CARE Nicaragua
Mid-Term Evaluation
CHILD SURVIVAL XIV
Matagalpa, Nicaragua
October 1, 1998 to September 30, 2002
Cooperative Agreement No. FAO-A-00-98-00076-00
October 2000
Prepared by: CARE USA Contact:
Renee Charleston, MPH
Consultant
Judiann McNulty, DrPH
Deputy Director Child Health
TABLE OF CONTENTS
A. SUMMARY 1
B. ASSESSMENT OF PROGRESS 3
1. Technical Approach 3
a. Overview 3
b. Interventions 4
c. New tools or approaches 7
2. Cross-cutting Approaches 9
a. Community mobilization 9
b. Communication for behavior change 10
c. Capacity building approach 12
d. Sustainability 15
C. PROGRAM MANAGEMENT 16
1. Planning 16
2. Staff training 17
3. Supervision 17
4. Human resources 17
5. Financial management 18
6. Logistics 18
7. Information management 19
8. Technical and administrative support 20
D. CONCLUSIONS AND RECOMMENDATIONS 20
E. ACTION PLAN 23
F. RESULTS HIGHLIGHTS 33
ATTACHMENTS
A. Information from the DIP
B. Evaluation Team Members
C. Evaluation Methodology
D. Persons Interviewed and Contacted and Documents Reviewed
ACRONYMS
ARI Acute Respiratory Infection
BFV Breast Feeding Volunteer
CDD Control of Diarrheal Disease
CHW Community Health Worker
CM Community Movement
CS Child Survival
DIP Detailed Implementation Plan
ENACAL Environmental Education Project funded by UNICEF
FS Food Security
IMCI Integrated Management of Childhood Illnesses
INEC Nicaraguan National Institute of Statistics
KPC Knowledge, Practice and Coverage
LAM Lactational Amenorrhea
MECD Ministry of Education, Culture and Sports
MINSA Municipal level Ministry of Health
MOH Ministry of Health
MTE Mid-Term Evaluation
NGO Non-Governmental Organization
PVO Private Voluntary Organization
TIP Trials of Improved Practice
UNICEF United Nations Children’s Fund
USAID United States Agency for International Development
WRA Women of Reproductive Age
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A. Summary
CARE Nicaragua is implementing a USAID/BHR/PVC funded Child Survival (CS) project in
the municipality of Matagalpa in north-central Nicaragua. The main partner in this project is the
Municipal level Ministry of Health (MINSA). The project has three main goals:
1. To improve the capacity of the Ministry of Health personnel in community outreach, and
delivery of quality services, including health education.
2. To empower communities to organize, analyze health and nutrition problems, and seek
solutions.
3. To enable families to practice healthy behaviors, identify and resolve health risks, and access
quality services.
The project works in the intervention areas of breastfeeding, nutrition/food security, control of
diarrheal disease and pneumonia.
The project got off to a late start because Nicaragua was hit by Hurricane Mitch in October of
1998. Project activities did not begin until February 1999 because staff was involved in disaster
work (paid for by other CARE funds). The project is on time with implementation according to
the Action Plan presented in the DIP, but modifications have been made in terms of introducing
innovative approaches, such as Child-to-Child, Hearth Model and Trials of Improved Practices.
The project is completing a modified version of each of the originally-proposed activities.
One of the greatest areas of frustration for volunteers, and CARE and MINSA staff is the lack of
participation of many community members. There are reasons for this lack of interest in the
project, and the biggest challenge during the next two years will be to identify what those
barriers are and how to reach people in ways which attract them, especially in the urban area.
Some of the most outstanding aspects of the project are:
• Coordination with MINSA at the local level
• Accreditation of health facilities as Baby Friendly Units by UNICEF
• Improvement in coordination with the communities
• Use of qualitative and quantitative studies for baseline information and to guide project
implementation
Some of the areas of greatest weakness which need to be prioritized during the next two years:
• Follow-up and supervision of all aspects of the project
• Improving the Integrated Health Visits by the Municipal team
• More focus on improved methods for changing behavior, not just giving health “talks”
• Information System which should be used at all levels
• Further strengthening of IMCI
One of the most exciting recommendations to come out of the MTE is the planning for
differences in activities based on the annual cycle of temporary migration and workload of
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project participants. Planning for the work cycle, especially in the urban area, will greatly
enhance effectiveness of the interventions, and take a more realistic view of what activities can
be accomplished.
Priority Recommendations:
1. The project needs to re-evaluate the number of communities, beyond the original 70, where
there will be direct intervention, and prioritize by risk level, population of under fives, and
level of interest of the community.
2. Increased technical assistance should be provided in the urban area to motivate the use of
existing resources in establishing small patio gardens. An additional food security (FS)
Extensionist should be contracted, specifically to work in the urban area.
3. An increased focus on training in IMCI and follow-up on training to insure proper
application is needed at all health facilities.
4. Analyze, with communities, the concepts of Community Development Committee and
Network of Volunteers to define their roles and potential for sustainability.
5. The project needs to continue to move away from the use of health "talks" to give
information towards the use of other more interactive and innovative methods of adult
education.
6. Take advantage of the months from July to September for group meetings and training. From
October to June, focus on the use of indirect methods such as radio, popular education,
printed materials, home visits, and activities with the schools. Take advantage of Sundays
when people are at home.
7. Improve the involvement of the community in the planning, implementation and evaluation
of MINSA/CARE plans.
8. One or two additional Extensionists should be hired to cover the additional communities not
accounted for in the original proposal and the number of communities per Extensionist
should be equitably divided.
9. It is recommended that a complete budget analysis be made by the project manager, health
coordinator, and accountant, so that a realistic spending plan can be developed for the
remaining two years.
10. More training is needed at all levels to understand the use of information in decision making.
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B. Assessment of the progress made toward achievement of program objectives
1. Technical Approach
a. Overview
CARE Nicaragua is implementing a USAID/BHR/PVC funded Child Survival (CS) project in
the municipality of Matagalpa, in the department of Matagalpa, in north-central Nicaragua.
CARE has worked since 1983 in water and sanitation in the department of Matagalpa, and for
the last 12 years has also worked in agriculture and natural resource management in the rural
area. This is the first project to work in health in the urban area. The main partner in this project
is the Municipal level Ministry of Health (MINSA) focusing their efforts in 14 health facilities-7
in the rural area and 7 in the urban area. The project has three main goals:
1.To improve the capacity of the Ministry of Health personnel in community outreach,
and delivery of quality services, including health education.
2.To empower communities to organize, analyze health and nutrition problems, and seek
solutions.
3.To enable families to practice healthy behaviors, identify and resolve health risks, and
access quality services.
The project works in the intervention areas of breastfeeding, nutrition and food security, control
of diarrheal disease (CDD) and acute respiratory infections (ARI).
The project planned to begin activities in October of 1998, but because Nicaragua was hit by a
devastating Hurricane in October, project activities did not actually begin until February of 1999.
Project staff was involved in emergency activities from October to January with funding from
European and private donors which included; refugee resettlement, prevention of epidemics, and
an inventory of agricultural and infrastructure losses. Actual project activities have been carried
out for only 17 months.
The Mid Term Evaluation (MTE) was conducted July 24 to August 4, 2000, utilizing a
participatory methodology described in Attachment C. Recommendations for improving the
project during the next two years were made by the 18-person evaluation team, which included
both project and MINSA staff. All recommendations and results from the Analysis Workshop
are included in Attachment F. Key recommendations are included in bold throughout this
document and summarized in Section E. Attachment E contains the instruments used during the
MTE for information collection, as well as the results of community interviews.
The target population for the project was estimated as 24,210 children under 5 and 18,218
Women of Reproductive Age (WRA) in the DIP. This was based on census information from
the Nicaraguan National Institute of Statistics (INEC), figures which have since proven to be
overestimated. One of the first steps in implementing the project was for volunteers to conduct a
census and establish a map of their community. The information from the census varies greatly
from the INEC figures, for example in Jucuapa, the project is working in the 2 communities
which correspond to this health post. INEC estimates the <5 population as 455 and women
WRA as 669. What the volunteers found was 186 <5 and 334 WRA. This difference in figures
has greatly effected the project’s ability to provide direct services to 24,210 children under 5 and
18,218 WRA participants. During the past year, as it became clear that the target population
might be less, the project began to attempt to reach these target numbers and added communities.
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The addition of communities solely to satisfy the target numbers has created an unrealistic work
situation.
This situation is exacerbated by:
• Most urban areas are already included in the project, except for middle or upper class
neighborhoods
• Not all communities are interested or motivated to participate in project activities and should
not be forced
• Some communities are so small, the population of <5 is only 2-3 children
• Some communities in the municipality were involved in the previous CARE project, and are
deliberately excluded now, further limiting the number of communities where the project can
work
• A move into another municipality would dilute project focus and make impact minimal
• Staffing patterns are based on 70 communities, as outlined in the DIP
• Other organizations work in the area and the project should strive to avoid duplication of
activities.
One of the main focuses of the project is the strengthening of MINSA, which will result in
improved services to a wider population than the numbers specified in the proposal and DIP.
The project is now working in 96 communities (instead of the 70 originally planned in the DIP),
some of which have not responded well to the project. CARE-MINSA plans to continue working
in as many of these communities as possible, but will decrease the number based on health risks,
population size and level of interest. The project needs to re-evaluate the number of
communities, beyond the original 70, where there will be direct intervention, prioritizing
by risk level, population of under fives, and level of interest of the community.
b. Interventions:
BREASTFEEDING
During the past year and a half, the project focused on breastfeeding in order to assist MINSA in
their quest for Baby and Mother Friendly accreditation. This year, all health posts and centers in
the municipality of Matagalpa were accredited by UNICEF as Mother and Baby Friendly. The
process included completing 11 steps which were certified during UNICEF visits. This is a
major step forward in the promotion of breastfeeding and has had the positive effect of focusing
all health staff on a common goal. Throughout the evaluation process, a clear message was
heard in support of prolonged and exclusive breastfeeding. The challenge to MINSA will be to
maintain the accreditation through continuous follow-up and continuing education for staff.
During 1999, 183 volunteers have been recruited and trained specifically to promote
breastfeeding. These BFV (Breast feeding volunteers), were trained in breastfeeding promotion
and 52 in Lactational Amenorrhea (LAM). The BFV transmitted breastfeeding information to
mothers but when the training was initially held last year the concept of a support group was not
clear to the trainers and a traditional use of “health talks” was promoted. After a clarification of
what a support group should entail, retraining was carried out and 49 BFVs were re-trained in
formation of support groups.. During the MTE, 6/18 BFV reported receiving training in support
group concepts with 17/18 reporting training in breastfeeding. According to project records, as of
June 2000, 12 support groups had been formed with 22 sessions held during April to June.
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The concept of a support group based on an exchange of ideas between peers, versus more
traditional ways of channeling messages, is new to community volunteers. Additional training
in formation of support groups, accompanied by follow-up in the field, is needed in all
communities.
 
