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ESPERANCA PERU 
FINAL CHILD SURVIVAL EVALUATION REPORT 
Cooperative Agreement Number: FAO-A-00-97-00058-00 
Written by: 
Richard Crespo, Ph.D. 
Marshall University School of Medicine 
August 2001 
TABLE OF CONTENTS 
A . EXECUTIVE SUMMARY ................................................................................................................. 3 
1 . PROGRAM OBJECTIVES ......................................................................................................................... 3 
2 . MAIN ACCOMPLISHMENTS .................................................................................................................... 4 
3 . BASELINE COMPARED TO FINAL INDICATORS .......; ........................................................................... 5 
4 . PRIORITY CONCLUSIONS ....................................................................................................................... 7 
B . ASSESSMENT OF RESULTS AND IMPACT ............................................................................ 7 
1 . SUMMARY RESULT OF MEASURABLE INDICATORS .............................................................................. 7 
2 . RESULTS: TECHNICAL APPROACH ....................................... .............................................................. 10 
A) Results in Diarrhea Control ........................................................................................................ I1 
B) Results in Breastfeeding ............................................................................................................. 12 
C) Results in Nutrition .................................................................................................................. 12 
D) Results in Immunization .............................................................................................................. 13 
E) Innovative Approaches ............................................................................................................... 13 
3 . RESULTS: CROSS-CUTTING APPROACHES ......................................................................................... 14 
A) Community Mobilization ............................................................................................................. 14 
B) Conzrnunication for Behavior Change ...................................................................................... 15 
C) Capacity Building Approach ....................................................................................................... 15 
D) Sustainability Strategy ................................................................................................................ 19 
C . PROGRAM MANAGEMENT ........................................................................................................ 20 
1 . PLANNING ............................................................................................................................................ 20 
2 . STAFF TRAINING ................................................................................................................................. 21 
3 . SUPERVISION OF PROGRAM STAFF.. ................................................................................................... 21 
4. HUMAN RESOURCES AND STAFF MANAGEMENT ............................................................................... -22 
5 . FINANCIAL MANAGEMENT .................................................................................................................. 22 
6 . LOGISTICS ........................................................................................................................................... 22 
7 . INFORMATION MANAGEMENT ............................................................................................................ 22 
8 . TECHNICAL ASSISTANCE AND ADMINISTRATIVE SUPPORT ................................................................ 23 
9 . MANAGEMENT LESSONS LEARNED .................................................................................................... 23 
D . OTHlER ISSUES ............................................................................................................................ 24 
E . CONCLUSIONS AND RECOMMENDATIONS .......................................................................... 24 
PRIORITY RECOMMENDATIONS .... , ....................................................................................................... 24 
APPENDIX 1 : METHODS USED .......................................................................................................... 27 
APPENDIX 2: EVALUATION TEAM ................................................................................................... 28 
A. Executive Summary 
CHARACTERIZATION OF THE PROJECT ZONE 
This project is located in the Southern highland of Peru, in the Department of Apurimac, 
Cotabambas Province. The communities served by the project are located between 10,000 
and 15,000 feet above sea level. They are draped across Andean mountain peaks and 
require hours of hiking to traverse from one to the other. The people are Quechua 
speakers; In fact the vast majority of women only speak Quechua. All of the project's field 
staff are native Quechua speakers. 
Access to healthcare. The Esperansa project zone in Cotabambas Province is 
characterized by extremely difficult circumstances for geographical and cultural 
access to Ministry of Health (MINSA) services. 
Geography of the zone. The intervention area encompasses 130 Quechua￾speaking communities located 8-14 hours from Cusco by car, plus an additional walk 
of 0-12 hours beyond the road. During the rainy season, road access is significantly 
limited due to landslides and high rivers. 
MINSA health services. Health services in the project zone suffer from 
infrastructure and personnel shortages due to inaccessibility and a relatively low 
level of financial investment from MINSA. For example, half of the health 
establishments in the project zone do not have any means of outside 
communication, such as a radio or telephone line. Half are staffed only by health 
technicians (non-professional health personnel), and there is no surgical capacity 
anywhere in the project zone. Difficult working conditions lead to constant staff 
turnover, and especially a difficulty in retaining experienced Quechua-speaking 
health personnel. 
Culture and health practices. A recent survey in the project communities found 
that over 70% of births are attended in the home by the husband or other family 
members. 85% of mothers reported that they are exclusively Quechua speakers, 
and 80% say that they do not read or write Spanish or Quechua. 
1. Proaram Objectives 
A) PROJECT GOALS AND ACTIVITIES 
Since 1998, the Esperanra Child Survival project has worked with community health 
promoters, families and the Ministry of Health (MINSA) on education and technical skills in 
four areas of intervention: pneumonia case management (PCM), diarrheal disease control, 
nutrition/growth monitoring, and maternal health/obstetrical emergency management. 
The project has four child survival interventions: The specific objectives for each 
intervention are listed in Table 1, page 6. 
The overall goals for the project were to I) Reduce infant, child, and maternal 
morbidity/mortality in the project zone; 2) Faciiitate sustainable improvements in the 
quality of health services in the project zone; and, 3) Strengthen the capacity of the 
partner organization CADEP for health programming. 
PROJECT HIGHLIGHTS: 
1. Monthly training of 130 health promoters, formation of health committees at each 
health post, and a local health committee in each community. Support for routine 
training of traditional birth attendants. 
2. Health education of families in 130 communities to reduce child morbidity and 
mortality. 
3. Implementation of a pictorially-based referral system for health promoters and 
traditional birth attendants. Health promoters manage patients' follow-up care in 
the community. 
4. Development of IEC (Information, Education and Communication) materials: health 
promoter flip-charts for each program, a health promoter manual, greenhouse 
manual, radio spots, sociodramas, stretchers, community medicine chests. 
2. Main Accomplishments 
Community-level health knowledge 
1. Mothers have a strong sense of change in community health over the last four years. 
They identified maternal-child health insurance and better maternal-chiid health as 
the most important change. 
2. Mothers can identify the main sign of pneumonia. Data from the final survey found 
that 73% could state the sign of rapid breathing at rest. Almost all mothers 
answered immediately with no hesitation. 
3. Mothers know the signs of dehydration from diarrhea. Data from the final survey 
show that 64% of the mothers could identify at least one sign. 
4. Mothers giving solids to children six months or older during incidents of diarrhea and 
mothers knowledge of the sign for pneumonia were two interventions that attained 
both a substantial change from the baseline and had a high level of adoption at the 
end of the project. (Charts 1 and 2, pgs. 7 and 8). 
