WORLDWIDE WORLDWIDE
 (U.S.) Inc. Bangladesh
CONCERN WORLDWIDE (U.S.) Inc.
CONCERN WORLDWIDE BANGLADESH
CHILD SURVIVAL PROGRAM
Saidpur and Parbatipur Municipalities
USAID-CONCERN-MUNICIPALITY PARTNERSHIP
MIDTERM EVALUATION REPORT
Cooperative Agreement No. FAO-A-00-98-00077-00
October 1, 2000 - September 30, 2004
Submitted on 8t
 November 2002 to USAID/GH/HIPN Washington, USA
Prepared by: Jean Meyer Capps, RN, BSN, MPH
External Evaluator
Syed Izaz Rasul, MBBS, MPH
Local Consultant
In collaboration with: Breda Gahan, RN, MPH
Michelle Kouletio, MPH
A.K.M. Musha, MBBS
Child Survival Staff and Stakeholders,
Saidpur and Parbatipur
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Acronyms
AI Appreciative Inquiry
ANC Antenatal Care
ARI Acute Respiratory Infection
BCC Behavior Change Communication
BDHS Bangladesh Demographic and Health Survey
BP Blood Pressure
CDD Control of Diarrheal Disease
CHP Community Health Promotion
CHV Community Health Volunteer
C-IMCI Community Integrated Management of Childhood Illness
CORE Child Survival Collaborations and Resources Group
COSAS Coverage Survey Analysis System
CRWRC Christian Reformed World Relief Committee
CSP Child Survival Program
CSGP Child Survival Grants Program (USAID)
CSTS Child Survival Technical Support Project
CWI Concern Worldwide Incorporated
DIP Detailed Implementation Plan
DPT Diphtheria, Pertussis, Tetanus
EG Entry Grant
EmOC Emergency Obstetric Care
EPI Expanded Program of Immunization
ESP Essential Services Package
FGD Focus Group Discussion
FP Family Planning
FT Field Trainer
FPAB Family Planning Association of Bangladesh
FWV Family Welfare Visitor
GoB Government of Bangladesh
HICAP Health Institution Capacity Assessment Process
HMIS Health Management Information System
HPSP Health and Population Sector Programme
HR/D Human Resource/Development
IMCI Integrated Management of Childhood Illnesses
IMR Infant Mortality Ratio
INACG International Vitamin A Consultative Group
IOCH Immunization and Other Child Health Project
ISA Institutional Strengths Assessments
KPC Knowledge, Practice and Coverage Survey
LAMB Lutheran Aid to Medicine in Bangladesh
LFA Logframe Analysis
LOP Life of Program
LQAS Lot Quality Assurance Sampling
M&E Monitoring and Evaluation
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MBBS Bachelor of Medicine and Bachelor of Surgery
MCHC Maternal and Child Health Care
MCWC Maternal and Child Welfare Center
MO Medical Officer
MHC Municipal Health Committee
MHS Municipal Health Services
MOHFW Ministry of Health and Family Welfare
MOLGRD Ministry of Local Government and Rural Development
MSH Management Sciences for Health
NGO Non-Government Organization
NSDP NGO Service Delivery Project
ODU Organizational Development Unit
OJT On the Job Training
OPV Oral Polio Vaccine
PBR Parbatipur
PHC Primary Health Care
PLA Participatory Learning for Action
PP Private Practitioner
PVO Private Voluntary Agency (US-based NGO)
RA Research Assistant
RMP Rural Medical Practitioner
SBC Social Behavior Change
SNID Special National Immunization Day
SWOT Strengths, Weakness, Opportunities, Threats
STO Senior Training Officer
TBA Traditional Birth Attendant
THC Thana Health Complex (Now Upazilla Health Complex)
TO Training Officer
TOT Training of Trainers
TT Tetanus Toxoid
UHC Upazilla Health Complex
UHFPO Upazilla Health & Family Planning Officer
UFHP Urban Family Health Partnership
UNICEF United Nations Children's Fund
USAID United States Agency for International Development
WHC Ward Health Committee
WHO World Health Organization
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Table of Contents
A. SUMMARY.............................................................................................. 1
B. ASSESSMENT OF PROGRESS TODATE............................................. 4
B.1. Technical Approach...............................................................................................4
B.1.a. Project Overview .......................................................................................4
B.1.b. Specific Technical Interventions ...............................................................6
B.1.c. Tools, approaches, operations research and special studies..........................15
B.2. Crosscutting Approaches ....................................................................................17
B.2.a. Community Mobilization.......................................................................17
B.2.b. Communication for Behavior Change ...................................................... 18
B.2.c. Capacity Building Approach ....................................................................19
B.2.d. Sustainability Strategy .............................................................................27
C. PROGRAM MANAGEMENT................................................................. 29
C.1. Planning ..........................................................................................................29
C.3. Supervision of Program Staff...........................................................................30
C.4. Human Resources and Staff Management........................................................31
C.5. Financial Management.....................................................................................32
C.6. Logistics..........................................................................................................32
C.7. Information Management.................................................................................32
C.8. Technical and Administrative Support ............................................................34
D. OTHER ISSUES IDENTIFIED BY THE TEAM...................................... 35
E. CONCLUSIONS AND RECOMMENDATIONS......................................... 36
F. RESULTS HIGHLIGHT............................................................................. 42
G. ACTION PLAN NOTES......................................................................... 43
H. REFERENCES...................................................................................... 55
Attachments
A. Baseline Information from the DIP
B. Team members and their titles
C. Assessment methodology
D. List of persons interviewed and contacted
E. Parbatipur and Saidpur selected activities per output
F. Selected Special Study Reports
 BCC Strategy
 TBA Study
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A. SUMMARY
Program description and objectives
The USAID-Concern-Municipality Partnership Child Survival Program (CSP) is a four￾year project that follows a successful two-year Entry Grant. The goal of the project is to
contribute to the reduction of maternal and child mortality and morbidity, and increase
child survival through the development of a sustainable Municipality Health Service in
the Saidpur and Parbatipur municipalities of Bangladesh. The project seeks to strengthen
the municipalities’ capacity to deliver specific child survival activities of good quality,
which can be sustained within existing Municipal, and Ministry of Health and Family
Welfare (MOHFW) resources. Through a capacity building partnership on multiple
levels, the CSP seeks to improve services in Immunization (EPI), Vitamin A, Maternal
and Newborn Care, IMCI (Integrated Management of Childhood Illnesses – acute
respiratory infections (ARI), diarrhea, and malnutrition), and Community Health
Promotion (CHP).
The major program strategies include developing the management capacity of
municipality managers and supervisors, developing the technical capacity of the
municipality staff on selected child survival activities and strengthening the
municipalities community approach through training, facilitation and supporting the
formation of health committees.
There are five program outputs:
• A developed Municipality Health Planning and Management System
• Institutionalized and well managed activities (related to the interventions areas)
• A sustainable Community Health Promotion System
• Competent and independent Municipality staff and supervisors
• Improved Child Survival Program planning and management.
Main Accomplishments to Date
Through the support of municipal authorities, the CSP has succeeded in building capacity
for delivering health services at every level, from the municipal health committees to the
communities. All capacity indicators and the five program outputs listed above in the
Detailed Implementation Plan are on target, or have already been achieved.
CSP advocacy and training support have increased municipal health service staffing and
quality. Ward Health Committees (WHCs) are established in every ward. Some are
almost ready to function independently, with little input from the CSP. Ward Health
Committees are selecting, supporting and supervising Community Health Volunteers
(CHVs) and Traditional Birth Attendants (TBAs) and organizing community level health
promotion events.
The CSP succeeded in significantly raising immunization and Vitamin A coverage rates
during the Entry Grant with USAID, and monitoring data indicate that these levels have
been maintained. TBAs have been trained in clean, safe delivery and referring women
with danger signs during delivery and postpartum period to health facilities. Project
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operations and qualitative research have documented increases in facility deliveries and
other positive maternal and newborn care practices. CHVs are very active in communities
and community awareness of danger signs, indicating the need to seek health care for
mothers and children, has increased significantly.
Main Constraints and Obstacles
Early in the project, Concern had to overcome considerable local political obstacles to
secure the support and commitment of the municipality/local authorities to take action at
the institutional level to use their own resources to improve the health status of the
population. Obstacles were so great that the CSP had to leave one municipality and select
another municipal partner following a change of political leadership. Close collaboration
with project partners and stakeholders over a long period established the trust necessary
to overcome barriers and engage in joint planning. The resulting CSP partnership may
serve as a model for other municipal health programs in Bangladesh. Concern
Bangladesh has already received requests from other municipalities to replicate the CSP.
Resource constraints to serve a largely poor population inhibit some project efforts to
improve health services. These factors are largely out of the project's direct control.
Maintaining the service and quality gains already accomplished in the program, while at
the same time shifting focus to the other program interventions will require a number of
adjustments in the day to day management of the program. Significant advocacy,
facilitation and technical assistance inputs will be needed to engage all health providers in
improving access to quality referral care. Fortunately, all stakeholders have expressed
strong commitment to the additional efforts needed to further improve maternal and child
survival in their communities.
Major Capacity Building Efforts
The major CSP capacity building efforts have focused on strengthening the municipality
health system by joint planning, training and support at all levels. Skills training in
planning, program implementation, data collection and analysis, problem solving and
consensus building encourage institutionalization of maternal and child survival health
services.
The Institutional Strengths Assessment (ISA) and Health Institution Capacity Assessment
Process (HICAP) are organizational self-assessment tools employed by the project to
understand baseline organizational situations, establish mutually agreed upon
organizational objectives, and assess progress over time. Both tools are founded on the
principles of appreciative inquiry. These have helped Concern and the municipalities to
set capacity goals and specific programmatic plans.
Prospects for Sustainability
The CSP's institutional partner is the Municipal Authority/Paurashava with a tripartite
partnership of communities, WHCs and the Municipal Health Services (MHS) with the
shared goal of increasing health capacity and improving sustainable health status through
the municipalities. The program is so thoroughly integrated with the partners, that the
term "CSP" is synonymous with the partnership. Municipal governments and WHCs are
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raising funds locally to support improved services, including providing emergency
transport and covering medical costs for the poorest members of the community. These
efforts are developing mechanisms for financial support after CSP funding ends.
Project advocacy efforts insure that health is well placed on municipal government
agendas. This indicates that program impacts will probably continue long after the
funding period ends. Building advocacy skills can have a spill-over effect into other
municipal programs that can support the child survival program. Communities already
express a commitment to cleanliness and environmental sanitation that they attribute to
the community health promotion activities of the CSP. Locally sustainable material
inputs are used, therefore supplies and equipment used by the CSP is not a major
consideration after the CSP ends.
Priority Recommendations
• For additional impact on mortality reduction, the CSP needs to shift focus away
from EPI and Vitamin A, which have been largely successful, to newer areas of
maternal and newborn care and integrated management of childhood illness
• The CSP will need to engage in networking, coordination and advocacy with all
major health care providers in the project area to address the main causes of
maternal and child mortality by improving quality curative care in referral health
facilities in the municipalities.
• To move the CSP towards sustainability, the CSP should make concerted efforts
to implement an exit strategy for WHCs, CHVs and strengthening the
municipality health management information system (HMIS).
• To reach the majority of children with life-threatening illnesses, the project must
find ways to include private practitioners in quality of care improvement efforts.
• To impact on key household decision-maker behaviors, the CSP should find ways
to promote greater community-level male involvement in the program.
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B. ASSESSMENT OF PROGRESS TODATE
B.1. Technical Approach
B.1.a. Project Overview
When the CSP began with a USAID/BHR/PVC Entry Grant in 1998, the municipal
governments of Saidpur and Parbatipur did not have health on their agenda. This was in
spite of the 1995 Government of Bangladesh (GOB) circular requiring formation of
health committees at the municipal and ward levels. The 1977 Paurashava Ordinance had
already charged municipalities with responsibility for EPI and Vitamin A services as well
as environmental sanitation, infectious disease control, community health promotion, and
a variety of other public health duties.
Concern Worldwide (U.S.) Inc. was awarded the Entry Grant to develop a CSP in two
urban locations, Mymensingh and Saidpur. The March 1999 municipal elections in
Mymensingh resulted in a new cabinet that was not supportive of the Concern CSP
capacity building approach. Due to conflicts of interest and insurmountable differences
between the CSP and the new municipal cabinet ministers, Concern Bangladesh had to
withdraw from Mymensingh and select another municipal partner. Parbatipur, in
Dinajpur District adjacent to Saidpur, was selected from several municipalities as one
with interests that were the most compatible with the CSP.
