Save the Children
District Health through a Living University 
Egypt CS-14 
Report of the 
Midterm Evaluation 
Cooperative Agreement No. FAO-A-00-98-00026-00 
September 30, 1998 – September 29, 2002 
Submitted by 
Save the Children/US 
to USAID/BHR/PVC 
November 20, 2000
Save the Children CS-14 Egypt Midterm Evaluation i
Executive Summary 
The Child Survival 14 (CS-14) project District Health through a Living University is 
implemented by Save the Children – USA and its partners in the District of Samalout, 
Governorate of Minya, Upper Egypt. The CS-14 goal is to improve the health status of 
mothers and children under 5 through improved health behaviors and use of key health 
services in five areas of Samalout District. The “Living University” (LU) strategy, 
developed by SC in Vietnam, is to pilot a development program with a few communities, 
the LUs. After measurable effects are demonstrated, other communities learn from the 
initial LU sites, implement the program with support from the LUs, and then become LUs 
themselves when the program is expanded to new sites. CS-14 applies this model to 
establish a district-level mechanism for replication and expansion of safe motherhood and 
child survival services. 
The Midterm Evaluation (MTE) of the CS-14 project was conducted in Minya from 
August 29 to September 7, 2000. The MTE team was composed of a “core MTE team” 
of three external members and three SC/Minya staff, and of all the other CS-14 staff and 
selected partner representatives. The “Extended MTE team” of 21 members participated 
in most meetings, group work, field visits, and in discussions about the findings and 
recommendations of the evaluation. The present report represents the synthesis of the 
various contributions of the team members. 
The work plan in the DIP describes three implementation phases: phase 1, framework 
development (10 months), to establish the office, human resources and partnership 
infrastructure needed to implement the project; phase 2, model development (18 months), 
to implement the LU strategy in two rural villages and one urban slum of Samalout City; 
and phase 3, model replication (20 months), to implement the LU strategy in two 
additional villages. The CS-14 project began September 30, 1998 and will end in 
September 29, 2002. By and large, the implementation schedule is in accordance with 
that in the DIP. The MTE took place at month 23, just a few months before the transition 
from phase 2 to phase 3. 
Building on past and current projects and its long-term presence in Minya governorate, 
CS-14 is successful in implementing the Living University strategy to improve maternal 
and child health in three project areas of Samalout District. CS-14 has identified strong 
community-based partners. In June 2000, three Community Development Associations 
(CDA) were supervising a total of 103 Community Health Workers (CHW) who were 
covering 72% of the children under five in the project areas. CS-14 has also been 
successful in setting up various Local and District Health Action Committees in which 
community-defined problems are presented, discussed, and often adequately addressed or 
solved. 
A fundamental strategy of CS-14 is to use CHWs and MOHP health workers to promote 
healthy practices among pregnant women and mothers of children under five. The MTE 
team found a lack of focus on key strategic messages, and a lack of communication 
materials to support the behavior change activities conducted by CHWs during their 
home visits. 
Save the Children CS-14 Egypt Midterm Evaluation ii
The effectiveness of most of the CS-14 interventions depends at least partially on the 
availability, accessibility, and quality of facility-based health services. The MTE found 
that CS-14 had not begun to systematically work with the MOHP and the private 
providers to develop standards of quality of care, conduct systematic health facility 
assessment or joint supervisory visits, establish effective referral linkages between 
communities, health centers, and hospitals, and begin building quality improvement 
systems in health services. 
CS-14 and its partners have secured competent and motivated personnel who are now 
carrying out intensive field activities. This active base of operation provides 
opportunities for SC senior executives to provide high-level technical and managerial 
support and ensure that both the impact and model development objectives of CS-14 are 
met by September 2002. 
The MTE team formulated three main recommendations: 
1. To ensure effectiveness and efficiency of CHWs’ work, CS-14 should: 
 Review and refine its communication objectives, strategies, and key messages for 
each intervention. 
 Identify a limited but complete set of communication materials for CHWs and 
health workers to use and distribute to mothers. 
 Focus CHW home visits on households with pregnant women and/or infants. 
2. To strengthen the Maternal and Newborn Care intervention, CS-14 should: 
 Review the objectives and strategies of this important component of the project, 
then the related work plan and budget. 
 This work plan should build on achievements in the project area, and consider 
how to cover deliveries that occur without trained attendants; set up a system of 
emergency transport and referral; ensure the quality of emergency obstetrical 
services; and monitor and learn from maternal and infant deaths. 
3. To further develop cooperation with Ministry of Health and Population, CS-14 
should: 
 At the Governorate level, maintain close contact with key technical officials to 
facilitate the introduction in Samalout District of selected programs such as 
Integrated Management of Childhood Illness, Emergency Obstetrical Care, and 
Quality Assurance. 
 At the District level, propose participation and assistance in the development of 
comprehensive health development plans involving communities and partners, 
and develop a comprehensive community-defined plan to improve quality of care. 
 At the health unit level, facilitate communication between health workers, private 
providers, and communities. 
In addition, CS-14 should: 
4. Carefully plan the transition from phase 2 to phase 3, 
5. Develop an explicit “exit strategy,” and 
6. Consider applying for a cost extension. 
Save the Children CS-14 Egypt Midterm Evaluation iii
Table of Contents 
I. Introduction and Midterm Evaluation process ...................................................... 1
II. Assessment of Progress Towards Achieving Program Objectives ................... 5
A. Overview ................................................................................................................. 6
B. Technical Approach ................................................................................................ 8 
(1) Maternal and newborn care ............................................................................. 8 
(2) Pneumonia case-management ....................................................................... 10 
(3) Diarrheal diseases ......................................................................................... 11 
(4) Nutrition ........................................................................................................ 11 
(5) Immunization ................................................................................................ 12 
C. Cross Cutting Approaches .................................................................................... 14 
(1) Behavior Change Communications .............................................................. 14 
(2) Community Mobilization .............................................................................. 15 
(3) Training ......................................................................................................... 15 
(4) Partnership with Community Development Associations ............................ 17 
(5) Partnership with the Red Crescent Society ................................................... 18 
(6) Partnership with MOHP ................................................................................ 19 
(7) Sustainability Strategy .................................................................................. 20 
D. Program Management ........................................................................................... 21 
(1) Planning ........................................................................................................ 21 
(2) Information Management .............................................................................. 21 
(3) Human Resources Management ................................................................... 21 
(4) Financial Management and Logistics ........................................................... 22 
(5) Technical and Administrative support .......................................................... 23 
E. Conclusions ........................................................................................................... 24 
F. Recommendations ................................................................................................. 25 
G. Results Highlight .................................................................................................. 27 
III. The Action Plan ................................................................................................... 28
IV. Attachments ......................................................................................................... 30
Attachment 1 Baseline information from the DIP ...................................................... 31 
Attachment 2 Map of Samalout District ..................................................................... 41 
Attachment 3 Scope of Work for the MTE Team Leader .......................................... 42 
Attachment 4 MTE team composition ........................................................................ 43 
Attachment 5 MTE program ....................................................................................... 44 
Attachment 6 Group discussion topics and composition ............................................ 46 
Attachment 7 Site visits group composition and interviewees ................................... 47 
Attachment 8 Major CS-14 activities by month, October 1998 – August 2000 ......... 48 
Attachment 9 Selected health services statistics in the three CS-14 project areas ..... 49 
Attachment 10 Antenatal services utilization in three CS-14 and three non CS-14 
areas of Samalout District, 8/1998-8/2000 ................................................................. 51 
Attachment 11 Key messages by technical interventions ........................................... 52 
Attachment 12 Partner’s roles and responsibilities in CS-14 ..................................... 54 
Attachment 13 List of equipment provided to health facilities ................................... 56 
Attachment 14 CS-14 staff in Cairo and Minya ......................................................... 58 
Save the Children CS-14 Egypt Midterm Evaluation iv
Acronyms 
AC Advisory Committee 
ANC Antenatal Care 
ARI Acute Respiratory Infections 
BCC Behavior Change Communication 
BHR/PVC Bureau of Humanitarian Response, Office of Private & Voluntary 
Cooperation 
CDA Community Development Association 
CDD Control of Diarrheal Diseases 
CHW Community Health Worker 
DHMT District Health Management Team 
DIP Detailed Implementation Plan 
DPT Diphtheria/Pertussis/Tetanus Vaccine 
EFO Egypt Field Office 
EmOC Emergency Obstetrical Care 
EPI Expanded Program for Immunizations 
FP Family Planning 
HAC Health Action Committee 
HIS Health Information System 
IEC Information, Education, Communication 
KPC Knowledge, Practice, and Coverage 
LU Living University 
MCH Maternal Child Health 
MIS Management Information System 
MNC Maternal and Newborn Care 
MOHP Ministry of Health and Population 
NGO Non-Governmental Organization 
ORS Oral Rehydration Solution 
ORT Oral Rehydration Therapy 
PCM Pneumonia Case Management 
PD Positive Deviance/Positive Deviant 
PVO/CS Private Voluntary Organizations Child Survival Grants Program 
RC Red Crescent 
SC Save the Children Federation (USA) 
TA Technical Assistance 
TBA Traditional Birth Attendant 
TT Tetanus Toxoid 
USAID United States Agency for International Development 
Save the Children CS-14 Egypt Midterm Evaluation 1
I. Introduction and Midterm Evaluation process 
The Child Survival 14 project District Health Through a Living University (CS-14) is 
implemented by Save the Children – USA (SC) and its partners in the District of 
Samalout of the Governorate of Minya, Upper Egypt. CS-14 is jointly funded by the 
USAID Bureau of Humanitarian Response, Office of Private and Voluntary Cooperation 
(BHR/PVC) through its PVO Child Survival Grants (PVO/CS) program ($0.50 million), 
by USAID/Egypt ($0.50 million), and by SC ($.34 million). It began on September 30, 
1998 and will end on September 29, 2002. 
The CS-14 goal is to improve the health status of mothers and children under 5 through 
improved health behaviors and use of key health services in five areas of Samalout 
District with the poorest health indicators. The total population of these areas is about 
220,000 inhabitants. The overall design of the project is to link the families in the project 
areas to eight local Non Governmental Organizations (NGOs)--Community Development 
Associations (CDAs); to one governorate-level NGO--the Red Crescent (RC) Society; 
and to the local health services of the Ministry of Health and Population (MOHP). The 
“Living University” (LU) strategy is to pilot a development program with a few 
communities, the LUs, until measurable effects are demonstrated; other communities can 
then actively participate, learn from the initial sites, and become LUs themselves. CS-14 
applies this model to establish a district-level mechanism for replication and expansion of 
child survival services. The specific child survival interventions supported by the project 
are maternal and newborn care (MNC), pneumonia case management (PCM), control of 
diarrheal diseases (CDD), nutrition, and immunization. Baseline information from the 
Detailed Implementation Plan (DIP) is provided in Attachment 1, and a map of the 
Samalout District and the three current project areas in Attachment 2. 
The Midterm Evaluation (MTE) of the CS-14 project was conducted in Minya over a ten￾day period from August 29 to September 7, 2000. SC had developed the scope of work 
for the MTE Team Leader (Attachment 3) and selected Dr Marc Debay, Assistant 
Scientist at The Johns Hopkins School of Public Health, Division of Community Health 
and Health Systems. The MTE Team Leader proposed to follow the PVO/CS MTE 
guidelines as much as possible because of the valuable expertise involved in their 
preparation, the potential benefits to the PVO/CS program from having evaluation reports 
comparable across projects, and the need to continuously test and improve such 
guidelines. In accordance to principles highlighted in the MTE guidelines, all partners in 
the project were invited to participate in the evaluation design, data collection, and 
discussions of findings and recommendations; the DIP was translated and distributed to 
all MTE members as the reference for the project design; and project monitoring and 
managerial data were used whenever possible to answer the evaluation questions. 
Finally, the outline proposed for the MTE report and related questions were 
systematically used to organize the teamwork. In addition to coordinating this process, 
the MTE Team Leader served as the author and editor of the present report. 
Save the Children CS-14 Egypt Midterm Evaluation 2
The MTE team included two other members external to the project implementation in 
Minya: Dr Eric Starbuck, Child Survival Specialist, Office of Health, Save the Children￾USA; and Della Dash, Child Survival Technical Advisor, USAID/BHR/PVC. On their 
first day in Cairo on Tuesday 8/29, the three external members met with Dr Attalah 
Khuttab, Director of SC Egypt Field Office (EFO). This meeting was an opportunity to 
learn about the decentralized management of SC programs in Egypt, and that of CS-14 in 
particular. General personnel and financial issues were also briefly discussed. 
Arrangements for travel to Minya were finalized in coordination with those for two 
USAID/Cairo staff members who were able to join the team in Minya for two days. Dr 
Khuttab also proposed to join the MTE team in Minya for a final debriefing. 
In the evening of their arrival in Minya, the three external team members and the two 
USAID/Cairo staff members were welcomed in meeting organized by SC/Minya that 
included all CS-14 staff and partners representatives. During that meeting, SC/Minya 
presented the CS-14 project and its achievements. Then the first two days of the MTE 
were intentionally spent with the entire CS-14 staff and several partner representatives on 
establishing the participative approach and clarifying the PVO/CS MTE guidelines. 
During the first meeting in the SC/Minya office on Wednesday morning (8/30), the CS￾14 staff and partner representatives willing to participate in the MTE were identified. 
Then, a first field visit previously planned by SC/Minya took place: the participants to 
this visit had the opportunity to see one clinic, interview health workers, and meet with 
CDA members and community health workers. This early field visit provided the 
external team members with a feeling for the local context and culture that turned out to 
be very useful for planning the MTE. It also gave the opportunity to have an immediate 
and very informative feedback from the two USAID/Cairo staff members before their 
return to Cairo. On Thursday morning (8/31), the PVO/CS MTE guidelines were 
presented and discussed with all CS-14 staff. After a visit to a LU CDA training event 
and a meeting with MOHP officials in Minya, these discussions resumed in the afternoon 
with the CS-14 partners representatives. 
The final composition of the MTE team was only defined at the end of the second day 
(Attachment 4). A “core MTE team” of six persons included the three external members 
and three SC/Minya staff: Dr Samir Khamis, SC/Minya Program Management and CS-14 
Project Manager, Ms. Samaa Sayed, SC/EFO Technical Unit Training & Institutional 
Development Officer, and Mr. Wael Zaki, SC/Minya CS-14 Team Leader. This core 
MTE team met regularly to discuss the MTE process and make the necessary 
arrangements to maximize the participation of the other team members. The “extended 
MTE team” included the 6 members of the core team, 7 CS-14 staff members, and 8 
partner representatives. The MTE team of 21 participated in most meetings, group work 
sessions, and field visits, and therefore in all discussions about the design, schedule, data 
collection, findings and recommendations of the evaluation. 
