CARE PERU
ENLACE PROJECT
1996-2000
OTUZCO-JULCAN PROVINCES
LA LIBERTAD, PERU
FINAL PROJECT EVALUATION REPORT
October 2000
Prepared by: CARE USA contact:
Laura C. Altobelli, DrPH, MPH Judiann McNulty, DrPH
Public Health Specialist Deputy Director Child Health
This project was funded under the PVO Child Survival Grants Program CS-XII, 1996-
2000, by the United States Agency for International Development, USAID/BHR/PVC.
i
EXECUTIVE SUMMARY
The Enlace Project was designed and implemented by CARE from 1996 to 2000 in the poor
mountainous provinces of Otuzco and Julcán in the La Libertad Region of northern Peru.
The project was funded by the United States Agency for International Development under
the PVO Child Survival Grants Program, CS-XII 1996-2000. Project objectives were
focused on three interventions areas. The first area was prevention and control of diarrheal
diseases in children through increased breastfeeding and use of liquids, better recognition of
dehydration, decreased use of antibiotics and anti-diarrheal medicines for diarrhea, and
increased hygiene behaviors. The second set of objectives was on control of acute
respiratory infections and pneumonia through improving mothers’ recognition of danger
signs and increasing utilization of health services for treatment. The third intervention area
was improving maternal health through recognition of danger signs and symptoms in
pregnancy, childbirth, and postpartum, increased use of services for preventive care for all
pregnant women and for all women with complications in pregnancy, childbirth, and
postpartum. 
Main accomplishments of the Enlace Project were the design and development of several
innovative organizational strategies that are a major contribution to international work in
community health development. One was the design of organizational structures –
APROMSAs and COPROMSAs – for health promoters that allowed them to work within
a legalized institutional framework that represents promoters in their relationships with the
health system and other community leadership organizations such as municipalities. These
structures provided a firm basis for sustainability of health promoter work that is rarely found
in community health programs. Another innovation was the development of a complete
community surveillance system – SIVICS – that provided an effective methodology for
health promoters to identify and monitor community members at high risk of needing health
services (i.e. children under age one, pregnant women, and women of reproductive age). 
SIVICS has gained the attention of the Peruvian Ministry of Health, which is interested in
expanding the methodology to the rest of the country. Creative communication techniques,
designed based on community preference studies, were an important contribution to changing
health behaviors and attitudes toward use of health services. The Enlace project also
developed a gender approach to community health through training of “Women Leaders” in
communities instead of the more common male health promoters, increasing the cultural
acceptability and therefore effectiveness of health education to women on women’s health
issues. A unique model was developed for obstetrical emergency evacuation from remote
communities, based on organized readiness plans with participation of local authorities,
promoters, and community members.
Highlights from the comparison of baseline and final evaluation KPC surveys include some
of the following improvements in the target population between 1996 and 2000
• 46% to 64% of infants under six months were exclusively breastfed.
• 30% to 15% of diarrhea cases were treated with antibiotics or other medicines.
• 19% to 56% of mothers recognized two signs of pneumonia in children.
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FINAL PROJECT EVALUATION REPORT
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• 33% to 60% of children with cough, rapid or difficult breathing received medical
care.
• 3% to 51% of mothers identified two signs or symptoms of obstetrical risk.
• 45% to 93% of women with complications in pregnancy, delivery, or postpartum
received medical care.
Priority conclusions of the project were the following:
The project provided important confirmation that the organizational and managerial aspects
of a community health program are at least as, if not more, important as the technical
approach taken. 
One of the key features of the Enlace Project was the high degree of co-implementation with
the Ministry of Health (MOH). The participatory working style of Enlace strengthened both
institutional capability and acceptability of the project products on the part of the MOH.
The technical approach in the three intervention areas was effective because it was oriented
to best-recommended practices, with strategies based on pre-project analysis of mothers’
beliefs and practices. The focus was on preventive measures, identification of danger signs
and symptoms, and referral or emergency evacuation to a health facility.
The project identified the importance of using a gender approach to maternal health
interventions in communities, using of “Women Leaders” trained to promote maternal health
in the community, overcoming resistance to male providers and male health promoters.
The project highlighted the advantages of a flexible project design and open management
style to be able to respond to community-generated solutions to their needs for structuring
health services and designing information delivery systems.
Finally, suggestions based on project findings are provided at the end of the report as to how
the Ministry of Health should improve its policies to support the development of community￾based health systems in order to more effectively reach health sector goals of reducing
needless morbidity and mortality in the most vulnerable populations.
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TABLE OF CONTENTS
Executive Summary i
Table of Contents iii
Abbreviations iv
I. Introduction and Background 1
II. Assessment of Results and Impact of the Project 2
A. Results: Summary Chart 2
B. Results: Technical Approach 4
C. Results: Cross-cutting approaches 13
1. Community Mobilization 13
2. Community Health Surveillance 15
3. Communication for Behavior Change 16
4. Capacity Building Approach 18
a) Strengthening the PVO Organization 18
b) Strengthening Local Partner Organizations 19
c) Health Facilities Strengthening 21
d) Strengthening Health Worker Performance 22
e) Training 23
5. Sustainability Strategy 24
III. Program Management 27
A. Planning 27
B. Staff Training 28
C. Supervision of Program Staff 29
D. Human Resources and Staff Management 29
E. Financial Management 30
F. Logistics 30
G. Information Management 30
H. Technical and Administrative Support 32
I. Management Lessons Learned 33
IV. Conclusions and Recommendations 33
ATTACHMENTS
A. Evaluation team members
B. Assessment methodology
C. List of persons interviewed and contacted
D. Copy of formal agreement between
Agallpampa CLAS-APROMSA-Municipality of Agallpampa
E. Promoters trained by topic and micro-network
F. Description of APROMSA Development
G. Birth Planning Form
H. KPC Final Survey Report
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ABBREVIATIONS
ADD Acute diarrheal disease
APROMSA Asociación de Promotores de Salud
(Health Promoter Association)
ARI Acute respiratory infection
CARE Care And Relief Everywhere
COPROMSA Comité de Promotores de Salud
(Health Promoter Committee)
CLAS Comité Local de Administración de Salud
(Local Health Administration Committee)
DIP Detailed implementation plan
DISA Dirección de Salud Regional
(Regional Health Department Office)
EOC Emergency obstetrical care
HIS Health information system
IEC Information, education and communication
MOH Ministry of Health of Peru
NGO Non-governmental health organization
PRONAA Programa Nacional de Asistencia Alimentaria
(National Food Assistance Program)
PVO Private voluntary organization
SIVICS Sistema de Vigilancia Comunal de Salud
(Community Health Monitoring System)
TBA Traditional birth attendant
TOT Training of trainers
UPAO Universidad Privada Antenor Orrega
UTES Unidad Territorial de Salud
(Territorial Health Unit)
CARE PERU ENLACE PROJECT 1996-2000
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I. INTRODUCTION AND BACKGROUND
This is the final evaluation report of the Enlace Project, carried out by CARE-Trujillo, Peru,
under a grant from the PVO Child Survival Grants Program, funded by USAID/BHR/PVC,
in the funding cycle CS-XII 1996-2000. 
Enlace Project beneficiaries were 47,000 women of reproductive age and children 0-5 years
of age among an estimated 128,000 inhabitants living in 597 scattered communities in two
poor rural provinces of Otuzco and Julcán in the highlands of the Department of La Libertad
on the northern Pacific coast of Peru in South America. This inland zone of steep hills and
valleys has difficult access from the coastal departmental capital, Trujillo. The area has no
asphalt roads, and only the main roads between the five main towns are “firmed” dirt roads.
 Poverty in the area was exacerbated during most of the project implementation period due
to severe flooding (related to the El Niño phenomenon of 1998) and alternating drought. 
This was alleviated in the final project year with normal rains and a bountiful harvest that,
combined with reforestation projects in the area, created a stunningly beautiful landscape.
The provinces of Otuzco and Julcán comprise the territory covered by the Territorial Health
Unit (UTES) No. 8 of the Regional Health Office of La Libertad. Access to health services
increased dramatically during the past five years through a number of mechanisms put into
place by the Ministry of Health. The five health centers and 10 health posts mentioned in the
1997 Detailed Implementation Plan (DIP) increased by an additional 11 health posts for a
present total of 26 peripheral health facilities in UTES-8, in addition to the small hospital in
Otuzco. The “Strengthening Health Services Project” through an IDB loan provided
equipment and some management training. Staffing was facilitated by the “Basic Health for
All Program” (PSBPT), funded by the public treasury, which provides financial incentives
for health professionals to work in isolated facilities under 3- to 6-month contracts. PSBPT
provided for lengthening working hours of health facilities from 6 hours to 12 hours, and in
some facilities to 24-hour coverage. The majority of facilities are now open seven days a
week. Contract renewal under PSBPT depends on performance evaluations and monitoring
of service production. These rules resulted in improvements in work habits and increased
adherence to MOH norms for patient care. Still, high turnover of personnel was a problem.
At the beginning of the Enlace project, 80 of 88 MOH health staff in Otuzco-Julcán were
contracted by PSBPT. 
Another project working in the Otuzco-Julcán area was “Project 2000”, a maternal-child
health project financed by USAID Peru during 1995-2000 with goals to increase quality and
effectiveness of health services. The project was to provide a series of inputs such as
establishing a permanent capability in model hospitals and model health centers for training
of health personnel, systems for continual quality improvement, IEC, training of community
health workers, and others. Recently extended for a two-year period, Project 2000 has had
only partial implementation in Otuzco-Julcán, with initial activities just beginning in clinical
training of health personnel and some aspects of quality improvement. Community activities
under Project 2000 were not implemented in the Otuzco-Julcán area. CARE Peru is the
major sub-contractor to Pathfinder under this project.
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An important intervention in the Otuzco-Julcán area occurred in 1999, when the Regional
Health Office of La Libertad converted all health facilities in UTES - 8 to administration
under the “Shared Administration Program”1
, with five Local Health Administration
Committees (CLAS) conforming five micro-networks of the 26 health facilities. According
to the Regional Health Office of La Libertad, the conversion to CLAS in Otuzco-Julcán was
done in recognition of the “high level of community participation in health achieved through
Enlace.” One of several advantages of the CLAS model is that personnel are contracted by
CLAS under private sector law with additional benefits, so that personnel turnover is reduced
and quality is improved due to the social control over the health facility by the community.
Any evaluation of Enlace must take into consideration the above-mentioned health inputs
that may have influenced project impact. In other words, it may be difficult to attribute
improvements in project impact indicators only to Enlace. However, the in-depth key
informant interviews in communities, health facilities, the UTES, and DISA leave little doubt
of the major and probably lasting effect of Enlace on changing attitudes, paradigms, and
organizational structures in the communities of Otuzco-Julcán, and the potential of its
strategies for expansion to other areas. The expansion of Enlace strategies is already being
seen in their incorporation into other projects and programs through the MOH in other parts
of Peru. 
II. ASSESSMENT OF RESULTS AND IMPACT OF THE PROGRAM
A. Results: Summary Chart
Baseline and achieved values for all Enlace Project indicators are listed in Table 1in the
three main intervention areas: (1) control of diarrheal diseases; (2) control of pneumonia
cases; and (3) maternal health. The table also lists the expected values of the indicators, as
listed in the 1997 Detailed Implementation Plan (DIP). The confidence interval on the
percentage listed as achieved is provided in order to assess how well the achieved value
corresponds to the expected value. If the expected value is within the confidence interval of
the achieved value, then the objective was successfully reached. Several indicators
significantly surpassed the expected value.
 
1
 The Shared Administration Program is a new form of health services administration under the Peruvian health
reform in which an elected committee of community members forms a legally constituted private non-profit
organization (Comité Local de Administración de Salud - CLAS). The committee receives and manages public
funds under a contract with the DISA for implementation of a Local Health Plan. With the health facility
medical director as CLAS manager, the CLAS is responsible for monitoring implementation of the Local Health
Plan, with decision-making power for hiring and firing health personnel, for allocating of funds gained through
charging fees-for-service, among other responsibilities. As a private entity, CLAS can generate additional
funding for health-related activities from other public and private sector sources.
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Table 1
ENLACE PROJECT 1996-2000
OTUZCO Y JULCAN – PERU
BASELINE AND FINAL EVALUATION INDICATORS
CONTROL OF DIARRHEAL DISEASE
CONTROL OF ACUTE RESPIRATORY INFECTION / PNEUMONIA CASES
Increase from 33% to 60% the proportion of mothers with 60**
children 0-23 months of age who seek appropriate medical
care for their child with cough and rapid or difficult breathing.
32 60
51<p<61
Increase from 37% to 70% the proportion of children 0–23 70.7**
months of age with cough and rapid or difficult breathing treated
by MOH health providers or community health promoters. 
37 70
63<p<73
Increase from 18.7% to 70% the proportion of mothers who 56**
recognize two signs of pneumonia in children.
18.7 70
50.5<p<60.5
(%) INDICATOR
BASELINE
1996
EXPECTED ACHIEVED
2000
Increase from 46.4% to 70% the proportion of children less than 64*
six (0-5) months of age with exclusive breastfeeding. 
46.4 70
60<p<70
Increase from 70% to 85% the proportion of children 0–23 84.6
months of age who received an equal or greater amount of breast
milk during a diarrhea episode in the last 2 weeks. 
70 85
80.6<p<88.6
Increase from 63% to 75% the proportion of children 0–23 72.6*
months of age who received an equal or greater amount of liquids
and/or breast milk during a diarrhea episode in the last 2 weeks.
63 75
67.6<p<77.6
Increase from 49% to 65% the proportion of non-breastfeeding 63.0*
children 0-23 months of age who receive equal or greater amount
of food during a diarrhea episode in the last 2 weeks.
49 65
58<p<68
Decrease from 30% to 15% the proportion of mothers with 16.5*
children 0 a 23 months of age who gave medicines or antibiotics
when their child had diarrhea in the last 2 weeks.
30 15
12.5<p<20.5
(continued on next page)
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MATERNAL HEALTH
Increase from 60% to 80% the proportion of mothers who, 79*
verified by immunization cards or prenatal care cards, received
two or more doses of tetanus toxoide vaccine before the birth of
their child 0-23 months of age. 
60 80
75<p<83
Increase from 38% to 60% the proportion of mothers with at 72.7**
least one prenatal visit before the birth of their child 0-23 months
of age. 
