1 World Vision HAITI Title II MYAP Mid-Term Evaluation, Report #2 February 2008 – February 2013, FFP-A-00-08-00024-00 Prepared by the Mid-Term Evaluation Team: Dr. Richard Swanson, External Consultant & Team Leader, Economic Anthropologist Gregory Charles, Agronomist Colette Vilgrain, M.D. Wesner Antoine, Statistician July 31, 2010 2 LIST OF ACRONYMS A/V, ACDI/VOCA Agricultural Cooperative Development International/Volunteers in Overseas Cooperative Assistance ADP Area Development Program (of WVH) or PDZ (Programme de Développement de la Zone) BAC Bureau Agricole Communale BCC Behavior Change Communication BND Bureau de Nutrition et Développement CBO Community Based Organization Col Vols Community Volunteers CS Cooperating Sponsor CSB Corn Soybean Blend CHW Community Health Workers CMAM Community Management of Acute Malnutrition CRS Catholic Relief Services DAP Title II Development Assistance Program EWS Early Warning System FANTA Food and Nutrition Technical Assistance FFA Food for Assets FFP Food for Peace FFW Food for Work GoH Government of Haiti HAS Hospital Albert Schweitzer HDDS Household Dietary Diversity Score FY Fiscal Year IPTT Indicator Performance Tracking Table IYCF Infant and Young Child Feeding LQAS Lot Quality Assurance Sampling MAHFP Months of Adequate Household Food Provisioning MARCH Management & Resources for Community Health MARNDR Ministry of Agriculture, Natural Resources and Rural Development MCHN Maternal and Child Health and Nutrition M&E Monitoring and Evaluation MoH, MSPP Ministry of Health, (Ministere e la Santé Publique et de la Population) MUAC Mid-Upper Arm Circumference MUSO, MUSOGs Mutuelle de Solidarity (Self Help Group), Mutual Solidarity (savings and loan) Groups MYAP Multi-Year Assistance Program OVC Orphans and Vulnerable Children PM2A Preventive Malnutrition under Twos Approach PDA Personal Digital Assistant PEPFAR President’s Emergency Plan for AIDS Relief PFA, PTFA Poid faible pour l’age, Poid tres faible pour l’age (low weight for age, very low weight for age) PLWA Persons Living with HIV PMP Performance Monitoring Plan PMA Preventive Malnutrition Approach (see PM2A) SAVE Save the Children SO Strategic Objective SYAP Single Year Assistance Program USAID United States Agency for International Development W/H Weight for Height Index WVH World Vision Haiti WVUS World Vision United States 1 carreaux = 1.29 hectares 3 World Vision Haiti MYAP Report #2 Table of Contents Map 0.0 Introduction & Overview of World Vision Haiti MYAP Activities 0.1 Background 0.2 Schedule and Multi-Disciplinary MTE Team 0.3 Description of World Vision Haiti Geographic Area 0.4 Targeting Vulnerable Groups 1.0 World Vision Haiti Program Management Approach & Implementation 1.1 Site Program Management & MYAP Coordination 1.2 Priority Activities & Approaches 1.2.1 Cropping Systems and Focus for Improved Productivity 1.2.2 Value Chains Targeted 1.2.3 Health & Nutrition 1.2.4 Early Warning System 1.3 M&E System and Targeting of Beneficiaries 1.4 Links to GoH 1.5 Internal Reporting & Communications 1.6 Staffing & Capacity Development 1.7 Finance & Commodities 1.8 Environmental Impacts 1.9 Conclusions, Best Practices, and Lessons Learned 1.10 Recommendations 2.0 World Vision Haiti Strategies and Outcomes Achieved to Date 2.1 Improved Nutritional and Health Status of Targeted Vulnerable Groups 2.2 Improved Quality of and Access to Health Services for Vulnerable Groups 2.3 Increased Food Production and Household Assets 2.3.1 Improved Food Security 2.3.2 Appropriateness of Early Warning System 2.4 Enhanced Market-Based Livelihoods 2.5 Rehabilitated Natural Resources and Local Capacity to Sustain These 2.6 Challenges Faced and Overcome in Program Implementation 2.7 Highly Successful Strategies 2.8 Unsuccessful Strategies and Proposed Changes 2.9 Conclusions, Best Practices, and Lessons Learned 2.10 Recommendations 3.0 External and Internal Factors 3.1 Impact of Internal Factors on Program Activities 3.2 External Factors Influencing Outcomes and Program Responses 3.3 Negative Impacts or Unintended Consequences 4.0 Sustainability of Interventions 5.0 Conclusions Annex 1: World Vision Haiti MCHN Program Description 4 World Vision Haiti MYAP Geographical Distribution: Upper Central Plateau, Lower Central Plateau, Artibonite, and La Gônave Island: Target Population: 540,369 Beneficiaries Cover Page Photo: Food Distribution Point 5 World Vision Haiti MYAP 0.0 Introduction & Overview of World Vision Haiti (WVH) MYAP Activities 0.1 Background World Vision has been operational in Haiti for more than 30 years and currently has 705 staff members working through some 33 special projects and 21 micro-regional development initiatives in its Area Development Programs (ADPs) in five regions of the country. Core activities are built around some 52,000 sponsored children.1 Following its proposal submission in November 2007, World Vision Haiti (WVH) was awarded in February 2008 this 5-year United States Agency for International, Food for Peace (USAID/FFP) Title II Multi-Year Assistance Program (MYAP) to begin operations, efforts that continued forward many of the activities in some of the same communes benefiting from a FFP preceding Development Assistance Program (DAP). As a result, WVH was able to become operational almost immediately. This MYAP continues through September 2012. The MTE team‟s arrival in April 2010 coincided with the half-way point of field implementation. This World Vision Haiti MYAP has its focus in six communes of the Upper Central Plateau, 8 communes in the Lower Central Plateau and the Artibonite valley, and the two communes on the Island of La Gônave – intended to reach some 540,369 beneficiaries or about 108,000 households, believed to represent about 57% of the population in these areas. Maternal Child Health and Nutrition (MCHN) activities in the Lower Central Plateau and Artibonite valley were subcontracted to three international and local NGO, Save the Children, Hospital Albert Schweitzer (HAS), an Management and Resources for Community Health (MARCH), while WVH implements agricultural initiatives in three (of eight) of these communes. WVH maintains program wide responsibility for the management and distribution of all MCHN rations. AGRIDEC, a private enterprise company, received a sub-contract working with farmer groups to link key agricultural commodities to regional and international markets – with a focus on high value vegetable crops under rehabilitated irrigation systems. A quantitative population level survey was conducted in early 2009 to establish a baseline for the program. The strategic approach for this MYAP is described in the MTE Report 1. The goal of this FFP MYAP is “to reduce food insecurity and increase resiliency of vulnerable and extremely vulnerable rural households in four regions of Haiti…by targeting its most vulnerable members: women, children, youth, and the communes they live in”.2 That last phrase „and the communes they live in” opened the door to more generalized rural development efforts and a tendency to lose focus on „the most vulnerable’. In the past year, WVH has begun to refocus towards the specific section communales of the 16 communes in which they work, as not all parts of the communes were receiving focus at the beginning. 0.2 Schedule and Multi-Disciplinary MTE Team The quantitative survey team and enumerators, assisted by World Vision Haiti field staff, began its work on both La Gônave Island and in both Upper and Lower Central Plateaus and the Artibonite region May 5, and completed this by May 14. The qualitative survey team began its field visits with WVH, within the same communes as the quantitative survey team, on April 22, spending the next 11 days traveling to 1 PowerPoint presentation given to MTE team on April 15, 2010. 2 World Vision, Inc., MYAP FY 2008-FY 2012 proposal, SAK Plen Resiliency Enhancement Program, November 30, 2007, p.7. 6 program sites. We began by taking a MAF plane to La Gônave Island, and then continuing on to the Upper Central Plateau (Hinche, Thomassique, Colladere), and then traveling on to the Lower Central Plateau and the Artibonite Valley (Lascahobas, Verrette, Mirebalais). Field visits were completed on May 4. The MTE team was not able to provide the WVH team with an initial debriefing until May 28. At all three regional sites within World Vision‟s MYAP program, the MTE initiated work by meeting with local regional program management staff who were available, having already met with senior management (MYAP manager and associate manager, MCHN director, M&E coordinator) at World Vision‟s national offices in Port-au-Prince, prior to initiating field work. Annex 2 of the MTE overview Report #1 provides the detailed scheduling for this evaluation, and Annex 5 provides a list of all the key people and groups interviewed within WVH MYAP areas of implementation. Focus group meetings were held with farmers benefiting from the agricultural activities underway, as well as meetings with program health practitioners (doctors, nurses, health auxiliary staff, and community health workers) and mothers within the existing Mothers Clubs. We were able to visit regularly scheduled mobile clinics, several rally points, and a food distribution point, observing WVH MYAP staff undertaking their tasks, and working with the beneficiary populations. We were also able at these times to randomly meet and discuss program activities with both WVH MYAP staff and beneficiaries. 0.3 Description of World Vision Haiti Geographic Area Within the context of Haiti, MYAP programs work within geographic Departments, which are sub￾divided into Communes, then Section Communales, and finally Localities. Localities represent the lowest level for geographic distribution of MYAP services. Rally Points, for example, are established at this level, though not all localities in all Section Communales of MYAP programs are covered by Rally Points, for lack of resources. Mothers with children under 5 years of age coming to a specific locality Rally Point are formed into one or more Mothers Clubs at this level as well. With the notable exception of La Gônave, travel within World Vision‟s program areas was not as difficult or potentially hazardous as that encountered within ACDI/VOCA‟s regions of intervention within the Jacmel region. On La Gônave, WV‟s work covers the entire island, and its two communes Anse-a￾Galets and Pointe-a-Raquette. The rocky, brush covered, rugged hills of La Gônave do not lend themselves to significant agricultural production, and access to water for domestic consumption, much less use for other purposes, is one of its greatest constraints. World Vision has been present on the Upper Central Plateau and La Gônave for decades; 10 of their 21 ADPs are located in this region. No ADPs are located in the Lower Central Plateau or Artibonite. Livestock are common throughout the region, 7 particularly goats and donkeys, and rainfall patterns permit two planting seasons in most areas (March through June and August through October).3 0.4 Targeting Vulnerable Groups Malnutrition in Haiti Because addressing the issue of child malnutrition is such a central focus of the MCHN component of World Vision Haiti‟s MYAP program, a few observations need to be made to set the context of the discussion that follows. According to World Vision strategic orientations, “Malnutrition is the main underlying cause of one third of all deaths among children under five. This is because malnutrition weakens a child’s immune system, making it harder for them to fight off infections such as diarrhea, pneumonia, and malaria…The key to reducing …malnutrition is prevention” 4 through activities that reduce the prevalence of diseases that affect micronutrient status. This explains the importance of the Preventive Malnutrition under Twos Approach (PM2A) that is so important for all three Haiti MYAPs. This also explains the importance of the many MCHN indicators addressing different aspects of this issue (exclusive breastfeeding, infant feeding practices, immunization campaigns, improving water and sanitation, malarial control and treatment of worms and parasites). The IPTT indicator monitoring the incidences of diarrhea cases, for example, is linked to the impact of such activities in rapid response and improved hygiene and sanitation practices within communities. Health and nutrition programs generally focus on children under five and their mothers for broader support of this strategy. “Proper nutrition needs to start with mothers, before and during pregnancy. The first two years of life are critical, as this is the period of most rapid brain growth and the time when most malnutrition begins. It is also the highest period of development with the highest risk of child mortality. This is why World Vision focuses its nutrition programming on children under five and their mothers.”5 Components linked to CMAM (community mobilization, supplemental feeding, outpatient therapeutic care, and stabilization centers) are helping the WVH MYAP to quickly rehabilitate children with moderate to severe malnutrition” which is why discussions of PFA and PFTA, MUAC measurements, etc. will be important in the discussions below. A major strategy adopted by World Vision Haiti, with variations in CRS and ACDI/VOCA programs, is the Community Management of Acute Malnutrition (CMAM) approach. “CMAM has been identified as a proven, successful and effective model in the treatment of acute malnutrition in children under five.” 6The approach permits “the inclusion of communities in screening, diagnosis, treatment, and referral of acutely malnourished children”,7 and according to WVH, has improved the management of the MCHN component of the MYAP. The MTE team would certainly concur that the inclusion of local leadership is critical to the sustainability of these initiatives, and the efforts of the MYAPs to secure community 3 Swanson et al, “Farmer Needs Assessment Exploratory Surveys”, PADF Mirebalais Region 3, Productive Land Use Systems, SECID, August 1993, p. 24. 4 World Vision, Nutrition & Health, on-line reporting on the Community Management of Acute Malnutrition Approach used in the WVH MYAP, http://www.worldvision.ca/Programs-and-Projects/International￾Programs/Documents/Nutrition_and_Health_web_v3_ICP-1230.pdf, 2010, page 1,2. 5 Op Cit. page 4. 6 Op. Cit. Page 4. 7 WVH MYAP FY 2009 Annual Report, November 2, 2009, p.13. 8 participation and local ownership will be a major continuing effort of training and communication over the remaining life of the MYAP. The MTE encountered discussion within all three MYAPs with respect to better identification of malnutrition, particularly severe malnutrition, and the changing GoH protocols with respect to the MUAC measurements and weight for height criteria. The MTE team gives significant attention to the linking of vegetable home gardens, fruit trees, and small animal husbandry activities for Mothers Clubs because of the importance of increasing the intake of micronutrients through dietary diversification in support of CMAM initiatives. It is also why the integration of MCHN and agriculture for program beneficiaries is such a critical issue in all Haiti MYAPs. Targeted groups within the MYAP intervention regions included (1) pregnant and lactating women, (2) infants 6-24 months, (3) malnourished children 24 – 59 months, (4) PLWA and (5) orphan and other vulnerable children (OVC). This was to be accomplished through individual households, (agricultural) producer groups, and by working closely with community leaders. Linkage between MCHN and agriculture was specified from the very outset. In the Upper Central Plateau and La Gônave, efforts are being made to better support malnourished children (distribution of dry ration, CMAM linked to PM2A, agricultural training. However, in the Lower Central Plateau and Artibonite, children remain vulnerable, with high malnutrition rates (as we have been able to observe through home visits) in areas where the health component has not yet been established. Notwithstanding the agricultural potential, one will find cases of malnourished children in association with intestinal parasites. Very often vaccination coverage is not complete. Growth monitoring program is not yet implemented. As proven by their cards, children have not been weighed or had home visits since the month of September 2009. So malnourished children are only seen in the health centre and leave just with a few tips in hygiene that a mother may have difficulty in understanding and put into practice. These children (or their households) may not be integrated into agricultural activities of the project, because there is not yet any means of screening or referral by health promoter to the agricultural technicians already active in certain areas. 1.0 World Vision Haiti Program Management Approach & Implementation 1.1 Site Program Management & MYAP Coordination World Vision Haiti describes itself as having “a three-tier management structure for all operations. It includes the National Office in Port-au-Prince (PAP), Regional Offices (North, South, Central Plateau, Northwest, and La Gônave) and individual Area Development Programs.” 8 World Vision Haiti is very centralized in PAP – yet the regional offices are in themselves very large and complex organizations. The procurement process for regional offices, through the PAP central office, can be very frustrating and time￾consuming. Required inputs that must be purchased out of PAP are often delayed, impacting implementation which must follow set periods of the agricultural rains and cycles. Financial inputs and procurement are very slow. Management attention needs to be given to this. WVH MYAP personnel and activities are laid over this structure, within its areas of operation, with its own personnel (cf. Figure 1 below), and some shared personnel with WVH. 8 World Vision, Inc., MYAP FY 2008-FY 2012 proposal, SAK Plen Resiliency Enhancement Program, November 30, 2007, p.12. 9 The WVH MYAP has regular planning meetings at several levels. There is the monthly EWS meeting, which is chaired by USAID in PAP at the WVH central office. There once were, before the January 2010 earthquake, monthly coordination meetings between the 3 cooperating sponsors (CS) in subject areas (agriculture and health/nutrition); these ceased to take place for a couple months but these are in process of being reinstated. There are also program leadership monthly meetings and Planning Meeting at the end of each FY to plan the next FY program and budget. MYAP regional managers, when they do site visits, appear to spend most of their time at the program office checking over the work, reports of the staff, and discussing these with them. More needs to be done in actually meeting with program beneficiaries themselves to view progress and impact at their levels. For program management monitoring, there is an issue of quality control and checking if real progress is being made to achieve program objectives. While Data Quality Assessments (DQAs) are taking place on the F indicators of the program, this has become a fairly mechanical task. What is missing is the “So what” question being asked of each set of data. What does this data actually mean, and is it being properly analyzed – at the right level – to show impact? The MTE team received the impression that WVH MYAP field staff are so involved in the PROCESS of implementation, that no one is taking a look at the big picture or closer-up local picture and looking at impact on program beneficiaries - asking if targets and accomplishments are appropriate or not. While the WVH MYAP is certainly fortunate in having seven full-time M&E personnel at different program levels, these personnel appear largely focused on number crunching and data reporting up the chain of command. Because they have the opportunity to travel and see different program sites more often than other program personnel, such personnel need to be more analytical about what is taking place within the program. We do not believe they have been even asked to think about the quality of these data and to analyze its meaning for specific areas. When the MYAP Director is not present in PAP – or out of the office - activities can slow down when final financial check signing needs to take place (for example) - even though WVH MYAP now has a deputy Director.9 The Deputy MYAP Director is always in charge when the MYAP Director is out of the office, but according to WVH policy does not have the authority to sign checks to keep things moving when the MYAP Director is not present. The MYAP Director has final authority for approving everything. WVH has 7 staff members to sign checks (for World Vision programs overall) and all MYAP field Sector Managers are responsible to sign requests for supplies and inputs for their respective sectors. One cannot have a program this large with financial authority concentrated in PAP. It is already difficult to get things done in a timely manner for field authorizations – delays within WVH itself need to be eliminated to streamline this process better. Annual work plans have budgets with specific tasks and goals to accomplish. When these are agreed to at the beginning of the year, then the funds and authority should be decentralized to the regional level Sector Managers (so they don‟t have to make requests for the money) to permit timely and rapid responses to implement the work plan. There needs to be good financial monitoring, of course, but such delegation is important. While the two principal program components (MCHN and agriculture) have their own separate structures, WV has made an effort for these two groups to meet regularly at the different program levels (regional, communal, section communales) to try integrate their efforts. Yet this is often made difficult by where the different activities of each component actually take place. 9 These observation were made both by the experience of the MTE team in its own financial interaction with the WVH financial office in PAP, as well in our questioning of some of the MYAP management staff about this issue. 