AMREF KENYA Mid-Term Evaluation 1 Bomb Blast Survivors Medical Assistance Program SEPTEMBER 2000 Dr. Mary Amuyunzu-Nyamongo Dr. Parmenas Kibagendi Oroko Ms. Njeri Muriithia Winner 1999 Conrad N Hibn Humanitarian Prize TABLE OF CONTENTS Executive Summary 1.1 Project Background 1.2 Internal Review 1.3 Project Achievements 1.4 Project Constraints 1.5 IsswsandGaps Recomrneodations 2.1 Information 2.2 Research 2.3 Survivors Discharge and Weaning Off 2.4 Co-ordination 2.5 Funding and Long - Term Follow-Up Of Survivors Project Background Loformation Project Objectives Evaluation Methodology Project Comoonents ~edical Assistance 6.1.1 Survivor Identification 6.1.2 Referrals 6.1.3 Medical Care 6.1.3.1 Investigations 6.1.3.2 Treatment 6.1.3.3 "Silent Victims" 6.1.3.4 Rehabilitation Co-ordination 6.2.1 The Survivors 6.2.2 Intra-Coordination 6.2.3 Inter-Coordination Project Management 6.3.1 Project Concept 6.3.2 The Project Goal and Objectives 6.3.3 Project Strategies 6.3.4 Project Monitoring and Evaluation 6.3.5 Phasing OutExit Shategy 6.3.6 Support StructuRs 6.3.7 Project LmplemenIation 6.3.8 Capacity Building 6.3.9 KC0 Management Support to the Project 6.3.10 Perceived Project Benefits 7.0 Achievements 7.1 Survivor Identification Casestudy-GraceKy~na Case Study - Hemy Jimmy Koweru 7.2 Referral System 7.3 Collaboration with the Private and Public Sectors 7.4 Management of Medical Ailments 7.5 Recognition 8.0 ConstraintslChalknges 8.1 WOW 8.2 Wide Range of Medical Ailments 8.3 Survivors' Mentality and Dishonesty 8.4 Retrenchment and Low SociiEconomic Status of the Survivors 8.5 Funding Limitations 9.0 ISSUeSiGaps 9.1 The Project Document 9.2 Inforamtion Produdion and Dimination 9.3 Documentation 9.4 Coordination 9.5 Support Groups 9.6 Survivors' Discharge and Weaning Off 9.7 Sustainability 9.8 SraffDevelopment 9.9 KC0 Management Support 10.0 Conclusions Annex I Terms of Reference Annex U CliniciadFacility interview guidelines Annex ILI CoUaborators' Interview Annex IV Guidelines for Survivor In-depth Interviews Annex V Survivor Questionnaire Abbreviations NGOs - ADRA - KSB - APDK - KNAD - KSD - MAP - KNH - ENT - SDA - UDPK - Non Governmental Organisations Adventist Relief Agency Kenya Society for the Blind Association for the Physically Disabled of Kenya Kenya National Association for the Deaf Kenya Society for the Deaf Medical Assistance Programme Kenyatta National Hospital Ear, Nose and Throat Seventh Day Adventist United Disabled Persons of Kenya Executive Summary Project Background AMREF has been running a two-year Medical Assistance Programme (MAP) funded by USAID 6um July 1999 to luw 2001. The project goal is to enarre adequate physical medii and surgical treatment and rehabilitation for the survivors of the August 7, 1998 bomb blast in Nairobi 'Ihe project has nine objectivff, whicb can be classified into; provision of medical assistance, coordination; research documentation and dissemination The internal mid-term evaluation was conducted mainly to assess the project implementation pmms and make recommendations on areas tbat need improvement. The evaluation team involved various categories of stakeholders including clinici and other service providers; survivors, collaboratow project staff and the domr. The methods used for gathering the idonnation were one-to-one interviews, self￾administered questionnaires, obseMttion of the Eacilities, ad general conwrsatiom The evahratmn team focused on three main components, namely medical asistance. coordination of the survivor assistance programmes and project management. The medical assistance component has been implemented through seaing certain procedures in place. These include survivor identification and re- systems to enabk smooth flow of patients and approwe attention to their medical needs Doctors have been identified to cater for the .survivors' variant needs of care such as dentistry, gynaecological, orthopaedic surgery, neurological and ENT, among ohm. The kilities used by MAP range 6um private hospitals (e.g. Nairobi h4ater and Aga Kban), public hospitals (Kenyatta National Hospital) and others (laboratoris, pharmacies and Physical Therapy). Collaboration with the other organisations serving the survivors has also been an important component of MAP. The other organisations are ADRA (which co￾ordinates KSB, KNAD, APDK and UDPK), AMANl Counselling Centre and Erneslde Young. This collaboration has mainly been in terns of referrals and in attdi pint meetings. Although AMREF has been vested with the a+ordhion rok this bas not been very effective mainly due to the indepeodence of the organisations in their impkmentation and also as a result of an unclear mandate from the donor. Project management has been WU done. 'Ihe project implementation bas been timely with a ckar exit strategy, which was in-built in the project document. The project manager has been submitting hex quarterly reports to the donor on time. 'Ibe staff members see themselves as a team and are highly appreciated by the survivors The nmin problem encountered by the staff has been the worWoad which tms afZcied staff development. The staff needs capacity building in various areas including counselling. &mation technology, research and documentation. Project Achiewmet~ts The project has many achievements. There is a system in place for awivor identification and for referrals to the doctors and other facilities. Collaboration with the private and public sectors has been shown to be possible through this project. The fact that survivors and service providers can attest to improved health and well beii is an indicator of achievement. AMREF is currently recognised as a credible institution capable of intervening in emergency and traumatic situations. Project Cotrrtraints The project has, however, encountered several cousbaints iocluding heavy wrWoad on the staff. The range of medical ailments has mpassd the initial miections aod the number of ptiem-has more than doubled. The skivors' men& oi impatience and perceptions of themselves as the uafortunaie victims is very dedi on the staff and service providers. Dishonesty of some survivors has resuhed in financial losses that have necessitated a shift in strategies. The current Kenyan economy and the wab- of retrenchment are a threat to the gains made through counselling. Issues and Gqs Several issues and gaps have been identified in this review. The objectives as stated in the document lack clarity and are therefore wt an effective monitorinp. - and evaluation tool. AD issue of co-~lcern for both the survivors and service providers is on infortnation production and Bow. In addition, documentation and dissemination of data and experiences has been very slow in taking off. Another area of concern is the AMREF co-ordination role, which is seen mainly as a facilitative one in tans of organising joint meetings. Sustainability, staff development and KC0 support are some of the other areas that require refining in the mnahing project period andinthepmposedphaseII. RECOMMENDATIONS: I). ItIfwmati0)r Informationflow~thepojecSsurvivorsaodthecollaborato~~hasbeeo~ and thRe is need for improvemed Fmm discussions with the key stakeholdas h is evideu that~isneedtodothefollowing: Improve communication b and anmng the swice povidas in orda to be more effective in meeting the needs of the survivors This could be done thollgh hum such as a newsletter or a brochm whik the use of e-mail for such an adivity would make h cheaper and more efficient; Improve commlmication with the survivors by providing rele~lnt and timely information on the available services This should be dom in a manna that is appopriate and sensitive to the survivDrsl abiiiesldisabilitKs e.g. notices in a Language that can be undRstood by all using different communication channels; and Improve information and data collection pmwses This could be done ttaollgh building the staff capacities to collect and store the information 2). Research Research was identified as one of the key objectives of this prow Research is aucial in providing information br fhm disaster intMions. Unbltunately, this process has just been initiated. Considering the importance of research especially in such a unique situation the project needs to focus on this urgently. The evaluation team recommends that: AU appropriate information and data be coUected, aaalyd and A system of documenting the process and any oh information needs to be dewbped urgently. This should also involve ok players such as the docton and coUaborators; Publication of the research Wings should be an important product ofthis pow To ensure adequate rehabilitation of survivors there is need to: Discharge those whose medical treatment and rehabilitation is completed: and To wean the rest of the survivors off the programme. This process should be gradual with cost sharing being started initially at the pharmacy and later in the other areas Coordination of the survivor assistance programmes is crucial if the service provision is to be streamlined and the information generated used for documentation for wider dissemination Thus: There is need for the survivors to be given a single number which should be used by all the organisations for identification and follow-up purposes; and This w-ordination can only be achieved if the coordinating orgmkation has a mandate to do so. It is, therefore, recommended that USAID reviews the coordination objectives and provides a mandate to AMREF or any of the other organisatiors to co￾ordinate the survivor assistance programmes. 