International Eye Foundation
Nsanje District Health Management Team
IMPROVED CHILD SURVIVAL IN NSANJE 
DISTRICT, MALAWI THROUGH COMMUNITY 
BASED INTERVENTIONS AND STRENGHTENING 
OF THE HEALTH DELIVERY INFRASTRUCTURE
Mid-Term Evaluation, October 2004
Implementing a XVIII Child Survival Project
October 2002 - September 2006
Cooperative Agreement HFP-A-00-02-00027-00
Presented to:
United States Agency for International 
Child Survival Grants Program
Document prepared by:
Renee Charleston, Team Leader/External Evaluator
Contacts:
John M. Barrows, Director of Programs
International Eye Foundation
10801 Connecticut Avenue, Kensington, MD 20895
Tel (240) 290-0263; Fax (240) 290-0269;
jjbarrows@iefusa.org
Geoffrey Ezepue, MD, Country Director
International Eye Foundation, Malawi
P.O. Box 2273, Blantyre, Malawi
ief@Malawi.net
K.J. Chikande
District Health Officer
Ministry of Health and Population
P.O. Box 30, Nsanje, Malawi
November 11, 2004
i
Acknowledgements
The following persons were involved in writing and editing the Mid-term Evaluation report:
Principal author
Renee Charleston, Team Leader/External Evaluator
Contributors to writing and editing
John M. Barrows, Director of Programs, International Eye Foundation, USA
Geoffrey Ezepue, MD, Country Director, International Eye Foundation, Blantyre, Malawi
Other persons contributing to the Mid-term Evaluation report and whom must be
acknowledged for their devotion and tremendously hard work evident in the results
achieved thus far include - 
IEF/Nsanje
Ms. Edna Tembo, Project Manager and her staff Frank Chola, George Mekiseni, Elton
Chiumia, Henry Dzuwalatsoka, and Hopson Ntenthaonga.
District Health Management Team
K.J. Chikande, District Health Officer, Ministry of Health and Population, Nsanje, Malawi
and his staff Kennedy Chikonde, Kennedy Ndau, Kalima Chikafa, Dikilani Chadza, Wasili
Mathumula, Izak Phiri, George Mlolo, Kalima Chikafa, Mr. Kandulu, M. Sosono, and all Zone
Supervisors 
The IEF would also like to acknowledge and thank Peter Benson, World Vision
International, Hellen Phallaza, Africare, William Allen, Mr. Malunga, and Hans Richter,
Christian Hospital Association of Malawi, for their excellent contributions and
commitments to child survival .
And special thanks go to the community leaders, mothers and children of Nsanje District.
ii
Table of Contents
A. SUMMARY .............................................................................................................................. 1
B. PROGRESS MADE TOWARD ACHIEVEMENT OF OBJECTIVES ............................ 4
1. TECHNICAL APPROACH........................................................................................................ 4
a. Overview............................................................................................................................. 4
b. Progress report by intervention area................................................................................ 12
c. New Approaches............................................................................................................... 21
2. CROSS-CUTTING APPROACHES .............................................................................................. 22
a. Community Mobilization.................................................................................................. 22
b. IEC and Behavior Change Interventions......................................................................... 23
c. Capacity Building Approach............................................................................................ 24
d. Sustainability Strategy ...................................................................................................... 31
C. PROGRAM MANAGEMENT ............................................................................................. 33
1. PLANNING.............................................................................................................................. 33
2. STAFF TRAINING.................................................................................................................... 33
3. SUPERVISION OF PROGRAM STAFF ......................................................................................... 34
4. HUMAN RESOURCES AND STAFF MANAGEMENT.................................................................... 34
5. FINANCIAL MANAGEMENT..................................................................................................... 35
6. LOGISTICS.............................................................................................................................. 35
7. INFORMATION MANAGEMENT................................................................................................ 36
8. TECHNICAL AND ADMINISTRATIVE SUPPORT......................................................................... 37
D. CONCLUSIONS AND RECOMMENDATIONS............................................................... 38
E. RESULTS HIGHLIGHT....................................................................................................... 43
F. ACTION PLAN ...................................................................................................................... 44
G. ATTACHMENTS ................................................................................................................. 45
ATTACHMENTS 
A. Baseline information from the DIP
B. Evaluation Team members and their titles
C. Evaluation Assessment Methodology
D. List of persons interviewed and contacted
E. Results of the Evaluation 
G. Project Data Sheet form
iii
ACRONYMS
ARV Anti Retro Viral Drugs
BCC Behavior Change Communication
BCI Behavior Change Intervention
CHAM Christian Hospitals Association of Malawi
CSMC Child Survival Management Committee
DHMT District Health Management Team
DHO District Health Officer
DOSA Discussion Oriented Self Assessment
DRF Drug Revolving Fund
DTC District Technical Committee
EPI Expanded Program for Immunization 
GMV Growth Monitoring Volunteer
HF Health Facility 
HH/C IMCI Household and Community Integrated Management of Childhood Illness
HIV/AIDS Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome
HMIS Health Management Information System
HSA Health Surveillance Assistant
IEC Information, Education, and Communication
IEF International Eye Foundation
IMCI Integrated Management of Childhood Illness
IPT Intermittent Presumptive Treatment
IR Intermediate Result
ITN Insecticide Treated Net
KPC Knowledge, Practice, Coverage Survey
LQAS Lot Quality Assurance Sampling 
MCH Maternal Child Health
MK Malawian Kwacha (monetary unit of Malawi)
MOHP Ministry of Health and Population
NDH Nsanje District Hospital
OCAT Organizational Capacity Assessment Tool
ORS Oral Rehydration Solution
ORT Oral Rehydration Therapy
PD Hearth Positive Deviant Hearth Community Nutrition Methodology
PMTCT Prevention of Mother-to-Child Transmission (of HIV/AIDS)
PSI Population Services International 
SO Strategic Objective
SP Sulphadoxine-pyrimethamine (Fansidar)
TBA Traditional Birth Attendant
U-5 Under Five
VCT Voluntary Counseling and Testing
VHC Village Health Committee
Mid-Term Evaluation
IEF/DHMT Nsanje Malawi
C.A.: No: HFP-A-00-02-00027-00 Page 1
A. SUMMARY
The partnership of International Eye Foundation (IEF) and the Nsanje District Health
Management Team (DHMT) is implementing a four year (2002-2006) Child Survival Project
in the Nsanje District in southern Malawi. The project includes the technical interventions
of Pneumonia Case Management 20%, Malaria 20%, Nutrition 20%, HIV/Aids 20%, EPI 5%,
and Diarrhea Case Management 15%. The project’s Strategic Objective is: Families and
caretakers with young children increase the practice of healthy behaviors and seek
medical care from quality sources. This objective will be achieved through four
Intermediate Results: 
IR1. District Organizational Effectiveness and Management Support for Quality Child
Care Strengthened.
IR2. Health Provider Skills in Prevention and Management of Childhood Illness Improved. 
IR3. Availability and Accessibility to Quality Preventative and Curative Health Services
Increased. 
IR4. Community Participation, Ownership, and Demand for Health Services Increased. 
The implementation of facility based and household/community IMCI through the training
of health providers and community volunteers and a system of supportive supervision has
been the major thrust of the CSP during the first two years. The IEF/DHMT team is
implementing a good quality project in compliance with the DIP and work plan. Some
activities have been delayed due to staff shortages at both IEF and the MOHP but there
is no evidence that the project is not capable of completing all major activities before the
end of the grant period. The strong points of the CSP at the mid point are:
™ Population coverage-increased well beyond original targets. 
™ Development of village health committees is a good step towards improving community
structure for sustainability.
™ The CSP has contributed to a wider national movement to distribute bednets to make a
significant impact on prevalence of malaria.
™ Introduction of concepts and tools for supportive supervision has changed the
paradigm of supervision as a policing action.
™ The analysis and improvement of operational systems is a sustainable way to use
resources more effectively and efficiently.
Mid-Term Evaluation
IEF/DHMT Nsanje Malawi
C.A.: No: HFP-A-00-02-00027-00 Page 2
The focus during the next two years should be on:
¾ Continued focus on systems improvement.
¾ Implementation of Quality Assurance tools for systems analysis and improving quality
of care at HFs.
¾ Investigation of needs for IEC and BCI activities in order to have the most impact in
the district, focusing on improving nutrition behaviors.
¾ Increased emphasis on HIV/AIDS activities.
¾ Implementation of the cost sharing activities of cost ward and spectacle shop.
All stakeholders interviewed during the MTE reported an increased demand for services.
The increased demand places increased pressure on the MOHP system due to lack of
staff. The solution to this problem is outside the scope of this project, but has been the
most important barrier to implementation during the two years of the CSP and will
continue to be the primary barrier in the future. 
The CSP emphasizes capacity building through strengthening the quality of district
programming (primarily IMCI); assisting the DHMT to improve planning skills, establish
more effective supervision and monitoring systems, and strengthen their ability to manage
small funds achieved through cost recovery mechanisms. As part of the sustainability
strategy, the CSP is introducing two concepts for cost sharing; a cost ward within the
Nsanje District Hospital, and an eye glasses shop that offer an innovative way to bring
additional funds into the hospital.
The 14-member Mid-Term Evaluation Team developed recommendations for improvement.
As the recommendations came from the project implementers, there is a high level of
“buy-in” and commitment to putting them into action for improving the CSP. A detailed
action plan will be written by the principal implementers during November, but work has
already started on finding ways to improve project implementation. The following
represent the priority recommendations for the DHMT and IEF:
1. Strengthen and implement a comprehensive behavior change communication strategy on
HIV/AIDS including VCT and PMTCT.
2. Conduct a review of the planned need for ITNs and of the management system of the
sale of ITNs in communities and HFs.
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C.A.: No: HFP-A-00-02-00027-00 Page 3
3. Develop a system for sharing information with the villages using maps and/or
information recorded in poster form at the village level to stimulate action planning 
4. Liaise with BCI Coordinator to identify, procure and distribute IEC materials for use
by CHVs, HSAs, and Health Facilities. 
5. Develop and implement a comprehensive IEC/BCI plan for the CSP, including PD
Hearth, the BEHAVE Framework, or other appropriate methodologies.
6. Initiate a mechanism for information sharing and to enhance coordination between
principal organizations in the district; NGOs, DHMT, and CHAM. 
7. Monthly meetings between IEF and DHMT should be planned on a set day and time
through out the year for planning and monitoring project activities.
8. Introduce Quality Assurance strategies and tools to conduct systems analysis to
determine what the root problems are in each system; what aspects are working well,
and how systems can be improved to be more efficient and effective.
9. Conduct a review of the HIMS to verify the quality of data being collected and
processed, and encourage the use of data for decision making at all levels. 
Mid-Term Evaluation
IEF/DHMT Nsanje Malawi
C.A.: No: HFP-A-00-02-00027-00 Page 4
B. PROGRESS MADE TOWARD ACHIEVEMENT OF OBJECTIVES
1. Technical Approach
a. Overview
International Eye Foundation (IEF) and the Nsanje District Health Management Team
(DHMT) are in the process of implementing a four-year (2002-2006) Child Survival
Project (CSP) in the Nsanje District in southern Malawi. The CSP has reached the mid
point of implementation, the motive for conducting this Mid Term Evaluation (MTE). 
The CSP works with the Ministry of Health and Population (MOHP) and the Christian
Hospitals Association of Malawi (CHAM) health infrastructure throughout the district,
which consists of the Nsanje District Hospital, one mission hospital, 11 health centers and
eight health posts providing basic services. Nsanje District is one of the neediest
districts in Malawi.
The original population planned for the project was 194,481, which included 33,000
children under five and 45,000 women of reproductive age in 450 villages in the district.
The project has far exceeded those figures. The population data used in the Detailed
Implementation Plan (DIP) and proposal and officially by the MOHP is based on 1998
census figures, the last available official data. In a census carried out in 2003 by Health
Surveillance Assistants (HSAs) the actual population was estimated to be 237,000. While
this is not an official census, it does show a probable population growth in the area. There
has been a large inward migration (both temporary and permanent) from Mozambique due
to civil strife and lack of development in Mozambique. There are no official figures on the
number of Mozambicans who are accessing health services within Malawi. The project is
actually working in 513 villages with a corresponding increase in the number of Community
Health Volunteers (CHVs) compared with the original estimates.
The partnership between IEF and the DHMT is responsible for the overall implementation
of the CSP. The Child Survival Management Committee (CSMC) was created during the
first year of the project to strengthen coordination. The team is comprised of MOHP
personnel, the DHMT, IEF Technical Advisors and Program Manager, the IEF Country
Director, the Director of Planning from the District Assembly, and a representative of
CHAM. The CSMC is responsible for project planning, monitoring and evaluation,
supervision, providing technical support, reviewing the technical content, and financial
monitoring, and for ensuring that project implementation follows the overall plan as
outlined in the Detailed Implementation Plan (DIP). The group meets on a quarterly basis
to analyze progress, identify barriers, and problem solving. The District Health Officer
chairs the committee, and the CSP Project Manager serves as the Committee Secretary. 
Mid-Term Evaluation
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C.A.: No: HFP-A-00-02-00027-00 Page 5
Based on both quantitative and qualitative research in the district, the CSP decided to
divide their efforts in improving child health by working in the following technical
interventions: Pneumonia Case Management 20%, Malaria 20%, Nutrition 20%, HIV/AIDS
20%, Expanded Program for Immunizations 5%, and Diarrhea Case Management 15%. All
interventions are included under the umbrella strategy of IMCI (Integrated Management
of Childhood Illnesses).
The overall goal of CSP is to reduce infant and child mortality in the district. The
project’s Strategic Objective (SO) is: Families and caretakers with young children
increase the practice of healthy behaviors and seek medical care from quality sources. To
achieve this, the project outlined the following Intermediate Results (IR) in the DIP: 
IR1. District Organizational Effectiveness and Management Support for Quality Child
Care Strengthened. This will be achieved by strengthening planning, training,
supervision, and evaluation skills; increasing inter-sectoral coordination, and
introducing new financial sustainability strategies.
IR2. Health Provider Skills in Prevention and Management of Childhood Illness Improved.
This will be achieved by increasing inter-sectoral understanding of
Household/Community IMCI (HH/C IMCI), increasing the skills of health facility
providers at all levels, and increasing the skills of community volunteers. 
IR3. Availability and Accessibility to Quality Preventative and Curative Health Services
Increased. This will be achieved by strengthening under five clinic services;
increasing the availability to malaria Insecticide Treated Nets (ITN) and
Intermittent Presumptive Treatment (IPT) services, improving nutrition by
adopting the Hearth strategy, and expanding HIV/AIDS prevention, testing and
counseling services.
IR4. Community Participation, Ownership, and Demand for Health Services Increased.
This will be achieved by improving community mobilization and support to HSAs and
CHVs in prevention and promotion activities; increasing access to appropriate and
quality care and information by trained CHVs, and improving district communication
skills using the BEHAVE framework.
The main strategies of the CSP remain as originally described in the DIP. Some activities
that were scheduled for the first two years have been delayed, but there is no evidence
that the project is not capable of completing all major activities before the end of the
grant period. 
Mid-Term Evaluation
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C.A.: No: HFP-A-00-02-00027-00 Page 6
The following tables summarizes activities completed during the first two years and
activities which need to be completed during the second half of the project. Results for
the SO and each IR based on Monitoring and Evaluation activities are also included. While
many of the changes comparing baseline to MTE levels are not statistically significant,
they represent a trend towards improvement in most indicators. 