10 Figure 1 below provides an overall perspective of WVH‟s MYAP organizational structure. Three main programmatic blocks (commodities, MCHN, agriculture) are linked together through the MYAP Manager, with the M&E team assisting in tracking progress. The fact that there are three health coordinators, three commodity officers, and three agriculture coordinators is because each is located in a separate WVH regional office (Upper Central Plateau, La Gônave, and Lower Central Plateau). Figure 1: World Vision Haiti MYAP Organogram In meeting WVH national and regional office personnel, we found the interaction between WVH MYAP personnel and WVH (non-MYAP) regional program management staff was not always clear. We believe some have partial appointments between the two programs. This is because MYAP personnel and activities also relate to World Vision Haiti‟s own regional structure, overseeing regional Area Development Programs (ADP) and other WV activities. World Vision has made an effort to provide some coordination regionally between their regional programs – and MYAP activities certainly support local ADP program efforts in many locations. An example would be the MYAP regional and local agro￾forestry tree nurseries. All senior MYAP management personnel are based in PAP. At the regional level there is a Regional Coordinator who oversees the work of the regional MCHN and Agriculture regional coordinators. Note that at the bottom of the MCHN structure are the 320 health agent employees who interact at the rally posts and with the Mothers Clubs. CRS and A/V, at this level, use Col Vols, voluntary health workers who receive some special training and a small stipend and field supplies to undertake their work. Health 11 Coordinators are medical doctors, operating out of World Vision established or renovated GoH dispensaries or clinics. Each project component essentially has its own reporting structure and personnel, working with their own targeted beneficiary groups who may or may not include households being worked with by another project component. Integration of MCHN and agriculture might have been easier to achieve had the lowest level field agents been generalists working with the identified vulnerable households in their localities of responsibility. These MYAP field personnel need to work more closely together as a team. 1.2 Priority Activities & Approaches 1.2.1 Cropping Systems and Focus for Improved Productivity The Agriculture and Market-based Livelihood component utilizes a combined approach to improve agriculture productivity and profitability in eight of the sixteen communes that constitute the WVH‟s MYAP program target areas. In the selection of the agricultural program beneficiaries, World Vision Haiti does not directly target mothers of the children of 0 to 5 years old. Some priority was granted to the mothers of MCHN Clubs and to the parents of ADP sponsored children, particularly with activities relating to the establishment of bio-intensive vegetable gardens, production of compost, distribution of improved seeds, fruit trees, goats and chickens. Enhanced Seed Production The program has supported quality seed production and diffusion in project areas through technical assistance in seed production technology, training, and through support in basic equipment and materials. Indeed, the farmers in all project areas noted that their cereal output (maize in particular) has more than doubled. That is due to the quality of the seed varieties introduced and the application of new agricultural technologies. Outputs obtained by model farmers for certain crops are 50% higher on average than that realized by the other farmers. According to the beneficiary recipients, this difference is due to the high rate of adoption of the new technologies or management practices suggested by the program. According to the individuals in charge of one association met by the MTE team, 2.7 kg of improved seeds TLOA gives an output of 270 kg of maize in irrigated zone, a 100% increase. The ultimate commercial prospects for success, however, will depend on World Vision Haiti‟s ability to link this „community-based seed production enterprise (SPE)‟ group of seed producing farmers with the suppliers of the certified seeds being promoted - suppliers such as Port-au-Prince based Double Harvest or ORE. To date, World Vision Haiti itself has played the middleman in this transfer, which is not sustainable. Improved Storage Practices To maximize the impact of anticipated increases in cereal grain production (maize, sorghum, black beans), WVH promoted the introduction of improved grain storage containers in its program intervention areas. Two types of storage containers are being distributed: (1) solos for Emergency Seed reserves which are large silos of approximately 5 MT capacity used to store seed to respond to emergencies and (2) small household solos (pictured below) of about 400 kg. capacity which are used mainly to reduce post-harvest loss in household storage. This latter activity is intended to reduce post-harvest losses that occur when grain is stored (rodents, insect or moisture damage) In Upper Central Plateau, World Vision Haiti sent 10 local artisans to the Dominican Republic for training in building these grain silos. Training 12 also included creating pails, water cans for home gardens, water and feeding trays of chickens and other useful metal utensils. These new local artisans have yet to begin to realize any commercial success – no sales have yet been made of these metal silos. For all WVH MYAP program inputs (seeds, silos, trees, goats, etc.), an in-kind revolving fund approach is used to enhance short-term impact, but sustainability be another issue. For example, someone receiving a „free‟ female goat will repay with an offspring female goat to the „revolving fund‟ so that another family can receive this animal. Improved seed given out to community members are also „repaid‟ in a similar manner to be redistributed to someone else.10 USAID Haiti funded a long term program in the early 1990s (Productive Land Use Systems) that undertook many of the same activities and approaches being implemented by the current Haiti MYAPs – and in the same regions of the country.11 Their approaches also trained groups for reforestation, raising goats, pigs, doing demonstration trials with improved varieties, etc. Why, one must ask, are we still doing the same things – which will likely have the same results (little long term impact). What could we be doing differently that might have more long term results? The MTE team believes the core issue here is that the right development approaches are not being used – with too much emphasis towards free services with conditions that quickly disappear with the departure of the donor. WVH‟s revolving fund approach may work as long as it is overseeing these efforts, and beneficiaries believe there may be more to come, but once WVH no longer is present, will these groups continue to expect animal pass-ons – or continue agreements put into place by the MYAP? This is one reason why it is so important that the MYAP have a graduation strategy in place during the life of the program so that such questions can begin to be answered before a program ends. One needs to target people who are willing to make the effort to build up their own small enterprises. Experience suggests that organized groups simply do not seem to be able to do this in the absence of a generous donor. 10 But the quality of initial seed will diminish over time, especially for maize, so new sources of quality seed need to be available. 11 Dr. Richard Swanson led a team of three Haitian consultants in a Farmer Needs Assessment for this SECID program in October, 1993. 13 Vegetable Gardening and Household Production Diversification MYAP agricultural efforts to introduce bio-intensive vegetable gardens on the very small household plots upon which hillside farmers live show great promise. Access to water is often critical, and MYAPs need to resolve this issue for these households as well. Sometimes this will mean introducing a small-scale drip irrigation kit12; sometimes this will mean installing gutters on the house to capture rain water into cisterns. Or it may be necessary to develop large cisterns or impluviums from which multiple farmers can use a drip irrigation system to water their small gardens year-round. Vegetable gardening has proven to make a major impact on household nutrition as well as provide a possible additional source of household income. Indeed, on La Gônave, where little else grows, World Vision Haiti has found that vegetable gardening is particularly welcomed and holds great potential to not only improve household food security and diets, but also become an important source of additional income. Some of the farmers met by the MTE showed us the goats they had purchased – which had multiplied and were used as a source of income for other household needs (school fees, additional food, etc.) Water availability is certainly the #1 problem on La Gônave, and access to it competes with human consumption and animal needs, as well as vegetable gardening. Given the potential of the WVH SYAP to disrupt certain program activities on La Gônave, some prioritization of SYAP expenditures towards a focus on providing large cisterns and impluviums to capture run-off water from adjacent hillsides could prove an extremely valuable means of supporting MYAP activities in an area where it could have maximum impact on future vegetable gardening on La Gônave, as well as care for the thousands of fruit trees being planted. Such water sources 12 VVVH’s MYAP proposal stated that “given that super bucket drip irrigation kits have already proven their appropriateness and cost effectiveness in Haiti, 10,000 kits will be provided to Mother’s Clubs to irrigate up to 100 ha. of land over the LOA” with special reference to La Gônave (November, 2007). This is one goal the MTE team will be fully realized. 14 could permit drip irrigations systems to be installed below the catchment areas. Because so many vulnerable Haitian small farmers don‟t even own any land of their own, but practice a system of meteyage (share-cropping), these farmers frequently have difficulty establishing the productive assets that could help eventually earn a little money that might lead them to possess small plots of their own. The MYAP concept of home gardens is a good one. It refers to the cultivation of a small piece of land around the household residence and integrates micro-irrigation, vegetable crop production, fruit trees, and small livestock. These home gardens have a double vocation: household nutrition and economic benefits through the marketing of produce. Initially, these efforts should target all local households having malnourished children, and realized as an activity through Mothers Clubs. Within the framework of World Vision Haiti‟s existing program, however, this has not always been the case. These home gardens are present in places where households have access to some water in Upper and Lower Plateau Central. On La Gônave, these home gardens are supported by the micro drip irrigation systems introduced by World Vision Haiti. As observed by the MTE review team on La Gônave, in periods of dryness or in the event of breakdown (sometimes intentional) of distribution lines of water, many households had discontinued with their vegetable gardens. For home gardens – particularly those to be used year round – water will be the major issue, and the program needs to concentrate its efforts on finding a realistic solution to it. A first step would seem to be to make sure that households at least capture the run-off water from their mostly metal roofed homes – into large plastic containers if not cement cisterns. In Lower Plateau Central, the strong involvement of women (in Mothers Clubs) with vegetable gardening was evident. The households devote time to their gardens for seedlings, transplanting, watering, etc). An elevated seedling bed (to protect from chickens, and rodents) was established by a Mothers Club at the homestead of one of their members (with access to water for regular watering). When ready to be transplanted, each woman in the Mothers Club would get her share for her own prepared household plots. When discussing their nursery (above), the seed had been given at no cost to them by WVH. However, the woman stated that they were willing to purchase their own seed, if it were available locally. Also, some of the women expressed interest in the idea of themselves raising vegetable seedlings (especially chili peppers) to sell locally – given the apparent demand. This is not something WVH itself has consider 15 promoting.13 In all World Vision Haiti project areas, according to WVH staff members, incomes already being realized from the sale of part of the harvest of these vegetable gardens enables households to purchase animals, to pay for the school expenses of the children, and other expenses. The women of the nursery above gave evidence of this as well. Household Diversification through Small Animals Breeder‟s associations are being created and established in World Vision Haiti program areas to support the restocking process. Some multiplication centers and/or breeding stations are being established in program areas, but usually under the close management of World Vision Haiti employed personnel – as is the case with their breeding center operated by the Hinche ADP. Contact leaders from selected communities have been trained to manage the improved bucks. These are bred at the center. Distribution of the breeding animals is then undertaken into the surrounding areas under the technical support of World Vision Haiti field staff. According to the households interviewed, the improved races introduced by the program are superior to the local races for several reasons:  They develop more quickly (rapid growth) and therefore can be sold more quickly  They are hardy  They sell for twice the cost of a single local race animal This activity is being conducted in collaboration with the Ministry of Agriculture, Natural Resources and Rural Development (MARNDR) who, we were told, would train contact leaders to provide vaccination 13 The first impulse of WVH, and other NGOS in Haiti, appears to be to always give out the material, with organization providing the seed and training. The idea of actually helping specific entrepreneurial individuals establish their own micro-businesses to provide these services to their communities is rarely considered. 16 and de-worming services for a small fee. Whether or not this will actually happen remains to be seen – and should be evaluated at the final project evaluation. Households are very interested in the improved breeds of chickens as well. However, farmers are more inclined to practice poultry farming at the household level (individual) activity rather than as a „group (collective) activity‟ which World Vision Haiti seems to prefer to encourage. These improved chickens are sold for twice the price of local chickens, but are also very susceptible to chicken diseases. Many of the households interviewed had lost some if not all of the animals they had received. They were not able to get the vaccinations on time to prevent these loses (or had no means of paying for it if it was available). World Vision Haiti would have had to do this „for free‟ as well. Agro-forestry and Household Production Diversification: The establishment of multi-purpose regional and community level nurseries has been an important MYAP activity that has been implemented with great care and expertise. World Vision Haiti livelihood activities have also introduced fruit trees and multi-purpose trees into the areas around the homesteads of beneficiary farmers. The promotion and distribution of fruit and multi-purpose trees is seen as a way to provide an additional source of household nutrition and income in addition to an effort to restore the environment. The program made it possible for beneficiary households to have access to (free) fruit trees and fast growing multi-purpose trees that have an economic interest. Central and community nursery seedbeds were installed by the WVH MYAP in all their regions of intervention. Seedlings are started as seeds in plastic bags furnished by World Vision Haiti (and planted by employees who also filled these bags with dirt). Nurseries are also fenced and managed by World Vision Haiti paid employees, and the seedlings are then delivered at no cost to area beneficiaries. 17 Fruit Trees: MYAP agricultural efforts to promote the use of fruit trees on the small parcels of vulnerable households, usually located on eroded hills and mountainsides within the region have been very well received and have the potential to have an impact on these households in the future. Because of the food/nutritional value of fruit as well as the potential to earn extra household income through the sale of fruit, people, it is hoped, will be less apt to be cut fruit trees down for firewood in future years – as is the case with other agro-forestry tree species. On La Gônave, the MTE review team visited World Vision Haiti‟s main nursery which included a couple of greenhouses filled exclusively with mango and citrus seedlings; these will be grafted once established on farmer‟s fields. This activity would appear to have the potential for significant impact – though again the intention is for the „free distribution‟ of these grafted tree seedlings. On La Gônave, with its two communes and 11 section communales, we visited a large nursery run by World Vision Haiti in La Palma which we were told had a large group of farmers associated with it. People are hired for piece work, as shown here, filling bags with soil for planting seed, caring for seedlings, watering, and other work needed for upkeep of greenhouses. World Vision Haiti has contributed the fencing, greenhouses themselves, and other materials needed for these greenhouses. No effort has been made to help specific farmers on the island to themselves become the producers of such seedlings, that they could in the future sell to their neighbors or to international organizations like World Vision Haiti or others interested in promoting agro-forestry on the island. One could imagine two or three enterprising farmers being assisted by World Vision Haiti – with fencing, one greenhouse each, and other materials – to initiate their own small businesses producing seedlings and possibly also raising high value horticulture crops that bring a good price on the island and near-by mainland communities (Miragoane, Leogane, St. Marc). 18 Rehabilitated Natural Resources Resiliency Soil conservation work is carried out using food for work (FFW). Work consisted primarily of treatment of gullies and slopes above certain strategic zones (surface of collection for springs, or for an irrigated perimeter). The techniques of soil conservation learned within the MYAP were replicated by certain recipients on their own parcels of land. According to the recipients, this work enabled them to cultivate plots of land which had not been cultivated for several years. In the Lower Central Plateau, the strategy to group program recipients to engage in common mutual assistance activities within the community and to choose one day for each recipient to work on their own land without Food for Assets compensation appears to have been well receive. This could be easily undermined by SYAP FFW activities however, if not managed properly. Collective Groups: World Vision Haiti seems to have been seduced by the approach to working with farmers through „farmer groups‟ as the way to extend messages to the most people, in the most effective manner.14 The concept is so entrenched within the organization, that even discussing it appears counter intuitive. Why would anyone want to do it in any other manner? This has become a common approach in many developing countries, one that national governments also encourage as well through their extension programs. The problem is that most farmers, if given the choice, would prefer a more entrepreneurial approach. Haitians in Port-au-Prince don‟t run their businesses as collective groups; these are often extended family business enterprises. Yet, it appears that when it comes to the rural farmers, they should be organized into farmer groups for almost every kind of activity (associations, cooperatives, etc.) to “get the message out”. When the farmers learn the technique, the argument goes, then they can „do it on their own land‟, if they want to. In the mean time, farmers have to learn to work collectively together, have a president, vice-president, secretary, and treasurer, and try to „make money for the group‟ to pay for their operating costs as a group, help them to jointly purchase inputs (hopefully bypassing the middle men in 14 Haitian farmers have a practice of ‘combite’ labor, where people come together to work on field preparation or weeding, after which local beer and some food will be provided. But this system is practiced on the personal plots of farmers – they certainly don’t share the produce from this land. 19 their communities). The management systems of such groups are almost never successful, are fraught with distrust of leadership, etc. The system is stacked against permitting the development of private entrepreneurship within the local communities. An example of this would be the group nursery on La Gônave at Palma. We observed six beautifully established nursery beds, under cover. The entire area was fenced by the project, and run by the WVH MYAP to provide fruit tree seedlings (mango and citrus) and fast growing tree species. People are employed to fill the bags that will be used to plant seeds. Community members will be given these seedlings to plant on their land. Fruit trees, once established, will be grafted with improved mango and citrus cultivars. This site is supposedly operated for the benefit of a several hundred community members. Yet, it is also certain that, without World Vision Haiti‟s continuing management of this site (paying for salaries, and key work that is done, not to speak of the hardware and materials), that this „group‟ and nursery would disappear. Was consideration given to perhaps identifying four or five „model farmers‟ who could be assisted to each develop one of these „covered shelters‟ as their own nursery enterprises? World Vision Haiti could assist them, in the same way that they are already doing for the „group‟, but in this case would be helping establish enterprises from which they could purchase their seedlings in the future, or any other organization or GoH. Because the techniques are also so similar, such „enterprises‟ could also become experts in small scale irrigated vegetable seedling preparation as well. Because access to water is often limited, having a place where such nurseries can develop the planting material to be used when rains come, for instance, can be important. If World Vision Haiti wants to subsidize the cost to farmers to themselves purchase tree seedlings, which would be possible, this could be done. But then it would be the actual demand of farmers that would determine what was grown in these nurseries. If a farmer were to use some money to purchase some tree seedlings, would they choose fruit trees for grafting, or would they choose fast growing trees for future firewood? Would they purchase vegetable seedlings for out￾planting? The same approach is used for the introduction of chickens. Farmers at the household level often resist keeping their chickens cooped up and watering and feeding them enclosed. Farmers seem to prefer to let their chickens wander around, pecking in places that they shouldn‟t (like in vegetable gardens). But when real value begins to come out of these gardens, farmers do manage to make this management change.15 It is so hard to initially get them to keep them in cages, and to feed them through intensive management. This sounds like the rationalization used when Haiti‟s pig population was re-introduced after they were all 15 The MTE team observed an excellent example of this taking place in La Vallée with the ACDI/VOCA program where significant profits coming from household gardens implicating both wife and husband led to enclosure of chickens. 