The purpose of the CSP is to strengthen the capacity in each municipality to deliver
specific child survival services of good quality and to improve the health status of
mothers and children which can be sustained within existing Municipal and MOHFW
resources.
The CSP program methodology is based on the assumption that health security is
achieved when people improve their knowledge, attitude and capacity for positive health
practices. Participatory community development and capacity building are essential
elements of community empowerment, which enable community members to reduce
risks, and recognize and seek care for life-threatening conditions. The municipal health
care systems are simultaneously strengthened at the institutional and community levels to
address priority public health problems.
The three main strategies of the CSP are: 1) to develop the management capacity of
municipality managers and supervisors via training, facilitation and participatory
planning methods; 2) to develop the technical capacity of municipality staff on selected
Child Survival activities via training and workshops, on-the-job training, and the
development of a staff support system; and 3) to strengthen the municipalities’
community approach through training, facilitation and supporting health committees with
the resulting community based health promotion process.
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The CSP Detailed Implementation Plan (DIP) described planned program activities in
detail for years 1 & 2, allowing for detailed planning for years 3 and 4 after the necessary
municipal health structures were in place. This allowed the project to focus on building
capacity in the municipalities. The CSP strengthened MHS, assisted in the establishment
of WHCs, and helped them train TBAs and the select, train and place CHVs. Technical
interventions, in the addition to improving the quality of TBA care and motivating care￾seeking behaviors, focused heavily on improving EPI and Vitamin A coverage and
quality. These were selected as priority activities since most other health services are not
the direct responsibility of municipal governments. As of the midterm evaluation, the
program has implemented the workplan according to the schedule provided in the DIP.
Exceptions, along with the rationale, are noted in the individual technical implementation
sections in this report.
The CSP conducted considerable formative research in preparation for the more
technically challenging interventions after the second year. As anticipated, the midterm
evaluation process has provided the basis for the detailed action plan for the remainder of
the project. (See the Action Plan section on page 43.)
As previously mentioned, the DIP contains five program outputs to provide the
framework for the program plan: 1) a developed municipality health planning and
management system; 2) institutionalized and well managed activities; 3) a sustainable
community health promotion system; 4) competent and independent municipality staff
and supervisors; and 5) improved child survival program planning and management for
Concern.
Since the time the DIP was approved, the project has developed intermediate, or process
monitoring indicators, which are measured on a regular basis by the CSP HMIS for each
of the five outputs. Based on the HMIS, project records and the management information
system, the project has already achieved, or is on target in achieving targets in all five
output areas.
Over the next year, the program will refine definitions and measurement methods of the
outputs to reduce subjectivity and further articulate program impact.
(See Table 1 in Annex A that lists program interventions, estimated program effort and
USAID funding from the Detailed Implementation Plan and Section J-4 specific
measurable indicators. Program technical interventions are discussed in detail in the
technical sections; crosscutting activities including Behavior Change Communication and
Community Health Promotion are discussed in section B.2.)
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B.1.b. Specific Technical Interventions
This section addresses the major technical intervention activities, progress towards
technical objectives and outputs since the beginning of the CSP grant, major
accomplishments thus far, and challenges to intervention implementation. (Note that
Community Health Promotion is a crosscutting approach and addressed in section B.2.a.
Community Mobilization).
The CSP selected EPI, Vitamin A, TBA training and CHP as initial activities, since these
interventions are under the control of the municipal government. The CSP strategy was to
get these interventions well established before moving into other areas. At the midterm,
this strategy proved to be wise. The DIP planned for the major efforts in IMCI and
Maternal Newborn Care to be implemented in years 3 and 4. The program strategy has
now been expanded to include assisting the MHS to coordinate these other technical areas
with referral health facilities in the project area.
(Planned next steps and rationale are discussed in the technical intervention section;
recommendations are in Section E.)
EPI (12% program level of effort years 1 & 2)
Based on findings from the EPI Facility Assessment, completed during the Entry Grant,
the CSP focused on improving management and technical efficiency, community support
and quality of the cold chain. The CSP worked closely with the Immunization and Other
Child Health Project (IOCH) and WHCs to develop a community level registration
system for newborns and pregnant women. Project staff provided on-the-job field support
to improve vaccination technique and cold chain maintenance, and improve record
keeping, reporting, and the monitoring system. [DIP p. 76, 2002 first semester report, site
visits].
The CSP focuses EPI efforts on:
• Improving quality of care both at outreach and fixed (institution) centers
• Increasing the demand and participation in availing the services
• Improving both management and technical skills of the service providers
• Establishing functional coordination between municipality and other relevant
stakeholders both in Government and NGOs for sustained cooperation [DIP year 2
first semester report]
Specific EPI program activities include:
• Regular refresher training for all stakeholders
• Government policy updates including changes in the government HMIS and
population estimates relative to the (1991) census (the report from the 2001
census is not yet available).
• Support for extensive stakeholder involvement in the SNIDs.
• Regular review/planning meetings with Municipality Health staff.
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• CSP representation at Upazilla Health Meetings and IOCH EPI Coordination
meetings
• Supervision support for EPI facility management and disease surveillance and
reporting
Technical assistance from the CSP team, particularly the Field Trainers, has considerably
improved municipal EPI service delivery. Quality has improved in sterilization, injection
techniques, registration of clients, follow-up of dropouts, etc. The CHVs and TBAs
provide support in session management, and house-to-house client tracking. Field
Trainers, many of whom have several years of experience as vaccinators with Concern,
provide the majority of the technical support.
The HMIS helps the municipality track progress towards EPI targets, especially
monitoring the vaccine coverage rate. Municipalities use the computer generated
statistical reports to assess program performance and monitor program plan
implementation against established targets. Colorful graphic charts tracking EPI, Vitamin
A and ANC coverage are prominently displayed in municipality offices.
The CSP is also instrumental in mobilizing support for Special National Immunization
Days (SNIDS), one of which occurred during the MTE fieldwork. Varieties of
community groups, including scouts, assist at vaccination sites throughout the project
area.
The project uses the Coverage Survey Analysis System (COSAS), a more accurate
method of EPI coverage validation than those used in most PVO child survival projects.
The COSAS measures the number and type of vaccinations, but also analyzes the timing
of vaccinations to derive the "fully effective coverage". This method was used by IOCH,
the USAID mission follow-on to BASICS I. Percentages calculated in this way are often
significantly lower than those derived by usual EPI data collection.
Effective EPI coverage increased in Saidpur from 43% to 70%, and in Parbatipur from
49% to 89% by the end of the Entry Grant. The CSP information system, taking data
from immunization cards, estimates that current coverage is over 80%, exceeding end of
project targets. This is well above the 65-70% coverage level required to avoid periodic
measles outbreaks in preschool children.
Additional program efforts undertaken during the current grant focus on improving EPI
service delivery. These efforts include refresher training, strengthening supervisory skills,
data analysis and dissemination, advocacy for staff and equipment and community
mobilization.
The project monitoring system measures five EPI program quality elements. Each has
shown measurable improvements from January 2001 to December 2002 as illustrated in
table 1.
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Table 1: Comparison of EPI Performance Monitoring Criteria, Saidpur
Municipality 2001-2002
Performance Element Jan '01 - Dec '01 Jan ' 02 - Jun '02
Sterility & Hygiene 64% 87 %
Cold Chain 60% 91%
Record Keeping & Reporting 74% 92%
Vitamin A Administration 70% 92%
Vaccine Administration 78% 84%
Source: Saidpur CSP, An Overview, 2002
Support for EPI in the second half of the project will continue to focus on cold chain
quality, strengthening MHS supervisory capacity and refreshing Concern project staff
immunization technical skills. These activities will prepare for turning over most of the
EPI and Vitamin A program implementation and supervision to the Municipalities early
in the second half of the project.
Challenges and Constraints
Sustainable progress has been constrained by the temporary status of municipal health
department staff, several of whom were abruptly laid off at one point during the project.
In Parbatipur, some EPI workers, including some supervisors are employees of the
Upazilla Health Complex, and are not permanent members of the MHS staff.
Vitamin A (8% of program effort)
Vitamin A distribution is a component of the regular EPI services as well as the SNIDs.
The project tracks Vitamin A data from the MHS facilities and includes this information
in the HMIS reports. Postpartum women can receive a high dose Vitamin A capsule at
the time they bring the child for their first immunizations. Content on consuming Vitamin
A rich foods as well as the importance of Vitamin A supplements are included in training
curricula for stakeholders in all levels. CSP information, education and communication
(IEC) products, including wall murals with messages, were observed in several locations
around the project area. Project EPI community mobilization efforts also contribute to
increased Vitamin A coverage.
A MOHFW policy change from allowing capsules only in the first two weeks postpartum
to up to 6 weeks postpartum has encouraged health workers to pay more attention to this
activity. Trained TBAs obtain Vitamin A from the municipalities, who keep the records,
and administer the dose to their clients. In principal, women delivering in health facilities
also receive supplements, but this is not within the control of the CSP. Women who
deliver, neither in facilities nor with the assistance of CSP trained TBAs, are unlikely to
receive Vitamin A capsules, unless they receive them at EPI sessions. Thus, the CSP
approach working with TBAs and the EPI program is designed to approach Vitamin A
coverage at multiple levels but does not have access to all new mothers.
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The vast majority of TBAs, both trained and untrained, promote early and exclusive
breastfeeding to their clients. Breastfeeding is the recommended strategy for promoting
Vitamin A intake for infants under 5-6 months of age. TBAs also provide counseling
about Vitamin A supplementation to postpartum women during their postnatal checks.
(Concern Bangladesh, TBA Study 2002).
Challenges and Constraints
There are constraints to effective coverage for both children and postpartum women.
Vitamin A capsules are not available for women during the SNIDs. Only child doses are
provided. In addition, SNID tally sheets do not provide for recording supplements to
women. This is consistent with the SNID/Vitamin A programs in other countries.
Tracking postpartum Vitamin A supplement coverage, and supplements provided to
children who have completed immunizations, is not well developed in Bangladesh.
Targeting and coverage is a problem in many developing countries and needs to be
addressed by the national government program, especially since SNIDs for polio
eradication and Vitamin A distribution are scheduled to end soon. This will severely
decrease mass distribution of supplements to children.
The role of Vitamin A in preventing of blindness "and other diseases" is emphasized in
messages to the community, but not the important role Vitamin A plays in reducing
infectious disease morbidity and mortality in children. There is a perception among CSP
staff that mothers would not be receptive to messages that Vitamin A will prevent
mortality. Additional qualitative investigation could assess the determinants of positive
behaviors relative to Vitamin A. This would help the project to know what information is
more effective in motivating families to consume Vitamin A rich foods and obtain
supplements for children and lactating women.
Postpartum Vitamin A supplementation is particularly important in Bangladesh, since
most newborns, especially low birth weight infants have little or no Vitamin A stores in
their livers. A significant percentage of Bangladeshi women have low or deficient levels
of Vitamin A in their breastmilk. Infants fed with breastmilk low in Vitamin A are more
likely to develop deficiency and have weak immunity when exposed to infectious
diseases. (West 2002) (Miller 2002) There is also strong new evidence that Vitamin A
deficiency interferes with iron metabolism and contributes to childhood anemia.
(LINKAGES).
Integrated Management of Childhood Illness (20% of program effort)
The CSP has adopted the IMCI approach to address three major child survival
interventions: pneumonia, diarrheal disease control and nutrition. Malaria is not included,
because it is not a major cause of child morbidity and mortality in the project area.
Vaccine preventable diseases, including measles, are included as part of EPI and Vitamin
A activities. Prevention and treatment of malnutrition itself has several sub-interventions:
breastfeeding promotion, maternal nutrition, prevention and control of micronutrient
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deficiencies, (including anemia), and promotion of appropriate complementary feeding
for weaning, and during illness.
The CSP conducted formative research in preparation for implementation of the IMCI
components of the program early in 2002. Focus group discussions with TBAs, CHVs,
WHC members, municipality health staff, private providers and health facility personnel
were included in the analysis. Project staff acknowledged that more time was needed for
in-depth discussions with each of these groups. Nevertheless, the reports yielded valuable
information that will help to develop messages to be disseminated to mothers on diarrheal
illness, pneumonia, and malnutrition. Information on private provider behavior, coupled
with participatory situation analysis conducted in the CSP Behavior Change
Communications (BCC) Strategy has provided a basis for the more intensive C-IMCI
efforts planned for the second half of the project.
