MITRA 
Partners for Tuberculosis Control in 
Banten Province, Indonesia 
Mid Term Evaluation Report 
October 31-November 15, 2007 
Ranjani Gopinath, MD 
Evaluation Team Leader
Submitted to 
USAID Child Survival and Health Grants Program 
Date of Submission: 
December 2007 
Cooperative Agreement: GHS-A-00-05-00008-00 
October 1, 2005-September 30, 2009 
CARE Indonesia Contact: CARE USA Contact: 
Gayle, Steckley Dr. Khrist Roy 
Country Director CARE Indonesia Technical Advisor, Children’s Health 
Jl. Pattimura 33 CARE USA 
Kabayoran Baru 151 Ellis St. NE Atlanta, GA 30303 
Jakarta 12110 Tel: 404-979-9147 
Tel: 021-727-96661 Fax: 404-589-2624 
Fax: 021-722-2552 Email: kroy@care.org 
Email: @careind.or.id; 
 
ii
ABBREVIATIONS AND ACRONYMS 
ACD Assistant Country Director 
ACSM Advocacy, Communication, and Social Mobilization 
BAPEDA Badan Perencanaan Daerah or Planning Board at province level 
AIDS Acquired Immune Deficiency Syndrome 
BCC Behavior Change Communication 
BHS Basic Human Services 
CBO Community-Based Organization 
CBS Community-Based Structures 
CDR Case Detection Rate 
CII CARE International Indonesia 
CNR Case Notification Rate 
CS Child Survival 
CSHGP Child Survival and Health Grants Program 
DAP Development Assistance Program
Depkes Departemen Kesehatan or Ministry of Health 
DHO District Health Office 
Dinkes Dinas Kesehatan or Health Office (can be at province or district 
level) 
DIP Detailed Implementation Plan 
DOT Directly Observed Treatment 
DOTS Directly Observed Treatment Shortcourse 
Dukun Traditional Healer 
FA Facility Assessment 
FBO Faith-Based Organization 
FDCs Fixed Drug Combinations 
FO Field Officer 
GFATM The Global Fund to fight AIDS, Tuberculosis, and Malaria 
GOI Government of Indonesia 
HIV Human Immunodeficiency Virus 
HSP Health Services Project 
IDAI Ikatan Dokter Spesialis Anak Indonesia (Indonesian Pediatricians 
Association 
IDI Ikatan Dokter Indonesia (Indonesian Physicians/Medical Doctors 
Association) 
IEC Information, Education, and Communication 
ISTC International Standards for Tuberculosis Care 
Kabupaten District, Regency 
KAP Knowledge Attitudes Practice 
KNCV Koninklijke Nederlandse Centrale Vereniging tot Bestrijding der 
Tuberculose or Royal Netherlands Tuberculosis Association 
Kota City 
KPC Knowledge Practice Coverage 
MDR Multi-Drug Resistant 
MITRA Membangun Integrasi Program Tuberkulosis di Republik Indonesia 
iii
MO Medical Officer 
MOH Ministry of Health 
MOU Memorandum of Understanding 
NGO Non-Governmental Organization 
NTP National Tuberculosis Program 
PCI Project Concern International 
PM Project Manager 
PMO Pengawas Menelan Obat or Treatment Observer 
Posyandu Pos Pelayanan Terpadu or Integrated Health Post (child growth, 
monitoring and IMCI- based screening post at village Level) 
Polindes Pondok Bersalin Desa or Maternity Hut at Village Level 
PKK Program Kesejahteraan Keluarga or Family Welfare Program 
 (Voluntary organization led by wives of administrators) 
PKM Puskesmas, sub-district level Public Health Center (urban and rural) 
PPs Private Practioners 
PPTI Persatuan Pemberantasan Tuberkulosis Indonesia or the Indonesian 
TB Association 
PS or Puskesmas Satelit or Satellite Health Center (urban and rural) 
PVSM Poor, Vulnerable, and Socially Marginalized people 
QA Quality Assurance 
SO Strategic Objective 
TB Tuberculosis 
TBCAP Tuberculosis Control Assistance Program 
TBCTA Tuberculosis Coalition for Technical Assistance 
TC Training Coordinator 
TO Tuberculosis Officer at DOTS Center (Puskesmas) 
TSR Treatment Success Rate 
USAID United States Agency for International Development 
WASOR Wakil Supervisor or the District TB Coordinator 
WFP World Food Program
WHO World Health Organization 
iv
Index 
A. Summary………………………………………………………………………………… 1 
B. Assessment of the Progress……………………………………………………………….7 
1.Overview of the Project………………………………………………………………………….7 
2. Progress report…………………………………………………………………………………..8 
2.1 SO I: To create sustainable community-based TB control structures…………………………8 
2.1a. Planned activities…………………………………………………………………8 
2.1b. Knowledge and Treatment Seeking Practices………………………………….11 
2.1.c. KPC Findings……………………………………………………………………12 
2.1.d Qualitative Evaluation Findings……………………………………………… ..13 
2.1.e Community Based Structures and Individuals…………………………………..15 
2.1.f Recommendations………………………………………………. ……………...18 
2.2 Strategic Objective 2. To strengthen the delivery capacity of the district and provincial TB 
program……………………………………………………………………… ……………...19 
2.2a Planned Activities……………………………………………………………….19 
2.2.b Development of New Cadre: CBTO Coordinators……………………………..20 
2.2.c TB Posts…………………………………………………………………………20 
2.2.d: Capacity Building of Puskesma…………………………………………………21 
2.2.e Advocacy Related Progress ………………………………………………….....24 
2.2.f Recommendations ………………………………………………………………25 
2.3 Strategic Objective 3: To increase private sector participation in the TB 
program……………………………………………………………………………………....25
2.3.a Planned Activities ………………………………………………………………25 
2.3.b Capacity Building of Private Providers…………………………………………26 
2.3.c Recommendations……………………………………………………………….27 
3. Cross-cutting approaches ……………………………………………………………………...27 
3.1 Community Mobilization……………………………………………………………………..28 
3.1.1 Recommendations…………………………………………………………… …29 
3.2 Communication for Behavior Change………………………………………………………..30 
3.2.1 BCC Strategy……………………………………………………………………30 
3.2.2 Project’s BCC Activities ………………………………………………………..30 
3.2.3 IEC Efforts by Other Stakeholders……………………………………………. .31 
3.2.4 Measuring of BCC Outcomes …………………………………………………..31 
3.2.5 Recommendations……………………………………………………………….32 
3.3. Capacity Building Approach………………………………………………………………... 32
3.3.1 Strengthening the Grantee Organization…………………………………….. …32 
3.3.2 Strengthening Local Partner Organizations……………………………………. 33 
3.3.3 Strengthening Health Worker Performance……………………………………. 36 
3.3.4 Training………………………………………………………………………… 36 
3.3.5 Health Facilities Strengthening …………………………………………………36 
3.3.6 Recommendations……………………………………………………………….37 
3.4 Quality Assurance…………………………………………………………………………… 38 
3.4.1 Case Detection by Quality-Assured Sputum Smears Microscopy…………….. 38 
3.4.2 Treatment of TB Cases with Standard Short-course chemotherapy .………….. 38 
3.4.3 Uninterrupted Supply of Quality Drugs ……………………………………...... 39 
3.4.4 Recording and Reporting …………………………………………………...…. 39 
3.4.5 Community Defined Quality …...……………………………………………... 39 
3.4.6 Recommendations …………………………………………………………….. 40 
v
3.5 Sustainability Strategy……………………………………………………………………40 
3.5.1 Progress…………………………………………………………………… .40 
3.5.2 Child Survival Sustainability Assessment (CSSA) framework…………….42 
 3.5.3 Recommendations…………………………………………………………..42 
C. Project Management: 
1. Planning…………………………………………………………………….43 
2. Staff Training……………………………………………………………….44 
3. Supervision of Project staff…………………………………………………44 
4. Human Resources and Staff management………………………………….44 
5. Financial Management……………………………………………………..45 
6. Logistics……………………………………………………………………45 
7. Information Management…………………………………………………..45 
8. Technical and Administrative support……………………………………..46 
9. Mission Collaboration………………………………………………………47 
D. Other Issues Identified by the Team…………………………………………………48 
E. Conclusions and Recommendations…………………………………………………48 
F. Results Highlight…………………………………………………………………….52 
G. THE ACTION PLAN……………………………………………………………….53 
Annexes 
Annex A: Evaluation Team members and their Designation 
Annex A.1: KPC Team Members and their Designation 
Annex B: Assessment Methodology 
Annex C: List of persons interviewed and contacted 
Annex D: Evaluation Schedule and Activities 
Annex E: Action Plan 
Annex F: HFA 
Annex G: KPC 
Annex H: Project Data Form 
List of Tables 
Table 1. Knowledge and Treatment seeking indicators for SO 1………………………………..11 
Table 2: Key TB Knowledge Indicators in the community………………………………………12 
Table 3. Indicators to measure performance of community based structures…………………….15 
Table 4. Progress on Capacity Building of CBTO coordinators – Output Indicator for SO 2…...20 
Table 5. Progress on Puskesmas level Trainings – Output Indicators for SO 2………………….21 
Table 6. Performance Level Indicators for SO 2………...……………………………………….23 
Table 7. Advocacy related Output Indicators……………...……………………………………..24 
Table 8. Progress on Indicators for Private Participation…...……………………………………26 
Table 9. Lab Quality Assurance……………………………………………………..…………...38 
Table 10. CDR and Treatment Success Rates……………………………………………………39 
vi
 
A) Summary
Overview of the Project: 
CARE International Indonesia (CII) is working in four districts of Banten province￾Tangerang district, Pandeglang district, Cilegon City, and Tangerang City, with the 
primary implementing partners - Indonesia’s National Tuberculosis Program (NTP), 
KNCV (Royal Netherlands TB Association), participating District Health Offices, 
primary government health centers (Puskesmas with DOTS facility) and 
government/province planning board (BAPEDA). The project named MITRA – 
Membangun Integrasi Program TB di Republik Indonesia (“Partners for TB control in 
Indonesia”) falls in the “Tuberculosis” grant category and dedicates 100% of its resources 
to improving TB control and treatment activities. The duration of the project is from 
October 2005 to September 2009. The project’s goal is to support NTP in decreasing 
morbidity and mortality caused by tuberculosis in the project population of 6,188,365; 
achieve 85% Case Detection Rate (CDR); and maintain at least 88% Treatment Success 
Rate (TSR). The project aims to target 47,000 patients in four years, out of which smear￾positive or active pulmonary TB cases are expected to be 19,667. About 807 
communities are expected to benefit from the project’s interventions. The strategic 
objectives of MITRA are: 1) To create sustainable community-based TB control 
structures 2) To strengthen the delivery capacity of the district and provincial TB 
Program; 3) to increase private sector participation in the TB 
Program. 
Main accomplishments: 
The project has demonstrated establishment of some innovative community based 
structures and individuals like the Paguyubans who support patients visiting health 
centers (Puskesmas) and promote positive health seeking behaviors; TB posts which 
enables DOTS provision closer to the community; Community Based Treatment 
Observer (CBTO) Coordinators who provide supportive supervision to the treatment 
observers (who are mostly family members) and improve their linkages with the health 
centers. The proportion of people who thought TB was curable has gone up from 31% at 
baseline to 50% at midterm. Similarly there has been an 87% (data extrapolated from 
Quarter 2 data for 2007) increase in suspected patients seeking diagnosis in health 
centers. The project did well in identifying poor performing areas through a composite 
score card for initiation of project activities thus providing more than three years of 
implementation period to these areas. 
 
Progress in achieving project objectives: 
MITRA has exceeded targets in terms of identifying and training treatment observers in 
poor performing areas. MITRA has not expanded beyond 25 health center areas (107 in 
project area) covered in the first year of project implementation. The Behavior Change 
Communication Strategy (BCC) has been articulated recently and the use of BCC 
material is minimal. Therefore the achievements listed above cannot be solely attributed 
to project efforts. The project is beyond schedule in committed indicators for capacity 
building of private providers. The committed coverage for communities has not been 
possible owing to a delay in expansion of project activities. Project does not have any 
 1
 
structured partnership with CBOs (Community Based Organizations) or NGOs to aid 
expansion of activities. The committed trainings of health center staff could not be 
executed by MITRA due to the district/provincial health office’s requests and availability 
of the global funds within the government apparatus. 
Constraints and Problems and Areas needing further attention: 
 The trainings that the government said would be conducted with Global Funds could not 
be carried out due to temporary suspension of funds in Indonesia. Two training 
coordinators left the project while replacement for one was found; the project is still 
looking to fill the other position. The CII is working towards a reshuffling of roles and 
responsibilities of staff and job descriptions to make the project work more responsively 
to the work plan. Advocacy and relationship between project and the district/provincial 
health offices need strengthening. Similarly there is a need for strengthening the 
managerial and community skills of the health center and district TB officers. 
Effects of Capacity-Building: 
The capacity building of community and the community based volunteers (CBTOs and 
CBTO coordinators) have been carried out successfully resulting in a growing awareness 
of the population, improved health seeking and treatment completion. The capacity 
building for health center staff needs to be reworked owing to changing realities and 
MITRA may do well to consider enhancing the managerial and community skills 
capacity of the public providers. Similarly within the capacity building strategy for 
Private Providers there is a need for training sessions on BCC and partnership modalities. 
Prospects of Sustainability:
There is no phase out plan as of yet. The establishment of Community Based Observer 
(CBO) Coordinators has a high prospect of sustainability as Community Based Treatment 
Observers (CBTO), who are mainly family members, may not wish to continue their role 
after the treatment of their kin. The government is highly committed to involving private 
providers and MITRA support in improving the quality of their trainings will ensure 
continuing positive TB outcomes. The Child Survival Sustainability Framework (CSSA) 
workshop has not been carried out as yet. 
Conclusions: 
In conclusion, the project is behind schedule. The MITRA activities are taking place in 
25% of the project areas. Community mobilization efforts have been made in these areas 
demonstrating some scalable models. Introduction of the cadre of CBTO coordinator 
presents the possibility of a sustainable structure who can act as a link between the 
community and the facilities. 
Recommendations for the Project and the Grantee’s Response
1. Coordinate with Dinkes and Puskesmas 
a) Expand activities to cover more than 25 Puskesmas areas. Sign MOU’s as planned 
with able local NGO/CBO partners to achieve expansion. 
 2
 
Grantee’s response - The project is expected to scale up into the remaining puskesmas in 
each district, prioritizing the weaker ones. 
b) Improve information sharing with the Puskesmas through structured methods for 
better utilization, monitoring and sustainability of strengthened community 
structures and individuals. 
Grantee’s response -The project will systematically use the quarterly Monitoring 
meeting at the puskesmas level for better coordination and utilization of 
volunteer efforts by linking them to the puskesmas. 
c) Rethink the trainings that MITRA wants to give at the Puskesmas level. Who will 
be trained? What will be the content? How will this be done? Drop the indicators 
pertaining to training of Puskesmas staff. Consider managerial and leadership 
training for Puskesmas staff if NTP restarts technical trainings for them through 
the latest round of GFTAM funding. 
Grantee’s response -To date the project has worked with the MOH at district and 
province levels. The project will continue to work together with them as per the 
unfolding scenario of global funds. It appears that Pandeglang district will 
justifiably need more support in terms of difficult to reach areas and high staff 
turnover. 
d) Jointly with the Dinkes, investigate the use of recommended score cards for 
pediatric diagnosis to identify reasons for over diagnosis and train providers to 
address the situation (either through MITRA funded trainings or through NTP). 
Use quarterly monitoring meetings to underline the need for using standardized 
pediatric score cards. Assess the need for capacity building and advocate for 
fulfilling the gaps in capacities. 
Grantee’s response -The project will work with the Dinkes and the IDAI local 
chapters to focus attention on proper diagnosis and management of pediatric TB, 
using the national score cards. 
e) Through regular analysis of monitoring reports and field feedback, identify 
drug/lab/reporting issues and advocate for resolutions at appropriate forums. 
Advocate for resolution of issues related to sharing of drug boxes and 
unavailability of streptomycin at provincial and national level. 
Grantee’s response -The project together with the Dinkes will systematically 
monitor reports at all levels for early identification of areas of weakness and work 
with the partners to resolve them. 
f) To ensure drug stocks and that individual boxes are meant for only one patient. 
Seek help at different levels to address this issue. 
Grantee’s response -As this has been identified as an issue of significance, 
MITRA will review this immediately in the identified districts and work with the 
Dinkes to resolve this issue. 
g) Conduct CSSA framework workshop and monitor sustainability indicators. 
Grantee’s response -The project will conduct the CSSA workshop with its 
partners. 
 3
 
2. BCC Related 
 a) Conduct a workshop of all key stakeholders to finalize the draft BCC strategy. 
Quickly adapt, produce and disseminate IEC materials to community based 
partners and the Puskesmas. 
 Grantee’s response -A BCC workshop will be conducted shortly. Points (b) and 
 c) below will be a part of the BCC workshop. 
b) Include messages on side effects, HIV – TB linkages and MDR TB to the 
appropriate extent. Address some of the identified misconceptions about TB 
(using same utensils will cause TB, TB is sexually transmitted, TB patient should 
be isolated) which generate stigma. 
 Grantee’s response – Please see point (a) above 
c) Advocate for development of linkages between TB-HIV programs, as Banten is 
 deemed as a high HIV prevalence area. 
 Grantee’s response – Please see point (a) above. 
d) Remove the indicator “100% increase (from 30% to 60%) in knowledge of 
symptoms of TB and its curability in the community” as this is already captured 
in two other indicators and is merely repetitive. 
Grantee’s response - Accepted 
e) Rephrase indicator “at least 20% increase in the number of TB suspects from 
6,560 in 2005 to 7,800 by September 2009 combined for the 4 districts.” – to read 
“ at least 40% increase in number of suspected TB patients reaching or screened 
by the Puskesmas in four project districts from 27,953 in 2005 to 39,134 in 2009.” 
Grantee’s response -The project accepts the suggestion on the indicators above. 
3. Strengthening of CBOs
a) Build on successful experiences of community groups, Paguyubans and CBTO 
coordinators.
 Grantee’s response -The project will rapidly scale up these experiences in all 
 districts except Cilegon. 
b) Utilize the simple monitoring formats to measure outputs and outcomes of 
CBTO/Volunteer activities. 
 Grantee’s response - Monitoring formats will be revisited and used to measure 
 the outputs and outcomes of volunteer activities. 
4. Working with PP - Piggy back with MOH/KNCV initiatives 
a) KNCV is planning to work with Hospitals and larger clinics in Indonesia and a 
 collaborative effort with them would be mutually beneficial. 
 Grantee’s response - The project has already sounded out KNCV to work with 
them in the hospitals of Banten Province. 
b) Develop a simple monitoring format for issues not covered by existing TB 
formats – support required, problems faced – which can be used by the PP to 
communicate with the Puskesmas. 
Grantee’s response - The project will develop DOTS TB related material for PPs 
to make their diagnosis, counseling and referral simpler and more systematic. 
 4
 
5. Improve Coordination with NTP at all levels to expand definition of 
coordination to include problem solving.
 a) Discuss with NTP the support required to bridge the gaps in quality diagnosis. 
Identify the role that MITRA can play. In case that NTP does not require MITRA 
support then, follow up, monitor, share findings and advocate for improving 
quality. 
Grantee’s response - The project will coordinate with NTP at national, province 
and district levels to bridge identified gaps. The project will use the mechanism of 
the quarterly meeting forum to do so. 
b) Develop a specific, written strategy for engaging decision-makers. District, 
provincial and national level interactions should be utilized to avert possible 
quality assurance related issues in a timely manner. 
 Grantee’s response – The project will develop a specific written strategy to 
 engage with decision makers.
Recommendations for Scaling up and Down
1. Cilegon has been performing well on the DOTS indicators and the linkages 
between health centers and the communities are well established. MITRA can 
consider phasing out community activities in Cilegon and support improvement of 
quality in private provider trainings. 
 Grantee’s response -Though MITRA was expected to phase out of Cilegon, some 
activities like PP trainings and BCC related activities especially for HIV and 
MDR will be undertaken in Cilegon as per the request of the Dinkes team. 
2. Consider working with CBTO coordinators as against CBTOs. Since most 
CBTOs are family members, their interest in continuing as CBTOs beyond the 
treatment of their kin is moot. Scale up Pagyubans and TB posts. 
Grantee’s response - MITRA will now focus primarily on CBTO coordinators. 
3. Drop identified indicators which are either redundant or cannot be achieved 
(owing to change in government stance) 
 Grantee’s response -We accept this recommendation. 
4. Consider dropping COPE for DOTS quality monitoring indicators. For example 
proportion of providers both government and private who are using BCC 
principles and IEC materials for TB suspects and patients. 
 Grantee’s response - CARE Atlanta will follow up with EngenderHealth and CRS 
to see if the TB COPE is possible in given circumstances. If it is found to be 
difficult in the next 6 months, then MOH quality monitoring indicators for DOTS 
will be used. 
5. Dovetail the government’s efforts to train private providers by enhancing the 
community and managerial aspects of their skills. 
Grantee’s response - As suggested MITRA in conjunction with the MOH will do 
some pilots and study outcomes. 
6. MITRA has done exceptionally promising work in some areas like working with 
the religious leaders for BCC. This should be scaled up. However, it is running 
into obvious impediments in its work with Village Health Committees. MITRA is 
also considering the PP as only the doctors while in Indonesia the PP includes the 
 5
 
Midwives, who are also doing private practice, or government midwives who can 
practice privately after office hours. Hence the recommendations are: 
a) Scale up work with Religious leaders as what we saw in the field was good and 
maybe that will be effective for BCC. 
b) Reducing the number of PPs to be reached from 150 to 50 and then scale up, if 
success is met, or clarify the number 150 to include PPs + Bidans + 
private clinics etc. 
c) Reduce the work with village health committees to 30- 50 pilot villages and scale 
it up based on lessons learnt.
Grantee’s response – As recommended MITRA will work more intensively with 
religious leaders and document the effectiveness of this approach, and will 
include the bidan training as training of PP and MITRA will draw lessons from 
both these experiences to scale up. The project will also intensively pilot its work 
with 30 VHC and study the results before scaling it up.
Point to Ponder for USAID
1. TB programs worldwide are very structured and rigid which makes it difficult for 
NGO partners to carve a role for themselves. Further the role carved is restricted 
to some aspects, with no controls on other aspects of DOTS. However, DOTS 
does not work until all five components come together. There is a need for future 
project designs to envisage a larger and more active role for local missions and 
TBCAP partners, to ensure that the factors outside the control of NGO partner can 
be advocated at a higher level. 
2. Consider incorporating an indicator pertaining to ‘initial defaulters’. These are 
people who approach care provider and are diagnosed to be sputum positive, but 
are not put on treatment. This indicator can act as an indicator to assess quality of 
service provision within the control of NGO. 
Grantee’s Responses to MTE recommendations
Please see above 
Action Plan 
Please See Annex (E) 
Note – Some generic and specific responses have already been noted above. The specific 
action plan will cover more broad and cover other significant areas in the 
recommendations as given by the consultant. 
 6
 
B) Assessment of the Progress – Technical Approach
The Mid Term Evaluation (MTE) MITRA project was carried out between 30 October 
and 15 November 2007. The evaluation process included a Knowledge Practices and 
Coverage (KPC) survey and a participatory qualitative analysis. It is important to note 
while interpreting findings that while the sampling universe for the KPC was the entire 
project area, the sampling for qualitative analysis was done in those areas where the 
project has initiated activities. 
1. Overview of the Project
CARE International Indonesia is working in four districts of Banten province, located on 
the country's most populous island, Java: Tangerang district, Pandeglang district, Cilegon 
City, and Tangerang City (large urban center), with the primary implementing partners - 
Indonesia’s National Tuberculosis Program (NTP), KNCV (Royal Netherlands TB 
Association), participating District Health Offices, primary government health centers 
(Puskesmas with DOTS facility) and government/province planning board (BAPEDA). 
The project will strengthen tuberculosis (TB) control efforts in these four districts of 
Banten province, a USAID priority province. The project named MITRA – Membangun 
Integrasi Program TB di Republik Indonesia (“Partners for TB control in Indonesia”) 
falls in the “Tuberculosis” grant category and dedicates 100% of its resources to 
improving TB control and treatment activities. The duration of the project is from 
October 2005 to September 2009. 
The project’s goal is to support the NTP in decreasing morbidity and mortality caused by 
tuberculosis in the project population of 6,188,365; achieve 85% Case Detection Rate 
(CDR); and maintain at least 88% Treatment Success Rate (TSR). 
The project districts accounted for 68.6% of TB cases (all types) in the province and had 
a CDR of 62.8% at the time of proposal design. The project aims to target 47,000 patients 
in four years, out of which smear-positive or active pulmonary TB cases are expected to 
be 19,667. About 807 communities are expected to benefit from the project’s 
interventions. 
At the time of DIP preparation it was found that the Cilegon district had exceeded 
WHO/NTP and MITRA's end of project targets. Therefore, it was decided that activities 
in Cilegon would focus more intensively on Private Provider and industry collaboration, 
an intervention proposed under operations research. After deliberations with the CII 
team, the district MOH/ DOTS team, the provincial MOH/DOTS team, the KNCV 
representative in Banten, the local USAID mission, and with USAID (Washington, DC) 
approval, CARE added the Pandeglang district to its geographical working area. 
 7
 
Pandeglang was a larger district and did not have 100% DOTS coverage. Consequently it 
was decided that the project will focus on the entire district with advocacy and capacity 
building activities (the latter restricted to the Puskesmas staff) and community level 
activities will be undertaken in 10 to 15 Puskesmas areas which had operational zed 
DOTS strategy. 
The project’s Strategic Objectives (SO) are: 
1. To create sustainable community-based TB control structures 
2. To strengthen the delivery capacity of the district and provincial TB program 
3. To increase private sector participation in the TB program. 
The project commits to addressing three (text in bold) of the five components of the 
DOTS strategy: (1) Sustained political commitment; (2) Access to quality-assured TB 
sputum microscopy; (3) Standardized short-course chemotherapy for all cases of TB 
under proper case management conditions, including direct observation of 
treatment; (4) Uninterrupted supply of quality-assured drugs; and (5) Recording and 
reporting that enables outcome assessment. 
2. Progress Report 
This section describes the activities planned during the DIP under each Strategic 
Objectives; progress towards benchmarks; effectiveness of the interventions; successes; 
constraints and recommendations. The progress on monitoring indicators is presented at 
the end of this section so that ample perspective could be developed. 
Important methodological note: KPC and NTP data are for the entire project area. The 
qualitative evaluation is restricted to 25 Puskesmas areas where project has ongoing 
activities. 
2.1 Strategic Objective 1: To create sustainable community-based TB control 
structures
2.1.a. Planned Activities and their Effectiveness
The objective of building sustainable community-based structures aims to improve TB 
care seeking, treatment adherence and decrease default rates among the project 
population. Baseline KPC surveys revealed that though more than 86% of the 
respondents knew that TB is curable, only 31% could cite common symptoms of TB. 
Further the barriers to achieving cessation of TB transmission were related to care 
seeking. The project found that there are no dedicated sustainable structures for 
promoting TB awareness, referring suspects, observing treatment; and that the linkages 
between the community and the health facilities were weak especially in Cilegon city. 
This was further compounded by care seeking through a chain of traditional healers and 
private practitioners. Besides being expensive this delayed and worsened the patient’s 
condition. MITRA aimed to address these constraints by improving community TB care 
 8
 
seeking behavior and providing support to patients to complete treatment through trained 
cadre of observers and volunteers 
The Strategic Objective one has the following output level objectives: 
a) Build capacity of community-based organizations to implement TB control 
activities 
b) Build capacity of volunteer health workers to generate community awareness and 
support TB patients and their families to fully participate in DOTS 
c) Use Behavior Change Communication (BCC) to increase the TB health-seeking 
practices of the community. 
In the first year, as described in the first annual report, CARE met with key stakeholders 
and a decision was taken to initiate project activities in poor performing areas of each 
district. The partners (CARE and local Ministry of Health officials) identified the poor 
performing areas in each district based on criteria which included TB program data, staff 
performance, availability of local NGO/CBO/FBOs, availability and capacity of health 
kaders (volunteers at village level), number of TB patients detected (the TB dense 
pockets), hard to reach populations (accessibility problems) and proportion of poor 
people living in the area. 
A scoring system was developed based on the above mentioned criteria and a total of 25 
out of 107 project Puskesmas were selected for implementation in the first year, with the 
distribution as follows: three (out of 8 in Cilegon), six (out of 30 which had DOTS in 
Pandeglang), six (out of 25 in Tangerang city) and ten (out of 40 in Tangerang 
Kabupaten). 
 
While this was an excellent strategy to reach poor, vulnerable and marginalized 
populations and provide them the benefit of four years of project implementation, the 
project did not expand activities beyond these identified the 25 Puskesmas areas in the 
second year of the project. This has resulted in the project falling behind schedule. 
In each of the communities where the project has initiated activities, various volunteers 
and Community Based Organizations (CBOs) have been identified. These include: 
• Community Based Treatment Observers (CBTOs): Most CBTOs are better 
educated family members who are expected to ensure that the patient consumes 
the required medication. The CBTO also supports the patient by commuting to the 
Puskesmas to collect drugs. Prior to project initiation CBTOs were only 
supervised upon their visit to the Puskesmas, leading to drop outs and cessation of 
treatment. 
• Kaders: They are community members who provide voluntary support to the 
activities at the Integrated Health Pots (Posyandus). Puskesmas build on the 
availability of this structure and provide extension/outreach services through this 
post every month. There are five to six Kaders in each Posyandu and one of them 
has been designated as the TB Kader by the project. 
 9
 
• Bidan Desa: These are the village midwives who manage the community level 
maternal and reproductive posts (Polindes). These Bidans also have practice 
privately after the government duty hours. There are a smaller number of Bidans 
who are exclusively in private practice. The system of private practice by Bidans
is more common in Pandeglang where there are very few doctor managed private 
clinics. The project is currently working with the government Bidans at the 
government Polindes, but not at their private practices. A larger proportion of 
Bidans in private practice are the government Bidans. 
• PKKs (Program Kesejahteraan Keluarga or Family Welfare Program) This is an 
associations of women, cascading down from national level down to the street￾level. The head of each level is the wife of that level’s administrator for example -
President/Governor/Bupati/Camat/Village head/Sub-village head/Neighborhood 
head/Street head. The members at the lower level however are all the women in 
the street. This makes all women in Indonesia (in principle) a PKK member. 
PKKs have been traditionally involved in developmental activities. 
• Religious groups Many religious congregations have been identified by the 
project. The Koran recitation meetings (pengajian) are used as an opportunity to 
interact with the community members. 
• CBTO Coordinators MITRA has created a cadre of CBTO coordinators. They 
are either Posyandu volunteers (Kaders) or are community volunteers (PKK 
members, religious leaders and teachers). leaders, who regularly meet with them 
to discuss constraints in treatment adherence and to provide appropriate advisory 
support. 
• Paguyuban TB Paguyuban in Bahasa means ‘a group of people with the same 
interest or goals’. Paguyuban TB therefore is a group of ex patients, who get 
together on TB days (for e.g. Monday/Wednesday) at Puskesmas and disseminate 
TB related information. They form a support group as well to the patients 
currently on treatment. There are four such groups in the project area. The first 
was formed by the effort of Pulo Merak Puskesmas. Owing to its success three 
more Paguyubans were formed. MITRA supports the activities of Paguyubans
and plans to facilitate expansion of these groups. 
• Community Groups MITRA has facilitated the formation of community level 
groups which consist of current and ex TB patients, their family members (many 
of them are the treatments supporters), Kaders, and PKK members (a cascading 
association of women led by wives of local administrators). 
• Village Health Comittees These are village level institutions envisioned under 
USAID’s Health Services Project in Tangerang District and by CARE’s BERSIH 
Program (this is the USAID funded Development Assistance Program). The final 
vision for this project is the formation of "Desa Siaga" or 'alert villages' where 
village health councils are able to intelligently monitor health issues in the 
population both in an acute setting like influenza and a chronic setting like TB 
and to be able to plan and prepare for both. 
MITRA developed orientation material and training manual (which also includes sessions 
on community mobilization and communication skills) and built the capacity of these 
 10
 
identified individuals and groups to disseminate TB information; and support patients on 
treatment. 
However, the BCC strategy workshop which was to be carried out in the beginning of the 
second year could not take place because the selected consultant was unable to deliver on 
the contract. A new consultant has been identified, a draft BCC document has been 
developed prior to the mid term evaluation and a BCC workshop is expected by February 
2008. This document has been informed by the NTP’s Advocacy, Social Mobilization 
and Communication (ASMC) strategy and outlines desired behaviors expected from 
patients, communities and providers. Project has also identified available IEC material. 
However these material require adaptation as they are verbose, need more illustrations 
and Sundanese language inputs (one third of project population speaks the Sundanese 
language). 
2.1.b. Knowledge and Treatment Seeking Practices 
Although there has been an absence of a clear and written BCC strategy and dearth of 
IEC material (project has not made available materials to volunteers, providers and health 
centers), the project has been training its volunteers to disseminate TB messages with 
some success. 
 
Table 1. Knowledge and Treatment Seeking Indicators for SO 1. 
Output Indicators Baseline to Mid Term Comments 
By the end of the project at 
least 70% of the population can 
list 2 common symptoms of TB 
 31% to 50% 
There has been a significant 
improvement in the knowledge 
levels of the communities 
regarding TB symptoms. Whether 
this is entirely attributable to 
MITRA’s interventions cannot be 
commented upon. MITRA 
currently covers 25 Puskesmas
areas out of the 107 in the project 
area. Furthermore NTP ran a mass 
media campaign between March 
and May this year. 
By the end of the project at 
100% of the population knows 
that TB is curable
 87% to 94% 
This increase though not 
statistically significant should be 
seen in the light of the fact that it 
was already high at baseline, 
making it difficult to reach 
significant increase. 
100% increase (from 30% to 
60%) in knowledge of 
symptoms of TB and its 
curability in the community 
This is a repetition of the above 
two indicators and should be 
deleted hereafter. 
At least 20% increase in the 
number of TB suspects from 
6,560 in 2005 to 7,800 by 
Total sputum positive 
cases detected n four 
project districts: 
The indicator has not been worded 
appropriately. It should either read 
‘20% increase in new sputum 
 11
 
September 2009 combined for 
the 4 districts. (total number of 
TB suspects registered in the 
project area in year 4 or 
2009/total number of TB 
suspects registered in the 
project area in year 1 or 2005 ) 
source- Provincial NTP 
reports, Oct 07 
2005: 4137 
2006: 4487 
2007: 2489 (Q2)
Total patients 
suspected of TB 
2005: 27,953 
2006: 35,332 
2007: 26,161 (Q2) 
positive patients put on treatment 
or registered from year one to year 
four / 
OR 
20% increase in number of 
suspected TB patients reaching or 
investigated by Puskesmas. 
If it is the latter then there has been 
tremendous progress. Patients 
approaching Puskesmas and being 
investigated for TB has increased 
26% between 2005 and 2006. 
There is an 87% increase in this 
number when Q2 2007 data is 
extrapolated for the whole year. 
This phenomenon of more people 
seeking TB diagnostic care from 
the Puskesmas has not translated 
into increased CDRs* except in 
Pandeglang district. However, 
since MITRA works in only 25 of 
the 107 Puskesmas areas, results 
cannot be attributed solely to 
project. 
*CDR and other TB indicators are 
described under quality assurance 
section. 
2.1.c. KPC Findings 
A Knowledge Practice and Coverage (KPC) survey using the 30 x 10 cluster sampling 
technique was carried out parallel to the qualitative evaluation. Enumerators gathered 
information from 330 (age greater than 17 years) respondents and the survey covered 
1629 household members. 
Some of the key findings are detailed in table number 2. 
Table 2: Key TB Knowledge Indicators in the Community 
Variable Baseline 
(2005) 
MTE 
(2007) 
Other 
Sources* 
Has heard about TB disease Not asked 88.2% 92.4%
Knows that TB is curable 86.5% 93.7% 88.2%
Aware of TB symptoms+ 30.8% 50% 24.8%
How is TB transmitted? #
Cough & Sneeze 37% 44% 51.1%
Touching of patient 8% 8% Not Available
Transmitted through food 22% 11% 62.6%
 12
 
Sharing of utensils - 36% Not Available
Sexual Intercourse 0.6% 2% Not Available
Others 9% 21% 15.6%
Don’t Know 21% Not Available
*TB prevalence survey 2004 (NIHRD – Indonesia MOH); 
+MITRA (as does the national survey) defines it as productive cough > 3 weeks as the symptom; 
# Difficult to compare as TB prevalence survey classifies responses as fully correct, not fully correct and incorrect. 
KPC does not clarify how many respondents mentioned only the correct answer (exposure to sputum - cough or sneeze) 
The findings suggest that there have been positive changes in the knowledge level of the 
community with regards to certain key information points on TB especially their 
knowledge regards common symptoms of TB. 
About 12% household members were reported to have productive cough suggesting 
continuing higher prevalence of TB. Whereas the 2004 TB prevalence survey in 
Indonesia found that 7.7% respondents (in Java-Bali area) had either cough for more than 
a month or hemoptysis. 
2.1.d Qualitative Evaluation Findings 
1) Knowledge 
The qualitative evaluation teams found that most of the patients and community members 
knew about TB. They knew that TB is a disease and that it is curable. Many cited 
prolonged cough, fever and loss of weight as the symptoms of TB. Although most 
thought that TB spread through exposure to cough, they also thought that TB could be 
spread through sharing food with the patients. While patients knew that they had to cover 
their mouths while coughing; and dispose sputum hygienically to prevent the spread of 
TB; community members in addition to the above mentioned good air and nutrition as 
means of preventing TB. 
Both patients and community members knew that drugs had to be taken regularly for 
periods between six to eight months. Although most respondents had heard of HIV, only 
one or two could explain the relationship between HIV and TB. Again very few had 
heard of MDR TB. 
Patients reported getting TB messages from television, radio jingles, through Kaders and 
in Koran recitation meetings. Very few reported seeing any material other than leaflets 
and they saw flipcharts during meetings conducted by MITRA staff. Patients said they 
did not receive much information at the Puskesmas and had rarely seen IEC material in 
these centers. 
2) Treatment Seeking Behavior 
Most patients reported going to the Puskesmas for treatment following four to five weeks 
of symptoms. This is perhaps because project works in the poorer communities of the 
districts (prioritized project areas for the first year of implementation). Some of them 
however, though they claimed that they could not afford it, preferred using the services at 
private clinic as they believe that the drugs provided by the private provider are better in 
quality. Very few people reported going to the traditional healer (Dukun) first as they 
were closer and cheaper. Interestingly most focus group members said that more or equal 
 13
 
numbers of women as compared to men suffer from TB. However there were no 
differences in treatment seeking behaviors between the two sexes. 
Many focus group members reported having undergone sputum tests for diagnosis, but 
could not specifically mention the details of follow up sputum test requirements. Many 
reported having undergone X-Ray examination as well. Patients spend nearly four to five 
US dollars for an X-Ray examination. The expense for the trip to Puskesmas was also 
stated as being prohibitive. In addition patients pay a registration fee at the Puskesmas, a 
nominal amount of USD 0.30. However, focus group members in Jatiuwung Puskesmas
area (Tangerang city) reported paying for drugs as well. No other focus group reported 
paying money for drugs and everyone was aware that the drugs are provided free of cost 
in the Puskesmas. 
Although the population in the project districts has grown on an average by 2% annually, 
the proportion of patients approaching Puskesmas and being investigated for TB has 
increased tremendously – 26% increase between 2005 and 2006. Extrapolating from data 
for the first two quarters of 2007, this increase in 2007 would be 48% over 2006. This 
phenomenon of more people seeking TB diagnostic care from the Puskesmas has not 
translated into increased CDRs except in Pandeglang district (detailed in quality 
assurance section). However, as MITRA works in 25 out of 107 Puskesmas areas, this 
cannot be attributed to project efforts alone. 
3) Treatment Adherence 
Most patients reported receiving ample support from their CBTO (who is generally a 
family member) and from the CBTO coordinator or Kader. The supporters were credited 
with inspiring the patients to consume drugs, accompany them to the Puskesmas and at 
times bring back drugs from the Puskesmas. Many forms of incentives are available to 
the patients for adhering to and completing treatment. These range from food (noodles 
and rice from WFP in Tangerang city) to transport cost reimbursement (in Cilegon city). 
These were much appreciated by the patients. The project is committed to carrying out 
operations research on the impact of existing enablers/incentives on CDR and TSR, 
however, this has not been carried out as yet. 
“I must not stop taking medication; if I do then I will have start all over again.”-Patient 
in Kota Tangerang area
There is a huge demand for treatment centers closer to the community; the prohibitive 
expenses of seeking treatment being one of the two main reasons for discontinuing 
treatment. Patients suggested that the CBTO coordinator or the Kaders should stock the 
drugs so as to facilitate adherence and completion of treatment. The other most 
commonly cited barrier to treatment adherence was side effects. Patients have to 
approach the TB staff in the Puskesmas to resolve side effects related issues and many 
times stop the intake of medicines without approaching the doctor. The trainings for 
CBTOs and their coordinators include sessions on familiarity of side effects. However, 
they need to refer patients to the Puskesmas for further management for all the side 
effects except discoloration of urine caused by Rifampicin. 
4) Stigma 
 14
 
Most patients did not perceive any overt stigma from the community members and felt 
they were treated no differently because of their tubercular status. Community members 
however said that there was a subtle stigma attached to being a tuberculosis patient and 
some admitted that if they were to get the disease they would hide the fact from others. 
This however did not seem to affect treatment seeking among the community. 
“TB can be spread via plates, glasses and spoon and by using shirts of the patients” 
Community member, Labuan Puskesmas area, Padeglang 
5) Pediatric TB 
There were at least one or two care takers of pediatric patients in each FGD group. 
Children who are in close contact with a patient; have a family member who is a patient; 
or are malnourished (under the -‘red line’- of for underweight) were found to be referred 
to the Puskesmas for diagnosis and treatment by Posyandus. An unusual finding was a 
child aged four years, who was found to be on treatment for the last three years according 
to the grandmother. The reasons for this prolonged treatment need to be investigated 
further by MITRA. Some of the Puskesmas were found to have more pediatric cases than 
adult cases, raising the question of over diagnosis. This is further discussed in the section 
pertaining to health facilities. 
2.1.e Community Based Structures and Individuals 
The variety of community based structures identified by MITRA was detailed in the 
previous section. Progress made against monitoring indicators is presented in Table 3. 
MITRA has identified and trained 956 kaders, 471 CBTOs and 152 CBTO coordinators 
in the project area. It should be noted here that many of the CBTO coordinators are 
Kaders. While the first two categories (Kaders and CBTOs) have been given one day 
orientation in DOTS, the latter (CBTO coordinators have undergone a training of trainers 
for 3 days. 
Table 3. Indicators to measure performance of community based structures 
PERFORMANCE 
INDICATORS 
OCT 05 TO SEP-07 COMMENTS 
At least 1,284 (25%) of 
village based institutions like 
the integrated nutrition and 
health posts - Posyandus
(total number 5,136) in 
project area are disseminating 
TB information. 
113 posts in 26 
villages, 6 sub-districts 
The qualitative evaluation team 
found that Posyandu Kaders
(volunteers) were well trained and 
were disseminating messages to the 
community. There are 5-6 Kaders in 
each Posyandu. One of these has 
been trained as a TB Kader. These 
Kaders were actively referring 
suspected patients to the Puskemas
for diagnosis; and supporting 
patients to complete treatment. 
However they did not have any IEC 
material available to aid their 
counseling and group discussion 
sessions. 
 15
 
At least 710 (15%) of all 
places of worship (total 
number 4,736) in project area 
communicate monthly 
message on TB/DOTS 
24 religious groups 
(places of worship) in 
21 villages, 14 sub￾districts 
The Kaders and CBTOs trained by 
the project were found to be taking 
the lead in utilizing the Koran 
recitation meetings for discussing 
TB related messages. Project 
monitoring reports however do not 
capture the number of such meetings 
conducted or the issues identified 
and resolved. Again due to overall 
lack of IEC material in the area, 
these meetings were found to be 
relying on group discussions as 
means of communication. 
At least 285 (30%) of (total 
number of 953 midwives) 
especially those (Bidan Desa) 
who work at village maternal 
and reproductive health 
centers at (Polindes) and 
other identified village health 
center workers, oriented or 
trained on DOTS 
134 midwives in 22 
health centers
(Puskesmas) areas 
Trained Bidan Desa were actively 
disseminating the messages, 
referring suspected patients, 
specially those malnourished 
children who were not improving 
despite nutritional interventions. 
Communities were found to have 
more Bidans than those posted at the 
polindes. These Bidans have private 
practices and are expected to be 
seeing suspected TB patients, due to 
their close proximity to the 
community, especially in 
Pandeglang, which does not have 
any private clinics. Project has an 
opportunity to bring these Bidans
into the fold of DOTS. 
By the end of the project, at 
least one new village 
committee or existing CBO in 
each selected project area 
(Puskesmas level) has the 
capacity to organize the 
community to implement 
community-based TB control 
activities
Need to revisit this 
indicator. Please see 
comments for reasons. 
CBOs at community level include 
the Posyandus. Therefore this 
indicator subsumes the first indicator 
in this table. Other CBOs available 
in MITRA area are: Polindes, 
Paguyuban, PKK, Health 
Committees and local governments. 
MITRA actively involves local 
governments at village (in rural areas 
- Desa) and Ward (in urban areas - 
Kelurahan) level. Members of Desa
and Kelurahan developmental 
agencies have been oriented to 
DOTS and TB control issues. 
PKKs have been oriented and trained 
by MITRA and are actively 
participating in disseminating TB 
information and supporting patients. 
Very few village health committees 
(under the HSP program) have been 
 16
 
formed and recently, hence MITRA 
has not been able to intervene to the 
desired extent here. However, 
MITRA has involved health 
committees formed under CARE’s 
BERSIH project. 
MTE teams met with various cadres of community level volunteers and groups and 
through focus groups tried to understand their roles and capacities. All volunteers were 
found to have good knowledge of TB, its cause, modes of spread, modes of prevention 
and importance of regular and completed treatment. They were found to be actively 
supporting patients – accompanying them to Puskesmas, following up on the regularity of 
treatment, preventing default and ensuring treatment is completed. They were cognizant 
of the side effects and were found to be referring the patients to the Puskesmas for 
appropriate interventions. Detailed sessions on side effects and the actions needed to be 
taken formed a part of trainings of the volunteers who act as CBTO coordinators. 
Different districts have different incentive systems and some involve incentives to the 
CBTOs and volunteers as well. These come in the form of transportation charges or food 
packets. As described before very few CBTOs or volunteers have IEC material which 
affects the quality of their communication, especially with a new audience. Most 
volunteers were found to be well connected to the Puskesmas. This coordination between 
community volunteers and the Puskesmas have the scope for improvement from the 
perspective of Puskesmas and should be structured for measuring the sustainability of 
efforts. 
Most awareness sessions in the community are held at the Posyandus. These are the 
integrated nutrition and health posts at community level. While the set up of the 
Posyandu and its monthly gatherings provides an opportunity in terms of attendance by 
community members, the Kaders are busy with growth monitoring and immunization 
activities at the same time. 
The presence of trained community volunteers means that a suspected patient will receive 
appropriate advice; however, the possibility of having a regular dissemination of TB 
information through this post needs to be measured. The project assumes that TB 
information will be shared with the community but is not currently monitoring outputs 
from the community volunteers to ascertain this. Simple formats were developed in Jan 
2007 for this purpose but have not been utilized as yet. The project team informs that all 
FOs have been familiarized with the formats as of August 2007. 
The volunteers are utilizing various community gatherings (for instance - Koran 
recitations meetings) to talk about TB. Further owing to the fact that they belong to the 
community, they are accessible to suspected patients and are aware of local patients on 
treatment. 
MITRA has facilitated the formation of community level groups which consist of current 
and ex TB patients, their family members (many of them are the treatments supporters), 
 17
 
Kaders, and PKK members (association of wives of local leaders). Four such groups have 
been formed in Pandeglang (3, of which one is a TB post, discussed in detail in the next 
section) and Tangerang district (1). The need for the association emanated from the lack 
of any cohesive community structures dedicated to TB. These associations meet monthly 
and discuss problems associated with treatment and TB related information. The Kader 
utilizes the opportunity to follow up on current patients and discuss support requirements. 
This also provides an opportunity for the Kader to learn about any community member 
who has been suffering from a prolonged cough or is suspected of having TB. The 
participation of the PKKs provides the issue of TB a developmental platform. 
In addition MITRA built on the existence of Paguyuban TB in Cilegon. This Paguyuban
first formed in by the Pulo Merak Puskesmas has done exemplary work in supporting 
patients visiting the centers. Members get together on TB days (eg. Monday/Wednesday) 
at Puskesmas and disseminate TB related information. They have been active in TB day 
campaigns and recently have been registered as a Community Based Organization (CBO) 
and acknowledged by the local government at the sub-district level. Owing to its success, 
MITRA facilitated the formation of four (three in Cilegon and one in Tangerang City) 
more Paguyubans in partnership with Dinkes. MITRA plans to facilitate expansion of 
these groups. 
These are excellent examples of community involvement in supporting TB treatment, 
disseminating TB information and reducing stigma by opening up discussions. The 
groups can be strengthened to take a greater responsibility for networking across the 
community and expanding awareness activities. 
MITRA has initiated collaboration with Village Health Committees (VHC) formed under 
USAID’s HSP and managed by Tangerang and Pandeglang District Dinkes and VHC 
formed by CARE’s BERSIH Program. MITRA has started by developing a set of training 
modules (basically improving the existing CBTO-supervisor modules), which consists of 
4 modules for DOTS and TB (diagnosis & treatment, monitoring patients), 
communication skills for IEC, and community TB activities for the VHC members. So 
far MITRA has worked with one VHC formed by HSP at Rawakidang village, Sukadiri 
sub-district, Tangerang district. There are 12 VHCs in Tangerang district and 12 VHCs in 
Serang district (which is outside MITRA working area). 
Lack of IEC materials restricts the activities which can be undertaken currently and 
absence of monitoring system has resulted in project’s inability to measure the outputs 
and outcomes of such groups. 
The rapid expansion of these groups with support from local NGO partners and 
development of linkages between these groups and Puskesmas staff will ensure that 
sustainable community level structures are available for continuing treatment support and 
behavior change. 
 18
 
2.1.f Recommendations 
1. Expand activities to cover more than 25 Puskesmas areas. Sign MOU’s as 
planned with able local NGO/CBO partners to achieve expansion 
2. Build on successful experiences of community groups and Paguyubans. 
3. Improve information sharing with Puskesmas through structured methods for 
better utilization, monitoring and sustainability of strengthened community 
structures and individuals. 
4. Remove the indicator “100% increase (from 30% to 60%) in knowledge of 
symptoms of TB and its curability in the community” as this is already captured 
in two other indicators and is merely repetitive. 
5. Rephrase indicator “at least 20% increase in the number of TB suspects from 
6,560 in 2005 to 7,800 by September 2009 combined for the 4 districts.” – to read 
“ at least 40% increase in number of suspected TB patients reaching or screened 
by Puskesmas in four project districts from 27,953 in 2005 to 39,134 in 2009.” 
6. Carry out the committed operations research on impact of incentives on CDR. 
7. Follow up the identified child in Waliwis village and investigate the reasons for 
continuing treatment even after three years. 
8. Utilize the simple monitoring formats to measure outputs and outcomes of 
CBTO/Volunteer activities. 
Please note that the BCC related recommendations are covered under the BCC section. 
2.2 Strategic Objective 2. To strengthen the delivery capacity of the district and 
provincial TB program
2.2a Planned Activities 
The key activities planned to achieve this objective include capacity building; and 
coordination/advocacy for quality assurance (including drug availability and slide cross 
checking). The capacity building activities were aimed at developing a cadre of CBTO 
coordinators (called treatment observers supervisors in DIP) in selective geographical 
areas of the project; in partnership with the Puskesmas create TB posts, which are closer 
to the community; and train identified Puskesmas and Dinkes staff in DOTS. To ensure 
that the components of DOTs not addressed directly by the project (continued political 
commitment and availability of quality assured, uninterrupted supply of drugs) and the 
components of DOTS which the project chose to support without direct control of the 
project (quality assured sputum examination for diagnosis), MITRA planned coordination 
and advocacy activities. The MITRA plans include: 
• Identify and ascertain the reasons for high error rates; and train Puskesmas laboratory 
technician who are not preparing the slides for regular cross checking
• Coordinate with KNCV/NTP to ensure availability of drugs, microscopic facility and 
other infrastructural inputs into DOTS program
 19
 
• Participate in TB partners forum 
• Regularly meet and discuss project issues with stakeholders at National level 
• Identify and solve program problems with counterparts at provincial and district level 
2.2.b Effectiveness of interventions - Development of New Cadre: CBTO 
Coordinators 
Table 4 Capacity Building of CBTO coordinators – Output Indicator for SO 2 
Output Indicators Oct 05 to Sep-07 Comments
In identified poor 
performing areas 100% 
PMO supervisors 
(minimum number 100) 
receive training in 
counseling and 
supportive supervision 
skills 
152 treatment 
observers’ 
coordinators 
(supervisors) 
MITRA has exceeded targets and has done 
well in developing the much required 
community component in the poor performing 
areas. MITRA has identified one of the Kaders
to act as CBTO coordinator at each Posyandu 
in the 25 poor performing Puskesmas areas, 
where project was initiated. They have 
received three days training on DOTS and 
communication skills. The development of 
this training manual received assistance from 
CARE Atlanta’s health interns 
The CBTO coordinators have an important role to play as most CBTOs are family 
members although oriented to DOTS through MITRA efforts. The coordinators follow up 
regularly on treatment adherence, sputum checks and problems, either through the 
Posyandu meetings or through community visits. This is a good mechanism for providing 
support to a TB patient, especially because current prevalence levels (even when they are 
high) mean that there are only one or two patients in a community and it is resource 
intensive to train one person in each community to act as a CBTO. The success of a 
community member acting as a CBTO is further dependent on this person’s interest in 
supporting the patient. A family member on the other hand is interested in the well being 
of the patient and can be monitored through the mechanism of a CBTO coordinator who 
has undergone in depth training. Furthermore the coordinator provides continuing support 
and education to both the patients and the CBTO (family member). 
“I wanted to stop treatment. I was very tired and depressed. I have been able to complete 
my treatment owing to the support of the Kadre and my sister who is my treatment
observer.” – Patient in Waliwis Puskesmas area, Tangerang District 
MITRA has done well in developing this cadre in poor performing areas. The 
coordinators along with the CBTOs are creating community level awareness about TB 
control as reported by the MTE team. Though MITRA has committed to this activity in 
 20
 
poor performing areas, it should consider replicating this model across the project area, 
even if on pilot basis and disseminate the success at Puskesmas and Dinkes level. 
2.2.c Effectiveness of TB Posts 
In addition to creating the cadre of CBTO coordinators, MITRA facilitated the formation 
of TB posts. These are seven DOTS TB drug distribution posts of which three are active. 
Six are established by MITRA and one by PKM. One TB post is in Kabupaten 
Tangerang and the rest are in Pandeglang district. Once the patient is registered and drug 
boxes requisitioned, the patient box is transferred to the TB post. The patients visits this 
community based facility to consume and collect drugs. This strategy overcomes barriers 
pertaining to transport costs and allows for closer monitoring of patients through trained 
facility workers. The post is managed by a trained paramedic or the TB officer and is 
open on scheduled days of the week. Some of the posts’ even help carry the sputum 
samples of patients to the Puskesmas. 
2.2.d: Effectiveness of Capacity Building at Puskesmas
Table 5. Progress on Puskesmas level Trainings – Output Indicators for SO 2 
Output Indicators Oct 05 to Sep-07 Comments 
100% of District TB Supervisors 
total number 5 (Wasor) are re￾trained in TB DOTS 
programming 
Nil 
This indicator was included to 
reflect a specific request made by 
Dinkes during DIP preparation. 
However, later Dinkes requested 
that CARE not carry out these 
trainings as they would be 
conducted through Global Fund 
to fight TB AIDS and Malaria 
(GFTAM) budgets. These have 
been however not carried out by 
Dinkes owing to temporary 
cessation of GFTAM funds. 
100% of all doctors, nurses TB 
officers, and laboratory 
technicians in 107 government 
health centers (excluding those 
who are already trained) 
oriented/trained in TB DOTS 
37 doctors, 16 TB 
officers, and 14 lab 
technicians of 17 
Puskesmas oriented to 
DOTS through one day 
workshops 
Similarly the project was not 
allowed to carry out planned one 
day orientations to additional 
Puskesmas staff. Project however, 
trained a few before Dinkes
requested that CARE not to carry 
these trainings. 
75 (70%) of TB-Leprosy officer 
in designated health centers 
(Puskesmas) are trained in DOTS Nil 
Because the Dinkes requested 
CARE not to implement these 
trainings as they had commitment 
from Global Funds. 
 21
 
It was intended that all DOTS staff (TB and Leprosy Officers) and other non-technical 
staff in the Puskesmas and those in the periphery (Bidans and para medical staff) would 
be oriented to DOTS through one day workshops. The inclusion of training indicators for 
Doctors and Nurses means an intention to train them. MITRA, by increasing the number 
of oriented personnel at each Puskesmas hopes to overcome the problem of frequent 
transfers at the center. Having additional able staff also means that in the absence of the 
TB officer, patients receive guidance and education. At the time of DIP, NTP had plans 
to train doctors through NTP/WHO training modules. MITRA however incorporated 
indicators to reflect that the doctors and the lab technicians would also be oriented to 
DOTS. While orienting non-technical staff to DOTS ensures better referrals into the 
DOTS, one-day orientation to doctors who may not have undergone the national 7-day 
training does not build the capacity of technical staff to dispense medication, monitor 
patients or help with reporting and does not ensure that DOTS programs continue 
seamlessly when a trained staff is transferred. As the NTP clearly requested CARE to 
refrain from the technical trainings for the Puskesmas staff, it is best to consider dropping 
this indicator. 
Besides, managing a DOTS program requires not only technical training but also 
managerial capacities which were not envisioned as a part of capacity building strategy 
during design of the project. A training needs assessment was carried out by MITRA in 
collaboration with NTP and various medical/professional organizations (IDI, PDPI, 
PPNI, IBI). However the needs assessment did not enquire into the managerial 
capabilities of the providers. MITRA recognized this aspect and suggested to Provincial 
Dinkes a 5day management supervision training for Wasors. This was rejected both by 
the Province and Dinkes of Tangerang city because KNCV had done this training 
throughout Banten from 2004 – 2006, and the Province was planning to hold refresher 
trainings conducted by the NTP and funded by the Global Fund in 2007. 
MTE teams found that there are issues pertaining to management of DOTS across the 
Puskesmas and the Dinkes. The quantitative data for health facility assessments are 
detailed in the Capacity Building section. 
Drug Management: By the policy of NTP, no buffer stocks are held in the Puskesmas. 
Drugs are requisitioned once the patient is registered. It takes a week to a month for the 
drugs to arrive at the Puskesmas. Some Puskesmas were found to be dipping into 
designated boxes of registered patients to treat newly registered patients, to overcome the 
delay in receipt of drugs from the Dinkes. Most Puskesmas have not put patients on 
Category II as Streptomycin has not been easily been made available to them. According 
to TB officers interviewed category II patients are put on Category I drugs. Discussions 
with Dinkes and Wasors revealed that there is a dearth of Streptomycin; however this was 
not cross checked by the MTE team through a visit to warehouses. NTP at the national 
level informed that drugs were indeed available and that no warehouse has seen stock 
outs. NTP also informed that Puskesmas lacked the capacity to increase the CDR, do not 
capture Category II patients, hence do not requisition for the drugs which are evidently 
available at the national/province level. 
The delay in provision of drugs to a diagnosed patient can give rise to the possibility of 
initial default – that patients default even before being put on treatment. This is being 
recognized as one of the reasons for CDRs not increasing beyond a point in other parts of 
the world. Although this point is being made in retrospect and was not investigated in the 
 22
 
field, this forms a good indicator of quality of services which the NGO has direct control 
over. 
IEC material: Similarly while IEC materials were found to be available at Dinkes, they 
haven’t been requisitioned either by the Puskesmas or by MITRA. MTE teams did health 
facility assessments in 26 out of the 107 Puskesmas across four project districts. Fifteen 
out of the 26 Puskesmas visited did not have any IEC material on display. 
Lab related issues: Lab reports continue to be late. Though more labs have started 
reporting, not all labs submit reports on time. Some lab officers in Pandeglang Puskesmas
have not been trained and some are not analysts. Currently there is one trained sputum 
analyst out of nine posted. Due to the high staff turnover of around 30% a year the 
number of technicians that need to be trained remains high. Details of the lab 
assessments carried out during the MTE are covered in the health facility assessment 
section. 
Pediatric cases: There seems to be a possibility of over diagnosis of pediatric cases. In 
Puskesmas Jatiuwung, in Tangeran City, nearly one third of the patients on treatment 
were children. There were 67 children on treatment against 46 Category I adults and 84 
Category III adults. A pediatric score card was launched nation wide through revised 
NTP guidelines and these were released in Aug 2007 and have not gained familiarity in 
the Puskesmas. It was expected that prior to the introduction of this score card (detailed 
in the DIP) there would be a situation of over diagnosis. 
Table 6 Performance Level Indicators for SO 2 
Performance Indicators Oct 05 to Sep-07 Comments 
2.1 New DOTS centers or TB 
posts opened at 60 villages 
(community level), for 
example, at the sub-centers, 
midwife centers, and village 
health posts 
4 TB post in 4 villages 
Three of these have been created by 
MITRA. MTE found that the fourth 
has been running for four years and 
is managed from the residence of a 
Puskesmas TB officer. MITRA has 
actually created 7 TB posts of which 
three are active. 
2.2 100% of Puskesmas (total 
number 88*) had smear slides 
for cross checking collected by 
the District Wasors regularly 
It is difficult to 
conclude on this 
indicator with the 
available data. Please 
see comments. 
MITRA planned to work with 88 
Puskesmas with lab facilities. While 
the las assessments carried out 
during the MTE revealed that 100% 
labs visited kept slides for cross 
checking and that these were picked 
up by the Wasor, the provincial 
level TB data reveals that except 
Cilegon city, information for cross 
checking of slides is not available 
for all labs on a quarterly basis for 
years between 2005 an 2007 (Q2). 
However, the number of labs 
sending slides for cross checking 
has increased over the last two 
years. 
2.3 Special indicator for 25 of 34 (73.5%) At baseline 13 Puskesmas were 
 23
 
