Project HOPE in Peru
CSXII Final Evaluation
1
DRC 7979
Project HOPE
Improving Maternal-Child Health in the Huallaga Valley of Peru
CHILD SURVIVAL XII: 1996-2000
Cooperative Agreement No. FAO-0500-A-00-6056-00
FINAL EVALUATION
September 2000
San Martin, Peru
Renee Charleston, External Consultant
Contact persons at Headquarters: Contact person in the Field:
Juan Carlos Alegre, M.S. Sandra Contreras, R.N., M.P.H.
Program Manager National Director - Perú
Luis Benavente, M.D., M.Sc.
Associate Director, MCH Programs
Project HOPE in Peru
CSXII Final Evaluation
2
Table Of Contents
A. Summary ……………………………………………………………………...…. 1
B. Assessment of Results and Impact of the Program ……………... 3
1. Summary Chart ……………………………………………………….... 3
2. Technical Approach ……………………………………………….….… 4
a. Overview …………………………………………………………. 4
b. Interventions …………………………………………..………. 5
a. Nutrition ………………………………………….…………. 5
b. Breastfeeding …………………………….……………….. 7
c. Control of Diarrheal Diseases ……….………………. 10
d. Family Planning ………………………..…………………. 12
c. New Tools and Approaches ……………..………………… 12
3. Cross-cutting approaches ……………………………………….…… 13
e. a. Community Mobilization …………………..…………… 13
f. b. Communication for Behavior Change …….………. 15
g. c. Capacity Building Approach …………………….……. 16
h. d. Sustainability Strategy ……….………………………… 22
i.
C. Program Management ………………….…………………………………. 24
j. 1. Planning ………………………………..……………………………… 24
k. 2. Staff Training …………….…………………………………………. 25
l. 3. Supervision of Program Staff ………….………………………. 25
m. 4. Human Resources and Staff Management ……….………. 26
n. 5. Financial Management …………………………………………….. 26
o. 6. Logistics ………………………….……………………………………. 27
p. 7. Information Management ………………………………………. 27
q. 8. Technical and Administrative Support ……………………… 30
9. Management Lessons Learned ……………………………….. 31
r.
D. Conclusions and Recommendations ……….……………………………. 31
s. E. Results Highlight-Fortified Food ……………………………………………. 37
ATTACHMENTS
A. Team members and their titles
B. Assessment methodology
C. List of persons interviewed and contacted
D. Results of the Final Evaluation Interviews
Project HOPE in Peru
CSXII Final Evaluation
3
E. Results of the Final Evaluation Workshop
F. Special reports-Final Survey Results-KPC, Food Consumption and Biochemical Surveys
ACRONYMS AND ABBREVIATIONS
AIN Atención Integral del Niño (Integrated Care of the Child)
ARI Acute Respiratory Infection
BF Breastfeeding
CDD Control of Diarrheal Disease
CEPCO Eastern Center of Studies and Community Promotion
CHV Community Health Volunteer
CS Child Survival Project
DIP Detailed Implementation Plan
DIRES-SM Regional Ministry of Health - San Martín
EBF Exclusive Breastfeeding
FE Final Evaluation
FP Family Planning
GALME Grupo de Apoyo a la Lactancia Materna Exclusiva (EBF Support Group)
GM/P Growth Monitoring and Promotion
HIS Health Information System
IMCI Integrated Management of Childhood Illness
KPC Knowledge, Practices and Coverage Survey
LHC Local Health Committee 
MINSA Ministry of Health
MTE Mid Term Evaluation
NGO Non-Governmental Organization
ORS Oral Rehydration Solution
ORT Oral Rehydration Therapy
PANFAR Program of Food & Nutrition for High Risk Families
PCM Pneumonia Case Management
PRISMA Projects in Information, Health, Medicine, and Agriculture
PVO Private Voluntary Organization
UPCH University Peruana Cayetano Heredia
UROC Community level Oral Rehydration Unit
USAID United States Agency for International Development
Project HOPE in Peru
CSXII Final Evaluation
1
A. Summary
The Project HOPE Child Survival XII project funded by USAID (10-96 to 9-00) 
focuses on community organization, training and supervision of CHVs, training and 
motivation of Ministry of Health (MINSA) field staff, and community education. Four 
intervention areas were included; Nutrition and Micronutrients, Breastfeeding, 
Control of Diarrheal Disease, and Family Planning. The project is located in Región 
San Martín of central Perú on the eastern slope of the Andes and includes three 
Health Networks: El Dorado, Lamas, and San Martin. The principal partners in the 
project are MINSA and the University Peruana Cayetano Here dia.
The original four-year project has been awarded a three-year extension to 
continue working in the same 162 communities with the introduction of malaria 
and respiratory infections, and improve collaboration with MINSA, by transfer of 
responsibilities, training and supervision, and institutional strengthening. 
It is difficult to appreciate the impact of the project due in part to the use of 
indicators that do not reflect what the project has accomplished in the last four 
years. Only three of the 13 objectives were actually met during the four-year 
period. This can be partially explained by an overly ambition proposal and not 
taking into consideration factors which were outside of the scope of the project. 
The project has shown positive impact in two important areas; women who 
exclusively breastfeed until 6 months and stunting in children. Other 
improvements include frequency of growth monitoring, initiation of breastfeeding 
and use of family planning methods.
Some of the major achievements of the project include: 
· the development of a very effective educational methodology
· encouraging the valuation of local foods-not donated or processed foods, 
· improved quality of nutritional surveillance, 
· development of formula for fortified foods, 
· studies which have allowed: focused messages, better understanding of 
complex disease states, and improved information for use by MINSA officials, 
· development of leadership skills and greater solidarity in women,
Major Problems that still need to be addressed during follow-on project:
· Information System is not fully functioning
· Supervision and monitoring is weak at all levels
· Collaboration and communication with MINSA needs to be further improved
· Defining the needs for capacity building and institutional strengthening
· Further strengthening of community structures 
Priority Lessons Learned: 
· The development of activities which respect and value the local culture have 
the greatest impact
Project HOPE in Peru
CSXII Final Evaluation
2
· For adequate implementation, the project should involve all partners (MINSA 
HOPE Community) from the beginning
· Continuous follow-up and support are needed for the development of new 
abilities
· The greatest impact in changing practices comes with clear, simple 
messages, based on previous study 
· Take advantage of the felt need of women to meet in their own group, 
according to their own vision
· To decrease the prevalence of diarrheal disease it is necessary to improve 
sanitation conditions through coordination with other organizations 
· A project can not advance without the support of local authorities.
· The use of checklists clarifies expectations and defines what elements are 
essential
· Other members of the community need to be trained to create an 
environment of change
Priority Recommendations:
· The project should select one measure for determining nutritional status and 
focus training on counseling the family 
· Alliances should be formed with organizations that have financing and/or 
offer technical assistance in sanitation and agriculture.
· Strengthen the UROC as a community structure with an integrated 
preventative health role in the community. 
· Implement family planning activities by involving men 
· Training for committee members and leaders in community organization 
should be prioritized during the next 3 years.
· MINSA and HOPE should strengthen follow-up to insure the quality of 
replication of training and the education in the communities.
· HOPE should seek technical assistance on institutional assessments from 
other NGOs who have experience in this area.
· Both a formal and informal system of communication should be developed 
between HOPE and MINSA. 
· The strategy of using CHV couples should be re-evaluated during the second 
phase of the project.
· Establish a system of indirect supervision using regular monthly meetings 
between health post staff and all CHVs. 
· Create Trainers within MINSA in health, gender and educational 
methodologies.
· Create Trainers within the municipalities and teachers in community 
development, leadership and participative methodologies.
· The DIP for the 3 year extension should be developed in a participatory 
manner, involving community, and MINSA at all levels.
· A comprehensive study of needs and an information use plan for the 
development of an inclusive HIS is urgently needed.
Project HOPE in Peru
CSXII Final Evaluation
3
B. Assessment of Results and Impact of the Program
Results: Summary Chart (Shaded areas indicate the objective was reached)
Objectives Baseline Midterm Final
1. Increase from 0% to 20% exclusive 
breastfeeding for the first 6 months of age of 
children
O% # 65.9% 68.5%
2. Increase from 3 to 5 the average number of 
meals offered daily to children less than 2 years 
of age
3 # 4 3.7
3. Decrease prevalence of growth faltering from 
55% to 40% 55% 44% 40%
4. Increase number of children with a diet that 
includes adequate proteins (5/week or 1/day) 
and calories
Not collected at 
baseline
% of children 
consuming at least 
90% of recommended 
dietary intake:
For protein: 67.8%
For calories: 39%
% of children 
consuming at least 90%
of the recommended 
dietary intake:
For protein: 55.7%
For calories: 25.3%
5. Increase dietary intake of micronutrients, 
including Vit.A, and iron sources to 3 times per 
week
Not collected at 
baseline
% of children 
consuming at least 
90% of recommended 
dietary intake:
For iron: 15.3%
For Vit. A: 43.1%
% of children 
consuming at least 90% 
of the recommended 
dietary intake:
For iron: 5.1%
For Vit. A: 26.9%
6. Decrease the prevalence of anemia in 
children under 3 yrs from 44%; and 3-6 yrs 
from 52% to 35%
51.2% 54.3% 58%
7. Decrease the prevalence of serum retinol 
deficiency from 7.6% to 4.0% for <10µg/dl, 
from 68% to 50% for <20µg/dl
<10 µg/dl = 8% 
<20µg/dl=68%
Not collected at Mid 
term
<10 µg/dl = 0.5%
<20µg/dl= 12%
8. Increase number of mothers using ORS from 
19% to 30% 19% 21% 15%
8a. Increase mothers using some form of ORT
54.2% 63.9% 50%
9. Increase number of mothers who give more 
liquids during a diarrhea episode from 25% to 
60%
25% 37% 38%
10. Increase number of mothers who give equal 
or more food during a diarrhea episode from 
63% to 80%
62% 47% 45%
11. Increase number of mothers who give food 
more often and in smaller feedings after a 
diarrhea episode from 34% to 50%
* * *
12. Decrease prevalence of diarrhea in children 
between 6-36 months from 67% to 50% 67% 66% 61%
13. Increase child spacing to 2 years in families 
with children less than 3 years * * *
* Information not available 
# These values were obtained using a different methodology at baseline, making them not comparable with 
midterm and final values.