NUTRITION-FOOD SECURITY
The project has a dual approach to improving food security in both the urban and rural areas, by
increasing the availability of food through production and post-harvest activities, and improving
the utilization of food through health education in appropriate feeding practices and a decrease in
common illnesses.
A number of strategies are being implemented in the area of agricultural production; small scale
nurseries for fruit trees, home vegetable gardens, seed banks for beans, and chicken production.
The impact of these intervention has been three-fold 1) improve the nutritional status of the
family through direct consumption 2) improve the economic situation of the family through sale
of excess production, 3) serve as a motivating factor for participating in other aspects of the
project.
The philosophy of cost recovery is being implemented by the project in a number of ways:
• Seed banks, managed by the community committee, recover 120 pounds of seed for each 80
pounds borrowed. The excess is stored in silos and sold when the market price is high.
• Chickens are sold to families through the community committee on a gradual pay back
system, the money used again by the committee so that additional families can purchase
chickens.
• Farmers are taught to select seeds from vegetable and fruit production, so new seeds are
always available for planting
• A new system is being proposed for revolving funds for vegetable gardens. The volunteer
garden promoter would receive seeds from the project as capital to begin selling seeds to
interested families. The promoter would make a small profit as an incentive for his/her work,
and because seeds are purchased in bulk, a lower price can be maintained for individual
families.
The goal for this calendar year of having 1931 families participating in at least one food
production activity has not yet been reached. As of the MTE, 954 families were involved in food
security endeavors. More families will be included by the end of the reporting period in
December, as the rains have just started marking the beginning of the agricultural season. The
954 families include 204 families with revolving credit seed banks for beans and fertilizer and
post harvest storage in silos, and 373 families with a revolving chicken program in 11 urban
neighborhoods and 24 communities. Twenty percent of these families are participating in 3
different food production activities. Improved monitoring and supervision of food security
activities is required to improve the impact of the intervention and to provide additional
support to the agronomist and the FS volunteers.
The CARE-MINSA project has a focus on urban food production projects. With the beginning
of revolving funds for vegetable seeds, in urban neighborhoods, the momentum for finding
innovative ways to produce fruits and vegetables in a small area should increase. Increased
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technical assistance should be provided in the urban area to motivate the use of existing
resources in establishing small patio gardens. An additional Extensionist should be
contracted, specifically to work with food security activities in the urban area.
An aspect of the nutrition component is growth monitoring and promotion. MINSA in the
municipality of Matagalpa has adopted a program originally developed in Honduras (AIN), of
integrated health care for children based on community level growth monitoring. The CARE￾MINSA project has begun training monitors in some communities in this activity. The project
reports 10 communities with the AIN system. A strong component of the original Honduran
system was counseling for mothers. This has unfortunately been somewhat diluted in the
Nicaraguan training module, but still contains elements of dialogue with the mother to identify
her needs and possibilities for changing health behaviors. This methodology attempts to reach
an agreement with the mother as to some activity she will try to change in the short term.
While the AIN system is a valuable tool for working in an integrated manner at the community
level, it is too complicated for use with volunteers with limited reading skills. The system calls
for a percentile conversion which is only to report to MINSA and not for local use. There is also
a conversion from pounds to kilograms, again only to report as the scales and growth cards can
be used in either pounds or kilograms. A study should be made by the project as to ways the
AIN system could be simplified in the mechanics of weighing and reporting weights, so that
more energy could be focused on counseling mothers for growth promotion.
The project works with a local NGO, Community Movement (CM) in five nutrition centers.
There was a lack of clarity at the planning stage as to what the objective of the nutrition centers
was. The centers serve the important function of day care center for working parents, but do not
have a role in nutritional recuperation, making them an inappropriate venue for the introduction
of the Hearth Model, as was explained in the first annual report. Training has been held in the
five centers in hygiene, food preparation-with a focus on recipes using soy products, growth
monitoring (which had not been implemented in the center visited during the MTE), childhood
illnesses, and breastfeeding. The DIP calls for monthly supervision of the centers by
MINSA/project staff, but little evidence was seen during the MTE of regular supervision.
CONTROL OF DIARREAL DISEASE (CDD)
Activities in CDD form an integral part of the IMCI (Integrated Management of Childhood
Illnesses) strategy currently being implemented throughout Nicaragua. The project has been
instrumental in improving training for MINSA staff in IMCI concepts, as well as distribution of
IMCI tools. There has been less success in insuring the use of this improved approach to
improve the quality of care. A QofC study was conducted last year, utilizing a tool developed by
BASICS for measuring quality of care in IMCI. Unfortunately, due to the delay caused by
Hurricane Mitch, no study was complete before project activities began to serve as a baseline.
Preliminary results of this study show a correct response level of 63% in an examination of
questions in 14 categories of knowledge of IMCI procedures with 24 people. Twenty-two
observations were made on application of IMCI procedures, with a 63% correct rating on 13
points. An increased focus on training in IMCI and follow-up on training to insure proper
application is needed at all health facilities.
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Twenty-two of the 28 CHWs interviewed during the MTE who had received training, reported
receiving training on CDD. Thirteen of the 32 CHWs interviewed could identify 2 or more signs
of severe diarrhea and 18 could identify 3 or more signs of dehydration. The use of ORS (Oral
Rehydration Solution) has been widely promoted with 28 of the 32 of CHWs reporting that they
advise mothers to use ORS and 12 of the 16 of the Base Houses visited during the MTE having a
supply of ORS.
Several complementary projects are also having an impact on CDD. Approximately 6,700 water
filters were provided by USAID in the municipality of Matagalpa as part of the Hurricane Mitch
recovery program. The CARE-MINSA project spearheaded the logistics, training and
distribution of the filters to improve the quality of water for human consumption within the
project area. The project continues with monitoring the use and maintenance of the filters and
providing supportive education to CHWs and teachers on the importance of the use of filters.
Also MINSA has a chlorine distribution program through the Base Houses, 58 of which have
been reactivated or organized since the project began. The combination of the two activities, plus
hygiene education, has had the reported effect of lowering the incidence of diarrheal diseases.
This was not directly measured in the MTE, but in 39% of interviews with BFV, 56% of mothers
groups and 33% of health personnel reported this observation.
ACUTE RESPIRATORY INFECTIONS (ARI)
This intervention also forms part of the IMCI approach but so far has received less emphasis by
the project. During the MTE interviews, only 15 of the 32 CHWs reported being trained in ARI
(compared to 22 in CDD). During the MTE it was found that 19 of the 32 CHWs could identify
2 or more signs of pneumonia, and 22 know that a child with a severe respiratory infection
should be referred to a health facility. CHWs do not provide pneumonia treatment at the
community level. One hundred ninety-eight CHWs have been trained in Acute Respiratory
Infections during the first two years of the project. The project takes an integrated approach to
child health in the IMCI and AIN models, yet continues to train CHWs in separate CDD, ARI
and nutrition modules. An increased focus on training in IMCI at the community level
should be incorporated in all re-training during the next 2 years.
c. New Tools/Approaches
A number of studies have been conducted by the project to provide baseline information as well
as to better understand local beliefs and limitations. A standard KPC was conducted in January
1999, which was used to develop the DIP and for focusing project activities. A Food Security
Assessment was conducted in coordination with the KPC, which included focus group
interviews, household observation and a food security questionnaire. The methodology of
Participatory Rapid Appraisal was utilized in February 1999 for information gathering and
planning purposes. An anthropometric Survey was carried out in June of 1999, the complete
results of which were presented in the First Annual Report.
A Quality of Care study, utilizing a tool developed by BASICS has been completed in 6 health
posts. Unfortunately this study was not previously completed as a baseline before project
activities began but was used to measure practical application of IMCI concepts after the first
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training. The results have shown the need to improve the training curriculum and provide more
supervision and follow-up in application.
A qualitative study on breastfeeding attitudes and practices was completed in July 1999 with
financial and technical support from LINKAGES to provide information on constraints to
breastfeeding in the urban population. The findings were used to develop the behavior change
strategy for improving exclusive and prolonged breastfeeding.
OTHER APPROACHES
Work with Schools
In an effort to involve local schools as a method for disseminating health information the project
entered into an agreement with the Ministry of Education, Culture and Sports (MECD) to train
teachers in health concepts which they would then use to teach children and their parents. The
project signed an agreement with MECD to train 105 4th, 5th, and 6th grade teachers. The actual
number trained was 120 teachers. The training was implemented in coordination with an
environmental education project (ENACAL) funded by UNICEF using post-Mitch funds.
During MTE interviews with teachers, three out of five did not know the objectives of the project
and all were unaware of the agreement between the project and MECD. All teachers should
receive information about the signed agreement between MINSA and MECD.
This is a good strategy for involving teachers more in community education, four out of five
teachers interviewed during the MTE were trained in diarrheal disease and three in respiratory
disease. Additional training is scheduled this year in nutrition, hygiene and environmental health.
Three out of five of the teachers reported receiving materials during the training. Project staff
felt that the materials used, which had been developed by MECD, could be improved. Assist
MECD to improve the quality and quantity of materials given to teachers, especially
making them more applicable for children to transmit health messages to other children
and parents.
After completing the agreed upon training, it was felt by the MECD representative interviewed
during the MTE that the training of 120 teachers was too ambitious as a first step, and should
have been a pilot project, using a community diagnosis to identify priority areas. According to
the teachers interviewed, all said they had not received supervision or support in implementing
health activities, although three out of five teachers reported that they replicated messages
through health talks and two out of five through clean-up campaigns. The current limitation is
lack of supervision and following-up on activities, responsibilities MECD agreed to assume.
The next training is in nutrition which will make technical assistance and follow-up even more
critical. Identify mechanisms to insure the follow-up and monitoring of health activities in
the schools.
In order to improve the sustainability of this activity, a stronger link needs to be developed
between MINSA and MECD, at both the local and municipal levels. Teachers should be
encouraged to meet quarterly with the nearest health post to coordinate activities. An
agreement to coordinate activities should be developed between MINSA and MECD at the
municipal level.
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Integrated Health Visits
This is one project strategy on which no progress has been made to date. Little impact has been
seen so far in improving the visits made to communities by the municipal MINSA team, which
currently focus on immunizations, prenatal care, sanitation inspections and general medical
consultations. MINSA needs to take a lead in identifying ways to enhance the impact of this
activity. The evaluation team developed the following recommendations for improving the visits:
• CARE Extensionists should periodically accompany the Integrated Visits, with a
specific role as team member.
• A procedure manual for Integrated Visits should be developed, including definition of
roles, monitoring system with specific indicators, and focus on working with the
community in planning, implementation and evaluation of activities.
• The Municipal Management team should actively monitor and supervise the Integrated
Visit teams, including analysis of information from the information system.
• Administrative systems of MINSA need to be improved to facilitate the distribution of
medicines and payment of per diem for Integrated Visits.
• Innovative methods of education should be used by MINSA during the Integrated
Visits.
Credit
A micro-credit program for urban women was planned in the DIP but has not been implemented.
During negotiations with local NGOs working in credit, CARE was unable to locate a local
partner who offered credit to women without collateral. There are credit programs in the area,
but all require a guarantee of property for loans and none utilize a solidarity group approach that
allows low-income women access to credit. CARE will soon directly implement a savings and
loan group approach, where savings groups are formed and then begin establishing a revolving
credit plan once sufficient capital is accumulated. Technical assistance was received on this
methodology by Brian Larson, who developed the approach in CARE Niger and has
disseminated it other CARE countries and in Ecuador with Peace Corps. A credit promoter
should be hired to spearhead the savings and loan group approach focusing on the urban
area.
2. Cross-cutting approaches
a. Community Mobilization
The CARE-MINSA project has undertaken three main community mobilization activities:
• Formation of community committees
• Formation of health worker networks
• Revitalization of community Base Houses which are used for distribution of ORS, chlorine
for disinfecting water, and referral to health facilities.
During the MTE, it was reported by community members that there is an increased interest on
the part of most communities in health activities. CHWs have become more active and are
taking a renewed interest in health activities, and new volunteers have been trained to more
evenly distribute the workload. The project reports that 58 Base Houses are currently
functioning, there is more of an interest in utilizing the Base Houses as a center for health
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activities, including the Integrated Health Visits of the MINSA team. The improved coordination
between health posts and communities have strengthened community empowerment.
One of the goals of the project is: To empower communities to organize, analyze health and
nutrition problems, and seek solutions. Of the three goals, this is the most problematic in terms
of reaching project objectives and having a sustainable impact. The project lacks a clear vision of
what they anticipate as an end product for community organization. A number of models exist
for organization and there is no one model that will fulfill the needs of all communities,
particularly given the difference in needs between urban neighborhoods and rural communities.
During the MTE, 56% of the committees saw their function as providing health education and
only 31% mentioned community organization. 85% of the committees had been trained in
breastfeeding, but only 25% of the committees mentioned that they had received training in
community organization. In most communities, a “Network” of volunteers has been established
which serves an extremely important function of providing mutual support among community
volunteers. These networks meet on a regular basis to discuss problems, plan activities and
implement activities together. In many instances these Networks also form the community
committee. Their focus centers on health activities of the project, not the concept of Community
Development Committees with health as an integrated activity within a broader developmental
context. Analyze, with communities, the concepts of Community Development Committee
and Network of Volunteers to define their roles and potential for sustainability.
One of the major constraints to community participation is migration; both temporary and
permanent. Another is employment pressures, especially for those working in the coffee
industry, where a work day is reportedly as long as 16 hours a day. The major problem identified
by volunteers is the lack of participation of community members due mainly to lack of interest in
health activities, which are not seen as a priority by many people. There is a strong political
bias, especially in the urban area, where some local NGOs pertain to one political party or the
other. As local elections will be held soon the political climate will become even more divisive,
limiting some people’s involvement in health activities, especially those implemented in
conjunction with local partners. More innovative approaches are needed to overcome the
constraints to participation, such as migration, employment demands, lack of interest, and
political divisions.
Security in the urban areas is a barrier for project staff to be able to complete their activities.
Many families are more available for night meetings, but violence and gang activities limit
staff’s ability to work in some areas.
b. Communication for Behavior Change
The project is using some methodologies that have a great potential for changing behavior. Use
of support groups, dialoguing with mothers to reach an agreement for behavior change and mass
media have the potential to make sustainable changes in health behaviors. Most of these
activities are just beginning and should be the focus for increased emphasis during the second
half of the project. The project needs to continue to move away from the use of health
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"talks" to give information towards the use of other more interactive and innovative
methods of adult education.
All of the messages being promoted by the project are in accordance with official MINSA policy
and all essential elements are included. The project works in excellent coordination with ministry
staff and uses whenever possible MINSA educational materials.
