1 Catholic Relief Service: HAITI Title II MYAP Mid-Term Evaluation, Report #3 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) 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 CNSA Coordination Nationale de la Securite Alimentaire 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 Ministry of Health MUAC Mid-Upper Arm Circumference MUSO, MUSOGs Mutuelle de Solidarity (Self Help Group), Mutual Solidarity (savings & 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 PNA Preventive Nutrition 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 CRS: Communes of the South Department (Les Cayes) MYAP Report #3 Map Table of Contents 0.0 Introduction & Overview of CRS MYAP Activities 0.1 Background 0.2 Schedule and Multi-Disciplinary MTE Team 0.3 Description of CRS Geographic Area 0.4 Targeting Vulnerable Groups 1.0 CRS 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 1.3 M&E System and Targeting of Beneficiaries 1.4 Links to GoH 1.5 Internal Reporting & Communications 1.6 Staffing & Capacity Development 1.7 Environmental Impacts 1.8 Conclusions, Lessons Learned & Best Practices 1.9 Recommendations 2.0 CRS 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 Exit and Graduation Strategies 2.10 Conclusions, Lessons Learned & Best Practices 2.11 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 Annex 1: Summary Table of MCHN Programs and Linkage to Agriculture/Livelihoods Activities 4 CRS MYAP Map 1: CRS MYAP Geographic Distribution Cover Page: Rally Point Meeting, led by male Col Vol 5 Catholic Relief Service (CRS), Haiti Title II MYAP 0.0 Introduction & Overview of CRS MYAP Activities 0.1 Background CRS has worked in the South Department of Haiti for over 30 years, and has centered two FFP Development Assistance Programs (DAPs), as well as this MYAP, out of the Les Cayes region. Caritas, the major development branch of the Catholic Church in Haiti, is a significant partner in this MYAP, and has had a long presence in the region as well, centered out of Camp-Perrin. At the beginning of the MYAP, collaboration with the Haitian Ministries of Agriculture and Health encouraged CRS to center their activities out of the commune of Les Anglais with later expansion down the coast into the communes of Chardonnières, Tiburon, Port-a-Piment and Port Salut. MCHN activities have targeted the twelve communes of the South Department, two within the Nippes Department, and one in the Grand￾Anse Department. CRS made a strategic decision years ago, long before this MYAP, to always center their programmatic approaches in support of existing or expanding Government of Haiti (GoH) institutions, personnel and initiatives. Government priorities within the regions of program activities are always supported in one way or another, if they can be linked to MYAP goals and objectives. This has meant that CRS will not create its own new clinics or dispensaries, or staff them with their own personnel; it will however help in providing training, supplies, and refurbishing equipment and some infrastructure to existing health facilities. Catholic medical institutions, independent of the state ones, however, are also provided training and services through this MYAP, as seen in the Dispensaire Saint Patrick in St. Louis du Sud and with CARITAS. As can be seen from the map of MYAP program distribution within the Southern Department, CRS has focused what they have referred to as their „full package‟ of activities, which includes the principal components of MCHN, agriculture/livelihood, education, and „safety net‟ activities in the band of communes stretching from Tiburon down to St. Jean du Sud, including Ile a Vache. Further east, several other communes were targeted with only MCHN activities, and no agriculture. In reality, even within the „full package‟ areas, specific households receiving specific activities of the MYAP were not intentionally targeted to receive the „full package‟. Rather the concept essentially meant that the „full package‟ was delivered within the commune and directly or indirectly benefiting community members. 0.2 Schedule and Multi-Disciplinary MTE Team The MTE team spent a period of 10 days with the CRS field team in the South Department, centered out of Les Cayes, beginning with an afternoon meeting with CRS MYAP management leaders on May 5, exploring in greater depth program orientations and activities, and finalizing our priorities with respect to individuals and small groups with whom we would be visiting. Field visits began in the Communes of Les Anglais and programs around Tiburon, Chardonnières where MYAP activities were initiated. This was followed by reviewing program activities and meeting beneficiaries down the coast within the Port-a￾Piment and Coteaux regions. These all represented areas in which beneficiaries received what CRS called 6 their „full package‟ (MCHN and agriculture activities). We then spent two days in the Aquin region, an area benefiting only from MCHN activities, finishing up field visits on Friday, May 14. The quantitative survey team had already begun its survey work when we arrived, and had departed before we were finished. Both surveys were undertaken in the same communes, with the former passing our questionnaire with 245 beneficiary households, and the latter meeting for focus individuals and group discussions about the benefits of the MYAP to date. Prior to its departure from the region, the MTE team provided the CRS management team with a 2+ hour debriefing on our observations. Annex 2 of the MTE evaluation Report #1 provides the detailed scheduling for this evaluation, and Annex 5 provides a list of all the key people and groups interviewed within CRS‟s 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 several rally points, and two food distribution points (one a GoH clinic, one a Catholic dispensary), observing CRS personnel undertaking their tasks with GoH health personnel, and working with the beneficiary populations. We visited one of the school programs supported by the program, and the feeding program linked to this. We were also able at these times to randomly meet and discuss program activities with both CRS staff and beneficiaries. 0.3 Description of CRS 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. Travel within CRS‟s program areas was not as difficult or potentially as hazardous as areas encountered within ACDI/VOCA‟s regions of intervention, or WV‟s La Gônave areas. Access into the hills coming down to the western coast can be difficult as well, however, particularly following rains. Hillsides are fairly barren, and mostly cultivated. Most of the „integration‟ activities in the past two years have been in the commune of Les Anglais, with only very recent expansion into Chardonnières and Tiburon communes. In one region (Aquin), only MCHN activities are implemented, without any attempt to link to agricultural activities. However, in the „full package areas‟, most of the targeted households for agriculture were not beneficiaries of MCHN 7 activities. The same could be said for MCHN targeted mothers in mothers clubs and at rally posts, they were not targeted for agricultural activities. The CRS definition of „full package‟ is that “all services are available to the households in the communities. This does not mean that all the MCH households directly participate in all agricultural activities”1 ; all households can potentially participate directly or indirectly from the impact of MYAP activities. The mid-term evaluation team did encounter areas of some overlap, and CRS has in recent months been taking the initiative to become more integrated in this way. New field activity tracking formats go so far as to note whether mothers clubs have a livelihood activity or not, but the same is not done for the agricultural programs (if they have mothers clubs). Farmers in this region are blessed by having two growing seasons each year, though CRS MYAP experience in their targeted areas as illustrated in quarterly CNSA early warning bulletins, is that rainfall is generally less than that shown in Figure 1 for nearby Camp Perrin above. As shown, rainfall in January – March 2010 has been significantly lower than long term averages, and has had an impact this year with delayed planting and increasing market prices for basic commodities. Furthermore, rainfall is erratic, highly variable in closely adjacent areas, with periods of drought experienced, as illustrated in the January – March, 2010 figure above from the CNSA bulletin published in May 2010 for the South Department. This coastal region also often receives the brunt of the mid-summer hurricane season. Nevertheless, there is usually enough rainfall all year long to permit some gardening (manioc, plantain), particularly in coastal areas where irrigation canals exist. First annual plantings (maize, pigeon pea, bean, manioc, sweet potato and yams) normally take place in February, and later plantings (usually beans, mélange) take place in September. Long-term rainfall tendencies are illustrated for Camp Perrin, located nearby, and serve to show periods of rainfall throughout the year.2 1 CRS communication by email to Richard Swanson, July 15, 2010. 2 Swanson et al, “Farmer Needs Assessment Exploratory Surveys”, PADF Les Cayes Region 1, Productive Land Use Systems, SECID, Report # 13, August 1993, p. 25. 8 0.4 Targeting Vulnerable Groups In its MYAP proposal, CRS specifies the following „food insecure people‟ as their targets: (1) Pregnant and lactating mothers (who will also receive food aid as a nutritional supplement) (2) Weaning age children between 6-24 months (who will also receive food aid as a nutritional supplement) (3) Children under 5 years of age with malnutrition (who will also receive food aid as part of recuperative therapy (4) PLWHA and TB patients (with food aid to improve overall health and use of antivirals ) (5) Selected primary school children (with food aid for energy for learning and incentive to go to school (6) Participants in FFW programs in vulnerable watersheds (7) People suffering from natural disasters will receive emergency feeding (8) Extremely vulnerable people (orphans, sick, homeless, destitute, elderly) (with food as safety net)3 CRS also intends on focusing on improving women‟s access to resources and to prioritize their involvement in health and nutrition programs, as through the mothers clubs. Little is said initially in the CRS MYAP proposal about how they would integrate MCHN with their agriculture/livelihood activities other than the statement that they would “develop watershed management plans with communities… which will enable the MYAP to link with other watershed and agro-enterprise programs to complement and leverage Title II supported agriculture and natural resource management activities.”4 It is only at the end of their proposal that some excellent thoughts are put forward about integrating MCHN and other agriculture/livelihood activities stating that “program sector integration is more conducive to achieving greater desire results.”5 This appears to have been forgotten until recent renewed interest for better integration. CRS Program Management Approach & Implementation MCHN: As noted by CRS program management, about 34% of their total MYAP budget goes to supporting the health and nutrition activities of the program, while 27% supports both agricultural and infrastructural (like rehabilitation of irrigation perimeters), 23% supports the educational activities, and finally 16% for reserved safety net activities. 3 CRS MYAP proposal, Kole Zepol, August 22, 2007, p 9. 4 Op. Cit. p. 12. 5 Op. Cit. p. 36. 9 Health and nutrition activities focus all activities around medical centers – the dispensaries and mostly government run health clinics within the communes targeted, though a number of private clinics and dispensaries also receive such support. These community health centers are the hubs of the program. The spokes of the hub are linked to the scores of Rally Posts within the Commune or region served by the health clinic. The Rally Posts are each managed by one Col Vol – or volunteer community health worker. Some, like Esperance Dieufort in Figure 2, manages three Rally Posts, meeting on the 2nd Saturday, 3rd Saturday, and 3rd Sunday of each month. Figure 2: Lists of Cols Vols and Rally Posts in commune of Les Anglais A few Cols Vols also have one Mother‟s Club made up mostly 20 mothers attending the specific Rally Point (cf. Annex 1 for all Col Vols and their mothers clubs). The list of names in Figure 2 above was one of three posted on the health clinic walls of the dispensary at Les Anglais, with 51 Cols Vols covering 62 Rally Posts, of whom only 9 (17%) were women. Malnutrition data were later analyzed by the MTE team for nine of the Rally Posts in Les Angeles, one of the communes in which CRS has worked the longest (Rally Posts: Veron, Caiman, Casse, La Chaine Bon Pas, Bocco, Losier, Figuier, La Source, Petite Place). Hundreds of mothers, over time, will come to a specific Rally Post, but only a selected 20, or at the most a second group of 20, will be found at any one of these locations formed into a Mothers Club. The CRS strategy is that these selected women will pass on their training to their peers within their communities. Figure 3 below shows an additional management tool CRS management has provide to the local community, classifying the Rally Points in Aquin Commune into those with (1) very difficult access (red stars), (2) difficult access, and (3) easy access (blue stars- near the road) - something we observed done at a number of the health centers and dispensaries as another management tool. Beside this chart, on the wall of the dispensary, where mothers visiting the clinic could see it, were also the names and locations of all the Rally Posts within this region (see example above in Figure 1), and the day when the monthly meeting takes place. Similar charts were seen at all the health centers visited. Cols Vols are recruited from people living within the specific localities of this region (21 shown in Figure 3 below), but they need to sometimes walk 3-4 hours to go to the health clinic where they report in to, and where the data they summarize from their registers is recorded for MYAP records. 10 Figure 3: Rally Posts (Postes de Rassemblements) linked to the Saint Patrick Dispensary at Aquin, visited by the MTE team Rally Posts are intended for anyone with children within that locality, with special focus on children under 5 years of age; here children receive vaccinations‟, deworming, Vitamin A supplements, and their growth monitored on each child‟s growth monitoring and vaccination health card (CHEMEN LASANTE –„ROAD TO HEALTH‟). For children found to be malnourished (either „low weight for age‟ or „very low weight for age‟ – PFA or PTFA), the Col Vol records this at the monthly Rally Post weighing sessions. If malnourished, the Cols Vols instruct mothers to take their child to the health clinic – which may be 4-5 hours walk across the mountains, down paths and dirt roads, to the center. 11 Figure 4: Mother and Child (below), with Volunteer Health Worker (Col Vol); child‟s growth monitoring card above. This mother didn‟t take her child to the clinic – she said it was too far, she couldn‟t afford it, and she herself was not well. Once they arrive at the health center, they must pay a 25 gourde fee to receive service (and the food supplements their child will receive), along with possibly the message that they must purchase some medicines for their child. The MTE team found that often less than half of the mothers with such children actually go down to the health center, as instructed by the Cols Vols, for a host of reasons. They may even cease coming to Rally Post because they know the Cols Vols will simply tell them again to go to the health center. In fact their names are removed from the Rally Post in subsequent months until they comply. The MTE team also was told that, as should be obvious, the Rally Posts located in the most difficult locations for access (red stars in Figure 3 above) are the ones with the greatest incidence of malnutrition – clearly households and regions which should receive particular attention by the MYAP. Unlike World Vision programs on the Central Plateau, which delivers the food supplements for pregnant, nursing mothers, and malnourished children to a Distribution Point near several Rally Posts, these „beneficiaries „are sent from the Rally Post and must present themselves to their distant Health Clinics (where their children are once again weighed), before they will receive their rations. Food supplements are given out at the institutional or community health centers to increase the utilization of services at these points The 6 photos below show this process at the Government Health Center of Les Anglais, where mothers are lined up for reweighing of their children, before they again line up to get their measures of lentils, oil, and wheat blend. They may have walked 2, 3, or 4 hours to get here this morning. First they sit outside the clinic where the CRS Cols Vols weigh the children again, and where a short educational message (behavioral change communication) is given out (this can take hours) (Photos 1-3). Then these mothers take their child on into the clinic where a GoH health worker takes her card, records the data, then gives the mother a numbered tag (this can take another hour)(Photo 4); then the mother goes into the hallway and sits down again (Photo 5) waiting for the person who is going to open the door at the end of the corridor to begin to give out the food rations (this can take another hour or more)(Photo 6).When this is done, the mother walks back home again with her child in her arms (perhaps 3-4 hours away); she is probably a bit tired and hungry!! 