Child Survival 18-Guinea
Final Evaluation Report 
Cost Extension of Cooperative Agreement No. FAO-A-00-98-000024-00 
Community Health Initiative for the Districts of 
Kouroussa and Mandiana Guinea 
1 October 2002 - 30 September 2006 
Dr. Eric Sarriot 
Evaluation Team Leader 
Contact Person: 
Eric Swedberg MPH 
Child Survival Advisor 
December 2006 
Acknowledgements 
Thanks are due to the departmental and regional health teams in Kankan, Mandiana and 
Kouroussa for their active participation in the evaluation. All the members of the evaluation 
team, beginning with the Save the Children team and its partnering NGOs GAAPE and AJVDM, 
put in a great amount of work during the project and its evaluation. 
The CS-18 project is financed by the United States Agency for International Development under 
the reference: Cost Extension of Cooperative Agreement No. FAO-A-00-98-000024-00. 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 2
Table of Contents 
Page 
Table of Contents…………………………………………………………………… 3 
Acronyms and Terms……………………………………………………………….. 4 
A. Executive Summary…………………………………………………………….. 6 
B. Assessment of the Results and Project Impact…………………………………... 9 
 1. Introduction…………………………………………………………………….. 9 
 2. Graphic Summary……………………………………………………………… 9 
 3. Results: Technical Approaches………………………………………………… 11 
 4. Results: Cross-Cutting Approaches……………………………………………. 36 
C. Project Management…………………………………………………………….. 45 
D. Other Topics Identified by the Evaluation Team……………………………….. 46 
E. Dissemination of Lessons Learned and Results………………………………… 46 
F. Results Highlights………………………………………………………………. 47 
G. Conclusions and Recommendations……………………………………………. 47 
 1. General Recommendations Made by the Evaluation Team…………………… 47 
 2. Specific Recommendations Made by the Consultant………………………….. 48 
H. List of Annexes…………………………………………………………………. 50 
Annexes 
1. Excerpts from the DIP with Baseline Results………………………………. 
2. Evaluation Team Members…………………………………………………. 
3. Final Evaluation Methodology……………………………………………… 
4. List of People Contacted……………………………………………………. 
5. List of Participants in the Final Evaluation Debriefing…………………….. 
6. Training Plan for the Health District of Mandiana…………………………. 
7. Training Plan for the Health District of Kouroussa………………………… 
8. Analysis of Deaths Avoided…………………………….………………….. 
9. Interventions with the Greatest Estimated Impact…………………………. 
10. Final Evaluation Photographs………………………………………………. 
11. Explanation of the Index “Percent of Deficit Filled”………………………. 
12. Summary of Project Progress………………………………………………. 
13. Results Highlight…………………………………………………………… 
14. Updated CSHGP Data Form……………………………………………….. 
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CS-18 Guinea, Final Evaluation, Save the Children, December 2006 3
Glossary of Acronyms and Terms 
AJVDM Association des Jeunes Volontaires pour le Développement de 
Mandiana – the Association of Young Volunteers of Mandiana 
AVHC Association of Village Health Committees 
BCG Tuberculosis Vaccine 
C-IMCI Community-Integrated Management of Childhood Illness 
CBDA Community-Based Distribution Agent 
CHW Community Health Worker 
COGES Health Facility Management Committee 
CSHGP Child Survival and Health Grants Program 
CS Child Survival 
CSTS Child Survival Technical Support 
DHS Demographic and Health Survey 
DIP Detailed Implementation Plan 
DPS District Health Office 
DPT Diphtheria-Pertussis-Tetanus Immunization 
DRS MOH Regional Director 
EBF Exclusive Breastfeeding 
EPI Expanded Program on Immunization 
FE Final Evaluation 
FHI Family Health International 
FP Family Planning 
GAAPE Kouroussa NGO- Groupe d’Appui à l’Auto Promotion Paysanne 
et à Protection de l’Environnement – the Support Group for the 
Self Promotion of the Land and the Protection of the Environment 
HC Health Center 
HIS Health Information System 
HIV/AIDS Human Immuno-Deficiency Virus/Acquired Immune Deficiency 
Syndrome 
HW Health Worker 
IMCI Integrated Management of Child Illness 
IUD Intra-uterine Device 
JHU Johns Hopkins University 
KPC Knowledge, Practice, and Coverage Survey 
M&E Monitoring and Evaluation 
MCH Maternal and Child Health 
MMR Maternal Mortality Ratio 
MOH Ministry of Health 
MSH Management Sciences for Health 
MTE Midterm Evaluation 
MURIGA Community-funded revolving emergency health loan fund 
NGO Non-Governmental Organization 
NIDS National Immunization Days 
OR Operations Research 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 4
ORS Oral Rehydration Solution 
PLG Program Learning Group 
PRISM Pour Renforcer les Interventions en Sante Reproductive et 
MST/SIDA-MSH Regional Health Project-Bilateral USAID 
project led by MSH 
PSI Population Services International 
PVO Private Voluntary Organization 
RH Reproductive Health 
SBA Skilled Birth Attendant 
SC Save the Children Federation, Inc. (US) 
STI Sexually Transmitted Infection 
TA Technical Assistance 
TBA Traditional Birth Attendant 
TT Tetanus Toxoid 
UNICEF United Nations Children's Fund 
USAID United States Agency for International Development 
VCT Voluntary Counseling and Testing 
VHC Village Health Committee 
WRA Women of Reproductive Age 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 5
A. Executive Summary 
CS-18, ISCOM (The Community Health Initiative for the Districts of Kouroussa and Mandiana 
Guinea; “Initiative pour la Santé Communautaire”) was implemented by Save the Children (SC) 
through funding from USAID/Washington (Office of Global Health; Child Survival and Health 
Grants Program—CSHGP) from October 2002 to September 2006 (cycle CS-18 of CSHGP 
grants). This project followed two funding cycles: 
1) From 1997 to 1998 (CS-12), SC performed baseline studies in the Mandiana District. 
2) This was followed by a child survival project (CS-14) in the Mandiana District, from 
1998 to 2002. 
CS-18 expanded its interventions to the entire district of Mandiana and, in the case of certain 
interventions, to the district of Kouroussa. The human geography of the two districts includes 
527 villages, with a total population of 393,060 inhabitants; 85,402 of whom are children under 
the age of five and 106,753 are women of reproductive age (WRA). 
When the project was launched, the under-five mortality rate was estimated at 222 per 1,000 live 
births, and the maternal mortality rate was estimated at 528 per 1,000,000 live births. The project 
was designed to reduce the principle causes of these mortality rates, by addressing the following 
factors: 1) low utilization of health facilities by the population, 2) weak health information 
systems, and 3) great difficulties in the provision of quality health services necessary to improve 
the health indicators in both districts (and particularly in the district of Kouroussa, which had not 
benefited from the previous material and human investments that led to the success of “The 
Mandiana Model”1
). 
CS-18 focused on improving these indicators through five principle technical interventions: 
Maternal and Newborn Health (commonly called Maternal and Child Health (MCH) in the 
project’s documentation); family planning; nutrition and micronutrients; immunization; and 
HIV/AIDS prevention. 
The project design was unique as it established the role of the SC teams as that of a catalyst and 
supervisor of technical interventions in health centers and at the community level. These 
interventions were carried out directly by the District Health Offices (DPS: “Directions 
Préfectorales de la Santé”) and two local NGOs which were just beginning to implement health 
services. These two NGOs were: 
1) GAAPE (Groupe d’Appui à l’Auto Promotion Paysanne et à Protection de 
l’Environnement, The Support Group for the Self Promotion of the Land and the 
Protection of the Environment) in Kouroussa, and 
2) AJVDM (Association des Jeunes Volontaires pour le Développement de Mandiana, The 
Association of Young Volunteers of Mandiana). 
These NGOs had no previous experience in health, but had a recognized presence and 
involvement in both districts at the community level. 
 
1
 See the 2002 final evaluation report for CS-14, and the investigation done by the MSH PRISM Project in 2003. 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 6
The project goals were to: 
ƒ Increase utilization of services by the communities through the development of community￾based services; 
ƒ Promote appropriate health practices for both mother and child at the household and 
community levels; 
ƒ Develop the capacity of partnering NGOs and further develop the capacity of the DPS. 
Two of the key channels identified at the start of the project to implement this strategy were the 
Village Health Committees (VHC), and the MURIGAs (mutual village funds for the treatment of 
obstetrical emergencies, and later on for other child health emergencies). 
The final evaluation took place in September 2006 and showed significant success in several 
areas, including: 
ƒ Perinatality: increase of prenatal consultations and of trained birth attendant (TBA) coverage, 
a doubling of awareness of danger signs during pregnancy and delivery, and of Vitamin A 
during postpartum (from 45% to 70%); 
ƒ The project had an undocumented impact on the Maternal Mortality Ratio (MMR), and 
clearly demonstrated an increase of deliveries assisted by a TBA and a skilled birth attendant 
(SBA) (from 64% to 99% for both categories combined); 
ƒ CS-18 established a well-functioning community health fund system (MURIGAs) where 
none previously existed, to manage obstetrical emergencies in the community; 
ƒ Nutritional behaviors (breastfeeding, complimentary feeding) improved significantly and 
under-nutrition indicators were reduced to close to 50% lower than the national average; 
ƒ Contraception utilization rates doubled over the course of the project, and unmet needs 
decreased by half, leading to 53% of women having their contraception needs satisfied; 
ƒ In terms of vaccination, the coverage rate for all antigens doubled, reaching 39%; 
ƒ Success was achieved on a smaller scale, mostly in terms of developing strategies such as the 
use of peer educators, rather than results, regarding the issue of HIV/AIDS, which was new 
for CS-18. 
ƒ Finally, further substantial benefits were achieved in non-targeted interventions, such as the 
treatment of respiratory infections through the Integrated Management of Childhood Illnesses 
(IMCI). 
An analysis of avoided mortality, based on the Lancet series, indicates that more than 600 child 
mortalities were averted in four years (Annex 8). This estimate does not take into account the 
deaths avoided by a regression in indicators that remained at the same level. This analysis does 
not demonstrate the significant development of capacities of individual organizations (such as 
the VHC, MURIGAs, local NGOs, Health Centers and DPS), or the functional link created 
between these institutions. 
CS-18 was designed to replicate the “model of Mandiana”. The final evaluation revealed that 
through the initial collaboration between the two districts, the original achievements in 
Mandiana were largely replicated and possibly even surpassed in Kouroussa. Over the course of 
the project, Mandiana, using about 1/3 of the initial human and material investment, faced 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 7
mitigated results: it improved the status of half of the targeted indicators, but saw a deterioration 
of the other half. CS-18 therefore provides elements of analysis, not only regarding the 
efficiency of a promising model for community health in Upper Guinea, but also regarding the 
dose-effect relationship between investments and technical assistance, and the sustainability of 
the achievements. As a result, it is clear that this model is highly effective and sustainable. Areas 
for further study should include exploration of potential levels of sustainability that can be 
achieved with reduced resources and for how long. 
Summary of Conclusions and Recommendations:
Several recommendations can be found at the end of this report, however there is only one 
fundamental recommendation for all partners: 
CS-18 demonstrates a potentially viable model of an effective community health 
program in Upper Guinea. This model created a functional bond between the 
professionals and managers of health, and the community forces. In the middle of 
this model are the local NGOs whose goodwill was shown, and whose capacity 
was developed. All the partners, including the DPS and DRS, recognize the 
importance of these new partners for the achievement of project success.
The five key parts of this recommendation include:
1) The MOH and district structures must quickly define a viable model to maintain a viable 
community health system, with or without external support. Of course the level of realization 
will vary depending on the type of support received, but the national MOH needs to define 
the community health model that Guinea wants to develop. 
2) In order to advance in this direction, it is recommended that the DPS/DRS organize, without 
delay, a roundtable to formalize the first stages of this process. Within this framework, there 
should be a discussion of the transfer of the project motorcycles to the local NGOs in order to 
contribute to the continuation of activities and achievements. 
3) SC should seek to develop a new project in Upper Guinea with the objectives of studying the 
costs of obtaining sustainable progress. 
4) At the same time, USAID and/or other potential donors should consider the potential of the 
CS-18 project. The next phase, Phase 3, could test the minimum investment needed to 
achieve minimum progress in the districts of Mandiana and Kouroussa, while also allowing 
for the extension of activities to a new zone. Such an investment would include agreements 
and contracts with civil society, and detailing of expected results, and the necessary support 
of the model from administrative authorities (districts, decentralization, social affairs). This 
proposal is an opportunity to combine efforts of good governorship with concrete health 
benefits for children under five and WRA at the community level2
. 
5) Finally, stakeholders in Guinea, and especially the MOH, must quickly find a way to ensure 
adequate levels of essential drugs and medical supplies. It will not be useful to increase the 
demand (which will be high) for services, and to increase access to care, if the essential 
vaccines, contraceptives and drugs are not available. Solutions exist, but they must be put 
into place if Guinea wants a true primary health care system. 
 
2
 Examples of concrete results for good governorship include: deaths avoided, improved health indicators, 
reinforcement of community organization and the potential of the communities to require better services; and 
balancing of the public-NGOs roles in the district development. 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 8
B. Assessment of the Results and Project Impact 
1. Introduction 
SC hired an international consultant to lead this final evaluation. The terms of reference required 
a highly participative approach for this evaluation, and included the following objectives: 
ƒ To analyze the level of achievement of CS-18 project objectives; 
ƒ To assess the strengths, weaknesses, and lessons learned; 
ƒ To examine the potential sustainability of project achievements and health benefits; 
ƒ To make recommendations for the continuing role of Save the Children in the health of 
mothers and children in Upper Guinea. 
The evaluation methodology and the FE team members are listed in Annexes 2 and 3. 
This evaluation was conducted between September 11 - 22, 2006. The results are presented 
below according to the format required by the USAID/CSHGP. Recommendations are presented 
following the discussion of the results by intervention. 
2. Graphic Summary 
As per the FE guidelines, the key project indicators with measurable result for both periods 
(2002 and 2006), are presented in a single graphic summary. The information is presented in 
Figure 1 and is detailed in the following section. 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 9
Figure 1: Graphic Summary: Progression of the key indicators from 2002-2006
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Two prenatal consultations
Knowledge of danger signs
Referals for obstetrical complications
Deliveries by trained attendants
Deliveries by skilled attendants
Contraceptive prevalence
Complete vaccination by 12 mo.
BCG vaccination
BCG-measles drop-out
DTP3
Measles
TT 2 doses
DTP drop-out
Early BF
Exclusive BF
Complementary Feeding 6-9 mo.
Postpartum Vit. A
Use of iodized salt
Knowledge of two means of HIV/AIDS prevention
STD in last 12 months
Treatment of STDs
2002
2006
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 10
3. Results: Technical Approaches 
For each intervention, a table will present the objectives established in the Detailed 
Implementation Plan (DIP) approved by USAID. A general table is available in Annex 1. Results 
and more detailed comparisons follow and are accompanied by the evaluation team analyses. 
The results are presented overall for the project. A separate analysis of the two districts is 
presented in a next section. The results presented are from the KPC study, unless otherwise 
noted. 
a. Global View of CS-18 Implementation Strategies 
CS-18 began with the development of an action plan and annual project plans, the identification 
of NGO partners and an evaluation of their capacity, and the conduction of baseline studies, and 
the dissemination of their results.
Field activities began five months before the end of the first year. Principle project activities 
included: 
ƒ Capacity assessment of the Village Health Committees (VHC); 
ƒ Conduction of numerous trainings (see “Cross-cutting Interventions/Training”), and 
exchange visits abroad and between the two districts;
ƒ Support of DPS activities (National Immunization Days (NIDs), World AIDS Day and 
others);
ƒ Operations research (for example on the use of the intra-uterine devices for family 
planning, and the creation of village pharmacies in pilot zones at Mandiana); and
ƒ Daily field work by the NGOs community animators, with motorcycles and stipends 
provided by SC. The essential responsibilities of these animators were:
- Supervision of the community health agents (CHW) and traditional birth 
attendants (TBA);
- The conduct or support of community education sessions; 
- The microplanning of the activities with the health centers (HC), the VHC, the 
peer educators and others working in HIV/AIDS prevention and the distribution 
of contraceptives;
- The support for the activities of MURIGAs (Community-funded revolving 
emergency health loan fund);
- Creation of the Associations of VHC (AVHC); and
- Relaunching and expansion of the Youth Listening Centers.
A team of four SC employees were incorporated with each of the two DPS offices, and worked 
in close collaboration to support the DPS. The project sought synergies of intervention with the 
other stakeholders in the area3
 and took an active part in the coordination of activities at the 
district, regional, and national levels (District Technical Committees of Health, Regional 
Technical Committees of Health, National Reviews of the Expanded Immunization Program 
(EPI) and Review of Primary Health Care). 
 