20 killed off after the swine fever scare in the mid-80s. This introduction was a chance to show Haitians how to „really‟ keep pigs the way they should – by intensive management. This was more than likely the approach practiced in La Gônave 20 years ago. Irrigation: In the high plateau, the MTE observed two different large irrigations systems with which the WVH MYAP has been working with for a number of years, beginning in the previous DAP. In both cases, large groups of farmers were organized in the rehabilitation of old existing canals, or extending the primary concrete canals to carry water towards areas that did not have access to water – permitting cultivation year around. At Coladère, a small catchment dam was constructed from which some 300 meters of primary canal were constructed, followed by training of the farmer groups in production of a range of high value crops. AGRIDEV has led in this effort by helping develop links to marketing, particularly for red peppers (see below). At Cerca La Source, a major effort permitted 500 meters of primary and secondary canals to be constructed, making possible the irrigation of some 229 hectares of land in three different zones. In all cases, labor was provided by the group members (FFW), but materials (cement, rock, etc.) by the MYAP. Maize, rice, and a wide range of vegetable crops are currently being cultivated by over 300 members. The land that has been improved through irrigation belongs to some 55 different farmers – with holdings ranging from 12 to 60+ carreaux. Most of the owners are absentee landlords living in urban areas or even in the USA or elsewhere. They have their agents who manage the land, renting out or permitting sharecroppers use of the land. Over half of the plots of the newly improved irrigation lands are used by small farmers through sharecropping, with most of the balance renting their plots. The perimeter farmers in the groups we met with all noted that the best „deal‟ was to rent the plot for a fixed annual fee – permitting three cropping seasons while the share cropper must give back about 1/4 of his or her production each cropping season. 21 The mostly small farmers benefitting from having access to these irrigated lands clearly were enthusiastic about the impact that this has had on their own livelihoods and access to additional food and income generated. One large group of farmers has been organized, since the former DAP, and further reinforced through the current MYAP during the past two years, in growing improved seed which WVH purchases and redistributes throughout its zone of operation. Redistributed seed is given to households who „repay‟ the local ADP committee 150% of the seed grain provided. (This past year, this was not collected because of the impact of the earthquake in the increased populations being fed). The foundation seed is being purchased by WVH from Double Harvest in PAP, and brought to the region. This past year .8 tons of TLOA variety of maize seed was provided to the seed producers group (55 farmers), with a harvest of 14 tons of seed corn; a second contract has been signed by WVH with this group for another 16 tons of seed corn this year. To assure delivery of the seed corn, WVH pays 125/gourds a marmite (about twice the going price for local corn) – the group pays its members 100 gourdes/marmite and resells it to WVH for 125 gourdes. This was found necessary because of the demand for the seed locally, with much finding its way across the border to the DR. The major issues with both systems observed are that functioning water user management systems have not been put into place for the maintenance of the systems. At Circa la Source, members of that group broke up into an argument in front of the MTE team about current plans to extend the cannel this year further – not wanting other farmers to get the water, wanting to keep all the water they have now for themselves. Nor was a user association in existence, though WVH noted that they were going to address this as well. This is an issue that should have been addressed before any work began on any system. One would have thought that some kind of agreement with the large (and well off) landowners who are the first to benefit from their land becoming more valuable through the investment made by the MYAP in the irrigation canals. A ¼ carreaux plot that once rented for 5,000 gourdes a year will now cost the renter 9,000 gourdes this year – a doubling in cost. Land issues are an explosive topic in rural Haiti, and though one would have thought that some kind of agreement could have been reached with landowners for a rent fee holiday for the small farmers given access to their land for a period of time - say 5 years – before they continued to tax farmers. Yet, small farmers are being helped despite this problem. A more serious issue is the management of the system itself, and the farmer‟s access to improved seed. The MYAP continues to provide seed to farmers and, in the case of the improved foundation maize seed being brought in, has yet to link farmers to Double Harvest where they can obtain the seed themselves. Foundation seed will always need to be produced by a special source, such as Double Harvest, GoH, or other private company specializing in maintaining the genetic purity of improved cultivars. Developing seed producer groups, or model farmers, to have access to foundation seed to produce 1st generation commercial seed regionally is a well-tested model for rural development.16 The group is happy to let WVH bring them their seed, give it to them, provide a significant advance to farmers to grow the seed, including additional advances during the year until the maize is finally provided – including the added cost in purchasing the seed when delivered. In fact, the group also has a contract now with FAO to 16 It is unlikely that such rural seed producing groups can themselves produce foundation seed itself, as access to such seed would seem difficult over time. The MTE team believes it is better to leave the maintenance of foundation seed to professional seed companies, and promote the multiplication of 1st generation commercial seed from foundation seed by rural groups. The challenge will be to help rural seed producers be recognized and integrated into a system of access to foundation seed or new improved varieties. 22 provide an improved bean seed – using the same support system initiated by WVH. This will not be sustainable. 1.2.2 Value Chains Targeted World Vision Haiti does consistently follow a value chain approach in all its agricultural program activities. Certainly, sub-contractor AGRIDEV applies this approach in attempting to link specific commodities like mangos or hot peppers of some MYAP supported groups to the market, where issues transport, quality and quantity are important. But the value chain approach is more than marketing, though this is a critical element. The value chain approach includes access to seed sources over time, other inputs as well, including water needs. Activities with vegetable gardening have not looked at problems that farmers have already mentioned about finding quality seed for the next planting season. Where do Mothers‟ Club mothers with home gardens obtain quality seed? Seed that is available from local merchants on La Gônave does not always germinate well (perhaps old stock). So linking farmers to a reliable source for future quality and varieties of vegetable seeds will be important for sustainability. Nor does WVH concern itself with how and where farmers will sell their vegetable produce, simply noting that there is a market on the La Gônave and that people are also selling produce on the mainland – taken over by small boats. When the thousands of fruit trees begin to produce citrus and mango in a few years, marketing will be an issue as well.17 On the Haut Plateau within the Hinche region, the MTE team observed a range of activities, beginning with impressive improved irrigation canals bringing water to large tracts of dark and fertile low land valley soils. These lands are owned by both larger (sometimes absentee) landholders, who rent or offer their land to sharecroppers -- as well as small landholders – with ½ - ¾ carreaux of land. They are now cultivated year around with a cycle of maize and different high value vegetable crops: peppers, cabbage, onions, and most recently papaya, being the most valued as cash crops, but also including the entire range of other vegetables consumed by local households (beets, tomatoes, carrots, etc.). In other areas, pumps are used to lift water through pipes to irrigate surrounding fields. The WVH MYAP has subcontracted with 17 ACI/VOCA’s experiment to purchase fruit crates for producers to rent to Madame Saras to take to the urban market is a good example of looking at this problem. Both the merchants of the fruit, and producers, are helped by increasing the volume and quality of the produce that reaches the market. 23 AGRIDEV to support these fortunate farmers to develop marketing links for their produce both regionally and nationally. The impact on this particular area seemed significant in that households stated that they were better off, were making profits on their sales – including those loaning and sharecropping the land. The farmers of this group also shared out of their abundance following the January 12 earthquake by donating produce to be sent (by World Vision Haiti) to urban areas where displaced people were in need. World Vision Haiti‟s approach to tree nurseries on the Haut Plateau mirrors what is done on La Gônave – creating large MYAP run base nurseries – and then encouraging the development of smaller, local community run nurseries. In all cases, the seedlings, once developed, are given at no cost to the farmers in the area (fruit and fast growing tree species intended for future charcoal production). Though appreciated by the local population, this approach will not lead to any local entrepreneur/ gardener being able to establish nurseries from which they could make a living selling these seedlings in the future – because people expect „free trees‟. Twenty five years ago, USAID, through Winrock International, supported a center outside of Hinche to bring in improved races of goats for meat and milk production. Dr. Swanson visited it at the time, and hopes were high that local breeds would be improved as a result. This center has since gone out of existence. But World Vision Haiti, back in a former DAP starting about 2004, built another „goat center‟ in the Hinche area, where they manage a small flock of these improved goats, several bucks and does. The center is managed, like the nurseries, by WVH personnel. The stated purpose is to place breeding animals in community run groups, who will care for the buck and permit members and others to bring their does for breeding. People do value these animals in the region, and do seek such services. The MTE team met with one farmer group, whose „lead farmer‟ showed us their buck. He noted that the buck has serviced dozens of does since they received it. Up to now, this „servicing‟ is done at no cost. This approach may be an opportunity lost in that not creating the possibility of developing entrepreneurial skills in management. The lack of direct ownership of these animals, and not charging fees for services, does jeopardize the long term sustainability of such programs (as in the earlier program). The farmer we met with clearly stated that if he owned the buck, he would charge people a small fee for breeding (about 250 gourdes). Because these animals – even the crossed ones - grow much more quickly than the local breeds, they also bring more income into the household faster as well. 24 1.2.3 Health & Nutrition World Vision Haiti‟s regions of MYAP focus fall within some of the most remote and underserved – in terms of GoH medical facilities (hospitals and clinics with their curative approaches) populations in all of Haiti. Curative health services which did exist at the beginning of the MYAP were largely provided through private clinics and hospitals of NGOs and Christian religious organizations. No GoH clinics at all existed on La Gônave, for example. As a result, the WVH MYAP, more orientated towards a preventive approach for rural communities, has hired regional medical coordinators (doctors) and nurses, to oversee the services of WVH employed health practitioners who worked directly with program target beneficiaries at the Section Communales of the 16 Communes selected for MYAP assistance. WVH MYAP‟s use of the „preventing malnutrition of children under two approach‟ (PM2A) provides blanket feeding to all children 6-24 months of age regardless of nutrition status, while also targeting pregnant and lactating mothers with Behavior Change Communication (BCC) preventive health care and food supplementation. The PM2A also provides food supplements to severely malnourished children who 24-59 months, identified through the rally posts. World Vision Haiti health and nutrition activities fall within five key thematic areas: (1) Rally Posts (2) Mobile Clinics (3) Home Visits (4) Food Distribution Points (5) Mothers Clubs The priority activities conducted by the WVH MYAP are the following: Rally Post: Once a month, in specific areas, health activities are conducted by the health promoter. These activities include distribution of Oral Rehydration Salts (ORS) and chlorine tablets as needed, 25 immunization, health education, vitamin A supplementation, deworming, and growth monitoring activities. The average number of rally posts managed by each health promoter every month is between 6 and 8. But the number of health promoters may vary considerably especially in areas where the project is co-managed with other partners. Health promoters and their assistants are trained by the WVH MYAP or by the Ministry of Health of Haiti (MSPP). The number of stations depends on the distance between households and the health center. Each health promoter has a register to report children seen at rally post. Mobile Clinics: Mobile units are active in the WVH MYAP operational areas providing 121 mobile clinics per month (cf. Annex 1). An auxiliary nurse and community health worker move from one community provided place to another, on a specific day, providing services and health messages. Women coming to the community mobile clinic benefit from pre and post natal services, distribution of iron and foliate supplements, immunization, voluntary counseling and testing (VHT) , post-partum and newborn assessment/care, growth monitoring an promotion, Vitamin A and de-worming, child health and treatment for malaria, acute respiratory infection (ARI) and diarrhea, education on danger signs and exclusive breastfeeding. Pregnant women are told by the health promoters that on a monthly base (once a month for each area) the mobile nurse will meet them at a school, church or private house near their place of living to provide those services. To maximize services and for convenience, rally posts and the mobile private clinics may be located at the same place. Home Visits: The health promoter visits some specific household for enquiring about a malnourished child or a newborn. A follow up is made upon mothers and children who did not come to rally post. Food Distribution Points: Food distribution points have become an incentive for the utilization of health services. For example, all pregnant women are eligible for food rations, with the condition that they continue attending prenatal services. What WVH looks for is that during pregnancy, pregnant women receive at least 3 prenatal visits. Children have to be completely vaccinated to continue receiving the ration. This increases the utilization of health services. Management of moderate and acute malnutrition: During rally post sessions, underweight children are identified, using a scale and the growth monitoring card (carte chemen la santé). When identified at the rally post, mothers are told to bring the malnourished child to the health center for recovery. Children with a moderate malnutrition (PFA) are eligible to receive a monthly dry ration at 26 distribution points. Severely malnourished children (PTFA), or those identified through MUAC measurements, receive the above ration, as well as a ready to use therapeutic food. This is given at health centers for medical follow up. Mothers Clubs: The Mothers Clubs strategy was launched during the earlier Development Assistance Program (DAP). Though Mothers Clubs are mentioned in the current WVH MYAP as “the primary venue for education and the Behavior Change Communication (BCC) strategy, one will have to look closely in their annual report to find the actual number of Mothers Clubs supported. This appears, after pages and pages on # of women and/or children receiving various kinds of social services and treatment, on page 12 of the last annual report where it is reported that approximately 15,000 mothers are grouped into 2,046 clubs. Mothers Clubs are essentially a means to an end of organizing mothers or specific categories of children into sub-groups for focused training or receiving of social services – and for easier recording of data to respond to M&E program indicators. From the social organization point of view, Mothers Clubs are among the most important community-structure organizing groups of women for mutual support and care of their children – specifically those targeted under 5 years of age. Here in Haiti, Mother‟s Clubs are essentially cohorts of women passing through different development stages, starting with: (1) Fetal stages: pregnant women = the pregnant women‟s clubs (2) Babies 0- 6 months of age = the: lactating mother‟s clubs (3) Babies 6 – 24 months of age; this is further sub-divided in some areas for 6-12 months, and 12-24 months) = these are Mothers Clubs of children aged 6-23 months (4) Malnourished children under 5 years of age = these are Mothers Clubs with malnourished children 24-59 months of age. The reason that WVH has so many Mothers Clubs is because all these groups are counted as separate clubs, and some may only have two or three members – unlike CRS that was targeting 20 women per club. And the women who make up CRS Mothers Clubs are quite different from those making up WVH groups – being specially selected as potential mother leaders in their community. All the mothers in these different Mothers Clubs also receive training and support from WVH MYAP technicians hired by the project for conducting agricultural and livelihood (vegetable gardens, chickens, goats…) activities. The MTE team‟s first encounter with WVH MYAP‟s approach to Mothers Clubs took place on La Gônave. We met with a group of 13 women at one site – part of a group of 19 women who 27 belonged to a literacy club organized by another organization. Yet most of these women also had children under 5 years of age and were associated with the MYAP Mother‟s Club program. On La Gônave and in the Haut Plateau, multiple clubs have been established. During a two year cycle, 15 to 20 mothers transit as a cohort through following clubs (same mothers gather at different periods following the growth stage of their children, on different schedules): As noted above, the focus of the Mothers Clubs is not on the mothers themselves, but the age of the children concerned. A pregnant woman, once her child is born, passes on to the next club, and so on, until her child is over 5 years of age, when she is no longer a club member. She can still bring her children to Rally Points for continued growth monitoring, and does, as MYAP records show. In some WVH regions, some mothers were members of more than one club (with a baby, and a child of 23 months of age, for example); or some mothers had once been in a Mothers Club, left, but now are part of one again because of a new baby. The main point of entry to this program is the prenatal consultancy. Mothers should have at least 3 prenatal consultancies which is a criterion to be included in the program. They are then invited by the health promoter to attend Mothers Club training meetings (once a month), and are also eligible for food distribution. Their regular presence at meetings is a condition for supplementary feeding. During these trainings, they are taught birth preparedness, the importance of immunization, exclusive breastfeeding and hygiene practices. An attendance sheet is maintained by the health promoter. Model mothers are mothers who show good understanding of lessons taught, who also practice the birth spacing method and have the capacity to transfer their knowledge to other mothers. Some of these mothers, after additional training, become themselves health assistance promoters and have their own Mothers Clubs. 