1 CONCERN WORLDWIDE COMMUNITY HEALTH AND NUTRITION PROGRAM , MALANGE PROVINCE END EVALUATION REPORT MARCH, 2004 Prepared by: CONSAÚDE -LDA Public Health Specialist CHWs in the community – Malange 2 INDEX Page Summary 3 Introduction 4 Objectives of the Evaluation 7 Methodology 7 Results 8 Conclusions 13 Recommendations 13 3 SUMMARY The Concern Worldwide Program in Malange Province - Angola began in 1999 working in the areas of nutrition , health , micro enterprises and small infrastructure rehabilitation. Concern has been implementing a two-year, OFDA/USAID funded, community based health and nutrition program in Malange city since February 2002. The program is due to end on April 30th 2004. The purpose of the program was to achieve health and nutritional improvement through education and empowerment, with a special emphasis on poor and vulnerable communities. The current evaluation demonstrated that the Angolan Program has been successful in providing emergency nutrition feeding in an integrated manner which is financially accessible to users. Health promotion and nutrition monitoring activities using MUAC criteria’s are carried out on a “voluntary basis” by motivated teams which interact with the communities. 4 Partnerships between the Program and the state sector and local and International NGOs have been established and are flourishing. However this end evaluation occurs 9 months after the Nutritional centers were closed , the positive impact of the Program can be seen in the following indicators: - Increased health/nutritional knowledge amongst the population. - a high level of popularity of CONCERN Angola’s community based activities - favourable partnership and acceptance by MOH Malanje Among the strengths observed are the management and provision of services by Angolan personnel, and the community based approach to health promotion. Weaknesses include the difficulty of maintain CHW services according to the province demand, the project area limited to Malange municipality, and the frailty of the system for referral of seriously ill patients and certain inadequacies in the community based teams. It is felt that the rich experience gained by CONCERN during the period in question should be shared with the Ministry of Health and other interested partners. 5 EVALUATION REPORT ON THE CONCERN – COMMUNITY BASED HEALTH / NUTRITION EMERGENCY PREVENTION PROJECT – MALANGE - ANGOLA I - INTRODUCTION 1. Concern´s Operational History CONCERN WORLDWIDE is a International a Non-Governmental Organisation . Concern became operational in Malange - Angola in November 1993, working in the areas of nutrition, health, micro-enterprise and small infrastructure rehabilitation. They were the first of the international agencies to open in the city, but were closely followed by many other groups. At the time severe malnutrition was 19.8% (z-score) and global malnutrition 34.4% (z-score), in the under five age group. Concern's response was to open 8 therapeutic feeding centers. These programs were closed by 1998 due to general condition improvements, and Concern withdrew from Malange to concentrate on other areas of Angola. In 1999, following a nutritional survey, the Ministry of Health and other NGOs requested that Concern return to Malange to address the deteriorated situation. At this time the global malnutrition rate was recorded at 31.8%, and severe at 15.2%. Food security and nutritional status had deteriorated drastically due to the escalation of war. As security access was regained in August 1999, Concern returned to evaluate the situation and re-establish emergency nutrition feeding, an intervention that began in early September. The nutrition situation has since then improved, as well as the general security, even though it remained very fragile until early 2003. Different groups have worked in the area of nutrition in Malanje. In the city, many groups have supported MINSA in the hospital including Concern, GVC and MSF-H who took it over and provided a 40-bedded therapeutic feeding unit, for children only. World Vision's therapeutic center in Culomuxito was to be handed over to MINSA in 2001. It catered for both adults and children and frequently had beneficiaries from Malanje city transferred there for care, as the only adult facility. MSF-H have run a therapeutic center in Cangandala algo, which too caters for adults and children. 6 A wet supplementary center was run by Concern until February 2001. Concern ran the only supplementary dry ration center in Malange until June of 2003, catering for the City´s population. The food, supplied by WFP was given to targeted beneficiary groups within specific criterion. World Vision, OIKOS and ADRA-Angola, have been the biggest implementing partners for WFP, to distribute general food ration. WFP also has had many different food for work projects, implemented through various different partners. In Lombe, the only targeted food distribution was done by Concern, who distributed a dry supplementary ration, to the moderately malnourished children and to malnourished pregnant and lactating woman, as in Malanje. 