5). F~itdmgandhlg- Term Follow-Up ojSun.irws While most survivors' medical treatment and rehabilitation would have ken completed at the end of the current phase of the project, 20 - 3o?'O will require long-term treamma and follow-up. These are mainly those with respiratory problems, repmdwtive heahh problems, the deaf, those with prosthesis and the silent victims. F& medical assistance is required by the survivors who are still suffering and those who are presenting with new ailments that may be of research interest to the programme. AMREF has presented a proposal to USAID for another Wing year (2001 - 2002). It is, therefore, recommended that: Survivors with long-term problems should be identified by their doctors with a medical report being sent to AMREF; AMREF should form a medical board which will be responsible for reviewing the cases requiring long-term medical care; AMREF should work closely with USAID to come up with a feasible system of medical provision beyond the Wing period; and AMREF should identify companies and other organisations to fund MAP acaivities beyond the USAID Wing period. This would ensure a follow-up of the survivors. and specifically the silent victims for a much longer penod. 1. Project Background Information A terrorist bomb aimed at the United States of America embassy exploded on August 7. 1998. It resulted in an immense loss of lives (an estimated number of 260 dead and 5000 injured respectively) and property. The effects of the bomb blast led to immediate responses hm individuals, companies, donors and agencies. AMREF intervened through setting up a Bomb Response Unit and used its fiends and offices in Europe and North America to set up a special Ead African Emergency Appeal. AMREF received a total of US$ 1,258,323 to directly provide medical care to the bomb blast slwivon AMREF worked in collaboration with USAID and Kenvakta < National Hosoital in the screening of 1,400 survivors and providing reco~ve surgery for 380 survivors Upon realishg the need for continued survivor assistance, USAID awarded Kenya funds for the survivok' rehabiiion and for busi that were affected. This money was channelled through different organisations AMREF was awarded USS 1,619,33 1 to run a --year Medical Assistance Programme (MAP) hm July 1999 to June 2001. Orher agencies contracted were Kenya Red Cross (KRC)' to provide mental health and school k services and Adventist Development Relief Agency (ADRA) to cater for the phyxically disabled survivors. At the end of the first year of the implementation of MAP, AMREF decided to conduct en internal mid-term evaluation to assess the implementation processes. Terms of rehoce were developed for the evaluation team (Annex 1) and the exercise took place in September 2000. Kmya Red Cross had major management problems, which led to the csnedl.tia, of meir mmbacl Two agsnisatims wae awarded these antracts - AMANI Canslling Centre (Madll Heplth) nd Fmesl& 2. Project Objective The project goal is to ensure adequate (physical) medical and surgical treatment and rehabilitation for survivors of the August 7, 1998 bomb blast. The objectives are to: 1. Ensure the start ador completion of reconstructive, ophthalmology, orthopeedic and dental surgeries; 2. Ensure adequate rehabilitation, in form of physiotherapy, hydrotherapy and occupational therapy to survivors that require the service; 3. Identify, assess and assist special cases that need specialised medical treatment and rehabilitation outside the country where incountry care is not available; 4. Provide therapeutii devices as necessary - including dentures, bridges, eyeglasses, orthopaedic prosthesis, lumber corsets, hearing aids, and eye prosthesis; 5. Study the milestone development of babies born to mothers affected in the bomb blast; 6. Assist in coordination of efforts for agencies working on bomb blast survivors' projects; 7. Collect, synthesise and die information to NGOs, patients and government bodies on bomb blast related matters; 8. Form communication wtwork for implementing agencies through the development of a website on bomb blast survivor assistance, in view of verification of true survivors, avoid duplication of services provided and information on survivor assistance bemg offered; and 9. Research on overall medical responses to the bomb blast and national impact. 3. Evaluation Methodology The evaluation team held a oneday planning meeting, which was also an& by the project team to identify the people to be involved in the review process The aahration tools were also developed. The participants in the evaluation process were categorid as: Clinicians; 0 Survivors including parents of silent victims; Medii facilities; ProjectM,and Collaborators. MAP is currently working with 22 clinicians hm a wide range of specialisation It was decided that each of the specialities represented be involved in the discussion i.e. 0 Ophthalmology; 0 Physicians, Ortbopaedicsllrgery; Dermatology; Recorrdructivesurgery; Ear,Nose and Throat, Neurology; GynaeCology; Urology; 0 Paediatrics;and Dentistry. In areas where only one doctor is involved, the oame was autonmtically taken Howwer, in cases where there was more than one, random sampling was used for sekction. MAP has registered 1,200 survivors and the evaluation team considered it very mid to hear their views about the prognumne. The project umoagement team observed that the office receives around 20 patients daily. It was therebre agreed that 200 petKnts be given a questionnaire to fill and 20 be interviewed on a one-to-one basis by the evaluation team MAP utilises the services of hospitals (Mater, AgaKhan, KNH, Nairobi and SDA (Better Living Centre), Eros Pharmacy, Plaza X-Ray (Nginyo Towers and Re-ii Plaza), laboratories (AMREF ad Omicron) and physiotherapy (Physical Therapy and Nairobi Hospital). Tbe evaluation team selected to visit KNH, Nairobi Hospital, SDA, AMREF Laboratory and Physical Therapy. The other organisations providing services to the survivors were also included in the data collection desigo, i.e. ADRA, AMANI Counselling Centre, KSB, KNAD, APDK. UDPK, and Ernest & Young. The followiog, are therefore, the people, organisations and firilities involved: Clinicians 12 Medical facilities 8 Survivor interviews 27 Survivor questionnaires 127 Collaborating organisations 7 Project staff 5 The data colleawn instruments used in this process are attached in anoexes 2.3.4 and 5. Out of the 127 people who filled in the questionnaire, more than 50 % were involved in low paying jobs ad about 11% were unemployed as illustraled bebw 0ccup.tiou Clerks Unemployed Ye 25.5 16.5 Housewife Manager No answer 8.7 3.9 2.4 37.8 Although some patients did not respond to this qwstion, it is clear that it would be difficuh for most of the survivors to afford the medical services being provided outside the project period. 4. Project Components This project has two main operational components: Medical Assistance and Co-ordinat'in The third component included in this evaluation is project miinagement. 