Pandeglang district** 100% 
DOTS coverage (34 health 
centers) 
delivering DOTS services. This has 
increased at mid term. MITRA has 
contributed by orienting the 
Puskesmas staff to DOTS and 
formation of three TB posts. 
Note: * Only 15 health centers in Pandeglang will be covered 
** All other districts have 100% DOTS coverage
To enable the creation of TB posts across the project, and provide quality DOTS care 
MITRA will need to consider building managerial capacities at Puskesmas level. 
2.2.e Advocacy Related Progress 
Recognizing the need for comprehensive support for the five-pronged DOTS strategy, the 
project committed to coordinating with all relevant stakeholders to identify, discuss and 
bridge gaps in DOTS delivery at the provincial and district level. This intervention was to 
ensure that issues like drug availability, diagnostic quality and training needs are 
addressed as and when they affect the project. At the district level, the project and project 
functionaries are to interact with the District Health Officer, who is responsible for all 
medical and public health activities; and the Wasor who is responsible for the 
organization of TB activities in the district. At the sub-district/health center (Puskesmas) 
level CARE is to interact with a team of Medical Officer designate, lab Supervisor and 
Treatment Observer Supervisors, to monitor the quality of the program, build capacity of 
community partners, NGOs, and Private Practitioners, and implement treatment 
activities, e.g. timely diagnosis of cases and supply-related issues. Some of the staffing 
positions detailed above may or may not be present in all Puskesmas. 
However, MITRA has not been able to resolve identified problems (detailed in previous 
sections) through its coordination efforts. 
Table 7 Advocacy related Output Indicators 
Output Indicators Oct 05 to Sep-07 Comments 
2.1 100% (4 per year) attendance 
of WHO-sponsored TB 
Partnership meetings at National 
level 
8 meetings attended 
2.2 100% (2 per year) attendance 
of TB Partnerships meeting in 
District and Province level
3 meetings attended 
2.3 At least one monitoring and 
evaluation meeting in each year 
attended by NTP, Province TB 
Team, District TB Team, KNCV, 
and other TB partners 
2 meetings conducted 
The attendance at these meetings 
have not been utilized to 
successfully address the 
identified problems in DOTS 
implementation throughout the 
project area 
 24
 
It can be concluded that MITRA needs to rethink its capacity building strategy for the 
Puskesmas staff and make a concerted effort to identify problems in a timely manner 
seeking solutions at district, provincial and national level.
2.2.f Recommendations 
1. Build on success of CBTO coordinator capacity building strategy 
2. Rethink the trainings that MITRA wants to give at Puskesmas level. Who will be 
trained? What will be the content? How will this be done? 
3. Drop the indicators pertaining to training of Puskesmas staff. 
4. Consider managerial and leadership training for Puskesmas staff if NTP restarts 
technical trainings for them through the latest round of GFTAM funding. 
5. Jointly with Dinkes, investigate the use of recommended score cards for pediatric 
diagnosis to identify reasons for over diagnosis and train providers to address the 
situation (either through MITRA funded trainings or through NTP). 
6. Through regular analysis of monitoring reports and field feedback, identify 
drug/lab/reporting issues and advocate for resolutions at appropriate forums. 
Advocate for resolution of issues related to sharing of drug boxes and 
unavailability of streptomycin at provincial and national level. 
2.3 Strategic Objective 3: To increase private sector participation in the TB 
program.
2.3.a Planned Activities 
Planned project activities to promote and improve participation of Private Practitioners 
(PPs) are: 
• In line with MOH and IDI (Indonesian Association of Doctors) strategy train PPs as 
per International Standards for TB Care (ISTC) 
• Regularly attend quarterly IDI meetings to enable enrollment of PPs into the training 
program 
• Provide the doctors with WHO/KNCV/NTP designed literature like, treatment 
algorithms, disease diagnosis, classification and the treatment regimens in 
information capsules in the form of flyers and posters. 
• Link them with nearest government health center and support identification treatment 
observers in the community. 
• Facilitate reporting of patients and defaulters to health centers 
• Strengthen capacity of health centers staff to partner; provide support in prompt 
follow up on defaulters through community based treatments supporters and 
volunteers. 
• Identify industrial clinics, orient them in ISTC, support implementation of DOTS and 
promote TB BCC employees. 
 25
 
2.3.b Effectiveness of Capacity Building for Private Providers 
Table 8. Progress on Indicators for Private Participation 
Output Indicators Oct 05 to Sep-07 Comments 
At least 330 (30%) of 1,102 
Private Practitioners (physicians) 
receive International Standards of 
Tuberculosis Care (ISTC)/DOTS 
orientation 
27 
Project behind schedule. 
PPs are oriented to ISTC guidelines. 
There is no training manual which 
addresses issues ranging from 
technical protocols to how to partner 
with Puskesmas and link with the 
community. PPs await the second 
round of trainings to enable their 
linkages with the above-mentioned 
partners. Furthermore PPs have 
received copy of ISTC guidelines, but 
have not received any handouts or 
IEC materials. 
Project has plans to incorporate these 
in their upcoming workshops. 
At least 125 private hospitals and 
clinics management team receive 
ISTC/DOTS orientation 
Nil 
Project behind schedule. Initial 
interactions with hospital 
managements have taken place. 
Identify, orient and help 
implement in at least 20 industry 
clinics on ISTC/DOTS 
Nil 
Project behind schedule. Initial 
interactions have been held this year. 
The MOH through NTP is highly committed to the involvement of PPs in providing 
DOTS. District Dinkes have been organizing several training programs for both 
individual practitioners and industry clinics/hospital staff. Tangerang Kabupaten Dinkes
officials informed the MTE team that the district had trained 80 PPs this year. However 
there are constraints involved in enrolling the PPs. This year the Dinkes of Kota 
Tangerang invited 150 PPs of whom 30 attended trainings and a mere 5 committed to 
participating in DOTS. The orientation sessions take a day, which keeps the PPs away 
from practice for a longer duration that they desire. KNCV has been using lunch sessions 
for orienting PPs, an initiative which will perhaps overcome the problem of low 
attendance in these trainngs. 
 26
 
The Dinkes has introduced a Memorandum of Understanding (MOU) between committed 
PPs and the MOH. This details the roles and responsibilities of both parties. While the 
role of MOH/Dinkes/Puskesmas is to provide training, drugs for each registered patient, 
IEC material and support with follow up of default patients; the role of PP is to report 
each patient to the Puskesmas, also defaulters for follow up and retrieval and display IEC 
material along with the fact that the drugs are free of cost. 
Many of the PPs are government doctors who by law are allowed to practice after their 
duty hours. These are the doctors who have been targeted first. MTE teams met trained 
PPs, some with and some without these MOUs. All of them understand the importance of 
DOTS in controlling TB and face problems with default retrievals. They feel the need for 
support from the Puskesmas to link patients with treatment supporters and default 
retrievals. 
They also expect to receive IEC material from MITRA/MOH to promote BCC. Those 
with MOUs also face a problem with delays in drug receipt. It takes them a week to 
receive drugs from the Puskesmas following patient registration. This is because, as 
described before even for patients treated in Puskesmas, drugs have to be requisitioned 
from Dinkes, as per NTP policy. 
“The General Practitioners understand DOTS – but we find it difficult to implement it. 
We need cooperation of the community” – Private doctor from Tangerang District
MOH has been able to successfully enroll some larger hospitals and industrial houses into 
ISTC orientations. 
Parallel to the MTE, MITRA held an orientation for PPs in Cilegon City. The interesting 
aspect of these trainings were sessions on strengthening partnerships with Puskesmas and 
through them with the community and modalities of managing reporting and default 
retrieval. 
2.3.c Recommendations 
• Since MOH has been training more private practitioners and has allocated budgets 
for the purpose, MITRA can dove tail these efforts by providing quality 
enhancing inputs – put together a training manual in consultation with IDI and 
KNCV; help develop training sessions to include action plans, partnership 
modalities, available community support; put together a kit of treatment 
algorithms, ready reckoners, IEC material and handouts with information on 
community/Puskesmas contacts. 
• In collaboration with local Dinkes develop a simple monitoring format for issues 
not covered by existing TB formats – support required, problems faced – which 
can be used by the PP to communicate with the Dinkes and Puskesmas. 
• Consider splitting the entire training into one hour lunch hour sessions to increase 
the participation of PPs. 
• PPs are willing to network with their peers. Utilize this willingness to enroll more 
PPs. 
 27
 
• Dovetail MOH relationship with hospitals and industrial clinics and offer to bring 
on board the above-mentioned quality enhancing inputs. 
• Actively link up volunteers and CBTOs trained by MITRA with the PPs and the 
Puskesmas. 
3. Cross-cutting approaches 
Some of the background information and analysis for this section has been covered in the 
above sections. The following sections will build on them to avoid repetition. 
3.1 Community Mobilization 
Community mobilization activities
Strategic Objective one aims at creating new community based structures for TB 
control. These structures and individuals are being enabled to generate awareness 
and improved care seeking behavior in the community. 
The project works by building the capacity of the existing volunteers 
(Kaders/Bidans) and groups (religious and developmental – PKK) so as to 
achieve continuing community conversations on TB control. 
The Field Officers (FOs), having identified and trained these individuals and 
groups, carry out planned discussions with community members either through 
monthly Posyandu gatherings or through Koran recitation meetings. Each meeting 
is supported by MITRA through provision of refreshments, commuting expenses 
to the Kader and training material (which may include copies of training manuals 
for CBTOs and IEC material). 
Most of the meetings are led by the FOs and it is assumed that some are organized 
by the active Kaders/PKK members; however, this cannot be quantified as project 
monitoring data does not measure outputs of volunteers. 
Community response to BCC activities 
FGDs with community members revealed that they are aware of TB and most 
believe that TB is curable. Communities could list important symptoms of TB 
(prolonged cough, blood in cough, fever, weight loss, lymph node enlargement). 
However, they expressed ignorance about the connection between HIV and TB 
and had never heard of MDR TB. Many misconceptions continue to exist about 
how TB spreads. Although most cite exposure to cough or sneeze (key message in 
the MITRA training modules) as one of the means, they also list, sharing utensils 
and sexual contact as means of spread. There is also a perception that severely 
malnourished children may have TB, which while partially correct, may be the 
cause for exceptionally high pediatric cases registered in the Puskesmas. Most 
admitted to going to Puskesmas as a first resort for treatment since MITRA works 
in poorer communities. 
 28
 
 
Focus groups in communities admitted to stigmatizing behavior towards patients, 
though interestingly the patients did not perceive this as stigma. Community 
members admitted to avoiding close contact with the patient, talking, sharing 
utensils and not inviting them to community gatherings. 
Some respondents expressed problems with the time consuming process of 
seeking treatment in the Puskesmas. More members reported X-ray as means of 
diagnosis as compared to sputum analysis, which reflects the continuing use of X￾rays for diagnosis in private and perhaps public sector. This is important because 
of the cost implication of x-ray examination to the patient. 
Most focus groups consisted of family members of TB patients, which may be the 
reason for the similarity in knowledge and perceptions. MTE teams also met with 
religious and community leaders and found similar findings. They also shared 
information about support provided to TB patients (transport charges, food 
incentives, forum for discussion of TB related information). 
The effort of Paguyuban, discussed in earlier sections, is commendable and is an 
excellent example of community participation in supporting TB treatment. 
Currently five such groups exist, one in Tangerang district and four in Cilegon. 
MITRA’s plans to facilitate the formation and strengthening of more such 
associations will indeed benefit the community and help improve quality of 
services in Puskesmas. 
Similarly community based groups of ex and current TB patients; Kaders, CBTOs 
and their coordinators, PKK members and community members is yet another 
example of mobilized community efforts. 
MITRA has initiated activities with village health committees formed under the 
USAID’s HSP and CARE’s BERSIH programs. There is a scope for expansion 
of TB control activities wherever these structures are available. 
It can be concluded that more people in the community are now aware and 
mobilized to support TB control activities, albeit the numbers of these groups are 
small and not across the entire project area. Misconceptions exist which need to 
be addressed through robust BCC interventions. 
3.1.1 Recommendations 
1. Expand activities to cover all project areas. Build on the success of 
Paguyubans and community groups. 
2. Sign MOUs with identified able local NGO/CBO partners to ensure transfer 
of expertise and expansion of activities. 
3. Plan to withdraw support to mature groups and develop simple monitoring 
formats to measure the outputs and outcomes of community activities. 
 29
 
3.2 Communication for Behavior Change 
3.2.1 BCC Strategy 
During the DIP process MITRA presented the key desired behaviors pertaining to TB 
control and the audience to be addressed through these messages. The BCC workshop 
along with finalization of a BCC strategy document was slated for October 2006. 
However, this was however not carried out as planned. A draft BCC strategy document 
was ready in time for the mid term evaluation and is attached with this report. This draft 
document is informed by and is in line with the NTP’s Advocacy, Communication and 
Social Mobilization Strategy (ACSM). MITRA has collated available IEC material 
(leaflets, brochures, flipcharts, posters, CDs of movies and radio jingles etc). These 
require adaptation as most of the print material is verbose and may not suit the 
requirements of the largely semi literate and illiterate community. Furthermore, the 
language used in these tools is Indonesian and is deemed quiet formal. The project 
communities mostly speak and understand the Sundanese language and have expressed a 
need for more informal content. 
3.2.2 Project’s BCC Activities 
Community level
In the absence of a BCC strategy document, the project staff have been using messages 
detailed in the DIP document; training manual for volunteers; and those presented 
through the NTP/PCI’s IEC material to communicate TB messages to the communities. 
Flip charts published by PCI’s TB project in Indonesia were identified as one of the key 
tools of communication. These are being used by the FOs. These were not reproduced 
pending the conduct of the BCC workshop. MITRA received another set of flipcharts 
from Persatuan Pemberantasan Tuberkulosis Indonesia (PPTI -The Indonesian TB 
Association). Nine of these flipcharts have been given to the volunteers trained by 
MITRA. The project received 200 additional copies of these flipcharts in June 2007, 
which were not distributed as they required amendments and adoption. These were not 
reproduced by MITRA and distributed to all volunteers and groups across the project 
communities. Furthermore, Dinkes staff informed the evaluation team members that they 
had ample stocks of IEC material, although these are distributed to the Puskesmas only 
when requisitioned. Most Puskesmas which were visited during the MTE had very few 
communication materials available in stock. MITRA has not made any attempt to utilize 
and disseminate the material available with the district Dinkes. 
 30
 
“When I counsel patients without BCC aids its like giving food without the sauce” -
Health officer at Bojong Puskesmas in Padeglang 
The current communication activities do not include messages pertaining to side effects 
link between HIV and TB and MDR TB. 
MOH level
Advocacy at Puskesmas, Dinkes and Provincial MOH level is done through 
monthly/quarterly meetings. DIP committed to the formation of a provincial coordinating 
committee with participation from relevant stakeholders like MOH, KNCV, HSP 
(USAID) MITRA, IDI/IDAI, District MOH representatives and Industry representatives. 
However this has not been formed and these meetings are attended by MOH officials and 
MITRA staff. Most meetings at the Puskesmas and district levels are led by mostly by 
Field Officers (FOs) and sometimes by Trainings Coordinators. Though monitoring visits 
and routine interaction at Puskesmas level may be carried out either by the FO or the 
Training Coordinator; protocol and culture in Indonesia demand that the interaction and 
problem-solving meetings at Dinkes are attended by the Project Manager. Although the 
FOs seem to manage the relationship well, they expressed the need for further support 
from their superiors. 
Private Practitioners
Project has been training Private Providers in the DOTS strategy but has not supported 
them with the provision of IEC material. This was one of the supports requested by the 
doctors interviewed by the MTE team. There is no articulated strategy to advocate and 
expand participation of private practitioners in the DOTS program. The key barrier as 
expressed by the project is the lack of government systems to deal with the integration of 
PP and DOTS. 
3.2.3 IEC Efforts by Other Stakeholders 
In addition to having an ACSM working group (members include: NTP, WHO, KNCV 
and Koalisi untuk Indonesia Sehat or Coalition for a Healthy Indonesia (KuIS – a local 
NGO), NTP has a developed a strategy for national mass media campaign and launched it 
on the world TB day this year. The campaigns ran between March and mid May and had 
to be discontinued due to the cessation of Global Funds. A variety of IEC tools were 
developed for this campaign – radio shows, jingles (based on the popular dangdut form 
of dance and song style), TV ads, posters for public and for Puskesmas, and health 
seminars. Project areas had the benefit of these campaigns as well. 
WHO in partnership with NTP has developed a Health Care Provider Communication Kit 
which was designed by JHU CCP. 
 
 31
 
A local Muslim Charity Organization (Dompet Dhuafa) hosted a biking event to generate 
awareness about TB during the World TB day celebrations this year, which received 
ample media coverage. 
3.2.4 Measuring BCC Outcomes 
Project captures ‘proportion of population who are aware of at least two symptoms of TB 
and know that TB is curable’ at baseline, mid term and end line. Project management 
information system captures number of community based organizations actively 
undertaking TB activities along with dissemination of information. Further it utilizes the 
monthly reports from Puskesmas to quantify the number of suspected TB cases seeking 
care, on treatment and completing treatment. However, MITRA does not collect any data 
to quantify number and coverage of BCC activities. 
3.2.5 Recommendations 
1. Conduct a workshop of all key stakeholders to finalize the draft BCC strategy 
2. Quickly adapt, produce and disseminate IEC material to community based 
partners and Puskesmas. 
3. Include messages on side effects, HIV – TB linkages and MDR TB to the 
appropriate extent. Address some of the identified misconceptions about TB 
(using same utensils will cause TB, TB is sexually transmitted, TB patient should 
be isolated) which generate stigma. 
4. Build capacity of the partners to use the material. 
5. Develop monitoring formats to quantify coverage with the tools and measure 
effectiveness. 
6. Partner with identified local NGOs to support BCC activities in the community 
7. Develop an IEC kit for the private providers who have partnered with MITRA 
and the DOTS program 
8. Utilize project monitoring data and NTP data to share, identify problems and 
resolve them at Puskesmas, district, province and national level 
9. Actively coordinate with NTP to be informed by and be able to contribute to the 
national ACSM activities. 
3.3. Capacity Building Approach
3.3.1 Strengthening the Grantee Organization
There has been substantial capacity building of the grantee organizations at all levels. 
In the field 
• The FOs and TC have received the standard DOTS TB training for one week. 
• Some of the FOs and TC were also trained in qualitative data gathering and 
analysis for the DOTS drop out study carried out in Banten Province. 
 32
 
• The project staff underwent a training of trainers’ course for DOTS TB. 
• Staff have also undergone exposure to specific trainings, like orientation 
training of PPs, MOH doctors, nursing staff and bidans and training of health 
post staff. 
• MITRA staff have been exposed during baseline and MT to qualitative and 
quantitative data gathering methods like FGD, IDI and KPC and its synthesis 
and reporting. 
• The PM underwent a CORE organized workshop for DOTS TB managers in 
2006. 
• A TC participated and shared MITRA work with the rest of the CARE CS 
team in 2007. 
In short the staff has benefited and learned about public health project implementation 
in general and DOTS TB in particular. The staff trainings are slightly behind 
schedule. 
At the HQ in Atlanta 
The backstop for HQ is a co-chairman for the TB working group in CORE and that 
relationship has enhanced capacities on either side. 
• The use of Elluminate was encouraged by CORE. The TB working group was 
led in its very first presentation on Elluminate by the CARE HQ TB backstop 
person, and now this has become a standard practice for the CORE -TB 
group. 
• A web course was designed for CBTO and shared with larger CORE TB 
group members and its on the CORE TB-Working group web site and is open 
to use by any PVO working on DOTS TB. 
• The new TRM for TB was updated through efforts of the CSTS+ and CORE 
TB working group and the final editing was done by the backstop person from
CARE HQ inAtlanta. Sections on XDR were included for the first time and 
section on MDR was updated. 
• In 2007, CARE presented a paper on training of CBTOs in Banten province at 
TB-ETN hosted by CDC. 
 
CARE HQ benefited from 
• Attending nearly all subsequent Elluminate sessions with the CORE TB 
working group which has greatly enhanced the knowledge of HQ. 
• A proposal written by CORE – TB working group as a joint bid for WHO for 
evaluation of DOTS TB programs was a very good experience to build 
capacity on writing joint bids. 
 33
 
• Through CORE TB working group sharing experiences of ACSM between 
different PVOs, documentation and finally a representation by CORE at WHO 
STOP TB platform was enriching. 
• Finally, the CORE-TB working group hosted a best practices and lessons 
learned workshop for the USAID TB PVO community. CARE HQ benefited 
from this exposure. 
The project has increased capacities in CII and HQs on DOTS-TB project 
implementation and management. The project is influencing work on TB in Banten 
Province and the CORE-TB working group to some extent. 
3.3.2 Strengthening Local Partner Organizations 
MITRA partners with the government, private health care practitioners and the 
community based organizations for TB control. 
a MOH and NTP 
The main partner for this project is the MOH and NTP program at Puskesmas, Dinkes
and Provincial Level. 
The NTP, launched in 1979, is delivered through a well designed organization 
framework, which has been detailed in the DIP. The district level health services are 
regarded as the basic unit for TB control in the country. Microscopic facilities for TB 
control are available at the district hospital, microscopic health centers and independent 
health centers. Treatment services are provided at all these facilities. The treatment 
register for the entire district is maintained by the tuberculosis officer or the district TB 
coordinator called "Wasor", who regularly visits all facilities to collect data, collate and 
report treatment and notification outcomes. The Wasor also ensures communication 
between various facilities and ensures drug supplies. 
In a recent policy, following suspension of GFTAM funds, drug boxes are made available 
to Puskesmas by the Dinkes upon registration of the patient. Puskesmas send a request to 
Dinkes with the sputum and investigation reports of the patient. It takes between a week 
to a month (quicker in the two cities) to receive the drugs from the Dinkes. Drugs are 
stocked in the warehouses at Dinkes, Provincial level and National level. 
The reporting is through sets of structured formats. These formats flow from Puskesmas
and labs to Dinkes and Provinces – finally collated at national level. 
 34
 
NTP is highly committed to private – public partnerships and in project districts has been 
able to forge partnerships with PPs and hospitals. Dinkes coverage of private providers in 
project areas with trainings is far more than that of the project. 
The support envisioned from MOH/NTP in MITRA is to provide diagnostic and drug 
logistics support, human resources for TB control along with continued political 
commitment. 
MITRA committed to building the capacity of additional non-technical staff (those not 
covered by planned NTP trainings) to increase the depth of TB capacity at Puskesmas
level. Furthermore MITRA, through active coordination and advocacy forums, planned to 
support monitoring, problems identification and resolution at all levels. 
At the beginning of the project MITRA conducted training needs assessments of 
Puskesmas staff members; however this was restricted to technical areas. Opportunities 
for informal assessments which could have been possible through regular meetings and 
project monitoring did not identify capacity of staff to adhere to technical guidelines (e.g. 
use individual drug boxes) or managerial capacity at Dinkes (e.g. proactively manage 
drug shortages at Puskesmas and Dinkes level). This failure to either identify or actively 
support resolution resulted in findings already detailed in previous sections. 
MITRA planned to orient Puskesmas staff to DOTS. However, following a few trainings 
they were not given permission to train, as Dinkes expected to carry out these trainings 
through global funds. 
MTE teams observed 30 patient consultations (10 suspected and 20 on treatment) both 
old and new) in all four districts to ascertain the quality of patient-provider interactions. 
The tool for this observation was adapted from that used by PCI for their Tb project in 
Mexico. 
Some of the positive salient findings are as follow: 
• Sputum tests were ordered for all suspected patients. 
• X-rays were ordered for 12% of patients (those testing negative for sputum) 
• Drugs were prescribed and dispensed appropriately to 20 patients on treatment 
• Four patients were asked to get an HIV test done which indicates that there is 
ample understating of the linkages between TB and HIV 
Findings pertaining to education provided are: 
• While 64% of patients received education about preventing transmission, about 
33% received information about treatment adherence and side effects. 
• TB testing of close contacts was discussed with 33% patients and follow up 
instructions were given to 88% patients. 
 35
 
MITRA has successfully (as described in previous sections) built the capacity of 
peripheral MOH staff (those closer to the community – Kaders, Bidans and paramedics) 
to address issues pertaining to TB control. Better coordination between these individuals 
and the Puskesmas is required though to improve linkages between centers and 
communities. 
Challenges faced by the project include lack of local NGO or CBO partner to rapidly 
expand these capacity building activities at community level; and inability to either 
monitor or highlight identified quality issues discovered through monitoring in advocacy 
forums. 
b Private Practitioners
MITRA has partnered with 27 private practitioners in the project area. This was initiated 
in June 2007. Capacity building has been so far limited to training. Although MITRA 
plans to improve linkages of PPs with Puskesmas and the communities, this has not taken 
place successfully. The trained providers await a second round of discussion with 
MITRA to develop the aforesaid linkages. The training is actually an orientation to the 
ISTC guidelines as no training manual has been developed. Further, as planned MITRA 
has not provided PPs with any BCC material. 
In a workshop for PPs held parallel to the MTE, these issues were identified and 
addressed by the project and MITRA plans to focus on strengthening community linkages 
support to trained PPs. 
PPs are keen to partner with NTP, but would need clearly articulated roles and 
responsibilities, provision of drugs from Puskesmas and support with follow up of 
patients in the community. The MOUs being signed between Dinkes and PPs addresses 
most of these issues. MITRA could play a major role in strengthening linkages. 
3.3.3 Strengthening Health Worker Performance 
MITRA has identified and trained 956 kaders, 471 CBTOs and 152 CBTO coordinators 
(all volunteer health workers) in the project area. Their performance and capabilities has 
been discussed in previous sections. This aspect of the project has been effective in 
providing community level information and services to the community. Further, MITRA 
oriented 37 doctors, 16 TB officers, and 14 lab technicians of 17 Puskesmas in DOTS 
through one day workshops. 
3.3.4 Training 
The training strategy has worked for the community based volunteers and workers. It did 
not work for the Puskesmas staff primarily because few were given orientations before 
they were stopped by the Dinkes as a result of the expected role of the global fund. 
Progress against objectives has been discussed under SO 2 section. 
 36
 
The training strategy for private providers has been discussed in detail under the SO 3 
section. The project is behind schedule and needs to make recommended changes in its 
training strategy for private providers. 
3.3.5 Health Facilities Strengthening 
The project committed to using COPE for enhancing delivery of quality services through 
health facilities (Puskesmas). This was however not carried out. There are no new tools 
for health facility assessment. The project collects NTP forms which include monitoring 
supervisory visit formats of the Wasor. This has not been effectively utilized to identify 
and resolve problems in a timely manner. 
MITRA will need to focus on strengthening linkages between facilities and the 
community further. 
MTE teams carried out a health facility assessment and lab assessments. These were 
carried out by the consultant, national facilitator, CARE Atlanta backstop and 
Pandeglang Wasor using a checklist designed for the purpose. 
Salient Findings of the Facility Assessments 
• Total of 26 Puskesmas were assessed. 
• On an average Puskesmas investigated 32 suspected TB patients in the last month, 
excluding four Puskesmas who were found to be investigating 150-400 patients. 
• Pediatric cases: Two of the twenty six centers visited had equal number of 
children on treatment as adults. 
• Barring three centers, all centers are able to register and hold positive patients 
detected by them. 
• Consistency between number of doses on treatment card and the boxes: 58% . 
• 96% of centers are making prompt house visits to retrieve defaulters. 
• In two centers drugs had crossed the date of expiry. 
• Half of the facilities received supervisory visit within the last three months; most 
(90%) facilities received supervisory visits in the last five months. Feedbacks 
provided include improvement of reporting, case finding, quality assurance of 
slides and community outreach. 
• More than half of the centers did not have in their stock TB registers, formats and 
IEC material. 
• Three out of 22 Puskesmas reported facing drug shortages for periods ranging 
from one to three months.
Salient findings from Lab Assessments
• Total of 10 labs were assessed. 
• All labs were found to have a separate designated place to operate from; had 
standard operating procedures, lab registers, binocular microscopes and adequate 
reagents, slides and other consumables. 
 37
 
• Seven out of nine labs had a trained lab technician performing the sputum 
examination. Almost all lab technicians met have been trained in the past two 
years. 
• 9 out of 10 labs kept slides and were reviewed by their supervisors. Slides for 
internal quality analysis were maintained by all labs. 
• All labs visited had received supervisory visits by their superior in the last one to 
three months.
• Reports of site evaluation by supervisor were present in eight labs
• Most labs were disposing waste as per norm
• One lab was performing culture and drug sensitivity tests.
• Error rates of the reporting labs has been discussed under quality assurance 
section
The primary problem concerns the management of drugs and other consumables. While 
Dinkes and Puskesmas have made attempts (not all successful) to borrow drugs from 
neighboring districts/centers (as reported in the in-depth interviews), their capacity to 
foresee, negotiate and advocate needs to be built up by the project. 
3.3.6 Recommendations 
Some recommendations have been covered in the previous sections. Additional ones 
include: 
1. Build the capacity of Puskesmas and Dinkes in managerial and leadership aspects 
2. Use monitoring data to foresee problems and coordinate efforts to find solutions. 
3. Build capacity of Puskesmas staff to implement BCC interventions with support 
from structures like Paguyuban
4. Advocate for development of linkages between TB-HIV programs, as Banten is 
deemed as a high HIV prevalence area. 
5. Use quarterly monitoring meetings to underline the need for using standardized 
pediatric score cards. Assess the need for capacity building and advocate for 
fulfilling the gaps in capacities. 
3.4 Quality Assurance 
3.4.1 Case Detection by Quality-Assured Sputum Smears Microscopy 
Quality here is defined as: all laboratory technicians being trained; being supported with 
provision of microscopes, reagents and equipment; and random sampling of sputum 
slides for cross checking. MITRA committed to addressing the issue of quality checks for 
sputum slides and timely reporting through trainings to lab technicians. MITRA was 
however requested by the Provincial Health Department to not plan for these trainings as 
they expected the trainings to be done by the GFTAM. The training matrix in DIP does 
not describe any planned technical trainings for lab technicians. The lab technicians who 
have been trained by MITRA so far have received one day orientation to DOTS. 
 38
 
Lab quality assurance data from NTP reports at provincial level are detailed in Table 9. 
Table 9 Lab Quality Assurance 
 Tangerang C Tangerang D Cilegon Pandeglang 
No. of Puskesmas in 
Districts 25 40 8 15 34 
 2005 2006 2005 2006 2005 2006 2005 2006 
Q1 11 20 NA 19 8 8 5 8 
Q2 14 20 8 8 9 
Q3 6 15 22 8 8 
Number of peripheral lab 
(Puskesmas) had slides cross￾checking 
Q4 10 18 14 8 
Q1 2 8 9 1 1 4 2 
Q2 3 8 1 0 4 
Q3 3 6 3 0 0 
Number of peripheral lab 
(Puskesmas) had error rate 
more than 5% 
Q4 3 6 4 1 
It can be seen from the above table that the except for Cilegon problems continue - is not 
100% and error rates continue to be high for some labs. CDR is discussed in the next 
paragraph. 
3.4.2 Treatment of TB Cases with Standard Short-course chemotherapy 
Elements detailed in DIP include: Refresher training for Puskesmas TB officers in DOTS 
to ensure important rules of DOTS are not forgotten, patients are correctly categorized 
and individual drug boxes are maintained for each registered patient. 
While refresher training in the form of orientation to DOTS has been provided to 
Puskesmas staff, project has either failed to monitor or successfully advocate for 
resolutions of problems identified through monitoring. MTE found that Category II 
patients are put on Category I drug regimen as Puskesmas and Dinkes have failed to 
organize streptomycin and many Puskesmas are sharing drug boxes between patients. 
Table 10 – Key DOTS Implementation Indicators 
Impact Indicators Year: Jan-Dec 
(4 districts) 
Comments 
1.1 increase TB case 
detection rates (CDR) to 
85% by the end of the 
project. 
2005: 62.88% 
(baseline) 
 2006: 67.51% 
While the CDR increased 
significantly in Tangerang city and 
Pandeglang, it decreased (not 
significantly) in Cilegon and 
Tangerang district. 
1.2 increase and/or maintain 
to at least 88% in the 
treatment success rate (TSR)
2004: 95.54% 
(baseline) 
2005: 95.82% 
Treatment success rates are very 
high and well maintained. 
 39
 
With expansion of DOTS in Pandeglang the CDR has gone up significantly. The exact 
reasons for changes in the other districts cannot be explained with available data. 
3.4.3 Uninterrupted Supply of Quality Drugs 
Dinkes of all four districts reported facing drug shortages between the months of May and 
July for a period of one to three months. NTP clarified that drugs were available in 
provincial and national warehouses. Dinkes reports dearth of streptomycin. NTP clarifies 
that category II patients are not captured by Puskesmas, hence these drugs are not being 
requisitioned by Dinkes. MITRA has not been able to influence the timely resolution of 
these issues. 
3.4.4 Recording and Reporting 
This has improved. Most Puskesmas receive supervisory visits regularly and receive 
supportive feedback from the Wasors. Reporting from labs for quality assurance is 
however low. Some Puskesmas faced shortages of reporting formats and TB registers 
between the months of May 07 and July 07. 
3.4.5 Community Defined Quality 
MITRA successfully created a cadre of CBTO coordinators and few examples of 
Paguyubans to improve the relationship between communities and the Puskesmas. 
However, the envisioned use of COPE as a tool for quality assurance could not be taken 
forward. As COPE is a TM protected method CARE along with CRS (TB Philippines 
project under CSHGP) entered a preliminary understanding for doing COPE TB. This 
understanding could not be taken forward owing to differences in working modalities 
between the agencies. 
3.4.6 Recommendations 
Some of the recommendations have already been covered in previous sections. 
Additional recommendations include: 
1. Discuss with NTP the support required to bridge the gaps in quality diagnosis. 
Identify the role that MITRA can play. 
2. In case that NTP does not require MITRA support then, follow up, monitor, share 
findings and advocate for improving quality. 
3. Support improvement of services provided by Puskesmas through structures like 
Paguyubans. 
4. MITRA may decide to either reopen the negotiations to employ COPE or to adopt 
internal quality parameters instead of COPE TB. 
 40
 
3.5 Sustainability Strategy 
MITRA’s sustainability strategy is designed to 
• Promote governments; community organizations; and the private sector to 
advocate for higher quality health services 
• Enable the effective delivery of health services at the local level; and 
• Ensure that improved practices and behaviors are adopted at the community and 
household level. 
It is envisioned that a focus on community TB planning and budgeting at the local 
government level will build a lasting mechanism for the provision of district-level, high￾quality basic human services. Similarly the focus on building behavior change and 
advocacy capacity of local NGOs, as well as mechanisms to maintain and improve this 
capacity, will strengthen technical capacity at the level where it is most needed. 
Principles for achieving sustainability as detailed in DIP include: 
• Build on what already exists. 
• Foster capacity to provide technical assistance. 
• Focus on institutionalizing planning, budgeting, and management capacity. 
• Respect absorptive capacity. 
3.5.1 Progress 
MITRA through its SO 1 has identified/created and strengthened various community 
based structures and individuals who are promoting TB awareness, supporting patients to 
access services and complete treatment. However as the project is behind schedule and 
has covered 10-25% of committed numbers, it is difficult to comment on the 
sustainability of behaviour change in the project communities. The few examples of TB 
associations in the project are good examples of built community capacity to provide 
support to TB activities. These need to be expanded across the project. Furthermore, the 
Puskesmas or the TB posts need to be linked to these associations so that continued 
support could be provided and activities are sustained beyond project life. 
MITRA does not have any local NGO partner; however it has actively interacted with 
and involved the PKK (associations of the wives of administrators) and religious leaders 
through activities in Koran recitation meetings. 
Village Health Committees (VHC) have been formed in Tangerang under the USAID’s 
Health Services Program and CARE’s BERSIH program. These committees are meant to 
put health on the village developmental agenda. MITRA has initiated interventions in one 
VHC and plans to take this forward in the other 12 VHCs formed so far. MITRA has 
been actively interacting with the village level administrators and orienting them on the 
importance of TB control and DOTS. There are some examples of monetary support from 
 41
 
the village developmental budgets to poor patients to enable access and completion of 
treatment. 
The government through its NTP is committed to providing quality DOTS services to all 
patients. MITRA has built the TB capacity of additional staff in the Puskesmas to 
overcome frequent transfers and HR shortages. Through better communication with the 
Puskesmas and by actively promoting the linkages between newly created community 
structures and groups, MITRA can ensure sustained governmental capacity to provide 
community level services. 
MITRA’s design does not have any plans for management or financial strengthening 
interventions for either community structures, Puskesmas or Dinkes. When MITRA 
partners with a local NGO/CBO/FBO partner, for expansion of activities, it will have to 
be informed by CARE’s partnership strategy/framework. Based on initial capacity 
assessments of partners, MITRA should look at how CARE will enable the partner in 
being sustainable. This will involve, perhaps, building capacity of the partner in 
managerial and financial aspects. The management trainings for Puskesmas and Dinkes, 
along with the new partners have been identified by MTE team as one of the areas which 
if implemented will help identify the shortage of crucial inputs into the DOTS program. 
Provincial and District Dinkes are committed to involving private practitioners, private 
hospitals and industrial clinics (especially in Tangerang and Cilegon cities). Currently 
MOH is actively orienting private providers to the ISTC guidelines. No training manual 
exists for training the providers. The orientation is restricted to technical aspects and is 
wrapped up with a MOU (when willing) between Dinkes and the provider. There are no 
sessions pertaining to follow up action and set formats for reporting partnership issues. 
MITRA’s recent intervention in Cilegon trainings (detailed in the capacity building 
section) is a good example of creating meaningful and strengthened partnerships. MITRA 
can play an active role in incorporating these partnership building and community 
linkages sessions in all private provider trainings, whether conducted by Dinkes or by 
MITRA. 
MITRA has not been able to forge any partnerships so far with industrial clinics and 
major private hospitals. Since Dinkes has proved to be better at inviting and orienting 
these providers, MITRA could focus on bringing on board the above-mentioned facets to 
the training therefore contributing to the sustenance of private participation in the project 
area. 
MITRA has been participating in district and provincial level meetings, promoting joint 
reviews of program and has advocating for the inclusion of a column to identify PVSM 
population in the TB formats. These advocacy level meetings need to be utilized to 
identify and avert possible quality assurance related issues in a timely manner (over 
diagnosis of paediatric cases, drug shortages etc). 
3.5.2 Child Survival Sustainability Assessment (CSSA) framework 
 42
 
CII committed to using the CSSA framework for MITRA. All three dimensions of the 
CSSA sustainability framework are applicable to the project. MITRA intends to use the 
framework with its partners to assess the current status and track progress on its 
sustainability efforts. 
The CSSA workshop which was slated for January 2007 was not conducted as planned. 
Project has not developed any phase out plan as yet. 
3.5.3 Recommendations 
1. Expand formation of TB associations at community level and strengthen their 
linkages to the Puskesmas or the TB posts so that continued support could be 
provided and activities are sustained beyond the project life.
2. Partner with already identified local NGOs and CBOs (PKK and Village committees) 
to expand activities and develop local capacitates to implement TB control activities.
3. Build on existing groups to actively advocate for TB control; and link them to 
strengthened volunteers and TB groups to ensure sustained capacities at the 
community level.
4. Improve communication with Puskesmas and actively promote the linkages between 
newly created community structures and groups to ensure sustained governmental 
capacity to provide community level services.
5. Consider managerial and leadership trainings for Puskesmas through funds saved 
under technical trainings to avert shortages of crucial inputs into the DOTS program. 
6. Develop a comprehensive training manual based on ISTC guidelines, which builds 
the technical, managerial and partnership skills of private providers and support the 
improvement of linkages between community. 
7. Actively partner with MOH to expand partnerships with industrial clinics and major 
private hospitals. MITRA should focus on aspects pertaining to partnership 
strengthening and community linkages thereby contributing to the sustenance of 
private participation in the project area. 
8. Develop a specific, written strategy for engaging decision-makers. District, provincial 
and national level interactions should be utilized to avert possible quality assurance 
related issues in a timely manner. 
9. Conduct CSSA framework workshop and monitor sustainability indicators. 
C. Project Management System
1. Planning
a) Groups involved in planning 
The planning process has involved TB patients and their families, Community Based 
Treatment Observers, Religious Leaders, Kaders, Village Elders, leaders at the local 
level, midwives and NGOs such as KuIS, , PKK members, and Muhamaddiyah. 
 43
 
The Ministry of Health has supported the project planning process by involving the 
Health Post workers, the puskesmas staff, the district health teams, the district planning 
teams of all four districts and the province NTP team and the Bapeda. 
Additionally, the planning process was shaped by inputs from KNCV, WHO, Private 
Practitioners, and the NTP. 
b) DIP work on schedule 
Throughout the project implementation has included nearly all activities that it undertook 
initially. The two crucial activities that MITRA has not addressed yet are: 
1) The BCC workshop – However, a BCC strategy has been prepared. 
2) COPE TB – This was an activity to be undertaken with EngenderHealth, (who 
owns the COPE Trademark), but has yet to occur. 
MITRA is behind to a degree in working with the PP, although some good pilot work has 
been done in Cilegon. The project has also moved slower than expected in establishing 
community-level efforts with TB patient bodies and DOTS TB centers. 
c and d) Understanding of project objectives by project partners 
The project’s objectives are well understood by all partners, and good collaboration on 
project activities exists among partners. For example, during the training of PP, the 
Cilegon MOH partnered with MITRA to cost-share the trainings. The posyandus have 
dedicated one of the kaders for TB in this grass-root facility. The KNCV at the province 
level has had a very close collaboration with MITRA since the beginning of the project. 
The national players, including KNCV/TB-CAP/WHO and USAID local missions, have 
continuously mentored the project and have participated in DIP planning. The DIP 
document has been widely shared among these partners. 
e) Use of monitoring inputs to revise project implementation 
The project has used feedback from its partners to update and revise its implementation 
strategies. For example, the MOH asked the project not to duplicate the efforts of Global 
Fund in training the MOH staff. Since that request, CARE has not trained MOH staff on 
DOTS TB. In another situation, Pandeglang district asked for help from MITRA to 
initiate the DOTS TB posts, so CARE – MITRA helped the district to initiate this 
promising activity. Quarterly M&E activities at the district and province level are 
regularly attended by MITRA staff. Though an official system of documentation of 
these meetings has not yet begun in MITRA. The review of data and successes/challenges 
in DOTS TB programming is done at each level, and MITRA staff work with the MOH 
officials to revise project inputs based on these discussions. 
2. Staff Training
a) Effectiveness of Staff Training 
The standard, national 1-week DOTS training recommended by the MOH has been 
imparted to all MITRA staff (excepting one new staff). All field staff also underwent a 
 44
 
training of trainers. These two trainings have helped to boost the confidence of the staff 
in their technical knowledge, skills, and ability to be effective trainers. The MITRA field 
staff are now carrying out field trainings and follow up of the trained 
volunteers/professionals, including doctors, bidans, kaders, CBTO etc. 
b) Monitoring of Trainee Performance 
The performance of the MITRA staff is monitored by their supervisors, the training 
coordinators, during sessions when the field officers are conducting trainings. The MOH 
and MITRA staff follow up with former training attendees by monitoring of the 
volunteers/professionals trained. 
c) Are adequate resources dedicated to staff training 
MITRA staff are involved in their training needs assessment – one such assessment was 
done by the technical backstop from Atlanta, which helped to identify that the training of 
trainers was needed by MITRA staff. MITRA staff are encouraged to identify their 
training needs and communicate these with the project management. 
3. Supervision of Project Staff
a and b) Training coordinators directly supervise the FO work
Each training coordinator is based in the geographical district they supervise to make 
supervision more direct (Cilegon is supervised by the adjacent district Training 
Coordinator, but this arrangement may change soon as the involvement in Cilegon will be 
scaled down as per the DIP). There have been discussions in CII regards changing the 
supervision structure from a geographical basis to instead be based on individual’s 
specific skills, which means that the Training Coordinators will be designated as DOTS 
specialist, Training Specialist, and Partnership Specialist, rather than district supervisors. 
The debate continues and may go past MTE to come to a conclusion. If it comes to 
fruition, it is expected that this arrangement may ‘step up’ the areas in which MITRA is 
lagging behind with more focused inputs from the Training Coordinators. 
4. Human Resources and Staff Management
a) Personnel Management 
In general, all project positions have been filled. The project has continuously had a PM 
and training coordinators. One training coordinator left the project, so her position was 
filled in through the promotion of a FO, whose position was filled by hiring a new FO. 
Two months ago, another Training Coordinator left, and that position remains unfilled, 
largely because of internal discussions on the possibility of a new managerial-level 
change as was noted above in the Supervision of project staff section. 
b) Key staffing policies and procedures in place 
All key personnel policies and procedures are in place based on CII policies and 
procedures. 
 45
 
c) Morale and Cohesion of staff 
The project is likely to be stressed in the near future because of staffing decisions that 
must be made. During the evaluation, the FOs in general felt they experience a very good 
work environment and are receiving capable supervision. The FOs however also felt that 
project management could be improved and become more aware of issues in the field. 
There was a similar feeling expressed at the TC level, and CII has taken note of it and is 
working towards identifying and rectifying the cause of this dissatisfaction. One of the 
remedies suggested was to have TC work as ‘specialists’ rather than geographical 
supervisors as mentioned earlier in point 3, so this is being seriously considered. 
 d) Staff Turnover
Please see section 4 (a) 
 e) Staff Transition at the end of the project:No plans have been made for staff 
transition at the end of the project. 
5. Financial Management
CII follows the SCALA financial management system, which is a double entry system. 
This enables the head office to monitor and track expenses in near real time at different 
levels of account and account tracking. At MTE, burn rate for the project was lower than 
projected because of slower progress on project activities, as has been noted in earlier 
sections. 
6. Logistics
The project has an adequate number of vehicles for transport, and no bottlenecks are 
expected. Supplies to the project have been both adequate and timely and are expected to 
remain so. 
7. Information Management
MITRA relies on two sets of systems for its information management 
1) The MOH DOTS - TB program information management system – MITRA does 
not intend to duplicate this well-entrenched and functional system. This system 
generates the data to be used at both the local and national level and keeps track 
of a comprehensive set of indicators such as new case detection rate, cure rates, 
treatment success rates, etc. CARE is encouraging the province MOH to include 
the PVM in their data systems so that analysis can be done. 
2) The internal MITRA monitoring system – This allows the project management to 
plan and study the work of the FOs in collaboration with partners. The system 
allows for comparison of the planned and executed activities and expenses. It also 
tracks the work of individual FO and TCs and checks if targets have been met or 
not. 
 46
 
a) System to measure progress 
Both systems are used in conjunction so as to arrive at a big-picture view of the 
project achievement, and progress towards targets. 
 b) A systematic way to collect data at all levels 
 The information is collected every quarter starting at the health post and 
 puskesmas level and is collated at the district level and shared with the province 
before being widely distributed to partners. 
e) What types of data are generated? 
 Please see 7.1 and 7.2 
 d) Project is using and supporting existing data systems
The project uses and supports the existing MOH DOTS-TB system and has no 
 plans to establish any other system. 
 e) Use of data
 Please see C.1 (e) 
 f) Findings and use of assessments 
The following project assessments have been done after the baseline: 
1) Study of reasons for drop out of TB patients – please see annex 
2) Mid term evaluation, KPC and HFA – please see annex F and G 
8. Technical and Administrative Support
a) The project has received external technical support from numerous sources 
1) Project Manager underwent A CORE organized exposure visit to Chennai in India 
in 2006. 
2) TC participated in the annual child survival workshop in Gadchiroli in India in 
2007 
3) KNCV personnel trained MITRA staff in DOTS – TB. Consultants were hired to 
help start the process for BCC related activities. 
4) FOs were trained by DAP (USAID) staff in training of trainers. 
5) MITRA staff was trained on qualitative survey design, data gathering and 
preliminary analysis by Emory Intern. 
6) During MTE the staff was exposed and learnt from the qualitative tool designing, 
data collection and presentation. Some staff also learnt the 30x10 cluster sampling 
technique from design to analysis. 
7) Specifically Atlanta back stop visited MITRA in June/July 2007 for preparation 
of MTE and staff training needs assessment. Atlanta backstop has had monthly 
phone calls to help project in budget, staffing and field implementation issues. 
 b) Te project anticipates training needs for 
 47
 
1) COPE – TB. 
2) Improving the training of PP to make it more implementation friendly. 
3) Supportive supervision training with MOH to link volunteers to MOH DOTS 
program. 
4) Working with hospitals and clinics. 
d) The Atlanta backstop supported the project on the DIP and the annual CS 
workshop. A special visit to support the project for a smooth MTE was done in 
June/July of 2007. Regular monthly phone calls with project management were 
done to help out with the day to day work. Names and contacts of BCC 
consultants and others were shared to facilitate the project to move forward. 
 
10. Mission Collaboration
MITRA contributes to USAID’s strategic plan for Indonesia 2004-2008, specifically to 
SO 2, which aims to achieve an improvement in health, education environment and other 
conditions for the global population; with intermediate results of 
-Governments, community organizations and the private sector mobilized to advocate 
higher quality basic health services. 
-Basic human services delivered effectively at local level. 
-Improved practices and behaviors adopted at the community and household levels. 
Through MITRA, CARE responds to the Global Health Bureau’s strategic objective 5: 
Increased use of effective interventions to reduce the threat of infectious disease of major 
public health importance. 
The USAID local mission provides need based support to the project. CARE works with 
the Mission in Banten Province through BERSIH and the Safe Water System (SWS) in 
Tangerang District and City. MITRA coordinates with these projects and with USAID’s 
flagship program - Health Services Program in Tangerang District. The mission staff 
participated in and provided valuable inputs to the DIP process. The CII team meets with 
the local mission regularly and attends meetings pertaining to USAID evaluation of the 
KNCV project in Banten, thus keeping abreast of the latest developments in TB 
programming. Similarly, MITRA Project Manager met the evaluators from the USA at 
the PCI office in Pandeglang. Updates on the project progress are done on an annual 
basis. Furthermore, interactions are also held with the mission personnel via telephone 
and e-mail. 
The evaluation team met with Ms. Lisa Baldwin, MPH, Senior HIV/AIDS Technical 
Advisor and Ms. Gretchen Antelman, ScD, MPH, Senior MCH Advisor, Basic Human 
Services; and shared the findings of the evaluation. CII utilized this opportunity to make 
a brief presentation about MITRA and CII’s health programs in Indonesia. 
D. Other Issues Identified by the Team
 48
 
No other issues were identified by the MTE team. 
E. Conclusions and Recommendations
In conclusion, the project is behind schedule. The MITRA activities are taking place 
in 25% of the project areas. Community mobilization efforts have been made in these 
areas with demonstration of some scalable models. MITRA has exceeded targets in 
terms of identifying and training treatment observers and has done well in developing 
the much required community component in the poor performing areas. BCC strategy 
is not in place and needs to be finalized rapidly. While trainings of the Puskesmas 
staff have could not been carried out owing to the reluctance of Dinkes, the 
introduction of the cadre of CBTO coordinator project has demonstrated the 
possibility of a sustainable structure that can be a link between the community and 
the facilities. The activities pertaining to private provider involvement are behind 
schedule and a clear cut strategy to make this sustainable is emerging now. The 
project has not been able to advocate successfully at the provincial, district or facility 
level to resolve identified issues. There are project management issues which have 
resulted in delays in implementation of planned activities. 
Recommendations for the Project
Increasing and Strengthening Community based TB control Structures 
1. Expand activities to cover more than 25 Puskesmas areas. Sign MOU’s as 
planned with able local NGO/CBO partners to achieve expansion 
2. Build on successful experiences of community groups and Paguyubans.
3. Improve information sharing with Puskesmas through structured methods 
for better utilization, monitoring and sustainability of strengthened 
community structures and individuals. 
4. Remove the indicator “100% increase (from 30% to 60%) in knowledge of 
symptoms of TB and its curability in the community” as this is already 
captured in two other indicators and is merely repetitive.
5. Rephrase indicator “at least 20% increase in the number of TB suspects 
from 6,560 in 2005 to 7,800 by September 2009 combined for the 4 
 49
 
districts.” – to read “ at least 40% increase in number of suspected TB 
patients reaching or screened by Puskesmas in four project districts from 
27,953 in 2005 to 53,111 in 2009.” 
6. Carry out the committed operations research on impact of incentives on 
CDR. 
7. Follow up the identified child in Waliwis village and investigate the 
reasons for continuing treatment even after three years. 
8. Utilize the simple monitoring formats to measure outputs and outcomes of 
CBTO/Volunteer activities. 
Strengthen District Capacity of District and Provincial TB Program 
1. Build on success of CBTO coordinator capacity building strategy 
2. Rethink the trainings that MITRA wants to give at Puskesmas level. Who will be 
trained? What will be the content? How will this be done? 
3. Drop the indicators pertaining to training of Puskesmas staff. 
4. Consider managerial and leadership training for Puskesmas staff if NTP restarts 
technical trainings for them through the latest round of GFTAM funding. 
5. Jointly with Dinkes, investigate the use of recommended score cards for pediatric 
diagnosis to identify reasons for over diagnosis and train providers to address the 
situation (either through MITRA funded trainings or through NTP). 
6. Through regular analysis of monitoring reports and field feedback, identify 
drug/lab/reporting issues and advocate for resolutions at appropriate forums. 
Advocate for resolution of issues related to sharing of drug boxes and 
unavailability of streptomycin at provincial and national level. 
Participation of Private Providers 
1. Since MOH has been training more private practitioners and has allocated budgets 
for the purpose, MITRA can dove tail these efforts by providing quality 
enhancing inputs – put together a training manual; help develop training sessions 
to include action plans, partnership modalities, available community support; put 
together a kit of treatment algorithms, ready reckoners, IEC material and handouts 
with information on community and Puskesmas contacts. 
2. Develop a simple monitoring format for issues not covered by existing TB 
formats – support required, problems faced – which can be used by the PP to 
communicate with the Puskesmas. 
3. Consider splitting the entire training into one hour lunch hour sessions to increase 
the participation of PPs. 
4. PPs are willing to network with their peers. Utilize this willingness to enroll more 
PPs. 
5. Dovetail MOH relationship with hospitals and industrial clinics and offer to bring 
on board the above-mentioned quality enhancing inputs. 
6. Actively link up volunteers and CBTOs trained by MITRA with the PPs and the 
Puskesmas. 
 50
 
Community Mobilization 
1. Expand activities to cover all project areas. Build on the success of Paguyubans 
and community groups. 
2. Sign MOUs with identified able local NGO/CBO partners to ensure transfer of 
expertise and expansion of activities. 
3. Plan to withdraw support to mature groups and develop simple monitoring 
formats to measure the outputs and outcomes of community activities. 
BCC 
1. Conduct a workshop of all key stakeholders to finalize the draft BCC strategy 
2. Quickly adapt, produce and disseminate IEC material to community based 
partners and Puskesmas. 
3. Include messages on side effects, HIV – TB linkages and MDR TB to the 
appropriate extent. Address some of the identified misconceptions about TB 
(using same utensils will cause TB, TB is sexually transmitted, TB patient should 
be isolated) which generate stigma. 
4. Build capacity of the partners to use the material. 
5. Develop monitoring formats to quantify coverage with the tools and measure 
effectiveness. 
6. Partner with identified local NGOs to support BCC activities in the community 
7. Develop an IEC kit for the private providers who have partnered with MITRA 
and the DOTS program 
8. Utilize project monitoring data and NTP data to share, identify problems and 
resolve them at Puskesmas, district, province and national level 
9. Actively coordinate with NTP to be informed by and be able to contribute to the 
national ACSM activities. 
Capacity Building 
1. Build the capacity of Puskesmas and Dinkes in managerial and leadership aspects 
2. Use monitoring data to foresee problems and coordinate efforts to find solutions. 
3. Build capacity of Puskesmas staff to implement BCC interventions with support 
from structures like Paguyuban.
4. Advocate for the development of linkages between TB-HIV programs, as Banten 
is deemed as a high HIV prevalence area. 
5. Use quarterly monitoring meetings to underline the need for using standardized 
pediatric score cards. Assess the need for capacity building and advocate for 
fulfilling the gaps in capacities. 
Quality Assurance 
1. Discuss with NTP the support required to bridge the gaps in quality diagnosis. 
Identify the role that MITRA can play. 
2. In case that NTP does not require MITRA support then, follow up, monitor, share 
findings and advocate for improving quality. 
 51
 
3. Support improvement of services provide by Puskesmas through structures like 
Paguyubans. 
4. MITRA may decide to either reopen the negotiations to employ COPE or to adopt 
internal quality parameters instead of COPE TB. 
Sustainability 
1. Expand formation of TB associations at community level and strengthen their 
linkages to the Puskesmas or the TB posts so that continued support could be 
provided and activities are sustained beyond project life.
2. Partner with already identified local NGOs and CBOs (PKK and Village 
committees) to expand activities and develop local capacities to implement TB 
control activities.
3. Build on existing groups to actively advocate for TB control; and link them to 
strengthened volunteers and TB groups to ensure sustained capacities at the 
community level. 
4. Improve communication with Puskesmas and actively promote the linkages 
between newly created community structures and groups to ensure sustained 
governmental capacity to provide community level services.
5. Consider managerial and leadership trainings for Puskesmas through funds saved 
under technical trainings to avert shortages of crucial inputs into the DOTS 
program. 
6. Develop a comprehensive training manual based on ISTC guidelines, which 
builds both technical, managerial and partnership skills of private providers and 
support the improvement of linkages between community 
7. Actively partner with MOH to expand partnerships with industrial clinics and 
major private hospitals. MITRA should focus on aspects pertaining to partnership 
strengthening and community linkages thereby contributing to the sustenance of 
private participation in the project area. 
8. Develop a specific, written strategy for engaging decision-makers. District, 
provincial and national level interactions should be utilized to avert possible 
quality assurance related issues in a timely manner 
9. Conduct CSSA framework workshop and monitor sustainability indicators. 
Scaling up and Down 
1. Cilegon has been performing well on the DOTS indicators and the linkages 
between health centers and the communities are well established. MITRA can 
consider phasing out community activities in Cilegon and support improvement of 
quality in private provider trainings. 
 52
 
2. Consider working with CBTO coordinators as against CBTOs. Since most CBTOs 
are family members, their interest in continuing as CBTOs beyond the treatment of 
their kin is moot. Scale up Pagyubans and TB posts. 
3. Drop identified indicators which are either redundant or cannot be achieved (owing 
to change in government stance) 
4. Consider dropping COPE for some internal quality monitoring indicators. For 
example proportion of providers applying BCC with their patients. 
5. Dovetail the government’s efforts to train private providers by enhancing the 
community and managerial aspects of the skills. 
Points to Ponder for USAID
1. TB programs worldwide are very structured and rigid which makes it difficult for 
NGO partners to carve a role for themselves. Further the role carved is restricted 
to some aspects, with no controls on other aspects of DOTS. However, DOTS 
does not work until all five components come together. There is a need for future 
project designs to envisage a larger and active role for local missions and TBCAP 
partners, to ensure the factors outside the control of NGO partner can be 
advocated at a higher level. 
2. Consider incorporating an indicator pertaining to ‘initial defaulters’. These are 
people who approach care provider and are diagnosed to be sputum positive, but 
are not put on treatment. This indicator can act as an indicator to assess quality of 
service provision within the control of NGO. 
F. Results Highlight
1. Online course for Treatment Observers
CARE has developed an online course for Treatment Observers. The url for the 
course is: 
http://www.careacademy.org/health/tb/tuberculosis_e_training1_24_tb_course_p001.
htm
The course is divided into five modules covering definition; diagnosis; treatment; role 
of treatment observers; and counseling skills. The sessions are interactive and include 
numerous role plays and frequently asked questions. It has a separate tools section 
which details checklists for side effects, counseling, treatment and diagnosis. The site 
provides links to other external resources and offers a forum for sharing information 
and discussing issues of interest. 
2. Monitoring Inclusion of Poor Vulnerable and Socially Marginalized (PVSM) 
People 
The NTP in Indonesia has programmed DOTS as a free medicine provision service 
through the government health delivery system. But as decentralization has taken 
root, and more and more decisions are being taken at the local level, a few 
government primary health centers have opted for a one-time patient registration fee 
which varies between centers and districts, ranging from USD 0.2 – 0.5. Few centers 
 53
 
also levy a revisit fee which is minimal. MITRA plans to identify these centers and 
use its advocacy skills to make registration for all its project patients as free. ‘Kartu 
Miskin’ or 'Surat Keterangan Tidak Mampu' is a government identity card given to 
poor families which identifies the poor in the administrative area. Holders of these 
cards get subsidized or free health services. 
As a first step towards this intention, MITRA had a series of successful discussions 
with the Provincial MOH to include a column on the TB formats identifying a patient 
with Kartu Miskin. During the MTE CII team was informed that the Province will 
need support to print the new formats until funds from the latest round of Global 
Funds become available. MITRA has agreed to support the printing of the formats 
which will perhaps be the stepping stone to negotiating for free registration of these 
patients into DOTS services and improving monitoring of access to TB treatment by 
PVSM population. 
G. Action Plan is attached as Annex E. 
 54
 
Annexes 
Annex A: Evaluation Team members and their Designation
Name Designations 
Dr. Ranjani Gopinath Consultant, external evaluator 
Dr. Abdul Manaf National Consultant MTE and Ex Director, NTP, Indonesia 
Dr. Beatricia Iswari Program Manager, MITRA 
Dr. Khrist Roy CARE USA Headquarters; Technical Advisor, Child Health 
CARE Indonesia 
Ms. Diyan Ratnasari Field Officer, MITRA 
Ms. Ika Suciani Field Officer, MITRA 
Mr. Jordan Jempormase Training Co-ordinator, MITRA 
Ms. Nurlaili Field Officer, MITRA 
Ms. Humairoh Anahdi Field Officer, MITRA 
Mr. Kaji Field Officer, MITRA 
Ms. Umi Kulsum Field Officer, MITRA 
Mr. Samsudin Field Officer, MITRA 
Ms. Ani Kristanti Field Officer, BERSIH Project 
Ms. Lani Indrayanti Field Officer, BERSIH Project 
Mr. Dodi Ardiansyah Field Officer, BERSIH Project 
Mr. Ibnu Aji Field Officer, BERSIH Project 
NTP and MOH Staff 
Ms. Meiyetti Burina, SKM Chief of Technical Service Unit for Pulmonary Diseases 
(UPTD), Dinkes, Cilegon. 
Mr. Yudi Hermawan, SKM District TB Supervisor (Wasor), Pandeglang 
Mr. H. Mudhar District TB Supervisor (Wasor), Cilegon 
Ms. Fatmawati Kader of Paguyuban Pulo Merak, Cilegon 
Ms. Iis Nurmayasari Kader of Pandeglang District 
Ms. Suwarni Kader of Jatiuwung Puskesmas
Ms. Nuchyatul Aliya Kader of Tangerang District
NGO Members 
Dr. Loekman Hakim 
Siregar 
Senior Technical TB Officer, PPTI also ex Chief in Banten 
Province for KNCV 
Mr. Asep Surjana LAZ-harfa 
Ms. Jaorana Amiruddin Vice TB Coordinator for Aisyah (Central Unit) 
Others 
Ms. Yuliana Tansil Translator and Interpreter for Khrist Roy 
Mr. Widodo Guntarto Interpreter for Ranjani Gopinath 
 55
 