During the MTE, anecdotal reporting of changes in practices was wide spread. In interviews
with volunteers, community members and health personnel all reported that they observed
changes in practices, primarily in increased breastfeeding, better hygiene, increased use of ORS
and decreased use of baby bottles. A KPC survey was used at baseline to measure essential
health behaviors in mothers with children under 2. This KPC was not repeated at mid term, but
will be used to measure project impact as part of the final evaluation.
The use of information concerning changing health behaviors has not been formalized in the
project. CHWs report using home visits as an informal method for measuring changes at the
household level, especially in hygiene and use of water filters. In some communities, CHWs
report discussing health issues with the CHW network or committee, but the practice was not
widely reported. In about half of the health facilities there are monthly meetings between health
personnel and community volunteers for the purpose of sharing experiences.
One of the most exciting recommendations to come out of the MTE is the planning for
differences in activities based on the annual cycle of seasonal employment and workload of
project participants. Planning for the work cycle, especially in the urban area, will greatly
enhance effectiveness of the interventions, and take a more realistic view of what activities can
be accomplished.
A large percentage of the rural and urban population migrate temporarily to pick coffee and
another segment to work in coffee processing. Work conditions are terrible-with long hours, few
breaks, low pay and no benefits. It is unrealistic to expect that project activities will be able to
continue at the same intensity during the months when the majority of people are working 15-16
hour days, than when they have less demanding work loads during other months. Take
advantage of the months from July to September for group meetings and training. From
October to June, focus on the use of indirect methods such as radio, popular education,
printed materials, home visits, and activities with the schools. Take advantage of Sundays
when people are at home.
Another strategy to reach more people is to provide education where the people work,
particularly taking advantage of the higher literacy rate of the urban population. There has been
some attempt to do this, but there is so much potential that increased effort should be made.
Increased efforts should be made to disseminate health information at work centers
including the coffee processing plants (beneficios).
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c. Capacity Building Approach
(i) Strengthening the PVO Organization
The majority of CARE Nicaragua staff involved in the CS project has worked in previous CARE
health projects and are competent professionals. In order to maintain technical and
programmatic expertise, all staff has received a number of training courses , including; IMCI,
breastfeeding, community empowerment, community organization, logframe planning, theater
and puppets, chicken production, gardens, and LAM. During weekly staff meetings, there is a
focus on continued education. Some of the staff has had the opportunity to attend a number of
CARE regional and international events to keep up-to-date on technical issues and to share
lessons learned with other projects.
A missed opportunity for CARE to enhance the impact and efficacy of the project is through
coordination with other NGOs and GOs. There are a number of organizations working in the
municipality of Matagalpa, and particularly in the urban area.
Some opportunities for coordination include:
• Coordination with PROSALUD should continue in order to maximize use of the additional
USAID Nicaragua resources they are putting into the Department of Matagalpa.
PROSALUD works in the more outlying areas of the department and there is strong
collaboration with the other CARE health project in those municipalities.
• A suggestion from MECD, was for NGOs in Matagalpa to develop together a plan for
working in the schools, so that the ministry doesn’t receive numerous requests from
organizations wanting to work with teachers.
• In the DIP, a pilot community pharmacy was planned. If the pilot pharmacy is implemented,
an organization called Colectivo de Mujeres now has a system of community pharmacies and
would be an excellent resource for developing the pilot pharmacy.
• There are other agricultural and health projects working in the same rural communities as the
CARE-MINSA project, such as ADDAC. To avoid duplication of effort, closer coordination
is needed.
CARE should assume a leadership role in sponsoring (a minimum of) an annual workshop for
NGOs, to provide an opportunity for sharing work strategies and annual plans, and for
identifying points of coordination.
(ii) Strengthening Local Partner Organizations
The principal partner in this project is the Municipal level Ministry of Health (MINSA).
MINSA’s involvement in the project is exemplary, as it has been fully involved in project
planning, implementation and evaluation as an equal partner with CARE. A self-assessment of
needs for capacity building was made as part of proposal and DIP development. The activities
outlined in the DIP were selected by MINSA, based on this evaluation. During the MTE, the
participation of MINSA staff greatly increased the quality of the evaluation, and hopefully, the
commitment to put the recommendations into action.
13
One of the main areas of weakness, based on activities outlined in the DIP, has been the progress
so far in improving the quality of Integrated Municipal Visits. This was one area of analysis
during the MTE, and several concrete recommendations resulted and were previously discussed.
There has been more success in strengthening the visits made by local health facility staff to the
communities, often accompanied by CARE Extensionists. The main limitation to further
strengthening many aspects of the project is the ability of MINSA and CARE to bring on board
other more reluctant MINSA staff to work towards putting the recommendations into action.
Health facility staff reported receiving a number of training courses, 100% in breastfeeding
promotion and IMCI, plus others in formation of support groups, community empowerment,
LAM, community organization and planning and evaluation. They felt the training had allowed
them to better plan their work and to improve health care services for children.
Political will within MINSA will be the greatest challenge during the remainder of the project.
While municipal level MINSA is fully motivated and engaged, they have encountered difficulty
getting approval from SILAIS leadership to implement improvements and new programs.
CARE needs to assist by using contacts with PROSALUD, USAID Nicaragua, and MINSA
Central to influence SILAIS support.
(iii) Health Facilities Strengthening
The main thrust of the project in strengthening health facilities is to improving technical capacity
and organizational expertise. All health post staff have been trained in IMCI and planning and
evaluation. The training received on planning has been put into action in all health post with
quarterly and annual plans.
One of the problems identified by the MINSA staff was the inadequate link between community
and health facility. The project has made a concerted effort in this area. MINSA has modified
the structure for training CHWs. Training was previously centralized in Matagalpa, and has now
been decentralized to each health post, thus increasing contact between the local MINSA staff
and community volunteers. Regular meetings are being held in most posts with volunteers. 83%
of the health posts reported meeting monthly with CHWs in the MTE.
A system of referral from the community to the health post has been strengthened and was
reported to be functioning in 13 of the 18 communities visited during the MTE. The referral
system involves training the CHW to recognize danger signs which justify a referral to the health
post. The CHWs in charge of a Base House have been trained and have received copies of the
referral slip. The CHW fills out the slip to send with the person to the health post, retains a part
of the slip for his/her own records, and a third section is to be filled out by the attending medical
personnel and returned with the patient to the CHW for follow-up care. There are still some
problems with the system, particularly in collecting information about referrals being made.
There are problems with MINSA staff returning the counter-referral slip to the CHWs.
The supervision of MINSA staff was identified as another issue to improve during this project.
A new supervisory system has been introduced and even though it is not functioning 100%, most
people expressed concurrence that it has improved. Supervisors are now using a supervision
14
form, which focuses on improving performance through an agreed upon plan of action. When
health personnel were asked during the MTE how the supervision system could be improved,
50% said by having more frequent supervisory visits.
(iv) Strengthening Health Worker Performance
The project identified CHWs who had been previously trained, to recover this underutilized
resource. According to results from the MTE, 11of the 32 CHWs interviewed had been working
over 2 years. Nine of the 32 CHWs had been recently selected and trained (worked less than 6
months). By increasing the number of volunteers in each community, the workload has been
more adequately divided. Project records show 248 CHWs as actively working, far above the
original target number.
An excellent strategy has been the formation of a network of volunteers within each community,
which include volunteers with various roles, such as the CHW in charge of the Base House,
Breast feeding Volunteer, and Growth Monitoring Volunteer. This network provides a strong
support system for volunteers, where new volunteers can learn from more experienced
volunteers and responsibilities can be shared. The project has encouraged the formation of
sectors within each community, so that each volunteer would be responsible for specific families.
This idea has not been adopted in all areas, but many communities have found it to be an
effective way to organize.
CHWs are visited on a regular basis by either/or the CARE Extensionist and MINSA health post
staff. Eighty-three percent of the CHWs stated that they receive visits at least once a month. The
main purpose of these visits was to strengthen knowledge in health and to help in organizing
their work. CARE/MINSA staff uses this opportunity to evaluate the competency of the CHWs
to identify areas that need further emphasis.
Maps, drawn by the network or committee were observed in most communities visited during the
MTE. This has helped develop a sectorization plan but has not been fully exploited. The project
planned to teach mapping techniques to communities to facilitate the identification of high-risk
cases, population, etc. Volunteers and committees need to be taught how to use the
information from community maps to plan and evaluate actions to improve heath and
nutrition status.
(v) Training
The project uses a cascade approach, were CARE and MINSA municipal staff are trained first,
CARE and MINSA then train health post staff, and the health post staff are responsible for
training CHWs. CHWs then provide education to families. MINSA staff also provide direct
education to the community. The strategy appears to be functioning to reach the maximum
number of families with education. Take advantage of organized groups and community
activities as another method for disseminating health information. Experiment with the use
of mothers networks (for example; where each woman is responsible for talking with five
neighbors) as an alternative approach. New methodologies need to be strengthened to avoid
simply giving messages. (Previously discussed in Section 2b. Communication for Behavior
Change)
15
The original training schedule included the training in CDD, breast feeding, pneumonia, and
nutrition within the first two years. This schedule was modified and nutrition has not yet been
included as a topic, as it was temporarily substituted for community empowerment. It became
evident to the staff that empowerment concepts were not clearly defined and would impede
progress in working with the communities, so empowerment was done first, and nutrition will be
covered in the next 6 months. An integrated training plan should be developed for the next 2
years, including activities in Food Security.
One of the main problems in using the cascade approach is how to maintain quality during
replication. This seems to be an important issue in the current project. Training courses in key
project interventions were reported to vary from 2 to 12 hours in length and appear to vary in
content and methodology. Thirty-one percent of the CHWs interviewed during the MTE stated
that the courses they already received should be repeated, demonstrating a feeling of insecurity
in the topics they had received. A consistent plan for what should be included in every
training course needs to be developed, including practical experience on how to replicate
the information to the next level and an evaluation plan to ensure that each level of
participant understood the material.
d. Sustainability Strategy
The stated sustainability objectives for the project are as follows:
1. 100% of MOH staff trained in skills and concepts for effective Child Survival.
2. 100% of MOH staff using IMCI for assessing and diagnosing all children under five.
3. An effective supervision and self-supervision system in place for MOH staff and CHWs.
4. MOH staff using antibiotics to treat less than 30% of ARI cases.
5. The MOH central outreach team will be visiting each community every two months to
provide immunizations, patient follow-up, growth monitoring, home visits, health
education, CHW supervision and in-service training, and support to the community
development committees.
6. The MOH will have a long-term plan for supervising and training CHWs and BF
counselors.
7. The MOH will have adopted quality assurance as an integral part of operation.
8. The MOH will have a long-term plan for assessing their own training needs and for in￾service training.
9. A referral-counter referral system will be functioning effectively between all CHWs and
the health units.
10. Seventy communities will have action plans and functioning CDCs.
11. Seventy communities will have a functioning base house used by residents.
12. Fifty percent of households will be participating in at least one of the food security
activities: gardens, credit, or family budgeting.
13. Seventy breastfeeding counselors will be functioning and breastfeeding support groups
will be established in each community or barrio.
14. A minimum of 70 CHWs will be conducting home visits and tracking health status of 30
families each, conducting growth monitoring, providing education and counseling,
making referrals and following up on patients counter-referred.
15. 25% of the CDCs will be planning and executing self-help projects related to health.
16
A good start has been made on meeting sustainability objectives, but much work still needs to be
done. The systems for referral, supervision, and planning are beginning to be used. Some
impressive changes have taken place within MINSA in terms of decentralizing functions, a
greater focus on quality, better coordination with the communities and increased supervision
Several cost recovery plans are currently being implemented through revolving funds in
agricultural activities and future plans for cost recovery through pilot pharmacies and savings
and loan groups.
In order to insure the sustainability of the efforts made so far, increased emphasis is vital on
follow-up and supervision. This continues to be a main weakness in the project, as many
activities are implemented, without adequate follow through. No specific exit strategy needs to
be developed, because MINSA is involved in the direct implementation of all activities. The
main issue in the future will be the lack of transportation to communities, a service CARE is
occasionally supplies, and frequent training workshops.
When CHWs and committees were asked during the MTE about sustainability issues, they saw
the principal strategy as working more with MINSA in the future. This linkage between the
communities and MINSA is a vital one for insuring sustainability of project activities.
One strategy for sustainability which has been overlooked is fomenting ties between the
communities and other NGOs and GOs. The project needs to assist communities in
identifying and accessing alternative resources, through the mayor’s office, other NGOs,
and other governmental agencies.
C. Program Management
1. Planning
The main players in the initial planning process were CARE local and headquarters staff, and the
MINSA municipal team. There was no reported involvement of health post level staff, but they
did have a copy of the project objectives and evaluation plan. Focus groups with community
members were used to provide community input into the planning process.
There is a good understanding of the project’s main objective of decreasing morbidity and
mortality in the under 5 population at all levels. During the MTE, it was seen that the majority
of CHWs and other community volunteers understood the main objective, and in addition
thought the objectives were; increasing breastfeeding, improving nutritional status and food
security.
The work plan is being implemented as presented in the DIP, but while the implementation of
specific activities is on schedule, the main problem is with supervision and follow-up to those
activities.
A good system of ongoing planning exists:
• Within CARE, with weekly meetings every Monday to share ideas, problems, innovations,
and advancements.
17
• Within MINSA, with the development of quarterly and annual plans
• Between MINSA and the community, monthly meetings for planning are held at most health
posts but they could improve the involvement of the community in the planning,
implementation and evaluation of MINSA/CARE plans.
• Between CARE and MINSA, developing a monthly work plan together and meeting weekly
or every two weeks. Evaluations are held jointly every quarter and annually. The results of
these evaluations are used to improve coordination and implementation of activities.
2. Staff Training
CARE Nicaragua recently implemented a new plan for staff development which includes a self￾evaluation to identify needs and interests of each staff member. Individual training plans were
developed and adequate funds have been allocated for training. Within the project, CARE staff
has had the opportunity to receive training in a number of technical and managerial topics,
including Total Quality Management. CARE health sector coordinator, CS project coordinator
and supervisor have participated in three international conferences on topics of empowerment,
supervision, and sustainability.
The project takes advantage of the regularly scheduled Monday meetings as an opportunity for
continuous training of staff, based on identified needs and areas of weakness.
3. Supervision of Program Staff
As has been stated several times in this document, supervision and follow-up is one of the main
weaknesses. This applies also to supervision of the project staff. CARE Extensionists
infrequently receive supervision, and there is no specific format used during the supervision
visits. Part of this problem is the result of a vacancy in the position of CS Supervisor from
January to May of this year. CARE should strengthen the supervision system in order to
improve the quality and efficacy of supervision of all CS staff.
The CARE staff seems to receive good support and indirect supervision through weekly
meetings and personal contact with management. There are currently six Extensionists, working
in approximately 96 communities. The original work plan called for six Extensionists for 70
