MIDTERM EVALUATION REPORT
SYNERGY AND ACTION FOR NUTRITION+ 
PROJECT (SAN+) 
Koulikoro region in MALI October 2005 – September 2009 
Cooperative Agreement # 
GHS-A-00-05-00013-00
June 2008
Marguerite Joseph, Consultant
LIST OF ACRONYMS 
ANC Antenatal Care 
ASACO Community Health Associations 
ATN National Technical Assistance Project – USAID Mali 
BCC Behavior Change Communication 
CNIECS National Center for Health Information, Education and Communication
CROCEP Regional Committee for Orientation, Coordination and Evaluation of 
CSCom Community Health Centers 
CSHGP Child Survival and Health Grants Program 
CSRef Reference Health Center 
CSTS Child Survival Technical Support 
DESAM MOH developed software system 
DIP Detailed Implementation Plan 
DNS National Health Directorate
DRDSES Regional Directorate for Social Development and Economic Solidarity 
DRS Regional Health Directorate 
ENA Essential Nutrition Actions 
FINSA International Training in Nutrition and Food Sciences 
GAIN Global Alliance for Improved Nutrition 
HFA Health Facility Assessment 
HIS Health Information System 
HKI Helen Keller International 
HQ Head Quarters 
IEC Information Education Communication 
IFA Iron+Folic Acid 
IMCI Integrated Management of Childhood Illness 
IPT Intermittent Preventive Treatment 
ITN Insecticide Treated Nets 
KPC Knowledge, Practice and Coverage (Survey) 
LAM Lactation Amenorrhea Method 
LQAS Lot quality Assurance Sampling 
M&E Monitoring and Evaluation 
MI The Micronutrient Initiative 
MOH/SD Ministry of Health and Ministry of Social Development 
MOU Memorandum of Understanding 
MTE Midterm Evaluation 
NCHS National Child Health Survey 
NGO Non-Governmental Organization 
OFDA Office of Foreign Disaster Assistance (USA) 
ORTM Malian Office of Radio and Television Broadcasting 
PKC Projet Kénéya Ciwara 
PRODESS Mali’s 10-year Health and Social Development Program 
PVO Private Voluntary Organization 
RUTF Ready to use therapeutic food 
SAN+ Synergy and Action for Nutrition+ 
SASDE UNICEF-implemented Accelerated Child Survival and Development project 
SC Save the Children (US) 
SIAN Semaine d’Intensification des Activités de Nutrition (National Nutrition 
Week) 
SP Sulfadoxine-pyrimethamine 
TBA Traditional Birth Attendant 
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TOT Training of Trainers 
UNICEF United Nations Children’s Fund 
URTEL Mali Union of Free Radios and Televisions 
USAID United States Agency For International Development 
VAC Vitamin A Capsule 
WFP World Food Program 
WHO World Health Organization 
WRA Women of Reproductive Age 
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A. Summary 
The overall project goal of the Mali Synergy and Action for Nutrition + Project (SAN +) 
is to improve the nutritional status to reduce morbidity, and mortality in children 0-23 
months and women of reproductive age (WRA) in the Koulikoro Region. HKI and its 
partners are implementing nutrition and breastfeeding as the child survival technical 
interventions (80% nutrition and 20% breastfeeding). HKI works primarily with health 
facilities (CSComs) and community health committees (ASACOs). 
General Objectives include: Improve nutritional status of children 0-23 months; Improve 
nutritional status of pregnant women; Improve nutritional status of postpartum women; 
Improve access and availability of nutrition services; Improve quality of key nutrition 
services. The SAN+ project is applying 4 cross-cutting strategies 1) joint design, 
implementation, and evaluation of approaches to deliver a minimum package of essential 
nutrition services consistent with MOH/SD standards and protocols; 2) capacity-building 
and training to improve access, availability, and quality of facility-based services; 3) 
community mobilization to improve demand for, and use of, key health services; and 4) 
tailored BCC and advocacy to improve key household behaviors and care-seeking 
practices and commitment of local decision makers 
Main Accomplishments
1. Contribution to the development of key messages, technical guidelines and a 
national strategy to prevent and treat malnutrition and micronutrient deficiency in 
Mali. 
2. Successful re-integration of nutrition and micronutrients into the minimum 
package of primary health services: routine service provision in the form of IEC 
and counseling which is recorded in health registers; annual planning and 
budgeting for bi-annual micronutrient campaigns. 
3. Capacity building of health providers in essential nutrition actions and successful 
‘repositioning’ of the importance of breastfeeding and nutrition in health 
providers’ perceptions and practices. 
4. Support for integration of de-worming into routine health services and campaigns 
as a key nutrition intervention nationwide. 
5. Implementation of a successful radio program with the collaboration of 29 
community radio stations. 
6. Important contribution to increased knowledge and behavior change in the target 
population in the area of breastfeeding, complementary feeding with foods rich in 
micronutrients, hygiene and care-seeking during illness. 
7. Increased availability and coverage in micronutrient supplementation for the 
target population: Vitamin A for postnatal mothers and children over 6 months of 
age and iron for pre and post natal mothers. 
8. Leveraging of resources to supplement child survival funding, strengthening 
project activities and achievements (CTC, Vitamin A supplementation, 
Communication for Development, fortification of cotton oil, sorghum and maize ) 
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Challenges
• Large size of intervention area – Region-wide project covers 150 + CSComs, with 
some located as far as 200 km away from district headquarters. 
• High MOH staff turnover, especially among the heads of CSComs 
• Lack of success in support and advocacy for use of zinc supplementation for 
diarrhea case management (limited health staff knowledge and management of 
source: product introduced to region was on the point of expiring). 
• Insufficient funds for pursuing potential operations research opportunities as 
hoped at the time of the development of the DIP, i.e. research on anemia. 
In terms of the capacity-building effects of the project, although still somewhat seen by 
MOH partners as the HKI domain, nutrition/micronutrient has been fully integrated into 
existing services and health providers and clients report such that this is now routine. 
This is also the case with planning at the district and regional levels. Advocacy for the 
integration of nutrition with the regional and district MOH has been quite successful, and 
nutrition interventions such as the bi-annual National Nutrition Week (SIAN) and 
micronutrient supplementation are very much included in their respective annual plans. 
The partnership and capacity-building focus of the project makes sustainability of the 
above more feasible. 
Gaps so far have been related to the MOH inability to conduct supervision due to their 
budget constraints, and the fact that SAN+ did not prioritize and budget for this. With 
supplementary project funding (OFDA funded CTC), HKI will be able to begin funding 
joint supervisions during the second half of the project. Nevertheless it is clear that future 
consistent support of health workers on the part of local partners will depend on their 
ability to mobilize funding for this, and ability to provide adequate support to these 
interventions during integrated supervisions visits. 
Conclusions and recommendations 
In addition to the achievements highlighted above, some specific strengths and 
weaknesses were also identified. 
 
Strengths
• Considerable strengthening of technical and policy capacity of MOH partners at 
the district, regional and national levels 
• Good collaboration with UNICEF in the region reinforcing project reach and 
impact 
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Areas of Weakness
• Lack of follow-up on the Quality Assurance component of project, e.g. 
recommendations were developed during a QA Workshop but there has been poor 
documentation and dissemination of these and no action taken. 
• Lack of budget for strategic activities such as joint supervisions and coordination 
meetings with government counterparts. 
• Gap in community-level interpersonal communications activities for ENA in 
communities not being supported by other projects such as Keneya Ciwara (thus 
synergy is uneven across the region, and no specific work has been done with 
women’s associations as discussed in the DIP). 
Key Recommendations 
Community level 
1. Encourage message dissemination within women’s associations via CSCom 
matron’s participation in these groups. 
2. Encourage women to organize themselves to bring together ingredients for the 
implementation of cooking demonstrations. 
3. Gain the support of grandmothers in new nutrition practices through regular group 
contacts organized by matrons. 
4. Develop linkages with government and non-government institutions to support 
communities with the promotion of vegetable gardening and the production of 
soya beans. 
5. Implement strategies already identified to follow up and support CHWs, i.e. 
participate in outreach activities being carried out by the health facilities every 
month. 
6. Involve the ASACOs and mayors office during supervision activities. 
7. Mobilize additional resources to adequately support the radio program 
component. 
Health Facility level 
8. Encourage the mayor’s office, the communities and their partners to ensure the 
support of outreach activities. 
9. Ensure the completion of training for health personnel in the Nara and Kolokani 
districts emphasizing feeding during childhood illness and maternal nutrition. 
10. Strengthen collaboration with grandmothers as key to the adoption of new 
nutritional practices in the household. 
District level 
11. Ensure that funding is allocated for joint supervision of the nutrition 
interventions. 
Regional Level 
12. Support joint supervision missions with the regional health team twice a year. 
13. Strengthen the collaboration with the regional team on the management of project 
activities. 
14. The project should continue to encourage the Regional Directorate of Health’s 
involvement in Nutrition activities and support the integration of the ENA 
(prevention) and CTC (treatment) approaches 
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National Level 
15. Accelerate the local production of flour enriched with Vitamin Mineral Complex. 
16. Support joint supervision missions with the national nutrition division once a 
year. 
17. Be proactive as a member of the Nutrition Working Group to stimulate increased 
products and investment in the fight against malnutrition and micronutrient 
deficiency. 
HKI Management 
18. Develop posters on ENA to display at health facilities 
19. Advocate for increased MOH responsibility in the provision of Vitamin A to 
maintain the high levels of coverage achieved, as part of the project’s phase-out 
strategy in 2009. 
20. Review and follow-up on the QA recommendations developed during the 2007 
workshop and adapt and implement with the regional and district teams as needed 
and feasible. 
21. Strengthen project staff capacity for using project-related data for management 
and decision-making. 
An MTE action plan, addressing recommendations is included in the annex. 
B. Assessment of the progress made toward achievement of project objectives 
1. Technical Approach 
a. Overview 
The Mali Synergy and Action for Nutrition + Project (SAN +) targets malnutrition as one 
of the primary underlying causes of child mortality in one of the most densely populated 
and least resourced regions of the country. As outlined in the situational analysis, a 
number of factors contribute to the high rates of malnutrition in the region. Most 
directly, sub-optimal infant and child feeding and poor maternal health and nutrition are 
important causes of malnutrition in Mali. The overall project goal is to improve the 
nutritional status and reduce morbidity and mortality among children 0-23 months and 
women of reproductive age (WRA) in Koulikoro Region. HKI and its partners are the 
following child survival technical interventions: 70% nutrition, 10% control of diarrheal 
diseases, 10% malaria, 10% breastfeeding. SAN+ includes maternal nutrition, 
breastfeeding, complementary feeding, nutritional management of early childhood 
illness, micronutrient malnutrition, and anemia control for mothers and children. HKI 
works primarily with health facilities (CSComs) and community health committees 
(ASACOs). 
General Objectives 
- Improve nutritional status of children 0-23 months 
- Improve nutritional status of pregnant women 
- Improve nutritional status of postpartum women 
- Improve access and availability of nutrition services 
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- Improve quality of key nutrition services 
The SAN+ project is applying 4 cross-cutting implementation strategies 1) joint design, 
implementation, and evaluation of approaches to deliver a minimum package of essential 
nutrition services consistent with MOH standards and protocols; 2) capacity-building and 
training to improve access, availability, and quality of facility-based services; 3) 
community mobilization to improve demand for, and use of, key health services; and 4) 
tailored BCC and advocacy to improve key household behaviors and care-seeking 
practices and commitment of local decision makers. 
HKI aims to apply intervention approaches focused on: 
o Using integrated (nutrition and health) delivery strategies at health 
facilities 
o Expanding coverage through improved delivery at community level 
(National Nutrition Weeks or vaccination campaigns) as a complement to 
health system-based services 
o Promote synergies through regional planning processes among HKI and 
other regional and national partners operating various projects in the 
region and other child survival projects/programs in other regions. 
o Capitalizing on various experiences of HKI in Mali and others countries 
b. Progress report by intervention area 
 
i. Activities related to specific interventions as proposed in DIP.
Activities outlined in the DIP work plan under are discussed under objectives as 
presented below: 
Objective 1: Improve nutritional status through the decrease of the prevalence of 
underweight children under two. 
The project successfully trained 162 rural (auxiliary) midwives in the Essential Nutrition 
Actions (ENA) framework and in using behavior change communications (BCC) 
techniques to promote the seven key actions1
 together with appropriate hygiene practices. 
They were also able to provide an orientation on key program areas to the chief clinician 
in each community health center (CSComs). Although the training did not cover the 
entire number of midwives in the Koulikoro region, per midterm evaluation interviews 
many of the others have learned from their colleagues. This was not through a concerted 
effort by the latter, but rather through observation. 
As a result of the project training, and ensuing support from the SAN+ supervisors based 
in each of the districts, at the time of the midterm it was clear that the health providers in 
this region have fully integrated nutrition as part of the minimum package of activities at 
 
1
 Breastfeeding within one hour of birth and exclusively for six months; continued breastfeeding with 
nutritionally appropriate complementary feeding through 24 months and beyond; maternal nutrition; 
nutritional care of the sick and malnourished child; integrated control of anemia and control of vitamin A 
and iodine deficiencies. 
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the health centers. This includes regular health education sessions covering nutrition 
topics an average of two times a month or more, and individual counseling of clients 
coming in for child health and antenatal care (ANC). Midwives report having frequent 
contact opportunities with clients, although this is limited to contacts in the health facility 
and during the special outreach activities (Stratégie Avancée). When asked, they were 
able to correctly explain the steps in counseling. Mothers interviewed during FGDs 
confirmed that they have regular contact with health providers and receive health 
information from them. Although the heads of the CSComs were not able to receive 
training on the essential nutrition actions (ENA) as were the rural midwives, (due to 
budget constraints already envisaged at the time of the DIP), the former were still able to 
supervise this activity and periodically provide support to midwives when they conduct 
group health education (prior to ANC, vaccination and growth monitoring activities). 
The project fell a little behind in the area of IEC message development for counseling 
cards specifically, because they wanted to work with the national stakeholders to develop 
a consensus around the wording of all the key ENA messages to be disseminated. 
Nevertheless, they did go ahead and develop counseling cards for Vitamin A after their 
BEHAVE workshop. Counseling cards were provided to health centers as education 
guides for the midwives. These cards include information about foods rich in vitamin A 
(such as as liver, milk, fish, mangoes, papaya, wild fruit, and green leafy vegetables) and 
complementary feeding for children above the age of six months. The importance of 
using iodized salt is also being promoted using a poster developed by UNICEF. At the 
time of the MTE, a group of Malian stakeholders were leaving to attend a regional 
ENA/BCC workshop, where they hoped to complete the development of the remaining 
key messages for the counseling cards. With the completion of this activity, other 
projects working in nutrition, such as the National Technical Assistance Project funded by 
USAID Mali (ATN) and UNICEF, as well as government health agents, will also be able 
to contribute to the dissemination of these messages through counseling cards used 
nationwide. The development of the aforementioned counseling cards is a key strategy 
that the project identified to promote optimal breast-feeding practices, Vitamin A and 
iron supplementation and the consumption of nutrition-rich foods. 
 