3
 HKI, EH, FHI, PRISM, UNICEF. 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 11
The number of villages reached by the project in Kouroussa increased after the midterm 
evaluation (See Table 1). Additionally, several end of project studies were conducted before the 
final evaluation which enhanced the analysis included in this report. 
Table 1: CS-18 Geographic Coverage by District
Mandiana Kouroussa
Urban community (head office DPS) 1 1
Sub-districts 11 11
Total number of villages in the district 133 289
Number of villages targeted by CS-18 133 (100%)
as of May 2003
80 (28%)
42 as of May 2003
+ 38 after September 
2004
Number of VHCs supported 133 80
Number of Assoc. of VHC 12 12
Number of MURIGAs supported 133 80
Number of villages targeted for vaccination 
outreach visits
107 67
b. Environmental Constraints 
A certain number of environmental constraints had an impact on project achievements and must 
be noted:
ƒ Repeated increases in the cost of fuel and primary food products;
ƒ Stock-outs of vaccines, drugs and management tools;
ƒ Elections: presidential (2003), communal and community (2005);
ƒ An epidemic of meningitis in the district of Mandiana (2006); and
ƒ General Strike of workers (2006).
c. Maternal and Newborn Health 
The CS-18 project has addressed its objectives and obtained substantial results for this 
component. Certain limitations in achievement were observed due to the insufficient 
measurement of indicators and the inability to overcome some constraints, previously mentioned.
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 12
Table 2: Achievements by Objective
Performance Indicators Objective Final result * 
Three antenatal consultations, one of which is in the 
9th month of their last pregnancy 
[two antenatal consultations] 
80% Nm 
[+] 
Mothers know at least two danger signs during 
pregnancy and the postpartum period 60% √
Use of a chemoprophylaxis (iron folate and 
chloroquine) during the last pregnancy 80% √
Last birth assisted by trained personnel 80% √
At least two postnatal visits including one in the first 
week of birth [two postnatal visits] 60% Nm +
Complications referred in a medical facility during 
the last pregnancy 80% X 
* Key: 
√ Achieved objective 
+ Proven or probable progress 
X Objective not obtained 
Nm Not Measured 
d. Use of Pre and Postnatal Consultation Services 
The very specific indicators defined in the DIP, were unfortunately not measured (“80% of the 
pregnant women carry out three antenatal consultations, one of which was in the 9th month at the 
time of their last pregnancy”; and “60% of the women carry out at least two postnatal 
consultations including one during the first week”). The analysis is therefore performed on 
specific elements.
The use of antenatal consultations (at least two consultations) nevertheless increased from 68%) 
to 91% overall (particularly remarkable in Kouroussa). The use of three antenatal consultations 
is around 70% overall. This is a positive result compared with the national level DHS data 
(2005), which indicates that 73% of women had two antenatal consultations or more .
The PRISM Project measured the achievement of three antenatal consultations, one of which was 
in the 9th month of pregnancy in 2003, and showed higher levels in Mandiana and Kouroussa 
(two traditionally resource-poor districts) compared to the regional capital district of Kankan 
(Figure 2). The number of women having at least two postnatal consultations in 2006 is 
equivalent in the two districts (58% overall), but was not measured in 2002. 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 13
Figure 2: Use of Prenatal Consultation Services in Three Districts of Upper Guinea
(PRISM 2003)
60% 56%
44%
0%
20%
40%
60%
80%
3 Prenatal Care Visits - one in 9th month
Mandiana Kouroussa Kankan
i) Quality of pre and postnatal care 
Several indicators are used to measure the quality of ante and postnatal consultations, as well as 
the effectiveness of CS-18 efforts to reach women with essential messages for maternal health. 
These results are mixed, but several are encouraging:
ƒ Ninety-two percent (92%) of the women received a prophylactic antimalarial treatment 
during their last pregnancy. However, the treatment was most often chloroquine rather 
than Fansidar, which is the drug of choice according to the national policy which is more 
than one year old, because of drug resistance to chloroquine. (Only 8% of the women 
received Fansidar.)
ƒ The coverage rate for two doses of TT for pregnant women remained stable (73% in 2002 
and 78% at the endline KPC survey).
ƒ On the other hand, knowledge of danger signs during pregnancy by women, doubled in 
four years in the two districts (Figure 3).
ƒ The coverage of women receiving a megadose of Vitamin A in the postpartum period 
increased by 45% to 70% between 2002 and 2006.
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 14
Figure 3: Knowledge of at Least Two Danger Signs During Pregnancy and Childbirth by 
Mothers of Children Less Than 24 Months Old (KPC Survey 2006)
32%
68%
0%
10%
20%
30%
40%
50%
60%
70%
80%
2002 2006
 
ii) Management of Uncomplicated Childbirth 
The project strategy for improving childbirth was based primarily on the training of traditional 
birth attendants (TBA). Such a strategy can sometimes reduce the proportion of deliveries by 
skilled health personnel, however, this was not the case in CS-18 (Figure 4). During CS-18, not 
only does the number of births assisted by trained TBAs increase by almost a third (from 43% to 
56%), but one also observes an increase in the proportion of childbirths in health facilities which 
leads to: 
ƒ A doubling of the proportion of births assisted by skilled health personnel (from 19% to 
43%)4
; and 
ƒ The reduction in the number of unassisted births at home. 
These results are remarkable, especially since the KPC survey fully covered each of the two 
districts, whereas the coverage of project community activities reached only half of the villages 
in Kouroussa (see Table 1). The project received reports of villages without VHCs (not covered 
by CS-18) which received services from neighboring TBAs, either in the assistance with 
uncomplicated births, or in organizing obstetrical referrals to a health facility. 
4
 This result is similar to the PRISM project survey in 2003. 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 15
Figure 4: Personnel Assisting with the Most Recent Birth According to KPCs in 2002 and 
2006
45% 56%
19%
43%
0%
20%
40%
60%
80%
100%
2002 2006
Trained TBA Skilled Personnel
 
iii) Obstetrical Referrals 
The project worked hard to increase the number of obstetric referrals by encouraging the creation 
of MURIGAs and providing support to VHCs, in addition to training TBAs and health workers 
in emergency obstetrical and neonatal health. The results obtained provide a mixed view: 
ƒ The KPC shows a reduction in the percentage of women reporting having been referred 
during a pregnancy or a complicated birth (from 69% to 49% between 2002 and 2006). 
However, this indicator has many limits since it asks mothers to recognize and remember 
danger signs. In addition, the number of births in health centers has increased, therefore 
resulting in fewer referrals from the community to the health centers.
ƒ The number of referrals supported by the MURIGAs has nevertheless increased each 
year, from 33 per annum in 2004 to 59 per annum in 20065
. 
ƒ The percentage of obstetrical referrals compared to the births recorded in the health 
information system (HIS) has remained stable (around 1.5%), except for a peak in the last 
two quarters 2004, which was not maintained (Figure 5).
Overall, during the three last years, the HIS reports the following data:
ƒ 29,671 recorded births;
ƒ 67 maternal deaths (or 225 deaths for every 100,000 live births);
ƒ 12,344 births assisted by TBAs (41%);
ƒ Only 1,604 births (5%) were assisted by untrained TBAs;
ƒ 10,632 births were assisted by health personnel (36% of deliveries);
ƒ 5,091 births assisted in a health facility (17%);
ƒ 617 referrals to the health centers and 314 to a hospital (3.1% of the births having been 
referred).
5
 See the section on MURIGAs 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 16
Figure 5: Percentage of Births Recorded by the HIS Referred to a Health Center or a 
Hospital per Quarter
1.6% 1.7% 1.4%
4.0%
15.4%
1.7%
3.0%
1.8% 1.1% 1.8% 1.5%
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
18.0%
Dec-03
Feb-04
Apr-04
Jun-04
Aug-04
Oct-04
Dec-04
Feb-05
Apr-05
Jun-05
Aug-05
Oct-05
Dec-05
Feb-06
Apr-06
Jun-06
iv) Maternal Deaths 
Figure 6 shows the total number of maternal deaths recorded by the HIS over the last ten 
quarters. These figures cannot be considered as absolute from a statistical point of view, as there 
may be under-reporting of births and deaths. They do, however, present a very encouraging 
trend which should be tracked and confirmed over time.
v) Discussion: Maternal and Newborn Care Intervention 
The evaluation team identified the following elements of success: 
ƒ Identification, training and equipping of TBAs; (107 TBAs trained and equipped); 
ƒ Training of Health Agents in emergency obstetrical and neonatal health (59 health 
workers trained); 
ƒ Communication and continuing education of WRA by the health agents and in particular 
by the VHC supported by the NGO animators; 
ƒ Support for the TT vaccination campaigns of pregnant women; 
ƒ The installation of MURIGAs and the decentralization of their management; 
ƒ Training of VHCs on danger signs during pregnancy and childbirth; 
ƒ Intensive follow-up of activities by trained NGO animators and health workers; and 
ƒ The management of the HIS by the district health authorities. 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 17
Figure 6: Number of Maternal Deaths Recorded by the HIS for Mandiana and Kouroussa 
per Quarter
12
4 6 8 6
10
4 6 2
18
14
14
6 8 4
4
4
2
0
5
10
15
20
25
30
35
Dec-02
Mar-03
Jun-03
Sep-03
Dec-03
Mar-04
Jun-04
Sep-04
Dec-04
Mar-05
Jun-05
Sep-05
Dec-05
Mar-06
Jun-06
Sep-06
Kouroussa Mandiana
Among these success factors, some interventions are particularly critical for the replication of 
this model, including: 
ƒ The identification, training, and equipping of TBAs; 
ƒ The regular follow-up of activities on all levels, especially through local NGO animators; 
and 
ƒ Training on different levels, and the active involvement of community structures (VHCs) 
in communications about, and mobilization and management around maternal health 
issues. 
Several constraints restricted the achievement of project objectives. 
ƒ The first constraints are related to the environment: 
- The mobility and seasonal movement of women to and from the mining zones; 
- Distance to the medical facilities; 
- The high workload of women in the households; and 
- The remoteness of certain villages. 
ƒ Structural weaknesses of the health system: 
- Limited outreach visits and active case finding of pregnant women or women recently 
delivered; 
- Frequent breakdowns of logistics and fuel stock-outs at the health centers; 
- Stock-outs of drugs and management tools; and 
- Insufficient number of health personnel; 
ƒ Finally, the strategy of creating MURIGAs only covered part of Kouroussa District. 
Problems of over charging for services in the hospital were not completely solved. 
e. Family Planning 
The CS-18 Project obtained remarkable results in its family planning (FP) intervention, 
exceeding the objectives set and making substantial progress in increasing the accessibility and 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 18
use of FP services. However, the health system remains fragile as demonstrated by frequent 
stock-outs, which threaten these gains. 
Table 3: Achievements of FP Objectives
Performance Indicators Objective Final result * 
% of mothers which do not wish to have another 
child in the two next years and who use a modern 
contraceptive method 
50% √
Knowledge of three FP methods -- √
% of women living in a 5km radius of FP services -- √
% of health centers offering at least three FP methods -- √
Absence of stock-outs in the last four months -- √
* Key: 
√ Achieved objective 
+ Proven or probable progress 
X Objective not obtained 
Nm Not Measured 
i) Knowledge and Use of Contraceptive Methods 
The use of modern FP methods by mothers not wanting another child in the next two years, 
doubled overall (from 24% to 51% against an objective of 50% - Figure 7). This progress is 
largely due to tremendous gains made in Kouroussa which multiplied this indicator by 7 (from 
9% to 66%). The rate in Mandiana remained stable or progressed slightly (from 37% to 43%)6
. 
The use of a contraceptive method by mothers in the KPC study was 50%, as compared to the 
2005 DHS in which only 9.1% of the women in union currently used a method of contraception. 
Almost all women (96%) in the two districts know at least three methods of contraception. 
Figure 7: Use of Modern FP
24%
51%
0%
10%
20%
30%
40%
50%
60%
2002 2006
 
 In terms of impact, 73% of the women of Mandiana and Kouroussa, spaced their last two 
pregnancies by at least 24 months. According to the DHS study, 86% of the women in the area of 
Kankan had at least 24 months between pregnancies. There was no comparable measurement in 
the 2002 KPC study. 
6
 The difference observed for Mandiana from 37% to 43% is not statistically significant, but the overall change for 
both districts and Kouroussa is. 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 19
Figure 8: Comparison of the Contraceptive Prevalence of Mothers in CS-18 Districts and 
the National Level. (Mothers of children less than two years old in the KPC 2006 and mothers 
in the DHS 2005 survey). 
49%
9%
0%
10%
20%
30%
40%
50%
60%
Mand / Kourou 06 DHS 2005
ii) Availability and Access to FP Services 
Access to FP services is high (76%) within a radius of less than 5 km, in particular due to the 
provision of contraceptive pills by peer educators and the community-based providers who are 
now authorized to provide this method. The 24 centers supported by the project (12 in each 
prefecture) offer three methods of FP, but had many stock-outs in the last four months (Figure 9). 
CS-18 also conducted operations research (OR) in nine villages of Mandiana to increase the use 
of intra-uterine devices (IUD), by a combination of training health workers, mobilization, and 
dissemination of information at the community level. This OR was evaluated by FHI and 
included the insertion of 73 IUDs between January and June 2005, compared with only 13 during 
the previous period. 
Figure 9: Stock-outs of Contraceptives in the Last Four Months (N= 12 Centers of Health 
in Kouroussa and 12 in Mandiana)
10
6
16
2
6
8
0
5
10
15
20
Mandiana Kouroussa Total
Stockouts No Stockouts
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 20
iii) Discussion: Family Planning 
The following factors have enabled these remarkable results: 
ƒ Training of health workers, community-based agents, and peer educators; 
ƒ The availability of oral contraceptives at the community level; 
ƒ Follow-up and supervision by the NGO partners and the health agents supported by the 
NGO animators (in micro-planning and logistical support); 
ƒ Effective involvement of the VHCs in social mobilization; 
ƒ Orientation and involvement of the religious and community leaders; and 
ƒ Installation of a buffer stock of contraceptive supplies to prepare for stock-outs. 
The primary constraints faced were: 
ƒ The reservations of certain religious leaders, and cultural attitudes which were sometimes 
expressed in a violent way against FP clients. Despite the progress made, this progress 
needs to be sustained. 
ƒ Repetitive stock-outs are an overall threat to maintaining the communities’ health. 
iv) Flexible Fund Questions 
USAID provided Flexible Fund support for some of the FP activities in this project. Flexible 
Funding reporting guidelines require that the following sections be addressed. (This information 
is provided throughout this FE report, however a synthesis is presented here.) 
(a) The project worked very closely with the USAID Mission in Guinea and its PRISM Project. 
The PRISM Project provided a buffer stock of contraceptives, but did not take responsibility 
for long-term, logistical support. In fact, the community approaches of CS-18 highlighted a 
latent demand for contraception and the capacity to increase this demand to satisfy the unmet 
FP needs. This more clearly revealed the frailty of the health system, and its ongoing 
management and logistics challenges related to contraceptives and essential drugs. 
(b) The project increased the use of the contraceptive methods and engaged the community in 
the reduction of cultural obstacles, which are important and sometimes resulted in domestic 
violence. The involvement of the VHC and the religious leaders was significant. 
(c) The FE did not focus on the quality of FP services. This was addressed by both the PRISM 
Project (common tools) and MOH authorities. Access to services was increased and the 
provision of contraceptive methods closer to the communities, helped improve the quality of 
these services. 
(d) Access was improved primarily because of the provision of oral contraceptives at the 
community level. However, stock-outs are frequent in health centers and call into question 
the sustainability of this improved access. 
(e) CS-18 led a pilot effort to offer IUDs as a contraceptive method. This pilot was successful 
and could be expanded. 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 21
(f) There is no indication of a lack of compliance with the Mexico City Policy or the Thiart 
Amendment. 
(g) The project showed the validity and effectiveness of involvement of local NGOs to 
implement community health activities, including FP. This was deeply appreciated and 
recognized by the medical authorities. 
f. Vaccination 
CS-18 supported the improvement of vaccination coverage in the two districts, despite extremely 
difficult conditions, including lack of fuel and vaccine stock-outs. Important progress was 
achieved, even though the (overly) ambitious objectives were not fully realized. 
Table 4: Vaccination Achievements by Objective
Indicators of performance Objective7 Final result * 
Children 12-23 months old completely vaccinated 
before one year of age 80% X +
Coverage of BCG 90% X +
DTC3 before one year of age 80% X +
Measles before one year of age 80% X +
Outreach visits increased 85% X
TT Vaccination8 80% X
Drop-out BCG – Measles9 -- +
Drop-out DPT1-DPT3 -- +
* Key: 
√ Achieved objective 
+ Proven or probable progress 
X Objective not obtained 
Nm Not Measured 
i) Vaccine Coverage Rate 
Figure 10, based on the KPC, shows the progress made in vaccination coverage for each antigen. 
On the whole, complete vaccination coverage doubled, increasing from 17% to 39%, despite 
numerous stock-outs. These solid results are supported by the HIS EPI data analysis, shown in 
Figure 11. It is important to note that coverage in Kouroussa caught up with coverage in 
Mandiana. This will be discussed later in this report. 
 
