1 ACDI/VOCA HAITI Title II MYAP Mid-Term Evaluation, Report #4 Award Number: FFP-A-00-08-00029-00 Prepared by the Mid-Term Evaluation Team: Dr. Richard Swanson, External Consultant & Team Leader, Economic Anthropologist Gregory Charles, Agronomist Colette Vilgrain, M.D. Wesner Antoine, Statistician July 31, 2010 2 LIST OF ACRONYMS ACDI/VOCA Agricultural Cooperative Development International/Volunteers in Overseas Cooperative Assistance ADP Area Development Program (of WVH) or PDZ (Programme de Développement de la Zone) BAC Bureau Agricole Communale BCC Behavior Change Communication BND Bureau de Nutrition et Développement CBO Community Based Organization Col Vols Community Volunteers CS Cooperating Sponsor CSB Corn Soybean Blend CHW Community Health Workers CMAM Community Management of Acute Malnutrition CNSA Coordination Nationale de la Sécurité Alimentaire CRDA Centre de Recherche et de Développement Agricole CRS Catholic Relief Services DAP Title II Development Assistance Program DDASE Direction Départementale Agricole du Sud‟Est DSSE Direction Sanitaire du Sud‟Est 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 Reference Sheet IYCF Infant and Young Child Feeding LQAS Lot Quality Assurance Sampling MAHFP Months of Adequate Household Food Provisioning MARCH Ministry of Agriculture, Natural Resources and Rural Development MCHN Maternal and Child Health and Nutrition M&E Monitoring and Evaluation MoH, MSPP Ministry of Health (Ministere de la Santé Publique et e la Population) MUAC Mid-Upper Arm Circumference MUSOGs, MUSO Mutuelles de Soliarite Groupements, Mutual Solidarity (savings and loan) Groups MYAP Multi-Year Assistance Program OVC Orphans and Vulnerable Children PM2A Preventing Malnutrition in Children Under Twos Approach PDA Personal Digital Assistant PEPFAR President‟s Emergency Plan for AIDS Relief PFA, PTFA Poid faible pour l’age, Poid tres faible pour l’age (low weight for age, very low weight for age) PLWA Persons Living with HIV PMP Performance Monitoring Plan PMA Preventive Nutrition Approach (see PM2A) PNA Preventive Nutrition Approach SAVE Save the Children SNS Service National Semencier 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 3 1 carreaux = 1.29 hectares 4 ACDI-VOCA: Southeast Department (Jacmel region) MYAP Report #4 Map Table of Contents 0.0 Introduction & Overview of ACDI-VOCA MYAP Activities 0.1 Background 0.2 Schedule and Multi-Disciplinary MTE Team 0.3 Description of ACDI-VOCA Geographic Area 0.4 Targeting Vulnerable Groups 1.0 ACDI-VOCA 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 Finance & Commodities 1.8 Environmental Impacts 1.9 Conclusions, Best Practices & Lessons Learned 1.10 Recommendations 2.0 ACDI-VOCA Strategies and Outcomes Achieved to Date 2.1 Improved Nutritional and Health Status of Targeted Vulnerable Groups 2.2 Improved Quality of and Access to Health Services for Vulnerable Groups 2.3 Increased Food Production and Household Assets 2.3.1 Improved Food Security 2.3.2 Appropriateness of Early Warning System 2.4 Enhanced Market-Based Livelihoods 2.5 Rehabilitated Natural Resources and Local Capacity to Sustain These 2.6 Challenges Faced and Overcome in Program Implementation 2.7 Highly Successful Strategies 2.8 Unsuccessful Strategies and Proposed Changes 2.9 Conclusions, Best Practices, & Lessons Learned 2.10 Recommendations 3.0 External and Internal Factors 3.1 Impact of Internal Factors on Program Activities 3.2 External Factors Influencing Outcomes and Program Responses 3.3 Negative Impacts or Unintended Consequences 4.0 Sustainability of Interventions 5.0 Conclusions Annex 1: ACDI/VOCA Management Structure (Personnel Organogram) Annex 2: ACDI/VOCA IPTT Annex 3: ACDI/VOCA Health Staff & Facilities 5 ACDI/VOCA MYAP Geographic Distribution 6 Introduction & Overview of ACDI-VOCA MYAP Activities 0.1 Background ACDI/VOCA was awarded this 5-year Multi-Year Assistance Program (MYAP) to begin operations in February 18, 2008, having received official recognition as a registered NGO by the GoH in December 2007. Unlike World Vision and CRS who both have been present in Haiti for over 30 years and have long-established links within their regions of operation, ACDI/VOCA was new to Haiti; they had not been involved in previous Haiti FFP Development Assistance Programs (DAPs) – this was their first FFP Title II activity in Haiti. What they brought to the MYAP program was an excellent track record in other developing countries for their strategic approach to increasing agricultural productivity and livelihood opportunities among resource poor farmers, an approach that focused on commodity value chains linking producers with market driven strategies. Targeting seven communes in the Southeast Department, program field activities were first initiated in La Vallée and Bainet communes through a June 2008 rapid appraisal survey to support planning for the February – March 2009 planting season. The MTE team‟s arrival in April 2010 coincided with the beginning of the second full year of field implementation. Though the project began late in FY 2008, ACDI/VOCA nevertheless was successful in launching some well focused activities that would lead provide initial progress in reaching set targeted results. ACDI/VOCA created a partnership with Management Sciences for Health (MSH) and the Bureau de Nutrition et Développement (BND), to work in the Southeast Department of Haiti (Jacmel region) with a plan to address agriculture, health and nutrition issues, and the development of an early warning system (EWS). ACDI/VOCA would focus on agriculture and EWS efforts, while MSH would develop the Mother Child Health and Nutrition (MCHN) component. BND would provide food aid logistics support, commodity management and delivery of the food packages that would be provided to target vulnerable households as well as support to rural community to promote improved sanitation (latrines) systems and treatment of water. Selection of sites for latrines prioritized health centers, schools and places where multiple families could have access to a latrine (each with their own private spaces and doors). ACDI/VOCA proposed activities appear fully consistent within the context of FFP‟s 2007 strategic framework below: (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; 1 The ACDI/VOCA MYAP would target 14,550 households over the life of the project, with an estimated 72,750 individual beneficiaries, “while approximately 24,000 of these direct beneficiaries will receive agricultural support”.2 0.2 Schedule and Multi-Disciplinary MTE Team The quantitative survey team and enumerators, assisted by ACDI/VOCA field staff, began its work in the Jacmel region May 5 and completed this work by May 14. The qualitative survey team arrived in Jacmel May 17, and after initial program orientation meetings with the MYAP Chief of Party and other management staff, spent the next 9 days traveling to program sites in the communes of La Vallée, Bainet, Côtes-de-Fer, and Belle Anse – the same regions sampled for the quantitative survey. Focus group 1 Food for Peace, Country/Cooperating Sponsor FY 08 – FY XX Multi-Year Assistance Program (MYAP) Proposal, Proposal Application Format, August 1, 2007, page 4. 2 ACDI/VOCA MYAP Proposal Application, FY 2008-FY 2012, March 31, 2008, p 1. 7 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 existing Mothers Clubs. We observed a Save the Children mobile clinic at a project „Fixed Point‟, observed two Rally Points in action, and visited the BND base commodity storage center where food is repackaged into „nutrition kits‟ to be received by pregnant and lactating mothers, children < 2 years of age, and malnourished children. 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 ACDI/VOCA‟s area of implementation. 0.3 Description of ACDI-VOCA Geographic Area of Intervention Of the three Haiti MYAPs visited, ACDI/VOCA‟s Southeast Department is without doubt the most difficult logistically (travel, lack of infrastructure, difficulty of access) to work in – particularly in the three eastern communes of Belle Anse (7 section communales), Grand Gosier (1 section communales), and Anse-à-Pitre (2 section communales).3 In Belle Anse, for example, the largest of the communes, there are only 2 health centers for 60,000 people. ACDI/VOCA‟s agricultural activities have focused most of their early activities in those communes with the greatest agricultural production potential (La Vallée, Bainet, and Thiotte) – though activities have also been extended into the other four communes as well (Anse à Pitre, Belle Anse, Thiotte and Côtes de Fer). At the western end of the Department, ACDI/VOCA works in the commune of Côtes -de-Fer with its 5 section communales, and in high, cool and moist La Vallée and Bainet communes. As can be seen from the first map above, ACDI/VOCA based its selection of communes within this Department on the Goth‟s classification of poverty – defined as access to services (health, agricultural extension, education, etc.). Others constraints noted by ACDI/VOCA through focus groups included „poor prices for agricultural commodities, lack of agricultural inputs, poor road infrastructure, limited access to credit, weak CBO and association management‟ 4 . ACDI/VOCA selected those communes which were classified as „extremely weak‟, or „very weak‟. One which was classified as „moderately weak‟ (Thiotte) has received support 3 The only comparable zone among the partner MYAPs is World Vision’s work on the Island of La Gonave, where the rocky trails closely resemble the trails in the Southeastern Department. 4 ACDI/VOCA MYAP Proposal Application, FY 2008-FY 2012, March 31, 2008, p 10. 8 because of its high agricultural potential and importance of the coffee sector. Better off „less weak‟ communes like Marigot, Cayes-Jacmel and Jacmel were not included. It is surprising that ACDI/VOCA staff is willing to work in the Eastern three communes of the Southeastern department at all, given the almost total lack of adequate housing for them, or of even transport. Currently, ACDI/VOCA has only 2 vehicles assigned for the use of the doctors, nurses, and others working in the two communes (Thiotte and Cotes de Fer). The program is waiting for the delivery of 3 new vehicles for the field which will be placed in Belle Anse, Anse a Pitre, and La Vallée. Nevertheless, these vehicles must be shared between the livelihood and health team. The program certainly needs additional vehicles for the sole use of the MCHN teams in Cotes de Fer, Belle Anse, Grand Gosier, Thiotte, and Anse à Pitre, including the drivers as required fuel and repair costs that will need to be budgeted. The road east after Paridot is nothing but a rocky trail up and down the mountains, potentially dangerous to travel upon when wet from rain because of the slippery mud and steep drop￾offs5 . The MTE team‟s last day in the region was cut short because of rain and barely got out; a program BND truck delivering nutrition kits to malnourished children in the section communale of Baie d‟Orange that we visited became stuck, and the team with it could not get out that night (without a place to stay, or sleeping materials). The region, like much of Haiti enjoys, enjoys two cropping seasons each year, February through May/June, and August through November/December. The end of June and the entire month of July usually are usually characterized by a „dryer season‟ as are the months of early December through February. Because of the amounts of rainfall vary by season; the types of crops that are grown vary. The MTE team was present during the first of these seasons, and saw different crops in the field depending on whether we were in the higher hills overlooking the sea, or on the plains. The back and forth movement of the planting of some crops is characteristics of the coastal/mountain zones of the country. Black beans that are grown in the plains in the 1st season, will be planted in the higher cooler hills during the 2nd season. The rainfall pattern for Marigot in Figure 1 above resembles the patterns throughout the region, except that the amounts of rainfall that farmers get in the mountains above can be 400-500 mm/year more. More recent rainfall statistics from 9 different stations in which the MYAP works shows the degree of inter-region variability received during the current rainy season – data provided in the CNSA Southeast Department bulletin published in March, 2010. These data suggest that rainfall during this December /January period is actually slightly higher than the long term averages, though November was dryer than normal. 0.4 Targeting Vulnerable Groups 5 It takes about 4 hours to travel from Jacmel to Belle-Anse and another two hours on to Grand Gosier, where upon arrival, there is little support infrastructure to receive program staff. 9 Implementation of the three major components of the ACDI/VOCA program (agriculture, MCHN, and EWS) involved three sets of program staff working with specific, usually different, target groups in often different geographic regions, in the Southeast Department. Integration of agriculture and MCHN activities was NOT a major preoccupation of the program from its design stage, nor was any focus towards „Mothers Clubs‟ mentioned in any great detail in early program planning.6 As recently as its FY 2010, 1st quarterly report, ACDI/VOCA speaks of its „non-MCHN areas‟, and that in these areas there was “an estimated 20% overlap between MCHN and agricultural interventions.”7 In its MCHN strategy document, mothers are to be organized into “a peer group structure…to help develop a sense of communal responsibility for meeting the health needs of children…Peer groups are ideally about 10-15 members and are divided based on mothers physiological status and the child’s intervention group. MYAP health agents and Col Vols help organize peer groups.”8 ACDI/VOCA program managers have become aware of the issue of integration in recent months and have begun to seek ways to improve this focus. MCHN activities were largely planned to be done through Rally Points and health clinics or „Fixed Points‟ where clinics were not available. ACDI/VOCA activities in La Vallée, Bainet and Thiotte Communes worked exclusively on developing the agricultural productive potential of these resource rich and agro-ecologically favored regions. This was also supported, actually encouraged, by the GoH through the Ministry of Agriculture which discourages food distribution (especially foreign food) in such areas. They recommended to the MYAP a focus on the development of the agricultural productive potential of these communes. Indeed, from a rainfall perspective, most of the mountainous and high hill regions of the Southeastern Department have annual rainfalls exceeding 1,000 mm, with some as high as 1,700 mm. The coastal regions of Côtes de Fer, Grand Gosier, Anse-à-Pitre and Belle Anse, with lower rainfall levels – in the 700 – 800 mm range – are more susceptible to drought and are also more food insecure as a result. One of the challenges of the program was that of reconciling two fairly different approaches to „reducing food insecurity‟ in the region. It is not helpful to classify most households or the population within a region as „vulnerable and food insecure‟ – this makes the term meaningless for targeting purposes and is simply not true. It masks the real differences that exist within different localities of a commune. From a purely agricultural development perspective, one would want to focus on those areas and farmers with the greatest undeveloped or underdeveloped potential, with the reasoning that by increasing agricultural production, the livelihoods of these people will be improved and the additional production would benefit the country as a whole. But this would also mean working with farmers who were not necessarily among the „extremely vulnerable‟ – they at least possessed enough land, with large enough plots, with productive potential. ACDI/VOCA has initiated excellent work in this regard through this MYAP, particularly in the La Vallée and Bainet communes, and has already made an impact, as we shall describe below. 6 According to the ACDIVOCA team, there are some exceptions, as there are areas where a higher degree of integration exists between programs (e.g. Mabriole in Belle Anse, Grand Gosier, Cotes de Fer and some other areas they MTE team did not visit. 7 ACDI/VOCA MYAP, Quarterly Activity Report (October 2009-December 2009), April 5, 2010, p.5 8 ACDI/VOCA Haiti P.L. Title II MYAP Strategic Objective 2 Strategy Paper, November 9, 2009, p. 19 10 Given this reality, ACDI/VOCA put forth a strategy for MYAP implementation that was first to build upon existing assets so as to tap into the agricultural productive potential with these areas of intervention and introduce new cultivars and techniques to increase agricultural productivity. This then is followed up by transferring the potential and benefits from one area to another or from one perhaps less vulnerable farmer to the more vulnerable within a locality. During the first two years of the program the MYAP successfully used the method of demonstration plots on model farmer‟s land, to introduce the new crop varieties and techniques. To work, the model farmers could not be the „most vulnerable farmers‟ in these areas who would or could not bear the risk of trying these new techniques. As a result of this methodology, newly introduced techniques are in the process of widespread adoption. However, this was only the initiation phase, where, working initially with less vulnerable farmers, techniques could be validated within the region before they could be expanded out to and adopted by the most vulnerable. This is also an important stage for the MYAP to build trust and confidence in the program and organization. The MTE team observed this with the introduced black bean variety arifi introduced and multiplied in La Vallée and Bainet, and was then shared with less high potential areas and the more vulnerable farmers in Belle Anse, Grand Gosier, Anse à Pitre, and Cotes de Fer. This foundation permits the MYAP to focus more towards the most vulnerable during the remaining life of the program, while retaining the gains already realized. Title II, FFP programs emphasize focus towards the most vulnerable, and reducing the food insecurity and vulnerability of these people. One aspect of the universal targeting approach under the PM2A program of all pregnant and lactating women, and children 6-24 months, actually ensures that one will NOT have only vulnerable and extremely vulnerable food insecure households. There appears to be an inherent contradiction in a purely MCHN beneficiary focused approach which assumes that all people who meet this criteria are vulnerable, thereby meeting a „food insecure‟ label. Households representing these people tend to have less land resources, and are often located in areas that have less agricultural production potential (hillside slopes), whose children are more likely to also be malnourished. ACDI/VOCA itself recognizes that there is a need for a different livelihood approach to such groups. The MTE team finds that within the existing FFP strategic framework for the MYAP, both approaches can be justified. However, we also find that the ambiguity caused by these two approaches dilutes the potential impacts of the MYAP, particularly when attempting to integrate MCHN and agriculture/livelihood activities to impact the most vulnerable. Resources are not sufficient to do both, and one of our principal recommendations will be the reorientation of MYAP resources to those approaches which actually target the most vulnerable. ACDI/VOCA‟s strategy as described above fits well with these concern, permitting the foundation for what could be greatly increased impact on these more vulnerable during the last few years of the MYAP. 1.0 ACDI-VOCA Program Management Approach & Implementation 11 In one of its early MYAP documents, ACDI/VOCA states that their approach “of working with the same beneficiary population for both agriculture and health will reinforce the messages about food security and enable beneficiaries to look at food security from different angles.”9 This does not speak of working with the same vulnerable households for both components of the program however. ACI/VOCA designed its approach to delivering health messages through three types of locations, as illustrate below in Figure 1: (1) health centers/dispensaries managed by the GoH health ministry (MSPP), (2) „fixed points‟ (“designed to provide health care to populations in the absence of health centers or dispensaries which may be far away from the population”)10, and Rally Posts, defined here as „any community structure (school, community center, etc.) that can be made available for short-term use to provide health services‟. Rally Posts are seen as sites for „large-scale behavior change activities‟, including recruitment of mothers to participate in Mothers Clubs‟. ACDI/VOCA employees staff both the Fixed Points and Rally Posts. Targeted beneficiaries for both food distribution and behavioral change training include pregnant and lactating women, children under 5 (especially prevention of malnutrition for under twos approach – PM2A) and their mothers. Beginning in Côtes de Fer commune, the MYAP has been expanding activities out to Belle Anse, Grand Gosier, Thiotte, and Anse-à-Pitre. Currently, there are no MCHN health agents or Col Vols in Thiotte due to the presence of MSH health agents under a USAID DA funding activity – SDSH. However, the MYAP is considering the need for this coverage in Thiotte to correspond directly to program objectives which are not entirely the same. The project has also engaged GoH MSPP representatives to ensure that nutrition and other health protocols are respected, and have contributed to health-related discussions in MSPP meetings and conferences. ACDI/VOCA has worked, and will continue to work, to coordinate and complement the efforts of other programs working in its communes to avoid duplication of efforts. 