Annex A.1 KPC Team Members and their Designation 
Name Designations 
Ms. Listya Permana 
Hapsari 
Enumerator 
Ms. Devi Lestari Enumerator 
Ms. Yudhiani Enumerator 
Ms. Jayanti Enumerator 
Ms. Rina Yuga Utami Enumerator 
Ms. Evi Nilawati Enumerator 
Ms. Nur Akmalia Enumerator 
Mr. Bobby Anggi Putra H. Data Entry 
Ms. Ira Akhira Mardiani Field Officer MITRA 
Ms. Lidya Fanida Field Officer MITRA 
Mr. Luly Arfan Field Officer MITRA 
Mr. Yosef Heribertus Turut Field Officer MITRA 
Mr. Sutan Royansyah Monitoring and Database Officer MITRA/Data Entry and 
Analysis 
Dr. Lutfi Syeban Training Coordinator MITRA/MTE coordinator for KPC and 
Health Facility Assessment 
 56
 
Annex B: Assessment Methodology 
The Mid Term Evaluation of MITRA project involved 
a) KPC survey; 
b) qualitative survey; and 
c) Internal debriefing of team members, CARE Senior Management; debriefing of local 
USAID Mission, and NTP. The detailed schedule of the evaluation is in Annexure D. 
Qualitative Survey
Preparing the tools
To carry out the qualitative survey, CII shared key documents with the consultant and 
provided clarifications for questions arising out of review of these documents. Consultant 
discussed and listed key stakeholders who were to be contacted for assessments. Based 
on this listing draft tools for the community level FGDs/IDIs/meetings/facility 
assessments and clinical observations were shared first with CII team and the National 
MTE Consultant for review and translation. 
Key Partner Inputs
The tool designs were informed by additional inputs from NTP, KNCV and WHO at 
national level. These meetings helped understand the questions national stakeholders 
needed answered through the evaluation process. 
Survey Workshop and participants
Two days were slotted for the workshop of which the first had to be spent familiarizing 
with the tools, the second day was used for facility assessments and practice skills 
through role plays. To overcome the paucity of time, senior technical team members were 
given the responsibility of carrying out the health facility assessments and guide their 
district teams through the other tools in the field. The Project Manager and CARE 
Atlanta back stop guided two teams while the Team leader and National Consultant 
guided the other two district teams. 
CARE invited various stakeholders to be part of the evaluation team and managed the 
logistics. The participants of the tool finalization workshop were oriented to the 
objectives of the workshop, given an overview of the project strategies and KPC findings 
and oriented to the qualitative methodology. They were informed about the differences 
between the questions asked during a quantitative and a qualitative survey. They were 
also oriented to various participatory evaluation methodologies like FGDs, IDIs and Key 
informant interview. MOH officials (mainly Wasors from each districts), Kaders, one ex 
TB patient and local NGO members participated in the tool finalization workshop. On the 
second day of the workshop, district teams were constituted (comprising of CARE staff 
and ample representation of stakeholders on each team) and they underwent training in 
interviewing techniques through role play. 
 57
 
Not many team members had prior experience in survey methodology, however, each 
district team leader was asked to spend time with their teams to review the tools further. 
Each team was given a synthesis format so as to maintain consistency on district reports. 
List of various tools used is at the end of this section. 
Since the qualitative teams were to cover a total of twelve health facilities it was decided 
that the KPC team would carry out additional facility assessments in order to provide 
ample quantitative data on facilities. 
Sampling
Purposive sampling was carried out to identify field areas. Three Puskesmas areas - some 
functioning well and some performing poorly were selected. Teams visited villages and 
communities in these areas to carry out discussions and interviews. 
Conducting the survey
Over the next five days, four teams with 4-5 members each visited 22 Villages and 4 
urban wards in the four project districts and met a total of 297 people. These included TB 
patients, TB associations, community members, religious leaders, volunteers, CBOs, 
Puskesmas staff, Private providers and District/Province level MOH officials. Consultant 
visited communities in two project areas - Tangerang City and District; details of tasks 
carried out are listed in the evaluation schedule. The full list of communities and health 
facilities visited, and list of persons interviewed is included in the annex C “Interviews, 
Contacts and Participants”. 
Synthesis of data
Each district team synthesized the findings in a participatory manner and listed the key 
findings, lessons learnt and recommendations. The district reports were presented to the 
entire evaluation team. These presentations were attended by Junior and Senior Technical 
Program Leader Health and Assistant Country Director Programs, CARE Jakarta. 
KPC 
The KPC survey was conducted parallel to the qualitative evaluation and was designed 
and led by Pak Abdul Manaf the local consultant and Dr. Lutfi. The collection of data 
was carried out by external enumerators. A 30 x 10 cluster sample technique was 
employed to collect data on three to four knowledge indicators. The final report of the 
survey is being submitted as a separate document. While KPC covered the entire project 
area the qualitative survey included only those areas where MITRA had initiated 
activities. 
Debriefing
Separate meetings were held to debrief Senior Project and CII staff, local USAID 
Mission and NTP at Jakarta. The project is expected to share the district level findings 
with key district stakeholders at a later date. 
 58
 
Annex C: List of Persons Interviewed and Contacted 
Name Designation 
CARE International Indonesia 
Dr. Khrist Roy Technical Advisor Child Health, CARE Atlanta 
Ms. Heather Van Sice Assistant Country Director, Programs 
Dr. Damayanti D Soekarjo
 
Technical Program Leader, Health and Nutrition 
Mr. Frank Page Urban Program Manager 
Dr. Sri Kusuma Hartani Junior Technical Program Leader, Health 
All MITRA staff 
Central NTP/KNCV/WHO 
Dr. Carmelia Basri Head NTP, Sub- Directorate TB, MOH 
Mr. Cecep Slamet Budiono National Technical Officer, KNCV 
Mr. Sjoerd Postma Country Representative, KNCV 
Ms. T. Candyana Yohan ACSM Partnership Officer
USAID Local Mission 
Ms. Lisa Baldwin Senior HIV/AIDS Technical Advisor 
Ms. Gretchen Antelman Senior MCH Advisor, Basic Human Services
Provincial Level 
Mr. Akhmad Zubaidillah Chief of Social and Cultural Division of Banten Province 
Planning Commission 
Ibu Nurmetia Staff member 
Tangerang District 
Respondent Tool Number Area 
TB Patients FGD/IDI 2 Kosambi Dalem and Salembaran Jati 
Community members 
including religious 
leaders 
FGD 2 Pisangan Jaya village and Kosambi Dalem 
Volunteers FGD 2 Salembaran Jati, Kosambi Dalem 
TB Post staff IDI 1 PKM* Sepatan 
Puskesmas staff IDI 7 PKM Kosambi, PKM Sepatan, PKM Walwis 
Facility assessments Checklist 3 PKM Kosambi, PKM Sepatan, PKM Walwis 
Lab assessments Checklist 3 PKM Kosambi, PKM Sepatan, PKM Walwis 
Clinical Observations Checklist 3 PKM Kosambi, PKM Sepatan, PKM Walwis 
and Dinkes lab 
District Dinkes Staff IDI 2 Tangerang District 
Provincial Dinkes
Staff 
IDI - - 
Private Practitioners IDI 2 Pamulang Barat 
*PKM: Puskesmas
 59
 
Tangerang City 
Respondent Tool Number Area 
TB Patients IDI 7 Jatiuwung, Sukasari, Pabuaran Tumpeng and 
Karawaci Baru PKM 
Community members 
including religious 
leaders 
FGD 2 Karawaci Baru and Jatiuwung PKM 
Volunteers FGD 2 Jati Uwung, Posyandu Aster, Sudimara 
selatan village and Cileduk ward 
TB Post staff IDI - - 
Puskesmas staff IDI 13 Jatiuwung, Sukasari, Pabuaran Tumpeng and 
Karawaci Baru 
Facility assessments Checklist 4 Jatiuwung, Sukasari, Pabuaran Tumpeng and 
Karawaci Baru 
Lab assessments Checklist 4 Jatiuwung, Sukasari, Pabuaran Tumpeng 
Karawaci Baru 
Clinical Observations Checklist 5 
District Dinkes Staff IDI 4 Tangerang City Dinkes
Provincial Dinkes
Staff 
IDI - - 
Private Practitioners IDI - - 
Industrial Clinic Meeting 
With 
management
1 Sulin Dufin Industry 
Cilegon City 
Respondent Tool Number Area 
TB Patients IDI 1 PKM Ciwandan 
Community members 
including religious 
leaders 
FGD 1 PKM Cibeber 
Volunteers FGD 1 Kel. Banjar Negara 
TB Post staff IDI -- - 
Puskesmas staff IDI PKM Cibeber and PKM Pulo Merak 
Facility assessments Checklist 2 + 1 PKM Cibeber, PKM Pulo Merak and RSKM 
hospital or the Krakatua Medika Hospital (this 
private hospital belongs to the Krakatua 
Steel) 
Lab assessments Checklist 2 PKM Cibeber, PKM Pulo Merak 
Clinical Observations Checklist 6 
District Dinkes Staff IDI 4 
Provincial Dinkes
Staff 
IDI - - 
Private Practitioners IDI 2 + 3 Cilegon City + 3 hospital staff 
Industrial Clinic IDI 2 Indonesia Power 
 60
 
Pandeglang District 
Respondent Tool Number Area 
TB Patients IDI 1 Labuan PKM 
Community members 
including religious 
FGD 2 Village of Batu Ranjang Sub-District of 
Cipeucang and BKB of Caringin Sub-District 
of Labuan 
Volunteers FGD 3 Labuan, Bojong, Panimbang PKM 
TB Post staff IDI 1 Village of Mogana Sub-District of Banjar 
Puskesmas staff IDI 9 Labuan, Bojong, Panimbang PKM 
Facility assessments Checklist 3 Labuan, Bojong, Panimbang PKM 
Lab assessments Checklist 3 Labuan, Bojong, Panimbang PKM 
Clinical Observations Checklist 5 
District Dinkes Staff IDI 1 Pandeglang District 
Provincial Bapeda IDI 2 Pandeglang 
 61
 
 62
 
Annex D: Evaluation Schedule and Activities 
Date Activity 
Wednesday 
31 Oct 2007 
Consultant arrival in Tangerang 
Meeting with MITRA team; preparation for tools workshop 
Thursday 
1 Nov 2007 
Meetings with NTP, WHO, KNCV and CII senior management 
Team led by Urban Program Manager was split into small groups to review 
tools 
Friday 
2 Nov 2007 
Tools finalization; orientation to qualitative methodologies; practicing 
techniques through role plays; district team formation and logistics 
Saturday 
3 Nov 2007 
Additional sessions with MITRA staff and KPC enumerators 
Sunday 
4 Nov 
Team took off, Consultant reviewed draft BCC strategy 
Monday 
5 Nov - 
Friday 
9 Nov 
Field work, places visited and people met in Annex C 
Saturday 
10 Nov 
Orientation to evaluation team on process of synthesis 
Sunday 
11 Nov 
Team took off, consultant reviewed national TB survey document 
Monday 
12 Nov 
Synthesis workshop – to collate findings and recommendations in a 
participatory manner 
Tuesday 
13 Nov 
Findings and recommendation sharing by district evaluation teams 
Wednesday 
14 Nov 
Sharing of findings with USAID local mission; Internal debriefing for CII 
senior management and meeting with KPC team 
Thursday 
15 Nov 
 Debriefing with Dr. Carmelia Basri, NTP and consultant’s departure from 
Indonesia 
 63
E. Action Plan 
The following Action Plan was developed by CARE MITRA staff and managers based 
on preliminary recommendations following the MTE in November 2007. 
Recommendation Current 
Status
CS Project 
Plans 
Responsible Target Date 
Key Strategies 
1) Coordinate with 
Dinkes and 
Puskesmas to 
ensure drug stocks 
and that individual 
boxes are meant for 
only one patient. 
Seek help at 
different levels to 
address this issue. 
Some 
Puskesmas 
have reported 
stock outs 
temporarily and 
sporadically. To 
cope some of 
them have 
reached to other 
HF to share 
medicines and 
or started 
sharing 
medicine boxes 
of patients 
As this matter is 
both Important 
and Urgent – 
MITRA will use 
the 
dissemination 
meeting 
platform at 
district and 
province level 
to share the 
finding and 
making aware 
the DOTS 
guidelines do 
not permit 
sharing of 
medicines and 
will strive to 
find the cause of 
disruption of 
supplies and 
address the gap 
at all levels. 
MITRA will 
include in all 
quarterly M&E 
agenda at all 
levels – sub￾district, district 
and province – 
DOTS stock 
issues. Thus 
ensuring 
sustainability of 
stock supplies 
issues 
Facilitating 
access of the 
formats at 
community and 
All MITRA 
staff and 
reporting 
centers for 
DOTS 
Feb 2008 
Recommendation Current 
Status
CS Project 
Plans 
Responsible Target Date 
health facility 
levels. 
2) Pediatric TB 
diagnosis is 
according to 
national guidelines. 
Almost all 
puskesmas have 
Pediatric TB 
patients enlisted 
for DOTS. 
Very few 
puskesmas have 
more pediatric 
TB patients 
than adult TB 
patients. 
a) Orientation of 
HF staff on use 
of national score 
card b) Bring 
the issue up in 
the 
dissemination 
and quarterly 
M&E meetings 
at all district 
level. 
 all MITRA 
staff. 
February 2008 
3) 
BCC related 
a) Existing and 
Available IEC 
material to be 
used by HW 
and volunteers 
b) Come out with 
MITRA BCC 
strategy which 
is line with 
NTP and 
includes 
HIV/TB 
intersection 
c) Use Sundanese 
language IEC 
materials as 
needed 
a) MITRA 
to help 
distribute 
existing BCC 
material in the 
4 districts 
b) Draft BCC 
strategy is 
ready – BCC 
workshop 
needed to 
garner 
consensus on 
strategy and 
material 
a) MITRA 
will facilitate 
use of currently 
available BCC 
material. 
b) MITRA 
will organize 
BCC workshop 
c) Material 
in Sudanese 
language will be 
made 
a) PM/TC to 
identify 
currently 
existing IEC 
material and 
FO to use and 
distribute in 
the community 
b) PM 
organizes 
BCC 
workshop 
c) All MITRA 
staff to help 
facilitate its 
use and 
monitor BCC 
activities that 
ensue in the 
community 
a) December 07 
b) BCC workshop 
January 2008 
c) BCC material 
distribution in 
March 2008 
4) Strengthening 
of CBOs 
a) Increase number 
of Pagubayans 
b) Work with local 
CBOs, FBOs, 
NGOs to increase 
geographical 
coverage 
a) Currently 4 
pagubayans 
active. 
b) A few 
Religious 
leaders are 
working with 
MITRA. 
c) Many
CBOs are 
a) More 
pagubayans will 
be formed. 
b) Work 
with PMO 
coordinators 
Kaders will be 
increased 
c) Where ever 
possible work 
with religious
a) TC 
will take lead
on work on 
pagubayan 
formation. 
b) FO 
will take lead
on work with 
PMO 
Coordinators 
c)PM will 
a) Ongoing
activity 
b) Ongoing
activity 
c) Partnership 
strategy approved 
by Feb 2008 
d) Based on 
lessons learnt
from partnership 
formal contracts 
Recommendation Current 
Status
CS Project 
Plans 
Responsible Target Date 
working with 
MITRA 
informally like 
KuIS, PKK etc. 
leaders will be 
increased. 
lead on 
religious 
leaders and 
NGOs by 
outlining a 
partnership 
strategy 
which will be 
translated into 
action by TC 
and FO 
d) Other 
opportunities 
to work with 
partners will 
be identified 
will be entered 
into. 
Information sharing and use 
 5) Piggy back with 
MOH/KNCV 
initiatives to work 
with PP 
a) PP 
b) Private Bidans 
c) Industries and 
Hospitals 
MITRA is 
already holding 
discussions 
with KNCV 
and MOH 
regards work 
with all of the 
mentioned 
private players 
and has MOU 
with some of 
these 
independently 
or with their 
agencies. 
a) Use successes 
of Cilegon for 
working with 
PPs and 
industries in 
other districts. 
b) Pandeglang 
to try this model 
after referral 
from the 
puskesmas. 
c) Again use the 
Cilegon model 
for work with 
industries in 
Tangerang 
Kota, and work 
in tandem with 
KNCV on 
hospitals. 
Review C-HIS, 
strengthen the 
feedback route
for use of 
information at 
community 
level. 
a) TC 
b) TC 
Pandeglang 
c) All TCs 
Ongoing activity 
Recommendation Current 
Status
CS Project 
Plans 
Responsible Target Date 
6) Improve 
Coordination with 
Dinkes and expand 
definition of 
coordination to 
include problem 
solving 
Regular 
quarterly
meetings are 
held with MOH 
1) Joint 
supervision 
visits to be 
made regular 
and focus on 
problem
solving using 
supportive 
supervision 
checklists 
2) MITRA 
to support all 
M&F 
meetings at 
all levels 
1) PM 
responsible for 
generation of 
Supportive 
supervision 
checklist 
2) All staff to 
attend M&F 
meetings at 
their levels 
Ongoing activity 
Attachment F - MTE Health Facility Assessment – MITRA Project – Banten Province 
November 2007 
Objectives of the Health Facility Assessment 
The main purpose of conducting this health facility assessment in CARE’s project areas in Indonesia is to 
assess the performance of DOTS treatment centers for TB patients and to obtain information on key 
indicators for health services, including availability of laboratory facilities and adequate supervision in the 
district. The findings of the health facility assessment will be compared to baseline data for CARE’s project 
area to assess if project activities and interventions helped to achieve original targets for given health 
indicators. 
Specific Objectives of the Health Facility Assessment: 
1) To assess and determine quality of health care delivered to TB patients at DOTS treatment and 
outreach facilities 
2) To assess and determine availability of key health system supports that are required for treatment of 
TB patients, such as laboratory equipment and adequate supervision 
3) To assess and determine the availability of correct treatment practices for TB patients in DOTS 
treatment centers, including adequate drugs and treatment supporters 
4) To make comparisons between the baseline and current survey findings 
Methodology 
Selection of HF
HFA was planned to be done in conjunction with the KPC 30x10 survey. 
Hence the closest puskesmas/HF to the selected KPC village was chosen for the survey making the selection 
of HF random. For the lab facility only 10 sites were chosen where all the team leaders would go individually 
and report it themselves, this was done to ensure quality reporting for the laboratories which in some districts 
were considered to be weaker and needed strengthening. 
Training of Survey team
The survey training team was led by the external consultant and re-enforcement was done by individual 
district team leaders who included Pak Manaf, Pak Lukeman, Dr. Ranjini, Dr. and Dr. Khrist. The teams 
were exposed to the standardized tools, their inputs taken and lead by the team leader the first few days. 
Tools used
Standardized tools were used by all team members as checklists to ascertain the current practices in the HF. 
Initially three sets were designed to be used for the HF 
a) The DOTS facility tool 
b) The laboratory tool 
c) Patient observation and exit interview – as there were very few patients in the facilities visited, the 
survey did not get significant numbers to do an analysis of the numbers. We would like to recommend 
that greater number of days are needed per facility to get adequate numbers of patients for 
observation 
Table One: DOTS TB Center Performance (n=26) 
 (Missing values are not show but add to 100%) 
Measured Indicator Frequency Percent 
DOTS Facilities Clean 
Yes 17 73.9 
No 6 26.1 
Adequate Arrangement for Provision of 
Injectable SM 
Yes 20 87 
No 3 13 
Prompt Home Visits Made to Bring 
Irregular Patients Back to Treatment 
Yes 23 95.8 
No 1 4.2 
Any Drugs in Patient Boxes Past 
Expiration Date 
Yes 2 9.5 
No 19 90.5 
Home Address Verification Done for 
Patients Before Treatment Starts 
Yes 21 95.5 
No 1 4.5 
Timing of Last Supervisory Visit of TB 
Officer 
> 1 month ago 2 10 
1-3 months ago 8 40 
3-5 months ago 8 40 
5-7 months ago 1 5 
9-11 months ago 1 5 
Drug Boxes are Being Marked and 
Maintained for Outpatients Receiving 
Treatment at the DOTS Center 
Yes 19 82.6 
No 4 17.4 
Consistency between Doses on Treatment 
Card and Doses in Patient’s Box 
Yes 11 57.9 
No 8 42.1 
Summary Findings from Table One: The majority of drugs that are provided to patients appear to be recent 
drugs that are not expired, indicating that available drugs are being used by health facilities. However, less 
than 60% of the drugs being disbursed to patients are being effectively tracked to see that they are used 
according to the treatment regimen prescribed. The drugs prescribed versus the drugs in the box of the 
patient are matching exactly in over 40% of those facilities surveyed. 
Prompt home visits are being made to keep patients in treatment, and home addresses are most often 
collected prior to treatment to enable these home visits. Other services listed above appear to be available in 
most sites, and supervisory visits are occurring on a mostly quarterly or less than quarterly basis it appears.
Table Two: Lab Facilities Assessment (n=10) 
Measured Indicators Frequency Percent 
Existence of Distinct Lab 
Space 
10 100% 
Existence of Standard 
Operating Procedures 
10 100% 
Presence of Lab Register 10 100% 
Functional Binocular 
Microscope 
10 100% 
Trained lab technician 
performing sputum 
microscopy 
Yes-7 
No-2 
Yes-77.8% 
No-22.2% 
Adequate reagent, slides, and 
consumables for one month’s 
time 
10 100% 
Monthly summary of 
microscopy activities 
Yes-9 
No-1 
Yes-90% 
No-10% 
Lab technician preserving 
slides for review by 
supervisor as per quality 
assurance protocol 
Yes-8 
No-1 
Yes-88.9% 
No-11.1% 
Is biomedical waste disposed 
as per norms 
Yes-8 
No-1 
Yes-88.9% 
No-11.1% 
Lab engages in 
Mycobacterium culture and 
drug susceptibility testing 
10 100% 
Slides maintained for internal 
quality 
10 100% 
Table Three: Supervision Assessments (n=10) 
Measured Indicators Frequency Percent 
Occurrence of lab 
supervisory visit 
Yes-9 
No-1 
Yes-90% 
No-10% 
Supervisor is reviewing 
preserved slides onsite 
Yes-9 
No-1 
Yes-90% 
No-10% 
Monthly supervisory reports 
available onsite for at least 
one month 
Yes-8 
No-2 
Yes-80% 
No-20% 
Correction actions 
recommended by reports 
being carried out 
Yes-7 
No-2 
Yes-77.8% 
No-22.2% 
Summary of Findings from Table Two and Three: Out of eleven indicators to assess adequate laboratory 
facilities, seven are being met in all health facilities surveyed. Of the four that remain, the two of greatest 
concern are that only 7 facilities report having a trained technician perform sputum microscopy; this could 
potentially create problems with diagnosis, especially since only 8 facilities report actually keeping slides for 
review as per the quality assurance protocol, again brining into question possibly flawed diagnoses. 
None of the indicators to assess adequate supervision were met by all health facilities. Most notable among 
these indicators however is that the lowest percentage is reported for the indicator of “corrected actions 
recommended by reports being carried out.” Even if supervisory visits are occurring, if no changes are being 
made accordingly, then these visits are wasted time and resources. 
Table Four: Stock Out Table (n=26) 
Sum
mary 
of 
Findi
ngs 
from 
Table 
Four: 
Stock 
outs 
appea
r to 
be a 
huge 
problem in these health facilities surveyed. In all cases, nearly half of the facilities report not having adequate 
supplies. 
Measured Indicators Frequency Percents 
Registers 
Yes 14 58.3% 
No 10 41.7% 
TB Forms 
Yes 14 58.3% 
No 10 41.7% 
IEC Material 
Yes 14 56% 
No 11 44% 
Counseling Material 
Yes 11 45.8% 
No 13 54.2% 
Table Five: Prevalence of TB in Patients 
Name of Puskesmas TB suspects examined for 
diagnosis in the last 
month 
TB suspects found to test 
positive 
PKM Waliwis 414 52 
PKM Sepatan NA NA 
PKM Kosambi 127 65 
PKM Bokang 26 5 
PKM Banjar 379 48 
PKM Sukasari 60 5 
PKM Karawaci baru 28 5 
PKm Babuaran Tumpeng 303 61 
PKM Pulau Merak Cilegon NA 48 
PKM Cikole NA NA 
PKM Bangkonol 4 3 
PKM Ciputat 57 2 
PKM Rajeg 44 9 
PKM Kronjo 15 4 
PKM Jambe 27 7 
PKM Karawaci Baru 28 5 
PKM Tigaraksa 40 13 
PKM Jombang 43 3 
PKM Cisoka 37 5 
PKM Pagadungan 7 4 
PKM Cisauk 21 2 
PKM Cikedal 9 5 
PKM Carita 15 5 
PKM Cikupa 55 6 
PKM Mauk 67 4 
PKM Pakuhaji 41 7 
Summary finding of Table 5 
There is a huge variation in the numbers of TB suspects being referred and diagnosed, while a lot maybe 
explained by differing catchment population, the project needs to take a closer look at the wide variability. 
Table Six: Prevalence of Positive TB Slides 
Sub District Total 
examined 
slides 
Total positive 
slides 
Total 
negative 
slides 
Total 
positive 
slides (%) 
Total 
negative 
slides (%) 
Sepatan 
Kosambu 127 5 3 3.9% 2.4%
Labuan 54 13 41 24.1% 75.9%
Banjar 165 27 138 16.4% 83.6%
Sukasari 180 15 165 8.3% 91.7%
Karawaci 
Baru 30 15 15 50.0% 50.0%
Pabuaran 
Tumpeng 144 71 73 49.3% 50.7%
Pulo Merak 118 12 103 10.2% 87.3%
RSKM 
Cilegon 320 22 298 6.9% 93.1%
Cibeber 336 117 219 34.8% 65.2%
**Note that the range of percent positive slides ranges from less than 7% to 50%, indicating the existence of 
a wide range of infection depending upon sub-district location.** 
Summary of findings of Table 6 
Again a wide variation is seen in the slide positivity rate, some centers are showing only 4% positive rate while 
others are showing around 50%. This can be explained by differences in numbers and type of suspects being 
referred to the facilities. 
Table Seven: Patient Performance and Treatment 
Name of 
Puskesmas 
Number of 
patients 
registered 
(I.17) 
Number of 
dedicated 
drug boxes 
(I.18) 
Adequate 
Drug 
Boxes 
(Y/N) 
Number of 
defaulters 
(I.19) 
Number 
with 
treatment 
supporters 
(I.20) 
Adequate 
Treatment 
Supporters 
(Y/N) 
PKM Waliwis 52 52 Y 0 52 Y
PKM Sepatan 153 123 N 0 153 Y
PKM Kosambi 65 55 N 3 65 Y
PKM Bokang 21 8 N 1 6 N
PKM Banjar 38 38 Y 10 38 Y
PKM Sukasari 
PKM Karawaci 
baru 84 84 Y 3 84 Y
PKm Babuaran 
Tumpeng 144 112 N 10 114 N
PKM Pulau Merak 
Cilegon 30 62 Y 0 62 Y
PKM Cikole 25 25 Y 1 25 Y
PKM Bangkonol 20 2 N 0 1 N
PKM Ciputat 171 150 N 14 106 N
PKM Rajeg 13 117 Y 3 117 Y
PKM Kronjo 118 118 Y 0 118 Y
PKM Jambe 81 5 N 3 81 Y
PKM Karawaci 
Baru 84 84 Y 3 84 Y
PKM Tigaraksa 40 10 N 0 13 N
PKM Jombang 43 10 N 0 3 N
PKM Cisoka 37 15 N 1 5 N
PKM Pagadungan 21 2 N 0 5 N
PKM Cisauk 6 116 Y 0 115 Y
PKM Cikedal 5 6 Y 0 5 Y
PKM Carita 15 N 0 5 N
PKM Cikupa 128 135 Y 5
PKM Mauk 139 139 Y 3 139 Y
PKM Pakuhaji 175 175 Y 1 175 Y
Summary of Findings from Table Seven: Out of 26 total health facilities surveyed for the patient treatment 
indicators noted above, 12 facilities report not having adequate drugs and 9 report not having adequate 
treatment supporters for TB-positive patients. These both indicate major deficiencies in the supplies and 
personnel at DOTS treatment centers. 
Conclusion
The above results from surveyed health facilities indicate that major problem still exist with DOTS treatment 
ers 
centers not having adequate drug supplies and health personnel. Laboratory facilities are adequate for the 
most part, and patient follow up through the treatment centers appears to be adequate as well. DOTS cent
do need to improve upon implementing recommendations made by supervisory visits and also improve upon 
tracking exactly how drugs distributed to patients are being used. 
Attachment G - Results of Knowledge Attitude and Practice for TB using the 
30x10 cluster technique at the community level in four districts of Banten Province 
Table of Contents 
RESULTS OF RAPID QUALITATIVE ASSESSMENT 
AT THE COMMUNITY LEVEL 
BACKGROUND ……………………………………………………………………………………………1
METHODS..................................................................................................................................................... 3
FINDINGS AND RESULTS………………………………………………………………………………..4
SOCIO-DEMOGRAPHIC DESCRIPTION OF RESPONDENTS…………………………………………………...4 
Presence of TB symptoms in the family…………………………………………………..5 
Causes of TB disease………..…………………………………………………………….6 
Key TB knowledge indicators at the community level…..……………………………….7 
Conclusion………………………………………………………………………………...8 
List of villages visited for the 30x7 cluster……………………………………………….9 
 
 
Prepared by Dr. Manaf 
March 11, 2007 
For CARE’s MITRA TB project program, Tangeran 
1
Background 
CARE International Indonesia works in four districts and municipalities in Banten 
province on the island of Java, the most populated area of the country. These include 
Tangerang District, Pandeglang District, Tagnerang City, and Cilegon town. Funded by 
USAID under CSHGP (2005- 2009), CARE’s MITRA project worked towards the goals 
of reducing morbidity and mortality due to TB in project areas by increasing community 
knowledge and promoting behavior change in regards to healthy TB practices. 
Tuberculosis was declared an emergency disease by the World Health Organization in 
2003. Worldwide, TB kills approximately 2 million people annually. Indonesia ranks 
third globally for the highest TB burden, with an estimated incidence of smear-positive 
cases of 107 per 100,000 population. Regional variances in this number range from 64 
per 100,000 in Bali to 210 per 100,000 in the Eastern provinces. An annual total of 
approximately 100,000 deaths occur, the majority of which are in the economically 
productive age groups. CARE’s MITRA project aims to combat this serious TB problem 
in the project areas by working with the NTP to increase the case detection rate (CDR) 
while holding the TSR to their currently high levels. 
Since 2005, the project has undertaken the following activities to accomplish its strategic 
objectives: 
1.1 Built capacity of community-based structures (CBS) to implement TB control 
activities. The volunteer groups will implement TB control activities and act as 
community based treatment observers (CBTOs, also called as kaders, PMO coordinators 
and PMO). The project will also build the capacity of places of worship for awareness 
building on TB/DOTS, services available and stigma reduction messages. 
1.2 Built the capacity of volunteer health workers to generate community awareness and 
support TB patients and their families to fully participate in DOTS. These volunteer 
health workers will generate awareness for early health care seeking behavior in the 
community, support patients and families for treatment regularity and success and link 
with treatment observer supervisors (identified staff at puskesmas. 
2.1 Untrained TB/DOTS health staff oriented/trained on DOTS at the district and health 
center levels. 
2.2 Developed working partnerships with the NTP, KNCV, WHO, district and provincial 
tuberculosis officials and other stakeholders like the Indonesian Physicians Association 
(IDI), Indonesian Pulmonologists Association (PDPI), and Indonesian Pediatricians 
Association (IDAI) 
3.1 Built capacity of Private Practitioners (PP) to adopt the DOTS strategy for TB 
treatment. 
These activities at the community level are expected to increase correct and healthy TB 
knowledge, attitudes, and practices in the population with the ultimate goal of reducing 
morbidity and mortality from this devastating disease in project areas. 
2
Objectives: 
The objectives of the survey undertaken were as follow: 
1. To describe the knowledge, attitude, and practice regarding TB among the 
community in two districts and two municipalities of Banten Province. 
2. To compare findings about community-level factors that might have either 
positive or negative influence on the success of the TB control program between 
the baseline and MTE surveys. 
3. To inform MTE on project progress and give recommendations for future 
direction of the project. 
Methodology: 
The latest data on the total population of the four districts provided by the Provincial 
Health Office of Banten Province is as given below. 
• Total population of Tangerang City was 1,488,666 
• Total population of Tangerang District was 3,317,331 
• Total population of Cilegon City was 319,555 
• Total population of Pandeglang District was 1,062,813 
Thus, the total coverage population was 6,188,365. All four districts were divided into 
cluster proportional to size, with each cluster being represented by one village chosen 
randomly. Within each village (cluster), 10 households were chosen randomly using the 
method outlined below: 
1. Sampling Interval and random numbers were generated using standard 
methodology. 
2. In the village the bottle spin technique was used to select the direction from the 
center of the village. 
3. Along the selected street of the village, households having a door closest to each 
other were interviewed till 10 such houses were covered. 
4. If the respondent was not available, enumerators went to the next closest door. 
3
5. Only one village was substituted (closest to the chosen village) as the first 
randomly selected village was not motor able. 
 The tools used in the MTE were the same as those used to complete the baseline survey, 
with minor changes to the general socio – demographic indicators and the addition of a 
variable on poverty status (percentage of Gakin cards, also known as poor cards). 
Findings and Results: 
Table One: Socio-demographic status of families 
SN Variable Baseline (2005) MTE (2007) Other Sources 
TB prevalence survey 
2004 (NIHRD – 
Indonesia MOH) 
1. Total number of respondents 363 330 708 
2. Gender distribution of 
respondents 
Women 69% (51.57%); 
3. Total number of family 
members 
1629 72,705 
4. Poverty Status (Gakin Card 
or poor card) 
18.2% This specific info is 
not available 
5. Type of House Permanent – 73% 
Semi Permanent – 
16% 
Non- Permanent – 
10% 
Upper Class – 14% 
Middle Class – 53% 
Lower – 37% 
This specific info is 
not available 
6. Distance from Puskesmas This specific info is 
not available 
The total number of respondent households for the MTE KPC was 330 (age greater than 
17 years) 69% of whom were women. The total number of individuals covered in the 
4
households through the survey was 1629, with a subpopulation of 828 women. This 
sample over represented females slightly compared to national surveys where only 
51.57% of the sampled population was female. 
A new poverty variable was added to the MTE, measuring the prevalence of poor card 
holders in the population since TB is known to be both a cause and an effect of poverty. 
Gakin card or poor card holders were 18% of the sample, which closely mirrors the 
national level of poverty, but this percentage could be expected to be higher in poorer 
districts like Tangerang, Kabupaten, and Pandeglang. The poverty level might be better 
reflected by the type of housing or social class, and it appears that 37% of housing could 
be classified as dwellings for the poor in this sample. 
 
Table 2: Presence of TB symptoms in the families 
SN Variable Baseline (2005) MTE (2007) Other Sources 
TB prevalence 
survey 2004 
(NIHRD – 
Indonesia MoH)
1. Productive cough persisting 
greater than 3 weeks 
16% 15% 8.3% 
2 Fever 5% 9% 30.4% 
3 Weight Loss 10% Not 
Mentioned 
25,9% 
4 Haemoptysis 5.8% 8% Not available 
5 Night Sweat 12.7% 13% 28,6% 
6 Lack of appetite 9.1 Not 
Mentioned 
30,9% 
7 Difficulty in breathing 3.3% Not 
Mentioned 
47,3% 
8 Chest Pain Not Mentioned 22% 42,6% 
About 15% household members were reported to have productive cough for greater than 
3 weeks. This number was very different from the findings of the National Health 
5
Survey. In 2001, the National Health Survey found 37% of the respondents complained 
of coughing (not productive cough however). This frequency of productive cough in 
households was not significantly different however from the percentage found in the 
baseline survey in the same project areas, although symptoms frequencies did change 
somewhat but lower than the national survey and might be explained by the survey 
conducted in different seasons. 
Table 3: Known Causes of TB disease 
SN Variable Baseline (2005) MTE (2007) Other Sources 
TB prevalence 
survey 2004 
(NIHRD – 
Indonesia MoH)
1. Bacteria 9% 12% 51.1% 
2 Hereditary 1.1% 11% 12.6% 
3 Smoking related 0.6% 26% Data not available, 
4 Alcohol intake 3% 62.6% 
(includes 
transmission 
through food) 
5 Fatigue 1% 2% Data not available 
6 Others 20.7% 23% 17.8% 
Though the understanding of the actual cause of the disease does not seem to be clear, the 
category of bacterial infection seems to have improved during project duration in 
intervention areas (though still far below the prevalence in the national survey), the 
findings are not consistently positive. Causes such as hereditary, smoking, and alcohol 
intake were all reported as major causes of the disease. This survey can suggest that 
levels of knowledge about the disease and its potential causes are increasing; it does not 
have sufficient strength to suggest however that the changes or significant or positive, nor 
to claim that the changes are due to MITRA project activities alone. 
6
Table 4: Key TB Knowledge Indicators in the community 
SN Variable Baseline (2005) MTE (2007) Other Sources 
TB prevalence survey 2004 
(NIHRD – Indonesia MOH), 
for Banten province in Annex 
A.
1. Have heard 
about TB 
disease 
Not done in baseline 88.2% 92.4% 
2 If TB 
disease is 
curable 
86.5% 93.7% 88.2% 
3 Common 
Symptoms 
of TB* 
30.8% 50% 72% 
4 How is TB 
transmitted 
Cough & Sneeze - 37% 
Touching of patient – 8% 
Transmitted through food – 
22% 
Sharing of utensils - 
Sexual Intercourse – 0.6% 
Others – 9% 
Don’t Know – 21% 
Cough & Sneeze - 44% 
Touching of patient – 8% 
Transmitted through food – 
11% 
Sharing of utensils -36% 
Sexual Intercourse – 2% 
Others – 21% 
Violence (been hit on 
the chest: 1,1%; 
Curse/ Magic: 1,2%; 
Hereditary: 12,6%; 
Food: 62,6%; 
Droplet: 51,1%; 
Pollution: 43,4%; 
Others: 15,6%. 
*NIHRD – defines it as one main symptom. MITRA defines it as productive cough > 3 
weeks as the symptom. 
The findings here suggest that there have been real and positive changes in the level of 
knowledge in the community in regards to certain key TB information. Especially 
positive results were found with increased knowledge of common symptoms of TB, 
7
awareness of TB being a curable disease, and knowledge of modes of transmission for 
TB. 
These results indicate that despite a persistent prevalence of the disease and poverty in 
CARE intervention areas and lack of complete knowledge concerning the cause of TB, 
the project has made progress on educating the community on the recognition of TB as a 
curable disease and on ways in which it can spread throughout their villages. Increased 
knowledge on recognition and how to prevent transfer are likely to contribute to 
decreased transmission and incidence in the future. 
Conclusion 
A major objective of this MTE survey was to compare results from the baseline survey to 
these findings in order to outline future directions for CARE’s project. After comparison 
of the baseline and MTE KPC surveys, we note that there are certain key aspects of TB 
knowledge and understanding in the community which have improved in the last two 
years, including the following: 
1) More people understand that TB is a curable disease. 
2) More people identify and can recognize the common symptoms of TB. 
3) More people correctly identify the mechanism of transmission of TB in their 
communities. 
However, we also acknowledge the existence of certain areas where the improvement is 
not so clear, including: 
1) The number of community members that can correctly identify the true cause of TB 
2) The connection between gakin card holders (defined poverty-level households) and the 
incidence of TB in the community is not clear but also does not appear to be declining. 
The ultimate conclusion of this MTE is that efforts should be continued in areas where 
project interventions are likely having a positive effect and that CARE should increase 
BCC efforts to change misconceptions that still exist, in particular to clarify the true 
cause of TB. Stigma is likely to continue interfering with critical treatment and control 
8
efforts in the community as long as the population does not understand the true cause; 
this will work against the progress that has been made in increasing knowledge of how 
the disease spreads and in recognition of cases in the community and will ultimately work 
against the goal of decreasing morbidity and mortality due to TB. 
Therefore MITRA should increase efforts in BCC to change the misconceptions regards 
the areas found to be weaker and continue on efforts in areas which are considered to be 
strong. Stigma in community is less likely to go away till the population is not clear on 
critical communication aspects of TB disease.
Selected clusters in the four districts 
City / District Sub District / Village 
Kota Tangerang Tajur 
 KARAWACI BARU 
 GEBANG RAYA 
Kab. Tangerang Budi Mulya 
 Dukuh 
 Sarua 
 Cipayung 
 Rengas 
 Cisauk 
 Selapajang 
 Kadu 
 Kutruk 
 Rawa Burung 
 Tamiang 
 Kronjo 
 Kedung Dalem 
 Cihuni 
 K o h o d 
 Pondok Cabe Ilir 
 Mekar Bakti 
 Gelam Jaya 
 Pondok Kacang Barat 
 Jurang Mangu Barat 
 Mekarsari 
 Pondok Jaya 
 Rawa Buntu 
 Gintung 
 Tegal Angus 
 Cileles 
9
Kab, Pandeglang 
 Pagadungan 
 kawoyang 
Kota Cilegon 
 Kalitimbang 
10





MITRA Tools Draft: 24 October 
TB Patients 
Focus Group Discussion Topic Guide for TB Patients 
MITRA (TB Project) Mid Term Evaluation 
CARE International Indonesia
Topic Discussion/Transitions 
Introduction 
and Greeting 
Facilitator’s and Observer’s name, appropriate greetings 
Purpose of FGD We are from CARE and have been working on a project to improve 
treatment and cure of TB in (Name of the Kaleruhan). Since you are 
a TB patient your ideas and feelings can help us understand how our 
project is performing and inform us about any changes that we can 
incorporate to improve TB care. May we begin the discussion? (Allow for 
those who do not want to participate in the discussion leave). 
No right or 
wrong answers 
We would just like to know your frank opinion. There is no right or 
wrong answers to any of the questions. This is not a test. We just 
want to learn from you 
Length of time The discussion would take about an hour 
Talking to one 
another 
As we will be discussing about each of your opinions, it will be 
important that we do not talk at once because we will want to hear 
each other so we should not talk together. Every body should try and 
participate and every body will be given a chance to put forth their 
views. If you have any queries they would be addressed at the end. 
Explain note 
taking 
Confidentiality 
(Name of Observer/reporter) will be writing down some of the 
things that we will be talking so we can remember later. Does 
anyone object? We are the only ones who will know your names, we 
will not use any names in our reports 
Checking 
understanding 
Clarify 
Does everyone understand what I have said? Does anyone have any 
questions? 
Participants 
introductions 
(Warm up) 
Please introduce yourselves 
Let us begin: 
Did you know about TB before you contracted it? 
When do we say that a person is suffering from TB? 
General 
Do you know of any others who have suspected TB either in 
your family or in your community? 
MITRA Tools Draft: 24 October 
TB Patients 
Have these people sought care or are on treatment? If yes from 
where? 
• How is TB caused? 
• What are the main symptoms of TB? 
• How does TB spread? 
• What can be done to control the spread of TB 
• Can TB be cured? 
• What can be done to cure TB? 
• Have you heard of DOTS, if yes from where? 
• Have you heard of HIV? 
• What is the association between TB and HIV 
• Can TB be cured in people with HIV 
Knowledge 
• Have you heard of MDR TB? Why is it caused? Can this be 
prevented? 
Access to care • How many days of having got the symptoms did you seek 
care? 
• If response indicates a delayed seeking pattern then ask - 
When should you have sought care? 
• Whom did you approach for diagnosis and treatment 
• Why did you choose this particular facility or provider?
• If the interviewee prefers a private provider then ask - Why 
don’t you access a government facility? 
• Is there a TB provider (this may be a bidan, private doctor, 
or a community worker) near your house? 
• What was done to diagnose TB? Probe for various tests 
• What additional information did you receive from the 
provider? 
• After being diagnosed of TB, how long it took to start the 
treatment?
• Did you face any problems in treatment? Describe the 
problems. (distances, time, loss of wages, side effects, drug 
shortage, behavior of staff etc) 
• Do women in your community seek care the same way as 
men? 
Adherence to 
treatment 
• How long did your treatment last, if still on treatment then 
since how long have you been taking the medicines? 
• How long does it take to cure the disease?
• Can treatment be stopped if you are feeling better? 
• What happens when the treatment is not completed? 
• How often do you take the medicine? What happens when 
you forget to take medicine? 
• When do you think the patient is called as cured? 
• What are the symptoms of being cured? 
• Have you ever stopped taking your medicines or know of a 
MITRA Tools Draft: 24 October 
TB Patients 
person who has? 
• If so what were the reasons? 
• Is there anyone who supports you to take treatment? 
• If yes what has been this person’s role 
• Did you have to undergo any tests during treatment, how 
many times and why? 
• Have you received any enablers to complete your treatment 
(incentives) 
Stigma 
associated with 
TB 
• What reactions did you face once family and friends came to 
know of your tubercular status? Please describe 
• If there is a cured patient in your group ask him/her – would 
you feel comfortable talking about your success in cure to 
others? 
About project 
MITRA 
• Have you heard about CARE or MITRA? 
• If yes what are the activities being carried out under the 
project 
• How have the activities helped TB patients and community 
at large? 
• What are some of the activities you liked? 
• What are some of the activities you did not like? 
• What can be done to further fight the problem of TB? A) to 
increase knowledge of the community, b) to improve care 
seeking, c) to regularly ingest drugs and complete treatment, 
d) to improve services at facilities, e) to reduce stigma in the 
community 
IEC/BCC • Has someone ever shared any information regarding TB with 
you, if yes please describe some of the IEC material you may 
have seen? 
• Have you received any counseling or attended any talks 
about TB? If yes please describe what was discussed during 
these talks. 
Summary Mention main themes discussed and participant’s responses. Is there 
anything else that we talked about that I forgot to mention? 
Closure Thank you for your time. Do you have any questions that you would 
like to ask? I am not sure that I will be able to answer all of them, 
but I will try (Record all questions do not lecture) 
During FGD 
Recorder should keep notes by making cards for each section. Note responses on each 
card of respondents by numbering them as R-1 from the left of the facilitator and going 
clockwise around the room. Note if participants seem to all be agreeing with a statement 
or if there is a visible disagreement among participants when someone is speaking. Write 
down any quotes on a separate sheet provided for quotes. Note those quotes which are 
MITRA Tools Draft: 24 October 
TB Patients 
emphatic, well articulated and summarize the general feelings of the group for a 
particular topic. Responses during the introduction (all questions from introduction of 
facilitators through participant introductions) can be grouped together. 
After conducting the FGD 
Immediately after the session the facilitators should: 
a. Review the notes for clarity and understanding 
b. Compare and record observations about the group not readily clear from the notes 
c. Discuss and record any insights or ideas that the interview created while they are 
fresh in your mind 
d. Prepare a summary of the FGD for your team 
MITRA Tools Tools 1 
TB Patients 
Panduan Topik Focus Group Discussion untuk Pasien TBC 
MITRA Project (TB Project) Mid Term Evaluation 
CARE International Indonesia
Topik Diskusi/ Transisi 
Perkenalan 
Nama fasilitator dan pengamat 
Selamat pagi, siang, ...... 
Tujuan Diskusi Kami dari CARE dan bekerja dalam proyek ini untk memperbaiki 
pengobatan TB di (nama kelurahan). Karena Bapak/Ibu berada 
dalam wilayah proyek dan mungkin mengenal beberapa pasien 
TBC, ide dan perasaan Bapak/Ibu dapat membantu kami untuk 
memahami bagaimana proyek ini berjalan dan memberitahukan 
kami perubahan apa yang bisa kami lakukan untuk meningkatkan 
perawatan TBC. Bisa kita mulai diskusinya? (Berikan kesempatan 
bagi yang tidak ingin ikut diskusi untuk pergi). 
 
Tidak ada 
jawaban benar 
atau salah 
Kami hanya ingin mengetahui pendapat Bapak/Ibu secara jujur. 
Tidak ada jawaban yang benar atau salah. Ini bukan ujian. Kami 
hanya ingin belajar dari Bapak/Ibu 
Rentang waktu Diskusi ini akan memakan waktu sekitar satu atau dua jam 
Berbicara satu 
sama lain 
Karena kita akan membicarakan mengenai pendapat Bapak/Ibu, 
sangat penting kita tidak bicara pada saat yang bersamaan karena 
kita ingin mendengar satu sama lain, jadi kita tidak boleh bicara 
bersamaan. Semua orang harus berusaha untuk ikut serta dan semua 
orang akan diberikan kesempatan untuk mengutarakan pendapatnya. 
Apabila ada pertanyaan, bisa ditanyakan pada bagian akhir. 
Sampaikan 
mengenai 
kerahasiaan 
catatan 
(Nama Observer/reporter) akan menuliskan beberapa hal yang kita 
bicarakan jadi kami bisa mengingatnya kembali nanti. Apakah ada 
yang keberatan? Kami ingin mengetahui nama Bapak/Ibu, kami 
tidak akan menuliskan nama pada laporan. 
Memeriksa 
pemahaman 
Klarifikasi 
Apakah semuanya sudah memahami apa yang saya katakan? Ada 
yang punya pertanyaan? 
Perkenalan 
peserta 
(Pemanasan) 
Silahkan memperkenalkan diri 
Mari kita 
mulai: 
Selain bapak/ibu, adakah orang lain di lingkungan bapak/ibu yang 
menderita TB? 
Umum 
Sebelum bapak ibu tertular, apa yang Bapak/Ibu ketahui mengenai 
MITRA Tools Tools 1 
TB Patients 
TB/TBC? 
Menurut bapak/ibu kapan seseorang dikatakan sakit TBC? 
Apakah Bapak/Ibu mengenal seseorang yang menderita TBC baik di 
keluarga Bapak/Ibu ataupun di lingkungan Bapak/Ibu? 
Apakah orang ini sudah mendapatkan perawatan? Apabila iya, dari 
mana? 
• Menurut bapak/ibu, bagaimana TBC bisa terjadi? 
• Apa tbapak/ibu atau gejala utama TBC? 
• Bagaimana TBC bisa menular? 
• Apa yang bisa dilakukan untuk mencegah penularan TB? 
• Apakah TBC bisa disembuhkan? 
• Apa yang bisa dilakukan untuk menyembuhkan TBC? 
• Apakah Bapak/Ibu sudah pernah mendengar mengenai 
DOTS? Bila ya, dari mana? 
• Apakah Bapak/Ibu pernah mendengar mengenai HIV? 
• Apa hubungan antara TBC dengan HIV? 
• Apakah TBC pada ODHA bisa disembuhkan? 
Pengetahuan 
• Apakah Bapak/Ibu pernah mendengar mengenai MDR TB? 
Apa yang menyebabkan hal ini? Apakah hal ini dapat 
dicegah? 
Akses untuk 
Berobat 
• Jika Bapak/Ibu dan keluarga sakit, di mana memperoleh 
pengobatan/obat? 
• Setelah menunjukkan gejala TB, berapa lama Bapak/Ibu 
menunggu sampai akhirnya berobat? 
• (Apabila respon menunjukan pola penundaan) Tanyakan 
kapan sebaiknya Bapak/Ibu mencari perawatan? 
• Jika sakit, dimana biasanya mencari pengobatan? 
• Jika bapak/ibu pergi ke tempat berobat, siapa yang ingin di 
temui? 
• Mengapa ke sana? 
• (Apabila responden lebih memilih pelayanan kesehatan 
swasta) Tanyakan, mengapa mereka tidak berobat atau 
datang ke fasilitas pemerintah? 
• Apakah ada tempat pengobatan TB di dekat rumah 
Bapak/Ibu? 
• Apa yang biasanya dilakukan untuk memeriksa orang yang 
diduga TBC, di tempat pelayanan kesehatan tersebut? 
• Informasi tambahan apa yang Bapak/Ibu dapatkan dari unit 
pelayanan kesehatan tersebut? 
• Setelah didiagnosis TBC, berapa lama sebelum memulai 
pengobatan? 
• Permasalahan apa yang dihadapi dalam mendapatkan 
diagnosis dan pengobatan? 
• Apakah Bapak/Ibu mengetahui bahwa laki-laki lebih banyak 
MITRA Tools Tools 1 
TB Patients 
menderita TB daripada wanita? 
• Apakah perempuan di lingkungan Bapak/Ibu juga berobat 
dengan cara yang sama dengan laki-laki? 
Kepatuhan 
terhadap 
pengobatan 
• Sudah berapa lama bapak/ibu berobat? 
• Menurut ibu/bapak, seperti apa pengobatan TB itu?
• Bagaimana jika pengobatan tidak di selesaikan? 
• Berapa kali bapak/ibu minum obat dalam sehari? 
• Menurut bapak/ibu bagaimana pasien TB dikatakan sembuh? 
• Apa yang bapak/ibu ketahui, apabila pengobatan tidak 
diselesaikan? 
• Dukungan seperti apa yang bapak/ibu dapatkan untuk 
menyelesaikan pengobatan? 
• Tes atau pemeriksaan apa yang bapak/ibu lakukan dan 
berapa kali selama pengobatan? 
• Bantuan apa yang bapak/ibu dapatkan untuk menyelesaikan 
pengobatan? 
Stigma yang 
dihubungkan 
dengan TBC 
• Apa yang bapak/ibu lakukan jika keluarga dan teman 
bapak/ibu mengetahui bahwa bapak/ibu menderita TB? 
• Bagaimana jika ibu/bapak menceritakan pengalamannya 
setelah sembuh dari TB, kepada orang lain? 
Tentang 
Program 
MITRA 
• Apakah Bapak/Ibu pernah mendengar mengenai CARE atau 
MITRA? 
• Apabila iya, kegiatan apa saja yang dilakukan di bawah 
proyek ini?
• Bagaimana kegiatan ini membantu pasien TBC dan 
masyarakat? 
• Kegiatan apa saja yang Bapak/Ibu sukai?
• Kegiatan apa saja yang tidak Bapak/Ibu sukai?
• Apa lagi yang bisa dilakukan untuk mengatasi permasalahan 
TBC? a) untuk meningkatkan pengetahuan masyarakat, b) 
untuk memperbaiki pencarian perawatan, c) menelan obat 
secara teratur dan menyelesaikan pengobatan d) 
memperbaiki pelayanan pada fasilitas, e) mengurangi stigma 
di masyarakat 
KIE/ KPP • Apakah ada yang pernah memberikan informasi TBC kepada 
Bapak/Ibu, apabila ya tolong ceritakan mengenai informasi 
TB yang pernah Bapak/Ibu lihat? 
• Apakah Bapak/Ibu pernah mendapatkan konseling atau 
mengikuti penyuluhan mengenai TBC? Apabila ya tolong 
ceritakan apa saja yang dibahas pada saat diskusi penyuluhan 
tersebut. 
Ringkasan Sebutkan tema utama yang dibicarakan dan respon peserta. Apakah 
ada hal lain yang kita bicarakan tadi yang saya lupa sampaikan? 
Penutup Terima kasih atas waktu Bapak/Ibu. Apakah ada pertanyaan? Saya 
MITRA Tools Tools 1 
TB Patients 
tidak yakin saya bisa menjawab semuanya, tetapi saya akan 
mencoba (catat semua pertanyaan jangan berceramah) 
Selama FGD 
Recorder harus mencatat dengan cara membuat kartu untuk setiap bagian. Catat respon 
pada setiap responden pada kartu-kartu yang diberi nomor mulai dari R-1 untuk 
responden yang duduk langsung di sebelah kiri fasilitator dan bergerak searah jarum jam. 
Catat apakah semua peserta sepertinya setuju akan satu pernyataan atau adakah 
ketidaksetujuan yang jelas terlihat diantara peserta pada saat seseorang berbicara. 
Tuliskan semua pernyataan pada kertas terpisah yang disiapkan untuk pernyataan. Catat 
pernyataan yang bersifat empati, disampaikan dengan baik dan ringkas perasaan umum 
kelompok untuk topik tertentu. Respon selama perkenalan (semua pertanyaan dari 
perkenalan fasilitator sampa peserta) dapat digabungkan. 
Setelah Melakukan FGD 
Segera setelah sesi, fasilitator harus: 
a. Mereview catatan untuk kejelasan dan pertanyaan 
b. Membandingkan dan mencatat observasi mengenai kelompok yang belum jelas 
dari catatan 
c. Mendiskusikan dan menuliskan setiap insight atau ide dari wawancara selama 
masih jelas di pikiran Bapak/Ibu 
d. Siapkan ringkasan FGD untuk tim Bapak/Ibu 
MITRA Tools Draft: 26 October 
Community support structures 
Focus Group Discussion Topic Guide Community Support Structures/Individuals
MITRA (TB Project) Mid Term Evaluation 
CARE International Indonesia
This guide may be used for Kadres, PMOs, Bidans, PKK etc 
Topic Discussion/Transitions 
Introduction 
and Greeting 
Facilitator’s and Observer’s name 
Appropriate greetings (Selamat) 
Purpose of FGD We are from CARE and have been working on a project to improve 
treatment and cure of TB in (Name of the Kaleruhan/sub-district). 
Since you belong to the project area and may be familiar with some 
TB patients, your ideas and feelings can help us understand how our 
project is performing and inform us about any changes that we can 
incorporate to improve TB care. May we begin the discussion? (Allow for 
those who do not want to participate in the discussion leave). 
Length of time The discussion would take about an hour 
No right or 
wrong answers 
We would just like to know your frank opinion. There is no right or 
wrong answers to any of the questions. This is not a test. We just 
want to learn from you 
Talking to one 
another 
As we will be discussing about each of your opinions, it will be 
important that we do not talk at once because we will want to hear 
each other so we should not talk together. Every body should try and 
participate and every body will be given a chance to put forth their 
views. If you have any queries they would be addressed at the end. 
Explain note 
taking 
Confidentiality 
(Name of Observer/reporter) will be writing down some of the 
things that we will be talking so we can remember later. Does 
anyone object? We are the only ones who will know your names, we 
will not use any names in our reports 
Checking 
understanding 
Clarify 
Does everyone understand what I have said? 
Does anyone have any questions? 
Participants 
introductions 
(Warm up) 
Please introduce yourselves 
Let us begin: 
• Since when have you been involved in volunteering 
activities? 
General 
• Since when have you been supporting TB activities? 
MITRA Tools Draft: 26 October 
Community support structures 
• When do we say that a person is suffering from TB? 
• What are activities you support? If supports treatment 
observation, then how many patients does he/she support? 
•
• How is TB caused? 
• What are the main symptoms of TB? 
• How does TB spread? 
• What can be done to control the spread of TB 
• Can TB be cured? 
• What can be done to cure TB? 
• Have you heard of DOTS, if yes from where? 
• Have you heard of HIV? 
• What is the association between TB and HIV 
• Can TB be cured in people with HIV 
Knowledge 
• Have you heard of MDR TB? Why is it caused? Can this be 
prevented? 
Access to care • When should a person with suspected TB symptoms seek 
care? In your community when do people generally do so? 
• Whom do the patients generally approach for diagnosis and 
treatment? 
• Why this particular provider? 
• If the interviewee prefers a private provider then ask - Why 
don’t they access a government facility? 
• Is there a TB provider (this may be a bidan, private doctor, 
or a community worker) near your house? 
• What is generally done to diagnose TB? Probe for various 
tests 
• What are the problems faced to get diagnosis and treatment? 
What can be done to address these problems? 
• Do women in your community seek care the same way as 
men? 
Adherence to 
treatment 
• What is the cure for TB? 
• How long does it generally take for TB to be cured? 
• Can treatment be stopped if one is feeling better? 
• What happens when the treatment is not completed or 
irregular? 
• When do you think the patient is called as cured? 
• What are the symptoms of being cured? 
• Do you know of any patient who did not complete the 
treatment? 
• If so what were the reasons for stopping medication? 
• What actions did you take to ensure that the patient 
continues and completes the treatment? 
• Do patients receive any incentives to complete treatment? 
MITRA Tools Draft: 26 October 
Community support structures 
• Tell us some of the barriers faced to complete treatment and 
what can be done to address this? 
Stigma 
associated with 
TB 
• How do you feel when you hear that a family or a 
community member has contracted TB? 
• How does the community generally socially treat a TB 
patient? 
• What can be done to ensure that TB patients are not socially 
shunned?
About project 
MITRA 
• Have you heard about CARE or MITRA? 
• If yes what are the activities being carried out under the 
project? 
• Did you receive any direct support from the project? 
• What benefits did the community receive?
• Was there any support that should have been provided and 
was not?
IEC/BCC • Has someone ever shared any information regarding TB with 
you, if yes please describe some of the IEC material you may 
have seen? 
• Have you received any orientation or attended any talks 
about TB? If yes please describe what was discussed during 
these talks. 
Summary Mention main themes discussed and participant’s responses. Is there 
anything else that we talked about that I forgot to mention? 
Closure Thank you for your time. Do you have any questions that you would 
like to ask? I am not sure that I will be able to answer all of them, 
but I will try (Record all questions do not lecture) 
During FGD 
Recorder should keep notes by making cards for each section. Note responses on each 
card of respondents by numbering them as R-1 from the left of the facilitator and going 
clockwise around the room. Note if participants seem to all be agreeing with a statement 
or if there is a visible disagreement among participants when someone is speaking. Write 
down any quotes on a separate sheet provided for quotes. Note those quotes which are 
emphatic, well articulated and summarize the general feelings of the group for a 
particular topic. Responses during the introduction (all questions from introduction of 
facilitators through participant introductions) can be grouped together. 
After conducting the FGD 
Immediately after the session the facilitators should: 
a. Review the notes for clarity and understanding 
MITRA Tools Draft: 26 October 
Community support structures 
b. Compare and record observations about the group not readily clear from the notes 
c. Discuss and record any insights or ideas that the interview created while they are 
fresh in your mind 
d. Prepare a summary of the FGD for your team 
MITRA Tools Tools 2 
Community support structures (Kader, PMO, KPMO,bidan,dll) 
Panduan Topik Focus Group Discussion untuk Community Support 
Structures/Individuals
MITRA (TB Project) Mid Term Evaluation 
CARE International Indonesia
Panduan ini dapat digunakan untuk Kader Posyandu, PMOs, KPMO, Bidan, PKK dll 
Topik Diskusi/ Transisi 
Perkenalan dan 
salam 
Nama fasilitator dan pengamat 
Selamat pagi/siang, assalamualaikum 
Tujuan FGD Kami dari CARE dan bekerja dalam proyek ini untk memperbaiki 
pengobatan TB di (nama kelurahan). Karena anda berada dalam 
wialayh proyek dan mungkin mengenal beberapa pasien TBC, ide 
dan perasaan anda dapat membantu kami untuk memahami 
bagaimana proyek ini berjalan dan memberitahukan kami perubahan 
apa yang bisa kami lakukan untuk meningkatkan perawatan TBC. 
Bisa kita mulai diskusinya? (Berikan kesempatan bagi yang tidak 
ingin ikut diskusi untuk pergi).
Tidak ada 
jawaban benar 
atau salah 
Kami hanya ingin mengetahui pendapat anda secata jujur. Tidak ada 
jawaban yang benar atau salah. Ini bukan ujian. Kami hanya ingin 
belajar dari anda 
Rentang waktu Diskusi ini akan memakan waktu sekitar satu jan 
Berbicara satu 
sama lain 
Karena kita akan membicatakan mengenai pendapat anda, sangat 
penting kita tidak bicara pada saat yang bersamaan karena kita ingin 
mendengar satu sama lain, jadi kita tidak boleh bicara bersamaan. 
Semua orang harus berusaha untuk ikut serta dan semua orang akan 
diberikan kesempatan untuk mengutarakan pendapatnya. Apabila 
ada pertanyaan, bisa ditanyakan pada bagian akhir. 
Sampaikan 
mengenai 
kerahasiaan 
catatan 
(Nama Observer/reporter) akan menuliskan beberapa hal yang kita 
bicarakan jadi kami bisa mengingatnya kembali nanti. Apakah ada 
yang keberatan? Hanya kami yang akan mengetahui nama anda, 
kami tidak akan menuliskan nama pada laporan. 
Memeriksa 
pemahaman 
Klarifikasi 
Apakah semuanya sudah memahami apa yang saya katakan? Ada 
yang punya pertanyaan? 
Perkenalan 
peserta 
(Pemanasan) 
Silahkan memperkenalkan diri 
Mari kita 
mulai: 
MITRA Tools Tools 2 
Community support structures (Kader, PMO, KPMO,bidan,dll) 
• Sejak kapan anda terlibat dalam kegiatan penanggulangan 
penyakit TBC? 
• Kegiatan apa saja yang anda dukung? 
• Apabila PMO, siapa pasien yang anda awasi? 
Umum 
• Apabila PMO, berapa pasien yang anda awasi?
• Apa itu penyakit TBC ? 
• Apa gejala-gejala utama TBC? 
• Bagaimana terjadinya penularan penyakit TBC ? 
• Apa yang bisa dilakukan untuk mencegah penularan TBC 
• Apakah TBC bisa disembuhakan ? 
• Bagaimana proses penyembuhannya ? 
• Apakah ada sudah pernah mendengar mengenai DOTS, dari 
mana? 
• Apa itu DOTS ? 
• Apakah anda pernah mendengar mengenai HIV? 
• Apa hubungan antara TBC dengan HIV 
• Apakaha TBC pada ODHA (Orang Dengan HIV AIDS) bisa 
disembuhkan ? 
Pengetahuan 
• Apakah anda pernah mendengar MDR TB ? Mengapa itu 
bisa terjadi ? Apakah hal ini dapat dicegah? 
Akses ke 
perawatan 
• Kapan sebaiknya seseorang yang dicurigai dengan gejala 
TBC mendapatkan perawatan? Dalam lingkungan anda 
kapan biasanya seseorang melakukan hal tsb? 
• Kemana biasanya pasien TBC mencari pelayanan 
pemeriksaan dan pengobatan ? 
• Mengapa ke sana? 
• Apabila responden lebih memilih swasta, tanyakan￾Mengapa mereka tidak mengakses fasilitas pemerintah 
(Puskesmas, RS Pemerintah)? 
• Apakah ada perawatan TBC(mungkin bidan, DPS, atau 
kader) di lingkungan anda? 
• Apa yang biasanya dilakukan untuk mengetahui seseorang 
itu menderita TBC? Probing untuk berbagai tes 
• Permasalahan apa yang dihadapi dalam mendapatkan pelayanan 
pemeriksaan dan pengobatan ?
• Menurut pengamatan anda, apakah laki-laki atau perempuan 
yang lebih banyak menderita penyakit TBC dilingkungan anda?
• Apakah perempuan di lingkungan anda juga mencari 
perawatan dengan cara yang sama dengan laki-laki? 
Kepatuhan 
terhadap 
Pengobatan 
• Apakah anda tahu obat TBC? Sebutkan jenisnya? 
• Biasanya berapa lama waktu yang dibutuhkan untuk 
menyembuhkan TBC? 
• Apakah pengobatan bisa dihentikan apabila seseorang 
merasa lebih baik? 
MITRA Tools Tools 2 
Community support structures (Kader, PMO, KPMO,bidan,dll) 
• Apa yang terjadi apabila pengobatan tidak diselesaikan atau 
tidak teratur? 
• Menurut anda kapan pasien dikatakan sembuh? 
• Apa tanda-tanda kesembuhan? 
• Apakah ada dilingkungan anda pasien TBC yang tidak 
menyelesaikan pengobatan? 
• Apa alasan mereka untuk menghentikan pengobatan? 
• Apakah pasien TBC di lingkungan anda mendapatkan 
dukungan untuk menyelesaikan perawatan mereka? 
• Siapa yang mendukung ? 
• Apa peran dari orang yang memberikan dukungan ini? 
• Apakah pasien mendapatkan insentif untuk menyelesaikan 
pengobatan? 
Stigma yang 
dihubungkan 
dengan TBC 
• Bagaimana perasaan anda pada saat mendengan keluarga 
atau warga dilingkungan anda tertular TBC? 
• Bagaimana masyarakat pada umumnya memperlakukan 
pasien TBC? 
Mengenai 
Proyek MITRA 
• Apakah anda pernah mendengar mengenai LSM CARE atau 
Program MITRA? 
• Apabila iya, kegiatan apa saja yang dilakukan ? 
• Keuntungan apa yang didapatkan oleh masyarakat? 
• Apakah ada dukungan yang seharusnya diberikan tetapi tidak 
diberikan?
• Apa lagi yang bisa dilakukan untuk mengatasi permasalahan 
TBC? a) untuk meningkatkan pengetahuan masyarakat, b) 
untuk memperbaiki pencarian perawatan, c) menelan obat 
secara teratur dan menyelesaikan pengobatan d) 
memperbaiki pelayanan pada fasilitas, e) mengurangi stigma 
di masyarakat (lingkari sesuai jawaban responden) 
KIE/ KPP • Apakah ada yang pernah memberikan informasi TBC kepada 
anda, apabila iya tolong ceritakan informasi tersebut? 
• Apakah anda pernah mendapatkan konseling atau mengikuti 
penyuluhan mengenai TBC? Apabila iya tolong ceritakan 
apa saja yang dibahas pada saat diskusi penyuluhan tersebut 
? Media apa yang digunakan (leaflet, brosur, pamphlet, 
lembar balik, dsb) 
Ringkasan Sebutkan tema utama yang dibicarakan dan respon peserta. Apakah 
ada hal lain yang kita bicarakan tadi yang saya lupa sampaikan? 
Penutup Terima kasih atas waktu anda. Apakah ada pertanyaan? Saya tidak 
yakin saya bisa menjwab semuanya, tetapi saya akan mencoba (catat 
semua pertanyaa jangan berceramah) 
MITRA Tools Tools 2 
Community support structures (Kader, PMO, KPMO,bidan,dll) 
Selama FGD 
Recorder harus mencatat dengan cara membuat kartu untuk setiap bagian. Catat respon 
pada setiap responden pada kartu-kartu yang diberi nomor mulai dari R-1 untuk 
responden yang duduk langsung di sebelah kiri fasilitator dan bergerak searah jarum jam. 
Catat apakah semua peserta sepertinya setuju akan satu pernyataan atau adakah 
ketidaksetujuan yang jelas terlihat diantara peserta pada saat seseorang berbicara. 
Tuliskan semua pernyataan pada kertas terpisah yang disiapkan untuk pernyataan. Catat 
pernyataan yang bersifat empati, disampaikan dengan baik dan ringkas perasaan umum 
group untuk topik tertentu. Respon selama perkenalan (semua pertanyaan dari perkenalan 
fasilitator sampa peserta) dapat digabungkan. 
 