The three key components of the generic IMCI approach are 1) improving health worker
case management skills, 2) improving the overall health system, and 3) improving family
and community health care practices. The CSP, appropriately, has decided to focus on the
third component initially, but will attempt to address the second component in the second
half of the project.
The CSP trains Field Trainers (FTs) in IMCI promotion, who in turn train Ward Health
Committee members, CHV's and TBAs to deliver messages on the danger signs of
diarrhea, pneumonia, and malnutrition in communities. CHV's educate 20-30 families
each, while TBAs provide IMCI related information individually to their clients during
postpartum checks.
The primary behavioral message focuses on taking children exhibiting danger signs to
health facilities for case management. The project staff considered training TBAs and
CHVs to count respirations, but decided against doing so because of concerns about
accuracy. They chose, instead, to emphasize prompt referral to health facilities. Given the
urban setting of the project, most facilities can be reached within a reasonable amount of
time.
Additional pneumonia danger signs included as training topics in the DIP include ill
child, drowsy, cough, chest indrawing, fever, and rapid breathing. More information on
Community Health Promotion, which currently contains most of the C-IMCI activity, is
discussed in the crosscutting approach section. Section B-2.
Challenges and Constraints
At the time the DIP was written, the national IMCI adaptation process was underway in
Bangladesh. Piloting was scheduled to begin in selected districts shortly thereafter. The
CSP had hoped to assist national implementation by training both government and private
providers in IMCI case management. At the time of the MTE, however, piloting was
taking place in only three districts, outside of the project area. Without a national IMCI
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program in place, the CSP staff felt it was not appropriate to move forward with the
anticipated "training of all municipal health staff and 96 private providers in case
management protocols per MOHFW policy guidelines."
PVO Community IMCI is in its infancy in terms of lessons learned in effective program
approaches. Effectiveness of current project efforts at community education and behavior
change motivation was studied recently during the BCC strategy development. Further
investigation is scheduled in year 3 to refine the program approach to implementation and
measurement of effective behavior change in support of IMCI. In January 2001, after the
CSP DIP was approved, CORE released the C-IMCI framework "Reaching Communities
for Child Health: Advancing PVO Technical Capacity and Leadership in Household and
Community IMCI.” The framework was endorsed by the entire CORE membership in
April 2001. This framework is only now reaching PVO field projects. Without substantial
implementation examples, many CSP projects were reluctant to begin C-IMCI
implementation. This should change in the next few years as the first PVO projects are
completed and the results are disseminated.
There is convincing evidence that several child health interventions contained in C-IMCI
can substantially reduce child mortality in high mortality settings if good population
coverage is achieved. Even when the facility-based IMCI is implemented on a national
scale, IMCI component III will be required to achieve sufficient coverage to impact on
infant and child mortality. C-IMCI promotes sixteen "Key Community IMCI Practices"
to prevent illness, improve home care, and increase use of health services. None of the
suggested activities contradicts current MOHFW policies and in fact, many are already
promoted by the Concern CSP.
Staff capacity to address the training needs to implement this intervention should be
assessed by Concern, and additional training will probably be required. Providing for the
input of updated information on strategies into the project for this, and other program
components, will need to be addressed.
As in many similar situations internationally, IMCI is still viewed as a collection of
disease-specific interventions. Integration has not yet occurred in terms of viewing child
health holistically, but the foundation is present in the multi-faceted development
approach Concern employs in its development programs. Described in C-IMCI
documents as "the development platform" upon which the C-IMCI program elements can
be built, these activities make success of the C-IMCI more likely. The challenge will be
to remain engaged as the implementation issues of the integrated approach are refined,
and then adapted, to the situation as it exists in the CSP area. In the meantime, the CSP is
approaching the components of C-IMCI in the most reasonable way possible. After
discussions of the BCC strategy in Year 3, the project will need to develop ways of
integrating the individual components.
The Entry Grant Review conducted in June 2001 accurately described the challenges of
implementing IMCI in urban areas, where the municipalities, not the MOHFW, are
responsible for health services. Project activity and training reports document TBAs,
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CHVs, WHC members, and Imams were provided training on Pneumonia, Malnutrition
and Diarrhea. Health facilities have not been included. Due to the lack of referral health
facility assessments, it is difficult to determine the type of capacity building support the
CSP will need to initiate over the next few years. There is no guarantee that health
facilities will agree to participate in the necessary service quality improvements.
Maternal and Newborn Care (28% of program effort)
The CSP maternal and newborn care intervention has three major components:
• Promoting increased attendance at antenatal clinics (ANC)
• Promoting of clean, safe home delivery through training Traditional Birth
Attendants (TBAs)
• Recognition of obstetric complications and prompt referral for emergency
obstetric care (EmOC)
(Community mobilization in support of these activities is described in the Community
Health Promotion section.)
The CSP has trained 156 TBAs in the two municipalities. TBA training objectives were
clearly described in the DIP (p. 57). GoB certified TBA trainers provide 21 days of
training interspersed with time to practice some skills before moving on to others.
Training topics include promoting attendance at ANC, clean, safe delivery, referral to
health facilities for obstetric complications, immediate newborn care, and postpartum
checks. The training also provides TBAs with the opportunity to spend a day working in
the health facility. This has helped provide a linkage and improve communication
between the CSP, MOHFW and Upazilla level Health and Family Planning workers in
the area.
TBAs provide messages to motivate mothers to vaccinate their children, obtain Vitamin
A supplements, use ORS for children with diarrhea, and recognize and seek care for
infants with dangers signs of pneumonia, diarrhea or malnutrition as part of their routine
postnatal visits. These activities are designed to support the other CSP program
interventions.
Municipality Health Staff and Concern FTs currently provide TBA refresher training. In
monthly refresher sessions, the FT provides for continuity and support, curriculum
reviews, discuss birth preparedness, data collection and assist in problem solving. Topics
included in the training include cord care, respiratory resuscitation, breastfeeding,
keeping the baby warm and follow up postnatal checks.
In May 2002, Concern completed a follow-up study comparing performance behaviors of
109 trained TBAs with 32 untrained TBAs. Mothers with recent births were included in
the study to triangulate information provided by the TBAs. The study showed that 58% of
trained TBAs visit with mothers during the antenatal period, compared with 22% of
13
untrained TBAs. Trained TBAs offer some antenatal services at these visits, but not the
same services expected to be available at ANC clinics, (e.g., blood pressure and weight
measurement, urine or blood screening and eye tests).
TBA training and other CSP efforts have improved maternal health practices in the area.
Women with three or more ANC visits has doubled from 40% (KPC 1999) to 80% (TBA
study, 2002). Institutional deliveries have increased from 24% (KPC 1999) to 31% (TBA
study, 2002). Combined data from both municipalities indicate overall deliveries by a
trained attendant (trained TBA and health facility) to be 64% project-wide from baseline
figures of 52% in Saidpur and 35% in Parbatipur. Data from the TBA report also suggest
that trained TBAs encourage mothers to adopt family planning measures at almost three
times the rate of untrained TBAs (36.4% vs. 13.8%). A summary report of the study as
Attachment F is included.
Challenges and Constraints
Access and Quality of Emergency Obstetric Care Referral Services
At the beginning of the program, suitable emergency obstetric services were limited,
especially in Saidpur. Care at the 50-bed referral hospital was perceived to be unreliable
and often of poor quality. While not specifically attributable to the CSP, the situation has
improved somewhat in Saidpur since the DIP. The 50-bed hospital now has capabilities
for cesarean section and blood transfusion.
A full range of EmOC services is available at the LAMB Hospital, located just outside of
Parbatipur. Access to care for the poorest families is a high CSP stakeholder priority.
Services are available for women who cannot pay for them at the Lamb Hospital, but the
hospital uses it's own criteria to make financial eligibility determinations. Due to previous
experiences with clients misrepresenting financial need, Lamb Hospital has not been
willing to accept recommendations for free care from anyone outside of the hospital,
including municipal officials. The hospital is experiencing significant decreases in
external financial support and each free case is in reality an "out of pocket" expense.
Hospital officials expressed willingness, however, to discuss ways of increasing access to
care for poor families with the CSP and municipal authorities, while at the same time
explaining their need to protect the financial viability of the hospital.
TBA Training
TBA training is based on the MOHFW curriculum developed in the early 1990's. Further
government investment in TBA curriculum development stopped when the GOB moved
away from a TBA strategy for maternal care. CSP training managers have updated the
curriculum in the CSP, but how updates will continue after the CSP ends is not yet
defined.
During focus group discussions during the MTE fieldwork, TBAs described a need for
someone to answer questions about problems they experience during and after assisting
deliveries. One example cited was handling a newborn with breathing difficulties. Health
14
professionals with extensive delivery experience best provide the technical training in
safe delivery and newborn care to answer questions like this. Training to strengthen
program continuity, data collection, motivation support, and many other program aspects,
is well implemented by the Field Trainers.
Assessing individual TBA technical performance needs strengthening, as most
supervision is currently done either by group meetings, FT observation visits, or by the
WHCs. Methods to identify weaknesses in individual TBA delivery performance using
the monitoring system should be included.
Because of the high levels of illiteracy among TBAs, and the volume of information that
must be retained by them to perform safe deliveries, care must be taken not to overload
them with too much additional information nor activities. Effectiveness of training
methods and materials in content retention require periodic evaluation as was done by
CSP during the TBA assessment in January 2002.
Quality of Care in Antenatal Clinics
The 1999-2000 Bangladesh Demographic and Health Survey (DHS) included a series of
questions on components of quality antenatal care. Respondents were asked if they had
received certain services during at least one of their antenatal visits. For 913 births in
urban areas nationally and 1,271 births in the Rajshahi Division, the following
percentages of women received specific standard antenatal care (ANC) services:
Table 2: Components of Antenatal Care in Bangladesh, 1999-2000
Informed
of signs of
complica￾tions
Woman
Weighed
Height
Measured
Eyes
tested
Blood
pressure
measured
Urine
sample
given
Blood
sample
given
Rec’d
iron
tablets
Urban 27.5 59.9 47.6 27.7 47.5 39.5 34.9 50.0
Rajshahi 15.2 38.1 32.8 21.7 29.3 17.9 15.8 41.4
National
Average
15.9 35.3 27.4 16.4 28.9 19.2 15.7 36.4
Source: DHS Bangladesh 1999-2000
Specific project area ANC services have not yet been assessed, but one assumes health
facilities assessments would yield comparable results. Verbal autopsies conducted in the
CSP BCC strategy audience analysis implied some of the maternal deaths studied might
have been related to eclampsia. Poor quality antenatal services, such as those measured in
the DHS, may not detect treatable maternal complications in the antenatal period. Until
the MTE, the project focused on increasing ANC coverage, but did not focus on the
services available at the clinics.
Changes in technical approaches from the DIP
15
No major changes in technical approaches have been made. Technical interventions have
been implemented consistent with year 1 and 2 in the LFA and the budget. The CSP
accelerated training for the WHCs to engage support from communities and the
municipal cabinets.
The extensive time and effort required for the CSP to establish the MHCs and increase
quality of EPI services meant that work on quality of health services with private
providers and MOHFW facilities has been minimal. The evaluation team agrees that this
investment was crucial to establishing support for the additional CS activities scheduled
for years 3 and 4. Although this was anticipated in the DIP, the time remaining in the
LOP may not be sufficient to see full implementation of the technical strategies. (Please
see discussion of a no cost extension request in the Financial Management section.) In
addition, Concern did not offer the IMCI case management training for the reasons given
in the IMCI technical intervention section.
B.1.c. Tools, approaches, operations research and special studies
Use of Research and Technical Assistance in Program Planning
The Concern Bangladesh Country Director cited that emphasis on using research for
program development is a major CSP contribution to Concern's programming. Concern
Bangladesh has conducted more qualitative and quantitative research than is usually seen
in new child survival programs. These studies can provide the basis for additional
program elements. There are three full time positions dedicated to research, though the
two field research assistants have been performing substantial administrative support to
the project.
The project has benefited from outside technical assistance. Fortunately, there are
numerous indigenous technical assistance organizations in Bangladesh. Talented public
health professionals are also available, as independent consultants, or from NGOs, PVOs,
private research institutions and government organizations. Concern has successfully
accessed these resources, decreasing the necessity for expatriate technical assistance and
minimizing technical assistance costs.