4. I Medical Assistance Survivors were identified using predetermined criteria through a thorough scruhy of medical records, letters hm employers and appropriate medical history. The main challenge encountered by the project team was whether the medical problem presented were specifically bombrelated. Statements by the survivors that a particular problem developed after the bomb blast have been admissible. This probkm may be as a resutt of the dearth of information on bomb related problems in medical literature. Cousequeatly, the survivors tend to expect treatment of all their medical conditions under MAP. The project nurse and their doctors have however, specifically informed them that the programme covers only bombrelated conditions. The survivors who do not meet the criteria set for regist&in, as bomb survivors haw mt been included in MAP. There have been around 2 cases of fike survivors who have cheated the system but when they were discovered they were dully thrown OUL All referrals are channelled through the pmject nurse who directs the survivors to specific doctors who have been identified. The doctors mainly work in the public sector and all of them have appropriate speciality training and experience. They have all been head hued and were recruited in good time, between July 1999 and November 1999. Referrals br rehabilitation have been dow in collaboration with NGOs who have appropriate experience and ensure sustainabiiity of care beyond project penod. Such referrals are ako provided through the project nurse. Most of the survivors (94.5% 0=127) comidered the doctors to be very good. For survivors who have had problems with theii dodors, a change has been authorised by the nurse after consultatiins with the respective dodon 4. I. 3 Mecfcal Care The doctors observed that the survivors tend to be more demanding than other paticats are, they have a seme of entitlement and generally expxt all ailments to be covered by the project. One doctor expressed that AMREF has created "a dprp ofpsoplc who wamf 10 k aprioriry,~~andcrnddowuttod. Themainchallengeisthat manyof the survivors are poor and would find treatment costs beyond their meam if asked to pay. Good quality treatment is administered by appropriately qualified medical staffs who are cognisant of the sustainability of care. The hilities bemg utilised by MAP vary, but they are generally adequate for the care of survivors. Only a few of the survivors have required treatment overseas Most of the patients (over Wh) appreciate the services reodered by MAP and attest to improvement in health. Thus, the treatment and rehabilitation of many of them can be terminated at the end of the funding period. However, there are some (approximately 20 - 30%) who may require long term follow-up such as patients with mental and reprodwive heahh problems and those with prosthesis. (i) Investigations Laboratory tests are performed in good time. The main complaint by the survivors is that it is inconvenient because they make a specific trip to AMREF. which is geographically removed, hm wbere all the doctors are located. AMREF laboratory gives reliable resuhs for routine investigations However, tbese are presented using the Imperial System of units while most doctors are ww used to the International System For more specialised tests e.g. specialid chemistry, hormonal tests and histopathology, survivors are appropriately referred to Nairobi Hospital. Good quality x-rays are obtained at Plaza X-Ray centre. These are taken expediiiously and are all reported by a radiologist, the facilities at this centre are excellent. Facilities at KNH, specifically the ENT department are, however, inadequate. There are an insufficient number of audiometers and some are borrowed hm KNAD and KSB, which means that survivors have to wait longer for appointments becaw of the numbers of audiometers available. Currently, there is no working audiometer belonging to KNH. There is a need to acquire such equipment to facilitate the follow-up of the survivors. AU the survivors have however had their tests done. (ii) Treatment Most of the surgical treatment has been completed which has been rnainly reconstruction work, which has involved the removal of foreign bodies, tendon repaim, revision of scars and excision of keloids. Most of this was done under local anaesthesia at the SDA Better Living Centre and Nairobi Maxillofacial clinic while some has been done under general anaesthesia at Kenvatta National Howital IKNH). Almost all these survivors have been discharged as the& treatment has b&n cokpleted. Orthopaedic patients who have had implant removal and repair of tendon injuries have also been discharged while tbose with backache and other m&uloskeletal pa& have been referred IO physbtherapy. Those uh have had amputations have been fitted with artificial limbs and surgical boots as appropriate, these patients require Life long prosthetic management and should be considered during the exit plaa Neurological patients mainly had head injuries while most of them are left with post head￾injury syndrome, which manifests with wn-specific symptoms of headaches. blurred visimn and nightmares. Such survivors will require long-term follow-up. Some survivors have had removal of slipped discs and have improved. One child had a brain turnour, which was removed unfortunately, the child died post-operatively. Facilities for such operations are, however, adequate. More than 170 survivors had dental probkms including missing teeth, 6achues of the teeth, soft tissue injuries and gum disease. These have received gum thetapy, extraction, crowns, bridges, dentures and fillings as necessary. Most have been discbarged and only 20 - 30 may need follow-up beyond the present project pbase. AU the dental care was provided at SDA Better Living Centre, which has good kilities for dental work. Urological patients have had mainly psychological concerns manifesting with genite urinary probkms inchding impotence and bed-wetting. These are being appopiately heated and rekmd for counselling. Investigations facilities at KNH are adequate. Survivors with gynaecological problems have had probkms manifesting in hormonal imbalances with premature menopause; pregnancy losses and cyck irregularity and a kw have had inter-ckent problems-like pelvic pa&. lnvestigat& facili& adequate. Treatment is adequate for most of them except for a group vrho have premature menopause. Instead of receiving hormone replacement therapy, they are getting symptomatic treatment because of fear by the doctors of being unable to sustain the expensive treatment beyond the cmt phase of the project. Most of the survivors ref& to ENT department have had hearing loss (7 of the survivors are deaf). Some suffer dizziness and tinnitus (nagging sensation in ears). Otd of 82 hearing aids required, only 46 have been obtained of which 32 have been fitted. These aids were sourced hm Denmark and are adjustable. Thirty-six bearing aids are still required plus a small safety stock. These survivors will require Life long fob-up. ENT department has tended to give counselling as part of the aeatment process This could explain the small number of patients rekmd to KNAD. Most patients with arrgically correctable d&s have been operated, with improvement in bearing being reaiised. Only one survivor needs to go abroad for firrther treatment. Survivors with optbalmological probkms have either loss of sight (hm pRforating injuries or direct injury to the eye) or eye discomfort, pain, itch or redness T~armem bas included surgery for perforations, corrective leases ad topical mediiion One of the survivors, a young girl who lost one eye was grateful to AMREF for enabling her to see again. She is still very aware of her situation and always wears braided hair. which covers the blind eye. Medical patients have tended to have allergies leading to upper respiratory tract infactions bronchial asthma, enema and conjunctivitis Some have had awiet)., depression, hypertension and vague musculoskeletal symptoms. Majority have new symptoms and some have worsening of already existing conditions. tke survivors tend to be fresuent attendees at the diierent health care hilities. It is estimated that 20 - 30% will require long-term follow-up especially those with respiratory probkms. Skin conditions have been mainly allergic in nature. Tbese are