Health Program Portfolio Review American Red Cross/ Haiti March 2012 Submitted by: Bonnie Kittle TABLE OF CONTENTS Executive Summary 4 Chapter One - Lessons Learned Health Portfolio Review 7 Chapter Two - Future Health Programming 28 Chapter Three - Partnering 33 Chapter Four – Partner -Implemented Cholera Programs 35 Chapter Five – Working in the Camps 36 Chapter Six - Comments on the LAMIKA Proposal 37 Annexes Annex 1 – Notes on Behavior Change Annex 2 - Partnership Defined Quality Annex 3 - Barrier Analysis Annex 4 - Care Groups Annex 5 - ARC/Cambodia experience with Care Groups Annex 6 – Village Savings and Loan web link Annex 7 - TOR Annex 8 - Interview Tool Template Annex 9 - Review Methodology 3 Executive Summary The health portfolio of the American Red Cross/Haiti has undergone enormous changes since the earthquake struck Port-au-Prince in January 2010. It has grown from two community-based projects1 (Together We Can and the Malaria Prevention) worth $1.1 million to a communityfocused portfolio2 worth more than $8.5 million. In addition to the size of the programs, the conditions under which these recent programs have been implemented have been extremely challenging. Now that life in Haiti is emerging from the need for relief and emergency, there is time to reflect on the lessons learned over the past two years and apply them to future programming decisions as Haiti enters its recovery stage. With this intent in mind, a health program review was commissioned by the Haiti Assistance Program of the American Red Cross to determine the relevance, effectiveness, and coverage of the Haitian Assistance Program (HAP) health portfolio and to determine directions of future health programming. This portfolio review was undertaken in February 2012 by an external consultant. The study methodology described in detail in Annex 9 included the review of program documents, in-depth interviews with HAP and NHQ staff, discussions in Haiti with ARC delegate and staff and partners, observations of current projects and visits to field sites outside of Port-au-Prince. Discussion of the interview guides used is provided in Annex 8. Key recommendations from the portfolio review are provided below with corresponding findings and conclusions provided in table format in the body of the report. Summary - Key Recommendations LAMIKA 1. Ensure the success of the LAMIKA project by making the necessary changes in Human Resources and security policies (allow families, allow driving for example) so that the appropriate staff can be recruited and retained. Offer only 2-year contracts for LAMIKA and National program staff. 2. Design the LAMIKA project so it includes the construction/renovation of a health center/ CTC in the neighborhood to facilitate care seeking related to: diarrheal disease/cholera, malaria, HIV/AIDS care and testing, gender-based violence counseling, pre and post natal care, assisted deliveries, child spacing services and childhood vaccinations. Working with the MSPP, ensure that the health center is appropriately staffed and that quality services are being provided. Consider conducting a Health Facility Assessment to better ascertain the quality of care and to inform provider capacity building activities necessary. 1 2 Does not include the two hospital/facility-based projects with PIH and ICRC. Current hospital-based programs are funded to $17.9 million. 4 National Program 3. When designing the rural project for the N/NE follow the integrated approach combining water and sanitation activities, maternal and child health (including diarrheal disease prevention) and livelihoods. Building on the recommendations of Christy Gavitt, center activities around health care facilities to facilitate care seeking and consider applying the Partnership Defined Quality approach to improve the quality of care provided. (http://www.coregroup.org/storage/documents/Social_Behavior_Change/Save_PDQ_Facil_G uide.pdf) Consider using the Community-led Total Sanitation approach to promote latrine and hand washing station construction. ( http://www.communityledtotalsanitation.org) 4. When designing the rural project for the N/NE, introduce the women’s saving and loan program following the village savings and loan model. (see Annex 6 https://www.msu.edu/unit/phl/devconference/CAREVillSavLoanAfr.pdf ) Behavior Change (see Annex 1 for more information about behavior change) 5. In support of Christy Gavitt’s recommendation, train all key ARC/Haiti and HRC staff in Designing for Behavior Change to gain the skills necessary to implement the recommendations related to behavior change. Ensure that key Haitian staff participates in the course so the ‘learning/skills development’ stays in-country. Design effective behavior change strategies using the Designing for Behavior Change framework. 6. Build the capacity of all health promoters and volunteers to be effective agents of behavior change rather than just communicating messages. 7. When designing any project, plan to conduct formative research around the key behaviors and plan appropriate activities based on a better understanding of the determinants. Avoid focusing only on message communication and commodity distribution Monitoring and Evaluation 8. Design all future project proposals so that outcomes are behaviors among target groups. Avoid confusing Inputs with Outputs. 9. Modify monitoring and evaluation plans so they track changes in behaviors (outcomes) not just the actions of the implementers (provision of inputs and implementation of activities). Conclusion 5 The findings of this study show, it is time to shift from emergency response to longer term impact. This progression requires more focus on behavior change – a strengthening of knowledge and skills from the highest levels to the Red Cross volunteers working directly with families. It also suggests a wider set of interventions (not just focused on single diseases) that will enable the most vulnerable sub-groups of the population (pregnant women and young children) to gain strength so they are more resilient if and when another natural disaster occurs or an epidemic breaks out. The LAMIKA and Nationwide (North/Northeast) projects currently being designed are perfect opportunities to implement these new approaches. 6 CHAPTER ONE Lessons Learned – Health Portfolio____________________ WHAT LESSONS CAN BE LEARNED FROM PAST AND CURRENT ARC HEALTH PROJECTS (PREAND POST-EARTHQUAKE) THAT CAN INFORM THE FUTURE HEALTH PROGRAM? Post-Earthquake Health and Hygiene Promotion (PEHP)( May 2010 – Nov. 2011)/Health Transition Project (HTP) (Dec. 2011 – June 2012) BACKGROUND/OVERVIEW The PEHP project was an 18-month-long initiative (May 2010 – Nov. 2011) that was designed to be implemented among residents of the IDP camps. Its purpose was to provide first aid and to educate camp residents about the prevention of cholera, malaria, HIV and sexual and genderbased violence. Haitian Red Cross Volunteers were recruited and trained to conduct health education and commodity distribution (soap, Aqua Tabs, ORS ) going from tent-to-tent staying in a camp for 8 weeks before transferring to another camp. A total of 50 camps were targeted to reach approximately 190,000 people. The project was implemented in the same camps where disaster risk reduction and disease mitigation (latrine and hand washing station construction) were underway; a strategy that complimented the health prevention activities. The PEHP project was only underway for a few months when the cholera epidemic broke out. In response, ARC recruited an additional 100 volunteers for a total of 200 staff, and the cholera work began to over shadow the PEHP project’s non-cholera work. One of the findings of the PEHP evaluation report is of particular interest to the task of assessing effectiveness and potential lessons learned. The$project$changed$dramatically$over$time,$especially$in$scope.$As$there$ was$no$adaptation$of$the$project$targets$or$intended$outcomes$since$June$ 2010$it$has$become$irrelevant$to$look$at$whether$the$project$managed$to$ achieve$its$intended$outputs$and$outcomes.$The$project$certainly$exceeded$ reaching$its$intended$number$of$beneficiaries$but$this$was$to$be$expected$ with$almost$doubling$its$human$resource.$What$needs$to$be$questioned$ though$is$whether$the$initially$set$targets$were$realistic$if$the$project$ changes$had$not$been$made.!!PEHP!Evaluation,!Pg.!27! Despite this conclusion, driven by the fact that the PEHP project morphed into something else as a result of the cholera epidemic, by looking at the design of the PEHP project some lessons can be gleaned and one of them is related to the final statement above. Rather than looking at the 7 targets set (number of people reached with messages) and determining if these were realistic had the changes not occurred, at the end of a project it is more appropriate to assess the significance of the indicators and their relationship to the stated goal. Although sexual and gender-based violence (SGBV) was supposed to be a component of the PEHP project, ARC had a difficult time identifying a suitable partner to implement these activities and juggling that requirement with the demands of the cholera response. By the time the International Relief Committee (IRC) was identified as a suitable partner, the populations in the camps had begun to disperse and it was decided to incorporate the SGBV activities into the Urban Neighborhood project (LAMIKA) being designed. Before the end of the PEHP project IRC was able to training project staff in SGBV, but there was little time for this training to have had an impact on the project. In December 2011, a modified version of the PEHP project was extended by 7 months (until June 2012) in order to retain 50 volunteers working on the project and in anticipation of the Urban Neighborhood project (LAMIKA) being designed. The new project is called the Haiti Transition Project (HTP). These volunteers are now promoting hygiene behaviors, many of which are associated with cholera prevention, in and adjacent to the areas of PAP where the LAMIKA project will be implemented. There are many positive aspects of the PEHP project which should be carried over into future cholera prevention activities. These include: 1. Strong training of promoters in interpersonal communication 2. Promoters working in pairs – typically mixed gender 3. Promoters raising awareness and encouraging behavior change through interpersonal communication and dialogue 4. Promoters saturating a given area with similar messages to create a sense of social norm change 5. Close supervision and support of promoter’s work 6. Use of monitoring forms to control quality of work Comments regarding the PEHP project and the lessons learned and recommendations are included in the table below. 8 PEHP ! Findings! 1! Many!of!the!PEHP!project!indicators! (outcome!and!outputs)!!have!to!do! with!“numbers!of!people!reached”!and! “number!of!commodities!distributed”.! 2! The!training!provided!to!the!HRC! volunteers!focused!on!technical! content!and!communication,!but!not! behavior!change!skills.!! Conclusions! These!are!fairly! meaningless! measures!since!they! don’t!specify!in!what! meaningful!way!the! people!were!reached! (or!even!if!the!target$ audience!was! reached)!and!if! people!are!using!the! commodities!that! were!distributed.!! !!! HRC!volunteers!are! not!skilled!in! promoting!behavior! change.!!They!are! missing! opportunities!to! promote!behavior! change.!! 9 Recommendations! Project!design! frameworks!should! identify!outcomes!as!the! desired!behavior!changes! (using!soap,!using! aquatabs,!using!latrines,! washing!hands),!and!all! strategies!and!activities! should!support!those! changes.!!When! measuring!“people! reached”!there!needs!to! be!a!qualifier!that!states! in!what!meaningful!way! which!people!were! reached.!!The!measure!of! commodities!distributed! should!only!be! considered!a!measure!of! activity!implementation.!! Volunteers!should!be! trained!in!behavior! change!promotion!skills! including!negotiated! behavior!change.!!There! are!modules!already! designed!for!this!purpose! that!can!be!adapted!for! use!by!ARC.!! ! 3! Findings! IRC!has!been!invited!to!design!a!SGBV! component!of!the!LAMIKA!project! without!knowing!what!the!LAMIKA! project!is!all!about.!!This!was!done! because!the!systems!within!ARC/NHQ! are!so!slow!that!decisionXmakers!did! not!want!to!risk!delaying!the!SGBV! work!further.!! Conclusions! IRC!will!not!be!able! to!design!a!SGBV! component!that! compliments!the! work!and!strategies! of!the!LAMIKA! project.!!The!SGBV! work!risks!to!be! implemented! ‘alongside’/! independent!of!the! LAMIKA!work!rather! than!integrated!into! to.!!!Loss!of!cost! effectiveness.!! 10 Recommendations! Allow!the!agreement! with!IRC!to!be!reviewed! and!approved!by!the! ARC/Haiti!CD!to!avoid! the!delays!associated! with!the!involvement!of! HAP.!!! Show!IRC!the!LAMIKA! project!proposal!and!ask! them!to!design!a!project! that!compliments!the! strategies,!activities! already!planned.!The!IRC! proposal!should!not!just! focus!on!counseling! abused!women!but!also! preventive!behaviors! Cholera BACKGROUND/OVERVIEW ARC Directly Implemented ($4.3 million) Ten months after the devastating earthquake which struck Port-au-Prince (PAP), Haiti in January 2010, a cholera epidemic broke out in October 2010, in the capital and other parts of the country. The story of ARC’s response to the epidemic is complicated. ARC planned two different cholera prevention and treatment efforts. The first was directly implemented by ARC promoters and took place in 50 camps of Internally Displaced People (IDP) over a six-month period. This effort was initially integrated into the Post Earthquake Health and Hygiene Project (PEHP) which was already underway (May 2010 – June 2012). The presence of the PEHP project facilitated cholera response activities because the PEHP promoters were quickly trained in cholera prevention and deployed in the camps. Soon thereafter another 100 promoters were hired, trained and sent to work in the camps. While the response to the cholera epidemic derailed the planned strategy of the PEHP project, which called for promoters to rotate through the camps on eight-week shifts and included health education on the prevention of cholera, malaria, and HIV and included first aid, the rapid scale up of cholera prevention activities in the camps likely helped save many lives. Project activities included tent-to-tent distribution of soap, Aqua tabs (for purifying water), Oral Rehydration Solution packets, and jerry cans (in some cases) and instruction on the use of these commodities; the establishment of Oral Rehydration Points/Posts; and the installation of hand washing stations and latrines. After some months, as the number of cholera cases diminished, activities in the IDP camps were reduced, and activities were extended under the Haitian Transition Project (HTP) to include work in schools, public areas in certain neighborhoods and residences in Carrefour-Feuilles (Bariajou and Campeche), all in PAP. The second cholera initiative was the Cholera Prevention and Treatment Project (or Cholera Response Project), an 18 month-long project (January 2011- June 2012), which only got underway in June 2011, a full 8 months after the epidemic started. This project is being implemented through the Haitian Red Cross using HRC volunteers, in 23 communes of the North and North/East Departments and 2 communes in the West. It includes the same types of activities described above. The health promotion activities are accompanied by water and sanitation activities including the construction of latrines and hand washing stations. Due to a series of delays related to things like not knowing project targets and specific intervention areas, the baseline survey was conducted only in December 2011, six months into the project. Unfortunately this delay means that the baseline does accurately reflect the reality at the outset of the project. Some results of that survey are shown below: 11 • • • • • • • • Cholera!Response!Project!Baseline!Data! 39%!could!correctly!describe!use!of!Aqua!Tabs! 39%!had!a!latrine!and!used!it! 75%!know!signs!of!cholera! 23%!know!means!of!cholera!transmission! 39%!know!3!cholera!prevention!methods! 62%!could!describe!ORS!preparation! 77%!reported!having!sought!care!for!suspected!cholera! 