28 In La Chapelle, the Mothers Clubs function differently, accordingly to the previous approach of HAS. The MTE team observed one group of 40 mothers who have gathered together since July 2008. Their registers have the name of the mothers, but not that of the children. Here, each club has 1 or 2 leading mothers, a secretary, and a treasurer. During educational activities the leading mother transmits the messages. These leading mothers may also weigh the children. Since the beginning of the MYAP, they have not yet received other training or materials. But they have regular meetings with the monitrice to plan the next training session. Mother‟s clubs hold a saving box allowing them to start an income generating activity or to face health emergencies. Contrary to other areas managed by the WVH MYAP, attendance at these meetings is not a condition to supplementary feeding at La Chapelle. The table above provides a recent summary on La Gônave of the MYAP direct beneficiaries. We see the large numbers of Mothers Clubs based on the developmental stage of the children. For example, there are 83 Mothers Clubs with children between 0-6 months. The World Vision La Gônave program has 5 nurses, 8 nurse auxiliaries, 71 health promoters, 326 matrones (trained local mid-wives) working out of 7 dispensaries – a large program indeed. Although mothers recognize the benefits of gathering together to improve their knowledge, they do not identify themselves as an organization (no name recognition, the group leader is often the promoter, not a mother). The meetings are always held by the health promoter. However when a mother becomes a health promoter, she is also a leader, but this is not a common case. Groups are settled only for the duration of training; in that cohort, too many changes occur (size of group, day of meeting) when children reaches 6 or 24 months. This can affect the sustainability of Mothers Clubs. Improvements can be done by helping the cohorts organize themselves as a group who meet until the child reaches 5 years, mothers could become future leader mothers with their own club. It is important to help them also initiate or invest into income generated activities. In that way, food distribution would not be the sole incentive keeping them into Mothers Clubs. Associative groups: Women and men in Haut Plateau identify themselves sometimes as a group which implements economic activities. Those groups are different from Mothers Clubs meetings. Ti fwaye: These groups are different from the mother‟s groups. In those ti fwaye (literally small foyer) mothers of malnourished children receive an intensive 2 weeks demonstration on food preparation (using local and donated food) and hygiene messages. Of the 15 mothers interviewed in one meeting with the MTE team on La Gônave, they fell within the different sub-groups mentioned above. None of them had the small scale irrigated vegetable gardens that WVH agronomists in the region believe to be the most appreciated agricultural activity WVH is undertaking in the region. Of these 15 women, only one was involved in the introduction of chickens, also considered to be a very important and appropriate activity for this region. When asked, all the 29 women said that what they would like would be their own, household level, chickens raising programs – over doing this through the „collective group model‟ for chicken raising that WVH employs. This, of course, raises the issue of just how effective the program here has been in integrating health and nutrition with appropriate agricultural themes that would help these same households towards food security and improved livelihoods. Women noted that they were all interested in starting their own small scale businesses (selling things). On La Gônave, we met one Health Promoter who was also, himself, one of the ten „midwives‟ at La Source. He said that he manages 6 Mothers Clubs with a total of 59 women. This included one group of pregnant women, one group of 0-6 month old children and their mothers, one group of 6 months to 12 months, two groups of 24 – 59 months (malnourished), plus an additional group. Some of these groups were very small in number. Lower Central Plateau (Bas Plateau) and the Artibonite World Vision Haiti, which has not had an ADP presence in this region, implemented the MCHN component of MYAP activities through its three sub-contractors (HAS, MARCH, and Save the Children) in the 8 communes of this region. All three have worked in the region prior to the MYAP, participating in an earlier FFP Save the Children program DAP. WVH itself during this MYAP initiated agricultural activities in three of the eight communes, and also provides the logistics and commodities for food supplements to HAS, MARCH, and Save. However, this attempt at cross-NGO partnership has not worked out well, with weak partners, lacking in resources, resulting in lack of sufficient performance. This in turn has impacted negatively on the MYAPs ability to respond to the real needs in this region. World Vision Haiti MYAP support within the Lower Plateau and Artibonite was intended to only complement the pre-existing and already established community health programs of MARCH, Save, and HAS). Appropriate financial support was provided for specific nutrition interventions, and was not intended to finance a full health program as is operational in the Upper Central Plateau and on La Gônave. Probably the greatest problems have been experienced with sub-contractor MARCH: The World Vision Haiti Regional Director for the Lower Plateau wrote in March 2010 “After two years of the MYAP implementation, World Vision Haiti cannot hope something better from MARCH because, in the proposal, MARCH (was) supposed to work in 4 communes: Mirebalais, Lascahobas, Savanette and Saut-d’Eau and establish 300 rally posts. However MARCH has no health agents to implement any rally posts. We have to take the decision to suspend the partnership agreement with MARCH to protect our reputation and have the best possibility to respond at the objectives we fixed in the proposal”. This has led to a situation in which, if the MYAP is to continue to operate in this region, World Vision Haiti has only two options before it: (1) either insert itself into the region and take over the direct management and implementation of the program similar to that developed in the Upper Central Plateau, or (2) provide the lacking resources to HAS, Save, and MARCH (through additional MYAP resources, currently not available within the WVH contract) so that they can provide the required services. The MTE team did not have the opportunity to meet with any of the sub-contractor management team leaders, so was not able to receive their own explanation for this situation. One Save the Children field personnel 30 noted to us that they simply did not have the resources within their programs to accomplish what was expected of them – something we could verify by the presence of only one broken down vehicle for their field use. 1.2.4 Early Warning System (EWS) The World Vision Haiti MYAP, because of the regions within which it works, plays an important role in the national EWS system that has been put into place by the GoH and donors alike. At the donor level for the MYAP, USAID chairs a monthly EWS meeting at the World Vision Haiti office in PAP. Those who attend include USAID FFP linked personnel, one or two participants from each MYAP CS (World Vision Haiti, CRS, ACDI/VOCA), GoH represented by the Centre National de Securite Alimentare (CNSA) and/or representatives from FEWSNET. The purpose is for coordinating and informing the MYAP partners for food security in their regions. However, a visit to the CNSA website will not find any quarterly bulletins posted by the WVH MYAP, though CRS has been posting them for three quarters now, and ACDI/VOCA one quarter. At the regional level, the actual EWS data are shared in monthly regional meetings, chaired by a representative of the GoH (Observatoire de Securite Alimentaire) where the key function is to monitor food security issues. The UN agencies are involved at this level, as are other regional players. This group helps to coordinate data collection at the regional level, to avoid duplication or double counting. There are three key data points that are reviewed: (1) Rainfall (monthly) (2) Market prices for key commodities grown in the region (3) Food distribution (MT made available to specific parts of the region) The MTE team asked WV for a copy of the agenda for the December, January and February meetings of this committee, and though promised, never did receive these for our review. Nor were we able to review any of the past bulletins completed. Unusually heavy rainfall, or a hurricane, will seriously impact standing crops in the field – particularly on Haiti‟s steep cultivated slopes; the impact results in lost future harvests and damage to rural dirt roads. Market prices will jump when there is a disaster, and is much closer to showing what might be taking place at the rural level with respect to food availability and security. Household incomes may be impacted negatively if they need to purchase food for consumption when there are price hikes, but most rural households have some stores available for the near future (often in the ground – manioc, sweet potato). At the same time, it must be remembered that most of the food purchased in local markets comes from the farmers themselves in surrounding community, and price increases also puts additional money into their pockets. Bringing in external „food aid‟ can actually undercut other Haitian farmer households trying to make a living from their crop surpluses. A copy of the EWS market data collection form, used in the Commune of Thomassique for the month of March, 2010 is shown here. 31 The MTE team believes that an additional one or regularly monitored indicators need to be developed that directly measures, at the household level, negative impact on household food security and well being. All MYAPs are in a position to provide data on one very important indicator as a result of their thousands of Mothers Clubs and rally post programs. Though this is not yet well institutionalized, there is absolutely no reason why a couple „malnourishment indicators‟ could not be included within the EWS. The “% of children 6-59 months with weight for age below -2 Z score” for a number of sentinel posts (rally posts representing a specific locality) could be provided as one possible indicator of malnourishment. Another, using the MUAC measurement, could suggest the possibility for acute or severe malnourishment (through presence of kwashikor or marasma). The IPTT tracks the former indicator every two years, but for the EWS, tracking these percentages for a number of sentinel locations could be an early warning of impact from some natural disaster resulting in food insecurity leading to possible malnourishment or severe malnourishment.18 As the # of such children spikes due to lack of food within households, resulting in possible severe malnutrition (MUAC measurement), this could be early warning evidence of a serious problem which is currently being dealt with through the Mothers Clubs and rally posts. 1.3 M&E System and Targeting of Beneficiaries WVH has a well-staffed M&E team that is quite centralized. The MYAP has developed an excellent system for tracking key data sets MCHN and agricultural data from farmer fields, rally posts and mobile clinics to regional and the central office. Appropriate data sheets aggregate these data, and these are frequently under review for improvements. However, there are too many indicators which greatly increase the efforts of the field staff in registering, handling these data, and reporting on them. 18 Clinically these suspected cases of acute malnutrition would need to be confirmed of course, but as a proxy measure of possible severe malnutrition, it could be a useful tool for early trends of a problem. 32 At least in the case of the Mothers Clubs of the health and nutrition portion of the WVH MYAP program, it would appear that reporting of data for project monitoring has influenced the very approach the MYAP has taken to reach mothers about health and nutrition messages. While the messages are clearly getting through to these specific women, the process itself appears flawed because the mothers themselves in these Mothers Clubs are not being institutionalized within these regions. This is very unfortunate, and a major opportunity lost. The World Vision Haiti‟s MYAP M&E system has some 58 indicators on the IPTT (and close to these numbers for CRS and ACDI/VOCA). Added to the other indicators WVH is tracking in these same areas, this amounts to a tremendous amount of time being spent, all the time, in data collection at all levels of the program. While tracking data is important, consideration needs to be given to determining if these indicators might not be reduced. The MTE team spent time with the WVH M&E coordinator going over each IPTT indicator and reviewing their importance or difficulty in obtaining the required data. Without going through all these again here, examples can be pointed out of indicators that perhaps should be eliminated or reported upon in another manner. Some of these are believed to be required by either USAID/Haiti or FFP itself – but if data cannot be obtained that are meaningful, reconsideration of this requirement might be given. (1) Couple-years of protection (CYP) in USG-supported programs. Data are not available, nor have targets even been established. (2) % of households with incomes increased as a result of USG assistance. This is an baseline￾midterm- final evaluation type impact indicator that is almost impossible to obtain data for in a meaningful manner, unless some other proxy data is used (like presence of new housing infrastructure, metal roofs, etc.). The same is generally true for increase in numbers of household animals for which people almost never report on truthfully. (3) % of farmers adopting improved and environmentally friendly agricultural technologies. This indicator has yet to be reported upon. (4) % of communities with improved physical infrastructure to mitigate impact of shocks. This indicator has yet to be reported upon and would better simply be discussed in the narriative section of EWS bulletins. (5) % of communities with improved capacity. This indicator too has yet to be reported upon and really does not mean much. One‟s definition of „community‟ can change from one MYAP to another; every community in which MYAPs work receive some form of improved capacity. In some cases, two indicators are essentially the same, except one is for USAID, one for FFP. A decision should be made which is the one to track, and the other dropped. An example of one pair: (6) Number of vulnerable households benefiting directly from USG assistance (7) Number of rural households benefiting directly from USG assistance. The MTE team, within the discussion of the quantitative survey and the FFP common indicators, has made observations there about some of these which we consider not effective as well. This is not repeated here. The MTE team, within the discussion of the quantitative survey and the FFP common indicators, has made observations there about some of these which we consider not effective as well. This is not repeated here. 33 At the same time, a number of indicators are not being tracked on the IPTT which are probably more important in terms of long term impact than some of those on the IPTT. An example of a several such indicators:  The number of community health workers (volunteers in some cases) that have been trained who manage the Mothers Clubs and rally points  The number of Mothers Clubs that have been formed  The number of mothers that are being trained in these Mothers Clubs  The number of children > 5 years of age in all the households represented by these Mothers Clubs and  The number of children < 5 years of age in all the households represented by these Mothers Clubs. While some of these numbers are included in more generic indicators (like # of beneficiaries, or # of people trained), these numbers actually say something about the breadth and scope of the health and nutrition activities of these MYAPs and are sometimes included in the narrative portions of the quarterly reports. Monitoring and supervision of the project: Previously, certain communes were not entirely covered by the MYAP. World Vision Haiti health providers would limit themselves to a portion of the commune. Now, with the meetings and development of reports at the section communales level, WVH wants to ensure that all the sections communales within communes are covered by the project. To be really effective, this should be done at the locality level (sub-unit of section communales) and this would also require a significant increase in the number of community health workers needed – one reason that the volunteer Col Vols of CRS and A/V programs are considered so important. The MTE team found it unfortunate that, with all the data being collected and reported on a monthly basis through existing rally posts and mobile clinics that so little of it appears to be analyzed at the field level or at the central level. Aggregated by section communale or commune, such data are not particularly useful, but at the rally post or locality level, this information 34 can be more useful. For example, trends of PFA and PTFA at the locality rally post level would allow the WVH team to assess the performance of the MYAP over a period of time; the objective would be to decrease malnutrition rates in specific areas over time. This chronological series of data on underweight children would be useful to follow the project‟s performance and make adjustments. A chart, similar to that below prepared for each WVH ADP, could be a wall chart at the PDZ (ADP) or health clinics, for different rally posts, and discussed both with health promoters in order to analyze the amount of efforts towards a reduction of malnutrition. 1.4 Links to GoH World Vision Haiti has been established on La Gônave and in the Upper Central Plateau region for many years, even before the 5 year DAP that preceded this MYAP. At the time, existing GoH authorities helped in the priority areas for activities to begin, generally responding to areas of greatest need. World Vision Haiti regional leaders participate in GoH lead quarterly coordination/strategy and information sharing meetings about progress of activities, with efforts to reduce overlapping activities. These regions are also characterized by a weak GoH presence at the Section Communales level, with WVH itself leading efforts in establishment, rehabilitation, and providing services through a number of rural health clinics. On La Gônave, the WVH MYAP works in close collaboration with the representative of the MARNDR through the local Bureau Agricole Communale (BAC). Strategies of intervention within the agricultural sector are always discussed with the BAC prior to implementation. . In Upper Central Plateau, all the documents of the MYAP are sent to MARNDR. MYAP managers regularly take part in meetings organized by the GOH on Central Plateau to share their experiences, and encourage joint planning. Animal breeding activities are being conducted in collaboration with the 35 Ministry of Agriculture who train the program contact leaders to provide vaccination and de-worming services for a small fee. 1.5 Internal Reporting & Communications World Vision Haiti takes program reporting very seriously, and has developed a highly structured approach channeling information from the lowest levels – at the beneficiary levels – from local to sectional communales to commune and regional level, with final transmission of narrative and data rich quarterly reports by regional directors of the two major components to the central office in PAP. There, MYAP national coordinators for each of the two major components track progress of the program, and submit consolidated quarterly reports for USAID. It is at the PAP level that WVH receives the narrative and data reports from its sub-contractors in the Lower Central Plateau and the Artibonite (MARCH, SAVE, and HAS). The PAP M&E office coordinates data for the IPTT through a newly developed MIS system, where information can be sent electronically. Generally speaking, the entire program appears geared towards these data, and these reports. Reporting appears cumbersome with numerous different kinds of forms to track the complex program – particularly in the MCHN programs. The monthly data reports for MCHN (a 7 page document) are full of very detailed data summaries about the program, completed by each regional health advisor in his or her register, which is then aggregated with similar data from other health advisors and sent to the WVH MYAP 36 overall health coordinator. The first page of this report (shown here) provides the aggregated data from 4 communes in the Central Plateau. Here we see the number of rally posts planned (201) and held (198) during March 2010 among these communes, the number of Mothers Clubs organized (997). Data for immunizations, receipt of vitamin A are sub-divided by children less than 6 months, 6-11 months, 12-23 months, and 24-59 months. This is a parallel system in addition to the M&E indicator sheets that need to be completed for the IPTT reporting. The fifth page of this monthly report, shown below, summarizes nutritional levels of children who are being monitored for growth at the different rally posts in these 4 communes. From this we see that World Vision health agents weighed 6,825 children (disaggregated by sex), of whom 621 were somewhat underweight and 76 whose weight for age was considered extremely low (severely malnourished – a rate of about 10% (PFA + PTFA). A better measure for this is being included for measuring MUAC (as as estimate for severe malnutrition). Food supplement commodities are distributed to pregnant women, lactating mothers, and all mothers with children under 2 years of age, and all malnourished children. However to receive these, there are several conditions that need to be met – like attending a several consulting visits at a health center for pregnant women, or regularly attending a Mothers Club for mothers of under two children or malnourished children, and coming to the rally points for growth monitoring. The chart below is an example of the planning tool for monitoring this for each food distribution site – the number of children (male or female) who are expected to receive a ration, the number who actually receives it that month, the number of new children entering the supplemental feeding program this months, and those leaving it. Participation with Mothers Clubs depends on the developmental stage of the enfant in question. The photo below shows three women, one a mere child, who are pregnant and members of one such club. On La Gônave, for example, between October 2009 and March 2010, 60 Mothers Clubs were in existence for pregnant women (468 mothers); 98 Mothers Clubs were operating for mothers with children 0-6 months of age (736 lactating mothers), 266 Mothers Clubs were operating for mothers with children 6-24 months of age (2,696 mothers), and 6 Mothers Clubs for the 54 mothers with malnourished children 24-59 months of age. The number of participants in any one of these Mothers Clubs will vary from quarter to quarter, as children move out of one age group to another, or are no longer classified as „malnourished‟. 