PLAN Cameroon FE

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Plan International USA

with

Helen Keller International

and

Population Services International

CAMEROON EXPANDED IMPACT CHILD SURVIVAL PROJECT (EIP)

FINAL EVALUATION

11 Health Districts of Cameroon:

Akonolinga | Awae | Bafut | Batouri | Bertoua | Doume |Esse | Fundong | Mbengwi | Ndop | Nguelemendouka

Cooperative Agreement #GHS-A-00-05-00015-00

September 30, 2005 September 29, 2010

Report submitted on:

September 22, 2010

Report Writing by:

Bonnie L. Kittle, Independent Consultant

Edited by:

Ephraim Toh, EIP Project Coordinator, Plan CameroonNgwa Chris Akonwi Fuh, EIP Assistant, Plan Cameroon

Judy Chang, Technical Backstop, Plan USA


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Plan International USA EIP Final Evaluation Report ii

ACRONYMS

ACMS Association Camerounaise pour le Marketing Social (local affiliate of PSI)ACT Artemesinin Combination Therapy

ANC Antenatal Care

ARI Acute Respiratory InfectionBCC Behavior Change CommunicationCBO Community-Based Organization

CBS Capacity Building SupervisorCCM Community Case Management

CCM/M CCM/MalariaCCM/P CCM/Pneumonia

CDD Control of Diarrheal DiseaseCHW Community Health Worker

C-IMCI Community-based Integrated Management of Childhood IllnessCS Child Survival

CSHGP Child Survival and Health Grants ProgramCSSA Child Survival Sustainability Assessment

DIP Detailed Implementation PlanDMO District Medical Officer

EBF Exclusive BreastfeedingEIP Expanded Impact Program

EPI Expanded Program on ImmunizationHIS Health Information Systems

HKI Helen Keller InternationalIEC Information, Education and Communication

IHC Integrated Health CenterIMCI Integrated Management of Childhood Illness

IPT Intermittent Preventive TreatmentITN Insecticide Treated Net

KPC Knowledge, Practice and Coverage SurveyLLIN Long Lasting Insecticidal Net

LNGO Local NGOLQAS Lot Quality Assurance Sampling

M&E Monitoring and EvaluationMOH Ministry of Health

MTE Mid-term Evaluation NGO Non-Governmental Organization

NID National Immunization DayOR Operations Research

ORS Oral Re-hydration SaltsORT Oral Re-hydration Therapy

PD Positive DeviancePHC Provincial Health Coordinator

ProFam ACMS-affiliated network of private clinicsPSI Population Services International


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Plan International USA EIP Final Evaluation Report iii

RBM Roll Back MalariaTOT Training of Trainers

TT Tetanus ToxoidU5 Children under five years of age

USAID United States Agency for International Development


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Plan International USA EIP Final Evaluation Report iv

TABLE OF CONTENTS

ACRONYMS .............................................................................................................................iiTABLE OF CONTENTS ........................................................................................................... iv

EXECUTIVE SUMMARY ......................................................................................................... 1I. Overview of the Project ......................................................................................................... 5II. Data Quality: Strengths and Limitations ............................................................................. 12

III. Presentation of Results ........................................................................................................ 13IV. Discussion of the Results .................................................................................................... 16

V. Sustained Outcomes, Contribution to Scale, Equity, Community Health Worker Models andGlobal Learning .................................................................................................................. 26

VI. Conclusions and Recommendations .................................................................................... 30

ANNEXES

ANNEX 1. Results Highlight ................................................................................................... 32

ANNEX 2. List of Publications and Presentations .................................................................... 33ANNEX 3. Project Management .............................................................................................. 36

ANNEX 4. Work Plan Table .................................................................................................... 45ANNEX 5. Rapid CATCH Table ............................................................................................. 47

ANNEX 6. Final KPC Report .................................................................................................. 48ANNEX 7. Community Health Worker Training Matrix ........................................................ 103

ANNEX 8. CBO Performance Indicators (as shown on CBO Supervision Form) .................. 104ANNEX 9. List of Evaluation Team Members ...................................................................... 105

ANNEX 10. Evaluation Methodology .................................................................................... 106ANNEX 11. List of People Interviewed and contacted during Final Evaluation ..................... 107

ANNEX 12. Special Reports .................................................................................................. 108ANNEX 13. Project Data Form .............................................................................................. 127

ANNEX 14. Grantee Plans to Address Final Evaluation Findings .......................................... 167ANNEX 15. Grantee Response to Final Evaluation Findings ................................................. 170


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Plan International USA EIP Final Evaluation Report 1

EXECUTIVE SUMMARY

A. Project DescriptionThe Expanded Impact Project (EIP) is a five year (2005 2010) initiative being implemented by

Plan International, Helen Keller International (HKI) and Population Services International

(known in Cameroon as ACMS - Association Camerounaise pour le Marketing Social) incollaboration with the Ministry of Health/Cameroon, six local NGOs1

and hundreds ofcommunity-based organizations (CBOs). Activities in the five intervention areas Malaria

(40%), Nutrition (30%), Diarrhea Disease Control (10%), Pneumonia (10%) and Immunizations(10%) are being carried out in 11 health districts in three Provinces East, Central and

Northwest. The beneficiary population includes 481,441 women of reproductive age and211,473 children under age five, living in approximately 1,000 communities. The EIP seeks to

accelerate the scale-up of Integrated Management of Childhood Illness (IMCI) and Roll BackMalaria (RBM) in Cameroon, and to disseminate successful program interventions, through the

concerted effort of organized communities and public, private and international institutions. TheEIP Detailed Implementation Plan (DIP) also identified the following three results: 1) improved

family behaviors and home care, 2) increased access to quality maternal and child health servicesand 3) improved capacity of public and private partners systems and structures to sustain Child

Survival (CS) activities.

B. Main AccomplishmentsScale-up. The EIP has significantly contributed to scale-up in the areas of IMCI, Roll Back

Malaria and Nutrition through its work on these national working groups, training and operationsresearch (OR). See below for specifics.

C-IMCI. The Expanded Impact Project has increased access to maternal and child health

information by training 910 CBOs who promote key community-based IMCI (C-IMCI)behaviors among pregnant women and mothers of children under age five. Nine types of health

education materials have been provided to each CBO to facilitate their behavior change efforts,including two new flipcharts and a message booklet created during the second phase of the

project. Ten out of the 18 health indicators were achieved or surpassed including the followingkey behaviors (targets are in parentheses):

ITN use by children under two increased from 11.8% to 66.4% (60%) ITN use by pregnant women increased from 15.7% to 66.7% (60%) Malnutrition in children under two decreased from 15.9% to 9.5% (10%) Exclusive breastfeeding among children 0-5 months increased from 50.8% to 74.9%

(75%)

Iron/folic acid supplementation among pregnant women increased from 27.2% to70.8% (60%)

The percentage of children consuming vitamin-rich food increased from 41.3% to80.9% (60%)

Appropriate hand washing increased from 7.7% to 42.2% (30%) Timely care seeking among children with signs of severe illness increased from 37.4%

to 74.1% (67.7%)

1Originally, 11 local NGOs worked on the project. These were reduced after the mid-term evaluation to 6 LNGOs.


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IMCI. The EIP has supported the scale-up of IMCI by training a pool of national IMCI trainers

who have not only trained 346 health care providers in the EIP project area (including 72 inProFam clinics), but also 62 providers in other regions. Staff at 312 public health facilities in

three regions are now practicing IMCI.

As a result of advocacy efforts by project partners, IMCI has been approved by the Ministry ofHealth for inclusion in the pre-service training curriculum for nurses, and steps are being taken to

recruit trainers.

Malaria Prevention and Treatment. Access to ITNs has been increased through the projectsprovision of 39,000 ITNs in the project area, increasing ITN use among children under two from

11.8% to 66.4% and among pregnant women from 15.7% to 66.7%.

Access to treatment has been increased through the community case management of malariaapproach supported by the project. The project supported the training of 5,973community-based

Malaria Relays.

Nutrition. With significant assistance from the EIP, a National Nutrition Working Group wasestablished, which has developed a national nutrition strategic plan to guide the efforts of the

countrys nutrition initiatives. More specifically, the working group has developed a detailedprotocol for the administration of Vitamin A and has approved nationwide training of health care

providers in Essential Nutrition Actions (ENA). A total of 324 health care providers weretrained in ENA; 241 of these are from within the EIP area, while 83 are from other regions of the

country.