83%!drink!potable!water! Both cholera projects aim to reduce morbidity and mortality due to cholera through improved prevention and treatment practices such as hand washing and latrine use, and increased access to commodities and services. Unlike the PEHP and HTP efforts, the Cholera Response project in the N/NW and West contains four indicators that relate to specific life-saving behaviors, one of which is hand washing. A closer look at the project design however, reveals that the focus has primarily been on increasing knowledge and the behavior change strategy is not strong enough to ensure the achievement of the behavior-related objectives. This is because the training of the volunteers has not imparted the requisite behavior change skills and because the contact between the volunteers and the target audience is not frequent enough. Also while some commodities (soap, aquatabs, ORS etc.) were distributed, it was planned only to give each family one set of commodities and some were distributed en masse rather than house-to-house and used as a training tool. And finally, it is not clear which determinants of behavior change are the most important for the target audience vis-à-vis the desired behaviors. Implementing this project in rural areas is quite different from that in the camps and the urban areas has proved a challenge. Rather than recruiting and positioning volunteers in relation to population size and density, equal numbers of volunteers were recruited for each commune regardless of geographically challenges such as the mountainous terrain in the NE. As mentioned in Christy Gavitt’s trip report (Jan. 2012), this made it impossible for the volunteers to distribute the commodities to each house and 2 mass distributions of commodities were undertaken which proved to be quite a challenge and much less effective than the house-tohouse approach. Furthermore, visiting families who live in widely dispersed communities in mountainous terrain takes more time and man power than the project anticipated. The rural cholera response program has establish 51 OR Points in the Northeast Department, 75 in the North Department, and 50 in the Communes of Archaie and Caberet, in the West. It is also planned to install 25 pumps in the north and another 25 in the NE. Latrine construction has been delayed due to poorly functioning procurement systems and only began in January 2012, one year into the project. Seventy-five (75) latrines will be constructed in the North Department, 225 in the NE (51 at OR Points and 174 in individual houses) and 50 in Archaie/Caberet all at OR Points. The approach planned to be used for latrine construction a separate contract for each phase (pit digging, framing, cement, door) of latrine construction contains predictable problems and should be reconsidered per the recommendation below. ARC should also look into way to make their procurement systems function more effectively. 12 CHOLERA – DIRECTLY IMPLEMENTED – HAITI TRANSITION PROGRAM (HTP) AND CHOLERA PREVENTION AND TREATMENT PROJECT (N, NE, ARCH/CABERET) ! Findings! Conclusions! Recommendations! 1" The"cholera"epidemic"broke"out"in"Oct." Response"to"this"epidemic"was"too"slow," Shift"decisionJmaking"authority"more" 2010."The"promoters"working"on"the" especially"for"a"relief"and"emergency" to"the"field"staff"so"they"can"take" PEHP"project"in"the"camps"immediately" response"organization."" decisions"in"a"more"timely"manner" began"to"promote"cholera"prevention" and"respond"to"emergencies"quickly."" and"treatment"behaviors.""The""‘official’" ARC/cholera"program"was"approved"in" Jan."2011"but"activities"only"got" underway"in"June"2011; Operational" issues"on"the"ground"were"the"biggest" challenge"to"project"startJup" (recruitment,"procurement,"office"set" up,"etc)."The"other"challenge"was"the" slow"recruitment"of"volunteers." Latrine"and"hand"washing"station" construction"only"began"in"January"2012." 13 ! 2" Findings! The"HTP"project"strategy"calls"for"the" promoters"to"pass"messages"to"the" target"audiences"(students,"street" vendors,"household"members)"through" interpersonal"contact"and"group" awareness"raising"talks"to"students."" The"HRC"Volunteers"also"focus"primarily" on"passing"and"memorization"of" messages."Increased"knowledge,"rather" than"behavior"change"is"seen"as"the" ultimate"objective"in"most"cases.""" " The"training"for"HRC"volunteers"and"HTP" promoters"has"not"equipped"them"to"be" effective"behavior"change"promoters."" Conclusions! Just"because"someone"can"memorize"a" message"related"to"cholera"doesn’t"mean" that"they"will"be"able"to"adopt"the" behaviors"that"will"prevent"them"from" getting"cholera."" " " The"volunteers/promoters"are"not"effective" behavior"change"agents.""" 3" The"HTP"strategy"calls"for"promoters"to" visit"one"geographic"area"just"enough" time"to"ensure"that"targeted"people"can" repeat"the"key"messages"accurately." The"promoters"have"too"few"opportunities" to"promote"behavior"change"among"their" target"audiences."" This"will"make"monitoring"and"evaluating" the"effectiveness"of"this"approach," practically"impossible.""" 14 Recommendations! Use"the"training"module"that"has" already"been"designed"by"PIH"for"use" in"Haiti"to"build"the"capacity"of"all"HTP" Promoters"and"Cholera"HRC" volunteers"to"become"effective" behavior"change"agents"rather"than" simply"focusing"on"the"memorization" of"messages.""These"skills"can"be" developed"sufficiently"in"a""½"to"1"day" training.""With"these"skills"the" promoters/"volunteers"will"be"able"to" help"their"target"audience"identify"the" barriers"to"behavior"adoption"and" find"ways"to"remove"these"barriers."" Use"this"approach"in"future"health" promotion"activities."" Promoters"should"stay"in"a"defined" area"until"60%"of"the"people" contacted"show"credible"signs"of" having"adopted"the"three"key"cholera" prevention"behaviors"(see"below)."" Project"management"should"devise"a" way"to"ensure"that"promoters"contact" the"same"people"at"least"10"times."" A"monitoring"system"would"need"to" be"developed"to"enable"target" audience"tracking."" ! 4" Findings! The"HTP"promoters"are"supposed"to" promote"adoption"of"many"behaviors;"all" of"which"are"healthy,"but"only"a"few"of" which"are"directly"related"to"preventing" cholera."" Conclusions! The"most"important,"lifeJsaving"behaviors" are"getting"the"same"attention"as"less" important"–"nonJlife"saving"behaviors."" " There"are"fewer"opportunities"for" promoting"lifeJsaving"behaviors.""" 5" HTP"Promoters"meet"with"large"groups" There"is"no"way"to"know"if"any"of"the" of"students"and"give"health"education"to" messages"have"‘stuck’"with"any"of"the" them"as"a"group."" students"or"if"any"behavior"change"is"taking" place."" 6" (outside"PAP)"The"volunteer"numbers" and"distribution"was"based"on" administrative"divisions"(communes)"and" not"on"more"pertinent"considerations," such"as"population"size,"density"and" geography."""" Volunteers"working"in"remote"rural" areas"have"had"a"very"difficult"time" reaching"their"target"audience."" "There"is"an"extreme"imbalance"between" the"work"loads"of"volunteers." " Volunteers"are"not"being"as"effective"as" they"could"be.""! 15 Recommendations! Reduce"the"behaviors"being" promoted"to"those"most"directly" related"to"cholera"prevention"and" care:""hand"washing,"water"treatment" and"latrine"use,""and"care"seeking" (recognition"of"signs"of"cholera"and" where"to"seek"medical"care)"" If"a"new"project"is"designed,"consider" applying"some"of"the"childJtoJchild" concepts"to"the"cholera"prevention" work."That"is:"identifying"students" who"promise"to"take"the"message" home"–"or"better"yet"promise"to"do" some"JcholeraJrelated"homework" with"their"family"–"and"report"on"it" back"at"school."Discussions"with" students"should"quick"evolve"from" “what"messages"can"you"remember?”" to"“what"behaviors"did"you"practice" today?”"" The"ratio"of"volunteersJtoJ beneficiaries"needs"to"take"size"and" location"of"beneficiaries"into"account" as"well"as"population"density"and" work"load."" ! 7" Findings! (outside"PAP)"Several"times"commodities" have"been"distributed"‘en"mass”,"rather" than"houseJtoJhouse"as"part"of"an" education"campaign."" Because"distributors"had"not"been" trained,"chaos"ensued."! 8" Promoters"(HTP)"are"supervised"quite" closely"and"there"are"tools"available"for" this"purpose."" " Promoters"are"not"aware"of"the"criteria" by"which"their"performance"is"being" evaluated."" " There"was"a"6"month"delay"before"the" supervision"tools"were"developed"for" use."" " [The"work"of"the"HRC"Volunteers"was" not"observed."]"" Conclusions! During"mass"distribution,"there"is"no"way"to" use"the"commodities"for"behavior"change" purposes;" No"way"to"teach"recipients"how"to"use"the" commodities"correctly;" No"way"to"avoid"“double"dipping”! Recommendations! Avoid"‘en"mass’"distribution"by" helping"volunteers"in"remote"areas"to" transport"the"commodities"to"central" places"closer"to"the"target"houses;"" If"unavoidable,"provide"guidelines"for" controlled"‘en"mass’"distribution.""" Always"use"commodities"as"a"way"to" promote"behavior"change" (commodity"use"and"reuse)."" Always"teach"recipients"how"to"use" commodities"correctly"and"where"to" replenish"supplies.!! Monitor"who"got"which"commodities" AND"who"replenished"their"supplies" on"their"own.""" The"current"supervision"approach,"while" Consider"using"Quality"Improvement" strong,""is"not"as"effective"as"possible"at" and"Verification"Checklists"(QIVC)" improving"the"quality"of"promoter" model"for"improving"and"monitoring" performance."It"does"not"allow"the" the"quality"of"volunteer/promote" supervisor"to"rate"the"performance"of"each" work."" volunteer;"Volunteers"are"not"given"the" " chance"to"selfJevaluate"their"performance.""" During"their"training"or"supervision" meetings,"discuss"the"performance" criteria"with"the"promoters."" " Ask"Promoters"to"selfJevaluate"their" own"performance."" " Consider"doing"the"same"for"HRC" volunteers" 16 ! 9" Findings! The"ARC"Watsan"Engineers"propose"to" contract"several"different"contractors" each"to"work"on"a"part"of"each"latrine"–" hole"digging,"paint,"wood,"masonry,"iron" work."" It"would"take"several"different" contractors"to"finish"just"one"latrine." 10" Volunteers/Promoters"are"in"the"field"all" day"touching"many"different"things"and" people.""They"do"not"have"a"means"to" keep"their"hands"clean."" 11" Promoters"use"megaphones"to"amplify" their"voices"when"doing"presentations"to" masses"(market"places)."" 12" The"cholera"prevention"education"of"ARC" is"not"being"deliberately"supported"by" the"schools"where"education"is"provided."" Conclusions! Recommendations! This"piecemeal"approach"is"a"recipe"for" Enter"into"contracts"with"just"a"few" having"many"unfinished"latrines"with"no"one" contractors"each"of"whom"will"be" to"hold"responsible.""" responsible"for"all"aspects"of"latrine" construction/completion."""Make" payments"only"upon"completion"and" inspection"of"latrines.""Consider" training"or"hiring"female"contractors" or"contractors"who"employ"women."" The"opportunities"for"getting"infected," All"field"workers"(volunteers," contracting"and"spreading"cholera"or" promoters,"team"leaders,"field" another"disease"are"high."" managers)"should"be"given"a"supply" of"hand"sanitizer"to"use"throughout" the"day."" Mass"messaging"of"this"sort"is"highly" Maintain,"strengthen"personJtoJ ineffective"as"a"behavior"change"approach."" person"behavior"change"approaches."" Cease"the"use"of"the"megaphone"in" such"places"as"markets.""If"mass" messaging"is"deemed"necessary," consider"using"the"radio."" The"project"is"missing"an"opportunity"to"reJ ARC"should"sign"an"agreement"with" enforce"the"cholera"prevention"messages" all"schools"that"receive"a"hand" and"behaviors"they"are"promoting."" washing"station,"requiring"all"students" to"wash"their"hands"before"lunch" time.""(Teachers"should"remind" students"and"give"them"time.)" 17 ! Findings! Conclusions! 13" The"diarrheal"disease""control"(DDC)"and" Cases"of"diarrheal"disease/dehydration" treatment"work"conducted"by"ARC"and" among"U5"may"be"going"untreated"due"to" its"partners"has"focused"on"cholera;" the"focus"on"cholera"in"adults."" however"diarrheal"disease"is"still" experienced"most"frequently"and"is"lifeJ threatening"among"children"U5.""There"is" no"specific"promotion"of"ORS"Point"use" among"mothers"of"children"under"age"5."" The"forms"examined"for"this"study"used" by"OR"Point"people"suggest"little"use"by" children"U5"and"there"is"no"special"place" on"the"form"to"register"U5"use"of"ORS."" It"is"not"clear"that"the"training"of"ORS" Point"people"covered"DDC"among" children."" 18 Recommendations! Future"cholera"prevention"efforts" should"train"ORS"Point"people"to" promote"ORS"use"among"children"U5" and"ORS"Point"forms"should"be" modified"to"highlight"ORS"use"by" children.""" Partner Implemented Cholera Projects ($10.1 million) In early 2011, ARC decided to partner with three International NGOs (Save the Children, Care and International Medical Corps), one local NGO (HOPE) and one Red Cross National Society (the French Red Cross) to extend the reach of its cholera prevention and treatment work. In fact, through their partners, ARC was able to provide treatment services by funding the establishment of cholera treatment centers (CTC), a service that ARC itself did not attempt to provide. Thus, with all five partners, ARC was able to facilitate a much larger coverage and wider set of services than it would have had it worked alone. That said, the contracts signed with these partners did not contain adequate plans for monitoring and evaluating the work and because these contracts were negotiated by NHQ staff and not the Senior Health Delegate in PAP, the oversight function was not as clear as it should have been. In the frenzy to respond to both the earthquake and cholera emergencies NHQ and ARC/Haiti developed project plans that created tension and over-taxed the capacity of the PAP-based team to monitor the partner’s work effectively. Further to this, the contracts signed with the partners did not require that ARC or the partner evaluate the achievement of stated objectives. As a result, none of the cholera program partner’s work has been evaluated by ARC and ARC doesn’t know for sure if the objectives were achieved. In most cases, it is too late to tend to this. In the context of this review, the consultant interviewed representatives of Save the Children and International Medical Corps and visited the work site of HOPE, the only local NGO, in Borgne and Ti Bouk in the North Department (2-3 hours west of Cap Haitian). Some lessons learned by partners’ cholera efforts include: • When establishing CTCs do not hire a separate staff; rather integrate the work of caring for cholera patients into the everyday work of the current staff. • Do not ‘Top Off” the salary of MSPP staff as an incentive to work, rather hire additional staff at the same salary • As far as possible do not set up separate (from MSPP) CTCs • Where possible work through local NGOs or work with I-NGO who partner with local NGOs • Focus on behavior change, not just repeating messages • Don’t expect MSPP to assume responsibility for thing established (CTC, community work, OR Points) by the INGO • Plan to strengthen supervision and management systems • Don’t forget about diarrhea disease among U5 • Clarify ARC/Haiti role with NHQ/HAP-signed contracts – or have them signed in country instead 19 • Plan to monitor LNGOs work more strategically, closely and in a more timely manner – especially the purchase and use of materials Positive Aspects of Cholera Partner’s Work 1. Partnering allowed ARC to provide some services such as Cholera Treatment Centers that it wasn’t able to provide directly. 2. The cholera partners allowed ARC to extend its coverage to various parts of the country. 3. The cholera partners allowed ARC to reach a much larger population. 4. The work of the cholera partners provided opportunities to learn valuable lessons about future cholera programming. . 20 CHOLERA – PARTNER-IMPLEMENTED ! 1" 2" 3" (SAVE, IMC, HOPE WERE INTERVIEWED) Findings! Conclusions! No"standard"approach"to"ORS"Posts"were" This"degree"of"variation"makes"it" followed"" very"difficult"to"monitor"and" ORS"Posts"are"very"different"one"from" evaluate"projects"and"their"relative" another.""Some"are"just"houses"along"the" impact"on"responding"to"the" road"where"boxes"of"ORS"packets"are" cholera"epidemic."" kept"with"some"potable"water"and"a" person"who"can"explain"ORS"preparation;"" others"are"manned"24/7"by"trained" medical"personnel"who"can"set"up"an"IV," perform"triage"and"call"an"ambulance"for" transfer"if"need"be." Some"CTCs"were"established"in"IDP" This"made"it"very"difficult"to" camps."