Africare
Cooperative Agreement #: GHS-A-00-03-00002-00
TAMBACOUNDA HEALTHY START PROGRAM
Health Districts of Tambacounda and Koumpentoum 
in Senegal
(2003-2008)
MID-TERM EVALUATION
REPORT
In collaboration with
The Ministry of Health and Prevention
The Health Districts of Tambacounda and Koumpentoum
USAID’s Tambacounda Healthy Start Program (THSP)
Africare Senegal
October 2006
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This report was written by Kim Sanwogou, Lead Consultant and edited by Jim Dean,
Africare Senegal Country Representative, Ms. Ikupa Akim, the THSP Program Coordinator, 
Dr. Mor Ngom, Africare Senegal Health Program Manager, and Mr. Ousseynou Samb, 
Africare Senegal Program Officer. 
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CONTENTS
A-SUMMARY....................................................................................................................5
B- ASSESSMENT OF THE PROGRESS MADE TOWARD ACHIEVEMENT 
OF PROGRAM OBJECTIVES .....................................................................................10
1. Technical Approach...............................................................................................10
a. General overview..............................................................................................10
b. Progress report by intervention area ................................................................10
2. Cross-cutting approaches.......................................................................................25
a. Community Mobilization..................................................................................25
b. Communication for Behavior Change ..............................................................26
c. Capacity Building Approach.............................................................................27
d. Sustainability Strategy ......................................................................................30
C- PROGRAM MANAGEMENT.................................................................................32
1. Planning .................................................................................................................32
2. Staff Training.........................................................................................................32
3. Supervision of Program Staff ................................................................................33
4. Human Resources and Staff Management.............................................................34
5. Financial management ...........................................................................................35
6. Logistics.................................................................................................................36
7. Information management .......................................................................................36
8. Technical and administrative support....................................................................37
9. Mission collaboration ............................................................................................37
D- OTHER ISSUES .........................................................................................................37
E- CONCLUSIONS AND RECOMMENDATIONS ...................................................40
F- RESULTS HIGHLIGHT ...........................................................................................45
ATTACHMENTS ............................................................................................................47
Attachment A: Baseline information from the DIP......................................................49
Attachment B: Knowledge, Practices and Coverage (KPC) survey report.......................
Attachment C: Evaluation Team Members and their Titles..........................................50
Attachment D: Evaluation Assessment Methodology...................................................51
Attachment E: List of Persons interviewed and contacted ..........................................52
Attachment F: CD with electronic copy of the report in MS Word 2000......................54
Attachment G: Program Data Sheet Form- Updated Version.......................................55
Attachment H: Action Plan...........................................................................................56
 
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ACRONYMS
ARI Acute Respiratory Infection
BCC Behavior Change Communication
CBO Community Based Organization
CHW Community Health Worker
DMO District Medical Officer 
HPNOIC Health Post Nurse Officer in Charge
CS Child Survival 
CW Community Worker
DIP Detailed Implementation Plan
EB Exclusive Breastfeeding 
EPI Expanded Program of Immunization
GMP Growth Monitoring and Promotion
GOS Government of Senegal
HE Health Education
HP Health Post
JICA Japanese Agency for International Cooperation 
IEC Information, education, and communication 
KAP Knowledge, Attitudes, and Practices
KPC Knowledge, Practice and Coverage
LAM Lactational Amenorrhea Method
M&E Monitoring and Evaluation
MCH Maternal and Child Health
MOH Ministry of Health and Social Affairs
NGO Nongovernmental organization
NID National Immunization Days
ORS Oral Rehydration Salts
ORT Oral Rehydration Therapy
URO/CREN Oral Rehydration Unit/Center for Nutritional Educational and Rehabilitation 
PNC Prenatal Consultation
PVO Private and Voluntary Organization
TBA Traditional Birth Attendant
USAID United States Agency for International Development
WG Women’s Promotion Groups
WRA Women of Reproductive Age
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A- SUMMARY
The Tambacounda Healthy Start Program (THSP) is a five year maternal and child health
program implemented by Africare in the Tambacounda Region of Southeastern Senegal. The 
program has the goal of reducing maternal and child morbidity and mortality among pregnant 
women and children under one year of age. The program’s five objectives are to: 
1) Increase the access to, demand for, and use of quality maternal and child health
services, including emergency care;
2) Improve case management of malaria for pregnant women and children under five at
the community and health post levels;
3) Improve nutrition of pregnant women and newborns, including promoting vitamin A
supplementation and the practice of exclusive breastfeeding;
4) Improve diarrhea recognition and management at community and household levels;
and 
5) Improve the capacity of local partners to plan, implement, monitor, and evaluate child 
survival interventions at the community and district levels, with an emphasis on
capacity in maternal and newborn health, malaria, nutrition, and breastfeeding.
To date the main accomplishments of the THSP are substantial increases in the number of
women attending antenatal clinic and those being assisted by a trained person during
delivery. The program’s sustained campaign to promote prenatal care to women has also led 
to the increase in the number of women who are accessing intermittent preventive treatment
(IPT) against malaria. In collaboration with partner districts and UNICEF, the program has
also increased access to vitamin A supplementation in children and post partum women.
Since the program’s inception, regular IEC activities have also led to increased use of iodized 
salt and an increase in the number of caretakers who recognize diarrhea danger signs that
need prompt treatment. The percentage of mothers who understand the need to wash their 
hands at specified times to prevent diarrhea transmission has also doubled from baseline.
Overall, the THSP has progressed towards the attainment of all its objectives and in a few
instances may have already exceeded some targets. Given the program’s late start and the 
many challenges facing the program team these results are commendable. However, much 
remains to be done. The program will need to address those indicators that seem to be in
decline compared to the baseline, such as the prevalence of underweight children (which
increased slightly from 20% at baseline to 23.5%). The program managers have asked to 
validate certain results of the mid-term KPC that indicate large increases over the baseline
KPC. Given the THSP’s focus on health promotion this may be more an indication of a high 
level of sensitization in the population, rather than an actual change in behavior. The 
respective indicators will be discussed in the appropriate technical sections.
The main constraints affecting program implementation are a lack of sufficient financial and
human resources to cover the vast program area of the Tambacounda region. Villages tend to 
be small and dispersed and the roads are some of the worst in Senegal. While the program’s 
capacity building has significantly improved access to, demand for, and utilization of 
community health services, it has also prompted an increase in referrals to district health
posts and regional health centers for emergency services and more complex care. This
increase in referrals is of some concern to district and regional health service providers; they
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are worried about their ability to meet a rising demand given the public health system’s lack 
of human, logistical, and infrastructural resources in the Tambacounda region.
The program has made some progress in grounding its sustainability plan. It has established
Village Committees that are designed to continue child survival activities once the program
ends. To date, the program has created 209 Maternal Care Groups and has trained 235 
Community Health Workers (CHWs) in health promotion and facilitation. A functional cost￾recovery scheme allows the CHWs to earn a small stipend from each medicine or insecticide 
treated bednet (ITN) that they sell. In addition, the program is poised to launch its micro￾credit component, which should further contribute to sustainability. 
Thus far, the program has limited its monitoring activities to collecting process data and has
not yet established a system to collect impact data to regularly measure behavior change. The 
establishment of such a system will allow the program to validate the mid-term KPC results, 
and provide a framework for decision-making, allowing program managers to make more
efficient use of limited resources. Below is a selected list of conclusions and
recommendations from the evaluation.
Conclusion #1: The program’s levels of human resources in the original program design are
inadequate to account for the realities of the program area (vast territory, geographically
dispersed villages, semi-nomadic populations, and poor road infrastructure). Since its
inception, the THSP has been understaffed (operating during the first two years with only
three supervisors for the entire zone). Recommendation: Scale down the planned total 
number of program villages and the number of targeted beneficiaries to strengthen program
implementation. Improve workload distribution by hiring more supervisors for the remainder
of program implementation.
Conclusion #2: Certain line items in the program are under-budgeted for the scope of
program activities. Recommendation: Realign the budget and locate additional funding to
strengthen program activities with additional human resources and equipment. 
Conclusion #3: To date, the program has only collected data for monitoring purposes and has 
not evaluated progress towards achieving program objectives on a regular basis. 
Recommendation: Hire a Monitoring and Evaluation Specialist to carry out these activities. 
Conclusion #4: The Maternal and Child Health intervention appears to be the strongest
component, achieving and even exceeding some of its targets. While the number of births
assisted by trained personnel has risen from 45% to 65%, there is still a signal lack of trained 
birth attendants in the intervention zone (for the 137 program villages in Tambacounda
district, there are only 24 TBAs, nearly half of whom are in the urban setting of
Tambacounda commune. Recommendation: Help identify those CHWs who meet the
minimum requirements for becoming TBAs and work with the communities and the health
districts to facilitate the training of these candidates. Provide refresher training in 
reproductive health including prevention of infection.
Conclusion #5: While the Child Survival component (nutrition, diarrheal, and malaria
prevention and management) is making progress towards its objectives, it needs additional
strengthening. Recommendation: Reinforce complementary feeding, nutrition management
of the sick child and diarrheal management with ORS. Collaborate with the Bureau Régional 
de L’Alimentation et de la Nutrition (BRAN) on technical aspects of the nutrition component.
Conclusion #6: The Health District facilities have difficulty meeting the increased demand 
for services resulting from THSP referrals and increased health seeking practices. This is due 
to lack of adequate medical equipment, facilities, and trained human resources. 
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Recommendation: Seek outside collaborating agencies who will help equip health facilities
in obstetric emergency equipment and train district staff
Grantee’s response to the MTE recommendations:
Recommendation: Scale down the planned total number of program villages and the number 
of targeted beneficiaries to strengthen program implementation. Improve workload
distribution by hiring more supervisors for the remainder of program implementation. 
Response: In May 2006, the program hired six additional experienced supervisors, which
brings the total number of program supervisors to nine. The program also received a
matching grant from Pfizer which pays for the salaries of several of these supervisors. The 
actual number of program villages is presently 155 central villages and 174 satellite villages.
This represents 82% of the end of program target of 400 villages. However, the program
managers anticipate that some of the villages that were recruited in the first years of the
program will no longer require the same intensive level of supervision in the second half of
the program, thus allowing the supervisors to extend their coverage while improving
workload distribution. The program team will review the salary line item of the THSP budget 
to determine whether of not it will be financially feasible to hire additional supervisors. They 
will also explore the possibility of further matching grants for the same purpose.
Recommendation: Realign the budget and locate additional funding to strengthen program
activities with additional human resources and equipment. 
Response: Because of the late start of program activities, Africare did not spend the budgeted 
program amount in year 1 of the program. Savings were especially significant in the “local
salaries” line item. This allowed Africare to recruit additional supervisors in year 3.
However, a realignment of budget line items is necessary (the logistical and general
subsistence line items are almost exhausted, for instance). Africare will seek a modification
of agreement (MAARD) to do so. Africare was also be able to attract matching grants from 
the Japanese International Cooperation Agency (JICA) for a community health component in
the Maka zone, from the World Bank for a nutrition component in Tambacounda commune, 
and from Pfizer for an Acute Respiratory Infection (ARI) activity that covers the entire
program area. Nevertheless, additional funding will be necessary in years 4 and 5 to make 
ends meet. Although Africare has already met its matching grant requirements for the entire 
program, the Dakar program team is presently exploring several potential leads for additional
matching grants. 
Recommendation: Hire a Monitoring and Evaluation Specialist to carry out these activities. 
Response: We agree that this is an area of need. We will be hiring an M&E specialist by
December 2006. 
Recommendation: Help identify those CHWs who meet the minimum requirements for
becoming TBAs and work with the communities and the health districts to facilitate the
training of these candidates. Provide refresher training in reproductive health including the 
prevention of infection. 
Response: We agree with these recommendations. See action plan below.
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Recommendation: Reinforce complementary feeding, nutrition management of the sick child
and diarrheal management with ORS. Collaborate with the Bureau Régional de
L’Alimentation et de la Nutrition (BRAN) on technical aspects of the nutrition component. 
Response: We will explore possibilities of collaborating with BRAN. Since October 2006, 
the program has been backstopped in Washington by an experienced nutritionist who will
provide technical assistance on child health.
Recommendation: Seek outside collaborating agencies that will help equip health facilities in
obstetric emergency equipment and train district staff. 
Response: The Japanese International Cooperation Agency (JICA) has started a large
technical assistance project aimed at improving the quality of services at the health posts and 
health centers of the Tambacounda region. While there is a certain amount of de facto
collaboration between the THSP program and the Japanese project on the ground, we have 
asked USAID Senegal to broker a more formal partnership between Africare and JICA.
USAID recognizes that a successful collaboration between the two programs would likely
result in an increased positive impact for the beneficiaries, and has agreed to mediate the
partnership. 
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Action Plan (see Annex I).
Changes from program description and DIP:
Change in level of effort for main interventions: There have recently been several changes 
in national policy as it relates to the first line treatment of malaria (from chloroquine to dual
therapy with amodiaquine and SP to ACT). At the time the DIP was written, the MOH was 
not authorizing community-based distribution (CBD) of anti-malarials. The new MOH
policy is that trained Auxiliary Health Agents (AHAs) can distribute ACT through the health
huts. The selection of those AHAs to train rests on the same criteria as for CBD of
cotrimoxazole for acute respiratory infections (ARIs): one of the requirements is that the 
AHA must have at least a primary school education and be able to read and write in French. 
At present, the MOH has begun training the AHAs in first-line treatment with ACT. 
As mentioned in the DIP, the level of effort for the malaria intervention was reduced to 20% 
from 30% and a diarrhea intervention was added at a 10% level of effort. The basis for 
adding the diarrheal intervention resulted from the 2004 baseline KPC survey results which
revealed diarrhea as the number one childhood illness reported (with a 45% prevalence). 
Budgetary changes: Since the submission of the original program budget, Africare has been
compelled to deal with a drastic decrease in the exchange rate. At the time the proposal was 
written, one US dollar was worth 700 CFA. Since the beginning of the program, the US 
dollar has hovered at a rate between 500 and 550 CFA. Rather than request an increase in the 
budget, Africare has realigned cost centers (decreasing some line items while increasing
others) to meet the increased costs while remaining within the overall limit of available funds 
and has obtained a number of matching grants to facilitate program implementation. A
revised budget and budget narrative was submitted with the DIP.
Maternal Care Groups: The proposal stipulated that 600 Maternal Care Groups of 10
members each would be established. Due to human resources constraints, THSP decided to 
create larger Maternal Care Groups ranging in membership from 18 to 30. Hence, the total
number of Maternal Care Groups at program end may be reduced as a result of this change. 
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B- ASSESSMENT OF PROGRESS MADE TOWARD ACHIEVEMENT 
OF PROGRAM OBJECTIVES
1. Technical Approach
a. General overview
The Tambacounda Healthy Start Program (THSP) located in the department of
Tambacounda, aims at reducing maternal and child morbidity and mortality through four
interventions: 1. Maternal and newborn care (LOE: 50%), 2. nutrition/exclusive breastfeeding
(LOE: 20%), 3. malaria prevention and control (LOE: 20%), and 4. diarrheal prevention and 
management (LOE: 10%). The THSP’s goal is to decrease the morbidity and mortality rates 
of pregnant women and children under one year of age in the Tambacounda Region by
improving community based health care services, increasing community access to health 
information, and strengthening community linkages with the health care system. The THSP’s 
five objectives are to:
1. Increase the access to, demand for, and use of quality maternal and child health
services, including emergency care;
2. Improve case management of malaria for pregnant women and children under five 
at the community and health post levels;
3. Improve nutrition of pregnant women and newborns, including promoting vitamin
A supplementation and the practice of exclusive breastfeeding;
4. Improve diarrhea recognition and management at community and household levels;
5. Improve the capacity of local partners to plan, implement, monitor, and evaluate
child survival interventions at the community and district levels, with an emphasis on
capacity in maternal and newborn health, malaria, nutrition, and breastfeeding.
Key strategies to attain these objectives include: 
1. Building capacity at the health posts and community levels by training 70 health
personnel and 200 Traditional Birth Attendants (TBAs); 
2. Assisting communities to establish functioning referral and transport systems in
collaboration with the MOH and community health committees; 
 3. Educating and mobilizing communities by training 400 CHWs drawn from among
the members of local women’s groups; 
4. Organizing pregnant women, care givers, and grandmothers into maternal care
groups; 
5. Designing and carrying out a social marketing campaign to increase access to and 
use of ITNs, ORS, safe birthing/hygiene kits, and iron pills.
 b. Progress report by intervention area
 