7
 The objectives of vaccination coverage set in the DIP were based on the denominator of children less than two 
years having a vaccination chart. The cover rate for this sub-group will be increasingly higher than for all children 
less than two years old. Even by using this measurement, the objectives set were not achieved by the project. In this 
report, we use the most strict measurement of coverage by antigen, i.e. “number of children of less than two years 
old with a vaccination by the antigen confirmed by card/a total number children of less than two years of the 
sample.” A child vaccinated at the time of a campaign, but whose vaccination is not noted in the notebook, thus is 
regarded as not vaccinated. This very conservative definition, is recognized internationally. 8
 See section on Maternal and Newborn Health for TT, whose indicator remained constant. 
9
 The indicator of drop-out used by the project is that of BCG-Measles to conform to the Guinea national policy. The 
drop-out rate for DPT1-DPT3 is more commonly used internationally and will also be shown. 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 22
Figure 10: Vaccination Coverage by Antigen (KPC 2002 and 2006)
32% 32%
19% 19% 17%
52% 51%
44% 42% 39%
0%
10%
20%
30%
40%
50%
60%
BCG DTP1 DTP3 Measles Complete
2002
2006
Figure 11: Vaccination Coverage According to the HIS in the Districts of Mandiana and 
Kouroussa (six-month periods 1 (January-June 2002) through period 9 (January-June 
2006)
23%
34%
46%
64% 63%
74%
81%
84%
90%
64%
81%
64%
80%
86%
82%
90%
85%
92%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
123456789
Kouroussa
Mandiana
Prior to the project, in 1999 the district BCG coverage levels were lower (31%) than the national 
level. Now, through the project, they have caught up with the national levels (both 52%). 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 23
Figure 12: Comparison of the BCG Coverage Between the CS-18 KPC Studies (Mandiana￾Kouroussa) and DHS Studies. Two periods of comparison: before the current project (1999 for 
the DHS and 2002 for CS-18) and at the end of the project (2005 for the DHS and 2006 for CS￾18) 
32%
52%
46%
52%
0%
10%
20%
30%
40%
50%
60%
Before ISCOM End of ISCOM
Mandiana&Kouroussa National Coverage
Figure 13 represents very important progress made in the vaccination drop-out rate, which was 
reduced by half or more over the course of the project. It is also an indicator of the improvement 
of the quality of care, and improvement made in the recording of health data. 
Figure 13: Vaccination Drop-out Rates
43% 41%
20%
14%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Drop-out BCG-Measles Drop-out DTP1-DTP3
2002
2006
ii) Support for Vaccination Outreach Visits 
The project actively supported outreach visits by health center staff, by encouraging 
microplanning, through monitoring, and on occasion, by providing logistical support when the 
HC transportation failed (through motor bikes borrowed from the local NGO animators). 
Nevertheless, it is necessary to note that project objectives for immunization were not fully 
reached, with only 54% of the programmed vaccination outreach visits carried out. 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 24
Table 5 shows the number of outreach visits made to the number of villages targeted by this 
strategy for each year. The planned number was reduced in Mandiana after 2004, to allow for an 
intensification of the efforts in Kouroussa. This was an effective strategy since Kouroussa 
reached and then exceeded the number of outreach visits in Mandiana (reaching almost three 
visits per village per annum in 2006, incomplete year), whereas the level was maintained in the 
last two years in Mandiana. 
Table 5: Planning and Achievement of Outreach Visits by Target Village in the Two 
Districts by Year
Activities/Village 2003 2004 2005 2006
Programmed 2.2 5.4 2.7 2.7 Mandiana Actual 1.8 2.4 1.4 1.7
Programmed 1.8 4.3 3.6 4.3 Kouroussa Actual 1.6 1.0 1.5 2.9
iii) Discussion: Vaccination 
The FE team identified the following successes: 
ƒ The involvement of VHCs in vaccination activities; 
ƒ Outreach visits and active case findings of defaulters (mothers and children who get the 
first immunization, but do not return for the second or third dose) were conducted; 
ƒ Production and distribution of management tools to the DPS and HCs by the project; 
ƒ Reach Every District Campaigns organized at the national level with the support of 
UNICEF; and 
ƒ Personal efforts, for example the Districts Director of Kouroussa transported the vaccine 
herself from Conakry to Kouroussa to prevent vaccine stock-outs. 
Important constraints however, limited the achievement of objectives: 
ƒ The project and its partners could not conduct all of the outreach visits and support all of 
the active case finding efforts for vaccination drop-outs; and 
ƒ In addition to the socio-cultural constraints (for example movement to the mining zones, 
and feared side-effects of vaccination), the weaknesses of the health system continue to 
be the principle limiting factor (frequent breakdowns of logistics; frequent fuel stock￾outs, stock-outs of vaccines and management tools; lack of adequate numbers of health 
personnel). 
g. Nutrition and Micronutrients 
The project achieved important results in its nutritional intervention. These results certainly 
contributed to lowering the prevalence of malnutrition compared to national levels. This 
component also had an important impact on improving health and the reduction of child 
mortality. However, this component is also one of the most problematic in terms of 
sustainability, due to the cost of the strategies and the limited success of the growth monitoring 
and promotion strategy. Finally, while there was progress in Vitamin A supplementation, the 
iodized salt strategy was not successful. 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 25
Table 6: Achievements by Objective in Nutrition
Performance Indicators Objective Final result * 
Early breastfeeding (1st hour) 40% √
Exclusive breastfeeding (0-6 months) 60% √
Appropriate complementary feeding (6-9 months) 70% X +
Moderate malnutrition level (weight/age <2DS and 
>3DS) 15% √
Severe malnutrition -- √
Vitamin A coverage (6-59 months) 90% Nm 
Post-partum Vitamin A 60%10 √
Use of iodized salt -- X
* Key: 
√ Achieved objective 
+ Proven or probable progress 
X Objective not obtained 
Nm Not Measured 
i) Nutrition of the Young Child 
The percentage of newborns benefiting from breastfeeding within the first hour, as well as the 
percentage of children benefiting from exclusive breastfeeding (EBF) for up to six months, 
doubled during the life of the project (Figure 14). An increase in the percentage of children from 
6 to 9 months old benefiting from complementary feeding also increased (to 52%), but did not 
reach the project goal of 70%). 
The level of EBF achieved (70%) represents the principle intervention contribution to preventing 
deaths (see Annex 8) and compares very favorably with the regional figures (50% in the PRISM, 
2003 Survey, and 27% in the national DHS 2005). 
 
10 The objective set was for two doses of Vitamin A, while the final indicator was one megadose of Vitamin A. 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 26
Figure 14: Breastfeeding and Complementary Feeding of the Young Child (KPC Surveys)
23%
36% 33%
48%
70%
52%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Early BF Exclusive BF 0 - 6 mo. Complementary
Feeding 6-9 mo.
2002
2006
ii) Nutritional Monitoring and Growth Promotion of Children 
Efforts to improve the monitoring of children’s nutritional status achieved modest results. 
According to the KPC survey in 2006, only 48% of the children have at least one weighing noted 
on their health record. The project monitoring system indicates that the community weighing and 
growth promotion sessions in Mandiana as well as in Kouroussa, do not include more than 17% 
of the expected number of children targeted in the growth monitoring sessions. In one quarter, 
this percentage reached 40%. The NGO partners reported that the organization of community 
growth promotion and monitoring sessions is very hard. Mothers find it difficult to regularly 
attend growth monitoring and promotion sessions to their other daily activities. 
During the community weighings, the percentage of children in the red zone (severe malnutrition 
wt/age) oscillates around 2% (1% to 5%), and for the yellow zone (moderate malnutrition 
wt/age) it oscillates around 14% (8% to 16%). This overall stable situation hides differences 
between the two districts. The figures for Kouroussa were more worrisome at the beginning of 
the project and have now been reduced to the Mandiana levels. There was a downward trend, 
particularly for moderate malnutrition in Kouroussa, as Figure 15 indicates. 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 27
Figure 15: Percentages of Children in the Red Zone (severe malnutrition) and in the Yellow 
Zone (moderate malnutrition) During Community Weighings in the District of Kouroussa
2% 4% 5% 4% 5% 7% 6%
3% 2%
5%
40%
28%
23%
16%
12%
17%
20%
16%
13% 15%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
Dec-03
Feb-04
Apr-04
Jun-04
Aug-04
Oct-04
Dec-04
Feb-05
Apr-05
Jun-05
Aug-05
Oct-05
Dec-05
Feb-06
Apr-06
Jun-06
% in red zone % in yellow zone
iii) Supplementation of Vitamin A and Use of Iodized Salt 
The majority of postpartum women (70% compared to 16% at baseline) received a megadose of 
vitamin A. The availability of the Vitamin A capsules and the number of TBAs trained in their 
distribution, largely contributed to the increase in the coverage in the project districts. 
The coverage of Vitamin A supplementation of children 6 to 59 months old, unfortunately was 
not measured. Vitamin A supplementation is primarily done during the National Immunization 
Days (NIDs), but is rarely done routinely during visits to the health centers. 
The proportion of mothers who add iodized salt to meals did not increase between 2002 and 
2006 (18%). This result remains very weak compared with the results of the last DHS where it is 
43.9%. This low level is explained by the lack of iodized salt in the market and the rupture of the 
salt testing kits which allow households to know the content of iodine in their salt. The project 
did not specifically seek to address this. 
iv) Nutritional Status of Children 
There are no clear comparative measurements to evaluate the impact of the project on the 
nutritional status of children. One can nevertheless carry out comparisons with the data from the 
latest DHS. Figure 16 shows that 16% of the children in the project zones suffer from moderate 
or severe malnutrition; this is in comparison with a national average of 29% according to 2005 
DHS. The project has in fact reached a rate of moderate malnutrition lower than the objective of 
15% which had been set. 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 28
Figure 16: Rates of Malnutrition (ponderal deficit) Compared Between the CS-18 Project 
Zone (CPC 2006 investigation) and the National Indicators (EDS 2005) 
4% 7%
12%
22%
0%
5%
10%
15%
20%
25%
30%
35%
Mand/Kour National
Moderate Malnut 
Severe Malnut 
v) Discussion: Nutrition and Micronutrients 
The elements which contributed to the improvement of the nutritional status of children in the 
project zones include: 
ƒ Growth monitoring and promotion sessions, and culinary demonstrations, in addition to 
education and counseling sessions; 
ƒ Training of nutritionists within each VHC and the organization of hearths when more 
than eight cases of severe malnutrition are detected among the children during 
community weighings; and 
ƒ The constant involvement of the local VHCs and the support of NGOs. 
Constraints faced include: 
ƒ Efforts to organize the growth promotion and monitoring sessions, did not result in an 
increase in the proportion of children served, and is not likely to be sustainable without 
project support; 
ƒ Resources necessary for conducting hearths are limited; and 
ƒ Absence of iodized salt and kits to test salt, as well as the absence of a specific strategy to 
improve this situation. 
h. HIV/AIDS Prevention 
The CS-18 project refocused its work on malaria (CS-14) to begin a new intervention addressing 
HIV/AIDS and STIs in CS-18. Many efforts were made to develop the necessary strategies, and 
interesting results were observed in terms of process and inputs, but not yet in terms of behavior 
change. 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 29
Table 7: Achievements by Objective in the Nutrition Component
Performance Indicators Objective Final result * 
Use of condoms with non-regular partners (by 
mothers) 80% X NM 
Adolescents 15-24 years old who know that condoms 
can protect against HIV/AIDS 80% X
Mothers who know at least two means of HIV/AIDS 
prevention 80% X +
WRA who know that the condom can protect against 
HIV/AIDS 80% X +
Four leaders per village (700) trained on the 
prevention of HIV/AIDS 700 √
Reduction in STIs reported by mothers in the last 12 
months 
Between 3% and 
10% X
Treatment for STIs sought by women -- +
* Key: 
√ Achieved objective 
+ Proven or probable progress 
X Objective not obtained 
Nm Not Measured 
i) Knowledge and Condom Use 
The goal of 80% use of condoms with “non-regular” partners was overly ambitious for the 
project, considering the time allowed and the number of other project interventions. However, 
there was progress in terms of information are shown by the KPC studies, where the level of 
knowledge doubled in four years: 
ƒ The percentage of women who know two means of protection against HIV/AIDS 
increased from 29% (2002) to 61% (2006); and 
ƒ The recognition of the condom as a means of protection for women, increased from 21% 
to 46%. 
The use of a condom by mothers at the time of a sexual encounter with a non-regular partner was 
not measured in 2002 and its estimate in the 2006 KPC had to be rejected after detailed review 
by the evaluation team. It seems that there was confusion within the project on the nature of this 
objective, which is recorded in contradictory ways in project documents. 
The project also carried out a study of young people with access to the Youth Listening Centers, 
mainly in urban/semi-urban environments. This survey was not randomized, so the results can 
not be extrapolated to the general population of young people in the two districts. Of 220 young 
people questioned, 43% reported always using a condom, and 30% said they used a condom 
sometimes. 
The evaluation team also met with the groups of peer educators. At least once, an evaluation 
team member observed a peer educator in a rural area with a display of various contraceptive 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 30
methods that did not include condoms. In group discussions however, the peer educators were 
motivated and mobilized to promote protective behaviors (including the use of condoms) during 
sexual relations. In an anonymous rapid survey conducted during the focus groups, the great 
majority reported having used condoms in their last sexual encounter. 
ii) Sexually Transmittable Infections (STIs) 
One of CS-18’s objectives was the reduction of STIs reported by mothers during the KPC study. 
In Figure 17, there is an increase of 8%, to 14%, several problems arise in how this objective was 
defined. 
ƒ On one hand, women are often asymptomatic and are not aware if they have an STI; and 
ƒ If an intervention is effective in the detection of STIs and their treatment, there will be an 
increase in the rates of infection observed, as they are more likely to be detected and 
reported. Therefore, there will appear to be an increase in the incidence before a 
reduction is noted. The rates of infection do not necessarily increase, but rather more 
infections (which would otherwise go unnoticed) are detected. 
While inconclusive, this possibility is reinforced by the increase in the number of women 
informed of an infection and who sought treatment. This last indicator increased from 51% to 
80% (Figure 17) and constitutes a very positive result of the project. 
Figure 17: Sexually Transmittable Infections (STI) Reported and Treated (KPC 2002, 
2006).
8%
51%
14%
80%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
STD Reported STD Treated
2002
2006
iii) Discussion: HIV/AIDS and STIs 
The progress observed in this project component is due to the diversity of approaches used 
including, varied channels of communication (peer educators, radio, and listening centers) to 
reach the young people. The cultural obstacles for the prevention of HIV/AIDS are important. 
The project reached 700 community leaders, the majority of whom were religious leaders, and 
conducted necessary discussions on the prevention of AIDS and religious standards. 
Additionally, HC staff were trained on the syndromic treatment of STIs, and community 
structures (youth listening centers and VHCs) were included in the communication and education 
efforts. 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 31
The strengths of this intervention identified by the evaluation team are: 
ƒ Identification and training of motivated peer educators; 
ƒ Decentralization of youth listening center activities; 
ƒ Communications targeting multiple channels; 
ƒ Advocacy meetings and orientation of key leaders; 
ƒ Training of the health workers on the syndromic management of STIs; and 
ƒ Parallel activities undertaken by PSI11. 
Despite these strengths, the goals for this intervention were not fully achieved. The FE team 
identified the following factors that limited the achievement of project objectives: 
ƒ Stock-outs of drugs for the syndromic management of STIs; 
ƒ The difficulty of conducting partner notification of patients presenting with STIs; 
ƒ Cultural barriers which were only begun to be addressed; 
ƒ The project duration (four years with major programmatic changes) was too short given 
the complexity of interventions (MCH, FP and HIV/AIDS). Based on the degree of the 
HIV/AIDS epidemic in Guinea, the results obtained by the project, and the time it takes 
to change sexual behaviors, the inclusion of this intervention in this project remains valid. 
However it is not surprising that the results on this new component are modest; 
ƒ The difficulty in addressing environmental constraints: 
- Displacements of populations to the mining zones; and 
- The absence of a strategy to reach specific target groups (“free women”, drivers, and 
military personnel). 
ƒ The broader absence of AIDS interventions (nonexistent or unknown sites for testing and 
antiretroviral treatment) which can have an effect of creating demand for prevention 
activities. 
iv) Disaggregation of the Mandiana and Kouroussa District Results 
CS-18 project activities were conducted in two distinct districts: 
1) The District of Mandiana, where after six years of programming and positive results in 
maternal and child health the district became known as the “Mandiana Model”; and 
2) The District of Kouroussa, a resource-poor district in a region which as a whole, is 
underserved. 
 
