MID-TERM EVALUATION OF 
THE INSTITUTIONAL STRENGTHENING PROJECT 
FOR
THE CENTRO PARAGUAYO DE ESTUDIOS DE 
POBLACION (CEPEP)
Award No 526 – A – 00 – 99 – 00008 – 00
SO 526 005 Use of voluntary reproductive health 
services increased
Produced by:
Sandra Wilcox, Consultant
November, 2003
2
ACKNOWLEDGEMENTS
The principal author of this report would like to thank the staff at the Centro 
Paraguayo de Estudios de Poblacion (CEPEP) for their support, hard work and 
patience during the period of this Mid - Term Evaluation. They gave freely of 
their time despite their very busy schedules and responsibilities. It is also 
important to acknowledge the high degree of dedication and professionalism 
that they bring to their work. It is evident in the quality of the programs that 
CEPEP manages under challenging conditions.
The efforts and support of the USAID/ Paraguay office must also be 
acknowledged for their guidance before, during and after the evaluation.
Despite the best efforts of CEPEP and the project staff, factual errors may still 
persist in the report. They must be considered the responsibility of the principal 
author who tried to understand the complexity of the environment within a short 
period of time.
3
Table of Contents
1. Executive Summary 4
2. Introduction 8
3. Findings 10
A. Result 1. Sustainability
B. Result 3. New types of Services and Products 15
C. Result 2. Decentralization 16
4. General Conclusions and Recommendations 19
ANNEXES 22
i) Questionnaires used
ii) Field visits and Contacts 
iii) Agenda
iv) CEPEP’s Response to Recommendations
4
1. EXECUTIVE SUMMARY
During August 2003, a mid-term evaluation was conducted of the Centro Paraguayo de 
Estudios de Poblacion (CEPEP), which is the International Planned Parenthood affiliate in 
Paraguay. Five years ago CEPEP underwent an organizational restructuring and began 
focusing on institutional sustainability through the development of self-financing strategies. 
In 1999 USAID/ Paraguay began supporting this sustainability effort through the ‘CEPEP 
Institutional Strengthening Project.’ In 2002 CEPEP was granted an extension of this project 
through 2006. The purpose of the project is to promote the USAID Mission’s Strategic 
Objective of “Use of voluntary reproductive health services increased,” and support 
Intermediate Result 1.1 “Decentralized community based health care provided” and I.R. 1.2 
“Access to quality reproductive health services expanded. It was expected that these 
activities would be accomplished through CEPEP’s network of clinics, by training provided 
to health clinic staff and the community health care system.
The expected results of the project include:
Result 1: CEPEP will be able to recover 80 percent of it’s basic annual operating costs 
through it’s own revenues.
Result 2: CEPEP will create new agreements with local governments (three per year) to 
provide FP/RH services, which will be evaluated in terms of use, quality and sustainability of 
said services. This result was amended to: Result 2: Decentralization: By 2004, 12 
communities will have created programs that have agreements with local governments.
Result 3: CEPEP will implement three or more new services and products based on market 
studies and feasibility. The Research and Evaluation Department will offer research, 
evaluation and market study services.
The Mid-Term evaluation of CEPEP was conducted by a team composed of Dr. Romero 
from the CEPEP Board of Directors, Josceline Betancourt and Gabriela Frutos from the 
USAID Health and Population Unit and Sandra Wilcox, an external consultant. The 
evaluation took place in Paraguay between the 3rd to the 15th of August 2003. Sites visited 
included Ascuncion, Atyra, Coronel Bogado and San Miguel. In the San Miguel area sites 
visited included the city of San Miguel, Arazape and Ita Yuru. 
The evaluation findings indicate that CEPEP is close to achieving its Result 1 objective of 
recovering 80 percent of its annual operating costs (COBA). Using the COBA calculation, in 
1999 CEPEP recovered 58 percent of its basic annual operating costs (COBA). In 2000 it 
recovered 62 percent, in 2001, 64 percent, and in 2002 - 77 percent. Much of the dramatic 
gain in 2002 was attributed to improved systems and increases in sales of services and 
products. According to budget figures, the most cost effective activity comes from the 
community distribution program run by volunteer health promoters. During 2002, the cost of 
this program totaled 245,073,966 guaranis and the income generated from this program was 
524,009,550 guaranis providing a 214 percent sustainability rate. Significant income was also 
generated through the Associated Professionals program (PAC) through which 
contraceptives and other products and services are sold. Both of these programs have the 
advantage of being able to sell services and products without having to pay personnel costs. 
5
Impressive restructuring and improvements have been made in the administration and 
finance department and the services and projects department allowing the above 
improvements. In addition important advances were made by the information services 
department, which allowed CEPEP to upgrade its financial management structure, its 
personnel system, patient records and services statistics. It also significantly upgraded 
personnel computer skills through extensive training. The evaluation and research 
department is also bringing in business by selling its research products to other organizations 
needing surveys and studies. They are currently making preparations to conduct the 2004 
DHS survey.
Regarding Result 3: New products and services: Each year CEPEP has set a goal to add at 
least five new products to the medicines and products being sold through its social pharmacy 
system and each year it has surpassed it. In 2001, CEPEP added 15 new products and in 
2002 it added 21. Examples of new products include pregnancy kits, female condom, new 
medicines for the social pharmacy and new types of laboratory testing materials. In addition 
CEPEP had great success in selling videos, flipcharts and other IEC materials mainly related 
to family planning and reproductive health. They also received permission from the MOH to 
reproduce their Norms and Procedures manuals and has sold these as well as Contraceptive 
Technology manuals. In 2002, CEPEP has also negotiated a number of contracts with 
hospitals and organizations for specialized services at reduced cost for patient referral. 
CEPEP receives a small percentage of the fee for its services. So far, these services have 
included voluntary sterilization, mammography, dermatology, and urology. 
As further support for its sustainability efforts, CEPEP has made use of its donated 
contraceptives from USAID by setting up rotating funds in its clinics and charging prices 
based on USAID’s value calculations. By the end of 2002, CEPEP had met its 2004 
contraceptive sales goals. CEPEP also sells contraceptives at low cost to the MOH and other 
agencies that have run out of their supply.
The biggest effort in the new services areas is that of the new clinic in Asuncion, which has 
been bought and is being remodeled by CEPEP. It is due to open in November of 2003. 
This clinic will strengthen financial stability and is large enough to accommodate the central 
office and expand services. 
As part of its institutional strengthening cooperative agreement with USAID, CEPEP was 
included as a member of the Alliance for health Project, which is a consortium of three non￾government agencies (NGOs). In addition to CEPEP there is the Centro de Informacion y 
Recursos para el Desarollo (CIRD) and the PRIME II Project run by Intra Health 
International (a USAID Cooperating Agency). The purpose of the Alliance is to strengthen 
the provision of reproductive health in accord with the decentralization of health services 
occurring at the local level. The local level work has been divided among the three partners 
who are operating in 12 communities. Indicator 2.1 of the Alliance cooperative agreement 
stipulates that “CEPEP’s responsibility is the training of community health promoters in the 
design, implementation and evaluation of an RH health promoter system and in the provision 
6
of contraceptives. By 2004 12 communities will have a community program, within an 
agreement with local governments.”1
 
Since this agreement was signed, there have been several changes in the partnerships and 
roles of partners. According to the partners interviewed there is no updated agreement to this 
respect.2
 CEPEP is responsible for training community based health promoters but is not 
distributing contraceptives because CIRD is managing the social pharmacies in the 
communities.3
 Also, these promoters function differently from the CEPEP promoters in that 
they are not self-supporting and do not distribute and sell contraceptives and other products. 
Their function is to educate community members and promote the local MOH health services 
by working closely with the health services and the local councils who both supervise their 
work. CEPEP and the Alliance partners agreed that this different kind of promoter role was 
required to further the project’s decentralization objectives. However, managing this Alliance 
project promotion activity has been challenging for CEPEP as it requires that the institution 
develop Alliance promoters that have a different set of skills in order to they meet and 
develop implement this MOH related social promotion agenda objectives. At the same time 
CEPEP needs to continue supporting and developing the role of its own CBD promoters who 
are supporting its institutional objectives. It would be useful for these promoters to also 
develop more community empowerment and democracy skills to enhance community 
outreach effectiveness. . as well as their above described institution strengthening objectives. 
In addition to these objectives being at odds with one another, it appears that Thus, the 
Alliance activities are also requiring more and more institutional and staffing commitments 
resources from CEPEP, thus sidetracking it from meeting it’s sustainability goals. Presently 
there is no coordinating agency among the various organizations in the “Alliance,” though 
there is a coordinating committee in which only the three main partners and USAID 
participate. Without an agency designated to manage the activity, CEPEP and the other 
partners indicated that USAID’s role has become very important in facilitating the work 
coordination process between the partners. The other major issue here is that because the 
decentralization process has not yet been implemented in Paraguay, so the administrative 
structures and local funding mechanisms are not in place to really make it happen. This 
requires that the Alliance partners, including CEPEP, work diligently with local communities 
and health structures to create “democratic structures” and an enabling environment that will 
allow the decentralization of health services to occur. Since the August evaluation, CEPEP 
has discussed with USAID its interest in changing its role with the Alliance project. It has 
proposed to put more emphasis on working with the government (MOH) to mobilize public 
support for the new National Health Plan.