Project HOPE in Peru
CSXII Final Evaluation
4
2. Results: Technical Approach
a. Overview
This XII Child Survival (CS) project was funded by USAID from October 1996 to 
September 2000. The project focus is community organization, training and 
supervision of CHVs, training and motivation of MINSA field staff, and community 
education. The project does not supply any direct services. The project also 
provides technical assistance to the DIRES-SM in planning, evaluation, 
administrative reform, epidemiology, and professional improvement and in 
acquisition of basic intervention-specific pharmaceuticals. Four intervention areas 
were included; Nutrition and Micronutrients, Breastfeeding, Control of Diarrheal 
Disease (CDD), and Family Planning (FP). 
The project is located in Región San Martín of central Perú on the eastern slope of 
the Andes along one of the main tributaries of the Amazon, the Huallaga River. For 
administrative purposes the Ministry of Health (MINSA) divides Región San Martín 
into units called Health Networks. The project includes three Health Networks: El 
Dorado, and Lamas, which include nearly all of the two mountainous provinces of 
the same name, and the lower part of the San Martin Health Network, which is a 
very inaccessible region along the lower Huallaga River and its tributaries. These 
three Health Networks are among the four in the region with the poorest health 
indicators.
The target population of 24,763 women of reproductive age and 13,202 children 
under five in 190 communities was planned. At the time of the first annual 
report, the number of communities was reduced from 200 to 162 communities 
(20 in Lamas, 63 in El Dorado, 79 in San Martin) with the same total target 
population. Actual figures show 17,460 direct beneficiaries according to project 
census or 24,284 according to MINSA estimates. Indirect services to a greater 
number of women and children are provided by MINSA staff to communities 
outside of the project area.
Principal partners in the project are MINSA and the School of Public 
Health/University Peruana Cayetano Heridia (FASPA/UPCH). Collaboration with 
two local NGOs CEPCO and PRISMA also serves to increase knowledge of local 
conditions.
The original four-year project has been awarded a three-year extension, to 
continue working in the same 162 communities. During the extension, major 
changes will be to introduce malaria and ARI (Acute Respiratory Infections) and 
to improve collaboration with MINSA, through a transfer of responsibilities, 
training and supervision on the use of MINSA protocols, and institutional 
strengthening. A qualitative Final Evaluation (FE) was conducted during August￾September of 2000 with complementary information from a Knowledge, Practices 
Project HOPE in Peru
CSXII Final Evaluation
5
and Coverage (KPC) survey, a biochemical analysis of retinol and hemoglobin, 
and a food consumption study (included in Attachment F). This report serves to 
summarize the findings and recommendations of a participatory process 
involving various stakeholders. A detailed explanation of the methodology used 
is included in Attachment B. Results from the FE are attached, divided into 
results from interviews with community members and MINSA staff (Attachment 
D), and results from team analysis during two workshops (Attachment E). The 
purpose of the evaluation is dual; to learn from the experience of implementation 
during the first four years (Lessons learned are printed in Italics) and 
recommendations for improving strategies during the next three years 
(Recommendations are printed in Bold).
b. Interventions
Nutrition
2. Increase from 3 to 5 the average number of 
meals offered daily to children less than 2 years 
of age
3 # 4 3.7
3. Decrease prevalence of growth faltering from 
55% to 40% 55% 44% 40%
4. Increase number of children with a diet that 
includes adequate proteins (5/week or 1/day) 
and calories
Not collected at 
baseline
% of children 
consuming at least 
90% of recommended 
dietary intake:
For protein: 67.8%
For calories: 39%
% of children 
consuming at least 90% 
of the recommended 
dietary intake:
For protein: 55.7%
For calories: 25.3%
5. Increase dietary intake of micronutrients, 
including Vit.A, and iron sources to 3 times per 
week
Not collected at 
baseline
% of children 
consuming at least 
90% of recommended 
dietary intake:
For iron: 15.3%
For Vit. A: 43.1%
% of children 
consuming at least 90% 
of the recommended 
dietary intake:
For iron: 5.1%
For Vit. A: 26.9%
6. Decrease the prevalence of anemia in 
children under 3 yrs from 44%; and 3-6 yrs 
from 52% to 35%
51.2% 54.3% 58%
7. Decrease the prevalence of serum retinol 
deficiency from 7.6% to 4.0% for <10µg/dl, 
from 68% to 50% for <20µg/dl
<10 µg/dl = 8% 
<20µg/dl=68%
Not collected at Mid 
term
<10 µg/dl = 0.5%
<20µg/dl= 12%
The Nutrition component increased from 40% of project effort to 45% after the 
MTE. A major effort of the project has been in nutritional surveillance, the 
impact is easily seen through the KPC with the percent of children being weighed 
in the last 4 months increasing from 36.5% at baseline to 94% at final. Sixty￾nine percent of the 162 communities weighed and measured children during the 
last surveillance in May.
Project HOPE in Peru
CSXII Final Evaluation
6
The project has shown a rather amazing 15% decrease (from 55% BL to 40% 
FE) in stunting (Height/Age<-2z) over the four years of the project, but a similar 
decline has not been seen in wasting (Wt/Ht<-1z) which did not show significant 
variation from 29%BL to 30%FE. Anemia increased by 7% in children under 
three.
In addition, the project has revealed a significant reduction of serum retinol 
deficiency from 7.6% to 0.5% for <10µg/dl and from 68% to 12% for <20 
µg/dl. These results shown that the project has contributed to the eradication of 
vitamin A deficiency in the project target areas. Whereas the food consumption 
study did not show an improvement in dietary intake of Vitamin A, it can be 
assumed that the retinol increase is due to Vitamin A supplementation.
Other results from the food consumption study are difficult to interpret mainly 
due to myriad factors which effect food consumption, which are outside the 
control of the project. For example, it was found that during the MTE 49% of 
the families surveyed received donated food, during the FE this was reduced to 
22% of the families. The appropriateness of the nutrition indicators selected for 
this project need to be further studied by Project HOPE, so that indicators which 
are more indicative of project results are utilized during the extension period of 
this project. A report of the KPC, biochemical and food consumption surveys is 
included in Attachment F.
An interesting finding was the presence of salt with adequate levels of iodine in 
55% of households at FE, compared to 14% at BL. This can be attributed to 
improved supervision of the iodizing process by DIRES and the availability of low 
cost iodized salt at health centers, in part motivated by project findings during 
the baseline survey.
Through the use of a participatory adult education methodology, CHVs have 
been trained in nutrition concepts and nutritional surveillance. A supervision 
checklist on quality of anthropometric measures and on-site supervision 
supported the training in nutritional surveillance. Of the 15 observations made of 
CHVs weighing and measuring a child during the FE, only one had problems. 
The training has been very effective and the use of the checklist has reinforced 
training. The problems identified were with the registration of the numbers 
(weight, height, age) on a growth card and graph for diagnosis. The FE team 
did not evaluate counseling skills during the field visits.
The system currently being used for diagnosis of malnourished children at the 
community level is too complex and time consuming for the health promoter and 
misses the point that weighing and measuring children is not the project goal￾intervening in family level feeding habits is where the project wants to have 
impact. A great deal of effort has gone into the mechanics of anthropometric 
Project HOPE in Peru
CSXII Final Evaluation
7
measures and little on counseling mothers on what to do when a child is 
malnourished. 
The project should select one measure for determining nutritional 
status and focus training on counseling the family on what concrete 
actions can be taken. It is strongly suggested that the MINSA child growth 
card be used for the diagnosis, and that HOPE not introduce new measurement 
instruments which have been shown in other projects to not be sustainable.
A balanced diet cooking contest generated a lot of enthusiasm and support for 
the use of local foods. During the height of coca production, people were 
moving towards the use of processed foods, and under-valuing the importance 
of locally produced foods. Focusing people once again on the value of local 
products has increased acceptance and impact of the project.
A unique aspect of the CS project is the provision of research and technical 
development of a fortified food to treat anemia. After a number of studies of 
various options, it was decided to develop the idea of cocoa fortified with heme 
iron. Cocoa is a locally produced product and heme iron from cow’s blood can 
be purchased from Chile. The project has worked with a number of local NGOs 
and the university to develop a formula for the fortified cocoa and is working 
with local entrepreneurs by providing technical assistance to market the product. 
The project is encouraging a local NGO, who distributes Title II foods, to 
purchase the cocoa as an addition to donated foods. A study carried out using 
the cocoa plus an anti-parasite drug, showed a 50% decline in anemia. A brief 
explanation of the steps taken in developing this product is included in Section E. 
A prototype solar dryer, for preserving fruits and vegetables, was developed and 
presented at a local fair, using informational pamphlets and demonstrations. The 
project is evaluating the possibility of linking the dryer with another HOPE project 
in the area-village health banks. The cost of the dryer (over US$ 100 in materials 
and an additional US$100 in labor) will place it out of the reach of most 
individual families. The effect of efforts made during this project in the 
development of the solar/gas food dryer and fortified food products are not yet 
visible. As part of the final evaluation of the follow-on project, the 
impact of the food dryer and fortified food should be included.
Project HOPE in Peru
CSXII Final Evaluation
8
Lessons Learned
· The development of activities which respect and value the local 
culture have the greatest impact
· Involving MINSA in training activities aides in reaching the 
communities with health messages.