(IMC"comment)" control"infection"rates"and"to" establish"the"fact"that"cholera" treatment"is"the"responsibility"of" MSPP"health"care"providers."" Save"the"Children"trained"and"established" This"approach"makes"handing"over" separate"CTC"staff"to"operate"their"CTC"in" of"responsibilities,"more" Leogone;"MSPP"refused"to"take"over"the" challenging."" operation"of"the"CTC." IMC"recommends"not"setting"up"parallel" services"to"those"of"the"MSPP."!" 21 Recommendations! Since"no"standard"OR"Point"guidelines"exist"(I" asked"CDC"about"this"too),"ARC"should" establish"some"guidelines"that"orient"their" own"work"and"that"of"their"partners.""In" proposals"implementers"should"identify" which"type"of"OR"P"they"will"establish"or"how" many"of"which"types."" They"should"also"stipulate"how"the"OR"Points" will"be"continued"after"the"project"or"phased" out.""" Do"not"set"up"Cholera"Treatment"Centers"in" IDP"camps;"establish"CTCs"in/near"public" health"facilities" Do"not"establish"separate/parallel"CTC"team" –"integrate"them"into"the"usual"MSPP"or" private"sector"health"care"provider"team."" 4" 5" The"partnerships"with"INGOs"and"one" local"NGO"for"cholera"work"were" negotiated"only"with"the"Haiti"External" Partnership"Manager,"with"little/no"input" from"the"Sr."Health"Delegate"or"regard"for" her"work"load."" Despite"this,"the"Sr."Health"Delegate"was" tasked"with"monitoring"the"work"of"the" cholera"partners."" The"Sr."Health"Delegate"did"not"agree" with"some"of"the"partnerships"that"were" entered"into." ARC"has"not"evaluated"the"work"of"the" Cholera"partners."" Some"partners"evaluated"their"own" cholera"work."""""""""""""""""""""""""""""" The"inVcountry"team"had"little"time" to"monitor"the"work"of"the"cholera" partners."" " At"least"one"partner"mismanaged" their"funds"unbeknownst"to" ARC/Haiti."" Decisions"about"whether"or"not"to"partner" and"with"which"organizations"and"to"do"what" should"be"taken"jointly"by"the"Haiti"External" Partnership"Manager"and"the"Sr."Health" Delegate"(in"consultation"with"the"Cholera" Delegate,"if"there"is"one),"with"the"Sr." Delegate"having"the"final"word.""Agreements" should"clearly"define"the"roles"and" responsibilities"of"ARC"and"partners" regarding"reporting"and"supervision."" ARC"does"not"know"if"the"partners" achieved"their"stated"objectives."" " ARC"does"not"know"if"it"would"be" good"to"partner"with"them"in"the" future."" Ask"the"partners"to"share"any"evaluations" they"may"have"conducted"of"their"cholera" work.""Assess"any"gaps"in"the"information" these"provide."Develop"a"brief"interview" guide"and"interview"a"key"informant" regarding"the"work"undertaken," achievements"and"lessons"learned.""In"the" future"make"sure"to"stipulate"in"the" agreements"that"partners"are"responsible"for" evaluating"their"own"work"(with"ARC"funds)," but"that"the"ARC/"Q&L"Delegate"needs"to" approve"the"TOR"and"if"possible"and"ARC" should"participate"in"the"evaluation."!" 22 PrevSida ($6.1 million) BACKGROUND/OVERVIEW The USAID-funded PrevSida (preventing HIV/AIDS) Project is an off-shoot of the Together We Can (TWC – 2004 – 2010) Project which sought to prevent the spread of HIV/AIDS among 550,000 Haitian youth ages 10 – 24 years of age by providing education, strengthening life skills and improving decision-making and encouraging safer behaviors. The PrevSida project is a multi-consortium effort with the MARP (most-at-risk-populations) consortium being led by PSI and implemented in collaboration with several partners, one of whom is the Haitian Red Cross/American Red Cross partnership. Each of the PSI/MARP consortium member organizations is responsible for a particular most-at-risk population. At-risk youth (15 – 24 yrs.) is the target audience of HRC/ARC. The HRC/ARC activities are implemented in 9 widely disbursed areas of the country and the strategies include: 1) interpersonal communications (small group and one-on-one talks), 2) awareness raising (sensitization) sessions (21 to 100 people), 3) Community-wide events (more than 100 people) and 4) condom education and distribution. Haitian Red Cross Volunteers have been trained in the key messages and communication techniques, and working in pairs (sometimes bi-gender) they roam the areas where at-risk youth congregate or can be found during the day. These volunteers are supervised by Field Managers who are in turn supervised by Regional Coordinators. During interpersonal communication encounters, volunteers give 15 – 20 minutes talks to the youth they come across in the street; discuss means of transmission; the importance of testing, demonstrate how to use a condom correctly and give samples of condoms to the youth. While the project proposes to change the following behaviors: condom use, concurrent sexual partners, and STI testing and treatment, the strategies proposed will not facilitate behavior change because the volunteers have not been trained in behavior change skills and more importantly, the volunteers do not have a means to interact repeatedly with the individuals or small groups of the target audience. This said, the HIV/AIDS Delegate and the Sr. HIV/AIDS Advisor at NHQ have recently been trained in the Designing for Behavior Change (DBC) approach and they are planning to conduct a barrier analysis (BA) survey which will help them better understand the obstacles preventing at-risk-youth from adopting the behaviors and will allow them to create determinant-related messages which would be more effective. There are many positive aspects of the PrevSida project which should be carried over into future HIV/AIDS prevention activities. These include: 1. Volunteers recruited from among the target area 2. Training of volunteers in interpersonal communication 23 3. Volunteers working in pairs – preferably mixed gender 4. Volunteers raising awareness through interpersonal communication and dialogue 5. Visible work in the community 6. Hands-on demonstrations 7. Close supervision and support of volunteer’s work 8. Barrier Analysis study – use of BA result to create more effective messages and strengthen the BC strategy. There is still ample time left in this project to re-enforce these positive aspects and make the necessary modifications to increase its effectiveness by focusing on behavior change. 24 PREVSIDA ! Findings! 1" The"project"proposal"calls"for"the"HRC" volunteers"to"pass"messages"to"at8risk" youth"through"interpersonal"contact," awareness"raising"meetings"and"mass" media."All"of"these"encounters"are" primarily"for"increasing"knowledge.""" 2" The"training"for"HRC"volunteers"has"not" equipped"them"to"be"effective"behavior" change"promoters."" 3" In"the"project"design,"there"are"no" opportunities"for"meeting"with"specific" at8risk"youth"more"than"one"time."" 4" 5" Conclusions! Just"increasing"knowledge"and"handing" out"condoms"will"not"result"in"changed" behavior."" " " Volunteers"do"not"have"adequate" behavior"change"skills" Volunteers"have"too"few"opportunities" to"promote"behavior"change"among" individual"at8risk"youth;" This"will"make"monitoring"and" evaluating"the"effectiveness"of"this" approach,"practically"impossible.""! PrevSida"staff"are"planning"to"conduct" The"results"of"the"BA"survey"will" barrier"analysis"(BA)"on"specific" provide"valuable"information"about" behaviors! the"obstacles"faced"by"beneficiaries" regarding"key"behaviors."" This"information"can/should"be"used"to" strengthen"the"BC"strategy.! The"PrevSida"design"framework"and"the" ARC/HRC"is"not"able"to"assess"the" ARC/HRC"e"monitoring"tools,"focus" effectiveness"of"its"current"approach"as" primarily"on"the"delivery"of"inputs"(talks," it"relates"to"behavior"change.""" condoms"distributed,"meetings,"mass" media"events.)."" There"is"no"mechanism"currently"to" measure"behavior"change"(outcomes).""" 25 Recommendations! Use/adopt"the"PIH"training"module"on" behavior"change"to"build"the"capacity"of"all" volunteers"to"become"effective"behavior" change"agents"rather"than"focusing"on" memorization"of"messages.""" " Help"them"to"learn"negotiated"behavior" change.""" Project"staff"in"consultation"with"HRC" should"explore"modifications"to"the" project"design"that"would"allow"HRCVs"to" meet"individual"at8risk"youth"repeatedly."" Use"the"results"of"the"BA"to"create" determinant8based"messages"which"will"be" more"pertinent"to"at8risk"youth"and"to" design"more"effective"behavior"change" strategies"than"the"ones"currently"planned."" Devise"a"mechanism"to"monitor"behavior) change"among"ARY.""This"will"require" figuring"out"how"to"access"the"same"target" client"(at"risk"youth)"multiple"times"over"a" specific"period"of"time.""Proxy"indicators"to" consider"might"be"the"possession"of" condoms"at"all"times,"being"able"to"name" the"closest"location"to"have"an"STI"test."" ! 6" 7" 8" Findings! Conclusions! Recommendations! Use"a"strong"monitoring"system"as"a"proxy" for"evaluation.""" HRC"volunteers"don’t"have"any"handouts" HRCVs"have"to"hold"the"attention"of" Develop"and"distribute"materials"to" or"visuals"(aside"from"the"wooden"penis)"" the"ARY"while"making"IPTs"without"any" support"the"key"behaviors.""If"possible,"use" to"give"to"at8risk"youth"(ARY)" assistance.""" the"results"of"the"Barrier"Analysis"to"inform" during/following"the"Interpersonal"Talks." Targeted"ARY"are"not"left"with"any" the"information"on"the"handouts." information"to"encourage"them"to" At"the"very"least,"have"a"handout/flyer" reflect"on"the"message"they"received." about"where"to"get"essential"commodities" ARY"are"not"left"with"key"information"–" and"services."" where"to"get"condoms,"where"to"get" tested,"counseling"services.""" ARC"has"not"received"any"pre/post"test" ARC"has"no"way"of"knowing"if"the" ARC"and"project"partners"should"modify" results"from"the"training"of"HRC" participants"in"the"training"learned" the"Training"Report"form"to"include" volunteers.""The"form"used"to"report"on" what"they"were"supposed"to"learn;""" pre/post"test"results."" training"does"not"include"a"section"to" " Review"the"pre/posttest"and"provide" show"pre/post"test"results."" ARC"cannot"accurately"assess"the" suggestions"to"HRC"about"ways"to" The"pre/posttest"being"used"is"true/false" effectiveness"of"the"training"approach" strengthen"it."" and"does"not"cover"any"aspects"of" –"and"if"modifications"may"be" Make"it"multiple8choice"and"cover" communication"skills" necessary.""" communication"skills"and"behavior"change" skills"as"well."Or"devise"another"way"to"test" communication"skills."" Plan"to"conduct"‘recyclage’"and"use" pre/post"tests"for"these"events"as"well."" The"first"objective"in"the"PrevSida"Log" It"will"be"very"difficult"to"use"this"log" Negotiate"with"PSI"to"correct"the"errors"in" frame"(To"identify"populations"and" frame"to"develop"an"effective" the"log"frame."" settings"with"high8risk"sexual"behavior" monitoring"and"evaluation"system."" " and"to"identify"the"dynamics"of"the" behavior.)"is"not"an"outcome;"it"is"an" activity.""The"indicators"for"this" ‘outcome’""do"not"measure"it."" 26 ! 9" Findings! Some"of"the"other"indicators"on"the"log" frame"are"not"outcome"indicators"but" process"indicators"" HRC"is"required"to"submit"monthly" narrative"reports"to"ARC."" 10" The"Field"Managers"did"not"have"their" supervision"forms"with"them"on"the"day" the"consultant"observed"them."" Conclusions! Recommendations! Project"staff"will"spend"too"much"time" in"report"preparation"which"will"take" them"away"from"project" implementation.""" ARC"PrevSida"Staff"do"not"have"time"to" read"these"reports"and"make"any" recommendations"based"on"them."" If"supervisors"don’t"have"their" supervision"forms"with"them"in"the" field,"their"ability"to"assess"and" monitor"the"quality"of"volunteer" performance"in"a"structured"and" objective"is"limited."" Reduce"the"frequency"of"the"reporting" requirements"to"every"2"months"or" quarterly"and"make"the"format"short"and" simple."Ask"HRC"to"track"behavior"changes," not"just"the"actions"of"the"volunteers."" 27 Consider"using"the"Quality"Improvement" and"Verification"Checklist"(QIVC)"approach" to"supervision"and"skills"development."" CHAPTER TWO FUTURE HEALTH PROGRAMMING______________ WHAT TECHNICAL AREAS OF INTERVENTION (E.G. MCH, HYGIENE EDUCATION, ETC.) AND COMMUNITY-BASED APPROACHES (COM. BASED HEALTH AND FIRST AID, CARE GROUPS, ETC.)—WHETHER A CURRENT FOCUS OF ARC PROJECTS OR THOSE OUTSIDE OF CURRENT ARC PROJECTS—ARE MOST RELEVANT TO THE FUTURE HEALTH PROGRAM GIVEN ARC/HRC CAPACITY? B) FOR THE RURAL SETTING IN THE NORTH AND NORTHEAST DEPARTMENTS C) FOR THE URBAN SETTING IN THE NORTH AND NORTHEAST DEPARTMENTS (CAP HAITIAN) ARC/Haiti is planning to build on the work initiated under the Cholera Response Project, and continue its presence in the North and Northeastern Provinces to strengthen the population’s behaviors related to Disaster Risk Reduction, including cholera prevention. This new initiative is referred to as the National Program and will be designed in the second trimester of 2012. While ARC has gained a tremendous amount of experience through its response to both the earthquake and the cholera epidemic, one additional thought should be taken into consideration when reflecting on what makes a population more resilient; better able to survive, cope and recover when a natural disaster or an epidemic takes place. Populations, particularly the most vulnerable segments of the society, will be more resilient and better able to survive, cope and recover when a natural disaster occurs, if they are in good health and nutritional status when the event happens. Understanding this concept should be the foundation of the National Program (and also the LAMIKA Project) and should guide the project design efforts of ARC in the North and Northeast Provinces. The focus of project activities should be on the most vulnerable families – those with pregnant women and children under age five. Efforts should also include a focus on improved quality of (facility-based) care, as “careseeking” is essential to good health and health care providers are essential ‘first-responders’ in the time of crisis. Pregnant women who do not eat enough and who suffer from malaria and/or anemia are more likely to give birth to underweight newborns. These infants may have difficulty nursing, may be given formula or other foods too early which will cause diarrhea and weaken their immune systems leaving them open to other illnesses, leading to malnutrition. In Haiti, 16% of women are malnourished, 43% of pregnant women are anemic, 24 % of children (6-23 months) suffered from a case of diarrhea in the 2 weeks prior to the Demographic and Health Survey of 2005; and 10% (up from 5% in 2000) are too thin for their age and 25% are chronically malnourished (2005-6 DHS) . When a natural disaster strikes or an epidemic breaks out, these are the first victims because they are already weak and vulnerable. Families of these children 28 will expend enormous amounts of energy and resources to save their lives – often to no avail – when they are also trying to survive, cope and recover themselves. Armed with this understanding, ARC’s National Program should not limit its focus on the usual DRR and cholera prevention activities but should include activities that will help women give birth to healthy children and to maintain their children’s health and nutritional status so they are best able to resist the consequences wrought by hurricanes, earthquakes and epidemics. It should also be recognized that families with some disposable income are: 1) better able to meet their daily needs (eat well, build a latrine, buy Aquatabs and ORS, purchase medicines); and 2) have resources to bring to bear in the event of a natural disaster/epidemic. For this reason, the National Program should strongly consider launching a women’s saving and loan initiative similar to the one developed by CARE/Niger and which CARE/Haiti is piloting. The current (new) Livelihoods Delegate has experience with this very successful approach which has the secondary benefit of empowering the women members (see attached description in Annex 6). 29 National Program – North and Northeast Provinces ! Findings! Conclusions! Recommendations! ! RURAL!AREAS!–!TECHNICAL!AREAS!OF!INTERVENTION! 1! ARC!has!gained!valuable!experience! There!is!a!need! Continue!to!promote! increasing!knowledge!regarding!diarrheal! to!increase! Diarrheal!Disease! disease!prevention!