 
1
 Ibid
2 According to CIRD and CEPEP, CEPEP was originally going to sell contraceptives through promoters but 
once CIRD took over the pharmacies, this role changed. CIRD and CEPEP also had to adjust their work plans 
once PRIME was added as a partner. In addition CIRD’s sub partners, CETEC and Promesa are also working 
with health promoters and IEC activities in the same communities where CEPEP is working and both 
expressed concern to the consultant about their overlapping roles with CEPEP’s promotor activities.
3
The Alliance partners decided consensually that the community based social pharmacies would be a good 
mechanism for facilitating access to contraceptives, given the tendency for stock-outs in many MOH services. 
CEPEP provides the contraceptives for these social pharmacies or dispensaries. The Local Health Councils 
have made a decision that the health promoters will not distribute or sell any products including contraceptives.
7
Conclusions and recommendations are included at the end of the report. CEPEP’s response 
to the recommendations are included in Annex 4.
8
2. INTRODUCTION
During August 2003, a mid-term evaluation was conducted of the Centro Paraguayo de 
Estudios de Poblacion (CEPEP), which is the International Planned Parenthood affiliate in 
Paraguay. Five years ago CEPEP underwent an organizational restructuring and began 
focusing on institutional sustainability through the development of self-financing strategies. 
In 1999 USAID/ Paraguay began supporting this sustainability effort through the ‘CEPEP 
Institutional Strengthening Project.’ In 2002 CEPEP was granted an extension of this project 
through 2006. The purpose of the project is to promote the USAID Mission’s Strategic 
Objective of “Use of voluntary reproductive health services increased,” and support 
Intermediate Result 1.1 “Decentralized community based health care provided” and I.R. 1.2 
“Access to quality reproductive health services expanded. It was expected that these 
activities would be accomplished through CEPEP’s network of clinics, by training provided 
to health clinic staff and the community health care system.
The expected results of the project include:
Result 1: CEPEP will be able to recover 80 percent of it’s basic annual operating costs 
through it’s own revenues.
Result 2: CEPEP will create new agreements with local governments (three per year) to 
provide FP/RH services, which will be evaluated in terms of use, quality and sustainability of 
said services. This result was amended to: Result 2: Decentralization: By 2004, 12 
communities will have created programs that have agreements with local governments
Result 3: CEPEP will implement three or more new services and products based on market 
studies and feasibility. The Research and Evaluation Department will offer research, 
evaluation and market study services.
CEPEP now operates its own central clinic in Asuncion as well as clinics in San Lorenzo, 
Encarnacion and Ciudad del Este. In addition it has more than 100 associated professionals 
(doctors, registered nurses, and nurse midwives) who sell contraceptives provided by 
CEPEP’s visiting distributors or by the CEPEP clinics. In addition, CEPEP sells supplies 
and contraceptives at a reduced rate to numerous ‘associated institutions’ including the Red 
Cross, the National Hospital, the Salvation Army and others. CEPEP also supports a 
network of more than 400 Community distributors and conducts numerous training events 
with members of these different groups. 
Through the Alianza Para La Salud project that CEPEP participates in together with two 
other organizations, CIRD (a local NGO) and PRIME (a USAID funded cooperating 
agency), CEPEP supports and trains health promoters in 12 communities in the four 
municipalities of Coronel Bogado, Ita, Atyra and San Miguel.
The purpose of the evaluation was to review progress to date in meeting these objectives and 
report on the findings. Please see Annex for a copy of the Scope of Work.
-
9
Methodology
The Mid-Term evaluation of CEPEP was conducted by a team composed of Dr. Romero 
from the CEPEP Board of Directors, Josceline Betancourt and Gabriela Frutos from the 
USAID Health and Population Unit and Sandra Wilcox, an external consultant. The 
evaluation took place in Paraguay between the 3rd to the 15th of August 2003. Sites visited 
included Ascuncion, Atyra, Coronel Bogado and San Miguel. In the San Miguel area sites 
visited included the city of San Miguel, Arazape and Ita Yuru. 
In Asuncion interviews were conducted with Dra Cynthia Prieto, the executive director of 
CEPEP as well as with Ing. Raul Hoeckle and Dra. Raquel de Horvath the president and 
treasurer of the Board of Directors, respectively. In addition, the evaluators met with the 
staff and department heads of Health Programs, Research and Evaluation, Administration 
and Finances and Information Services. The consultant also visited the partner organizations 
participating in the Alliance project with CEPEP. These included the key staff of CIRD, Dr. 
Agustin Carrizosa, Lic. Ruben Gaete and Dra. Esperanza Martinez. In addition the 
consultant met with Gregorio Soriano from PRIME II, Sonia Marchewka from PROMESA 
and Rosa Martinez from CECTEC. In addition, the team met with the USAID director, 
Wayne Nilsestuen.
During the site visits to Atyra, Coronel Bogado and San Miguel, the evaluators met with the 
local municipal councils, the health promoter teams that are trained by and working directly 
with CEPEP, and the local health center and health post staffs involved with supervision of 
the promoters. (Please see annexes for more details on places visited and contacts). 
As part of the CEPEP evaluation, the evaluators met with staff and directors of the clinics in 
Asuncion, San Lorenzo and Encarnacion. In addition the evaluators interviewed the CEPEP 
promoters at each of these clinics.
In addition documents and reports were reviewed (see Annex for a list of documents). Two 
debriefings were held at the end of the visit. One was with the USAID staff and members of 
CEPEP’s executive and Board members. A second debriefing was held with the department 
heads and staff of CEPEP.
10
3. FINDINGS
A. Result 1: Sustainability
The objective is for CEPEP to recover 80 percent of it’s basic annual operational costs using 
locally generated revenues. 
Indicator 1.1: Operational cost recovery targets are: 60% the first year, 65% the second year, 
70% the third year, 75% the fourth year and 80% the fifth year of agreement. Cost recovery 
is measured by the percentage of operational cost paid by revenues generated from services 
and products.
CEPEP uses a specific definition of basic annual operating costs (COBA), which is 
calculated every fiscal year. This cost is that which CEPEP needs to continue implementing 
all it’s priority projects and maintain normal services, assuring quality care within a 
controlled rational budget system. This basic operating cost condition excludes investments 
in new equipment, infrastructure, research and training, though a basic percentage of 
necessary supplies and equipment is included. Supervision costs are reduced by half. The 
COBA calculation is based on the yearly operating and budget plan and is recalculated 
annually in accord with the plan. 
Although contraceptives are donated, they are included as a cost in the basic budget 
calculations since CEPEP realizes that it will have to cover these costs once the donation 
period ends.
Only locally generated income is included from user fees/donations, exchange rate 
differentials and interest, in addition to other income generated from sales of research 
studies, IEC materials etc.
COBA does not include subsidies from international donors even though they may fund 
some regular costs.
The annual COBA costs include salaries of permanent personnel, though not personnel 
contracted for specific projects or other short-term activities. In 2002, 65 percent of 
personnel costs were included in the COBA calculation. Transportation and per diem costs 
are only calculated for essential supervision. In 2002, this was 50 percent of the annual 
amount budgeted for transport and per diem. 80 percent of the rent and public service costs 
were included in the calculation. This figure assumed a restricted use of public services and 
elimination of the library facility.
Using this system, in 1999 CEPEP recovered 58 percent of its basic annual operating costs 
(COBA). In 2000 it recovered 62 percent, in 2001, 64 percent, and in 2002 - 77 percent. 
Much of the dramatic gain in 2002 was attributed to improved systems and increases in sales 
of services and products. According to budget figures, the most cost effective activity comes 
from the community distribution program run by volunteer health promoters. During 2002, 
the cost of this program totaled 245,073,966 guaranis and the income generated from this 
program was 524,009,550 guaranis providing a 214 percent sustainability rate. Significant 
11
income was also generated through the Associated Professionals program (PAC) through 
which contraceptives and other products and services are sold. Both of these programs have 
the advantage of being able to sell services and products without having to pay personnel 
costs.
Although CEPEP did not reach its sustainability goals each year, it was certainly on track for 
2002. At this rate it would seem that it could easily reach it’s 80 percent target for 2003. 
However, much will depend on how well the organization manages the move and change of 
services to its new clinic in Asuncion at the end of 2003. At the end of 2002, the Asuncion 
clinic had a 90% sustainability rate, San Lorenzo’s was 95%, clinica del Este had 101% and 
Encarnacion was at 94%. According to the evaluation findings, each of these has space and 
time available that would allow it to increase its services volume and plans to do so in the 
coming year. 
Part of the reason for such dramatic increases in sustainability levels is attributed to the 
improved efficiencies and systems implemented at CEPEP since the USAID funded 
institutional support project began in 1999. 
In addition to all the efficiencies carried out by the Administration and Finance department 
discussed above, the Information Services Department has played an important role in 
sustainability. In a relatively short period of time, CEPEP has significantly upgraded its 
computer systems and equipment, acquiring 30 PCs, 12 printers, 13 monitors, 5 scanners 18 
UPS systems among other things. In addition numerous software programs were acquired 
and installed including the purchase of 43 Corporate Norton Antivirus programs. All these 
systems are maintained monthly. In addition, after a lengthy unsatisfactory trial period with 
MSH technical assistance, CEPEP developed and installed its own financial systems. During 
the last year the information services department developed an automated receipt system and 
an automated salary and wage system. It also developed a system for tracking requests for 
equipment and services. In addition, the information department has trained each of the 
administrative secretaries in each of the four CEPEP clinics so as to assure that all 
accounting, services statistics and other reporting is managed correctly. The evaluators 
spoke with some of these secretaries and found that not only are they confidently managing 
these systems but also other staff have learned them in case the secretary is not available. 