· Unifying the language used in messages promotes better learning
· For an adequate implementation, the project should involve all 
partners (MINSA HOPE Community) from the beginning
· Continuous follow-up and support are needed for the development 
of new abilities
· The supervision checklist on anthropometric measurement was very 
effective
Breastfeeding
1. Increase from 0% to 20% exclusive breastfeeding for the first 6 
months of age of children
Information 
not reliable 65.9% 68.5%
The project showed an increase in exclusive breastfeeding (EBF) from 0% at 
baseline to 68.5% at final. The data from the baseline is unreliable because the 
question on EBF asked recall of the mothers of children 6-36 months old, rather 
than measuring actual practice in children under 6 months of age. During the 
midterm the question was re-worded and mothers were interviewed with 
children 0-6 months of age showing a rate of EBF of 65.9%. The increase in EBF 
was also reported anecdotally during interviews as part of the FE. The KPC also 
showed an increase in the percent of women with children 0-23m, who were 
beginning breastfeeding within the first eight hours after birth, from 65% at BL 
to 82% at final. 
A model example of how to change behavior was carried out by the project to 
modify breastfeeding practices. Students from UPCH studied cultural practices of 
breastfeeding and introduction of foods using focus groups and developed a 
social marketing strategy to motivate people to put off the introduction of 
bananas until 6 months. The project used the study to modify the messages and 
then one simple message was the focus of education-don’t give ripe banana 
(maduro) to the child until 6 months of age. Maduro is the traditional first food, 
and is many times introduced during the first month. This simple message has 
been extremely effective, everyone gave the same clear message, through 
various sources and the effect has been extremely positive.
One of the principal strategies for encouraging breastfeeding was through the 
formation of breastfeeding support groups (GALME). GALMEs are reportedly 
present in 94% of the communities, although according to the groups of women 
interviewed during the FE, half of the GALMEs are not meeting (8/16).
Project HOPE in Peru
CSXII Final Evaluation
9
The GALMEs do not follow the model of what a support group is but have 
developed into more of a mothers group. A support group would work well in a 
community that already has a women’s group and the GALME would be a sub￾group, but when no mothers group exists, the GALME is seen as only focusing on 
a few women, and excluding the others. The GALME is used by MINSA and the 
CHV as a way of channeling information to the communities. The GALMEs look 
at other issues, not just BF or health and want to be involved in a number of 
activities, sports, sewing classes, gardens, etc. The concept of a support group 
is not an indigenous idea and was perhaps introduced prematurely by the 
project. 
Women are hungry for their own group, which they control. Almost all CHVs are 
men, and they would be in charge of any group they were involved in. By having 
women chose a female coordinator, the GALME had the unexpected result of 
providing women with a safe environment for developing leadership skills and 
self-esteem. All mothers groups interviewed during the FE reported that their 
husbands were supportive of their attending GALME.
The project needs to focus efforts on organizing women in a group which they 
are comfortable with, not excluding older women, midwifes, etc. or having 
“rules” as to how the group should be formed. The suggestion was even made 
during the FE to include men in the group. The concept of support groups is not 
really understood in the communities, and perhaps in the future when women 
are more accustomed to leading a group and sharing ideas (instead of 
“receiving” talks), it would be more appropriate to introduce support groups. 
One of the ideas discussed informally during the FE was to link new mothers or 
women with BF problems to a “yunta” or partner on a one-to-one basis for 
support and guidance. This strategy might be better understood and accepted 
than the support group.
Other activities to support EBF were the participation with MINSA during National 
Breastfeeding Week which included community marches to increase awareness 
of the importance of EBF.
The formation of a network of GALMEs was planned but was not possible during 
this period. An informal network around sporting events has grown up to link a 
few groups. Several alternatives were brought up during the FE to support the 
exchange of ideas between GALMEs. The formation of a link between 
GALMEs should be established, using one (or more) of the following 
mechanisms: 
1). Formation of a network of GALMEs
2). Integration of the Coordinators of GALMEs into the CHV network
Project HOPE in Peru
CSXII Final Evaluation
10
3). Visits between groups for sports events and to exchange ideas 
about health issues
4). Annual conference of all coordinators to reinforce their work and to 
define future directions
Lessons Learned:
· The GALME should not solely be a receptor of messages, but 
an opportunity to develop leadership skills.
· The GALME should be for all women, include other topics of 
interest to the women and include activities with their 
husbands.
· The greatest impact in changing practices comes with clear, 
simple messages, based on previous study 
· Take advantage of the felt need of women to meet in their 
own group, according to their own vision
Project HOPE in Peru
CSXII Final Evaluation
11
Control of Diarrheal Diseases (CDD)
8. Increase number of mothers using ORS from 19% to 30%
19% 21% 15%
8a. Increase mothers using some form of ORT
54.2% 63.9% 50%
9. Increase number of mothers who give more liquids during a 
diarrhea episode from 25% to 60% 25% 37% 38%
10. Increase number of mothers who give equal or more food 
during a diarrhea episode from 63% to 80% 62% 47% 45%
11. Increase number of mothers who give food more often and in 
smaller feedings after a diarrhea episode from 34% to 50% ** ** **
12. Decrease prevalence of diarrhea in children between 6-36 
months from 67% to 50% 67% 66% 61%
The project objective of increasing the percent of mothers using Oral 
Rehydration Solution (ORS) during an episode of diarrhea from 19% to 30% was 
not met. Final KPC results show a decreased use of ORS to 15%. The focus of 
this objective was modified during implementation, to bring it more in line with 
MINSA policy. ORS is recommended to be used only in cases of dehydration, 
and home-based fluids are recommended for uncomplicated cases. The indicator 
was also measure as ORT (Oral Rehydration Therapy), which includes all fluids, 
in addition to ORS. The use of ORT was also unchanged according to results of 
the KPC. Baseline results showed a 54% use rate and FE showed 50%. There 
was an increase in mother giving more liquids (from 25% to 38%) during 
diarrhea, but a decrease from 62% to 45% of mothers giving the same or more 
foods. Neither of the indicators reached the stated goal of 60% and 80% 
respectively.
Project staff felt that not enough emphasis had been given to the home based 
nutritional management of disease conditions. During the extension project a 
more integrated approach using IMCI principles will be implemented. Elaborate 
and broadcast basic integrated messages aimed at improving 
knowledge and practices of mothers with ill children (Diarrhea, 
respiratory infections, malaria) with a focus on feeding during and 
after the illness.
Mothers most commonly identified weakness/no energy as a sign of when to 
seek medical attention in cases of diarrhea, instead of a more specific sign such 
as dry mucous membrane, decreased urine/tears, etc. More focus is needed on 
recognition of signs of danger for both mothers and CHVs.
An important point related to CDD that was not addressed during this CS project 
is the high use of anti-diarrhetics and antibiotics when child has diarrhea. 
According to the baseline KPC 55% of mothers thought that in cases of diarrhea 
the child should be given anti-diarrheal drugs or antibiotics. This element was 
Project HOPE in Peru
CSXII Final Evaluation
12
not reported on in the Midterm and Final KPC reports. The widespread use of 
these medications was also reported during the FE. During the next phase of 
the CS project, one focus of education should be aimed at decreasing 
the use of inappropriate medications for diarrhea.
A small decrease in the prevalence of diarrhea was seen from 67% to 61% in 
children 6-36 months of age, according to results of the KPC. Decrease in cases 
of diarrhea may in part be attributed to the distribution of anti-parasite drugs 
and through improved hygiene practices. 
A greater focus on sanitation is needed to have an impact on the prevalence of 
diarrhea. The technical needs for jungle areas are more complicated for latrines 
and water and require specialized technical assistance. The ability of the 
department of sanitation of MINSA to effectively work with communities is 
limited by a minimal budget and personnel. They do provide an important 
function of motivating and supervising the use of facilities. The project needs to 
help communities to develop proposals to present to municipal authorities and 
other organizations for sanitation projects. Alliances should be formed with 
organizations who have financing and/or offer technical assistance in 
construction or latrines, water systems, etc.
Community oral rehydration units (UROCs) are present and functioning in 131 
communities. The UROCs need to be modified to provide a more integrated 
preventative health approach. The centers-possibly to be renamed “House of 
Health” or “House of the Promoter”-would take on the role of integrating care 
within the community-namely CDD, ARI and malaria. In many communities the 
UROC already houses a community pharmacy and sometimes a family planning 
center. Strengthen the UROC as a community structure with an 
integrated preventative health role in the community through 
increased community participation involving the CHV, LHC, leaders, 
GALME group, and health staff.
Lessons Learned:
· To decrease the prevalence of diarrheal disease it is 
necessary to improve sanitation conditions through 
coordination with other organizations that work in this area.
· Educational messages which focus on improving feeding 
during and after a disease episode will have the greatest 
impact on changing knowledge and practices
Project HOPE in Peru
CSXII Final Evaluation
13
Family Planning
13. Increase child spacing to 2 years in families with children less 
than 3 years * * *
* Information not available
MINSA has a major family planning promotional effort in the region, resulting in 
a fairly high acceptance of modern methods. This project supports MINSA's 
educational efforts and assists with stabilizing the supply of methods. The scope 
of this intervention is limited, it accounts for only 5% of the project’s effort. The 
information on child spacing is not yet available, but the percent of mothers who 
desire no more children in the next two years or are not sure, who are using a 
modern contraceptive method increased from 62% at BL to 77% at final.
While this change can not be attributed solely to the project, training efforts to 
188 CHVs and participation by CHVs in family planning campaigns of MINSA have 
helped to encourage the use of modern FP methods. It was found in the BL KPC 
that the contraceptive pill used to be most commonly used method, but now the 
most common used method is anovulatory injections. The injections have long 
been the preferred method, but there were problems in the past with supplying 
the method. Those problems have been resolved and adequate supply has been 
greatly improved.
Lactational Amenorrhea is not specifically encouraged as a FP method but is 
mentioned as one of the benefits of breastfeeding. 