SO: Families and Caretakers with Children Under Five Years of Age Practice
Healthy Behavior and Seek Care From Quality Providers
Performance Indicator (%) Baseline
KPC
Target
MTE LQAS MTE KPC
1 % of children 12-23m who are fully immunized
before their first birthday
63
CI: 55-71 75 72 59
CI: 51-67
2 % of children 12-23m who receives measles
vaccine before 1st birthday
70
CI: 62-77 80 73 64
CI: 57–71
3 % of children 6-23m who received VAC within
6 months of the survey date
89
CI: 84-93 90 67 77.5
CI: 72-82
4 % of caretakers who treat children 0-23 months
with ORT during their last diarrhea episode
55
CI: 47-64 65 90 85
CI: 79–91
5 % of children 0-23m who slept under an ITN the
night prior to the survey
17
CI: 13-21 35 53 52
CI: 46-58
6 % of women who took SP to prevent malaria
during her last pregnancy
75
CI: 70-80 80 88 72
CI: 67–77
7
% of caretakers who took children 0-23 months
to health workers for diarrhea, fever, or difficult
breathing after recognizing illness symptoms
84
CI: 72-92 90 78 90
CI: 82–98
8 % of children 0-5 months who are exclusively
breastfed
55
CL: 44-66 60 - 66
CI: 55-77
9
% of children 6-23m who consumed the same
amount of foods during most recent episode of
reported illness
49
CI: 50-58 60 68 52
CI: 43–61
10
% of children 0-23 months who are underweight
(-2SD from median WFA WHO/NCHS
reference)
39.5
CI: 33-45 35 - -
11 % of household that possess a bed net 29
CI: 24-34 - 59 64
CI: 59-69
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C.A.: No: HFP-A-00-02-00027-00 Page 7
IR1. Strengthened Organizational Effectiveness and Health Management Systems
Major Activities Completed To Be Completed
Management Functions
• IEF established the project office within
the district and contracted appropriate staff 
Strengthen Planning
• Supervision and Planning workshop for
CSMC 
• DIP, Baseline and MTE surveys
• OCAT DHMT organizational assessment
• Zones established and functioning
Strengthen Systems
• Introduced LQAS as monitoring tool
• Established training and supervision
systems
• Supervision teams functional
• Provided TA for financial system
Strengthen Sustainability
• Introduced concepts of cost sharing
activities
Improve Inter-Sector Coordination
• Conducted DTC and District Assembly
orientation
• Conducted CSMC coordination meetings
and annual planning session
Management Functions
• Maintain adequate staff levels 
Strengthen Planning
• Conduct LQAS and final survey
• Develop and review District Organizational
strengthening plan
• Repeat OCAT DHMT organizational
assessment before EOP evaluation
• Assess district Zone system
Strengthen Systems
• Introduce concepts of Quality Assurance
and systems analysis 
• Use bi-annual LQAS monitoring survey 
• Conduct analysis of logistics & inventory
system
• Improve use of information
Strengthen Sustainability
• Finalize Cost ward and spectacle shop 
Improve Inter-Sector Coordination
• Continue to improve coordination within
the district, particularly with other NGOs 
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C.A.: No: HFP-A-00-02-00027-00 Page 8
IR1. Strengthened Organizational Effectiveness and Health Management Systems
Performance Indicator Base
line
Target
MTE LQAS
IMCI
Super
Aug 04
Qtrly
Super
Aug 04
MTE
1
% of facilities that have a
stock out of essential medical
supplies (e.g., ORS, SP,
Cotrimoxazol)
- 8 - 21 21 1/5 HF
(20%)
2
% of facilities by zone that
have received at least 1
supervisory visit using
observation of health worker
practice in the 3 months prior
to the facility assessment
67 85 - 92 100
100%
received but
not specific
observation
3
% of HSAs by zone received
at least 1 supervisory visit
using observation of
performance and feedback in
3m before assessment
89 90 61 - -
100%
received but
not specific
observation
4
% of VHC/GMVs by zone that
have received at least 1
supervisory visit by HSA
using a checklist in the 3
months prior to the facility
assessment
- 60 64 - -
5/7 received
but 1/7
(14%) with
checklist
5
% of VHCs that are
established, trained that meet
at least 1 time per quarter as
verified in village records
70 80 37 - -
9/12 met
No village
records
6 % of CSP annual work plan
activities completed on time - 85 - - - 76%
completed
7
% increase in self-earned
revenue from hospital
sustainability activity per year
0 5 - - - 0%
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C.A.: No: HFP-A-00-02-00027-00 Page 9
IR2. Improved Prevention and Management of Childhood Illness.
Major Activities Completed To Be Completed
Establish HH/C-IMCI Framework 
• Health staff in 13 Health facilities trained and
implementing IMCI
• Established supervision system for IMCI
• Training held in adult learning techniques.
• Trained CHVs in HH/C-IMCI 
• Conducted Orientation for HH/C-IMCI for
Facility support staff, HSAs, Traditional Healers,
Drug Vendors
• Conducted Training of Trainers for IMCI 
Establish HH/C-IMCI Framework
• Focus on Quality Improvement
• Continue supporting Zone training
IR2. Improved Prevention and Management of Childhood Illness
Performance Indicator Base
line
Target
MTE
IMCI 
Super
Apr 04
IMCI
Super
Jun 04
IMCI 
Super
Aug 04
1
% of sick children 0-5 years health cards
were checked for immunization, VA
status and growth monitoring.
- 85 100 71 100
2
% of sick children 0-5 years who present
with fever and are correctly assessed,
counseled & treated for febrile
illness/malaria
- 80 92 44 96
3
% of sick children 0-5 years who present
with difficulty breathing and or cough
and are correctly assessed, counseled &
treated for ARI
- 70 100 17 100
4
% of sick children 0-5 years who present
with diarrhea and are correctly assessed,
counseled & treated for diarrhea
- 70 23 - 86
5
% of HSAs demonstrate competence in
EPI vaccination and GM protocols at
time of assessment
- 60 - - -
6
% of HSAs demonstrate competence in
counseling VHC & GMV in promotion
of home care practices (ORT, malaria,
ARI, W & S) at time of assessment
- 60 - - -
7
% of GMVs demonstrate competence in
counseling mothers and families in home
care practices (ORT, malaria, ARI, BF,
W & S) at time of assessment
- 65 - - -
8 % of sick children referred by GMVs
received attention by HF - 60 - - -
9 # of DRFs established & operational
according to the new strategy. - 20 - - -
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C.A.: No: HFP-A-00-02-00027-00 Page 10
IR3. Increased Availability & Accessibility to Quality Preventative & Curative Health Services
Major Activities Completed To Be Completed
Strengthen EPI/ VA/ DCM, ARI Services
• 22 static & mobile U5 outreach clinics providing
vaccine and VACs services in 6 Zones 
• Supported annual District immunization campaigns
and outbreaks
Malaria
• Technical exchange and training conducted.
• Conducted training for CHVs in ITN use
• 100 ITN committees providing ITNs in 6 Zones 
Pilot Drug Revolving Funds
• This intervention has not been implemented
Improve Nutrition Services
• Training conducted in PD/HEARTH including trial
PD Inquiry
• Identified community for pilot 
Improve HIV/AIDS Counseling - VCT
• VCT services available at district hospital, Trinity
Hospital and 1 Health Center
• Established communication with DHMT HIV/AIDS
Coordinator
Strengthen EPI/ VA/ DCM, ARI Services
• Continue strengthening logistics and referral systems
Malaria
• 350 ITN committees providing ITNs in 6 Zones 
Pilot Drug Revolving Funds
• Recommended to not continue with this intervention
Improve Nutrition Services
• Develop a district wide forum to establish an inter-sector
nutrition team
• Develop comprehensive plan for using IEC/BCI
strategies to improve nutritional status district wide
• Proceed with PD/HEARTH pilot
• Make informed decision to expand PD/HEARTH
Improve HIV/AIDS Counseling - VCT
• Improve HIV/AIDS Counseling - VCT
• Strengthen VCT at 3 centers
• Facilitate training of counselors and availability of
essential testing equipment
• Conduct formative research
• Document best practices 
IR3. Increased Availability & Accessibility to Quality Preventative & Curative Health Services
Performance Indicator Base
Line
Target
MTE LQAS
Qtrly
superv
Aug 04
MTE KPC
1 % health facility that provide daily
immunization services - 80 - 21 -
2 % of planned (17,000) ITNs sold* - 60 - - 18,000
distributed
3
% of planned persons tested and
counseled by NDH VCT unit in the 3
months prior to the assessment (600/yr)
- 50 - - Not
operational
4
% of mothers of children 0-23 months
who know at least 2 ways of reducing
the risk of HIV/AIDS
58
CI: 52-64 70 23 - 66
CI: 61–71
5
% scheduled Under 5 clinics (static and
mobile) conducted in the 12 months
prior to facility assessment**
80 90 - - TBD
* Data on the number of ITNs sold is not available.
** Data on the number of scheduled U5 clinics was not available.
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C.A.: No: HFP-A-00-02-00027-00 Page 11
IR4. Increased Community Participation & Demand for Preventative & Curative Services
Major Activities Completed To Be Completed
Improve Community Mobilization
• Community mobilization strategy implemented
• Conducted HH/C-IMCI for CHVs 
Improve Health Communication Strategy 
• Conducted assessment of MOH education
materials and education practices.
• Conducted BCI orientation meeting.
Improve Community Mobilization
• Establish village maps
• Strengthen VHCs understanding of role and
responsibilities for supporting CHVs. 
• Assess Zone implementation strategy
• Continue training and support of CHVs.
Improve Health Communication Strategy 
• Coordinate with BCI Coordinator to inventory
existing materials and approaches
• Develop comprehensive IEC/BCI strategy;
disseminate and implement
• Establish links with partner NGOs for sharing of
IEC materials
• Obtain technical assistance for IEC/BCI
• Implement PD Hearth and BEHAVE framework 
• Conduct BCI formative research
• Identify strategies to address priority
intervention’s target audience in child health
behaviors 
IR4. Increased Community Participation & Demand for Preventative & Curative Services
Performance Indicator Baseline
KPC
Target
MTE LQAS MTE
KPC
1 % of mothers with children 0-23 months able to
demonstrate correct use of ORS
52
CI: 46-58 70 6 71
CI: 66–76
2
% of mothers with children 0-23 months who
report hand washing with soap/ash before food
preparation or child feeding, after use of latrine
or cleaning after child
3
CI: 1-5 30 46 7
CI: 4–10
A Mid Term Evaluation was conducted during October 3 to 16, 2004 with a 14 person
evaluation team comprised of representatives from IEF Malawi, IEF Headquarters, MOHP
Nsanje District, Africare, and World Vision, and an external evaluator, principal author of
this report. The team visited 12 villages and interviewed mothers, Village Health
Committee (VHC) members, Breast Feeding Support Groups (BFSG), Growth Monitoring
Volunteers (GMVs) and HSAs. Five health facilities were also visited and health staff
interviewed. Additional interviews were held with DHMT and IEF staff, and a
representative from the District Assembly and USAID in Malawi. For detailed information
on the MTE methodology see Attachments B and C. A list of all persons contacted and
interviewed during the evaluation is included in Attachment D. Recommendations,
Mid-Term Evaluation
IEF/DHMT Nsanje Malawi
C.A.: No: HFP-A-00-02-00027-00 Page 12
developed primarily by the full evaluation team, are included throughout this report in bold
lettering and summarized in Section D. Details on the results of the evaluation (outputs
from the Analysis Workshop) are included in Attachment E.
b. Progress report by intervention area
Integrated Management of Childhood Illness (IMCI) 
The implementation of IMCI, both facility based and household and community (HH/C
IMCI) has been the major thrust of the CSP during the first two years of the project. All
project intervention areas are included in the IMCI strategy. The activities carried out
are generally as described in the DIP and in accordance with MOHP policy. The progress
made in this activity is impressive, with 309 people trained at the hospitals and (Health
Facilities) and 6,402 at the community level. 
In June 2003 a IMCI survey was conducted in 12 HFs to provide baseline information on
out patient services provided for children under 5 before district wide implementation of
the IMCI program for evaluating the impact of IMCI training. The most common reason
for clinic visits was malaria in 39% of the cases, followed by 31% for respiratory
infections. Three fourths of the mothers interviewed were not told the diagnosis of their
child’s illness and only 12% of the cases were assessed for danger signs.
Three trainings on facility based IMCI were organized for the district health staff. A
total of 53 personnel from health centers and hospitals participated in the eleven-day
training. IMCI trainers from other districts facilitated the training. The material used
during the training was the WHO/UNICEF/MOHP Malawi curriculum with Trainers Guide,
which provides a completed IMCI training with field practice. 
The following community members and staff received a three-day training in basic IMCI
messages:
• HSA 184
• Village Health Committee (VHC) 5,298 members in 513 villages
• Growth Monitoring Volunteers (GMV) 400
• Breast Feeding Support Groups (BFSG) 513
• Traditional Birth Attendants (TBAs) 173
• Traditional Healers 10
• Drug Vendors 8
• HF Support Staff 72
• Ministry of Agriculture Extension Workers 54
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Also 52 CSMC, MOHP and District Assembly Members received a one-day HH/C-IMCI
orientation. Eleven nurses and clinicians and 2 IEF staff received a 5-day IMCI Training of
Trainers workshop and a 5-day IMCI supervisor’s training. Due to staff rotation some
trained personnel have already left the area, mainly at the hospitals. Continue IMCI
Facility Based training during the next two years, plus HH/C-IMCI training for people
who did not receive the initial training. A one-day orientation to IMCI should be used
to train support staff, which are not directly responsible for IMCI implementation
(drivers, clerks, Ward and Patient Attendants, administrative staff). 
The training of health providers is an essential element in the provision of quality health
services. Supportive supervision coupled with a process of continuous quality improvement
is the second crucial element in the provision of quality health services. Following the
training, supervisory visits took place to consolidate the initial training and resolve
problems with IMCI implementation. Weak areas identified in the supervisory visits
included lack of child health cards and ORT corner equipment. These problems were
analyzed and solutions identified during the supervisory visits. IMCI checklists have been
developed for use with integrated supervision visits at HFs and at the community level.
Progress in improving the quality of care provided has been noted as a result of the IMCI
training. Health care providers who have been trained have shifted their thinking to
assess children holistically rather than simply concentrating on a child’s symptoms. Some
staff interviewed during the MTE mentioned that they do not have time to use IMCI
consistently, and only use it a few days a week. Introduce Quality Assurance strategies
and tools to be used in strengthening ongoing IMCI supportive supervision.
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The following indicators show progress in measuring IMCI implementation:
Performance Indicator -
IMCI
Base
line
Target
MTE LQAS
IMCI
Apr
04
IMCI
Jun 
04
IMCI
Aug
04
MTE
KPC
% of caretakers who took
children 0-23 months to health
workers for diarrhea, fever, or
difficult breathing after
recognizing illness symptoms
84
CI: 72-92 90 78 - - -
90
CI: 82-
98
% of facilities that have a stock
out of essential medical
supplies (e.g., ORS, SP,
Cotrimoxazole)
- 8 - 21 - 21
20
MTE
visits
% of sick children 0-5 years
whose health cards were
checked for immunization, VA
status and growth monitoring.
- 85 - 100 71 100 -
% of sick children 0-5 years
who present with fever and are
correctly assessed, counseled
& treated for febrile
illness/malaria
- 80 - 92 44 96 -
% of sick children 0-5 years
who present with difficulty
breathing and or cough and are
correctly assessed, counseled
& treated for ARI
- 70 - 100 17 100 -
% of sick children 0-5 years
who present with diarrhea and
are correctly assessed,
counseled & treated for
diarrhea
- 70 - 23 - 86 -
All stakeholders interviewed during the MTE, including community members, reported an
increased demand for services. The increased demand places increased pressure on the
MOHP system due to lack of staff. The solution to this problem is outside the scope of
this project, but has been the most important barrier to implementation during the two
years of the CSP and will continue to be the primary barrier in the future. The challenge
for the project during the next two years will be to increase efficiencies and continued
emphasis on supportive supervision, systems improvement, and a focus on improved quality.
