PERU CHILD SURVIAL XVI
Departments of Cajamarca & La Libertad
 REDESS
FAO-A-00-00-00030-00
October 1, 2000 - September 30, 2004
FINAL EVALUATION
December 2004
Consultant: Renee Charleston
CARE HQ Contact: CARE Peru Contact:
Joan Jennings, MPH Carlos Cardenas
Senior Technical Advisor: Child Health Country Director
CARE USA CARE Peru
151 Ellis Street NE Aparto 11-0628
Atlanta, GA 30303 Lima 11, Peru
Tel: 404-979-9413 Tel: 51-14-317430
Email: jjennings@care.org Email:cardenas@care.org.pe
ACRONYMS
ANA Analysis of Learning Needs (Analisis de Necesidades de Aprendizaje)
AOP Annual Operating Plan (POA in Spanish)
ASOACS CHA Association
ARI Acute Respiratory Infection
BCC Behavior Change Communication
CDD Control of Diarrheal Disease
CHA Community Health Agent (includes promoters, TBAs, women leaders)
CHP Community Health Promoter (Volunteer)
COACS CHA Committee
CODECO Community Development Committee
CS Child Survival
CSHGP Child Survival and Health Grant Program
DCM Diarrheal Case Management
DIP Detailed Implementation Plan
ENLACE Previous CARE Peru CS project 1996-2000.
FE Final Evaluation
FOGEL Facilitating Local Government Participation in Health
HC Health Center
HH/C IMCI Household/Community Integrated Management of Childhood Illnesses
HIS Health Information System
HIV/AIDS Human Immunodeficiency Virus/Acquired Immunodeficient Syndrome
HQ CARE Headquarters in Atlanta
IEC Information, Education, Communication
IMCI Integrated Management of Childhood Illnesses
KPC Knowledge, Practice, and Coverage Survey
LQAS Lot Quality Assurance Sampling
MNC Maternal Newborn Care
MOH Ministry of Health (MINSA)
MTE Mid Term Evaluation
NGO Non-Governmental Organization
ORS Oral Rehydration Solution
PCM Pneumonia Case Management
PVO Private Voluntary Organization
SIVICS Community Health Information System
TBA Traditional Birth Attendant
TOT Training of Trainers
TT Tetanus Toxoid 
USAID United States Agency for International Development
WRA Women of Reproductive Age
Table of Contents
A. Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
B. Assessment of Results and Impact of the Program. . . . . . . . . . . . . . . 4
1. Results: Summary Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
2. Results: Technical Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
3. Results: Cross-cutting approaches . . . . . . . . . . . . . . . . . . . . . . . 15
a. Community Mobilization. . . . . . . . . . . . . . . . . . . . . . . . . . . 15
b. Coordination with Government Structures. . . . . . . . . . . 21
c. Communication for Behavior Change. . . . . . . . . . . . . . . . . 24
d. Capacity Building Approach. . . . . . . . . . . . . . . . . . . . . . . . 28
i. Strengthening the PVO Organization. . . . . . . 29
ii. Strengthening Local Partner Organizations. . 31 
iii. Health Facilities Strengthening. . . . . . . . . . . 33
iv. Strengthening Health Worker Performance. 34
v. Training. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 
e. Sustainability Strategy. . . . . . . . . . . . . . . . . . . . . . . . . . . 39
C. Program Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
1. Planning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
2. Staff Training. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
3. Supervision of Program Staff. . . . . . . . . . . . . . . . . . . . . . . . . . . 42 
4. Human Resources and Staff Management. . . . . . . . . . . . . . . . . 43
5. Financial Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
6. Logistics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
7. Information Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
8. Technical and Administrative Support. . . . . . . . . . . . . . . . . . . . 48 
9. Management Lessons Learned. . . . . . . . . . . . . . . . . . . . . . . . . . . 49
D. Conclusions and Lessons Learned. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
E. Results Highlight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 
ATTACHMENTS:
A. Evaluation Team Members 
B. Evaluation Assessment Methodology
C. List of persons interviewed and contacted
D. Final KPC Report
E. Project Data Sheet
1
A. Summary
CARE Peru received a Child Survival XVI grant to implement a four year 
project (10/00-9/04) in two northern Departments, La Libertad and 
Cajamarca. REDESS is a follow-on project to the previous ENLACE CS 
project 1996-2000. Many of the strategies which were proven effective 
during ENLACE were modified, improved, and implemented as part of 
REDESS. The replication of these interventions in a different geographic 
area was successfully accomplished. The underlying goal of these projects 
has gone beyond implementing technically sound health interventions to a 
broader scope of changing social structure-within communities and local 
governments. REDESS received a four month no-cost extension (through 
1/05). A participatory Final Evaluation was conducted during 12/04 by a 14-
person team of representatives from MOH central, regional and local 
offices, CARE Peru and headquarters, and an external evaluator. 
The project goal of improved maternal-child health results from reaching 
four intermediate results through a partnering relationship between CARE 
Peru, the Ministry of Health (MOH), Community Health Agents (CHAs), local 
governments and community organizations within a national process of 
Health Sector Reform and decentralization. These changes have focused on 
health promotion, increased local control of resources and decision making, 
and strengthening of strategic alliances among all stakeholders. CARE has 
positioned itself to be ahead of these changes, developing models for local 
control and networks before legislation has mandated them. The 
institutionalization of interventions is a key element of sustainability.
IR 1 Improved coverage and quality of services provided by health 
networks REDESS influenced both the demand for services and the supply 
of quality services. The focus was not on improving the technical capacity of 
the MOH, rather on improving community outreach and management skills. 
IR 2 Increased caretaker knowledge and practice
REDESS did not reach many preset targets for changing knowledge, in part 
because indicators were complex and measured multiple answers. The 
project did make significant changes in practices, for example:
ÿ Increased from 48% to 78% mothers who seek appropriate medical 
treatment for children age 0 to 23 months with signs of pneumonia
ÿ Increased from 55% to 84% women with an obstetrical complication who 
are treated by a health professional 
ÿ Increased from 56% to 81% women with 4 or more prenatal care visits
2
ÿ Increased from 33% to 83% children 0 - 6 months exclusively breastfed
The approach utilized to stimulate behavior change through campaigns using 
a variety of methods and media, support groups, and education sessions was 
an effective way to improve the health of the population. 
IR 3 Improved quality and coverage of care provided by CHAs.
The implementation by CHAs of the referral system, community support 
groups, and emergency evacuation plan have increased demand for services, 
linkages between Health Centers and communities have been strengthened 
by improving MOH staff skills and providing opportunities for coordination. 
IR 4 Strengthened relationships between CHA associations, governments 
and civil society. The emphasis was to strengthen the structure within 
which technical interventions are implemented. This structure consists of 
CHAs, CHA and community organizations, MOH staff, local governments, and 
consensus building committees. CHA organizations have gained the skills 
necessary for self-management and for collaborating with the MOH and 
other community organizations. Community committees have given people a 
voice and mechanism for reaching consensus within an organized community. 
REDESS has been able to successfully meet all intermediate results, or make 
substantial progress in completing them. The strength of this project was 
not the technical focus, (divided between maternal newborn care 40% and 
60% integrated IMCI (nutrition 30%, pneumonia case management 15%, 
control of diarrheal disease 15%) but on the cross cutting approaches which 
were implemented. The first two strategies are expected to be adopted by 
program partners for wider scale applicability:
s Community Health Information System (SIVICS) including community 
mapping of vulnerable groups, census, and referral system,is a key tool for 
strengthening the link between communities and the health sector. 
s Structure, organization, and operational skills of the CHA organizations
s Strengthening of community development committees, CHA 
organizations, and local government structures and the linkages united them.
s Health facility strengthening through improved organization and training 
of health staff, including IMCI training
Sustainability can be viewed based on four principles- permanent behavior 
change- KPC survey results show an increase in knowledge, practices, and 
coverage; supportive structures- REDESS has woven together a structure 
to support health activities; links with permanent institutions-The strength 
3
of this project has been the focus in this area that is very much in step with 
current national political restructuring, and financial support- REDESS has 
encouraged financial sustainability at various levels.
The inclusion of partners and communities throughout the entire process 
foments excellent community ownership and pride in the work accomplished.
The project took on the very difficult task of weaving together a structure 
capable of sustaining improved health practices and services. The 
improvements seen to date are the results of the sum of training at various 
levels. The fabric that has been woven is still very fragile, but the project 
has been able to successfully improve capacity, leaving human resources 
capable of continuing, and improving upon, health activities. REDESS has left 
excellent models for decentralization and increased citizen participation, 
but these models need to be systematized and replicated in other areas, 
including within other sectors as a model for grassroots development, CARE 
Peru and partners are actively seeking funding to support scaling up.
Key lessons learned during project implementation include:
s Information collection is not a valid activity unless that information is 
used for decision making. All projects need to create a culture of 
information use.
s Implement principal activities during the first two years of the project, 
and use the last two tears for monitoring and supervision
s Documentation and marketing of successful models is a long term 
challenge for CARE and its partners.
s Adult Education Methodologies should be used in all training events
s Training should never be held alone, without a follow-up plan for 
monitoring and supervision, particularly in IMCI
s Supervision visits made with an integrated focus and team are most 
effective
s Having a greater understanding and sensitivity to the local culture makes 
communication more effective.
s Advocacy and diffusion of project experiences is needed at local, regional 
and central levels. 
s To achieve behavior change it is important to use a variety of media and 
techniques, each with the same standardized message. 
4
B. Assessment of Results and Impact of the Program
1. Results: Summary Chart
Technical Interventions: Measured by KPC Survey at Baseline and Final
Final Reached Target Improved Indicator
Pneumonia Case Management (15%): Improve pneumonia case management in children age 0-23 months
Increase from 5.7 to 80% mothers who recognize 
two signs of pneumonia
59.6% No Very significant improvement
 P=.000
Increase from 47.8 to 80% mothers who seek 
appropriate medical treatment for children age 0 
to 23 months with signs of pneumonia
78.1% Yes
Significant Improvement
P=.001
Prevention and Control of Diarrheal Disease (15%): Reduce prevalence of diarrhea in children age 0-23m
Increase from 0.3 to 60% mothers with children 0 
-23 m. that correctly identify at least two signs of 
dehydration and two signs of severe diarrhea
6.2% No Significant Improvement
P=.000
Increase from 36.7 to 70% mothers, with children 
age 6 to 23 months with diarrhea, that receive the 
same or more food during the episode
56.2% No
Significant Improvement
P=.006
Decrease from 25.2 to 10% children age 0-23 
moths with diarrhea who receive antibiotics 
during the episode
18% No No
Maternal Health (40%): Improve prenatal care, early detection of obstetric risk and post-natal practices
Increase from 19.9 to 60% women of 
reproductive age that recognize at least two 
danger signs each during pregnancy, childbirth 
and post-partum
18.5% No
No, there were problems with 
measuring this indicator as few 
women mentioned 2 danger signs, 
for each stage, but approx 65% 
could mention 1 sign per category
Increase from 56.3 to 80% pregnant women with 
4 or more prenatal health care visits
81.1% Yes Very significant improvement
 p=.000
Increase from 37.6 to 80% women of 
reproductive age who had received two or more 
doses of tetanus toxoid before their last childbirth
54.5% No
Very significant improvement
 p=.000
Increase from 55.4 to 70% women with an 
obstetrical complication who are treated by a 
health professional
84.3% Yes
Very significant improvement
p=.000
Increase from 11.1 to 60% mothers with children 
under two who can recognize three or more 
danger signs in newborns
27.2% No Very significant improvement
 p=.000
Nutritional Improvement (30%): Improve child feeding practices in children age 0 to 23 months
Increase from 33.3 to 70% children 0 to 6 months 
exclusively breastfed 82.5% Yes
Very significant improvement 
p=.000
Increase from 11.8 to 70% children age 6-23 
months who receive five feedings per day 31.5% No
Very significant improvement
 p=.000
Increase from 8.7 to 60% children age 6-23 
months who receive treatment for parasites every 
6 months.
11.7% No No
Additional project indicators are included in respective sections on capacity 
building and sustainability. The complete KPC report is included in Annex D.
5
2. Results: Technical Approach
a. Summary
CARE Peru received a Child Survival XVI grant to implement a four year 
project (October 2000-September 2004) in the northern Andean highlands 
in two contiguous Departments, La Libertad and Cajamarca. The REDESS
Child Survival Project was implemented by CARE Peru, in collaboration with 
the Ministry of Health (MOH), Community Health Agents (CHAs) and local 
governments. The REDESS Project covers the entire province of Sanchez 
Carrion in the Department of La Libertad, consisting of 12 Districts, and 
three of the four districts in the province of Cajabamba in the department 
of Cajamarca. (Each department consists of provinces and each province is 
made up of districts.)
REDESS is a follow-on project to the previous ENLACE CS project 1996-
2000 in provinces of Otuzco and Julcán in the Department of La Libertad.
Many of the strategies which were proven effective during ENLACE were 
adapted, improved, and implemented as part of REDESS. To understand the 
basic philosophy of both of these projects, it is helpful to look at the 
meaning of the two names; ENLACE translates to “links” and REDESS means 
“networks”. The underlying goal of these projects has gone beyond 
implementing technically sound health interventions to the larger scope of 
changing social structure and health care interaction-within communities and 
local governments.
GOAL: By the year 2004, to have improved the health of children under age five and women of 
reproductive age, with a focus on decreasing maternal, perinatal and infant morbidity and 
mortality, in 382 rural communities in Sanchez Carrion and Cajabamba provinces.
Result 1
Improved MOH 
capacity for 
community outreach.
Result 2
Increased community 
responsibility for 
improved personal 
health. 
Result 3
Sustained provision 
of front line 
services by CHAs.
Result 4
Sustained participation 
of local governments in 
health management. 
Intermediate 
Result 1
Improved coverage 
and quality of 
services provided by 
local health networks 
Intermediate
Result 2
Increased caretaker 
knowledge and 
practice 
Intermediate 
Result 3
Improved quality 
and coverage of 
care provided by 
CHAs.
Intermediate 
Result 4
Strengthened 
relationships between 
CHA associations and 
local municipal 
governments and civil 
society.
6
The project premise of improved maternal-child health was assumed to
result from an emphasis on positive changes in health knowledge, attitudes
and practices by individuals, families, communities and local health units
through a partnering relationship between CARE, the Ministry of Health,
local government and community organizations within a national process of
modernization of health services. The partnership will ensure the
institutionalization of program interventions as a key element of
sustainability of health improvement actions.
Child survival interventions prioritized maternal newborn care (MNC) with
40% of project effort, followed by nutritional improvement at 30% effort, 
and pneumonia case management (PCM) and control of diarrheal disease
(CDD) at 15% effort each. All interventions were implemented in accordance 
with plans outlined in the DIP (Detailed Implementation Plan).
The project proposed to serve 382 rural communities (269 in Sanchez 
Carrion and 113 in Cajabamba) with an estimated population of 160,169 and 
to provide benefits to 67,116 beneficiaries, consisting of 22,659 children 
under age five and 44,457 women of reproductive age (WRA). The actual 
project coverage was 348 communities (268 in Sanchez Carrion and 80 in 
Cajabamba). This change significantly effected the direct beneficiary 
population (121,957 actual vs. 160,169 planned). However the capacity￾building and training activities for MOH staff in the province of Sanchez 
Carrion in the Department of La Libertad and the province of Cajabamba in 
the department of Cajamarca provided for improvements in health care for 
the entire MOH coverage area.
METHODOLOGY
REDESS received a four month no-cost extension (through January 2005) 
consequently the Final Evaluation (FE) was conducted during 
November/December 2004. A participatory evaluation was conducted by a 
14-person evaluation team of representatives from MOH central office, 
MOH regional offices of La Libertad and Cajamarca, local Health Network 
MOH, CARE Peru REDESS, CARE USA headquarters, and led by an external 
evaluator, author of this document. Results from the FE were presented to 
CARE Peru and partners through a series of opportunities, including a 
presentation in Lima, attended by representatives from central MOH 
(including the new Health Promotion division); regional MOH, USAID, and 
7
other NGOs. For additional information on the methodology used please see 
Annex B, for information on team members, see Annex A, and Annex C for a 
list of persons interviewed and contacted during the FE. The main objective 
of the FE was to identify lessons learned during the implementation of the 
REDESS project which would be useful to CARE, the MOH, or other 
organizations implementing similar projects in the future. Lessons learned 
are underlined and included throughout the document, as well as summarized 
in the final section. 
The Summary Chart on page 3 summarizes the principal project indicators 
that were measured through a KPC (Knowledge, Practices, Coverage) Survey 
in 2000 and repeated in 2004. A copy of the complete final KPC Survey 
report is included in Annex D. Nine of the 13 (69%) indicators did not meet 
the target set at baseline, but 77% (10 of the 13) indicators showed a 
significant improvement. The strength of this project was not the technical 
focus, (which was adequate and in line with MOH policy) but on the cross 
cutting approaches which were implemented, the most important being:
s Community Health Information System (SIVICS)
s Health facility strengthening through improved organization and training 
of health staff, including IMCI (Integrated Management of Childhood 
Illnesses) training
s Strengthening of community development committees (CODECO), CHA 
committees and associations, and local government structures and the 
linkages united them within the context of new opportunities for action 
through decentralization to municipal governments and increased 
opportunities for civil society participation (e.g. "participatory budget 
process").
b. Progress report by intervention area
Maternal Newborn Care (MNC) (40%) 
The main activities completed during the four-year project were:
1. Focus education in communities and training for CHAs (including 
traditional birth attendants) on recognizing signs and symptoms of 
danger during pregnancy, birth, postpartum and in the newborn
2. Organize Training of Trainers (TOT) workshops for MOH personnel to 
train CHAs in recommended prenatal and postnatal health care actions 
3. Train CHAs to assist pregnant women to develop a Birth Plan
8
4. Development of SIVICS for surveillance of WRA which allowed CHAs to 
concentrate monthly home visits on households with pregnant women and, 
with referral and counter-referral for pre/post-natal care and follow-up. 
5. Provide CHAs with health education materials for maternal health 
promotion to use in talks to groups of mothers or individual counseling to 
pregnant women. 
6. Trained some MOH staff in the BABIES methodology to provide a deeper 
understanding of the causes of neonatal mortality and help determine 
appropriate interventions at the facility and community levels.
7. Train CHAs and CODECOs to motivate their communities and develop 
sustainable emergency evacuation plans 
8. Work with the hospital and health centers (HCs) to provide training in 
emergency obstetric care, and supply two-way radios
9. Promote use of professional health personnel for delivery in either a 
home or institutional setting
10. Train mothers to perform basic interventions for newborns and to 
recognize danger signs.
These activities had the following impact, as measured by KPC Survey:
Indicator Final
Increase from 19.9 to 60% WRA that recognize 
at least two danger signs each during pregnancy, 
childbirth and post-partum
18.5%
Increase from 56.3 to 80% pregnant women with 
4 or more prenatal health care visits
81.1%
Increase from 37.6 to 80% women of 
reproductive age who had received two or more 
doses of tetanus toxoid before their last childbirth
54.5%
Increase from 55.4 to 70% women with an 
obstetrical complication who are treated by a 
health professional
84.3%
Increase from 11.1 to 60% mothers with children 
under two who can recognize three or more 
danger signs in newborns
27.2%
The first indicator for danger signs was unchanged by project activities but 
broken down shows an increase in knowledge; 76% of women surveyed could 
name one sign of danger during pregnancy (an increase from 27% at baseline) 
and 68% a danger sign during birth (an increase from 26%). More than half 
of the women surveyed recognized vaginal bleeding (the principal cause of 
maternal mortality) as a danger sign during pregnancy, 45% as a danger sign 
during birth, and 52% postpartum.
9
It is not logical that 81% of women had 4 prenatal visits and only 55% had 
tetanus toxoid (TT). The reason for this difference is that the denominator 
used in calculating women with prenatal care was only those women with a 
health card, whereas the denominator for women with TT was all women in 
the survey, but using the health card to verify vaccination. This does point 
out a potential problem related to accuracy of the information or retention 
of maternal immunization card. 
The percent of births that took place in a health facility did not 
significantly change (17% at baseline to 24% at final) even though people 
informally reported that more women were delivering in health facilities. 
However, almost half (45%) of births are attended by health personnel in 
either a health facility or a home delivery. 
IMCI
The remaining 60% of project effort was implemented under the integrated 
IMCI approach. The principal activities included:
s Training of MOH staff in HH/C IMCI (Household and Community) 
and Clinical IMCI
s Training of CHAs in two IMCI modules- Well Child and Sick Child
s Providing educational materials in two IMCI modules- Well Child 
and Sick Child for CHAs to use in educating community members
s Assist CHAs to develop appropriate techniques for community 
health education activities
s A supervision system for HH/C IMCI has been developed with the 
MOH and promoted by REDESS but the actual implementation was 
very limited. Supervision includes a CHA interview, client (mother) 
interview, and home visit observation.
s Implemented SIVICS for monitoring key IMCI activities
Project indicators did not include specific IMCI measures, but the project 
did measure Rapid CATCH indicators during the final KPC Survey. Details on 
all Rapid CATCH indicators can be found in Annex D. Some significant 
observations were:
s The percent of mothers who reported increased liquids and continued 
feeding for children 0–23 months with an illness in the 2 weeks prior to the 
survey increased significantly from 18% to 43%.
10
s The indicator for signs requiring care seeking was incorrectly asked 
during the survey. As this was CARE Peru’s first experience in collecting 
Rapid CATCH indicators, some misinterpretation is understandable. CARE 
should increase training on the use of KPC 2000+, including the Rapid CATCH 
indicators, to ensure correct interpretation and data collection.
s Immunization was not a specific project focus but the KPC survey showed 
that children 12-23 months of age with all vaccines increased from 46.5% to 
69%.
An additional capacity building indicator was included which relates to IMCI 
implementation:
Indicator Result Achieved Comment
80% of CHAs receive 
sufficient supplies of 
essential medicines 
(cotrimoxazole and 
ORS).
 0% of CHAs have 
supply of essential 
medicines 
(cotrimoxazole and 
ORS).
MOH policy does not allow CHAs to distribute 
cotrimoxazole. Due to a shortage of supply of ORS, 
CHAs are taught to advise mothers to increase 
liquids during diarrhea and if danger signs are 
present, to refer the child to a HC
Work with MOH at all levels to advocate for changes in policy which limit 
child survival activities e.g. distribution of cotrimoxazole and ORS.
Nutrition (30%) 
Principal project activities included:
1. Infant and child nutrition health messages included in all training for 
CHAs
2. Assist development and articulation between CHAs and local health units 
of SIVICS for surveillance of children, with referral to HC growth 
monitoring and nutrition programs
3. Provide CHAs with health education materials on appropriate feeding 
practices for children, including breastfeeding
4. Provide TOT to MOH to train CHAs in nutrition topics and support group 
facilitators
5. Create mothers' support groups and demonstration sessions to focus on 
breastfeeding, use of locally available foods, preparation of weaning 
foods, balanced diet, hygiene in food preparation, and maternal nutrition.
6. Promote use of growth monitoring services at HC through referral 
system. 
Indicator Final
Increase from 33.3 to 70% children 0 to 6 
months exclusively breastfed 82.5%
Increase from 11.8 to 70% children age 6-23 
11
months who receive five feedings per day 31.5%
Increase from 8.7 to 60% children age 6-23 
months who receive treatment for parasites 
every 6 months.
11.7%
Exclusive breastfeeding showed a very significant improvement and 
surpassed the project target. The comparison between baseline and final is 
not completely comparable as the baseline question ask “have you ever 
given...” (list of foods and liquids), whereas the final evaluation ask “have you 
given in the last 24 hours... (list of foods and liquids), 
Feeding children 5 times per day did not reach the target of 70%, but the 
target may have been set too high for changing a practice and should have 
been stated differently as recommendations for feeding children 6-8 
months of age are 2-3 times per day, children 9-11 months is 3-4 times per 
day, and children 12-24 months is 4-5 times per day. In the final KPC, 
children 6-23 months of age were fed 4 or more times per day in 60% of 
cases.
The indicator for parasite treatment was unchanged because although it was 
a project indicator, the MOH decided to prioritize other activities such as 
maternal health due to alarming rates of maternal mortality. REDESS 
respected this re-prioritization and did not implement anti-parasite 
activities.
Other changes in nutritional practices were observed in the KPC survey, 
including the addition of oil to children’s food that increased from 61% to 
92%, and the use of colostrum during the first three days after birth 
increased from 76% to 93%.
The project also collected the Rapid CATCH indicator for underweight. 
Levels of underweight (weight for age >-2 standard deviations from 
WHO/NCHS mean) showed an increase from 15% to 23% comparing baseline 
to final. While this was not a project indicator, it does point out an alarming 
trend in the area. Acute malnutrition also showed an increase from 0.3% to 
3.7%. Chronic malnutrition (height for age) decreased from 41% to 35% 
during the same time period. These results are inconsistent with an informal 
investigation during the FE, in which no factors were found to suggest 
possible food shortage or severe change in household economic status. CARE 
12
Peru’s Title II program in the area should look further into this and/or 
compare data from its program.
Pneumonia case management (15%)
The prevalence of ARI is much higher in the project area compared with 
national levels. The prevalence did not change from baseline to final as 
measured by the KPC Survey (50 to 54), which is much higher than the 
national level of 20. Due to MOH policy, none of the CHAs interviewed 
during the FE had cotrimoxazole. This policy has changed recently in a 
national effort to control prescription drugs.
Project activities included:
1. Organize TOT workshops for MOH personnel to develop training of CHAs 
in standard case management protocols for pneumonia. 
2. Assist development and articulation between CHAs and local HCs of 
SIVICS for surveillance of at-risk children, monthly reporting of PCM by 
CHAs, and referral and counter-referral of cases
Increase from 5.7 to 80% mothers who recognize 
two signs of pneumonia
59.6%
Increase from 47.8 to 80% mothers who seek 
appropriate medical treatment for children age 0 
to 23 months with signs of pneumonia
78.1%
The indicator for recognition of signs of pneumonia did not reach the target, 
but did very significantly increase. In interviews with CHAs during the FE, 
all could mention two signs of pneumonia. According to the KPC Survey, 
women that did not know any sign of pneumonia decreased from 44% to only 
19%. Even though the knowledge level did not reach the target, the change in 
care seeking practice was almost 80%.
Control of diarrheal disease (15%)
There is a high prevalence of diarrhea in the area, compared to national 
standards. Baseline level was 35% with diarrhea in the previous two weeks 
and 37% at final (no significant change). The national average is 15%. None 
of the CHAs interviewed during the FE had ORS due to nationwide shortages 
resulting from the MOH’s lack of funds to purchase ORS. CHAs are taught 
to advise mothers to increase liquids during diarrhea and if danger signs are 
present, to refer the child to a HC. The percent of mothers who reported an 
13
increase in liquids and continued feeding for children 0–23 months with an 
illness in the 2 weeks prior to the survey increased significantly from 18% to 
43%. The project is teaching the use of homemade Sugar-Salt solution, but 
in asking two different people during the FE what the recipe was, two 
different answers were given, underscoring observations in other countries 
that implementing a standardized Sugar-Salt solution is very difficult. An 
increase in all liquids, including breastmilk, should be the emphasis for 
children with diarrhea, not the preparation of a homemade sugar and salt 
solution or ORS, if not readily available. 
Project activities to support changes in knowledge and practices relating to 
diarrhea control included:
1. Organize TOT workshops for MOH personnel to develop training of CHAs 
in standard case management protocols for childhood diarrheal episodes. 
2. Establish SIVICS for surveillance of at-risk children, monthly reporting 
of CDD treatment and preventive education by CHAs, and referral and 
counter-referral of cases.
3. Perform community risk mapping to motivate community members to 
improve community hygiene (building of latrines, development of potable 
water projects).
4. Assist CHAs to organize into associations and to develop the skills 
necessary to effectively communicate community demands and to 
coordinate community contribution to municipal-supported projects and 
Title II projects.
5. Enhanced linkages between CODECOs/CHA organizations, and the 
participatory budgeting process of local municipal governments which 
frequently resulted in improved water and sanitation.
Increase from 0.3 to 60% mothers with children 
age 0 to 23 months that correctly identify at least 
two signs of dehydration and two signs of severe 
diarrhea
6.2%
Increase from 36.7 to 70% mothers, with children 
age 6 to 23 months with diarrhea, that receive the 
same or more food during the episode
56.2%
Decrease from 25.2 to 10% children age 0-23 
months with diarrhea who receive antibiotics 
during the episode
18%
Dehydrations signs were widely recognized as a sign of severe diarrhea and 
mention of blood in the stool increased from 3% to 39%, while persistent 
14
diarrhea only increased from 11% to 14%. The problem of persistent 
diarrhea was not a project focus and this was reflected in the KPC outcomes 
as well as in interviews with CHAs during the FE. 
The lack of more improvement in the indicator for increased feeding during 
diarrhea may be caused by confusion with the message which was promoted 
to give food more frequently, but in smaller amounts. Mothers who reported 
giving less food but more frequently increased from 5% to 56%. 
The project did not focus a specific message on decreasing the use of 
antibiotics and anti-diarrheal medicines, just a basic message included in 
IMCI protocols. 
c. New Approaches
Strategies implemented during the REDESS project built upon successful 
experiences in the ENLACE project. The replication of these successful 
interventions in a different geographic area was an objective of the REDESS 
project which was successfully accomplished. Two key integral strategies are 
expected to be adopted by program partners for wider scale applicability: 
a) the elements, organization and use of SIVICS and b) the structure, 
organization, and operational skills of the CHA Committees and Associations 
(COACS and ASOACS). Both of these approaches will be discussed in the 
next section of this document.
15
3. Results: Cross-cutting approaches 
The emphasis of REDESS was to strengthen the structure within which the 
technical interventions were implemented. This structure consists of 
community level actors- CHAs, CHA organizations, and CODECOs; MOH 
staff at HCs, Micro-Networks, Networks, regional and central levels; and 
local governmental structures, including municipalities and consensus building 
committees at district and provincial levels. As one of the CARE Peru staff 
said; “we are weaving together a structure that can sustainably support 
health activities at all levels.”
a. COMMUNITY MOBILIZATION
Community mobilization was the centerpiece of the REDESS project. The 
main target groups were: CHAs (which includes health promoters, traditional 
birth attendants, and support group facilitators); CHA organizations; 
committees-COACS and associations-ASOACS; and community development 
committees (CODECO). A clear focus on community development came late 
to the project, particularly in Cajamarca, but the results of this effort had 
an extremely positive impact on the sustainability of health activities. During 
the FE, results from the KPC Survey were analyzed with community members 
and one of the over-riding outcomes of these discussions was the 
commitment expressed to continue health activities in the future. Concrete 
ideas were expressed by community members as to how activities could be 
maintained, such as closer coordination with the MOH and local governments, 
continued educational activities by CHAs, and income generating projects. 
CHAs 
“They are our eyes and ears in the communities, and sometimes our hands 
too.” That was the way it was expressed by a nurse in one of the HC visited 
during the FE. The CHA has been accepted within the MOH structure as a 
member of the team and given an identification card sponsored by the MOH. 
REDESS has helped to broaden the role of the CHA to be a more active 
health agent in the community, rather than only a link for organization with 
and communication to and from local health posts. They are no longer seen as 
just an appendage of the MOH, but as a health decision maker in the 
community. Of the 348 communities where REDESS works, 293 communities 
(84%) have trained CHAs. There is a total of 554 CHAs trained by the 
project, approximately 79% are men and 21% women. 
16
Three of the four CHAs interviewed during the FE dedicated 5-10 hours per
week to their work as a CHA. Only one of the CHAs worked within the ideal 
situation, according to MOH policy, that is to have various CHAs per 
community, each one with a maximum of 30 families. The other CHAs either 
worked with only a segment of the community (leaving the rest of the 
community unassisted) or were responsible for 85-110 families.
CHAs mentioned that the main impact of the project has been to improve 
mothers' hygiene practices and to promote a more balanced diet for weaning 
children, as well as increased use of health services (births, prenatal control, 
vaccinations). Health staff that were interviewed felt that the CHAs had 
been particularly effective in recognizing danger signs and referring 
patients. Other important contributions of the CHAs are:
s Providing continuous community health education activities primarily 
through education sessions and home visits. Support group facilitators have 
established groups for self-learning and demonstration sessions to improve 
nutrition. CHAs received health education materials to enhance the 
effectiveness of their education
s Use of SIVICS which includes a community census and map to identify 
cases and keep track of pregnant women and children under one year of age. 
CHAs accompany health staff during home visits to high risk families. 85% 
of communities have a census; 73% have a community map.
s Monthly reports by CHAs track cases of illness seen and educational 
activities
s Use of the referral system for identifying high risk cases and for 
encouraging routine health care
s Another component of SIVICS is the emergency evacuation system 
established in many communities by CHAs and CODECOs 
s Development of female leaders through Support Group Facilitators which 
gives women a chance to develop skills and increase self-esteem while 
gradually moving into a leadership role within the formal power structure.
Selection criteria to help identify potential CHAs was developed in a 
checklist format for use by communities. The Human Resources Development 
office in the MOH Health Network regulates certification of CHAs. 
Certification requires 1 year of experience, completion of a least two 
training modules, participation in monthly meetings and monthly reporting, 
referral of patients, updating of vital statistics and census, providing 
17
education in the community and participation in COACS. The process is a 
good idea, but took a lot of time. Ways to simplify and streamline the 
procedure need to be identified. The certification of CHAs can be an 
effective method for motivating CHAs and ensuring good quality work if the 
process is carried out in a timely fashion. 
CHAs are supervised by an integrated team of MOH staff and a 
representative from the COACS. CHAs find the supervision they receive to 
be motivating, but may be problematic to continue in the future due to lack 
of transportation. They also mentioned the importance of monthly meetings 
with MOH staff, which in the long run may prove to be more sustainable. 