12 #1 #2 #3 #4 #5 #6 Agriculture Component: The CRS MYAP also includes an agricultural component that is to reinforce the largely MCHN program described above, and its targets. Most agriculture activities are currently located in the commune of Les Anglais (South Department), with more recent extensions throughout the Tiburon-St. Jean du Sud watershed area. These activities feed into two intermediate results: “Vulnerable communities practice improved soil and water conservation techniques” and “vulnerable communities have increased farm and off farm income”. To carry out activities aimed at achieving their Strategic Objective, CRS has been working in partnership with Caritas Les Cayes, the International Center for Tropical Agriculture (CIAT), the Organisation pour la Réhabilitation de l‟Environnenemt (ORE), and Bèl Solèy (enterprise of export of fruit and vegetables). 13 1.1 Site Program Management & MYAP Coordination Program management for the CRS MYAP takes place at the CRS regional base in Les Cayes – in the center of their areas of implementation. This is excellent, as it places management much closer to those who are being supervised in the field. Commune Promoteurs Matrones Auxiliaire Infirmieres Medecins Femmes enceintes Allaitant es moins 6 mois 6-23 mois Enfants malnourris Tiburon 44 40 2 1 0 131 256 ----- 159 Les Anglais 60 80 5 4 1 249 270 694 431 Chardonnières 71 80 2 6 2 250 436 659 275 Port a Piment 30 15 3 3 1 86 244 ---- 71 Coteaux 44 37 4 4 2 139 251 164 95 Roche a Bateau 40 40 5 0 1 136 416 569 134 Port Salut 9 0 2 0 0 ----- ----- ----- 30 St Jean du Sud 26 25 2 3 2 ----- ----- ----- 30 Ile a Vache 21 40 2 2 1 ----- ----- ----- 44 Cavaillon 20 0 4 0 2 ----- ----- ----- 76 St Louis du Sud 45 20 3 0 0 103 203 594 197 Aquin 136 63 20 35 14 357 582 1978 582 Fond des Negres 26 35 23 11 5 266 156 ----- 189 Miragoane 22 19 17 13 7 314 281 ----- 78 594 494 94 82 38 2031 3095 4658 2391 The table above provides recent information about the distribution of partner staff that CRS MYAP staff partially support within the MCHN program in particular, through whom MYAP efforts were undertaken, and offers some perspective to the size of the program. This is one of the defining characteristics of CRS‟s approach – i.e. working through GoH and other local health services. Annex 1 provides greater detail on this, including the numbers of rally posts and mothers clubs. We note there are 593 health promoters, some of whom are the Col Vols, 494 matrones (traditional mid-wives), 38 medical doctors and 82 nurses. Currently some 2,031 pregnant women are being worked with, and 3,095 nursing mothers of babies less than 6 months. Some 4,658 infants between 6-23 months are also receiving food supplements, as are some 2,391 other children less than 5 years of age. These numbers of course change from month to month, as some leave and others come into the program. Sub-component MYAP activities are undertaken by different teams of people specializing in their subject areas, often in different geographic localities. They do try to work together as interdisciplinary teams, with common target groups, but in different program areas, each doing what they have been contracted or sub-contracted to do (X number of linear rows of conservation structures, for example, through community self help activities). CRS noted that they regularly conduct quarterly meetings during which results are shared, activities planned – with an effort to coordinate and integrate activities among the different program components. We were told that calendars of regional meetings are always shared 14 among the different component teams. A CRS health worker, with partners, may work in supporting a specific rally post and the mothers with children who come there. Another CRS agronomist may work with a large group of farmers managing an irrigated perimeter (a group of a150 farmers that might have been initiated in a former DAP for this purpose). One purpose within this MYAP activity is to encourage production of high value vegetable crops, like peppers, for sale to the regional markets. An impression the MTE team received in the CRS zones of operations was that the inclusion of a household member in a MYAP support livelihood activity, who might be part of a MCHN mothers club, or attending rally points for their malnourished children, would be by chance, and not be design. Les Cayes Field Office Ass. MYAP Coord (PAP) Safety Net MRD MYAP coordinator (Cayes) Education Sante/Nutrition DMER Agriculture CRS MYAP Org Chart Coordination of agricultural activities, or MCHN activities, in the orbits around supported health clinics would be by CRS agricultural or health coordinators, who themselves would be coordinated by supervisors over communes or regions. As described by CRS, “animators of each program are responsible for data collection and counter verified by an M&E officer…Data processing will be done by the M&E officer who is responsible to a first analysis and reports to the DME MYAP coordinator. This person will do an accurate data verification an analysis, and reports to the DMER Unit Coordinator” and who coordinates with the MYAP manager for program reporting.6 6 CRS/Haiti MYAP, Performance Monitoring Plan, 2008-2010, 2009, p. 10. 15 At the highest level regionally, a regional health coordinator, often a medical doctor, would oversee the health work, and being sure that data were being aggregated from rally points to the health clinic level to commune levels and ultimately program wide level for quarterly reporting within the IPTT. A team of M&E personnel helped in the technical data input of these data in the Les Cayes headquarters, where aggregate data eventually find their way. However, the most interesting data are to be found in the registers that are in the hands of the Col Vols, tracked over the 12 month period of each year. When the year is over, each Col Vol submits a monthly report to the health institution, which in turn produces a consolidated report. The monthly consolidated report produced by the health institution is then sent on to CRS. The actual registers remain in the hands of the Col Vols throughout the year. To actually understand project impact on decreasing malnutrition however, it is the actual data from specific Col Vols rally points and not the consolidated data that can best illustrate trends. Choice of the recipients: Firstly, the recipients of agriculture/livelihood assistance are the members of usually already organized groups of producers. The program also targeted groups of young people from 16 to 25 years for support in the production of mango seedlings (francisque) for grafting. The CRS MYAP agricultural program has only recently begun to integrate mothers clubs, mothers APP, and Col Vols with selected activities like vegetable gardens, and nursery management of fruit tree and multi￾purpose forest trees. The choice for specific areas of MYAP intervention with livelihood activities was made after an analysis led in liaison with different ministries of the GoH (MARNDR, MDE, and MPCE). Their priorities including focus on three communes: Les Anglais, Chardonnières and Tiburon. The majority of the livelihood/agriculture activities of the MYAP began initially in Les Anglais. It was only at the end of 2009 that the MYAP extended its agriculture/livelihood activities into the two other communes referred to above. DMER Org Chart / MYAP Laura Dills Director of Programming Ramon’s C. Jean-Philippe DMER Unit Coordinator Junior J. Sander DMER MYAP Coordinator Emmanuel Floreal Data Base Manager M&E Officer (SNP) Pierre Cernio M&E Project Officer (Ag) Rose Daphné St-Fort M&E Project Officer (Edu) Jean Marcel Cherestal M&E Project Officer (Health) Dié Jude Kernande Data Entry Clerk To be hired Data Entry Clerk Similien William Junior Data Entry Clerk . Rubens Germain Data Entry Clerk 16 1.2 Priority Activities & Approaches The different sub-components of the CRWS MYAP are led by different groups of people working within often different communities or sub-groups of people within the communities of the targeted communes. For example, ORE (Organization for Rehabilitation of the Environment), a local NGO, was sub￾contracted to form groups of 10 young people in each commune for training in fruit tree grafting – beginning with the creation of a small groups nursery. The supplies for this nursery were provided to the trainees by CRS at no cost (seeds, plastic bags, grafting tools, watering cans, etc.). The sites where the small nurseries were located were provided, at no cost, by some local landowner for the purposes of this training event. A notice was published in the community for young people who would be interested in learning how to do grafting for the benefits of the community, and both young men and women applied and 10 selected. We were told by the young people interviewed by the MTE team that the grafted Francisque mangos observed by the MTE team were to be „given to the community‟ to improve their well-being, and that some of the seedlings would be planted on their own plots of land so that they could raise these trees to. No one ever mentioned that this could be a potential source of revenue for them, that they could or would continue this as a means to sell within the community, or that they saw this as a business opportunity for themselves. 1.2.1 Cropping Systems and Focus for Improved Productivity A) Vulnerable communities practice improved soil and water conservation techniques To achieve this result the MYAP associated with Caritas and ORE, for the implementation of activities in the areas of intervention (Les Anglais, Chardonnières and Tiburon). During our field visits, we observed that the knowledge and skills of many farmers had indeed increased in the targeted areas. Farmers trained have protected their plots with anti-erosive structures, specifically contour canals with tree seedlings planted along the contour. According to farmers interviewed, the development of these protected plots will be much more advantageous during the crop years to come. 17 Within communities, greater mobilization has been noted for the production, planting and maintenance of fruit/forest trees which have an economic interest (mango, cashew nuts, citrus, cocoa, coffee, avocado, cedar, oak, etc) to farmers. However, very few people expressed any desire to buy these trees. Thus, even if groups of young people or even model farmers would be interested to invest in the establishment of fruit and/or multi-purpose forest trees, it will be difficult for them to find a market. Why? This is because the communities have become so accustomed to receiving, year after year, tree seedlings in the form of gift seedlings through reforestation programs. It will be difficult for the local groups which have profited from the „community nurseries‟ established with the help of CRS to continue this activity. This is because they will not have sufficient resources to renew the inputs necessary (plastic bags, seeds, etc.); because the fruit trees and forest trees are not sold but are given away for nothing as per MYAP strategy. While it may be difficult now to sell agro-forestry tree seedlings, hope still remains that grafted fruit trees could have a different history – if all NGOs programs stop giving them away through their programs. With respect to component integration, the MTE team did observe four Col Vol led groups and 5 APP groups that had benefited from their community nurseries. The problem is that they probably won‟t last long after the end of the MYAP. Vulnerable communities have increased farm and off-farm income Output 1: Farmer groups practice improved agricultural techniques Several model farmers met by the MTE team were able to correctly explain the various agricultural techniques learned (density of sowing, preparation of vegetable seeds, preparation of compost, etc). According to them, the yields obtained for certain cultivars are significantly higher than those obtained by other farmers using local varieties. According to these recipients, this difference is due to high adoption rates for these new varieties and cropping/ management practices introduced by the MYAP. 18 The concept of home gardening by the CRS program is good. This refers to the cultivation of a small area around the homestead. Household women apply themselves seriously to the installation and the maintenance of their vegetable gardens. According to these women, these home gardens have a double vocation: food for their children and increased incomes for themselves. Among the 97 functioning mothers clubs, 86 of them have recently begun to initiate savings and loan activities, and 57 have members who have started small vegetable gardens (cf. Annex 1). This is a good start that needs to be dramatically expanded to other mothers clubs throughout the MYAPs areas of intervention. Furthermore, as a result of savings and loan initiatives, many mothers in these clubs have been able to initiate their own small micro-business commercial activities (11 mothers clubs). But it was clearly the vegetable gardening that has captured the greatest interest, with mothers testifying that their vegetable gardens now allow them to increase both available food and their incomes. Output 2 Agro-enterprise practices adopted by vulnerable rural households ORE was contracted by CRS to provide the needed technical expertise for developing agro-enterprises among their targeted beneficiary populations. A first initiative was to train young people in learn how to establish a small nursery of mango seedlings, and then to learn how to graft them. The tree grafting and fruit tree nurseries with youth groups was advertised by CRS in the communities as an opportunity to develop new skills and to start their own businesses. A corollary objective was to contribute to the improvement of tree cover in the watersheds. At the time of the MTE review, 60 young people had already been so-trained (some of them pictured here) (6 groups of 10, about half women). In our conversations with them, we noted that these young people clearly now understood how to do grafting. Several of them told us that they had already started to establish their own orchards. We were disappointed to learn that these young people had no sense that what they had learned was for the purpose of starting their own businesses, however. When we asked: “Why did you agree to take this training” their response was that “We are doing this to provide a service to our community”. A noble sentiment, perhaps, but this is not one that is going to help them make a living. Indeed if their services continue to be expected to be free (because they were given their training and graft supplies for free), they will create a climate within their communities where an entrepreneur could not make a living in this way. This would be unfortunate. 19 These young people did not seem to see their expertise as something of such value, that they can now SELL their services to friends and neighbors. The MTE team views the issue in the following manner: if a program does not began – at the very first day – in letting trainees know that the ultimate objective is to help them learn a life-skill that will profit them, then the program has started off on the wrong track. Even the recruitment and very selection of the first trainees should be based on their own stated interest in becoming such entrepreneurs. This would help reduce the field of candidates. ORE perhaps could have focused better on this at the initiation of this activity. With further questioning, the grafters had no idea of the cost of the materials and inputs they had been given to carry out this activity (nursery fence, buckets for water, grafts, seeds, plastic bags, etc.). They had not discussed how their services might be marketed, nor did not know how much one could charge for a graft on an existing tree, or sell a grafted seedling such as we observed. It is not too late yet to refocus in this way of course with those already trained. The program could yet end up with a number of young people with the skills needed to go into business in their areas; but one doesn‟t want too many either or competition for work will limit possibilities. There should be demand for their services given the growing number of producers in the area and the demand for the product from buyers coming into the area. The MYAP has also assisted the current mango producers to negotiate and directly sell their fruit to a regional association/network of fruit producers and vendors (ASPVEFS) which buys the large, high quality mangos for market export. Last year 660 dozen mangos were bought by ASPVEFS from mango producers of Les Anglais. Long-term success of this effort may require some support to ASPVEFS as a key link within the value chain. The CRS MYAP has also initiated some interesting work within some catchments for the production of high value vegetable crops (chili pepper, papaya). There has been in effort to link these farmers with a national export company called Bèl Solèy , an enterprise specializing in the export of fruit and vegetables. The MYAP currently works with a group of about 50 farmers in an irrigated perimeter of Les Anglais which was rehabilitated. The perimeter currently has under production about 4,000 square meters of chili pepper whose purchase is guaranteed by this company. At the time of the arrival of the MTE team, these farmers were in the process of taking the seedlings from their nursery to transplant into this area. Bèl Solèy itself has provided them with some support in establishing this system. The CRS MYAP also has engaged an existing group of farmers on number of irrigated perimeters in the Les Anglais area to become producers of high quality seed for some of the principal crops grown within the region. This group, calling itself PESA, groups some 180 farmers. The MYAP 20 contracted CIAT to support these farmers in the