11 The evaluation team could not meet with the PSI team in Kankan, which has a very small team involved in 
condom distribution in the two districts. For the period from January 2002 to July 2006, PSI reports the distribution 
of the following products: 
- Injectable contraceptives (Dépo-Provera): Kouroussa: 201 units; Mandiana: 161 units; Total Upper 
Guinea: 2,948 units. 
- Oral contraceptive “Planyl”: Kouroussa 435 cycles; Mandiana: 3 cycles; Total Upper Guinea:7,824 cycles. 
- Condoms “Prudence Plus”: Kouroussa: 161,160 condoms; Mandiana: 102,480 condoms; Total Upper 
Guinea: 3,680,380 condoms. 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 32
The two districts have different levels of health indicators related to the project. The comparison 
of progress made on improving indicators is difficult because the starting point is different for 
each district. A useful tool for comparison is a gap analysis of the percent difference, or the 
deficit. The deficit to be filled is defined by how much remains in order to reach an optimal level 
of the indicator. The percentage of deficit to be filled is an indication of project performance. 
This index is explained in Annex 11. 
The analysis of the 23 indicators for which we have pre and post measurements for the two 
districts is now possible. Table 8 gives the percentage of the deficit between 2002 and 2006 for 
the principle project indicators, as well as the four childhood illness or IMCI indicators not 
targeted by the project. 
Table 8 shows the following: 
1) Overall, notable progress was made on the IMCI indicators even though they were not 
targeted by the project. This reflects the artificial aspect of identifying specific technical 
interventions for projects using an integrated approach. Progress on these indicators is 
the best evidence that CS-18 established and effective C-IMCI strategy. (Progress in the 
treatment of respiratory infections is the second greatest contributor to avoided deaths 
during the project, after breastfeeding.) 
2) Kouroussa achieved a reduction in the deficit for all indicators. For half of them, this 
reduction is higher than 52%. 
3) Mandiana achieved a reduction of the deficit for 12/23 indicators. For these 12 indicators, 
the median deficit filled is 30%. 
4) For 11 indicators, Mandiana observed a regression (the median of the regression is 36% 
for these 11 indicators). 
5) For all the indicators except one (drop-out DPT 1-3), Kouroussa had better results than 
Mandiana12. 
 
12 Remember that this measurement is making up the difference between the baseline and the objective. In general, 
the indicators reached similar levels in the two districts in 2006. 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 33
Table 8: Analysis of the Deficit Made up by Indicator for the Two Districts (see Annex 11 
for Explanation)
Percentage of the Deficit Made up Between 2002 and 2006 Mandiana Kouroussa
Maternal Health
Recognition of danger signs +33% +69%
Trained deliveries +16% +26%
TT Vaccination - 36% +46%
Referral for complicated births (reported by women) - 309% +20%
Two antenatal care visits +57% +92%
Family Planning
Modern FP use +13% +61%
Nutrition
Early breastfeeding (1 hr.) +26% +36%
Exclusive breastfeeding (0-6 mos.) +43% +60%
Complementary feeding (6-9 mos.) - 21% +58%
Postpartum Vitamin A - 60% +67%
Vaccinations
Drop-outs DPT1-3 +83% +56% 
BCG - 130% +35%
DPT1 - 150% +52%
DPT3 - 13% +51%
Measles - 28% +49%
Complete vaccination - 5% +41%
HIV/AIDS
Knowledge of condoms by women +3% +53%
Treatment of STI +8% +79%
Knowledge of two modes of HIV/AIDS prevention - 7% +85%
Other Indicators
Respiratory infection treatment +36% +45%
Breastfeeding during diarrhea +2% +34%
ORS use - 47% +3%
Knowledge of insecticide treated mosquito nets +36% +77%
Several explanations can be given for this: 
ƒ After the success of the preceding phases in Mandiana, the possibility of loss of 
motivation cannot be completely ignored. 
ƒ For Kouroussa, on the other hand, the opportunity to collaborate with a project like CS￾18 was a new source of energy, which has contributed to other positive elements: 
- New energy due to the nomination right before the beginning of CS-18 of the first 
woman DPS in Guinea; and 
- The neglected district also benefited from support from the World Bank (new 
offices), UNICEF (transportation) support, and a new paved road through the district. 
ƒ CS-18 staff and partners decided to intensify efforts in Kouroussa, where the delay on 
several indicators was larger, during the MTE. This choice was reasonable and suggests 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 34
several possible lessons. Figure 18 represents the intensity of the efforts of CS-18 in each 
district, according to three criteria: 
- In blue, the direct costs ascribed to activities in each district are divided by the 
number of targeted villages (133, that is to say the total number of villages in 
Mandiana; and 80 is one third of the villages in Kouroussa). According to this 
measurement, the efforts were 2.2 times greater in Kouroussa than in Mandiana. 
- In purple, the number of people trained during the four years of the project in relation 
to the number of targeted villages. According to this measurement, the efforts were 
2.7 times greater in Kouroussa than in Mandiana. 
- In yellow, the number of NGO animators used to cover 100 villages. According to 
these measurements, the efforts were 2.5 times more intense in Kouroussa than in 
Mandiana. 
- These were coarse measurements of the intensity of efforts, but it is important to 
notice the similarity of the three comparisons. 
The differences observed apply to all of these factors, and it should be noted that the KPC 
included the entire district of Kouroussa, not only the 80 targeted villages. There are various 
considerations offered from this analysis: 
ƒ For the DPS of Mandiana: a phenomenon of the erosion of project benefits has started. 
How will the DPS react to consolidate the benefits with its partners? 
ƒ For the DPS of Kouroussa: Kouroussa was able to benefit from the lessons learned in 
Mandiana during the previous project cycles. How will the DPS avoid following the same 
path towards an erosion of the acquired benefits (of course with its partners)? 
ƒ For Save the Children: CS-18 has created an opportunity for serious operations research 
on sustainability. How will this be considered if there is an opportunity to obtain new 
funding from donors? 
Figure 18: Intensity of Project Efforts According to Three Measurements 
0
5
10
15
20
Mandiana Kouroussa
$100 per village Persons trained/village Anim/100 villages
The relationship between the levels of effort in Kouroussa compared to Mandiana oscillates 
around 2.5 for the three measurements presented. 
ƒ For USAID: With funding and reduced intensity of efforts in general, Mandiana 
maintained the benefits acquired (it made some progress in some areas counterbalanced 
by an almost equivalent number of regressions). Can USAID draw some lessons in terms 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 35
of a progressive and realistic approach to the link between sustainability and scale of 
programming? What would have been the evolution in Mandiana without any support? 
How many lives were saved at lower cost, compared with a new zone which was just 
starting off? Is there an advantage to continuing investments where successes were 
obtained, making it possible to draw global lessons? Is it possible, after one or two phases 
of interventions, to target minimal investments for a durable and slower progress in the 
old zones, while extending the benefits to new zones? 
4. Results: Cross-Cutting Approaches 
a. Capacity Development and Partnerships 
The CS-18 approach was based on the establishment of solid partnerships, and the development 
of the institutional and inter-organizational capacities. This strategy was shown in the DIP by a 
number of indicators known as sustainability. Separately, the indicator on the development of 
VHC capacities (achieved between 80% and 97%) and that on NGO and DPS capacity (judged 
more qualitatively), achieved 100% (Table 9). 
Table 9: Achievements of the Sustainability Objectives
Performance Indicators Objective Final result * 
Villages will have volunteers providing community￾based services 80% √
Villages will have a system of funding obstetrical 
emergencies (MURIGAS) 80% √
VHCs proficient in planning and conducting 
community health activities 80% √
Villages which will have a health development plan 80% √
Sub-districts will have associations of VHCs 80% √
Reinforce the competences of NGOs and the DPS 
offices (HIS system) -- +
* Key: 
√ Achieved objective 
+ Proven or probable progress 
X Objective not obtained 
Nm Not Measured 
The following sections discuss the achievements for the principle partner organizations. 
i) Partnership with the DPS 
The two DPS are very satisfied with the CS-18 partnership. The SC teams were integrated in the 
DPS office space, and initially presented some logistical challenges in Mandiana (Kouroussa has 
new buildings built by the World Bank). 
Materially, CS-18 contributed a limited but important share in terms of electrification with solar 
panels, and some data-processing help in addition to the reproduction of management tools for 
the health centers and buffer stocks for the community initiatives. 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 36
This partnership is one of proximity and daily working together on the same issues. In Mandiana, 
a rotating “presidency” was organized to direct the team meetings. The “presidency” alternated 
between the DPS or his assistant, and the SC district coordinator. This approach was not used in 
Kouroussa. The evaluation team did not examine in detail the pros or cons of this team approach, 
but it is important to note that the district directors needed to understand that the field activities 
needed to be stimulated and orchestrated, more than controlled. The institutional responsibility 
for health services ultimately rests with the DPS, not with the international NGO partner. 
In addition to daily collaboration, exchange visits abroad were organized to benefit the DPS. 
These trainings and trips were directly related to the innovations and joint initiatives of the DPS 
and CS-18, however, other health system staff expressed jealousy at these perceived “perks”. 
There are intangible benefits of a close partnership and joint monitoring of activities, even when 
the joint supervisions were not carried out as often as planned (only once in 2005 in Mandiana 
and not since). 
The emphasis on joint supervision is perhaps inappropriate. Indeed the DPS conducts field 
supervisions with support (primarily vehicles, fuel, and too often per diem) by donors and 
partners including UNICEF, PRISM, and CS-18. This dependency required the DPS to align 
their plans with the calendars of these agencies (for example vaccination days for UNICEF). 
Consequently, it becomes difficult to respect a calendar of joint supervision with CS-18, in 
addition to the other calendars. Moreover the results were obtained without this joint supervision 
actually being conducted regularly13. 
The following collaborative activities were carried out: 
ƒ Quasi-regular (weekly) coordination meetings and review of monitoring data; 
ƒ reflection and resolution of problems; and 
ƒ launching and support of initiatives (operations research or pilots). 
Finally, the effective first level of supervision (community-based distributors, TBAs, health 
posts, VHCs, peer educators) was done thanks to the intense efforts of the NGOs animators. 
Their support and efforts supporting the health centers (which frequently lacked fuel or a means 
of transportation to carry out outreach visits and supervisions), were tremendous. 
The key role of the DPS on this level was to integrate the civil society – through both local 
NGOs – as active stakeholders in the health system of the districts. Instead of playing a role as 
competitor or hindrance (too often observed when the medical authorities feel threatened in their 
role), the two DPS (as well as the DRS and the higher levels of the MOH) had the wisdom to 
integrate the efforts of GAAPE and AJVDM through CS-18, into their own plans to improve 
pubic health. 
 
13 Each DPS has 12 health centers to supervise. At this level, even two annual visits for tens and hundreds of health 
posts and community agents is enormous. It is not the supervision starting from the DPS which can make a 
difference, but the supervision by the health center staff. 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 37
This integration of community strategies was developed thanks to the support of CS-18 including 
the use of community HIS data. The semi-annual reports and plans of the DPS, now integrate the 
HC and HP data with the reports from the CBDAs, TBAs and even the VHCs and MURIGAs. In 
the sense that CS-18 facilitated this process, the project played an important part in the 
development of the capacity of the DPS beyond the health system. 
The DPS and CS-18 used two parallel information systems starting from only one data 
collection. It was not ideal, but the DPS produced semi-annual reports rich in information and 
will be able to continue to do so. The project was also in a position to produce the quarterly data 
required of it. This system thus seems to have functioned well. In the future, more efforts could 
be placed at the DPS level to use the routine data in a strategy for continuous quality 
improvement. 
ii) Partnership with NGOs: GAAPE and AJVDM 
Both local partner NGOs played an essential part in the success of the project. Since the start, SC 
began the work of rigorous diagnosis and development of the institutional capacity as well as the 
technical trainings necessary for project activities. 
Tables 10 and 11 show the results of the institutional capacity evaluations of the two partners. A 
detailed report is available in French. CS-18 used an approach of self-evaluation, where the 
facilitators led a critical self-analysis. 
The value and the limits of the analysis are summarized in this extract of the NGO evaluation 
report, referring to the improvement of the scores in the capacity: 
“The results of this evaluation are not universal and are also partly subjective 
although the evaluation was based on testimonies and document review. The scores 
obtained to determine the level of development of NGOs are a function of the 
criteria defined in the tool used. Admittedly, these scores can vary with another type 
of tool. Consequently, the scores with 100% of progress do mean that the maturity 
of these elements is complete. However, it clearly also notes real progress of these 
NGOs in their working environment with tangible results. This can be shown by 
certain elements which make the NGO more credible in the eyes of donors and 
governmental institutions, including inter alia: The segregation of the organization 
into separate bodies with transparent governorship, the development of strategic 
plans, handbooks of procedures and management, capacity to develop projects, the 
tendency of these NGOs to work with regional approval and the extension of their 
activities to other districts as well as taking into account gender in their internal 
policies. The general assembly meetings which are the opportunities to report 
progress and define the annual priorities, became regular with the invitation of the 
representatives of donors and the districts administrative authorities showed their 
transparency and efforts to obtain the support of all. Before the contractualization 
with Save the Children, the majority of these indicators of institutional and 
organizational development were not taken into account by AJVDM and GAAPE 
given that they were really Associative Groups.” 
 -NGO Evaluation Report, July 2006 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 38
Table 10: AJVDM’s (Mandiana) Capacity Assessment
Background information AJVDM Mandiana
Date of creation 15/11/98 
Legal recognition agreement 146/P/97/Mna and 
O50/RAK/KK/CAB/SERACO 20/11/2005 
Date of assessment 01/04/2003 25/07/2006 
Capacity element evaluated Score Score
1. NGO Structure 7/12 10/12 
2. Mission and strategic planning 4/10 8/10 
3. Monitoring and evaluation 1/8 4/8 
4. Programs and services 1/7 7/7 
5. Financial resources 2/6 6/6 
6. Human resources 1/14 9/14 
7. Leadership/management 4/9 8/9 
8. Financial system 5/13 12/13 
9. External relations 2/3 3/3 
10. Gender 1/3 2/3 
TOTAL 28/85 69/85
Table 11: GAAPE’s (Kouroussa) Capacity Assessment
Background information GAAPE (Kouroussa)
Date of creation 17/07/97 
Legal recognition agreement 23/P/97/Kssa and 
06 RAK/KK/CAB/SERACO 31/08/2001 
Date of assessment 31/03/2003 25/07/2006 
 Capacity element evaluated Score Score
1. Structure of NGO 7/12 10/12 
2. Mission and strategic planning 2/10 9/10 
3. Monitoring and evaluation 3/8 6/8 
4. Programs and services 5/7 7/7 
5. Financial resources 2/6 6/6 
6. Human resources 2/14 10/14 
7. Leadership/management 8/9 9/9 
8. Financial system 5/13 11/13 
9. External relations 2/3 3/3 
10. Gender 1/3 3/3 
TOTAL 37/85 74/85
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 39
This institutional strengthening (development of strategic plans and administrative procedures, 
reorganization on the basis of evaluations, development of recruitment procedures, improvement 
of monitoring systems, and improved communication with donors) resulted in advancements in 
the development of technical knowledge. This leads to the NGOs developing an increased 
capacity to develop and manage contracts with other partners and to diversify their funding 
sources. In the sustainability analysis, this corresponds to an improvement of capacity as well as 
the viability of the organizations. These improvements will still need to be reinforced by 
obtaining recognition at the district, regional and national levels. 
However, as indicated in the preceding section, beyond the individual capacity development of 
the organization, the greatest contribution from CS-18 was in the effective and coordinated 
involvement of local NGOs. Additionally, the activities of the MOH helped to increase the 
visibility of NGOs vis-à-vis the MOH and donors. 
This involved expanding the NGOs’ activities and competences, ensuring their participation in 
planning, and monitoring and evaluation activities, and also a reciprocal transfer of knowledge 
by exchange visits between the two NGOs. Additional success factors included: training; 
ongoing “coaching”; material support; and the existence of detailed agreements between SC and 
GAAPE/AJVDM. 
b. Development of the VHCs and AVHC 
The VHCs and AVHCs drove the community level activities: 
ƒ 213 VHCs were created in the project intervention zone; and 
ƒ 24 AVHCs were created more recently. 
CS-18 used a tool similar to that used with local NGOs to assess the capacity and self-sufficiency 
of the 213 VHCs. From this analysis, the VHCs were divided into three categories according to 
their degree of organizational maturity. Table 12 shows the results of this analysis. 
Table 12: VHC Capacity in Self-Management, as per the CS-18 Institutional Diagnosis
VHC Capacity in 
self-management 
“Advanced” “In progress” “Limited” 
Mandiana 95 33 5 
Kouroussa 76 3 1 
Total 171 36 6 
According to this analysis, the project achieved its goal, with 80% of VHCs having an 
“advanced” capacity and 97% having an “advanced” capacity or being “in progress.” Figure 19 
shows a modest but probable difference between the VHCs of Kouroussa and Mandiana which 
may be explained by the presence of the NGO animators. VHC capacity was 2.5 times weaker 
in Mandiana than in Kouroussa. 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 40
The VHC evaluation report is available in French. The FE did not allow for a detailed and 
critical study of these results. The study of the VHCs would certainly present questions related to 
methodologies, but the report shows a credible effort to obtain reliable, quality data. 
Figure 19: Distribution of VHC Capacity “Advanced”, “Average”, or “Low” for Mandiana 
and Kouroussa
71%
95%
25%
4% 4%1%
0%
20%
40%
60%
80%
100%
Mandiana Kouroussa
Weak VHC
Average VHC
Strong VHC
 
