Wawa Sana
Mobilizing Communities and Health Services 
for Community-Based IMCI:
Testing Innovative Approaches for Rural Bolivia
Cooperative Agreement No.: FAO-A-00-00-00010-00
September 30, 2000 – September 29, 2004
In Partnership with APROSAR and the
Ministry of Health Districts of Challapata, Eucaliptus, & Huanuni
Report of the Bolivia CS-16
Midterm Evaluation
Prepared by
Renee Charleston, Consultant
Submitted to USAID/GH/HIDN
October 31, 2002
Table of Contents
A. Summary 1
B. Progress Made Toward Achievement of Objectives 3
1. Technical Approach 3
2. Cross-cutting approaches 16
a. Community Mobilization 16
b. Communication for Behavior Change 18
c. Capacity Building Approach 19
d. Sustainability Strategy 26
C. Program Management 28
1. Planning 28
2. Staff Training 29
3. Supervision of Program Staff 29
4. Human Resources and Staff Management 29
5. Financial Management 29
6. Logistics 30
7. Information Management 30
8. Technical and Administrative Support 31
D. Conclusions and Recommendations 34
E. Results Highlight 38
F. Action Plan 39
ANNEXES
A. Baseline Information from the DIP
B. Team members and their titles
C. Assessment methodology
D. List of persons interviewed and contacted
E. Results of the Evaluation
F. Recommended changes to project indicators
Lograr que las comunidades sean actores de sus propias 
actividades a través de una capacitación adecuada.
The Wawa Sana project assists communities to become the 
principal actors in their own lives, through adequate training.
Vision of the Evaluation Team
Midterm Evaluation
Wawa Sana Project, Oruro, Bolivia 
September 2002
ACRONYMS AND ABBREVIATIONS
APROSAR Association of Rural Health 
Promoters (Asociación de 
Promotores de Salud del Area 
Rural)
ARI Acute Respiratory Infection
BASICS Basic Support for 
Institutionalizing Child Survival 
(USAID Project)
BCC Behavior Change 
Communication
CAI Committee for Analysis of 
Information or TAI
CB-IMCI Community-Based 
Integrated Management of 
Childhood Illnesses
CDD Control of Diarrheal Disease
CORE Child Survival Collaborative 
and Resource Group
CS Child Survival
CSSP Child Survival Support Project, 
Johns Hopkins University
CSTS Child Survival Technical 
Support Project, Macro 
International
DCM Diarrheal Case Management
DIP Detailed Implementation Plan
DJC Desarrollo Juvenil Comunitario
(Save the Children/Bolivia) 
EPI Expanded Program of 
Immunizations
HQ Headquarters 
H/PD Hearth Model of Positive 
Deviance
HPN Health, Population, and Nutrition 
sector of Save the Children/US
IEC Information, Education, 
Communication
JHU Johns Hopkins University
IMCI Integrated Management of 
Childhood Illness
IR Intermediate Result
KPC Knowledge, Practices and 
Coverage Survey
MOH Ministry of Health
MTE Mid Term Evaluation
NGO Non-Governmental Organization
OH Office of Health at SC/US
ORS Oral Rehydration Solution
PAHOPan American Health 
Organization
PCM Pneumonia Case Management
PCS4 Population Communications 
Services 4 Project Johns 
Hopkins University
PLG Program Learning Group of 
Save the Children’s HPN sector
PROCOSI PVO/NGO Network in 
Bolivia (Programa de 
Coordinación en Salud Integral 
PVO USAID Registered, Private 
Voluntary Organization
RHD Rural Health District
SECI Integrated Community 
Epidemiology Surveillance 
System(Sistéma Epidemiológico 
Comunitario Integral)
SEDES Ministry of Health 
departmental level in Oruro 
SC/B Save the Children in Bolivia
SC/HQ Save the Children/US 
Headquarters
SNIS National MOH Information 
System (Sistema Nacional de 
Información en Salud)
TA Technical Assistance
USAID United States Agency for 
International Development
Wawa Sana “Healthy Child.” Sana is 
Spanish for “healthy.” Wawa is 
Aymara and Quechua for 
“child.”
WHO World Health Organization
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A. Summary
The Bolivia Child Survival-16 Project, called Wawa Sana, is funded from September 
30, 2000 through September 29, 2004 through a $1 million “New Program” grant from 
USAID/BHR/PVC, and a $1 million match from Save the Children. The project is 
located in three Ministry of Health Rural Health Districts in the Department of Oruro, 
Bolivia. The project is being implemented jointly with APROSAR (Association of 
Rural Health Promoters) and the three MOH Rural Health Districts.
The project will benefit an estimated 13,500 children under five. The project 
interventions include: nutrition and micronutrients, pneumonia case management, 
control of diarrheal disease, and immunization. The main strategies of the project 
are: Community Based Integrated Management of Childhood Illnesses (CB-IMCI), 
the Hearth Model using a Positive Deviance approach (H/PD), and the Community 
Epidemiology Surveillance System (SECI). CS-16 Goals include: a sustained 
improvement in nutrition status of children in Hearth/PD communities; a sustained 
reduction in under-five mortality in the three health districts; and innovative 
approaches inform policy and improve programming in Bolivia. 
To assess the process and progress made in CS-16, a midterm evaluation was 
carried out in September 2002. The MTE revealed the Wawa Sana project showed 
good potential for meeting all project objectives.
Approximately 167 Promoters have been trained in CB-IMCI by the project. Data 
from SECI showed 1,052 children had been treated for respiratory infections during 
the first 6 months of 2002. This represents a 43% increase from those treated in all 
of 2001. Data for Huanuni revealed, during the first six months of 2002, five times as 
many children with diarrhea were treated by Promoters or health facilities than in 
2001. 
The SECI strategy, which promotes the joint collection, analysis, and use of health 
information/data by MOH staff and communities to address local health problems, 
has been very effective. Motivated by the discussion of data on their own illnesses 
and health care utilization, communities have increased health care utilization, taken 
communal action such as construction of a health post, and demanded information 
on health topics. Often health service providers respond immediately, even during 
the very same meeting.
H/PD has been implemented in 13 communities. The strategy continues to be 
adapted to meet local needs. The documentation of this process will be used to 
inform future projects.
SC/B feels that “sustaining important innovative approaches on a larger scale 
through “uptake” by other organizations may be more meaningful than a concept of 
sustainability which focuses mainly on the project site.” (DIP 2000) Of the three 
strategies, IMCI is already a national program and shows good potential for 
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sustainability due to support by the government, donors, and other NGOs. SECI has 
the potential to be scaled up to a national level strategy and there is a lot of interest 
in replicating the strategy in other areas. H/PD will probably never have the same 
potential for sustainability due to the intensive investment in time. But the strategy 
has enormous potential for being expanded with outside funding from other NGOs.
There are two basic flaws in the original design of this project which form two 
important lessons learned: (1) Implementation of CB-IMCI is premature until clinical 
IMCI is well established; and (2) Creating a demand for services in health facilities, 
without a parallel effort to improve the quality of services at those facilities, provides 
an incomplete package of services.
Areas Needing Further Improvement:
1. Formation of a Wawa Sana team which includes SC/B, APROSAR and MOH: 
there is too much of a focus within the project of “belonging” to SC/B
2. Development of a monitoring and supervision system for all aspects of the project. 
3. The lack of an adequate instrument for measuring institution capacity, and the 
subsequent lack of an agreed upon plan with the major partner, APROSAR, has 
lessened the potential impact of this project in the vital area of institutional 
strengthening.
Key Recommendations:
1. Modify the objective of H/PD from a curative focus of recuperating malnourished 
children to one of changing household level practices to prevent malnutrition.
2. A documentation plan should be developed for all three strategies now so 
appropriate information can be collected during the next two years.
3. Develop a concrete plan to improve the retention of Promoters. A mechanism 
should be developed to strengthen sector and area CAIs. This could greatly 
increase understanding of health issues and local decision making ability. 
4. A one-day annual conference to present project advances and the next year’s 
plan would help to keep all stakeholders informed.
5. SC/B staff needs technical assistance in tools available for assessing institutional 
capacity and the development and monitoring of capacity building plans for 
partners.
6. M&E plan should be simplified and re-translated so that project indicators and 
means of verification can be easily identified by Wawa Sana team and other 
stakeholders.
7. An annual plan for the next two years needs to be made by the Wawa Sana team; 
a combined planning process will improve project ownership for partners and 
develop the tools necessary for monitoring project indicators. This plan should 
include the expansion of the three strategies into new communities within the 
three RHD.
8. Direct field supervision of SC/B project staff needs to be improved, and 
supervision tools developed for tracking improvement and problem solving.
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B. Progress Made Toward Achievement of Objectives
1. Technical Approach
a. Overview of the project 
This four-year Child Survival Project is based on two contributions which Save the 
Children Bolivia (SC/B) feels it can make towards improving child survival in Bolivia 
which are: (1) documenting the feasibility of replications by other organizations and 
results of implementing innovative approaches to improving community capacity to 
identify and effectively address priority child health needs, which have excellent 
potential for “uptake” by other organizations and improving child survival 
programming in other areas of Bolivia, and; (2) partnering with the MOH and NGOs 
at the district-level to improve their capacity to support community activities and to 
implement innovative culturally acceptable approaches to child survival. (DIP 2001)
The Bolivia Child Survival (CS)-16 Project called Wawa Sana is funded from 
September 30, 2000 through September 29, 2004 through a $1 million “New 
Program” grant from USAID/BHR/PVC, and a $1 million match from Save the 
Children.
The project is located in three Ministry of Health (MOH) Rural Health Districts (RHD) 
in the Department of Oruro, Bolivia: Challapata, Eucaliptus, and Huanuni. The project 
is being implemented jointly with APROSAR (Association of Rural Health Promoters 
Asociación de Promotores de Salud del Area Rural) and the three RHDs.
The project will benefit an estimated 13,500 children under five. The project 
interventions and their corresponding level of effort include: Nutrition and 
Micronutrients (30%), Pneumonia Case Management (30%), Control of Diarrheal 
Disease (20%), and Immunization (20%).
Main strategies of the Wawa Sana Project: 
Community Based Integrated Management of Childhood Illnesses (CB-IMCI)
Focuses on training and supporting Promoters to provide CS services for children in 
an integrated manner in their communities, and supporting the concurrent MOH 
implementation of clinical IMCI.
Hearth Model using a Positive Deviance approach (H/PD)
To rehabilitate malnourished children at the community level and have a sustainable 
influence on preventing malnutrition by identifying positive practices of mothers of 
well nourished children utilizing local resources and sharing these with mothers of 
malnourished children in communal education/cooking sessions.
Community Epidemiology Surveillance System (SECI)
Promotes the joint collection, analysis and use of health information by MOH staff 
and communities to address local health problems.
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H/PD and SECI were both pilot tested in the Eucaliptus District during a previous 
USAID mission funded CS Project. The Wawa Sana project represents a scaling up 
of these two strategies and the introduction of the national level MOH program of CB￾IMCI. 
Main components: Training, Coordination, Transportation, Information, Education and 
Communication (IEC), Access to Basic Supplies, and Referral.
Geographical changes since the DIP include moving from the Huari area to the
Qaqachaca area in March 2002. The project found that due to the disperse 
population of communities, low population density, and lack of interest by 
communities in Huari, their work was not productive. Some activities are still carried 
out in the zone, but major project effort has shifted to Qaqachaca. This area was 
mentioned in the DIP as being unstable due to internal conflict. Peace has been 
restored in the area and this was one of the areas visited during the Mid -Term 
(MTE).
In the DIP the focus was on working in communities with a minimum population of 
120 people. It was found that there were not enough communities that fit this criterion 
and the project is now working with a minimum of 80 people. (See Attachment F for 
suggested modifications to project indicators)
This document presents the results of a participatory midterm evaluation (MTE) 
which was held September 2-13, 2002. The evaluation team included representatives 
from SC/B, APROSAR, MOH, BASICS and an external consultant, principal author of
this document. See Attachments B, C, & D for more information on the evaluation 
methodology. Specific recommendations are underlined throughout the document 
and summarized in the final section. A summary of the MTE team results is included 
in Attachment E, including detailed conclusions and recommendations.
b. Progress report by intervention area
1. Nutrition and Micronutrients 
The nutrition intervention was implemented in accordance with MOH and 
international standards and essentially as outlined in the DIP. Indicators for this 
intervention include:
1. 85% of 12-23 month olds with cards received 1/more vitamin A capsules in last 
year. (Baseline 64%)
2. 30% decrease in 6-35 month olds in Hearth/PD communities below -2Z weight-for￾age (pre-/post-).
3. 30% decrease in 6-35 month olds in Hearth/ PD communities below -3Z weight￾for-age (pre-/post-)
4. 50% of the nutrition status impact on % of all 6-35 month olds below -2Z WFA is 
sustained 1 year after the end of Hearth sessions 
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5. 50% of the nutrition status impact on % of all 6-35 month olds below -3Z WFA is 
sustained one year after the end of Hearth sessions 
Suggested changes to these indicators are included in Attachment F. The most 
important change to these indicators is a modification in the objective of the H/PD 
strategy from a curative focus of recuperating malnourished children to one of 
changing household level practices to prevent malnutrition. This is discussed further 
in Section B.1.c.3 New Approaches-H/PD. It is also recommended that indicators 3 
and 5 be omitted due to the low prevalence of severe malnutrition (0.5-1%), any 
resulting changes in the indicator would not be significant.
The principal activities for this intervention are:
Training for SC/B, APROSAR, and MOH staff, and Promoters
Coordination with Municipal and local authorities, MOH and other NGOs
Access to services via transportation and to supplies i.e. Vitamin A
Community education for improved knowledge and practices
Integration with the IMCI framework
Training:
SC/B has been able to access technical support from LINKAGES through their 
involvement in PROCOSI as part of a national effort to improve breastfeeding and 
complementary feeding practices. SC/B and LINKAGES have a signed agreement 
outlining technical assistance. A 2-day LINKAGE’s training was received by 12 SC/B 
and three APROSAR staff. This training, on breastfeeding, introduction of foods, 
negotiation skills, and home visits, was replicated in a series of 3-day training 
courses for 98 Promoters, 11 MOH staff, and 8 people from other NGOs. Training 
has been provided, but the process lacks follow-up to insure quality implementation. 
An excellent quality manual and educational materials have been supplied to 
Promoters on all the training topics. 
A course on anthropometric measurement, with an accompanying manual was given 
by La Paz SC/B staff to 15 SC/B Wawa Sana staff. SC/B and partner staff also 
received training on nutritive value of foods, IMCI, and the H/PD strategy. 
Approximately 48 Promoters and 50 representatives from other NGOs have been 
trained in H/PD. The three SC/B District Coordinators received extensive training with 
Jerry Sternin (15 days) on positive deviance inquiry. 
Supply of Vitamin A:
Results from the baseline KPC showed 64% of children with cards had received 1 or 
more doses of Vitamin A as verified by vaccine card. Staff reports that this is 
probably an underestimation as many times Vitamin A is given and not recorded on 
the card. The supply of vitamin A has apparently been unstable. MOH data 
presented during the MTE, using their information system SNIS, showed Vitamin A 
supplementation has declined by 65% during the last three years (comparing 1999 to 
2001). There seems to be a lack of clarity as to who should pay for the supplies. The 
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MTE data shows that 13% (2/16) of Promoters had capsules as did 88% (7/8) of 
auxiliary nurses and 100% of area doctors (7/7). Also 100% of auxiliary nurses and 
doctors visited during the MTE had ferrous sulfate pills and syrup. The role of the 
Promoter in distributing vitamin A and Iron is not clearly defined. Municipal funds are 
available in some areas to purchase vitamin A. This issue requires further 
investigation by the project to eliminate the bottleneck of vitamin A supply. 
Use of the term “malnutrition” by project staff, without defining what is meant is very 
confusing. Project staff uses the term 1st, 2nd, and 3rd degree malnutrition, meaning 
usually weight/age of greater than -1SD, -2 SD, -3 SD. Project indicator and the VEN 
system of the MOH classify moderate malnutrition as >-2SD and severe malnutrition 
is considered >-3 SD (or z scores). Sometimes malnutrition is defined as Ht/Age, 
without distinguishing from Wt/Age.
Community Education:
During interviews with Promoters and community groups all groups mentioned at 
least some of the signs of malnutrition. There is general agreement about the 
importance of weighing children to see if they are malnourished.
In talking with women during the MTE it seems a misconception has arisen as to the 
relative value of adding vitamins to the diet (through increased vegetables and fruits) 
and adding calories (through calorie dense foods such as oil and sugar). Teaching 
women to resolve problems of malnutrition by adding vegetables to the diet of a child 
will only lead to frustration for the mother and lack of impact for the project. More of 
an emphasis needs to be given to increasing caloric density through the addition of 
oil to common foods.
A more detailed discussion on the progress in this area can be found in section
B.1.c.3 New Approaches-H/PD.
2. Pneumonia Case Management 
The PCM (Pneumonia Case Management) intervention was implemented in 
accordance with MOH and international standards and essentially as outlined in the 
DIP. The indicators for this intervention include:
1. 90% of APROSAR Promoters have adequate supply of cotrimoxazole 
2. 23% annual increase in total <5 pneumonia cases treated by CS-16 facilities & 
Promoters.
3. 80% of CS-16 ARI-trained Promoters pass pneumonia knowledge & skills test
4. 80% of caretakers of children recently treated by CS-16 facilities/ Promoters report 
correct dose & course of cotrimoxazole for pneumonia.
5. 75% of mothers of children under 2 years report that help should be sought if their 
child has “fast and agitated breathing.” (KPC Baseline17%)
6. 50% of mothers of children under 2 years report that help should be sought if their 
child’s “thorax is sunken” (chest indrawing) (KPC Baseline 2%)
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Suggested changes to these indicators are included in Attachment F. The most 
important change being recommended is due to the ambiguity of current MOH policy 
on use of cotrimoxazole by Promoters. It is recommended that this indicator be used 
to measure access to basic IMCI supplies by measuring Promoters with Oral 
Rehydration Solution (ORS). Additionally, the percent of change for the indicators for 
mother’s knowledge of danger signs is very high and the project should consider 
lowering them.
Data from SECI showed 737 children treated with respiratory infections during 2001 
and 1,052 during the first 6 months of 2002. This represents a 43% increase. With 
the suggested modifications to indicators, there is good reason to believe that the 
project will be able to reach all objectives for PCM.
The principal activities for this intervention are:
Training for SC/B, APROSAR, and MOH staff, and Promoters
Coordination with Municipal and local authorities, MOH and other NGOs
Access to services via transportation and to supplies i.e. Cotrimoxazole
Community education for improved knowledge and practices
Integration with the IMCI framework
Four of the 18 Promoters interviewed during the MTE had Cotrimoxazole, as did 
100% of the auxiliary nurses and area doctors. Further discussion of IMCI can be 
found in section B.1.c.1 New Approaches-CB-IMCI.
3. Control of Diarrheal Disease (20%) 
The CDD (Control of Diarrheal Disease) intervention was implemented in accordance 
with MOH and international standards and essentially as outlined in the DIP. 
Indicators for this intervention include:
1. 75% of mothers of 6-23 month olds with DD in last 2 weeks report feeding 
increased fluids during DD. (24%)
2. 80% of CS-16 CDD-trained Promoters pass CDD knowledge & skills test 
3. 80% of caretakers recently counseled on DD by CS-16 facilities/ Promoters report 
following three DD home care rules 
Suggested changes to these indicators are included in Attachment F. The most 
important change being recommended is to omit the indicator for measuring 
caretaker’s practices due to the difficulty of conducting exit interviews on patients of 
Promoters and at most health centers. The percent of change for the indicator for 
mother’s practice in increasing fluids is very high and the project should consider 
lowering it. With the suggested modifications to indicators, there is good reason to 
believe that the project will be able to reach all objectives for CDD.
The principal activities for this intervention are:
Training for SC/B, APROSAR, and MOH staff, and Promoters
Coordination with Municipal and local authorities, MOH and other NGOs
8
Access to services via transportation and to supplies i.e. ORS
Community education for improved knowledge and practices
Integration with the IMCI framework
Training:
All IMCI trained promoters (about 167 according to the IMCI section) have had a 
session on diarrhea, which takes about 4 hours.
Access to ORS:
Of great concern is the lack of availability of ORS via Promoters. During the MTE, 
only 1 of 16 Promoters (6%) interviewed had ORS. All of the auxiliary nurses and 
area doctors had a supply of ORS. This points out a serious access issue, if one of 
the simplest, least expensive, and best documented CS activities is not being 
implemented. The solution to this problem should be a top priority of Wawa Sana.
 