beii ireated wilh topical creams and have generally improved. It is estimated that up to half of these nwivon will still require treatment after the current fimding phase expires. The phannacy located at AMREF has worked well in terms of controlling over￾prescription and fraud. All drugs are generaUy available but occasionally, howleyer, patients need to collect drugs hm the main pharmacy in town Physical hcilitii are limited making storage difficult. Further, the pharmacy is only open during afternoon hours making it inconvenient for some of the survivors. There is, however, an arrangement where children can get medication out of hours at Nairobi Hospital Some of the survivors noted that they have problems over the weekends because the pimmwy operates hm Monday to Friday. (iii) "Silent Victims" Forty-seven (47) children are being followed up at Nairobi Hospital Tbese are mostly children born to mothers who were prepant and were in the vicinity of the bomb blast. Five were born to mothers not expecting at the time of blast, while one was already I year old. Most of these children tend to be irritable but this has tended to settle bv one vear. Ln addition, they tend to have more respiratory problems (blocked mse, cougb wheeae) tfian other children as reported by the mothers and the paediatrician. They are being anended to at a Well-Baby clidic and &dl require long-term follow-up to 6nd iut if the pkblems will persist or others will arise. Further, these children may require ENT evahrati and psychological assessment before discharge. Rehabilitation is mainly co-ordinated by ADRA who identified the collaborators These are NGOs with experience in rehabilitating people with physical disabilities - APDK, KNAD, KSB and UDPK. ADRA bas case -ers who identifi the smvivors' ogds Facilities in each of the NGOs were variable, KSB for instance, iswellorganidwith good Facilities. It was involved in the initial screening of patients after the bomb blast and followed-up the survivors. Out of an initial caseload of 236 survivow 70 were listed for follow-up, 62 regained sight after treatment and 38 were registered totally bli. To date, 19 are legally blind and have been My rehabilitated. The project officer noted &at tk survivors are quickly rehabilitated compared to others who usually contxt KSB much later. The project officer observed that KSB's facilities were strained with the bomb blast and it bad to get traiwrs hm the provinces to mme to Nairobi. Another trainer was obtained hm USA through the Baptist Mission. With these personnel and its existi physical fixiiies in Nairobi ad Machakos, the society has done well. In Nairobi a computer￾training programme for the blind has enabled some survivors to go back to work. KSB, however, continues to follow-up survivors who should have My been discharged hm theii care due to lack of confidence in ADRA case managers in the rehabilitation of blind people. KNAD has done a good job considering its limited physical facilities. It ob colnseUing services and teaches sign language using a home-based program it also offers sign language classes to KNH-ENT department stafE, and offers interpretation services to the deaf. There, however, seems to be a low referral rate hm KNH-ENT to KNAD department whereas this could help rehabilitate many of the affected survivors. APDK has inadequate facilities, but it has personnel to o& a wide range of rehabilitation services inchding physiotherapy, occupational therapy and orthopaedic technology. ADRA has hied to improve its capacity but it still requires upgrading of its equipment to offer a satisfictory service, the current firilities are very strained Cost &ring has reduced numbers hm over 200 to 98 survivors. However, there needs to be clear goals of rehabiiion with patients who have not improved beii sent back to the referring doctor for finther assessment. Communication between APDK and referring doctors needs improvement for better rehabilitation of survivors. MAP bas sent some of the survivors' to Physical Therapy Services. This facility is well equipped and should be commended for having clear goals of rehabilitation, good communication with AMREF and the reking doctors. Support groups have been formed at TSC and TARDA (for mothers pregnant at time of bomb blast and those who have since delivered though not then pregnant). The TSC support group is now divided with some mothers being paid up members and others not. The paid up members seem to have changed the initial ideals of the group of providing support to one another to a financial group. The group leaders should be emuraged by ADRA to remain a support group pursuing their origii goals. One of the mothers said; "we nud swrtfrom AMREF to form another se group The canmU one ir fmd on making morvy but not sharing our children's mhtma whkh )~lpy the initial objcdivc". 4.2 Coordination In addition to implementing the medical assistame programme, AMREFs other role is to a+ ordinate the key players in the USAID futxjed bomb relief assistance programme. Tk evaluation team sought to find out how the coordination is viewed by the collaborators and the beneficiaries Tbe survivors are happy with the project's coordination of the key medical care providas However, they expresd unhappiness at the flow of information and swices provided by the other organkahns The poor information flow made the swivors to kl that there was more assistance, which they wae not aware of. Some survivors are sspicious that otb may have mre information on savices available hence may be gethg mre assistance. .\fedical..(srisfmrce F'qrmnme Rniew 000 It was however, noted by the project manager and the domr qmsenmive that di&mu media including radio, newsletters and fice-to-h have been used for giving inhrmation but the survivors still mend mt to be aware of the services AMREF is suppod to have pmduced a brochure to coqkme-ot the other forms of communicat'in but ~mfommately this hasmtmaterialised. The collaboration between the different organktiors was viewed by the members of Mas good and quite fiuitful to them and the beneficiaries Flow of inhrmation mtemdy is good and this has enhanced the successful project impkmentation The MAP project M atso statedthattheyfelttheycollaboratedwahtheotkragenciesadtheserviCe~vidasu~~ However, due to the demands and needs of the survivors, the information flow is delayed or at times mt available. OthR d- at AMREF do not seem to be aware of the project's activities apart hm kmwing that bomb relief survivors visit the AMREF offices The coordination between the key players in bomb slwivors assistance prognun was loosely passed on to AMREF. The coordination mandate was "assumed" and is mt clearly defined This may explain the collaborators' view of AMREF mainly as a firilitator (calling) of meetings AMREF was rated high by the collaborators m its abii to get the key actors togetk for meetings However, it was mted that information flow ad sharing of the same. especially from AMREF, was mi up to the expected levels, e.g. the collaborators refer patients to AMREF and they expect to receive feedteck on the patients but this does mt happen The collaborators also expected AMREF to provide a forum for hrhg infbrmation ad experhxs on bomb relief and this has also mt materialised. The collaborators' suggestion for apmt information mnpnline was mt agreeabk to AMREF who adually oped out of the venture. One of the collaborators stated that this was unhir as AMREF has been given money for this activity. The collaborators feh more add be done to hnprow infbrmation between the survivors' programmes as they all assist the same people. 