Despite the delays in development of the counseling cards, rural midwives and radio 
agents did receive training on nutrition and health themes. This included the following: 
the advantages of immediate breastfeeding and colostrom; advantages of exclusive 
breastfeeding; nutrition during pregnancy; feeding during episodes of childhood illness; 
advantages of prenatal consultation and iron supplementation; importance of vitamin A 
supplementation during the immediate postpartum period and for children 6 to 59 
months; the advantages and content of appropriate complementary feeding from the age 
of six months; the importance of systematic de-worming of children every six months; 
and the importance of hand washing with soap for the prevention of diarrhea. 
A key strategy outlined in the DIP as a means to reach the population with this 
information, was to broadcast messages through a rural radio program. SAN+ was able to 
start this initiative in mid 2007 with 3-month contracts. They identified 29 rural radios 
across the program area and subsequently conducted two-day training sessions for 29 
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radio broadcasters. The training provided the broadcasters with an orientation on nutrition 
and ENA, prevention of malaria for pregnant women and children and the promotion of 
hand washing. This training was aimed at ensuring that radio broadcasters would gain 
enough knowledge and understanding to be in a position to respond to phone call 
questions and inquiries coming from community members after project-developed, pre￾recorded programs were aired. Based on interviews undertaken in several sample radio 
stations across the program area during the MTE activity, it is clear that this component 
has seen a tremendous amount of success. Radio agents interviewed spoke about the 
immense popularity of these radio programs and the very enthusiastic response from 
community members. They have also undertaken radio competitions, which they say are 
very popular, and developed dynamic initiatives such as radio theater and debates that 
have elicited a lot of interest and questions on the part of community members. One radio 
agent estimated that 80% of women answered correctly the questions posed during a 
radio contest the station implemented. The radio programs, on average, are broadcast as 
many as four to five times a week for half an hour. The frequency and consistency of 
these radio programs have clearly been a very important factor in the achievements seen, 
i.e. increased knowledge about health and nutrition and increased demand for health 
services; both evident in the MTE qualitative interviews. Most radios broadcast to a 50-
km radius. Mothers interviewed during FGDs confirmed that the radio is a major source 
of health information. 
Although the SAN+ project is focused primarily on district and health facility level 
support (mostly benefiting the population within a 5 km. radius and thus with relatively 
easy access to the CSCom), communities located more than 5 km from a health facility 
do received services through monthly or periodic outreach activities (Stratégie Avancé). 
Thus in this way, they also benefit from project-supported IEC/BCC nutrition messages. 
The frequency of these visits depends on the number of eligible children in a given 
community, and the budget available to the health center for this activity (normally 
funded out of the Community Health Association – ASACO – budget). 
Despite the fact that the project did not have staff on the ground to work directly with 
communities, as outlined in the DIP, they did have the intention of getting communities 
to mobilize for such things as the National Nutrition Week activities (SIAN). The latter 
are biannual activities implemented on a national level, usually involving polio 
vaccination and vitamin A distribution. In May, 2006, the project and its government 
partners successfully tested integrating the deworming of children 12-59 months into 
SIANs in the Koulikoro district; since then, deworming has been included at the national 
level. With the involvement of the multiple partners, in December, 2007 the SIAN was 
expanded to become an integrated campaign, adding measles vaccination and insecticide￾treated bednet (ITN) distribution to the three other interventions. As a primary 
stakeholder for nutrition and key partner in the Koulikoro region, HKI was well placed to 
implement this pilot activity. The project support for the integrated SIAN has included 
financing radio messages around the activity, the training of community members who 
help carry out the activity, supporting the preparation of the equipment, and the 
supervision of the activity with the provision of vehicles and participation of project staff. 
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The SIAN is normally implemented by a national team accompanied by the regional 
team. Districts teams also carry out support activities. 
It is important to note that SAN+ has also been encouraging and supporting the use of de￾worming during routine treatment as part of the package of nutrition services. 
 