communities. One or two additional Extensionists should be hired to cover the additional
communities not accounted for in the original proposal and the number of communities per
Extensionist should be equitably divided.
4. Human Resources and Staff Management
Human resource management is managed in the CARE Managua office. A personnel manual
outlining policies is regularly updated and job descriptions are available for each position. An
annual evaluation is conducted in December of each year, which provides staff with another
opportunity to identify individual needs for training and/or support. A salary survey is currently
being completed, to insure that CARE staff salaries are in line with other similar organizations.
Staff turnover has been reasonably low during the 2 years of the project, with the majority of
staff being employed since initiation of the project. The original project manager position was to
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be divided among three projects (CS, SALUMAI, and MESA, a reproductive health project) and
this was later changed to a full time Child Survival position. The original supervisor was then
named as full-time manager. The position of supervisor was filled in May 2000 after a vacancy
of approximately 5 months, a situation which weakened the project’s ability to adequately
supervise and provide follow-up on training.
The project is understaffed considering the diversity of activities planned during the next two
years. It is recommended that the project hire an additional person for the savings and
loan groups, and an additional person for food security activities in the urban area. It is
also recommended that 1-2 additional Extensionists be hired to provide better coverage for
the communities and a more adequate work load.
CARE will provide a transition for project staff to other jobs at the end of the project through
two mechanisms;
1. by training of staff for professional development, making them more employable at the
end of the project, i.e. training in English, computer, auto repair, etc.
2. CARE tries to absorb as many staff members as possible from a terminating project into
any new projects
5. Financial Management
CARE’s current accounting system is outmoded and limited in providing adequate information
for project management. A new system (SCALA) is being introduced and will be in place by
December of this year. The new system will provide a more complete package of information,
including sub-categorization, inventory control, planning and a network of management
information.
As a stop-gap measure, the project manager and accounting office had a series of meetings to
design a reporting system which provides information to the project manager in a more utilizable
format. Communications has been good between the project and the accounting office.
It appears that even with this measure the budget information is not in a readably understandable
format. According to calculations made by CARE’s accountant, the project has only expended
18% of the total four year budget, and 23% of the USAID budget at mid term. Some of this
underspending can be accounted for by the late start-up of the project due to Hurricane Mitch,
but the rhythm of spending also needs to be analyzed to insure that spending is adequately being
monitored. It is recommended that a complete budget analysis be made by the project
manager, health coordinator, and accountant, so that a realistic spending plan can be
developed for the remaining two years.
6. Logistics
Logistics management within the project appears to be adequate, no major problems were
identified and no major challenges exist for the remainder of the project.
The only logistics issue which came up during the evaluation had to do with a confusion
concerning vehicle insurance. There appears to be some confusion as to when people are
19
covered by motorcycle insurance, some staff felt that they were unable to coordinate with other
NGOs in transportation, because only CARE staff are covered on the motorcycle. This appears
to be erroneous and is only based on the policy that helmets must be worn by all. This issue
should be clarified to staff, as confusion on this issue may limit coordination.
The other issue was whether the motorcycles would be covered by insurance on weekends, as
frequently the Extensionists need to work weekends. This question requires some additional
clarification. One suggestion was to change the schedule of Extensionists to a Sunday to
Thursday schedule, or some other combination. It should be kept in mind that MINSA staff
works Monday to Friday and it would be difficult to maintain close coordination, if work
schedules varied. The issue of modifying the work schedule to take advantage of community
members’ free time on Sunday should be studied by both MINSA and CARE to reach people
when it is most convenient for them.
7. Information Management
The information system begins in the community, with a simple registration of activities in a
blank notebook by volunteers. The information recorded is not standardized in all communities
but usually includes educational activities, number attending, home visits, use of ORS and
chlorine, training received, cases referred, meetings held, etc. The information is then collected
by CARE and MINSA staff, some information is incorporated into the MINSA monthly report of
educational and service activities and some information goes to CARE’s computerized reporting
system.
The community committee in most cases has developed maps and a census. There has been little
follow-through on how to use these valuable tools. The census was summarized in some
communities and health posts, but not all. In most cases the individual family sheets were being
updated with births and deaths, but not summarized. The maps have been drawn, but the plan for
covering them in plastic so that high risk families can be identified has not been done.
CARE’s computerized system consists of five Excel files:
Quarterly report of indicators in health
Quarterly report of indicators in Food Security
Monthly monitoring of bank accounts for revolving funds
Community population (for 63 communities, sporadically updated)
Monthly budget expenses
List of participants at Training Courses
And a WORD file of total number of people (by category) trained
The communities and MINSA and CARE staff also have a system of planning, monthly,
quarterly and annually which is used for evaluation purposes. CARE also has a weekly planning
system.
CARE Extensionists are asked to fill out a number of reports; weekly plan and evaluation of
plan, monthly narrative report and quarterly report of indicators. The format for the monthly
report has been changed twice and some confusion exists as to what they are required to report
on. The reporting requirements for Extensionists should be reviewed to collect only the
20
minimum information necessary to detect problems and advances. Direct supervision
should be used more to determine the quality of the work being completed.
The use of information by the community committee was a focus in the DIP, but little has been
done to motivate the use of information in decision making. Most committees meet monthly,
mainly to discuss health activities and the level of participation in activities. There are a large
percentage of volunteers and committees who see the main function of collecting information
only to report it to CARE/MINSA. More training is needed at all levels to understand the use
of information in decision making.
8. Technical and Administrative Support
Technical support includes visits from CARE USA headquarters by Judiann McNulty, Deputy
Director of Child Health. Visits have been made at least twice each year during strategic times,
including developing the DIP and the MTE. Staff found the visits to be very helpful. Other
technical assistance was from Brian Larson, formerly of CARE Niger, to work with staff on
developing a strategy for savings and loan groups. Several CARE staff members and a MINSA
nurse traveled to Honduras to visit an urban CARE CS project which contains many of the same
activities and interventions. The CS project coordinator and health sector coordinator also
visited CARE’s highly successful, innovative CS XII project in Peru.
Through the CARE headquarters’ partnership with the Centers for Disease Control, CARE was
able to provide a technical team to train MINSA staff in Total Quality Management, a practical
application training through which municipal staff completed an assessment project on client
satisfaction.
The CARE staff is satisfied with the level and quality of technical assistance they have received.
Plans and future needs include more on savings and loan programs, management of community
pharmacies, breastfeeding counseling and support groups, and TIPS.
D. Conclusions and Recommendations
The project got off to a late start because Nicaragua was hit by Hurricane Mitch in October of
1998. Project activities did not begin until February 1999 because staff was involved in disaster
work (paid by other CARE funds). This has not affected the project’s ability complete all
programmed activities, according to the DIP, which was written taking the delay into account.
The project is on time with implementation according to the Action Plan presented in the DIP,
but modifications have been made in terms of introducing innovative approaches. For example
the DIP outlined the training of teachers using Child-to-Child techniques, this was modified to
training teachers in a much more traditional manner. The work with nutrition center was
originally to be done introducing the Hearth Model, it was later found that this would not reflect
the reality of work being done at the center, and has been dropped, as was explained in the first
Annual Report. The Trials of Improved Practices (TIPs) model for motivating behavior change
has not yet been introduced as was originally planned. Credit and community pharmacies have
not been implemented yet, but will be implemented by the end of the calendar year.
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One of the greatest areas of frustration for volunteers, and CARE and MINSA staff is the lack of
participation of many community members. There are reasons for this lack of interest in health
and nutrition and the biggest challenge during the next two years will be to identify what those
barriers are and how to reach people in ways which attract them, especially in the urban area.
Some of the most outstanding aspects of the project are:
• Coordination with MINSA at the local level
• Accreditation of health facilities as Baby Friendly Units by UNICEF
• Improvement in MINSA coordination with the communities
• Use of qualitative and quantitative studies for baseline information and to guide project
implementation
Some of the areas of weakness which need to be prioritized during the next two years:
• Follow-up and supervision of all aspects of the project
• Improving integrated Health Visits by the Municipal team
• More focus on improved methods for changing behavior, not just giving health “talks”
• Information System which should be used at all levels
• Further strengthening of IMCI
One of the most exciting recommendations to come out of the MTE is the planning for
differences in activities based on the annual cycle of seasonal employment and workload of
project participants. Planning for the work cycle, especially in the urban area, will greatly
enhance effectiveness of the interventions, and take a more realistic view of what activities can
be accomplished. The project is planning to use alternative methodologies during the heavy
work months, such as theater groups, puppet show, radio and home visits. During less
demanding months, training and group activities can be conducted.
Recommendations
1. The project needs to re-evaluate the number of communities, beyond the original 70, where
there will be direct intervention, prioritizing by risk level, population of under fives, and
level of interest of the community.
2. Additional training in formation of support groups, accompanied by follow-up in the field, is
needed in all communities.
3. Improved monitoring and supervision of food security activities is required to improve the
impact of the intervention and to provide additional support to the agronomist and
agricultural volunteers.
4. Increased technical assistance should be provided in the urban area to motivate the use of
existing resources in establishing small patio gardens. An additional FS Extensionist should
be contracted, specifically to work in the urban area.
5. A study should be made by MINSA as to ways the AIN system could be simplified in the
mechanics of weighing and reporting weights, so that more energy could be focused on
counseling mothers for growth promotion.
6. An increased focus on training in IMCI and follow-up on training to insure proper
application is needed at all health facilities.
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7. An increased focus on training in IMCI at the community level should be incorporated in all
re-training during the next 2 years.
8. All teachers should receive information about the signed agreement with MECD. Identify
mechanisms to insure the follow-up and monitoring of health activities in the schools.
9. Teachers should be encouraged to meet quarterly with the nearest health post to coordinate
activities.
10. An agreement to coordinate activities should be developed between MINSA and MECD at
the municipal level.
11. CARE Extensionists should periodically accompany the Integrated Visits, with a specific role
as team member.
12. A procedure manual for Integrated Visits should be developed, including definition of roles,
monitoring system with specific indicators, and focus on working with the community in
planning, implementation and evaluation of activities.
13. The Municipal Management team should actively monitor and supervise the Integrated Visit
teams, including analysis of information from the information system.
14. Administrative systems of MINSA need to be improved to facilitate the distribution of
medicines and payment of per diem for Integrated Visits.
15. Innovative methods of education should be used during the Integrated Visits.
16. A credit promoter should be hired to spearhead the savings and loan group approach focusing
on the urban area.
17. Analyze, with communities, the concepts of Community Development Committee and
Network of Volunteers to define their roles and potential for sustainability.
18. More innovative approaches are needed to overcome the constraints to participation, such as
migration, employment demands, lack of interest, and political divisions.
19. The project needs to continue to move away from the use of health "talks" to give
information towards the use of other more interactive and innovative methods of adult
education.
20. Take advantage of the months from July to September for group meetings and training. From
October to June, focus on the use of indirect methods such as radio, popular education,
printed materials, home visits, and activities with the schools. Take advantage of Sundays
when people are at home.
21. Increased efforts should be made to disseminate health information at work centers.
22. CARE should assume a leadership role in sponsoring (a minimum of) an annual workshop
for NGOs, to provide an opportunity for sharing work strategies and annual plans, and for
identifying points of coordination.
23. Volunteers and committees need to be taught how to use the information from community
maps to plan and evaluate actions to improve heath and nutrition status.
24. Take advantage of organized groups and community activities as another method for
disseminating health information. Experiment with the use of mothers networks (where each
woman is responsible for talking with five neighbors) as an alternative approach.
25. An integrated training plan should be developed for the next 2 years, including activities in
Food Security.
26. A consistent plan for what should be included in every training course needs to be developed,
including practical experience on how to replicate the information to the next level and an
evaluation plan to insure that each participant understood the material.
23
27. The project needs to assist communities in identifying and accessing alternative resources,
through the mayor’s office, other NGOs, and other governmental agencies.
28. Improve the involvement of the community in the planning, implementation and evaluation
of MINSA/CARE plans.
29. CARE should develop a system for improving the quality and efficacy of supervision of all
CS staff.
30. One or two additional Extensionists should be hired to cover the additional communities not
accounted for in the original proposal and the number of communities per Extensionist
should be equitably divided
31. It is recommended that a complete budget analysis be made by the project manager, health
coordinator, and accountant, so that a realistic spending plan can be developed for the
remaining two years.
32. The reporting requirements for Extensionists should be reviewed to collect only the
minimum information necessary to detect problems and advances. Direct supervision should
be used more to determine the quality of the work being completed.
33. More training is needed at all levels to understand the use of information in decision making.
E. The Action Plan
The Action Plan completed by CARE and MINSA staff in August following the mid-term
evaluation is presented below. Along with it is an up-date including progress made towards
implementing the recommendations as of October.
24
CARE
Nicaragua
CHILD SURVIVAL PROJECT
ACTION PLAN
ACTIVITY RESULT DATE PERSON IN CHARGE
MANAGEMENT
Hiring of personnel. 3 new staff hired. August Ivette Aráuz
August-December 2000 planning for MINSA-CARE Health
Posts.
Plan prepared for Health Posts. August 14-18 Harold Rugama
Meeting of Health Post Directors and Extensionists.
• Review of current situation and preparation of
recommendations.
• Joint review of plans, with feedback.
Plans revised and feedback
obtained.
August 21 Harold Rugama
Amelia Reyes
Meeting with Community Leaders.
• Review of current situation and preparation of
recommendations.
Recommendations prepared. August 28 Harold Rugama
Planning with communities.
(CDC, Extensionists, Health Posts)
Community plans for Health Posts
prepared.
August 28 Harold Rugama
Yamileth Alegría
Review current forms for supervision. Four forms revised (AIN, CHWs,
BF Counselors, Extensionists).
August 28 to 31 Ivette Aráuz
Review current distribution and number of communities. Communities distributed equitably
among extensionists.
August 9 Ivette Aráuz
Yamileth Alegría
Review project’s computer information system. Data gathered and standardized. Ivette Aráuz
Harold Rugama
Abundio Jarquin
Training for health personnel and extensionists on
computer information system and decision-making.
Personnel trained. Harold Rugama
Ana C. Salinas
Preparation of Municipal MINSA-MECD Agreement. Agreement prepared. October Yamileth Alegría
Review and preparation of budget for next 2 years. Budget prepared. August 14 to 18 Elena McEwan
Ivette Aráuz
25
ACTIVITY RESULT DATE PERSON IN CHARGE
NUTRITION
Monitoring of Growth and Development (AIN):
Evaluation of AIN in 10 communities. AIN implementation evaluated. September 1 Nidia Espinoza
Ivette Aráuz
Implementation in new communities.
• Situational assessment and identification of
communities.
• Training for new Monitors.
• Accompaniment at first AIN session.
Situational assessment in prioritized
communities.
Monitors trained.
AIN Monitors assisted in first
session.
September 1-30
October 1-15
As per Calendar
Nidia Espinoza
Ivette Aráuz
Training for MINSA on Nutrition. Personnel from 27 sectors trained. October Amelia Reyes
Ivette Aráuz
Training for volunteers and mother’s groups on:
Green leaves, Vitamin A, Soya
October-December Amelia Reyes
Harold Rugama
FOOD SECURITY
Preparation of curriculum, compilation, adaptation of
material on: household money management.
