agents identified and trained by the project.
MATERNAL AND CHILD HEALTH INITIATIVE (MCHI) MIDTERM EVALUATION
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List (in a table if desired) the titles and numbers of all categories of project staff
and of other personnel with whom the project is working (voluntary and paid,
including government and NGO staff), identify the organization for which they
work, and note their main roles in relation to the child survival project.
List the frequency of contacts for support and supervision of all categories of
project-associated health workers and facilities providing child survival services,
and the ratios of supervisors to those being supervised.
Comment on whether the numbers, roles, and workload of personnel and
frequency of supervision are appropriate for meeting the technical and managerial
needs of the project.
B. QUALITY AT THE COMMUNITY LEVEL
Has the project defined specific messages for each MCH interventions that are
culturally appropriate? Are these messages technically up-to-date? How and
when are the messages communicated to members of the community? Have any
essential messages been omitted?
How has the project assessed understanding of messages or levels of knowledge
or practices, what have been the findings of these assessments and how has the
project used this information?
Discuss your conclusions regarding the project’s effectiveness in reaching the
site’s population (in terms of geographic location, age/gender, and risk status)
with communications and other child-survival services. If any groups are
probably not being reached, then please discuss why this is the case.
C. QUALITY OF HEALTH WORKER AND FACILITY SERVICES
List the tools used by the project to promote quality of service (such as:
guidelines, training curricula and manuals, protocols, algorithms, performance
standards, and supervisory checklists, etc.), and briefly describe how these tools
are being used to assure quality or assess performance.
Discuss the extent to which the project has identified essential materials and
supplies for each type of health workers including community health agents (AC)
identified and trained by the project and facility, how effectively the project has
monitored supply levels since the start of intervention activities, and actions the
project has taken to correct any deficiencies.
Assess the knowledge, skills, practices, and supplies of health workers and AC
and facilities associated with the project.
ANNEXES
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Discuss your conclusions regarding the effectiveness of project-related training,
support, monitoring, and supervision in promoting quality service delivery by
each type of health worker and facility associated with the project.
Describe the extent to which the project is using and supporting government or
information system has been set up, and if set up, how much of the data being
collected is other existing data collection systems, the extent to which an
independent project-specific health being used to manage and monitor the project.
D. CAPACITY BUILDING AND SUSTAINABILITY
Describe the project’s plans and progress in increasing the capacities of partner
organizations and promoting the sustainability of child survival activities and/or
benefits.
E. TECHNICAL AND ADMINISTRATIVE SUPPORT
What are the types and sources of external technical assistance the project has
received to date, and how timely and beneficial has this assistance been?
Discuss the technical and administrative support from the PVO regional or central
offices in relation to the needs of field staff, and any constraints the project faces
in obtaining this support.
F. FINANCIAL EXPENDITURE
Assess activity’s current budget expenditures and project funds needed for the
remaining life of project.
G. ACCOMPLISHMENTS AND CONSTRAINTS
Please provide a thorough discussion of the extent to which actual implementation
of each child survival intervention is consistent with the annual (98) grant
continuation application, and whether all essential elements of each intervention
are being addressed by the project and its partners.
Briefly discuss the extent to which the overall project is being implemented on
schedule, as planned in the annual (98) grant continuation application.
Briefly describe the most important achievements of the project to date. What
factors have contributed the most toward the achievement of progress?
What factors have impeded progress, and what actions are being taken by the
project to overcome these constraints?
MATERNAL AND CHILD HEALTH INITIATIVE (MCHI) MIDTERM EVALUATION
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H. ISSUES IDENTIFIED BY EVALUATION TEAM, PROJECT, OR PVO
Did the evaluation team, project staff, or PVO headquarters identify any other
questions to be addressed by the midterm evaluation? If yes, then please discuss
these issues.
Evaluation Method
USAID/Guinea is requesting a participatory evaluation. As such, the mission requires the
participation of projects staff and representatives from project partners and stakeholders
in planning and conducting the evaluation, including PVO country office and
headquarters, government health services, NGOs, and community members. The
consultant will be responsible for reviewing the scope of work and developing a
participatory action plan for the evaluation. The consultant will review the plan with
USAID/Conakry prior to conducting the evaluation. Upon completion of the evaluation,
the consultant will be responsible for preparing a formal presentation to USAID/Guinea,
Africare as well as the MOH. A draft report of the evaluation in English is required.
USAID/Guinea will review the draft and provide comments while consultant is still in
country. Within two weeks of receiving these comments, the consultant will provide
USID/Guinea with a final report. The Contractor shall also submit a French version of
the report to USAID/Guinea one-month after the Contractor submits the final report to
USAID/Guinea.
In order to conduct the evaluation, the consultant shall:
Review available documents
Conduct interview with USAID/Guinea, MOH (central and regional staff)
PSI/OSFAM, PRISM, Africare local staff, beneficiaries
Conduct field visits
Conduct qualitative research
Any additional methods the consultant finds appropriate to complete the mid-term
evaluation need to be discussed with USAID/Guinea Health Team.
The evaluation team leader/the consultant should be someone who is not
employed by, or otherwise professionally associated with the concerned PVO or
child survival project. This person will be identified or must be approved by
USAID/Guinea SO2 prior to the evalutation. This person should be a child
survival specialist with extensive five to ten years experiences in community
based activities in developing countries as well as experiences in conducting
participatory evaluations. The incumbent will have FS-4 level oral and written
skills in French and English.
ANNEXES
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1.4 Reporting and Dissemination Requirements
The final evaluation report should be in English and in French. The consultant will
be responsible for providing five copies of the report in English and five copies in
French. A diskette should be provided for each report in MS Word.