Setelah Melakukan FGD 
Segera setelah sesi, fasilitator harus: 
a. Mereview catatan untuk kejelasan dan pertanyaan 
b. Membandingkan dan mencatat observasi mengenai kelompok yang belum jelas 
dari catatan 
c. Mendiskusikan dan menuliskan setiap insight atau ide dari wawancara selama 
masih jelas di pikiran anda 
d. Siapkan ringkasan FGD untuk tim anda 
MITRA Tools Draft: 24 October 
Family/community members 
Focus Group Discussion Topic Guide for Community and Family Members 
MITRA (TB Project) Mid Term Evaluation 
CARE International Indonesia
Topic Discussion/Transitions 
Introduction 
and Greeting 
Facilitator’s and Observer’s name 
Appropriate greetings (Selamat) 
Purpose of FGD We are from CARE and have been working on a project to improve 
treatment and cure of TB in (Name of the Kaleruhan). Since you 
belong to the project area and may be familiar with some TB 
patients, your ideas and feelings can help us understand how our project 
is performing and inform us about any changes that we can incorporate to 
improve TB care. May we begin the discussion? (Allow for those who do 
not want to participate in the discussion leave). 
No right or 
wrong answers 
We would just like to know your frank opinion. There is no right or 
wrong answers to any of the questions. This is not a test. We just 
want to learn from you 
Length of time The discussion would take about an hour 
Talking to one 
another 
As we will be discussing about each of your opinions, it will be 
important that we do not talk at once because we will want to hear 
each other so we should not talk together. Every body should try and 
participate and every body will be given a chance to put forth their 
views. If you have any queries they would be addressed at the end. 
Explain note 
taking 
Confidentiality 
(Name of Observer/reporter) will be writing down some of the 
things that we will be talking so we can remember later. Does 
anyone object? We are the only ones who will know your names, we 
will not use any names in our reports 
Checking 
understanding 
Clarify 
Does everyone understand what I have said? Does anyone have any 
questions? 
Participants 
introductions 
(Warm up) 
Please introduce yourselves 
Let us begin: 
• Have you heard of TB? 
• When do we say that a person is suffering from TB? 
General 
• Do you know of anybody who have TB either in your family 
MITRA Tools Draft: 24 October 
Family/community members 
or in your community? 
• Have these people sought care or are on treatment? If yes 
from where? 
• How is TB caused? 
• What are the main symptoms of TB? 
• How does TB spread? 
• What can be done to control the spread of TB 
• Can TB be cured? 
• What can be done to cure TB? 
• Have you heard of DOTS, if yes from where? 
• Have you heard of HIV? 
• What is the association between TB and HIV 
• Can TB be cured in people with HIV 
Knowledge 
• Have you heard of MDR TB? Why is it caused? Can this be 
prevented? 
Access to care • When should a person with suspected TB symptoms seek 
care? In your community when do people generally do so? 
• Whom do the patients generally approach for diagnosis and 
treatment? 
• Why this particular provider? 
• If the interviewee prefers a private provider then ask - Why 
don’t they access a government facility? 
• Is there a TB provider (this may be a bidan, private doctor, 
or a community worker) near your house? 
• What is generally done to diagnose TB? Probe for various 
tests 
• What are the problems faced to get diagnosis and treatment? 
• Do women in your community seek care the same way as 
men? 
Adherence to 
treatment 
• What is the cure for TB? 
• How long does it generally take for TB to be cured? 
• Can treatment be stopped if one is feeling better? 
• What happens when the treatment is not completed or 
irregular? 
• When do you think the patient is called as cured? 
• What are the symptoms of being cured? 
• Do you know of any patient who did not complete the 
treatment? 
• If so what were the reasons for stopping medication? 
• Do TB patients in your community receive any support to 
complete their treatment from anyone? 
• If yes what has been this person’s role 
• Do patients receive any incentives to complete treatment? 
MITRA Tools Draft: 24 October 
Family/community members 
Stigma 
associated with 
TB 
• How do you feel when you hear that a family or a 
community member has contracted TB? 
• How does the community generally socially treat a TB 
patient? 
About project 
MITRA 
• Have you heard about CARE or MITRA? 
• If yes what are the activities being carried out under the 
project 
• What benefits did the community receive?
• Was there any support that should have been provided and 
was not?
• What can be done to further fight the problem of TB? A) to 
increase knowledge of the community, b) to improve care 
seeking, c) to regularly ingest drugs and complete treatment, 
d) to improve services at facilities, e) to reduce stigma in the 
community 
IEC/BCC • Has someone ever shared any information regarding TB with 
you, if yes please describe some of the IEC material you may 
have seen? 
• Have you received any counseling or attended any talks 
about TB? If yes please describe what was discussed during 
these talks. 
Summary Mention main themes discussed and participant’s responses. Is there 
anything else that we talked about that I forgot to mention? 
Closure Thank you for your time. Do you have any questions that you would 
like to ask? I am not sure that I will be able to answer all of them, 
but I will try (Record all questions do not lecture) 
During FGD 
Recorder should keep notes by making cards for each section. Note responses on each 
card of respondents by numbering them as R-1 from the left of the facilitator and going 
clockwise around the room. Note if participants seem to all be agreeing with a statement 
or if there is a visible disagreement among participants when someone is speaking. Write 
down any quotes on a separate sheet provided for quotes. Note those quotes which are 
emphatic, well articulated and summarize the general feelings of the group for a 
particular topic. Responses during the introduction (all questions from introduction of 
facilitators through participant introductions) can be grouped together. 
After conducting the FGD 
Immediately after the session the facilitators should: 
a. Review the notes for clarity and understanding 
b. Compare and record observations about the group not readily clear from the notes 
MITRA Tools Draft: 24 October 
Family/community members 
c. Discuss and record any insights or ideas that the interview created while they are 
fresh in your mind 
d. Prepare a summary of the FGD for your team 
MITRA Tools Tools 3 
Family/community members 
Panduan Topik Focus Group Discussion untuk Masyarakat dan Anggota Keluarga 
MITRA (TB Project) Mid Term Evaluation 
CARE International Indonesia
Pmo, Koordinator PMO, anggota keluarga. 
Topik Diskusi/ Transisi 
Perkenalan dan 
salam 
Nama fasilitator dan pengamat 
Selamat pagi/siang, assalamualaikum 
Tujuan FGD Kami dari CARE dan bekerja dalam proyek ini untk memperbaiki 
pengobatan TB di (nama kelurahan). Karena anda berada dalam 
wialayh proyek dan mungkin mengenal beberapa pasien TBC, ide 
dan perasaan anda dapat membantu kami untuk memahami 
bagaimana proyek ini berjalan dan memberitahukan kami perubahan 
apa yang bisa kami lakukan untuk meningkatkan perawatan TBC. 
Bisa kita mulai diskusinya? (Berikan kesempatan bagi yang tidak 
ingin ikut diskusi untuk pergi).
Tidak ada 
jawaban benar 
atau salah 
Kami hanya ingin mengetahui pendapat anda secata jujur. Tidak ada 
jawaban yang benar atau salah. Ini bukan ujian. Kami hanya ingin 
belajar dari anda 
Rentang waktu Diskusi ini akan memakan waktu sekitar satu jam 
Berbicara satu 
sama lain 
Karena kita akan membicatakan mengenai pendapat anda, sangat 
penting kita tidak bicara pada saat yang bersamaan karena kita ingin 
mendengar satu sama lain, jadi kita tidak boleh bicara bersamaan. 
Semua orang harus berusaha untuk ikut serta dan semua orang akan 
diberikan kesempatan untuk mengutarakan pendapatnya. Apabila 
ada pertanyaan, bisa ditanyakan pada bagian akhir. 
Sampaikan 
mengenai 
kerahasiaan 
catatan 
(Nama Observer/reporter) akan menuliskan beberapa hal yang kita 
bicarakan jadi kami bisa mengingatnya kembali nanti. Apakah ada 
yang keberatan? Hanya kami yang akan mengetahui nama anda, 
kami tidak akan menuliskan nama pada laporan. 
Memeriksa 
pemahaman 
Klarifikasi 
Apakah semuanya sudah memahami apa yang saya katakan? Ada 
yang punya pertanyaan? 
Perkenalan 
peserta 
(Pemanasan) 
Silahkan memperkenalkan diri 
Mari kita 
mulai: 
MITRA Tools Tools 3 
Family/community members 
• Sejak kapan anda terlibat dalam kegiatan penanggulangan 
penyakit TBC? 
• Kegiatan apa saja yang anda dukung? 
• Apabila PMO, siapa pasien yang anda awasi? 
Umum 
• Apabila PMO, berapa pasien yang anda awasi?
• Apa itu penyakit TBC ? 
• Apa gejala-gejala utama TBC? 
• Bagaimana terjadinya penularan penyakit TBC ? 
• Apa yang bisa dilakukan untuk mencegah penularan TBC 
• Apakah TBC bisa disembuhakan ? 
• Bagaimana proses penyembuhannya ? 
• Apakah ada sudah pernah mendengar mengenai DOTS, dari 
mana? 
• Apa itu DOTS ? 
• Apakah anda pernah mendengar mengenai HIV? 
• Apa hubungan antara TBC dengan HIV 
• Apakaha TBC pada ODHA (Orang Dengan HIV AIDS) bisa 
disembuhkan ? 
Pengetahuan 
• Apakah anda pernah mendengar MDR TB ? Mengapa itu 
bisa terjadi ? Apakah hal ini dapat dicegah? 
Akses ke 
perawatan 
• Kapan sebaiknya seseorang yang dicurigai dengan gejala 
TBC mendapatkan perawatan? Dalam lingkungan anda 
kapan biasanya seseorang melakukan hal tsb? 
• Kemana biasanya pasien TBC mencari pelayanan 
pemeriksaan dan pengobatan ? 
• Mengapa ke sana? 
• Apabila responden lebih memilih swasta, tanyakan￾Mengapa mereka tidak mengakses fasilitas pemerintah 
(Puskesmas, RS Pemerintah)? 
• Apakah ada perawatan TBC(mungkin bidan, DPS, atau 
kader) di lingkungan anda? 
• Apa yang biasanya dilakukan untuk mengetahui seseorang 
itu menderita TBC? Probing untuk berbagai tes 
• Permasalahan apa yang dihadapi dalam mendapatkan pelayanan 
pemeriksaan dan pengobatan ?
• Menurut pengamatan anda, apakah laki-laki atau perempuan 
yang lebih banyak menderita penyakit TBC dilingkungan anda?
• Apakah perempuan di lingkungan anda juga mencari 
perawatan dengan cara yang sama dengan laki-laki? 
Kepatuhan 
terhadap 
Pengobatan 
• Apakah anda tahu obat TBC? Sebutkan jenisnya? 
• Biasanya berapa lama waktu yang dibutuhkan untuk 
menyembuhkan TBC? 
• Apakah pengobatan bisa dihentikan apabila seseorang 
merasa lebih baik? 
MITRA Tools Tools 3 
Family/community members 
• Apa yang terjadi apabila pengobatan tidak diselesaikan atau 
tidak teratur? 
• Menurut anda kapan pasien dikatakan sembuh? 
• Apa tanda-tanda kesembuhan? 
• Apakah ada dilingkungan anda pasien TBC yang tidak 
menyelesaikan pengobatan? 
• Apa alasan mereka untuk menghentikan pengobatan? 
• Apakah pasien TBC di lingkungan anda mendapatkan 
dukungan untuk menyelesaikan perawatan mereka? 
• Siapa yang mendukung ? 
• Apa peran dari orang yang memberikan dukungan ini? 
• Apakah pasien mendapatkan insentif untuk menyelesaikan 
pengobatan? 
Selama FGD 
Recorder harus mencatat dengan cara membuat kartu untuk setiap bagian. Catat respon 
pada setiap responden pada kartu-kartu yang diberi nomor mulai dari R-1 untuk 
responden yang duduk langsung di sebelah kiri fasilitator dan bergerak searah jarum jam. 
Catat apakah semua peserta sepertinya setuju akan satu pernyataan atau adakah 
ketidaksetujuan yang jelas terlihat diantara peserta pada saat seseorang berbicara. 
Tuliskan semua pernyataan pada kertas terpisah yang disiapkan untuk pernyataan. Catat 
pernyataan yang bersifat empati, disampaikan dengan baik dan ringkas perasaan umum 
group untuk topik tertentu. Respon selama perkenalan (semua pertanyaan dari perkenalan 
fasilitator sampa peserta) dapat digabungkan. 
Setelah Melakukan FGD 
Segera setelah sesi, fasilitator harus: 
a. Mereview catatan untuk kejelasan dan pertanyaan 
b. Membandingkan dan mencatat observasi mengenai kelompok yang belum jelas 
dari catatan 
c. Mendiskusikan dan menuliskan setiap insight atau ide dari wawancara selama 
masih jelas di pikiran anda 
d. Siapkan ringkasan FGD untuk tim anda 
MITRA Tools Draft:25 October 
Facility Provider IDI
In Depth Interview Guideline for Facility Based Providers
MITRA Mid Term Evaluation 
CARE International Indonesia
Name of the Interviewer________________________ 
Date_________________________ 
Selamat 
Introduce Self 
Preamble: We are from CARE International Indonesia and have been implementing a community based TB 
control project called MITRA, in this district/in four districts. We are here as to understand the activities of the 
project from your perspective. This will enable us to make improvements in the project strategies and identify 
issues requiring resolution. This will be a confidential discussion and your name will not be attached to your 
quotes. It will also involve an assessment of your facility and review of your registers. We anticipate the 
discussion to take about one hour. Do we have your permission to proceed? 
If response no, move to the next available facility worker. 
If response yes, continue with the questions. 
Location_______________________________________________ 
Type of Facility/whether treatment/treatment + lab/only lab______________________________ 
Name of the Interviewee and designation____________________________ 
Total months of association with the Project:______________ 
Total months in the current facility:__________________ 
Staff in the facility 
We may keep this here or in the facility assessment checklist 
Staff Position Sanctioned Functioning Trained in DOTS 
1. What are your main duties in this facility? 
2. What proportion of your time is spent in TB related activities (diagnosis/ treatment/counseling/ 
community outreach/follow up/reporting) 
3. Were you given any training to carry out TB control activities? If yes when, what training and who 
conducted this training? 
4. Was this training useful? What further support did you receive? Please describe the additional support 
that would have helped you to perform your duties better. 
5. Do the patients come to you directly or are referred by your other colleagues in the facility (or a mix of 
both)? 
6. Now I would like to ask you some technical questions. When do you suspect TB in a patient? 
7. What is done when you suspect TB in a patient?
 Page 1 of 3 
MITRA Tools Draft:25 October 
Facility Provider IDI
8. Could you tell the criteria upon which TB patients are classified into various categories? 
9. What additional support is required in this facility to diagnose patients?
10. What are the common side effects of the DOTS drugs? 
11. When you attend to a suspected patient and after you initiate treatment, what information do you 
generally give to your patient? 
12. What IEC material is available with you? Are they useful? Do you want to suggest some modifications 
to the material available? 
13. Is it a norm to identify a treatment supporter for every patient who is registered for DOTS? 
14. Are you required to go to the community for follow up or TB extension activities? If yes please describe 
your community level activities. 
15. What is your role in identifying a supporter, following up on default (and without probing ascertain 
whether the provider is involved in counseling as well) 
16. What is your role in drug management (maintaining adequate drug supply) and lab management ( if a 
lab is attached to the facility : ensuring adequacy of lab consumables, supervision, reporting etc) 
17. What reporting formats are you required to submit? Did your training have sessions on formats? 
18. Who supervises your work? When did you last receive a supervisory visit? What does your supervisor 
check when he/she visits you? Please list. Did you receive any feedback? Was it useful? 
19. If you had a choice, would you work with TB patients?
20. Do you think that a health care worker, who has TB but is not sick, should be allowed to continue to 
work?
21. If a member of your household became ill with TB, would you want it to remain secret? 
22. Some people think that TB patients deserve the illness that they have. Do you agree with this point of 
view? 
23. What support has this facility received from MITRA? (trainings, review meetings, linkages with 
treatment supporters etc) 
24. Do the activities of this facility undergo any review? If yes how often and who are the participants in 
the review? 
25. Does this facility partner with any community based groups or other NGOs 
26. Please describe some key problems faced to control TB. Please tell us what can be done to overcome 
these problems. 
Thank you indeed for your time. We would like to observe the facility now and review some of your registers. 
 Page 2 of 3 
MITRA Tools Draft:25 October 
Facility Provider IDI
27.
Thank you for your time! The survey is complete. 
 Page 3 of 3 
MITRA Tools Tools 4a2 
Facility Provider IDI (RS/pojok DOTS) 
Panduan Wawancara Mendalam untuk Pemberi Layanan Berbasis Fasilitas
MITRA Mid Term Evaluation 
CARE International Indonesia
Nama pewawancara________________________ 
Tanggal_________________________ 
Selamat 
Perkenalan 
Pembukaan: Seperti yang telah anda ketahui, kami sedang melaksanakan evaluasi pertengahan periode untuk 
proyek MITRA di kabupaten ini dan kami ingin mengetahui pandangan anda mengenai kekuatan dan 
kelemahan dari strategi proyek ini dan program DOTS. Diskusi ini bersifat rahasia dan nama anda tidak akan 
dihubungkan dengan jawaban anda. Kami juga akan melihat-lihat fasilitas anda, catatan anda dan berdiskusi 
dengan beberapa orang staff Dinkes. Diskusi ini akan memakan waktu kurang lebih setengah jam. Bisa kami 
lanjutkan? 
Apabila jawaban tidak, lanjut ke orang berikutnya. 
Apabila jawaban ya, lanjutkan dengan pertanyaan. 
Lokasi_______________________________________________ 
Tersambung dengan fasilitas, kalau iya/ apakah fasilitas pengobatan/ pengobatan dan lab/ hanya lab 
______________________________ 
Name responden 
Total bekerja dengan proyek :______________bulan 
Total bekerja pada fasilitas ini:__________________bulan 
Jumlah staff pada fasilitas ini 
Posisi staff Penunjukan Fungsi Pelatihan DOTS 
1. Apakah tugas utama anda di fasilitas ini? 
2. Berapa banyak waktu yang anda habiskan untuk kegiatan yang terkait dengan TB (diagnosis/ 
pengobatan/ konseling/ penjangkauan masyarakat/ tindak lanjut/ pelaporan) 
3. Apakah anda pernah mendapatkan pelatihan untuk menjalankan kegiatan penanggulangan TB? Apabila 
ya, kapan, pelatihan apa dan siapa yang memberikan pelatihan ini? 
4. Apakah pelatihan ini bermanfaat? Dukungan apalagi yang anda dapatkan? Tolong sebutkan dukungan 
lain yang dapat membantu anda untuk melaksanakan tugas anda dengan lebih baik lagi. 
5. Apakah pasien datang kepada anda secara langsung atau dirujuk oleh rekan anda di fasilitas (atau 
gabungan dari keduanya)?
6. Sekarang saya ingin menanyakan beberapa pertanyaan teknis. Kapan seseorang dicurigai mengidap TB? 
7. Apa yang harus dilakukan pada saat seseorang dicurigai mengidap TB? Bagaimana pasien diperiksa? 
8. Fasilitas apa sajakah yang tersedia di kabupaten untuk mendiagnosa pasien suspek TB? 
 Page 1 of 2 
MITRA Tools Tools 4a2 
Facility Provider IDI (RS/pojok DOTS) 
9. Apakah anda bisa menyebutkan kriteria-kriteria yang digunakan dalam penggolongan penderita TB ke 
dalam berbagai kategori? 
10. Obat apa yang diresepkan? Sebutkan (lihat apakah berbeda untuk kategori yang berbeda) 
11. Apa sajakah efek samping yang biasa disebabkan oleh obat DOTS? 
12. Materi KIE apa sajakah yang tersedia di kabupaten? Apakah materi-materi tersebut berguna? Apakah 
anda memiliki saran untuk perubahan materi yang ada sekarang? 
13. Apakah anda diwajibkan untuk terjun ke masyarakat untuk menindaklanjuti kegiatan penyuluhan KPP? 
Apabila ya, tolong ceritakan mengenai kegiatan anda pada tingkat masyarakat 
14. Apa peran anda dalam menunjuk PMO, menindaklanjuti kasus drop out (dan tanpa memastikan apakah 
responden juga terlibat dalam konseling) 
15. Apa peran anda dalam manajemen obat (menjaga kecukupan pasokan obat) dan manajemen lab (apabila 
ada lab di fasilitas tsb: memastikan kecupukan perlengkapan lab, pengawasan, pelaporan, dll) 
16. Siapa yang mensupervisi pekerjaan anda? Kapan terakhir kali anda mendapatkan kunjungan supervisi? 
Apa yang biasanya dia periksa pada saat berkunjung? Sebutkan. Apakah anda mendapatkan umpan 
balik? Apakah hal tersebut berguna? 
17. Menurut anda, apakah seorang petugas kesehatan, yang menderita TB tetapi tidak sakit , diperbolehkan 
untuk tetap bekerja? 
18. Apabila anggota keluarga anda menderita TB, apakah anda ingin merahasiakan hal tersebut? 
19. Beberapa orang beranggapan bahwa penderita TB pantas untuk mendapatkan penyakit tersebut. Apakah 
anda setuju dengan pandangan ini? 
20. Dukungan apa yang sudah didapatkan kabupaten ini dari MITRA? (pelatihan, pertemuan monitoring, 
penguhubungan dengan PMO dan swasta, dll) 
21. Apakah kegiatan-kegiatan di tingkat kabupaten ini sudah pernah dievaluasi/ ditinjau? Apabila ya, 
seberapa sering dan siapa sajakah peserta peninjauan? Kapan terakhir kali diadakan peninjuan? Apa 
hasil dari peninjauan tersebut? 
22. Apakah kabupaten memiliki hubungan kemitraan dengan Ormas atau LSM lain? 
23. Apakah ada upaya untuk melibatkan swasta? Tolong ceritakan pengalaman anda (kesulitan dan ide 
inovatif, apabila ada) 
Terima kasih atas waktu anda. Sekarang kami ingin melihat-lihat fasilitas dan catatan-catatan anda. 
Thank you for your time! The survey is complete. 
 Page 2 of 2 
MITRA Tools Draft:28 October 
Lab officer IDI
In Depth Interview Guideline for Wasors
MITRA Mid Term Evaluation 
CARE International Indonesia
Name of the Interviewer________________________ 
Date_________________________ 
Selamat 
Introduce Self 
Preamble: As you are aware we are carrying out the mid term evaluation of project MITRA in this district and 
would like to understand your perspective on the strengths and weakness of project strategies and the DOTS 
program. This will enable us to make improvements in the project strategies and identify issues requiring 
resolution. This will be a confidential discussion and your name will not be attached to your quotes. It will also 
involve an assessment of your facility and review of your registers. We anticipate the discussion to take about 
half hour. Do we have your permission to proceed? 
If response is yes then continue with the questions. 
Location_______________________________________________ 
Attached to a Facility or Lab______________________________ 
Name of the Interviewee _______________________________ 
Total months of association with the Project:______________ 
Total months in the current position:__________________ 
1. Please describe your role as a Lab Officer. How many Labs do you monitor and support? 
2. What proportion of your time is spent on each of the TB control activities 
Actual lab work 
supervision 
reporting 
Management 
3. What is the current load of disease in your area? Is it increasing or decreasing? 
4. Please describe some of the difficulties you face in implementing the program and possible solutions 
Case notification 
Case detection 
Diagnosis 
Lab functioning 
Treatment 
MDR TB 
Budgets 
Information management 
5. What trainings have you received to carry out efficient lab management and networking. Who 
conducted these trainings? 
6. Was this training useful? What further support did you receive? Please describe the additional support 
that would have helped you to perform your duties better. 
7. Now I would like to ask you some technical questions. When does one suspect TB in a patient? 
8. What is done when one suspects TB in a patient? How is the patient investigated? 
9. What are the facilities available in the district to diagnose suspected TB patients? 
10. Could you relate the criteria upon which TB patients are classified into various categories? 
11. What additional support is required in the district to diagnose patients?
12. Please describe how you coordinate activities and what support do you get from 
 Page 1 of 2 
MITRA Tools Draft:28 October 
Lab officer IDI
District health officer 
Wasor 
BCC officer 
MO communicable diseases 
13. How is the internal quality assessment done? How frequently is this done? What problems do you face 
in carrying out internal quality assessment? 
14. How is the external quality assessment done? How frequently is this done? What problems do you face 
in carrying out internal quality assessment? 
15. Is the availability of equipments, infrastructure and consumables adequate in the district labs? Do you 
face any problems in this regard? 
16. What reporting formats are you required to submit? Did your training have sessions on formats? 
17. Who supervises your work? When did you last receive a supervisory visit? What does your supervisor 
check when he/she visits you? Please list. Did you receive any feedback? Was it useful? Describe the 
support you receive from the NTP. 
18. What support has this district received from MITRA? (trainings, review meetings, linkages with 
treatment supporters and private providers etc) 
19. Do the activities at district level undergo any review? If yes how often and who are the participants in 
the review? 
20. Is there an effort to involve private providers? Please describe your experiences (difficulties and 
innovative ideas if any) 
Thank you indeed for your time. 
 Page 2 of 2 
MITRA Tools Tools 4c 
Peninjauan laboratorium 
Checklist untuk Peninjauan Laboratorium
MITRA (TB Project) Mid Term Evaluation 
CARE International Indonesia
I. Infrastruktur dan Kegiatan Laboratorium 
Apakah ada ruang khusus untuk laboratorium Yes/No 
Apakah ada protap yang tersedia Yes/No 
Ada catatan laboratorium Yes/No 
Apakah ada miskroskop binokular yang berfungsi? Yes/No 
Apakah pemeriksaan dahak dilakukan oleh teknisi/petugas 
laboratorium? Kapan terakhir pelatihan 
Yes/No 
Apakah terdapat persediaan reagen, slide dan persediaan lainnya untuk 
satu bulan ke depan? 
Yes/No 
Apakah reagen laboratorium dipersiapkan secara fresh (segar)? Yes/No 
Apabila iya, kapan hal tersebut dipersiapkan (pada a/b/c)? Yes/No 
Apakah nama dan alamat pada catatan laboratorium TB ditulis dengan 
jelas 
Yes/No 
Apakah ada rangkuman kegiatan mikroskopis pada setiap akhir bulan? Yes/No 
Apakah teknisi laboratorium menyimpan slide untuk dilihat kembali 
oleh supervisor untuk protokol memastikan kualitas? 
Yes/No 
Adakah kunjungan supervisi terakhir dan siapa yang melakukan 
Apakah supervisor/wasor melihat juga slide yang disimpan oleh teknisi 
laboratorium pada saat evaluasi on-site? 
Yes/No 
Apakah laporan evaluasi yang dilakukan oleh supervisor tersedia di 
fasilitas/tempat ini (setidaknya untuk bulan lalu)? 
Yes/No 
Apakah ada upaya revisi/korektif yang disarankan pada laporan 
dilakukan oleh fasilitas? (status pada saat ini dapat digunakan sebagai 
ukuran apakah upaya revisi/korektif sudah dilakukan atau belum) 
Yes/No 
Apakah sampah biomedis dibuang sesuai aturan Yes/No 
Apakah laboratorium mengembangkan kultur mycobacterial dan tes 
suscepsibilitas obat 
Yes/ No 
Slide disimpan untuk QA internal Yes/No 
Total slide yang diperiksa 
Total slide positif 
Total slide negative 
II. Sumber Daya Manusia: 
Pelatihan dan Sensitisasi yang dilakukan pada 4 triwulan terakhir: 
Jenis staff 
1 
2 
3 
4 
Jenis pelatihan Jumlah hari pelatihan
MITRA Tools Draft:26 October 
Private Provider IDI
In Depth Interview Guideline for Facility Based Providers
MITRA Mid Term Evaluation 
CARE International Indonesia
Name of the Interviewer________________________ 
Date_________________________ 
Selamat 
Introduce Self 
Preamble: We are from CARE International Indonesia and have been implementing a community based TB 
control project called MITRA, in this district/in four districts. We are here as to understand your association 
with the project and issues pertaining to TB control in the private sector. This will enable us to make 
improvements in the project strategies and identify gaps that require bridging. This will be a confidential 
discussion and your name will not be attached to your quotes. We anticipate the discussion to take about one 
hour. Do we have your permission to proceed? 
If response in negative, move to the next available facility worker. 
If response yes, continue with the questions. 
Location_______________________________________________ 
Type of Facility/whether treatment/treatment + lab/only lab______________________________ 
Name of the Interviewee and qualifications____________________________ 
Total months of association with the Project:______________ 
Total months in the current facility:__________________ 
Staff in the facility (number trained in DOTS) N (n) 
1. What are your main duties in this clinic? Do you also work in any government facility? 
2. What proportion of your time is spent in TB related activities (diagnosis/ treatment/counseling/ 
community outreach/follow up/reporting) 
3. On an average how many suspected TB patients do you see in a month? 
4. Currently how many TB patients are undergoing treatment here? 
5. Were you given any training to carry out TB control activities? If yes when, what training and who 
conducted this training? 
6. Was this training useful? What further support did you receive? Please describe the additional support 
that would have helped you to perform your duties better. 
7. Do the patients come to you directly or are referred by your colleagues from other clinics (or a mix of 
both)? 
8. Now I would like to ask you some technical questions. When do you suspect TB in a patient? 
9. What is done when you suspect TB in a patient? How do you investigate them? 
10. Could you tell us the criteria upon which TB patients are classified into various categories?
11. What are the facilities available in this clinic to diagnose suspected TB patients? If none, then where do 
you refer them for investigations? 
12. When you attend to a suspected patient and after you initiate treatment, what information do you 
generally give to your patient? 
13. What IEC material is available with you? Are they useful? Do you want to suggest some modifications 
to the material available? 
14. What drugs do you prescribe? List (note if different for different categories) 
15. What are the common side effects of the drugs used for treatment? 
16. Do you dispense the drugs or just prescribe them? 
17. Where do the patients buy these drugs from? 
 Page 1 of 2 
MITRA Tools Draft:26 October 
Private Provider IDI
18. If provider mentions referral to government facility for free drugs – ask him which facility and how 
does he/she follows up on the patient? 
19. How often do you ask the patient to visit you? What happens when the patient does not come for his 
next follow up visit? 
20. Do you follow a system of appointing treatment supporters fro you patients? 
21. If there is labs in the facility then ask – what are the measures taken to ensure quality in the lab. Is 
external/internal quality monitoring done? 
22. Are you required to submit any reports? If yes what reports do you submit and to whom? 
23. If you had a choice, would you work with TB patients?
24. Do you think that a health care worker, who has TB but is not sick, should be allowed to continue to 
work?
25. If a member of your household became ill with TB, would you want it to remain secret? 
26. Some people think that TB patients deserve the illness that they have. Do you agree with this point of 
view? 
27. What support have you received from MITRA? (trainings, review meetings, linkages with treatment 
supporters etc) 
28. Are you required to attend any meetings under this project, if yes what meetings and the purpose of 
these meetings. 
29. Please describe some key problems faced to control TB. Please tell us what can be done to overcome 
these problems. 
Thank you indeed for your time. 
 Page 2 of 2 
MITRA Tools Tools 5 
Private Provider IDI
Panduan Wawancara Mendalam untuk Pemberi Layanan Berbasis Fasilitas
MITRA Mid Term Evaluation 
CARE International Indonesia
Nama pewawancara________________________ 
Tanggal_________________________ 
Selamat 
Perkenalan 
Pembukaan: Seperti yang telah bapak/ibu ketahui, kami sedang melaksanakan evaluasi pertengahan periode 
untuk proyek MITRA di kabupaten ini dan kami ingin mengetahui pandangan bapak/ibu mengenai kekuatan 
dan kelemahan dari strategi proyek ini dan program DOTS. Diskusi ini bersifat rahasia dan nama bapak/ibu 
tidak akan dihubungkan dengan jawaban bapak/ibu. Kami juga akan melihat-lihat fasilitas bapak/ibu, catatan 
bapak/ibu dan berdiskusi dengan beberapa orang staff . Diskusi ini akan memakan waktu kurang lebih setengah 
jam. Bisa kami lanjutkan? 
Apabila jawaban tidak, lanjut ke orang berikutnya. 
Apabila jawaban ya, lanjutkan dengan pertanyaan. 
Lokasi_______________________________________________ 
Tersambung dengan fasilitas lain? , kalau iya/ apakah fasilitas pengobatan/ pengobatan dan lab/ hanya lab saja 
______________________________ 
Name responden 
Total bekerja dengan proyek :______________bulan 
Total bekerja pada fasilitas ini:__________________bulan 
Jumlah staff pada fasilitas ini (jumlah yang mendapatkan pelatihan DOTS) 
1. Berapa lama bekerjasama dengan program MITRA? 
2. Berapa lama bekerja di tempat ini? 
3. Berapa jumlah staf yang bekerja di tempat ini? Berapa orang yang sudah dilatih DOTS dan siapa yang 
memberikan pelatihan? 
4. Apakah tugas utama bapak/ibu di klinik/tempat ini? 
5. Berapa banyak waktu yang bapak/ibu habiskan untuk kegiatan yang terkait dengan TBC (diagnosis/ 
pengobatan/ konseling/ penjangkauan masyarakat/ tindak lanjut/ pelaporan) 
6. Berapa banyak suspek TB yang bapak/ibu periksa dalam 3 bulan terakhir? 
7. Saat ini, ada berapa orang pasien TB yang masih berobat di sini? 
8. Pernahkah bapak/ibu mengikuti pelatihan TB ? jika pernah, bisakah menyebutkan materinya dan siapa 
yang melaksanakan (mengadakannya)? 
9. Apakah pelatihan TB tersebut bermanfaat? Dukungan apalagi yang bapak/ibu dapatkan? Tolong 
sebutkan dukungan lain yang dapat membantu bapak/ibu untuk melaksanakan tugas bapak/ibu dengan 
lebih baik lagi. 
10. Apakah pasien/suspek TB, datang kepada bapak/ibu secara langsung ke tempat praktek bapak/ibu atau 
dirujuk dari tempat lain? 
11. Menurut bapak/ibu, gejala apa yang menyebabkan seseorang dicurigai mengidap TBC? 
12. Apa yang harus dilakukan pada saat seseorang dicurigai mengidap TBC? Bagaimana pasien diperiksa? 
13. Apakah bapak/ibu bisa menyebutkan kriteria-kriteria yang digunakan dalam penggolongan penderita 
TBC ke dalam berbagai kategori? 
14. Fasilitas apa sajakah yang tersedia di klinik ini untuk mendiagnosa pasien suspek TBC? Apabila tidak 
ada, kemana bapak/ibu akan merujuk mereka untuk pemeriksaan? 
15. Apabila bapak/ibu merawat pasien suspek dan setelah bapak/ibu memulai pengobatan, informasi apa 
yang umumnya bapak/ibu berikan kepada pasien bapak/ibu? 
 Page 1 of 2 
MITRA Tools Tools 5 
Private Provider IDI
16. Materi penyuluhan apa, yang pernah bapak/ibu terima? Apakah materi-materi tersebut berguna? 
Apakah bapak/ibu memiliki saran untuk perubahan materi yang ada sekarang? 
17. Obat apa yang bapak/ibu resepkan? Sebutkan (lihat apakah berbeda untuk kategori yang berbeda) 
18. Apa sajakah efek samping yang biasa disebabkan oleh obat yang digunakan dalam pengobatan? 
19. Apakah bapak/ibu menyediakan obat atau hanya menuliskan resep saja? 
20. Di mana pasien biasanya membeli obat? 
21. Apabila responden menyebutkan rujukan ke puskesmas atau pelayanan kesehatan lain yang 
memberikan obat gratis - tanyakan fasilitas mana dan bagaimana dia menindaklanjuti pasien? 
22. Berapa kali bapak/ibu meminta pasien untuk datang kembali ke tempat bapak/ibu? Apa yang terjadi 
apabila pasien tidak datang pada kunjungan berikutnya? 
23. Apakah bapak/ibu menunjuk seorang PMO untuk pasien bapak/ibu? 
24. (Apabila terdapat laboratorium pada fasilitas tersebut) tanyakan, langkah-langkah apa sajakah yang 
diambil untuk memastikan kualitas pengawasan yang dilakukan? 
25. Apakah yang bapak/ibu melakukan pelaporan kasus TB yang bapak/ibu tangani? 
26. Apabila diberi pilihan apakah bapak/ibu bersedia memberikan pelayanan kepada pasien TBC? 
27. Menurut bapak/ibu, bagaimana jika seorang petugas kesehatan yang menderita TBC tetapi tidak sakit , 
diperbolehkan untuk tetap bekerja? 
28. Apabila anggota keluarga bapak/ibu menderita TB, apakah bapak/ibu ingin merahasiakan hal tersebut? 
29. Beberapa orang beranggapan bahwa penderita TB pantas untuk mendapatkan penyakit tersebut. Apakah 
bapak/ibu setuju dengan anggapan ini? 
30. Dukungan apa yang sudah didapatkan kabupaten ini dari MITRA? (pelatihan, pertemuan “review”, 
penguhubungan dengan PMO dan swasta, dll) 
31. Apakah bapak/ibu pernah mengikuti menghadiri pertemuan pada proyek ini, apabila ya, pertemuan apa 
dan apa tujuan dari pertemuan ini? 
32. Sebutkan apa saja yang menjadi kendala dalam pengendalian TB? Bagaimana cara mengatasinya? 
 