Health staff has a monthly meeting with CHAs and COACS to collect 
information, provide additional training in identified areas of weakness, and 
problem solve. Some HCs provide competitions with prizes to motivate 
friendly competition. During final evaluation interviews, HC personnel stated 
they feel constrained at how little opportunity and means they have to 
recognize the contributions of CHAs.
During the first year of the project, the desertion rate of CHAs was as high 
as 30%. In part this was due to unrealistic expectations on the part of some 
CHAs as to the objectives of the work and the benefits they would receive. 
The dissemination of project objectives and strategies from the beginning 
to all communities would clarify expectations and attract CHAs who are 
more dedicated, and serve to motivate communities. 
In the KPC Survey, 88% of women knew that there was a CHA in their 
community and 55% of those women had received some service from them. 
The principal responsibilities of the CHA mentioned by mothers was to 
conduct education sessions, make home visits and refer cases to HCs.
CHA organizations: COACS and ASOACS 
One of the unique aspects of REDESS, is the focus on providing an 
organizational structure for CHAs. All CHAs who work in the catchment 
area of each health facility come together to form a CHA committee 
(COACS). They pay a small quota to join the committee. The COACS elects 
a board of directors, comprised of president, vice president, secretary and 
treasurer. Monthly meetings are held with CHAs and health facility staff, in 
which promoters turn in monthly reports, solve problems, and plan activities. 
18
To support the COACSs, an association of CHAs (ASOACS) is formed, 
comprised of the presidents of each COACS in an MOH micro-network of 
health facilities. The ASOACS is legally inscribed in the public registry as a 
private non-profit organization. 
REDESS worked to establish four ASOACS in Sanchez Carrion and to 
strengthen the existing ASOACS in Cajabamba, called APROMSA-PAT. 
APROMSA-PAT was established in 1994; CARE helped them to reorganize 
and re-elect leaders and the group now has 22 members or representatives 
from COACS level? committees. Of the four ASOACS in Sanchez Carrion, 
two have been legally recognized, one has begun the legalization process, and 
one is still preparing documentation to begin the process. 
REDESS has accomplished the following activities with CHA organizations:
1. Assisted COACS/ASOACS to develop annual operating plans (AOP), which 
articulate both short-term activities and long-term sustainability 
strategies, and to monitor the completion of AOPs and reschedule or 
redesign plans as necessary.
2. Train COACS/ASOACS in the transmission of leadership and 
organizational skills acquired.
3. Provide training to COACS/ASOACS in skills and tools necessary to 
provide supportive supervision to CHAs. This unique contribution of the 
project provides an opportunity for peer review and is an excellent way to 
motivate and inspire CHAs. The supervision tool creates an environment 
of positive support by focusing on what the CHA is doing well.
4. Provide training in managerial and leadership skills that enable members 
to be effective representatives of their communities in local government 
- civil society structures
5. Provide training in managerial and leadership skills that enable women 
community leaders to be effective representatives of their communities. 
Organizations interviewed during the FE reported approximately 21% of 
their leaders were women.
The COACS/ASOACS developed through REDESS have gained the skills 
necessary for self-management and for collaborating with the MOH as well 
as with a variety of other community organizations. According to CHA 
leaders interviewed during the FE, the main role of the COACS is to 
supervise and motivate CHAs, providing technical and moral support. They 
19
feel they are now in a better position to negotiate with the MOH and have 
accomplished the following:
s Prepared AOPs which are reviewed on a regular basis to guide and 
evaluate progress on their activities. They are monitoring the completion of 
these plans and various COACS/ASOACS reported that they had 
accomplished 40-100% of their plans
s Held monthly meetings to coordinate and plan with MOH staff to carry 
out preventive and promotional activities in communities
s COACS supervised and evaluated the work of individual CHAs jointly with 
the MOH staff and ASOACS supervised COACS
s Participated in the participatory budget process and consensus building 
committees, including presenting their AOP for funding 
s Organized network and micro-network-wide contests and other IEC 
activities to promote popular participation in health-related issues
s Motivated individual CHAs to be more involved and committed to their 
work in the community 
s Used exchange visits as a method of motivating and exchanging 
experiences among the different organizations
s Solicited MOH and other multi-sectoral support for CHAs such as 
provision of training, supervision, and other types of coordination
Some problems still to be faced by the COACS/ASOACS are:
1. Desertion of CHAs. This is a problem all CS projects face in general and 
one the CHA organizations will continue to struggle with.
2. Continued supervision activities. The opinion was expressed that 
realistically supervision could only be carried out once a year to all CHAs. 
The suggestion was made that they should program less frequent 
supervisions to CHAs who were working well and prioritize problematic CHAs 
3. Economic sustainability. The COACS/ASOACS have been able to raise 
some funds through activities such as raffles, sale of food at community 
events, and quotas, as well as establishing small businesses of gardens and 
small animals. COACS/ASOACS have become active voices in some 
governmental processes and will need to continue with advocacy and 
convincing authorities of the value of the organization.
4. The establishment of the ASOACS was mainly accomplished during the 
last year of the project, not allowing sufficient time to cement to still 
fragile structure. As one ASOACS director put it; “ REDESS has given us 
the wings to know how to fly.” The establishment of organizations such as 
20
COACS/ASOACS and CODECO needs to be started early in the project 
cycle to allow sufficient time to acquire experience and to gain political 
support.
CODECOs
Of the 340 communities where REDESS worked, 289 are organized into 
CODECOs (85%) and 237 of those implemented a health project last year 
(70%). The percent of women in the CODECOs varies from 10-33% with an 
average of 24%
CODECO leaders interviewed during the FE felt the most important role of 
the CODECO was to give people a voice and a mechanism for reaching 
consensus, and to improve management, organization and coordination in the 
community. They felt the implementation of the participatory budget 
process had made the municipalities pay more attention to the CODECOs and 
that they were now able to effectively negotiate with municipal authorities, 
“CARE helped them to see that they could solve problems by forming 
alliances with other organizations, not just the MOH”. REDESS has helped 
community representatives change their focus of requests for municipal 
input to capacity building activities and not only "inputs" such as water and 
sanitation systems. This change is only incipient as the majority of funds 
still focus on infrastructure. Several of the mayors mentioned during the 
FE that this is exacerbated because the part of the budget assigned to the 
participatory budgeting process is the amount of the budget specifically 
assigned to “works".
CODECOs have accomplished the following:
s Popularly elected 7-person committee
s All have statues and most have been legally recognized so they can 
represent the community
s CHAs are usually a member of the CODECO and are able to ensure a 
focus on health concerns in community planning processes. 
s Written community development plans and AOPs
s Includes representatives from education, agriculture, and economic 
development, as well as from other organizations, such as teachers, Mothers 
Clubs, or the Glass of Milk food distribution program.
21
s Presented AOPs to pertinent government authorities to be included in 
the participatory budget process, mainly receiving funds for water and 
sanitation projects. 
s Supported CHAs in establishing active and shared-responsibility 
community emergency evacuation committees in 91% of communities with 
CHAs in Huamachuco Province and 71% in Cajabamba.
REDESS has developed a comprehensive planning system for use by 
CODECOs. This includes an adaptation of guidelines provided by the Peru 
Ministry of Finance for use by Municipal Government in guiding the 
"participatory budget" process. It is a prioritization of actions based on the 
scope of the problem (effects everyone, half the people, less than half), the 
severity of the problem (serious, medium, mild) and the difficulty of the 
solution (easy, medium, hard). Additional, REDESS helped build the capacity 
of CODECOS to develop a annual work plan by months of the year in the 
sectors of health, education and community development, including available 
resources from the community and external resources. Lastly, although 
some orientation and skills-building training was provided to CODECOs, 
evaluation of AOPs and reprogramming of incomplete activities was not yet 
conducted.
In the final KPC Survey 28% of mothers interviewed knew what CODECO 
was and 26% knew if one was active in their community. Although 81% did 
not know the specific functions of CODECO, those who did know said that 
CODECO coordinates with other organizations (14%), 6% said they help with 
emergency evacuations and 5% said they support the CHAs.
Begin community mobilization by organizing the development committee, this 
provides support for the CHAs and the early implementation of project 
activities such as SIVICS,
An equal amount of effort should be dedicated to community organization 
and the training of CODECOs as is dedicated to forming CHAs, to provide 
them with sustainable support.
b. COORDINATION WITH GOVERNMENT STRUCTURES
In Peru, the last decade has been characterized by sweeping institutional 
changes, including Health Sector reform and governmental decentralization. 
These changes have focused on health promotion, increased local control of 
22
resources and decision making, and strengthening of strategic alliances 
among all stakeholders. CARE PERU has identified these structural changes 
as an opportunity in their recent Strategic Plan (2204-2009). CARE has 
positioned itself to be ahead of these changes, developing models for local 
control and networks before legislation has mandated them. 
As was previously described, a major focus of REDESS has been on the 
development and strengthening of CODECOs at the community level and CHA 
organizations. An additional focus has been on working with elected 
governmental officials within District and Provincial structures to form 
networks of decision makers that include COACS, ASOACS and CODECOs. 
Accomplishments in this area were focused on building the capacity of 
government-civil society consensus building groups and made possible due to 
receptiveness of the participants and to CARE's interest in assisting civil 
society to participate in health actions at multiple levels of government. 
Some of the most important activities in this arena are:
1. Participatory Budget Process
In an effort to encourage citizen participation, health advocacy as a means 
of influencing political leaders at various levels has been at the forefront of 
project activities. One of the most functional and output-oriented 
mechanisms for advocacy is through the participatory budget process. This 
process brings together health and other sectors to prioritize local needs to 
be included in the municipal budget. Health has gained a place in 
“development” but traditionally health was just infrastructure, and this is 
still the focus of many government officials. Through the participatory 
budget process it has been possible to also prioritize training, CODECO 
conferences, preventative activities, and in some area funds have been 
designated to help families while a family member is in the hospital. 
Municipal authorities interviewed as part of the FE feel the most important 
steps they could take to ensure sustainability are to continue providing 
support to the CHAs and CODECOs, including their participation in the 
participatory budget process at district and provincial levels.
2. Coordination with other CARE project
CARE’s Title II project is working in the some of the same areas as 
REDESS, also in governmental strengthening, and includes projects like 
agriculture and water & sanitation. The Midterm Evaluation (MTE) found 
23
that the project has been able to build upon the local government 
strengthening efforts of the FOGEL component of CARE's Title II program 
(Facilitating Local Government Participation in Health), in which 
municipalities developed long-term strategic plans that incorporate a focus 
on health needs, and to share problem analysis and action planning techniques 
with local government and civil society representatives. REDESS has 
supported and facilitated provincial and district Consensus Building 
Committees during the two years of project implementation. The greatest
impact of this effort found at MTE was the direct contribution by roughly 
half of municipal governments in support of CHA organizations - primarily 
through the provision of office space/supplies.
3, Consensus Building Committees
Revitalization of Consensus Building Committees at District and Provincial 
Levels, and Eje Tematica, a sub committee of the Consensus Building 
Committee was one of the planned activities for REDESS. CARE began 
promoting Consensus Building Committees in 1998 before they were 
mandated by the government in 2001. Previously established committees 
have been combined with government mandated Consensus Building 
Committees Against Poverty (Mesa de Concertacion de Lucha Contra la 
Pobreza). The Consensus Building Committee consists of sub-committees for 
health, education, economic development, etc. but unfortunately in some area 
the health sub-committee is more active than the committee. Committees 
are made up of representatives from the MOH and other ministries, 
education, other NGOs, and COACS/ASOACS. Consensus Building 
Committees provide an opportunity for community participation, in 
developing and implementing a Strategic Development Plan, and in increasing 
the coordination of projects e.g. CHAs with the municipality and MOH with 
CARE in a garden project. Seven of 11 local government districts have a 
Consensus Building Committee that is active. Continued effort is needed to 
maintain the Consensus Building Committees as an active body which is 
inclusive of all social actors.
4. Development of Strategic Plans
Local governments received support from REDESS in developing Strategic 
Development Plan and seven local governments (64%) have developed a plan 
which included health activities. Local authorities are taught to analyze 
24
problems, plan and evaluate actions to improve health and coordination with 
the MOH.
Other important steps taking place to strengthen the political network are:
s TOT for CHA Associations and MOH in health problem analysis, action 
planning and health advocacy techniques
s Linkage with activities for capacity building of COACS/ASOACS, 
CODECOs, and other community leaders
s Participation of women in community development processes through 
events at the district level, such as encounters of social actors and CODECO 
encounters, which are held three or four times a year.
Opportunities for citizen participation are increasing, but the quantity of 
participation is not enough, participation with knowledge is vital. REDESS has 
developed some important practical models for providing opportunities for 
civil society participation within the Peruvian context. There is a need to 
continue educating the population and political leaders in issues relating to 
health and development for effective decision making.
c. COMMUNICATION FOR BEHAVIOR CHANGE
The approach utilized by REDESS to stimulate behavior change was an 
effective way to improve the health of the population. Results from the final 
KPC Survey showed an improvement in 10 out of 13 health indicators. MOH 
staff interviewed during the FE felt that people are able to make better 
decisions relating to care seeking and home care with the increased 
knowledge they had received from project activities. The main BCC 
strategies utilized by the project were support groups, radio messages, 
education campaigns, educational sessions, including food preparation 
demonstration, home visits, and use of educational materials.
Support Groups
The original intent in the DIP was to form community support groups to 
increase exclusive breastfeeding. This was modified during the project to 
include a variety of types of groups including pregnant women, mothers of 
malnourished children, adolescents, WRA, and breastfeeding women. A 
range of topics are covered from danger signs for care seeking, to general 
maternal-child health, balanced diets and hygiene. The group observed 
25
during the FE contained a number of elderly women, who can be influential 
decision makers in the community. 
The support groups normally meet monthly and are usually combined with a 
food preparation session. The groups are comprised of 6-15 people. Support 
groups have a highly structured agenda which includes a greeting, 
announcements, thoughts from the previous meeting, presentation of 
participants, review of previous agreements, topic for the day, summary, 
evaluation, and farewell. Women are given the option to decide what future 
topics should be.
The support groups are lead by Facilitators, usually women who have been 
trained in technical health areas, as well as adult education and facilitation 
skills. This is one of the principal ways in which leadership skills for women 
are enhanced, by providing women with the opportunity to practice 
leadership skills and gain self confidence. 
According to an LQAS survey conducted in 2003, the support groups have 
been effective in changing both knowledge and practices. Some examples of 
results from the study show that 57% of women in a support group began 
breastfeeding within 1 hour after birth, compared to 33% of women not in 
support groups. 71% of women in support groups could mention two signs of 
pneumonia compared to 8% of women not in a support group.
Food Preparation Demonstrations
Demonstrations are usually conducted during a support group meeting with 
the objective of learning by doing. During the demonstrations, community 
members donate all of the food for the session. Sessions include preparation 
of weaning foods, use of locally available foods, and the importance of a 
balanced diet.
Education Sessions
CHAs generally educate community members through either group sessions 
or individual home visits. According to CHA monthly reports 66% of CHAs 
provide health education. During interviews with mothers as part of the FE, 
home visits were mentioned most frequently as the activity which helped to 
change behaviors. Home visits provide an opportunity to tailor education to 
specific family needs and to include all family members. CHAs received 
26
training in adult education methodologies, as well as the importance of 
complimenting mothers on the "good" practices they have, along with 
discussing changes in behavior. 
Health Campaigns
REDESS coordinated the participatory development, along with MOH 
personnel and input from the Private University of Antenor Orrego, of a 
behavioral change communication campaign plan that incorporates multiple 
strategies to reach project beneficiaries through a variety of methods and 
media. These include: radio spots disseminated to all rural communities; 
"popular education" activities, such as games, songs, etc., in locations where 
community members normally gather; inter-personal methods of 
communication between CHAs and community members, such as individual 
counseling and support groups; the HC would have bulletin boards with the 
message; and community-based activities, such as painting murals. Examples 
of topics covered are: "Importance of Antenatal Control", "Warning Signs 
for Pregnant Women and Newborns", "Promotion of Institutional Delivery", 
"Control of ARIs", "Malaria Prevention", and "Diarrhea Prevention 
Measures." 
The REDESS communication campaign was a strategic way of implementing 
measures that lead to behavior change. It included the various key steps, 
such as a baseline study of the problem; campaign planning and preparation; 
campaign implementation; and impact evaluation. During these campaigns 
health personnel, acting with the support of the project and the 
Communication Sciences Faculty, validated and produced pamphlets and radio 
spots covering the issues addressed in the campaigns. 
Radio Spots
Use of the radio was listed during FE interviews as one of the three most 
important ways health information was communicated, along with home visits 
and demonstration sessions.
Educational Materials
All CHAs interviewed during the FE had educational materials including three 
flipcharts made of durable fabric and an accompanying guides on IMCI-Well 
Child, Sick Child and Maternal Health as well as an IMCI notebook. The high 
quality materials were developed through social marketing steps; adapting 
27
messages to local context and validating all materials at the community level. 
As was pointed out during an interview with MOH staff during the FE, the 
BCC strategies and materials have helped to improve the quality of education 
by standardizing messages, making sure than everyone presents the same 
message.
A qualitative investigation on preferences for communications methods was
conducted by students from the Communications Sciences Department at 
the Private University Antenor Orrega in Trujillo with the goal of developing 
an appropriate and effective IEC strategy. For example, the study found
that almost all rural families listen to radio programs during the mid-day 
lunch break, especially radio Los Andes. Roughly half of men stated they 
completely trust in the information they hear on the radio, as compared to 
100% of women. The information gathered was put to excellent use by
REDESS to develop a varied and creative set of community education
methods.
The most important lessons learned relating to behavior change were:
Having a broad base of support at all levels is vital; within the communities 
both with leaders, men and women, and within all levels of governmental 
structures. This means that all actors should receive basic education in 
health issues, depending on their level of need and once the desired behavior 
is identified, the decision makers who influence that behavior needs to be 
included in educational activities.
To achieve behavior change it is important to use a variety of media and 
techniques, each with the same standardized message. 
“Learning by Doing” using locally available resources, leads to better
understanding by CHAs and community members.
When one of the Consensus Building Committees was asked what they would 
have done differently if they could repeat the project they mentioned the 
importance of; Having a greater understanding and sensitivity to the local 
culture makes communication more effective. The REDESS project
addressed cultural sensitivity, and good examples of changes made due to 
this emphasis were seen, but more could have been done to enhance cultural 
understanding.
28
d. CAPACITY BUILDING APPROACH
The following objectives and indicators of capacity building were presented 
in the DIP:
Indicators Accomplishment Comments
1. Capacity Building of CHA Associations and Community Organizations: Improve capacities of CHA Association 
members and community leaders to provide leadership and to plan, manage, and evaluate their organizations
1. 5 CHA Associations will 
complete 80% or more of 
their annual operating 
plan objectives and 
activities.
2. 80% of CHAs receive 
quarterly supervisory 
visits and feedback from 
CHA Committee 
members.
3. 50% of CHA Associations 
have representatives in 
local government working 
groups (consensus 
building committees)
4. 50% of communities have 
women leader 
representatives in 
consensus-building at the 
community and district 
level
1. 5 CHA Associations 
completed approximately 50% 
of activities in AOP
2. 29% of CHAs are supervised 
annually
3. 60% of CHA associations are 
participating in roundtable 
discussions and/or budgetary 
planning
4. 85% of communities (289 of 
340) have been organized into 
CODECOs, all of these have 
women as part of board of 
directors
1.5 associations were established due to combining CHAs 
from the hospital with another mirco-network.
In addition, 24 CHA committees were formed, completing 
approximately 70% of their planned activities
2. Most supervision visits are done in conjunction with MOH 
staff, using supervision checklist and feedback mechanism. 
All CHA association leaders and some MOH staff have been 
trained in supervision.
3.The active participation in the workshops convened by local 
governments to define "Participatory Budgets" has been a 
major step forward. Acting in alliance with health personnel 
and CODECOs they have managed in some districts to 
earmark resources for CHA activities in the areas of health 
and training
4. CODECOs are the principal organization promoting 
development and identifying community problems and needs 
addressed in AOPs. CODECO acts as a point of entry and an 
opportunity for women to gain prominence in district and 
provincial government forums as representatives of their 
communities. 
2. Capacity Building of Local Health Unit Personnel: Improve and strengthen local health unit personnel 
capacities in the training and management of CHAs.
1. 80% of CHAs receive 
sufficient supplies of 
essential medicines 
(cotrimoxazole and ORS).
2. 80% of CHAs receive 
quarterly supervision and 
feedback from local 
health unit personnel
1. 0% of CHAs have supply of 
essential medicines 
(cotrimoxazole and ORS).
2. 29% of CHAs are supervised 
annually (see above in section 1 
also)
1. MOH policy does not allow CHAs to distribute 
cotrimoxazole. Due to a shortage of supply of ORS, CHAs 
are taught to advise mothers to increase liquids during 
diarrhea and if danger signs are present, to refer the child to a 
HC
2. Due to time constraints, focus on service provision, and 
lack of transport MOH staff are not able to fully supervise 
CHAs in the field
3. Capacity Building of CHAs: Improve CHAs leadership and organizational abilities for community 
development actions.
1. 80% of CHAs conduct 
monthly health education 
activities and home visits.
2. 50% of communities 
execute at least one health 
development project /year.
66% of CHAs provide health 
education
2. 70% of communities have 
health activities in their AOP
1.Educational activities and home visits by CHAs have been 
conducted in the framework of the campaigns implemented 
by health personnel. It is necessary to strengthen Community 
Planning of Health Education which should be led by CHAs. 
2. It is important to note the change in previously prioritizing 
only infrastructure projects to now including health 
promotion activities
4. Capacity Building of Local Government-Civil Society Structures: Assist local government-civil 
society groups to analyze community health problems and develop effective action plans
1. 50% of local government￾civil society groups 
develop annual action 
plans for community 
health. 
2. 50% of communities have 
representatives engaging 
1. 64% of local governments￾civil society groups have action 
plans including health actions
2. 59% of community 
CODECOs have presented 
AOPs which include health 
1. All local governments (11 total) have began implementing 
a participatory budget process which allows CODECOs to 
present their AOP for inclusion in the municipal budget
2. At Encounters for Social Actors and CODECOs REDESS 
has been increasing the awareness of community 
representatives, local governments, MOH personnel, and 
29
representatives engaging 
in advocacy efforts to 
promote their Annual 
Operating Plan with the 
local government 
AOPs which include health 
activities to the local 
governments as part of the 
participatory budget process 
representatives, local governments, MOH personnel, and 
representatives of other institutions with respect to co￾responsibility for tackling the challenges of improving 
quality of life
5. Capacity Building for CARE Peru: Improve management and technical skills in child survival 
programs for REDESS Project staff
1. 100% of REDESS staff 
design and train partners in 
innovative BCC strategy 
implementation
2. 100% of REDESS staff 
facilitate TOT workshops in CS 
technical interventions
3. 100% of REDESS staff 
demonstrate mediation skills in 
conflict resolution with MOH, 
CHA groups and local 
governments
4. 100% of REDESS staff 
assess capacity building needs 
of partners and design activities 
for continuing improvement 
1. 100% trained in Support 
Groups, Adult Education, 
design of IEC campaigns and 
negotiation MOH staff has 
received TOT
2. 85% of staff facilitated TOT 
in technical areas
3. 75% received informal 
training in conflict resolution. 
All of the team practices 
mediation with civil 
society/governmental 
organizations
4.100% of staff were trained in, 
and utilize ANA, as a method 
for assessing needs and 
designing capacity building 
activities
1. CARE International, in particular the Child Health Unit 
has provided the team with opportunities to update their 
knowledge of innovative BCC strategies. 50% of the 
technical team has attended international workshops on these 
issues. This has allowed the team to transfer this learning to 
partners and CARE Peru, to strengthen the facilitators 
network the capacity of CARE Peru 
2. 75% of team received training in MNC, 100% in IMCI and 
LQAS 
3. Technical assistance in conflict resolution was not 
obtained but informal training was provided through sharing 
of experiences within the REDESS team but this is clearly a 
need in CARE programs.
4. The ANA methodology was an effective way to define 
training needs and was used with CHAs, as well as MOH 
staff.
i. Strengthening the PVO Organization
Participation in the USAID Child Survival program has greatly benefited
CARE as an organization. Specific examples include the institutionalization 
of monitoring and evaluation including information systems and survey 
methods, standards for project design and grant writing, and the
development of a highly qualified technical Health Unit at HQ. CARE HQ 
capacity in Child Survival programming has increased during the life of this 
project through multiple opportunities provided through CORE and/or CSTS 
sponsored learning opportunities. HQ technical staff have attended
workshops on the following topics and have disseminated this information to 
field staff during annual site visits:
o Adult Learning Methodologies
o BEHAVE framework for Behavior Change Communication
o Child Survival Sustainability Assessment
o Networking and Leadership
CARE was one of the first CS-implementing PVOs to incorporate the Child 
Survival Sustainability Assessment framework into the DIP phase of their 
CSXIX Project in Sierra Leone. In addition, CORE annual meetings and 
CARE participation in CORE Working Groups, along with the mini-university 
30
DIP presentation approach, have provided opportunities to share with and 
learn from other implementing PVOs.
One of the principal capacity building effects for CARE Peru has been an 
improvement in the documentation and application of lessons learned through 
Child Survival projects. One of the criticisms of the ENLACE project was 
the lack of adequate documentation of the experience. The REDESS project 
has corrected this mistake and documented most of the key project 
strategies. One suggestion to improve the quality of the documentation is: 
All project documents should include the date they were produced and a 
brief two page summary of the document. A summary of key points, critical 
steps, etc. is necessary to truly enable these documents to function as tools 
to disseminate techniques and strategies. 
As CARE country offices move from a project to a program focus, the 
successful strategies, approaches and methodologies, as well as staff 
expertise, need to be transferred from individual projects to other 
programmatic and geographic areas, and funding sought to scale-up lessons 
learned to continue to work towards the goal of improved health. The 
experience gained during REDESS has been documented and will be 
presented and discussed within and outside CARE (MOH, NGOs) during 
workshops and conferences. Project summaries will also be published and 
distributed to MOH and NGO representatives and health workers. Based on 
the REDESS experience, CARE Peru will be able to propose better designed 
health and development programs to national and international institutions 
for implementation, partnership and financial support.
The CSP has worked closely with CARE Peru Title II project, as there is
overlap between approximately 17% of the CSP communities. The Title II 
project will continue working for an additional two years in Cajamarca and 
Sanchez Carrion at the municipal level and with CODECOs. Their focus
includes micro credit and agricultural activities which will further serve to 
motivate and strengthen institutional structures.
REDESS and the Title II program have been working closely in the analysis 
of program strategies to ensure they complement each other, with a view to 
benefiting from a mutual learning process, focusing on already validated 
methods. For example, Title II has adopted the Strategic Communication 
31
Campaigns methodology developed by REDESS. Likewise REDESS has 
applied to their capacity building activities for MOH personnel and CHAs the 
Title II training framework. They also shared learning opportunities for 
CARE staff in the areas of strengthening civil society organizations and 
working with local governments, where, in addition to pooling the experience 
acquired from organizing CODECOs they implemented a territorial division 
aimed at improving institutional impact.
Other ways in which capacity has been improved in CARE Peru is through 
strengthening skills in facilitating community participation and 
empowerment, in training trainers, in supervision, use of participatory 
education methods and conceptual frameworks to achieve behavior changes, 
and in monitoring changes in partner or community capacity. This capacity 
was vital in assisting communities and municipalities assume the 
responsibility of administration of health services within decentralization.
Lessons learned for CARE Peru during this CS project include:
Advocacy and diffusion of project experiences is needed at local, regional 
and central levels to ensure sustainability of project achievements. 
CARE can play a role in encouraging media to highlight local health service 
successes, as a balance to the occasionally sensationalistic focus on problem
areas. This will help civil society have a more balanced view of health service 
strengths and weaknesses as they begin to be more involved in local
government-health action. The establishment of strategic alliances with the
communication media helps to involve them as watchdogs of the political
process of health implementation and in the promotion of actions for the
social well-being of the population. 
ii. Strengthening Local Partner Organizations
The principal partner in the implementation of REDESS was the MOH at 
regional and local levels. Other partners include the CHAs, CHA 
organizations and local governments. Project impact on these partners was 
discussed in Sub-sections A & B of 3. B Cross-Cutting Approaches. The 
primary capacity strengthening activities for the MOH are Strengthening 
Health Facilities and Health Staff which are included in the next two points 
of this document. 
32
The SWOT (Strengths, Weaknesses, Opportunities and Threats) 
methodology was used to assess the management and service delivery 
capacity of the La Libertad and Cajamarca Regional MOH offices, the Health 
Networks, and Micro-Networks during 2001. This assessment was not 
repeated at the conclusion of the project.
The MOH has been a particularly strong partner in the REDESS project. The 
participation by the MOH in the FE was exemplary of the commitment at all 
levels. The Network Health Director in Huamachuco was a particularly 
strong advocate and supporter of project activities as was the Network level 
team, almost 100% of who were the same people since the start of the 
project, which was very beneficial for project implementation.
At the beginning of the project the roles and responsibilities of each 
partner were clearly defined as part of the DIP development process. In 
general the commitments made by all partners were fulfilled. In the 
agreement, the MOH was responsible for facilitating the availability of 
human resources at the project implementation level. The permanence of 
human resources at health centers has been an ongoing problem during 
project implementation. The barrier to implementation which was most 
often mentioned during FE interviews was the frequent rotation of MOH 
staff at HCs. There are a number of reasons for the turnover, but this issue 
is not new, nor will it go away in the short term. REDESS was able to 
partially confront this situation through annual repeat training workshops 
and helping to develop a plan for orienting and mentoring new staff in key 
project activities. Advocacy at the central and regional levels of the MOH is 
vital, but projects need to accept that this situation has existed for years 
and design project based on the Peruvian reality. Projects should be 
designed based on local realities; this includes frequent MOH staff rotation.
Much of the positive coordination which has been developed has taken place 
over years of working together so that when changes occur, new relationship 
have to be built. This underscores the importance of institutionalization of 
project activities within the MOH structure. REDESS has been documenting 
all project strategies so modules on all major initiatives are available at HCs 
to be used in training new staff. The problem of not having a clear plan for 
the orientation of new staff was discussed by the Health Promotion 
33
representatives of each HC. A plan for the orientation of new staff needs to 
include the incorporation of health promotion activities.
Another limitation to implementation of activities, exacerbated by MOH 
policy, is that personnel evaluation and supervision is based on health care 
coverage indicators but no indicators are used to measure health promotion 
work and reflect the efforts of CHAs. The result is that the Regional MOH 
puts pressure on health personnel to target health care activities, even 
though the latter recognize that community work is valuable and important 
for bringing about an improvement in the health of the population. The 
evaluation and supervision systems of the MOH would be more coherent with 
current policy if they included health promotion activities.
iii. Health Facilities Strengthening
The project has had an impact on both the demand for services and the 
supply of quality services. The implementation of the referral system, 
community support groups, and emergency evacuation plan have increased 
demand for services by motivating use of health facilities, as well as 
dispelling fears of use of services. Implementation on a national level of free 
health services for priority groups has simultaneously had a positive impact 
on increasing demand for services.
A number of activities were carried out to improve the quality of services 
offered at MOH facilities. Staff were trained in both technical and 
managerial topics, some work was done on cultural sensitivity, model health 
centers were established, and efforts to make the HCs more client focused 
were implemented such as; a suggestion box with smiling, neutral and 
frowning faces, traffic light for privacy- red for do not enter or green for 
enter, signage on services available and costs, visual maps explaining the 
steps to follow to receive services, children’s room with colored cartoons, 
and delivery rooms which offer the option of birthing positions. 
A great deal of effort went into improving the organization of the HCs in 
order to improve efficiency and effectiveness of services, examples are; 
s Sectorization maps to define zones of responsibility
s Monitoring of CHAs annual plans
34
s Family files were implemented so that all members of the same family are 
included in one chart, when any member of the family is seen, the records 
for the entire family are reviewed
s Follow-up cards are maintained for prenatal visits, vaccinations, etc., if 
the person does not come for their appointment, the CHA is contacted to 
visit the home and encourage them to visit the HC for the needed service. 
s Human resource map that showed CHAs, CODECOs, other organizations 
s Improved documentation of activities and use of information for decision 
making such as BABIES analysis charts 
s Radios were provided in HCs which did not previously have them that have 
provided improved communication during emergencies
An important project strategy was to strengthen the linkages between HCs 
and communities by improving MOH staff skills (see more information 
below), providing opportunities for coordination through monthly meeting of 
MOH and CHAs, establishment of COACS at each HC to assist MOH staff in 
supporting and motivating CHAs, and defining the micro-network structure 
of health facilities. The link between HCs and CODECOs was also
strengthened, which is a seminal effort to develop local citizens committees 
at each HC to involve civil society in the functioning of health facilities.
iv. Strengthening Health Worker Performance
The focus of this project was not so much on improving the technical 
capacity of the MOH, rather on improving their community outreach and 
management skills. Technical training was provided in maternal health, 
obstetric emergencies, and IMCI, but a formal assessment of technical skills 
and knowledge was not carried out. Exit interviews with MOH clients would 
be an effective way to further contribute to building capacity for civil 
society participation to improve health service quality and as a measure of 
health worker performance.
MOH personnel at HCs interviewed as part of the FE mentioned the 
following as the most important aspects of REDESS:
s Improving the relationship between HCs and the communities
s Increasing demand for services, especially in pregnant women
s Strengthening CHAs and their linkage to the HC
s Educational materials made training more effective
s Training for HC staff, especially in Adult Education Methodologies
35
The MOH staff clearly sees their role in REDESS as direct implementers. 