The remaining of the MTE program was established on an ongoing basis with all the 
team members (Attachment 5). Overall, the various field visits that SC/Minya had 
scheduled were maintained but postponed to allow prior discussion of the purpose of the 
MTE with all team members. As this participatory approach was unfamiliar to most CS-
Save the Children CS-14 Egypt Midterm Evaluation 3
14 staff and partners’ representatives, the planning process took more time than expected, 
in particular at the beginning. Also, the contribution of most team members remained 
limited and hesitant during the first few days, but increased enormously as soon as the 
participatory process appeared more clearly. 
At the end of the second day in Minya, the six core MTE team members met for the first 
time to assign discussion topics and distribute all the MTE team members into working 
groups (Attachment 6). Each group included one external and one SC/Minya core team 
member. On Friday and Saturday, three groups worked on the project “technical” and 
“cross cutting” approaches, and on Sunday, two groups worked on the “program 
management.” An Arabic translation of the DIP was distributed to all team members 
who were asked to review the sections relevant to their topics and provide answers to a 
list of questions adapted from the MTE guidelines. As most participants were not familiar 
with the DIP, the time allocated to the workgroup sessions turned out to be too short to 
cover all the questions. However, the participative approach and information sharing 
resulted in very valuable and productive exchanges among CS-14 staff and partner 
representatives. 
Most field visits were conducted from Sunday 9/3 to 9/6. The sites visited and people 
met are in Attachment 7. After discussing the main MTE questions and issues, each 
group defined the data needed from these field visits. One observation and interview 
guideline was developed for each type of site and informants: health facilities and staff; 
CDA offices and members; groups of CHWs and mothers. The groups’ composition 
varied for each visit to ensure that each member had the opportunity to conduct each type 
of visit and interview, and to encourage exchange among all team members. The goal of 
these visits was not to collect quantitative, reproducible, and representative data but to 
build a common understanding of the project and its achievements among the team 
members, and to allow constructive discussions leading to concrete, agreed-upon 
recommendations. During each visit, one Arabic-literate recorded the group observations 
and interviews; these records were then translated into English and discussed in plenary 
meetings held on a daily basis. At the same time as the field visits, a few team members 
stayed in the SC/Minya office to gather and review project records, materials, and 
reports, or to write-up various notes from the group discussions and field visits. 
At the end of the 9th day on the MTE, the core team members prepared a first draft of the 
main findings and recommendations. On the 10th and last day, a whole-day synthesis 
meeting was organized for about 30 persons, that is, the entire extended MTE team and a 
few more SC/Minya and CS-14 partner staff. The meeting was intentionally structured 
in a rather formal way, with a president of the meeting, various session chairs, recorders, 
translators, and a timekeeper. This was to ensure that all the key points would be covered 
in a timely manner and that the discussions would remain focused and constructive. The 
agenda followed the main outline of the report. Each session was introduced by a 
bilingual Power Point presentation of the draft prepared by the core team. Then 
questions, clarifications, and a general discussion followed. During the last session of 
the meeting, the various remaining tasks to complete the report were discussed and 
responsibilities assigned. These tasks included the preparation of a few additional 
Save the Children CS-14 Egypt Midterm Evaluation 4
documents to include as attachment to the report, the discussion with partners about some 
of the findings and recommendations, writing success stories and a “Results Highlight” 
section, and reviewing the draft report to be prepared by the MTE Team Leader. The 
minutes of the meeting were translated into English and sent to the MTE Team Leader. 
The present report represents the synthesis of these various contributions. Its primary 
audience includes the local partners (MOHP, RC, and CDAs), Save the Children staff 
from headquarters, Egypt Field Office and Minya offices, USAID/BHR/PVC, and 
USAID/Egypt. It is hoped that it will also used by a wider audience. 
Save the Children CS-14 Egypt Midterm Evaluation 5
II. Assessment of Progress Towards Achieving 
Program Objectives 
Save the Children CS-14 Egypt Midterm Evaluation 6
A. Overview 
The CS-14 “Program Goals and Objectives” section of the DIP includes one “Results 
Framework” and one “End-of-Project Objectives” table (both are reproduced in 
Attachment 1). The Results Framework constitutes a good summary of the rationale of 
the project: it explains how intermediate results lead to the result of Improved Health 
Behaviors and Use of Key Health Services and contribute to the overall goal of Improved 
Health Status of Mothers and Children Under 5. However, the Results Framework 
remains general and does not provide indicators. The End-of-Project Objectives, on the 
other hand, are directly related to the table of indicators in the Monitoring and Evaluation 
section of the DIP, which includes health outcome indicators. However, these objectives 
and indicators are so specific that they do not adequately capture the entire scope of the 
project as needed for the MTE. 
Therefore in the present assessment of the progress towards achieving CS-14 objectives, 
the results and intermediate results from both the Results Framework and the End-of￾Project Objectives are used. All the relevant results are listed at the beginning of each 
sub section below before presenting the findings of the MTE team. The results and 
intermediate results from the End-of-Project Objectives are listed (bulleted) first because 
they are more specific and they are proposed in the DIP as quantitative measures of the 
success of the project. Then the related intermediate results from the Results Framework 
are listed (numbered) because they clarify the rationale for the proposed activities. 
The MTE team assessment of the progress towards achieving CS-14 objectives is 
presented in three steps. First, the various “technical” interventions proposed in the DIP 
are examined. Here the assessment focuses on the changes expected at the individual 
level (mother or children under five) in terms of health behavior or use of health services. 
The findings are observations about the adequacy of the CS-14 activities directly related 
to these changes. Second, the “cross-cutting” activities are examined. These activities 
are critical to achieving the health objectives of the project but relate to all technical 
interventions. Finally, the findings related to the management of CS-14 by SC are 
presented. There are no objectives for this aspect of the project. In addition to the 
findings of the MTE team, a few “success stories” reported by the CS-14 staff are 
presented here and there as they related to a particular finding. 
The work plan in the DIP describes three implementation phases: 
1. Phase 1- Framework development (10 months): establishment of the 
infrastructure needed to implement the project: human resources and management 
capacity; partnerships agreements; preparation of project sites; and baseline 
assessments. 
2. Phase 2- Model development (18 months): implementation of the LU strategy and 
child survival interventions in two rural villages (Taha and Bayhoo) and one 
urban slum of Samalout City (Maasara Shark); 
3. Phase 3- Model replication (20 months): two sites of the previous phase, the 
“Living University,” now implement the strategy in two additional villages 
(Shosha and Estal). 
Save the Children CS-14 Egypt Midterm Evaluation 7
The CS-14 project began September 30, 1998 and will end in September 29, 2002. The 
MTE was conducted at month 23 of implementation, that is, nearly at the end of phase 2. 
Attachment 8 presents the major CS-14 activities by month from October 1998 to August 
2000. During the first quarter of project implementation, SC/Minya rented, equipped and 
furnished office space and hired staff for CS-14. In addition, the project Advisory 
Committee was established, and the roles and responsibilities of all project Partners were 
agreed upon. The five project sites were selected according to MOHP statistics at the end 
of the first quarter. At the end of the second quarter, the LR CDAs were selected in each 
site according to criteria established by the Ministry of Social Affairs, and local Health 
Action Committees were created. Then the CHWs were selected and trained, and by the 
third quarter, began their monthly home visits. The District Health Management 
Committee was created during the first quarter of the project, but regular meetings only 
began six months later. Training of MOHP health workers occurred just a few months 
after the CHWs began their home visits, and MOHP facilities received supplies during 
the same period. By and large, this implementation schedule is in accordance with the 
DIP. 
Save the Children CS-14 Egypt Midterm Evaluation 8
B. Technical Approach 
(1) Maternal and newborn care 
Results  80% of TBA-assisted deliveries in past 6 months are performed by CS￾14 trained TBAs 
 Clean birth kits are used in 80% of home births in past 6 months 
Intermediate 
Results 
 90% of women with infants under age 6 months know two or more 
obstetric danger signs 
IR 1.1: Essential drugs and medical supplies available at health facilities 
IR 1.2: Increased community-based access to information and services, 
including clean birth kits, PCM, and ORS 
IR 1.3 Referral linkages between communities, health centers, and 
hospitals established and/or strengthened 
IR 2.1 Active surveillance of infant/maternal mortality and EPI￾preventable diseases 
IR 2.3 Quality of care standards developed, tested, and applied 
IR 3.1: Enhanced recognition of pregnancy-related danger signs by TBAs, 
CHWs, and adults in the community 
 CS-14 has conducted training of CHWs, MOHP health workers, and LR CDA 
members in communication skills for health education in all the project interventions 
including maternal and neonatal health care. These activities are discussed in section 
C(1). 
 CHWs are identifying pregnant women in the community, and during their home 
visits, they are encouraging them to register to an antenatal clinic (ANC). Table 4 in 
Attachment 9 shows the number of new and total (“registered”) antenatal visits in all 
three CS-14 areas in the periods January-June 1998 and January-June 2000. The 
number of new visits increased slightly in Taha and El Bayhoo and doubled in El 
Maasara Shark. The proportion of new pregnancies diagnosed as dangerous remains 
the same in the three areas. The number of visits per pregnancy increased from 1 in 
1998 to 3 and 4 in El Bayhoo and Taha, respectively, but only to 1.5 in El Maasara 
Shark. 
The effect of CS-14 on this increase in the number of visits per pregnancy is 
supported by the data presented in Attachment 10 on the utilization of antenatal 
services in three CS-14 and three non CS-14 areas of Samalout District between 
August 1998 and August 2000. The coverage of pregnant women increases slightly 
in all six villages, but the number of visits per pregnancy remains stable in the non 
CS-14 villages while it is increasing in the three CS-14 villages. 
Save the Children CS-14 Egypt Midterm Evaluation 9
Although this increase in the number of visit per pregnancy is in accordance with the 
MOHP policy of recommending 14 antenatal visits per pregnancy (1 per month 
during months 1 to 6, 2 per month during months 7 and 8, and 4 during month 9--the 
MOHP registers “at least 5” visits during pregnancy as completed antenatal care), 
CS-14 has not made any assessment of the quality and potential effectiveness of these 
services. CS-14 contribution to the quality of antenatal services so far has been 
through the training of health workers, primarily in health education, and provision of 
limited medical equipment. 
“In El Maasara Shark (Samalout city), a woman living near the CDA delivered five 
times without going to any health facility. She delivered her sixth child alone. 
During her last pregnancy she went to the health facility with a CS-14 CHW, got 
a monitoring card, and went back regularly until delivery.” 
In Etsa-El Mahata (El Bayhoo area), many women had no information about ANC 
services. One woman had four deliveries and never went to a health facility to 
monitor her pregnancies. In her fifth pregnancy, the CHW provided her with 
health education during home visits. This woman then registered in a health unit 
and went regularly to monitor her pregnancy because she knew that she would get 
many benefits. 
 CS-14 did not conduct several MNC activities included in the DIP, as explained 
below. Therefore the related objectives in the DIP must be changed or these activities 
must begin. 
1. There has not been any training of TBAs because the MOHP’s policy is now to 
promote the use of trained health workers (physicians or nurses/midwives) rather 
than TBAs for assistance in home deliveries. Table 2 in Attachment 9 shows the 
number of deliveries by type of attendance and place of deliveries in the three CS￾14 areas during the periods January-June 1998 and January-June 2000. Although 
the number of deliveries attended by doctors or nurses or that occurred in a clinic 
did increase, still 54% of the births were attended by TBAs during the first 
semester of 2000. Therefore a strategy must be developed and implemented to 
ensure that these deliveries are attended by qualified or trained persons, and 
conducted in the best conditions. 
2. There has not been any distribution of clean birth kits because the MOHP and 
UNICEF planned to conduct this activity. However, CS-14 should ensure that 
these or similar delivery kits are available to women who plan to deliver at home. 
3. Except for the establishment of Emergency Funds with the CDAs and HACs, 
there has not been any development of community-based system for referral and 
emergency transport of obstetrical complications and severe childhood diseases. 
Also, there has been some promotion of the concept and tools for developing birth 
plans with pregnant women, but these are not linked to practical solutions in case 
of emergency. CS-14 should make a careful assessment of the current situation 
with respect to Emergency Obstetrical Care services. 
4. There has not been any systematic assessment of the availability and quality of 
obstetrical care. This will be further discussed in section C(6). 
Save the Children CS-14 Egypt Midterm Evaluation 10
5. There has not been any active surveillance and inquiries into maternal and infant 
deaths. 
 The DIP proposes an “Estimated Project Effort and USAID Funding by Intervention” 
of 40% for the MNC intervention (see Attachment 1). Although this measure is 
poorly defined, the MTE team concluded that CS-14 has not achieved this relative 
effort so far. 
(2) Pneumonia case-management 
Results 
Intermediate 
Results 
 85% of mothers with children <36 months report that rapid breathing 
is a sign of pneumonia 
 IR 1.1: Essential drugs and medical supplies available at health facilities 
IR 1.2: Increased community-based access to information and services, 
including clean birth kits, PCM, and ORS 
IR 2.1: Improved diarrheal disease and ARI case management 
IR 3.2: Increased correct knowledge among caretakers about ORS 
preparation and use, and signs of pneumonia
 During interviews of CHWs and mothers the MTE team observed a fair knowledge of 
the appropriate home management acute respiratory infections. CHWs are promoting 
related messages based on existing materials from the MOHP and UNICEF. 
Communication materials and message contents are discussed in section C(1). The 
baseline value of the knowledge indicator for this intervention is low at 26%, and 
therefore achieving the objective of 85% will require focused and sustained efforts. 
 Table 3 in Attachment 9 shows that the number of visits for Acute Respiratory 
Infections increased between January-June 1998 and January-June 2000, but that the 
number of visits for pneumonia decreased. 
 CS-14 has not systematically assessed the quality of pneumonia case-management in 
MOHP and private health facilities, and the accessibility to antibiotics in particular. 
This question of availability of antibiotics in health facilities was brought at least 
once to a District Health Committee meeting. The MOHP provides some antibiotics 
to MCH clinics on the basis of the number of registered women, but the quantity 
available is usually insufficient. The prescription practice of the private providers 
and the type and cost of antibiotics available in pharmacies are unknown. One 
suggestion for mothers who cannot pay for antibiotics has been the use of the 
Emergency Funds by the CDAs. 