9 ACDI/VOCA, Haiti MYAP FY 2008-2013 Resources Request Summary, March 31, 2008, p. 39 10 ACDI/VOCA Haiti P.L. 480 Title II MYAP, Strategic Objective 2 Strategy Paper, November 9, 2009, p. 11. 12 A Figure 1: ACDI/VOCA MYAP Service Delivery Points11 During implementation the first year, while MSH proved to have the required expertise to support training within the context of Haiti Ministry of Health facilities (hospitals and rural clinics), it was totally out of its depth when it came to developing the necessary links into rural communities themselves without rural health facilities. Several major aspects of the program that needed to be developed – the identification and training of community based health volunteers (Col Vols), the development and management of new Rally Posts in underserved regions, and helping rural mothers to organize into appropriate Mothers Club structures. This did not take place, and information flow back to ACDI/VOCA to fill required indicator tracking was not taking place. ACDI/VOCA moved quickly to resolve this issue, within a politically very charged Southeast Department environment, and succeeding in receiving Health Ministry support to terminate this sub-contract and to take over the management of this component of the program themselves. By October 2009, ACDI/VOCA had merged MSH field staff with its own new leadership, focusing early efforts in Côtes de Fer, Belle-Anse, Anse à Pitre, Thiotte and Grand-Gosier. 11 ACDI/VOCA Haiti P.L. 480 Title II MYAP, Strategic Objective 2 Strategy Paper, November 9, 2009, p. 13. Health Services, Food Distribution, Growth Monitoring, Behavior Change Activities Fixed Points Rally Posts Food Distribution, Growth Monitoring, & Behavior Change Activities MSPP Community Health Centers Health Services Food Distribution 13 1.1 Site Program Management & MYAP Coordination ACDI/VOCA only maintains a small office in PAP to help coordinate travel through PAP to the Jacmel region, and reporting purposes with USAID. ACDI/VOCA‟s M&E Manager is based here, and receives reports from one M&E specialist based in Cyvadier. The principal office is based in Cyvadier, just east of Jacmel town, where the Chief of Party, Deputy Chief of Party & Grants Manager, Health and Nutrition Director, Early Warning System Manager, Livelihood Manager and other more junior staff and support personnel are based. From this location, travel to both west and east along the coast are possible to program field sites. The project appears to be fairly decentralized in its management approach, with the COP visiting each region about once or twice/year, the Deputy COP and other senior managers visiting about once a quarter, with more frequent field visits by qualified field-based regional personnel to specific project sites. An organogram of the program is provided in Annex 1. The fourth organogram shows how ACDI/VOCA is now seeking to integrate its MCHN and agricultural components – and this approach appears reasonable to the MTE team. ACDI/VOCA approaches the distribution of food commodities in a very different way from both CRS and WVH MYAPS with its sub-contract with BND. As shown here, BND pre-packages the food kits for the different groups that receive the food supplements, thereby greatly facilitating the actual process of delivery to beneficiaries. Pictured here are women lined up to receive their food „package‟ at Labiche. BND‟s organization structure is also shown in Annex 1, showing the three major warehouses in the region from which food supplements are distributed (Belle Anse, Ricot and Thiotte). Pictured here are pre-sorted bags of lentils to be placed in a sack with portions of other commodities to create the rations that will be distributed to each qualifying beneficiary. 1.2 Priority Activities & Approaches All ACDI/VOCA MYAP agriculture activities are currently located in the South East Department communes of La Vallée, Bainet, Anse à Pitre, Belle Anse, Côtes de Fer Thiotte and Grand Gosier, while no MCHN activities take place in the first two communes. ACDI/VOCA has addressed constraints related to food availability by working through groups of farmers to enhance agricultural productivity and bolster the managerial and financial capacity of Community Based Organizations (CBOs) and local groups. ACDI/VOCA‟s asset-based approach builds upon local natural and human resources (CBOs), NGOs, working with existing Government agencies (Ministry of Health, Ministry of Agriculture and related structures: DSSE, DDASE, BAC, CRDA/SNS, CNSA). 1.2.1 Cropping Systems and Focus for Improved Productivity ACDI/VOCA initiated its MYAP agricultural activities in two communes (La Vallée and Bainet) These activities include a concentrated focus on improving the principal crops cultivated by farmers (maize, 14 sorghum, black beans, manioc, yams), and helping to bring in improved varieties to that far out yield existing varieties. The program has also given some focus to a small nursery organized with program support for establishing about 30,000 bitter orange seedlings which, in a few months, will be big enough for grafting as manderines. Manderines were introduced into this area by the French “ASSODLO” program some 7 years ago, and the fruit trees from this time have become a very important and well￾known product of this region (La Vallée), where the higher elevation and cooler mountain air, fertile soils, and abundant rainfall produce fruit of high quality. ACDI/VOCA is planning to increase the volume of production in future years by giving out a targeted 50,000 trees, at no cost, to local community members. The MTE team debated this issue with the ACDI/VOCA team, seeking to understand the justification for this approach. As explained by the local team, the approach is linked to the critical integration of agriculture and the environment by getting farmers to switch from annuals to perennials on steep slopes. This is alone excellent way to accomplish this objective, and so the MYAP believes the end does justify the means. Years of agro forestry in Haiti support this approach: the successful PADF Forestry project in the 1990s which used a similar approach, as well as the French program “ASSODLO” that created the mandarin legacy which currently exists in La Vallée, which continues to this day, and which is a critical income source and slope control stabilizer. Many of these latter trees were felled during hurricane Gustav, thus there is also the need to address this situation with an improved variety with bitter orange seedlings (for grafting). Essentially the justification is that by giving out these trees, a valued asset will have been placed into the hands of local farmers, and stimulate fruit production, even if they themselves would not be willing to initiate these seedlings themselves, or purchase seedlings from a local entrepreneur. The „free tree‟ mentality is very strong. So the end (fruit marketing and steep slope management) justifies an approach which may not be sustainable in itself. 1.2.2 Value Chains Targeted ACDI/VOCA clearly has a value-chain approach to the commodities they focus program activities on, and this is certainly one of the strengths of the program approach. Attention is being given to supply chain issues for coffee growers and selected improved cultivar varieties, scaling up production to meet demand requirements, and post-harvest issues like improved transportation of products to market. The MTE team would recommend that the MYAP use this approach to strengthen their MCHN program as it becomes more focused in integrating with agricultural activities. For instance, helping Mothers Clubs with vegetable gardens should become a priority of the program, and in doing so, must look at the entire chain of events required to make these successful where they are located (household gardens or near households). This will mean confronting the issue of water needs during periods of the year when it is less available (but most in need) for these gardens. This will mean looking at those who can be trained to make quality seed always available within the communities. And after focusing on household consumption and preparation of these vegetables, it will mean looking at diversifying the markets for vegetable crops should sufficient volumes become available. As a livelihood activity, ACDI/VOCA is already expanding opportunities of this kind. For example, in Cotes-de-Fer, mothers care groups are making angels out of sisal which will be sold in Jacmel town and even exported. An order for 300 has already been placed for shipment to the USA. Efforts in supporting past and current ACDI/VOCA MYAP successes in these regions should focus towards being sure that the farmers who have adopted these new cultivars and techniques are able to do so 15 on their own – that they know where to go for help when they need to. This may require slightly withdrawing from activities in La Vallée and Bainet towards the end of the MYAP to permit this to happen, and monitor to see what additional help may be needed. The field team notes that withdrawing immediately from activities in La Vallée and Bainet may be damaging to the program. These areas constitute the core of the seed multiplication activity that the other communities benefit from and the MYAP is still in the process of empowering the seed producers so that have the capacity to manage this activity on their own as a profitable business. This may take another two years to be fully autonomous and sustainable. A possible withdrawal before this time would require a secure funding from sources other than FFP to allow that this process be completed. The MTE team would support this process for the MYAP. Review of this will be needed at the time of the final evaluation. 1.2.3 Health & Nutrition The approach of ACDI/VOCA in the Southeast Department to reaching underserved localities differs from both World Vision and CRS. Because of the extreme lack of GoH health facilities (clinics and dispensaries) throughout the logistically difficult regions covered by this MYAP, the program developed an approach that created community „Fixed Points’. Fixed points are represented by a room or two in some structure offered by a local community where ACDI/VOCA would place health related materials and supplies, and an auxiliary nurse, to respond to the urgent needs of the surrounding communities. Such care includes providing services to malnourished children identified in the one or more „Rally Posts’ in the different localities (Figure below shows location of Fixed Points, but not Rally Posts, which have yet to be geographically identified). 16 Among the greatest challenges is the chain of supervision that links each level from Rally Posts to fixed points and health clinics to project offices, and the flow of the required data or information up or down this chain. Because of the difficulty of access to most areas (in hills and mountains) and the delivery of materials to the health staff at the different levels (health supplies, forms, food supplements, etc.) the program has been delayed in development. The cost of these logistics was greatly underestimated by both ACDI/VOCA and its initial implementation partner, MSH. In the absence of increased support, they may not be able to reach targets set at the beginning of the program. FIXED POINTS: In order to improve access to health services, ACDI VOCA established “fixed points” to provide services in the communal sections where there are no health centers. A fixed point is a physical structure running like a clinic, but that is not yet under the nomenclature of MOH. We visited Labiche fixed point. This center was built by the Labiche community with the financial support from the Public Treasury. It has been equipped by ACDI VOCA with a consultation table, a desk and the following materials: scales, stethoscope, aneroid, metric ribbon, educational boards. But it does not yet have a refrigerator for vaccines. This structure works 5 days per week (Monday to Friday, 8 am-2 pm), with the support of 2 service providers who are 2 nurses assistants (auxiliaries) recruited by ACDI VOCA. The auxiliary nurses and health agents are contracted by MSPP but paid directly by ACI/VOCA using the government‟s salary structure. These auxiliaries provide services by rotation; a work week includes 2 days in the fixed point and 3 days of supervision of the rally post. Trained in maternal child health and nutrition, they organize educational sessions at fixed point for matrons. Fixed points currently have mainly visual materials and training guides for matrons. Low fees (10 gourdes) are requested from beneficiaries for consultation. The idea for these charges originated within the communities themselves as a means to reinvest in the fixed point buildings. This money is delivered to the community for renovations needed at the fixed point. 17 RALLY POSTS: Rally Posts are managed by community based health volunteers „collaborating volunteers‟ (Col Vols), supervised by an health auxiliary agent (who themselves are managed by the ACDI/VOCA health worker based out of the „Fixed Points‟ or health center. Here mothers bring their children for growth monitoring, vaccinations, and other services. Children who are identified as being acutely malnourished using mid upper arm circumference (MUAC) are sent to the Fixed Point (or a health center if it is closer) where their anthropometric status is further evaluated using weight for height. Children who are 24-59 months of age are moderately malnourished (<2 SDs W/H) are entered into the supplementary feeding program (children who are 6-23 months of age are entered into the PM2A program). Children with severe acute malnutrition (<3 SDs W/H) are referred to a Save the Children health worker who provides care for severally malnourished children. We noted that “ACDI/VOCA will use the weight for height measurement to admit children into the recuperative feeding program, and make a concerted effort to implement the Preventive Malnutrition in Children under Two Approach (PM2A) where the program will mainly focus on providing rations, health care, and education to pregnant and lactating women and children 6-23 months.” 12 This new focus towards prioritizing all children less than two years of age (PM2A) is an important step towards preventing chronic malnutrition from developing in the first place. Using MUAC to screen children for acute malnutrition and weight for height to confirm acute malnutrition and enter them in a recuperative feeing program is also an excellent step. HEALTH Workers and health Volunteers: The MYAP has both community health volunteers (Cols Vols) and health workers; the latter are being paid and have more responsibilities than the first. The Cols Vols receive only a small allowance for their activities (750 gourdes/month) for their commitment for 3-5 days each month. Community volunteers, besides special training, also receive field working materials: rain coats, boats, megaphones. They weigh children at the rally post and educate mothers at clubs and rally posts. The health worker is the one who administers the vaccines, indicates the theme for the month‟s education, and offers family planning to mothers. At the fixed point‟s level, an auxiliary nurse is based and provides more 12 ACDI/VOCA Haiti, Fiscal Year 2009 Annual Results Report, November 4, 2009, p. 8 18 appropriate preventive health services to the beneficiaries. IMMUNIZATION: Some children are still not vaccinated because of a shortage of vaccines and late request at the MOH. But this has been resolved. Activities in some ACDI/VOCA MYAP regions have only just begun in 2009, so there has not been an opportunity to affect the immunization coverage. Pictured here is a child being vaccinated at the St. Joseph health clinic. MOTHERS CLUBS: The introduction of Mothers Clubs within the program has barely begun – with only about 57 formed so far, and no significant project experience has been developed here. The ACDI/VOCA person placed in charge of this part of the program was hired less than two months ago, and has not yet visited himself all the program sites where MCHN activities are underway. Given the size of the different targeted communes, one could expect close to a 1,000 Mothers Clubs by the end of the MYAP. Existing mothers‟ club groups include mothers of children under 5 years old. Some of them were already present when CRS was previously in Cote de Fer area; others are newly created (as in Belle Anse). Pictured here is an infant being weighed at a Cote de Fer Rally Post by a health worker and child‟s mother. The participation of mothers in mothers‟ club meetings is not a condition to receiving supplementary feeding for their children if malnourished – though it probably should be. Some mothers groups have begun to save money for their own savings and loan activities. ACDI/VOCA is only now beginning to address the issue of Mothers Clubs, which they prefer to refer to as „mother care groups‟, and want them to be lead by Lead Mothers. Establishing proper Mothers Clubs is, according to program management, a top priority going forward. Mother‟s club meetings are currently held by the health worker. However, some mothers say that with the training they have received through Mothers Clubs, they are able to lead new clubs themselves in their