Following the successful OR study on zinc conducted with support from EIP, in January 2009,zinc was approved by the MOH for inclusion on the Essential Drug List for the management of

diarrhea. Steps have been taken to: 1) incorporate the treatment protocol into the pre-servicetraining of health providers; 2) inform current health providers of the treatment protocols; 3)

ensure adequate supplies of zinc to all health facilities; and 4) increase access to ORS and zinc atthe community level.

Pneumonia. The EIP initiated and supported an OR study on Community Case Management

(CCM) of pneumonia, the results of which will inform the MOHs decision regarding the scale-up of community-based treatment of pneumonia. The studys final evaluation suggests that cases

of severe pneumonia have decreased from 83% to 14% as a result of having access to earlytreatment of uncomplicated pneumonia at the community level.


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Table 1. Summary of Primary Inputs, Activities and OutputsInputs Activities Outputs

Malaria Prevention and Treatment Staff training Training curricula equipment and supplies

(scales, motorbikes, etc.procured with PVO

match funds)

IEC and BCC materials Supervision tools Financial resources Technical advice

Train CBOs in C-IMCI Train health care providers in

IMCI

Train community-based MalariaRelays

Develop/distribute healtheducation materials for use by

CBOs and IHC staff; CBOs promoting ITN use and

prompt care seeking

Distribute ITNs Establish sale points for ITNs &

retreatment kits Participate in Malaria Working

Group

9 types of health education materialsdeveloped including 3 since MTE

37,421 health education materials

distributed 346 health care providers trained in IMCI

in the EIP area, 62 in other regions

910 CBOs trained in C-IMCI Increased access to ITNs (39,000

distributed)

Increased access to health information(910 villages, 11 districts, 3 provinces)

Increased access to malaria treatment(5,973 Malaria Relays trained)

IMCI approved for pre service training ofnurses

Nutrition

See above, plus: Provision of scales to

910 CBOs

See above, plus: Develop protocol and implement

Operations Research on zinc Train PD/Hearth trainers Implement PD/Hearth in 3

villages

CBOs conducting monthlycommunity-based growthmonitoring and education on

EBF, complementary feeding and

feeding during illness

Train 324 providers in EssentialNutrition Actions

See above, plus: Increased access to nutrition information

through CBOs and trained health careproviders

National Nutrition Working Groupformed and informing nutrition-related

policies, including vitamin A

administration

Diarrheal Disease ControlSee above

Support for ZincOperations Research

See first box, plus:

Establishment of sales points forOrasel and zinc;

Hand washing promotion byCBO members


Increased access to water treatmentproducts;

Increased access to Orasel and zinc Increased access to health education and

rehydration services

Zinc included on the essential medicineslist for the treatment of diarrhea

PneumoniaSee first box See first box, plus

Operations Research on CCMconducted

CBOs referring sick children tohealth center

See first box; plus:

Increased access to health informationpromoting timely care seeking for ARI

ImmunizationsSee first box See first box, plus

Health and Nutrition ActionWeek organization and

implementation

CBOs maintaining thecommunity register


Community-based childhoodimmunization tracking system maintained

by CBOs

Increased access to immunization services(through support to Health Week)


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C. Summary of Main Conclusions and Recommendations

1. The Child Survival Health Grants Program (CSHGP) should seriously consider continuing tooffer the Expanded Impact (EI) category of Child Survival Grants so that NGOs have the

opportunity to promote scale up of innovative health approaches. Should CSHGP decide to

continue the EI category, there should be set indicators to measure the scale-up efforts.2. To support scale-up, a strategic choice of partners to include those who have experienceadvocating at the national level is critical. Allocating resources for work at the national level

and pilot testing new approaches is also essential to scale-up.3. When implementing the C-IMCI approach, NGOs should consider training members of

existing womens groups. This helps to reduce the expectation for remuneration since thegroup already existed and were working together voluntarily. It probably also helps sustain

the group beyond the life of the project.


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I. Overview of the Project

A. Project DescriptionThe Expanded Impact Project (EIP) is a five year (2005 2010) initiative implemented by Plan

International, Helen Keller International (HKI) and Population Services International (known in

Cameroon as ACMS) in collaboration with the Ministry of Health/Cameroon, six local NGOsand 910 community-based organizations (CBOs). Activities in the five intervention areas Malaria (40%), Nutrition (30%), Diarrhea Disease Control (10%), Pneumonia (10%) and

Immunizations (10%) are being carried out in 11 health districts in three Provinces East,Central and Northwest, as detailed in the table below. The beneficiary population includes

481,441 women of reproductive age and 211,473 children under age five. To reach all of thesecommunities in a rational manner, the EIP was implemented in two phases. During Phase 1,

activities were initiated in 407 remote communities with the worst health indicators. DuringPhase 2, the project was extended to another 503 communities, for a total of 910 communities

2in

11 districts.

Table 2. Targeted DistrictsEast Province Center Province Northwest Province

Districts

Batouri Akonolinga Bafut

Bertoua Awae Fudong

Doume Esse Mbengwi

Nguelemendouka Ndop

The EIP seeks to accelerate the scale-up of IMCI/RBM in Cameroon, and to disseminatesuccessful program interventions through the concerted effort of organized communities and

public, private and international institutions. The EIP DIP also identified the following threeresults: 1) improved family behaviors and home care; 2) increased access to quality maternal and

child health services; and, 3) improved capacity for public and private partners systems andstructures to sustain Child Survival (CS) activities. To achieve these, the project partners

implemented the activities cited in Table 1 at three levels: National, Provincial/District andCommunity. The activities that take place at the national level contribute almost immediately to

scale while those at the provincial, district and local levels serve as a model for implementersoutside the project area.

The Expanded Impact Project (EIP) operated on several different levels to achieve its objectives.

It worked on the demand side, the supply side and the policy side to improve maternal and childhealth.

At the community level the project trained members of community-based organizations (CBOs womens organizations) in the key elements of community-based Integrated Management ofChildhood Illnesses (C-IMCI). These CBO members were responsible for raising awareness and

promoting behavior change in specific neighborhoods and households using visual aids and othersupplies provided by the project. Together they created behavior maps (which became tables

2At the community level, the EIP works with CBOs. In most, but not all cases, there is one CBO per community.

In some cases, however, due to the large size or geographical area of the community, more than one CBO was

trained. Therefore, the 910 CBOs do not represent the same number of communities.


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after the mid-term evaluation (MTE)) and registers in which key health data about all U5children was recorded, including information on childhood vaccinations, Vitamin A for children

and pregnant women, iron consumption, ITN use and child growth.

Table 3. Numbers of CBOs Trained per Region/Phase

The CBOs were trained andsupervised by local NGO (LNGO)promoters (and later Plan Promoters

see the section on partnerships) whowere in turn trained and supervised by

Plan staff (Capacity BuildingSupervisors and Provincial Health

Coordinators, who are based in the three regions of the EIP.) In total, 910 CBOs were trained asshown in Table 3. During Phase 1 (20062008), 407 of the more remote and needy communities

were targeted and were supervised on a monthly basis. During Phase 2 (20092010), 503additional CBOs were trained and received monthly supervision while the Phase 1 CBOs were

supposed to be visited every other month. Supervision became a significant issue, especially inPhase 2, when the number of CBOs to be supervised became overwhelming for the promoters.

In Phase 2 of the project, performance indicators were established for both the CBOs and

LNGO/Plan Promoters. The CBO performance indicators (see Annex 8) were used to rate the performance of the CBOs according to the set criteria. Between March-May 2010, the

performance of the CBOs was rated; the results are discussed in Section V of this report.

Also at the community level, the project sought to increase access to health care services andproducts. In this regard, community members were trained as Community Relays for Malaria

(CCM/M) and equipped to treat mild cases of malaria and refer more serious cases to the nearesthealth facility. ACMS (the Cameroon affiliate of PSI) established sale points where products

such as ORS (and later zinc) and water guard were sold; their regionally-based promoters alsotrained CBO members in such things as how to hang a mosquito net.

During the first phase of the project, organizational development (OD) activities were carried out

to strengthen the institutional capacities of 11 local NGO (LNGO) partners, with an eye towardproviding sustained support to the trained CBOs after the project. During the second half of the

project, this approach was changed and institutional support was no longer provided. Rather,Plan entered into performance-based contracts with a reduced number of six LNGOs.