Save the Children CS-14 Egypt Midterm Evaluation 11
(3) Diarrheal diseases 
Results  90% of mothers of children <36 months with diarrhea in the previous 
month report feeding fluid (other than breast milk) during diarrhea 
 85% of mothers of children 6-36 months with diarrhea in the previous 
month report feeding foods (other than breast milk) during diarrhea 
Intermediate 
Results 
 90% of CHWs correctly teach ORT & ORS preparation 
IR 1.1: Essential drugs and medical supplies available at health facilities 
IR 1.2: Increased community-based access to information and services, 
including clean birth kits, PCM, and ORS
IR 2.1: Improved diarrheal disease and ARI case management 
IR 3.2: Increased correct knowledge among caretakers about ORS
preparation and use, and signs of pneumonia 
 CHWs are promoting nutritional messages to mothers during their home visits. These 
messages are based on existing materials from the MOHP and UNICEF. 
Communication materials and message contents are discussed in section C(1). 
 As the baseline value of the two above indicators of mothers’ practice of appropriate 
feeding patterns during diarrhea are high (80% and 70%, respectively), achieving the 
proposed results will require careful identification and targeting of the mothers who 
have not adopted these practices. 
 CHWs distribute limited amount of ORS packets along with demonstration of use 
during their home visits. These packets are given for educational purposes as on￾hand supply for emergency (average about 5 packets per house.) These packets are 
also given free of charge at MOHP units. 
 CS-14 has not systematically assessed the quality of diarrheal disease case￾management in health facilities and the accessibility to ORS. 
 There is no baseline and target for the indicator of mothers’ knowledge of ORS use. 
There is no indicator of ORS use. 
(4) Nutrition 
Results  80% of mothers report providing at least one Positive Deviant food 
to their 6-35 month old child and following at least one key PD 
child care practice 
Intermediate 
Results 

 IR 3.4: Mothers know “Positive Deviant” foods and child care practices 
Save the Children CS-14 Egypt Midterm Evaluation 12
 CHWs are promoting nutritional messages to mothers during their home visits. These 
messages are based on existing materials from the MOHP and UNICEF. 
Communication materials and message contents are discussed in section C(1). 
 Building on the earlier UNICEF-funded Positive Deviance Project that demonstrated 
an impressive decline in malnutrition in non-CS-14 areas in Samalout District, 
SC/Minya conducted Positive Deviance Inquiries (PDI) in several CS-14 villages 
(Taha, El Ameda, Hassan Basha, and El Hatahta). The findings have then been 
generalized to other CS-14 villages, and a PDI consultant introduced the information 
and messages about “Positive Deviant” foods and child care practices in the training 
provided to CHWs. The MTE did not examine these messages and assess the 
potential effectiveness of their delivery outside a growth monitoring and nutritional 
education and rehabilitation program (NERP) such as that included in the Positive 
Deviance Project mentioned above. 
 Although nutrition is one of CS-14 interventions, the project staff and partners have 
often expressed the need for more resources in this area, and in particular to support 
NERP sessions. In the meantime, with financial and technical support from UNICEF 
and Tufts University, respectively, SC/EFO continues to test, refine, and document its 
Positive Deviance nutrition model with the aim of expanding such interventions in the 
future through the Living University program including CS 14 villages in Area 2. 
(5) Immunization 
Results  85% of mothers of children <36 months have received two or more 
doses of TT 
 80% of 12-23 month old children have received three or more doses of 
DPT 
Intermediate 
Results 

 IR 1.4: Expanded access to EPI services through mobile outreach 
IR 3.3: Enhanced caretaker knowledge of EPI schedules 
Save the Children CS-14 Egypt Midterm Evaluation 13
 CS-14 made an effective use of CHWs to help the MOHP achieve universal coverage 
in DPT and OPV coverage rates. During home visits, CHWs are encouraging 
mothers to bring their children to the health facilities for immunization. CHWs are 
also systematically contacting health workers in MOHP facilities to have the names 
of children to bring for a first contact or for a follow up visit. Several MOHP 
officials and health workers confirmed to the MTE team the valuable contribution of 
the CHWs to the recent increase in childhood immunization rates in the project areas. 
Table 5 in Attachment 9 shows the DPT3 and OPV3 immunization coverage 
estimated through health services statistics in the three CS-14 areas in the periods 
January-June 1998 and January-June 2000. These coverage rates increased in all 
three areas, and in particular in the El Maasara Shark, the slum area in Samalout city. 
These results are impressive but need to be interpreted with caution because the 
estimate of DPT3 coverage is 46% in the baseline household survey and the CHWs 
only started their home visits program in July 1999. 
 CS-14 also contributed in increasing neonatal tetanus immunization coverage among 
women of reproductive age. Table 1 in Attachment 9 shows a major increase in the 
number of tetanus toxoid doses provided in all three CS-14 areas between the periods 
January-June 1998 and January-June 2000. Here also, the increase is the largest in El 
Maasara Shark (235%). This result is at least partially related to Tetanus Toxoid (TT) 
doses provided during antenatal visits, and if sustained, will directly affect the value 
of the indicator for this intervention (67% at baseline). It probably also reflects a 
better implementation of the MOHP policy of immunizing all women of reproductive 
age through five TT injections, and therefore part of this increase in the number of TT 
doses (those given to women who will not be pregnant in the coming three years or 
all the third or subsequent doses) will not affect the specific End-of-Project Objective 
of 85%. 
“In El Maasara Shark, there was a woman who had eleven children who had never 
immunized any of them except when health workers came to her home during 
national campaigns. When she had her twelfth child and a CS-14 CHWs 
provided her with health education, not only did she go to the health facility and 
get her child immunized, but she also participated in health education seminars 
held in El Rahman CDA.” 
 CS 14 received a ‘Thank You’ letter from MOHP officials for effective participation 
in national EPI mobile outreach campaigns through coordination of the CHWs, CDAs 
and health units’ work. 
Save the Children CS-14 Egypt Midterm Evaluation 14
C. Cross Cutting Approaches 
(1) Behavior Change Communications 
 All CS-14 safe motherhood and child survival results and many intermediate results 
relate to specific behavior or knowledge changes, and have been discussed under the 
corresponding interventions in the previous sub sections. Only general findings are 
discussed here. 
 CS-14 has conducted training for MOHP health workers and CHWs in 
communication skills and health education messages related to the various project 
interventions. The number, type of persons trained, and content of training are 
discussed in section II.C(3) below. These skills are applied during the interactions 
between CHWs and mothers during home visits, and between health workers and 
mothers during clinic visits. 
 At the end of the MTE, CS-14 staff prepared a list of Key messages by technical 
interventions (Attachment 11). These Key messages must be considered as 
“positioning statements” to be broken down into specific messages by the CHWs or 
other health educators according to individual cases of maternal or child health. The 
Key message for pneumonia case management for instance, indicates that all mothers 
should know the danger and the importance of early diagnosis and treatment of 
pneumonia. In addition, CHWs should be teaching mothers the specific signs of 
pneumonia (rapid breathing, chest in drawing) in newborns, older infants, or children, 
as the case maybe, and exactly when, where and how to seek care. For 
immunization, every mother should know that complete and timely immunization 
protects children from serious diseases. In addition, CHWs should elaborate more 
specific messages about the different types of vaccines for children or pregnant 
women, and when and where to obtain them. The MTE team did not examine the 
specific messages taught to CHWs and other health educators. These can probably be 
found in various training documents (most of them in Arabic). During interviews 
with CHWs and mothers, the MTE noticed a generally sound understanding of 
specific health messages. 
 The MTE team gathered the various health education materials available at the 
SC/Minya office and that CHWs or health educators use to communicate key 
messages to mothers. In accordance with the DIP, all these materials are borrowed 
from the MOHP, UNICEF, or other organizations working in Egypt. CS-14 has very 
limited amount of these materials (in type and numbers) and CHWs generally do not 
have materials to support their talk and demonstration or to distribute to mothers. 
 Although most of the project activities relate to the work of the CHW and in 
particular to that of health education of mothers and caretakers, CS-14 has not 
adopted any indicators for monitoring behavioral change yet (see discussion on 
Save the Children CS-14 Egypt Midterm Evaluation 15
information management in section D(2). Such indicator should be related to the 
training, the competency, and the activities of the CHWs and other health educators. 
(2) Community Mobilization 
Results  All 5 HACs report MOHP has effectively addressed > 50% of 
concerns raised in quarterly meetings 
Intermediate 
Results 

 IR 2.5 Increased community participation in defining and monitoring 
quality of care 
IR 4.3 Scheduled, regular MOHP/community problem-solving 
 CS-14 has established effective community-defined problem solving mechanisms 
using CHWs, CDAs, LHAC, and DHAC. 
“In El Shaarawya (El Bayhoo area), the government had refused to open a health 
unit that was built on cultivated land. In cooperation with the local community 
leaders, this problem was presented to the first DHAC meeting and the unit was 
soon opened and provided with water and electricity. It then appeared that the 
unit was not assigned any health staff, faced regular shortage of equipment and 
supplies, and remained dependent on the Medical Center in Samalout. All these 
problems were presented again to the DHAC, and the DHMT then provided a 
resident doctor and a complete health team from the nearby units and villages. As 
the unit was also recognized as separate from the Medical Center, the health 
district delivered a MCH register to the MCH, the nurse was trained by the RC, 
some simple equipment was provided, and the unit started to provide the needed 
medical services.” 
“In El Hatahta (El Bayhoo area), the health unit was open but was not provided with 
electricity. The problem was presented to the DHAC and this unit now has 
electricity.” 
“In Al Amoudeen (Taha area), the CDA began motivating the local community to 
define and solve their health problems. They soon identified a sewage canal in 
the village as a major cause of nuisance and health problems in the community. 
The issue was presented to the DHAC and to the Taha Local Council, and the 
village obtained support to cover the canal.” 
(3) Training 
Results 
Intermediate 
Results 
 90% of CHWs correctly teach ORT & ORS preparation 
 
Save the Children CS-14 Egypt Midterm Evaluation 16
 SC/Minya estimates that about 80% of the training activities included in the DIP were 
successfully conducted. The table below gives the number of training recipients and 
topics by professional categories. The same recipients may have been trained several 
times. The CHWs, for instance, received training during 3 days in communication 
skills, 3 days in CDD, 6 days in ARI, ANC, EPI, and nutrition, and 2 one-day 
refresher training seminars (see Attachment 8). 
Training recipients Number Subject 
CHWs 103 Communication skills and 
CS-14 interventions 
LR CDA members 33 
Primary Health Care Units: 
Physicians
Nurses
20
 20
CS-14 interventions 
DHMT members 20 Training of trainers 
 Consultants and partner organizations conduct most of the CS-14 training. During 
discussions within the MTE team, both CS-14 staff and partners’ representatives have 
expressed the need for a establishing a comprehensive system including design, 
implementation and evaluation of training activities in order to ensure the best 
quality. 
 The DIP includes one quantified End-of-Project Objective of competency directly 
related to the result of training activities. This and similar competencies for other 
interventions could be standardized to help focus the training and monitor its impact 
on the recipients. The related behavior among caretakers (correct use of ORS, in the 
example above) can then also be measured and monitored. 
 CS-14 has contributed to the establishment of a training hall in the Health District 
office in Samalout. All CDAs would like to have their own training hall with 
modern training equipment. 
 The MTE team has recorded many requests for further training. The MTE team 
found that CS-14 should indeed respond to the needs below: 
o CHWs on communication skills but with clearer emphasis on specific health 
messages 
o LR CDA on financial and administrative management, to better prepare them to 
become LU CDA 
o LU CDA on training of trainers 
o MOHP physicians in the CS-14 areas on project interventions, and specially MNC 
Other frequent requests such as training of CHWs in first aid and injections 
techniques did not meet the approval of the MTE team. 
Save the Children CS-14 Egypt Midterm Evaluation 17
(4) Partnership with Community Development Associations 
Results 
Intermediate 
Results 
 Both CS-14 LU CDAs have experienced trainers, curricula, & 
materials 
 Both CS-14 LU CDAs provide training & TA to Learner CDAs 
 
 CS-14 has identified strong community-based partners and used them effectively to 
implement the Living University strategy. Early in its implementation, CS-14 has 
defined adequate roles and responsibilities for the LR CDA supervisor, coordinators, 
and training coordinators, as well as those of SC (Attachment 12). 
 One of the main functions of the LR CDA in CS-14 is to select, coordinate, and 
supervise the CHWs. In June 2000, the three LR CDAs were supervising a total of 
103 CHWs in 16 villages and who covered 13,067 children under five. This 
represents 72% coverage of the target population of children under five. Typically, 
each CHW conducts about 6 visits a day and covers about 100 households. She also 
visits the local health facility three times a week, attends Local Health Action 
Committee meetings once a month, and attends District Health Action Committee 
meetings once a quarter. Each CHW receives a supervisory visit from the LU CDA 
coordinator every month. 
 Both LU and LR CDAs have managed their CS-14 sub grants adequately. The LU 
grants cover the cost of training activities, of a coordinator, and some office support. 
The LR CDA grants cover the cost of the CHWs incentives, of one person, and of 
some office support. The three LU CDAs have been responsive and effective in 
building the capacity of the three LR CDAs through training, weekly technical 
assistance and monitoring visits, and exchange of experience. The three LR CDAs 
have shown dynamism and determination in building their managerial capacity, in 
supervising CHWs, and in working with the communities, the Local Health Action 
Committee, and the MOHP. 
“In El Bayhoo, the LR CDA already submitted a number of proposals after receiving 
technical assistance on project design and proposal writing from the LU CDA 
Zohra. One proposal was to provide clean drinking water to poor families; 
another one was to carry out an environmental project. CARE recently approved 
one health project, and the CDA board members are now being trained for its 
implementation.” 
“In Al Ameda (Taha area), the LR CDA El Fath received training from the LU CDA 
Taha on how to write and present project proposals. The LR CDA presented a 
proposal to SC and got support to open two nursery classes in its building and 
four nursery classes in private homes. This was because of the CDA believed in 
the importance of early childhood development.” 
Save the Children CS-14 Egypt Midterm Evaluation 18
 Despite the progress, the LR CDAs are not ready to become LU CDAs and begin 
sponsoring other CDAs. LR CDA members expressed the need for enhanced skills in 
financial and managerial management, and for more opportunities to visit and learn 
from LUs’ experiences. During their supervisory visits to the LR CDAs, the three LU 
CDAs have identified many training needs that for budgetary reasons cannot been 
addressed. This leaves the three LR CDAs unready to act as LU CDA during the next 
phase of the project. 
 CS-14 has strengthened the capacity of the LU CDAs by providing them the 
opportunity to train, mentor, and work with the LR CDAs. Their role in phase 3 of 
CS-14 now raises unresolved questions. CS-14 is assisting the LU CDA board 
members in defining themselves their future role in CS-14 and in their communities. 