community. As it is important that there be at least one mother in a mothers club who is literate (for record keeping), a leader mother may designate such a person for the group keeping the books and registers. Not all mothers of children under 5 years old participate in clubs. The reasons are the following:  Health volunteer currently are the ones to "select" mothers who can participate in clubs  The number of mothers accepted to the Mothers Clubs is limited. A quota of 20 mothers is established; so the recruitment process is stopped once this figure is reached. It also appears linked to the PM2A program. ACDI/VOCA should leave membership in mothers care groups to the mothers themselves of children under five years of age (many will have older children too) – keeping the initial membership numbers fairly low to permit future growth as friends and neighbors wish to join. As the MTE team has discussed elsewhere, we believe limiting Mothers Clubs to groups of women at specific developmental stage of a 19 child limits the usefulness of this grouping of women for the MYAP program as a whole as well as the long-term viability of such a small group of women caring for their children.13 Age-appropriate messages are of course important to mothers, but mothers in groups of children of the same age are not the only way that such messages can be delivered.14 Most mothers have children of multiple ages – even though their most recent one may be only 3 months, or 24 months of age. Tailored messages for different gestation ages are important, and certainly should be included for Mothers Clubs with children under two – but this does not mean all the mothers in the group have to have children of this age for it to be appropriate. Young mothers are going to hear from older mothers (if they have kids of less than 5 years of age) as well, and it is best to include them together so that they can enrich the discussion with their own experiences. Mothers in a mothers club that may have already heard the lessons on how to care for a 3 month old child will reinforce these messages when these are the monthly themes presented by the leader mothers or Col Vol. Visual training materials, such as that shown here for the training of local mid-wives, are prepared by the MYAP for the different themes discussed at the beginning of every rally post session, and during monthly Mothers Club meetings. Monthly themes for training should be tailored to the reality of the children under 5 within the Mothers Clubs – with special focus on those less than 2 years of age. Creating a new mothers care group out of a group of mothers who might happen to be all pregnant at a particular time, or who all have babies less than 6 months of age also puts women together who may not necessarily know each other well, who may not necessarily live close together (for their monthly meetings and visitation). It is extremely important that the members of a mothers club live close together, to facilitate communication and mutual support. As the Mothers Clubs are also an ideal vehicle for mothers to remain together in future years for common livelihood activities (such as savings and loan programs, or other livelihood activities), it is important that the mothers have a level of trust among themselves as well. Young girls have cohorts of friends they grow up with, or went to school with, and like to be with each other. As they begin to have babies, they would be a natural group to associate together in their own „mothers club‟ as they begin to have children – if they live fairly close together. Young women who become pregnant the first time will most likely prefer to join the mothers club in which her girl friends are perhaps already located. This is why the initial size of a mothers club should be limited (perhaps 10-12 women) to permit such natural growth in membership. These mother clubs become the vehicle through which the MYAP can integrate agriculture and MCHN activities for the entire household. 13 This discussion is given from the perspective of an anthropologist who has observed the social interactions that takes place under these kinds of circumstances. Medically trained personnel like to view this from a more focused ‘tailored’ perspective, not realizing what is lost in the social interaction that takes place with a larger definition which permits women with children less than 5 years of age being part of the same group. If the sole purpose of the mothers care group was to train for a specific child at a specific age, then this approach would be justified. But the purposes of a MYAP are much broader. 14 The MTE team believes that only initial qualification for participants of Mothers Clubs would be that they have children less than 5 years of age. 20 One of the major disadvantages observed in the World Vision Haiti sites where Mothers Clubs are organized based on a cohort of women with children of the same age was that they did not develop long term solidarity as a group of women. The groups were WV groups, not formed for their own reasons of mutual support for infant and child caring and economic advancement. The membership of these groups kept changing as pregnant women had their babies and joined a „lactating mothers‟ group. Then again, when these particular children grew beyond a year in age, they became a „1-2 years of age‟ group, etc. New members could be added to such groups along the way if they had young children of the „right‟ age. Yet the women in the lactating group of mothers could also have children of 3 and 5 years of age, and older. Therefore the monthly lessons taught the women by the MYAP and Col Vols – through the leader mothers – needs to be appropriate to other ages as well. Sanitation and nutrition training is relevant to an entire household. The MTE team believes it would be a serious error for ACDI/VOCA to adopt the World Vision approach to Mothers Clubs for these and other reasons. MANAGEMENT OF ACUTE MALNUTRITION: ACDI VOCA follows the national protocol for the treatment of acute malnutrition. This protocol promotes the use of MUAC and weight for height measurements. Severely malnourished children receive a RUTF (Ready to use therapeutic food, named Plumpy nut). This is done in partnership with Save the Children. Moderately malnourished children 24-59 months are entered into the supplementary feeding program where they receive food supplements for a 3 month period. For both groups, health education, medical examination and treatment occur in health centers (for small fees) or in remote areas at fixed point (for free). At the beginning of the project, recovery of cost at health center was a common practice. But after the earthquake, there was free care in some facilities of the Southeast Department. Malnutrition rates seemed not to increase after the January 2012 earthquake. The early warning system provides some explanation. The earthquake had an impact on the evolution of prices (increase) and there was a response of donors through rapid food distribution leading to price reduction. 1.2.4 Early Warning System (EWS) ACDI/VOCA has invested considerable effort within the region over the past two years to develop capacity „at the field level‟ to monitor changes that may have an impact on food security and provide an early warning to potential problems. The system that has developed includes all major GoH (MANR, CNSA, MoH) and local partners (civil authorities and NGOs) and is led by an enthusiastic ACDI/VOCA Early Warning Systems Director, an agronomist, with strong M&E and quantitative skills. Informative bulletins and newsletters are being produced. The EWS covers all 30 section communales of the 10 communes of the MYAP. Food security „observation posts‟ have been established, along with a network of 20 rainfall measuring stations and sixteen local markets where key crop prices are monitored each month by ACDI/VOCA itself. The EWS partners meet every two months to review results and seek to coordinate efforts within the region. The GoH used to have its own system of rainfall collection stations, and monitoring of market prices, but this has collapsed years ago; the current efforts of this MYAP, as well as others, has been to put back into place a system to track impacts of seasonal and unexpected events on the well-being of the Haitian population with respect to food security. Training of local authorities in disaster preparedness and the creation of a Local Civil Protection committee in La Vallée are actions that have helped in the recent 2010 earthquake. As a member of the Haitian National Council for Food Security (CNSA), a department under MARNDR, ACDI/VOCA beginning in FY 2009 has also provided support at the national level as 21 well in providing some 100 rain gauges for national level use; as a member of the CNSA Southeast Department food security observatory, ACDI/VOCA has also supported in the monthly newsletters of this GoH service. EWS data and narrative reports for the Southeast Department are presented on the CNSA website www.cnsahaiti.org, where the first bulletin can be reviewed. Here tables and time series graphs can be reviewed for rainfall in different locations of the Department, as well as market prices data. The ACDI/VOCA support to the EWS has begun to lead to the regular publication of bulletins summarizing the data being monitored. This information is currently used by the GoH in their own internal reports, and has already led to influencing actions taken by the GoH in the region. The MTE team was told that leadership of the EWS system is planned to rotate among the different members of the EWS, but until now it has been ACDI/VOCA itself that has led the effort. While the quality of the effort cannot be disputed, the MTE team does wonder how this system can in fact become sustainable. The GoH, however much they are pleased with the system, does not yet itself take the lead in this activity – saying they do not have „the resources‟ to do so. Given the quality of the data being obtained at the over 300 rally posts throughout ACDI/VOCA‟s operational regions, the MTE team would strongly recommend that sentinel posts in localities with known high malnutrition rates be established and monitored over time as part of this EWA system – thereby linking rainfall and market prices to specific problem areas. Such a „sentinel post‟ would use monthly averaged data from the monthly registers of Col Vol specific rally posts to monitor the changes in the number of cases of severe malnutrition (kwashikor, marasma) as a best practice over time. Just as a sample of markets are monitored, or a number of rain gauges, such rally post data would also show trend lines over time, and how critical events, such as a hurricane in the region, might impact nutrition levels. 1.3 M&E System and Targeting of Beneficiaries ACDI/VOCA has done a good 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 performance tracking table (IPTT), descriptive performance indicator reference sheets (PIRS), and a schedule of performance management tasks for M&E over the life the program. Also included is a flow chart showing how responsibilities for implementing, reporting and monitoring the program will take place.15 It will be important to update this PMP each year. Of all the Haiti MYAPs, ACDI/VOCA has the least well-staffed M&E team, with only two individuals responsible for organizing data to respond to the quarterly IPPT indicators, one based in PAP and the other in the Field Office headquarters in Cyvadier, near Jacmel. The system does not appear as centralized as that of CRS and WVH, but this has led to greater delegation and sharing of data monitoring responsibility to the other component of the project, which the MTE team believes is a good thing. For example, we were able to obtain data on the updated numbers of rally posts, fixed posts, and the number of different kinds of health agents in the MCHN program from the health component leader (cf. Annex 3) without delay, which was not the case with CRS or WVH. Requesting for such data also revealed „holes‟ in the data sets that need future updating. For example, though the number of Mothers Clubs was known, but the number of actual mothers in these Mothers Clubs was not known, nor the total number of children in the households of the mothers in these Mothers Clubs. These are all direct beneficiaries of the program that are not being counted. 15 ACDI/VOCA, Haiti MYAP, Performance Management Plan FY 2010, December 2009 22 ACDI/VOCA, like WVH and CRS, has developed a good system for tracking their key data sets from rally posts and fixed points, through the health clinics and to the central office. Appropriate data sheets also track agriculture information being obtained. As with the other Haiti MYAPs, the MTE team believes there are too many indicators being tracked - 48 for ACDI/VOCA - which greatly increases the efforts of the field staff in registering, handling these data, and reporting upon them. There are a number of indicators which should be dropped, as the program has not been able to respond to them. These include: (1) # of hectares in areas of biological significance under improved management as a result of USG assistance16 (2) # of MSMEs receiving business development services (3) # of MC meetings attended in target areas (4) # of safety net proposals complete by community in target areas (5) # of people with increased economic benefits derived from sustainable NRM (similar to another indicator) (6) # of people of reproductive age using a modern family planning method. One may try to get this from a final survey, but the results are not likely to be very truthful.17 Other indicators could be improved upon. For example the indicator stating “% increase in group savings” would be more meaningful to rephrase as “Total cumulative value ($) of savings in all group saving accounts”, followed by “Total cumulative value ($) of all savings funds loaned out to group members for commercial and other needs”. There are a number of others which do not make much sense – mainly because the numbers are so small over the life of the project and it would be better to simply state these in the narrative portion of the report. Example: (1) # of new technologies or management practices made available for transfer. How this indicator is interpreted differs somewhat from one MYAP to another, and only about 4 or 5 such technologies area transferred in the course of the project. In other cases, two indicators are essentially the same, except one is for USAID, one for FFP. A decision should be made which is the one to track, and the other dropped. For example: # of targeted direct beneficiaries reached # of rural households benefiting directly from USG assistance (USAID F indicator); 1.4 Links to GoH 16 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 steep slopes. 17 This is an important family planning indicator, but if the data gathered for it are highly suspect in terms of truthfulness, then we are only planning with figures that do not mean a great deal. More realistic data would come from a simple survey every couple years to record the # of children households within a specific area have. Households are generally truthful about listing their children, and from this family size be estimated. Continuing large family sizes would be a good proxy that family planning efforts have yet to make an impact. 23 Most of the activities of the agricultural sector of MYAP are planned and sometimes even executed with the participation of human resources (specialists) of MARNDR. From what we could observe, ACDI/VOCA was the only MYAP that had such direct involvement with MARNDR. The introduction of improved varieties of seed and tubers is validated by the agencies of MARNDR (CRDA/SNS, PNSA). Specialists in MARNDR have even been involved in the technical training of beneficiaries. MARNDR‟s strong support of the MYAP program is another example of the value the government places on ACI/VOCA‟s unique approach towards the promotion of agricultural production.18 Links with the Ministry of Health in Jacmel (Ministere de la Sante Publique et de la Population - MSPP) are equally important, as we found in our discussions with the GoH regional health representative in Jacmel. The MoH has been directly involved in determining the location of the „fixed points‟ used by ACDI/VOCA, so as to avoid duplication of effort of other programs and strongly supports the Col Vols approach for volunteer community health workers. The MYAP has been able to support MSPP in augmenting their government medical staff, and in promoting the GoH guidelines of Haiti‟s Health System Reform through increasing community access to the Paquet de Service Prioritaries Integres, components which target key health services for rural populations. 1.5 Internal Reporting & Communications Program management has established what appears to be a well-functioning system for monthly and quarterly reporting of progress within the different components of the program in the field. ACDI/VOCA was the only MYAP from whom the MTE team was able to obtain the 1st Quarterly report of the current FY 2010, for example. Field activities during the last week of every month are reduced significantly to permit field staff the time to aggregate data sets and prepare their reports. For example, there are few, if any, Rally Posts meeting during the last week of each month. 1.6 Staffing & Capacity Development ACDI/VOCA, understanding the difficulties its field staff works under, has developed a creative method to keep staff motivated and returning to their work month after month. In areas where access is difficult, staff are expected to remain „in the field‟ for 4 weeks – including weekends - but then are permitted to return to their home bases for a full week (leave) before starting another month of work. We would encourage ACDI/VOCA to also provide opportunities for key field staff to make short visits to other MYAP regions to observe how other field teams are dealing with similar situations they are facing. The fact that the MCHN health workers are chosen among the Cols Vols is a positive element to the sustainability of services, because health workers continue their work even after the withdrawal of the project. However, during the course of the MYAP, offering them a small stipend encourages them toward taking more responsibilities. For example, as volunteers, Cols Vols say, they would participate only at the rally post; now, with the small stipend, they conduct home visits to follow up after childbirth or to check on malnourished children and sick people at their home residences. If greater attention is given to 18 The MTE’s suggestion that the MYAP scale back on one of the most successful and notable components of the ACDI/VOCA program is not because such activities should not be continued. They certainly should be. Our question is whether continued (or growing) attention to non-vulnerable households in a FFP MYAP is appropriate. We would encourage building upon the success in establishing successful technologies but increasingly prioritizing in extending these successes towards the vulnerable households of the communes in which the program works. Other USAID funding should support increasing efforts to further strengthen the productive base of the less vulnerable farmers, who provide agricultural production both regionally and nationally. 24 increasing the numbers of Mothers Clubs, with leader mothers, then Cols Vols‟s monthly training sessions of leader mothers will further increase their tasks. But doing so will also increase the number of volunteers – through the leader mothers - who themselves could lighten the burden of the Cols Vols by visiting the mothers in their group and verifying that mothers are following training given in their households. 