38 60
67.7<p<77.7
Increase from 3.5% to 60% the proportion of mothers with 50.7**
children 0–23 months of age who can correctly identify at least
two signs or symptoms of obstetrical risk.
3.5 60
47.6<p<57.6
Increase from 24% to 80% the proportion of mothers who can 50.7*
correctly identify the health facilities that offer emergency
obstetrical care (EOC).
24 80
45.7<p<55.7
Increase from 45% to 65% the proportion of mothers with a 92.9**
prenatal, intranatal, or postnatal complication who are treated in
a health facility. 
45 65
90.2<p<95.5
TOTAL NUMBER OF CASES N=321 N=355
(*) Significant difference from baseline: p< .05
(**) Highly significant difference from baseline: p< .01
Source: Chavez, Carlos and Freddy Marreros, Proyecto Enlace Evaluación Final: 31 de julio – 20 de agosto
2000.
B. Results: Technical Approach
1. Overview of the project
The original project document (DIP) for Enlace provided a general program strategy that,
while solid in itself, was significantly surpassed in scope and depth by on-going strategy
development. Many of the innovations were born from continual suggestions from project
workers, health personnel, promoters, and the community itself. A flexible project
management style permitted various ideas to be tested and expanded to the entire project
area. The innovations, while maintaining original project objectives, involved implementing
new organizational structures and strategic alliances that provided a firmer foundation for
project interventions and post-project sustainability.
According to the DIP, the original project had three basic approaches to meet its goals. 
These were:
• Community-level participation – including community organization to resolve
maternal-child health problems, design in the community of an emergency
transportation system, training health promoters in three priority CS
interventions, utilization of improved IEC methods, and systems for community
monitoring that would be compatible with the standard MOH information
system. 
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• Institutional strengthening – specifically focusing on strengthening the
APROMSAS2
 and the MOH to improve their capacity to deliver sustainable
services in communities, especially child survival services. The original strategy
included building on a previous CARE Water and Sanitation (W&S) project in
the Otuzco area that had developed a large cadre of W&S promoters. That
project had helped to organize two APROMSAS in the areas of two out of five
health centers (micro-networks of health centers with their 4-5 health posts). The
APROMSAS were seen to play a role as links between MOH facilities and
promoters, providing a channel through which health care could better reach
communities, and through which communities could better express their needs
to the MOH. The idea was to strengthen the APROMSAS through training in
leadership and organizational development, eventually helping them to develop
a capacity to certify health promoters as able to carry out their functions in home
treatments and promotion. The MOH would be institutionally strengthened by
Enlace providing technical assistance to: (1) adapt the three priority CS protocols
(diarrhea, ARI, and maternal health) to the community level; and (2) improve
MOH training and logistics systems by training of trainers and support systems
to the community.
• Synergy with other CARE projects – including especially the CARE Water and
Sanitation Project, the CARE Multi-sectoral Population Project (PMP), and
Project 2000. The general plan of Enlace was to work on strengthening the
community and the link between MOH and community, while other projects were
to strengthen health facilities to deliver services.
As the Enlace project progressed, needs were identified, and specific strategies, many of
them innovative, were developed to meet those needs. By the end of the first year, several
issues became clear to project staff regarding the project plan:
• The original plans for strengthening APROMSAs in each micro-network would
benefit from an expansion to an organized promoter committee in each health
facility, not just one in an entire micro-network of health facilities.
• The community health surveillance system could be organized into an integral
community health system,
• The IEC approach needed a strong community-based orientation, and
• The expected synergy with other projects to strengthen health facilities was not
clearly on the horizon; therefore, action would have to be taken by Enlace to fill
some of the needs at that level to support their community health work.
In more detail, these innovations were:
APROMSAs/COPROMSAs -- Health promoters themselves identified the need for
decentralization of promoter organization down to the level of each health facility, resulting
in the development of COPROMSAs (Comités de Promotores de Salud), which would
 
2
 An APROMSA (Association of Health Promoters) is a legally constituted private non-profit entity with
statutes and regulations that guide its structure and functions.
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oversee the work of individual promoters. The APROMSAs, which were organized at the
level of a micro-network of health facilities, then developed a more managerial role in
coordinating with the MOH and other local organizations, planning, supervising, fund￾raising, and other means of supporting all COPROMSAs within its micro-network.
Community information system -- Design of a community surveillance system developed
into a very organized and integral system for community health diagnosis, risk assessment,
monitoring, identification, referral and follow-up of cases. The name SIVICS was given to
the system – Community Health Surveillance System (Sistema de Vigilancia Comunal de
Salud).
IEC approach -- The approach became one of basing the selection of messages and medium
on the preferences expressed by the community itself. A study was commissioned by Enlace
to the Department of Social Communications at the Universidad Privada Antenor Orrego
(UPAO) to identify the ways people prefer to obtain information in communities. The study
results were put into immediate use by Enlace to enrich the project IEC component.
Health facility personnel training -- Enlace provided many more training resources than
expected to health personnel to improve their capacities in the areas of information gathering
and utilization, educational methodology, leadership and management, and other specific
topics. These are listed in more detail below.
2. Progress report by intervention area
The three basic intervention areas were (1) diarrheal disease control, (2) ARI/pneumonia case
control, and (3) maternal health. Each of these is discussed here briefly, with the caveat that
the vertical program design in three specific intervention areas of child survival as expressed
in the DIP was not carried through in the same vertical spirit (to the benefit of the project).
Rather, the crosscutting approaches were the most important developments of the project that
strengthened sustainability, and that will allow easy expansion of effort to other important
health issues, such as child nutrition and growth, family planning promotion, and others that
were of expressed interest by the promoters and mothers in communities. Approximately
half of the Enlace promoters had been trained previously under other projects, and this was
reflected in the broad range of interests expressed by them in their requests for additional
training in the Annual Operating Plans developed by the APROMSAS.
It was useful for the project to work on only three intervention areas to focus attention,
facilitate learning, and simplify project implementation. In addition, fewer intervention areas
in this project allowed time for developing high quality methods for training and IEC
components. This facilitated the acquisition of skills by MOH personnel and promoters to
be able to transfer skills to other topic areas. 
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a. Diarrheal disease control
Excellent results were achieved by Enlace on diarrheal disease control indicators. All five
key indicators were achieved within 6 percentage points of the expected proportion, and four
of them were within 2.5 percentage points. 
The baseline KPC in 1996 showed that more than half of mothers did not know what danger
signs to look for in the case of diarrhea. During the project, the major messages transmitted
to mothers by Enlace promoters on diarrheal diseases were consistent with the MOH
National Diarrheal Disease Control Program standards to increase breast milk and liquids
during diarrhea episodes, continue feeding during diarrhea, reduce utilization of antibiotics
or other medicines, and to exclusively breastfeed children under six months of age for
prevention of diarrhea. Promoters also provided education on prevention of diarrhea through
better household and personal hygiene. 
Information on the prevention and treatment of diarrhea was clearly portrayed in flipcharts
and guides that each promoter had in her/his possession, that were utilized for group talks
or individual counseling in home visits to high risk families in the community. This work
was facilitated and focused by the SIVICS community surveillance system which allowed
promoters to concentrate monthly home visits on households with children under the age of
five, with special focus on under ones. With the SIVICS monitoring and reporting system,
promoters were motivated to provide information to mothers on recognition of diarrhea and
how to start early home treatment with increased breastfeeding, liquids, and feeding. 
Project staff reported that, at the beginning of the project, many mothers demanded oral
rehydration solution (ORS) salt packets to treat diarrhea at home. Enlace had to reinforce
the idea that promoters should teach mothers to increase their use of liquids (in general, not
with ORS) for diarrhea in the home, and how to recognize the signs of dehydration. The main
messages were: 1) the mother should start increasing liquids at home as soon as diarrhea
begins; 2) mothers should not use ORS salt packets for diarrhea cases without dehydration;
3) if dehydration occurs, take the child immediately to a health unit; and 4) do not use self￾prescribed medicines for diarrhea. 
Mothers also received hygiene messages from Enlace promoters who had previously been
trained as water and sanitation promoters under the CARE Water and Sanitation Project. In
the final evaluation qualitative interviews, a good number of the convenience sample of 37
promoters remarked that one of the ways in which mothers had changed was that they were
using more hygienic practices than before. Promoters also said they were seeing fewer
diarrhea cases now. These observations were supported by results of the final impact
evaluation showing a decrease in 15-day prevalence of diarrhea from 33.6% at baseline to
25.6% at the end of project.
In-depth interviews with a convenience sample of 26 mothers for the final evaluation showed
that nearly all had learned new things about diarrhea and hygiene from personal contact with
health promoters. Expected levels of behavioral change were achieved in four indicators
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related to home management of diarrhea, as shown in Table 1. Compared with baseline,
mothers learned to give an equal or greater amount of breast milk (considering only children
who were currently breast fed) during diarrhea (70% at baseline increasing to 85% at the end
of project); to give equal or greater amounts of liquids and/or breast milk during diarrhea
(63% increasing to 73%); and to give an equal or greater amount of solid or semi-solid food
during diarrhea (49% increasing to 63%). Breastfeeding was a topic that many had learned
about directly from promoters, with fewer mothers receiving information on that subject in
areas where the project had been active only in the final project year (micro-network
Callancas). This was consistent with reports from promoters interviewed in that zone who
had not yet received the training on breastfeeding, providing a possible explanation for why
the exclusive breastfeeding indicator fell a bit short of the expected figure. Despite the
shortfall, much was achieved. At baseline, 46.4% of children less than six months of age
were exclusively breastfed, and this increased significantly to 64% at the end of project. The
expected proportion had been set at 70%.
In addition to the project indicators on diarrhea disease control, data from the MOH
information system shows that the number of cases of dehydration treated in the UTES – 8
Otuzco-Julcán Network decreased from 38.7% 1996 to 21.8% in 1999.
Lessons learned in the diarrheal disease control component revolve around the importance
of the following characteristics of the Enlace strategy:
• Focus on danger signs and symptoms in training of promoters and education of
mothers.
• SIVICS system for continual home visits for education, monitoring, and referral.
• Referral and counter-referral system.
• Availability of educational material (flipcharts) to educate mothers on key messages.
• Existence of a receptive health care system that worked harmoniously with
community agents.
b. Acute Respiratory Illness/Pneumonia Cases
The DIP provided the framework followed by Enlace for ARI with the focus on teaching
mothers how to recognize the signs and symptoms of pneumonia. The strategy also included
working with mothers to ensure effective care and support at home for children with colds
and upper respiratory infections, discourage self-prescription of antibiotics, and immediate
evacuation to a health facility of children with signs or symptoms of lower respiratory
infection or pneumonia.
Enlace also would have liked to prepare all promoters to administer a first dose at home of
cotrimoxazole before transferring a case of pneumonia to a health facility. However, the
MOH had serious reservations on approving this. Enlace negotiated with the MOH to allow
promoters to handle cotrimoxazole if they live in communities that are distant from a health
facility, on the condition the promoter receive substantial training and supervision.
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The same as for diarrheal diseases, information on the early identification and treatment of
acute respiratory infections (ARI) and pneumonia was clearly portrayed in flipcharts that
were utilized by promoters in group talks and home visit counseling. The SIVICS
monitoring and reporting system motivated promoters to provide information to mothers on
recognition of signs and symptoms of ARI/pneumonia, and how it was essential to notify the
promoter immediately to assist them with seeking medical care if needed. As ARI
researchers note3
, it is difficult for even a physician at times to describe the difference
between a common cold and pneumonia, so the best course of action is to make sure the
child is seen by a health provider.
Enlace impact evaluation results showed successful implementation in changing mothers
knowledge and practice in ARI. The prevalence of ARI in the project area increased from
41.2% at baseline to 52% at the end of project, suggesting either a seasonal difference in
prevalence, or a better ability of mothers to identify and report respiratory symptoms in their
child. The final evaluation survey of 352 mothers found that 62.5% mentioned difficult
breathing as one of the danger signs of ARI, compared to 17% of mothers who identified this
symptom in the baseline survey. Another danger sign, sub-costal retractions (hundimiento
de piel debajo de las costillas) was mentioned by 32.1% of interviewed mothers, an increase
from the baseline value proportion of 0.6% of mothers who mentioned that as a danger sign.
In total, the proportion of mothers who knew no danger signs of ARI was reduced by more
than half from 47% at baseline to 20% by the end of project. 
Looking at actual behavior in the impact evaluation, there was an increase from 37% at
baseline in 1996 to as much as 71% of children ages 0-23 months with cough and rapid or
difficult breathing during the previous two weeks who received care from either promoters
or MOH providers. Considering the proportion of children in this age group with ARI who
were treated by MOH providers, a baseline value of 37% was increased to 60% at the end
of project. Impact evaluation results also showed an increase in the proportion of mothers
who recognize two signs of pneumonia in children from 18.7% at baseline to 56% at the end
of project. Although the achieved level did not reach the expected 70% on this indicator, the
increase of nearly 30 percentage points is a tremendous change of public health significance.
Lessons learned in the ARI/pneumonia component revolve around the importance of the
following characteristics of the Enlace strategy:
• Focus on danger signs and symptoms of ARI.
• Early evacuation for treatment at a health facility.
• SIVICS system for continual home visits for education, monitoring, and referral.
• Referral and counter-referral system.
• Availability of educational material (flipcharts) to educate mothers.
• Existence of a receptive health care system that worked harmoniously with
community agents.
 
3
 Mull, D et al. (1994) “Mothers’ perceptions of severe pneumonia in their own children: a controlled study
in Pakistan”, Soc. Sci. Med. Vol. 38, No. 7, pp. 973-987.
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c. Maternal Health
The area of Otuzco-Julcán has had one of the highest rates of maternal mortality in Peru due
difficult access routes and paucity of health facilities, in addition to cultural and economic
barriers to access. The Enlace strategy in maternal health was to provide mothers with the
principal messages on signs and symptoms of danger during pregnancy, birth, and
postpartum and the need for early evacuation to a health facility at any sign of complications.
Enlace promoted consistent professional prenatal and postnatal care and professional birth
attendance in facilities or in the home. 
A key aspect of the maternal health strategy was the development in each community of a
system for emergency evacuation. Enlace worked with community leaders and health
promoters to organize a community committee for emergency evacuation, which often
became part of the role of a community multi-sectoral committee or local health committee.