4.3 Projed Managemem 'IbeProjectconceptisaresultoftheeltperiencesandprobkm~~~the~of assisting the bomb blast survivom AMREFs response was immediate afta the catastrophe and e&rts were made internally to mbise appropriate resources to meel the needs However, the internal Wing was mt adequate to meel the needs (medical coumelling and socialscommic needs of the survivors). Based on this, AMREF sough fimding hm the USAID for two years (June, 199) to June, 2001). (ii) The Project Goal mid Objectives TheRojectgdstatedasistotodedequatephys~medicaland~icaleestmedand rehabiiin for persons injured in the Nairobi bomb blast" is clear and gives a picme of what the project seeks to achieve, although it leaves out tk mend beahh componed Tk project objectives are many and mt clearly de6ued ie. they are mt specific, dk, achievable, realistic and time bound (SMART). Given the em and magniude of the injlnies and the scope of worWactivities, 111 realisation of these obptiives is an llphill t& The objectives should be reformutated and targets appended on each of them and wke the objective requires long-term intaventions, these needs to be stated to albw for the d&eloPment of amk proposaL The evaluation team mted tbat the pro* has made major achievements ht measured aga& the objectives the achievements may mt be "visible". The project shakgh are broad and at times one is mt able to qmale the "bow" ie. stmegk and the "what" i.e. activities, that need to be undeataken to achieve the set god and objectives Strategies also have mt taken into considedon some of the objectives such as the research objective. This may explain why the budget Qes mt retlect adequate ~sollrces for research and documentation (iv) Project Mmniori~g mid Evahratimi Som mechanisms such as the quarterly reports to the donors are available and thse giw a general didin of wke the project is, in as lkr as the csdivhies are concerned H~WWT, some aucial mnitoring tools such as the logical fianmwrk are mt in the doc- For ease of clarity and in orda to give a quick sympsis of the project, this tool is importad and shouldbedevel0pedhrth:nextfUndingperiod The document also identifies the collaborative manag- team (managas &om otba survivor sssistance programnres) as part of the mnitoring paces This mle did mt however, come out clearly during the discussions with the project mauager and neiha did there seem to have been the "every six weeks" meet@. Whrm the pro* doamrd states that wmise documentation on survivors' medical pogress will be done and made available, the collaborators felt that this is an area that needs a lot of improwm because they do mt get feedback on the survivors ref& to AMREF for wdical assistance. (v) PhrralIg Ou1 Exit stralrg). The phasing out stmtegy as stated in the document is mble and due considedon was taken in identifying the implementation of this exit whhold jeopardising the survivors' healthkvek. However, the rrahrre of tmmm and the inj~lries sustained duriug the bomb blast were beyond what one could have expected or iolagioed. Some eh of the bomb are delayed and are just being mticed mw and some of these are long-term Refd to tk public hospitals is a m& idea considering the extent of the injuries and the time reqd to heal and rehabilitate. However, some of the survivon may need specialised trrampd br a long time and this may prove quite expemive considering the survivors' bw social-ewmmic status Cost sharing concept is a good exit strategy, but there is d to address the WOLX@ cas by case considering that some of tk survivors bst their abii to be podudive. When the survivors were asked about their wihgms to cost-share, tk folbwing mpoms were given: w "It is okay if it will enswe that the medii assistance codinues wben the project ends". "I would like this prograaune to continue but if 1 have mney I will pay". "Ibis is a tad time ecommically". "AMREF huld ask the Am&am to provide more moy". "If they introduce cost sharing, it mam we will mt get tRatmed because i is difl6cult even for me to get he to come to AMREF. (vi) Sttpporr Structures ~projectdocumentdoesmtideotifysupportstiudurrstbatwouldbe~ed~the fimding period to address the needs of the survivors This may explain some of the pMena euwuntered in setting up the "silent victims" support group as lack of clean linkages between the diffiaent stakehok The survivors' anihde of grabbii any opportdy my explaio why creating new support smctum may mt be feasible: they warrt tangiik, prefixably financial benefits (viij Project Implemenlatio~~ The project initiation started as scheduled and this was lnamfy due to the kt that AMREF had provided provisiiiml fimding. Most of the staff reauited for this project was inherited from the previous bomb Mit In October 1999 the projed manager, the . . . smetary and the rnessenga were made regular AMREF empbyees by being awarded iw+ year contracts Tbe evahratin team mted that these wx mt Wwed br their posts because their 8~90~iation with the previous project begun on a wludary basis exep br the project manager who was issued wah a short-term centred and mxk regular with ibis pro* This, however, does mt seem to have &ed project impkdn as the staff members are reported by the beneficiaries to be eathusiisstic and quite helpfbl. Idad, 96% (n=127) of the respondents noted tbgl the staff roembm are belpful and responsive to their needs Thecowlbranltheprojectnursewaereuuitedmu~h~andfromthe~W received from the survivors they too are doing a good pb. Mobilisat'in of the other project murces and materials was timely and this may be contributing to the prows sllccesr The domr is happy with the staff and the donor cqmemtk wted that AMREF is do* a great pb and reporis reach her of& on time. (viii) Ccywrciity BtrilJIg Staff devebpment has been identifad in the project including conputa eainqg and counselling. However, except hr a brief e&rt to train the pasormel on axinselling the other areasbawnotbeenadrtressed Thereisneedto~thisasarnstlaofugeocyasthe project is quite b-gone. The capacity building wouM atso contni immady to the success of the project and staff mtmtm . . n The staff -bas em enthusii and hsppy to be working witb the survivors It was clear to the evaluation team that the workload at the bomb relief office is quite overwhelming and the staff have made tremendous effort to cope despite the numaom chalienges. Initially there used to be reguk staff mdngs but these secm to have fizzJed WahtimecluetoinreasedWMkbgL Thestaffexpesscdtheneedtorevkthesemetkgsas they provide brums fw discussion and sharing of expexkms m wwlring wih tk bomb survivors and 0th~ stakeblders fix) KC0 Mmmgement St~ppofl to the Project 'I5e evahratiDn team noted that tk project manager bas done quite ~RU inimplnaeding the pro* & with inadequate support hm KC0 mmgemmt For the suw=sM idemalisatpdinalisation of this iniiative, there is oead h W invohremed m the projed especially mw as it draws to an end (x) Perceived Project Benefits I)llring the evahdon exercise, a survivor rrwated that: I got sewral injwies during the bomb md I was so disillu~ioned with myprer6:aMlll to the pint of loosing hope. It&&, there were mny times I emkd the people who riicd &ng the bomb. Some of these depressing momen~s mme when my children ralked to me ad I could nor respond and they were stunned and co+d by my new state. I wed to mite messages ro ny wife md she wuld in hwn mite and this wns ad quite &pressing. I visi~ed the bomb reliefofi md na referred to a &or for he hearing aid When I gor the hearing aid I was so exited ad wed to svrpnie my-family. I pd on a cqtohidethehearingaidmdIwen~home. h+wifewotehermesrogemdmwnr nod when mirim she nvuld talk M. I red her More she dd hand owr the message and she w& just stunned h+ &test hqpiness - howwer. when my chi￾me backjivm school and they talked not expecting me to hear. You c- imagine their shock when I responded to them Out of the 127 survivors interviewed, 992% reported that the pro+ has been very helpful to them. There is only one patient who did not sx any change in his heahh status despite the medical attention he has received since 1999. 