In order to enhance the effectiveness of IMCI there is a need to supply durable,
washable, visible IMCI flow charts for the wall of each HF, and a small personal copy
for principal HF staff. Each HSA needs portable, durable IEC materials to use during
home visits in villages to teach danger signs for common illnesses.
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Revolving Drug Funds were planned in the DIP but have not been implemented. There has
been a change in the political climate since the DIP was written which makes it unfeasible
for the drug funds to be implemented. A free drug program was developed, and even
though it has not been implemented as widely as planned, does complicate the introduction
of a revolving fund at this time. Also the CSP has a number of other priority activities for
the second half of the funding period. The CSP is investigating the funding of HSA kits,
which would contain essential medicines such as Vitamin A, iron, aspirin, etc. The strategy
of Revolving Drug Funds should not be pursued during the second half of the project
due to a change in the political climate and time constraints and focus instead on
piloting HSA’s medical kits.
The problem of lack of a functioning referral system was identified as a weakness of the
health system. The CSP is working to establish a referral form to be used for referrals
from the HF to secondary hospital facilities as well as the link between communities and
HFs. Currently CHVs are told to refer, but no written system exists. Design and
implement a referral system, including a referral form for use by HFs and a
community referral procedure based on the official child/maternal health card (Health
Passport). The design process should keep in mind the literacy levels and work loads of
community volunteers. 
Nutrition 20% 
Nutrition indicators include the following:
Performance Indicator – Nutrition Baseline Target
MTE LQAS MTE
% of children 6-23m who received VAC
within 6 months of the survey date
89
CI: 84-93 90 67 77.5
CI: 72-82
% of children 0-5 months who are
exclusively breastfed
55
CI: 44-66 60 - 66
CI: 55-77
% of children 6-23m who consumed the
same amount of foods during most recent
episode of reported illness
49
CI: 50-58 60 68 52
CI: 43-61
% of children 0-23 months who are
underweight (-2SD from median WFA
WHO/NCHS reference)
39.5
CI: 33-45 35 - -
Anthropometric measurements were not included as part of the MTE KPC, but will be
repeated as part of the Final Evaluation.
PD Hearth was the primary strategy for nutrition improvement outside of the inclusion of
nutrition activities within IMCI (growth monitoring, nutrition education, breastfeeding,
Vitamin A and iron supplementation). A consultant was hired to train IEF and MOHP staff
in the methodology, including a practice session for conducting a Positive Deviance Inquiry.
Twenty-five CSMC, IEF, HSAs and Zone Supervisors were trained during a five-day PD
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Hearth workshop. Staff plans to introduce the methodology in one community in the South
Zone beginning in October. 
In view of the extremely limited human resources in the district to implement PD Hearth
or to potentially sustain it in the future, the process should be temporarily suspended to
allow the CSP to develop a more comprehensive nutritional plan for the remainder of the
project. The project will concentrate their efforts during the next two years on improving
the IEC/BCC strategies and it was decided during the MTE to focus this effort on
nutrition. This issue is discussed further in Section B.2.b. Behavior Change Interventions.
The project should evaluate what role it can play in the district to improve nutrition on a
district-wide basis. There was a Target Nutrition Program coordinating meeting which was
previously held monthly with the DHMT and NGOs working in food security. The meeting is
not currently active because World Vision, who sponsored the meeting, is no longer
involved. This would be one forum for the CSP to involve themselves in to obtain a more
global view of what is currently being done in the district. Organize a review meeting for
all stakeholders in nutrition programs to understand what is currently being done in
order to develop a concrete plan for CSP involvement.
The DHMT was advised that when PD Hearth is implemented, to ensure that 600-800
calories and 25-27 grams of protein is provided daily, divided between a snack and a meal
to complement (not replace) normal feeding times of the child. Hearth sessions should run
for 10-12 days followed by 2 weeks of follow up.
Growth monitoring is routinely carried out at Under Five (U5) clinics which are generally
held once a week in the HFs and twice a week in the hospitals. Outreach clinics are usually
an additional one to two days per month at each HF. The HSAs conduct the growth
monitoring sessions and GMVs have been trained in some villages to help the HSAs. GMVs
were only trained in villages which are not close to a HF. During the MTE some GMVs were
interviewed, but they seemed to be the most problematic of the cadre of volunteers in
terms of definition of their job responsibilities and motivation. Clarify the role and
function of the GMV and increase the number of trained GMVs.
The indicator for children who have received Vitamin A was one of the few that showed a
decline in coverage levels. There has been a supply problem with obtaining capsules but at
the time of the MTE 80% of HFs and 75% of HSAs had capsules. The reasons for the
decline were not clear and need to be investigated further. 100% of HFs had iron
supplements, but only 50% of the HSAs had them. Improvements to be made in the supply
system will be discussed further in Section B.2.c. Capacity Building.
Breast feeding support groups have been established in most villages to promote exclusive
breastfeeding and child feeding. The groups interviewed during the MTE had an
interpretation of “support group” which varies from the traditional concept. The groups
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see themselves as being the primary educators of the rest of the community on child
feeding issues. They meet primarily to plan education sessions for all of the mothers in the
community. The “support” functions as mutual support in their role as educators. The role
of the BFSG in promoting PMTCT (Prevention of Mother To Child Transmission) is
unclear and needs to be strengthened in the future.
HIV/AIDS 20%
This intervention has been the weakest even though it represents 20% of project effort.
The main activities implemented so far are:
• Inclusion of health messages on HIV/AIDS as part of HH/C IMCI
• The presentation of HIV/AIDS Basic Facts and Awareness messages to 49 District
Assembly members and 105 Junior hospital staff 
• CSMC members in collaboration with Churches Aid Relief Development trained several
district drama groups on HIV/AIDS issues. These groups will be instrumental in
disseminating HIV/AIDS health messages to communities.
• A district-wide HIV/AIDS Day was celebrated as part of a national campaign in
September of 2003. The theme of the day was “LOVE US – LET’S LIVE.” Songs, drama
comedies, quizzes and testimonies from people living with AIDS were used to
communicate information. The purpose of the day was to raise awareness on
HIV/AIDS and other sexually transmitted diseases and their transmission and
complications. Information on voluntary counseling and testing (VCT) services was also
disseminated. 
• Thirteen nurses and clinicians and one IEF staff participated in a 10-day course on
Syndromic Management Approach of Sexually Transmitted Infections. 
The indicator for this intervention is: 
Performance Indicator – HIV/AIDS Baseline Target
MTE LQAS MTE
% of mothers of children 0-23 months who
know at least 2 ways of reducing the risk of
HIV/AIDS
58
CI: 52-64 70 23 66
CI: 61-71
The district is involved in a number of new nationally directed initiatives in HIV/AIDS
which were not established when the DIP was developed. The CSP choose to delay
implementing activities until a clear need and role was defined. The process to obtain ARV
(Anti Retro Viral) drugs for use in PMTCT has been initiated by the DHMT. A letter was
sent from the district to the MOHP central Reproductive Health program to be forwarded
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to UNICEF as the first step in the process to obtain Nevirapine for use with HIV positive
pregnant women. A visit is scheduled in December for a site visit to determine ARV
implementation strategies for the district. Three district staff are currently receiving
training in ARV therapy but a supply of ARVs are not yet available in the district. A PMTCT
Coordinator has been hired by the district and new activities are just beginning in this
important area. VCT is currently available in three HFs (2 hospitals and 1 Health Center)
but on a very small scale. For example in Trinity Hospital, the counselors have not received
the currently required training and services are only offered 4 hours per week serving 25-
40 people per month.
Due to the rapidly changing services for prevention and treatment of HIV/AIDS, the CSP
needs to re-evaluate their role in district initiatives. Strengthen and implement a
comprehensive behavior change communication strategy on HIV/AIDS including VCT
and PMTCT.
Malaria 20%
The following indicators show an impressive increase in availability and use of Insecticide
Treated Nets (ITN) for the prevention of malaria. The CSP has contributed to this change
through the prevision of nets, training of ITN village committees, and a strong focus on
education at the community level.
Performance Indicators - Malaria Baseline Target
MTE LQAS MTE
% of mothers reporting the presence of a bed
net in the house
29
CI: 24-34 - 59 64
CI: 59-69
% of children 0-23m who slept under an ITN
the night prior to the survey
17
CI: 13-21 35 53 52
CI: 46-58
% of women who took SP Sulphadoxine￾pyrimethamine (Fansidar) to prevent malaria
during her last pregnancy
75
CI: 70-80 80 88 72
CI: 67-77
The DHMT Malaria Coordinator, who is also the Medical Assistant in charge of a Health
Center, is in charge of the distribution of ITNs to HFs and villages. 3,000 nets were
purchased by IEF, in addition to 3,000 nets being provided by PSI (Population Services
International), and 7,000 from UNICEF/WHO. PSI developed a national system for ITN
distribution which includes three types of nets: those distributed in communities by ITN
committees which cost MK 100; those available in HFs for children under five and pregnant
women which cost MK 50; and those for sale commercially at a cost of MK 400. Nets sold
in either the community or the HF are part of a revolving fund whereby 80% of the cost is
returned to the Malaria Coordinator for the purchase of additional nets and 20% remains
with the community or HF. 
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One hundred ITN committees have been trained (50 with CSP funds); the goal in two years
is to have 350 committees trained and functioning. In many cases the ITN committee is
comprised of the same people as the VHC, but this is not always the case, thus diluting the
effect of having funds go to the community-which are not under the control of the VHC,
but a separate group of people. 
In interviews with HF staff during the MTE, problems were reported in terms of
allocation of nets, supply mechanism and monitoring of sales. The CSP should develop a plan
for analyzing the flow of information and funds from the District to community ITN
committees and back again to identify opportunities for strengthening the system. A good
place to start would be in understanding exactly what systems have been developed by PSI
for ITN management. Conduct a review of the planned need for ITNs and of the
management system of the sale of ITNs in communities and HFs.
An additional challenge for the project during the remainder of the funding period is to
investigate the current practices regarding dipping the nets with insecticide according to
standard protocol, and ways to ensure the efficacy of the nets being used.
The use of SP for pregnant women has not shown an increase, even though at the time of
the MTE, 100% of the HFs had SP on hand. The CSP should investigate why the
Intermittent Presumptive Treatment of malaria for pregnant women did not increase
during the last two years.
Expanded Program of Immunizations (EPI) 5%
The following results show no measurable change in vaccination coverage comparing the
KPC at baseline with the MTE KPC. During the MTE, three out of the five HFs visited did
not have the full complement of antigens on the day of the visit.
Performance Indicators – EPI Baseline Target
MTE LQAS MTE
% of children 12-23 months who are fully
immunized before their first birthday
63
CI: 55-71 75 72 59
CI: 51-67
% of children 12-23 months who receives
measles vaccine before 1st birthday
70
CI: 62-77 80 73 64
CI: 57-71
One of the planned activities of the CSP was the encouragement of establishing continuous
vaccinations at the HFs. District policy restricts this initiative due to the wastage of
antigen by opening a vial of vaccines for only 1 or 2 children. Vaccinations are only available
during U5 clinics. A three-day training on Cold Chain Maintenance was held for 47 HSAs.
Evaluate the number, distribution and frequency of Under 5 immunization clinics
(static and mobile) to determine whether gaps remain which limit access by
communities.
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Pneumonia Case Management 20% 
Diarrhea Case Management 15%
Both of these interventions are included within IMCI and specific activities were already
addressed in the IMCI section. Indicators specific to diarrhea case management include:
Performance Indicators –
PCM and DCM Baseline Target
MTE LQAS MTE
% of caretakers who treat children 0-23
months with ORT during their last diarrhea
episode
55
CI: 47-64 65 90 85
CI: 79–91
% of mothers with children 0-23 months able
to demonstrate correct use of ORS
52
CI: 46-58 70 6 71
CI: 66–76
% of mothers with children 0-23 months who
report hand washing with soap/ash before
food preparation or child feeding, after use of
latrine or cleaning after child
3
CI: 1-5 30 46 7
CI: 4-10
The CSP focus has been on:
• Revitalization of ORT corners, ORT equipment was provided to 13 HFs.
• Improvement in the supply of ORS, antibiotics, and other supplies; All HFs and 75% of
HSAs had ORS but there is no mechanism to make ORS available permanently in the
communities through the VHC or other system. Cotrimoxazole was available in four out
of the five HFs visited and is not available to the HSAs, according to MOHP policy.
• Timers or a watch with a second hand were available in only two of the five facilities
visited. The DHMT expressed a preference for using a watch for measuring
respiratory rate, as they felt this was more sustainable than a timer.
• Community education in hygiene and hand washing. 
• Education on recognition of danger signs and referral.
• Increased liquids during illness and recuperative feeding.
Strengthen hygiene promotion activities to target hand washing instead of general
promotion of latrines and rubbish pits.
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c. New Approaches
As part of the sustainability strategy, the CSP is introducing two concepts for cost
sharing; a cost ward within the Nsanje District Hospital and an eye glasses shop. While
neither initiatives are functioning yet nor will they be the answer to financial
sustainability, they offer an innovative way to bring additional funds into the hospital. The
additional value of the activity is to raise awareness about cost recovery, and
improvements in the management systems of recovered funding providing positive
experience in advance of national decentralization initiatives.
The model for the cost-ward is the CHAM facilities that have semi-private and private
rooms set aside for those who prefer to select and pay for services. The ward itself will
be an existing room at the district hospital that will be improved by repairing and painting
walls, floor, windows, ceiling, and doors and providing new amenities including a toilet and
shower area; new curtains, beds and bedding, furniture, lamps, and either a fan or air
conditioner. The service will be redesigned to include greater attention and time spent
with patients by the medical doctor and nurses, greater privacy, and better food services.
The changes are designed to provide a viable choice for patients to self-select whether
they want to receive free services in the general ward, or pay a fee. 
IEF has been working with eye hospitals in Lilongwe and Blantyre. A new spectacle shop in
Blantyre will soon be operational. Once the shop is established IEF will extend services to
Nsanje district. The optical shop is now operational since June, and is grossing
approximately $10,000 month, but IEF extension to Nsanje is part of a larger plan to
market glasses to several districts and awaits implementation in early 2005. At Nsanje
District Hospital, the existing eye department will be improved and provided with a supply
of ready-made low cost glasses in the range most commonly prescribed. Subsidized prices
appropriate for Nsanje will be established, and a small profit based on sales will benefit
the hospital. The spectacle shop fosters increased hospital management of a revenue
generating activity and provides a new service to the public.
IEF will assist the CSMC in business planning and help strengthen management and
accounting practices.
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2. Cross-cutting approaches 
a. Community Mobilization
Perhaps the CSP activity which has had the most impact at the community level has been
the establishment and strengthening of the Village Health Committee (VHC). The VHC has
responsibility for:
• Role as peer educator. According to groups of women interviewed during the MTE, all
had received health education, and the most often mentioned source was the VHC and
HSAs.
• Provides support for the other CHVs (Community Health Volunteers; GMVs, BFSG, and
TBAs) which have received training from the CSP, although this role needs to be
articulated and strengthened.
An unplanned impact has been the inclusion of women in the VHC, providing a vehicle for
women to assume non-traditional leadership roles. Women were active VHC members in the
majority of communities visited during the MTE.
Five of the 12 groups of mothers interviewed during the MTE mentioned that they had
observed an increase in community participation in health activities since the beginning of
the project. According to information received during the MTE, there are no major
barriers to participation in health activities; all families participate. An ongoing challenge
for the project is the motivation of CHVs and the community in general. Many community
members take a very passive role in health activities, having an attitude of receiving
benefits rather then promoting prevention. CHVs receive an allowance of 130 MK
(US$1.25) to attend training. A payment which motivates in the short term but is
unsustainable by the MOHP.