Every family in each community knew what its role was in case a pregnant woman, or
anyone else in a medical emergency, needed to be evacuated to a health facility. To evacuate
patients, each community had a litter made of a long canvas cloth with tubular slots sewn in
on each side (provided by Enlace) into which two long poles or branches (provided by the
community) were slid to form a stretcher. The rule was that the neighbors living on either
side of the person in danger were responsible for carrying the stretcher. The litter was stored
at the house of the health promoter or the home of a community leader; whichever was more
centrally located in the community. The litter was carried on foot, sometimes at great
distance, to the closest point where a vehicle could be found to transport the patient to an
appropriate health facility. The radio system installed by Enlace in all 26 health centers and
posts was used in these cases by health posts to call into network centers to send an
ambulance to pick up the patient. Though the emergency evacuation system was originally
meant for obstetrical emergencies, Enlace found that cooperation with the system was
increased in communities when the orientation was to any emergency. Complete information
is not available on how many lives have been saved with the emergency evacuation system,
but one anecdotal report was that at least 10 evacuations had taken place in one of the five
micro-networks of Otuzco-Julcán. Another micro-network designed a emotive mechanism
to encourage emergency evacuations, creating a poster with a ‘Garden of Life’
commemorating of all the children, women, and men whose lives had been saved, with their
photos glued on in place of the flowers. 
To complement the emergency evacuation system, CARE promoted family savings for
health expenses (the MOH charges for most services). First on a pilot basis in one micro￾network, CARE distributed plastic piggy banks to pregnant women and families with
children under five. This was so successful, the activity was then promoted by the
APROMSAs in the other areas. The piggy banks were sold by the APROMSAs at a small
profit. The family savings scheme was described more fully in the mid-term evaluation.
Through a series of focus groups with women in communities on the subject of
breastfeeding, Enlace found that an emphasis on maternal health required a female to
provide information, counseling, and referral for female health issues. The focus groups
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indicated that traditional birth attendants (TBA) or other women leaders in the community
could play this role, receiving the same training as health promoters, with an emphasis on
maternal health. Enlace chose well to assign the name, “women leaders” to this new
community agent. The volunteer community agents trained in maternal health therefore
included male and female health promoters and “women leaders”. Unlike other MOH
projects, such as Project 2000, that train TBA in how to attend “clean births” and provide
them with a delivery kit, Enlace made a policy decision to not promote home deliveries by
non-professionals. 
The training was on identification of signs and symptoms of complications and evacuation,
and promotion of professional care for all prenatal visits and birth attendance. Information
on maternal health was clearly portrayed in flipcharts in the possession of volunteers for talks
to groups of mothers or individual counseling to pregnant women. Again, this work was
facilitated and focused by the SIVICS community surveillance system which allowed
volunteers to concentrate monthly home visits on households with pregnant women and
women of reproductive age. With the SIVICS monitoring and reporting system, volunteers
were motivated to provide key information to mothers on maternal health.
Highly significant changes were recorded on mothers’ knowledge and behavior on key
indicators of maternal health. Enlace impact evaluation results showed an increase from
3.5% at baseline to 50.7% the proportion of mothers with children 0–23 months of age who
could correctly identify at least two signs or symptoms of obstetrical risk. This fell
somewhat short of the expected 60%. A much higher proportion of mothers identified at
least one symptom of obstetrical risk.
The indicator on correct identification of health facilities that offer emergency obstetrical
care (EOC) showed a baseline value of 24% of mothers of children 0-23 months of age,
increasing to 50.7% by the end of the project. This proportion could have been closer to the
expected 80%, but it is possible that health volunteers handled this information themselves,
and just made sure that women knew which facility to go to for prenatal care and birth
attendance, since only the hospital in Otuzco offers comprehensive EOC. At the time the
project began, it had been expected that Project 2000 would provide inputs for increasing
resolutive capacity for obstetrical emergencies in several of the micro-network health centers.
This has not occurred yet. Other indicators of maternal health service use reached the
expected value, or went significantly beyond the expected values. Receipt of two or more
doses of tetanus toxoide vaccine before the birth of their child 0-23 months of age increased
from 60% to 79% (expected was 80%). At least one prenatal visit was obtained by 72.7%
of women with a birth in the past two years, up from 38% at baseline in 1996, and
significantly surpassing the expected 60%. 
One of the most impressive results on the impact of Enlace was that 92.9% of women with
a complication in pregnancy, birth, or postpartum in the previous two years received
treatment at a health facility. This figure more than doubled the value of that indicator, 45%,
found at baseline in 1996. The other important finding was the increase in professional birth
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attendance from 14.5% at baseline to 34.8% at the end of project (disaggregated into 24.8%
in health centers or posts, and 10% at home by a professional).
Lessons learned in the maternal health component revolve around the importance of the
following characteristics of the Enlace strategy:
• Focus on danger signs and symptoms of pregnancy, birth, and postpartum and
immediate evacuation of complications.
• Training of female community agents (“women leaders”) for educating mothers on
women’s health issues.
• SIVICS system for continual home visits for identification of pregnant women,
education, monitoring, and referral.
• Volunteers assisting families to make a birth plan. (Attachment G)
• Referral and counter-referral system.
• Availability of educational material (flipcharts) to educate mothers.
• Existence of a receptive health care system that worked harmoniously with
community agents.
3. New approaches and special studies
Two major new approaches developed by Enlace were the organizational development of
promoter associations - APROMSAs and COPROMSAs (described in more detail in section
II.C.1. on Community Mobilization), and the SIVICS Community Health Surveillance
System (described in more detail in section II.C.2 on Community Health Surveillance). 
A smaller innovation was the implementation of a stand-alone counter-referral form. While
CARE has been successfully promoting referral counter-referral systems in many countries
in recent years, Enlace and the health unit staff created a modification, giving a form to a
patient who comes in without a referral to take back to their local health volunteer. This
serves to introduce the patient to the promoter’s role and alerts the promoter to follow-up
with the patient for treatment compliance, return appointments, etc.
Special studies conducted under the project and the way the information was used were as
follow:
Study on breastfeeding – Focus groups were held in 1998 to determine the best ways to
develop mothers’ breastfeeding support groups in communities. The results were used to
design and develop a Community Support System in Breastfeeding, the methodology of
which was taught to a group of 20 health care providers from health centers (1), health posts
(11), and the Otuzco Hospital. An evaluation of the actual organization of community
support groups has not been done. An important unexpected result of the breastfeeding focus
groups was to discover the importance to women of having other women give them
information on their health. Up until then, the great majority of health promoters were men,
and their role to discuss with women about women's health issues was little accepted by
either women or the male promoters themselves. These findings encouraged Enlace to
develop the strategy of “Women Leaders”, which found high acceptance among both men
and women in communities.
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Study on beliefs and attitudes of mothers in ARI and breastfeeding - This study was
commissioned to students at the Universidad Privada Antenor Orrega (UPAO) in Trujillo,
with the results utilized for developing educational materials for mothers. 
Study on preferences for communications methods - This study was also commissioned
to students at the Universidad Privada Antenor Orrega (UPAO) in Trujillo with the goal of
developing an appropriate and effective IEC strategy. The information gathered was put to
excellent use by Enlace to develop a varied and creative set of community education
methods that are described in more detail in section C.2. of this report.
C. Results: Cross-cutting approaches
1. Community Mobilization
Community mobilization was the centerpiece of the Enlace Project. Three different target
groups were health promoters (including promoter organizations, APROMSAs and
COPROMSAs), community leaders and organizations in larger towns (to form multi-sectoral
committees), and leaders and members of individual communities (to form local health
committees).
APROMSAS and COPROMSAS
The aspect that makes Enlace stand out as a unique community health project in Peru, in
Latin America, and perhaps in the world, is its system giving a unique and firm
organizational structure to health promoters. A formal health promoter committee
(COPROMSA) in each health facility groups together all the promoters in the relevant
surrounding communities. They pay a small quota to join the committee. The COPROMSA
elects a board of directors, with president, vice president, secretary, treasurer, and fiscal. 
Monthly meetings are held with all promoters and health facility staff, in which promoters
turn in monthly community surveillance reports, solve problems, and plan activities. To
support the COPROMSAs, an association of promoters (APROMSA) is formed, comprised
of the presidents of each COPROMSA in an MOH network of health facilities. There are
approximately 4-6 COPROMSAs represented in each APROMSA, which also elects from
among its members a board of directors, with president, vice president, secretary, and
treasurer. The APROMSA is a very strong and sustainable organization, since it is legally
inscribed in the public registry as a private non-profit organization. (See Attachment F for
more on history and organization of APROMSAs.)
The promoter organizations as developed through Enlace have gained the skills necessary
for self-management and for collaborating with the MOH as well as with a variety of other
community organizations. These relationships have even been formalized in signed
agreements (convenios) between APROMSAS, MOH health facility or CLAS, and municipal
governments that stipulate the obligations of each party in providing for community health
services. A copy of the signed agreement between the MOH CLAS Agallpampa, the
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APROMSA of Agallpampa and the Municipal Government of Agallpampa is attached in
Attachment D, as is that of micro-network of Usquil.
APROMSAs and COPROMSAs were trained to prepare annual operation plans, which they
review on a monthly basis to guide and evaluate progress on their activities. MOH
recognizes that the APROMSA and their annual operating plans allow promoters to function
more effectively in some of the following ways: 
a) Holding monthly coordination meetings with the health facility staff,
b) Coordinating with MOH staff to carry out preventive and promotional activities in
communities,
c) Organizing network and micro-network-wide contests and other IEC activities to
promote participation of the population in health-related issues, 
d) Getting individual promoters more involved and committed to their work in the
community,
e) Soliciting MOH and other multi-sectoral support for health promoters such provision
of training, supervision, and other types of coordination, and
f) Supervising and evaluating promoters.
APROMSAs have a complete system of self-supervision that provided an additional means
of technical and organizational sustainability after the end of Enlace. From the point of view
of the APROMSAs, there are at least five levels of supervision:
a) Promoters supervise mothers and children in communities,
b) COPROMSAs supervise and evaluate the work of individual promoters,
c) APROMSAs supervise COPROMSAs,
d) Coordinating Committee of APROMSA Presidents supervise APROMSAs, and
e) The MOH supervises the APROMSAs every three months.
APROMSAs and COPROMSAs view their organizations as benefiting promoters in the
following ways:
a) The organizations supervise the work of promoters, and identify training needs,
b) The organizations provide incentives for promoters to be motivated in their work,
c) The organizations have mechanisms to coordinate and make plans with MOH health
personnel,
d) The organizations have mechanisms to coordinate with local authorities to replace
promoters who have deserted or who do not work well, and
e) For many, the training and knowledge received as a promoter is the best benefit they
could receive.
A concrete sign of the consolidation and determination of these organizations, and the
community support being provided, was the effort of several APROMSAs and
COPROMSAs to obtain an assignation of land from the community governing body for he
building of their own permanent office and meeting hall. Some APROMSAs and
COPROMSAs had already been provided a temporary meeting place in a central location by
local authorities. Interviews with local authorities revealed that the APROMSAs and
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COPROMSAs have already gained recognition as another community organization that
deserves to be dealt with by the community government.
Community leaders and organizations in larger towns - multi-sectoral committees
Enlace actively sought to promote multi-sectoral committees in all towns with a health
facility and COPROMSA. There is no precise information on how far along these
committees had come in their development. Larger towns had a better level of development
than smaller towns. In any case, final evaluation interviews with 15 community leaders from
all parts of Otuzco-Julcán revealed that all, with exception of a very few who were new in
their posts, had a very high level of knowledge and approval of health promoter activities,
the COPROMSAs and the APROMSAs. More than half of those interviewed mentioned
ways in which the community leadership organization provides material support to the
promoters, including such items as gasoline and food for training sessions.
Leaders and members of individual communities - health committees
Leaders at this level were organized in all communities with assistance of Enlace to form
committees for emergency evacuation, with a plan of action for immediate mobilization to
evacuate mothers with obstetrical complications or any other type of medical emergency.
Near the end of project, Enlace was beginning to make progress in organizing health
committees in each small commune that would have a broader role than just emergency
evacuation, drawing on the leadership of all commune-based governmental and non￾governmental organizations, and in linkage with the health promoter committee
(COPROMSA). Communal leaders interviewed for this evaluation all attested to working
with promoters and supporting them to meet their needs. 
2. Community Health Surveillance
The data collecting system formed part of a systematic and integral system designed by
Enlace called SIVICS (Sistema de Vigilancia Comunal de Salud) or Community Monitoring
System. The system has the following components:
• Sectorization – Geographical mapping of the jurisdiction of a health facility into
sectors, each of which is assigned to a health provider who is then responsible for all
extramural work in that sector. Health promoters within sectors, each of whom is
responsible for approximately 30 families, work with the health professional assigned
to that sector.
• Community census – a house to house survey is conducted by promoters and is
updated on a continual basis on “family cards”, with information that is reported on
a monthly basis to the MOH facility on population size by age groups, including
monthly birth and death data.
• Community maps – each promoter creates a map of all houses for which s/he is
responsible, numbering the houses, and identifying with labels which have “high
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risk” members, i.e. under one year of age, pregnant woman, or woman of
reproductive age.
• Home visits – monthly visits are made to all “high risk” households to monitor health
and provide health education, and make referrals if necessary for preventive or
curative care at the health facility.
• Monthly reports – each promoter turns in a monthly report on number of high risk
persons in the community, number of cases of illness identified by type, number of
cases referred, number of educational activities completed, etc. 
• Extramural visits by health providers – based on monthly promoter reports, health
personnel can make specific monitoring and follow-up visits to high risk patients in
the community, accompanied by the health promoter in each sector, thus making
extramural work more efficient and effective.
It is clear that SIVICS is a data collection system that provides immediate inputs to a
community health management system. The role of COPROMSAS in monitoring the
monthly reporting system helps to ensure that promoters adhere to the system, and provides
sustainability to SIVICS.
SIVICS was a major development of Enlace that has drawn the interest of MOH officials in
the DISA of La Libertad, in other DISAs, and in the central level MOH General Office of
Epidemiology (OGE). The DISA Director in La Libertad, Dr. Henry Rebasa, expressed his
plans to expand SIVICS to all communities in his jurisdiction. The OGE Director, Dr. Percy
Minaya, provided financial and technical support to Enlace to develop a series of videos on
the SIVICS system to facilitate dissemination of the methodology to other areas, regionally,
nationally, and internationally.
