Emergency Response Fund | Central African Republic | Project Evaluation Report

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Project Evaluation Report

Evaluation details

Project title • Primary healthcare and community healthcare in Ouadda and surrounding villages
and for refugees and host population in Sam Ouandja (ERF/IMC3)
• Therapeutic feeding centre and supplementary feeding centre for refugees and host
populations in Haute-Kotto and Vakaga (ERF/IMC4)

Organisation International Medical Corps (IMC)

Sector Health, Nutrition

Project duration 1 November 2007 – 30 April 2008 (for both projects)

Project budget (ERF) $250,000 (ERF/IMC3 health project); $150,000 (ERF/IMC4 nutrition project)

Place Sam Ouandja, Ouadda (Haute-Kotto prefecture), Ouanda-Djallé (Vakaga prefecture)

Dates of evaluation 21 – 22 February 2009

Evaluation team members Nicolas Rost, OCHA, rostn@un.org

(name, organisation, contact)

Examined documents (project Project documents, final reports

sheet, work plan, reports)

Context
Briefly describe the context in which the project was implemented, including the local security and
political context, the displacement situation, and the assessed needs of the people in the area.

People in Vakaga and Haute-Kotto prefecture in the northeast of the Central African Republic suffered
from fighting between the UFDR rebel group and government troops (later supported by the French
army) mainly in late 2006 and early 2007. In November and December 2006, the UFDR took over the
town of Birao for about one month. In March 2007, they launched another attack but were pushed
back after heavy fighting during which more than 700 houses were burned down and most of the
town’s inhabitants were forced to flee. At its peak, internal displacement reached 20,000 people (35%)
in Vakaga prefecture, and 17,000 people (18%) in Haute-Kotto prefecture. Some 3,000 people from
this area even fled to Sudan’s Darfur region. Most displaced people have now returned although there
are still an estimated 8,000 people still displaced in both Vakaga and Haute-Kotto prefectures.

In addition to politically motivated fighting, the northeastern prefectures have long been affected by
banditry, poaching, conflicts between nomadic herdsmen and sedentary farmers, and, increasingly, an
exploitation of ethnic lines which has led to further violence. The presence of about 200 EUFOR
soldiers has somewhat improved security but has not prevented attacks on Am Dafok and Sam
Ouandja in late 2008.

Vakaga and the northern part of Haute-Kotto prefecture are economically more closely linked to
Sudan than to Bangui, CAR’s capital. During the six-month rainy season, roads from Bangui to Birao
become impassable.

Profiting of an inter-agency mission to Vakaga prefecture, OCHA conducted a ‘rapid evaluation’ of

three projects in this area that had received ERF-funding, including these two IMC projects. In contrast
to regular evaluations which are conducted by a team of one NGO, one UN and one donor

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representative and which are facilitated by OCHA, this rapid evaluation was carried out directly by
OCHA.

Results
Compare the results (outcomes and impact) on the ground with the ‘expected outcomes’ and
indicators in the project sheet and work plan. If possible, add summaries

The mission visited a health post in Sérégobo, a health centre in Ouandja, a hospital in Ouanda-Djallé
and a health centre in Ouadda, all supported by IMC. The mission did not visit Sam Ouandja, where
IMC also provides basic healthcare and nutrition assistance to more than 3,000 Darfur refugees and
the local population. The mission met with IMC’s international and national staff, as well as Ministry of
Health staff, patients, their family, and inhabitants and local authorities of the towns and villages where
IMC operates.

In support of these health infrastructures, IMC provides routine vaccinations, vitamin A supplements
for children, prenatal care and consultation, mosquito nets, nutrition counselling and assistance, HIV
prevention, hygiene promotion, mobile health teams for vaccination, first aid and health promotion,
training for health staff, rehabilitation of health centres, and – most importantly – free-of-charge
healthcare with a referral system from health posts to health centres to the hospital in Ouanda-Djallé
or the upgraded health centre in Ouadda. As elsewhere in CAR, the weak point of the referral system
is the absence of safe transport means, as well as poor road conditions. People have to walk or use
bicycles or, if they are lucky, travel with a commercial truck if one happens to pass by. IMC has an
ambulance in Ouanda-Djallé but this is insufficient to cover the entire area. IMC started its programme
in this area in September 2007. Since then, the number of consultations and patients treated has
dramatically increased in all health structures visited. Excluding Sam Ouandja, IMC’s catchment
population is about 37,650 people. (The catchment population in Sam Ouandja is about 16,000
people.)

According to IMC’s final project reports, most of the project targets have been achieved. With regard
to the health project:
- 80% of registered pregnant women attended at least two antenatal care visits
- 65% of women of reproductive age received TT2 vaccinations
- 60% of children between 9 months and 15 years were fully immunized (BCG, polio, D, C)
- 70% of children under five years were screened for malnutrition; the global acute malnutrition
(GAM) rate was 14.1%.
- Weekly hygiene promotion sessions, home visits by community health workers, traditional birth
attendants and health promoters, and HIV prevention campaigns with condom distributions
were carried out
- 20 traditional birth attendants and mid-wives, as well as 15 community health workers, were
trained

With regard to the nutrition project:

- The recovery rate was 96%
- The default rate was 1%
- The death rate in therapeutic feeding centres was 3.8%, a decrease from the earlier 5.2%
- Weekly health and nutrition education sessions are conducted during distributions, and daily
home visits by community workers