CARE has done a very good job of facilitating a process, not just 
implementing a project. 
The entire HC teams were involved in training the CHAs initially, but after 
the central MOH restructured and formed the health promotion division, 
each HC has one person assigned to health promotion and another to 
training. The Health Promotion In-charge directly works with the CHAs. At 
Network level REDESS worked closely with the Human Resources 
development office and the training team. The entire HC team should be 
involved in supervising and coordinating with CHAs, not just the health 
promotion person.
The supervision of CHAs ideally is being done by COACS and MOH together. 
A supervision checklist is being used, which includes identifying what is being 
done correctly, before focusing on problems. There are a number of 
shortcomings in the system, mainly having to do with the sustainability of 
the process. As was previously discussed, indirect supervision through 
monthly reports and meetings may be more sustainable than direct 
supervision visits, due to transportation limitations. The supervision visits 
made with an integrated focus and team are most effective. The supervision 
checklist is cumbersome to use, contains unnecessary information, and 
should be simplified. 
Other important steps taken by REDESS include:
1. Assisted MOH personnel through the ANA (Analysis of Training Needs) 
process utilizing a results-based outcome to define training needs. ANA 
is most effective when used with all groups involved in the project, from 
the beginning.
2. Increased MOH personnel capacity to train and supervise CHAs through 
TOT activities in technical interventions. A mechanism needs to exist to 
generate new institutional trainers to ensure sustainability of project 
strategies.
3. Introduced aspects of the MOH human resource development package, 
but the evaluation module was not fully implemented.
4. Provided training for HC personnel in skills for management of CHAs, 
including use of SIVICS as a management tool
36
5. Developed health education materials jointly with MOH and based on 
IMCI norms and protocols
6. A very positive change has been the improved coordination with local 
authorities MOH staff works with CHAs and CODECOs to develop 
community AOP and also has a positive working relationship with COACS
7. Some improvements were made in enhanced cultural understanding but 
this needs to continue to be included in all projects.
v. Training
The majority of training objectives presented in the DIP were met, or show 
a positive trend. 
Objectives Indicators Achievement Comments
1. Improved 
MOH Capacity 
for Community 
Outreach
At the end of the training 
program 80% of MOH 
personnel in the project area 
will be able to:
1. Provide on-going training 
and supervision to CHAs 
2. Use community HIS 
information as a 
management tool
3. Give educational sessions 
to CHAs and CHA 
committees/associations
80% of MOH staff 
provide on-going 
training and use 
SIVICS
Only 25% of MOH 
staff provide 
ongoing 
supervision
 
In all HCs, one person is 
designated as in charge of 
health promotion and another 
in charge of training. For this 
reason, not all HC staff are 
involved in training and 
supervision
2. Increased 
Community 
Responsibility 
for Improved 
Personal Health
At the end of the training 
program 50% of communities 
in project area will be able to:
1. Provide peer health 
education and support
2. Participate in health 
advocacy to local 
government 
3. Execute at least one 
health development 
project annually
4. Diffuse health education 
messages 
5. Develop emergency 
evacuation plans and 
systems
318 Support Group 
Facilitator were 
trained in nutrition 
and 170 in MNC . 
Only one HC did 
not train 
Facilitators
14 Health 
campaigns were 
carried out by 
communities
73% (255) 
communities have 
emergency plans
3. Sustained 
Provision of 
Front Line 
Services by 
Community 
Health Agents 
At the end of the training 
program 80% of CHAs in the 
project area will be able to: 
1. Develop community 
health education plans
2. Determine criteria for 
referral regarding CDD, 
50% of CHAs 
implement and 
report on health 
activities
60% of CHAs are 
referring patients 
CHAs are not developing 
health education plans, rather 
they present topics according 
to programmed campaigns
For more information on the
referral/counter-referral 
37
PCM, nutrition and 
maternal care to local 
health unit service
3. Make the appropriate 
referrals to health centers
4. Follow-up of counter 
referrals
5. Conduct monthly health 
education activities and 
6. Follow a protocol for 
home visits based on risk 
factors
based on pre￾determined criteria
77% (2645) of 
referrals were 
counter-referred. 
No information is 
available on 
follow-up
66% of CHAs 
make home visits
system, see Section E. Project 
Highlight
The protocol for prioritizing 
home visits was pregnant 
women, children under 1 and 
follow-up on cases seen or 
referred 
4. Sustained 
participation of 
six local 
governments in 
health 
management 
At the end of the training 
program 50% of local 
governments in the project 
area will be able to:
1. Execute annual action 
plans for rural community 
health
2. Engage in problem 
analysis and action 
planning for improved 
maternal-child health in 
their communities
3. Prepare a budget for 
health activities
64% of local 
governments 
develop AOP and 
budget for health 
Approximately $35,000 has
been designated in the Sanchez 
Carrion province for health
activities such as CHA
organizations and BCC
activities
The following people were trained during the REDESS project:
CHAs in 347 communities with a total of 840 CHAs 
Promoter 
men
Promoter
women
TBA 
men
TBA 
women
CHA 
Total
W/ pre￾post test
Certified
HH/C IMCI 
module 1
411 116 4 163 694 35% 32%
HH/C IMCI 
module 2
397 112 4 161 674 325 29%
MNC 422 118 4 165 709 53% 51%
Adult Learning 425 115 4 166 710 38% 29%
Nutrition 184 41 4 76 305 16% 16%
SIVICS 404 116 4 162 686 36% 36%
Environmental 
Sanitation
397 112 4 161 674 31% 25%
Bartonelosis 28 11 0 3 42 3% 2%
First Aid 411 118 4 162 695 23% 23%
CODECOs 348 communities with a total of 820 members
Topic Number Trained Percent
Situational analysis 471 57%
38
SIVICS 312 38%
 Development Plans 471 57%
Community Empowerment 312 38%
Community projects 22 3%
Leadership 17 2%
Management 144 18%
MOH Staff 17 HC within the project area with 104 professional staff
Topic Number Trained Percent
Adult Education 83 80%
SIVICS 51 49%
MNC 28 27%
HH/C IMCI 71 68%
Clinical IMCI 70 67%
Support group facilitators 28 27%
Sectorization 55 53%
Environmental Sanitation 16 15%
Bartonelosis 5 5%
HIV/AIDS and STI 12 12%
BABIES 4 4%
Some of the more important lessons learned in training were:
The identification and development of Learning Centers (model centers 
where staff could visit to learn new ways of working) is a positive method 
for exchanging experiences and motivating staff, but they need to be 
developed in a timely fashion.
Training should never be held alone, without a follow-up plan monitoring and 
supervision, particularly in IMCI
It is more effective to work with a Training System (systematic 
methodology for determining training needs and monitoring implementation), 
rather than a Training Plan (pre-determined plan for training staff).
Adult Education Methodologies should be used in all training events to 
increase effectiveness of changing behaviors
The availability of detailed lesson plans and curriculum for all training events 
increases consistency and quality
39
e. SUSTAINABILITY STRATEGY
The following sustainability objectives and indicators were presented in the 
DIP. The majority have been reached by the REDESS project, of particular 
note is the system for CHA certification, the referral/counter referral 
system, the involvement of women in leadership roles, and local governments 
assigning funds for health.
Indicators Accomplishments
1. Sustainability of Community Health Association/MOH Linkage: Assist CHAs, within an 
institutionalized structure, to becoming active health change agents that create demand for and 
access to quality health care by at-risk groups within their communities.
1. 6 health micro-networks institutionalize the 
community health information system.
2. 80% of CHAs certified by MOH
3. 80% of CHA's refer WRA and children age 
0 to 59 months to local health unit services
4. 80% of referrals are counter referred to the 
CHA
4 micro-networks and 1 network are finalizing the 
institutionalization of SIVICS
2. 66 % of CHAs certified
3. 60% of CHAs are referring cases
4. 77% of referrals are counter-referred to the CHA
2. Sustainability of CHA/CHA Association/Local Government Linkage: Assist CHA 
Associations and other community leaders in becoming effective agents of community health 
advocacy for health administration
1. 80% of CHAs are incorporated as members 
in CHA committees and/or associations
2. 5 CHA Associations have with 
sustainability strategies defined in annual 
operating plans
3. 50% of local governments assign funds to 
community health activities
4. 50% of communities have women leaders 
actively working on health issues: health 
surveillance, BCC
1. 100% of CHAs are members of COACSs 
840 CHAs were trained by the project, of these 554 
(66%) are active
2. All ASOACS have sustainability activities 
included in their AOP, including income generation
and supervision
3. 64 % (7 of 11) of local governments assign funds 
for health
4. 48% of communities have women in active 
leadership roles
Sustainability can be viewed based on four principles- permanent behavior 
change, supportive structures, links with permanent institutions, and 
financial support.
Behavior change- KPC survey results show an increase in knowledge, 
practices, and coverage. These improvements can be sustained through the 
use of effective BCC strategies, a focus on adult learning, and neighbor-to￾neighbor learning i.e. support groups. The project lacked a clear focus on 
inter-generational and family decision-making. An important behavior to 
change is the use of health services. Demand for services has increased (e.g. 
prenatal care, immunizations) through implementation of the referral 
system, emergency evacuation and improved quality of attention (improved 
40
organization of HC, IMCI, training for HC staff). Community members and 
MOH staff interviewed during the FE were very motivated to continue 
working towards improving services, as quality of attention is still a barrier 
to access, and increased use institutional health care.
Supportive structure- the weaving together of a structure to support health 
activities
s Community structure-excellent progress has been made in forming 
and training CODECOs which represent, not just health, but education 
and community development. 
s Local Governments- remains a challenging area as decentralization 
is bringing about many new changes and adaptations of former 
paradigms but many advances have been made in this area by building 
capacities and achieving results that were visible to communities 
within the life of the project.
s ASOACS/COACS- have the potential to improve retention of 
volunteers, as well as maintain the quality of their activities. 
Additional support will be necessary to provide them with the political 
base they need to survive in the future.
s MOH HC, Micro-Networks and Networks- the work completed by 
REDESS, with a focus on planning and organization, will provide a 
stronger organizational structure, if changes are institutionalized.
Links with permanent institutions- MOH and governmental agencies
The strength of this project has been the focus in this area that is very 
much in step with current national political restructuring; there are a 
number of positive examples of newly formed and/or strengthened links:
s Monthly meetings with MOH and CHAs for in-direct supervision and 
continuous training, 
s SIVICS to collect and use information at all levels. 
s Referral system improves communication and creates demand
s Emphasis on political advocacy at multiple levels
s Consensus building forums for sharing ideas and coordinating activities
Financial Support- REDESS has encouraged financial sustainability at 
various levels:
Community-the self-financing of community activities on a small but 
important scale; raffles, bingo, selling food at sporting events, has 
41
represented a proactive community contribution and an important lesson for 
communities that they are capable of self-financing health activities. 
CODECO- some are creating emergency funds which can be loaned to 
families during an emergency but the most important step has been in 
developing AOPs for presentation as part of the participatory budget 
process.
COACS/ASOACS- have been able to raise money to help pay for training 
activities, received office space from local health units or local governments, 
and established small scale income-generating activities to support some 
operational costs, coordinating with the Economic Development Unit of the 
provincial municipality to obtain technical assistance in the design and 
presentation of projects.
Local Governments- Participatory Budget provides a mechanism for financing 
health activities in the future. Seven of the 11 municipalities have included 
health activities within their 2005 budget. The provincial government has 
designated $35,000 for improvements in the Hospital Leoncio Prado and 
activities of SIVICS and BCC.
The key program “devolution strategy” is to inherently avoid the need for 
"devolution" of program activities by incorporating partners in the design, 
implementation, and monitoring and evaluation throughout the life of the 
project. All partners are committed to the institutionalization of strategies, 
activities, and tools. 
What is lacking is the institutionalization of positive project strategies. 
There is a proposal developed by La Libertad Region to incorporate the 
SIVICS system throughout the region, but lack funds to do this. CARE Peru 
and the MOH continue to seek funds to expand project strategies to other 
regions of the country. ENLACE and REDESS have both left excellent 
models for decentralization and increased citizen participation, but these 
models need to be systematized and replicated in other areas, including 
within other sectors as a model for grassroots development. 
42
C. Program Management
1. Planning
The initial planning of REDESS was very inclusive. During the FE, community 
members in two different communities mentioned that they had been 
involved in the original design of the project, and were now involved in the 
final evaluation. This inclusion throughout the entire process foments 
excellent community ownership and pride in the work accomplished. It is a 
wonderful comment on the entire process when community members can 
clearly articulate the process of project design, implementation and 
evaluation.
The work plan developed as part of the DIP process was well thought out and 
provided good guidance to project staff in implementing the project. Staff 
was able to make adjustments to the project based on input from the LQAS, 
MTE, and other studies to adapt to changing needs.
2. Staff Training
No formal assessment of staff skills was carried out, but an assessment of 
training needs is incorporated in CARE’s annual staff evaluations. Initial 
planned training included in the DIP were:
1. Development of BCC strategies
2. TOT facilitation skills
3. Conflict Resolution
4. Needs assessments
The majority of the CARE staff also were employed in the ENLACE project 
and brought substantial experience with them to this project. Sufficient 
funds were available for training and details on technical assistance provided 
to staff are included under number 8. Technical and Administrative Support 
in this section.
3. Supervision of Program Staff
CARE endorses the concept of "supportive supervision", in which staff are 
active partners in assessing project progress. Staff are adequately 
supervised and have ample opportunities for exchanging ideas and 
experiences within a supportive environment.
43
4. Human Resources and Staff Management
As an international PVO working in Peru for more than 20 years, CARE Peru 
has well-defined personnel policies and procedures, including detailed job 
descriptions for each project position. Annual performance evaluations, 
based on CARE's human resource management system, are conducted. The 
Project Coordinator reports to the CARE Peru Regional Director in 
Cajamarca, who reports to the Assistant Country Director for Programming. 
After the MTE the staff structure changed from geographical assignments 
with five Technical Assistants and one Team Leader to five Technical 
Specialists in different lines of action: Organization of CHAs, Capacity 
Building, Organization of Health Care, Local Government Strengthening, 
Nutrition and Communication Strategies. They were each assigned a given 
zone of the target area. The structure later changed to four Specialists and 
two Technical Assistants. At the time of the FE there were three 
Specialists remaining, one person had left CARE and the two Technical 
Assistants had been hired by the Title II project. CARE attempts to retain 
staff whenever possible, as the institution invests a great deal in training 
and supporting staff and regards their trained human resources as one of 
their most valued assets. 
Except for the changes based on structural readjustments, there has been 
very little turnover of project staff. REDESS staff are a tight-knit group 
that actively support one another in work planning, project implementation 
and problem-solving. 
5. Financial Management 
The financial management of the project was carried out at three levels; 
CARE Peru’s regional office in Cajamarca; CARE Peru’s central office in Lima, 
and CARE USA HQ in Atlanta. Each of these levels has clearly defined 
responsibilities and the links between offices has functioned efficiently with 
good communication and joint problem solving, when needed. CARE Peru has 
years of experience in managing USAID funded projects, including the 
previous CS project, ENLACE. 
Since 2001, CARE Peru has used the financial management system SCALA, 
developed by CARE USA headquarters. The Project Coordinator, with 
accounting support from the project Administrative Assistant, manages the 
44
program budget. Accounting reports are submitted to the CARE Peru 
financial administration unit. Costs are tracked quarterly and financial 
reports are formulated in accordance with the approved budget line items 
and headings. The CARE Peru financial administration unit submits financial 
reports to CARE HQ for review by the Child Health Unit and the Financial 
Officer.
The project administration has been audited through both internal CARE 
audits, as well as an external audit, conducted by Price Waterhouse in 2002.
As of the projected end date of this funding (September 2004), there was a 
sum of approximately $ 65,000 remaining in the project budget. Anticipating 
this overage, a no-cost extension was requested and granted for an 
additional four months (October 2004 to January 2005). The main activities 
during the extension will be systematization and dissemination of project 
strategies, provision of additional technical and managerial support and 
strengthening of linkages. 
6. Logistics
There have been no problems with logistics management during the life of 
the project which adversely effected project implementation. The principal 
purchases made during the project were radios to improve communication at 
MOH HCs and litters for communities to use for emergency evacuations. 
7. Information Management
The data collection system of REDESS is based on a simplified version of a 
system designed by ENLACE called SIVICS (Sistema de Vigilancia Comunal 
de Salud) or Community Monitoring System. The system has the following 
components:
· Sectorization – Geographical mapping of the jurisdiction of a health 
facility into sectors, each of which is assigned to a health provider 
who is then responsible for all outreach in that sector. 
· Community census – a house-to-house survey is conducted by CHAs 
and is updated on a continual basis on “family cards”, with information 
that is reported on a monthly basis to the MOH facility on population 
size by age groups, including monthly birth and death data. According 
to project documentation there are 348 communities, 250 have a 
community census; of these, 157 (63%) are current.
45
· Community maps – each CHA creates a map of all houses for which 
s/he is responsible, numbering the houses, and identifying those which 
have “high risk” members, i.e. under one year of age, pregnant woman, 
or woman of reproductive age. According to project documentation 
there are 348 communities 215 have a community map, but only 108 
(50%) of these are current .
· Home visits – monthly visits are made to all “high risk” households to 
monitor health and provide health education, and make referrals if 
necessary for preventive or curative care at the HC.
· Monthly reports – each CHA turns in a monthly report on number of 
high risk persons in the community, number of cases of illness 
identified by type, number of cases referred, number of educational 
activities completed, population, etc. 
· Outreach visits by health providers – based on monthly CHA reports, 
health personnel can make follow-up visits to high risk patients in the 
community, accompanied by the CHA in each sector, thus making 
outreach work more efficient and effective.
· Supervision – Conducted by ASOACS/COACS with MOH staff using a 
supervision checklist. Checklist needs to be simplified.
· Birth plan – all pregnant women are encouraged to fill out a birth plan 
prior to delivery. The plan includes monitoring for TT, prenatal visits, 
postpartum family planning, who will attend birth, where the birth will 
be , who will go with the woman, what position preferred for the birth, 
who will watch the other children, plus educational messages on the 
four types of danger signs, saving for emergency and things to 
prepare for the newborn and the mother.
· Referral System – CHAs have a three part form for referring 
patients to HCs. The first section of the form is retained by the CHA 
as a permanent record of their referral, the second part is retained 
by the HC staff, and the third section is returned to the CHA by the 
patient with follow-up instructions. A register in the HC of referrals 
provides the ability to verify the validity of the diagnosis of the CHA.
· Emergency Evacuation System - REDESS worked with CODECO and 
CHAs to organize a community committee for emergency evacuation 
and this has perhaps been one of the most successful strategies for 
contributing to efforts to reduce maternal mortality (see F. 
Highlight). Every family in each community knows what its role is in 
case of a medical emergency which needs to be evacuated to a HC. To 
46
evacuate patients, each community has a litter made of a long canvas 
cloth with tubular slots sewn in on each side (provided by REDESS) 
into which two long poles or branches (provided by the community) are 
slid to form a stretcher. The litter is stored at the house of the CHA 
or a community leader; whichever was more centrally located in the 
community. The litter is carried on foot, sometimes at great distance, 
to the closest point where a vehicle can be found to transport the 
patient to an appropriate HC. The radio system installed by REDESS 
is used to call centers to send an ambulance to pick up the patient. 
According to project documentation there are 348 communities, 208 
(60%) communities have emergency evacuation teams and 301 (86%) 
have emergency litters. The final KPC survey showed that 73% of 
women surveyed knew the community had an emergency evacuation 
system. To complement the emergency evacuation system, CARE 
promoted family savings for health expenses. This aspect did not 
appear to be as strong and may be a reflection on the worsening 
economic and security situation in the area. As one CHA put it “people 
do not want everyone to know they have money in their house”.
· Family files - are ideally kept by CHAs and updated monthly at the 
HC family file. This includes a system for identifying families which 
practice certain health behaviors as “Model Families” This did not 
really work out as it is too time consuming for CHAs and while 
identifying model families can be motivating, it can also cause social 
problems if publicly identified as such.
Cajabamba has a similar system but with more emphasis on epidemiological 
surveillance (reporting of infection diseases) and environmental risks 
(presence of vectors). The role of COACS in monitoring the monthly 
reporting system helps to ensure that CHAs adhere to the system, and 
provides sustainability to SIVICS.
SIVICS was a major development of ENLACE that had drawn the interest of 
MOH officials in the region of La Libertad, in other regions, and in the 
central level MOH, including the development a series of videos on SIVICS 
to facilitate dissemination of the methodology to other areas. With 
REDESS the regional Director in La Libertad has expressed interest in 
expanding SIVICS to all provinces in the region. SIVICS is a model system, 
but CARE will need to market SIVICS at local, regional, national and 
47
international levels. The documentation and marketing of successful models 
is a long term challenge for CARE and its partners.
Systems need to be as simple as possible, with a direct relationship between 
information collected and actions that can be taken based on the 
information. Simplification should be the goal to decrease time spent by 
volunteers on record keeping.
Implement principal activities during the first two years of the project, and 
use the last two tears for monitoring and supervision
Other Methods of Information Collection and Use
A MOH quality care assessment and a CHA quality care assessment were 
slated to be a principal tools for measuring change in project indicators at 
midterm and final. There was no provision made to conduct these 
assessments, only to rely on measurement through a limited final evaluation 
process (see Annex B for methodology of final evaluation). All measurements 
methods outlined in the M&E plan should have a clear plan for conducting
them.
Qualitative studies were conducted on effectiveness of interventions with 
CODECO leaders and Support Group facilitators. Insight gained by these 
studies helped to shape ongoing activities. A qualitative investigation on 
preferences for communications methods was conducted by students from 
the Communications Sciences Department at the Private University Antenor 
Orrega with the goal of developing an appropriate and effective IEC 
strategy.
A 30-cluster KPC survey was conducted in 2000 and 2004 as baseline and 
final measurements of primary project indicators. See Annex D for the
complete KPC Report. Consultants were hired to conduct both KPC surveys. 
The final survey was of particularly good quality but it was observed in their 
bibliography that they utilized the Johns Hopkins University 1995 guide to 
completing the KPC. Updated information on use of KPC 2000+ should have
been provided to the consultants.
REDESS staff was trained in the LQAS (Lot Quality Assurance Sampling) 
methodology and an additional KPC was conducted in April 2003. The survey 
48
lost some of its value as a monitoring tool by the inclusion of all indicators, 
rather than a selected sub-set of critical indicators. Results were used to 
identify priority zones.
Two weaknesses in the information system of REDESS are; lack of adequate 
follow-up and monitoring of training activities and institutional capacity 
building, and lack of a clear focus on use of information. Information 
collection is not a valid activity unless that information is used for decision 
making. All projects need to create a culture of information use.
8. Technical and Administrative Support
Technical assistance visits were received from CARE USA Headquarters on 
the following occasions:
s Proposal development (Judiann McNulty)
s BABIES training (Namita Kukreja, Susan Ross)
s Midterm Evaluation (Elena McEwan, Joan Jennings)
s Preparation of Third Annual Report (Elena McEwan)
s Final Evaluation (Joan Jennings)
REDESS staff had the opportunity to attend CARE’s Annual Child Survival 
Conferences which included the following topics:
2001 in India: Community Information Systems
2002 in Kenya: Adult Learning
2003 in Nicaragua: BCC
2004 in Baltimore: CORE Group meeting
Additional visits were made to Atlanta to participate in Maternal Health 
activities.
Other external technical assistance was received in:
s DIP Preparation (Lynn Johnson, Consultant)
s Community IMCI (NicaSalud, BASICS)
s IMCI Materials (Red Cross)
s Support Groups (Josefina, Consultant)
s Adult Education Methods (Bonnie Kittle, Consultant)
s LQAS (NicaSalud)
In addition to technical support visits, a supportive system of communication 
exists via email and phone conversations, CARE HQ backstop staff regularly 
49
disseminate state-of-the-art technical materials to child survival project 
staff. For example, the CARE-developed tools for promoting Quality 
Maternal and Newborn Care (developed in partnership with Centers for 
Disease Control) were widely disseminated among CARE health project staff. 
Sufficient and timely technical assistance was provided to REDESS staff. 
Training in conflict management by CARE USA was planned but never 
implemented.
9. Management Lessons Learned
USAID/DCHA/PVC Child Survival Grants Program
Several suggestions for modifying indicators were made in the 3rd annual 
report, but these changes were never officially incorporated in project 
documents. For example; originally 6 CHA associations were planned, but 
during project implementation it became clear that the most logical 
configuration would be to combine CHAs from the hospital in Huamachuco 
with CHAs from one of the mirco-networks, making the total number of 
associations 5. A lack of clarity exists for exactly how to make this type of 
adjustments during project implementation.
A clear mechanism for modifying indicators throughout the life of the 
project would make implementation better adapted to changing needs and 
local realities.
50
D. Conclusions and Lessons Learned
REDESS has been able to successfully meet all intermediate results, or make 
substantial progress in completing them. The project objectives were very 
ambitious for a four year project and concerns exist as to the sustainability 
of some activities, such as the COACS/ASOACS organizations, however, 
within the limits of the life of this project, much has been achieved to 
promote potential for sustainability. The project results will be shown with 
time, whether sustainable provision of services and sustainable participation 
of local governments are the final outcome of project activities. 
Result 1
Improved MOH 
capacity for 
community outreach.
Result 2
Increased community 
responsibility for 
improved personal 
health. 
Result 3
Sustained provision 
of front line 
services by CHAs.
Result 4
Sustained participation 
of local governments in 
health management. 
Intermediate 
Result 1
Improved coverage 
and quality of 
services provided by 
local health networks 
Intermediate
Result 2
Increased caretaker 
knowledge and 
practice 
Intermediate 
Result 3
Improved quality 
and coverage of 
care provided by 
CHAs.
Intermediate 
Result 4
Strengthened 
relationships between 
CHA associations and 
local municipal 
governments and civil 
society.
The project took on the very difficult task of weaving together a structure 
capable of sustaining improved health practices and services. The 
improvements seen to date are the results of the sum of training at various 
levels. The fabric that has been woven is still fragile, but the project has 
been able to successfully improve capacity, leaving human resources capable 
of continuing, and improving upon, health activities.
The most outstanding achievements of this project have been:
ÿ Health facility strengthening through improved organization and training 
of health staff, including IMCI training
ÿ Strengthening of community development committees (CODECO), CHA 
committees and associations, and local government structures and the 
linkages united them.
ÿ Referral system and emergency evacuation which have a very important 
role in decreasing maternal mortality
51
ÿ SIVICS system which brings together multiple elements for monitoring 
activities 
ÿ The MOH staff clearly sees their role in REDESS as direct 
implementers. CARE has done a very good job of facilitating a process, not 
just implementing a project.
ÿ Focus on identifying positive aspects, not just weaknesses this was 
evident in the CHA supervision checklist, in steps for effective counseling, 
and in steps for making home visits
ÿ This inclusion of project partners and communities throughout the entire 
process of design, implementation and evaluation foments excellent 
community ownership and pride in the work accomplished
ÿ Focus on planning and organization which provides an important cross 
cutting skill: at the family level-birth plan; at the community level- AOP; 
and at the HCs-organization of activities and evaluation of efforts
Constraints affecting program performance:
ÿ Lack of institutionalizing health promotion activities so that MOH staff 
are rewarded for these preventative services
ÿ Problems of quality of care in some HCs, including lack of cultural
sensitivity
ÿ Late implementation of some key activities, not allowing sufficient time
for gaining experience.
Summary of Lessons Learned: 
s CARE should increase training on the use of KPC 2000+, including the 
Rapid CATCH indicators, to ensure correct interpretation and data
collection.
s Work with MOH at all levels to advocate for changes in policy which limit 
child survival activities e.g. distribution of cotrimoxazole and ORS.
s An increase in all liquids, including breastmilk, should be the emphasis for 
children with diarrhea, not the preparation of a homemade sugar and salt 
solution or ORS, if not readily available. 
s The certification of CHAs can be an effective method for motivating 
CHAs and ensuring good quality work if the process is carried out in a timely 
fashion. 
s The dissemination of project objectives and strategies from the 
beginning to all communities would clarify expectations and attract CHAs 
who are more dedicated, and serve to motivate communities
52
s The establishment of organizations such as COACS/ASOACS and 
CODECO needs to be started early in the project cycle to allow sufficient 
time to acquire experience and to gain political support.
s Begin community mobilization by organizing the development committee, 
this provides support for the CHAs and the early implementation of project 
activities such as SIVICS,
s An equal amount of effort should be dedicated to community organization 
and the training of CODECOs as is dedicated to forming CHAs, to provide 
them with sustainable support.
s Continued effort is needed to maintain the Consensus Building 
Committees as an active body which is inclusive of all social actors.
s Having a broad base of support at all levels is vital; within the 
communities both with leaders, men and women, and within all levels of 
governmental structures. This means that all actors should receive basic 
education in health issues, depending on their level of need and once the 
desired behavior is identified, the decision makers who influence that 
behavior needs to be included in educational activities.
s To achieve behavior change it is important to use a variety of media and 
techniques, each with the same standardized message. 
s “Learning by Doing” using locally available resources, leads to better
understanding by CHAs and community members.
s Having a greater understanding and sensitivity to the local culture makes 
communication more effective.
s All project documents should include the date they were produced and a 
brief two page summary of the document
s Advocacy and diffusion of project experiences is needed at local, regional 
and central levels. 
s The establishment of strategic alliances with the communication media
helps to involve them as watchdogs of the political process of health
implementation and in the promotion of actions for the social well-being of 
the population.
s Projects should be designed based on local realities; this includes 
frequent MOH staff rotation. 
s A plan for the orientation of new staff needs to include the incorporation 
of health promotion activities
s The evaluation and supervision systems of the MOH would be more 
coherent with current policy if they included health promotion activities.
53
s The entire HC team should be involved in supervising and coordinating 
with CHAs, not just the health promotion person.
s The supervision visits made with an integrated focus and team are most 
effective
s ANA is most effective when used with all groups involved in the project, 
from the beginning.
s A mechanism needs to exist to generate new institutional trainers to 
ensure sustainability of project strategies.
s The identification and development of Learning Centers is a positive 
method for exchanging experiences and motivating staff, but they need to 
be developed in a timely fashion.
s Training should never be held alone, without a follow-up plan monitoring 
and supervision, particularly in IMCI
s It is more effective to work with a Training System, rather than a 
Training Plan
s Adult Education Methodologies should be used in all training events to 
increase effectiveness of changing behaviors
s The availability of detailed lesson plans and curriculum for all training 
events increases consistency and quality
s . The documentation and marketing of successful models is a long term 
challenge for CARE and its partners.
s Systems need to be as simple as possible, with a direct relationship 
between information collected and actions that can be taken based on the 
information. Simplification should be the goal to decrease time spent by 
volunteers on record keeping.
s Implement principal activities during the first two years of the project, 
and use the last two tears for monitoring and supervision
s All measurements methods outlined in the M&E plan should have a clear 
plan for conducting them.
s Information collection is not a valid activity unless that information is 
used for decision making. All projects need to create a culture of 
information use.
s A clear mechanism for modifying indicators throughout the life of the 
project would make implementation better adapted to changing needs and 
local realities.
54
Plans for the sharing best practices to the development community: 
CARE strives to utilize best practices based on lessons learned from its own 
programs and by improving models from other programs. REDESS has 
developed several materials, including a videotape in English and Spanish and 
supporting print literature, that explain the steps and elements necessary 
for successful implementation of a community information system (SIVICS). 
These materials have been distributed to CARE country offices and shared 
with other PVOs during CORE meetings. Recently, a CARE Peru CS staff 
member presented these and other best practices (strengthening civil 
society capacity for social management of health issues at the municipal 
level) at the American Public Health Association meeting. A presentation on 
the support group experience was presented during the La Leche League 
International conference in 2003. In the last month of the project 
extension, a "package" of best practices documentation will be finalized with 
the assistance of a local consultant. This package will then be shared with 
all CARE Spanish-speaking (Latin America) or reading (for example, 
Mozambique and Angola) country offices.
Highlights on best practices are also regularly shared among all CARE 
country offices through the Health Unit Quarterly Newsletter. The 
newsletter ensures staff are aware of available materials and have the 
chance to request additional copies and/or technical assistance, cross-visits, 
etc. as relevant.
CARE Peru also plans to "market" these best practices throughout Peru, 
specifically and primarily to Regional Directorates of the MOH. The new 
central MOH division for Health Promotion has recently received USAID 
funding and local level MOH management is being encouraged to seek 
assistance in accessing and utilizing these available funds. The Regional 
Directorate for La Libertad has made minor adaptations to SIVICS and is 
discussing plans to scale-up and utilize this system throughout the region. 
They have officially requested CARE Peru assistance with this strategy and 
CARE Peru is actively seeking funding to support the scale up of this element 
within a series of best practices ready to go to scale (including supportive 
supervision tools, efficient organization to optimize the IMCI approach, 
quality of care actions and tools, and more).
55
F. Results Highlight 
The CARE REDESS (Networks for Health) Child Survival Project (October 2001 to January 
2005) has built upon previous CARE experience in Community Health Surveillance Systems. 
The ready acceptance by Ministry of Health personnel of the central elements of the system --
such as community mapping of vulnerable population groups, community census and 
documented referral system between Community Health Volunteers and local health units -- has 
enabled it to flourish and develop into a key tool for strengthening the link between communities 
and the health sector. 
During final evaluation, a review of documented referrals tabulated by the municipal-level 
Ministry of Health Management Team showed that, among a population of roughly 44,000 
women of reproductive age and 22,000 children under age five, there had been 9,723 referrals in 
2003 and 2004 (15% of the target population). The majority of the referrals were for preventive 
health services. Referral for prenatal care for pregnant women accounted for 22% of referrals, 
while children benefited from 13% of referrals for the third dose of DPT immunization or 
measles vaccine and 16% for growth monitoring. Referrals for treatment amounted to roughly 
25%, including referral for treatment of pneumonia and diarrheal disease, and management of 
danger signs during pregnancy.