Concern staff are committed to evidence-based programming. This is demonstrated by
employing a variety of participatory learning for action (PLA), focus group discussions
(FGD), and interview techniques to learn about the local situation to support program
planning. CSP stakeholders are enthusiastic about "lessons learned" from similar projects
and have participated in cross-visits to other municipal and child survival health
programs.
Concern conducted Institutional Strengths Assessments (ISAs) at the international,
national and field levels with subsequent follow-up discussions and action plans. Concern
Bangladesh's Organizational Development Unit (ODU) used Appreciative Inquiry to
conduct two "Health Institution Capacity Assessment Process” (HICAP) studies to assist
16
municipalities to document progress towards goals. A report of FGDs in preparation for
IMCI implementation was completed in January 2002.
In April 2001, the Concern Bangladesh Health & Nutrition Manager presented on
experience using Appreciative Inquiry approach to Institutional Assessment (HICAP) at
the Annual CORE meeting and in May 2002 presented at the Global Health Council at a
Community Participation roundtable.
Early in 2002, Concern Bangladesh completed "An Assessment of the Effectiveness of
TBA training on TBA practices for Safe Maternal and Newborn Care." This paper was
accepted by the Child Survival Technical Support program and presented to CORE PVO
members and other Child Survival professionals at the "Data for Action" workshop in
September 2002.
To develop the BCC Strategy, a local consultant guided the CSP team through an
Audience and Institutional Analysis, published in June 2002. This analysis included in￾depth interviews, focus group discussions, observations and verbal autopsies of maternal
and child deaths. The BCC strategy is important for many reasons. The most significant
is highlighting the importance of focused attention to changing the behavior of the
decision-makers within the household. Most often, these decision-makers are husbands
and grandmothers. Male household members, in turn, are heavily influenced by the
teachings they receive from the Imams. The BCC studies and strategy will help the CSP
target program activities to these groups, in addition to activities targeting mothers.
DIP reviewers emphasized the need for the CSP to work with private providers. The BCC
strategy highlighted this as well. This recommendation has been acknowledged
throughout the project, and the CSP has organized FGDs and orientation meetings for
these groups. PVO child survival experience in this area is limited, but working with
private providers has been receiving much more attention in recent years. The experience
gained through CSP efforts in this area will be valuable for other PVOs working with
projects in similar settings.
Challenges and Constraints
The high proportion of staff and stakeholder time devoted to research was raised as an
issue during the BCC strategy development. Research activities may not leave sufficient
time for effective implementation. The amount of information already collected is
probably sufficient to implement much of the rest of the program. With the exception of
Health Facilities Assessments, Quality of Care baseline information, and private provider
training needs assessments, limiting additional research to improving the monitoring and
evaluation system, including the HMIS, will allow more time for program
implementation.
17
B.2. Crosscutting Approaches
B.2.a. Community Mobilization
Community Health Promotion (CHP)
Municipal Health Committees (MHCs) have been formed in both of the municipalities
consisting of a Chairman, Ward Commissioners, Municipal Medical Officer (Saidpur
only) and representatives from government, NGO and private health facilities. These
committees have regularly scheduled meetings. The CSP has assisted these committees to
develop annual workplans and budgets. The municipal governments acknowledge this as
a major accomplishment of the CSP. With the assistance of the Concern Organizational
Development Unit, the project has used the HICAP Appreciative Inquiry tool (described
elsewhere), to motivate the municipalities and provide a self-assessment of progress.
MHCs and WHCs (15 in Saidpur, 9 in Parbatipur) were formed with broad representation
from several sectors in the communities. Coalescing primarily around increasing EPI and
Vitamin A coverage, ANC attendance, clean delivery and referrals for EmOC, the
Concern CSP partnership has achieved remarkable success in galvanizing every sector of
the municipalities for action in improving the health status of the population. (See
Strengthening Local Partner Capacity in the Capacity Building section B.2.c.)
By the time of the MTE, all WHCs were in place and functioning (exceeding the end of
project target of 80%). Ward Health Committees select TBAs and CHVs for training
and provide support and supervision for them while they are performing their duties.
Ward Health Committees monitor CSP activities and provide feedback to all
stakeholders. In addition, municipalities organize a number of yearly community
awareness-raising activities, such as AIDS day, Safe Motherhood Day, Breastfeeding
Week, "ideal mother" and "ideal father" competitions to recognize positive health
behaviors, and support of the SNIDs. Communities have responded enthusiastically with
heavy attendance at events. Strong and enthusiastic CHV response to provide service to
their communities has been impressive. CHVs have been observed in their communities
or helping at events far in access of their volunteer commitment. (Additional information
on the roles of CHVs, TBAs, and WHCs can be found in B.2.b Communication for
Behavior Change,. B.2.c. Capacity Building and the Maternal and Newborn Care
technical section.)
Media and Social Marketing
Television is widely available in the project area, but not a significant source of health
information for the project target groups. Community radio is not yet common in
Bangladesh. The CSP uses folk singers, street drama groups, and community art (such as
wall murals and rickshaw painting) for community health education
18
Challenges and Constraints
Male Involvement
Men are major decision-makers in household care seeking behavior, yet they have not
been targeted to a significant degree by the CSP. The BCC strategy paper also recognized
their importance as one of the target populations. Men often complain that they do not
know how to recognize life-threatening household situations and are unfamiliar with the
benefits of health prevention behaviors. The project area is primarily Muslim, and Imams
have major influence on men's perceptions and behavior. The project has provided
orientation to Imams, and wants to engage them more substantially in CSP activities. (See
Behavior Change Communication for additional information on this topic.)
Community Health Volunteers
Because the CHVs are primarily students, or older adolescents, there is concern that their
involvement with the program will change, as they grow older and assume adult
responsibilities. Some volunteers, primarily girls, report their families are not supportive
of their involvement because their parents do not know what they are doing. The MTE
team made several recommendations about broadening the population sector eligible to
be CHVs, how the municipalities can recognize volunteers and how the WHCs can
educate their parents about their contribution to the communities.
Political and Security Factors in Community Mobilization
Security is not a general consideration for working in communities in the project area. On
the other hand, political general strikes, or "hartals," disrupt program plans to some extent
on a regular basis. In general, however, program activities continue during such
disruptions, but they may be delayed or scaled back. In general, CSP participants show
remarkable resilience in adverse conditions, another indicator of widespread support for
the program. There is always a risk that politics could influence community health
promotion activities. If political offices change hands, community support could be
affected.
B.2.b. Communication for Behavior Change
Up to the CSP midterm, the focus for BCC efforts has been the municipal health system,
including municipal health committees, WHCs, TBAs and CHVs and “awareness
raising” training for communities. All levels of the MHS have been trained to deliver
messages regarding EPI, Vitamin A, and danger signs of diarrhea, ARI and obstetrical
emergencies. TBAs deliver behavior change and health awareness messages at
postpartum checks and appear to be effective in motivating mothers to attend ANC
sessions, take their children to EPI and go to health facilities in emergencies. CHVs
support EPI drop-out tracking and deliver messages to the community on care seeking for
danger signs of ARI and diarrhea, or malnutrition.
Focus group discussions with mothers of children under one year of age indicate a direct
relationship between instructions from the CSP-trained TBAs and their decision to seek
19
care at a health facility for obstetric complications. Measurement of the percentage of
home deliveries versus health facility deliveries undertaken in the TBA study indicates a
decrease in home births and subsequent increase in health facility births. This is one
internationally recognized positive maternal and newborn care behavioral indicator. (See
Maternal and Newborn Care in the technical section) Mothers also stated that
motivational messages from CHVs have influenced their decisions to take sick children
to health facilities for treatment.
The BCC approach has evolved since the time of the Entry Grant from giving basic
information and messages to WHCs, TBAs, CHVs and MHS to developing a
comprehensive BCC strategy. The breadth and detail of the strategy especially the
audience analysis and consensus building was impressive.
The implementation of the specific BCC strategy will start in year 3. The project's
monitoring and evaluation system, including planned improvements, will be used to
monitor effectiveness after sufficient time has elapsed for the strategy to influence
behavior.
Most of the BCC plans will be incorporated into the overall Action Plan for the second
half of the project. Measurement of the BCC strategy effectiveness will be done using
qualitative (FGD and key informant interview) and quantitative (LQAS and/or KPC,
health facility statistics, MHS data) methods.
Challenges and Constraints
The challenge for the CSP will be to implement the strategy with sufficient time
remaining in the project to demonstrate its impact.
(Specific issues relative to CS intervention behavior change are discussed in the technical
sections. See also discussion of no-cost extension application discussed in the Financial
Management section.)
B.2.c. Capacity Building Approach
Concern's definition of Capacity Building, as stated in the policy paper, is as follows:
" . . . An approach to programming which emphasizes enabling and strengthening
individuals, groups, organizations, networks and institutions to increase their ability to
cope with crises and to contribute long-term to the elimination of poverty."
Concern's work is guided by two key documents, an organizational policy statement and
a current Concern Worldwide Strategic Plan. These two documents, as well as country￾specific strategic plans guide overseas programs. Other policy papers, including the
capacity building policy approved in April 2001, serve as the framework for Concern's
overseas activities and serve to align them with current best practices in each policy area.
The capacity building policy addresses strengthening local development partners,
20
including CBOs, local NGOS and state organizations that have common development
interests.
(i) Strengthening the PVO Organization
The capacity building indicators listed in the beginning of the DIP were limited to the
functioning of the two partner municipalities. Specific indicators for Concern Worldwide
and Concern Bangladesh were not articulated. Concern Worldwide, Concern Bangladesh,
and the CSP Field Offices in Saidpur and Parbatipur, however, have participated in the
Institutional Strengths Assessment (ISA), followed by office-wide discussions and action
plans. Concern Worldwide completed a follow-up questionnaire from CSTS. Another
ISA is planned for mid-2003 at which time the results will be compared with the original
studies.
Capacity Building in Concern Bangladesh
Concern Bangladesh has an entire department, the Organizational Development Unit
(ODU) and has full time staff devoted to staff capacity building. Concern Worldwide's
commitment to staff capacity building is reflected in the organizational structure of the
Concern Bangladesh country office. The lessons learned from the CSP are more likely to
be disseminated throughout the entire Concern Bangladesh development program. At the
same time, the CSP will benefit from capacity building from other programs, whether or
not they involve health. For example, the lessons learned about transparent financial
management gained from the Rural Development Program can be used to benefit the
sustainability of the WHCs’ emergency health funds in the CSP.
Training programs, such as IMCI management training and cross visits to other projects
in Bangladesh and Nepal (described elsewhere) contribute to Concern Bangladesh's
capacity to implement CSP programs. Increased health program capacity has enabled
Concern Bangladesh to obtain funding for similar programs in other parts of the country.
The ODU contributed to the HICAP, participatory program planning, organizing the
cross-visit to India and facilitating the MTE. These are only a few of the examples of the
valuable contributions this unit plays in the CSP.
Capacity Building in Concern Worldwide (U.S.)
Since joining the Child Survival Grants Program in 1998, Concern Worldwide staff
members have been active participants in the annual CORE Headquarters Workshop, as
well as the HIV/AIDS and Social/Behavior Change CORE Working Groups. CORE has
been a venue for frequent sharing of project innovations, such as the HICAP studies. The
CSP Coordinator from Concern Bangladesh traveled to Washington, D.C. in 2000 to
attend the DIP review workshop and CORE Headquarters Workshop. In September 2002,
he presented the TBA Training Assessment study at a CSTS sponsored workshop "Data
for Action in PVO programs". The Bangladesh CSP is featured in the CSTS CSP
Review (2001). Concern Worldwide also provided USAID/Washington documentation
for the annual USAID Child Survival Report to the United States Congress.
21
Concern Worldwide acknowledges that the extensive amount of effort and documentation
required to participate in the CSGP has helped the organization improve and develop
programs in high priority areas. Through this involvement, the PVO community is also
becoming more aware of the unique contribution that Concern has to offer Child Survival
with some of their innovative approaches to health programming.
(ii) Strengthening Local Partner Organizations.