5. Mothers know the signs of risk during delivery. Data from the final survey found 
that 68% of the mothers knew at least one sign. 
6. Mothers know the meaning of the infant growth chart, Interviews with 189 mothers 
showed that 88% knew the meaning of the green zone, 84% knew the meaning of 
the yellow zone and 79% knew the meaning of the red zone. 
Community health promotion 
1. Health promoters have been selected and trained in all 130 project communities in 
the areas of pneumonia control, nutrition, diarrhea control and maternal health. 
According to the final survey, health promoters are active and are recognized for 
their labors both by their communities and the Ministry of Health (MINSA). Mothers 
who were interviewed during the field survey for this report gave them a rating of 
on a 3-point scale for quality of their work. 2. MINSA also gives high marks for the 
promoters' performance. They gave them a rating of 2.9 on a four-point scale. 
2. The community substantiates the promoters' perception of their role. When asked 
about the most important things that the promoters do, mothers and community 
leaders all identified the same top three activities of the promoters: home visits, 
health talks, making referrals to the health center. The health promoters are truly 
active in their communities. 
* 
3.Cornmunity support is broad-based. All 125 communities have health committees. 
Most of them have been working on birthing centers and creating plans for 
emergency transport of patients to the health center. 
Baseline Compared to Final Indicators 
Please refer to Table 1, on the next page. A discussion of the indicators will be made in the 
corresponding sections of this report. 
Table 1: Baseline Indicators Compared to final 
Objective 
1. Children from 0-6 months will receive exclusive breastfeeding. 
Baseline 
59% 
2. Children from 6 to 24 months will eat solid food, complimented by breast 
milk. 
40% 
3. Children less than 2 years of age will receive monthly growth monitoring, 
as documented by their growth charts. 
37% 
4. Children 0 to 6 months who have an episode of diarrhea, will receive 
more breast milk than usual. 
79% 
5. Children 6 to 24 months old who have an episode of diarrhea will receive 
more liquids, including breast milk and ORS, than usual. 
54% 
6. Children 6 to 24 months old who have an episode of diarrhea will receive 
more food than usual for 2 weeks after the episode. 
22% 
7. Mothers with children less than 2 years of age will be able to recognize 
two signs of diarrhea. 
21 % 
1 
8. Mothers with children less than 2 years who have diarrhea danger signs 
will promptly seek appropriate care. 
1 
91 % 
9. Mothers with children under 2 will recognize one sign of pneumonia. 
10. Mothers with children under 2, who have signs of pneumonia, will 
promptly seek appropriate care and comply with SCM. 
16% 
79% 
11. Communities will have an emergency transport plan to promptly take 
sick children to an appropriate care provider when indicated. 
NA 
! 
12. Pregnant mothers will have 2 doses of tetanus toxoid vaccine 
document by their maternal health card. 
13. Pregnant mothers will have at least two prenatal care visits 
documented on their maternal health card. 
62% 
63% 
14. Women of childbearing age will be able to recognize 3 signs of 
obstetrical emergencies. 
N A 
15. Communities will have an emergency transport plan to promptly take 
women with obstetrical emergencies to appropriate care. 
N A 
2. Prioritv Conclusions 
1. It is possible for change in knowledge and behavior to occur in traditional, illiterate 
societies in a relatively short time. 
2. Substantial progress has been made since the mid-term. In large part it is because 
the Esperanza staff trained and worked through the promoters instead of working 
directly with mothers. 
3. The consistent perception of the promoters' role among mothers and community 
leaders gives evidence of the quality of their work. 
4. The level of support: from MINSA appears to be superficial and is not likely to be 
sustained unless there is strong leadership from the new DIRESA Director. 
5. Assessment of Results and Impact 
1. Summarv Result of Measurable Indicators 
The project showed an improvement from the baseline to the end in seven of its 
measurable indicators. The following table presents the indicators and the amount of 
change in percentage points. 
Chart 1: Indicators that achieved improvement from the baseline 
Pregnant mothers with 2 TT doses 
Exclusive breastfeeding 
Prenatal visits 
Mothers know signs of dehydration 
Growth monitoring 
Mothers know sign of pneumonia 
Children from 6 to 24 mo. eat solids & breast milk. 
0 10 20 30 40 50 60 70 
Percentage Point Improvement 
These indicators give evidence of substantial improvement in the health status of mothers 
and their children. It is especially important to note the amount of change in mother's 
ability to recognize signs of dehydration and pneumonia, the two greatest causes of infant 
morbidity and mortality. 
Another way to obtain a perspective on the achievement of the project is to note that the 
project attained a level of at least 50% in knowledge or practice of preventive behaviors in 
all but two of its indicators. This is evidence of a broad foundation for improving the health 
status of mothers and their children. The areas in which 70% or more of the mothers had 
the intended knowledge and skills are presented in the following chart. 
> 
Chart 1: Indicators that had the highest achievement. 
Exclusive breastfeeding 
Mothers know sign of 
pneumonia 73% 
i 
Growth monitoring 82% 
Emergency transport 
Children from 6-24 mo. 
lave solids & breast milk 
Prenatal visits 
The fact that 100% of the mothers who had their maternal health card went to the health 
center for prenatal visits is a major accomplishment. One must note that for over half of 
the villages it is more than a four-hour walk to the health center. For the most isolated 
villages it is up to a 12 hour walk. This also shows the Quechua population has grown in 
its acceptance of the government health centers. 
Another important achievement is the high percent of mothers who exclusively breastfeed 
their infants up to six months of age. The tradition has been to supplement breastfeed 
after a couple of months to make the babies fatter. The fact that so many mothers now 
accept exclusive breastfeed is a significant change and will contribute to reducing infant 
morbidity. 
According to the data in Table 1, page 5, there has only been a 14-percentage point 
difference between the baseline and final survey in exclusive breastfeeding. It should be 
noted that at the mid-term evaluation the team questioned the reliability of the baseline 
data. The field staff believed that mothers did not fully understand the questions because 
of language difficulties and their lack of exposure to this kind of questioning. Thus the 
significance of the change from the baseline is possibly understated. 
Combining data from Charts I and 2, above, it is noteworthy that two interventions 
attained both a substantial change from the baseline and had a high level of adoption at 
the end of the project. These were giving solids to children six months or older and 
knowledge of the sign for pneumonia. Regarding the first intervention, it should be noted 
that while there had been a tradition of giving teas and infusions to infants, most mothers 
(60% according to the baseline) introduced solids late during the child's development. The 
extent of change in nutrition for young children and early treatment for signs of pneumonia 
should make a significant difference in the morbidity and mortality of children in this 
province. 