Maternal and Child Health 
Activities
Maternal health activities include the creation of Maternal Care Groups, reproductive health
education and discussions, family planning, identification and pairing of pregnant women
with a mentor for reproductive health and child growth monitoring, birth plan development,
micro-credit for pregnancy-related expenses, pre-and postnatal care promotion, pregnancy
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danger sign recognition and reduction in the delays to seek care, deliveries by a skilled
attendant, home visits, and referral of obstetrical emergencies. 
Progress towards intermediate objectives
According to the initial KPC and to mid-term focus group responses, before the program
started, women sought prenatal care infrequently and irregularly. They were often sick and 
did not know pregnancy danger signs. They treated themselves with traditional medicines of
plants and roots such as goyé and kinkéliba, and would seek assistance from traditional
healers. They only went to the health post as a last resort after having tried various remedies. 
When women did seek antenatal care, those consultations often took place late in the
pregnancy. Many women would hide their pregnancies from their husbands. Many were
also reluctant to be examined by male nurses. Most women gave birth at home. Post-natal 
consultations were rare. Women rarely used modern contraceptives. Villagers often had to 
travel considerable distances to obtain medicines and vitamins such as iron. 
Participants from all focus groups indicated that they have adopted many behavior changes in 
reproductive health since the THSP program came into their lives. Women, men, village 
leaders, and CHWs all report that women seek prenatal care more regularly and recognize 
pregnancy danger signs more readily. Through the program facilitated discussions on family
planning that are held in the Maternal Care Groups, women have gained a better
understanding of family planning. They are less likely to conceal their pregnancies.
According to the community leaders’ focus groups, pregnant women now take the initiative 
to seek antenatal care and manage their pregnancies by communicating with nurses and
trained TBAs. Most give birth at the health post now, since they have learned the risks of 
home births. The number of women seeking post-natal care has increased and more women 
use family planning for child spacing. 
Male focus group respondents indicated that they do participate in discussions, take part in
home visits, and volunteer on community sanitation days. They also provide financial
support for reproductive health services, medicines and transportation for their wives. Some 
of the men had helped establish Maternal Care Groups by making financial contributions. 
Some men also show support by calling on the husbands of women who seem disinterested in 
Maternal Care Group activities. Some men indicated that their wives shared with them the 
information they received in the Care Groups. The majority of focus group men, however,
said that they had never directly participated in program activities, since they were not invited 
to participate. 
Knowledge, Practices and Coverage (KPC) survey results seem to corroborate most of the
qualitative findings. However, the program managers intend to validate the quantitative
results of the mid-term KPC for the following reason: The focus on health promotion may
have led to a high level of sensitization among the population. The large increase in positive
responses may reflect this sensitization rather than actual changes in behavior. In December
2005, the program conducted a qualitative study that included focus group discussions with
maternal care groups. The results of the study indicated that women knew the “right
answers” to the initial set of questions. Upon further questioning, they had not yet adopted 
the appropriate behaviors. 
Given that caveat, however, all indicators in this intervention increased above the 2004
baseline. The number of mothers who attended at least three prenatal care visits rose 27 
percentage points from the baseline 33%, thus reaching the EOP target of 60 percent. Births 
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assisted by a qualified person increased by ten percentage points from 45% to 55%, nearly 
attaining the EOP target of 60 percent. One-third of mothers reported breastfeeding
newborns during the first hour after birth, which represents a 13 percentage point increase
over the baseline survey. Utilization of at least one method of modern contraception
increased from 10% to 21%, surpassing the EOP target of 13 percent. This represents
approximately twice the national average of 11%. 
Tambacounda Health District data also reveal an increasing trend in selected reproductive
health indicators. As of 2004, MOH increased the number of recommended prenatal care
visits to a minimum of four. The percentage of women who sought three prenatal care visits 
in 2003 increased from 26% to 45% in 2005. Those who sought four antenatal care visits 
increased almost fourfold between 2003 (5%) and 2005 (19%) respectively. As for
deliveries, a qualified person assisted approximately one-quarter (26%) pregnant women in
2003 compared to 37% in 2005. Some of these increases can be attributed to intensified 
Health District prenatal care outreach activities which took place in 2005 with the support of
the United Nations Population Fund (UNFPA). Another possible factor is the MOH decree 
of that same year, stating that all deliveries (both vaginal and by Cesarean section) are free of 
charge. With respect to the use of modern contraceptives among women of reproductive age, 
the district does not have reliable data available for comparative purposes. 
Effectiveness of RH intervention
The program’s strategy to reduce maternal and neonatal mortality is: 1) to increase demand 
for maternal and newborn care in the community; 2) to increase adoption of key behaviours 
during pregnancy, birth, and the post partum period; 3) to improve quality of maternal and 
new born care at community and health level.
The THSP has centered its maternal health technical intervention on UNICEF’s four delays 
framework. To date, the program has been working to address delay #1: delays in problem
recognition due to traditional beliefs, low perceived risk, low knowledge of causes of death, 
danger signs and complications, and ineffective screening; and delay #2: delays in deciding to 
seek care due to a woman’s low status/lack of participation in decision making, lack of birth
planning/preparedness, high rates of unattended home births and untrained attendants, and 
poor quality services. 
Overall, referrals and improved utilization of health services have increased. This increase is 
supported anecdotally, by qualitative interview results, and statistically by health post
admission figures. The program interventions that have been particularly effective in
affecting positive behavior involve the Maternal Care Groups as: 1) fora for intimate
discussions among women on reproductive health topics, 2) the stimulus for birth
preparedness plans involving first the pregnant woman and her mentor, then the husband and 
family, 3) a basis for advocacy, and 4) an enabling environment for IEC/BCC interventions.
Here are some of the program highlights:
Maternal Care Groups
The cornerstone to THSP’s strategy to reduce maternal and neonatal mortality is the Maternal 
Care Group. THSP is working with women’s groups in participating villages to establish and 
facilitate groupings of women that allow women to learn about the importance of key health 
behaviours, birth preparedness, recognizing danger signs during and after pregnancy, to 
establish systems of referral for emergencies in an intimate setting using existing networks of 
solidarity among local women.
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In each village, the program team meets with the village committee and members of women’s 
groups to explain the concept, structure, and function of the Care Group (CG). Members of 
women’s groups are then asked to group themselves into Care Groups of no more than 25 
women per group; each village is limited to a maximum of four CGs to allow the volunteer 
facilitator enough time to meet with each CG every month.
Each CG has a coordinator, and a treasurer, and a facilitator. The facilitator is either the TBA 
or CHW (RH volunteer) based in the village, and is always a woman. Activities carried out 
with CG include:
ß Group discussions by the TBA or CHW on key behaviours such as prenatal visits,
exclusive breast feeding etc. 
ß Mentoring of pregnant women within the group by more experienced group members. 
This mentoring includes joint preparation of a birth preparedness plan and home
visits. 
ß Regular contributions to a fund to help women who need financial assistance for ANC 
visits, referral, and emergencies. These funds can also be used to purchase drugs for
women who can’t afford them.
This year the program has established a total of 209 Care Groups in the Tambacounda
District, with a membership of 5,225 women of reproductive age. Between October 2005 
and September 2006, over a thousand members of the CG were mentored during their
pregnancy, of these, 833 were also helped to develop a birth preparedness plan. Care Group 
members also provided financial support for 583 to members who needed medical care for
themselves or for their children. Care Group members made over 2,700 home visits to
members who were either pregnant or had recently delivered, and 619 follow visits to women 
who had been referred to a health facility. 
The program has been successful in mobilizing women in the beneficiary communities, and
participation in the Care Groups is very high. However, some work still has to be done to 
empower women to take ownership of their groups. Most women are happy to participate in 
CG activities, and indeed, there is a great demand by women’s groups to form Care Groups. 
However, organization of the groups’ activities is still left to the CHW or TBA, and in
general CG coordinators lack the capacity to facilitate the groups. The THSP will thus have 
to provide some capacity building support to CG members to ensure their sustainability after 
the EOP. A particular problem has been women’s inability to contribute even nominal sums 
to the basket fund. The imminent start of the micro credit activities is expected to improve 
CG fund raising capacity.
Health promotion for improved maternal and newborn health outcomes
The THSP’s strategy for behaviour change consists of group discussions and home visits
carried out by CHWs and TBAs, village level social mobilisations, and radio programs
addressing key maternal and newborn health topics. This year THSP volunteers reached over 
15,500 women and approximately 1,900 men though discussion groups and home visits.
Health education topics included prenatal consultation, assisted delivery, post natal
consultation and family planning. THSP also invited district and region staff to discuss
maternal health topics on its weekly radio program. The program is aired on the RTS
Tambacounda which has regional coverage.
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Referral of women to the health post 
To promote pre and post natal visits, the early identification of problems during and after
pregnancy, and assisted births, the program has trained CHWs and TBAs in the identification
of cases for referral. The volunteers are provided with referral forms that they can issue to 
members of their communities who need further care at the health post. The volunteer fills 
out the patients’ problem in the section marked ‘reason for referral’ on the form. The 
program also informed District and Health Post staff about the use of the form, which
provides space for health staff to write down the diagnosis and treatment given to the
patients. Volunteers can then check the form during follow-up home visits and ensure that 
the prescribed treatment is being followed. Between October 2005 and September 2006,
1500 women were referred to the health post for reproductive health reasons, the vast
majority these referrals, 1091, were for prenatal consultations.
Community Based Services
The program has trained TBAs in the program zone to provide basic reproductive health
services. These include pre and post natal consultations for TBAs based in health posts and 
health huts, as well as the provision of IPT during prenatal visits and vitamin A within 42
days after delivery. The program has also supported refresher training in simple deliveries
for all TBAs and has trained them in basic life saving first aid to mothers and newborns. The 
small number of TBAs active in the intervention villages limits the effectiveness of this
activity. In Tambacounda district, the program identified 24 active TBAs in the 75 central
villages; eleven of these are based in structures less than 5 kilometres away from the district 
health center1
. In the past year, TBAs have conducted a total of 1,040 consultations and
assisted in 666 simple deliveries. In Koumpentoum district, where the program has just
completed the enrolment of 95 new villages, the program has identified a total of 23 active
TBAs. 
Changes in approach
There were no changes in this approach
Special outcomes, unexpected successes or constraints
Successes: Given the generally low use of family planning in Senegal and a number of
traditional barriers to FP in the program zone, the twofold increase in modern FP use among
WRAs enrolled in the program constitutes an unexpected success. 
Constraints: Although the program’s IEC/BCC strategies contributed to breaking down a 
number of barriers to FP use, many such barriers remain, particularly among men. Focus
group discussions revealed mixed opinions about FP, as well as misinformation, ignorance
and fear. Differing Islamic interpretations and understandings of the topic complicate the
issue of family planning. 
For example, during the focus group sessions, one man said: “In the beginning, everyone said 
that Islam does not accept family planning, but now, we know it is for the mother’s and
child’s health. So, it is a good thing.” A second man countered: “For me, all that is not 
accepted by Islam, I would not do it and I would not allow my wife to do it either.” Another
male participant stated that: “There are negatives to modern family planning such as
infertility, the risk of giving birth to twins, and miscarriages. There exist traditional
contraceptive methods which are more effective and with fewer risks.” Yet another pointed 
 