The VHCs were an essential means of social mobilization and provided effective communication 
for promoting changes in health behaviors. The media were used to complement their efforts. 
The VHC collaborated with health centers and the DPS to: 
ƒ involve themselves in the NIDs, to conduct active case findings (for both vaccination 
drop-outs and for pre/postnatal consultations) and to investigate infectious disease 
monitoring; 
ƒ support outreach visits and conduct social mobilization; 
ƒ ensure the follow-up of pregnant women in certain cases, and ensure Vitamin A 
supplementation; and 
ƒ facilitate mediation between community members and health agents for the correct 
payment of consultation fees14. 
Additional efforts have been made through collaboration between VHCs and NGOs to obtain 
funding from other sources. In one instance, a contract was established between AJVDM and 
the VHC of Mandiana II. 
The role of the AVHC is greatly appreciated and recognized by all, but their existence is too 
recent (and rather fragile) to be assured in the future. Guinea also has a system of COGES 
(management boards for the HCs) which is largely non-functional. In the future, the AVHC 
could continue to support the VHCs and alleviate weaknesses with the COGES, which lack 
community representatives like the AVHCs. However, at this time, the existence of the AVHCs 
is too new for the partners to consider this option. 
Other factors, in addition to the frailty of the recent structures (AVHC) which restrict this 
approach, are fatigue and possible lack of motivation by community members, if they are not 
14 The current prices are inconsistent and don’t make sense. As a result, the communities question the credibility of 
the health system when the official prices are circumvented. 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 41
supported by the local NGOs and the AVHCs. Many members of the community are still 
illiterate and need considerable organizational, coordination and monitoring skills. The project 
developed practical and visual tools which enable the accomplishment of this work without 
literacy skills, however, the potential danger exists for the loss of voluntary resources when the 
work is too professionalized. 
c. Creation of MURIGAs 
MURIGAs were created in response to credibility problems which arose when their management 
was centralized. They gradually supported a growing number of obstetric referrals, particularly 
in Mandiana, where they were established earlier (Figure 20). A review of the operations of 
MURIGAs was conducted with the partners and their coverage was extended to include 
emergency pediatric referrals. 
Figure 20: Obstetrical Referrals Supported by the MURIGAs - 2003 to 2006
00 2 3
33
37
56
0
10
20
30
40
50
60
70
2003 2004 2005 2006
Mandiana
Kouroussa
Between 2003 and 2006, the MURIGAs covered the cost of 131 of 931 obstetrical referrals 
recorded by the HIS (14%). The HIS data shows a progressive increase in the number of referrals 
managed by the MURIGAs between 2003 and 2006. 
The factors of successes identified by evaluation team are: 
ƒ Related to operations: 
- Decentralization of funds at the village level; 
- Establishment of a three-part agreement between MURIGAs, taxi unions, and 
hospitals; 
- Training of fund managers; 
- Contribution of members; and 
- Expanding the coverage to both obstetrical and pediatric emergencies. 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 42
ƒ Related to supports: 
- Subsidization of the MURIGA by certain districts; 
- Involvement of the local authorities. Support of the state and the partners for the 
reinforcement of institutional capacities and management of the MURIGA 
(ambulances, radio, motor bikes, management tools); 
- Existence of a system of management tools for monitoring; 
- Training of the TBAs/Health Workers/VHC/NGOs; 
- Collaboration with the MOH through the Division of Reproductive Health; 
- Monitoring of the MURIGAs’ activities in the DPS reports; 
- Organization of meetings to improve communication and diffusion of messages by 
the rural radio. 
The FE team identified the following limiting factors: 
ƒ Cases of non-observance of the tripartite convention and tariffs by people receiving 
benefits; 
ƒ The poor treatment of patients by referral facilities; 
ƒ The irregularity of repayments (and sometimes of the contributions); 
ƒ The limited coverage of the villages (some villages were not included in CS-18); and 
ƒ Cultural concerns like the fear of being in debt, which discourages certain families from 
using the MURIGAs. 
Repayment of borrowed funds does not occur, however this is not creating a deficit because of 
the high level of contributions. The still limited use of the funds and the absence of repayments 
nevertheless calls for monitoring of fund management. Continued support in their management 
is necessary. 
d. Training 
The project established and conducted an ambitious and multidimensional training scheme 
(technical, managerial, personal, and organizational). The training plan is available in Annex 12. 
e. Innovation and Sustainability: Research on the “Mandiana Model” 
Undoubtedly, the most important lesson of the CS-18 project is the potential of an effective 
model of community health in Upper Guinea. Three essential elements contributed to the 
improvements in MCH: 
ƒ The mobilization of community structures; VHC and MURIGAs; 
ƒ The expansion of health services from the HCs to the communities and the support of 
these services by the VHC; and 
ƒ The support provided by GAAPE and AJVDM, under DPS supervision, to ensure the 
micro–planning and monitoring of health activities. 
Figure 21 represents the essential institutions and their relationships which made the model a 
success. Figure 22 shows the institutional relationships whose existence is threatened by the end 
of the project, in dashed lines. The challenge for the MOH, the DRS, and the local actors will be 
to maintain this collaboration. Recommendations for this are made at the end of this report. 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 43
Figure 21: An Effective Model of Community Health 
DPS 
HC 
HP 
Village Drug Kit 
AVHC 
VHC
Local NGO 
TBA CA 
MURIGA
Rural Community
Resources 
Support 
« Cement » 
Figure 22: Threatened Sustainability of the Community Health Model 
DPS 
HC 
HP 
Village Drug Kit 
AVHC 
VHC
Local NGO 
TBA CA 
MURIGA
Rural Community
Key: 
- - - - - precarious bonds and institutions post-project 
In the analysis of progress made toward sustainability conducted by the project during the DIP15, 
important progress was ensured in components 1 (health results), 2 (quality of the care), 3 
(organizational capacity) and 5 (community capacity). However, important threats remain in 
terms of the viability of NGOs in their current role, the financial viability of MURIGAs, the 
15 The analysis framework on sustainability examines six essential components or directions needed to establish 
sustainable progress: 1) health indicators; 2) service indicators; 3) local organizational capacity; 4) local 
organizational viability; 5) community capacity; and 6) socio-ecological environment. See 
http://www.childsurvival.com/documents/CSTS/SustainabilityArticleIJHPM_2004_22.pdf.
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 44
viability of the support of health centers for community-based service (component 4), and in the 
essential functions normally provided by the MOH (component 6). 
C. Project Management 
The management of the project was examined in great detail during the MTE, and therefore it 
was not the subject of detailed study for this FE. 
The following observations were noted however, during the FE: 
ƒ CS-18 developed an effective system of planning and monitoring activities. This planning 
was conducted at all levels: at the Kankan office, with each DPS and NGO partner, and 
through follow-up of the micro-planning performed by NGO partners with the VHC and 
HCs. 
ƒ When there were delays related to planning (as is often the case with projects with 
training components16), project staff was able to identify them and make appropriate 
adjustments. 
ƒ The project personnel were obviously motivated, qualified and trained well. The doctors 
and technical staff of the project were led by a chief of project, whose administrative and 
personnel skills, attitudes, and intelligence were noted by all the partners, including 
USAID and the MOH. Various team members worked well together and provided mutual 
support. CS-18 staff and partners functioned as an effective and well-oiled team. It is 
unfortunate that the project approach creates a situation where this kind of capacity can 
not always be maintained, but must be rebuilt again elsewhere. 
ƒ Financial management was not examined, but detailed statistical data was provided on a 
timely basis during the evaluation, when requested by the evaluators. 
ƒ The project had little time to compensate for logistical failures in the health system. Its 
own logistics system was reliable. During the course of the project it would not have 
made sense to replace the logistics system which is the MOH’s responsibility. Serious 
and repeated deficiencies do remain in the health system’s logistical process which 
threatens the progress achieved by the project. 
ƒ The monitoring and evaluation system, and HIS function well and provide valuable 
information. The project team had prepared a detailed analysis for the FE. This shows a 
tremendous capacity to produce, analyze, and apply information. Certain errors were 
found in the analyses, but were corrected with the technical support of the CS Advisor 
based in Westport. Recently, the project’s HIS Officer left this position, however, this 
position was filled before the FE Team Leader arrived, and information was provided as 
requested. 
ƒ Collaboration with the USAID Mission was excellent. The USAID Mission staff 
expressed a high degree of appreciation and satisfaction for SC’s work, despite their 
absence during the final debriefing. 
 
16 If one calculates the number of lost working days represented by training plans, it would become necessary to 
close the whole health system during the first year of the project to be able to conduct these trainings. Fortunately, 
the project managers had the good sense to delay some of the trainings. Projects designed to develop local capacity 
should operate with a longer calendar than projects developed to quickly address a deficiency in a health service. 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 45
D. Other Topics Identified by the Evaluation Team 
The FE team identified the following lessons learned: 
1) Community involvement is necessary to improve health. 
ƒ VHCs can be effectively involved in basic health activities through: 
- Training/equipment; and 
- Support and follow-up by local NGOs (for success and sustainability); 
ƒ The support of leaders (community, religious) is essential for VHC activities. 
2) Institutional resources and collaboration are necessary for success. 
ƒ The capacity of local NGOs can be developed and their involvement helps to improve 
health indicators. 
ƒ The involvement of national NGOs can be integrated into MOH activities to advance 
achievements of health indicators. 
ƒ The co-location of the DPS team with the project team in the same room, facilitates 
their integration and coordination. 
ƒ The AVHC can be involved in the resolution of long-term problems facing the VHC. 
3) Lessons learned for increasing sustainability: 
ƒ Arrangements between partners (for example DPS-NGOs) need to be formalized in 
order to be sustained. 
ƒ The formalization of this collaboration facilitates motivation and fundraising. 
ƒ The early weaning of the AVHC and VHC from external/SC support (one year after 
establishing an approach) is a risk for the sustainability of gains made. 
4) Lessons learned related to technical approaches: 
ƒ The following approaches showed very important results: 
- Training and monitoring of TBAs; 
- Advocacy with religious leaders; 
- Peer education; 
- Combination of tools and approaches for communication; and 
- Nutritional demonstrations, sensitizing, weighings combined with drug 
distribution. 
E. Dissemination of Lessons Learned and Results17
SC will disseminate these lessons learned to development professionals initially in Guinea, 
through quarterly meetings with MOH partners in Kankan. Several of the recommendations 
suggest a roundtable organized by the MOH authorities, in order to define a viable model of 
community health for Guinea. SC also hopes to transmit the lessons learned through participation 
in the new bilateral project which will emphasize good governorship. SC organizes an annual 
Program Learning Group (PLG) meeting for its health programs, where this experience will be 
 