Another activity outlined in the project DIP was the development of small-scale and in￾home food fortification using multi-micronutrient sachets. HKI was not able to secure the 
funding it expected and have not been able to undertake this activity. It has also been 
constrained by the international concerns about iron supplementation of children under 5 
in malaria endemic areas. 
The project has supported the government’s working group for nutrition. Staff has 
participated in a couple of meetings, but it should be noted that these meetings have not 
been held consistently and thus need to be revitalized. They are supposed to be held once 
every quarter, lead by the MOH Division of Nutrition, and with the participation of 
various organizations such as UNICEF, HKI, Save the Children, WFP, CRS, ATN, and 
World Vision. 
With regard to quality assurance for nutrition, SAN+ supported the organization of a 
quality assurance workshop at the Koulikoro region, which included the participation of a 
select number of health facility providers as well as some district representatives. This 
workshop was facilitated by the regional health team (who received technical assistance 
from the University Research Corporation (URC). Although the workshop participants 
went so far as to develop process indicators for quality assurance, to be shared and used 
for purposes of supervision, nothing has, in fact, been implemented. There has been no 
follow-up to this workshop activity, and no quality assurance monitoring implemented by 
the SAN+ Bamako based staff (Coordinator, Deputy and a Mickey Leland Hunger 
Fellow attached to the project) or the MOH district and regional staff. In theory, this 
follow-up would be the responsibility of the SAN+ project supervisors under the 
guidance of the Coordinator and Deputy, as most of their time is dedicated to the 
technical support of CSComs in their efforts to re-integrate nutrition as a key component 
of their daily tasks. 
Although the standards have been established and communicated, QA is an area that 
needs more attention on the part of the senior project staff and district/regional staff. Both 
the districts and the region have supervisory responsibilities, but problems related to the 
budget have prevented them from carrying them out. The one UNICEF-supported 
monitoring activity for 2007 was eventually not funded because of issues and delays with 
the request. According to observations about quality assurance related by SAN+ 
supervisors from routine supervision visits, one health service provider has multiple 
responsibilities and consequently conflicting priorities and demands, leading him or her 
to skip or rush through activities. 
The project hoped to conduct some research on anemia. This has not been undertaken yet, 
and there is concern that the $1500 budgeted is inadequate for such an activity. 
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Nevertheless, the staff has been in dialogue with the University of Mali and may be able 
to participate in a regional study designed to compare the incidence of malaria in two 
groups (one supplemented with Vitamin A, and the other with Vitamin A and Zinc 5 days 
per week). The study will look at incidence of diarrhea and ARI in these two cohorts. 
Objective 2: Improve the nutritional status of women 
Activities specific to this objective include the promotion of prenatal care. Not 
surprisingly, the project again chose to work primarily through the rural midwives (this is 
the case for all the intervention areas). Maternal health is included as a component of the 
ENA training supported by the project, which encourages the use of iron folic acid 
supplements, insecticide treated nets (ITNs), Intermittent Preventive Treatment (IPT) of 
malaria during pregnancy, and maternal nutrition. It should be noted that CSCom staff 
have also benefited from similar training provided by the national malaria and 
reproductive health programs. 
Per interviews with health providers, the supply of free iron tablets for antenatal care is 
sporadic. Many health facilities write a prescription and women are asked to fill this at 
the local pharmacy. That they cannot receive IFA at the health facility itself, and have to 
pay for it are both likely to create impediments to compliance. SAN + is not directly 
supporting the distribution of ITNs, but the distribution by UNICEF and PSI has made 
for excellence synergy. Sulfadoxine-pyrimethamine (SP) for the intermittent treatment of 
malaria is provided by CSComs. Women attending ANC clinics are also given advice on 
maternal nutrition, e.g., the importance of eating dark green leafy vegetables, liver and 
other meat products during pregnancy. These messages are also disseminated through the 
radio as discussed above. 
To promote postnatal care, the project has reinforced the distribution of Vitamin A and 
iron to postpartum mothers. Again, this component is included in the ENA training and is 
further supported by the SAN+ supervisors who monitor stocks in the CSComs and help 
to expedite requests for supplies from the district (as they often frequent the health 
centers more than the district staff themselves). Vitamin A is provided to postpartum 
mothers primarily when they come back to the health center for child health services. 
There is no distribution immediately after delivery for those who deliver at home. 
Women attending ANC clinics are encouraged to plan for delivery at the health facility; 
indeed, there is often the threat of a fine imposed on those who choose to deliver at home. 
But it should be noted that for those not residing in the village where the CSCom is 
located, delivering at the center is not a general practice because of the distance. 
Objective 3. Improve nutritional status through breast-feeding 
Many of the activities to promote this objective have been discussed above. This includes 
supporting community health education sessions at the CSComs, broadcasting radio 
messages, promoting nutrition-rich foods and supporting the SIAN activities (all 
activities specifically highlighted as DIP work plan activities). In addition, the project 
supported community mobilization during World Breastfeeding Week. These events also 
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included supporting three community celebrations for the certification of baby friendly 
hospital initiatives. The project has also advocated with UNICEF and MOH for the 
inclusion of other CSComs in the baby friendly hospital initiative. The project hopes to 
encourage CSComs to work with groups of grandmothers and women leaders and 
enhance their involvement in the promotion and support of immediate and exclusive 
breastfeeding practices. 
One activity that SAN+ had not yet undertaken at the time of the MTE was that of 
strengthening women’s associations. Staff and partners will dedicate some time to this 
during the second half of the project. 
Objective 4 – Reduce mortality from malaria 
Many of the activities outlined for this objective have already been discussed. This 
includes developing and broadcasting messages on the radio and during community 
health education sessions. Again, the counseling cards for malaria prevention and case 
management have not yet been developed and distributed. Making full use of the 
opportunities for synergy (for which the project is titled), the SAN + program area 
benefited from other partner-supported distributions of long-lasting ITNs. This included 
UNICEF and PSI who launched campaigns to promote ANC clinic attendance and the 
complete vaccination of children under one. Nets were distributed to ANC clients and all 
children who completed their vaccinations. The MOH national malaria program has 
trained all the heads of health centers on the management of both severe and moderate 
malaria, and they have also provided the CSComs with a large drug stock to manage 
cases. Rural midwives were also trained on the use of Sulfadoxine-pyrimethamine (SP) 
for intermittent treatment and prevention (ITP) of malaria in pregnant women. With 
support from the Global funds, Artesunate Combined Treatment (ACT) is provided free 
of charge for all children under five. Pregnant women are treated with quinine. 
The HKI Country Director has been participating in the Technical and Financial Partners 
Group malaria group meetings. They meet once a month and discuss achievements, 
experiences and program strategies. 
 Obj. 5 - Reduce mortality from diarrheal diseases 
The diarrhea component has also been discussed above. Although not yet included in the 
counseling card messages, the priority message was hand washing with soap and was 
covered during the training of midwives and radio broadcasters. This message is also 
being prioritized on a national level. For the management of diarrhea episodes, the 
project disseminated messages about increasing the number of meals and liquids during 
illness. The project made a special effort to introduce and promote zinc as part of facility￾based, case management of diarrhea. This was included in the ENA training to providers, 
and the project supported the region with the purchase of an initial stock of zinc. 
Unfortunately this stock was close to the expiration date at the time of its arrival in 
country, and thus it was not available for a long duration. Some district partners 
interviewed during the MTE mentioned that they had to dispose of part of that stock, and 
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the government has no immediate plans to purchase more. Another issue raised during 
MTE interviews was the fact that, although HKI provided some zinc, use of oral 
rehydration salts (ORS) has fallen because UNICEF is not currently providing the new 
formulation. Thus although zinc would normally be provided as a complement to ORS, 
this is not currently the case. 
Highlights of Monitoring and Evaluation, Partnership and Capacity Building Activities
Most activities outlined under these cross-cutting areas were implemented, including 
baseline studies, development of project M&E, supervision, signing of MOU etc. With 
regard to quarterly regional meetings in Koulikoro, these were not held systematically. 
Bi-annual technical updates for partners were not held. Annual review of progress on DIP 
was not conducted formally with the MOH partners, but the partner does integrate HKI in 
its annual plans. HKI participates in the MOH’s bi-annual and quarterly reviews and 
planning, and the project staff developed a work plan for Year 2. 
As discussed later in this report, the project achieved more or less all training objectives. 
It did not conduct a separate training in M&E for the partners; however, the ENA and 
CTC trainings conducted included an M&E and communications component. (CTC 
training was conducted in two districts during this project period and preparations for the 
scale-up to the seven other districts have been underway). And although the CSCom 
Certification Committee was established to support the creation of nutrition-friendly 
health centers, the project saw that it made more sense to work with the existing baby 
friendly initiatives first. 
ii. Progress toward benchmarks or intermediate objectives. 
The HKI SAN+ project did not set specific quantitative objectives for the midterm. All 
indicators have an end of project target. The project has access to other data from the 
SIAN activities, as well as the routine districts data as indicated in the following table. 
 DISTRICT CHILD HEALTH DATA (distribution outside of campaigns ) 
Total Target Rate 
# of children from 6 -11 months who received one dose 
of vitamin A 
44,522 45,477 98% 
# of children from 12-59 months who received one dose 
of vitamin A 
25,304 79,584 32% 
# of children from 12 -59 months who received two 
doses of vitamin A 
29,309 79,584 37% 
#of children who received insecticide treated bed nets 23,974 98,440 24% 
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 DISTRICT WOMEN’S REPRODUCTIVE HEALTH DATA 
Total Target Rate 
Number of pregnant women who attend at least three ANC 
sessions 
17061 73830 32% 
Number of pregnant women who receive ITNs 28289 73830 38% 
Number of pregnant women who received one dose of SP 43003 73830 58% 
Number of pregnant women who received two doses of SP 28881 73830 28% 
Number of pregnant women who received iron folic acid 69056 73830 94% 
Number of women in the immediate postpartum period who 
received vitamin A capsule 
20259 73830 27% 
Of the several indicators identified in the above district data, those for routine de￾worming coverage are not available. The project has been encouraging deworming as 
part of routine services, but for the most part, coverage of both VAS and deworming have 
been assured through the SIAN, most recently implemented in June and December 2007. 
For example, in the integrated campaign held in December 2007, VAS coverage for the 
region was: infants 6-11 months: 60,479 (85%); children 12-59 months: 362,819 (93%); 
while coverage with deworming medication among children 12-23 months was 292,271 
(95%). 
Unfortunately it is difficult to compare the above data with the KPC baseline, e.g. the age 
group for Vitamin A in the project is 6-23 months, and not 6-11 months. But it is very 
encouraging nevertheless, as the project baseline was 31%, and thus a dramatically lower 
coverage than the above, regardless of the bigger age group. The project indicator for IFA 
specifies consumption in the last 24 hours, versus the above IFA ‘received’ during 
pregnancy. The baseline KPC result for postpartum Vitamin A coverage was very high 
(65%), compared to the above 27% for routine district health data. This difference may 
be attributed to the additional impact of national campaigns on coverage levels. Coverage 
during national campaigns is very effective. Coverage outside of the campaigns is 
considered to be supplementary. 
SAN+ will have the opportunity to conduct a study in August 2008 for their OFDA 
funded CTC project (a project that also serves to provide good synergy to the child 
survival activities). UNICEF reports that it will also be conducting a nutrition survey in 
the coming months. 
From a qualitative standpoint, there appears to have been a great deal of progress in the 
area of immediate breastfeeding. This was reported by mothers during FGDs, as well as 
health providers. The purported increased adoption of this practice may be attributed to 
various project and other interventions: the increased deliveries in health facilities; the 
vibrant radio program; television media supported by the national program; and 
interpersonal and group communication sessions conducted by rural midwives. Exclusive 
breastfeeding was also discussed during qualitative interviews, and this also appears to 
have seen some progress. This may be attributed to the strong synergy among the 
national program efforts in this area. That is to say, there has been considerable 
15
investment in the promotion of exclusive breastfeeding through television advertisements 
and skits. These are aired nationwide, and although not all community members have 
access to television, community members in the intervention area had seen them. So it 
appears that television has been a medium for reaching the population. Both men and 
women interviewed reported that people no longer give young infants water, although a 
few conceded that the traditionally common practice of giving young infants concoctions 
has not been completely erased. This suggests there is still some work to be done in this 
area. 
In most of the program villages sampled, women also reported that they give much more 
attention to personal and environmental hygiene than they used to. They spoke about 
washing their hands with soap prior to eating, after using the toilet, after cleaning an 
infant who has defecated, and before cooking. They were also able to identify that this 
helps to avoid diarrhea. Some mentioned reducing stomach pains and vomiting. There is 
a national initiative to encourage community clean-up activities every Saturday, and 
people mentioned this during interviews. Some mothers reported that as a result of these 
various changes, cases of diarrhea among children have decreased. Mothers mentioned 
in the FDGs that they pay attention to the importance of preventing dehydration during 
illness, through increased fluids and increased feedings. 
During interviews with men in the program communities, many raised the point that 
women follow advice they’re hearing in taking care of the children. They reported that 
the less a child gets sick, the better it is for them because it is cost-saving and reduces the 
burden on the family. This was mentioned in relation to exclusive breastfeeding, 
complementary feeding, and hygiene in particular. 
Progress with regard to building partnerships can be seen clearly in the rural radio 
collaboration with SAN+. At the time of the MTE, the initial three-month contract with 
these radio stations had come to an end, and there had been a multi-month delay in the 
renewal of these contracts. Despite this, most of the radio stations were still broadcasting 
recorded tapes several times a week, and said that they expected to continue doing so 
even if there are no contracts forthcoming. A major reason is that demand has been 
created for these programs. The public likes to hear the broadcasts and complains if they 
are canceled. One rural radio station reported that thanks to their relationship with the 
HKI project, their status has been elevated and they have been able to attract other NGOs 
(PSI, PACT and Plan) and obtain more contracts to help support the radio. 
iii. Effectiveness of the interventions 
Focusing the primary training efforts and supportive supervision on the rural midwives 
has been an effective strategy, as these MOH personnel are less mobile, i.e. they do not 
transfer as often as the heads of the CSComs. Moreover, these midwives appear to be 
dramatically improving the quality of service provision. This was ascertained during the 
key informant interviews with midwives as well as the heads of the health centers. Both 
groups spoke about the activities the midwives have undertaken since the support of HKI, 
and how the project training has helped them increase their knowledge in the areas of 
16
nutrition, breastfeeding and health. Several of those interviewed mentioned that prior to 
the training they knew the information in general terms, but were unable to provide 
details when conducting health education or giving advice to mothers. Thus the training 
has helped them improve their knowledge, counseling and has raised their self￾confidence. And because the project places importance on clients and services, providers 
also report that SAN+ has contributed to improving client-provider relationships. This is 
also confirmed by mothers, who say that services have improved, they feel welcomed, 
and health providers are approachable. Mothers in one FGD mentioned that in the past 
they did not like to frequent the health facility because health providers often treated 
them badly. 
From all accounts, it appears that the rural radio program strategy has also been very 
effective. It has a large audience and listeners report very much enjoying the learning 
opportunity and subject matter (per FDG's and the feedback that radio agents reported). 
The interesting initiatives such as competitions and contests have drawn active 
participation and enthusiasm from the communities, and appear to have had a big impact. 
The effectiveness of radio is strengthened by the training strategy, which has reinforced 
the knowledge of project messages among key sources of information in the community. 
This makes for very good synergy, further reinforced by the periodic television 
campaigns. It is important to mention that for the most part, rural radios have a weekly 
slot allocated to the local health authorities for public health programming. Thus some of 
the health providers already have a relationship with the radio and can communicate with 
the public through this avenue. When health staff is not on the air, some of the radios 
have taken advantage of the cassettes provided by SAN+ to fill that space. 
The effectiveness of the interventions in terms of the contributions that interpersonal 
communications can make towards behavior change can only be estimated among the 
populations living within a 5 km radius of the CSComs. As designed, the project does not 
intend to have the same impact in communities beyond this area, which are not 
considered the target population. The more remote population does not have as much 
access to the CSComs and receives limited outreach services. As previously mentioned, 
SAN+ staff have organized only limited activities beyond the CSComs. HKI has recently 
increased these efforts, with a decision to actively participate in outreach activities that 
are implemented in communities beyond the 5 km radius. These outreach activities cover 
vaccination, antenatal services, IEC and, with OFDA funding, will also include follow up 
with the community health workers (CHWs) who will be trained in the identification and 
case management of malnutrition. CHWs will screen children using MUAC 
measurements and health providers can verify the diagnosis by taking weight and height 
measurements during the outreach activities. 
Overall, SAN+ has been quite effective in maximizing the potential for synergy. The 
collaboration that HKI has with several NGOs, projects and institutions has greatly 
increasing the opportunities for the populations in the Koulikoro region the project 
targets. The collaboration with UNICEF at the regional level is very good. UNICEF 
provides the region with ITNs, SP and Vitamin A used to support routine service 
provision and has also contributed equipment such as weighing scales, height 
17
measurement, mid upper arm circumference (MUAC) measurements tapes, and drug kits. 
HKI, in turn, often assists with the transportation of these materials to the CSComs. 
UNICEF will be further supporting the CTC activity with the F100 and F75 milk, as well 
as antibiotics. 
HKI is also part of the USAID/Mali-funded ATN project, and the partners collaborated in 
piloting the integration of additional interventions into the SIAN starting in 2006 (that 
year ATN provided the albendazole and SAN+ was the implementing partner). The 
presence of the USAID/Mali-funded Keneya Ciwara health project implemented by 
CARE in various communities of the region with CHWs and community health 
committees (ASACOs) has also been beneficial because SAN+ does not have staff based 
and working within the communities. HKI became a partner in the Micronutrient 
Initiative (MI) and along with UNICEF assists with the provision of Vitamin A capsules. 
Thus in some districts and communities, several projects have been contributing to the 
prevention and treatment of malnutrition and micronutrient deficiency. HKI itself is 
implementing the OFDA-supported CTC project, which is allowing for the training of all 
the heads of health centers, and will provide some support to CHWs. In addition, HKI has 
the An be Jigi (hope for All) project which focuses on improving nutritional intake in two 
districts of Koulikoro through the participatory testing of iron- and zinc-rich varieties of 
millet and sorghum and promoting dietary changes to increase bioavailability of these 
elements. This project has engaged the support of a Peace Corps Volunteer and is funded 
by the McKnight Foundation. 
District health staff interviewed during the MTE stated that it is due to HKI that the 
nutrition program has been strengthened, properly re-integrated into the minimum 
package of services, and that Vitamin A distribution has become an important priority. 
Although the government ensures a part of the supply, the region gets a lot of support 
from the project as well. Assuring the supply of Vitamin A, while emphasizing its 
importance, has also contributed to the effectiveness of this intervention. The presence of 
a project supervisor in each district who dedicates 100% of his/her time to nutrition has 
given nutrition a high profile and the attention needed to get it ‘repositioned’ in the eyes 
of the regional, district and health facility staff. 
iv. Changes in the technical approaches outlined in the DIP and 
rationale. 
There are no changes in the technical approaches outlined in DIP. 
v. Special outcomes, unexpected successes or constraints. 
Although the project did not specifically define any special outcomes, the synergy that 
the project has been able to bring about is remarkable. For example, although SAN+ is 
not working beyond a 5 km radius of health facilities (outside of the great reach of the 
radio program), UNICEF, Keneya Ciwara and others have been providing this support. 
HKI also leveraged OFDA funding for a CTC activity, which provides training in the 
identification and treatment of malnutrition as well as for its prevention. The CTC project 
18
is integrating these complementary activities and building community linkages region￾wide. 
vi. Follow-up and next steps. 
The follow-up and next steps discussed during the midterm evaluation are articulated in 
the recommendations and action plan developed. This includes emphasizing certain 
aspects of BCC, working with women's groups and associations, increasing contact with 
the Musokoroba, or grandmothers, and strengthening the district and regional 
partnerships with increased joint supervision and monitoring of the nutrition integration 
process. Next steps also include taking advantage of the OFDA funding to provide more 
training on ENA to the heads of health facilities and to community health volunteers. The 
project leadership will also prioritize completing the development of counseling cards 
that highlight the other important key ENA messages, and support the follow-up of 
Quality Assurance (QA) recommendations developed during the workshop held. 
c. New tools or approaches, operations research 
In its complementary CTC project (implemented by the SAN+ team), HKI helped the 
MOH elaborate a protocol and develop a training module for the community-based 
management of acute malnutrition. They also worked with the Ministry to develop data 
collection tools adapted from the standard tools. This activity will benefit the SAN+ 
goals because it gives health providers increased skills and knowledge in the area of 
nutrition, and emphasizes both the treatment and prevention of malnutrition as priority 
health activities. SAN+ also developed a one-page guideline for de-worming activities 
and supported the integration of de-worming into SIANs. This guideline used by health 
workers highlights the importance of de-worming, which kind of medications should be 
prescribed, target groups (children 12-59 months and pregnant women) and the treatment 
protocol. The project also developed a one-page guideline for Vitamin A 
supplementation, and can be given credit for helping the MOH to modify the registry for 
Vitamin A and de-worming used during campaigns (routine services use their own 
registers). 
As previously mentioned, SAN+ has been in dialogue with medical faculty at the 
University of Mali who will be implementing a study that will be conducted as part of a 
West Africa regional project to compare the incidence of malaria, diarrhea and ARI in 
two groups: one supplemented with Vitamin A, and the other with Vitamin A and Zinc. 
There is a strong likelihood that this study will be conducted in Koulikoro, in 
collaboration with HKI. HKI can provide technical assistance to the study, but funding is 
still needed. Results in Burkina Faso have been encouraging, reportedly suggesting that 
daily zinc and a single large dose of Vitamin A reduced the incidence of malaria by 30% 
and delayed subsequent attacks. There is an interest in seeing this replicated in 
Cameroun, Mali and Ghana with larger sample sizes. 
19
2. Cross-cutting approaches 
a. Community Mobilization 
i. Community mobilization activities 
For community mobilization, the project undertook one major activity: advocacy 
workshops in which administrative, communal, religious and female leaders and a 
representative of each of the over 150 ASACOs were invited into a dialogue to promote 
community participation in health and nutrition develop strategies to increase food 
production/availability, and encourage active community mobilization through outreach 
activities and campaigns. Unfortunately, these communal representatives (ASACOs) are 
limited to working within their five-year annual plans, and their budgets are usually very 
tight. It is important to acknowledge, however, that they do contribute to health service 
strengthening. They tend to focus on providing support for health infrastructure 
development such as maternity sections in CSComs, and they often support vaccination 
and SIAN campaign activities as well. 
ASACO members interviewed in various sample communities during the MTE appear to 
be very active and have a good working relationship with Ministry of Health personnel. 
They report that they hold regular meetings, discuss health and nutrition, and support the 
dissemination of health and nutrition messages. Traditional leaders interviewed were, 
likewise, clearly very knowledgeable on health and nutrition. They were aware of key 
messages and health information being transmitted in the community: exclusive 
breastfeeding, complementary feeding, hygiene and sanitation. When asked, these 
community leaders responded that they play a supportive role in community mobilization 
for the aforementioned activities. 
Aside from the advocacy workshops, the project did not work directly in the area of 
community mobilization, although some of the populations in 4 of the 9 districts of the 
Koulikoro region have benefited from the activities of the CARE Keneya Ciwara project, 
which is now ending. This project provided support to the SAN+ by working with 
ASACOs and CHWs linked to health providers who are also working in partnership with 
HKI. HKI has seen the need to do more in this area, and would like to provide more 
concrete support to health providers implementing community outreach activities. SAN+ 
field staff begun to include this in their monthly schedules prior to the midterm. 
ii. Community response
 