SECI showed an increase from 12 cases of children with diarrhea being treated by 
Promoters or health facilities in 2001 to 69 cases during the first six months of 2002 
in Huanuni.
Community education:
In interviews with community members and Promoters, during the MTE, there 
appears to be a good level of knowledge of danger signs of diarrhea (two or more 
signs of dehydration; sunken eyes, pliegue, agitated/ crying, thirsty, diarrhea for more 
than 14 days, and blood in the stool), with the exception of duration of chronic 
diarrhea. 
4. Immunization (20%)
The Immunization intervention was implemented in accordance with MOH and 
international standards and essentially as outlined in the DIP. Indicators for this 
intervention include:
1. 80% or more DPT3 coverage of infants in all CS-16 municipalities (KPC 32%)
2. 60% of 12-23 month olds have maternal history or card for measles immunization. 
(KPC 27%)
Suggested changes to these indicators are included in Attachment F. The most 
important change being recommended is to follow standardized CS indicators for 
immunizations, including measuring immunizations in children 12-23 months and the 
use of a vaccination card for verification. (Only 48% of children in the KPC had a 
card.) It may be difficult to reach the levels set in these indicators unless a serious 
effort is made to ensure all children have vaccination/growth card. It is understood 
that the DPT3 indicator is meant to coincide with the MOH indicator, but information 
could be collected in both formats-one for the MOH and a standardized CS indicator 
as measurement of progress in the Wawa Sana project.
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Main activities include:
* Use of SC/B vehicle for transportation of MOH staff to isolated communities to 
provide immunization and other health services
* Creation of demand for services through education, follow-up of child 
immunization status and community health meetings using SECI
* Integration within the IMCI framework
It was found during the MTE that 100% of health centers and post visited had basic 
supplies for immunization activities; vaccines, thermoses, syringes, etc
Details regarding SECI activities and progress can be found in section B.1.c.2 New 
Approaches-SECI.
Each of the three districts has been provided with a vehicle, a driver and fuel. They 
average approximately 18 community visits with "multiprogramatic activities" per 
month. The visiting team includes a nurse from the District provides vaccinations and 
does growth monitoring, a doctor to treat sick children and adults, a nurse from SCB 
to do group education or SECI and sometimes the District dentist. 
c. New Approaches
The Wawa Sana project is using three innovative approaches for the implementation 
of CS activities. These three strategies form the main structure of the project within 
which the CS interventions are implemented. The three strategies are:
Community Based IMCI (CB-IMCI)
Community Epidemiology Surveillance System (SECI)
Hearth/Positive Deviance (H/PD)
SC/B recently received funding for a USAID Food For Peace Title II development 
project in the Department of La Paz. CB-IMCI, SECI, and Hearth/PD will be a focus 
of the Title II project’s health component, and experience gained through 
implementation of CB-IMCI, SECI, and H/PD in Wawa Sana will be used by SC/B to 
inform implementation and improve performance in the Title II site.
SC/B has shown good use of lessons learned from previous experiences, including 
the use of the Warmi methodology for decision making developed by SC/B 1990 to 
1993. SC/B provided TA to MOH and other agencies on the WARMI methodology 
expanding it to national level. CS-16 is a scaling up of activities from a 
PROCOSI/USAID funded CS project in the RHD of Eucaliptus. 
1. CB-IMCI
Planning for the implementation of clinical IMCI by the MOH in Oruro was started in 
1999, with a training team being formed and functioning in 2000. The implementation 
of IMCI was slower than expected and much work still remains to be done, 
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particularly in monitoring and supervision. The MOH training team was instrumental 
in training SC/B staff but a number of the MOH staff has never been trained. SC/B 
facilitated training of MOH staff in both clinical and CB-IMCI.
Based on a study conducted nation wide (UNAP/PAHO/BASICS, 2002) it was found 
that 70% of the appropriate MOH health staff had been trained in clinical IMCI 
(189/270) in the department of Oruro, with a 61% implementation rate. The study 
also found in Challapata 87% of the personnel had been trained with 50% applying 
IMCI and in Eucaliptus 70% of staff was trained but only 29% were implementing the 
strategy. One of the main problems noted was the lack of follow-up after training. A 
majority of RHDs visited during the study (including Challapata and Eucaliptus) had 
not had any monitoring visits. This was confirmed during the MTE during interviews 
with doctors and auxiliary nurses, the majority had not received monitoring visits for 
clinical IMCI. 
One of the important lessons learned from this project is that clinical IMCI needs to 
be functioning well first before CB-IMCI can be introduced. The introduction of CB￾IMCI was perhaps premature, until IMCI was being adequately used on a clinical 
basis. 
SC/B coordinates with PROCOSI and BASICS as a member of an IMCI working 
group, along with UNICEF, PAHO and other NGOs. With funding from CORE Group 
they have been able to continue coordinating with the MOH for the quality 
implementation of IMCI including field testing and improving instruments. SC/B and 
Plan International are the only two PROCOSI members who are members of this 
working group, due to their field experience in implementing CB-IMCI.
The MOH has materials for CB-IMCI, which have been adapted with the help of 
BASICS. This includes a manual for training Health Promoters and a Procedure 
Manual (which 16 of the 18 Promoters interviewed during the MTE had) and 
registration sheets (which 17 of the 18 Promoters interviewed had), for use in 
evaluating children under 5. Seventeen of the18 Promoters also had an IMCI flipchart 
for use in educating families. BASICS has also developed checklists, interview and 
focus group guides for monitoring CB-IMCI. One of these checklists was used during 
the MTE for monitoring IMCI home visits by Promoters. It was noted during the MTE 
that some of the materials are hard for the Promoters to use. New materials are 
being developed and piloted by BASICS. 
CB-IMCI can improve coordination with health facilities, improve relationships with 
communities, and provide Promoters with a valuable tool for viewing child health from 
a more holistic point of view. The problems in implementing the strategy include:
ß High turnover in MOH staff and Promoters
ß Materials are expensive and still being tested
ß Some Promoters (and MOH staff) feel it takes too much time
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ß The MOH official IMCI course is very short which limits the amount of supervised 
practice that students receive
ß The role of the Promoter in IMCI is somewhat different than the role of APROSAR 
Promoters who have used rotating drug funds for years. Official policy is for 
Promoters to refer patients to health facilities for most problems and usually are 
not supplied with ORS or parecetamol. This was evident during the MTE when it 
was found that only 1 out of 16 (6%) of Promoters has ORS and 5 out of 17 (29%) 
had parecetamol, two essential supplies for IMCI. On the other hand APROSAR 
Promoters are better supplied and manage cotrimoxazole and other drugs, which 
provides them with a small income. It is contradictory to tell them that now they 
cannot treat illnesses which they have been treating for years. 
ß Promoters lack essential equipment such as scales and chronometers
Notwithstanding these barriers, IMCI is the official child health strategy in Bolivia. 
Approximately 167 Promoters have been trained in CB-IMCI by the project. The 
implementation of clinical IMCI needs time to be absorbed by MOH staff and a 
continued effort is needed to strengthen the link between MOH staff and the 
Promoters. An exchange visit for Wawa Sana staff is planned to visit IMCI projects in 
Tarija and Chuquisaca. SC/B will continue efforts via the IMCI working group to 
advocate for policy changes that will enhance the implementation of CB-IMCI.
2. SECI
Of the three new approaches, SECI is definitely seen as the most successful. The 
system is very effective in rapidly returning information to the communities in a 
manner that helps them to use the information to analyze the health of the community 
and take positive actions to improve health. At first some health staff felt it was 
stirring up a hornet’s nest, trying to revolutionize rural communities, but as people 
have become more knowledgeable about the strategy, there is a greater level of 
acceptance. The strategy also supports the Bolivian government’s Popular 
Participation reform. SECI gives communities a more proactive role in their own 
development.
One of the motivations for health personnel to work with SECI is because it improves 
their coverage by increasing demand for services such as immunizations and 
prenatal care. A number of anecdotal examples were given of the success of SECI 
community action plans; for example to build a health post, give vaccines in a 
community which before had rejected all immunizations on religious grounds, 
coordinate with municipal authorities, etc. 
One issue is that many people see that knowledge of the situation is enough (and 
this is definitely a step in the right direction) but more of a focus on actions is needed. 
A newsletter twice a year on what decisions communities are making with the 
information might stimulate ideas. Many times communities simply do not know what 
to do. This is a first experience for many of them of making decisions based on health 
data and they need to be helped to see possible actions. This can be a very 
12
empowering experience for communities, but sometimes they need help in visualizing 
potential activities.
The SECI strategy appears to be having a very positive impact in rural communities 
where a great deal of autonomy in decision-making exists. The strategy has been 
less successful however in urban areas. Many of the urban groups meet, not based 
on geographical area but on mutual interests. This means that the political decision￾making ability of the group is greatly limited. SC/B has developed several alternative 
approaches to working with urban populations:
o In Caracollo working with 20 students of the adult learning center 
“Cetha” and intermediate level students
o University medical students in Oruro 
o Military personnel in Challapata 
These three pilot projects use the same concepts of dividing the urban area into 
manageable sectors, using volunteers to collect information on health conditions, 
then applying a feedback mechanism to the general population, occasionally via 
television. SC/B will need to continue trying new approaches to SECI in urban 
environments and documenting these experiences.
There are a total of 575 communities in the project area, those defined as eligible for 
implementation for SECI are shown below. There was an effort made to combine 
several small communities into one for purposes of data collection, but in general this 
was unsuccessful. Active communities are defined as presenting consolidated 
information monthly. Some communities only collect data bi-monthly. 
Huanuni Challapata Eucaliptus Total
Comm > 80 54 38 64 156 
Comm w/ SECI 24 21 42 90
Defined as Active 2 6 30 38
Some suggestions and observations made during the MTE to improve SECI are:
ß SECI has a good focus on ensuring anonymity and confidentiality in the 
collection of health information
ß Take the cloth flipchart apart into it’s 3 components and display them on a wall 
at the same time. When you flip over from one to the other and cover the 
information on preceding pages, the relationship gets lost. There would be 
greater understanding if people could see how one page of information relates 
to the next.
ß Look for ways to compare month to month, or community to community, as the 
information is not put into a comparative context.
ß In one of the action plan observed during the MTE, the steps were very vague-
“vaccinate children” and the responsible person was the “nurse”. These 
actions need to be broken down into “How?” steps-the first step would be to 
take the child to the health center and the responsible party would be the 
parents. Another step might be to have the child’s vaccination card. Health 
13
staff needs to be seen as a resource or support. The parents/community are 
responsible for making sure everyone is vaccinated not the health staff. 
Another example was; a cause of malnutrition was listed as lack of vitamins, 
the solution was to get vitamins from health personnel, while no mention was 
made of giving foods that contain vitamins.
ß In the action plans developed by the communities, there appears to be little 
follow-up on whether any of the actions are taken. Some action plans seen 
during the MTE were many months old, with no follow-up on whether the 
activities were completed 
ß The words and numbers on the bandera are too small to read in a group
ß The spaces on the forms are too small, people with limited literacy skills tend 
to write larger than people with more advanced skills
ß The consolidation form should indicate what information the Promoter will 
provide and what information comes from the MOH, to avoid confusion
ß The SECI manual for volunteers is very complex and needs to be simplified to 
make it easier for the Promoter to understand
ß The form for reporting community planning was modified by APROSAR-so that 
it includes a copy of the Action Plan developed by the community. This change 
might make it easier to monitor the completion of planned activities.
The computer system that was developed to complement the community collection of 
data is very easy to use and flexible in terms of modifying which indicators are 
monitored. The software includes a short video on how the integrated system works 
and a tutorial for learning the software.
The SECI specialist has provided training to the statisticians and other staff in the 
three RHDs and makes approximately three follow-up visits to each RHD per year. In 
three municipalities the SECI software has also been installed and they are using 
information from the SECI system in writing their annual development plans. The 
municipalities have also named someone to be in charge of the SECI system. 
A number of other organizations have expresses interest in the SECI strategy and 
some have received the software and training from SC/B, including PLAN 
International in Tarija, Project Concern International in Cochabamba, and Nur 
University in Cocabamba. Training in SECI has also been held for SC/B CS staff, 
APROSAR, and a computer specialist for the newly funded SC/B/USAID Title II 
project, which will also be using the SECI strategy. 
SECI information is presented in the MOH analysis meetings (CAI) by SC/B, not yet 
by MOH staff which is an objective of the project, A monitoring plan is needed for 
SECI to ensure the quality of the data being used.
APROSAR wants to add some additional indicators in the SECI system, such as 
pneumonia, other risk signs during pregnancy, etc. If technical assistance is required, 
SC/B should provide guidance to APROSAR on modifying the software. It should be 
14
kept in mind that the beauty of SECI is its simplicity, tracking too many indicators 
would make the system burdensome.
3. H/PD
The positive deviance model is a step in the right direction to focus more on who is 
doing things right rather than identifying only those people with problems. It can be 
very empowering as communities discover their own solutions and it has been shown 
to maintain improved levels of nutrition even after the program ended because the 
changes are based on solutions which were developed locally. H/PD is a good way to 
mobilize the community, provide leadership opportunities to women, encourage the 
use of local foods and resources, and aid in the self-discovery of beneficial practices.
H/PD is currently in 2 communities in Challapata, 5 in Eucaliptus and 6 in Huanuni for 
a total of 13. In the first Annual Report the project proposed working in 30% of the 
communities with a population over 120, approximately 35 communities. It is doubtful 
that that many communities could be successfully implemented.
In the pilot project during the previous USAID mission funded CS there was a greater 
level of energy expended in H/PD but now that more communities are using the 
strategy, the amount of time spent on each one is less. H/PD requires intensive work 
to implement and monitor.
Some of the issues that are currently impeding implementation are:
ß Can be frustrating if it doesn’t work; a number of examples were given when even 
after following all of the steps, the child did not improve (this is partially attributed 
to the long distances some children travel to participate in the communal kitchen), 
ß Does not take into consideration the work load of women nor the agricultural 
cycle, participation in the program takes not only a lot of staff time, but mother’s 
time as well
ß H/PD is based on practices, resources, needs of every individual community, the 
strategy needs to be specific to each community so it is hard to use on larger 
scale 
ß Population density is very important; it does not appear to work in small or 
disperse communities and may be more successful in urban areas
ß Some of the areas where H/PD is now being implemented are mining and urban 
areas, where people do not produce their own food, so it is more difficult for them 
to contribute to a communal kitchen
ß Men do not like the women using their household food to share with others 
ß The strategy of providing one additional meal is not working, the meal prepared in 
the group merely replaces the family lunch 
ß Mothers who can’t bring food simply don’t come, eliminating the poorest families
ß Leaders become unmotivated because the women do not attend. 
ß The social stigma of being identified as a “negative” family is obvious. A change in 
terminology is needed to identify “model mothers” without subsequently saying 
15
that the other mothers are “bad”. The same applies to classifying families as rich 
and poor. This causes friction among community members.
ß The project has not really been able to identify key practices which differ between 
positive and negative deviants
The original structure of H/PD was for 10-20 children under five and their caretakers 
to attend a communal kitchen 14 days per month for 8 months, 2-3 hours per day, to 
prepare food together, in addition to normal meals, which contains 600-800 calories 
and 25-27 grams protein. Each woman contributes part of the food based on a pre￾determined schedule. This has not worked for most communities for reasons 
previously listed.
Some alternatives have been tried, with mixed success:
ß Intersperse months to better adapt to agricultural and work calendar
ß Meet for 3-4 days with a break of 2 days, then repeat
ß Three time a week for 5 weeks
ß Meeting on weekends only
ß Instead of having all (10-15) mothers cook each time-rotate responsibilities 
with 3-4 mothers cooking and the rest only bring their children to eat
The Wawa Sana Project should modify the objective of the H/PD strategy from 
a curative focus of recuperating malnourished children to one of changing 
household level practices to prevent malnutrition. If the intense period of feeding 
is not included, the rapid recuperation of children will not function. Don’t give up the 
idea of recuperating children completely but be honest with mothers-if you come 14 
days in a row you will probably see a quicker change than if you come 14 days 
spread out over 3 months-but give them more flexibility in how the strategy is 
implemented. The basic outline of H/PD should include some minimal criteria: 
identifying model mothers, forming groups to employ improved nutritional practices, 
meeting at least once per week, identifying positive practices, and following up on 
malnourished children. Then let communities make their own decisions on the details 
of how to implement. One of the main goals of the Wawa Sana project is the 
documentation of the implementation experience. A documentation plan 
should be developed for all three strategies now so appropriate information 
can be collected during the next two years.
Other Suggestions for Improvement:
ß Needs better monitoring tools and clearer steps for implementation. 
ß Continued effort is needed to identify what practices differentiate between well 
nourished and malnourished children by looking at family environment, 
morbidity, and frequency of disease 
ß Need Implementation Manual 
ß Recipes need to be improved to be shared with mothers. SC/B recipes only 
have ingredients with no amounts or steps to preparation. APROSAR gives 
out too much info on nutritional content i.e. grams of protein and 
carbohydrates and needs to include steps to prepare the recipe. 
16
ß Need more involvement of men
ß Child feeding centers (PAN) exist in many of the same communities as Wawa 
Sana. Investigate ways the H/PD strategy can integrate activities with the 
PAN centers to improve nutritional status of children. 
ß The H/PD sessions were adding oil reinforced with vitamins A & E that was 
available from the health posts free. This supply is ending, but the message 
should be stated much more strongly that calories are needed to prevent and 
cure malnutrition. 
Increasing the flexibility of the implementation strategy will probably lead to better 
acceptance of H/PD but will probably mean that Wawa Sana will not be able to show 
significant improvement (30% decrease) in nutritional status. The nutrition indicators 
will be hard to reach. The SECI Specialist is currently starting a monthly database on 
nutritional status (name/wt/ht/age/sex) in H/PD communities in EXCEL, which will be 
later transferred to EPI-NUT for analysis. It is recommended that the project 
continue to monitor both weight/age and height/age in order to see if a 
significant impact is seen in either one. The SECI specialist needs technical 
assistance in use of EPI-NUT. 
2. Cross-cutting approaches 
a. Community Mobilization 
The effect of SECI in community mobilization has been very impressive, as was 
discussed previously. There are many anecdotal accounts of communities being able 
to effect change both within the community and through advocacy at other levels to 
improve health conditions. Other community mobilization activities revolve around the 
selection, training and retention of a Promoter in the majority of communities with a 
population over 80 people and in establishing a link between Promoter, community, 
MOH, and municipal authorities.
Promoter
Information from SECI for 2002 shows a total of 242 Promoters, 144 active and 98 
inactive. This represents a 40% desertion rate. This is very high and brings into 
question the sustainability of the Wawa Sana strategies. This issue really needs to be 
further studied. There is a proposed ratio of 25-30 families that each Promoter should 
be responsible for. There are currently 167 SECI promoters and 164 IMCI promoters￾but most times these are the same people. The workload of the Promoter needs to 
be taken into consideration, especially if they are working in two or more labor￾intensive activities such as CB-IMCI and SECI. During the MTE workshop many 
ideas for motivating Promoters were discussed, these ideas need to be 
formalized by the Wawa Sana team and a concrete plan developed to improve 
the retention of Promoters by the project and to clarify what the project will 
accomplish in terms of training new Promoters for expansion into additional 
communities during the next two years.
17
In some area the Promoters have been recognized as part of the MOH health team, 
some receive free medical care, and others, municipal support. Communities are 
reported to be much more supportive of the work the Promoters do now, compared 
with when the Wawa Sana project first started. A number of communities have 
modified the traditional work exchange system, relieving Promoters of community 
work activities due to their volunteer health work and working in the Promoter’s fields 
as compensation for his/her work. These positive first steps need to be supported 
and disseminated so other areas can begin taking concrete steps to support the work 
of these valuable community resources. Wawa Sana should encourage the 
formation of Promoter organizations that will exert a level of internal
control/self-governance and support of the Promoters. The project should also 
foment the exchange of experiences and use of sector CAIs as an opportunity 
for Promoters to share experiences. I
CAI or TAI Meeting
Bolivia has an excellent national system for the analysis of health information called 
CAI (Committee for Analysis of Information) or TAI (Workshop for Analysis of 
Information). The system is designed to function at all levels of data collection; 
community, health post (sector), municipality (area) and district. At the sector, area 
and district levels there are supposed to be regular meetings to look at the 
information collected through the MOH information system (SNIS) and to use it for 
decision making. The system is quite successful in some areas but needs to be 
strengthened in the 3 RHDs where Wawa Sana works. Area meetings are usually 
every 2 months, and District meetings every 3 months (but as infrequent as every 6).
The direct supervisory visits by MOH staff to the Promoters have been limited. A 
direct supervisory system by the MOH after CS funding ends may not be sustainable. 
An excellent opportunity exists for indirect supervision of all Promoters, with a system 
for prioritizing those Promoters who need a direct visit, through the already 
established sector CAI meeting. The CAI at the sector level is a missed opportunity to 
provide sustainable, low cost, continuous support to the Promoters and should be 
strengthened. A guide for conducting CAIs needs to be developed with the MOH so 
that the CAI meeting is a forum for: 
1.consolidating reports and analyzing information, 
2.resupplying the Promoter, i.e. ORS packets, 
3.an exchange of experiences and a problem solving session for Promoters, 
4.monthly refresher training in an area identified by MOH staff or the Promoters 
as a weakness.
A mechanism should be developed to strengthen sector and area CAIs. This 
could greatly increase understanding of health issues and local decision 
making ability. 
18
Formalizing Community/Municipal relations
With the Popular Participation Law of decentralization, funds are available at the 
municipal level for social services and development activities. A set percentage of the 
municipal budget is dedicated to health. This requires constant pressure to make 
sure that what is supposed to be for health is used for health. Fund disbursement is 
behind schedule from municipal authorities in paying the national Basic Insurance. 
Both SC/B and APROSAR have been active in advocacy at the municipal level to 
include funds for health in the annual budget, plus inclusion of money to support the 
Promoters, i.e. funds for travel to training courses, perdiem, purchase of basic 
materials, etc. The project needs to continue with this proactive position in working 
with communities and municipalities to define responsibilities for a sustainable future. 
During MTE interviews there was openness on the part of community leaders 
towards supporting the Promoters through helping with their agricultural work, paying 
for transportation to training course and general support, but this needs to be 
formalized at the municipal and community level to ensure adequate support.
Wawa Sana needs to improve communication with RHDs, Municipalities, and other 
stakeholders about project objectives, activities and advances. A one-day annual 
conference to present project advances and the next year’s plan would help to 
keep all stakeholders informed.
SC/B has been involved in the strengthening of municipal structures through the 
creation of a Mancomunidad in Challapata. This structure includes various 
municipalities, plus NGOs: SC/B, APROSAR and ABRIR Salud who pool resources 
to effect a regional area. The main focus is on increasing services and IEC in health. 
The annual budget is approximately $8,000, half of which has been pledged by the 
mayor of Challapata. The NGOs mainly provide technical assistance. The formation 
of another Mancomunidad is planned in Eucaliptus. This is an excellent example of 
municipal coordination to enhance sustainability. Links with municipalities is the key 
to sustainability for the Promoter. Promoters should be trained in how to develop 
and present small projects for funding.
b. Communication for Behavior Change
The Wawa Sana project is implementing several excellent Behavior Change
Communication (BCC) strategies; Positive Deviance within H/PD and “dialogue of 
knowledge” within SECI. Both of these strategies are effective in helping communities 
to identify their health issues and take positive steps towards improving their own 
health. The CB-IMCI uses a methodology of home visits which incorporates ORPA 
(Observe, Reflect, Personalize, Take Action) and the identification and prioritization 
of problems. 
SC/B and some APROSAR and MOH staff have been trained in negotiation by 
LINKAGES, but the use of this methodology is limited. Some Wawa Sana staff 
received a course on interactive learning which was presented by CEPRA, but the 
19
focus was mainly on the transmission of messages. A second course will be 
presented by CEPRA to assist SC/B in the elaboration of mass media materials, 
mainly for local radio stations.
The project also has an IEC focus, mainly through the use of mass media for the 
transmission of messages. The main IEC activities are:
ß APROSAR has been particularly active in radio, both through regularly 
scheduled health programs and health message “spots” 
ß Weekly radio program with Radio Bahai, which has national coverage, in 
coordination with the Carrocollo hospital 
ß Coordination with the mancomunidad in Challapata for strengthening IEC
ß Use of television in some areas, but this need strengthening as the project still 
lacks materials and expertise.
Wawa Sana staff has little understanding of BCC theory even though they have 
received training in specific BCC methodologies such as Positive Deviance, dialogue 
of knowledge, and negotiation. The term IEC is used interchangeably with BCC, with 
mainly a focus on the transmission of messages. One of the main weaknesses of 
this component is the lack of measurement of the impact BCC and IEC approaches 
are having on changes in knowledge and practices. 
The Wawa Sana team should receive technical assistance in general theory of 
BCC (vs. IEC) and techniques for monitoring changes in knowledge and 
practices. Several of the indicators for the project depend on measuring changes in 
skill level of partner staff, Promoters and community members. See Attachment F for 
more detailed information on the need to develop tools for monitoring indicators.
c. Capacity Building Approach 
(i) Strengthening the PVO Organization 
Save the Children/HQ
SC/HQ completed an Institutional Strengthening Assessment (ISA) in March 2002 
with assistance from CSTS utilizing the following methodology: 
ß Completion of an organizational profile by SC’s CS Team.
ß A self-assessment participation of three members of the Office of Health (OH) CS 
Team, staff from Human Resources, Finance, and International Programs; and 
written input from the OH Manager and Regional Health Advisors.
ß Field input from six field respondents from current USAID-supported CS projects. 
ß Data analysis involved the following methods: 
ß Scores were calculated by capacity area.
ß The range of scores identified where there was agreement and for identifying 
‘critical questions.’
20
ß Within each capacity area areas of strength and areas for improvement or 
further assessment were identified.
ß Quantitative and qualitative input was utilized
ß A self-assessment results-sharing and prioritization meeting was held to 
developed criteria for establishing priority: feasibility and highest impact.
 Findings
ß SC/OH, working within an established agency of formidable experience, is a 
strongly performing PVO unit. 
ß SC/OH has a strong sense of self-efficacy demonstrated by the homogeneity of 
scores in all six areas of capacity
ß Technical skills and knowledge, management and governance, organizational 
learning and human resources management are the strongest areas 
ß Administrative procedures and structures, and financial management, are the two 
weakest 
Initial Recommendations from the CSTS/ISA Team to SC/OH
1. The area needing most attention is financial management; timely access to cost 
information, including financial management and analysis training of CS staff 
2. Enhance focus on quality assurance to ensure project success and long-term 
sustainability.
3. Other areas for improvement: conduct organizational capacity assessments with 
local field partners, design and implementation of sustainability strategies, and 
behavior change communication (BCC) interventions.
4. Develop a more systematic approach to building management, leadership, 
crosscutting, and technical skills for field staff through training, mentoring, visits. 
5. Continue focus on including communities in all aspects of project design, 
implementation, and evaluation, and ensure that lessons learned are 
systematically shared. 
6. More country-specific managerial support to the field may be indicated, as well as 
more frequent management training for field staff. 
7. Institutionalize periodic review of staffing needs for OH and the field against 
program requirements and funding levels. 
8. Explore increasing the translation of selected programmatic documents into local 
languages.
Concrete steps which have been taken with OH as a result of the ISA exercise 
include:
1. Field training/clarification regarding budget line-item flexibility; and training for 
program managers in Ethiopia and are planned 11/02 & 5/03 for SC Middle￾East/Eurasia and Africa area staff.
21
2. Further develop BCC support capacity by adding a Behavior Change 
Communication Specialist Karin Lapping on a part-time basis.
3. Diversify donor base & increase resource mobilization to support OH MCH-related 
initiatives.
4. Train field staff in & implement capacity assessments at field level in Guinea, 
Tajikistan, and Viet Nam.
5. Further development and implementation of a Quality Assurance program.
6. Build field capacity in management, leadership, and technical and crosscutting 
(M&E, research, training, etc.) skills and knowledge.
Save the Children/Bolivia
SC/B has undergone a rapid expansion, growing from 40 staff to 120 in a few years 
time. This has lead to some growing pains administratively. SC/HQ has developed a 
Quality Management Guide: A Save the Children Management Toolbox which was 
used by SC/B for an administrative assessment. A study was also made by SC/B of 
staff on their motivation in completing their job and general satisfaction. Results from 
these two studies have led to the following administrative steps being taken:
o Updating of policies and procedures which have become out-of-date
o Development of a staff training plan and budget for strengthening 
technical and managerial abilities
o A salary scale study is being conducted to adjust salaries as needed.
Other steps, which have been taken to strengthen the organization are: 
ß SC/B staff have been involved in a continuous learning process calles Living 
University; which includes exchange visits from CEPAC in Santa Cruz, Comision 
Técnica de Belgica Santa Cruz, ADRA in Chuquisaca, Food for the Hungry in 
Cochabamba, the PUENTES project, and a delegation from the MOH in Puno, 
Peru. SC/B and partner staff will be making exchange visits in the future to Puno, 
Chuquisaca, and Tarija.
ß Focus on opened leadership, shared responsibility, and team building
ß Training for management in Meyers-Briggs personality types to appreciate and 
complement different learning and leadership styles
ß Quality circles-monthly meetings at all levels of the organization which provide a 
forum for sharing experiences and problem solving
ß Active involvement in PROCOSI which has offered the opportunity to share 
experiences with other organizations working in health in Bolivia. SC/B is one of 
the founding members of PROCOSI and has been active in all phases of its 
development.
(ii) Strengthening Local Partner Organizations
A complete listing of capacity building indicators is included in Attachment F.
A baseline capacity building assessment was conducted with APROSAR, 4 hospitals 
and three MOH District offices. The SC/B staff had very limited understanding of what 
an institutional diagnosis should include and the instrument used for this diagnosis 
22
was inadequate. No capacity building plan was developed with partners after the 
diagnosis was conducted. It is difficult to use the same tool for an independent local 
NGO and a government office. A great deal of work has been done in the last several 
years on institutional strengthening within the CS context, for example by the CORE 
group. SC/B staff needs technical assistance in tools available for assessing 
institutional capacity and the development and monitoring of capacity building 
plans for partners.
APROSAR Capacity Building
APROSAR has conducted their own needs assessment as part of the development 
of a 5 year strategic plan and re-engineering of their organizational structure. The tool 
they used was a self-diagnosis using the SWOT technique (strengthen, weaknesses, 
opportunities, threats). They also solicited input from external sources, such as 
municipal authorities. APROSAR staff feels their reputation as an organization has 
been enhanced through participation in Wawa Sana, they have been able to improve 
community mobilization with SECI, and improve the technical abilities of their staff. 
They identified a number of areas which require strengthening including: 
* Development of a training plan
* Development of a plan for institutional marketing
* Strengthening the area of IEC
* Forum for sharing experiences with other NGOs
* Follow-up and supervision of field staff
* High turnover of Promoters
* Broaden donor base
SC/B and APROSAR need to work together to develop a comprehensive 
institutional strengthening plan for the next two years, based on felt needs of 
APROSAR and abilities of SC/B.
The current SC/B supervisory structure of APROSAR is inadequate. APROSAR is 
made up of a competent group of professions and a full time staff liaison is not 
necessary. It is recommended that the current structure of supervision of 
APROSAR be modified. The current SC/B staff position could be better utilized to 
develop a comprehensive monitoring and supervision plan. Support for APROSAR 
can be accomplished through monthly meetings at managerial level, plus monthly 
exchange between Trainers of SC/B and Trainers of APROSAR to look at technical 
and operational experiences. This project is to test strategies, so open exchange is 
needed on alternatives. There is a richness and creativity within both organizations 
that needs to be exploited further. 
Additional coordination with APROSAR is needed to jointly develop instruments for 
monitoring various project initiatives, i.e. change in skill levels of partner staff and 
Promoters, impact of BCC and IEC activities, and other project indicators. These 
tools need to be developed with partners and tested with partners in order to have 
tools that are both functional and effective.
23
MOH Capacity Building
Coordination with the MOH is on three levels; at the Departmental level by SC/B CS 
Coordinator, at the three MOH Districts which work closely with the SC/B District 
Coordinators, and at the area and sector levels with the SC/B Trainers. At the District 
level coordination is enhanced by having SC/B staff housed at the MOH facility. 
The main steps taken so far in building capacity with the MOH has been through 
technical training in IMCI, both clinical and community, and in the strategies of Wawa 
Sana; H/PD and SECI. Five of the eight auxiliary nurses and six of the seven area 
doctors interviewed during the MTE reported receiving training during the last year, 
the majority in SECI, IMCI and H/PD.
SC/B also finances transportation for MOH staff to increase access to basic health 
services, and transportation and supplies for the CAI/TAI meetings.
One of the capacity building indicators is to see an improvement in facilitation skills of 
MOH staff, yet no plan for accomplishing this has been formalized. Formal courses 
are not necessarily required, but would be one way of enhancing facilitation skills. 
Mentoring by SC/B staff is a very valid methodology, but the steps in this mentoring 
process need to be clearly outlined and monitored.
It was stated in the DIP that “The organizational assessment indicated that all 
districts believed that their capacity to support cultural sustainability, by ensuring that 
the work of their institutions is consistent with values, beliefs and practices of the 
communities, was unsatisfactory.” One of the major weaknesses in the design of this 
CS project is the lack of a focus on improving the quality of services in health facilities 
parallel to creating a demand for those services. One step towards improving patient 
relations would be to follow-up on this statement from the DIP and develop training 
for MOH staff to overcome the problem of cultural understanding. In the district of 
Challapata the NGO ABRIR Salud has already done a lot of work in this area, and 
could perhaps serve as a resource for developing a curriculum for use in the other 
two RHDs. PROCOSI could also serve as a valuable resource.
SC/B should provide additional training as part of the capacity building effort 
for MOH staff through the strengthening of facilitation skills and cultural 
sensitivity.
 (iii) Health Facilities Strengthening
Health facility strengthening was also previously discussed in the section on Capacity 
Building for the MOH. 
Referral System
One of the principal mechanisms for linking the health facilities with the communities 
is through a referral system. It was found during the MTE that 11/18 of the Promoters 
had referral slips, but only 50% of the auxiliary nurses had referral slips. At both 
24
levels the system is working moderately well, but at neither level does the counter￾referral aspect work. According to a study on IMCI implementation in Bolivia 
(UNAP/PAHO/BASICS, 2002) 83% of the health facilities in Oruro have problems 
with the referral system but this has not been identified as a priority by the Oruro 
MOH.
SC/B uses a referral slip which does not have a designated counter-referral function. 
APROSAR uses another type of slip which is more graphic for use by Promoters, it 
also does not have a specific tear-off section for returning information from the health 
facility to the Promoter. The referral system should be modified to better serve 
the needs of the Promoter and Health Facility, and include a clearly stated tear￾off section for counter-referral.
Access to Services
Wawa Sana has improved access to services through providing transportation to 
MOH staff for immunization and other services on a monthly basis and by creating an 
increased demand for services. One of the project indicators is: 75% of CS-16 
population is within a 1 hour walk of facility or IMCI-trained promoter. This indicator is 
already met in Huanuni and Challapata due to the distance from MOH facilities. 
Additional effort will be needed in Eucaliptus through training additional Promoters.
Percentage of Population with Access to Services
Eucaliptus 30% <1 hr 26%>1 hr w/ Promoter 44% > 1hr w/out Promoter
Huanuni 82% <1 hr 5% >1hr w/ Promoter 11% >1hr w/out Promoter
Challapata 78% <1hr 8% > 1hr w/ Promoter 14% >1hr w/out Promoter
Problems with population estimate figures continue to plague the project, estimates 
from the national census and Institute of National Statistics are high as migration 
figures are misrepresented due to people from the rural area returning to be counted 
at their traditional home, even though they have migrated to other areas. 
Quality of Services
One of the Intermediate Results is to improve the quality of services in the RHDs but 
this was a weakness in the original project design, as very little was planned in this 
area, even though it was clearly stated that it is one of the main reasons people do 
not seek care. In Challapata a DIFD project, ABRIR Salud is working with improving 
quality of care at MOH health facilities. In the other two RHDs, an effort should be 
made to incorporate at least minimal training for health staff on improving patient 
relations. Training materials and curriculum are available from other NGOs working in 
Bolivia. 
(iv) Strengthening Health Worker Performance
25
The main activities for strengthening health worker performance are:
Training (discussed in next section)
Coordination
Provision of transportation to improve access to services (discussed in 
previous section)
The coordination between MOH and SC/B is generally positive. SC/B staff is well 
known in the area and meet regularly with MOH staff to schedule use of the vehicle 
and other activities. There is a certain level of lack of motivation on the part of MOH 
staff; many see the project as only adding additional work for them, with very little 
results. The increased pressure to implement IMCI has also added some resistance. 
Greater effort is needed to form a partnership among SC/B, MOH and APROSAR, to 
form a united Wawa Sana team, not to have the project identified as “belonging” to 
SC/B.
A health services study was completed as part of the baseline, but the results were 
incomplete and inconclusive. No other tools have been used to assess worker 
performance. No tools are available to monitor change in worker performance.
(i) Training
The training strategy is a cascade approach; SC/B and partner staff receiving 
training, then replicated the topics for Promoters, then the Promoter has the 
responsibility for transmitting topics to community members. Some variation is seen 
with SC/B or partner staff helping Promoters to provide community education. SC/B 
staff received some topics and they replicated the training for partner staff. At the 
beginning of the project all training for Promoters was being done exclusively by 
SC/B and APROSAR, but now there is greater involvement of the MOH.
A very good facilitation guide is used for training Promoters in IMCI. Facilitation 
guides were not available for all topics. It is difficult to comment on the effectiveness 
of training as no monitoring tools are being used. During interviews with MOH staff, 
Promoters and community members, there appears to be a high level of knowledge 
of CS topics.
Training of Promoters has followed the DIP plan with the additional of training in 
breastfeeding, complementary feeding and negotiation skills through replicating 
training received from Linkages. The training plan from the DIP included the training 
of 120 Promoters; Wawa Sana needs to take into consideration the high turnover rate 
of Promoters and plan for additional training during the second half of the project for 
new Promoters.
The training plan presented in the DIP has been completed as planned, with the 
exception of courses in MOH regulations and facilitation skills. The course on MOH 
regulations should be completed after the next set of rules for Seguro Basico de 
26
Salud are realized (supposed to be later this year) as there are many questions about 
how IMCI fit with the Basic Insurance. Training in facilitation skills for MOH staff 
still needs to be completed, plus a tool for monitoring the use of these skills.
d. Sustainability Strategy
The sustainability objectives for this project are:
1. 50% of the nutrition status impact on % of all 6-35 month olds < -2Z WFA is 
sustained 1 year after the end of Hearth sessions 
2. 50% of the nutrition status impact on % of all 6-35 month olds < -3Z WFA is 
sustained one year after the end of Hearth sessions 
3. MOH or other PVO/NGO has written plans for implementation of SECI and/or 
Hearth/PD in two other health districts 
It is a recommendation of the MTE to omit the second objective because the 
prevalence of severe malnutrition is so low that any change would not be significant. 
The first sustainability objectives will be difficult, but not impossible to meet. The 
problem with this indicator is that it will be measured a year after the end of the H/PD 
sessions, a date which has not yet been reached for any community at the time of the 
MTE, and with changes in the H/PD, as previously outlined in this report, may not be 
able to be measured prior to the final evaluation of this project. This indicator is tied 
to the indicator for change in nutritional status, that is a 30% decline in malnutrition 
rates. If this nutrition change indicator is not met (and it will be difficult to improve by 
30%) then obviously the lesser percent change will be easier to maintain.
SC/B feels that “sustaining important innovative approaches on a larger scale 
through “uptake” by other organizations may be more meaningful than a concept of 
sustainability which focuses mainly on the project site.” (DIP 2000) The third 
sustainability indicator has probably already been met; by having other NGOs 
present written plans for including SECI in two other areas of Bolivia. CEPAC, PLAN 
International Tarija and Nur University have all made plans to incorporate SECI in 
their CS activities. CEPAC will use SECI in implementing a subgrant from SC/B for a 
neonatal project in Potosi with Gates Foundation funding.
The sustainability of health activities at the community level will be attained through 
having competent, well trained community volunteers, a strong supportive community 
structure, and a strong linkage between the community and MOH services. Wawa 
Sana is moving towards impacting each of these three aspects.
Of the three strategies, IMCI is already a national program and shows good potential 
for sustainability due to support by the government, donors, and other NGOs. SECI 
also has the potential to be scaled up to a national level strategy and there is a lot of 
interest in replicating the strategy in other areas. H/PD will probably never have the 
same potential for sustainability due to the intensive investment in time. It would be 
surprising for H/PD to be replicated by the MOH alone. But the strategy has 
27
enormous potential for being expanded with outside funding from other NGOs. The 
concept of Positive Deviance also has great potential for being applied to other 
health problems, besides nutrition of children. 
During the MTE, communities and local authorities were asked about sustaining
activities, they suggested a closer link with municipal government as an alternative 
source of funding, they also suggested increased support of the Promoters and 
linkages with the MOH. 
While advocacy was not a direct part of the sustainability plan, its effect can certainly 
lead to more sustainable programming. Both SC/B and APROSAR have taken steps 
in advocating change in policy which will effect health programs. They both actively 
work with municipalities to motivate the inclusion of a budgeted amount for Promoter 
activities, such as training, transportation and some supplies. Additional needs for 
effecting policy include advocating for increased stability of trained MOH staff 
and for supplying Promoters with ORS and paracetamol. Carol Miller, SC/HQ's
Associate Vice President for Public Policy & Advocacy has been working on a draft 
advocacy plan for health with senior health staff.
28
C. Program Management
1. Planning
There has been limited involvement of partners and field staff in the planning 
process. People at all levels understand the basic goals of decreasing mortality and 
morbidity and improving the health of children, but specific objectives are not clearly 
understood.
The DIP was never completely translated and the translation which was made was of 
poor quality as to make it of limited use for CS staff and partners. The objectives and 
indicators were presented during the start-up workshop, but again the poor 
translation has limited their use. In the sub-contract with APROSAR, different 
indicators are used which do no coincide with DIP indicators. There is little tracking of 
the indicators, making use of the indicators during the MTE a challenge. The M&E 
plan which was included in the DIP is perhaps useful to SC/HQ staff, but is extremely 
complex and not understandable to CS or Partner staff. The M&E plan should be 
simplified and re-translated so that project indicators and means of verification 
can be easily identified by Wawa Sana staff and other stakeholders.
There are monthly meetings called quality circles within SC/B at each level of project 
management; district level, Oruro office, and La Paz SC/B, These meetings have 
both a planning and a problem solving function and are used for developing a 
monthly calendar for use of the vehicles and programmed activities. These calendars 
should be developed with the initial input of partners.
There is a good quarterly evaluation and planning process (including La Paz staff 
and APROSAR), held one day every three months jointly with child sponsorship, 
health, education and teen programs. Activities monitored during these meetings 
include: community planning activities, training for communities, promoters and staff, 
new communities SECI, follow-up on use of SECI software, community EDP 
activities, supervision of promoters, population with access to services, monthly staff 
meetings, coordination efforts and CAI meetings. Results from these quarterly 
evaluations should be shared with partners and other stakeholders to improve 
an understanding of what Wawa Sana is doing.
There is no annual planning process for defining activities or monitoring change. The 
only annual tool currently being used is the original four-year plan included in the 
DIP, which is not sufficiently detailed to be a stand-alone instrument. The DIP work 
plan has been followed but more detailed planning is needed. As was previously 
mentioned in this report, there is a lack of a monitoring plan to be used in improving 
implementation through a continuous planning process. An annual plan for the next 
two years needs to be made by the Wawa Sana team, a combined planning 
process will improve project ownership for partners and develop the tools 
necessary for monitoring project indicators. This plan should include the 
expansion of the three strategies into new communities in the three Districts.
29
2. Staff Training
SC/B staff have been well trained, with an adequate budget for training, Courses 
received include:
Linkages: Breastfeeding, complementary feeding, negotiation, home visits 
SECI, H/PD, IMCI Clinical and CB by MOH
Anthropometric measurement and nutritive value of foods
Interactive Methodologies for Training & IEC-development and transmission of 
messages CEPRA, Rapid Food Security Assessment, Cultural Sensitivity, etc.
There is no system for assessing and monitoring staff competencies or for ensuring 
that new knowledge is put into practice. As part of the capacity building plan for SC/B 
a staff training plan and budget are being developed for strengthening technical and 
managerial abilities.
3. Supervision of Program Staff
There is a good system of indirect supervision through monthly meetings or Quality 
Circles. There was a need identified by all levels of field staff for improving the direct 
supervision in the field, with a particular emphasis on problem solving through 
supportive supervision. There is no supervision format or schedule. Direct field 
supervision of SC/B project staff needs to be improved and supervision tools 
developed for tracking improvement and solutions to identified problems.
4. Human Resources and Staff Management
SC/B has a well organized personnel system, including clear policies for recruiting, 
orienting and evaluating staff. A written personnel manual outlining organizational 
policies is available to all staff and there are current job descriptions for all positions. 
Staff benefits include health insurance, life insurance and other benefits as required 
by law. Staff turnover in the CS project has been low; most of the staff has been with 
the project since it began and a great many worked on the previous mission funded 
CS project. Two of seven trainers left the CS project within the last 2 years to work on 
the Title II project, to be nearer their families in La Paz. They have subsequently 
been replaced; one of the new trainers was a previous APROSAR employee. The 
SC/B team works as a cohesive unit, morale seems high and collaboration is evident
All staff that completes 2 years in their position becomes permanent staff by Bolivian 
law. SC/B adheres to all local labor laws, including the payment of one additional 
monthly salary per year and for permanent staff, the payment of three months salary 
if they leave the organization. SC/B sees their staff as an investment and a valuable 
resource and whenever possible try to retain staff when one project ends until 
additional financing can be obtained. 
5. Financial Management
SC has good experience in managing CS projects in the past and has several levels 
of USAID compatible financial control systems with regular internal and external 
audits. SC has a computerized accounting system which is approved by USAID. 
30
Financial reporting on a quarterly basis to USAID is carried out without problems and 
good financial support is received from CS/HQ.
The budget shows approximately 60% has been spent of USAID funds and 50% of 
SC/B match funds. A vehicle valued at $45,000 was budgeted for during YR2 with 
match funds, but these funds have not been expended. Review the budget for the 
next two years and make adjustments as needed within USAID guidelines. 
There are funds available in some line items which could be internally 
transferred to cover additional supplies i.e. minimal equipment for IMCI (scales 
for growth monitoring) and a large amount of funds are available for additional 
training i.e. training for MOH staff in educational methodologies or improved 
patient relations.
A recent change in financial management has been made so that Oruro now has it’s 
own bank account. This is a very positive change as the flow of funds was very 
cumbersome using only a petty cash system. CS-16 financial reports are sent to the 
CS Coordinator, but not on a regular basis. It is vital that the CS Coordinator receives 
a monthly print-out of the budget, with year to date figures, and if possible life-of-the￾project figures also. The CS Coordinator should receive a complete orientation 
to the budget and monthly budget reports so that he can more adequately 
manage the CS project.
PROCOSI facilitated external audits for all of its principal members in March of 2002, 
resulting in only minor observations. The last external audit from SC/HQ was in 1995. 
There is an internal auditor within SC/B who audits program documents on a rotating 
basis. The subcontract with APROSAR has not presented any financial difficulties. 
APROSAR presents monthly financial reports and receives disbursements of funds 
every three months. The head of accounting for SC/B is planning a visit to APROSAR 
in October of this year to review APROSAR’s financial system and documentation. 
6. Logistics
Logistics and procurement have not been major limitations during the implementation 
of this project. These aspects are well planned and managed and should present no 
challenges to staff during the remainder of the project.
7. Information Management
The information system of Wawa Sana has four main components: 
· KPC survey which is one of the main instrument for measuring indicators
· SECI community epidemiological surveillance system
· SNIS national MOH information analysis system 
· Other qualitative studies (Focus groups, Institutional Assessment)
KPC
The KPC was conducted at baseline and will be repeated at final. The KPC was 
conducted for two age groups; mothers with children <2 and mothers with children 2-
4 years. A total of 659 women were surveyed. Results from the KPC show a high rate 
31
of incomplete interviews, this problem is mainly a result of not using the standard 
KPC CSSP/CSTS methodology for supervising numerators in the field. Improvement 
in the KPC can be made by clarifying information through the following suggestions:
ß Use standard indicators when reporting data i.e. 12-23m for vaccination coverage, 
food intake from 6-9 months (not 6-23m), use of card to verify vaccines, 
prolonged breastfeeding should be measured as 20-23months.
ß “n” for vaccines and Vitamin A should be all children 12-23 m, not just those with 
cards
ß The response for home treatment of diarrhea is somewhat confusing as the 
answer “homemade medicines” should be separated between homemade liquids￾teas, etc, and other homemade remedies to have a better idea of intake of fluids. 
ß The indicators presented by APROSAR do not coincide with the Wawa Sana 
indicators and some of these additional indicators will need to be included in the 
final KPC. 
It is recommended that future KPCs follow the CSSP/CSTS methodology for 
the collection of field data and description of indicators.
The project has 31 indicators (this report is suggesting the elimination of six of those). 
A number of the indicators will be measured through the KPC survey as part of the 
final evaluation or through SECI, but a great many have no monitoring tool available. 
A chart is included in Attachment F on suggested changes for the indicators and 
indicating which indicators still require the development of a monitoring tool. A priority 
area for the next two years needs to be the development of a monitoring and 
supervision system for all aspects of the project.
SECI
A complete discussion of the SECI strategy is included in Section B.1.c.2 New 
Approaches-SECI. The project indicators, which will be measured via SECI, with 
some modifications, are outlined in Attachment F.
SNIS
The main use of the SNIS system is to analyze MOH indicators during regularly 
scheduled CAI/TAI meetings. These CAI meetings also provide an opportunity to 
share results from the SECI system. The SECI system supports the SNIS system; 
there is no duplication of effort as SNIS focuses on facility services and SECI on 
community activities.
Other Studies 
Basic information was collected from each community, as well as a census and 
community map. This information is included in the SECI to provide valuable 
information about each community.
32
Focus groups were conducted with women at baseline for use in defining project 
content. These focus groups were very well conducted and documented, and 
provided valuable information for the project on cultural beliefs and practices.
The institutional Assessment and Health Services Staff Survey were both used at 
baseline, but were both of questionable quality. The results were inconclusive and no 
apparent actions were taken as a result of these surveys. Both methodologies could 
provide valuable input into project design, if improved instruments were used.
8. Technical and Administrative Support
SC/HQ’s CS Specialist, Dr. Eric Starbuck, is budgeted at 15% time for the Wawa 
Sana project in Year 1, and at 10% in Years 2 through 4. The Health Office Manager, 
Carmen Weder is budgeted at 12% time in Year 1, and at 10% in Years 2 through 4. 
The CS Advisor, Dr. David Marsh is budgeted at 3% time in Years 1 through 4. 
SC/HQ staff support for Wawa Sana has focused on the initial CS-16 design work, 
application, baseline assessments, and DIP. Since the last visit for the development 
of the DIP support has been in the form of e-mails and review/revision of the first 
annual report. Ms. Carmen Weder, Manager, OH, provides financial and 
administrative backstopping for the project. Most of her support was also for the initial 
application budgeting, and negotiating the award/budget with USAID. She also works 
with field office staff on sub-agreements, regular monitoring of expenditures and 
grant compliance, reporting of budget pipelines to AID and SC field office 
counterparts, and responds to questions from field offices.
SC/B program and administrative staff feel that the level of support they receive from 
SC/HQ is adequate and timely. SC/B staff in Oruro is also satisfied with the support 
they receive from the La Paz office.
 