1.7 Finance & Commodities Initial estimations of commodity needs for the targeted populations served were underestimated and increasing the flow of needed commodities, because of pre-planned targets, have been slow to change and expand. For example, upon approval of the new MCHN strategy in late 2009 by FFP, ACDI/VOCA had 4,400 MCVHN primary beneficiaries in the program. At the time of the MTE review, this number had increased to 8,244 – a doubling of the program during a time of great tumult, nearly reaching the FY 2010 target of 8,600 primary beneficiaries/households. USAID and FFP have been responsive to stated needs however, and improvements are taking place. Part of the problem with commodity estimates is also linked to how these are calculated in the first place. GoH expects programs to use an average figure of 5 people/household to guide in putting together „packages of food assistance‟. One will see that when converting from # of households to # of beneficiaries, ACDI/VOCA always multiplies households by 5 individuals. This is greatly underestimated. The quantitative survey showed that, among MYAP beneficiaries, the average size household varied between 7 and 8 individuals, depending on the region concerned. However, as observed many times within this region, as well as elsewhere in rural Haiti, actual household sizes are considerably larger than this – with between 6-10 children in many households not uncommon. ACDI/VOCA has been challenged by the logistical difficulties in working in several of its communes. The MTE team has suggested that better focusing of project activities, and tighter integration of MCHN and agricultural activities could help resolve some of these challenges. The MTE team did not have the time to sufficiently explore issues of commodity management and fiscal reporting, though in discussions with USAID/Haiti, the mission appears quite pleased with the responsiveness of the program. 1.8 Environmental Impacts ACDI/VOCA agro-forestry efforts have contributed to local efforts for reforestation. Of longer term impact will be future efforts of the MYAP to help individual local entrepreneurs become established in the production of nurseries of fruit trees (for grafting) and vegetable seedlings for transplanting – all for a fee. Because of the almost immediate profit that can be generated for a buyer of vegetable seedlings, this can be applied more easily. It will be important to monitor the evolution of these initiatives, helping these people to establish markets, obtain materials, etc. The MYAP‟s attention towards establishing high-value fruit trees and valued trees on the steep slopes of the Southeast Department is based, as noted earlier, on the lessons learned by past programs within the region. ACI/VOCA has been aggressive in helping farmers with such steep slopes to acquire the bitter citrus seedlings on which grafting can be performed to give the highly commercialized manderines in La Vallée and Bainet. To the extent that these or other appropriate high value fruit tree species can be extended in a similar manner to other regions for such slopes, this should be encouraged. Indeed, it is often the most vulnerable (and poor) farmers who have to cultivate on such steep slopes, so their support should represent a natural constituency for this MYAP. The real value of such trees, through sale of fruit 25 produce, lessens the risk that farmers will chop them down for firewood, as is frequently the case with other forest tree species, leading to increased flooding and landslides through deforestation. The Southeast has some of the highest elevations in Haiti, and is first to receive the brunt of the frequent heavy rainfall and hurricanes that strike the coast of Haiti. The resulting flooding down these slopes and into the plains below introduces a number of challenges not as frequently faced in other regions of the country. ACDI/VOCA has also been creative in addressing the impact on such cultivars as the improved varieties of black beans introduced. When promising demonstration plots were wiped out by flooding during hurricanes that hit in 2008, and heavy rains of 2009, the program expanded seed production on Double Harvest plots near Port-au-Prince, seed that could then be brought back to Jacmel‟s mountain slopes and coastal regions. The MYAP has also begun to focus on the long standing tradition of the movement of seed from coastal areas to mountain slopes, and back again as a means of strengthening the sustainability of improved cultivars being introduced. 1.9 Conclusions, Best Practices, and Lessons Learned Leadership of MCHN: ACDI/VOCA has been successful in closing out of the MSH sub-contract for SO-2 MCHN activities by the end of FY 09 and has itself become fully engaged in taking over leadership of these activities. The MTE team would agree with the statement that ACDI/VOCA “has continued its health and nutrition activities without impact to its beneficiaries such as food distribution, prenatal and post natal visits and children growth monitoring, vaccinations, and basic health care”.19 A good leadership team has been put into place, and the MYAP will be able to accelerate its strong preventive MCHN program efforts within the many needy localities of these Southeast Department communes. Integration: Integration of MCHN and Agricultural activities has not been a major focus for this MYAP from its conception. Though this was envisioned, program management notes that this was not fully realized, and that there has only been about a 30-40% crossover between the programs. Though sometimes working in the same geographic regions, most activities have been moving in parallel tracks, with different targeted beneficiary groups and different geographic focus areas as well. For example, ACDI/VOCA itself notes an “estimated 20% overlap between MCHN an agricultural interventions”.20 In its MYAP proposal, ACDI/VOCA states that “ACDI/VOCA and its partners will take a holistic approach such that livelihood strategies and health interventions are occurring in the same communities to ensure sustainability and have complementary impact.”21 Or again, under the „integration of agriculture and health and coordination with the Government of Haiti, “ACDI/VOCA’s approach of working with the same beneficiary population for both agriculture and health will reinforce the messages of food security and enable beneficiaries to look at food security from different angles.”22 Program management has noted that this proved quite hard to do in reality based on an agricultural design where model farmers must have sufficient land for demonstration plots – land which is also accessible by road, with farmers well respected in the community and actively engaged in farming. The MTE team believes this approach of „the community‟ or „beneficiary population‟ within a commune as the basis for „integration‟ is too broad to have much impact on specific vulnerable households within these communes. This might be a „trickle down‟ approach which hopes to eventually reach the most 19 ACDI/VOCA Strategic Objective 2 Strategy Paper, November 9, 2009, p. 5 20 ACDI/VOCA Fiscal Year 2009 Annual Results Report, November 4, 2009, p.2. 21 ACDI/VOCA MYAP FY 2008-FY 2012 Resources Request Summary, March 31, 2008, p.18. 22 Op. Cit, p. 39. 26 vulnerable within communities, but the MTE team believes that FFP priorities prioritize directly addressing specific targeted households with the most vulnerable members of these communities. Who are these? For MYAP purposes, these are the pregnant and lactating mothers, children under 5 years of age, and most specifically those less than two years of age, community children who are malnourished, and orphans and the chronically ill within households within each community (PLWHA, TB, blind, crippled, etc.). The ACDI/VOCA team rightly points out some of the internal contradictions that are inherent in FFP programs. For example, in principal, all pregnant mothers are eligible under the PM2A approach – yet some of these women may come from economically very well off households; they are not vulnerable. The household may possess 20 hectares of land with coffee as their primary livelihood. Such are the realities of field implementation. However, this does not preclude the MYAP to always bring back its focus towards the truly vulnerable within these communes. In the case above, perhaps the mother of the prosperous household, included in the PM2A program, could be encouraged to be a leader mother of a mother‟s club that included many vulnerable households. This would parallel the situation were model farmers become the best means through which the ends sought by the MYAP can be ultimately achieved. What is important is that such linkage be overt and monitored for its impact on the intended target population. Commune Focus: Many of the communes of the Southeast Department are in an agro-ecological region that is favored climatically. La Vallée, Bainet, and Thiotte – indeed some of the hill areas of the other ACDI/VOCA communes as well - also enjoy soil, rainfall, and elevation characteristics that hold considerable potential for agricultural production. The project has focused most of its initial agricultural activities in these more productive regions (La Vallée and Bainet). This was in accordance with the strategy laid out by the MYAP to then reach out from this base towards the other less favored areas. All seven communes currently have agricultural activities. The project does not currently have its own MCHN program in La Vallée or Bainet, nor, with the possible exception of some areas of Bainet Commune, does it need to have one. Malnutrition appears to be low, and the health clinics in these regions appear to have their own rally points and health services. ACDI/VOCA notes that Bainet itself has extremely poor coverage for health clinics, especially in the coastal areas and in the mountainous areas of Haut Grandou which are not accessible following heavy rainfall and flooding. Looking at some of the health clinic records in La Vallée, the MTE team concluded that while some malnutrition exists, it did not appear to be high (i.e. below 10% of children weighed). Agricultural Impact: This ACDI/VOCA MYAP has a quality program of targeting crops and introducing new agricultural techniques. From a purely economic and agricultural production point of view, ACDI/VOCA has already achieved important impacts with the improved seed cultivars introduced, leading to increased yields – with the black bean variety (Arifi wurifi) the most appreciated and frequently mentioned by farmers to the MTE team. Farmers who have benefited from the presence of ACDI/VOCA agronomists are very vocal in their high praise of the benefits they have received from training and inputs. They appreciated the approach to „demonstration plots‟ on model farmer‟s fields, whose observable results convinced them to adopt the new varieties. Indeed, the MTE team was surprised to see farmers coming to our meetings with their own notebooks to take notes on the discussions we were having. Continued support and monitoring of those activities already initiated would seem appropriate through the end of the MYAP, to realize anticipated impacts and to continue to serve as the hub of agricultural 27 support activities for the other communes of the Southeast Department. The importance of La Vallée within the overall agricultural strategy for the Southeast Department is compelling, and should be encouraged. Funding other than that from FFP should be secured before beginning any possible withdrawal process, particularly if this should happen before the next two years (see 1.2.2 above). However, initiation of new or expanded agricultural and livelihood enhancement activities in this region should be possibly scaled down, permitting ACDI/VOCA to use FFP resources in regions with more clear vulnerability and need and where a more integrated approach linking agriculture with MCHN can be realized. If funding other than FFP Title II funding were to become available, ACDI/VOCA work in this region should indeed be expanded and reinforced, as the production potential of this region is very important to national and regional food security needs. Yet the MTE team believes that the strategy that centers MYAP support towards the more disadvantaged section communales of the Southeast Department through initiatives out of La Vallée and Bainet are sound and that, as long as such linkages remain clear, they should be maintained. If ACDI/VOCA is to continue to work in the four communes of the Southeastern Department, which are the most vulnerable areas in their regions of activity, then immediate steps need to be taken to improve both the logistics and living conditions for staff working in this region.23 MCHN: The early reliance on trained Col Vols and local health agents to „recruit‟ and „organize‟ women in Mothers Clubs, often differentiated by their child under 5 years of age‟s „developmental stage‟ (pregnant mothers, lactating mothers, mothers with children < 2 years of age) sounded a little like World Vision‟s approach. While these may be standard MCHN approaches in Haiti, they are not so in all FFP programs elsewhere. Yet most of the Mothers Clubs met by the MTE team included mothers with children of different ages, and this was good. The numbers of Mothers Clubs are very limited, given the number of actual mothers that visit the Rally Posts to receive the services provided there. In the minds of most field health personnel, each Rally Post will have one mothers club, led and managed by the Health Worker at this site, with assistance from the Col Vol. In some cases, the Col Vol was also observed to be the „leader‟ of the mothers club at that Rally Post. As seen elsewhere within Haiti MYAP programs (CRS and WV) the number “20” seemed to be the size of many Mothers Clubs, with mothers „invited‟ by the health agent or Col Vol to be part of the group for that Rally Post. Once formed, they receive „special training‟ initially, followed by monthly meetings (same day each month – i.e. 2nd Tuesday of May). Women making up these groups came from different parts of the locality, and were not necessarily neighbors or know each other prior to this grouping. The MTE team randomly interviewed some mothers who had brought their children to a couple Rally Posts. Why, we asked, were they not part of a mothers club? The response, invariably, was that they had „not been invited‟ to form into such a group –but that they would like to be part of a mothers club. Efforts have been made by the ACDI/VOCA MYAP to intensify coverage of health services through fixed point or even mobile clinics when fixed points are not available. Positive strengths of the program include the promotion of volunteers (Col Vols), the motivation and the dynamism of the staff in difficult conditions for transportation and accommodation, and excellent human resources. M&E Data: There are far too many indicators being monitored within the IPTT of this MYAP (currently 48 in number). The most recent version of the IPTT, with up-dated data for all indicators, may be reviewed in Annex 2. The MTE team has also provided some suggestions to the M&E manager on a 23 ACDI/VOCA MYAP FY 2008-FY 2012 Resources Request Summary, March 31, 2008, p.18 28 number of indicators that FFP and USAID might consider permitting ACDI/VOCA to drop from the current list of indicators, as well as a couple new ones tracking outcomes and impact. Furthermore, in the judgment of the MTE team, data from the Rally Point level are probably the most important data actually existing for all MYAP partners that can best determine impact of program activities to changing behavior leading to improved preventive practices and reduced malnutrition. Yet these data are not currently being analyzed at all at this level. Use of PDAs by Rally Post health workers or perhaps a part-time college or secondary educated person could perhaps permit this to happen for the first time and greatly improve monitoring the long term impact of the MYAP program at this level.24 World Vision currently has a pilot program of the LMMS PDA, though these are expensive at $1,000 each. Yet the benefits in improved access to field data in real time, permitting analysis at the rally point level, would seem to justify this expense. USAID and FFP would do well to support the trial testing of this technology in some localities.25 At the very least, this should be initiated during this MYAP in a couple section communales so that the experience gained could help inform future efforts in Haiti and elsewhere. ACDI/VOCA are currently looking at starting with an electronic beneficiary registration and commodity tracking, possibly using WVH‟s pilot tool LMMS which might also integrate some of such data. Project End Game and Graduation of Programs from Specific Localities The project mind set seems to be that the end of the project is when „results‟ and impact should be „delivered‟. No mention is given in the ACDI/VOCA MYAP proposal of how „successes‟ during the course of the project, could lead to accomplishing goals set by the project and phase-out of activities. To what level must „food insecurity‟ be brought to „reduce the vulnerability‟ of local populations – particularly the „most vulnerable’ who are the intended targets of FFP programs? The MTE team believes that malnutrition rates as being currently measured, at the locality geographic level – at rally posts - should be established as the criteria for „graduation‟ of activities in specific localities as well as initial identification of sites for MYAP activities in the first place. The basic time series data collected by the MYAPs through the rally posts become an extremely valuable tool for program monitoring over time – and in some cases even more valuable for measuring ultimate impact than initial baseline and final evaluation quantitative data which measure population impact within specified regions. The MTE team believes that FFP should rethink where and how baseline, mid-term, and end of project quantitative surveys are undertaken. Technology currently available to program field personnel, used in the right way, can provide a MYAP with on-going information of progress towards reaching desired impact. Early Warning System: What ACDI/VOCA has accomplished in organizing partners to work within the current system, and the quality of the bulletins, is impressive. The collaboration with CNSA only began in January 2009, and since then their headquarters were destroyed in the January 2010 earthquake. Their capacity and funding levels to take greater ownership of this process is currently limited. Ideally, 24 We understand that special training would need to be given. Many Col Vols are illiterate and would probably have difficulty undertaking this task. The MTE team sought to use local college-educated students who had previously been involved in the MYAP baseline surveys to use PDAs for the mid-term quantitative survey. PDAs were programmed with the questionnaire and these enumerators provided two days of training. However, this was not enough, as too many of them were unable to quickly learn how to properly enter these data, so we had to abandon the PDAs go back to the paper format for interviews. But we believe, with better training, and a more simple entry format for these PDAs that this could still be possible for limited field key data entry. 