5. Achievements This is a complex project, ~ch has realid many achievements. MAP has been able to develop guidelines tha! are followed in checking the authenticity of the clients. Although as noted earlier few fake survivors have been given assistance, h has been possible for the management to identify them and promptly discontinue senice provision. There have been success stories as swnmarised below. Case Study I: Grace Kiuna Grace Kiw a secretary at the Minishy of Trade lost her right eye mtained cUs on her face. Afier the firsf surgety at Kenyatta National Hospital, her rigk ey could blurry see and she had completely lost sight on the leji eye. She hadfiequem heodoches and her right eye wvls shrinking. This dected my appearance and I lost my confiince, for example I had to mn any time I crossed rhe rood I nas frusbaled because I cdd mi even do some small house chores as pouring tea imo a cup wirhour spilling a lot. These me things I had alwqys considered almost automatic bur I reolised tky were dificulr to do" "plains Grace. Following various examinations, Germany doctors said the eye was inoperable and Grace has beneiited hm perfectly fitting eye prosthesis. She has gained her facial appeanure and balance back. Her kfl hand, which was also seriously injured, was operated again in Germany and is recovering well and she is now having physiotherapy. Grace has now resumed her Secretarial duties at the Ministry of Tmde. This is a grow ofjmtients thr wnt to Germav (November 1999) for opihalmoIogical treaiment. Case Study U: Henry Jimmy Koweru Jimmy is a 9-year-old boy, who was caught up in the bomb blast and sustained deep cuts on the forehead He is the only son of a blind divorced lady. Both mother and son were at the ground floor of w-operative house during the bh, and since the mother did not know what was happening, and was not abk to see the cuts on the boy's forehead she immediately left for Kisumu where the boy received initial treatment. He undenvent first stage recoastructive surgery and rmdenuen~ the second stage in July 1999. The young man has Rgained his appearance and contidence, seeing him at the AMREF offices renewed MAP'S determination of continuing with the senices to bomb blast survivors. 5.2 Referal System The project has put in place a system of evaluating the survivors and referring them to doctors and the other survivor assistance prognumws as deemed necessary. Foms have been designed for the referrals to doctors and facilities, which the doctors fill and kmg back to the phannacy at AMREF. Although a kw of the survivors find the ~fenal process cumbersome, many found it a necessary evil given the bad experiences MAP bas bad in the past. However, the referral system still requires some improvement because a few of the referrals sent to the doctors are often vague, e.g. iphysiotherapy" withDut any additional information by the referring person 5.3 Collaboration with the Prirvrte and Public Sectors MAP has successllly collaborated with the doctors and private hospitais/ciinics and other kakb provision centres Ahhough this process lms been rigomus involving several meetings and comultatiom, the health providers on board are pmvidii swiQs adequately and have made the survivor programme a priority. Tbe doctors identified are committed to the programme and have a bt of empathy for the survivors. The foundation bas also played an important facititative rok for the survivor assistance programmes, which is mgnised by the different partnm AMREF has also organised and facilitated two wrkshops on the Medical Assi Programme in March and June 2000, which involved the collaborators and dodots attending to the survivors' needs Presentations were made and the reports are avaifable for reference and follow-up. 5.4 Management of Medical Ailments This project is considered very helpful and successful as confirmed by all the survivors involved in this evaluation. Comments such as "ningek nimekujia" (I would be &ad) were made by many of the survivors. For the individual patients their ability to walk. smile, hear and see are testimonies of the success of MAP. For the project management statrand the doctors, progressively witnessing improved well being of the survivors is an indication of success. For the donor, the successful implementation of MAP was also attested to. 5.5 Recognition AMREF has gained recognition hm the survivors, their families and the nation at large as an NGO, which is focused on alleviating the suffering resuhing hm the bomb blast. Due to this recognition, the project management team has been involved in the national planning meetings on disaster resporse. AMREF is also in the process of its disaster response unit under the flagship of MAP'S manager. The evaluation team identified 5 main co~ts/challenges, namely, workload, wide range of medical ailments, survivors' mentality and dishonesty, retrenchment and bw economic status of the survivors, and Wing limitations. 6.1 Workload This programme has been very involving for the staff and the workload has surpassed the initial eltpectatiorrr The project targeted 600 survivors but this number has already doubled. If the current oldreach activities by the other collaborators are successhrl this number may increase drastiily. Although more members of staff have so far pined the team, the staff is still overwhelmed. For instance, the wumelbr cannot accommodate all the clients seeking help and yet more are asking to be seen by her. 6.2 Wide Range of Medrcal Ailments The programme is increasingly finding it difficult to divide the patients who have diva personalities and needs, into different parts That is, in terms of what codition is bomb￾related and what is not. There are also emerging health problem that were not foreseen initially. For instance, in one of the afternoon sessions during this eduahn hur women complained of wetting their beds at night but they had never told anybody on the programme about this because of shame and also in fear of being told that this condidion is not bomb-related. This is an issue that needs to be followed-up by the doctors attending to the survivors. 6.3 Survivors ' Men~aliy and Dishotwsr). The survivors have the tendency to be impatient. This may be a resuh of the initial special treatment they received immediately after the blast or due to the care and attention they have been accorded over time. They do not We waiting when they visit any of the health facilities, and for those survivors who were involved in the evaluation their main concern was "long waiting time". This puts pressure on the doctors and on the project staff who are trying to serve each of the patients as diligently and as quickly as possible. Some of the survivors are hanging onto the programme in hope for better things to come. ksurviv~rnotedthat:~Ihopctogda~e~~~~formysdfanddkeikby".Thisisa mentality that has created dependency and increase in number of people who are seekiug medical care. This fact was captured clearly when the survivors were asked how they will sustain their health when the programme period ends. Many responded: " I dl srrmly &", "you should go on for 5 yccvs". "Ask the Armriaus to give you morr moncp". Although many of the survivors are honest, a few dishonest individuals have managed to get money and services Wulently hm the project. This lmppened in 1999 when MAP lost thousands of Kenya Shillings in a pharmacy scam More recently, the project manager has discovered that some patients do not provide their NHIF numbers when admitted in hospital but claim the money later. This has led to some shifts in operation, such as the running of the pharmacy in AMREF which some of the survivors find cumbersome and time conmnhg. 6.4 Retrerichmenl and Low, kio-Economic Slams of /he Suni ' wrs The government is currently retrenching civil servants using criteria that are oot clear to most people. What is, however, certain is that the government would be milling to maintain a sickly person and retrench a productive one. This is a major problem hr the survivors who are often sick requiring many days off on sick leave or in search of treatment. There are fears that the gains made through counseUing may soon be lost whcn the survivors loose their jobs. A female survivor noted: "a dw not tmaer whalpom hd n8edvringcoYlLFCIling. whenIgohonuandmycLicLFareontof~andIhmK nodkingtoeat, Ishq~&gobackwhereIstortai" Some of the survivors were affected by the bomb Mast to such an extent that they could oot go back to their employment. Some of them were self-employed and as such they can m longer continue with their busii. The imminent withdrawal of MAP is wonying these survivors especially in view of the high costs of medical care in this country. Although MAP was well funded by USAID, the fimds are already exhausted due to the high demand and cost of medical care. Catering for over 1,200 clients instead of 600 and having to deal with new emergent he& problems has stretched the budget. This has resuhed in the suspension of some of the services, e.g. dental consultations and care. The limited funding has also forced AMREF to be sekctive in the problems to be bandled to the dismay of some of the survivors. One survivor said that: "you UU the nurse yoair probkmandshe~thtitbnothmbrelatcd ~bbopmblatIrvvrrhad before the &nubn. How does one tell the patient that may be she would have developed the problem even if she had not been involved in the bomb blast? Should the project cow all the problems? If it does so, where will the money come from? These are issues that the project management is currently grappling with 7.1 7he Project Document This project has 9 objectives most of which are not SMART which makes monitoring and evaluating complex There are no clear goals and some of tbe objectives are phrased as activities or strategies. For instance: "assist in coordination of efforts for ageocies working for bomb blast survivors projectsn and "provide medical assistance for babies born to mothers who were pregnant and were within the vicinity of the blast" are not meamable objectives. For an evaluation exercise, it becomes dicuh to assess the levels of achievements when objectives are phrased in this manner. The objectives hew no indicators of achievement and yet this is an important project that can provide very useful experiences and oppommities for research and for future interventions. 