–!particularly!as!it! efforts!to! Control/Cholera! relates!to!cholera.!! promote! prevention!behaviors! ! diarrhea!disease! among!U5!and!for! Authorities!in!Haiti!concur!that!cholera! prevention! cholera!prevention.!! outbreaks!are!likely!to!resume!when!the! behaviors.!! Focus!on!hand!washing,! rainy!season!begins!! water!treatment,!and! ! latrine!use;!ORS! 24%!of!children!6N24!mth.!had!diarrhea!in! administration!for!adults! past!2!weeks.!(DHS)! and!U5,!careNseeking!and! exclusive!breastfeeding! for!U6!mths.! Support!behavior!change! with!latrine!construction! activities.! Study!the!determinants! related!to!key!behavior,! design!a!strong!behavior! change!strategy!based!on! the!research!results.!! Train!volunteers!to!be! effective!behavior! change!agents.!! 2! ARC!has!gained!valuable!experience! There!is!a!need! Continue!to!promote! increasing!knowledge!regarding!Malaria! to!increase! Malaria!prevention! prevention.!! efforts!to! especially!LLIT!bed!net! 7.5%!of!PAP!families!have!one!ITN;!12%!/! promote!ITN!use! use!for!U5!and!pregnant! 11%!(N/NW)!of!families!have!an!ITN.! and!other! women!! malaria! Study!the!determinants! preventive! related!to!key!behavior,! behaviors! design!a!strong!behavior! especially!among! change!strategy!based!on! children!U5!and! the!research!results.!! pregnant! Train!volunteers!to!be! women.! effective!behavior! change!agents.! 3! ARC!has!gained!valuable!experience! There!is!a!need! Continue!to!promote!HIV!! increasing!knowledge!regarding!HIV/AIDS! to!increase! prevention,!testing,!! prevention,!treatment!and!care.!! efforts!to! treatment! 30 HIV/AIDS!continues!to!be!a!serious!health! concern.!! ! 4! ! 5 promote! HIV/AIDS! prevention,! testing!and! treatment! behaviors.! Study!the!determinants! related!to!key!behavior,! design!a!strong!behavior! change!strategy!based!on! the!research!results.!! Train!volunteers!to!be! effective!behavior! change!agents.! Integrate!maternal!and! reproductive!health! behaviors!such!as!! prenatal!consultations,! TT!vaccination,!Iron! supplementation,! assisted!deliveries,! immediate!and!exclusive! breastfeeding,!BCG! vaccination!and!birth! spacing!into!the!DRR! program.!!! Current!DRR!programming!ignores!the!fact! There!is!a!need! that!helping!vulnerable!populations!to! to!increase! become!resilient!before!a!natural!disaster! efforts!to! strikes!should!be!an!integral!part!of!DRR! promote! programming!in!the!future.!!Pregnant! maternal,! women!and!children!U5!are!the!most! reproductive,! vulnerable!to!natural!disaster!and! infant!health!! epidemics!–!as!proven!by!the!following!! DHS!statistics.!! N Only!68/46%!of!women!(PAP/rural)!have! had!4!or!more!!prenatal!consultations! N !Only!50/15%!of!births!(PAP/rural)!!are! attended!by!a!trained!health!provider;!! N Only!45/!21%!(PAP/Rural)!of!newborns! had!a!postNnatal!exam!within!2!days!of! delivery;! N Only!24%!of!infants!U6!months!are! exclusively!breastfed!! N 24%!of!children!6N24!months!had! diarrhea!in!past!2!weeks.!! N Only!17.9%!of!Women!of!Reproductive! Age!!use!a!modern!contraceptive! method!!! N Only!50%!of!women!who!want!to!use!a! contraceptive!method,!use!one! URBAN!–!CAP!HAITIAN!TECHNCIAL!INTERVENTION! Recommendation Although there are undoubtedly many needs in the city of Cap Haitian, because ARC already has a presence and experience working in the rural parts of the North and Northeast Provinces, it would be wise to first gain experience through the LAMIKA project regarding urban development before tackling the urban issues of Cap Haitian. ! 31 Regarding!the!Need!for!Family!Planning! “Family!planning!is!a!key!intervention!required!for!any!improvement!in!the! disastrous!current!situation.!Women!still!have!nearly!twice!as!many!children!as!they! wish,!even!though!a!quarter!or!more!of!the!pregnancies!end!in!induced!abortions!–! which!are!still!illegal!here!in!Haiti.!If!15!years!ago!women!had!had!the!number!of! children!they!had!wanted,!we!would!not!be!having!300,000!births!a!year!now,!with! 300,000!infants!to!be!vaccinated!and!250,000!children!6!years!old!who!should!be! starting!first!grade.!Whatever!the!real!numbers!are,!they!would!be!half!”!!!Dr.!Glen! Bouchard,!CARE!Health!Advisor,!resident!of!Haiti!since!1989! Proposed Approaches - Rural Areas: o Integrated approach – Health, WatSan, Livelihoods, DRR o For Livelihoods, strongly consider implementing the Women’s Savings and Loan program – the model developed by CARE/Niger (see Annex 6 for description) o Implement the project over a five year period to ensure sustainability o Plan to conduct baseline, mid-term and final evaluations; develop a strong design framework with behaviors as the key outcomes o Use the Care Group model (http://www.caregroupinfo.org/blog/criteria and Annex 6 & 4) as the behavior change strategy; Care Group mothers can be HRC volunteers as was the case with Red Cross Cambodia o Center the intervention area around a clinic or health center where no other NGOs are working; consider using the Partnership Defined Quality (http://www.coregroup.org/our-technical-work/initiatives/diffusion-of-innovations/83 and Annex 6) to improve the quality of care through a participatory approach); o Use Quality Improvement and Verification Checklist (QIVC) to improve supervision approaches and increase the quality of activity implementation o All promoters/volunteers/Care Group members trained as behavior change agents; o Conduct formative research such as the barrier analysis (see Annex 6) to inform multi-sectoral Behavior Change strategy design 32 CHAPTER THREE PARTNERING________________________________ HOW CAN PARTNERSHIPS BE INTEGRATED INTO THE OVERALL HEALTH STRATEGY, AND PARTICULARLY IN A WAY THAT WOULD MUTUALLY REINFORCE DIRECT IMPLEMENTATION PROGRAMMING? BACKGROUND/OVERVIEW Currently and in the recent past, ARC has engaged in numerous partnerships including International NGOs such as Partners in Health, CARE, Save, IMC and IRC; National Societies such as the Canadian, French, German and Finish Red Cross and local NGOs such as HOPE and of course the Haitian Red Cross. These partnerships allow the ARC to achieve three things: 1) to do work that is outside their areas of expertise (hospital renovations, CTC establishment); 2) to work in other geographical areas 3) to help ARC achieve their project objectives (SGBV). All of these partnerships have been established by the HNQ Partnership Manger and agreements are signed between the partner and the NHQ. Discussion of who to partner with and what the scope of the work will be is decided by NHQ with little input from the ARC/Haiti delegates and staff. When it comes to monitoring the work of (at least some of) the partners, however, this has fallen to the in-country staff. The ARC/Haiti staff, however, is sometimes not fully aware of the scope of work expected of the partners and quite often they are already too stretched to add additional tasks to their portfolios. Actors on both sides of the issues seem to agree that this approach has not been as effective as it could have been and merits examination and potentially some modifications. PARTNERSHIPS Findings! Partnerships!are!established! and!agreed!upon!by!NHQ! staff;!not!ARC/Haiti!staff.!! ! ARC/Haiti!staff!is!tasked!with! monitoring!and!supervising!of! the!partners’!work!–!despite! other!work!demands.!! Conclusions! Tension!has!arisen! regarding!the!approaches! taken!to!partnering.!! Some!partners’!work!has! not!been!monitored!as! closely!as!it!should!have! been;!ARC!is!not!fully! aware!of!the!quality!of!the! work!being!undertaken! 33 Recommendations! Now!that!the!work!of!ARC! is!transitioning!toward! recovery/!development,!it! would!be!beneficial!for!all! future!partnerships!to!fit! into!the!third!category!–! complimenting!the!work!of! ARC/working!in!the!same! intervention!area.!! with!ARC!funds! ARC!doesn’t!know! concretely!if!the!current! partners!will!make!good! future!partners.!! 34 As!recommended!by! Christy!Gavitt,!ARC!!NHQ! should!seriously!consider! hiring!a!person!to!be! responsible!for! partnerships!to!be!based!in! Haiti.!! All!future!partnership! agreement!should!include! solid!targets!and!areas!of! intervention!and!M&E! plans!approved!by!the!Q&L! team!in!Haiti.!!Roles!and! Responsibilities!regarding! monitoring!should!be!clear.!! CHAPTER FOUR PARTNER-IMPLEMENTED CHOLERA PROGRAM IS IT FEASIBLE TO EVALUATE THE PARTNER-IMPLEMENTED CHOLERA PROGRAMS ALONG THE OECD/DAC/HAP CRITERIA (IMPACT, EFFECTIVENESS, EFFICIENCY, COORDINATION, SUSTAINABILITY, ETC.), GIVEN THE CONSTRAINTS WE ARE FACING (LACK OF PROJECT BASELINE, MAJORITY OF PROJECTS ALREADY COMPLETED, ETC.)? Since ARC is planning to continue to fund partner-implemented cholera prevention and treatment activities, there is an interest in knowing the extent to which the partners achieved their stated objectives. Because all but one (HOPE) of the partners’ work has been concluded already and some of their staff has moved on to other activities (in some cases) ARC should consider the following options to evaluate the work undertaken with ARC funds. 1. Since some of the partners have evaluated their own projects, ARC should ask for copies of these reports. 2. Some of the partners may have had very strong monitoring systems and some of these might even have accumulative results. ARC could ask the partners to share the near end-of-project monitoring results to get a sense for the achievements. 3. Once this is done, ARC’s Q&L unit should identify the specific information (gaps) that is needed to help decide whether or not to continue funding their cholera activities. Using this information, a brief and succinct in-depth interview guide should be developed and used to interview (by phone would be possible, or by sending an electronic questionnaire) a key informant in each of the partners. 4. Since HOPE’s activities are still on-going, if there are pressing questions about their work that are not answered by the above mentioned approaches, then a quick evaluation could be cared out to help decide if future funding is warranted. In the future, ARC should plan and budget to evaluate any projects that are 12 months or longer. For shorter projects, ARC should use the partner’s monitoring systems (which should collect data on outcomes) to assess effectiveness. Because these contracts are drawn up and signed in a hurry (to respond to an emergency) the Q&L unit should write up a boiler plate M&E section in advance so it will be ready to be inserted into all partner contracts when needed. 35 CHAPTER FIVE WORKING IN THE CAMPS_______________________ WHAT WOULD BE THE BEST WAY TO CONTINUE WORKING IN THE CAMPS? It is estimated that 500,000 people still live in IDP camps in and around PAP; and there are rumors that some people are either moving to camps from settled neighborhoods, or not relocating back to settled neighborhoods because the conditions in the camps are better. This is a major dilemma facing ARC and other NGOs who are shifting gears toward recovery and development. In Christy Gavitt’s trip report, she suggests the following actions regarding continued work in the camps. 1. ARC should look into extending cholera prevention interventions (at least to December 2012) in camps until such time as the camps for which ARC is responsible close. 2. Since ARC is the only organization that is involved in cholera in the camps, and because another outbreak of cholera is anticipated when the rains begin, ARC should continue to man the ORS Points until the camps are closed. Doing so will also put ARC in a good position to monitor and report on possible outbreaks. 3. Regarding the ORS Points, once the assessments are conducted, and adjustments are made, two volunteers could staff each post. In case of a surge of cholera cases during the upcoming rainy season, one of the two volunteers could man one of the surge ORPs, returning to staff the “original” ORP as the number of cases reduce. 4. ARC’s WatSan division needs to identify an alternate approach for requesting DINEPS or another responsible party to empty latrine pits, especially with the approach of the rainy season. 36 CHAPTER SIX Comments on the LAMIKA Proposal_________________ 1. What technical areas of intervention (e.g. MCH, hygiene education, etc.) and community-based approaches (Com. Based Health and First Aid, care groups, etc.)—whether a current focus of ARC projects or those outside of current ARC projects—are most relevant for the Port-au-Prince Neighborhoods project? 2. What recommendations do you have related to the LAMIKA Proposal, particularly related to the Social Empowerment (health, WatSan and DRR) pillar? 3. What general comments do you have on the LAMIKA Proposal? These three questions are related to the urban project, LAMIKA, that ARC is currently designing that will be implemented in a low-income neighborhood of Port-au-Prince. This is an ambitious endeavor that ARC is uniquely positioned to undertake, because ARC has the requisite funds to make a significant difference in the community; has the organizational capacity to work in multiple sectors ((health, DRR, WatSan, housing, livelihoods); has the experience partnering with other organizations, including the Haitian Red Cross, to access additional manpower and expertise, and because ARC can set its own timeframe for implementation. This set of opportunities rarely present themselves to one organization in a timely fashion and this make the LAMIKA project quite special. If the LAMIKA project can be implemented successfully, it will be a shining example of what the American Red Cross is capable of and will provide a long list of lesson learned to guide future such initiatives. With each opportunity there are risks. If the risks are identified during the design stage, then these areas of vulnerability can be addressed/ removed and the opportunities for success increased. Preeminently linked to the success of the LAMIKA project is staffing. To succeed, the project needs a very strong and experienced Chief of Party. I recommend not calling this person a delegate, to separate this position from the typical the role of other delegates who work sectorally. I also recommend that one expatriate for each of the three pillars be hired to work on LAMIKA for the first two years. (All LAMIKA staff should be offered 2-year contracts only to ensure consistency and to attract serious candidates.) During that time one of their primary responsibilities, in addition to planning and implementing the activities of their pillar, would be to mentor a Haitian who would then take over for the expat in the third year of the project. This would achieve two things; ensure that LAMIKA gets off to a good start, and ensure capacity development and transition to Haitian staff. In order to attract the level of staff required for these positions, however, changes in the current employment conditions will need to be made. 37 These conditions, including being able to bring families and live independently, should be considered necessary exceptions to the rule – a pilot test, if you will – to see if the overall conditions for employment for delegates could also be relaxed3. In addition to staffing, other systems also need to be strengthened to support the LAMIKA (and National and other ARC/Haiti) project. These include human resources (the ability to hire staff in a timely manner and manage staff effectively) and procurement systems. Many of these decisions are currently taken at the HAP/NHQ level which is not very efficient. In large part because of the centralized decision-making, most if not all of the directly implemented projects in Haiti are behind schedule. To address this, decision making authority of ARC/Haiti – particularly the LAMIKA staff - should be increased so they can work efficiently and effectively and project implementation is not thwarted by over centralized decision-making. 3 The author of this report lived in PAP from 1984 – 1990, a time of higher violence and crime than is presently the reality in Haiti. At that time, expats lived independently with their families and had private vehicles. 38 LAMIKA ! 