One suggestion has been to train some members of the LU CDA as trainers who 
could be used in some of the CS-14 activities. SC could also assist them in 
developing health-related proposals to submit to other agencies, and offer technical 
and executive backstopping. 
(5) Partnership with the Red Crescent Society 
 CS-14 has strengthened the capacity of RC to provide training primarily through the 
opportunities to coordinate such activities. There has not been any assessment of the 
quality of the training provided and of the possible need for training of RC staff and 
consultants in training skills and in CS-14 interventions. 
 There has not been other activity to strengthen RC’s technical and managerial 
capacity to play a leadership role in health development in Minya, as indicated in the 
DIP. CS-14 could involve RC in other activities than training such as baseline 
surveys, needs assessments, participation in the DHMT and the AC meetings. The 
agreement between SC/Minya and RC may need to be revised to explicitly include 
such activities. 
Save the Children CS-14 Egypt Midterm Evaluation 19
(6) Partnership with MOHP 
Results  DHMT has quarterly action plans which reflect community feedback 
and facility assessments 
Intermediate 
Results 

 IR 1.3 Referral linkages between communities, health centers, and 
hospitals established and/or strengthened 
IR 2.1 Active surveillance of infant/maternal mortality and EPI￾preventable diseases 
IR 2.3 Quality of care standards developed, tested, and applied 
IR 2.4 Supportive supervisory skills transferred and applied 
IR 2.5 Increased community participation in defining and monitoring 
quality of care 
IR 4.2 District Health Management Team independently continues 
planning cycle 
IR 4.4 MOHP using revised MIS 
 The DHMT does not have its own comprehensive plan of activities for the district. 
The Health District in Samalout primarily uses plans and directives from Minya and 
Cairo, and does not engage in a local planning and coordination process with health 
workers, partners, and communities. Building on the successful organization of 
District Health Action Committees for problem solving (see section II.C(2)), CS-14 
could propose their participation and assistance in such planning and coordination 
process, as suggested in the DIP. 
 CS-14 has not developed standards of quality of care, conducted systematic health 
facility assessment or joint supervisory visits, established effective referral linkages 
between communities, health centers, and hospitals, and begun building quality 
improvement systems in health services. The MTE team noticed that the MOHP has 
not begun quality improvement activities in Samalout either. 
 CS-14 has distributed minor medical equipment to 14 health facilities (Attachment 
13). The items were selected through some consultations with MOHP officials in 
charge of the project areas facilities but without explicit technical assessment related 
to specific CS-14 interventions. MOHP heath workers and officials have often 
expressed needs for more equipment and supply during the MTE visits and meetings. 
 CS-14 prepared a training room of 20-person capacity in the health district in 
Samalout and provided tables and chairs, a white board, a flip chart holder. The 
Health District has provided a TV/ video and an overhead projector. 
Save the Children CS-14 Egypt Midterm Evaluation 20
(7) Sustainability Strategy 
Results 
Intermediate 
Results 

 IR 4.1 Living University “campus,” “faculty,” “curriculum,” and 
Community Trustee in place 
IR 4.2 District Health Management Team independently continues 
planning cycle 
IR 4.5 Communities independently supporting community-based providers
 The Living University strategy underlying CS-14 builds local capacity and involves 
communities. The overall design appears sustainable. The challenge is to ensure that 
the LU CDAs, LR CDAs and CHWs continue their activities at the end of the project. 
 The three LU CDAs that have been working during the present model development 
phase should be able to sustain their capacity and possibly their activities at the end of 
this phase. This should occur outside of CS-14 since the DIP does not include a grant 
for the initial LU CDAs in phase 3. As mentioned in section II.C(4), LU CDAs are 
now questioning their role in phase 3 of CS-14. A sound solution should be 
developed and that will be applicable to the three new LU CDAs (current LR CDAs) 
at the end of the project. 
 Activities of CHWs in the five CS-14 areas should continue beyond the end of the 
project. On several instances during meetings with the MTE team members, CDAs 
members discussed the possibility of cost recovery of the CHWs’ incentives and 
transportation costs through a fee-per-visits scheme. A fee of 1 Egyptian Pound is 
often proposed as acceptable by mothers. On the other hand, the current incentive 
given to CHWs is often considered “too low.” These issues should be further 
explored, and possible solutions tested in the three first areas before the end of the 
project. 
 SC/Minya has not clearly defined a “CS-14 exit strategy” yet. However, the MTE 
team noticed a good awareness of sustainability issue among SC/Minya and partners 
staff. 
Save the Children CS-14 Egypt Midterm Evaluation 21
D. Program Management 
(1) Planning 
 The MTE reviewed the various weekly and other work plans used by CS-14 Field 
Coordinators. These detailed plans allow careful coordination and monitoring of their 
activities. 
 Overall, there seems to be a good participation from the various CS-14 partners in the 
definition of their respective roles and responsibilities, and in the preparation of the 
work plans. As noted before, however, there is no DHMT level comprehensive 
planning system that involves all partners and encourages coordination and 
collaboration. 
 The USAID/Egypt Mission, which funds half of the CS-14 project, has not received 
the DIP, annual report, or other relevant planning documents. 
(2) Information Management 
 CS-14 and its partners routinely collect or has access to a wealth of information that 
is not fully used for decision-making and program design. Typical examples of data 
available from the MOHP facilities were presented earlier (see Attachment 9 and 
Attachment 10). The DIP suggests the active use of the MOHP vital registration data 
for the detection and systematic inquiries into cases of maternal and child deaths. 
Others sources of information are the good records that the Field Coordinators and 
Team Leader keep about their various activities (monthly, weekly, and daily work 
plans, meeting minutes, correspondence with partners) and those of the CHWs. The 
latter data can give information on the coverage of the home visits program. 
 CS-14 is revising the CHWs reporting system. New forms have been designed to 
provide epidemiological and behavioral, in addition to programmatic, information. 
The aim is to provide better information to prioritize interventions, monitor the 
impact of these interventions, and communicate with the communities and MOHP 
facilities. The new system proposes to use printed rather that hand-written forms for 
CHWs. A complete review of the feasibility (time, cost) and usefulness (indicators 
obtained) of the proposed system should be done, maybe with external experts from 
the MOHP or other project in Egypt or from SC/HO. This review should include 
assessment and analysis of the existing data. 
(3) Human Resources Management 
 Attachment 14 presents the current staff of SC/EFO and Minya supported by CS-14. 
Most of this staff including the project manager is based in Minya. Most of CS-14 
staff has remained stable and this has contributed to building good relationship with 
the various partners. The CS-14 project manager, who is also the SC/Minya Program 
Manager, has been replaced with a senior public health physician with extensive 
Save the Children CS-14 Egypt Midterm Evaluation 22
experience in public health and communication programs, and in Minya in particular. 
The transition was smooth and the new management style welcome. SC/Minya 
recently recruited a new senior public health physician with previous experience in 
similar community-based project, and more recent experience in several critical areas 
for CS-14 such as information systems and quality assurance. SC/Minya also 
recently recruited a new training and institutional development specialist with 
obvious competence for improving current training and capacity building strategies. 
This new personnel will certainly give new directions and impetus to the CS-14 
project. There is no obvious need for additional long-term personnel on the project. 
 The CS-14 Team Leader and Field Coordinators reported that their salaries are lower 
than those of staff with similar qualifications in other SC projects. The Program 
Manager recognized that, with overtime pay, errand boys in SC’s Minya office earn 
more than the Field Coordinators who do not receive payment for overtime work. 
 The CS-14 Team Leader and Field Coordinators noted that CS-14 will expand into 
two new sites during the next phase of the project and asked whether all three teams 
of Field Coordinators would be retained during this phase. A review of the CS-14 
budget revealed that seven Field Coordinators are budgeted for during the last two 
years of the project. 
 The CS-14 Team Leader and six Field Coordinators request English language and 
Internet training. The MTE team also identified training needs in technical areas such 
as quality assurance, behavior change communication, financial management, and 
project interventions. These training should be defined and provided soon to ensure 
benefits during the final two years of the project. 
(4) Financial Management and Logistics 
 There has not been overspending in any of the main CS-14 budget categories. During 
group discussions about CS-14 financial management, various misconceptions about 
the flexibility of the budget lines appeared that were clarified by the SC/HO and 
USAID/BHR/PVC MTE team members. It turned out that only minor change might 
be necessary and these within the main budget categories (changing the topic of 
training seminars, for instance). In any case, SC should refer to the cooperative 
agreement with respect to this issue and make the relevant section of this document 
available to CS-14 staff in Minya before budget changes are proposed as a result of 
the MTE. 
 The need for all CS-14 staff to be well-aware of the budgetary issues was also raised 
and discussed: program managers and field coordinators need to know the financial 
constraints of the project and financial managers need to know the program needs to 
achieve the project objectives. 
Save the Children CS-14 Egypt Midterm Evaluation 23
 The CS-14 Team Leader and six Field Coordinators used to share two rooms in 
SC/Minya offices. Currently, the Team Leader and three male Field Coordinators 
each have a desk and share one room. Two female Field Coordinators share a room 
with three nutrition program staff. The third female Field Coordinator is on maternity 
leave. Two weeks before the start of the MTE work in Minya, SC’s Program 
Manager asked the female Field Coordinators to join the male CS-14 staff and share 
desks in one room. The CS-14 staff refused to share desks in one room workspace, 
noting that even though they spend much of their time in the field, their fieldwork 
schedules require them to be in the office at the same time early each morning and 
late each afternoon. They report that they each need their own desk to do their 
required written work. After the MTE and the time of writing this report, the CS-14 
staff had been provided with a special place for filing and records keeping in addition 
to a health library and Internet service and all staff is satisfied with the new upgrade 
and reseating in the current office. 
 The Team Leader and six Field Coordinators currently use two computers purchased 
with CS-14 funds. They are requesting a third computer. Alternatives to purchase of 
a third computer include a reduction in the amount of written work required from the 
Team Leader and Field Coordinators, use of other SC staff to do some of this work 
while the Field Coordinators are in the field, and provision of training in word 
processing to Field Coordinators to enhance their efficiency in using the available 
computers. 
 Overall, field coordinators all recognized having adequate transport support to 
conduct their field activities. 
(5) Technical and Administrative support 
Through the various reviews presented above and the related discussions with CS-14 staff 
and partners, the MTE team identified three main areas for which SC/Minya may benefit 
from technical support (in addition to training in the related areas): 
 Review of the existing BCC messages and materials, and development of strategic 
communication plans for each interventions 
 Development of a strategy for quality of care improvement with involvement of the 
community and the MOHP service providers. 
 Review of and training in project financial management. 
Save the Children CS-14 Egypt Midterm Evaluation 24
E. Conclusions 
 SC/Minya is successful in implementing the Living University strategy to improve 
maternal and child health in Samalout District, building on its past and current 
projects and on its long-term presence in Minya governorate. This strategy is 
promising in terms of community involvement and potential for scaling up. 
 CS-14 made an effective use of CHWs to help the MOHP increase the utilization of 
MCH services. The MTE team identified several opportunities for improving the 
effectiveness and efficiency of the current activities, as noted in the MTE 
recommendations. 
 A fundamental strategy of CS-14 is to use CHWs and MOHP health workers to 
promote healthy practices among pregnant women and mothers of children under 
five. SC/Minya intentionally decided to use the large amount of health education 
materials existing in Egypt for the interventions proposed in the DIP. The MTE team 
did not disapprove of this approach, but found that it may have resulted in a lack of 
focus on key strategic messages. The MTE team also found that CHWs lack 
materials to support their behavior change activities during their home visits. 
 CS-14 has been successful in setting up various Local and District Health Action 
Committees in which community-defined problems have been presented, discussed, 
and often adequately addressed or solved. The MTE team found that these 
community mobilization and participation mechanisms have not been fully used to 
develop a more comprehensive district-level health planning and coordination system 
with the DHMT and its partners. 
 The effectiveness of most of the CS-14 interventions depends at least partially on the 
availability, accessibility, and quality of facility-based health services. The MTE 
found that CS-14 had not begun to systematically work with the MOHP and the 
private providers to assess and improve the quality of care offered to its target 
population. 
 SC/Minya and its CS-14 partners have secured competent and motivated personnel 
who are now carrying out intensive field activities. At midterm of implementation, 
this active base of operations provides opportunities for senior executives at 
SC/Minya, EFO, and HO to provide high-level technical and managerial support to 
these personnel and ensure that both the impact and model development objectives of 
CS-14 are met by September 2002. 
Save the Children CS-14 Egypt Midterm Evaluation 25
F. Recommendations 
1. Ensure effectiveness and efficiency of CHWs’ work 
 Undertake a systematic review of the specific health education messages used within 
CS-14 (in current training materials, in MOHP health facilities, etc) and other settings 
accessed by CHWs and mothers (television, private providers, etc). Define explicit 
communication objectives and strategies for each intervention. Identify among 
existing materials a limited set for CHWs and health workers to use and distribute to 
mothers. Identify the materials that are missing or inappropriate and need to be found 
somewhere else or redesigned. Estimate the number of each item needed and the 
potential sources of supply during the CS-14 and after. Define objectives and 
measurable indicators for the specific communication competencies expected from 
CHWs for each intervention (one example available for CDD, for instance, is: “90% 
of CHWs correctly teach ORT & ORS preparation”). 
 Define a few priority criteria for home visits by CHWs. Given the limited time and 
number of CHWs, there is a risk that the same households with well-known mother 
and children under five are visited every month while other households with greater 
risk and need for health education and advice remained uncovered. Priority criteria 
should include households with pregnant women or infants, with sick children (follow 
up), and with immunization dropouts. In addition, CHWs should give priority to first 
visits to household with a newly identified pregnant woman or child under five, and 
high-risk households (poor, illiterate, known health problems). CS-14 should use the 
available data collected by the CHWs to assess the current pattern of visits and 
activities (age distribution of children visited, activity conducted, other available 
information) and to define these priority criteria. CS-14 should incorporate the 
related information in the new CHW HIS, as appropriate. 
2. Strengthen the Maternal and Newborn Care intervention 
 As several MNC activities planned in the DIP have intentionally been dropped or 
have not begun, CS-14 and its partners should first thoroughly review the objectives 
and strategy of this component, then the related work plan and budget. This review 
should build on the achievements in the other aspects of the project and take the other 
MTE recommendations into consideration. Except for training of TBAs and the 
distribution of clean delivery kits, most of the plans in the DIP still seem appropriate. 