Also during the second half of the project, and in response to a recommendation of the MTE, the

EIP began to more deliberately create links between the staff of the integrated health centers(IHCs) and the CBOs. The heads of the IHC were introduced to the CBO members in their area

and CBOs were asked to send a copy of their monthly report to the IHC. Only a very few CBOsregularly send reports to the IHC, however, primarily for lack of the forms, which should be

supplied by Plan. CBO members support the work of the IHC by identifying children in need ofvaccination and referring sick children to the health center. To reinforce the link between the

IHC staff and CBOs it was planned to provide training to IHC heads in C-IMCI. Training in C-IMCI was initially only provided to the health care providers in the Northwest region, however,

Region #Promoters # CBOs TrainedPhase 1 Phase 2 Total

NW 9 128 344 472

East 7 174 101 275

Center 5 105 58 163

Totals 21 407 503 910


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because Plan/Cameroon decided that C-IMCI should be showcased in that region and otherapproaches highlighted in other regions. C-IMCI training for the IHC staff in the Center and

East Regions was conducted in September 2010.

The EIP also provided much support at the district level to the District Medical Officers and their

teams in order to improve the provision of essential services. This included training (IMCI,supervision, health facility assessment surveying (LQAS), Epi Info, and Essential NutritionActions), support for the bi-annual Child Health and Nutrition Action Weeks, and some supplies

and equipment. IMCI was the approach used to improve the quality of service delivery tochildren and along with training trainers, the project supported the training and equipping of

health care providers in the 11 districts of the EIP project.

Table 4 . IMCI Coverage

ACMS supports 25 private health clinics based in Yaound called ProFam, and during theproject, about 72 health care providers in these clinics were trained in IMCI, including the clinic

owners. Due to high staff turnover, attributed by the ACMS ProFam clinic supervisor to lowsalaries, at the end of the project only 22 of those trained are still working at ProFam clinics. The

ACMS clinic supervisor also pointed out that IMCI is not well suited to the private sector because it is not seen as being cost effective, especially when drugs available at the private

clinics are more expensive (since they cannot be purchased at the central pharmacy where theMOH procures their drugs). The attempt to implement IMCI in the ProFam clinics will allow

ACMS the opportunity to study the results and learn important lessons regarding IMCIimplementation in the private sector. These lessons can then be applied to a future project.

Plan regional staff and LNGO promoters attended monthly meetings at the District Health Office

and shared their project reports at this level so that all activities taking place at the communitylevel were known at the district level as well.

Toward the end of the project, the Government of Cameroon set in motion a decentralization

plan which gives much more authority to Local Councils. In keeping with this change, LNGOs

3 Refers to the percent of health facilities with staff trained in IMCI and following the protocol.

Health District % IMCI

Coverage3

Esse 100

Awae 33Akonolinga 40

Batouri 89

Bertoua 100

Doume 100

Nguelemendouka 33

Bafut 40

Ndop 67

Mbengwi 25

Fundong 83


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and regional Plan staff were encouraged to meet with the Local Councils and inform them aboutthe project and solicit their support. Some LNGOs reported having received fuel money from

the Local Council to support field work.

Unlike most child survival projects, the EIP was also very active at the national level, helping to

create and support IMCI and Nutrition Working Groups, collaborating with UNICEF and WHO, promoting policy changes with regard to IMCI, service delivery approaches (Health and Nutrition Week and ENA), zinc and, in the last year, CCM/pneumonia. The two OR studies

were developed and implemented with support from the national level and have, in the case ofzinc, and will, in the case of CCM/pneumonia, influence policies at the national level.

Partnerships

In the EIP project, there were several different types of partnerships: partnership between thethree International NGOs (INGOs) Plan, PSI and HKI; partnership between the project (the

INGOs) and the MOH at various levels (national, regional, district and local); and partnershipbetween local NGOs (LNGOs) and Plan.

As the first two types of partnerships are discussed elsewhere in this document, this section will

focus on the partnership between LNGOs and Plan.

The EIP design foresaw partnership agreements being entered into with 11 local NGOs. Thepurpose of the partnerships was to strengthen the capacities of these LNGOs so they could train,

support and supervise the CBOs and their work with mothers and pregnant women. Workingthrough LNGOs was also an essential part of the sustainability plan since it was thought that by

strengthening the LNGOs as organizations, they would be able to continue to support thecommunity-level work of the CBOs after the project ended. During the first year of the project,

an Organization Capacity Assessment (OCA) was conducted to determine the level of capacityof each LNGO and to guide the provision of training and support to build institutional capacity.

The initial OCA confirmed that most of the 11 LNGOs were quite weak organizationally andPlan proceeded to provide technical assistance to each LNGO according to their needs. Despite

this, by mid-2008, Plan had decided that a few LNGOs were not responding adequately to theorganizational development assistance being provided and/or proved untrustworthy. The plan

was to not renew the contracts of those LNGOs but rather to employ their promoters directly asEIP (Plan) staff. Plan also decided to find a different OCA tool and to re-administer it after the

MTE.

Despite the recommendation by the MTE team to re-administer the OCA and continuestrengthening LNGOs, the Plan/Cameroon Country Management Team, headed by the Country

Director, decided to curtail the provision of organizational development support and renegotiatedperformance-based contracts with all of the LNGOs (which had been reduced to six) and the 12

newly hired Plan promoters.

This decision removed an essential element of the projects sustainability plan since, despite theirbest intentions, few, if any, of the LNGOs have the means to continue supporting CBOs (they

had difficulty doing it even with project funds). Furthermore, because it took a year (from Aug.2008 to Aug. 2009) to write and finalize the new contracts, support to Phase 1 CBOs was


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suspended for 12 months, and the 503 new CBOs only benefited from eight to 12 months ofsupport. Rather than helping the LNGOs to gain capacity to function effectively and solicit

funding for their activities, the project used the LNGOs promoters as sub-contracted staff andset up a performance-based system (see Table 5 below) according to which LNGO and Plan

Promoters were remunerated.

EIP staff report that while occasionally remuneration was withheld if a certain number ofsupervisory visits werent made in a given month, this was a rare case and could be made up the

following month.

Table 5. Minimum Performance Indicators for LNGO and Plan Promoters

Items Minimum Performance Indicators

Training Train CBOs with respect to their schedule

Train CBOs using the curriculum and all other support documents

Supervision A health promoter should supervise at least 10 to 15 CBOs per month

Work plans

(Monthly andquarterly)

LNGOs should submit detailed monthly and quarterly action plans to Plan

prior to the implementation of any activity

Organization

of CBO files/

Database

Databases should be updated on a monthly basis (# of CBOs

trained/supervised, materials received, etc.);Files for each CBO should be updated and classified in chronological order

(report, materials received, etc.)

Accountability Distribute IEC, training materials to CBOs as soon as received and submit

reception attestations to Plan

Reporting Submit complete training/supervision/financial reports, following the format

given to them and with respect to the time frame, in hard and soft copies

This change in strategy begs the question: Wouldnt it have been better for Plan to directly hireall of the promoters needed to train, support and supervise the CBOs rather than work throughthe LNGOs? In hindsight, the response seems quite clearly, yes, especially since the

sustainability strategy during the second half of the project was to rely much more heavily on theIHC staff to support the CBOs in their area. This latter approach seems much more logical in

many ways, as the IHC staff should utilize CBOs to reach their own objectives (vaccination,vitamin A coverage, ITN use, etc.), the IHC staff is numerous enough to reach all of the CBOs,

and funding (limited as it is) is already available for community outreach activities, which wouldfacilitate supporting the CBOs by IHC staff.

In future project designs, then, Plan should more thoroughly examine its commitment and ability

to strengthen local NGOs and consider if it wouldnt be more cost- and time-efficient to directlyhire promoters to work at the community level and develop the links between the IHC staff andthe CBOs.

Mission Collaboration

Until May 2010, there was no USAID presence in Cameroon and EIP reports were sent to theUSAID Regional Office in Accra, Ghana. In April 2010, a Country Program Coordinator, Ms.

Aisatou Ngong, was appointed and one of her responsibilities is to oversee such centrally-funded


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projects as the EIP. Upon hearing of her appointment, the Project Coordinator and PlanCameroon Country Director visited and introduced the project to her and subsequently sent her

project reports and invited Ms. Ngong to visit the project, which she did. According to Ms.Ngong, the EIP project is consistent with mission priorities in the region and supportive of the

MOHs country priorities.