The National Health Coordinator, Ccoya Sejas traveled to Washington D.C. for 
the DIP defense and attend the 2001 Health Program Learning Group to share 
project advances with worldwide SC health staff. The National Health Advisor, 
Caroline Hilari attended the 2002 SC’s Health Program Learning Group. The 
cross-fertilization of CS programs that occurs through these visits strengthens 
SC’s overall ability to manage CS programs regionally and worldwide. This is an 
opportunity to review and analyze the project, and to make strategic decisions 
about necessary project modifications and adjustments.
Other technical assistance received: 
H/PD specialist Jerry Sternin
Training through Linkages and other local organizations has already been 
described under staff training
33
Technical assistance needs for the future include:
Budgeting information for the CS Coordinator
Capacity Building Assessments and Planning
Behavior Change Communication and monitoring change
34
D. Conclusions and Recommendations
The Wawa Sana project is an exciting project because it is pioneering new ground 
with very innovative strategies, particularly H/PD and SECI. There is a great deal of 
learning taking place about how, and when, to use these strategies. The project 
shows good potential for meeting all project objectives (with the modifications 
suggested in this document), with the exception of the nutritional indicators. Some of 
the strengths of this project include:
ß A focus on strengthening the Promoter as a principal actor in implementing and 
sustaining health activities;
ß Use of local languages at the community level to encourage greater participation 
and sharing;
ß Involvement of Municipalities to improve coordination and as part of the 
sustainability strategy;
ß Empowerment of communities and women; all three strategies contain elements 
of finding solutions within the community and contributing to the development of 
organizational and leadership skills;
ß Formation of strong team within SC/B, but this concept needs to be extended to 
include the greater team of Wawa Sana; and
ß Good technical approaches.
Areas Needing Further Improvement:
1. Formation of a Wawa Sana Team which includes SC/B, APROSAR and MOH: 
there is too much focus on this project as “belonging” to SC/B. Partners should 
be involved in all aspects of the project, including a decision making role.
2. Based on comments in the DIP review, in the first Annual Report it was stated that 
checklist for monitoring field staff and quality assurance would be in place by 
January 2002. This has not been done and continues to represent one of the 
major weaknesses of the project. A priority area for the next two years needs to 
be the development of a monitoring and supervision system for all aspects of the 
project.
3. Capacity building for partners is a current weakness of the project. The lack of an 
adequate instrument for measuring institution capacity, and the subsequent lack 
of an agreed upon plan with the major partner, APROSAR, has lessened the 
potential impact of this project in the vital area of institutional strengthening.
There are two basic flaws in the original design of this project which form two 
important lessons learned: (1) Implementation of CB-IMCI is premature until clinical 
IMCI is well established; and (2) Creating a demand for services in health facilities, 
without a parallel effort to improve the quality of services at those facilities provides 
an incomplete package of services.
35
Wawa Sana needs to improve communication with RHDs, municipalities, and other 
stakeholders about project objectives, activities and advances. A one-day annual 
conference to present project advances and the next year’s plan would help to keep 
all stakeholders informed.
Recommendations: 
1. One of the main goals of the Wawa Sana project is the documentation of the 
implementation experience. A documentation plan should be developed for all 
three strategies now so appropriate information can be collected during the next 
two years.
2. SC/B will need to continue trying new approaches to SECI in urban environments 
and documenting these experiences.
3. The Wawa Sana Project should modify the objective of the H/PD strategy from a 
curative focus of rehabilitating malnourished children to one of changing 
household level practices to prevent malnutrition.
4. The SECI specialist needs technical assistance in use of EPI-NUT. 
5. The Wawa Sana team should receive technical assistance in general theory of 
BCC (vs. IEC) and techniques for monitoring changes in knowledge and 
practices.
6. SC/B staff needs technical assistance in tools available for assessing institutional 
capacity and the development and monitoring of capacity building plans for 
partners.
7. It is recommended that future KPCs follow the CSSP/CSTS methodology for the 
collection of field data and description of indicators. 
8. A one-day annual conference to present project advances and the next year’s 
plan would help to keep all stakeholders informed.
9. The M&E plan should be simplified and re-translated so that project indicators and 
means of verification can be easily identified by Wawa Sana staff and 
stakeholders.
10.Results from quarterly evaluations should be shared with partners and other 
stakeholders to improve an understanding of what Wawa Sana is doing.
11.An annual plan for the next two years needs to be made by the Wawa Sana team; 
a combined planning process will improve project ownership for partners and 
develop the tools necessary for monitoring project indicators. This plan should 
36
include the expansion of the three strategies into new communities in the three 
Districts.
12.Investigate ways the H/PD strategy can integrate activities with the PAN centers 
to improve nutritional status of children. 
13.It is recommended that the project continue to monitor both weight/age and 
height/age in order to see if a significant impact is seen in either one. 
14.Ideas for motivating Promoters need to be formalized by the Wawa Sana team 
and a concrete plan developed to improve the retention of Promoters by the 
project and to clarify what the project will accomplish in terms of training new 
Promoters for expansion into additional communities during the next two years.
15.Wawa Sana should encourage the formation of Promoter organizations that will 
exert a level of internal control/self-governance and support of the Promoters. 
16.A mechanism should be developed to strengthen sector and area CAIs. This 
could greatly increase understanding of health issues and local decision-making 
ability. 
17.The project should also foment the exchange of experiences and use of sector 
CAIs as an opportunity for Promoters to share experiences. 
18.Promoters should be trained in how to develop and present small projects for 
funding.
19.SC/B and APROSAR need to work together to develop a comprehensive 
institutional strengthening plan for the next two years, based on felt needs of 
APROSAR and abilities of SC/B.
20.It is recommended that the current structure of supervision of APROSAR be 
modified.
21.SC/B should provide additional training as part of the capacity building effort for 
MOH staff through the strengthening of facilitation skills and cultural sensitivity.
22.The referral system should be modified to better serve the needs of the Promoter 
and health facility, and include a clearly stated tear-off section for counter-referral.
23.Training in facilitation skills for MOH staff still needs to be completed, plus a tool 
for monitoring the use of these facilitation skills.
24.Additional needs for effecting policy include advocating for increased stability of 
trained MOH staff and for supplying Promoters with ORS and paracetamol.
37
25.Direct field supervision of SC/B project staff needs to be improved and 
supervision tools developed for tracking improvement and solutions to identified 
problems.
26.Review the budget for the next two years and make adjustments as needed within 
USAID guidelines. There are funds available in some line items which could be 
internally transferred to cover additional supplies i.e. minimal equipment for IMCI 
(scales for growth monitoring) and a large amount of funds are available for 
additional training, i.e. training for MOH staff in educational methodologies or 
improved patient relations.
27.The CS Coordinator should receive a complete orientation to the budget and 
monthly budget reports so that he can more adequately manage the CS project.
38
E. Results Highlight 
The SECI (Community Epidemiology Surveillance System) Methodology
SECI promotes the joint collection, analysis, and use of health information/data by 
MOH staff and communities to address local health problems. During community 
gatherings, local health care providers and community promoters present health data 
to the community members using colorful, easy-to-understand SECI tools, analysis, 
and planning guides. Using culturally appropriate materials suitable for adults without 
literacy or numeric skills, a space above each indicator (represented by a colorful 
picture) is filled with small images of women, boys, or girls to represent the number of 
cases recorded in the CB-HIS. The corresponding denominator is attached to a 
space at the top corner of each banner. Red, yellow, and green color-coding on 
individual health cards and presentation banners categorizes three levels of risk 
(dangerous, at risk, healthy). The SECI strategy has been very effective:
1. Families have increased their use of health care services. Compared to 
controls, more households in the intervention communities reported: 
· Complete child immunization (OR = 4.78, 11.2% versus 2.6%, p<.05), 
· Vitamin A supplementation (OR = 1.96, 58.6% versus 41.9%, p<0.05), 
· Possession of a health card (OR = 2.12, 44.9% versus 27.7%, p<.05), 
· Early postpartum breast-feeding (OR = 2.62, 25.7% versus 11.7%, 
p<.05), and 
· Oil supplementation for young children (OR = 1.95, 67.5% versus 
51.6%, p<.05).
2. Communities have changed their meeting agendas. Health used to be the last 
topic in their meetings, long after political issues, boundary conflicts with 
neighboring territories, road maintenance and other community works, and 
issues related to schools. With the introduction of SECI, health is now 
discussed first on the agenda.
3. Motivated by the discussion of data on their own illnesses and health care 
utilization, communities have demanded information on health topics. 
Frequent demands on information have included topics such as appropriate 
child feeding, diarrhea and cough management, as well as antenatal care and 
management of labor and delivery. Usually, health service providers respond 
immediately, during the very same meeting.
4. Local authorities used their power to convince families to increase their use of 
health care services, specifically immunizations.
5. Local community representatives have been mobilized to demand leveraging 
of funds from the local governments to address specific health needs.
39
F. The Action Plan
The Wawa Sana team (SC, APROSAR, MOH and Promoters) will have a one-day 
workshop during October to develop a plan of action for implementing the 
recommendations from the MTE after the final version of the MTE evaluation 
document is received and translated into Spanish. Additional stakeholders will be 
invited to this process, including municipal and community authorities, MOH 
management staff, and other NGOs .As the evaluation team developed the 
recommendations included in this document, they will be able to move forward on 
implementing the recommendations immediately. The process of involving the MOH 
in the evaluation has served to strengthen their commitment to improving the project 
over the next two years.
1
Attachments
A. Baseline Information from the DIP (page 2)
B. Team Members and their Titles (page 24)
C. Assessment Methodology (page 25)
D. Persons Interviewed and Contacted (page 32)
E. Results of the Evaluation (page 33)
F. Recommended Changes in Project Indicators (Page 67)
2
ATTACHMENT A
A. Baseline information from the DIP
No significant changes were made since the DIP, expect as noted in the body of this 
document.
1. Executive Summary: 
Estimated Program Effort and USAID Funding by Intervention
Intervention % Effort USAID Funds (a)
Micronutrients 30% $300,000
Pneumonia Case 
Management 
30% $300,000
Control of Diarrheal 
Disease 
20% $200,000
Immunization 20% $200,000
(a) Estimated amount of USAID funding (excluding PVO match funds) the program will devote 
to each intervention to be implemented
Target Beneficiaries:
Type Number
0-59 month old children: 13,500
Beneficiary Residence:
Urban/Peri-Urban % Rural %
27% 73% 
3
2. Program Goals and Objectives: 
CS-16 Goals, Results, Intermediate Results, and Selected End of Program Objectives
Goal 2: Sustained 
reduction in under-five 
mortality in the 3 health 
districts.
Goal 3: Innovative CS-16 
approaches inform policy and 
improve CS programming in 
other areas of Bolivia.
Goal 1: Sustained 
improvement in nutrition 
status of 6-35 month olds in 
Hearth/PD communities.
R-1: Improved capacity 
of APROSAR & 3 RHDs 
to support community 
activities & implement 
innovative culturally 
acceptable CS approaches.
R-2: Improved capacity 
of communities in the 3 
health districts to 
identify & effectively 
address priority health 
needs of children <5.
R-3: Increased use of 
key CS services and 
improved CS practices
at household level in the 
3 health districts.
R-4: Uptake of
successful innovative 
CS-16 approaches by 
MOH or by other 
organizations.
· 3 RHDs have 
incorporated SECI 
data, discussion, & 
planning in district 
information analysis 
meetings.
· 90% of APROSAR 
Promoters receive 
regular support and 
supervisory visits from 
APROSAR staff.
· 75% of SECI 
communities have 
action plans with 
service providers to 
address CS needs.
· 75% of communities 
with action plans revise 
plans based on analysis 
of SECI/SNIS data.
· 23% annual increase in 
# of <5 pneumonia 
cases treated by CS-16 
facilities & Promoters. 
· 80% DPT3 coverage in 
infants in all CS-16 
municipalities. 
· 85% of 12-23 month 
olds with cards got 
1/more vitamin A 
capsules in last year.
· MOH or other 
PVO/NGO has 
written plans for 
implementation of 
SECI and/or 
Hearth/PD in two 
other health districts.
IR-1: Increased 
availability of selected 
child survival services in 
the 3 health districts.
IR-2: Improved quality
of selected child survival 
services in the 3 health 
districts.
IR-3: Increased 
caretaker knowledge/ 
awareness in 3 health 
districts of selected CS 
issues.
IR-4: Documented 
results and feasibility of 
implementing 
innovative CS-16 
approaches.
· 60% of communities 
with pop. over 120 have 
CB-IMCI-trained 
Promoter or MOH 
facility.
· 75% of CS-16 
population is within a 1-
hour walk of facility or 
ARI-trained Promoter 
with cotrim. stock.
· 80% of PCM-trained 
Promoters pass 
pneumonia knowledge 
& skills test.
· 80% of caretakers 
recently counseled on 
DD by CS-16 facilities 
& Promoters report 
following 3 home care 
rules.
· 75% of mothers of 
<2’s report that help 
should be sought if 
child has “fast and 
agitated breathing.” 
· 50% of mothers of 
<2’s report that help 
should be sought if 
child’s “thorax is 
sunken.”
Documented results & 
marginal cost of 
human resources & 
supplies for service 
delivery & support to 
implement:
· CB-IMCI;
· Hearth/Positive 
Deviance; and
· SECI.
IR-5: Demonstrated SC/B capacity in CB-IMCI, SECI, & H/PD capacity building of CS-16 partners & advocacy.
· 75% of CS-16 partners & community capacity building objectives achieved.
· SC/B advocates for implementation of effective & innovative approaches to child health at public and NGO levels.
4
CS-16 Nutrition Status and Sustainability Goals, Results, Objectives, and Means of Verification
Goal or Result End of Program Objectives Means of Verification
Goal 1: Sustained 
improvement in nutrition 
status of 6-35 month olds in 
Hearth/PD communities.
· Nutrition Status: 30% decrease in 6-35 month olds 
in Hearth/PD communities < -2Z weight-for-age 
(pre-/post-).
· Nutrition status: 30% decrease in 6-35 month olds 
in Hearth/ PD communities < -3Z weight-for-age 
(pre-/post-).
· Sustainability: 50% of the nutrition status impact 
on % of all 6-35 month olds < -2Z WFA is 
sustained 1 year after the end of Hearth sessions. *
· Sustainability: 50% of the nutrition status impact 
on % of all 6-35 month olds < -3Z WFA is 
sustained one year after the end of Hearth sessions.
Nutrition Status: 
Hearth/PD community￾wide pre- and post-Hearth 
growth monitoring records.
Sustainability: Hearth/PD 
community-wide post- and 
one-year post-intervention 
growth monitoring records.
Result 4: Uptake of 
successful innovative CS-16 
approaches by MOH or by 
other organizations.
· Sustainability: MOH or other PVO/NGO has 
written plans for implementation of SECI and/or 
Hearth/PD in two other health districts.
PROCOSI, MOH, and/or 
donor reports and 
interview information.
* An example of these objectives being met would be a mean pre-intervention Hearth/PD community-wide rate of 
30% underweight in 6-35 month old children, reduced by the end of Hearth sessions to a mean of 20%, and one year 
after the end of Hearth sessions to a mean of 24%.
5
CS-16 Capacity Building Results, Objectives, and Means of Verification
Result or IR End of Program Objectives Means of Verification
R-1: RHDs’
capacities to 
support community 
activities & 
implement 
innovative 
culturally 
acceptable CS 
approaches 
improved.
· SECI Data: 3 RHDs incorporate SECI 
data, discussion, & plans into district 
info. analysis (CAI) meetings.
· SECI Facilitation: 60% of permanent 
Auxiliary Nurses demonstrate good 
skills in co-facilitating SECI meetings.
· H/PD Training: 80% of permanent 
MOH staff demonstrate good skills in 
co-facilitating H/PD training.
· CS-16 reports and CAI 
meeting minutes.
· Facilitation methods & 
skills checklist during 
observation of Auxiliary 
Nurses at SECI meetings.
· Training methods & skills 
checklist during 
observation of training.
R-1: APROSAR’s
capacity to support 
community 
activities & 
implement 
innovative 
culturally 
acceptable CS 
approaches 
improved.
· Training: All APROSAR trainers 
demonstrate competency in CB-IMCI, 
SECI, & H/PD training of Promoters.
· Support: 90% of APROSAR 
Promoters receive support/ supervisory 
visit from APROSAR staff in the 
previous 3 months.
· Supply: 90% of APROSAR 
Promoters have adequate supply of 
cotrimoxazole.
· Training methods & skills 
checklist during 
observation of training.
· Checklists from SC visits to 
APROSAR Promoters. 
· Checklists from SC visits to 
APROSAR Promoters.
R-2: Communities’ 
capacities in the 3 
RHDs to identify & 
effectively address 
priority health needs of 
children under 5 
improved. *
· CB-IMCI: 60% of communities with pop. 
over 120 have CB-IMCI-trained Promoter or 
MOH facility.
· SECI: 75% of SECI communities have action 
plans with service providers to address CS 
needs.
· SECI: 75% of communities with action plans 
revise plans based on analysis of SECI/SNIS 
data.
· Women: 40% participants in CS-16-related 
community meetings women.
· CS-16 reports.
SECI meeting records, SECI 
Joint Planning and Meeting 
Monitoring forms, joint 
action plans, attendance lists, 
and other CS-16 reports (for 
last 3 indicators).
IR-5: SC/B
capacity 
demonstrated in 
CB-IMCI, SECI, & 
H/PD capacity 
building of CS-16 
partners and 
advocacy.
· Capacity Building: 75% of partner & 
community capacity building 
objectives achieved.
· Support: 100% of CS-16 APROSAR 
& permanent MOH staff receive 
support/ monitoring visit from SC staff 
in last 6 months. 
· Advocacy: SC/B advocates for 
implementation of effective & 
innovative approaches to child health 
at public and NGO levels.
· Review of capacity 
building achievements 
during final evaluation.
· CS-16 records, MTE & 
final evaluation interviews 
with APROSAR & MOH 
staff.
· Review of CS-16 advocacy 
plan and activities during 
final evaluation.
* See table below for family/individual prevention & care-seeking objectives (related to Result 3).
6
Use/Practice, Availability, Quality, & Knowledge: Results & Objectives (Baseline Values)
Result or IR End of Program Objectives Means of Verification
R-3: Increased use
of key CS services 
& improved CS 
practices at 
household level in 
the 3 RHDs.
· EPI: 60% of 12-23 month olds have maternal history or 
card for measles immunization. (27%)
· EPI: 80% or more DPT3 coverage in infants in all CS-16 
municipalities. *
· Vit. A: 85% of 12-23 month olds with cards received 
1/more capsules in last year. (64%)
· CDD: 75% of mothers of 6-23 month olds with DD in last 
2 weeks report feeding increased fluids during DD. (24%)
· ARI: 23% annual increase in total <5 pneumonia cases 
treated by CS-16 facilities & Promoters.*
1
· KPC survey
· DHO EPI records, 
estimated <1 pop.
· KPC survey
· KPC survey
· DHO, facility & 
Promoter records.
IR-1: Increased 
availability of 
selected CS 
services in the 3 
RHDs.
· ARI: 75% of CS-16 population is within a 1-hour walk of 
facility or ARI-trained Promoter with cotrim. stock.
· 60% of communities with pop. over 120 have CB-IMCI￾trained Promoter or MOH facility.
Checklists from SC￾APROSAR-facility staff 
supervisory visits, and 
review of CS-16 site map.
IR-2: Improved 
quality of selected 
CS services in the 
3 RHDs.
· ARI: 80% of CS-16 ARI-trained Promoters pass 
pneumonia knowledge & skills test.
· CDD: 80% of CS-16 CDD-trained Promoters pass CDD 
knowledge & skills test.
· ARI: 80% of caretakers of children recently treated by CS￾16 facilities/ Promoters report correct dose & course of 
cotrim. fed for pneumonia.
· CDD: 80% of caretakers recently counseled on DD by CS￾16 facilities/ Promoters report following 3 DD home care 
rules.
· Refresher training needs 
assessment of Promoters 
previously trained by CS￾16.
· SC-APROSAR-facility 
staff interviews with 
caretakers of children 
recently treated by CS-16 
facilities/ Promoters.
IR-3: Increased 
caretaker 
knowledge & 
awareness of 
selected CS issues.
· ARI: 75% of mothers of children under 2 years report that 
help should be sought if their child has “fast and agitated 
breathing.” (17%)
· ARI: 50% of mothers of children under 2 years report that 
help should be sought if their child’s “thorax is sunken” 
(chest indrawing) (2%)
KPC survey
* CS-16 objective and indicator corresponds to MOH HIPC objective and indicator.
 