There is a lack of knowledge about the inter-relationship in the villages among various
committees. Many of these committees are project driven (borehole maintenance), some
are traditional (defense) and in many cases there is an umbrella organization (Village
Development Committee). Competing community priorities may be effecting the project’s
ability to mobilize the community. For community structure to be sustainable it must fulfill
a role within the community definition and not just the project defined role. Leaders of
different village committees should be encouraged to meet and outline modalities to
coordinate their activities.
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During the MTE, innovative ideas for sustaining activities were presented by various VHCs.
Emphasize the positive; identify positive deviant villages which can serve as models for
other villages. Identify well-functioning VHCs to be involved in sharing their
experiences. 
One effective method of motivating volunteers is through frequent supervision visits.
Malawi has a unique MOHP system of paid HSAs who are responsible for the health of the
community, including responsibilities in environmental health, disease surveillance,
information gathering and education. These people play an important role in the
sustainability of health activities in the villages. Strengthen follow-up and supportive
supervision of CHVs by CSMC, HSAs and Zone Supervisors. Modify the system of
community supervision to include VHCs as supervisors within their own communities. 
Another means of motivating volunteers is through the formation of a supportive network
within the village; mutual support among all volunteers. In order to ferment this
camaraderie, each person’s role must be very clear and opportunities for support
highlighted. Identify mechanisms to encourage coordination at the village level of all
community health volunteers. Clarify the job descriptions of all community health
volunteers.
At the time of the MTE, the project was beginning plans to implement a Village Register
for use by VHCs. It was recommended that the register be re-evaluated to determine the
feasibility of its use given the workload, level of motivation and level of literacy of the
VHCs. Other ways information could be presented to communities include mapping, use of
an annual calendar showing changes in disease conditions, coverage, sanitation services,
etc., or graphics that display community health indicators compared with community goals.
Develop a system for sharing information with the villages using maps and/or
information recorded in poster form at the village level to stimulate action planning. 
b. IEC and Behavior Change Interventions
The project is working with the entire Nsanje District, with a population of well over
200,000 people. In order to reach this number of people with health messages a mixture
of IEC (Information, Education, Communication) and BCI (Behavior Change Interventions)
methodologies are required. During the first two years of the CSP, the focus has been to
disseminate basic IMCI messages to as wide an audience as possible. A continued emphasis
on IEC is appropriate for the remainder of the project, given the audience size and the
scope of the project. All messages are up-to-date and in line with national and
international standards. 
A three-day training course was given to 6 CSMC members in adult learning and facilitation
skills and 16 CSMC members received a one-day orientation to BCI. CHVs and HSAs need
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reinforcement on their communication skills i.e. adult learning and facilitation. This
could be accomplished through supportive supervision visits and feedback after actual
education sessions.
One of the weaknesses of the current IEC strategy is the lack of materials for use in
educating community members. HSAs and CHVs have almost no materials to help explain
concepts or to remind them of key messages. Any materials used need to take into account
the level of illiteracy. Liaise with BCI Coordinator to identify, procure and distribute
IEC materials for use by CHVs, HSAs, and Health Facilities. 
In addition to using IEC methods, the project will begin exploring BCI options to increase
the focus on behavior change for specific high risk behaviors. In the DIP it was originally
planned to introduce PD Hearth as a response to the high levels of malnutrition in the
district and the use of the BEHAVE framework as a means to targeting high risk
populations. At the time of the MTE, it was felt that instead of simply moving forward on
introducing these two concepts, it would be advisable to re-evaluate the needs of the
district and plan a comprehensive IEC/BCI strategy for the next two years. The IEC/BCI
emphasis will be on nutritional improvement and will require technical assistance. Develop
and implement a comprehensive IEC/BCI plan for the CSP, including PD Hearth, the
BEHAVE Framework, or other appropriate methodologies.
c. Capacity Building Approach
i. Strengthening the PVO Organization
During December 2003 IEF conducted a two-part exercise to strengthen its strategic
planning and self-assessment processes. This is part of an annual review and planning
meeting at IEF Headquarters and a biannual use of the Discussion Oriented Self
Assessment (DOSA) methodology to re-assesses core capacity indicators.
Seven headquarters staff participated in the DOSA self-assessment exercise. In
comparison with the assessment conducted in 2000 there were minor changes in the Core
Capacity scores (strengths and weaknesses), however, there were marked decreases in the
Consensus scores in all Core Capacity areas. Capacity scores ranged from a low of 63 to a
high of 80, and the Consensus scores ranged from a low of 51 to a high of 72. Explanation
of the differences may be due to the small number of participants, the length of service
of staff, and the diverse IEF programming (Child Survival/nutrition, onchocerciasis,
sustainability planning for eye care hospitals, and the IEF social-enterprise SightReach
Surgical®). 
IEF recognizes the value and limits of the DOSA methodology and uses the exercise to
stimulate discussion for planning purposes, and not to measure change over time.
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Eight headquarters staff and one Board Member met for a one-day group exercise to
review and revise IEF’s strategic plans. A Strengths, Weakness, Opportunities, Threat
analysis was conducted of each of the major program areas including SightReach Surgical,
SightReach Management, Childhood Blindness, Child Survival and Vitamin A, onchocerciasis,
and fundraising. The objectives of the meeting were: 1) create clear understanding of the
mission, program initiatives, development activities, and funding sources, 2) Review
consensus on perceived strengths and weakness in key capacity building areas, and 3)
identify priority programs and activities and options to be included in a new operational
plan for the next 3 – 5 years.
One of IEF’s strengths is the emerging success of the SightReach Management program
that is demonstrating the effectiveness of a sustainability planning model for eye care
hospitals presently operational in six countries. The lessons learned from these
experiences is a reference for work in other programming including child survival.
Emphasis on establishing standards and benchmarks for productivity and efficiency;
improving the quality of care and services, and establishing mechanism for cost recovery
are crucial to meet patient and community demand for services.
IEF Malawi did not conduct a separate institutional assessment. It is recommended that
IEF Malawi conduct an institutional assessment and strengthening plan, similar to the
process proposed for the DHMT.
In order to more effectively and efficiently implement the CSP, IEF needs to take a
leadership role in working with all NGOs working in the district, not just health NGOs, but
a more global vision of how health is part of development. What organizations exist with
programs in education, agriculture, civil society which could be partners in enhancing the
impact of the CSP's efforts in health? The project could improve the synergistic effect
of coordinating with other organizations such as Family Health International, Salvation
Army, PSI, and World Vision. This also applies at the national level, where increased
coordination with other organizations is crucial. A mechanism for information sharing and
to enhance coordination between principal organizations in the district; NGOs, DHMT,
and CHAM facilities, should be initiated by IEF.
ii. Strengthening Local Partner Organizations
The principal partner for the implementation of this CSP is the district level MOHP
District Health Management Team (DHMT). The roles and responsibilities of the DHMT
within the CSP remains the same since it was initially described in the DIP. One of the
major constraints in working with the DHMT is the severe shortage of professional staff
at all levels. This is a national problem, as there has been a lack of development of new
human resources and a migration of Malawian professional to other countries. This
shortage limits the pace at which new concepts can be implemented, as anything new is
perceived to require more effort and time (and initially, usually does).
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In order to have a starting point for discussions on capacity building between IEF and the
DHMT, the Organizational Capacity Assessment Tool (OCAT) methodology was used. This
methodology is based on an adaptation of the Organizational Capacity Assessment
approach developed by PACT. Numerous changes were made to develop a tool that could
be used in a governmental setting where the organization provides direct service delivery.
A total of 13 persons participated in the Organizational Capacity self-assessment
conducted February 2004. The purpose of conducting the assessment was to initiate
discussion on what is meant by strengthening “capacity building” by introducing the DHMT
to a series of indicator/questions related to institutional capacity. 
Prior to administrating the questionnaire, additional time was taken to clarify the group’s
understanding of “stakeholder” as this term is used throughout the questionnaire.
Secondly, a lengthy discussion took place to clarify what was the subject of analysis.
Unlike an NGO with a private legal identity, the DHMT is a committee with loosely defined
authority and decision making powers. It was generally understood that the District
Health Officer, representing the district hospital and the district health centers is the
Local District Health System. The District Health Office through the DHMT is a
representative management structure responsible for oversight of this health system.
This loose definition was employed during the assessment.
A total of 144 indicator questions are included in the assessment. Organizational
assessment team members respond to each item using a 1-5 scale. Capacity scores ranged
from 78 to 50 percent among the seven capacity score areas. In general, the greatest
weakness of the DHMT are organizational in nature especially the limitations on the DHMT
to ‘govern’ themselves; lack of clarity over decision making in regards to staff and financial
management; incomplete management systems, lack of transparency in reporting, especially
financial, and limited use of information. A repeat use of this tool is planned as part of
the 3rd year assessment and report, but no follow-up has been given to the results of the
assessment, nor is any action plan based on the results evident. Additional follow up to this
exercise is required to discuss issues raised in the assessment and develop an Action Plan.
The CSP emphasizes capacity building through strengthening the quality of district
programming (primarily IMCI); assisting the DHMT to improve planning skills, establish
more effective supervision and monitoring systems, and strengthen their ability to manage
small funds achieved through cost recovery mechanisms. The principal capacity building
activities that have taken place are: 
Training: 
Training was planned and conducted in the areas of Planning and Supervision, Adult
Learning and Facilitation Skills, IMCI, and PD Hearth. Eighteen DHMT members, 11 HF
In-charge Staff, and 6 Zone Supervisors received a three-day training course on
Supervision and Planning Skills. Training in IMCI and PD Hearth was previously described.
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Systems Strengthening:
Planning – in the areas of implementing the annual planning processes, sharing of monthly
plans, and quarterly zonal meetings held in the 6 zones. These areas should be
strengthened further through monthly planning meetings. Monthly meetings between IEF
and DHMT should be planned on a set day and time through out the year for planning
and monitoring project activities.
Training – in the areas of adult learning and facilitation, introduction of BCI concepts, and
adaptation of IMCI curriculum. These areas should be strengthened through increased
emphasis on IEC and BCI activities.
Supervision – in the areas of development of a zonal supervision system, supervision tools,
and annual or bi-annual integrated HF visits. The district was divided into six supervision
zones, with zone supervisors assigned in each zone which has enhanced direct supervision.
The overall supervision system needs to be strengthened through the implementation of
draft supervision tools for CHVs, and client satisfaction; and by looking at the whole
process and its link to the training, logistics, and M&E systems, not just isolated
supervision visits. Results from supervision visits should be summarized so that learning
can take place about overall strengths and weaknesses to be used to identify training
needs and to look at issues which need to be solved at other levels i.e. logistics. Use
supervision as a way to identify positive points for cross learning through exchange
visits or peer supervision.
Accounting – the district accounting system is still a manual system operated by one
person; an accounting clerk. The IEF Administrator in Nsanje has been working with this
clerk to implement a Quicken® system on a computer donated by the project. While the
Quicken® system is not compatible with the official MOHP system which will be
implemented in the future, it does give the clerk computer and spreadsheet experience.
IEF should continue the on the job training for the District Accounts Clerk.
During the next two years, the project should continue efforts in strengthening the
previously mentioned systems, as well as begin efforts to improve the functioning of the
Information System and the Logistics System. The focus on systems analysis provides the
DHMT with sustainable improvements to increase efficiency and effectiveness of services.
Introduce Quality Assurance strategies and tools to conduct systems analysis to
determine what the root problems are in each system, what aspects are working well,
and how systems can be improved to be more efficient and effective.
Information System - Three main areas need to be improved; validation of information
collected, information sharing, and use of information. These issues are further discussed
in Section C. 7 Information Management.
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Logistics System (transportation and supplies) - A number of issues were discussed by the
MTE evaluation team regarding transportation. The number of issues underscores the
importance of this problem, but also can lead to a band-aid approach unless the entire
system is studied to determine where the most critical needs are, given the limited
resources of the district and CSP. A comprehensive study should be made of the
transportation system to determine how improvements can be made.
The following additional points should be taken into consideration:
• Improve the coordination of the transportation system.
• Continue to request new vehicles from central MOHP. 
• Employ a full-time trained mechanic for the district.
• Examine and revise, if needed, policies and procedures for vehicle use. 
• Repair or replace zone supervisors’ motorcycles. 
• Establish policies for HSAs purchase of bicycles and establish a spare part revolving
fund or other maintenance plan.
A recent national modification in the logistics system whereby the MOHP Central Medical
Stores is now directly supplying health centers with drugs has met with success so far. But
continuing problems with the supply system elicited a number of recommendations:
Determine why materials/supplies are inadequate in some HFs and identify the
solutions to those problems, including the timely requisitioning of drugs and other
supplies. 
Identify the HFs needs for equipment and office supplies essential for the
implementation of the CSP; procure, distribute and monitor those supplies. (CSP to
make initial purchase of files, hole punches, staplers, papers, and staples).
iii. Strengthening Health Facilities and Health Worker Performance
Project works with personnel in 1 MOHP hospital, 1 CHAM hospital, 8 MOHP Health
Centers, 3 CHAM Health Centers and 8 MOHP Health Posts. HFs are assessed through the
Health Facility Assessment carried out in 2002 which will be repeated for the Final
Evaluation, and the ongoing IMCI and Integrated Supervision visits. Results from various
supervision visits were summarized in the results tables on pages 5-11 of this document. In
June of 2004, the CSP conducted an LQAS survey to look at HSAs knowledge levels. A
sample of HSAs were asked seven questions on basic IMCI messages with an average score
of above 90%.
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The main activities to strengthen health facilities and health workers were:
Training: 
Training of HF staff and HSAs in IMCI including Ward and Patient Attendants, other
support staff IMCI training- three were held for 51 HF staff and two IEF staff. Fifteen
people have been trained in IMCI and left the district. Thirteen people were trained in
TOT to provide a sustainable pool of trainers for IMCI. A sustainable system should be
designed to conduct in-house IMCI training for the remaining untrained staff as
efficiently as possible.
Supervision:
A major focus has been on encouraging integrated supervision with a checklist for health
facilities. Supervision checklist were being field tested at the time of the MTE to evaluate
HH/C IMCI through the supervision of HSAs, VHCs, Traditional Healers, Drug Vendors,
GMVs, BFSG, and TBAs. Checklists were also being developed to monitor community
members’ perceptions of work being carried out by HSAs, VHC, GMV, BFSG, Traditional
Healers, TBA and Drug Vendors. Client satisfaction surveys have also been developed for
use at inpatient and outpatient HF clinics. 
Supply of materials:
IEF purchased and distributed 6,500 health cards for children under 5, 6,500 for women
and 3,250 for the general public. The health card/passport used in Malawi is an interesting
adaptation from the more commonly used growth/vaccination card as it contains those
elements plus a clinical history for all visits to HFs. The cards cost MK 15 (US$0.13 ). This
money is then used to purchase additional cards from the district.
IEF also purchased and distributed 3,000 ITNs, as well as, the supplies to establish Oral
Rehydration Therapy Corners at HFs.
In interviews with HF staff during the MTE, they felt that supervision had been effective
in problem solving and encouragement and that the training they had received had
improved patient management. All HFs visited said that the demand for services had
increased since the CSP began.
The major linkage between the health facility and the communities is through the
government paid Health Surveillance Assistant (HSA). The HSAs responsibilities are
varied, and is the primary entrance to the community for all MOHP programs, as well as
NGOs. 