The mid-term evaluation report should:
Provide an executive summary
Summarize the highlights of the midterm evaluation, including:
Evaluation methods, sites visited, and dates of field work,
Main “Accomplishments and Constraints” of the project, and conclusions
regarding the extent to which implementation is consistent with the
project’s approved work plan. Main conclusions regarding the “Quality of
Programming”, “Quality at the Community Level”, and “Quality of Health
Worker and Facility Services” (from sections 3, 4, and 5).
Present the recommendations of the evaluation. For each recommendation:
Discuss the problem or concern identified by the evaluation,
Recommend the action(s) to be taken,
Identify the organization(s) which should implement the recommended
action (field project, PVO headquarters, etc), and
Suggest the date by which the recommended action should be
implemented.
Appendices will include:
Scope of Work
Documents consulted
Name, title, and institutional affiliation of all members of the mid-term
evaluation team, and all authors and editors of the evaluation report.
Include the resume/CV of the evaluation team leader/the consultant.
Sites visited
ANNEX B
QUESTIONNAIRES AND DISCUSSION GUIDES
ANNEXES
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Questionnaire pour les Agents Communautaires
General
1. Quels sont les objectifs du projet ISMI?
a) Ameliorer l’etat nutritionelle (allaitement immediate/exclusive, FADU)
b) Aider les meres a gerer les cas de palu
c) Reduire les cas de diarrhee
d) Promouvoir l’utilisation de la SRO
e) Autres ________________________________________
2. Quels sont les activites que vous effectuez avec le projet ISMI?
3. Oh ! c’est beaucoup d'activites! Que fait votre communaute pour vous aidez dans vos
autres activites quotidiennes?
4. Quels sont les comportements sanitaires chez les femmes que vous cherchez a
changer?
5. Quels sont les etapes a suivre au cours de la pesee?
a) correct et complet = bon accueil; faire deshabiller l’enfant; verifer si la
balance est tarer; proceeder a la pese de l’enfant; communique la poid de l’enfant
a la maman; faire l’interpretation sur le tableau communautaire; faire un feedback
a la mere par apport a la chemin de la croissance; donner la conseil a la mere;
pour les cas sur la rouge, referer l’enfant au CS/PS ; donner le date pour la
prochian rendez-vous
b) incomplet
6. Pendant la pesee, a qui donnez-vous le conseil?
7. Est-ce que vous pouvez nous montrer vos outils de gestion et materiel IEC?
a) registre
b) cahier de rapport mensuel
c) cahier de reference
d) fiches de croissance
e) affiche Vit A
f) poster allaitement
g) boite a image LMD
8. Combien d’enfants de moins de 3 ans avez-vous enregistrer dans ce village?
__________
9. Parmi ces enfants combien ont ete pesee le mois d’Octobre?
10. Combien de ces enfants etaient bien nourri? ___________________
MATERNAL AND CHILD HEALTH INTIATIVE (MCHI) MIDTERM EVALUATION
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11. A quoi sert le registre?
a) connaitre le nombre d’enfant d’etre pesee
b) suivre la croissance de chaque enfant
c) suivre les enfants de foyer
d) suivre les cas de reference
e) identifier les cas de deces
12. Quels sont les messages du projet destine aux femmes enceinte?
a) allaitement immediate
b) allaitement exclusive
c) prophylaxis pour le palu
d) assister au consultation CPN
e) autres ___________________________
13. Comment arrivez-vous a atteindre les femmes enceintes dans vos messages?
14. Avez-vous entendu parlez de foyer? OUI NON
Si oui, quoi sert le foyer?
15. Quel est votre role dans le foyer?
16. Pensez-vous capable de gerer un foyer seul? OUI NON
si oui, quels sont les etapes a suivre?
a) pendant le pesee, identifier les enfant malnutris
b) identifier les Mamans Lumieres et les maman participants
c) identification des recettes
d) enquete de marche
e) negocier avec la manan Lumiere et les participants
f) formation ML
g) execution du foyer pendant 12 jours
h) suivi post foyer
17. Avez-vous des sachets de SRO disponible? OUI NON
18. A partir d’ou vous vous approvisioner en SRO?
19. Pendant les dernier six mois, y-a-t-il eu une rupture de stock en SRO? OUI NON
20. Combien de temps la rupture en SRO a duree? _______________
21. Combien de SRO avez-vous vendu pendant le mois d’Octobre? ________
22. A quel prix vous les avez vendu? ___________
Supervision
23. Qui est votre superviseur? _______________________________________________
ANNEXES
59
24 .Votre superviseur vous rendre des visite de supervision avec quel fréquence?
a) Each month
b) Once every 3 months
c) once every 6 months
d) _______________________________________
25. Quand est-ce que votre superviseur vous a rendu en visit de supervision pour le
dernière fois? ________________________________
26. Qu’est-ce qui c’est passe pendant sa visite?
27. Avez vous reçu du retro-information pendant/après sa visite? OUI NON
Si oui, sur quoi?
Agents Communautaire
Questionnaire de Connaissance
La Nutrition
1. Pourquoi pesez-vous les enfants?
a) pour connaitre l’etat de croissance de l’enfant
b) detecter les cas de malnutrition
c) donner de conseil aux meres
d) autres __________________________
e) ne sait pas
2. Comment faites vous la difference entre un enfant mal nourri et celui bien nourri?
a) par le pese (ses poids)
b) autre ____________
c) ne sait pas
3. Quelle est l’importance du premier lait (colostrum) de la mere pour l’enfant?
a) pour renforcer l’immunite de l’enfant/protoger contre les maladies
b) develop l’intelligence de l’enfant
c) creer l’affection entre la mere et l’enfant
d) favorise la delivrance rapid du placenta
e) favorise la secretion du lait
f) autres ____________________
g) ne sait pas
4. A quel age donner vous un autre aliment en plus du lait maternel à un bébé?
a) correct = 6 mois
b) incorrect
5. Quels sont les chemins qu’il faut suivre pour assurer une bonne alimentation de
l’enfant?