on-farm testing of a number of high yield varieties of bean, maize and manioc. Currently, PESA is in the selection phase, having already identified those varieties that have shown the best adaptability in this zone. One variety of maize was selected, a new variety of manioc, and two varieties of bean Tiocanela (a kidney bean) and EAP (black bean). Yield plots for these varieties have given a 40:1 ration between produce and seed planted. According to these farmers, this out yields their local varieties by 400%. This is a positive indication for their future. The farmers are motivated and they are themselves in search of an institution of microfinance to obtain a loan to increase their working capital and to improve the conditions of storage of their grain, before marketing. The only cautionary tale here to note is that twenty years ago the USAID supported ADS-II project worked in these same regions on the same varieties – black beans, manioc, sweet potato, maize, rice, and others. Some exceptional varieties were farm tested (Tamazulapa black beans, Amina rice) and widely disseminated, and groups of farmers trained in caring for these new varieties. And we are still doing the same thing today. Ultimately rice production was not successful because imported subsidized rice sold for less than what farmers could grow it for. Output 3: Internal savings and lending methods successfully adopted by vulnerable rural households The program to encourage groups in savings and loan schemes called mutuelles de solidarité (MUSO) is proving to have an important impact among some of the households involved. In these MYAP supported efforts, no external injection of capital is taking place – which is probably why they are working. The MYAP has been targeting the mothers clubs for this effort. Each woman in the savings and loan group must contribute each month to the group fund, and from this loans are given out to members for a 4 months period. The capital and the interests are refunded over the next 4 months. Interest is fixed at 2% a month (24% a year). People are serious about their MUSO, and it works, payments are made on time. Books are kept tracking who owes what. The MTE team met with several such groups of women – some which we considered too large (two groups of 20 from two mothers clubs put together by Col Vol, for example). Advantages they noted to us were that the MUSO permitted:  The access to the capital at a cost lower than the sources of credit available, in particular the some widespread networks with usurious loans whose interest rate can reach 25% the month;  Increase and the stabilization of the credit for market activities in the communities;  The answer to certain family requirements (food, payment of the school fees of the children, access to the health care);  An increase in the autonomy and the respect of the women at the level of their households. According to the participants, it is a credit program which goes well. There is no problem of management of the funds and refunding is done without difficulty. It will be important for the MYAP individuals who monitor the progress of this work to keep records of the aggregated loans that are given out (and repaid) each year, the amount of interest earned. Then support should be extended to the women taking out these micro-loans in record keeping of their small business. These data will become important at the time of the final evaluation. 21 Value Chains Targeted It is yet too early to know what the impact of the MYAP efforts with the commercialization of chili peppers, grafted mangos, and the various high yielding cultivars being developed as seed stock for the region. Success and impact will depend on the program‟s ability to develop true entrepreneurial leaders who are helped to know enough about the value chain of their target commodities to become successful in production and sales. This means knowing where to get new seed stocks, how to use the needed fertilizers or agents for pest control, and how to market their goods. Transport frequently becomes an issue. The final evaluation will look at these issues and whether these good starts are sustainable or not. 1.2.2 Health & Nutrition Maternal, Child Health and Nutrition Education: This is accomplished mainly through the monthly rally post gatherings, by community health volunteers (Col Vols) and through mothers clubs. Volunteers (Col Vols) training: The central approach to the CRS MCHN program in the Southern Department has been the training of community health volunteers called Cols Vols. Some of these Col Vols have continued on from the previous FFP DAP in many of the same regions. Training sessions of health volunteers are organized by CRS with the technical support of MOH. As volunteers, they remain active in their area of residence for many years. They give an average of 3 days to the project through their leadership, each month, of at least one rally post, as well as one or two mothers Club monthly meetings and for the preparation of reports. Those volunteers perform the growth monitoring (weighing of children) and the education of mothers at these rally posts. They are often accompanied by a health worker of the MOH who administers vaccines and also offers to women family planning health. Some Col Vols receive MOH training to themselves administer vaccines. According to mothers, the educational training received is more important than the supplemental food rations received. One of the strengths of CRS MYAP is the educational materials used for these training sessions (visual charts), and the orderly progression of topics covered from month to month on different themes. Clearly from the experience over the years, CRS has not done enough to introduce new health and nutritional materials into these sessions to maintain interest from year to year. The theme for which there is less visual support is vaccination. But even with the material availability, health promoters need to ensure that key messages are actually understood, accepted and that mothers improve their practices, 22 leading to behavioral changes. One of the reasons the MTE team believes that stronger focus on mothers clubs, with leader mothers, is needed is that these local neighbor leader mothers will be more persistent in visiting „their mothers‟ to see if they are adopting messages of the month, and encourage them to do so if they are not. Rally posts: Within a locality, a rally post is established for anthropometric measurement (weighing), education of mothers and the administration of necessary vaccinations, deworming, and vitamin A supplements. The number of rally posts depends on the distance between households and the health center and may vary considerably especially in areas where the project is co-managed with other partners. The health volunteers are trained by CRS or by MOH. Each health volunteer has a register to report children seen and weighed at their rally post. They sometimes visit children at home, but this is not a systematic thing. Mothers encountered at these rally posts are often very young, sometimes teenage mothers, with their baby in arms. It should be noted that in this area fertility is very high, some mothers having 6, 7 or even 9 children. The use of contraceptive or family planning methods has had little impact so far. The MTE team observed also that the frequentation of rally post by children over 24 months is not very high. Maybe it is because some of them are in pre-schools. The other reason may be for a lack of motivation to come once the child has received all its vaccines and is no longer in the food distribution program. Mothers Clubs: The quality of the training given to mothers at Rally Points and particularly through the limited Mothers Clubs (97) appears generally excellent. Mothers with whom the MTE team met of existing Mothers Clubs were enthusiastic about the training they had received, and about how important it was for the well-being of their households and children. All had children less than 5 years of age, and many had a number of older children as well. Many do pass this knowledge on to their non-member friends and neighbors. The MTE team met, at the rally posts, with many of such „friends and neighbors‟ who clearly were somewhat jealous of the special attention that the Mothers Club mothers had 23 received from CRS. Why didn‟t they then form into their own Mothers Clubs, we asked? We were not „invited to join such a club‟ and had no way to obtain this special training - was a very common response. CRS‟s strategy for Mothers Clubs (Club de mères) “consists of organizing mothers or those responsible for children under five years of age who are regular attendees at the Rally Points to meet for the purpose of reinforcing their knowledge, practices, and understanding (of child health and nutrition). The 15 minutes given for such education at the Rally Points (by Cols Vols) does not permit us to reach the 3rd objective of MCHN component of the DAP whose goal is changing behavior.”7 Stated objectives include: (1) Assuring the sustainability of the Mothers Clubs (2) Encouraging mothers to practice the health/nutrition themes taught to them (3) Facilitate the introduction of other (livelihood) activities (4) Reduce the rate of malnutrition within the localities served (5) Encourage them to develop their own savings and loan group(s) How were these Mothers Clubs formed? “Each Col Vol trainer chooses 20 mothers for each club and meets with them once each week for about an hour for 12 weeks. CRS provided each mother with 25 gourdes, and 50 gourdes to each Col Vol for each session.8 At the end of the training, certificates were given to each mother of each newly created Mothers Club, with the expectations that each month thereafter they would gather to receive subsequent training from the Col Vol9 . Unfortunately, results of this effort were not satisfactory and a new strategy is needed.” The new strategy adopted, and which the MYAP is currently trying to put into action, is to target pregnant and lactating mothers – and following the process described above, to invite 20 women to form a new Mothers Club, where the training would be focused towards that specific developmental groups (perhaps a nod to what World Vision has been trying to do). This will create cohort groups who began in the group when a child was of a particular age (unborn, newly born, 6-23 months). The group would be maintained for two years, with monthly meetings led by the area Col Vol. The community health workers (Col Vols) are supported in their work by the CRS Health animateurs, who are certified community health nurses and health service providers in the health facilities who are acting to promote the strategy and assure access to all the mothers in the area. 7 CRS review of Mothers Club Strategies at end of last DAP, undated two page document probably written in 2007, before the beginning of the MYAP, page 1. 8 CRS budgeted these amounts to provide a snack to the mothers and Col Vols, but they preferred to receive the cash instead of the snack. 9 According to the CRS review document on mothers clubs in the former DAP, some 261 new Mothers Clubs were formed at the time in the then 4 zones of intervention with some 128 Col Vols. 24 A weakness of both the new approach, and the old, is probably that it this has always been far too structured. A Col Vol “invites” specific mothers – usually those who are have shown regular participation and interest - coming to a rally post to form into a new Mothers Club. Indeed, CRS informed the MTE team that “in the CRS strategy, each member of a mothers club is considered as a Leader Mother and her mission is to share the key messages from the training to their peers in the communities”.10 Then the mothers club continues to meet once each month, with the Col Vol as leader. In some cases, some exceptional mothers of past mothers clubs have become Col Vols themselves. In discussing the conditions of the formation of their „mothers clubs‟ with various mothers, the MTE team was told that the mothers who are „invited‟ to form these clubs can come from different places around the Rally Post – as far as an hour or more in either direction. The women do not necessarily know each other, do not necessarily live close to each other, and perhaps more importantly, would not otherwise associate themselves together – apart from the project asking them to do so. The presence of a mother at a mothers club meeting is not a condition (or guarantee) to supplementary feeding. Mothers recognize the benefits of gathering together to improve their knowledge of caring for their children‟s health and hygiene. Mothers appreciate the education received within the clubs, and readily state that can observe an improvement in the situation of their children (of any age) since they are in clubs. They cite the example of exclusive breastfeeding practiced and the good health of children born since the outset of the MYAP. Many of the „old DAP‟ CRS mothers clubs have withered away – sometimes being merged by the Col Vols into new groups. Mothers drop out because they have lost interest in the repeated cycle of themes over time and have moved on to other things. Seeing these reactions, CRS realized the need to give them some other reason for meeting as a group, and began to introduce MUSO (mutual savings and loan group) activities, a cross-cutting livelihood activity, which has indeed sparked renewed interest for some of the old groups. Indeed, women are invited to bring their young children to rally posts by a Col Vol. The registers and reporting formats that have been prepared by CRS health agents and that are used by the field personnel (Col Vols) monitoring mothers and their children coming to the Rally Points is impressive. The MTE team believes the system breaks down when it goes down to the next level – the few Mothers Clubs that were established and that have been 10 CRS Jude Marie Banatte email to Richard Swanson, July 15, 2010. 25 maintained by these Col Vols over time. The mothers clubs as they have been operating for eight years or more in some cases (two DAPs, plus this MYAP) include mothers with children of different ages, who have been cycled through the training program two or more times. Because of the heavy involvement of the volunteer Col Vols with a couple mothers clubs, they have little incentive (and certainly not the time) to see the numbers of mothers clubs expand at specific rally posts. Nor does CRS ask that they do so. Perhaps the CRS expectation that the mothers in the existing mothers clubs will train their peers within their communities is not realistic, either, and that a somewhat more formal method is needed to reach other mothers with children within targeted communities. For example, the mother‟s club approach used by WV and ADRA in Rwanda has the Col Vols responsible for training, with occasional inputs from health agents, of the one leader within each mothers clubs, who in their turn pass on their knowledge to the mothers in the mothers clubs they lead in regularly scheduled monthly meetings. MYAP programs there have several thousand mothers clubs with 15 or more members – as compared to the targeted 97 in the CRS Haiti MYAP program. In that way the volunteer Col Vols are not overextended – reaching 20-30 mothers club each through their leader mothers and an additional volunteer leadership level is created – the leader mother. CRS has organized some women‟s groups for mutual savings and groups (mutuelles). The mothers clubs were not initially targeted for this (perhaps because the women „put together‟ for these clubs would not necessarily work together for something like this, which requires mutual trust). The MTE team met with several such groups. One had 40 members, only one of whom was a member of a mothers club. They hold a green saving box into which all members are expected to deposit a specific amount each (the actually amount varies by group, and is a group decision). Money that accumulates is then loaned out, with interest, within the group to initiate small commercial ventures or specific needs. One group interviewed by the MTE team had accumulated $2,249, and 25 members currently had all the money taken out ranging in loans averaging between 1,000 (lowest) and 5,000 gourdes (highest). These amounts are carefully tracked and must be paid back within 4 months, with interest. Each member must contribute 100 gourdes each month into their saving system, and an extra 10 gourdes/month goes into the red box. Another small savings account is placed in their red box for member health emergencies. When given out, this need not be repaid. Recipients are a group decision. Unless they participate in some savings and loan activity like this, mothers (who are in a mothers club) do not identify themselves as an organization. The MTE team asked this group of women why they were not part of a woman‟s club. Their response: “We have not been invited to do so”, or “we have not been authorized to do so”. They noted that mothers in the clubs they knew about had “un pil avantage‟ (great advantage) in what they learned for the care of their children – and they too would like to be part of such a club. Too bad that the two approaches were not combined from the beginning! The women noted that if they formed their own mothers club without the „authority of a Col Vol‟, it would not be the same. Clearly Col Vols need to be involved, but the change should be made towards Col Vols training of Leader Mothers of formed mothers clubs. 26 However participation in mothers clubs is only offered to a few privileged mothers. The reasons are the following:  The local Col Vol health volunteer is the one to "select" mothers who can participate in clubs.  The number of mothers accepted to the clubs is limited. A quota of 20 mothers is established; so the recruitment process is stopped once this figure is reached.  