Among elements to consider in this review are how to cover the 54% of deliveries 
that currently occur without trained attendants; how to set up a system of emergency 
transport and referral; how to ensure the quality of emergency obstetrical services in 
the areas; how to monitor and learn from maternal and infant deaths occurring in the 
project area. 
3. Further develop cooperation with MOHP 
 Different types of activities can be conducted at different level of the health system: 
Save the Children CS-14 Egypt Midterm Evaluation 26
o At the Governorate level, maintain close contact with key technical officials by 
exchanging information and inviting participation in key project decision-making 
and activities, as appropriate; 
o At the District level, propose participation and assistance in the development of 
comprehensive health development plans involving communities and partners; 
o At the health unit level, facilitate communication between health workers, private 
provider, and communities. 
 Facilitate the introduction in Samalout District of selected programs sponsored by the 
MOHP and its partners at the national or governorate levels: 
o Integrated Management of Childhood Illness 
o Emergency obstetrical care 
o Quality assurance 
 Develop a comprehensive community-defined plan to improve quality of care, 
building on the network of CHWs and CDAs, the system of Local and District Health 
Action Committees, and the collaborative relationship with the MOHP. 
4. Plan CS-14 transition from phase 2 to 3 carefully 
 This transition is critical to the success of the project. This has to be considered as a 
test of the “Living University” model. SC/Minya should expect resistance at various 
levels, recognize it objectively, and address it constructively. The current LR CDAs’ 
capacity to become a LU CDAs should be assessed according to explicit criteria. 
SC/Minya should continue assisting LU CDAs in defining their role and contribution 
to better health in their areas. 
5. Develop an explicit “exit strategy” 
 This strategy should be formulated and tested before the end of the project. Such 
strategy and its implementation does not imply that SC will leave Minya but that it 
will choose to work on different activities or geographical areas. The exit strategy 
should be specific to project activities and have a timeline. The question of 
incentives to CHWs is one example of such activities needing a specific exit strategy. 
The successful implementation of these strategies will be an indicator of success of 
the project and model. 
6. Consider applying for a cost extension 
 CS-14 is at least partially about model development, and it is necessary that the entire 
cycle be completed. A cost extension application, if necessary, should demonstrate 
the good results so far and the benefits for PVOs and for other child survival projects 
in Egypt and elsewhere. CS-14 should be prepared to apply in about a year to ensure 
a smooth transition. SC/Minya and the EFO should keep USAID/Cairo well 
informed of these developments. 
Save the Children CS-14 Egypt Midterm Evaluation 27
G. Results Highlight 
The Living University: 
Addressing Community-Defined Problems, Disseminating Healthy Practices, 
 and Scaling-Up Child Survival Activities in Upper Egypt 
The Living University approach was developed by Save the Children (SC) in Vietnam as a mechanism 
for program expansion and for fostering local capacity to implement and sustain development projects, 
built on the principle of “learning by doing.” The LU began in a few communities to pilot and closely 
monitor an innovative nutrition program. Upon demonstrating measurable effects, the initial site 
became a “Living University,” a “laboratory” where those wishing to learn about the program actively 
participated in its protocols and activities. Upon “graduation,” LU students returned home and began 
program implementation. After refinement, their areas became LUs, from which further expansion 
occurred. This approach enabled the SC nutrition program to expand from a population of 40,000 to 
1.5 million, while maintaining program quality and impact. 
In Upper Egypt, through the USAID Mission-funded “Partnering for Institutional Development” 
(P/ID) project in Minya Governorate, the LU has enabled Community Development Associations 
(CDAs, government registered local NGOs) to plan, implement, and manage economic opportunity, 
education, early childhood development, and primary health programs, employing local expertise and 
resources. 
SC’s child survival project in Minya (CS-14) is employing this successful model to address 
community-defined problems, disseminate healthy practices throughout communities, and scale-up the 
project to reach new areas. Currently, three experienced LU CDAs from the P/ID Project are training 
and supporting three new CS-14 “Learner” (“LR”) CDAs to assess health needs, to mobilize 
communities, and to plan and manage development activities. Each CDA receives a sub-grant from 
SC, with each LU CDA mentoring one LR CDA. LU CDAs and SC are working with LR CDAs to 
train, support, and monitor female Community Health Workers (CHWs) to provide CS services in 
their communities, and to link these community health activities to government health services. 
Following CS-14 expansion into two new areas, two of the current LR CDAs will become LU CDAs 
to build capacity of two new LR CDAs. 
In CS-14, CDAs and CHWs have been particularly effective in increasing antenatal visits and tetanus 
immunization. Before CDAs had taken up the issue with local health services, it had been common 
practice for pregnant women not to be registered or receive ANC booklets unless they were at least 
four months pregnant. CDAs where informed of this practice by CHWs who learned during their 
work about community concerns regarding the quality of ANC services at health facilities. Following 
several meetings in which CDA members and SC staff brought these issues to the attention of health 
facility staff, the number of ANC visits has increased 265%, TT immunizations by 67%, and pregnant 
women now receive ANC booklets during their first visit to a health facility. Joint problem solving by 
CDAs and district health staff has also led to several other improvements, including a closed health 
facility being opened and staffed. SC-supported CDAs are now writing proposals and receiving funds 
for community development activities from other donors, suggesting important implications for the 
sustainability of this approach. 
Save the Children CS-14 Egypt Midterm Evaluation 28
III. The Action Plan 
This section will be completed collaboratively by SC and partners soon 
after the MTE report is approved. It may be in the form of a separate 
document. It will address all the MTE recommendations, provide a 
discussion about whether they will be implemented or not (and if not, why 
not), and specify what actions will be taken by which date and by whom. 
It will include a short written plan and budget amendment, as necessary. 
Save the Children CS-14 Egypt Midterm Evaluation 29
INSERT SC ACTION PLAN HERE 
Save the Children CS-14 Egypt Midterm Evaluation 30
IV. Attachments 
Attachment 1 Baseline information from the DIP 
The text and tables below primarily comes from the CS-14 DIP and constitutes a summary of the 
key points in the DIP relevant to the MTE. Only minor changes in the formulation and 
presentation have been made to ensure coherence and clarity. For more detail, please refer to the 
original DIP document. The present summary follows the outline below: 
A. Field Program Summary 
B. Program Goals and Objectives: 
C. Program Location 
D. Program Design 
E. Partnerships 
F. Health Information System 
A. Field Program Summary 
Estimated Project Effort and USAID Funding by Intervention 
Intervention Effort Funding
 Immunization 10% $100,000 
 Nutrition and Micronutrients 10% $100,000 
 Breastfeeding Promotion 0% $0 
 Control of Diarrheal Disease 20% $200,000 
 Pneumonia Case Management 20% $200,000 
 Control of Malaria 0% $0 
 Maternal and Newborn Care 40% $400,000 
 Child Spacing 0% $0 
 STI/HIV/AIDS Prevention 0% $0 
 Others (specify) 0% $0 
 Total 100% $1,000,000 
Project Site Population: Children and Women 
Population Age Group Number in Group 
Infants (0 – 11 months) > 7,000 
12 – 23 Month Old Children 7,000 
24 – 59 Month Old Children < 21,000 
Total 0 – 59 Month Olds 35,000 
Women (15 – 49 years) 46,000 
Estimated annual number of live births in the site: 8,654. Numbers of 
live births, children under five, and women 15 to 49 based on 1998 
information obtained from the MOHP in Minya. 
B. Program Goals and Objectives 
Goal:
Improved Health Status of 
Mothers & Children under 5 
Result: 
Improved Health Behaviors 
and 
Use of Key Health Services 
IR 1: IR 2: IR 3: IR 4:
Increased Availability/Access Improved Quality of Care Improved Knowledge About Child Sustained Health 
To Information and Services Survival & Safe Motherhood System Improvement 
1. Essential drugs and medical 
supplies available at health 
facilities 
2. Increased community-based 
access to information and 
services, including clean birth 
kits, PCM, and ORS 
3. Referral linkages between 
communities, health centers, and
hospitals established and/or 
strengthened
4. Expanded access to EPI services 
through mobile outreach
1. Improved diarrheal disease and 
ARI case management 
2. Active surveillance of 
infant/maternal mortality and 
EPI-preventable diseases 
3. Quality of care standards 
developed, tested, and applied 
4. Supportive supervisory skills 
transferred and applied
5. Increased community 
participation in defining and 
monitoring quality of care
1. Enhanced recognition of 
pregnancy-related danger signs 
by TBAs, CHWs, and adults in 
the community 
2. Increased correct knowledge 
among caretakers about ORS 
preparation and use, and signs of 
pneumonia 
3. Enhanced caretaker knowledge 
of EPI schedules 
4. Mothers know “Positive 
Deviant” foods and child care 
practices
1. Living University “campus,” 
“faculty,” “curriculum,” and 
Community Trustee in place 
2. District Health Management 
Team independently continues 
planning cycle 
3. Scheduled, regular MOHP￾Community problem-solving
4. MOHP using revised MIS
5. Communities independently 
supporting community-based 
providers
Save the Children CS-14 Egypt Midterm Evaluation 33
End-of-Project Objectives for Safe Motherhood, Child Survival, and Capacity Building & Sustainability 
Level Safe Motherhood Child Survival 
Capacity Building 
& Sustainability 
Results  80% of TBA-assisted 
deliveries in past 6 
months are performed 
by CS-14 trained TBAs 
 Clean birth kits are used 
in 80% of home births in 
past 6 months 
 90% of mothers of children <36 months with diarrhea 
in the previous month report feeding fluid (other than 
breast milk) during diarrhea 
 85% of mothers of children 6-36 months with 
diarrhea in the previous month report feeding foods 
(other than breast milk) during diarrhea 
 85% of mothers of children <36 months have 
received two or more doses of TT 
 80% of 12-23 month old children have received three 
or more doses of DPT 
 80% of mothers report providing at least one Positive 
Deviant food to their 6-35 month old child and 
following at least one key PD child care practice 
 DHMT has quarterly action 
plans which reflect 
community feedback & 
facility assessments 
 All 5 HACs report MOHP 
has effectively addressed > 
50% of concerns raised in 
quarterly meetings 
Inter￾mediate 
Results 
 90% of women with 
infants under age 6 
months know two or 
more obstetric danger 
signs 
 90% of CHWs correctly teach ORT & ORS 
preparation 
 85% of mothers with children <36 months report that 
rapid breathing is a sign of pneumonia (or a serious 
sign for a child with a cough) 
 Both CS-14 LU CDAs have 
experienced trainers, 
curricula, & materials 
 Both CS-14 LU CDAs 
provide training & TA to 
Learner CDAs 
Save the Children CS-14 Egypt Midterm Evaluation 34
C. Program Location 
Selected Characteristics of Samalout District and the CS-14 Project Site 
Characteristic Samalout District Project Site 
Population 480,000 220,000 
Village Areas 8 4 
District Hospitals 1 0 
Rural Hospitals 2 2 
Basic/Rural Health Units/Centers 36 17 
MOHP Doctors 228 41 
MOHP Nurses/Midwives 251 31 
D. Program Design 
CS-14 seeks to reduce infant, child, and maternal mortality, and introduce a sustainable 
district health model for introduction and expansion of safe motherhood and child 
survival services. The overall design of the CS-14 District Health Through a Living 
University project is to link Ministry of Health and Population (MOHP) facilities, staff, 
and systems; the Red Crescent (RC) Society; Community Development Associations; and 
families; for improved caretaker practices, access to care, and quality of care, through an 
approach which builds capacity at the individual, family, community, NGO, and facility 
levels through mobilization, organization, partnering, training, and support for 
measurable, replicable, sustainable health improvement. 
The “Living University” (LU) strategy begins with a few communities to pilot and 
closely monitor a quality program. Upon demonstrating measurable effects, the program 
and its principal actors become a LU where those wishing to access the model can 
actively participate in its activities. Since July 1998, SC has been implementing this 
strategy in Samalout and other districts of Minya Governorate through the USAID/Egypt￾funded “Partnering for Institutional Development” (P/ID) project. In this project, LUs 
have enabled local NGOs to plan for, implement, and manage economic opportunity, 
education, early childhood development, and primary health programs employing local 
expertise and resources. CS-14 will employ this successful model to establish a district￾level mechanism for replication and expansion of Child Survival services. In a first 
“model development” phase, three CDAs from the LU Project (LU CDA) will work with 
three CS-14 Learner (LR) CDAs to mobilize the communities, assess needs, and to plan 
and manage activities. In a second “model replication” phase, two of these three LR 
CDAs will become LU CDA and will work with two additional CS-14 LR CDAs. 
Other key CS-14 strategies are: 
 Health Action Committees to broker the interface of MOHP services and the 
community by guiding behavior change communication (BCC) efforts, identifying 
local providers for training/retraining, arranging emergency transport for patients and 
transport for MOHP partners, and for quarterly review of services with MOHP; 
Save the Children CS-14 Egypt Midterm Evaluation 35
 Community Health Workers and TBAs who facilitate access to health services and 
community participation; 
 Public/private collaboration through TBA retraining and through “infiltrating” the 
private sector with improved skills by training public providers who also run part￾time private clinics; 
 Strengthening the Red Crescent, which will identify and support female CHWs and 
train and support TBAs and MOHP staff; 
 BCC with carefully chosen, consistent messages targeting caretakers, decision￾makers, religious leaders, and other influential people through multiple channels; 
 Combined training where appropriate (i.e., nurses and CDA personnel) to build trust 
and cement community/MOHP links; and 
 A sustainable health information system which relies on population estimates, 
outputs, a newly introduced MOHP home-based health booklet, mortality 
surveillance, and occasional community- and household-level tallies. 
Project decision-making, coordination with partners, and oversight is achieved through 
three structures: 
 The Advisory Committee (AC) includes the SC Project Manager; Community 
Trustees from the LU; and representatives of the Governorate and District MOHP, the 
Red Crescent, and CDAs. The committee reviews Project development, cultivates 
political will, fosters integration, and links with key partners and programs outside 
Samalout. It directly advises the District Health Management Team (DHMT). 
 The DHMT includes the head of the district health department; the manager of the 
district hospital; representatives of rural hospitals and rural health centers; three 
elected members of the Health Action Committees; and the Community Trustee of 
the LU. This body executes the program plan, scheduling training, supervision and 
problem solving, including reviewing HIS and Quality Of Care data. 
 Internal coordination involves the Project Manager overseeing administration and 
logistics personnel, the training coordinator, the LU Community Trustee, and the 
Field Team Leader who supports the Field Coordinators. 