3. Communication for Behavior Change
Methods used by Enlace for communication and behavioral change were of two main types:
(i) face-to-face health education provided by promoters to community members, and (ii)
community-wide IEC activities. In both, Enlace sought to promote a three-stage
methodology of adult education beginning with (a) motivations based on one’s own previous
knowledge and experience, (b) problem analysis based on general theory or facts, and (c)
reflection and commitment to change to an improved practice. 
In order to develop their IEC component, Enlace commissioned a study on the subject of
community communication preferences, done by students in a social marketing class in the
Department of Social Communications of the Universidad Privada Antenor Orrego (UPAO).
This important study allowed Enlace to really understand the mechanisms needed to
communicate new ideas to people and the best ways to develop the messages to communicate
new ideas. With this approach, Enlace was able to come up with some unique and effective
means to communicate and promote behavioral changes. All IEC activities were conducted
directly by community health volunteers or MOH staff with Enlace providing training,
support and materials.
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The types of communication methods promoted by Enlace were, specifically:
Face-to-face health education:
• Counseling during home visits.
• Talks with groups of mothers – through an agreement with PRONAA (National
Program for Food Assistance) which is managed through municipalities,
promoters were allowed time to give talks to women in their monthly meeting to
receive PRONAA foods.
Community-wide IEC activities:
• Art in health - Several types of activities were in this category. Contests were
held among women's community groups to see who could design the best wall
mural on a specific topic (for example, on the topic of promoting institutional
deliveries). The winning designs were actually painted on large natural flat rock
walls in towns or next to roads that would be clearly visible to all passing by. 
The incentive was to have one’s art displayed. Other contests were held to write
songs, poems, and skits on health topics.
• Tómbolas - are group games organized during community festivals that
congregate large numbers of people from all surrounding areas. This involves a
roulette-type wheel that someone spins, landing on a number that corresponds to
a question on health. If the player or anyone else in the audience answers
correctly, they win a small prize (i.e. an inexpensive but useful plastic household
item). Health personnel assist the promoters ahead of time to prepare the
questions and answers. This is one of the most popular IEC strategies that health
personnel considered sustainable, since the prizes were very inexpensive and
could be purchased with health facility resources.
• Radio shows and spots - Many small towns had local private radio stations that
could be used for a fee for weekly or daily radio shows on health-related topics.
Enlace subsidized the cost at first. Later, arrangements were made for another
local NGO to subsidize the cost for promoters. Radio show scripts on health
topics were developed jointly between promoters and health facility personnel.
The training approach of Enlace in working with promoters on IEC was to make sure the
promoter understood the reason WHY each danger sign and signal was important, and WHY
it was important to give specific information to mothers in health education sessions. This
orientation was important for them to focus on educating the community on danger signs and
symptoms in the three intervention areas (diarrhea, ARI/pneumonia, and maternal health),
and to promote use of health services.
Enlace learned some of the following lessons from their experience with IEC:
• Always start with a diagnosis of practices, customs, beliefs, and myths of the people.
• Respect people's customs.
• Know people’s customs, and seek which ones can be used for means of
communication (i.e. painting large wall murals designed by the people themselves).
• Messages and means of communication should be born from the people themselves.
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• Messages transmitted by the MOH, NGOs, and health promoters should be
consistent.
• Various levels of communication should be used for the same message to achieve
impact.
• Work on only one theme at a time in an IEC activity.
• Material should always be adapted to a particular zone.
• Health personnel and promoters must be able to handle educational methodology for
adults.
• IEC methods should be entertaining and artistic.
• Use contests whenever possible (to promote healthy competition, increase self￾esteem, and provide a social activity).
• Take advantage of opportunities such as community meetings for the promoter to
speak.
• Take advantage of technical resources in local universities and other NGOs.
• Include all local institutions and organizations in communities to implement an
activity in order to make it more sustainable.
4. Capacity Building Approach
a) Strengthening the PVO Organization
CARE USA is a well-established and internationally recognized development agency with
50 years of experience working in 100 countries around the world. The experience gained
through the PVO Child Survival Grants Program funding of Enlace provides CARE with
innovations and strategies that CARE will be able to apply to future community health
projects.
How has this grant improved the capacity of the PVO to design, implement
and evaluate effective child survival programs? 
[Judiann McNulty]: “This grant has allowed us to implement possibly our most
effective, sustainable CS project ever. By having a flexible DIP and focusing on
strategy rather than specific technical interventions, we were able to innovate and
perfect as the project was implemented. We have been able to work in an
environment that allowed us to refine our approaches to working through the MOH,
learning how to take advantage of what motivates them, in order to garner their
support for community health (extra-murál) at all levels – local, district, regional, and
national. Through this grant, we have also learned how to make a complex design
work with minimal staffing. In sum, this project has "pushed us to the maximum" in a
good way - taking us to a much higher level in Child Survival programming.”
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Have effects of this grant influenced other programs operated by the PVO?
[Judiann McNulty]: “In subsequent projects, we are using the same strategy of
working through the Ministry (as opposed to simply in partnership), we are focusing
more on sustainability using the concepts learned, and we are replicating the strategy
of organizing community volunteers in Nepal, Tanzania, and Nicaragua. Most
importantly, we have developed an overall children’s health strategic plan, which
focuses on taking strategies developed in district-level projects such as this to national
scale. We have accomplished this through Enlace in Peru and we now know we can
do it elsewhere.”
b) Strengthening Local Partner Organizations
Enlace contributed to building organizational capacity of local partners in these areas:
(i) Strengthening the organization of community health promoters – The work of Enlace
to help organize health promoters into the formally structured committees and associations
of COPROMSAs and APROMSAs has been discussed elsewhere in the report. Due to the
legal and therefore permanent constitution of these structures, one would have to say that this
is the most solid instance of institutional strengthening achieved by Enlace.
(ii) Strengthening MOH community health and participation policies - For the UTES
– 8, the work of Enlace to develop a model of community health in Otuzco-Julcán was key
to strengthening the health care system of the entire zone. An MOH official stated that
community work was critical for the achievements in health care coverage in the mountains
of Peru. He noted that the MOH, in general “hasn’t learned how to collaborate with the
community”, the reasons being that there is no MOH policy on community work, and that
university programs for education of health professionals produce health providers that resist
working with communities. Many would agree with that observation. The MOH official
was of the opinion that SIVICS and the APROMSA/COPROMSA organizations were
excellent ideas, being of practical use and sustainable, but a worry was on the side of
financial sustainability, since the MOH is frequently in financial crisis. 
The MOH solution to sustainability was to create a formal Directoral Resolution that
formalized within UTES – 8 all the elements of the Enlace Project. Thereby, the entire
Enlace strategy was made official, specifying responsibilities of health facilities in
continuing to support the training, supervision, monitoring, and supply of health promoters,
as well as the organizational structures and information systems set up by Enlace.
Enlace worked with MOH from project initiation, beginning with joint work on the baseline
data collection and initial planning activities. On-going joint planning between the MOH
and Enlace permitted a high level of coordination between the two institutions. The UTES
recognized the large number of promoters trained previously by different projects, such as
GTZ-PRAS, CARE Water and Sanitation, and CARE-PMP. The UTES credits Enlace for
working with all of these promoters and organizing them into strong associations. Without
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Enlace, those promoters would have been lost, but now the entire system is strengthened.
An MOH official observed that NGO projects need to seek sustainability from project
initiation, coordinating with the MOH and avoiding as much as possible the financing of
activities that will not be able to be continued with financing from the MOH afterwards. For
example, incentives provided for completing a prenatal visit, or covering all the costs of food
and materials for a training program for health promoters. The MOH would then be forced
to find other ways of covering these expenses in order to sustain the activities.
According to Dr. Henry Rebasa, Director General of DISA La Libertad, Enlace was
instrumental in strengthening the institutional relationship between the MOH, community
health promoters, and local political structures such as the municipalities. He also
recognized the institutional strengthening aspect of helping the MOH, especially health
professionals in health facilities, to understand that increased productivity in services can
result from increased community health work.
(iii) Strengthening MOH human resources - Enlace could be credited with strengthening
the capacity of human resources in the DISA, UTES, and health facilities through various
program management activities. For example, Enlace included MOH staff from all three of
these levels in meetings and activities for:
• developing Enlace overall operational plans,
• developing micro-network operational plans in each micro-network,
• presentation and discussion of annual progress reports,
• evaluation planning,
• implementation of evaluations,
• presentation of evaluation results.
Results of the project’s participatory working style were to strengthen institutional capability,
increase acceptability of the project itself, and thus strengthen possibilities for project
sustainability. This represents somewhat of a watermark in MOH experience with
NGOs in Peru. Frequently in other projects, a lack of trust on the public sector side is a
detriment to successful transfer of knowledge and skills from the private to public sector.
(iv) Strengthening health networks and micro-networks - Enlace strengthened the
formation of the Network of UTES – 8 (Red UTES 8) and five micro-networks (Micro￾networks Agallpampa, Callancas, Ramón Castillo, Julcán, and Usquil) through a number of
mechanisms to strengthen the resolutive capacity of health facilities to respond to
emergencies and to administer community programs, including:
• Provision of 25 radios in 29 health facilities were a major contribution of Enlace to
strengthening the health care system in Otuzco-Julcán, especially given the difficult
access conditions and lack of telephone communications. (Information on the utility
of the radios was included in the mid-term evaluation report.)
• Coordination with the UTES on where to distribute Enlace-funded radios and other
resources.
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• The community-level information system strengthened the monitoring by micro￾networks and on a network level with opportune information. Enlace provided
training in EPI-INFO to facilitate compilation of data and analysis.
(v) Strengthening sustainability of community health processes - DISA La Libertad
officials noted several products of the Enlace Project that provide sustainability to MOH
community health development efforts:
• System for health education of mothers,
• Referral and counter-referral system,
• System for training of promoters,
• System for organizing promoters in APROMSAs and COPROMSAs,
• Model agreements between MOH-APROMSA-Municipality, and
• Model for community surveillance – SIVICS.
The DISA La Libertad says they are currently planning to expand the SIVICS model to at
least three other provinces in the Department, using it specifically to address the problem of
maternal mortality. They plan to support the development of APROMSAs and
COPROMSAs in those areas, which they see as essential to ensure the successful functioning
of SIVICS.
c) Health Facilities Strengthening
Strengthening of health facilities was included in the original DIP as mainly oriented to their
role in training, supervision, and logistics for supporting community promoters,
APROMSAs, and COPROMSAs. Strengthening of the training system was accomplished
through the Enlace system for the training provided to health personnel: training of
personnel in micro-network centers was done by Enlace with participation of UTES
personnel plus micro-network center personnel with experience; training of personnel in
health facilities was done by Enlace with participation of micro-center personnel plus health
facility personnel with experience. Strengthening of supervision capabilities was
accomplished by developing supervision instruments and helping to organize monthly
meetings between health personnel and promoters.
Continuing problems that made it difficult for health facilities to support extramural work
include: changes in health personnel, lack of fuel when funds did not arrive from Lima, and
lack of formats needed for SIVICS reporting system.
The original Enlace Project plan assumed that Project 2000 would take charge of most
aspects of health facilities strengthening, allowing Enlace to focus on community and on
making the link between health facility and community. Project 2000 installed management
committees (comités de gestión) in each micro-network in Otuzco-Julcán. Since Project 2000
completed only initial activities in the Otuzco-Julcán area, many health facility needs were
left unmet. Several needs were identified (lessons learned) for strengthening the health
facility to enable it to support community work:
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• Strengthen the management committees from the beginning of the project in order
for them to serve as the MOH counterpart for promoters and promoter associations.
• Install a system for performance evaluation in the health facility that considers four
sets of performance indicators: intramural management, intramural health services
delivery, extramural management, extramural health services delivery.
• Recognize community health work as part of the production of services that is
required for personnel evaluation.
• Find a way for health facilities to dedicate a budget line item for forms and
transportation to communities.
d) Strengthening Health Worker Performance
Health facility personnel were included in all the training provided for promoters,
APROMSAs, and COPROMSAs, resulting in the strengthening of skills and capability of
health facilities on a variety of issues related to support of promoters. A table in Attachment
E shows the courses given for MOH personnel by topic and profession. These included, for
example:
• Educational methodology for adults,
• Use of EPI INFO for data management,
• Management of SIVICS,
• Improved data reporting and processing of the MOH information system (HIS) for
diarrhea, ARI, and maternal health services,
• Use of community health information for management purposes,
• Leadership and management for APROMSAs, including how to develop annual
operating plans for APROMSAs,
• Breastfeeding counseling skills and organization of community breastfeeding support
groups,
• Personal and collective leadership strengthening of “Women Leaders”, and
• Planning for the systematization of the Enlace Project.
Health personnel were able to see that the organization of community work by promoters in
identification and referral of cases was helping them to meet their required goals of health
services coverage4
. They realized that by taking on health promoters as allies and sharing
with them their specific needs for health services production, that the promoters were further
motivated to collaborate with them, strengthening the links between health facilities and
communities. 
 
4
 The MOH requires monthly production figures by each health area within each vertical health program,
based on estimated population. This system is useful in “motivating” health personnel to do case-finding,
but at the same time is perverse, since population estimates may seriously under or overestimate the true
population, and the goals are mostly oriented to curative and not preventive health services.
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In the final evaluation interviews, health personnel themselves identified changes that had
taken place in their work because of Enlace. These included:
• Increased use of integrated health care approach.
• Increased use of family files for integrated admission procedures.
• Previous focus on immunizations and growth & development, now more focus on
preventive activities such as education, follow-up of cases in the community, and
identification of pregnant women in the community.
• Better relationship with communities – communities and health providers know each
other better now.
• Better-planned extramural work with promoters coordinating visits with
communities.
e) Training
MOH health facility personnel felt that the training provided to promoters by Enlace was
more effective than previous training provided by MOH to promoters, especially noting the
effectiveness of the Enlace flip charts on each subject area (diarrhea, ARI, maternal health)
that were used for training promoters who in turn used the same materials for educating
mothers. Providers considered that training of promoters before Enlace was not well
organized, lacked MOH funds, and lacked an organization on the part of the promoters such
as the COPROMSAS. Many health personnel interviewed felt that promoters still needed
continuing training on health subjects to improve their knowledge and skills in educating the
community.