In some of the interventions there has been a decrease in adoption of some indicators from 
the baseline to the end. These are presented in the following table. 
Table 2: Interventions in which there was a decrease between baseline to final 
survey. 
Objective 
Child. 6-24 mo. with diarrhea more liquids 
Baseline 
54% 
1 
Child. 6-24 mo. with diarrhea more solids 15% 
Mothers seek care for pneumonia 
1 
Of the five interventions in the above table, three have to do with treatment in cases of 
diarrhea. A further analysis of the date indicates that this table does not present the full 
picture. When the questions are expanded to include both the variables "the same amount 
of liquids" and 'more liquids" the data are represented as follows. 
Final 
50% 
22% -7 
79% 64% 
Child. 0-6 months with diarrhea, more breast milk 
Change 
(points) 
-4 
-1 5 
Mothers seek help child diarrhea -38 
79% 
91 % 53% 
19% -60 
Table 3: Percent of mothers who give the same amount or more liquids and 
solids during incidences of diarrhea. 
Objective 
Final 
Child. 6-24 mo. with diarrhea the same or more liquids 
Child. 6-24 mo. with diarrhea the same or more solids 
Child. 0-6 months with diarrhea, the same or more breast milk 
8 6 O/o 
It is especially important to note that 85% of infants 0 to 6 months old receive the same or 
more breast milk during an episode of diarrhea. Thus, the data in Tables 1 and 2 
misrepresent mothers' care of their children during incidences of diarrhea. Table 3 gives a 
more accurate picture. 
The other two areas that showed a decrease between the baseline and final surveys were 
help-seeking behavior for diarrhea and pneumonia. One factor that could possible affect 
the decrease in seeking help in cases of childhood diarrhea is the mothers' increased 
confidence and ability to address diarrheal disease at home, with the presence of the 
health promoter. Thus the decrease in seeking medical help for diarrhea from a distant 
health post can be regarded as a positive. 
2. Results: Technical A~~roach 
This project is located in the Southern highland of PerQ, in the Department of Apurimac, 
Cotabambas Province. The 125 communities served by the project are located between 
10,000 and 15,000 feet. They are draped across Andean mountain peaks and require 
hours of hiking to traverse from one to the other. The people are Quechua speakers; In 
fact the vast majority of women only speak Quechua. All of the project's field staff are 
native speakers. 
There are no paved roads in the province and communication is extremely limited. The 
town where the project is based has one community telephone. The vast majority of 
villages are not accessible by road, and most car access is curtailed during the rainy 
season. Generally, the project vehicles bring the field staff to drop-off points and they 
walk from there. 
It is important to note that four years ago Cotabambas had the highest infant mortality 
rate (118 per 1,000 live births) and maternal mortality rate (451 per 100,000) in Peru. It 
also had the lowest child development index, and the highest percentage (98%) of children 
with basic needs unmet, in the nation. (Source: Peru National Institute of Statistics and 
Information, 1996) 
Local MOH officials reported that the major causes of under-five mortality in the zone were 
pneumonia and diarrhea. Causes of maternal mortality were hemorrhage, gestational 
hypertension, infection, and trauma. 
The two broad project strategies were: 1) to improve the coverage and quality of health 
services at all levels by training MOH staff and community volunteer Promoters; and, 2) to 
improve the home care of children, the recognition of danger signslemergencies, and 
prompt seeking of appropriate care by training caretakers and communities. 
These strategies were to be addressed by using two main lines of action: training and 
communication. The project team used the Behavior Change Communication model as 
presented in Communication for Health and Behavior Change. The focus was on 
observable behavior and skills training. The plan was to follow these five steps: (1) 
assessing behavior, (2) planning for behavior change, (3) ski I Is training, (4) monitoring 
behavior change, and (5) maintaining health practices. 
A project director, one field supervisor, and seven field staff led the project. The field staff 
trained and worked alongside 15-20 volunteer health promoters each. 
6) RESULTS INDIARRHEA CONTROL 
The impotTant findings in this intervention were as follows. 
The incidence of diarrhea in the KPC survey, in children under 2 years old, was 30%. 
75% of mothers gave the same or more liquids when their children had diarrhea. 
86% of mothers gave the same or more breast milk when their infants had diarrhea. 
50% of mothers gave the same or more solids when their children had diarrhea. 
94% of the MINSA staff stated that their coverage of cases of diarrhea increased 
because of the work of the promoters. (n=16) 
89% of the promoters knew all of the signs of diarrhea in children under two. 
(n=18) 
The promoters who were observed by the evaluation team giving health talks on 
diarrhea control did so with complete accuracy. 
The educational materials on diarrhea prevention and management were based on 
culturally appropriate drawings which were well suited for this population. 
The staff team gave a high priority to this intervention because of the extent of the 
problem. At the baseline the incidence was 38%. Anecdotal evidence from interviews 
with promoters indicates that while cases of diarrhea in children still occur frequently, 
the mothers know how to manage it and they rarely need to refer a child to the health 
center because of dehydration. MINSA staff states that they rarely see cases of 
dehydration from the communities in the project-and findings from the final survey 
support this. 
These statements are supported by the large percentage of mothers who give more 
liquids in cases of diarrhea. Additionally, there was an increase in the percent of 
mothers who could give at least two sign of dehydration from 21% to 64%. While the 
Rnal percent is lower than one would want, it is important to recognize that mothers did 
achieve a 43-percentage point increase. 
The relatively low percent of mothers who give the same or more solids indicates a 
need for continued education in this area. MINSA staff and the promoters should 
continue to help mothers understand the importance of solids in managing diarrhea. 
The Key finding for this intervention was as follows. 
1. 73% of the mothers practiced exclusive breastfeeding. 
2. 99% of mothers stated that they gave introduced solids (in addition to breast milk) 
to children when they were six months and older. 
It is especially encouraging to know that mothers understand how to manage the transition 
from breastfeeding to solids and at what age to do so. Progress begins with the fact that 
73% of mothers practice exclusive breastfeeding. While the baseline survey results stated 
that 59% practice it, the field staff believe that mothers did not understand the question, 
and that exclusive breastfeeding was overestimated in the baseline survey. In their 
experience, most mothers gave water or teas to their infants by 3 months of age. Thus the 
field staff should be very proud of the fact that 73% now practice this behavior. 