1' 2' 3' Findings! Conclusions! Recommendations! SUGGESTED'TECHNICAL'AREAS'OF'INTERVENTION' ARC'has'gained'valuable'experience' There'is'a'need'to'increase'efforts'to' Continue'to'promote'Diarrheal'Disease' and'expertise'increasing'knowledge' promote'diarrhea'disease'prevention' Control/Cholera'prevention'behaviors' regarding'diarrheal'disease'prevention' behaviors'particularly'in'the'urban'areas' among'U5'and'for'cholera'prevention.' –'particularly'as'it'relates'to'cholera.'' of'PAP.'' Focus'on'hand'washing,'water'treatment,' Authorities'in'Haiti'concur'that'the' and'latrine'use;'ORS'administration'for' incidence'of'cholera'is'likely'to'resume' adults'and'U5,'care'seeking'and'exclusive' when'the'rainy'season'begins'' breastfeeding'for'U6'mths.'' '' ARC'has'gained'valuable'experience' There'is'a'need'to'increase'efforts'to' Continue'to'promote'Malaria'prevention' increasing'knowledge'regarding' promote'ITN'use'and'other'malaria' especially'LLIN'bed'net'use'for'U5'and' Malaria'prevention.'' prevention'behaviors.! pregnant'women' 7.5%'of'PAP'families'have'one'ITN;! ARC'has'gained'valuable'experience' There'is'a'need'to'increase'efforts'to' Continue'to''promote'HIV/AIDS' increasing'knowledge'regarding' promote'HIV/AIDS'prevention,'testing' Prevention'and'Treatment'amongst'all' HIV/AIDS'prevention,'treatment'and' and'treatment'behaviors.! youth'and'adults' care.'' ! 39 4' 5' ARC'has'gained'valuable'experience' There'is'a'need'to'increase'efforts'to' Start'to'promote'the'adoption'of'maternal' training'health'volunteers'and' promote'maternal'and'reproductive' and'reproductive'health'behaviors'such'as'' promoters.'' health'' Prenatal'consultations,'TT'vaccination,' X 68%'of'women'living'in'PAP'have' Iron'supplementation,'assisted'deliveries,' had'4'or'more''prenatal' immediate'and'exclusive'breastfeeding,' consultations' BCG'vaccination'and'birth'spacing' X 50%'of'births'in'PAP'are'attended' by'a'trained'health'provider;' X There'are'no'maternity'facilities'in' CarrefourXFeuilles'' X Only'45%''of'newborns'born'in'PAP' had'a'postXnatal'exam'within'2'days' of'delivery;' X Only'24%'of'Haitian'infants'U6' months'are'exclusively'breastfed'' X Only'17.9%'of'WRA''use'a'modern' contraceptive'method''' X 50%'unmet'need'for'contraceptives' COMMUNITY'BASED'APPROACHES'/'HEALTH'(PILLAR'ONE)'COMMENTS' One'of'ARC’s'strengths'is'its'ability'to' Although'there'are'many'advantages'to' To'increase'the'success'of'the'integrated' respond'to'different'needs'in'different' the'integrated'development'approach,' approach'(which'has'already'been' technical'sectors;' for'the'activities'to'be'truly'integrated'in' decided)'ARC/Haiti'will'need'to'recruit' Development'projects'are'more' the'field,'the'project'will'need'to'be' project'staff'who'have'experience'with'the' effective'when'they'can'address' managed'in'an'integrated'manner.'' integrated'approach'and'who'are' problems'in'multiple,'interXconnected' ' committed'to'it.''The'Chief'of'Party'should' sectors'' Management'and'monitoring'systems' set'the'tone'and'help'the'project'team'to' Although'ARC'has'many'sectors'(DRR,' will'also'need'to'be'‘integrated’.''' come'to'consensus'about'what'true' WatSan,'Health,'Livelihoods)' ' integration'means.'' implementing'different'sectoral' ' ' activities'in'the'same'location'is'not' ' ' the'same'as'their'being'integrated' ' ' 40 6' There'are'no'adequate'health'care' facilities'in'the'intervention'area'of' LAMIKA.'''' Care'Xseeking'is'a'key'behavior'related' to'HIV,'SGBV,'and'health'and'the' provision'of'first'aid.'''Health'care' providers'are'influential'people'who' can'help'promote'the'objectives'of'the'' project.'''In'the'event'of'an'' emergency,'health'care'providers'are' the'first'responders.'' Health'care'services'in'the'LAMIKA' intervention'are'totally'inadequate.'' '' LAMIKA'cannot'be'considered'a' successful'project'if'it'does'not'help'to' increase'access'to'quality'health'services.'' 7' The'LAMIKA'project'is'very'complex' The'LAMIKA'project'need'adequate'time' and'ambitious.'It'is'the'first'time'that' in'order'to'ensure'its'success.'' ARC/Haiti'is'attempting'to'implement' an'integrated'urban'development' project;'Delays'should'be'anticipated' as'many'aspects'of'the'project'require' coordination'and'approval'from'others' (land'owners,'government,'CBOs,' contractors).''Time'needs'to'be'taken' during'the'first'year'to'strengthen'the' CBOs'and'gain'the'confidence'of'the' population'before'of'the'other'aspects' of'the'project'can'be'initiated.''' ' 41 Plan'to'renovate/construct'a'health'center' in'the'LAMIKA'neighborhoods'that' corresponds'to'the'MSPP'plan.'' ' MSPP'should'staff'the'health'center'and' provide'such'services'as'ANC,'assisted' deliveries,'SGBV'counseling,'STD'testing' and'a'cholera'treatment.'' ' Consider'conducting'(if'time'permits)'a' rapid'health'facility'assessment'to'assess' the'quality'of'care'and'to'inform'training' options'for'staff.''' Plan'to'implement'the'LAMIKA'project'' over'a'fiveXyear'period;' ' Make'sure'there'are'annual'results'to' report'to'NHQ.' 8' The'CBHFA'training'approach'builds' CBHFA'might'not'be'the'most'effective' the'capacity'of'the'branches'and' strategy'for'promoting'behavior'change.'' volunteers;'however'regarding'health,''' it'focuses'primarily'on'communicating' health'messages.'' ' It'mistakenly'promotes'the'idea'that' all'behavior'change'only'happens'over' a'long'period'of'time.'' ' Compared'to'other'behavior'change' approaches,'the'CBHFA'has'not' proved'itself'to'be'effective'in' changing'behaviors.'' 9' ARC'has'developed'various'supervision' Some'of'these'(HTP)'could'be'improved' and'performance'monitoring'tools.''' by'strengthening'the'role'of'the' ' ‘performer’'in'the'performance' evaluation'and'by'making'them'more' objective.'' 42 Use'some'of'the'CBHFA'training'modules' but''deliver'the'messages'and'promote' behavior'change'through'the''Care'Group' approach'(see'Annex'6'&'4'for'intro'to' Care'Groups)''to'increase'effectiveness' and'sustainability.''Care'Groups'do'not' take'any'more'support'than'other'less' effective'approaches'and'have'proven'to' be'both'effective'and'long'lasting.' ' Also'consider'including'a'behavior'change' module'into'the'CBHFA'manual'to' strengthen'the'behavior'change'skills'of' those'trained'in'CBHFA.'''' ' Conduct'formative'research'(barrier' analysis)'and'use'the'results'to'design'the' most'effective'behavior'change'strategy.'' Reference''Quality'Improvement'and' Verification'Checklist'(QIVC)'and' determine'to'what'extent'their'use'would' improve'supervision'approaches'and'' increase'the'quality'of'activity' implementation.''' 10' Current'volunteers'and'promoters'are' accustomed'to'working'in'relief/' emergency'mode'which'is'a'different' attitude'and'approach'from' recovery/development.''They'are' accustomed'to'message' communication'not'behavior'change' and'handing'out'commodities'as'if' that'was'the'intended'end'result.''' 11' ARC’s'behavior'change'strategies'in' the'past'have'only'addressed'the' determinants'“selfXefficacy”'and' “access”.'ARC'has'yet'to'try'to'identify' which'other'determinants'might'be' significant.'' Volunteers'and'promoters'cannot'be' effective'if'they'do'not'transition'from' relief'to'recovery'mode.'' In'the'preXservice'training'of'HRC' volunteers'(multiXsectoral'promoters)' include'an'orientation'to'the'community' development'approach'(as'opposed'to' relief)'and'build'skills'in'negotiate' behavior'change.'' Other'determinants'are'likely'to'be'as'or' more'important'to'behavior'change.'' Conduct'formative'research'(barrier' analysis'or'doer/nonXdoer'surveys)'during' the'initial'phase'of'the'project'(once'the' desired'behaviors'have'been'identified)' and'use'this'to'create'more'effective' behavior'change'strategies'including'an' integrated'sets'of'activities.' 43 GENERAL'COMMENTS' 1' ARC'has'a'chance'to'break'new'ground' with'the'LAMIKA'project;'' ARC'is'uniquely'positioned'and' qualified'to'implement'the'LAMIKA' project'because'it'has'expertise'in' multiple'sectors'(health,'DRR,'WatSan,' housing,'livelihoods)'and'sufficient' funds'to'implement'this'ambitious' initiative;''' ARC'has'experience'partnering'with' other'organizations'to'access' additional'expertise'necessary;' ARC'is'not'time'bound.'' Many'decisions'are'only'taken'at'the' NHQ'level;'it'takes'inordinate'amounts' of'time'to'procure'necessary'supplies' and'equipment'and'to'hire'essential' staff'(delegates).'' All'directly'implemented'projects'are' behind'schedule'largely'due'to'overly' centralize'decisionXmaking'processes.'' 2' Many/most'programmatic'decisions' are'made'by'HAP'or'National'Head' Quarters'staff.'' Many'of'these'decisions'are'not'taken' with'sufficient'understanding'of'the' local'reality'or'in'a'timely'manner.''' These'advantages'are'outweighed' however'by'the'topXdown' management/implement'approach'which' requires'HAP/NHQ'to'be'overly'involved' in'project'implementation'decisions.''This' approach'has'proved'to'be'extremely' inefficient'and'detrimental'to'project' effectiveness.' Shift'at'least'some'decisionXmaking'power' to'the'field'to'make'the'systems'that' support'such'projects'as'LAMIKA'(and'the' rural'projects)'function'more'efficiently.' ' Improve'the'systems'(HR'and' procurement'in'particular)'in'ARC/Haiti'to' work'more'efficiently.' ' All'new'staff'to'ARC/Haiti'should'be'given' an'inXdepth'orientation'about'how'to'use' the'systems'(complete'forms'etc.)''''' Projects'that'are'directly'implemented'by' See'decisionXmaking'recommendation' ARC'are'behind'schedule'or'incomplete.'' above.'' Due'to'delays'they'have'not'addressed' the'emergency'as'efficiently'as'would'be' expected'of'a'world'renowned'relief' organization.''' 44 3' X'Recently,'only'4'out'of'24'Delegates' opted'to'renew'their'contracts;' XExcessively'strict'security'policies'(no' families,'communal'housing,'no' driving)'was'a'cause'regularly'cited'for' high'staff'turnXover.'' XFurther'to'this,'poor,'inadequate,' slow'support'from'NHQ'(HAP'team)' was'also'regularly'cited'as'a'reason'for' poor'morale'among'ARC'staff.''' High'turnXover'of'staff'causes'lack'of' continuity'and'frustration'among'local' staff;'' Delegates'don’t'get'a'chance'to'' understanding'Haiti'–'the'development' context'in'which'they'work/design' projects;' New'delegates'make''changes'in' policies/approaches'when'they'arrive' which'compromises'project/program' quality;' Some'delegates'especially'those'with' families'are'not'sufficiently'‘mentally' present’'to'be'effective;'' These'employment'conditions'do'not' attract'the'most'experienced'staff.'' ' 45 Offer'2Xyear'contracts'only'to' international'staff'on'the'LAMIKA'project''' 3' During'the'PostXearthquake'and' cholera'relief/emergency'response,' ARC'and'HRC'provided'many' commoditiesX'resources'free'of' charge.'' ' Many'organizations'operating'in'Haiti' require'even'the'poorest'families'to' make'and'inXkind'match'when' receiving'assistance.'' ' During'relief'and'emergency'times,' commodity'distribution'may'be' necessary'and'desirable.''' ' In'nonXrelief/emergency' areas/circumstances,'free'distribution'of' commodities/resources'encourages' dependence'and'reduces'selfXesteem' among'the'recipients.'' ' Benefactors'value'commodities'that'they' were'asked'to'‘match’,'more'highly'than' those'they'received'free'of'charge'(as'a' hand'out)'or'unsolicited.''' 46 To'build'the'selfXesteem'of'project' beneficiaries'and'in'recognition'of'the'fact' that'LAMIKA'is'not'a'relief/emergency' initiative,'free'distribution'of'commodities' (soap,'aqua'tabs,'condoms,'SRO'and'now' construction'materials)'should'be' curtailed.''' ' All'families'identified'as'beneficiaries'of' the'physical'improvement'program' (housing),'should'be'required'to'provide' some'construction'materials'proportional' to'their'economic'status.'Even'the'poorest' families'should'be'required'to'contribute' some'materials.''' Give'the'families''a'choice'of'what'they' will'provide.''' ' ' List of Annexes Annex 1 – Notes on Behavior Change Annex 2 - Partnership Defined Quality Annex 3 – Barrier Analysis Annex 4 – Care Groups Annex 5 - ARC/Cambodia experience with Care Groups Annex 6 - https://www.msu.edu/unit/phl/devconference/CAREVillSavLoanAfr.pdf Annex 7 – TOR Annex 8 – Interview Tool Template Annex 9 – Review Methodology 47 Annex 1. The DBC Framework – Planning for Behavior Change In 2004, The Academy for Education and Development (AED) joined forces with the Social and Behavior Change Working Group of the CORE Group and developed a tool called the BEHAVE Framework. The purpose of the tool was to help people and organizations working in developing countries to design more effective behavior change strategies. The BEHAVE Framework was modified by the SBC working group in 2008 and by the TOPS Project in 2011; based on feedback from people who had trained others in its use and practitioners using the BEHAVE Framework in the field. In 2008, the tool’s name was changed to The Designing for Behavior Change Framework (DBC) to reflect major changes to the framework and the curriculum used to train people in its use. The 2011 DBC curriculum is now suitable for use by organizations working in maternal and child health and nutrition, agriculture, natural resource management and various other sectors. The DBC framework is sector neutral; that is, it can and has been used to design behavior change strategies in many different sectors. The foundation of the DBC framework is its focus on the identification of the determinants of behavior change4 that are important to the target audience regarding the specific behavior. These determinants are usually barriers (but can also be motivators) which are identified by conducting formative research. The DBC training promotes the use of the Barrier Analysis survey because this method is very simple, low cost and provides results very quickly. People can learn to use the DBC framework and conduct a Barrier Analysis during the 5.5 day training, following the DBC curriculum. Once the important determinants are identified, activities can be developed which address the barriers to behavior change. This is quite different from the traditional approach, where designers guessed what the barriers were and chose activities haphazardly. Using the DBC framework and basing decisions on the evidence revealed by the formative research means that the behavior change strategies developed using this approach will be more effective, efficient and less costly. Likewise, field workers (volunteers and promoters) can also be more effective in their work, if their messages and actions are based on knowledge of the important determinants. Volunteers and promoters can be taught to go beyond simple message memorization and become effective agents of behavior change. 