The information department has also organized staff computer training courses, which the 
bulk of the staff completed during 2002 and 2003. This is a major accomplishment given 
how difficult it usually is to convince staff to learn new systems and skills. Staff that were 
interviewed seemed pleased and the majority of them had passed the internal computer exam 
given at the end of their training with high marks. All of these new systems, upgrades and 
training programs have greatly improved CEPEP’s operating systems and efficiency in 
delivering services and products. 
The Services and Projects department has also made substantial changes and contributions 
to CEPEP’s sustainability. According to its objective, the services department was to 
strengthen the network of providers between its own clinics, associated clinics, health 
professionals and community promoters. In addition CEPEP was to strengthen the 
management and quality of services in its four clinics. 
12
As noted above, the management systems at each of the clinics has been strengthened 
through the upgrading of computer systems, hardware and software as well as training of 
clinic personnel to operate the systems. The clinics are now able to administer services, 
produce receipts and document services provided much more efficiently than in the past. In 
addition, the Services department has encouraged COPE training and each of the four clinics 
conducts regular COPE meetings with its staff to review clinic issues and other factors 
affecting quality of service. The central staff has also conducted regular supervisory visits 
with all the clinics (at least 4 per year per clinic) and clinic staff reported that they were very 
satisfied with the visits and feedback received, informing evaluators that their issues are 
generally addressed promptly. Regarding associated clinics and health professionals, the 
Services Department has conducted regular family planning update training and promotion of 
CEPEP products with these groups in their four clinic areas. In 2002, CEPEP conducted 2 
courses and in 5 in 2001, thus meeting or exceeding its planned targets.. The training has 
obviously contributed to increased sales of contraceptives, medicines and other products. In 
addition the project has exceeded its planned targets for clinic staff training in reproductive 
health and management in the four cities.
The services department also completed the planned training of new and old promoters 
during the 2000 – 2002 period. In 2001, they held 8 training courses, training 178 promoters 
and had two supervisor training courses. In 2002, they conducted 7 promoter training 
courses for a total of 126 promoters and held one supervisor training course. The promoters 
interviewed seemed happy with the training but expressed a desire for more, particularly in 
the area of counseling skills since many of them find themselves providing contraceptive 
counseling in their neighborhoods. The promoter group in San Lorenzo expressed 
dissatisfaction with the price increase for pills. Apparently the clinic has decided to increase
the price of pills it sells to the promoter to 3000 guaranis per packet while maintaining a 
price of 2500 guaranis to be sold directly to patients at the clinic. When asked about this the 
clinic director indicated that she thought this was a decision taken by CEPEP to encourage 
sales at the clinics. However, the evaluators did not find this kind of price difference at the 
other CEPEP clinics visited. If this is the case, then CEPEP needs to reevaluate this strategy 
as it could endanger the continuity of the promoter program there and according to clinic 
data, this program generates more income than any other. 
The clinic directors interviewed also indicated they would like more management training. 
Given the importance of the clinics for sustainability, this appears a justifiable request. Most 
of the training they’ve received so far appears to be in the clinical area. The director in 
Encarnacion has also experimented with some successful marketing techniques such as radio 
promotions and offering classes in neighboring communities. The clinics were recently 
given new signs which are larger than what they had before. 
The objectives for The Evaluation and Research Department indicated that they would 
incorporate new professionals and by receiving technical assistance and upgrades computer 
systems, offer and market new types of research studies. 
13
As noted above the evaluation and research department assisted in improving the information 
system on services statistics which included upgrading the registry forms, training clinic staff 
and reworking the clinical registers to include IEC services and other consultations, 
developing an instruction manual for collecting information. The department is continuing to 
work on the master survey tool for the Demographic and Health Survey to be conducted in 
2004 by CEPEP. The department also hired two new staff to work on research and 
evaluation and provided them with additional training in 2002.
Overall, from the evaluation interviews, there is evidence of improved teamwork among 
CEPEP staff during the period of the USAID agreement and under the leadership of the 
executive director. The staff also exhibits a strong work ethic and real commitment to 
improving CEPEP’s sustainability. The director had joined CEPEP one year prior to the 
initiation of the project. She was hired as a result of CEPEP’s reorganization and was 
actively involved in seeking USAID support for the institutional strengthening project.
Needs and Challenges
· CEPEP is at a consolidation phase4
 in its organizational development. The strategy at 
this phase is to consolidate gains and deal with more complex internal and external 
management issues. The organizations’ critical tasks are to develop capacity to 
produce/deliver quality services/products through cost containment/recovery, quality 
control, diversification of funding sources and marketing. As discussed, CEPEP is 
engaged in all these activities, and is continuing to develop them. Eventually when 
consolidation is complete CEPEP will move on to the “sustainability” stage. At this 
stage the focus is on matching organizational competence with it’s present needs and 
future possibilities. The critical tasks are to maintain a strong, local, diversified 
financial base; respond to market needs; stay competitive and maintain a strategic 
mind-set.
At this stage the strategic thinking is directed at consolidating and strengthening the 
organization’s operations so that it can sustain itself and much of the focus is at the 
operational level. Also much of the strategic thinking is done by the executive 
director and some of the Board members. In the future it will be necessary to 
cultivate a group of ‘strategic thinkers’ within the organization, including department 
heads, who can think in terms of Paraguay’s future needs and CEPEP’s role in 
meeting them. 
· Although the organization has made some efforts to promote services through the 
design and placement of larger signs in locale’s close to their target populations 
(markets, bus stations, business areas etc.), there is more that could be done to 
promote services. Through her own initiative, the clinic director in Encarnacion 
developed a radio promotion activity, which greatly increased the volume of users 
during a few months of 2002. With the new clinic opening in Asuncion and the 
additional services it will be offering, there is a need to develop an active promotion 
 
4
S. Vriesendorp, L. Cobb, S. Helfenbein, J. Levint, J. Wolff. “Framework for Management Development of 
Family Program Managers” APHA paper presentation. 117th meeting. October 1989.
14
strategy so as not to lose existing patients as well as attract new ones from the new 
locale.
· According to CEPEP’s 2002 financial documentation and administrative staff, the 
most productive programs that CEPEP has are the health promoter programs and the 
associated professionals programs. This is largely because the institution does not 
pay personnel costs for the services it delivers through these programs. Given the 
importance of these programs it would seem necessary for CEPEP to really focus on 
strengthening the health promoter program. The evaluators were unable to determine 
the promoter retention rate, although it was estimated by clinic staffs that it was about 
60-70 percent. In addition during the past two years initial training has been given to 
a large number of new promoters. Many of these expressed a desire for more training. 
The promoters only distribute two methods, pills and condoms but they do refer to the 
clinics for other methods, including depo provera and IUDs as well as for other 
services. It would behoove the institution to consider programs that provide 
incentives for referrals (either material or non material) but this would require a better 
system for keeping track of referrals. One method for this might be the use of referral 
tickets that have a duplicate stub that is kept by the promoter and can be compared 
with clinic records and then receive some compensation. This sort of system would 
also encourage the promoters to do more promotion of clinic services. 
It would also be important to assure that the clinics sell contraceptives to promoters at 
the same price or lower than the price that they sell to clients. The situation in San 
Lorenzo where the clinic is selling to the public at a lower price than it is selling to 
the promoters is not a useful strategy and risks alienating the promoters and causing 
them to drop out of the program, which will not help promote the clinic’s services. If 
the clinic is unhappy with its level of sales it needs to rethink its promotion strategies.
· One of the concerns voiced by donors and some of the staff concerns the institution’s 
salary levels and their competitiveness and ability to attract professionals of 
sufficiently high caliber. Given CEPEP’s sustainability concerns, there is an obvious 
incentive to control salaries. However this issue will need to be reassessed regularly 
particularly given the institution’s growing needs to attract and hang on to qualified 
professionals. 
· In it’s original proposal, CEPEEP planned to develop its training capacity as a 
sustainable activity. However, in the final version, this was omitted. Given CEPEP’s 
strengths and on-going training capacity and activities that involve training its own 
staff as well as staffs from associated clinics and associated professionals, it would 
seem worth reconsidering this strategy. Independently, the clinic directors are being 
asked to provide training and education to local groups in their regions. Given 
CEPEP’s prominent role as a reproductive health provider and its need to maintain 
this role, it would be advantageous to develop and market a training strategy.
15
B. Result 3: New Projects Services and Products
Each year CEPEP has set a goal to add at least five new products to the medicines and 
products being sold through its social pharmacy system and each year it has surpassed it. In 
2001, CEPEP added 15 new products and in 2002 it added 21. Examples of new products 
include pregnancy kits, female condom, new medicines for the social pharmacy and new 
types of laboratory testing materials.