17 This section was written by Save the Children staff team. 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 46
shared extensively. SC recently disseminated some of the results during the most recent APHA 
meeting held in November 2006. Finally, the SC team and partners (the FE Team Leader and Dr. 
Peter Winch of Johns Hopkins) intend to publish an article on lessons learned from CS-18 with 
regard to progress on sustainability and implications for donors. 
F. Results Highlights 
Annex 13 presents a summary highlight page for use by USAID and underscores the results 
obtained in Maternal Health. 
G. Conclusions and Recommendations 
1. General Recommendations Made by the Evaluation Team 
The evaluation team collectively developed the following recommendations shown in Table 13. 
Table 13: Recommendations of the Evaluation Team 
Recommendations for the 
DPS 
1) Formalize bonds between DPS-HC-VHC 
2) Formalize a partnership between the DPS and local NGOs 
Recommendations for SC 1) Subsidize NGOs to ensure follow-up 
2) Equip NGOs with reliable transportation (motor bikes) 
Recommendations for 
NGOs 
1) To continue to ensure the supervision and refresher training 
of VHC and AVHC 
2) To work out the micro plans for community structures 
3) Fundraising 
4) To continue to support the DPS, the VHC, AVHC in the 
implementation of activities 
Recommendations for the 
VHC 
1) To mobilize the communities 
2) To hold growth monitoring sessions 
3) To develop micro plans 
4) To continue the activities after the project end date 
Technical 
Recommendations 
1) To combine community weighings with the distribution of 
Mébendazole and Vitamin A 
2) HIS: To take into account referrals carried out by the TBA 
towards the health centers (not only referrals to the hospitals) 
3) To pay attention to, and follow the nutrition activities at 
the national level 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 47
2. Specific Recommendations Made by the Team Leader 
In addition to the recommendations presented below, several points can be underlined and some 
additional recommendations can be made. 
I. Technically, the project does not have interventions where a major readjustment is necessary, 
if the intervention were repeated or extended. However, if this should occur, the following 
modifications should be considered: 
ƒ As discussed in the MTE, a malaria intervention could be added since the project 
obtained convincing results in other IMCI activities. An extension could support these 
activities. 
ƒ The HIV/AIDS component would deserve to have more time to develop and improve its 
results, but the general direction taken was good. 
ƒ In the event of an extension, greater attention must be paid to the key indicators which 
were not measured in a suitable way (for example the quality of pre- and postnatal 
services, and birth). Progress in child nutrition should be confirmed and accelerated. 
ƒ Efforts must be continued to ensure the supervision of TBAs, and to prevent postpartum 
hemorrhage. Future capacity development should reinforce supervision and support from 
the community HC structures. 
II. The principle recommendations related to ensuring the continuity of progress are: 
ƒ As recommended in the preceding section, the relationships and essential roles of the 
“model” must be formalized. 
ƒ The financial, administrative, and governance risks must be taken into account, especially 
in relation to providing oversight and support to the MURIGAs. 
ƒ The benefits of improving access to care (supplies and drugs) will not be sustained unless 
the MOH sets up an essential drugs logistics system, or it finds a way to develop a public￾private partnership with wholesalers. A solution must be found quickly. 
ƒ Certain vulnerable areas were identified (AVHC, MURIGAs, outreach visits, institutional 
bonds). The existing institutions and possible future projects will have to consider them 
closely. 
ƒ The central question for Guinean institutions should be, “Did Guinea, which defines 
community health as a national priority, find in Mandiana and Kouroussa the elements of 
its model for community health?” The answer to this question are proposed below. 
III. Save the Children should seek to develop a new project in Upper Guinea designed to study 
the costs of obtaining sustainable progress. 
IV. Additionally, USAID and/or other donors should consider the potential value of CS-18 
activities and accomplishments. This potential is illustrated in Figures 23a and 23b. 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 48
Phases 1 and 2 (Figure 23a and 23b) represent what was obtained during the CS-14 and CS-18 
projects: 
ƒ In Phase 1, the investment was in Mandiana, with very positive results shown by the fast 
ascent of the blue curve in Figure 23b. 
ƒ In the second phase, Mandiana did not receive more than approximately a third of the 
initial investment, and obtained only very limited growth of the health indicators (in fact a 
reasonable increase for half of them, and a regression for another group of indicators). 
During this time, Kouroussa achieved a fast increase in its indicators (see Figure 23b) with 
an investment of less than half the initial investment for Mandiana. 
ƒ The following phase (Phase 3) could test the minimum investment required to obtain a 
minimum progress in the districts of Mandiana and Kouroussa, while allowing an 
expansion of the benefit to a new zone. 
Figure 23a: Distribution of Investments Between Mandiana, Kouroussa, and an Extension 
Zone of a Possible Third Phase
0
200
400
600
800
Phase 1 (CS12-14) Phase 2 (CS18) Phase 3?
Intervention Phases
Distribution des 
ressources
Mandiana Kouroussa New Districts
Figure 23b: Progress of Health Indicators in Mandiana, Kouroussa, and a New Zone in a 
Third Possible Phase
0%
10%
20%
30%
40%
50%
60%
70%
80%
Phase 0 Phase 1 (CS12-14) Phase 2 (CS18) Phase 3?
Indic Man Indic Kou Indic Exten1 Indic Exten2
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 49
V. The district MOH structures must quickly define a viable model in order to maintain a viable 
model of community health. 
ƒ The structures of the MOH/DRS/DPS must accept and assume the leadership which falls to 
them. These structures can define the agenda for the country or wait for another model 
suggested by a donor. However, the leadership must take the initiative and engage their 
own resources. 
ƒ A negotiated role must be recognized for the local NGOs which carried out valuable work 
and whose presence on the ground cannot be replaced by more health structures. 
ƒ NGOs themselves will have to offer to the partners a reasonable cost structure. 
ƒ It is important to be realistic about the material constraints of the DPS and DRS, and it is 
also necessary to be determined to analyze them in a realistic and honest way. 
ƒ The prefect and the decentralization structures must be involved and helped to appreciate 
the social impact of an effective community health system. 
ƒ Various stakeholders must have a cohesive strategy with respect to donors, but must 
initially develop a cohesive in-house strategy on the model which they wish to develop. 
ƒ The problem of the unreliability of the essential drug supply must be solved quickly. 
ƒ A study on the models and their viability would readily support USAID’s interest in 
questions of governance. There is perhaps a convergence of interests between Guinea and 
its donors. 
VI. In order to advance concretely towards a viable institutional model, the DRS/DPS must 
urgently organize a roundtable to: 
ƒ Establish agreements and principles of operation beyond the involvement of SC; 
ƒ Outline a common vision for the long term roles of each in community health; 
ƒ Define the first realistic and realizable mechanisms to institutionalize relationships and to 
continue essential activities; 
ƒ Optimize the distribution of resources based on (including means of transportation used by 
GAAPE and AJVDM for the project period). 
ƒ In addition to the organizers, the participants in this roundtable should be: 
- GAAPE, AJVDM; 
- Save the Children; 
- Districts, structures of decentralization and social affairs; and 
- Leaders selected among the persons in charge for HCs and community organizations 
(AVHC). 
H. List of Annexes 
1. Excerpts from the DIP with Baseline Results 
2. Evaluation Team Members 
3. Final Evaluation methodology 
4. List of People Contacted 
5. List of Participants in the Final Evaluation Debriefing 
6. Training Plan for the Health District of Mandiana 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 50
7. Training Plan for the Health District of Kouroussa 
8. Analysis of Deaths Avoided 
9. Interventions with the Greatest Estimated Impact 
10. Final Evaluation Photographs 
11. Explanation of the Index “Percent of Deficit Filled” 
12. Summary of Project Progress 
13. Results Highlight 
14. Updated CSHGP Data Form 
 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 51
ANNEXES 
Annex 1. Excerpts from the DIP with Baseline Results 
Annex 2. Evaluation Team Members 
Annex 3. Final Evaluation methodology 
Annex 4. List of People Contacted 
Annex 5. List of Participants in the Final Evaluation Debriefing 
Annex 6. Training Plan for the Health District of Mandiana 
Annex 7. Training Plan for the Health District of Kouroussa 
Annex 8. Analysis of Deaths Avoided 
Annex 9. Interventions with the Greatest Estimated Impact 
Annex 10. Final Evaluation Photographs 
Annex 11. Explanation of the Index “Percent of Deficit Filled” 
Annex 12. Summary of Project Progress 
Annex 13. Results Highlight 
Annex 14. Updated CSHGP Data Form
Annex 1 
Excerpts from the DIP with Baseline Results 
A. Executive Summary 
This four-year Child Survival-18 Project, The Community Health Initiative for the Districts of 
Mandiana and Kouroussa, is a partnership between Save the Children (SC), the two District 
Health Offices (DPS) and two local non-governmental organizations (NGOs). This partnership 
builds on the extensive programming experience of SC in Guinea to address the primary causes 
of child and maternal mortality in an underserved, poor, and remote area of Guinea. SC and its 
partners will combine their resources and experience, and apply these towards improving child 
survival in Guinea by: (1) Increasing the use of key health services and improved maternal and 
child health practices at the household level; and (2) Increasing the capacity of local entities (the 
regional health office, the two district health offices, the two local NGOs, and community 
organizations) to assume responsibility for health activities and adopt innovative CS-18 
approaches. SC/Sahel’s extensive experience, capability, and credibility in community 
mobilization, maternal and child health interventions, and capacity building of partners in 
Guinea, position this partnership well to play an important role in this most needy region of the 
country. 
The report of the CS-14 final evaluation, conducted in Mandiana in August 2002, lists the 
following priority conclusions: 
 The project has met or exceeded most of its objectives for the technical interventions 
(Nutrition/Vitamin A, Maternal and Newborn Care, Immunization, Malaria Control, Family 
Planning) and sustainability. 
The project has had a positive impact on national health policy in: 1) the development 
and acceptance of a revised TBA training curriculum and manual; and 2) integrating Vitamin 
A distribution into NID. 
Prospects for institutional sustainability are strong due to a commitment to building 
capacity of partners, as well as communication and collaboration among the various 
stakeholders, including the DPS, VHC, and COGES. 
 The project’s recognized success has leveraged additional resources from other 
international organizations and donors. 
Engaging senior women and traditional practitioners into the communication strategy has 
brought about changes in social norms that enhance the potential for behavioral 
sustainability. 
The project has built financial sustainability at the community level through emergency 
revolving funds, transport plans, membership cards guaranteeing payment, cereal banks, etc. 
The project has been exemplary in its synergy and collaboration with other USAID￾funded projects and technical resources such as the American Collage of Nurse Midwives 
(ACNM), PRIME, CSTS, BASICS II, CHANGE, NGO Networks for Health, PRISM, etc. It 
has taken advantage of every opportunity to learn and apply state-of-the-art programming, 
and to promote best practices and quality of care. 
The project has been recognized as highly replicable, with potential for broader 
applications beyond Mandiana. 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 53
The project has empowered communities through capacity-building, literacy training, 
and the tools to collect and manage relevant health data for decision-making. 
The project has created a culture of communication, collaboration, innovation, 
monitoring, and quality of care that can be sustained and transmitted to NGO sub-grantees 
and other partners under CS-18.
The CS-18 project site will scale up the successful CS-14 strategies beyond the CS-14 original 
project site of the district of Mandiana and expand services to the district of Kouroussa, both in 
Upper Guinea. The two districts with 527 villages have a total population of 393,060 including 
85,402 children under five years old and 106,753 women of reproductive age. The CS-18 
Extension Project is designed to address high under-five and maternal mortality in these sites, 
estimated at over 222 deaths/1,000 live births and 528/100,000 live births, respectively. The 
populations of these two districts, especially that of Kouroussa, have low use of health services 
and health information, and the current health services do not meet their preventive and curative 
health needs. SC will work with two CS-18 partners, the two Health Districts, and two Guinean 
NGOs, to implement four child survival interventions, specifically: 
• Immunization (10% of intervention effort), 
• Nutrition and Micronutrients (30% of intervention effort), 
• Maternal and Newborn Care (40% intervention effort), and 
• HIV/AIDs (20% of intervention effort). 
CS-18 interventions will be implemented through the following strategies: 
• Joint DRS, DPS and SC design, implementation, and evaluation of approaches to maternal 
and child health in the districts that inform strategies of other PVOs and the MOH. 
• Improving the technical, financial, and institutional capacity of two local NGOs. 
• Mobilizing communities through Village Health Committees and Health Center Management 
Committees to improve essential health services and conduct focused education activities. 
• Improving the quality of health services provided in the community and the health facilities. 
SC will document the feasibility and results of implementing these four interventions through 
five innovative strategies for child survival in Guinea: 
(1) Training of traditional birth attendants (TBAs) using a revised and updated community-life 
savings skills curriculum; 
(2) Behavior Change interventions to improve utilization of early postpartum care; 
(3) The Positive Deviance (PD) Approach for sustainable community-based rehabilitation and 
prevention of malnutrition; 
(4) The Child-to-Child approach to increasing vaccination coverage, and; 
(5) Centres d’Ecoute (listening centers), which will provide safe venues for peer education, 
informal discussion groups, and structured socialization. 
The CS-18 design reflects SC experience and expertise with the community-level 
implementation of all four CS-18 interventions, and builds on current innovative SC/Sahel work 
with PD and community mobilization. The Project builds on the existing SC/Sahel current local 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 54
partnerships with one of the MOH Health Districts and with one of the local NGOs, and reflects 
extensive discussions with local NGOs, health districts, other regional NGOs, and the regional 
MOH. 
CS-18 Goals are: 
• A sustained reduction in under-five and maternal mortality in the two health districts; and 
• A sustained improvement in the nutritional status of 0 to 36 month-old children. 
The CS-18 Results are: 
• Increased use of key health services and improved Maternal and Child Health practices at 
the household level in two districts; 
• Local entities (MOH, local NGO, communities) will be able to assume responsibility for 
activities and adopt innovative CS-18 approaches. 
These Results will be achieved through the seven Intermediate Results: 
• Increased availability of selected MCH services in the two health districts; 
• Improved quality of selected MCH services in the two districts; 
• Increased caretaker knowledge and awareness of selected child survival issues; 
• Documented feasibility and results of implementing innovative CS-18 approaches; 
• Improved capacity of two district health offices to effectively support community health 
services and activities; 
• Demonstrated SC/Sahel capacity in capacity building of two local NGOs and two district 
health offices; and 
• Improved capacity of two local NGOs and communities to effectively address priority 
health needs of mothers and children under 5. 
Under the “Cost Extension” grant category, SC has received $1,250,000 of USAID funding over 
a four-year period, which started on September 30, 2002. This USAID funding is matched by 
$416,625 from SC (25% match). Principal authors of this draft DIP are: Dunni Goodman, 
Mamadou Balde, Carmen Weder, and Eric Swedberg although all the Guinea staff were involved 
in writing various sections. The USAID/Guinea Office Reproductive Health Advisor Kathy 
Jacquart participated in the DIP workshop in April 2003. The contact people at SC to discuss 
this application are, Carmen Weder Manager, Office of Health and Eric Swedberg, Child 
Survival Specialist. 
Summary Findings of Baseline Assessments: 
1. KPC Survey: The following table summarizes the KPC findings from the three surveys. 
Overall the KPC surveys suggest that in Mandiana the greatest progress has been in the 73 
district villages which were the major focus on CS-14 efforts. In the last two years of the project 
progress has also been made in the secteurs through the creation and training of VHCs in the 60 
secteurs. Indicators are still low and justify the choice of interventions of CS-18. In Kouroussa 
the low level of the indicators also suggest the CS-18 project interventions are merited. 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 55
Table 6: Selected Indicators of the KPC Studies 
Indicators Mandiana district 
1997 2002 
Mandiana 
sectors 
2002 
Kouroussa 
2002 
EDS 
99 
Proportion of children less than 6 
months exclusively breast fed 
6/55 
(10.9 %) 
(4 mo. 
age) 
35/90 
(38.9%) 
39/89 
(43.8%) 
17/58 
(29.3%) 12% 
Proportion of mothers having 
started to breast feed within one 
hour after birth 
62/293 
(21.2%) 
130/300 
(43%) 
75/293 
(26%) 
19/289 
(6%) 29.7% 
Proportion of mothers who add 
iodized salt to child’s meal 
36/293 
(12,3 %) 
54/192 
(28,0 %) 
8/119 
(6.7%) 
13/136 
(10%) 5% 
Proportion of children having their 
weight on a growth monitoring 
chart at least once 
5/293 
(1,7 %) 
79/117 
(67,5 %) 
15/46 
(32.6%) 
5/39 
(12.8%) 
Proportion of children aged 12 to 
23 months completely vaccinated 
by first birthday 
21/139 
(15.1 %) 
54/77 (70,1 
%) 
16/42 
(38.11%) 
20/136 
(15%) 30% 
Indicators Mandian
a districts
1997 
Mandiana 
sectors 
2002 
Kouroussa 
2002 EDS 99 
Indicat
ors 
Proportion of mothers who know at 
what age a child must be 
vaccinated against the measles 
12/293 
(4.1 %) 
200/300 
(66,7 %) 
58/293 
(19.8%) 
35/289 
(12.1%) 
Proportion of children suspected of 
being infected by pneumonia 
treated with an antibiotic 
5/25 
(20.0%) 
15/35 
(42.8%) 
11/63 
(17.5%) 
12/39 
(30.8%) 
Proportion of children with 
diarrhea given ORS 
2/59 
(3.4%) 
35/83 
(42.2%) 
19/75 
(42.2%) 
9/89 
(1%) 32.5% 
Proportion of breast fed children 
who had more breast feeding than 
usual during their last diarrhea 
episode 
6/52 
(11.5%) 
16/79 
(20.3%) 
8/75 
(10.7%) 
7/86 
(8.1%) 
Proportion of children not 
exclusively breast fed whose 
mother gave them liquid other than 
the maternal milk more than usual 
when they had diarrhea 
3/44 
(6.8 %) 
11/83 
(13.3 %) 
2/75 
(2.7%) 
5/85 
(5.9%) 53% 
Proportion of children 6 to 9 
months given additional food 
(meat, fish) 
15/34 
(44%) 
30/45 
(67%) 
24/62 
(39%) 
7/71 
(10%) 
Proportion of suspected cases of 
malaria treated with chloroquine 
52/121 
(43.0%) 
92/159 
(57.8 %) 
72/160 
(45%) 
53/76 
(69.7%) - 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 56
Proportion of suspected cases 
treated with chloroquine, correct 
posology 
23/121 
(19.0 %) 
69/92 
(75 %) 
31/72 
(43%) 
15/76 
(19.7%) - 
Proportion of mothers who 
recognize mosquito nets as a 
method to avoid malaria 
45/293 
(15.4 %) 
193/291 
(66.3 %) 
60/293 
(20.5%) 
31/289 
(10.7%) - 
Mothers having received at least 
two doses of TT 
70/293 
(23.9 %) 
154/177 
(87%) 
91/124 
(73.4%) 
80/109 
(73.4%) 43.1% 
Proportion of mothers having at 
least two antenatal visits during the 
last pregnancy 
133/293 
(45.4 %) 
259/300 
(86.3 %) 
169/293 
(57.7%) 
192/289 
(66.4%) 66.6% 
Proportion of women of 
reproductive age who know at least 
2 of the 5 signs of danger 
38/293 
(13.0 %) 
134/300 
(44.7 %) 
95/293 
(32.4%) 
73/289 
(25.3%) 
Proportion of women who do not 
wish a baby within next two years 
who use modern contraception 
method 
15/200 
(7.5 %) 
99/200 
(49.5 %) 
47/196 
(24%) 
18/186 
(9.7%) 
6.8% 
Proportion of mothers using a 
condom with irregular partner 34/44 
(72.7%) 
20/37 
(54.1%) 
8/17 
(47.1%) 20.1% 
Proportion of mothers having had 
the STI during the last 12 months 
and sought care at a health center 
15/23 
(65.2%) 
7/15 
(46.7%) 
22/54 
40.7% 
86.1% 
Proportion of mothers naming at 
least two ways of prevention 
against HIV 
143/298 
(48%) 
77/288 
(26.7%) 
62/275 
(22.5%) 
Nutrition: The KPC indicates that exclusive breastfeeding up to six months of age is higher in 
Mandiana (39% Districts and 44% Secteurs) than in Kouroussa (29%). In Mandiana districts 
43% of infants are breastfed within the first hour after birth. In the Mandiana secteurs (26%) and 
in Kouroussa (6%) this is much lower. Less than one third of mothers in Mandiana districts 
report using iodized salt in children’s meals. This practice is much lower in the Mandiana 
secteurs and Kouroussa and merits more emphasis in CS-18. The majority of children received 
vitamin A during the last six months through the national days of vaccination (NDV). Post￾partum Vitamin A supplementation is not the norm in Guinea and was not surprising to be much 