The project has not collaborated on any mission-funded bilateral programs.

Changes since the DIP (see Annex 4 for the Work Plan Table)Until the MTE, the project followed the DIP quite closely. In 2008, a few changes were made.

Most notably, the projects relationship with the LNGOs changed. Because LNGOs were notperforming as effectively as hoped, Plan decided to stop providing organizational strengthening

support and entered into performance-based contracts with a reduced number of LNGOs, asdescribed in detail in the previous section. It also decided to hire directly some of the promoters

who had been working for those LNGOs.

Also after the MTE, it was decided to train the IHC staff in C-IMCI so that they would be in abetter position to supervise and support the CBOs. At the time of the final evaluation, only the

IHC heads in the NW region had been trained. Plan/HQ reports that the IHC staff in the twoother regions were trained in the last month of the project. While it is fortunate that this training

has been conducted, the delay is regrettable, as the EIP staff will not be available to reinforce thelink between the CBOs and the IHC staff.

Contribution to Scale- up

The EIP has significantly contributed to scale-up in the areas of IMCI, Roll Back Malaria andnutrition through its work on these national working groups, training and OR. More specifically,

the EIP ensured that not only were health care providers within the project area trained in IMCI,but that 90 IMCI trainers nationwide were also trained, so that IMCI could be quickly scaled up

if/when support for the training could be secured. To date, 62 health care providers outside theproject area have been trained in IMCI. More significant is the Ministrys decision to include

IMCI in the pre-service training of nurses, as this will eventually eliminate the need to providein-service training, which is very expensive and difficult to organize.

The Child Health and Nutrition Week is another example of a service delivery strategy that has

been adopted nationally by the MOH after having been piloted by the EIP project. Now thisapproach is being supported by UNICEF, WHO and other organizations.

In the area of malaria, the project supported the development and validation of the training

manual used to train CCM/Malaria Relays. In total, the project supported the training of 5,973Malaria Relays nationwide, including 4,084 within the project area. Supporting CCM/Malaria

Relays also helped pave the way for consideration of CCM/Pneumonia Relays.

Helen Keller International (HKI) worked at the national level and advocated for the recruitmentof nutritionists to work in the MOH as well as for the training of nutritionists and dietitians in the

University of Ngaoundere. The first training began in 2008, and 15 nutritionists have beentrained. These actions will strengthen nutrition activities throughout the country.


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The OR study on the use of zinc in the treatment and prevention of diarrhea was a significant

success of the project and resulted in zinc being added to the Essential Drug List, steps beingtaken to import zinc and ACMS importing zinc for use by IHC staff and community members.

The OR Study on CCM/Pneumonia results will also inform the Ministrys decision regarding the

scale-up of CCM/Pneumonia. (See Annex 12 for reports on both the zinc and CCM/P ORstudies).

Also in the area of nutrition, HKIs work on the Essential Nutrition Actions (ENA) has resultedin trainings being conducted outside the project area supported by UNICEF.

Health System Strengthening

See the section on scale-up and Chapter Five, Discussion of Results, especially regarding IMCI.

The EIP strengthened the health system in many ways, as discussed in the Results Section of thisreport, but its major contribution was in the training provided in IMCI to all health facilities in

the 11 target districts. After the training, the project conducted annual health facility assessmentsto ascertain the extent to which providers were following the IMCI protocol. These results were

disaggregated by region and separated out the 25 ProFam clinics in Yaound as shown in Annex6. As the table shows, impressive improvements were made on almost all indicators, with only

two indicators showing poor results: proportion of children who had their nutritional status(vitamin A, weight, etc.) assessed, and proportion of children whose caretakers were counseled

on the importance of giving fluids at home. Due to the reassignment of staff by the MOHfollowing IMCI training, at the end of the project only 36.4% of the providers assessed had

actually been trained in IMCI. This suggests that new providers are being given an orientationon IMCI by current staff and that regular supervision by the district is having a positive effect on

IMCI practice.


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II. Data Quality: Strengths and Limitations

The EIP had a very rigorous and comprehensive data collection (monitoring) system thatcombined the use of quantitative and qualitative information. Tools included: monthly reports

submitted by CBOs, LNGO/Plan Promoters and ACMS promoters; and supervision checklists

for promoters (LNGO/Plan), CBS and Provincial Health Coordinators. While many of the formsand checklists do collect quantitative data, some areas are made available for more qualitativecomments. The collection of qualitative data could be strengthened, however. For example,

performance indicators for CBOs (Annex 8) only ask whether growth monitoring was conducted.A more qualitative question (though reflected in a percentage) would be: What percent of all

children were weighed? Furthermore, qualitative data needs to be verifiable, so asking ifappropriate advice was given (when this cannot be observed) is not particularly helpful.

Plan and its partners carried out annual KPC and Health Facility Assessments and used this

information to make programmatic adjustments. In turn, the MOH (District Medical Teams) usedthis information to redirect resources to areas where performance (coverage) was low.

The achievements mentioned in this report are not based on MOH/HIS data.

The projects two main data collection systems (KPC and Health Facility Assessment) collected

information at all levels except at the national level. The two data collection tools employed aretypically used to measure normal category Child Survival grants, which seek primarily to have

an impact at the community level. When the Expanded Impact (EI) category was created, noother data collection tool or alternative indicators were developed/offered to measure the impact

of the project at the national level. Should the Child Survival Health Grants Program decide tocontinue the EI category, set indicators to measure the scale-up efforts would be beneficial.


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III.Presentation of Results

Table 6. Presentation of Quantitative Results

Objectives Indicators BLD MT FE Target

MALARIA (40%)1 Increase from 11.8% to 60%

children age 0-23 months who

slept under an ITN the

previous night

% of children age 0-23 months who

slept under an insecticide-treated net

the previous night

11.8% 60.7% 66.4% 60%

2 Increase from 15.7% to 60%pregnant women who slept

under an ITN the previous

night

% of pregnant women who slept underan insecticide-treated net the previous

night

15.7% 43.2% 66.7% 60%

3 Increase from 11.7% to 60%children age 0-59 months whoreceived a full course ofrecommended anti-malarial

within the 24 hours of onset offever


received a full-course of recommendedanti-malarial (according to the MOHsrecently approved home-management

protocols) within the 24 hours of theonset of fever

11.7% 36.6% 51.9% 60%

4 Increase from 18.5% to 75%women who completed IPT

during their current or last

pregnancy

% of women who completed

Intermittent Preventive Treatment

(IPT) during their current or last

pregnancy

18.5% 51.4% 69.6% 75%

5 Increase by 25% the numberof net owners who have

retreated net at least once in

the last year

% of net owners who have retreated net

at least once in the last year

No

baseline

8% No

data

25%

increase

over

baseline

NUTRITION (30%)

6 Decrease from 15.9% to 10 %children age 0-23 months who

are under-weight (-2 SD fromthe median weight-for-age,

according to the WHO/NCHS

reference population)

% of children age 0-23 months who are

under-weight (-2 SD from the median

weight-for-age, according to theWHO/NCHS reference population)

15.9% 9.4% 9.5% 10%

7 Increase from 50.8% to 75.8%children age 0-5 months who

were exclusively breast-

feeding during the last 24

hours


were exclusively breast-feeding during

the last 24 hours

50.8%4 63.1% 74.9% 75.8%

8 Increase from 92.1% to 95%children age 6-9 months who

received breast-milk and

complementary foods during

the last 24 hours

% of children age 6-9 months whoreceived breast-milk and

complementary foods during the last 24

hours

92.1% 93.6% 90.2% 95%

9 Increase from 65.3% to 80%children age 6-9 months who

received animal and/or

vegetable protein during the

last 24 hours

% of children age 6-9 months whoreceived animal and/or vegetable

protein during the last 24 hours

65.3% 58.2% 84.1% 80%

4The baseline is already significantly higher than the national average because two of the three target regions

already had higher than average EBF rates and the project is not being implemented in the provinces with extremely

low EBF rates.