Delay in seeking care from the health establishment is often cited as a key contributing factor to 
high rates of child or maternal mortality in the project area. Clearly, the CARE REDESS project 
has had a positive impact in changing care-seeking behavior, thanks to the ability of Community 
Health Volunteers to convince their peers of the necessity and the benefit of early care-seeking.
The Community Health Volunteers, with the support of the Community Development Councils of 
which they are members, have also had noticeable success in addressing health care emergencies. 
More than 95% of communities have established Emergency Evacuation Committees which have 
developed a rotating plan of responsibility among 3-4 members for carrying patients on a litter 
provided through CARE, from the village to the nearest place in which motorized transportation 
can be obtained (health unit ambulance or, more often, local transport). 
Witnessing the dedicated efforts of community members and local staff to address the problems 
present in a remote and rugged area of the country, the municipal-level Ministry of Health 
Management Team saw the importance of balancing the emphasis on the negative (number of 
deaths) with recognition of the positive. They decided to track the number of deaths averted 
through emergency evacuation and successful treatment. In 2003 and 2004, more than 79 
maternal and 47 infant deaths have been averted due to the enthusiastic efforts of communities 
motivated by the CARE REDESS Project. During visits to communities during final evaluation, 
more than one moving testimony was given by families benefiting from these new practices. For 
example, in one village in the past month alone, two women had been evacuated during 
problematic childbirth (placenta previa and a primigravida with prolonged labor). Both were 
successfully evacuated, treated and are doing well, along with their babies.
ATTACHMENTS:
A. Evaluation Team Members 
B. Evaluation Assessment Methodology
C. List of persons interviewed and contacted
D. CARE Peru CS Project REDESS Final KPC 
Evaluation Report
E. Project Data Sheet form – updated 
version
A. Evaluation Team Members 
NAME TITLE ORGANIZATION
Carmen Parra Gallegos Community Participat 
Coordinator
MOH Central 
Regina Sánchez Sato Director of Health 
Services
La Libertad Region 
MOH
Imelda Medina Hoyos Mental Health 
Promotion Coordinator
La Libertad Region MOH
Celina Machuca Vilchez Community Participat. 
Coordinator
Cajamarca Region MOH
Luis César Alayo Chavez Manager of Health 
Network
Health Network 
Sánchez Carrión
Carmen Yolanda Paiva 
Heredia
Women’s Issues 
Coordinator
Health Network 
Sánchez Carrión
María Lucila Arteaga 
Vásquez
Health Promotion In￾charge
Health Network 
Sánchez Carrión
Francisca Rodríguez 
Rodríguez
Nutritionist Health Network 
Sánchez Carrión
Gloria Arcos Paredes Project REDESS 
Coordinator 
CARE PERU
Luz Elena Mendoza 
Navarro
Project REDESS 
Specialist 
CARE PERU
Rosario Vargas Lucar Project REDESS 
Specialist
CARE PERU
Silvia Valderrama Sánchez Project REDESS 
Specialist
CARE PERU
Renee Charleston Team Leader Consultant
Joan Jennings Senior Technical 
Advisor
CARE USA
B. Evaluation Assessment methodology
I. OBJECTIVES OF THE EVALUATION
The purpose of the Final Evaluation was to;
(a) assess if the program met the stated goals and objectives
(b) measure the effectiveness of the technical approach
(c) develop lessons learned from the project
(d) develop a strategy for use or communication of these lessons both 
within the organization and to partners.
The evaluation was carried out in accordance with USAID/DCHA/PVC Child 
Survival Grants Program Final Evaluation (FE) guidelines for August 2004 
and the evaluation report follows the suggested format.
II. COMPOSITION OF EVALUATION TEAM
The team was composed of representatives from CARE Peru, CARE USA 
Headquarters, MOH local network, district and central levels, and an 
external evaluator who served as team leader. Additional resource people 
participated in the Analysis Workshop including representatives from CHA 
Associations and committees, local government officials and additional MOH 
staff.
The team leader was responsible for coordinating all evaluation activities, 
supervision of the team, meeting all specified objectives, collaborating with 
CARE and MOH, and submitting a draft and a final report according to a 
defined timeline. 
III. EVALUATION PLAN
The evaluation was divided into four phases:
Phase I Planning
· Preplanning (Formation of team, logistics, document review, selection 
of communities) 
· 1 day Planning Workshop (KPC analysis, methodologies, design of 
instruments) 
Phase II Data Collection
· Field Work visits 
· Other interviews 
· Document review 
Phase III Data Analysis
· Summarize data 
· Analysis of data by the evaluation team (1 day Analysis Workshop)
· Analysis of data by other partners (1 day Analysis Workshop)
Phase IV Presentation
· Written report 
· Formal presentations to CARE Peru staff and to other stakeholders 
(MOH, USAID, other NGOs).
The evaluation team was divided into 2 small groups to collect information 
from the field. Each team consisted of 6-7 people. The teams were in the 
field for 4 days to visit four communities and two health facilities previously 
selected for visits, and interview project stakeholders.
A Planning Workshop was held for all team members to review the results of 
the KPC and to develop methodologies for defining lessons learned through 
interactive field visits to communities and MOH health centers.
An Analysis Workshop was held for all team members and other resource 
people to review the results of the field work and other information 
collected during the evaluation, and to formulate lessons learned during the 
four years of project implementation.
IV. METHODOLOGY
Using both a participatory approach and participatory methodologies, a 
multi-disciplinary term of key project stakeholders examined the 
implementation of CS activities using a variety of qualitative methodologies. 
Field visits allowed project participants and community volunteers to provide 
their inputs and suggestions to the evaluation process. The evaluation 
focused on the impact of project strategies including; capacity building of 
the MOH, community health agents and community health committees, 
implementation of IMCI, supervision, coordination with municipalities and 
the MOH, and CHA associations. The methodologies used to obtain 
information for the evaluation included:
Document Review
Key Informant Interviews 
Group interviews
Feedback of selected results from the KPC followed by a group 
analysis 
Inventory of supplies/equipment of CHAs
Observations of Supervision visits, Support Groups, and 
Demonstrations 
Questionnaires were designed during the Planning Workshop for use in group 
and individual interviews. The following activities were completed:
Date/Group Group Responsible Instruments
24 Wednesday
Health Promotion 
In-Charges
Facilitator: Regina
Notes:
Ma Carmen, Imelda
Guide # 1
KPC
Management 
Team-Health 
Network
Facilitator: Renee
Notes:
Ma Carmen, Regina
Guide # 1
KPC
Round Table Sub￾Committee
Facilitator: Imelda
Notes:Celina, Sylvia
Guide # 2
KPC
25 Thursday 
Group 1 Women Paquita
Facilitator: Luz 
KPC
CHAs Imelda Guide # 4
APROMSA PAT Gloria
Facilitator: Carmen
Guide # 6
KPC
Group 2 Women Mary KPC
CHAs Renee Guide # 4 
Health Center Sylvia Guide # 3
26 Friday
CODECOs Sylvia Guide # 5
KPC
CHA Organization Caro Guide # 6
KPC
Local 
Governments 
Joan/Gloria Guide # 2
KPC
Support Group 
Facilitators 
Renee Guide # 7
KPC
27 Saturday
Group 1 Women Paquita
Facilitator: Luz Elena
KPC
CHAs Imelda Guide # 4
CODECO Luz
Facilitator: Paquita
Guide # 5
Health Center Imelda
Facilitator: Gloria
Guide # 3
Group 2 Women Mary KPC
CHAs Renee Guide # 4 
ASOACS Caro Guide # 6
KPC
V. EVALUATION SCHEDULE 
November-December 2004
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
18
Preparation
19
Preparation
20
Travel
21
Evaluation 
Planning
22
Evaluation 
Planning￾Document 
Review
23
Workshop 
for 
Evaluation 
Team
24
Interview/ 
Meetings 
with partners
25
Community 
Visits
26
Community 
Visits
27
Interview/ 
Meetings 
with 
partners
28
Preparation 
of 
information
29
Preparation 
of 
information
30
Analysis 
Workshop 
for 
Evaluation 
Team
Dec. 1
Analysis 
Workshop 
for Project 
Partners
2
Presentati
on of 
Evaluation 
Results 
CARE Peru
3
Presentati
on of 
Evaluation 
Results: 
MOH, 
USAID, 
other 
NGOs
4
Travel
Evaluation of the Process
Six team members completed an evaluation of the FE process, during the 
Analysis Workshop. The results from the questionnaires were: 
® 4/6 (67%) of participants felt that the process used was very effective, 
and 2/6 (33%) that it was effective.
® Most participants felt that nothing was lacking from the process but 
three people mentioned not including members of ASOACS or the 
community in the evaluation process.
® What people liked most about the evaluation were the process of 
analyzing the information collected and the use of the FE as an 
opportunity to share results of the KPC survey. Other aspects people 
found positive were the high level of participation, the gallery walk and 
five stars methodologies, and the involvement of local government 
officials.
® Most people said there was nothing they disliked about the evaluation, 
but one point mentioned was the short amount of time devoted to the 
evaluation. Other negative aspects were conducting simultaneous 
activities so everyone did not get to participate in all activities and that 
communities were not randomly selected for visits.
® Several people mentioned they liked the process because it allowed them 
to learn new evaluation techniques and to analyze information .
C. List of persons interviewed and contacted
Interviews conducted during four days of field work included:
16 MOH staff in charge of Health Promotion at Health Facilities
10 members of the MOH Network Management Team
9 members of the health sub-committee of the Sanchez Carrion Roundtable 
12 members of APROMSAPAT (the ASOACS in Cajabamba)
4 CHAs
15 Support Group Facilitators
11 members of COACS and ASOACS (18% women)
10 MOH staff at three Health Centers
22 CODECO leaders
11 local government officials (18% women)
37 women in four communities
The following people participated in the Analysis Workshop on December 1st
NAME TITLE ORGANIZATION
Imelda Medina Hoyos Mental Health 
Promotion Coordinator
La Libertad Region MOH
Celina Machuca Vilchez Community Participat. 
Coordinator
Cajamarca Region MOH
Luis César Alayo Chavez Manager of Health 
Network
Health Network 
Sánchez Carrión
Carmen Yolanda Paiva 
Heredia
Women’s Issues 
Coordinator
Health Network 
Sánchez Carrión
María Lucila Arteaga 
Vásquez
Health Promotion In￾charge
Health Network 
Sánchez Carrión
Francisca Rodríguez 
Rodríguez
Nutritionist Health Network 
Sánchez Carrión
Gloria Arcos Paredes Project REDESS 
Coordinator 
CARE PERU
Luz Elena Mendoza 
Navarro
Project REDESS 
Specialist 
CARE PERU
Rosario Vargas Lucar Project REDESS 
Specialist
CARE PERU
Silvia Valderrama Sánchez Project REDESS 
Specialist
CARE PERU
Roxana Raimundo Manager of Mirco￾Network Curgos
Health Network 
Sánchez Carrión 
Mario Oblitas Mirco-Network 
Markahuamachuco
Health Network 
Sánchez Carrión
Mario Riveros Manager of Mirco￾Network El Pallar
Health Network 
Sánchez Carrión
Elsa Palomino Manager of Mirco￾Network CHAS
Health Network 
Sánchez Carrión
Hector Rodríguez Barboza Mayor Provincial Municipality 
Sánchez Carrión
Pedro Carranza Malqui Mayor District Municipality 
Curgos
Luis Rebaza Mayor District Municipality 
Cochorco
Oscar Fuentes Municipal Manager Provincial Municipality 
Sánchez Carrión
Alexis Rebaza Lopez Council Member Provincial Municipality 
Sánchez Carrión
Cecilia Gastañadui Council Member Provincial Municipality 
Sánchez Carrión
Napoleón Morales Council Member Provincial Municipality 
Sánchez Carrión
Rosa de la Cruz Aranda President ASOACS EL Pallar
Roger Serín President ASOACS Curgos
Jorge Quezada President ASOACS Markahuamchuco
Santos Gastañadui Education Management 
Unit UGEL
Zoila Morales Micro-region
Joan Jennings Senior Technical 
Advisor
CARE - USA
Other interviews were conducted with:
Gloria Arcos REDESS Coordinator CARE Peru
Luz Elena Mendoza Project REDESS Specialist CARE Peru
Rosario Vargas Project REDESS Specialist CARE Peru
Silvia Valderrama Project REDESS Specialist CARE Peru
Lourdes Huamani Administrative Assistant CARE Peru
Guillermo Frias Regional Director CARE Cajamarca 
Joan Jennings Senior Technical Advisor CARE USA
Luis César Alayo Manager of Health Network Sánchez Carrión Province
Regina Sánchez Director of Health Services MOH La Libertad Region
Rene Castillo Title II Program CARE Peru
Gladys Soto Finance Director CARE Peru
Carmen Rosa Calvo Health Program Analyst CARE Peru
D. CARE Peru CS Project REDESS Final KPC Evaluation Report
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Universidad Nacional Instituto de Seguridad Cooperación Alemana
Agraria La Molina Alimentaria Nutricional al Desarrollo
FINAL QUANTITATIVE EVALUATION OF THE 
CARE PERU
Cooperative Agreement No. FAO-A-00-00-00030-00
October 1, 2000 – September 30, 2005
XVI CHILD SURVIVAL PROGRAM 
“REDESS”
Guillermo López de Romaña Ricketts, MD
gromana@lamolina.edu.pe
Alejandro Vargas Vásquez, MPN
vargas_alejandro2004@yahoo.es
Instituto de Seguridad Alimentaria Nutricional 
[Nutritional Food Security Institute – ISAN]
Isan.gtz@lamolina.edu.pe
http://www.lamolina.edu.pe/pnp
Av. La Molina n/n. District of La Molina. Lima - Peru
Telephone: (51-1) 349-5647 / (51-1) 349-5669
September - October 2004
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ACKNOWLEDGEMENTS
General Coordinators
Gloria Arcos Paredes (REDESS Project - CARE PERU)
Luis Alayo Chávez (Sánchez Carrión Health Network - MOH)
Juan Modesto (Cajabamba Health Network - MOH)
Antonia Bermúdez Corcuera (Sánchez Carrión Health Network - MOH)
Maria Lucila Arteaga Vásquez (Sánchez Carrión Health Network - MOH)
Flor Cabrera Flores (Cajabamba Health Network - MOH)
SUPERVISORS, SURVEY TAKERS AND 
ADMINISTRATIVE SUPPORT PERSONNEL 
Full Names Institutional Affiliation
Sánchez Carrión Network -- Ministry of Health
1. Antonia Bermúdez Corcuera Sánchez Carrión Network
2. Maria Lucila Arteaga Vásquez Sánchez Carrión Network
3. Iovany Joel Guevara Diestra Sánchez Carrión Network
4. Araceli Esther Reyes Rodríguez Sánchez Carrión Network
5. Francisca Nereída Monzón Novoa Sánchez Carrión Network
6. Felicita Fernández Henríquez Sánchez Carrión Network
7. Carmen Yolanda Paiva Heredia Leoncio Prado Hospital
8. Maria Petronila Campos Vera Leoncio Prado Hospital
9. Lucia Otilia Marquina Uriol Chugay Health Post
10. Sonia Elizabet Gerónimo Quipas Cochabamba Health Post 
11. Gabriela Reyes Góngora Marcabal Grande Health Post 
12. Dante Daniel Choque Subia El Pallar Health Post 
13. Manuel Jesús Vera Iparraguirre Choquizonguillo Health Post
14. Rosa Alvina Carril Flores Uchubamba Health Post 
15. Eliseo Guevara Vásquez San Alfonso Health Post 
16. Rosamel Lavado Cruz Sarín Health Post
17. Blanca Flor De La Cruz Baltasar Sartimbamba Health Post 
18. Sonia Elizabet Gerónimo Quipas Cochabamba Health Post 
19. Nancy Genoveva Segura Murga Sanagorán Health Post 
20. Luz Dalila Alcántara Ruiz Curgos Health Post
21. Roger Fidel Serin Carhuallay Sarin Health Post 
22. Graciela Cabrera Mudarra Orogolday Health Post 
23. Jorge Antonio Chiguala Díaz Ventanas Health Post 
24. Ana Violeta Paredes Pérez Chugay Health Post 
25. Armandina Solomé Rodríguez Ultima Chugay Health Post 
26. Elsa Rodríguez Rodríguez Sanagorán Health Post
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Cajabamba Network -- Ministry of Health
1. Margarita Flor Sáenz Córdova Cajabamba Network V
2. Carlos Magno Cabrera Cabanillas Cajabamba Network V
3. Flor Cabrera Flores Cajabamba Network V
4. Marina Yolanda Toribio Fernández Cajabamba Network V
5. Maria Gutiérrez Lezama Cajabamba Support Hospital
6. Elsa Irene Morillo Altamirano Cajabamba Support Hospital
7. Milagritos Gladys Arcos Paredes Cajabamba Support Hospital
8. Miriam Silvia Campos Ruiz Uchubamba Health Post 
9. Irma Patricia Salazar Marroquín Algamarca Health Post 
10. Sabina Graus Rodríguez Otuto Health Post
11. Flor Marleni Tapia Ruiz Huañimba Health Post
12. Teofila Flor Lezama Risco Chuquibamba Health Post 
13. Elsa Leonila Córdova Alcalde Cauday Health Post
14. Luis Aquilino Carranza Sam Araqueda Health Post
Sanitation Technicians and Nursing Students
1. Lourdes Violeta Miraval Daza Huamachuco
2. Rosalias Maribel Acevedo Loloy Huamachuco
3. Carolina Antonia Grados Cruz Huamachuco
4. Demetrio Benítez Alfaro Huamachuco
5. Juana Prieto Polo Huamachuco
6. Edgar Presciliano Sánchez Vásquez Huamachuco
7. Fanny Viviana Santos Rondo Huamachuco
8. Patricia Amoroto León Huamachuco
9. Cecilia Roxana Jara Valdivia Huamachuco
10. Elsa Dalila Cruz Contreras Huamachuco
11. Eliza Esther Polo Rojas Huamachuco
12. Ella Mariela Yupanqui Narváez Huamachuco
13. Maria Margarita Julca Salinas Huamachuco
14. Rosmerg Janett Ruiz Vera Huamachuco
CARE PERU REDESS Project
1. Gloria Arcos Paredes 
2. Erika Jeanice Aguilera Rodríguez 
3. Luz Elena Mendoza Navarro
4. Marianela Cárdenas Armas
5. Rosario Vargas Lucar
6. Silvia Valderrama Sánchez
7. Lourdes Huamaní Medina
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 TABLE OF CONTENTS Page
Executive Summary 10
1. Background of the REDESS Project 12
1.1. Health situation in Peru and in the Project area. 12
1.1.1. Relevant socio-economic aspects in the REDESS Project area. 12
1.1.2. Policy guidelines of the Peruvian Ministry of Health. 14
1.1.3. Availability of health facilities in the REDESS Project area. 15
1.1.4. Situation of maternal and child health. 16
1.1.5. Role of community health agents 20
1.2. Goals, objectives and main activities of the REDESS Project. 21
2. Final Quantitative Evaluation of the REDESS Project: Goals and 
Implementation 23
3. Evaluation Methods 24
3.1. Survey of knowledge, practices and coverage (KPC). 24
3.2. Calculation of Indicators of Knowledge, Practices and Coverage. 26
3.3. Sampling. 29 
3.4. Training of Supervisors and Survey Takers. 31
3.5. Data Collection. 31
3.6. Analysis of the Data. 32
4. Results 33
4.1. Results of the KPC Survey 33
4.1.1. Socio-demographic data of the mother and the child 33
4.1.2. Knowledge and practices of breast feeding and nutrition. 34
4.1.3. Child immunization coverage. 40
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4.1.4. Prevalence of diarrhea and knowledge and practices on its 
control. 42
4.1.5. Prevalence of acute respiratory infection and knowledge and 
practices on its control.
46
4.1.6. Knowledge and practices of care and attention with respect to 
maternal health. 49 
4.1.7. Knowledge of prevention of Bartonellosis, Malaria and 
HIV/AIDS. 57
4.1.8. Community organization. 59
4.2. Results of the Anthropometric Study. 61 
 
4.3. Results of the evaluation indicators of the REDESS Project. 64
4.3.1. Indicators of the management of cases of pneumonia. 64 
4.3.2. Indicators of the prevention and control of diarrhea. 65
4.3.3. Indicators of maternal health. 66
4.3.4. Indicators of practices in child feeding. 68
4.4. Results of the indicators suggested by USAID. 70
4.4.1. Prevalence of malnutrition. 70
4.4.2. Indicators of the prevention of diseases and death. 70
4.4.3. Indicator of the management and treatment of diseases. 72
5. Discussion 74
6. Bibliography 79
7. Annexes 81
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 LIST OF TABLES Page
Table No. 1: Population information by Province and Department in 
REDESS Project areas. 12
Table Nº 2: Health facilities by micro networks in the Sánchez 
Carrión Health Network, Department of La Libertad. 15
Table Nº 3: Health facilities in the Cajabamba micro network of the Cajabamba 
Health Network, Department of Cajamarca. 16
Table Nº 4: Description of the calculation of the indicators of the REDESS Project 26
Table Nº 5: Description of the calculation of the indicators proposed by USAID 27
Table Nº 6: Number of surveys taken, by REDESS Project area. 33 
Table Nº 7: Age groups of the mothers surveyed in the initial and final evaluations. 34
Table Nº 8: Age Groups of the children participating in the initial and final 
evaluations. 34
Table No. 9: Indicators of the management of pneumonia cases. 65
Table No. 10: Indicators of the prevention and control of diarrhea. 66
Table No. 11: Indicators of maternal health. 68
Table No. 12: Indicators of practices in child feeding. 69
Table No. 13: Indicators of the prevalence of malnutrition. 70
Table No. 14: Indicators of the prevention of illnesses and death. 71
Table Nº 15. Indicators of the management and treatment of illnesses. 73 
 
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 LIST OF GRAPHS Page
Graph Nº 1: Commencement of nursing (REDESS Project, 2004) 35
Graph Nº 2: Average number of daily breast feedings, by age group 36
Graph Nº 3: Pattern of food consumption for children aged 6 to 8 months 
(REDESS Project, 2004) 37
Graph Nº 4: Pattern of food consumption for children aged 9 to 11 months 
(REDESS Project, 2004). 38
Graph Nº 5: Feeding pattern for children aged 12 months and older (REDESS 
Project, 2004). 38
Graph No. 6: Addition of oil or lard in the food of children under 2 years of age
(REDESS Project, 2004). 39
Graph Nº 7: Initial and final evaluations of Child Vaccination Coverage
(REDESS Project, 2004). 41
Graph Nº 8: Vaccination Coverage, by gender (REDESS Project,
October 2004). 41 
Graph Nº 9: Prevalence of diarrhea during the 15 days prior to the Evaluation 
(REDESS Project, 2004). 42
Graph N 10: Increased consumption of maternal milk, liquids or foodstuffs
during an episode of diarrhea in children under 2 years of age 
(REDESS Project, 2004). 43
Graph No. 11: Knowledge of mothers about feeding after an episode of diarrhea 
(REDESS Project, 2004). 43
Graph Nº 12: Knowledge of mothers about signs of dehydration (REDESS Project, 
2004). 44
Graph Nº 13: Knowledge of signs of persistent diarrhea caused by dysentery
(REDESS Project, 2004). 45 
Graph Nº 14. Practices of mothers in washing hands (REDESS Project, 2004). 45
Graph No. 15: Prevalence of ARIs in the Evaluations of the REDESS Project (2004). 46
Graph Nº 16: Percentage of children with rapid or difficult breathing, attended to
by different health providers in the area of the REDESS Project
compared with other areas (Project REDESS, 2004). 47
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Graph No. 17: Knowledge of mothers about the signs of pneumonia (REDESS
Project, 2004). 48
Graph Nº 18: Knowledge of feeding practices following an episode of ARI 
(REDESS Project, 2004). 48
Graph Nº 19: Mothers who receive prenatal attention in health facilities 
(REDESS Project, 2004). 49
Graph No. 20: Percentage of mothers in final evaluation with knowledge of the 
signs of danger during pregnancy (REDESS Project, 2004). 50
Graph Nº 21: Means of transportation used by mothers in case of an 
obstetric emergency (REDESS, 2004). 51
Graph No. 22: Use of an iron sulfate supplement by mothers during their most recent
pregnancy (REDESS Project, October 2004). 52
Graph No. 23: Percentage of mothers whose most recent childbirth was in a health 
facility (REDESS Project, 2004). 53 
Graph No. 24: Percentage of childbirths in institutions, by education level. 53
Graph No. 25: Percentage of mothers in the final evaluation who recognize danger 
signals during childbirth (REDESS Project, 2004). 55
Graph No. 26: Percentage of mothers who recognize danger signs in newborns
(REDESS, 2004). 56
Graph No. 27: Percentage of mothers who recognize danger signs following 
childbirth (REDESS Project, 2004). 57
Graph No. 28: Knowledge of signs and symptoms of Bartonellosis in mothers who 
Live in high-risk zones (REDESS Project, 2004). 58
Graph Nº 29: Type of help received by mothers from Community Health Agents
 (REDESS Project, 2004). 59
Graph No. 30: Percentage of mothers who know that their community is organized
to evacuate a person in case of a health emergency (REDESS Project, 
2004). 60
Graph No. 31: Prevalence of chronic malnutrition (< 2 Standard Deviations 
according to WHO/NCHS) in the area of the REDESS Project 
compared with other areas (REDESS Project, 2004). 62
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Graph No. 32: Prevalence of malnutrition (< 2 Standard Deviations according to
WHO/NCHS) in the area of the REDESS Project compared with other 
areas (REDESS Project, 2004). 63
Graph No. 33: Prevalence of acute malnutrition (< 2 Standard Deviations 
according to WHO/NCHS) in the area of the REDESS Project 
compared with other areas (REDESS Project, 2004). 64
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EXECUTIVE SUMMARY
In Peru, especially in the rural zones, there are high rates of maternal and child mortality.
The non-governmental organizations thus make a very important contribution to the efforts
of the State and civil society sectors. 
The objectives of the REDESS Project of CARE PERU were a) to improve the
management of cases of pneumonia and b) reduce the prevalence of diarrhea in children
under 2 years old; as well as c) improve the practices of child feeding by mothers and d) 
improve prenatal care, early detection of warning signs and post-birthing practices of
women in their fertile years who live in the rural communities in the provinces of Sánchez
Carrión and Cajabamba in the Departments of La Libertad and Cajamarca.
The evaluation was a transversal type, and the sampling technique was random with a
confidence level of 95% and a 10% margin of error. The anthropometric evaluation was
conducted on children under 2 years of age, and a survey of practical knowledge and health 
coverage was given to mothers of children under 2 years of age. To determine malnutrition 
in children, the referenced population of WHO/NCHS is used, and those with a z score of
<than –2 standard deviations were considered malnourished. To analyze the variables,
frequencies, homogeneity tests, analysis of variance and tests of normality were employed. 
The results show an improvement in the levels of knowledge and practices of the mothers 
with respect to maternal and child health and child nutrition, an increase in coverage of
maternal and child facilities, an improved ability of the community organization to resolve
health problems and deal with emergencies, and improved abilities to seek Ministry of
Health facilities.
With respect to the evaluation indicators, 84.6% of them have showed improvement, while 
33.3% have achieved the proposed targets. There was particular difficulty to achieve the 
targets set for the indicators for prevention and control of diarrhea and for nutritional
improvement. Of the Rapid Catch indicators that are comparable between the initial and 
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final evaluations, 91% have shown improvement. With respect to nutritional indicators,
there has been improvement in chronic malnutrition (p=0.055), but acute malnutrition
(p=0.009) and overall (p=0.023) are more prevalent that at the beginning of the Project.
Thus we can say that, on balance, there has been a positive improvement in the maternal
and child health conditions during the Project implementation period (October 2000 to 
September 2004).
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1. BACKGROUND OF THE REDESS PROJECT
The REDESS Project of CARE PERU was developed in the provinces of Sánchez Carrión
and Cajabamba, in the departments of La Libertad and Cajamarca in the Republic of Peru. 
It is a Project implemented in association with the Ministry of Health, the Organization of
Community Health Agents and the local governments, and it has been implemented from
October 2000 until September of the present year. 
Its area of intervention encompasses a total of 348 population groupings (in their majority
rural) with a total population of 123,670 people in 23,554 families. 73.5% of this
population is in the province of Sánchez Carrión, with the remainder in the province of
Cajabamba.
Table No. 1: Population information by Province and Department in
REDESS Project areas.
Department Province Population Families
La Libertad Sánchez Carrión 90,850 17,439
Cajamarca Cajabamba 32,820 6,115
Total 123,670 23,554
The departments of La Libertad and Cajamarca are in the north of Peru and the provinces of 
the intervention are in the Andean region. Each department is composed of provinces and 
each province, of districts. The REDESS Project covers the entire province of Sánchez
Carrión, which is composed of 8 districts, and three of the four districts in the province of
Cajabamba.
1.1. Health situation in Peru and in the Project area. 
1.1.1. Relevant socio-economic aspects in the REDESS Project area.
The population is 80% rural and lives in peasant farmer communities surrounding the
capital cities in each of the districts. The population is predominantly Catholic, although
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there are a variety of Protestant churches in the area. The local language is Spanish, and in
this part of Peru, people don’t speak indigenous languages (Quechua, Aymara, etc.). The
provinces of Cajabamba and Sánchez Carrión have been categorized as areas of extreme 
poverty by the Peruvian government. Several districts of these two provinces have as high
as 88% of the households with their necessities not satisfied in food, housing, basic
services, health and education (CARE, 2001). 
More than 40% of the households lack access to potable water systems, in both the rural
and urban areas in Sánchez Carrión, while in one rural district of Cajabamba, less than 25% 
of the communities have access to potable water (URMEI 1999). Thirty percent of the
children don’t attend primary school (INEI 1994). The population depends economically on
the sale of its agricultural and livestock production, principally composed of potato, wool
and grains. The illiteracy rate in Sánchez Carrión shows that more than half (55.3%) of the 
women don’t know how to read or write (Epidemiology Unit, MOH, La Libertad, 1998). 
The Baseline Evaluation of REDESS showed that 46.7% of the mothers of children under 
two years of age are illiterate (CARE, 2000a).
Difficult climatic conditions prevail in the area, especially during the months of June to
September, with very low temperatures that oscillate between 0 and 5º C. The months of 
October to March are characterized by frequent rain, and are associated with the period of
sowing agricultural crops on a small scale for self-consumption. 
The majority of the communities are small and dispersed through the Andean highlands, and 
an important number of them have difficult geographical accessibility. Road access is good to 
the provincial capitals (Huamachuco and Cajabamba); nonetheless, access to the communities 
is difficult, especially during the rainy season. There are neither highways nor mechanized 
means of transport into the majority of the communities. Therefore, the majority of patients 
are transported on foot (55.3%) and a small portion, by public transportation (11.2%). 
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1.1.2. Policy guidelines of the Peruvian Ministry of Health. 
Beginning with an analysis of the principal health problems, the Peruvian Ministry of
Health has proposed a series of Policy Guidelines to orient its activities until the year 2012. 
Included among these guidelines are the following:
The promotion of health and the prevention of illnesses seeks the promotion of healthy life 
styles through actions that are coordinated and concerted with the education sector, local
governments, civil society organizations and the family. This process will have to
recognize and take into consideration the health concepts of the population and the
interaction between the health system and the community.
The thrust is for a model of integrated health attention and extension and universalized
health protection. First, it is centered in the satisfaction of the health necessities, whether or 
not they are perceived, by individuals, families and the community. Secondly, is a state
insurance mechanism, oriented to the poor and extremely poor population that lacks free
access to the health facilities and medicines. With integral health insurance, mothers have 
access to prenatal and postnatal care, childbirth facilities and treatment of obstetric and neo￾natal complications. Children are offered free preventative and curative services, such as
checkups for growth and development, immunizations, attention in cases of acute respiratory
infections, acute diarrhea, etc. Thus, the MOH seeks to increase access to health facilities 
and to prevent the lack of attention to families with health problems. 
Human resource development is also promoted via policies of training that is permanent
and open to all professionals and non-professionals, the planned growth of the formation of 
health personnel, the protection of the career public functionary, the generation of a policy
of incentives, etc.
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The rest of the guidelines seek to strengthen the supply and rational use of medication, the 
role of sectoral management, and the internal and external financing that is geared toward 
populations with high indices of poverty. 
 
1.1.3. Availability of health facilities in the REDESS Project area.
In the province of Sánchez Carrión, health facilities are organized in a Health Network,
made up of the “Leoncio Prado” Support Hospital and 16 peripheral health facilities. These 
facilities, in turn, are forming 4 micro health networks that are units for health organization
and management.
Table Nº 2: Health facilities by micro networks in the Sánchez
Carrión Health Network, Department of La Libertad.
Network Micro Network Health facility 
Markahuamachuco Choquizonguillo Health 
Post 
Puente Piedra Health Post
Marcabalito Health Post 
Ventanas Health Post
El Pallar El Pallar Health Post 
Cochabamba Health Post
Uchubamba Health Post
Marcabal Grande Health
Post 
San Alfonso Health Post
CHAS Aricapampa Health Post 
Chugay Health Post
Sartimbamba Health Post 
Curgos Curgos Health Post
Orogolday Health Post 
Sarín Health Post
Sánchez Carrión
_________ Leoncio Prado Hospital 
In the province of Cajabamba, the health facilities are organized into a Health Network,
organized in the Cajabamba Support Hospital and a total of 20 peripheral health facilities
that are forming 3 micro networks. The REDESS Project has only been implemented in the 
jurisdiction of the Cajabamba micro network, which has 7 health facilities. 