lower in Kouroussa (9%). 
Vaccination: The vaccination campaign for children from 12-23 months is 70% in the district 
of Mandiana, 38% in the sectors against only 15% in the districts of Kouroussa. 
Maternal and Newborn Care: More than the half of mothers did at least two antenatal 
consultation within the districts and sectors of Mandiana and Kouroussa (Respectively 86.3% ; 
57.7% and 66.4%. The survey revealed that the majority of mothers have received the TT 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 57
vaccination at least twice( 87% in the districts of Mandiana and 73.4% in the sectors of 
Mandiana and Kouroussa.) The number of mothers assisted by a health professional (nurses, 
doctors) during childbirth is 23.3% in the districts of Mandiana, 14% in the sectors and 31.5% in 
Kouroussa but more than one third of childbirth is assisted by the TBA in Mandiana against 31% 
in Kouroussa. In the districts of Kouroussa around a quarter of mothers (25.3%) know at least 
two signs of danger during childbirth (or pregnancy). That proportion is about 44.7% in the 
districts of Mandiana and 32.4% in its sectors. 
HIV/AIDS/STD: The majority of the population interviewed (97.7 in the district of Mandiana ; 
98.3% in sectors and 94% in the district of Kouroussa) have heard of HIV/AIDS. Though, 48% 
of them know at least two ways of avoiding HIV/AIDS. That proportion is around 26.7% in the 
sectors of Mandiana and 22.5% for the districts of Kouroussa. Around 72 % of husbands who 
have had occasional sexual acts outside in the district of Mandiana have used a condom during 
the act. That proportion is around 54.1% for the sectors of Mandiana and 47.1% for the districts 
of Kouroussa. 
More than three fourths (87.4%) of mothers in the sectors of Mandiana have heard of STI. That 
proportion is 72.3% for the districts of Mandiana, only 25% for the districts of Kouroussa. But 
7.7% of mothers in the district of Mandiana have got the STI during the last 12 months. That 
proposition is about 5.1% for the sectors of Mandiana and 18.7% for the district of Kouroussa. 
among them around a third went to hospital for treatment. That proportion about 60.9% for the 
district of Mandiana. 
2. Village Health Committee Assessment: This assessment confirmed that the majority of 
VHCs in Mandiana continue to conduct health activities as well as other development activities 
in their localities. 73 of 133 VHCs have received official government legal recognition. There 
are not large differences between the district and secteur VHCs although the district VHCs which 
were created two years earlier are stronger. 124 or 93% of all the VHCs have overall strong 
functioning, while 9 VHCs (7%) need greater attention. 
3. NGO Capacity Assessments: Overall GAAPE is at 47 % of it’s institutional and 
organizational capacity and AJVDM is at 35 % of institutional and organizational capacity 
(Mandiana). The table below summarizes the results for the 10 capacity areas: 
Table 7: Institutional Capacity Assessment of Local NGOs 
C. Elements of the Evaluation D. NGO 
GAAPE AJVDM 
E. Date of creation 15 September 1997 15 November 1998 
F. Government agreement 23 / P / 97 / Kssa 146 / P / 99 / Mna 
1. Structure of the NGO : 
- status and policies and regulations 3/3 3/3 
- limitation of the mandates ½ ½ 
- functioning 3/7 3/7 
2. Mission and strategic planning : 
- mission ¼ 3/ 4 
- strategic plan 1/6 1/6 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 58
3. Monitoring and evaluation : 3/8 1/8 
4. Programs and services 7/7 1/7 
5. Financial resources 2/6 2/6 
6. Human resources : 
- recruitment 1/5 Voluntary integration 
policy (0) 
- Evaluation of personnel 1/8 1/8 
7. Leadership/Management : 
- leadership 4/4 3/4 
- administrative system 4/5 1/5 
8. Financial system : 
- financial management 3/4 2/4 
- accounting management No accountant (0) 1/5 
- internal control 2/4 2/4 
9. External relationships 2/3 3/3 
10. Gender 1/3 1/3 
TOTAL 39 / 83(47%) 29 /83(35%) 
4. Organizational Life Assessment in Kouroussa: All villages have agricultural associations, 
however none of the villages have community organizations concerned specifically with health 
issues. Village leaders have been involved in working with the MOH to inform and mobilize the 
population and they expressed the desire to form village health committees. The focus group 
participants identified the major diseases in children as: malaria, diarrhea, measles, tetanus, 
ARIs, tuberculosis, and intestinal parasites. Illnesses in women of reproductive health were 
identified to be: MSTs, malaria, anemia, malnutrition, eclampsia, intestinal parasites, and 
stomach illness. Adolescents mentioned: malaria, MST, parasites, anemia, hernias, migraines, 
malnutrition, diarrhea, hemorroids, and onchocerosis. Other general problems mentioned 
discussed were the high cost of medications, accessibility to health centers, and the lack of 
personnel. Ninety TBAs were identified in the prefecture 53% are trained, 33% are equipped, 
and 27% are literate. Eighty-one traditional healers were identified, 9% who have worked with 
health workers in the past. The majority have extensive experience; 60% with over 20 years of 
work experience. 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 59
Annex 2 
Evaluation Team Members 
N° Name Organization Position Location 
1 Dr Richard James DRS DRS Interim Director Kankan 
2 Adama Diop SC Advisor SR Mandiana 
3 Dr Abdoulaye Oumar Diallo SC District Coordinator Mandiana 
4 Adama Doumbouya SC NGO Advisor Mandiana 
5 Dr Mamadou Aliou Barry SC HIS Manager Kankan 
6 Mahamadou Sylla SC District Assistant Kouroussa 
7 Dr Mory Touré SC NGO Advisor Kouroussa 
8 Facely Kourouma SC District Coordinator Kouroussa 
9 Fatoumata Diakité SC RH Advisor Kouroussa 
10 Dr Aissata Condé DPS Director Kouroussa 
11 Ansoumane Doumessy NGO GAAPE Supervisor Kouroussa 
12 Adama Camara NGO AJVDM Supervisor Mandiana 
13 Eric Swedberg SC CS Advisor Westport 
14 Fatoumata Binta Barry SC Executive Assistant Kankan 
15 Dr Amara Traoré DPS Director Mandiana 
16 Eric Sarriot Consultant USA 
17 Damou Rahim Keita SC 
Coordinator of Health 
Program Kankan 
18 Dr Mamadou Oury Diallo SC M&E Coordinator Kankan 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 60
Annex 3 
Final Evaluation Methodology
The final evaluation of CS-18 was conducted according to the usual participative evaluation 
methodology of USAID/CSHGP. 
The project collected a significant amounts of data in the months prior to the evaluation. These 
studies informed the final analysis and are as follows: 
1. Knowledge, Practices, and Coverage Surveys in Mandiana and Kouroussa (KPC 2006); 
2. Evaluation of NGO partner capacity; 
3. Evaluation of VHC capacity; 
4. Qualitative Survey of the Youth in the Listening Centers; and 
5. Review of the MURIGA (community funds for obstetrical emergencies). 
Other secondary data was also available: 
6. Health Information System Monitoring Data of CS-18; 
7. Demographic Health Survey of Guinea 2005; and 
8. MOH Health information system/DPS. 
After the members of the evaluation team met with USAID in Conakry, the FE team, including 
the principle local partners (see Appendix 2), were invited to Kankan on September 12, 2006. 
During first days, the CS-18 team presented the results of the preliminary studies. This work 
allowed the joint development and prioritization of evaluation questions that needed to be 
addressed. The evaluation team then developed simple study tools, to guide individual interviews 
and group discussions. 
Two teams were sent to each district and led the following activities: 
- Discussions with VHC and AVHC members; 
- Discussions with health workers; 
- Discussions with mothers’ groups; 
- Discussions with TBAs; 
- Focus group discussions with peer educators; and 
- Discussions with the VHC nutritionists. 
In addition to these talks, the FE Team Leader independently led a visit and discussions with the 
directors of each DPS, and a focus group discussion with the NGO animators. The FE Team 
Leader also met with executives from the local NGOs. 
Upon return from the field visits, the evaluation team divided into subgroups to analyze 
information obtained and to present lessons learned and recommendations to the larger 
evaluation team. 
A first debriefing presentation was conducted with local partners on September 20, followed by a 
presentation in Conakry, with the Ministry of Health on September 22, 2006. 
 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 61
Annex 4 
List of People Contacted 
1 - Prefectoral Level Authorities:
 - Mr. Ibrahima KOITA, Secretary-General in charge of Administrative Affairs; 
 - Mr. Mory KOMA, Director of Micro Realization; 
 - Mr. Fankalo NANAMOU, Secretary-general of the Urban District; 
 - Mr. Moussa DIAWARA, Manager of Community Organizations; 
 - Mrs. Saran CAMARA, Secretary of the Prefect. 
2 - Prefectoral Level Direction of Health
 - Dr. Aissata COP, Prefectoral Director of Health; 
 - Dr. Odilon HABA, In charge of the Community Base Service; 
 - Dr. Ibrahima Kalil KEITA, Doctor In charge of the Diseases; 
 - Mr. Amara KOUROUMA, In charge of School Health; 
 - Mrs. Damba MARA, Radio Operator. 
3 - NGO Level – GAAPE
 - Mr. Ansoumane DIOUMESSY, Executive Director of NGO and Supervisor of the CS-18 
project activities; 
 - Mr. Famany TRAORE, Animator; 
 - Miss Saran CAMARA, Animator; 
 - Mr. Sayon KEITA, Animator; 
 - Mr. Moro DIALLO, Administrative and Financial Director of NGO; 
 - Miss Kany DIOUMESSY, Animator; 
 - Mr. Laye Kouroussa CAMARA, Animator; 
 - Mrs. Sabouyan CAMARA, Animator. 
4 - Health Center Level - Kouroussa
 - Mrs. Marie TRAORE, Head of the Health Center; 
 - Mr. Maxim KOLIE, Vaccinator. 
5 - CVS Level - Koumana
 - Mr. Aly KEITA, Secretary and Community Agent; 
 - Miss Nagnouma KEITA, Peer Educator; 
 - Mr. Kéballa KOUROUMA, President VHC; 
 - Mrs. Hawa KEITA, Nutritionist; 
 - Mrs. Mariame KEITA, TBA 
 - Mr. Kébama KOUROUMA, Treasurer COGES. 
6 - USAID Level 
 - Mrs. Elizabeth Kibour; Senior Health Sector Advisor and HIV TEAM Leader; 
USAID/Guinea 
 - Mrs. Traoré Soukeinatou; Public Health Specialist 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 62
Annex 5 
List of Participants in the Final Evaluation Debriefing 
NR NAME DEPARTMENT FUNCTION 
1 Dr. Pogba GBANACE Ministry of Public 
Health 
Principle Private Secretary to 
the Minister 
2 Dr. Mahi BARRY Ministry of Public 
Health 
National Director, Public 
Health 
3 Dr. Sidaty KEITA Ministry of Public 
Health 
Head of the Division of 
Reproductive Health 
4 Dr. Boubacar SALL Ministry of Public 
Health 
National Coordinator, 
Monitoring/Evaluation 
5 Dr. Séré KABA Ministry of Public 
Health 
National Coordinator, 
Maternity Without Risk 
Program 
6 Dr. Hawa TOURE Ministry of Public 
Health 
National Assistant 
Coordinator, Maternity 
Without Risk Program 
7 Dr. Camille Tafsir SOUMAH Ministry of Public 
Health 
National EPI Coordinator 
8 Dr. Did not gum ONOVOGUI Ministry of Public 
Health 
Head of the MCH Section 
9 Mr. Damou Rahim KEITA Save the Children Coordinator, Health 
Programs 
10 Mr. Eric SWEDBERG Save the Children CS Advisor 
11 Mr. Eric SARRIOT Independent Consultant 
12 Dr. Aissata COP Ministry of Public 
Health 
Prefectoral Director of Health 
Kouroussa 
13 Dr. Amara TRAORE Ministry of Public 
Health 
Prefectoral Director of Health 
Mandiana 
14 Dr. Richard JAMES Ministry of Public 
Health 
Regional Direction of Health 
Kankan 
 15 Dr. Delphine Nagnouma 
TOUNKARA
Ministry of Public 
Health 
Division Promotion of Health 
16 Dr. Faroumata TOURE Ministry of Public 
Health 
Responsible for Family 
Planning 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 63
Annex 6
Training Plan for the Health District of Mandiana
THEME Prévus Atteints REFERENCE DUREE
Formation SONU
PERIODE
PLAN DE FORMATION DISTRICT SANITAIRE DE MANDIANA (2002 - 2004)
CIBLES
SMI
PARTICIPANTS
VOLETS 
Personnel CS18/DPS 4 4 1 mois T1/A1 Document du participant/Fiche 
d'apprentissage en santé maternelle 
et néonatale/Guides du participant
AS 33 32 12 jours T3/A1 Document du participant/Fiche 
d'apprentissage en santé maternelle 
et néonatale/Guides du participant
Formation sur facteurs de risque au 
cours de la grossesse Animateurs 6 6 T1/A2
Les soins prénatals 5 jours
Muriga/caisse communautaire
Formation SONU
Guide de formation des animateurs 
et superviseur ONG
Guide de formation des animateurs 
et superviseur ONG
NUTRITION
SMI
Alimentation de l'enfant de 0-35 mois
La malnutrition protéino-énergétique Animateurs 6 6 T1/A2
Les micro nutriments et leur carence 5 jours
Le FARN
Alimentation de l'enfant de 0-35 mois 20 16 May-04
La surveillance nutritionnelle
La malnutrition protéino-énergétique AS 20 16 5 jours T3/A2
Les micro nutriments et leur carence
Le FARN
Surveillance nutritionnelle des enfants de 
0-35 mois
Secrétaire des CVS 60 60 3 jours T2/A2
Guide de formation des AC sur la 
surveillance nutritionnelle des 
enfants de 0-36 mois
Module de formation des AS en 
nutrition
Guide de formation des animateurs 
et superviseur ONG
Guide de formation des animateurs 
et superviseur ONG
IMMUNISATION
NUTRITION
La vaccination des enfants
Le calendrier vaccinal Animateurs 6 6 2 jours T1/A2
La vaccination des femmes enceintes
Animateurs 6
Guide de formation des animateurs 
et superviseur ONG
Guide de formation des animateurs 
et superviseur ONG
6 T1/A2
PF
IMMUNISATION
Importance de la planification familiale
Les méthodes de PF disponibles en 
Guinée 5 jours Animateurs 6
Guide de formation des animateurs 
et superviseur ONG
Guide de formation des animateurs 
et superviseur ONG
6 T1/A2
PF
IST/VIH/SIDA
Les infections sexuellement 
transmissibles Animateurs 6 6 Jun-04
Paires éducateurs 120 120 5 jours T2/A2
Curriculum de formation des pairs 
éducateurs/boîte à image santé 
jeune IST/SIDA 
Le VIH/SIDA
Guide de formation des animateurs 
et superviseur ONG
Curriculum de formation des AC en 
PCIME-C
AUTRES
IST/VIH/SIDA
PCIME-C
Animateurs 6 6 3 jours T3/A2
Nutritionnistes et AV 
des CVS 120 110 3 jours T3/A2
Curriculum de formation des AC en 
PCIME-C
Personnel CS18 1 1 T4/A1
Animateurs 6 6 3 jours TA/A1
Secrétaire des CVS 60 60 3 jours T1/A2
Guide de formation des CVS en 
système de collecte des données 
démographiques et sanitaires au 
niveau village
Gestion des caisses Trésorier des CVS 72 72 3 jours T2/A2
Technique de Supervision Animateurs 6 6 5 jours
Guide de formation des animateurs 
et superviseur ONG
Andragogie et Mobilisation sociale Animateurs 6 6
Guide de formation des animateurs 
et superviseur ONG
T1/A2
SIS
Guide d'utilisation des informations 
démographiques et sanitaires au 
niveau communautaire
Curriculum de formation des AC en 
PCIME-C
AUTRES
PCIME-C
CS-18 Guinea, Final Evaluation, Save the Children, December 2006
 64
Prévus Atteints
10 jours
SMI Formation en SONU AV 25 25 T2/A4 Curriculum AV
PF Recyclage formel en distribution directe AC 266 266 3 jours T3/A4 Curriculum AC
des contraceptifs oraux
Planification
Gestion 4jours/session T3,T4/A3 Modules
Plaidoyer et mobilisation des ressources ACVS 12 12 en 4 sessions T1,T2/A4
RENFORCEMENT Gouvernance interne
DE CAPACITES Formation en Word 5 jours en Modules
Formation en Excel Equipe 2 sessions
Formation en SIS Cadre 1 1 3 jours T2/A3 Modules
Formation sur Outil Enquete Fait/Non fait District 4 4 5 jours T2/A4
ONG 1 1 10 jours en T2/A3 Modules
Planification Strategique 2 sessions
VOLETS THEME CIBLES DUREE REFERENCE
2 2 T1/A2
PLAN DE FORMATION DISTRICT SANITAIRE DE MANDIANA (2004 - 2006)
PARTICIPANTS
PERIODE
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 65
Annex 7
Training Plan for the Health District of Kouroussa
PLAN DE FORMATION DISTRICT SANITAIRE KOUROUSSA (2002 - 2004)
VOLETS TYPES DE FORMATION CIBLES Prevu Atteint DUREE PERIODE REFERENCE
Orientation des formateurs 
AV
Medecin chef maternite 1 1
3 jours T4/A1
Guide des Formateur en SONU
et sages femmes 3 3
SMI
Formation des superviseurs 
AV
Agents PEV,CPS et 10 10
2 jours T4/A1
Guide de formation
agent GAAPE 6 6 Fiche Nationale de supervision
Formation des superviseurs 
SBC
Agents PEV,CPS 10 10
5 jours T1/A2 agent GAAPE et 6 6 Curriculum Formateurs/SBC Conseiller d'ONG 1 1
PF
Formation des CVS en PF Hommes 42 42 5 jours T1/A2 Femmes 42 42 Curriculum AC/SBC
SMI Formation en SONU AV 42 42 10 jours T2/A2 Curriculum national AV
Formation en collecte des 
donnees demo sanitaire au 
niveau communautaire
Vice Presidents 42 42
3 jours SIS Presidents 42 42 T2/A2 curriculum SIS communautaire
Formation des CVS
Nutritionnistes 42 42 Curriculum nutrition
Assainissements 42 42 5 jours T2/A2 Curriculum PCIME-C
NUTRITION
Formation des agents de Agents PEV 6 6 Curriculum nutrition
Sante en nutrition Chefs de Postes 4 4 4 jours T2/A2 Curriculum PCIME-C
IST/VIH/SIDA Formation Pairs educateurs Jeunes leaders 84 81 T3/A2 Curriculum Pairs educateurs
Formation des Gestionnaires Presidents CVS 84 84 3 jours
SMI MURIGA Tresorier CVS 84 84 T4/A2 Curriculum Gerant Muriga
VACCINATION
L' importance vaccination VA CVS 42 42
Les maladies cibles du PEV Nutritionniste CVS 42 42 2 jours T2/A2 Curriculum AC/Poster PEV
Le calendrier vaccinal Agents assainissement 42 37
Les effets secondaires
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 66
PLAN DE FORMATION DISTRICT SANITAIRE KOUROUSSA (2004 - 2006)
VOLETS TYPES DE FORMATION CIBLES Prevu Atteint DUREE PERIODE REFERENC
E
Formation des superviseurs 
AV 3 jours T1/A3
Guide de formation
SMI Agents PEV,CPS et 6 6 Fiche Nationale de supervision
Formation des superviseurs 
SBC
Agents PEV,CPS 10 10 5 jours T1/A3 Curriculum SBC PF
Formation des CVS en PF 
Hommes 38 38 5 jours T1/A3 Femmes 38 38 Curriculum AC/SBC
Formation en collecte des 
donnees demo sanitaire au 
niveau communautaire
Vice Presidents 38 38
3 jours SIS Presidents 38 34 T2/A3 curriculum SIS communautaire
Formation en nutrition et 
PCIME-C
Nutritionnistes 38 38 Curriculum nutrition
Assainissements 38 33 5 jours T2/A3 Curriculum PCIME-C
NUTRITION
Formation des agents de Agents PEV 6 6 Curriculum nutrition
Sante en nutrition Chefs de Postes 2 2 4 jours T2/A2 Curriculum PCIME-C
IST/VIH/SID
A Formation Pairs educateurs Jeunes leaders 76 73 T3/A3 Curriculum Pairs educateurs
Formation des Gestionnaires Presidents CVS 38 34
SMI MURIGA Tresorier CVS 38 38 3 jours T4/A3 Curriculum Gerant Muriga
Formation en SONU AV 38 40 10 jours T2/A3 Curriculum national AV
VACCINATION
L' importance vaccination AV CVS 38 38
Les maladies cibles du PEV Nutritionniste CVS 38 38 2 jours T2/A3 Curriculum AC/Poster PEV
Le calendrier vaccinal Agents assainissement 38 33
Les effets secondaires
RECYCLAGE Distribution des 
FORMEL EN PF contraceptifs oraux en Agents communautaires 160 158 3jours T2/A4 Curriculum AC
premiere intension
Formation en Word 10 jours
Formation en Excel Equipe cadre District 3 3 en 2 sessions T2/A3 Modules outil informatique
SIS 3 jours T1/3 Module SIS
Techniqu Enquete Fait/ 5 jours T2/A4 Outil Fait/Non fait
Non fait
RENFORCEMENT DE Planification et gestion
CAPACITES Paldoyer et mobilisation ACVS 12 12 5 jours/session T2,T3/A4 Modules
des ressources en 3 sessions
Gouvernance interne
Planification strategique ONG 1 1 5jours/session T2/A3 Modules
en 2 sessions
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 67
Annex 8 
Analysis of Death Avoided (According to the Lancet and thanks to Jim Ricca) 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 68
Annex 9 
Interventions with the Greatest Estimated Impact 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 69
Annex 10 
Final Evaluation Photographs 
A project leader encouraged by the results presented and analyzed by the partners and members of the 
project team. 
Mandiana Reststop (to recover from the bumps on the way) and the beautiful road of Kouroussa. 
A success for health. A team strategy: Health/DPS, health agents, community agents, VHC members 
VHC, peer-educators, NGO animators, VHC nutritionist, and district coordinator of Save the Children… 
In Kouroussa as in Mandiana, the Save the Children team works within the offices of the DPS. A support 
for stock-outs of management tools was extremely appreciated. 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 70
Equipment for the health centers: scales and suggestion boxes for quality improvement. Posting of 
unfortunately irrational costs of services: cost of purchase of the sachets SRO = 450 FG; posted cost of 
sale = 200 FG! With that, stock-outs will continue. 
Local NGOs, GAAPE and AJVDM, organize, develop their capacity and project towards the future. 
Irreplaceable resources: executives and animators of the local NGOs, and the famous means of transport. 
Analysis and compilation of various sources of information by the teams. 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 71
Debriefing and development of the final recommendations: in Kankan, then in Conakry. The debriefing 
for the MOH was organized by the DRS, with the two DPS for Mandiana and Kouroussa. 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 72
Annex 11 
Explanation of the Index “Percent of Deficit Filled” 
Figure A illustrates the principle of construction of this index: 
• Indicator X progresses from Phase 1 to Phase 2, from 20% to 40%. The deficit to be 
filled was of: 
ƒ (100% - 20%) = 80%. 
The percentage of this made up deficit is of: 
ƒ (40% - 20%)/80% = 25% 
• The indicator Y begins on a level much higher (80%). As it is frequently the case, it is 
more difficult to advance an indicator already on this level. In this example indicator Y is 
measured at 85% in Phase 2. The deficit to be filled was of: 
ƒ (100% - 80%) = 20% 
The percentage of this made up deficit is of: 
ƒ (85% - 80%)/20% = 25%. 
• The last example is the indicator Z, which increased by 10% to 55% and thus filled 50% 
of the deficit which was (100% - 10%) = 90%. 
CSTS frequently uses this index in its analyses for USAID. Unpublished work analyzing the 
results of many projects shows that the percentage of recovered deficits progresses independently 
of the initial level of the indicators. One commonly observes in projects financed by 
USAID/CSHGP, a percentage reduction of the deficit by 30%, regardless of the starting level of 
the indicators. 
• In the example of Figure A, progress carried out between the various indicators is 
compared. Progress for the first two indicators is equal, with a filling of 25% of the 
deficit in both cases. The performance for the last indicator is much better, since one 
observes a reduction of 50% of the deficit to be addressed. 
Figure A: Illustration of the principle of the percentage of deficit to address
20%
40%
25%
80% 85%
25%
10%
55% 50%
0%
20%
40%
60%
80%
100%
Level Phase 1 Level Phase 2 % to be filled between
Phase 1 & 2
Indicator
Indicator
Indicator
 