Materials prepared. November Ivette Aráuz
Urban gardens:
Preparation of revolving fund strategy. Strategy proposal prepared. August 20 - 28 Abundio Jarquin
Presentation of proposal in 20 barrios. Revolving fund strategy discussed
and feedback offered by 20 barrios.
September 1-15 Abundio Jarquin
Selection of participant families. 430 families selected. September-October-November
Purchase of seeds and inputs. Seed purchased. September Abundio Jarquin
Training for 40 agricultural promoters in:
• Implementation of bio-intensive gardens
• Management of diverse crops
• Preparation of organic repellents and fertilizers
40 agricultural promoters trained. September
October
November
Establishment of gardens and training of women’s groups. Gardens established in 20 barrios. September-November Abundio Jarquin
Technical assistance for gardens. 20 barrios receive technical
assistance
Continual Abundio Jarquin
26
ACTIVITY RESULT DATE PERSON IN CHARGE
FOOD SECURITY (cont.)
Fuel-efficient stoves:
Preparación of CARE – Project Cuencas-Movimiento
Comunal Agreement.
Selection of participant families.
Implementation of stoves in rural families.
Agreement prepared.
50 families selected.
Families start using preparation
stoves.
September
September-October
January 2000
Ivette Aráuz
Ivette Aráuz
Ivette Aráuz
Savings and Credit Groups:
Promotion of Savings and Credit program. Women’s groups from 10 barrios
know about program.
September Ivette Aráuz
Initiation of savings program activities. Women’s groups initiating program
activities.
October-November Ivette Aráuz
Continuation of program. Extension of program to other
barrios.
As of December Ivette Aráuz
BREAST-FEEDING
Clinical course in breast-feeding. Medical and nursing personnel
trained.
October Nidia Espinoza
Ivette Aráuz
Training for MINSA personnel and extensionists in
counseling skills.
MINSA Health Post directors and
teams trained.
October Nidia Espinoza
Ivette Aráuz
Support from Breast-feeding Advisor for
Latin America
Recruiting and training of local leaders for breast-feeding. Local leaders involved in promotion
of breast-feeding.
October-November Nidia Espinoza
Ivette Aráuz
Training for counselors on support group methodology. 100% of Counselors trained in
leading support groups.
October-November Harold Rugama
Follow-up to support group sessions. Counselors accompanied and
offered feedback in group sessions.
Continual Harold Rugama
Elaboration of documentation with plan and criteria for the
nomination of communities friends of breast-feeding.
Document prepared. October Nidia Espinoza
Harold Rugama
DIARRHEA AND PNEUMONIA
Training for the CHW network on diseases prevalent
among children (mainly ARI&DD, danger signs, and
management).
CHWs recognizing danger signs for
and managing diseases prevalent
among children.
Beginning in October 00 / First
Quarter of 2001
Harold Rugama
Amelia Reyes
Training for all volunteers on referral and counter-referral
system.
Volunteers using the referral and
counter-referral system.
Beginning in October 00 / First
Quarter of 2001
Harold Rugama
Amelia Reyes
27
ACTIVITY RESULT DATE PERSON IN CHARGE
INTEGRATED HEALTH DAYS
Preparation of guidelines for Integrated Health Days. Manual/guidelines prepared. September Yamileth Alegría
Definition of indicators to be monitored on Integrated
Health Days.
Indicators to be monitored have
been defined.
September Ivette Aráuz
Yamileth Alegría
Elaboration of monitoring and evaluation for the plan for
Integrated Health Days.
Integrated Health Days evaluated. Beginning in October in monthly
technical meetings.
Yamileth Alegría
IEC
Preparation, revision and feedback on project’s IEC
strategy.
Strategy prepared and revised. October Harold Rugama
Amelia Reyes
Lourdes Haslam
Planning of IEC activities. Plan prepared. Last week of October Harold Rugama
Amelia Reyes
Lourdes Haslam
Implementation of plan. Clear and consistent messages
reaching population.
Permanent Harold Rugama
Amelia Reyes
Lourdes Haslam
SUPERVISION
Improve supervision of CARE field staff. New supervision form developed.
Plan implemented for regular
supervision visits.
By October Harold Rugama
Ivette Arauz
Additional supervision of IMCI in health units. MINSA has performance-based tool
and implements supervision plan.
By November MINSA staff
Supervision plan implemented for CHWs and CDCs. Tools developed and plan
implemented.
By December Harold, Ivette, Amelia, Lourdes
COMMUNITY PHARMACIES
Meeting of CARE and Colectivo de Mujeres and other
NGOs.
Meeting of CARE and MINSA.
Focus group with community leaders.
Implementation of plan.
Collaboration determined.
Implementation plan prepared.
Activity Implemented.
September-November
September-November
January-February 2000
Ivette Aráuz
Ivette Aráuz
Ivette Aráuz
28
Action to Date on MTE Recommendations - October 21, 2000
Since the Action Plan was prepared in mid-August following the mid-term evaluation, and
progress has been made during the intervening two months, CARE is also presenting this
summary of action to date. Progress is presented for each recommendation in italics. Related
recommendations have been grouped. 
Management
The project needs to re-evaluate the number of communities, beyond the original 70, where there
will be direct intervention, prioritizing by risk level, population of under fives, and level of
interest of the community. After meetings with MINSA and the communities, it was decided to
continue in all of the present communities.
The number of communities per Extensionist should be equitably divided. Immediately after the
MTE, the community assignments were evenly distributed among the Extensionists.
One or two additional Extensionists should be hired to cover the additional communities not
accounted for in the original proposal. An additional FS Extensionist should be contracted,
specifically to work in the urban area. A credit promoter should be hired to spearhead the
savings and loan group approach focusing on the urban area. Another extensionist, a food
security specialist for the urban area and a credit specialist were all hired in August.
Follow-up and supervision of all aspects of the project:
• CARE should develop a system for improving the quality and efficacy of supervision of all
CS staff. A supervision form for CARE personnel has been developed and is now in use
with regular supervision visits.
• Supervision plan with MINSA for IMCI The supervision plan has been developed with
MINSA and is being implemented in every health facility.
• Assist MECD to develop a plan, and form for supervising teachers and monitor
implementation. Discussions are underway with MECD to develop a feasible monitoring
and supervision system. A meeting is to be held Nov. 3-4 with all the teachers to evaluate
where they are with the health education program.
• With MINSA, implement supervision of CM day care centers. This is in the planning
stage.
• Develop and implement a plan for supervising committees and volunteers.. All reporting
forms are being revised. MINSA has not yet had time to develop a plan.
The reporting requirements for Extensionists should be reviewed to collect only the minimum
information necessary to detect problems and advances. Direct supervision should be used more
to determine the quality of the work being completed. Reporting forms have been revised by the
staff themselves in two work sessions. A regular supervision plan is in effect.
Information System should be used at all levels. More training is needed at all levels to
understand the use of information in decision making Data to be gathered has been
29
standardized. Training for MINSA/CARE staff (to replicate in the communities) was held
October 16-23.
Improve the involvement of the community in the planning, implementation and evaluation of
MINSA/CARE plans. A 3-month plan has been made with the health post staff and the
communities, is being implemented and will be evaluated in December
It is recommended that a complete budget analysis be made by the project manager, health
coordinator, and accountant, so that a realistic spending plan can be developed for the remaining
two years. The health sector coordinator and the project coordinator made a complete budget
analysis and spending plan for the next two years.
Training
1. An integrated training plan should be developed for the next 2 years, including activities in
Food Security. This plan has been developed..
2. A consistent plan for what should be included in every training course needs to be developed,
including practical experience on how to replicate the information to the next level and an
evaluation plan to insure that each participant understood the material. Training plans are
being standardized with MINSA.
Food Security
1. Improved monitoring and supervision of food security activities is required to improve the
impact of the intervention and to provide additional support to the agronomist and
agricultural volunteers. The food security staff are receiving the same increased level of
supervision as all other CARE staff.
2. Increased technical assistance should be provided in the urban area to motivate the use of
existing resources in establishing small patio gardens. An additional food security specialist
has been hired to focus on the urban area and has started training more volunteers after
have met with women of 20 barrios who are interested in gardens. Another food security
intervention, the savings groups, has been initiated. Women’s groups have been formed in
two barrios. In the rural areas, the plan of fuel efficient stoves described in the DIP has
been implemented with 50 stoves build in 5 communities. 250 more are planned.
Breastfeeding, Nutrition, Diarrhea, Pneumonia
1. Additional training in formation of support groups, accompanied by follow-up in the field, is
needed in all communities. Fifty more BF volunteers are receiving the support group
training during October and Noviembre. CARE’s Latin American RTA for Breastfeeding
and Nutrition will be in Nicaragua during Noviembre to assess the quality of work in BF
and support groups and will return there in December to train CARE and MINSA staff.
2. A study should be made by MINSA as to ways the AIN system could be simplified in the
mechanics of weighing and reporting weights, so that more energy could be focused on
30
counseling mothers for growth promotion. The twenty volunteers who were originally
trained have been 4 more days of training focued on counseling and on negotiating
changes with the mother or care-giver. A second group of 30 is being trained the last week
of October and the beginning of Noviembre with the expanded curriculum which includes
counseling. The AID manual has been revised according to these recommendations and is
being re-printed. In addition, CARE is preparing implementation guides for each
community based on the PAHO community IMCI materials.
3. An increased focus on training in IMCI and follow-up on training to insure proper application
is needed at all health facilities. As mentioned above, a new supervision system is being put
into place to monitor application of IMCI in the health facilities. Based on results, more
traininig may be given.
4. An increased focus on training in IMCI at the community level should be incorporated in all
re-training during the next 2 years. (Note from CARE: Neither MINSA Central nor the
SILAIS have approved community-level IMCI, therefore CARE cannot follow this
recommendation in the near future, but will continue to advocate for acceptance.)
Health Promotion through Schools
1. All teachers should receive information about the signed agreement with MECD. Identify
mechanisms to insure the follow-up and monitoring of health activities in the schools.
Teachers already trained have been informed. CARE and MECD are disucssing a
monitoring plan. CARE is supplying improved teaching materials.
2. Teachers should be encouraged to meet quarterly with the nearest health post to coordinate
activities. No action has been taken pending the start of the new school year in February.
3. An agreement to coordinate activities should be developed between MINSA and MECD at
the municipal level. MINSA is taking the lead on this, as is appropriate.
Integrated Health Visits of MINSA
1. CARE Extensionists should periodically accompany the Integrated Visits, with a specific role
as team member. There is resistance from MINSA to this recommendation.
2. A procedure manual for Integrated Visits should be developed, including definition of roles,
monitoring system with specific indicators, and focus on working with the community in
planning, implementation and evaluation of activities. This is being prepared with MINSA
and will be presented on October 30.
3. The Municipal Management team should actively monitor and supervise the Integrated Visit
teams, including analysis of information from the information system. Part of the plan.
4. Administrative systems of MINSA need to be improved to facilitate the distribution of
medicines and payment of per diem for Integrated Visits. Part of the plan mentioned above.
31
5. Innovative methods of education should be used during the Integrated Visits. This will be
addressed through an overall training on participatory adult education.
Community Organization and Education
1. Analyze, with communities, the concepts of Community Development Committee and
Network of Volunteers to define their roles and potential for sustainability. Meetings were
held in August with the community leaders to do an internal evaluation and discuss these
concepts. Follow-up to their recommendations is in process from both sides.
2. Volunteers and committees need to be taught how to use the information from community
maps to plan and evaluate actions to improve heath and nutrition status. Staff will now be
providing this orientation following the recent staff training on the subject.
3. More innovative approaches are needed to overcome the constraints to participation, such as
migration, employment demands, lack of interest, and political divisions.
4. The project needs to continue to move away from the use of health "talks" to give
information towards the use of other more interactive and innovative methods of adult
education.
5. Take advantage of the months from July to September for group meetings and training. From
October to June, focus on the use of indirect methods such as radio, popular education,
printed materials, home visits, and activities with the schools. Take advantage of Sundays
when people are at home.
6. Increased efforts should be made to disseminate health information at work centers.
7. Take advantage of organized groups and community activities as another method for
disseminating health information. Experiment with the use of mothers networks (where each
woman is responsible for talking with five neighbors) as an alternative approach.
8. The project needs to assist communities in identifying and accessing alternative resources,
through the mayor’s office, other NGOs, and other governmental agencies.
In regards to the community education recommendations above, a new IEC plan was
developed with input from the health posts. Materials are now being developed, including
radio, murals, placards, video and brochures. CARE/MINSA staff will have a training in
adult participatory education early in 2001 which will be replicated with the volunteers. PLA
exercises will be used during the community evaluations in Noviembre and December.
32
Inter-institutional Coordination
1. CARE should assume a leadership role in sponsoring (a minimum of) an annual workshop
for NGOs, to provide an opportunity for sharing work strategies and annual plans, and for
identifying points of coordination. CARE is investigating with the NGOS whether or not
they are interested in such a meeting.
.
2. CARE could coordinate with the Colectivo de la Mujer to learn about their experience with
community pharmacies. CARE has not only met with Colectivo de la Mujer to learn about
their pharmacy experience, but has found another NGO with useful relevant experience.
This NGO has offered to provide training, supplies and supervision. CARE will provide
the initial capital. One volunteer will be selected at each of the targeting 5 health posts
and training will be conducted in January.
F. Results Highlight
Accreditation as Baby and Mother Friendly Municipality
In March of 1999 the Municipal Management Team (MMT) of the Ministry of Health in
Matagalpa, Nicaragua accepted the challenge to become a Baby and Mother Friendly
Municipality. A Child Survival project was just beginning with funding from USAID and CARE
International, which included working towards accreditation as a project priority. The first step
was to form a Breastfeeding Committee of the MMT and CARE which developed a work plan.
Training at all levels
• 160 MOH health staff received an 18 hour breastfeeding course.
• Two 8 hours workshops were held for administrative, support and dental staff.
• 138 Breastfeeding counselors were trained representing 14 Health Centers.
• 151 Community Health Workers were trained in 39 workshops by MOH and CARE staff.
• 22 educators working in 5 day care centers were trained in breastfeeding.
• Health center staff were trained in forming support groups and counseling on LAM.
Putting Training into Action
After receiving the training the 138 counselors of the municipality began to:
• Present education activities during home visits and in schools,
• Encourage the formation of support groups in urban and rural communities
• Participate in educational activities in health centers and informational murals
Special events
• LINKAGES and CARE completed a qualitative study on breastfeeding practices.
• Breastfeeding Week was celebrated with the following activities:
Women’s meetings in every health center, with the distribution of materials
Mural competition at the municipal headquarters
Role Model Assembly with health workers
• In October a 3 month long local radio campaign began promoting breastfeeding
• In November the first interagency meeting was held to encourage the promotion of successful
exclusive and prolonged lactation by all local NGOs. Health workers from the organizations
received an 8 hour course on breastfeeding and LAM.
• In February of 2000 a stand at the NICAMER community fair promoted breastfeeding with
murals, videos, and the distribution of materials.
Official Recognition
In September UNICEF evaluated the 11 required steps for promoting exclusive and prolonged
lactation and named the municipality of Matagalpa as Baby and Mother Friendly. The official
accreditation ceremony was held in April 2000 attended by the Vice-Minister of Health and the
UNICEF Representative in Nicaragua. The goal of increasing from 10% to 30% the percentage of
women who breastfeed exclusively and from 14% to 50% those who practice prolonged
breastfeeding will be reached through the daily effort of all health workers, Extensionists of
CARE, and personnel from other organizations working together with community health
volunteers, support group leaders, midwives, and the general public, to support breastfeeding
women in their effort to have healthier babies.
ATTACHMENT A
Information from the DIP
ATTACHMENT A
Baseline information from the DIP
There have been no significant changes in any of the following since the writing of the DIP.
1. Field Program Summary
PVO/Country: CARE Nicaragua Program duration (dates): 9/30/98 1
– 9/30/2002
1. ESTIMATED PROGRAM EFFORT AND USAID FUNDING BY INTERVENTION
Intervention % of Total Effort (a) AID Funds in $ (b)
Nutrition and Micronutrients 35% $296,986.00
Breastfeeding Promotion 25% $212,133.00
Control of Diarrheal Disease 20% $169,706.00
Pneumonia Case Management 20% $169,706.00
Total 100% $848,53.00
2. Program Site Population: Children and Women (c)
Population Age Group Number in Age Group
Infants (0-11 months) 4.328
12-23 Month Old Children 4.212
24-59 Month Old Children 15.670
Total 0-59 Month Olds 24.210
Women (15-49 years) (d) 18.218
♦ Estimated annual number of live births in the site: 4742
♦ Sources of the population estimates above: Nicaraguan National Institute of Statistics
 