When the project began there was a wide range of practices regarding the transition from 
breastfeeding to giving solid foods. It was a common practice to give solids to infants in 
their third month in order to make them fat and beautiful. On the other end of the 
spectrum there were numerous mothers who delayed giving solids until eight to twelve 
months of age. They primarily gave breast milk to their infants. The fact that 99% of the 
mothers knew how to mange this transition has been a major change. 
In this project problems related to the knowledge and practice of breastfeeding and of 
when and how to give solids were intrinsically linked. 
Dl RESULTS IN NUTRITION 
1. 88% of the mothers in the field survey (n=189) were able to state the meaning of a 
child in the green area of the growth chart, 84% the meaning of the yellow area, and 
79% of the red area. 
3. No growth chart that was reviewed in the field survey showed a child in the danger 
area. Additionally, no child stayed in the "warning" or yellow area of the growth 
chart for more than one weighing period. 
4. 82% of the children 5 months or older had been weighed at least once in the last 
four months (up from 37% at baseline). 
5. The community leaders who were interviewed (n=17) and the promoters (n=18) 
stated that one of the important ways that they supported each other was in 
distribution of the child food supplement to prevent child malnutrition. 
6. 89% of the 18 promoters who were interviewed in the field survey could identify the 
three food groups without any prompting. 
Teaching on nutrition was one of the last interventions that the project worked on. This 
makes sense given the extent of the problems in diarrhea and respiratory infections. Good 
progress was made in this area despite the relatively short time that was dedicated to it. 
The data on growth monitoring are very encouraging. Given the circumstances of 
geography and climate it, these data represent: good progress. It is especially note worthy 
that the mothers understand the dangers of underweight babies and have done a good job 
in weight management. This finding is linked 
section on breastfeeding and the transition to 
with the observations made earlier in this 
giving solids. 
The important findings regarding this intervention are as follows. 
1. 85% of the mothers in the KPC survey had their child's vaccination card available. 
2. 76% of the children 12 to 24 months old were fully immunized. 
3. All seven of the mothers who were pregnant during the KPC survey had their 
prenatal cards. 
4. All seven of these mothers had at least one tetanus toxoid vaccination. 
5. 38% of all mothers in the KPC survey still had their prenatal cards available to 
demonstrate to the interviewers. 
6. 69% of the mothers who had a prenatal card showed evidence of at least two 
tetanus toxoid vaccinations. 
Improvement was clearly seen in maternal immunizations. At the baseline 16% of the 
mothers had their maternal health card, while 38% did so at the final. Sixty nine percent 
of these mothers had at least two tetanus toxoid vaccinations. More importantly, all seven 
of the mothers who were pregnant at the time of the final survey had their cards and had 
at least one vaccination. While this number is small, this is a better indicator, since many 
mothers discard their maternal health cards when their children reach one year old. 
The child immunization rate at the end of the project was satisfactory; however, it is 
difficult to give a fully accurate assessment of this intervention because of two intervening 
factors. One factor is that the distance most mothers must walk to get to the health center 
represents a major barrier to following the prescribed schedute. It is very common that a 
child will be slightly behind schedule on vaccinations because families try to time visits to 
the health post with other activities they may need to conduct outside of their community. 
The second factor is the politics surrounding immunization rates. The project staff were 
not able to report the low immunization rate from the baseline KPC because the provincial 
health authorities stated that according to their records the rate was 90%. 
Thus while the vaccination rate of 76% may be modest in comparison to other CS projects, 
it is likely that the increase from the baseline was substantial. One indicator of the 
improvement is that the percent of mothers with a child vaccination card rose from 42% at 
baseline to 85% at the final KPC survey. 
F) INNOVATIVE APPROACHES 
One innovative approach was the project's use of drawings to communicate health 
messages. Initially health teaching was in lecture format and communicated by the 
project's field staff. After the mid-term evaluation the field staff created drawings of the 
health messages on cloth flip charts and taught the health promoters how to use them. 
These were a big attraction, as almost no graphics existed .in the communities except for 
consumer items. The flip chart on cloth instead of paper made them easy to carry and 
were more durable than paper. This gave the promoters a great incentive for doing home 
visit and community health talks. In many communities the promoters were invited to give 
talks as part of community meetings. During the field evaluation, promoters were asked to 
give a demonstration and in every case they communicated the health messages 
accurately and in an engaging manner. 
Another innovation for this province was the construction of maternal waiting houses 
(Casas de Espera). These are Quechua-style houses built next to the local health center 
where mothers and their family can stay during the last two weeks of the pregnancy. This 
is a concept that is well suited for an area like this where more than half of the villages are 
more than a six hour walk from a health center and there are almost no roads. At the time 
of the final field evaluation the majority of health centers either had a maternal waiting 
house or one was being planned. A critical feature of these centers is that the community 
constructs them with support from the health center, on land donated by the municipality. 
Shared ownership will contribute significantly to the sustainability of this innovation. 
One of the main goals of the project was to help communities organize emergency 
evacuation plans in cases of a medical emergency. A creative technique for stimulating 
community organization was that the project sponsored a stretcher making competition 
with the Health Promoter Committee at each of the health centers. The committees took 
the challenge seriously and the competitions had a festive air. As a result most of the 
villages now have defined their evacuation procedures and have stretchers. 
3. Results: Cross-cutting amroaches 
A) COMMUNITY MOBILIZATION 
One of the obstacles inherent in this project is the rural, isolated location of the target 
communities, among the most challenging places to access in Peru. Despite this difficulty, 
the field staff did a commendable job in maintaining a regular pattern of visiting most 
villages on a monthly basis, For the villages requiring more than a 10-hour walk, a goal 
was set that these would be visited at least six times a year. 
Due to regular contact with each community, and monthly contact with each health 
promoter, the project has been able to assist in the formation and training of local health 
communities in all 130 villages. The primary task of the committees has been to recognize 
the importance of community organization to react immediately to live-threatening 
emergencies, particularly for during births and the post-partum period. The field staff 
made substantial progress in this area since the mid-term evaluation, when there were 
only three health committees. 
Another achievement in community mobilization has been in involving community leaders 
in the supporting community-level health promotion activities. During the final field 
survey, the evaluation team interviewed 17 community leaders. The key findings are as 
follows. 
1. They see themselves as active participants and have a high sense of ownership of the 
promoter-based health system, in contrast to regarding MINSA as having control. 
Eighty eight percent of the community leaders stated that either they alone, or in 
conjunction with MINSA, participate in the naming of new promoters. This is a major 
change from the beqinninq of the project. 
2. They have a high regard for the work of the health promoters, giving them a rating of 
2.2 on a 3-point scale (1 being low quality of work, and 3 high). 