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Table Nº 3: Health facilities in the Cajabamba micro network of the Cajabamba 
Health Network, Department of Cajamarca.
Network Micro Network Health facility
Cajabamba Cajabamba
Cajabamba Health Center
Algamarca Health Post
Araqueda Health Post
Chuquibamba Health Post
Cauday Health Post
Otuto Health Post 
Huañimba Health Post 
1.1.4. Situation of maternal and child health.
Children under five years old and women at fertile age (15 to 49 years old) are
considered by the Ministry of Health (MOH) as groups at high risk of death.
Nonetheless, the most vulnerable are children under one year old and pregnant women. 
According to ENDES 2000, in rural areas, infant mortality (children under 1 year old) is 
estimated at 60 per 1000 live births, while mortality in children under 5 years old is
estimated at 85.0 per 1000 live births. At the national level, there is a clear tendency
downward during the last 30 years for both indicators. With respect to maternal mortality
at the national level, during the last decades there has also been a progressive reduction in
the Maternal Mortality Rate, from 400 per 100,000 between the years 1955 and 1969, to 
185 per 100,000 live births in the years 1993 to 2000.
Among the factors that have contributed to these tendencies, we can mention the process of 
concentration of the population into the large cities, which favors more families being
closer to health facilities. Other factors were the implementation of two important
initiatives in public health -- the Project to Strengthen Health facilities financed by the
Inter-American Development Bank and “Basic Health for All,” a program sponsored by the 
Peruvian government that increased the number of personnel in the health facilities and the 
number of hours they attend to the public and offered training in basic health and
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management. Together with the universalization of health insurance, which has helped poor 
children and women gain free access to health care.
In spite of this, it is worth mentioning that the infant mortality rate in Peru is still among the 
highest in Latin America, only superceded by the Dominican Republic, Nicaragua, Bolivia
and Haiti, which are all countries where per capita income is lower than in Peru. The
Maternal Mortality Rate is also one of the highest in Latin America (MOH, 2002). 
According to ENDES 2000, 25.4% of children under 5 years old suffer from chronic
malnutrition, and 13.2% of mothers are malnourished (Cajamarca = 18.2%; La Libertad = 
15.3%). Likewise, anemia represents a public nutrition problem, being prevalent in 49.6%
of children under 5 years old (Cajamarca = 52.7%; La Libertad = 38.0%) and 31.6% of
women of child-bearing age (Cajamarca = 35.5%; La Libertad = 27.2%) (INEI, 2001). The 
last evaluation of the level of hemoglobin in the blood (gr Hb/dl) conducted by the Center 
for Feeding and Nutrition (2003) in women of child-bearing age reported a prevalence of
anemia of 32.9%, similar to the level obtained by ENDES 2000; nonetheless, it shows that 
the prevalence in Cajamarca fell from 35.5 to 30.4% and in La Libertad, it increased from
27.2 to 36.9% (INS, 2003).
In recent years in Peru, we can observe an epidemiological pattern that shows a prevalence
of chronic and degenerative diseases in the wealthiest quintile of the population and a
prevalence of infectious diseases in the poorest quintile, although at the present time we are 
experiencing a process of epidemiological transition, with an increase in non-infectious 
diseases among the poor. 
In the last two decades, there have been improvements in maternal and child health care
and in the control of diseases that are preventable by use of vaccines (polio, measles) as
well as in the control of some transmissible diseases (TB), all of which have had a positive 
impact on mortality. Nonetheless, these improvements have not been homogeneous, as the 
zones that have evolved positively are preponderantly those that are more developed. In
zones of extreme poverty, problems of maternal mortality persist; and in general, there
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were increases in malaria, dengue, multi-drug resistant TB, AIDS, Bartonellosis, accidents,
injuries and violent deaths from different causes (CARE, 2001; MOH 2002).
In the Project area, the principal causes of mortality in children are diarrhea, pneumonia,
nutritional deficiencies and problems during birth. The principal causes of death in children
less than one year old include malnutrition, respiratory infections (including bronchitis and
pneumonia) and diarrhea (CARE, 2001). The prevalence of acute diarrhea, in the last 15 
days, in children under 2 years old was 35%, while the prevalence of acute respiratory
infections was 50.1% (REDESS, 2000). According to ENDES 2000, the prevalence of
acute respiratory infections in children under five years old in rural zones is 20.6%, while
the prevalence of diarrhea is 17.6%. The initial evaluation of the Project reported a
prevalence of chronic malnutrition of 41.4% and of overall malnutrition, 15.1% (CARE,
2000). According to ENDES 2000, 40.2% of children under five years old who live in rural 
areas suffer from chronic malnutrition and 11.8%, from overall malnutrition (INEI, 2001).
With respect to immunization coverage, in the year 2000, it was 64.1%, 56.3%, 56.9%,
47.8%, respectively, for the vaccines BCG, Anti-polio, DPT and Measles (CARE, 2000a). 
Other factors that contribute to the high rates of mortality include low education levels,
short periods between pregnancies, inadequate pre- and post-natal care by the providers, as 
well as low birth weight (CARE, 2001).
High maternal mortality remains a serious problem in rural Peru. According to the INEI
(1996), the Maternal Mortality Rate in highland regions of Peru is estimated at 379 per
100,000 live births. Its direct causes include hemorrhage, sepsis and eclampsia. Among
the factors that may be contributing in the Project area are the high proportion of home
deliveries (81.4%, CARE 2000a) and the fact that, when there is an obstetric emergency, 
women let the husband make the decision on seeking treatment, that emergencies occur at 
great distances from health centers, and the response capacity of rural health facilities
remains limited.
ENDES 2000 shows that, while 69.6% of women in the countryside received prenatal care, 
only 26.2% of the births were attended by health professionals. It also indicates that
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fertility rates in rural areas have decreased from 5.6 in 1996 to 4.3 in 2000, principally due 
to the use of family planning methods. Nonetheless, while 72.3% of the women who live 
with a partner in rural Peru don’t wish to have more children, only 40% declare that they
use modern contraceptive methods (INEI, 2001).
There has been an ongoing Bartonellosis epidemic in Sánchez Carrión Province since the 
first case was detected there in May 2002. Since the end of 1993 more than 700 cases of 
Bartonellosis have been reported, and 99.5% of these have evolved favorably. The
population group most affected is children under 15 years old, which account for 56% of 
the cases, the 5 to 9 year-olds group being most vulnerable (OGE, 2003).
In another area of concern, the occurrence of intervals between births of less than 24
months is 25.8% in Cajamarca, while in La Libertad, it is 18.4%. The results of ENDES 
2000 confirm that the risk of child death is greater when the period between pregnancies is 
less than 24 months, the child mortality rate is elevated to 78 per 1000 live births; there is 
also almost three times less risk of death when the period between pregnancies is 48
months or more (mortality rate: 28 per 1000). It should be noted that in the rural areas, 
23.4% of births occur with intervals of less than 24 months, and if we compare the ENDES 
1966 with that in 2000, we observe a decrease from 24.2 to 20.3% (INEI, 2001). 
In Cajamarca, 27.8% of women know one or more ways to avoid contracting AIDS, while 
in La Libertad, 54.7% have this knowledge. The average in rural zones in Peru is 35.4% 
(INEI, 2001). The majority of them know only one valid form of avoiding infection. 
The maternal and child health care offered by health facilities is being formalized according
to norms emitted by the Ministry of Health. These protocols stipulate both technical and
programmatic aspects. At present, the following are employed: Procedures and Protocols
for Women’s Health care (MOH, 1999), Procedures and Protocols for Child Health care in 
Health Centers and Posts (MOH, 1999), Norms for the Care of Children under 5 Years of 
Age (MOH, 1996), Norms for the Control of Diseases that are Preventable by Vaccination 
(MOH, 1995) and Guidelines for Child and Maternal Nutrition (MOH, 2003). 
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1.1.5. Role of community health agents
The rural communities in the Project area have such community health agents as health
promoters, traditional midwives and female leaders. These community leaders enjoy the
confidence and respect of the population. The Project has supported their organization and 
training and, at the same time, promoted their participation in different decision making
spaces at the local, district and provincial levels. 
The principal activities of health promoters include identification of groups at high risk
from disease and death (children and mothers), education in maternal and child health and 
nutrition, case referrals and follow-up, evacuation of emergency cases, community
organization, etc. 
The midwives, identify women who are pregnant, participate in referring them to the health
facility, organize the measures to be taken by the family with respect to the pregnancy,
childbirth and post-pregnancy (Birth Plan), give advice to the mothers, and attend the
childbirth together with the health personnel, among other tasks. 
The women leaders are local leaders who support educational activities in health and
nutrition, participate in the referral of cases, and help evacuate emergency cases to the
nearest health facility. 
1.2. Goals, objectives and main activities of the REDESS Project.
The project goal was to improve the health of children under five years of age and women 
of reproductive age, with an emphasis on the reduction of maternal, peri-natal and child
morbid-mortality in rural communities of the provinces of Sánchez Carrión and Cajabamba
in the departments of La Libertad and Cajamarca, respectively.
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In order to achieve this goal, the Project has encouraged families to commit to taking
responsibility for their health, through a group of systematic interventions by the
Community Health Agents (CHA) in close coordination with the Ministry of Health
(MOH) facilities, community organizations (Community Development Committees, Water
and Sanitation Committees, Mothers’ Clubs, etc.) and local institutions (Local
Governments, Consensus-building Committees, etc.).
The Objectives of the REDESS Project were to:
· Improve the management of cases of pneumonia in children from 0 to 23 months old.
· Reduce the prevalence of diarrhea in children from 0 to 23 months old.
· Improve prenatal care, early detection of warning signs and post-natal practices.
· Improve child feeding practices of mothers with children from 0 to 23 months old.
Among the principal activities that have been implemented by REDESS are the following: 
· Organization and Implementation of AIEPI/IMCI Workshops about health care
protocols for healthy and sick children directed to MOH Personnel and CHA.
· Design and implementation of communication campaigns on health and nutrition and
on prevention of acute respiratory infections and pneumonia, diarrhea and dehydration,
and malnutrition and obstetric and peri-natal complications. 
· Implementation of a community referral and counter-referral system.
· Design and provision of training materials in maternal and child health and nutrition for
the volunteer health agents that have messages aimed at prevention, recommendations
for healthy practices, identification of warning signs and recommended actions for
treatment.
· Training Health Personnel and CHAs in adult education techniques. 
· Design and implementation of Training Plans for Health Personnel and CHAs.
· Design of Training Curricula for Health Personnel and CHAs.
· Push forward the mapping of the communities by their community leaders in order to
identify the population groups with the highest risk of illness and death (children under
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1 year old, women of reproductive age and pregnant women), the numeration of houses 
and identification of risk zones (garbage dumps, potential landslide areas, etc.).
· Motivate the directors, leaders and communities members to improve hygiene in the
community (construction of latrines and potable water projects, etc.).
· Support the CHAs to organize themselves into committees and associations.
· Develop the leadership capabilities of the CHAs to participate effectively in the various 
organizations of coordination and management (neighborhood associations, consensus￾building groups, community development committees, etc.).
· Train the CHAs to support pregnant women to develop and implement a Childbirth
Plan.
· Support the CHAs and the MOH to develop a community system to look after women 
of reproductive age for their prenatal and post-natal health care. 
· Make two-way radios available for health care coordination in emergency cases and
referrals to health care facilities with superior capacities.
2. FINAL QUANTITATIVE EVALUATION OF THE REDESS PROJECT:
OBJECTIVES AND IMPLEMENTATION 
In the context described earlier, and given the end of the period of Project implementation
(October 2000 to September 2004), it was proposed that the quantitative final evaluation be 
conducted by the ISAN. 
The objectives of the final evaluation were:
· Develop a Quantitative Final Evaluation of the REDESS Project, based on a Survey
of Knowledge, Attitudes and Practices in maternal and child health and nutrition. 
· Develop a Final Nutritional Evaluation of children under 2 years of age, based on
anthropometric information. 
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The final evaluation of knowledge, practices and coverage, and the anthropometric 
evaluation involved the participation and commitment of the social actors who were Project 
associates, including MOH personnel, Community Health Agents and local government
directors.
This process has the following phases: prior coordination, training of field personnel for the 
interviews and the anthropometric registration, the collection of the information and,
finally, its analysis.
There was an active participation of the personnel from the health facilities of the Sánchez
Carrión and Cajabamba Networks, from the planning of the evaluation, to the elaboration
of instruments to collect information, and the collection and the analysis of the information. 
During this work, a group of questions were proposed and incorporated in order to examine 
the levels of recognition, knowledge and practices by the mothers in the face of cases of
Bartonellosis in the zones of both Health Networks. 
On the other hand, the CHA also played an important role in the identification and location
of the families that were selected for the interview through random sampling procedures. 
The local governments provided the facilities necessary in order that the teams of survey
takers and supervisors were able to transport themselves to the selected communities. 
Some of the restrictions that made the evaluation process less participatory were the many
activities programmed in the MOH that were associated with training activities for health
personnel and coordination meetings and evaluation of the management at the level of the
Regional Health Directorate. 
3. EVALUATION METHODS 
3.1. Survey of knowledge, practices and coverage (KPC).
The survey has 95 questions, divided in the following manner:
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Section 1: Prevention of Illnesses
Section 1A: Breast feeding and Child Nutrition, with 16 questions
Section 1B: Immunizations, with 2 questions
Section 1C: Hand hygiene, with 1 question.
Section 1D: Malaria, with 3 questions
Section 1E: HIV / AIDS, with 2 questions
Section 2: Sick Child.
Section 2A: Diarrhea, with 15 questions
Section 2B: Acute Respiratory Infections, with 12 questions
Section 3: Maternal health
Section 3A: Prenatal care, with 15 questions.
Section 3B: Care at childbirth, with 4 questions.
Section 3C: Post-natal and newborn care, with 11 questions.
Section 4: Bartonellosis
Section 4A: Bartonellosis, with 4 questions.
Section 5: Community organization.
Section 5B: Community organization, with 10 questions.
I should be mentioned that the 1995 KPC Module survey (The John Hopkins University,
1995) served as the basis for the elaboration of the final KPC survey, and it was applied in 
the Initial evaluation in the year 2000. 
A series of questions were incorporated in this evaluation, principally on health practices,
that had been planted in the 2000 KPC Modules and revised by the Child Survival
Technical Support Project (CSTS) and the CORE Monitoring and Evaluation Working
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Group. Also, a series of questions on Bartonellosis were included at the request of the
MOH.
3.2. Calculation of Indicators of Knowledge, Practices and Coverage.
The evaluation indicators of the REDESS Project total 13. The details of how the
indicators were calculated are explained in Table Nº 4.
Table Nº 4: Description of the calculation of the indicators of the REDESS Project
Indicator Numerator Denominator
Management of cases of pneumonia.
Increased number of mothers who 
recognize two signs of pneumonia (rapid 
breathing and difficulty breathing).
Number of mothers who know 2 or 
more warning signs of pneumonia Total number of mothers 
Increased number of mothers who seek 
adequate medical treatment for their 
children from 0 to 23 months old with 
signs of pneumonia. 
Number of mothers of children who 
have had pneumonia and who seek 
treatment in a health facility 
Total number of mothers 
whose children have 
pneumonia
Prevention and control of diarrhea.
Increased number of mothers with 
children from 0 to 23 months old able to 
correctly identify at least two signs of 
dehydration and two signs of persistent 
diarrhea and dysentery 
Number of mothers who know 2 or 
more signs of dehydration and also 
two or more signs of persistent 
diarrhea and dysentery 
Total number of mothers 
Increased number of mothers with 
children from 6 to 23 months old with 
diarrhea who administer the same or a 
larger amount of food during the episode.
Number of mothers with children 
older than 5 months with diarrhea and 
who administer the same or a larger 
amount of food during the diarrhea 
Total number of mothers 
with children older than 5 
months with diarrhea
Reduced number of children from 0 to 23 
months old with diarrhea who receive 
antibiotics (self-medicated) during the 
episode
Number of mothers of children with 
diarrhea and who have received 
antibiotics without a prescription 
Total number of mothers 
of children with diarrhea 
Indicators of maternal health
Increased number of women of 
reproductive age who recognize at least 2 
danger signs of pregnancy, childbirth and 
post-childbirth.
Number of mothers who recognize 2 
or more danger signs of pregnancy, 
childbirth and post-childbirth.
Total number of mothers 
Increased number of women pregnant with 
4 or more prenatal checkups.
Number of mothers who have 4 or 
more prenatal checkups during their 
last pregnancy 
Number of mothers who 
have a card showing the 
checkups during their 
pregnancy
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Increased number of women in 
reproductive age group who received 2 or 
more tetanus shots prior to their last 
childbirth.
Number of mothers who have 
received 2 or more tetanus shots 
prior to their last childbirth.
Total number of mothers 
Increased number of women with obstetric 
complications who are treated by health 
professionals 
Number of mothers who have had 
complications during pregnancy or 
childbirth and were treated by health 
professionals 
Total number of mothers 
who had complications 
during pregnancy or 
childbirth
Increased number of mothers with children 
under 2 years old who can recognize 3 or 
more warning signs in newborn children
Number of mothers who recognize 3 
or more warning signs in newborn 
children
Total number of mothers 
Nutritional improvement 
Increased number of children from 0 to 5 
months old with only maternal lactation.
Number of children from 0 to 5 
months old who received only 
maternal milk the day before
Total number of children 
from 0 to 5 months of age
Increased children from 6 to 23 months 
old who are fed five times daily
Number of children from 6 to 23 
months old who are fed at least 5 
times the day before the survey 
Total number of children 
from 6 to 23 months of 
age
Increased number of children from 12 to 
23 months old who receive anti-parasite 
treatment every 6 months.
Number of children from 12 to 23 
months old who receive medication 
for parasites. 
Total number of children 
from 12 to 23 months of 
age
Also in this evaluation calculations were made for a group of indicators that wad been
proposed by USAID. These indicators total 13, and principally measure practices in child 
health and nutrition. The details of how the indicators were calculated are explained in
Table Nº 5.
Table Nº 5: Description of the calculation of the indicators proposed by USAID
Indicator Numerator Denominator
Indicator of overall malnutrition
Percentage of children from 0 to 23 months old 
who have low weight ( - 2 Standard Deviations 
from the median weight for their age according to 
WHO/NCHS for the referenced population) 
Number of children from 0 to 23 
months old whose weight is less 
than - 2 Standard Deviations from 
the median weight for their age 
according to WHO/NCHS
Total number of 
children from 0 to 23 
months old were 
weighed
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Prevention of illness and death
Percentage of children from 0 to 23 months of age 
who have been born at least 24 months after the
last live birth. 
Number of children from 0 to 23 
months old with brothers and 
sisters older than 24 months
Number of children
from 0 to 23 months 
old who have brothers 
and sisters
Percentage of children from 0 to 23 months of age 
whose births were attended by trained health 
personnel
Number of children from 0 to 23 
months old whose births were 
attended by doctor, obstetrician, 
nurse and sanitary technician.
Total number of 
children from 0 to 23 
months old
Percentage of mothers with children from 0 to 23 
months of age who received at least 2 doses of 
tetanus toxide prior to the birth of their last child
Number of mothers who have 
received 2 or more doses of 
tetanus vaccines prior to the birth 
of their last child
Number of mothers 
who have a tetanus 
vaccination card or a 
card showing the 
checkup of their 
pregnancy
Percentage of children from 0 to 5 months of age 
who have received only maternal lactation during 
the past 24 hours
Number of children from 0 to 5 
months old who received only 
maternal milk the day before
Total number of 
children from 0 to 5 
months of age
Percentage of children from 6 to 9 months of age 
who have received maternal milk and 
complementary feeding during the past 24 hours
Number of children from 6 to 9 
months old who consumed 
maternal milk and complementary 
feeding 
Total number of 
children from 6 to 9 
months old
BCG
Number of children from 12 to 23 
months old who have been 
vaccinated for BCG 
Total number of 
children from 12 to 23 
months old 
DPT
Number of children from 12 to 23 
months old who were vaccinated 
with the 3 doses of DPT 
Total number of 
children from 12 to 23 
months old
Percentage of children from 12 to 23 
months of age who have been 
completely vaccinated against the 
five preventable diseases before their 
first birthday
Anti-polio
Number of children from 12 to 23 
months old who were vaccinated
with the 3 doses of polio vaccine
Total number of 
children from 12 to 23 
months old
Percentage of children from 12 to 23 months of 
age who have been vaccinated against measles 
Number of children from 12 to 23 
months old who were vaccinated 
with measles or SPR vaccine 
Total number of 
children from 12 to 23 
months old
Percentage of children from 0 to 23 months of age 
who sleep under mosquito netting treated with 
insecticide.
(only in areas with risk of malaria)
Percentage of mothers with children from 0 to 23 
months of age who know at least 2 forms to 
reduce the risks of infection with AIDS.
Number of mothers who know 2 
or more forms to reduce risks of 
infection from AIDS
Total number of 
mothers
Percentage of mothers with children from 0 to 23 
months of age who have reported that they wash 
their hands with soap or ash prior to preparing 
food, prior to feeding the baby, after defecating, 
and after attending to a child who has defecated. 
Number of mothers who wash 
their hands in all 4 situations 
Total number of 
mothers
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Management and treatment of illnesses
Pneumonia
Number of mothers who know 2 
or more signs of pneumonia
Total number of 
mothers Percentage of mothers with children 
from 0 to 23 months of age who 
know at least 2 signs of childhood 
diseases that indicate the need for 
treatment. Diarrhea
Number of mothers who know 2 
or more signs of dehydration 
during la diarrhea
Total number of 
mothers
Percentage of sick children from 0 to 
23 months of age who have received 
continuously increased amounts of 
fluids and solid foods during an 
illness in the last 2 weeks.
EDA
Number of children from 0 to 23 
months old with diarrhea and who 
have received more fluids and 
solid foods continuously 
Number of children 
from 0 to 23 months 
old with diarrhea
3.3. Sampling.
3.3.1. Calculation of the size of the sample for the study of knowledge, attitudes and 
practices.
The technique of sampling by clusters recognized by WHO (The John Hopkins University, 
1995), was employed. This technique was used in the Baseline Survey of the REDESS
Project, and is known to permit obtaining precise information about the communities.
The sampling was realized in 2 stages: first, 30 clusters were randomly selected; secondly, 
10 homes with children under 2 years old were randomly selected. This sample size
provided an estimate with ± 10% level of precision and a confidence level of 95% (Sarriot 
E, Winch P, Weiss W, Wagman J, 1999). 
It is worth noting that it was planned to survey additionally 2 homes per cluster in order to 
replace those homes that had incomplete information or a faulty registration. 
The sampling method was by clusters. The number of clusters assigned to each province 
where the Project was implemented was proportional to the population in these areas. 
According to the population information that was given to us, around ¾ parts of the
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population is located in the province of Sánchez Carrión (90,850 inhabitants) and ¼, in the 
province of Cajabamba (32,820 inhabitants). 
Thus, 24 clusters were selected in the province of Sánchez Carrión, and 6 in the province 
of Cajabamba (See Annexes Nº 1 and 2). 
In homes with 2 or more mothers with children under 2 years old, the concept of family
was used according to which “a family is a group of persons who eat from the same family 
pot”. Thus if the mothers prepare their food separately, both were surveyed. When 
mothers with 2 children under 2 years old were identified, the younger child was selected 
for the survey. In all cases, the mothers showed the birth certificate or checkup card of the 
child. In doing so, the birth date was verified and the age of the child was calculated. Also, 
the child’s biological mother was always surveyed. 
3.3.2. Calculation of the Sample Size for the Anthropometric Evaluation.
The following formula was used for the calculation of the sample size (Gross R, Kielmann
A, Korte R, Schoeneberger H, Schultink W. 1997):
In which:
c = confidence level for the anthropometric study (a 0.95). 
p = estimated prevalence of chronic malnutrition in the location of the
evaluation.
For the calculation of the sample size, the prevalence of chronic malnutrition in rural zones 
will be considered to be 40.2%, as found in the 2000 National Demographic and Health
Survey (INEI, 2001).
n = 354 children.
n = 
c x p x (100 - p) 
26
(3.8416) x (40) x (60)
26
n = 
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Thus it was planned to evaluate 354 children.
3.4. Training of Supervisors and Survey Takers.
3.4.1. Training and Standardization of Supervisors and Survey Takers.
A 3-day training workshop was held during the days prior to the survey and in the city of
Huamachuco in the province of Sánchez Carrión. Sixty-one persons participated, among
them personnel from the Sánchez Carrión and Cajabamba Health Networks. The workshop 
consisted of theoretical and practical sessions about the methodological and ethical aspects
of the application of the survey. It also incorporated a revision of the technical contents of
the survey. The program for the implementation of the training workshop is found in
Annex Nº 3. 
The methodology of anthropometric measurements for children under 2 years old was also 
reviewed, both in theory and in practice. A trial of the standardization of antropometrists
(people who measure height and weight) was also conducted that consisted of an analysis 
of the variation in the weight and height measurements obtained by the antropometrists. 
The measurements of all the supervisors and survey takers were thus standardized prior to 
the collection of data.
3.5. Data Collection.
Instruments employed - KPC survey formats, anthropometric registration sheets, child
measurement charts, scales, pencils, erasers and clipboards. 
Work teams - Six work teams were formed for the survey in the Sánchez Carrión Network, 
with each one containing 2 supervisors and 4 survey takers. Each team was assigned 4
clusters, and was required to realize 1 cluster per day. The routes were planned in detail, as 
were the places to sleep in order to avoid major inconveniences. In the end, the 24 clusters 
were completed in 4 days. 
Two work teams were formed for the collection of data in the Cajabamba Network; each
was made up of 2 supervisors and 4 survey takers. Three clusters were assigned to each
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team, which realized work in 1 cluster per day. In the end, 6 clusters were completed in 3 
days. 
Each team was made up of personnel from CARE and the Ministry of Health as well as
nursing students. 
Mobilization of the teams - The routes were established according to the locations of the 
selected clusters, the availability of vehicles and the places to spend the night.
Quality Control - Was realized in the KPC surveys and in the anthropometric registries. 
The birth date of the child was verified and his/her age was again calculated, also if the 
surveys were correct and filled out completely, if the instruction for answering the
questions (mark one answer or more than one answer) were followed. Additionally, prior to 
the field work, all the antropometrists were submitted to standardization tests to assure the 
quality of the information.
The first control was conducted by the field supervisors; the second was conducted by
themselves before turning the surveys into the team consultant and the last was conducted
by the consulting team before its processing. 
In the case of quality control of the anthropometric measurements and registration, the
supervisors were in charge of verifying the correct application of the methodology of
anthropometric measurement, in some instances they also weighed and measured to verify
the measurements of the survey takers. They also verified the correct and complete filling
out of the forms for the anthropometric registration. 
3.6. Analysis of the Data.
A descriptive analysis of the variables of the study was undertaken. The Homogeneity Test 
was conducted for the comparison of categorical variables. The continuous data was
subjected to an analysis of variance, for which first, their statistical assumptions must be
demonstrated, including: normality of residuals and homogeneity of variances. In the case
of the weight and height data, the Kolmogorof Smirnof Test was applied to prove the
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normal distribution of the data. Statistical programs (SPSS Version 11.0, Epi Info 2000
and Epi Data 3.02) were used for the statistical analysis.
4. RESULTS
The field work was undertaken in 11 days, without inconveniences. Taking place between
September 8 and 14 in the province of Sánchez Carrión and between September 15 and 18 
in Cajabamba, a total of 356 mothers with children under two years old were interviewed. 
Their distribution, by location, was as follows:
Table Nº 6: Number of surveys taken, by REDESS Project area.
Department Province Number of Surveys 
La Libertad Sánchez Carrión 292
Cajamarca Cajabamba 64
TOTAL 356
For the anthropometric evaluation of the children, the children of the mothers who
responded to the surveys of knowledge, attitudes and practices were evaluated. As had
been planned initially, a total of 354 children were evaluated.
4.1. Results of the KPC Survey
4.1.1. Socio-demographic data of the mother and the child
The age average of the mothers interviewed in the final evaluation was 28.5 ± 7.4 years, 
very close to the age of the mothers interviewed in the initial evaluation (27.3 ± 7.2 years). 
Also, the largest percentage of mothers interviewed varied between 20 and 29 years old in
the initial evaluation (52.7%) as well as in the final (46.7%). 
Comparing the age groups in Table Nº 7, we see that among those interviewed, the
percentage of adolescent mothers (15 to 19 years old) and those from 20 to 29 years old 
was slightly smaller the Final KPC than in the Baseline KPC, and the percentage of
mothers 30 years and older was higher (from 36.1% to 43%).
Final Quantitative Evaluation of the XVI Child Survival Program “REDESS” -- CARE PERU 2004 
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Table Nº 7: Age groups of the mothers surveyed in the initial and final evaluations.
Age of Mothers Baseline KPC Final KPC 
(years) No. % No. %
15 to 19 39 11.2 36 10.2
20 to 29 184 52.7 165 46.7
30 to 34 57 16.3 75 21.2
35 to 39 47 13.5 47 13.3
40 to 49 22 6.3 30 8.5
Total 349 100.0 353 100.0
The average age of the children whose mothers were interviewed is 10.9 ± 6.6 months, 
similar to the average found in the initial evaluation (10.5 ± 6.5 months). 27.2% are under 
6 months, 26.4% between 6 and 11 months, while the children 12 months or more represent 
46.3%. This distribution is very similar to that found in the initial evaluation, when there
were 27.4%, 27.4% and 45.3%, in the respective age groups.
 
Table Nº 8: Age Groups of the children participating in the initial and final
evaluation.
Age of Children Baseline KPC Final KPC 
(months) No. % No. %
0 to 5 96 27.4 97 27.2
6 to 11 96 27.4 94 26.4
12 to 23 159 45.3 165 46.3
351 100.0 356 100
4.1.2. Knowledge and practices of breast feeding and nutrition.
We see that more than 99% of the children have received maternal milk, both in the initial
survey (99.1) and in the final (99.7%). 58.6% of the mothers say they initiated breast
feeding during the first hour after childbirth, a percentage that is slightly higher than the
national average (54%) (INEI, 2001) and 14% higher than what was observed in the initial
evaluation (44%).
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The consumption of maternal milk during the first three days increased from 75.9%, in the 
initial evaluation, to 92.4% in the final evaluation. 
The average number of breast feedings received by children less than 2 years old was 9.7 ±
3.3 times per day, being larger in the group of children under 6 months old (10.9 times;
n=95) than in those from 6 to 12 months old (9.4 times; n=111) and in those older than 12 
months old (8.7 times; n=108). 
Graph No. 1: Commencement of nursing (REDESS Project, 2004) 
1.4
29.9
58.6
27
44
24.7
13.5
0.8
0
10
20
30
40
50
60
70
Don't remember During the first
hour after giving
birth
Between one and
eight hours after
giving birth
More than eight
hours after giving
birth
%
Baseline (%)
Final (%)
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Graph Nº 2: Average number of daily breast feedings, by age 
group
10.9
9.4 8.7
0.0
2.0
4.0
6.0
8.0
10.0
12.0
Less than 6 months 6 to 12 months More than 12
months
%
To demonstrate the pattern of food consumption of the children under 2 years old, they
were divided into 3 age groups: from 6 to 8 months, 9 to 11 months and 12 a more months. 
The food was also grouped into energizers, constructers and protectors, which provide
energy, proteins and vitamins and minerals, respectively. 
Among children from 6 to 8 months old, it was observed that the foods providing energy 
(cereals and tubers) and protectors (fruits and vegetables) were consumed the most. 
Proteins were consumed in a smaller percentage, and in this group those of animal origin
are consumed even less. On the other hand, we can indicate that foods rich in iron, such as 
liver, blood sausage or green leafy vegetables are consumed by only 27% of these children. 
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Graph Nº 3: Pattern of food consumption of children aged 6 to 8 
months (REDESS Project, 2004) 
64.9
48.6
27
51.4
37.8
27
27
21.6
64.9
62.2
0 10 20 30 40 50 60 70
Carrots, squash, mangos, papaya, etc.
Banana, apple, etc.
Green leaf vegetables, spinacf, etc.
Tarwi, peas, lima beans, etc.
Eggs, cheese, yogurt
Meat, chicken, fish, seafood
Liver or other giblets
Cow or goat milk 
Hops, oats, rice, wheat, etc.
White potato, yucca, olluco
%
The pattern of food consumption in children from 9 to 11 months of age is very similar to 
the group from 6 to 8 months old. Nonetheless, we can observe an increase in the
consumption of proteins, such as the case of legumes (from 51.4 to 64.9%), meat, chicken
and fish (from 27 to 42.1%) and milk (from 21.6 to 28.1%). The consumption of foods rich 
in iron is similar to the 6-to-8-month-old group. 
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Children 12 months and more of age have patterns of food consumption similar to the 
previous groups. 
Graph Nº 5: Feeding pattern for children aged 12 months and older 
(REDESS Project, 2004).
77.6
67.3
31.5
66.1
63.6
41.8
33.3
22.4
76.8
75
0 10 20 30 40 50 60 70 80 90
Carrots, squasho, mangos, papaya, etc.
Banana, apple, etc.
Greef leafy vegetables, spinach, etc.
Tarwi, peas, lima beans, etc.
Eggs, cheese, yogurt
Meat, chicken, fish, seafood
Cow or goat milk 
Liver or other giblet
Hops, oats, rice, wheat, etc.
White potato, yucca, olluco
%
Graph Nº 4: Pattern of food consumption of children aged 9 to 11 
months (REDESS Project, 2004). 