1
 Actual Project Start-up was delayed until 1/15/99 due to Hurricane Mitch.
2. Program Goals and Objectives:
Project Goals:
1. To improve the capacity of the MOH health personnel in community outreach, and delivery of quality services,
including health education.
2. To empower communities to organize, analyze health and nutrition problems, and seek solutions.
3. To enable families to practice healthy behaviors, identify and resolve health risks, and access quality services.
Indicators: (All refer to children under two whose mothers are interviewed except where <5 is stated.) Baseline
measurement
Final
measurement
1. Increase from 10% to 30% the number of mothers who exclusively breastfeed for the first 6 months. KPC survey KPC survey
2. Increase from 14.5% to 50% the number of mothers who continue breastfeeding their child between 12 and 24 months. KPC survey KPC survey
3. Reduce from 36% to 20% the mothers who discontinue breastfeeding before 3 months of age. KPC survey KPC survey
4. Increase from 60% to 80% the number of children weighed in the previous 4 months. KPC survey KPC survey
5. Increase from 24% to 50% the number of children who receive more liquids during diarreal episode 2 wks. prior to survey. KPC survey KPC survey
6. Decrease from 39% to 15% the number of mothers who give less food or withhold food during diarrheal episode. KPC survey KPC survey
7. Increase from 2.1% to 40% the mothers who can list 3 signs of dehydration and 2 of severe diarrhea. KPC survey KPC survey
8. Increase from 69% to 80% those who seek medical care for a child with rapid or difficult breathing. KPC survey KPC survey
9. Increase from 2.4% to 50% the mothers who can describe 2 signs of pneumonia. KPC survey KPC survey
10. Increase from 3.5% to 20% the children between 1 and 5 years who are offered food 5 times a day. Food security Ass. Food security Ass.
11. Increase 20% over baseline the number of children under 5 diagnosed with pneumonia who receive their antibiotic from
MINSA
Q of C Assessment. Q of C
Assessment.
12. Increase from 10% to 30% the childdren under 5 who are offered Vitamin A-rich food 3 times a week. Food security Ass. Food security Ass.
13. 30% of families with children under 5 eating new foods (fruits, vegetables, proteins). Food security Ass Food security Ass
14. Increase from 33% to 50% the families with children under 5 who produce some food in their yard. KPC survey KPC survey
.
16. Decrease from 56% to 46% the number of families with children under 5 cooking over a wood fire. Household observ. Household observ.
17 Decrease from 8% to 0% the number of families with children < 5 who have no food in the house around noon on Sat. in Feb. Household observ. Household observ.
3. Program Location:
The project is located in north-central Nicaragua in the Department of Matagalpa
within the municipality of the city of Matagalpa. The target area, which is under the
jurisdiction of the Municipal Health District of the SILAIS of Matagalpa takes in thirty￾eight barrios within the city of Matagalpa and thirty-two communities in the adjoining
rural areas (see Appendix B). A complete list of the barrios and communities in the
target area with their respective populations is included in Appendix A. The total
beneficiary population includes 24,610 children under five and 17,716 women of
reproductive age. In spite of relatively good access to MOH health facilities (10
minutes to 4 hours walking), morbidity and mortality rates are higher for the
municipality than for other municipalities in the Department.
Matagalpa is a large mountainous Department (province), inhabited by subsistence
farmers who plant corn and beans, and raise some livestock. There is some
commercial cultivation of coffee, rice, and vegetables, which provides seasonal
employment in harvesting and processing. Nearly a quarter of the population of the
department lives in the city of Matagalpa.
The population is ethnically homogenous, Spanish-speaking, with both Catholics and
Evangelical Protestants. Despite machismo, women often participate in family and
community decision-making. Literacy campaigns were extensive in the 1980's, but
only 66% of the population over age ten is literate to any degree (UNICEF, 1997).
During the baseline KPC survey conducted for this project, 78% of the women in the
target area interviewed said they are literate, while the PRA revealed that only 57%
of the women and 63% of the adult men actually know how to read.
Matagalpa, the capital of the Department, is the fourth largest city in Nicaragua and is
growing rapidly with the influx of migrants fleeing the desperate poverty of the
countryside. The World Bank estimates that 60% of the rural population lives in
extreme poverty with annual family incomes less than US$202.64 (World Bank,
1995). Successive years of drought, and then floods, have spurred rural-to-urban
migration. The baseline survey of this project found that 30.9% of the population
had lived in the barrio for two years or less. The recent immigrants live in shacks
constructed from plastic sheeting, cardboard, old boards, and rusty sheet metal,
perched precariously on the steep hills around Matagalpa. These asentamientos or
barrios have virtually no access to water or sanitation at the household level.
Men, women and children seek whatever work they can find in the city streets or as seasonal
laborers in commercial agriculture. According to the baseline research, only 37% of the
target population have permanent, salaried work; the others are unemployed, seasonally
employed, or work in the informal sector. The project baseline survey found that women
head 56% of households, and in 48% of all households, the woman is the main wage earner.
Of the population surveyed 31% of mothers with children under two work outside the home.
It is possible a higher percentage of all mothers with children under five work outside the
home because those with very small children are the most likely to stay home due to lack of
childcare. (Sixty-nine percent of the children selected for the survey were under 12 months of
age.)
Of those mothers staying home, 16% engage in some kind of income generating
activity. The women surveyed indicated that when they are away from home, 18%
take the child, 22% leave the child with older siblings, and 48% leave their small child
with relatives, usually a grandmother, but 6% with the father. The project believes
that the children of the working mothers are at higher risk. Analysis of the baseline
survey results showed a significant relationship between the mother working away
from home and the point prevalence of diarrhea and with reduced duration of
breastfeeding.
Even in the center of the city inhabited by middle class families there is no consistent
access to piped water. The aging water system is inadequate for the size of the
population and houses have water for a couple of hours three times per week at
most. Due to the lack of clean water, Matagalpa has suffered repeated cholera
outbreaks in the past three years. The municipal government has just received
funding from an external donor to improve the water system, but it is not clear
whether the proposed improvements will provide water to all the hillside barrios.
According to the National Institute for Water and Sanitation (INAA), approximately
thirty percent of the homes in the rural area have access to water, usually at hand￾dug public wells.
Because of the high level of poverty and the population's lack of access to basic
services, the Department of Matagalpa has been designated a priority area by
USAID, the government of Nicaragua, and CARE. CARE has been working in the
rural areas of Matagalpa since 1983 with projects in water and sanitation, sustainable
agriculture, natural resource management and most recently, with a small USAID
mission-funded child survival and food security project in selected rural
municipalities. Through these projects, CARE has earned a high degree of credibility
with the population, the MOH, and the local government.
Major causes of under-five mortality
For the Department of Matagalpa, the infant mortality rate during 1996 was 89 per
1,000, according to both the MOH and the National Census Bureau. No data for
under-five mortality is available at the Department level, but the MOH estimates that
it is higher than the national rate of 69/1000. The major cause of mortality in children
under five who survive the neonatal period is pneumonia, followed closely by
diarrhea. In the target municipal health district, according to MOH figures for 1998,
35% of <5 mortality was due to ARI, (probably pneumonia, but HIS does not
distinguish) and 23% to diarrheal disease, with all of these deaths occurring among
the urban population.
Due to the economic crisis and repeated crop failures, both acute and chronic
malnutrition are widespread. A nutrition survey commissioned by USAID with Title II
funding was conducted in the region in 1997. The report showed that over 35% of
children under 5 showed stunting (>-2 z.) The National Micronutrient Survey in 1994
found that 37% were severely anemic and 8% had serum retinol levels <10 indicating
severe Vitamin A deficiency. Local and regional data on micronutrient status are not
available.
Existing health services and child survival programs
The Ministry of Health provides nearly all health care services to the municipality of
Matagalpa. The MOH operates a 250-bed hospital, which is staffed by 78 part-time
physicians, 32 nurses and 92 auxiliary nurses. The hospital is equipped with a blood
bank, oxygen services, neonatal incubators, and a basic laboratory. Seventy-eight of
the beds are reserved for pediatric care, including recuperation of severely
malnourished children.
Ambulatory care is provided through one health center and eight health posts (four
peri-urban and four rural). The health center serves part of the urban area and is
staffed by twelve part-time physicians, four graduate nurses, and nineteen auxiliary
nurses. The health center has a basic laboratory and offers free family planning
services. The rural health posts are staffed by auxiliary nurses (one at each post)
who have minimal training. The four peri-urban health posts have part-time
physicians (final year medical students) and an auxiliary nurse. CARE's experience
with the MOH in the Department has shown that the staff have difficulty following
norms for standard case management, and frequently lack necessary medicines,
more often due to lack of planning and management than to lack of resources.
The auxiliary nurses at the health posts have traditionally been responsible for
community outreach but found it difficult because of lack of transportation, lack of
clarity about what they were to do in the community, and no one to cover the health
post while they were out. To overcome these problems, the local MOH is piloting a
new system of having a rotating team from the health center do the community
outreach. The team's efforts consist almost entirely of immunizing because they lack
orientation in how to work with community committees, supervise CHWs or make
home visits and provide education to families.
Health care workers are paid very low salaries and hence are not highly motivated.
Physicians earn the equivalent of US$350 a month, while nurses and auxiliary nurses
earn $190 and $120 respectively. Their work is hindered by lack of supervision and
inadequate supplies, particularly antibiotics.
There is high staff turnover at the management level since the positions for SILAIS
(regional MOH administrative unit) directors and many health center directors are
political appointments. This leads to lack of long-range programming and
inconsistency in policies. In contrast, the lower-level staff tend to stay in the system
indefinitely even though they are rotated between the health posts and the health
center.
The MOH commonly does community work through volunteers known as brigadistas.
There are currently 292 of these CHWs in the municipality, but they have received
only limited training and have virtually no supervision due to lack of planning and
prioritizing on the part of the MOH. The MOH would like them to distribute ORS, do
health education, advise the community of immunization campaigns, and make
referrals.
An initiative of the MOH and the local community development committees (CDCs)
has been the formation of "Base Houses" which are focal points in the communities
for health activities. Sometimes it is the CHW’s house or another existing house. In
some communities, residents have constructed a simple shelter. The Matagalpa
MOH reports that there are 54 Base Houses in rural communities in the proposed
project area and 8 in the urban area, but they have no way of knowing whether or not
the population knows the location of the Base Houses or that they serve as
distribution centers for ORS and chlorine and as meeting points for health team visits.
At the national level, the MOH currently is receiving USAID-funded technical
assistance through the second phase of a contract to Management Sciences for
Health. The first-phase project, called Decentralized Health Services Project
(PSSD), focused on strengthening management at the SILAIS level by providing
assistance in the implementation of information, administrative, financial and
monitoring systems. The PSSD also collaborated with the MOH and PAHO in
implementing programs in Integrated Women's Health, Integrated Management of
Childhood Illness (IMCI) and a training program in the Rational Use of Antibiotics
which has successfully minimized over-prescription of antibiotics, leading to more
stable supplies and considerably reduced costs in the regions where it has been
piloted. This project has now been extended through 2002 in a new contract to MSH
from USAID called PROSALUD and will be based in Matagalpa.
PROFAMILIA, the Nicaraguan IPPF affiliate, provides family planning services in
Matagalpa as does a local NGO called IXCHEN. Both charge fees for these
services. PROFAMILIA has also set up 117 community-based distribution centers
throughout the Department.
Two other international PVOs have health projects in the Department of Matagalpa.
Catholic Relief Services is implementing a BHR/PVC-funded Child Survival project in
the remote eastern half of the Department. Oxfam-Belgium is doing some primary
health care work in a small municipality in the south of the Department.
Concurrent to this CS project, CARE was awarded a grant from USAID Nicaragua to
implement a 3-year institutional strengthening project within the SILAIS of Matagalpa.
The project, called SALUMAI for Salud Materno-Infantíl, focuses on improving the
capacity of MINSA at both district and local levels in quality of care, monitoring,
supervision, financial and logistics management, and mid-to-long range planning as
well as enhancing MINSA-community interaction.
 Because this CS project is in an urban area, the population has access to numerous
pharmacies (unlicensed) and to many private professional practitioners. The
baseline survey shows that 12% of mothers went to private medical professionals for
a child with diarrhea and 5% sought private care for a child with rapid breathing.
Only two mothers reported seeking help at a pharmacy. Only two mothers sought
help from traditional birth attendants and no one went to traditional healers.
4. Program Design:
Strategy:
The overall project strategy is to implement activities in conjunction with MINSA staff,
a collaboration which started with joint planning at the proposal stage and has
continued through the baseline assessments and the preparation of this DIP. CARE
and the MOH will jointly design and conduct assessments of the quality of care
provided by the health center and health posts for diarrhea, pneumonia and nutrition,
and then develop plans which will include training or reinforcing training of MOH
physicians, nurses and auxiliary nurses in IMCI, Rational Use of Antibiotics, and
supervision. Together CARE and the MOH will implement plans for training and
supervision of CHWs, referral and reporting systems. The MOH staff will also be
trained in IEC and in the collection and use of qualitative and epidemiological data for
program planning and decision-making.
The MSH project and PAHO are working with the MOH to implement IMCI as the
national protocol. Matagalpa Department has been chosen as one of two pilot sites
for the initiation of IMCI. Only 4 selected MINSA health care staff in the Matagalpa
municipal health district have been trained in IMCI at this time, but plans are
underway for the training of the others. This project along with PROSALUD and
SALUMAI will help fund this training. The CARE project supervisor will also be
trained in IMCI and will receive technical support from CARE HQ, PROSALUD and
PAHO in how to facilitate local planning and appropriate supervision, including Q of C
assessments, to reinforce adoption of IMCI.
A significant effort of the project will be to enhance the MINSA community outreach.
In most of Nicaragua, the auxiliary nurses who staff the health posts are supposed to
visit the communities, but in Matagalpa the municipal MINSA has implemented a
team approach to covering communities. Different members of the relatively large
health center staff take turns participating on the team to visit each major community
(i.e., those that pertain to the health center as well as all those that correspond to
health posts) every two or three months. This involves mobilizing only one vehicle,
which is assigned permanently to this function.
So far, the main purpose of these team visits has been to immunize children,
distribute micronutrient supplements, conduct pre-natal exams, and sometimes weigh
children. Because the team lacks organization and skills for working with the
community, these visits are not used as opportunities for health promotion activities,
patient follow-up, or supervision of CHWs. A CARE staff person will be assigned to
accompany the teams to help them learn to plan for optimal visits, maximize use of
their time and resources in the communities and evaluate the outcomes of these
visits.
This strategy of using a central team to do community work has great potential to be
replicated in all other regions of Nicaragua. The lack of transportation and the
problem of leaving the health posts unattended are major barriers to community
outreach throughout the country. As a result, health workers rarely venture out into
the communities. If the CS project is successful in improving the quality of this
central team approach to outreach by including home visits, health education, patient
follow-up, growth monitoring, supervision of CHWs, and coordination with CDCs, it
could serve as a model for the MOH to replicate.
MINSA currently lists 292 volunteer CHWs called brigadistas in the municipality, but
many are not active. They lack supervision, and training has been didactic without
providing them the necessary skills for community education or mobilization. CARE
has assisted MINSA in defining the responsibilities of the CHWs, and will help in
conducting a training needs assessment, and implementing adequate training and
supervision programs with the intent of creating a cadre of 70 well-trained, active
volunteers. All of this is being coordinated with Community Movement, which claims
most of the same supposedly existing volunteers and has provided training in
reproductive health and hygiene. CARE would like to see the volunteers consider
themselves responsible to their community or barrio, rather than to MINSA or
Community Movement.
According to the focus groups conducted during the baseline and the KPC, there is
little recognition of the location or function of the Base Houses by the urban
population. Only one barrio described satisfaction with the Base House. In the rural
areas, they are well-known and the mothers report going there for ORS and chlorine.
MINSA staff say the only form of supervision is the contact with the CHW when
he/she comes to the health center or post for re-supply. Both CHWs and MINSA
staff report that the supplies are consistent and sufficient. CARE will help MINSA
and the volunteers develop appropriate promotion of the Base Houses and will
assess and improve the quality of services as described under the Diarrhea section
of this document.
MINSA has asked CARE specifically to assist them in achieving Baby-Friendly Health
Unit status, a take-off program from UNICEF’s Baby-Friendly Hospital Initiative,
which certifies health units which meet criteria for promotion of exclusive breast￾feeding. This will involve training MINSA staff, recruiting and training breast-feeding
counselors, and starting mother-to-mother support groups in the barrios and
communities, and in advocating for policy changes within the health units.
CARE and MINSA staff will also train at least one primary school teacher in each
community, who will train other teachers in simple health and nutrition messages for
children. The action-oriented messages will focus on healthy behaviors that children
can practice at home with younger siblings or demonstrate to parents.
CARE and MINSA will work with Community Movement and the Ministry of Social
Action to integrate health into the community organizations (CDCs) they have formed
and will continue to form in all communities. The CS project will teach these
committees how to collect and analyze data on local health problems and assist them
in making plans to solve these problems. The community development committees
will be encouraged to implement health promotion activities at the community level,
using the "Base Houses" as a focal point for activities. The director of Community
Movement participated in the development of this DIP and their local committees
were involved in facilitating access to the communities for the baseline survey and
qualitative research.
The project strategy has been designed to complement and strengthen the MINSA
strategy. MINSA objectives include improving quality of care, implementation of
IMCI, rational drug use, expanded coverage of growth monitoring, and establishing
training programs for health care personnel and community volunteers in order to
improve the detection of and attention given to high risk groups, particularly at the
community level.
5. Partnerships:
CARE's principal partner in this proposed CS project is the Ministry of Health,
specifically the Matagalpa Municipal Health District (MINSA). One of the principal goals
of the project is to develop the capacity of MINSA to deliver quality services and
outreach, particularly in the areas of nutrition, breastfeeding promotion, diarrheal
disease, and pneumonia. By undertaking project activities as partners, MINSA has
been actively involved in identifying areas that need to be strengthened and learning all
the steps necessary for improving. The municipal MOH staff have already been
involved in the design of this project starting with decisions of target communities,
interventions and roles and continuing with the plans for strategies and activities. A
formal partnership agreement is included in Annex II.
In coordination with the project the MINSA will be responsible for continued curative and
preventive services for the target population; organization of the outreach team for bi￾monthly visits to each community; provision of immunizations, micronutrient
supplements, patient follow-up and health education during community visits; training
and supervision of CHWs, teachers and breastfeeding counselors; participation in Q of
C assessments and designing training plans; supervision of MOH staff; supplying the
pilot community pharmacy; and motivation and support of the CDCs. In addition, they
will participate in additional qualitative research, IEC development, and the mid-term