Enlace provided training of trainers (TOT) to health facility personnel in workshops on
“Methodology for Adult Education” which provided a useful method for planning behavioral
change, called AAMMEE. This stands for: Analysis (of the problem, the target population,
beliefs, behavior change objectives, etc.); Attention (plan to draw attention to the subject);
Motivation (making people recognize the problem); Message (provision of correct
information on the problem); Exercise (group dynamics for participatory learning); and
Evaluation (feedback on message comprehension). This component of TOT training was
considered highly useful by all health personnel interviewed in the final evaluation.
A listing of all training provided by Enlace is found in Attachment E, showing the types of
training provided, number, and type of training participants.
Evidence that the training strategy was effective - There are innumerable types of
evidence that the training strategy was effective. Regarding training of health promoters, one
can see evidence of the training in the following results, for example:
• Each promoter’s community map.
• Monitoring panels identifying pregnant women, cases of diarrhea and
ARI/pneumonia.
• Monthly SIVICS report of each promoter.
• Monthly home visiting plans.
• Reports on supervision of individual promoters by COPROMSAs.
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• Annual operating plans of APROMSAs and COPROMSAs.
• Notebooks with minutes of each COPROMSA meeting.
• Notebooks with minutes of each APROMSA meeting. 
• Correspondence of COPROMSAs and APROMSAs requesting coordination with
other institutions, for fund-raising, etc.
• Use of evacuation litters in communities.
• Use of family bank for emergency expenses.
Regarding training of health providers, one can see evidence of the training in some of the
following results:
• Improved consistency between HIS data and program data.
• Increased use of counter-referral slips.
• Community map with sectors indicated.
• Schedules for extramural visits to sectors.
• Health personnel knowledge of project objectives, and functions of promoters,
APROMSAs and COPROMSAs.
• Schedules for monthly meetings with promoters.
5. Sustainability Strategy
Sustainability goals and objectives - Four major goals of the Enlace sustainability strategy
as listed in the DIP were: a) the APROMSAs are effective advocates of change, b) the
promoters mobilize communities to demand quality child survival services, c) community
leaders administer local responses to needs, and 4) the MOH deals with themes of quality of
care and equity. All of these major goals were met, including the specific objectives
articulated in the DIP for each goal. 
The “required activities” identified in the DIP varied somewhat from what the project
actually did to meet the objectives. For example, the vision of how APROMSAs would
support promoters to create change under the first goal was significantly broadened from the
plans elaborated in the DIP. 
The fourth goal for the MOH to deal with quality and equity was met to a lesser degree,
because the technical assistance to have been provided by Project 2000 did not come through
in time. “Required activities” for the fourth goal, regarding approval of norms and clinical
protocols, and personnel performance evaluations, were implemented in other parts of the
country by the Basic Health and Nutrition Project (PSNB) funded under a World Bank loan,
but not in the Otuzco-Julcán Network. Coordination between CARE and Project 2000 could
have been better. The Enlace project manager made a concerted effort to maintain
communication with the local Project 2000 coordinator (also a CARE employee), but there
was insufficient support from CARE Lima to assure synchronization of activities.
Phase-over plan - The project has been run since the beginning with implementation by and
through the MOH. Enlace has provided technical assistance at all times and at all levels of
CARE PERU ENLACE PROJECT 1996-2000
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the health system so that the project would in effect be “owned” by the MOH at the end of
project. 
DISA level: The Project Coordinator, Dr. Luis Espejo, worked continually with his
DISA counterpart, Lic. Luisa Ancajima, in charge of the Community Participation Office for
the DISA, and other DISA officials. Plans are being made by the DISA to use Otuzco-Julcán
as a training area for extension of the Enlace model to other provinces in La Libertad, and
to other DISAs as well.
UTES level: The Chief Technical Assistant of Enlace, Alejandro Vargas, worked
with his counterparts in the UTES–8 Otuzco-Julcán Network. The UTES Director signed
a Directoral Resolution, thus making an official regulation to maintain all components of the
Enlace strategy in MOH facilities of the UTES.
Health facility level: Enlace professional field staff personnel worked with MOH
health facilities to provide the technical assistance necessary so that MOH personnel would
train and supervise the promoters, APROMSAs, and COPROMSAs. The project is ending
now in Otuzco-Julcán, and no further technical or management assistance will be provided
by Enlace. However, health personnel state that they plan to continue training promoters and
working with APROMSAs. Health personnel say they will continue to meet with community
leaders to inform and involve them in health activities. Nearly all health personnel see the
APROMSAs and COPROMSAs as very solid organizations that are sustainable. At the same
time, some MOH personnel say they need help to train promoters, and that the APROMSAs
still need additional strengthening through more training. Many were concerned that there
will be no MOH resources for training, and that it will be difficult for the APROMSAs to
generate all the necessary resources on their own. They were also concerned about their
perception that the DISA does not prioritize community work.
Financial sustainability – The main issue of sustainability that is of concern to MOH
officials and staff at all levels, from the DISA on down, is the financial sustainability. 
Enlace paid for all costs of promoter and MOH personnel training, materials, activities,
meetings, etc. during the entire project until the final year when costs where beginning to be
transferred to the promoter associations themselves, with plans made for the associations to
acquire financial independence. APROMSAs and COPROMSAs were trained in how to
organize fund-raising activities, such as raffles, chicken barbecues, and other community
activities, precisely to ensure their self-sustainability. New promoters were charged a fee of
five soles (about US $1.50) to be enrolled as a member of COPROMSA. A rule was agreed
that 15% of COPROMSA income was to be given to the APROMSA. These strategies were
having some success. 
Still, there are costs for certain items that will need subsidizing from somewhere, without
which some project activities are in danger of collapsing. This particularly concerns the
continual reprinting of forms for the SIVCS surveillance system and a series of other forms
for monitoring and supervision. At the end of the project, the UTES-8 was beginning to
realize that printing costs might not be too excessive, once they made some cost calculations.
The solution discussed was to have each micro-network budget for its own forms and pay
the UTES to print the forms in bulk for economy of scale. A final agreement had not been
reached as of preparation of this report.
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Another issue is the financing of monthly promoter meetings in the health center run by the
COPROMSA and health facility personnel. These meetings are critical to keep promoters
in the loop, motivated, to provide them with new information or training, and to maintain the
monthly reporting for SIVICS. Due to distances, promoters usually have some transportation
and food costs. Various types of arrangements were being explored to cover the food
problem, such as agreements with government food programs (PRONAA), asking the
promoters’ communities to send food to be cooked at meetings, or having the promoter bring
her/his own food. Transportation cost was still a question. Of course, none of these small
costs would be a problem if the MOH had a policy to allow vertical child survival program
budgets to cover some of these costs, or if CLAS would use some of its self-income for
community health activities.
Demand for services - As to whether the project has built demand for services, we are
convinced that the strategies implemented of well-focused health education provided by
promoter, SIVICS, the referral system, and organizational efforts in communities for the
emergency evacuation system have all contributed importantly to a sustainable demand for
services. Data5
 show that the number of patient-care contacts for children under five years
of age in the Otuzco-Julcán Network of 26 health facilities increased from 23,945 in 1995
to 61,782 for the year 1999. As discussed in the introduction, it is difficult to determine how
much of this can be solely attributed to Enlace, considering the other MOH inputs into
strengthening health services availability and quality during the same period. This qualitative
final evaluation suggests that the promoters served an extremely important role to identify
high-risk cases, educate community members, and make successful referrals.
 
5
 Official data of the DISA La Libertad - Office of Statistics and Informatics, based on the HIS reporting
system.
PATIENTS ATTENDED IN OTUZCO-JULCÁN AND REFERRALS BY 
HEALTH PROMOTERS 
1993-1999
1
10
100
1000
10000
100000
1993 1995 1997 1999
YEAR
CASES
Patients Attended
Referrals
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Was community engaged to influence provision of services - As health promoters increase
their leadership in communities and begin to take more of a role as elected community
members of CLAS, they will have an increasing possibility to influence how health services
are delivered. At this time, each of the five CLAS in the Otuzco-Julcán Network have
between one and five health promoters serving on the six-member committees. In the
Agallpampa Micro-network, an Enlace health promoter who became president of the
APROMSA is now the president of the showcase CLAS Agallpampa. This is an outstanding
example of community health leadership development through a project, interacting with a
health sector reform initiative to permit citizen participation in health.
III. PROGRAM MANAGEMENT
A. Planning
Planning process - Project planning for Enlace was done by CARE staff and consultants
based on previous CARE project experience in the Otuzco-Julcán area. Experiences in other
areas of the world were also drawn on. The actual process of implementation used the
original plan as a basis, but progressively modified the plans based on inputs from
communities, promoters, COPROMSAs, and APROMSAs.
Practicality of the DIP – The detailed implementation plan (DIP) was a good basic working
document that, in retrospect, could have anticipated some issues, leaving these as lessons
learned for future projects. These lessons included:
• Presumptions were made about inputs from other projects on which the Enlace
project depended. The lesson is that all indispensable components should be
included as part of the project, not depending on presumptions. For example, the DIP
assumed that health personnel and facilities in micro-networks would have a
reasonable resolutive capacity to treat obstetrical emergencies. Enlace found this not
to be the case.
• The DIP assumed that Project 2000 would provide clinical protocols on child survival
interventions for training and performance monitoring and evaluation of health
personnel. This was not the case. An attempt should have been made to coordinate
the use of clinical protocols in integral child health and maternal health developed
by the PSNB project. Project 2000 had an agreement with PSNB to not duplicate the
effort of developing new protocols.
Gaps in the DIP – Several issues were identified that were not included in the DIP, but
should be included in future DIPS, based on Enlace experience. These are listed as follows,
with a description of how Enlace addressed the issue during project implementation:
• No mention in the DIP of gender focus– Enlace created a line of work with “Women
Leaders” to promote women’s health in communities.
• No mention in the DIP of strengthening organizational aspects of the health services
– Enlace worked to support the organization of the Otuzco-Julcán network into
micro-networks, and instituted the strategy of “sectorization” of communities to
organize the extramural work of MOH health providers. 
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• No mention in the DIP of strengthening organizational aspects of health promoter
associations and how these would articulate with health services – Enlace made
tremendous progress in creating legal and sustainable organization structures for
health promoters, and the design of mechanisms for the articulation with health
services and other community leadership organizations.
• No specific mention in the DIP of how communication strategies would be developed
– Enlace developed a mechanism of community level (bottom-up) design of IEC
strategies.
• No specific mention in the DIP of how a community obstetrical emergency
evacuation system would be implemented – Enlace developed a system based on full
community participation, with structured organizations of community leaders, health
promoters, and community members to take charge of the system in each community.
Enlace also developed the idea (based on community suggestions) of helping
communities obtain stretchers made with simple appropriate technology for carrying
patients in emergencies.
• No mention in the DIP of savings plans for emergencies – Enlace developed and
promoted a family savings system using piggy banks. This system, where
implemented in the project area, had a very enthusiastic response among women who
learned that it was to their benefit to store spare coins for health needs, since only
some health services are free from the MOH.
In summary, Enlace did much to augment the DIP, which had more of a focus on technical
health service issues. The project was taken as a “work of art in progress”, with an on-going
identification of gaps, and working with health facilities and communities to seek
organizational solutions to organizational problems. Future DIPs should recognize the need
for organizational solutions and should try to budget for them, but not assume having full
knowledge of what will be needed or what will be the best solutions.
B. Staff Training
Enlace staff attended at least ten different courses during the project period, some in Peru
and others internationally, most organized by CARE International and others offered by
Peruvian technical organizations. Enlace staff who attended a course were expected to
replicate the training for the remainder of staff who didn’t attend. Enlace saw these courses
as having been key to the development of various innovations within the project. The fresh
ideas and exchanges of materials and methods from CARE projects in other countries served
many purposes for Enlace: staff motivation, personal development of staff members, and
maintenance of teamwork. 
Courses taken by Enlace staff were on the following subjects: indicators and data collection
instruments for community work, referral systems, supervision, community empowerment,
sustainability based on organizational strengthening, institutional strengthening, strategic
planning, leadership and project design, planning for training, IEC, maternal health, and
participatory evaluation.
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C. Supervision of Program Staff
Adequacy of supervisory system - Three levels of program supervision were implemented,
most of which was considered highly effective in content and methods. These were:
1. CARE International (Atlanta, GA) to CARE-Trujillo: The Deputy Director of Child
Health of CARE USA made supervisory visits twice a year during the entire project
duration. The technical input was felt to be excellent. Project personnel considered
this an important accompaniment for them to validate the decisions being made on
the ground.
2. CARE Peru in Lima to CARE-Trujillo: Frequent supervisory visits were made to
Trujillo from the main CARE Peru office during the first phase of the project, with
an excellent level of technical input and support. Much less direct supervision from
this level was carried out in the latter phases of the project was done, with
communications mainly by telephone and electronic mail. 
3. CARE-Trujillo to Enlace Project field staff: Supervision meetings were held at least
once per month in the field during the first two years of the project when the major
project components were being designed and installed in the field. In the last two
years of the project, these meetings were more like learning interchanges with
exchanges of experiences among project staff to disseminate new ideas. Monthly
reprogramming of activities was done based on different staff experiences.
Institutionalization of the CARE supervisory system is not relevant to this project, since there
is no plan to continue to project. The supervisory system developed within the project for
self-supervision of APROMSAs and COPROMSAs and health promoters was
institutionalized within the statutes of the promoter organizations.
D. Human Resources and Staff Management
Personnel policies and procedures - The Enlace project was not intended to be self￾sustaining as a project after the end of four-year funding cycle. Rather, the project was
designed and implemented to be absorbed into MOH operations by MOH personnel. 
Therefore, the sustainability of Enlace personnel policies and procedures is not relevant. 
Morale, cohesion and working relationships - The external evaluator observed a high level
of moral and cohesion among Enlace staff, which was clearly reflected in several indicators.
First, the staff-turnover during four years of operation was minimal. There were eight core
field staff: one coordinator (a physician) and seven technical and program assistants (three
nurses, one midwife, one nutritionist, one social worker, and one administrator). Only one
of them left Enlace and this was after three years with the project. (She was transferred to
another CARE child health project to apply the skills and lessons learned from Enlace to that
project.) The continuity achieved in project relationships with communities, health
promoters, and MOH personnel was one of the factors that contributed to project success.
Secondly, the Enlace staff has chosen to continue working together in a new CS project in
an area of even more difficult access than Otuzco-Julcán. 