Terima kasih untuk waktu bapak/ibu. 
 Page 2 of 2 
MITRA Tools Draft:27 October 
DHO Officers - DHO
In Depth Interview Guideline for District Health Officer
MITRA Mid Term Evaluation 
CARE International Indonesia
Name of the Interviewer________________________ 
Date_________________________ 
Selamat 
Introduce Self 
Preamble: As you are aware we are carrying out the mid term evaluation of project MITRA in this district and 
would like to understand your perspective on the strengths and weakness of project strategies and the DOTS 
program. This will enable us to make improvements in the project strategies and identify issues requiring 
resolution. This will be a confidential discussion and your name will not be attached to your quotes. It will also 
involve an assessment of your facility, review of your registers and discussions with some key staff members of 
the Dinkes We anticipate the discussion to take about half hour. Do we have your permission to proceed? 
Location_______________________________________________ 
Attached to a Facility if so /whether treatment/treatment + lab/only lab______________________________ 
Name of the Interviewee 
Total months of association with the Project:______________ 
Total months in the current position:__________________ 
1. Please describe your role as a District Health Officer. How many facilities do you monitor and support? 
2. What proportion of your time is spent on each of the TB control activities 
3. What are the current challenges, pertaining to TB, in your district? Is it increasing or decreasing? 
4. Please describe some of the difficulties you face in implementing the program and possible solutions. 
5. Have you received any orientation towards DOTS If yes when, what orientations/training and who 
conducted this training? 
6. What further support did you receive? Please describe the additional support that would have helped 
you to perform your duties better. 
7. What are the facilities available in the district to diagnose suspected TB patients? 
8. What additional support is required in the district to diagnose patients?
9. What IEC material is available in the district? Are they useful? Do you want to suggest some 
modifications to the material available? 
10. Please describe the role of the 
Wasor 
BCC officer 
MO communicable diseases 
11. What reporting formats are you required to submit? Did your training have sessions on formats? 
12. What support has this district received from MITRA? (trainings, review meetings, linkages with 
treatment supporters and private providers etc) 
13. Do the activities at district level undergo any review? If yes how often and who are the participants in 
the review? 
14. Does the district have partnerships with any community based groups or other NGOs? How have these 
contributed to the program? 
15. Is there an effort to involve private providers? Please describe your experiences (difficulties and 
innovative ideas if any) 
Thank you indeed for your time. 
 Page 1 of 1 
MITRA Tools Tools 7a 
DHO/Distric Health Office IDI 
Panduan Wawancara Mendalam untuk Kepala Dinas Kesehatan Kabupaten 
MITRA Mid -Term Evaluation 
CARE International Evaluation 
Nama pewawancara :………………… 
Tanggal :…………………… 
Salam, 
Perkenalan: 
• Saya…………beserta tim Evaluasi, diikut sertakan pada kegiatan pelaksanaan 
evaluasi pertengahan periode untuk Proyek MITRA diempat Kabupaten, salah 
satunya Kabupaten yang Bapak/Ibu pimpin ini. 
• Pada wawancara ini kami ingin mengetahui pandangan Bapak/Ibu mengenai 
kekuatan dan kelemahan dari strategi proyek ini berkaitan dengan program 
DOTS. 
• Diskusi ini bersifat rahasia dan nama Bapak/Ibu tidak akan kemi hubungkan 
dengan jawaban Bapak/Ibu 
• Dalam proses evaluasi ini kami akan mewawancarai staf Dinas Kesehatan, pasien 
dan masyarakat yang terlibat Proyek MITRA, erta melihat fasilitas pelayanan, dan 
melihat catatan-catatan yang diperlukan. 
• Diskusi dengan Bapak/Ibu akan memakan waktu kurang lebih satu jam. 
• Apakah wawancara ini bisa kita mulai ? 
Nama lokasi:…………….. 
Nama responden:…………………. 
Proyek Mitra di Kabupaten ini sudah berjalan berapa Bulan………., 
dan berapa orang yang terlibat…………. 
1. Tolong ceritakan peranan Bapak/Ibu sebagai Kepala Dinas. 
2. Berapa banyak waktu yang Bapak/Ibu gunakan untuk pengendalian TB ? 
3. Apa tantangan yng Bapak/Ibu hadapi di Kabupaten ini. 
4. Tolong ceritakan beberapa kesulitan yang Bapak/Ibu hadapi dalam menjalankan 
program dan sekaligus apa pemecahan (solusi) nya. 
5. Apakah Bapak pernah mendapat orientasi/pelatihan dari DOTS, …….apa bila ya 
kapan,……………., orientasi/pelatihan 
apa………………………………………………, dan siapa penyelenggara 
pelatihan?…………………………………… 
6. Dukungan apa yang Bapak/Ibu pernah terima 
………………………………………….., dan dukungan tambahan apa lagi yang 
bapak/Ibu perlukan untuk pelaksanaan tugas yang lebih baik 
?...................................... 
7. Fasilitas apa saja yang tersedia untuk mendiagnosa suspek TB 
1
MITRA Tools Tools 7a 
DHO/Distric Health Office IDI 
8. Dukungan apa yang dibutuhkan Kabupaten untuk mendiagnosa pasien TB ? 
9. Materi penyuluhan (KIE) apa yang tersedia di Kabupaten ? 
10. Tolong ceritakan mengenai peran dari: 
Wasor:…………………………………. 
Petugas KPP/Promkes:…………………………… 
MO (Medical officer) penyakit menular:…………………….. 
11. Dukungan apa yang sudah didapat Kabupaten dari MITRA ? 
 (pelatihan, pertemuan “review”, berkaitan dengan pengobatan , swasta dsb). 
12. Apakah kegiatan tingkat Kabupaten pernah di “di- review” ?
13. Apakah Kabupaten memiliki hubungan kemitraan dengan ORMAS atau NGO 
lainnya ? 
14. Bagaimana cara hubungan kerja dalam rangka memberikan kontribusi kepada 
Kabupaten. 
15. Apakah ada usaha untuk melibatkan swasta? 
 ........................................................................................................ 
 Tolong ceritakan pengalaman Bapak/ IBU 
 (kesulitan dan ide-ide inovativ apabila ada). 
………………………………………………………………………… 
2
MITRA Tools Draft:25 October 
Facility Provider IDI
In Depth Interview Guideline for Wasors
MITRA Mid Term Evaluation 
CARE International Indonesia
Name of the Interviewer________________________ 
Date_________________________ 
Selamat 
Introduce Self 
Preamble: As you are aware we are carrying out the mid term evaluation of project MITRA in this district and 
would like to understand your perspective on the strengths and weakness of project strategies and the DOTS 
program. This will enable us to make improvements in the project strategies and identify issues requiring 
resolution. This will be a confidential discussion and your name will not be attached to your quotes. It will also 
involve an assessment of your facility and review of your registers. We anticipate the discussion to take about 
one hour. Do we have your permission to proceed? 
If response no, move to the next available Wasor. 
If response yes, continue with the questions. 
Location_______________________________________________ 
Attached to a Facility if so /whether treatment/treatment + lab/only lab______________________________ 
Name of the Interviewee 
Total months of association with the Project:______________ 
Total months in the current position:__________________ 
1. Please describe your role as a Wasor. How many facilities do you monitor and support? 
2. What proportion of your time is spent on each of the TB control activities 
Diagnosis 
Treatment 
Counseling 
community outreach/follow up 
supervision 
reporting 
3. What is the current load of disease in your area? Is it increasing or decreasing? 
4. Please describe some of the difficulties you face in implementing the program and possible solutions 
Case notification 
Case detection 
Diagnosis 
Lab functioning 
Treatment 
Drug management 
Community outreach 
Defaults/transfers 
Default retrievals 
MDR TB 
Partnerships with private and NGO sector 
Budgets 
Information management 
 Page 1 of 3 
MITRA Tools Draft:25 October 
Facility Provider IDI
5. Were you given any training to carry out TB control activities? If yes when, what training and who 
conducted this training? 
6. Was this training useful? What further support did you receive? Please describe the additional support 
that would have helped you to perform your duties better. 
7. Now I would like to ask you some technical questions. When does one suspect TB in a patient? 
8. What is done when one suspects TB in a patient? How is the patient investigated? 
9. What are the facilities available in the district to diagnose suspected TB patients? 
10. Could you tell the criteria upon which TB patients are classified into various categories?
11. What additional support is required in the district to diagnose patients?
12. What drugs are prescribed? List (note if different for different categories) 
13. What are the common side effects of the DOTS drugs? 
14. What IEC material is available in the district? Are they useful? Do you want to suggest some 
modifications to the material available? 
15. Is it a norm to identify a treatment supporter for every patient who is registered for DOTS? 
16. Are you required to go to the community for follow up or TB extension activities? If yes please describe 
your community level activities. 
17. What is your role in drug management (maintaining adequate drug supply) and lab management ( if a 
lab is attached to the facility : ensuring adequacy of lab consumables, supervision, reporting etc) 
18. Please describe the role of the 
district health officer in TB control 
BCC officer 
MO communicable diseases 
19. What reporting formats are you required to submit? Did your training have sessions on formats? 
20. Who supervises your work? When did you last receive a supervisory visit? What does your supervisor 
check when he/she visits you? Please list. Did you receive any feedback? Was it useful? Describe the 
support you receive from the NTP. 
21. What support has this district received from MITRA? (trainings, review meetings, linkages with 
treatment supporters and private providers etc) 
22. Do the activities at district level undergo any review? If yes how often and who are the participants in 
the review? 
23. Does the district have partnerships with any community based groups or other NGOs 
24. Is there an effort to involve private providers? Please describe your experiences (difficulties and 
innovative ideas if any) 
Thank you indeed for your time. 
 Page 2 of 3 
MITRA Tools Draft:25 October 
Facility Provider IDI
Thank you for your time! The survey is complete. 
 Page 3 of 3 
MITRA Tools Tools 7b 
Communicable Diseases officer IDI
Panduan Wawancara Mendalam untuk Wasor
MITRA Mid Term Evaluation 
CARE International Indonesia
Nama pewawancara________________________ 
Tanggal_________________________ 
Selamat 
Perkenalan 
Pembukaan: Seperti yang telah anda ketahui, kami sedang melaksanakan evaluasi pertengahan periode untuk 
proyek MITRA di kabupaten ini dan kami ingin mengetahui pandangan anda mengenai kekuatan dan 
kelemahan dari strategi proyek ini dan program DOTS. Diskusi ini bersifat rahasia dan nama anda tidak akan 
dihubungkan dengan jawaban anda. Kami juga akan melihat-lihat fasilitas anda, catatan anda dan berdiskusi 
dengan beberapa orang staff Dinkes. Diskusi ini akan memakan waktu kurang lebih setengah jam. Bisa kami 
lanjutkan? 
Apabila jawaban tidak, lanjut ke Wasor berikutnya. 
Apabila jawaban ya, lanjutkan dengan pertanyaan. 
Lokasi_______________________________________________ 
Tersambung dengan fasilitas, kalau iya/ apakah pengobatan/ pengobatan+lab/ hanya lab 
______________________________ 
Name responden 
Total bekerja dengan proyek :______________bulan 
Total bekerja pada posisi ini:__________________bulan 
1. Tolong ceritakan peran anda sebagai staff P2PL. 
2. Apakah daerah memiliki strategi menyeluruh untuk kesehatan? Apabila iya, tolong jelaskan strategi 
yang menyangkut pengendalian TBC. 
3. Tantangan apa yang sedang dihadapi kabupaten terkait dengan penyakit menular? 
4. Peran apa yang anda mainkan dalam mengatasi permasalahan TBC dan HIV? 
5. Apakah anda memiliki rencana aksi untuk menjalankan kegiatan pengendalian bencana? Apabila ya, 
bisa tolong anda jelaskan? 
6. Apakah anda mendapatkan dukungan anggaran yang memadai? 
7. Materi KIE apa sajakah yang tersedia di kabupaten? Apakah materi-materi tersebut berguna? Apakah 
anda memiliki saran untuk perubahan materi yang ada sekarang? 
8. Apakah anda diwajibkan untuk terjun ke masyarakat untuk mensupervisi kegiatan penyuluhan? Apabila 
ya tolong ceritakan mengenai kegiatan anda pada tingkat masyarakat. 
9. Bagaimana anda mengkoordinasikan kegiatan anda dengan dinkes, petugas promkes, koordinator 
labkesda dan wasor? 
10. Dukungan apa yang sudah didapatkan kabupaten ini dari MITRA? (pelatihan, pertemuan, 
monitoring/peninjauan, penghubungan dengan PMO dan pelayanan kesehatan swasta, dll) 
11. Apakah kegiatan-kegiatan di tingkat kabupaten ini sudah pernah dievaluasi/ ditinjau? Apabila ya, 
seberapa sering dan siapa sajakah peserta review? 
12. Apakah kabupaten memiliki hubungan kemitraan dengan Ormas atau LSM lain? 
13. Apakah ada upaya untuk melibatkan swasta? Tolong ceritakan pengalaman anda (kesulitan dan ide 
inovatif, apabila ada) 
Terima kasih atas waktu anda. 
 Page 1 of 1 
MITRA Tools Draft:27 October 
BCC officer IDI
In Depth Interview Guideline for Wasors
MITRA Mid Term Evaluation 
CARE International Indonesia
Name of the Interviewer________________________ 
Date_________________________ 
Selamat 
Introduce Self 
Preamble: As you are aware we are carrying out the mid term evaluation of project MITRA in this district and 
would like to understand your perspective on the strengths and weakness of project strategies and the DOTS 
program. This will enable us to make improvements in the project strategies and identify issues requiring 
resolution. This will be a confidential discussion and your name will not be attached to your quotes. We 
anticipate the discussion to take about half hour. Do we have your permission to proceed? 
Location_______________________________________________ 
Attached to a Facility if so /whether treatment/treatment + lab/only lab______________________________ 
Name of the Interviewee 
Total months of association with the Project:______________ 
Total months in the current position:__________________ 
1. Please describe your role as the BCC Officer. 
2. Does the district have an overall BCC strategy for health? If yes describe the strategy for controlling 
and preventing TB. 
3. What are the current TB BCC challenges facing the district?
4. What role do you play in addressing the issue of TB?
5. What additional support do you need to ensure patients seek treatment, adhere and complete treatment, 
and are not stigmatized by the society? 
6. Do you have a plan of action for implementing BCC activities? If so could you please describe it? 
7. Are you sufficiently supported by budgets?
8. What IEC material is available in the district? Are they useful? Do you want to suggest some 
modifications to the material available? 
9. Were you given any training pertaining to TB control? If yes when, what training and who conducted 
this training? 
10. Was this training useful? What further support did you receive? Please describe the additional support 
that would have helped you to perform your duties better. 
11. Now I would like to ask you some technical questions. When does one suspect TB in a patient? 
12. What is done when one suspects TB in a patient? How is the patient investigated? 
13. What are the facilities available in the district to diagnose suspected TB patients? 
14. Could you tell the criteria upon which TB patients are classified into various categories?
15. What drugs are prescribed? List (note if different for different categories) 
16. What are the common side effects of the DOTS drugs? 
17. Is it a norm to identify a treatment supporter for every patient who is registered for DOTS? 
18. Are you required to go to the community for follow up BCC extension activities? If yes please describe 
your community level activities. 
19. How do you coordinate your activities with the DHO, MO communicable diseases and the Wasor 
20. What support has this district received from MITRA? (trainings, review meetings, linkages with 
treatment supporters and private providers etc) 
21. Do the activities at district level undergo any review? If yes how often and who are the participants in 
the review? 
 Page 1 of 3 
MITRA Tools Draft:27 October 
BCC officer IDI
22. Does the district have partnerships with any community based groups or other NGOs 
23. Is there an effort to involve private providers? Please describe your experiences (difficulties and 
innovative ideas if any) 
Thank you indeed for your time. 
 Page 2 of 3 
MITRA Tools Draft:27 October 
BCC officer IDI
Thank you for your time! The survey is complete. 
 Page 3 of 3 
MITRA Tools Tools 7c 
BCC officer IDI
Panduan Wawancara Mendalam untuk Staf Promkes
MITRA Mid Term Evaluation 
CARE International Indonesia
Nama pewawancara________________________ 
Tanggal_________________________ 
Selamat 
Perkenalan 
Pembukaan: Seperti yang telah anda ketahui, kami sedang melaksanakan evaluasi pertengahan periode untuk 
proyek MITRA di kabupaten ini dan kami ingin mengetahui pandangan anda mengenai kekuatan dan 
kelemahan dari strategi proyek ini dan program DOTS. Diskusi ini bersifat rahasia dan nama anda tidak akan 
dihubungkan dengan jawaban anda. Kami juga akan melihat-lihat fasilitas anda, catatan anda dan berdiskusi 
dengan beberapa orang staff Dinkes. Diskusi ini akan memakan waktu kurang lebih setengah jam. Bisa kami 
lanjutkan? 
Lokasi_______________________________________________ 
Tersambung dengan fasilitas, kalau iya/ apakah pengobatan/ pengobatan+lab/ hanya lab 
Name responden 
Total bekerja dengan proyek :______________bulan 
Total bekerja pada posisi ini:__________________bulan 
1. Tolong ceritakan “peran dan tugas” anda sebagai petugas KPP. 
2. Apa sajakah tantangan yang sedang dihadapi di kabupaten ini, terkait dengan KPP TBC?
3. Bagaimana cara anda memotivasi pasien untuk berobat secara teratur ? 
4. Bagaimana menghapuskan stigma tentang TB dimasyarakat? 
5. Apakah anda memiliki rencana kerja untuk melaksanakan kegiatan-kegiatan KPP? Apabila ada, bisa tolong 
anda ceritakan? 
6. Apakah anda didukung dengan anggaran yang memadai? 
7. Materi KIE apa sajakah yang tersedia di kabupaten? Apakah materi-materi tersebut berguna? Apakah anda 
memiliki saran untuk perubahan materi yang ada sekarang? 
8. Apakah anda mendapatkan pelatihan mengenai pengendalian TB? Apabila ya, kapan, pelatihan apa dan 
siapa yang memberikan pelatihan? 
9. Apakah pelatihan tersebut bermanfaat? Dukungan apa lagi yang anda dapatkan? Tolong ceritakan mengenai 
dukungan tambahan yang dapat membantu anda untuk menjalankan tugas anda dengan lebih baik. 
10. Menurut anda, kapan seseorang dicurigai mengidap TBC? 
11. Apa yang harus dilakukan pada saat seseorang dicurigai mengidap TBC? Bagaimana pasien diperiksa? 
12. Apa sajakah efek samping yang biasa disebabkan oleh obat DOTS? 
13. Apakah biasanya setiap pasien yang mengikuti DOTS diberikan satu orang PMO? 
14. Apakah anda diwajibkan untuk terjun ke masyarakan untuk menindaklanjuti kegiatan penyuluhan KPP? 
Apabila ya tolong ceritakan mengenai kegiatan anda pada tingkat masyarakat. 
15. Bagaimana anda mengkoordinasikan kegiatan anda dengan dinkes, MO Penyakit Menular dan Wasor 
16. Dukungan apa yang sudah didapatkan kabupaten ini dari MITRA? (pelatihan, pertemuan “review”, 
penguhubungan dengan PMO dan swasta, dll) 
17. Apakah kegiatan-kegiatan di tingkat kabupaten ini sudah pernah dievaluasi/ ditinjau? Apabila ya, seberapa 
sering dan siapa sajakah peserta review? 
18. Apakah kabupaten memiliki hubungan kemitraan dengan Ormas atau LSM lain? 
19. Apakah ada upaya untuk melibatkan swasta? Tolong ceritakan pengalaman anda (kesulitan dan ide inovatif, 
apabila ada) 
Terima kasih atas waktu anda. 
 Page 1 of 1 
MITRA Tools Draft:28 October 
Lab officer IDI
In Depth Interview Guideline for Wasors
MITRA Mid Term Evaluation 
CARE International Indonesia
Name of the Interviewer________________________ 
Date_________________________ 
Selamat 
Introduce Self 
Preamble: As you are aware we are carrying out the mid term evaluation of project MITRA in this district and 
would like to understand your perspective on the strengths and weakness of project strategies and the DOTS 
program. This will enable us to make improvements in the project strategies and identify issues requiring 
resolution. This will be a confidential discussion and your name will not be attached to your quotes. It will also 
involve an assessment of your facility and review of your registers. We anticipate the discussion to take about 
half hour. Do we have your permission to proceed? 
If response is yes then continue with the questions. 
Location_______________________________________________ 
Attached to a Facility or Lab______________________________ 
Name of the Interviewee _______________________________ 
Total months of association with the Project:______________ 
Total months in the current position:__________________ 
1. Please describe your role as a Lab Officer. How many Labs do you monitor and support? 
2. What proportion of your time is spent on each of the TB control activities 
Actual lab work 
supervision 
reporting 
Management 
3. What is the current load of disease in your area? Is it increasing or decreasing? 
4. Please describe some of the difficulties you face in implementing the program and possible solutions 
Case notification 
Case detection 
Diagnosis 
Lab functioning 
Treatment 
MDR TB 
Budgets 
Information management 
5. What trainings have you received to carry out efficient lab management and networking. Who 
conducted these trainings? 
6. Was this training useful? What further support did you receive? Please describe the additional support 
that would have helped you to perform your duties better. 
7. Now I would like to ask you some technical questions. When does one suspect TB in a patient? 
8. What is done when one suspects TB in a patient? How is the patient investigated? 
9. What are the facilities available in the district to diagnose suspected TB patients? 
10. Could you relate the criteria upon which TB patients are classified into various categories? 
11. What additional support is required in the district to diagnose patients?
12. Please describe how you coordinate activities and what support do you get from 
 Page 1 of 2 
MITRA Tools Draft:28 October 
Lab officer IDI
District health officer 
Wasor 
BCC officer 
MO communicable diseases 
13. How is the internal quality assessment done? How frequently is this done? What problems do you face 
in carrying out internal quality assessment? 
14. How is the external quality assessment done? How frequently is this done? What problems do you face 
in carrying out internal quality assessment? 
15. Is the availability of equipments, infrastructure and consumables adequate in the district labs? Do you 
face any problems in this regard? 
16. What reporting formats are you required to submit? Did your training have sessions on formats? 
17. Who supervises your work? When did you last receive a supervisory visit? What does your supervisor 
check when he/she visits you? Please list. Did you receive any feedback? Was it useful? Describe the 
support you receive from the NTP. 
18. What support has this district received from MITRA? (trainings, review meetings, linkages with 
treatment supporters and private providers etc) 
19. Do the activities at district level undergo any review? If yes how often and who are the participants in 
the review? 
20. Is there an effort to involve private providers? Please describe your experiences (difficulties and 
innovative ideas if any) 
Thank you indeed for your time. 
 Page 2 of 2 
MITRA Tools Tools 7d 
Lab officer IDI
Panduan Wawancara Mendalam untuk pengelola Laboratorium
MITRA Mid Term Evaluation 
CARE International Indonesia
Nama pewawancara________________________ 
Tanggal_________________________ 
Selamat 
Perkenalan 
Pembukaan: Seperti yang telah anda ketahui, kami sedang melaksanakan evaluasi pertengahan periode untuk 
proyek MITRA di kabupaten ini dan kami ingin mengetahui pandangan anda mengenai kekuatan dan 
kelemahan dari strategi proyek ini dan program DOTS. Diskusi ini bersifat rahasia dan nama anda tidak akan 
dihubungkan dengan jawaban anda. Kami juga akan melihat-lihat fasilitas anda, catatan anda dan berdiskusi 
dengan beberapa orang staff Dinkes. Diskusi ini akan memakan waktu kurang lebih setengah jam. Bisa kami 
lanjutkan? 
Apabila jawaban tidak, lanjut ke Wasor berikutnya. 
Apabila jawaban ya, lanjutkan dengan pertanyaan. 
Lokasi_______________________________________________ 
Tersambung dengan fasilitas, kalau iya/ apakah pengobatan/ pengobatan+lab/ hanya lab 
______________________________ 
Nama responden 
Total bekerja dengan proyek :______________bulan 
Total bekerja pada posisi ini:__________________bulan 
1. Tolong ceritakan peran bapak/ibu sebagai kepala laboratorium kesehatan. Berapa fasilitas bapak/ibu 
yang anda monitor dan berapa yang anda dukung? 
2. Seberapa banyak dari waktu anda yang bapak/ibu gunakan untuk masing-masing kegiatan pengendalian 
TB 
Pekerjaan lab 
Supervisi 
Pelaporan 
Manajemen 
3. Seberapa banyak kasus TBC di daerah bapak/ibu? Apakah meningkat atau menurun? 
4. Tolong ceritakan kesulitan-kesulitan yang anda hadapi dalam menjalankan program dan solusi yang 
dimungkinkan 
Notifikasi kasus 
Penemuan kasus 
Diagnosis 
Fungsi lab 
Pengobatan 
MDR TB 
Anggaran 
Manajemen informasi 
5. Pelatihan apa yang pernah anda dapatkan untuk melaksanakan manajemen lab dan jejaring yang efisien 
siapa yang memberikan pelatihan ini? 
6. Apakah pelatihan ini bermanfaat? Dukungan apa yang anda dapatkan? Dukungan tambahan apa sajakah 
yang dapat membantu anda untuk melaksanakan tugas anda dengan lebih baik? 
 Page 1 of 2 
MITRA Tools Tools 7d 
Lab officer IDI
7. Sekarang saya ingin menanyakan beberapa pertanyaan teknis. Menurut anda, kapan seseorang dicurigai 
mengidap TB? 
8. Apa yang harus dilakukan pada saat seseorang dicurigai mengidap TBC? Bagaimana pasien diperiksa? 
9. Fasilitas apa sajakah yang tersedia di kabupaten untuk mendiagnosa suspek TB? 
10. Apakah anda bisa menyebutkan kriteria-kriteria yang digunakan dalam penggolongan penderita TBC ke 
dalam berbagai kategori? 
11. Dukungan tambahan apa yang dibutuhkan kabupaten untuk dapat mendiagnosa pasien? 
12. Tolong ceritakan bagaimana anda berkoordinasi dengan dan dukungan apa yang anda dapatkan dari 
Kepala Dinas Kesehatan 
Wasor 
Petugas KPP 
MO penyakit menular 
13. Bagaimana cross check dilaksanakan secara internal? Seberapa sering hal ini dilakukan? Permasalahan 
apa yang anda hadapi dalam melaksanakan penilaian kualitas internal? 
14. Bagaimana cross check dilaksanakan secara eksternal? Seberapa sering hal ini dilakukan? Permasalahan 
apa yang anda hadapi dalam melaksanakan penilaian kualitas eksternal? 
15. Apakah sudah tersedia peralatan, infrastruktur dan perlengkapan yang memadai pada laboratorium 
kabupaten? Apakah anda memiliki permasalah terkait dengan hal ini? 
16. Format pelaporan seperti apa yang anda harus sampaikan? Apakah pada pelatihan yang anda ikuti ada 
sesi mengenai format? 
17. Siapa yang mensupervisi pekerjaan anda? Kapan terakhir kali anda mendapatkan kunjungan supervisi? 
Apa yang biasanya dia periksa pada saat berkunjung? Sebutkan. Apakah anda mendapatkan umpan 
balik? Apakah hal tersebut berguna? Ceritakan dukungan yang anda dapatkan dari Program TB 
Nasional. 
18. Dukungan apa yang sudah didapatkan kabupaten ini dari MITRA? (pelatihan, pertemuan “review”, 
penguhubungan dengan PMO dan swasta, dll) 
19. Apakah kegiatan-kegiatan di tingkat kabupaten ini sudah pernah dievaluasi/ ditinjau? Apabila ya, 
seberapa sering dan siapa sajakah peserta evaluasi? 
20. Apakah ada upaya untuk melibatkan swasta? Tolong ceritakan pengalaman anda (kesulitan dan ide 
inovatif, apabila ada) 
Terima kasih atas waktu anda. 
 Page 2 of 2 
MITRA Tools Draft: 25 October 
Facility Assessment Checklist 
Checklist untuk Peninjauan Fasilitas (termasuk Lab) 
MITRA (TB Project) Mid Term Evaluation 
CARE International Indonesia
Nama fasilitas: 
Jenis a) fasilitas pengobatans saja b) lab mikroskopi c) pengobatan and mikroskopi 
Nama observer: 
Tanggal kunjungan : 
I. Informasi Umum 
Area terpisah di mana pasien TBC melapor Y N 
Sistem untuk merujuk pasien suspek TB ke petugas DOTS pada 
fasilitas 
Y N 
Materi KIE ditempelkan pada fasilitas Y N 
Sarana pembuangan dahak yang aman Y N 
Staff khusus untuk melayani pasien TBC Y N 
Proporsi staff yang mendapatkan pelatihan TBC (N) terlatih 
Proporsi staff yang tidak mendapatkan pelatihan TBC (N) terlatih 
Apakah ada pencatatan TBC dan kemuktahiran Y N 
Apakah ada format TBC yang memadai dan apakah diisi secara 
tepat 
Y N 
Apakah kesediaan obat mencukupi (kecukupan sebagai ukuran 
terhadap jumlah pasien baru yang mendaftar setiap caturwulan) 
Y N 
Suspek TB diperiksa untuk diagnosis (untuk bulan lalu) (N) 
Suspek TB yang positik (N) 
Suspek TB yang menjalani pemeriksaan dahak ulang (N) 
Suspek TB yang ditemukan positif pada pemeriksaan ulang 
dahak 
(N) 
Pasien follow up yang diperiksa (N) 
Jumlah pasien follow up (N) 
Jumlah pasien yang terdaftar (N) 
Jumlah kotak obat yang tersedia (N) 
Jumlah drop out (N) 
Jumlah yang memiliki PMO (N) 
II. Kegiatan Diagnosis 
Proporsi suspek TB yang menjalani 3 pemeriksaan dahak untuk 
diagnosis? 
(Dapat diperkirakan dengan mempelajari beberapa halaman 
dari catatan lab)
(N) Done % 
Proporsi suspek TB yang menjalani 2 pemeriksaan dahak untuk 
diagnosis? 
(Dapat diperkirakan dengan mempelajari beberapa halaman 
dari catatan lab)entries in the Lab register)
MITRA Tools Draft: 25 October 
Facility Assessment Checklist 
Jumlah DO pada caturwulan sebelumnya: 
III. Infrastruktur dan Kegiatan Lab 
Apakah ada ruang khusus untuk lab Yes/No 
Apakah ada protap yang tersedia Yes/No 
Ada catatan lab Yes/No 
Apakah ada miskroskop binokular yang berfungsi? Yes/No 
Apakah pemeriksaan dahak dilakukan oleh teknisi lab? Kapan terakhir 
pelatihan 
Yes/No 
Apakah terdapat persediaan reagen, slide dan persediaan lainnya untuk satu 
bulan ke depan? 
Yes/No 
Apakah reagen lab dipersiapkan secara fresh (segar)? optional Yes/No 
Apabila iya, kapan hal tersebut dipersiapkan (pada a/b/c)? optional Yes/No 
Apakah nama dan alamat pada catatan lab TB ditulis dengan jelas Yes/No 
Are the positive results written in red & negative in blue/black? Don’t 
know if this is a norm in Indonesia 
Yes/No 
Apakah ada rangkuman kegiatan mikroskopis pada setiap akhir bulan? Yes/No 
Apakah teknisi lab menyimpan slide untuk dilihat kembali oleh supervisor 
untuk protokol memastikan kualitas? 
Yes/No 
Last supervisory visit and from whom 
Is the supervisor reviewing slides preserved by the LT during the on site 
evaluation? 
Yes/No 
Is there evidence of EQA ( ‘x’, ‘o’ marks in the Lab register) again please 
review for the norm in Indonesia
Yes/No 
Apakah laporan evaluasi on site yang dilakukan oleh supervisor tersedia di 
fasilitas (setidaknya untuk bulan lalu)? 
Yes/No 
Apakah ada upaya korektif yang disarankan pada laporan dilakukan oleh 
fasiltias? (status pada saat ini dapat digunakan sebagai ukuran apakah 
upaya korektif sudah dilakukan atau belum) 
Yes/No 
Apakah sampah biomedis dibuang sesuai norma Yes/No 
Apakah lab mengembangkan kultur mycobacterial dan tes suscepsibilitas 
obat 
Yes/ No 
Slide disimpan untuk QA internal (optional) Yes/No 
Total slide yang diperiksa 
Total slide positif 
Total slide negatif 
Optional : blinding, errors detected, resolved 
IV. Kegiatan pengobatan:
Apakah kotak obat untuk pasien ditandai dan dijaga untuk setiap pasien berobat jalan 
yang mendapatkan pengobatan pada pusat DOT? 
Apakah fasilitas untuk DOTS memuaskan ( air bersih, gelas sekali pakai, privasi)? 
Apakah ada pengaturan yang memadai untuk SM injeksi (apabila ada pasien kat 2 
mendapatkan pengobatan di pusat DOTS ini)? 
MITRA Tools Draft: 25 October 
Facility Assessment Checklist 
Apakah terdapat konsistensi antara jumlah dosis yang ada di kartu pengobatan dan kotak 
obat? (periksa 2 kotak) 
Kotak 1 (nama_____________) Kotak 2 (nama_____________) 
Apakah ada kunjungan rumah untuk membawa pasien yang tidak teratur berobat 
kembali? (Atau pasien yang tidak datang untuk dosis, bagian dari kartu pengobatan 
dapat diperiksa)
Apakah ada obat di kotak obat pasien yang sudah kadaluarsa 
Kotak 1 (nama_____________) Kotak 2 (nama_____________) 
Apakah alamat pasien diverivikasi sebelum memulai pengobatan? (KArtu pengobatan 
dapa diperiksa untuk kunjungan rumah awal)
V. Sumber Daya Manusia: 
Pelatihan dan Sensitisasi yang dilakukan pada 4 cawu terakhir: 
Jenis staff 
1 
2 
3 
4 
Pelatihan RNTCP Formal Sensitisasi RNTCP
VI. Mekanisme rujukan untuk pengobatan dan umpan balik: 
• Apakah ada catatan rujukan untuk pengobatan yang dilakukan? 
• Apakah formulir pengobatan digunakan untuk merujuk pasien yang didiagnosa di 
fasilitas ke tempat lain? Di dalam dan di luar kabupaten? 
• Apakah ada kenda dalam perujukan pasien ke pusat TBC? 
• Apakah ada umpan balik mengenai pasien yang berikan ke departemen perujuk 
oleh pusat DOTS? 
VII. DOTS Indoor: (untuk RS- termasuk observasi kunjungan ke bangsal TB- Paru/ 
Medicine Department) 
• Apakah obat-obatan yang dipasok oleh PTN digunakan di bangsal untuk pasien 
rawat inap? 
• Apakah ada sumber lain untuk OAT (yang sudah tersedia melalui PTN) untuk 
pasien rawat inap? 
• Apakah pasien rawat inap juga tercatat di tempat lain? 
• Apakah mekanisme “Transfer Out” dicatat dengan baik pada saat rawat inap? 
VIII. Koordinasi TB/HIV (berdasarkan kunjungan ke pusat VCT dan ART, kalau ada
• Apakah ada pusat VCT di fasilitas atau disekitar? 
• Apakah ada standar mekanisma perujukan silang antara pusat DOTS dan VCT? 
• Apakah ada mekanisme untuk membawa pasien TB dalam ART ke pusat DOTS? 
IX. Supervisi dan Monitoring: 
• Kapan terakhir kali pertemuan supervisi diadakan?
• Siapa yang berkunjung? 
MITRA Tools Draft: 25 October 
Facility Assessment Checklist 
• Umpan balik apa yang diberikan pada kunjungan tersebut? 
• Tindak lanjut apa yang telah dilakukan berdasarkan umpan balik? 
MITRA Tools Draft: 25 October 
Facility Assessment Checklist 
Checklist for Facility (including Lab) Assessment 
MITRA (TB Project) Mid Term Evaluation 
CARE International Indonesia
Name of the Facility: 
Whether a) treatment only facility b) microscopy lab c) treatment and microscopy 
Name of the Observer: 
Date of Visit: 
I. General Information 
Separate area where all suspected TB patients report Y N 
System for referring suspected TB patients to DOTS provider 
within facility 
Y N 
IEC material displayed in the facility Y N 
Provision for safe sputum disposal Y N 
Dedicated staff to attend TB patients Y N 
Proportion of TB Staff Trained (N) Trained 
Proportion of non-TB staff trained in DOTS (N) Trained 
Whether TB register present and up to date Y N 
Whether adequate TB formats available and filled appropriately Y N 
Whether adequate drugs available (adequacy as a measure of 
expected number of new patients registered on a quarterly basis) 
Y N 
TB suspects examined for diagnosis (for the last month) (N) 
TB suspects found to be positive (N) 
TB suspects undergoing repeat sputum examination (N) 
TB suspects found to be positive on repeat sputum examination (N) 
Follow up patients examined (N) 
Patients positive on follow up (N) 
Number of patients registered (N) 
Number of dedicated drug boxes (N) 
Number of defaulters (N) 
Number with treatment supporters (N) 
II. Diagnostic Activities 
Proportion of TB suspects for whom 3 sputum smears were done 
for diagnosis? 
(Can be estimated by examining a few pages of entries in the Lab 
register)
(N) Done % 
Proportion of TB patients for whom 2 sputum smears were done 
during follow up 
examination? (Can be similarly estimated by examining a few 
pages of 
entries in the Lab register)
MITRA Tools Draft: 25 October 
Facility Assessment Checklist 
No. of initial defaulters in the previous quarter: 
III. Lab Infrastructure and Activities 
Is there a separate lab space Yes/No 
Is there a Standard Operating Procedure present Yes/No 
Lab register present Yes/No 
Is there a functional binocular microscope in the MC? Yes/No 
Is a trained Lab Technician (LT) doing the sputum microscopy? When last 
trained 
Yes/No 
Are there adequate supplies of reagents, slides and other consumables for 
the next one-month? 
Yes/No 
Are the lab reagents freshly prepared? optional Yes/No 
If yes, where are they prepared (at a/b/c)? optional Yes/No 
Are the names and addresses in the TB laboratory register written legibly? Yes/No 
Are the positive results written in red & negative in blue/black? Don’t 
know if this is a norm in Indonesia 
Yes/No 
Is there a summary of the microscopy activities at the end of each month? Yes/No 
Is the LT preserving slides for review by the supervisor as per the quality 
assurance protocol? 
Yes/No 
Last supervisory visit and from whom 
Is the supervisor reviewing slides preserved by the LT during the on site 
evaluation? 
Yes/No 
Is there evidence of EQA ( ‘x’, ‘o’ marks in the Lab register) again please 
review for the norm in Indonesia
Yes/No 
Are the reports of On Site Evaluation done by supervisor available in the 
facility (at least for last month)? 
Yes/No 
Is corrective action as suggested in report being carried out by the facility? 
(current status may be used as an assessment about the corrective actions 
taken) 
Yes/No 
Is the bio-medical waste disposed as per norms Yes/No 
Does the lab engage in Mycobacterial culture and drug susceptibility 
testing 
Yes/ No 
Slides maintained for internal quality (optional) Yes/No 
Total slides examined 
Total slides positive 
Total negative slides 
Optional : blinding, errors detected, resolved 
IV. Treatment Activities:
Are patient-wise drug boxes being marked and maintained for each outpatient receiving 
treatment at the DOT Centre? 
Are the facilities (clean water, disposable cups, privacy) for DOTS satisfactory? 
Is there adequate arrangement available for providing Inj SM (if Cat II patients are 
receiving treatment at this DOT centre)? 
MITRA Tools Draft: 25 October 
Facility Assessment Checklist 
Is there consistency between the number of doses on treatment card and drug box? (check 
any 2 boxes) 
Box 1 (name_____________) Box 2 (name_____________) 
Are prompt home visits made to bring irregular patients back on treatment? (For patients 
who have missed doses, the relevant section on treatment card can be checked for 
entries)
Have any of the drugs in the Patient Wise Boxes (PWBs) crossed the date of expiry 
Box 1 (name_____________) Box 2 (name_____________) 
Is home address verification done for patients before start of treatment? (Treatment cards 
can be examined for entries in the section for Initial home visit)
V. Human Resources: 
Training and sensitization held in the last four quarters: 
Kind of staff 
1 
2 
3 
4 
Formally Trained in 
RNTCP
Sensitized in RNTCP
VI. Referral for treatment and feedback mechanism: 
• Is a Referral for Treatment Register maintained? 
• Are Treatment Forms used to refer patients diagnosed in the facility to other 
centers? within and outside the district? 
• Are there any constraints in the referral of TB patients to the DOT centers? 
• Is any feedback regarding referred patients provided to the referring department 
by the DOTS centres? 
VII. Indoor DOTS: (for hospitals - includes observations based on visit to wards in TB￾Chest/ Medicine Department)
• Are the NTP supplied drugs used in the wards for indoor patients?
• Are there any other source of anti-TB drugs (which are already available under 
NTP) for indoor patients? 
• Is the in patient registered elsewhere also? 
• Is the “Transfer Out” mechanism working satisfactorily registered while on 
indoor treatment? 
VIII. TB/HIV Coordination (to be based on visit to VCTC and ART centre, if any) 
• Is there a VCTC in the facility or nearby? 
• Is the standard cross-referral mechanism between the DOTS center and VCTC 
established? 
• Is there a mechanism to put TB patients treated in the ART centre on DOTS? 
IX. Supervision and Monitoring: 
• When was the last supervisory visit made? 
MITRA Tools Draft: 25 October 
Facility Assessment Checklist 
• Who made this visit? 
• What feedback was provided during that visit?
• What follow up action was taken based on the feedback? 
ENDLINE
SURVEY
KNOWLEDGE,
PRACTICE AND
COVERAGE
IN
KANCHANPUR, DOTI,
DADELDHURA AND
BAJHANG.
SUBMITTED
TO
•
•
car
CARE NEPAL
CHILD SURVIVAL PROJECT
KRISHNA GALLI, LALlTPUR
JULY 2007
SUBMITTED
BY
SOLUTIONS CONSULTANT P. LTD.
KATHMANDU, NEPAL
977-1-4224246
info@solutions.com.np
http://www.solutions.com.np
TABLE OF CONTENTS
LIST OF TABLES...................•....................................................................................... 111
ACRONYMS ...............................................................................................................•...•V
ACKNOWLEDGEMENT............•••................••...•...........•.••............................................VII
EXECUTIVE SUMMARY VIII
RAPID CATCH PRIORITY INDICATORS...••........•........•...••..••..............•..•..................XIII
CHAPTER ONE INTRODUCTION .....................•.........•......••..•...................••................•. 1
1.1 BACKGROUND ......................................................................................................................•..2
1.2 CARE/CSP EFFORTS TO COMBAT OF CHILD HEALTH ISSUES •.••••••.•.•...•....•..•••.•••.•••.•••••••••••••••• 3
1.3 OBJECTIVES OF CAREfCHILD SURVIVAL PROJECT (CSP) •••••••..•••.••••..•••.••..••••.•••.•••.•••••••••••••••• 3
1.4 A BRIEF OVERVIEW OF PROJECT AREA ••.••••••••.•••.•.......•••••••.•.•.••••••.....•.....•.•••.•••...•...........•••••••4
1.5 OBJECTIVES OF THE ENDLlNE STUOY 6
CHAPTER TWO METHODOLOGY.....•...•....•.................•...••...•............••..•...................... 7
2.1 STUDY AREA 8
2.2 STUDY DESiGN 8
2.3 STUDY POPULATION......•...••.•.••..••••...••...•..••••••••.••....•....•..•••...•••...••...•....•..••••••••••••.••..•••..•••.•.••• 8
2.4 DEVELOPMENT OF QUESTIONNAIRE .••...••..••••••••••••••••••••••.••••.•••••••••••••••••••••••••••••••••••••••••••••••••••• 9
2.5 SAMPUNG DESIGN, SIZE AND PROCESS ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••.•.•...••...•••••••• 9
2.6 REGIONAL AND DISTRICT levEL ORIENTATION AND TRAINING 11
2.7 DATA COU.ECTlON PROCEDURE ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• 11
2.8 VAUDlTY AND CONSISTENCY OF INTERVIEWS •••••..••...•....•...••..•••...••....•....•..•••••••..•...•....•...••..... 12
2.9 DATA CODING, PROCESSING AND MANAGEMENT••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• 12
2.10 DATA ANALYSIS 12
2.11 RESULTS AND DISCUSSION••..•••..•••..••...••..•••.••••...•...••...••..•••.•••....•....•...••..••••••••••••••...••••..••••••• 13
2.12 UMITATlON QF THE SURVEY••••••••••••••••••••••••••••••••••••••.••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• 13
CHAPTER THREE PRESENTATIONS OF THE FINDINGS: HOUSEHOLD SURVEY 14
3.1 DEMOGRAPHIC CHARACTERISTICS, BIRTH SPACING AND CHILD CARE ••...•.•.•••••••••••••••••.•••••••••• 15
3.2 CHILD HEALTH, NUTRITION AND BREASTFEEDING ••••••••••••••••••••••••.••••••••••••••.•••.••••••••••••.••••.••••• 20
3.3 MATERNAL AND CHILD HEALTH RELATED INFORMATION•••••.••••.••••.••••.••••.•••.•••••••••..••.•••••••••••••• 27
3.4 IMMUNIZATION •.•••••..•••...•••.••••..•••.•••••••••..•••..•••.••.••.........•••.••••..•.•.••............•••••,•••..............•.•••• 38
3.5 INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESSES •.•...••..••••••.•••••.•••..••••••••.•••.••••••••.••••••••• 40
3.6 ACUTE RESPIRATORY INFECTION .•.•........••••.•••.••••••••..••••.•.....•.••••••.••••.•••.••••.•••.•••.••••••••••••••••••• 45
3.7 INFORMATION ON MALARIA•.••••.••••.••••.••••••••.•••.••.....••••••••••••.•••••.•••.......•••••••.•••••••••...............•..48
3.8 KNOWLEDGE ABOUT AND PREVENTION OF HIV/AIDS ......•..••.••.•••.••..........••.••••••••••••••••••••••.•••.• 50
3.9 FCHV AND THEIR ROLE IN HEALTH CARE DELIVERY •••...•..•••••••••••••••••••..•••••••••••••••••••••••••••••.••• 51
3.10 KNOWLEDGE ON IODINE AND SALT USE •••••••••••••••••••••.••••••••••••••••••••••••••••••••••••••••••.••••••••••••••••• 52
3.11 MOTHERS' INVOLVEMENT IN COMMUNITY ORGANIZATION ....••••.•••...•.....•...•.....••••.............•.•..•••. 53
3.12 ANTHROPOMETRIC MEASUREMENT 53
CHAPTER FOUR PRESENTATIONS OF THE FINDINGS: HEALTH FACILITY
ASSESSMENT ••..........•..•.............................................................................................. 57
4.1 STAfFING PATTERN IN SruDY HEALTH FAC1UTlES ••••••••••••••••••••••••••••••••••••••••••••••.......••..••....••. 58
4.2 STOCK SITUATION ••....••..•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••. 59
4.3 AVAlLABIUTY, FUNCTIONING AND USE OF ESSENTIAL INSTRUMENT ••••••••••••••••••••••••••...•...•.•••..•• 62
4.4 AVAllABlUTY OF SEPARATE PLACE FOR ANC/PNC••.•••••••••••••••••...•.........•..••••••••............•....••. 64
4.5 AVAlLABIUTY OF STANDARD TREATMENT SCHEDULE •••••••••••••••••••••••••••••••••••••••••••..•....•........••• 64
4.6 PROPORTION OF FUNCTIONAL PHC/ORC ••••••••••••..........••••••••••••..................•.•.•••.................••• 65
4.7 FUNCTIONAL EPI CUNIC •..••..•••••.••.........•...•••••••••.•......•.•....••••••••••••••..•....•••••••••••••••••••••••••••••.• 65
4.8 SUPPLY OF VACCINES .••.•.••••.•..................•.•••.•..•................•...•••................•••••••.••••••••..•...•••.••• 66
4.9 PLANNING OF HEALTH SERVICES •.•.•........••••••••••.••••••••••••.•••••••••••••••••••••.••••••••••••••••••••••.••••••••••• 66
4.10 PROPORTION OF HEALTH FACIUTIES HAVING GUlDEUNES BY DiSTRICT•••••••••••••••••••••••••••••••••••• 67
4.11 DISPLAY OF IEC MATERiAL IN THE HEALTH FACIUTY BY DISTRH:T ••.•••••••••••••••••••••••••••••••••••••••• 67
4.12 SUPERVISION VISrT FROM HIGHER AUTHORITY •.•••...•....••..•••.••••..••..•••...••...••••••••••••...•..•••••••••••• 68
4.13 SUPERVISION PLAN AND IMPLEMENTATION OF HEALTH FAClUTlES 68
CHAPTER FIVE PRESENTATIONS OF THE FINOINGS: HEALTH WORKERS
CAPACITY ASSESSMENT ...................................................•................•.................••..• 70
5.1 RESPONDENT CATEGORY 71
5.2 SUPERVISION ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• 71
5.3 DIAGNOSIS AND MANAGEMENT OF CHILDHooO ILLNESS 72
CHAPTER SIX PRESENTATIONS OF THE FINDINGS: FEMALE COMMUNITY
HEALTH VOLUNTEERS' CAPACITY ASSESSMENT........•........................................ 78
6.1 CATEGORY OF FCHVs 79
6.2 SUPERVISION 79
6.3 DIAGNOSIS AND MANAGEMENT OF CHILDHOOD ILLNESS 79
6.4 SUPPLIES 86
CHAPTER SEVEN 87
CONCLUSION 87
REFERENCES 91
ANNEX 92
ii
LIST OF TABLES
Table 1. Age, Educational and Ethnicity status of the interviewed mothers 16
Table 2. No. of children below 5 years of age in the household 16
Table 3. Age and Sex of the targeted children below 24 months 18
Table 4. Spacing between births 19
Table 5. Caretaker of the children in absence of mother 19
Table 6. Breastfeeding practices of the mothers 21
Table 7. Pre-Iacteal feeding practices 10 the newborn within 3 days 22
Table 8. Mothers currently breastfeeding their children 22
Table 9. Knowledge and practices of mothers for introducing complementary food to children 23
Table 10. Liquid foods consumed by children (less than 24 months) within 24 hours
preceding the interview (multiple responses) 24
Table 11. Children receiving full complementary solid meal within 24 hours preceding the
interviews 24
Table 12. Knowledge on Sarbottam pitho (Super-flour) 25
Table 13. Infonnation on kitchen garden 26
Table 14. Growth monitoring 27
Table 15. Antenatal care, pregnancy check up and TT vaccination 28
Table 16. Counseling and knowledge of danger signs during pregnancy 30
Table 17. Consumption of ironlfolic acid tablets 31
Table 18. Delivery care 31
Table 19. Cord culling practices and use of safe delivery kit 33
Table 20. Newborn care 34
Table 21. Postnatal care 35
Table 22. Maternal and infant care 37
Table 23. Vaccination Coverage 38
Table 24. Immunization coverage in children aged 12-23 39
Table 25. Symptoms of Childhood illnesses 40
Table 26. Knowledge of mothers about feeding of fluid and food during childhood ~Inesses 41
Table 27. DiarThoeal Disease 42
Table 28. Knowledge of mothers about the preparation of ORS 43
Table 29. Household with toilet and use 44
Table 30. Hand washing Practices 44
Table 31. Prevalence of ARI and treatment sought by mothers in two weeks preceding
the interview 45
Table 32. Knowledge of mothers about sign and symptoms of pneumonia 46
Table 33. Knowledge of mothers about danger signs of ARI requiring urgent medical
treatment (multiple responses) 47
Table 34. Treatment seeking (first) by mothers in pneumonia 47
Table 35. Prevalence of malaria among the children and treatment-seeking behavior
of mothers 48
Table 36. Mothers' knowledge about the prevention of malaria (multiple responses) 49
Table 37. Availability and use practices of bed nets 50
Table 38. Mothers knowledge on HIVlAIDS 50
Table 39. Availability and service delivery by FCHV 52
Table 40. Knowledge and practices of mothers on iodized salt 52
Table 41. Involvement of mothers in local community organizations and their activities 53
Table 42. Nutrition status of children 55
Table 43. Mid-upper arm circumference of children and mothers 56
Table 44. Staffing situation 58
Table 45. Endline Assessment of Staffing situation by districts (Kanchanpur and Doti) 59
Table 46. Endline Assessment of staffing situation by districts (Dadeldhura and Bajhang) 59
Table 47. Stock situation (in %) 61
Table 48. Availability, functioning and use of Essential instrument 62
Table 49. Separate place for ANC/PNC 64
Table 50. Standard treatment schedule 65
Table 51. Functional PHCJQRC 65
Table 52. Functional EPI clinic 66
iii
Table 53. Supply of vaccines
Table 54. Plan for seNices
Table 55. Guidelines
Table 56. IEC Materials
Table 57. SupeNision in last six months
Table 58. SupeNision Plan and Implementation
Table 59. Type of inteNiewed health workers
Table 60. SupeNision
Table 61. Diarmea related information
Table 62. AAI related information
Table 63. Cases seen and treatment outcome in last two weeks
Table 64. Malaria related infonnation
Table 65. Neonatal tetanus related information
Table 66. FCHVs
Table 67. SupeNision
Table 68. Diarrhea related information
Table 69. ARI related information
Table 70. Cases seen and treatment outcome with in two weeks
Table 71. Malaria related infonnation
Table 72. Neonatal tetanus related information
Table 73. Proportion of FCHVs with supplies
66
67
67
66
6B
69
71
71
72
74
76
77
77
79
70
60
B3
B4
B5
85
86
ACRONYMS
AHW
AIDS
ANC
ANM
ARI
BCG
BL
CB-IMCI:
CDD
CMA
CPR
CSP
CYP
DHO
DHS
DPT
EL
EOP
EPI
FCHV
FWDR
FY
HA
HDI
HFOMC:
HIV
HMG
HP
HW
IDD
KPC
MCHW:
MUAC
NGO
ORS
PHCC
PNC
RHD
Auxlliary Health Worker
Acquired Immuno-deficiency Syndrome
Ante-natal Care
Auxiliary Nurse Midwife
Acute Respiratory Tract Infection
Bacille Calmette-Guerin
Baseline
Community Based Integrated Management of Childhood Illness
Control of Diarrhoeal Diseases
Community Medical Assistant
Contraceptive Prevalence Rate
Child SUlVival Project
Couple Year of Protection
District Health Office/Officer
Demographic and Health SUlVeylDepartment of Health SelVices
Diphtheria Pertussis Tetanus
Endline
Emergency Order Point
Expanded Program on Immunization
Female Community Health Volunteer
Far Western Development Region
Fiscal Year
Health Assistant
Human Development Indicators
Health Facility Operation and Management Committee
Human Immuno-deficiency Virus
His Majesty's Government
Health Post
Health Worker
Iodine Deficiency Disorders
Knowledge Practice and Coverage
Maternal and Child Health Worker
Mid-upper Arm Circumference
Non Governmental Organization
Oral Rehydration Solution
Primary Health Care Centre
Post-natal Care
Regional Health Directorate
v
SHDK
SHP
TBA
n
nBA
UTBA
VDC
VHW
WHO
Safe Home Delivery Kit
Sub Health Post
Traditional Birth Attendant
Tetanus Toxoid
Trained Traditional Birth Attendant
Untrained Traditional Birth Attendant
Village Development Committee
Village Health Worker
World Health Organization
vi
ACKNOWLEDGEMENT
The study team would like to extend our sincere appreciation to CARE Nepal, Child Survival
Project for entrusting us with the study. Without their trust and support, this study would not have
been successful.
Special heartfelt thanks 10 the mothers with children less than 24 months and health worXers
including FCHVs, who participated in the study and provided the valuable information. which is
the basis of this assessment. Without their contribution, this study would not have been possible.
Our sincere thanks to the District Health Officers and the learns, CARElCSP learn at the
Regional and District levels and supervisors, local authorities and others whose support was
essential to implement this study.
The research team of Mr. Bishnu Chaulagai, Mr. Badri Nath Shatta, Mr. Rajesh Gahalraj and Mr.
Shyam Purkoti deserve special thanks for their hard work and dedication for carrying out
supervision of the study under difficult and trying conditions. Likewise, we would also like to
thank the following enumerators - Siddha R. Bhatta, Pankaj Rawal, Kamal Shahi, Lalit Kalhayat,
Anupama Pandey, Pushpa Chand, Kamala Singh, Shanti Tamang from Kanchanpur; Pushkar
Paneru, Khem Raj Bhatla, Surendra Bhatla, Yagya Bahadur Bhatla, Hikmat Bahadur Saud,
Kamalbhrava Bhandari, Bhubaneswori Ojha, Bhagirathi Paneru from Dadeldhura; Satya Singh,
Basanti Joshi, Radhika Nath, Ishoo Rokaya, Hanlal Bhatlarai, Yogendra Rokaya, Jagat Gin,
Deepak Raj Ojha from Bajhang and Gokama Prasad Bhat, Amrita Sob, Saraswati Telar, NirmaJa
Bhal, Manmati Oli, Hem Bogali, Sindhu Sharma, Bhajan Malasi, Tripti Rana from Doli. We would
also similar1y like to thank the team members engaged in data management to ensure the data
quality.
We would also like to thank CARE/CSP team and particularly, Ms. Nirmala Sharma, Mr. Ram
Sharan Pyakhurel, Mr. Deepak Poudel for providing us with valuable inputs, support and
feedbacks during the course of the assessment
Solutions Consultant (P.) Ltd.
Madhusudan Subedi
Ashish Shrestha
Niraj Pradhan
vii
EXECUTIVE SUMMARY
The endline study for cs XIX is aimed at establishing an endline and compare with the baseline
information in the four project districts, Kanchanpur. Doli, Dadeklhura and Bajhang. The main
objective of the endline study is to estimate the present ~vel of maternal and child health
indicators at household and community levels and 10 compare the progress against the baseline
result carried out by the project in January 2004. The study methodology was developed based
on KPC 2000+ module. By using cluster sampling method. total of 1310 mothers of children age
0-23 months; 209 health wortl:ers; 79 health facillties and 133 FCHVs were included in this study.
Data was conected on the major intervention areas, namely, nutrition and breastfeeding,
diarrhea, acute respiratory infection, malaria, maternal and newborn care. The data also includes
mother's knowledge of HIV/AlOS.
District-wise results are presented in the main text of the report. Baseline and endtine data are
compared between Kanchanpur and Other districts (Bajhang, Dadeldhura and Dob) as CSP in
these districts is being implemented at the same lime with the same objectives and approaches.
In Kanchanpur, however, the CSP project was extended.
Child Health, Nutrition and Breast Feeding
o Nearty all the children (100% in Kanchanpur and 99.6% in Other districts) of age 0-23
months were breastfed at some point during their life.
o The percentage of mothers who initiated breast milk within one hour of delivery has
increased from 52.7 % to 83.0% in Kanchanpur. and from 56.0% to 59.2% in Other districts.
o Practice of mothers feeding their first milk to their child has increased from 74.7% to 83.9%
in Kanchanpur, and from 36.7% to 73.2% in Other districts.
o 100% of the mothers in Kanchanpur and 99.1% of the mothers in Other districls were
currently breastfeeding their children of age 0-5 months.
o Children aged between (}.5 months who were exclusively breastfed during the last 24 hours,
has increased from 50% to 87.7% in Kanchanpur and 67 10 69.5% in Other districts.
o The practice of giving complementary food within four months has decreased in all the
districts. This could be due 10 the increase knowledge and practice of mothers for exclusive
breastfeeding.
o KnO'Niedge of -Sarbottam pitho- (Super Flour) by the respondent mothers has increased in
all districts compared to baseline survey. However, only 48.1 % mothers of Kanchanpur and
26.4% mothers of Other districts had knowledge about the availability of Sarbotlam pitho in
local market, which clearly shO'NS that Ihere is a need 10 continuously educate mothers about
Ihe knowledge and availability of Sartlotlam pitho in the local market.
o 35.2% of children of Kanchanpur, and 17.3% of children of Other districts had been weighed
at birth. likewise, 51.2% children of Kanchanpur and 16.3% children of Other district had
viii
their gl"O'Nth monitoring card. These figures are higher than the base One survey, with room
for increasing the the level of possession of the growth monitoring card in all of the four
districts.
o 73.9% of the mothers of Kanchanpur had visited health care provider for ANC during
pregnancy. ukewise, ANC coverage has increased from 36.9% to 56.3% in Other districts.
o 51.2% of the mothers In Kanchanpur and 16.3% of the mothers in other districts had growth
monitoring card for the children. The baseline figures were 29.3% in Kanchapur and 20.5%
in Other districts.
o Among the male children, 22.9% in Kanchanpur and 26.7% in the Other districts were found
to be severely stunted (below -350), while among the the female children, 20.8% in
Kanchanpur and 21.6% in the Other districts were found to be severely stunted (below￾350). While, 42.2% male and 40.3% female children of Kanchanpur. and 48.1 male and
45.0% female children of Other districts were found to be stunted ( below -250). During the
base line survey 32.7% male and 23.8 female children of Kanchanpur were severely stunted
and 59.5% male and 64.4% female children were stunted.
o 6.9% of male and 4.1% of female children of Kanchanpur, and 5.3% of male and 4.3% of
female children of Other district were severety wasted (below -350). ukewise. 12.2% male
and 16.4% female children of Kanchanpur, and 14.6% male and 11.9% female children of
Other districts were wasted (below -2S0). During the baseline survey, 8.9% male and 9.3%
female children of Kanchanpur were severely wasted and 12.2% male and 16.4% female
children were wasted.
o 9.2% male and 8.6% female children of Kanchanpur. and 9.8% male and 6.3% female
children of Other districts were severely underweight (Below -350). Similarly, 32.6% male
and 21.9% female children of Kanchanpur. and 34.9% male and 27.9% female children of
Other districts were found underweight (Below -2S0).
o Among the children of age 12-23 months, as indicated by a mid upper arm circumferences
(MUAC) of less than 12.5 cm, 32.1% children of Kanchanpur were severely malnourished
against 27.3% in baseline survey. likewise 21.9% children of Other districts were severely
malnourished in Other districts against 18.2% in baseline survey.
o Among the respondent mothers, 5.2% in Kanchanpur and 5.7% mothers in Other districts
had MUAC less than 21 cm.
Integrated Management of Childhood Illness (IMCI)
o It was found that, 70.6% of the mothers in Kanchanpur and 67.4% in the Other districts had
knowledge on at least 2 danger signs of illness requiring treatment for the children. The
baseMne figure of this indicator was 84% in Kanchanpur and 58.2% in Other districts.
o The practice of "Giving more or same amount of fluid to a child during iUness~. as mentioned
by the respondents was found to have increased from around 64% in baseline study to 68%
in Kanchanpur, and from 40.9% to 58.4% in the Other districts.
Diarrheal Diseases
o The prevakmce of dian1lea among children, in the two weeks prior to the interview, was
found to be 4.9% in Kanchanpur and 17% in the Other districts against the baseline survey
of 12.7% in Kanchanpur and SO.7% in the Other districts.
o 32.7% of the mothers of Kanchanpur and 27.3% of the mothers of the Other districts
mentioned that they gave more fluids than usual to their children during the diarrheal
episode. This indicates that the majority of the mothers are still not aware about the need of
feeding fluids during childhood disease.
o 26.4% of the mothers of Kanchanpur and 15.4%of the mothers of the Other districts were
found to be feeding solid foods more than usual during childhood diarrhea.
o 72.1 % of the mothers of Kanchanpur and 67.6% of the mothers of the Other Districts had
correct knowledge about the symptom of Diarmea. However, 52.7% of the mothers of
Kanchanpur and 19.0% of the mothers of the Other districts did not have knowledge about
signs of diarrhoeal dehydration.
o 76.4% of the mothers of Kanchanpur and 58.1% of the mothers of the Other districts claimed
that they could COITectly prepare Oral Rehydration Sokrtion. However, only 58.8% mothers
of Kanchanpur and 29.9% mothers of the Other districts were found to have the correct
know1edge on ORS preparation.
o Households having their own toilet increased from 36% to 47% in Kanchanpur, and from
23.7% to 29.9% in Other districts, compared to the baseline study.
o Hand washing practices among the mothers - with soap or ash in four stipulated condilions
(before food preparation, before feeding the child, after defecation, and after handling the
child who had defecated) were found 10 be 7.6% in Kanchanpur and 10.2% in the Others
districts against the baseline survey of 16% in Kanchanpur and 1.9% in the Other districts.
Acute Respiratory Infection (ARI)
o The prevalence of ARI among the children aged below 2 years, in the last 2 weeks prior to
the interview decreased from 18.3% to 14.2% in Kanchanpur, and from 39.2% to 21.3% in
Other districts compared to the base line survey.
o 46.1% of the mothers of Kanchanpur and 39.2% of the mothers of the other districts
mentioned fast Of difficun breathing and chest IrHfrawing (i.e. correct knowledge) as the sign
and symptoms of pneumonia. This figure is higher than in the baseline survey.
o A vast majority of Health workers seemed 10 be managing dehydration with the use of ORS,
followed by giving more fluids, advice for breast feeding and referrals to health facilities.
,
o 93.3% of the health 'NOrkers of Kanchanpur and lOOfe than 95% of the health workers in the
Other districts mentioned that pneumonia shouJd be treated with antibiotics.
o 72.1% of the pneumonia cases of Kanchanpur, and more than 80% of the cases of the
Other districts were cured, a significant improvement compared to baseline survey.
Malaria
o k:. per the mothers' reports, in the two weeks preceding the endline survey, 2.1 % and
10.3% of the children aged between 0-23 months suffered from malaria in Kanchanpur and
the Other districts respectively, against the baseline data of 9.0% in Kanchanpur and 11.6%
in the Other districts.
o Mothers of Kanchanpur had better knowledge about preventing malaria as compared to the
mothers of the Other districts.
o In Kanchanpur, 91.5% of the households reported having bed nets while only 10.1% of
households in the Others districts had bed nets against baseline figures of 93% in
Kanchanpur and 6.8% in Other districts.
Maternal and Newborn Care
o About 14% of the mothers of Kanchanpur and 56.3% of the mothers of the Others districts
had visited antenatal ainic at least once, against the baseline figures of 62.3% in
Kanchanpur and 36.9% in the Others districts.
o Based on the card plus maternal recall, 88.4% of the mothers in Kanchanpur and 66.5% of
the mothers in the Others districts had received at least two doses of TT during the last
pregnancy, as against the baseline figures of 65.3% in Kanchanpur and 45.8% in the Others
districts.
o Children aged between 0-23 months and whose births were attended by skilled health
personnel has increased from 24% during the baseline to 34.8% in Kanchanpur, and from
10% to 15.1 % in the Other districts.
o About 61% of the mothers of Kanchanpur and 59% of the mothers of the Other districts had
knowledge of at least two danger sign and symptoms during pregnancy against the baseline
figures of 43% In Kanchanpur and 38.6% in the Other districts.
o Practice of taking any ironlfolic acid by the pregnant mothers increased from 56% to 84.8%
in Kanchanpur and from 33.4% to 59.5% in the Other districts. when compared with the
baseline figures.
o Majority of the deliveries took place with the assistance of the family members. The der.very
being assisted by skilled health professional has slightly increased as compared to baseline
survey.
o Among those deliveries conducted in home, a safe deivery kit was used by 32.4% of the
mothers of Kanchanpur and 11.0% ot the mothers of the Other districts against the baseline
figures of 31.6% in Kanchanpur and 10.5% in the Other districts.
o 80.3% of the mothers of Kanchanpur and 47.7% of the mothers of the Other districts had
received Vitamin A within 45 days after delivery against the baseline figures of 63.7% in
Kanchanpur and 33.9% in other districts.
Knowledge of Mothers about HIVlAIDS
o 66.7% of the mothers of Kanchanpur and 34.7% of the mothers of the Other districts had
heard of HIVlAIDS as against 56.3% mothers of Kanchanpur and 21.6% mothers of the
Other districts in baseline survey.
o The percentage of the mothers who cite at least two known ways of reducing the risk of HN