1
The actual incidence of WHO algorithm positive pneumonia is very difficult to measure accurately, and is likely to vary 
between sites. The Global Burden of Disease and Injury Series (Murray CJL, Lopez AD. Volume II, Global Health Statistics, 
Harvard University Press, 1996, Table 105) estimates an average incidence of "lower respiratory infection" of 0.45 episodes per 
infant/child under five years of age per year in developing countries. The actual incidence of WHO algorithm positive 
pneumonia in children in Bolivia is unknown. Thus, SC decided to use the MOH indicator relating to the annual increase in the 
number of children treated for pneumonia, instead of an indicator relating to a rate of treatment. However, SC also believes that 
an effective facility- and CB-IMCI program in rural Oruro, a high mortality setting, should achieve combined rates of treatment 
between 0.2 and 0.5, and thus will also monitor the rate of treatment. MOH data for January through December 2000 indicate 
that all MOH facilities in the CS-16 site treated under-fives for pneumonia at a rate of approximately 0.08 cases per child per 
year (or approximately 18% of the expected incidence of 0.45 episodes per child per year).
7
End of Program Objectives, Indicators, and Means of Verification for IR-4:
Documented Feasibility and Results of Implementing Innovative CS-16 Approaches 
Objectives Indicators Means of Verification
Documented 
feasibility and 
results of 
implementing 
CB-IMCI. **
· Feasibility: Estimated marginal cost of human 
resources & supplies for service delivery & 
support for implementation of approach.***
· PCM/Use: Annual increase in # of <5 pneumonia 
cases treated by CS-16 facilities-Promoters. *
· PCM/Quality: % of PCM-trained Promoters 
passing pneumonia knowledge & skills test.
· CDD/Quality: % of caretakers recently counseled 
on DD by CS-16 Promoters who report following 
3 home rules.
· PCM/Availability: % of CS-16 population within 
a 1-hour walk of facility or trained Promoter with 
adequate cotrim. stock.
· SC/B & CS-16 records.
· DHO-facility & Promoter records.
· CS-16 Promoter refresher training 
needs assessment tests.
· Follow-up of recently counseled 
DD cases by SC-APROSAR￾DHO staff.
· Checklists from SC-APROSAR￾DHO supervisory visits & review 
of site map.
Documented 
feasibility and 
results of 
implementing 
Hearth/PD. **
· Feasibility: Estimated marginal cost of human 
resources & supplies for service delivery & 
support for implementation of approach. ***
· Nutrition status/sustainability: % of all 6-35 
month olds in Hearth/ PD communities < -2Z 
weight-for-age.
· Nutrition status/sustainability: % of all 6-35 
month olds in Hearth/ PD communities < -3Z 
weight-for-age.
· SC/B & CS-16 records.
Hearth/PD community-wide pre￾vs. post-H/PD intervention (status), 
& post- vs. one-year post￾intervention (sustain.) growth 
monitoring records (for both 
indicators).
Documented 
feasibility and 
results of 
implementing 
SECI. **
· Feasibility: Estimated marginal cost of human 
resources & supplies for service delivery & 
support for implementation of approach. ***
· Community Capacity: % of SECI communities 
having action plans with service providers to 
address CS needs.
· RHD Capacity: % of RHDs in which SECI data 
is incorporated in quarterly district information 
analysis meetings.
· EPI/Use: % of 12-23 month olds have maternal 
history or card for measles immunization. (27%)
· EPI/Use: % or more DPT3 coverage in infants in 
all CS-16 municipalities. *
· SC/B & CS-16 records.
· SECI meeting records, JPMM 
form, joint action plans, other CS￾16 reports.
· Records of the 3 DHOs quarterly 
information analysis meetings.
· KPC survey
· DHO EPI records, estimated <1 
populations.
* CS-16 indicator corresponds to MOH HIPC indicator.
** With regard to these three strategies, the end of program objectives are to document the feasibility and results of 
implementing the strategy. However, all indicators, except those for feasibility, also have numeric end of program 
objectives described in the tables above on capacity building, sustainability, and/or CS-16 interventions.
*** This is intended to estimate the additional cost to another organization of implementing this approach over a 
four-year period in an area where the organization already has ongoing development activities.
8
3. Program Location: 
The CS-16 Site and Population
Bolivia is divided into three geographical zones: the Altiplano (high plains), the valleys, and the 
sub-tropical zone; and administratively into nine Departments. Oruro Department is located on 
the Altiplano, south of La Paz. The Department covers an area of 53,588 square kilometers, has 
an estimated total population of 394,000,2
 and is administratively divided into one urban and six 
Rural Health Districts (RHDs). The urban health district, which includes Oruro City, has a total 
population of 241,000. 
The CS-16 site includes two entire Rural Health Districts and most of a third RHD. 3
 Each 
district is divided into “areas” (most of which have one hospital), and each area is divided into 
“sectors” (most of which have one health center). (Please see map, next page): 
· District I, Huanuni (in the east of Oruro Department), 
· District III, Challapata (in the southeast of Oruro Department, excluding the area of 
Cacachaca in the east of the RHD, and the municipality of Salinas4
 in the west, where 
CS-16 will provide limited indirect support to selected MOH child health activities and 
include MOH staff from these areas in CS-16-supported training activities),5
 and 
· District V, Eucaliptus (in the north of Oruro Department), where SC has been working 
since 1997. 
The site includes approximately 450 communities,6
 with a total population of approximately 
104,500, and 13,500 children under age five.7
 The MOH estimates that there will be 
approximately 13,600 live births in the site over the four-year life of the project.8
 
2
 According to the 1992 national population census, Oruro Department had 340,114 inhabitants. The National 
Statistics Institute estimates that Oruro had a total population of 393,991 in the year 2000.
3
 The site includes a total of 9 provinces and 12 municipalities.
4
 Precise definition of the municipality of Salinas: Excluded from CS-16 will be the province of Ladislau Cabrera 
(Health Service Areas of: S. Garci Mendoza, Luca, Puqui, San Martin, and Ucamasi), except for the municipality 
and Health Service Area of Pampa Aullagas, which is included in CS-16.
5
 These areas (containing a total population of approximately 8,000, and 1,000 children under 5) are excluded from 
CS-16 because a complex local vendetta has led to increasing violence, including approximately 50 deaths during 
the first six months of 2000, and substantial out-migration. Salinas in the west of the RHD is also excluded because 
of its isolation and sparse population. (See: “Bolivia’s deadly West Side Story,” in The Economist, July 22nd, 2000, 
page 37.)
6
 The 450 CS-16 communities range in population from 3 to 9,800, with a mean of only 230 people (30 children 
under five) per community in this mostly rural area with low population density. For the purposes of the CS-16 
survey of communities, any settlement ½ hour or more walk from the nearest neighboring community was 
considered a “community” in its own right.
7
 Total and under-five population estimates for the CS-16 site are for 2001 from the central MOH. These are based 
on the estimate that children under five are 12.93% of the total population in this area.
8
 This is based on the MOH estimate that there will be 3.24 live births per 100 total population in this area, a CBR of 
32.4. This estimate is clearly not consistent with the MOH estimate that infants make up 2.59% of the total 
population, nor with MOH estimate of the <5 population in the site (unless mortality were several times higher than 
9
Though most of the people of the CS-16 site are Roman Catholics, rural Oruro, as the rest of 
Bolivia, is culturally heterogeneous. Most of the population speaks Spanish, though Aymara or 
Quechua is the first language of many.
Languages Spoken in the Three RHDs of the CS-16 Site9
Speak Spanish Don’t Speak Spanish
Spanish only: 20% Aymara only: 8%
Spanish & Aymara: 28% Quechua only: 3%
Spanish & Quechua: 35% Aymara & Quechua: 6%
Total: 83% Total: 17% 
Agriculture is a primary occupation, but production is limited in this area due to the poor soil 
quality and harsh environmental conditions, with Oruro suffering from a process of 
desertification due to prolonged draughts over the last few decades. Agricultural products 
include potato, oca, barley, and quinoa. Animal husbandry is practiced on a small scale as well, 
and primarily includes raising llamas, alpacas, and sheep. The area’s poverty results from low 
incomes due to the weak position of traditional farming systems in the agricultural economy, 
limited non-farm job opportunities, and low wages in the rural sector. Income from the sale of 
farm products by rural households is impeded by market imperfections such as the poor quality 
of access roads and resulting high transaction costs, and physical and financial barriers to 
retailing in urban markets (fees and fines). Income from working in the mines, once a significant 
industry, has been decreasing as prices have dropped and the cost of extracting ore is increasing. 
The production of traditional arts and crafts generates little income as well in a market that 
appears to be quite saturated and controlled by intermediaries. 
The household food economy in rural Oruro is definitely determined by the combination of 
limited agricultural production, low income, and unfavorable terms of trade. Many rural 
residents are net purchasers of food, with the average number of months that households are self￾sufficient in food ranging from five to seven months. Access to food is further constrained by 
relatively high prices for food items not produced locally, such as rice, bread, pastas, fruits, 
vegetables, salt, and sugar. The decline of the farm economy with resulting unfavorable terms of 
trade for small-scale farmers, has forced more and more of them to seek income-generating 
opportunities outside of their home communities. For that reason, seasonal and permanent out￾migration is high from this area.
The Altiplano and rural areas of Bolivia have the worst health and social indicators in the 
country. The rate of illiteracy in people over age 15 is 15% nationwide, 9% in urban zones, and 
28% in the rural areas. In Oruro Department as a whole (which is 70% urban), 6% of men and 
24% of women over age 15 are illiterate, while in the three rural health districts of the CS-16 
site, 11% of men and 38% of women are illiterate.10
MOH Child Health Services in the CS-16 Site
 
reported, or there is substantial out-migration of infants soon after birth). SC believes that it is possible that the 
under-five population is being under-counted/estimated and the number of expected live births over-estimated.
9
 Atlas Estadístico de Municipalities, INE, MDSP, COSUDE, 1999.
10 Atlas Estadístico de Municipalities, INE, MDSP, COSUDE, 1999.
10
Government hospitals and health centers are the principal providers of formal health services for 
the population of the CS-16 site. However, in Oruro Department, 70% of MOH staff are 
working in Oruro City.11 MOH health facilities in the three Rural Health Districts of the CS-16 
site include nine hospitals and 38 Health Centers. 
Health Facilities in the Three Rural Health Districts of the CS-16 Site
Level Facility Huanuni Challapata Eucaliptus Total
District District Offices 1 1 1 3
Area Hospitals 2 3 4 9
Sector Health Centers 9 18 11 38
Hospitals in the three RHDs have basic essential drugs and equipment, and professional staff 
including physicians in place, but do not conduct surgery and do not provide comprehensive 
emergency obstetric care. Approximately 11 Health Centers in the CS-16 site have between two 
to eight beds, and staff that usually includes a doctor and a nurse. Small Health Centers 
(formerly called Health Posts) are staffed by an Auxiliary Nurse, are equipped with basic 
medicines, and do not have the capacity to admit inpatients.
MOH Staff in the Three Rural Health Districts of the CS-16 Site12
District Service Personnel
Unit Doctors Admin. Staff Nurses Aux. Nurses Others
Dist. Office 1 2 1 0
Hospitals 6 7 3 10 Eucaliptus
H. Centers 1 0 0 11
Dist. Office 1 2 1 0 2
Hospitals 7 8 5 9 6
Challapata
H. Centers 5 5 6 22 0
Dist. Office 1 2 1 0 1
Hospitals 8 5 4 7 3
Huanuni 
H. Centers 4 2 11 4 2
Government hospitals and health centers offer the following services for children under five: 
management of diarrheal diseases and of acute respiratory infections; growth monitoring and 
nutrition counseling; vitamin A supplementation; in-patient management of malnutrition; and, 
immunizations. Maternal health services include: prenatal care, delivery, postpartum care, iron 
supplementation for pregnant women, and family planning. From a supply-side perspective, the 
Expanded Program on Immunization (EPI) is one of the strongest MOH interventions in the CS￾16 site. In the three Rural Health Districts, a cold chain is well established, EPI vaccines and 
supplies are available at health facilities, and EPI-related technical knowledge and skills of staff 
are good.
The Bolivian government introduced reforms in recent years to make public services more 
responsive to communities. In 1994, the Law of Popular Participation mandated grassroots 
 
11 Reported to SC staff by Dr. Martha Mejia, Child Survival Consultant, PAHO/Bolivia, 11/4/99. 
12 Servicio Departamental de Salud, MOH, 2001
11
representation on district health and social sector councils. In 1995, Administrative 
Decentralization transferred economic and political decision-making for key public services and 
resources, including the health system, to regional departments, municipalities, local citizens’ 
councils, peasants’ unions and ethnic groups. In 1998, the Ministry of Health and Social Welfare 
instituted universal access to primary care that covered basic MCH services, paid for through 
funds distributed to municipalities. 
The Basic Health Insurance law now regulates the services offered by the MOH. According to 
this law, primary health care services for women of reproductive age and for children under five 
are provided free of cost. The costs of these services are supposed to be reimbursed by the 
municipal government through payments to the health district on a per visit/per service basis. 
The law states that Mayors must reserve at least 6.4% of their municipal budget to pay for these 
basic health insurance costs. The law is relatively new, and there are still many problems 
implementing the scheme, with some municipalities accumulating over a year’s worth of debts, 
while others are unable to spend their health budgets.
Other Child Health Services in the CS-16 Site
A Bolivian NGO and CS-16 partner, APROSAR, The Association of Rural Health Promoters 
(Asociación de Promotores de Salud del area Rural), has been training and working with 
Promoters over the last 17 years in Oruro. Promoters are volunteers who carry out health 
education and promotion activities and provide basic curative care in rural areas to communities 
that do not have easy access to formal health services. APROSAR currently has 87 Promoters in 
the three rural health districts of the CS-16 site, each elected in community meetings. 
APROSAR’s selection criteria for Promoters include: sense of public service, honesty, 
willingness to be responsible for the health of families and the community, leadership abilities, 
and respect in their communities. Current services provided by Promoters include: ORT and 
referral for diarrhea when appropriate, detection and referral of children with ARI in need of 
further assessment (and treatment of pneumonia with cotrimoxazole by some Promoters), clean 
delivery and recognition of maternal danger signs, growth monitoring, nutrition and 
breastfeeding counseling, detection of epidemics, family planning, providing immunization with 
DHO support, first aid, prenatal and postnatal care visits, home visits, and health education in 
community meetings. Promoters receive 30 days of training, including training in participatory 
methods and inter-sectoral coordination. Medicines are sold to clients, with Promoters retaining 
a 10% profit, and re-supplied to Promoters through regular supervisory visits by APROSAR 
nurses. APROSAR provides Promoters with food during their training, reimburses them for 
travel costs to and from the training site, and provides some non-monetary incentives, such as 
books, jackets, and bicycles when funds are sufficient. 
SC/Bolivia (SC/B) estimates that approximately 10-15% of the under-five population of the CS￾16 site currently receive small food supplements through programs in Eucaliptus and Huanuni 
RHDs supported by the World Bank and the European Union. Other organizations supporting 
child survival-related activities in the CS-16 site include GTZ, which supports MOH institution 
strengthening and reproductive health in District III (Challapata), and DFID, which is initiating a 
family health project in the same district, though activities will be concentrated in Challapata’s 
urban area. A Bolivian NGO, Reform, is supporting the construction and staffing of health 
centers and is initiating some community health activities in District III with World Bank 
support. Food for the Hungry has recently phased out its support for health-related activities in 
Challapata RHD, which included food supplements. While there is much development activity 
12
going on in Challapata, very little is being done to mobilize rural communities around basic 
health issues, nor are mechanisms being provided to the district health office to respond to 
prioritized community needs. In meetings with SC, local authorities and the District Director 
have explained their intention of working via a unified community health vision (“perspectiva de 
mancomunidad”), by coordinating with the other projects that work in Challapata. 
Traditional health providers, called “Yatiris,” “Jampiries,” “Laris,” “Kallawayas,” “Tataquitos” 
(men), or “Mamaquitas” (women), are recognized by some for their powerful knowledge and 
effectiveness in treating illnesses.13 These traditional providers are respected and feared because 
they can use their powers against the people, provoking severe illnesses. They use herbs, 
flowers, fruits, seeds, wood, tobacco, animal feces, honey, oil, parts of different animals, 
minerals, urine, and petrol, among other things, to cure illness caused by bad wind, loss of soul, 
or lightening, and to make offerings to offending gods and goddesses. Huari in Challapata RHD 
is an important center for the purchase of herbs and supplies for rituals. Mothers participating in 
CS-16 focus group discussions did not cite supernatural causes of childhood illnesses frequently. 
Use of traditional healers was mentioned in three of the twelve focus group discussions, and was 
much less commonly cited than was use of home and traditional remedies, neighbors, drug 
shops, Promoters, and health facilities. In the CS-16 KPC Survey, less than three percent of 
mothers reported seeking advice from healers for childhood diarrhea or for serious respiratory 
illness.
Some private providers, including doctors, nurses, and pharmacies, also provide CS-related 
services in the larger towns of the CS-16 site (please see table below). In the CS-16 baseline 
KPC Survey, only three percent of mothers reported seeking advice from drug stores for 
childhood diarrhea or respiratory infections. 
Private Health Providers in the Three Rural Health Districts of the CS-16 Site
Huanuni Challapata Eucaliptus Total
Doctors 0 1 0 1
Dentists 1 2 0 3
Nurses 2 0 0 2
Laboratories 0 0 0 0
Pharmacies 3 3 0 6
Traditional Providers * 5 1 1 7
* This data is only for the urban areas of each district. SC estimates that each district has 20 to 30 
traditional health providers.
 