MATERNAL AND CHILD HEALTH INTIATIVE (MCHI) MIDTERM EVALUATION
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a) correct/complet = allaitement immediate et exclusive, introduction des autre
aliments des 6 mois; FADU
b) incorrect/incomplet
Le Paludisme
6. Quels sont les signes du paludisme face aux quels la reference est urgente?
a) correct et complet = corps très chaude; secousses violents de tout le corps ;
perte de connaissaice; urine chocolatee (coka)
b) incorrect/incomplet
c) ne sait pas
7. Que doit faire un agent communautaire devant un enfant qui a le paludisme?
a) correct = envelopper l’enfant, référer l’enfant au Centre de Santé ou Poste de
Santé
b) incorrect/incomplet
c) ne sait pas_____
8. Le paludisme est plus dangereux chez qui?
a) correct/complet les enfants 0-5 ans, les vieilles personnes, les femmes enceinte
b) incorrect/incomplet
c) ne sait pas_______
9. Quelles sont les mesures qui protegent contre le paludisme?
a) correct/complet : dormir sous une moustiquaire, assainir l’entourage ;
 donner chaque mois de la choloroquine aux femmes enceintes
b) incorrect/incomplet
c) ne sait pas______
Contrôle des Maladies Diarrhéiques
10. Quels mesures peuvent protéger quelqu’un contre la diarrhée?
a) vaccination contre la rougeole, utilisations de latrines, bonne préparation et
bonne conservation des aliment, allaitement immédiat et exclusive (0-6 mois)
b) incorrect/incomplet
c) ne sait pas
11. Que doit faire une mère pour soigner un enfant avec le diarrhée?
a) continuer a allaiter, continuer a donner a manger plus que d’habitude, donner
plus a boire que habitude, préparer et administrer le SRO
b) incorrect/incomplet
c) ne sait pas____
Communication Interpersonnel
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12 Quels sont les qualités d’un bon message?
a) correct/incomplet- simple, clair, precis, faisable,
b) incorrect/incomplet
c) ne sait pas
13. Quels sont les qualités d’un bon communicateur?
 a) être patient
 b) donner le pouvoir (la parole) a tout le monde
 c) être respectueux des coutumes du milieu
 d) autre _______________________________
14. Quels sont les obstacles lies a la bonne communication? (au moins 4 response)
a) les mots trop difficiles/complique
b) le ton non respectueuse
c) la langue n’est pas du milieu
d) l’émotion - manque de confiance de parler en public
e) le niveau d’instruction - utilise les images pour passer les messages
f) culture de l’auditoire - prendre en compte des réalité socioculturel
g) la différence de sexe - ne melange pas les sexes
h) les coutumes du milieu - jamais critiquer les coutumes
i) l’attitude - AC doit avoir une attitude respectable
le temps/climat
Nom de l’enqueteur _______________________ Lieu _________________________
MATERNAL AND CHILD HEALTH INTIATIVE (MCHI) MIDTERM EVALUATION
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Questionnaire pour les Meres
Introduction
Nous sommes ici pour discuter avec vous les activites sanitaires
Questions Generals
1. Quelles sont les activites sanitaires qui sont menes ici?
2. Avez-vous un agent communautaire ici? OUI NON
3. Si oui, quels sont ses activites?
4. Que pensez vous de son travail?
5. Que fait la communaute pour aidez l’AC dans ses activites quotidiennes?
6. Participez-vous a la pesee? OUI NON
si oui, pourquoi? (A quoi sert la pesee?)
7. Quel est l’avis de votre mari par rapport a la pesee?
8. Jusqu’a quel age l’enfant doit etre pesee?
a) 3 ans
b) autre
c) ne sait pas
9. (Demandez a la mere de vous montrer sa carte de croissance de son enfant.) Pouvez￾vous m’expliquer ceux qui se trouve sur la carte (sa sense)?
a) Identified la courbe de poid
b) Donner l’interpretations des couleur
c) Type de courbe
d) (qu’est-ce que la courbe nous dit sur l’etat de votre enfant?) (le poid) de son
enfant (bonne ou non)
e) si la poid a augmenter ou diminuer depuis la dernier fois
f) ne sait pas
10. Avez-vous participe aux autres activites mene par l’AC. OUI NON
si oui, lesquelles?
a) vad
b) caueries en groupe
c) strategie avance/vaccination
d) foyer
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e) activites d’hygiene
f) autres _________________________
11. Avez-vous entendu parlez du foyer? OUI NON
si oui, qu’est-ce que le foyer?
12. Pensez-vous qu’il y a des changements dans l’etat sanitaire des enfants depuis que
l’AC a commence son travail? OUI NON
 si oui, quels sont ces changements?
Connaissance
L’allaitement Maternel
13. Qu’est-ce qu’ une mere doit donner a son nouveau ne immediatement apres sa
naissance?