The Project shares with MOHP the vision of improved public health. CS-14 will train 
MOHP health facility staff, selected private practitioners, and TBAs through Red 
Crescent trainers, provide orientation and health education materials to private 
pharmacists, and provide some basic MCH equipment and supplies to MOHP facilities 
and clean birth kits to TBAs. The MOHP will support CS-14 activities by providing 
facility-based services; trainers, venues and materials for training TBAs, nurses, and 
doctors; meet quarterly with Health Action Committees for problem-solving/case review; 
and co-implement with SC a Quality Assurance approach to monitor and improve the 
quality of clinic services. 
CS-14 CHWs will visit all targeted households in the project site (those with pregnant 
women or children under five) and orient household members to Project objectives and 
activities. CHWs will then visit targeted households on a monthly basis for health 
education and follow-up regarding illness, immunization status, use of health services, 
and practice of emphasis behaviors. Access to and use of important health services by 
Save the Children CS-14 Egypt Midterm Evaluation 36
mothers and children will be facilitated by the Health Action Committees. The HACs 
will facilitate referral and transportation of women and children to health facilities and 
transportation of MOHP EPI outreach teams to the more remote communities. TBAs will 
be trained and supported to assist with clean deliveries, recognize and promptly facilitate 
referral to appropriate facilities of all women with danger signs, and conduct follow-up 
visits during the first 40 days after the delivery. 
The Project interventions are: 
 Maternal and Newborn Care is the central intervention because of demonstrable 
health and social need, and the existence of key health system elements, which, if 
strengthened, supported, and coordinated, are likely to contribute to substantial 
impact. 
 Control of Diarrheal Diseases (CDD) and Pneumonia Case Management (PCM): 
Although the MOHP is committed to the gradual introduction of integrated 
management of childhood illness, implementation in Minya is not expected to 
commence before several years. In the meantime, CS-14 will support MOHP CDD 
and PCM activities, and seek to improve care in the home and by private providers. 
 Immunization is included because complete DPT3 coverage among 12-23 month old 
is under 46% in the Project site; the MOHP aims to eliminate target diseases and this 
requires strengthened services and surveillance; and the EPI program has public’s 
trust and can leverage other activities. 
 Family Planning: CS-14 decided not to include a FP intervention because services 
are available in the project area, supplies appear adequate, staff are in place, and 
many facilities have a “Health Promoter” for community follow-up and referral. The 
Project will conduct an assessment of availability, access, use, and quality of FP 
services in the project area, and seek funding for SC FP activities if the assessment 
indicates a need for this. 
 Nutrition and Micronutrients: The focus of this intervention is education for better 
child nutrition based on the findings of Positive Deviance Inquiries. CS-14 will 
address the substantial childhood protein-energy malnutrition in the Project site by 
building on the experience gained through implementation of the UNICEF-funded SC 
Positive Deviance Pilot Nutrition Intervention project in nearby areas of Minya 
Governorate since September 1998. In addition, CS-14 will encourage mothers to 
seek concurrent immunization and vitamin A supplementation for their children as 
soon as possible after they reach 9 and 18 months of age, according the current 
MOHP policy.
E. Partnerships 
The Project depends on a partnership with the (MOHP), and on sub-grant partnerships 
with a governorate-level NGO, the Red Crescent (RC), and with eight local NGOs, the 
Community Development Associations (CDAs). 
 
MOHP: Important roles of the MOHP in CS-14 include identifying staff roles, training 
and supporting staff to provide services, and collecting and sharing health data with 
Project management and coordinating bodies. Joint data collection and Project 
monitoring activities will promote improved “data for decision making” in the MOHP. 
Save the Children CS-14 Egypt Midterm Evaluation 37
Through joint training and training of trainer activities, SC and the Red Crescent will 
build the capacity of the MOHP to provide effective training to their staff in MCH topics. 
Joint supervisory visits to MOHP health facilities and the application and promotion of 
quality assurance methods will be important components of the CS-14 SC/MOHP 
partnership to build MOHP capacity to deliver high quality MCH services. MOHP 
linkages to CDAs and HACs will promote increased MOHP contact with community 
organizations to further promote community-defined quality of care. Finally, SC will 
provide some key MCH supplies to MOHP facilities in Samalout District. 
Red Crescent Society: A CS-14 sub-grant will support RC to provide training to groups 
of MOHP physicians and nurse-midwives in project interventions. The Project will 
enhance the RC’s management and technical capacity through joint implementation of 
these activities, and impart community medicine and epidemiological principles through 
“learning by doing” participation in baseline, mid-term, and other assessments. 
Consultant trainers for unfamiliar content will also upgrade RC members’ skills. The 
sub-grant to RC will also support some office expenses such as photocopying and 
transportation. SC will enhance the management and technical competence of RC by: 
 modeling state-of-the-art management (such as “action-oriented” meetings and 
minutes); 
 including them in key activities (needs assessments, surveys, evaluations) and in 
routine activities (quarterly meetings with rotating chair); 
 tracking mutually agreed-upon time-dependent deliverables; and 
 critical thinking and creative problem-solving through the environments of the Living 
University, Advisory Committee, and DHMT. 
Community Development Associations: Community-level partners will include five 
Community Development Associations (CDAs), which are already established in each of 
the Project’s five areas, and three CDAs from the current SC Living University P/ID 
Project. All eight CDAs (three LU CDAs and five CS-14 CDAs) will receive sub-grants 
to carry out Project related activities. 
The LU CDAs will build capacity of the initial three CS-14 CDAs, which will then build 
capacity of the remaining two CDAs following expansion of the CS-14 Project. The 
major task of the three LU CDAs will be training and support of the initial three CS-14 
CDAs in community mobilization and Project planning and management. Each LU CDA 
will mentor one CS-14 CDA. In addition, LU CDA board and staff members will work 
with the selected CS-14 CDAs’ boards and staff and SC field coordinators to identify and 
train suitable women as CHWs. The Project will partner with the LU CDAs to build 
capacity of CS-14 CDAs in needs assessments, data analysis and data-based decision￾making, planning and management, CHW support, and dialogue with the MOHP to 
improve quality of services from the community perspective. 
Current experience in Minya shows that CDAs are well motivated by learning, by 
community service, and especially by dialogue with government officials. Technical 
knowledge will be upgraded through scheduled, responsive, on-the-job, and peer training 
Save the Children CS-14 Egypt Midterm Evaluation 38
(both as trainer and trainee). SC and the LU CDAs will also support and monitor the 
activities of the CS-14 CDAs to: 
 Coordinate, motivate, monitor, and supervise CHWs; 
 Provide incentives for CHWs on the basis of number of visits made and quality of 
work; 
 Maintain linkages between individual CHWs and trained TBAs; 
 Participate in quarterly Health Action Committee meetings with MOHP staff from the 
local health facility to discuss quality of care from the community perspective. 
 In cooperation with HACs, set up emergency referral/transport for obstetric 
emergencies/sick children (for example, a list of taxis/drivers available in an 
emergency and a revolving fund to pay the driver if the family could not immediately 
find the money). 
 Work with CHWs on mortality/morbidity surveillance for problem-solving review at 
the quarterly meetings with MOHP. 
 Conduct community inquiries into health practices and health needs for discussion 
and feedback with MOHP. 
F. Health Information System 
The CS-14 Project will rely on the health information system of the MOHP, on 
community and household measurements, as well as standard baseline and final surveys 
in each Project area. Project-specific, community-based records include: CHW rosters 
and activity records, TBA activity records, HAC surveillance records, and Field 
Coordinator activity records. 
Each CHW will have a simple roster of 100 families, giving the name of the head of 
household; mother’s name; each child’s name (under age 5), birth date, and gender; and 
the total number of people in the household. The roster will record the visit date, BCC 
subject covered, and any important observations or vital events involving mothers or 
children. CHWs will complete activity tally sheets to track the number of homes visited 
and BCC topics covered. 
CS Field Coordinators and CDA members will monitor the CHW activities. All SC field 
staff and NGO partners will have activity records with flow sheets to track common 
activities, and check-lists to regularize support and supervision. LU Community Trustee, 
initially with SC support, will oversee use, feasibility, and sustainability of each record. 
Community and facility-based mortality surveillance will identify cases for review, 
targeting remediable health system weaknesses and/or caretaker practices. The 
surveillance will first identify some child and all maternal mortality. With experience, 
the MOHP will strengthen surveillance to add morbidity from EPI-preventable diseases. 
CHWs, TBAs, and community members will report mortality and morbidity from EPI￾preventable diseases to HACs, which will note it on a surveillance record for review with 
MOHP and action to address any identified problems. 
Save the Children CS-14 Egypt Midterm Evaluation 39
The Project will monitor and improve the coverage of CS services using service output 
data and community-based tallies to focus Project efforts on those households, 
communities, and providers which are not benefiting fully from CS-14 activities and 
services. MOHP output-based estimates will be used for quarterly estimates of EPI 
coverage, using estimated catchment area populations. MOHP tallies will also measure 
births (including complications), and ANC and Post Partum Care visits. Providers will 
record diarrheal diseases and acute respiratory infections treatments in booklets. The new 
MOHP mother’s health booklet will be an important Project monitoring tool to track 
antenatal visits and immunization status. All pregnant women and newborns will receive a 
health booklet on their first visit to the health center. The Project will work with the 
MOHP to train facility staff to accurately update booklets and to encourage mothers to 
bring them. Older children, born before the booklets, have a birth certificate with an 
attached immunization schedule, which will also be reviewed. CHWs will record children 
under five on rosters to track key variables, and track the progress of pregnancy and 
neonate. TBAs will use either non-literate or literate activity tally forms to record deliveries 
and outcomes, supervised by MOHP nurse-midwives. “Rolling surveillance” performed by 
CHWs will measure ORT usage and knowledge concerning prompt recognition and care 
seeking for pneumonia, during alternate rounds of monthly home visits. Baseline and final 
surveys will quantitatively determine key coverage and practice variables. 
CS-14 will monitor and improve quality of CS services and performance of MOHP staff, 
CHWs, and TBAs through assessments of training needs, training, regular reporting, 
supportive supervision, and post-training assessments of health facility, CHW, and TBA 
performance, and by supporting a continuing dialogue between Health Action 
Committees and the MOHP to improve the quality of services from the perspective of the 
communities. SC and MOHP staff and CDAs will provide quarterly village area support 
and supervision, including monitoring CHW activity (e.g., ANC visit tallies), and 
knowledge (e.g., danger signs, ORS preparation and use), TBA activity (e.g., deliveries, 
early breast feeding tallies) and knowledge (e.g., danger signs), and HAC activities (e.g., 
perceived MOHP quality of care, emergency transport arrangements). SC, in cooperation 
with the MOHP/Minya, will apply the Quality Assurance indicators, tools and methods 
which were developed and adopted by the Ministry and are currently being used in one of 
the Minya districts north of Samalout. 
Quarterly field coordinator visits to HACs will monitor MOHP participation in quarterly 
Project area support and supervision. SC will also monitor the activities and performance 
of the CDAs and the Red Crescent through regular meetings and reviews of reports. The 
Advisory Committee will track important aspects of quality at the Project-level, such as 
the performance of the District Health Management Team. 
The monitoring and evaluation indicators proposed for the CS-14 are presented in the 
table below. 
Save the Children CS-14 Egypt Midterm Evaluation 40
CS-14 Indicators: Baseline Values, Mid-Term and Final Targets, Sources of Data, and Frequency of Collection 
Indicator Base Midtm Final Method (by/from whom) Freq. 
% of TBA-assisted deliveries in past 6 months performed by 
CS-14 trained TBAs 
NA* 50% 80% KPC with mothers of children <6 months 
(by SC, CDAs, CHWs) 
Twice 
% of home deliveries in past 6 months in which a clean birth kit 
was used 
NA* 70% 80% KPC with mothers of children <6 months 
(by SC, CDAs, CHWs) 
Twice 
% of women with infants under age 6 months who know two or 
more obstetric danger signs 
NA* 75% 90% KPC with mothers of children <6 months 
(by SC, CDAs, CHWs) 
Twice 
% of mothers of children <36 months with diarrhea in previous 
month who report feeding fluids (other than breastmilk) during 
diarrhea 
80% 85% 90% KPC with mothers of children <36 
months (by SC, CDAs, CHWs) 
Thrice 
% of mothers of children 6-36 months with diarrhea in previous 
month who report feeding foods (other than breastmilk) during 
diarrhea 
70% 75% 85% KPC with mothers of children 6-36 
months (by SC, CDAs, CHWs) 
Thrice 
% of mothers of children <36 months who have received 2 or 
more doses of Tetanus Toxoid 
67% 75% 85% KPC with mothers of children <36 
months (by SC, CDAs, CHWs) 
Thrice 
% of 12-23 month old children who have received three or more 
doses of DPT 
46% 60% 80% KPC with mothers of children 12-23 
months (by SC, CDAs, CHWs) 
Thrice 
% of mothers who report feeding at least one Positive Deviant 
food to their 6-35 month old child and following at least one key 
PD child care practice 
NA* 60% 80% KPC with mothers of children 6-35 
months (by SC, CDAs, CHWs) 
Twice 
% of CHWs correctly teaching ORT & ORS prep. NA* 80% 90% Evals. of CHW skills, Supervision 1/4ly 
% of mothers with children <36 months who report that rapid 
breathing is a sign of pneumonia 
26% 60% 85% KPC with mothers of children <36 
months (by SC, CDAs, CHWs) 
Thrice 
DHMT has quarterly action plans which reflect community 
feedback & facility assessments 
NA* Yes Yes Mid-term and Final Evaluations Twice 
HACs report MOHP has effectively addressed >50% of 
concerns raised in quarterly meetings 
NA* All 3 
HACs 
All 5 
HACs 
Mid-term and Final Evaluations Twice 
LU CDAs have experienced trainers, curricula, & materials NA* NA* 2 LU 
CDAs 
Final Evaluation Once 
LU CDAs provide training & TA to Learner CDAs NA* NA* “ Final Evaluation Once 
* NA = Not yet applicable/available (Clean birth kits are rarely used. Baseline data on danger signs was obtained only through focus groups)
Save the Children CS-14 Egypt Midterm Evaluation 41
Attachment 2 Map of Samalout District 
Source: SC/Minya 
Save the Children CS-14 Egypt Midterm Evaluation 42
Attachment 3 Scope of Work for the MTE Team 
Leader 
Egypt CS-14 Midterm Evaluation 
1. The Evaluation Team Leader shall, following AID/BHR/PVC CS-15 guidelines for 
midterm evaluations, lead the evaluation team in conducting evaluation fieldwork of 
Save the Children’s CS-14 project in Egypt, and write a report of the evaluation, 
synthesizing the findings and inputs from members of the team. 