37 Agricultural data tracked vary from one region to another, depending on the particular activities underway – providing laying hens to mothers in Mothers Clubs, distributing improved goats (breeding bucks) as genitors for different communities, working with different groups for multiplications of improved varieties of major local crops (maize, beans, sweet potato), and agro-forestry/soil conservation activities. Efforts were made to integrate MCHN with agriculture, but this was not always possible. For example, some areas receiving MCHN had no agricultural activities planned at all. 1.6 Staffing & Capacity Development Though the MTE team was not able to go into sufficient depth in looking at staffing and capacity development, there was a sense that WVH is not doing enough for capacity development/training of personnel. WVH, in this MYAP, does not have a training coordinator per se, but relies on the WVH human resources office to decide how to respond to the requests or lists of training that come from regional directors, supervisors and from personnel requests. We could not determine whether such requests were actually followed up upon or not. The training budget is focused towards beneficiaries, and this training appears to be fairly effective, though there is a clear lack of sufficient visual training materials for community health agents and for use of Mothers Clubs themselves. There is a need for providing greater opportunities for regional field staff to travel and observe activities for which they are responsible being implemented in other MYAP regions. The different MYAP CS frequently approach issues differently than WVH, and it would be healthy for internal debate for greater exposure to take place. This is particularly true for approaches to savings and loan issues (CRS & mutuelles), for household level vegetable gardening (with micro drip irrigation)(ACDI/VOCA), and in approaches to Mothers Clubs (CRS, Camp Perrin). Seeing actual model farmers and small groups implementing these programs speaks much more than any amount of theoretical training on how to do something. The MTE team met household level entrepreneurs who have excelled in household level vegetable cropping. One household in the Cote de Fer commune of Jacmel should become the lead extension agent for this activity within the MYAPs. The husband has also developed skills in grafting of fruit trees – showing us one citrus tree with three species of citrus growing on different branches. He had also grafted improve eggplant on to hardy local stock capable of producing for as long as a year, being also drought resistant. Both husband and wife are closely involved in different aspects of this activity, with visible 38 effects on household prosperity and well-being. Excellent examples of savings and loan groups also exist. Indeed, the three MYAPs should begin a program that recognizes the most creative and enterprising households for the different ventures undertaken – promoting cross-learning. Categories of health staff and volunteers met during the MTE team field visits: Health Promoters and Assistant Promoters: They organize rally posts; assist with mobile clinics and mother‟s training clubs, and undertake targeted household visits. At La Chapelle, this work is done by agents called „field workers for community health‟. Training sessions of promoters are organized by World Vision Haiti with the technical support of MoH. Nurse Auxiliary: she examines pregnant women and lactating mothers (up to six months) during mobile clinics. Monitrices: They organize the hearth nutritional sessions (ti fwaye) with mothers of children under five. These groups are specific to areas where the MYAP is conducted through health partners (as for example La Chapelle through HAS and Marchand Dessalines through Save the children). Field workers do growth monitoring during rally posts and household visits, then refer malnourished children to monitrices who invite mothers to attend these ti fwaye with their kids during a two weeks intensive training. Matrons: They are community worker who traditionally attend birth delivery. Training of matrons and a supply of a clean delivery kit is organized by World Vision Haiti with the technical support of Ministry of Health. Members of ADPs: In WVH‟s 21 Area of Development Programs, located in five regions of Haiti, economic development activities toward reduction of poverty and vulnerability take place through a child sponsorship program. ADPs are located in vulnerable zones; the MYAP complements these activities. ADP representatives, as volunteers, also help in screening poor and vulnerable households who will benefit from the MYAP program. 1.7 Finance & Commodities According to data provided to the MTE team from the commodities unit, the following three tables summarize commodity distribution from the beginning of the MYAP through March, 2010. To date 89% of the beneficiaries of FFP food commodities have been MCHN targeted groups, with approximately 12,405 metric tons of food distributed. Each recipient receives commodities for a 1 one-month period, sufficient to provide supplemental feeding for a 5 person household; about 86,456 households have benefited through this component of the program. 39 Years MCHN Beneficiaries Food for Asset Beneficiaries FY 08 16,655 0 FY 09 28,192 2,255 FY 10 (through December 2009) 32,378 6 976 Months Regions PLWA OVC Pregnant Mothers Lactating Mothers Children Total January 2010 La Gônave 34 112 295 196 1,291 1,928 Upper Plateau 0 0 633 642 3,742 5,017 Lower Plateau/ Art. 0 0 1,103 1,079 3,103 5,285 Total January 34 112 2,031 1,917 8,136 12,230 February 2010 La Gônave 74 482 761 624 3,541 5,482 Upper Plateau 0 0 1,703 2,560 11,404 15,667 Lower Plateau/ Art. 0 0 2,173 1,759 5,339 9,271 Total February 74 482 4,637 4,943 20,284 30,420 March 2010 La Gônave 76 485 775 668 3,762 5,766 Upper Plateau 0 0 2,135 2,757 11,690 16,582 Lower Plateau/ Art. 0 0 1,684 1,996 4,575 8,255 Total March 76 485 4,594 5,421 20,o27 30,603 From the table above, it is clear where the bulk of the food commodities are going: to children under 5 years of age, and most of these are under 2 years of age. The PLWA programs here are clearly fairly small, as are the Orphans and Vulnerable Children (OVC) numbers. Pregnant and lactating mothers represent the next largest group of people receiving food rations. World Vision MYAP provides food rations for OVC and PLWA only on La Gônave. PLWA in the Central Plateau and the Artibonite are already attending existing programs implemented by Partners in Health (PIH) and other providers, for testing, counseling, and nutritional support. The quantities in metric tons (MT) to various categories of beneficiaries are show in the table below, over the life of the MYAP so far. Clearly, the MYAP has been able to maintain service to beneficiaries close to that initially planned for its targets. Fiscal Year 2008 March – Sept. 08 Regions MT Distributed # of Planned Beneficiaries # of Beneficiaries actually Served % of Budgeted Target La Gônave 295.21 2,580 2,429 94% Upper Plateau 1,372.20 10,759 10,427 97% Lower Plateau/ Art. 237 4,198 3,789 90% 1,905.04 17,537 16,655 93% FY 2009 Oct. 2008 – Sept. 2009 La Gônave 1,059.07 4,768 4,607 97% Upper Plateau 3,542.43 16,406 15,373 94% Lower Plateau/ Art. 1,864.69 9,351 8,213 88% 6,466.19 30,525 28,192 93% FY 2010 Oct 2009 –April 2010 La Gônave 740.41 5,713 5,577 98% Upper Plateau 2,139.72 16,813 16,310 97% Lower Plateau/ Art. 1,153.94 9,852 9,548 97% 4,034.07 32,378 31,435 97% 40 1.8 Environmental Impacts Within World Vision Haiti programs everywhere, there appears to be a great passion for the plantation of fruit trees and multi￾purpose forest tree seedlings. This is quite evident by the presence of established nurseries in all regions. Local communities participate fully, as long as the tree seedlings are delivered at no cost to themselves. Delivery of these seedlings is accompanied by training from the World Vision Haiti local community agricultural agents. This includes the improved management of the trees themselves; this includes a balance respected between cutting and planting of new tree seedlings. The majority of micro basin slopes of the zone of intervention of the program have actions of protection of soil (erection of stone cords, correction of gullies, plantation of trees on the slopes, etc). On the pieces of land immediately surrounding households, a space is reserved for the production of fodder for household animals. With respect to the management of the environment, the program encourages households to manage their soils (with organic matter) before crop planting. Several techniques of soil conservation are encouraged by the program. Agricultural diversification promoted by the program is an effective strategy which facilitates a certain rejuvenation of the environment. Irrigation and Water Management In Upper Central Plateau during the first two years of this MYAP, World Vision Haiti intervened in 6 small irrigated perimeters. This consisted of the installation of three pumps with Bernaco, Goyave and Corail and with the rehabilitation of three irrigated perimeters: Bohoc, Los Posos and Saltadère. The rehabilitation of the three above mentioned perimeters made possible the development of completely new irrigated perimeters. The program made possible the development of approximately 250 ha of irrigated land. The majority of the users of this newly exploitable land are sharecroppers or farmers renting and exploiting small plots of approximately ¼ cx in size (1 cx. is 1.29 hectares). AGRIDEV, a World Vision Haiti sub￾contractor, is committed to ensure the agricultural development of these perimeters likely to make profitable the investments carried out and to increase the incomes of the producers. It provides a technical framing brought closer to the users through the organizations to producers. AGRIDEV works with these organizations in the identification of new market outlets (regionally and 41 internationally) in order to facilitate the flow of the market-gardening products. Prioritized commodities include pepper, onion, shallot etc. Beneficiaries have been very receptive to the package of services provided by AGRIDEV. Their testimony leads us to believe that they are, in fact, experiencing increased yields on these plots following the rehabilitation work supported by the MYAP. The intensification of the market gardening promoted by the MYAP has led to increased income, beginning with their first pepper crop in particular. Two major problems were raised by the small farmers supported by the MYAP. Land tenure continues to be a major constraint for these resource poor farmers on these irrigated perimeters. The majority of the parcels are share-cropped. The producer makes all the investment and is obliged to divide shares in his production with the land owners (usually 1/3 of each seasons production) – collected by an agent of these usually absent landlords (who may live in Miami, New York, or PAP). While these land poor farmers would prefer to rent a piece of land for an entire year (one fixed fee for the entire year, no matter how many seasons of produce the farmer may gain from the pot of land), landowners prefer the sharecropping arrangement as most beneficial to themselves. MYAP investments in improving these irrigated perimeters actually increases the value of the irrigated lands of these well-off land owners – said to be 50 landowners at the above perimeter, but exploited by several hundred small farmers. In fact, with the MYAP improvements, landowners were able to double the rental cost of the land they rented to small farmers. In spite of this downside, these resource poor farmers, whose only land holding were on rocky pieces of hillside slopes, were happy to at least have the opportunity to access to more productive land where they could realize some increased production. A second problem is linked to the increase in the availability of water on the perimeters. Water management is creating conflicts, as water management committees were not created with agreed upon 42 rules before the improvements made in the irrigate perimeter. This was a tactical mistake made by World Vision Haiti, and not one that will easily be overcome at this point in time – though it is World Vision Haiti‟s intention to now begin this process. Perhaps AGRIDEV might be able to bring some support to this potentially serious issue – water management – if the long term success of the commodities from these perimeters is to continue. One option might be to consider introduction of a farmer managed drip irrigation system into this perimeter, which would permit everyone with enough water for their parcels. As it is, much water is wasted as it flows from the secondary cannels and into ditches/furrows along the side of the irrigated fields. Most of water is lost through infiltration into the soil long before it gets to the plants being irrigated. The success of the trial plots overseen by AGRIDEV in two communes (Lascahobas, Boucan Carre) targeting onion, pepper, shallot, broccoli, with the support of the WVH agriculture team seems to have convinced these farmers that intensive (year around) vegetable horticulture production is the route they should take on these perimeters. AGRIDEV‟s support has been greatly appreciated by farmers. 1.9 Conclusions, Lessons Learned & Best Practices Following 9 days of field interviews and observations of World Vision Haiti‟s field program, the results presented in the last WVH MYAP annual report for FY 2009 were clearly on track and representative of MTE findings. The MTE team has questioned a number of program approaches/activities of this MYAP and whether in fact best practices are being followed. This was particularly the case with the organization to Mothers Clubs, the approach to in-kind revolving loans and the too extensive practice of giving services and commodities away with little or no conditions attached. World Vision Haiti operates a highly structured, quality program, touching and improving the lives of many thousands of vulnerable Haitians. The MCHN component of the program clearly dominates activities, reaching a majority of the households in the targeted section communales within the 16 communes targeted with children under 5 years of age. The Agriculture and Economic Development component of the program, does not work in all section communales of the regions targeted, and are not always integrated with the same beneficiary households targeted for the MCHN program. Some conclusions have already been put forward in the discussions above, and will not be repeated her. Other important conclusions with respect to the WVH MYAP‟s health and nutrition and MYAP agricultural activities include the following: Enhanced Seed Production: The setting-up of seed producer associations for improved seeds, such as that seen at Cerca La Source, should allow for sufficient improved seed production to initially supply all farmer members of the groups concerned. Excess could then go to the open market for commercial seed. The WVH NYAP is successfully applying this model in all their areas of intervention. The introduction of the improved, high yielding, maize variety TLOA 43 through such associations should be reinforced. However, these groups have yet unrealized potential to be transformed into a true production company for improved seeds in the concerned regions. The sooner this action takes place, the greater the possibility for sustaining this achievement. Improved Storage Practices: It is yet too soon to know if these activities can be sustained by these trained individuals, or whether they will be able to build their home shops to supply such equipment within their communities. World Vision Haiti will need to begin by providing additional support in costing this equipment, and linking them to potential sales outlets – beginning with World Vision Haiti itself as a buyer. However, realistic prices need to be set for the local market. There is the danger that if WVH is the only buyer, the trained local artisan will request (and receive) a price from WVH that no local person would ever be able to afford. Should this be the case, then ultimate impact of this training is dubious. It is important for the WVH MYAP program to help these local artisans to produce and develop their markets to sell these silos – dependency on WVH’s purchases for this economic activity will lead nowhere long-term. The popularization of these silos in World Vision Haiti program areas will facilitate the storage of maize seeds as part of the emergency seed reserve system. This activity aims at reducing the impact of potential natural disasters on seed supply. In case no disaster occurs, the seed will be made available to seed activity participants before the following production cycle. Yet, it is also important that World Vision Haiti not simply purchase these silos from these individuals and give them away to seed production groups. In the past quarter, WVY purchased “161 silos that were distributed to 11 local Federations. The Federations are responsible for the diffusion of the silos according to pre-established loan contracts between farmers and the Federations”.19 This only reinforces the image that NGOs will give out everything for free, and undercut any hope for private entrepreneurship ever developing. However well intentioned a program may be, it is extremely important to consider – before any action is taken – what will likely be the impact when WVH is no longer present. Diversification through Small Animals: The distribution of improved goats and chickens can lead to really fast increase in the incomes of households if the control of the breeding is done under good conditions and if food and the fight against the diseases can be resolved. From the observations of the MTE team, these “ifs” are daunting ones, and it is unlikely that the World Vision Haiti program is focused enough on the issues of the value chains for each animal (goat, chicken) . The MYAP works with farmers‟ associations, producer groups, and individual farmers, and depending on the activities, more focus may be given to a specific beneficiary group. However, the ultimate goal is to empower households in order to increase production, develop entrepreneurship, and enhance cash incomes. This being the case, it is therefore important that WVH, during the remaining life of this MYAP, move more quickly to showing some impact at this household level. The MTE team, in June 2010, saw few pigs on La Gônave that were NOT black. Pigs seen were wandering around, or tied by a cord around the neck at different places as has always been the custom in Haiti. Management practices take a long time to change, and have economic consequences. This lesson should instruct the WVH MYAP approach to promoting improved chickens. First of all, it is NOT going 19 WV Haiti MYAP Quarterly Report, January – March 2010, April 2010, p. 11. 44 to be easy to be successful; appropriate time in training and close supervision will be necessary, and working with really motivated people is also essential. Getting farmers to raise chickens „as a group‟ where they would be managed intensively, so that they hopefully will begin to do so at home, is not likely to have much long term impact. It might work for more wealthy farmers, with the capital to obtain inputs, but for the target farmer groups of the MYAP – the rural vulnerable – this approach is questionable. It might be better to consider identifying a number of „model farmers‟ who would develop their chicken enterprises following the recommendations of the program, with a group of neighborhood farmers as satellite observers who would be provided with the next generations of chickens (pass-ons) if they followed the lead farmer‟s example. In this way, the value chain linking the raising of chickens (for eggs and meat) to markets could be developed in a way that would support development of household level enterprises. Infrastructure and Social Services: Most of World Vision Haiti‟s regions of operation have no functioning GoH health facilities or personnel in place to serve the needs of these communities. A good example would be the sites on La Gônave visited. Working with regional GoH authorities as to priority needs and placing, World Vision Haiti has used MYAP funding to either build or renovate existing local structures to serve as rural health clinics, and staffing them with WVH MYAP paid medical personnel (nurses or health auxiliaries). As an example, the health center at Ti Palmiste, La Gônave was rehabilitated and upgraded from 6 to a 15 bed facility, including upgrading of laboratory facilities as well. This was also done at La Source, a center constructed by WVH under the previous DAP. These individuals in turn provide support to the mobile clinics established further out in specific sub-regions, where rally points for local populations are held under the management of the locally employed, by WVH, health promoters. Where some GoH health structures may exist, WVH seeks to provide support through them in the same manner. Such a center in Lascahobas in the Lower Central Plateau was visited by the MTE team – a center that has received little of the expected support from a sub-grantee (MARCH), and where the program was in disarray. The GoH health center damaged by the January 12 earthquake was run down without supplies or equipment or appropriate visual aid materials for the health practitioners of the area. Nor did the local health practitioners have adequate materials for the monitoring services they were being asked to perform at Rally Points and with Mothers Clubs. Growth monitoring cards of mothers interviewed here showed many children with malnutrition that was not being addressed. WVH will be stepping in themselves to rectify this situation in the coming months. Health Promoters: First of all, the total number of trained and field experienced health practitioners is not officially tracked on the IPTT, though known. These are the 300 Haitian personnel, largely women, who are most responsible for the regular contacts with thousands of World Vision Haiti program Mothers Clubs and lead efforts through the Rally Posts, where immunizations take place, vitamin A supplements given out, deworming. These are the front line workers daily interacting with beneficiaries and the true backbone of the program. These are also the key people, living locally within the various zones of operation, who are best placed to link all future GoH public health services (or that provided through NGOs) to local communities. WVH MYAP has built in an incentive system for mother‟s to organize into Mothers Clubs and to receive food rations for their youngest and/or malnourished children by regular monthly attendance to key program sponsored events: the mobile clinics, the rally points for growth monitoring and other social services, the Mothers Clubs. The MTE team observed some of these events, and met with representatives of all the sub-category mothers groups organized by the program. Training sessions held by the health promoters, sometimes using visual support materials provided by the MYAP, 45 cover such subjects as “exclusive breastfeeding, diet diversity, and child feeding practices, treatment of diarrhea, nutrition education, immunization, family planning, hygiene, and HIV/AIDs”.20 Mother’s Clubs: World Vision Haiti‟s approach to Mothers Clubs is quite different from that of other MYAP CSs, and even different from common WVH best practices in other countries (e.g. Rwanda). On La Gônave, it was immediately clear that the mothers in the Mothers Clubs encountered had developed no sense of „ownership‟ in their groups. They did not have a „special name‟ for their groups. Most of them moved as a cohort from one „club‟ to the next. The „clubs‟ were essentially monthly gatherings where the WVH health promoter communicated specific messages relevant to the children or mothers at each of these developmental stages, and gathered data which is recorded on the health promoters register which is then used to report on the FFP indicators in the IPTT. Indeed, it would appear that this may be one reason that this format for Mothers Clubs was chosen – i.e. facilitating M&E data recording for the required IPTT indicators. FFP indicators are exactly framed in this way. WVH personnel defend the approach by saying that this makes communicating the appropriate messages to these specific groups of mothers much more effective, which may be true. However, this may be at the expense of building community mothers groups that could become a permanent and institutionalized feature within these communities in the future – in the absence of WVH. As it is, the grouping of mothers in these Mothers Clubs will almost certainly disappear when WVH MYAP leaves, as the very nature of each group is so transitory. They are certainly not sustainable. Our observations of these Mothers Clubs beneficiaries was that they clearly are receiving quality and well focused training needed for the children of these mothers at these developmental stages. The mothers themselves were extremely grateful for the training and services received (supplemental feeding, vaccinations, deworming when needed, vitamin A, etc.). What was clearly lacking, however, was the institutionalization of the idea of Mothers Clubs within the communities themselves. Because of the fluidity of the groups from one stage to the next, even when comprising many of the same cohort mothers, there did not appear to be any sense of group identity developed that is so common to Mothers Clubs in other programs or countries with which the external consultant has been familiar. Mothers Clubs are not led by a Volunteer Leader Mother, as common in some Mothers Clubs in other countries, who keeps a register of the names of the women in the Mothers Club, their children under 5 years of age, with monthly records of grown monitoring results (yellow, orange, or red) for malnutrition. Volunteer Leader Mothers (of Mothers Clubs) do not regularly visit the homesteads of their mothers to see if lessons are being applied and if household children are being alright. Mothers of different WVH MYAP Mothers Clubs, at the different developmental stages, do not necessarily come from the same local communities, though they certainly come to know each other because of their shared circumstances. World Vision Haiti‟s approach to Mothers Clubs may be limiting the deeper and more long-lasting impact their activities could be achieving if these clubs were to be structured in a different way. Children < 5: Thirdly, though the key FFP target groups for children are tracked, by name, there is no record of the total number of children less than 5 years of age with whom the MYAP has worked since its beginning. 