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Project Assistance Completion Report –PACR￾Better Health for Rural Women and Children 
Cooperative Agreement No. 520-A-00-97-00060-00
I. PROJECT SUMMARY
Date of Authorization: September 5, 1997
Project Assistance Completion Date: November 4, 2001
Implementing Agency: Project Concern International –PCI￾Total Amount Authorized: US$ 4,829, 855
Total Amount Obligated & Expended: US$ 4,829,362
Counterpart Contribution: US$ 2,842,450
 
II. PROJECT DESCRIPTION
In September 1997, USAID/G-CAP signed a Cooperative Agreement with
Project Concern International –PCI- to develop the “Better Health for Rural 
Women and Children” project. The purpose of the agreement was to
provide assistance to PCI to join USAID’s other partners in achieving the
SO, “Better Health for Women and Children”. 
The PCI Agreement was amended on various occasions, five of these (No. 
1, 2, 4, 9 and 10) to provide incremental funding. Amendment No.5
changed the requirements for financial reports and corrected the base for
cost sharing percentage. Amendment No.6 followed the Mid-term 
Evaluation and included a) a decrease to the total estimated cost by 
$1,511,023; b) budget modification; c) amendment for the Key Personnel
Section; d) amendment to the Indirect Cost Section; e) amendment to the
Program Description; f) updated the Standard Provisions, and g)
incorporated Annex A, entitled “Program Approach and Proposed
Activities”, Annex B, entitled “Management Plan”, Annex C entitled
“USAID/Guatemala-CAP Strategic Objective “Better Health for Rural
Women and Children”, and Annex D, entitled “Performance Monitoring
Plan” into the agreement. Amendments 7, 8 and 11 changed the period
for submission of SF-272 financial reports, deleted a key position (Regional 
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Operation Manager solicited by PCI) and replaced the Required as
Applicable Standard Provision No.6 entitled “Voluntary Population
Planning” with CIB-01-08. The last amendment extended the completion
date of the Agreement to November 4, 2001 without increasing the TEC. 
III. DESCRIPTION OF PCI COOPERATIVE AGREEMENT 
The purpose of this agreement was to support the Mission’s Strategic Objective 
(SO) in health, “Better Health for Women and Children.” The specific objectives 
of this agreement were:
1. To develop and promote integrated approaches to improving women 
and children’s health, especially in the departments of San Marcos, 
Quetzaltenango, Totonicapán, Sololá, Chimaltenango and the 
municipalities of Ixcán, Quiché, Barillas and Huehuetenango.
2. To enhance the empowerment of women and communities and to
more fully engage them in health-related decision-making.
3. To create/sustain partnerships among public and private sector
entities with the aim of increasing the coverage and quality of health
services in underserved areas.
4. To increase the programmatic, financial and social sustainability of
local health programs.
As a key partner in activities to support the SO, PCI agreed to extend 
services in maternal health, child survival, reproductive health and family 
planning, as well as community and household prevention activities in the 
geographic areas noted above. The main implementation vehicle for this work 
was the recruitment and assistance to non-governmental organizations (NGOs) 
that would, in turn, provide these basic health services at the community level. 
This strategy was similar to that adopted by Guatemala’s Ministery of Health for 
their rural outreach program, the Integrated System for Health Care (Sistema 
Integral de Atención en Salud –SIAS-) and was designed to complement this 
work. A client/Mayan focus, gender perspective and community problem solving 
approaches were specified as central to achieving the results desired under the 
SO.
PCI success in carrying out this program was to be measured by 
progress on results, benchmarks and indicators spelled out in the SO Results 
Framework. The Intermediate and Lower Level Results specified in the 
Agreement were:
Intermediate Result 1 (IR1):More Rural Families Use Quality Maternal and Child 
Health Services.
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LLR1.1. More Households in priority areas adopt better health care 
practices.
LLR1.2. More community agents provide quality care.
LLR1.3. More health facilities provide quality services.
Intermediate Result 2 (IR2): Maternal Child Health Programs are Better 
Managed
LLR2.1. Supplies and equipment are continuously available.
LLR2.2. Improved financial and administrative systems to support 
decision-making.
LLR3.3. Communities actively participate in decision-making.
LLR2.4. Program planning, monitoring and evaluation are based on 
quality data.
Intermediate Result 3 (IR3): Greater Local Advocacy for Improved Access to 
Health Care, Especially for Women
LLR3.1. Local level entities facilitate advocacy activities.
LLR3.2. Documentation and dissemination of lessons learned at the 
local level.
LLR3.3. Linkages/partnerships formed with national level advocacy 
activities. 
The initiation of PCI project activities in Guatemala began in late 
September 1997, but PCI was unable to provide the originally proposed Project 
Director. This was followed by a long delay in identification of another 
acceptable candidate, who finally took up the position in early 1998, after 
Spanish instruction. The difficult project start-up, the difficulty in developing 
reasonable workplans for the first two years, the lack of overall progress toward 
accomplishments within the Mission’s Results Framework and serious issues 
with PCI management of the in-country program and its coordination with other 
key partners particularly SIAS, were the reasons USAID/G-CAP decided to 
document PCI’s performance through an mid-term external evaluation. 