3. They give strong support for distribution of enriched oatmeal for mothers with children 
under two years of age and for health talks. The promoters who identified these as the 
areas in which community leaders provided the greatest support independently 
confirmed this. 
Bl COMMUNICATION FOR BEHAVIOR CHANGE 
Project activities in this area involved extensive baseline qualitative assessments in 
maternal health, nutrition, diarrheal disease and respiratory illness. This information 
served as the base for the development of an information, education and communication 
plan including: 
A training plan for health promoters in the four primary intervention topics 
Sociodramas (skits) performed by health promoters, project staff, and MINSA health 
personnel 
Radio spots and dramas broadcast by radio (which only reached a percentage of 
communities) and taped as part of community health education campaigns 
A health promoters work manual, using culturally appropriate images and health 
practices 
A pictorially-based community reference system for health promoters and traditional 
birth attendants, for reference and counter-reference from the health post. 
A culturally-appropriate greenhouse manual and training program. 
A community notification system, with pictorially-based birth and death registry. 
One of the most important changes in the project from the mid-term the shift from project 
staff conducting the majority of community health education to training the health 
promoters to communicate health messages. Once given the responsibility to deliver 
health messages, the promoters were able to reach many more people and do so more 
frequently. The results are evident in the high percentage of mothers who know the basics 
of diarrhea and pneumonia control, family planning methods and growth monitoring. 
As mentioned in the section on innovative approaches, the use of drawings on cloth flip 
charts was a communication tool that was very well received. 
If Esperanca has the opportunity to continue working in this province, this evaluator 
recommends that they integrate literacy training with the communication of health 
messages. This strategy was made popular by Paulo Freire and has been used extensively 
in other parts of Latin America. 
Esperanca should also increase their use of stories, drama and parables to communicate 
health messages, instead of a dry recitation of facts. Along with these techniques they 
should write discussion guides so that the listeners have the opportunity to discuss and 
analyze the health messages for themselves. Developing critical thinking skills will make 
an important contribution to development in this region. 
CI CAPACITY BUILDING APPROACH 
i. Strenuthenina PVO 
Esperanca intended to work in partnership with CADEP, a local NGO. They did not have a 
prior working relationship, and it showed as over the four years of this project the two 
organizations have struggled to define their roles, with only a little success. Three factors 
played a predominant role in this struggle. One was the fact that CADEP is primarily an 
15 
agricultural agency, with little experience in health care or child survival. Esperanca 
underestimated CADEP1s learning curve, and CADEP assumed that they knew more about 
maternal-child health than they did. A second factor was the revolving leadership in CADEP 
until 2000. With an average of one director for each year of the project, it was almost 
impossible to implement a consistent relationship. A third factor was that the CS project 
was implemented in an area where CADEP was not originally working. Without a presence 
in the area it was impossible to work together. 
Despite the factors that limited the strengthening of CADEP, a positive relationship has 
developed between the two organizations. CADEP has conducted an extensive evaluation 
of its institutional capacity, and now has a health division, with short and long-term goals. 
A very encouraging postscript is that as this CS project was finishing, CADEP had received 
a grant to implement literacy training in Cotabambas Province. Esperan~a and CADEP 
finally had a true opportunity to work together and were doing so. Esperanqa field staff 
were working hard to help CADEP get started. If Esperan~a is able to obtain continuation 
funding, they could have a strong working relationship in the future. 
Also, it is important to note that despite the difTiculties, CADEP has consistently provided 
valuable logistical and administrative support to the project. Staff of both organizations 
have been open with each other in discussing issues, which has set the stage for a 
partnership that will continue as Esperanqa implements activities with funding received 
from the USAID mission in Lima and seeks ways to continue working in Cotabambas. 
ii. Sfrenathenina Local Partners 
The local partner in this project was the Ministry of Health (MINSA) at the regional, health 
network and local level. The project staff had an excellent working relationship at the 
regional level (Direccidn Regional de Salud de Apurimac-DIRESA), primarily due to the 
strong support of the regional director. On the other hand, the relationship with the health 
network level staff was an on-going struggle, impacted by frequent personnel changes at 
this level. Following are the important findings from the field survey. Sixteen MINSA staff 
were interviewed and completed a questionnaire. 
1. MINSA staff stated that the project increased their coverage in all four major 
interventions. Table 6, following presents data from the survey, 
Table 6: Percent of MINSA staff who stated that the project has improved 
coverage of Child Survival interventions 
Intervention 
Diarrhea Control 
Umer Res~iratorv Infections 
2. A major change is MINSA's enthusiastic support for the community-based patient 
referral system managed by health promoters. 100% of the respondents supported 
Result 
94% 
94% 
Growth Monitoring 
Prenatal Care 
Obstetrical Emergencies 
75% 
63% 
56% 
* 
referrals from the promoters and they rated the prompters work in making referrals 
as 2.6 on a 3-point scale. In turn the promoters also stated that the referral system 
was a primary area of improvement. At the mid-term MINSA did not have a high 
regard for the promoters and did not give much significance to their referrals. After 
the mid-term the project staff created a perforated, three-part form for referral and 
counter referrals that became a standard tool. 
3. Health personnel at individual health posts do not see themselves as having the 
financial or logistical resources to provide incentives for the promoters'contribution. 
Their support for the health promoters is superficial in this respect as they rate the 
value of the promoters highly (87% rated their work either good or excellent), but 
they are not willing to provide much tangible support. When asked what incentives 
MINSA could provide after USAID funding ended, the only two meaningful 
contributions were training (25% of the respondents) and free medical care (19% of 
the respondents). 
4. MINSA however, benefits financially from the promoters referrals by billing the 
maternal-child social security system, but they are not willing to share the 
reimbursement with the promoters. It will not be long before the promoters catch 
on, and demand that they be compensated. If this is not resolved, the prornoter￾based community health system will crash. 
5. There is a contrast between the high value that MINSA places on the promoters and 
the low level of support that the promoters say they receive from MINSA. Sixty one 
percent of the promoters stated that they receive no support from MINSA. Those 
who did say they receive support were evenly divided between receiving training and 
supplies. 
6. The project staff made a major effort to work alongside their MINSA counterparts. 
They had offices in the health centers and when they were not making community 
visits, they worked out of the health center. Whenever possible Esperansa 
scheduled joint visits to communities with the counterpart at the local health center. 
Additionally, Esperansa provided funding so that MINSA staff could receive CS 
training. 
iii. Strenutheninu Health Facilities 
This was not an area in which this CS project intended to provide major assistance. 