2. Program Background Concern has been implementing a two-year, OFDA/USAID funded, community based health and nutrition program in Malanje city since February 2002. The program is due to end on April 30th 2004. This program was officially due to commence on the 1th of February 2002, but due to staffing Problems did not commence until the 1st of November of the same year; OFDA accepted this as a no cost extension. A further No cost extension was granted from November 2003 to finally end the program on the 30th of April 2004. This gives a total project time of 27 months. The first 6 months of the actual project time was spent hiring the National team, continuing the Supplementary feeding activities and commencing the project activities. A base line study was also carried out, this formed the base for the log frame used for the project, which was reviewed throughout the project timeframe. In June of 2003 the Nutritional centers were closed due to the improved nutritional status of the population. A KAP study and nutritional surveys have also been conducted during the project time period for monitoring and evaluation. 7 The purpose of the program was to achieve health and nutritional improvement through education and empowerment, with a special emphasis on poor and vulnerable communities. The program's intended outputs were: 1. Improved capacity of the MoH in Malange to support and develop the work of their CHWs (Community Health Workers) at a satisfactory professional working level. 2. Revitalised and improved capacity of community health workers, according to the Angola MoH strategic 3. Continued delivery of curative nutrition care for malnourished children in Malanje and newly accessible areas, subject to assessments. 4. Increased health/nutritional knowledge amongst the population through participatory and practical health/nutritional education. 5. Improved co-ordination of community based health assistance provided to the community. 6. Strengthened nutritional/food security surveillance system through a permanent out reach Team. Although the main objective was the provision of information the area of nutrition / health, in Angola extra capacity was developed for the provision of integrated health care, covering malaria prevention through mosquito nets distribution, “clean campaign” promotions and condoms distribution. While serving the population as a whole, CONCERN gives priority to the most disadvantaged groups, such as displaced people, low income groups and the needy. The provision of knowledge to the population, increasing the capacity and capability of communities to prevent diseases and malnutrition is one of the strategies used to implement the project so that it can be both accessible and self-sustainable. This report gives the results of the evaluation carried out, in line with the terms of reference drawn up by CONCERN WORLDWIDE. 8 II - OBJECTIVES FOR THE PARTICIPATORY EVALUATION: ™ To assess progress towards the purpose and identify specific achievements. ™ To examine the effectiveness of implementation against the planned outputs, including an appraisal of the methods and approaches used. ™ To assess the overall impact of activities linked to each output, measured according to the indicators in the log- frame. ™ To assess prospects for the sustainability of project impact ™ To assess the effectiveness of Concern interventions, staff, management and technical ™ To assess the program's efficiency (Cost-effectiveness/value for money), and expenditure patterns as against original budget. ™ To draw out the lessons learned to feed into future work in the area, and to contribute to Concern' s organisational development. ™ To identify the strengths and weaknesses of the Angolan Program and make relevant recommendations III – METHODOLOGY USED - Review of existing documentation, including reports , KAP and Nutritional surveys and statistical information - 3 days visit to Malange and Lombe Municipality to do a qualitative assessment : - Interviews with center staff, local Concern staff, - Interviews local government officials ( provincial health director , municipalities administrator, MoH Nutritional center supervisor ) - Interviews with local partners ( PAM , OCHA) - Interviews with male and female community members, water committees, M&E committees, extension workers, – focus group in Katepa , Kanambua , Kangambo 4 , Vila Matilde and Campo da Aviação . - Focus group discussion on health education- CHW, CHV ( Community health volunteers) - Visits to oldest center – Escola Amilcar Cabral in Malange 9 IV - RESULTS a) Relevance The activities are in accordance with the priorities of the Ministry of Health and the concerns of the Malange community. They are as follows: ™ Trained 38 Community health workers in priority issues using the National Curriculum. ™ Worked closely with the counterpart in Malange MoH. ™ Supervise and co-ordinate the health activities in the community. ™ Provide supplementary feeding program for malnourished children through Feeding program ™ Monitoring and surveillance of the health/nutrition situation. ™ Preventative care. ™ Promote kitchen gardens by distributing vegetable seeds to beneficiaries in the feeding program and to vulnerable families within the community. 10 ™ Income generating activities for the CHWs by distribution of agricultural kits and tree seedlings CHWs and their material distributed by Concern Finding: The program is relevant and meets the population’s needs in terms of nutrition/primary health care. 11 b) Accessibility The evaluation of the accessibility of services found that: - The CHW activities (health and nutritional education and food security surveillance) is only carried out in 11 bairros of Malange city and Lombe. - One distribution dry supplementary ration center in Malange Municipality and one in Lombe - The CHWs works in a daily basis. Materials used at the feeding centers Finding: The Program is perfectly accessible to the population in the targeted areas, regardless of the individual’s social category, area or financial position. 