a) Correct = lait maternel
b) Autre
c) Ne sait pas
14. Est-ce que vous connaissez le colostrum? OUI NON
15. Quel est son importance?
a) pour renforcer l’immunite de l’enfant/protoger contre les maladies
b) develop l’intelligence de l’enfant
c) creer l’affection entre la mere et l’enfant
d) favorise la delivrance rapid du placenta
e) favorise la secretion du lait
f) autres ____________________
g) ne sait pas
La Diversification Alimentaire
16. Quand est-ce une mere doit adjouter d’autre aliments que le lait maternel?
a) Correct = au eme mois
b) ne sait pas
c) incorrect
17. A partir de six mois que doit manger un enfant?
a) lait maternel, bouillie enrichie, et jus de fruit
b) incorrect
c) ne sais pas
18. A partir de 6 mois, combien de repas un enfant doit recevoir pour etre an bon sante?
a) 4-6 repas par jour
b) incorrect
c) ne sait pas
MATERNAL AND CHILD HEALTH INTIATIVE (MCHI) MIDTERM EVALUATION
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Hygiene
19. Que doit faire une mere pour eviter la diarrhee?
a) laver les mains avec l’eau and de la savon avant de manger
b) utiliser les latrines
c) laver ou cuire les aliments cru avant de les manger
d) autres _______________
e) ne sais pas
Palu
20. Quel est la cause du palu?
a) les piqure des moustiques
b) incorrect
c) Ne sais pas
21. Comment proteger contre le palu?
a) eviter les piqures
b) utilise un moustiquaire
c) ne sait pas
22. Qu-est-ce qu’on doit faire quand un enfant a la fievre?
a) Voir l’AC
b) envelopement humide
c) l’amener au centre de sante/post de sante
d) incorrect
e) ne sait pas
La Diarrhee
23. Qu’est-ce qu’il faut faire pour un enfant qui a la diarrhee?
a) donner le SRO ou TRO
b) continuer a allaiter
c) continuer a donner a manger plus que d’habitude pendant et apres
d) ne sait pas
24. Ou procurez-vous des sachets de SRO?
a) chez l’AC
b) au centre de Sante
c) chez l’agent de Sante
d) boutique
e) autre ________________
f) ne sait pas
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24. A quel est prix?
a) ________________
b) ne sait pas
Vaccination
25. Pourquoi vaccinez-vous vos enfants?
a) pour les proteger contre les maladies
b) incorrect
c) ne sait pas
26. A quel age une enfant doit etre completement vacciner?
a) 1 ans
b) incorrect
c) ne sait pas
27. Une femme en grossesse doit etre vacciner combien de fois?
a) 2 fois
b) incorrect
c) ne sait pas
MATERNAL AND CHILD HEALTH INTIATIVE (MCHI) MIDTERM EVALUATION
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Questionnaire pour les Agents de Terrain
Brief introduction of each person with a little background information-education, prior
experience, languages spoken
General Questions
1. By component, what does your work for ISMI entail? (What do you do?)
2. How many ACs are you each responsible for?
3. Is this ratio enough, too much, too little? Explain?
4. By project component - nutrition, palu, diarrhea, FP-What does the AC’s work entail?
(How much time are they supposed to work each week?)
5. Taking each of their tasks separately, what are the AC’s strong points? What are their
major weaknesses?
6. How do the ACs raise awareness among the mothers?
7. How often do you visit each AC?
8. What do you do during a typical visit?
9. Do you supervise AC?
10. What does your supervision entail?
11. Do you have a supervision form (checklist) to guide you or to complete? (Have a look
at several)
12. By what criteria do you judge if an AC is working well?
13. What is done with the supervision forms? How are they used? By you, by your
supervisors?
14. What is the distance between the AC’s and the villages they cover (how long does it
take the AC to travel to his furthest district/village?)
15. What are the project’s key health messages? What behaviors does the project seek to
change among mothers?
16. Do you have a way to assess the effectiveness of ACs’ IEC work? (That mothers are
understanding the messages and changing behaviors?)
17. What information do the ACs provide you with each month? (Monthly report)
18. What do you do with this information? How is it used, by whom?
19. Is this information shared with anyone outside the project? (Head of Health Center,
DPS)
20. How would you describe the rapport between yourself and the health center staff
(agent de sante)?
21. What contact do you have with them? What about? Regularity?
22. How often do the AS visit the AC at their sites?
23. How often do the ACs visit the health centers for supervision?
24. Do you feel qualified to do your work? Have guides and manuals to help them do
their work, so they feel pretty comfortable?
 Has the training provided by the project adequately prepared you to do your work?
Any deficiencies? Does anything else need to be done?
25. Of the activities/benefits brought about through the project, which ones do you think
will be continued after the life of the project? How? By whom?
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What needs to be done to make sure the benefits, if not the activities, will continue
after the project? The activities of the AC need to be coordinated with the AS.
26. What are the primary achievements of the project thus far?
27. Do you think the AC can take charge of the FARN on their own?
Les Questions de Connaissance
Control des Maladies Diarrheiques
1. Quels sont les signes de deshydration (non-grave) chez un enfant?
a) agite, irritable
b) yeux enfonces
c) adsentes de larmes
d) bouche et langue seche
e) assoiffie, boit avec avidite
f) pli cutane s’efface lentement
g) ne sait pas
2. Quel est la prise en charge d’un enfant avec les signes de deshydration cite en haut.
(Plan B).
a) Peser l’enfant
b) Prendre l’age de l’enfant
c) administration de SRO (quantite selon l’age)
d) pendant quartre heures
e) re-evaluer l’etat de l’enfant apres 4 heures
f) ne sait pas
3. Qu’est-ce que un Agent Comunautaire doit faire pour prendre en charge en cas de
diarrhee aigue chez un enfant?