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Staff transition – All but one of the Enlace staff have transferred employment to a new
Enlace-type project deeper into the mountains.
E. Financial Management
CARE is a firmly established institution internationally, with 30 years of experience of
financial management in Peru with most of it’s funding from USAID. Many years of
successful financial audits have shown the fiscal integrity of the institution and its accounting
procedures. In the case of Enlace, the accounting was managed under standard operating
procedures with no major issues arising, according to the Financial Manager of the CARE
Peru office in Lima. 
The CARE Trujillo staff reported some information-related problems for the project office,
due to its administrative distance from both the main country office in Lima and the
international office in Atlanta. The CARE-Trujillo office did not feel that it was ever
provided with complete information on project financial status, since CARE-Lima managed
most of the budget, including salaries and most purchases. This created a challenge for
CARE-Trujillo to adequately program its expenses on a month-to-month basis. Near the end
of project, CARE-Trujillo was advised of a balance in its favor, which had to be hurriedly
programmed in order to not lose it. They would have preferred to spend the money over a
longer period to support activities.
F. Logistics
Logistics for the project administration and some project operations were coordinated
between the CARE offices in Lima and Trujillo. Large purchases such as vehicles were
made directly by Lima, with recommendations made by Trujillo. Other purchases were made
by either Lima or Trujillo, based on where the best prices could be obtained for the products.
Medicine-related supplies required for implementation of community health activities were
all under the responsibility of the MOH. For Enlace, the logistics system of the MOH was
responsible for distribution to health facilities of ORS salt packets and, for promoters living
in distant communities for whom it was relevant, supplies of cotrimoxazole. For the most
part, the MOH system was efficient in maintaining supplies.
G. Information Management
Effectiveness of progress measurement – The baseline and end-of-project KPC surveys
appeared to be well done in terms of sample selection, data collection, and analysis. It would
have been helpful to have a control group in a different province with both baseline and final
measurements to control for the effects of other MOH inputs in the primary care system that
may have contributed to the dramatic increase in health service coverage in the Otuzco￾Julcán area. Enlace did collect data to be compared to the final survey in a neighboring
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province Huamachuco. While Huamachuco supposedly had the other same inputs from the
various MOH institutional strengthening programs, it is more remote with higher levels of
poverty and lower literacy resulting in limitations in direct comparability. (See results of the
KPC survey in Attachment H.)
Near the end of year three, the project conducted a rapid assessment using the 30-cluster
sample methodology to assess whether the project IEC strategy was bringing about changes
in knowledge and behaviors among the target population. A complete report of these results
was included in the Third Annual Report. Based on these results, Enlace re-emphasized the
role of the community health agents (volunteer promoters and women leaders) as conveyors
of information and facilitators of behavior change in individuals and families.
To support its quantitative measurements, Enlace did well to conduct focus groups on a
yearly basis throughout the project to assess community reaction to project inputs and
determine how to improve interventions. Focus groups and interviews were also conducted
for the mid-term evaluation.
Improvements in MOH information systems due to Enlace - At least three different
strategies were used to assist the MOH to improve its data collection and usage. 
1. HIS – The HIS is the standardized health information system used by the MOH to
code and register all patient care contacts. This system has always had problems with
reliability and validity due to little personnel training in how to fill out the form,
exacerbated by high turn-over rates of personnel and little pre-service orientation for
new staff. Enlace provided special training to health personnel in the Otuzco-Julcán
Network to improve their skills in filling out HIS forms so that there is more
consistency with data reported on each vertical program.
2. Vertical program reporting forms - Enlace was instrumental in getting the UTES
to include data items on their reporting forms for diarrheal diseases, ARI, and
maternal health which quantify the work of community health promoters. These
were: 
• On the diarrheal disease program reporting forms: # of cases referred by
promoters
• On the ARI program reporting forms: # of cases referred by promoters
• On the maternal-perinatal health reporting forms: # of deliveries attended by
traditional midwives and promoters and # of referrals from volunteers.
3. Community information system - Enlace developed a community monitoring
system and helped MOH facilities to install and learn to use EPI INFO software to
track monthly reports submitted by health promoters. Information on case
identification in the community by each promoter and the response to each case (i.e.
whether an educational session or if a referral was given) was entered into a computer
and analyzed. The system allowed the MOH to track whether or not the case
management provided by promoters was appropriate. For example, for each case of
child dehydration identified and reported by a promoter, the data analysis would
show if the cases were continuing breastfeeding, if education was given to the
mothers on breastfeeding, and if the dehydration cases had been referred (all cases
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were supposed to be referred). If it was found that children with dehydration were
not referred, or if some other aspect of appropriate care was not completed, then this
information was used in monthly meetings with promoters to reinforce training on
proper management of dehydration. Some health facilities needed additional training
in use of EPI INFO, and will continue to need updating as new staff enter.
Project information has been utilized within CARE and USAID in Peru to support expansion
of project strategies to other program. The MOH is utilizing project information now to
disseminate project strategies to other MOH programs and other DISAs.
H. Technical and Administrative Support
Technical support was provided through the contracting of NGOs or individual consultants
who were expert in specific technical areas identified as needed by Enlace. Most of the
support was in the form of designing and implementing one or more training sessions or
workshops attended by MOH health facility personnel, promoters, and Enlace project staff.
Once the initial training was given, Enlace staff or MOH personnel took charge of
implementing replica training to other persons. All of this training was put to good use by
the project. Technical support was obtained in the following areas:
• Breastfeeding promotion and community breastfeeding support groups – by CEPREN
(Centro de Promoción y Estudios en Nutrición), a Lima-based NGO.
• Community empowerment – by ATINCHIC, a Lima-based NGO.
• EPI INFO – by a CARE Lima expert, Freddy Marreros.
• Use of information for management – by a Project 2000 Monitoring and Evaluation
consultant, Juan Seclén.
• HIS – by PRISMA (Peruvian NGO) consultants, Doris Valdez and Juan Espejo.
• Baseline KPC planning and implementation – by CARE consultant, Alonso Wind.
• Post evaluation KPC planning and implementation – by CARE consultants, Carlos
Chavez, Freddy Marreros, and Rachael McClennen.
The project needed, but could not obtain, technical assistance for developing a health
promoter manual that would explain why the promoter should so things a certain way, not
just what he needs to do. An attempt to hire a consultant did not work out since the person
was unable to do the job requested.
Planning for technical assistance needs at the beginning of this project would have been
difficult, since most technical assistance needs were identified during the process of project
implementation. The needs could not have been anticipated to such a precise degree. What
is learned here is that technical assistance should be an open process for ongoing needs
identification. The best planning would be to have the expectation of using technical
assistance and have funding available for use when needed.
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CARE headquarters technical support was very good with the twice-yearly site visits. 
Follow-up was done in the field of specific project systems, such as the supervision,
monitoring and evaluation systems. Managerial support was also provided by CARE
headquarters at different points in the project when additional funding was needed to
continue work if there was a cash-flow problem, or to add an additional component such as
the breastfeeding community support group technical assistance.
I. Management Lessons Learned
Major management lessons learned were:
1. True teamwork was the most effective for project management. All project staff
members had equal access to all project information and could made suggestions at
any time.
2. Each project field staff member had specific responsibility for developing a technical
component of the project, such as training, IEC, and community participation. This
allowed field staff to make a creative professional contribution to the project, and not
just be in a routine of field implementation. There was no distinguishing between
thinkers and doers. Everyone did both.
3. The most important management lesson was to allow freedom for creativity, and not
try to maintain a rigid adherence to the original project document when field
experience showed that there was a more effective way to do things that had not been
thought of initially.
IV. CONCLUSIONS AND RECOMMENDATIONS
In conclusion, the Enlace Project has contributed importantly to the development of
community health programs worldwide. The two major contributions were the design and
testing of effective organizational structures - APROMSAs and COPROMSAs - to support
and sustain the work of volunteer community health promoters, and development of a
community health surveillance and referral system – SIVICS – which structures linkages
between the community and the health care delivery system. Both of these systems have
caught the attention of the Peruvian MOH, and have a high probability of being replicated
in other parts of Peru. The project provided important confirmation that the organizational
and managerial aspects of a community health program are at least as, if not more, important
as the technical approach taken
One of the key features of the Enlace Project was the high degree of co-implementation with
the Ministry of Health (MOH). MOH personnel were trained by Enlace to implement
promoter training and supervision, to collect and utilize community surveillance information,
and to implement IEC activities. Continual project coordination with mid-level (UTES) and
high–level (DISA) MOH administrative offices in the Region of La Libertad contributed to
institutional strengthening and technology transfer to the public sector. MOH project
collaborators had the highest praise for the professionalism, humane sincerity and dedication
of the Enlace project coordinator, Dr. Luis Espejo. The same was true for the Enlace
CARE PERU ENLACE PROJECT 1996-2000
FINAL PROJECT EVALUATION REPORT
34
professional field staff that worked directly with health facilities and promoters. The
participatory working style of Enlace strengthened both institutional capability and
acceptability of the project products on the part of the MOH.
The technical approach in the three intervention areas was effective because it was oriented
to best-recommended practices, with strategies based on pre-project analysis of mothers’
beliefs and practices. This approach did not include teaching promoters to provide low￾technology solutions to health problems, except for early home treatment of diarrhea with
increased fluids and continued feeding. Rather, the focus was on promoter identification of
danger signs and symptoms, and referral or emergency evacuation to a health facility, or to
organize a home visit by health personnel. 
The project effectively used a variety of health communication methods that were identified
by the community as their preferences for receiving information. These included especially
contests for designing wall murals, songs, poetry, and theater-type presentations for
transmitting health messages. Community gatherings for religious or other festivals were
effectively used for organizing group games (la tómbola) with health-related questions and
prizes for correct answers. Local radio transmitting stations were also used effectively for
mass communication.
To improve the design of interventions, the project effectively used local technical resources
at low cost to implement needed field studies. University students completing required
internships conducted several studies for Enlace. In addition, local NGOs with specific
skills were successfully employed to fill in needs for technical assistance.
The project identified the importance of using a gender approach to maternal health
interventions in communities and developed a training program for “Women Leaders”
(including TBAs and leaders of women’s groups) for promotion of maternal health in the
community, overcoming resistance to male providers and male health promoters.
The project highlighted the importance of not making promises that cannot be kept. Enlace
was very organized and met all of its scheduled activities as programmed. This was
important to build and maintain trust among project beneficiaries. This is frequent problem
in public programs with competing levels of command. For example, the standard monthly
meeting date between promoters and MOH health staff should be respected by the UTES and
DISA, who should avoid scheduling other activities for their health staff on those dates. 
It was found that project implementation should preferably make initial entry into all project
areas at the beginning of the project, covering all health facilities and a number of
communities in each. As the project progresses, increase the number of communities in the
area of each facility. This is preferable to completing areas before moving into others, since
the last health facilities to enter will be the weakest, such as what happened to Callancas in
the Enlace project.
CARE PERU ENLACE PROJECT 1996-2000
FINAL PROJECT EVALUATION REPORT
35
Use of cotrimoxazole by promoters living in remote communities for early treatment and
referral of pneumonia cases was apparently successful in this project. The cases in question
should be evaluated in more depth to be able to make conclusions and recommendations to
the MOH Program for Acute Respiratory Infections.
The project highlighted the advantages of a flexible project design and open management
style to be able to respond to community-generated solutions to their needs for structuring
health services and designing information delivery systems.
The MOH should take note of how it could and should strengthen health facilities to enable
them to support community work:
• Strengthen health facility management committees and CLAS associations so that
they are able to serve as the MOH counterpart for promoters and promoter
associations.
• Install a system for personnel performance evaluation in the health facility that
considers four sets of performance indicators: intramural management, intramural
health services delivery, extramural management, extramural health services delivery.
• Recognize community health work as part of the production of services that is
required for personnel evaluation.
• Find a way for health facilities to dedicate a budget line item for forms and
transportation to communities. Promoters may need minimum support to continue:
copies of reporting forms, and some economic support to be able to attend monthly
meetings.
Finally, the Enlace project is now serving as a model to the rest of the country for
community health surveillance systems and community health promoter organization. It is
recommended that a minimum staff be assigned by the MOH to: (1) serve as a continuing
source of technical support to health facilities, APROMSAs, COPROMSAs, promoters, and
communities to maintain the level of achievement attained, (2) serve as local guides to
visitors for the dissemination process, and (3) provide technical assistance in other areas for
monitoring the replication of the Enlace community health model in other zones.
ATTACHMENT A
Evaluation Team Members
EVALUATION TEAM MEMBERS
Evaluation Team Leader
Dr. Laura C. Altobelli is a senior public health professional specialized in maternal and child
health and nutrition, with considerable experience in Latin America working in research,
evaluation, and consulting for the World Bank, International Development Bank,
USAID/Peru, the Population Council, UNICEF, ADRA-OFASA, CARE, the Academy for
Educational Development, University Research Corporation, Environmental Health Project,
Westinghouse Health Systems, JHPIEGO, and others.
Evaluation Team Member representing CARE USA
Dr. Judiann McNulty is Deputy Director of Child Health, Health Unit, CARE USA, Atlanta,
Georgia. She has been responsible for providing technical assistance and overall supervision
and monitoring to the Enlace Project since April, 1997.
KPC Leaders and Analysts
Carlos Chávez, MD, CARE consultant
Freddy Marreros, Statistician, Hospital María Auxiliadora, Office of Statistics
Rachael McClennen, MPH, CARE consultant
Data collection assistants
Eight nursing students from the University of Trujillo, who were completing an internship
of rural service, assisted with the fieldwork in application of KPC survey questionnaires and
in-depth interviews with project beneficiaries for the final evaluation.
ATTACHMENT B
Assessment Methodology
ASSESSMENT METHODOLOGY
Planning for the final evaluation was done prior to field observations, beginning with a
review by the evaluation team leader of a series of project documents and videos produced
by the Enlace project. This was followed by the preparation of six different guides for in￾depth interviews of project beneficiaries that were later revised upon review by Enlace staff
and the evaluation team member from CARE USA. Interview guides were developed for the
following groups to assess knowledge and attitudes about various aspects of project
components:
• Health personnel in MOH facilities
• APROMSAs and COPROMSAs
• Health promoters and women leaders
• Community leaders
• Mothers in communities
Fieldwork for the final evaluation was completed during the week of August 14-18, 2000.