Esperanca, however, did provide educational materials, support for obstetrical emergency 
evaluation transportation, infrastructure for Maternal Waiting houses, and occasional 
medicines and medical supplies. With its own funds, Esperanca donated an ultrasound 
machine to the provincial health office, 
iv. Strenuthenha Health Worker PerFormance 
After the mid-term Esperanca made a substantial contribution to the health promoters' 
performance. As stated eariier in this report, after the mid-term evaluation the project 
staff changed direction and began working through the promoters instead of working 
directly with mothers. Much of the motherst gains in knowledge and practice came after 
this change in strategy. The following list of findings provide evidence of the quality of 
their work and their acceptance in the community. 
1. The promoters say they are primarily involved in health talks, home visits and 
making referrals, which is supported by observations from the community leaders 
and mothers. The consistency in the comments which were made independently by 
the mothers and community leaders provides a solid indication that the promoters 
indeed assumed the educational role of the project staff. 
2. Promoters ' level of knowledge in the areas of pneumonia case management, 
diarrhea control, perinatal care and nutrition is very high. The following table 
presents the promoters ' responses to open-end answers about health issues and 
danger signs for the health of women and children. They had to site all relevant 
factors in order to obtain a correct response. 
Table 7: Promoters knowledge base. 
Topic 
Percent who reported all signs 
correctly 
Signs of pneumonia 
Signs of diarrhea 
Identify three food groups 
(with examples) 
3. The promoters state that one of the most significant resources that they have been 
given are the small boxes of non-prescription medicines called "community 
pharmacies." This tangible resource gives them very high credibility in the 
community, while attracting patients to share health complaints with the promoter 
for possible referral to the health post. 
4. Promoters also value their educational materials. There is a good balance between 
their regard for their role in health promotion and medical care. When asked during 
the KPC what additional materials they require, health promoters requested health 
materials on new topics be provided for community education. This is an important 
recommendation for allowing health promoters to refresh their materials, and 
expand community knowledge of new health issues. 
5. In the last year of the project there was a less than 10% turnover in promoters. 
This is an indication of the value that the promoters place on their role, and of the 
support that they receive from the community. This makes it all the more important 
that the ministry of health place a high priority on finding ways to support them. 
89% 
89% 
89% 
Postpartum danger signs 
The following table contains the sustainability plan from the detailed implementation plan 
(DIP) with the end-of-project status. The status of the objectives listed below is very 
positive; however, MINSA's institutional capability to follow through is weak. Despite the 
progress that has been made in mothers' knowledge and practice, and in the community￾level health system, the sustainability of this project is dependant on the new 
government's commitment to supporting community health. 
94% 
Elements of the project which have been institutionalized in the project zone: 
1. Role of health promoters as a crucial link between MINSA health services and the 
community (health education, referral of patients, management of emergencies) 
2. Monthly training of health promoters in topics related to maternal and child health 
3. Formation of local health committees in each community (although the role of these 
committies, and training agenda need to be formalized) 
4. Health Promoter Committees are active in each health post, under a signed 
document outlining the roles and responsibilities of promoters and health personnel 
5. Community-based patient referral and counter-referral system has been 
institutionalized as part of MINSA standard procedure 
6. Community-based birth and death registry provides health data which in the past 
has been unrecorded by the Peruvian government. 
with skills to improve the health of 
their children 
107 communities with skills to 
improve the health of their families 
and access health services 
effectively implement MOH 
programs and coordinate with their 
respective health units 
13 health units with staff better 
able to provide quality services and 
manage the community health 
system 
The MOH of the department of 
Apurimac with a well-managed 
health system in its most difficult 
province 
The partner organization CADEP 
with a vision for health, 
programming and the capacity to 
carry out that vision 
C. Program Management 
End of Project Status 
73% of mothers know the sign of 
pneumonia 
64% of mothers know the signs of 
diarrhea 
100% of pregnant mothers had 
documented prenatal visits 
100% of the 130 communities have a 
health committee. 
4 100% have a plan for emergency 
evacuations for a medical crisis. 
At least one promoter in all 130 villages. 
Refer to Table 7, above, for a report on 
their base knowledge. 
Less than 10% turnover in the last year of 
the project. 
A high level of acceptance by mothers, 
community leaders, and MINSA. 
A functionha referral svstem with MINSA. 
Staff from all 14 health centers have 
received training CS training. 
A functioning referral system with the 
health promoters. 
Recognition by MINSA staff that the 
project has improved their coverage in CS 
interventions. 
A very low commitment on the part of 
MINSA to support the community health 
program once USAID funding is ended. 
r Constantly changing leadership in CADEP 
has been a major limitation. 
CADEP has conducted an extensive 
evaluation of its institutional capacity, and 
now has a health division, with short and 
long-term goals. 
1. Planninq 
Throughout the project, the project director faithfully held monthly technical meetings with 
the entire staff to review the previous months activities, review objectives and make 
activity plans the coming month. Both of the project directors conducted these sessions in 
a participatory style, and the staff made substantial contributions. 
The staff coordinated all activities on a monthly basis with the MINSA staff, but the 
response from individual health centers was sometimes sporadic and inconsistent. 
Regardless of what is stated in the Ministry of Health policies and procedures, in this 
remote area formal systems are not going to be studiously applied. What it comes down to 
is the quality of the individual and their commitment to community health-unfortunately 
this is a commitment that no external agent can successfully impose. 
With rotating responsibility, the project staff and MINSA convened a monthly training 
meeting with the health promoters pertaining to each health center. The project took 
primary responsibility for the training agenda every other month, and the health center 
staff assumed the coordination every other month. After the mid-term there was good 
attenda,nce and these meeting gave the promoters a change to participate in program 
planning and in setting priorities. They considered these meetings an important part of 
their work and felt validated by them. 
2. Staff Traininq 
MINSA did the initial training in CS interventions and the project staff participated with 
their health center counterparts. Esperan~a did a good job in providing continuing 
education for project staff in relevant areas of staff interest. They took advantage of 
training events sponsored by other NGOs in Peru, and when needed, the project sponsored 
its own training. The effect of the training was evident in the staff's high level of CS skills. 
Usually training is more effective the closer it is to the area in which it is to be 
implemented. In this situation, however, the staff had to go outside of their region 
because it was so difficult to reach the project area. Additionally, the staff benefited by 
seeing other CS projects. 
3. Supervision af Procrram Staff 
The organizational structure of the project worked well, particularly considering the 
distances and lack of reliable communication in the project zone (mostly radio 
communication was used). 