CEPEP also had an objective to develop new packages of educational materials to market to 
the public and other institutions. During 2001, it used technical assistance to design and 
validate materials (flipcharts, flyers, brochures etc.). During 2002 the services department 
set an objective to produce two packets of IEC materials and sell five of each of them. It 
turned out that groups and individuals were not interested in IEC packets but rather in 
purchasing individual items. CEPEP had great success in selling videos, flipcharts and other 
IEC materials mainly related to family planning and reproductive health. They also received 
permission from the MOH to reproduce their Norms and Procedures manuals and has sold 
these as well as Contraceptive Technology manuals. Over time As time goes on there has 
been an increasing demand for these manuals, as there which are never a sufficient number 
available to reach all the service providers. However, this is also something that CEPEP 
could promote more. 
 In 2002, CEPEP through its Services Department has also negotiated a number of contracts 
with hospitals and organizations for specialized services at reduced cost for patient referral. 
CEPEP charges a small percentage of the fee for its services. So far, these services have 
included voluntary sterilization, mammography, dermatology, and urology. CEPEP also has 
a contract with the National Hospital to refer patients for voluntary sterilization that will be 
provided to CEPEP’s patients at minimum cost. In turn, CEPEP lends the hospital 
instruments and sells them low cost medical supplies.
The biggest effort in the new services areas is that of the new clinic in Asuncion, which has 
been bought and is being remodeled by CEPEP. It is due to open in November of 2003. 
This investment will allow for more financial stability and will avoid having to move (as 
they have had to do in the past). In addition, it is much larger and will include space for the 
central office staff in addition to a larger pediatric area and a dental clinic (another new 
service).
Needs and Challenges
· CEPEP will need to pay attention to its Asuncion clinic move in November in order 
to minimize disruption of services and loss of revenue, which could adversely affect 
its sustainability rate. This another reason to have a strong clinic promotion/ 
marketing strategy in place at the time of the move.
· As a requirement of its USAID agreement, CEPEP has developed a number of new 
services and products and it would be useful to analyze the effectiveness of these 
16
different strategies, whether they could be improved or expanded, if they should be 
continued in addition to deciding whether new services are needed. 
C. Result 2: Support for Decentralization: The Health Alliance Project
In its institutional strengthening cooperative agreement with USAID, CEPEP was included as 
a member of the Alliance for health Project, which is a consortium of three non-government 
agencies (NGOs). In addition to CEPEP there is the Centor de Informacion y Recursos para 
el Desarollo (CIRD) and the PRIME II Project run by Intra Health International (a USAID 
Cooperating Agency). The purpose of the Alliance was to strengthen the provision of 
reproductive health in accord with the decentralization of health services occurring at the 
local level. 
The original agreement stipulated that “CIRD will develop a technical assistance package for 
selected health centers and health posts in four targeted departments. CEPEP will provide 
training to improve the quality of services in these facilities and will develop a system of 
community-based health care that includes community health agents who provide training 
and supervision to a system of community health promoters. The cooperation between 
CEPEP, PROMESA and CIRD within the Alliance framework will have a focus in the 
design, implementation and evaluation of this community health program in which promoters 
will then be able to offer basic reproductive health services and make referral to health 
clinics for specific services. CEPEP will also establish a logistics system that will allow 
local health councils and health promoters to distribute contraceptives and other projects.”5
The specific Indicator 2.1 that applies to CEPEP is as follows: “A Reproductive Health 
community program based on health promoters functioning in at least one health center and 
two health posts in four departments. CEPEP’s responsibility will be the training of health 
promoters in the design, implementation and evaluation of this health promoter system in 
reproductive health and in the provision of contraceptives. By 2004 12 communities will 
have a community program, within an agreement with local governments.”6
Since this modification, there have been several changes in the partnerships and roles of 
partners. According to the partners interviewed there is no updated agreement to this respect. 
Since this time, PRIME II has joined the alliance as one of the three key partners, the other 
two being CEPEP and CIRD. CECTEC and PROMESA are subcontractors to CIRD and 
work in the community IEC area. They report directly to CIRD and have no direct contact 
with the other key partners. The three partners have carved out their roles as follows: CIRD 
is responsible for working with and developing administrative management skills of the local 
councils including management of community social pharmacies, PRIME is responsible for 
strengthening the administrative and technical skills of the local MOH health services, and 
CEPEP is responsible for training community based health promoters. However, these 
 
5
 Attachment A. Modificatoin No 5. CEPEP Cooperative Agreement#526-A-00-99-00008-00
6
 Ibid
17
promoters function differently from the CEPEP promoters in that they are not self-supporting 
and do not distribute and sell contraceptives and other products. Their function is to educate 
community members and promote use of the local health services working closely with the 
health services and the local councils who both supervise their work. Because the promoters 
do not distribute contraceptives and because the social pharmacies are implemented through 
the CIRD work with the local councils, the cooperative agreement role of CEPEP to establish 
a contraceptive logistics system is not really happening. Each of the three key agencies have 
separate agreements with USAID to carry out their assigned tasks, though as noted, some of 
the tasks have changed since the agreements were written. Also there is no coordinating 
agency among the various organizations in the alliance, though there is a coordinating 
committee in which only the three main partners and USAID participate. Without an agency 
designated to manage the activity, CEPEP and the other partners indicated that USAID’s role 
has become critical in facilitating the work coordination process between the partners.
According to interviews, CIRD believes that they should have been the lead agency and 
everyone else their subcontractors for this activity. They clearly have the most support for 
this activity (from both the Health and Democracy offices of USAID) and have been doing it 
the longest. The other major issue here is that the decentralization process has not yet been 
implemented in Paraguay so the administrative structures and local funding mechanisms are 
not in place to really make it happen.
Given this somewhat confusing status of the Alliance project, this report will now outline the 
strengths and weaknesses of the CEPEP Result 2 activities that they were able to determine.
Strengths
The evaluators found that the promoters were very committed to their work and very 
motivated by their mission. They all expressed strong commitments to their respective 
communities and noted that their promotion work made them feel like important community 
contributors. The training they received made them feel like they had something important to 
offer and it obviously enhanced their self-esteem. 
It was also clear that the local councils were very enthusiastic about the work being 
conducted with the promoters although in one community (Arazape) there appeared to be 
some difficulty in establishing strong linkages with the council. There was also evidence of 
good coordination with the local health centers and health posts. The health staffs at the 
facilities who supervised the promoters were enthusiastic about what they were 
accomplishing with the promoters and believed that their work had increased use of local 
services. 
Although there was evidence of continuing training needs that will be discussed below, the 
quality of the initial reproductive health training appeared to be good. The promoter manual 
and other training materials have the requisite technical information and are written at a basic 
enough level to serve as a reference.
Challenges and Weaknesses
18
As mentioned above, perhaps the greatest weakness of the project is the lack of management 
coordination between the different project partners, which has created confusion regarding 
each one’s responsibilities and roles and led to gaps and overlaps in implementation. For 
example, both of CIRD’s partners, Promesa and CETEC as well as CEPEP are involved in 
IEC and work with health promoters in the project communities. The responsibilities of the 
different organizations are not clearly delineated and as a result there are overlaps in 
activities being performed. Because CETEC and Promesa do not participate in the regular 
Alliance partner meetings, they do not have an opportunity to discuss and clarify these issues 
with the project management and are often left out of the loop when decisions are made. 
Since CETEC and Promesa work under CIRD, CEPEP does not believe they should be the 
ones to tell the other two what their role should be. According to Promesa, CIRD is not 
fulfilling it’s role of coordinating IEC activities with the two subcontractors and coordinating 
activities with CEPEP. USAID seems to believe that because this is a democracy promotion 
project, that this is something that the groups can and should work out “democratically” 
among themselves. Unfortunately, none of the Alliance partners that the evaluator spoke 
with believe that this is possible due to the competitive positions that these organizations 
occupy for USAID funding and due to past histories that engendered mistrust. Most of these 
agencies believe that one agency should be coordinating the project and that the logical 
organization to do this is CIRD but they also indicated that they would be reluctant to work 
under CIRD’s direction.
Another weakness identified by the evaluators was that there was insufficient training being 
given to the promoters for the activities that they are expected to complete. They are given 
one session on community organization by CIRD and then four on technical health areas by 
CEPEP. From interviews it was clear that many of them needed refresher training or on￾going supervision as their grasp of reproductive health messages was weak. Also because of 
the nature of their work which is more concerned with reaching community members 
through various IEC strategies than it is about selling contraceptive methods and products, 
there needs to be more training on communication, public speaking, community organization, 
activity planning, promotion strategy development etc. In fact because most of the work 
involves promotion and developing innovative ways to reach people about health needs 
instead of service delivery, it would be appropriate to rethink the training program and focus 
the bulk of the time on these areas and spend less time on technical health areas, since those 
service related issues would be addressed at the health center. 
When discussing the training issues with the supervisors at the health clinics and health 
posts, it was evident that many of them did not have a good understanding of their role as 
trainers and supervisors of the promoters. They need specialized training to help them plan 
and organize the community work to be carried out by the promoters. It would be helpful for 
them to develop short range strategic and operational plans for the community activities that 
need to be completed with the promoters in their respective areas. There also seemed to be 
some confusion about the difference in roles/ profiles for the supervisors versus the 
promoters. For example in Coronel Bogado, they indicated that the clinic nurses who were 
supervisors were also going to function as promoters in their communities.