20 World Vision Haiti FY 2009 Annual Results Report, November 2009, p. 6. 46 Children > 5: And finally, there is no record of the number of older children, between 5 and 18 years of age, in the households of the mothers of the Mother‟s Clubs. Health and nutrition training received by these thousands of mothers does not only benefit their > 5 years children, but their other children as well and the entire household. Community Management of Acute Malnutrition (CMAM): This is an important initiative within the Haiti MYAP which brings together many of the key elements of addressing infant malnutrition, and provides guidelines of where focus needs to be given for this to be effective. WVH is ideally positioned to support CMAM through their established ADP community structures, which in turn reinforces these activities in other locations without ADPs. Mid-Upper Arm Circumference Measurement (MUAC) in Mothers Clubs: Weight-for-age and MUAC measure different types of malnutrition – underweight children and wasting respectively. They are not correlated enough to be used interchangeably. The MTE team concludes that Leader Mothers should be have the capability to undertake these measures, thereby reducing the workloads of Col Vols at rally posts. Leader Mothers of Mothers Clubs will need to be well trained to speak about each measure and to keep records separate. The MUAC measures will contribute to the MYAP CMAM interventions while the weight-for-age data (PFA, PTFA) should be used as part of growth monitoring and promotion. 1.10 Recommendations The most important recommendations concerning this MYAP, along with the other two MYAPs reviewed by the MTE team are presented in the major recommendations section of Report #1: Haiti MYAP Overview, Methodological Approaches, with Major Conclusions, Lessons Learned, and Recommendations. Report 1 must be taken together with this Report 2 to receive a full understanding of the mid-term evaluation. We did not wish to repeat all of the major recommendations here or in 2.10 below. Only a few have been selected for inclusion here. 1. Establish a formal system to track the number of different mothers that are being trained through the Mother’s Clubs. The best way to do this is to establish a Volunteer Leader Mother (who may be one of the Model Mothers) as the Leader of each Mother‟s Club, one of whose responsibilities would be to keep a Club register with all the names of the mothers who are currently part of the Club, with the names of each of their children under 5 recorded. These registers are currently kept by World Vision Haiti Health Practitioners, off site, for the reporting needs of the MYAP. However this misses the opportunity to institutionalize these Mother‟s Clubs within their rural settings, giving the Leader Mother‟s a special leadership status as they provide training support and advice and monitor her satellite group of 10-15 mothers and their children. This would permit future tracking of the actual number of children within the targeted households, from whom these mothers‟ come. 2. Consider adopting a different approach to structuring Mothers Clubs. The MTE team does not think it practical to suggest restructuring WVH Haiti‟s entire MYAP program, as it concerns Mothers Clubs, as this would be too disruptive for the remaining life of the MYAP. But as a long term objective, this should be considered. We would suggest adopting a different approach within the region currently having been operated by MARCH in the Lower Central Plateau however. Until now, the Mothers Clubs have never been differentiated into the smaller developmental stages clubs, but have organized the mothers into clubs which included mothers with children under 5 years of age. We would suggest 47 retaining this existing structure, but providing it with greater structure – identifying a Volunteer Leader Mother who would be the principal point of contact for the health practitioners. Health Practitioners would keep records of the different Mothers Clubs they provided training to, and the Leader Mothers of each Mothers Club would be trained to keep similar records. 2. Provide the means for all vulnerable targeted hillside households to obtain fruit trees to place upon their small household resident plots and give these trees to the women of the household for their care and management. Track carefully the numbers and species given out by household, and over time track survival rates. Eventually, if possible in subsequent years, take a sample of these households and track actual produce obtained and how it is actually used (consumed or sold). 3. Establish bio-intensive household vegetable gardens as the first, and most important, agricultural activity for MYAP targeted vulnerable hillside farmers. For share cropping farmers who may be particularly vulnerable, consider providing a small funding source for payment to some local person to transport the couple pails of water needed to irrigate small drip-irrigated household vegetable gardens. Track this cost carefully per farmer household, as well as actual produce that results and how it is used (consumed or sold). Subsequent growing seasons would be at the total cost of the household itself, and then track if households are now able to maintain these themselves. Household women should be targeted for this activity as well, though household men will certainly be involved in some of the land preparation. 4. Inter-MYAP Capacity Building: The three MYAPs should begin a program that recognizes the most creative and enterprising beneficiary households (not groups) for the different ventures undertaken – promoting cross-learning. This would also help sharpen the skills of the MYAP component trainers. 5. Fact Sheets for Major Project Activities: Field visits to activities in the field area frequently hampered by lack of objective information about project accomplishments for the different activities undertaken. The MTE team would recommend that WVH consider assigning, as one analytic task for local field agents, to create one page fact sheets about specific project themes. These should be updated each quarter. So as not to over-burden any one person, different activities should be given to different staff members. For example, chickens and goats are themes developed in the Upper Central Plateau. One of the local field agronomists or livestock personnel should be assigned the fact sheet for improved goats, another fact sheets for improved chickens. The sheet would summarize, year by year, by commune, when activities began, and key outputs (in eggs, chickens sold, goats distributed, successful breeding, value of fees obtained by buck owners, etc.) each year. The focus should be on the income generated for vulnerable households from these activities. When the final evaluation arrives for this MYAP, the evaluators should be handed this sheet for each region that summarizes actual impacts on beneficiary households. Each staff member given the task for a specific fact sheet would become the „regional authority‟ on this subject. Similar fact sheets should include data about specific rally posts, specific mobile clinics, and Mothers Clubs. A fact sheet could be created for the commercial development of chili peppers. Such records can improve the quality of MYAP reporting on outcomes and impacts – while most reporting now consists of reporting quarterly outputs. 48 6. AGRDEV: AGRIDEV will need to continue to: (1) help producers identify the agricultural produce (vegetables in particular) with the highest potentialities for marketing, with special attention to linking hillside small producer who are members of households participating in Mothers Clubs to have an outlet for aggregating their home garden products as well. Linkage would be with those farmers benefiting from small scale irrigation programs in the valleys and the products they are marketing with AGRIDEV assistance. (2) train producers on the techniques of marketing, storage, and product transformation so they can manage this themselves and (3) Move more quickly to link producers to agricultural service providers of inputs (seeds in particular). 7. Community Management of Acute Malnutrition (CMAM): It will be important for the MYAPs to document, perhaps through case studies, examples of increasing ownership of local communities in dealing with acute malnutrition within their localities. The emphasis for reinforcing MYAP activities in the Lower Central Plateau should be first to fill the gap of MCHN interventions that have not been realized to date. Addressing severe malnutrition among children 24-59 months could be addressed through the CMAM approach. WVH has already commissioned a report looking at this option, and good recommendations have been put forward. 49 2.0 World Vision Haiti Strategies and Outcomes Achieved to Date Based on the MTE team‟s review of MYAP documents, including the IPTT and our field visits, World Vision Haiti over the past two and half years has certainly accomplished much. Since the beginning of the MYAP in February, 2008 and through the end of the 1st Quarter of FY 2010, besides the more intangible aspects of training and new knowledge received by beneficiaries, the following are representative of outputs, some outcomes and impacts, to date. 2.1 Improved Nutritional and Health Status of Targeted Vulnerable Groups Since the beginning of the MYAP through to the end of the 2st Quarter of FY 2010, World Vision Haiti MYAP has certainly had an impact on the lives of many people from the MCHN health perspective. If we consider some of the achievements listed in the IPTT and in quarterly repots, we note that:  30,117 pregnant and lactating mothers have received food rations (currently at about 10,189/quarter)  55,389 children aged 6-23 months have received monthly food rations (18,299 last quarter)21  There have been 4,832 antenatal care (ANC) visits by skilled health personnel to beneficiaries  8,040 children less than 5 years of age have been reached by the MYAP nutrition programs  6,553 children less than 12 months have receive their full DPT3 vaccinations in a given year  24,256 children less than 5 years have received Vitamin A from the MYAP  1,742 cases of child diarrhea have been treated through the MYAP If we consider a series of numbers, not reported in the IPTT, about how the MYAP is reaching these program beneficiaries (cf. Annex 1), we note that:  WVH MYAP has nine medical doctors, 17 nurses, and 16 auxiliary nurses aids supporting 298 trained health promoters or their assistants (Col Vols) provide support to these rally points, conduct home visits, assisting in growth monitoring, and supporting 2,046 Mothers Clubs.  There are at least 15,000 mothers in these Mothers Clubs,22 with some 13,259 children under 5 years of age;  WVH MYAP supports 29 health centers/dispensaries, 121 mobile clinics, and more than 647 rally posts in the communes of intervention.  To date, approximately 33,000 children under 5 years of age are being assisted each quarter through these rally points with growth monitoring;  About 571 traditional mid-wives (matrons) have received some training to improve their skills in helping mothers through their home-based deliveries. It is matrones who are the ones who are called to rural homes in the event of childbirth – few women actually go to formal health clinics for their deliveries.  WVH MYAP supports distribution of food supplements through 134 distribution points. 21 There is some double counting taking place here, as one child may receive food rations for longer than 3 months, and # s are counted each quarter. This is true for some of the other indicators which follow. It is the ‘# of children doses of Vitamin Agiven out that is counted, not actual # of different children which would be virtually impossible to track. 22 WVH MYAP FY 2009 Annual report, November 2009, p 12. The number of children that follows this figures is low because the project has not consistently counted the children under 5 in these mothers clubs, something that we recommend that all MYAPs do in the future, including also the older household children.. 50 Reducing malnutrition: The objective of reducing malnutrition is not yet achieved in certain areas. Various reasons have been mentioned by the health staff: seasonal effects, migration of mothers leaving children with non trained people, influx of children from other areas (after the earthquake). Many other factors could explain this: absence of the mother and temporary care of the child by untrained individuals, recruitment of new malnourished children, child or mother ill, no recovery (even when malnourished children 24 - 59 months are supported with supplementary feeding during 9 months). Moreover, we must point out many cases of poorly nourished children in Lower Central Plateau where the health component is not yet implemented. This delay in the implementation of activities will affect the achievement of the objectives of the project as a whole. Whatever the valid reason explaining the stagnation of malnutrition rates, closer attention should be given to these children, not only at rally posts or health centers, but mainly at the household levels. Each malnutrition case should be investigated and followed-up to better assess their vulnerability and the persistence of malnutrition in communities. Such tracking should be reinforced through greater attention to Mothers Clubs and their mothers with the help of the local community health agents. Coverage of health services: It is important that children be protected against contagious diseases and monitored closely to prevent malnutrition. The MCHN component should be present in all areas, even if the reinforcement of agriculture is not the priority for this area. However MCHN was barely begun the Lower Central Plateau and Artibonite, and has not yet been able to target all children but only a small group. As an example of the financial problems that exist, La Chapelle has reduced the number of rally posts from 40 to 20 stations. Previously 13 health workers were employed. Currently they are only four (4). Why adequate financial resources were not available to the sub-contractor through the MYAP could not be adequately explored. We had neither the time in the field to pursue this more fully or to meet with their program personnel back in PAP. We understand from WVH that though MYAP resources were available for the agreed upon budget line items, these institutions themselves (HAS and SAVE) did not have the complementary resources they thought they might have to fulfill their responsibilities. Had they been able to obtain additional resources from the MYAP, they may have been able to better meet their obligations.23 Integration of health services and agricultural activities: World Vision Haiti is making an effort to include mothers of malnourished children into agricultural activities. This has been observed in areas where there is the agricultural component of the MYAP. With the support of the MYAP, they can better manage their vegetable gardens (seed‟s donations, improved irrigation techniques). However this is a selective process; not all mothers of children under 5 years or in mother‟s clubs benefit from the agricultural component of the project, unless their children are severely malnourished. And despite of their eligibility, some mothers are not involved in agricultural activities for the following reasons: dropping out due to new pregnancy or disease; WVH training quota number already reached. We observed that WVH health promotion activities, as for example with exclusive breastfeeding, helped mothers save money for investing in businesses. 23 In the end, if WVH takes over most, if not all of what has been left unaccomplished with its own ‘additional’ MYAP resources, then it might have been prudent to have provided these earlier to HAS and SAVE so that the ultimate beneficiaries would not have suffered the consequences of unrealized objectives. The MTE team encountered a number of examples of institutional rivalry, competition for funding, resistance to sharing data, between NGOs that were not flattering to the concerned groups. 51 2.2 Improved Quality of and Access to Health Services for Vulnerable Groups For health and improved nutrition, the WVH MYAP intervenes directly in La Gônave and in the Central Plateau. In the Lower Central Plateau, WVH implements the health component through 3 partners (MARCH, HAS, and SAVE). HAS was given responsibility for program implementation of MCHN activities in the Lower Artibonite, and more specifically within the Communes of Verrettes and Petite-Rivieres de l‟Artibonite where they were associated with an earlier FFP DAP with SAVE. Specifically targeted groups included pregnant women, lactating mothers, and children less than 5 years of age. Key means of accomplishing these tasks have been through growth monitoring out of their 6 dispensaries, rally posts, conducting „Ti-Foyers‟, monitoring of Mothers Clubs, health and nutritional training, mobile clinics, and supplemental food distribution. Staff employed by HAS received parts of their salaries through the MYAP, and part through their own means. In FY 2009 some 140,738 children under 5 were so monitored. At an average of 12,794 children each month, results showed about 14% with some level of weight for age malnourishment (PFA + PTFA).24 HAS personnel also serviced about 3,075 rally posts meetings or about 254 per month. Rally posts managed by WVH are expected to be visited once each month by a health agent, but this does not seem to be the case with HAS, as the number of rally posts held each month is reported with different numbers each month, from a low of 111 in March 2010 to a high of 292 the previous October. During the past fiscal year, HAS also been experiencing difficulties in meeting its own financial obligations, and has had to substantially reduce the coverage of its efforts. For example, only 4 of their 6 dispensaries are currently active; a year ago they covered 42 rally points, now they are only able to support 20 of these. They went from 13 to 4 health agents. Mobile clinics are difficult to cover as hoped for. The presentation of their MCHN data to WVH also did not match how WVH was reporting their own MCHN data, so comparisons across the MYAP became difficult.25 Mobile clinics were one method used HAS to bring skilled medical services closer to where people lived, and during the first quarter of FY 2010, 214 such clinics were held, while only 70 clinics were held during the 2nd quarter of FY 2010. HAS recognizes itself that, because of its own lack of field personnel and resources, it has not been able to provide the services anticipated or in increasing the number of Mothers Clubs for preventive health training.26 The HAS approach to Mothers Clubs does not follow the WVH model used in the Central Plateau (it is closer to what the MTE team proposes as a better approach); discussions with WVH about this has led to conclusion that they will „start over‟ their approach to forming Mothers Clubs, beginning with „newly pregnant‟ women to form into Mothers Clubs – which would more closely resemble the WVH cohort approach elsewhere. The MTE team would not consider this as an improvement, but that existing Mothers Clubs need to be reinforced or increased in numbers, provided better leadership and materials – and linking these to livelihood activities. The Mothers Clubs met by the MTE team in 24 This average monthly number appears high, and probably reflects the same child weighed twice (perhaps once at rally post, and then at the health clinic) with numbers from the two locations aggregated. This is one reason why it is important to analyze rally post monthly data without aggregations to understand possible general levels of change in malnutrition rates. 25 WVH only reports to USAID/FFP information from HAS, SAVE, and MARCH on nutrition information; data from other health activities (such as immunization, vitamin A distribution, de-worming) from partners are not reported, as they are already are reporting these data by other USAID funded programs like MSH, to avoid double counting. But WVH monitors all the partner activities to ensure that these data are available and being provided as reported to MCHN beneficiaries. 26 HAS FY 2010 1st and 2nd quarterly reports, written by Roland Noel, HAS MYAP program coordinator, both allude to their need for additional WVH support if objectives are to be reached. 