a) faire boire a l’enfant plus de liquides que d’habitude
b) donner a manger en abondance/un repas de plus par jour pendant 2
semaines/donner le sein frequemment
c) amener l’enfant a l’agent de sante si’il ne va pas mieux apres trois jours
d) ne sait pas
Paludisme
MATERNAL AND CHILD HEALTH INTIATIVE (MCHI) MIDTERM EVALUATION
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4. Quels sonts les signes de paludisme grave? (trois reponses neccessaire pour etre
correct)
a) douleur articulaire
b) secousses violentes de tout le corps
c) pertes de connaissances
d) yeux enfonces
e) paleur
f) ne sait pas
5. Quel est le mode de prevention de paludisme chez une femme enciente?
a) prendre le nivaquine jounaliere pendant sa grossese jusqu’a sixieme semaine
apres l’acchouchement
b) utilisation de moustiquaire
c) ne sait pas
6. Pourquoi il est tres grave quand une femme enceinte a le palu?
a) elle risque de perdre les poids/compromettre le developement de l’enfant
b) faible poid a la naissance
c) risque d’accouchement premature
d) mort de la femme et son enfant
e) ne sait pas
Sante de la Reproduction
7. Quels sont les signes evocateur d’une MST?
a) correct et complet = l’ecoulement vaginale/uretrale, gonflement inguinal,
ulceration genital, ophtalmie de nouveau ne
b) incorrect
8. Quels conseil un Agent de Sante doit donner a malade suspecte avoir le virus
VIH/SIDA?
a) correct et complet = referer a une SC pour le test specifique; conseil
l’utilistation des preservatifs; notifications des partener pour le depistage
b) incomplet
e) ne sait pas
9. Quels sont les contre indications absolues a la contraception hormonale?
a) Thrombo-embolie
b) Infections Vaginales
c) Hepatite virale
d) Mastalgie
e) Ne sait pas
La Nutrition
10. Quel est l’avantage de la Vitamin A chez un enfant?
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a) prevenir la cecite
b) prevenir les autres infections comme le rougeole
c) ne sait pas
11. Quel conseil un AC ou Agent de Sante doit donner a une femme enceinte sur
l’allaitmentation de sont nouveau ne?
a) allaitement immedaite
b) allaitement exclusive
c) ne sait pas
12. Quels actions une mere doit-elle entreprendre pour assurer la bonne sante de son
enfant de mois d’un ans?
a) Le faire vacciner completement
b) allaitement maternal - immediat et exclusif
c) l’introduction des autres aliments a partir de 6 mois?
d) Ne sait pas
13. Combien de piqures il faut avoir pour qu’un enfant soit completement vacciner.
a) cinq fois
 b) incorrect
14. Pourquoi il faut commencer a donner d’autre aliments en plus du lait maternel a un
enfant de 6 mois?
a) Pour augmenter l’apporte des autres nutriments essentiels
b) pour qu’il apprenne a manger
c) ne sait pas
15. Expliquez le principe de FQDU dans l’alimentation d’un enfant.
a) correct = F
b) incorrect
16. Quels sont les etapes qu’un agent communautaire doit suivre pour peser un enfant.
a) correct et complet = bon accueil; faire deshabiller l’enfant; verifer si la
balance est tarer; proceeder a la pese de l’enfant; communique la poid de
l’enfant a la maman; faire l’interpretation sur le tableau communautaire; faire
un feedback a la par apport a la chemin de la croissance; donner la conseil a la
mere; pour les cas sur la rouge, referer l’enfant au CS/PS.
b) incomplet
Communication interpersonel
17. Quels sont les qualites d’un bon message IEC?
a) simple
b) clair
MATERNAL AND CHILD HEALTH INTIATIVE (MCHI) MIDTERM EVALUATION
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c) precis
d) faisable
e) ne sait pas
18. Quels sont les commandements de la communication eficace?
a) commander l’attention de groupe/individu
b) clarifier le message
c) offrir un message coherent
d) inciter a l’action
e) communiquer un avantage
f) creer la confiance
19. Quels sonts les obstacles a la bonne communication? (au moins 4 de ces responses =
correct)
a) les mots trop difficiles/compliques
b) le ton non respectueuse
c) la langue n’est pas du milieu
d) l’emotion - manque de parler en publique
e) le niveau d’instruction, prendre en compte les realites socioculturelle
f) culture de l’auditoire
g) la difference de sexe
h) les coutumes du milieu
i) l’attitudes (non respect)
j) le temps/climate
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Project Staff (Senior Staff - Project Coordinator, Deputy and Supervisors)
A. Quality of Programming
1. In what ways does the MCHI work with other health-related development
organizations in the project area? How does the project collaborate/share
information/lessons learned with DFSI/ ISAD?
2. How does the project define adequate access to health services?
3. What percentage of the target population has access (according to this definition) to
the health facilities supported by Africare/MCHI? According to the prefecture
stats?
4. Is the project’s work in building/renovating health posts related to improving
access?
5. What is the status of the building/renovations?
6. To what extent will the construction improve access?
7. Do all project villages/districts have agents communautaires?
8. Explain the supervision strategy. Who supervises whom?
9. What is the frequency of supervisory visits? Monthly of AT.
10. What does supervision consist of?
11. What instruments are used?
12. What is the ratio of agent de terrain to agents communautaires?
13. What is the ratio of agents communautaires to population/district?
14. How often do ATs visit ACs? What do the ATs think of their workload? (Get job
description for AT and ACs)
15. What is the AT’s rapport with the MOH agents de sante?
16. Why did the census comprise 0-5 year old kids, when the project only weighs 0-3
year old kids? Can the percent of children 0-3 be calculated somehow?
17. What percentage of the sous-prefectures do you think the project can effectively
cover? How will this be done?
MATERNAL AND CHILD HEALTH INTIATIVE (MCHI) MIDTERM EVALUATION
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B. Quality at the Community Level
18. What does the IEC strategy consist of? (How, when and by whom are key
messages communicated to target groups?)
19. What does the project do to assess mothers’ understanding/practice of the key
messages? How do you use this information?
20. Does the project collect information about use of health facilities?
 C. Quality of Health Worker and Facility Services
21. What instruments and tools are used by the project? (Get list)
22. Referring to the instruments and tools developed/used by the project - ask by
whom are these tools used, and how? How do these tools help staff to make
informed decisions? Give examples.
23. Essential materials and supplies table: What other materials might be needed?
How are supplies/materials monitored? (Mustapha) supervision reports materials
and stuff is checked.