The HSAs are directly supervised by Senior HSAs at each HF, who are supervised by the
Zone Supervisors, a new supervisory structure introduced by the CSP to improve
supervision and monitoring. The Zone Supervisors are supervised by the district. The
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system works very well in terms of service provision. The job description of the HSAs,
compared to actual tasks, is not realistic. There is often little coordination between
district programs (MCH, HIV/AIDS, nutrition, TB) with the result of adding more and
more tasks to HSAs. Due to the shortage of health staff, many times the HSA is
assuming responsibility for tasks which are beyond their professional expertise, such as
VCT counseling. Twenty-seven HSAs were brought to the district hospital to bolster gaps
in staffing.
Of HSAs interviewed during the MTE, only one was female (out of 11) and 83% had worked
for longer than five years. Ninety two percent of HSAs had a weighing scale, but only
75% had ORS and Vitamin A, 58% had Albendazole and 50% had iron tablets. The HSA is
sustainable within the MOHP system, but their job descriptions, efficiency and
performance could be improved in order to enhance the effectiveness of this vital position
in bridging the gap between the HF and communities.
The ways in which the CSP could collaborate to improve the performance of the HSAs are: 
• Improve the frequency and quality of supportive supervision received by the HSAs.
• Review and revise the job description of the HSAs and improve coordination of their
use by multiple programs.
• Ensure that HSAs have an Essential Health Package (ORS, iron, Albendazole and
Vitamin A, etc.) 
iv. Training
The CSP uses the cascade approach to training, with CSMC members trained to train HF
staff or HSAs. HSAs are responsible for training and supervising CHVs, who then provide
education to community members. There is a great deal of overlap in these levels, as CSMC
members sometimes directly train CHVs and HSAs provide education to community
members. This strategy has been effective in reaching a large audience and surpassing
training objectives, but during the second half of the project, a greater emphasis will be
required on ensuring the quality of replication at all levels.
The MTE KPC survey showed increased knowledge and change in some behaviors as
demonstrated by project indicators on pages 5-11. LQAS results also showed increases in
project indicators. 
Topics for community education should be determined by interest and need, focusing on
one or two topics in each session, rather than providing an overwhelming amount of
information in a single session. Define themes for education messages by HSAs and
CHVs based on a district IEC/BCC plan which includes disease patterns (months of
high cholera prevalence), upcoming campaigns or activities (vaccination campaigns) or
specific problems identified in the community (low existence of latrines). 
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Training coupled with supportive supervision has been shown to be the most effective way
to increase health workers’ abilities. Training needs to be viewed more as a part of a
process, not an isolated activity as the panacea for solving all problems. There is concern
on the part of the MOHP that excessive amounts of training interfere with the normal
staff workload.
d. Sustainability Strategy
The CSP did not use the CSSA sustainability framework during DIP formulation, but bases
sustainability on five pillars:
1. Financial - implementation of a cost ward and spectacle shop within the Nsanje
District Hospital and strengthen financial management systems.
2. Behavioral - maintaining positive health behaviors within the family and the
community by demonstrated effectiveness of behaviors and the involvement of men
in health decision making.
3. MOHP structure - focusing on systems improvement provides the DHMT with
sustainable improvements to increase efficiency and effectiveness of services.
4. Community structure - strengthening intra community coordination both by forming
a network of volunteers and by integrating the health committee into the larger
village structure.
5. Links to MOHP - through strengthening the referral system and links via the HSAs
and zone supervisors.
In February 2004, seven persons participated in a discussion on sustainability during a
technical assistance visit by IEF’s Program Director. There was limited participation from
the DHMT due to scheduling constraints. The purpose of the orientation was to introduce
concepts of sustainability and initiate steps towards developing a District Sustainability
Plan. Group discussions were used to stimulate thinking about sustainability including the
following points:
• Why discuss sustainability?
• What is sustainability?
• What are the critical components of sustainability?
• Based on what we are doing – what do we want to sustain, and why?
• What are we doing now that supports sustainability?
• What can we do to further our sustainability efforts?
• What do we need to know to develop a plan for sustainability?
The key concepts of the Child Survival Sustainability Assessment framework were also introduced. 
The short time and inability of the DHMT to fully participate limited the effectiveness of
the discussions. No follow up has taken place since the organizational assessment and
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discussion on sustainability took place. Given that the major training activities in IMCI are
now completed, the CSP will resume the development of a plan for capacity building with
the DHMT and to develop a realistic sustainability plan in early 2005. 
During interviews with groups of mothers during the MTE, when asked how they have been
able to support CHVs, the principal response was to follow their advice; little focus was
found on helping them financially (labor sharing strategies). However, when mother were
asked how health activities could be continued in the future the three most common
responses were: the Community to continue practicing healthy behaviors (7); the VHC
should continue providing health messages (6) and, Coordination among community members
(5). These observations fit within the sustainability framework of the CSP of focusing on
strengthening the community structure and maintaining positive health behaviors at the
household level.
Project participants and village volunteers were asked during the MTE about the desire to
sustain activities and their ideas on how that could be done. Suggestions included; doing
piece work to have enough money to buy ITNs, and work sharing to motivate CHVs and to
provide them with enough time to do health activities. Some VHCs are experimenting with
establishing a family quota for health emergencies and small income generating projects
such as tree nurseries and gardens. This concepts need to be further explored with
villages so that they also focus on strategies for sustaining activities. The potential for
financial sustainability of services in these villages is extremely limited.
The CSP proposed two mechanisms for cost recovery in the DIP 1) cost wards in the
Nsanje District Hospital, and 2) an eyeglass shop. The hospital has identified some
potential rooms for renovation, but much planning remains to be done. IEF has been
working with the MOH at the Lions Eye Unit of the Queen Elizabeth Central Hospital in
Blantyre and the IEF sponsored eyeglass production workshop began production in June. A
wider plan to market glasses in the districts is being developed and should start in early
2005. Both of these activities have been slightly delayed, but will be a focus of the
project during the next two years.
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C. PROGRAM MANAGEMENT
1. Planning
The DIP was developed in a participatory manner during a workshop conducted in Nsanje.
Twenty-one people participated in the workshop included members of the CSMC and a
representative from World Vision and Africare. The workshop analyzed KPC survey results
and streamlined strategies for implementing the project. The DIP has been shared with all
project partners and there is general understanding of project objectives. Being the
project “roadmap,” the DIP is used as a reference guide for all activities, especially for
the monitoring of activities. 
The work plan of the DIP has been implemented on schedule except for the introduction
of BCI methods (PD Hearth and BEHAVE Framework) and Quality Assurance activities.
Both of these activities will be completed during the second half of the project. The Drug
Revolving Funds will not be implemented. 
There are mechanisms in place for annual, quarterly and monthly planning. The monthly
planning process could be more participatory if all actors met together and planned as a
group, rather than presenting individual plans which are then summarized. It is unusual
that a project follows the DIP as closely as this project has. Given the ambitious number
of activities in the DIP especially the roll out of C-IMCI training, and the complexity of
the supervision, and monitoring, the workplan provided good guidance for the first two
years. Some of the major planned activities were not implemented on time based on
judgments made by the CSP team, e.g., VCT. While the DIP is the official work plan of the
program, the environment in which a project is implemented changes over time and
flexibility is needed to adjust to new opportunities and challenges. Program monitoring
data should be used for revising program implementation plans during the remainder of the
project time period.
2. Staff Training
IEF staff has taken advantage of various training opportunities. Many of the staff had
previously worked in another IEF USAID funded health project, so they came to the CSP
with substantial experience. One of the weaknesses of staff training is the lack of a
training plan, based on an assessment of project needs and staff abilities. Adequate funds
are available for staff training.
The IEF Maternal and Child Health Trainer attended a 5-day international workshop
organized by WHO/AFRO, focusing on the implementation community IMCI. The
workshop took place in Blantyre during May of 2003. The goal of the workshop was to train
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IMCI facilitators on specific techniques, procedures and tools for community
interventions to improve child health, growth and development. 
The Child Survival Project Manager along with the Nsanje District Environmental Health
Officer attended a 5-day, CORE-sponsored workshop in May of 2003. The workshop
focused on the use of qualitative research to improve child health programs. The workshop
included why and when qualitative research techniques are appropriate as well as how
qualitative research findings can and cannot be used. 
Two project staff participated in a workshop organized by the National AIDS Commission
of Malawi. The purpose of the workshop was to develop national indicators for HIV/AIDS.
In addition, participants designed a format for consistent reporting on HIV/AIDS
activities in the country.
The IEF Malawi Country Director and IEF HQ Child Survival/Vitamin A Coordinator
participated in the Mini University at Johns Hopkins University in June of 2003.
Other training received by IEF staff included: IMCI case management 11 day training;
Proposal writing 2 days; Quality Assurance Training of Trainers 10 day, and PD Hearth 5
days. 
Assess training needs for all IEF staff based on project objectives. Project Manager
should receive additional mentoring/training in management, especially budget
management.
3. Supervision of Program Staff
Supervision of project staff was reported to be adequate. There is no supervision
schedule or supervision form but all staff felt they received adequate support, with
appropriate frequency, to be able to complete their job responsibilities. There are
frequent meetings between the Project Manager and other staff for problem solving.
4. Human Resources and Staff Management
All staff has written job descriptions, but there is not a comprehensive personnel policy
manual for the IEF Malawi office even though policies are covered with contracts and
written memos. Personnel policies such as leave allowance, hardship allowance and benefits
need to be clearly documented to ensure transparency and clarity for all employees. IEF
Malawi should develop a personnel policy manual which includes employee benefits,
policies, and procedures.
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Staffing problems for the MOHP were previously discussed but staffing has also been
problematic for IEF. Because Nsanje District is perceived as a ‘hardship post,’ retention
of qualified staff has been difficult. Three staff hired to fulfill IEF technical advisor
positions resigned within three months of their employment, citing other opportunities in
better locales as the reason for leaving. For over a year, two critical staff positions were
vacant. IEF currently has a full complement of planned staff, but the MCH and IMCI
coordinators were recently hired respectively 2 and 3 months ago. Staff morale and
motivation is low and staff retention may continue to be a problem. 
IEF Malawi provides a severance package for staff when the project ends, amounting to
one month of salary for each year they worked for the project. No other severance
benefits are anticipated, but an attempt will be made to retain employees for other
projects, if possible. Three of the current staff were retained from a previous project.
5. Financial Management
IEF’s Director of Administration and Finance visits the project annually to ensure
compliance with IEF accounting practices and financial management. The Director of
Administration and Finance provided an orientation to the new Country Director, and
provided refresher training to IEF staff at the beginning of the project. He also
performs an annual internal audit, assuring that bookkeeping is properly and fully
completed according to IEF and USAID policies. An annual external A-133 audit is also
completed at IEF headquarters.
The organization uses a Quicken accounting system to track project expenditures. To
guarantee that project expenditures are completely accounted for, all payments are made
by check. In conjunction with the Country Director, the Project Administrator is
responsible for the project’s financial management. The Project Administrator has many
years of service working with IEF and is well trained and experienced in the use of the
Quicken system, along with IEF procedures and policies. There are no banking facilities
available in Nsanje, making financial transactions difficult. 
Budget management needs to be decentralized from the Blantyre office, with greater
exchange of information and shared decision making between the Blantyre and Nsanje
offices. Technical assistance for the Project Manager in budget management would
increase her effectiveness as a manager.
6. Logistics
The principal procurement issue which limited project implementation was the delayed
purchase of a project vehicle, which was not completed until 2004. The government of
Malawi imposed an obligatory 40% excise tax over-and-above the regular duty tax on the
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purchase of goods. This substantially increased procurement costs and the project’s
solution to this problem was to stall the purchase of the more expensive items in the
budget until a wavier could be obtained. Now that this issue has been resolved, there
should be no other logistics challenges for the remainder of the project. The only other
large purchase to be made is motorcycles for use by Zone Supervisors.
7. Information Management
The Monitoring and Evaluation plan of the CSP consists of: 
• Knowledge Practice and Coverage (KPC) survey, using a 30 cluster sample at baseline,
MTE, and final, and the use of Lot Quality Assurance Sampling (LQAS) every six
months beginning in 2004. 
• Health Facility Assessment at baseline and final.
• IMCI, integrated, and community supervision used for monitoring.
• Health Management Information System (HMIS) of the MOHP.
• Training reports after each training event.
• Organizational Capacity Assessment for DHMT and DOSA for IEF.
Four baseline surveys were conducted during the first year of the project: KPC survey
(11/02); Health Facility Assessment (2/03); Community Health Workers survey (4/03); and
a second Health Facility Assessment focusing on service provision and IMCI performance.
The three survey reports were included in the DIP. 
In June 2003 an IMCI survey was conducted in 12 HFs to provide baseline information on
outpatient services provided for children prior to district wide implementation of IMCI
for evaluating the impact of IMCI training. Integrated supervision visits were conducted
during February and September of 2004.
A LQAS was conducted as part of a training exercise in April 2004 using selected
questions from the KPC 30 cluster baseline survey. A three-day training on the
methodology was attended by 17 IEF staff, HSAs, and Zone Supervisors. The CSP plans to
continue using the LQAS sampling methodology every six months as a monitoring tool.
Suggestions for simplifying the process were made during the MTE and included 1) Using a
“spin the bottle” technique for selecting the random household rather than community
mapping, 2) Only include a subset of indicators based on a prioritization of activities
during each LQAS, and 3) Incorporate the interviews within the monthly supervision visits
of the Zone Supervisors
The CSP has an adequate system for collecting information including the MOHP official
HMIS which has been recently revised. The weakness is the lack of systematic use of
information for decision making at all levels. The need to strengthen the information
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system was previously discussed as an important step in capacity building for the DHMT
and also at the community level.
One of the problems identified during the MTE was the lack of techniques for the clear
presentation of data and the use audience segmentation to identify specific needs for
reporting and information sharing which leads to decisions being made and actions being
taken. Train DHMT/IEF on techniques for presenting data to enhance the use of
information for decision making.
This is directly related to the need to strengthen how information is shared between
people and organizations. Create a “library” for reports, documents, statistics that is
accessible to everyone.
To avoid a band-aid approach, it will be necessary to review the information system as a
whole, particularly the HMIS. As the official system for the nation, the accuracy of
information being used in the system needs to be verified as well as educating people on
how best to use the information, not simple reporting it to the next level. Conduct a
review of the HIMS to verify the quality of data being collected and processed, and
encourage the use of data for decision making at the district and HF levels. 
The use of information for decision making at the community level also needs to be
strengthened. This was previously discussed in B.2.a. Community Mobilization.
8. Technical and Administrative Support
The following technical assistance has been received by the project to date:
Date Who provided Purpose
September
2002 IEF’s Director of Programs
Assist in the hiring process of the CS project
Technical Advisors, as well as provide an initial
orientation to project stakeholders
September￾October 2002
IEF’s Child Survival and
Vitamin A Coordinator
Develop a baseline KPC instrument, as well as to
conduct KPC training for KPC team members
February
2003 IEF’s Director of Programs
Orient the new IEF Country Director to IEF policies
and procedures, as well as overall programming in
Malawi
March - April
2003
IEF’s Child Survival and
Vitamin A Coordinator
Conduct a DIP orientation workshop for the DHMT
and IEF staff, and to write the DIP
February
2004 IEF’s Director of Programs Conduct Institutional Assessment and develop
Sustainability Plan
May
2004 Consultant Train IEF, DHMT and other MOHP staff in the PD
Hearth methodology
October
2002 IEF’s Director of Programs Participate in the Mid Term Evaluation
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The technical assistance received was reported to be helpful and timely. Communication
between the IEF Malawi Country Director and IEF Headquarters Director of Programs is
frequent and supportive, both by email and telephone. In the original project proposal IEF
anticipated having two staff members to provide technical assistance to the Malawi
project. Since that time, the Child Survival and Vitamin A Coordinator has resigned and
not been replaced. IEF’s Director of Programs is providing technical support to the CSP.
He devotes approximately 15-20% of his time to the project. 