CSP capacity building assistance to specific municipal structures are described in detail
below:
a) Municipal Authorities (Chairmen and Ward Commissioners)
At the time of the MTE, Chairmen and Ward Commissioners were very vocal in their
support of the capacity building assistance from the CSP. Several ward commissioners
were members of the MTE core team. The CSP has developed an effective partnership
ensuring municipal participation in the program. The support of the municipal authorities
and health staff were critical to the CSP success in working with the Municipal Health
Committees and Ward Health Committees. Providing orientation and training on new
roles and responsibilities in providing health services and support to develop better
planning, financial and administration systems, the CSP has encouraged the municipal
leaders to provide leadership in implementing MOHFW health policies. The CSP
advocates at the municipal and national level to fill vacant health positions, on issues
relevant to institutional health development, and for equitable health care for the very
poor.
b) Municipal Health Services (MHS)
The CSP has strengthened the MHS Departments on several levels from senior
management to addressing client needs. The CSP has updated municipal health staff on
GOB/MOHFW policies and strategies and provided technical support to improve MHS
health management capacity. Staff training and follow-up for HRD support in technical
and information management has improved planning and management of health services.
Health planning assistance has resulted in monthly review and planning meetings, and
support for emergency health preparedness and response. The CSP has collaborated with
the MHS in conducting research for better design, monitoring and evaluation of services.
Partners are now mobilized on multiple levels to advocate and support better quality of
care in health services MHS control. Since participating in Learning Exchange visits,
municipal health staff members state they have a better vision of improvements they can
make in their municipalities. With CSP support, the MHS assisted and supported the
development of Ward Health Committees, helping them to comply with the GoB circular.
Challenges and Constraints
22
Challenges to the program include lack of control over health supplies, such as sterilizers
and disposable needles, which are only available through MOHFW sources. Outstanding
requests for sufficient sterilizers have gone unanswered for several months. Unstable
funding sources, and the temporary nature of municipal staff appointments, make
planning difficult. In Parbatipur, some EPI staff are seconded from the Upazilla Health
Complex. There is concern that these employees may be recalled at some time in the
future. The MHS has no authority over public and private referral centers in their areas,
so they do not directly control the quality of the services delivered in those facilities.
As the CSP addresses quality of care and more technically challenging child survival
interventions, intensive support for MHS management will necessarily have to taper off.
Phase out of day-to-day support is part of the exit strategy. Additional management and
advocacy training for the WHCs will be needed to facilitate this process.
c) Municipal Health Committees (MHCs)
Through major training and advocacy activities, the CSP has made major contributions to
improving EPI services and providing community health promotion. Through baseline
and follow-up appreciative inquiry health systems assessments, (HICAP), joint meetings
and FGDs the CSP has enabled the municipalities to determine where they started and
measure their progress towards mutually agreed upon capacity goals. A quote from the
follow-up HICAP summarizes the major changes the CSP felt have taken place since the
baseline HICAP:
"For the CSP, capacity building is both a means and an end. Therefore during
this period of capacity development activities, (the) CSP tried to involve (the)
community as well as the . . . municipal representatives to conceptualize and
develop understanding about (the) entire project goal and its benefit . . . the
project also tried to empower people to realize their potential, involve them to
use their capabilities better and assured ownership and sustainability of the
process".
The municipalities are the actual implementers of all program activities. Concern plays
the role of advocate, trainer, and facilitator but in a seamless way. Integration is so
complete that when one speaks of the CSP, it stands for Concern staff and stakeholders
together. There has been a reduction in misunderstandings between the partners, positive
changes in health behaviors and community confidence in MHS staff has increased
through this collaboration. There is also a greater community commitment to cleanliness
and environmental sanitation.
As the CSP addresses quality of care and more technically challenging child survival
interventions, the intensive support for MHS management will necessarily have to taper
off. Phase out of day-to-day support is part of the exit strategy.
d) Ward Health Committees (WHCs)
23
Intensive on-site facilitation by Concern CSP Field Trainers has helped the municipalities
form WHCs in every ward. Because of a phased-in approach, some WHCs have existed
for around 2 years, while others are newly formed. While they are a political entity,
multiple sectors of the community are represented, from businessmen and schoolteachers,
to CHVs and TBAs. Field Trainers, most of whom have social science and primary health
care backgrounds, train TBAs and CHVs in health promotion. Social mobilization and
support is fostered with urban health rallies and public health campaigns. The HMIS
measures WHC, TBA and CHV meeting attendance and adherence to workplans.
Measuring Capacity Building Progress
Indicators selected in the DIP apply the HICAP Appreciative Inquiry technique for the
Municipal Health Department to assess their own progress. (Qualitative indicators can be
validated to measure “process change” based on a tree assessment scale developed by
CRWRC.) The HICAP is a powerful tool for motivating participation in the process of
organizational change. This approach was adopted after discussions with the CSTS
Director in 2000 and is scheduled for review during his visit in February 2003.
Two municipal capacity indicators, "2 Municipal Health Committees and 80% of Ward
Health Committees are functional" and "At least 6 Municipal Health/ Inter-Agency
Coordination Meetings are held annually" have already been fulfilled.
Challenges and Constraints
Ward Health Committees are political entities and are subject to influences from outside
of the committee members and the communities they serve. Sustainability of WHCs
could be enhanced if one WHC was able to help another. Some reservation has been
expressed by Concern Bangladesh about the political complications that might arise from
this seemingly benign gesture. Those who live in the area and the WHCs themselves can
best answer if the above concerns are justified.
Further indication of progress towards the program outputs and objective measures to
determine if "interventions are institutionalized" or municipality staff and supervisors
"are competent and independent" (outputs 4 and 5) remain to be refined.
(iii) Health Facilities Strengthening
The DIP acknowledged the crucial role health facilities must play in providing curative
care to achieve mortality reduction. The need to focus on establishing municipal health
capacity precluded extensive involvement with facilities in the first half of the project.
Current involvement with health facilities primarily involves data collection for Monthly
Activity Reports as well as a health facilities data collection tool. Information collected
includes areas of maternal/newborn care and certain child illnesses, in addition to EPI and
Vitamin A data. These data have been a helpful complement to other aspects of the
government HMIS, but in some cases, only report on numbers of cases, or numbers of
24
training inputs. Without information on target populations, measurement of coverage
increases attributable to the CSP is difficult.
Linkages between the health facilities and community health workers, especially the
TBAs, have strengthened facility participation in TBA skill updates. Interviews with
mothers reveal that care seeking at health facilities has increased for both mothers and
children because of CSP activities.
Challenges and Constraints
Government health facilities face continuous resource constraints. With a national health
budget of approximately $4 per person per year, government facilities lack sufficient
drugs and treatment to treat a largely poor population. Other quality issues include poor
logistics, unreliable availability of staff and poor health worker morale. Inadequate
interpersonal communication skills adversely affect provider-client relationships. When
services are considered poor, community members often by-pass the closest facilities and
travel long distances to NGO facilities. Providing access to health care for the poorest
sectors of the community continues to be a problem for municipalities. The second half of
the CSP will focus on joint problem solving to increase access to quality health services
for the poorest community members.
The BCC strategy development process included SWOT (Strengths, Weaknesses,
Opportunities and Threat) analysis of the CSP. The report stressed that while there was
partnership with municipalities, which do not have their own services facilities, there was
"no or inadequate strategic partnership with available service institutions" and "(a) weak
monitoring and evaluation system, especially to monitor the institutional
strengthening/system development efforts" (p. 17). The evaluators interpreted the latter
comment to mean formal health facilities, since the aforementioned HICAP is monitoring
processes in the development of the Municipal Health Systems. Without the ability to
influence quality of care at referral health facilities, the impact of the CSP on mortality is
very limited. Backup referral sources for curative services are an essential component of
C-IMCI and maternal and newborn care.
(iv) Strengthening Health Worker Performance
As mentioned in the technical intervention section, strong training and support from the
Field Trainers to municipal health workers has significantly strengthened EPI and
Vitamin A service delivery. Ward Health Committees monitor MHS health worker
performance and provide feedback to the supervisors. WHCs supervise TBAs and CHVs
with support from CSP Field Trainers and the MHS.
The CSP expanded the role of the CHV beyond the twice a year SNIDS and Vitamin A
campaigns. CSP experience has shown that the CHVs embrace the expanded
responsibilities, are eager to learn and serve the community. CHV's are nominated by the
Ward Health Committees and trained by the CSP. Assisted by the MHS, Ward Health
Committees supervise the CHVs and reinforce their work with community members.
25
(See the Maternal and Newborn Care technical section for information about TBA
training and support. .Strengthening Municipal Health Service workers is addressed in
several other parts of this report, including the EPI and Vitamin A technical section.
Training in planning, service delivery, supervision, record keeping and data analysis have
resulted in significant improvement in the quality of services.)
Challenges and Constraints
Until now, the CSP has not been significantly involved in health facility worker training
Poor quality care at local facilities has been identified as a major impediment to mortality
reduction. If CSP advocacy efforts result in the health facilities consenting to conduct
quality of care self-assessments, the CSP may become actively engaged in improving
health facility worker performance. Improving provider interpersonal communication
skills is another way the CSP can improve quality of care, without requiring significant
additional outside resources.
There are several types of private providers in the project area. Some treat sick children
more than others do. Homeopaths, for example, are the provider of choice for small
infants. Rural Medical Providers, drug sellers and homeopaths all have different
backgrounds and means of getting information about illnesses and treatments.
Addressing the quality of care given by private providers was identified early in the
project as an essential component of addressing sick child case management. The CSP
has conducted research and held meetings with private providers. One training strategy
alone will not be sufficient for all categories of private providers. This will make
addressing this programmatic need a major challenge for the CSP. A much stronger
emphasis on private provider participation and training is included in the Action Plan for
the second half of the project.
Six female Field Trainers do monthly TBA refresher training, but only one of them has
delivery experience. While the training provided to the TBAs keeps the program
functioning well and assists in monitoring and support, needs for significant technical
advice on delivery are unlikely to be met this way (see the Maternal and Newborn Care
technical section.). Part of the exit strategy will require that duties currently performed by
Field Trainers will need to be turned over to the MHS.
The CSP will need a means to monitor individual TBA performance and determine if the
CSP program strategy in maternal care is working. Improving performance monitoring
will alert the CSP if TBA performance begins to deteriorate for any reason and allow for
corrective measures. CSP monitoring system refinement could determine whether or not
women are able to reach facilities in sufficient time to address complications
successfully, since TBAs are not trained in obstetric first aid.
(v) Training
26
The CSP Coordinator and the Senior Training Officer (STO) jointly develop training
curricula and methods. Field Trainers collaborate with the CSP Coordinator and STO to
facilitate most trainings, with expert consultant trainers used when necessary. TBAs and
CHVs train community members. Training effectiveness is assessed by self-reported
behavior change in focus group discussions and interviews. In addition, pre and post
testing is used to evaluate trainings (for example EPI, TBAs, CHVs). Field Trainers
provide on the job training and support, providing opportunities for some direct skills
observation.
The STO appears to have a solid background in training methodology, material
development and adaptation of materials. He has responsibility for all capacity building
of the CSP team and partners, which is a very large and diverse group with widely
varying training needs.
Challenges and Constraints
Staffing has not been sufficient, given the CSP's heavy multidisciplinary and multilevel
training strategy. This has resulted in planned training courses postponed or canceled due
to lack of trainers. Concern has decided to hire a Training Assistant to address this issue.
Teaching aids are not adequate for the amount and sophistication of CSP technical
training, especially as the CSP moves into higher level technical training in IMCI and
Maternal Newborn Care, and may engage in health facility worker training. There are
sufficient funds in the budget to address these needs.
The CSP is not devoting sufficient attention to training follow-up activities in every
intervention to determine the effectiveness and sustainability of the training approaches.
This is largely due to the staffing constraints mentioned earlier and has implications for
training plans for the second half of the project. Training needs assessments require
strengthening to appropriately organize training activities and allocate the necessary
resources. Clear behavioral training objectives and measurement methods will aid in
evaluation of training activities after they are implemented.
(vi) Quality of Care (QOC)
The first years the CSP devoted significant attention to improving the quality of MHS
technical services. Quality case management at facilities and by private providers has
been a major issue in CSP discussions, but the project has not had much opportunity to
directly impact curative care services. Health providers attend CSP meetings, but
substantive joint programming has not taken place.
To have significant impact in the Maternal and Newborn Care and IMCI interventions,
the CSP will have to address the quality of referral services. The KPC results showed that
up to 70% of the population first seek care from private providers. Therefore, the CSP
must engage these providers in quality improvement efforts.
27
Significant formative research has been done with all major health providers, including
private practitioners. The CSP can use this information to assist municipalities to
coordinate health providers and try to persuade them to participate in quality
improvement. Effective advocacy and consensus-building skills are essential. Concern
has the experience to provide training in both.