25 The MTE team observed, while visiting remote locations in rural areas, local entrepreneurs who had somehow acquired small solar units to charge local cell phones for a small fees. Perhaps this would be one way to charge these PDAs while also stimulating local entrepreneurs. 29 though it would be good for ACDI/VOCA to begin to play a more supportive role to the GoH in taking leadership of this activity within the region, this may not be realistic under current conditions in Haiti. The EWS bulletins are too important to program planning within the South and Southeast Departments where these have been well established for lack of strong continued support to happen. Furthermore, there are other areas of Haiti that have not yet become part of the system, and leadership needs to be encouraged to support this process development elsewhere as well. Bulletins should also give some space to describing how the use of EWS information is actually leading to results on the ground. Recommendations are provided at the end of the bulletins, but whether or not these recommendations are acted upon in terms of actual responses is not clear from what the MTE could see. 1.10 Recommendations The most important recommendations concerning this MYAP, along with the other two MYAPs reviewed by the MTE team are presented in the major recommendations section of Report #1: Haiti MYAP Overview, Methodological Approaches, with Major Conclusions, Lessons Learned, and Recommendations. Report 1 must be taken together with this Report 4 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. M&E Indicators: As observed also with both WV and CRS field sites, ACDI/VOCA data collected at the Rally Points and fed up through the Col Vols to the Fixed Point health workers (or health centers in CRS‟s case) is rarely, if ever, analyzed and reported upon in quarterly or annual reports. Data are simply aggregated for health reporting separate from IPTT indicators. Certainly, data trends at the rally point level do not appear to have been analyzed. These data are not considered part of the M&E system, which, according to the ACDI/VOCA M&E Coordinator, is limited to supplying the data and reports for the IPTT indicators. Even though there is now an M&E specialist for MCHN based in Jacmel, these indicators are already a very heavy burden on the program, which is very much understaffed.. As a point of comparison, World Vision has at least 6 M&E full time personnel addressing similar data sets, led by a MYAP M&E coordinator. The MTE team would recommend that ACDI/VOCA, and probably all MYAP PVOs, test a new system of data entry at the Rally Point level where mothers are bringing in their children for growth monitoring, and where PFA and PTFA are initially determined. These and other data are recorded in standardized registers. Our recommendation is that each program selects a couple of section communales within their intervention areas and supply each of their Col Vols the training and PDAs needed to enter the monthly register data into the PDA for each of their Rally Points. This would be less expensive than for the entire MYAP to begin doing so; we also believe that there is no reason that some Col Vols or local health agents could not be trained for such use – they already use their cell phones for many purposes. Such data could then be transferred by flash drive (or sent by cell phone digitally) to the Health Coordinator who would download the data, aggregate as desired, and transmit this to the Head Office in Jacmel for further use and analysis. The raw data should also be transmitted, to keep the time series from each Rally Point separate to permit analysis of malnutrition trend lines for this community. This should be initiated immediately, so that by the end of the year the MYAPs can determine if using this software/hardware will facilitate data transfers currently taking place using the paper trails. Registers would continue to be kept at the local Col Vol level, and could be checked from time to verify that information is being properly recorded and transmitted. After of year of such use, the MYAPs can 30 determine the costs and benefits of doing this, and if justified, perhaps extend the system to all program sites. Naming Conventions: The MTE team would also recommend that ACDI/VOCA use a more common designation for their „meeting points‟ which appear to resemble the Rally Posts or Points of CRS and WV respectively. A common vocabulary at least for the MYAPs would help to develop a common approach within FFP programs in Haiti. We would suggest the use of the term “Rally Points” for all MYAPs, and „mother clubs‟ rather than „mother care groups‟ by this MYAP. Program Targeting of Mothers Clubs: Mothers Clubs – and not the Rally Points, should be considered by ACDI/VOCA as the target population for the MYAP program as a whole. Households represented by these mothers would be the priority focus for all MCHN behavioral change messages, as well as most livelihood/agricultural focused activities of the program – thereby creating true integration. We also recommend that Mothers Clubs follow a more standard format as well, with leader mothers and self￾selecting groups of mothers around specific Rally Points. Mothers Clubs: Mothers coming to Rally Points should be „encouraged‟ by the ACDI/VOCA to form into self-selecting small groups of mothers with children under five years of age. Many of these mothers will have older children as well. Under no circumstance should the health worker or Col Vols „select‟ or chose which women should form into which groups. Mothers Clubs should be of limited size (10-15 members is a good number to begin with), but the mothers should be asked to organize themselves according to friendships, proximity, etc., because the purpose if for them to work closely together to share messages that will improve the health and welfare of their children and household. Incentives to organize and report their groupings to the local Rally Post heath worker or Col Vol need to be put into place: these would include assurance of direct once/month training by the Col Vols to Rally Point totally voluntary Leader Mothers selected by the locality Mothers Clubs; these Leader Mothers would themselves hold regularly scheduled monthly meetings with their small group of mothers to pass on this information. Leader Mothers would also promise to give regular home visits to see that training discussed was being applied among her women. Each Leader Mother would also keep a register showing all mothers and their children < 5 years of age and their monthly weight gain status (yellow, orange, red); she can be helped by someone within group who is literate, even a household child if need be. Other incentives would include special assistance to the Mothers Club for developing their own mutual solidarity groups (MUSOGs), establishment of household level vegetable gardens (with micro-drip irrigation systems if necessary), or other livelihood activities. The potential importance of the MUSOGs for mothers within a Mothers Club, for instance, is illustrated by to MUSOGs established six months ago in Anse a Pitre and Bainet. “They started their savings portfolio with 5,000 Haitian Gourdes (about $125) and are now managing a portfolio of close to $2,500” – money which they are loaning out to members of the group for various entrepreneurial activities or household needs.26 Announcements for special prizes and recognition of 10% of all Mothers Clubs showing strong commitment of its members could be announced by ACDI/VOCA each year – with such prizes as grafted fruit trees for household gardens, perhaps a couple „improved race‟ chickens for each mother within club, etc.). Free Stuff: Avoid giving out anything in the MYAP to beneficiaries „for free‟ – whether this is food supplements or commodities (improved seed, grafted fruit trees, multi-use agro-forestry trees). While it is true that, in principal Title II program‟s MCHN component gives out „free food‟, the giving out of this 26 ACDI/VOCA Haiti January –March 2010 Quarterly Report, June 2, 2010, p.8. 31 food is usually (or should be) based on some expected actions of the recipients (attending rally points, receive counseling of some kind, bring child to clinic for treatment, become a member of a mothers club, etc. If some kind of distribution of some of these items is desired, always tie it to some specific project sought-for activity or change in behavior (as in the formation of Mothers Clubs). The normal course of ACDI/VOCA seed multiplication activities with farmers, they sign a contract, before receiving the seed grain, that they will reimburse in kind the see that is given to them. Farmers respect this contract which helps to explain why this activity has been so successful. The MTE team actually was able to have a strong discussion about this topic with a group of ACDI/VOCA farmers shown here and they clearly said themselves that “what I get for free I don’t care for like something I pay for”. We saw several households that had been „given‟ free cisterns by an NGO which were no longer in use (for minor repair problems). One household (pictured below) had even managed to get a second NGO to give them a second cistern – with a large older one standing next to it in disrepair. Many households do not even make the minimal effort to put rain gutters on their metal roofed homes to catch rain water. ACDI/VOCA may wish to consider how some form of „repayment‟ might be arranged (by contract agreement) for the distribution of their citrus seedlings, which later are to be grafted as manderines. Perhaps an agreement that cuttings can be made from their future trees or a specific quantity of fruit delivered for distribution to the needy in the region. Logistics: It is essential that at least two additional vehicles be assigned for permanent use in the three eastern communes of the Southeast Department, and that improved housing and living conditions be made available for senior staff assigned to this area. The MTE team would recommend that continued attention be given to improving existing infrastructure and housing.27 Efforts have already been initiated to furnish staff in Cotes de Fer and Thiotte with propane tanks for propane fridges, solar panels with inverter and a small satellite dish to provide the field team with internet connections and digital communications of project data to the Jacmel headquarters. Efforts are also underway to so for Belle Anse as well. Internet is already being installed in some offices now in Thiotte and Cotes de Fer, which is a good start. These and other appropriate measures should be done 27 There are Haitian companies in PAP that have the capacity to quickly construct pre-fab ‘foam-walled’ houses, fully equipped and these might also be an option to consider. 32 immediately to retain the staff that is currently working in almost impossible conditions. The eastern portion of this Department is a region where continued assistance will almost certainly be needed beyond the life of this MYAP. Concentration of MYAP Activities: ACDI/VOCA resources should be concentrated to meet the full need of the specific localities being served by their programs. Program MCHN mangers pointed out the experience in Haiti where it is not realistic to expect high coverage rates, particularly given the mountains of the Southeast Department.28 They strongly stated that achieving rates close to 100% of pregnant and lactating mothers, all children under two years of age (in PM2A approach), and all malnourished children in receiving the needed assistance is completely unrealistic. ACDI/VOCA, responded to this issue in their 2009 PREP document, when stating that “While we hope to reach 100% of the target population, food distribution programs, especially in rural areas, very rarely reach 100% of their target population. Considering the mountainous rural terrain of the implementation area, coverage rate standards for similar feeing programs, and the experience of World Vision with PM2A coverage in Haiti, we still feel that planning for a 50% participation rate would be appropriate for our program”. 29 Accepting this reality, therefore, means that having a major impact on changing overall malnutrition rates within these specific areas will be difficult to achieve. There may not be enough critical mass of mothers changing their behaviors to result in long term improvements. The MTE team sensed that the real issue was one of programming for the needs of specific communities – not that if project resources could be sufficient to cover specific areas, that most of the beneficiaries targeted would not find a way to avail themselves of the food assistance. MYAPs annually pre-program to cover only for a certain rate level (e.g. 50%) and when these supplies are used up, there is not sufficient for others. The MTE team would still maintain that the MYAP should only cover those where most of the need can be made available, if those seeking such assistance respond by seeking this help. During the next year, the MYAP might target some particularly vulnerable localities for higher rates of coverage to see if, in fact, beneficiaries did not respond to this increased availability of food and if this did not result in an 28 The MTE team was referred to the literature in the Lancet on coverage rates achieved by WVH in the central region of Haiti where rates are of around 73% were achieved in a very accessible region compared to ACDI/VOCA’s mountainous regions. Other literature regarding feeding programs in rural areas considers >60 or >70% coverage rates as acceptable. 29 Communication received from ACDI/VOCA, July 15, 2010; referring to ACDI/VOCA PREP: Pipeline and Resource Estimate Proposal FY 2010, August 28, 2009, p.10. 33 overall lower rate of malnutrition in this specific area. Based on what appeared to be much lower rates of malnutrition in some MYAP sites (in productive areas, along roads), we believe results will be positive.30 The MYAP also needs to look again at the issue of what appeared, to the MTE team, to be less than 50% of mothers (and their children) being sent to a health center or Fixed Point‟ for further treatment and services for their malnourished children who do not actually show up; then there are those who do qualify to receive food assistance but actually do not receive the monthly ration. ACDI/VOCA tracking of such situations does not show that this is a problem, so the MTE may have misunderstood this situation. The MTE team also believes more appropriately formed Mothers Clubs (with leader mothers) would go a long way to addressing such issues locally, where they may be a problem. Furthermore, livelihood activities also need to be focused within these communities, with special linking to members of households represented by the Mothers Clubs formed around Rally Points. Graduation or Program Phase-Out Plans: Given the budgetary and logistic issues raised by the ACDI/VOCA with the MTE team, we would strongly recommend a clear „graduation strategy‟ from specific localities within communes being worked in. We would also suggest that the key criteria for such „graduation‟ should be based on an objective measure - like the reduction of malnutrition rates within a specific locality (around a rally post) to levels below 10%. For this reason, it is essential that ACDI/VOCA maintain records of PFA and PFTA for all children coming to Locality Rally Points, and also include MUAC results for the area as well. Time series data showing total children weighed, divided by „normal‟, PFA, PTFA exist. Adding the PFA + PTFA, and dividing this number by the total number weighted each month will give a proxy estimate malnutrition rate for that site. Should a rate below 10% be maintained at a locality for six months or longer, then ACDI/VOCA might consider „graduating‟ this community from receipt of program services (food assistance, livelihood activities). These resources should then be concentrated to other localities of program interventions that are underserved.31 2.0 ACDI-VOCA Strategies and Outcomes Achieved to Date 2.1 Improved Nutritional and Health Status of Targeted Vulnerable Groups Since the beginning of the MYAP through to the end of the 1st Quarter of FY 2010, ACDI/VOCA has certainly had an impact on the lives of many people from the MCHN health perspective. If we consider some of the achievements listed in the IPTT, we note that:  967 pregnant and lactating mothers have received food rations  2,091 children aged 6-23 months have received food rations  There have been 4,832 antenatal care (ANC) visits by skilled health personnel to beneficiaries  6,933 children less than 5 years of age have been reached by the MYAP nutrition programs  1,455 children less than 12 months have receive their full DPT3 vaccinations in a given year  8,145 children less than 5 years have received Vitamin A from the MYAP 30 The MTE team also agrees with the MYAP that it would be difficult and inadvisable to stop food programming in an area where this has already been initiated, as this would cause major problems for the program as a whole. Rather, additional supplemental food would need to be acquired to permit greater increases in specific areas to achieve higher coverage rates. 31 Should the MYAP not consider this to be the most realistic approach to graduating activities from specific areas to move towards areas of greater need, then the MYAP should suggest its own strategy. What the MTE team objects to is the concept that once a MYAP begins work in a specific area, they must remain there until the end of the project, when there are other specific areas within their targeted regions of intervention where malnutrition rates are much higher. 34  1,246 cases of child diarrhea have been treated through the MYAP If we consider a series of numbers, not reported in the IPTT, about how the MYAP is reaching these program beneficiaries, we note that:  ACDI/VOCA has three medical doctors, 2 nurses, an 20 auxiliary nurses aids supporting 97 trained health agents who are supporting 3 health centers, 6 dispensaries, 13 „fixed points‟, and <300 rally points in the communes of intervention  Some 288 Community Health Volunteers (Col Vols) provide support to these rally points, conduct home visits, assisting in growth monitoring, and supporting 57 Mothers Clubs.  To date, approximately 18,809 children under 5 years of age have been assisted through these rally points, and an additional 75,256 children between 5 and 18 have also been assisted (cf. Annex 3).  