According to women’s groups interviewed during the FE, one way to improve the 
use of FP methods is to provide information to the couple and to improve 
communication with the husband. The new approach for the next 3 years will be 
to involve men in child spacing discussions and decision making, as a partner 
with women. Implement family planning activities by involving men and 
husbands in educational activities.
c. New tools or approaches 
A principal partner of the project is the School of Public Health/UPCH. This 
relationship has opened a unique opportunity for operations research, with 
positive results for the project in obtaining new information to help guide 
program decisions, and for the university by providing a opportunity for students 
to complete field studies in a needed area. The project has been involved in the 
decision of what studies were to be conducted, and the locale for studies. A total 
of 28 students participated in project field activities: 20 from UPCH (school of 
medicine, nursing, and public health), 5 from UNIFE (school of nutrition), 2 from 
Universidad Antenor Orrego (school of communications), and 1 from Pontificia 
Universidad Católica del Perú (anthropology).
Project HOPE in Peru
CSXII Final Evaluation
14
Project staff felt the relationship had been positive with UPCH and other 
universities that cooperated with the project and encouraged continuing the 
relationship, and including nursing students in the future. The university 
supported the staff in their own research, helping to develop protocols and 
publishing their results.
A number of studies were conducted, many focusing on the use of fortified food 
to treat anemia, cultural patterns in geophagia as a source of iron, and 
breastfeeding. One of the more interesting studies on breastfeeding beliefs and 
practices was previously discussed in the Breastfeeding section. The project 
activity on food fortification was previously discussed in the Nutrition section. 
In addition to research activities, the project expanded the traditional use of the 
KPC survey to include a food consumption study and biochemical indicators 
(hemoglobin, parasites, iodine content of salt, and retinol). These studies were 
utilized as part of the baseline, midterm and final evaluations and have added to 
the national and international body of knowledge. Results from these surveys 
have been instrumental in working with MINSA to prioritize action, i.e. study of 
the actual iodine content of iodized salt has lead to actions to monitor the 
iodizing process.
3. Results: Cross-cutting Approaches
 a. Community Mobilization 
Community organization continues to be a challenge for the project. According to 
the DIP, communities will be given assistance in learning to make decisions 
based on information, prioritize issues, conduct democratic meetings, access 
other sources of technical assistance and funding, motivate citizen involvement, 
and to evaluate efforts. The project reports committees in 96 communities. 
According to committee members interviewed during the FE, 6 of the 8 
committees meet monthly, but only 1 of the 8 had developed a work plan. 
Communities need to be involved more in planning and evaluating, and in the 
use of information for decision making. 
A great deal of additional work needs to be done to strengthen community 
structures, particularly the Local Health Committee (LHC) and community 
leaders. During the FE authorities were open about their lack of knowledge 
about health problems and project activities and eager to receive training. 
Training for committee members and leaders in project development 
and community organization should be prioritized during the next 3 
years.
Project HOPE in Peru
CSXII Final Evaluation
15
A model structure presented in the DIP was to include the coordinator of GALME 
and the CHV as members/technical assistants to the health committee. This has 
not been accomplished, but will continue to be a strategy during the next three 
years. Women’s participation in the committees is negligible. According to 
interviews during the FE, only 2/16 committees have participation of a woman. 
Women traditionally do not attend community meetings.
The formation of a community support system where CHV, GALME coordinator, 
committee and leaders all work together to provide mutual support is imperative. 
This support system should be based first on improved communication to insure 
that everyone has a clear understanding what the others are doing. According 
to interviews during the FE, 11 of the 16 GALME coordinators, 3 out of 8 of 
committees, and 10 out of 12 leaders did not know how many malnourished 
children there were in the community. Real change within a community will 
come when everyone moves together with the same messages. Sustainability 
must come from within the community, through encouragement and 
prioritization of health as an action issue.
A network of CHVs has been organized in the district of San Jose Sisa, El Dorado 
Health Network. Twenty-one CHVs organized in July of 1999 and wrote bylaws 
for the organization. The bylaws were being used in another Health Network to 
replicate the activity. A network of CHVs already exists in San Martin, with the 
help of a local Catholic priest. A network of GALMEs was also planned for the 
first four years, but was not accomplished. Suggestions for continuing with this 
activity during the next period were already discussed in the Breastfeeding 
section. 
Good relations have been developed by the project with municipal authorities, 
who have been sharing costs for CHV training, based on their fiscal possibilities.
Agreements have been signed with municipal authorities for specific short term 
needs. The municipal authorities are excellent contacts for the communities for 
the funding of future small projects, such as latrines. 
Another challenge for the project in the next 3 years is how to involve more 
community members in the educational process, so an environment of change 
can be established, rather than just some women trying to change without 
community support. During interviews as part of the FE, most groups mentioned 
the importance of involving men as well as other community members such as 
midwives and older women. 
Additional work needs to be completed in the next 3 years to consolidate efforts 
made in community organization. During discussions with community leaders, 
committee members, volunteers and women, there seems to be a strong positive 
feeling about the project, and a desire to continue working together in the 
Project HOPE in Peru
CSXII Final Evaluation
16
future. Listening more to communities to encourage their involvement is needed 
to cement relations and move in directions defined by mutual agreement. 
Community diagnosis should not just be seen as a one time event; evaluation, 
analysis and planning need to be ongoing. Community diagnosis and 
ongoing meetings to evaluate, analyze and plan should be held 
together; community (including women), health personnel and HOPE.
Lessons Learned:
· A project can not advance without the support of local authorities.
· Communities must be involved as full partners in the development process, 
including being involved more in planning and evaluating
b. Communication for Behavior Change
Educational modules in community participation/leadership, nutrition and micro￾nutrients, nutritional surveillance, CDD, breastfeeding and adult education have 
been developed by HOPE staff. The modules are of very high quality and include 
a number of inter-active participatory activities which enhance learning. Good 
evaluation tools to insure understanding of the concepts have also been 
developed. The project has an excellent focus on message delivery for CHVs and 
MINSA. The courses have been well received, and positive progress has been 
made in providing information at the community level but the process needs to 
be taken to the next step. CHVs and GALME coordinators need improved 
skills in more than message delivery but also in counseling, identified 
barriers to change and negotiating behavior change.
During the FE, in questions asked to the CHVs, the main messages given to 
mother of malnourished children were to increase the frequency of feeding, give 
thick foods instead of thin soups, and give a balanced diet, but the addition of oil 
to the child’s food was not mentioned. This is just an example of why basic 
messages need to be strengthened to enhance the impact of actions on the part 
of the mother. Teaching a concept to CHVs does not mean it will be correctly 
transmitted to mothers. MINSA and HOPE should strengthen follow-up to 
insure the quality of replication of training courses and the education 
in the communities. A checklist should be developed for insuring quality of 
educational activities of CHVs, GALMEs and MINSA staff.
Educational materials are an effective strategy for 1.) enhancing learning by 
community members, and 2.) motivating CHVs and MINSA staff. The current 
project had a very limited budget for materials, and this was recognized as a 
limiting factor in implementing the project (Group work during the Analysis 
Workshop identified the lack of materials as a limiting factor and even the 
mothers groups interviewed during the FE said educational sessions would be 
better with materials). The follow-on funding also has an extremely limited 
budget for educational materials. HOPE has received a grant to develop materials 
Project HOPE in Peru
CSXII Final Evaluation
17
with BASICS and CHANGE to help women recognize danger signs and risk factors 
which require medical care. In addition to this, HOPE should determine a 
mechanism for acquiring educational materials for all communities and 
MINSA health posts to support educational messages. This funding 
should come from a modification of the budget of the 3-yr follow-on 
project, or through complementary funding.
c. Capacity Building Approach 
(i) Strengthening the PVO Organization 
The CS grant has improved the institutional capacity of Project HOPE through a 
number of mechanisms;
· Through the design and evaluation process of the CS grant, HOPE has 
increased their expertise in project development and monitoring, and the 
identification of high quality technical assistance to strengthen both technical 
and managerial aspects. 
· Project HOPE has been able to strengthen their management of human 
resources; by clearly defining roles and responsibilities of local staff, 
development of concrete job descriptions, and the elaboration of a personnel 
evaluation protocol.
· The monitoring of financial aspects has assisted HOPE to identify weaknesses 
in their system, and motivated the development of a complementary tool for 
financial control, which has been used in other HOPE programs. Project 
HOPE is continuing to improve the financial system to better serve the needs 
of CS and other programs.
· Project HOPE has improved inter-and intra-agency communication through 
the development of a Internet web site used to disseminate lessons learned 
from Child Survival projects within the People-to-People Health Foundation 
and to other organizations and the general public. 
(ii) Strengthening Local Partner Organizations
An agreement was signed between the CS project and DIRES-San Martin in 
October of 1996. There were a number of problems during the first two years of 
this grant period when HOPE was working very independently from MINSA. The 
MTE was a turning point in evaluating project strategies and coordination has 
markedly improved in the last two years, but is still not 100%. 
The first step in improving work with MINSA is to identify together what areas 
need to be prioritized. An institutional diagnosis of MINSA should be carried out 
as part of the development of the DIP for the second phase to identify individual 
training needs and points for institutional strengthening. The diagnosis could be 
repeated at the end of 3 years to measure progress. HOPE should seek 
technical assistance on institutional assessments from other NGOs who 
have experience in this area.
Project HOPE in Peru
CSXII Final Evaluation
18
Capacity building in the future should focus on strengthening systems, for 
example; referral system, supervision system, a simple system at the health post 
level to track who the CHVs are and what training they have received to enhance 
supervision and planning for training.
MINSA sees the educational methodology developed by HOPE as one of the most 
valuable contributions. MINSA has applied the training they received from HOPE 
to their own work by replicating courses for their staff in other Health Networks 
where the project does not work, thus increasing the impact of the project in 
other geographical areas. The Basic Language of Nutrition was a particularly 
successful course which was originally given to nurses, but later physicians were 
so impressed with the course, that an additional course was provided for them. 
Other MINSA projects such as the cervical cancer awareness project and ELITES 
are also using the methodologies.
There are good personal relations and good coordination with the MINSA staff, 
particularly at the DIRES level. MINSA has seconded one nurse full time to the 
project, and HOPE pays an additional stipend to equalize her salary with other 
HOPE staff. Many former HOPE staff now work with MINSA and many former 
MINSA staff now work with HOPE. The greatest change seen in the working 
relation with MINSA is greater enthusiasm for the project and a better 
understanding of the role of HOPE. Continued effort is needed to achieve a good 
understanding at all levels and a sense of ownership on the part of MINSA of the 
CS project.