A Col Vol can only manage one or two mothers clubs  Under the new CRS approach, new clubs will include only pregnant and breastfeeding women. Thus a mother whose child has more than 6 months, who was not in a club before or is no longer pregnant, will be excluded. Mothers recognize that their participation in the community would be greater if the number of clubs would increase. Some capable mothers stated to the MTE team their wish to be the Leader Mother for their own mothers clubs; they would create this with other mothers in their neighborhoods. There would need to be at least one mother in the group who was literate. However, while believing that having mothers clubs, each with its own Leader Mother, would be an interesting approach, they felt that they would need the "permission" of CRS through their Col Vols to do so. Thus, they do not feel they have the personal freedom to spontaneously create new clubs if it is not required by the MYAP. STEPS FOR THE MANAGEMENT OF CHRONIC AND ACUTE MALNUTRITION 1. Food distribution. The program targets pregnant women in their second and third trimester; lactating women during their first six months post partum and their infants; infants from 6 to 24 months (preventive feeding); children 6 to 59 months in need of recuperative therapy. It was not possible to make the link with patients receiving treatment for TB, HIV and AIDS, at the time of the MTE. If prenatal visits are required before being able to subscribe to the food distribution program, the participation to a mothers clubs is not a requirement, nor is the complete immunization of children. The choice of sites for the supplementation of dry rations is done in conjunction with the Ministry of Health. Thus, areas deemed less vulnerable in terms of food insecurity by the MoH have no preventive ration. 2. Monthly meeting of children under five years old at rally post: At the level of the health center, plans are determined where rally points should be established, and then with the local populations, the day for the rally post is established (same day each month), considering what is most practical for women to come (e.g. not conflicting with market days, for example, or other regularly scheduled events). During rally posts, underweight children are identified, using a scale and the growth monitoring card (carte “chemen la santé”). According to the mothers interviewed by the MTE team, all community children have attended the rally post during this intervention. The child in card below has been in and out and again in a malnourished state over its life. 27 However by reviewing records submitted by the health volunteers, we can observe that the number of children seen at the rally post varies each month. Thus, not the same children are seen each month at rally post. The following graph shows the evolution of the nutrition status of children (weight for age) at a rally post in the commune Les Anglais. Many fluctuations are observed (cf. Figure 1 below & page 40 for the specific data). The dark blue line is the average of nine rally points (cf. p. 40) while the light blue line represents the actual rates for one rally point called Casse. Averaging (data consolidation) smoothes out the line showing monthly variability between 9% and 19% and is misleading of what is actually taking place locally. Averaging for an entire region would show an even flatter line. Monthly variability for one specific rally point (Casse) shows much greater variability – between 6% and 29%! Nor do we see any pattern from year to year for the supposed seasonal „hungry months‟ often reported locally for increased malnutrition. Figure 1 - Time series. Children weighted at a rally post. % of low weight for age 0 5 10 15 20 25 30 35 Figure 1: CRS, Commune Les Anglais, I’ere Section Verone (PFA+PTFA) Series1 Series3 28 Why such variability? One explanation is mentioned by the service providers: once the child is referred to health center, he or she is no longer monitored at the rally post. Our visits in communities also revealed that some children whose mothers have no capacity to bring them to the Health Center (for economic reasons or because of the health status of the mother) do not return back to the rally post and so are not counted. It also suggests that mothers in the general community are not „hearing and applying‟ the behavioral change communications that CRS hopes the mothers of existing mothers clubs are sharing with their neighbors. A change in this strategy would seem to be indicated. 3. Referrals to the health center or dispensary: Children whose weight is low for age (PFA￾orange ) or very low weight for age (PTFA-yellow)(see card on page 10 & 26 above) are referred to the health center. Once arrived at the center along with their mother, a medical examination is done; these children benefit also from food ration. To ensure recovery, mothers are asked to bring their malnourished children every two weeks at the health center, to be weighed and to receive the food at the same time. Additional anthropometric measurements are carried out (weight, height, mid upper arm circumference or MUAC) in order to assess those in acute malnutrition. A complementary project (PEPFAR) following the MOH protocol for acute malnutrition, allows some children to receive a RUTF (Ready to use therapeutic food, named Plumpy nut). However, although this approach greatly promotes the medical follow up of children in institutional environment, the path from the rally post to the health center is difficult. The following barriers restrict access of several children to the program. The health of mothers: Some of them report being sick. This is a determinant of the care of children, whose nutritional situation has worsened then. Moreover, such mothers don‟t themselves the physical capacity to carry their children to the health center and back. The distance from home to the health center: Though this distance is sometimes overestimated by mothers, this distance can nevertheless be an obstacle for many, especially if their health is already precarious. The costs of services: The visit to a health center is not totally free, except for the child who is severely malnourished or in acute malnutrition. All other children must pay for the services, causing their mothers to spend for medical expenses (lab tests, drugs cost at least 100 gourdes), especially when there is no policy exemption in the centre. Shortage of food supplements: Shortages are rare (perhaps not more than once or twice a year), and this usually occurs in the rainy period when transport may be a problem. According to providers, "even if some abandoned happens, the vast majority comes". Nevertheless some malnourished children are thus lost to the program, even when health providers (workers and volunteers) and supervisors encourage mothers during home visits. Health workers noted with discouragement that “sometimes we need to use force and persuasion” to get mothers to bring their children to the health center for care. The exit: An exit from the food supplement program occurs as soon an improvement in the nutritional status of children is observed (increase in weight and return to a normal growth curve – the red in card above). However a child is eliminated after 8 months whatever the situation of the child or after 3 months 29 if the child‟s weight remains stationary. Some children remain in a situation of malnutrition despite the distribution of dry rations, even when attempting to retrieve them with the administration of Plumpy nut. In these cases, the child is referred to a PVO named Terre des Hommes (at Les Cayes) which manages a specialized nutritional recovery center. The following figure shows some of the stages in which the pipeline to better health and nutrition can be broken when all preceding barriers are not addressed. Figure 2 - The Pipeline to better health and nutrition. (1) Rally post (2) At health center (3) Toward other referral points.  Red dots above are malnourished children returning to „normal‟, yellow dots are malnourished children, some of whom even when they go through the pipeline to better health, never reach it. Monitoring and Supervision: The structure for a good supervision is adopted for the project. Each rally post is supervised by a nurse employee of the MYAP PROJECT. They consciously do their work, assuring that volunteers (Col Vols) perform their duties correctly. We might suggest, to reinforce this supervision, that there be more encouragement to do home visits, and that a closer look at the number of children visiting the rally posts be considered, with a closer follow up of referrals to health centers. One way to accomplish this, without adding to the burden of the Col Vols, would be through the created of Leader Mothers within all mothers clubs – who would receive some training (not to level of Col Vols) about what their duties as leaders within their mothers 30 clubs should be. They don‟t have to be literate, but someone within group should be. To conduct data collection, the smallest unit of observation is actually the rally post. Data are analyzed at health center level. However, the MTE team was concerned to see that these data are simply collected at rally post, but not sufficiently analyzed at this level in order to allow a rapid assessment of the effect of the program, in order to take immediate actions at the lowest level. For example, trends of PFA and PTFA would allow the local team to assess the performance of their MYAP activities over a period. The form to monitor a mothers club in Aquin is shown here. The Col Vol who leads the group is shown, the group‟s name is given, and the month of the last regular meeting given. Like so many CRS mothers club, this too has 20 members whose names are shown. These women, combined, have 15 children less than two years of age, 16 between 2 and 5, an additional 24 older children. Of these children 36 of them are in school. The health monitor showed the MTE team her records for the month of April, 2010 for all her mothers‟ clubs. The form below, shows one additional mothers club, and then sums up all the mothers for Aquin in the mothers clubs: 91 mothers with a total of 249 children, of whom 165 are in school. 1.2.4 Early Warning System The documentation on the CRS early warning system was obtained by the MTE team through visiting the website www.cnsahaiti.org. CRS has been very active in leading the efforts in the CNSA for the Southern Department and the four quarterly bulletins produce so far. The observatory was established in the Southern Department towards the end of 2008. The stated purpose for the system is to create „food security observatory posts‟ throughout the country to monitor food security and to respond in a timely manner to critical areas. Led by the Ministry of Agriculture, Natural Resources, and Rural Development (MARNDR),it is highly participatory, multi-disciplinary, in that many local partners (Ministry of Health, NGOs, donors) are working together to make this reporting system possible. The bulletins provide timely and useful information for regional and national level policy makers on the evolution of market prices, rainfall trends, agricultural and livestock information. Each bulletin, which includes grafts and figures of rainfall and market price trends, ends with a list of suggested action steps that might be considered by GoH policy makers, donors, and local NGOs and other partners working within the region. Though the early warning system is only mentioned in passing in the most recent CRS document we possessed (August 2009) which states that the “EWS is in place and feeding the project on a regular basis on the food security in the project area‟. Focus groups are also held to follow up on food 31 security situation”.11 Yet, from the existence of these bulletins, and the amount of effort it must take to gather and analyze the market and rainfall data, it is also clear that considerable effort is expended for the EWS. Similar effort is also given by ACDI/VOCA for the South-East Department, as the MTE team also observed. Given the amount of high quality data available to CRS and other MYAP CSs, through their rally posts, the MTE team was surprised that a sample of such sentinel locations were not being regularly monitored and reported upon with respect to changes in malnutrition rates of children less than 5 years of age. 1.3 M&E System and Targeting of Beneficiaries M&E: CRS, like both WVH and ACDI/VOCA, has done an excellent job in preparing their MYAP performance management plan (PMP) which includes the components that make it complete (strategic framework, output and impact indicators placed within this structure within an indicator tracking table (IPTT), descriptive performance indicator reference sheets (PIRS), and a schedule of performance management tasks for M&E over the life of the MYAP. Also included is a flow chart showing how responsibilities for implementing, reporting and monitoring the program will take place.12 It will be important to update this PMP each year. CRS has a well-qualified staffed M&E team and is fairly centralized in the Les Cayes offices. The program has developed a good system for tracking their key data sets from the multiple components of the program, using numerous data forms that are reviewed periodically. For example, recent reviews, and a desire to track program integration between MCHN and agricultural components led to a change in forms to show this. However, as with the other MYAP programs in Haiti, the MTE team believes there are too many indicators. CRS has the most at 61 – partly because of their four components - which greatly increases the efforts of field staff in registering, handling these data, and reporting upon them. CRS has very well kept data from each of their hundreds of rally points, data that have been aggregated to section communales levels, then again aggregated to the commune level and then regional level – where it finally is included into quarterly and annual reports and responds to IPTT indicators. Unfortunately, there is so much data, that the best the program can do is to keep aggregating it towards those reports and indicators – insufficient time is being spent to understand just what this rich trove of data actually means for local management purposes, or for purposes of improving performance at rally points or to look at long term trends for malnourishments, for example. One would expect that, if training were being effective in specific communities, that one would find that over time the overall malnutrition rates would fall significantly. Unfortunately, the data do not seem to support this case, and this suggests that the very approach being used by CRS with its limited numbers of mothers clubs, the way it forms and structures these, and the way training is delivered by Col Vols may not being having the long term impact desired. CRS, in all regions, has coded its rally points with access as “very difficult” moderately difficult, or easy (cf. Figure 3, p 10). The very difficult are marked with red stars. Review of these shows that these are the locations that are farthest from the health centers, up in the distant hills, where road access is more difficult, where mothers must walk 3-5 hours one way from their homes to the health center should their 11 CRS MYAP, Pipeline and Resource Estimate Proposal, August 3, 2009, p 8. 12 CRS Haiti, MYAP Performance Monitoring Plan, 2009-2012, undated. 32 children need attention when categorized by Col Vols as malnourished or extremely malnourished. These are the most vulnerable within the areas served, while the „easy posts‟ are those where malnutrition is extremely low, located in the low lands where water is also more abundant, and where agriculture production potential is higher and easier to achieve. CRS has classified all their regions as „vulnerable‟ which permits them to work with anyone and everyone in the area through their community approach. This ends up being a general rural development approach where almost any agricultural or livelihood activity could be justified. By better targeting of the most vulnerable geographic areas (those distant rally posts), and encouraging all others of children under 5 years of age to form into self-selecting small groups of women, most of these vulnerable households would be captured in some grouping of people. These small groups would become, with their leader mothers, the first line of defense for mothers of children who may slip into a state of malnourishment. The MTE team spent time with the CRS 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. For example: (1) # of additional hectares under improved technologies or management practices as a result of USG assistance. Though this indicator in itself may be important, the effort to obtain such data, in hectares, appears to have been difficult. Knowing the number of successfully established procedures may be sufficient, as with the # of grafted fruit trees that have been established on the slopes of participating farmers. (2) # of new technologies or management practices made available for transfer as a result of USG assistance. This is an example of an indicator which does not make sense because the total numbers are so small over the life of the project. It would be better to simply state these in the narrative portion of quarterly reports. In this case the total LOP target was 7. Another example: (3) # of MSMEs receiving business development services as a result of USG-assistance. The total LOP of project goal is again 7. Because what different MYAPs define as „their MSMEs‟ varies so much, it would be better to simply speak of the specific seed producer groups or mango grower association in the narrative section of the CRS quarterly report. Otherwise, one should begin to count all of the small businesses being developed out of the Mutuelle or MUSO groups (self-help savings and loan). CRS is not tracking these, but they could number in the hundreds by the end of the MYAP. (4) # of people with increased economic benefits derived from sustainable NRM and conservation as a result of USG assistance. This indicator has yet to be reported upon because of the difficulty of obtaining such data (or even asking the question). (5) # of children who have gained weight. This, like other similar FFP output indicators, may be counting the same children from one year to the next (at least for a two year period). 