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10 Increase to 90% children age6-59 months who receivedvitamin A supplementation in

the prior six months


received a Vitamin A supplement in theprior six months

80.9% 76.6% 69.3% 90%

11 Increase to 80% mothers

giving birth in the last 12months who received two

vitamin A supplements within

eight weeks post partum

% of mothers of children age 0-23

months who received two Vitamin Asupplements within eight weeks post

partum

21.6% 30% 38.3% 80%

12 Increase from 9.2% to 40%sick children age 0-23 monthswho received increased fluids

and continued feeding during

an illness in the past two

weeks

% of sick children age 0-23 months

who received increased fluids andcontinued feeding during an illness in

the past two weeks

9.2% 14.6% 13.9% 40%

13 Increase in 30% points (frombaseline) of pregnant womentaking iron/ folic acid

supplements daily for at leastfive months during their last

pregnancy

% of mothers of children age 0-23taking iron/folate supplements daily forat least 5 months during their last

pregnancy

27.2% 33.7% 70.8% 60%

14 Increase in 25% points (frombaseline) of children 6-59

months of age eating vitaminA rich foods daily during the

past week

% of children 6-59 months of age

eating vitamin A rich foods daily

during the past week

41.3% 86.7% 80.9% 60%

DIARRHEA (10%)

15 Increase from 7.7% to 30%mothers of children age 0-23

months who report that they

wash their hands with

soap/ash before foodpreparation, before feedingchildren, after defecation and

after attending a child who has

defecated


months who report that they wash their

hands with soap/ash before food

preparation, before feeding children,

after defecation and after a attending achild who has defecated

7.7% 15.5% 42.2% 30%

PNEUMONIA (10%)

16 Increase from 65.9% to 80%mothers of children age 0-23

months who know at least two

signs of childhood illness (fast

breathing and chest in-drawing) that indicate the

need for treatment


months who know at least two signs of

childhood illness (fast breathing and

chest in-drawing) that indicate the need

for treatment

65.9% 70.4% 77.9% 80%

17 Increase from 37.4% to 67.7%children with signs of severechildhood illness who wereseen by a qualified public or

private provider in the past

two weeks

% of children with signs of severechildhood illness who were seen by a

qualified public or private provider inthe past two weeks

37.4% 51% 74.1% 67.7%

IMMUNIZATION (10%)


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18 Increase from 70.5% to 80%children age 0-23 months whoreceived vaccination coverage

for all antigens

% of children age 1223 months who

are fully vaccinated (against the fivevaccine-preventable diseases) before

the first birthday

70.5% 73% 67.2% 80%

19 Increase from 58.9% to 80%

mothers of children age 0-23months who received 2TT

during their last pregnancy


months who received 2TT during theirlast pregnancy

58.9% 56.8% 63.2% 80%


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IV.Discussion of the Results

A. Malaria (40%)

Indicators Baseline Midterm Final LOP

Target% of children age 0-23 months who slept under aninsecticide-treated net the previous night

11.8% 60.7% 66.4% 60%

% of pregnant women who slept under an insecticide-

treated net the previous night

15.7% 43.2% 66.7% 60%

% of children age 0-59 months who received a full-course of recommended anti-malarial (according to the

MOHs recently approved home-management

protocols) within the 24 hours of the onset of fever

11.7% 36.6% 51.9% 60%

% of women who completed Intermittent Preventive

Treatment (IPT) during their current or last pregnancy

18.5% 51.4% 69.6% 75%

% of net owners who have retreated net at least once in

the last year

No baseline 8% No data 25%

increase

overbaseline

The malaria component of the EIP seeks to reduce the number of malaria cases among childrenand pregnant women through ITN use and IPT, and to increase access to quality treatment

through symptom recognition, timely care seeking, and quality of care improvement andcommunity case management of malaria (CCM/M). A full list of activities is shown in Table 1.

As the table above shows, the two indicator targets related to ITN use were achieved. The

objective associated with treatment of malaria in children came within eight percentage points of being achieved, and IPT for pregnant women missed its mark by five percentage points. The

project decided not to measure ITN re-treatment, as long-lasting bed nets were distributed in alarge proportion of the project area.

These achievements are due to the projects initiatives on many fronts national,

regional/district and community and to the partners combined efforts. At the national level,the EIP was represented on the Malaria Working Group and was instrumental in designing the

Community Relay/Malaria (a CHW who is trained in CCM for Malaria only) training curriculumand supporting the training of 5,973 Community Relays/Malaria nationwide, 4,084 of whom are

based in the project area. Among these are 546 CCM/M Relays trained by ACMS with matchingfunds who work in five of the EIP districts The projects support of these activities contributed

to the scale-up of the Community Case Management of Malaria (CCM/M) approach throughoutthe country, greatly improving access to curative services. As mentioned in the MTE report, one

problem in this initiative was the failure of the MOH to make ACTs available to the CCM/Mrelays once they were trained. The kits were only distributed nine months after the training. The

final evaluation team interviewed a sample of CCM/M Relays and found that many stillexperienced long stock outs of ACT and some had difficulty accurately naming the signs of

severe malaria and when to refer a patient. Clearly, the issues of supply and supportivesupervision still need to be addressed.


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At the regional and district levels, the EIPs training of 346 health care providers working in 171out of 175 facilities in EIP areas in IMCI ensures the accurate diagnosis and treatment of malaria

cases, including severe malaria.

Furthermore, Plan and ACMSs contribution of 39,000 ITNs during the first half of the project

using funding from another project helped to increase ITN use, especially among children.During the second half of the project, EIP partners did not receive a new supply of ITNs fordistribution, and the MOHs efforts in this regard (Rounds 3 and 5 of the Global Fund) focused

on distributing ITNs to pregnant women during antenatal consultations. Some facilities providedITNs to infants born in the district hospital. The work of the CBOs in creating demand for ITNs

contributed to the success of this initiative.

At the community level, the projects training of approximately 40,600 CBO members in anestimated 910 communities in C-IMCI significantly increased access to information about how

to prevent malaria and when and where to seek care. More importantly however, ACMSprovided training to CBO members about how to hang an ITN, and the most active members of

the CBOs, usually four to seven per community, conducted monthly home visits to each familywith children U5 to see if they had a mosquito net hung over the bed and if the child slept under

it. The same was done for pregnant women. This very personal and proactive measure goes onecrucial step beyond ITN ownership, to ensure ITN use. And lastly, to increase the degree of

protection, the project (ACMS) also facilitated the re-treatment of ITNs by establishing sale points for re-treatment kits and promoting the practice during bi-annual Health and Nutrition

Weeks. Re-treatment of ITNs was emphasized much less during the second half of the project,however, because the Ministrys Roll Back Malaria Initiative (RBM) distributed only long-

lasting mosquito nets, making re-treatment less of a concern.

The malaria component in the Central Region was also greatly assisted by a malaria project thatwas funded by Plan Netherlands and Plan France. This five-year project, which began in 2005,

has the same objectives as the EIP malaria component and has contributed mosquito nets andfunds to support activities similar to those of the EIP.

B. Nutrition (30%)

Indicators Baseline Midterm Final LOPTarget

% of children age 0-23 months who are under-weight (-2 SD

from the median weight-for-age, according to the

WHO/NCHS reference population)

15.9% 9.4% 9.5% 10%

% of children age 0-5 months who were exclusively breast-

feeding during the last 24 hours

50.8%5 63.1% 74.9% 75.8%

% of children age 6-9 months who received breast-milk and

complementary foods during the last 24 hours

92.1% 93.6% 90.2% 95%

% of children age 6-9 months who received animal and/or

vegetable protein during the last 24 hours

65.3% 58.2% 84.1% 80%

5The baseline is already significantly higher than the national average (23.5%) because two of the three target

regions already had higher than average EBF rates and the project is not being implemented in the provinces with

extremely low EBF rates.


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% of children age 6-59 month who received a Vitamin A

supplement in the prior six months

80.9% 76.6% 69.3% 90%

% of mothers of children age 0-23 months who received twoVitamin A supplements within eight weeks post partum

21.6% 30% 38.3% 80%

% of sick children age 0-23 months who received increased

fluids and continued feeding during an illness in the past two

weeks.

9.2% 14.6% 13.9% 40%

% of mothers of children age 0-32 taking iron/folate

supplements daily for at least 5 months during their last

pregnancy

27.2% 33.7% 70.8% 60%

% of children 6-59 months of age eating vitamin A richfoods daily during the past week.

41.3% 86.7% 80.9% 60%

The nutrition component of the EIP focused on improving the nutritional status of children U5and on improving micronutrient intake especially Vitamin A, zinc, iron and folic acid. The

target audiences for this components activities were children U5 and pregnant women. Thestrategies used are cited in Table 1.

