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Plan International USA with Helen Keller International and Population Services International

CAMEROON EXPANDED IMPACT CHILD SURVIVAL PROJECT (EIP) FINAL EVALUATION 11 Health Districts of Cameroon: Akonolinga | Awae | Bafut | Batouri | Bertoua | Doume | Esse | Fundong | Mbengwi | Ndop | Nguelemendouka Cooperative Agreement #GHS-A-00-05-00015-00 September 30, 2005 September 29, 2010 Report submitted on: September 22, 2010

Report Writing by: Bonnie L. Kittle, Independent Consultant Edited by: Ephraim Toh, EIP Project Coordinator, Plan Cameroon Ngwa Chris Akonwi Fuh, EIP Assistant, Plan Cameroon Judy Chang, Technical Backstop, Plan USA

ACRONYMS ACMS ACT ANC ARI BCC CBO CBS CCM CCM/M CCM/P CDD CHW C-IMCI CS CSHGP CSSA DIP DMO EBF EIP EPI HIS HKI IEC IHC IMCI IPT ITN KPC LLIN LNGO LQAS M&E MOH MTE NGO NID OR ORS ORT PD PHC ProFam PSI Association Camerounaise pour le Marketing Social (local affiliate of PSI) Artemesinin Combination Therapy Antenatal Care Acute Respiratory Infection Behavior Change Communication Community-Based Organization Capacity Building Supervisor Community Case Management CCM/Malaria CCM/Pneumonia Control of Diarrheal Disease Community Health Worker Community-based Integrated Management of Childhood Illness Child Survival Child Survival and Health Grants Program Child Survival Sustainability Assessment Detailed Implementation Plan District Medical Officer Exclusive Breastfeeding Expanded Impact Program Expanded Program on Immunization Health Information Systems Helen Keller International Information, Education and Communication Integrated Health Center Integrated Management of Childhood Illness Intermittent Preventive Treatment Insecticide Treated Net Knowledge, Practice and Coverage Survey Long Lasting Insecticidal Net Local NGO Lot Quality Assurance Sampling Monitoring and Evaluation Ministry of Health Mid-term Evaluation Non-Governmental Organization National Immunization Day Operations Research Oral Re-hydration Salts Oral Re-hydration Therapy Positive Deviance Provincial Health Coordinator ACMS-affiliated network of private clinics Population Services International

Plan International USA EIP Final Evaluation Report

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RBM TOT TT U5 USAID

Roll Back Malaria Training of Trainers Tetanus Toxoid Children under five years of age United States Agency for International Development

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TABLE OF CONTENTS ACRONYMS .............................................................................................................................ii TABLE OF CONTENTS ........................................................................................................... iv EXECUTIVE SUMMARY ......................................................................................................... 1 I. Overview of the Project ......................................................................................................... 5 II. Data Quality: Strengths and Limitations ............................................................................. 12 III. Presentation of Results ........................................................................................................ 13 IV. Discussion of the Results .................................................................................................... 16 V. Sustained Outcomes, Contribution to Scale, Equity, Community Health Worker Models and Global Learning .................................................................................................................. 26 VI. Conclusions and Recommendations .................................................................................... 30 ANNEXES ANNEX 1. Results Highlight ................................................................................................... 32 ANNEX 2. List of Publications and Presentations .................................................................... 33 ANNEX 3. Project Management .............................................................................................. 36 ANNEX 4. Work Plan Table .................................................................................................... 45 ANNEX 5. Rapid CATCH Table ............................................................................................. 47 ANNEX 6. Final KPC Report .................................................................................................. 48 ANNEX 7. Community Health Worker Training Matrix ........................................................ 103 ANNEX 8. CBO Performance Indicators (as shown on CBO Supervision Form) .................. 104 ANNEX 9. List of Evaluation Team Members ...................................................................... 105 ANNEX 10. Evaluation Methodology .................................................................................... 106 ANNEX 11. List of People Interviewed and contacted during Final Evaluation ..................... 107 ANNEX 12. Special Reports .................................................................................................. 108 ANNEX 13. Project Data Form.............................................................................................. 127 ANNEX 14. Grantee Plans to Address Final Evaluation Findings .......................................... 167 ANNEX 15. Grantee Response to Final Evaluation Findings ................................................. 170