4 Social norms, perceived positive and negative consequences, self-efficacy, action efficacy, perceived susceptibility, perceived severity, cues for action, policy and culture 48 Annex 2. Name of Method or Tool: Partnership Defined Quality (PDQ) Purpose: When and Where it Can be Used; Criteria for Implementation • The Partnership Defined Quality approach is used when seeking to improve the quality and accessibility of health care services with community involvement in defining, implementing and monitoring the improvement process. PDQ links quality assessment and improvement with community mobilization. It is especially useful when the perspective of the community in the improvement of services is desired. It is most often used in more rural settings where the audience being served by a particular facility is most clearly defined. While the approach was developed for use in health care, it may be possible to modify the approach to improve quality in other services (e.g., agriculture) provided to communities. This approach is especially suited to bridge communication between different groups with different priorities and points of view (e.g., health facility staff and mothers of young children; government agricultural extension service staff and farmers). • This approach is particularly suited for use in areas where an organization wishes to strengthen and increase usage of client services (e.g., health care services). It is also useful for assuring marginalized groups get the services that they desire and need. • Specific health care services that the PDQ has been used to improve include: Maternal and child health services, including emergency obstetrical care; skilled birth attendance care, postnatal care, Tetanus Toxoid (TT2+) coverage, referral systems from health post to health facility, TB detection rate, student exams, HIV/AIDS prevention services for youth, adolescent reproductive health services, VCT services for men who have sex with men and female sex workers, and nutrition services. • The PDQ approach is best used in projects with a duration of two years or more and with sufficient staff and budget to adequately support the PDQ process. The four steps in the PDQ process (up to preparing the Work Plan) typically require 3 months to complete. Evidence for Efficacy of the Method/Tool: The PDQ approach was designed by Save the Children (US) in 2000 and has been implemented in more than 20 countries by many organizations, including Save the Children, Georgetown University Institute for Reproductive Health, Johns Hopkins University, CARE, AMREF and Project Hope. Although minimal operations research has taken place, participants in PDQ claim that utilization rates have increased, and that overall quality of services has improved, including, client satisfaction and provider performance. Intervention and comparison groups in Pakistan and Nepal confirm these claims. Engaging the community in quality improvement dialogue can also increase demand for services. Community and health provider perspectives often change after “bridging the gap,” and it is realized that they all want the same thing – the provision of quality care. Although labor intensive, there is some evidence of sustainability of PDQ. In Armenia, three years after the Maternal and Child health project ended, a return to PDQ communities revealed 49 that Quality improvement teams were still continuing to operate and benefit overall community health and well-being. This is also a measurement of sustained community capacity for selfdevelopment. The main result of the PDQ process is the shared vision, definition and responsibility of improving the quality of services. Once action plans are developed, quality improvement teams continue to dialogue and monitor quality improvements, while mobilizing the community to use services. While it can be difficult for marginalized subgroups and health providers to work together, team building exercises help the two groups communicate more freely. Rather than create a new structure, PDQ seeks to build upon existing mechanisms to increase the likelihood that quality improvement teams will continue to function. In projects that have program management units, they meet regularly to monitor progress against the action plan. The PAIMAN project in Pakistan, where PDQ was implemented at scale, reported the following direct results: An ambulance was procured through citizen community board (CCB) of local government. • Provision of clean drinking water at two health facilities by providing extra pipelines and digging wells. • The staff shortage problem was solved by the Quality Improvement (QI) teams by influencing key administrators at district and provincial levels. • Communities have been mobilized to collect emergency transport funds. • A QI team has provided curtains for the women’s waiting room to ensure the privacy according the local “purda” tradition. Compared to other quality improvement approaches – such as COPE5 – the advantage of PDQ is that the community perspective is taken into consideration and a dialogue between providers and clients is opened. Providers and community members assume responsibility for implementing the quality improvement activities. • Details of Use: Overview: PDQ engages communities and health care providers in a series of facilitated meetings where perceptions of clinic-based quality of care are explored and shared mutual responsibility for problem solving is emphasized. The result is improvement in community empowerment and health care quality. The PDQ Process Members of the community - service users and nonusers – are engaged in a discussion regarding their service preferences, barriers to use, and their definitions of quality. A concurrent session is held with care providers (e.g., health care professionals), in which they discuss their perceptions and concerns about serving various groups of the community, barriers they perceive those groups face in using services and their definitions of quality of care. A “bridging the gap” workshop is then held that brings together all community groups 5 See http://www.engenderhealth.org/files/pubs/qi/toolbook/cope_maternal_toolbook.pdf 50 and providers during which they create a shared vision of quality. A core team of providers and community representatives, called the Quality Improvement Team (QIT) is then formed and , tasked with developing and carrying out a work plan for implementing and monitoring the desired changes.. The PDQ process consists of the following four steps: Step 1. Building Support – This first step consists of a workshop (or series of meetings) during which time support for working to improve quality improvement is generated by examining indicators (e.g., health indicators); and mapping the catchment area of the service facility to identify key QI issues. This data will help complete the PDQ Inquiry Checklist. Key questions that may be discussed during this first step include: Why improve quality? What are the costs of poor quality care? Why should the clients be involved in the process? Step 2. Exploring Quality – The purpose of this step is to gather the perspectives of each of the key audiences (clients and providers) with regard to quality improvement. To ensure honest and open discussion, separate workshops (or series of meetings) are conducted for clients and providers. These workshops/meetings are facilitated by independent people who have been trained. In addition to exploring QI issues and barriers to quality of care, each group also identifies a few people to participate in the Bridging the GAP meeting. In preparation for the next phase of the process – “Building the Bridge” – representatives from the client group meet to review information and establish a common voice. Representatives from the provider group also hold a similar meeting. During these separate sessions, participants categorize information collected during the prior step, integrate it for presentation, analyze the gaps, and identify possible ways to (diplomatically) bridge differences between providers and the community. Step 3. “Bridging the Gap” – During this step, representatives from each of the two groups (clients and providers) present their ‘findings’ with regard to quality of care and the barriers to each other. This process provides an understanding of the needs and perspectives of quality among clients and service providers, fosters mutual respect between these groups, and integrates their perspectives into a shared vision of quality. The discussion results in a jointly created list of priority problems that need to be addressed. During this step a small group of representatives from clients and providers are selected by their peers to make up the Quality Improvement Team (QIT) who work on Step 4. Step 4. Working in Partnership – Using the list of priority problems developed by both groups during the “Bridging the Gap” workshop – the Quality Improvement Team now analyzes each problem and develops a Plan of Action for addressing each problem. The Plan of Action includes the proposed and accepted solutions, the persons responsible for solution implementation, the time frame for implementation, and a column for monitoring progress. It also stipulates the resources needed and the source of those inputs. The QIT meets on a regular basis to monitor implementation of the Plan of Action and the QIT also reports back to the community. 51 Usual Audiences: In addition to the health care providers, audiences that have been involved in the PDQ process in various projects around the world include: o o o o o o mothers of young children women of reproductive age husbands and mothers-in-law (when they are decision makers) TB patients and their families students youth (HIV/AIDS and Reproductive Health Services) Level of skill needed: PDQ is meant for use by project staff members who are working to improve the quality of services in order to achieve project outcomes. It does not require any formal professional preparation, but staff members with experience in running meetings and facilitating discussions will find it easier to carry out. Staff members should be trained in PDQ, or have a thorough understanding of the PDQ manual. It is preferable if they have cross cultural skills and monitoring and evaluation skills. Time/staff required: The PDQ process is time-consuming because the four-step process described above must be followed for each service facility where the quality of services/care needs to be improved. Before the process can begin, project staff members need to be oriented to the process and trained as workshop facilitators. Skills are also needed in monitoring and evaluation, Once the workshops have been conducted, however, and assuming there are no major implementation issues, the involvement of the project staff is limited to monitoring implementation of the QITs as they implement their Plan of Action. Common constraints/difficulties: o o o o o Time commitment (process is intensive and time consuming) Maintaining political will and process Identifying the “right” facilitators Gaining true community representation and participation at all levels Involving the least advantaged people and poor in a planning team requires a great “ideological shift” Resources: o PDQ Manual: http://www.savethechildren.org/publications/programs/health/PDQ-Manual-UpdatedNigeria.pdf o PDQ Facilitation Guide: http://www.coregroup.org/storage/documents/Social_Behavior_Change/Save_PDQ_ Facil_Guide.pdf 52 Annex 3 Name of Tool: Barrier Analysis: Purpose: • Barrier Analysis6 is a rapid assessment tool that can help organizations identify why a promoted behavior has low coverage or has not been adopted at all. It is usually used at the beginning of a program to determine key messages, strategies and activities for boosting behavior change in food security, child survival and other community development programs. It can also be used in an ongoing program to evaluate how to improve the promotion of specific behaviors that continue to show low adoption rates. Evidence for efficacy of the Method / Tool: • Barrier Analysis was designed by Food for the Hungry staff in 1990 using the scientific literature on behavior change. The main theories that support the method are the Health Belief Model and the Theory of Reasoned Action. Knowledge is not enough to change behavior. There are many different determinants of behaviors that should be explored when putting together a behavior change plan. • “Powerful to Change Analysis7” was conducted by the CORE Group SBC Working Group in order to compare those projects that successfully boosted behavior change for different practices (e.g., exclusive breastfeeding, handwashing with soap) in comparison with those that did not. Those projects that showed the highest levels of behavior change used formative research tools like Barrier Analysis and Doer/NonDoer Analysis. • Barrier Analysis has generally been used to improve health, nutrition and hygiene practices at the household and community levels, working with health personnel, community health workers, mothers and caretakers. However, the methodology has recently been updated based on determinants of agricultural and NRM practices, and the latest Designing for Behavior Change manual (available on the Food Security and Nutrition Network website) includes these modifications. Barrier Analysis should be useful for better understanding all types of behavior at the community level, including behaviors related to value chains. It has been applied in both developing and industrialized countries. • Barrier Analysis is practical because it can be applied in a short time frame, does not require a lot of time or money, and produces enough information to design behavior change communication messages, strategies, and activities for food security, child survival and other types of programs. It is useful for use at the beginning of a project focusing on key practices most linked with impact, and later in a project focusing on other practices where widespread adoption has not occurred. Details of Use: Overview: Barrier Analysis explores 12 behavioral determinants: perceived selfefficacy/skills, perceived social norms, perceived positive/negative consequences, access, perceived barriers/enablers, cues for action/reminders, perceived susceptibility, perceived severity, perceived divine will, culture, and policy. Ninety respondents are selected (45 6 Davis, Thomas. Barrier Analysis Facilitator’s Guide. http://barrieranalysis.fhi.net/annex/Barrier_Analysis_Facilitator_Guide.pdf 7 For an example, see http://www.coregroup.org/storage/Social_Behavior_Change/EBF_Final_Report_and_Annex.pdf 53 “Doers” and 45 “NonDoers” of the behavior) and asked a series of questions to identify which determinants are impeding them – or enabling them – to do the behavior. This comparison of people who do and do not do a behavior is very helpful to identify which of the determinants are the most important ones on which to focus during the behavior change plan. The tabulation table allows the user to make statements such as “Doers of the behavior are 5.2 times more likely to say that their husband approves of the practice than NonDoers.” Project staff members then use these results to develop key activities and messages to make changes related to each determinant found to be important (e.g., to convince husbands to approve of the practice). There are seven steps in developing barrier analysis: 1) Define the Goal, Behavior & Target Group 2) Develop the Behavior Question 3) Developing Questions About Determinants and Pretest Questionnaire 4) Organize the Data Collection 5) Collect Field Data for Barrier Analysis 6) Organize and Analyze the Results 7) Use the Results of Barrier Analysis • • • • Usual Audiences: Farmers and mothers of young children. Sometimes BA is done with groups of people who influence the key beneficiary group, such as fathers and grandmothers of young children, or agricultural extension agents. Level of skill needed: The tool is meant for use by project management staff and community-level implementers. Past experience with social and behavior change programs is helpful, as well as skills in conducting interviews, developing questionnaires, and using MS Excel. Analysis is done manually with markers, paper, and a computer loaded with an Excel BA Tabulation Table (which can be downloaded8). Time/staff required: Barrier Analysis can be done quite rapidly by trained personnel. Training in Barrier Analysis is usually done as part of the 6.5 day Designing for Behavior Change training. If you have a team of 10 people available to carry out Barrier Analysis, the data collection for each behavior you study can usually be done in about 9-10 communities in 1-2 days (total). Tabulation of the data can usually be done in a single day. A larger group can generally analyze more behaviors in the same amount of time. Common constraints/difficulties: Sometimes it is difficult to find enough Doers (people currently doing the behavior) for certain behaviors. The facilitator in the process should be skilled in helping people to think of activities that focus on each determinant identified to be important. (Participants will often default to only focusing on new messages.) Resources: • Designing for Behavior Change for Agriculture, Natural Resource Management, Health and Nutrition (manual). Produced by TOPS, FSN Network, & CORE Group. October 2011. 