7.2 Ir$onnatioti Production mad Dissemimtion At the begig of AMREF's intervention immediately after the bomb blast, there was a weekly newsletter that was circulated to all the collaborators. This newsletter contained information on the survivor programmes and it was found useful by both the survivors and the service providers. The newsletter died a slow death and it was supposed to be replaced by a brochure. The project manager indicated that the brochure should be ready in October 2000 but this will be too late because this funding phase ends in June 2001. Information tlow is a problem in term of the feedback process. The doctors do not get feedback when they refer patients to other doctors or for rehabiiin AMREF and tbe other collaborators do not give feedback to each other unless there is a problem Most of the survivors int erviewed claimed ignorance regarding the range of services availaMe for them This was, however, blamed on the mentality of the survivors who decide to forget everything when asked and yet they know. In addition, survivors have a tendency not to tell one amther about the available services. A problem identified by the evaluators is the mode of communication adopted and its relevance to the survivors. For instance, in the bomb rebef office there is an announcement regarding "cost sharing". This announcement is in English and has been placed on the wall. The assumption here is that all the survivors can see and can read English The use of diverse modes of communicating targeting the different survivor capabilities is wcessary for this group. Although objeciive 7, 8 and 9 focus on the issue of docurnuratios very link of this has been done. It is understandable that the first year was used mainly for the provision of medical attention, however, this being a very important prnjact this process should have received equal attention This is aa opportunity for AMREF to document a rare happening scientifically. There is an indication that the process has started (through recruiting a data entry clerk and initiating a docton' discussion) but a lot more needs to be done to make sure that the information is collected, synthesised, documented and disseminated. AMREF has the dual responsibility of intervening directly on the survivors and co￾ordidq the entire survivor assistance programmes. The latter requires couslant communication with ADRA (KSB, KNAD, APDK and UDPK), AMANI cornstlling centre and Ernest and Young. This coordination has been mainly effected in having monthly join! meetings though which the various implementers she eltpRiences and their plans it has, bowever, not been easy for AMREF as the co-ordinator, to step in when things are clearly going wrong. There have also been differences in managema behween the organisatiom, which have been difficult to resolve. Survivors are managed differently and have in the past taken advantage of the diierent implementation pocesses. Sustainability is an issue of concern to AMREF management and this has been a point of contention with some of the organisations that have gone as far as picking patko~~ &om home and taking them kk. How do we sustain this when the funding comes to an ed? This is a crucial question that should be addressed. The survivor assistance programmes have a wealth of information that can be used to inform the rest of the world regarding the impact, repercussious and implicatiom of a bomb blast on the lives of individuals, communities and the nations at huge. The organisations involved in these programmes have not produced inforumtion for wider dissemination The coordinating organisation shouki facilitate this process if given the mandate to do so. The initial omyear has largely been used in intervening on the medical and socioeconomic needs of the survivors. However, this secood year should focus on consolidating the information and disseminating the same. The dodors involved on MAP have agreed to form a committee in charge of documentation and they requke support hrn all the survivors' assistame programmes They also require constant follow-up due to their busy schedules 7.5 Support Groups MAP initiated the concept of support groups as a way of emuraging the slaivors to accept their circwmtama and go on with their lives. Mothers of the silent victims were mobili and kilitated to establish a support group. This group is, however, in shambles because, according to one mother "a's Me an ad& club fov thaw who can gord to pcry 1300 and are in&dd in iwns". From the questionnaire data, it became evident that many of the respondents belong to other groups such as Churches. self-help and social welfare. It may be better for MAP to encourage and enhance the capacity of such groups rather than facilitate the creation of very specific non-sustainable groups 7.6 Srrnivors ' Discharge and Weaning Ofl The survivor programme is very expensive such that there is need for the programme implementem to establish a system of dischargii people who haw recovemi without causing any psychological damage. In addition, for those who stiU require help, they should be weaned off in order to abw them to go on with their lives becauz the programme might be causing false hope by continuing with medical assistance. This is a problem for all the survivor assistance programmes. Do ADRA, KSB. APDK, UDPK and KNAD have systems for discharging and weaning off patients? For organisatins such as KNAD, UDPK and KSB the survivors should be taken up in their regular semks for the disabled. The issue of sustainability has to be tackled by this project although it evokes bier feelings hm the survivors Some feel that the US government owes them a lot because it caused the blast and consequently thew suffering. MAP is fairly expensive and sustainability should, therefore, be viewed in terms of the survivors' health and the possibility of continuing with research activities. AMREF has proposed the introduction of a cost-sharing system starting October 2000. It should, however, be noted that AMREF being a non-profit making organisation may not have a system of collecting and dispensing such money. More thought needs to be put in this area so that the system does not become too involving and complicated for the already strained statf. Survivors who are ready for discharge are not a big problem. However, there are survivors (approximately 20 - 30%) who may require long-term follow-up and a system has to be put in place to ensure that their conditions do not deteriorate upon the withdrawal of the project. The proposal by the project manager to pay an insurance company a hunp some of money for the care of these patients for a longer period should be considered and suppotted. The process of deciding who among the patients sbould receive such assistance has to be done in conjunction with the doctors and the collaborators. Discussions held with the project staff identified areas where tbey need to be dewbped. Due to the fact the staff deals with a very special group, they need counselling skills. Although the counsellor had scheduled to give them these lessons, her tight schedule has