More specifically, the Evaluation Team Leader will: 
2. Design/revise appropriate tools to answer questions relating to midterm evaluations 
(MTE) in the AID/BHR/PVC CS-15 evaluation guidelines. 
3. Coordinate activities of the MTE team for evaluation fieldwork. 
4. Compare project plans with actual implementation, based on a review of CS-14-
related documents (including: baseline survey, DIP, DIP review comments, annual 
report), and project archives (training inputs and reports, project studies, project 
budget, etc.). 
5. Interview people associated with the project (such as MOH, USAID, and counterpart 
staff, and community members) to review project activities, achievements, 
constraints, project sustainability, and lessons learned. 
6. Analyze information on project interventions and progress toward achievement of 
objectives, and highlight strong and weak points of implementation strategies. 
7. Assess the potential for sustainability of project benefits. 
8. Seek to develop a consensus on key findings and recommendations with the rest of 
the MTE team members. 
9. (If feasible) Debrief project, SC, MOH, and USAID staff re. the MTE. 
10. Write the report of the MTE (submitting a complete draft of the report to SC for 
comment by October 15, 2000). 
Save the Children CS-14 Egypt Midterm Evaluation 43
Attachment 4 MTE team composition 
# NAME TITLE / ORGANIZATION 
Core MTE team 
1. Dr. Marc Debay Team Leader 
2. Dr. Eric Starbuck Child Survival Specialist, Office of Health, Save the 
Children-USA 
3. Ms. Della Dash Child Survival Technical Advisor, 
USAID/BHR/PVC /CSH 
4. Dr. Samir Khamis SC/Minya Office, Program management and CS-14 
project manager 
5. Ms. Samaa Sayed SC/EFO Technical Unit located in Minya, Training & 
Institutional Development Officer 
6. Mr. Wael Zaki SC/Minya Office, CS-14 team leader 
Extended MTE team 
7. Mr. George Aiad SC/Minya Office, CS-14 field coordinator 
8. Ms. Gihan Shawkhy SC/Minya Office, CS-14 field coordinator 
9. Mr. Mahmoud El-Shaal SC/Minya Office, CS-14 field coordinator 
10. Mr. Mohamed Nagi SC/Minya Office, CS-14 field coordinator 
11. Ms. Mona Aid SC/Minya Office, CS-14 field coordinator 
12. Ms. Reham Osama SC/Minya Office, CS-14 field coordinator 
13. Dr. Seham Yasain SC/Minya Office, Health Officer 
14. Mr. Kotb LU coordinator, Talla CDA 
15. Mr. Adel LU coordinator , Zohra CDA 
16. Mr. Ali LU coordinator, Samalout El-Balad CDA 
17. Mr. Aiad LR supervisor, Bayahoo CDA 
18. Mr. Osama LR supervisor, El Amoudain CDA 
19. Ms. Salwa LR supervisor, El Massarah CDA 
20. Dr. Medhat MOHP-Minya Governorate, Deputy Director, MCH 
21. Mr. Aziz Coordinator, Red Crescent 
Additional resources persons 
22. Mr. Ahmed Farouk SC/Minya Office, financial manager 
23. Mr. Attalah Khuttab SC/EFO, Director 
24. Mr. Hazem Shawky SC/EFO, Financial manager 
25. Dr. Omnia MOHP 
26. Dr. Helda MOHP 
Save the Children CS-14 Egypt Midterm Evaluation 44
Attachment 5 MTE program 
DAY TIME AGENDA 
Tue 
29/8 
19:00 Arrival of MTE external team members and two USAID/Cairo 
officials to Minya 
20:30-22:30 Project presentation meeting with CS-14 staff and key 
partners representatives 
Wed 
30/8 
09:00-10:30 Planning meeting with SC/Minya and CS-14 staff: 
MTE participative process and team composition 
11:00-03:30 Field visit in Taha-El Ameda: clinic (health workers) and the 
LR CDA (supervisor and CHWs) 
04:00-06:30 Recap meeting with USAID/Cairo officials 
Thur 
31/8 
09:00-11:00 Planning meeting with SC/Minya and CS-14 staff: 
MTE guidelines 
11:15-12:45 Visit to CDA LU Visioning Exercise and Positive Deviance 
training 
13:00-14:00 Meeting with MOHP officials in Minya 
14:30-17:00 Partners meeting to present MTE guideline and set Friday work 
plan 
17:00-18:00 Recap meeting with SC CS-14 staff and identification of the 
core MTE team (Marc, Eric, Della, Samir, Samaa, Wael) 
21- 23:30 Planning meeting of the core MTE team: 
Guidelines for group work 
Fri 
1/9 
09:30-15:00 Entertainment: A trip to Tall El-Amarna organized by the 
partners 
17:00-17:45 Planning meeting: work group composition and discussion 
topics 
18:00-21:30 Group work 1 on the Technical Approaches of CS-14 
22:00-23:00 Plenary for brief reporting of the group work and for setting the 
work plan for Saturday 
Sat 
2/9 
11:00-11:45 Planning meeting: work group discussion topics 
11:45-16:00 Group work 2 on the Cross-cutting Approaches of CS-14 
16:00-16:45 Planning meeting: work plan for Sunday and LU visits schedule 
17:15-19:30 Meeting of CS-14 seven staff members and MTE external team 
21:00-22:00 Presentation of USAID BHR/PVC/CS program and its 
international resources by Della Dash for CS-14 staff. 
Sun 
3/9 
09:00-10:30 Planning meeting: work group discussion topics and 
composition, site visits 
10:45-13:00 Group work 3 on the Program Management of CS-14 
14:00-15:30 Plenary meeting: work group reporting on cross cutting and 
program management, setting a preliminary field visit plan for 
Monday to Wednesday, and group composition for field visits 
Save the Children CS-14 Egypt Midterm Evaluation 45
DAY TIME AGENDA 
16:00-17:00 Review of the product of the group work from the three sessions 
to identify the data needs and their sources (field visits or office 
documents) 
17:00-18:30 Group work: development of data collection tools for health 
facilities, CDAs LU & LR, and CHWs & mothers 
18:30-19:40 Presentation and discussion of evaluation tool for the LU CDAs 
20:30-22:30 Field visits to Talla & Zohra: LU CDAs 
Mon 
4/9 
09:00-11:00 Group work: finalizing the data collection tools 
11:30-15:30 Field visits in Bayhoo: 
 Health Facilities: Bayhoo integrated health hospital, Itsa El 
Mahata and Itsa El Balad health unit. 
LR CDA: Bayhoo board and CS-14 supervisor 
CHWs: Bayhoo and Itsa ElBalad. 
16:00-18:00 Plenary meeting: sharing results from interviews and 
experiences with the data collection tools; finalizing the site 
visits schedule and team composition for Tuesday 
18:00-19:30 
19:30-23:00 
Group work: revising the health facilities data collection tool and 
designing a tool for the CHW coordinator; cleaning up the field 
notes 
20:30-22:30 Field visit in El Ameda: LR CDA 
 09:00-10:30 Discussion about Health Information System with SC/Minya 
Health Officer 
11:00-14:30 Field visit in Taha:
HF: Taha health group 
CHW: CHW coordinator and mothers 
11:00-15:00 Office work at SC/Minya: documents review and translation 
16:30-18:00 Sharing results from field visits & office work 
18:15-19:30 Planning meeting: the last two days of the MTE (Wed and 
Thur) 
20:00-22:00 Preparation of logistics for MTE synthesis meeting 
Wed 
6/9 
10:00-15:00 Field visit in Samalout: DHMT meeting, Samalout health 
center, CHW (one focus group for CHWs and one for mothers) 
10:30-16:00 Office work at SC/Minya: Finalizing document review and 
translation 
16:00–17:00 Sharing results from field visits and office work 
18:00-19:00 Finalizing logistics for the MTE synthesis meeting 
19:00-23:30 Preparing MTE synthesis meeting: presentation of preliminary 
findings and recommendations 
Thur 
7/9 
09:00-16:15 MTE synthesis meeting 
16:15-17:15 Final meeting with MTE external team members and SC staff 
18:00 Departure of the MTE external team 
Save the Children CS-14 Egypt Midterm Evaluation 46
Attachment 6 Group discussion topics and 
composition 
GROUP 1 GROUP 2 GROUP.3 
Discussion topics: Technical and cross-cutting approaches 
MNC 
Strengthening Partner 
Organizations, 
Sustainability 
PCM, CDD 
Community Mobilization 
BCC 
Immunization, Nutrition 
Training 
Health Facility Strengthening 
Health worker performance 
Group composition 
MO HP: Medhat 
Field coordinators: Mona, 
Mahmoud 
CDA LR: Ousama 
CDA LU: Ali 
Red Crescent: Aziz 
Save Management: Sama 
External: Marc 
MOHP: Holda 
Field coordinators: 
George, Riham 
CDA LR: Aiad 
CDA LU: Adel 
Save Management: Samir 
External: Eric 
Field coordinators: Gihan, 
Mohamed 
CDA LR: Salwa 
CDA LU: Kotb 
Save management: Wael 
External: Della 
GROUP 1 GROUP 2 
Discussion topic: Program Management 
Planning 
Human Resources 
Supervision 
Staff Training 
Capacity Building of RC 
Financial 
Logistics 
Technical & 
Administrative Support 
Group composition 
MOHP: Medhat 
Field Coordinator: Mona, 
Mahmoud, George 
LR CDA: Ausama 
LU CDA: Ali, Adel 
RC: Aziz 
SC/Minya: Sama, Seham 
External: Eric 
MOHP: Omnia 
Field Coordinator: 
Reham, Gihan, Mohamed 
LR CDA: Salwa, Aiad, 
Kotb 
SC/Minya: Samir, Wael, 
Seham 
External: Marc 
Save the Children CS-14 Egypt Midterm Evaluation 47
Attachment 7 Site visits group composition and 
interviewees 
DATE SITE GROUP 
COMPOSITION 
INTERVIEWEES 
3/9 Tallah LU CDA Marc, Samaa, Nagy, 
Reham 
LU CDA Board Members 
3/9 Zohra LU CDA Eric, Samir, Wael, 
Mahmud,George, Mana 
LU CDA Board Members 
4/9 HF El Bayhoo Marc, Samir, Wael, 
Medhat 
Dr Abdallah 
MCH ward Ebrahim 
4/9 HF Etsa Albald Samir, Mana Dr Abdellah 
MCH nurse: Fatma Abd 
Elfadil 
4/9 Al Bayhoo Eric, Seham, George, 
Gehan 
CHW: Monira,Esha, 
Hanaan 
4/9 Etsa Albald Eric, Seham CHW: Mansoura-Amna￾Zeinab 
4/9 Al Bayhoo Sama, Nagy CDA Board Members 
4/9 Taha Marc, Medhat, Reham, 
Iman 
LU CDA El Fath Al 
Amadin 
4/9 (Al Bayhaa) Itsa 
Al Mahta 
Marc, Medhat, Wael, 
Samaa, Nagy 
Dr AhmEd Eliwa , MCH 
Nurse Hania Abd Elhamid 
5/9 Taha Samir, Reham Nemot Abd Elkafy Ibrahim 
5/9 Taha Nagy, Reham 7 Mothers 
5/9 Taha Seham, Nagy 2CHWs; Laila – Eman 
5/9 Taha Eric, Samaa, Sayd, 
Mahmud Yaussif, Medhat, 
Atto, Mana Eid 
Dr Khalil, MCH 
nurse Zeinb Abd Elfatah 
6/9 LR CDA El 
Maasara 
Nagy, Marc, Seham 6 mothers 
6/9 LR CDA El 
Maasara 
Reham, Seham CHWs coordinator Mana 
Gamaa 
6/9 LR CDA El 
Maasara 
George, Medhat CHWs 
6/9 LR CDA El 
Maasara 
Marc, Seham, Medhat, 
George, Reham 
Medical Center 
Save the Children CS-14 Egypt Midterm Evaluation 48
Attachment 8 Major CS-14 activities by month, October 1998 – August 2000 
Activity 1998 1999 2000 
Framework Development (10 months) Model Development (18 months) 
10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 
Formation of CS-14 Advisory Committee (9/98) 
CS-14 office space rented, equipped, and furnished X 
SC CS-14 staff hired (11/01/98) X 
Selection of 5 CS-14 Phase II & III areas X 
Baseline assessments & writing of DIP X X 
Selection of 3 CDAs for Phase II X 
Formation of Health Action Committees X 
Training of 3 CS-14 CDAs X 
Selection of CHWs X X X 
Training of CHWs (see note below) 1 2 3 4 4 
Monthly home visits by CHWs X X X X X X X X X X X X X X 
Formation of District Health Management Committee X 
Meetings of District Health Management Team X X X X X 
Training of MOHP health facility staff X X 
MOHP facilities receive CS-14 equipment/supplies X X X 
Midterm evaluation team in Minya (8/30 – 9/7) 
CHW Training Course: 
1. 3 day training in communications skills 
2. 3 day CDD training 
3. 6 day training in ARI, ANC, EPI, and nutrition 
4. 2 days (total) refresher training (2 one day programs) 
Save the Children CS-14 Egypt Midterm Evaluation 49
Attachment 9 Selected health services statistics in the 
three CS-14 project areas 
1. New and registered antenatal visits and TT immunizations in the three CS-14 project 
areas during the periods January-June 1998 and 2000 
Area 
1998 20000 
New 
Dangerous 
Registered 
TT immunization 
New pregnant 
Dangerous 
Registered 
TT immunization 
Taha 580 253 545 682 557 298 2385 766 
El Bayhoo 483 195 621 564 590 200 1902 787 
El Maasara Shark 254 90 221 313 520 180 770 1048 
Total 1317 538 1387 1559 1667 678 5057 2601 
2. Total, type of attendance, and place of deliveries in the three CS-14 project areas during 
the periods January-June 1998 and 2000 
Area 1998 2000 Total 
Type of attendance Place 
Total 
Type of attendance Place 
TBA 
Doctor 
Nurse 
Other
Home 
Clinic 
Other
TBA 
Doctor
Nurse 
Other 
Home 
Clinic 
Other
Taha 773 452 196 100 25 632 66 75 733 391 230 81 31 563 88 82 
El 
Bayhoo 768 460 174 94 40 613 123 32 793 398 202 180 13 615 130 48 
El 
Maasara 
Shark 
261 156 75 30 - 217 31 13 286 188 85 13 - 193 64 29 
Total 1802 1068 445 224 65 1462 220 120 1812 977 517 274 44 1371 282 159 
Save the Children CS-14 Egypt Midterm Evaluation 50
3. Registered ARI and pneumonia cases in the health units in three CS-14 project areas 
during the periods January-June 1998 and 2000 
Area 1998 2000 
ARI Pneu. ENT ARI Pneu. ENT 
Taha 1067 179 163 1140 144 160 
El Bayhoo 600 194 62 1005 166 80 
El Maasara Shark 41 13 28 105 20 85 
Total 1708 386 253 2250 330 325 
4. Registered cases of diarrhea and dehydration and number of ORS packets distributed in 
health units in the three CS-14 project areas in the periods January-June 1998 and 2000 
Project Area 
1998 2000 
Diar. Dehyd ORS 
pckts Diar Dehyd ORS 
pckts 
Taha 690 134 6770 720 114 4736 
El Bayhoo 724 281 7050 734 253 5698 
El Maasara Shark 146 38 1460 67 11 670 
Total 1560 453 15280 1521 378 11104 
5. Immunization (DPT3 and OPV3) coverage in the three CS-14 areas in the periods 
January-June 1998 and 2000 
Project Area 1998 2000 
OPV3 DPT3 OPV3 DPT3 
Taha 98% 98% 100% 99% 
El Bayhoo 96% 96% 99% 99% 
El Maasara Shark 87% 86% 98% 98% 
Total 97% 93% 99% 99% 
Source: Samalout Health District, MOHP 
Save the Children CS-14 Egypt Midterm Evaluation 51
Attachment 10 Antenatal services utilization in three 
CS-14 and three non CS-14 areas of 
Samalout District, 8/1998-8/2000 
1. Coverage of pregnant women 
0
25
50
75
100
125
150
175
A-98
S-98
O-98
N-98
D-98
J-99
F-99
M-99
A-99
M-99
J-99
J-99
A-99
S-99
O-99
N-99
D-99
J-00
F-00
M-00
A-00
M-00
J-00
J-00
A-00
Percent
Taha Dakoof
El Amodin El Kotosha
Bny Samrg Terfa
CS-14 areas Non-CS-14 areas
 2. Number of visits per pregnancy 
0
1
2
3
4
5
6
7
8
A-98
S-98
O-98
N-98
D-98
J-99
F-99
M-99
A-99
M-99
J-99
J-99
A-99
S-99
O-99
N-99
D-99
J-00
F-00
M-00
A-00
M-00
J-00
J-00
A-00
Visits per pregnancy
Taha Dakoof
El Amodin El Kotosha
Bny Samrg Terfa
CS-14 areas Non-CS-14 areas
Source: Data collected from MCH register by MTE team during visit in Samalout Health 
District, MOHP. Data for some months were not collected because of lack of time. 