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EXECUTIVE SUMMARY A. Project Description The Expanded Impact Project (EIP) is a five year (2005 2010) initiative being implemented by Plan International, Helen Keller International (HKI) and Population Services International (known in Cameroon as ACMS - Association Camerounaise pour le Marketing Social) in collaboration with the Ministry of Health/Cameroon, six local NGOs1 and hundreds of community-based organizations (CBOs). Activities in the five intervention areas Malaria (40%), Nutrition (30%), Diarrhea Disease Control (10%), Pneumonia (10%) and Immunizations (10%) are being carried out in 11 health districts in three Provinces East, Central and Northwest. The beneficiary population includes 481,441 women of reproductive age and 211,473 children under age five, living in approximately 1,000 communities. The EIP seeks to accelerate the scale-up of Integrated Management of Childhood Illness (IMCI) and Roll Back Malaria (RBM) in Cameroon, and to disseminate successful program interventions, through the concerted effort of organized communities and public, private and international institutions. The EIP Detailed Implementation Plan (DIP) also identified the following three results: 1) improved family behaviors and home care, 2) increased access to quality maternal and child health services and 3) improved capacity of public and private partners systems and structures to sustain Child Survival (CS) activities. B. Main Accomplishments Scale-up. The EIP has significantly contributed to scale-up in the areas of IMCI, Roll Back Malaria and Nutrition through its work on these national working groups, training and operations research (OR). See below for specifics. C-IMCI. The Expanded Impact Project has increased access to maternal and child health information by training 910 CBOs who promote key community-based IMCI (C-IMCI) behaviors among pregnant women and mothers of children under age five. Nine types of health education materials have been provided to each CBO to facilitate their behavior change efforts, including two new flipcharts and a message booklet created during the second phase of the project. Ten out of the 18 health indicators were achieved or surpassed including the following key behaviors (targets are in parentheses):        
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ITN use by children under two increased from 11.8% to 66.4% (60%) ITN use by pregnant women increased from 15.7% to 66.7% (60%) Malnutrition in children under two decreased from 15.9% to 9.5% (10%) Exclusive breastfeeding among children 0-5 months increased from 50.8% to 74.9% (75%) Iron/folic acid supplementation among pregnant women increased from 27.2% to 70.8% (60%) The percentage of children consuming vitamin-rich food increased from 41.3% to 80.9% (60%) Appropriate hand washing increased from 7.7% to 42.2% (30%) Timely care seeking among children with signs of severe illness increased from 37.4% to 74.1% (67.7%)

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

Plan International USA EIP Final Evaluation Report

IMCI. The EIP has supported the scale-up of IMCI by training a pool of national IMCI trainers who have not only trained 346 health care providers in the EIP project area (including 72 in ProFam clinics), but also 62 providers in other regions. Staff at 312 public health facilities in three regions are now practicing IMCI. As a result of advocacy efforts by project partners, IMCI has been approved by the Ministry of Health for inclusion in the pre-service training curriculum for nurses, and steps are being taken to recruit trainers. Malaria Prevention and Treatment. Access to ITNs has been increased through the projects provision of 39,000 ITNs in the project area, increasing ITN use among children under two from 11.8% to 66.4% and among pregnant women from 15.7% to 66.7%. Access to treatment has been increased through the community case management of malaria approach supported by the project. The project supported the training of 5,973 community-based Malaria Relays. Nutrition. With significant assistance from the EIP, a National Nutrition Working Group was established, which has developed a national nutrition strategic plan to guide the efforts of the countrys nutrition initiatives. More specifically, the working group has developed a detailed protocol for the administration of Vitamin A and has approved nationwide training of health care providers in Essential Nutrition Actions (ENA). A total of 324 health care providers were trained in ENA; 241 of these are from within the EIP area, while 83 are from other regions of the country. Following the successful OR study on zinc conducted with support from EIP, in January 2009, zinc was approved by the MOH for inclusion on the Essential Drug List for the management of diarrhea. Steps have been taken to: 1) incorporate the treatment protocol into the pre-service training of health providers; 2) inform current health providers of the treatment protocols; 3) ensure adequate supplies of zinc to all health facilities; and 4) increase access to ORS and zinc at the community level. Pneumonia. The EIP initiated and supported an OR study on Community Case Management (CCM) of pneumonia, the results of which will inform the MOHs decision regarding the scaleup of community-based treatment of pneumonia. The studys final evaluation suggests that cases of severe pneumonia have decreased from 83% to 14% as a result of having access to early treatment of uncomplicated pneumonia at the community level.