As the above table shows, out of the nine nutrition indicators, six have been nearly achieved orsurpassed. Five of the indicators do not require access to outside resources and therefore aresusceptible to change through community-level promotion alone, including indicators having to

do with child feeding practices. The other behaviors require access to a resource such as vitaminA or iron/folate. The indicator related to reduced malnutrition (underweight) is associated with

many factors.

Regarding the reduction in malnutrition, during the MTE it was concluded that the reduction inmalnutrition was more likely attributable to reduced morbidity (malaria and diarrhea) than to

significant improvements in feeding habits. This conclusion was also supported by anecdotalevidence provided by health center staff who reported reduced incidences of diarrhea and

malaria. Recognizing the links between morbidity and malnutrition, during the second phase ofthe project ,HKI spearheaded the effort to modify the acute malnutrition management protocol to

include some elements of IMCI. This should help improve the effectiveness of case managementof acute malnutrition in children.

During the final evaluation, one District Medical Officer attributed the reduction in malnutrition

in the Eastern Region to the efforts of UNICEF and Doctors Without Borders (MSF), which havebeen more widely active in the region and provide inputs as such Plumpy Nut and CSM (corn,

soy, maize mix). That said, when the data from the KPC survey was disaggregated to show theresults of the Positive Deviance (PD)/Hearth approach implemented in Ngeulemendouka Health

District (where neither UNICEF nor MSF works), the data showed that at baseline, 43.8% of

children weighed were malnourished (% of children age 0-23 months who are under-weight:


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After participating in PD/Hearth, 584 (94%) of the children were rehabilitated. These resultsshow the potency of PD/Hearth and suggest that it should be applied more widely in areas were

malnutrition in children is a prevalent and where long-term sustainable solutions are sought.

Child feeding behaviors are being promoted by IHC staff and CBO members who were trained

by the project. Three hundred twenty-four (324) health care providers in the EIP area weretrained in ENA and all 910 CBOs and IHC staff were trained by the project in C-IMCI. Duringthe second half of the project, 503 CBOs (approximately 17,191 members) were trained in C-

IMCI using a new curriculum developed and revised by the EIP partners. Despite having madeimprovements over the prior curriculum based on MTE recommendations to use more

participatory learning methods, the four days allotted to learn the material especially suchcomplex tasks as growth monitoring (which was taught in 60 minutes), health education

techniques, and health information systems was insufficient. One of the improvements madein the curriculum was the use of a pre-/post-test approach suitable for illiterate populations. The

project should be commended for taking on this challenge. Unfortunately, the method deviseddoes not allow the facilitators to know which questions the respondent answered correctly, but

only the number of correct and incorrect responses. While this is a vast improvement over notadministering any pre-/post-tests, further research into other methods that are more useful is

needed. Furthermore, the pre-/post-test questions should be revised to focus on the most commonlife-threatening problems faced by children (currently three of the 25 questions are on

HIV/AIDS).

While over 40,000 CBO members were trained over the course of the project, only a handful ofCBO members in each village actively promote the key behaviors in their community. These

include the CBO President, the secretary (who helps with growth monitoring and maintains thecommunity register) and block chiefs (neighborhood leaders who identify the households in their

neighborhoods who have children U5 or pregnant women and promote behavior change throughgrowth monitoring, home visits and group talks). The final evaluation team also found that

regardless of the size of the community, the number of CBO members trained remained around30. In communities with many inhabitants, several CBO groups were selected to make sure the

workload of each CBO member did not exceed 10 to 20 households. While this decision wasbased on guidance about training group size, it was not logical from a programming perspective.

Villages with only 97 inhabitants need far fewer trained CBO members than communities with300 residents or more. In a follow-on project, there should be about one trained CBO member for

about 10-15 households with young children.

The MTE recommended that additional and better quality visual aids be provided to CBOs tohelp promote behavior change. In response to this, EIP partners, especially HKI and ACMS,

developed two flipcharts and a message booklet. One of the flipcharts contains drawings andphotographs on nutrition messages only. This flipchart took into consideration the results of the

Doer/Non-doer survey conducted as part of the BEHAVE training during the first half of theproject, which indicated that the grandmothers of well-nourished children encouraged exclusive

breast feeding, feeding with bush meat, and consumption of food prepared with red palm oil.Specific messages and pictures were created to promote these practices. To further increase

access to appropriate visual aids throughout the country, HKI created a data bank of nutrition


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education materials prototypes for use by interested parties. The use of this data bank will go along way to ensure the standardization of messages and promotion of key behaviors.

Regarding community-based growth monitoring and promotion, in most villages children are

weighed monthly on a house-to-house basis by the block chief who carries the scale and a small

notebook door to door. She, and perhaps the secretary, weigh the child, mark the weight in thenotebook and then later record this information in the community register since the register is toolarge to carry around. Done in this way, the activity is more a data collection exercise than a

counseling or screening opportunity. While CBO members are taught to be alert for children whodo not gain weight each month, done in this way, they cannot know at the time of the weighing if

the weight has increased or decreased or if the weight is normal for the age of the child. Thissituation puts into question the validity of the data gathered and reported each month by the

CBOs. To address this, a separate training (perhaps in-service) on growth monitoring should be provided to select CBO members and those people should be instructed to use the Message

Booklet (Chart 23) which contains the Road to Health graph to chart the childs weight anddetermine actual nutritional status of the child.

In some communities visited during the final evaluation, the team found that adult scales, rather

than Salter scales, had been distributed by the project. This makes growth monitoring morecomplex and less accurate, as a mathematical calculation has to be made and the scale is not as

sensitive. Furthermore, in some communities a very small percent of the children are weighedeach month which means that even if the weighing is accurate, the information only reflects a

portion of the under three population. One of the indicators used to measure the performance ofCBOs and to evaluate the quality of their growth monitoring work only determines if growth

monitoring was conducted and does not specify a target level of coverage/participation, e.g.,80% of children 0-36 months weighed. In a subsequent project, this kind of coverage

measurement would be advised.

Three of the nutrition indicators did not reach their targets. The two related to Vitamin Acoverage relied on the availability of Vitamin A provided by the MOH and stock outs thwarted

efforts to achieve higher coverage. With regard to improved feeding of sick children, althoughsick children are a target audience for CBO home visits, a review of the revised C-IMCI

curriculum shows that the message about feeding a sick child is only mentioned once and only inthe module on diarrhea. Despite the fact that the message is clearly communicated in the

Message Booklet in Chart 15, it seems that the message about feeding a sick child, regardless ofthe illness, was not communicated strongly enough to promoters or CBO members.

The project has also supported nutrition activities at the national and regional levels. These

include support for the establishment of a National Nutrition Working Group, an OR study onthe introduction of zinc, ENA training for health care providers and PD/Hearth training.

The National Nutrition Working Group brings together stakeholders from around the country to

develop a strategic plan, to set nutrition policy and to consider means to improve nutritionalstatus among various target audiences. The EIP not only supported members participation in the

working group, but EIP staff attended the meetings regularly and influenced decisions. Theworking group was officially sanctioned by the government in 2008.


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The zinc OR, conducted by HKI, was a pilot research intervention carried out in the Bertoua

Health District of the East province between August 2007 and February 2008. The purpose of theresearch was to study how best to introduce the use of zinc in the country for the management of

diarrhea. The study found that: a) the ORS/zinc combination is affordable, b) compliance is

acceptable; c) zinc treatment for diarrhea increased the use of ORS/ORT but did not influencethe correct use of antibiotics by health personnel; and d) information about zinc is primarilycommunicated by health care providers and community relays. The report recommends that in

addition to treatment being provided at the health centers, diarrhea treatment kits comprised ofORS and 10 zinc tablets be made available to the population through trained CBO members and

local pharmacies.

As a result of the study, zinc has been included on the list of essential drugs in Cameroon and theprocess is in place to establish the means of importation. Furthermore, steps are being taken to

include the administration of zinc in the IMCI protocols for treatment of diarrhea. ACMS isimporting low osmolarity ORS and zinc, and through the health education efforts of IHC staff

and CBOs, some mothers are now aware of the added value of zinc in the treatment of diarrhea.