and final surveys. (They already participated in the baseline research and KPC and the
development of this DIP.) Since all of these activities enhance their ability to achieve
national goals for coverage and improvements in quality of services, MINSA staff have
a vested interest in assuming and sustaining all the proposed activities. MOH and
CARE management staff will continue to meet monthly to plan and evaluate project
activities, assess the partnership and coordination, and seek solutions to difficulties.
The plans for improving MOH managerial and technical skills have been described in
the sections on project design and training. Due to decentralization, the local MOH
appears to have adequate financial resources to carry on the essential activities
described in this proposal, but needs to learn to plan, prioritize, and improve
management and supervision systems. They are hampered by high staff turn-over
and some frozen vacant positions, but through modeling and exercises in planning
and time management, CARE will try to assist them to maximize use of the time of
the existing personnel.
A secondary partner is a national NGO called Community Movement (CM), which is
promoting community organizations (CDCs) in both rural communities and barrrios.
CARE will assist the CDCs to identify and understand health issues and to make plans
to addresss health related problems. CARE will also work closely with CM to improve
the efficacy of the five child feeding centers as described in the Nutrition intervention
section of this DIP.
As a companion project, CARE will also partner with a local NGO who operates a
successful micro-credit programs in Matagalpa. This arrangement is in the process of
being formalized and CARE does not feel it can divulge names of the organizations until
the agreements are signed due to the involvement of funds. The NGOs will be
responsible for the disbursing loan capital and the administrative management of the
credit programs, while CARE Child Survival staff will be responsible for promoting the
credit and organizing the women in the communities to learn about the proffered credit.
The credit programs have built-in sustainability in that the women learn the
administration as an integral part of the process, and the interest they pay is re-invested
in new loans, thus creating a sustainable mini-bank in three to five years.
6. Health Information System:
As a basis for program monitoring, CARE and MINSA will conduct a comprehensive
census of the municipality, by barrio and community. This is an essential first step
because MINSA currently uses population estimates from the 1993 census as the
denominator for their rates and coverage. Since immigration has accelerated, this
gives a distorted view, for example, that they have achieved more than 100%
coverage on immunizations. Once, the census is completed, CHWs will maintain the
accuracy by reporting births, deaths, and migration on a monthly basis to the
corresponding health unit. The census will be tabulated by age and sex. The census
data will be shared with municipal authorities, community and barrio leaders, and
other organizations working in the area.
In addition, CHWs of the rural communities and more stable barrios will be
encouraged to prepare schematic maps locating families by name. These maps will
be duplicated to give MINSA a reduced-size copy while the community retains the
orginal, which will be coated in plastic to allow for writing on changing information
such a pregnant women, high risk children, etc.
The maps and accompanying information such as socio-economic and morbidity data
from the baseline studies, population figures, numbers of pregnant women,
malnourished children, etc. will be shared with community members during initial
organizational meetings. Community members will be assisted through PLA
exercises in interpreting the data and understanding how to draw conclusions and
make decisions based on such information.
MINSA needs reports from the CHWs on number of ORS packets and chlorine
tablets distributed. The current reporting form will be evaluated and space added for
the CHW to up-date census data and to report efforts such as home visits and
educational activities. These are turned in to MINSA once a month and will be used
by MINSA, CARE and the community to monitor level of CHW effort and to identify
training and support needs. MINSA will also track the number of referrals made by
CHWs through the referral stubs retained at the health units. Contact will be made
with CHWs who do not report to determine why and what assitance they need to
become more active. MINSA will maintain a 3-ring binder in which to keep these
forms, sorted by CHW. The activity levels will be tabulated quarterly and incentives,
such as certificates, given to high performance CHWs.
To effectively manage data collection and utilization, CARE will use a minimum of
forms to collect only the data necessary to monitor the inputs, outputs, and outcome
indicators listed below and to assess staff and CHW performance. At the end of
each training session, the staff responsible will record who was trained in what. With
MINSA, a chart will be developed to track this information on an on-going basis.
CARE will also record this information in a computer data base to allow for rapid up￾dates and print-outs to be used in planning. In addition, the CARE-MINSA training
team will keep the pre and post-test results to use for supervision and possible re￾training.
CARE, MINSA, and CM are establishing a paper data base to monitor community
organization and empowerment. This will consist of one form per community or
barrio which lists basic infomation on each community (leaders, infrastructure,
population, existing groups) and has spaces to note when each CDC has
accomplished a step towards empowerment or has successfully executed a
community activity or project related to health. These forms will be reviewed on a
monthly basis by the coordination committee of CARE, MINSA, and CM. From
these reports, decisions can be made about which community committees need more
training, reinforcement, or other attention. Accomplishments will be registered by
CARE in their Management Information System (computerized) to monitor progress
towards community empowerment and sustainability.
A. Process Monitoring
The following chart lists the indicators and data collection necessary to monitor
project progress in capacity building, institutional strengthening, and sustainability.
The draft summary report form to be used by the project is shown in Annex II.
Number of communities/barrios
1, with up-dated census and map
Data sources:
CDC reports and extensionist reports
2.. organized with functioning CDC
3. PLA diagnosis completed
4. Equiped and functioning base house
5. with 6-month operating plan made
6. implementing 6-month operating plan
7. with functioning referral system
monthly CDC and ” “
monthly extensionist reports
CDC and MINSA reports
CDC and extensionist reports
CDC and extensionist reports
MINSA records of referrals
 No. of community committees trained in:
1. FODA
2. Community organization
3. planning and evaluation
extensionist monthly reports
 “ “ “
 “ “ “
No. of community volunteers trained in: MINSA-CARE training reports
1. referral system
2. participatory adult education
3. breast feeding promotion (TBAs, CHWs)
4. nutrition
5. food security interventions
a. family food production (gardens,fruit, poulty)
b. family financial management
1. IMCI
2. Diarrhea case management
3. base house operation
4. pneumonia recognition and follow-up
5. reporting and community census
6. as breastfeeding counselors
No. of MINSA staff trained in: CARE training reports
1. referral counter-referral system
2. supervision
3. leadership and teamwork
4. planning and evaluation
5. PLA methods
6. nutrition and food security
7. community mobilization and organization
8. IMCI
9. quality assurance
10. Total Quality Management
11. IEC design
12. counseling
13. formation of BF support groups
Quality of services - No of health units Data sources:
1. with Q of C assessment
2. implementing IMCI
3. with referral system functioning
CARE project MIS
MINSA records, CARE supervisor report
MINSA records
4. with functioning supervision system
5. using TQM for problem resolution
6. implementing Baby Friendly inititative
7. certified “Baby Friendly” by UNICEF
8. number of BF support groups formed
CARE supervisor report
CARE supervisor report
MINSA report
UNICEF records
MINSA and CARE records
Community activities: CHW reports
Number of home visits made
Number of referrals made, counter referrals received
Number of follow-ups to counter referrals
Number and type of educational activities conducted
Number of children weighed in GM communities
Number of cases of DD treated in Base House
Number of families growing food for consumption
Number of families with improved stoves
Number of families enrolled in credit project
B. Outcome Indicators
The project outcome indicators and how they will be measured are listed in the table
at the beginning of the Project Design Section.
C. Performance Monitoring
Each CARE extensionist will complete a monthly report of activities which he/she will
review personally with the CARE supervisor, who will also accompany staff on a
regular basis to provide supportive supervision in the their assigned work. As a first
step to performance-based supervision, the extensionists participated in the
development of their own job description. A corresponding supervision form is being
developed for use by the supervisor based on PHC MAP models. The supervisor
will maintain a supervision log to monitor performance and remind her of needed
follow-up. The CARE extenisionists will maintain an informal daily log in a notebook
for their own use in tracking activities, problems, follow-up, etc.
A dual system will be implemented to assess health worker performance and monitor
improvements. First, the project will conduct a quality of care assessment using an
adaptation of existing IMCI quality of care assessment tools validated by BASICS,
which will be repeated at mid-term and again at the end of the project.
The very comprehensive tool assesses health worker ability and the availability of
essential drugs, materials, and equipment. The results will be used to plan and
reinforce training and supervision. In addition, CARE will assist MINSA to implement
supervision check lists adapted from the PHC MAP series to monitor staff and CHW
performance on a regular schedule and provide constructive feedback.
ATTACHMENT B
Evaluation Team Members
ATTACHMENT B
Evaluation Team Members and their Titles
Team 1
Harold Rugama López*, CARE Supervisor
Dalia V. Pérez Alániz, CARE Extensionist
Nidia Espinoza, AIN Coordinator, MINSA
Maritza Manzanarez, CARE Extensionist
María Lourdes Haslam, Brigadista Coordinator, MINSA
Renee Charleston, Consultant, Overall Team Leader
Team 2
Ivette Aráuz C.*, CARE Project Manger
Ronald Uriarte, CARE Extensionist
Amelia T. Reyes, Head of Municipal Training Unit, MINSA
Urania Umanzor, CARE Extensionist
Judiann McNulty, CARE USA Representative
Team 3
Abundio Jarquin R.*, CARE Agricultural Extensionist
Wilfredo Vargas, CARE Extensionist
Guadalupe Paz, Head of Health Post Palcila, MINSA
Socorro Palacios, Health Center Nurse, MINSA
Elizabeth Rodríguez, CARE Extensionist
Elena M. McEwan, CARE Health Coordinator
Additional Resource People:
Erlinda Cuadra, Head of Nursing, MINSA
Maria Ausuncion Meza, SALUMAI Project Manager, CARE
*Team Coordinador
The overall team leader was responsible for coordinating all evaluation activities, supervision of the team,
meeting all specified objectives, collaborating with CARE, MINSA and USAID, and submitting a draft and a
final report according to the defined timeline. Each field team had a coordinator during the field data collection
whose role included overall coordination, planning and logistical support of the team.
ATTACHMENT C
Evaluation Methodology
ATTACHMENT C
Evaluation Methodology
PARTICIPATORY EVALUATION PROCESS
I. OBJECTIVES OF THE EVALUATION
The purpose of the Midterm Evaluation was to identify what is working well, identify problems,
and recommend useful actions for improvement during the last half of the Project. The objectives
of the evaluation were:
1. Review progress made towards the goals and objectives of the Child Survival
project, as outlined in the Detailed Implementation Plan.
2. Evaluate the implementation process of the project, identify what has worked
well as well as problems and limitation to implementation.
3. Make recommendations as to modifications or adjustments required to improve
the project’s potential for obtaining sustainable impact.
III. METHODOLOGY
Using both a participatory approach and participatory methodologies, a multi-disciplinary term of
key project stakeholders examined the process of implementation using a variety of quantitative
and qualitative methodologies. The team was comprised of representatives from CARE and the
Ministry of Health. Field visits allowed project participants and community volunteers to provide
their inputs and suggestions to the evaluation process. The evaluation focused on the quality of
activities including; planning, community participation, linkage with other organization, and
sustainability. The methodologies used to obtain information for the evaluation included:
Document Review
Key Informant Interviews
Group Interviews
Observations
IV. EVALUATION PLAN
The evaluation was divided into four phases:
Phase I Planning
• Preplanning (Formation of team, logistics, document review)
• Planning Workshop (Content, methodologies, design of instruments)
Phase II Data Collection
• Field Work visits
• Other interviews
• Document review
Phase III Data Analysis
• Summarize data
• Analysis of data by team and resource persons
Phase IV Presentation
• Written report
• Formal presentation August 3 in Matagalpa, Nicaragua
The evaluation team was divided into 3 small groups to collect information from the field. Each
team consisted of 5- 6 people. The teams were in the field for 3 days to visit 18 communities
previously selected for visits. The communities were selected using the following criteria:
-Remove all communities that take longer than 1 hour on foot, or due to the rains, would
be difficult to reach
-Remove all communities where the project has been working less than 6 months
-Randomly select communities (6 from the urban area and 8 from rural communities).
-From the list of programmed activities, purposively select 2 urban and 2 rural
communities with selected project activities.
 -Identify two health center to be visited by each team
A two-day Results Workshop was held for all team members plus resource people to review the
results of the field work and other information collected during the evaluation, and to formulate
recommendations for improving the quality of project implementation.
V. EVALUATION SCHEDULE
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
July 22
Review of
Documents
23
Travel to
Nicaragua
24
Evaluation
Planning
25
Workshop
for
Evaluation
Team
26
Workshop
for
Evaluation
Team
27
Preparation
of evaluation
tools
28
 Community
Visits
29
Community
Visits
30
Community
Visits
31
Analysis of
information
Interviews
August 1
Analysis of
information
2
Evaluation
Workshop
3
Evaluation
Workshop
4
Travel to
Managua
Interviews
5
Travel to US
6
August 11th-Present Draft Document
18th –Present Final Document after review by CARE
TALLER DE PLANIFICACION
25 de Julio
9:00-9:30 Bienvenida e Introducion de participantes Ivette
9:30-10:30 Evaluacion Participativa Renee
10:30-11:00 Refrigerio
11:00-1:30 Presentacion de resultados del proyecto Ivette/Harold/Abundio
1:30-2:30 Almuerzo
2:30-3:00 Como Evaluamos Renee
3:00-5:00 Trabajo de Grupos-Situacion Ideal
26 de Julio
8:30-10:00 Plenaria
10:00-10:30 Contenido de la evaluacion Renee
10:30-1:00 Trabajo de Grupos:
Formulacion de Preguntas
1:00-2:00 Almuerzo
2:00-3:00 Como Hacer Entrevistas Elena
3:00-4:30 Formacion de equipos Coordinadores
4:30-5:00 Proximos Pasos Renee
TALLER DE ANALISIS
2 de Agosto
9:00-10:00 Experiencias en el campo
 Cinco Estrellas
Revision de informacion colectada
10:00-1:00 Trabajo de Grupos-Situacion Actual
1:00-2:00 Almuerzo
2:00-3:30 Plenaria
1:30-3:30 Trabajo de Grupos-Recomendaciones
3:30-5:00 Plenaria
3 de Agosto
9:30-11:30 Trabajo de Grupos- Estrategias Especificas
11:30-1:30 Plenaria
1:30-2:30 Almuerzo
2:30-4:00 Revision y Priorizacion de las Recomendaciones
4:00-4:30 Recomendaciones Adicionales
4:30-5:00 Evaluacion del Proceso y Clasura
An evaluation of the MTE process was completed by all team members at the end of the
Evaluation Workshop. The results from 15 questionnaires were:
♦ 93% of participants felt that the process used was very effective
♦ The main thing lack from the process was the involvement of community members in the
evaluation process
♦ What people liked most about the evaluation was the team involvement in all steps of the
evaluation process, the involvement of MINSA, listening to all members of the team and
respecting their ideas and the opportunity to learn new participatory methodologies,
particularly the selection of communities randomly and the comparison between “Ideal
Situation” and “Actual Situation”
♦ What people liked least was that the questions were too repetitive for people having more
than one role in the community
♦ 67% felt that the process used was very applicable in their work and 33% felt it was
applicable, Examples included; the methodology was a good way to have a better
understanding of where the project is currently at, and to organize where the project
needs to go.
♦ Suggestions for improving the process in the future were: observe more actual activities
and visit communities not in the project as a control.
ANALYSIS AND RECOMMENDATIONS FROM THE WORKSHOP
Entrega de Servicios de Salud
Situacion Ideal Situacion Actual Recomendaciones
- Familias apropriadas de sus problemas
y gestionando en conjunto con la red
comunitaria
- Familias que continuan alimentando los
<5a durante los episodios de diarrea
- Familias dando liquidos (SRO) a todo
menor de 5años durante la diarrea
- Familias idenificando al menos 2 signos
de peligro de EDA-IRA y haciendo uso
de Casa Bases
- Casa Bases funcionando con personal
capacitado y reconocidas por las
familias.
- Familias asistiendo a los pesajes de
<5a en su comunidad, por lo menos 6
veces al ano.
- Integracion de las familias al menos de
una actividad de salud en su
comunidad.
- Familias organizadas en actividades de
abatizacion, clorando agua, e higiene
comunitaria
- Falias poniendo en practica en el hogar
consejería recibido por el Brigadista
- Integración de la familia en grupos de
apoyo, intercambiando experiencia de
acuerdo al intereses del grupo
- Madres con <6m dando lactancia
materna exclusiva
- Madres lactando (trabajadoras)
poniendo en practica técnicas de
extracción manual y conservación de
leche
- Algunas familias reconocen sus problemas de salud y están
gestionando a nivel local la solución de problemas; pero la mayoría
de ellas no conocen los canales donde pueden gestionar o
consideran que necesitan de agentes externos que les resuelvan sus
problemas.
- La mayoría de las madres conocen a los brigadistas y utilizan la
casa base de sus comunidades para retirar las sales de rehidratación
y cloro, realizar las sesiones de AIN, reuniones para recibir
mensajes de salud de lactancia materna, EDA, IRA. Sin embargo la
mayoría de los grupos les gustaría que los servicios de la casa base
se ampliaran y que fueran de forma permanente.
- Los mensajes de salud han sido impartidos por las consejeras de
lactancia materna y las monitoras de AIN; las cuales ya han sido
capacitadas en los temas antes descritos, además han recibido
materiales para realizar las actividades de IEC.
- Las consejeras y monitoras refieren como problemas: que no todas
las madres participan en las actividades de salud; las causas más
mencionadas son: timidez, desinterés, falta de tiempo de las madres.
Como soluciones a los problemas mencionaron visitar a los padres,
pedir que miembros de CARE-MINSA les acompañen en las
visitas domiciliares.
- El cambio de prácticas en las madres, referidas por las consejeras
y monitoras de AIN son; que las madres dan mas lactancia
materna, han mejorado sus practicas de higiene personal y
ambiental, utilizan los filtros caseros, cloran el agua de consumo
humano.
- Al preguntárseles por la importancia de la tarjeta, la mayoría
contesto que sirve para llevar el control e las vacunas para poder
ser atendidas en las u/s.
- La mayoría de los grupos reportaron que la mayoría de las madres
acuden directamente a las unidades de salud para la atención
integral de sus niños. Esta practica se corresponde con el hecho que
- Selección de comunidades en base: Enfoque
de riesgo, mayor número menores de 5 años.
Demuestran intereses en las actividades de
desarrollo.
- Distribuir comunidades por número manejable
por extensionista.
- Que el trabajo coordinado de MINSA-CARE,
sea involucrado todo el equipo de cada unidad
de salud.
Red comunitaria
- Integrar mayor cantidad de miembros en la
red.
- Reorientar el trabajo de manera integral en el
comité.
- Sectorizar la comunidad para facilitar el
trabajo del brigadista.
- Analizar el concepto y el que hacer de la red y
comité (buscar la horizontalidad)
- Mejorar la metodología de transmisión de
mensajes y de capacitación como facilitadores
- Elaborar plan de supervisión y
acompañamiento (extensionista y personal de
salud), con resultados que puedan monitorear
lo que está cambiando.
- MINSA implemente en cada Puesto de Salud,
mural de información y comunicación con la
Red comunitaria.
- Revisar contenido de mensajes radiales para
estimular la participación de la red comunitaria
y familias en la comunidad y reconocer las
buenas prácticas de la familia.
- Mantener formatos de recolección de forma
Situacion Ideal Situacion Actual Recomendaciones
- Familias no automedicándose en el
hogar (antibióticos/antidiarréicos
- Toma de responsibilida de la madre en
el cumplimiento de la Referencia y CR
- Familias asistiendo con sus hijos al
VPCD en su P/S
- -Madres y Padres de familia
conociendo la importancia del registro y
componentes de la tarjeta de AIN
el AIN comunitario esta en proceso de organización en las
comunidades y que el sistema de referencia no es conocido por las
madres.
- Al preguntarles si conocían al BS todos los grupos reportaron que
si, relacionándolo con dar consejería (11/16) y hacer visitas
domiciliares (6/16). Al preguntar si acudían a pedir referencia
cuando sus niños se enfermaban, las madres contestaron que la
mayoría acuden a las u/s directamente y un 37% habían solicitado
una referencia para acudir a las u/s.
- La mitad de las consejeras encuestadas refirieron que esta
organizando los grupos de apoyo. Estos están en diferentes estados
de desarrollo que van desde grupos de madres reunidas para recibir
charla has grupos que se reúnen para compartir experiencias (10/18
entrevistadas). Para lograr lo anterior las consejeras refirieron
haber sido capacitadas en consejería, lactancia materna, grupos de
apoyo. Ellas refirieron como beneficios en mejorar su trabajo el
hecho que les ha ayudado a como dar consejería (12/18) a grupos de
mujeres que van desde 5 madres por grupo hasta 15 madres por
grupo. La mayoría de las consejeras refirieron que solo se han
reunido unas dos veces. Y que no solo han abordado el tema de LM,
sino que además han hablado de EDA e IRA (7 y 5 de nueve
grupos respectivamente)
- Los logros de los temas abordados en los grupos de apoyo, según
las consejeras son: que las madres dan mas pecho, usan cada día
menos las pachas.
sencilla y manejable por la comunidad.
VISITAS DEL PERSONAL MINSA A LAS COMUNIDADES
ASPECTO POSITIVOS ASPECTOS A MEJORAR RECOMENDACIONES