1
See reviews of CSHGP progam. 
2
Performance Index analysis. Bill Weiss. CSSP. Unpublished. 1999. 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 73
Annex 12 
Summary of Project Progress 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 74
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 75
Annex 13 
Results Highlight 
Maternal mortality in Guinea, which was 528 in 1999, has jumped to 980 per 100,000 live births in the 
2005 DHS. This figure reflects an overall increase in adult mortality and is also attributable to the 
failure of the health system to provide adequate prenatal, emergency obstetrical care, and post-partum 
care coupled with poor nutritional status of women in their reproductive years. Indications are that 
causes of maternal mortality are similar to other developing countries, including hemorrhage, abortion, 
and sepsis. 
SC has worked in two districts of Upper Guinea over the last ten years to developed effective 
interventions for addressing several of the major causes of maternal and newborn mortality. The 
recent USAID-funded CS-18 child survival project included maternal and newborn care interventions 
that have been universally accepted by community residents, religious leaders, village authorities, 
health providers and traditional practitioners. 
Although demand for antenatal care was already relatively high (68%), the project increased demand 
through educational activities, so that now 91% of women benefited from at least two antenatal 
consultations. Rapid recognition of danger signs is important in order to get a mother to a higher level 
of care as needed. Educational activities sought to increase the proportion of women able to recognize 
at least two danger signs and this indicator more than doubled from 32% to 68%, over the life of the 
project. 
At the start of project activities, only about a fifth (19%) of births were attended by a skilled health 
care provider, and 45% were attended by trained TBAs, while about a third delivered at home without 
any trained assistance. The CS18 project taught obstetrical skills to 59 health workers as well as the 
basics of clean delivery and community life-saving skills to 107 TBAs. Now, 43% of births are 
attended by skilled providers, 56% by trained TBAs, and less than 1% lack any trained assistance. 
At the beginning of the project, postpartum care was almost unheard of in this region of Guinea. CS￾18 developed an early postpartum care program (EPP) that includes the use of trained TBAs as links 
who are closely associated with the village health committee and skilled providers. The EPP care 
includes: (1) recognizing and referring for danger signs of hemorrhage and infection; (2) supporting 
exclusive breastfeeding; (3) recognizing and treating common breast conditions, such as engorgement 
and mastitis; and 4) support of and referral to the MOH for family planning. At the end of the project, 
58% of women received two postnatal consultations. 
SC and its partners established a health insurance scheme to support both the transportation and health 
care costs of obstetrical emergencies. A total of 171 schemes called “MURIGAs” were established 
and have been used to cover the costs of 131 of a total of 931 obstetrical emergencies. The insurance 
schemes are managed by the local village health committees and provide timely financial support to 
families. These women would most likely not have received referral care without this support. The 
village health information system established by the project indicates a steady and dramatic decrease in 
the number of maternal deaths from 82 in the first year to about 22 in the last year. Although 
incomplete, this data does suggest the project interventions are effectively addressing the maternal 
mortality crisis in this area of Guinea. 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 76
Annex 14 
Updated CSHGP Data Form 
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 77
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 78
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 79
CS-18 Guinea, Final Evaluation, Save the Children, December 2006 80
Child Survival and Health Grants Program Project Summary
Dec-06-2006
Save the Children 
(Guinea)
General Project Information: 
Cooperative Agreement Number: FAO-A-00-98-00024-00
Project Grant Cycle: 18
Project Dates: (9/30/2002 - 9/29/2006)
Project Type: Cost XT
SC Headquarters Technical Backstop: Eric Swedberg 
Field Program Manager: Dunni Goodman 
Midterm Evaluator: 
Final Evaluator: Eric Sarriot 
USAID Mission Contact:
Field Program Manager Information:
Name: Dunni Goodman
Address:
Phone:
Fax:
E-mail: dgood1980@yahoo.com 
Alternate Field Contact:
Name: Damou Kieta
Address:
Kankan 
Phone: 224 710725 
E-mail: savegnea@sotelgui.net.gn 
Funding Information:
USAID Funding:(US $): $1,400,000  PVO match:(US $) $416,675 
Project Information:
Description:
This cost extention program will scale up the program’s goals of:
1) a sustained reduction in under-five and maternal mortality in the two health districts; and
2) a sustained improvement in the nutritional status of 0 to 36 month-old children. 
It proposes to continue the efforts in the following intervention areas; immunization,
nutrition and micronutrients, maternal and newborn Care, and HIV/AIDS. 
The programs interventions will be implemented through the following strategies: 
1) Joint DRS, DPS and SC design, implementation, and evaluation of approaches to
maternal and child health in the districts that inform strategies of other PVOs and the MOH. 
2) Improving the technical, financial, and institutional capacity of two local NGOs. 
3) Mobilizing communities through Village Health Committees and Health Center
Management Committees to improve essential health services and conduct focused
education activities. 
4)Improving the quality of health services provided in the community and the health
facilities.
Location:
Districts of Kouroussa(expanded area for CS XVIII) and Mandiana(original project site in
CS XIV project) 
Project Partners Partner
Type
Subgrant
Amount
Support Group for the Self Promotion of the Land and the Protection of the Environment Subgrantee $40,000.00 
The Association of Young Volunteers of Mandiana Subgrantee $40,000.00 
Subgrant Total $80,000.00
General Strategies Planned:
Private Sector Involvement
Advocacy on Health Policy
Strengthen Decentralized Health System
Information System Technologies 
M&E Assessment Strategies:
KPC Survey
Organizational Capacity Assessment with Local Partners
Participatory Rapid Appraisal
Community-based Monitoring Techniques
Participatory Evaluation Techniques (for mid-term or final evaluation) 
Behavior Change & Communication (BCC) Strategies:
Mass Media
Interpersonal Communication
Peer Communication
Support Groups 
Groups targeted for Capacity Building:
PVO Non-Govt
Partners
Other Private
Sector Govt Community
CS Project
Team 
Local NGO Traditional Healers Dist. Health
System
Health Facility
Staff
Health CBOs
CHWs 
Interventions/Program Components:
Immunizations (10 %)
 (IMCI Integration)
 (CHW Training)
  - Polio
  - Classic 6 Vaccines
  - Vitamin A
  - Surveillance
  - Mobilization
  - Community Registers
Nutrition (15 %)
 (IMCI Integration)
 (CHW Training)
  - ENA
  - Comp. Feed. from 6 mos.
  - Hearth
  - Cont. BF up to 24 mos.
  - Growth Monitoring
  - Maternal Nutrition
Vitamin A (5 %)
 (IMCI Integration)
 (CHW Training)
  - Supplementation
  - Post Partum
  - Integrated with EPI
Micronutrients (5 %)
 (CHW Training)
  - Iron Folate in Pregnancy
Maternal & Newborn Care (35 %)
 (IMCI Integration)
 (CHW Training)
 (HF Training)
  - Emerg. Obstet. Care
  - Neonatal Tetanus
  - Recog. of Danger signs
  - Post partum Care
  - Delay 1st preg Child Spacing
  - Integr. with Iron & Folate
  - Normal Delivery Care
  - Birth Plans
  - Home Based LSS
  - Control of post-partum bleeding
  - Emergency Transport
Child Spacing (10 %)
 (CHW Training)
  - Child Spacing Promotion
  - Pre/Post Natal Serv. Integration
HIV/AIDS (20 %)
 (CHW Training)
  - Behavior Change Strategy
  - Access/Use of Condoms
  - ABC
Target Beneficiaries:
Infants < 12 months: 17,080
Children 12-23 months: 14,689
Children 0-23 months: 32,299
Children 24-59 months: 51,242
Children 0-59 months: 85,402
Women 15-49 years: 106,753
Population of Target Area: 393,060
Rapid Catch Indicators:
Indicator Numerator Denominator Percentage Confidence
Interval
Percentage of children age 0-23
months who are underweight (-2
SD from the median
weight-for-age, according to the
WHO/NCHS reference
population)
89 563 15.8% 4.5
Percentage of children age 0-23
months who were born at least
24 months after the previous
surviving child
290 397 73.0% 9.5
Percentage of children age 0-23
months whose births were
attended by skilled health
personnel
334 597 55.9% 7.2
Percentage of mothers of
children age 0-23 months who
received at least two tetanus
toxoid injections before the birth
of their youngest child
311 402 77.4% 9.5
Percentage of infants age 0-5
months who were exclusively
breastfed in the last 24 hours
144 206 69.9% 13.0
Percentage of infants age 6-9
months receiving breastmilk and
complementary foods
67 128 52.3% 15.2
Percentage of children age 12-23
months who are fully vaccinated
(against the five
vaccine-preventable diseases)
before the first birthday
91 162 56.2% 13.8
Percentage of children age 12-23
months who received a measles
vaccine
88 162 54.3% 13.7
Percentage of children age 0-23
months who slept under an
insecticide-treated bednet the
previous night (in malaria-risk
areas only)
376 597 63.0% 7.5
Percentage of mothers who
know at least two signs of
childhood illness that indicate
the need for treatment
346 597 58.0% 7.3
Percentage of sick children age
0-23 months who received
increased fluids and continued
feeding during an illness in the
past two weeks
296 335 88.4% 10.6
Percentage of mothers of
children age 0-23 months who
cite at least two known ways of
reducing the risk of HIV
infection
357 585 61.0% 7.5
Percentage of mothers of
children age 0-23 months who
wash their hands with soap/ash
before food preparation, before
feeding children, after
defecation, and after attending to
a child who has defecated
21 597 3.5
% 2.1
Comments for Rapid Catch Indicators