About 351 traditional mid-wives (matrons) have received some training to improve their skills in helping mothers through their home-based deliveries. The challenge in these numbers however is to question what they actually mean, and how do these numbers indicate whether or not the MYAP is reaching its stated goal of reducing vulnerability to food insecurity through the three objectives outlined (cf. page 28 of MTE MYAP report #1). How is maternal and child health improved, how is there now increased access to nutritious foods for vulnerable populations. Who are the vulnerable populations? What percent of the vulnerable populations in a specific area are actually helped by these programs? How are the MYAP agricultural activities actually helping to reinforce MCHN efforts to reach program objectives? In the Belle Anse area visited by the MTE team, the MTE team met with a very large group of women who said that they regularly come to the Rally Post there. Currently, there is only one mothers club at this Rally Post, made up of 37 mothers. They started in December 2009 (6 months ago), and were formed by the ACDI/VOCA nurse working at this location – under whom there are three Col Vols. We asked the women why they didn‟t form into smaller mothers club groups, and one young outspoken woman said that they had not „been authorized „to do so (by the nurse) – they had simply been told to form into a „mother‟s club‟ group. They had also just started a „sol’ savings group on their own,32 which is not a mutuelle savings and loan system like ACDI/VOCA is promoting elsewhere within Mothers Clubs. The women were telling us that they wanted „lots of women to join their group‟ so that they would „have more money‟ to give to the person who would get benefits each month. Our impression was that these groups were not being very well led and were not focused towards caring for their children – they were too large.33 The Col Vol was an older woman who has been a Col Vol since 2008 when ACDI/VOCA began in region (through MSH). We also received the impression that there was not a high rate of malnutrition among the children of this group. One of the lessons the MTE team has learned during the course of this review is that there is a great deal of variability in malnutrition rates among children at different localities within the same section communales of a MYAP. This was certainly true with ACDI/VOCA as well. This has led us to suggest 32 Each month, one person receives the total amount collected by the group for some personal commercial venture or other need. No interest is charged on the amount given out. 33 Mothers care groups, as ACDI/VOCA is calling them, are not just for woman with malnourished children. They are for any woman with a young child, regardless of their anthropometric status. The MTE team fully agrees with this orientation, though women who come to a rally point who have malnourished children should be encouraged to become part of such a group – or participate in the formation of a new one. In fact, the MTE team believes that this should actually be part of the expected outcome if free food is to be given to this household. Without some expectations of this kind, impact will not be made. 35 0% 10% 20% 30% 40% Jamais Vu Grille Dassa haut Lherisson Ricot that the targeting of vulnerable populations within a commune or section communales needs to be done at a geographic level that is meaningful for monitoring purposes. Stating that a region has 23% malnutrition rates masks the fact that some areas are much lower, and others are much higher. The MYAP needs to be focusing its resources on these localities where the rates are high. One should reasonably expect that over the course of two or more years, the MYAP should be able to provide the services listed above, and training for behavioral changes, linked to livelihood activities, that will reduce the malnutrition rates of these localities to a level that would permit refocusing resources towards other areas. 2.2 Improved Quality of and Access to Health Services for Vulnerable Groups Figure 1 below shows a time series of data for malnutrition rates (PFA+PTFA) for seven rally posts in one section communales in the Commune of Cote de Fer. The six Rally Posts in ACDI/VOCA‟s Southeast Department region, over a seventeen month period above in Figure 1, show considerable variation in malnutrition rates from month to month. What is interesting are the data from the Jamais Vu and Dassa Rally Posts that show long-term malnutrition rates below 5% and 10%, while Grille and Martineau show very high rates of malnutrition. MYAP programs needs to review such data and determine why this is so. The answers may lead to reinforcing some areas and reducing efforts in others. The MTE team‟s observations on this kind of information both in the Jacmel and Les Cayes regions suggests that the presence of health clinics in the locality may explain lower rates, while higher rates are associated with sites at considerable distances from clinics. Figure 1: Southeast Department (Jacmel Region), Cotes de Fer Communes, Section Communales: 6ieme Jamais Vu (6 Rally Post Localities)(ACDI/VOVCA, January 2009 – May 2010)(PFA+PTFA as a percentage of total children weighed) ACDI/VOCA‟s efforts to place „fixed points‟ into some of these more distant places is a direct response to this issue. Photo here shows a fixed point at the Baie d‟Orange). Another variable may be the presence of sufficient Mothers Clubs that help reinforce messages that can help reduce overall malnutrition by improved child feeding and hygiene 36 practices (with less diarrhea for example). In any case, the MTE team would suggest that ACDI/VOCA analyze their malnutrition rate data at the locality level to determine the combined impact of their MCHN and agricultural activities on the concerned households. Success in reducing these rates below 10% may justify a strategy to reallocate MYAP FFP resources to other localities where rates remain high. ACDI/VOCA is changing the qualification of children 24-59 months for its supplementary feeding program to the protocol used by the Ministry of Health. Rather than qualifying children using PFA+ PTFA (weight for age), ACDI/VOCA is screening children using MUAC an qualifying them for the supplementary feeding program using weight for height. Using weight for height to enter children into the supplementary feeding program will reduce the number of children who qualify (only 5-6% of the children in the areas of implementation are estimated to be acutely malnourished), therefore ACDI/VOCA has lowered its target numbers in its IPTT. The reasoning is that because of the level of chronically malnourished children, that this focus will help move attention to those children, particularly those under 2 years, where immediate attention will have more long term positive results. It is also important to follow MoH established protocols. Though ACDI/VOCA would continue to measure PFA and PTFA at the Rally Points, they would no longer report these data in their IPTT. 2.3 Increased Food Production and Household Assets Outcomes Achieved since the beginning of the project to March 2010 include:  16,070 rural households benefiting from the program  4,967 individuals who have received short term agricultural sector productive training  744 hectares under improve technologies or management practives  30 metric tons of improved variety Arifi wurifi black beans (MT) produced locally  A total of 346 hectares of bean (Arifi, Buena vista, DPC 40) established  1,610 farmers trained in bean production and seed multiplication  67 hectares of short cycle sorghum variety planted  Distribution of improved corn seed to 384 farmers  169 ha of corn seeds planted throughout the region  202 farmers in la Vallée and Bainet trained in yam improved seed production (mini-sets)  4.87 MT yam tubers distributed to 190 farmers  464 farmers receive short-cycle sweet potato, planted to about 14.5 hectares; this variety matures two months sooner than local varieties  125 farmers in dry areas also received cuttings of manioc  1,321 farmers received vegetable seedlings as a means to enhance dietary diversity and provide supplemental household income, and 1024 received training in vegetable production  30,000 citrus seedlings prepared for distribution and graft as manderines  70,463 fruit and multi-purpose trees were distributed and planted this past year  17 individuals trained in fruit tree grafting, and 1,200 mangoes were top-grafted  3,000 improved coffee seedlings of different varieties were distributed in Thiotte  Several CBOs were trained in how to set up and manage Mutual Solidarity Group (MUSOG) saving and loan systems 37 The program supported farmers to access improved seeds and planting techniques, which are key elements to increasing production. The program supported tuber and vegetable production, which equally enhanced the producers‟ nutrition and income. In FY 2009, ACDI/VOCA introduced a new high yielding black bean variety (Arifi Wurifi) to the Southeast region. The variety has impressive yields, is resistant to “mustia” (a common yield-reducing bean fungus) and is adaptable to the agro-ecological conditions of the region. Lead farmers were trained on bean seed production by MARNDR‟s leading expert. According to the farmers in the mountainous areas without irrigation, the output obtained starting from this variety is 4 to 5 times higher than that of the local varieties. As a result, this variety is in the process of widespread adoption. Plots of “Arifi Wurifi” seed black beans in Morne à Bruler and Musac (La Vallée de Jacmel The strategy of forming farmers into groups facilitated training on the new methods of production taught by the MYAP. The project‟s extension agents, working with a bean expert from the Ministry of Agriculture, trained the lead farmers on improved production and seed multiplication techniques. In each commune, to help make the future production of this seed become sustainable, the MYAP facilitated the creation of small groups of producers (15 to 20). These small groups in the future will supply the market with this bean variety. The MTE would recommend the program consider helping a select number of these farmers to develop their own seed production businesses to market quality seed. Because the mountain and plain agro-ecological zones have different planting seasons for these seeds, it is important that a formal link develop between entrepreneurs in these two zones.34 According the model farmers met by the MTE team, black beans are one of the main crops grown in the Southeast Department of Haiti. The region poses significant challenges to farming, however, and local varieties of bean tend to produce poorly due to their susceptibility to the mustia fungus, which is common in the area. Furthermore, during planting seasons, farmers usually cannot buy enough seed at reasonable prices. Farmers noted that this new variety is well adapted to the zone “It is the first time we have seen a variety of bean with such results”. The MYAP depends on the success of these model farmers to continue to expand the production of this variety in throughout this region. 34 Farmers will not successfully plant this black bean in the save zone, two seasons in a row. In one season, it is planted in the low lands, and in the next it must be taken to the highlands, and grown by a different group of farmers. 38 A short cycle sorghum variety (RCV) developed by the Centro Internacional de Agricultura Tropical (CIAT) and approved by MARNDR was also introduced in the dry and marginal areas of Côtes de Fer, Anse à Pitre and Bainet. This short-cycle variety has the potential to produce between two and four harvests per year compared to the local variety, which may only be harvested once a year. According to what the MTE team heard from local farmers, this variety is also gaining the confidence of the farmers of the area. Through active collaboration with MARNDR, ACDI/VOCA obtained nearly 500,000 short-cycle sweet potato cuttings from the seed multiplication sites of the Programme National de Securité Alimentaire (PNSA), which is the Ministry‟s project on food security located in the Artibonite Plain. The improved variety can be harvested after two and a half months compared to six months for the local variety. Sweet potato also serves as a safety net during hurricane seasons since the tuber grows underground and is not as exposed to flooding or wind damage. According to farmers met with at Baie d‟Orange (Belle Anse), a cutting of this variety of sweet potato “Ti savien” produced 8 tubers compared to the local varieties whose output rarely exceeds 4 sweet potatoes. They are unanimous in recognizing that the new methods of planting, advised by the ACDI/VOCA extension agents, will enable them to reduce the risks of loss due to the flooding. This is because the period of planting corresponds with the height of the hurricane season. For them, this variety resists better to the “tiogan”. In conjunction with Haiti‟s leading yam specialist from the MARNDR, farmers in Bainet and La Vallée communes received training on the mini-set technique, a yam seed preparation technique which allows the preparation of more yam seeds from a single tuber. According the farmers, this technique has helped them to greatly increase the multiplication of yams as a food security and cash crop. Vegetable gardening activities were conducted with the farmers to diversify their agricultural revenue and diet. Vegetable nurseries were established with farmer groups. A major constraint in agricultural production is the availability of water. In order to promote efficient water management, micro drip irrigation kit technology has been tested. The project installed 10 drip irrigation kits, which were donated by a local church in Côtes de Fer to water vegetable plots supervised by extension agents. 39 ACDI/VOCA introduced vegetable farming to these mountainous areas in the Southeast of Haiti, which generally produces only yam tubers and pulses. According the farmers who have participated in an agricultural extension training organized by ACDI/VOCA, after receiving the training and harvesting their seeds, they had been thrilled with the results of their first foray into vegetable farming. According to farmers we met, this is the first time they have ever produced as many vegetables (cabbage, okra, eggplant, hot chili pepper). Model farmer in Gris Gris (Cote de Fer)with some of his produce (Note micro-drip irrigation system in background with hanging pail) Furthermore, the vegetables they have produced with the help of the ACDI/VOCA extension agents were huge compared to those they usually see in the local markets. The variety of eggplant shows above sells for 25 gourdes on the local market. According to beneficiaries, the first vegetables obtained helped them to feed their children, but also generated enough income to pay for their children school fees as well. The model farmers encountered were proud to tell us about the profits that they have made with their vegetable gardens. The model farmer pictured above said that the benefits of his vegetable sales (chili pepper, eggplant, tomato, etc) have allowed him to improve the structure of his house and to increase his livestock (in particular goats and poultry). This farmer has also learned to graft fruit trees, showing us a citrus tree with three types of citrus branches on it. He also has taken a wild local variety of eggplant “Zamourette", resistant to drought and lasting a year, and grafted to it an improved variety of eggplant. We Bottom of For heard a similar story from a neighbor to the farmer above, who also wanted us to see her vegetable gardens. She noted that one of her major outside-the-household duties is the sale of vegetables coming from her gardens. She noted that her son of 18 months is better fed; that the income of the household has increased since the household‟s participation in the program. We also noted that she raises hens for eggs which she keeps penned up so that they would not get into her gardens. These two model farmers encountered now also specialize in the production of vegetable seed as well, as with the hot chili pepper seed shown here. 40 The MYAP has also introduced a range of other vegetable varieties, such as one called the "Swiss Chard" which is a large leafy green, somewhat like lettuce, very appreciated by the beneficiaries. Bottom of FormIn Thiotte, a traditional coffee growing area with good rainfall, ACDI/VOCA worked with CBOs and their members to regenerate coffee farms. The program has distributed approximately 19,000 improved coffee seedlings to 190 farmers, which were planted on 12 ha. Technical assistance was provided on coffee parcel management. Now, the program will focus on scolyte control, a pest affecting many coffee farmers in Haiti. The MTE thinks that it is a good strategy to strengthen this crop which has great commercial value for the Haitian farmer of this region. The MYAP has also ventured into helping farmers in La Vallée with the regeneration of plantations of mandarin. Nearly 50,000 seedlings will be produced and distributed during this year. The MYAP also plans to support the entire value chain by linking producers and traders (Madam Sara). One effort already underway is to improve the packaging of the products in order to reduce losses estimated at more than 30% in transport. The MYAP has supplied farmers with fruit boxes that will be rented to the saras for their transport to the PAP market. This approach is significant because it brings into contact two important actors of the value chain by introducing a technique which will profit both. Improved managerial and financial capacity of community based organizations and local groups ACDI/VOCA supported a fishermen‟s association, Association des Pêcheurs de Brésilienne (APEB), in La Brésilienne, Bainet in the implementation of a pilot intervention to increase the association‟s fish catching capacity. This pilot project seeks to utilize the value chain approach to improve the revenues of fishermen and traders in the Southeast Department of Haiti. The project is also designed to build the capacity of the selected associations, developing and improving its processes and procedures. The pilot project is focusing on each aspect of the fishery value chain, including fish catching (placing FAD in the ocean), cold storage, processing (salting and drying) and marketing. In other places of the country, this system will be fully functional and this activity has allowed improving both dietary diversification and increased incomes. Increased access to financial resources Several CBOs were identified and informed about the Mutual Solidarity Groups (MUSOGs) concept. This program of saving and internal credit to the group will permit:  Access to the capital at a cost lower than other sources of credit available, in particular the more widespread networks of informal credit whose usurious loans can reach 25% interest each month),  Increase and the stabilization of the credit of the marketing activities in the communities, 41  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 household level. The program will also help the groups in the management of the funds to avoid the problems of reimbursement. It is important that the MYAP NOT become involved itself in making additional funds available to these MUSOGs. As they gain experience, they may themselves approach micro-credit lending agencies. The MTE team met a large group of farmers at a broken down irrigation perimeter, capable of irrigating about 30 hectares, though it was not doing so because of some unrepaired breaks in the system. Though farmers told us they „owned‟ their land, this was not true – almost all sharecrop their land – which belongs to a Minister in the GoH, a very powerful figure in the region. The crops that were being irrigated did not look good, as there has been problem in managing the available water. There is no water users association. Trying to create one at this point probably will fail given the land tenure of the system. ACDI/VOCA has wisely not gotten involved in the improvement of this system, but took advantage of some of the land of these farmers to introduce the much appreciate improve variety of black beans and a variety of maize. They have not yet gotten into vegetable production. It is not clear whether or not ACDI/VOCA should continue to be associated with this group. The best the MYAP can do is to link them with farmers in the hills who can supply them with seed for the March/April season, and they supply the hillside farmers with their November/December seed needs - something they are already used to doing. We would recommend focusing exclusively on household level vegetable production (and markets) and mutuelle within the Mothers Clubs in the hills, where malnutrition is actually substantially above 10%. The MYAP has enough data now from Rally Points to be able to determine where they should focus their assistance. 