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, 33 has made observations there about some of these which we consider not effective as well. This is not repeated here. In some cases, two or more indicators are essentially the same, except one may be for USAID/Haiti, one for FFP. A decision should be made which is the one to track, and the others dropped. An example of one set of three indicators: (1) # of direct beneficiaries reached b the NRM program; (2) # of people receiving USG supported training in NRM and/or biodiversity conservation. The numbers reported by the project are almost the same, as the same people are being counted in a slightly different way. (3) # of vulnerable households benefiting directly from USG-assistance. Data are essentially the same numbers put in the two above. And since the MYAP in one sense counts all households they are dealing with directly as vulnerable in one way or another (e.g. all households represented by the mothers visiting rally posts alone), this number for both agriculture, education, and MCHN should be in the thousands. Or another pair: (1) # of learners enrolled in USG-supported primary or equivalent non-school-based settings (2) # of students enrolled in USG supported primary schools receiving a daily meal. Sine all the learners/students receive meals, these two numbers are essentially the same. Or yet another pair: (1) # of farmers (individuals) that received extension outreach services, or (2) # of individuals who have received USG supported short-term agricultural sector productivity training. Again these data sets are almost the same, with targets exactly the same. 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 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. 34 Targeting: For the purpose of this MYAP, as well as the previous DAPs, CRS classified all the communities within the targeted communes as „vulnerable‟; essentially stating that most of the households were vulnerable to one degree or another. As such, any group of people or sub-area worked in would meet the requirement of working with the vulnerable populations of the area, estimated by the program as 196,123 people out of a total area population of 280,175, or 70% of the population. The MYAP, continuing many of the activities initiated with the earlier DAP, with the same groups of people, rally points, Col Vols, etc. then initiated its implementation plans for this new 5 year period. Food for Peace‟s strategic framework, created in 2007, upon which the Haiti MYAPs were designed, had four broad components: (1) Human capabilities protected and enhanced; (2) Livelihood capacities protected and enhanced; (3) Community resiliency protected and enhanced; (4) Community capacity to influence factors (decisions) that affect food security increased; With such a broad plate to choose from, CRS designed what was basically a community development program that favored three areas of particular interest: MCHN, selected agricultural/livelihood pursuits, and elementary education support. A special social assistance, „safety net‟ (welfare) component was focused towards groups of extremely vulnerable people cared for by a number of institutions (orphans and other vulnerable children (OVC), old people‟s homes, people with chronic diseases & PLWHA and disabled) – many living in the Port-au-Prince and Leogane areas well outside of the Department du Sud. There was no specific core group or organizing principal around which CRS MYAP activities would be organized for maximum impact. CRS, in its project proposal for this MYAP stated that “The DAP demonstrated how program sector integration is more conducive to achieving greater desired results. In the MYAP, for example, members of the same families will be reached by several different programs. The father could be involved in soil conservation projects while the mother might be reached by the MCHN component and the children by the education component. At the same time, entire families will benefit from the cross-cutting themes (gender, civil society, good governance) inter-woven throughout MYAP activities)”.13 Having made these bold and probably accurate statements, CRS MYAP implementation promptly continued earlier DAP program efforts not, in most areas, following their own good judgment and past observations about the importance of integration. It has only been in the past few months that CRS has begun to intentionally try to link some of their activities by explicitly noting on project forms if mothers clubs, for example, were receiving other program support activities (very few were). However, the problem is that the activities themselves are not always geographically located in the same areas with the same local population groups, or undertaken by the same MYAP staff personnel who are linked to different project component activities and supporting partners. Those working within specific agriculture or livelihood activities would not know who the members of mothers clubs were, or those with malnourished children coming to rally points – their groups were focused around other objectives – agro￾forestry, soil conservation, marketing of mangoes, developing irrigated perimeters for production of high value crops. 13 CRS MYAP Project Document, KOLE ZEPOL, August 22, 2007, p 36. 35 1.4 Links to GoH The CRS MYAP has developed an excellent working relationship with Haitian Ministry of Health (MoH) and other government entities linked to the Early Warning program and agriculture (CNSA/MARNDR) and the education department through their educational programs. Because of the CRS project, the Port Salut UCS (smallest management unit of MoH) has been able to improve its performance. In addition, MoH health workers have been recruited from among the CRS volunteer workers (Col Vols). The MoH attends regional quarterly health and nutrition meetings organized by CRS planning. Indicators are chosen together with the MoH. Also, in conjunction with MoH staff, CRS organizes the training sessions to the benefit of traditional birth attendants and health volunteers Meetings are regularly held with the representatives of the BACs of the communes of Les Anglais, Port à Piment and Chardonnières. The latter take an active part in the planning of the activities of the agricultural sector of the MYAP. They are regularly invited to take part in quarterly meetings that the agricultural sector of the MYAP organizes with its partners. Currently, a partnership is developing with the MARNDR through its representative in Les Anglais for the implementation of the improved seed multiplications programs of the MYAP. 1.5 Internal Reporting & Communications CRS internal reporting appears excellent. Documents that we saw appeared very well written. However, it also appears that CRS management has been late in submitting its quarterly narrative reports during the current fiscal year – and the MTE team was not able to obtain any copy of these either. Our repeated requests for these documents received the response that we would receive these soon, but we never have. The MTE team is not sure why CRS management is having difficulty in submitting these reports in a timely manner, as the other MYAP CS have been submitting these on a regular basis – albeit a bit late because of the January 12 events. 1.6 Staffing & Capacity Development The promotion of health volunteers (Col Vols) is a positive element to the sustainability of community based health service. This is because the MTE team was able to observe that they continue to perform their duties even after the withdrawal of past projects. For example, in the South, a project funded by the IDB used to recruit and pay health workers from among these community based health volunteers. At the withdrawal of this project, these Col Vols are still active – back to their community volunteer services with this MYAP. The MTE team also met a number of matrons (traditional birth attendants) during our field visits. They are community workers who traditionally attend birth delivery. Training of matrons and supplying them with a clean delivery kit is organized by this CRS MYAP with the technical support of MOH. The CRS supervisor meets monthly with these matrons to ensure clean birth delivery, and to track the work they are doing. 36 1.7 Environmental Impacts Because it is a GoH national priority, CRS has been very focused on this issue and seriously looks for ways to integrate environmental programs into their programs. All the program soil conservation and agro-forestry work in intended to support this. To the extent that it is feasible, fruit trees are planted onto slopes so as to provide an erosion control measure that will be less likely to be cut down for fire wood. 1.8 Conclusions, Lessons Learned & Best Practices MCHN: CRS‟s MYAP proposal talks about targeting. Integration was said to be important, but integration did not actually happen systematically; however, in recent months, efforts have been initiated to address this situation. A first step in this direction was to revise the form tracking Mothers Clubs (shown above, p. 29), for example, by noting what, if any, other MYAP activity a member of a specific household might be involved in. Annex 1 for the 97 existing mothers‟ clubs shows that most of them have initiated at least one livelihood activity. The CRS approach to provide MCHN and agricultural training support through existing GoH institutions is having the desired result of helping to strengthen the capacity of the Government of Haiti‟s Ministry of Health and MARNDR to improve rural delivery of health and agricultural services. It has also been responsible for linking GoH into a successful and potentially sustainable system of voluntary community self-help initiatives which organizes communities to reach towards GoH services. It is a strength that the community based health structure remains independent and voluntary and NOT linked to government – while GoH official health services reach as far as they can towards these community structures. Local residents meet at the Rally Posts and health clinics themselves, and through the services of the voluntary Cols Vols. Though it may be tempting for GoH to formalize such relationships to these community structures, this would probably end up by destroying them. The strength of the community structures is their very informal and voluntary nature – based on household level defined needs and mutual support among friends and neighbors. Training provided to mothers at the Rally Posts once each month per locality by a Col Vol is limited in its scope – only lasting about 15 minutes, followed by the more lengthy process of weighing the children and recording the results on both the Col Vols register, as well as the child‟s growth monitoring card. More intensive training is given by the Cols Vols to the selected group of mothers in the current Mothers Clubs they may lead, though the numbers of such groups is very limited within the CRS zone (97). This training is of high quality and well delivered through the existing mothers clubs. Record keeping by Col Vols in the registries kept for each mothers club appears excellent, and the foundation upon which program monitoring has been successfully based. Information from these registers flows to the health centers or dispensaries and on to the CRS regional health practitioners/nurses and their auxiliary helpers. There is a problem, however, with the existing mothers‟ club system. The problem, in the MTE team‟s view, is in the way they have been organized or structured. Even though CRS‟s concept paper says that mothers clubs are not to exceed 15-20 members, what has happened, in practice, is that the earlier DAPs, and then now the MYAP, began initiating cohorts of pregnant and lactating mothers into groups of 20 mothers (not 8 or 10 or 13 members but 20. Then these mothers groups were placed under the training/coordination of the Col Vols (who selected them) directed by the program. The Col Vols are 37 people (men or women) identified by CRS and the local health clinics as meeting the criteria to become „Col Vols‟, representing the different localities within the communes and section communales in which CRS has targeted for the MYAP. While Col Vols indeed provide these services „for free‟, they also represent the „official‟ local contacts for the health service (and other services if need be) within the local communities to render special government services if needed. Sometimes these services are paid for, so it is one incentive for a person to be registered as a Col Vol. They are in a sense „pre-selected‟ people for these potential future paid services. The criteria to be a Col Vol include: (1) Willing to provide at least three days of services each week. This includes assisting in the monthly rally points within their respective communities and/or leading one or more mother‟s groups. Not all Col Vols lead mothers clubs, but all Col Vols that lead a mothers club also assist at the monthly rally points. (2) Must be literate and able to communicate publically. Mothers Clubs are perceived by rural households as a CRS program. It was CRS that proposed the approach, it was CRS that said that the groups should have ‟20 members‟, it was CRS that told the mothers clubs that they were „closed groups‟ – that other community members could not join them once established – since they were already at their „maximum‟. The MTE team met with members of several clubs. Of the Col Vols we met (we met 8 at one meeting), all had been Col Vols for the past 14 years – there were no new ones, as they were still working with the „old groups‟. One mothers group we met with noted that there was one „cohort‟ that had started in 2004, and another group of 20 that started in 2006, but none since. We were told that now CRS is thinking about starting a new cohort of pregnant and/or lactating mothers of 20 in the area. What happened to all those women in the year‟s in-between who were pregnant, or had children, and who were not part of the established mothers clubs? The answer was that these woman and their children all could came to the rally points where they received training, growth monitoring, and other social services – but that they were not part of mothers clubs. This was the situation in all the CRS MYAP areas visited. The weakness of the current method of mothers club is that the community women and mothers are not given the flexibility to themselves form into self-selecting groups of women (of whatever size), and choosing among themselves to nominate a mother leader who could receive special training from the Col Vol or other program health agents to pass to the mothers group. When we spoke of this as an option, the mothers were quick to agree that this would be something they would like very much to do – that indeed many of them already pass on their training on their own to other women friends who are not able to be part of the „official mothers club‟. As noted earlier, it is the CRS strategy that mothers in these selected mothers clubs are in fact consider all considered as „leader mothers‟ who are expected to pass on their training to their community peers. One woman had in fact created her own group of 40 women – mirroring the 40 women who were currently making up her own „official mothers club‟ – a combination of two groups of 20 „old groups‟, that are now also organizing for some livelihood programs (vegetable gardening, saving and loan ). This natural extension of the program is an excellent witness to its importance and the success of past training received – but one notes that the reason for the „new group‟ was to form for economic purposes. The concept of „mothers groups‟ has not caught on within the CRS area as something the mothers themselves would want to form into for the purpose of linking to health services and training provided 38 through Col Vols and the rally clubs, as well as livelihood activities. Why not? A couple women said that they didn‟t want to be Col Vols – they didn‟t have the time to give to do all the things that Col Vols were asked to do, or go to all the meetings they had to go to. But what if they were only to lead their own small group of 7, 8, 12, etc. women friends with babies and small children – would this be of interest? Here, the response was very much in the affirmative. Indeed, some of the best practices models elsewhere for mothers clubs (e.g. in Rwanda where the external consultant has also worked), mothers clubs of 10 – 15 self-forming mothers, are led by volunteer leader mothers from within the group who is herself trained by what would be the equivalent to the Col Vols or rural volunteer health workers (under supervision of PVO staff linked to Government health clinics/services. The Leader Mothers role is to pass on the training she receives from the volunteer health workers to her friends/neighbors who wanted to be part of this local mothers club. They are bound together by having children less than 5 years of age initially – but the group can continue into the future should they wish to do so (as they continue to have new babies, or as they begin to venture into livelihood activities as a group of women who have worked together over the years and trust each other. Leader Mothers (in the Rwanda example given above) duties include visiting the households of each of the mothers in her group to check on the children under 5, to see if mother has understood the trainings given and is practicing them, and to provide the growth monitoring services. The Leader Mothers (or a person in the club) keeps a register for their group that tracks the children of their group – whether they are „normal‟, malnourished, or severely malnourished. Children who fall into the malnourished category are linked to the PVO for supplemental feeding and special attention for household feeding practices, clean water issues, etc. Children who are severely malnourished are referred to the local health clinic where special emergency assistance is given. Groups like these do not disappear when the project ends. Groups like those established by CRS might be expected to disappear if CRS were not to be present any longer – unless they had ventured into some livelihood group activities to justify their continuity. CRS, in response to the concepts about leader mothers for mothers clubs stated that “Neither CRS, neither the MoH, can guarantee that a Leader Mother can keep a mothers club by themselves, and guarantee the quality of the messages they are able to transmit”. 