12 c) Health Promotion This activity was conducted by 38 CHWs and 5 volunteers (outreach workers) for Nutritional screening through MUAC. The evaluation identified a high degree of motivation, a good level of awareness and a basic knowledge of health education. The topics about which there was most awareness and knowledge coincided with the main public health problems in Malange, particularly: - hygiene and sanitation associated with malaria - good nutrition - breast feeding The activities of the teams reach the most vulnerable groups in society and those most at risk. They work with families in groups and from house to house. The groups have made notable contributions to Ministry of Health vaccination campaigns. The use of educational charts and the approach of group presentations to the community are well received by the population. 13 Finding: This activity could be improved by strengthening the knowledge and skills of the volunteers and by increased production of more diverse educational materials targeting Malange community needs and language. d) Cost-Effectiveness The following aspects are the most significant in this regard: - The rapid evaluations done by the humanitarian community in the past are now conducted by MoH staff who have been trained by Concern - The Community Health Volunteers team is made up of thirty eight members each from the community . They work with the local leaders support. - The teams and the community were more in control of planning their own day and how to best find and address the needs of their communities. - The CHW are able to monitor the situation using monthly MUAC screenings and to refer children to MOH nutritional centers for care. - The practicality of the information given has been noted to be very useful in making health care accessible to all - The materials and equipment used at office are appropriate for the location and pre-established objectives (low cost and long working life). - Health promotion activities do not involve onerous modalities. - The salaries paid to National staff are above the national standard and compatible with the hours worked. Finding: The integration of the program in the community is effective. 14 e) Coherence with Sectoral Objectives and Complementarities As stated earlier, the activities carried out are in accordance with the priorities of the Ministry of Health. In the area of community based health promotion, CONCERN has distinguished itself among foreign NGOs by the multiple themes included in its activities. Its participation in Provincial Committee of Nutrition, joint ventures with WFP, MSF-H, ADRA and an anti-malarial treated mosquito-nets project in partnership with UNICEF are favourable evidence of coherence and complementarities. Finding: The Program is consistent with sectoral objectives and operates as a unit which effectively complements the provincial health network. f) Organisational Development Strong Points - The Program is integrated and relevant - Health promotion initiatives are well accepted by the community. - CHW and CHV receive the support of their own traditional leaders and from their own communities. - The principle of voluntarism and the bonus payment system for community health promoters are fundamental in terms of mobilisation, motivation and continuous development. - Co-ordination of the program by a national team improves collaboration and helps to integrate the Program. - Coherence with sectoral objectives and strong linkages with the Ministry of Health and other institutions. Weak Points - Small health network in terms of coverage. - Absence of Program Director during 1 year during the project time The local Concern staff 15 - Handling of patients in terms of transport and the quality of the referrals network (highlighted by focus group discussion). - Inadequate academic training of activists despite their level of school education. - Insufficient educational material in national / local languages. g) Training The basic training of the CHWs was appropriate. They participated in almost all Ministry of Health training activities in the area of nutrition. However, a fuller integration in training activities promoted by the Ministry of Health in other national programs would be desirable. 16 V - CONCLUSION Concern has participated in conjunction with other international NGOs and MOH Malange. In this way Concern has assisted in reducing the level of malnutrition, along with other influencing factors such as cessation of conflict activity, increased access with road and land. Concern Program has developed significantly from an organisational perspective and in service provision. The system of training CHW is exemplary in terms of primary health care in an urban setting. It is currently self￾sustainable and well integrated at community and institutional levels. Although there are only 38 CHW´s , they have achieved significant coverage and operate efficiently. There is scope to expand and improve community based health promotion activities. The actual Program’s National Co-ordinator showed an awareness of reality and demonstrated skill and competence in management, organisation, the mobilisation of resources and integration with the National Health System. VI – RECOMMENDATIONS The results demonstrated by the Program are positive: Given the experience gained and skills developed in the areas of organisation and sustainability 1- As the Program fits within the priorities of the Ministry of Health in its quest for valid strategies in this area, it is recommended that it should be continued and expanded to all Province , presented to senior officials of the Ministry of Health and a workshop should be held at a later date with other NGOs in order to exchange experiences. Beneficiários- Malange