19
USAID has expressed concern that CEPEP as an institution has not developed the required 
community empowerment/ development skills and focus required by the Alliance project. 
This weakness is demonstrated by two factors: on the one hand CEPEP’s Alliance team 
lacks community mobilization skills that promote democratic practices and two, they are 
used to functioning in a more directive, vertical role when working with communities rather 
than a facilitative one. This has lead to a training style that does not encourage horizontal 
relationships and participation between promoters. The training technologies also need 
strengthening so that they not only increase knowledge transfer but also encourage attitude 
changes that lead to behaviors supportive of reproductive rights. For these reasons USAID 
believes that CEPEP needs to change its role and the methodologies it employs in the 
Alliance project to one that promotes community generated interventions through democratic 
processes that support decentralization. CEPEP’s reponse to this is that they have recently 
been making significant efforts to improve their training of health promoters and supervisors. 
They have taken several steps including the recruitment of new trainers and use of new 
materials including participative techniques. According to service reports from MOH 
facilities where the promoters are working, there has been a significant increase in services 
utilization. Regarding the need to recruit more skilled staff with higher salary requirements, 
CEPEP states that it pays salaries that are consistent with what the market will bear and at the 
same time are within the institution’s sustainability goals.
Although CEPEP has developed community census forms and trained the promoters on how 
to fill out the forms, the promoters and supervisors do not appear to understand that the 
census tracking system is a tool for them to keep and use to conduct community follow-up by 
regularly monitoring families’ health status and health center activities in their respective 
neighborhoods. Ultimately this can be useful tool for documenting community health status 
and activity monitoring.
One concern expressed by CEPEP and others is the sustainability of the community health 
promoters. To date, there has been close to a 50 percent turnover rate among promoters that 
have been trained. This may be because the majority of promoters have been youth who 
have needed to move on from their communities for jobs or to continue their educations. 
However, this has important implications for building a stable cadre of volunteers to say 
nothing of the poor cost-benefit ratio. Because they are not distributing services or products 
in the way the CEPEP promoters do, they do not generate any income from their promotion 
activities. When asked about how they planned to sustain the promoters, the local councils 
indicated that once the government goes through with the decentralization process and they 
have local resources, they will be able to provide on-going support for promoter activities. 
However, it is expected that the promoters will always be volunteers. There is good 
coordination with the health service providers who obviously see the promoters as their 
community extension agents and this has positive implications for their sustainability as part 
of the health system. However, this will have to be carefully crafted into the new 
decentralized health system, when it happens. 
Clearly more thinking regarding the promoters’ role and related training requirements as well 
as long-term sustainability issues is required for this program to function as intended.
20
5. Conclusions and Recommendations
· In keeping with the challenges noted under Result 1, as CEPEP as an institution
moves forward in its Consolidation phase of development into its Sustainability 
phase, it will be of increasing importance to cultivate a leadership group composed of 
selected Board members and the executive staff. This group should include 
individuals from departments within the organization, who can bring their operational 
experience to guide strategic thinking and planning for future directions of the 
institution. 
Given current trends in the institution and the experience of similar institutions, it is 
likely that CEPEP will achieve sustainability at the clinic level, particularly if they 
continue to increase volume and diversity of services offered. The challenge will be 
sustaining the costs of the central office. Some of the departments will sustain 
themselves through sales of services and products, such as the Research and 
Evaluation Department and the IEC interventions. However, the institution will need 
to come up with other strategies for covering the costs of the central staff. Some 
family planning and primary health care agencies in similar situations have come up 
with mechanisms for contracting out the services of some of their senior staff, among 
other things. This strategy has the advantage of not only covering their costs and 
adding income to the institution through overhead fees, but also gives the senior staff 
opportunities to grow and challenge themselves. 
As CEPEP contemplates this current and next phase of institutional development, it is 
recommended that senior staff visit other institutions that have been through this kind 
of growth experience and interact with them about the opportunities and challenges 
they faced and how they managed them. An example might be the IPPF affiliate in 
Bolivia, CIES, and/or Prosalud, which is a private Bolivian primary care organization 
with over thirty clinics throughout the country. Both of these organizations target 
lower middle income audiences and have addressed similar issues as those facing 
CEPEP. 
· As CEPEP continues through its growth process, it will be important to hone in on its 
primary strategic mission as an institution. Through this USAID-funded project, it is 
addressing two strategic areas: 1) as a private organization that focuses on delivery of 
cost-effective high quality FP/RH services delivery and 2) as an organization that 
promotes reproductive rights-based public policy specifically through the CNSSR 
(MOH) backed health committees in 12 Alliance communities, and that trains health 
promoters to promote the MOH services in these communities. a social promotion 
agency that is helping the country, specifically the MOH, address its decentralization 
mandate. While both of these areas are important, they do require different skills and 
institutional strategies. At the time of the evaluation, discussions with CEPEP’s staff 
and Board members confirmed that they were feeling pulled between these two 
21
competing activities and strategies. Strengthening public sector services is outside 
CEPEP’s institutional sustainability goals and detracts from its central mandate. Since 
the evaluation visit and debriefing in August, CEPEP has discussed with USAID the 
possibility of reorienting this project’s Result 2 Activities in two areas: a) consistent 
with it’s institutional mission, it will focus solely on reproductive and sexual health, 
and to the extent possible, work with the new National Sexual and Reproductive 
Health Plan, and b) work in close coordination with the Ministry of Health at all 
levels, including the central level, on this national plan. However, so far CEPEP has 
not been able to acquire funding for this proposed activity. Given that the Alliance 
community health promoter activity with it’s corresponding budget would be 
assigned to another agency by USAID, CEPEP will look for financing for this 
National Plan support activity from other donors. In the meantime, in accord with its 
agreement with USAID, CEPEP will focus on the 2004 Demographic and Health 
Survey, the community youth project directed towards adolescents, and continue its 
institutional sustainability activities. CEPEP has been careful to note that USAID’s 
support of it’s diverse institutional sustainability activities and restructuring has been 
invaluable. 
It is recommended that CEPEP conduct a self-analysis or strategic planning exercise 
that assesses the viability of these two strategic directions for the institution. If after 
careful analysis, CEPEP decides that either one or both of these areas are consistent 
with its mission then it needs to develop strategies that allow it to complete each area 
without compromising the institution. CEPEP is currently planning to strengthen the 
management staff working on the Alliance project. It will also need to think through 
the management role it will play with the Alliance project. If, on the other hand, it 
decides that it cannot continue in both directions if it is to survive as a viable 
institution, then the donors need to respect this decision and work with CEPEP in the 
context of its stated mission. This is because the primary objective of the USAID 
project is to strengthen CEPEP’s institutional capacity and sustainability.
If CEPEP decides to continue working in the decentralization area through the 
Alliance Project, it is recommended that USAID work carefully with the Alliance 
partners to develop a viable management structure. The partners interviewed seemed 
to agree that CIRD would be the logical choice for a lead agency, but it is unclear 
whether PRIME and CEPEP will agree to work with CIRD in this context. 
Therefore, USAID will have to play a key role in organizing this structure and in 
getting all partners to agree on their roles.
· Given the importance of the CEPEP health promotion program in generating income 
for the organization, it is recommended that CEPEP seriously consider strengthening 
its support to this area. More training activities for promoters and supervisors in 
technical areas and in the area of counseling and education would be beneficial. 
CEPEP could also explore other methods and/or products that the promoters could 
distribute (such as ORS packets, vitamins, etc.), as well as specific incentives for 
referrals. Also if the promoters received more training on community mobilization 
and democratic processes, they could be more effective as change agents and increase 
22
demand for services. Some of the experienced promoters that have been with CEPEP 
for 4-5 years could become powerful change agents with a minimum of additional 
training. This additional training would empower them and provide further incentive 
for them to become influential community leaders. 
· In accordance with the discussion of the challenges facing the Alliance project, If 
CEPEP continues with the Alliance activities then, in addition to strengthening the 
health promoters democracy and SRH skills, it is recommended that CEPEP work 
together with USAID, and the other Alliance partners to come up with a more 
satisfactory project management structure that reduces the gaps and overlaps between 
partners in the project design and allows for better coordination. (See discussion 
above). Along with this CEPEP should reorganize its training for health promoters so 
that they are better prepared to meet the demands of their community promotion 
roles. Since the evaluation visit, CEPEP has undertaken a process to revise the 
training modules and materials that will include a more participatory approach (see 
above discussion). Better coordination among partners should also strengthen their 
support and integration with the local counsels and the MOH health delivery system.
23
ANNEXES
1. Questionnaires Used 
2. Field visits and Contacts 
3. Agenda
4. CEPEP’s Response to recommendations
24
ANNEX 1
Interview Questionnaires
25
INSTRUMENTO # 1
PERSONAL DEL PROYECTO
Nombre de la persona entrevistada o posicion: .........................................
Nombre del entrevistador: ......................................................................................
1. Por cuanto tiempo ha trabajado Ud con el proyecto? 
2. Que son sus responsibilidades a dentro del proyecto/
A. DISENO DEL PROYECTO
1. De qué manera las intervenciones suyas ha contribuido al desarrollo de las
intervenciones para este proyecto?
q Al finalizar este proyecto usted tiene cabal conocimiento y entendimiento del
proyecto?
Si, porqué? ........................................................................................................
...........................................................................................................................
No, porqué? ......................................................................................................