13 Alba Fernandez Juan, Between life and death, campesinos’ health providers, 1996.
13
4. Program Design: 
Broad Program Approach
SC will work with the site’s three MOH Rural Health Districts and the NGO APROSAR to 
implement four child survival interventions: Nutrition and Micronutrients, Pneumonia Case 
Management, Control of Diarrheal Disease, and Immunization. SC will document the feasibility 
and results of implementing these four interventions through three innovative approaches to child 
survival in Bolivia: (1) Community-Based-IMCI (CB-IMCI), focussed on training and 
supporting volunteer Rural Health Promoters to provide selected child survival services in their 
communities, based on the PAHO CB-IMCI materials adapted for Bolivia, while supporting 
concurrent MOH implementation of IMCI at health facilities; (2) The Hearth model using a 
Positive Deviance approach (Hearth/PD) to sustainable community-based rehabilitation of 
malnourished children and prevention of malnutrition, building on SC’s recent experience 
piloting Hearth/PD for the first time in Bolivia and building on SC’s success with this approach 
in other countries. If successful and cost-effective in CS-16, Hearth/PD has good potential for 
“uptake” by other organizations and reducing childhood malnutrition in other areas of Bolivia, 
and; (3) The Community Epidemiology Surveillance System (SECI), recently developed by 
SC/Bolivia to promote joint collection, analysis, and use of health information by health 
providers and communities to address local health needs, will be scaled-up through CS-16 based 
on SC’s initial success in ten communities of rural Oruro. SECI has great potential for 
improving utilization of health services on a large scale in Bolivia, if the approach continues to 
be successful and feasible following implementation throughout the CS-16 site.
CS-16 Goals and Results
CS-16 Goals include: 
· A sustained improvement in nutrition status of 6 to 35 month old children in Hearth/PD 
communities (which will be documented through CS-16);
· A sustained reduction in under-five mortality in the three health districts; and 
· Innovative CS-16 approaches inform policy and improve programming in other areas of 
Bolivia. 
These goals will be achieved through the CS-16 Results of:
· Improved capacity of APROSAR and the three health districts to support community 
activities and implement innovative, culturally-acceptable child survival approaches;
· Improved capacity of communities in the three health districts to identify and effectively address priority health 
needs of children under five;
· Increased use of key health services and improved child survival practices at household level in the three health 
districts; and 
· Uptake of successful innovative approaches by the MOH or by other organizations in 
Bolivia.
These Results will be achieved through the CS-16 Intermediate Results of:
· Demonstrated SC/Bolivia capacity in CB-IMCI, SECI, and H/PD capacity building of CS-16 
partners and advocacy;
· Documented feasibility and results of implementing innovative CS-16 approaches;
· Increased availability of selected child survival services in the three health districts;
· Improved quality of selected CS services in the Program site; and
14
· Increased caretaker knowledge and awareness in the three health districts of selected child 
survival issues.
The following three sections describe the analytical basis and methodologies for combinations of 
CS-16 strategies and interventions to address key CS-related needs of rural Oruro in an 
integrated way, and increase equitable access to and use of key CS services.
(1) Implementation of PCM, CDD, and EPI Activities through the CB-IMCI Approach
The Bolivian MOH has made IMCI its most important strategy to reduce child mortality in the 
country. Community-Based-IMCI is being developed to address community and family 
practices related to child survival, and to address poor access to health facilities, especially in 
isolated rural communities. PAHO has developed three training packages for CB-IMCI: a basic 
CB-IMCI training course for community health workers, a module on “Talking with Mothers,” 
and a course for planning IMCI at the community level. The MOH, together with PAHO, 
BASICS and an inter-institutional team (of which SC/B is a member), has recently completed the 
adaptation of the generic PAHO CB-IMCI materials for use in Bolivia. The Bolivian MOH CB￾IMCI approach is based on training and supporting Rural Health Promoters to provide 
appropriate CS services, including health education, in their communities.
Because of the very high under-five mortality in rural Oruro, poor geographic access of much of 
the population to health facilities, and the low utilization of health services, CB-IMCI is 
particularly important in this setting. The CDD and PCM interventions address two of the 
leading causes of under-five deaths in Bolivia. The immunization intervention will address low 
immunization coverage in the project site. All three are key IMCI, and particularly CB-IMCI, 
interventions. SC has had substantial experience and success working with Promoters and 
implementing of CDD, PCM, and immunization activities at the community level in Eucalyptus 
Health District through the recently completed Mission/PROCOSI 14
-funded child survival 
project. 
SC/Bolivia, in coordination with the MOH and PAHO, will implement CB-IMCI on a pilot basis 
through CS-16, while supporting concurrent MOH implementation of IMCI at health facilities in 
the project site. The CS-16 CB-IMCI approach is based on training and supporting Rural Health 
Promoters to provide appropriate child survival services in their communities, including 
promotion of key CS practices at the household-level and utilization of key CS services, and case 
management of childhood illness in communities with poor access to health facilities. 
Promoters, working out of their own homes, will provide diarrhea and pneumonia case 
management services for ill children, assess immunization and nutrition status and refer children 
for immunization and nutrition rehabilitation (at Hearths or health facilities). They will provide 
health education services from their homes when seeing ill children, during home visits (when 
SECI information is collected, see below), and during community-level group activities, 
including community/SECI meetings, using SC, MOH, and PAHO CB-IMCI materials adapted 
for Bolivia, and interactive methods, including SECI information analysis and discussion.
 
14 “PROCOSI is a network of nonprofit Bolivian organizations who contribute to the improved health of the 
population through activities to strengthen the health and development programs of its members and to influence 
public opinion.” (PROCOSI’s mission statement). SC was one of the three PVOs which developed and submitted 
the original proposal for PROCOSI to USAID in 1987, and has continued to play a leading role in the organization.
15
CS-16 will conduct a field test of the PAHO CB-IMCI materials adapted for use in Bolivia and 
of the entire CB-IMCI strategy, testing different methodologies and approaches. CS-16 will help 
define and describe a CB-IMCI model for rural Bolivia, including definition of roles of Rural 
Health Promoters, service providers, communities, and NGOs in CB-IMCI; revise draft CB￾IMCI materials adapted for Bolivia, if required; develop a revised Promoter job description; 
determine and meet needs for CB-IMCI BCC materials; define content and methodology of 
training courses; conduct CB-IMCI training and follow-up activities, including meetings to 
assess progress, in-service TA and supervision, and refresher training. 
CS-16 will establish links between CB-IMCI, facility-based IMCI, and other organizations. 
Links with facility-based IMCI will be promoted through the establishment of a two-way referral 
system for ill children between Promoters and health facilities, and through joint training, 
monitoring, exchange of information, and joint CS activities at the community level. Links with 
other organizations will be promoted through inter-institutional participation in training and 
follow-up of Promoters, joint design of educational materials, and advocacy with the MOH to 
approve policies that facilitate the work of Promoters. PAHO and the MOH in Bolivia support 
SC’s proposed introduction of CB-IMCI, and are committed to providing assistance to the 
project. 
(2) Improving Child Nutrition through the Hearth Model Using a Positive Deviance Approach
The Hearth/PD approach seeks affordable, sustainable, community-based nutritional 
rehabilitation and prevention of childhood malnutrition. The approach is based on “positive 
deviance” (PD), the observation that most poor communities include impoverished families with 
well-nourished children. These poor “Positive Deviant Families” who have well-nourished 
“Positive Deviant Children” are the living proof that it is possible for poor families to have well￾nourished children, before economic improvements occur or clean water and sanitation are 
accessible to all. The positive deviance method identifies these families, catalogues the unique 
behaviors (including healthy breastfeeding and complementary feeding practices, among others), 
which have enabled them to raise healthy children, and then disseminates these behaviors among 
neighbors through Hearth sessions, leading to new community norms for child feeding and 
caring. 
Building on work by other PVOs in Haiti and Bangladesh, SC has demonstrated and brought to 
scale a measurable, replicable, community-based approach to sustainably alleviate childhood 
malnutrition in Vietnam.15,16,17 The Hearth/PD approach has only recently been introduced in 
Bolivia for the first time by SC on a small scale through the recently completed 
Mission/PROCOSI-funded child survival project in Eucaliptus. CS-16 will build on initial SC 
experience with Hearth/PD to further refine the approach, and document impact on nutritional 
status of children and feasibility of implementation. Because of the lower population density and 
 
15 Sternin M, Sternin J, Marsh D, Scaling Up A Poverty Alleviation and Nutrition Program in Viet Nam, for 
Marchione T, Scaling Up, Scaling Down: Capacities for Overcoming Malnutrition in Developing Countries, in 
press, Gordon and Breach.
16Sternin M, Sternin J, Marsh D, Rapid, Sustained Childhood Malnutrition Alleviation Through a “Positive 
Deviance” Approach in Rural Vietnam: Preliminary Findings” in Keeley E, Burkhalter BR, Wollinka O, Bashir N 
(eds) The Health Nutrition Model: Applications in Haiti, Vietnam, and Bangladesh, Report of a Technical Meeting 
at World Relief Corporation, Wheaton, IL, June 19-21, 1996, Arlington: BASICS, 1997.
17 Larimer T, Nghia T, Vietnam’s Deadly Puzzle, Time, 152(1), July 13, 1998.
16
lower rates of childhood malnutrition in rural Oruro than in Vietnam, the marginal costs of 
Hearth/PD implementation in relation to nutrition status outcomes will be an important issue to 
be documented by CS-16. If successful and cost-effective, Hearth/PD could be implemented as a 
component of CB-IMCI through other organizations, and make an important contribution to 
reducing childhood malnutrition in other areas of Bolivia.
CS-16 will gradually phase-in Hearth/PD activities in eligible communities throughout the 
project site based on the SC Hearth/PD Field Guide18 and CORE Group/CSTS Field 
Cookbook.19 Hearth/PD eligible communities will be identified based on the following criteria: 
(a) Twenty or more underweight (< -2Z weight-for-age) 6 to 35 month-old children identified in 
the community through the H/PD nutrition status survey; (b) Availability of affordable local 
foods; and (c) Mothers willing to work as Hearth Volunteers. Following the selection of 
communities, local human resources for support of Hearth/PD will be identified and oriented, 
including: community health committees, health volunteers, and formal and non-formal health 
workers. This will be followed with a situational analysis of malnutrition in children, including a 
baseline nutrition survey, focus group discussions, and then a joint CS-16/community definition 
of Hearth/PD program goals. Then, through the Positive Deviance Inquiry (PDI), villagers and 
program staff will identify the PD families’ special and demonstrably successful current feeding, 
child care, and health-seeking practices which enable them to “out perform” their neighbors 
whose children are malnourished but who share the same resource base. For example, in the 
initial PDI in six communities of Eucaliptus Health District in June-July 1999, quinoa, eggs, 
llama meat, carrot juice, and papaya were identified as PD foods; and feeding the child a mid￾morning snack, using games and songs to convince children to eat, and active feeding, were 
identified as a PD feeding practices.20
 
Based on the PDI findings, the villagers and the program staff plan a “Nutrition Education and 
Rehabilitation Program” (NERP) to sustainably rehabilitate malnourished children and prevent 
malnutrition in young children in the community through the promotion of current successful 
child feeding, caring, and health-seeking behaviors. The NERP plan includes Hearth menus and 
messages, identification of household PD food contributions as the price of admission to the 
Hearth sessions, Hearth health and nutrition education protocols, and plans for support of and 
integration of other existing nutrition-related programs into NERP, particularly the MOH vitamin 
A supplementation program. Each month, over a two-week period, caretakers of malnourished 
children identified through regular growth monitoring are invited to participate in daily Hearth 
sessions to rehabilitate their children with the help of neighborhood volunteer mothers. These 
Hearth Volunteers supervise caretakers preparing a calorie-dense meal and feeding it to their 
malnourished children.
(3) Mobilizing Communities and Health Services through SECI, the Community Epidemiology 
Surveillance System
 
18 Sternin M, Sternin J, Marsh D. Designing a Community-Based Nutrition Program Using the Hearth Model and 
the Positive Deviance Approach – A Field Guide. Save the Children, December 1998.
19 The Field Cookbook for the HEARTH Nutritional Model Using the Positive Deviance Approach, First Draft, 
Sponsored by the CORE Group and CSTS, Written and compiled by Donna Sillan, MPH, September 2000.
20 The Results and Application of a Positive Deviance Inquiry on the Bolivian Altiplano. Melissa Cribben, Rollins 
School of Public Health, and Save the Children/Bolivia.
17
Two important lessons were learned through the Warmi Project that have helped to guide the 
design of SECI: (1) Communities need to have access to relevant information on their health 
status, and on what has and has not worked in other similar settings, to make informed decisions 
about priorities, to develop appropriate strategies, and to be able to monitor their progress toward 
their objectives; and (2) A development approach to health where external organizations work in 
parallel is not ideal. Some organizations work almost exclusively with service providers to build 
capacity for service delivery while others almost exclusively work with communities to increase 
demand for services and improve health behaviors, without paying attention to how these groups 
relate. This can result in services that are not responsive to clients’ needs, and can lead to client 
expectations that may not be realistic. While there are important and valid reasons to provide 
assistance to communities and service providers separately, this paradigm does not allow for the 
possibility of sharing responsibility for health by establishing common objectives and building 
on the joint resources and commitment of service providers and communities.
SC/B’s experience in Bolivia has also shown that disseminating key messages from a biomedical 
perspective through health talks and other means, has limited impact on the adoption of these 
practices by rural families. Health service providers and others who work with communities, 
such as those in rural Bolivia where traditional beliefs and practices are strong, need to recognize 
the importance of both kinds of knowledge: the scientific technical and the popular traditional 
knowledge. Establishing a respectful dialogue between the two can lead to innovative and 
effective “new and improved practices” and a broader understanding of the rationale behind 
existing and recommended actions. SC/B applied this approach successfully in its work with the 
Warmi project, and will adapt these methods to incorporate a “dialogue of knowledge” between 
service providers and communities around priority child health topics at general community 
meetings at which SECI is implemented.
SECI, recently developed and introduced on a small-scale by SC in Eucaliptus RHD through the 
JHU PCS4 grant, attempts to address these concerns by adopting a partnership and team-building 
approach, so that respectful dialogue and analysis can take place, leading to joint action based 
upon common goals and objectives. SECI consolidates primary health care data collected by 
health service providers and community health Promoters using simple forms and community 
maps. SECI facilitates increased communication between communities and health service 
providers, first by bringing Promoters and service providers together to consolidate the data. 
They then present the data in easy to understand graphics to the community so that together, they 
can obtain and analyze new information about community health problems and articulate health 
priorities that reflect community priorities. Communities and service providers acting together 
have also been able to leverage increased financial resources for health services from municipal 
health budgets, and SECI meetings have stimulated joint community and service provider action 
that has led to several improvements in local health services. (Please see examples in DIP 
Section I.I. on the CS-16 Devolution Strategy.) 
An evaluation of the SECI pilot was conducted in June 1999, in collaboration with 
Emory University, and showed promising results. The evaluation assessed the 
experiences of villagers and health personnel who participated in SECI for one year, and 
compared health practices and use of MCH services in intervention and control 
communities. SC staff kept project-related records for all ten intervention communities 
and supervised an ethnographic study involving fifty key informants and nine focus 
groups in three of the intervention communities. Local interviewers conducted a cross-
18
sectional survey in seven intervention and seven control communities, randomly 
sampling 218 households and 344 children. The evaluation found that SECI enabled 
communities to assess their health, plan, and act as partners in the local health system. 
Intervention communities promoted local health, demanded more responsive and 
accountable health services, and built positive working relationships with participating 
health personnel. Intervention communities were more likely to use several types of 
child health services and practice healthier behaviors. More intervention than control 
households reported: complete child immunization (11% vs. 3%, p<.05); vitamin A 
supplementation (59% vs. 42%, p<.05); health card possession (45% vs. 28%, p<.05); 
early breastfeeding (26% vs. 12%, p<.05); and adding oil to complementary foods for 
young children (67% vs. 52%, p<.05).21 However, caregivers’ recognition and home care 
of child illness, and caregivers’ knowledge of contraceptive methods did not appear to be 
influenced by participation in the project, and participation in the project did not appear 
to influence use of services for child illness or reproductive health (including antenatal 
care and tetanus-toxoid immunization).
In the ten pilot communities, a total of 2,334 people participated in regular monthly community 
meetings into which SECI has been incorporated to analyze health data and plan solutions 
together with service providers. Evaluation “participants reported that community members and 
leaders were more concerned about maternal and child health than they had been before.” 
Meeting records and key informants indicated that community members were adopting new 
health behaviors to “protect” maternal, infant and child health in order to prevent illness and 
death “so they would not feel sorry later.” 
“The results of this study support the hypothesis that SECI mobilized community members to 
use health information to improve maternal and child health. SECI has provided a new way for 
communities to organize around health issues. Qualitative data indicated that SECI was 
successful in bringing community members, health professionals, and community authorities 
together to discuss maternal and child health problems and issues related to health services.”
Based on these initial encouraging results and on MOH interest in SECI, CS-16 will phase-in 
SECI throughout the three health districts of the project site, following the SC/Bolivia SECI 
manual. A “dialogue of knowledge” will be incorporated into general community meetings at 
which SECI is implemented. The dialogue begins with an in-depth exploration of existing 
attitudes, beliefs, and practices, based on a series of questions that a facilitator will pose to 
community participants. The dialogue begins with a general discussion about children and what 
children mean to a family and the community, what it means to a family when a child is born and 
when a child dies, when a child is sick and when a child is healthy. The discussion will then 
focus on priority health problems as identified by the community through analysis of SECI data. 
Communities will share their experience with these priority health problems, discussing what the 
problem is called locally, what people believe causes the problem, how it is treated, and what 
happens when it is not treated or treatment is not effective. At this point, there are no correct or 
incorrect answers and the service providers’ role is to listen, ask questions, and learn. Service 
providers then have the opportunity to share what the current “state-of-the-art” medical practice 
is in terms that community members can understand. A discussion then ensues between all 
 
21 Cynthia P. Willis, Dirk G. Schroeder, Lisa Howard-Grabman, David Marsh, and Fernando Gonzales. 
Strengthening partnerships in local Bolivian health systems with community-based health information, Draft, 
February 14, 2001.
19
participants to explore what is feasible, what is currently working well, and which practices are 
harmful. At this point, positive deviance approaches may be used to discuss healthy/PD 
practices of community members with the healthiest children. Based on these discussions, the 
participants negotiate “new” and/or “improved” practices. They then monitor the results of 
adopting these new practices, and revise practices if necessary.
SC and the MOH believe that SECI has the potential to make an important contribution to 
improving the utilization of health services on a large scale in Bolivia if the approach continues 
to be successful and feasible following implementation throughout the CS-16 site.
5. Partnerships:
Selection, Description, and Roles of CS-16 Partners
The selection of the CS-16 site, covering Rural Health Districts I and III, in addition to District 
V, Eucaliptus, where SC has been working since 1997, was based on detailed discussions with 
the NGO APROSAR and the Directors and staff of all three RHDs, and their enthusiasm for 
jointly implementing CS-16 with SC. These three districts are the three most populous Rural 
Health Districts of Oruro Department. CS-16 partnerships build on SC/Bolivia’s relationships 
with the Eucaliptus MOH Rural Health District and with APROSAR to implement “Child 
Survival in Oruro”22 from February 1998 through January 2001, and “Community Mobilization” 
(SECI)23 from July 1997 through June 2000. APROSAR had a sub-contract with SC to support 
these child survival activities in Eucaliptus, including SECI and Hearth/PD, through APROSAR 
Promoters.
APROSAR was born out of grassroots organizing of Rural Health Promoters with initial 
assistance from Project Concern International from 1980 through 1989. Since its inception, 
APROSAR’s Promoters have been working with communities on child survival and other 
primary care activities in Oruro and Northern Potosí. In 1992, APROSAR was legally registered 
as a non-governmental organization in Bolivia. APROSAR’s mission is to preserve and promote 
health in communities with scarce resources, respecting their customs and culture, emphasizing
self-care in health to contribute to community development. APROSAR has worked in 
partnership with several institutions including Freedom from Hunger, CIES, CARITAS, the 
MOH in selected districts, and municipal governments and local health districts. In the CS-16 
site, APROSAR is currently implementing a reproductive health project funded by PROCOSI 
and an adolescent reproductive and sexual health project funded by Population Concern, both in 
Huanuni RHD. 
Most CS-16 activities, with the exception of financial management and reporting, will be 
conducted jointly with APROSAR and the three District Health Offices. SC will: Develop 
detailed action plans with CS-16 partners; Coordinate and organize project activities with 
partners; Train partners in CB-IMCI, Hearth/PD, and SECI; Provide technical assistance to CS￾16 partners in the use of SECI and SNIS health information systems, management, logistics, 
 
22 Funded through PROCOSI/USAID.
23 Funded through Johns Hopkins University PCS4/USAID.
20
human resource management, strategic planning, and financial management; Supervise the 
subcontract with APROSAR and ensure the fulfillment of commitments; Support, supervise, and 
evaluate Program activities; Monitor CS-16 progress; Identify and resolve technical and 
organizational problems; Implement baseline assessments and mid term and final evaluations; 
Promote the organizational development of the partners; Document and disseminate results; 
Encourage the MOH to establish policies favorable to CB-IMCI and Promoters; Adapt, test, and 
revise new CB-IMCI materials with partners, and; Prepare and submit program and financial 
reports for SC and BHR/PVC.
The three MOH Rural Health Districts will: Participate in the training of Promoters and 
Auxiliary Nurses in CB-IMCI, SECI, and Hearth/PD; Jointly supervise and support Promoters 
and Auxiliary Nurses; Implement CB-IMCI community activities; Facilitate SECI sessions and 
help develop community health plans; Help design and implement baseline assessments and 
evaluations; Maintain SECI information in the district SECI database, incorporate SECI data into 
SNIS, and use this information in the Information Analysis Committees (CAI’s); Establish a 
two-way referral system with Promoters; Develop annual operations plans which include CS-16 
activities, and; Participate in the quality circles, as part of quarterly evaluation and planning 
meetings. All MOH health facilities in the three RHDs are under the jurisdiction of the District 
Health Offices. The roles of these facilities in CS-16 includes: Treatment of ill children, 
provision of immunization services in the facility and in outreach sites, and contribution of one 
member of their staff for regular participation in SECI meetings. 
In Huanuni RHD and Totora Municipality of Eucaliptus RHD, APROSAR will: Develop a work 
plan for CS-16 activities; Participate in the training of its Promoters in CB-IMCI, SECI, and 
Hearth/PD; Ensure completion of CS-16 work plan activities; Support, monitor, and evaluate 
implementation and quality of the work of Promoters; Evaluate the completion of the quarterly 
results and propose modifications to the quarterly plan, and; Participate in the midterm and final 
evaluations.
PAHO will: Provide technical assistance for the adaptation, testing, and revision of CB-IMCI 
materials; Provide technical assistance for evaluation of the CB-IMCI strategy; Participate in the 
evaluations, and; Promote change in policies to facilitate CB-IMCI and work of Promoters.
SC/B also has agreements which support CS-16 activities, or which relate to CS-16 activities, 
with the following organizations in Bolivia: the MOH at central level in La Paz and departmental 
level in Oruro, PROCOSI, and the World Bank.
6. Health Information System: 
F.2. Program Monitoring and Evaluation Plan
SC/B’s Organizational Approach to M&E: As noted in Section II.A., above, CS-16 will be 
managed, and program performance monitored, through the Quality Circle management structure 
currently used by SC in Bolivia, which has proven effective in rural project management. This 
structure provides for an appropriate delegation of authority to promote efficient decision 
making. The CS-16 field staff will have monthly quality circle meetings to plan for the next 
month, as well as to discuss and propose solutions to immediate problems. Senior project 
management from Oruro and La Paz, APROSAR, and MOH district staff will participate in the 
21
monthly quality circle meetings. APROSAR & MOH STAFF DO NOT PARTICIPATE IN 
MONTHLY MEETINGS
Quarterly project evaluations also take place as part of the normal implementation process. All 
SC/B program staff are familiar with the monthly quality circles and quarterly evaluation 
structures, and participate actively in the collection and presentation of quarterly information for 
their programs. Quarterly evaluations document activities from the last quarter, assess progress 
toward achieving results and objectives, and serve as a basis for planning activities for the 
upcoming quarter. As currently implemented by SC, senior management from La Paz will 
participate in the quarterly evaluations. Feedback is provided by the entire office, not just from 
health staff. Senior and key staff review the information for accuracy and make appropriate 
strategic management decisions to improve program quality. A quarterly plan is then created 
and agreed upon by the participants. A quarterly report is produced, documenting results, plans, 
and decisions made. This information will be used for CS-16 reports to partners and 
collaborating organizations in Bolivia, to SC’s Home Office, and contribute to annual reports 
and mid-term and final evaluations. 
CS-16 Approach to M&E, Relationship to Community and Facility Data, and Tools Used: SECI 
and the MOH SNIS (described in DIP Section I.F.3) form the core of the CS-16 approach to 
monitoring. Evaluation of program performance will be based on measuring achievement of the 
CS-16 objectives using the means listed in the tables above, and based on midterm and final 
evaluations following BHR/PVC guidelines.
SECI consolidates primary health care data collected by health service providers and community 
health Promoters using simple forms and community maps. SECI also contributes more 
complete reporting of health information from communities to the RHDs. Currently the 
following information is collected by Promoters during home visits every two months, and
included in SECI data analysis and presentations/discussions in community meetings every two 
months:24 number of live births, stillbirths, children <5 with diarrhea in last month, <5s with rash 
and fever in last month, <5 deaths, signs prior to death in infants and in 1-4 year olds, number of 
pregnancies, deliveries with the help of trained personnel, deliveries without trained personnel, 
maternal deaths, signs prior to maternal deaths, and observations/remarks. Communities may 
decide to collect information on additional variables. Health facility staff currently contribute 
the following information to SECI: The same variables as reported by Promoters (above), but for 
cases seen at health facilities, pregnancies with anemia, pre-natal visits, nutrition status data from 
growth monitoring sessions (through Hearth/PD in some communities), immunization coverage, 
and pneumonia treatment. This set of variables also varies over time and between communities 
as variables are added and dropped by community members and health workers in SECI 
meetings. 
After SECI is initially introduced in a community and Promoters trained in data collection, 
Promoters start collecting information during home visits together with SC staff. SC staff also 
conduct periodic home visits without Promoters to ensure validity of data collected by the 
Promoters, and check Promoter and RHD/health facility data for errors.
SECI facilitates increased communication between communities and health service providers, 
first by bringing Promoters and service providers together to consolidate the data. They then 
 
24 Mortality data is presented and discussed every six months. 
22
present the data in easy to understand graphics to the community so that together, they can obtain 
and analyze new information about community health problems and articulate health priorities 
that reflect community priorities. The methodology builds in a series of analysis questions and 
ways to present the data so that community members and service providers can compare trends 
over time, monitor progress, and determine where alternative strategies are needed. As changes 
are implemented, the health information system will continue to help the communities and health 
staffers work together to monitor progress toward achievement of agreed upon objectives and to 
make decisions on municipal and community resource allocation. Communities and service 
providers acting together have been able to leverage increased financial resources for health 
services from municipal health budgets, and SECI meetings have stimulated joint community 
and service provider action that has led to several improvements in local health services. (Please 
see examples in DIP Section I.I. on the CS-16 Devolution Strategy.)
SECI tools include a manual,25 problem picture cards, pictorial ways of presenting quantitative 
information to literate and illiterate community members (for example, using the national flag 
with red, yellow, and green bands to represent high, medium, and low risk), and an optional 
software package to consolidate community-level data from health Promoters with SNIS national 
health information system service-based data, and translate this more complete epidemiological 
picture into graphics that can be used with communities. CS-16 will use the SECI software to 
computerize all basic/uniform data from Promoters and health services on the variables listed 
above. CS-16 SECI implementation will include an operational assessment of how the SNIS 
national health information system is functioning; training of DHO staff in the use of the SECI 
software package and SNIS; monitoring and supervising trainees in the flow of SECI and SNIS 
information, and use of this information in the District Health Information Analysis Committees; 
and providing technical assistance to the Area and District Health Information Analysis 
Committees. 
SECI and SNIS are essentially complementary systems. The SNIS focuses on collecting data 
from health facilities on services provided, while SECI focuses on data from households on 
events in the households. SNIS data is analyzed and presented at the RHD, departmental (Oruro) 
and national levels, while SECI data is analyzed and presented at the community level. CS-16 
seeks to develop RHD capacity to effectively collect and use both SECI and SNIS data. CS-16 
does not seek to integrate SECI data into the SNIS, an important issue raised in the USAID 
Bolivia Mission review of the CS-16 application. 
CS-16 staff will also monitor the quality of CS-16-related services, and obtain feedback on 
which program approaches are working well and which need to be improved, through 
participatory reviews of CS-16 progress with health workers and community members during the 
community-wide SECI meetings. Other sources of information for monitoring CS-16 progress 
and performance include: Assessments of health worker performance and availability of essential 
supplies through supervisory visits; Assessments of health worker knowledge and skills during 
refresher training needs assessments, and; the DHO reporting system for data on use of health 
services, including pneumonia and diarrhea case management and EPI coverage.
Information from the DHO, SECI, and APROSAR/Promoter reporting system will be analyzed 
on a quarterly basis by CS-16 staff. Reasons for comparatively very high or very low rates of 
 