52 Deschappelle were far too large (45 women in one group, 40 in another, 39 in yet another), and their size is more related to responding to creating groups for commercial purposes (commerce of bananas, for example). Some have, on their own, started savings schemes different from the savings and loan groups activities that have shown such promise in CRS areas. Save the Children was given responsibility for MCHN implementation activities in the Lower Artibonite communes of Maissade and Marchand Dessalines. The MTE team met with Dr. Micheline Bien Aimé, Save‟s MYAP coordinator based in Marchand Dessalines. Save‟s MYAP main implementing partner in Dessalines is the Hospital Claire Heureuse. Their programs also focused on pregnant and lactating women, children under two and malnourished children under five. World Vision provided the food rations at designated distribution points. Services included growth monitoring, preventive health service through a Behavioral Change communication campaign, and food rations for vulnerable children. Growth monitoring of children less than 5 years in the 2nd quarter of FY 2010 reached 33,147 children, and showed average malnutrition rates of 21% for Maissade and 12% for Dessalines. Of the 1,602 registered as malnourished, only 833 were able to be given supplemental food rations last quarter because of the cut backs in program staffing. Most certainly there was greater variability at specific localities with dispensaries or benefiting from mobile clinics. Data were not disaggregated in this manner. Behavioral Communication Change (BCC) campaigns by Save through some 128 rally posts, home visits, Mothers Clubs, and food distribution sites communicated about improved nutrition, hand washing, hygiene and sanitation, family planning, immunizations and prevention against diarrhea and HIV/AIDS transmission. More than 26,000 mostly mothers benefited from such training. By the end of this last quarter, 841 rally posts and 36 mobile clinics had been set up within the two communes. Save programs were severely impacted by the January 12 earthquake, and though Save managed to maintain program activities in these two communes, most of their national efforts were diverted to emergency responses. Maissade and Dessalines, though not directly affected by the damage from the earthquake, were certainly strained with an influx of IDPs (7,738 reported in Dessalines alone). By early May, during the MTE teams visit, many of these people reportedly had returned to PAP and other urban centers. Though our time with Save was quite limited, the MTE team left with the impression of an organization barely functioning in the field, one that was not sure what its numbers actually were (MYAP coordinator spoke of 128 functioning rally posts, while FY 2010 2nd Quarterly report speaks of 841 rally posts. We could not determine which numbers were correct, and doubt that WVH knows either (cf. Annex 1). Save is also experiencing „competition‟ from another NGO (Partners in Health) in their areas of intervention. PIH has begun to work with some of the same beneficiaries as Save, and distributing food assistance closer to where people live – while Save requires people to travel to health clinics for this provisioning. There is a considerable variation in access to health care services between WVH regions, particularly with regard to reproductive health practices. For example, in some areas, mothers have many children (more than 5), and are only just beginning to practice exclusive breastfeeding. But at Cerca La Source, the average children per mother is around 2, with larger birth spacing than other areas; here mothers have a better and long term practice of family planning which they appreciate very well. Most behavior changes are reached through Mothers Club meetings. Because these meetings have as a principal objective to train mothers, they are more effective than the training sessions at rally posts where 53 multiple activities are set together (immunization, distribution of vitamin A, weighing of children, etc.). The training sessions at the rally posts are also much shorter – about 15 minutes. Access to health services: It is important that children be protected against contagious diseases and monitored closely to prevent malnutrition. The WVH MCHN component activities should be present in all areas, even if the reinforcement of agriculture is not the priority for this area. However, the program is barely starting in the Lower Central Plateau and Artibonite, with targeting of only a small group of those in need. Financial difficulties at La Chapelle led to a reduction in the number of rally posts from 40 to 20 stations. Previously 13 health workers were employed. Currently they are only four. In other areas where the health component has been implemented, there is an increase of access to health services.  Rally points and the private mobile clinics allow the vaccination of children less than five years old near their residence – greatly appreciated by the local populations.  There has been in increase in the number of prenatal and post natal visits among pregnant mothers. Antenatal visits are now possible every month, within a 1 hour walking distance from a health centers or mobile clinic. This has been possible with the support of the project; however child birth is more often done at the household level by trained matrons who sometimes still lack the needed equipment and materials to assist in this process. This situation was also observed at health centers (example of the dispensary Colombier).  The project targets younger children who more frequently attend MCHN clinics and rally posts than older children. In this way, attendance at clinics and rally posts is increased. Children now can get full immunization coverage before they reach their first anniversary. So they are better protected against communicable disease and have a better start in life.  WVH activities have also led to improved growth monitoring as this is an activity which clinic staff are trained to carry out. This contributes to lower malnutrition rates in communities. It also addresses the main nutritional problems among the 12-23 month age children where levels of malnutrition are highest.  WVH activities have multiplied exposure of mothers to education messages: at rally posts, at mother‟s clubs, at mobile clinics. The mothers consider the education very helpful as they observe the difference in the growth and health of their youngest children compared to their older ones. So they encourage other women to come to the activities.  WVH has succeeded in improving the logistic support to the cold chain for vaccination. Fuel and refrigerators are provided by MoH, with transportation assured by the MYAP. In the event of rupture in fuel stocks, the fuel is bought by the MYAP. The health worker or the auxiliary of the PDZ enrolled by the MYAP take seriously their duties in monitoring the temperature of these vaccines. The MYAP also facilitates transportation for drugs and supplies at the local health centers, including family planning methods and materials. 54  World Vision Haiti has supported the rehabilitation of health centers within their communes of intervention. On La Gônave, for example, seven (7) clinics have been rehabilitated with the support from the MYAP. Knowledge and practices regarding nutrition and hygiene. The World Vision Haiti MYAP has done an excellent job through its MCHN training programs. At the time of the MTE evaluation, within the groups we met, mothers were observed to have good knowledge about exclusive breastfeeding, and complementary feeding, especially within the Upper Central Plateau and some areas of Lower Plateau where there is a health component. Management of infant feeding by the mothers has clearly improved. Mothers add their own milk to prepared meals when they cannot get other milk, they do give at least 3 principal meals to the child, and some supplements at other times of the day. However, in certain areas (La Gônave, for example), some practices need to be reinforced. Mothers should not wait until the evening to give the principal meal to the child with the risk that he falls asleep, or wait until 10th months of age to introduce semisolid foods. The diversification of meals could be improved if mothers use available products in the region. Apart from mango or banana, certain fruits and vegetables (coconut or spinach) were not mentioned in the child‟s diet even when available in the gardens. Use of dry rations: As mothers said, their child enjoys the flour pure, mixed with salt water, or enriched with milk and sugar when they have the means, sometimes enriched with eggs, figs (most often), sugar. While wheat is especially appreciated by adults, they nevertheless will not eat flour reserved for the child. When wheat is used for the child, the preparation is thicker. Oil is used in various household meals. Lentils are also consumed by various members of the household. Frequency of meals: Sometimes, the child spends days without supplemental food, but not more than one or two times a week, according to mothers. The ration lasts almost a month but must be complemented by something else; otherwise the ration would not be sufficient to feed the children. The ration is shared among members of large households (even reaching ten to twenty persons), sometimes even with the neighbors. Hygiene practice: The distance from water points varies. Most women find a water source near their households. Others must walk for some distance. Mothers report using soap and water to wash their hands before meals, and after toilet use. Processed water is used for drinking purpose; chlorine is provided by World Vision Haiti. Such practices are promoted both in Mothers Clubs and at school. Among other practices, mothers mentioned the use of bed nets against mosquitoes. They cover dishes and utensils filled with drinkable water. They scatter wood ashes in latrines and ensure that toilets are well covered. However, some have no toilet or latrine, these being too costly. 55 2.3 Increased Food Production and Household Assets Agriculture/Livelihoods Component: Our interviews with program beneficiaries revealed that households associated with the agricultural activities of the program are certainly better off , and are more food secure. Farmers were ready to both state this and show evidence of this as we visited them, and walked their fields and gardens on La Gônave, the Upper Central Plateau, and in the Lower Central Plateau.  39 groups of farmer producers trained  9,905 households profited from various agricultural activities  60 metric tons of improved variety maize seed produced and distributed  364 hectares of land being used by seed producers for improved maize production  1,384 chickens (mostly laying hens) distributed to woman – many in Mothers Clubs  705 improved race of female goats distributed  250 improved race of goats distributed – and being used as breeding bucks within local communities  259 pigs distributed  955 household level vegetable gardens established – about 220 of whom were mothers in Mothers Clubs  45% of the targeted households in La Gônave received drip micro-irrigation kits to help with vegetable gardening  760,250 fruit-bearing seedlings distributed to 8,044 households; over 100,000 additional seedlings have been produced and await distribution  1.13 million tree seedlings were produced and some 718,000 distributed  36.8 hectares protected with soil conservations measures  16.4 kilometers of terraces created in gullies to slow speed of descending water and capture silt According to World Vision Haiti beneficiary households, with the interventions of the MYAP, many more households have products for consumption and sale throughout the year. This increase is especially due to the distribution of improved varieties of maize seeds and to the intensification of the market vegetable gardens (home gardens). 2.3.1 Improved Food Security? Generally speaking, on the level of the household food security, results suggest that the period going from April to July each year has traditionally been the most difficult in term of food availability for all project areas. According to the testimony of program beneficiaries, they may be obliged to sell their cattle or goats, or produce charcoal, or borrow money to purchase needed food at these times. MYAP beneficiaries admit to being able, during the past two years of the MYAP, to have been able to set aside more assets for these difficult periods. They have applied with increase rigor the new technologies or management practices taught by World Vision Haiti advisors in various topics: selection of seed, conservation of soil, diversification of production, planting of fruit trees and multi-purpose forest trees, etc. They manage to store food better, and consequently have been able to substantially decrease the period of food shortage. Getting any farmer to admit to food security, however, is almost impossible. Results from the mid-term quantitative survey among MYAP beneficiaries below show that household food security levels are lower 56 than that recorded for the earlier baseline. The table below shows the Months of Adequate Food Provisioning (MAFP). To ask the question, the enumerator must ask the household concerning the months of the year without enough food. The data below show the percentage of all household respondents who believed that, during a specific month, they did not have enough food to meet the family needs. For example, during the month of February, 2010, 71.9% of WVH MYAP beneficiaries‟ stated that they did not have enough food. MAFP annualizes this information by averaging the months for which more than 50% of households surveyed expressed a lack of food, and then subtracting from 12, giving for WVH a MAFP of 4.2 for the year (only 4 months of the year with enough food). The MYAP baseline in early 2008 gave a value of 5.6 months of enough food for 2007. As discussed elsewhere, the MTE team does not believe that these numbers reflect the farmers reality and that farmers are much more food secure than these numbers suggest. May 2010 Mid-Term Quantitative Survey PARTNERS AREA WV Beneficiaries (N=276) CRS Beneficiaries (N=238) ACDI VOCA Beneficiaries (N=227) 8.3 - In the past 12 months, were there months in which you did not have enough FOOD to meet your family's needs? (% yes) 257 (97.3%) 231 (97.1%) 226 (100%) Months of Adequate Household Food Provisioning 4.2 4.8 5.8 April 2010 200(73.3%) 180(76.3%) 190(83.7%) March 2010 183(66.8%) 169(71.6%) 162(71.4%) February 2010 195(71.2%) 124(52.5%) 141(62.1%) January 2010 197(71.9%) 80(33.9%) 117(51.5%) December 2009 130(47.4%) 85(36%) 41(18.1%) November 2009 159(58%) 121(51.5%) 109(48%) October 2009 167(60.9%) 172(72.9%) 131(57.7%) September 2009 178(65%) 169(71.9%) 121(53.3%) August 2009 179(65.3%) 145(61.4%) 95(41.9%) July 2009 165(60.2%) 139(58.9%) 46(20.3%) June 2009 177(64.6%) 145(61.7%) 77(34.1%) May 2009 193(70.7%) 150(63.6%) 166(73.1%) 2.3.2 Appropriateness of Early Warning System The EWS system has been operational within World Vision regions for more than a year now, and multiple bulletins have been produced. Regular monitoring of market prices and rainfall at selected locations has taken place, as well as quarterly meetings with regional partners discussing the implications of these data. World Vision staff participated with other organizations in the period following the January 12 earthquake to monitor the food situation as well as a rapid assessment in PAP and MYAP regions to help inform decision makers preparing for an emergency response. Until now, the WVH MYAP bulletin data has not been incorporated into the GoH national EWS sytem, as has those of both CRs and ACDI/VOCA (www.cnsahaiti.org). Nor was the MTE team able to learn whether or not the specific data being collected within the EWS is actually contributing to action steps. However, an obvious value of the EWS is that it has brought various GoH and NGO groups together to share food security information about their respective regions, and what is being planned, if responses are 57 believed necessary. Such communication helps to reduce overlap between different programs working within the same region and the sometimes competing interventions of the NGO groups concerned. 2.4 Enhanced Market-Based Livelihoods The livelihood market-based program is being implemented by AGRIDEV. We have noted a large diffusion of best production packages and high value commercial crops integrating a set of activities that include seed selection and testing, establishment of demonstration plots, holding farmer field days (around the demonstration plots) and farmer to farmer extension visits to learn from each other. Also, WVH staff contacted several potential international markets to help farmers market their agricultural products. Regional buyers contacted included hotels, restaurants and super markets both at the regional and more distant Port-au-Prince. Similarly, AGRIDEV has contacted and made arrangements for a trial shipment of 405 lbs of hot chili pepper to the USA. This test demonstrated the export potential of these chili peppers, and has been an encouragement to farmers. The MTE team would encourage the seeking of new markets for commodities of value within these regions. Quality and volume are always issues, and involve risk to farmers, so this needs to be explored in a very professional and realistic manner. When such markets are indentified, it is important that the farmer groups be associated from the very outset in meeting and interacting with purchasers – even though it is tempting for WVH to fill this role. To do so will jeopardize sustainability of this effort. It is much better to play a background supporting role in this process – from the very beginning. This is also important for continuity of the improved seed materials which will need to be renewed every couple years (e.g. maize). Our advice to the MYAP on these initiatives is to focus in on a couple that appear particularly promising (like hot chili) and to then do everything possible to work through all the value chain links that are associated with these activities. Household vegetable gardens have proven to be an important initiative linking household nutrition and income security that needs more broad-based attention – (e.g. thousands, not scores, of micro-irrigation systems need to be established over the remaining years of the MYAP if real impact is to be achieved). This may mean development of local entrepreneurs to put together these drip-irrigation kits, and to be able to demonstrate and sell them within their communities (like the silo producers). 2.5 Rehabilitated Natural Resources and Local Capacity for Their Sustainability Soil conservation work is carried out through Food for Work. Work consisted primarily of the protection of gullies and slopes above certain strategic zones (spring collection areas, irrigated perimeters). The techniques of soil conservation used within the framework of the MYAP were shown to the MTE team while visiting the actual parcels of the farmers concerned. According to such beneficiaries, the soil conservation work accomplished has enabled them to cultivate plots of land which had not been in cultivation for several years. In the Lower Central Plateau, the MYAP used the traditional group labor force (combite) to undertake the soil conservation work being done on the slopes that day. MYAP technicians were present to guide the work and to lay out the contours structures to be constructed. This work was done without Food for Asset 58 assistance as the farmers understood the importance of protecting their own hillside plots from further erosion. The MTE team believes one of the more promising initiatives underway has been the association of high value (grafted) fruit trees with hillside reforestation. As these trees begin to produce marketable quality produce, these slopes will be better protected. The MYAP might consider reducing the numbers of other multi-purpose trees which must be „given away for free‟ and encourage these higher value trees that may potentially be able to be sold as seedlings. The MYAP needs to make a serious attempt to development private entrepreneurship opportunities here as well, though this will need some creative imagination and experimentation. Perhaps contracts can be created with recipients of „free fruit tree seedlings‟ to give a certain number of fruit to their ADP for several years, as a condition of this initial „gift‟, or pre￾permission for graft cuttings. Greater initiatives might be considered in expanding these efforts towards a wider range of fruit, based on the local genetic stock available. For example, besides mango grafting, one might consider guava. Doing so will need to include focused support for the entire value chains that any specific fruit tree species will require to be successful. 2.6 Challenges Faced and Overcome in Program Implementation Among the greatest challenges faced by the WVH MYAP were the three consecutive hurricanes of 2008 and the disastrous January 127.0 magnitude earthquake which forced program personnel to shift priorities towards rapid, short-term emergency measures, including rapid assessments, while also trying to maintain on-going, longer term development program activities in the Departments. Emergency response and relief efforts are one of WVH‟s greatest strengths, so responses were both based on past experience and timely. Haitian communities were fortunate for this organizational strength, particularly because of the fact that the GoH, in many cases, had itself suffered serious damage and was in no position to help either. The MYAP has also been active in seeking new and more effective ways for both field implementation and in managing the mass of data being acquired and transmitted from field agents. Several examples can be given here. The M&E program has been active in developing an on-line, real-time - MIS that will permit data entry in the field to be immediately available to program managers – showing with different alert colors whether targets are being achieved or behind in planned outputs. Other Haiti MYAPs may wish to evaluate this for adapting this to their own programs. The MYAP has also been, from the beginning, active in seeking new ways to use PDA technology with field agents to speed up the acquisition and transmission of data. The MTE team‟s quantitative survey was initially planned to use some of WVH‟s expertise for PDA programming and data input, but time did not permit sufficient training of the enumerators to use this. However one might reasonably expect this tool to be more frequently used in future years by all the Haiti MYAPs. The development of mobile clinics to extend the outreach of established dispensaries and health clinic services into more remote areas of the section communales in which the program is working has also been an effective response to community expressed need. This is also true of WVH‟s efforts to bring food supplements for needy rural populations targeted by the MCHN to food distribution points closer to where people live. This again has been a direct response to community expressed need, permitting mothers with malnourished children easier access to food without walking often long distances to an urban clinic or dispensary. 