1
 Four health posts are in the Tambacounda municipality which is the regional, departmental, and district 
capital; the regional hospital and district health centre are both located here.
15
out that “Some women seek contraception secretly, that means they want it but their
husbands are not convinced.” Discussions with CHWs revealed that although people in their
villages readily discussed FP, they did not think that many people practiced it. Other CHWs 
claimed that some village and religious leaders in the program intervention zone forbid
discussions on family planning. Nevertheless, it seems clear that as women become more
informed, they have been empowered to take the initiative for their reproductive health by
seeking to obtain FP methods. 
In the THSP proposal, Africare had planned to provide refresher training for 200 trained birth 
attendants (TBAs). This was based on figures provided by the Tambacounda Health District
and by Engender Health, an NGO that had trained TBAs in the Tambacounda region in 2001-
2002. At program start-up however, the THSP was able to identify only 25 TBAs in activity 
in the entire program zone. Many of the original TBAs had been absorbed into the health
system in other parts of Senegal, or had gotten married and moved away, etc. As a result, 
most program villages do not have access to a TBA. The THSP program cannot support the 
initial training of prospective TBAs due to budgetary and time constraints. TBAs undergo a 
six month practical training by midwives at the district health center. Because the training is 
supervised by district midwives only a limited number of TBAs (six) can be trained at one
time. To make up the deficit of TBAs for Tambacounda district alone, the THSP would need 
to support eight back-to-back, 6 month training sessions. 
To fill the gap created by the lack of TBAs, the THSP program has collaborated with the 
Health Districts to train 53 female volunteers (some of whom are traditional birth attendants)
in reproductive health promotion. These volunteers were given a special title, of 
“Reproductive Health CHWs.” This differentiates them from TBAs, since they are not 
officially recognized as being trained to assist deliveries. 
The 53 RH CHWs completed their training in January 2006, but some only received their
didactic materials (cartes conseils or “advice” cards) in October 2006. The cards produced 
by BASICS were in French and Wolof, whereas the main languages in Tambacounda are
Mandinka and Fulani. The program was obliged to translate the documents into those 
languages before reproducing the cards. 
In her most recent supervision report, based on a field trip undertaken with the Tambacounda 
District Reproductive Health Coordinator, the THSP Maternal and Child Health Advisor has 
recommended that some TBAs based in village health huts be provided with additional
equipment for disinfection of the obstetric utensils they received in their delivery kits. This 
equipment includes pots for boiling, gas stoves, and timers or watches. At present, some of
them are using their cooking pots and wood burning fires for disinfecting utensils. The
program will work with the concerned Village Committees to resolve this constraint.
Next steps
Maternal Health:
The program should concentrate on developing communications and transportation systems
for obstetric emergencies to address the following barriers: delays in reaching the health
facility due to geographic distance; lack of resources to pay for services; inadequate
communication and transportation systems; and inadequate knowledge of where to seek care 
and how to get to the facility. The THSP will need to mobilize communities to organize and 
establish a system to evacuate obstetrical and other emergencies. While mobile phone
16
ownership in villages has increased exponentially in recent years, and Senegal has an
extensive cell phone network, many program areas are still out of reach of the network. 
Nevertheless, the THSP should sensitize beneficiaries to learn their health post telephone
number and their Health Post Officer in Charge contact information to call for the district
ambulance in the case of emergencies. While the district ambulance typically evacuates from
health post to health centre, according to the former District Primary Health Care Supervisor, 
the district ambulance does respond to village emergencies and has saved a number of lives. 
Although under-utilized due to lack of awareness, the emergency transportation system is
also insufficient. In Koussanar, the Rural Community has raised funds for an ambulance
which is based at the health post, but this is only one of 12 posts in the area. 
The THSP, in collaboration with the communities and the Health district, should explore
other options to combine with Health District emergency transportation. The option of the
horse and buggy has met with criticism due to the fact it is not adapted to the terrain,
especially during the rainy season. Moreover, the high degree of care necessary to maintain a
horse is a problem. One alternative would be connecting women with at-risk pregnancies to 
care houses in proximity of health infrastructures. The THSP should facilitate a dialogue
between the health districts and beneficiaries to plan and find resources to establish and
support such facilities. Women should then be encouraged to move to these facilities as they 
near their due dates and a communications action plan should be established and launched at 
onset of labor. This may be arranged through the Maternal Care Groups or the larger
women’s groups at the community level. 
The THSP has improved quality of care through outreach, referral and follow-up. However, 
the program cannot fully address delay #4, given the program’s focus on community services 
and referral. Delay #4 involves delays in receiving quality treatment at the health facility due 
to lack of medicine, supplies and equipment to treat complications, cumbersome
administrative processes, lack of competent, motivated personnel, lack of adequate
supervision and management information systems, lack of outreach and follow-up 
mechanisms. Although the THSP has strengthened health facilities by building the capacity 
of selected health district personnel in obstetric emergencies management, the district health
care facilities lack the necessary medical equipment to truly reduce maternal mortality. The 
next step for the THSP should be to seek the collaboration of a partner organization that can 
supply the regional and district health facilities with the appropriate medical equipment. 
Family planning: 
The program should train its Reproductive Health CHWs in the lactic amenorrhea method
(LAM). Given the confusion surrounding family planning among men, FP discussions and
activities need to target and involve men, particularly with respect to their role in contributing
to a healthy family. Potential topics include the importance and benefits of delayed
marriages and pregnancies (waiting until their fiancées or wives are at least 19), the financial
responsibility and consequences of large families, and the man’s role in high-risk pregnancies 
and maternal mortality. The latter includes discussions of the “four toos”: pregnancies at too 
young an age (girls aged <18), too old an age (women aged >35), too many children (>3) and 
children too close to each other in age (children born less than two to three years apart.) 
Nutrition and breastfeeding
Activities
Nutrition and breastfeeding activities include:
17
o maternal care group and community discussions on exclusive breastfeeding for up to
six months, 
o promotion of complementary feeding with continued breastfeeding up to at least two
years, 
o culinary demonstrations and growth monitoring in selected villages, 
o iron and vitamin A supplementation for pregnant and post-partum women during
prenatal and post-natal consultations and 
o referral of obstetrical emergencies and severely malnourished children to the health
post. 
The MOH targets children under 5 for vitamin A supplementation, deworming and
immunizations during its annual Child Survival Days. The THSP collaborates with the
MOH, the Health District, and UNICEF on National Immunization Days (NID), National
Micronutrient Days (NMD) and Child Survival Days to target children under five for vitamin
A supplementation, deworming and immunizations. The THSP supports those initiatives by
contributing logistical support (fuel, cars), human resources (for social mobilization,
identification of households needing immunizations and re-treatment of bednets), and funds. 
Those activities scheduled in the DIP that have not yet taken place are:
o the referral of moderately malnourished children to the 17 Centres d’Education et de 
Récupération Nutritionnelle (CERN) for nutrition rehabilitation, 
o support of community efforts to raise poultry for consumption and 
o establishment of micro-credit schemes to expand such activities. 
The CERNs were established by Africare’s PARINS project in the Tambacounda commune, 
and are managed and financed by the communities they are located in. These communities
raise funds locally to finance the feeding sessions. As the program does not yet intervene in
Tambacounda commune (this will begin this year) no children have yet been referred. The 
program is also working with present village committees where growth monitoring takes
place to explore the possibility of establishing similar centers. 
Progress towards intermediate objectives
The mid-term KPC results show that most THSP indicators in nutrition and micronutrient 
supplementation improved as compared to the baseline. With respect to maternal nutrition,
60% of mothers received vitamin A supplementation within 42 days post-partum as
compared to 11% at baseline. Iodized salt consumption within households increased from
49% to 59 percent. As for child nutrition, 85%2
 of mothers report practicing exclusive
breastfeeding for six months compared to 24% at baseline. Vitamin A supplementation of
children 6 to 24 months increased from 40% to 72 percent. However, growth monitoring
decreased from 37% to 21% and malnutrition (underweight) increased from 20% to 24% in
the intervention zone. 
As a comparison, Tambacounda health district data indicate that only 12% of postpartum
women received vitamin A supplementation within the 42 days after delivery in 2005. Data
for the other indicators were not available. Typically, the Health Districts take advantage of
UNICEF-financed Child Survival Days to supplement children in vitamin A. Some Officers
in Charge (OICs) also take the opportunity to stock their health posts with vitamin A
supplements left over from the micronutrient campaigns. However, not all OICs regularly 
 
2
In Senegal, the MOH accepts as exclusively breastfed, children who have had nothing other than breast milk 
and the one-time blessed water associated with Muslim beliefs in this part of the world. 
18
restock their health posts in vitamin A. Despite the MOH’s 2004 mandate concerning routine 
vitamin A supplementation, according to the THSP MCH Advisor, postpartum women in the 
Tambacounda District’s Health Center do not receive vitamin A supplementation. The 
Tambacounda District’s Primary Health Care Supervisor believes that this is a financial issue:
the health structures prefer to obtain free vitamin A from the UNICEF campaign rather than 
to purchase vitamin A. The program managers believes it is more a question of bad planning, 
as UNICEF has informed Africare that it provides the district with Vitamin A for mass
campaigns as well as routine administration. 
Effectiveness of the intervention
Overall, this intervention seems effective for micronutrient supplementation. The THSP’s
IEC/BCC and social mobilization strategies (engaging influential personalities such as
religious leaders, village chiefs and CHWs) are very effective in rallying communities to
national and district campaigns for targeted interventions like deworming, vitamin A
supplementation, and immunization during Child Survival Days and other National
Immunization and Micronutrient Days. However, overall child nutrition shows a negative
trend, with growth monitoring on the decrease and malnutrition on the rise.3
 
In fact, nutrition appears to be the weakest THSP intervention, primarily due to the program’s
original design. Evaluation team members had the opportunity to visit the village of Koar
where the IMCI CHW presented exclusive breastfeeding and complementary feeding to a
group of 33 women and children. Although this village has been enrolled in the THSP for 
more than a year and a half, the CHW was presenting this nutrition theme for the first time 
(until then the focus had been on RH, malaria and diarrhea). The messages were accurate 
(exclusive breastfeeding for six months, complementary feeding with food variety and
nutrient-rich foods with a focus on vitamin A). One important message the IMCI CHW did 
not address was the proper positioning for optimal breastfeeding. 
A few evaluation team members attended a growth monitoring session and a culinary
demonstration in Koussanar. The IMCI CHW held accurate books, weighed and read
weights correctly, and gave appropriate, standard nutrition advice. The culinary
demonstration utilized World Food Programme (WFP) enriched flour donated to the Case des 
Tout Petits (the GOS’s educational programme for children age two to five). The porridge 
comprised of WFP enriched ground flours of maize, peanuts, beans seasoned with onions,
dried and smoked fish, local vegetables, iodized salt and red pepper, seemed nutritious and 
was tasty. 
As many beneficiaries have historically been used to receiving supplemental food for
improved nutrition during growth monitoring sessions from other non-Africare programs, 
some beneficiaries are unmotivated to attend growth monitoring sessions where no food
incentives are distributed. The CHWs report this as a problem for THSP growth monitoring
sessions. To further compound the problem, some Health Post OICs do not offer growth
monitoring regularly due to their heavy workloads. As a result, most children under five are 
not growth monitored. 
The original proposal design and the DIP focused primarily on micronutrient 
supplementation and exclusive breastfeeding indicators for improved child survival. While 
 
3
The baseline and the mid-term KPCs were conducted during the dry and rainy seasons respectively. The 
increase in malnutrition rates may be seasonal due low availability and access to foods during the rainy season 
until after the harvest. 
19
the THSP has progressed on these indicators, they are insufficient in making a nutritional 
impact considering that most malnutrition happens between the ages of 6 and 24 months.
The introduction of complementary foods after exclusive breastfeeding has stopped, and 
increased risk of infection through this vehicle (poor food preparation, hygiene and 
sanitation, inadequate foods) and increased mobility of the child, all make children in this age 
group particularly vulnerable. Until the THSP reinforces these areas, overall malnutrition 
(under-nutrition) rates may either remain stable or continue to rise. The consultant highly 
recommends that the program extends the intervention age range to at least 24 months, so as 
not to miss a serious impact opportunity if the age range is not extended and the strategies are 
not strengthened. The HEARTH approach would be an appropriate strategy to build 
community capacity to nutritional rehabilitation.
Changes in technical approach
There were no changes in this approach.
Special outcomes, unexpected successes or constraints
Budgetary constraints and a program design that focuses primarily on micronutrient
indicators and exclusive breastfeeding seem to limit the nutrition component of child
survival. Only 27 villages will implement important activities such as growth monitoring
combined with culinary demonstrations. At the midterm, 15 CHWs had been trained in
growth monitoring and had received Salter scales. 
According to the results of the initial KPC, grandmothers are the main caretakers (35%) of 
children in the program zone. Given this statistic, and the fact that grandmothers do not
automatically participate in the Maternal Care Groups, the project needs to do more to enroll 
grandmothers. The administration of toxanthal (Islamic holy water that is often non-sterile) 
remains a practice that may interfere with exclusive breastfeeding. According to the mid-term 
KPC, 50% of children under two received the holy water. According to the Africare Senegal 
Health Program Manager, the holy water is typically administered as the first drink the child 
receives as protection before even breastfeeding. The MOH has been tolerant of this practice
and counts children as exclusively breastfed if they receive no other food or drink than breast 
milk and holy water. 
The Health District’s ability to offer health care services to severely malnourished children
who are referred remains inadequate due to lack of medical equipment and expertise at the 
health post level. The present procedure is to refer these children to the Health Center in
Tambacounda. Some caretakers refuse this referral for lack of resources and/or because of the 
distances involved. This results in inadequate treatment of these cases at the health post level. 
The THSP’s community efforts to refer, link and increase health care services access and
utilization among severely malnourished beneficiaries are thus frustrated by this weak link in
the referral system. Again, the use of the HEARTH model is recommended to resolve this 
constraint.
Follow-up and next steps
Exclusive Breastfeeding
The next steps for this component consist of reinforcing exclusive breastfeeding. 
Considering there are alternatives to ingesting the non-sterile holy water (such as whispering
Coranic verses in the child’s ear), the THSP should consider promoting and emphasizing
other acceptable blessings. Grandmothers need to be systematically enrolled in the program
20
and need to participate in the discussions and health education sessions on the importance of
exclusive breastfeeding. Finally, the IMCI CHWs should demonstrate and discuss proper
breastfeeding positions for optimal breastfeeding rather than waiting for the RH CHW or the 
TBA to discuss it in the Maternal Care Group sessions or when a woman gives birth. 
Complementary feeding
Complementary feeding should be reinforced with messages grounded in age appropriate
feeding Frequency, Amount, Density, Utilization, and Active Feeding (FADUA). While 
food variety has been a strong message, active feeding on the part of the mother/caregiver, 
cleanliness and hygiene, and frequency of feeding need more emphasis. 
Feeding the sick child
Since diarrheal and malaria prevalence in children remain high, the THSP needs to
disseminate more messages on feeding the sick child more frequently during and for two
weeks after illness to assist the child in catch-up growth. 
Growth monitoring
Growth monitoring is the main method to assess proper growth and physical development
from a nutrition perspective. The THSP should mobilize and increase awareness for seeking
this service. CHWs should also address the question of supplemental food at these sessions: 
this should not serve as an incentive for assessing a child’s health. 
Control of Malaria
Activities
Malaria prevention and case management activities consist of health education discussions
within Maternal Care Groups and in the wider community. These discussions focus on
prevention, early recognition and care seeking, promotion and distribution of Insecticide
Treated Nets (ITN), re-treatment of bednets, referral of suspected malaria cases and of
pregnant women for Intermittent Presumptive Treatment (IPT). 
Health promotion of key behaviors
Community health workers trained in the IMCI community approach and RH CHWs carry 
out group discussions, home visits to sensitize mothers and caretakers on:
o the prevention of malaria using insecticide treated nets, 
o the importance prompt care seeking for fever and other signs of malaria, 
o the danger signs of malaria for children and pregnant women 
o intermittent preventive treatment of malaria for pregnant women. 
Through these activities CHWs and TBAs have reached over 31, 000 women and 
approximately 6,400 men in the year 2005/2006. 
Referral of children less than five and pregnant women 
Until June 2006; the Ministry of Health policy stipulated that all treatment of malaria cases 
including IPT and the new combination therapy with ACT be prescribed by qualified health 
personnel. To support this strategy, THSP volunteers were trained to refer to the health post all 
suspected cases of malaria and pregnant women for IPT. In the past year, 645 children less than 
five and 91 pregnant women were referred to the health post for fever and other symptoms of 
malaria; as pregnant women referred for prenatal care also receive IPT.
21
More recently, the MOH decreed that ACT can be administered through the health huts by 
trained auxiliary health agents (AHAs). The MOH has begun training AHAs in first-line 
treatment with ACT in some districts, although the districts of Tambacounda and Koumpentoum 
have as yet to train AHAs.
Community Based Distribution of ITN
The THSP supports local efforts to sell high quality ITNs at a reduced price at the village
level through community based organizations. Village Committees (VCs) were asked to raise 
funds to purchase a starter pack of products including ITNs, to be sold by CHWs and TBAs. 
Since the start of program activities, Africare’s efforts to secure ITNs through UNICEF and 
the National Malaria Control Program (PNLP) were unsuccessful mainly because of the 
unavailability of nets nationally. Efforts to secure nets locally through the district were also
unsuccessful as the districts also did not have nets. Nets became available in the districts in
June 2006. The district has signed agreements with 40 VCs to sell nets on its behalf. The 
agreement stipulates that the VC buys the net at 800 CFA from the district and resells it at 
1,000 CFA to the community, and, that women and children should be given priority. To 
date the VC have purchased a total of 580 nets from the district of Tambacounda. 
National Malaria Control Program Grant
In November 2005, the THSP signed a partnership with the PNLP that provided $20,000 
from the Global Fund for malaria-specific activities. The funding was used for activities such 
social mobilizations, environmental sanitation (inside and outside of the households), and the 
distribution of insecticide treated nets. In addition to the funds, the PNLP also provided 1,000 
bednets. 
Activities were essentially focused on:
o Social mobilizations which consisted of mobilization days and community quizzes
in 30 villages; 
o Theatre performances in 22 villages;
o Village sanitation days known as set setals in 20 villages.
The grant also financed a radio programs aired on RTS which has regional coverage.
Through the PNLPP grant the program also provided 45 VC with grants of 40,000 CFA. The 
grants were provided to each VC upon signature of an agreement. The VC’s responsibilities 
include supervising program activities, fundraising and mobilizing community members. The
grant money was used in part to purchase a starter kit of products to be sold in the village.
 