14 However, they would not be doing so „by themselves‟ as they would be receiving regular training and visits by their MYAP Col Vols or other program health agents. And this has been proven to be possible in other FFP programs in other countries, though perhaps not yet in Haiti. Furthermore, success rates in reducing malnutrition rates in many CRS areas, in spite of many years of efforts, suggests that relying on the trained members of current mothers clubs to share their special training with their community peers may not be as successful as desired. CRS cannot guarantee what messages mothers in current mothers clubs are transmitting within their own communities either. Without some accountability or MYAP assisted semi-formal structure for such community diffusion of messages of the current mother‟s club members, it is unlikely that there will be much more than a minimal diffusion taking place in changing behaviors as desired. 14 CRS email communication to Richard Swanson, dated July 15, 2010. 39 Agriculture/Livelihoods: The implementation of different agriculture activities are focused on different target groups. This has resulted in weak integration between the MCHN and Livelihood components of the project. For example, the vegetable gardens with a nutritional and economic vocation are not systematically implemented within the mothers clubs with their children from 0 to 5 years. It is interesting to note that the CRS MYAP took the initiative to focus on the value chains of two specific commodities (mango and pepper), which is clearly leading to an increase in the production of both in the concerned regions. This focus has also helped to attract the market buyers to the region, thereby linking the two groups together. Focusing this way is important. 1.9 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 3 to receive a full understanding of the mid-term evaluation. We did not wish to repeat all of the major recommendations here. Only a few have been selected for inclusion here. Mothers Clubs and MCHN (1) Encourage existing „old‟ mothers clubs to reform into smaller group of their choice, if they wish to, based on proximity and close friendships relationships (not less than 5 members), and choose a volunteer leader mother among themselves – preferably one who is literate who will be expected to keep a register for the mothers club, showing names of mothers and all their children and their growth monitoring records. This will mean reconsidering the actual effectiveness of the current strategy of expecting each member of current mothers clubs to informally share the key messages they are learning from the MYAP to their peers within their communities. (2) Encourage some of the members of the „old‟ mothers clubs, who have already been through the cycle of training courses from pregnant women through that given for children two years or younger to, should they be interested in doing so, take the lead in forming new mothers club groups with a circle of their own personal friends or age mates. It is better that groups not initially exceed around 10-14 mothers, thereby permitting natural growth in the group as time goes on – as new neighbors/friends become pregnant and wish to join the neighborhood mothers club. There will always be some attrition as people move away, die, or simply wish to quit. If groups grow to exceed more than 20 women, encourage them to split into two smaller groups, each with their own volunteer leaders. This permits natural growth in both the numbers of mothers clubs and mothers within the community who can become members of these mothers clubs. (3) Identify „Leader Mothers‟ for each mothers club – whose volunteer services will be to their own small circle of mothers only – and NOT beyond this circle. These may be the „model mothers‟ of the existing mothers clubs if they are willing to do this. Then, provide the additional training, to 40 these groups through their leader mothers. It will be the responsibility of Col Vols to meet with groups of 15-20 leader mothers to provide the training themes of each month; the leader mothers will then pass these messages on to their own groups of mothers in their next meeting – which should be scheduled a few days later.. Make it clear to each mothers club that it is up to them to rotate new Leader Mothers of their club if they wish to – this is their mothers club, not CRSs or the Col Vols – so they need to manage it themselves. (4) Include growth monitoring within the tasks of the Leader Mothers, and remove this entirely from the Rally Point tasks. Growth monitoring should use the paper strips method (MUAC), rather than weight scales. Include at least once a month visits by the Leader Mother to each of the households of the mothers of the mothers club she leads, and more frequently when they know that there may be malnourished children in some households. They should take special concern that „their‟ mothers have learned the lessons and are applying better practices for the wellbeing of their children and households. (5) Have an exit plan strategy from most of the areas where CRS has these „old mothers clubs‟ – probably within the year – after initiating the process described above, and then only continue a light monitoring of the continuity of these groups, and the continued link through the Col Vols of the community at the Rally Points. Keep track if mothers continue to meet each month to provide the training, if children are being growth monitored, and if they continue to come to the rally points where the other social services are provided. Track if the nutrition levels of the Rally Points is rising or falling. The exit from the mothers club should probably take place not longer than 2-3 years from the beginning of the club. By this time the groups should be well established, both as a group of mothers caring for their ever growing children, as well as having initiated some livelihood activities. (6) Focus livelihood activities at the household level and NOT at the „group‟ level. The group can be used as the initial training ground, but it is almost always better to establish the training at the level of an actual household „model‟, for others to emulate. In the case of establishing bio￾intensive high value vegetable gardening for both nourishing food for the households as well as for cash crops, it is better that this be done at the household level. A mothers club group might establish their small seed nursery at the home of one of the mothers, with access to water for easy watering, but then the transplanted seedlings would go into the private bio-intensive gardens of the specific members. This „model‟ household could become the focal point for the group to initially obtain their seedlings for transplanting into their own gardens (as opposed to doing this as a „group‟ activity‟. Either the CRS livelihood team would target these groups, or the ColVol would be trained in showing the how to establish these nurseries, helping with the initial seed and other appropriate techniques. (7) Initiate, from the beginning of mothers clubs, thinking among the women to focus on two key livelihood activities: high value vegetable gardening – at the own households (and not as a group), and initiating a savings and loan program within the group, modeled after CRS‟s best practices model developed in Malawi.. These two livelihood activities should be the core activities of any agriculture/livelihood effort of the program - and targeted at the mothers clubs. 41 (8) Provide incentives for the establishment of these home gardens and saving and loan activities through a program that publically recognizes a certain % of the mothers clubs in a section communale by providing cash based prizes (maybe $ deposited into the savings account to spur increased internal group loans and new ventures) or a year‟s supply of plastic bags and an assortment of most valued seed for the vegetable gardens). The incentive is VERY important to spur ALL the groups to increase their own initiative to surpass others in their own group‟ success. (9) For vegetable gardening, identify an especially active and successful „model mother with vegetable garden production‟ to become the supplier of quality seeds for each locality. Link her to the best source of suppliers for seed, as well as the plastic bags for seedlings. Though getting Haitians to purchase agro-forestry seedlings is a losing prospect, given the bad precedents established in the country for free distribution, this is NOT the case for fruit tree seedlings that will subsequently be grafted, or for high value vegetable seedlings that can be transplanted from established vegetable nurseries. (10) Move away from dependence on “organized community groups” to produce everything for „usually free‟ distribution to members and other community members to one where selected entrepreneurs are developed, perhaps from within such groups, to develop small businesses to provide these services. Community groups are effective in beginning program demonstration trials, because they often have access to the resources (land) that more vulnerable households may not. (11) Provide these targeted small businesses with setting up their businesses, providing training in costing their services realistically, and help them to link to suppliers they need for success (sources for quality seed for example) and for marketing their products within the community. If the project wishes to distribute „free trees‟, don‟t produce them through „community groups‟ which will almost certainly disappear when the project ends, but purchase them through a series of commune or section communale level entrepreneurs to provide these services. If the PVO wants to „give‟ seedlings to targeted groups (like small farmers in a targeted watershed), give them vouchers that they can redeem for seedlings at one of the private entrepreneurs (who in their turn can redeem the vouchers from the PVO). This helps to build local capacity in a manner which has a greater potential for sustainability. (12) Hire local student interns to work with health workers in mining their rich source of data at the section communale level – looking at trends at the rally post levels – to identify where CRS should be planning to retreat from, and where special attention needs to be given. (13) Create a database, using a number of GPSs, of all the points for the location of rally points, food distribution points, location of health clinics, location of meeting places of mothers clubs, etc. Then have these mapped out using GoogleMaps and use these as tools for planning and 42 management within the program. This would be an easy way to identify and track rally points, for example, from which CRS begins to withdraw. 2.0 CRS Strategies and Outcomes Achieved to Date 2.1 Improved Nutritional and Health Status of Targeted Vulnerable Groups Effects on the Nutritional and Health Status of Targeted Vulnerable Groups This program addresses several factors which affect low nutrition rates among children. Deworming and water/sanitation activities, which are extremely important factors, are not consistently addressed in all areas. Trends in malnutrition as analyzed in time series since the beginning of the MYAP by the MTE team in certain areas do not always show a decrease of malnutrition levels. During our visits, we observed a lack of follow up of children under five for several reasons, and various factors could explain this:  child or mother is ill, or the absence of the mother who leaves the child with another person who themselves have not received training on health and nutrition of infants;  Some children in preschool settings do not come to rally point when the latter are organized during mornings;  Some health volunteers do not actually follow up with home visits to find out why a particular mother did not bring in her child for services, or why services are not proving effective;  Lack of support of the community. Some mothers are sometimes ostracized by their peers as being a „neglecting parent‟ instead of being helped by other mothers trying to understand the barriers and coping with her toward the better care of their children; there are often good reasons why this is so.  New arrival of acute or chronic malnutrition cases into the community.  An increase of malnutrition levels, particularly of acute malnutrition after a dry season or a disaster (hurricane) affecting the geographic area;  A lack of rapid response to acute malnutrition cases. Or… no recovery (even when malnourished children 24 - 59 months are supported with supplementary feeding during 9 months). 43 Commune Les Anglais 1iere Section Verone Annee 2008 Etat Nutritionnel des Enfants en surveillance Janvier Fevrier Mars Id Nom Postes Rassemblement N PFA PTFA K Presents N PFA PTFA K Presents N PFA PTFA K Presents 1 Casse 50 9 1 0 60 56 6 1 0 63 52 10 0 0 62 2 Figuier 20 0 0 0 20 14 1 0 0 15 16 1 1 0 18 3 Bocco 22 5 1 0 28 29 2 1 0 32 34 3 0 0 37 4 La Source 45 1 0 0 46 43 0 0 0 43 24 1 0 0 25 5 Cayiman 46 4 1 0 51 44 5 1 0 50 45 4 1 0 50 6 Verone 53 3 2 0 58 68 4 1 0 73 65 5 0 0 70 7 Petite Place 12 5 0 0 17 14 4 0 0 18 0 0 0 0 0 8 La Chaine Bon Pas 12 1 2 0 15 17 1 0 0 18 20 1 0 0 21 9 Losier 8 2 1 0 11 13 3 0 0 16 22 4 0 0 26 Total 10 268 30 8 0 306 298 26 4 0 328 278 29 2 0 309 Nbre de cas malnutrition / mois 38 10 30 7 31 10 % 12.4% 16.7% 9.1% 11.1% 10.0% 16.1% Moyenne mensuel Population en surveillance 322 Moyenne mensuel cas de malnutrition 40 % 12.4% The table above illustrates data the MTE team was able to obtain in the Commune Les Anglais for the 1st Section Communale of Verone. In this section communale, there were 9 rally posts, as shown. We asked for the data shown for the period January 2008 (about the beginning of the MYAP) through until April 2010, wishing to see if there was any trend line towards reducing malnutrition rates (PFA + PTFA) in these localities when compared to those measured as „normal‟. The chart above only shows these data for the first three months of 2008. Such data sets exist for all of CRS rally points and section communales, but we received no documents from CRS showing that they had ever analyzed these data to assess the impact on their activities. Remember also that these are regions in which CRS has worked for over 10 years (two DAPS + current MYAP). The time-series graph for these 27 months of data (cf. p. 27, Figure 1) did not show any steady decline in malnutrition, but very irregular jumps over time, starting at around 12% for the average of all 7 rally points and ending just below 10%. Single rally post data show even more fluctuations in monthly rates. 