24. How does the HIS work?
25. Who is in charge of the HIS?
26. Does the project use the MOH HIS or has it developed its own system?
27. How did the project decide what data to collect?
28. Does the project collect information on impact indicators as well as
process/outcome indicators?
29. Does the project track inputs? Which ones?
30. What behaviors among the HC staff does the project seek to improve?
31. What is senior staff’s rapport with Health Center staff? Regular contact?
D. Capacity Building and Sustainability
1. Does the project have a partner capacity building strategy? If so, what is it?
ANNEXES
73
2. Does the project track institutional capacity building? If so, how?
3. Does the project have a sustainability plan? With objectives, indicators, activities,
etc.?
4. What efforts have been made to get the agents de sante to take responsibility for
training the AC?
5. What prevents them from participating in the AC training? Time/interest
6. What efforts have been made to get the agent de sante to supervise the AC?
E. Technical and Administrative Support
1. What TA has the project received thus far? (Table of external TA provided,
including timeliness and benefit) How timely was this TA? How much did you
benefit from this TA?
2. TA and support from Africare DC.
 F. Accomplishments and Constraints
1. Is actual implementation of each CS intervention consistent with the grant
continuation application? (Copy the chart from the annual report)
2. Have any of the activities been delayed (with relation to what was planned in the
CA)
3. In your opinion, what are the most important achievements of the project to date?
 What factors have contributed to these achievements?
4. What factors have impeded progress, and what actions have been taken to
overcome these?
G. Issues Identified by Evaluation Team, USAID or Project
 1. What other issues do you want the evaluation team to look into?
 
ANNEX C
SUMMARY OF EVALUATION FIELD WORK
ANNEXES
75
Summary Of Evaluation Field Work
Group 1: Bonnie Kittle, Gouley Cisse, Tadiba Kourouma
Subprefecture District #AC Day
Dogoma Kobolonia Alpha Diallo + 3 November 10
Commune Urban Kigneko Moctar Barry + 3 November 11
ArphaMoussaya Nyalen Allasane Conde + 3 November 12
Group 2: Kadiatou Keita, Abdoulaye Diallo, Etiene Wendeno
Subprefecture District #AC DAY
Banko Souarela Fode Souare November 10
Kankama Matiguila Nyarra Traore November 11
Bissikorouma Demdeleya Assatou Bah + 2 November 12
USAID/Conakry
Cathy Bowes, Health Unit Manager
Elizabeth Kibour, MCHI Project Officer
Miriama Bah
Africare Staff
Jonathan Lachnit, Country Representative
Michelle Ismering, Administrator
MCHI Project Staff
Agneiska Sykes, Project Coordinator
Gouley Cisse, Assistant Project Coordinator
Mustapha Grogovui, Supervisor/IEC/HIS/Trainer
Abdoulaye Diallo, Assistant Supervisor/Trainer
Field Agents (9)
Ministry of Health
 Conakry
Dr. Macoura Olare, Nutrition and Food Division
M. Diallo and team, Malaria Control Program
 Dabola
Dr. Yattara, DPS
6 Health Center Chiefs
4 Health Post Chiefs
16 Health Agents
17 Community Workers
MATERNAL AND CHILD HEALTH INITIATIVE (MCHI) MIDTERM EVALUATION
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Community Members
68 mothers
Project Partners
UNICEF Lina Mahy
PRISM Michael Blake and Elenore Rabelahasa
PSI William Stringfellow
GTZ David Blankhart
ANNEXES
77
ANNEX D
PROJECT INDICATORS

 BLD = Baseline Data
MTE = Midterm Evaluation
Project Indicators
Objective 1: To strengthen and expand existing government health services
Proposal Indicators Continuation Application Indicators BLD Related MTE Data/Comments
90% of health personnel will have
participated in MCHI-sponsored training
courses
Africare was asked by USAID/Guinea to
omit indicators related to the number of
people trained by the project.
80% of health personnel will appropriately
treat and/or refer childhood illnesses
(diarrhea, malaria, malnutrition)
Recommended to be dropped officially since
the GTZ project and PRISM are addressing
this issue.
Six new health posts will be constructed No. of new health posts constructed
No. of health posts renovated
0
0
Three are under construction and likely to be
finished before the end of the year.
80% of health facilities will have
functioning cost recovery systems
Recommended to be dropped officially since
the GTZ project and PRISM are addressing
this issue.
90% of health facilities will submit accurate
monthly reports on time
Recommended to be dropped officially since
the GTZ project and PRISM are addressing
this issue.
No. of health centers with adequately
functioning cold chain equipment
Indicated that
no problem
exists with
the cold chain
Given the results of the BLD, this indicator
was omitted.
Objective 2: To increase community capacity to take responsibility for their own health
Proposal Indicators Continuation Application Indicators BLD Related MTE Data
Nutrition 68 mothers interviewed
30% of infants will be exclusively
breastfed through 4 months of age
12% of infants exclusively breast fed through 6
months of age
2% ß 85% say that breast milk should be a
newborns first food.
94% have heard of colostrum.
80% could correctly cite one advantage of
colostrum
70% of mothers will be able to
cite/explain appropriate weaning
foods and practices
78% of mothers giving their children at the age of 6
months appropriate weaning foods in the form of
porridge.