Progress toward intermediate objectives
KPC data illustrate that malaria/fever prevalence two weeks prior to the survey was at 50
percent. This represents an increase of 25 percentage points from baseline. The most likely
explanation for this increase is that the data for the two KPCs were collected at different
times of the year. The baseline KPC was carried out in March 2004, the end of the dry
season, whereas the mid-term KPC data were collected in September 2006 towards the end of 
the rainy season. 
The Tambacounda Health district data show a substantial decrease between 2003 and 2005 in 
malaria cases in children under five (from 25% to 11%) and among pregnant women from
(18% to 3%). KPC results also show a substantial increase in the percentage of women with 
access to Intermittent Presumptive Treatment (IPT), from 2% to 68%. In comparison, district 
records show that only 41% of pregnant women received two IPT doses in 2005, data for 
22
2003 is not available. There was a slight decrease in the percentage of women able to cite a 
malaria danger sign that necessitates care seeking within 24 hours; the percentage went from
48% to 40% at mid-term with the program’s target set at 60%. As for reported ITN use, it 
increased more than fourfold for both pregnant women (from 18% to 83%) and for children 
under two (from 21% to 94%).
The decrease in malaria prevalence in children under five and in pregnant women may be
attributed to several factors. Due to the program’s IEC/BCC activities, there is an increased 
awareness among women of the means of malaria prevention, its danger signs and the 
appropriate care seeking behavior. Secondly, the MOH now provides free IPT for pregnant 
women at the health post, and part of the THSP health promotion activities has been to raise 
awareness among women of this service. However, according to the program managers, the 
mid-term KPC’s figure for the reported access to IPT by pregnant women (68%) seems high 
and requires further verification. According to the KPC, only 46% of women surveyed
actually possessed an antenatal card and could therefore be confirmed as having attended 
their prenatal visits. 
The large increase in reported ITN use may be explained by various factors. Over the past 18 
months, the THSP has implemented an intensive awareness raising campaign on the
importance of net use for malaria prevention. The program has also supported the UNICEF￾financed Child Survival Days, organized twice yearly throughout the region, during which
CHWs distribute nets and re-treat existing nets. More recently, the PNLP launched its
accelerated phase for ITN distribution, although it should be noted that the nets only became 
available in June 2006. 
The evaluator recommends that the program take steps to validate the level of net use among 
its beneficiaries during routine monitoring activities. Traditional healers also report that are
treating fewer cases of malaria. According to them, this is due to increased community
awareness on how to prevent the disease. It is important to note that this is based on reported
cases of malaria, as opposed to confirmed cases. Nevertheless, it is reasonable to conclude 
that the THSP’s malaria-related health promotion activities and logistical support have acted
as a catalyst for improved health outcomes.
Effectiveness of the interventions
Overall, the intervention mix which targets pregnant women and young children seems quite
effective in reducing malaria cases. Africare, as a participating collaborator in the National
Malaria Control Program, mobilizes communities and raises awareness about ITN use. 
Changes in the technical approach
No changes in the technical approach. 
Special outcomes, unexpected successes or constraints
Constraints: Delays in receiving ITNs have affected the implementation of this intervention. 
Although the PNLP ordered a supply of ITNs in December 2005, they only arrived in June 
2006. Cases of malaria are still quite high (1 in 2 children contracted fever two weeks prior to 
the midterm KPC.) Village Committees lack equipment such as shovels, wheel barrows and
the like to undertake their environmental sanitation activities. 
23
Follow-up and next steps
Malarial prevention
The THSP needs to put in place a system for monitoring and ensuring regular bednet re￾treatment. The PNLP reportedly will be promoting indoor household spraying as a
complement to ITN use. 
Malaria case management
As indicated in the nutrition section, CHWs need to draw attention to feeding the sick, febrile 
child more food throughout illness and particularly during the two weeks after illness so as to 
help the child regain its strength and weight it may have lost during loss of appetite. 
Control of diarrheal diseases 
Activities
Diarrheal control and management activities include health education discussions on causes
of diarrhea and methods of prevention, key behaviors for the correct management of diarrhea 
at the household level including promotion and distribution of Oral Rehydration Salts, and
recognition of danger signs for referral. Mothers and caretakers of children are also sensitized 
on the importance of increased fluid intake during an episode of diarrhea, as well as increased 
feeding for children who have been weaned. CHWs trained using the community IMCI
approach are responsible for carrying out these activities. They also refer all cases of diarrhea 
presenting danger signs.
At 10% of LOE, the diarrhea intervention is the THSP’s smallest component and has the
most limited number of activities. Rather than spreading out the planned activities over a 12
month period, program managers instead decided to focus diarrhea specific activities on the 
cholera/diarrhea months of March to May. This is a time when there is a particular risk of
cholera outbreaks due to an annual religious pilgrimage to the northern Senegalese town of
Touba. During 2005-2006, the program reached approximately 1,500 women and 323 men
with health promotion messages on diarrhea. Volunteers also referred over 200 children to
the health post for diarrhea associated danger signs.
Progress towards intermediate objectives
The KPC results reveal that diarrheal prevalence during the two weeks preceding the survey
decreased from 45% at baseline to 28% at the mid-term. Roughly one-quarter of surveyed 
mothers (27%) treated their child with ORS compared to the target of 65 percent. This
represents a decrease from baseline results wherein half the mothers (52%) utilized ORS. The 
target for this indicator stands at 65 percent. Recognition of danger signs doubled from 43% 
at baseline to 87 percent. Conversely, a lower percentage of mothers (39%) at the midterm
evaluation report their child ate the same amount or more foods during a diarrheal episode
compared to 48% at baseline. 57% of mothers report giving their child the same amount or 
more liquids during a diarrheal episode compared to 48% at baseline. In terms of diarrheal
prevention, 14% of mothers report washing their hands at the four critical times (i.e., before 
food preparation and feeding children and after using the toilet and cleaning a child who has 
defecated) compared to 7% at the baseline. 
Tambacounda health district data show that health facilities had only 3% of diarrheal cases
for treatment among children 0-5 in 2005. Comparative data for 2003 were not available. 
Some influential factors that may explain the twofold increase in hand washing include
increased awareness for washing hands due to the MOH’s hand washing awareness campaign 
24
which occurred earlier this year in 2006 after a cholera outbreak. The intensive hand washing
promotion spillover effects would also reduce the diarrheal prevalence, which almost halved 
(seasonality.) As the mid-term evaluation was conducted during the rainy season, a period of 
lean times, it may be that mothers offered less to their children during the diarrheal episodes 
in the past two weeks as they may not have had much to offer. However, their behaviors are 
probably linked to the nutrition component which may not have addressed or emphasized
sufficiently feeding of the sick child. 
There are differing views on the decreased use of ORS. According to the Tambacounda
District Primary Health Care Supervisor, it may be due to lack of access to ORS due to a
Regional ORS stock out, which had been in effect for four months at the time of the
evaluation. The THSP program managers, however, are not aware of any recent stock outs 
for ORS. The TSHP ordered ORS sachets several times between February and July 2006 for 
Village Committees. Along with UNICEF, the THSP program managers believe the low use 
may be due to the lack of promotion of ORS use by health facility staff who tend to prescribe 
antibiotics for diarrhea cases. Some mothers and children also reported disliking the taste of
the ORS. 
Effectiveness of the intervention
This intervention seems to be experiencing issues primarily due to the late and infrequent
introduction of the topic of diarrheal prevention and management in some villages. 
According to the Program Coordinator, CHW are only required to conduct a minimum of
three group discussions a month, for a total of 36 a year. Since CHWs and TBAs work on a 
volunteer basis, the program managers estimate that a 3 group discussions and 4 home visits 
are a reasonable workload for people who are working at other occupations. This may
explain why some messages are not be well assimilated or retained; if one misses a session, 
they are more likely not to have the opportunity to get the information in a short interval. For 
example, at the Koussanar village growth monitoring session, an evaluation team member
asked one mother whose child had diarrhea, if she knew how diarrhea was contracted. She 
indicated that it was from drinking cold milk. The CHW advised her of some transmission
modes but not the most critical one of hand washing. Coupled with the low reported use of
ORS, this makes it all the more difficult to change behaviors positively in diarrheal
management. 
Changes in the technical approach
No changes in the technical approach.
Special outcomes, unexpected successes or constraints
During focus group discussion with a group of CHWs and TBAs, some did not know the four 
critical times hand washing should take place. This is not optimal for dissemination of
comprehensive, complete messages for diarrheal prevention. 
Follow-up and next steps
Capacity building
IMCI CHWs should receive on the job refresher training on diarrheal transmission modes,
prevention and management. The consequences of poor diarrheal management should also be 
addressed. 
25
Diarrheal prevention
CHWs need to increase their efforts to promote hand washing as a diarrheal prevention
method. The THSP should ensure that all CHWs know the four critical times when hand
washing needs to take place consistently (two befores: before food preparation and before
eating/feeding a child; and “two afters”: after defecating and after cleaning a child who has
defecated.) The beneficiaries should also increase their hand washing knowledge and
practices. 
Diarrheal Management 
Considering conflicting explanations regarding the reasons for the low use of ORS, the THSP 
should conduct a qualitative study to find out the reason(s) for low use among beneficiaries. 
The study could also examine hand washing practices and beliefs. Additionally, CHWs
should emphasize increased fluids and breast milk or only breast milk for those younger than
six months during diarrheal episodes. As mentioned for the nutrition intervention, CHWs
need to underscore that nutrition management is crucial to a child’s survival and recovery
during illness and especially for two weeks after illness to regain any weight loss. 
2. Cross-cutting approaches 
1. Community Mobilization 
Community mobilization strategies include engaging influential community personalities to
mobilize their communities. The community members summon the local Imam to make an 
announcement on Fridays during the weekly prayer at the mosque. The public crier
circulates on foot or by horse-drawn cart through the program villages announcing various 
THSP activities through his megaphone. Monitoring committees and the presidents of
community groups act to mobilize communities for program activities. These strategies seem
effective. 
Overall, targeted beneficiaries have responded adequately to mobilization activities. Social
cohesion seems particularly strong within the Maternal Care Groups. Village Monitoring
Committees support CHW activities. Evaluators had the opportunity to observe a radio 
crochet (a community quiz) which comprises an entertainment component such as music or a 
local dance interspersed with health questions and prizes for correct answers. The latter
provides a means of evaluating community knowledge retained from the discussions. 
Barriers to social mobilization include the scorching heat for over six months of the year, 
which can reach temperatures that exceed 40 degrees Celsius (over 104 degrees Fahrenheit.) 
Understandably, people are not willing to come out to receive a health education session in a 
public place under such heat. To resolve this constraint, CHWs conduct sessions in the late 
afternoons or at night when the temperature is cooler. The rainy season also constitutes a
barrier to access populations particularly for supervisory visits. The program attempts to deal
with this issue by rescheduling sessions. 
The turnover rate of CHWs seems to be problematic. Absenteeism and non-committed 
CHWs impact program activities negatively. Since the beginning of the program several
CHWs have left and continue to leave the program in search of better opportunities that are 
remunerated. This sets the program back as new CHWs have to be identified and trained. 
26
In an informal interview of CHWs, they expressed their frustrations with both the THSP and 
the communities they serve (despite their current dedication). According to them, the THSP 
stated that CHW would be compensated through the cost recovery program. The program
also promised that when the Maternal Care Groups’ microcredit component was launched,
the CHWs would be first to benefit from the credit. To date, THSP has not launched the
micro-credit program and the cost recovery program earns minute amounts.
4
 
The CHWs also feel that the program does not appreciate the time it takes to get from one 
village to another on foot, which, can be as far as five to seven kilometers (3 to 4 miles.)
Once communities have been informed and mobilized for activities, they have a tendency to 
come very late, further “wasting our time.” Beneficiaries do not offer to help cultivate the
CHWs farms in exchange for their services or to show appreciation. 
According to some CHWs, they volunteer ten days a month. The program managers believe 
they commit only five days. To address some of these frustrations, the THSP coordination
team authorizes and encourages public recognition of CHWs with a gift, as a form of
motivation and appreciation. However, most supervisors are not regularly taking advantage
of this opportunity to motivate the CHWs they supervise. The THSP in collaboration with its 
community partners needs to put in place a strategy to motivate and show appreciation for the
CHWs to boost morale and motivation for their work. 
2. Communication for Behavior Change 
The THSP centers its BCC strategy on the BEHAVE framework. A local dramatic theater 
troupe, a local community radio program, home visits, group discussions, interviews,
community quizzes (radio crochets), and meetings comprise the mass communication and
interpersonal strategies for behavior change. The program’s approach is appropriate and
effective given the variety in its strategies and target audiences. 
The greatest barrier to behavior change may be attributed to the extremely high illiteracy rate 
in the district. Beneficiaries and CHWs alike find it challenging to retain and thoroughly
understand selected information. Program supervisors have tried to address this problem by
closely monitoring and providing assistance and guidance to CHWs with literacy-related 
problems, but this has been an on-going challenge and will remain so throughout the
program. 
Another important constraint for behavior change is the conservative and traditional nature of
Tambacounda communities. The majority of women in the target villages still rely on
decisions made by either their husbands or their mothers–in-law. A woman who is in labor 
and needs to be evacuated still has to wait for her husband to give the go ahead before she 
can leave for the health post. Women who seek care at a health facility and are prescribed 
medication still need to return home to get permission from their husbands to buy the drugs. 
Men tend not to take part in activities that are attended by women: according to the THSP 
monitoring records, the program is reaching five times as many women as men with its
IEC/BCC activities. The program will have to revisit its approach for enrolling men and
incorporate more IEC activities that specifically target them. 
The program has dealt with other barriers to behavior change, such as women refusing to
seek ante-natal care consultations from male nurses, primarily through small discussions and
 