infection, has increased from 38% to 52.4% in Kanchanpur and from 10% to 18.2% in the
Other districts, compared to baseline survey.
Others
o Compared to the baseine survey, the stock balance update was better for many essential
commodities in all districts. Availability, functioning and use of essential instrument were
better in an districts.
o This endline survey dearly sho'Ns that KPC of the mothers on the maternal and dlild health
has improved as compared to the baseline survey. However, there are many areas to
improve the existing KPC ievel of the mothers on child health. There is stin a need to
strengthen the quality of health care at the health facility; fulfill the vacant posts; and improve
the professional competency of the health workers at various levels and issues.
o The earlier period of civil unrest and insurgency in the project districts. the hardship caused
10 the ordinary people and the project staff are not discussed in this report due to the
quantitative and KPC focused nature of the survey. Problems faced by the project staff and
difficulties to implement various program as per the schedule might have to be included in
other qualitative reports. Ahhough the civil unrest and insurgency did not specifically target
the health services and the health workers, but the project staffs did have to encounter
problems for monitoring and supervising the programs due to the regular strikes and
unfavourable security environment. Similarly, the endline survey was done arnest nine
months eaTtier than the stipulated end of the program to maintain seasonal consistency with
the baseline survey. Mer April 2006, the political situation in Nepal has changed
dramaticaly, and the project staffs of CARE/CSP program are working at the field level with
dose cooperation with various stakeholders. In this situation one COlIId easily expect mOfe
achievement within forthcoming nine months and the progress indicator would be better by
the end of the project.
xii
RAPID CATCH PRIORITY INDICATORS
Indicators Kanchanpur Bajhang Dadeldhura Doti
1. Percentage of children age 0-23
months who are underweight (-2SD 27.5% 42.1% 23.4% 28.2%
from the median weight-for-age, [141269) (1251297) (661282) (851301)
according to the WHOINCH$
reference POPulation).
2. Percentage of children age 0-23
months who were born at least 24 63.4% 77.0% 72.9% 74.4%
months after the previous surviving (71/112) (134/174) (135/185) (128/172)
child
3. Percentage of children age 0-23
months whose births were attended 34.8% 8.5% 26.9% 9.6%
by skilled health personnel (Note: (1151330) (281328) (89/330) (31/322)
Includes doctor, nurse, ANM,
MCHW)
4. Percentage of mothers with children
age 0-23 months who received at 79.4% 50.3% 60.1% 46.3'1.
least two tetanus toxoid injections (2621330) (165/328) (1991330) (1491322)
before the birth of their youngest
child (by card)
5. Percentage of children age 0-5
months who were exdusivety 87.7% 91.3% 63.9% 12.6%
breastfed during the last 24 hours. (79190) (43158) (55186) (53/79)
6. Percentage of children age 6-9
months who received breastmilk 82.2% 86.0% 82.5% 74.1%
and complementary foods during (60/73) (68179) (52163) (43158)
the last 24 hours.
7. Percentage of children age 12-23
months who are fUlly vaccinated 53.3% 54.1% 74.5% 54.2%
(against the five vaccine- (40/75) (13/24) (35/47) (19/35)
preventable diseases) before the
first birthday.
8. Percentage of children age 12-23
months who received a measles 79.3% 81.2% 79.6-;' 73.0%
vaccine. (1151145) (1261155) (121/152) (122/167)
9. Percentage of children age 0-23
months who slept under an 2.4% 0% 0.3% 0%
insecticide-treated net (in malaria (81330) (0/328) (1/330) (0/322)
risk areas) the previous night.
10. Percentage of mothers with children
age 0-23 months who cite at least 52.4% 14.0% 18.5% 22.0%
two known ways of reducing the risk (173/330) (46/328) (61/330) (71/322)
of HIV infection.
11. Percentage of mothers with children
age 0-23 months who report that 7.5% 19.5% 4.2% 6.8%
they wash their hands with (251330) (64/328» (141330) (22/322)
xiii
soap/ash before food preparation,
before feeding children, after
defecation, and a after attending to
a child who has defecated (washed
hands in all four conditions).
12. Percentage of mothers of children
age 0-23 months who know at least
two signs of childhood illness that
indicate the need for treatment.
13. Percentage of sick children age 0-
23 months who received increased
fluids and continued feeding during
an illness in the past two weeks.
86.3%
(2851330)
33.3"'.
(22/66)
88.4%
(2901328)
19.6%
(20/102)
84.5%
(2791330)
16.1.".
(24/149)
84.7%
(2731322)
16.4%
(21/128)
Consolidated Information of four Districts on Rapid Catch
Indicators
Indicator Kanchanpur Other districts
(Doti, Dadeldhura, Bajhang)
Baseline Endline Baseline Endline
Aug 03 Jan 07 Jan04 Jan07
1. Percentage of children age 0-23
months who are underweight (-2S0
from the median weight-for-age, 38% 28% 38% 32% according to the WHOINCHS
reference population).
2. Percentage of children age 0-23
months who were born at least 24 68% 63.4% 75% 74.7% months after the previous surviving
child
3. Percentage of children age 0-23
months whose births were attended
by skilled health personnel (Note: 24·/. 34.8% 10% 15.1%
Includes doctor, nurse, ANM,
MCHW)
4. Percentage of mothers with children
age 0-23 months who received at
least two tetanus toxoid injections 65% 79.4% 46% 52.3% before the birth of their youngest
child (by card 2!: reported verbally
by mother)
5. Percentage of children age 0-5
months who were exclusively 50% 87.7% 67% 69.5%
breastfed during the last 24 hours.
6. Percentage of children age 6-9
months who received breastmiJk 83% 82.2% 71% 81.5% and complementary foods during
the last 24 hours.
xiv
Indicator Kanchanpur Other districts
(Doli, Dadeldhura, Bajhang)
Baseline Endline Baseline Endline
Aug03 Jan07 Jan04 Jan07
7. Percentage of children age 12-23
months who are fully vaccinated 74% 53.3% 45% 63.2% (against the five vaccine￾preventable diseases) before the
first birthday.
8. Percentage of children age 12-23
months who received a measles 87% 79.3% .0% 77.8%
vaccine.
9. Percentage of children age 0-23
months who slept under an 2% 2.4% 0% 0.1% insecticide-treated net (in malaria
risk areas) the previous night.
10. Percentage of mothers with children
age 0-23 months who cite at least 38% 52.4% 10·;' 18.2% two known ways of reducing the risk
of HIV infection.
11. Percentage of mothers with children
age 0-23 months who report that
they wash their hands with
soap/ash before food preparation. 7.5% 2% 10.2% before feeding children, after ,.%
defecation, and after attending to a
child who has defecated (washed
hands in all four conditions).
12. Percentage of mothers of children
age 0-23 months who know at least 84% 86.3 58-;' 85.9 two signs of childhood illness that
indicate the need for treatment.
13. Percentage of sick children age 0-
23 months who received increased
fluids and continued feeding during NA 33.3% NA 17.2%
an illness in the past two weeks.
Note: All consolidated infOfmation are unweighted, at Cl 95% and error margin of 10%.
CHAPTER ONE
INTRODUCTION
In this chapter:
1.1 Background
1.2 CARE/CSP Efforts to Combat of Child Health Issues
1.3 Objectives of CARE/Child Survival Project
1.4 A Brief Overview of Project Area
1.5 Objectives of the Endline Study
1
CHAPTER ONE
INTRODUCTION
1.1 Background
Nepal's economic development has been severely constrained by geographic, topological and
soci<rcultural factors. Mortality and morbidity rales especially among and children are alarmingly
high. Acute preventable childhood disease, complication of child birth, nutritional disorders and
endemic disease such as malaria, tuberculosis, SIDs and vector borne disease continue to
prevail at a high rate. Detenninanls of such conditions are associated with pervasive poverty, low
literacy rates, poor mass education, rough terrain and difficult communications, low levels of
hygiene and sanitation facilities, and limited availability of safe drinking water. These problems
are further exacerbated by underutilization of resources; shortage of adequately trained
personnel; underdeveloped infrastructure; poor public sector management; and weak intra and
inter-sectoral coordination.
As a result of planned development, health sector has improved substantially. However, from the
point of view of health indicators, satisfactory progress has not been made yet as compared with
other developing countries. Especially remote and rural communities and the people there who
are devoid of health services have not been benefrted from the essential health services.
Healthy human resource, low mortality rates of infant and children, development of safe
motherhood improves the various aspects of human development indicators (HDI) and hence
contribute to reduction of poverty. The health indicators are comparatively weaker in the Mid￾western and Far-western development regions (Tenth Plan 2002).
CARE began working in Nepal in 1978. The early focus was on improving infrastructure and
implementing agriculture extension activities with investment in natural resource management. A
strategic programmatic shift occurred in the early 1990s with the introduction of more diversified
portfolio. CARE Nepal, Ministry of Health and population and Social Welfare Council are jointly
implementing Child Survival Project-XIX, a four year program to support health system in
Bajhang, Dadeldhura, Doti and Kanchanpur Districts of Far-western Development Region. The
project aims at contributing to improve the health of the children (under age five) and pregnant
and lactating mothers in the four districts. The project has identified key interventions -
Community Based Integrated Management of Childhood Illness (CB-IMCI), Health Facility
Operation and Management Committee (HFOMC) strengthening of Far-westem Region of Nepal.
2
1.2 CARElCSP Efforts to Combat of Child Health Issues
Child Survival Project, CS XIX (Oct 2003 - Sept 2(07) is one of the CARE Health project, being
implemented in four districts (Bajhang, Doli, Oadek:lhura and Kanchanpur) of Far Western
Devek>pmenl Region after the successful completion of ChiJd Survival Project X)I (Od 1999 -
Sapt 2003) in Kanchanpur district. The project goal is to reduce chik1 and maternal mortality and
morbidity through strer.gthened community, local NGO and MOH capacities in Far Weslern
Region of Nepal. The project targets to benefit 146,514 under-fIVe chikJren and 47,484 pregnant
and lactating women among total population of 932,054 from the four project districts. The
project focuses on key interventions at the health facility and community level.
Working Approach
The working framework of CSP project is CB-IMCI, one of the most prlorltized areas of
Government of Nepal. Ministry of HeaMh and Population; to increase the access to health
services, the quality of care and behavloral change towards healthy practices. The key strategic
approaches are:
• To demonstrate successful and sustainable implementation of CB-IMCI (especially for
management of pneumonia and diarrheal disease) through improved quality of care
strategies.
• To strengthen linkages between k:H:a1 government and civil society participants in health care
management at the Health Post (HP). Sub Hea"h Post (SHP) and district Heahh level.
• Develop a sustainable program implementation model in Kanchanpur through strengthening
community support and linkages with line agencies of Government of Nepal.
• Strengthening of project staff and other slakeholders capacity (especially marginalized
communities and women) to operate in existing environment of insurgency in Nepal;
• Evidence-based advocacy to increase support for CB-IMCI by regional and national MOH
Child Heahh Division.
1.3 Objectives of CARE/Child Survival Project (CSP)
The objectives of CARE/Child survival project are:
• Access 10 5efl1ces SUpPlies: Families have increased sustainable access 10 health
education, quality health services, and essential medicine at the community level.
• Quality of Care: Community level MOH personnel, Female Community Health Volunteers
(FCHV), and other service providers practice appropriate care management of pneumonia
and diarrhea, and other key IMCI intervention areas.
• Behavioral Change: Caregivers of children below five years of agepractice healthy behaviors
and seek medical care from trained sources when needed.
3
• Building Local Capacities. Local and community-based institutions and local NGOs are
strengthened to support chikt survivat5 activities on a sustainable basis.
1.4 A Brief Overview of Project Area
Nepal has made progress in a number of health indicators in recent years including some with
direct bearing on maternal and chikt health. Yet women and children are still at a risk and largely
neglected population in the country. Nepal has the world's highest matemal mortality rate.
Similarly, infant mortality is 64/1000 live births and the risk of neonatal deaths (39/1000 live
births) is one and half times higher than the risk of post-neonatal deaths (26/1000 live births).
(Annual Report - DoHS, 2003).
Under 5 mortality rate in Far-westem Development Region of Nepal have averaged 149.20 over
the past 10 years compared to 91.2 currently at national level. Remoteness due to the lack of
roadneworks and infrastructures, kM' level of female literacy are the major obstacles 10 effective
delivery of health care services as well as the utilization of available health services (OHS, 2(01).
Bajhang district is bordered with Bajura and Humla at East, Baitadi and Darchula at the West,
Humla and TIbet at the North and Doti and Accham at the South. Total area of the disbid is
3,422 square KM and fertile land is 268.83 squarEHun. Total population of the district is 167,026.
The district is divided in 10 47 VDC with no municipality at all. The total numbers of health
facilities are 52 with one district hospital. The literacy rate is 38%, of which only 16% are female.
There weren't any non governmental organizations wori<ing for the children and maternal health
(CARElCSP Baseline Survey 2004).
Dadeldhura, one of the project districts is occupying an area of 1,538 sq. km. It is bordered with
Doti in the east, India in West, Baitadi in north and Kailali and Kanchanpur in south. The attitude
ranges from 432m to 2,639 meter from sea level. Around 76% of the district is covered with deep
green forest. According to 2001 C8flSUS, total popUlation of the district is 126,162 (female- 65,197
and male- 60,965) with population density of 83-personlsq km. The literacy rate of district is
53.07% with female literacy rate of 35.45%. Administratively, the district is divided into one
municipality and twenty Village Development Committees (CARElCSP Baseline Survey 2004).
Doli is bordered with Achham and Surkhat in East, Dadeldhura and Baitadi in West, Bajhang in
north and Kailali in South. The total area of the distrid: is 2025 sq. Km. For the administrative
purpose; the district is divided in 50 VDCs and one municipality. Total population of the district
according to Census data 2001 is 207,066 (male- 103,521, female- 103,545) with population
density 102 persons per sq km.
4
Kanchanpur is one of the most densely populated districts in the Far-westem Development
Region of Nepal. According to the 2001 census, the district has a total population of 3n,899.
The migration from the hills and mountain to Kanchanpur is a common phenomena resulting in a
high population growth (annual growth rate of 3.9%) for the period of 1991-2001. The iteracy
rate of the district is 59.6%, with a female literacy rate of 46.9%. Agricuhure remains the major
occupation in the district. Although there is an access to a motor road fOf most of the flatlands of
the district, some highlands of the district are still deprived of such access, electricity alld
telecommunication facilities. Kanchanpur remains one the districts with the lowest heahh service
facility - population ratio in the country. There are 21 primary heahh care units in the distJict
including 2 Primary Heahh Care Centers (PHCC) to serve the entire population. This ratio is
much lower compared to one of the similar tarai districts in the Central region; in Saptari, for
example, 116 such units serve a population less than half the size of that in Kanchanpur.
5
1.5 Objectives of the Endline Study
The endline study for CS XIX Is aimed al establishing an endline data and compare with baseline
data in the four project districts. Thus the main objective of the endline study is to estimate the
present level of maternal and child indicators at household and community levels and to compare
the progress against the baseline result carried out by the project in January 2004. The specific
objectives of this study were to assess:
Al household level:
o Knowledge, coverage and practices of women regarding breastfeeding and nutrition
o Knowledge and practice of women regarding maternal and newborn case
o Knowledge, coverage and practices of women regarding management of childhood
illness
o Knowledge and practice of mothers about micronutrients (Vitamin A, Iron and Iodine)
o Knowledge and practice of mothers about malaria and HIVlAIDS
o Growth monitoring of children
At heahh facility level:
o Assess the heahh staff situation (sanctioned and filled) at the PHCC, HP and SHP
o Assess the existing child heahh service delivery pattern of PHCC, HP and SHP
o Assess the stock situation of essential commodities in PHCC, HP and SHP
At heahh worker (and Volunteer) level
o Assess the technical competency of heahh workers and volunteers in providing child
and maternal health services in the project districts
o Assess the training types and outcome of the heahh worKers at PHCC, HP, SHP and
FCHVs.
6
CHAPTER TWO
METHODOLOGY
In this chapter:
2.1 Study Area
2.2 Study Design
2.3 Study Population
2.4 Development of Questionnaire,
2.5 Sampling Design, Size and Process
2.6 Regional and District Level Orientation and Training
2.7 Data Collection Procedure
2.8 Validity and Consistency of Interviews
2.9 Data Coding, Processing and Management
2.10 Data Analysis
2.11 Results and Discussion
2.12 Limitations of the Survey
7
CHAPTER-II
METHODOLOGY
The study methodology was developed based on KPC 2000+ module.
The evaluation team revieYled the projed documents, including the project proposal, baseline
survey report and detailed implementation plan. Key indicators to be measured were identified
from the Iog-frame of the DIP, Rapid CATCH, KPC 2000+ modules and the baseline report. An
evaluation plan was designed. The KPC gUidelines were reviewed and discussed for finalizing
the methodological approach to the survey.
2.1 Study Area
The endline survey was conducted in the following four districts of Far-western development
region.
• Bajhang
• Doli
• Dadeldhura
• Kanchanpur
2.2 Study Design
District based cross sectional design was selected for this study to explore the overall
effectiveness of the program. A 3G-c1uster sampling design was adopted to select the mothers of
children 0.23 months. Key indicators to be measured were identified from the log-frame of the
DIP, Rapid CATCH, KPC 2000+ modules and the baseline report. An e....aluation plan was
designed. The KPC guidelines were re....iewed and discussed for finalizing the methodological
approach to the survey.
2.3 Study Population
• Household mothers having children below two years of age
• District Ie....el governmental health facilities
• Child health services providers
8
2.4 Development of Questionnaire
An initial draft questionnaire was prepared in English and Nepali languages by CARElCSP and
shared among the team. The questionnaire was finalized after incorporating feedback from
various slakeholders in Silgadi Doli, CARElCSP Regional Office. The questionnaire was pre￾tested in each district Based on the results of field-testing, the translation was reviewed and
corrected. The final questionnaire is part of the Annex to this report.
The questionnaire covered the following modules:
• General characteristics of respondent mothers
• Nutrition and breastfeeding
• Growth monitoring and immunization
• Maternal and new born care
• Integrated management of dliJdhood ilness
• Pneumonia case management
• Oiarrhea
• Malaria
• HIV/AlDS
In addition, the survey also included anthropometric measurement and mid upper ann
circumference (MUAC) for children and mothers. Accuracy of the measuring instrument was
periodically checked.
2.5 Sampling Design, Size and Process
In a simple random sampling design, the sample size is derived using the formula n= z 2 (p q)/d ,
With p=0.5, (q=~), a pt'ecision of 10% (d=O.l), assuming 95% confidence interval (z=l.96) the
required sample size (n) is 96.
In 3Q-clusler design with the same values of p, d and z, minimum sample size is 210, where
design effect is considered 2, that is 7 per c1usler. To maintain an approximate ± 10% level of
precision for mosl variables, since design effect is variable-specffic, the minimum sam~ size for
the KPC survey was set al 300 (30 clusters of 10 respondents) instead of 210. Taking ltIis into
consideration, as well as 10 provide for 10% non-response, a sample size of 330 was selected.
Therefore, to obtain 330 samples, 11 households from each c1usler were covered for the
interview.
9
Ward of VDCs and municipality were used as cluster in the present endline study. The total
population of the district and population of each ward were used according to 2001 Census
conducted by Central Bureau of Statistics. All the wards with in the districts were eligible for
selection and clusters were not limited to project areas only. The sampling interval was derived
from the formula given in the guideline, that is, total population divided by 30. The first duster,
the ward with equal or less than population of sampling interval. was randomly chosen using a
computer program. All the process was done together with Consultants, CARE/CS? team and
enumerators during the training sessions following the process given in the guidelines.
A public place within the duster was chosen as the centre of the cluster. Direction of households
from the centre to be surveyed was randomly selected by spinning a bottle. Following the
direction of bottle, 11 subsequent households and mothers with children under 24 months were
selected for interviews. The household was defined as a unit or people living together and
sharing the same kitchen. In case where there were two families in the household with the
children aged less than 24 months, the responding mother was selected by flipping a coin. If the
mother had more than one child of less than 24 months, the youngest on was chosen as the
reference or index child, (A list of the selected clusters is presented in Annex). During the
regional level meeting in Doti, it was mentioned by the CARE/CSP team that at least proposed
sample size would be available in each cluster. During the field visit, however, required sample
size was not available in few clusters. For example, in Jijidamandu -4 of Doti district, there were
only 3 mothers; in Mashdev -3 of Bajhang there were only 9 mothers. Therefore, the total number
of surveyed mother is slightly less in the two districts. This number, however. is not less than the
minimum sample size in each cluster.
In case of heahh facility and heahh workers, twenty five percent of the heahh facility of each
district was selected purposively and one child health service provider was interviewed from each
of the selected health facilities. Thirty FCHVs were selected ensuring one from each cluster in
each district as well. Health facilities were selected (PHC/HP/SHP) proportionately to represent
the whole district.
Sample distribution
KPC HW HF FCHV
District
Questionnaire Questionnaire Questionnaire Questionnaire
Bajhang 328 48 18 30
Dadeldhura 330 47 18 31
Doti 322 66 28 40
Kanchanpur 330 48 15 32
Total 1310 20. 7. 133
10
2.6 Regional and District Level Orientation and Training
A tolal of three days regional level orientation and training was conducted in Doti starting from
the 31st of January 2007 for the consistency of the endline survey. CARElCSP team from the
Kathmandu Office and respective districts. and consultants from Kathmandu had a detail
discussion on war1<ing modality. The training consisted of field procedures for the survey,
detailed review of the questionnaires, sampling design, prac1icing weighing and measuring
children and role play interviews among the participants. Furthermore, discussion was focused
on roles and responsibility of consultants; CARElCSP learn al the Central, Regional and District
levels and supervisors; questionnaire guidelines; interview tips; supervision; editing and
maintaining the data quality in the field.
Enumerators' training was conducted in the individual districts. For this purpose, 32 local people
with health background (CMA, ANM) and/or with previous exposure in similar studies were
selected as enumerators for the endline survey. Interviewers were locally recruited; of which half
of them were female. CSP senior staff, DHO staff and partner NGOs supervised the quality of
data at the field level.
Three days training schedule for the emumerators and supervisors in each district included
objective of the evaluation, sampling process of 30 cluster sampling design, selection of actual
clusters, objective of each questionnaire mentioned for the interview, interview technique and
data collection process and other practical issues during the fieldwork.
2.7 Data Collection Procedure
After the data collectors were trained each pair (one male and one female in a team) was sent to
collect data to cover all the 30 clusters. Daily schedule of the survey for all the groups was
finalized before the survey started. This allowed supervisors 10 monitor the interviews in various
clusters. Based on this schedule, a separate schedule was prepared for the supervisors.
In each district, 4 pairs of enumerators visited different clusters under the close supervision of
Survey Coordinator of Solutions Consultants, DHO staff and CARElCSP senior staff. A total
number of 4-6 supervisors have supervised the team that consisted of 8-9 local enumerators
(two in each group) from each study district resulting in a total of 4-5 teams of field researchers.
The supervisor checked at least two questionnaires from each cluster on the spot and corrected
immediately any missing or incorrectly recorded information, discussed with the interviewers
about their problems and constraints in data collection and tried to fix them.
The information was collected from the 11 households (KPC questionnaire) and 1 questionnaire
of Female Community Health Volunteer in each cluster. Each household survey was conducted
11
to gather information about all members of the household. For this purpose a mother with a child
of age below 2 years was identified and administered KPC questionnaire. Mid-upper Arm
Circumference of the mother and Height, weight and Mid-upper Arm Circumference of her child
(the target one) was measured. It took approximately 1-1.5 hours to administer the KPC
questionnaire and half an hour to health worker questionnaire.
After completing data collection, each team returned to the district headquarters for final
debriefing meeting. At that time. they reviewed profiles of the respondents and addressed some
issues that arose during data collection. Data collection process started and ended within the
month of February 2007 in each district.
2.8 Validity and Consistency of Interviews
All measurements were made for the field workers whose training included both inter and intra￾observer standardization. Each enumerator was trained in preparation for the work and had been
regularly supervised including random controls of their recording procedures. For the indirect
validity testing, supervisors had focused on:
• Interviewers' rapport building process and probing during the interview
• Cross verification of the data. For example, present age of youngest child vs. date of birth.
• Re.interview of about 10% mothers to check the consistency of reporting.
2.9 Data Coding, Processing and Management
Data processing involved:
(a) Coding to allow classification and tabulation
(b) Editing to minimize the errors and to ensure clean data.
Similarly. the data management system was developed that incorporated a system of editing and
documentation at allievel of the study. The data entry was done using EPI Data, Version 3.1.
The confidentiality was maintained. Multiple back checks were carried out on computerized
records in Solutions Consultants, Kalhmandu.
2.10 Data Analysis
To facilitate the process of data processing, a standardized data entry I management software
package had been developed with a number of quality control devices, including validity checks,
duplicate detection and verification procedures. The cleaned data set were analyzed using SPSS
12
14. The anthropometric analysis was also done in SPSS using the macros developed by WHO.
(Available in WHO website - http://www.who.intlchildgrowthlsoftwarelmaaos.speciaLspsslenfndex.hlrn9.
2.11 Results and Discussion
Results are organized in different sub sections. Each section provides infoonation on different
study indicators. In the beginning of this section, summary of rapid CATCH indicators are given
in separate tables. The details of the results are given in subsequent sub sections. For the
convenience of reader, results and discussions are integrated in the same section. In the
executive summary section and some other revevant sections, the results are catagorized into
Kanchanpur and other districts (Bajhang, Oadeldhura, Ooti), and are compared with the baseline
data and project goals where the indicators are revevant. Thus, other district, in this report refers
the combined data of Bajhang, Oadeldhura and Ooti. The CSP project started in these districts is
being implemented at the same time with the same objectives and approaches. In Kanchanpur,
the CSP project was extended.
2.12 Limitation of the Survey
Maoist insurgency and counter-insurgency operations in the project districts, hardship caused to
the ordinary people and the project staff are not discussed in this report due to the quantative
and KPC focused nature of the survey. Problems faced by the project staff and difficulties to
implemenl various program as per the schedule might be included in various qualitative reports.
Although Maoist did specifically target the health services and the health WOf'1<ers, but the project
staffs did have problems on the aspects of monitoring and supervising the programs due 10
regular strike and unfavourable security environment. Similarly, the endline survey was done
almost nIne monlhs earlier to maintain seasonal consistency of the baseline and endline survey.
After April 2006, political situation In Nepal has changed dramatically, and the project staffs of
CARElCSP program are working at the field level with close cooperation with various
stakeholders. In this situation one could easily expect more achievement within forthcoming nine
months and the progress indicator would be better by the end of the project.
13
CHAPTER THREE
PRESENTATIONS OF
THE FINDINGS:
HOUSEHOLD SURVEY
In this chapter:
3.1 Demographic Characteristics, Birth Spacing and Child
Care
3.2 Child Health, Nutrition and Breastfeeding
3.3 Maternal and Child Health Related Information
3.4 Immunization
3.5 Integrated Management of Childhood Illnesses
3.6 Acute Respiratory Infection
3.7 Information on Malaria
3.8 Knowledge about and Prevention of HIV/AIDS
3.9 FCHV and their Role in Health Care Delivery
3.10 Knowledge on Iodine and Salt Use
3.11 Mothers' Involvement in Community Organization
3.12 Anthropometric Measurement
14
CHAPTER -Ill
HOUSEHOLD SURVEY
3.1 Demographic Characteristics, Birth Spacing and Child Care
This subsection presents selected background characteristics of the respondents included in
both the baseline (Bl) and the endlne (EL) surveys. A tolal of 1,320 mothers having children less
than 24 months of age were included in the baseline survey and 1,310 in the endline survey were
included in the study. Other districts, in this report, refer to Bajhang, Dadeldhura and Doli
districts.
3.1.1 Age, Educational Status and Ethnicity
Age, educational status and ethnicity are important demographic and socio-cultural variable and
are primary basis of demographic classification. Among the respondent mothers, the majority of
them were of the age group 2Q.-30 years (77.6% in Kanchanpur and 68.2% in the Other districts).
In case of the baseline (BL) survey, the corresponding figures were 60% and 70% respectively.
In the endline survey, 7.9% of the mothers were between the age of 30-40 years in Kanchanpur,
whereas 30.7% of the responding mothers were of the same age group in the baseline survey.
The age composition of the respondents between baseline and endline surveys for the Other
districts was similar (see Table 1.).
Data indicates that there is high proportion of household mothers who have no education. 38.5 %
of mothers were found to be illiterate in Kanchanpur, followed by 70% in other districts. In the
case of the baseline survey, the corresponding figure was 48% and 72.5% respectively. The
secondary and higher level education attainment was very low both in the baseline and endline
surveys. The literacy rate seems to have slightly improved in the districts over the last 3 years.
The endline survey categorized caste and ethnic groups into three major headings: ethnic group,
Dalits and others. The baseline survey, however, categorized it into different way. Therefore, the
castelethnic data are not clearly comparable between endline and baseline survey. However, the
large proportion was represented by 'high caste hills' (e.g. Brahmin and Chhetri) and 'hill dalits'
(i.e. Kamai, Damai, Sarki and other occupational groups) in the baseline and endline surveys
(see Table 1.).
15
Table 1. Age, Educational and Ethnicity status of the interviewed mothers
District Kanchan , Do' Dadeldhura Ba'han other Districts
BL EL BL EL BL EL BL EL BL EL
0 330 330 330 322 330 330 330 328 990 980
% % % % % % % % % %
Age
< than 20 years 93 13.3 4.9 5.9 9.1 6A 6.0 73 70 6.5
20 - 30 years 60.0 77.6 70.9 630 69.0 73.0 70.0 68.3 70.0 68.2
30 - 40 years 30.7 7.9 20.9 27.0 19.0 18.2 20.0 22.6 20.0 22.6
> than 40 years 1.2 3.3 4.0 3.0 2A 4.0 18 3.0 2.8
Literac)'
lIIiterate 48.0 38.5 81.2 76.1 63.0 63.0 73.0 71.0 72.5 70.0
Not been to school but 14.0 11,2 10.6 15.2 15.0 9A 20.0 18.0 15.2 14.2 read and write
Primary (Class 1-5) 12.0 13.9 3.3 5.6 10.0 10.3 2.1 3.0 52 6.3
Middle (Class 5-7) 11.0 18.5 1.2 1.9 6.1 10.6 2A 2.1 3.2 4.'
Secondary (Class 9-10) 7.7 9A 2A 0.6 3.6 4.2 1.8 1.5 2.6 2.1
Above Class 10 (SlC 73 8.5 1.2 06 2.1 2.4 06 4.3 1.3 2.4 and Above)
Ethnicity
High Caste Hills 47 51.8 78.2 66.8 72.1 72.1 70.9 72.9 73.7 70.6
Hill Dalils 29.7 8.2 21.5 26.7 26.1 22.7 26.7 27.1 24.7 25.5
Ethnic Groups 93 39.1 59 1.2 4.5 2A 1.2 3.5
High Caste Terai 06 0.3 0.3 0.2
Terai Dalils 0.3 0.3 0.3 0.2
Others 14.0 0.3 0.6 0.3
3.1.2 Number of Children below 5 Years and 24 Months
The number of children in the household affects the matemal and child health. In the endline
sUlvey, 55.2% of the respondents in Kanchanpur, 37.3 % in Doti. 37.9% in Dadeldhura and
39.0% in Bajhang had one child whereas during in the baseline survey; 55% in Kanchanpur,
37.9% in Doti, 40.9 % in Dadeldhura and 33.6 % in Bajhang had one child (see Table 2.). The
figures in the Table 2. shows that the findings of endline survey indicate that there has been
increase in households with 3 or more children (15.5% in endline) in the Other districts compared
10 baseline survey (10.0%)
Table 2. No. of children below 5 years of age in the household
District Kanchanpur Doli Dadeldhura Bajhang Other Districts
BL EL BL EL BL EL BL EL BL EL
0 330 330 330 322 330 330 330 328 990 980
% % % % % % % % % %
No. of Children in household
1 Child 55.0 55.2 37.9 37.3 40.9 37.9 33.6 39.0 40.0 38.1
1B
2 Children 32.4 47.0 42.5 44.6 50.3 43.9 46.0 50.0 46.3
-:,3~C~h~"'="=- ' 45.0' _ ___;7~.O,,___;.~.5;____;12~.~'__'~'~.•;_-~9.~'c--,'~3~.3,------;9~.';-_5~.~O-___;1O~.'~ 4 and more 5.5 6.6 8.1 2.7 2.7 9.1 5.8 5.0 5.5
1 DI.mg the baseline SlJfWy in Karchanpur, the number of d'Ii1dren in Ihll household was calegOf1zed into two main
gtOUps: one ctIiId llftCllWO Of" more children.
17
The youngest children In the household under the age of 24 months was chosen as the targeted children for the purpose of the endline survey. During the
baseline survey in Kanchanpur 47.7% of these targeted children were male, while 54.5% of the sampled children under the age of 24 months were male In
endllne study. The composition of male and female children under the age of 24 months in the sample was similar In both baseline and endline surveys In the
Other districts (see Table 3.). Representation of male child of age less than six months sampled in Kanchanpur was 30.6% in endline survey, while It was
23.1 % in baseline survey. The representation of male child of age less than six months in the sample in the Other districts was similar for both endline and
baseline surveys.
Table 3. Aae and Sex of the targeted children below 24 months
District' Kanchanpur. Ootl Oadeldhura Balhanl:l' Other DiltrIctI
aa..llne Encllln.. Baseline Endline Baseline EndJine Baseline Endline' Baseline Enclllne
sex M-. F.,. M-. F"",* Male Female Male Female Male Female Male Female Male Female Male Female MeIe F...... M-.
n 143 157 180 150. 174 156 161 161 176 154 186 144 169 161 171 157 519 471 518 482 %, 47.7 52.3 54.5 52.7 47.3 50.0 50.0 53.3 46.7 56.4 43.6 51.2 48.8 52.1 47.9' 52.4 41.8 52.9 41.1
Age _ % % % % % % % % % % % % % % % _ % % % %
< 6 month 23.1 22.3 30.6 23.3. 20.1 26.9 19.3 29.8 21 27.9 26.9 25 21.8 21.7 17 18.5 21 25.5 21.2 24.5
6·11 months 42 43.3 25 33.3' 27 26.227.3 19.9 25 21.4 26.9 29.230.7 3131.6 38.gi27.6 26.328.6 29.2ij
12·23monlhs 35 34.4 44.4 43.3152.8 46.7 53.4 50.3 53.9 50.6 46.2 45.8 47.3 47.2 51.5 42.7 51.4 46.2 50.2 46.3
3. 1.3 Birth Spacing
Birth Intervals or spacing Is associated with maternal and child health status. Short birth Intervals are associated with an Increased risk of death for the
mothers and the children. This Is partlcularty true for the babies born less than 24 months after a previous birth, It was found that 36.6% of the births In
Kanchanpur, 25.6% and 27.0% births of DoU & Dadeldhura, and 23.0% births of BaJhang occurred within 24 months. This finding Indicates that there has not
been much changes from the baseline assessment.
18
Malaria Control Program
Program overview, Achievement and Lessons Learned
Malaria Control Program
CARE International in Nepal
Krishna Galli, Pulchowk
GPO Box # 1661, Kathmandu, Nepal
Phone: 977-1-5522800, Fax: 977-1-5521202
Email: care@carenepal.org URL: www.carenepal.org
Malaria Control Program, Kanchanpur 2
Acknowledgements
It is our great pleasure to present the Final Report of the Malaria Control Program in
Kanchanpur funded by Nepal Family Health Program and implemented by the Child Survival 
Project of CARE Nepal. The program was implemented during the period of Jan 2005 to
September 2006. We would like to take this opportunity to extend our heartfelt thanks to all 
those who have contributed successfully in the completion of the program.
First and foremost our sincere thanks go to Mr. Bal Bahadur Mahat, Public Health
Administrator; Mr. Hem Raj Joshi, Vector Control Assistant, and the District Public Health 
Office Kanchanpur team in Kanchanpur for their guidance, cooperation and support in each 
and every steps of the program planning, implementation and follow up. We would also like 
to thank District Development Committee, Kanchanpur and District Education Office,
Kanchanpur for their cooperation and support in this program.
We would like to express our sincere thanks to Dr. Steve Hodgins, Chief of Party, Mr. Don 
Boring, Deputy Chief of Party, Mr. Ashoke Shrestha, Deputy Chief of Party, Mr Madan Raj 
Thapa, Team Leader/Field Coordination Team; and Mr Shambhu Nath Jha, Infectious 
Disease Coordinator and all team leaders of NFHP for their cooperation and support. We 
would also like to thank NFHP Kanchanpur team for their cooperation and support in 
implementation of this program.
At this point, we would like to appreciate the untiring efforts and dedication of the project 
staff on malaria control program, especially Mr Mukesh Hamal, Malaria Control Officer; Mr 
Shashi Dev Shah, District Health Coordinator and all team members of CARE Kancahnpur 
team.
At last but not the least, our genuine thanks go to all the community people, Health Facility 
Operation and Management Committee members, Female Community Health
Workers/Volunteers, school teachers and local leaders for their enthusiastic and tireless 
support in the program implementation.
Malaria Control Program, Kanchanpur 3
Executive summary 
Malaria Control Program is one of the programs of CARE Nepal, implemented in
Kanchanpur district through Child Survival Project and funded by Nepal Family Health 
Program (NFHP) with an aim to support/assist District Public Health Office Kanchanpur to 
increase the availability, accessibility and quality of the services provided to control malaria 
at the household and community levels. The ultimate objective of the program was to
prevent mortality and reduce morbidity due to malaria by providing support/assistance to 
DPHO Kanchanpur to increase the availability, accessibility and quality of the services
provided to control malaria at the household and community levels.
The major activities of the program has been to establish malaria laboratory facilities and its 
strengthening for early diagnosis and proper management of cases at health facility and 
community level, training of institution as well as peripheral and grass-root-level health 
workers in malaria case identification and its proper management and to improve the 
quality of service provided; promotion of health education, awareness and advocacy
programs both at the community and health facility level to prevent vector transmission of 
disease; and strengthen monitoring mechanism of district health system on malaria control.
Altogether there are 12 labs with malaria microscopy facility in Kanchanpur, of which 9 
were established through the project by mobilizing Health Facility Operation and
Management Committee (HFOMC) and 3 initially operating labs at primary health care 
centers (PHC) through national health system. Further, there has been a momentum of 
establishment of malaria microscopy labs in other VDC of the district. Through this program, 
CARE Nepal has provided support for the recruitment of one local laboratory technician for 
seven malaria microscopy centers on cost sharing basis with agreement between the 
HFOMC, DPHO Kanchanpur and CARE Nepal. From the existing 12 malaria microscopy 
centers in the district communities are benefiting from a wide range of services, in addition 
to the malaria microscopy services provided from these centers. The service delivery
statistics showed that a total of 18,294 beneficiaries have benefited from the malaria
microscopy centers in the project period. 
To deliver better quality and sustainable malaria control activities through institutional and 
individual capacity building: institutional development trainings, orientation and supervisory 
visits have been continuously provided from CARE Nepal and DPHO Kanchanpur. 
Individual capacity building has been promoted through training and orientation programs for 
lab assistants, health facility staffs, schoolteachers and FCHV. Seven-days malarial
microscopy training was conducted for five newly recruited laboratory technicians (three 
from the initially proposed malaria microscopy centers and two additional newly established 
malaria microscopy centers) in coordination with NFHP Infectious Disease Coordinator. 
Monitoring, supervision and trainings to health facilities’ staffs, lab assistants and community 
level health workers have continuously been provided to ensure the provision of quality 
services provided by the health facilities. Lab accreditation has been one activity that is 
planned in the district to ensuring the quality of malarial microscopy services provided from 
the private sector for which orientation has been provided to 14 private labs in the district.
Two-days orientation program was conducted for FCHVs on Malaria Prevention and Control
in the district was conducted in all the 19 VDC and Mahendranagar Municipality through 32 
events. A total of 748 out of 833 FCHVs were oriented through the program where other 
grass-root and peripheral level health workers, viz. AHW (2), ANM (7), VHW (20), MCHW 
Malaria Control Program, Kanchanpur 4
(11) and 4 Lab Assistants (4) were oriented totaling to 793 health workers and volunteers
receiving orientation. Altogether 218 treatment FCHV for malaria control activities in the 
district have been selected for taking blood slides from clinical malaria cases, providing 
Chloroquine, maintaining records, reporting and referral of complicated case. Awareness 
raising for behavioral change has been by far the most crucial and effective intervention of 
the program which has resulted in a significant change in the behaviour of the communities, 
particularly the school children. 
Community-based communication strategies, particularly through FCHV to mothers’ groups 
and health education to school children has been the major strategy adopted for behavioural 
communication. With the ultimate goal of enhancement of the participation of
schoolteachers and school children in contributing towards malaria control activity school 
health education program was conducted in the district through the two activities, viz., 
orientation to school-teachers and health facility staffs and health education sessions with 
school children. A two-days orientation program was conducted through 4 events, for 50 
schoolteachers from 49 schools both from secondary and lower secondary level schools 
and 15 health-facility staffs (health facility in-charge) with the objective to support the 
district's malaria control program by conducting health education programs and monitoring 
the malaria control program at their respective schools and communities. A 5-sessioned 
school health education program each for grades VII, VIII and IX was conducted in 49 
schools with the joint efforts from the oriented schoolteachers and health-facility staffs as 
per the plans developed by them at the orientation program. Altogether 8,819 school 
students both from the secondary and lower secondary levels benefited from the program. 
Free distribution of insecticide treated nets (LLIN) and social marketing approach has been 
promoted in the district as a method of vector control and transmission risk-reduction. 
17,000 LLIN were distributed by the D(P)HO/Kanchanpur in the year 2005 in the high-risk 
areas for malaria while in this year 2006, 17,498 LLIN has been distributed by PSI/Nepal 
has distributed nets through social marketing approach to make the ITN available to 
communities that were not reached by the free distribution scheme at a subsidized. An 
estimated 103,494 people are thought to be having benefiting from the free-distributed nets.
The LLIN have reached the population of low socio-economic status, particularly, the low￾income and the poorest segment, illiterate and socially deprived groups like the Dalits, the 
Janajatis and the marginalized. IRS as a major vector control activity in malaria control has 
been a regular intervention activity of D(P)HO Kanchanpur in malaria prone areas of the 
district every year. 86,629 people of the district have been covered this year by the regular 
IRS program. 
The changes brought about by the program so far has not yet been reflected through the 
indicators. However, significant changes have been observed in the health behaviour of the 
communities that suggests for an unexpectedly better outcome. Effective coordination with 
D(P)HO and partners realization of the program as their own program by D(P)HO and
communities has been a major reason for success.
Community participation, particularly the one who are most at the risk in planning
interventions appropriate to address their needs and social mobilization for awareness 
raising; strategic shift to make prevention and control activities gain a civil concern rather 
than the responsibility of certain organizations; and harnessing local initiatives, local
resources, community mobilization and a sense of ownership among the people who are 
most affected by the problem has been the have been the approach looked forward for 
future malaria control program. 
Malaria Control Program, Kanchanpur 5
Table of content 
Cover page 1
Acknowledgement 2
Executive summary 3-4
Table of content 5-6
Chapter 1 Introduction 7-9
Background 7
Malaria Control Program 8 
Objectives 8 
Expected outcome 9
Chapter 2 Program overview 10-25 
General preview 10 
Changes 22 
Challenges 24 
Summary of lessons learned from the overall malaria control program 25 
Chapter 3 Looking forward 26-36 
Terms and concept 35
References/bibliography 36
Annex I List of acronyms 37
Annex II District map 38
Annex III Scope of Work, Malaria control program 39
Malaria Control Program, Kanchanpur 6
List of boxes, tables and figures
Boxes
Box 1 Strategies: Malaria Control Program 9
Box 2 Health Facility Operation Management Committee managed 
malaria microscopy centers 10
Box 3 Summary of lessons learned from established malaria microscopy 
centers 12
Box 4 Increased services and increased service utilization, key to 
sustainable lab operation 13
Box 5 Summary of lessons learned from malaria microscopy training 14
Box 6 Summary of lessons learned from FCHV orientation on malaria 
prevention and control 15
Box 7 HFOMC-managed malaria microscopy – a boon for child survival 15
Box 8 Summary of lessons learned from school health education program 16
Box 9 Poor are likely to be deceived 18
Box 10 Social barrier in use of LLIN 19
Box 11 Summary of lessons learned from the distribution of insecticide￾treated nets 20
Box 12 Indicators of malaria control program 22
Box 13 Outcomes of malaria control activities in the district 23
Box 14 Summary of significant changes seen: findings from the follow-up of 
school health education program 24
Tables
Table 1 Summary of CSP/NFHP CARE Specific malaria control activities 
for the year 2006 11
Table 2 Summary of malaria control activities conducted by 
D(P)HO/Kanchanpur and other organizations in the year 2006 21
Table 3 Reported malaria cases by type (probable or clinically diagnosed 
and laboratory confirmed) 22 
Figures
Figure 1 Use of LLIN 19
Figure 2 Trend of malaria in the district 23
Malaria Control Program, Kanchanpur 7
INTRODUCTION
Background
Malaria is a parasitic infection of the blood transmitted by night biting female Anopheline
mosquitoes. It is one of the most serious diseases in the developing countries. Once the first 
symptoms appear, malaria can kill very rapidly – and often does. Malaria, particularly, 
Plasmodium falciparum is potentially a fatal disease, if not recognized and treated in time. 
Clinical conditions of patients suffering from Pl. falciparum may suddenly deteriorate within 
24 hours of the presentation of febrile illness. Malaria can affect all segments of the 
population, but children, pregnant women, people living in emergency situations and people 
living with HIV/AIDS are particularly vulnerable to this devastating disease. In pregnant 
women and children malaria has a profound effect due to lower immunity in these groups 
making them vulnerable to developing severe complications. Malaria in pregnancy induces 
abortion, stillbirth, premature births, underweight babies and complications of delivery.
Cerebral and other complications particularly severe anemia, hypoglycemia and pulmonary 
edema are more common in pregnant women than non-pregnant women. The children who 
survive a severe bout of malaria may develop chronic anemia and neurological impairment.
Malaria has been a major public health problem in Nepal since a long time. It is transmitted 
in all areas of Nepal except the eleven Himalayan districts and the three districts that make 
up the Kathmandu valley. The majority of malaria transmission in Nepal occurs in only 12 
districts and these have been labeled "priority" districts. Pl. vivax is the predominant 
malarial parasite (approximately ten times more common than Pl. falciparum) in Nepal for 
past several years. However, about 10 per cent of Pl. falciparum cases are seen at the 
times of outbreak in the country. 
Western Terai of Nepal has been identified as highest malarious region. Kanchanpur is a 
malaria endemic Terai district of Far West Nepal that constituted the highest proportion of 
malaria cases, i.e. 52 per cent, in 2003 (HMG/N, 2003). The entire population of
Kanchanpur 377899 (CBS, 2001) is regarded as risk population for malaria. The District has 
been classified under "Stratum I and II" having low receptivity and seasonal transmission 
from March through October and constitutes the highest proportion of malaria cases. The 
sub-tropical climate here is favorable for mosquitoes to breed and transmit malaria through 
out the year. Furthermore, the district is surrounded by Dadeldhura and Kailali, in the north 
and east, respectively and India (Uttar Pradesh and Uttaranchal) in the south and west, 
respectively. Out of the 19 VDCs and 1 Municipality in the district, 11 VDCs and 1
Municipality (it constitute more than 60 percent of its part) are adjoining with Indian Territory. 
This suggests for the high population mobility due to free open border that accounts for the 
inestimable inter-country transmission of malaria in this region. The national data shows that 
in districts bordering with India, 85 per cent of the total cases were collected out of which 89 
per cent were positive for malaria (DoHS, 2004). 
The first attempt to control malaria in Nepal was initiated in 1954 through the Insect Borne 
Disease Control Program, supported by United States Agency for International Development 
(USAID). In 1958, the malaria eradication program was launched, the first national public 
health program in the country, with an objective of eradicating malaria from the country 
within a limited time period. Due to various constraints, this objective could not be achieved 
1
Malaria Control Program, Kanchanpur 8
and consequently the program reverted to malaria control in 1978. Prevailing ecological, 
epidemiological and socio-economic factors suggested changes in the malaria control
strategy, and as a result the current strategy was revised in accordance with the Global 
Malaria Control Strategy 1992 of World Health Organization (WHO). Nepal has also been 
signatory to the United Nation's Declaration of Millennium Development Goals (MDG)
accepting the commitment to fulfill the eight goals set, combating malaria being MDG 6th out 
of the eight goals. 
The Government of Nepal’s National Health Policy for Malaria Control in Nepal is to provide 
anti-malarial services at the doorsteps of the community, free of cost, through existing 
network of Primary Health Care (PHC) Centers, Health Posts (HP) and Sub Health Posts 
(SHP) by adopting PHC approach. It has been providing malaria control services to the 
people in Kanchanpur district in accordance with the revised Global Malaria Control Strategy 
(GMCS) 1992 of WHO and transmission risk-reduction through increased access to early 
detection and prompt treatment of malaria for the people living in high risk areas has been a 
principal to reach the goal of 'Roll Back Malaria’ (RBM). Indoor residual spraying (IRS); 
information, education and communication (IEC); and disease surveillance are the other 
major strategies within the RBM approach. The goal of National Malaria Control Program 
(NMCP) is to sustain the prevention of mortality and reduce the morbidity of malaria by 50 
per cent in Nepal by the year 2010; prevention and control of epidemics with particular 
reference to Pl. falciparum; and containment of Pl. falciparum and drug resistant malaria. 
Malaria Control Program, Kanchanpur
Malaria Control Program is one of the programs of CARE Nepal in Kanchanpur district, 
funded by Nepal Family Health Program (NFHP) and implemented by Child Survival Project 
to support/assist District Public Health Office Kanchanpur to increase the availability,
accessibility and quality of the services provided to control malaria at the household and 
community levels. NFHP is a USAID project to support the Government of Nepal in its long￾term goal of reducing fertility and under-five mortality. CARE Nepal, as a collaborating 
partner of NFHP, with its objective to support /assist D(P)HO to increase the availability, 
accessibility and quality of the basic package of Family Planning/Maternal and Child Health 
(FP/MCH) services at household and community level. NFHP is also supporting D(P)HOs 
for vector borne disease control program in selected Core Program Districts (CPD) viz., 
Dhanusa, Mahottari and Kanchanpur. 
Objectives
The ultimate aim of the program is to prevent mortality and reduce morbidity due to malaria 
with the aim of contributing for better health of children (under age five) and pregnant and 
lactating women as a direct contribution on improving household livelihood security and 
health status of rural people in Kanchanpur district through different health interventions.
General objective
The major objective of the program is to support/assist D(P)HO/Kanchanpur to increase the 
availability, accessibility and quality of the services provided to control malaria at the
household and community levels.
Specific objectives 
1. To support the Health Facility Operation Management Committees (HFOMC) for
sustainable running of malaria microscopy centers on cost-sharing basis;
Malaria Control Program, Kanchanpur 9
2. To strengthen the capacity of grass-root level health workers in malaria case
identification and case management;
3. To conduct health education, awareness and advocacy activities to improve the
community access to malaria microscopy services, early diagnosis and proper 
treatment, and promote personal protection measures;
4. To conduct operational research to assess and monitor communities' KAP on
malaria prevention and control, and impact of malaria control program;
5. To monitor the quality of private malaria microscopy clinics on regular basis and to 
provide necessary recommendations and feedbacks based on the findings; and
6. To support D(P)HO/Kanchanpur in coordinating, implementing, monitoring and
supervising the malaria control activities in the district.
Expected outcome
The expected outcomes of the 
program were: 
· Increased malaria case
identification and better
management of malaria cases 
through FCHV and health
facilities in Kanchanpur district;
· Reduced incidence of malaria 
related illness among the
population of Kanchanpur
district;
· Increased awareness among
community people on ways of 
malaria prevention and control 
in Kanchanpur district leading 
to EDPT;
· Strengthened capacity of
D(P)HO/Kanchanpur to have effective management of vector borne diseases, especially 
malaria in the district; and
· Effective management system of malaria and other vector borne diseases control
program in D(P)HO/Kanchanpur.
Box 1
Strategies: Malaria Control Program
· Establishment of laboratory facilities and its strengthening for 
early diagnosis and proper management of cases at health 
facility and community level;
· Training of institution as well as peripheral/grass-root-level 
health workers in malaria case identification and its proper
management and to improve the quality of service provided;
· Passive Case Detection 'Volunteers' (PCD'V') strengthening in 
malaria prone areas;
· EDPT of uncomplicated cases and strengthening prompt
referral mechanism for complicated and severe cases;
· Promotion of health education, awareness and advocacy
programs both at the community and health facility level
thereby contributing to RBM campaign in its attempt to prevent 
vector transmission of disease;
· Promotion of operational field research on malaria;
· Monitoring and supervision of malaria control activities; and
· Strengthen monitoring mechanism of district health system on 
malaria control.
Malaria Control Program, Kanchanpur 10
PROGRAM OVERVIEW
General preview
Following the baseline survey on malaria that was carried to assess the situation on different 
aspects of malaria in the district and incorporating recommendations from the survey, 
malaria control activities were initiated in the district in coordination with
D(P)HO/Kanchanpur to reduce child and maternal mortality and morbidity, particularly due to 
malaria in the district. With the basic theme, those at risk must have access to the most 
effective preventive measures, and those suffering from malaria must have access to
prompt and effective treatment, the malaria control activities were planned and carried out in 
the district under following sectoral interventions:
1. Establishment of new malaria microscopy centers
In many areas of the district, the public health system was unable to reach a significant 
proportion of the population at risk. Therefore, a new mechanism was put in place to provide 
access to health services for these people. In order to work in partnership with the local 
communities and strengthen the
capacity of the local bodies through 
the approach of community
involvement; allow rapid expansion 
of malarial services; provide
employment opportunities to local
people; and enhance access to
quality prevention and treatment
services at reasonable cost closer to 
the homes of the most affected 
establishment of malaria microscopy 
centers was planned for further three 
new sites viz. Krishnapur, Pipladi,
and Suda VDC, in addition to already 
operating four sites Jimuwa, Daijai, 
Jhalari and Tribhuvanbasti VDC of
Kanchanpur, in close coordination
with D(P)HO/Kanchanpur. Malaria 
microscopy centers has been
established in those health facilities, 
which do not have provision of lab 
facilities, i.e. health posts (HP) and
sub-health posts (SHP), through the National health Policy (1991). CSP/NFHP CARE has 
supported the D(P)HO and HFOMC through technical, logistics and financial assistance for 
the establishment. 
Currently, there has been a momentum of establishment of malaria microscopy labs in other 
VDC of the district. Labs have been established in additional VDC, viz. Rampur bilashpur 
and Dekhatbhuli VDC. Altogether there are 12 labs, 9 established through HFOMC and 3 
initially operating labs at primary health care centers (PHC) through national health system.
Box 2
Health Facility Operation Management Committee managed 
malaria microscopy centers 
An approach of managing health through local health
management committee is the outcome of the implementation of 
decentralization policy and local self-governance act of
government of Nepal. Health Facility Operation and
Management Committees (HFOMC) have been established as a 
result in the entire VDC of Kanchanpur district. 
With technical support from CSP/NFHP CARE and D(P)HO 
Kanchanpur the HFOMC have recruited local lab assistant and 
established malaria microscopy centers at seven sites
(additional two on their own initiation). For this, D(P)HO 
Kanchanpur have provided microscopes. It has been providing 
slides, prickling needles, chemicals and reagents for the
microscopy of malaria and tuberculosis. HFOMC and
CSP/NFHP CARE have provided salaries of the lab assistants 
on cost sharing basis. It is planned that it would be to be 
provided fully by the HFOMC from January 2007. The training 
for the lab assistants on malaria microscopy are managed by the 
D(P)HO. 
****
2
Malaria Control Program, Kanchanpur 11
Summary of CARE (NFHP) Specific malaria control activities for the year 2006
S.N. Activity Target group Unit Indicator Data needed Target Achievement
N No. of HFOMC 
conducting MMC 
1 Establishment of new 
malaria microscopy 
centers
Three sites at 
Suda, Pipaladi 
and Krishnapur 
VDC
Site % Of HFOMC 
conducting malaria 
microscopy centers D Target MMC 
3 5 
(166.67%)
N No. of MMC provided 
glassware and 
furniture 
2 Lab facility support Three newly 
established labs
Site % Of MMC provided 
glassware and 
furniture support
D Target MMC 
3 3 (100%)
3 Orientation of FCHV N No. of FCHV oriented 
on malaria prevention 
and control
All FCHV (833) Person % Of FCHV covered 
in the orientation D Target no. of FCHV 
833 748 (89.79%)
4 Malaria microscopy N No of LA trained 
training
Newly recruited 
Lab Assistants
Person % Of newly 
recruited laboratory 
technicians taking 
malarial microscopy 
training 
D Target no. of LA to be 
trained
3 5 (166.67%)
N No. of schoolteachers 
oriented 
5 Orientation of 
schoolteachers on 
malaria prevention 
and control
School-teachers 
and health facility 
staffs
Person % Of orientation 
conducted for 
school teachers D Target no. of 
schoolteachers to be 
oriented 
60 49 (81.67%)
N No. of schools 
conducting SHEP 
6 School health 
education program on 
malaria prevention 
and control
Secondary-Level 
school students 
from 60 school of 
Kanchanpur 
district
School % Of schools 
conducting SHEP 
on malaria 
prevention and 
control
D Target no. of schools 
60 49 (81.67%)
7 LQAS survey Mothers of 0-23 
months children
Event Successful 
conduction of LQAS 
Survey 
 1 
8 Follow-up study on 
LLIN distributed by 
Global Fund
Household 
distributed LLIN in 
FY 2006
Event Successful 
conduction of follow -
up study 
 