Supervision of activities at the community level by MINSA staff has improved. 
The supervision checklist for anthropometric measurement has been very 
effective in clearly defining expectations of what is quality. The 
anthropometric checklist should be expanded to include diagnosis of 
malnutrition and counseling of the mother on what actions she can 
take. The checklist concept should be expanded to include other areas 
for supervision.
Meetings are frequently held at the DIRES level, but communication is still a 
problem at the other levels. The project can not just assume that information will 
filter through channels, contact is required at all levels. Both a formal and 
informal system of communication should be developed between HOPE 
and MINSA: 
· HOPE should participate in the planning and evaluation 
meetings of the AIN 2001(Integrated Care of the Child) 
program. 
· Regular meetings with the DIRES, Health Networks, health 
center and health post levels
Project HOPE in Peru
CSXII Final Evaluation
19
· An annual planning and evaluation workshop should be 
implemented with participation from all levels, to review 
project achievements and plan together for needed 
readjustments.
Lessons Learned
· Don’t divide the work with MINSA, go with them to support the 
implementation and quality of the work. 
· The use of checklists clarifies expectations and defines what elements are 
essential
· CHVs should not have an institutional affiliation, but should clearly be of the 
community. In the FE when mothers were asked whom the CHV worked for, 
all groups said for the benefit of mothers and children in the community.
(iii) Health Facilities Strengthening 
The project works with 52 MINSA staff at the health center and post level. Most 
health posts are staffed with only one technician, many of whom have received 
very little training. San Martin is one of the most isolated areas of the country 
and work conditions are poor. Assignment to the area is usually perceived as a 
punishment so most people see their work in San Martin as short term, leading 
to a high rate of turnover. This is somewhat contradicted by findings from the FE 
of 5 of the 9 staff having more than 4 years in their position.
There is a system of supervision for MINSA staff, with guidelines based on each 
program. Each health facility has a supervision notebook where observations 
and recommendations of the supervisor are noted. The development of an 
integrated supervision system could potentially be an area where HOPE’s 
intervention could strengthen MINSA’s institutional structure.
MINSA staff does not prioritize CS project activities because they have other 
assigned priorities, a heavy workload, and an unrealistic burden of reporting 
information. Part of the institutional assessment previously recommended 
should include an assessment of health facilities.
National efforts to develop Integrated Management of Childhood Illness (IMCI) 
programs are being developed in Peru. As a complement to this effort the 
DIRES of San Martin developed a comprehensive package of AIN (Integrated 
Attention for the Child) in 1999. The CS project did not directly include the 
strengthening of these programs within their objectives, but this will be included 
in the follow-on project. 
The HOPE staff is collaborating with the ELITES-mobile clinics for disperse 
populations (formerly SAIZADIP). ELITES have worked in about 20-25% of the 
same communities as HOPE in Dorado and San Martin for the past year. They 
Project HOPE in Peru
CSXII Final Evaluation
20
work in each community 1 day every 2 months providing medical care,
medicines, and community organization. The ELITES staff has been trained in 
CS project educational methodology and some are former HOPE employees. So 
far they have coordinated well with the project and offer an incredible service to 
isolated communities. The sustainability of this group is questionable as it is just 
being piloted, but HOPE should continue, and expand, the collaboration with this 
group.
(iv) Strengthening Health Worker Performance
A good first step in working with community volunteers was to identify existing 
CHVs and begin working with them. The original goal of the project was to train 
400 CHVs (200 couples) in approximately 190 communities. The current 
database of the project contains 145 CHVs, 32 of which are recognized as 
inactive, but project staff reports 230 active CHVs. The strategy of working with 
couples has not been implemented, mainly due to constraints on women to 
travel to centralized training courses. New strategies need to be implemented to 
involve women as CHVs- the coordinators of GALMEs is an excellent way to begin 
as well as selecting in the future the wives of community authorities and current 
CHVs to receive training. More flexibility in the training plan is required to get 
these women trained. The roles of the women can be different compared to the 
men, they don’t both have to do the same thing. Women should be able to 
receive training in their own communities. The strategy of using CHV 
couples should be re-evaluated during the second phase of the project.
It is difficult to determine exactly how many CHVs have been trained during the 
life of the project due to a deficient Health Information System (HIS). It was 
reported in the first annual report that 135 CHVs were trained during the first 
year, including 118 trained in CDD, FP and nutrition. As these CHVs are not 
included in the current database (of 145 CHVs), it is unclear whether an 
additional 145 CHVs have been trained, or if some received various courses.
In the DIP, the planned ratio of CHV to families was 1 CHV couple per 16 
families, or 1 person per 8 families. This ratio is very unrealistic and the actual 
ration is about 1 CHV per 50 families. The planned ratio of 1 MINSA staff per 5 
couples (or 10 people) was more realistic. Staff estimates that each health post 
(1 MINSA staff person) has 10-15 CHVs.
Of the 23 CHVs interviewed during the FE, 14 have worked as a CHV for three 
years or more, and of the GALME coordinators 8 out of 16 have worked as 
coordinator for 2 years or more. The actual turnover rate of CHVs is not known, 
but the project needs to extend its focus on how to maintain CHVs as active 
agents within the communities. This needs to be done through improved 
communication with the CHVs and CHV associations, which have recently been 
formed. Results of the FE interviews with health personnel showed that the two 
Project HOPE in Peru
CSXII Final Evaluation
21
best ways to motivate the CHVs were to provide incentives and to meet monthly 
with them. Ideas for incentives presented during the FE included: identification 
cards from MINSA, free (or reduced cost) medical care, caps, educational 
materials, and tee-shirts.
Knowledge and performance of the CHV is measured through:
· Pre- and post-tests at training course
· Nutritional surveillance checklists
· Completion of nutritional surveillance forms for the database 
These measures also need to be complemented with a more comprehensive 
supervision and monitoring system.
During interviews with health personnel, a frequent response as to how to 
support the CHVs and GALME coordinators to improve their work was through 
frequent follow-up and supervision. Supervision of the CHVs is an area of great 
weakness in the project, it is not being done on a regular basis and no 
supervision format is being used, except for the checklist for anthropometric 
measurement. Project staff use the results of pre/post–tests, non-assistance at 
training, anthropometric checklist, and not completing nutritional surveillance as 
ways to prioritize visits to CHVs for follow-up. Given MINSA’s limited budget and 
mobility, the next phase of the project should be used to identify sustainable 
ways in which the community volunteers can be supported by MINSA. Establish 
a system of indirect supervision using regular monthly meetings 
between health post staff and all CHVs from the post. The meetings 
would be used for analysis of information, to reinforce training topics, 
distribution of materials (ORS), discussion of problems and solutions, 
and to prioritize needs for direct supervision visits. 
HOPE and MINSA should collaborate on the development of an 
integrated supervision instrument.
Lessons Learned
· Initially identify CHVs who have been trained by other organizations
· Regular contact is essential to support the work of the volunteer
(v) Training
The training for the CHVs has been very effective, the principal problems related 
to training are;
· Not all CHVs were trained in all topics
· The HIS is inadequate to track who has received what training (during the 
first 2 years)
· Other people who were planned to be trained, did not receive training 
(Coordinators, teachers, midwives)
· More flexibility is needed in training strategies to include women as CHVs
Project HOPE in Peru
CSXII Final Evaluation
22
The principal training topics for CHVs were Community Organization/Leadership, 
Nutrition/Micronutrients, Nutritional Surveillance, FP, Breastfeeding, Education, 
CDD and First Aid and all topics originally planned were carried out. Not all CHVs 
however have received all courses. Some of the GALMEs coordinators have been 
trained, but not many (10 of the 16 coordinators interviewed during the FE had 
not received training). No training has been given for teachers, midwives, or 
committee members, as was planned in the DIP
The project focuses on message delivery, and this has been effective, but more 
involvement of other decision-makers is needed; men, older women, midwives, 
and teachers. The strategy of home visits as an educational tool has been 
underutilized. Use of radio was mentioned in the DIP, but has not been 
implemented.
The project should take more of a gender focus to provide an environment of 
equity for women to participate in activities. The San Martin area is known as a 
very male dominated culture and project strategies need to be modified to give 
women a chance to participate, given the constraints of the culture. One of the 
principal barriers is travel and staying over night at training courses. 
Decentralized training at the community level, induction of the wives of current 
CHVs and community leaders, graduation of Coordinator to become CHVs, are all 
ways in which more women could be involved.
The main reported change in behavior was regarding EBF and waiting to 
introduce bananas. Fifteen of the 16 coordinators interviewed felt more women 
where breastfeeding exclusively and community leaders felt that there was less 
diarrhea and less malnutrition.
Male CHVs were not trained in BF because the project thought they would not be 
the principal source of information concerning this topic, but the CHVs really 
need to understand these issues so they can influence other men and support 
women’s actions.
There has been a good system used for evaluating the level of understanding of 
CHVs after receiving training. A system of pre-and post-tests was developed and 
have been consistently used to improve training and prioritize supervision.
Lessons Learned
· More emphasis needs to be given on training to train and supervising the 
replication of training.
· Other members of the community need to be trained to create an 
environment of change
· Sustainable training structures must be developed
Project HOPE in Peru
CSXII Final Evaluation
23
d. Sustainability Strategy 
Sustainability Goals andObjectives
Objectives Goals * Status at Final Evaluation
1. Promoters working for 
their communities
- 400 trained promoters responding to 
the community
- To be recognized by the community
Database show 145 CHVs trained (but 32 of 
these inactive) Other information estimates 
230 CHVs, HIS inadequate for tracking 
CHVs
2. Sustainable community 
committees conducting 
health-related activities
- 190 communities organized
- Regular meetings
- Implementation of projects
The project reports active committees in 96 
communities.