4 Medicines are sold at affordable prices for impoverished communities. 
27
increased awareness. However, the THSP has rarely conducted focus groups to truly assess 
barriers to behavior change. According to the Program Coordinator, this was due to lack of 
human resources and also to the late start in program implementation. 
With respect to the technical soundness of the messages disseminated, they are in keeping
with Ministry of Health’s protocols and international best practices. The program’s home
visits engage husbands and paternal grandmothers and serve as fora to negotiate behavior
changes and teach skills. Since its implementation, the THSP has not measured the effects of 
behavior change activities. Consequently, there is no data to drive programmatic decisions to 
reinforce or promote other behavior changes. The THSP has focused primarily on increasing 
awareness and health–related knowledge. Anecdotal accounts suggest that the innovation and 
piloting of Maternal Care Groups has been successful in changing behaviors among women
of reproductive age. These groups are directly responsible for changing such problems as the 
under-utilization of health services and delayed health care seeking practices. It is safe to say
that this has contributed to the reduction of maternal and child morbidity and mortality in the 
program zone. A more in-depth description of maternal care groups can be found in the
Highlight Results of the document. 
3. Capacity Building Approach
Strengthening the Grantee Organization
At the field level, due to the program’s late start, the THSP staff was unable to benefit from 
planned capacity building opportunities from KPC baseline data collection, analysis and
interpretation or DIP development. These activities took place prior to hiring the program
staff. Likewise, at the mid-term evaluation, due to time constraints, program staff focused on
focus group data collection while the district concentrated on KPC surveys. Nonetheless,
program staff has been monitoring and documenting program implementation and lessons
learned. To date, program staff has not had much opportunity for professional development. 
With respect to the field office and Africare HQ, at the time the proposal was submitted,
Africare had just welcomed Mr. Julius Coles as its new president, who articulated his vision
of “Africare being the largest PVO on the African continent,” at a 2002 organizational wide
strategic planning meeting in Dakar, Senegal. The following organizational development
objectives were put forth in the proposal to strengthen Africare namely: 
· Promote organizational learning: headquarters and field staff capacity for program
design and implementation will be enhanced with increasing cross-fertilization 
between country programs.
· Develop partnerships between Africare and other PVOs and agencies in implementing
child survival programs.
· Improve financial system effectiveness: create real-time interface between HQ and
Field operations, avoiding re-work and reducing lag time for production of financial
reports.
· Improve human resources aspects: a job classification system and remuneration
survey conducted and implemented over time leading to higher staff retention. 
· Improved Management Information Systems (MIS): creation of a web-based system
allowing country offices for prompt access to resource documentation. 
To date, headquarters is in the process of working towards its organizational development
objectives. It completed the job classification and remuneration system. 
28
Strengthening Local Partner Organizations
The Tambacounda and Koumpentoum Health Districts, local community-based 
organizations, and beneficiaries, have been the main partners collaborating with THSP since
its launch. The health districts constitute both partners and beneficiaries with respect to
capacity building. Their roles and responsibilities include taking the lead in selected health
activities such as immunization, vitamin A supplementation, and deworming campaigns,
conducting supervisory visits, providing human resources for capacity building and guidance
on health-related activities. 
In collaboration with the health districts, THSP provided capacity building on reproductive
health, obstetric emergencies, contraceptive technologies and Community IMCI with a focus
on malaria, nutrition and diarrhea. CBOs and their communities by their sheer numbers
comprise the largest partner benefiting from the trainings. Health district staff represents the 
second largest group. New Health District staff primarily benefited from capacity building
on these themes and served as refresher training for veteran health personnel. While most of
the District staff had been trained in clinical IMCI, THSP brought a new dimension by
introducing community IMCI. This reinforced the Nurse Officer in Charge’s (OIC)
knowledge and capacity to better supervise CHWs who use these community techniques. In
addition to capacity building, Africare Senegal strengthened the Koumpentoum Health
district center with some much needed equipment for its set up. Equipment included a fax
machine, a universal power source (UPS) machine, a sterilizer and a printer. 
The THSP collaborates with UNICEF primarily during its annual Child Survival Days
focused on vaccination, vitamin A supplementation, immunizations, deworming, and ITN
distribution. UNICEF’s role is to ensure child survival through immunization activities,
capacity building in immunization and provision of vaccines and equipment. Although the
THSP Coordinator attempted on numerous occasions to collaborate with UNFPA, Mr.
Babacar Mané, Tambacounda Region UNFPA expert, recognized that he had been
unavailable to truly collaborate. Mr. Mané has now taken a position with Population Council 
beginning in October 2006 and maybe there will be opportunities to collaborate with his
successor. Aside from the above, no formal collaboration has taken place with other local
partners mentioned in the proposal including TOSTAN, Groupe d’Action pour le
Developpement Communautaire (GADEC), Fédération des Groupements Féminins (FGF),
Programme de Développement Intégré de la Santé (PDIS).
The program does provide a regular forum for feedback and input from local stakeholders 
through its Steering Committee. The SC is chaired by the Tambacounda Prefet and has 25
members who meet every quarter to discuss the program’s progress. Committee members
also pay regular visits to project sites and participate in the program’s mobilization activities.
As of the mid-term evaluation, THSP had not regularly assessed institutional capacity or its
partners’ quality of services. The program needs to organize more in-depth discussions with
government partners to identify their needs and proceed with an agreed-upon action plan. 
Health Facilities Strengthening
To date, the THSP has strengthened health facilities in selected domains. Per the Health
Facilities Assessment (HFA) conducted in March 2004, the THSP has focused on the 
following recommendations: 1. build capacity of community health workers (referred to as
lower level health personnel), 2. increase health service utilization by increasing demand
29
through IEC/BCC; 3. revitalize health committees, 4. provide logistic support for outreach
activities; and 5. organize a workshop to sensitize traditional healers on key maternal and
child health practices. 
The aforementioned activities are in keeping with the program’s objectives and adapted to
selected facilities’ needs for strengthening. Aside from the supervisory tool to assess CHW
performance, the THSP has not assessed health facilities since the baseline. Due to budgetary 
constraints, the THSP opted not to collect any intermediate monitoring data for its health
strengthening activities. 
The THSP has reinforced linkages between health facilities and communities, though not in
all cases. CHWs and TBAs refer cases of malaria, diarrhea, malnutrition, high-risk 
pregnancies and obstetrical emergencies to health facilities. Health post nurses work together 
with trained TBAs to deliver normal and high-risk pregnancies as well as obstetric
emergencies at the district health facilities. OICs, trained in community IMCI, now have an 
improved capacity to supervise CHWs and TBAs. They do not always carry out these
supervisions on a regular basis. Reasons for irregular supervision include time constraints,
lack of organization, and no specified times for activities. 
Strengthening Health Worker Performance 
Program strategies to strengthen health worker performance concentrate on capacity building
and monitoring through supervisory visits. Overall, these strategies have been more effective 
for some than for others due to the underlying problem of low or incomplete illiteracy. A low 
level of illiteracy is reflected in the CHW’s performance, in the form of incomplete
information, misunderstandings and the inability to properly convey health messages. The 
program’s training materials and performance assessment tools are not well adapted for low
literacy. For example, the IMCI CHW supervisory tool measures CHW performance,
knowledge and ability keep his/her books accurately. The knowledge section fails to test the 
four critical moments for hand washing, or the definition of malnutrition and some of its
causes. During meetings, staff members solve problems and seek solutions with the
assessment results to improve service quality. The THSP primarily tries to address these gaps 
between performance standards and actual performance with more supervisory visits and
one-on-one assistance. 
Training
The THSP has adopted the cascade training strategy promoted by the MOH. A consultant or 
senior level specialist trains all senior level district personnel in a training of trainers’ session. 
They subsequently train the next level of personnel who, in turn, train the lower level
personnel. The THSP, in collaboration with its partners, has conducted training sessions in
the following topics: C-IMCI, reproductive health, contraceptive technology. Below is a
summary table of partners who received this training.
Table 1: Capacity Building targets and themes 
Target Group Total number trained Target Theme
Community Leaders 105 Reproductive Health
Health Post Nurse 
Officers in Charge
14 Reproductive Health
Traditional 
Practitioners
375
50 Malaria and 
Reproductive Health
 
5
Traditional Practitioners attended an informational seminar rather than a training. 
30
Trained Traditional 
Birth Attendants 
(Matrones)6
25 (Received Refresher 
training)
200 Reproductive Health 
and safe deliveries 
Health Post Head 
nurses
16 Contraceptive 
Technology
Midwives 2 Contraceptive 
Technology
CHW, C-IMCI 186 (C-IMCI), 54 
(RH), 
400 C-IMCI
CHW, RH 54 Reproductive Health
CHW 15 27 Growth monitoring
Health Post Nurse 
Officer in Charge and 
midwives 
51 (21 in 
Tambacounda and 30 
in Koumpentoum)
70 C-IMCI (51); RH 
(14); contraceptive 
Technology (18)
Pre- and post-test indicated improvement in knowledge. Some participants’ skills are
assessed through supervisory visits. 
4. Sustainability Strategy
To date the THSP has focused on five sustainability strategies:
Village Committees
The Village Committees (VC) have been involved in the implementation of activities since
the launch of the program. After selecting villages in collaboration with the Districts, the
THSP program staff held general assemblies in every participating village. The objective of
the general assembly was to:
o Present the program objectives, strategies and activities to community members
o Identify community leaders and other stakeholders, particularly women’s groups
o Determine if a Health Committee existed in the village and whether it was active
o Where there was no Health Committee, elect members for a Village Committee
o Together with the members of the VC, select the community health volunteers.
The VCs are the program’s representatives in the community. The VCs monitor the work of
CHWs and TBAs, and each month receive a copy of the volunteers’ monthly report. The VC 
is also responsible for fund raising and management of funds raised through the cost recovery
scheme; they provide a nominal payment to the volunteers from money raised this way. To
improve their leadership and management capacities the program will be training VC
presidents and treasurers in management and leadership in the coming year. The program
aims to progressively capacitate the VCs to take over monitoring of activities in their
villages, and to assist them to create viable ways of generating income to support the work of 
volunteers.
Maternal Care Groups
The THSP has integrated its behavior change activities in already existing networks of
women’s groups and community-based organizations. The THSP, in collaboration with the 
 
6
There exists two types of traditional birth attendants: 1. the matrones (trained TBAs) (have completed formal 
training in reproductive health and delivery); 2. the Accoucheuses traditionnelles (have not received any training 
in clean and safe deliveries but still deliver in the community, although not recommended by THSP).
31
presidents of CBOs, divided their membership into smaller groups to create Maternal Care 
Groups. The program’s present 209 Maternal Care Groups (with 18 to 30 members each)
have become fora for health discussions, behavior change, monitoring and supporting
pregnant and lactating women. They also provide assistance for members who cannot afford 
transportation costs and or medication. As the groups are within an already existing
framework and led by a trained volunteer, this activity seems quite sustainable. Focus group 
data suggest that women prefer Care Group discussions and have indicated that they were
convinced in such a setting to adopt more healthy behaviors. For a more detailed description 
of the Maternal Care Groups see the Results Highlight section.
Behavior Change Communication
The THSP has established a mentoring system between more experienced mothers and
pregnant women to ensure positive behavior change. The strategy relies heavily on trained
CHWs for guidance, advice and skills strengthening towards better health management. 
CHWs conduct home visits and private discussions with husband and wife (sometimes
including paternal grandmother depending on the topics) for more attention focused on skills
development and negotiating behavior change. 
Integration of health service interventions within the GOS health system
The program’s premise is to improve the linkage between the community and the district and 
regional health systems. MOH policies and standards serve as the framework for the 
program’s community health services. Referrals from the community to the health systems
serve not only to improve health but also to integrate and link the community with the MOH. 
Additionally, the MOH integrates the data from community health activities in its statistics. 
Community cost recovery of health products
The THSP provided TBAs and RH CHWs with supplies of iron pills, hygiene kits, 
contraceptives (the pill7
, spermicide, female and male condoms). IMCI CHWs received
ITNs, ORS, mebendazole (deworming syrup and pills). CHWs sell these health products at 
community-affordable prices and restock their supplies. This cost recovery also exists at the 
health post. However, little remains for CHWs as compensation or motivation for their time 
and services. 
Aside from the cost recovery schemes, the THSP has not yet initiated activities to build
financial sustainability. The planned micro-credit component to support health activities and
motivate CHWs has yet to be launched. In May 2006, Africare Dakar Assistant Program 
Manager Ousseynou Samb and Program Manager Gorgui Sène Diallo spent a week in
Tambacounda establishing a microcredit action plan. 
The THSP staff acknowledge that all steps of the micro-credit action plan have not yet been 
completed. Although Africare Senegal has sufficient funds to launch the micro-credit
component, the Country Representative wants to resolve some outstanding debt issues in the
Tambacounda department before releasing additional amounts of credit. The program managers 
have provided assurances that as soon as these issues are cleared up, the microcredit component 
of the THSP will be launched. 
 
7 Women must see qualified personnel at the health post for the first visit and prescription of contraceptive pills. 
At that time, they receive a three-month supply from the health post and the TBA or RH CHW can refill 
prescriptions, as long as there are no complications. In the event of problems related to the pill, the TBA must 
refer the woman to the health post for further check up. 
32
During focus group discussions, the beneficiaries proposed a several alternative funding
sources at EOP. Some CHWs suggested that Maternal Care Group members could contribute to 
a revolving credit scheme where half the members would receive the credit and work and later 
the other half would benefit from the same. They also stated that income generation activities
such as small gardening and trade would help to increase their funds. Other ideas included
linking community leaders to financial institutions for increased access to credit and taking
advantage of open bank accounts so that Maternal Care Group members and the rest of the
community can benefit from financing.
Focus group participants believed that community members and district personnel were the
best choices to sustain activities at program end. Village chiefs (for spearheading a decision
and endorsing an activity and mobilizing their community), heads of households, women
(because they are not as mobile as men seeking employment opportunities), religious leaders
(to mobilize men), CHWs (for IEC/BCC activities), Village Committees (responsible for THSP 
activities, mobilizations, management and inventory of medicines, organizing discussions, 
encouraging population seek advice and health care from trained TBAs, financial management 
of products), Maternal Care Group members (to organize microcredit activities) and OICs in
Charge (for capacity building) were in the best position to ensure that activities are sustained at 
program-end. 
At present, the program has difficulty evaluating its sustainability factor. The THSP’s
monitoring system focuses primarily on process data. To date, for instance, the program has
established 209 Maternal Care Groups and has enrolled 234 active CHWs. Beyond such
process indicators, the program has no system to measure achievement of further sustainability
objectives. 
C. PROGRAM MANAGEMENT 
1. Planning
Since the beginning of the program, the THSP coordination team does most of the planning. 
The coordination team meets quarterly to plan three months worth of activities. They also
meet monthly to assess field activities and resolve constraints. Partners are integrated at
various levels and for selected activities. Every program supervisor has a coordination
meeting with the community health volunteers of his/her zone to plan activities for the next
three months. 
The collaboration between program supervisors and District Health Post OICs varies on a
case by case basis. Some OICs collaborate more than others. Overall, the Health District and 
the beneficiaries have been the two main groups involved in participatory program planning. 
The THSP field staff, Africare Senegal, Africare HQ personnel, local level partners, and the 
program communities all understand and have a copy of program objectives. However, not 
all partners share the program’s monitoring and evaluation plan. The program CHWs have
tools for data collection. The THSP management team synthesizes program activity
monitoring data, discusses problems at monthly meetings and brainstorms solutions to
program implementation barriers. As of the midterm, most of the activities are on schedule
despite the late recruitment of the Program Coordinator. 
33
Village enrollment seems to be behind schedule. To date, only 123 villages of the 400 have
fully launched activities. Another 96 villages in Koumpentoum have recently been enrolled.
The late launch of activities, the low number of supervisors (3) during the first two years of
the program, and the re-zoning of health districts are among the constraints that have caused 
delays. 
2. Staff Training 
The THSP staff received capacity building in C-IMCI (5 days), Reproductive Health (5
days), and supervisory techniques (5 days). They participated in the Training of Trainers. 
Pre- and post-tests were administered to measure their learning curve during those trainings.
Since the initial training no additional assessments have occurred to monitor performance in
new skill areas. New supervisor hires as of May 2006 will be fully trained in October of this 
year. 
3. Supervision of Program Staff
The Country Representative directly supervises the THSP Coordinator, who has general
oversight of THSP personnel (advisors and supervisors). The MCH and the Communications 
Advisors manage the supervisors. Per their titles, the MCH Advisor focuses on the technical 
aspects of the training (i.e., reproductive health and C-IMCI), the Communications Officer
concentrates his efforts in social mobilization and IEC/BCC strategies. The supervisors
monitor and provide guidance to CHWs in their respective zones. 
From a programmatic perspective, supervisory methods include one-on-one consultations, 
group meetings, and supervisory visits. The THSP advisors schedule several monthly
supervisory visits to observe and guide supervisors in their field activities. However, due to 
logistical constraints, the THSP team supervisory visits are not of optimal frequency. This
leaves supervisors without adequate supervision. 
In fact, supervision within the THSP constitutes a weak link in the program. The number of 
staff hired to implement the program remains inadequate. During the first two years of the 
project, when the THSP had only three supervisors, a single supervisor had up to 27
dispersed villages and more than 50 volunteers to oversee. Currently, with the six newly hired 
supervisors, each supervisor will be expected to oversee 17 to 20 villages with a minimum of 
five community workers and committee members per village8
, making a minimum total of up 
to 100 supervisees per supervisor. The excessive workload and responsibility for training and 
adequately supervising a low-literate population contributes to making the work all the more
labor-intensive. Each supervisor submits a monthly plan of the villages where s/he intends to 
perform supervisory visits. Each village should receive at least one supervisory visit per
month, which means the supervisor needs to travel most days of the month to make the
rounds. For various reasons, some CHWs have received more supervisory visits than others 
since program activities were launched. 
In the efforts to supervise and support staff in their work, program staff received technical
training in RH and C-IMCI as well as supervisory methods. Three types of planning
meetings exist, namely monthly, quarterly and annual. The monthly meetings serve to plan
 
8
 Supervisors guide Monitoring Committees responsible for THSP activities, mobilizations, management and 
inventory of medicines, organization of causeries, encouraging communities to seek advice and health care from
other community health workers, financial management of products. 
34
activities for the month, review activities implemented in the past month (i.e, compare
planned activities to those that were actually implemented) and problem solve through 
discussion any issues which may have arisen. Quarterly and annual meetings serve only the
purpose of planning activities for those periods. 
In sum, supervision, at all levels (from the program management staff, to the supervisors, to
the community health workers) has suffered due to the program’s late start, time constraints, 
the nature of the terrain, the dispersion of program villages, the excessive workload, and 
logistical problems. 
 