44 2.2 Improved Quality of and Access to Health Services for Vulnerable Groups Among the achievements of the CRS MYAP within its MCHN and education initiatives during FY 09 are the following:15  10,054 women received a monthly dry ration (pregnant or lactating mothers)  Over 100 community health workers received special subject training  26,012 children less than 5 years of age receive growth monitoring services through some 686 rally posts each month  2,219 malnourished children on the average receive food supplements each month in FY 09  2,957 PLWHA and 821TB patients receive monthly supplemental rations  44,583 children received a hot meal through their school program  1,180 teachers from 123 schools receive training to improve their pedagogical skills  34,045 people received 24.6 metric tons of MYAP commodities for emergency feeding following the three 2008 hurricanes, an even larger number of people were assisted following the January 2010 earthquake near PAP. Though malnutrition may be identified among children at the Rally Points, less than 50% of mothers are actually taking their children „down‟ to the health center to receive help and the food supplements they could receive. Several Cols Vols the MTE team met referred to these mothers as “negligent”, and not caring properly for their children. However, it is equally possible that these mothers are making an entirely rational and economic decision. They have performed their own “quick and dirty cost benefit analysis” and found that the costs outweigh the benefits of that long trip to the health clinic, and the cost in time and money this would certainly involve. Furthermore, not all children less than 5 years of age come to the Rally Posts each month – and many of the ones the MTE team observed included largely mothers with children under two years of age. So it would appear evident that the other children under 5 years of age might also be malnourished, and the only potential messages that could help them are only being received by those mothers have actually come to the Rally Post that month, where they heard a 15 minute talk by the Col Vol on some health related them before their children were weighted. There is a great increase of access to health services (particularly for women and lactating women). • It increases attendance to health center (greater number of prenatal and post natal visits among pregnant mothers). This has been possible with the support of the project, thus providing the supplementary feeding is an incentive. However delivery is more often done at household level by trained matrons but sometimes lacking of equipment and materials. • The rally points and the private mobile clinics allow the vaccination of children less than five years old near their residence. In such a way, it increases the attendance of clinics and rally posts. They now can get full immunization coverage before they reach their first anniversary. So they are better protected against communicable disease … and start better start in life. 15 Taken from CRS MYAP Pipeline and Resource Estimate Proposal, August 3, 2009 45 • It also leads to improved growth monitoring and 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. • It multiplies exposure of mothers to education: at rally posts, at mother‟s clubs. In all regions, mothers consider the education useful when they observed the growth and health of youngest children compared to the oldest. They encourage other women to come to rally post, and would do so for mothers clubs, if more mothers would be allowed in those clubs (by creating new clubs). • CRS has improved the logistic support to the cold chain for vaccination. Fuel and refrigerators are provided by MOH and transportation assured by the MYAPP. In the event of rupture, the fuel is bought by the MYAP. However, distance and the cost of services in certain areas limit access of children to health centers, despite the supplementary feeding program. One of the success of the program is toward improving knowledge of pregnant women about danger signs, and other signs that would require a visit to the health center. There is also a gap between regions, regarding the level of malnutrition. For example, along the coast, or in Aquin, few malnourished children have been reported for many months. But in the mountains, where there is less access to health services, we have been able to observe more malnourished children in rally posts. Knowledge and practices regarding nutrition and hygiene. Regarding Child feeding, at the time of evaluation, mothers have good knowledge about exclusive breastfeeding, and complementary feeding. Management of infant feeding by the mothers has improved. They give at least 3 principal meals to the child, and some supplements at other time of the day. According to mothers, the ration distributed can last a week because it is shared with other members of the family. For the rest of the month, they complete the meals with food available in the household. Water and sanitation is a major problem in most visited areas. Even though, mothers are educated to wash their hands or to treat water, there is a lack of access to water for household use and culture. There is no distribution of chlorine by the program. Mothers who retain the messages learned use chlorine only when they have the economic capacity to get it ... otherwise they still promote the use of lemon which was not the recommendation. The washing of hands is done with SOAP or ash, when water is available. They know that they should cover dishes and utensils filled with drinkable water. Some mothers say that they lay ashes in latrines and ensure that toilets are well covered. However, some have no toilet nor latrines... too costly... and no adequate water and sanitation promotion strategy. 2.3 Increased Food Production and Household Assets The agricultural component of the program has remained fairly focused on a number of promising commodities that show commercial promise, and households associated with these activities will most certainly experience increased assets, though this has still to be realized in most cases. CRS proposed to 46 do what they are doing, and they are doing a fine job in this area. What raises some questions for the MTE team is that the households benefiting from most of the agricultural work are not linked in any way to the MCHN component of the program – and the CRS proposal implied that it would. Our suggestion would be that for the balance of this MYAP the focus shift to greater attention to specific localities where malnutrition remains high and focus on the mothers clubs and through them closely integrate some appropriate livelihood and agricultural activities. And all livelihood activities should seek a clear entrepreneurial focus on leaders for specific ventures. Among the top achievements to this point (through end of FY 09) in the MYAP are:16  7,743 mango seedlings planted in 4 nurseries; of these 1,217 have been grafted by 60 youth trained to do so  353,564 seedlings were established in 65 nurseries; 134,038 have been out-planted to the fields of participating farmers  1,431 farmers received training in soils and water conservation  449 hectares of farmland were protected by soil and water conservation structures  126 farmers have received training in improved seed production and post-harvest storage  67 farmers have been training in seed production of a high yielding black bean variety  2 mango producer groups (100 farmers) were organized and helped in the commercialization of 665 dozen Francisque mangos  23 MUSO (savings and loan women‟s groups) were helped to launch their savings groups, and 6 new ones were assisted in writing their bylaws.  710 additional hectares under improved technologies or management practices as a result of USG assistance  2,490 direct beneficiaries reached by the NRM program  3,323 people receiving USG supported training in NRM and/or biodiversity conservation  3,696 vulnerable households benefiting directly from USG-assistance  392 farmers (individuals) that received extension/ outreach services  360 individuals who have received USG supported short term agricultural sector productivity training  34 producer organizations, water associations, trade & and business associations and CBOs receiving USG assistance  4 MSME´s receiving business development services 2.3.1 Improved Food Security? The CRS South Department region should not be a region of food insecurity. The region is blessed by better than normal rainfall – in spite of occasional dry spells – which the right techniques should be able to resolve. There are many irrigated perimeters that have high potential. With the improved varieties already introduced this area should be able to move forward. The MTE team believes one of the most important food security themes the MYAP should continue to develop further is the aggressive extension 16 Taken from CRS MYAP Pipeline and Resource Estimate Proposal, August 3, 2009 47 for high value vegetable gardening – beginning with the household gardens. Because water IS an issue during some parts of the year, then water is the issue that must be solved for these home gardens. Greater attention should be given to cisterns in this area and the use of small-scale drip irrigation household level systems. Their primary purpose would be for improved household nutrition (during those months when there may be less food) and secondarily as a source of additional income. 2.3.2 Appropriateness of Early Warning System The EWS as currently operating with CRS input in the Southern Department appears to be an excellent tool for policy makers and implementation agencies alike to address food security issues in a timely manner. The MTE team would suggest adding another element to the mix of information regularly shared within the existing bulletins placed on the CNSA website. We suggest selection of sentinel rally points, preferably in the „difficult to reach rally points‟ areas to track changes in malnutrition rates (PFA and PTFA) as the key indicator for early warning. We believe this would be a good measure to add along with the rainfall and market price data currently used. Though excellent recommendations are given in the existing EWS bulletins, we would suggest that information also be included at to whether action actually took place with respect to earlier action recommendations. It is important that CRS show evidence that this work is actually helping is some concrete manner; otherwise these efforts may be quickly abandoned at the end of the project. Though success of the EWS system in the Southern Department depends on many different institutions, working together, it is important that there be increased evidence of the GoH entities involved taking increasing leadership in supporting this useful tool. 2.4 Enhanced Market-Based Livelihoods The CRS focus on only a few commodities that have real commercial potential in this region has been an excellent strategy to take, and one that we would expect will give some very significant impacts by the end of the MYAP. The MTE team would suggest that the agricultural team closely monitor the volume and value of the mangoes, chili peppers, and other high value crops that are being directly commercialized by the groups they are working with. Short, one page fact sheets should be developed for each of these activities and updated regularly. This is not information currently being obtained in the M&E system, but is information on outcomes and impacts the program must not fail to obtain. 2.5 Rehabilitated Natural Resources and Local Capacity to Sustain These The MTE team did not observe a great deal of activity by CRS in this area – though we know that some 449 hectares of FFW soil conservation work was done and at least 353,564 tree seedlings planted. CRS was not as deeply involved in the business of developing and managing tree nurseries in different regions, as was the case with WVH, though 43 nurseries have been developed and many trees given away „for free‟. On a smaller scale, what we observed were some small nurseries with mango seedlings for grafting, with a serious attempt to link this with more commercial scale ventures with high-value commodities (vegetable crops, mangoes, avocado, etc.). 48 2.6 Challenges Faced and Overcome in Program Implementation Like the other MYAPs, CRS faced the same wave of people fleeing the earthquake disaster of January 2010, bringing in many people looking for temporary food and shelter. Interviews with beneficiaries suggest that most of these people have returned to PAP or Leogane, leaving some of the younger children behind. CRS was required to move from a development mode of operation to an emergency relief mode, but appears to have done so very well. Having a strong field staff already in place permitted CRS to be an important partner for the GoH and USAID in determining the need and responding to it. 2.7 Successful Strategies Col Vols: The unpaid Collaborating Volunteers (Col Vols) through whom the CRS MYAP reaches most of the program beneficiaries within the MCHN component of the program appears successful. These are the estimated 596 men and women who have received special focused training in health and nutrition over the many years in which CRS has worked within this region. These are the people who manage most of the activities of the Rally Points, sometimes with the presence of a CRS health coordinator. Many Co Col Vols have received additional training as health agents, including giving vaccinations/shots, and have the special designation of „picurs‟. Many Col Vols noted that they have been doing this with CRS for 19 years – since 1991. The large majority are men. GoH Linkage: The linkages with GoH local and regional institutions and holding planning and strategy meetings with them on a regular quarterly basis have been very successful and important. Similar linkages exist with the agriculture sector, or the Ministry of Education for the school programs worked with. CRS has developed an excellent working relationship with the MOH and other government entities. Along with the CRS project, the Port Salut UCS (smallest management unit of MOH) has been able to improve its performance. In addition MOH health workers have been recruited among the CRS volunteer workers. The MOH attends regional quarterly health and nutrition meetings organized by CRS planning. Indicators are chosen together with the MOH. Also, in conjunction with the MOH staff, CRS organizes the training sessions to the benefit of traditional birth attendants and health volunteers. The existence of the EWS system and the completed four quarterly bulletins also attests to a successful CRS working relationship with GoH and other regional partners in EWS. 2.8 Unsuccessful Strategies and Proposed Changes Mothers Clubs: Mothers Clubs were not considered of central importance to the CRS program as is reflected in the target of 110 for the entire life of the project. Actually some 153 have been established to date, according the CRS IPTT – though only 97 of these are supposed to be active, according to data CRS gave the MTE team in June 2004 (Annex 1). However, the approach to local communities through the existing CRS Haiti Mothers club approach is not working, nor does the MTE team believe the proposed „new strategy‟ to target uniquely pregnant and lactating mothers to form „new clubs of cohorts‟ will be likely to be successful either in communicating behavioral changes with respect to health/nutrition messages through the general local population. 49 The real issue here is with how Mothers Clubs are initially structured in the first place. Mothers clubs‟ are seen by local people as a CRS tool to organize them to receive specific training for specific „chosen‟ mothers. Mothers are “invited by CRS and Col Vols” to form into such groups of 20 women, most recently in cohorts of pregnant and/or lactating mothers around specific Rally Points. These are not necessarily women who know each other; they may live at some distance from each other. Their only reason for being in a newly created group is because they fit a selection criteria for some of mothers coming to a Rally Point, and were „invited by the Col Vol‟ to receive several special weeks of training (for which they received a certificate). Following this training, the Col Vol would continue each month to provide this select group of women with continued training, with themes cycling through a series of health, child care, food preparation and nutrition, and other health related topics. Each Mothers Club is associated with one Col Vol. This is not a self-selecting group. 2.9 Exit and Graduation Strategies A frequent observation in development assistance programs is that we seem to continue to do the same things over and over again, often using the same approaches over time. We set and meet most of our targets, we deliver the commodities to the targeted number of children or households, but in the end the changes in behavior sought for do not take place. The project ends, and new ones begins, often in the same area (by the same organization, or by some other group or donor), only to repeat once again the same approaches, with again the same results. Programs become established which require the perpetual presence of outside support for continuity. Local populations have seen this coming and going over the decades and have changed to accommodate this development assistance approach and become dependent on it. If one waits long enough, someone will come and give „us‟ foreign assistance, will give „us‟ free trees to plant, and will give us free food for our malnourished children. Donors like „us‟ to form into „groups‟ to receive assistance, so we will form into whatever kind of groups they desire to receive their support. CRS has been present in this region of Haiti for a very long time in one program after another, addressing the same communities, groupings of households, or regrouping of communities and households in different ways over time. There was a FFP DAP 1, followed by a DAP 2, and now further followed by this MYAP. Does this process never end? CRS, in this MYAPs project proposal rendered a real service to FFP Haiti MYAP programs in general by directly addressing the issue of exit and graduation strategies head-on.17 They quote a FANTA technical report that defined these concepts: “Exit refers to the withdrawal of all externally provided resources from the entire program area. Graduation refers to the withdrawal of resources from selected communities, program sites, or program activities”.18 While the issue of the seemingly never-ending presence of a given NGO in a specific region itself might be a worthy topic to contemplate (i.e. the exit strategy as defined above), the MTE team will only consider the issue of „graduation‟ here. We know that resources available will never be adequate to the actual need everywhere, or to address all the expressed „need‟. So we prioritize and focus our activities. CRS clearly hypothesizes that “by carrying out (our) integrated health, education, and livelihood interventions in tightly targeted geographic areas, food insecurity will be reduced enough over time 17 KOLE ZEPOL, CRS MYAP Project Document, August 22, 2007, p 36. 18 Beatrice Rogers and Kathy Macias, Technical Note 9, “Program Graduation and Exit Strategies: A Focus on Title II Food AID Development Programs, FANTA, November 2004. 50 to warrant exiting, or „graduating‟ a community from the Title II program”. 