3. MINSA staff involved 
in community work
- Staff from 85 health sites involved in 
community work
- Participation of DIRES-SM staff in 
the follow-up and strengthening of 
community work
HOPE estimates that 52 MINSA staff in 
health sites are working with the project
4. Fortified food on sale - Product demand Not on sale, but product developed and 
marketing just beginning
5. UROCs functioning - 190 UROCs functioning UROCs are present and functioning in 131 
communities
6. Support groups or BF 
counselors
- 200 support groups functioning
- Establishment of an association in 
each Health Network 
Approximately 152 groups are formed, but 
not all active, most coordinators have 
received training. No associations formed.
7. Continuing growth 
monitoring
- Growth monitoring of children under 
5 in 190 communities
- 400 promoters trained in growth 
monitoring
Growth monitoring carried out in 70% of 
communities Project records show 322 
CHVs trained in Growth Monitoring No 
separate GMVs trained
8. Teachers teaching 
basic messages
- 100 school teachers providing basic 
messages
This project did not work with teachers 
during the 4 years
9. Adequate sanitary 
practices in community
- 50% of communities with adequate 
sanitary practices
Information not available
10. Participation of birth 
attendants in the 
promotion of BF/ FP
- 80% of birth attendants encouraging 
exclusive BF and family planning 
practices 
This project did not work with birth 
attendants during the 4 years
11. Improved dietary 
practices
- 30% of mothers adopt appropriate 
food practices
- Staff from 85 health sites-(MINSA) 
and 400 trained promoters on adequate 
dietary practices and adult education
- 25% of the communities looking for 
technical support to improve agriculture
KPC showed increase knowledge and 
practices in some areas. 
MINSA staff from 52 sites trained, 147 
CHVs trained in adult education 308 CHVs 
trained in nutrition 
Technical support not being monitored
* Goals were modified in the first annual report when total communities decreased from 200 to 162 
Further work is required in all areas to meet the sustainability goals of the 
project. As the role of HOPE changes during the follow-on project, a focus on 
sustainability must be prioritized. No cost-recovery was planned during this 
project. 
Project HOPE in Peru
CSXII Final Evaluation
24
Planning for Sustainability During the last year of this project HOPE worked 
closely with MINSA in a phase-over process which included IVSA:
I= Identification of one person who is responsible for the transfer process
V= Visits together to the communities
S= Supervision in an integrated fashion, design of a supervision instrument and 
training of MINSA staff in supervision skills
A= Articulation of activities involving the HIS
Directors of the Health Networks are very involved in the phase-over process. In 
the future DIRES plans to have one or two specific people assigned to work 
closely with HOPE. Continuous planning with MINSA is needed to strengthen the 
structure of the institution and to plan for those elements which can realistically 
be sustained.
Linkage between the communities and governmental/non-governmental 
organizations There has been good involvement on the part of MINSA and the 
municipalities in supporting CHV training, both organizations provide some part 
of the cost of training courses, lodging, transport, food, etc. Both MINSA and 
municipal authorities have made good efforts to recognize the importance of the 
CHV and the value of the work they are doing. MINSA sponsored a Day of the 
Promoter, which was celebrated, with some of the best CHVs being selected to 
attend a conference. During the first conference, each NGO sent 5 CHVs, for a 
total of 30 participants. The link between communities and MINSA and 
municipalities has been strengthened during this project, but further work is 
required.
Increased coordination with other organizations is needed to provide a linkage 
between organizations (NGOs) and the community. HOPE and MINSA staff 
needs to gather information regarding the requirements of other organization for 
presenting projects. This information could be shared with community leaders to 
strengthen the link between the community and other organizations. Increase 
the coordination between communities and municipalities and other 
organizations.
Strong community structures with a clear vision of development The foundation 
has been laid for strengthening community structures, but this needs to be an 
area of more effort during the second phase of the project. MINSA-HOPE needs 
to work more with the LHC and leaders so that they assume greater 
responsibility for the health of the community, and develop an amplified vision of 
development. 
Sustainable Training Structure In order for training to be sustainable a system 
needs to be established which makes training ongoing, taking into account staff 
turnover within MINSA. During the FE, the evaluation team formulated the 
following recommendations for improving the sustainability of training:
Project HOPE in Peru
CSXII Final Evaluation
25
· Create Trainers within MINSA in health, gender and educational 
methodologies.
· Create Trainers within the municipalities and teachers in 
community organization and project development, leadership 
and participative methodologies.
· Encourage communities to identify alternative resources for 
training and development activities.
· Advocate for the commitment of CHVs who retire from service to 
train a replacement
· Investigate, with the CHV associations, what role they can play 
in training new CHVs
Because of the high turnover within MINSA, two strategies need to be 
emphasized, 1.) Train trainers at the DIRES level, where staff is 
relatively stable, who can replicate educational methodology, 
2.) Develop a self-guided manual for medical students who work 1 year 
in the rural area and new MINSA staff on community participation
Community demand/responsibility for health services The demand for health 
services has increased dramatically in response to new national policies which 
provide free health care for women and children. Child insurance began in 1997 
and saw demand far outstrip supply. Maternal insurance is still in the pilot stage, 
but should be implemented nation-wide this year. These two systems of basic 
health insurance will change the pattern of use of health care facilities. Another 
change in government policy will change the community’s ability to influence how 
services are delivered. CLAS-Local Health Administration Committees are 
recently being established in the San Martin area at the Health Network level. 
The committee is composed of MINSA, community members, education sector, 
and municipal authorities to improve the administration of health services and 
health facilities. HOPE needs close communication with MINSA to maintain 
flexibility in how to best work within these new systems.
C. Program Management
1. Planning
The current DIP was overly optimistic and objectives were formulated which did 
not take into account factors which are outside the scope of the project, i.e. 
prevalence of anemia and diarrhea and food consumption. The DIP needs to 
include more clearly defined objectives and more realistic goals. The DIP was 
well translated into Spanish, and was used as a guide for project 
implementation.
The selection of the area for project implementation was based on a high-risk 
focus and even though it is an extremely difficult area to work in the project has 
shown substantial impact. According to the director of DIRES; HOPE has broken 
Project HOPE in Peru
CSXII Final Evaluation
26
out of the traditional NGO role of choosing more accessible communities and 
serves as a model for other NGOs. MINSA was involved in the selection of 
geographic location and interventions.
With improved communication via email, HOPE headquarters hopes to be able to 
involve field staff more in the development of proposals and the DIP. The DIP 
for the 3 year extension should be developed in a participatory manner, 
involving community, and MINSA at all levels.
2. Staff Training
The Project HOPE staff has received excellent training throughout the four years 
of the project, unfortunately MINSA staff has not enjoyed equal opportunities. 
Some of the most notable training was in adult participatory education, both 
from a local NGO, Kallpa, and an international consultant. Other important skills 
gained were in negotiation and working with groups.
HOPE has had the opportunity to acquire the skills for both technical and 
professional development. The image of HOPE at the beginning was “the little 
girls of HOPE”; they lacked credibility due in part to their youth and inexperience. 
Through outside training, and the formation of a strong supportive team, the 
HOPE staff has been able to turn around the previous perception and command 
respect, particularly in educational methodologies. 
The project was able to identify appropriate training for the staff and sufficient 
funds were available for training. Project staff has started to participate in 
national and international training sessions on community-based IMCI. 
PAHO/Peru invited HOPE Peru staff to participate in the national committee for 
IMCI implementation. Additional training is needed in IMCI and supervision and 
monitoring.
3. Supervision of Program Staff
A formal system for the supervision of program staff does not exist. There is a 
supervision format, but it is not adequate for the needs of staff, is not being 
implemented and should be modified. Staff receives supervision visits 2 – 3 times 
a year. Through good working relations, the staff responses well to indirect 
supervision with monthly meetings and frequent contacts. As supervision is one 
of the aspects that HOPE would like to strengthen within MINSA, a good place to 
start would be with the development of a model system within HOPE. At all 
levels the supervision needs to be improved.
Project HOPE in Peru
CSXII Final Evaluation
27
4. Human Resources and Staff Management
The staff, at the time of the FE, was all women, with the exception of the driver 
and part-time computer person. This situation changes the dynamic of staff 
cohesiveness, as there is a strong feeling of accomplishment and solidarity. 
Despite the high morale, staff turnover in the project has been high, of the 
original 10 positions, only 3 staff are still with the project after four years. There 
are several reason for this high turnover; the work conditions of the project are 
arduous and require a high level of adaptability, particularly in the long term; the 
educational level of the staff is extremely high, for a Child Survival project; most 
of the staff are not local, but are from Lima. The high level of qualified staff has 
allowed the project to strengthen the relationship with MINSA by suggesting new 
strategies and improve the integration of activities. This strategy will continue 
during the follow-on phase.
A key staff, Dr. Luis Benavente, Country Director, was hired by HOPE 
headquarters and now offers technical assistance to the project in his new role 
as Associate Director of Maternal and Child Health Programs.
The project has a Human Resources Manual, which forms part of the 
organization’s Procedures Manual. Personnel policies are clearly spelled out and 
there were no reported problems. All staff is evaluated every 6 months, using a 
form based on a model distributed by HOPE headquarters. The evaluation is 
both a self-evaluation and a team evaluation based on established individual 
goals. 
Job descriptions have been developed for all positions. The majority of the staff 
from the CSXII project will be carried over to the follow-on project. Some staff 
will not be hired for the 3-year extension and good effort has been made by the 
project to help them find new positions, some have been hired by MINSA. Due 
to the extensive training that the staff received throughout the project, their 
skills are in high demand.
5. Financial Management 
A new financial system was introduced by HOPE headquarters in July 1999 using 
Quick Books, but is not functioning 100% and communication is slow between 
headquarters and the local office. On the first of September, the latest budget 
report, which the local office had received, was for June 2000. To overcome this 
lack of timely information, a spreadsheet was developed to complement the 
system and provide the information needed for managing the project locally. 
HOPE is seeking technical assistance to improve the financial system at their 
headquarters.