4. Human Resources and Staff Management 9
Africare Tambacounda
The Program Coordinator, Ms. Ikupa Akim manages and supervises the THSP team at the
Africare Tambacounda office. The rest of the program team is comprised of: the Maternal
Health Advisor, Mrs. Kany Sall Diop, the BCC/IEC Advisor, Mr. Saboye Diagne; and nine
Project Supervisors, (5 based in Tambacounda health district and 4 based in Koumpentoum 
health district). The Program Coordinator reports directly to the Africare Country 
Representative. 
Africare Dakar
Africare Country Representative Jim Dean backstops the THSP at Africare Dakar. He also 
heads the Africare Dakar program team comprised of: 1. Health Program Manager Dr. Mor 
Ngom, 2. Program Manager Gorgui Sène Diallo, and 3. Assistant Program Manager
Ousseynou Samb. The Country Representative reports to Mr. William Noble, Regional
Director, Francophone Africa, at Africare headquarters in Washington, D.C. 
Washington
Africare’s Francophone Regional Office provides the primary operational support to the
program. Mr. William Noble, one of Africare’s three Regional Directors, now runs this
office with the assistance of a team. The Regional Office is responsible for coordinating the 
technical and managerial inputs of the program.
Africare’s Office of Health and HIV/AIDS (OHHA) is the primary source of technical
support to the program. The Health Office consists of a technical team of health
professionals that assists the headquarters regional offices by providing direct technical
support to programs and programs in the field. Mr. Charles De Bose, the unit’s director, is a 
seasoned health professional with many years of experience working in the health sector in
Senegal. 
Overall, the major human resources and staff changes which have taken place since the DIP 
include: 
o Hiring six10 additional program supervisors to manage the vastness of the
intervention zone.
 
9 Adpated from Detailed Implementation Plan: Tambacounda Healthy Start Program in Tambacounda, Senegal, 
2004.
10 Four of the newly hired supervisors since May 2006 are funded under Pfizer funding for Acute Respiratory 
Infections. 
35
o Appointing a new Regional Director for Africare HQ’s Francophone Regional
Office. Mr. William Noble now holds this position and has replaced Mr. Myron 
Golden as of July 2006. 
o Nutritionist Jolie Dennis has recently replaced Kendra Blackett-Dibinga as the
Office of Health and HIV/AIDS backstop at Africare headquarters.
With respect to the program, all positions have been filled per the proposal. However, there 
is a need for additional staff namely: a) a Monitoring and Evaluation Specialist; b) additional 
supervisors to manage the THSP intervention zones, c) a Microcredit Specialist to launch and 
guide the implementation of the microcredit component and d) a Coordinating Supervisor.
Personnel policies and procedures are available for the Program Coordinator but none are
available at the field level for local program staff. Job descriptions for positions are available 
at the regional and field offices, however, only the Program Coordinator has the version
which was distributed to personnel. Other offices have earlier drafts of the job descriptions. 
Staff turnover has not been an issue. Some THSP staff members who are veterans of several 
Africare programs complained about the lack of upward mobility and the lack of salary 
raises. Morale seems to be low, primarily due to frustrations about low salaries and the 
excessive workload. While this may impact program implementation, the supervisors remain
dedicated to making a difference in the lives of the beneficiaries they serve. 
As per Africare’s general policy, the THSP will facilitate program staff’s transition to other
Africare programs when the program ends. 
5. Financial management11
The Program Coordinator manages the program budget and submits a quarterly request for
program activities, salaries and administrative costs to Africare Dakar. The technical team at 
Africare Dakar reviews the request and compares it with the work plan. Once the request is 
approved Africare Dakar transfers the requested amount from the THSP account in Dakar to 
the program account in Tambacounda. The Program Coordinator in Tambacounda signs the 
checks in payment of all program goods and services. 
Monthly program accounting is computerized and forwarded electronically to the Dakar
office by the first week of the following month. Hard copies of all receipts and vouchers are 
also sent. The Africare Dakar accounting office enters its program expenditures into the
monthly accounting and then prepares a monthly batch (hard copies) of all program field
expenditures. The Financial Manager sends the batch to Africare Washington via DHL by the 
fifteenth of the following month. 
At Africare Washington, the Office of Finance reviews the vouchers, adds any headquarters 
expenditures and enters the total monthly expenditures into the program’s general ledger. On
a monthly basis, the Office of Finance reviews fund transfer requests, petty cash imprest and 
checking payments, petty cash and check disbursement vouchers, charges against expenditure 
accounts and line item budgets, issuances of advances, and settlement of accounts receivable. 
Program expenditures are thus tracked at three successive levels: against the monthly activity
budget in Tambacounda, against the overall field budget in Dakar and against the combined 
field and headquarters budget in Washington. 
 
11 Excerpt adapted from Tambacounda Healthy Start Program Annual Report, Oct. 29, 2005
36
Africare’s Office of Management Services in Washington reviews program recording, the
management and use of program and office equipment and supplies, vehicle use, and
employee time and attendance records. Africare headquarters provides feedback and specific 
guidance to the Country Representative and the Program Coordinator resulting from these 
reviews, to reinforce correct administrative and management practices, and to advise and
assist with any needed improvements.
The Program Coordinator does not do financial planning for sustainability for the local
partners. 
Overall, the financial system seems to pose a problem with respect to delaying program
implementation. When the finance department in Washington receives a request, it takes a
week or two before the transfer of funds occurs to the Africare Senegal office. By the time 
the Africare Dakar transfers the funds to the various programs it manages, many Africare
programs including THSP have had to interrupt the implementation of planned activities as
they await the transfer from the Africare Dakar bank. To further compound the problem,
Africare Washington transfers only half the amount requested based on the daily cash balance 
available the day it is reviewed. While utilizing DHL to expedite batches to the Washington
office may have resolved the problem of late batches arriving in Washington, it seems to have 
created a system of serious over-expenditure for the telephone and mail budgetary line item. 
6. Logistics
Not surprisingly, logistics has been a major problem for the program given the difficult
nature of the Tambacounda terrain. This has impacted the implementation of the program by
delaying supervisory visits, negating planned program activities, and complicating the
transportation of program goods and equipment. 
Since the beginning of the program, the THSP had been relying on one used Toyota 
Landcruiser Hardtop for program activities. Three program staff had been juggling the use of 
this vehicle for work-related purposes, including the support of the Health District’s outreach
activities. The program team did have access to the PARINS project pick-up truck for 
emergencies. The logistics office at Africare Dakar would send a spare Landcruiser to
Tambacounda when the program vehicle needed repairs or routine maintenance in Dakar. 
Since May 2006, Africare has added a second vehicle to the program. The nine supervisors 
have 125 CC cross-country motorcycles. Most of these motorcycles are second-hand and
several are already five years old. They break down frequently. Given the limited mechanical
expertise in Tambacounda, the motorcycles must be transported to Dakar for reliable repairs. 
Spare parts are expensive; repairs can run up to $1,000 and take several weeks. The Africare 
Dakar logistics office maintains a stock of spare motorcycles that they ship to the field to
replace the bikes that are being repaired. 
Some program CHWs would greatly benefit from bicycles to transport them from central
villages to satellite villages for outreach activities. Although most CHWs work in the village 
in which they live, some walk a fair distance to neighboring satellite villages for their THSP 
activities. In sum, transportation logistics will continue to impact program implementation
and remain a major challenge for the remainder of the program. 
7. Information management
At the midterm evaluation, there was no built-in evaluation system in place to measure 
progress towards program objectives. The program managers planned to use the mid-term 
37
and the final KPC results to serve this purpose. To date, the program collects only process 
data and utilizes it to inform decisions on strengthening program activities. 
Program staff, partners, and beneficiaries collect and analyze data as follows: CHWs report 
the types and numbers of activities, as well as the attendance to these activities, on a
program-designed form. They also include what types of activities they are planning in the
near future. CHWs generate a monthly report for their supervisor, who in turn aggregates all
program zone data and submits them to the monitoring and evaluation unit of the program
(consisting of the Program Coordinator, the Maternal and Child Health Advisor and the
Communications Officer) for synthesis. The program team shares these results at the
monthly program coordination meetings, and informs program staff of activity progress, 
highlights problems and compares planned activities to those implemented. 
The program activity data are integrated into the MOH data collection system. In addition to 
a weekly report on program activities, the Program Coordinator also submits a quarterly
technical report to the Africare Senegal office. Most of the data and reports are filed and
stored at the Tambacounda program office. 
8. Technical and administrative support
As of the mid-term evaluation, the TSHP had not received any external technical assistance. 
The technical and administrative assistance that it has received has come from the Africare
Senegal office and Africare HQ. Africare Dakar has oversight of the Administrative Assistant 
in Tambacounda and provides administrative support to the program including the translation 
of documents. The Dakar office has also provided workshops and assistance on the Detailed 
Implementation Plan, the program implementation plan, a training on the BEHAVE
framework, and on the sustainability strategy. 
Africare Headquarters (HQ) supports the program by serving as a liaison between the
program and the CORE group and with USAID Washington. The Program Coordinator
receives information from Africare HQ and CORE updates. Africare HQ provides
administrative and technical support, particularly with the annual reports. With the exception
of her visit to assist with the DIP, the HQ Health Program Manager has not visited the
program since the Program Coordinator was hired. The regional and HQ program 
backstopping staff devote respectively 25% and 15% time to supporting the program. 
9. Mission collaboration
The THSP’s technical interventions and activities are in keeping with USAID Senegal’s
1998-2006 Strategic Plan for Health. The THSP plays a role in improving maternal and child 
health through improved service utilization per Strategic Objectives (SO) #3 and Intermediate 
Results (IR) 3.1 and 3.2. Strategic Objective #3 refers to “Increased and Sustainable Use of 
Reproductive Health (Child Survival, Maternal Health, Family Planning, and Sexually
Transmitted Diseases/AIDS) Services in the Context of Decentralization.” THSP contributes 
to achieving Intermediate Result 3.1, “improved access to quality child survival, maternal
health, family planning, and sexually transmitted diseases/AIDS services” through the 
development of community-level services for maternal and neonatal care and malaria
management as well as technical strengthening of the health post level through follow up
training and management of obstetric emergencies. It also contributes to IR 3.2 through 
education and community mobilization including behavior change strategies, training and
support of health workers and health committees’ capacity building and support, as well as 
strengthening of referral systems.
38
Although the Senegal USAID Mission recommended the Tambacounda Department to
USAID Washington as an intervention site outside of the USAID Mission’s intervention zone 
to complement and extend the mission’s activities in another geographical zone, it has not
collaborated with THSP extensively. According to former USAID Child Survival Program
Manager, Dr. Mactar Camara, NGOs with USAID Washington funding operating outside of
USAID intervention zones should have the freedom to implement their programs without too
much USAID Senegal Mission intervention. Dr. Camara, who is now USAID’s Policy and 
Health Financing Specialist,12 indicated that he had visited the program only once when Mrs. 
Namita Agravat, the USAID Headquarters Child Survival and Health Grants Advisor came
for a visit. Overall, he was impressed with the THSP’s Village Committees and Maternal
Care Groups. He also indicated that he and the THSP Program Coordinator corresponded
electronically to keep each other informed of health-related data or other pertinent
information for the THSP program or Tambacounda region.
Considering that the THSP and the USAID mission have had only a superficial relationship, 
the Mission has not sought to utilize program results and lessons learned. However, during
the THSP midterm debriefing, USAID Senegal offered to facilitate a dialogue between the 
Japanese Agency for International Cooperation (JICA) and Africare to collaborate on
strengthening health care facilities with medical equipment and related capacity building. As
mentioned earlier in the report, GOS health facilities are ill-equipped to address obstetrical
emergencies and third degree malnutrition. JICA has been working in other geographical
zones of Tambacounda providing health centers with medical equipment. In the future,
USAID Senegal hopes to serve as a liaison to foster collaboration between the two NGOs. 
D- OTHER ISSUES 
Target Beneficiaries
There seems to be some confusion concerning the target age group for THSP children 
beneficiaries. The main documents (the proposal, the DIP and the KPC) mention a maternal 
and newborn health intervention, a target of infants under age one, program activities for 
children under five, and evaluation of progress towards objectives primarily in the under 
twos (though the malaria indicator refers to children under five). The lack of consistency and 
clarity in the program documents has made it difficult to properly limit the boundaries of the 
evaluation. Considering the initial baseline KPC targeted children under two, the age which 
is most critical for growth and development, the consultant recommended to continue age 
appropriate activities for all children under five but measure progress towards final objectives 
with the KPC and the under twos. However, the program management feels that they need 
indicators that will capture changes in such areas as stunting for children under five to reflect 
potential program impact in child beneficiaries that have benefited from interventions at an 
earlier age. Stunting needs at least 12 months between baseline and comparison measures to 
reflect improvement in this chronic malnutrition measure. This indicator can therefore be 
used to capture lag effects in program impact by monitoring stunting percentages in ages 24 
to 59 months. 
 