During the assessment of the Otuzco-Julcán area, the evaluators split up into two teams to
visit a total of five health centers and 10 health posts. At each health facility, evaluators
conducted in-depth interviews with health personnel, APROMSA and COPROMSA
members. Some of these were also interviewed regarding their work as individual
promoters. A number of communities were visited at random to interview individual health
promoters, communal leaders, and mothers. In addition, UTES personnel in Otuzco were
interviewed in depth. During a second visit, to the Departmental capital of Trujillo, DISA
personnel were interviewed, and a day-long focus group session was held with the Enlace
project team. Names and titles of the persons interviewed and contacted for the evaluation
are found in Attachment C.
The evaluation team also reviewed the work of the KPC team to verify data analysis methods
and results.
The final project evaluation report was prepared by the team leader based on the KPC results,
in-depth interviews, project documents, and field observations.
ATTACHMENT C
List of Persons Interviewed and Contacted
LIST OF PERSONS INTERVIEWED AND CONTACTED
HEALTH FACILITY/
COMMUNITY
TITLE OF PERSON
INTERVIEWED
NAME
DISA LA LIBERTAD
General Director Dr. Henry Rebasa
Director Personal Health & Director
of Epidemiology
Dr. Ana María Burga Vega
Director of Health Programs Dr. José Manuel Burgosa Zavaleta
Director of Community Participation Lic. Luisa Ancajima Hernández
UTES No. 8 – OTUZCO-JULCAN
General Director Dr. Gilberto Gutierrez Cardenas
Coordinator of CLAS, Training, and
Community Participation
Lic. Consuelo Chávez Fernández
MICRO-NETWORK AGALLPAMPA
C.S. Agallpampa CLAS Manager
CLAS President Otilio
APROMSA Members (3)
COPROMSA Members (2)
Promoters (3)
La Florida Lieutenant Governor Walter Rodriguez Mariños
Mothers (3)
P.S. Mache Medical Director Dr. Rocío Razún Araujo
Midwife Adriana Crisanto Nuñez
COPROMSA Members (4)
Mache Governor Glomer Rubio Valderrama
Regidora del Consejo Amanda Castro
Quinigon (Mache) Lieutenant Governor Juan Manuel Cipriano Cayetano
Mothers (2)
C.S. Salpo Medical Director Dr. Ronald Sumarán Aguilar
COPROMSA Member (1)
Promoters (3)
Salpo Governor José Castillo Velasquez
Mother (1)
Purrupampa (Salpo) Municipal agent Antonio Lozano
Mother (1)
Milluachaquo (Salpo) Mother (1)
MICRO-NETWORK CALLANCAS
C.S. Callancas Nurse
Midwife
APROMSA Members (2)
Callancas Bajo Mothers (2)
P.S. Charat Health technician Yolanda Bareta
COPROMSA Members (2)
Charat Justice of the Peace Paulino Guzman Alfaro
MICRO-NETWORK JULCAN
C.S. Julcán Nurse Miriam Beltrán
Midwife
Health technicians (2)
APROMSA Members (4)
COPROMSA Member (1)
Promoters (4)
P.S. Sichal Promoter (1)
Auxillary nurse
Oromalqui (Sinchal) Mothers (2)
P.S. Extensión Julcán Head Nurse Ana Macín Moya
Health Technician Silvina Valiente Miranda
COPROMSA Member (1)
Chugurpampa Promoter (3)
President Multisectoral
Committee/School Director
José Nestor Otiniano Delgado
Mothers (2)
Victor Julio Rosell Municipal Agent Cristian Burgos R.
Mother (1)
MICRO-NETWORK RAMON CASTILLO
C.S. Ramón Castillo Head Nurse Carmen
APROMSA Members (2)
P.S. Samne Medical Director Marisol Loyola Verde
COPROMSA Members (4)
Promoters (5)
Mayor Jorge Chacón
Mothers (2)
P.S. Monchacap Nurse Silvia Caffo Gonzales
P.S. Pango COPROMSA Members (2)
Promoters (3)
Mother (1)
La Libertad (Pango) Lieutenant Governor Abundio Amancio Mendoza
Mother (1)
Tambillo (Pango) Lieutenant Governor Ascensión Mankrez Castillo
Mother (1)
MICRO-NETWORK USQUIL
C.S. Usquil CLAS Manager Nurse Maruja Aniseta Urteaga
Midwife – Com. Partic. Coordinator Janette Landa Ramirez
Lab Technician – IEC Coordinator Ismenia Cerna Hernández
APROMSA Members (4)
COPROMSA Members (2)
Promoters (3)
Usquil Lieutenant Governor Walter Gil Obeso
President Potable Water Council Manuel Rodriguez Rodriguez
President Mothers´Club Rosa Grinaldina Cordova Chávez
Mothers (3)
P.S. Coina COPROMSA Member (1)
P.S. Cuyuchungo Head Nurse Evidelvia Reyes Minchola
COPROMSA Members (4)
Promoters (3)
P.S. Barro Negro Midwife
Health technicians (2)
COPROMSA Members (3)
Promoters (4)
Mothers (3)
CARE PERU STAFF
Trujillo Enlace General Coordinator Dr. Luis Espejo
Chief Technical Assistant Alexandro Vargas Vasquez
Extramural Specialist – Community
Participation Coordinator
Silvia Valderrama Sánchez
Technical Assistant – IEC Coord. Jenny Milla Risco
Program Assistant – Training Coord. Rosario Vargas Lucar
Program Assistant Luz Elena Mendoza Navarro
Administrative Assistant Sandra Sánchez Araujo
Lima Financial Manager Sra. Gladys Soto de García
CARE HEADQUARTERS STAFF - USA
Atlanta, Georgia Deputy Director, Children’s Health Dr. Judiann McNulty
Total number of persons interviewed:
Enlace and CARE Staff 9
MOH – DISA and UTES 6
MOH Health Facility Personnel 23
APROMSA Members 15
COPROMSA Members 27
Health Promoters 37 (many of these were also interviewed as APROMSA or COPROMSA members)
Community leaders 15
Mothers 26
ATTACHMENT D
Copy of Formal Agreement Between
Agallpampa CLAS-APROMSA-Municipality of
Agallpampa
Attachment D
Copy of formal agreement between Usquil CLAS, the APROMSA and the Municipal
Government of Usquil.
Copy of formal agreement between Agallpampa CLAS, the APROMSA, and the
Municipality of Agallpampa
ATTACHMENT E
Promoters Trained by Topic and
Micro-Network
PROMOTERS TRAINED BY TOPIC AND MICRO-NETWORK
TOPIC Usquil OtuzcoAgallpampa Julcán Callancas TOTAL
ARI/Pneumonia 138 172 195 190 38 733
Diarrhea 135 168 195 190 20 708
Maternal Health 118 172 27 18 33 368
Breastfeeding 96 160 137 190 14 597
Educational Methodology for Adults 138 168 167 190 29 692
Leadership/Management I 6 8 6 7 0 27
Leadership/Management II 5 4 7 4 4 24
Management 13 18 23 35 13 102
Supervision 0 0 25 30 0 55
Community Empowerment 0 0 23 30 0 53
WOMEN LEADERS TRAINED
1998 0 0 0 55 0 55
1999 0 33 45 160 0 238
2000 40 14 148 0 0 202
TOTAL 40 47 193 215 0 495
MINISTRY OF HEALTH PERSONNEL TRAINED BY TOPIC
TOPIC Physician Nurse Midwife Nurse TechnicianOther PersonTOTAL
Educational Methodology for Adults I 6 13 4 17 1 41
Educational Methodology for Adults II 7 14 5 7 1 34
SIVICS 31 36 21 41 14 143
EPI INFO 8 6 2 3 5 24
HIS/MIS 20 30 14 30 9 103
Use of information for management 7 10 5 2 1 25
Breastfeeding 1 9 6 1 0 17
Community Empowerment 25 2 0 0 9
Leadership/Management I 54 0 0 0 9
Leadership/Management II 44 0 0 0 8
ATTACHMENT F
Description of APROMSA Development
1
Health Promoter Associations: A Strategy for Sustainability
CARE/Project Enlace
 By Rachael McClennen1
Introduction
The sustainability of any child survival project is an issue of great concern for project staff and
funding agencies from the outset. Typically, such projects enter a certain geographical area and
train volunteer community health promoters2
 in interventions such as diarrheal diseases,
respiratory infections, maternal health, breast feeding, immunizations, and nutrition, among
others. The project coordinates with the Ministry of Health (MOH) in order to increase the
sustainability of the work of the health promoters when the project has left the area. The
expectation at the completion of the project is that the MOH and the health promoters have
attained a solid working relationship and the necessary skills to ensure that the work will
continue.
Two issues affect the ability of Ministries of Health in sustaining the efforts of community health
volunteers. The first is that of resources. Rarely does the MOH have funds to provide refresher
training for the volunteers or to recruit and train new volunteers. Nor do Ministry staff have time
and transportation to travel to communities to maintain supervision and communication with the
promoters. Secondly, there is the issue of MOH perception of the value of the work of the
community volunteers in relation to the amount of effort required to support them. Without
MOH support, training and supervision, volunteers soon lose their motivation and cease
participating. Desertion rates in excess of 50% are common when PVOs withdraw.
When the link between the MOH and the health promoters is not strong enough, and leadership
and self-sufficiency of the volunteers not fully developed, the end result is less health impact than
expected, unsustained behavior changes, disillusioned health promoters, unsatisfied MOH
personnel, and wasted money.
CARE’s Proyecto Enlace3 (Project Link) in the highlands of La Libertad region of northern Peru
has utilized the strategy of forming and strengthening Health Promoter Associations
(APROMSAs) that will greatly increase the level of sustainability of volunteers. As the project
nears its end, it is clear that the APROMSAs and the MOH have gained the necessary skills and
credibility in their communities to elaborate annual operating plans, including supervision and
activities that allow for generating funds. This allows for complete self-sufficiency of the health
promoter associations, which in turn leads to better-developed communities, active health
promoters, and satisfied MOH personnel.
 
1
 This was originally written as part of an internship experience for a Masters in Public Health, Harvard School of
Public Health in the summer of 1999. This current version was edited by Judiann McNulty, DrPH, Deputy Director
for Children’s Health at CARE, USA in September, 2000.
2
 The terms volunteer and promoter are used interchangeably in this document. 3
 Project Enlace was funded by CARE and USAID under a grant from BHR/PVC for Child Survival XII.
2
This report gives the history of APROMSAs in Peru, explains how Project Enlace has utilized
and strengthened their presence, and what lessons the CARE has learned that it can apply to
future child survival projects.4
 By taking advantage of this strategy, other child survival projects
will be even more sustainable because they will leave self-sufficient institutions working together
with the MOH to improve health in rural communities.
History of Health Promoter Associations in Peru
The oldest APROMSA in Peru was formed in 1980 in San Marcos, Cajamarca. In 1979, the
Catholic Church trained a number of health promoters from nearly 50 communities in various
health interventions. Because the promoters soon felt that their activities were not well
coordinated with each other, they decided to join together to form an association, in hopes of
being more easily recognized by their communities, the MOH, non-governmental organizations
(NGOs), and the state. At that time, they formed a board of directors that had the responsibility
of overseeing its approximate 80 members.
The Church was only one of the institutions to help form and strengthen the APROMSA San
Marcos, as time went along. The APROMSA also had a large amount of support from MOH
personnel, in particular Dr. Alfonso Nino Guerrero, who was on staff from 1980 to 1984.
Although the APROMSA members received no formal leadership training, they were empowered
by Dr. Nino, which has aided them to continue to be an organized institution despite his later
absence. In addition, the APROMSA received support from various organizations such as
UNICEF, CARE, CEDAS/IDEAS, and APRISABAC. The various NGOs, the MOH, local
governments, and the Catholic Church each helped to support the training of the APROMSA
members and its board of directors in various health interventions and limited accounting
principles. They have also donated materials and logistical support for training such as
transportation and meals, and educational materials for promoters to use in their communities.
It was not until 1995 that APROMSA San Marcos decided to obtain legal status, including a
constitution and bylaws. The board of directors chose to apply for legal status in order to more
easily solicit funding, material, and logistical support. Having official legal status has improved
the reputation in the communities, allowed organized coordination with the MOH, and in turn
created a more efficient APROMSA.
Current APROMSA San Marcos
Currently, the APROMSA San Marcos is a well-established and respected institution. It has a
house that serves as a meeting place for the board of directors, and as a place to receive patients
with a small pharmacy. The house is currently being renovated for the purpose of adding a
community soup kitchen and small hotel. The board of directors hopes to generate enough funds
to be able to support the cost of a telephone and vehicle.
 
4
 As of September, 2000, the APROMSA strategy of CARE is being adopted by the Ministry of Health of Peru as an
essential component of their community program for other regions of Peru.
3
The board of directors is comprised of a president, vice-president, treasurer, secretary, finance
officer, and various minor officers. The health promoters elect a new board of directors every
two years. The board meets about every two months in order to review the work of the health
promoters, and to follow up on fundraising and financial issues. In addition to the board of
director meetings, all members of the APROMSA meet twice a year for workshops, refresher
courses, and to address financial issues. Underneath the board of directors, three coordinators are
responsible for overseeing the work of the promoters in their geographical region.
The APROMSA San Marcos organizes various activities in order to improve health in its
communities and to generate funds to support the APROMSA. In addition to having promoters
in each community who are in charge of disseminating health messages to community members,
the APROMSA produces a daily radio hour, and holds health fairs to educate the community.
Also, the APROMSA has received a loan in the amount of approximately $2000 from a local
NGO. The APROMSA has used those funds to begin a rotating fund that its members can use
for personal investments, such as seeds, tools, land, etc. The interest that the APROMSA makes
from those loans is used to help finance things such as food and transportation during the
refresher courses that the MOH gives. The APROMSA also continues to apply for funds and
receive support from the MOH, NGOs, and local governments. In addition to health activities,
the APROMSA takes part in regular multi-sector meetings in the communities, as well as round
table discussions to address specific development issues.
In spite of APROMSA San Marcos’ overall operational efficiency, the organization contends
with various obstacles. Members of the board of directors admit that they lack certain skills to be
able to continue to grow and provide development in their communities. For example, although
they have received some training in accounting principles, they desire more to better track their
rotating fund. In addition, they admit that they lack skills in managing paperwork, administering
projects, and fundraising. Structurally, the APROMSA San Marcos has its weaknesses as well.