Project HOPE in Peru
CSXII Final Evaluation
28
A brief financial management manual is part of a HOPE Procedure Manual, which 
also includes human resources management. The administrator changed in 
October of 1998. The previous administrator received hands-on training from 
HOPE Guatemala staff. The new administrator received limited information from 
the previous administrator at turnover but good support from headquarters. 
Project HOPE has provided good technical support to the current administrator to 
overcome problems with the administrative system. A good system of 
communication exists between the local office and HOPE headquarters via email. 
The budget was adjusted in 1998 to allow more local staff to be hired. Significant 
savings during the first two years of project implementation allowed for an 
increase of local staff, which was approved by USAID/BHR/PVC. Other minimal 
internal adjustments were made between line items, which did not necessitate 
USAID approval.
The current budget was poorly classified, due to a lack of firm cost figures at the 
time of proposal development. Local staff was more involved in developing the 
budget for the extension, and the project has better experience at calculating 
costs, consequently the extension budget should better support the 
implementation of the next project.
6. Logistics
No major issues were identified during the Final Evaluation relating to logistics. 
While transportation and communication are extremely limited due to the 
isolated nature of communities, the project has successfully worked within the 
constraints of their environment. In some cases, project staff had to travel by car 
for two hours, take a boat ride for another 3 or 4 hours, and walk up to 9 hours 
in some instances to reach project target communities. This scenario has been 
one of the most difficult ones that HOPE has ever faced in a CS project. Yet, 
logistics barriers were overcome as part of a team effort at HOPE Peru with the 
continued support from HOPE headquarters.
7. Information Management
Most information systems consist of three components: impact surveys, process 
monitoring and qualitative guidance. The project has a system of KPC, food 
consumption and biochemical surveys to measure progress toward impact 
indicators. Most principle objectives were measure three times (baseline, MTE, 
FE) and summarized in the table on page 3. The project also uses qualitative 
methodologies to adjust project implementation. The measurement of ongoing 
activities and process indicators is deficient.
Project HOPE in Peru
CSXII Final Evaluation
29
Impact surveys
Due to changes made in the KPC format, HOPE loses comparability with other 
Child Survival projects. For example, HOPE’s survey asks at what age a child 
began receiving (various foods and liquids) the model KPC asks if the child is 
actually receiving (various foods and liquids). Although the questions are similar, 
they are not totally comparable. Unless there is compelling evidence that the 
manner of asking the questions which HOPE employs is superior, it is suggested 
that the model KPC questions be used. One of the strengths of the KPC 
developed by CSSP is the ability to compare indicators across various CS 
projects.
Another example of how comparability could be enhanced is with the indicators 
for the extension project. The indicator for child spacing is: % of mothers who 
do not want children in the next two years and use modern FP methods. By 
simply modifying the concept, it could be comparable to the USAID Key 
indicator: % of mothers who desire no more children in the next two years or 
are not sure who are using a modern FP method. The project should try and use 
generic indicators whenever possible.
Process Monitoring
Ongoing activity reports have not been developed. A monthly format exists for 
use by the CHV, but its use is limited. Hope staff submits a monthly narrative 
report by area and each HOPE staff member maintains a notebook to keep track 
of activities. One of the recommendations from the Analysis Workshop of the FE 
was to develop a trimester report for GALME coordinators.
A community information sheet was developed to measure changes at the 
community level and has been used during 1997 and repeated in 1999. It 
includes use of the UROC, formation of LHC, latrines, other projects, and 
community population. The information from this sheet was not focused enough 
to be used in guiding project implementation. This could be a valuable tool for 
project management, but HOPE needs to more clearly define what their 
information needs are. The census is updated every 4 months with new births 
(although deaths are not registered) and annually by MINSA.
Qualitative Studies
Focus groups were carried out on a number of occasions: 
· to learn about breastfeeding beliefs and practices used to develop 
educational messages; 
· to discuss with CHVs problems in one zone, information from these 
groups was used to improve the supervision system and coordination; 
· groups with women were used to design educational materials and 
identify locally available foods.
The use of qualitative methods has been one of the strengths of the project.
Project HOPE in Peru
CSXII Final Evaluation
30
Nutritional Surveillance
The nutritional surveillance system being used is ANA, a software package 
developed by PRISMA and shared with HOPE. HOPE has completed 9 weighing 
sessions as of May 2000 and currently have 2,287 children registered in the 
database which includes an analysis of Wt/Ht, Wt/Age, Ht/Age. 
CHVs and health personnel receive a computerized feedback report of which 
children are malnourished usually within 1 month. The feedback loop is 
unnecessary and creates a dependency on the computerized system. CHVs 
should identify malnourished children, and begin immediate actions including 
reporting to the LHC and community. To do this, the CHVs need additional 
support and training in diagnosis and follow-up. The feedback loop should only 
be used by MINSA staff to insure that the CHV is following-up on all cases.
In two Health Networks, MINSA staff is beginning to enter data into ANA and 
HOPE continues to do the data entry in the other area. Information from the 
nutritional surveillance has been distributed to MINSA at various levels and has 
been used for information on the nutritional status at the community level, to 
verify malnutrition levels in the region, and in the prioritization of areas for food 
distribution programs, but the widespread impact of information from the project 
comes more from special studies as previously discussed in B.2.c New 
Tools/Approaches. The completion of the surveillance is used as an indicator of 
the level of activity of CHVs and as a way of prioritizing supervision visits. 
Is the ANA system sustainable? Given the other priorities of health staff and the 
limited use of the information from the database, which is already available at 
the community level without a computerized system. The project should 
seriously evaluate the value of maintaining the ANA database, in terms of 
sustainability and impact at the household level in solving the problems of 
malnutrition.
Information Management and Use
A computer specialist was hired 4 months ago to work with the CS and 
community bank projects. The management of the HIS is decentralized, with 
some people working on each database. The principal databases are; Census, 
Community Information, Training received by CHV, and Nutrition status 
(ht/wt/age). The computer person has received little training, for example in 
Epi-Info; he learned mainly by working on the KPC.
The project needs a clear vision of what they want to accomplish with the HIS 
during the next three years, whether the focus is on the community use of 
information, or support of the MINSA system. Given the lack of progress in this 
Project HOPE in Peru
CSXII Final Evaluation
31
area during the first four years, it is doubtful whether both objectives can be 
reached. 
If HOPE opts for working more on community use of information, simple 
mechanisms need to be developed such as a chart showing the number of 
malnourished children in the community month by month. Information needs to 
be put within a context that communities can understand and use. Community 
maps were introduced, but have not been sufficiently used to reach their 
potential as a community tool. Community mapping as an information use tool 
should be strengthened. 
Sixteen of the 23 CHVs interviewed during the FE reported that they 
communicate to the community the number of malnourished children, but few 
communities were motivated to take any specific actions based on the 
information. Community leaders, committees and volunteers require additional 
support for identifying concrete steps for resolving health problems.
A comprehensive study of needs and an information use plan for the 
development of an inclusive HIS is urgently needed for the 3-year 
extension. The development of the HIS should be completed simultaneously 
with the DIP, to insure that all indicators are measurable with the HIS.
8. Technical and Administrative Support
The former HOPE director and UPCH liaison in Peru has now been hired directly 
by HOPE headquarters’, where he continues to offer technical assistance to the 
project in technical issues and assistance with the KPC. This relationship provided 
good continuity throughout the four years of the CS-XII project.
A great deal of technical support for the project comes from the relationship with 
UPCH. The university has been instrumental in providing the CS project with 
numerous research studies and support for planning and analyzing data from 
project studies, such as the KPC. The current HOPE director also has professor 
status at the university, so it is anticipated that this close relationship will 
continue.
HOPE headquarters’ representative has visited the project approximately twice a 
year during the four years of the grant. No visits were made during the last 
year, until the FE. The backstopping person is allocated 3pm (person months) 
for this project, but actually devotes approximately 35% of his time. He is also 
responsible for partially backstopping projects in Nicaragua, Guatemala, Ecuador, 
Haiti, and Mozambique
More technical assistance is needed in family planning, HIS development and 
management, and IMCI. HIS development may be possible through an 
Project HOPE in Peru
CSXII Final Evaluation
32
exchange visit by staff from HOPE-Nicaragua or HOPE Guatemala. Technical 
assistance in IMCI has already been arranged with PAHO during October of this 
year.
9. Management Lessons Learned
· Planning of the project and development of the DIP is crucial and needs more 
involvement of the field office, all levels within MINSA, and the community
· If MINSA is a full partner, they need the same access to training and staff 
development as HOPE staff
· Ongoing planning of activities, including evaluation and modifications of 
strategies should occur continuously during the life of the project with 
principal partners.
D. Conclusions and Recommendations
It is difficult to appreciate the impact of the project due in part to the use of 
indicators that do not reflect what the project has accomplished in the last four 
years. Only three of the 13 objectives were actually met during the four-year 
period. This can be partially explained by an overly ambition proposal and not 
taking into consideration factors which were outside of the scope of the project, 
i.e. prevalence of anemia and diarrhea and food consumption. The project has 
shown positive impact in two very important areas; percentage of women who 
exclusively breastfeed until 6 months of age and percentage of stunting in 
children. Other important improvements include frequency of growth 
monitoring, early initiation of breastfeeding and use of family planning methods. 
Some of the major achievements of the project include: 
· the development of a very effective educational methodology
· encouraging the valuation of local foods-not donated or processed foods, 
· improved quality of nutritional surveillance, 
· establishment of a network of trained CHVs, 
· development of formula for fortified foods, 
· studies which have allowed: focused messages i.e. initiation of feeding 
bananas; better understanding of complex disease states, i.e. anemia; and 
improved information for use by MINSA officials i.e. iodine content of salt., 
· development of leadership skills in women and greater solidarity through 
GALME, 
· efforts made by the staff to implement a good quality project under very 
adverse conditions.