25 Save the Children/Bolivia, Johns Hopkins University. Manual SECI, “Sistema Epidemiologico Comunitario 
Integral.” September, 1999.
23
service provision in any community or by any facility or health worker, will be investigated, and 
actions taken to improve performance if indicated. Meetings at the RHD-level with DHO, 
facility, APROSAR, and SC staff will be used to review progress, activities, and achievements, 
and to identify and solve problems.
Monitoring and Improving Performance of Health Workers: Quality CS services will be 
achieved through: Basing health worker training and behavior change messages on good and 
current curricula and materials, and on participatory SECI meeting results regarding beliefs, 
practices, and satisfaction with services; Competency-based training involving clinical and 
counseling practice with small groups of trainees and ill children and their mothers; Using 
standards of practice during health worker training and supervision; Providing refresher training 
to address identified problems; Regular supportive supervision and provision of essential 
supplies, and; Through regular meetings to discuss activities and achievements, and identify and 
solve problems. Supervisory visits will include reviews of health worker’s records and stocks of 
essential supplies, and discussions about activities, problems, and solutions.
Tools Used by CS-16 to Promote Quality of Service: In addition to the SECI tools described 
above, other important tools to promote quality of service in CS-16 include the PAHO CB-IMCI 
materials adapted for Bolivia and Hearth/PD materials. Although the CB-IMCI materials 
contain several mistakes, the national IMCI committee has decided that this year all the 
organizations that are implementing IMCI should use this material, and after one year, this same 
committee will make a revision with inputs from other organizations. SC/B plans to contribute 
suggestions based on experience with the materials gained through implementation of CS-16 and 
the DAP. Hearth/PD materials adapted for Bolivia, are not yet available, but will be developed 
through CS-16 and the DAP, based on the SC Field Guide, materials from SC/Vietnam, and the 
draft CORE cookbook. The Hearth/PD materials will be complemented by nutrition materials 
produced in Bolivia by the LINKAGES Project in cooperation with the MOH and PROCOSI 
members. Training curricula, supervisory checklists, and job descriptions of MOH staff, CS-16 
staff, and Promoters in CS-16 are being developed by the project. Tools to be used to promote 
quality of service currently being designed with all CS-16 partners include: checklists to be used 
on a quarterly basis to assess performance of Promoters, MOH staff, and CS-16 staff, based on 
CB-IMCI guidelines, the draft PD cookbook, training messages and curricula. THESE HAVE 
NOT BEEN DEVELOPED
Aspects of the M&E System which May Be Sustained by the Community: SC hopes that joint 
implementation of SECI through CS-16 will allow the three Rural Health Districts, APROSAR, 
Promoters, municipalities, and communities to reach sound decisions about which of the 
program’s approaches and activities they wish to and can sustain following the end of the 
project. SECI data collection through home visits by promoters may not be very sustainable. 
During the last year, the frequency of home visits has been reduced from once a month to once 
every two months. Other possibilities for more time efficient methods of SECI community data 
collection include collection of information at market days or through women’s and other 
groups, or more Promoters could be used to reduce the data collection burden on each Promoter.
24
Attachment B
Team members and their titles
Name Position Institution
Albina Chacolla 
Nelson Tola
Carmelo Churo 
Felix Condori 
Carola Cossio
Jaime Leon
Juan Laime
Marcelino Brañez
Delia Flores
Raul Salinas
Silverio Padilla
Edgar Callahuara
Jorge Viricochea
Julia Lipiri
German Viscarra
Ruth Perez
Alfredo Juaniquina
Carolina Reynaga
Zenon Caceres
Jaime Salinas
Alberto Tenorio
Romelia Antonio
Renee Charleston
Gonzalo Arevalo
Ccoya Sejas
District Coordinator Eucaliptus
Health Trainer Totora
Promoter Sacari
Statistician Challapata
Health Trainer Challapata
Health Trainer Huayllamarca
Health Trainer Qaqachaca
District Coordinator I Huanuni
Trainer Health Poopo
Director Hospital Caracollo
Trainer Health Pampa Aullagas
Promoter
District Director Challapata
Nurse Pampa Aullagas
Health Trainer Caracollo
District Coordinator Challapata
District Coordinator Huanuni 
Health Trainer Eucaliptus
Promoter Eucaliptos
Statistician Eucaliptos
IMCI
Trainer Health Challapata
Team Leader 
CS Coordinator
National Health Coordinator
SAVE
APROSAR
MOH
SAVE
SAVE
SAVE
SAVE
APROSAR
MOH
SAVE
MOH
MOH
SAVE
SAVE
APROSAR
SAVE
MOH
BASIC
SAVE
Consultant
SAVE
SAVE
Other participants in Planning and Analysis Workshops
Jovana Centeno
Reyna Arteaga
Caroline Hilari
Dr. Lesmes Muñoz
Teresa Peleaz 
Iber Tapia 
Wilge Arandia
Anastasio Choque
Health Trainer Pazña
Health Trainer Huanuni
National Health Advisor
Departmental Planner 
Departmental CB- IMCI
MIS/SECI Specialist
Health Sector Coordinator
Director
APROSAR
APROSAR
SAVE
MOH
MOH
SAVE
APROSAR
APROSAR
25
Attachment C
Assessment methodology
PARTICIPATORY EVALUATION PROCESS
I. OBJECTIVES OF THE EVALUATION
The purpose of the Midterm Evaluation was to;
1. Assess progress in implementing the DIP; 
2. Assess progress towards achievement of objectives or yearly benchmarks; 
3. Assess if interventions are sufficient to reach desired outcomes, 
4. Identify barriers to achievement of objectives, and 
5. Provide recommended actions to guide the program staff through the last half of the 
program.
The evaluation was carried out in accordance with USAID/BHR/PVC MTE guidelines and the 
evaluation report follows the suggested format.
The objectives of the evaluation are:
· Identify the principal achievements of the project, focusing on which strategies were most 
effective and the barriers which were overcome during the implementation.
· Develop recommendations for improving project strategies in order to achieve greater impact 
during the next two years.
· Develop recommendations on how to improve sustainability.
II. COMPOSITION OF EVALUATION TEAM
The team was composed of SC Project staff and SC Bolivia staff, MOH staff, APROSAR staff, 
Community Health Promoters, and a representative from BASICS, plus an external consultant 
who served as team leader. The team leader was responsible for coordinating all evaluation 
activities, supervision of the team, meeting all specified objectives, collaborating with SC, 
APROSAR and MOH, and submitting a draft and a final report according to the defined 
timeline. Three SC Project staff functioned as the coordinators of the teams for field data 
collection, including overall coordination, planning and logistical support of the team.
III. METHODOLOGY
Using both a participatory approach and participatory methodologies, a multi-disciplinary term 
of key project stakeholders examined the implementation of CS activities using a variety of 
qualitative methodologies. Field visits allowed project participants and community volunteers to 
provide their inputs and suggestions to the evaluation process. The evaluation focused on the 
process of activities including; capacity building, planning, information system, community 
participation, coordination with MOH and APROSAR, and sustainability. The methodologies to 
obtain information for the evaluation included:
Document Review
Key Informant Interviews
Group Interviews
26
Observations
IV. EVALUATION PLAN
The evaluation was divided into four phases:
Phase I Planning
· Preplanning (Formation of team, logistics, document review, selection of communities) 
· Planning Workshop (Content, methodologies, design of instruments) 
Phase II Data Collection
· Field Work visits 
· Other interviews 
· Document review 
Phase III Data Analysis
· Summarize data 
· Analysis of data by the evaluation team (2 day Analysis Workshop)
Phase IV Presentation
· Written report 
· Formal presentation to be scheduled after report is finalized
A two-day Planning Workshop was held for all team members plus additional collaborators, to 
define the objectives of the evaluation, the content of the evaluation and to develop instruments 
for obtaining information during field visits.
The evaluation team was divided into 3 small groups to collect information from the field. Each 
team consisted of 7-8 people. The teams were in the field for 3 days to visit 12 communities 
previously selected by SAVE staff for visits. Visits were also made to Municipalities, Area MOH 
hospitals, and a training session for CHWs. A fourth team made up of the team leader, CS 
Coordinator and National Health Advisor traveled with each of the three teams on a rotating 
basis as indicated in the following table.
 7 of SEPT. SATURDAY 8 of SEPT. SUNDAY 9 of SEPT. MONDAY
District Huanuni Eucaliptus Challapata
GROUP 1
Albina*
Nelson
Carmelo
Felix
Carola
Jaime L.
Juan
Totoral
Antequera
(IMCI)
Hospital
Eucaliptus
(IMCI)
Quemalla
(H/PD)
Hospital
Qacachaca
(SECI)
Í
Municipality
Hospital
GROUP 2
27
Marcelino*
Delia
Raul
Silverio
Edgar
Jorge
Julia
German
Casa Lopez
(H/PD)
Í
COMUSA
Huayllamarca
Chillcani
(SECI)
Municipality
Sacari
Challapata
(IMCI)
Hospital
Municipality
GROUP 3
Ruth *
Alfredo
Carolina
Zenon
Jaime S
Alberto
Romelia
Callipampa 
(SECI)
Municipality
Caracollo
(IMCI)
Í
Hospital
Totorani
(H/PD)
* Team Coordinator 
Í Observers: Renee, Ccoya, Gonzalo visited: Group 2 Saturday
Group 3 Sunday
Group 1 Monday
Each team visited at least one community or peri-urban area with an activity in each of 
the 3 interventions.
Completed Activities￾Interviews with:
ß 6 MOH Area Doctors
ß 8 MOH Auxiliary Nurses
ß 19 Health Promoters
ß 6 H/PD Leaders
ß 11 Meeting with Municipal Authorities (including a meeting with 
COMUSA, a municipal health committee)
ß 8 Meetings with 18 community leaders
ß 9 Community meetings, including 34 men and 130 women
Observations of:
* 5 H/PD Sessions
* 14 IMCI Home Visits
* 3 SECI Sessions
A two-day Analysis Workshop was held for all team members, plus additional 
collaborators, to review the results of the field work and other information 
28
collected during the evaluation, and to formulate recommendations for improving 
the quality of implementation during the second half of the project.
V. EVALUATION SCHEDULE 
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
August30
Preparation
31
Document 
Review
Sept 1
Travel 
2
Evaluation 
Planning
3
Workshop 
for 
Evaluation 
Team
4
Workshop 
for 
Evaluation 
Team
5
Interviews
Document 
Review
6
 Preparation 
of 
evaluation 
tools
7
Community 
Visits
8
Community 
Visits
9
Community
Visits
10
Interviews
11
Preparation 
of 
information
12
Evaluation 
Workshop
13
Evaluation 
Workshop
14
Wrap-up 
and de￾briefing
15
Travel
16
Interviews
17
Write 
Report
18
Write 
Report
19
Write 
Report
20
Write 
Report
21 Submit 
draft 
report
22
23 24 25 Project 
returns 
comments
26Re-write 
Submit 
Final
27 28 29
TALLER DE PLANIFICACION
Evaluación de Medio Termino
Wawa Sana
3 de Septiembre
9:00-9:30 Bienvenida Gonzalo
Introducción de participantes Romelia
9:30-10:30 Evaluación Participativa Renee
10:30-11:00 Refrigerio
11:00-1:00 Presentación del Proyecto –SAVE Bolivia
1:00-2:00 Almuerzo
2:00-2:30 Presentación del Proyecto-Distritos de Salud
2:30-5:00 Trabajo de Grupos-Situación Ideal
3:30-4:00 Refrigerio
4 de Septiembre
8:30-10:00 Plenaria
10:00-10:30 Contenido de la evaluación Renee
29
10:30-11:00 Refrigerio
11:00-1:00 Trabajo de Grupos: 
Desarrollo de Instrumentos Para la Recolección de Información
1:00-2:00 Almuerzo
2:00-3:00 Como hacer entrevistas Caroline, 
Carolina. Juan
3:00-4:30 Formación de equipos Coordinadores
4:30-5:00 Próximos Pasos Renee
5:00 Refrigerio
TALLER DE ANALISIS
12 de Septiembre, Jueves
8:30-9:00 Experiencias en el campo Gonzalo
9:00-9:30 Revisión de información colectada
9:30-12:00 Trabajo de Grupos￾Análisis por Intervención - Situación Actual
11:00-11:30 Refrigerio
12:00-1:30 Trabajo de Grupos￾Análisis por Intervención- Recomendaciones
1:30-2300 Almuerzo
2:00-5:00 Plenaria
5:00-5:30 Refrigerio
13 de Septiembre, Viernes
8:00-10:30 Trabajo de Grupos- Temas Transversales Ccoya
10:30-11:00 Refrigerio
11:00-12:00 Plenaria- Temas Transversales
12:00-12:30 Priorización de Acciones
12:30-1:30 Almuerzo
1:30-2:00 Recomendaciones Adicionales Renee
Cinco Estrellas
2:00-2:30 Evaluación del Proceso
Clausura Varios
30
Documents Reviewed
Análisis de la implementación de AIEPI en Bolivia, UNAP. OPS, BASICS, 4/02.
Bolivia CS-16, Detailed Implementation Plan, WAWA SANA, Mobilizing Communities and 
Health Services for Community-Based IMCI: Testing Innovative Approaches for Rural Bolivia, 
April 2001, Save The Children.
Child Survival 16, Presented to USAID Bolivia December 1999, Save the Children. (Proposal)
Collazos Olivaros, D., Plan Estratégico 2001-2006, APROSAR, Consulting & Engineer Services 
SRL, Oruro, Bolivia
DAP Proposal, Save the Children Bolivia, FY02-FY06.
Evaluación Trimestral Enero-Febrero-Marzo, Desarrollo Comunitario 4/02, Oruro.
Evaluación Trimestral April-Mayo-Junio, Desarrollo Comunitario 7/02, Oruro, Bolivia.
Guia del Facilitador, AIEPI, Seguro Básico de Salud, MSPS, 12/00, Bolivia
Institutional Capacity Study: SEDES/APROSAR, SC/B, 2000.
Manual de Procedimientos, AIEPI, Seguro Básico de Salud, MSPS, 12/00, Bolivia
Manual SECI Sistema Epidemiológico Comunitario Integral, Save the Children Bolivia, Centro 
de Programas de Comunicación de Johns Hopkins en Bolivia
Prevención y Rehabilitación Comunitaria de la Desnutrición Infantil Mediante el Enfoque de 
Desviación Positiva, Manual de Implementación, Save the Children, DJC, 10/02.
Proyecto: Superviviencia Infantil No. 16, APROSAR, 2000.
Quality Management Guide: A Save the Children Management Toolbox, prepared for LAC 
Regional Meeting 4/02, El Salvador.
Qualitative Study on Health and Nutrition Practices Using Focus Groups: Districts of Eucaliptus, 
Huanuni, and Challapata.
Study on Knowledge, Practices, and Coverage (KPC) in the Districts of Eucaliptus, Huanuni, 
and Challapata.
Wagonhurst, P. El Sistems Epidemiologico Comunitario Integral (SECI) Process Monitoring and 
Formative Evaluation. 1/00, La Paz, Bolivia.
Willis, C, D. Schroeder, L. Howard-Grabman, D. Marsh, The Integrated Epidemiological System 
(SECI): Local Participation in Community Health Assessment and Planning in Rural Bolivia. 
Summary of Preliminary Findings 11/99.
31
Evaluation of the Process
Thirty-four team members and resource persons completed an evaluation of the 
MTE process, during the Analysis Workshop. The results from the questionnaires 
were: 
® 17/34 (50%) of participants felt that the process used was very effective, and 
17/34 (50)% that it was effective.
® 38% of the respondents felt that the participation of municipal and local 
authorities was lacking from the process, making this the principal 
recommendation for improving evaluations in the future.
® What people liked most about the evaluation (59%) was the team participation 
of SC, APROSAR, MOH, BASICS and Promoters. While there was a strong 
positive feeling that the MOH participation improved the MTE, some thought 
this should have been strengthened even more. Other positive aspects were the 
visits to the communities, the participatory methodology used and developing 
their own recommendations.
® Four people said what they liked least was that field visits were made on the 
weekend when health personal and authorities were unavailable, in some cases. 
® 21/34 (62%) felt the content of the evaluation was very adequate for 
developing strategies for guiding the project in the future, 13/34 (38%) said 
the content was adequate.
® The main suggestion for improving the process in the future was to have more 
prior information on the development of the evaluation team and the selection 
of communities, as changes had to be made during the planning process. 
32
ATTACHMENT D
Persons Interviewed And Contacted
SAVE THE CHILDREN
Gonzalo Arevalo, CS Coordinator 
Iber Tapia, MIS/SECI Specialist
Ccoya Sejas, National Health Coordinator
Caroline Hilari, National Health Advisor
Beatriz Gorritti, Human Resources Director
Daisy Beltran, Accounting
Hugo Paniagua, Accounting
Agusto Costas, Oruro Regional Manager
Ruth Perez, District Coordinator
Marcelino Brañez, District Coordinator
Albina Chacolla, District Coordinator
Carolina Reynaga, Health Trainer
Romelia Antonio, Health Trainer
Silverio Padilla, Health Trainer
German Viscarra, Health Trainer
Carola Cossio, Health Trainer
Jaime Leon, Health Trainer
Juan Laime, Health Trainer
APROSAR
Delia Flores, Health Trainer
Jovana Centeno, Health Trainer
Reyna Arteaga, Health Trainer
Wilge Arandia, Health Sector Coordinator
Anastasio Choque, Director
Marcos Herbas, Technical Manager
Alfredo Juaniquina, District Coordinator
MOH
Dr. Lesmes Muñoz, Departmental Planner
Dr. Roberto Núñez, Departmental IMCI in Oruro 
Dr. Jorge Viricochea, District Director
Teresa Peleaz, Departmental CB-IMCI
Other Interviews
Alberto Tenorio, BASICS
Dilberth Cordero, BASICS
Walter Agreda, PROCOSI
Jose Ignacio Carreño, PROCOSI
Jorge Velasco, USAID
Julia Costas, Director CETHA
33
ATTACHMENT E
Results of the Evaluation
EVALUACION MEDIO TERMINO
PROYECTO WAWA SANA
SAVE/DJC/APROSAR/MSPS
19 PROMOTOR
1. Cuánto tiempo estas como Promotor?
5 = < 1 año 7 = 1 – 5 años 7 = > 5 años
2. Conoces cuales son los objetivos del proyecto WAWA SANA?
Evitar la mortalidad infantil.
Desminuir la desnutrición de las Wawas.
Mejorar la salud de las Wawas. desde Recién Nacido hasta los 5 años.
Orientación capacitación en SECI – AIEPI Y EDP.
3. Has recibido capacitación en este último año? 19 SI En que?
19 AIEPI Comunitario 17 SECI 5 EDP
Otros : Lactancia Materna , SBS, Salud Reproductiva .
4. Que sugerencias tienes para mejorar las capacitaciones?
Apoyo constante y reforzamiento.
Apoyo continuo de DJC – APROSAR.
Capacitación en manejo de medicamento.
Folletos de capacitación para uso en grupo.
Apoyo con trasporte.
5. Crees que necesitas mas capacitación? 10 Si En que?
6 en AIEPI 8 en SECI 7 EDP Otros : 2
OTROS: capacitación continúo en los programas de salud.
Capacitación en tejidos y telares, 
Capacitación SBS , Nutrición.
Capacitación en como organizar a las comunidades.
6. Cada cuanto te vista el personal del centro de salud y que actividades realizan con ellos? 
Mensualmente 12 , 2 veces al mes, no visita 3.
Visita al centro de madres para realizar control de peso y vacunas.
Controles prenatales y charlas educativas en los programas de salud.
7. Sabes cuantas familias hay con niños menores de 5 años en tu comunidad? 
< 5 familias respondieron 4. de 5 – 10 familias 3 10 – 20 familias 7
 20 – 50 familias 2 >50 familias 3
Cuando visitas a las familias con niños menores a 5 años? 
Cada mes 9 Cada semana 4 En reuniones 3
8. Que haces en tus visitas domiciliarias? 
34
Buscamos signos de peligro.
Hace educación a la comunidad.
Identifican niños con problemas de salud y comunica por radio .
Control de peso y recolecta información para SECI.
9. Que opinan las familias en tu comunidad sobre tus visitas domiciliarías?
Le tienen confianza, piden apoyo del promotor y quieren más visitas continuas para saber más sobre 
salud.
Quieren atención gratuita.
Les gusta las capacitaciones y charlas que se realizan en la comunidad.
10. Cómo reconoces a un niño desnutrido? 
Realizando el control de crecimiento y desarrollo, utilizando la hoja de AIEPI, nos 
damos cuenta que está con: Bajo peso, cabello amarillo, flaco, estomago crecido, 
pantalón caído, pies hinchados, palidez palmar, deja de comer, esta desganado, 
anemia, piel sin grasa y deja de comer.
11. Cómo te das cuenta cuando un niño está con diarrea grave? Que haces en este caso?
Diarrea con sangre, ojos hundidos, signo del pliegue, tiene mucha sed, no quiere 
comer ni lactar, pálido, llora mucho, niño deshidratado, ojos asustados, vomita, no 
juega y se utiliza la hoja de referencia.
12. Cómo te das cuenta cuando un niño está con tos grave? Que haces en este caso?
Respiración rápida, estridor o ruidos raros, tiraje, tos másde21 días, fiebre, ojos 
boca morada, no lacta, agitación, le duele la garganta, tos fuerte y seguido.
13. Estás realizando seguimiento a los niños enfermos? Como lo haces?
Si 
Mediante las visita domiciliaria
Para capacitar 
Mediante el registro 
Para realizar seguimiento
14. Has recibido visitas de supervisión? Si De quien? 
Con que propósito?
DJC APROSAR Centro de Salud Autoridad
No reciben
15. Recibes apoyo de tus autoridades? Si Que tipo de apoyo 
 recibes?
Apoyo moral
Reúne a la comunidad
Apoyo de padres de familia
Apoyo en capacitación
16. En algunas comunidades, después de algún tiempo los 
35
 Promotores dejan de trabajar, cómo se puede evitar el 
 abandono de Promotores?
Mas capacitaciones por otras instituciones
Buscar apoyo económico de otras instituciones
Elegir un promotor responsable
Que viva permanente en la comunidad 
SECI
1. Conoces el SECI? Si
Si la mayoría
2. De que forma te ayuda el SECI en tu trabajo y a tu comunidad?
Identifica necesidades de por ejemplo en vacunas
Niños con algunas enfermedades
Embarazadas
Conocer el numero de niños desnutridos
Priorizar algunas enfermedades
Valorar el trabajo del promotor
Analizar 
Reúne a la comunidad
3. Que decisiones ha tomado la comunidad con la información del SECI.
Llevar al centro de salud a los niños desnutridos 
Reflexión sobre la salud de la comunidad 
Mejorar la desnutrición de la mala alimentación
Controles prenatales en las mujeres embarazadas
Capacitar en temas de priorizadas en la comunidad
Buscar en otros ONGs que trabajan con apoyo y equipamiento
Participan las autoridades
4. Que logros ha conseguido tu comunidad con el SECI?
Asistir a los controles prenatales 
Capacitación y concientizacion sobre diferentes temas de salud
Alimentación de las wawas
Coberturas de vacunas
Participan las autoridades en SECI
Sabré de las enfermedades de los niños
5. Te dan espacio en las reuniones de la comunidad para poder hablar y discutir de salud con tu 
comunidad?
12 si 8 no 
Raras veces me dan tiempo 
36
6. Con que materiales cuentas para trabajar con el SECI? Crees que es suficiente?
Registros de SECI y libro de actas 
Bandera de salud y munecos
Manual de SECI y rotafolio
7. Te es difícil el llenado de los formularios? Si 7 No 18 Porque?
Consolidado no es claro 
No tiene suficiente material
 