The EIP supported the training of 74 health care providers as ENA trainers in the project area.This training has allowed the MOH to train 324 MOH staff and extension workers to more

effectively and proactively promote the key nutrition behaviors that CBO members are promoting as a part of C-IMCI. The training of trainers also helped scale up this approach

throughout the country, and with assistance from UNICEF, 103 para-medical students and 2,310community members have been trained in ENA outside the project area. HKI asserts that the

ENA work has helped to increase iron supplementation among post-partum women.

In reviewing the nutrition indicators, the evaluation team felt that from a design perspective itwould be better to focus on behaviors with quite low (below 75%) compliance. The

complementary feeding indicator was already above 90% at baseline and therefore did not reallymerit the attention of this project.

C. Diarrheal Disease Control (10%)


Target

% of mothers of children age 0-23 months who report that

they wash their hands with soap/ash before food preparation,before feeding children, after defecation and after a attending

a child who has defecated.

7.7% 15.5% 42.2% 30%

Although the EIP partners only chose one indicator to measure their efforts to control diarrhealdisease, the projects efforts to prevent diarrhea and reduce its negative consequences focus on

hand washing, water treatment, and ORS/ORT administration. The treatment and prevention ofdiarrhea was also addressed by the OR study described in the nutrition section. Two strategies

were used to address diarrhea. Through C-IMCI training CBO members learned to promotehand washing, to use ORS/ORT and to treat their drinking water.


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As the M&E table shows, the EIP surpassed is final target of 30% with regard to hand washing.This is due to a focus on this message during the second half of the project accompanied by new

visual aids and improved C-IMCI curriculum in which hand washing is emphasized. Evaluationteam members reported that hand washing was not only studied during training events, but also

practiced as a model personal hygiene behavior. It appears now that hand washing with soap at

least in some circles has become a cultural norm.

ACMS was particularly involved in the activities for the control of diarrheal disease (CDD), and

it is regrettable that there were not one or two more indicators to measure their efforts. Anindicator on ORS use and/or water treatment would have been a valid choice. ACMS increased

access to Orasel and later, after the zinc was included on the Essential Drug List, low osmolarityORS with zinc by establishing 99 sale points in and near the targeted EIP communities, resulting

in the sale of 20,000 sachets of ORS (both types).

ACMS also helped to reduce exposure to causes of diarrhea by increasing access to potablewater through in-home water treatment with Water Guard. Nine hundred sixty-two (962) points

of sale for Water Guard have been established by ACMS, with 3,979 bottles of Water Guard soldin the project area. During the second half of the project however, ACMS experienced serious

challenges with regard to the supply of Water Guard, which resulted in prolonged country-widestock outs of the product. When tested by the government authorities, the locally produced

Water Guard was not approved for distribution and an entire batch of the product went unused.PSI/HQ subsequently changed its supplier, causing extended and inexplicable stock outages. As

a result, during the second half of the project, EIP community members have not had access toWater Guard to treat their drinking water.

D. Pneumonia (10%)


Target% of mothers of children age 0-23 months who know atleast two signs of childhood illness (fast breathing and chestin-drawing) that indicate the need for treatment.

65.9% 70.4% 77.9% 80%

% of children with signs of severe childhood illness who

were seen by a qualified public or private provider in the

past two weeks.

37.4% 51% 74.1% 67.7%

In addition to the recognition of signs of acute respiratory infection (ARI) and timely careseeking promoted by trained CBO members, and improved quality of ARI treatment by IMCI-

practicing health care providers, the EIP had hoped that the government would adopt the CCM/Papproach following a visit to Senegal and review of case studies from neighboring countries

where CCM has proved effective. Instead, the MOH decided that another OR study was needed.

At the time of the MTE, the protocol for the CCM/P OR was being developed. The firstprotocol, developed by a researcher at the Faculty of Medicine and Biological Sciences at the

University of Yaound I, was not approved and had to be modified. Finally the MOH approvedthe protocol and the 12-month CCM/P OR finally got underway in November 2009. It was

implemented only in Bafut District in the Northwest Region and entailed a two-day training for90 Community Relays/health workers the majority of whom were previously trained and


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currently serving as Malaria Community Relays/health workers. The training was based on thebooklet Caring for Sick Child. Each CCM/P Community Relay/health worker is responsible for

providing care to children with signs of uncomplicated pneumonia living in three communities.They are also supposed to diagnose complicated cases of pneumonia and refer these cases to the

health center. Pneumonia education is also among their responsibilities, but in reality the

CCM/P focus primarily on their curative tasks, leaving the education responsibilities to theCBOs. The project supported all aspects of the OR implementation, including the initial supplyof amoxicillin, which the MOH was then expected to replenish as needed. IHC heads, Plan CBS

and the Provincial Health Coordinator are charged with monthly supervision of each CommunityRelay. A final evaluation of the study was carried out in September 2010 and showed the

following results. (See Annex 12 for the full report.)

Table 7. Reported Source of Care for Sick Child

The information shown in

Table 7 suggests thatamong the caregivers

interviewed, a largenumber have begun to

seek care from trainedCCM of pneumonia

community relays. Theyhave greatly decreased their reliance on traditional healers, but at the same time, there are also

fewer caregivers seeking care from health facilities. Overall, these results suggest animprovement in access to health care for pneumonia since the CCM/P Community Relays live

closer to the population than the health center.

Treatment compliance among mothers of pneumonia patients was also quite high at 88.4%.When checking the performance of the relays, their performance was quite encouraging. 97.8%

of the relays filled out their monthly report correctly and 10% experienced stock outs ofamoxicillin. All of the relays had been supervised during the preceding six months and 92.2%

had been supervised in the last month. All of the relays could name two signs of uncomplicatedpneumonia, and 95.6% could name two signs of complicated pneumonia. 98.9% of the relays

could correctly prescribe the treatment of pneumonia in a child 2-11 months, and 100% couldname the correct treatment of an older child age 12-59 months.

These results show a significant improvement from the mid-term evaluation. It is clear that

strong supervision and on-the-job training which were conducted after the mid-term evaluationimproved the knowledge of the community relays. However, there is some concern that the

relays do not have many opportunities to practice their treatment skills/knowledge. Several ofthe relays interviewed during the final evaluation had only treated one to two children in the last

quarter. The link between health center staff and the CCM/P relays should also be strengthened.

E. Immunization (10%)


Target

Source Baseline

11/09

Mid Term

5/10

Final

9/10

Comm. Relay/Pneumonia 2.4 23.7 45.3

Health Facility 49.5 30.2 35.0Traditional Healer 32.7 1.2 1.1

Self Medicated 9.7 8.8 5.4

Shop Keeper 5.7 5.6 2.1


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% of children age 1223 months who are fully vaccinated

(against the five vaccine-preventable diseases) before the first

birthday

70.5% 73% 67.2% 80%

% of mothers of children age 0-23 months who received 2TT

during their last pregnancy

58.9% 56.8% 63.2% 80%

The table above shows that neither immunization indicator was achieved. Given the amount ofeffort that the MOH and the project invested in increasing vaccination rates, this is likely due tothe requirement of the KPC survey that the vaccination card be used as evidence; stock outs of

vaccination cards were common during the second half of the project. Mothers recall, amonitoring indicator of the project, suggests that childhood vaccination rates exceed 80%.

As with the other intervention areas, the IMCI strategy was meant to improve vaccination

coverage rates. The role that IMCI was to play in ensuring that every child is completelyimmunized through well baby or sick child consultations was hindered, however, by a MOH

policy which prohibits providers from opening an entire vial to immunize only one or a fewchildren, and only vials with multiple doses are currently available. Consequently, the IMCI

strategy was not able to have a major impact on improving immunization coverage.

To compensate for this, and to improve coverage of other services, health care providerstypically informed mothers about the next vaccination day being held at the clinic. They also

conducted outreach vaccination days where health center staff travel to a specific location andvaccinate all children within a specific radius. CBOs whose registers indicate which children

need to be vaccinated are sometimes solicited to help find children in need of vaccinations. Inthis way, community members contribute to increasing vaccination coverage. During the final

evaluation, team members examined CBO registers and found that rather than writing in theactual date the vaccination was given, they only marked a check. While it is preferable that the

date be written in, in reality, if the register is primarily used just to identify unvaccinated

children, the check would suffice.

In addition to this outreach, the EIP developed a strategy called the Health and Nutrition Week.