...........................................................................................................................
q Se diseñó apropiadamente el proyecto?
Si, porqué? ........................................................................................................
...........................................................................................................................
No, porqué? ......................................................................................................
...........................................................................................................................
B. PROCESO
26
1. Cómo se ejecuta sus responsibilidades del proyecto?
2. Se ejecuta tal como se diseñó? Porqué?
3. Qué actividades realiza dentro de sus funciones?
4. Cuales fueron sus interacciones en el proyecto, en la participación de actividades
conjuntas en salud comunitaria, con socios, y otros?
C.PRODUCTO
1. Cuáles fueron los mejores resultados del proyecto bajo su percepción?
2. Podría identificar resultados negativos en el proyecto? Qué hicieron para resolver?
D.ANALISIS DEL COSTO – BENEFICIO
1. Cree que los costos del proyecto justifican los beneficios? Porque?
2. Los beneficios son sostenibles? Porque?
27
3. Que opina sobre el plan o enfoque de auto-suficiencia y sostentabilidad que tiene CEPEP?
4. Que es la estrategia de Cepep para sostenerse a largo plazo? Que son los niches del
mercado? Criteria?
E. GENERAL
1. Quién le supervisa a usted?
2. Cada cuánto tiempo lo hace?
3. Se siente satisfecha con este tipo de supervisión?
Si ................. No ..................
Porqué?
4. Ha recibido algun tipo de capacitacion desde que se ha trabajabo con el proyecto? (si 
contesta que si) que, cuando, duracion? 
3. Piensa Ud. que la capacitacion recibido es suficiente para realizar sus trabajos?
4. Que otro tipo de capacitacion le gustaria recibir?
28
INSTRUMENTO #2
PV ___ Mujer comunitario____ Hombre comunitario_____
Nombre del Entrevistador:_______________________ Fecha:______ 
Nombre de la zona:_____________________________
Explique el propósito de la entrevista, luego empiece hacer las siguientes preguntas:
1.Porque decidia ser promotor de salud?
Que ventajas hay para Usted de ser promotor?
3. Hace cuanto tiempo participa en actividades junto al proyecto?
4. En que actividades puntuales ha intervenido hasta ahora?
-
-
-
-
5. Explique que actividades le ha gustado desarrollar más? Y diga porque?
29
6. Cuál de las actividades desarrolladas por usted ha beneficiado a la comunidad,
explique por favor como? (O si esta todavia capacitandose – Piensa Ud que estes 
actividades beneficiara la comunidad? Porque?
7. Que capacitaciones ha recibido hasta ahorra? podría nombrar los temas de
capacitación?
5.a. Si no recuerda, preguntar tema por tema.
Planificación familiar/anticonceptivos ........... 
ITS ............
Salud materna ...........
Liderazgo ...........
AIEPI comunitario ...........
EDA ...........
Infección respiratoria aguda ............
8. Sobre el tema …..........………….., podría nombrar tres mensajes claves?
30
9. Qué tipo de supervisión/acompañamiento ha recibido? De quien? Cuando? 
Que actividades ha realizado el supervisor?
- reviso los registros reviso su plan de trabajo
- apoyo directo entrego suministros
- preguntaba sobre problemas observo visitas domiciliarias
10. Ha cambiado usted por el trabajo comunitario en relación a sí misma? Cómo?
11. Esta cambiando su comunidad a raiz del trabajo? 
Si ................... No .................
Cómo? 
(SI ESTAN TRABAJANDO)
12. Cuantos clientes ha visto durante el ultimo mes? 
13. Cuantas referencias? Y para que?
14. De las referencias conoce Ud si el paciente ha ido al servicio? Como?
15. Que son los problemas mas graves que se encuentra en su trabajo de promotor? 
Que sera la mejor manera para resolverlos?
16. Puedes mostrarme tu cuaderno de campo?
31
INSTRUMENTO #3
ENTREVISTA A INSTITUCIONES Y OTRAS AUTORIDADES
Nombre del Entrevistado/a:_______________________ Institución: ............... 
Nombre del entrevistador: .......................................................................................
Fecha:______ 
1. Ha realizado actividades conjuntas con CEPEP?
2. Qué actividades?
3. Estan satisfechos con la colaboracion que reciben de CEPEP?
32
BOLETA DE OPINIÓN DE CLIENTES CEPEP
Nos interesa su opinión para mejorar nuestros servicios.
Le agradecemos el llenado de la presente boleta. Por favor marque en el lugar que
corresponda a su respuesta.
1. Está es su primera consulta en el Centro CEPEP?
 Si .......... No ...........
1a. De qué zona viene? ............................
2. Cómo se animó a venir a CEPEP?
a) Por un amigo/a (nombre de la persona)
(Promotor?) ...................
b) Por la radio .................
c) Por un volante .................
d) En una feria .................
e) Por los letreros de la calle .................
f) Otro ................
3. Cuánto tiempo esperó para su atención desde que llegó 
al Centro?
a. De 15 a 30 minutos .................
b. Más de 30 minutos .................
c. Más de 1 hora .................
d. No sé ................
4. Cómo fue el trato que recibió del personal de CEPEP?
 Bueno Malo No tuvo contacto
1. Médico ...... ...... .......
2. Enfermera ....... ...... .......
3. Orientadora ....... ...... .......
4. Secret/cajera ....... ....... ....... 
5. Le dieron alguna charla sobre el cuidado de la salud?
 Si ............. No ..............
6. Si le dieron, en qué temas
a) Planificación familiar o anticonceptivos ..........
b) Derechos sexuales y reproductivos ..........
c) Salud materna ..........
d) Infecciones de transmisión sexual ..........
e) Cáncer y prueba de Papanicolaou ..........
f) Otros ........................................................
6.a. Qué le pareció? B M R
7. Si ha optado por un método anticonceptivo, Ud ha 
decido por:
a) Libre voluntad .............
b) Se ha sentido obligada ............
c) El personal de CEPEP ha decidido por Ud. ............
si b ó c Porqué? ..........................................................
.......................................................................................
8. Está contento/a con los servicios recibidos en CEPEP?
 Si .............. No ............
9. Qué le gustó más? 10. Qué no le gustó?
33
INSTRUMENTO 5
Personal de las Clinicas, Centros y Puestos
Nombre or Posicion del Entrevistado__________________________________________
C. Capacitacion
1. Ha recibido algun tipo de capacitacion desde que se ha trabajabo con el proyecto? (si 
contesta que si) que?cuando? duracion? 
2. Piensa Ud. que la capacitacion recibido le ha aydado para realizar sus trabajos?
3. Que otro tipo de capacitacion le gustaria recibir?
D.
E. Supervision
4. Quién le supervisa a usted?
5. Cada cuánto tiempo lo hace?
6. Se siente satisfecha con este tipo de supervisión?
Si ................. No ..................
Porqué?
7. Que actividades realizaban durante la ultima visita?
- reviso los registros/informes reviso suministros
- reviso su plan de trabajo reviso equipos
- supervision acompananda entrego suministros
- preguntaba sobre problemas observo entrega de servicios
34
7. Que retroalimentacion recibia de la visita? 
8. Cuantas visitas ha recibido durante el ano?
A. Informes
9. Guarde copias de los informes que se manda al CEPEP? MOH? Otro?
10. Ud. Utiliza los informes?
11. Que retroalimentacion recibia de su ultimo informe?
F. Servicios
12. Sabe Ud cuales de sus clientes ha dejado de usar PF? Como?
13. Como se hace referencias para otros servicios? 
14. Sabe si el cliente se ha ido al servicio? Como?
15. Cada cuanto se ve los Promotoras en su zona? Donde?
16. Conoce que clientes estuvieron referidos por un Promotor?
Cuantos clientes estuvieron referidos aqui durante el mes?
17. Cuales fueron los problemas de PF mas importantes que Ud ha visto?
18. como pretende resolverlos?
19. Con quien consultas sobre estes problemas?
Director de la Clinica
1. Que apoyo recibieron Uds del proyecto de USAID?
35
2. Cuantos de su personal recibian capacitaciones?
3. Ud tiene reuniones regulares con el personal? Cada cuanto?
4. Tiene Ud metas para servicios de PF? Otros servicios? (que son?)
5. Tienen estandards, normas para calidad de servicios? Que son? Como los miden?
D.ANALISIS DEL COSTO – BENEFICIO
1. Cree que los costos del proyecto justifican los beneficios? Porque?
2. Los beneficios son sostenibles? Porque?
3. Que opina sobre el plan o enfoque de auto-suficiencia y sostentabilidad que tiene CEPEP?
4. Que es la estrategia de Cepep para sostenerse a largo plazo? Que son los niches del
mercado? Criteria?
36
ANNEX II
Field Visits and Persons Contacted
37
EVALUACIÓN PROYECTO CEPEP – USAID 
Entrevistas:
Viernes 8 de Agosto
ATYRÁ
13:00hs a 17:00hs
Atyrá - Candia 
· Presidente del Sub Consejo Local de Salud: Sr. Elias Torales
· Promotor: Sr. Derlis Gaona
Atyrá – Centro 
· Intendente Municipal: Sr. Juan Francisco Ferreira
· Presidente del Consejo Local de Salud: Sr. Isabelino Ferreira
· Coordinadora Distrital: Sra. Amalia Saldivar de Duarte
· Tesorera del Consejo Local de Salud: Sra. Crisnilda de 
Ferreira.