For example, its structure is such that there is one board of directors and three coordinators who
try to oversee the work of all of the health promoters. This has limited their capacity to provide
supervision and support to all members.
APROMSAs of Project Enlace
When Project Enlace began its work in La Libertad region in October of 1996, two of the current
five APROMSAs were already loosely formed by a previous CARE water and sanitation project
in the early 1990s. They were modeled after the San Marcos experience. APROMSA Usquil did
not have a legal constitution, bylaws, accounting books, or legal recognition by the government
Although the APROMSA Otuzco had legal status, it was not sufficiently organized and active.
These two APROMSAs were organized in such a way that the members had been working
together as a group of promoters for the duration of the water and sanitation project, yet
following the project their coordination was somewhat weak. Because the APROMSAs did not
have recognition throughout the community, the MOH and the local governments were reluctant
to recognize their possible advantages of improving the health of the population. Project Enlace
focused on the strengthening of those two APROMSAs, in addition to the formation and
strengthening of three new APROMSAs in the project area, as one of its strategies of
4
sustainability. Each APROMSA covers a geographical area known as a “micro-network”.
Because the MOH’s jurisdiction of the project area is divided into five micro-networks, three
additional APROMSAs have been formed, and the two existing ones strengthened. At the level
of each micro-network, there is one main health center and various smaller health posts.
Essential Steps for Successful APROMSAs
Project Enlace has used a variety of strategies to form and strengthen the five APROMSAs. In
addition to educating the promoter members in the specific health interventions of the child
survival project, Enlace trained the APROMSA boards of directors in skills pertaining to
management.
1. Selection of the Volunteers
At the beginning of the project, Enlace held meetings in each of the project communities to help
facilitate the communities’ process for identifying potential community leaders. Once the health
promoters were selected, or existing promoters reaffirmed, Enlace trained the MOH staff to train
the promoters and began to form and strengthen the APROMSAs. This process allowed the
MOH to build a direct relationship with the promoters.
2. Training of the APROMSA Health Promoters
All of the health promoters began receiving training from MOH personnel in the interventions of
the Project Enlace: diarrheal case management, respiratory infection case management, maternal
health, breast-feeding, and methodology in adult education. Trainings were organized in a
decentralized manner. Each health unit (post or center) trained its corresponding APROMSA
members, allowing for better communication and mutual understanding between the APROMSA
members and MOH personnel.
3. Formation of the APROMSA
Even as the promoters began receiving their technical training, the organization of the
APROMSA began. The first step, an innovation of Enlace, was to organize local groups around
each health unit. These groups are called COPROMSAs for Committees of Health Promoters.
The purpose of the COPROMSA is to allow for close coordination and supervision of the
promoters among themselves and to serve as a channel of communication with local MOH
personnel. In each COPROMSA, a board of directors was elected, including a president,
secretary, treasurer, and vocal. Once the boards of directors of all of the COPROMSAs were
formed, board members met at the micro-network level to discuss and propose statutes which
would be used in the APROMSA’s constitution. (Normally, each APROMSA is made up of
about five COPROMSAs, depending on the number of health facilities in the micro-network)
The proposed statutes developed by the boards of directors of the COPROMSAs were then
shared with all of the health promoters of that APROMSA, and the board of directors developed
5
the constitution based on the agreed upon statutes. The health promoters met and agreed upon
and signed the constitution, thus formalizing the APROMSA.
Once the constitution was signed, an electoral committee was formed to aid in the election of the
board of directors of the APROMSA. The electoral committee decided upon the voting process,
and then carried out the election, by process of secret vote, of the APROMSA’s president, vice￾president, finance officer, secretary, and treasurer. In addition, the president of each
COPROMSA represents his/her COPROMSA within the APROMSA.
Upon the election of the board of directors of the newly formed APROMSAs, they began a
fundraising process in order to pay for the registration of the institution with the government.
Upon acquiring the necessary funds, the board of directors of the APROMSA was then able to
take the constitution to a public registry in order to gain legal status.
APROMSA and COPROMSA Primary Roles
The principal objective of forming and strengthening the board of directors of the COPROMSAs
is to provide support and supervision to the health promoters in each cluster of communities.
Members of the COPROMSA board, on a regular schedule, visit the other health promoters in
their communities to observe their work with community members, give advice regarding how to
improve their work, and address any questions that the promoter may have. In addition, the
COPROMSA makes an annual operating plan with the local health staff and coordinates
participation of the health promoters in health promotion events carried out as a group.
The primary role of the APROMSA board is to raise funds for activities and keep the
APROMSA and COPROMSAs active. This includes establishing and maintaining strong
relations with municipal authorities and micro-network health officials. In addition, the
APROMSA board of directors also serves a supervisory and supportive role over the
COPROMSA board. In order to oversee the APROMSAs, the various presidents of the
APROMSAs have formed themselves into an informal supervisory committee to supervise each
APROMSA. This system allows for mutual support, continual sharing of experiences and
efficient problem-solving.
4. Training of the APROMSA Leaders
Once the board of directors of the APROMSA was selected, Enlace began trainings to strengthen
the APROMSA leaders and the MOH personnel. (The MOH personnel designated to work with
the health promoters needed to learn the organizational and management skills necessary to
support the APROMSAs and to train future leaders.) In order to address the areas that needed
the most strengthening, Enlace staff held a workshop with the board of directors of the
APROMSAs (including the president from each COPROMSA who has the job of representative
to the APROMSA) and key MOH personnel. In the workshop, they identified needs for training
that would allow them to have a self-sustaining APROMSA and an empowered MOH. They also
discussed possible visions for their institutions, including the role that each functionary would
6
play. All members of the boards of directors of each APROMSA and each manager at the micro￾network health center level began receiving workshops. The themes that the participants
identified, and in which they were subsequently trained, included the following: accounting
principles, supportive supervision, communication skills, how to work in teams, leadership,
fundraising skills, gender issues, facilitation, training of trainers, self-esteem building,
management, project design, and how to formulate, evaluate, and monitor an annual operating
plan.
These skills were taught in workshops given by Enlace, other CARE staff, and outside
consultants. For example, in the case of accounting principles, one of the CARE accountants
facilitated the workshop. In the case of the leadership workshops, an outside consultant was
hired to facilitate. The complete boards of directors of the APROMSAs took part in the
workshops along with the manager of each head health center. The workshops usually lasted two
or three days, and they were more centralized than the workshops that the MOH facilitated, in
that they were based in a central location as opposed to the communities. In addition to this
format being logistically effective, it also allowed for APROMSA leaders to share their
experiences with others. They were able to learn about each others’ difficulties, challenges and
successes. As a step towards sustainability, from the beginning, costs of the training were shared
by CARE, the MOH, and APROMSAs.
In addition, Enlace implemented meetings of all APROMSAs on a bi-monthly basis to allow the
leaders of the COPROMSAs and APROMSAs to exchange their successes, challenges, and
lessons learned. This proved to be extremely valuable because it allowed the leaders to motivate
and support each other.
In addition to formal workshops addressing the previously listed themes, Enlace staff members
made frequent visits to the health centers to be able to reinforce the skills taught in the
workshops, both at the level of the MOH and with the boards of directors of the APROMSAs
and the president of each COPROMSA. Enlace staff monitored the elaboration of the
APROMSA’s annual operating plan, utilized opportunities to give and receive feedback,
reinforced leadership skills, encouraged teamwork, gave advice for fundraising and managing of
funds, etc.
Currently, the COPROMSAs and APROMSAs have well-defined visions and work plans that
correspond with MOH goals. These work plans are made in conjunction with the MOH and
municipal government. The APROMSAs coordinate with the MOH and local governments in
planning health fairs, radio programs, refresher courses, and plays for community members.
All members of the COPROMSAs typically meet once a month with MOH personnel to present
and discuss reports, solve problems, evaluate progress toward the work plan, and plan future
activities. Usually, the board of directors of the APROMSAs meets once a month with MOH
staff, and with all the promoters every three months. New boards of directors are elected every
two years.
Benefits of APROMSAs
7
The advantages of having organized and active APROMSAs superceded the expectations of
Enlace staff. One of the most positive outcomes of the presence of APROMSAs has been greater
respect of promoters on the part of the local government, the MOH, and NGOs. By observing
MOH staff and promoters interact, one can note the mutual respect that each hold in the work
environment. APROMSA members note that the MOH appreciates promoters’ work because it
leads to increased coverage, increased use of health services and improved health behaviors. The
MOH is particularly pleased to have the accurate census data that promoters continually up-date.
MOH personnel are also more aware of the fact that health promoters are volunteers, and have
come to value their work to a larger degree.
In turn, the personal relationship between promoters and health personnel has resulted in the
health personnel leaving the clinics more often to provide services and education in the
communities and visit patients in their homes. When health staff travel to a village, they know
they will be met by the volunteer, presented to the households they need to visit, and
accompanied in their activities. They also know they can send word to the promoter to follow-up
on specific patients. The MOH staff state that it is much easier to plan and work with the
promoters as an organized group rather than as disperse individuals when it comes to arranging
for training, meetings, or other organized events.
APROMSAs have asked for and received financial or logistical support from their local
governments in their work activities. Two have already been successful in acquiring donated land
to build a place for training and meetings. Another has successfully negotiated with the
municipal government to provide food for future training workshops. Because they recognize
that health is not the only issue in development work, they participate in multi-sector committees
in their communities. The APROMSAs also have plans for soliciting support from NGOs and
government institutions and well as regular fund-raising activities such as raffles, barbecues, etc.
All APROMSAs were given motorcycles by CARE’s water and sanitation project, which they
use to provide supervision and attend provincial meetings. However, they now must use some
funds that they generate in order to pay for maintenance and gas of the motorcycles.
APROMSA leaders comment that they have gained greater respect within their communities.
Although in the beginning stages of their work, community members only searched them out for
free medicines, the people now have come to understand that the role of the promoter is more of
a preventative one. They have come to see the difference that the health promoters are making in
their community. In addition, the leaders of the APROMSAs and COPROMSAs note the
personal satisfaction of being leaders in their communities. They have the advantage of learning
how to manage an organization and how to participate in fundraising
The promoters have also made personal gains as a result of their involvement. Some have
become active in helping plan civic events, others have become members of the Local
Committee of Health Administration (CLAS), health advisors to mayors, literacy teachers,
nursing students, and secondary school students. Such impressive personal and professional
growth among APROMSA leaders was an unexpected result in the strategy of forming and
strengthening APROMSAs.
8
A major advantage of the formation of the APROMSAs is that there is a better flow of
communication among the promoters, continuous supervision, and therefore more effective
outcomes. Leaders of the APROMSAs believe that having their own system of supporting and
supervising health promoters leads to more active promoters and less drop outs. Because the
promoters are continuously given feedback and support, they are more motivated to continue
working and improving their skills. The desertion rate among promoters after 4 years is 12%,
almost entirely attributable to migration from the area.
Board members of the APROMSAs also comment on the importance of meeting with and having
exchanges with other APROMSA leaders. They are able to give each other suggestions, share
successes, and problem solve together.
Challenges that APROMSAs Face
APROMSA leaders identify very few disadvantages that they face in light of being part of an
organized institution. Even though membership in the COPROMSA and APROMSA requires
even more donated time, members do not see that as a problem. In fact, Enlace and the MOH
have observed that the promoters who devote the most time to their community activities are the
same ones who are most willing to accept an elected position or committee assignment in their
APROMSA.
On an institutional level, the principle challenges are maintaining commitment of the individuals
to the organizations, and the constant quest for funds to support operation and activities. The
leaders feel these challenges can be dealt with by continually reconfirming the purpose of the
organization in order to motivate the membership.
Current Sustainability Situation
The APROMSA leaders state that when Enlace leaves the project area, they will continue to
function as they have been functioning currently. They already have the skills and the experience
to be able to successfully solicit funds and logistical support from local governments, the MOH,
and other NGOs.
Very important to sustainability is the mutual commitment with the MOH. The APROMSAs
have very strong relationships with the current MOH personnel at the level of each health unit.
Two of the micro-reds have signed agreements with the APROMSA and the municipal
government to support the APROMSA and the work of the promoters. In addition, the district
health administration (UTES-8) has written a resolution pledging on-going support of the
APROMSAs and their work.
Lessons Learned
9
Interestingly enough, those who state that the transition to post-Enlace work will be challenging
are the COPROMSA leaders, not including the presidents. They are the leaders who have not
received the same workshops that the APROMSA leaders received, such as leadership,
fundraising, accounting principles, etc. This is an important issue to consider in future
replication. It will be most effective to train all APROMSA and COPROMSA members for the
most sustainable results.
Because the exchanges of experiences have proven to be so useful to APROMSA and
CORPOMSA leaders, it may be helpful to hold more formal events in the future. Such
opportunities for sharing experiences allow for peer support and encouragement.
Another important lesson that Enlace staff have learned is the importance of involving female
leaders, such as mid-wives and members of the mother’s club, in APROMSA activities. Because
the percentage of female promoters is between 35% to 40%, it is important to involve other
female leaders from the communities. In future projects, other strategies to involve women in the
project could be found, for example, increasing the quantity of female health promoters or by
fully incorporating other female leaders in the communities.
Like any well-organized institution, APROMSAs should also have a written vision that is
defined by the promoters. By having a future to work towards, the APROMSA membership is
more likely to be active in activities and fundraising.
Conclusion
Project Enlace’s strategy of forming and empowering health promoter associations has proven to
be a sustainable way to ensure active, efficient, and effective promoters when the project is no
longer in the area. It allows for a self-sufficient institution, that now has the skills to manage its
own members, solicit funding from outside institutions, and to continually make a difference
with respect to the health of their community members. The APROMSA model must not be
limited to isolated projects. It has potential to be scaled up into national health programs
throughout the world.5
 
5
 CARE is currently replicating the strategy in Nepal and Tanzania to show adaptability for Asia and Africa.
At one meeting of a COPROMSA, one volunteer informed the others that he was planning to resign as his
community's designated health promoter. A newly elected local authority was publicly trying to decrease
community respect for his actions as health promoter. The other COPROMSA members gave him moral
support, stressing all the good he had achieved in several years of community service. They convinced him
his actions were of great value to his community and gave him advice on how to defuse the situation. In the
end he was convinced to continue.
ATTACHMENT G
Birth Planning Form
ATTACHMENT H
KPC Final Survey Report