Interviews with men, women, village chiefs and community health committees 
(ASACOs) indicate that the community has responded well to the project efforts. While 
the project’s principal partner is the MOH at the district and health facility levels, the 
involvement of the ASACO in the management of the CSComs extends that partnership 
to these community representatives. The latter speak about the fact that as a result of 
HKI's presence, nutrition has been given more importance. It is a regular topic of 
discussion during their monthly meetings with the health providers. Many communities 
also have general community meetings, and this has been an opportunity for key 
20
messages to be disseminated to regular community members, especially men. It is 
common practice for men to attend these meetings, while more women are reached when 
attending the CSCom, and through the outreach or campaign activities. 
Where there are CHWs who have been developed and trained by other programs 
(sometimes in collaboration with SAN+), these individuals also disseminate ENA 
messages during home visits, and during health education sessions. This creates the 
synergy that was the vision of the child survival project at the time of the design. Some 
rural midwives interviewed also mentioned that they participate in the women's ‘tontins,’ 
which are cooperatives where members are able to benefit from monthly collections to 
cover individual expenses or collective activities. These groups provide midwives the 
opportunity to reach numbers of women with health/nutrition messages. Some midwives 
reported that when they do not participate in the ‘tonins,’ they become socially isolated. 
So, based on the above, it appears that project activities (training of midwives and 
supporting message development and dissemination by community partners) have both 
contributed to, and taken advantage of existing social cohesion in the target population to 
disseminate messages. The project supports at least one urban-based health facility in 
each of the nine districts in which it works (some have more than one), and health staff 
also reach urban women through similar cooperatives, which meet weekly or two to three 
times per month. Nevertheless, health providers report that women in urban areas are 
difficult to reach outside of the ANC and child health clinic sessions because they are 
very busy and because cooperatives tend to be less cohesive in the urban areas. 
 
iii. Refining of project implementation. 
There have been no particular changes or modifications made to initial project plans. 
iv. Barriers to prevent members of the community from benefiting from 
the project
The major barrier to community members benefiting from the project is the fact that in 
general, health personnel do not have resources to provide services outside the health 
facilities. Routine home visits or community level visits are not activities that MOH staff 
can really undertake. Needless to say, those communities located in the outer areas of the 
health facility catchment area are dealing with distance as a barrier, and do not have easy 
access to the CSCom. But the new emphasis on the quality of outreach services, and 
being able to maximize this as a health and nutrition intervention, is increasing 
community access. In urban settings, CSCom staff report that the barrier is mainly that 
people are very busy. 
v. Impact of community and other factors on project implementation 
During the MTE discussions, among the factors identified as having impacted the 
project's ability to mobilize the community were those of the long-distances involved, i.e. 
some villages are as far as 200 km from the district centers (although it should be noted 
21
that the average distance of most health facilities from the district is approximately 50 
km). This reduces the frequency with which a project supervisor can support program 
activities in those areas. Some districts have a greater number of health facilities than 
others; e.g. the Kati district has 42 health facilities, while some have 11 and 12. Several 
supervisors also mentioned the fact that new CSComs are constantly in development, 
which changes the workload of supervisors and coverage. They report that approximately 
19 new CSComs have been opened in the region since the DIP was approved, so virtually 
all of the SAN+ supervisors are working with more facilities than was initially planned. 
And in addition to this, the frequent CSComstaff turnover makes the supervisors’ work 
even more challenging. Of the 120 health centers covered by HKI supervisors 
interviewed, 32 had seen a change in the head of the center, i.e. 27% (with two of those 
on their second change of staff). There are no real problems related to security, except for 
the fact that when traveling through isolated areas supervisors have to be vigilant for 
potential robbery. 
 
b. Communication for Behavior Change 
i. Existence of Behavior Change strategy 
The project's behavior change strategy is via radio programming, as mentioned above, 
and through work with health providers as channels of communication. The ENA training 
modules used to train the midwives in the region, and, which will be expanded in the 
second half of the project to include CSCom heads, has interpersonal BCC methods 
(negotiating for behavior change) integrated into the program. Thus ENA and BCC are 
considered linked strategies. Synergy for behavior change is also provided by other 
projects implemented in the region, and national campaigns via the television etc. 
 
ii. Appropriateness and effectiveness of project’s approach to behavior 
change 
Where there is the prior mentioned complementary coverage, i.e. in the 4 districts where 
the Keneya Ciwara project was being implemented, the project approach was certainly 
appropriate and effective. However, due to the vastness of the districts targeted by the 
Keneya Ciwara project, only a portion of the total communities in these four districts 
were able to benefit from this project. On the other hand, where Keneya Ciwara was 
present, there was no duplication of effort and all activities contributed to great synergy 
and potential impact. There are districts in Koulikoro with no organizations, local or 
international, working at the community level. In such cases, one can argue that program 
efforts have not been sufficient, i.e., the radio program does not provide for interpersonal 
communication and dialogue, and health workers are not able to spend much time in 
outreach beyond the health facility. 
The project implemented community advocacy workshops in each district, which had the 
potential to contribute to behavior change. But these only had the potential to have 
impact in areas where community mobilization through Keneya Ciwara encouraged these 
leaders to become more active champions for health and nutrition. Evidence of how much 
of an influence or impact these workshops had is not clear because there was no follow￾22
up. ASACOs who speak about their activities tend to emphasize that this is a result of 
their collaboration with the health workers rather than an outcome of the advocacy 
workshop. 
 
iii. Message quality 
The messages being used by the project are technically up-to-date, and have been 
developed in collaboration with the National Center for Health Education and 
Information (CNIECS). These are the same messages prioritized in other programs. As 
mentioned, SAN+ is working with the other nutrition stakeholders to complete the 
development of tools promoting the other key ENA messages. They are also interested in 
reviewing the data from a BEHAVE workshop hosted by the SAN+ project in Mali in 
January 2007, where secondary groups were identified; and may adapt or add messages 
to take those into consideration. 
iv. BCC messages teaching skills, negotiating changes and influencing 
social and behavioral norms
Health staff interviewed mentioned that cooking demonstrations they were able to 
implement through previous programs and the support of WFP foods, for example, were 
always a big help in putting nutrition knowledge to practice. This activity used to be 
conducted about once a week, and after cooking together, everyone would eat together. 
Some communities with the help of the ASACO, have also taken the initiative to bring 
food for cooking demonstrations. These initiatives will likely to be undertaken again 
through the HKI CTC activity. In communities where a strong effort is being made to 
encourage mothers to deliver in CSComs, immediate breast-feeding is put into practice 
by the health provider. Mothers report that as a result of all the education they have 
received, a lot of traditional practices such as feeding the newborns concoctions have 
been abandoned. During FGDs, mothers in various communities spoke about how they 
have fewer cases of illness such as diarrhea, and that this is a direct result of the hand￾washing and hygiene practices that they have learned and adopted. 
 
v. Effects of the behavior change activities and tools used 
The project planned for a baseline and the final KPC survey at the end of the four year 
period to measure the effects of behavior change activities. Outside of this, as it is a 
project that covers an entire region and is not a community-based project per se, the 
effects of the behavior change activities such as the radio broadcast program and the 
counseling that teaches skills in negotiation etc, is generally only measured qualitatively 
through informal reports from health facility staff and radio program agents – all of 
which have been very positive. The project has not chosen to do any close or routine 
monitoring of health facility data as a means to measure the effects of the aforementioned 
behavior change activities, although they do monitor the results of each SIAN which also 
confirms the population’s positive response to project-supported activities. 
As already mentionned, the project assisted the MOH to develop Vitamin A and de￾worming data collection tools that are now used during campaign activities. 
23
vi. Use of data 
The data gathered are used by CSComs and Districts. When interviewed, staff were able 
to speak about progress and improvements, i.e. reduced cases of illness and deaths. The 
regional health office stated that they had lower coverage statistics because they were not 
able to provide health facilities with supervisions and support in 2007 (funding 
problems). Per interviews, communities with CHWs collect and use data as well. But 
those without CHWs, or with inactive CHWs, don’t have access to data or use it. It 
should be noted that community members have a good idea of what is happening too. 
Their discussions of observations of changes included reduced cases of illness, mortality 
etc, as a result of HKI and other program support. 
vii. Innovative approaches successful in changing behavior 
The project intended to use a grandmother (Musokoroba) approach, implemented under 
previous HKI Mali child survival project. Thus far staff has not been able to implement 
this due to limited resources and the geographic scope of the project, spread across 9 
districts (region-wide). 
c. Capacity Building Approach 
i. Strengthening the Grantee Organization 
• Progress 
The progress made in terms of capacity building objectives was good. More or less all 
activities that were in the DIP training plan were implemented, and clearly appear to have 
contributed to staff capacity to manage and implement this program. Other capacity 
building activities undertaken by the project include the training of project staff in 
interview techniques for the KPC survey and for Health Facility Assessments as well as 
hemoglobin assessment. Staff also benefited from training in ENA, M&E, and the 
BEHAVE model for BCC. The first project Coordinator was able to travel to Benin for 
ENA training, and both the current Coordinator and Deputy were able to travel to 
Senegal for training in BCC and M&E respectively. 
Staff also benefited from training by URC in Quality Assurance (QA), although, as noted, 
impact has been reduced by lack of follow up in applying supervision tools and checklists 
developed in the workshop. Playing a supportive role, rather than implementing directly, 
has also increased project staff skills in support and supervision. It should also be noted 
that the team has gained substantial experience in the area of revitalization/integration of 
nutrition into existing services. 
One area of weakness that does stand out in the area of progress and growth of the 
country team, is the lack of systematic, periodic and routine documentation, reporting and 
information-sharing for the project. Data coming in from field staff is supposed to be 
entered into the database, and then used for analysis and decision-making. It is not clear 
that these data are routinely shared and discussed among the project leadership. Reports 
24
written or documentation of training, workshop and other activities is entirely dependent 
on the MOH partner, who rightly plays a leadership role in these events. But as a result, 
this documentation is sometimes missing at the project office level (even though, being 
activities that are funded or supported by the project, the project is responsible for 
reporting on these activities), e.g. in the case of the QA workshop, the meeting notes 
including indicators developed and follow-up activities outlined were not available at the 
time of the MTE because they could not be found in the office. 
• Approaches and tools used to assess capacity 
Pre- and post-tests tools are generally used for training activities, although not for the 
trainings for project staff. During staff meetings and technical updates, discussions and 
participation from staff enable the project leadership to assess staff capacity to implement 
the program. 
• Activities related to organizational capacity building 
Please refer to the above as it pertains to in-country staff training. No capacity building 
activities were undertaken for the HQ level aside from routine participation in the CORE 
group. 
• Indications that the project has increased organizational capacity 
From all accounts implementing the ‘scale- up’ SAN+ project has been an opportunity 
for HKI in-country to increase staff skills in capacity building, quality improvement of 
services and ability to work region-wide. Feedback given to the MTE teams by project 
partners at the district and health facility level was very positive. The regional team noted 
that when health districts with NGO support are performing better than those without, it 
becomes very difficult for the regional team to manage the varying needs and disparity. 
The regional approach of SAN+ helps with uniformity and equity, which is particularly 
important in this case because the intervention is the re-integration and strengthening of a 
key component of the minimum package of services. 
ii. Strengthening Local Partner Organizations 
• Organizational capacity building efforts with the local partners 
The main organizational capacity building efforts conducted by the project for the 
primary local partner were the following: Training of Trainers (TOT) in ENA/BCC, and 
subsequent support for training of district and health facility staff in ENA/BCC; an 
attempt to introduce quality assurance by supporting a workshop to which several district 
and health facility staff were invited to participate; and more recently, under the parallel 
Community Therapeutic Care (CTC) funding, a TOT for CTC. The main participants for 
these aforementioned activities have been the district and CSCom staff, although the 
regional office has had representatives participate in all activities. To begin MOH staff 
capacity building process, the project in fact, organized an advocacy meeting at the 
25
Koulikoro regional level where different government representatives and ministries were 
invited to participate. 
As previously mentioned, the QA workshop does not appear to have been very effective 
as there has been no follow up of the workshop recommendations (indicators to be used 
etc). Again, it should be noted that the project does use supervision tools/checklists that 
measure the quality of IEC and counseling services being provided at the health facility 
level, as well as growth monitoring of children. But as mentioned earlier, many district 
teams do not manage to participate in supervisions conducted by the project staff. There 
has been a major problem at the ministry level with funding for supervision activities. 
Both the region and districts report that they are dependent on outside agencies to support 
these activities; primarily because these are not budget expenses that seemed to be 
approved at the national level. In Koulikoro, UNICEF appears to be the only entity that 
supports supervision (an annual supervision/monitoring activity conducted by the 
regional team and a separate one by the district team, covering each health facility). But 
the approval processes for this is generally accompanied by delays, and sometimes no 
funding, as was the case in 2007. 
The radio network is another local partner that has been strengthened. The project 
collaboration was an opportunity for these community radios to strengthen their skills in 
broadcasting for health, build up existing materials and content for health and nutrition 
programs, and become active champions in this area. Their ability to develop interesting 
and creative health programs is evidence of this, as well as the ability of at least one of 
the rural radios interviewed to attract other contracts. 
• Roles and responsibilities of each of the local partners 
The regional health directorate of Koulikoro provides technical guidance to districts, 
supports strategic planning and the dissemination of norms and standards etc. Districts 
health offices have more of a supervisory role in the implementation of health services, 
although they do not manage to reach most CSComs on a regular basis. They aggregate 
statistics collected at the CSComs and monitor progress on key indicators. When they 
have the resources, they organize trainings and meetings for district-wide staff. In the 
case of SAN+, HKI has financed specific training activities with the districts, and the 
regional staff participated in TOT activities and took a leadership role in training. Aside 
from training, the district and regional staff involvement has been limited to occasional 
meetings and supervision, as they have tended not to have an adequate budget to cover 
the latter. Although project field staff would have liked to be accompanied by their 
counterparts (who could ride out on the back of the motorcycle with them) during visits 
to health facilities, this solution is undermined by the lack of per diem; it is often difficult 
to get MOH staff participation without this. The child survival project budget is 
particularly stretched because it is a region-wide project covering nine districts. One of 
the issues discussed during the MTE was the lack of project budget for joint supervision 
activities. These activities were generally not undertaken during the first half of the 
project, but HKI recognizes that this needs to be remedied in order to assure not only the 
26
involvement of the government counterparts, but to facilitate the process by which these 
local health authorities take more responsibility for the nutrition integration activities. 
The ability of the local MOH partners to carry out their job responsibilities is very much 
a challenge, as they will readily tell anyone who broaches the subject. The regional and 
district teams are usually balancing priorities and donor activities. Many districts are 
understaffed and/or dealing with issues of low motivation. All health facility staff 
interviewed stated that they had received more visits from the HKI team than they had 
from their own districts health teams in the previous year. They have a lot of appreciation 
for the support that they have received from the project, and feel less isolated as a result; 
nevertheless, a solution that would permit more government supervision is desirable and 
more sustainable after the project ends. 
• Outcomes of any assessment 
The project conducted a health facility assessment at the time of the DIP development 
and will be conducting a follow-up assessment at the end of the project period. Aside 
from this, project staff report that they conduct pre- and post-test knowledge assessments 
at every training workshop. For the ENA training for example, staff reports verbally that 
the lowest mark in the post tests was higher than the average mark in the pretest, but has 
not written up the summary and discussion of these results. 
• Changes in local partner organizational capacity 
Per interviews, local partners at every level feel that they have increased their capacity as 
a result of the project. Health providers across the board report that their knowledge went 
from being general to specific. Some of their practices have also changed. For example, 
they now provide two capsules of (200,000 IUs) Vitamin A to postnatal mothers rather 
than one. Health providers and SAN+ supervisors report that IEC now includes a strong 
focus on ENA, with key messages to encourage behavior change (as noted in the IEC 
books kept by the midwives to document these sessions). Health providers can cite 
specific steps in counseling for behavior change, and systematically include nutrition and 
micronutrient supplementation in their routine mother and child health activities. During 
outreach activities, there is now a stronger focus on education around key nutrition and 
health messages. It is apparent that the project has had a big impact with regard to the 
integration of nutrition into basic health service provision at the health facility level. And 
this is also the case at the district and regional levels where nutrition is now 
systematically included in annual planning; usually the provision for Vitamin A 
supplementation through biannual campaigns, and seeking partners to finance training 
and technical updates for new and existing staff. 
• Challenges in further building the capacities of partners 
Among the challenges that the project will continue to face is the fact that there are 
always more needs in training than resources. Although the CTC project funding offers a 
considerable opportunity for further training, facilitating the engagement of more CSCom 
27
staff, there are still limits to the project’s capacity to meet all training needs in a region￾wide project. Per project staff, and also reflected during MTE interviews, everyone wants 
to have the opportunity to participate in a training activity (although they also conceded 
that they generally learn from others who have received training, and share information 
among themselves during staff meetings as well). Training is considered a perk and 
privilege, and sparks discussions around inequity when some receive training and others 
do not. 
Challenges related to building the capacity of community partners are similar. Per MOH 
guidelines and requirements discussed during interviews, the project should train one 
CHW for every 33 households or 250 inhabitants across the region. But even with the 
additional CTC program budget, the project cannot cover this expense. Moreover, some 
communities do not currently have enough CHWs; others have not had recent NGO 
support. All of these factors have to be taken into consideration. According to project 
staff, each district has a different situation. Some CHWs have received training in 
nutrition but not in IMCI, and vice versa. (The training proposed under the OFDA-funded 
project will be in C-IMCI, and include CTC in that module). One advantage, as was 
mentioned before, is the presence of UNICEF, whose priorities also include the training 
of CHWs in C-IMCI. So the two organizations will be able to again join forces in 
supporting the MOH with this endeavor. 
iii. Health Facilities Strengthening 
• Appropriateness and effectiveness of health facility strengthening 
activities 
As discussed above, by all accounts, the HF strengthening activities have been 
successful. All training was followed up by supportive supervision, conducted by HKI 
field staff and this particular strategy enabled rural midwives, in particular, to improve 
their knowledge and skills in nutrition, health education and counseling, and facilitated 
the overall re-integration of this as part of minimum package of services. The one 
missing component of this activity was the close involvement of the districts in support 
and supervision. But this does not seem to have had an adverse impact on the successful 
integration process. Health facility heads are quite used to working independently and 
managing the CSCom team. Interviews with different representatives of this cadre 
suggest they have bought into the importance of nutrition interventions, and have been 
providing their support by supervising rural midwives with periodic observation of group 
health education sessions being conducted at the health center, and discussions/review 
during their weekly meetings. 
• Tools used for health facility assessments 
For the baseline and final HFA, the project is using the standard tool. In addition to this, 
SAN+ uses a checklist for assessing education sessions and a checklist for assessing 
growth monitoring and counseling. Monthly activity reports from the project supervisors, 
require the monitoring of health facility stocks (IFA, SP, Vitamin A etc.); and the number 
of IEC sessions and counseling, as well as participants and content of these sessions. 
28
These checklists are used by the nine project supervisors based in the districts. The 
checklist for education sessions looks at a list of 17 elements related to the method used 
by the health provider, and an additional 11 points covering the discussion itself and 
thoroughness on content. The guide also assists supervisors with how to conduct 
feedback. It uses a participatory method whereby the health provider does an auto 
critique, and together they come up with points to strengthen and actions to be taken. The 
checklist for growth monitoring and counseling consists of a list of 19 items covering the 
steps that the health provider should be following, and the interaction that he/she has with 
the client. 
The MOH uses a monitoring guide every six months to assess progress made at the health 
facility level. SAN + is negotiating with the Health Directorate to include more nutrition 
related indicators in these guidelines (Vitamin A is already included). 
 