77.2
70.2
29.8
64.9
59.6
42.1
28.1
26.3
82.1
77.2
0 10 20 30 40 50 60 70 80 90
Carrot, squash, mangos, papaya, etc.
Banana, apple, etc.
Green leaf vegetables, spinach, etc.
Tarwi, peas, lima beens, etc.
Eggs, cheese, yogurt
Meat, chicken, fish, seafood
Cow or goat milk 
Liver or other giblets
White potato, yucca, olluco
Hops, oats, rice, wheat, etc.
%
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In summary, the pattern of food consumption is similar among the different age groups. It 
can also be observed that the pattern of food consumption of the children is equal to the 
pattern of the family’s food consumption, so it is possible that the whole family, including
the very small children, eats from the same kettle. 
With respect to the addition of lard or oil to the food of the children, we see a significant 
increase of 27.2% (p=0.000) between the initial and final phases, even surpassing the
national average of 57% (INEI, 2001). 
The use of iodized salt in the preparation of the meals of the children under 2 years old
remains above 95% in both the initial and final Project evaluations.
82.0% of the mothers know they should give their children only maternal milk until 6
months of age and the concept of exclusive breastfeeding.
Checkup of the child’s growth by the health facilities should be at least 7 times during the 
first year of life, according to present norms. In the Project area, 34.7% of the children
observed this norm. We see the coverage in the sample from the Province of Cajabamba 
(30.3%) is just over half that in the Province of Sánchez Carrión (59.1%). 
Graph No. 6: Addition of oil or lard in the food of children 
under 2 years of age
(REDESS Project, 2004). 
60.8
88
0
20
40
60
80
100
Initial (2000) Final (2004)
%
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On the other hand, the administration of Vitamin A by the health services to children over 6 
months of age only reaches 54.8%, according to the results of the evaluation. 
4.1.3. Child immunization coverage.
In the REDESS Project area, according to the final evaluation, 88.5% of the mothers had a 
growth and vaccination card; while 87.9% said that their children had been vaccinated at
some point in time. One can see a small difference in the vaccination coverage among boys 
(51.7%) and girls (48.3%). 
With respect to the coverage of BCG vaccine, we see an increase of 19.7% (64.1 to 83.7%) 
between the initial and final evaluations. This coverage is still below the national average 
of 96%.
Also observed is an increase of 22.4% in coverage of children over 4 months old who are 
vaccinated with a third dose of DPT vaccine (from 56.9 to 79.3%). Nonetheless, coverage 
in the final evaluation (79.3%) is still below the national average (85%, according to INEI, 
2001). In this same group of children (over 4 months old), coverage of the third dose of
anti-polio vaccine also increased by 21.2% (from 56.3 to 77.5%) slightly surpassing the
national average, which is 76% (INEI, 2001).
Measles vaccination coverage rose from 51.8 to 63.2%; nonetheless, it remains below the
national average of 84%. It should be mentioned that last year there was an irregular
supply of vaccines. 
The percentages were calculated based on verifying the child growth and development data.
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Graph Nº 7: Initial and final evaluations of Infant 
Vaccination Coverage
(REDESS Project, 2004).
56.3 56.9
83.7 77.5 79.3
63.2
76
85 84
64.1 51.8
96
0
20
40
60
80
100
120
BCG Anti-polio DPT Anti-measles
%
Initial Final Peru (2000)
It was found that there were not significant changes in child vaccination coverage measured 
by gender; however, coverage of girls was lower.
Graph Nº 8: Vaccination Coverage, by gender (REDESS 
Project, October 2004). 
52.7 52.1 52.1 51 47.3 47.9 47.9 49
0
10
20
30
40
50
60
BCG DPT Anti-polio Measles
%
Male Female
4.1.4. Prevalence of diarrhea and knowledge and practices on its control.
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During the 15 days prior to the final evaluation, diarrhea was found in 37.4%, of children
under 2 years old, a figure similar to that found in the Initial Evaluation (35.0%). 
Nationwide, diarrhea was found in 17.6% of children under 5 years old who live in rural
zones; the national average of 15.4% (INEI, 2001). 
Graph Nº 9: Presence of diarrhea during the 15 days prior to the 
Evaluation 
(REDESS Project, 2004).
35
37.4
17.6
0
5
10
15
20
25
30
35
40
Initial Final Rural Peru (2000)
%
Next, we present the results of some feeding practices by mothers when their children
suffer an episode of diarrhea. 77.3% of mothers mention having given the same quantity or 
more maternal milk; this percentage is slightly more than that obtained in the initial
evaluation (69.1%). If we analyze the percentage of mothers who give more maternal milk, 
this increased significantly from 17.9 to 35.6% (p=0.001). Also, the percentage of mothers 
who mention having given more liquids to their child increased from 37.4% in the initial
evaluation to 48.9% in the final evaluation (p=0.064). At the same time, the percentage of 
children who receive more solid foods or semi-solids also increased significantly from 4.9 
to 20.3% (p=0.000).
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Graph N 10: Increased consumption of maternal milk, liquids 
or foodstuffs during an episode of diarrhea in children under 2 
years of age (REDESS Project, 2004).
17.9
37.4
4.9
35.6
48.9
20.3
0
10
20
30
40
50
60
More maternal milk More liquids More solid food
%
Initial Final
After the end of the period of diarrhea, proper feeding is important for the process of the 
child’s recuperation. It can be seen that the percentage of mothers who know that they
should give more foods than usual increased very significantly (from 4.6% to 33.1%)
(p=0.000) between the initial and final evaluations, as did the percentage of mothers who 
mention that they should feed in less quantity, but more frequently (from 5.4 to 56.2%)
(p=0.000).
Graph No. 11: Knowledge of mothers about feeding after an 
episode of diarrhea 
(REDESS Project, 2004).
4.6 5.4
33.1
56.2
0
10
20
30
40
50
60
More foods than usual Foods in less quantity and more
frequenty 
%
Baseline Final
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When asked about the person or persons who decide where to go to treat the diarrhea of the
child, 76.5% of the mothers said that they take the decision themselves. Additionally,
56.3% of those interviewed decided to take the child, first, to a health facility, a percentage 
greater by 20.9% than in the initial evaluation (35.4%).
With respect to knowledge of the signs of dehydration, it was observed in each of the
dehydration signs analyzed, the percentage of mothers who know signs of dehydration is
greater than at the beginning of the Project. Some signs, such as dry mouth and sunken
eyes are the best known, while crying without tears, sunken fontanelle and little urine are 
the least known. 
 
Graph Nº 12: Knowledge of mothers about signs of dehydratation 
(REDESS Project, 2004).
0.3
13.7
27.1
4.3 0.3 2.8
42.7
67.1
9.6
1.4
0
10
20
30
40
50
60
70
80
Head sunken Dry mouth Eyes sunken Cry without tears Little urine
%
Initial Final
A significant increase (p=0.000) can be observed in the percentage of mothers who
recognize a sign of dysentery diarrhea (initial = 2.8%; final = 39%). A slight increase can 
also be observed in those who recognize a persistent diarrhea (from 10.8 to 14.0%).
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Graph Nº 13: Knowledge of signs of dysentery and persistent 
diarrhea (REDESS Project, 2004). 
2.8
10.8
39
14
0
5
10
15
20
25
30
35
40
45
Diarrhea with blood Diarrhea for more than 14 days
%
Initial Final
With respect to the practice of hand washing, the practice most common among mothers is 
washing prior to preparing foods (88.2%); other practices are less common. 
Graph Nº 14. Practices of mothers in washing hands (REDESS 
Project, 2004).
88.2
52.2
2.5
1.7
54.8
64.6
0 10 20 30 40 50 60 70 80 90 100
Before preparing food
Before giving food to children
After defecating
After cleaning child who has defecated 
After touching the animals 
Other
%
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4.1.5. Prevalence of acute respiratory infection and knowledge and practices on its 
management.
During the 15 days prior to the final evaluation, the prevalence of ARIs in children under 2 
years of age was 53.7%, a level slightly higher than that found in the initial evaluation
(50.1%). Nationwide, la prevalence of ARIs in children under 5 years of age is 20.6% in 
rural areas; a percentage that is well below that found in the Project area. 
Graph No. 15: Presence of ARIs in the Evaluations of the REDESS 
Project (2004).
50.1
53.7
20.6
0
10
20
30
40
50
60
Initial Final Rural Peru (2000)
%
Of the children who had respiratory problems, almost half of them (46.6%) had rapid and 
difficult breathing or breathed as if tired or agitated. This level was practically the same as 
that found in the initial evaluation (47.2%). In these cases, seeking attention to treat
respiratory problems was realized the same day in 36.1% of the cases, while 43.1% of the 
mothers sought help the following day. 78% of these mothers sought attention of health
facilities (Health Center = 75.3; Hospital = 2.7%); this percentage is 30.2% greater than
that found in the initial evaluation (47.8%). 
In 68.5% of the cases, the mothers participated in the decision to elect where to seek care to 
attend to their child’s rapid or difficult breathing. We consider this percentage to be
important; the husband or partner participated in 47.9% of the cases. 
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The majority of children with rapid and difficult breathing are treated in health facilities 
(Health Center or Post = 80.5%; Hospital = 6.8%). To compare these results with the
ENDES 2000 (INEI, 2001), the children who received treatment in a health facility,
pharmacy or by a health promoter were grouped together into a category called “children 
attended to by health providers.” This group of children reaches up to 91%, and is larger 
than the averages, for children under 5 years of age, in the Department of Cajamarca
(44.7%), the Department of La Libertad (46.5%) and even the national average (57.6%). 
Graph Nº 16: Percentage of children with rapid or difficult 
breathing, attended to by different health providers in the area 
of the REDESS Project compared with other areas 
(Project REDESS, 2004). 
91.4
44.7 46.5
57.6
0
10
20
30
40
50
60
70
80
90
100
REDESS (2004) Cajamarca (2000) La Libertad (2000) Peru (2000)
%
The final evaluation permits us to say that a greater percentage of mothers know each of the 
signs of pneumonia. The sign of pneumonia that is best known by mothers is rapid and
difficult breathing (73.9%), while 42.1 and 39.9%, respectively, identify the signs “sunken
skin below the ribs” and “fever.” On the other hand, the percentage of mothers who do not 
know any sign of pneumonia was 44.2% in the initial evaluation and 19.1% in the final
evaluation. 
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Graph No. 17: Knowledge of mothers about the signs de pneumonia (REDESS 
Project, 2004).
34.8
6.8
25.6
73.9
42.1 39.9
0
10
20
30
40
50
60
70
80
Rapid and agitated breathing Sunken skin below ribs Fever
%
Initial Final
Comparing the results of the initial and final evaluations with respect to the knowledge of
the mothers about feeding a child after an episode of ARI, we observe an increase in the 
percentage of mothers who know at least one adequate practice (from 58.7 to 80.6%). In 
addition, the majority of them know that they should give them more food than usual
(52.8%), while smaller percentages mentioned that they should feed more than usual
(28.1%) and provide food with a high caloric content (22.5%).
Graph Nº 18: Knowledge of feeding practices following an 
episode of ARI (REDESS Project, 2004). 
19.4 22.5
3.1
28.1
52.8
22.5
0
10
20
30
40
50
60
Feeding in less quantity, but
more frequently
More food than normal Food with high caloric
content
%
Initial Final
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4.1.6. Knowledge and practices of care and attention with respect to maternal health.
4.1.6.1. With respect to prenatal care. 
The number of mothers who had some prenatal checkup in a health facility increased by
21.5% compared to the initial evaluation (from 68.1 to 89.6%), surpassing the average for 
rural zones, which is 73.2%, and slightly greater than the national average, which is 85%
according to the ENDES 2000 (INIEI, 2001). 80.9% identified the obstetrician as the
professional who realized their prenatal checkups.
Graph Nº 19: Mothers who receive prenatal 
attention in health facilities (REDESS Project, 2004).
68.1
89.6
73.2
85
0
10
20
30
40
50
60
70
80
90
100
Initial Final Rural (2000) Peru (2000)
%
During the prenatal checkups, the mothers remember having received orientation sessions
about: family planning (78.4%), identification of danger signs during pregnancy (73.7%), 
child feeding during the first 6 months (70.5%) and planning for childbirth (68.3%). Only
5.6% mention not having received any health and nutrition advice. 
The percentage of mothers who have knowledge of at least 1 danger sign during pregnancy
has increased (initial = 27.4%; final = 76.4%). Graph Nº 20 shows that the sign most
recognized by the mothers - vaginal bleeding - is a danger that could cause death. 
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Graph No.20: Percentage of mothers in final evaluation with 
knowledge of the signs of danger during pregnancy 
(REDESS Project, 2004)
11
31.2 26.7
36.2
14.3 11.5
37.1
58.4
0
10
20
30
40
50
60
70
Fever
Excessive
vomiting
Loss of
amniotic
fluid
Bleeding
Swelling of
face, hands,
feet
Contractions
before due
date
No fetal
movement
Severe
headache
On the other hand, 94.9% of the mothers mention that they seek out care in a health center 
in case they experience a danger sign during their pregnancy, while only 3.9% said they
would seek a health promoter. This tendency has remained nearly the same as in the initial 
evaluation, when the majority of mothers also mentioned seeking out a health facility
(88.5%) and a smaller percentage, going to a health promoter (1.1%). 
When asked about the persons who participate in the decision to decide the place where the 
mother should be transported when some danger sign presents itself during pregnancy, we 
see that the husband or partner participate in the decision-making in 60.4% of the cases. 
The mothers participate 39.3% of the time, while their mothers or mothers-in-law 
participate 19.1% of the time. This tells us that the husband or partner plays an important 
role in making this decision. 
According to the project evaluation, the majority of the mothers arrive from their houses to 
a health facility in less than 3 hours. In the initial evaluation, this figure was 88.9%, while
in the final, it was 91.8%. 
A variety of means of transportation are used to transport mothers in cases of emergency. 
Among those used the most are being carried by stretcher (55.3%), the ambulances of the 
Final Quantitative Evaluation of the XVI Child Survival Program “REDESS” -- CARE PERU 2004 
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health facilities (20.8%) and a private vehicle (10.6%). Recently, the use of public
transport has diminished (from 28.0% to 11.2%) as has the use of an animal, such as a
horse or donkey (from 10.3 to 8.1%).
Graph Nº 21: Means of transportation used by mothers in 
case of an obstetric emergency (REDESS, 2004).
28
37.7
19.1 20.8
8.1
55.3
10.6
10.3
11.2 11.1
0
10
20
30
40
50
60
Public
transport or
bus
Private car Ambulance Animal
(horse, burro)
Walking
(being
carried)
%
Initial Final
When asked in the final evaluation about complications during pregnancy or childbirth,
mothers recognized having suffered principally swelling (22.9%), vaginal hemorrhaging
(18.6%), obstruction or delayed childbirth (17.1%) and severe vomiting (17.1%). In the
initial evaluation, it was observed that the principal complications were obstruction or
delayed childbirth (32.3%), infections or fever (12.3%) and vaginal hemorrhaging 10.8%).
Comparing the consumption of iron sulfate during pregnancy, we see an increase from
40.6% to 66.1% between the initial and final evaluations. The average consumption in the 
initial evaluation was during 23.6 days (DE=1.45), while in the final, it was 67.8 days (DE= 
60). 
Also observed in the final evaluation was that 40.2% of the mothers consumed iron pills for 
more than 3 months, way above the 1.5% in the initial evaluation, as well as the 9% 
average for rural areas (INEI, 2001) and the 23% that is the national average (INEI, 2001). 
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Graph No. 22: Use of an iron sulfate supplement by mothers 
during their most recent pregnancy 
(REDESS Project, Octubre 2004).
58.6
16.2
22.2
6.9 4.6 6.9
0
31.6
0 0
1.5
8.3
19.4
23.6
0
10
20
30
40
50
60
70
0 months 1 month 2 months 3 months 4 months 5 months 6 to 9
months
months
%
Baseline (%) Final (%)
4.1.6.2. With respect to care during childbirth. 
The percentage of mothers who were cared for in a health facility during their last
childbirth was 17.4% in the initial evaluation and in the final, 23.6% (p=0.098). The
percentage in the final evaluation is very close to the average for rural zones (23.8%)
(INEI, 2001), but still way below the national average of 57.9% (INEI, 2001). 
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Graph No. 23: Percentage of mothers whose 
most recent childbirth was in a health 
facility (REDESS Project, 2004).
17.4 23.6 23.8
57.9
0
10
20
30
40
50
60
70
Initial Final Rural Peru
(2000)
Peru (2000)
%
Analyzing the relation between the mother’s education level and the place they were cared 
for during childbirth, we observe a significant direct relation in the case of births in health
facilities, and an inverse relation in the case of births in their home or other places
(p=0.034). 
Graph No. 24: Percentage of childbirths in institutions, by 
education level.
57.1
70.0
30.0
14.5
42.9
85.5
0
10
20
30
40
50
60
70
80
90
No schooling (n=55) Primary (n=150) Secondary or higher
(n=14)
Educational level
%
Health Facility Others
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It should be emphasized that almost half the childbirths are attended to by health personnel
(44.9%), including attention in health facilities and in homes. 42.1% are still attended to by 
midwives or close friend, 9.3% by a family member, and only 3.4% by health promoters. 
When asked about the persons who participated in the decision of the place to take the
mother for care during childbirth, it was found that in 48.0% of the cases, the husband or 
partner participated, while in 46.3% of the cases, the mother participated.
With respect to the knowledge that the mothers have about at least 1 danger sign during
childbirth, an increase of 42.8% was observed (initial = 25.5%; final = 68.3%). In the final 
evaluation, the best known danger signs were hemorrhaging (44.9%), the hand, foot or
umbilical cord dropping outside the vaginal opening (39.8%), the retention of placenta 
(27.0%) and prolonged childbirth (25.8%).
Graph No.25: Percentage of mothers in the final evaluation who 
recognize danger signals during childbirth (REDESS Project, 2004)
0
5
10
15
20
25
30
35
40
45
50
Hemorrhage Prolonged
labor
Hypertension Retention of
placenta
Hand, foot or
cord extruded
"Water break"
>6 hrs
previous
4.1.6.3. With respect to post-natal and newborn care.
Between the initial and final evaluations, the practice of cutting the umbilical cord by the
health personnel almost doubled (initial = 23.7%; final = 43.8). Nonetheless, a midwife,
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close friend or family member still did this in 56.2% of the cases. In these cases, only 5.5% 
used a new razor blade.
Of the mothers interviewed, 82.1% referred to the place where their newborn was placed 
immediately after birth was next to her. In addition, 63.5% of them mentioned that their
first action was to breast feed their newborn.
It can be seen that the knowledge of the mothers regarding the identification of the alarm
signals in newborns has improved, as is shown in Graph Nº 26. Mothers also now
recognize other alarm signals, such as the child not crying (25.6%), the child being cyanotic 
(20.2%) and the child with cold skin (18.5%). Also increasing was the percentage of
mothers who recognize others signs, such as not breast feeding well, sleeping a lot and
difficulty breathing. 
Graph No.26: Percentage of mothers who recognize danger 
signs in newborns (REDESS Project, 2004)
34
5.7 5.7
0 0 0 0 0
64.9
9.3
16 18.5
11.5
20.2
1.1
25.6
0
10
20
30
40
50
60
70
Difficulty breastfeeding
Difficulty in breathing
Sleeps much
Skin cold
Low birth weight
Cianotic
Convulsions
Doesn't cry
Initial Final
On the other hand, 81.7% of newborns have received some health care during the first 28 
days after childbirth, and 40.4% of mothers have received health care during the first day
after childbirth. In these visits, they remember that advice was given about vaccination of
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the child (84.8%), child feeding (78.3%) and family planning (74.5%), as well as in the
recognition of danger signs in a child with diarrhea or pneumonia (57.0%). 
The level of knowledge of the mothers on the danger signs after childbirth has improved.
We observe an increase from 8.3 to 25.6% of those who mention fever, an increase from
14.3 to 52.2% in those who mention excessive bleeding, and 10% now mention a bad odor 
from the vagina as a danger sign.
Graph No.27: Percentage of mothers who 
recognize danger signs following childbirth 
(REDESS Project, 2004)
8.3
14.3
0
25.6
52.2
10.7
0
10
20
30
40
50
60
Fever Excessive bleeding Bad vaginal odor
Initial Final
4.1.7. Knowledge of prevention of Bartonellosis, Malaria and HIV/AIDS.
4.1.7.1. Bartonellosis.
In the Project area, according to information furnished by the Ministry of Health, there are 
51 communities qualified as zones with risk of Bartonellosis (See Annex Nº 4). Six of
these communities - San Miguel, Caracmaca, Soquian, Naranjopampa, Llur and Tayanga -
were evaluated in the final Project evaluation. The results presented below correspond to 
this group of communities. 
87.5% of the mothers who live in zones of risk have heard about Bartonellosis. In this
group of mothers, almost half identify fever and paleness as signs and symptoms of
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Bartonellosis; 36.5% identify yellow skin and eyes, while 28.6%, pain in the bones. Lesser 
known signs are hemorrhaging and petechias.
Graph No. 28: Knowledge of signs and symptoms of bartonelosis 
in mothers who live in high-risk zones 
(REDESS Project, 2004).
42.9
36.5
52.4
6.3
28.6
9.5
0
10
20
30
40
50
60
Pale skin Fever Aching bones
%
Likewise, 96.8% say that they would go to a health facility in case they suspect that a
family member has Bartonellosis. Regarding preventative measures, 33.3% of mothers 
know they should cover cracks and holes in the walls of their homes, while a quarter of the 
mothers know the following measures: using clothing that covers almost their entire body
(25.4%), sleep inside the house (27.0%), use mosquito netting (27.0%), and bury manure 
(25.4%). A lesser percentage of mothers recognize the use of latrines (12.7%) as a
preventative measure.
4.1.7.2. Malaria. 
In the Project area, based on information furnished by el Ministry of Health, 25
communities are identified as zones with risk of Malaria (See Annex Nº 4). In the Project’s 
final evaluation, none of these zones of risk were evaluated.
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4.1.7.3. HIV/AIDS.
64.0% of the mothers have heard about AIDS, and 42.5% of them know at least one way to 
avoid contracting AIDS. This percentage is above the average for rural zones in Peru
(26.9%), the average in the Department of Cajamarca (19.8%) and almost equal to the
average in the Department of La Libertad (40.3%) (INEI, 2001).
Concerning the ways to avoid contracting AIDS, the best known among the mothers are 
having only one partner (23.2%) and avoiding sex with persons who have various sexual
partners (13.2%). Comparatively small portions of mothers mention that they should limit
the number of sexual partners (8.8%), use a condom (8.4%) and avoid blood transfusions 
(8.3%). Nationwide, 38.1% of mothers know that the use of a condom is a form to prevent 
contraction (INEI, 2001). 
4.1.8. Community organization.
87.6% of the mothers acknowledge the existence of a promoter or midwife in their
community. Of these, 55.4% have received some service from this CHA. The mothers
acknowledge that the CHA have helped them principally through educational talks, home
visits and case references to health facilities. A small portion of them acknowledge having
received follow-up treatment for sick people who have gone to health facilities, evacuation
of cases of emergency and attention during childbirth.
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Graph Nº 29: Type of help received by mothers from Community Health 
Agents (REDESS Project, 2004).
24
5.1
20.8
5.1 3.8
28.2
0
5
10
15
20
25
30
35
40
Home visit Educational talk Follow-up References Evacuation of
emergencies
Assistance with
Birthing
%
27.5% of the mothers know what is a Community Development Committee (CODECO), 
and 26.3% know that one is currently functioning, although 80.6% do not know the specific 
functions of these community organizations. The majority of the mothers who do know
mention that the CODECOs make arrangements with other institutions (14.0%). Smaller 
percentages mention that they participate in the evacuation of emergency cases (5.9%) and 
support to the CHAs (4.8%).
72.5% of the mothers acknowledge that their community is organized for the transportation
of health emergency cases. This percentage is well above that obtained in the initial
evaluation, which was 29.4%. 
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Graph No. 30: Percentage of mothers who know that 
their community is organized to evacuate a person in 
case of a health emergency 
(REDESS Project, 2004).
29.4
72.7
0
10
20
30
40
50
60
70
80
Initial Final
%
On the other hand, the percentage of mothers who know that their community has a
stretcher to transport cases of health emergencies is 65.4% (final evaluation). This
percentage surpasses that obtained in the initial evaluation (1.1%). Likewise, 85.7% of the
mothers know that their community has a stretcher also know its location in the
community. 
31.8% of the mothers interviewed acknowledge that in their community there exists a
community support group in health. 
4.2. Results of the Anthropometric Study.
The prevalence of chronic, overall and acute malnutrition in the Project area have been
estimated in the current evaluation. To accomplish this, in first place, z scores were
calculated for each child with relation to the reference values established by the
WHO/NCHS. Then the children with z scores below < 2.0 standard deviations from the 
reference values are classified as malnourished, and the prevalence of malnutrition is
calculated. 
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4.2.1. Prevalence of chronic malnutrition
The indicator of chronic malnutrition relates the size of a child to his age. The z scores 
found vary between –3.92 and 2.85, with a mean value of –1.57 ± 1.16. The data have a 
normal distribution (Smirnof Kolmogorof Proof = 0.945). 
Descriptive statistic of the z-score values for the size -age indicator 
N
Minimum 
Value
 Maximum 
Value Mean Standard Deviation
Z-score values 354 -3.92 2.85 -1.57 1.16
The prevalence of chronic malnutrition found is 34.7%, showing a decline in comparison
with the initial evaluation (41.35%). This percentage of reduction is significant,
considering that the “p” value is very close to confirming it (p=0.055) and if the amount of
data analyzed were larger, it would probably be significant.
Graph No. 31: Prevalence of chronic malnutrition 
(< 2 Standard Deviations according to WHO/NCHS) in the area of 
the REDESS Project compared with other areas (REDESS 
Project, 2004).
41.35
34.7
0
10
20
30
40
50
Initial Final
%
p = 0.055
4.2.2. Prevalence of overall malnutrition. 
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The overall malnutrition relates the weight and age of the children. The z-score values
found vary between –3.83 and 3.04; with a mean value of –1.09 ± 1.12. The data have a 
normal distribution (Smirnof Kolmogorof Proof = 0.848). 
Descriptive statistic of the z-score values for the weight - age indicator 
N Minimum 
Value
 Maximum 
Value Mean Standard Deviation
Z-score values 354 -3.83 3.04 -1.09 1.12
The prevalence of overall malnutrition is 22.3%, which is significantly greater (p=0.023)
than that reported in the initial evaluation (15.06%).
Graph No. 32: Prevalence of malnutrition 
(< 2 Standard Deviations according to WHO/NCHS) 
in the area of the REDESS Project compared with other 
areas (REDESS Project, 2004). 
15.06
22.3
0
5
10
15
20
25
Initial Final
%
p = 0.023
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4.2.3. Prevalence of acute malnutrition. 
This indicator relates the weight and height of the children. The z-score values vary
between –3.26 and 2.62, with a mean value of –0.09 ± 1.06. The data have a normal
distribution (Smirnof Kolmogorof Proof = 0.941). 
Descriptive statistic of the z-score values for the weight - height indicator
N Minimum 
Value
 Maximum 
Value Mean Standard Deviation
Z-score values 348 -3.26 2.62 -0.09 1.06
We can observe a significant increase in the prevalence of acute malnutrition (p = 0.009) 
when we compare the findings of the initial and final evaluations. This finding is alarming, 
and should alert local authorities and spark interest in developing a holistic analysis of the
nutritional problem. 
Graph No. 33: Prevalence of acute malnutrition 
(< 2 Standard Deviations according to WHO/NCHS) 
in the area of the REDESS Project compared with other areas (REDESS 
Project, 2004).
0.32
3.7
0
1
2
3
4
5
Initial* Final*
%
p = 0.009
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4.3. Results of the evaluation indicators of the REDESS Project.
The text that follows will show the results for the 13 indicators of the Project evaluation. It 
should be mentioned that the goals that were planned at the beginning of the Project have 
an accuracy of +/- 10%. Therefore, if the results obtained in the final evaluation are found 
to be within that interval, we can consider that the corresponding goal has been achieved.
The methodology for calculating the indicators was the same as that employed in the initial 
evaluation. 
4.3.1. Indicators of the management of cases of pneumonia.
We observe an improvement in the 2 indicators; nonetheless, only indicator Nº2 attained
the expected target. With respect to indicator Nº 1, although the planned target was not 
achieved, a very significant increase (p < 0.01) could be observed compared to the initial
evaluation. 
Table No. 9: Indicators of the management of cases of pneumonia.
No. Indicator Baseline
Final 
Evaluation
and 
95% C.I.
Target
Statistical 
significance 
(p)*
Target
Achieved?
Improve￾ment in 
Indicator? 
01 Increased number 
of mothers who 
recognize two 
signs of 
pneumonia.
5.7% 59.6% 
[54.5 ; 64.7] 
80% 0.000 NO YES
02 Increased number 
of mothers who 
seek adequate 
medical treatment 
for their children 
from 0 to 23 
months old with 
signs of 
pneumonia. 
47.8% 78.1%
[73.8 ; 82.4]
80% 0.001 YES YES
* if p <0.05 the differences are significant; if p<0.01 these differences are highly significant.
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With respect to indicator Nº 1, we must state that, according to the calculations undertaken 
using the data base from the initial evaluation, the prevalence found by the Consultant
Team is 17.9%. Therefore, the Consultant Team used 17.9% as a base to estimate the
statistical significance of the increase in this indicator.
4.3.2. Indicators of the prevention and control of diarrhea.
Table No. 10 shows indicators Nos. 3, 4 and 5. We can observe that 2/3 of them have 
improved and 1/3 have remained the same. Nonetheless, 100% of the indicators have failed 
to achieve the planned target. 
Indicator Nº 4 shows a very significant increase (p<0.01), while indicators Nos. 3 and 5
show tendencies, in terms of percentages, that might suggest a positive effect of the Project 
actions. 
Table No. 10: Indicators of the prevention and control of diarrhea.
No. Indicator Baseline
Final 
Evaluation
and 
95% C.I. 
Target
Statistical 
significance 
(p)
Target 
Achieved?
Improve
ment in 
Indicator
? 
03 Increased number 
of mothers with 
children from 0 to 
23 months old able 
to correctly identify 
at least two signs of
dehydration and 
signs of persistent 
diarrhea and 
dysentery 
0.3% * 6.2 %
[ 3.7 ; 8.7 ]
60% 0.000 NO YES **
04 Increased number 
of mothers with 
children from 6 to 
23 months old with 
diarrhea who 
administer the same 
or a larger amount 
of food during the 
episode.
36.7% 56.2%
[51.2 ; 61.2]
70% 0.006 NO YES
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No. Indicator Baseline
Final 
Evaluation
and 
95% C.I. 
Target
Statistical 
significance 
(p)
Target 
Achieved?
Improve
ment in 
Indicator
? 
05 Reduced number of 
children from 0 to 
23 months old with 
diarrhea who 
receive antibiotics 
(self-medicated) 
during the episode
25.2% 18%
[14.1 ; 21.9]
10% 0.164 NO NO
* The value of this indicator has been recalculated, given that the value consigned in the report of the 
initial evaluation was 1% but not calculated correctly as a composite indicator. The estimation of 
the Consultant Team, working with the same data base, was 0.3%. 
** The increase from 0.3 to 6% is significant (p=0.000), so the indicator is considered to have improved.
4.3.3. Indicators of maternal health.
Table No. 11 presents the 5 indicators of this section (6, 7, 8, 9 and 10). Apparently, the 
percentage observed for indicator Nº 6 shows no variation between la initial and final
evaluations. Nonetheless, we must mention that the figure that was consigned in the initial
evaluation (19.9%) does not correspond precisely to the description of the indicator, which
considers the knowledge of the mother of at least 6 danger signs (2 during pregnancy, 2 
during childbirth and 2 in post childbirth), and in addition, the data base of the initial
evaluation does not permit it to be estimated. It is therefore not possible to compare the 
prevalence of this indicator from the baseline to the final evaluation. In the final
evaluation, it was determined that 18.5% of the mothers completed the conditions
established for this indicator. Our comments, therefore, will refer to the other indicators. 
It can be observed that 100% of the remaining indicators have shown improvement
between the initial and final evaluations. Nonetheless, only 50% of them have achieved the 
level hoped for in the established Project targets. 
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Of the 2 indicators which did not achieve targets, Nº 8 and Nº 10 present statistically very 
significant increases, with values of p = 0.000 and p = 0.000, respectively. With respect to 
indicator Nº10, it should be indicated that this Consultant Team has recalculated (correctly) 
the baseline indicator, using the initial data base, and found a prevalence of 11.14%; the 
final evaluation shows 27.2%, thus indicating a significant increase.
Table No. 11: Indicators of maternal health
No.
Indicator Baseline
Final 
Evaluation
and 
95% C.I. 
Target
Statistical 
significance 
(p)*
Target 
Achieved?
Improve
ment in 
Indicator
? 
06 Increased % women 
of reproductive age 
that recognize at 
least 2 signs of 
danger during 
pregnancy, labor & 
delivery and post￾partum.
19.9% 18.5%
[14.5 ; 22.5]
60% Un￾Determined *
---- ---
07 Increased % of 
women with 4 or 
more prenatal care 
visits during last 
pregnancy.*
56.3% 81.1%
[ 77 ; 85.2 ]
80% 0.000 YES YES
08 Increased % of 
women of 
reproductive age that 
have received two or 
more doses of 
tetanus toxoid before 
last childbirth.**
37.6% 54.5%
[49.3 ; 59.7]
80% 0.000 NO YES
09 Increased % of 
women with 
obstetric 
complications that 
are treated by a 
health professional.