12 At the writing of this report, Dr. Camara had assumed a new position and title within the USAID Senegal 
Mission. The consultant chose to interview Dr. Camara as he would have the most current information related 
to the program. The new Child Survival Backstop, Mrs. Elisabeth Benga De had only assumed her role 
approximately one month prior to the THSP midterm evaluation visit. 
39
Baseline KPC methodology
According to the methodology utilized for the baseline KPC, the mid-term evaluation
consultant is of the opinion that the results may be slightly biased. In section 2.3 Sampling
Methodology of the Tambacounda Healthy Start Program Baseline Survey on Knowledge, 
Practice and Coverage in the field of Child Survival, Final Report, March 2004 (English
version); it states “the youngest child within the ages of 0-23 months in each household was 
recruited [for the survey].” This approach will tend to create a systematic age bias towards 
the youngest children. Hence, the results may not be as reliable as they might have been and 
a comparison of both the mid-term and the final results may be impacted. However, it is
possible the bias is minimal in the case there are few households with more than one child 
under the age of two. A more reliable methodology would have been to recruit all children 0-
23 months in each household to minimize the age bias. The mid-term evaluation consultant 
recommended that the mid-term limited KPC address this issue in their methodology. 
Budgetary Constraints
The program was under-budgeted for several line items and amply budgeted in the capacity
building line item. The original budget allowed for only three supervisors for the 400
program villages. Distances and gas needed to implement activities were not adequately
taken into account in the original proposal, particularly for CHW formative supervision. In 
addition, the initial proposal planned activities on the assumption that there were 200 active 
TBAs when the THSP launched its activities. At the beginning of the program however, there 
were only 55 active TBAs in the entire program zone. Another 145 TBAs would need to be 
trained to meet the proposal’s objectives to increase community access to quality services (if
the original calculations are correct.) The Tambacounda district health center presently has
the capacity to train up to six TBAs per six month period, and thus it would take over four 
years to train the requisite number. In addition, the program did not budget for any of the six￾month training required. The additional funding would need to come from the communities
themselves or from a matching grant. In the meantime, as mentioned earlier, the THSP has 
opted for the less expensive and less-time consuming (but less optimal) alternative of training
reproductive health CHWs, who are not officially authorized by the MOH to deliver babies. 
To further compound the program’s budgetary problems, gas prices have doubled since the 
inception of the program and the exchange rate has plummeted from 700 FCFA to 500 FCFA 
to the US dollar. A matching grant from Pfizer to conduct ARI activities in the program zone 
has allowed the program to hire additional supervisors and to purchase of four new 
motorcycles. 
Communication and Information Sharing
There does not seem to be an effective manner of communicating with all the Africare offices 
and programs. Some people are informed while others are not; some receive reports while 
others do not. This creates unnecessary confusion. The Country Representative and the
Program Coordinator need to be more consistent in sharing information and reports at
meetings at all levels and via email to minimize alienation and increase a sense of team. This 
problem is not only present with Africare offices but also seems to be a problem with
information flowing to and from partners and beneficiaries as well as among themselves. 
Establishment of new Health Districts 
When the THSP first launched its activities in the Tambacounda Department, Tambacounda 
was the only health district in the department. Since then, the GOS has divided the
40
department into three health districts: Tambacounda, Koumpentoum and Maka Koulibantang. 
When the Koupentoum health district was created in project year two, the program pulled out 
of Koumpentoum to focus its activities in the Tambacounda district. This was to allow the
Koumpentoum health team the necessary time to establish its offices, create a new health
center and to hire its staff. In project year three, the THSP has enrolled 96 villages in
Koumpentoum. However, the MOH has recently split the Koumpentoum district to create the 
new Maka Koulibantang district. 
E- CONCLUSIONS AND RECOMMENDATIONS
The THSP has progressed well in achieving its objectives. The program has already reached 
or exceeded the targets for nearly half (9) of the indicators for its seventeen intermediate
objectives, with three further indicators near achievement. The program’s IEC/BCC strategy
mix, combined with the technical expertise of its staff, its productive capacity building, and
strong process indicator monitoring have contributed to program successes in each area of
intervention. 
The THSP has done a particularly good job of implementing the maternal health component,
as all intermediate objectives have increased, reached their EOP target, or even exceeded it. 
The THSP MCH advisor and the Health District’s Reproductive Health Coordinator have 
years of experience in the region and have collaborated closely (even prior to the program); 
they make a strong team. Under the supervisory umbrella of these two women, the TBAs 
received a 15-day refresher training and close monitoring to reinforce their skills and
knowledge. The TBAs have benefited not only from the initial six-month training with
practicum prior to the THSP, but also from many refresher trainings from various programs
in the region, particularly from UNFPA which has been active in the area for many years. 
Altogether, this has contributed to making the THSP’s reproductive health component quite 
strong. The THSP should further strengthen this component by training additional TBAs and 
providing them with equipment. 
While the Child Survival component achieved many of its intermediate objectives in vitamin
A supplementation, exclusive breastfeeding, and prevention and management of diarrheal and
malaria, these interventions have some weak links. Complementary feeding, nutritional
management during and after illness, hand washing at four critical times and growth
monitoring are all areas where the THSP needs to place more emphasis and effort. 
Additionally, the program should seek to reduce malaria prevalence by increasing awareness 
and promoting insect repellants and household sprays.
The Maternal Care Group approach remains the program’s most effective behavior change 
strategy: it stands out as an innovative approach to capturing women’s attention and
channeling their considerable energy towards improved health seeking practices and the 
household management of childhood illnesses. Based on the focus group sessions, whether it 
be women, men, leaders, administrative authorities or the district health personnel, all seem
excited about the Maternal Care Group strategy and its potential. Through the Care Groups, 
the program has managed to overcome difficult cultural barriers, such as the taboo of
announcing a pregnancy early. Health discussions within organized women’s groups
constitute intimate settings where women feel comfortable to express themselves freely and
learn at their own pace. This forum empowers women to take the initiative to seek preventive 
and curative health care for both themselves and their children. The Maternal Care Group 
serves not only as a forum for education and a source of information, but as an empowering 
41
environment for psychological and social support, and a resource base for those in need of
financial assistance. 
Overall, social mobilization methods have been successful in mobilizing targeted 
populations, primarily women of reproductive age. However, the THSP must more 
consistently engage men and grandmothers. Men control the decision-making power and the 
financial resources in Senegalese society. After mothers, grandmothers form the largest group 
of caregivers. They need to understand the premise of exclusive breastfeeding and breast milk
composition. The lack of participation in growth monitoring activities, combined with the 
increase in malnutrition, is also an area of concern. This intervention needs to be improved, 
and more work must be done to counteract the incentive problems (and other possible factors) 
that seem to have led to a decrease in growth monitoring. Likewise, the community-at-large 
would benefit from a session on the importance of actively and frequently feeding young 
children. 
The THSP has been met with a number of constraints including a late start, a vast
intervention zone, dispersed villages, inadequate human, financial and logistic resources and
health district re-zoning. These constraints have negatively impacted the quality of
performance (particularly regarding supervision) and the number of villages enrolled in the
program. Given that slightly more than half (219) of the planned 400 villages are enrolled at 
the program’s mid-point, the consultant recommends a scale down of the intervention zone
and the number of program beneficiaries, to focus resources on strengthening current
program activities.
Despite these odds, the THSP has attained significant results thus far. The program has
managed to mobilize populations and to sensitize them towards increased health facility
utilization. 
The largest concern and barrier to maternal and child mortality reduction remains the 
inability of district health facilities to accommodate obstetrical and severely malnourished
emergencies. The fourth delay is compounded by insufficient and inadequate equipment at
the health facilities. There has been a shift in location of maternal deaths from the home to 
the hospital (or en route to the hospital.) Mothers with obstetrical emergencies are more
likely to pass away at the hospital than at home. The quality of care provided to severely
malnourished children at the health posts is inadequate. The THSP must locate and
collaborate with other donors and programs that can focus on equipping health facilities and 
providing the necessary capacity building for health personnel. 
The THSP has developed strong relationships with its collaborating partners. Program
activities including planning, implementation, supervision and evaluation have taken place
together at all levels; however, this collaboration is not systematic or consistent for all
involved. A more systematic integration of partners (specifically in regard to planning) might 
strengthen activities with more health district expertise. While the program has increased
health district capacity (particularly for newer district employees) in reproductive health, C￾IMCI and contraceptive technology, the program should seek to identify other capacity
building needs and to expand its institutional strengthening activities. 
 
In sum, THSP has progressed very well towards its intermediate objectives and has overcome 
a number of constraints. The program’s IEC/BCC mix combined with social mobilization
42
activities have proven successful in changing behavior. The consultant recommends the
reinforcement of current activities for increased performance over the rest of the program. 
Recommendations
CORE/USAID
Ensure that future maternal health and child survival RFAs allow sufficient financial
resources for health systems strengthening. This would allow future programs to procure the 
medical equipment necessary for obstetric emergencies and the rehabilitation severely
malnourished children. Initiating HEARTH child nutrition rehabilitation activities, even as a
pilot in the area, could help increase community-based solutions to moderate to severe
malnutrition, and could also prevent cases of severe malnutrition needing outside referrals. 
An alternative would be to assist in linking implementing PVOs with companies who are
capable of equipping hospitals and health centers
Tambacounda Healthy Start Program 
o Limit program implementation to the 155 central villages and improve coverage of
129 satellite villages to strengthen the current program given the budget, geographical
constraints, and logistic issues. 
o Realign budget and seek additional funding to support the need for additional human
resources and equipment for program implementation.
o Hire or promote a current qualified staff as a Monitoring and Evaluation Specialist
whose responsibilities will include assessments in knowledge, behavior change and
capacity building among beneficiaries, health facilities and program staff. The M&E
specialist will also monitor and manage program supervisors. 
o Train program supervisors and district staff in monitoring and evaluation techniques
including sampling and survey methodology, data collection and analysis. 
o Launch impact evaluation activities to include monitoring of progress towards
intermediate objectives and to assess barriers to program implementation. 
o Hire more supervisors to alleviate workload for the remainder of program
implementation, depending on availability of funds. 
o Collaborate further with the Bureau Régional de L’Alimentation et de la Nutrition
(BRAN) and explore possibilities for technical reinforcement for the Nutrition
component. 
o Reinforce the nutrition component with nutrition messages grounded in Frequency, 
Amount, Density, Utilization and Active Feeding (FADUA) (See www.aed.org for
more information).
o Provide refresher training in prevention of infections for TBAs.
o Hire a specialist or promote a currently experienced staff to launch and manage the
micro-credit component. 
43
o Study possibilities and solutions to improve logistics for more frequent field visits. 
o Supply Trained Birth Attendants outside of health posts with equipment for proper
disinfection of obstetric utensils such as pots, gas stoves, timers or watches. 
o Provide refresher training to CHWs in RH and IMCI utilizing more hands-on and
diversified approaches such as games, creation of songs, and quizzes among others.
o Assist communities to organize appreciation ceremonies in recognition of CHWs. 
o Ensure all community work plans have times specified for all activities. 
o Increase community awareness about contacting the health post or the Nurse Officer
in Charge to mobilize the district’s ambulance during emergency situations. 
o Plan and ensure that each and every CHW and working in THSP program zone
receives formative supervisory visits.
o Better integrate the districts in all levels of planning, implementation, supervision and
evaluation of THSP activities.
o Actively engage in mobilizing men and other caretakers including grandmothers to 
participate in health education and behavior change activities. 
o Collaborate with Africare’s new community health program to reinforce newborn care 
activities. 
o Ensure that future KPC data collection focuses on children 0-59 months since over the 
life of the project, child beneficiaries will show potential improvement as they grow
older, thus target indicators for under fives could capture this change
Districts
o Ensure that all health posts and the health centers have vitamin A for postpartum
supplementation, per MOH guidance.
Community
o Reinforce the maternal health component by mobilizing communities to develop
communications and transportation systems for obstetrical emergency evacuations. 
o Increase community awareness about contacting the health post or the Nurse Officer
in Charge to mobilize the district’s ambulance during emergency situations. 
o Study possibilities such as micro-credit to provide support to RH CHWs to receive
training towards becoming a trained birth attendant. 
o Organize appreciation ceremonies in recognition of CHWs. 
o Select and replace inactive CHWs.
44
45
F- RESULTS HIGHLIGHT
Maternal and child morbidity and mortality in the Tambacounda region are linked to poor
health behaviors in the management of childhood illnesses, low utilization of antenatal
services, non- or late recognition of danger sign recognition, delayed health care seeking,
poor emergency obstetric referral, and poor management of obstetric care. To address these
problem, the THSP has used Women’s CBOs as a venue to establish Maternal Care Groups; 
These groups provide a forum for community mobilization, IEC and BCC, microcredit and
and the close monitoring and support for pregnant women by more experienced mothers
under the guidance of a TBA. Below is a description of the Maternal Care Groups. 
Most villages have a CBO of which most of the women of the village are members. This 
organization is divided into smaller groups of 25 to form the Maternal Care Groups. Women 
who are not members of the larger CBO may join a Care Group. Criteria to become a 
member include: 1. monthly financial contributions, 2. regular participation to IEC/BCC
activities. Once these two criteria are met, a member can benefit from the microcredit. 
Maternal Care Group members contribute a monthly minimum of 100F CFA (approximately
US$0.20 cents) to the cashbox for the purpose of assisting pregnant women who may need 
pregnancy-related financial assistance. All borrowed money must be reimbursed. 
Pregnant women are identified13 and paired with a mentor (a more experienced woman who 
has already had children.) The godmother is responsible for accompanying and ensuring her 
pregnant mentee attends all her prenatal care sessions, takes vitamins or medicines as
prescribed, respects appointments, follows the CHW’s advice and doing general home visits. 
The mentor checks on and monitors her mentee until the latter’s child turns two years old (the 
age when the toddler may be weaned from breastfeeding.) 
The Maternal Care Groups are composed of older mothers and women of reproductive age. 
A group coordinator, a treasurer and an accountant serve on the governing board. Each
village has a TBA or a CHW trained in reproductive health, who is responsible for health
education and communication reproductive health-related activities which take place within
the Maternal Care Groups. In addition to her IEC/BCC obligations, the TBA initiates and
draws up a birth plan with family members of the pregnant woman (husband, mother-in-law) 
beginning at the fifth month of pregnancy and of course, is available for clean and safe
deliveries. Each TBA or RH CHW is responsible for a maximum of four or five Maternal
Care Groups. 
This approach is innovative. Focus group results indicate that women are really excited and 
motivated by Maternal Care Group activities. The main barrier of seeking prenatal care
services from primarily male nurses seems to be overcome with small discussions and
awareness activities in the Maternal Care Groups. Prior to Maternal Care Groups, many
women hid their pregnancies from the community until their fifth month at which time they
would seek their first prenatal consultation. The Maternal Care Group forum seems to create 
a sense of solidarity and its organization serves as a safety net both from the financial
(microcredit) and social support perspectives. At this juncture, it may be too early to confirm 
quantifiable or impact results directly linked to increased prenatal services utilization and
 