59 2.7 Highly Successful Strategies Transferring Production Technologies: MYAP agronomists have been effective in communicating, through model farmers and demonstration trials, the importance of improved cultivars and cultivation techniques. High adoption rates were evident among those interviewed by the MTE team. This has led to greater farm productivity among beneficiaries. Renovation of a number of small irrigation perimeters has also provided access to hundreds of vulnerable households to land (even if share-cropped or rented) that is permitting them increased food security and added income from the sale of some of this produce. Household Production Diversification: Household income and food security diversification initiatives of the WVH MYAP integrate activities that include bio-intensive vegetable gardening, fruit tree planting, and small animal restocking – particularly chickens and goats. All of these initiatives have been very effective among MYAP beneficiaries and now need to be exponentially expanded if real impact is to be achieved. For example, all mothers in Mothers Clubs should be targeted as potential recipients of these efforts as a way to diversify diet and to help fill food gaps of the household in times of need. Rather than launching new activities, these successful strategies need to multiply. Doing so means budgeting the resources to do so, and remaining flexible to unexpected developments along the way. As a commodity value chain develops and expands, new challenges will be encountered along the way that needs immediate attention if the entire initiative is not to be compromised. WVY Haiti has learned some of the lessons linked to attention to value chains through the recent trial shipment of chili peppers to the USA. Quality and volume issues need to be foreseen from the onset so as not to slow the pace of expansion. The communication of appropriate MCHN information to mothers of children of different ages through the CMAM interventions and PM2A approaches have been extremely successful and valuable training and visual materials have been created in this process. Communities are increasingly becoming engaged in understanding and engaging with the MYAP to address issues of malnutrition. The targeting of specific mothers through the PM2A approach is excellent, though all mothers within targeted communities with children under 5 years of age should also be the initial target for the creation of Mothers Clubs. WVH now needs to reconsider whether the structure of their program to provide such information (e.g. via their current definition for Mothers Clubs) is as effective as it might be (see below). 2.8 Unsuccessful Strategies and Proposed Changes Collective Groups: Though WVH probably believes their work with community groups to be one of their successful strategies, the MTE team believes otherwise. With this approach, farmers learn the techniques (the argument goes) and then they can do it on their own land, if they want to. The problem is that most farmers, if given the choice, would prefer a more entrepreneurial approach. It would be more interesting to create dynamism around local model farmers – with a small group of satellite neighbor farmers - so that the model farmer can be transformed into small business ventures within their areas of expertise. Others can emulate them if they desire to do so, perhaps purchasing seed from these individuals, for example. Mothers Clubs: Much has been said in this report about WVH‟s approach to Mothers Clubs. The MTE team has suggested that while the message is well communicated, the structure need not limit mothers within Mothers Clubs to the developmental stages of specific young children. This greatly limits the 60 opportunities to create thousands of vibrant self-help and mutually supporting mothers groups that will endure long after the life of the MYAP. WVH‟s current approach to Mothers Clubs limits their role as a potential socio-economic vehicle within these rural communities as well. Though, in principal, one could maintain the existing structure of Mothers Clubs, and then encourage other self-forming mothers groups for livelihood/agriculture type activities, including self-help Mutual Solidarity (savings and loan) Groups, it would be much more efficient to do so in the same groups. As currently formed and structured, current WVH Mothers Clubs do not lend themselves easily to this larger function. World Vision has already well tested, best practice examples for Mothers Clubs in other parts of the world, of which we are best aware of Rwanda. The MTE has made specific recommendations about how these Mothers Clubs should be structured to achieve the greatest impact for this MYAP. 2.9 Conclusions, Best Practices, and Lessons Learned  The MYAP has realized important achievements in the fields of reinforcement of the infrastructures of production, environmental protection and the breeding of goats.  Reinforcement of local capacities is an important asset which has allowed behavioral changes among farmers. This has resulted, for example, in permanent transfer knowledge through the establishment of a group of model farmers within communities. This is likely to guarantee the durability of different interventions in agriculture.  The MYAP has focused at the level of production with the commodities they have targeted in the value chain. It is not clear yet that the sufficient attention to the entire value chain is being given to result in sustainability of program interventions.  Vegetable gardens make it possible for households not only to provide an additional nutritional contribution to the children but also in certain cases, they increase the incomes of households.  Work to protect and restore the hillsides plots that farmers use to cultivate their crops, and the better management/conservation of water has had a visible impact. Formally abandoned land has been brought back into production as a result.  From the MTE team‟s perspective, it looked like HAS was facing challenges keeping its central program operating and meeting needs – that of their hospital and 6 dispensaries. Recruiting, training, and managing a community based and orientated health and nutrition program through rally posts and Mothers Clubs appears to simply be beyond their current capacity.  It is very clear that World Vision Haiti needs to reconsider their approach to Mothers Clubs in general – if they wish to leave behind them groups of mothers who will remain associated into the future for both the well-being of their children as well as for livelihood activities. MTE recommendations with respect to Mothers Clubs may not be practical at this mid-point of the MYAP – though we do believe a change should be considered. 61  Save the Children, like HAS, should in principal be able to fully engage in their MYAP MCHN activities if they have the financial means to do so. Yet Save does not appear to be doing so, and why this was the case we were not able to determine in the time we were able to spend with them. Save activities, working with MYAPs elsewhere in Haiti (e.g. A/V region) are doing excellent work in serving the needs of those identified as severely malnourished. At the same time, it was also apparent that the way SAVE was approaching their MCHN responsibilities differed from that of WVH on the Upper Plateau and La Gônave.  At a regional coordination level, the perceived intrusion of Partners in Health into WVH/Save‟s communes of intervention has the potential to cause problems for both programs. Because different approaches are taken to reaching out to targeted beneficiaries, a decision must be made about who will do the task, and avoid such overlapping and undercutting of other organization efforts. 2.10 Recommendations  Define a better targeting approach to MYAP beneficiaries through the participatory approach, including the boards of directors of the ADPs, the communities concerned and the Health sector agents.  Facilitate the continuation of the vegetable gardens year-round – including periods of dryness or water scarcity; this means better addressing of water harvesting techniques, which may include water tank installation, run-off water impluviums, rain gutters on homes, etc. Better use of this valuable scarce resource would be achieved by much greater attention to small scale drip irrigation systems for home gardens of Mothers in Mothers Clubs.  Identify with the MYAP beneficiaries, the tree seedlings (fruit and multipurpose trees) which interest farmers the most. Fruit and multipurpose trees must have a real economic interest for them, if they are to give adequate care to such seedlings, and to get to the point where they may be willing to invest some money in acquiring them.  Continue to create dynamism around the model farmers, intentionally linking them to select small groups of neighboring farmers to respect and follow their example and advice on technical farming matters.  Continue to encourage farmer access to high quality improved seed materials, linked directly to the above „model farmers‟ within each community. Do not be over dependent on „farmers groups‟ to maintain this link for seeds within communities. This will improve the food security of MYAP beneficiary household (better quality seeds, available at the right time of the year, access to water, and agricultural credit – perhaps through small group savings and loan programs within Mothers Clubs).  Include focusing on the entire value chain of any commodity of particular interest (strategic advantage) addressed by the MYAP. This will mean reducing the number of activity areas being 62 addressed by the program so as to have sufficient resources to do this job properly. It would be better not to even begin addressing an agricultural commodity area if this approach is not to be used exclusively.  Promote individual ownership and management of breeding stock (goats or chickens) over an approach of working through groups of farmers to achieve this purpose. The latter approach is sure to fail in the long run, while the former approach permits expression of entrepreneurship and individual creativity.  Using the HAS hospital and clinics of these regions as a base, World Vision itself probably needs to either take over the management, training, and implementation of these field activities, or provide HAS (and probably Save as well) with sufficient additional MYAP resources to do so themselves. HAS clearly was not able to meet their own intended financial commitments as a sub-contractor within the MYAP. Because of this internal HAS financial shortfall, MYAP specific resources have been under spent. HAS personnel appear committed and able to perform the needed tasks, but without funds cannot do so. Should the latter, preferred approach be taken, then WVH will need to be more proactive in standardizing MCHN and livelihoods activities as suggested in this report. The situation with MARCH is quite different, and the MTE team believes that this is a more clear case that WVH should take over the full management, training, and implementation of the health programs in this area, if these are to continue through until the end of the MYAP.  Consider modifying WVH approaches to Mothers Clubs by testing changes proposed by MTE team within the Lower Central Plateau and Artibonite where WVH will need to take greater implementation leadership.  Save the Children activities either need to be reinforced (additional human and financial resources) so that they may be able to more fully meet their targets within their two communes, or WVI will need to step in and increase its own efforts within this region as well. Whatever is done, care must be given to building upon what has been accomplished and to focus future activities carefully. We would suggest that this focus should include Mothers Clubs as recommended by the MTE team, with reinforcement of the existing rally points and mobile clinics. 3 External and Internal Factors 3.1. Impact of Internal Factors on Program Activities Some constraints have been identified:  Logistics: Irregular or insufficient provision of food to CSFP feeding points, especially in Artibonite where the program is co managed by partners (SC and HAS).  Geographic distance: There are constraints to implement the program in remote areas. The rally points are very remote and useful for an outreach approach. Some rally posts are 6 hours away from the health centers; expecting a health agent to walk to these distant rally posts from the health center to bring the vaccines is asking a great deal (4 hours sometimes 6 - 8 hours). Getting 63 there can be further complicated when motorcycles or horses are not available, or when administrative procedures are not rapidly dealt with to reimburse personnel for transportation fees they are incurring.  Weakness of partnership: Implementation of the MYAP through partners has proven challenging; the coordination of activities and the reception of reports within time limits has proven especially problematic. The approach of subcontracting partners for the implementation of activities leads to logistics problems such transportation (as seen at Marchand Dessalines). It can also effect the supervision of the project by World Vision Haiti. Each partner – World Vision Haiti, March, Save, HAS, DAI, AGRIDEV - has its own approach and structure. USAID/Haiti has strongly encouraged MYAP CS to use local partners – but doing so has also reduced the effectiveness of efforts in some of these areas as a result. In the Lower Central Plateau, the withdrawal of World Vision Haiti‟s main partner in health (MARCH) from the region has led to a break in the provision of health services. Actually, MARCH did not have sufficient resources to run the project and provide data. In the Rompa section of Lascahobas, many children are malnourished (PFA and PTFA, as seen on their growth monitoring card) but receive insufficient care. There is an urgent need to implement the health component. It is suggested that the health component be directly implemented by WVH. In this area, despite the potentialities for agriculture, many factors can affect the health of children (communicable diseases, worms, etc.). Both Save and HAS also have similar problems related to their own financial constraints, so they have not been able to effectively use the MYAP resources set aside for MCHN support of their programs. 3.2 External Factors Influencing Outcomes and Program Responses The January 12, 2010 earthquake: MYAP activities were directly impacted from mid-January through the end of March as 100% of WVH resources were refocused to emergency responses. The development of a fully functioning, independent relief office then removed this burden, permitting MYAP programs to continue. During this time, some 2,004 metric tons of food relief were distributed out of MYAP stocks. Quick response from USAID has permitted the replenishment of these stocks for MYAP purposes. Within MYAP regions, some families not directly impacted by the earthquake became more vulnerable, following the increase of household size as extended family members (survivors) fled Port-au-Prince for rural areas. After several weeks in the countryside, more than 50% of these people are reported to have returned to PAP, where relief assistance was getting underway. However, this unexpected influx of people upon rural households used up already limited food resources of these households, and has caused increased deforestation in some areas as a need for local fuel to cook food surged. The MTE team frequently observed the presence of orphans who had arrived after the earthquake, left in rural areas as adults returned to the cities. Many of these children cannot go to school because of the lack of economic resources. Families who accepted these orphan and vulnerable children have not yet received any support nor ration increase. The Lower Central Plateau also directly felt the effects of the earthquake: cracked houses, animals killed from rock falls. 64 3.3 Negative Impacts or Unintended Consequences One unintended consequence the MTE team encountered during our field visits was the frequently mentioned unease of program personnel about the impact of some SYAP activities upon their MYAP program activities. There was a fear that, however well intentioned, insertion of some SYAP activities (food for assets or work) could make it harder to promote individual or community initiatives in soil conservation measures. The continuing emphasis on giving MYAP services and commodities away „for free‟ has reinforced a dependency mind-set among most rural Haitians – to the point that personal initiatives, while not discouraged, are made more difficult. Breaking this mindset will be difficult and the MYAP will need to be look for creative ways to begin to push back against this unhealthy expectation. WVY Haiti‟s approach to Mothers Clubs has been very effective in communicating targeted messages to specific small groups of mothers with children at defined developmental stages. An unintended consequence of the approach however has been that these every changing groups do not lead to enduring groups of mothers for other socio-economic activities, or continue to associate for child caring. 4.0 Sustainability of Interventions Sustainability implies continuous training and a group or entrepreneurs‟ ability to acquire, in the absence of the donor, the needed inputs. Seed producers who are unable to acquire foundation seed to grow commercial seed for regional sales will not long be in business. WVH created Mothers Clubs are not currently sustainable, for example. Homogeneous groups of Mothers Clubs have been created as a communication channel by the MYAP for better transmission of health and nutrition messages. Yet, unfortunately, mothers within these groups do not show any particular commitment to these groups. However, trained mothers, especially model mothers, would be interested to create and promote their own Mothers Clubs, with new mothers in their community. Actually, as stated by mothers, there are incentives encouraging them to gather. For the majority of current WVH Mothers Clubs, it is the supplementary feeding program that draw them – though the training received is itself considered valuable. However, within other Mothers Clubs, incentives are more likely to be linked to livelihood activities. For example, some women benefited from vegetable seeds for their home gardens (but did not know how to regenerate them). Other groups are linked by savings and loan MUSOGs arrangements, acquiring some group capital that can be used by members to start their own small commercial ventures. Such initiatives should be encouraged for the better sustainability of the group itself. 5.0 Conclusions World Vision Haiti MYAP activities are reaching most of the targets set for the program, are providing important income enhancing inputs to farmers and improving the well-being of many thousands of children through the MCHN program. With some adjustments, the MYAP has set about to do what was proposed, and to which USAID and FFP agreed at the on-set of this project. The preventive approach to health and nutrition training and behavioral change among women with small children is without question 65 giving high quality and useful information to the mothers receiving it – information that is having a direct benefit on improving the well-being of the infants and children of these mothers. With its overview of all three Haiti MYAPs, the MTE team has suggested that some of the approaches being used by WVH may not achieve the desired outcomes, or are too limiting, in terms of sustainability. Some of our recommendations with respect to giving Mothers Clubs a more important role within the program, and prioritizing agricultural or livelihood activities towards the households of these Mothers Clubs may be difficult to implement at the mid-point of this MYAP. The level of refocusing that would be necessary might be too disruptive to the program at this stage, requiring changes in data collection forms, etc. and may need to be reconsidered should there be a new and future MYAP. Yet other recommendations focused towards better integration of MCHN and agriculture/livelihood activities should be possible during the remaining life of the project, as would also greater attention towards identifying individual entrepreneurs to provide the local leadership in agricultural promotion efforts. High levels of malnutrition among children under 5 years of age is one of the more visible and destructive elements of food insecurity in Haiti; seeking to reduce malnutrition rates among these children, with greatest attention of those under two years, appears to be one of key impacts that this MYAP should be seeking to accomplish and demonstrate. Yet the focus on this issue has not been sufficiently rigorous. By focusing on this, as an organizing theme within the MYAP, the MTE team believes WVH could have an even greater impact than it will likely have, if it continues unchanged current practices. Continued MYAP involvement in specific regions should be linked to outcomes that are quantifiable within smaller geographic areas – such as the localities in which health clinics or rally posts are located. The WVH goal of reducing population-level malnutrition rates from 23.5% to 21% over the life of this MYAP in their regions of implementation seem low when compared to WVH data on beneficiaries reporting 8.4% underweight children among the 33,151 monitored each month.27 This figures masks great variability between sites, and suggests that plans to reduce MYAP interventions in some locations should already be taking place (where rates have been low for 6+ months), and moving resources to locations where the rate may still be high. Major recommendations are provided to possibly orientate the MYAP towards more consciously addressing this. MYAP activities and planning for the Lower Central Plateau and the Artibonite Valley will need to be carefully considered. Because less than three years remain to this MYAP, the MTE team would suggest that WVH itself take the leadership in implementation within these regions, but that it do so in a much more focused manner than it has been practicing in the Upper Central Plateau and La Gônave. For example, we would suggest that agriculture and livelihood supporting activities are limited exclusively towards addressing the food security needs of the most vulnerable target groups – and that this be done though the Mothers Clubs. Agricultural initiatives already underway should be supported, but there should be a conscious effort to link these towards household members of the Mothers Clubs. WVH might consider testing the use of PDAs or something like them for entering data from rally posts (growth monitoring, pregnant and lactating mothers) in the section communales of this region – and more closely monitor impact on changing the rate of malnutrition at the locality levels. 27 WVH, January-March 2010 Quarterly Report, April 2010, p.7. 66 Annex 1: World Vision Haiti MCHN Program Description