8 The Excel file can be downloaded here: www.caregroupinfo.org/docs/BA_Tab_Table_Eng_9_30_10.xls. An instruction sheet for use of the BA Tabulation Table is available here: www.caregroupinfo.org/docs/BA_Analysis_Excel_Sheet_Tab_Sheet_Explanation_Sept_2010.doc 54 • • Barrier Analysis Facilitator´s Guide. Food for the Hungry. Reprint 2010. Download from here: http://barrieranalysis.fhi.net/annex/Barrier_Analysis_Facilitator_Guide.pdf. Please see this important preface to the second printing: www.caregroupinfo.org/docs/BA_Preface_to_Second_Printing.doc Barrier Analysis Narrated Presentation: http://caregroupinfo.org/vids/bavid/player.html 55 Annex 4 Name of approach: Care Groups: Purpose: The Care Group model helps organizations to organize, train, supervise and motivate volunteers for household-level behavior change and community mobilization in a cost-effective and potentially sustainable manner. Care Groups increase coverage and behavior change by creating a large network of volunteer women. Each group is composed of 6-16 volunteer, community-based health educators who regularly meet together with NGO project staff for training and supervision. Each of these volunteers then go out at least monthly to do health promotion with a cohort of mothers of young children and pregnant women in no more than 15 households (who have elected the volunteer). They act as peer (woman-to-woman) maternal, newborn and child (MNCH) health educators and promote a standardized set of evidence-based, maternal and household prevention and care-seeking behaviors. Limited data is also collected on each household that is visited. Each project staff health promoter trains and supports as many as nine Care Groups. Staff from World Relief (WR) developed the Care Group model during a USAID Child Survival project implemented in Mozambique from 1995-1998 and further refined the methodology in an additional grant in the same area. Food for the Hungry (FH) adopted the model in Mozambique in 1997 after discussions with WR project staff, and both organizations have pioneered use of the model since then. Since that time, the CORE Group has helped document and disseminate the model, and it has been used by 22 (and counting) NGOs through the support of governmental (e.g., USAID) and private donors. In particular, the USAID Child Survival and Health Grants Program has provided funding to numerous Care Group projects. The Office of Food for Peace (Title II Food Security) has now funded many programs using the Care Group model, as well. Care Groups now exist in at least 21countries, and are mainly being used in development settings, but have also been used successfully in several relief and transitional situations (e.g., post-earthquake Haiti and in Ethiopia during the recent drought). Details of Use: • Staffing: A project supervisor oversees the work of several paid Health Promoters (HP) who each in turn trains and oversees up to nine Care Groups, each composed of 6-16 volunteer women. Promoters supervise the CGVs working in pairs during meetings, and individually supervises the work of one CGV per group after each meeting. • The NGO first hires the Supervisors who train Health Promoters in how to mobilize communities to form Care Groups. All households with children 0-23m or pregnant women in the project area are formed into groups of 8-15 geographically-adjacent households. The CG volunteer should not have to walk more than 45 minutes to get to the furthest house that she visits so that regular visitation is not hindered. (In many CG projects, the average travel time is much less than this.) Women in each of these groups meet together to elect the Care Group Volunteer who will serve them. (This woman can be one of the women in their 8-15 household group, or another woman.) • Groups of 6-16 CGVs meet together once or twice a month in the Care Group, and attendance is monitored. Meetings generally last 1.5 to 2 hours and are held in a public place that is easily accessible by foot from the CGVs’ homes. During these CG meetings, CGVs report on vital events, illnesses and health promotion progress, and are trained by the 56 • • • • • • Promoter – using participatory methods – in the current health module that they will use when they meet with the mothers and pregnant women who elected them (either in a small group or home visits). After each CG meeting, each CGV visits an established number of households with a pregnant woman or young child (0-23m) near their own house and promote behaviors with the mothers and other caregivers using what they have learned in the Care Group meeting. Contact with beneficiary mothers is monitored (e.g., using mini-KPC surveys). CGVs also collect a limited amount of information on vital events that they report to the Promoter during the Care Group meetings. CGVs are sometimes taught a particular step-by-step process for counseling the mother (e.g., FH’s ASPIRE method). CGVs promote behavior change with mothers and other household members geared towards reduction in maternal and infant/child mortality and malnutrition. This is done using a standardized flipchart that covers a set list of topics. Common topics include essential hygiene actions, essential nutrition actions, key MNCH prevention behaviors, recognition of danger signs during pregnancy and child illness. In many projects, they also provide information about upcoming campaigns and health outreach activities implemented by the Ministry of Health. They also collect information on pregnancies, births and deaths from each household and report this information to the Promoter at their Care Group meetings. (Promoters often share this information with health facility staff.) Information from KPC surveys and other formative research (e.g., Barrier Analysis studies, positive deviance studies) are used to guide message and activity selection and development and SBCC materials. Examples of Care Group training materials that can be adapted are available on the Care Group website (www.CareGroupInfo.org). Outreach services to children 24-59m are often done, as well, but these mothers of theses children are generally not visited on a biweekly basis. Common outreach activities for this age group include vitamin A supplementation, deworming, and screening/referral for malnutrition. The picture below illustrates the configuration of a typical Care Group Usual Audiences: Pregnant women and mothers/caregivers of children under two years of age are the usual audience, and other family members who sometimes participate in the learning sessions (e.g., grandmothers, daughters). Other activities are sometimes used 57 alongside the Care Group structure to reach the community at large, specifically targeting influential members of the community (e.g., community leaders, men, grandparents, religious and educational leaders, traditional health providers) to support household-level behavior change. Level of skill needed: The paid health promoters have at least a high school education, but often have additional education. Promoters sometimes cover a medium-sized geographic area, and move from one community to the other on bicycle or by foot. Supervisors usually use motorcycles. CGVs are often illiterate, and materials they use to promote behavior change with beneficiary mothers are adapted for their level of education. Time/staff required and incentives: Care Group Volunteers usually devote about six hours a week to attending CG meetings and meeting with beneficiary mothers in groups or home visits. It is important to keep in-kind incentives to a minimum with these volunteers as the most successful programs often gave very few incentives (e.g., a wrap-around skirt once every two years).9 Promoters, Supervisors, Trainers, and Managers are usually full-time paid staff. Due to the large number of volunteers, about 80% of the total hours devoted to the project will be done by the volunteers, about 15% will be done by the community-based Promoters, and 5% will be done by other project staff (e.g., Supervisors, Managers, backstops). Common constraints/difficulties: If households are widely dispersed, the number of households per CGV and CGVs per group may need to be reduced. If communities are far apart from each other, the number of Care Groups per Promoter (or their means of transport) may need to be adjusted. Care Groups may not be the best methodology to use in very low population density areas (e.g., 5 people per square km). Also, there is currently no standard methodology for incorporating CGs or CGVs into government health systems, and district MOH offices usually have no focal person charged with forming and maintaining community groups such as Care Groups. For sustainability, strategies to transition management and training functions of the NGO into government systems should be considered. Despite this fact, CGVs have been found to continue visiting mothers and doing health promotion in some programs long after project funding has ended (e.g., World Relief’s projects in Gaza Province, Mozambique). • • • Evidence for efficacy of the Method/Tool: • 9 Examining the evidence of under-five mortality reduction in a community-based programme in Gaza, Mozambique. Transactions of the Royal Society of Tropical Medicine and Hygiene (2007) (Trans R Soc Trop Med Hyg. 2007 Aug;101(8):814-22.) This study showed the Care Group model is able to dramatically increase coverage of key health behaviors (e.g., use of bed nets, oral rehydration therapy and prompt health care seeking). The program led to a 66% reduction in infant mortality and a 62% reduction in under-five mortality. For more information on Care Group Volunteer and CHW motivation, see these presentation: http://www.caregroupinfo.org/vids/CHW_Motivation/CHW_Motivation.html and http://www.caregroupinfo.org/vids/CGMotivation/CGMotivation.html and 58 • Accelerating progress in achieving the millennium development goal for children through community-based approaches (Freeman P, Perry H, Gupta SK, Rassekh B, Global Public Health, 03 November 2009). This article demonstrates that interventions proven to reduce mortality in high mortality settings must have a strong community-based component to succeed. The article describes a number of community-based approaches that work, including the Care Group model. • Essentials of Global Community Health (textbook) by Jaime and Rosa Gofin. Jones & Bartlett Learning, pubs. Case Study 4 (written by Henry Perry et al.) gives details of a Cambodia Care Group project. • There are also a large number of Care Group final evaluation reports listed on the website www.CareGroupInfo.org/blog/results, contributing to a large body of gray literature in support of this model. A narrated presentation on indicator gap closure in Care Group projects (vs. non-Care Group CSHGP projects) can be found here: http://www.caregroupinfo.org/vids/CGGapClosure/CareGroupGapClosure.html. 59 Annex 5 Results Highlight: ARC/Cambodia - Promising Practice – The Care Group Model in Siem Reap, Cambodia Cambodia continues to have one of the highest child morbidity and mortality rates in Southeast Asia. Of every 1,000 live births, 65 infants do not survive their first year of life; 83 children die before their fifth birthday.10 Diarrhea, acute respiratory infection, and malaria, all complicated by malnutrition, continue to be the primary causes of childhood death. The American Red Cross is working with the Cambodian Red Cross (CRC) to implement an Integrated Child Health project in Angkor Chum Operational District in Siem Reap Province, Cambodia. The project’s achievements in meeting and in some cases exceeding its endline targets can largely be attributed to the nearly 2,000 strong the Red Cross volunteer network it put in place to conduct home visits and mobilize their respective households to access health services. Through this extensive volunteer network, the ICH project is benefiting over 43,000 children and 52,744 women of reproductive age in the Pourk, Angkor Chum and Varin districts. The care group model11 (CVCG) consists of 8-10 female volunteers where each woman is responsible for visiting households and a care group leader serves as a coach and mentor. The volunteers are trained and meet as a group to discuss care seeking behavior, incidence of illness, and collect information about births and deaths. Each group is assigned to complete home visits to promote and negotiate improved health practices with up to 20 households with children under five years old at least once a month. Volunteers are recruited in proportion to the population as opposed to recruiting a certain number per village. During the project’s life, many lessons have been learned to strengthen the CVCG network. Particular attention was given at mid-term on strengthening the role of the group volunteer leader as a coach and trainer. The project conducted on the job trainings and introduced participatory learning methods such as motivational interviewing, group facilitation and role plays to bolter leadership, facilitation and coaching skills. The final evaluation also found that many volunteers felt that the 1:20 household ratio was difficult to maintain especially in more remote villages. Volunteers recommended that 15 visits would be more feasible. The CVCG success can also be measured by viewing volunteer commitment and satisfaction. For example, the mid-term evaluation found the volunteer dropout rate was very low (less than five percent) and the majority of volunteers reported a high level of job satisfaction. From the onset the project chose a non-cash, performance-based incentive scheme that included a modest snack (e.g., fruit) during village-based training and information sharing meetings, tee-shirts and caps, LLINs, iodized salt, volunteer ID cards, sarongs, nail clippers, and soap as well as bicycles for volunteer leaders. In addition to these incentives volunteers also were motivated to serve their communities and improve their health status. Looking ahead the CRC is committed to maintaining and strengthening the project’s CVCG. The CRC will work to better understand the underlying reasons for inactivity among volunteers and barriers to conduct the monthly household visits. They will support the communities to 10 National Institute of Public Health/National Institute of Statistics, Cambodia Demographic and Health Survey, Preliminary Report, July 2006 11 The Care Group Model was first developed by World Relief in Mozambique. 60 facilitate replacement of non-active RCVs and strengthen recruitment practices and develop supervisory and spot check tools to verify RCV activity and quality of home visits. 61 Annex 6 - 62 ! ! ! Annex!7!'!Terms!of!Reference!for!External!Consultant! Health!Portfolio!Assessment!and!Recommendations!for!Future!directions,!Haiti! 26!January!2012! ! 1. Description!of!program!to!be!reviewed! ! 1.1. Background! ! Port%au%Prince,camp%based,programs, ! The!January!2010!earthquake!was!one!of!the!worst!natural!disasters!in!recent!history.!Approximately! three!million!Haitians!were!affected,!with!more!than!1.3!million!people!displaced!!households!were! forced!to!find!refuge!in!overcrowded!camps,!living!in!tents!or!under!tarps!in!unsanitary!conditions! without!proper!hygienic!resources.!A!recent!report!indicates!there!are!still!519,000!displaced!people! living!in!camps!as!of!30!November!2011.!!The!risk!of!disease!and!illness!has!been!high,!and!ARC!was!in!a! position!to!establish!an!emergency!health!promotion!project!(PEHP)!in!many!of!those!camps.!With!the! sudden!outbreak!of!cholera,!ARC!also!implemented!an!emergency!response!which!includes!supporting! multiple!local!and!international!partner!organizations!to!address!cholera!in!rural!and!urban!areas! throughout!Haiti.!This!included!support!to!IMC,!Care,!Save!the!Children,!French!Red!Cross!and!HOPE.!! ! In!late!October!2010,!the!first!cholera!outbreak!in!Haiti!in!at!least!a!century!was!confirmed.!!! The!American!Red!Cross!began!implementing!a!wider!Cholera!Response!Project!in!Jan.!2011!with!the! goal!of!reducing!the!incidence!of,!and!morbidity!and!mortality!from,!cholera!in!the!West,!North!East!and! North!departments!of!Haiti.!The!project!implementation!strategies!include:!!(1)!strengthening!cholera! prevention!in!target!communities!through!intensive!houseWtoWhouse!hygiene!promotion,!and!commodity! distribution;!(2)!improving!the!availability!of!ORS!at!the!community!level!through!active!case!finding,! and!the!establishment!of!ORS!posts/distribution!points!at!the!community!level.!Later!a!latrine! component!was!added!to!areas!in!the!Northeast!and!North.! ! These!are!joined!with!other!ARC!implemented!health!projects,!which!include!a!current!multiWregional! HIV/AIDS!program!(ARC!is!part!of!a!consortium!led!by!PSI!that!also!includes!FOSREF,!MARCH!and!POZ),!! and!a!recently!ended!malaria/hygiene!project!in!the!N/NE!departments.!Reviewing!these!current! projects!is!crucial!in!identifying!the!most!effective!methods!for!ARC’s!continued!support!to!the!health! sector,!considering!multiWsectoral!integration,!especially!as!the!overall!HAP!focus!transitions!to!the! larger!integrated!approach!in!two!specific!neighborhoods!of!Port!au!Prince.! ! Port%au%Prince,camps,to,“Neighborhoods”,program, 63 ! Over!the!next!four!to!five!years,!ARC!will!implement,!through!two!phases,!an!Integrated!Neighborhood! Reconstruction!and!Recovery!Program.!The!goal!of!this!urban!development!program!is!to!enhance! community!and!household!resiliency,!while!providing!safer,!healthier!and!more!secure!living!conditions.! As!the!program's!primary!implementation!area,!ARC!has!chosen!two!neighborhoods!in!Carrefour! Feuilles,!Baillergeau!and!Campeche.!Carrefour!Feuilles!is!a!district!of!PortWauWPrince!where!a!high! proportion!of!homes!were!damaged!or!destroyed!by!the!January!12!earthquake.!ARC!already!has!a!long! history!of!programming!in!Carrefour!Feuilles,!both!before!and!since!the!earthquake,!resulting!in!strong! links!with!the!local!population.!! ! The!specific!objectives!of!this!urban!development!program!are!to:! 