13 In Senegal many women hide their pregnancies as long as possible from the community so as to protect their 
unborn child from the evil eye. Hence, some of the Maternal Care Groups have come up with discreet ways to 
indicate their early pregnancy status (such as wearing one earring or wearing a certain color pagne), that only 
Maternal Care Group members would understand, and take them under their wing for antenatal care. 
46
improved health care seeking behaviors. Overall, the Maternal Care Group Intervention
reaches 61,624 direct beneficiaries, which constitutes 37% of the population covered by
CSHGP at this time. 
47
III. Action Plan
IV. ATTACHMENTS
A. BASELINE INFORMATION FROM THE DIP
B. EVALUATION TEAM MEMBERS AND THEIR TITLES
C. EVALUATION ASSESSMENT METHODOLOGY
D. LIST OF PERSONS INTERVIEWED AND CONTACTED
E. CD WITH ELECTRONIC COPY OF REPORT
F. H. PROGRAM DATA SHEET FORM
ATTACHMENTS
49
Attachment A: Baseline information from the DIP 
The chart below presents THSP objectives, baseline and midterm results by intervention.
Comparative chart baseline and Midterm results
Indicators by intervention
Baseline 
KPC
%
Target
%
Midterm 
results
%
Maternal and Child Nutrition /Micronutrients
Underweight (z score < -2) for children 0-23 months 20 - 24
Percentage of mothers practicing exclusive breastfeeding for 
six months 24 60 85
Percentage of mothers taking vitamin A forty-two days after 
delivery 11 60 60
Percentage of children 6-23 months of age receiving vitamin A 
supplementation in the previous six months 40 80 72
Percentage of households using iodized salt 49 70 59
Control of diarrhea
Prevalence of diarrhea 45 - 28
Percentage of children aged 0-23 with diarrhea in the last two 
weeks who received ORS and/or recommended home fluids. 52 65 27
Percentage of children aged 0-23 with diarrhea in the last two 
weeks who were offered more fluids during the illness. 48 60 57
Percentage of children aged 0-23 with diarrhea in the last two 
weeks who were offered the same amount or more foods during 
the illness. 
48 60 39
Percentage of children aged 0-23 with diarrhea in the last two 
weeks whose mothers sought outside advice or treatment for 
the illness.
31 50 87
Percentage of mothers who usually wash their hands with soap 
or ash before food preparation, before feeding children, after 
defecation, and after attending to a child who has defecated.
7 50 14
Control of Malaria
Prevalence of malaria/fever 25 - 50
Percentage of pregnant women with access to IPT 2 60 68
Percentage of caregivers recognizing severe danger signs of 
malaria and seeking appropriate care within 24 hours 48 60 40
Percentage use of ITNs among pregnant women 18 50 83
Percentage use of ITNs among children under age two 21 50 94
Maternal and Newborn Care
Percentage of women making at least three antenatal care visits 33 60 60
Percentage of deliveries attended by skilled birth attendants 45 60 55
Percentage of newborns breastfed during the first hour after 
birth 20 30 33
Percentage of women using at least one modern method of 
contraception 10 13 21
50
Attachment C: Evaluation Team Members and their Titles 
Tambacounda Healthy Start Program Staff
1. Ms. Ikupa Akim, Program Coordinator 
2. Mr. Saboyé Diagne, IEC/BCC Manager
3. Mrs. Kany Sall Diop, Reproductive Health Manager
4. Ms. Yacine Gueye, Supervisor
Koumpentoum Health District
5. Dr. Mamadou Ndiaye, District Chief Medical Officer 
6. Mr. Sara Aw, Ex. Primary Health Care Supervisor
Tambacounda Health District
7. Mr. Yoro Baldé, Regional Supervisor for Primary Health Care
8. Dr. Basssirou Ndir, District Chief Medical Officer
9. Dr. Gervais Kabou, District Deputy Chief Medical Officer
10. Mr. Dame Fall, Primary Health Care Supervisor 
11. Mr. Lamine Souko, Expanded Programme for Immunization
12. Mr. Papa Saboye M’Baye, Health Education
13. Ms. Fatou Ndiaye Thiamb, Reproductive Health Coordinator
United Nation’s Children’s Fund (UNICEF)
14. Mr. Fofana Amadi, Tambacounda Regional Health Consultant
15. Mr. Abdoulaye Diop, Kolda Regional Health Consultant
External Consultant
16. Ms. Kim Sanwogou, Team Leader and Evaluation Consultant
Attachment D: Evaluation Assessment Methodology
An evaluation team comprised of 14 members from Africare, UNICEF, the Health Districts of
Koumpentoum and Tambacounda and an external consultant conducted the THSP evaluation from
September 8 to September 30, 2006. The team utilized a participatory method to develop and
validate questionnaires, collect qualitative and quantitative data and provide inputs to the report. 
Team members divided tasks based on their expertise, interest and availability. The evaluation
centered on four main assessment methods namely focus groups, informal interviews, direct 
observation and surveys for triangulation. A more in-depth description of each method follows.
Focus groups: The evaluation team organized eight focus groups targeting mothers/community￾based organizations (2), community leaders (2), men (2) and community health workers (2). The 
focus groups took place in the villages of Sinthiou Maleme and Botou. The IEC/BCC Advisor
provided refresher training to THSP supervisors in focus group methodology. Each supervisor and 
secretary pair facilitated a focus group from a zone which s/he did not supervise habitually. A
number of evaluation team members observed several focus groups. Limitations of this method
include the fact that results are not generalized to the wider population. 
Direct observation: The evaluation team observed six field activities and sites namely: 1. a
growth monitoring session and 2. a culinary demonstration (Koussanar village), 3. a health
education session on exclusive breastfeeding and complementary feeding (Koar village), 4. a health 
post (Missirah village), 5. Radio Crochet and 6. a health education session on diarrheal prevention
and management (Medina Sara Khollé village). 
Informal interviews: The external consultant conducted individual and group informal interviews
of approximately 54 people from the USAID Senegal mission, Africare Senegal, THSP program
staff, Tambacounda and Koumpentoum administrative authorities and Health District professionals,
as well as local partners. 
Survey: A survey team conducted a modified KPC to measure quantitative progress towards 
objectives. The Program Coordinator as well as survey and evaluation consultants ensured that
questions pertaining to CATCH and impact indicators were included in the questionnaire. Thirty
villages were selected randomly and a 30 by 10 cluster was utilized to obtain a total sample of 300. 
A total of 16 questionnaires were not valid and had to be excluded from the original sample of 300, 
thus reducing the sample size to 284. The evaluation consultant recommended that all children in
each household be surveyed and that surveyors over-sample for the 0-6 month age group to ensure 
a large enough sample for disaggregation by age. This was a corrective measure from the baseline 
KPC. For a more detailed methodology description, please refer to the full report in Attachment B. 
The limitations of the midterm survey are three fold: 1. they are based on a limited KPC that 1) did 
not contain all of the filter questions 2) was done with a limited sample 3) was carried out by a 
group of interviewers who were not as experienced as those Africare has used in the past.
 
Attachment E: List of persons interviewed and contacted 
Division de l’Alimentation, de la Nutrition, et de la Survie de l’Enfant (DANSE)
1. Dr. Youssou Gaye, Director
United States Agency for International Development Senegal Mission
2. Dr. Mactar Camara, USAID, former Child Survival Program Manager 
3. Ms. Ramatoulaye Dioume, USAID HIV/AIDS/TB Chief Technical Officer (CTO)
Africare Senegal (Dakar)
4. Dr. Jim Dean, Country Representative
5. Mr. Gorgui Sène Diallo, Program Manager/Management Information Systems specialist
6. Dr. Mor Ngom, Health Program Manager
7. Mr. Ousseynou Samb, Program Officer
8. Mrs. Aissatou Bakhoum, Financial Manager
9. Mrs. Lacha Fall, Administrative Assistant 
Africare Tambacounda Healthy Start Program Staff
10. Ms. Ikupa Akim, Program Coordinator 
11. Mr. Saboyé Diagne, IEC/BCC Manager
12. Mrs. Kany Sall Diop, Reproductive Health Manager
13. Mr. Alpha Diallo, Superviseur, Arrondissement Koumpentoum (Rural communities of 
Koumpentoum and Kouthiaba)
14. Mr. Abdoulaye Diallo, Superviseur, Arrondissement Koussanar (Koussanar, Sinthiou 
Malème)
15. Ms. Yacine Guéye, Supervisor, Tambacounda Commune and Arrondissement Missirah
(Nétéboulou, Hafia, Pont)
16. Mr. Amadou Bassirou Diawara, Superviseur, Arrondissement Missirah (Missirah, Bira) 
17. Mr. Kandara Seck, Superviseur, Arrondissement Missirah (Dialocoto, Tessan)
18. Ms. Ndèye Thiab Diouf, Superviseur, Arrondissement Koussanar and Tambacounda
Commune (Saré Guilèle, Bohé Balédji)
Tambacounda Medical Region
19. Mr. Mamoudou Tidiane Dia, Chief Medical Officer, Regional Bureau for Immunization and
Epidemiologique Surveillance (BRISE)
20. Mr. Yoro Baldé, Regional Supervisor for Primary Health Care
Administrative Authorities-Tambacounda Department
21. Mr. Cheikh Anta Dieng, Deputy Préfet
22. Mr. Balla Ndiaye, Deputy Sous-Préfet, Missirah 
23. Ms. Oumou Diallo, President, Association of Locally Elected Women and Deputy Mayor of
Commune of Tambacounda
Koumpentoum Health District
24. Dr Mamadou Ndiaye, District Chief Medical Officer
25. Ms. Amy Sarr, Deputy Midwife
26. Mr. Bocar Diallo, Primary Health Care Supervisor
27. Mr. Sara Aw, former Primary Health Care Supervisor
Tambacounda Health District
28. Dr. Basssirou Ndir, District Chief Medical Officer
53
29. Dr. Gervais Kabou, District Deputy Chief Medical Officer
30. Ms. Fatou Ndiaye Thioub, Reproductive Health Coordinator
31. Mr. Lamine Sonko, Expanded Programme for Immunization
32. Mr. Papa Saboye MBaye, Health Education
33. Mr. Dame Fall, Primary Health Care Supervisor/Health Nurse, Afia 
34. Ms. Thérèse Cécile Faye, Health Post Deputy Nurse Officer in Charge, Koussanar
35. Mr. Bra Seye Niang, Health Post Nurse Officer in Charge, Sinthiou Malème
36. Mr. Amadou Doucouré, Health Post Nurse Officer in Charge, Saré Guilèle
37. Mr. Thierno Seye, Health Post Nurse Officer in Charge, Missirah
38. Mr. Thomas Fall, Health Post Nurse Officer in Charge, Dialacoto 
LOCAL PARTNERS
Koar Village
39. Mr. Tidiane Tamba, CHW, IMCI
Koussanar Village
40. Mr. Samba Yatassaye, C-IMCI
41. Mr. Aldiouma Diallo, CHW
42. Mr. Gallo Diallo, President, Cases des Tout Petits (Huts for the little ones) 
Community Health Workers
43. Ms. Aminata Traoré, Trained TBA, Botou
44. Ms. Awa Sow, RH CHW, Djinkoré
45. Mr. Hamadi Diallo, C-IMCI CHW, Djinkoré
46. Mr. Abdoulaye Diallo, CHW, Madina Dian
47. Mr. Dady Sow, CHW, Sinthiou Malème
48. Ms. Nafissatou Dansouba, Trained TBA, Touba 
49. Mr. Mamadou Dansokho, CHW, Guinguinéo
50. Mr. Bou Fofana, C-IMCI CHW, Botou
Association of Traditional Practitioners
51. Mr. Amadou Oury Kane, Tambacounda Regional President of Health Traditional
Practitioners
52. Mr. Mamadou Seime, Secretary General of Tambacounda Department
53. Mr. Boubacar Seime, Secretary General of the Region 
Bilateral organizations
54. Mr. Babacar Mané, UNFPA Expert, Tambacounda Region 
55. Mr. Fofana Amadi, UNICEF, Tambacounda Regional Health Consultant
Attachment F: CD with electronic copy of the report in MS Word 2000
54
55
Attachment G: Program Data Sheet form—Updated version
Attachment H: Action Plan (See attached Excel Spreadsheet)
56
October November December January February March April May June July August September
Reccomendation Activity Responsible
 Census of villages that can feasibly 
be covered by CHW on bicycle
Consultant
Purchase of bicycles for CHW who 
regulalry carry out activities in 
satellite villages 
Dakar
2. Realign budget and seek 
additional funding to support the 
need for additional human 
resources and equipment for 
program implementation
2.1 Realign THSP budget based on 
information from accrual. 
Dakar
2.2 Submit revised budget to USAID 
for approval.
Dakar
2.3 Discuss with USAID the possibility 
of submitting a concept paper to 
receive funds from the PMI for Dakar
3.1 Advertise post of M& E Officer in 
local media (pending budget 
realignment and approval)
Dakar
3.2 Interview and shortlist candidates Dakar
3. 3 Hire M&E Officer Dakar
4.1Determine intermediate target 
indicators for each technical 
intervention
THSP PC/ M&E 
Specialist
4.2 Identify and plan appropriate 
evaluation activities
THSP M&E 
Specialist
4.3 Collect data for relevant 
indicators
THSP M&E 
Specialist
4.4 Feedback of evaluation to 
program team, partners and other 
stakeholders
THSP M&E 
Specialist
5.1 Recruit several supervisors 
depending on resources available after 
budget realignment
THSP PC
5.2 Determine zones of supervisoin 
and assign villages to new supervisors
THSP PC
6.1 Meet with BRAN Regional focal 
point to discuss areas of collaboration 
THSP MHA
6.2 Develop a joint plan of action for 
nutritional intervention THSP MHA
7.1 Prepare a technical sheet using 
relevant FADUA messages
THSP PC/MHA
7.2 Orient project Supervisors and OIC 
in use of the technical sheet for 
training CHW
THSP MHA
7.3 Train CHW and TBAs during 
coordination meetings
THSP Supervisors 
and District OIC
7.4 Carry out supervisions of nutrion 
IEC/BCC activities
Supervisors,OIC 
and Coordination 
team
8.1 Recruit a Micro-credit specialist THSP PC
8.2 Complete enrolment of 
beneficiary groups 
MC Specialist
8.3 Develop list of incime generating 
activities and estimation of finacial 
THSP, MC 
Specialist
8. 4 Identify partner Micro-credit 
Institutions and sign MOU
THSP, MC 
Specialist
8.5 Establish monitoring committees 
at zonal level 
THSP, MC 
Specialist 
8.6 Traind CBO members and develop 
business plans
THSP, MC 
Specialist 
8.7 Dispensing of loans and financial 
and technical supervision of micro 
projects
THSP, MC 
Specialist
9. Study possibilities and solutions to 
improve logistics for more frequent 
9.1 Purchase new motorcycles to 
replace older motorcycles 
Africare Senegal 
CO
ACTION PLAN THSP (October 2006- September 2007)
TRIM 1 TRIM 2 TRIM 3 TRIM 4
1. Limit program implementation 
to the 155 central villages and 
improve coverage of 64 satelite 
villages to strengthen the current 
program given the budget, 
geographical constraints, and 
logistic issues 
3. Hire or promote a current 
qualified staff as a Monitoring 
and Evaluation specialist whose 
responsibilities will include 
assessments in knowledge, 
behavior change and capacity 
building among beneficiaries, 
health facilities and project staff. 
The M&E specialist will also 
monitor and manage program 
supervisors. 
7. Reinforce the nutrition 
component with nutrition 
messages grounded in Frequency, 
Amount, Density, Utilization and 
Active Feeding (FADUA)
8. Hire a specialist or promote a 
currently experienced staff to 
launch and manage the micro￾credit component
5. Hire more supervisors to alleviate 
workload for the remainder of 
program implementation, depending 
on availability of funds.
6. Collaborate further with the 
Bureau Régional de L'Alimentation et 
de la Nutrition (BRAN) and explore 
possibilities for technical 
reinforcement for the Nutrition 
component
4. Launch impact evaluation 
activities to monitor progress 
towards intermediate objectives 
and to assess barriers to program 
implementation. 
11/1/2006
October November December January February March April May June July August September
TRIM 1 TRIM 2 TRIM 3 TRIM 4
9.2 Plan and carry out quarterly 
supervision visits with OIC
THSP 
Coordination team
10. Retrain TBAs on prevention of 
infections
10.1 Provide continuous training on 
prevention of infections during 
coordination meetings
THSP MHA
11. Provide refresher training for 
CHWs in key messages and 
diversiefied communication techniques
11.1Refresher training of CHW and 
TBAs using manual developed by 
THSP supervisors and Peace Corp 
Volunteers
THSP Supervisors, 
Health Post OIC, 
PC Volunteers
11.2 Ensure regular supervision of 
trained CHW
THSP Supervisors, 
Health Post OIC
12. Assist communities to 
organize appreciation ceremonies 
in recognition of CHW
12. Meet with village committees to 
plan appreciation ceremonies for 
CHWs selected as best worker at 
coordination meeting
THSP Supervisors, 
Health Post OIC
13. Increase community 
awareness about contacting the 
health post to mobilize the 
district's ambulance during 
emergency situations
13. Meet with District and village 
committees to discuss how ambulance 
can be contacted regularly
THSP PC, 
Supervisors
14. Plan and ensure that CHW 
and TBAs undergo formative 
supervision within a calender 
year
14.1 Develop detailed supervision 
calender
THSP M&E 
Specialist
14.2 Supervision of field activities 
including formative supervision
THSP M&E 
Specialist
15. Actively engage in mobilizing 
men and other caretakers 
including grandmothers to 
participate in BCC activities
15. 1 Group discussions and other 
IEC/BCC activities for men and 
grandmothers
THSP IEC Officer
16. Collaborate with Africare's 
WEER community program to 
reinforce newborn care activities
16.1 The Community health project 
field activities will effectively start 
in February 07
The Dakar office 
will ensure smooth 
collaboration 
between both 
projects
17. Revise and ensure that all 
objectives refer to children 0-23 
months since KPC focus on that 
target group
17. 1 Revise project objectives and 
indicators
THSP 
Coordination team
17.2 Share new indicators and 
objectibbves with Steering Comittee 
members and other stakeholders
THSP PC
11/1/2006