The above tools are appropriate and have reportedly been very effective, as health 
providers unanimously report that HKI supervisor visits are useful and serve as learning 
opportunities for them. When supervisions are conducted by the Bamako-based project 
leadership, they typically develop terms of reference based on priority areas, training 
provided and/or gaps previously identified (as does the MOH). The terms of reference 
serves as a tool for that particular supervision and is changed or modified when planning 
for every new supervision activity. 
It should be noted that the project team in Bamako has not been conducting field 
supervisions and assessments as frequently as they had initially expected to be doing. 
This first half of the project has involved a lot of coordination and collaboration with the 
Nutrition Division at the national level, (including providing technical assistance to the 
development of policy norms and procedures for the nutrition program which has also 
involved USAID and other stakeholders). HKI also participates in stakeholder meetings, 
as a major partner, and the project leadership has spent a lot of time and effort leveraging 
additional support for health and nutrition, e.g. the MI and CTC programs. 
• Discuss linkages between these facilities and the communities. 
Rural midwives have a lot of contact with women and family members frequenting the 
CSCom. They conduct the ANC clinics, as well as growth monitoring, family planning 
and counseling. They report having contact with grandmothers, who often accompany 
clients to the health centers for their first ANC visit or when they are ready to deliver. In 
addition, as mentioned before, health providers, and specifically midwives, also have 
contact with communities during the outreach activities, when they are conducted. The 
presence of community health committees (ASACOs) at each CSCom also facilitates 
communication with communities, because these community leaders work with the 
health team in the management of the community health center and then carry 
information into their communities. 
Per the interviews held with both midwives and women, it is clear that linkages with 
communities are stronger now, and have been influenced by the project training and 
29
support of health providers in improved service provision and nutrition integration. The 
radio program dissemination of key messages has also encouraged more prompt care 
seeking behavior and communication with health providers. 
iv. Strengthening Health Worker Performance 
Please refer to the above sections for details on strengthening health worker performance. 
Again, performance is assessed during supervision visits conducted by HKI supervisors 
based in the districts. The focus of their visits has either been on post training support for 
practice of new knowledge and skills, or specifically revolves around correcting areas of 
weakness. SAN+ has been using this strategy of consistent support to try to address the 
gaps between performance standards and actual performance. In addition to this, MTE 
findings highlighted the fact that there is a need for project leadership to participate more 
actively in district level coordination meetings, taking advantage of such opportunities to 
review, discuss and problem solve with the team of HF heads and their district 
supervisors. 
v. Training 
• Training strategy, and its effectiveness.
Again, the training strategy used under this project was that of TOT for select regional 
and district participants, and support for the training of rural midwives. This was 
effective in that a large number of MOH personnel were able to receive training, and the 
training was conducted by district and regional supervisory staff who at the end of the 
project will be the stakeholders responsible for ensuring the sustainability of these 
activities. 
• Progress on objectives 
 
Overall the project achieved most of its training objectives. In addition to the training of 
midwives, they were able to carry out nutrition orientation activities with heads of health 
centers, conduct advocacy with community leaders, train radio broadcasters on key 
messages and communication techniques, and undertake a BEHAVE workshop to 
develop a BCC strategy. While they did conduct a quality assurance workshop as well, as 
mentioned, there has been no follow up. During the workshop there was some 
brainstorming on criteria and assessment methods for QA, along with the development of 
a list of indicators to use in assessing quality of health services, but these were not 
implemented. Thus this is one activity staff will need to undertake during the second half 
of the project. And although the DIP states, “HKI will take a pro-active approach to 
incorporate gender into all aspects of SAN+,” the training strategy did not have specific 
focus on gender (project staff report that it is more or less integrated in all their 
activities). 
30
• Evidence that training implemented has given results. 
Please refer to previous comments made with regard to this point. In addition, from a 
monitoring standpoint, project supervisor monthly reports provide supportive evidence 
that project training and supportive supervision have resulted in increased knowledge and 
skills among health staff trained, as well as among those who did not participate in 
training. In addition to the HKI reporting, the MTE discussions with project supervisors, 
and interviews with quite a number of health center heads confirmed this finding. Health 
facilities are also able to provide documentation of their activities through the IEC books, 
which record all of the education sessions that they undertake; including the subjects 
covered and the number of participants. The micronutrient supplement coverage reports 
also show progress in this regard (VAS 6-11 months 85%; VAS 12-15 months 93%; 
deworming 12-23 months 95% in the December 2007 integrated campaign). 
d. Sustainability Strategy 
i. Progress on meeting sustainability objectives 
Per the project DIP, the SAN+ project approach was basically ‘not to create something 
new’ but rather strengthen the existing system and help solve bottlenecks and barriers to 
the proper functioning of health services and community access to the services. The 
sustainability section of DIP specifically outlines the following: 
Sustainability will be assured through: 
• Reliance largely on existing personnel, relationships, and structures; 
• Responding to needs identified by Regional Health Directorate and other 
implementing partners; 
• Strategies and activities consistent with MOH/SD policy or modification of 
policies where appropriate; 
• Joint assessment, planning, implementation, monitoring, and evaluation; 
• Community Health Associations, ASACOs, with increased capacity to assess, 
plan, implement, monitor, evaluate and manage CSComs (facility and outreach); 
• CSComs with increased capacity to deliver the Nutrition+ package; 
• District Health Officers /Reference Health Centers with increased capacity to 
assess, supervise, coach, monitor; 
• Regional Health Directorate with increased capacity to assess, plan, monitor and 
evaluate; 
• MOH/SD at national level with increased capacity to adopt state-of-the-art 
policies, strategies, approaches and translate these policies into programs; 
• Rural radios with increased capacity to design and disseminate effective, accurate 
messages promoting utilization of CSComs and improved household practices for 
infant and young child feeding; 
• Communal and cercle councils with increased understanding of health and 
nutrition issues and provision of increased investments in health and nutrition; 
• Mali URTEL, ORTM, and local, regional and national ASACO associations with 
increased capacity to support member organizations programmatically. 
31
The MTE process involving FGD's and key informant interviews across several districts 
and region and the national levels was an important opportunity for the external 
consultant, HKI headquarters staff, project staff and partners to review progress towards 
achieving the above. As discussed throughout the report, SAN+ is very much on track as 
it relates to its intervention-related and capacity building objectives. Sustainability 
objectives as articulated above, were an integral part of the program design. When 
referring to the above list, overall the project appears to have made excellent progress in 
terms of process and coverage. (Some of the district indicators look better than others, but 
SIAN campaign coverage has been very good as noted on the previous page). The area of 
weakness again, is that of joint assessment, planning, implementation, monitoring, and 
evaluation. 
The district teams interviewed displayed evidence of relatively strong technical and 
management capacity, and have a system in place for supervision and monitoring. The 
regional team's focus seems to be more on juggling priorities, overall management and 
leveraging financial support from the various partners. It could be argued that the 
program did not necessarily need to dedicate effort in the area of technical capacity 
building for planning, supervision, assessment and monitoring. But the project has not yet 
explored how it might strengthen district health officers /reference health centers capacity 
to assess, supervise, coach, monitor, and regional health directorate capacity to assess, 
plan, monitor and evaluate. Instead, the project has prioritized health service provision 
during this first two years of activities, and project staff has been completely taken up by 
this. In addition, there are approximately 19 new health facilities since the development 
of the DIP. This dramatically increases the effort the project has to make at this level. 
During the MTE interviews, the main complaint of these program partners is that HKI 
was not helping to finance joint supervisions to support district and regional staff 
involvement in the above. 
ii. Groundwork for the phase-out 
The program strategy is one of partnership and sustainability. Not many resources other 
than staff technical support and training have been provided, and this should facilitate 
phase-out. But the success of the nutrition re-integration has primarily been due to the 
support and supervision provided by the HKI supervisors. It was starkly clear from 
interviews with health providers indicating they have not received many visits from their 
supervisors in the district during this first two-year period. This is a big gap that will need 
to be addressed prior to the phase-out of HKI support. 
iii. Approaches to building financial sustainability 
The SAN+ project has not undertaken any specific work to build financial sustainability. 
But certainly it should be noted that in the area of Vitamin A (which has been an 
important contribution of HKI’s in Mali), HKI has contributed to making this a national 
priority. The MOH Division of Nutrition is now purchasing Vitamin A to support the bi￾annual campaigns nationwide. This is also considered a priority by the regional team; 
something that has become part of the annual planning and budgeting. So the MOH 
32
expects to continue mobilizing resources to get the supplies needed. The project staff 
should continue its dialogue with the national and regional health divisions about 
budgeting for appropriate supervisory visits and for micronutrient supplies needed for 
both routine service delivery and periodic campaigns. 
 