The primary technical assistance need in the future is for IEC/BCC to define what the
appropriate integration between IEC and BCC should be for the CSP to best complement
the Nsanje District implementation plans.
D. CONCLUSIONS AND RECOMMENDATIONS
The IEF/DHMT team is implementing a good quality project in close compliance with the
DIP and generally in line with the work plan. Some activities have been delayed due to
staff shortages at both IEF and the MOHP. The strong points of the CSP thus far are:
™ Population coverage - increased well beyond original targets. 
™ VHC-development - of health committees is good step towards improving community
structure for sustainability.
™ ITNs - the CSP has contributed to a wider national movement to make a significant
impact on prevalence of malaria
™ Supervision - introduction of concepts and tools for supportive supervision has changed
the paradigm of supervision as a policing action.
™ Focus on Systems - the analysis and improvement of operational systems is a
sustainable way to use resources more effectively and efficiently.
The focus during the next two years should be on:
• Continued focus on systems improvement.
• Implementation of Quality Assurance tools for systems analysis and improving quality
of care at HFs.
• Investigation of needs for IEC and BCI activities in order to have the most impact in
the district, focusing on improving nutrition behaviors.
• Increased emphasis on HIV/AIDS activities.
• Implementation of the cost sharing activities of cost ward and spectacle shop.
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All stakeholders interviewed during the MTE, including community members, reported an
increased demand for services. The increased demand places increased pressure on the
MOHP system due to lack of staff. The solution to this problem is outside the scope of
this project, but has been the most important barrier to implementation during the two
years of the CSP and will continue to be the primary barrier in the future. The challenge
for the project during the next two years will be a continued emphasis on supportive
supervision, systems improvement, and a focus on improved quality while working within the
constraint of limited health personnel. The CSP should also work more closely, where
possible, with the District level actors (Agriculture, Water, Education, and Community
Development) under the DEC and DCs office to improve collaboration of resources focused
at the community level. 
A participatory evaluation was carried out by a 14 person team comprised of
representatives of the DHMT, IEF Malawi, IEF Headquarters, other NGOs, and an
external evaluator. The majority of the recommendations included in this document were
written by the team, some additional recommendations were added by the external
evaluator. The priority recommendations for improving implementation of the CSP during
the next two years are:
1. Continue IMCI Facility Based training during the next two years, plus HH/C-IMCI
training for people who did not receive the initial training. A one-day orientation to
IMCI should be used to train support staff which are not directly responsible for
IMCI implementation (drivers, clerks, Ward and Patient Attendants, administrative
staff). 
2. Introduce Quality Assurance strategies and tools to be used in strengthening ongoing
IMCI supportive supervision.
3. Design and implement a referral system, including a referral form for use by HFs and a
community referral procedure based on the official child/maternal health card (Health
Passport).
4. Organize a review meeting for all stakeholders in nutrition programs to understand
what is currently being done in order to develop a concrete plan for CSP involvement.
5. Strengthen and implement a comprehensive behavior change communication strategy on
HIV/AIDS including VCT and PMTCT.
6. Conduct a review of the planned need for ITNs and of the management system of the
sale of ITNs in communities and HFs.
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7. Evaluate the number, distribution and frequency of Under 5 immunization clinics (static
and mobile) to determine whether gaps remain which limit access by communities.
8. Leaders of different village committees should be encouraged to meet and outline
modalities to coordinate their activities.
9. Identify well-functioning VHCs to be involved in sharing their experiences. 
10. Strengthen follow-up and supportive supervision of CHVs by CSMC, HSAs and Zone
Supervisors. Modify the system of community supervision to include VHCs as
supervisors within their own community. 
11. Identify mechanisms to encourage coordination at the village level of all community
health volunteers. 
12. Clarify the job descriptions of all community health volunteers.
13. Develop a system for sharing information with the villages using maps and/or
information recorded in poster form at the village level to stimulate action planning 
14. Liaise with BCI Coordinator to identify, procure and distribute IEC materials for use
by CHVs, HSAs, and Health Facilities. 
15. Develop and implement a comprehensive IEC/BCI plan for the CSP, including PD
Hearth, the BEHAVE Framework, or other appropriate methodologies.
16. It is recommended that IEF Malawi conduct an institutional assessment and
strengthening plan, similar to the process proposed for the DHMT.
17. A mechanism for information sharing and to enhance coordination between principal
organizations in the district; NGOs, DHMT, and CHAM facilities, should be initiated by
IEF. 
18. Monthly meetings between IEF and DHMT should be planned on a set day and time
through out the year for planning and monitoring project activities.
19. Introduce Quality Assurance strategies and tools to conduct systems analysis to
determine what the root problems are in each system, what aspects are working well,
and how systems can be improved to be more efficient and effective.
20. A comprehensive study should be made of the transportation system to determine how
improvements can be made.
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21. Determine why materials/supplies are inadequate in some HFs and identify the
solutions to those problems, including the timely requisitioning of drugs and other
supplies. 
22. Identify the HFs needs for equipment and office supplies essential for the
implementation of the CSP; procure, distribute and monitor those supplies. (CSP to
make initial purchase of files, hole punches, staplers, papers, and staples).
23.Train DHMT/IEF on techniques for presenting data to enhance the use of information
for decision making.
24. Create a “library” for reports, documents, statistics that is accessible to everyone.
25. Conduct a review of the HIMS to verify the quality of data being collected and
processed, and encourage the use of data for decision making at the district and HF
levels. 
Other important recommendations are:
1. Clarify the role and function of the GMV and increase the number of trained GMVs.
2. In order to enhance the effectiveness of IMCI there is a need to supply durable,
washable, visible IMCI flow charts for the wall of each HF, and a small personal copy
for principal HF staff. Each HSA needs portable, durable IEC materials to use during
home visits in villages to teach danger signs for common illnesses.
3. The role of the BFSG in promoting PMTCT (Prevention of Mother To Child
Transmission) is unclear and needs to be strengthened in the future.
4. The CSP should investigate why the Intermittent Presumptive Treatment of malaria
for pregnant women did not increase during the last two years.
5. Strengthen hygiene promotion activities to target hand washing instead of general
promotion of latrines and rubbish pits.
6. The strategy of Revolving Drug Funds should not be pursued during the second half of
the project due to a change in the political climate and time constraints and focus
instead on piloting HSA’s medical kits.
7. CHVs and HSAs need reinforcement on their communication skills i.e. adult learning and
facilitation. This could be accomplished through supportive supervision visits and
feedback after actual education sessions.
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8. A sustainable system should be designed to conduct in-house IMCI training for the
remaining untrained staff as efficiently as possible.
9. IEF Malawi should develop a personnel policy manual which includes employee benefits,
policies, and procedures.
10. IEF should continue the on the job training for the District Accounts Clerk.
11. Define themes for education messages by HSAs and CHVs based on a district IEC/BCC
plan which includes disease patterns (months of high cholera prevalence), upcoming
campaigns or activities (vaccination campaigns) or specific problems identified in the
community (low existence of latrines).
12. Ensure that HSAs have an Essential Health Package (ORS, iron, Albendazole and
Vitamin A, etc.)
13. Assess training needs for all IEF staff based on project objectives. Project Manager
should receive additional mentoring/training in management, especially budget
management.
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E. RESULTS HIGHLIGHT 
Two years ago, the International Eye Foundation and the District Health Management
Team (IEF/DHMT) introduced a Child Survival Project in the southern district of Nsanje
bordering Mozambique. Nsanje district (population 200,000) is notorious as a very hot
place full of mosquitoes, due the low-lying areas next to the Shire River running the length
of the district. Malaria accounts for 39% of patient cases and is the leading cause of
morbidity and mortality of children under five in the district. 
The major thrust of the child survival project during the first two years has been the
implementation of facility and community-based Integrated Management of Childhood
Illness (C-IMCI) through the training of health providers and community volunteers and a
system of supportive supervision. One focus of the project is to promote malaria
prevention and use of Insecticide Treated Bed-Nets (ITNs). The project works with
Village Health Committees to select and train community members and form ITN
committees. 
After the training of the ITN committees, there was a huge change in the peoples’
perception of malaria. The committees teach community members on the causes and
prevention of malaria focusing on the dangers to pregnant women and children under five.
The project also helps increase the
availability of ITNs at the rural health
facilities and in the community. More
than 18,000 ITNs, provided by UNICEF,
PSI, IEF, and other NGOs were provided
to health facilities and village ITN
committees for distribution.
The increased availability of ITNs at low
price ($0.50 to $1.00) has resulted in
more people buying and using ITNs, and
the demand is increasing each day. After
two years of the project’s assisted implementation, about 52% of mothers with young
children report sleeping under an ITN.
During a recent visit to one ITN committee, a member commented that “less children are
visiting the health facility due to malaria today than two years ago, we are safe at last.”
Many more people understand the benefits of using bed nets, and there is growing
confidence that the demand for ITNs is increasing as knowledge and access to a reliable
supply continues to improve. 
• The percentage of mothers reporting the
presence of a bed net in the house
increased from 29% to 64% in less than
two years
• The percentage of children 0-23 months
who slept under an ITN the night before
the survey increased from 17% to 52%
in less than two years.
KPC survey data 2002 and 2004
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F. ACTION PLAN 
The MTE report highlights the progress made towards results to date, uncovering areas of
challenge, and evaluating stakeholder concerns at all levels. The CSP is developing an
Action Plan ensuring that there is a high degree of participation from all stakeholders.
After the final report is received a planning process will be carried out. The DHMT and
other key district actors (District Planning Officer) will convene a planning meeting to 1)
review the report and the recommendations, 2) reach consensus on recommendations,
prioritize and clarify where needed, and 3) define activities, establish time lines,
responsibilities, and budgets. A summary work plan document will be drafted, reviewed,
and forwarded to IEF for submission to USAID by the end of November.
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G. ATTACHMENTS
A. Baseline information from the DIP
B. Evaluation Team Members and their titles
C. Evaluation Assessment methodology
D. List of persons interviewed and contacted
E. Results of the Evaluation
F. Project Data Sheet form 
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G. ATTACHMENTS
A. Baseline information from the DIP
B. Evaluation Team Members and their titles
C. Evaluation Assessment methodology
D. List of persons interviewed and contacted
E. Results of the Evaluation
F. Project Data Sheet form 
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A. Baseline information from the DIP
No substantial changes have been made in the IEF/DHMT Child Survival Project in southern Malawi
since the approval of the DIP. A few minor changes include: 
• Elimination of Drug Revolving Funds
• Increase in total population coverage from 194,000 to over 200,000 people
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B. Evaluation Team Members and their titles
Name Position Organization
Hellen Phallaza HIV/AIDS Coordinator Africare Project
Renee Charleston Team Leader Consultant
Kennedy Ndau MCH Coordinator DHMT
Edna Tembo Project Manager IEF
Elton Chiumia HIV/AIDS Advisor IEF
Frank Chola Administrator IEF
Geoffrey Ezepue Country Director IEF
George Mekiseni Monitoring & Evaluation Advisor IEF
Henry Dzuwalatsoka MCH Advisor IEF
Hopson Ntenthaonga IMCI Advisor IEF
John Barrows Director of Programs IEF USA
Kalima Chikafa Clinical Officer MOHP
Dikilani Chadza Health Inspector/Zone Supervisor MOHP Ndamera HC
Peter Benson Health Coordinator World Vision International
Participated only in the Analysis Workshop
Hans J. Richter Head of Medical Department Lulwe &
Chididi HCs
CHAM 
Kennedy Chikonde DHO DHMT
Wasili Mathumula DEHO DHMT
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C. Evaluation Assessment Methodology
I. Objectives of the Evaluation
The purpose of the Midterm Evaluation was to;
1. Assess progress in implementing the DIP.
2. Assess progress towards achievement of objectives or yearly benchmarks.
3. Assess if interventions are sufficient to reach desired outcomes.
4. Identify barriers to achievement of objectives, and 
5. Provide recommended actions to guide the program staff through the last
half of the program.
The evaluation was carried out in accordance with Child Survival and Health Grants
Program USAID/GH/HIDN/NUT mid term evaluation guidelines (MTE) dated
August 2004 and the evaluation report follows the suggested format.
The objectives of the evaluation were to:
• Identify the principal achievements of the project, focusing on which
strategies are most effective and the barriers encountered and how they
were addressed during implementation.
• Develop recommendations for improving project strategies in order to
achieve greater impact during the next two years.
• Develop recommendations on whether to pursue certain interventions to full
scale during the next two years.
• Develop recommendations on how to obtain sustainability in all aspects of
the project.
II. Composition of the Evaluation Team
The team was composed of IEF Malawi staff, an IEF Headquarters’ representative,
MOHP staff, representatives from Africare and World Vision, plus an external
consultant who served as team leader. The team leader was responsible for
coordinating all evaluation activities, supervision of the teams, meeting all specified
objectives, collaborating with IEF and MOHP, and submitting a draft and a final
report according to the defined timeline. Three team coordinators functioned as
the coordinators of the teams for field data collection, including overall
coordination, planning and logistical support of the team.
III. Methodology
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Using both a participatory approach and participatory methodologies, a multi￾disciplinary term of key project stakeholders examined the implementation of CS
activities using a variety of qualitative methodologies. Field visits allowed project
participants and community volunteers to provide their inputs and suggestions to
the evaluation process. 
Questionnaires were developed to collect information from mothers, GMVs, BFSG,
HSAs, VHC, and HF staff through individual or group interviews. Two indicators
from the KPC survey were also shared with community mothers and VHCs using a
participatory methodology to stimulate discussion about project activities, barriers
to change and sustainability of activities. The evaluation focused on the process of
activities including; District Health Management Team organization and team
building, planning, information use and feedback, IMCI capacity building,
supervision, referral, logistics and monitoring systems, community participation,
coordination with all partners, quality of services and sustainability issues.
The methodologies used to obtain information for the evaluation included:
• Document Review, Key Informant Interviews, and Group Interviews
IV. Evaluation Plan
The evaluation was divided into four phases:
Phase I - Planning
• Preplanning (Formation of team, logistics, document review, selection of
communities) 
• Planning Workshop (Content, methodologies, design of instruments, review of
KPC) 
Phase II - Data Collection
• Community visits 
• Visits to Health Facilities, including 2 hospitals
• Visit to District Office 
• Other interviews 
• Document review 
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VILLAGES AND HEALTH FACILITIES VISITED BY THE EVALUATION TEAM
* Team Coordinator
Phase III - Data Analysis
• Team members summarized and presented field observations 
• Analysis of information by the evaluation team (2 day Analysis Workshop)
• Outputs from the Analysis Workshop 
Phase IV - Presentation
• Written report 
• Action plan to be developed after report is finalized 
• Debriefing of USAID Malawi Mission
The evaluation team was divided into 3 smaller groups to collect information from
the field. Each team consisted of 4-5 people. The teams were in the field for 2
Day 1
Friday Oct 8
Day 2
Saturday Oct 9
SOUTH ZONE BOMA ZONE
Tizola Nkhutche
Kumbukani Kaledzera
Team 1
Franck Chola*
Geoffrey Ezepue
Kalima Chikafa
Peter Benson
George Mekiseni Mbenje Health Center Chididi Health Center
BANGULA ZONE TENGANI ZONE
Laiton Mpamba
Chadzuka Mthembwe
Team 2
Henry Dzuwalatsoka*
John Barrows
Hopson Ntenthaonga
Dikilani Chadza Kalemba Health Center Tengani Health Center
MAKHANGA ZONE MLOLO ZONE
Mbingwa Kanyelamalo
Nkolimbo Gundani
Team 3
Edna Tembo*
Elton Chiumia
Kenneth Ndau
Hellen Phallaza
Renee Charleston Makhanga Health Center Trinity Hospital
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days to visit 12 communities and 5 Health Centers (in 6 supervision zones) selected
for visits. Communities were selected using a stratified random process. The area
of Misamvu in Bangula Zone was removed from the sampling frame due to the
difficulty in traveling there. 