Promotores:
· Sra. Salvadora Saldivar
· Sra. Nélida de Ferreira
· Sra. Isabel Alarcón
· Sra. Corina Rotela
· Sr. Marcelino Maldonado
· Sra. Mirta de Maldonado
Representantes del Servicio de Salud
· Dir. del Centro de Salud de Atyrá: Dr. Félix Carosini
· Enfermera jefe del Centro de Salud de Atyrá: Lic. Olga Páez 
de Gayozo.
38
Obs.: No se realizo entrevista individual, hubo una reunión general 
donde se realizaron varias preguntas a los presentes.
39
B.
C. Lunes 11 de Agosto
CLÍNICA DE LA FAMILIA CEPEP SAN LORENZO.
· Directora Dra. Ana Avalos
· Enfermera Srta. Nilda Britez, con sus promotoras:
o Florentina de Duarte
o Juliana Ovelar
o Amada Pino
o Jenny de Romero
o Mario Benitez
o Porfirio Giménez
o Malvis Galeano
o Norma Morales
o Mirta Benítez
o Fidelina de Pertile
o Ma Magdalena de Velásquez
o Librada Ruiz de Duarte
CLÍNICA DE LA FAMILIA ASUNCIÓN
Entrevistas con pacientes de la clínica:
· Amancia Estigarribia
· Sofía Duarte
· Catalino Rojas
· Elisa Grance
40
Martes 12 de Agosto
1° ARAZAPÉ 10:30 hs
· Presidente del Consejo Local de Salud: Daniel Medina
· Secretaria de relaciones del Consejo Local de Salud: Ana Zorrilla de Ortiz
· Encargada del Puesto de Salud: Antonia Bernal de Rojas
G.
Supervisores 
· Emigdia de Cuellar
· Segundo Ortiz
PROMOTORES
· Julio Ramírez
· Lourdes Rolón
· Alejandro Fernández
· Catalina de Portillo
· Ma. Nidia Cristaldo
· Matilde Fernández
· Juan Guzmán Cristaldo
3° ITA YURÚ 14:00 HS.
· Presidenta del Consejo Local de Salud: Secundina Caballero
· Vicepresidenta del Consejo Local de Salud: Claudia de Fernández 
· Servicios de Salud Alberta de Rodas
Promotores 
Liz González
Rosalba Rolón
Norma Rolón
Amalia Fernández
4° San Miguel Urbano 16:00 hs.
SAN MIGUEL URBANO
41
Autoridad:
Intendente Municipal: Prof. Efrén Gonzalez
Servicios de Salud
Dir. del Centro de Salud: Carmen Zorrilla
H. Supervisores
· Dr. Ramón Ramírez
· Prof. Gladys de Jacquet
· Aida Luz Jacquet
I. Promotores
· Lilian Latorres
· Ma. Pabla Azar
· Irma Gonzalez
· Asunción Benitez
· Dominga Carolina Latorre
Miércoles 13 de Agosto 2003
CLÍNICA DE LA FAMILIA ENCARNACIÓN 
· Directora de la Clínica: Dra. Maria Teresa Barán
· Enfermera y Encargada de PCSR: Lic. Lucia Acosta
· Secretaría Administrativa: Lic. Alba R. Agüero
· Encargada de Limpieza: Sra. Natalia González
Promotoras Comunitarias:
· Sra. Ramona Castillo de Zayas (B° Mbo´i Ca´e - Enc)
· Sra. María Edelina Vda. de Terwindt (Jesús – Pueblo)
· Carmen Delgado (Encarnación – Centro)
CNEL BOGADO (11:30 HS.)
· Prof. Félix Ayala 
· Dr. Marcelino Rodríguez
· Enfermera Jefe Hermelinda Arguello
· Mario Aquino
· Nidia Lamarra
· Enfermera del Hospital Magdalena Matta
42
ANNEX III
Agenda
43
agosto agosto MIERCOLES 
6 agosto
VIERNES 8 
agosto
9 agos
Semana 2 
Eval.
Trabajo 
de 
campo: 
visita al 
Paraguay.
Llegada 
domingo 
3 de 
agosto 
8:00a 10:00hs. 
Reunión de 
inicio con 
Equipo 
Evaluación, 
presentación 
de 
metodología, 
herramientas 
y calendario 
definitivo 
evaluación. 10 
a 12 hs. 
Reunión con 
Dir. Ejecutiva 
y gerentes: 
presentación 
del proyecto. 
Realización de 
citas para 
entrevistas de 
la evaluadora 
13:00 a 18 hs 
Trabajo de 
oficina: 
revisión de 
documentos, 
fotocopias, 
diseño e 
impresión de 
herramientas 
de evaluación, 
etc.
8:00 a 10 hs. 
Reunión Equipo 
Eval: aprobación 
final de 
herramientas y 
metodología. 10 hs. 
Entrevistas con 
Dir. Ejec, 
(resultados 1, 2 y 
3) con Dir y 
personal de 
Investigación y 
Evaluación, 
resultado 1 
(fortalecimiento 
DIE), 2 (reg. 
familiar y eval 
Alianza) y 3 (venta 
de investig.). 14 hs. 
Viaje a Atyra, con 
M. Centurión: 
Consejo de Salud, 
Resultado 2. 
8 a 10:30 hs. 
COBA y 
sustentabilidad, 
Resultado 1, 
con Dir. 
Administrativa. 
resultado 1 y 3 
(FS). Informe 
financiero 
Farmacia 
Social, 
resultado 3. 
10:30 a 11:30 
hs.
11:30 Visita a 
Edificio 
CEPEP con 
Dir. 
Administrativo
14:00hs Rosa 
Martínez de 
CECTEC (Dir. 
Manuel 
Dominguez 
1048 entre 
EEUU Y 
Brasil)
15:30 hs 
Entrevista con 
Alianza, Marín 
Estigarribia.
9:00 hs Entrevista 
con Dep de 
Informática 
(CEPEP)
11:00 hs 
Entrevista con 
Rubén Gaete, 
Agustín Carrizosa, 
Esperanza 
Martínez (CIRD).
13:30 Entrevista 
con Director de 
USAID.
14:30 hs Sonia 
Marchewka 
(PROMESA).
9:00 hs 
Entrevista 
con 
Gregorio 
Soriano 
(PRIME)
13 hs. Viaje 
a Atyra: 
curso en 
Candia, 
Resultado 2.
11:00 hs 
viaje a 
Atyra
(12) 
domingo 
10 agosto
(13) LUNES 
11 agosto
(14) MARTES 12 
agosto
(15) 
MIÉRCOLES 
13 agosto
(16) JUEVES 14 
agosto
(17) 
VIERNES 
15 ag 
(18) SAB 
16 ag
Semana 3 
Eval
8 a 11 hs. 
visita a 
Clínica de San 
Lorenzo,
resultado 1 y 
3 (entrevistas 
a personal, 
promotores y 
usuarias). 
13 a 14:30 hs 
entrevistas 
con Directora 
de UPS y 
personal de 
IEC. 
14:30 hs. 
Visita clínica 
ASU 
(entrevistas a 
usuarias y 
personal), 
Resultados 1 y 
3.
17:00 hs. 
Reunión con 
miembros del 
Consejo 
Directivo 
(Pte. y Sec.), 
Viaje a San Miguel 
con M 
Estigarribia:Salida 
10:30 hs.,Reunión 
en Arazapé 
14:00 hs. en 
Itayurú 
16:00 hs. San 
Miguel Urbano 
(entrevistas a 
autoridades, 
Consejo, servicio 
salud, encarg. local 
del CEPEP y de la 
Alianza, 
supervisores y 
promotores), 
Resultado 2. 
Luego pernocte en 
Encarnación. 
8:30 a 10:30 
Visita a 
clínica de 
Encarnación
(entrevistas a 
personal y 
usuarias), 
Resultado 1 y 
3. Reunión 
con 
promotores 
CEPEP y 
regreso. De 
regreso 
entrevistas en 
11:30 hs 
Cnel. Bogado 
con gente de 
la Alianza y 
del Consejo 
Local de 
Salud, 
resultado 2.
Pernocte en 
D. 8:30 
a 11 hs. 
Reunión de 
cierre de 
trabajo 
operativo con 
Equipo Eval 
en CEPEP:
presentación 
de hallazgos y 
recomendacio
nes mas 
importantes. 
11:30 a 12:00 
hs. Reunión 
de cierre con 
staff CEPEP. 
13 hs.
Traslado al 
aeropuerto. 
FERIADO
Llegada a 
Atlanta
Inicio 
borrador 
de 
informe 
de 
valuacion
44
ANNEX IV
CEPEP’s Response to Recommendations
45
RESPUESTA DEL CEPEP A LAS 
RECOMENDACIONES 
DE LA EVALUADORA DE MEDIO TERMINO 
SANDRA WILCOX
El Consejo Directivo del CEPEP ha analizado profundamente las conclusiones y 
recomendaciones de la evaluadora S. Wilcox, concordando con sus recomendaciones, 
muchas de las cuales ya están en ejecución. Seguidamente presentamos las respuestas del 
CEPEP a las recomendaciones de la evaluadora.