As this was a rapid evaluation, the mission did not verify the statistics at all health infrastructures. Yet,
the mission wishes to highlight the following points:
- In its reports from May 2008, IMC mentions that there are “too many IDP sites”. This situation
has improved since. While there are still a number of displaced people, they live in villages or

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towns and not in sites. For instance, there are reportedly about 200 displaced people in Birao
and about 160 in Ouanda-Djallé.
- Similarly, malnutrition has sharply decreased. In early 2008, IMC still found a GAM-rate of
14.1%. This has now decreased; IMC staff told the mission that the GAM-rate had decreased
to between 2% and 3% (excluding the Sam Ouandja area), including cases of severe acute
malnutrition at about 1%. The health centre in Ouadda, for instance, receives about three
children with severe and 12 to 15 children with moderate acute malnutrition. If accurate, these
rates would be much lower than the national average.
- A therapeutic feeding centre (TFC) is in place in Sam Ouandja, and another one is being
constructed in Ouanda-Djallé. In Ouadda, there is a nutrition programme but no formal TFC or
supplementary feeding centre (SFC). IMC’s project report was somewhat misleading in this
regard, stating that “supplementation feeding centres are in place in each health centre
(OuaddaJalle, Ouadda, Sam Ouandja, refugee camp)”.
- IMC recently partnered with UNICEF for the distribution of mosquito nets. About 95% of children
under five years received a net. Another laudable recent initiative is the start of a programme
to prevent and respond to sexual and gender-based violence. So far, 20 survivors have been
identified by community health workers, mainly from the 2006/2007 conflict. IMC is now
seeking funds to establish ‘centres d’écoute’ for GBV survivors and people living with
HIV/AIDS.

Overall, both the health and the nutrition programmes are well implemented, and are ongoing after the
end of the ERF project duration.

Constraints
What constraints were faced during the implementation of the project, including security and logistical
constraints or constraints internal to the organisation (lack of staff, etc.)? Was the project duration
extended as result? If yes, was it justified?

Organisations working in this area face constant security and logistical challenges when implementing
their programmes. It took the evaluation mission six days to travel the 1,100km from Birao to Bangui.
During this time, bandits attacked and robbed travellers on at least five different occasions in the
triangle Sam Ouandja – Ouanda-Djallé – Ouadda. This makes work especially difficult in an area with
an extremely low population density. Yet, the two programmes were implemented without delays.

Another serious constraint is the lack of support from the Ministry of Health, which leaves IMC taking
over tasks (such as paying staff) that should clearly be carried out by health authorities (see
recommendations below).

Finally, health staff in this area, as elsewhere in the country, have to deal with many at-risk
pregnancies, due to the young age of many pregnant women. The youngest mothers can be 12 or 13
years old. During the evaluation, a 32-year old woman was referred to the hospital in Ouanda-Djallé
but it was too late to prevent a miscarriage – it was her tenth pregnancy.

Impact of ERF funding

What impact did ERF funding have on the overall programme activities of the organisation? Were
ERF-funded activities compatible to activities of other organisations in the same area? Were these
well coordinated?

ERF funding helped in maintaining the health and nutrition projects, extending them, and guaranteeing
the quality of health and nutrition services provided to refugees, displaced people, people affected by
conflict and violence, and others in the region. IMC has secured funding from other sources to

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continue the project once ERF funding had ended, although this funding was insufficient to maintain
previous staffing levels (see recommendations below).

Conclusion
What is the evaluation team’s overall conclusion? Was ERF funding helpful? Was the project
implemented according to the plan? Did it have an impact on the ground? What are the lessons
learnt?

Overall, IMC’s health programme seems to be very professionally implemented. Health posts and
centres and the hospital are well maintained and relatively well equipped, e.g. with mosquito nets on
each bed. IMC’s medical drugs and equipment depot, as well as the pharmacies in the health centres
and posts it services, are well equipped, with more drugs available than in many other places in CAR.
There are two main points of concern, which IMC should address.

First, IMC’s reliance on and training of local staff is laudable. However, due to funding shortages, IMC
had to reduce the number of international staff from three to one (a medical doctor/surgeon), covering
the entire project area with three IMC bases in Sam Ouandja, Ouanda-Djallé and Ouadda, as well as
the many smaller health centres and posts supported by IMC. While there is also a local medical
doctor/surgeon in Ouadda, it seems that this capacity is insufficient, both in terms of responding to
referrals of urgent medical cases and in terms of project supervision. When the evaluation mission
visited in February 2009, the international IMC staff conducted his first supervision visit to Ouadda
although he had been in Ouanda-Djallé since October 2008. It would certainly be helpful for IMC to
recruit a locally based project manager who would be responsible for project coordination, logistics,
finances, administration, etc.

Second, while IMC’s health project seems to be implemented in a very professional manner, there is a
lack of involvement of the Ministry of Health. Many health workers who are nominally employed by the
Ministry of Health only receive a subsidy pay from IMC and have not received their regular salary in
months or years. The Ministry of Health has not made an effort to send additional health workers to
the area (which is a pity, as they would have received excellent training from IMC staff). This problem
is recognized by IMC, as stated in one of the project reports. Thus, IMC’s health and nutrition
programme risks becoming a victim of its own success as the Ministry of Health relies on international
aid rather than providing its own share. IMC should advocate and negotiate with the Ministry of Health
so that the government fulfils its responsibilities in providing basic services to its citizens. IMC should
do so directly, as well as via WHO as lead of the health cluster.

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