Save the Children CS-14 Egypt Midterm Evaluation 52
Attachment 11 Key messages by technical 
interventions 
Maternal and Newborn Care (MNC) 
Key Message 1: 
Visit the health unit to have the highly trained nurse and doctor take good care of your 
pregnancy needs, through helping you to get your TT shot, examine you, and provide you 
with your personal Follow-up Card. 
Key Message 2: 
In order to be healthy, and your pregnancy and delivery be safer, you should eat a 
balanced integrated and affordable meal; meaning a meal that contains three items 
together: one that make your pregnancy grow (such as…), another that make you active 
and agile (as…), and one that protects your body from diseases (as…) 
Key Message 3: 
We are here to serve you and meet your pregnancy information needs. 
Do : wear wide clothes, get enough sleep, etc. 
Don’t: Carry heavy loads, peel nipples scabs with your hand (visit the doctor), etc. 
Key Message 4: 
When you suspect or recognize any of the pregnancy/delivery danger signs (swollen legs, 
bleeding or discharge, persistent headaches, etc.), visit the health unit’s doctors that you 
trust, for personal counseling and examination. 
Key Message 5: 
It’s wise for your health and your new baby’s health to visit the health unit doctor to 
provide you both with comprehensive post-partum care (immediate breastfeeding, 
postpartum/newborn danger signs, birth planning). 
Pneumonia case management 
Key Message: 
It’s important to save your child and protect his health, and learn how to early recognize 
pneumonia and other severe infections, you must promptly visit the doctor to provide 
appropriate care and learn how to care promptly 
Control of Diarrheal Diseases 
Key Message 1: 
It’s important to protect your child’s health and learn how to early recognize dehydration, 
dysentery, and persistent diarrhea, and learn how to care promptly to save her/his life, 
(ORS preparation and use, continued breastfeeding, other DO and DON’T.) 
Save the Children CS-14 Egypt Midterm Evaluation 53
Key Message 2: 
When your sick child has these serious signs (Diarrhea over three days, vomit more than 
four times/hour, has fever,...) you must promptly visit the doctor to provide appropriate 
care. 
Nutrition 
Key Message 1: 
In order for your child to grow, play, and be healthy, you should feed her/him a balanced 
integrated and affordable meal; meaning a meal that contains three items together: one 
that make her/him grow (such as…), another that make him/her play and agile (as…), and 
one that protects his body from diseases (as…) 
Key Message 2: 
Your child health and nutrition is better ensured through maintaining good child-care and 
health-care practices (as…) 
Immunization 
Key Message: 
Complete and timely immunization of your child will protect her/him from serious but 
preventable diseases. 
Save the Children CS-14 Egypt Midterm Evaluation 54
Attachment 12 Partner’s roles and responsibilities in 
CS-14 
First: The Project LR CDA supervisor 
 Monitoring the CHWs’ work through field follow-up visits (at least four field visits 
to the project villages a month) to follow-up their home visits. 
 Selection of CHWs in coordination with CDA board and Sc. 
 Periodically Presentation of the project activities to the CDA board. 
 Coordination with the CDA to overcome any constraints and problems that may the 
CHWs and the coordinator face during their work. 
 Coordination in preparing training workshops and meetings to exchange experiences 
with the LU CDA training coordinator. 
 Accessing the effect of the project in the community. 
 Participating in identifying the health committee members arranging for holding 
periodical meetings and writing reports to be presented to the central committee. 
 Coordination with the board in participating in supervising the emergency funds. 
 Preparing the reports and the monthly plans to the whole project activities in 
coordination with the project CDA coordinator, presenting them to the board, sending 
a copy of them to SC and keeping a copy in CDA file. 
 Preparing all the project files in the CDA (administrative, Financial, activities) 
Second: The project LR CDA coordinator 
 Field Monitoring of the CHWs through preparing a monthly plan to monitor the 
CHWs through gathering there home visits monthly plans, reports, and through 
assessing the performance – review of their home visits registers. 
 Preparing and coordinating with the CHWs to prepare for meetings with SC 
coordinators and writing reports of these meetings. 
 Visiting the health visits to know how far the coordination between the CHWs and 
the Health Units is. 
 Coordination and Coordination between LU CDA training coordinators and the 
project supervisor in the LR CDA in preparing the monthly plan. 
 Presenting the problems and constraints the CHWs face during their work to the SC 
Coordinators and the CDA project supervisor. 
 Training of new CHWs on the Health messages and the ways of communicating them 
in cooperation and Coordination with a coordinating. 
 In forming the CHWs about the urgent meetings whenever needed in Coordination 
with the CDA supervisor. 
 Preparing the project Fields in cooperation and Coordination with the CDA 
supervisor. These files are for [CHWs meetings – Finance and administration – 
Meetings between the emergency fund and the Health Committee - Reports and 
monthly plans – Letters: IN\Out – Files of recruiting CHWs]. 
Save the Children CS-14 Egypt Midterm Evaluation 55
Third: The LU CDA training Coordinator 
 Monitoring the CHWs’ performance to identify their training needs at least six times 
a month through [the monthly plans – the monthly reports]. 
 Assessing the training needs periodically [CHWs – CDA board]. 
 Assessing, Preparing and Implementing the CHWs and CDA board training 
programs. 
 Monitoring of the CDA files and register in coordination with the CDA supervisor. 
 Coordinating with the CHWs coordinator and CDA supervisor to prepare and present 
the monitoring monthly plan – the monthly plan of what have been accomplished. 
 Preparing for meetings of the CDA board with SC. 
 Motivating of the LR CDA through encouragement, meetings and exchanging 
experience visits from four to six times a month. 
 Training of new CHWs in Coordination with LR project coordinator. 
 Attending Health committee meeting. 
Fourth: Save the children roles and responsibilities 
 Field monitoring of the CHWs through [reports – plans – data and statistics – 
coordination with health unit – performance a assessment meeting]. 
 Coordination with CDA coordinator and CHWs the transportation allowance 
monthly. 
 Coordination with the CDA board in selecting the new CHWs. 
 Supervising the preparation and implementation of the CDA board members and 
CHWs trainings. 
 Monitoring of the CHWs coordinator in the CDA through [reports – plan – statistics – 
coordination between the health offices – meetings – performance assessment]. 
 Cooperation and Coordination with the CDA supervisor in [problem – solving – 
presenting the project activities to the CDA board – preparing the monitoring plan]. 
 Monitoring of the LU CDA Training coordinator in [the monthly plan for monitoring 
CHWs – the monthly plane for exchanging experiences visits with the LR CDA - the 
quarterly plane for assessing the training needs – preparing the suggested financial 
plan for training]. 
 Supervising the extended of coordination between LU CDA training coordinator and 
LU CDA supervisor and CHWs supervisor and CHWs coordinator. 
 Coordination between SC consultants, LU CDAs and LR CDAs in providing the 
technical support. 
 Coordination between SC projects for improving the complementation of the project. 
Save the Children CS-14 Egypt Midterm Evaluation 56
Attachment 13 List of equipment provided to health facilities 
No Type Total 
No 
Taha village council Bayhoo village council Medical 
center 
Taha 
Ameda 
Bani smrg 
hasan 
total 
byho 
Itsa 
Itsa 
Shaa 
Hath 
Galaa 
Aways 
Totl 
1 Nebulizer 3 speeds 12 1 1 1 1 4 1 1 1 1 1 1 1 7 1 
2 Centrifuge 7 - - 1 - 1 - - 1 1 1 1 1 5 1 
3 Brick pin (box) 40 3 3 5 3 14 4 4 4 2 2 2 3 21 5 
4 Tongue depressor (box) 80 6 6 10 6 28 5 5 4 4 4 4 4 30 22 
5 Paterry thermometer 12 1 1 1 1 4 1 1 1 1 1 - 1 6 2 
6 Thermometer 60 5 5 5 5 20 4 4 4 4 4 4 4 28 12 
7 Tongue depres. Holder 12 1 1 1 1 4 1 1 1 1 1 1 1 7 1 
8 Sphygmomanometer 3 - - 1 - 1 - - - 1 - - - 1 1 
9 Surgical gloves (box) 8 - - 2 - 2 1 0.5 0.5 0.5 0.5 0.5 0.5 4 2 
10 Disposable gloves (box) 60 5 5 5 5 20 6 6 5 5 5 5 6 38 22 
11 Test tubes 400 - - 50 - 50 30 29 29 28 28 28 28 200 150 
12 Centrifuge test tubes 120 - - 20 - 20 12 12 11 10 10 10 10 75 25 
Save the Children CS-14 Egypt Midterm Evaluation 57
No Type Total 
No 
Taha village council Bayhoo village council Medical 
center 
Taha 
Ameda 
Bani smrg 
hasan 
total 
byho 
Itsa 
Itsa 
Shaa 
Hath 
Galaa 
Aways 
Totl 
13 Slides (box) 20 - - 2 - 2 3 3 2 1 2 1 2 14 4 
14 Slides cover (box) 20 - - 2 - 2 3 3 2 1 2 1 2 14 4 
15 Stick for sugar analysis 24 box 2 2 2 2 8 3 3 1 1 1 1 2 12 4 
16 Benedict solution (leter) 5 0.5 0.5 0.5 0.5 2 0.5 0.25 0.25 0.25 0.25 0.25 0.25 2 1 
17 Coolman 2 - - 1 - 1 - - - 1 - - - 1 - 
18 Silk threads (roll) 8 - - 2 1 3 1 1 1 - - - 1 4 1 
19 Needle (dozen) 12 1 1 1 1 4 1 1 1 0.5 1 0.5 1 6 2 
20 Dissectors (box) 12 1 1 1 1 4 1 1 1 0.5 1 0.5 1 6 2 
21 Jars 4 - - - - - 1 1 1 1 - - - 4 - 
22 Tube holder 16 - 1 1 1 3 3 2 1 1 1 1 1 10 3 
23 Forceps holder 12 1 1 1 1 4 1 1 1 1 1 1 1 7 1 
24 Stethoscope 3 - - 1 - 1 - - - 1 - - - 1 1 
25 Scales 4 - - 1 - 1 1 - - 1 - - 1 3 - 
Save the Children CS-14 Egypt Midterm Evaluation 58
Attachment 14 CS-14 staff in Cairo and Minya 
CS-14 Cairo staff 
NO NAME POSITION TITLE PERIOD TIME %
1 Jerry Sternin FOD 10/98-3/99 5
2 Golda El-Khoury FOD 3/99-4/99 5
3 Attalah Khuttab FOD 5/99-9/99 5
4 Attalah Khuttab FOD 10/99-8/00 18
5 Hazem Shawky Finance & Admin Manager 10/98-9/99 10
6 Hazem Shawky Finance & Admin Manager 10/99-8/00 18
7 Mohamad Safwat Admin Officer 10/98-9/99 5
8 Mohamad Safwat Admin Officer 10/99-8/00 18
9 Samahar Momtaz Accountant 10/99-8/00 18
10 Farouk Salah MIS 10/99-8/00 18
11 Said Ibrahim Driver 10/99-8/00 18
12 Zakaria Abdel-Fattah Office Boy 10/99-8/00 18
CS-14 Minya staff 
NO NAME POSITION TITLE HIRE DATE TIME 
1 Dr. Samir Khamis Minya Director 15/9/99 50%
2 Wa'el Hoseen Zaki Team Leader 1/11/98 100%
3 Mahmoud Yoseef Field Coordinator 1/10/99 100%
4 Reham Usama Field Coordinator 1/11/98 100%
5 Mohamad Nagi Field Coordinator 1/2/99 100%
6 Mona Eid Field Coordinator 1/11/98 100%
7 George Wahba Field Coordinator 1/11/98 100%
8 Gihan Shawki Field Coordinator 1/11/98 100%
9 Ahmed Farouk Accountant 1/11/98 50%
10 Howida Hosni Admin Assistant 7/11/99 50%
11 Abdel-Fattah Mohamad Driver 1/11/98 100%
12 Yehia Hassan Driver 7/11/99 50%
13 Zeen Abdel-Salam Office Helper 1/11/98 50%
14 Sayed Mohamed Office Helper 1/11/98 50%