2.3.1 Improved Food Security According to households interviewed, MYAP livelihood activities have already brought in new cultivars and techniques that are helping households to cope better throughout the year. This increase is especially due to the distribution of improved of black bean variety (Arifi Wurifi), a sorghum variety, tubers (sweet potato and yam seed. Of all the activities undertaken, however, the efforts ACDI/VOCA has initiated with drip irrigation systems and the intensification of vegetable gardening (home gardens) hold the greatest potential to addressing food security issues during those times of the year when resources are scarcer. It is also fair to point out that success under the Livelihood SO would not have been possible if the MYAP had ONLY worked with the most vulnerable households without land resources. The strategy of building upon the strengths of each region, and incorporating model farmers (who may not themselves be considered „vulnerable) as leaders within their communities to supply quality seed and tested techniques for the more vulnerable within their own areas, as well as in adjacent areas, has worked. However, attention must also be given to the available resources of truly vulnerable households to help them to improve their situation. For example, many farmers do not have enough of their own land to cultivate, and must practice share-cropping. Helping such farmers increase their financial resources so as they can rent land (and perhaps ultimately purchase small plots of land), would reduce their vulnerability. 2.3.2 Appropriateness of Early Warning System 42 It is still too soon to know if the EWS systems being developed both within this MYAP and those with the other MYAPs will lead to local communities and regions being able to respond better to future natural disasters or food shortages. The weakness in all these systems is that their maintenance, financing, and reporting mechanisms still depend too much on outside personnel (NGOs) and resources. Until the national will and means is developed, these systems may not be sustainable. 2.4 Enhanced Market-Based Livelihoods ACDI/VOCA‟s approach to supporting technologies for productive increases to food commodities is very much market based and has targeted those groups and regions within their MYAP that have the greatest potential for expansion. Farmers associated with these efforts are clearly benefiting and have had their own livelihoods enhanced. 2.5 Rehabilitated Natural Resources and Local Capacity to Sustain These The MYAP‟s focus on high value fruit trees (mangoes, manderines, coffee), and the grafting of these as well, has been met with positive responses from farmers. These are assets considered of value to farmers in the different communes, assets that will bring increased incomes to benefiting farmers in the years to come. These trees will also not be those that farmers will be cutting down in the future, as is so often the case with other tree species used in for hillside soil erosion measures. Greater attention needs to be given to encouraging entrepreneurship among some individuals currently associated with the ACDI/VOCA supported community nurseries to become established as vendors of these assets – perhaps associating them with the production of vegetable seedlings as well for sale within adjacent irrigated perimeters or on individual household gardens. With some 50,000 seedlings being distributed for later grafting, with thousands of farmers receiving vegetable seedlings – the MYAP would be missing an opportunity of not establishing several local vendors from whom these supplies could be obtained. The MTE team believes dependence on „groups‟ to maintain such nurseries will not prove to be a sustainable approach, and that other approaches should be encouraged. The environmental education campaign in which the MYAP has become engaged in would be an example of seeking other opportunities to engage a broader base of people in building understanding of environmental issues. 43 2.6 Challenges Faced and Overcome in Program Implementation Constraints Although ACDI/VOCA‟s approach using clinics and „fixed points‟ greatly promotes the medical follow up of children in an institutional environment, the path from the rally post to the health center can be very difficult. The most difficult is the long walk from homesteads to centers, by mothers who carry their children in the arms. There simply are not sufficient numbers of health centers in these very large and mountainous communes. The initial challenges faced and overcome with respect to the MYAP‟s initial MCHN sub-contractor MSH show the programs adaptability as well. Supplemental food is also offered, as a preventive approach to children of age 6-23 months. However, the amount of food is not sufficient for all children. Household sizes are often significantly larger than the estimated 5 people/household used to establish ration size. The MTE team completely understands the need to establish such guidelines; yet it is also true that one result is that supplemental food received by the household cannot possibly be enough for all the children in the family, and that the shared food will result in the intended youngest children actually receiving less than they actually need. But something is certainly much better than nothing. Furthermore, the MTE team observed in some of the sites visited that only 50% of the children actually selected to receive supplemental feeding within a community actually end up receiving this ration. This seemed to be confirmed by some BND 35 sheets we reviewed as well. The ration was there to be collected, but the mother, for one reason or another, didn‟t come to take it. The MCHN team does attempt to track this situation with adherence sheets and believe our observations may exaggerate the actual situation. The MCHN team noted to us that, according to their own adherence sheets that in May 2010 only 4% of malnourished children didn‟t collect their food ration. If this is the case, then this is certainly reasonable. Management is difficult for procurement and supervision particularly in some areas, as for example Belle Anse. A lack of appropriate logistics (cars, motorbikes) renders this supervision even more difficult. ACDI/VOCA‟s introduction of „fixed points‟ has been an important step taken within this region to try to addresses some of these issues. The use of the BND to pre-package food commodities and then distributing these as close as possible to the beneficiaries is also an important step to overcome problems for women reaching these commodities. Understanding of the critical role of water at certain periods of the year has led ACDI/VOCA to increased attention to drip irrigation systems, and the recent association with an Israeli firm specializing in these. ACDI/VOCA has also been creative in finding a way to encourage its field staff to work in very difficult locations – though greater support and funding will be needed to truly resolve this challenge. The key to meeting such challenges is the willingness of an institution and program management to be flexible and creative in looking for solutions. The MTE team found that ACDI/VOCA team has these characteristics. 2.7 Highly Successful Strategies 35 BND is the sub-contractor who sorts and pre-packages the supplemental food kits distributed. 44 The approach to using model farmers as the testing ground to demonstrate to local farmers the value of new techniques or new cultivars has been very successful and the response from farmers has been good. Reaching underserved communities with MCHN messages and services through „fixed points‟ has also been very effective, and these need to be further expanded. Efforts then need to be made to help GoH incorporate these into their regional recognized outreach programs. The establishment of rally points around these fixed points and health centers has also further brought health services and messages to households that have never had such support. Use of the BND to prepackage supplemental food to make the process of delivery easier for rural households is also considered a successful strategy that could be considered by other MYAPs. 2.8 Unsuccessful Strategies and Proposed Changes As noted elsewhere, the MTE team would suggest that ACDI/VOCA reevaluate their approach to using ‟community groups‟ as the launching pad for all their activities. Such groups certainly have an important role to play within the community, and for communicating messages, but if long term sustainability of key MYAP messages are to take place, these need to be also focused towards the „innovative leaders‟ that every community possesses and helping them to become viable entrepreneurs (seed production, seedling production, fruit tree grafting, etc.). 2.9 Conclusions, Best Practices, and Lessons Learned Malnourished Children vs. Acute Malnutrition: Since the reporting on the PFA + PTFA indicator for tracking general levels of underweight, malnourished (weight for age) children at Rally Points will continue, and can still be used by the program for local monitoring, if needed, the change within the IPTT to MUAC acute malnutrition monitoring is preferable. MUAC data represent an important indicator to track the general impact of MYAP activities at the Rally Point locality level, over time. At stated by ACDI/VOCA, acute malnutrition, which is what the MUAC measurement records, is a much more sensitive indicator to the nutrition situation in an area. A spike in acute malnutrition rates is a clear sign that something, in the short term, has changed. The level of undernourished children (weight for age) will take quite a long time to actually change as about 80% of this indicator is related to stunting and chronic malnutrition. MYAP activities should show a malnutrition rate drop from initial high levels in some localities (as high as 23%) to below 10% or lower. This could be a trigger for graduating MYAP activities from this locality and move resources to areas of greater need.36 Training: The reinforcement of the local farmer capacities has been an important asset which has led to behavioral change of the farmers – use of new varieties and cropping methods. This has resulted in a permanent transfer to knowledge – knowledge that now resides in these model farmers within these communities. 36 ACDI/VOCA notes that though monitoring the number of children who report to a rally post and are measured to be underweight is beneficial to know in a general sense, they do not believe they necessarily represent the nutritional situation of the population around that rally post – and therefore has limited power to making programmatic decisions. The MTE team is not sure that this is true. We believe that, given the care that most Haitian households give to their children, that in fact most mothers will bring their children to a rally post when these are not too distant from their homes. And most, thought certainly not all, mothers want to do what is best for their children, if they knew what to do. This is why multiple Mothers Clubs around rally posts are so important to extend health and nutrition knowledge. 45 Support for local Entrepreneurship: The program has not yet sufficiently encouraged farmers to develop their own business of seed production (bean seed or vegetables seedlings, for example). Yet ACDI/VOCA is moving in this direction. The development of MUSOGs (Mutual Society Groups) Links to GOH: A strong involvement with GoH agencies in the activities of MYAP was found. 2.10 Recommendations Malnourished Children: ACDI/VOCA should keep tracking malnutrition rates (weight for age: PFA + PTFA) at the rally post level – and analyzing it at this level only. The change to the new indicator (MUAC) - weight for height - using the arm band circumference measure method is a good move. Dropping PFA + PTFA as an aggregate IPTT indicator is appropriate, as the aggregation of these data means little. The MUAC (illustrated in photograph), however, shows acute malnutrition spikes related to incidences of kwashikor and marasma that can be treated early. We would also suggest that this latter indicator be highlighted as a new EWS indicator for severe malnutrition as it does show something taking place in the short time. The monthly rate of MUAC changes should be compared along with time series of PTA+PFA data at the locality level (not aggregated as this currently is). Visual Training Materials: An area the MTE team observed that could be improved would be in the increased availability of visual charts for Col Vols (and Leader Mothers if our recommendations about these are adopted) for training on the key themes covered each month at Rally Posts and for mothers‟ clubs. These could be 8 ½ by 11”, in size, preferably in color, for the small mothers‟ clubs groups, but this would increase interest and improve understanding of the themes being covered. Furthermore, Col Vols demonstrations of new „cooking techniques‟ for preparing foods, or other behavioral change tools, would best be accomplished through the mothers‟ clubs themselves – perhaps at the household of the Leader Mother providing the demonstration. The more that community health workers and Col Vols can implicate the Leader Mothers of each Mothers Club in providing the necessary training, the more sustainable these activities will be beyond the life of the program. For mothers, education is more important than the supplemental food. However, there is not enough materials on different themes (yes, available for family planning, delivery, pre natal and post natal care, but not for hygiene and nutrition). Even with the availability of materials, it is important to ensure that key messages are retained through home observations using a check list and an adequate questionnaire on child feeding. Train officers health workers/volunteers and Mothers Clubs leader mothers to do a food recall on a 24 hours period, including the quantity and food diversity. 46 Optimize the management of acute malnutrition, as it is already done in some areas; for this approach, the MUAC must be promoted by volunteers at rally posts and during home visits. Easy to use, it can also be a main tool used by the Mothers Clubs as they monitor for acute malnutrition. It should be complementary to the weigh/age data recorded at rally post, and weight/height at fixed points or health centers. PFA and PTFA (weight/age) will continue to be important data of the program‟s impact over time, and analyzed at the rally point level. One should also be able follow the recovery of a child, and register this progress on the „Chemen Lasante’ Charts. Until a new Chart is provided by MoH, we recommend keeping the old system, while relying primarily on the new approach for treating acute malnutrition. When MCHN is done by another partner in the area (La Vallée, for example), work with the health Center to identify families of malnourished children, which constitute a vulnerable target group. Enhance the quality of the data collected at the Rally Points, as the number of children seen each month varies too much and does not reflect all of the children under 5 years of this locality. : a) ensure that the same children are seen each month; b) pay greater attention to home visits for children who could not attend the rally post and the report of the data collected during those visits, while avoiding duplication; c) continue to follow up all children, even those referred to health centers; d) also track the number of migrants. The MTE team believes one way to accomplish this is through greater emphasis on identifying and training of volunteer Leader Mothers within Mothers Groups. These Leader Mothers will be in a much better position to do some of this necessary follow-up work that may be beyond a Col Vols time availability. Leader mothers should not be paid, even a stipend. Multiply fixed points or strengthen the services at rally posts (also an opportunity for mobile clinic by the nurses who would not only supervise that post). Many children do not go to the health center when they are referred; or some children already supported in the past with supplementary feeding get malnourished again. Readmission is allowed one time after an initial recuperation. If a child becomes acutely malnourished a third time, then ACDI/VOCA health personnel investigates the situation more closely. Often in such cases, this may be a situation in which the child has HIV. This is done so as to avoid parents purposely withholding food from their child so they can continue to qualify for the program. Encourage the use of small savings (“caisse rouge”) to pay for some fees requested at health center, when promoting Mothers Clubs to develop their loan and savings groups. This would be an important means for some mothers to find the means of going to the health clinic with their children. Improving, going forward, the identification of areas in greatest need for the preventive rations, based on malnutrition rates, would improve targeting of the most vulnerable. Communes were initially targeted using a nutritional study prepared by the MSPP in 2004 (EMMUS IV), and because of the limited health services available (cf. 1st map, page 4). Currently, all pregnant and lactating women and children 6-23 months are admitted into the PM2A program, and therefore receive preventive rations. These supplementary feeding programs need to be coupled more effectively with livelihood activities, and by encouraging these mothers to be part of a mothers club in their locality. Increase MYAP resources to addressing the issues of water and sanitation, a major constraint in most areas visited by 47 the MTE team - mainly to increase access to water and the building of toilets. This might require an amendment of the budget. It is urgent because there is a great need of water for both domestic use and vegetable gardening. These activities are costly. Mothers Clubs: As Mothers Clubs are expanded, prioritize the development of vegetable gardens and the creation of MUSOGs (savings and loan systems). Economic activities that individual mothers in these Mothers Clubs will pursue with their internal loans can be quite diverse. Pictured here is a Mothers club at the Labiche health clinic. ACDI/VOCA‟s IR 1.4 which focuses on the diversification of livelihoods through crafts, salt production in appropriate tidal areas, beekeeping, fishing/fish sales, compost sales, etc. is well positioned to focus on such groups. Entrepreneurship: Encourage farmers to develop their own activities: multiplying seed, grafting skills and to think about their farming as a business. Continue to create dynamism around the use of model farmers and to hold these people up as the true models to be followed and respected within their communities. Link such producers to service providers and marketing outlets should also be a priority of the program. Drip Irrigation: Encourage the expanded development of the micro irrigation to support vegetable gardening, particularly among the household members of Mothers Clubs. The impact of this on their households can be dramatic, beginning with improved household nutrition, followed by some increased income from local vegetable sales. We would recommend focusing on some of the more vulnerable section communales for this effort initially, as this can be costly. Micro￾drip irrigation kits can be purchased for less than $10/kit, including the needed drip tape, and requires the local purchase of a plastic bucket. Consider means of increasing the availability of water supplies where large cisterns or (run-off ground water) impluviums could serve the needs of a number of such households. Perhaps SYAP resources could help where MYAP budgets are limited. 