53% ß 73% know that a baby needs other foods
by age 6 months;
70% of mothers will be able to cite
energy-dense foods
47% of mothers giving their children ages 6-11
months protein-rich foods in the form of peanuts
27% ß 85% know what to first feed a six month
old;
ß 61% know that a six month old needs to be
fed 4-6 times per day
80% of mothers will be participating
in nutrition promotion sessions held
in communities
Chronic malnutrition
21.5%
27.5% ß 100% were participating in the growth
monitoring program
Malaria Control
80% of mothers will be able to
identify two malaria prevention
techniques
50% of mothers able to identify at least one means
of reducing the risk of getting malaria
20% ß 52% were able to identify at least 1 means
of reducing the risk of getting malaria
70% of cases of fever in children will
be treated with appropriate anti￾malarial drugs
62% of children who had a fever in the last 2 weeks
and were taken to a health facility
37% ß 77% knew to take a child with fever to the
health center
70% of women will have used
appropriate chemo-prophylaxis during
last pregnancy
63% of mothers were given chemo-prophylaxis
during their last pregnancy
38%
Proposal Indicators Continuation Application Indicators BLD Related MTE Data
CDD
80% of mothers will be able to
describe ORS and ORT
35% of mothers whose children had diarrhea in the
last 2 weeks gave their child ORS
15% 73% knew to give ORS/ORT to a child with
diarrhea
70% of mother will be able to
describe appropriate preparation and
administration of ORS
74% of mothers whose children had diarrhea in the
last 2 weeks and who continued to breast feed the
same amount or increased breast-feeding.
49%
80% of mothers will be able to cite
two methods of preventing diarrhea
80% of cases of diarrhea will be
treated appropriately with ORS/ORT
in health facilities
Safe motherhood/Family Planning
70% of women will have had at least
one prenatal visit (before 7th month)
during last pregnancy
53% of women had at least 2 prenatal visits during
their last consultation
33% 39% know that a pregnant women needs two
TT vaccinations
5% of women aged 15-49 will report
current use of modern contraception
7% of WRA report current use of modern
contraception
2%
Immunization
60% of children will be fully
immunized at 12 months (indicators
for individual antigens to be added
after KPC)
66% of infants who received a DPT 1 vaccine
(demonstrating increased access)
41%
46% of infants 12 to 23 months who received DPT3
coverage
26% 51% know that a child should be completely
vaccinated by 12 months of age

ANNEX E
SUPERVISION FORM
ANNEXES
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Fiche De Supervision Des Agents Communautaires ISMI/Dabola
Sous prefecture ____________________Date de supervision _____________________
District __________________________ Nom de l’AC __________________________
Secteur __________________________ Superviseur ____________________________
* = renseignement que vous puvez prendre directement de fiches du rapport de l’AC
NO. Non
Ou Oui
Commentaires
Verification des outils de gestion de des materiels
1. Fieche du rapport disponible?
2. Fiche de rapport correctement
remplie?
3. L’agent dispose-t-il d’un
materiel de travail complet?
Identifier ce qui manque
(balance, tableau, velo, etc.)
4. Les contraceptifs et SRO
sont-ils disponibles et bien
conserves?
Activities
5.* Pesee mensuelle executee? No. des enfant pesees _____
6.* Nombre d’enfants referes
pour malnutrition
No. de Foyer:______
No. de enfant ayant participe: _____
7.* Y a-t-il eu un foyer pendant le
mois?
8. Nombre d’enfant peses 4
semaines apres sa
participation au foyer?
9. Nombre d’enfants vus pour
diarrhee?
10.* Nombre d’enfants referes
pour diarrhee?
11. Nombre d’enfats vue pour
fievre?
12. Nombre d’enfants referes
pour fievre?
13. Nombre des femmes vu en
rattrapage actif?
14.* Y a-t-il eu des clients recu No. des nouveau clients: ____
MATERNAL AND CHILD HEALTH INITIATIVE (MCHI) MIDTERM EVALUATION
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pour PF? No. d’anciens clients: _____
Preciser les produits vendue:
Activites d’IEC/CIP
15.* Nombre des participants aux
séance d’IEC
Nombre
16. Preciser le ou les sujets
abordes (N/LMD/CP/PF/H)
Observation Directe des Activities (0-2)
17. Apprecier le qualite des
causeries educatives entre
l’AC et les meres pendant les
seances de pesee
18. Apprecaier le contenu des
messages d’IEC transmis a la
communaute
19. Apprecier l’AC entrain de
communiquer a la
communaute la
preparation/l’utilisations du
SRO
20. Apprecier l’AC entrain de
communiquer aux femmes
l’importance de l’utilisation
de la chloroquine pour les
femmes en grossesse
21 Apprecier l’AC entrain de
communiquer sur la PF
22. Indiquer les facteurs qui ont facilite le travail ce mois pour l’AC.
23. Indiquer les difficultes recontrees ce mois par l’AC
AIDE MEMOIRE POUR l’AT
ß Faire la retro-information a l’AC et discuter sur les principaux resultats recueillis.
ß Faire le rapport de supervision dans le cahier de l’AC
(commentaire/recommendation en precisant la date).
ß Preparer l’AC sur la verification de l’execution de ces recommendations lors de la
prochaine supervision.
ANNEXES
87
ß Faire la retro-information (AT) a la coordination du projet (evoquer contraintes et
les solutions).
Supervision faite par ________________________Signature ______________________
ANNEX F
IEC MESSAGES PROMOTED BY MCHI
(TRANSLATED FROM FRENCH)
ANNEXES
89
IEC Messages Promoted by MCHI
 (Translated From French)
Breastfeeding
1. Put the child to the breast at birth so he/she benefits from the first milk. (Explain the
importance of colostrum)
2. Mother’s milk is the only nourishment that a child needs during the first 6 months of
her/his life.
Varied Diet
1. From 6 months, mother’s milk needs to be complemented by a richer and more varied
diet:
6 to 9 months: breastmilk + fortified porridge + fruit juice
9 to 12 months: breastmilk + puree + semiliquid foods + fruit juices
12 to 18 months: breastmilk + family’s food + vegetables + fruits
2. From 6 months of age a child should be fed 4 to 6 meals per day
3. A good diet should be frequent, sufficient in quantity, well balanced and useful
(FADU)
Hygiene
1. Always boil drinking water taken from wells, ponds and rivers.
2. To protect yourself from illness, one should wash his/her hands with soap and water
before eating.