During the start-up phase of the project and establishment of the field office in Haquira, 
the project director resided almost exclusively in the project zone. Later, the project 
director was based out of the local counterpart organization in Cusco, spending roughly a 
week each month in the project zone, with additional time spent in Abancay at the regional 
health directorate. The Esperansa team regularly explored other options, but the need to 
coordinate with the Ministry of Health, other NGOs and the Esperanga home office kept an 
office in Cusco with the local counterpart. 
This arrangement worked well and the field staff were well supervised. The two important 
reasons for this were, one, good training, and two, on-the-job supervision. There was one 
traveling field supervisor for seven staff. The supervisor worked alongside each field staff 
at least once a month and did the liaison work with the local health authorities. Esperansa 
quickly did away with performance check lists because these could not account for all the 
variability in the field and because of the competency and dedication of the field staff. It is 
important to note that they were Quechua-Spanish speaking bilingual, which is essential in 
this area, especially working with women. 
The field staff merit special commendation for sticking with the work and for their 
commitment to the Quechua people. They worked in the field for 18 consecutive days at a 
time, renting a room as their base in one of the communities. From this base they would 
make two to four-day walking trips to visit their communities, sleeping on the floor of a 
promoter's home in their sleeping bags. Nighttime temperatures were almost always 
below zero year around, and torrential rains and landslides make access to the 
communities extremely difficult during three-four months of the year. Most days they 
would have a four to six hour walk in the mountains to reach the next village, They 
worked under the most difficult conditions seen by this evaluator, and they did not quit. 
4. Human Resources and Staff Manauement 
Please refer to the previous section for comments on this section. 
5, Financial Manauement 
Both of the project directors kept good control of finances, consistently staying close to 
budget. No major problems occurred. 
6. Loaistics 
Logistics were difficult because the drive from Cusco to the field office took ten hours to 
cover 80 kilometers. The drive was more like a boat trip in rough seas than riding on a 
road. There were frequent problems in getting supplies to the area, especially when 
Esperan~a tried to coordinate logistics with CADEP. The difficulties related to the problems 
between the organizations that have been mentioned earlier, which were differing missions 
and geographic locations, While logistics were challenging, none of the problems were a 
significant hindrance to the project's activities. 
7. Information Manauement 
The health information system (HIS) functioned satisfactorily. Field staff kept good records 
of their perFormance and progress and their reports were studiously used in the monthly 
planning meetings. After the mid-term, the team conducted local rapid assessments to 
monitor the status of measurable indicators in diarrhea and pneumonia control. This 
helped them greatly in assess their performance in the field. 
The team communicated the finding of their HIS with the local health centers, but these 
were not always well-received. Sometimes health center directors would be threatened by 
the information and sometimes it would contradict the data that they reported to the 
Ministry of Health. Efforts at coordinating health information systems depended on the 
strength of character and goodwill of health center staff. This is something that the project 
staff could not control. 
The project team could have done a better job of sharing health information with the 
community. While there were barriers of literacy and lack of supplies, the health 
promoters could have been used more effectively to set outcome goals in their 
communities and monitor progress. They did keep records but the information was used 
more for project reporting than for giving feedback to the community. 
8. Technical Assistance and Administrative Su~~ort 
Esperan~a did a good job in providing technical assistance for its staff. When a need arose, 
the organization responded promptly. The field staff stated that they could not have asked 
for more responsiveness. 
Administrative support was difficult because of the geographic and logistic circumstances. 
The project directors did not use this as an excuse, however, and were dedicated to 
supporting the field staff. This was one of the reasons for the low staff turnover, and 
helped to compensate for their difficult working conditions. 
9. Manaaement lessons learned from the ~ersaective of the Es~eranca aroiect 
staff 
Coordination with community leaders should have been done from the beginning. 
I. The project staff decided to complete training in all of the interventions before engaging 
in community organizing. In retrospect they believe that they should have started 
organizing right after promoters received training in the first intervention. Training and 
community organizing need to be implemented concurrently. The limitation is that 
implementation of all of the interventions will be delayed. There is a trade off between 
doing Child Survival interventions and community organizing, however, the project staff 
believe that it would have been more effective if these are done in concert, rather than 
sequentially. 
2. Community organizing. The DIP should have anticipated the need for training local 
leaders in community organizing and included a budget item to hire contractors who are 
skilled in this area. While the staff have made good progress in this area, they feel that 
more could have been done. 
3. MENSA staff should be invited to contribute to community organizing activities. It is 
possible that they would have been more supportive because of doing so. 
4. More emphasis should have been given to organizing women's groups and training them 
in their rights. The level of spouse abuse and degradation of women has been much 
higher than anticipated. 
Use of Health Information System and project data 
5. The health information system should have had a stronger focus on monitoring changes 
in knowledge and behavior rather than document activities. Tracking knowledge and 
behavior would have also provided opportunities for research during the life of the 
project. 
6. The field staff and the promoters would have gotten off to a faster start if they had had 
a manual with procedures and instruments from the beginning. 
7. A map and census of each community should be done at the beginning. This would be 
a good activity for giving health committees a concrete activity, thus giving a solid 
impetus to community organization. 
8. The data from the census should be used to assign the field staffs territory so that 
there is not an imbalance numbers of communities and population. 
Activities and Training 
9. Health promoters had difTiculty establishing their credibility for the first two years. The 
project should have provided them with teaching materials and a community pharmacy 
at the beginning. 
1O.Family gardens should have been one of the planned interventions in the DIP. This is 
another example of a tangible activity that can spark interest in health promotion. 
(Although this activity was not in the DIP, the project has successfully implemented 
greenhouses, training activities, and educational materials on their management) 
11. A package of incentives for health promoters should be established from the beginning. 
The project staff did not do this until the mid-term and consequently lost a lot of 
momentum because of high promoter turnover early in the project. 
12. Training field staff and health promoters in adult education techniques should be 
integrated with training in the planned interventions. At the end of the project the only 
technique that the promoters have is flip charts. Very soon people will become bored 
with this technique and promoters will not have alternatives. 
13. The next time Esperan~a should consider hiring at least some of the field staff with 
specialized skills in areas such as nutrition, community organizing, adult education, etc. 
D. Other Issues 
As mentioned earlier in this report, the lack of support from MINSA has the potential to 
erode much of what has been accomplished by the Esperan~a project unless the existing 
project (now USAID mission-funded) makes a strong commitment to the sustainability of 
the project activities. Cotabambas is one of the most isolated and dif'Ficult places to live, 
thus it is understandable that the Ministry of Health will face significant challenges in 
serving the health needs of the province. On the other hand, the difficult conditions only 
outline the extent of need quality health workers and services. Even though it is out of the 
purview of this evaluator, it seems obvious that the Ministry of Health should offer 
adequate incentives for health care workers who serve in the most difficult conditions. 