3.0 External and Internal Factors 3.1 Impact of Internal Factors on Program Activities MCHN implementation was delayed during the first year of implementation because of the inability of local sub-contractor, MSH, to deliver on their obligations. ACDI-VOCA was able to creatively and fairly quickly resolve this situation by itself taking over the field personnel and management of this component. The MYAP is currently set to expand these services within their communes of responsibility. However, because of the logistic difficulties in working particularly in the three eastern communes, greater resources will need to be made available to improve infrastructure that will permit ACDI/VOCA staff to operate effectively in this region. At the very least, a number of appropriate living arrangements need to be put into place, such as small fully equipped trailers which can be moved around as needed 3.2 External Factors Influencing Outcomes and Program Responses 48 The 2008 cyclone season, with three consecutive storms, set the seed development program back. Planting two sacks of an improved black bean, they ended up harvesting barely 1.5 sacks. With this, to not lose time, they took the seed to PAP where they planted it on Double Harvest land an were able to multiply their seed to 1.5 tons, which was then taken back to Jacmel and distribute out to the network of farmers in producing seed. This experience taught the program a lesson of caution for the hurricane season which they have applied in subsequent years – once again taking seed to PAP for even larger multiplication because of the dramatically growing demand. The program also began to plant in the high plateau during one season, and bringing the seed to the plains in the following season, creating a cycle for future years. 3.3 Negative Impacts or Unintended Consequences The most obvious example encountered of negative unintended consequences on the MYAP program is in reference to SYAP activities. SYAP activities usually arrive long after the initial „emergency‟ has passed and has been dealt with in one way or another by the MYAP. ACDI/VOCA was very responsive through the cyclones experienced in 2008 and earthquake of January 2010 in meeting peak food emergency needs out of MYAP resources. ACDI/VOCA‟s strategy of pre-positioning basic supplies in the more distant communes as part of their hurricane emergency plan – prior to the onset of the principal rainy season months beginning in May and the hurricane season – has proven extremely important. The creation of parallel working groups with SYAPs appears to the MTE team to have been disruptive to the normal on￾going MYAP program implementation. SYAP activities have recently been more focused towards food or cash for work activities – such as repairing of rural roads. While helpful in the short term, these roads quickly return to their state of disrepair with subsequent heavy rainfall and have minimal long term impact other than putting some money in people‟s pockets (or food for household consumption). While certainly not a „negative impact‟ on the people themselves – who needed the cash infusion - the money impact itself on the road system was not significant. What is needed is a GoH and donor supported program to develop more enduring roads in the Southeast Department that will have a greater impact on the long term economic development of this neglected region. 4.0 Sustainability of Interventions The MTE team believes that the interventions that will prove to be sustainable in ACDI/VOCA‟s regions of intervention will be those that have helped to develop household level individual initiatives for different ventures of the program. Training of the Col Vols will leave valuable community based health practitioner within every locality. Training Leader Mothers of Mothers Clubs to understand and practice MCHN principles in front of their circle of mothers will leave lasting influence for a generation. Mothers, through the rally points and Mothers Clubs, learning how to better care for their children through hygiene, vaccinations, and nutrition will help raise a generation of children better able to learn in schools and grow into contributing citizens of the country. Improved agricultural inputs will only be sustainable if people come to know where to get new seed materials for themselves, when the time comes, and how to market their produce. Efforts in establishing fixed points will hopefully lead to more formal GoH run health clinics at or near these locations. Yet it is also true that there are some actions that are beyond the capacity of the project that would also reinforce support to all of these actions – and that would be the construction of a proper network of farm to market roads in this region. 49 The three eastern communes of the Department are rich in potential that will never be realized until the GoH makes the needed road infrastructure investments that must be completed. The road from Jacmel to Marigot should be extended to the border of the DR. With significant funding currently waiting for targeting within Haiti, following the recent earthquake, ACDI/VOCA should be supported by USAID and other donors to do feeder road rehabilitation – the potential of this corner of the Southeast Department for both agricultural as well as tourism development is obvious. 5.0 Conclusions Program Creativity: ACDI/VOCA has been very creative and shown itself to be adaptable and flexible in responding to the many challenges they have faced during its first two years of operation within Haiti. This is demonstrated in its quick response to the challenges thrown at the agricultural program with the cyclones destroying test plots of high yield varieties. Rather than simply waiting until „the next‟ season to begin again, ACDI/VOCA took the initiative of putting out plots on Double Harvest fields in PAP to replicate enough seed to permit further expansion of the program at the next opportunity in the Jacmel region. They also have adapted quickly to the coastal plains vs. mountain environments along the coast for the rotating distribution of seed stock supplies and linking farmers in these two environments for this exchange of the new varieties. Within the important MCHN sub-component of the MYAP, ACDI/VOCA moved quickly to remove a non-performing sub-contracting partner (MSH) and taking over operations themselves. MYAP/SYAP: Better targeting of SYAP supported program activities to complement MYAP program activities would be very helpful. This has already begun to take place in the Grand Gosier commune where SYAP FFW funding is used to prepare a pasture land (fenced) where a goat improvement project will be put into place, prioritizing the restocking of vulnerable farmers in the Southeast Department. This would be particularly true if some of the SYAP funding could be used (or be accompanied by) funds to purchase such items as cement and steel bars for some construction needs. Because of the need for water in many drought prone areas, being able to use cash or food for work to construct run-off water impluviums, cisterns, provide rain-gutters to houses, etc. could expand vegetable gardening in many program regions. Malnutrition: High levels of malnutrition among children under 5 years of age is one of the more visible and destructive elements of food insecurity in Haiti; seeking to reduce malnutrition rates among these children, with greatest attention of those under two years, appears to be one of key impacts that this MYAP should be seeking to accomplish and demonstrate. Yet the focus on this issue has not been sufficiently rigorous. By this we mean that (1) agricultural/livelihood activities have not yet been sufficiently integrated with specific vulnerable households identified through the MCHN program activities, and (2) specific localities are not sufficiently monitored to document improvements in malnutrition rates. Certainly, the excellent work being accomplished, through model farmers and improved seed availability, promises to have an impact on greater food availability within these areas. And it is ACDI/VOCA‟s intention to increasingly help these vulnerable groups to have access to these new resources and techniques. 50 By giving increasing focus on such integration of MYAP activities (agriculture and MCHN support) as an organizing theme within the MYAP, the MTE team believes ACDI/VOCA could have an even greater impact. Continued MYAP involvement in specific regions should be linked to outcomes that are quantifiable within smaller geographic areas – such as the localities in which health clinics, fixed points and rally posts are located. The ACDI/VOCA goal of reducing population-level malnutrition rates from 23% to 18% over the life of this MYAP in their regions of implementation seems a low. This figures masks great variability between sites – as the MTE team visited some areas (i.e. La Vallée) where the children appeared healthier and less malnourished. This suggests that plans to reduce MYAP interventions in some locations could already be taking place (where rates have been low for 6+ months), and moving resources to locations where the rate may still be high. 51 52 Annexes Annex 1: ACDI-VOCA Management Structures ACDI/VOCA FY2008-2012 Haiti Title II Organizational Charts Organogram 1: Overall Structure ACDI/VOCA Bureau de Nutrition et Développement (BND) 53 Organogram 2: Organizational Structure Administrative Assistant Smith Yanick Janitor Wilson Nicaisse Cleaning Person Guirlène Jean 2e Adm Assistant Office & Security Manager (Jacmel) Suze Jolicoeur General Service clerk Bruno Zidor Drivers (5) 2 Jacmel, 1 LV, 1 CF, 1 Thiotte dasdf Commodity Manager (PAP) Fenold Clerval Accounting & Finance Manager (Jacmel) Guy Ambroise BND Other Grantees Extension Agents 30 (16 as of 5/21/09) Association Dev. Spec. (Jacmel) Georges Pierre Louis Admin and Office Manager (PAP) Myrtha durand Chief of Party Emmet Murphy Agronomists 1 (Thiotte) Consultant Agronomists 2 ( Belle-Anse) Jocelyn Merat Agronomists 3 (La vallée) Chrisnet St Vil Agronomists 4 (Anse a Pitre) Samuel Dol Agronomists 5 (Cote de fer) Roudy devil Deputy Chief of Party & Grants Manager Mathieu Lucius Livelihood Program Manager (Jacmel) Pierrot Basquiat MIS Manager (Jacmel) Eldivert Savoit M&E Manager (PauP) Nael Jean Baptiste Early Warning Sys. Dir. (Jacmel) Gerry Delphin Health $ Nutrition Manager (Jacmel) N/A Rural Community health Educator (Jacmel),N/A Water & Sanitation Coordinator (Jacmel), N/A Rural Community Health Physician Anse à Pitres Rosny Siméon Belle Anse Faunie Cadet Cote de fer Marie Michèle Roc Driver 1 Dieuseul Démosthènes Driver 2 Rigaud Charles 54 Organogram 3: BND Director Rob J. Padberg 50% Project Manager Alfred Etienne Project Manager Assistant Jyminor Guerisma Administrative Assistant Sherlie Romela Belle Anse Warehouse Manager TBD Ricot Warehouse Manager- Phené Bazile Thiotte Warehouse Manager- TBD Belle Anse Warehouse Manager Assistant TBD General Workers (2) TBD Driver TBD Ricot Warehouse Manager Assistant Jn Eddy Nosaliance General Workers (2) TBD Driver TBD Thiotte Warehouse Manager Assistant TBD General Workers (2) TBD Driver TBD Security Guard TBD Security Guard TBD Accountant Lorite Opont 30% Spot & Monitoring Officers Soter Myrs Jasmin Monitoring Officers(2) Denise Rémy Jdhymi Dulaurier Monitors (5) Mona Jeanty + 4 TBD Accountant Assistant (2) Fernande Raymond Et Pepinaud Emile Driver TBD Security Guard TBD Engineer TBD Stove Monitor TBD Budget Monitoring Manager Emmline Toussaint 30% Program Manager Michelle Routhier 25% 55 Organogram 4: Integration of Rural Health and Agriculture Teams37 37 Lead farmers and Col-vols will not always be a one-to-one match. Livelihood Program Manager Health & Nutrition Director Rural Health Doctor & Community Nurse Jr. Agronomist Health Extension Agent/Matron Agricultural Extension Agent Community Level Lead Farmer Col-vol DD to Vulnerable Groups Technical Specialist Rural Community Health Physician Community Level Lead Farmer Col-vol DD to Vulnerable Groups Community Level Lead Farmer Col-vol DD to Vulnerable Groups 56 Annex 2: ACDI-VOCA IPTT FY 2010 Indicator Performance Tracking Table, Updated for December 2009 # Indicator Baseline 2010 Target Quarter 1 Achievement Quarter 2 Achievement Quarter 3 Achievement Quarter 4 Achievement 2010 Achievement 2010 Achievement Vs. target 2010 Cumulative Achievement (2008+2009 + 2010 achievements) PROGRAM GOAL: Food insecurity among the vulnerable people of Southeast Haiti reduced (Baseline to identify direct beneficiaries) 1 % of underweight children (0-59 months) (<-2 WAZ) (PMP SO1) 23.30% 2 % of stunted children (0-59 months) (<-2 HAZ) (PMP SO2a) 29.30% 3 Average # of months of adequate household food provisioning (PMP SO3) 5.41 4 Household dietary diversity score (PMP SO4) 5.34 5 # of targeted direct beneficiaries reached (PMP IR 2.1) 0 55385 19137 19137 35% 47634 Objective 1: Increase Resiliency against future food insecurity through the protection and enhancement of livelihoods and the development of community capacities. IR 1.1 Enhanced agricultural productivity, environmental management and market linkages 6 # of producers using at least 2 sustainable agricultural technologies (FFP PMP IR 2.3) 0 5076 See end note 1 7 (F 4.5.2.4 ) # of new technologies or management practices made available for transfer as a result of USG assistance. 0 4 1 1 25% 6 8 (F 4.5.2.7 ) # of rural households benefiting directly from USG assistance. 0 11077 6103 6103 55% 16070 9 ( F 4.5.2.12 ) # of individuals who have received USG supported short term agricultural sector productivity training 0 7000 1024 1024 15% 4967 10 (F 4.5.2.5) Number of additional hectares under improved technologies or management practices as a result of USG assistance 0 3000 53.2 53.2 2% 744.2 11 ( F 4.8.1.4 ) # of people with increased economic benefits derived from sustainable natural resource management and conservation as a result of USG assistance. 0 150 0 0 0% 58 12 (F 4.8.1.5 ) # of people receiving USG supported training in natural resources 0 7000 88 88 1% 2234 57 # Indicator Baseline 2010 Target Quarter 1 Achievement Quarter 2 Achievement Quarter 3 Achievement Quarter 4 Achievement 2010 Achievement 2010 Achievement Vs. target 2010 Cumulative Achievement (2008+2009 + 2010 achievements) management and/or biodiversity conservation IR 1.2 Improved organizational and functional capacity of agricultural associations 13 % of communities with improved capacity (identified as producer associations) (PMP IR 2.7) 0 5 0 0 0 2 14 # of producer organizations, water user associations, trade and business associations, and community-based organizations receiving USG assistance (4.5.2.9 (F)) 0 15 5 5 33% 56 15 (F 4.5.2.13 ) # of women’s organizations/ associations assisted as a result of USG supported interventions. 0 5 2 2 40% 3 IR 1.3 Increased access to financial resources 16 % increase in group savings 0 30 See end note 1 IR 1.4 Diversification of livelihood strategies 17 # of grant recipient to diversify livelihood strategy into non agricultural action 0 150 0 0 0 0 Objective 2: Protect vulnerable populations against immediate food insecurity and develop capacity to address long-term nutrition and health needs IR 2.1 Increased access to nutritious foods at the household level 18 # of pregnant and lactating mothers receiving food rations 0 4550 446 446 10% 967 19 # of children aged 6-23 months receiving food rations 0 3570 1384 1384 39% 2091 20 # of malnourished children aged 6-59 months receiving food rations 0 516 See end note 2 21 # of fuel saving stoves distributed 0 25 0 0 0 50 22 Amount (Kg) of fuel saved via introduction of fuel efficient stoves[1] 0 32850 0 0 0 10980 IR 2.2 Improved maternal and child health 23 % of children 0–6 months of age exclusively breastfed (PMP IR 2.2) 45.6 60.6 48.2 48.2 80% 58 # Indicator Baseline 2010 Target Quarter 1 Achievement Quarter 2 Achievement Quarter 3 Achievement Quarter 4 Achievement 2010 Achievement 2010 Achievement Vs. target 2010 Cumulative Achievement (2008+2009 + 2010 achievements) 24 % of births attended by skilled health personnel (3.1.6.1) 11.10% 25 % of children 12-23 months fully vaccinated. (3.1.6.2) 20.60% 26 (F 3.1.6.3 ) # of postpartum/newborn visits in USG-assisted programs 0 2199 431 431 20% 1346 27 (F 3.1.6.4 ) # of antenatal care (ANC) visits by skilled providers from USG￾assisted facilities 0 1920 1700 1700 89% 4832 28 (F 3.1.6.5 ) # of service providers trained in maternal/newborn health through USG-supported programs 0 100 39 39 39% 39 29 (F 3.1.6.6 ) # of deliveries with a trained Traditional Birth Attendant (TBA) or Matrons in USG area 0 500 296 296 59% 296 30 # of service providers trained in child health care and nutrition through USG￾supported programs 0 100 0 0 0 0 31 (F 3.1.6.11 ) # of children reached by USG-supported nutrition programs 0 6697 3627 3627 54% 6933 32 (F 3.1.6.12 ) # of children less than 12 months of age who received DPT3 in a given year from USG-supported programs 0 1208 210 210 17% 1455 33 (F 3.1.6.13 ) # of children < 5 years of age who received Vitamin A from USG￾supported programs 0 5000 2510 2510 50% 8145 34 (F 3.1.6.14 ) # of cases of child diarrhea treated in USAID-assisted programs 0 800 401 401 50% 1246 35 % of people in reproductive age using a modern family planning method in USAID geographic target areas. (3.1.7.1) 25.50% 36 (F 3.1.7.2 ) Couple-years of protection (CYP) in USG-supported programs 0 3000 522.08 522.08 17% 589.08 IR 2.3 Improved household sanitation and access to water 37 % of caregivers demonstrating proper personal hygiene (hand washing) behaviors (PMP IR 2.2) 1.10% 38 (F 3.1.8.2 ) # of people in target areas with access to improved drinking water 0 0 0 0 0 0 59 # Indicator Baseline 2010 Target Quarter 1 Achievement Quarter 2 Achievement Quarter 3 Achievement Quarter 4 Achievement 2010 Achievement 2010 Achievement Vs. target 2010 Cumulative Achievement (2008+2009 + 2010 achievements) supply as a result of USG assistance 39 (F 3.1.8.3) # of people in target areas with access to improved sanitation facilities as a result of USG assistance 0 100 0 0 0 119 Objective 3: Improved ability to identify and successfully respond to vulnerabilities and impending shocks IR 3.1 Improved capacity of local organizations and groups to identify and respond to vulnerabilities and shocks 40 (F) Number of communities with Early Warning System link to a response system in place as a result of USG assistance 0 15 5 5 33% 90 41 % of assisted community with improved physical infrastructure to mitigate impact of shocks (PMP IR 2.5) 0 30 0 0 0 0 42 % of assisted communities with safety nets to address the needs of their most vulnerable members (PMP IR 2.6) 0 10 3 3 0.3 5 43 (F ) Number of people trained in disaster preparedness as a result of USG assistance 0 50 0 0 0 41 44 # of disaster preparation/ response plans with trigger indicators completed by DMCs in target area 0 10 0 0 0 6 45 # of disaster response recovery proposals prepared with DMCs and submitted to donor 0 11 0 0 0 0 46 # of DMC meetings attended in target area 0 20 0 0 0 11 47 # of risk reduction/ mitigation proposals completed 0 0 0 0 0 0 48 # of true safety nets established and run by community 0 5 3 3 60% 5 Note 1: Value for this indicator cannot be provided on a quarterly basis Note 2: Using the WfH criteria, 2,243 malnourished children aged 6-59 months were reached. But, the Ministry new protocol will be used to identify malnourish children by the second quarter. 60 61 Annex 3: ACDIVOCA Health Staff and Facilities