55.4% 84.3 %
[80.3 ; 88.3]
70% 0.000 YES YES
10 Increased % of 
women with 
children under age 
two that recognize 
three or more danger 
signs for newborns.
11.1% *** 27.2%
[22.6 ; 31.8]
60% 0.000 NO YES
* Calculation made among mothers with prenatal control identification card.
** Calculation made among all mothers.
*** This value was recalculated given that the prevalence assigned in the initial evaluation was 0.6% 
and not calculated correctly. This new estimate was made employing the same data base as the 
initial evaluation. 
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For indicator Nº 7, prenatal controls in their last pregnancy were examined. Likewise, the 
calculations were made considering only mothers who had a prenatal control identification
card. The calculations for indicator Nº 8 considered all the mothers who were interviewed. 
Likewise, the information on the vaccines was obtained from the mothers’ vaccination
cards. 
4.3.4. Indicators of practices in child feeding.
Table No. 12 presents the results for the indicators of this section. It is apparent that
indicator Nº 11 surpasses the target; note that the baseline value was recalculated
(correctly). With respect to indicator Nº 12, although the target was not achieved, it shows 
a very significant increase (p=0.000). 
Indicator Nº 13 remained unchanged between the initial and final evaluations, given the
there were no significant differences, in terms of percentage, between the initial and final
evaluations.
Table No. 12: Indicators of practices in child feeding.
* The value of the initial evaluation (36.9%) has been modified, given that it was calculated in 
children from 0 to 6 months. The new value of the indicator considers only children from 0 to 5 
months. After standardizing the values of the initial and final evaluations, the statistical significance 
was estimated. 
No. Indicator Baseline
Final Evaluation
and 
95% C.I. 
Target 
Statistical 
significance 
(p)*
Target 
Achieved?
Improve
ment in 
Indicator
? 
11 Increased number 
of children from 
0 to 5 months old 
with exclusive 
breastfeeding.
33.3% * 82.5%
[ 78.5 ; 86.5 ]
70% 0.000 YES YES
12 Increased number
children from 6
to 23 months old 
who are fed five 
times daily.
11.8% 31.5%
[ 26.7 ; 36.3 ]
70% 0.000 NO YES
13 Increased number 
of children 12 to 
23 months old 
who receive anti￾parasite treatment 
every 6 mos.
8.7% 11.7%
[ 8.7 ; 14.7 ]
60% 0.406 NO NO
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It should be mentioned that indicator 11, refers to feeding with only maternal lactation
during the 24 hours prior to the survey and not precisely to the definition of only maternal 
lactation according to WHO/UNICEF as defined at the 45th and 47th World Health
Organization Assembly (WHO, 1998). Likewise, we must indicate that the values of the
initial and final evaluations, for indicator Nº 11, are not completely comparable, as the final
evaluation employs the method of recording what was taken in the last 24 hours, while for 
the initial evaluation, the period of time of feeding was not specified, asking the question,
rather, “at some time, have you given...” 
4.4. Results of the indicators USAID Rapid Catch.
In addition to the indicators of the Project evaluation, others were calculated that were
suggested by the Inter-agency Working Group (IAWG) on the Integrated Management of
Childhood Illnesses (IMCI) and were included in the KPC 2000. The design of the survey 
of the final evaluation included a group of questions that would permit their calculation.
Nonetheless, when trying to calculate the 16 proposed indicators of the data base from the 
initial evaluation, 5 of them could not be estimated due to the fact that the questions were 
not formulated for that purpose at baseline, and in other cases, because the data available in 
the baseline electronic archive did not allow for a proper estimate. 
4.4.1. Prevalence of malnutrition.
The results permit us to indicate that overall malnutrition in the Project area increased in
comparison to the initial evaluation. 
Table No. 13: Indicators of the prevalence of malnutrition.
Nº Indicator Baseline Final 
evaluation 
Statistical 
significance 
(p)
Improvement 
in Indicator?
01
Percentage of children from 0 to 23 
months old who have low weight 
for age (- 2 standard deviations)
15.06% 22.6% 0.023 NO
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4.4.2. Indicators of the prevention of diseases and death.
This section has 12 indicators; it was possible to make comparisons with the initial baseline 
evaluation for 8 of them, while comparisons were not possible for 4 indicators. All the
indicators for which comparisons were made showed improvement. 
The prevalence of mothers with less than 24 months between pregnancies (indicator Nº 2) 
is 15.7%, which is less than the national average for rural areas (23.4%) (INEI, 2001). The 
prevalence of exclusive breastfeeding for children under 6 months old (indicator Nº 5) is
82.5%, a percentage that is superior to the nationwide average of 67.0% (varying,
according to age, from 79% for those 0 to 2 months, to 67% for those 2 to 3 months and 
57% for those 4 to 5 months old, according to INEI, 2001). 
With respect to indicator Nº 3, childbirths attended by health personnel, we see that 44.9% 
have received it, which is a figure above the national average of 28.7% (this includes a 
small percentage attended by health promoter) according to ENDES 2000 (INEI, 2001). 
It is found that 14.6% of the mothers in the Project area know 2 ways to avoid contracting 
HIV/AIDS (indicator Nº 12), slightly above the 8.5% national average among mothers who 
live in rural areas (INEI, 2001). There is no national-level information about hand washing 
that permits a comparison with the 17.1% obtained in the Project area.
Indicators Nº 4, 5, 7, 8, and 9 show increases between the initial baseline and final
evaluations that are very significant (p<0.01). Likewise, indicator Nº 10 shows a significant 
percentage increase (p<0.05). 
Table No. 14: Indicators of the prevention of illnesses and death.
Nº
Indicator Baseline Final 
evaluation 
Statistical 
significance 
(p)
Improve￾ment in 
indicator?
02 Percentage of children from 0 to 23 months 
of age who have been born at least 24 
months after the last live birth. 
Not asked at 
baseline. 84.3% Un￾determined *
---
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Nº
Indicator Baseline Final 
evaluation 
Statistical 
significance 
(p)
Improve￾ment in 
indicator?
03 Percentage of children from 0 to 23 months 
of age whose births were attended by trained 
health personnel
Not asked at 
baseline** 44.9% Un￾determined *
---
04 Percentage of mothers with children from 0 
to 23 months of age who received at least 2 
doses of tetanus toxoid prior to the birth of 
their last child
37.6% 54.5% 0.000
YES
05 Percentage of children from 0 to 5 months of 
age who have received exclusively breast 
feeding during the past 24 hours
33.3% 82.5% 0.000 YES
06 Percentage of children from 6 to 9 months of 
age who have received maternal milk and 
complementary feeding during the past 24 
hours
98.6% 92.3% 0.114
YES
07 BCG 66.7% 85.5% 0.000 YES
08 DPT 61% 80% 0.000 YES
09
Percentage of children 
from 12 to 23 months of 
age who have been 
completely vaccinated 
against the five 
preventable diseases 
before their first 
birthday
Anti-polio 60.4% 80% 0.000 YES
10 Percentage of children from 12 to 23 months 
of age who have been vaccinated against 
measles 
47.8% 60.6% 0.021 YES
11 Percentage of children from 0 to 23 months 
of age who sleep under mosquito netting 
treated with insecticide.
This indicator was not calculated because no zone 
with risk of malaria was evaluated. 
12 Percentage of mothers with children from 0 
to 23 months of age who know at least 2 
forms to reduce the risks of infection with 
AIDS.
Not asked at 
baseline. 14.6% Un￾determined *
---
13 Percentage of mothers with children from 0 
to 23 months of age who have reported that 
they wash their hands with soap or ash prior 
to preparing food, prior to feeding the baby, 
after defecating, and after attending to a 
child who has defecated. 
Not asked at 
baseline. 17.1% Un￾determined *
---
* “Undetermined” means it was not possible to make a statistical comparison.
** Note that the percentage of births "in a health facility" increased from 17.4% to 23.6%.
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Indicator Nº 6 was considered to have improved, given that its high level of prevalence
remained in the initial and final evaluations, with no difference between them (p=0.114). Its 
current prevalence is also above the national average, which is 81% (INEI, 2001). Children 
from 12 to 23 months old who were completely vaccinated against the 5 preventable
diseases, meaning they received the anti-polio, DPT and measles vaccines, increased from
46.5% in the initial evaluation to 69.0% in the final (p=0.000). 
Finally, indicator Nº 11 with respect to malaria could not be calculated because the random 
sample of the study does not include any zones with risk of malaria. 
4.4.3. Indicator of the management and treatment of diseases.
These indicators refer to the knowledge that mothers have to identify signs and symptoms
of pneumonia or dehydration, and practices of feeding their children during episodes of
diarrhea. Each one has shown improvement between the initial and final evaluations. 
The data shows in the regard that, in the Project area, mothers have increased very
significantly (p<0.01) their knowledge and improved their practices. 
Table Nº 15. Indicators of the management and treatment of illnesses.
Nº
Indicator Baseline Final 
evaluation 
Statistical 
significance 
(p)
Improve￾ment in 
indicator?
14
Pneumonia 17.9 59.0 0.000 YES
15
Percentage of mothers with 
children from 0 to 23 months of 
age who know at least 2 signs 
of childhood diseases that 
indicate need for treatment. * Diarrhea 10 62.6 0.000 YES
16 Percentage of sick children 
from 0 to 23 months of age who 
have received increased 
amounts of fluids and solid 
foods during an illness in the 
last 2 weeks.
Diarrhea 18 43.6 0.000 YES
* To calculate this indicator, the estimate was fitted to the questions in the survey of the final evaluation, which does not 
necessarily correspond to the indicator proposed by the Rapid Catch. Nonetheless, it is possible to consider that the 
indicator developed makes a stricter interpretation. 
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To calculate indicator Nº 16, children with diarrhea were considered, within which the
following situations were considered valid: a) in those under 6 months, greater
consumption of maternal milk or equal consumption of maternal milk plus other liquids, b)
in children from 6 to 23 months, more solid food plus more liquids or more maternal milk 
plus solid food or more liquid and solid food or more maternal milk and solid food. 
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5. DISCUSSION
A general appreciation of the results of the evaluation shows us a positive balance in the
variables that were studied. We can observe an improvement in the levels of knowledge
and practices of the mother about maternal and child health and nutrition, increase in the
coverage of maternal and child services, improvement of the organization of the
community to resolve health problems and confront emergencies, and improved use of
available services at local facilities of the Ministry of Health. 
With respect to knowledge and practices of maternal lactation and child nutrition, for which
comparisons with averages nationwide and in rural areas have been detailed earlier, show
an improvement in the early initiation of lactation and also greater consumption of maternal
milk (colostrum) during the three days after birth. Likewise, with respect to practices of
child feeding, improvements in the frequency of child feeding and in the addition of oil or
lard to the food of children under 2 years of age can also be observed. Child feeding is 
extremely varied, with a diversity of sources of Vitamin A. Nonetheless, the consumption
of foods rich in iron by young children is limited.
Significant increases can be observed in the vaccination coverages in children. 
Immunization coverage for BCG, DPT and anti-polio vaccines have increased around 20%, 
while the measles vaccination coverage rose by 11.4% (p=0.021). In the Project area, the 
polio vaccine coverage is level with the national average, while coverage for other vaccines 
is close to the national average, with the exception of measles. A comparison was made in 
search of possible significant differences in the vaccination coverage by gender, and no
such relation was discovered.
It was determined that the prevalence of diarrhea is high (37.4%) in comparison to the
national average for rural zones (17.6%) (INEI, 2001). Nonetheless, feeding practices
during the episode have improved. Mothers now give their children larger amounts of
liquids, solid food or maternal milk. The level of mothers’ knowledge has improved
ostensibly in relation to signs of persistent diarrhea or dysentery, and the signs of
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dehydration. In this question, the best known signs are dry mouth and sunken eyes. 
Similarly, in comparison to the initial evaluation, now a relatively high percentage of
mothers decide to take their children with diarrhea to a health service for care. 
The prevalence of acute respiratory infections (ARI) in children under 2 years old also 
continued to be high (baseline = 50.3%, final = 53.7%) and above the national average for 
rural areas, which is 20.2% (INEI, 2001). In the group of children with ARI, 46.6% had 
rapid and difficult breathing or breathing as if tired or agitated. The majority of mothers 
(85%), after observing these signs, went to a health service for care for their child. This 
positive attitude is a factor in the improvement of the survival of these children.
Nonetheless, still pending is the inter-sectoral labor to increase preventative measures for
ARI. During the period of the implementation of the Project, the number of mothers who 
know at least 1 sign of pneumonia has increased by 25.1% and those who know how to 
feed their child after an episode of ARI, by 21.9%. 
Children whose mothers have a relatively high level of education tend to have less
problems with acute diarrhea and ARIs. There is a significant indirect relation (p=0.006)
between education level and the prevalence of acute diarrhea, a greater association than 
between education level and the ARI variable (See Annex Nº 5.) 
With respect to the practices of prenatal care, the mothers in the Project area who received 
attention in the health services surpassed the national average of the ENDES 2000 (INEI; 
2001). The mothers also show important improvements in the recognition of alarm signals
in pregnancy (74.6% know at least 1), in childbirth (68.3%) and after childbirth (50% know 
more than 1). An increase can also be observed in the consumption of iron sulfate pills. 
40.2% of mothers consume iron pills for 3 months or more, placing them in a level well
above the average for rural zones, which is 9%, and the national average (23%) (INEI,
2001). 
With respect to care for childbirth in health facilities, the average obtained in the final
evaluation (23.6%) equals the average for Peru’s rural zones (23.8%). Nonetheless,
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significant differences are not seen between the initial and final evaluations (p=0.098). A
statistically significant direct relation was observed between the education level of the
mother and the care for childbirths in health services (p=0.034). It is important to mention
that almost half of the childbirths are cared for by health professionals, showing the
combined efforts of the different socials actors involved (promoters, midwifes, women
leaders, health personnel, authorities and the REDESS Project). With respect to the
decisions on attention for health complications during pregnancy and childbirth, we observe 
that the man takes a major role in the decision of what place to be transported to should an 
emergency occur during pregnancy, while the decision on where the childbirth is to take
place is taken by the husband or by the woman herself. On the other hand, only 5% of the 
childbirths that are attended to by a midwife, promoter or others employ a new razor blade 
to cut the newborn’s umbilical cord, thus exposing them to a high risk of contracting
tetanus. This calls for the urgent development of massive campaigns of promotion and
prevention. On the other hand, 34.3% of mothers still do not recognize any danger signals 
for newborns. 
It is worth mentioning that the maternal health actions are among the most important
priorities of the Peruvian Ministry of Health during the recent past. 
In the Project area localities that are zones of risk of Bartonellosis, we still see that 35.4% 
of the mothers do not know how to recognize a single sign or symptom of Bartonellosis,
and 35% still do not know one or more preventative measures. With respect to HIV/AIDS, 
73% of the women do not know one or more ways to avoid contracting this fatal illness. 
These are new and urgent challenges for the public and private institutions, and for the local 
civil society organizations. 
Very important advances have been seen in the strengthening of community organization,
increasing the number of community health agents, community organizations for the
improvement of maternal and child health (CODECO, Mothers Support Groups) and the 
percentage of communities with stretchers to transport patients (from 1 to 65%). Now a 
larger percentage of mothers (initial = 29.4%, final = 72.7%) acknowledge that their
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community is prepared to evacuate health emergency cases. These results might be
considered among the pillars of the results obtained via the REDESS Project.
There are 13 evaluation indicators of the REDESS Project, 7 of which refer to practices, 4 
to knowledge, and 2 to coverage. With respect to the indicator for the increase of mothers 
who know 2 or more danger signs in pregnancy, childbirth and just after childbirth, this
indicator cannot be compared with the initial evaluation due to the considerations described 
earlier. Nonetheless, we suggest that the level of knowledge of the mothers with respect to 
said danger signals has improved, given that we observe an increase from 6.9% to 44.9%, 
respectively, when we evaluate the increase of mothers who know at least 1 danger signal
in pregnancy, childbirth and post-childbirth between the initial and final evaluations. Thus
we consider it pertinent to suggest that the indicator has shown an improvement. 
Thus, the improvement in the indicator analyzed in the previous paragraph together
with number 6 in Table Nº 11, we see that 11 of the 13 evaluation indicators show
improvement, telling us that the Project has had an 84.6% improvement in the
proposed indicators. 
If we analyze the level achievement towards the goals planned for the Project, we observe 
that 4 of 12 indicators have reached the expected levels, so that the Project has had a 33.3% 
rate of achieving targets.
With respect to the different types of indicators, 50% of the indicators on coverage were 
achieved, as were 47% and 25% of the indicators on practices and knowledge, respectively. 
Thus we see that the indicators on knowledge were those that were attained the least. 
By sections, we observe that 100% of the indicator targets on the prevention and control of 
diarrhea were not achieved, nor were 66% of the section of indicator targets for nutritional 
improvement. The sections on the management of cases of pneumonia and maternal health
achieved 50% of their proposed indicators and showed improvement in 100% of their
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proposed indicators. This could suggest a major effort in actions related to these 2 last 
sections. 
Fifteen proposed Rapid Catch indicators were also analyzed. In four of them, it was
impossible to establish comparisons for the lack of information in la initial evaluation. 
Nonetheless, the comparisons made with the national averages according to ENDES 2000 
(INEI, 2001) showed their levels to be similar or superior to the national averages, except 
for the indicator on hand washing, which could not be compared. 
In the 11 remaining indicators, 91% of them achieved an improvement over the baseline 
values. Especially improved were aspects relative to the prevention of death and the
management and treatment of childhood diseases. 
It must be mentioned that the indicator of overall malnutrition in the Project area increased 
between the initial and final evaluations (p= 0.023). Regarding the 2 additional nutritional
indicators, chronic malnutrition diminished from 41.35 to 34.7% (p=0.055), while that for
acute malnutrition increased from 0.32 to 3.7% (p=0.009). It is suggested to contrast these 
results with other sources of information and develop qualitative studies to corroborate the
alarming prevalence of acute malnutrition that was found. From the information available,
we can say that the high rates of diarrhea and respiratory diseases may well be a cause or a 
consequence of the nutritional problem. 
This last finding and those already mentioned should be diffused among the different local
actors. Receiving their feedback is an obligation of the Project and a right of the
population, given their co-participation in the evaluation process. Not returning the
information is unethical in any investigation. Future meetings should be held to reflect on
the improvement or the maintenance of the results obtained. 
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6. BIBLIOGRAPHY 
a. CARE. 2000a. Informe de Evaluación Inicial del Proyecto REDESS. 
b. CARE. 2000b. Informe de Evaluación Nutricional del Proyecto REDESS. 
c. CARE. 2001. Plan Detallado de Implementación. Presentado a USAID/BHR/PVC 
el 16.04.2001 por Peru Child Survival XVI.
d. GROSS R, KIELMANN A, KORTE R, SCHOENEBERGER H, SCHULTINK W. 
1997. Guidelines for Nutrition Baseline Survey in Communities. Versión 1.2
Jakarta: GTZ, SEAMEO, TRPMED. 186 p.
e. INEI. 2001. Encuesta Demográfica y de Salud Familiar 2000. INEI, USAID, 
UNICEF. Lima – Perú.
f. INSTITUTO NACIONAL DE SALUD (INS). 2003. Informe Nacional de Niveles 
de Hemoglobina y Prevalencia de Anemia en Niños de 12 a 36 meses y Mujeres en 
Edad Fértil. Centro Nacional de Alimentación y Nutrición. Dirección Ejecutiva de
Vigilancia Alimentaria y Nutricional. 
g. MINSA. 1995. Normas de Control de Diseases Prevenibles por Vacunación.
Dirección de Salud de la Mujer y del Niño. Sub Programa de Inmunizaciones.
Lima-Perú.
h. MINSA. 1996. Normas de Atención del niño menor de 5 años. Programa de Salud 
de la Mujer y Niño. Sub Programa de Crecimiento y Desarrollo. Lima-Perú.
i. MINSA. 1999. Procedimientos y Protocolos de Atención en Salud de la Mujer.
Programa de Salud y Nutrition Básica. Convenio Perú – BIRF 3701.PE. 
j. MINSA. 1999. Procedimientos y Protocolos de Atención en Salud del Niño en
Centros y Puestos de Salud. Programa de Salud y Nutrition Básica. Convenio Perú 
– BIRF 3701.PE. 
k. MINSA. 2002. Lineamientos de Política Sectorial para el Período 2002-2012 y 
Principios Fundamentales para el Quinquenio Agosto 2001 a Julio 2006. Oficina de 
Comunicaciones MINSA. 
l. MINSA. 2003. Lineamientos en Nutrition Infantil y Materna. Instituto Nacional de 
Salud. Centro Nacional de Alimentación y Nutrition. Lima-Perú. 
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m. OGE. 2003. Boletín Epidemiológico Semanal. Oficina General de Epidemiología
del Ministerio de Salud del Perú. VOL. XII / Nº 37-2003 / Semana del 07 al 13 de 
Setiembre del 2003. Lima – Perú.
n. SARRIOT E, WINCH P, WEISS W, WAGMAN J. 1999. Methodology and
Sampling issues for KPC Surveys. Johns Hopkins University, School of Public
Salud, Department of International Salud
o. THE JOHN HOPKINS UNIVERSITY, 1995. Trainer’s Guide on Quick Surveys on 
Knowledge, Practices and Coverage. July 1995.
p. UNICEF. 2003. The State of the World Children. Statistical Tables. New York.
q. WHO, 1998. Complementary feeding of young children in developing countries: a 
review of current scientific knowledge. United Nations Children´s Fund, University 
of California, World Health Organization. Geneva. 228p. 
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Annex No. 1
SELECTED CLUSTERS - CAJABAMBA
ORDER COMMUNITY DISTRICT EVALUATED
1 EL MILAGRO ALGAMARCA X
2 HUACADAY ALGAMARCA X
3 AYANGAY OTUTO X
4 HUAÑIMBA HUAÑIMBA X
5 NUÑUMABAMBA HUAÑIMBA X
6 QUILLISPAMPA ARAQUEDA X
7 PANCHO JARA CAUDAY X
8 PACHILANGA CAUDAY X
9 CUNGUNDAY CAJABAMBA
10 LICLAMPAMPA CHUQUIBAMBA
Community numbers 7 to 10 were optional
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Annex N. 2
SELECTED CLUSTERS - SANCHEZ CARRION
ORDER COMMUNITY DISTRICT EVALUATED
1SAN MIGUEL MARCABALITO X
2CARACMACA SANAGORAN X
3COCHABAMBA CHUGAY X
4CACHIPAMPA SARTIMBAMBA X
5CHUGURBAMBA SANAGORAN X
6MUSHIT CHUGAY X
7VAQUERIA HUAMACHUCO X
8HUACHACHAL CHUGAY
9SOQUIAN COCHORCO X
10YAMAN CHUGAY X
11NARANJOPAMPA MARCABALITO X
12BUENA VISTA CHUGAY X
13PAJA BLANCA CHUGAY
14UCHUY CHUGAY
15MOLINO VIEJO COCHORCO X
16LICAME CHUGAY X
17JAULABAMBA HUAMACHUCO X
18ELPROGRESO CHUGAY X
19SANJAPAMPA HUAMACHUCO X
20LANLA SARTIMBAMBA X
21LA RAMADA HUAMACHUCO X
22MUNMALCA SARIN X
23LLUR SANAGORAN X
24LA PRIMAVERA CHUGAY
25CHUGAY CHUGAY X
26TAYANGA MARCABALITO X
27CURGOS CURGOS X
28HUAYLLAGUAL CURGOS X
29PUERTO RICO CHUGAY
30EL OLIVO CHUGAY
 communities 24 to 30 were optional
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Annex No. 3
PLAN OF THE MEETING TO TRAIN EVALUATORS AND 
SUPERVISORS IN THE APPLICATION OF A SURVEY 
ON KNOWLEDGE, PRACTICES AND COVERAGE AND THE 
ANTHROPOMETRIC EVALUATION
a. Date: September 9 - 11, 2004.
b. Place: Auditorium of the Hostal Real.
c. Duration: 3 days.
d. Objectives:
· Train survey takers and supervisors in the methodological aspects of the KPC
Survey.
· Practice the application of the KPC Survey. 
· Form the work teams (supervisors and survey takers) for the collection of
information.
e. Programming:
Day 1: Thursday, September 9, 2004 
Time Subject Responsible Method
9 – 10.00 Introduction of the participants REDESS -
MINSA
Cards
10.00 – 11.00 The methodological aspects for the 
application of the Survey KPC – 1. 
ISAN Exposition 
Dialogue
11.00 – 12.00 Practical exercise of identification of 
homes.
ISAN Group Work 
12.00 - 1.00 Techniques for the application of the 
KPC Survey. 
ISAN Exposition 
Dialogue 
1.00 – 2.30 Lunch
2.30 – 4.00 Review of the KPC Survey. ISAN Exposition 
Dialogue 
4.00 – 6.30 Practices for the application of the KPC 
Survey.
ISAN - MINSA
- REDESS
Group Work
6.30 – 7.00 Interchange of experiences of the 
practice of application and feedback.
ISAN Plenary
7.00 – 7.30 Meeting of Supervisors
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Day 2: Friday, September 10, 2004 
Time Subject Responsible Method 
8.00 – 8.30 Organization of the field practices REDESS Dialogue
8.30 – 12.30 Field practices for the application of the 
KPC Survey.
ISAN – MINSA 
– REDESS
Home visits
12.30 – 2.00 Lunch
2.00 – 4.30 Interchange of experiences of the field 
practices and final agreements. 
REDESS Plenary 
4.30 – 5.30 The nutritional evaluation and the 
anthropometric measurements. 
ISAN Exposition
5.30 – 6.00 The Anthropometric Registry ISAN Exposition
6.00 – 6.30 Meeting of Supervisors
Day 3: Saturday, September 11, 2004 
Time Subject Responsible Method 
8.30 – 12.30 Anthropometric Standardization of survey 
takers and supervisors.
ISAN Anthropometric 
Practice 
12.30 – 2.00 Lunch
2.00 – 3.00 Results of Anthropometric Standardization ISAN Group Work
3.00 – 4.00 Determination of routes and work plans by 
teams 
REDESS Plenary
4.00 – 5.00 Formation of teams and assignment of 
communities
REDESS Plenary
5.00 – 6.00 Distribution of materials. REDESS Group Work
Resources:
· Computer.
· Multimedia equipment.
· Diskettes.
· Construction paper.
· Large white paper and easel.
· Masking tape.
· KPC Survey Forms (practice).
· Anthropometric Registry Forms.
· Scales.
· Height measurers.
· Batteries for scales. 
· Anthropometric standardization forms.
· Others.
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Annex No. 4
ENTREVISTA
MADRES CON NIÑOS (AS) DE 0 A 23 MESES
ESTUDIO DE CONOCIMIENTOS, PRÁCTICAS Y COBERTURA
EVALUACIÓN FINAL 
CARE Perú, Proyecto REDESS. 
Huamachuco y Cajabamba, 2004
IDENTIFICACIÓN DEL CUESTIONARIO
# REGISTRO: _ _ _ _ _
CODIGO DEL CONGLOMERADO: ________________________________ # de Encuesta: _______________ 
FECHA DE ENTREVISTA _______/______/______
 (dd / mm / aa)
NOMBRE DE ENTREVISTADOR/A _____________________
NOMBRE DEL SUPERVISOR __________________
DEPARTAMENTO
ESTABLECIMIENTO DE SALUD _________________________________
COMUNIDAD ________________________________
INTRODUCCIÓN Y CONSENTIMIENTO
CONSENTIMIENTO DE LA ENTREVISTADA
Hola. Mi nombre es y estoy trabajando en CARE Perú / MINSA. Estamos 
realizando una entrevista acerca de la salud de mujeres y niños (as). Agradecemos mucho su participación en esta 
entrevista. Esta información ayudará a planificar y mejorar las actividades de salud. La entrevista tarda usualmente 
30 minutos. Cualquier información que nos dé será mantenida entre nosotros.
La participación en esta entrevista es voluntaria y de aceptar esperamos que responda las siguientes preguntas. Su 
opinión es muy importante. 
¿Tiene Ud. alguna pregunta?
Firma del entrevistador: Fecha: 
ESTÁ DE ACUERDO A SER ENTREVISTADA ? Si ( ) No ( )
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NOMBRE DE LA MADRE ______________________________
EDAD DE LA MADRE (EN AÑOS) ___ ___ (aprox.)
GRADO DE INSTRUCCIÓN DE LA MADRE:
 Sin Institución: --------------------------------------------- 1
 Primaria: --------------------------------------------------------- 2
 Secundaria: --------------------------------------------------- 3
Superior: ------------------------------------------------------- 4
UBICACIÓN DE LA VIIVENDA : ________________________ 
__________________________________________________
¿Cuantos hijos tiene ? ______
PEDIR BOLETAS DE NACIMIENTO / TARJETAS DE 
CRECIMIENTO DE SUS 2 HIJOS MENORES Y EL CARNET 
PERINATAL DE LA MADRE, LUEGO ANOTAR:
Datos del niño menor de 2 años a ser entrevistado:
Nombre del Niño/a : ………………………………………...
Fecha de Nacimiento _____/_____/_____ 
 (dd/mm/aa)
Edad del Niño (meses completo) : ____________
SI EL NIÑO (A) TIENE MENOS DE UN MES ANOTE 0.
Sexo del niño/a: M ó F (ENCIERRE EN CÍRCULO)
Datos del hermano anterior al niño/a encuestado/a ?
Fecha de nacimiento _____/_____/_____ o Edad ______ 
 (dd / mm / aa)
SECCION 1. PREVENCION DE ENFERMEDADES
SECCION 1 A: LACTANCIA MATERNA Y NUTRICIÓN INFANTIL
No. PREGUNTAS RESPUESTAS PASE
1
¿Usted, le ha dado alguna vez leche de pecho a 
(NOMBRE del niño/a)?
SI......................................................................1
NO...................................................................2 Ë7
2 ¿Cuánto tiempo después de que nació (NOMBRE 
del niño/a) le empezó usted a dar su pecho?
Si la respuesta fue MAS DE 8 HORAS, pregunte 
------------------------------------------------------------------Ë
No recuerda...................................................1
Antes de la primera hora después 
del parto..........................................................2
Entre Una y Ocho horas después 
del parto..........................................................3
Más de Ocho horas después del 
parto ................................................................4
Porque más de 8 horas:
___________________________________
___________________________________
3 ¿Le dio usted a (NOMBRE del niño/a) la primera 
leche de su pecho los tres primeros días (Calostro)? 
SI......................................................................1
Solamente una parte ...................................2
NO...................................................................3
No Recuerda..................................................4
4 ¿Está dando el pecho (NOMBRE del niño/a) ahora? SI............................................................... 1Ë
NO ………………………………………. 2
Pase a 6
5 ¿Hasta que edad le dio leche de pecho a 
(NOMBRE del niño) ? _____ meses cumplidos Ë Pase a 7
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No. PREGUNTAS RESPUESTAS PASE
6 ¿Durante el día y la noche de ayer, cuántas veces 
le dio pecho a (NOMBRE del niño/a) _______ No. de veces
7
Ahora me gustaría que me indique los alimentos 
que comió ayer (NOMBRE del niño/a) SI = 1 NO = 2 NO SABE = 8
A ¿Le dio agüita de hierba o té a (NOMBRE del 
niño/a) ?
B ¿ Le dio leche de vaca, cabra o leche de tarro o en 
polvo a (NOMBRE del niño/a) ?
C ¿ Le dio cebada, avena, harina de maíz, arroz o 
trigo a (NOMBRE del niño/a) ?.
D ¿ Le dio verduras de hojas verdes, como el chilche 
(huacatay), espinaca, apio, acelga, etc a (NOMBRE 
del niño/a) ??
E ¿ Le dio zanahorias, zapallo, mangos o papaya, 
papas rojas o amarillas, camote amarillo, ocas, etc 
a (NOMBRE del niño/a) ?
F ¿ Le dio frutas, como: plátano, manzana, etc a 
(NOMBRE del niño/a) ?.
G ¿ Le dio Tuberculos, como: papa blanca, yuca, 
olluco a (NOMBRE del niño/a) ?.
H ¿ Le dio Menestras, como: chocho, arveja, habas, 
lenteja, garbanzo, etc a (NOMBRE del niño/a) ?.
I ¿ Le dio Carne, pollo, pescado, mariscos a 
(NOMBRE del niño/a) ?.
J ¿Le dio hígado o sangrecita a (NOMBRE del 
niño/a) ?
K ¿Le dio huevos, queso, cuajada o quesillo a 
(NOMBRE del niño/a) ?
Si la madre responde NO a todas las preguntas No.7 entonces Ë PASE A LA 12.
 
SI = 1 NO = 2 NO SABE = 8
8 ¿En la comida de (NOMBRE del niño/a) le agregó 
aceite o manteca?
¿Usó sal yodada (como Sal de la Vida) en la 
preparación de la comida de (nombre del niño)?
9
PIDA QUE ENSEÑE EL PAQUETE DE SAL Y DE 
ACUERDO A LO OBSERVADO ANOTE
SI usa sal yodada..........................................1
NO usa sal yodada.......................................2
NO enseñó el paquete .................................3
10 ¿A que edad empezó a darle de comer a (NOMBRE 
del niño/a)?
Antes de los 6 meses ............................. 1
6 ............................................................. 2
7 a 8 ........................................................ 3
9 a 12 ...................................................... 4
Mas de 12 meses ................................... 5
No recuerda ............................................. 6
11 ¿Durante el día y la noche de ayer, cuántas veces 
le dio alimentos sólidos o semisólidos (comidas 
espesas, segundos y frutas) a (NOMBRE del 
niño/a)?
INSISTIR PREGUNTANDO, SI LE DIO FRUTAS 
Y/O VERDURAS EN ALGUN MOMENTO.