Challenges and Constraints
Some factors affecting quality of care in health facilities are not under the control of the
facilities, especially drugs and supplies, but the municipalities can advocate through
multiple channels for improvements. Concern can assist health facilities wishing to
improve QOC by providing technical assistance with health facility self-assessment and
training plan development.. Some QOC issues involve the need to improve counseling
and management skills. Concern can also assist in these areas.
With some exceptions, PVO Child Survival programs are only recently recognizing the
importance of working with private providers. Effective behavior change strategies have
been implemented only on a limited scale. Donors, however, are beginning to show
increasing interest in this area because of the essential role private providers play in
household case management. The CSP will have to make deliberate efforts to keep
abreast of developments in this area. If the CSP is successful in developing effective new
approaches, sharing the lessons learned will benefit the PVO Child Survival community
overall.
B.2.d. Sustainability Strategy
Concern Worldwide retains a broad-based definition of sustainability as the capacity of a
health system to function effectively over time with minimum external inputs.
The CSP's institutional partner is the Municipal Authority/Paurashava with a tripartite
partnership of communities, WHCs and the MHS. The goal of the partnership is to
increase health capacity and improve sustainable health status through building the
capacity of the municipalities.
The MTE team assessed perceptions of program sustainability at every level. Members of
municipal cabinets, Municipal Health Committees and Ward Health Committees, all felt
the Municipal Health Structure would continue after CSP support ends. While an exit
strategy has been discussed since the onset of the program, the MTE evaluation fieldwork
devoted substantive attention to this topic. According to the DIP, there are plans to share
experiences with other PVOs involved in urban health programs in Bangladesh, including
lessons learned during project phase out.
Some more established WHCs acknowledged be ready to operate more independently
from intensive CSP involvement, but would only be sustainable if they learned some of
the Field Trainer's skills. These skills include facilitation and motivational techniques,
leadership skills and transparent financial management.
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WHC fundraising at the local level to support priority activities bodes well for
continuation after the CSP. Some WHCs have secured significant additional financial
support from local private donors. In-kind contributions of access to vehicles, or meeting
space, also demonstrate the community's willingness and ability to support CSP
activities. If the older WHCs mentor the newer, weaker WHC's the number of sustainable
WHC's might be increased. However, as mentioned earlier, this approach may have
negative political implications that need to be explored locally.
During FGDs conducted by the MTE team, TBAs expressed confidence in their
sustainability. Their remuneration comes from their clients and they all intend to remain
in their communities. They stressed, however, that they need technical refresher training
periodically to maintain the quality of their care. Clients are the primary providers of the
clean birth materials, so neither the CSP, nor the municipalities provide basic supplies.
(See the Maternal and Newborn Care technical intervention section.)
The project plans to devote more time to exit strategy planning in the third year of the
project. In addition, a successful BCC strategy in support of community and household
healthy behaviors does not require outside support after the end of the project.
Challenges and Constraints
Sustainability of MHS staffing levels in both municipalities is tenuous due to unstable
funding levels. If staff positions were converted from temporary to permanent, many
MTE participants felt sustainability of municipal health staff would be more likely.
Revenue collection and budget allocations are out of the control of the CSP, aside from
the advocacy role it already plays. Municipalities are highly politicized. If the current
elected officials are replaced with members who have other priorities, the advocacy and
support elements that have made the CSP successful could be threatened. Efforts to
institutionalize health into the municipal agenda can help to mitigate the threat.
The CSP is very heavily training oriented. Each technical area requires periodic refresher
training. Finding local sources for refresher training support is a major sustainability
need.
The fact that CHVs are drawn from one demographic cohort raises concern about the
length of time that individual CHVs will remain volunteers as they grow older and
assume adult responsibilities. As municipalities assume responsibility for the recruitment
and training of CHV's, there will be a need to develop plans for periodic recruitment and
training of new volunteers.
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C. PROGRAM MANAGEMENT
C.1. Planning
Concern makes extensive use of participatory planning with stakeholders. Program
planning includes all program partners, especially members of the municipal and ward
health committees. Concern's national office collaborates extensively with national
MOHFW offices, NGOs, PVOs, and other international organizations. Multiple
departments including ODU, HR, and Financial Management are also included in project
planning.
The DIP workplan is on schedule. Detailed planning for the third and fourth years was
completed following the outcome of the MTE (See the Action Plan.) Budget allocations
by category were made, with allowance for detailed planning later in the project. Program
management was justifiably reluctant to initiate IMCI case management training until the
national IMCI program was in place
The evaluation consultants were very impressed with the strong professional skills that
Concern's staff have in carrying out participatory and consensus building activities. CSP
stakeholders also demonstrated considerable skills in participatory methods of
information gathering and consensus building in planning and problem solving, proof of
the positive effect of the program.
Challenges and Constraints
The CSP role in implementing the IMCI component still needs significant clarification.
(The Action Plan is included at the end of this report.) Since the national IMCI program
will not likely be in place soon, the CSP will need to plan IMCI implementation
accordingly.
C.2. Staff Training
The project has invested significant effort in training stakeholders and community level
workers, but has devoted less effort to updating Concern staff training in the CSP
interventions. Strengthening the EPI system and initiating programs for CHV training
appear to have been within the realm of preparation and experience existing in Concern
Bangladesh staff from the beginning of the project. Field trainers, many of whom have
had years of experience as vaccinators, are well-qualified to provide EPI refresher
training to municipal health staff. Participatory program planning and use of adult
learning techniques are strong in the existing Concern Bangladesh staff. The Concern
ODU Training Officer also professionally implements contemporary consensus building
methods and both national and field staff members appear to be comfortable using them.
30
Challenges and Constraints
There is a need, however, for increased emphasis on assessing staff capacity and training
needs to manage and implement several new and technically challenging activities.
Principles of epidemiology, quality health programming, client-provider relationships,
Quality of Care issues, and multidisciplinary approaches to public health programs
require different skills and preparation than the majority of the field staff have at this
time.
The CSP Coordinator and Team Managers could benefit from visiting other CSPs where
many of the issues the CSP staff face have been addressed. There are currently no other
active USAID/Washington-funded CSPs in Bangladesh. There are, however, current
programs in Nepal, India and Cambodia. PLAN/Nepal, for example, recently received a
cost extension (formerly known in the CSGP as a "follow-on" or "extension" CSP grant.)
That project has used Lot Quality Assurance Sampling (LQAS) methods effectively for
monitoring and evaluation for several years and may serve as a learning laboratory for
LQAS experience. In addition, several other organizations working in Bangladesh have
implemented CSPs in Bangladesh in the past. These groups include CARE, World
Vision, Save the Children (US) and World Relief. World Relief implemented the Hearth
model community program for addressing malnutrition. This relatively new approach to
sustainable community nutrition programs was described with other similar programs in a
BASICS publication. Many PVOs have since adapted the Hearth Model to their CSP
nutrition programs.
Concern Bangladesh health managers visited the JSI C-IMCI project in Nepal and have
training in some aspects of IMCI implementation. Community IMCI training has not yet
been offered in the Asia region. Discussions are underway within CORE for a PVO
regional Community IMCI workshop to be held early in 2003. As mentioned earlier, the
DIP planned for IMCI implementation in years 3 & 4. There have been many
developments in PVO C-IMCI implementation strategies since the DIP was written two
years ago. New strategies are presented annually. The CSP staff will be challenged to
remain current with these developments since they occur so rapidly.
C.3. Supervision of Program Staff
The organogram in the DIP seems to imply that the Regional Manager, not the CSP
Coordinator, has direct supervisory responsibility over the field staff. However, in
practice, the CSP Coordinator has direct influence over the CSP activities of the STO and
the CSP Team Leaders. The CSP management staff controls the technical implementation
activities; the Regional Program Manager provides administrative supervision. There are
specified job descriptions and regular performance reviews. Team Managers for each
Municipality are responsible for supervision of Field Trainers and Research Assistants in
their respective areas. The Regional Program Manager, in consultation with the CSP
Coordinator, conducts performance reviews. Management style is largely supportive and
teamwork is highly valued.
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C.4. Human Resources and Staff Management
Concern Bangladesh has taken positive steps to retain qualified and experienced Child
Survival staff though promotions to positions with greater geographic and programmatic
responsibility. This can serve to counter some of the career issues raised below that can
make professional health staff retention difficult. Concern also facilitates staff transition
into other programs after a particular project (such as the CSP) ends, one reason many
staff have been with Concern for many years. Concern also makes strong and deliberate
efforts to promote gender equity in hiring.
There is a plan for flow of technical information from the Concern Worldwide (US)
headquarters to the field level. The Program Manager and the CSP Coordinator will copy
all correspondence from Concern Worldwide US to the Country Director, Assistant
Country Director and the Regional Manager, even if it is of a technical nature and
requiring action. Thus, the information goes directly to the field technical staff, but
Concern Bangladesh senior management is kept "in the loop." In this way, technical
updates can benefit the CSP, as well as the rest of Concern Bangladesh.
Challenges and Constraints
Concern has had to address similar issues in organizational structure and personnel
policies as other PVOs working in Child Survival Programs. Problems arise when
programming focus changes from a collection of small operational projects to more
sophisticated capacity building or mentoring projects. The organization's comparative
advantage lies not in direct service delivery, but in the ability to bring a collection of
partners to a more complex level of functioning. These changes frequently require staff
with different skills such as proposal writing, satisfying donor's (increasingly complex)
reporting requirements, facilitating stakeholder decision making and empowering other
organizations to implement effective development programs. .Programs must hire and
retain health professionals with significantly higher educational preparation and
experience than operational projects generally require. These professionals can ask for,
and expect to receive, greater responsibilities and consequent compensation. Finding
qualified candidates willing to accept posts in remote, or rural areas can also be difficult.
These jobs often require long hours and working through days off and holidays. They can
also require extended periods away from families and the professional contacts in the
city. Where significant salary increases would cause internal organizational discord, some
organizations have been successful by providing a more generous compensation package.
Other organizations have found physicians will see such positions as professional "dead
ends" no matter what is provided, while other health professionals such as master's
prepared nurses, nutritionists, health planners, or health educators may not.
The organograms in the DIP do not reflect the joint management that is the reality in the
project. New project documents should address the actual management structure of the
program in the organograms.
32
Field Trainer (FT) responsibilities are unevenly distributed between the two project sites.
FTs in Saidpur have responsibility for significantly more population per field trainer than
in Parbatipur. They are assigned to cover three wards each, regardless of the number of
households in each ward.
C.5. Financial Management
Financial reports are forwarded to Concern Worldwide for submission to USAID
Washington quarterly. Because of slow start-up during the formation of the Municipal
Health Committees, several training activities and learning visits have been postponed
until after the MTE. In addition, unfilled budgeted positions have caused the project to be
under-spent at the mid-point. This is a common situation, especially in a new CSP.
The MTE process gave the project the opportunity to assess activities and staffing.
Positions allocated in the DIP that are still needed can be filled early in the second half of
the project. The MTE follow-up Action Plan accelerates spending in years 3 and 4, but
probably not to the extent where a no-cost extension request will not be necessary. An
additional year would provide greater opportunity to observe the effects of the BCC
strategy, lead to greater sustainability of the IMCI and Maternal and Newborn Care
components, and allow time for quality of care efforts to take effect. Concern will
probably request to extend the project implementation period until September 30, 2005.
Findings from the MTE support this request.
C.6. Logistics
Project reports and the Institutional Strengthening Assessment (ISA) reports indicate
some delays in equipment and supplies have been a problem during the project
implementation. Ground travel and telecommunications to Saidpur and Parbatipur
hamper timely communication and transport to a greater extent than in some other Child
Survival Projects assessed by this Evaluator. The latest ISA action plan dated February
2002 spelled out specific plans to address these concerns.
Concern Bangladesh staff in Dhaka addressed comments about computers in the reports
and clarified that the CSP wanted to be sure sufficient capacity was present in the
municipalities before providing the computers. There are plans to provide the hardware in
the near future.
C.7. Information Management
Objectives, indicators, logframes, HMIS monitoring reports, research and evaluation
reports are shared among all stakeholders. Until now, the color graphic depiction of CSP
monitoring data has been generated in the Dhaka office. The municipal health staff and
33
health facilities provide the data from which the reports are generated. Copies of the
printed reports are distributed back to the municipal health offices and to municipal
health committees where they are displayed.
Research Assistants at the field level and Dhaka collect data on program outputs and
compare them with project workplans and indicators to measure progress towards goals.
Combining existing MHS data, primarily regarding EPI and Vitamin A coverage, with
CSP process indicator tracking, Concern generates the reports.