iv. Community capacity to sustain project services 
As previously mentioned, there has not been a lot of effort put towards community 
mobilization, as the main strategy of SAN+ has been to work at the health facility level. 
But advocacy with community leaders was very much geared towards encouraging them 
to take initiatives and responsibility for supporting improved health and nutrition in their 
communities. Communities that have been working with the Keneya Ciwara CARE 
project have a clear advantage in this regard as community leaders and volunteers are 
already active and have demonstrated a good level of commitment to sustaining 
activities. ASACOs sometimes collect money from community members or mobilize the 
support of the commune to undertake specific activities. But there is no doubt that 
identifying alternate funding sources will remain a challenge for communities. 
v. Sustainability design methodology 
NA 
C. Project Management 
1. Planning 
a. Groups involved in project planning 
Project funding is led by the project coordinator in consultation with the MOH national, 
regional and district health teams. As this is a partnership project, the SAN+ team cannot 
undertake any activities without the collaboration and coordination of its primary partner. 
It is also important to note that maximizing impact by creating synergy has involved a lot 
of communication, collaboration and coordination with other projects such as ATN, 
UNICEF and other stakeholders working in nutrition and micronutrients interventions. 
b. Work plan in DIP on schedule 
The project has done a good job of sticking to the work plan submitted in the DIP. There 
have been no major delays in the implementation of activities outlined in the DIP work 
plan. 
c. Knowledge of project’s objectives 
Project objectives are understood by field and headquarters staff as well as local level 
partners, and community leaders. 
d. Copy of the project's objectives and the monitoring and evaluation plan 
Program partners participated in the development of the project and have copies of 
project documents. 
33
e. Use of project monitoring data for planning and/or revisions 
Per interviews with the HKI team, they closely follow district and regional monitoring. 
The project leadership receives copies of the quarterly monitoring reports from each 
health facility, and review/discuss the data with both the health facility and the district. 
The data often elicit questions and discussions around coverage, and providers will often 
cite challenges such as the lack of budget for outreach activities, problems with logistics, 
fuel cost, cold chain, human resource/health personnel drop-outs etc. Although this 
information is available to the project and its partners, staff report that because of the 
budgetary constraints of the project, these monitoring data have not been used to inform 
or revise program implementation. Thus the project staff use the data to assist in 
addressing problems on a piecemeal basis, but this approach does not address the gaps 
long-term. Data have been used to examine trends in coverage from quarter to quarter, 
identify problems, and, to the degree possible, solve those problems. This weakness may 
be addressed soon with the additional support of the OFDA funding and UNICEF. The 
SAN+ team expects to use these resources to train the heads of the CSComs to support 
their use of data for decision making and planning. The child survival project has targeted 
midwives for training because they are directly responsible for providing most of the 
MCH services. However, because most of the midwives do not have a high level of 
education, they may not have the capacity to use data for decision making. With the 
support of the center heads, who are responsible for planning, making revisions to 
services and supporting and supervising these midwives, the use of data may improve. 
2. Staff Training 
a. Effectiveness of the process for continual improvement of the project's 
staff 
HKI has invested in the training of its staff, as discussed above, including sending people 
to neighboring countries and workshops. Even the administrative/financial staff person 
reported having received training. New and existing SAN+ field staff have been provided 
with technical updates every few months relating to new activities and interventions that 
the project was undertaking. Periodic staff meetings between animators and project 
leadership have been opportunities for new animators to learn from existing field staff, as 
part of their orientation to program priorities and efforts. The project has not conducted 
any specific staff training needs assessments or follow-up assessments. In addition, there 
has been relatively limited supervision of staff at the field level by the Coordinator and 
Deputy due to conflicting priorities, requirements for collaboration and coordination at 
the national level, budgetary constraints, etc. There were budget problems due to the 
serious underestimation of certain costs at the time of the project design. HKI had never 
worked on such a big scale before in Mali (the previous CSP covered only three districts). 
The increasing cost of fuel and the devaluation of dollar have contributed to this problem. 
As a result of the above, it is not clear just how sure the project coordinators can be of 
field staff performance as it relates to their specific job responsibilities. These aspects are 
discussed during periodic meetings, or when field staff comes to Bamako monthly to 
34
collect salaries. But as the Coordinator and Deputy are not able to be consistently present 
in the field, observing and supporting the animators at work, they may have limited 
ability to assess specific qualitative aspects of field staff job performance. Again, the 
complementary funding from OFDA has facilitated increased contact between the project 
staff and field supervisors in the two pilot districts. As this component is expanded to 
cover the other 7 districts during the second half of SAN+, animators will benefit from 
more field supervision and support for continual performance improvement. 
b. Monitoring of trainee performance 
Monitoring of trainee performance is not done for HKI staff. 
c. Resources dedicated to staff training 
During MTE interviews, all staff reported that they feel adequate resources have been 
dedicated to staff training. Many of the project staff had prior experiences in NGO 
projects or in HKI projects. This was one advantage going in, and staff feels that they 
have been adequately prepared to undertake their job responsibilities. 
3. Supervision of Project Staff 
a. Effectiveness of process of directing and supporting staff 
An annual performance evaluation system is in place, and includes a feedback process 
etc. Please refer to the above comments on supervisory methods and training as it relates 
to staff. Joint work planning and problem solving as an entire team takes place once 
every few months; when the team meets for a specific technical update or orientation 
activity. But the Bamako-based project leadership (Coordinator, Deputy and Mickey 
Leland Hunger Fellow) works very closely as a team in the planning and coordination of 
all program activities and problem solving. 
 
b. Numbers, roles, and workload of personnel and frequency of supervisory 
visits appropriate for the technical and managerial needs of the project 
The workload is large because HKI Mali has multiple projects; several contribute to 
matching funds as well as synergy. HKI took the initiative of obtaining a Mickey Leland 
Hunger Fellow, as mentioned above, (also serving as match), who provides additional 
technical support, including help with documentation and report writing. 
The CTC OFDA-funded project has brought a lot of extra work for the team, as it does 
not come with a whole separate staff, but was designed to become an integral part of the 
CSP. Despite the extra workload, the SAN+ staff is very appreciative of this added 
intervention and funding because it provides synergy and complementarity to SAN+ and 
lends more visibility to the project with its district and community level partners. The 
latter are very happy with the extra funds that will be available for staff and community 
volunteer training in health, ENA and the identification and treatment of malnutrition 
cases. Community members are always very grateful when they get support in the form 
35
of therapeutic foods for the affected children as well. This added opportunity for 
community mobilization is a strong asset for the child survival project and will be of 
considerable assistance to the achievement of the SAN+ objectives. 
The infrequency of supervisory visits for SAN+ and potential impact on the quality has 
already been discussed. It is not clear whether, had the project leadership been able to 
spend more time with the district and regional teams, there would have been more 
systematic involvement of these teams in the nutrition integration process. The country 
leadership realizes that it would be desirable in the future for project senior staff to do 
more in the area of facilitating regional and district engagement in quality assurance, and 
provide advocacy and support for community outreach. It is important to note that the 
OFDA budget, together with UNICEF support for new CTC activities, will allow the 
project leadership to do more of this now; including supporting joint supervision visits 
(with district and regional partners) and action-planning based on these. The staff now 
expects to be able to conduct joint supervisions of all health facilities every two months, 
and this will help meet some of the technical and managerial needs of the project. 
The SAN+ team is trying to strengthen the relationship with the regional health 
directorate. They plan to increase contact and communication and hope that establishing 
a closer relationship will allow them opportunities to provide more support, e.g. increased 
participation in MOH regional meetings etc. The project budget does not include support 
for the cost of the regional meetings, however. Regional meetings are costly because they 
usually involve a 3-day trip for two to three technical staff from each district, and a 
chauffeur. 
Per discussions and observations during the MTE, the MOH district teams (and the 
regional team as well) are certainly overloaded by the different programs and job 
responsibilities. When one representative goes to meetings or trainings at the regional 
level, feedback to the rest of the team is not necessarily immediate or systematic because 
everyone is busy. From discussions, it appears that some of the district teams manage to 
share and discuss issues more than others. And sometimes, as is the case with some 
health facility personnel, colleagues are not receptive because they feel that they have a 
right to have their own training opportunities. The MOH is reportedly looking at trying 
to manage the issue of workload with restructuring; i.e., the development of two teams at 
the district level (one for public health and one for medical) so that technical and 
managerial responsibilities can be better handled. 
3. Human Resources and Staff Management 
a. Personnel management system and changes 
The personnel management system has not changed. All posts are filled. 
36
b. Presence of personnel policies and procedures, job descriptions, and work 
with partners 
All staff have copies of their job descriptions, and are briefed on policies when they are 
hired. Manuals and policies are available on the HKI intranet. An MOU has been signed 
with UNICEF for the CTC activity, articulating the nature of the relationship. HKI also 
has one with the Koulikoro regional health directorate ensuring commitment, partnership 
and the complementarity of efforts. 
 
c. Morale, cohesion and working relationships of project personnel 
There is very good team spirit among the staff. The staff is motivated. There is cohesion 
and good communication, sharing of tasks based on individual skill set and availability. 
The Bamako team has participated in the TOTs that have been organized by the project, 
and project supervisors always participate in the trainings at the district level. This has 
had a positive impact on project implementation. 
d. Staff turnover and impact on project implementation. 
Although the project did lose its first coordinator to WFP, this has not had a negative 
impact on project implementation. Despite the fact that HKI was not able to ensure a 
handover and overlap at the time of the first coordinator's departure in July of 2007, the 
new project coordinator is extremely qualified, and SAN+ has continued to make 
achievements since the staffing change. It should be mentioned that there was a change in 
HKI country directors during the same period; and no overlap between the old and the 
new in that case either. But HKI was fortunate enough to bring on an individual who had 
been living and working in Mali for a number of years, and so this was not particularly 
problematic. 
The loss of a project supervisor who resigned in August 2007 to pursue further studies 
did, however, have a significant impact on the continuity of support and supervision to 
the health facilities in that district. When asked how many supervision visits they had 
received in the last year by the project, CSComs visited in this district during the MTE 
generally responded that they had only received one, as compared to others who had 
received between two and four visits on average. (It is important to note though that a 
good part of the previous year had been dedicated to staff and partner training, and thus 
support and supervision activities had only really been taking place for about six months 
or so prior to the midterm). HKI was unable to replace this staff person until a full six 
months after his departure, and explained that this was due to difficulties finding 
someone with an appropriate background. Although other supervisors were not nutrition 
specialist when hired, they had a lot of field experience. 
HKI Mali does not report using specific strategies for staff retention. 
 
37
e. Facilitating staff transition to other paying jobs when the project ends 
When HKI develops new projects, staff usually transfers to those. They have been able to 
do this relatively successfully in the past with different staff. But this is very much 
dependent on funding and projects. 
 
5. Financial Management 
Management and accountability for project finances, planning for 
sustainability 
Each HKI country office and the headquarters develop annual and monthly budgets. 
Money is sent to the Mali country office from the headquarters in New York, and budget 
reviews are conducted every six months. The Mali office administrator and assistant, 
both of whom participated in the project design and budget development, also assist with 
this review. This administrative team, led by the country director, verifies and authorizes 
routine expenditures and produces monthly financial reports. 
 
Again the strategy for SAN + was one where limited material inputs would be provided. 
The project did not want to encourage too much dependence by introducing and 
developing programs that could not be sustained. Remaining true to the project's name, 
Synergy and Action for Nutrition plus, in addition to benefiting from the presence of 
other NGO projects, HKI has been able to obtain a lot of different funding for various 
types of nutrition-related activities (the office has about 14 donors). This includes OFDA 
support, the Micronutrient Initiative grant for the provision of Vitamin A during SIAN 
campaigns; and the Global Alliance for Improved Nutrition (GAIN), which entails the 
fortification of cotton oil with vitamin A. The project coordinator for the last has been 
contributing approximately 16% of his level of effort to the SAN+ project. HKI Mali was 
also able to get support from the McKnight Foundation to implement nutritional bio￾fortification of sorghum and maize. 
6. Logistics 
a. Impact of logistics on the implementation of the DIP 
HKI contributed one vehicle and nine motorcycles as match funds. They have not 
encountered any problems with logistics. They have purchased an additional vehicle with 
the OFDA funded project, which is integrated into the Child Survival project. 
b. Logistics challenges during the remainder of the project 
The devaluation of the US dollar will continue to have a negative impact on the project 
budget and availability of funds to work across nine districts. Program staff will continue 
to have to be very careful in the allocation of expenditures for logistics. 
 
38
7. Information Management 
a. System to measure progress towards project objectives 
Project data is collected through the existing Ministry of Health system. This is primarily 
related to Vitamin A coverage for children under five and postnatal mothers, de￾worming, SP and IFA for pregnant women. Thus in the area of coverage, the project is 
able to measure progress towards objectives. In addition to the routine health facility 
data, as mentioned before, the project has bi-annual SIAN data available. This system of 
measuring data is effective and sustainable as there is no duplication of effort. The 
project has supported the region for the modification and improvement of Vitamin A and 
de-worming campaign data collection tools. Behavior change objectives will be measured 
at the time of the final evaluation through a KPC survey. 
b. Collection, reporting and use of data 
Data are used at three levels: the CSCom, district and region. At the CSCom level those 
providers interviewed in the sample health centers visited during the MTE, spoke about 
improved coverage and strengthening of nutrition activities. Project supervisors also 
provide this staff with feedback when they have questions about the data/reports. With 
this continuous attention and support, providers have become very aware of the 
importance that is now being accorded to coverage in micronutrients supplementation, 
IFA, SP etc. 
Health facility data is compiled at the district level using a computer data system. A copy 
of this report is then sent to the region, and also shared with the project. The region 
subsequently consolidates data received from all nine districts. This data is discussed in 
quarterly coordination meetings at both the district and regional levels. 
c. Types of data, frequency and method(s) of data analysis 
Please refer to the above. 
d. Project use and support of government data collection systems 
The project is working and supporting the existing MOH data collection system (already 
discussed). 
e. Use of data to inform management decision-making 
As noted previously, despite the project’s access to MOH data, there does not appear to 
have been consistent sharing and discussion/analysis of these data on a monthly or 
quarterly basis between the project leadership, and documentation is weak. There are also 
no routinely scheduled monthly or quarterly SAN+ staff meetings taking place. Contact 
with the field staff is often ad hoc. Meetings tend to be scheduled only when there is the 
need to provide technical updates, or when there is something specific taking place. 
Although supervisors do use project data as they try to support health providers, it is not 
39
clear to what degree data have been used to inform management decision-making. The 
project leadership reiterated that budget constraints prior to the start up of the CTC 
activities did limit the flexibility of the project and frequency of meetings to discuss and 
use data for decision-making. As this project is working region wide, and not just in one 
or two districts, even uniting staff on a quarterly basis (let alone monthly as many 
projects do), has been a difficult. 
f. Purpose, methods, findings and use of any assessments 
Aside from baseline KPC and HFA activities, at the time the MTE, the project had not 
conducted any other types of assessments. 
8. Technical and Administrative Support 
a. Types and sources of external technical assistance 
The Child Survival Collaborative group provided technical assistance with a BEHAVE 
workshop, to help the project develop a BCC strategy and key messages. None of the 
project staff had prior experience in this area. The deputy coordinator was also able to 
attend M&E training in Dakar, and the first project coordinator received nutrition training 
in Benin. The project also received technical assistance from the University Research 
Cooperation in Quality Assurance. URC assisted with the implementation of the 
workshop at the Koulikoro region. Some of the external assistance provided to the project 
has not yet led to direct action on the part of the project and it's partners, i.e. the project 
delayed the use of some of the results from the BEHAVE workshop for reasons discussed 
above, and mentioned, there was no follow-up after the QA workshop. 
 
b. Anticipated technical assistance needs 
SAN+ does not anticipate the need for more technical assistance. 
 