Ninguna vez...................................................1
Una vez...........................................................2
Dos veces.......................................................3
Tres veces......................................................4
Cuatro veces..................................................5
Cinco veces o más........................................6
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No. PREGUNTAS RESPUESTAS PASE
12 ¿ Hasta que edad debe alimentar a su niño 
SOLAMENTE con leche materna ? 
Hasta los 6 meses ………..……………….1
No sabe ……………………………………..2
OTRO 96
(ESPECIFIQUE)
13 ¿Tiene (NOMBRE del niño/a) su carnet de 
crecimiento y desarrollo?
SI DICE QUE SI, SOLICITE QUE 
MUESTRE LA TARJETA. SI YA LA TIENE 
SOLO ANOTE. 
SI y lo muestra ………………………..….. 1
No tiene.....................................................2 Ë
Perdió la tarjeta ………………………… 3Ë
Pase a 15 
Pase a 15
14 VERIFIQUE EN LA TARJETA O CARNET DE 
CRECIMIENTO Y DESARROLLO.
Anote el numero de controles de peso y
TAMBIEN la fecha del ultimo control ------Ë
Menos de 5 ……………………………… 1
5 ………………………………………….. 2
6 ………………………………………….. 3
7 ………………………………………….. 4
Mas de 7 ………………………………… 5
No tiene ………………………………… 6
_____/_____/_____
dd / mm / aa
15 Recibió (NOMBRE del niño/a) una dosis de 
Vitamina A, como esta, durante los últimos 6 
meses. 
MOSTRAR A LA MADRES UNA CAPSULA DE 
VITAMINA A
SI ……………………………............. .1
NO …………………………… ............2
NO SABE …………………….............3
NO CORRESPONDE ...................... 4 Ë
Cuando el 
niño es < de 6 
meses
16 Ha recibido (NOMBRE del niño/a) alguna vez un 
tratamiento (con medicamentos) para lombrices, 
“bichos” o parásitos
SI......................................................................1
NO……………………………………………2
SECCIÓN 1B: INMUNIZACIONES 
No. PREGUNTAS RESPUESTAS PASE
17 Ha sido vacunado alguna vez (NOMBRE del 
niño/a)?
SI, y tiene carnet ………………………. 1
SI, y no tiene carnet …………………... 2Ë
NO...............................................................3Ë
No Sabe/No Recuerda............................4Ë
Pase a 19
Pase a 19 
Pase a 19
18 REVISE EL CARNET O TARJETA DE 
VACUNAS, RECIBIDAS POR EL NIÑO, 
ENCERRANDO EN CIRCULO LA DOSIS 
RECIBIDAS
Vacuna BCG …… RN 
Antipolio……….… RN 1ª. 2ª 3ª Ref.
DPT (Triple)…………….1ª 2ª 3ª Ref.
Antisarampión o SPR …………1ª Ref
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SECCIÓN 1C: HIGIENE DE MANOS 
No. PREGUNTAS RESPUESTAS PASE
19 ¿En que momentos se lava Ud. las manos con 
jabón/detergente/ceniza ?
PUEDE MARCAR UNA O VARIAS RESPUESTAS 
INSISTIR PREGUNTANDO:
Cuando más?
Nunca………………………………………… 1
Antes de preparar los alimentos……………2
Antes de dar de comer a su niño/a………...3
Después de hacer la caca o defecar………4
Después de limpiar/atender a su 
niño/a que ha hecho la caca ……………..5
OTRO 96
(ESPECIFIQUE)
SECCION 1D : MALARIA
No. PREGUNTAS RESPUESTAS PASE
20 Tiene Ud. algún mosquitero en su casa? SI..............................................................1
NO............................................................2
NO SABE ……………………………… 3
Ë 23
Ë 23
21 Quién / quienes durmieron bajo el mosquitero anoche?
PUEDE MARCAR UNA O VARIAS RESPUESTAS 
INSISTIR PREGUNTANDO:
Alguien más?
Su hijo (NOMBRE del niño/a) …………….1
Ella misma (encuestada) …………………..2
Nadie …………………………………………...3
OTRO (S) ________________________96
(ESPECIFIQUE)
22 Alguna vez su mosquitero ha sido mojado o humedecido 
en algún liquido repelente de mosquitos? SI..............................................................1
NO............................................................2
NO SABE …………………………….. 3
SECCION 1E : VIH/SIDA
No. PREGUNTAS RESPUESTAS PASE
23 Alguna vez ha escuchado de la enfermedad llamada 
SIDA? SI..............................................................1
NO............................................................2
NO SABE ………………………………3
Ë 25
Ë 25
24 Que puede hacer una persona para evitar contagiarse del 
SIDA.
PUEDE MARCAR VARIAS RESPUESTAS
Nada …………………………………………..1
Abstenerse de sexo…………………………...2
Tener una sola pareja…… …………………..3
Limitar el número de parejas sexuales …….4
Evitar el sexo con prostitutas………………...5
Evitar sexo con personas que tienen varias 
parejas sexuales...........................................6
Evitar contacto sexual con personas del
 mismo sexo……………………………….…..7
Evitar el sexo con quienes usan drogas por 
inyectables……………………………………..8
Evitar transfusiones sanguíneas…………....9
Evitar besos………………………………….10
Evitar picadura de mosquitos………………11
Evitar compartir navajas/hojas de afeitar…12
No sabe……………………………………….13
Usar condón ………………………………...14
OTRO___________________________96
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SECCIÓN 2: NIÑO/A ENFERMO/A
SECCIÓN 2A: ENFERMEDADES DIARREICAS 
No. PREGUNTAS RESPUESTAS PASE
25 Ha tenido (NOMBRE del niño/a) diarrea en las 
últimas 2 semanas?
SI .....................................................................1
NO...............................................................2Ë
No Sabe/No Recuerda............................3Ë
Pase a 36
Pase a 36
26
Cuándo (NOMBRE del niño/a) tuvo diarrea, ¿qué le 
dio? 
PUEDE MARCAR VARIAS RESPUESTAS
INSISTIR PREGUNTANDO:
Algo más?
Nada................................................................1
Sales de Rehidratación Oral........................2
Suero Casero.................................................3
Panetelas ........................................................4
Líquido, agüita, infusión, caldito..................5
Antidiarreico/Antibiótico sin receta .............6
Antibiótico con receta ...................................7
OTRO 96
(ESPECIFIQUE)
27 Durante la diarrea de (NOMBRE del niño/a) siguió 
dándole pecho (leche materna) ...?
LEA CADA UNA DE LAS OPCIONES Y 
ENCIERRE EN CIRCULO LA RESPUESTA.
Dejó de darle..................................................1
Más de lo acostumbrado..............................2
Igual a lo acostumbrado...............................3
Menos de lo acostumbrado.........................4
Ya no recibía pecho......................................5
28 Durante la diarrea de (NOMBRE del niño/a) ¿Le dio 
otros líquidos como aguita o te...?
LEA CADA UNA DE LAS OPCIONES Y 
ENCIERRE EN CIRCULO, LA RESPUESTA
Más de lo acostumbrado..............................1
Igual a lo acostumbrado...............................2
Menos de lo acostumbrado.........................3
No le dio aguitas o te ....................................4
Sólo recibió pecho.........................................5
29 Durante la diarrea de (NOMBRE del niño/a) ¿Le dio 
de comer...? 
LEA CADA UNA DE LAS OPCIONES Y 
ENCIERRE EN CIRCULO LA RESPUESTA
Más de lo acostumbrado..............................1
Igual a lo acostumbrado...............................2
Menos de lo acostumbrado.........................3
No le dio de comer .......................................4
Sólo recibió pecho.........................................5
30 ¿Buscó usted alguna atención fuera de casa para 
curar la diarrea de (NOMBRE del niño/a)? SI ........................................................... 1
NO.................................................... 2Ë Pase a 36
31 Cuándo (NOMBRE del niño/a) tuvo diarrea, ¿Dónde 
pidió atención primero?
Hospital General............................................1
Centro o Puesto de Salud............................2
Médico o Clínica Particular..........................3
Farmacia.........................................................4
Promotor de salud ………………………….5
Mujer líder.......................................................6
Curandero.......................................................7
Partera.............................................................8
Parientes ........................................................9
OTRO 96
(ESPECIFIQUE)
32 ¿Quién / quienes decidió ir a …………… (referirse 
al lugar o persona mencionado por el entrevistado) 
para atender la diarrea de (NOMBRE del niño/a)
PUEDE MARCAR VARIAS RESPUESTAS
Ella misma ………………………………….. 1
Esposo /conviviente …………..…………… 2
Parientes ……………………..…………….. 3
Amigos/vecinos. …………………..……….. 4
Promotor de Salud ………………………… 5
OTRO ___ 96
(ESPECIFIQUE)
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No. PREGUNTAS RESPUESTAS PASE
33 ¿Después buscó atención en otra parte? SI..............................................................1
NO......................................................2 Ë Pase a 36
34
¿De quien buscó atención?
PUEDE MARCAR VARIAS RESPUESTAS
INSISTIR PREGUNTANDO:
Alguien más?
Hospital General............................................1
Centro o Puesto de Salud............................2
Médico o Clínica Particular..........................3
Farmacia.........................................................4
Promotor de salud ………………………….5
Mujer líder.......................................................6
Curandero.......................................................7
Partera.............................................................8
Parientes ........................................................9
OTRO 96
(ESPECIFIQUE)
35 Después de la diarrea de (NOMBRE del niño/a) ¿Le 
dio a (NOMBRE del niño/a)otros líquidos como 
agüita o te...?
LEA CADA UNA DE LAS OPCIONES Y 
ENCIERRE EN CIRCULO, LA RESPUESTA
Más de lo acostumbrado..............................1
Igual a lo acostumbrado...............................2
Menos de lo acostumbrado.........................3
No le dio agüitas o te ....................................4
Sólo recibió pecho.........................................5
36 ¿Cómo reconoce que un niño con diarrea está 
deshidratado (sequito/chupadito)?
PUEDE MARCAR VARIAS RESPUESTAS 
INSISTIR PREGUNTANDO:
Algo más?
No sabe...........................................................1
Mollera hundida .............................................2
Boca Seca......................................................3
Ojos Hundidos ...............................................4
Signo del Pliegue...........................................5
Bebe ávidamente/Mucha sed .....................6
Letárgico / no despierta fácilmente ..........7
Irritabilidad / llora mucho / fastidiado …... 8
Llora sin lágrimas ..........................................9
Orina poco...................................................10
OTRO 96
(ESPECIFIQUE)
37 ¿Cómo reconoce que su niño tiene una diarrea 
persistente o disentérica (grave, severa o peligrosa)? 
PUEDE MARCAR VARIAS RESPUESTAS 
INSISTIR PREGUNTANDO:
Algo más?
No sabe...........................................................1
Diarrea con sangre........................................2
Diarrea por más de 14 días .........................3
Diarrea como agua de arroz y 
Vómitos (Cólera)............................................4
OTRO 96
(ESPECIFIQUE)
38 ¿Si su niño/a con diarrea presenta señales de 
peligro (gravedad) hacia donde acudiría 
primeramente para su atención? 
Hospital General............................................1
Centro o Puesto de Salud............................2
Médico o Clínica Particular..........................3
Farmacia.........................................................4
Promotor de salud ………………………….5
Mujer líder.......................................................6
Curandero.......................................................7
Partera.............................................................8
Parientes ........................................................9
OTRO 96
(ESPECIFIQUE)
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No. PREGUNTAS RESPUESTAS PASE
39
¿Cómo debe ser la alimentación de un niño/a para 
recuperarlo, después de haber tenido diarrea?
PUEDE MARCAR VARIAS RESPUESTAS
INSISTIR PREGUNTANDO:
Algo más?
No sabe...........................................................1
Dar alimentos en menor cantidad, 
pero, con más frecuencia.............................2
Más alimento de lo usual.............................3
Alimento con alto contenido calórico..........4
OTRO 96
(ESPECIFIQUE)
SECCIÓN 2B: INFECCIONES RESPIRATORIAS AGUDAS
No. PREGUNTAS RESPUESTAS PASE
40 ¿Ha estado (NOMBRE del niño/a) enfermo con tos o 
problemas respiratorios en las últimas dos semanas?
SI..............................................................1
NO...........................................................2
NO SABE................................................3
Ë50
Ë50 
41 ¿Tuvo (NOMBRE del niño/a) respiración rápida y difícil, 
respiraba agitado/a, como cansado/a (cansío) cuando 
enfermó? 
SI..............................................................1
NO...........................................................2
NO SABE................................................3
Ë50
Ë50 
42 ¿Buscó usted ayuda (atención) para curar a (NOMBRE 
del niño/a) cuando se enfermó con la respiración rápida 
y difícil (cansío)?
SI..............................................................1
NO...........................................................2 Ë50
43 Después que se dio cuenta que (NOMBRE del niño/a ) 
tenia respiración rápida o difícil (cansío) ¿ Cuanto 
tiempo demoro en buscar atención?
El mismo día ………………………… 1
Día siguiente ………………………… 2
Dos días o mas …..…………………. 3
44 Cuándo (NOMBRE del niño/a) estaba enfermo, ¿A 
quien pidió atención primero?
Hospital General............................................1
Centro o Puesto de Salud............................2
Médico o Clínica Particular..........................3
Farmacia.........................................................4
Promotor de salud ………………………….5
Mujer líder ......................................................6
Curandero......................................................7
Partera............................................................8
Parientes .......................................................9
OTRO 96
(ESPECIFIQUE)
45 ¿Quién / quienes decidieron ir a ……….….. (referirse 
al lugar o persona mencionado por el entrevistado) para 
atender la respiración rápida o difícil (cansío) de 
(NOMBRE del niño/a)
PUEDE MARCAR VARIAS RESPUESTAS
Ella misma ……………………………….. 1
Esposo /conviviente ………………………2
Parientes …………………………………..3
Amigos/vecinos. ………………………….4
Promotor de Salud ……………………… 5
OTRO 96
(ESPECIFIQUE)
46 ¿Después buscó atención en otra parte? SI..............................................................1
NO...........................................................2 Ë48
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No. PREGUNTAS RESPUESTAS PASE
47 ¿De quien más buscó atención?
PUEDE MARCAR VARIAS RESPUESTAS
Hospital General............................................1
Centro o Puesto de Salud............................2
Médico o Clínica Particular..........................3
Farmacia.........................................................4
Promotor de salud ………………………….5
Mujer líder ......................................................6
Curandero......................................................7
Partera............................................................8
Parientes .......................................................9
OTRO 96
(ESPECIFIQUE)
48 ¿ De quien recibió tratamiento, finalmente? 
PUEDE MARCAR VARIAS RESPUESTAS
Hospital General............................................1
Centro o Puesto de Salud............................2
Médico o Clínica Particular..........................3
Farmacia.........................................................4
Promotor de salud ………………………….5
Mujer líder ......................................................6
Curandero......................................................7
Partera............................................................8
Parientes .......................................................9
OTRO 96
(ESPECIFIQUE)
Ë50
Ë50
Ë50
 
49
¿ Que medicinas le dieron a (NOMBRE de niño/a)?
PUEDE MARCAR VARIAS RESPUESTAS
Nada …………………………………….…. 1
Aspirina …………………………………….. 2
Panadol …………………………………….. 3
Amoxicilina ………………………………….4
Eritromicina …………………………………5
Penicilina ……………………………………6
No sabe / no recuerda ……………………7
OTRO 96
(ESPECIFIQUE)
50 ¿Cuáles son las señales que le indican que un niño 
tiene neumonía? 
PUEDE MARCAR VARIAS RESPUESTAS 
INSISTIR PREGUNTANDO:
Algo más?
No sabe..........................................................1
Respiración rápida y agitada (Cansío)......2
Hundimiento de piel debajo de 
costillas ...........................................................3
Fiebre..............................................................4
Tos...................................................................5
OTRO 96
(ESPECIFIQUE)
51 ¿Cómo debe ser la alimentación de un niño/a, para 
recuperarlo, después de haber tenido una respiración 
rápida y difícil (cansío, neumonía) ?
PUEDE MARCAR VARIAS RESPUESTAS
INSISTIR PREGUNTANDO:
Algo más?
No sabe..........................................................1
Dar alimentos en menor cantidad, 
pero, con más frecuencia............................2
Más alimento de lo usual.............................3
Alimento con alto contenido calórico .........4
OTRO 96
(ESPECIFIQUE)
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SECCIÓN 3: SALUD MATERNA
SECCIÓN 3A: ATENCIÓN PRENATAL
No. PREGUNTAS RESPUESTAS PASE
52 Cuando Ud. estaba embarazada de (NOMBRE del niño/a) 
¿Recibió algún control por el personal del establecimiento 
de salud (Centro, puesto u hospital) ?
SI .............................................................1
NO...........................................................2 Ë 57
53 ¿Qué tipo de personal de salud le hizo los controles 
durante el embarazo?
PUEDE MARCAR VARIAS RESPUESTAS 
INSISTIR PREGUNTANDO:
Alguien más?
Médico………………………………………1
Obstetriz ……………………………………2
Enfermera…………………………………. 3
Técnico de Enfermería……………………4
54 ¿Cuántos controles en total recibió usted por parte del 
personal de salud, durante el embarazo de (NOMBRE del 
niño/a?
Número de CPN ___ ___
No recuerda ______________ 
55
SOLICITE POR FAVOR QUE LE MUESTRE:
La Tarjeta de Control de Embarazo ….. ( )
Plan de Parto ……………………………... ( )
PARA VERIFICAR EL NUMERO DE CONTROLES 
PRENATALES QUE TUVO DURANTE SU ULTIMO 
EMBARAZO
Menos de 4 controles……………………...1
4 ó mas controles……………………… ….2
No tiene carnet…………………….............3
Perdió su carnet…………………….. .........4
56 Durante sus controles del embarazo, le aconsejaron sobre 
lo siguiente:
¿Preparativos para el parto? ó ¿Plan de parto?
¿Lactancia materna?
¿ Como cuidarse para no tener hijos muy seguidos?
¿Señales de alarma o de peligro de muerte durante el 
embarazo?
LEA CADA UNA DE LAS PREGUNTAS Y 
PUEDE MARCAR VARIAS RESPUESTAS 
Preparativos para parto ó Plan de parto….1
Lactancia materna…………………………..2
Como cuidarse para no tener hijos muy 
seguidos …………………………..…….....3
Señales de alarma o de peligro de muerte 
durante el embarazo………………………..4
No recibió consejos …............................. 5
No recuerda …........................................ 6
57 SOLICITE POR FAVOR QUE LE MUESTRE:
La Tarjeta de Control de Embarazo ….. ( )
Carné de Vacunación Antitetánica …... ( ) 
Plan de Parto ……………………………... ( )
Alguna vez antes de su último parto ¿Recibió Ud. la 
vacuna antitetánica?
VERIFIQUE EL NUMERO DE DOSIS DE 
VACUNAS ANTITETANICAS RECIBIDAS 
ANTES DE SU ULTIMO PARTO.
Ninguna vacuna……………………….........1
Menos de 2 dosis………………………..….2
2 o más dosis…….………………………….3
No tiene medio de verificación ……………4
No sabe ……………………………………. 5
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No. PREGUNTAS RESPUESTAS PASE
58 ¿Conoce las señales de alarma o de peligro de muerte 
durante el embarazo?
PUEDE MARCAR MAS DE UNA RESPUESTA
INSISTIR PREGUNTANDO:
Algo más?
Fiebre..............................................................1
Vómitos exagerados.....................................2
Pérdida de líquido por la vagina.................3
Sangrado Vaginal .........................................4
Hinchazón de cara, manos y pies..............5
Dolores de parto antes de la fecha............6
El niño/a no se mueve, no patea................7
Dolor de cabeza............................................8
No sabe..........................................................9
OTRO 96
(ESPECIFIQUE)
59 ¿ A dónde iría usted si se le presentara algún signo de 
alarma o peligro durante su embarazo?
PUEDE MARCAR MAS DE UNA RESPUESTA
Algo más?
Hospital General ...........................................1
Centro o Puesto de Salud ...........................2
Médico o Clínica Particular.........................3
Farmacia........................................................4
Promotor de salud ………………………….5
Mujer líder......................................................6
Curandero......................................................7
Partera............................................................8
Parientes .......................................................9
OTRO 96
(ESPECIFIQUE)
60 ¿Quién / quienes deciden que Ud. Debiera ir …….. 
(referirse al lugar o persona mencionado por el 
entrevistado)?
PUEDE MARCAR MAS DE UNA RESPUESTA
Ella misma ………………………………..1
Partera …………………………………….2
Esposo/Pareja ……………………………3
Ambos ………………………………. ……4
Suegra ………………………………. …...5
Madre …………………………………….. 6
OTRO 96
(ESPECIFIQUE)
61 ¿Cuál es el medio de transporte más rápido que Ud. 
utiliza en caso de una emergencia?
PUEDE MARCAR MAS DE UNA RESPUESTA
Transporte público u ómnibus…………….1
Carro particular……………………………..2
Ambulancia………………………………….3
Animal (caballo, burro)………………….... 4
A pie (en litera)……………………………...5
No sabe.....................................................6
OTRO 96
(ESPECIFIQUE)
62
¿Cuánto tiempo demora en llegar desde su comunidad 
hasta el establecimiento de salud en caso de emergencia 
de una mujer embarazada?
Menos de una hora…………………………1
Entre una y menos de tres horas………….2
Entre tres y seis horas…………………….. 3
Más den seis ………………………………..4
No sabe………………………………………5
63 En su último embarazo y parto ¿Sufrió Ud. Alguna 
complicación de salud? SI .............................................................1
NO...........................................................2
NO Recuerda.........................................3
Ë 66
Ë 66
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No. PREGUNTAS RESPUESTAS PASE
64 ¿Cuál fue esa complicación?
PUEDE MARCAR MAS DE UNA RESPUESTA
INSISTIR PREGUNTANDO:
Algo más?
Hemorragia vaginal (sangrado fuerte, 
pérdida de Sangre).......................................1
Salida de mano/pie/cordón………………..2
Retención de placenta .................................3
Vómitos exagerados.....................................4
Infección/fiebre……………..........................5
Obstrucción, demora del parto……………6
Opilación/hinchazón ….……………………7
No sabe…………………………………….. 8
OTRO 96
(ESPECIFIQUE)
65 ¿Quién le atendió (dio tratamiento) cuando tuvo esa 
complicación?
PUEDE MARCAR MAS DE UNA RESPUESTA
INSISTIR PREGUNTANDO:
Alguien más?
Médico / Obstetríz.........................................1
Enfermera …………………………………. 2
Técnico en Salud..........................................3
Partera............................................................4
Promotor en Salud........................................5
OTRO 96
(ESPECIFIQUE)
66 Cuando estuvo embarazada de (NOMBRE del niño/a), Ud.
tomó pastillas de hierro.
MOSTRAR A LA MADRES LAS PASTILLAS DE 
SULFATO FERROSO
Si …........... 1 ¿Cuántos días? ______
 ¿Cuántos meses?_____
 No recuerda ___
No ..…….... 2
No sabe / No recuerda ........3
SECCIÓN 3B: ATENCIÓN DEL PARTO
No. PREGUNTAS RESPUESTAS PASE
67
¿Dónde dió a luz a (NOMBRE del niño/a)? Hospital ……………….........………. 1
Centro o Puesto de Salud ………… 2
Casa ………………………………… 3
OTRO ______________________96
(ESPECIFIQUE)
68 ¿Quién le atendió el parto de (NOMBRE del niño/a)? Personal de salud …………………… 1
Promotor/a …………………………… 2
Partera …………………………………3
Comadre …………………………..... 4
OTRO _______________________96
(ESPECIFIQUE)
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No. PREGUNTAS RESPUESTAS PASE
69
¿Quién / quienes tomaron la decisión del lugar de 
atención de su parto?
PUEDE MARCAR MAS DE UNA RESPUESTA
INSISTIR PREGUNTANDO:
Algo más?
Ella misma ……………………………1
Partera ……………………………… ...2
Esposo/Pareja ………………………...3
Ambos ………………………………. ...4
Suegra ………………………………. ..5
Madre ………………………………… .6
OTRO _______________________96
(ESPECIFIQUE)
70
¿Cuáles son las señales de alarma o de peligro de 
muerte durante el parto?
PUEDE MARCAR MAS DE UNA RESPUESTA
INSISTIR PREGUNTANDO:
Algo más?
Hemorragia o Sangrado .................. ..1
Parto Prolongado .............................. 2 
Hipertensión/desmayo/convulsiones . 3
Retención de Placenta ……………… 4
Salida de mano/pie …………………..5
Salida de cordón ……….……………. 6 
Rompimiento de fuente en un tiempo 
mayor de 6 horas antes del parto …. 7
No Sabe ……………………………… 8
OTRO _______________________96
(ESPECIFIQUE)
SECCIÓN 3C: ATENCIÓN POSTNATAL Y DEL RECIEN NACIDO
No. PREGUNTAS RESPUESTAS PASE
71 
Cuando nació (NOMBRE del niño/a), ¿Quién ató y cortó el 
“ombligo” o cordón? Ella misma......................................................1
Un familiar......................................................2
Partera/matrona............................................3
Personal de salud.....................................4Ë
Médico particular………………………...5Ë
No sabe..........................................................6
OTRO 96
(ESPECIFIQUE)
Pase 73
Pase 73
72
SI LA PERSONA QUE CORTO EL “OMBLIGO” NO FUE 
PERSONAL DE SALUD, PREGUNTAR
¿Qué usaron para cortar el “ombligo” o cordón?
Hoja de afeitar nueva………………………1
OTRO 96
(ESPECIFIQUE)
73
¿ Inmediatamente (apenas) nació (NOMBRE del niño/a) 
donde fue colocado? Junto a la madre………………….…………1
En el piso…………………………………….2
En otra cama………………………………..3
OTRO 96
(ESPECIFIQUE)
74
¿ Inmediatamente (apenas) nació (NOMBRE) qué hizo Ud. 
con él / ella?
LEA LAS OPCIONES
Le dio pecho………………………………… 1
Lo bañó……………………………………….2
Lo dejó dormir………………………………. 3
Lo llevaron a otro ambiente………………..4
OTRO 96
(ESPECIFIQUE)
Final Quantitative Evaluation of the XVI Child Survival Program “REDESS” -- CARE PERU 2004 
__________________________________________________________________________________________________
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No. PREGUNTAS RESPUESTAS PASE
75 ¿Cómo reconoce que un recién nacido esta enfermo y 
necesita atención médica?
PUEDE MARCAR MAS DE UNA RESPUESTA
INSISTIR PREGUNTANDO:
Algo más?
No mama bien...............................................1
Respiración rápida/dificultad para respirar2
Difícil de despertar / duerme mucho …….3
Piel Fría/Niño frío ..........................................4
Bajo peso al nacer........................................5
Piel morada/cianótico...................................6
Convulsiones .................................................7
No llora............................................................8
No sabe..........................................................9
OTRO 96
(ESPECIFIQUE)
76 Después de haber nacido (NOMBRE del niño/a) ¿Recibió 
alguna atención en salud en los primeros 28 días?
SI.........................................………… 1
NO................................……………2 Ë
NO Recuerda....................................3 Ë
 
Pase 78
Pase 78
77 ¿Quién atendió a (NOMBRE del niño/a) en esa 
oportunidad?
PUEDE MARCAR MAS DE UNA RESPUESTA
Partera............................................................1
Promotor.........................................................2
Personal de salud.........................................3
OTRO 96
(ESPECIFIQUE)
78 Después del parto de (NOMBRE del niño/a) ¿Cuándo 
recibió Ud. alguna atención en salud?
No Recibió …………………………….1Ë
Primer día después del parto......................2
Entre 2 y 7 días después del parto ............3
Más de 7 días después del parto ...............4
Pase 81
79 ¿Quién la atendió en esa oportunidad?
PUEDE MARCAR MAS DE UNA 
RESPUESTA
Partera............................................................1
Promotor.........................................................2
Personal de salud....................................... .3
OTRO 96
(ESPECIFIQUE)
80
En esa oportunidad, ¿le dieron consejos acerca de …… ? 
· ... como cuidarse para no tener hijos muy seguidos?
· ... cómo debe alimentar al niño/a (nutrición infantil)?
· ... la vacunación del niño/a (inmunización infantil)?
· ... la Señales de peligro en un niño/a con diarrea o neumonía?
LEA LAS OPCIONES
PUEDE MARCAR MAS DE UNA RESPUESTA
¿ Como cuidarse para no tener hijos muy 
seguidos? ………………………..……….. 1
Alimentación del niño/a (nutrición infantil) 
…..………………………………..………… 2
Vacunación del niño/a (inmunización infantil) 
….………………………….. ……………... 3
Señales de peligro en un niño/a con diarrea 
o neumonía …………………………….…. 4
No recibió consejos ……………………… 5
No recuerda ………………………………. 6
81 ¿Cuáles son las señales de alarma o de peligro de muerte 
de una mujer después del parto (desde las primeras horas 
hasta los 42 días)?
PUEDE MARCAR MAS DE UNA RESPUESTA
INSISTIR PREGUNTANDO:
Algo más?
Fiebre..............................................................1
Sangrado Excesivo.......................................2
Mal olor de la vagina (de sus partes).........3
No Sabe..........................................................4
OTRO 96
(ESPECIFIQUE)
Final Quantitative Evaluation of the XVI Child Survival Program “REDESS” -- CARE PERU 2004 
__________________________________________________________________________________________________
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SECCIÓN 4: ENFERMEDADES TRASMISIBLES
SECCION 4A : BARTONELOSIS
No. PREGUNTAS RESPUESTAS PASE
82
Conoce ó ha escuchado hablar de la Bartonelosis? SI..............................................................1
NO............................................................2
NO SABE ……………………………..3
Ë86
Ë86
83 Como reconocería Ud. que un familiar/persona tiene 
Bartonelosis?
MARQUE TODAS LAS RESPUESTAS MENCIONADAS 
POR LA MADRE
Palidez……………………………………….1
Piel y ojos amarillos………………………..2
Fiebre ……………………………………….3
Hemorragias………………………………..4
Dolor de huesos……………………………5
Petequias (puntitos rojos) ………………..6
Verruga ……………………………………..7
No sabe……………………………………..8
OTRO___________________________96
(ESPECIFIQUE)
84 Donde buscaría atención ayuda, si sospecha que un 
familiar/persona tiene Bartonelosis?
Hospital…………………………………….1
Puesto o Centro de Salud……………….2
Promotor…………………………………..3
Familiares…………………………………4
No sabe …………………………………...5
OTRO__________________________96
(ESPECIFIQUE)
85 Sabe Ud. que hacer para evitar enfermarse con 
Bartonelosis?
PUEDE MARCAR VARIAS RESPUESTAS
Usar ropa que le cubra casi todo el cuerpo…1
Dormir dentro de la casa……………………...2
Usar mosquiteros……………………………...3
Tapar grietas y huecos de paredes………....4
Enterrar el estiércol (guano)………………....5
Usar letrinas…………………………………...6
No Sabe………………………….……............7
OTRO________________________96
(ESPECIFIQUE)
SECCIÓN 5: ORGANIZACIÓN COMUNITARIA
No. PREGUNTAS RESPUESTAS PASE
86 ¿Existe una partera o promotor en su comunidad? SI..............................................................1
NO............................................................2
NO Sabe.................................................3
Pase
Ë 88
Ë 88
87 ¿Ha recibido alguna ayuda (apoyo) por parte de la 
partera o promotor?
PUEDE MARCAR VARIAS RESPUESTAS
Que más?
No recibió apoyo ………………………..1
Visita domiciliaria ……………………... 2
Charla educativa ……………………… 3
Seguimiento de casos ……………….. 4
Referencias …………………………… 5
Evacuación de emergencias ………… 6
OTRO________________________ 96
(ESPECIFIQUE)
Final Quantitative Evaluation of the XVI Child Survival Program “REDESS” -- CARE PERU 2004 
__________________________________________________________________________________________________
- 99 -
No. PREGUNTAS RESPUESTAS PASE
88 Ha escuchado Ud. acerca del CODECO (Comité de 
Desarrollo Comunal) ? SI…………………………………………1
NO………………………………………..2
89 En su comunidad funciona un CODECO?
Si la respuesta fue NO, entonces pregunte --------Ë
SI..............................................................1
No Sabe………………………………...2
NO....................................................... …3
Porqué no funciona (especifique)?
____________________________
(ESPECIFIQUE)
90 Sabe Ud. Que hace el CODECO, o cual es su función en 
la comunidad?
PUEDE MARCAR VARIAS RESPUESTAS
Evacuación de emergencias………….1
Hace gestiones con instituciones…….2
Apoya al ACS…………………………..3
Nada…………………………………….4
No sabe…………………………………5
OTRO 96
(ESPECIFIQUE)
91 ¿Su comunidad se encuentra organizada para evacuar a 
una persona en una emergencia de salud? SI..............................................................1
NO............................................................2
NO Sabe.................................................3
92 ¿Cuenta su comunidad con una litera/camilla para 
evacuar un caso de emergencia de salud? SI..............................................................1
NO.......................................................2Ë
NO Sabe............................................3Ë
Pase 
95
95
93
Sabe donde esta ubicada la litera / camilla? SI..............................................................1
NO............................................................2
94
¿ En su comunidad, han usado la litera para evacuar las 
emergencias de salud SI..............................................…........ 1
NO........................................................... 2
NO Sabe……………………………….3
95
Sabe Ud. Si existe un Grupo de Apoyo Comunitario, en 
su Comunidad ? SI…………………………………………1
NO……………………………………….2
NO SABE ………………………...…….3
AGRADEZCA LA ATENCIÓN Y EL TIEMPO BRINDADO
E. Project Data Sheet form – updated version