3. Wash or cook raw foods before eating them.
4. To avoid getting sick, one should use latrines and keep them clean.
Malaria
1. Mosquito bites give you malaria.
2. One should use a mosquito net to avoid mosquito bites which carry malaria
(particularly children and pregnant women).
3. All pregnant women should receive chloroquine and iron tablets each month.
4. A child with fever, whether he coughs or not, should be immediately brought to a
health center or post to get treated.
Diarrheal Disease Control
1. The medicine to use against diarrhea is ORS or ORT (home solution).
2. Health agents or community agents have ORS packets that they sell at reasonable
prices.
3. A breastfeeding child with diarrhea should continue to be breastfed and given enough
to drink.
4. A child with diarrhea needs supplemental feeding during and after her/his illness.
MATERNAL AND CHILD HEALTH INTIATIVE (MCHI) MIDTERM EVALUATION
90
Growth Promotion
1. A child under the age of 3 years should be weighed each month to know his growth
status.
2. The family and community should show interest and help with the growth monitoring
and promote the growth of children with help from the community chart.
Vaccination
1. To be protected against childhood illnesses, all children fewer than 1 year ought to
receive 6 vaccination in the health centers.
2. All pregnant women need to receive two vaccinations against tetanus.
ANNEXES
91
ANNEX G
TIME LINE (YEAR 2)
 OCTOBER 1998–SEPTEMBER 1999
Time line (Year 2)
October 1998–September 1999
X = the activity took place
0 = rescheduled for Year 3
Activities Oct. Nov. Dec. Jan. Feb. March April May June July Aug. Sept.
Training
Field agents, health facility staff in
malaria
X
(1st group of CAs, first 6 villages)
training in malaria control X
(2nd group of CAs, phasing in of 6
additional villages) 3 AS, training in
nutrition and CDD
X X
Field agents, health facility staff in
reproductive health X
1st and 2nd groups of CAs, training in
reproductive health O O
Supervision of Field Activities X X X X X X X X X X X X
Workshop
Feedback on 3AS and IEC workshop
for field agents
X
Construction
Preparation for construction/space
renovation of health posts (assess the
level of community participation)
X X X
Construction and Renovation of
Health Posts O O O O O O O O O O
Activities Oct. Nov. Dec. Jan. Feb. Mar. April May June July Aug. Sept.
Provision of Equipment X X X
Start procurement process for health
post equipment
Microenterprise
Research mircoenterprise activities
(i.e., tissue making) for women’s
groups in villages covered by MCHI
O O
Microentreprise activities X X X X X X
Direct Assistance to the DPS
Promotion of vaccination days (Polio
1 & 2 ) and vitamin A
X X
Participate in monitoring of health
facilities X X
Participate in CTPS X X
Participate in CTRS X X
Reports Due
Quarterly Reports X X X X
Activities Added to the Time line - October 1998-1999
Activities Oct. Nov. Dec. Jan. Feb. Mar. Apr. May June July Aug. Sept. Oct.
FARN CYCLE 1 X X
FARN CYCLE 2 X
FARN CYCLE 3 X
Preparations for FARN Workshop X X X X X X
National FARN Workshop X
NGO Coordination Workshop (for
NGOs working in Dabola and
Dinguiraye)
X X X

MATERNAL AND CHILD HEALTH INITIATIVE (MCHI) MIDTERM EVALUATION
96
ANNEX H
REFERENCES
MATERNAL AND CHILD HEALTH INITIATIVE (MCHI) MIDTERM EVALUATION
98
REFERENCES
Africare Funding Proposal. Maternal and Child Health Initiative in Upper Guinea.
Submitted by Jeff Gray and Laura Heomeke. June 1996. Revised August 1997.
Annual Report. October 1998. September 1999.
Application du Foyer de Demonstration Nutritionnelle (Hearth Nutrition Mode). A
Dabola. Guinee. Mars 1999.
Continuation Application. MCHI. July 1998. October 1998.
Emphasis Behaviors in Maternal and Child Health. Technical Report. BASICS, 1997.
Guide pour les Agents Communautaires et Agents de Terrain: Etapes pour la
Preparation du Foyer de Demonstration Nutritionnelle. October 1999.
Rapport de l’Atelier National sur le Foyer d’Apprentissage et de Rehabilitation
Nutriitionnelle. le 11-15 Octobre 1999.
Rapport Synthese. Formation en la Sante Reporductive. September 1999.
Sustainability of a Community-Based Mother-to-Mother Support Project in the Peri￾Urban Areas of Guatemala City. Technical Report. BASICS and La Leche League,
1997.
Sustaining Health Worker Performance in Burkina Faso. Technical Report. BASICS,
1997.
Sykes, Diallo, and Kennedy. Knowledge, Practice and Coverage (KPC) Baseline Survey,
Anthropopetry and Iodized Salt Test. MCHI, March 1998.
USAID/Guinee. Country Strategic Plan. FY 1998-2005.
ANNEX I
 EVALUATION TEAM MEMBERS
MATERNAL AND CHILD HEALTH INITIATIVE (MCHI) MIDTERM EVALUATION
100
EVALUATION TEAM MEMBERS
Bonnie Kittle - Team Leader, Outside Consultant.
Gouley Cisse - MCHI Assistant Coordinator
Tadiba Kourouma - MCHI Assistant Capacity Building (newly hired)
Kadiatou Keita - Midwife from MOH (Conakry)
Abdoulaye Diallo - MCHI Assistant Supervisor
Etiene Wendeno - DPS Health Center Head