Major Problems that still need to be addressed during follow-on project:
· HIS is not fully functioning
· Supervision and monitoring is weak at all levels
Project HOPE in Peru
CSXII Final Evaluation
33
· Collaboration and communication with MINSA needs to be further improved, 
the project’s role in supporting MINSA, that means total involvement 
together-planning, evaluation, implementation 
· Defining the needs for capacity building and institutional strengthening-find 
out what is needed and work on systems development
· Further strengthening of community structures, including liaison with MINSA, 
municipalities and other organizations, 
Hope should serve as a temporary bridge between MINSA and Communities, 
Communities and other organization, The darker lines represent the sustainable 
relation which the project should strive for. All levels need to be strengthened, it 
can not be assumed that strengthening the committee will automatically 
strengthen women, nor only working at the Health Network level will support the 
needs of staff at the health post level. 
Project HOPE has recently launched HOPENET, a web-based Intranet for the 
exclusive purpose to improve channels of communications within the Foundation 
in the U.S. and abroad. At this time, all HOPE field offices can access updated 
information on a variety of subjects pertaining current and past initiatives 
implemented by HOPE. As part of this effort, lessons learned from all HOPE 
programs will be posted on the Intranet for all HOPE staff worldwide. HOPENET 
will be updated on a quarterly basis to include not only information on CS 
projects but other HOPE initiatives as well.
Community:
Women
Men
Committee
Authorities
MINSA:
DIRES
HN
Center
Post
Municipalities
Other 
Organizations
 Project 
HOPE
Project HOPE in Peru
CSXII Final Evaluation
34
Lessons Learned: 
· HOPE, MINSA and the community have to work more closely together.
HOPE-MINSA needs to be established as a concept, not just each 
independently
· The development of activities which respect and value the local culture have 
the greatest impact
· Involving MINSA in training activities aids in reaching the communities with 
health messages.
· Unifying the language used in messages promotes better learning
· For adequate implementation, the project should involve all partners (MINSA 
HOPE Community) from the beginning
· Continuous follow-up and support are needed for the development of new 
abilities
· The supervision checklist on anthropometric measurement was very effective
· The GALME should be for all women, include other topics of interest to the 
women and include activities with their husbands.
· The greatest impact in changing practices comes with clear, simple 
messages, based on previous study 
· Take advantage of the felt need of women to meet in their own group, 
according to their own vision
· To decrease the prevalence of diarrheal disease it is necessary to improve 
sanitation conditions through coordination with other organizations that work 
in this area.
· Educational messages which focus on improving feeding during and after a 
disease episode will have the greatest impact on changing knowledge and 
practices
· A project can not advance without the support of local authorities.
· Communities must be involved as full partners in the development process, 
including being involved more in planning and evaluating
· Don’t divide the work with MINSA, go with them to support the 
implementation and quality of the work. 
· The use of checklists clarifies expectations and defines what elements are 
essential
· CHVs should not have an institutional affiliation, but should clearly be of the 
community. 
· Initially identify CHVs who have been trained by other organizations
· Regular contact is essential to support the work of the volunteer
· More emphasis needs to be given on training to train and supervising the 
replication of training.
· Other members of the community need to be trained to create an 
environment of change
· Sustainable training structures must be developed
· Planning of the project and development of the DIP is crucial and needs more 
involvement of the field office, all levels within MINSA, and the community
Project HOPE in Peru
CSXII Final Evaluation
35
· If MINSA is a full partner, they need the same access to training and staff 
development as HOPE staff
Recommendations:
· The project should select one measure for determining nutritional 
status and focus training on counseling the family on what concrete 
actions can be taken.
· As part of the final evaluation of the follow-on project, the impact of 
the food dryer and fortified food should be included.
· The formation of a link between GALMEs should be established, 
using one (or more) of the following mechanisms: 
1). Formation of a network of GALMEs
2). Integration of the Coordinators of GALMEs into the CHV 
network
3). Visits between groups for sports events and to exchange 
ideas about health issues
4). Annual conference of all coordinators to reinforce their work 
and to define future directions
· Elaborate and broadcast basic integrated messages aimed at 
improving knowledge and practices of mothers with ill children 
(Diarrhea, respiratory infections, malaria) with a focus on feeding 
during and after the illness.
· During the next phase of the CS project, one focus of education 
should be aimed at decreasing the use of inappropriate medications 
for diarrhea.
· Alliances should be formed with organizations who have financing 
and/or offer technical assistance in construction or latrines, water 
systems, as well as agricultural activities.
· Strengthen the UROC as a community structure with an integrated 
preventative health role in the community through increased 
community participation. 
· Implement family planning activities by involving men and 
husbands in educational activities.
· Training for committee members and leaders in project 
development and community organization should be prioritized 
during the next 3 years.
· Community diagnosis and ongoing meetings to evaluate, analyze 
and plan should be held together; community (including women), 
health personnel and HOPE. 
· CHVs and GALME coordinators need improved skills in more than 
message delivery but also in counseling, identified barriers to 
change and negotiating behavior change.
Project HOPE in Peru
CSXII Final Evaluation
36
· MINSA and HOPE should strengthen follow-up to insure the quality 
of replication of training courses and the education in the 
communities.
· HOPE should determine a mechanism for acquiring educational 
materials for all communities and MINSA health posts to support 
educational messages. 
· HOPE should seek technical assistance on institutional assessments 
from other NGOs who have experience in this area.
· The anthropometric checklist should be expanded to include 
diagnosis of malnutrition and counseling of the mother on what 
actions she can take. The checklist concept should be expanded to 
include other areas for supervision.
· Both a formal and informal system of communication should be 
developed between HOPE and MINSA: 
· HOPE should participate in the planning and evaluation 
meetings of the AIN 2001(Integrated Care of the Child) 
program. 
· Regular meetings with the DIRES, UBASS , health center and 
health post levels
· An annual planning and evaluation workshop should be 
implemented with participation from all levels, to review 
project achievements and together plan for needed 
readjustments.
· The strategy of using CHV couples should be re-evaluated during 
the second phase of the project.
· Establish a system of indirect supervision using regular monthly 
meetings between health post staff and all CHVs from the post. The 
meetings would be used for analysis of information, to reinforce 
training topics, distribution of materials (ORS), discussion of 
problems and solutions, and to prioritize needs for direct 
supervision visits. 
· HOPE and MINSA should collaborate on the development of an 
integrated supervision instrument.
· Increase the coordination between communities and municipalities 
and other organizations.
· Create Trainers within MINSA in health, gender and educational 
methodologies.
· Create Trainers within the municipalities and teachers in community 
organization and project development, leadership and participative 
methodologies.
· Encourage communities to identify alternative resources for training 
and development activities.
· Advocate the commitment of CHVs who retire from service to train a 
replacement
Project HOPE in Peru
CSXII Final Evaluation
37
· Investigate with the CHV associations what role they can play in 
training new CHVs
· Develop a self-guided manual for medical students who work 1 year 
in the rural area and new MINSA staff on community participation
· The DIP for the 3 year extension should be developed in a 
participatory manner, involving community, and MINSA at all levels.
· A comprehensive study of needs and an information use plan for the 
development of an inclusive HIS is urgently needed for the 3-year 
extension.
Project HOPE in Peru
CSXII Final Evaluation
38
E. Results Highlight
COCOA FORTIFIED WITH HEME IRON
EFFECTIVE STRATEGY FOR COMBATING IRON DEFICIENCY ANEMIA
The Child Survival project implemented in rural communities of northern Peru by Project HOPE 
and the Ministry of Health encountered a high level of anemia in women and children during the 
baseline study in 1997. The prevalence was 49% in children under 3 and 21% in women of 
reproductive age, along with a high incidence of parasites and diarrhea in children. As the main 
cause of anemia is a deficiency of iron this spurred the project to find a way to increase the 
availability and consumption of iron. In order to reduce the rate of anemia in women and 
children, the project looked at fortification as a viable strategy thus the idea of aiding the 
commercialization of a food product which offered a low cost, acceptable source of micro￾nutrients for vulnerable families was born. 
The following steps were followed in developing the final product
a.) Formulation 
The first step was to identify a locally available product which was compatible with fortification. 
A document review of fortification indicated that the most acceptable and available product 
would be FERRIMIN, a cow’s blood source of protein and iron with 2.7-3.1mg/g, heme iron with 
a bio-availability of 30% produced in Chile. Laboratory and cost studies evaluated physical 
characteristics, and products which offered approximately 150% of the daily requirement of a 
child at an affordable cost. Studies were made of cocoa, banana flour and cookies resulting in a 
product of 25% Ferrimin and 75% locally grown cocoa (1.25 grams Ferrimin/3.75 gms cocoa).
b.) Acceptability 
The formula underwent acceptability studies in four different products; cocoa mixed with water, 
mixed with milk, thickened with banana flour and fudge. Taste tests were carried out in the urban 
and rural areas with men, women, and children.
c. ) Effectiveness
Four studies were carried out in the project area by students from the University Peruana 
Cayetano Heredia on the effectiveness of the product in reducing anemia. A summary of the 
studies shows a high level of recuperation in various population groups:
 Quijano Alarcón L. Casanova B. Casanova
56% in 30 days 50 % in 56 days 63 % in 56 days 100 % in 28 d
Schoolchildren Adults-both sexes Adults-both sexes Women >14y
With anti-parasite With anti-parasite With anti-parasite
Cutoff points were 13 gr/100ml-men, 12 gr/100ml–women, 11gr/100ml for children and pregnant women.
It was concluded that cocoa fortified with Ferrimin had a high level of effic acy with a greater 
than 50% rate of recuperation of anemia with 1-2 months of treatment. It can be recommended 
that for use in treating iron-deficiency anemia, the cocoa be used in conjunction with an anti￾parasite drug, particularly in rural tropical areas.
d. ) Marketing
The project developed a package of technical information on fortified cocoa that was made 
available to small business entrepreneurs on the efficacy and merits of the product. Fortified 
cocoa is now available on the local market with limited distribution. The project continues with 
the challenge of acting as intermediary to encourage the production and distribution to a wider 
market, particularly those most effected by under nutrition.