E. Conclusions and Recommendations 
1. It is possible for change in knowledge and behavior to occur in traditional, illiterate 
societies in a relatively short time. 
2. Substantial progress has been made since the mid-term. In large part it is because 
the Esperanza staff has emphasized the training and supervision of local health 
promoters instead of working directly with mothers. 
3. The consistent perception among mothers and community leaders of the promoters' 
role gives evidence of the quality of their work. 
Priority Recommendations 
I. The level of support from MINSA is superficial and is not likely to be sustained unless 
there is strong leadership from the new DIRESA Director. The project must devote 
itself to strengthening the systems which would guarantee continuation of project 
activities, such as health promoter training) in the project zone. 
2. The relatively low percent of mothers who give the same or more solids during 
episodes of diarrhea indicates a need for continued education in this area. MINSA 
staff and the promoters should continue to help mothers understand the importance 
of solids in managing diarrhea. 
3. If Esperanp has the opportunity to continue working in this province, this evaluator 
recommends that they integrate literacy training with the communication of health 
messages. This strategy was made popular by Paulo Freire and has been used 
extensively in other parts of Latin America. 
4. Esperanqa should increase the use of stories, drama and parables to communicate 
health messages, instead of a dry recitation of facts. Along with these techniques 
they should write discussion guides so that the listeners have the opportunity to 
discuss and analyze the health messages for themselves. Developing critical 
thinking skills will make an important contribution to development in this region. 
5. MINSA benefits financially from the promoters' referrals by billing the maternal-child 
social security system, but they are not willing to share the reimbursement with the 
promoters. It will not be long before the promoters catch on, and demand that they 
be compensated. If this is not resolved, the promoter-based community health 
system will crash. Esperanqa should advocate for incentive policy for health 
promoters. 
- 6. More emphasis should be given to organizing women's groups and training them in 
their rights. The level of spouse abuse and degradation of women has been much 
higher than anticipated. 
Results Hiuhliuhts 
Child Health 
Child mortality rates have decreased significantly, especially in the key intervention areas 
of respiratory infections and diarrheal disease. The infant mortality rate in 1996 for the 
province was 118 per 1,000 births. For 2000, the rate is calculated as 72.5 per 1,000 
births in Apurimac. 
It is noteworthy that two interventions attained both a substantial change from the 
baseline and had a high level of adoption at the end of the project. 
These were: 1) giving solids to children six months or older, and 2) knowledge of the sign 
for pneumonia. 
Regarding the first intervention, it should be noted that while there had been a tradition of 
giving teas and infusions to infants, most mothers (60% according to the baseline) 
introduced solids late during the child's development. 
The extent of change in nutrition for young children and early treatment for signs of 
pneumonia should make a significant difference in the morbidity and mortality of children 
in this province. Mothers can identify and react to the primary danger signs of pneumonia. 
Data from the final survey found that 73% could state the sign of rapid breathing at rest. 
Almost all mothers answered this question immediately with no hesitation. 
Health Promoters 
The health promoters are active and are recognized for their labors. Mothers who were 
interviewed during the field survey for this report gave them a rating of 2.4 on a 3-point 
scale for quality of their work. Additionally, the community substantiates the promoters' 
perception of their role. When asked about the most important things that the Promoters 
do, mothers and community leaders all identified the same top three activities of the 
promoters: home visits, health talks, making referrals to the health center. The 
promoters are truly active in their communities. 
Mothers ' Awareness 
Mothers have a strong awareness of change over the last four years. Of same group of 
mothers, 70 of them identified maternal-child health insurance and 51 identified better 
maternal-child health as the most important change. A factor that gives added significance 
to the above findings is that at least 65% of the women in the province cannot read. Their 
knowledge based has increased substantially despite this limitation. 
Appendix 1: Methods Used 
Qualitative portion of final survev: 
The evaluation team of 10 divided into pairs and visited 24 communities spread out evenly 
among the four health districts. The evaluation team interviewed 189 mothers in 24 
communities using an interview format designed by the team with the evaluator. 
Sixteen MINSA staff were interviewed by the team from 10 health centers. They were 
given a questionnaire to fill out instead of being interviewed so that the interviewer would 
not influence their answers. 
The team interviewed 17 community leaders and 18 promoters using one on one 
interviews. This evaluator likes to use more interactive techniques but in this case it was 
not possible to bring groups of mothers and promoters together. 
Quantitative portion (KPC): 
For the quantitative portion of the final survey, the project used a version of the KPC 
2000-k survey, modified for applicability as comparison with the baseline survey. The 
survey was translated into Quechua, and also reverse-translated to improve the accuracy 
of the translation. 
The sample size was 312 mothers of children under the age of two, randomly selected by 
clusters (56 communities, in this case). The project contracted an all-female team of ten 
outside interviewers who had participated in a three-week duration course on interviewer 
training with another institution. The project trained the group for use of the Esperansa 
project questionnaire, and the detailed questionnaire guide. 
All surveys were conducted as verbal interviews of the mothers in Quechua, in the 
vocabulary that the project, the community and the Ministry of Health use to describe 
maternal and child health issues. A field trip was conducted to validate the questions in a 
Quechua-speaking community, and revisions were made after the validation. The survey 
guide was detailed so that the interviewers knew how not to prompt the mothers' 
responses, and exactly what language to use. The project staff were interviewer 
supervisors (each assigned outside of their own project territory), and they traveled with 
the independent interviewers to orient them in the remote communities, and to observe 
and correct their styles. None of the project staff filled out any part of the questionnaires in 
order to retain impartiality of the responses. 
Appendix 2: Evaluation Team 
Richard Crespo, Ph.D. - team leader 
Kali Erickson, MS, MPH -project director 
Arturo Palomino, nurse-midwife 
Daniel Mendoza, nurse 
Mancy Aragh, nurse 
Apolinar Coyla, nurse 
Juvenal Bautista, nurse 
Zaida Quispe, nurse 
Salorne Ccasani, nurse 
Health Personnel from throughout the Tambobamba Health Network, Cotabambas 
Interview team (independently contracted): 
Gloria Arredondo 
Raguel Zegarra 
Maria Elena Acurio 
Justina Nljfiez 
Rozana Auca 
Luz Marina Huaman 
Ana Guzmh 
Ahyluz Tupayachi 
Leoncio Tupayachi