1- Recomendación de Sandra Wilcox: Para que el CEPEP avance a la etapa de consolidación 
de la sustentabilidad debe desarrollar un equipo de liderazgo compuesto por selectos 
miembros del Consejo Directivo y de su staff gerencial que puedan planear estratégicamente 
el futuro de la institución.
Respuesta del CEPEP: El Consejo Directivo conformará un equipo de trabajo como el 
propuesto, con participación de gerentes del CEPEP y de miembros del Consejo, el que 
tendrá como objetivo analizar desde el punto de vista estratégico el rumbo futuro de la 
asociación, definiendo el plan estratégico 2004- 2008 del CEPEP y las acciones necesarias 
para fortalecer la institución y su sustentabilidad.
2- Recomendación de Sandra Wilcox: Teniendo en cuenta que el desafío es lograr la 
sustentabilidad de la oficina central, el CEPEP necesita desarrollar estrategias que le 
permitan financiar estos gastos. Otras entidades similares venden los servicios de consultoría 
de su staff gerencial. Será útil visitar entidades que han tenido éxito en esta clase de 
experiencias, como CIES o Prosalud, en Bolivia.
Respuesta del CEPEP: el equipo de trabajo deberá definir, en el marco de la planeación 
estratégica, nuevas acciones que permitan mejorar los niveles de sustentabilidad del CEPEP. 
Estas acciones se incorporaran a los planes anuales del CEPEP, para su ejecución. 
3- Recomendación de Sandra Wilcox: Es necesario continuar con el entrenamiento gerencial 
de los directores de las clínicas.
Respuesta del CEPEP: se intensificará el entrenamiento gerencial de los directores y gerentes 
teniendo en cuenta el desafío de la sustentabilidad que requiere de habilidades gerenciales de 
excelencia. Futuras capacitaciones en gerenciamiento a realizarse incluirán también al staff 
de gerentes y a mandos medios de la institución.
4- Recomendación de Sandra Wilcox: dado el rol del CEPEP como proveedor de SR seria 
ventajoso desarrollar y poner en el mercado una estrategia de entrenamiento que pueda 
generar ingresos a la institución para su sutentabilidad.
Respuesta del CEPEP: dentro de las actividades que serán desarrolladas luego de la 
habilitación de la clínica central esta contemplado convertir esa clínica en un lugar de 
entrenamiento en servicio en calidad de atención en salud reproductiva, con énfasis en 
planificación familiar: esto se denominara “Proyecto Calidad”. Se gestionará que esta 
46
actividad de capacitación sea apoyada financieramente por donantes generando ingresos para 
la sustentabilidad del CEPEP.
5- Recomendación de Sandra Wilcox: sería conveniente promover la elaboración de mas 
materiales de IEC para su venta.
Respuesta del CEPEP: el CEPEP realizará la impresión de mas materiales, mas variados, en 
cantidad y calidad adecuadas, para dar satisfacción a la creciente demanda de materiales de 
IEC de los proveedores de salud. También se ofrecen a costos accesibles actividades de IEC 
como ser charlas en colegios, etc.
6- Recomendación de Sandra Wilcox: En el proceso de crecimiento, será importante que 
CEPEP tenga redefinida claramente su misión. En el proyecto USAID el CEPEP desarrolla 
dos áreas estratégicas: a) Como una organización privada que se focaliza en la prestación de 
servicios de Salud Reproductiva de alta calidad. b) Actúa como una entidad de promoción en 
apoyo del proceso de descentralización del país, específicamente de los servicios del 
Ministerio de Salud. Si bien las dos áreas son importantes requieren del CEPEP diferentes 
habilidades y estrategias. En conversación con miembros del Consejo y del staff del CEPEP 
ellos han expresado que se sienten divididos y presionados entre estas dos estrategias y 
actividades que compiten. El fortalecimiento de los servicios del sector público esta fuera de 
los objetivos de sustentabilidad y no responde a ese mandato central. Es recomendable que el 
CEPEP realice un análisis interno o una planeación estratégica para analizar la viabilidad de 
estas dos estrategias. Si después de un análisis cuidadoso el CEPEP decide que ambas áreas 
son consistentes con su misión, entonces necesitara desarrollar estrategias que permitan 
desarrollar ambas áreas sin perjudicar a la institución. Por otro lado, si decide que no puede 
continuar en ambas direcciones si desea sobrevivir como institución viable, entonces los 
donantes deben respetar esta decisión y trabajar con el CEPEP en el marco de la misión 
establecida, considerando que el objetivo primario del proyecto es el fortalecimiento de la 
capacidad institucional y de la sustentabilidad del CEPEP.
Respuesta del CEPEP: la situación planteada ya fue analizada a nivel del Consejo y se 
encomendó a su presidente, el ing. Raul Hoeckle negociar con USAID una adecuación del 
resultado 2, buscando la implementación de un nuevo proyecto, con una orientación hacia la 
salud reproductiva, en consonancia con la misión del CEPEP y con actividades mas 
relacionadas con el accionar del CEPEP. Se incluye al final de este documento la propuesta 
de adecuación del resultado dos planteada a USAID. Este planteamiento, realizado al USAID 
recientemente, no ha podido concretarse por falta de financiamiento y el USAID asignará los 
fondos y la responsabilidad del resultado dos del acuerdo a otra entidad, a fin de que continúe 
con la implementación de los programas comunitarios de la Alianza.
7- Recomendación de Sandra Wilcox: Teniendo en cuenta la importancia que el programa 
comunitario tiene como generador de ingresos se recomienda que el CEPEP fortalezca esa 
área. Será beneficioso realizar mas capacitación a promotores y supervisoras. CEPEP debe 
explorar otros métodos y productos que los promotores puedan distribuir así como incentivos 
para las referencias.
Respuesta del CEPEP: Estamos totalmente de acuerdo en la importancia de ampliar y 
extender el programa comunitario del CEPEP, y este es uno de los componentes 
desarrollados en el marco del resultado esperado 1, con éxito. El CEPEP incentiva cada fin 
47
de año, con premios, a las promotoras que realicen mas referencias a los servicios de salud y 
analizará la posibilidad de incluir nuevos productos en el programa (multivitaminas).
8- Recomendación de Sandra Wilcox: Teniendo en cuenta la discusión sobre los desafíos de 
la Alianza se recomienda que el CEPEP, trabajando junto con USAID y los otros miembros 
de la Alianza acuerden diseñar una mejor estructura de gerenciamiento para el proyecto que 
reduzca las diferencias y las superposiciones entre miembros para una mejor coordinación. 
Al mismo tiempo CEPEP debe reorganizar la capacitación de los promotores de salud para 
que ellos estén mejor preparados para responder a las necesidades propias de su rol de 
promotores. Una mejor coordinación entre miembros de la Alianza también va a mejorar y 
fortalecer su integración con la comunidad local y con los servicios del Ministerio de Salud.
Respuesta del CEPEP: ver comentario del punto 6. En cuanto a la capacitación de los 
promotores, el CEPEP ya ha iniciado un proceso nuevo con diferentes metodologías, 
capacitadores y materiales, que incluye también la realización de repasos para los promotores 
activos y para supervisores. Estos repasos ya se están realizando en el municipio de San 
Miguel. También se continúa con la realización de la capacitación de nuevos promotores y de 
nuevos supervisores en C. Bogado, Atyra y Candia.
PROPUESTA DEL CEPEP
PARA ADECUACION DEL RESULTADO DOS
PRESENTADA A USAID
El CEPEP prestará asistencia técnica al Consejo Local de Salud y a los servicios de salud de 
las comunidades seleccionadas en el nuevo proyecto, en coordinación con la Región 
Sanitaria y el nivel central del Ministerio de Salud, a fin de apoyar la implementación 
operativa del Plan Nacional de Salud Sexual y Reproductiva, incluyendo mecanismos de 
monitoreo y evaluación. Se apoyarán las siguientes áreas: 
1. Incorporación del componente de salud sexual y reproductiva en el Plan Local de 
Salud. 
2. Capacitación en aspectos de salud sexual y reproductiva a los miembros del Consejo 
Local de Salud, a proveedores del servicio de salud y a personal de la Región 
Sanitaria, que faciliten el diseño y la operativizacion del Plan Nacional de Salud 
Sexual y Reproductiva en las comunidades seleccionadas, así como su evaluación y 
monitoreo.
3. Implementación de farmacias o dispensarios sociales que favorezcan el acceso de la 
población a insumos de salud sexual y reproductiva (anticonceptivos, medicamentos 
básicos, kit de parto, etc.). 
4. Capacitación a promotores o distribuidores comunitarios y a parteras empíricas, 
conforme a necesidades detectadas y a programación establecida a nivel local. 
5. Capacitación al personal de los dispensarios en aspectos relacionados a la 
operativizacion del Plan Local de Salud Sexual y Reproductiva, a fin de mejorar el 
acceso a los servicios e insumos de salud reproductiva. 
6. Apoyo y seguimiento a la implementación del Sistema de Vigilancia Epidemiológica 
de la Salud y de la Mortalidad Materna en cada comunidad, conforme a normas.
7. Mecanismo de logística de anticonceptivos establecido en cada comunidad, ya sea por 
medio de los dispensarios sociales, de distribuidores comunitarios o de otra 
modalidad definida en el Plan Local. 
48
Asunción, 3 de diciembre de 2003.