EDP
1. En tu comunidad se está realizando el EDP?
No 12 Si 6
2. En que consiste el EDP?
Preparar alimentos para niños desnutridos
Usar alimentos locales para mejorar los niños desnutridos
Dar cariño y afecto 
Control de peso y talla
Capacitación en grupos de mujeres
3. Que tareas cumples en el EDP? 
Ninguno 11
Distribución de grupos y enseñando los valores nutritivos de cada producto
Apoyar en la participación de las madres
4. Quiénes participan en los talleres hogareños? Que hacen?
Las mujeres algunos hombres
Cocinamos para nuestras wawas
Participan las mamas y niños menores de 5 años
Personal de salud
5. Recuerdas sobre el caso de algún niño desnutrido? Que hiciste? 
12 niños pero mejoraron con los talleres hogareños
Algunos no recuerdan
8 Entrevistas con 18 Autoridades Comunitarios
1. Ud. conocen que actividades realiza el proyecto WAWA SANA?
Capacitación a las mamas sobre salud.
Capacitación a los promotores.
Organización de talleres de salud y evaluación.
2. Que beneficios ha recibido la comunidad a través del proyecto WAWA SANA? 
Orientación a la comunidad para mejorar la salud.
37
Apoyo de movilidad al personal de salud, mensual.
Capacitación al personal de salud, para mejorar niños desnutridos.
Apoyo con menaje de cocina.
3. Tienen promotores capacitados en la comunidad?
Si 8 promotores.
4. Que actividades realiza el promotor de salud en su comunidad?
Realiza visitas domiciliaras.
Realiza capacitación en salud.
Coordina con autoridades y personal de salud.
5. Es importante el trabajo del promotor de salud en su comunidad? Si 
Realiza reuniones en la comunidad.
Apoya al personal de salud.
Da charlas de orientación en salud.
Atiende a niños enfermos.
Otros: Que maneje medicamentos de SBS.
6. ¿Como pueden apoyar Uds. al Promotor?
Dar apoyo mancomunada en agricultura (faina, cosecha).
Apoyo con transporte para que asista al taller.
Coordinar entre la autoridad y el promotor.
7. Viene el personal de salud a la comunidad? 
7 SI 1 NO.
8. Cómo Coordinan los promotores con el personal de salud?
Consolidando la información en salud.
Coordinan entre el Promotor y personal de salud para visitas a comunidad.
Otros :Mencionan que no hay buena coordinación con el centro de salud..
9. Cree usted que el hablar de salud en las reuniones es importante? 
7 SI 1 NO Porque?
Hay muchas necesidades, para dar solución a los problemas de enfermedades.
Conocer sobre Seguro Básico de Salud.
Para que las wawa estén sanos y fuertes.
10. Que hace Ud. como autoridad para mejorar la salud de las wawas de su comunidad?
Apoyar a reunir hombres y mujeres para que se capaciten.
Pedir mas capacitación al servicio de salud.
Reunirse con el centro de salud para campañas de vacunación.
11. Cuando termine el proyecto de WAWA SANA, como pueden Uds. continuar con las 
actividades que hace el proyecto WAWA SANA?
Continuar reuniéndonos a la cabeza del promotor.
38
Continuaremos con las actividades juntamente con el hospital
Continuaremos con las reuniones cocinando con las mamas
Buscar financiamiento
SECI
1. Conoce el SECI? 
Si 2 No 6
2. Conoce la bandera de salud? Cómo es la bandera?
Si 4 No 4
Tiene 3 colores rojo amarillo verde
3. Para que les sirve esta bandera?
Nos sirve para saber analizar si nuestra wawa esta bien o mal
Sirve para demostrar sobre la gravedad de salud en la comunidad
Algunos no saben sobre la bandera de salud
4. Participa en las reuniones de su comunidad? Con que frecuencia? Para qué sirven estas 
reuniones?
Si 8 No 0
Cada mes se reúnen para hablar de salud 
Sirve para dar solución a los problemas de salud
Sirve para orientar y educar en salud a la comunidad
5. Sabe que es un TAI? Participa en los TAI o CAI?
Si 6 No 2
Alguna vez participamos en los TAI de área, mas participan los promotores
EDP
1. Han escuchado hablar del EDP? Saben para que sirve el EDP? 
No 6 Si 1 1 no respondió
Conocen EDP como Taller hogareño
Sirve para ayudar a los niños desnutridos donde las mamas alimentan a sus niños y mejoren de 
peso
2. Que actividades se realizan para mejorar la nutrición de los niños(as)?
Alimentan a los niños 
Cocinan con las mamas
No sabe
Traen alimentos
Mejoran los platos
Capacitan y charlan
3. Las señoras de su comunidad participan en los Talleres hogares para mejorar la 
alimentación? 
39
Participan la mayoría 
No saben
Todas las mamas con wawitas
Las inscritas mamas
4. Cree Ud. que las practicas grupales de cocina mejoría la nutrición de las wawas?
Si 6
Es importante la higiene de niños y preparación de alimentos
No sabe 2
Mejora la nutrición cuando están juntas comen y acostumbran a comer
Preparan alimentos sólidos y combinan sus costumbres
Es bueno practicar
Las señoras preparan alimentos en grupos pequeños y queremos mas grupos
8 AUXILIAR DE SALUD
1. Hace cuánto tiempo trabaja en este Centro/Puesto de Salud?
3 = < 1 año 2 = 2 – 3 años 1 = > 10 años.
2. Sabe cuáles son los objetivos del Proyecto WAWA SANA?
Desminuir la desnutrición.
Mejorar la salud integral del niño.
3. En su opinión, cuales han sido los logros mas importantes del Programa WAWA SANA 
hasta ahora?
Comunidades concientizadas.
 Capacitación, seguimiento en EDP y visitas domiciliaras. 
Implementación de SECI de manda de servicio.
4. Cuál ha sido el efecto de las actividades del proyecto en su trabajo?
Seguridad de reunión en las comunidades.
Facilita la recolección de información.
Otras: en reunir a las mamas para las charlas educativas.
5. Ha recibido capacitación en este último año? 5 si - 1 no En que?
 3 AIEPI-Clinico 3 AIEPI-Comunitario 1 IEC
 4 SECI 3 EDP 3 Otro Lactancia Materna y Crecimiento y 
desarrollo
6. Que sugerencias tiene para mejorar las capacitaciones?
Capacitar a todo el personal de salud.
No cambiar cronograma del taller
7. Esta aplicando el AIEPI clínico? 4 si El AIEPI comunitario? No 
De que manera esta aplicándolos?
40
Utilizando los formularios para buen control de niño.
Otros : a medias por falta de tiempo.
8. En su opinión, el trabajo en WAWA SANA ha podido cambiar practicas de salud en las 
comunidades? Puede dar algún ejemplo?
Mas participación al servicio de salud.
Las señoras conocen los signos.
Otros : Mas interés de las mamas en las capacitaciones
9. Tiene en el centro de salud los formularios del AIEPI? 
De que manera afecta en su trabajo el uso de estos formularios?
No tiene.
Se tarda, cuando hay mucho usuario no se puede
10. Ha recibido vistas de supervisión post capacitación? Nos puede comentar como fueron? 
Que sugerencias tiene para mejorar estas supervisiones?
No .
Otros: manejo de SBS, de cardex,
11. Que ventajas y desventajas identifican al AIEPI? 
Nos permite evaluar en su integridad al niño.
Desventaja :
Seguro Básico no cubre todo.
No se cuenta con suficiente medicamento.
12. Cuantos promotores tiene en su sector? 4 sabe 2 no
13. Cuantos están capacitados en AIEPI? 3 sabe 3 no
14. Cuantos están capacitados en SECI? 4 sabe 2 no
15. Cuantos están capacitados en EDP? 1 sabe 5 no
16. Participa en las capacitaciones del promotor? Si
17. De que manera apoyo a los promotores? 
Consulta gratuita. 
Atendiendo pacientes referidos.
Dotando paracetamol.
Orientando sobre programas de salud.
18. Que opinión tiene sobre el trabajo de los promotores de su sector?
Colaboran bastante.
Nos refiere pacientes
Reúne a la comunidad y a las autoridades.
19. Sabe si los promotores de su sector realizan visitas domiciliarias? Cuándo las realizan? 
Si en las mañanas, algunos días de la semana.
Mensualmente se consolida la información.
41
20. Conoce los materiales que usa el promotor en el AIEPI-Comunitario? Cuales son? Cuales 
aplica?
Hojas de registro.
Hojas de referencia.
Rotafolio.
Cuaderno de registro
Otros : solo 1 no sabia.
21. Que actividades relacionadas con el AIEPI realizan con los promotores?
Visitas domiciliaras.
Como evaluar a los niños
22. Realiza seguimiento del trabajo del promotor en su sector? Que instrumento usa?
No se tiene un instrumento.
Acompañamiento en visitas mensuales.
23. El promotor esta refiriendo niños con problemas de salud a Ud.? Si
Está usando boletas de referencia y contra referencia?
Con boletas , Algunos sin boletas de referencias
 Otros: Lo que no funciona es contra referencia
24. Como esta funcionando el sistema de referencia?
No, la contra referencia
Los promotores usan cuaderno de registro
25. Cuenta con algún plan de IEC para capacitar en la comunidad?
No tiene 
26. ¿Cuando el proyecto WAWA SANA termine, va a poder seguir con todas las actividades?
Si Como ?
Se dará seguimiento.
Juntamente con Autoridades Municipales.
Autoridades comunales y Promotores.
27. Tiene sugerencias de como puede mejorar el trabajo del proyecto WAWA SANA?
Implementación de medicamentos, la gente no cuenta con recursos.
Apoyo material didáctico
SECI
1. Que opinión tiene de la bandera de salud?
Se capta mejor la realidad de la comunidad.
Es un instrumento que podemos usar con facilidad.
2. Cómo consolidan la información con el promotor? 
Haciendo una comparación con el personal de salud y promotor.
 Con que frecuencia?
42
Mensualmente en el centro de salud
3. Cómo utiliza la información del SECI en su área? 
Para devolver la información a la comunidad.
Sirve para el SNIS.
Buscamos soluciones.
4. Participa usted en las planificaciones conjuntas? 
Todas participan.
EDP
1. Sabe que quiere decir EDP o de que se trata?
2 Si 4 No.
2. Que opinión tiene de esta estrategia?
Es bueno para mejorar la alimentación del niño.
3 No respondieron
3. Ha participado en capacitaciones de EDP? Como?
1 Si 
Apoyando al facilitador durante el taller.
5 No participo 
4. Ha participado en un taller hogareño? Si 
De que manera?
Pesando los alimentos.
Reuniendo a las señoras para charla educativos.
8 COMUNIDADES
NUMERO DE MUJERES: 130 NUMERO DE HOMBRES: 34
1. Cuantos niños menores de 5 años existen en su comunidad?
159 niños menores de 5 años 
2. Hay promotor en su comunidad?
Si
3. Han recibido visitas del promotor?
Si
4. Con que frecuencia les visita el promotor?
7 cada mes 
2 alguna vez al mes.
Otros 2 veces al mes
5. Que atenciones recibieron del promotor? Nos puede contar?
Nos da charla sobre temas de salud:
· Alimentación 
· Diarrea
· Higiene Personal y aseo
· Planificación familiar
· Lactancia materna
· Como cuidar a los niños
· Cuando acudir al centro de salud
6. Que capacitación han recibido del promotor del salud y que recomendación les ha dado?
43
· Lactancia materna
· Cuidado del niño
· Alimentación complementaria
· Higiene
· Vacunas
7. Cuales de estas recomendaciones han podido poner en practica en su casa?
Lactancia materna inmediata
Grupos de alimentos
Como preparar alimentos
Higiene
Planificación familiar.
8. Como pueden ayudar al promotor para que mejore su trabajo?
Obedeciendo
Asistiendo a las reuniones
Que reciba mas capacitaciones
Que cuente con medicamentos del seguro básico de salud
Buscar apoyo de otras instituciones para apoyo al promotor
Trabajar un día en su chacra
9. Viene el personal de salud a la comunidad?
Si cada mes.
10. Que beneficios les ha traido la visitas a la comunidad del personal de djc, aprosar y del centro 
de salud?
· Capacitaciones sobre como criar a nuestras wawas
· Alimentar y grupos de alimentos
· Embarazo
· Como mejorar la salud de los niños
11. Que hacen cuando su wawa esta enferma? Porque?
Llevamos al promotor
Curamos con medicamentos caseros
Llevamos al centro de salud 
Cuando esta grave
12. Como se dan cuenta cuando un niño esta con diarrea grave?. Que hacen en este caso?
ojos undidos
signo de pliegue
Llora mucho
Tiene sed
No lacta
44
Hace caca como agua
Le damos sales de rehidratación oral
Llevamos al centro de salud
13. Como se dan cuenta cuando un niño esta con tos grave. Que hacen en este caso?
Tiene temperatura
Respiración rápida
Ruidos raros 
Tiraje intercostal
Dan mates caseros 
Otros llevan al centro de salud
14. Cuanto tardan en llegar al centro de salud o puesto de salud?
1 hora, 2 horas, 5 horas
15. El centro de salud que medicamentos les da en forma gratuita?
Aceite vitaminado, ferrosol, paracetamol, sales de rehidratación oral, vitamina A medicamento para 
la diarrea
16. Conoce el carnet de salud infantil? Si. 
Algunos no tienen
Han hecho perder
17. Recibe orientación en los servicios de salud sobre la manera de alimentar y cuidar a sus
wawas? Si
Si de DJC
Vacunas CSI
Alimentación
Lactancia materna
18. Como reconocen a un niño desnutrido?
Flaco Desganado
No come Hinchado
Bajo peso no es sano
Esta amarillo mediante el color de la lana
Pálido Comparando
19. Han escuchado mensajes por radio o televisión sobre salud de los niños. De que temas? Si 
Radio PIO XII
Lactancia materna
Alimentación 
Planificación familiar
Como cuidar a los niños
Radio Bahai
45
Alimentación complementaria, Lactancia exclusiva
20. Cuando ya no venga los de djc y aprosar como van a poder seguir con las actividades de
salud?
Reuniendonos con el promotor
Continuar con lo que se ha aprendido
Pidiendo ayuda al centro de salud
SECI:
1. Conoce el seci
Si conocen.
Otros no conocen el significado
2. Participa de las reuniones SECI de su comunidad? Con que frecuencia y porque?
Participamos de las reuniones del SECI una vez al mes. Porque queremos aprender.
Participamos de las reuniones del SECI cada dos meses
3. Conoce la bandera de salud?
Si. 7
Otros no 1
4. Para que sirve la bandera?
Para saber sobre las vacunas
Enfermedades 
Embarazadas
Control prenatal
5. Que significan los colores de la bandera?
Rojo: Malo, esta enfermo y puede morir.
Amarillo: regular
Verde: buena salud
Algunos no conocen.
EDP:
1. Han escuchado hablar del EDP?
Si 2 No 4 
Otros no saben la sigla pero conocen las actividades
2. Saben para que sirve el EDP?
Para mejorar la alimentación de las wawas
Aprendemos a cocinar otras cosas
Para que los niños no estén desnutridos
Cocinamos para nuestras wawas
3. Participa de grupos en los que se realiza practicas alimentarías para mejorar la nutrición de 
sus wawas? Que piensa de estos grupos?
46
En grupos
Aprendemos sobre los grupos de alimentos
Mejorar la alimentación
Todos participamos
4. Que actividades hacen para realizar la nutrición de los niños?
Cocinamos con los alimentos de nuestra comunidad
Hacer comer de rato en rato
Combinamos verduras 
47
8 Auxiliares de Enfermería
Item Si No Comentarios
Manual de AIEPI 7 1
Rotafolio AIEPI 8
Hojas de registro 5 3
Formularios clínicos 4 4
Balanza 7 1
Tallimetro 5 2
Boletas de referencia 4 4
Paracetamol 8
Cotrimoxazol 8
Sulfato ferrosos tabletas 8
Vitamina A 7 1
Aceite vitaminado 7 1
Mebendazol 7 1
Penicilina Procaina 8
Sales de rehidratación 8
Ferrosol 8
Vacunas 8
Carnet de salud infantile 8 Algunos solo tienen pocos
Equipo de URO Institucional 5 3
Termos de vacunas 8
Insumos PAI (Jeringas, agujas, etc.) 8
Bandera y muñecos 4 4
Croquis 8
Censo 5 3
Moto u otro vehículo 7 1
SECI
Formulario consolidado 4 4
Manual de SECI 5 3
Software de SECI instalado 0 8 Solo en el Distrito
Guías de SECI 5 3
EDP
Tablas peso y talla 3 3 No todos manejan el EDP
Protocolo o fotocopias manual 0 6
Formularios de seguimiento 2 4
Folletos volantes 1 5
Material educativo 1 5
6 Médicos de Area
Item Si No Comentarios
Manual de AIEPI 3 3
Rotafolio AIEPI 2 4
Hojas de registro 4 2
Formularios clínicos 4 2
Balanza 4 2
Tallimetro 4 2 Solo cinta métrica 
Boletas de referencia 5 1
Paracetamol 6
Cotrimoxazol 6
Sulfato ferrosos tabletas 6
Vitamina A 6
Aceite vitaminado 5 1
48
Mebendazol 6
Penicilina Procaina 6
Sales de rehidratación 6
Ferrosol 6
Vacunas 6
Carnet de salud infantil 6
Equipo de URO Institucional 3 3
Termos de vacunas 6
Insumos PAI (Jeringas, agujas, etc.) 6
Bandera y muñecos 3 3
Croquis 6
Censo 4 2
Moto u otro vehículo 6
SECI
Formulario consolidado 5 Solo 5 respondieron
Manual de SECI 5
Software de SECI instalado 2 3
Guías de SECI 5
EDP
Tablas peso y talla 1 4
Protocolo o fotocopias manual 1 4
Formularios de seguimiento 5
Folletos volantes 1 4
Material educativo 5
18 PROMOTORES
Item Si No Comentarios
Hoja de registro AIEPI (2) 17 1
Rotafolio de AIEPI 17 1
Manual de procedimientos 16 2
Cuaderno de seguimiento 14 4
Balanza 5 11 Algunos prestan del pers. de salud
Tallimetro 2 14 Solo Tienen cinta métrica
Boleta de referencia 11 7
Croquis 15 3
Censo 12 5
SRO 1 15
Vitamina A 2 14
Paracetamol 5 12 Algunos compran de APROSAR
Cotrimoxizol 4 12 Algunos compran de APROSAR
Sulfato ferroso 3 14
SECI
Manual de SECI 15 2 Un Promotor no trabaja con SECI
Formulario de consolidación 12 5
Formulario del Promotor 16 1
Bandera 7 10
Muñecos 7 10
EDP
Laminas de alimentos 2 3 Solo 5 Promotores trabajan con EDP
Formularios de seguimiento 2 3
Rotafolio 1 4
Folletos y Volantes 2 3
49
7 MÉDICOS DE ÁREA
1. Hace cuánto tiempo trabaja en este Servicio de Salud?
2 < 1 año 5 = 1 – 5 años
2. Conoce Ud. los objetivos del Proyecto WAWA SANA?
 2 tienen conocimiento sobre las tres estrategias 
 2 no conocen las estrategias.
Otros: mejoramiento del estado de salud, recuperar a todos los niños desnutridos, Capacitar a las 
madres en temas de salud reproductiva,
Reconocer casos de EDA - IRA 
3. Ha recibido capacitación en este último año ? 6 SI 1 No 
 En que ?
 3 - AIEPI-Clínico 3 - AIEPI-Comunitario 2 - IEC
5 - SECI 2 - EDP 1 - Otros Manejo de alimentos
 .Como pueden mejorar las capacitaciones?
- Capacitar al medico de planta.
- Aplicar y practicar con la comunidad
- Mas capacitación al personal
4. Utiliza los formularios de AIEPI? Como funcionan?
- Aplica los formularios clínicos un 50 %
- Un 50% no utiliza por que no cuenta con formularios.
5. Recibe seguimiento del programa de AIEPI? 
Como ve Ud. este seguimiento?
- 3 médicos han recibido seguimiento.
- 4 médicos no recibieron.
Otros mencionan que el seguimiento es mal. Por cambio constante del personal. 
6. Se reúnen con los promotores de salud? En estas reuniones que hacen?
- 4 se reúnen y 3 no .
- En las reuniones se Coordina y realizan cronogramas
- Planifican capacitación.
- Socializan de los temas aprendidos.
Otros mencionan que no es su función delegan a las licencias y auxiliares.
7. Sabe si los promotores de su sector realizan visitas domiciliarias? Cuándo las realizan? 
- 3 Si 2 No 1 No sabe.
8. De que manera apoya a los promotores? 
- Apoya en valoración en AIEPI.
50
- El personal de salud le da su lugar al promotor por son lideres.
- La información del promotor es incluida en el libro de consulta.
9. Que opinión tiene sobre el trabajo de los promotores de su sector?
- El trabajo del promotor es bueno, por que facilita el contacto con la comunidad.
- Uno menciona que el trabajo es relativo con sus actividades .
Otros no conocen el trabajo de los promotores
10. El promotor esta refiriendo niños servicio de salud? 
6 Si 1 No.
Otros: mencionan el trabajo del promotor es bueno y facilita el contacto con la comunidad. 
11. Está usando boletas de referencia y contra referencia? 
5 Si 2 No.
12. Esta funcionando el sistema de referencia?
7 Si 
La contra referencia no se esta utizando
13. Cuando tiene niños con desnutrición, que acciones se ha tomado con estos niños?
2 en forma adecuada 
4 en forma regula y 1 tiene dificultad.
14. Cuenta con algún plan de IEC para capacitar en la comunidad
_ Prestación de SBS con micro nutrientes
_ Dar orientación ,Educación y Capacitación a grupos de mujeres.
- Clasificación de alimentos.
15. Cuando termine el proyecto WAWA SANA de que forma continuaran las actividades que 
realizaba en el proyecto?
4 No 1 Si 
Otros : Plan interinstitucional para las capacitaciones.
 - Seguir con orientación a la comunidad.
- Hay personal con capacidad para dar continuidad SECI, AIEPI.
- Buscar apoyo de otras ONGs y municipio.
SECI
1. Conoce la estrategia SECI ? 
5 Si 2 No
2. Utiliza la información del SECI en sus TAIs de área? 
3 Si 4 No
3. Que utilidad le da la información del SECI?
Hace conocer la información para el área y Distrito, Para ver el avance de las 
coberturas.
4. Conoce la bandera de salud? Cuál es su opinión de la bandera de salud?
51
Todos conocen.
Otros: Es útil para diferenciar problemas y fácil de entender para la comunidad.
5. Sabe que son las planificaciones conjuntas? Participa usted en las planificaciones conjuntas?
6 Si 1 No
Otros: Reunión comunitaria para resolver problemas.
EDP
1. Sabe que quiere decir EDP o de que se trata?
5 Si 2 No
2. Que opinión tiene de esta estrategia?
Es bueno pero no hay un buen seguimiento.
Mejora la alimentación y conoce el valor nutritivo.
3. Ha participado en capacitaciones de EDP? De que manera?
4 Si 3 no
4. Sabe que es un taller hogareño? Ha participado en estos talleres? 
 4 Si 3 No
Otros : Donde la comunidad participa en preparación de alimentos.
5. Tiene sugerencias como puede mejorar el trabajo del proyecto WAWA SANA?
Que se realiza una buena socialización del proyecto.
Mayor seguimiento a promotores. 
Capacitación al personal de salud.
Apoyo logístico.
11 ENTREVISTAS CON 17 AUTORIDADES MUNICIPALES
1. Que organizaciones de salud trabajan en su municipio?
DJC 
APROSAR
HOSPITAL
OTROS: PAN - CRECER - ABRIR SALUD – CAEP – ONDI
2. Sabe con que programas y proyectos están trabajando?
Programas de capacitación y cursillos
Mejorando la nutrición y crecimiento de los niños
Dotación de medicamentos (ONDI)
Prestamos a las mujeres (CRECER)
Otros Control niño sano, diarreas, vacunas, prevención de la mujer y el niño, y dotación de material de 
escritorio y equipos
3. De que manera toman en cuenta actividades de salud en su POA?
Porcentajes previstos por ley 
Según requerimientos seguro básico
Otros no conoce y HIPIG 
4. De que manera incluyen al promotor y sus actividades en sus POAS?
No incluyen
A través de la mancomunidad 
Otros con viáticos y alimentación
5. Se ha ejecutado el presupuesto de salud el año pasado?
52
Si en un 70 a 80 %
No conozco
No se 
6. Tiene usted algún plan de cómo mejorar la salud de los niños en las comunidades?
Proyectando a las comunidades al personal de salud
Educando a las comunidades
No sabe como
Mayor apoyo con recursos económicos
Otros gestionar recursos humanos ante SEDES
Pedir mas puestos de salud a las autoridades
A través de la Mancomunidad Azanaque
Dando vitamina A
7. Cuando termine el proyecto Wawa Sana, como Uds. continuar con sus actividades en salud 
que esta apoyando el proyecto?
Buscar otras organizaciones que estén apoyando a los promotores
Incluir el tema de salud en el POA municipal
Coordinar mas estrechamente con el personal de salud de los hospitales
Que los promotores deben continuar con la coordinación interinstitucional
8. Tiene sugerencia de cómo puede mejorar el proyecto Wawa Sana?
Seguir capacitando a los promotores
IEC Información Educación y Comunicación
Incentivar la participación de la comunidad
Socializar los objetivos del proyecto
Interactuar con otros proyectos
Otros apoyo de las autoridades. No sabe
Visitas mas largas, continuas y oportunas
6 MADRES LÍDERES POSITIVAS
1. Le gusta ser líder? 
5 Si
1 No porque las señoras no escuchan
2. El ser líder ha cambiado su vida? De que forma?
5 Si
1 No
He podido mejorar el hogar (aseo)
Otros: Era nerviosa, pero ahora ya no; Ahora toma mas conciencia
3. Ha recibido alguna capacitación? 
6 SI
4. Que le han enseñado? Te sirve, lo estás practicando?
EDP, Aseo, Cocina, Nutrición
4 mencionaron que están poniendo en practica
Otros: es de beneficios de las compañeras, ayuda a mi familia
5. Que mas necesitarías aprender para poder trabajar mejor?
Mas sobre salud y nutrición; Cocina
Otro: Intercambio de experiencia con otras comunidades
6. Está de acuerdo con el tiempo que se usa en los talleres hogareños?
53
4 están de acuerdo
2 no están de acuerdo
Por los cosechas y siembra no es adecuada
Que seria una vez al mes
Otros: Hay que ver la posibilidad de las señoras
7. Vale la pena el tiempo que invierte con sus compañeras? 
1 No porque no tiene quien ayudar
5 Si
Porque estamos aprendiendo mucho y estamos mejores
8. Mamas están conformes con lo que cocinan y las actividades del taller?
5 Si
1 No, no están de acuerdo cada día, solo una vez a la semana
9. Recibes apoyo de tus compañeras y comunidad? De que forma? 
6 Si, reciben apoyo de las compañeras
Con la organización del grupo, Con la cocina
Otro: Se ponen de acuerdo con el aporte
10.Se siente apoyada por el capacitador o el auxiliar de enfermería?
Todas ha dicho que Si
De que manera?
Capacitándonos en salud; Con recetas mejoradas
11.Como se puede mejorar las actividades de EDP?
Visitas seguidas
Recetario
Reforzando los conocimientos
Otros: Carpa solar, visitas a las casas 
Inventario de Materiales y Equipo
Ítem Si No Comentarios
Menajes de cocina (Platos) 3 3 Casi todas falta algunas cosas, algunas prestan 
ollas
Espacio para cocinar 6 Algunas en aire libre
Combustible 5 1 Ellas traen leña, un grupo compra gas
Material desarrollo infantil 1 5
Receta mejoradas y menú 6 Falta procedimiento o preparación
Lista de asistencia de niños participantes 4 1
Observación de 3 Sesiones SECI
SI NO Comentarios
Llenado correcto de 
54
Formulario del Promotor 3
Llenado correcto de 
Formulario de
consolidación del SECI
3
Consolidación bimensual
Con ayuda del facilitador y 
personal de salud
Realiza el proceso de 
Planificación Conjunta 
correctamente
3
2-con participación 
Promotor, 2-sin 
participación del Promotor
Participación activa del 
grupo 2 1
Participación de hombres y 
mujeres
Usa materiales 
adecuados para la 
Planificación conjunta
3
Números, letras y muñecos 
son muy pequeños para 
diferenciar
Existe presencia de 
autoridades 3
Subcentral, Comité de 
Agua, Corregidor
Llegaron a una toma de 
decisiones a quienes 
involucra
3
Seria bueno hacer un plan 
de acción para cada 
concepto
Participación de personas 
claves en el proceso 3
Número de participantes: __25____ Hombres ___64____ Mujeres
Observación de 5 Sesiones EDP
SI NO Comentarios
CARPETA:
Información básica con croquis 4 1
Estudio EDP 5
Lista de niños 5
Peso/talla inicial 5
Peso/talla Seguimiento 5
Tasa de participación en el taller 
hogareño 4 1
Algunas mujeres ya no vinieron
Tasa de abandono en talleres 
hogareños 4 1
Ordenamiento y claridad 4 1
TALLER HOGAREÑO:
Presencia de la líder 5
Presencia del promotor 4 1
Presencia del auxiliar 2 3
Actitud positiva de los facilitadores
5
Trabajan en equipo
Participación activa de la 
55
comunidad 5
Ambiente limpio 3 2 Cocina en el patio
Agua limpia disponible 5
Lava las manos antes de cocinar
5
Cada niño tiene su toalla
Lava las manos antes de comer
5
Usa recetas mejoradas
Y apropiadas 5
Usa productos locales
Da respuestas a las preguntas de 
las mamas 4 1
Número de participantes: ___12_ Hombres ___65__ Mujeres
OBSERVACION DE 13 VISITAS DOMICILARIAS
ASPECTO OBSERVADO CORRECTO
SI NO
COMENTARIOS
Se presenta y genera un ambiente de 
confianza 13
Búsqueda de las 4 señales de peligro de 
muerte 6 7
Búsqueda y evaluación de tos, diarrea, 
fiebre y problema de oído 7 6
Olvido del oído
Búsqueda y evaluación de desnutrición y 
anemia 5 8
No hizo le evaluación directa en el niño
Búsqueda y evaluación de otros 
problemas 3 9
Revisión de vacunas empleando el 
Carnet de Salud Infantil 9 4
Evaluación del afecto y cariño 6 7 Menciono la importancia del cariño
Evaluación de la alimentación
10 3
Tiene dudas en como responder a las 
preguntas de la madre
Evaluación de medidas preventivas en el 
hogar 8 4
No hubo oportunidad, no estaba en casa
Según los problemas identificados 
“Decide que Hacer” 11 2
Da recomendaciones según la 
priorización de los problemas 
Encontrados
12 1
Muchos mensajes
Uso del rotafolio con el ORPA
8 5
Falta seguridad en usarlo
Uso de la hoja de registro 8 5 Uso la hoja, pero no correctamente
Realiza preguntas de verificación 8 5
Felicita a la madre 10 2
Acuerda próxima visita 9 2
56
EVALUACIÓN de MEDIO TERMINO
SECI (Sistema Epidemiológico comunitario Integral)