In July of 1999, however, PCI/San Diego changed leadership. After an 
exchange of decidedly frank letters with USAID/G-CAP about the project’s 
deficiencies, members of the organization’s senior management traveled to 
Guatemala for discussions about these problems. During this visit, the PCI/G 
Country Director resigned. Dr. Roberto Aldana, a Guatemalan physician who 
had recently joined the project to direct its clinical activities, was appointed as 
Interim Director. At the same time, a series of positive meetings were held with 
PCI/San Diego and PCI/G staff, the Mission and the Coordinator of the 
MSPAS’s SIAS Program. Finally, in August 1999, PCI/San Diego confirmed 
Dr. Aldana, who had prior experience as Director of a USAID/Washington 
project in Guatemala, and strong support in the Mission, as the new PCI/G 
Project Director. 
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The results of the midterm evaluation of Project Concern International confirmed 
the poor performance that the Technical Office of USAID had observed. The 
principal findings were the following: 
ÿ The project has not achieved significant progress towards any of the 
Intermediate Results (IRs) and the Lower Level Results (LLRs) specified in 
the agreement. 
ÿ The project has made minor efforts to increase access to clinical services, 
but without major impact. Furthermore there is no indication to suggest that 
the quality of services has improved. 
ÿ The reasons for the lack of progress towards results were complex. PCI had 
several operational and management problems during their first two years, 
which had a strong, negative impact on their ability to obtain results. Other 
factors that contributed were: a) PCI assumed that the successful, long-term 
relationship which it had with Rxiin T'namet, -its Mayan NGO partner￾constituted a model which was replicable with other Mayan organizations; b) 
the restricted profile that PCI defined in the selection of NGO's resulted in the 
signing of agreements with organizations with little capacity to execute a 
project of service expansion. 
The evaluation’s recommendations included several options or combination of 
options that PCI could use to establish priorities and to restructure the project, 
with the objective of achieving results inside the time frame and budget 
remaining. 
PCI presented to USAID its restructured plan of the project, which included a 
different profile for the selection of NGO's partners, assumed direct responsibility 
for training and technical assistance to the NGO's, incorporated partners that 
had a relationship with SIAS, included a new monitoring and evaluation plan and 
reduced the population coverage goal to 250,000. 
After the analysis of the results of the evaluation and the time and budget 
remaining, the Health SO Team took the following steps: 
1. As the new proposal contained more realistic and appropriate activities, the 
SO requested of the RCO that the agreement be amended by mutual 
consent to reflect the modifications to the Agreement’s Program Description 
proposed by PCI and concurred by the SO Team (Amendment No. 6). 
2. Did not request obligation of additional funds to the agreement but preserved 
the original cost sharing percentage of total program costs, thus reducing the 
USAID total contribution to $4,829,362 and the estimated PCI contribution to 
$2,901,624.
3. Did not request an extension for this activity beyond its termination date of 
September 4, 2001. (The Cooperative Agreement was later extended to 
November 4, 2001, to allow time for completion of final reports.) 
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4. PCI proposed, and SO concurred, to concentrate the actions of the project 
on Intermediate Results 1 and 2, while transforming IR3 from local level 
advocacy to local community participation in support of IR1 and IR2.
5. Approved the Monitoring and Evaluation Plan with revised indicators and 
targets and carefully monitored their achievement. 
IV. CA’s RESULTS
The strategy designed for the last two years of the project consisted of several 
key actions. Inside PCI there was restructuring of key personnel and regional
personnel, development of an effective information system, an improved
Monitoring and Evaluation Plan, and better assistance from PCI headquarters. 
In addition, PCI strengthened of the promotion and delivery of services from its 
NGO partners, modified the selection criteria for working with new NGO’s,
provided intense training and technical assistance on continuous improvement
of quality services, established the “botiquineros” network, increased services
diversification (included a Maternal Care House in Huehuetenango), and sought 
a better coordination between PCI and USAID-G/CAP Health partners. 
The population coverage met 89% of the goal; PCI provided coverage to
222,872 inhabitants through 10 NGO’s in 379 communities in six departments. 
Most of the NGO’s achieved an acceptable level of development and institutional 
strength, and at least a minimum of financial sustainability. Also, 16 clinical
centers, and 109 community centers were established in remote areas, with
1,165 medical and voluntary personnel, including 739 trained midwifes.
The level of development that the personnel of PCI’s NGO partners achieved in 
technical areas is important. They received training and upgrading of human
resources (competency-based), materials and equipment, and were under a
supervision process that focused on training and education. 
Additionally, they implemented an innovative strategy that permitted an increase 
in service coverage for the basic care package. Included in this strategy was the 
systematic supply and availability of modern family planning methods in rural
community medicine chests (Botiquines), community centers and health clinics;
health fairs that promoted and offered integrated health care services for women 
and children; “health sweeps” that intensified family home visits using a guide for 
systematic supply, and health campaigns focusing on Pap-smears and family
planning. 
Finally, the achievement of the M&E Plan indicators is as follows: 56% of the
indicators were met or surpassed and 44% were not met.
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V. Financial Report and Audits 
Financial monitoring of the Cooperative Agreement consisted of a review of the 
quarterly Financial Status Reports (Form 269) submitted by PCI, as well as
projected accrued expenditures, to assure that obligated funds did not exceed
forward funding guidance. Under the Cooperative Agreement, PCI was subject 
to the audit requirements found in OMB Circular A-133.
Peer the final financial status report submitted by PCI, the amount of matching
funds contributed was 37.05% of the total program amount versus a requirement 
of 37.53%.
VI. End Use Checks
The Project Officer in charge periodically performed end use checks.