not allowed her to do so. A system should be put in place for training the staff individually so as not to halt the provision of senices to the survivors. Some of the staff members who are not computer literate need to be trained (they noted their main constraint of attending such a course to be time which should be created). The staff dealing with programmatic issues requires training in research (data cobion, analysis and writing). The staff members also need training in report produdion so that even when the project manager is busy they can take over that responsibility or they can assist her. The senior pmject nurse requires training in project management, an area wk she has limited experience. . . Although KC0 management is expected to provide both technical and ' support to staff, this has been minimal. There is an overall need for KC0 to firilitate or co-ordinate documentation of information at the programme level This would benefit MAP because the project manager would receive the necessary technical supporl and push to collate the information and publisWdocument it. KC0 management should also be ready to support the staff in issues such as office space (which the project manager had to search for on her on) and other issues such as the fraud case that just finled out without anybody bei taken to count. 8. Conclusion This is a complex project whose implementation has been well planned and executed. lk processes put in place for serving the survivors are sound including the identification of the doctors and facilities in enntring that the survivors receive the best care available. The survivor identification process has been effective in limiting the number of people who would be tempted to cheat due to the project's benefits. Most of the survivors appreciate the project and are happy with the way the staff and the doctors address their needs. The project has had to deal with new emergent health problem that were not foresee aod large numbers of survivors than initially budgeted for (1200 instead of 600). This bas not only put pressure on the funds availed by USAID, it has also strained the staff members who often have limited time to e-ngage in their own staff and career development. The project staff members have, however, performed well and are working within the agreed timek with the donor. The co-ordination role that AMREF has been holding has not been well executed mainly due to the lack of a mandate and the concentration by the survivor assistance programmes in the tirst year on providing assistance. This collaboration should be utilised in documenting and publishing/disseminating the information being geaerated by these programmes. The coordinating organisation should, therefore. be given the madate to work with the implementers of the other programmes in coming up with research issues and processing the available and new data This would enlighten the programme implementers and the world at large on bombrelated issues. The issues and gaps identified by the evaluation team which include information low. research, documentation, sustainability and fiding should be looked at as the project draws to an end and as the project team makes its future pb The phase 11 proposal should also take on board some of the issues identified on the objectives in terms of clarity, speciality and measurability. There is need for the project team to come up with a logical hmework that would spell out the milestones and indicators of achievement. This is a very important document and having these gaps addressed will ensure tbat the project is weU documented and can be replicated in other situations and regions. Annexes Annex 1 Terns of Reference The evahratin team will carry out an assessment of the following activities during the mid-term evaluation exercise: I. study the project proposal; 2. Study the grant document; 3. Design a methodology to obtain feedback hm the survivors on des provided; 4. Assess the survivor registratin methods in the office; 5. Assess the referral systems to consultants and other service providers; 6. Visit at least ten (10) consultants to assess project activities, pro- quality of services offered and constraints; 7. Visit at least four (4) service providers (hospitals, X-ray departments and laboratories) to asses quality of the services provided to the survivors; 8. Visit other implementing NGOs (Kenya Red Cross, AMANI Counseli Center and ADRA) and assess the efforts made by AMREF co-ordination and collaboration aod also obtain feedback on provision of services offered to the survivors by the project; 9. Assess the documentation, record keeping and repofling systems; 10. Gather information hm survivors on services provided and improvement in hem 1 1. Assess the mental health component of the project and the impact it has on lhe physical and mental recovery of the survivors. Annex 2 ClinicianfFacility interview guidelines 1. Activities (No. of patients, mwlical problems and procedures) 2. Quality (Survivors, clinician facilities and referral) 4. View on MAP and suggestwns for improvernent/sustainabi~ (- of services) 5. Collaboration (MAP, Dodon etc) Annex 3 Collaborators' Interview 1.1 .In what areas do you collaborate with AMREF? 1.2 How do you view this collaboration? 1.3 How can it be improved? 1.4 Who are your other collaborators? 1.5 In what areas do you collaborate? 2.1 What kind of information have you been able to mllect and disseminate in relation to the bomb blast? 2.2 Whom have you sharedldisseminated the information to? 2.3 What modes of communication do you use in the information dissemination and networking? 2.4 How do you expect to use this information? 3.1 Have you carried out any operational research on the overall medical responses to the bomb blast and the impact on the nation? 3.2 If yes, what are the key resulting issues? 4.1 What are your achievements as per the planned activities? 4.2 Reasons for the achievements? 4.3 Are there any activities implemented which are not in your nmin operations? 4.4 If yes, which ones? 4.5 Have you fbiled to implement some planning activities? 4.6 If yes, what did you fail to achieve and for what reasons? 5.1 What lessons have your learnt during the implementation period? 5.2 What probknri/constraints are you encountering and how have you tried to overcome these? 5.3 What recommendations do you have for the survivors and programmes (sustainab'iity)? Annex 4 Guidelines for Survivors Indepth Interviews 1. When the client joined the medical assistance programme 2. The type of assistance she has received to date 3. View on the senices - AMREF - Doctors - Rehabilitation - Counseling 4. Proces, procedures and referrals 6. Impact of the project on their personal lives, family and others 7. How are you coping at home? 8. Suggestions for improvement and sustainability Annex 5 Questionnaire for Survivors This questionnaire is aimed at assisting us to evaluate AMREF medical assistance programme in order b be able to serve you better. Kindly answer aU questions honestly. I. Personal details 1.2 Sex: Male Female 1.3 Occupation: Secretary Teacher Clerk h4-W 2. Bomb Blast experience 2.1 Where were you during the bomb blast? - 2.2 How were you affected? 2.3 Did you receive immediate medical attention? Yes No 2.4 If Yes, Where? 2.5 If no, why? 3. Medical assistance programme 3.1 When did you pin the AMREF medical assistance programw? 3.2 What assistance have you received? (tick where appropriate) a) Doctors' examination and follow-up b) Reconstructive surgery c) Dental care d) Eye glasses e) Medication f) Operation g) Admissiotrs h) Counseling at Kenya Red Cross I Amani i) Cowling at AMREF 3.3 Have you received any other assistaoce? Yes No 3.3.1 If yes, what assistance? 3.3.2 If no, why? 3.4 Do you think this programme bas been helpful to you? Yes No 3.4.1 If yes, how? 3.4.2 If no, why? 3.5 a) Wkit is your view about AMREF staff in the medical assistance programme? c) What is your view about hospitals you are referred to by the medical assistaoce pwr-? d) What is your view about the Pharmacy services at AMREF? e) What is your view of the X-ray -nts? 3.7 Do you belong, to a support group? Yes No 3.7.1 if yes, which one(s) 3.7.2 If no, why? 3.8 What services do you think need to be improved? 3.9 How can this improvement be achieved?