N No. of Pvt. Labs 
accredited 
9 Private lab 
accreditation scheme
Interested private 
labs in 
Kanchanpur
Number % of private labs 
accredited
D Target no. of Pvt. 
Labs 
14 Process on￾going
10 Monitoring and 
documentation
All health facilities On￾going
 
Features of HFOMC managed malaria microscopy centers
Accessibility Access of the communities to malaria microscopy services has been ensured 
by the establishment of the lab services in the areas most affected by malaria. The services 
have been available to the community people at their doorstep.
Affordability Utilization of services is usually deterred from the payment of high prices for 
the lab services. The malaria microscopy has been providing low-cost services to the 
community. The poor could even benefit from the exemption schemes that are available at 
some centers.
Quality Provision of quality services through adequately trained lab assistants with
quality microscopes is one of the features of malaria microscopy centers. Quality service 
is further ensured through the periodic monitoring and supervision from the district.
Malaria Control Program, Kanchanpur 12
Community participation Community participation in the operation and management of 
the lab service through representatives from all possible groups of the community in 
health facility operation and management committee (HFOMC) is the most important 
aspect that is addressed by the labs. Committee members equitably participate in the 
identification of local issues in malaria control, need assessment, prioritization and 
identifying best possible solutions, communities’ resources and resource mobilization.
Equity The services are established in those are where there is actual need. Further, 
the needs of the poor and the most vulnerable are addressed in while providing lab 
services. 
Financial and logistics support 
The project has provided support for the recruitment of one local laboratory technician for 
seven malaria microscopy centers (i.e. Jimuwa, Daijai, Jhalari, Tribhuvanbasti, Krishnapur, 
Pipladi, and Suda VDC) on cost sharing basis with agreement between the HFOMC,
D(P)HO/Kanchanpur and CARE Nepal. The project covered the full cost of the lab
technician in all seven malaria microscopy centers until June 2006. From July to December 
2006, the project contributed 
50 per cent of the cost, and 
the HFOMC covered 50 per 
cent of the cost. From 
January 2007, it is expected 
that the HFOMC would take 
up all the responsibility of
covering the entire cost of lab 
operation. 
In order to support the
establishment of malaria
microscopy centers and in the 
sustainability in their
operation logistics support,
viz. furniture, glassware and
centrifugal machines were
provided in three new sites,
viz. Suda, Pipaladi and
Krishnapur VDC, as per the 
need. Support has also been 
provided to the newly
established site at Rampur
bilashpur VDC through
centrifugal machine. As per
the demand and need, fifty
per cent contribution has
been provided to the Suda
HFOMC in the purchase of
refrigerator with a view to
support not only the lab
services but the regular
immunization and safe￾motherhood program, too.
Box 3
Summary of lessons learned from established malaria microscopy 
centers
· Community has been empowered to identify their own problems and 
is capable of identifying the ways and resources to solve the
problems at their own efforts. In this regards the communities have 
now been realizing malaria as a major public health problem.
Lessons learned from other VDCs’ health intervention and
replicating the successful intervention has been the wide spread 
practice in the district. A momentum has, thus, been established in 
the district to establishing the labs at other VDCs
. So, there has 
been an increasing demand for the establishment of HFOMC￾managed labs.
· Sustainability of lab services has been by far the most important 
issue raised after its establishm ent. Assistance from external donors 
have short-term implication over the operation of labs while, health 
facilities own services charge are the most reliable source of income 
for its sustainable lab operation. So, approach to promote labs to 
provide wider range of quality services and encourage community to 
utilize the lab services provided would add a benefit to lab
operation.
· The active members of HFOMC and their active participation to 
seek ways for sustaining lab service is a key to its sustainability.
Selection of active members in HFOMC and strengthening the 
HFOMC and the HFOMC members for mobilization for identifying 
ways of sustaining labs and coordinating with district line agencies 
and development partners for support would be an important
approach.
· Communities’ perception about the quality of services provided
through governmental lab facilities have been the most important 
factor in the low utilization of the services provided through these 
labs. Changing communities’ perception would contribute to 
increased utilization of the services. External agencies, particularly 
CARE Nepal in Kanchanpur has a lasting impression upon the 
communities since it has been working with the communities since 
long as a development partner and communities are convinced by 
what it spells. A propagandist approach to make such organization 
advocate about the quality of lab services provided through
governmental lab facilities as a better one, for mass utilization,
would be an appropriate approach. 
Malaria Control Program, Kanchanpur 13
2. Capacity building of community level health workers 
To deliver better quality and sustainable malaria control activities through individual capacity 
building and institutional development trainings, orientation and supervisory visits have been 
continuously provided from CARE Nepal and D(P)HO. Institutional capacity building has 
been promoted through CARE Nepal specific activities like workshops and trainings on
HFOMC management and partners’ defined quality (PDQ). Planned technical support visits 
(TSV) have also been organized in order to develop institutional capacity on health service 
management and quality assurance. 
Individual capacity building has been promoted through training and orientation programs for 
lab assistants, health facility staffs, schoolteachers and FCHV.
a. Malaria microscopy training 
Seven-days malarial microscopy training was conducted for five newly recruited laboratory 
technicians (three from the initially proposed malaria microscopy centers in Krishnapur, 
Pipladi, and Suda VDC and two additional newly established malaria microscopy centers at 
Dekhatbhuli and Rampur bilashpur VDC of Kanchanpur district) in coordination with NFHP 
ID Coordinator. The training is effective to impart knowledge on both the theory and practical 
Box 4
Increased services and increased service utilization, key to sustainable lab operation
Malaria microscopy centers have not only provided the employment opportunities for the lab assistants in the 
district, but are also providing a wide range of low-cost and quality lab services, in addition to malaria microscopy 
services to the people of the communities. Health facilities have also been equally benefiting from the support 
provided to various other services there. Poor people who cannot afford high costs of laboratory services in the 
district can also benefit through free lab services provided through the exemption schemes for the poor. Talking 
about the quality of services provided through the labs, the slides sent for the crosscheck have also been proved 
to be cent percent accurate.
On one hand there is a problem for providing salary to lab assistants, while on the other hand the labs have not 
been able to meet the increasing demands of the communities that is necessary and can be provided through 
labs. There is a big question raised that if the HFOMC would be able to pay the salaries of lab assistants after 
the agreement between CSP/NFHP CARE, the D(P)HO/Kanchanpur and the HFOMC would be over in
December 2006. If this situation would come then not only the lab assistants would devoid of employment 
opportunity but also the health institutions as well as the community people would also devoid the affordable and 
quality lab services. This would also affect the other health services provided through the health facilities.
It has been therefore necessary to critically think about the continuity and sustainability of the services provided 
through labs. The support provided through the external agencies can only sustain for a short time. So, lab 
services charge is the only reliable source of income for the sustainable lab operation. Therefore, increasing the 
number of services provided through the lab would be the only approach to ensure lab sustainability. 
Further there is a wide spread perception among the community people that the private clinics/labs provide 
better quality services than the government ones. In one hand, the communities devoid of quality services that 
are provided from government labs by highly qualified and trained lab assistants and quality equipment while on 
the other hand they are compelled to pay high costs. So, it has been necessary that the community be informed 
and advocated to utilize the government labs for increased utilization. These messages if conveyed by external 
agencies would add a benefit since community largely has a faith on them and would accept what they would be 
easily convinced.
Apart from these donors’ assistance, district development committee (DDC) and village development
committee’s (VDC) contribution and contribution from OPD and CDP income would add value to it. 
****
Malaria Control Program, Kanchanpur 14
portion to the trainees. Since 
the academic training courses 
of lab assistant in the
institutions are not sufficient to 
give the proper knowledge to 
the lab assistants on malaria
the training is very effective for 
the lab assistants who intend 
to provide malaria microscopy 
services. 
b. Orientation of FCHV on
malaria microscopy 
Two-days orientation program 
was conducted for FCHV on 
Malaria Prevention and Control
in the district was conducted in 
all the 19 VDC and
Mahendranagar Municipality
through 32 events. 748 out of 
833 FCHV were oriented
through the program where
other grass-root and peripheral 
level health workers, viz. 2
AHW (2), 7 ANM (7), VHW
(20), MCHW (11) and 4 Lab
Assistants (4) were oriented
totaling to 793 health workers 
receiving orientation.
Altogether 218 treatment FCHV for malaria control activities in the district have been
selected (one treatment FCHV per ward in every VDC: 18 x 9, except 3 treatment FCHV in 
Rauteli bichawa VDC and 2 to 3 treatment FCHV per ward in Mahendranagar municipality). 
The major objective of the orientation was to update FCHV with national malaria control 
strategy and to strengthen their capacity in malaria case identification, case management 
and to mobilize them in health education, awareness and advocacy activities in order to
improve the community access to malaria microscopy services, EDPT, and promote
personal protection measures against malaria. The FCHV were oriented to clearly identify 
the clinical malaria cases in the community with the basic theme that any fever can be 
malaria and provide appropriate treatment only after taking blood slides. The treatment 
FCHV selected have been oriented to prepare blood slides before the suspected case has 
not taken any chemotherapy. They have also been oriented to properly maintain record for 
the clinical malarial cases they have identified and treated or referred and to realize their 
role in the advocacy for the utilization of these lab services for the quality malarial
microscopy services in the community. 
The major objective of the orientation was to update FCHV with national malaria control 
strategy and to strengthen their capacity in malaria case identification, case management 
and to mobilize them in health education, awareness and advocacy activities in order to
improve the community access to malaria microscopy services, EDPT, and promote
Box 5
Summary of lessons learned from malaria microscopy training
· It is well understood that the academic training course of lab 
assistant in the institutions are not sufficient to give the proper
knowledge to the lab assistants on malaria. Such training is found 
to have positive impact on the trainees to increase their
competency to identify parasites and provide quality microscopy 
services. 
· An estimated 60 per cent of the service has been provided by the 
private sector in Nepal where the services are provided through the 
lab assistants that do not have any reinforcing training apart from 
the academic training course. Similar trainings if provided to the 
private lab service providers would ensure the quality services 
provided through the private labs to a significant portion of the 
population. 
· Since, there has been an increasing demand for the establishment 
of community-managed (HFOMC) labs, there would be an
increased demand for malaria microscopy trainings
· Training, especially for malaria microscopy, would be effective if 
they are organized to have practical implication on the participants. 
Longer duration trainings with sufficient time for the trainees to 
examine the slides and training given in participatory environment 
set in real lab situation would be effective. 
· Refresher training in malaria microscopy to update their knowledge 
and skills, particularly to cope with the changing nature of malarial 
parasite, vector and latest change in the malaria microscopy
techniques would be beneficial
· Follow up of the training and supervision from the district from time 
to time to provide guidance to the lab assistants at their workplace 
and cross-checking the slides examined would ensure improved 
competency and quality of services provide through them
· Training often become an important incentive for such health
workers who are continually based on the health facilities
Malaria Control Program, Kanchanpur 15
personal protection measures against malaria. The FCHV were oriented to clearly identify 
the clinical malaria cases in the community with the basic theme that any fever can be 
malaria and provide appropriate treatment only after taking blood slides. The treatment
FCHV selected have been oriented to prepare blood slides before the suspected case has 
not taken any chemotherapy. They have also been oriented to properly maintain record for 
the clinical malarial cases they have identified and treated or referred and to realize their 
role in the advocacy for the utilization of these lab services for the quality malarial
microscopy services in the community. 
3. Quality assurance of health services provided for malaria control program 
Quality assurance of the malaria control services provided by health facilities (both
government and private) and community health workers has been one of the most important 
aspect of the malaria control program. Monitoring, supervision and trainings to health
facilities’ staffs, lab assistants and community level health workers have continuously been 
provided to ensure the provision of quality services provided by the health facilities.
Necessary supervision and on 
the spot guidance has been
provided as necessary.
Monitoring of the activities of 
the health workers has been
another aspect covered by the 
malaria control program to
ensure quality of malarial
services. Half yearly review
meetings have been carried
out in the district to ensure the 
qualitative recording and timely 
reporting. 
Lab accreditation has been
one activity that is planned in 
the district to ensuring the
quality of malarial microscopy
services provided from the
private sector. Orientation has 
Box 6
Summary of lessons learned from FCHV orientation on malaria prevention and control
· Continuous and sustained training is most effective. Initial training continued by refresher training, follow-up 
and support are effective to enhance greater confidence and competency to work field situation. So, training 
needs to be an on-going process. Refresher training needs to be offered periodically in order to sustain the 
impact of the interventions with the changing environment
· For health volunteers like FCHV trainings are often seen as incentives and a means of motivation to 
promote their continued participation. Further, training like this, which are directed at mobilizing them for 
better health outcomes in the community if able to show the necessity of their role in this regard are 
successful in developing feeling more positive about their contribution
· Follow-up and supervisory visits from the district and higher concerned authority made from time to time to 
provide motivation and guidance to FCHV at their workplace and monitor the quality of the slides prepared 
and records maintained and the practice of timely reporting are effective
Box 7
HFOMC-managed malaria microscopy – a boon for child survival
Kale Chaudhary, two and a half years old, has been one of the several 
beneficiaries of the malarial microscopy center in Krishnapur VDC of 
Kanchanpur district. Manamati Chaudhary, mother of the child, used to 
think that lab service provided by the private sectors is far better than 
the governmental labs. So, she did not hesitate to pay even a larger 
sum of money for the service provided by the private lab in the 
community when he r child was hit by fever.
She was reluctant to take her child to the governmental health facility 
when the private lab’s diagnosis found Plasmodium falciparum in the 
blood of the child and was advised that if she would delay any further 
her child would die out of malaria and also, that she would get the 
treatment against malaria for free there. But the lab diagnosis there in 
the HFOMC managed lab at Krishnapur health facility, Kanchanpur 
found no Plasmodium falciparum and even the RDT could not prove 
the presence of the parasite in the blood of the child. The child soon 
got well when treated for clinical malaria by Chloroquine. 
Manamati now realizes that her lab service in the Krsihnapur health 
facility was better than the private lab and was cheaper. The free 
treatment provided there for malaria has been a boon for her child 
survival. 
**** 
Malaria Control Program, Kanchanpur 16
been provided to 14 private labs in the district and consent has been taken from them in this 
regards. It is planned that the assessment of the quality of the services would be carried out 
and on the spot training; guidance and support would be provided to them as necessary in 
this scheme. Certification of the labs in malaria microscopy in the district has been one of 
the important aspects of the program.
4. Promoting behavior change 
Awareness raising for behavioural change has been by far the most crucial and effective 
intervention of the program which has resulted in a significant change in the behaviour of the 
communities, particularly the school children. Community-based communication strategies, 
particularly through FCHV to mothers’ groups and health education to school children has 
been the major strategy adopted for behavioural communication. Since women, particularly 
pregnant and children under five years of age are the most vulnerable to malaria infection, 
the behavioural change has been targeted to these groups to improve health seeking 
behaviour of caregivers so that they can recognize signs of severe illness and seek
appropriate care quickly. Behavioural change regarding the adoption of personal protection 
measures, particularly, on use of insecticide nets and environmental management has been 
targeted through school children. 
School health education program
CSP/NFHP CARE justified the role of school children to act as an important link between the 
community and the health facility and a medium to spread message on malaria prevention 
and control. With the ultimate goal of enhancement of the participation of schoolteachers 
and school children in contributing towards malaria control activity school health education 
program was conducted in
the district through the two 
activities, viz., orientation to 
school-teachers and health
facility staffs and health
education sessions with
school children. 
A two-days orientation
program was conducted
through 4 events, for 50
schoolteachers from 49
schools both from secondary 
and lower secondary level
schools and 15 health￾facility staffs (health facility 
in-charge) with the objective 
to support the district's
malaria control program by
conducting health education 
programs and monitoring the 
malaria control program at
their respective schools and 
communities. A 5-sessioned 
school health education
Box 8
Summary of lessons learned from school health education program
· Community mobilization through the involvement of schoolteachers 
and students on awareness raising activities has ensured the
intensification of the flow of information to large audience through less
effort within short time frame.
· The program has been successful to attract the attention of the 
students and the teachers that malaria is a major public health
problem that has led to an increased interest among them to combat 
malaria at their own efforts. For this they have been demanding similar 
programs in the future. Thus, community empowerment through
advocacy and awareness raising activities would be the most crucial 
step towards gaining the problem a public concern and consequently, 
to take responsibility on their own.
· The urgency to completing all the planned activities within less time 
due to time constraints and seasonal association of the disease for its 
transmission has been one of the major challenges for malaria control 
program in the district.
· Overlapping of various activities both in CARE and D(P)HO as well as 
other partner organizations in the district has created difficulty in the 
implementation of activities due to divided manpower and, proper
monitoring and supervision cannot be carried out as well.
· Mothers are the primary care takers of families, particularly of small 
children under five years of age. Behavioural change interventions 
aimed directly at this group would be a beneficial approach. Similarly, 
private sector, which is the major provider of first-contact malaria 
treatment in most communities, has not been included in the program. 
Activities aimed at linking the private sector with the behavioural 
change strategy should be initiated to ensure comprehensiveness in 
the program.
Malaria Control Program, Kanchanpur 17
program each for grades VII, VIII and IX was conducted in 49 schools with the joint efforts 
from the oriented schoolteachers and health-facility staffs as per the plans developed by 
them at the orientation program. Altogether 8,819 school students both from the secondary 
and lower secondary levels benefited from the program. Monitoring, supervision, evaluation 
and follow-up of the program was carried out jointly by the health facility staffs, CSP/NFHP 
CARE and D(P)HO Kanchanpur. 
Summary of malaria control activities conducted by D(P)HO/Kanchanpur and other 
organizations in the year 2006
General malaria-related services delivered
Services delivered in the district for malaria control include numbers of nets, numbers of 
households (HH)/units sprayed during IRS campaigns and number of population served by 
the locally established malaria microscopy labs. These services and services-related 
commodities mostly reflect core malaria control activities of national malaria control
program.
1. Insecticide-treated nets
Insecticide-treated nets are one of the key interventions promoted by the national health 
system. Insecticide-treated nets, if used properly, are one of the best ways to prevent
mosquitoes from biting people and infecting them with malaria. They are simple, safe and 
cost-effective: It has been shown that high levels of insecticide-treated nets coverage can 
reduce deaths in children by as much as 20 % from all causes, not just from malaria.
a. Free distribution
Free distribution of insecticide treated nets (LLIN) has been promoted in the district as a 
method of vector control and transmission risk-reduction. 17,000 LLIN were distributed by 
the D(P)HO/Kanchanpur in the year 2005 in the high-risk areas for malaria while in this year 
2006, 17,498 LLIN has been distributed by PSI/Nepal, , an international organization
working in Nepal to deliver health commodities through social marketing in the district with 
support from GFATM. 
Malaria Control Program, Kanchanpur 18
b. Distribution through public-private partnership
In order to make the insecticide-treated nets available to communities that were not reached 
by the free distribution scheme, through non-governmental channels such as social
marketing, LLIN were distributed in the district at a subsidized price through public-private 
partnership approach, so that those who deterred from purchasing ITNs by high prices might 
benefit. PSI/Nepal was involved in the distribution. About 150 private medical stores were 
first identified and were oriented about the importance and use of LLIN in malaria prevention 
in order to build awareness and influence attitudes and behaviours to promote demand 
creation for the LLIN. These stores were then provided with about 20 LLIN each to be 
distributed in low-subsidized price. 
Estimates of LLIN coverage 
Coverage of ITN is best assessed through household (HH) surveys which asks questions on 
possession and use of nets, as well as insecticide treatment status, among the target 
populations of children under five years of age (U5) and pregnant women. A follow-up study 
carried out on the effective use of LLIN gives a glimpse of household possession and use of 
nets, particularly, distributed through free-distribution in the district. 
Box 9
Poor are likely to be deceived
Mugi Lala Chaudhary (name changed), Krishnapur-1, Kanchanpur, from a family of Janajatis ethnic origin, is 
illiterate. He lives with a four-member-family. ‘Life has not always been easy for the poor’, he says with eyes 
soaked with tears, ‘and we are those that are deceived further.’ 
How happy he was when he was informed that his name was in the list of the person to get the LLIN that was to 
be distributed by the D(P)HO Kanchanpur. He took a breath of relief and was happy that his wife and his 
daughters would not have to face mosquito nuisance and they could take a cozy sleep even it was only in the 
night, after a laborious day in the farm. He had heard that the net was different than other nets in the market; 
more interesting was that mosquitoes would not come even around the house where it was used. How 
enthusiastic he was seeing the net.
Though it was not affordable for him to pay even NRs. 50 for the net, he was stunned when for the first time he 
was notified that the price for the net was increased to NRs. 100. But the hope for his family members’ pleasure 
enlightened him to search for the money further; he did not hesitate to pay the amount. He borrowed the money 
from his relative and hurried to purchase the net. But his hope, enthusiasm and wishes shattered into pieces 
when he found that somebody else has purchased the net in his name. “Poor are likely to be deceived”.
Though LLIN was supposed to be distributed free of cost, an uncertain price was imposed for it by the committee 
formed for its distribution in the district of which D(P)HO Kanchanpur is one of them. The price was not fixed but 
was to be decided by the respective VDC in which they were to be distributed. This money was supposed to be 
used for other malaria control activities in the district, particularly, if the treatment and re-treatment of the nets 
were to be carried out. However, the collected money has not been used for any activities yet in the district. 
Provision was also made for exemption for the poor who could not afford to pay the cost allocated; they would 
have to pay the amount they could afford. But, most of them do not know about it. It could have been better if 
these households are identified and informed earlier such practices could be avoided.
****
Malaria Control Program, Kanchanpur 19
About 3 persons in a
household with both the 
mother and the children 
along with the father are 
benefiting from the LLIN 
distributed with minimum 
of one person to
maximum of six persons 
in a household while an 
indirect protection has
also been provided to
others in the household 
with an average of 7.2
members and the
community as a whole
by reducing the overall
population of disease￾carrying mosquitoes due 
to its excito repellant
property, which drives
away mosquito even
away from the house. An 
estimated 103,494
people are thought to be 
having benefiting from the free-distributed nets. The LLIN have reached the population of 
low socio-economic status, particularly, the low-income and the poorest segment, illiterate 
and socially deprived groups like the Dalits, the Janajatis and the marginalized. 
The LLIN was available in 91.03 per cent of households that were distributed LLIN and 
among these households that had LLIN, 91.03 per cent were in use. Some households are 
compelled to preserve the LLIN due to social factors. About 73.48 per cent of the
households were easily able to pay for the LLIN while remaining 26.52 per cent of the 
respondents had to
burrow it from some other 
sources to pay for it.
Among the 78 households 
that had LLIN, in most of 
them (33 households)
husband and wife, along 
with children (if any), used 
to sleep under it followed 
by children (<5 years) in 
23 households, mother/-
to-be in 16 households
and in the remaining
households either grand
parents, the elder siblings 
or the male members
alone used to sleep under 
the LLIN. 
Box 10
Social barrier in use of LLIN
“Whom should I give the LLIN to?” Ram Singh Saud, an old man of 56 years of 
Tribhuvanbasti VDC, Kanchanpur, exclaimed when he was asked why had he 
not provided the LLIN, that he was provided, to one of his pregnant daughters -
in-law, “All the three daughters -in law are equal to me and all are pregnant.” He 
is not the only person in the district who is faced with such a problem. In many 
a household there is only one LLIN, but there are more than one pregnant 
woman or they have many small children less than five years of age in the 
same house. Sometimes, the issues like this have been a cause of quarrel in 
some households. So, in such cases the head of the households are compelled 
to preserve the LLIN in a safe place rather than to bring them in use. 
The practice of living in a joint family is common in many households of
Kanchanpur district where there might be more than one pregnant woman or 
small children of age less than five years at a time. Though the LLIN has been 
distributed to reach these groups of people in households, it is a difficult
situation to decide to them by whom the LLIN be used. 
So, the distribution programs, if able to address such social issues while 
planning for the distribution, the universal availability and effective utilization of 
the LLIN would be significant. As far as possible, if the number of the LLIN to 
be distributed are planned on the basis of the intended target, i.e. pregnant 
women and children (< 5 years) in a household rather than the taking a 
household as one unit for distribution, the LLIN would reach all the targets and 
there effective use can be ensured. 
**** 
Use of LLIN (n=78; multiple response ) 
23
16
33
12
0
5
10
15
20
25
30
35
Children (< 5
years)
Mother
(pregnant or
delivering)
Husband and
wife
Other
Source: CSP/NFHP CARE 2006
Malaria Control Program, Kanchanpur 20
2. Indoor residual spraying
Indoor residual spraying (IRS) as a major vector control activity in malaria control has been 
a regular intervention activity of national health system in malaria endemic-prone areas of 
the country. D(P)HO Kanchanpur has been carrying out IRS in malaria prone areas of the 
district every year. 86,629 people of the district have been covered this year by the regular 
IRS program. 
3. Lab facility services
From the existing 12 malaria microscopy centers in the district communities are benefiting 
from a wide range of services, in addition to the malaria microscopy services provided from 
these centers. 18,294 beneficiaries have benefited from the malaria microscopy centers at 
six sites, (except Suda). 
From the eight-months data (Poush 2062 – Shrawan 2063) compiled from six sites, it has 
been estimated that about 138.5 persons are benefiting from a malaria microscopy center 
per in a month where 24.21 per cent of the beneficiaries are of malarial cases only. The 
average number of lab services provided is 11 ranging from minimum of 5 to maximum of 16 
services at a site. In addition to this, anti-malarial drugs like Chloroquine and sulfadoxine￾pyremethamine (SP) for pregnant women are also provided from the malaria microscopy 
centers free of cost. RDT is also provided for the Pl. falciparum cases from the sites while, in 
Box 11
Summary of lessons learned from the distribution of insecticide-treated nets 
· Effective distribution of insecticide-treated nets as a practical efficient tool in the management of malaria 
on a large scale to reach the targeted population has been ensured through such program. However, 
disputes are likely to arise during its distribution due to inadequate numbers of insecticide-treated nets 
available for distribution than the actual number of target groups. Equally, active involvement of
community health volunteers, particularly, FCHV has been the most appropriate step not only in the 
dispute management but also to ensure the nets reach the most in need. So, mobilization of FCHV in 
such future programs is highly recommended. 
· The nets are usually inadequate to reach the entire target group in a specified time and costs, even 
subsidized through social marketing schemes, are high for the community to afford. Ordinary nets are 
available at almost all the households. The intervention activities related to the treatment and re￾treatment of the nets would, therefore, assure that the households not distributed the insecticide-treated 
nets also benefit from the treated nets. 
· As far as possible the number of the insecticide-treated nets to be distributed should be planned on the 
basis of the intended target, i.e. pregnant women and children (< 5 years) in a household rather than 
the taking a household as one unit for distribution. To ensure this, integration of the distribution with 
antenatal check-ups can ensured that all the pregnant women and children <5 years receive and use 
the insecticide-treated nets at their first clinic visit 
· Social issues are likely to affect the use of insecticide-treated nets and distribution programs,
particularly, free-distribution should address this issues appropriately while planning for the distribution 
· Exemption schemes have been available for the poor in the distribution but they have not been properly 
informed about it. Hence, they are likely to be deprived from such schemes and also very often deceive. 
As far as possible the insecticide-treated nets should be distributed free of cost, but if some charge is to 
be imposed upon it then the ability of the poorest families should be considered. If exemption scheme 
are available for them then the households that would be covered under such schemes should be 
identified and notified earlier so that none of them would have to deceive from getting it. 
· The households that were provided the insecticide-treated nets when not oriented properly about it have 
impact on its effective use. Orienting properly on insecticide-treated nets promotes positive attitude 
towards its use. The distribution program should, therefore, properly orient all the households provided 
the insecticide-treated nets on it for its universal and effective use. Further mobilization of the health 
workers and the health volunteers, particularly, FCHV would be the most effective approach.
Malaria Control Program, Kanchanpur 21
the health facilities where malaria microscopy services are not available RDT is the only 
malarial service provided with appropriate treatment free of cost and referral service as 
necessary.
FCHV of Dekhatbhuli VDC, Kanchanpur: FCHV can be the best resource to provide
malaria control services in the communities. They have been involved in providing health 
education on malaria; identifying clinical malaria cases in the communities, taking blood 
slides and providing Chloroquine (treatment FCHV at the time of epidemic), recording and 
reporting of malaria cases, providing referral services. Their involvement in distributing nets 
have been very much effective in the communities since it is ensured that the nets reach the 
target groups and the disputes associated with the distribution are very often appropriately 
dealt. Also, in some VDC the FCHV have imposed some charge on the nets and have 
collected a significant amount of money that they have planned to use in community health 
activities and strengthening their activities. FCHV can be the best source to disseminate key 
messages on malaria to the mothers and caretakers through mothers’ groups’ meetings.
Table 2 
Summary of malaria control activities conducted by D(P)HO/Kanchanpur and other 
organizations in the year 2006
S.N. Activity Target group Unit Indicator Data needed Target Achievement
N No. Of review meeting 
conducted at 
community level 
1 Review meeting of 
malaria program at 
community level
Health facility Time % Of review 
meeting conducted 
at community level
D Targeted review 
meeting to be 
conducted at 
community level 
1 1 (100 %)
N No. Of review meeting 
conducted at district 
level 
2 Review meeting of 
malaria program at 
district level
Health facility Time % Of review 
meeting conducted 
at district level
D Targeted review 
meeting to be 
conducted at district 
level 
1 1 (100%)
N No. of household 
distributed LLIN 
3 Distribution of 
insecticide treated 
nets (LLIN)
Household Number % Of household 
distributed LLIN
D Target no. of 
household 
17498 17498 
(100%)
N No of people covered 
by IRS
4 Indoor Residual Spray General 
population
Number % Of people 
covered by the IRS
D Target no. of people 
to be covered
66582
86629 
(130.1%)
N No. of blood slides 
collected for 
examination
5 Surveillance Blood slide Number % Of blood slides 
collected 
D Target no. of blood 
slides to be collected
60 49 (81.67%)
Research and Training Institute (RTI)/USAID 
1 Malaria prevalence 
survey
General 
population
Event Successful 
conduction of 
survey 
 1 1 
100 %
Malaria Control Program, Kanchanpur 22
Table 3: Reported malaria cases by type (probable or 
clinically diagnosed and laboratory confirmed)
Year Risk 
Population
CMI PV 
cases
PF 
cases
No of deaths 
due to malaria
1995 230671 - 343 1 0
1996 262282 - 510 642 15
1997 299764 - 473 132 0
1998 330304 - 382 13 0
1999 342185 - 356 43 0
2000 354495 - 242 18 1
2001 367247 - 2619 76 0
2002 380459 24.17 6621 1472 3
2003 405449 10.31 4118 208 1
2004 417731 8.75 1084 82 1
2005 429070 9.18 1113 28 0
2006 2570851
0.43 373 3 0
Source: HMIS/D(P)HO Kanchanpur, 062/063 (Date of last
report: 15 July 2006)
1
The risk population has been computed for seven months
Changes 
Malaria has been a major
threat to entire population of 
the district since long. With a 
major aim to reducing the
burden of malaria associated
with its morbidity and mortality 
the malaria control activities
have been carried out. Though 
there are cases of malaria
throughout the year in the
district, due to seasonal
association of disease
transmission the cases are
mostly concentrated from July 
through October. Hence, the
impact of the program activities 
is yet to be awaited. 
A set of indicators are already 
in use to measure and monitor 
the progress of the regular malaria control activities of the district health system, while an 
additional set of indicators have further been developed to assess and monitor the impacts 
of the intervention activities carried out in the district. It is well pronounced that this
additional set of indicators would be in practice from 2007. 
The changes brought about by the program so far has not yet been reflected through the 
indicators. However, significant changes have been observed in the health behaviour of the 
communities that suggests for an unexpectedly better outcome. The section below has tried 
to reflect the changes seen so far.
Epidemiological data
The data presented reflects the
trend of aggregated malaria
cases in the district since 1995. 
The data shows that there have 
been an increased proportion of 
Pl. falciparum cases every four to 
five years, which has been the
major cause of outbreaks
suggesting for a probable
outbreak in 2006/2007. The latest 
data obtained through the HMIS 
at 15 July 2006 suggests that
there is an increasing trend of 
blood slides collection in the
district. However, the data
regarding the impact of malaria
control program is yet to come
since the transmission of the
Box 12
Indicators of malaria control program
Basic indicators 
ABER : Annual Blood Examination Rate
API : Annual Parasite Incidence
SPR : Slide Positivity Rate
PF% : Percentage of Plasmodium falciparum
SFR : Slide Fatality Rate
CMI : Clinical Malaria Incidence
Additional indicators
· Insecticide-treated nets (LLIN) coverage percentage
· Percentage of received anti-malarial drugs (amDs
) within 24 hours 
of fever onset
· Percentage of malaria in < 5 years children
· Malaria in pregnancy
· Death record
· Referral record
· Indoor residual spray (IRS) coverage
Malaria Control Program, Kanchanpur 23
infection is concentrated from July through October. 
Annual blood examination rate 
(ABER) target for the district
has been 3 - 5 per cent. The 
district has not been able to
achieve this target for past few 
years and the achievement till 
the last date of reporting (15 
July 2006) has been 1.32 per 
cent while it was 3.17 per cent 
for 2005. However this year it is 
expected that the target would 
be met, since it has been well 
spelled by most health
institutions that there is an
increasing trend of blood slide 
collection at the health facilities 
which is suppose to strike a
peak during September –
October. The morbidity of
malaria in the district till the last 
date of reporting 0.001 per cent 
while it was 2.66 in 2005. This figure would increase slightly till the end of this year, 
however, this indicator is also supposed to fall sharply as there has been very few cases of 
malaria in the communities. The distribution of insecticide treated nets and IRS done has 
been stated to be the contributing factor to this fall. The given figure shows that there has 
been a sharp increase in
slide positivity rate (SPR)
this year (11.04 compared 
to 8.39 in 2005).
The findings from the
follow up study of LLIN
suggests that the episode 
of fever with malaria had 
been seen among the 1.51 
per cent of households
distributed LLIN and the
fever cases were entirely
from the adult group. This 
means that the LLIN have 
proved to be effective for 
the pregnant and children 
(< 5 years). It has been
evident that malaria has
been the primary cause of 
maternal mortality and
mortality in children under 
five in the malaria-prone 
regions. From a series of 
Box 13
Outcomes of malaria control activities in the district
There have been an increased number of people, particularly the 
school children, undergoing blood test in the labs when hit by a fever, 
before taking any medicine. It is proved by the fact that the students 
have been complaining about the absence of health staffs when the 
health staffs were in training programs in the district. In the earlier 
days, the people used to take Cetamol as soon they had fever, but 
they are now aware that blood should be taken for examination before 
taking any medicines. The community used to think that there were no 
blood test facility in the sub/health posts, but now they are aware 
about its establishment. 
Similarly, behavioural changes have been seen among the school 
children. They have been seen involved in filling the water-collected 
ditches around their houses. The children have started to give health 
education at their home about malaria. Their guardians have been 
continually been asking the school about the school health education 
program on malaria conducted at the schools. 
A change in attitude towards insecticide treated nets have been seen 
among the community people who had planned not to purchase the 
LLIN distributed by the D(P)HO due to lack of money, were convinced 
by their children to buy it. Also, they have realized that the insecticide 
in the nets would last for long even washing for several times and 
would not have effect on individuals health. 
****
Figure 2
Trend of malaria in the district (1995-2006)
0
5
10
15
20
25
30
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Year
ABER API SPR
Source: HMIS/D(P)HO Kanchanpur, 062/063 (Date of last 
report: 15 July 2006)
Malaria Control Program, Kanchanpur 24
studies it has been found that ITN have been shown to decrease severe malaria, anemia in 
the mothers, premature births, stillbirths, incidence of underweight among newborns,
morbidity of childhood malaria (< 5 years of age) and cut all-cause child mortality since 
malaria in pregnancy is associated with adverse consequences for mother and children. So, 
it can be assumed that the LLIN have had an impact upon these indicators in the district. 
However, the study has not been able to collect any data regarding this. 
Box 14
Summary of significant changes seen: findings from the follow-up of school health education 
program
· School children have been established as a linkage between the community and the newly
established malaria microscopy centers and health facilities for their proper utilization
· There has been increment in the number of persons undergoing blood test 
· There has been changes in the behaviour of children regarding the preventive measures and drug 
taking practice against malaria
· The community have been informed about the existence of malaria microscopy centers in their 
community 
· There have been an increased realization among the community about the importance of
insecticide treated nets 
· Before we used to think that the insecticide in the LLIN would go away through washing but we 
were wrong
· There a keen eye to watch over the malaria epidemic has been established in school teachers 
Challenges
· The urgency to completing all the planned activities within less time due to time
constraints and seasonal association of the disease for its transmission had been one of 
the major challenges for malaria control program in the district
· Overlapping of various activities both in CARE and D(P)HO as well as other partner 
organizations in the district had created difficulty in the implementation of activities due 
to divided manpower and, proper monitoring and supervision cannot be carried out as 
well
· Absence of data regarding the prevalence of malaria among pregnant mothers and
children had been one of the major handicap in assessing the situation and impact of the 
interventions
· There were no other district-stationed partner organizations working in the field of
malaria prevention and control in the district except for the D(P)HO itself for which future 
activities cannot be ensured
· Data from the private sectors regarding the malaria control activities were not reported 
which has influenced the evaluation of the program’s effectiveness
· An effective monitoring mechanism suitable for monitoring the program activities has not 
yet been developed in the district except for the monitoring of the national regular 
activities of D(P)HO
· Duplication of the planned activities between CARE NFHP and GFATM had created 
confusion in implementing the activities
Malaria Control Program, Kanchanpur 25
Summary of lessons learned from the overall malaria control program
External agencies that is external to the local community trying to do everything to prevent 
and control malaria in the community will always face a uphill struggle until the community at 
large internalizes the issues and acts against it. However, experiences show that
involvement of community through HFOMC have been one of the best approach that 
ensures communities’ responsibility and accountability for the malarial prevention and 
control in the respective communities.
Coordination has been done with the D(P)HO Kanchanpur in all phases of planning through 
implementation, monitoring and evaluation of the malaria control activities in the district. This 
has been one of the major reasons for the success of the accomplishment of activities in the 
district. Further realization of the program as their own program by the D(P)HO and
community itself has been another reason for success.
The program has made a considerable contribution in the establishment of malarial
microscopy centers through lab facility support and provision of salary for lab technicians on 
cost sharing basis with the active involvement of the HFOMC which has identified local 
human resources and other income generating services that ensures the ownership,
sustainability and effective operation and management of the centers. Sustainability of labs 
has been the most important issue raised. Providing wide range of services as an increased 
source of income and encouraging communities to utilize the services are the key to 
sustainability.
Community empowerment through advocacy and awareness raising activities has been by 
far the most crucial and effective intervention of the program which has resulted in an
increased attention that malaria is a major public health problem, in most parts of the district, 
is receiving as an issue of public concern. Consequently, community has started to identify 
possible resources and solutions to combating malaria.
Community mobilization through the involvement of school teachers, FCHV and students on 
awareness raising activities has ensured the intensification of the flow of information to large 
audience through less efforts within less time frame.
Community health volunteers such as FCHV and private health workers such as retail drug 
seller can provide first line anti-malarial treatment to patients suffering from
suspected/clinical malaria provided that these workers are adequately trained to do so.
Community-based interventions, particularly, education and trainings to these groups would 
enhance early diagnosis and prompt treatment.
A conducive atmosphere through appropriate encouragement is must for stimulating
partners to initiate support in the intended activities. For health facility-stationed health 
workers like lab assistants and community health volunteers like FCHV, trainings are often 
seen as incentives and a means of motivation. Further, continuous and sustained training 
are effective to enhance greater competency among the trainers. Trainings complemented 
by follow up and supervision at frequent intervals are key to quality services.
Insecticide-treated nets have proved to be the most effective tool to reduce the malarial 
incidence in the district. However, there has been a significant proportion of population, 
particularly pregnant women, who have not yet access to insecticide-treated nets.
Integration of distribution of nets with antenatal check up clinics can ensure that all the 
Malaria Control Program, Kanchanpur 26
pregnant women and children < 5 years receive and use insecticide-treated nets at their first 
clinic.
A large proportion of population has been served by the private sector in the district. Quality 
assurance of the services provided by private labs and an approach to bring them under the 
district health system would have an impact upon the malaria control in the district.
Malaria Control Program, Kanchanpur 27
LOOKING FORWARD
________________________________________
Malaria control program in Kanchanpur has been one of the successful programs of
CSP/NFHP CARE. Since the initiation of the program effective coordination has been done 
with D(P)HO Kanchanpur in all phases of planning through implementation, monitoring and 
evaluation of all malaria control activities. Further, realization that malaria is a major public 
health problem has received an issue of public concern and realization of the program as 
their own program by D(P)HO and communities has been a major reason for success.
However, communities’ participation particularly in planning of new interventions has not yet 
been incorporated well in the program design. 
Though involvement of community through HFOMC has been one step adopted that has 
ensured communities’ responsibility and accountability for the malaria control in respective 
communities, but communities, particularly the one at risk, have not been involved to take 
active part in planning interventions appropriate to address their needs. Emphasis has been 
given to assisting communities rather than seeking their active participation which is very 
often seen as a factor for failure to achieving what have been set out to do, by many 
programs. 
Future actions, therefore, should try to acknowledge the community in all phases of planning 
and program design and support them implement the programs that directly deals with those 
who are most affected. There should be a strategic shift to make prevention and control 
activities gain a civil concern rather than the responsibility of certain organizations. To
combat a long-standing disease like malaria one has to harness local initiatives, local
resources, community mobilization and a sense of ownership among the people who are 
most affected by the problem.
New interventions should identify the success of previous activities and programs and build 
on them. There is no need to reinvent the wheel. The steps to prevent and combat malaria 
have been well recorded in previous programs and activities. It is necessary to augment 
those areas of the strategy that may have reduced its success in the past and to build upon 
the experiences and lessons learned from the past activities. 
Effective interventions against malaria are available, yet the burden persists, largely for 
three reasons—most people at risk of malaria are unaware of interventions; they are unable 
to afford them; or the interventions are inaccessible. A lack of education, information and 
failure to achieve adequate coverage with effective interventions like drugs and insecticide￾treated nets restricts the success of program, especially among the poor and the most 
vulnerable. 
The basic steps that future program to prevent and combat the menace of malaria should be 
built upon are:
Step I: Setting stage
A foundation upon which the individual activities can be built with each activity having broad 
level of implication that goes beyond any individual theme. 
3
Malaria Control Program, Kanchanpur 28
a. Ensuring community participation
Every community has its own realities, its strengths and its limitations. Communities often 
have the knowledge and the will to combat a public health problem like malaria but lack the 
resources and the organizational capacity to sustain the effort. Encouraging communities to 
come up with meaningful ways to be involved with malaria control program should be 
adopted. We should be sensitive to folk health traditions and beliefs about malaria while we 
engage the community leaders in the planning process. It would be important to involve 
women’s groups, youth, village development committees and local community organizations 
from the start. Women and children are the ones who are most susceptible and they need to 
be involved in the planning from the beginning. The interventions to address the community 
needs and the resources needed to fulfill them needs to be identified and prioritized and 
options for developing effective interventions, their delivery and implementation needs to be 
done with the communities using participatory methods such as PLA or PRA. 
Objective: To ensure communities attempt to move away from the unsustainable position of 
being mere recipients of services, resources and development interventions towards being 
active partners, or owners, of the interventions
In order to help communities develop control, partners, particularly I/NGOs
 should 
contribute their knowledge and experience to improving local skills and abilities so 
that the community itself can make decisions and take the actions that they believe 
are essential for their own development. 
The development of plan should ensure: -
· Identification of possible partners, particularly the one that are most affected and the 
local institutions (mothers’ groups, women’s groups, youth groups/clubs and other
community based organizations)
· Communities participate at the inception and planning of new interventions whenever 
possible
· Leadership and planning that ensure the relationship is a cooperative one to minimize 
tension between the community’s role and those of other partners
· Interaction with other partners that build towards sustainable systems
· Decentralized authority and resources 
· Continuous monitoring and evaluation of community activities 
b. Broadening partnership
Partnership is a forum for participants to exchange resources, combine competencies and 
coordinate activities in a productive manner. Partnership includes the sharing of information, 
and the identification of common objectives and goals. Participatory approaches must
therefore build partnerships into the decision-making process at the earliest stages to bring 
about effective and sustainable change.
Objective: To assist communities establish partnership as a collaborative relationship 
between entities to work toward shared objectives through a mutually agreed division of 
labour.
Malaria Control Program, Kanchanpur 29
In order to develop communities identify and support their own community health 
interventions, our role would be to providing technical expertise and financial support 
in training, educating and supervising activities to maintain optimum quality of
service. 
The development of plan should ensure: -
· Identification of partners (private-clinics; NGOs
 and other organizations; government 
organizations; schools and civil societies)
· Fully involve partners from the very beginning of the program development
· Mobilize partners in the implementation of activities through a mutually agreed division of 
labour
· Ensure a proper mechanism to monitor and evaluate partners’ activities
Key issues
· A large proportion of population (an estimated 60 per cent) has been served by the 
private sector in the district. Private service providers as partners in health service
delivery should be brought under the district health system to have an impact upon the 
malaria control in the district.
· Overlapping of various activities both in CARE and D(P)HO as well as other partner
organizations in the district has created difficulty in the implementation of activities due 
to divided manpower and, proper monitoring and supervision cannot be carried out as 
well.
c. Integrating malaria programs with existing community – based interventions (IMCI, 
immunization programs, CDP, Safe motherhood, antenatal services)
Integrated approach that combine malaria control with other health and/or development 
activities that can increase the reach and impact of interventions while optimizing the use of 
human, material and financial resources. Therefore, it is necessary to collaborate with other 
existing programs.
The development of plan should ensure that the malaria control activities are integrated 
appropriately with:
· Safe motherhood antenatal services to ensure the provision and effective use of anti￾malarial drugs and nets, and intermittent preventive treatments (IPT)
· Community drug program (CDP), immunization programs, integrate management of 
childhood illnesses (IMCI) programs and child health services to ensure the provision of 
drugs to children 
Step II: Developing community level intervention channels
The initial phase in community health intervention involves identifying community leaders 
and other key persons in communities as a influential group of people in order to establish a 
community development committee. But if there is an existing health committee (health 
facility management committee, school health management committee, etc.) or other
community groups for it may be possible to strengthen them. 
Malaria Control Program, Kanchanpur 30
In order to develop effective channels for the intervention activities, our
responsibilities would be to decide responsibilities for such committees in
cooperation with partners.
The development of plans should ensure that the committee: -
· Represents all the existing social groups in a community
· Acts as a link between the district and communities
· Equitably resolve issues such as recruitment, remuneration and accountability
· Participate in needs assessment and analysis, as well as in prioritizing interventions.
· Contribute to identification and mobilization of resources, which may include the training 
of recruited health workers and community leaders, as well as the preparation of health 
education materials relevant to their community
Step III: Interventions into action
The weapons to fight malaria exist: medications, insecticide-treated mosquito nets and other 
materials, safe and effective insecticides, spraying equipment, tests to diagnose the
disease. But these weapons are useless if they do not reach those who need them. 
Affordable and accessible prevention and treatment measures are a key requirement for 
malaria control. Therefore, it is necessary to combine both prevention and cure strategies. 
The objectives of the intervention at community level should include:
· To improve recognition of malarial illness and provision of appropriate treatment by
caregivers within 24 hours of onset of illness;
· To strengthen the capacity of health systems, particularly at the periphery, so as to 
support community level actions, including access to anti-malarial drugs and referral 
mechanisms;
· To improve health-seeking behaviour of caregivers, family and community so they can 
recognize signs of severe illness and seek appropriate care quickly when referral is 
indicated;
· To improve access to insecticide-treated nets, and to promote their regular and proper 
use and re-treatment;
· To promote intermittent preventive treatment for pregnant women, particularly in areas of 
intense malaria transmission; and
· To promote vector control, including environmental management wherever appropriate.
a. Conducting health education
Raising awareness, in the communities, of the disease first and then its cause, the
communities will be able to incorporate preventive measures into local action. Knowledge 
also allows community to be aware of the presence of malaria, access early and effective 
treatment and effective. For this a number of trained health personnel would be required to 
lead the initiative. They need to be trained in the comprehensive community based malaria 
control strategy and they in turn would train the community health volunteers. The
volunteers would disseminate the information through community meetings, home visits and 
school health education. 
The behavioural change intervention through health education should ensure:
Malaria Control Program, Kanchanpur 31
· Social mobilization as key tool for awareness raising activities to mobilize civil society, 
communities and partners 
· Mobilization of trained volunteers, particularly, school teachers, FCHV and students 
· Community-based interventions, particularly, education and trainings to private health 
workers such as retail drug seller as a first line anti-malarial treatment providers and 
Mothers are the primary care takers of families, particularly of small children under five 
years of age
Key issues
· Mothers are the primary care takers of families, particularly of small children under five 
years of age. Behavioural change interventions aimed directly at this group would be a 
beneficial approach. Behavioural change strategy to mobilize FCHV through mothers’ 
groups to reach this group would ensure the achievement.
· Communities’ perception about the quality of services provided through governmental 
lab facilities have been the most important factor in the low utilization of the services 
provided through these labs. An approach to changing communities’ perception for
increasing the utilization of these services is essential. 
b. Capacity building
Capacity building initiatives to improve clinical care in health facilities should be increased
for both the providers and consumers. It is necessary to train health service providers as 
well as communities, particularly the primary caregivers and first line of contact for treatment 
to recognize the symptoms of malaria and to treat it with the appropriate medication, 
especially if they live far away from the nearest health institutions.
Key issues
· Initial and reinforcing training should be continued by follow-up, supervision and support.
· A significant proportion of the population is served by the private sector. So quality 
assurance of the services provided by the private sectors through appropriate trainings 
and necessary supervision and guidance is essential. For this, it is necessary to bring 
them into district health system.
c. Strengthening the management and coordination of community based malaria
control activities 
By empowering local health committees to identify and address issues related to malaria 
prevention and control and incorporate them into the plan, manage and evaluate malaria 
prevention and control activities issues are at the health facility level. For this necessary
interaction and technical supervisory visits should be provided by the district health system 
and I/NGOs
.
Key issues
· Sustainability of lab services has been by far the most important issue raised after its 
establishment. The active members of HFOMC and their active participation to seek 
ways for sustaining lab service is a key to its sustainability. Therefore, strengthening 
Malaria Control Program, Kanchanpur 32
HFOMC for identifying ways of sustaining labs and coordinating with district line
agencies and development partners for support would be an important approach.
· Follow up of the training and supervision from the district and higher concerned authority 
from time to time to provide guidance to ensure improved competency and quality of 
services provided and motivation of the staffs should be strengthened.
d. Delivering malaria control services
Net culture: Mosquito nets, if used properly, are one of the best ways to prevent
mosquitoes from biting people and infecting. They are simple, safe and cost-effective. It has 
been shown that high levels of insecticide-treated net coverage can reduce deaths in 
children and pregnant women. Therefore, a net culture should be established to promote the 
vigorous use of insecticide-treated nets especially among the young children and pregnant 
women. Wide publicity and promotion are first steps. Another way to ensure that insecticide￾treated nets are used and retained by the population at risk is to subsidize the price so the 
nets are affordable.
Key issues
· The nets are usually inadequate to reach the entire target group in a specified time and 
costs, even subsidized through social marketing schemes, are high for the community to 
afford. As far as possible the insecticide-treated nets should be distributed free of cost, 
but if some charge is to be imposed upon it then the ability of the poorest families should 
be considered. 
· Ordinary nets are available at almost all the households. By treating the nets with an 
insecticide (pyrethroid) enhances the protection as the chemical produces a barrier even 
beyond the net and protects the persons in the vicinity. A new treatment every six
months keeps the chemical working. The intervention activities related to the treatment 
and re-treatment of the nets would, therefore, assure that the households not distributed 
the insecticide-treated nets also benefit from the treated nets.
· Social issues are likely to affect the use of insecticide-treated nets and distribution 
programs, particularly, free-distribution should address this issues appropriately while 
planning for the distribution 
· The households that were provided the insecticide-treated nets when not oriented 
properly about it have impact on its effective use. Orienting properly on insecticide￾treated nets promotes positive attitude towards its use. The distribution program should, 
therefore, properly orient all the households provided the insecticide-treated nets on it for 
its universal and effective use. Further mobilization of the health workers and the health 
volunteers, particularly, FCHV would be the most effective approach.
Indoor residual spraying as a major vector control strategy: Vector control is a 
cornerstone in preventing malaria. Indoor residual spraying – to spray the inside of people’s 
houses with insecticide to kill mosquitoes, is one of the most effective interventions of vector 
control. Indoor residual spraying in specific situations (epidemic-prone areas) should be a 
promoted. 
Case-management: Ensuring that the community has good access to prompt diagnosis 
and effective treatment of malaria is key to success. For this health facilities will require 
improvement of their laboratory services and a regular supply of the best anti-malarial drugs. 
Chloroquine is now an effective drug against malaria, particularly for the vulnerable
Malaria Control Program, Kanchanpur 33
population groups such as children with acute fevers. Even better are the artemesinin-based 
combination therapies (ACT). Pregnant women another vulnerable group, intermittent
preventive treatment (IPT) using sulfadoxine-pyrimethamine (SP) at pre-defined intervals 
during pregnancy has proved efficacious in reducing the incidence of malaria, anemia and 
low birth weigh. An effective mechanism to administer these services should be ensured.
Key issues
Lab services and supply of appropriate anti-malarial drugs are all too often not widely known 
by local communities and not widely available or used.
· Lab services are not provided at all the health facilities. In order to ensure the malaria 
control services are provided to the entire community the alternate to these services 
should be sought. Rapid tests are now available that can quickly diagnose malaria. 
These services should be provided at these facilities devoid of lab services.
· The regular supply of Chloroquine is very often interrupted. So, integration of the malaria 
control activities with community drug program (CDP) would ensure the availability of the 
drugs.
· Intermittent preventive treatment for pregnant women’s is not very much given attention 
which should be integrated very much with the safe-motherhood and ante-natal services.
e. Strengthening the district capacity
As a responsible autonomous body of national health system, the district health system can 
play an essential role in guiding inexperienced communities, at the beginning of a program. 
In order to ensure that community-based activities are supervised, guided and assured of 
quality our role would be to provide technical expertise, information and financial resources 
to the district health system.
The development of plan should ensure the district health system: -
· Facilitate cooperation between the partnerships working in the district 
· Provide correct technical guidance in the use of tools and services for malaria prevention
and treatment at community level; correct messages are being given to communities in a 
consistent manner; adequate personnel and resources for such duties are available 
· Begin district planning activities by reviewing:
- The availability and quality of health care in public and private sectors
- Information provided by previous studies on key family health practices from district 
health service data, including demographic health surveys, knowledge, attitude and 
practice studies, ethnographic studies, etc.
- Any existing community-oriented communication materials from IEC units, NGOs, 
etc.
- The support systems for supervision, transport, distribution of drugs and insecticide￾treated nets.
- Community-level resources such as village health committees, women’s groups,
religious groups, community financing schemes, etc.
- The sources of funding, costs and budget implications.
Malaria Control Program, Kanchanpur 34
Step IV: Monitoring and evaluation 
Monitoring and evaluation of the impact of malaria control activities and strategies, and 
continuous assessment and modification of strategies to achieve maximum impact, should 
be integral components of disease control operation. As communities take more
responsibility for malaria control it is necessary that they are able to measure the success of 
their actions. By regularly monitoring key indicators in the community they will obtain
evidence-based information upon which to make decisions. This will also allow the
community to evaluate the effectiveness of their programs and improve their capacity. 
The key indicators include: 
· Number of households with insecticide-treated nets 
· Number of malaria cases treated within 24 hours of symptoms
· Overall reduction of incidence and mortality of malaria
· Cooperation with district management and other partners, personnel and the use of 
funds
Objective: To ensure communities monitor their own resources, including materials and 
finance, and the performance of the health workers in the community.
In order to ensure strengthened community self-monitoring and decision-making, our role 
would be to provide continuous monitoring and appropriate feedback as necessary. 
Recommendation for further studies
· A study to assess the impact of the LLIN on data concerning anemia in the mothers, 
premature births, stillbirths, incidence of underweight among newborns, morbidity of 
childhood malaria (< 5 years of age) and cut all-cause child mortality is recommended
· Absence of data regarding the prevalence of malaria among pregnant mothers and
children has been one of the major handicap in assessing the situation and impact of the 
interventions. So, a prevalence study to determine prevalence of malaria among
pregnant women and children (under age five) should be carried out. 
For this, the data can be obtained from the current malaria register of the district which if 
properly maintained could give an exact situation of the malaria prevalence among pregnant 
mothers and children (< 5 years) in the district. So, the proper maintenance of the register is 
crucial for the assessment and it must be ensured. The monthly monitoring review of data 
for malaria at the district with the health facility staffs responsible for recording and reporting 
would ensure the timely and quality data.
Money alone cannot solve the problem – fighting malaria requires commitment from affected 
communities, stakeholders and country as well as coordination among all stakeholders. 
Therefore, it is essential to continue advocacy campaigns to raise awareness of malaria at 
all levels so that malaria control is incorporated into all health and development policies, 
strategies and programs, thus keeping malaria high on development agenda, mobilizing 
resources for malaria control and for research into new and more effective tools, and 
ensuring that the vulnerable individuals are the key participants in malaria control activities.
Malaria Control Program, Kanchanpur 35
Terms and concepts
Advocacy — A continuous and adaptive process of gathering, organizing and formulating 
information into argument, with a view to raising resources or gaining the acceptance and 
commitment of political and social leadership to a development program, thereby preparing 
a society for its acceptance.
Clinical malaria — A person from malaria endemic area with fever or history of fever during 
last three days is considered as a cause of clinical or suspected malaria after the exclusion 
of other causes of fever.
Community — A group of people with common interests and fellowship living in the same 
local area (i.e. more intimately involved than at either district or regional areas).
Community participation — The active involvement of people living together in some form 
of social organization and cohesion in the planning, operations and evaluation of a program 
using local, national and other resources. It is a process through which communities 
ultimately influence and share control over the development, local initiatives, decisions and 
resources of projects (e.g. malaria control) that directly affect them.
Community ownership—Community participation that has been developed to increase 
people’s sense of control over issues that affect their lives.
Community-based organizations—Local organizations functioning at grassroots level.
Participatory learning and action (PLA)—A community development approach whereby 
facilitators work with communities to help them analyze their needs, identify solutions to fill 
those needs, and develop and implement a plan of action. PLA is based on many different 
participatory approaches, including participatory rural appraisal (PRA), rapid rural appraisal 
(RRA), and applied anthropology.
Participatory rural appraisal (PRA)—A way of learning from and with community members 
while investigating, analyzing and evaluating locally based development projects. It is a 
method by which a trained team can quickly and systematically collect information for the 
general analysis of a specific
development intervention (e.g. needs assessments, feasibility studies) in non-literate rural 
communities.
Social marketing—An approach using marketing techniques to promote and distribute 
socially beneficial interventions rather than commercial products.
Social mobilization—A process of bringing together all interested inter-sectoral partners 
and allies to determine felt needs and raise awareness of and demand for a particular 
development objective. It involves enlisting the support of all stakeholders, including
institutions, groups and communities, in identifying, raising and managing human and
material resources, thereby increasing and strengthening participation for self-reliance and 
sustainability of achievements. 
Malaria Control Program, Kanchanpur 36
References/Bibliography
CSP/NFHP CARE, Malaria microscopy training, Kanchanpur, May 16 – 22, 2006
CSP/NFHP CARE, Orientation program for FCHV on malaria, Kanchanpur, June 2006 
CSP/NFHP CARE, School health education program, Kanchanpur, May-June 2006
CSP/NFHP CARE, Use of long lasting insecticide-treated nets (LLIN): a follow-up study of 
LLIN in Kanchanpur district of Nepal, Kanchanpur, April 2006
International Labour Organization, Lessons learned for the Time Bound Program, 
Kathmandu, June 2001
Roll Back Malaria Partnership Secretariat, Looking forward: Roll Back Malaria
Roll Back Malaria Monitoring and Evaluation: Afghanistan country profile, April 2005
UMCOR Health Ministries, A proposal on community based malaria control 
United Nations Development Program/World Bank/World Health Organization, TDR 
strategic direction: Malaria, February 2002
Malaria Control Program, Kanchanpur 37
Annex I: List of acronyms
ACT : Artemesinin–based Combination Therapies 
AHW : Auxiliary Health Worker 
ANM : Auxiliary Nurse Midwife 
CBS : Central Bureau of Statistics
CDP : Community Drug Program 
CPD : Core Program District 
CSP : Child Survival Project 
DDC : District Development Committee 
DoHS : Department of Health Service 
D(P)HO : District Public Health Office 
EDPT : Early Diagnosis and Prompt Treatment 
FCHV : Female Community Health Volunteer 
FP/MCH : Family Planning/Maternal and Child Health 
GFATM : Global Fund For AIDS, Tuberculosis and Malaria 
GMCS : Global Malaria Control Strategy
HFOMC : Health Facility Operation Management Committee 
HMG/N : His Majesty’s Government of Nepal
HMIS : Health Management Information Service 
ID : Infectious Disease 
IEC : Information, Education and Communication
IMCI : Integrated Management of Childhood Illness 
I/NGO : International/Non-Governmental Organization 
IPT : Intermittent Preventive Treatment 
IRS : Indoor Residual Spraying
ITN : Insecticide Treated Net 
LLIN : Long Lasting Insecticide Treated Net 
MCHW : Maternal and Child Health Worker 
NFHP : Nepal Family Health Program 
NMCP : National Malaria Control Program 
OPD : Out Patient Department 
PCD'V' : Passive Case Detection 'Volunteer' 
PDQ : Partners’ Defined Quality 
PHC : Primary Health Care 
PLA : Participatory Learning and Action 
PRA : Participatory Rural Appraisal 
PSI/Nepal : Population Services International/Nepal 
RBM : Roll Back Malaria 
RRA : Rapid Rural Appraisal 
RTI : Research and Training Institute 
S/HP : Sub/Health Post
SP : Sulfadoxine-Pyrimethamine 
TSV : Technical Support Visit 
USAID : United States Agency for International Development
VDC : Village Development Committee
VHW : Village Health Worker
 WHO : World Health Organization
Malaria Control Program, Kanchanpur 38
Annex II: District map 
Annex III: Scope of Work for Malaria Control Program in Kanchanpur
Background:
Nepal Family Health Program is a USAID project to support His Majesty's Government of 
Nepal in its long-term goal of reducing fertility and under five mortality. CARE Nepal, as a 
collaborating partner of NFHP, is implementing the activities in seven of seventeen Core 
Program Districts (CPDs) in close coordination with District (Public) Health Offices 
(D(P)HO). The major objective of the program is to support/assist D(P)HOs toto increase the 
availability, accessibility and quality of the basic package of FP/MCH services at household 
and community level. Nepal Family Health Program is also supporting D(P)HOs for vector 
borne disease control program in selected CPDs (Dhanusa, Mahottari and Kanchanpur). 
Rationale:
Kanchanpur is the malaria endemic Terai district of Far West Nepal. Despite different efforts 
from governmental and non-governmental sectors, Kanchanpur covers about half of the total 
malaria cases in the country, though the annual incidence of malaria has decreased over the 
last two years. Due to the high prevalence of malaria cases in the district, the government 
system is not being able to provide adequate services to the community through its existing 
infrastructure and facilities. Thus, CARE-NFHP has decided to support the Kanchanpur 
District Public Health Office to deliver better quality health services and to improve 
community access to malaria microscopy, prevention and control facilities through health
facilities, and female community health volunteers. This component will also be a 
complementary to efforts of child survival in addressing the felt need of communities to 
protect the mothers and young children from the malaria related problems 
To respond to the burden of malaria in Kanchanpur, CARE Nepal has supported to establish 
three malaria microscopy centers in addition to three centers functioning under the 
government infrastructure. In addition, CARE Nepal is also supporting the Health Facility 
Operation and Management Committees to run and strengthen these centers through human 
resource support since its establishment to date and planning to handover the roles to the 
HFOMCs on cost sharing basis from June 2006 and completely from Dec 2006. The 
component will help give continuity to the above efforts and also to expand the provisions to 
few more health facilities so that the District Health office can work for the possible 
prevention and control of malaria related issues in a systematic manner.
Activities:
CARE/NFHP, in close coordination with District Public Health Office, Kanchanpur will 
provide support for following activities: 
1. Provide support to establish three new malaria microscopy sites (Krishnapur, Pipladi, 
and Suda VDCs), in addition to currently operating three sites (Jimuwa, Daijai, Jhalari 
and Tribhuvanbasti) in of Kanchanpur
Provide support for one laboratory technician for seven malaria microscopy centers 
established by CARE-NFHP (i.e. Jimuwa, Daijai, Jhalari, Tribhuvanbasti, Krishnapur, 
Pipladi, and Suda) on cost sharing basis.
The project will cover the full cost of the lab technician in all seven Malaria microscopy 
centers until June 2006. From July to Decemebr 2006, the project will contribute 50% of 
Malaria Control Program, Kanchanpur 40
the cost, and the HFOMCs will cover 50% of the cost. From January 2007, it is expected 
that the HFOMC will take up all the responsibility of covering the entire cost of lab 
operation. NFHP will reimburse the cost of salary provided to laboratory technicians in 
currently operating four malaria microscopy clinics for the period of January 2005 to 
Nov 2005. 
This support will help to improve the community access to malaria microscopy services; 
early diagnosis and proper treatment, and thus help to control the malaria problem in the 
district.
2. Conduct malarial microscopy training (about a week long) for three newly recruited 
laboratory technicians in coordination with NFHP ID Coordinator. This will enable the 
technicians to provide quality check-ups of malarial slides.
3. Carryout two days orientation for all FCHVs of Kanchanpur on community initiatives 
for malaria prevention and control. This will help update their knowledge on malaria and 
to motivate them to mobilize communities for malaria control.
4. Carryout two days orientation for sixty school teachers and thirty five health staffs from 
health facilities and District Public Health Office to improve their knowledge on malaria 
prevention and control.
5. Carryout school health program in sixty schools of Kanchanpur district for secondary 
level students to improve their knowledge on malaria prevention and control.
6. Carryout LQAS Survey (38 clusters X 19 sample) to assess community knowledge on 
malaria causation, prevention and treatment. This survey result will provide in-depth 
knowledge on the level of awareness among the people of Kanchanpur and will help to 
take appropriate strategies to overcome the existing barriers for malaria control.
7. Conduct follow-up study on use of Insecticide Treated Nets (ITNs) distributed by 
Global Fund to monitor the practice of using ITNs and its impact on malaria control.
8. Support NFHP in developing and implementing an accreditation system of private 
malaria microscopy clinics based on their accuracy on microscopy results of malaria 
slides, which will help to monitor the quality of malaria microscopy services from private 
clinics and to encourage/recognize those providing quality services.
9. Support District Public Health Office Kanchanpur in coordinating, implementing and 
monitoring malaria control program 
10. Prepare a final lessons learned document on malaria control initiatives in Kanchanpur.
Program management:
One Malaria Control Officer will be locally hired to oversee overall vector borne disease 
control program of District Public Health Office Kanchanpur but will also support in other 
family health activities ongoing in the district. The Malaria Control Officer will be based at 
District Public Health Office and will report to District Public Health Administrator and 
District Health Coordinator, Child Survival Project, Kanchanpur. He/She will work closely 
with Malaria Inspector, other district supervisors as well as Asst M&E Officer and NFHP 
Field Officer.
Malaria Control Program, Kanchanpur 41
The Child Survival Project will provide technical and backstopping support to the Malaria 
Control Officer, as and when required basis and the CARE-NFHP Project Manager will 
provide managerial support to the Malaria Control Officer. CARE Nepal Country Office, in 
coordination with NFHP Central Office will provide technical, monitoring and supervisory 
support to the team to carryout malaria control activities.
Regular progress updates will be shared with NFHP Field Coordination Unit and reported on 
the Semi Annual Report of CARE NFHP.
Expected Result:
ß Increased malaria case identification and better management of malaria cases through 
FCHVs and health facilities in Kanchanpur
ß Increased awareness among community people on ways of malaria prevention and 
control in Kanchanpur leading to early diagnosis and proper treatment.
ß Strengthened capacity of District Public Health Office to have effective management of 
vector borne diseases, especially malaria in the district.
ß Effective management system of malaria and other vector borne diseases control 
program in District Public Health Office in Kanchanpur
ß Reduced incidence of malaria related illness among the population of Kanchanpur.
Budget Summary:
The total budget for malaria control program will be US$ 27,400.00 (NRs 1917972.00). The 
detail breakdown of the budget has been shown in the annex.
Malaria Control Program, Kanchanpur 42
Annex: Budget
Activity Unit Quantity Rate Total NRS Remarks
Establishment of lab facility
Furniture 
Glassware
site
site
3
3
13000
15000
39,000
45,000
Strengthening lab facility
Salary (Jan 05 - Jun 06) - 100%
Salary (Dec 05 - Jun 06) - 100%
Salary (Jul 06 - Dec 06) - 50%
person month
person month
person month
4 X 18
3 X 7
7 X 6 
5000
5000
2500
360,000
105,000
105,000
Malaria Microscopy Training
Participants Allowance
Facilitator Allowance
Travel cost
Stationary and Refreshment
person
person
LS
LS
3 X 7days
2 X 7 days
--
--
300
500
10,000
5,000
6,300
7,000
10,000
5,000
FCHV Orientation on Malaria
Participant Allowance
Facilitator Allowance
Stationary and Refreshment
Misc (hall rent, helper)
person
person
events
events
833 X 2 days
80 X 2 days
40
40
150
500
3500
1500
249,900
80,000
1,40,000
60,000
School Health Program on malaria 
prevention and control 
Facilitator Allowance
IEC Materials 
Travel
Misc (hall rent, helper)
person
events
events
events
5 X 60
60
60
60
300
1000
3000
500
90,000
60,000
180,000
30,000
Orientation Program 
Facilitator Allowance
Participant Allowance
IEC Materials 
Travel
Misc (hall rent, helper)
person
persons
events
events
events
2 X 5X 2
95 X 2 days
5
5
5
800
400
10000
3000
1000
16,000
76,000
50,000
15,000
5,000
LQAS Survey on community
Enumerators allowance
Supervisor allowance
Questionnaire printing
Travel
Analysis and report writing
person days
person
LS
LS
LS
120
20
--
--
--
400
500
10000
10000
10000
48,000
10,000
10,000
10,000
10,000
Follow-up study on use of ITN
Enumerators allowance
Supervisor allowance
Questionnaire printing
Travel
Analysis and report writing
person days
person
LS
LS
LS
40
10
--
--
--
400
500
5000
3000
5000
16,000
5,000
5,000
3,000
5,000
Private lab accreditation scheme
Allowance for supervisor
Travel
Format development & printing 
person 
LS
LS
5
--
--
500
5000
5000
2,500
5,000
5,000
Compilation of lesson learned document 
on malaria control initiatives on KPur
LS -- 50000 50,000
Indirect cost @ 7.83% 139, 272
Total 1,917,972
D:\Deepak\NFHP\Malaria Control\Malaria Control Program in Kanchanpur_SOW 22 Nov 05.doc
CHILD SURVIVAL SUSTAINABILITY ASSESSMENT (CSSA) 
Child Survival Project, Kanchanpur 
CARE Nepal
 
Concept 
Sustainability is an intangible concept and a term without common definition. 
Different people define sustainability in different ways. The Oxford dictionary 
defined sustainability as ‘cause to continue or be prolonged for an extended 
period or without interruption’. 
In simpler term, in context of child survival project, sustainability can be defined 
as positive health outcomes in maternal and child health situation, even after 
project input cease or decrease. Positive health outcomes can have no real 
impact on children’s health, development and well being unless they are 
maintained over time; even if and when external assistance is reduced. In 
summary, sustainability can be understood as: 
- institutionalization of project efforts 
- population level impact through project efforts 
- community ownership on project efforts 
- multi-sectoral system level impact of project efforts 
These other definitions have included— 
● Institutionalization of strategies and practices in local organizations, often 
MOH structures or local NGOs; 
● Financial support for the continuation of activities, through cost-recovery and 
business development strategies; 
● Empowering communities, for instance to implement essential health 
activities or manage and oversee health committees; 
● Improving the supply and demand cycle for care services, by combining 
quality improvement efforts with cost-recovery schemes; 
● Development that meets the needs of the present without compromising the 
ability of future generations to meet their needs (i.e., “ecologically 
sustainable development”).1
The concept of Sustainability covers following issues in context of Child Survival 
Project 
 
1
 World Commission on Environment and Development (“Brundtland Commission”), United Nations, 
1987. 
Child Survival Sustainability Assessment of Child Survival Project, Kanchanpur Page 1 of 11 
• Improved health outcomes is what we seek to sustain (programs, 
activities, and institutions are merely means to accomplish that goal in a 
changing and complex environment). 
• Who owns tomorrow? Think in the local system, and work with others to 
complement, not compete. 
• Plan for sustainability now (ideally at the beginning of a project)! 
• Be accountable. Define contextually realistic objectives with your partners. 
• Assess in order to know where you start, and evaluate to show how far 
you have gone. Monitor progress along the way. 
• Find synergies between areas of intervention. 
• Balance process and results. 
Project Overview 
CARE Nepal implemented Child Survival project in Kanchanpur district since 
October 1999. The first phase of the project (CS XV, Oct 99 - Sept 03) was 
focused on intensive implementation of the project activities based on the 
framework of community based integrated management of childhood illness. The 
progress of the first phase of the project was remarkable and thus the second 
phase of the project (CS XIX, Oct 03 – Sept 07) was awarded to CARE Nepal for 
extending program impact to additional three districts of far west Nepal. 
Currently, CARE Nepal in close collaboration and coordination with District Public 
Health Office, Kanchanpur is implementing activities with an aim of sustained 
health impact in health, development and wellbeing of children in Kanchanpur, 
that was gained during the first phase of the Child Survival project. 
Dimensions of sustainability 
Sustainability in Child Survival projects is a contribution to the development of 
conditions enabling individuals, communities, and local organizations to express 
their potential, improve local functionality, develop mutual relationships of 
support and accountability, decrease dependency on insecure resources 
(financial, human, technical, informational), in order for local stakeholders to 
negotiate their respective roles in the pursuit of health, development and 
wellbeing, even beyond a project intervention. 
Every project operates in the local system comprising 
the individuals, groups, communities, local 
organizations and the environment on which they 
operate. These elements of local system are 
coordinated and linked through social actions and 
interactions and affecting the health of individual and 
community at large, either positively or negatively. 
Thus, there are three distinct dimensions of 
sustainability in context of Child Survival Project, 
Child Survival Sustainability Assessment of Child Survival Project, Kanchanpur Page 2 of 11 
namely i) health outcomes, ii) organizational capacity, and iii) enabling 
environment. 
Measurement of sustainability remained a big question in the development arena 
since a long time. In fact, measurement of sustainability is problematic, as this is 
an intangible concept. Sustainability is not only difficult to measure, but is quite 
unpredictable most of the times. The complexity of models, the multi-factoral 
nature of sustainability, and the practical difficulty of measuring post-intervention 
outcomes on various dimensions have constrained measurement of sustainability 
of development efforts. 
Though sustainability is difficult to measure, the Child Survival Collaboration and 
Resource (CORE) Group, Child Survival Health and Grants Program (CSHGP) and 
Child Survival Technical Support project (CSTS) have worked collaboratively to 
develop a system to measure sustainability of child survival project being 
implemented through various Private Voluntary Organizations (PVO). The 
framework, named as Child Survival Sustainability Assessment (CSSA) framework, 
has been used in various Child Survival projects being implemented through 
different PVOs and found fruitful in monitoring progress towards sustainability 
and to take appropriate actions on timely manner to drive the project towards 
sustainability. 
Methodology 
With the support of CSTS, encouragement from the local USAID mission and 
technical assistance of New Era, CARE Nepal decided to apply the CSSA 
framework in Kanchanpur district. Thus a list of possible indicators were selected 
in consultation with the project team and shared with CSTS and other PVOs 
during the CSSA orientation workshop in Kathmandu. Based on the feedback and 
suggestion from them, a final list of indicators was prepared. 
During the month of May 2006, CARE Nepal, Child Survival Project Organized 
two days workshop at Mahendranagar, Kancahnpur in presence of local 
stakeholders (CS project, District Public Health Office, District Development 
Committee, Mahendranagar Municipality, Female Community Health Volunteers, 
local NGO partners, and media). 
The Objectives of the CSSA Workshop in Kanchanpur was: 
- To orient district level Child Survival stakeholders on the concept of program 
sustainability in context of Child Survival Projects 
- To review project progress in context of program sustainability based on 
Child Survival Sustainability Framework 
- To build common understanding on improving program sustainability in 
context of Child Survival Project in Kanchanpur 
Child Survival Sustainability Assessment of Child Survival Project, Kanchanpur Page 3 of 11 
The workshop participants had interactive discussion on the short listed 
indicators and indicator value. The some of the indicators were modified, added 
and discarded as suggested by the workshop participants. Then, based on the 
final list of indicators, indicator value was score value was calculated in presence 
of all stakeholders. Data for such indicator value was obtained from different 
data source already available (e.g. LQAS, HMIS, LMIS etc). For some of the 
qualitative indicators, data value and score value was calculated through 
interactive discussions with participants. Finally, the score was plotted on the 
sustainability dashboard and presented in the plenary. The plenary analyzed the 
dashboard and conclusion was drawn. 
At the end, role of different stakeholder for sustaining the project impact was
discussed. All participants expressed their commitment to support and act in line 
with sustainability based on the exercise. 
How the Child Survival project, Kanchanpur is moving towards 
sustainability?
Local system:
Participatory exercise was carried out to identify local context in context of Child 
Survival Project. The stakeholders were identified in relation to their role and 
influence in the overall goal of the project. 
HFs
Local system
CSP
Kanchanpur Kanchanpur
DPHO KPur
FOLD
(LNGO)
FCHV-CC
(CBO)
Communities
DDC
RHD
RHTC
SSA
(LNGO)
SC US
(EDP)
NFHP/JSI
(EDP)
MNagar
Municipality
HFOMC
(CBO)
WDO
FCHV
Child Survival Sustainability Assessment of Child Survival Project, Kanchanpur Page 4 of 11 
Fig: Mapping the local system of Child Survival Project, Kanchanpur 
Vision:
“All women and children in Kanchapur will be healthy and prosper and will 
survive with wellbeing and dignity” 
Child Survival Sustainability Assessment of Child Survival Project, Kanchanpur Page 5 of 11 
Indicators:
Components Dimension/Elements Source Measured 
value 
Score 
value 
Remarks 
Health Outcomes 
Percentage of births attended by skilled personnel LQAS 31 41 
Percentage of under six months children exclusively breastfed LQAS 70 73.3 
Percentage of sick children receiving increased fluid and 
continued feeding during illness 
LQAS 89 89 
Percentage of underweight children (based on weight for 
age) 
Nutrition 
survey
20 70 
Health Services 
Health facilities with separate place for ANC and PNC 
maintaining privacy 
Discussion 60 60 
Health facilities having adequate stock of Cotrim NFHP TSV 
Data 
98 98 
Percentage of health workers treating pneumonia with Cotrim HWS 56 56 
Percentage of health workers able to correctly diagnose 
pneumonia case based on respiratory rate 
HWS 33.8 34 
Health and 
Health 
Services 
Percentage of FCHVs having four key commodities (ORS, 
Cotrim, Condom, Pills) available 
NFHP TSV 
Data 
63 63 
Organizational capacity 
Percentage of health workers received CB-IMCI training Training 90 80 
Health facilities having functional community drug program 
(updated register, income-expenditure, transparency, decision making 
etc)
Discussion 4 80 
Percentage of health facilities having Supervision and 
Monitoring Plan 
Discussion 30 20 
Percentage of health facilities having annual plan of action Discussion 20 13.3 
Organizational viability 
Extent to which HFOMC meetings are regular and decisions 
are implemented 
Discussion 3 40 
HFOMCs receiving cash or in-kind support from external 
agencies 
Qualitative 
survey
4 80 
Health facilities having own plan of action and implemented 
activities with their own initiation 
Qualitative 
survey
2 40 
Organizational
FCHVs facilitating regular meeting of mother groups to 
discuss on maternal and child health issues 
Qualitative 
survey
4 80 
Community Capacity 
Percentage of mothers group meeting regularly to discuss on 
health issues 
Qualitative 
survey
4 80 
Capacity of HFOMC to analyze local context, issues, need and 
capacity 
Discussion 1.5 30 
Capacity of FCHV Coordination committee to implement local 
level health awareness activities 
Discussion 2.5 50 
Capacity of local groups to discuss, analyze local issues on 
equity and social justice 
Discussion 4 80 
Extent of cooperation, cohesiveness and social harmony in 
community groups 
Discussion 3.5 70 
Enabling Environment 
Percentage of health staff positions filled AR, FWRHD 100 80 
Extent to which project activities has been disturbed by 
conflict 
Discussion 2.5 50 
Community 
and 
Environment 
Capacity of local NGO partners to carryout child survival 
activities 
Discussion 3 60 
Child Survival Sustainability Assessment of Child Survival Project, Kanchanpur Page 6 of 11 
Dash Board:
Fig 1: Sustainability Dashboard of CARE Nepal, Child Survival Project, Kanchanpur 
CARE Nepal, Child Survival Project (CS XIX), Kanchanpur 
'Sustainability Dashboard'
0
20
40
60
80
100
Health Outcomes
Health Services
Community Capacity
Enivronment
Organization Capacity
Organization Viability
Conclusion 
Based on the analysis of the dashboard, following actions are recommended for 
moving Child Survival project, Kanchanpur more towards sustainability. 
• The progress of the project towards health outcomes, health services and 
community capacity was found encouraging. 
• Efforts should be made to ensure that the progress made on health 
outcome, health services and community capacity be sustained over the 
period of time. 
• For the remaining period, project should focus on strengthening systems 
to improve organizational capacity, organizational viability and enabling 
environment. For this, project should identify actors that have roles on 
creating enabling environment and to strengthen organizational viability 
and mobilize them for sustainable health outcomes. 
Child Survival Sustainability Assessment of Child Survival Project, Kanchanpur Page 7 of 11 
• Project should regularly monitor its progress based on the CSSA 
framework and take appropriate actions. This system should be 
institutionalized within district public health system. 
References 
Sarriot, E. Sustaining Child Survival: Many roads to choose, but do we have a 
map?, CSTS/CORE, Sept 2002. 
CARE Nepal, Child Survival in Kanchanpur district Nepal, Final Evaluation Report, 
December 2003. 
Sarriot, E. et. al. Qualitative research to make practical sense of sustainability in 
primary health care projects implemented by non-governmental organization. Int 
J Health Plann Mgmt 2004; 19: 3-22. 
CSTS. Lessons learned from applying the Child Survival Sustainability Assessment 
(CSSA) framework to seven Maternal and Child Health Projects. Sept 2004. 
 