19 In their MYAP proposal, CRS offered 5 potential criteria for considering what program achievements might justify the „graduation‟ of Title II MYAP activities from a given community. The MTE has considered these, and offers our own observations at this mid-point of the MYAP program in Haiti. The criteria: (1) Average global malnutrition (age for weight) rates of children 6-59 months = < 10%. The MTE team would suggest that, of the five criteria offered here, this is the only one that is really important and achievable within the life of any specific MYAP. We would suggest that it alone should also be the trigger for graduation of a FFP program. We do not say that other development activities are not worthwhile – they are – but if food security is the core issue as stated in the program goal, and resources are actually limited, then this is the only criteria we should be concerned about achieving in a sustainable way for the targeted population in the „tightly targeted geographic area‟. Indeed, we would go further and state that the target should probably more close to < 4-6%, and not < 10%. If after working within a defined area for several years one is not able to reduce malnutrition to these levels, then there may be a problem with the approach. (2) A demonstrable commitment from local government health leaders to carry on Title II health activities, such as maintaining Community Health Worker (CHW) networks, growth monitoring of children 6-59 months, etc. This is a worthy goal, and one that should be promoted, but one which the MYAP cannot have any long term control of. As a criterion, it is a guarantee of the need for the presence of the caregiver (in this case CRS) in this region for the foreseeable future. For this criterion to be met there would need to be the national political will and resources to do this, which under the circumstances, do not presently exist in Haiti. GoH health facilities may be more widely available within the CRS areas of operation, but such distribution is not the case in all regions of the country (e.g. areas in which World Vision is working). The MTE team believes the more important issue here is whether the community outreach structures put into place by the MYAPs have any chance of continuity in the likely absence of such GoH commitment in the foreseeable future? This issue is addressed elsewhere. (3) Full-fledged (certified) PTAs formed This too is a worthy goal, but not one directly linked to Title II food security programs. These groups, as CRS has demonstrated, can be vehicles to reach households with appropriate messages with respect to the education and care of their children. But this criterion should not be considered a trigger that must be accomplished before a PVO would „graduate‟ their FFP supported activities from a specific community. (4) 50% of local farmers participating in a legalized agro-enterprise group It is easy enough to get farmers to organize themselves into groups – they have been responding in this way to donors for decades. Long decades of experience, however, also has demonstrated that legalizing them and creating them into „agro-enterprises‟ does not necessarily lead to sustainability. One need only think about Rwanda‟s obsession and experience with legal groups and cooperatives to know how these evolve and the ultimate result. Once program (outside) support is removed, most such groups collapse under the burden of their management/administrative structures, lack of proper or ethical financial 19 KOLE ZEPOL, CRS MYAP Project Document, August 22, 2007, p. 36. 51 structures and transparency, dominance of a small group of „leaders‟ at the top for political power or control, etc. They often only exist in the first place because the donor (or government) wanted to organize them to collectively have access to inputs (bypassing private sector import supplier merchants, if possible), selling „directly‟ to markets. It might be more meaningful to set as a goal the establishment of a number of private sector entrepreneurs with the specific „targeted areas‟ who have become capable of supplying the services (need for improved seed, inputs) or marketing of promising local products to regional and international markets. CRS‟s experience in helping to train groups of farmers to develop and improve their own grafted mango trees is a good example. These farmers are negotiating and selling their high quality fruit to regional companies who send their trucks into the area because the volumes justify their expenses of searching out and taking out the fruit. The „group‟ mentality would suggest that rural farmers organize themselves to take their own mangos to the urban markets – bypassing the regional outreach efforts of large in-country companies seeking national and international export markets. Such an approach is misguided. (5) 50% of the micro-watershed areas benefiting from soil and water conservation measures Again, this is a very worthy goal and actually potentially achievable within a very circumscribed area over a period of a few years. Doing so will provide a foundation for future productive use of these lands, leading to the improved livelihoods of those using these lands. However, using this as a trigger that would have to be achieved prior to graduating FFP Title II programs from a community, where „food security‟ is the central issue, does not seem necessary. The MTE would itself suggest two livelihood „triggers‟ that might be considered to be added to the first one listed above: (6) All FFP Title II programs focus on the MCHN component as their central organizing theme, with the target (within „tightly targeted geographic areas‟) on the majority of all mothers of children with children under 5 years of age through mothers clubs of self-selecting groups of women (with a leader mother), and (7) That the majority of these households be involved in at least one, preferably both, of the following two livelihood MYAP activities to qualify for food supplement assistance: (a) establishment of a bio￾intensive vegetable & fruit gardens and/or (b) participation in a savings and loan mutual group. Either or both will lead to both improved household nutrition of all family members and towards other economic livelihood opportunities of choice for the different individuals concerned. Any additional trigger categories may be considered examples of mission creep – worthy in themselves, and probably legitimate topics for other project ventures, but perhaps not for FFP. FFP may wish to reconsider their goals and key priorities for Title II funding which currently include the following four FFP strategic framework categories: (1) Human capabilities protected and enhanced; (2) Livelihood capacities protected and enhanced; (3) Community resiliency protected and enhanced; (4) Community capacity to influence factors (decisions) that affect food security increased; 20 20 Food for Peace, Country/Cooperating Sponsor FY 08 – FY XX Multi-Year Assistance Program (MYAP) Proposal, Proposal Application Format, August 1, 2007, page 4. 52 2.10 Conclusions, Lessons Learned, & Best Practices Mothers Clubs: The CRS MYAP may not appear to place a great deal of attention to mothers clubs – having as an overall end-of-project goal of forming only a total of 110 such clubs. Yet CRS does consider the especially well trained mothers within these mothers clubs as a select group of local women – actually „leader mothers‟ in much the same way as some farmers become „model farmers‟. CRS did consider these groups of women important enough to include it as one of their IPTT indicators (which the other Haiti MYAPS did not). Review of this IPTT, to date, shows that 153 mothers clubs have been formed, already exceeding the EOP target. However review of Annex 1 which the CRS MCHN program provided to us in May 2010 only shows a total of 97 such clubs in existence. The analysis of project implementation shows that a great deal of effort has already been expended toward the achievement of MYAP objectives.  Planned priority activities have been conducted in targeted areas;  There is a progressive introduction of preventive rations in the different communes, and we suggest continuing to analyze criteria for this introduction while improving them;  The number of rally posts to reach beneficiaries have increased, particularly in difficult to reach areas;  Field staff competence and motivation of the staff to implement activities. We have been able to observe major strengths in the project.  Increased # and Geographic Distribution of rally points  Dedicated staff working in difficult settings.  Health volunteers (Col Vols) as a sustainable approach, and the way CRS encourages them by integrating them also in a livelihood activity.  Savings and loan groups among mothers‟ clubs and associative groups.  Improved knowledge on MCHN, and better practices of exclusive breastfeeding (WV, CRS) Some areas must been strengthened, mainly:  The need for a better integrated approach (MCHN/agriculture/livelihood) at household level.  The use of monitoring data within „localities‟, to demonstrate a reduction in malnutrition (and better follow-up)  The follow up of referrals, at households‟ levels. Not all mothers bring their children to health center, even if referred by health agent at Rally Point It is important to focus on the following recommendations, in order to get all children under five years old, especially the malnourished children, into the pipeline for better health and nutrition, and to avoid losing them by addressing the several barriers identified during this evaluation. This will mainly improve the targeting of the intervention toward the most vulnerable children (malnourished children, children under 2, orphans, widows/women headed households, PLWA and other chronic diseases). The community nurseries will not remain beyond the MYAP because the seedlings are distributed but not sold. 53 Knowledge and skills in soil and water conservation are increasing in target areas. The farmers carry out the work of soil protection in their fields without food and cash being given to them to do so. Farmer groups are practicing improved agricultural techniques. Several model farmers met by the MTE team were able to correctly explain to us the various agricultural techniques learned (density of sowing, preparation of vegetable seeds, preparation of compost, etc). According to them, the outputs obtained by the model farmers for some of the improved varieties introduced are higher than those obtained by the other farmers. Food availability of the program beneficiaries has increased. It is interesting to note that the MYAP took the initiative to operate to the value chain of two products (mango and pepper) by encouraging an increase in the production but especially by linking the producers to the markets. Agro-enterprise practices are not completely adopted by the farmer, as with the young people taught grafting. They see themselves as volunteers within their communities for these techniques, rather than this being an opportunity for them to make a living. The CRS MYAP MUSO savings and loan program has found good reception among a number of groups within the program area. CRS has been highly effective in its contribution to support of the Southern Department‟s EWS observatory. Information reported, each quarter, on-line, appears useful and timely. 2.11 Recommendations  Give the establishment of mothers clubs and their linkage with agriculture/livelihood activities much greater importance within the MYAP. A program of this size should have over a thousand mothers clubs – not a mere 97 (cf. Annex 1). The creation of household vegetable gardens and the savings and loan programs (MUSO) should be the key agriculture/livelihood activities of the program.  Encourage solidarity among mothers, and the creation of new mothers clubs. This could be the center points of the programs, along rally posts. Mothers could be of great help to each other, ensuring an adequate care of children at households, conducting the child to health center for sick or very busy mother; using of small mutual savings to pay minimum health services fees. They should be encouraged to organize themselves as a group who meet until the child reaches 5 years, mothers could become future leader mothers with their own club with the support and training of the health agent. To receive MYAP services, mothers of children <5 (at least 80%) and 100% of mothers of registered malnourished children should join a mothers club. Other incentives than money or food might be offered for creating new groups: preferably seeds, plants, animals, education materials, or training into loan/savings groups and book keeping. Success stories of mothers‟ clubs could be shared at churches, in schools, at rally posts to encourage the creation of multiple mothers‟ clubs. 54  Enhance the quality of the data collected (number of children reported varies each month, and does not reflect all of the children under 5 years of this locality). Meanwhile, encourage the continuous follow up of children at rally post, even when referred to the health center. In addition, also track the number of migrants (particularly new children arriving into the households, as for example after earthquake). Growth monitoring at rally post and within mothers clubs can be improved to better track acute malnutrition by providing metric ribbons to measure mid upper arm circumference.  Encourage home visits, the collection and report of data through clubs of mothers, while avoiding duplication. Closer attention should be given to those children, not only at rally posts or health centers, but mainly at household levels. Each malnutrition case should be investigated in and followed-up to better assess their vulnerability and the persistence of malnutrition in communities. This tracking should be reinforced by mothers with the help of health agents for an extensive support of those mothers to their clubs and neighborhoods.  Particularly train health volunteers and mothers clubs to make an assessment of the quality of infant and child feeding during 24 hours, assessing not only the diversity of food but also the quantity and frequency of meals.  Chronological series of underweight children would be useful at each rally post to follow the project performance and make adjustments. Such a chart could be a wall chart at the health center, and discussed both with health promoters in order to analyze the amount of efforts towards a reduction of malnutrition. It would be useful for the identification of areas (locality) where the preventive ration is necessary (with better tracking of reduced rates of malnutrition under 5-10%).  Multiply rally posts and food distribution points, especially in remote areas and mountains, with an intelligent mapping of services and GPS coordinates. Whenever possible, organize mobile clinics not only for pregnant and lactating mothers, but also for children closer to their home. Strengthen the capacity of health workers and auxiliaries to support and manage acute moderate malnutrition because many children do not go to the health center when they are referred… in other cases, children get malnourished once again, when they get back from health center, but are not readmitted in the program. 3.0 External and Internal Factors 3.1 Impact of Internal Factors on Program Activities The main constraint identified has been the logistics of food commodity delivery, particularly difficult during rainy season. CRS does not attempt to bring these commodities closer to where the beneficiary live, as do both WVH and ACDI/VOCA. There is a reason for this of course, as it is the CRS strategy to increase local population visits to these clinics and the food supplements are one way to provide some 55 incentive to do so. Yet this strategy also reduces the number of needy children who actually take advantage of this service. The MTE team also observes that CRS has a number of additional activities not pursued by the other MYAPs, the largest being the school feeding programs, training of primary school teachers, and forming parents into PTAs – all worthy activities in themselves. This spread of resources will mean that less attention is able to be given to the agriculture and MCHN components. 3.2 External Factors Influencing Outcomes and Program Responses Some families within the CRS MYAP region were more affected than others by the January 2010 earthquake. We have observed during our field visits the presence of orphans arrived after the earthquake. Those children cannot go to school because of the lack of economic resources within the families where they are now staying. Families who accepted orphans and vulnerable children have not yet received any support no ration increase. The areas where CRS conducts its interventions have also been affected by the three hurricanes in 2008, thus reducing the capacity of the population to improve their conditions of living. 3.3 Negative Impacts or Unintended Consequences The only possible unintended consequences of programs we observed were the activities of the SYAP and other groups wishing to assist following the recent earthquake that have certainly disrupted some field activities. Staff at all levels has been affected as they have responded to the need for unanticipated surveys, etc. 4.0 Sustainability of Interventions Sustainability implies continuous training and acquisition of inputs. CRS has offered in the past, as stated by mothers, monetary incentives (25 gourdes per meeting during training sessions) encouraging them to gather. This could be a major inconvenience for creating new clubs. However, within other clubs, the mutual savings and loan programs are seen as an incentive to act together. Such initiatives should be encouraged for a better sustainability of the project. The Col Vol program is excellent and trains highly motivated people from within local communities who will continue to be resource people in the future. Annexes Annex 1: Summary Table of MCHN Programs and Linkages to Agriculture/Livelihood Activities