Research Assistants compile monthly Activity Reports. TBA training inputs provide the
primary tracking for the Maternal and Newborn Care intervention in these reports.
Additional data collection focuses on EPI and Vitamin A, areas where the municipalities
have primary responsibility. While the Logframe Analysis contained knowledge
indicators in three IMCI areas, impact indicators were not articulated at that time. The
project does not currently track data related to IMCI component, except cases of certain
diseases, such as diarrhea or ARI.
Data are also routinely collected from the Municipal Health Services and health facilities
in the area. Process indicators, such as number of meetings held and training inputs, is
included in these reports in addition to limited coverage data.
TBAs and CHVs collect demographic data on every family in their catchment area,
specifying 0-12 month olds, 1-5 year olds, and women of childbearing age. There is a
column for comments, but it does not appear to indicate births and deaths. A third form is
completed by the municipality and covers health statistics collected by the municipality
and other providers. In addition to EPI and TT data, Vitamin A, health center deliveries,
trained TBA deliveries, ante and post natal care, family planning, ARI, diarrhea and
malnutrition data are collected. There is apparently no place on the form, however, to
track maternal complications.
Challenges and Constraints
The BCC report states: "there is no continuous system to review maternal and child
deaths, including near miss, and thus no functional mechanism to use this information for
awareness building, mobilization of local people including local level advocacy," Some
major project activities have only knowledge indicators, but no behavioral indicators
related to them in the monitoring and evaluation system. The project cannot track
progress towards impact in these areas. The project tracks training inputs in all areas, but
they are not considered reliable measurements of impact on target behaviors.
The CSP system of data collection, analysis and use needs strengthening. During the
second half of the project, the monitoring and evaluation system, including the Health
Information System will need revision to demonstrate the contribution the project is
having on maternal and child survival. Data should be collected, and analyzed, as close to
where it will be used as possible. For sustainable use of data for decision-making, CSP
34
partners should be involved in this process to the greatest extent possible and generate
their own reports as part of the exit strategy.
C.8. Technical and Administrative Support
The New York Headquarters benefited significantly from the strong technical assistance
and support offered by Breda Gahan and Robert (Rob) Williams during the Entry Grant
and in the first half of the current grant period. Nine CS technical support visits, each
lasting several weeks, were made to the CSP before the MTE. Ms. Gahan provided
frequent technical and managerial support to the Concern Bangladesh CSP as well as
serving as a liaison with the CORE group and serving on CORE technical working
groups. She provided extensive technical guidance to the project based on over 10 years
of health field experience in developing countries. In 2002, Concern Worldwide, Inc.
(US) hired an experienced PVO Child Survival Grants Technical Advisor, Michelle
Kouletio. She has extensive experience working in a large US based PVO as well as
managing a CSP in Africa. She has work experience as a contributing member of a
CORE working group. In July 2002, she participated in LQAS training from which both
the Bangladesh and Rwanda programs will benefit.
CSTS provided technical assistance to Concern Headquarters by conducting the
Institutional Strengths Assessment. Concern staff state the findings were very helpful and
led to discussions and a follow-up action plan. The headquarters backstop and program
manager traveled to Washington D.C. in 2000 to discuss the DIP with nine technical
reviewers and USAID. While Concern staff appreciated the intensive technical
suggestions, the scope and volume of the recommendations were too extensive to be
incorporated into the program in their entirety during the first half of the program. Some
recommendations have not been implemented yet, (i.e. training private providers), but
will be addressed in years 3 and 4.
As mentioned earlier, Concern is very adept at identifying qualified CS consultants
within Bangladesh and has used a variety of individual consultants and technical
assistance organizations for different program elements. Early in the project, there was
discussion of plans for a CSTS staff member to visit the project. This visit is scheduled
for 2003.
The CSP can benefit from external technical assistance in the following areas during the
remainder of the program:
• Quality of Care (QOC) training, including health care facility assessments, to
compare facility compliance with national, and international standards
(assuming facility agreement to participate.) Continuous Quality Improvement
(CQI) or other approaches can apply to all aspects of CSP implementation.
• Strengthening the CSP Monitoring and Evaluation system to:
35
Design and implement monitoring systems to track progress and demonstrate
effectiveness in all program intervention areas (these may include LQAS,
verbal autopsies, "doer/non-doer analysis" or others). This will require
strengthening the HMIS.
Possible orientation to Results Framework program planning and evaluation,
as appropriate. (Results Frameworks are rapidly replacing Logframe Analysis
in many donor programs, including USAID.)
• Consensus-building advocacy techniques to forge agreement amongst the key
players in health delivery about the major causes of infant, child and maternal
mortality in the project area and the determinants of key behavioral measures
necessary to address them. (Concern Bangladesh already has considerable
skill in advocacy, but there may be specialized assistance in how to approach
multiple government agencies or constituencies simultaneously.)
• Technical updates on all C-IMCI and Maternal/newborn care program
implementation issues.
• Refresher EPI supervisory training for CSP management staff. with a focus on
partner management capacity building. (Classes are available in Bangladesh)
This is particularly important since national polio eradication campaign days
(SNIDs) are scheduled to end and adjustments to the EPI program will be
necessary.
• Participation in CORE South Asia regional technical workshops in BCC and
C-IMCI workshops scheduled for 2003.
D. OTHER ISSUES IDENTIFIED BY THE TEAM
The Midterm Evaluation Core Team stated that they wanted the evaluators and USAID to
know that the intensive investment in building the municipal health system was necessary
to build support for all interventions. Implementation of any intervention was impossible
until the municipal authorities were "brought on board" with the program. Delayed
initiation of certain parts of the program (IMCI) were planned from the beginning, not
inadvertently left out or forgotten. The slow national IMCI implementation gave further
justification to wait until other services were established before undertaking IMCI.
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E. CONCLUSIONS AND RECOMMENDATIONS
Conclusions
Concern Worldwide's CSP is consistent with the organizational values and goals as
expressed in their recent 2002-2005 strategic plan.
The project has achieved, or made significant progress towards, meeting all five project
objectives listed below:
1. A developed Municipality Health Planning and Management System
2. Insitutionalized and well managed activities (EPI and Vitamin A)
3. A sustainable community health promotion (CHP) system
4. Competent and independent Municipality staff and supervisors
5. Improved Child Survival Program planning and management.
Because the project specified objective capacity indicators at the beginning of the
program, confirmation of progress is easier for outputs 1-3, than for outputs 4 and 5. .
The MTE core team drew conclusions about outputs 4 and 5 from qualitative
assessments.
The CSP has already succeeded in establishing a municipal health system in Saidpur and
Parbatipur by motivating municipalities to implement the 1995 GOB circular requiring
formation of municipal and ward level health committees. This is a remarkable
accomplishment. The municipality has developed a community support system where
families at the community have direct linkage to all levels of municipal decision-making
in health matters.
The CSP succeeded in persuading the local municipalities to include health in their
agenda (where it was not previously). Consequently, health has higher priority in annual
planning and budgets. Through this process, the municipal and ward elected officials
have been brought closer, and made more visible, to their constituents. With this program
strategy, Concern Worldwide joins the over 70% of Child Survival grantees now engaged
in supporting strengthening of decentralized health services.
The CSP gives support to anecdotal evidence cited by CSTS that the Child Survival
Grants may have spill-over effects on civil society development by helping to build
problem-solving skills at the community level, developing community-based
development associations, and enhancing community response to conflict or disaster.
Concern's strategy for developing these municipal health structures has the potential to
become a model for facilitating urban health development throughout Bangladesh and
should be shared widely in both public health and civil society development settings.
37
The MHCs and the WHCs established by the CSP have demonstrated considerable ability
to bring together disparate groups to address identified health priorities in communities.
The CSP uses participatory methods to facilitate programming input from all sectors of
the community. At the field level, the CSP is an integrated partnership at every
implementation level with full participation of project stakeholders.
Program elements under the responsibility and control of the municipalities have
demonstrated a marked increase in quality because of the CSP. The activities included in
these interventions and program outputs, however, represent less than half of the overall
program effort. There were, however, insufficient program outputs and verifiable
indicators devoted to measuring impact of the Maternal and Newborn Care and IMCI
components articulated in the original DIP. Implementation of the IMCI component was
not scheduled to begin until the second half of the program; therefore, the CSP still has
time to develop end of program targets to measure impact in this program element.
Recommendations
1. To have further impact on decreasing maternal and child mortality, the CSP needs to
shift focus away from EPI and Vitamin A services, which have been largely successful,
and significantly increase emphasis on maternal/newborn care and community integrated
management of childhood illness (C-IMCI).
Specialized training for both staff and partners in Community/Household IMCI,
Safe Motherhood and Saving Newborn Lives will be necessary to assure project
impact on mortality and morbidity at the household level. Cross-visitation with
other CSP projects addressing Community IMCI and Safe Motherhood should be
pursued for the Project Managers, and possibly the Field Trainers (depending on
cost.)
Concern should seek opportunities to collaborate with partners of the new USAID
NGO Service Delivery Program (NSDP) to look for ways to strengthen the
Community IMCI and Safe Motherhood aspects of the project. New information
from the Saving Newborn Lives program implemented by Save the Children (US)
in Bangladesh can also be a valuable source of information to help address
perinatal mortality.
Implementing the IMCI component in the second half of the CSP
Since IMCI case management is unlikely to be implemented on a national scale in
Bangladesh within the next year to 18 months, and the absorptive capacity of the
municipal health staff to use the training is therefore very limited, the log frame
indicator “all municipal health staff and 96 PPs trained on IMCI case
management….” should be dropped, and replaced by adding an indicator to the
M&E plan that measures program activities in community/household IMCI. This
change will help to demonstrate the direct effect of CSP efforts. .
38
2. The CSP will need to engage in networking, coordination and advocacy with all major
health care providers in the project area to address the main causes of maternal and child
mortality in the municipalities.
The municipalities need to be proactive in networking with the health providers
within their municipality and strongly advocate for joint efforts to address the
major causes of infant, child and newborn deaths. These efforts include
advocating for staff recruitment at the municipal level, sharing epidemiological
information, coordination of health service referrals and finding ways of ensuring
access to health care for the poorest sectors of the population.
The CSP will also need to devote significant attention to quality of care issues at
all levels, including referral centers for danger signs of IMCI-related illnesses and
maternal complications. If the facilities agree, health facility self-assessments can
be conducted with Concern’s assistance to establish what needs to be done to
improve the quality of care. These assessments compare service delivery against
national and international standards for case management. The municipalities and
the facilities will then be better prepared when IMCI is implemented at the
national level.
3. The CSP can move towards sustainability through concerted efforts to develop an exit
strategy for WHCs, CHVs and Municipality HMIS.
EPI/Vitamin A
The CSP should plan to begin exiting from significant involvement in EPI and
Vitamin A activities early in FY 2003. The project should begin by assessing the
quality of services provided and develop plans for turning over the stronger
centers to municipality management.
WHCs
The ability of the CSP to graduate WHCs from significant external involvement
and ensure their sustainability requires the transfer of skills in facilitation, team
building and motivational skills and financial management from CSP staff to the
WHC members. WHCs will have to develop transparent management of the funds
they have collected to support CSP activities. Concern can apply lessons learned
from the Rural Development Project to assist in these efforts.
CHV's
The CSP and municipalities will have to address the issue of CHV turnover and
incentives to encourage sustainability of these activities. The CSP should also
consider selecting additional volunteers from other sectors of the population who
will remain in the community.
39
Concern and the Municipality should involve the parents of CHVs by informing
parents of the nature and importance of the work the CHVs do.
Municipal health staff should assume responsibility for training and refresher
training of CHVs beginning in FY2003. To address the inevitable turnover of
CHVs, plans should be developed for selecting, training and motivating new
CHVs from the community over time.
TBAs
TBAs have a continuing need for clinical updates on safe delivery, postpartum,
and newborn care. Experienced professionals with extensive delivery experience
should provide this training. To provide for sustainable TBA clinical refresher
training, the CSP should network with local health providers, such as LAMB
Hospital and the MCWC Maternity Hospital in Saidpur, to provide continuing
education in safe delivery for TBAs.
The CSP should commit to keep safe delivery, postpartum care, and care of the
newborn as the primary activities of the TBAs. Introducing new mothers to ways
of providing for the health of their infants, such as vaccinations, use of ORS and
watching for danger signs as part of the postpartum check can be appropriate as
long as the other quality elements of TBA performance are maintained.