Child Survival Sustainability Assessment of Child Survival Project, Kanchanpur Page 8 of 11 
CARE Nepal and District Public Health Office Kanchanpur 
Child Survival Sustainability Assessment Workshop 
28-29 May 2006 
Mahendranagar, Kanchanpur 
----------------------------------------------------------------------------------------------------------- 
Objectives: 
- To orient district level Child Survival stakeholders on the concept of program sustainability in 
context of Child Survival Projects 
- To review project progress in context of program sustainability based on Child Survival 
Sustainability Framework 
- To build common understanding on improving program sustainability in context of Child 
Survival Project in Kanchanpur 
----------------------------------------------------------------------------------------------------------- 
Agenda: 
Day I, Sunday 28 May 2006 
Time Agenda Responsible
10.00 – 10.15 Introduction, Objectives and Agenda sharing KPur
10.15 – 11.00 What is Sustainability and Program Sustainability? R Sharan 
11.00 – 1.00 Child Survival Sustainability Assessment Framework Jagat
• Framework sharing 
• Indicator transformation (concept and process) 
• Experience of other PVOs and other countries 
• CSSA Frame: “What it is?” and “What it is not?” 
• Usefulness of applying CSSA Framework
• Challenges and constrains 
1.00 – 2.00 LUNCH BREAK 
2.00 – 2.30 Brief review of Child Survival Project CSP RO
• Goal and Objectives 
• Strategic approach 
2.00 – 4.30 Applying CSSA in context of CSP Kanchanpur Deepak
• Identifying and defining local context 
• Visioning Exercise for Child Survival in Kanchanpur 
4.30 – 5.00 Wrap up and Summarization 
Child Survival Sustainability Assessment of Child Survival Project, Kanchanpur Page 9 of 11 
Agenda: 
Day II, Monday 29 May 2006 
Time Agenda Responsible
10.00 – 10.15 Review of Day I Notetaker
10.15 – 11.00 Indicators for measurements R Sharan 
• Indicator sharing and discussion 
• Group Exercise to finalize indicators 
• Sharing indicators by groups 
• Finalization of indicators 
11.00 – 1.00 Finalizing indicator values Deepak
• Group Exercise to finalize indicator value 
• Sharing indicator value by groups 
• Discussion and drawing conclusion 
1.00 – 2.00 LUNCH BREAK 
2.00 – 3.00 Preparing Sustainability DashBoard Jagat
• Dashboard sharing 
• Discussion, Interpretation and Conclusion drawing 
3.00 – 4.30 Drawing conclusion and Common Understanding R Sharan
• Drawing conclusion, based on application of CSSA 
• Suggestions and Recommendations 
• Next actions for sustained child survival in Kanchanpur 
4.30 – 5.00 Wrap up and Summarization and Closing 
Child Survival Sustainability Assessment of Child Survival Project, Kanchanpur Page 10 of 11 
CARE Nepal and District Public Health Office Kanchanpur 
Child Survival Sustainability Assessment Workshop 
28-29 May 2006 
Mahendranagar, Kanchanpur 
List of Participants 
SN Name of Participants Position Organization 
1. Bhagat Sing BK Coordinator Samajik Samanta Abhiyan 
2. Bhanmati Khadayat FCHV Coordination Committee FCHV, Daijee VDC 
3. Bhanu Dev Bhatt Program officer District Development Committee 
4. Bharati Singh FCHV Coordination Committee FCHV, Mahendranagar Municipality 
5. Bijay Bharati 
Research Monitoring and 
Documentation Specialist 
CARE, Child Survival Project, Regional 
Office 
6. Deepak Paudel Community Health Specialist CARE Kathmandu 
7. Dharani Bhatt Reporter Chhure Times (media) 
8. Ganesh Datt Joshi Focal person 
District Public Health Office, 
Kanchanpur 
9. Gomati Chandh FCHV Coordination Committee Suda 
10. Indra Adhikari 
Partnership and Advocacy 
Specialist 
CARE, Child Survival Project, Regional 
Office 
11. Induka Karki Health Supervisor 
CARE, Child Survival Project, 
Kanchanpur 
12. Jagat Basnet Resource Person New Era 
13. Karan Datta Aawasthi Secretary NFPA 
14. Keshav Datt Bhatt CDPA Pipladi 
15. Kusum Shahi Health Supervisor 
CARE, Child Survival Project, 
Kanchanpur 
16. Nandha Raj Bhatt AHW Laxmipur SHP 
17. Nava Raj Joshi AHW Jimmuwa HP 
18. Ram Sharan Pyakurel Project Manager 
CARE, Child Survival Project, Regional 
Office 
19. Ratan Singh Bist AHW Pitamber HP 
20. Shanti Raut Health Supervisor 
CARE, Child Survival Project, 
Kanchanpur 
21. Upendra Dhungel 
Asst Institutional Capacity 
Building Officer 
CARE, Child Survival Project, 
Kanchanpur 
22. Yagya Raj Chataut Program Coordinator FOLD 
Child Survival Sustainability Assessment of Child Survival Project, Kanchanpur Page 11 of 11 






KPC Survey
QUESTIONNAIRE 
Identification
Household number Interview Date * 
DD / MM / YY 
Interviewer's Name: _______________ 
District: --------------------- VDC/Municipality:__________ Ward No.___ 
Name of the village: __________ Cluster Number ____________ 
Information about mother
Name: ______________ Age: (In Completed Years) * _______ 
Ethnicity: ____________ 
 
Q N Questions and filters Answers Answer 
or Code 
Skip 
2 Can you read? 1. Illiterate 
2. Not been to school but 
 can read & write 
3. Primary (1-5 Class) 
4. Middle (6-8 Class) 
5. Secondary (9-10 Class) 
6. Higher (above 10th Class 
3 * How many children living in this 
household are under age five? 
Number of children _____ 
child 
4 * How many of those children are your 
biological children? 
(You gave birth) 
Number of children _____ 
child 
Information about the youngest child who is below 24 months
QN Questions and filters Answers Answer 
or Code 
Skip 
5 * Based on response to Q 4 record the name, age and sex of two youngest children 
 Name Sex Age Date of birth 
Child 1 __________________________ _________ months _____/_____/_____ 
(youngest child) DD MM YY 
Child 2 __________________________ _________ _____/_____/_____ 
 DD MM YY 
Calculate the age difference ____________ months 
 
6 Who takes care of (Name) when you
are away from the home? 
A Mother/Father-in-law 
B Husband 
C Elder siblings 
D Other family members 
E Relatives
F Neighbors/friends 
G Leave alone at home 
X Other 
_____ 
Nutrition and breastfeeding 
QN Question and filter Answers Answer Skip 
Annex H KPC and HF Qes Page 1 of 15 
or Code 
7 * Did you ever breastfeed (Name)? 1Yes 
0 No 
___ If No, 
Skip to 17
8 * How long after birth did you first put
(Name) to the breast? 
1 During the first hour of delivery 
2 During 1to 8 hours of delivery 
3 More than 8 hours of Delivery 
4 Don’t' remember 
8 Others (Specify) 
_______
9 Did you squeeze the fluid from the
nipple when you first put (Name) to
the breast 
1 Yes 
0 No 
9 Don't remember 
_______
10 During the first three days after
delivery, did you give (NAME) the
liquid that came from your breasts?
(Use the local term for colostrums)
1 Yes 
0 No 
 9 Don't remember 
_______
11 During the first three days after
delivery, did you give (NAME)
anything else to eat or drink before
feeding him/her breast milk? 
1 Yes 
0 No 
9 Don't remember 
_______ If No or
Don't 
remember 
Skip 13
12 What did you give (NAME)? 
Do not read the list 
Multiple responses possible 
Record all mentioned 
A Plain water 
B Commercially produced infant 
 Formula 
C Other Milk (cow/buffalo/goat milk) 
D Fruit juice 
E Tea/ Coffee 
F Other liquid (Sugar water, Grape 
 Water, Carbonated drink, Soup) 
G Cord, yogurt 
H Herbal traditional medicine 
X Other (specify) _____________ 
_______
_______
_______
_______
13 Are you currently breast feeding 
(Name)?
1 Yes 
0 No 
_______ If yes, 
Skip 15 
14 For how long did you breastfeed 
(NAME)? 
Number of months 
If less than one month, record “00” 
months. months 
15 Does (Name) eat or drink anything 
else besides breast milk? 
In case mother says no confirm it by 
probing that nothing means no water 
or any solids. 
1 Yes 
0 No 
If No. 
Skip 17 
16 When did you start giving solid/semi 
solid food to (Name)? Age of child ______ 
17 At what age of child should a mother 
start giving her child foods or liquids 
in addition to breast milk? 
Age of child ______ 
months 
18 * Now I would like to ask you about the 
types of liquids (NAME) drank 
yesterday during the day and at night 
(during the last 24 hours). 
Did (NAME) drink any of the 
following liquids yesterday during the 
day or at night? 
Read the list of liquids (a through x 
starting with “breastmilk”). 
Multiple responses possible 
Record all mentioned 
A Breast milk 
B Plain water 
C Commercially produced infant formula 
D Other milk such as tinned, powdered or 
fresh animal milk 
E Fruit Juice 
F Any other liquids such as sugar water 
flavored water, tea, coffee, carbonated 
drinks, infusions, or soup broth 
X Other (specify) __________ 
 
_______
_______
_______
_______
Annex H KPC and HF Qes Page 2 of 15 
19 Did (Name) drink any liquid from 
bottle with nipple yesterday day or 
night 
1 Yes 
0 No 
_______
20 Now I would like to ask you about the 
types of foods and number of times 
(NAME) ate yesterday during the day 
and at night (during the last 24 hours).
Did (NAME) eat any of the following 
foods yesterday during the day or at 
night? 
Read the list of foods 
Multiple answers possible
all the foods and number of times 
given to the child 
0 Nothing 
A Any food made grains (e.g. millet 
sorghum, maize, rice wheat porridge or 
other local grains) 
B Pumpkin, red or yellow yarn or squash, 
carrots or red sweet potatoes 
C Any other food made from root or 
tubers (e.g. white potatoes, white yarns, 
manioc, cassava) 
D Any green leafy vegetables 
E Mango, Papaya 
F Any other fruits and vegetables (e.g. 
bananas, apples/sauce, avocados, 
tomatoes) 
G Citrus fruits (lemon/orange) 
H Meat, poultry fish, shellfish or eggs 
I Food made from legumes ( lentils, 
beans, soybeans, pulses or peanuts) 
J Cheese or yogurt 
K Any food made with oil fat, or butter 
X Others--------- 
---- times
---- times
--- times 
---- times
---- times
--- times
--- times
--- times
--- times 
--- times 
--- times 
---times
21 How many times did you give the 
above foods, besides liquid, to (Name)
yesterday day and night? 
(Count only full meal of the child, do 
not count liquids and other small 
snacks) 
-------- Number of times 
 Don't remember
__times 
22 Do you know about Sarbottam pitho 
(Super flour)? 
1 Yes 
0 No 
_______ If No, 
Skip 26
23 Is Surbottam pitho available in the 
local market? 
1 Yes 
0 No 
9 Don't know 
_______
24 Did you give Sarbottam pitho to 
(Name) yesterday day and night? 
1 Yes 
0 No 
_______
25 Will you explain how do you prepare 
Sarbottam Pitho(Super flour)? 
1 Correct 
0 Incorrect 
_______
26 Do you have kitchen garden/land for 
producing vegetables and fruits? 
1 Yes 
0 No 
_______
27 
27 A 
If yes, Observe the kitchen garden and 
not if Vitamin A rich fruits and 
vegetables are available. 
If no kitchen garden, observe whether 
there is availability of vitamin A rich 
fruits/vegetables at home or not 
1 Available 
0 Not available 
1 Available 
0 Not available 
_______
Growth monitoring
28 Was (Name) weighed at birth? 1 Yes 
0 No 
9 Don't know 
______ 
29 Does (Name) have a growth￾monitoring card? 
(Observe the card) 
1 Yes 
0 No 
______ If No, 
Skip 31 
30 Has the (Name) been weighed in the
last four months? 
(Look at the growth monitoring card 
1 Yes 
0 No 
Annex H KPC and HF Qes Page 3 of 15 
and record ,if available) ____gm 
Maternal and newborn care 
QN Question and filter Answers Answer 
or Code 
Skip 
31 Did you see anyone for ANC 
(antenatal care) while you were 
pregnant with (Name)? (e.g. HP, 
mobile clinic or others) 
1 Yes 
0 No 
_______ If No, Skip
37 
32 Whom did you see? 
Only one answer 
1 Doctor 
2 ANM 
3 MCHW 
4 TBA 
5 FCHV 
8 Other 
_______
33 Do you have a maternal health card? 1 Yes 
0 No 
_______ If No, 
Skip 35
34 Record from the card 
 A Number of ANC visits 
 B Number of TT vaccines 
Number of visits 
Number of TT vaccines 
_______
_______
35 How many times did you see 
someone for care during the 
Pregnancy? 
For woman not having card 
Number of times _______
36 During your ANC were you counseled 
on the following? 
Multiple answer possible 
Read the options
1. Deliver preparation 
2. Breast feeding 
3. Child spacing 
4. Immunization 
5. Danger signs of pregnancy 
6. No counseling 
______ 
______ 
______ 
______ 
______ 
37 * Before you gave birth to (Name) did 
you receive an injection (TT vaccine) 
in the arm to prevent the baby from 
getting tetanus, that is, convulsions 
after birth? 
1 Yes 
0 No 
9 Don't know 
_______ If No or 
Don't know, 
Skip 39 
38 * How many times did you receive such 
an injection (TT vaccine)? 
1 Once 
2 Twice 
3 More than two times 
9 Don't know 
_______
39 During pregnancy did you consume 
iron pills/folic acid? 
1 Yes 
0 No 
9 Do not know 
If No or Do 
not know, 
skip 41 
40 For how long did you consume iron 
pills/folic acid? 
Number of ---------days _______
41 What danger signs/symptoms require 
immediate medical assistance during 
delivery? 
Multiple responses possible Record 
all responses 
Don't read the options 
O Do not know 
A Fast and difficult breathing 
B Bleeding 
C Swelling on legs, arms, face 
D High fever 
E High blood pressure 
F Blurred vision 
G Anemia 
H Persistent vomiting 
I Failure to gain weight during pregnancy 
X Others----------- 
42 Now I would like to ask you about the 
time when you gave birth to (Name) 
A Home 
B Other's home 
C Cow shed/ shed 
Annex H KPC and HF Qes Page 4 of 15 
Where did you give birth to (Name)? D Hospital 
G Private clinic/Medical shop 
H PHC 
I HP/Sub HP 
X Other--------- 
_______
43 Was it pre-decided on issues like 
where to go for delivery (Name), and 
to take the help of family in 
difficulty? 
1 Yes 
0 No 
If No 
Skip 45 
44 If pre-decided with the family, what 
was the decision? 
Multiple responses possible 
Read all the responses
A To take the help of TBA 
B To arrange expenses for delivery 
C Where to stay after delivery 
D Where to go in difficulty 
E Which transportation to be used 
F Helping person/organization for 
 Transportation 
G Whom to conduct the household 
 Work 
X Other--------------- 
_______
_______
_______
_______
45 Who assisted you with (Name's) 
delivery? 
Multiple responses possible
O No One 
A Doctor 
B Nurse/ANM 
C MCHW 
D Trained TBA 
E Untrained TBA 
 F Female Community Health Volunteer 
G Family member ______________ 
 Specify relationship 
H AHW 
X Other ______________ 
_______ If No one 
Skip 47 
46 What type of assistance you got 
during delivery? 
Multiple responses possible. 
Record all the responses 
A Massage 
B To cut the cord 
C To remove the placenta 
D Bathe the baby 
E Give food in time 
F Consolation/Patience 
G Check up the internal organs 
H Help to take out the baby during 
 Delivery 
X Other (Specify) _____________ 
_______
_______
_______
_______
_______
_______
_______
_______
_______
47 At the delivery of (Name) who tied 
and cut the cord? 
1 Doctor 
2 Nurse/ANM/ 
3 MCHW 
4 Trained TBA 
5 Untrained TBA 
6 FCHV 
7 Family member ________________ 
 Specify relationship 
O Self 
8 Other ______________Specify 
______ 
48 What instrument was used to cut the 
cord?
0 Don't remember 
1. New razor blade 
2. Old blade 
3. Sickle/knife 
4. Bamboo blade 
8 Other------- 
______ 
Annex H KPC and HF Qes Page 5 of 15 
49 Depending on the response to 
Q 42, ask this question, if the birth 
of (Name) was NOT given in the 
hospital. 
Was a safe birth kit used during this 
delivery of (Name)? 
1 Yes 
0 No 
9 Don't Know/not certain 
______ 
If No or 
Don't know,
Skip 51 
50 From where was the safe birth kit 
brought? 
9 Don't know 
1 Medical store 
2 General store 
3 From TBA/FCHVs 
8 Other places ----- 
______ 
51 What type of immediate care was 
given to the newborn (Name)? 
Multiple responses possible 
Record all responses
0 Don't Know 
A Bathed 
B Wrapped with warm cloth 
C Fed the newborn immediately 
D Cleaned face/Nose 
E Clean eyes 
F Wipe body 
X Other 
_______
_______
_______
_______
_______
_______
52 What danger signs/symptoms require 
immediate medical assistance during 
delivery? 
Multiple responses possible 
Note all the responses
O Don’t know 
A Prolonged labour 
B Convulsions 
C Excessive bleeding 
D Placenta not expelled within 30 
 minutes after delivery of baby 
E High fever 
F Lower abdominal pain 
G Mal-presentation 
X Other ___________ 
_______
_______
_______
___ 
53 After (Name) was born, did anyone 
check on your health? 
1 Yes 
0 No 
______ If No, 
Skip 58 
54 By whom were you checked? 1 Hospital/Doctor 
2 Nurse/ANM 
3 MCHW 
4 Trained TBA 
8 Other ___________ 
______ 
55 How many days or weeks after the 
delivery of (Name) did the first check 
take place? 
1 Within two days 
2 Within 3-5 days 
3 Within 5-9 days 
4 After 10 days 
8 Other (Specify) ___________ 
______ 
56 At that time, did the person check on 
(Name)'s health as well? 
1 Yes 
0 No 
______ If No 
 Skip 58 
57 If checked, what advice was given? 
Multiple responses possible
1 Protect from Infection 
2 Bathe the baby timely 
3 Visit HF in fever or when looks pale 
4 About breastfeeding 
5 Keep the baby warm 
6 Immunization 
7 Family Planning 
8 Other (Specify) ____________ 
______ 
Annex H KPC and HF Qes Page 6 of 15 
58 What danger signs/symptoms requires 
medical advice / help/ treatment after 
delivery? 
Multiple responses possible 
Note all the responses
O Don't Know 
A Fever 
B Excessive bleeding 
C Vaginal discharge with foul smell 
D Lower abdominal pain 
E Convulsions 
F Redness around the breast 
G Pale and weak 
H Repeated vomiting 
X Other (Specify) __________ 
_______
_______
_______
_______
____ 
59 What signs shows that the newborn is 
ill? 
Multiple responses possible 
Note all the responses
O Don't Know 
A Unable to suck the breast 
B Fast or difficult breathing 
C Not active 
D Redness around the cord 
E Red/discharging eyes 
F Convulsions 
G Cyanosis 
H Crying 
I Jaundice 
J Stiffness 
K High fever 
X Other (Specify) ___________ 
_______
_______
_______
_______
____ 
60 Did you take a Vitamin A capsule 
within 45 days of delivering (Name) 
1 Yes 
0 No 
9 Don't know 
______ 
Child immunization
61 * Do you have a card where (Name's) 
vaccinations are written down? 
If Yes, ask ' May I see it please?' 
1 Yes, seen by the interviewer 
2 Not available (lost/misplaced/not in
home) 
0 Never had a card 
9 Don't know 
______ If No or 
Don't know 
Skip 63 
62 * Record information exactly as it Day Month Year 
appears on (name's vaccination card BCG ________ _______ _______ 
Polio 1 ________ _______ _______ 
Polio 2 ________ _______ _ ______ 
Polio 3 ________ ________ _______ 
DPT 1 _________ _______ _______ 
DPT 2 _________ ________ _______ 
DPT 3 ________ _______ _ ______ 
Measles ________ ________ _______ 
Vitamin A _________ _______ _______ 
63 * Did (Name) ever receive an injection 
to prevent measles? 
For child not having EPI card
1 Yes 
0 No 
9 Don't know 
64 Ask about other vaccine 
Circle number of time vaccine given
 BCG DPT Polio 
 0 0 0 
 1 1 1 
 2 2 
 3 3 
Annex H KPC and HF Qes Page 7 of 15 
Integrated Management of Childhood Illness (IMCI)
65 * Sometimes children get sick and need 
to receive care or treatment for illness. 
What are the signs of illness that 
would indicate your child needs 
treatment? 
Do not prompt 
Record all the responses
O Do not know 
A Looks unwell or not playing 
 Normally 
B Not eating or drinking 
C Lethargic or difficult to walk 
D High fever 
E Fast or difficult breathing 
F Vomits everything 
H Convulsions 
X Others (Specify) 
 __________________ 
 __________________ 
 __________________ 
______ 
______ 
______ 
______ 
______ 
______ 
______ 
______ 
______ 
______ 
66 * Did (Name) experience any of the 
following in the past two weeks? 
Read choices and record all 
mentioned by the respondents 
O No problem at all 
A Blood in stool 
B Diarrhoea 
C Cough 
D Difficult breathing 
E Fast breathing/short, quick 
 Breathing 
F Fever 
G Malaria 
H Convulsions 
X Others (Specify) 
 __________________ 
 __________________ 
_______
_ 
_______
_ 
_______
_ 
_______
_ 
_______
_ 
_______
_ 
_______
_ 
_______
_ 
_______
_ 
67 * When (Name) was sick, was he/she 
offered less than usual to drink, about 
the same amount or more than usual 
to drink? 
Read the options 
9 Donot know 
1 More than usual 
2 same as usual 
3 Less than ususl 
0 others------ 
______ 
68 * When (Name) was sick, was he/she 
offered less than usual to eat, about 
the same amount or more than usual 
to eat? 
Read the options
9 Donot know 
1. More than usual 
2. same as usual 
3. Less than ususl 
0 others------ 
______ 
Other Childhood Diseases
Diarrhoea 
69 After how many loose stools do you 
consider (NAME) to be suffering 
from diarrhea? 
Number of loose stool _______
times 
Based on Q 66 Ask Questions from 70 to 75 if the child experienced diarrhea in the 
last two weeks
70 
What did you do (Name) to treat 
diarrhea?
Multiple response is possible 
Record all the responses
O Did nothing 
A Sugar, salt, Solution/ORS 
B Cereal based ORT 
C Injection 
D Rice Starch 
E Antibiotics or anti-diarrheals 
F Herbal Medicine 
G Infusion such as saline 
X Others (Specify) ___________ 
______ 
______ 
______ 
______ 
______ 
______ 
______ 
______ 
Annex H KPC and HF Qes Page 8 of 15 
71 Did you Breastfeeding (Name) during 
diarrhea?
Read the options
1 More than usual 
2 Same as usual 
3 Less than usual 
4 Stopped completely 
5 Baby can not suck the milk 
______ 
72 Was (Name) offered less than usual to 
drink, about the same amount or more 
than usual to drink? 
Read the options
1 More than usual 
2 Same as usual 
3 Less than usual 
4 Stopped completely 
5 Only breast milk 
______ 
73 Was (Name) offered solid/semi solid 
food less than usual to eat, about the 
same amount, or more than usual to 
eat? 
Read the options
1 More than usual 
2 Same as usual 
3 Less than usual 
4 Stopped completely 
5 Only breast milk 
______ 
74 Did you seek treatment (advice) from 
someone for (Name) for diarrhea? 
1 Yes 
0 No 
______ If No, 
Skip 76 
75 Whom did you seek advice or 
treatment for diarrhea? 
(Multiple response possible record 
all mentioned) 
A Hospital 
B Health post/sub health post/PHC 
C Out reach Clinic 
D Private clinic/medical shop 
E Community Health Workers 
(VHW/MCHW) 
F. FCHV
G. Faith healer 
H. Relatives, neighbors and friends 
X Other (Specify) ___________ 
______ 
76 What danger sing/symptoms would 
cause you to seek advice or treatment 
(Name) diarrhea? 
Multiple responses possible 
Record all mentioned
O Don't Know 
A Vomiting 
B Fever 
C Dry mouth, sunken eyes, sunken 
fontanel 
D Continuation of loose motion (14 days 
or more) 
E Blood in stool 
F Loss of appetite 
G Weakness or tiredness 
H Got Thirsty 
X Other (Specify) ___________ 
_______
_______
_______
_______
_______
_______
_______
_______
77 What are the sings of diarrheal 
dehydration? 
Multiple responses possible 
Record all mentioned
O Don't know 
A Eyes look dull and sunken 
B No tears 
C Dry tongue 
D Thirsty 
E Skin becomes dry and when pulled goes
back slowly 
_______
_______
_______
_______
_______
_______
______ 
X Other (Specify) 
78 Do you know how to prepare ORS? 1 Yes 
0 No 
______ If No, 
Skip 80 
79 If yes, ask her how does she prepare 
it?
1. Prepares correctly 
0 Prepares incorrectly 
______ 
80 Do you have a toilet at your home? 1 Yes 
0 No 
______ If No, 
Skip 82 
81 If yes, do you use it? 1 Yes, use regularly 
2 Yes, use occasionally 
0 No 
______ 
Annex H KPC and HF Qes Page 9 of 15 
82 * When do you wash your hands with 
soap/ash? 
Do not prompt 
Record all mentioned
A.Never 
B Before preparing and having food 
C Before feeding children 
D After defecation 
E After attending a child who has 
defecated
X Others----- 
_______
_______
_______
_______
_______
Acute Respiratory Infection (ARI)
83 What sings/symptoms does a child 
with pneumonia (Local term) have? 
Do not prompt 
Multiple responses possible 
Record all
O Don't Know 
A. Fast or difficult breathing 
B. Chest indrawing 
C. Fever 
D. Cough 
E. Unable to suck/drink 
F. Unable to wake up 
X. Other ---------(Specify) 
_______
_______
_______
_______
_______
_____ 
84 What are the signs / symptoms of 
respiratory infection that would cause 
you to take (Name) to a health 
facility? 
Do not prompt 
Multiple responses possible 
Record all the responses
O Don’t know 
A. Fast or difficult breathing 
B. Chest indrawing 
C. Loss of appetite 
D. Fever 
E. Cough 
F. Unable to suck/drink 
G. Unable to wake up 
X Other (Specify) ___________ 
_______
_______
_______
_______
____ 
85 Where do you seek treatment first 
when your child (Name) suffers with 
Pneumonia? 
1. Hospital/Doctor 
2. PHC 
3. SHP/HP 
4. AHW/MCHW 
5 Private clinics 
6 FCHVS 
8 Other (Specify) ___________ 
______ 
Based on Q 66 Ask Questions 86 and 87, if the child experienced Fast breathing in the last two weeks 
86 Did you seek advice or treatment for 
the cough/fast breathing? 
1 Yes 
0 No 
______ If No. 
Skip 88 
87 Where and with whom did you seek 
advice or treatment? 
Multiple responses possible 
A Hospital 
B Health post/sub HP 
C Primary health care center 
D ANM, AHW 
E Private Clinics 
F Community Health Workers 
(VHW/MCHW) 
G FCHV 
H TBA 
I Faith healers 
J Relatives/Friends 
K Ayurvedic Vaidya 
X Others (Specify) 
______ 
Malaria
QN Question and filter Answers Answer 
or Code 
Skip 
88 Has (Name) been ill with fever with 
chill and sweating in the last two 
weeks? 
1 Yes 
0 No 
9 Don't Know 
______ If No or 
Don't know 
Skip 90 
Annex H KPC and HF Qes Page 10 of 15 
89 If Yes, where was (Name) taken? 
Multiple responses possible
A. Nowhere 
B. Hospital/doctor 
C. Nurse/ANM/CMA 
D. SHP/HP 
E. VHW/MCHW 
F. Private clinic 
G. FCHVS 
X. Other-------- 
______ 
90 Do you know how malaria can be 
prevented? 
Do not prompt 
Multiple responses possible 
Record all mentioned
O Don’t know 
A. Use bed net 
B. Use wire nets to the doors and 
windows 
C. Make smoke 
D. Cover the pits 
E. Use Mosquito coils 
F. Clean the surroundings 
G. Insecticide Spraying 
X Other (Specify) 
_______
_______
_______
_______
_______
_______
_______
_______
_______
91 * Do you have any bed nets in your 
house? 
1 Yes 
0 No 
______ If No 
Skip 94 
92 * Who slept under the bed-nets last 
night? 
Circle all that apply 
1 Child (Name) 
2 Respondent 
3. Other family members---------- 
8 Other individuals (Specify) _______ 
_______
_______
_______
93 * Was the bed-net ever soaked or 
dipped in a liquid to repel mosquito or 
bugs? 
1 Yes 
0 No 
9 Don't know 
_______
HIV/AIDS
94 * Have you ever heard of an illness 
called AIDS? 
1 Yes 
0 No 
_____ If No, 
Skip 96 
95* What can a person do to avoid getting 
AIDS or the virus that causes AIDS? 
Multiple responses possible 
Record all mentioned
O Do not know 
A Nothing 
B Abstain from sex 
C Use condom 
D Limit sex to one partner/stay 
 faithful to one partner 
E Limit number of sexual partners 
F Avoid sex with prostitute 
G Avoid intercourse with persons of 
 the same sex 
H Avoid sex with the persons who 
 have many sex partners 
I Avoid sex with persons who 
 inject drug intravenously 
J Avoid blood transfusions 
K Avoid injection sharing 
L Avoid kissing 
M Protect from mosquioto bites 
N Seek protection from traditional healers 
P Avoid sharing razor, blades 
X Others ____________________ 
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
Other Questions 
96 Do you know any FCHV close to your
place?
1 Yes 
0 NO 
If no,Skip 98
Annex H KPC and HF Qes Page 11 of 15 
97 If yes,What kinds of services are 
provided by FCHVs? 
(Multiple response possible, record 
all responses) 
O Don’t know 
A. Vitamin A distribution 
B. ORS distribution 
C. Condom/Pills distribution 
D. Health education and counseling 
E. Mothers groups meeting 
F. Vaccination 
X Others 
98 What kinds of salt do you use in your 
Home? 
1.Powder salt(iodized) 
2.Crystal(Dhike) salt 
3. Others----------- 
99 Have you heard about iodine? 1.yes 
0 No 
If no, Skip 
101 
100 What are the different sources of 
iodine? 
1.salt 
8.others---------- 
101 Are you involved in any local 
community organization (mothers 
groups, micro-credit groups, forest 
consumer groups etc.)? 
1. yes 
0. No 
3.Do not exist 
If no or do 
not exist skip 
103 
102 If yes, what types of activities are 
carried out by the organization? 
1 Health related 
2. Income generating 
3. Agriculture/ forestry related 
8. others--------- 
Anthropometry
QN Question and filter Answers Answer 
or Code 
Skip 
103 May I weigh (Name) and measure his 
height 
1 Yes 
0 No 
104 If mother agrees, take the weight and 
height of the child and measure the 
MUAC of Child and mother. 
Weight of (Name) 
Height of (Name) 
MUAC of child (Name) 
MUAC of Mother (Name) 
_____________ gm 
_____________ cm 
_____________ cm 
_____________ cm 
Thanks the respondent 
Supervisor's Name: _______________ Checked Date 
 DD / MM / YY 
* Indicate the information at must be collected as of RAPID CATCH Questionnaire
Annex H KPC and HF Qes Page 12 of 15 
HEALTH FACILITY FORM 
District: Designation: (Please Circle) 
01 Medical Officer 
02 HA/Sr. AHW 
03 Staff Nurse 
04 AHW 
05 ANM 
06 MCHW 
07 VHW 
08 Other---------- 
Name of respondent: Type of health facility: (Please circle) 
01 PHCC 
02 HP 
03 SHP 
Name of Health facility: 
VDC/Municipality: 
A. Staffing 
S.# Position Sanctioned 
Posts (#) 
Filled Posts 
(#) 
Present on the
day of visit (#) 
Deputation ( 
from/to) 
1. Medical Officer 
2. HA/ Sr. AHW 
3. Staff Nurse 
4. AHW
5. ANM 
6. MCHW
7. VHW
8. Lab assistant 
B. Stock situation: ( Record these information from stock register / LMIS forms) 
S.# List of Commodities Stock Balance 
Update as of --------- 
Emergency Order 
Point 
( EOP) 
If stock< EOP 
Did you made 
emergency order? 
1. Iron/folic acid tab. 
2. ORS packets 
3. Cotrim. Pd. (100/20) 
tab.
4. Vit. A capsules 
5. Chloroquine tab. 
6. Primaquine tab. 
7. Condom 
8. Pills 
9. Depo povera 
10. IUD( Copper T) 
Note: LMIS form/register not filled. 
C. Essential instruments/ equipment 
(Ask if following instruments/equipment are available in the health facility and check if they are 
operational/functional) 
S. Available Functional 
# 
List of instruments 
Yes No Yes No 
Currently in use 
Y/N 
1. Stethoscope 
2. Foetoscope 
3. BP instrument 
Annex H KPC and HF Qes Page 13 of 15 
4. Weighing machine 
- Adult 
- Baby 
- Infant 
5. Vaginal speculum 
6. Labor table 
7. Measuring tape ( for height 
measurement) 
8. ARI timer 
9. ORT corner set( Glass, plastic jug, 
spoon, ORS pkt., bucket) 
10 Safe Delivery Kit 
D. Infrastructure and facilities( Please circle in the appropriate answers) 
1. Is separate/ private space for ANC/PNC check up available? 
01 Yes 02 No 
2. Do you have standard treatment schedule? 01 Yes 02 No 
3. How many PHC/ORC clinics do you have? --------- 
4. How many PHC/ORC clinics are regularly functioning?--------- 
5. How many EPI clinics do you have? ------- 
6. How many EPI clinics are regularly functioning? -------- 
7. Do you have regular supply of vaccines from the district health office? 
01 Yes 02 No 
8. Do you have any plan on what and when to provide different health services? 
01 Yes 02 No 
9. Do you have following guidelines available at your health facility? 
a. Diarrhea management guideline 01 Yes 02 No 
b. ARI management guideline 01 Yes 02 No 
c. Nutrition related guideline 01 Yes 02 No 
d. Maternal and child health guideline 01 Yes 02 No 
e. others-------------- 01 Yes 02 No 
10. Is IEC material displayed on following components? 
a. Child health ( including CDD/ARI, IMCI etc) 01 Yes 02 No 
b. Maternal health ( ANC, NC, PNC) 01 Yes 02 No 
c. HIV/AIDS 01 Yes 02 No 
d. others--------- 01 Yes 02 No 
E. Supervision ( Please circle in the appropriate answer or fill numbers) 
1. Did any one made supervision visits to your health facility within last six months? 
01 Yes 02 No 
2. If yes, number of supervision visits: 
a. From Central/ Regional level ------------ times 
b. From district level ------------ times 
c. From other health facilities (PHCC/HP) ------------ times 
d. From NGOs ------------ times 
3. Do you have supervision plan? (Please check) 01 Yes 02 No 
4. Did you/your staff made any planned supervision visits to health facilities, PHC/ORC, EPI clinic, 
Volunteers with in last six months? 01 Yes 02 No 
5. If yes, number of supervision visits 
a. to health facilities --------times 
b. to FCHVs --------times 
c. PHC/ORC--------times 
d. EPI clinic--------times 
Name of Interviewer/Date Name of Supervisor/Date 
Annex H KPC and HF Qes Page 14 of 15 
In Depth Interview Guideline for District Public Health Officer 
Bal Bachau (Child Survival Project) Final Evaluation 
CARE Nepal
Name of the Interviewer________________________ 
Date_________________________ 
Greet 
Introduce Self 
Preamble: You would be aware that the Government of Nepal and CARE Nepal have 
been implementing a Child Survival Program, Bal Bachau program in this district/in 
four districts. We are here as to understand the successes and failures of the program 
and seek your perspective. This will enable us to disseminate good practices and also 
improve upon the strategies that did not work, in our future projects. This will be a 
confidential discussion and your name will not be attached to your quotes. We 
anticipate the discussion to take about half an hour. Do we have your permission to 
proceed? 
If response no, move to the next available DPHO. 
If response yes, continue with the questions. 
Location_______________________________________________ 
Name of the Interviewee_____________________________ 
Total months of association with the Project:______________ 
Total years in the health department:__________________ 
1. What have been the main activities of the project in the communities of your 
district? 
2. What activities have been carried out with the health department at district, 
PHCCs, HPs and SHP level? If not forthcoming probe for training, meetings, joint 
supervisions, private public partnerships and health facility strengthening. 
3. What has been your role in these activities? Please describe. 
4. How has this project affected the ability/skills of health staff in your district? Do 
you think that the Capacity Building strategy delivered expected outcomes? What 
gaps do you think still exist in the capacities of the health workers to deal with 
child survival? 
5. How will the Capacity Building of the new health functionaries be funded after 
the project? 
6. Its been reported that FCHVs drop out of the program. Has the project addressed 
this issue? How would you tackle this problem in the coming future? 
7. Are you a participant in the HFMC? Please describe its activities and some 
achievements. Please also identify areas which you feel the functioning of the 
HFMC has not been as envisioned. 
8. How has this project affected the way care is being provided in your health 
facilities? Is there still scope for improvement? If so how do your think that can 
be brought about? 
9. How has the project affected the availability of essential drugs and equipment to 
your health functionaries? If it has improved then do you think it will continue to 
remain following the closure of the project? 
10. Were you a participant in the PDQ process? If so how useful do you perceive the 
process to be? 
11. Does the District health facility have a history of partnering with local NGOs for 
health/other activities, prior to the project? 
12. What has been the role of local NGOs in this project? 
13. Have you partnered with any NGOs for activities other than those of the CSP? If 
yes for which activities? 
14. How has the project activities affected the community perception of public health 
delivery systems? Has it improved, remains the same? 
15. How has the morbidity profile among children changed in your district in the last 
five years? Can you substantiate with some statistics? 
16. In your opinion has the project reached the marginalized groups? Have you 
observed any increase in number of these communities accessing care? 
17. Has the project met the desired results anticipated by you? If so how, If not in 
which aspects? 
18. Could you highlight some of the successes of the program?
19. How will the district administration sustain (ask those for which have received 
positive responses) 
• the interest generated in the community; 
• skills which have been strengthened (refreshers) 
• future skill upgradation (fresh trainings) 
• ensuring quality care through HF 
• mainstreaming of marginalized communities 
• partnership with NGOs, civil societies, DDCs, VDCs, FCHVCCs 
Thank you indeed for your insightful remarks. 
Focus Group Discussion Topic Guide for Mothers Group and Reproductive Age 
Group Mothers who are not members of Mothers Group 
Bal Bachau (Child Survival Project) Final Evaluation 
CARE Nepal
Topic Discussion/Transitions 
Introduction 
and Greeting 
Facilitator’s and Observer’s name 
Purpose of FGD We have been working on a project to improve maternal and child 
health in Name of the District/Ilaka/Village. Because you are mothers 
and belong to this mothers group we would like to learn from you about 
your opinions about pregnancy, nutrition, labor, delivery, postpartum, 
child care, nutrition, childhood diseases and related issues. Your ideas 
can help us understand how our project performed and inform us about any 
changes that we can incorporate in our future projects to improve maternal 
and child care. May we begin the discussion? (Allow for those who do not 
want to participate in the discussion leave). 
No right or 
wrong answers 
We would just like to know your frank opinion. There is no right or 
wrong answers to any of the questions. This is not a test. We just 
want to learn from you 
Length of time The discussion would take about an hour 
Talking to one 
another 
As we will be discussing about each of your opinions, it will be 
important that we do not talk at once because we will want to hear 
each other so we should not talk together. Every body should try and 
participate and every body will be given a chance to put forth their 
views. If you have any queries they would be addressed at the end 
Explain note 
taking 
Confidentiality 
(Name of Observer/reporter) will be writing down some of the 
things that we will be talking so we can remember later. Does 
anyone object? We are the only ones who will know your names, we 
will not use any names in our reports 
Checking 
understanding 
Clarify 
Does everyone understand what I have said? Does anyone have any 
questions? 
Participants 
introductions 
(Warm up) 
Please introduce yourselves 
Let us begin: NOTE: This is a comprehensive list of questions and will be 
modified following feedback from all concerned. 
• Have you heard of the Bal Bachau program? 
• What activities are being done under this program? 
• Has this program made any difference to the way you lead 
your lives in your community? 
• Can you name some good things about the program 
• Can you name some things that the program should have 
done in addition to its activities? 
General 
• Is there a FCHV who visits your community? What is her 
name? How often does she visit? 
• Which other functionary visits your community? What are 
their names? How frequently do hey visit your community? 
• What are the common health problems among children of 
this community? 
Child Health 
• What do you do when children fall ill? 
• Is it possible to prevent children from falling ill? 
• How can we prevent children from falling ill? 
• Can diarrhea be prevented? 
• Can you name a few things that can be done to prevent 
diarrhea? 
• Does everyone in the community practice these behaviors? 
• If no then why? 
Diarrhea 
Control 
• What do you do when children get diarrhea? (go to the 
appropriate question based on the responses of the women) 
• Where do you get ORS from?
• How do you prepare the ORS? 
• What do give your child to eat and drink during an episode 
of Diarrhea? 
• Where did you learn to do this? (restrict this question for 
positive practices) 
• How do you know that the child needs to see a doctor? 
(check for responses on signs of dehydration) 
• Has there been a complicated diarrhea case in your 
community or a death (death is an optional q and may be 
deleted based on CARE Nepal’s perspective on 
appropriateness). Why do you think that happened? 
• What role has the health worker or the FCHV played to 
prevent and control diarrhea in your community? 
• What do you think will happen once CARE staff visiting 
your communities and the project comes to an end? (could 
use this as a final question or may be used after every 
intervention to get specifics on sustainability of practices) 
Pneumonia 
Control 
• Let us talk about pneumonia now. Are there children in your 
community who have had pneumonia? 
• Why do children get pneumonia, can we prevent this? 
• Can you name a few things that can be done to prevent 
pneumonia especially in young infants? 
• How do you know that a child has pneumonia? 
• What do you do when the child has pneumonia? 
• What do give your child to eat and drink during an episode 
of pneumonia? 
• Where did you learn to do this? (restrict this question for 
positive practices) 
• Has there been a complicated diarrhea case in your 
community or a death (death is an optional q and may be 
deleted based on CARE Nepal’s perspective on 
appropriateness). Why do you think that happened? 
• What role has the health worker or the FCHV played to 
prevent and control diarrhea in your community? Probe and 
document details on respiration counting, provision of drugs 
(cotrim) and follow up. 
Nutrition • Now we will discuss a little about what you feed your 
children and the pregnant lactating mothers and how. Let us 
start with young infants. 
• When is the infant put to breast? Why? 
• How long is the infant breast fed 
• When is the infant given additional food? 
• For any positive practices enquire – why do you do so or 
who taught you to do so? 
• What additional food is given to children? 
• What about when infants are infants get ill? 
• How can you tell that a child hasn’t been fed properly 
• Are there any malnourished children in your community? 
• What role has the health worker or the FCHV played in 
improving the state of these children? 
• Has there been malnourished child who fell ill and got 
complications or died? (Death is an optional q and may be 
deleted based on CARE Nepal’s perspective on 
appropriateness). 
• What kind of salt you use at home? Why? (if answer iodated 
salt then ask the next question) 
• Why should we use the two-child salt? What happens if we 
don’t? 
• Is worm infestation a problem among children? 
• What problems can worm infestation lead to in children? 
• Have children received any medication for this from anyone? 
If yes how often? 
• Are you aware of Vitamin A? 
• What does Vitamin A do? 
• Have children in your community received Vitamin A? If 
yes from whom? 
• What kind of foods provides children with rich nutrients? 
Name them 
• Let us talk about childhood vaccines now. Can you name 
some of the vaccines that children receive in infancy? 
Immunization 
• What diseases do these vaccines prevent? 
• Who vaccinates the children of your community? 
• Are there mothers who do not get their children vaccinated? 
Why? 
• Can a child of 2-3 years who has not been vaccinated also be 
vaccinated?
• What role has the health worker or the FCHV played in 
ensuring vaccination for your children?
• Have there been any children with DPT/Polio or measles in 
the past 4-5 years? Were there any complications? 
• Is Malaria a problem in your community? 
• What causes malaria? 
• Can anything be done to prevent malaria? 
• Have you been provided with nets under the project? 
• If yes do you use them? Are there community members who 
do not use them, then why? 
Malaria (for 
Kanchanpur) 
• When do you assume that a person has malaria? 
• What do you do then? 
• What does the health care giver do when you report to them? 
• What do you advice and drugs do you receive from the 
Health Worker? 
• What role has the health worker or the FCHV played in 
malaria prevention and treatment? 
• What other activities are being undertaken by the health 
workers to control malaria (probe further on spraying 
activities and its acceptance) 
Maternal 
Health 
• Now we will talk a little about pregnancy and related topics. 
• How many of you are pregnant at the moment? 
• Can you name some complications associated with 
pregnancy? 
• Why are these caused? 
• Can you name a few things a woman can do to prevent these 
complications? 
• What are the preferences regarding aspects of behavior/care 
of complications in P/L-D/PP? 
Antenatal Care • How many times should a woman be seen by the HW during 
pregnancy?
• Are there some women who do not? If so then why? 
• What does the HW do during a check up? 
• What drugs and advice do you receive from the HW? 
• Why is TT important? How many TT should a pregnant 
woman receive? 
• Why is IFA important? Do women consume the IFA that is 
given by the HW? If not why? 
• What kind of salt should a pregnant woman consume? Why? 
• What kind of diet should a pregnant woman consume and 
why? 
• What kind of diet do women in this community generally 
consume? 
• Has FCHV and HW’s visit made any changes in the 
practices of the community? 
• Do women generally get any rest during pregnancy?
• What roles do your husband and mothers-in-law play during 
pregnancy? 
Delivery • Where do women generally deliver in your community? 
• What preparations are made for delivery (probe to find out 
about a birth plan) 
• Are you aware of a Safety Delivery Kit? 
• Is it available in your community? 
• Why should it be used? 
• Who delivers the baby? 
• Probe for reasons of not using a skilled birth attendant if 
response is such. 
• What is done immediately after the delivery 
• What role has the FCHV or the HW played in deliveries in 
the community? 
• Has there been a complicated pregnancy, where women had 
to betaken to a bigger hospital? What happened – positive 
and negative consequences and why? 
• What has been the experience of women who deliver in the 
health center (needs to be replaced with appropriate word) 
• Have there been any deaths of a pregnant woman? Why do 
you think that happened? – ? (Death is an optional q and may 
be deleted based on CARE Nepal’s perspective on 
appropriateness). 
• What community resources or support systems exist to assist 
women in getting care? – (this can be used as a general 
question at the end of the discussion to ascertain community 
resources and support to the health of mother and child.) 
Postnatal Care • What care is provided to a women post delivery? 
• Is the woman given any check up by HW? 
• What else does she receive from the HW? 
• What complications can arise during the postpartum phase? 
• Has there been any such example in the community? 
• Why did it happen and what could have been done to prevent 
that? 
Family 
Planning 
• How many children would you like to have? 
• What age difference would you like to maintain between 
your children and why? 
• What do you do to maintain this difference? 
• What role does the FCHV/HW play in supporting this?
• What facilities are available to you to achieve this? 
• Do you receive support from your husband or mother-in￾law? 
HIV/AIDS • Have you heard of HIV/AIDS? 
• How does the disease spread? 
• What can we do to prevent this? 
• Where did you receive this information from? 
Additional 
questions based 
on specific 
interventions 
• Is there a child club in your community?
• What are the activities of this club and the impact of these 
activities? 
• Is there a Dabi group in your community? How has this 
affected the community? 
• Is there a community drug depot in a facility close to you? 
• Is there a separate cotrim depot as well? 
• How has this affected the community? 
• Has there been a special drive to identify and care for the 
malnourished community? If yes how has that affected the 
community? 
• Have you heard the radio program 
• Have you watched the documentary? 
• Have you seen the TV serial? 
Sustainability 
questions 
• What do you think will happen once CARE staff visiting 
your communities and the project comes to an end? 
• Have you ever shared the information you received through 
the project with other community members? 
• What can be done so that the good things you have learnt 
and facilities being provided to you continue? 
Summary Mention main themes discussed and participant’s responses. Is there 
anything else that we talked about that I forgot to mention? 
Closure Thank you for your time. Do you have any questions that you would 
like to ask? I am not sure that I will be able to answer all of them, 
but I will try (Record all questions do not lecture) 
During FGD 
Recorder should keep notes by making cards for each section/question. Note responses 
on each card of respondents by numbering them as R-1 from the left of the facilitator and 
going clockwise around the room. Note if participants seem to all be agreeing with a 
statement or if there is a visible disagreement among participants when someone is 
speaking. Write down any quotes on a separate sheet provided for quotes. Note those 
quotes which are emphatic, well articulated and summarize the general feelings of the 
group for a particular topic. Responses during the introduction (all questions from 
introduction of facilitators through participant introductions) can be grouped together. 
After conducting the FGD 
Immediately after the session the facilitators should: 
a. Review the notes for clarity and understanding 
b. Compare and record observations about the group not readily clear from the notes 
c. Discuss and record any insights or ideas that the interview created while they are 
fresh in your mind 
d. Prepare a summary of the FGD for your team 
In Depth Interview Guideline for Medical Officer PHCC/HP in Charge/SHP 
Incharge 
Bal Bachau (Child Survival Project) Final Evaluation 
CARE Nepal
Name of the Interviewer________________________ 
Date_________________________ 
Greet 
Introduce Self 
Preamble: You would be aware that the Government of Nepal and CARE Nepal have 
been implementing a Child Survival Program, Bal Bachau program in this district/in 
four districts. We are here as to understand the successes and failures of the program 
and seek your perspective. This will enable us to disseminate good practices and also 
improve upon the strategies that did not work, in our future projects. This will be a 
confidential discussion and your name will not be attached to your quotes. We 
anticipate the discussion to take about half an hour. Do we have your permission to 
proceed? 
If response no, move to the next available facility manager. 
If response yes, continue with the questions. 
Location_______________________________________________ 
Type of Facility______________________________ 
Name of the Interviewee_____________________________ 
Total months of association with the Project:______________ 
Total months in the current facility:__________________ 
Staff in the facility 
Staff Position Sanctioned Functioning Trained in C-IMCI
(ask and fill this column 
after you have asked 
question 2) 
1. What have been the main activities of the project in the communities of 
your district? 
2. What activities have been carried out with the staff of PHCC? If not 
forthcoming probe for training, meetings, joint supervisions, private 
public partnerships and health facility strengthening. Name the kind of 
trainings. 
3. Could you please answer a few technical questions for us? 
a) How do you recognize a child with pneumonia? 
 Fast breathing (more than 60/min for 0-2 months children and more than 
50/min for 2-60 months children ) 
 Other (specify) _______________ 
 Don’t Know 
b) How do you recognize a child with dehydration? 
 Dull and sunken eyes 
 Tearing 
 Dry tongue 
 Thirsty 
 Dry/non elastic skin 
 Other _____________ 
4. Did these trainings and activities succeed in bridging the perceived gaps? 
If yes to what extent? 
5. What has been your role in these activities? Please describe. 
6. Are you supported by your supervisors (those who are from the higher 
facility say district) in implementing your activities? What guidance have 
you received and how often do you receive it? Has the frequency changed 
over the project duration? Please name some of the visitors who have 
made supervisory visit to your facility in the last three months. 
7. How are you being supported by the VDCs/DDCs? Please list the 
contribution. 
8. How has this project affected the ability/skills of health staff in your 
facility? Do you think that the Capacity Building strategy delivered 
expected outcomes? What gaps do you think still exist in the capacities of 
the health workers to deal with child survival? 
9. Do you believe that the capacity building activities will continue after the 
project? 
10. How has the project affected the support of FCHVs to your facility and 
your community activities? 
11. Have you experienced FCHV drop outs in your area? Has the project 
addressed this issue? How would you tackle this problem in the coming 
future? 
12. Are you a participant in the HFMC/CMC? Please describe its activities 
and some achievements. Please also identify areas which you feel the 
functioning of the HFMC/CMC has not been as envisioned. 
13. How has this project affected the way care is being provided in your 
health facilities? Is there still scope for improvement? If so how do your 
think that can be brought about? 
14. How has the project affected the availability of essential drugs and 
equipment to your health functionaries? If it has improved then do you 
think it will continue to remain following the closure of the project? 
Observe drug availability. 
ORS y/n ## 
Cotrim y/n ## 
IFA y/n ## 
Vitamin A y/n ## 
15. How has the CDP program changed since the project onset? 
16. Were you a participant in the PDQ process? If so how useful do you 
perceive the process to be? 
17. Does your PHCC have a history of partnering with local NGOs for 
health/other activities, prior to the project? 
18. What has been the role of local NGOs in this project? 
19. Have you partnered with any NGOs for activities other than those of the 
CSP? If yes for which activities? 
20. How has the project activities affected the community perception of public 
health delivery systems? Has it improved, remains the same? 
21. How has the morbidity profile among children changed in your district in 
the last five years? Can you substantiate with some statistics? 
22. How has the project affected the community health behaviors? Can you 
give us some examples? 
23. In your opinion has the project reached the marginalized groups? Have 
you observed any increase in number of these communities accessing 
care? 
24. Has the project met the desired results anticipated by you? If so how, If 
not in which aspects? 
25. What has been the role of your facility staff in engaging community 
members? 
26. Could you highlight some of the successes of the program? 
27. How will the district administration sustain (ask those for which have 
received positive responses) 
• the interest generated in the community; 
• skills which have been strengthened (refreshers) 
• future skill upgradation (fresh trainings) 
• ensuring quality care through HF 
• mainstreaming of marginalized communities 
• partnership with NGOs, civil societies, DDCs, VDCs, FCHVCCs 
Thank you indeed for your insightful remarks.
In Depth Interview Guideline for Project Advisory Committee 
Bal Bachau (Child Survival Project) Final Evaluation 
CARE Nepal
Name of the Interviewer________________________ 
Date_________________________ 
Greet 
Introduce Self 
Preamble: You would be aware that the Government of Nepal and CARE Nepal have 
been implementing a Child Survival Program, Bal Bachau program in this district/in 
four districts. We are here as to understand the successes and failures of the program 
and seek your perspective so as to share to a larger group of people the initiatives that 
worked and also improve upon the strategies that did not work, in our future projects. 
This will be a confidential discussion and your name will not be attached to your quotes. 
We anticipate the discussion to take 30-45 minutes. Do we have your permission to 
proceed? 
If response no, move to the next available PAC member. 
If response yes, continue with the questions. 
Location_______________________________________________ 
Name of the Interviewee_____________________________
Designation____________________________________ 
Months served as a PAC Member__________________________________ 
1. What is the role of the PAC? 
2. Is the role defined for the PAC adequate? If not how would you want to see 
the role expanded? 
3. Can you name some of the activities you undertake as a PAC member? 
(Probe further for attending meetings, role in problem solving, field visits, 
monitoring/supervision) 
4. Through which modality do you receive information about the project 
activities? 
5. Could you please briefly tell us what your understanding of the project 
strategies or activities is? 
6. In your opinion have these activities of the project been appropriate for the 
needs of the community? 
7. And have the strategies been developed in response to the environment of the 
community and health delivery systems? 
8. Project has made focused efforts to bring the marginalized communities into 
its fold. In your opinion has this focus translated into results? 
9. In your opinion how has the PAC been contributing to the Project? 
10. It is often felt that once a project comes to an end the special focus it brings 
begins to dilute. In your opinion which are the aspects which will continue 
beyond project life and why? (Probe to cover all aspects of sustainability if it 
is not forthcoming) 
11. Which are the aspects which may not continue and why? 
12. Can CARE make any efforts in the final stages of the project or through its 
participation in various advocacy forums to address outcomes which may not 
sustain? 
13. What were the major successes of the project? 
14. Could you list some areas which did not work as well? 
15. Would you like to add anything further that may help us design improved 
projects in the future? 
Thank the interviewee for their time and invite to the debrief workshop if 
appropriate. 
In Depth Interview Guideline for MCHW/VHW 
Bal Bachau (Child Survival Project) Final Evaluation 
CARE Nepal
Name of the Interviewer________________________ 
Date_________________________ 
Greet 
Introduce Self 
Preamble: You would be aware that the Government and CARE have been 
implementing a Child Survival Program, Bal Bachau program in this communities. We 
are here as to understand the successes and failures of the program and seek your 
perspective. This will enable us to disseminate good practices and also improve upon 
the strategies that did not work, in our future projects. This will be a confidential 
discussion and your name will not be attached to your quotes. We anticipate the 
discussion to take about half an hour. Do we have your permission to proceed? 
If response no, move to the next available worker. 
If response yes, continue with the questions. 
Location_______________________________________________ 
Type of worker and facility______________________________ 
Name of the Interviewee_____________________________ 
Total months of association with the Project:______________ 
Total months in the current position:__________________ 
1. What have been the main activities of the project in the communities of 
your district? 
2. What activities have been carried out with the staff of PHCC? If not 
forthcoming probe for training, meetings, joint supervisions, private 
public partnerships and health facility strengthening. Name the kind of 
trainings. 
3. Could you please answer a few technical questions for us? 
a) How do you recognize a child with pneumonia? 
 Fast breathing (more than 60/min for 0-2 months children and more than 
50/min for 2-60 months children ) 
 Other (specify) _______________ 
 Don’t Know 
b) How do you recognize a child with dehydration? 
 Dull and sunken eyes 
 Tearing 
 Dry tongue 
 Thirsty 
 Dry/non elastic skin 
 Other _____________ 
c) What are the key messages you would give a pregnant woman? 
 4 ANC check ups 
 2 TT injections 
 Better nutrition and rest 
 IFA and deworming 
 Skilled birth attendant 
 Birth planning
 Safe delivery kit 
 Post natal Vitamin A 
4. Did these trainings and activities succeed in bridging the perceived gaps? 
If yes to what extent? 
5. What has been your role in these activities? Please describe. 
6. Are you supported by your supervisors (those who are from the higher 
facility say district) in implementing your activities? What guidance have 
you received and how often do you receive it? Has the frequency changed 
over the project duration? Please name some of the visitors who have 
made supervisory visit to your facility in the last three months. 
7. How are you being supported by the VDCs? Please list the contribution. 
8. How has this project affected the ability/skills of health staff in your 
facility? Do you think that the Capacity Building strategy delivered 
expected outcomes? What gaps do you think still exist in the capacities of 
the health workers to deal with child survival? 
9. Do you believe that the capacity building activities will continue after the 
project? 
10. How has the project affected the support of FCHVs to your facility and 
your community activities? 
11. Have you experienced FCHV drop outs in your area? Has the project 
addressed this issue? How would you tackle this problem in the coming 
future? 
12. Is there a FCHV CC in your area? How has this affected the functioning of 
the FCHVs? What role do you play in these CCs? 
13. What is your relationship with the FCHVs? What role do they perform 
and how does this differ from your role? 
14. Are you a participant in the HFMC/CMC? Please describe its activities 
and some achievements. Please also identify areas which you feel the 
functioning of the HFMC/CMC has not been as envisioned. 
15. How has this project affected the way care is being provided in your 
health facilities? Is there still scope for improvement? If so how do your 
think that can be brought about? 
16. How has the project affected the availability of essential drugs and 
equipment to your health functionaries? If it has improved then do you 
think it will continue to remain following the closure of the project? 
Observe drug availability. 
ORS y/n ## 
Cotrim y/n ## 
IFA y/n ## 
Vitamin A y/n ## 
17. How has the CDP program changed since the project onset? 
18. How many mothers groups are there in your coverage area? How often 
do you get to interact with them? Do you think the mothers will continue 
to be grouped after the project staff stops visiting the communities? What 
can be done to sustain them? 
19. What materials has the project provided to generate awareness and 
change behavior? Do you have some of these with you? Which tool did 
you think worked the best? Which will you use once the project comes to 
an end? 
20. What has been the role of local NGOs in this project? 
21. How has the project activities affected the community perception of public 
health delivery systems? Has it improved, remains the same? 
22. How has the morbidity profile among children changed in your district in 
the last five years? Can you substantiate with some statistics? 
23. How has the project affected the community health behaviors? Can you 
give us some examples? 
24. What activities in your opinion will continue and which ones wont 
following the closure of the project? 
25. Any other comments 
Thank you indeed for your insightful remarks.
Bal Bachau (Child Survival Project) CARE Nepal
Framework for Final Evaluation (Qualitative) 
Methodology and Tools
1. At Community Level 
Groups/Individuals Numbers/ District 
Addressed 
Tools 
Kanchanpur Doti Dadeldhura Bajhang 
Mother’s Groups (MG) Focus Group Discussions 
(FGDs) 
6 6 6 6 
Women of reproductive age 
group (non-members of the 
MG/husbands and MILs? 
FGDs 4 4 4 4 
FCHVs In Depth Interviews 
(IDIs)/FGDs if time permits 
5/2 5/2 5/2 5/2
Local Resource Persons IDIs 2 2 
FCHV CC members IDIs 2 1 1 
VDC members IDIs 2 2 2 2 
DDC members IDIs 2 2 2 2 
Dabi group members FGDs 1-2 1 1 1 
VHW/MCHW/ANMs IDIs 5 5 5 5 
Health facilities – 
SHP/HP/PHCCs 
Facility assessments 4 4 4 4 
HFMC members IDIs 2 2 2 2 
Community Health 
Management Committee 
members 
IDIs 1 1 1 1 
Child clubs FGD 1 
Cotrim depots Observation/meeting 1-2 
Traditional Healers FGD/IDIs depending on 
availability 
1/2 1/2 1/2 
2. At District Level 
Groups/Individuals Numbers/ District
Addressed 
Tools 
Kanchanpur Doti Dadeldhura Bajhang 
DPHO IDIs 1 1 1 1 
Private drug retailers Meeting 1 
Civil Society Meeting 1 
Political leaders Meeting 1 
Media Meeting 1 
Other NGOs and INGOs 
(depending on availability) 
Meeting 1 1 
PAC Members IDI 1 1 
2. Regional Level Meetings 
• RDO 
• Officials of SWC 
• NGOs/INGOs (depending on availability)
• PAC Members 
3. National Level Meetings 
• NEPAS/NHTC 
• PAC 
• Other NGOs and INGOs (depending on availability) 
• USAID 
• SWC officials