During the Field Visits the following people were interviewed:
™ 228 Mothers in 12 villages 
™ 12 HSAs
™ 7 GMV
™ 11 BFSG
™ 80 Members of 12 VHCs
™ 5 Health Facilities visited to interview 16 Health Staff
™ Other interviews were conducted with DHMT and IEF staff and
6 Zone Supervisors. See Attachment D for a complete list of people
interviewed.
A two-day Planning Workshop was held for all team members to review the results
of the KPC and to develop methodologies and instruments for identifying the actual
project situation through interactive field visits to communities and MOHP health
facilities and the CHAM hospital.
A two-day Analysis Workshop was held for all team members plus additional
resource people to present the results of the fieldwork and to formulate
recommendations for the next two years. 
V. Evaluation Schedule October 2004
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
4
Evaluation
Planning
5 *
Planning
Workshop
6 *
Planning
Workshop
7
District
Office
Visit
Interviews
8 *
Field
Work
9 *
Field
Work
10
Preparation
of
Workshop
11
IEF Office
Visit
Interviews
12
District
Office
Visit
Interviews
13 *
Preparation
of findings
14 *
Analysis
Workshop
15 *
Analysis
Workshop
16
Wrap up
and de￾briefing
17
Travel
• All of the Evaluation Team was present
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Planning Workshop Agenda
October 5, Tuesday
8:00-8:30 Welcome - Introduction of Participants
8:30-9:30 Participatory Evaluation 
9:30-10:00 Tea Break
10:00-12:30 Presentation of CSP
12:30-1:30 Lunch
1:30-3:00 Ideal Situation - Small Groups
3:00-3:15 Tea Break
3:15-4:15 Plenary
October 6, Wednesday
8:00-8:30 Evaluation Content 
8:30-10:00 Formulation of Questions - Small Groups
10:00-10:30 Tea Break
10:30-11:30 Formation of Teams - Team Leaders
11:30-12:30 Summary of KPC Survey
12:30-1:30 Lunch
1:30-2:30 Development of Methodology for KPC 
2:30-3:30 Review of Interviewing Skills
3:30-4:00 Next Steps
Analysis Workshop Agenda
October 14, Thursday
8:30-9:00 Experiences in the field
9:00 – 10:00 KPC Gallery Walk
10:00 - 10:30 Review of Information
10:30 - 10:45 Tea Break
10:45 – 12:30 Small Groups by IRs
Define Actual Situation
12:30 – 1:30 Lunch
1:30 – 3:00 Develop Recommendations
3:00 – 3:15 Tea Break
3:15 - 5:00 Plenary
October 15, Friday
8:00- 9:00 Continuation of Plenary
9:00 – 10:30 Small Groups
Cross cutting Issues
10:30 – 10:45 Tea Break
11:00 - 1:00 Plenary
1:00 - 2:00 Lunch
2:00 - 2:30 Five Stars 
2:30 – 3:30 Cycles of Development
3:30 – 4:00 Additional Recommendations 
4:00 - 4:30 Tea Break
4:30 - 5:00 Evaluation and Closing
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VI. Evaluation of the Process
Fourteen evaluation team members completed a written evaluation of the MTE
process, during the Analysis Workshop. The results from the questionnaires were: 
♦ 7/14 (50%) of participants felt that the process used was very effective, and
7/14 (50)% that it was effective.
♦ Two people felt that the step of reviewing the finalized questionnaires before
using them was missing. 
♦ What people liked best about the process was the participatory nature of the
evaluations, the open discussions, and the methodology of comparing the ideal
situation to the actual situation. Various team members also mentioned the field
visits as what they liked best.
♦ The majority of participants said there was nothing that they liked least.
Several people felt the time for the evaluation was too short.
♦ 7/14 (50%) felt the content of the evaluation was an effective way to focus
the evaluation on sustainability. 6/14 felt the content was very effective and 1
person felt the content was little effective. 
♦ 8/14 people felt that the evaluation process was applicable to their work, 5/14
felt it was very applicable, and 1 person felt it was little applicable.
♦ The main suggestion for improving the process in the future was to identify the
most critical indicators to include in the evaluation, to involve a greater mix of
team members and more DHMT staff and an HSA representative. 
♦ Other comments included that it had given strength to the partners, and that
they felt they had gained a lot of knowledge and that is had been a positive
learning process.
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D. List of persons interviewed and contacted
The following people were interviewed during the MTE. In addition 228 mothers,
16 HF staff, 80 VHC members, 12 HSAs, 6 GMVs, and 11 BFSG were also
interviewed.
Name Position Organization
Mr. Malunga District Humanitarian Officer District Assembly
Kennedy Chikonde District Health Officer MOHP/DHMT
Kennedy Ndau Maternal Child Health Coordinator MOHP/DHMT
Wasili Mathumula District Environmental Health Officer MOHP/DHMT
Izak Phiri District Nursing Officer, Nsanje Hospital MOHP/DHMT
George Mlolo Malaria Coordinator MOHP/DHMT
Kalima Chikafa IMCI Coordinator MOHP/DHMT
Mr. Kandulu BCI Coordinator MOHP/DHMT
M. Sosono HIV/AIDS Coordinator MOHP/DHMT
Frank Chola Administrator IEF
Geoffrey Ezepue Country Director IEF
George Mekiseni Monitoring & Evaluation Advisor IEF
Edna Tembo Project Manager IEF
Elton Chiumia HIV/AIDS Advisor IEF
Henry Dzuwalatsoka Maternal Child Health Advisor IEF
John Barrows Director of Programs IEF/USA
Hopson Ntenthaonga IMCI Advisor IEF
Henry Tsamdoka Zone Supervisor Mlolo Zone
Martin Sempulo Zone Supervisor Makhanga Zone
Ovious Chauluka Zone Supervisor Bangula Zone
Richard Martin Zone Supervisor Tengani Zone
Rose Kapitapita Zone Supervisor Boma Zone
Dikilani Chadza Zone Supervisor South Zone
William Allen Administrator Trinity Hospital
Mexon Nyirongo Health and Nutrition Program Officer USAID Malawi
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E. Results of the Evaluation
IR 1. District Organizational Effectiveness and Management Support for Quality Child Care Strengthened.
Ideal Situation Actual Situation Recommendations
 Materials
• Office supplies
• Office equipments i.e. Computers,
printers, fax, email, etc
• Vehicles
• Motorcycles
• Manuals, checklists, questionnaires,
other tools
• Display case for glasses
• Ophthalmic equip/supplies
• Equipment/supplies for cost ward
District
Most supplies are available but have
occasional shortages especially at the Health
Center i.e. punches, staples, files etc.
Equipment
Chronic lack of functioning ambulances and
utility vehicles. Six zones have motorbikes
but repairs and replacements are required. 
Many HSAs have pushing bicycles but
spares are a problem.
Manual + checklist
Manuals, checklist, supervisory tools are
available. General documents, reports,
schedules are available, but some could be
widely available for distribution.
Identify the HF supply needs for office
supplies, procure, distribute and monitor
(CSP to make initial purchase of files,
punchers, staplers, papers and staples)
Equipment
• Continue to request new vehicles from
central MOH.
• Employ full-time mechanic for district
• Examine and revise, if needed, policies
and procedures for vehicle use.
• Repair or replace zone supervisors’
motorcycles.
• Establish policies for HSAs purchase of
bicycle and establish a spare part
revolving fund.
Human
Resource
• Motivated and aware:
• DHMT, CSMC
• CO, MA, Nurses, OMA, HSAs, VHCs,
Volunteers
• Consultant for sustainability, BCC,
QA/PI, Epi Info/data entry
• COs, MAs, Nurses Account Clerks are
very few at District Hospital level and
Health Facility. Urgently needed.
• Sufficient HSAs, there is need to replace
those that are lost.
• Procure one photocopy machine and
other equipment to serve CSP
• Create “library” for reports, documents,
statistics that is accessible to everyone.
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 Systems
Planning, Supervision,
Monitoring/Evaluation, Logistics (EPI,
drugs, maternity, ITNs, vehicle
maintenance),
Accounting/budgeting/management
Communication/coordination
• There is on going planning, supervision,
monitoring and coordination supported by
CSP. HIMS on going but problems with
data entry and analysis + use.
• Most drugs and vaccines are available
but experience shortages due to national
availability and lack of transport.
• ITNs are supplied direct by PSI to
facilities.
• Maintenance of vehicles is done locally
but very costly to District budget.
• Basic Accounting (manual) system is in
place and managed by clerk but need
more staff.
• Communication:- the district has
improved access to telephone, radio
messages but internet and email is
limited.
• Conduct review of HIMS and data
collection then processing and using data
for decision at district and HF level.
• Conduct review of management system
of ITNs
• Continue on job training for district
accounts clerk.
Activity
• Conduct surveys, assessments (KPC,
LQAS, HFA etc)
• Conduct training/orientation DTC/DA,
CSMC, DHMT, District forum
• Train Accountant
• Conduct Annual Review meetings
(Analysis, work plans etc)
• Conduct supervision visits
• Monitor zone activities.
The district has conducted a variety of
surveys, assessments; Annual Review
meetings etc. There has not been District
wide Forum to discuss health.
Quarterly district forums where all
stakeholders (technical) and NGOs
representatives.
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IR2. Health Provider Skills in Prevention and Management of Childhood Illness Improved
Ideal Situation Actual Situation Recommendations
Materials
Health cards, Weighing scales, MUAC tapes
and Height Board, Functioning Fridge with
Thermometer, Cotton wool, Gauze,
Thermometers, Drugs (IMCI), Respiratory
Rate Timer/second hand watch., IMCI
Guidelines, Desk/Table, cups of different
sizes, buckets, spoons, Syringes, Cooler
boxes, |Bicycles, Posters, Referral forms,
Registers, HIMS, Drug boxes, Inventory
sheets, Radio communication, Vehicles,
Vaccines.
Most materials were available with erratic
supplies on: vaccines, health cards, bicycles,
stationary, register, IEC materials, Iron tabs,
and village maps.
• Find out why these materials are
inadequate by conducting rapid +
random assessment.
• Encourage HF staff to order adequate
materials + drugs in time
• Each HSA should be given his/her own
bicycle and should be maintained by
him/her
• Encourage/advise HSA to have the map
for his/her catchment area.
• The DHO should budget according to
the District requirements.
Human
ResourceTrained IMCI Providers, Trainers/Supervisors, HSAs, Home craft workers, Hospital servants/ward attendants, Drivers, Clerks, GMVs, VHCs, TBAs, BFSGs, Traditional Healers, Drug Vendors. Trained in IMCI available but inadequate. Partially trained: Drivers, Traditional Healers, Hospital servants, Drug Vendors, Clerks. • Plan to train the remaining cadres (driver, clerks, Hospital servants, Drug Vendors and Traditional Healers) on HH/C-IMCI.
Systems
• Capacity building
• Quarterly Supervision (monitoring)
• Monthly Drug Delivery form
• CMS – Health Units
• Referral System (Community to HF and
HF to Hospital) 
Most are operational/done but: quarterly
supervision inadequate, feedback from
Health facility to community not done,
referral forms not available.
• Referrals form should be devised and
staff be oriented.
• Implement planned activities as planned
and share responsibilities and strengthen
coordination among project staff and
partners. 
Activity
• Under five clinics (daily, weekly) * 
• IMCI (quarterly) Assessments
• Trainings of different cadres
• Establishment of DRFs
• Timely Drug ordering
• Health Education
• Meetings with partners.
Most activities done except:
• Training of the hospital servants,
Traditional Healers, Drug Vendors.
• Establishment of DRF.
• Meetings with partners not regularly
done
• Train all the remaining cadres
Mid-Term Evaluation - Attachments
IEF/DHMT Nsanje Malawi
C.A.: No: HFP-A-00-02-00027-00 Page 58
IR3. Availability and Accessibility to Quality Preventative and Curative Health Services Increased
Ideal Situation Actual Situation Recommendations
Materials
• Drugs
• Syringes
• Needles
• Cleaning agents
• Consumables -cotton wool, gauze
• Sterilizers, Thermometer, BP machines,
Weighing scales
• Medical equipment –Forceps, Scissors
• Health Education Materials: Posters,
Leaflets
• HIV/AIDS Testing: Drug boxes, ITN
• Patient cards
• Amby bags
• Vaccines
• Cold chain system: Refrigerator, Cooler
boxes, Vaccine carriers
• Transport: ambulance, motor bike,
pushing bikes, lorries
• Stationery: forms, registers
Most materials were readily available except
vaccines, ITNs, Transport system (bicycles),
Stationary. Other materials were not
investigated eg. Cleaning agents, sterilizers,
and instruments.
• Coordinate transport system for
supplies.
• Procure more ITN
• Evaluate ITN revolving system
Human
ResourceDRs, COs, Nurses, HSAs, CHVs, Pharmacy Technicians, Lab Technicians, Administrators, Accountants, Support staff, (Clerks, drivers, Cleaners, Patient attendants, Ward Attendants ). At Health Facility level, Human Resources are not adequate. At community level, most community volunteers are available except GMVs that are still inadequate. • Train more GMVs • Clarify job description of community health volunteer
Mid-Term Evaluation - Attachments
IEF/DHMT Nsanje Malawi
C.A.: No: HFP-A-00-02-00027-00 Page 59
Systems
• Referral system
• Feedback
• Communication
• Logistic
• Transport
• Inventory (record system at District
Hospital with Health Centers)
• Maintenance
All the systems are in place but they are not
functioning as expected except the
communication system.
• Produce uniform referral forms
• Coordinate transport system 
Activity
Trainings on:
• IMCI
• PD Hearth
• Behave
• Counselors/VCT
• Conducting clinics
• Scheduling immunization
• Supervision
• Procure, distribute, store
• Mobilization of communities, patients,
staffs.
• Coordinating activities
• Conduct PD Hearth sessions
• IMCI and supervision activities have
been done effectively.
• PD Hearth has partially been done
• Conducting clinics, immunizations, ITN
distribution, coordinating activities are
on-going but needs much strengthening.
• Train community and introduce PD
Hearth model
• Continue IMCI training
• Scheduled community activity plan
should be distributed to communities
concerned early.
• Coordination at village level of all
community health volunteers.
• Organize a review meeting for all stake
holders in nutrition programs to
appreciate what is on the ground and
make future plans.
• Strengthen and implement
comprehensive behavior change
communication strategy on HIV/AIDS
including VCT and PMTCT
Mid-Term Evaluation - Attachments
IEF/DHMT Nsanje Malawi
C.A.: No: HFP-A-00-02-00027-00 Page 60
IR4. Community Participation, Ownership, and Demand for Health Services Increased.
Ideal Situation Actual Situation Recommendations
Materials
• ORS sachets
• 25 l water buckets
• 1 l jar
• 250/500ml cups
• Teaspoons
• ORT Room
• Benches
• Tables
• DTC Register
• Writing materials
• Basin
• Soap/ashes
• Running tap
• Bucket fixed with tap
• IEC materials eg. Posters
• 0.5% stock solution of HTH
Most materials are available except for
stationery and IEC materials (Benches,
Tables, Soap, Teaspoons, basins were not
assessed)
• Liaise with BCI Coordinator to identify,
procure and distribute IEC materials
• Essential materials/equipment to be
monitored [ORT materials]
• Maintain availability of stationary. 
Human
Resource
• Health workers
• Extension workers eg. HSAs, VHCs,
CHVs, TBAs, GMVs, Local leaders,,
Care takers, Administrator and Drivers
At Health Facility there were few Health
Workers trained and manning the Health
Facilities.
At community level, there are trained
CHVs but not fully discharging their
duties.