The Monitoring and Evaluation System, including the HMIS
Stakeholders place a high value on improved monitoring progress and
effectiveness of program activities. Concern can consider introducing some of the
newer, less costly and time consuming monitoring measures, such as Lot Quality
Assurance Sampling (LQAS), or "doer-non-doer" analysis to the program.
The HMIS should be expanded to include additional indicators to measure the
IMCI and Safe Motherhood interventions of the program. The M&E system
should refine objective indicators to measure progress in outputs 4 and 5.
Recommendations from the BCC strategy to add additional impact indicators
should be followed.
Additional attention needs to be paid to targeting and tracking Vitamin A
supplements to postpartum women and children who have completed their
immunizations by including this information in the HMIS and the M&E plan.
The CSP should closely monitor the volume of clients seeking formal health care
at referral health facilities in response to recognition of danger signs as promoted
through the community health promotion/BCC activities. The census-based
information system developed by the CSP, in principle, can track all maternal and
child deaths. Verbal autopsies, a methodology used in the CSP BCC audience
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analysis, is one way the project can monitor the effectiveness of this program
strategy in averting preventable maternal and child deaths.
The project should continue to monitor TBA performance, and develop ways of
monitoring and strengthening individual performance as a follow-on to the TBA
study. Duties can be deleted, or added, based on this monitoring to maintain the
quality of care.
To encourage use of data for decision-making and sustainability of data
collection, the CSP should provide a means for the municipalities to generate
HMIS reports for themselves and turn this responsibility over to them as soon as
possible. Concern can provide the training and has already arranged to provide the
equipment. This is an important step in the turnover of the HMIS, and
sustainability of the EPI and Vitamin A component depends on it.
Supervisors should make greater use of the HMIS to monitor program
effectiveness and select areas for increased supervisory attention and training.
This will require additional training for the supervisors.
4. To impact on the majority of life-threatening child illnesses, the project must find ways
to promote safe practices by private practitioners (PPs).
As recommended by the DIP review and baseline survey consultants, these
practitioners will need to be directly involved in designing activities to ensure
their participation. This will be a major challenge for the CSP in the next two
years.
PPs should be encouraged to be venues for health education on appropriate
behaviors (such as child feeding, exclusive breastfeeding, immunizations,
antenatal care) and referral of children with danger signs of life-threatening illness
to the appropriate health facilities.
Homeopaths, particularly, should be targeted for inclusion in the CSP because
they treat newborns and very young infants, who are known to be at the highest
risk of death from preventable causes. These infants are often the hardest to reach
of all targets groups in child survival.
5. The CSP should find ways to promote greater community-level male involvement in
CSP activities.
Although the program has involved men throughout the program, the CSP must
make stronger efforts to involve men in the project activities to obtain their
support. Along with mothers-in-law, they are the most important decision-makers
in household health care-seeking behaviors. Imams may be able to contribute to
greater male involvement because they play a strong role in influencing male
behavior.
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6. Plans for Sharing Lessons Learned
Concern and the other CSP partners should share lessons learned in the CSP
development process with other health NGOs and GOB offices as part of the
national level advocacy efforts.
Concern should encourage and facilitate opportunities for the municipal chairmen
and commissioners involved in the CSP to share the story of the CSP with their
colleagues throughout Bangladesh.
Concern might consider contacting other CORE members in Bangladesh with the
intention of starting a local version of CORE in Bangladesh. Several CORE PVOs
participated in the PVO Polio Eradication Initiative project scheduled to end in
2002. Discussions are underway for future CORE PVO collaborations in
Bangladesh and Concern can be a part of them.
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F. RESULTS HIGHLIGHT
Community Participation Promotes Swift Community-Based Action
Presented by Dr. Shahnewaz A Khan, Assistant Country Director, Concern Bangladesh
 at the Global Health Council, May 2002
Promoting health in urban settings presents many challenges for engaging residents in
health promotion. In Bangladesh, locally elected bodies form municipal governments.
While charged with coordinating health promotion and services, municipalities are
plagued by complex, bureaucratic decision-making procedures. Municipalities are also
responsible for multiple social and economic sectors, limiting their ability to concentrate
efforts on health. Further, the marginalized extreme poor have little clout and their needs
are rarely reach the local political agenda.
Since 1998, Concern Bangladesh and the municipal governments of Parbatipur and
Saidpur have jointly implemented a Child Survival program. In an effort to foster the
active participation of all segments of the community, the program facilitated the
establishment of Ward Health Committees. Members of the committee are diverse and
represent broad segments of the community including minority sub-population, women’s
groups, teachers, NGO workers, formal and informal health workers, as well as members
of the Municipality Cabinet. Community members participate in decision-making, some
contribute financially and others volunteer their time.
This committee meets regularly to identify and discuss a broad spectrum of local issues
and generate community remedial action. These committees are the first stop in managing
community health needs, allowing local action by bypassing the municipality’s complex
system.
An informal but sustainable community participation mechanism for local actions has
emerged under the leadership of this Ward Health Committee. Results of decisions
made by these groups have been clear and rapid. For example, several committees have
established emergency transportation plans, medical funds for indigents, recognition
programs for volunteer health promoters, and special campaigns for vaccination of
children from difficult to reach households. In response to this swift and decisive action,
many committee members, including elected representatives have gained popularity
within the community.
In conclusion, the child survival program has developed a model for sustained urban
community participation in health promotion. This model builds on basic principles of
community empowerment through development of leadership and coordination skills.
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G. ACTION PLAN NOTES
In a workshop from 24-25th August 2002, Concern Worldwide and Concern Bangladesh
met with CSP stakeholders used the key findings and recommendations to develop the
Action Plan for the remainder of the project. Recommendations were grouped into five
core areas for action. Each core area and discussion points are described below.
The overall purpose of the workshop was the participatory development of a preliminary
CSP workplan for years 3 & 4 through distillation of MTE Recommendations, DIP, BCC
strategic plan, and HICAP action plan.
Specific objectives of the meeting were to:
• discuss key evaluation recommendations to develop mutual understanding of their
intent
• identify optimal strategic directions that the CSP partnership should take to
effectively address each of the recommendations
• develop preliminary action steps to achieve directions set from the MTE
• review multiple plans into consolidated and preliminary workplan for years 3 and 4
Summary of Recommendations and Strategic Steps Proposed by the Team
Core Area #1: Shifting emphasis from EPI/Vitamin A which have been largely
successful to newer areas of maternal/newborn care and integrated management of
childhood illness (diarrhea, ARI/pneumonia, and nutrition)
As described in the MTE report, there are several issues raised about the need to make a
strategic shift of effort and resources towards the IMCI and Safe Motherhood
components. CSP team fully agrees and supports this recommendation. Some specific
points to be considered in the action plan include:
EPI/Vitamin A
While we are reducing the CSP effort, focus on improving the quality of EPI program,
particularly the cold chain operations remains critical. CSP will largely hand over
mobilization/tracking responsibilities to the WHCs and the CHVs but will need to
provide guidance to MHS in making this transition WHCs will maintain EPI as a regular
agenda item. CSP Coordinator will collaborate with UHFPO, IOCH for ensuring cold
chain and supplies during quarterly supervision. Concern will build skills of MHS to
advocate for better supplies, increase number of supervisors and permanent health staff in
both municipalities. Concern will continue to build supervisors skills in EPI management
as well as other critical areas of facilitation, team building, and motivation.
Safe Motherhood
This has largely been included as major focus of BCC strategy. Effort will include
awareness raising on ANC, EmOC/normal delivery, postpartum and newborn care
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service promotion. CSP will organize household group meetings for birth preparedness
(including men, in-laws and other influential family members).
Education materials will be provided for TBAs, MHS, WHC, and CHVs to promote SMI.
Further training in SMI and newborn care to be provided to MHS, WHC, CHVs as well
as Concern staff.
Professional staff from MCWC, LAMB, and the Saidpur 50-bed hospital will conduct
refresher training for TBAs. Practical trainings at these sites will be arranged.
A TBA referral system will be developed building on information from monthly meetings
and Safe Motherhood events.
Community IMCI
Objectives will be added to BCC strategy to include pneumonia, diarrhea and
malnutrition elements with an aim to raise awareness among community
mothers/caretakers about danger signs, early referral, and home care. Significant
strategic planning and training for Concern and MHS staff including cross-visits to C￾IMCI programs will be needed to advance understanding of the concept. C-IMCI
training for private providers, WHCs, CHVs and TBAs and education materials to be
adapted for the program.
Core Area #2: Moving towards sustainability through concerted efforts of an exit
strategy for WHCs, CHVs and Municipality HMIS
 The CSP team needs more support in capacity building planning and organization
development in order respond to this recommendation area better. A participatory
training and planning exercise is planned for February 2003 in which CSTS support has
been requested. An interim plan from the stakeholders is as follows:
a) Ward Health Committees strengthened to be independent and sustainable to work with
municipality health committee (most in Parbatipur are at nascent stage while at nursing
stage in Saidpur)
o Strategy (guidance, motivation, develop skill, leadership, team building and financial
management
o The work:
 Develop more skills to the WHC Chairmen and Secretaries for developing
leadership
 Training on facilitation, financial management, capacity building
 Support to establish better financial management systems
 Cross-visit/mentoring between WHCs
b) Developing partnership between CHVs for different activities
o Strategy (identify and explain the roles and responsibilities of CHVs, documentation,
and seeking the ways how to implement)
o The work:
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 Organize gathering for parents of volunteers to explain CHV roles and
responsibilities
 Review volunteer selection process and select new volunteers (as necessary)
 Award high performing volunteers
 Develop skill of MHS to train new CHVs
 Develop mechanism to supervise CHVs through WHCs
c) Develop a sustainable monitoring system meeting municipality health information
system requirements
o Strategy: Match the government HMIS with CSP system
o The work:
 Orient supervisors on HMIS
 Identify gaps in current HMIS
 Provide training to municipality staff on data analysis, use, and dissemination
Core Area #3: Networking, coordination, and advocacy to address main causes of
maternal and child mortality in the Municipalities
The CSP team embraces this recommendation but also realizes that it will not be easy as
so many of the issues are outside of the direct control of the MHS. The following are
initial thoughts on working towards the recommendation.
Increased coordination
• Strengthen MHC to organize regular meetings
• Ensure members attendance/participation
• Ensure municipality presence in district and sub-district level health meetings
• Organize coordination meetings between field staff of service providers
• Link to plans in BCC strategy to address quality of services and strategic
partnership
Advocacy to recruit municipality staff as per organogram
• Meeting with municipality cabinet – motivate them to recruit health staff
(internal lobbying)
• Municipality initiative to advocate on staff issues with support from other
partners
National level advocacy
• Organize national level workshop to disseminate lessons learned
• Share with other municipality leaders through Chairmen's’ Association
• Organization national level workshop
Core Area #4: Promote safe practices of key Private Practitioners (PPs)
The CSP team fully supports this recommendation and has long recognized their
importance in improving child survival. Over the first two years, the team has been
46
learning about the extent of private practitioners in the area including types, clients,
quality/practices, training, and factors for high use of their services.
Necessary Steps:
• Identify PPs (RMPs, Drug sellers (trained/untrained), homeopathic) that see the
most cases of ARI, diarrheal diseases, and newborn complications
• Training of selected PPs (curriculum drafted based on findings from CSP
assessments) will be separate for homeopaths
• Annual seminars for private practitioners only (continuing education)
• WHC Coordination meetings twice per year with TBAs, PPs, Homeopaths,
Herbalists
• Annual coordination meetings with formal health service providers with PPs
• Ensure attendance of PP representatives in monthly WHCs (but how will they
• Promotion of drug selling licensing to hold accountable to municipality (may
require circular from MOHFW/MOLGRD
• Recognition/reward for private providers
• Advocacy to formulate MOHFW/MOLGRD circular for PPs to support
municipality health programs
Core Area #5 Greater community-level male involvement: effective reach to
decision-makers
The CSP team has long recognized the role of men in household care-seeking
decision-making. They also realized the role of Imams in changing attitudes and
social norms. These aspects have already been incorporated in the recently
developed BCC strategy. Some additional thoughts from the team include:
• Provide training guardians of female TBAs, CHVs, and WHC to be
sensitized on core interventions
• Identify 60 men in each ward and provide training on core interventions so
as to spread information to other families
• Meetings of men’s groups on different health interventions
• Information dissemination through mobile projection unit (need to check
suitability of existing films)
• Involve men in observation of health events
• Work with Imams to create and disseminate messages