 El hecho de que las visitas se estén realizando.

 Disponibilidad del personal comunitario.

 Permite planificar con la comunidad.

 Actualmente se genera más involucramiento de la
población confianza en referir, confianza en
visitar la Unidad de Salud, sienten más fortalecida
su autoridad.

 Mejoría de la relación MINSA-Líderes. El
MINSA está conociendo más la realidad de la
gente.

 Se fortalece la autoridad local del brigadista.

 Hay mayor seguimiento a las actividades de la
comunidad.

 Se ha mejorado la percepción del papel del
comunitario, no se utiliza actualmente solamente
como correo, se involucra tomado en cuenta.
Ejemplo: No sólo se usa para avisar de la
vacuna.

 Tiene un enfoque de mayor integralidad,
involucra la red.

 Se ha mejorado el flujo de información de la Red
al MINSA.

 Definir objetivo concretos, uso de la información
existente, definir instrumentos y material a utilizar en la
visita.

 El seguimiento a las actividades planificadas con la
comunidad en conjunto con el MINSA.

 Debe mejorar la coordinación de la visita Red￾MINSA.

 El enfoque de la visita a mejorar la capacidad de la
gente (autonomía).

 Uso de las herramientas de supervisión.

 La retroalimentación a la Red.

 Los planes futuros en base a la retroalimentación.

 La recolección y el uso de la información.

 La autoevaluación de la visita.

 La transmisión de experiencia positiva y negativa
dentro del equipo.

 La discusión con las Unidades de Salud-Red acerca
de la situación higiénica sanitaria de la comunidad.

 Retroalimentación a la red sobre la situación encontrada
en la visita, análisis en conjunto de la información.

 Planificación de las visitas estableciendo objetivos en
base ala información existente

 Programación conjunta MINSA-CARE-Red
comunitaria

 Educación continua al equipo en temas de supervisión y
empoderamiento comunitario.
EDUCACIÓN URBANA
ASPECTO POSITIVOS ASPECTOS A MEJORAR RECOMENDACIONES

 Radio (mensajes)

 Red de Promotores por barrio.

 Interés de la gente

 Mejor contacto MINSA-Comunidad

 Existe Casa Base en algunos barrios.

 Coordinación MINSA-Movimiento Comunal￾ONG’s-otros.

 Existencia de actividades socio-educativas.

 Tomar en cuenta el ciclo de trabajo

 Tomar en cuenta uso de RR.HH. disponibles en la
comunidad. Ejemplo: jóvenes, niñ@s, amas de casa,
abuelas y líderes.

 Aprovechar la concentración de la gente. Ejemplo:
Centro de trabajo, paradas de buses, actividades
deportivas, actividades religiosas, escuelas, etc.

 Aprovechar alto índice de alfabetismo.

 Identificar otras alternativas para llegar a la gente.

 Aprovechar los meses de Julio a Septiembre
para:Visitas a domicilio, Reuniones, Capacitaciones.

 Aprovechar los días domingos

 De octubre a Junio enfocar en medios indirectos:
Radios ,Afiches, Folletos, Actividades con las
escuelas,Títeres, teatro.

 Difundir información en los centros de trabajo.

 Aprovechar grupos organizados y concentraciones de
gentes, para difundir mensajes; Promover educación en
cadena

 Expandir red con madres, jóvenes, abuelas, grupos
existentes y alumnos.

 Utilizar radio para estimular la red.
EMPODERAMIENTO COMUNITARIO
ASPECTO POSITIVOS ASPECTOS A MEJORAR RECOMENDACIONES

 Comité gestiona proyecto para su comunidad o
barrio.

 Comité se organiza según necesidades propias de
comunidad y barrio.

 Contar con un inventario de recursos de comunidad
y barrio.

 Crecer en número y cargos que sean funcionales.

 Reconocimiento y participación de la comunidad.

 Comunicación con comunitarios

 Planificación estratégica a mediano y largo plazo,
basado en necesidades.

 Plan de respuesta a emergencias (agrícolas,
naturales, traslados).

 Claridad en función/rol de sus miembros
(redistribución de cargos).

 Que todos los integrantes dominen conocimientos
para que apoyen a sus compañeros y/o asuman su cargo.

 Capacitar en todos los temas de salud a los miembros

 Facilitar la conformación o crecimiento en número de
miembros de acuerdo a la realidad de la comunidad o
barrio.

 Ver la manera de involucrar a la red comunitaria en la
planificación, ejecución y monitoreo y evaluación de los
planes.
SALIDAS INTEGRALES
ASPECTO POSITIVOS ASPECTOS A MEJORAR RECOMENDACIONES

 Hay una programación de salidas para seis meses

 Existe un formato de recolección de
productividad

 Es una forma que el MINSA hace presencia en la
comunidad.

 Se logra buena cobertura de inmunización.

 Hay logros en alta cobertura a embarazadas.

 Organización y disciplina

 Registro y análisis de la información.

 Supervisión y monitoreo.

 Integralidad en la atención
-AIEPI: Vitamina A, Hierro, consejería.
-Educación en salud a la población.

 Trabajo con la red comunitaria

 Enfocar la programación a las comunidades no solo
puestos de salud.

 Definición de los objetivos de las salidas.

 Definición de funciones de cada miembro.

 Incentivos al personal.
-Capacitación
-Reconocimiento
-Viáticos.

 Que el equipo CARE integrarse a las salidas integrales.

 Realización de un Manual de salidas integrales.

 Sistema de información
- Integrar nuevos indicadores
- Análisis periódico

 Definición de funciones de cada miembro por el equipo de
dirección.

 Realización de monitoreo y supervisión por el equipo de
dirección.

 Realización de actividades con red: planificación, ejecución
de actividades

 Mejorar el abastecimiento del medicamento.

 Mejorar entrega de viáticos.

 Coordinación con organismos para el vehículo

 Actividades novedosas de educación en salud
ATTACHMENT D
Persons Interviewed and Contacted
Documents Reviewed
ATTACHMENT D
Persons Interviewed and Contacted
During field visits the following people were interviewed:
129 mothers in 16 project communities
32 Brigadistas (CHW)
18 BFV (support group leaders)
 7 GMV (AIN volunteers) in 5 communities
11 Rural Agricultural Promoters
 4 Urban Agricultural Promoters
16 Community Committees
6 Health Facilities Staff
5 Teachers
Observation: 16 Base Houses
Agricultural activities
5 Growth Monitoring Demonstrations
Community Maps
Other interviews conducted as part of the MTE were:
MOH staff
Dr.Ana Cecilia Salinas, Asistant Director, MINSA Matagalpa
CARE Staff
6 Extensionists
Clarisa Molinares, MIS
Harold Rugama, CS Supervisor
Ivette Aráuz, CS Coordinator
Abundio Jarquin, Food Security Extensionist
Roberto Rámirez, Accountant
Elena McEwan, Health Sector Coordinator
M.J. Conway, Country Director
OTHER Organizations
Auxiliadora Torrez Ramero, Movimiento Comunal
Norma Altamiranda Castro , Ministry of Education
Carla Picada, Nutrition Center Cristobal Vanegas
USAID Nicaragua
Alonzo Wind, Health Officer
Kathy McDonald, Head of Social Investments
DOCUMENTS REVIEWED DURING THE MTE
Lopez, Margarita, Baseline Child Survival Project XIV, CARE International in Nicaragua,
1/99.
Rosenberg, J.E. and M.J. Moya de Suarez, Un Manual para Capacitadores y Supervisores
Sobre Tecnicas de Consejeria, Facilitacion de Grupos de Apoyo, y Educacion Popular, 8/96.
Manual de Personal Nacional, CARE International in Nicaragua, 4/98.
Atencion al Usuario, Municipio de Matagalpa, MINSA,Matagalpa, Nicaragua, 9/99
Annual Report, Child Survival XIV, CARE International in Nicaragua, 9/99.
Manual del Monitor y Monitora de Atencion Integral al Nino, CARE, Ministerio de Salud,
USAID, Managua, Nicaragua, 9/99.
Manual para Monitoras y Promotoras de Grupos de Apoyo en Lactancia Materna, Centro
Mujer y Familia, Managua, Nicaragua.
McEwan, E. & J. McNulty, Project Proposal Child Survival XIV, CARE Nicaragua & CARE
USA, 12/97.
McNulty, J. & E. MeEwan, Detailed Implmentation Plan, Child Survival XIV, Matagalpa,
Nicaragua, 1999.
Manual Para la Promocion y Desarrollo de las Casas Base, MINSA, Managua, 1995.
Resultados Antropometricos, CARE International in Nicaragua-MINSA-USAID,
6/99.
Enge, K. & M.J. Largaespada, Estudio Cualitativo Sobre Practicas de Lactancia Materna en
el Municipio de Matagalpa, Nicaragua, Linkages, CARE, 7/99.
Informe del Diagnostico Rapido Participativo, CARE International in Nicaragua, 2/99.
Perfiles de Puesto de Trabajo, CARE International in Nicaragua, 6/98.
Programa de Ahorro y Credito, Peace Corps, Ecuador, 2000.