c. Country Office, Headquarters and Regional support of the field project 
The Mali Country Director reports dedicating approximately 25% of her time to the 
SAN+ and CTC projects. She provides organizational support to the team, and has helped 
to clarify the roles of staff including the Fellow, and the integration of the new CTC 
activities into the CS project. The CD, again new to HKI, has made efforts to bring 
supervisors together more, and have team building. She recognizes that they have been 
left out on their own too much in the past, as discussed above. 
The percentage level of effort from HKI regional staff is between 5 and 10 percent. Since 
her arrival in early 2007, the HQ technical advisor gives approximately 20% level of 
effort to the Mali project. She has provided support with the annual report, reviewed 
project documents and receives updates from the country office periodically. 
40
9. Mission Collaboration 
HKI maintains regular communication with the USAID Mission about program activities, 
achievements and strategies. The project's goals and objectives fit into the Mission’s 
overall health objectives, demonstrated by the fact that the project also works very 
closely with other mission-funded stakeholders such as the ATN project, and provides 
synergy to the mission-funded Keneya Ciwara Project. 
E. Conclusions and Recommendations 
Strengths
Good collaboration with UNICEF in the region 
Areas of Weakness
• Lack of follow-up on the Quality Assurance component of project, e.g. 
recommendations were developed during a QA Workshop; poor documentation 
and dissemination of these and no action taken. 
• Project did not budget for strategic activities such as joint supervisions and 
coordination meetings. 
• Gap in community-level interpersonal communications activities for ENA in 
communities not being supported by other projects such as Keneya Ciwara (thus 
synergy is uneven across the region, and no specific work has been done with 
women’s associations and with the grandmother strategy as discussed in the DIP). 
Recommendations - Community level 
1. Emphasis on BCC messages needs to include feeding during illness and 
maternal nutrition. 
2. Project BCC messages need to emphasize animal sources of micronutrients as 
particularly important. 
3. The project should encourage message dissemination within women’s 
associations via matron’s participation in these groups. 
4. Encourage women to organize themselves to bring together ingredients for the 
implementation of cooking demonstrations. 
5. Gain the support of grandmothers in new nutrition practices through regular 
contact with the matrons. 
6. Develop linkages with government and non-government institutions to 
support communities with the promotion of vegetable gardening and the 
production of soya beans. 
7. Accelerate the planned training of CHWs in ENA to support the dissemination 
of messages in communities covering the entire health facility catchment area. 
8. The project should implement strategies already identified to follow up and 
support CHWs, i.e. participate in outreach activities being carried out by the 
health facilities every month. 
9. Increase advocacy with Community Associations (ASACO’s) and mayors to 
get them to invest more resources for nutrition activities. 
10. Involve the ASACOs and mayors office during supervision activities. 
41
11. Mobilize additional resources to adequately support the radio program 
component. 
12. Train additional radio agents to support and strengthen existing radio 
programs. 
Recommendations – Health Facility level 
13. Encourage the mayor’s office, the communities and their partners to ensure 
the support of outreach activities. 
14. It would be a good idea for the project to provide health facilities with the 
materials needed for cooking demonstrations, i.e. utensils to be able to 
conduct cooking demonstrations. 
15. The project needs to collaborate with the districts to ensure that new staff 
receive training in ENA. 
16. The project should ensure the completion of training for health personnel in 
the Nara and Kolokani districts emphasizing feeding during childhood illness 
and maternal nutrition. 
17. Strengthen collaboration with grandmothers as key to the adoption of new 
nutritional practices in the household. 
18. Encourage sharing and exchange between matrons on experiences and 
strategies related to collaboration with grandmothers. 
Recommendations – District level 
19. Ensure that funding is allocated for joint supervision of the nutrition 
interventions. 
Recommendations - Regional Level 
20. Support joint supervision missions with the regional health team twice a year. 
21. Strengthen the collaboration with the regional team on the management of 
project activities. 
Recommendations – National Level 
22. Accelerate the availability of the Vitamin Mineral Complex through enriched 
flour. 
23. Support joint supervision missions with the national nutrition division once a 
year. 
24. Strengthen the collaboration with the national nutrition division on the 
management of project activities. 
25. Be proactive as a member of the Nutrition Working Group to stimulate 
increased products and investment in the fight against malnutrition and 
micronutrient deficiency. 
Recommendations – HKI Management 
26. Develop posters on ENA to display at health facilities 
27. Accelerate the production and dissemination of remaining ENA counseling 
cards for service providers. 
42
28. Redistribute the supervisory allocation of health facilities in the Kati district to 
balance out workload for project supervisors 
29. Strengthen project staff capacity for using project-related data for 
management and decision-making. 
30. Advocate for increased MOH responsibility in the provision of Vitamin A to 
maintain the high levels of coverage achieved, as part of the phase-out 
strategy in 2009. 
31. Review and follow-up on the QA recommendations developed during the 
2007 workshop and adapt and implement with the regional and district teams 
as needed and feasible. 
32. Follow up on the potential for involvement and collaboration in the malaria, 
vitamin A and zinc regional research project. 
F. Results Highlight 
None highlighted 
43
MTE ACTION PLAN 
SAN + Midterm Evaluation Action Plan - Cross-cutting activities covering all program objectives 
COMMUNITY LEVEL 
Activity Persons 
Responsible 
Timing 
1. Emphasis on BCC messages needs to 
include feeding during illness and 
maternal nutrition. 
ƒOrganize IEC discussions on 
specific ENA topics 
ƒRadio broadcasts emphasizing 
specific ENA topics 
Matrons, 
Supervisors, 
ESS 
Radio stations 
Continuous
Continuous
2. Project BCC messages need to 
emphasize animal sources of 
micronutrients as particularly important 
ƒOrganize IEC discussions on 
specific ENA topics 
ƒRadio broadcasts emphasizing 
specific ENA topics 
Matrons, 
Supervisors, 
ESS 
Radio stations 
Continuous
Continuous
3. Encourage message dissemination 
within women’s associations via matron’s 
participation in these groups 
ƒOrganize discussion groups on 
ENA among women’s groups 
Matrons, CHWs Continuous 
4. Encourage women to organize 
themselves to bring together ingredients 
for the implementation of cooking 
demonstrations 
ƒRaise awareness of women about 
importance of contributing 
to/participating 
 in cooking demonstrations 
Matrons, 
CHWs, In￾Charge, HKI 
Supervisors 
Continuous
5. Gain the support of grandmothers in 
new nutrition practices through regular 
contact with the matrons 
ƒOrganize IEC discussions with 
Muso Korobas 
Matrons Continuous
6. Develop linkages with government 
and non-government institutions to 
support communities with the promotion 
of vegetable gardening and the production 
of soya beans. 
ƒSeek complementary 
funding/partnerships 
HKI 2008 
7. Accelerate the planned training of 
CHWs in ENA to support the 
dissemination of messages in 
communities covering the entire health 
facility catchment area 
ƒTrain CHWs in ENA/BCC HKI 2008 
8. The project should implement 
strategies already identified to follow up 
and support CHWs, i.e. participate in 
outreach activities being carried out by 
the health facilities every month 
ƒSupervise CHWs during outreach 
efforts 
In-Charge, HKI 
Supervisors, 
Matrons, 
Vaccinators 
Continuous 
(following 
training) 
9. Increase advocacy with Community 
Associations (ASACO’s) and mayors to 
get them to invest more resources for 
nutrition activities 
ƒOrganize advocacy meetings District, HKI 
Supervisors 
Continuous
10. Involve the ASACOs and mayors 
office during supervision activities 
ƒMeet with Mayors and ASACOs 
 during supervisions 
Supervision 
teams 
During 
each 
supervision
44
11. Mobilize additional resources to 
adequately support the radio program 
component 
ƒ Revise/reallocate project budget HKI-with 
USAID 
approval 
June 2008 
12. Train additional radio agents to 
support and strengthen existing radio 
programs 
ƒProvide training and refresher to 
radio broadcasters 
 
HKI Continuous
HEALTH FACILITY LEVEL (CSCOM) 
1.Encourage the mayors office, the 
communities and their partners to ensure 
the support of outreach activities 
ƒ Advocacy with mayors and other 
local authorities for funds to 
support nutrition outreach services 
HKI, District 
Health Office 
Beginning 
May 2008 
2. It would be a good idea for the project 
to provide health facilities with the 
materials, i.e. utensils to be able to 
conduct cooking demonstrations 
ƒ Provide cooking equipment to 
CSComs for cooking 
demonstrations 
HKI May 2008 
3. The project needs to collaborate with 
the districts to ensure that new staff 
receive training in ENA 
ƒ Train newly recruited health staff 
in ENA 
HKI, National 
and Regional 
Health 
Directorates 
May 2008 
4. The project should ensure the 
completion of training for health 
personnel in the Nara and Kolokani 
districts emphasizing feeding during 
childhood illness and maternal nutrition. 
ƒ Complete ENA training of health 
staff in Nara and Kolokani 
HKI, National 
and Regional 
Health 
Directorates 
July-Sept 
2008 
5. Strengthen collaboration with 
grandmothers as key to the adoption of 
new nutritional practices in the 
household. 
ƒ Organize formal discussion groups 
of Muso Koroba* 
ƒ Organize monthly discussion 
groups with Muso Koroba 
HKI, CSComs 
HKI, CSComs 
6. Encourage sharing and exchange 
between matrons on experiences and 
strategies related to collaboration with 
grandmothers. 
ƒ Facilitate sharing of experiences of 
matrons successfully working with 
Muso- koroba 
HKI/District May –June 
2008 
*Muso Koroba in the local language means grandmother 
45
DISTRICT LEVEL
1. Ensure that funding is allocated for 
joint supervision of the nutrition 
interventions 
ƒ Make resources available to the 
district team so that they can 
organize supervision visits 
HKI, District Starting 
August 
2008 
REGIONAL LEVEL
1. Support joint supervision missions with 
the regional health team twice a year 
ƒ Make resources available to the 
regional team so that they can 
organize supervision visits 
HKI, Region Starting 
August 
2008 
2. Strengthen the collaboration with the 
regional team on the management of 
project activities 
ƒ Make resources available to 
reinstitute quarterly Coordination 
meetings between the region and 
its partners 
ƒ Joint planning and implementation 
of supervision and training 
activities 
ƒ Participation of project staff in bi￾annual monitoring meetings and 
annual planning. 
ƒ Share reports and information on 
activities 
HKI, Region Starting 
August 
2008 
May 2008 
May 2008 
NATIONAL LEVEL
1. Accelerate the availability of the 
Vitamin Mineral Complex through 
enriched flour. 
ƒ Continue negotiations with WFP 
to support the availability of 
complex vitamin mineral from the 
national nutrition division team. 
 
HKI, Nutrition 
Division 
Starting 
August 
2008 
2. Strengthen the collaboration with the 
national nutrition division on the 
management of project activities 
ƒ Make resources available to 
organize supervision visits with a 
representative 
ƒ Share reports and information on 
activities 
HKI, Nutrition 
Division 
Ongoing 
3. Be proactive as a member of the 
Nutrition Working Group to stimulate 
increased products and investment in the 
fight against malnutrition and 
micronutrient deficiency. 
ƒ Pursue the collaboration with 
Nutrition Division and others 
stakeholders working in nutrition 
HKI, Nutrition 
Division, 
NGO’s 
Ongoing 
46
HKI MANAGEMENT
1. Develop posters on ENA to display at 
CSComs. 
ƒ Work in collaboration with the 
Division of Nutrition to produce 
updated posters and distribute to 9 
districts and all CSComs 
HKI October 
2008 
2. Accelerate the production and 
dissemination of remaining ENA 
counseling cards for service providers 
ƒ Complete design and production 
and distribute to 9 districts and all 
CSComs. 
HKI August 
2008 
3. Redistribute the supervisory allocation 
of CSCOMS in the Kati district to 
balance out workload for project 
supervisors 
ƒ Review and reallocate HFs 
between the project supervisors of 
Kati, Ouelessebougou and 
Kangaba 
HKI May 2008 
4. Advocate for increased MOH 
responsibility in the provision of Vitamin 
A to maintain the high levels of coverage 
achieved, as part of the phase-out strategy 
in 2009. 
ƒ Pursue advocacy at all level HKI May 2008 
5. Strengthen project staff capacity for 
using project-related data for management 
and decision-making 
ƒ Identify staff HKI/Mali or AFRO 
to mentor staff in lacking skills 
HKI Sept 2008 
6. Review and follow-up on the QA 
recommendations developed during the 
2007 workshop and adapt and implement 
with the regional and district teams as 
needed and feasible. 
ƒ Insert QA activities in the ToR of 
the joint supervision 
ƒ Conduct regular joint supervision 
HKI/ Regional 
Directorate of 
Health/ CSRef 
Sept 2008 
7. Follow-up on the potential for 
involvement and collaboration in the 
malaria, vitamin A and zinc regional 
research project. 
ƒ Pursue collaboration with MRTC 
( Malaria Research Training 
Center) to conduct the study 
MRTC/ HKI/ 
Nutrition 
Division 
Aug 2008 
47
Matching and Complementary Funding 
Donor Budget Period Title Region of Mali 
USAID/Office 
of Foreign 
Disaster 
Assistance 
(OFDA I) 
$169,886 10/2006 – 
9/2007 
Capacity Building for 
preventing and treating 
Malnutrition in the Sahel 
Burkina Faso, Mali, Niger 
Health districts of 
Nara and Kolokani 
OFDA II (cost 
extension) 
$420,637 10/2007 – 
9/2008 
Capacity Building for 
preventing and treating 
Malnutrition in the Sahel 
Burkina Faso, Mali, Niger 
Health districts of 
Banamba, Koulikoro, 
Kangaba, Kati and 
Ouelessebougou 
USAID $1,052,305 1/2004-
3/2008 
Communications for 
Development 
National 
USAID 
through Abt 
$505,442 10/2003-
9/2008 
National Technical 
Assistance (ATN) 
National 
The Richard 
and Rhoda 
Goldman Fund 
$40,000 3/2007- 
3/2008 
Community Therapeutic 
Care for Treatment of 
Malnutrition 
Koulikoro Region 
Monsanto 
Foundation 
$399,485 6/14/2007 
6/13/2010 
Community Therapeutic 
Care for Treatment of 
Malnutrition 
Kolokani and Nara 
districts in Koulikoro 
Micronutrient 
Initiative 
$347,380 3/2005-
5/2008 
National Vitamin A 
Supplementation for Child 
Survival 
National 
UNICEF provides in kind therapeutic foods: F100 (169 Cartons), F75 (46 Cartons), 
Plumpy-nut (138 Cartons), growth monitoring materials kits (33) 
WFP provides in kind food: CSB 178.4 tons; Cooking oil 17.85 tons 
IV. ATTACHMENTS 
A. Baseline information from the DIP 
Progress to date has not been measured against the baseline. 
 