• Regular follow up and supervision to CHVs
• Managers, Supervisors, Administrators to
motivate staff to be dedicated.
Mid-Term Evaluation - Attachments
IEF/DHMT Nsanje Malawi
C.A.: No: HFP-A-00-02-00027-00 Page 61
Systems
• Communication transport
• Referral
• Record keeping
• Monitor
• Procurement
• Recruitment
• Distribution
• Supervision
• Co-ordination
Most aspects of the system are in existence
but require concerted efforts to improve.
There is critical shortage of health workers
at facility level.
Inadequate information sharing affecting
the system.
• Improve on communication and
coordination among stakeholders.
• Introduce and use referral forms
• Continue monitoring/supervision
• Keep track of records
• Proper timely requisition of drugs
• Ensure that HSAs have Essential Health
Package (ie ORS, Fe, Albendazole and Vit
A.)
Activity
• Community mobilization
• Health Education
• Conduct village census
• Conduct training to VHCs in HH/C￾IMCI
• Conduct training to HSAs in HH/C￾IMCI
• Follow – up and supervision
• Conduct area health meetings
• Conduct adult learning/facilitation
skills
• Procure and distribute ORT equipment
• Train Health workers in IMCI
• Train staff in Behave
• Conduct formative research
• Solicit IEC materials and distribute
• Develop strategies and materials
• Monitor and evaluate.
Most activities were conducted and others
are on-going, ie facilitation skills for adult
learning, area health meetings.
• BFSG and GMVs roles not well
defined.
• Folllow-up/ supervision by HSAs to
CHVs inadequate
• Soliciting and distribution of IEC
materials has not been taken place.
• Behave and formative research not
done.
• Insufficient number of health workers
trained in IMCI.
• Inadequate supply of ORS.
• Not all the trained CHVs are holding
meetings and some do not know what
to impart to community members.
• Regularize supervision and follow-up to
CHVs.
• Solicit and distribute IEC materials for use
by CHVs, and Health Facilities 
• Train staff in Behave (i.e HSAs and Health
Workers)
• Continue IMCI Facility based training.
• Conduct meetings with CHVs.
• Managers and Supervisors to continue
monitoring and supporting staff 
• Have laminated posters that last
• Review IEC materials inventory 
• Identify, procure and distribute IEC
• Enhance use of information system.
Mid-Term Evaluation - Attachments
IEF/DHMT Nsanje Malawi
C.A.: No: HFP-A-00-02-00027-00 Page 62
KPC FEEDBACK—MOTHERS
Team 1
ACTIVITIES BARRIERS HOW TO SUSTAIN
ITN
• Supply and availability of ITN
• Relatively low price of ITN
• High Health Education on malaria
• Formation of ITN committees
• Lack of knowledge
• Low income
• Presents of alternatives like burning cow
dung
• Negative attitude
• Priority to buy food
• Sustain supply + availability at village
level
• Reduce price to K50 as Health Facility
based
• Continue health education
HIV
• Health Education through drama
• Training session to VHC
• Stigma
• Cultural practices sexual diseases
• Reluctant to change
• Shyness 
• Stop ritual cleansing.
• Modify ritual practices that promote HIV
through use of herbs.
Team 2
ITN
• Increased Health Education messages
• Trained ITN committees
• Trained VHC
• Lack of money
• Inadequate IEC
• Large families
• Uncomfortable to sleep under a net
• No interest
• Fear of unknown
• Use net for fishing
• Prioritize food/ nets
• Mass nets re-dipping
• Do piece work to find money for nets
• Continue giving Health Education
• The poor to be given free nets
Mid-Term Evaluation - Attachments
IEF/DHMT Nsanje Malawi
C.A.: No: HFP-A-00-02-00027-00 Page 63
HIV/AIDS
• Training of VHCs
• Drama shows
• Increased Health Education
• Pretending not to know
• Inadequate IEC messages
• No interest to HIV/AIDS messages
• Not free to express themselves
• Lack of knowledge
• Not believing that HIV is real
• Give Health Education on condom use and
HIV/AIDS
• Advice to be given to stubborn people
• Hold village meetings to discuss HIV/AIDS
issues
• Encourage shy ones to talk about HIV/AIDS
during discussions
Team 3
ACTIVITIES BARRIERS HOW TO SUSTAIN
ITN
• Education through GMVs and VHCs
• Increased knowledge on ITN importance
• Lack of money
• Women don’t attend health education
meetings
• Reduce ITN prices
• Continue education on ITNs
HIV/AIDS
• HH/C-IMCI
• IEC through drama
• Women usually don’t attend meetings
• Messages are not clear
• Men & VHC to encourage women to attend
Health Education meetings.
• Messages given to community be clear.
Mid-Term Evaluation - Attachments
IEF/DHMT Nsanje Malawi
C.A.: No: HFP-A-00-02-00027-00 Page 64
KPC FEEDBACK--VHC
Team 1
ITNs
ACTIVITIES BARRIERS HOW TO SUSTAIN
• Health Education
• Accessibility to cheap ITNs
• Train sessions to VHCs
• Lack of knowledge on dangers of malaria
• Low income levels
• Increases IEC
• Increase supervision by HSAs
HIV/AIDS
• Health Education
• Training sessions imparted knowledge on
HIV/AIDS
• Lack of knowledge 
• Shyness 
• Increase IEC
• HIV/AIDS messages door to door
• Increase women participation in drama
• Promote VCT before sexual cleansing
Team 2
ITN
• Reduce net prices
• Easy access to nets
• Inadequate IEC
• Lack of money
• Use of cow dung
• The poor to be given free nets
• Continue Education on ITNs
• Committees to continue selling nets
• Net should be readily available at the
community
HIV/AIDS
• Trained VHC • Not affected and/infected
• Most people do not accept young people to
give HIV/AIDS messages
• No interest
• Older people should be involved in giving out
HIV/AIDS messages
• Prefer external education
Mid-Term Evaluation - Attachments
IEF/DHMT Nsanje Malawi
C.A.: No: HFP-A-00-02-00027-00 Page 65
Team 3
ITN
• HH/C-IMCI
• Establishment of ITN committees
• Reduce ITN prices
• Poverty
• Negligence
• Ignorance
• Mozambicans purchase nets for fishing
• Inadequate supply of ITNs
• Reduce ITN price
• Continued education through village
headmen’s reinforcement
• Restrict Mozambicans from buying nets (put
tough measures)
• Increase ITN supply
HIV/AIDS
• HH/C-IMCI
• Education through drama groups
• Meetings with community leaders
• Poor attendance when Health Education
meetings are organized (cultural beliefs)
• Not interested in the messages during
meetings
• Intensify IEC
• Community leaders should be actively
involved in educating the community.
Mid-Term Evaluation - Attachments
IEF/DHMT Nsanje Malawi
C.A.: No: HFP-A-00-02-00027-00 Page 66
Cross Cutting Issues
Sustainability
What have we done What needs to be done Recommendations
• Trainings i.e IMCI Facility
Based and HH/C-IMCI.
• Supervision and Planning
skills workshop
• Supervision
• Zonal system enhanced
(supervision prominent)
• Quarterly meetings
• Information sharing to be
enhanced
• Participation of Community
Health Volunteers in
supervision.
• Zonal meetings/Area Health
meeting.
• Exchange visits (i.e VHC
toVHC and DHMT to other
DHMT)
• Modify the system of
community supervision to
include VHC.
• Identify well-functioning
VHCs to be involved in
exchange visits.
• Review and strengthen
information sharing system.
• Reinforce adult learning and
facilitation skills through
supervision.
Communication
What have we done What needs to be done Recommendations
• Training Community Health
Volunteers
• Provided IEC materials to
some Community Health
Volunteers
• Partial supervision
• Meetings – Community
Health Volunteers, HSAs
(DHMT/IEF/CSMC
• Refresher courses to
Community Health
Volunteers
• Improve on supervision
• Distribute IEC materials to
all Community Health
Volunteers.
• Improve on how HSAs use
IEC materials on daily basis
• Provide feedback to the
Community Health
Volunteers.
• Refresher courses – CHV,
HSAs, on communication
skills
• Strengthen supervision of
CHVs by DHMT, IEF.
• Train DHMT/IEF on
varieties of presenting data
(Information).
• Implement targeted
messages based on
community interest and
need.
Coordination
What have we done What needs to be done Recommendations
• Providing trainings
• Quarterly Integrated
supervision
• Quarterly zone meetings
• Coordination meetings
quarterly (stakeholders)
• Regulate quarterly zone
meetings
• The VHCs should identify
other committees that exist
in their village.
• Leaders of village
committees should be
encouraged to meet
regularly.
• HSAs should identify
Extension Workers and plan
work together 
• Include a concept of
coordination in all training
• Leaders of different village
committees should meet and
outline modalities to
coordinate their activities.
• Strengthen quarterly
meetings.
• Hold monthly meetings
between IEF and the DHMT
on a set day and time for
planning and monitoring
project activities
Mid-Term Evaluation - Attachments
IEF/DHMT Nsanje Malawi
C.A.: No: HFP-A-00-02-00027-00 Page 67
F. Project Data Sheet form – MTE Updated Version
Child Survival Grants Program Project Summary
Mid Term Submission: Nov-08-2004
IEF Malawi
Field Contact Information:
First Name: Dr. Geoffrey 
Last Name: Ezepue 
Address: Laws Road (Between Ryalls Hotel & Gov. Hotel Training School 
PO Box 2273 
City: Blantyre 
Country Malawi 
Telephone: 011-265-1-624-448 
Fax: 011-265-1-624-526 
E-mail: ief@malawi.net 
Project Web Site: www.iefusa.org
Project Information:
Project
Description:
The International Eye Foundation (IEF), in collaboration with the District Health Management
Team (DHMT) of Nsanje District, Malawi, is implementing a four-year child survival project
entitled “Improved Child Survival in Nsanje District, Malawi, Through Community-Based
Interventions and Strengthening of the Health Delivery Infrastructure.” The project is creating
synergy between the DHMT, heath facilities and the communities they serve. Health worker
performance and the health system are being strengthened through Integrated Management of
Childhood Illness strategies, both clinical and community based activities. New supervision and
monitoring systems are functioning a 6 Supervision Zones. Health interventions include
immunization, vitamin A, nutrition, diarrhea, pneumonia, malaria, and HIV/AIDS. New
interventions such as Voluntary Counseling and Testing, use of the Behave framework, and PD
Hearth are being utilized. The project is stimulating coordination between different district
departments, such as Agriculture, Community Development, and Water, as well as,
coordination between villages and health facilities. Innovative sustainability strategies to
generate income from a “cost ward” and sale of eyeglasses are being introduced. 
Partners:
The main partners are the District Health Management Team, 2 hospitals (1 MOHP and 1 semi￾private), 11 health centers, and 8 health posts. At the community level, the project is working
with a network of 184 Health Surveillance Assistants, and a network 513 Village Health
Committees, 1,096 community volunteers and traditional healers. IEF is also collaborating with
Malawi-based NGOs such as the Christian Hospital Association of Malawi, Population Services
International (for the provision of bed nets), and the National AIDS Commission, and other.
Project Location:
The project is located in Nsanje District, in the southern extreme of the Lower Shire Valley.
The district is one of the poorest districts in the nation, and has many of the country’s poorest
health indicators. The 1998 national census shows Nsanje District’s total population at 194,481
(census 1998), but the district estimates over 230,000 persons (unofficial census). 
Grant Funding Information:
USAID Funding:(US $) $1,112,811 PVO match:(US $) $1,082,667 
Mid-Term Evaluation - Attachments
IEF/DHMT Nsanje Malawi
C.A.: No: HFP-A-00-02-00027-00 Page 68
Target Beneficiaries:
Type Number
0-59 month old children: 33,000
Women 15-49: 45,000
Beneficiary Residence:
Urban/Peri-Urban % Rural %
5% 95% 
General Strategies Planned:
Strengthen Decentralized Health System
Strengthen Decentralized Health System
M&E Assessment Strategies:
KPC Survey
Health Facility Assessment
Organizational Capacity Assessment with Local Partners
Organizational Capacity Assessment for your own PVO
Participatory Rapid Appraisal
Lot Quality Assurance Sampling
Community-based Monitoring Techniques
Participatory Evaluation Techniques (for mid-term or final evaluation) KPC Survey
Health Facility Assessment
Organizational Capacity Assessment with Local Partners
Organizational Capacity Assessment for your own PVO
Participatory Rapid Appraisal
Lot Quality Assurance Sampling
Community-based Monitoring Techniques
Participatory Evaluation Techniques (for mid-term or final evaluation) 
Behavior Change & Communication (BCC) Strategies:
Interpersonal Communication
Peer Communication
Support Groups Interpersonal Communication
Peer Communication
Support Groups 
Capacity Building Targets Planned:
PVO Non-Govt
Partners Other Private Sector Govt Community
US HQ (General)
Field Office HQ
CS Project Team US HQ
(General)
Field Office HQ
CS Project Team 
(None
Selected) 
Pharmacists
Traditional Healers
Private Providers
Pharmacists
Traditional Healers
Private Providers 
Dist. Health
System
Health Facility
Staff
Dist. Health
System
Health Facility
Staff
Health CBOs
CHWs Health CBOs
CHWs 
Mid-Term Evaluation - Attachments
IEF/DHMT Nsanje Malawi
C.A.: No: HFP-A-00-02-00027-00 Page 69
Interventions:
Immunizations 5 %
** IMCI Integration
** CHW Training
** HF Training
Nutrition 10 %
** IMCI Integration
** CHW Training
** HF Training
Vitamin A 3 %
** IMCI Integration
** CHW Training
** HF Training
Micronutrients 2 %
** CHW Training
** HF Training
Acute Respiratory Infection 20 %
** IMCI Integration
** CHW Training
** HF Training
Control of Diarrheal Diseases 15 %
** IMCI Integration
** CHW Training
** HF Training
Malaria 20 %
** IMCI Integration
** CHW Training
** HF Training
Breastfeeding 5 %
** IMCI Integration
** CHW Training
** HF Training
HIV/AIDS 20 %
** CHW Training
** HF Training
Mid-Term Evaluation - Attachments
IEF/DHMT Nsanje Malawi
C.A.: No: HFP-A-00-02-00027-00 Page 70
Indicator Numerator Denominator Estimated
Percentage
Confidence
line
Percentage of children age 0-23 months who are
underweight (-2 SD from the median weight-for-age,
according to the WHO/NCHS reference population)
0 0 0.0 0.0
Percentage of children age 0-23 months who were
born at least 24 months after the previous surviving
child
0 0 0.0 0.0
Percentage of children age 0-23 months whose births
were attended by skilled health personnel 188 300 62.7 5.3
Percentage of mothers of children age 0-23 months
who received at least two tetanus toxoid injections
before the birth of their youngest child
227 300 75.7 5.3
Percentage of infants age 0-5 months who were
exclusively breastfed in the last 24 hours 48 73 65.8 11.0
Percentage of infants age 6-9 months receiving
breastmilk and complementary foods 38 43 88.4 9.6
Percentage of children age 12-23 months who are fully
vaccinated (against the five vaccine-preventable
diseases) before the first birthday
94 160 58.8 7.8
Percentage of children age 12-23 months who received
a measles vaccine 121 160 75.6 6.4
Percentage of children age 0-23 months who slept
under an insecticide-treated bednet the previous night
(in malaria-risk areas only)
156 300 52.0 6.0
Percentage of mothers who know at least two signs of
childhood illness that indicate the need for treatment 208 300 69.3 5.7
Percentage of sick children age 0-23 months who
received increased fluids and continued feeding during
an illness in the past two weeks
46 118 39.0 9.0
Percentage of mothers of children age 0-23 months
who cite at least two known ways of reducing the risk
of HIV infection
199 300 66.3 5.0