1. Improve!access!and!use!of!land,!housing,!services!!and!infrastructure! 2. Enhance!local!market!and!household!economy!by!providing!opportunities!for!income!and! asset!security!! 3. Improve!knowledge,!attitudes,!practices,!capacities!and!social!responsibility!of!community! and!service!providers!by!promoting!social!and!healthy!behaviors! ! The!consultant!will!focus!on!health!programs!and!approaches!that!address!the!third!objective.! ! In!addition,!ARC!is!developing!an!integrated!health,!disaster!risk!reduction!and!water!and!sanitation! program!in!collaboration!with!the!Haitian!Red!Cross!outside!of!PortWauWPrince.!(Nationwide! Project/Program)! ! In!summary,!the!health!component!of!this!urban!development!program!and!future!programming!is! expected!to!be!part!of!an!integrated!program!combining!a!holistic!health!approach!(including! Community!Based!Health!and!strengthening!of!referral!systems)!with!ARC’s!work!in!the!area!of!disaster! risk!reduction!and!water!and!sanitation.! ! Large%scale,partnerships, ! Reviewing!these!current!projects!is!crucial!in!identifying!the!most!effective!methods!for!ARC’s!continued! support!to!the!health!sector,!considering!multiWsectoral!integration,!especially!as!the!overall!Haiti! Assistance!Project!focuses!transitions!to!the!larger!integrated!approach!in!two!specific!neighborhoods!of! Port!au!Prince!as!well!as!shifting!its!malaria!and!hygiene!education!projects’!focus!in!the!rural!districts!of! the!North!and!Northeast!to!longerWterm,!comprehensive!communityWbased!programming!with!a!broader! program!portfolio!that!better!addresses!local!health!priorities.! ! ! 2. Program!Review!overview! ! 2.1. Purpose! 64 The!ARC!is!requesting!the!help!of!a!consultant!to!assist!the!Country!Director!and!Program!team!to! review!the!health!portfolio!and!provide!recommendations!for!future!health!programming!in!Port!au! Prince!and!in!the!North!and!Northeast!and!South!Departments.!!The!consultant!will!also!review!the! Phase!II!urban!development!proposal!for!Carrefour!Feuilles!and!provide!input!for!future!changes!and! modifications!to!the!proposal.! ! 2.2. Objectives! 1. Analyze!how!ARC!preW!and!postWearthquake!health!projects!can!inform!future!health! programming.! ! 2. Identify!relevant!opportunities!(and!potential!partners)!for!future!programming!!in!both!current! and!new!health!sectors!and!approaches,!taking!into!consideration!needs,!ARC!strategy!and! capacity!and!Haitian!Red!Cross!headquarters!and!branch!capacity.! ! 3. Review!the!health!component!of!the!Phase!II!strategy!(LAMIKA)!and!nationwide!strategy!and! provide!feedback!and!recommendations!based!on!analysis!from!the!Health!Program!Review.! ! ! 2.3. Main!audience! In!Haiti:!ARC!Head!of!Mission,!Health!Delegates,!Quality!&!Learning!Delegate! In!Washington:!Haiti!Assistance!Program!Management,!Senior!IRP!leadership,!Senior!Health! Coordinator,!Senior!HIV!Advisor,!M&E!Advisor! ! 2.4. Coverage! The!review!will!cover!the!following!health!projects:!PostWEarthquake!Health!!Promotion!(PEHP),! HIV/AIDS!prevention!(PrevSIDA),!Malaria/PHAST!and!!the!Cholera!Response!Project.!!All!geographic! areas!and!all!project!stakeholders!fall!under!the!scope!of!this!review.! ! ! 3. Key!questions! ! 1. What!lessons!can!be!learned!from!past!and!current!ARC!health!projects!(preW!and!postW earthquake)!that!can!inform!the!future!health!program?! ! 2. What!technical!areas!of!intervention!(e.g.!MCH,!hygiene!education,!etc.)!and!communityWbased! approaches!(Com.!Based!Health!and!First!Aid,!care!groups,!etc.)—whether!a!current!focus!of! ARC!projects!or!those!outside!of!current!ARC!projects—are!most!relevant!to!the!future!health! program!given!ARC/HRC!capacity?! a) for!the!Neighborhoods!project!(PortWauWPrince!urban!setting)! b) for!the!rural!setting!in!the!North!and!Northeast!Departments! c) for!the!urban!setting!in!the!North!and!Northeast!Departments! ! 3. How!can!partnerships!be!integrated!into!the!overall!health!strategy,!and!particularly!in!a!way! that!would!mutually!reinforce!direct!implementation!programming?! 65 ! ! 4. Scope!of!work!and!Review!design!! ! 3.1. Scope!of!work! The!consultant!will!be!responsible!for!the!following:! 1. Developing!review!methodology!and!work!plan! 2. Data!collection!and!analysis! 3. Report!writing! 4. Recommendations!for!Health!Strategy!(LAMIKA!and!Nationwide!program)!! 5. Presentation!of!findings!to!ARC!staff!in!Haiti!! ! 3.2. Methodologies! The!consultant!is!expected!to!use!the!following!methodologies:! 1. Desk!review!of!key!documents,!including!strategy!documents,!CommunityWBased!Health!and! First!Aid!(CBHFA)!documents,!prior!evaluation!reports,!trip!reports,!monitoring!reports!and! other!documents!judged!relevant.! 2. Literature!search!and!secondary!research!of!material!on!the!environment!in!which!the!program! operates,!and!recent!developments!which!impact!objectives!and!activities! 3. Interviews!with!key!project!staff!and!with!representatives!of!stakeholders!from!various!projects,! both!directly!implemented!and!through!partners! 4. Visits!to!project!sites!(present!and/or!future)! ! 3.3. Plan!of!action! After!the!consultant!has!had!the!opportunity!to!review!monitoring!data,!speak!with!key!program! personnel!and!review!background!and!program!materials,!the!consultant!will!prepare!a!plan!of!action! that!will!include!details!on!the!proposed!methodology!and!work!plan.!A!discussion!will!take!place!with! the!Program!Review!Manager!to!review!and!finalize!the!plan!of!action.! ! 3.4. Logistic!and!Administrative!Support! The!American!Red!Cross!can!support!the!consultant!with!airfare!to!Haiti,!and!with!accommodations!and! transportation!in!Haiti.!!A!translator!and!additional!requested!human!resources!can!also!be!provided.!! The!consultant!is!expected!to!bring!his/her!own!computer.! ! 3.5. Reporting!relationship! The!consultant!will!report!to!Meg!DiCarlo,!Senior!Health!Delegate,!who!is!the!designated!Program! Review!Manager.! ! 3.6. International!standards!&!Presentation!of!evidence! Standard!evaluation!and!survey!methodologies!and!good!practices!utilized!in!the!international! humanitarian!community!should!be!applied.!Such!resources!should!include!but!are!not!limited!to!those! promulgated!by!the!Active!Learning!Network!for!Accountability!and!Performance!and!the!Organization! for!Economic!CoWoperation!and!Development.!!In!particular,!all!findings!and!conclusions!should!be!based! on!evidence!that!is!presented!in!the!report.! 66 ! 3.7. Ethical!Guidelines! It!is!expected!that!the!evaluation!will!adhere!to!ethical!guidelines!as!outlined!in!the!American!Evaluation! Association’s!Guiding!Principles!for!Evaluators.!A!summary!of!these!guidelines!is!provided!below,!and!a! more!detailed!description!can!be!found!at!www.eval.org/Publications/GuidingPrinciplesPrintable.asp.!! 1. Informed+Consent:!All!participants!are!expected!to!provide!informed!consent!following!standard! and!preWagreed!upon!consent!protocols.! 2. Systematic+Inquiry:!Evaluators!conduct!systematic,!dataWbased!inquiries.! 3. Competence:!Evaluators!provide!competent!performance!to!stakeholders.! 4. Integrity/Honesty:!Evaluators!display!honesty!and!integrity!in!their!own!behavior,!and!attempt! to!ensure!the!honesty!and!integrity!of!the!entire!evaluation!process.! 5. Respect+for+People:!Evaluators!respect!the!security,!dignity!and!selfWworth!of!respondents,! program!participants,!clients,!and!other!evaluation!stakeholders.!It!is!expected!that!the! evaluator!will!obtain!the!informed!consent!of!participants!to!ensure!that!they!can!decide!in!a! conscious,!deliberate!way!whether!they!want!to!participate.!! 6. Responsibilities+for+General+and+Public+Welfare:!Evaluators!articulate!and!take!into!account!the! diversity!of!general!and!public!interests!and!values!that!may!be!related!to!the!evaluation.! ! 3.8. Future!use!of!data! All!collected!information!related!to!the!health!program!review!as!well!as!the!consultant’s!report!will!be! the!sole!property!of!the!American!Red!Cross.!The!consultant!may!not!use!the!gathered!information!for! their!own!research!purposes,!nor!license!the!data!to!be!used!by!others,!without!the!written!consent!of! the!American!Red!Cross.! ! ! 4. Expected!activities!and!Deliverables! ! 4.1. Expected!activities! Activities! 1. Desk!review,!literature!search,!secondary!research!on! project!regions,!discussions!with!key!ARC!staff,!formulation! of!key!questions!for!various!stakeholders! 2. Develop!and!submit!plan!of!action!for!approval! 3. Develop!data!collection!tools! 4. Travel!to!Haiti! 5. Conduct!information!gathering/primary!data!collection! activities! 6. Provide!written!input!to!Phase!II!health!proposal!(LAMIKA)! 7. Debriefing!in!Haiti!and!travel!back!to!US! 8. Review!and!provide!input!into!nationwide!program! strategy!(2!days)! 9. Prepare!and!submit!draft!report!(5!days)! 67 Number!of! days! Dates! ! ! ! ! 5! Feb!6W10! 1! Feb!12! 9! Feb!13W23! 1! Feb!24! 7! Feb!27W! Mar!4! 10. Finalize!report!in!line!with!ARC!feedback!! Total!expected!work!days:! 2! Mar!15W16! 25! ! ! 4.2. Deliverables! ! Deliverables! Expected!deadline! 1day!after!arrival!in!Haiti! 1. Plan!of!action! 3!days!after!arrival!in!Haiti! 2. Finalized!data!collection!instruments! 3. Draft!heath!program!review!report! 4. Written!input!to!Phase!II!proposal!(LAMIKA!and! Nationwide!program)! 5. Debriefing!of!ARC!staff!in!Haiti!! TBD! 6. Final!health!program!review!report! TBD! TBD! TBD! ! ! 5. Obligations!of!key!participants!in!the!program!review! ! 5.1. Obligations!of!the!Consultant! a. Inform!the!Program!Review!Manager!in!a!timely!fashion!of!progress!made!and!of!any! problems!encountered.! b. Implement!the!activities!as!expected,!and!if!modifications!are!necessary,!bring!to!the! attention!of!the!Program!Review!Manager!before!enacting!any!changes.! c. Report!on!a!timely!basis!any!possible!conflicts!of!interest.! , 5.2. Obligations!of!the!Program!Review!Manager! a. Make!sure!that!the!consultant!is!provided!with!the!specified!human!resources!and!logistical! support,!and!answer!any!dayWtoWday!enquiries.! b. Facilitate!the!work!of!the!consultant!with!beneficiaries!and!other!local!stakeholders.! c. Monitor!the!daily!work!of!the!consultant!and!flag!any!concerns.! d. Provide!the!consultant!with!an!ARCWaccepted!outline!of!the!program!review!report.! e. Receive!and!signWoff!on!deliverables!and!authorize!payment.! ! 5.3. Obligations!of!the!NHQ!Technical!Team! a. Review!and!approve!the!proposed!methodology.! b. Provide!technical!oversight!in!the!review!of!all!deliverables.! c. Provide!timely!comments!on!the!draft!report.! ! ! 6. Required!qualifications! + 1. Minimum!5!years!implementing!health!programming!in!rural!and!urban!developing!country! context! 68 2. Experience!leading!largeWscale!health!project!assessments!in!!rural!and!urban!developing! country!settings! 3. Experience!leading!large!evaluations!of!health!programming!in!developing!country!setting! required! 4. Experience!working!with!and!involving!multiple!stakeholders!in!program!development! 5. Good!facilitation!skills! 6. Excellent!English!written!and!oral!communication!skills! 7. Ability!to!work!in!French!required! 8. Knowledge!and!understanding!of!current!context!in!Haiti!preferred! + ! 69 Annex!8!–!In'depth!Interview!Guide! The in-depth interview guides were developed around the key questions in the TOR and three additional questions that were added during the field visit. 1. What lessons can be learned from past and current ARC health projects (pre- and postearthquake) that can inform the future health program? 2. What technical areas of intervention (e.g. MCH, hygiene education, etc.) and communitybased approaches (Com. Based Health and First Aid, care groups, etc.)—whether a current focus of ARC projects or those outside of current ARC projects—are most relevant to the future health program given ARC/HRC capacity? a) for the Neighborhoods project (Port-au-Prince urban setting) b) for the rural setting in the North and Northeast Departments c) for the urban setting in the North and Northeast Departments 3. How can partnerships be integrated into the overall health strategy, and particularly in a way that would mutually reinforce direct implementation programming? Added 4. Can the Cholera partners’ work be evaluated now and if so, how? 5. What should be done in the IDP camps? 6. What are my comments on the LAMIKA proposal/proposed project? Responses to questions on the above issues led to other questions that were not-foreseen but were taken into account when identifying findings, conclusions and recommendations. All of the recommendations included in this report stem from findings from various sources including comments and experiences of key informants (always more than one), accepted best practices and the consultant’s personal experience. Although questions varied from informant to informant based on their particular roles and responsibilities on health programming, the basic set of questions in the interview guides was: 1. For each of the health projects you are involved with, what were the lessons learned from project design and implementation? 2. What do you feel are ARC/Haiti’s strengths and weaknesses programmatically? Explain. 3. What are Haiti’s most pressing needs at this time? In settled communities? In the camps? 4. What is the best role for ARC (health) partners in the future? 5. General discussion about the LAMIKA project. 70 Annex!9!–!Review!Methodology! The Health Portfolio Review was conducted over a period of 25 days in February 2012, by an independent consultant with an in-depth knowledge of health issues in Haiti. The study was divided into three main parts: Document Review; Field Work and Report Writing. For the Document Review component, HAP and ARC/Haiti staff sent documents to the consultant for review. These included documents on all past and present projects and plans for future programming efforts. The Field Work was conducted over a 14-day visit to Haiti and included the following activities: - In-depth interviews with more than t15 ARC Delegates and other ARC staff (see list below and interview template in annex 7); - Visits to two health facilities in the target neighborhood of the LAMIKA project and interviews health care providers; - Observations of HTP Promoters in the market place; - Observation of and discussion with elementary school children where a hand washing station had been built - Observation of PrevSida RC volunteers - Role Play with ORS Post attendee (Archaie) - Working session with Promoter supervisors and field managers - Working session with 25 promoters on the HTP project - Visit to Cholera Project Sub-office in Archaie and discussion with staff - Visits to a Cholera Treatment Center in the North Province (Ti Bouk) - Discussions with the Cholera Partners HOPE (in Borgne), Save the Children, and IMC - Discussions with International Rescue Committee regarding the GBV work - In-depth interviews with the Health Directors of the Haitian Red Cross and IFRC - Discussions with the consultant writing the LAMIKA Proposal - Debrief with the Country Director, Deputy Director and Sr. Health Delegate The draft report was written and submitted within a week of return from the field and discussed with the HAP team prior to being finalized. List of Interviewees: HAP and NHQ: Christine Burkhart, Christy Gavitt, Nan Buzard ARC Delegates and staff: Deputy Director, Sr. Health Delegate, DRR Delegate, Quality and Learning Delegate and one staffer, Water and Sanitation Delegate, Cholera consultant and HTP manager, Community Mobilization Delegate, HIV/AIDS Delegate and PrevSida Staff, Security Delegate, Operations Delegate, Shelter Delegate, Livelihood Delegate,. Haitian Red Cross: Health Director 71 Partners: Save the Children, HOPE (and staff), IFRC (John Fleming), IRC (and consultant working on the GBV proposal), IMC Others: 5 Promoter supervisors and Field Managers; 25 promoters; 2 sub office staff (Archaie), 1 ORS Point attendant, 2 health care providers, 1 LAMIKA consultant, staff at Ti Bouk Clinic 72