B. KPC survey for MTE 
No KPC conducted 
48
C. Evaluation Team Members and their titles 
Evaluation Team Members 
Marguerite Joseph, external consultant 
Jennifer Nielsen, HQ Technical Advisor 
Mrs. Diakite Maimouna, Koulikoro region 
Dr. Tera Sinaly, National Nutrition Division 
Mr. Kassoum Kone, Ministry of Social development koulikoro 
Dr Sanagaré Anne Marie, Project Coordinator 
Mr. Zoumana Berthe, Deputy Project Coordinator
Daniele Nyirandutiye, Fellow 
D. Evaluation Assessment methodology 
The evaluation was led by an external consultant with the assistance of the headquarters 
technical backstop. MOH partners also participated as evaluation team members, per the 
above list. The external evaluator and headquarters backstop person conducted all of the 
staff and higher level partner interviews. The team split into two groups and conducted 
FGDs and key informant interviews at the health facility and community levels, targeting 
health service providers, ASACOs (HF Management committees), women, men, village 
chiefs, mayors and the rural radios. A total of 4 out of the 9 districts were selected for the 
above, with an evaluation criteria included whether there was the integration of CTC, 
(Kolokani,) Distance and accessibility issues (Nara), a balance of top performing and not, 
a sample of urban as well as rural. 
49
MTE Evaluation Schedule: 
March/April Day Activity 
Sunday 23rd • Late evening arrival of Marguerite and Jennifer in Bamako 
Monday 24th Day 1 • Discuss/Finalize MTE schedule with country team, including 
interview schedule. 
• Planning for field visits/identification of sample sites and 
constitution of teams for field visits 
• Finalize interview schedule (confirm interviewee availability 
etc); 
• Gather additional project documentation (assessments, staff 
trainings, partner trainings, quantitative data etc); 
Tuesday 25th Day 2 • Finalize planning and coordination with partners/participants 
• Project Staff interview begins 
Wednesday 26th Day 3 • Interviews with project staff continue 
• Work on draft questionnaires 
Thursday 27th Day 4 • Interview with regional health team in Koulikolo 
• Interview with country office staff 
• Finalize draft questionnaires (Marguerite/Jen) 
 
Friday 28th Day 5 • Meeting with USAID, ATN 8:30 am 
• Orientation meeting for MTE team (9:30 am): review choice 
of sites, field schedule, draft interview questionnaires etc.) 
• Meeting/Interview with MOH Nutrition Division ( 4 pm) 
Saturday 29th Day 6 • Interview with Project Supervisors 
• Prepare team packages for field visits 
• Interview with Project Coordinators continue 
Sunday 30th Day 7 • Departure to Nara (Team 1) et Dioila (Team 2) 
Monday 31st Day 8 • Work in Nara (Team 1); Work in Dioila (Team 2) 
Tuesday 1st Day 9 • Complete Nara/Dioila work, and travel to Kolokani 
 (Team 1) and Kati (Team 2) 
Wednesday 2nd Day 10 • Work in Kolokani (Team 1) and Kati (Team 2) 
Thursday 3rd Day 11 • Complete work in Kolokani and Kati, and travel back to 
Bamako 
Friday 4th Day 12 • Feedback from teams on field visits; Analysis/discussion 
• Action Plan Development begins 
Saturday 5th Day 13 • DAY OFF 
Sunday 6th Day 14 • Translation of action plan, key findings, recommendations 
• Consultant prepares final presentation for stakeholders 
 
Monday 7th Day 15 • Presentation of MTE findings to USAID and stakeholders. 
• Consultant Departs 
 
50
MTE SAN + 
Focus Group/Interview Discussion 
Women
1. Do you know the HKI project? If yes, what do you know about the project? 
2. Do you know the health workers? If yes, what do they do? What type of contact 
do you have with each of them? 
3. Have you heard health messages? What messages and through what channels 
have you heard them? (Asked them to repeat messages that they have heard) 
4. What do you think of the messages you have heard on the radio? (Try to 
understand if they were influenced to change their behavior) 
5. Do you know the advantages to regular hand washing with soap? If yes, what 
illnesses would a mother avoid if she were able to put this into practice? 
6. What do you give your children during an episode of diarrhea? 
7. Do you and your children sleep under an insecticide treated net? 
8. Have you noticed any change in the area of hygiene and sanitation since the 
beginning of the project? (What changes?) 
9. Have you noticed any changes in service provision in the health facility? (What 
type of changes have you noticed?) 
10. Did you immediately breast-feed after delivery? If yes, why? If no, why not? 
11. In your opinion, what does a child need to keep this and drink during the first six 
months of its life? 
12. Do you know the foods rich in micronutrients (Vitamin A and iron) that are 
appropriate for young infants between the age of six and 24 months? Give 
examples. 
13. Do you know the advantages to child weighing? 
14. In the area of nutrition have you noticed any change in behavior amongst the 
women in your community? 
Men
1. Do you know the HKI project? If yes, what do you know about the project? 
2. Do you know the health workers? If yes, what do they do? 
3. Do you have contact with these individuals? If so what type of contact you have 
with them? 
4. Have you heard health messages? What messages and through what channels 
have you heard them? (Asked them to repeat messages that they have heard) 
5. What do you think of the messages you have heard on the radio? (Try to 
understand if they were influenced to change their behavior) 
6. Have you discussed these messages with your wives? With other people? What 
subject did you discuss? 
7. Do you know the foods rich in micronutrients (Vitamin A and iron) that are 
appropriate for young infants between the age of six and 24 months? Give 
examples. 
51
8. Do you know the advantages to regular hand washing with soap? If yes, what 
illnesses would a mother avoid if she were able to put this into practice? 
9. Have you noticed any change in the area of hygiene and sanitation since the 
beginning of the project? Have there been other types of changes? (Example: 
child feeding?) 
10. As a father, what he you do to ensure the health of your wife and children? 
11. Do you know the advantages to child weighing? 
Local Authority/Village Chief/Mayor
1. Do you know the HKI project? If yes, what do you know about the project? 
2. Have you heard health messages? What messages and through what channels 
have you heard them? (Asked them to repeat messages that they have heard) 
3. What do you think of the messages you have heard? 
4. As a local authority in your community, what role do you play in supporting 
health for this community? 
5. Have you created a budget line item for nutrition in your annual health budget? 
(Question only to mayors). 
6. In your village, what do men do to support the health of children? 
Community Health Associations (ASACOs)
1. Do you know the HKI project? 
2. What is your relationship with the HKI project? 
3. What do you think of the partnership between HKI and the ASACO? 
4. What is your opinion of the activities that you have participated in (presentation 
of the project, advocacy workshops)? 
5. What are the activities that you undertake? With what frequency do you 
undertake these activities? 
6. Does the health facility worker undertaken activities at the community level? If 
yes, what? 
7. In your opinion, what are the achievements of the project? 
Health Center staff
1. What are the tasks related to nutrition that you undertake every week/month? 
2. Did the training that you received through the project help you fill your job 
responsibilities? If yes how? 
3. In your opinion, what added value has the project for CTC provided? (Only ask 
Nara and Kolokani interviewees). 
4. How many times have you been supervised or visited this year? (By 
HKI/district?), what did you think of the supervision/visits? 
52
5. What do you think of the nutrition messages by the project? (ENA - exclusive 
breast-feeding, complementary feeding). 
6. How do you conduct a counseling session with a client? (Example to promote 
exclusive breast-feeding). 
7. What do you do to encourage good performance alone health staff at the health 
facility? (Ask health center heads only) 
8. What do you do to encourage behavior change in nutrition with your clients? (Ask 
rural midwives). 
9. How does the drug supply system work (specifically for the supply of 
micronutrient's such as vitamin A, iron folic acid, zinc and iodine kits)? Do you 
have problems with stock out? 
10. What relationship do you have with the women's associations? Women leaders? 
11. What do you think of working with the grandmothers to promote good nutrition 
practices? 
12. What motivates you in your work? What are the difficulties that you encounter in 
your work/activities? 
13. The HKI project ends in September 2009. In your opinion without the support of 
the project, will the nutrition promotion and services be given the same 
importance as they have now? 
14. In your opinion, what are the changes in behavior that can be attributed to the 
project? 
15. What are your recommendations for the second half of the project? 
Community Radio 
1. What do you think of the HKI project? 
2. Did the training that you received from the HKI project of an impact on your 
services? If yes how? 
3. What do you think of the nutrition and health messages? 
4. How often were you able to defuse the messages? (Ask for the diffusion 
schedule). 
5. What kind oh of response from the community have you noted? (Including 
behavior change) 
District health team
1. Is nutrition taken into account in the annual operation plan of the districts? If yes, 
do you have a budget associated with this plan? 
2. In your opinion, what has been the impact of the HKI project on service 
provision? 
3. Has the project had an impact on the capacity building of the district personnel? 
If yes how? 
4. In the context of the limited budgets of HKI and the district, in your opinion, what 
should the project and other partners to accelerate community mobilization for 
53
behavior change in the area of nutrition? (Could grandmother as and community 
groups play an important role 
5. In your opinion, have there been any changes in health worker performance as a 
result of the project? 
6. What do you do during supervision to ensure the quality of this activity? Do you 
use tools for this? What are the difficulties that you encounter in implementing 
supervision? 
7. What is your system for monitoring MCH activities? Do you use tools for this? 
What of the difficulties that you encounter in implementing monitoring activities? 
8. How is the supply system for micronutrients (vitamin A, iron folic acid, zinc, 
iodine kits) working? Do you encounter stock outs? 
9. What type of collaboration do you have with the HKI supervisor? (Do you have 
joint activities? Is there exchange or sharing of information?) 
10. What are the recommendations for the second half of the project? 
11. The HKI project ends in September 2009. In your opinion without the support of 
the project will the nutrition promotion and services be given the same 
importance? 
Regional health team
1. Is nutrition taken into account in the annual operation plan of the districts? If yes 
do you have a budget associated with this plan? 
2. In your opinion, what has been the impact of the HKI project on nutrition 
services? All and other elements of health services? Did the HKI project's have 
an influence on you way of promoting nutrition? If yes how? 
3. Has the project had an impact on the capacity of the regional personnel? If yes 
how? 
4. As a project had an impact on the capacity of personnel in the nine districts? If 
yes how? 
5. In your opinion, have there been any changes in health worker performance as a 
result of the project? 
6. What is your system for supervision and monitoring? What of the difficulties that 
you encounter in implementing these activities? 
7. What are the recommendations for the second half of the project? 
8. The HKI project ends in September 2009. In your opinion without the support of 
the project will the nutrition promotion and services be given the same 
importance? 
Project Supervisors
1. What are the tasks that you undertake every week/month? What relationship do 
you have with the districts and the health facilities? 
2. Did the training you received from the project help you in filling your job 
responsibilities? If yes how? If no, why not? 
54
3. What easy to encourage improvement in service provision of the health facility? 
For example education sessions, growth monitoring, counseling? 
4. In your work do you have the opportunity to encourage behavior change amongst 
members of the communities? If yes, how? If no, what prevents you from being 
able to do this? 
5. What relationship do you have with women's associations? Women leaders? 
6. What do you think about the idea of working with grandmothers for the 
promotion of good nutrition practices? 
7. In your opinion, considering the current realities of the project, is there any way to 
work more with community members for the promotion of good nutrition 
practices? 
8. In your opinion, what are the changes in behavior due to the project? 
9. How often have you been supervised this year? What did you think of the 
supervision visits that you had? 
55
 
E. List of persons interviewed and contacted 
Koulikoro Regional Health Team 
Dr Bakary KONATE 
Dr Sidiki Kokaina – UNICEF, Koulikoro 
Oumane Toure 
CSCom heads - Dioila District 
Moussa TRAORE CPM du CSCOM de Nantjila 
Dr Ousmane Moussa TRAORE CPM du CSCOM de Banco 
Brehima FOMBA CPM du CSCOM de Wacoro 
Dr Soumaila Ballo CPM du CSCOM de N’Golobougou 
Mohamed EL HAIDARA CPM du CSCOM de Kola 
District Health Team - Dioila 
Arafa Toure 
Kadiatou Coulibaly 
Mohamed D. Diakite 
Siratigui K Diallo 
Dr Abdoulaye Guido 
Youssouf Tangara 
Seydou Diarra 
CSCom - Banco 
Kalifa Fomba 
Kalifa Mallé 
Rokiatou Marico 
Guimbala Keita 
Nianantigui Marico 
Mariam Mallé 
CSCom Heads - Kati District 
Dr Fousseyni Coulibaly - N’Gourouba 
Tamba Konate - Moutougoula 
Dr Ousmane Diarra - Sangarebougou 
Abdoulaye Tianka- Safo 
Dr Koké Diakite - Dialakorodji 
Mamadou Camara - Neguela 
District Health Team - Kati 
Dr Amadou Coulibaly 
Mme Coulibaly Simone Dembele 
Dr Kouyate Fatoumata Diarra 
Dr Maiga Sagadatou Maiga 
56
57
CSCom - Malibougou 
Mme Camara Debi 
Oumou Diarra 
Mme Camara Fatoumata 
Fatoumata Doumbia 
Mme Kone Korotoumou 
CSCom - Siby 
Mme Diarra Nana Camara 
District Health Team - Nara 
Dr DIARRA Dji Boubacar 
CSCom - Dilly 
Mr Maiga 
Aly Toure 
CSCom - Goumbou 
Daouda Diallo 
Aicha Traore 
Brianthé Traore 
Maya Doucoure 
Fatoumata Kone 
Aissa Kamissoko 
Radios stations: 
Radio de Dilly 
Radio de Nara 
Radio de Kolokani 
SAN+ Supervisors 
Coumaré Kadiatou Sanogo - Fana 
Moussa Koné - Kangaba 
Fama Konolo- Koulikoro 
Amanatou Traoré -Ouéléssebougou 
Mamadou Keïta- Kati 
Fakoro Koné- Banamba 
Kalifa Soumaro- Kolokani 
Management and SAN+ Senior staff 
Marjon Tuinsma - Country Director 
Dr Sanagaré Anne Marie - Project Coordinator
Zoumana BERTHE - Deputy Project Coordinator
Daniele Nyirandutiye, Fellow 
Note: The above list is not exhaustive of all interviews conducted at the CsCom and 
community level.