Situación Ideal Situación Actual Recomendaciones
Suministros Esenciales
· Banderas
· Material por niveles
· Muñecos por colores, sexo, gestación
· Registros del promotor y el 
consolidado
· Libros de actas
· Croquis
· Hoja de planificación conjunta
· Material de escritorio
· Material de capacitación – guías
· Equipo de computación (software)
· Material de apoyo del promotor
o SRO
o Balanza
o Tallimetro
o Bicicleta
o Cotrimoxasol
o Paracetamol
o Sello
Recursos Humanos Capacitados
· Comunidad
· Distrito
· Autoridades
· Escuelas Juntas Escolares Profesores
· Implementadores
· Existe parcialmente y algunos sucios
· Solo para el personal de salud
· Incompletos(faltan mujeres gestantes y niños)
· Existe 18 y 7 completar dificultad de manejo
· En algunas comunidades
· Falta y disposición inadecuada
· No verificado(manejado implementado, 
capacitador y no por el promotor)
· Cuentan pero insuficiente
· Tienen rota folio de AIEPI, LINKAJES
· Verificado en un área con software de SECI
o Ninguno
o Pocos
o Ninguno
o Propios del promotor
o Si = 4 No =12
o No , propios
o Ninguno
· No se a capacitado
· Al 100 % estadísticos, por cambios falta 
algunos directores
· Al 50 %
· No
· 100 %
· 50 %
· Dotar de rota folio SECI a cada sector y área 
(Muñecos diferentes por enfermedades)
· Talleres de reforzamiento sobre manejo de 
registros de diseño
· Croquis poner en lugares visibles de reuniones 
con la comunidad
· Socializar la hoja de planificación conjunta en 
SEDES, distrito y promotores
· Material de escritorio dotar según sus 
necesidades
· Optimizar equipo de computación área y tener 
visitas mensuales del técnico DJC
· Material de capacitación catalizar y optimizar el 
uso del AIEPI
· Material de apoyo al promotor
· Niveles de coordinación distritos
· Desarrollo de una estrategia con el MSPS para 
dotar SRO y paracetamol
· Balanza a analizar RREE
· Dotar sellos como incentivo
· socializar SMIA equipo wawa sana
· Uso de información SECI en toma de decisiones 
TAIs
· Uso de software que se utilice a nivel de distrito
y que haya mas capacitación a distrito para 
reciclar a áreas
· Nombrar responsable del personal de salud para 
la recolección y consolidación Áreas y sectores
57
Situación Ideal Situación Actual Recomendaciones
· Auxiliares enfermería
· Otras instituciones
· Municipio
· Lideres
· Promotores
Sistemas Funcionando
· Uso del Software CAI- TAI
· Recolección continuo de datos
· Reporte mensual
· Reporte mensual de informes a l centro de salud
· Que exista una persona responsable para 
recoger y consolidar la información
· Red de información funcionando
· Capacitación continua a todo nivel
· Incorporación del promotor en los TAI
· Motivación del promotor de distrito, municipio
· Planificación conjunta que genere plan de 
acción comunitario
· Planificación adecuada de trabajo (promotor –
distrito - ONG )
· Reunión mensual o bimensual de planificación 
conjunta
· Respetar liderazgo y jerarquía del promotor
· Organización interna de promotores
Actividades completadas
· Visitas domiciliarias por promotor mensual
· Planificación conjunta mensual, bimensual
· Análisis y uso de información por distrito y a 
todo nivel
· Participación del personal de salud en el 
proceso
· Plan de capacitación cumplido
· Promotores realizando viajes de intercambio de 
experiencias
· Actividades multiprograma ticas en comunidad
· Sistema de monitoreo y evaluación 
nultisectorial semestral al promotor capacitación
· Parcialmente
· Escaso
· Se realizo
· La mayoría
· A Nivel Distrital 2 utilizan de 3
· Regular
· Continuo
· Si
· Algunos sectores
· A mejorar
· Incompleta
· Mínima
· Existe consenso pero no se realiza 
· Parcial, poca participación del personal de salud
· Poca coordinación
· Si
· Si la comunidad y no así el personal de salud
· En algunos sectores
· Si
· Si 
· Mejorar
· Mejorar
· Mejorable, ajustar completar
· Escaso
· Si
· Socializar las capacitaciones
· Incorporación del promotor en TAI de sector y 
área como:
o Invitación escrita del director de 
área
o Fortalecer la incorporación del 
promotor en TAI comunidad, 
sector, área
o Coordinación con distrito
o Dotar de credenciales al promotor
· Motivación al promotor
o Distrito y municipio
o Incluirlos en el POA
1. Plan adecuado
2. Compartir las recomendaciones de este taller
3. Facilitar la organización del promotor para tener 
control interno
4. Incentivos positivos de parte del personal de 
salud
5. Promoción de intercambio de experiencia
6. Premio al mejor promotor
7. Realizar encuentros culturales y deportivos
8. Compartir experiencias en el desarrollo del 
sistema de monitoreo y evaluación APROSAR, 
DJC y MSP
9. Incorporación a personal MSPS en proceso de 
monitoreo y supervisión
58
Situación Ideal Situación Actual Recomendaciones
nultisectorial semestral al promotor capacitación
AIEPI (Atención Integral de las Enfermedades 
Prevalentes de la Infancia)
Suministros Esenciales
Comunidad
· Laminas para la comunidad
· Rota folio, grupo de madres organizados
Promotor
· Hojas de registro de AIEPI – Comunitario
· Rota folio de AIEPI Comunitario
· Laminas
· Material de escritorio
· Balanza, tallimetro
· Botiquín (paracetamol y cotrimoxasol, vitamina 
A y SRO)
· Boletas de referencia
· Croquis, Censo actualizado
· Cuaderno de seguimiento
· Equipo de URO – comunitario
· Una mochila
· Una chamarra o ropa de agua
· Una bicicleta
· Plan de actividades
Personal de Salud
1. Manual de AIEPI
2. Rota folio, hojas de registro
3. Balanza taquímetros
4. Boleta de referencia y contra referencia
· Falta instrumentos
· No tienen (laminas, rotafolios)
· Tienen
· Tienen
· Dotación en capacitaciones
· La mayoría no tiene o se presta del promotor de 
APROSAR no tienen
· 95 % no cuenta con medicamentos
· 11 tienen 7 no tienen
· tiene la mayoría
· tienen
· no tienen
· no se pregunto pero tienen algunos
· tienen solo los de APROSAR
· promotores antiguos de APROSAR
Promotores
1. Dotación de material de escritorio semestral 
(cuadernos, lápices, papelografos, etc.)
2. Inventario de balanzas en los servicios de salud
3. Dotar de balanzas salter a los promotores que 
están sin acceso a servicio
4. Hacer gestiones a través del SBS que todos los 
promotores cuenten con (SRO, paracetamol) 
estableciendo un sistema de control
5. Diseño de un sistema de contrarreferencia
6. Gestiones con la alcaldía para que incluyan en el 
POA, la implementación suministros (URO) 
estimulo para los promotores (equipos de 
trabajo)
59
Situación Ideal Situación Actual Recomendaciones
5. Plan de seguimiento a cada promotor
6. Contar con medicamentos esenciales
7. Croquis encuesta/ comunidad
8. Funcionando URO institucional
9. Formulario de AIEPI clínico
10. Carnet salud infantil
11. Vacunas
12. Balón de oxigeno
13. Mochila
14. Apoyo logística
15. Atención adecuada
16. Capacitación en AIEPI comunitario preventivo
17. Talleres de gestión de AIEPI comunitario
18. Buenas relaciones humanas
19. Calidad de atención
Sistemas Funcionando
1. Flujo de información
a. atención del niño (hoja de registro) –
comunidad
b. registro de atenciones (cuaderno del 
SECI) – promotor
c. informe al centro de salud 
(consolidado en libro de consulta 
externa) – personal de salud –
planificación conjunta
2. Referencia contra referencia
a. Referencia de niño con señales de 
peligro (promotor) –Centro de Salud 
mas cercano – contra referencia -
referencia a nivel superior
· La mayoría del personal cuenta con el personal 
de AIEPI
· La mayoría de Aux. de enfermería cuenta con el 
Rota folio AIEPI Comunitario
· La mayoría del personal de salud cuentan con 
balanzas y tallimetros
· La mayoría del personal de salud cuenta con la 
hoja de registro
· El 50 % de estos tienen URO institucional
· Todos los servicios de salud cuentan con 
croquis
· La mayoría tienen CENSO
· La mayoría de los servicios de salud cuentan 
con medio de transporte (motos o ambulancia)
· solo la mitad utilizan los instrumentos del 
AIEPI
· la información que genera el promotor de salud 
es incluida en el libro de consulta interna 
exterior y SNIS del servicio de salud
Sistemas funcionando
· Promover los POA, a niveles de sector área 
distrito, con la participación de todo los actores 
sociales
60
Situación Ideal Situación Actual Recomendaciones
Actividades completadas
· Visitas domiciliarias
· Referencia contrarreferencia
· Talleres AIEPI: promotores – Recursos 
humanos – servicios de salud
· Sistema de monitoreo
· Sistema seguimiento AIEPI (clínico 
comunitario)
Recursos Humanos
Comunidad
· Grupo de madres capacitados en AIEPI 
< 5 años
· Familias capacitadas
· Comunidad autoridades
Promotor o Líder
· Capacitado en:
· Manejo de suministros
· Manejo de instrumentos 
o Hojas registro
o Plan registro
o Plan mensual
o Carnet seguro infantil
o Técnicas participativas
o Peso talla
Personal de Salud
· Capacitados en AIEPI comunitario y 
clínico
· Capacitado reforzamiento del 
componente promoción prevención 
· Solo el sistema de referencia del promotor 
funciona al servicio de salud pero no funciona la 
contra referencia
· Más de la mitad de los promotores realizan 
visitas domiciliarias y además saben el objetivo 
de esta actividad
· La comunidad satisfecha
· Saben generar ambiente de confianza toman 
decisiones
· Recomiendan priorizando el tema
· La mitad busca señales de peligro
· 7 de 13 hacen búsqueda de evaluación de tos, 
diarrea y fiebre
· el personal de salud recibieron menos de la 
mitad capacitación en AIEPI
· seguimiento de monitoreo reciben menos de la 
mitad
· el promotor recibió supervisión mas de DJC y 
APROSAR poco del servicio de salud
· grupos de madres capacitados en AIEPI con 
niños menores 5 años como reconocer las 
señales de peligro de muerte
· las familias se dan cuenta para identificar algún 
signo de SEÑAL DE PELIGRO
PROMOTOR/ LIDER
· La mayoría de los promotores han sido 
capacitados en el AIEPI comunitario; SECI 
lactancia materna, SSR y algunos en EDP
Recursos Humanos
1. Reforzar con talleres de capacitación todos los 
grupos de madres de la comunidad para que 
aprendan a identificar señales de peligro
2. Completar y reforzar la capacitación al promotor 
en el manejo y aplicación de los instrumentos del 
AIEPI complotar y reforzar
3. Capacitación en la gestión de AIEPI comunitario 
para su involucramiento y seguimiento a los 
promotores
4. Mejorar el nivel de coordinación entre el 
personal de salud y el promotor para que la 
información sea incluidas en el SNIS, 
retroalimentación a la comunidad
5. adecuar al sistema de referencia y 
contrarreferencia, con intervención de servicio 
de salud, promotor y comunidad
Otras Actividades
1. SI fortalecer las actividades del promotor, 
mediante los procesos de capacitación y 
monitoreo
61
Situación Ideal Situación Actual Recomendaciones
· ID Prom.
EDP Estudio Desviación Positiva
Suministros esenciales
· Balanzas y tallimetros en comunidad (a 
cargo del promotor) 
· Carnet de seguro infantil
· Tablas de peso y talla por edad / sexo
· Banderas mas muñecos
· Espacio para pesaje / reunión 
· Cocina / fogón
· Mensajes de cocina /platos
· Productos
· Espacio donde cocinar
· Combustible
· Platos
· Vitamina A, Hierro
· Mebendazol 
· Material de desarrollo infantil
· Material educativo: rota folio, laminas 
de alimentos
· Papel y marcadores
· Protocolo o manual
· Formularios de investigación de 
seguimiento
· Transporte para capacitadores
· Recetas mejoradas
PERSONAL DE SALUD
· Menos de la mitad recibieron capacitación en 
AIEPI clínico y algunos en el comunitario
· Mas del 50 % entre promotores y lideres no 
cuentan con balanzas y tallimetros
· Cuentan con banderas y muñecos
· No cuentan con espacio adecuado para pesar 
talleres hogareños
· No existe material educativo para talleres 
hogareños
· Recetas mejoradas en los talleres hogareños
monitoreo
2. El personal de salud realice el seguimiento y 
monitoreo, para su sostenibilidad (acompañado 
en visitas domiciliarias y revisando el registro)
Suministros
1. Implementación de 10 balanzas con 
comunidades EDP
2. Elaborar una guía de implementación incluyendo 
información técnico
3. Ir preparando Manual EDP
· Mantener capacitaciones en comunidades 
62
Situación Ideal Situación Actual Recomendaciones
Recursos humanos capacitados
· Mujeres lideres capacitados madres (positivas, 
negativas y caso estudio)
· Promotores
· Auxiliares de enfermería
· Médicos de área y sector
· Autoridades de la comunidad informados 
motivados
· Otras ONGs.
· Personal de monitoreo
· Personal con experiencia en nutrición
Sistema funcionando
· Referencia para desnutridos
· Exámenes de laboratorio
· Programa de IEC
o Difusión de mensajes claves 
folletos, radio, ferias audiovisuales
Actividades completadas
· Pesaje del 100 % de niños
· Proceso de información
· Clasificación de familias
· Buena 77%
· Promotores 26 %
· Auxiliares 38 %
· Médicos 29 %
· Autoridades informadas y motivadas
· ONGs, personal de monitoreo, personal con 
experiencia en nutrición NO EXISTE
PROMOTORES
· Reconocen signos de desnutrición
· refieren al Aux. no todos con boleta
· No reciben contrarreferencia
AUXILIAR
· Refiere Con boleta
· No recibe contrarreferencia
MEDICO
· Manejo de casos desnutridos regular
· Refieren a niveles superiores ?
· No reciben contrarreferencia
· Hay actividad en radio
o Productores : LINKAJES
o Financiadores: APROSAR
o Difusores: Pió XII, Bahai
· Hubo feria y video pero no se menciono en 
entrevistas
· No hay folletos o material impreso
· No hay plan general monitoreo y evaluación
· 100% comunidades EDP cuenta con estudio
· personal de salud, promotor no conocen la 
estrategia
· se utilizan recetas mejoradas pero no cuentan 
con cantidades y de modo de preparación
· Reforzar en los próximos 2 años capacitación 
promotores auxiliares, médicos y autoridades 
comunales
· Fortalecer el monitoreo dentro del personal 
existente
· Capacitación al personal existente en nutrición y 
coordinación con instituciones socias que tienen 
nutricionistas
Sistemas funcionando
· Sensibilizar al personal de SEDES sobre el 
sistema de referencia y contrarreferencia
· Lograr una nota de apoyo de la SEDES para que 
el personal acepte el personal las referencias y 
contrarreferencias
· Mejorar las instrucciones de referencia y 
contrarreferencia
· Elaborar un plan de estrategia de IEC para su 
implementación que seria anual, por sectores y 
niveles
Actividades completadas
· Adecuar el EDP serán según necesidades de la 
comunidad
· Visitas domiciliarias con conserjería nutricional
· Feria de nutrición
63
Situación Ideal Situación Actual Recomendaciones
· Grupos focales visitas domiciliarias
· Devolución de información y análisis de 
información
· Capacitación a mujeres lideres, promotores y 
personal de salud
· Reunión con las mujeres para realizar los menús 
e identificar e incluirlos en los menús
· Taller hogareño (14 días)
· Administración de micronutrientes y 
desparacitación a niños participantes 
crecimiento y desarrollo
· Seguimiento
· 8 meses
con cantidades y de modo de preparación
· no se cumple con los 14 días esperados por la 
escasa disponibilidad de tiempo (solo se llevo a 
cabo un taller hogareño en cada comunidad)
· No se están haciendo ciclos de 8 meses/14 días)
· Existe administración de micronutrientes a los 
niños no así la desparasitación
· Existe seguimiento antropométrico mensual y 
un parcial seguimiento en desarrollo
· Sistematización y socialización de la 
información de EDP
64
MONITOREO Y SUPERVISIÓN
ASPECTOS POSITIVOS
1. MONITOREO A TRAVEZ:
· Libros de actas
· Formularios de desarrollo y crecimiento
· Formulario de planificación conjunta
· Cuadernillo de consolidación de información
· Formulario de monitoreo comunitario
· Software SECI
· Circulos de calidad mensual y trimestral
2. SUPERVISIÓN
· Informes Mensuales
· Informes trimestrales
ASPECTOS NEGATIVOS
· Sistema de monitoreo no funciona en todos los niveles del proyecto proyecto
· No existe un modelo de monitoreo del avance de actividades
· No existe una programación anual operativo 
· Que el circulo de calidad y evaluación trimestral implementado es sectorial y no como programa 
Wawa Sana
· No existe instrumento de supervisión en todos los niveles
RECOMENDACIONES
· Implementar instrumentos de supervisión y monitoreo, socializando y adecuando instrumentos de otras 
instituciones (APROSAR, SEDES y/o otros programas)
· Elaboración del POA Wawa Sana en todo los niveles
· Círculos de calidad transversales ampliado del proyecto Wawa Sana cada 3 meses donde participen del 
gerente al promotor.
COORDINACIÓN
ASPECTOS POSITIVOS
COMUNIDAD
· Coordinación con autoridades, madres, padres y lideres
· Promotor elegido por su comunidad
SECTOR
· Fácil coordinación con los auxiliares de enfermería
ÁREA
· Buena coordinación cuando el director es motivado y permanente
DISTRITO
65
· Tiene conocimiento de los programas del proyecto
· Convenios firmados
· Buena predisposición del equipo
ASPECTOS NEGATIVOS
COMUNIDAD
· Falta de información y motivación de las autoridades
· Falta de liderazgo de los promotores
SECTOR
· Confusión en el equipo de información entre el promotor SS – DJC
ÁREA
· Cambios frecuentes de recursos Humanos
· Actividad negativa de algunos Recursos humanos
DISTRITO
· Poca permanencia por actividades administrativas
RECOMENDACIONES
ONGs 
ÿ Formalizar y revisar convenios
ÿ Reuniones periódicas de intercambio de experiencias planificación 
programación 
SEDES ORURO DIRECCIÓN DEPARTAMENTO DE PLANIFICACION
ÿ Informe y reuniones de coordinación semestralmente programadas
ÿ Participación en los CAI regionales
MUNICIPIOS
ÿ Formalizar convenios
ÿ Informes reuniones de coordinación programadas
ÿ Incorporación al COMUSA
OTRAS ORGANIZACIONES
ÿ Formalizar convenios
ÿ Informes reuniones de coordinación programadas
ÿ Incorporación al COMUSA
ÿ PAN coordinar con promotor
ÿ Ejercito
ÿ Educación Informal
ÿ Radios
ÿ CETHA
COMUNIDAD
ÿ Informar a las autoridades por lo menos anualmente con reuniones programadas
ÿ Fortalecer capacidad resolutiva del promotor (Sello, credencial, SRO y paracetamol) 
gestionando con los municipios y distritos
SECTOR
ÿ Establecer un flujo de informaciones de los promotores que debe ser entregado a un 
Auxiliar de enfermería con copia para ONGs.
ÁREA
66
ÿ Reglamentar por instrumentos que si no se cumple las actividades programadas con 
el proyecto, acudir a la dirección Distrital, para tomar acciones
DISTRITO
ÿ Gestionar ante SEDES, permanencia y estabilidad de los recursos humanos
SOSTENIBILIDAD
ASPECTOS POSITIVOS
ÿ Las tres estrategias están diseñados para manejo comunitario
ÿ Existe respuesta de las Autoridades
ÿ Promotores dispuestos y capacitados
ÿ Autoridades comunitarias dispuestas a apoyar
ÿ Personal capacitado a todo nivel
ÿ Madres y mujeres motivadas y organizadas
ASPECTOS NEGATIVOS
ÿ Personal de sedes no comprometido
ÿ Autoridades municipales no comprometido
ÿ Falta de un balance en la capacitación entre nivel comunitario y personal de salud
ÿ Constante cambio del personal de salud
ÿ Poco apoyo de las autoridades hacia sus comunidades
ÿ Trabajo individualizado de parte DJC
RECOMENDACIONES
ÿ Involucrar planificar continuamente con las autoridades municipales comunitario para generar 
compromiso
ÿ Incorporar al personal del SEDES en la elaboración e implementación de las capacitaciones
ÿ Reforzar las capacitaciones de las tres estrategias en los diferentes niveles
ÿ Empoderamiento de las tres estrategias por los promotores para que lleven adelante solos
ÿ Lograr que las comunidades sean actores de sus propias actividades a trabes de una 
capacitación adecuada 
ÿ Que los promotores sean protagonistas en las capacitaciones de sus comunidades u otras
ÿ Promotores capacitados en gestión de proyectos
67
Attachment F
Suggested Changes to Indicators
CS-16 Wawa Sana Project Indicators
Current Indicator Suggested Change Measure Comments
1. 3 RHDs incorporate 
SECI data, discussion, 
& plans into district 
info. analysis (CAI) 
meetings *
Interview 
during Final 
Evaluation
2. 60% of permanent 
Auxiliary Nurses 
demonstrate good 
skills in co-facilitating 
SECI meetings *
60% of Promoters 
and Auxiliaries 
demonstrate good 
skills in co￾facilitating SECI 
meetings *
Need to 
develop tool 
to monitor 
this indicator
It is important that 
Promoter also acquire 
these skills
3. 80% of permanent 
MOH staff 
demonstrate good
skills in co-facilitating 
H/PD training *
60% of permanent 
MOH staff 
demonstrate good 
skills in co￾facilitating IMCI 
training *
Need to 
develop tool 
to monitor 
this indicator
Few MOH staff would 
have the opportunity to 
assist with H/PD 
training, most could 
with IMCI
4. All APROSAR 
trainers demonstrate 
competency in CB￾IMCI, SECI, & H/PD 
training of Promoters
Need to 
develop tool 
to monitor 
this indicator
5. 90% of APROSAR 
Promoters receive 
support/ supervisory 
visit from APROSAR 
staff in the previous 3
months*
Omit
This indicator was 
probably met before the 
project started. 
Supervision is one of 
APROSAR’s strengths. 
Capacity building 
indicators should be 
developed with 
APROSAR based on 
their need to improve
6. 90% of APROSAR 
Promoters have 
adequate supply of 
cotrimoxazole *
80% of Promoters 
have adequate 
supply of ORS *
Need to 
develop tool 
to monitor 
indicator
Due to MOH policy a 
focus on supply of ORS 
is more appropriate
68
Current Indicator Suggested Change Measure Comments
7. 75% of SECI 
communities have 
action plans with 
service providers to 
address CS needs *
Need to 
develop tool 
to monitor 
this indicator
Need to clarify that 
action plans can be what 
is written in the “libro de 
actas”
8. 75% of 
communities with 
action plans revise 
plans based on 
analysis of SECI/SNIS 
data *
75% of communities 
with action plans 
have implemented 
the plan *
Need to 
develop tool 
to monitor 
this indicator
Need to clarify that 
action plans can be what 
is written in the “libro de 
actas”
9. 40% participants in 
CS-16-related 
community meetings 
are women *
SECI
10. 75% of partner & 
community capacity 
building objectives 
achieved *
Omit
This objective is 
redundant as all capacity 
building objectives are 
already included in this 
M&E plan
11. 100% of CS-16 
APROSAR & 
permanent MOH staff 
receive support/ 
monitoring visit from 
SC staff in last 6m *
100 % of 
APROSAR and 
MOH staff in CS 16 
have coordinated 
activities with SC 
staff in the last 6 
months
Need to 
develop tool 
to monitor 
this indicator
The focus should be on 
coordination, not a 
monitoring function
12. SC/B advocates for 
implementation of 
effective/innovative 
approaches to child 
health at public and 
NGO levels *
SC/B advocates for 
effective 
implementation of 
child health at public 
and NGO levels *
Interview 
during Final 
Evaluation
Advocacy should 
include more than just 
implementing SCB 
approaches, but should 
influence policy at all 
levels
13. 60% of 12-23 
month olds have 
maternal history or 
card for measles 
immunization. (27%)
60% of 12-23 month 
olds have measles 
immunization 
measured by vaccine 
card 
KPC
Use of vaccine card for 
verification is 
recommended
14. 80% or more 
DPT3 coverage in 
infants in all CS-16 
municipalities (32%)
60% coverage of 
DPT3 or Pentavalent 
3 in children 12-23 
m measured by 
vaccine card in all 
CS-16 municipalities
KPC
Should measure 12-23m 
only for vaccines, use of 
card for verification is 
recommended but will 
lower percentage of 
change
69
Current Indicator Suggested Change Measure Comments
15. 85% of 12-23 
month olds with cards 
received 1/more 
capsules in last year. 
(64%)
50% of 12-23 month 
olds received 1/more 
Vitamin A capsules 
in last year as 
verified by with card 
(64%)
KPC
The denominator should 
be children 12-23 m, not 
just children with card
Verification with card 
makes 85% too high
16. 75% of mothers of 
6-23 month olds with 
DD in last 2 weeks 
report feeding 
increased fluids during 
DD. (24%)
50% of mothers of 
6-23 month olds 
with DD in last 2 
weeks report feeding 
increased fluids 
during DD. (24%)
KPC
Percentage of change 
originally set too high
17. 23% annual
increase in total <5 
pneumonia cases 
treated by CS-16 
facilities & Promoters.
23% annual increase 
in total <5 
respiratory infection 
cases treated by CS￾16 facilities & 
Promoters.
SECI
SECI collects 
respiratory infections, 
not necessarily a 
diagnosis of pneumonia
18. 75% of CS-16 
population is within a 
1-hour walk of facility 
or ARI-trained 
Promoter with cotrim. 
stock.
75% of CS-16 
population is within 
a 1 hour walk of 
facility or IMCI￾trained promoter. 
SECI
Currently tracking 
population with trained 
Promoter, not Promoter 
with Cotrimoxizole
19. 60% of 
communities with pop. 
over 120 have CB￾IMCI-trained 
Promoter or MOH 
facility *
80% of communities 
with pop. over 80 
have CB-IMCI￾trained Promoter or 
MOH facility 
SECI
With cutoff at 120 
insufficient # of 
communities, changed to 
cutoff of 80
20. 80% of CS-16 
ARI-trained Promoters 
pass PCM knowledge 
& skills test.
Need to 
develop tool 
for this 
indicator
21. 80% of CS-16 
CDD-trained 
Promoters pass CDD 
knowledge & skills 
test.
Need to 
develop tool 
for this 
indicator
70
Current Indicator Suggested Change Measure Comments
22. 80% of caretakers 
of children recently 
treated by CS-16 
facilities/ Promoters 
report correct dose & 
course of cotrim. fed 
for pneumonia
Omit
This indicator will be 
very difficult to measure 
as exit interviews for 
mothers with pneumonia 
will be difficult to 
conduct due to 
frequency of pneumonia
23. 80% of caretakers 
recently counseled on 
DD by CS-16 
facilities/ Promoters 
report following 3 DD 
home care rules
Omit
This indicator will be 
very difficult to measure 
as exit interviews for 
mothers with diarrhea 
will be difficult to 
conduct after counseling
24. 75% of mothers of 
children under 2 years 
report that help should 
be sought if their child 
has “fast and agitated 
breathing.” (17%)
40% of mothers of 
children under 2 
years report that help 
should be sought if 
their child has “fast 
and agitated 
breathing.” (17%)
KPC
Percentage of change 
originally set too high 
25. 50% of mothers of 
children under 2 years 
report that help should 
be sought if their 
child’s “thorax is 
sunken” (chest 
indrawing) (2%)
25% of mothers of 
children under 2 
years report that help 
should be sought if 
their child’s “thorax 
is sunken” (chest 
indrawing) (2%)
KPC
Percentage of change 
originally set too high 
26. Estimated 
marginal cost of 
human resources & 
supplies for service 
delivery & support for 
implementation of 
approach
Feasibility 
report 
completed
Need to develop plan for 
documenting strategies 
now
27. 30% decrease in 6-
35 month olds in H/PD 
communities below -
2Z weight-for-age 
(pre-/post-).
SECI
This indicator still under 
study and a decision on 
how to modify it will be 
included in the 3rd
Annual Report
71
Current Indicator Suggested Change Measure Comments
28. 50% of the 
nutrition status impact 
on % of all 6-35 
month olds below -2Z 
WFA is sustained 1 
year after the end of 
Hearth sessions ‡
SECI
This indicator still under 
study and a decision on 
how to modify it will be 
included in the 3rd
Annual Report
29. 50% of the 
nutrition status impact 
on % of all 6-35 
month olds < -3Z 
WFA is sustained one 
year after the end of 
Hearth sessions ‡
Omit
The prevalence of severe 
malnutrition is minimal 
(0.5-1%), so changes 
will not be significant. 
30. MOH or other 
PVO/NGO has written 
plans for 
implementation of 
SECI and/or 
Hearth/PD in two 
other RHDs‡
Interview 
during Final 
Evaluation
* Capacity Building Indicator
‡ Sustainability Indicator