Twice per year for one week, the entire health system in each health area mobilizes to offer a setof services (which varies by health district depending on the need) in every village. During this

period, vaccination services are provided in each village; injections being administered from afixed site and oral doses of polio and Vitamin A being provided during home visits. After only

two Health Weeks conducted by the EIP, the MOH adopted this strategy on the national leveland Health Weeks are now being conducted bi-annually nationwide with support from many

different partners, including international NGOs and bilateral and multilateral agencies.

While EIP reports show great improvement in coverage in some districts and lacking coverage inother districts, to date, no cost/benefit analysis has been conducted to determine the cost-

effectiveness of Health Weeks. In addition to this concern, there are two additional concerns: thatthis approach may encourage the population to wait for health services to come to them rather

than seeking them out on their own (which is the major message of the C-IMCI strategy), andsustainability. Unlike the outreach vaccination activity (strategie avanc), which is budgeted

for by the MOH and conducted on a routine basis, the Health and Nutrition Week depends onpartners to mobilize the necessary resources even though the MOH also funds a large part of the


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initiative. It would seem that such a massive mobilization would not be necessary if the IMCIand C-IMCI strategies were fully effective. Despite all of these concerns, it should be noted that

no outbreaks of childhood illnesses have taken place in the project areas during the EIP.

At the community level, trained CBO members are supposed to track immunization coverage

using two tools: the behavior map and the community register. The evaluation team attempted toassess the quality of the community health information system and found that while mostvillages had behavior maps that appeared to be kept up to date (including immunization status of

U5), the registers were not as well maintained. More importantly, however, it is not clear thatCBO members or IHC staff are using the registers to identify children whose immunization

status is not up to date to refer them to the health center.


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V. Sustained Outcomes, Contribution to Scale, Equity, Community Health WorkerModels and Global Learning

A. SustainabilityThe EIP took sustainability seriously, especially at the outset of the project, as evidenced by the

organization of a four-day Child Survival Sustainability Assessment workshop conducted by thePlan CS backstop officer in March 2006. Forty-one (41) people attended this workshop,including MOH representatives from each of the eleven districts. A key element in the

sustainability strategy was the role of the LNGOs who were expected to continue to support theCBOs after the project ended. As discussed in the section on local partner strengthening, the

focus on the LNGOs as part of the sustainability plan changed midway through the project wheninstitutional capacity building efforts for the six remaining LNGOs were curtailed and

performance-based contracts were signed. Without the ability to solicit funds from other donors,the LNGOs do not have the resources they will need to continue to support the CBOs.

Based on the MTE recommendation, the sustainability plan was amended (unofficially) to

provide for a more active role of the IHC in supporting the CBOs, as their work focuses onhealth. The final evaluation team found evidence of this strengthened role, but given the limited

staff at the IHCs and the rather limited time to reinforce their role, it is not certain if the IHC willbe able to provide enough support to the CBOs in their areas.

See the section on Community Health Worker Model (below) for its effect on sustainability.

All of the scale-up activities mentioned in this report are inherently linked to sustainability; once

responsibly for an activity is assumed by the Ministry of Health (or any other permanent entity),it will then be continued by that entity. Examples from the EIP include: The bi-annual Health

and Nutrition Week, inclusion of zinc on the Essential Drug List, and inclusion of IMCI in pre-service training for nurses.

B. Scale- upThe EIP was particularly effective in the area of scale-up. In addition to working effectively atthe community level to create demand, in each of the intervention areas (malaria, nutrition,

diarrhea disease control, immunization, and pneumonia), successes were noted regarding scale-up.

With regard to malaria, the project helped to modify the manual used to train CCM/Malaria

outreach workers both inside and outside the project area, and 90 CCM/Malaria were trained inthe project area. The projects ITN distribution was complemented by that of the Global Fund to

extend coverage.

Helen Keller International was especially effective in the area of nutrition, helping to establishand support the National Nutrition Working Group. The ENA approach has spread beyond the

EIP intervention area and with assistance from UNICEF, providers from other districts have beentrained.

The zinc OR effort resulted in zinc being included on the Essential Drug List for the


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management of diarrhea, and its use is now being promoted throughout the country.

The adoption by the MOH of the Bi-annual Health and Nutrition Week as a means to improvevaccination coverage (and the provision of Vitamin A and other services) is another example of a

new approach introduced and initially supported by the project that has been adopted outside the

project area and is currently being supported by the MOH and other donors.

Although the CCM/P OR study was only implemented in the last year of the project, the results

will be used by the MOH to determine whether or not CCM/P will be adopted by the MOH as anofficial strategy.

And finally, the projects assistance in getting IMCI accepted as an official treatment strategy

and incorporated into pre-service training of nurses (still being pursued) is another scale-upsuccess.

All of these scale-up efforts were effective because the project worked consistently at the

national level on various working groups and made it possible for working groups to convene.They used project funds to pilot test different approaches at the local level and demonstrate the

effectiveness of the approach. They then disseminated the results, encouraging MOH decision-makers and international partners such as UNCIEF and WHO to take action. The fact that the

project was present at the national, district and village levels and present in three provinces madea significant difference. A smaller project would not likely have demanded the attention of the

MOH or international partners such as UNICEF and WHO.

C. EquityThe main equity issue addressed by the project was gender. It did this by choosing to work with

womens groups (CBOs) that already existed in the communities. The project trained, onaverage, 30 female members of each CBO, thereby strengthening their ability to promote healthy

behaviors throughout the community. Interestingly, in the end, the project determined that theyalso needed the support of men to promote certain behaviors, and in some cases, men were also

invited to join the CBOs.

D. Community Health Worker (CHW) ModelsThe EIP trained three types of CHWs as shown in Annex 7. The largest and most important

group consisted of the 27,000+ CBO members from approximately 910 communities, who weretrained in C-IMCI to promote healthy behaviors among a specific number of households per

CBO member. Rather than train individuals as CHWs, the EIP decided that by training a pre-existing group of women, the chance that they would remain together and continue to work after

the project would be greater. They also thought that by training a large number of women (30)from each CBO, they would be creating a critical mass of learned people in the community,

which would serve as a more effective strategy of reaching all of the target families in acommunity. And finally, since most of the selected CBOs already had an income generating

raison dtre, it was thought that the issue of remuneration might be avoided.

The CBO members were trained, supervised and supported in two phases. About half wereselected and trained before the MTE (August 2008), and the remaining half were trained in the


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last year of the project. The CBOs were each supervised by several cadres of project staff andpartners, including LNGO promoters who were supposed to visit them each month and Plan CBS

and Provincial Health Coordinators and ACMS Promoters. This degree of support undoubtedlyhad a great deal to do with their performance. Another factor was the clarity of their roles and

responsibilities. Although their training wasnt particularly long (four days) or effective, the

CBOs eventually mastered the key behaviors they were promoting and the behavior maps helpedthem stay on target with regard to their work. They were all very clear about what behaviorsthey were promoting among whom and who was practicing those behaviors and who was not.

The Phase 1 CBOs had more time to learn this than the Phase 2 CBOs, who were supported for ashorter period.

Based on a recommendation from the MTE, the project developed performance indicators (see

Annex 8) for the CBOs to more objectively measure their capacity and performance. Table 8shows the results of the Performance Ratings for (mostly) the Phase 2 CBOs.

Table 8. CBO Performance Ratings

Most of the CBO performance indicators monitor thepresence of things (meeting minutes, tools,if growth monitoring and home visits were conducted) or actions that are not easily verified

(home visits, advice given) rather than the quality of implementation. Therefore, they do notmeaningfully measure performance. Simple adjustments to the wording of the indicators would

have made them more effective in measuring performance. For example, instead of just asking ifa CBO meeting was held, it would be better to ask if a meeting was held with 80% attendance.

Likewise, instead of just recording if growth monitoring was done, it is between to record if 80%of all eligible children were weighed.

This was a very worthwhile attempt to assess CBO performance. Had this approach been

adopted from the outset of the project and used to adjust support to each CBO, the results mighthave been more useful.

Although having chosen pre-existing CBOs may help the groups to continue to remain together,

without regular supervisory visits, it is not clear if they will continue to visit households eachmonth to promote and check on behaviors or if they will continue to weigh children. Some

CBOs who are not too far from the IHC might be visited, and some LNGO promoters may

6Due to rounding, totals may not add up to 100%.7In the NW and East Regions, not all the CBOs were classified. In the Center Region, not only the CBOs for Phase2 were classified but also some CBOs from Phase 1. This is why the total number of CBOs does not match other

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