Plan International USA EIP Final Evaluation Report

Table 1. Summary of Primary Inputs, Activities and Outputs


Inputs Malaria Prevention and Treatment
 Staff training  Training curricula  equipment and supplies (scales, motorbikes, etc. procured with PVO match funds)  IEC and BCC materials  Supervision tools  Financial resources  Technical advice

Activities

Outputs
 9 types of health education materials developed including 3 since MTE  37,421 health education materials distributed  346 health care providers trained in IMCI in the EIP area, 62 in other regions  910 CBOs trained in C-IMCI  Increased access to ITNs (39,000 distributed)  Increased access to health information (910 villages, 11 districts, 3 provinces)  Increased access to malaria treatment (5,973 Malaria Relays trained)  IMCI approved for pre service training of nurses See above, plus:  Increased access to nutrition information through CBOs and trained health care providers  National Nutrition Working Group formed and informing nutrition-related policies, including vitamin A administration

 Train CBOs in C-IMCI  Train health care providers in IMCI  Train community-based Malaria Relays  Develop/distribute health education materials for use by CBOs and IHC staff;  CBOs promoting ITN use and prompt care seeking  Distribute ITNs  Establish sale points for ITNs & retreatment kits  Participate in Malaria Working Group See above, plus:  Develop protocol and implement Operations Research on zinc  Train PD/Hearth trainers  Implement PD/Hearth in 3 villages  CBOs conducting monthly community-based growth monitoring and education on EBF, complementary feeding and feeding during illness  Train 324 providers in Essential Nutrition Actions See first box, plus:  Establishment of sales points for Orasel and zinc;  Hand washing promotion by CBO members

Nutrition
See above, plus:  Provision of scales to 910 CBOs

Diarrheal Disease Control


See above  Support for Zinc Operations Research See first box, plus:  Increased access to water treatment products;  Increased access to Orasel and zinc  Increased access to health education and rehydration services  Zinc included on the essential medicines list for the treatment of diarrhea See first box; plus:  Increased access to health information promoting timely care seeking for ARI

Pneumonia
See first box See first box, plus  Operations Research on CCM conducted  CBOs referring sick children to health center See first box, plus  Health and Nutrition Action Week organization and implementation  CBOs maintaining the community register

Immunizations
See first box See first box, plus:  Community-based childhood immunization tracking system maintained by CBOs  Increased access to immunization services (through support to Health Week)

Plan International USA EIP Final Evaluation Report

C.

Summary of Main Conclusions and Recommendations

1. The Child Survival Health Grants Program (CSHGP) should seriously consider continuing to offer the Expanded Impact (EI) category of Child Survival Grants so that NGOs have the opportunity to promote scale up of innovative health approaches. Should CSHGP decide to continue the EI category, there should be set indicators to measure the scale-up efforts. 2. To support scale-up, a strategic choice of partners to include those who have experience advocating at the national level is critical. Allocating resources for work at the national level and pilot testing new approaches is also essential to scale-up. 3. When implementing the C-IMCI approach, NGOs should consider training members of existing womens groups. This helps to reduce the expectation for remuneration since the group already existed and were working together voluntarily. It probably also helps sustain the group beyond the life of the project.

Plan International USA EIP Final Evaluation Report

I. Overview of the Project A. Project Description The Expanded Impact Project (EIP) is a five year (2005 2010) initiative implemented by Plan International, Helen Keller International (HKI) and Population Services International (known in Cameroon as ACMS) in collaboration with the Ministry of Health/Cameroon, six local NGOs and 910 community-based organizations (CBOs). Activities in the five intervention areas Malaria (40%), Nutrition (30%), Diarrhea Disease Control (10%), Pneumonia (10%) and Immunizations (10%) are being carried out in 11 health districts in three Provinces East, Central and Northwest, as detailed in the table below. The beneficiary population includes 481,441 women of reproductive age and 211,473 children under age five. To reach all of these communities in a rational manner, the EIP was implemented in two phases. During Phase 1, activities were initiated in 407 remote communities with the worst health indicators. During Phase 2, the project was extended to another 503 communities, for a total of 910 communities2 in 11 districts. Table 2. Targeted Districts East Province Batouri Bertoua Doume Nguelemendouka Districts

Center Province Akonolinga Awae Esse

Northwest Province Bafut Fudong Mbengwi Ndop

The EIP seeks to accelerate the scale-up of IMCI/RBM in Cameroon, and to disseminate successful program interventions through the concerted effort of organized communities and public, private and international institutions. The EIP DIP also identified the following three results: 1) improved family behaviors and home care; 2) increased access to quality maternal and child health services; and, 3) improved capacity for public and private partners systems and structures to sustain Child Survival (CS) activities. To achieve these, the project partners implemented the activities cited in Table 1 at three levels: National, Provincial/District and Community. The activities that take place at the national level contribute almost immediately to scale while those at the provincial, district and local levels serve as a model for implementers outside the project area. The Expanded Impact Project (EIP) operated on several different levels to achieve its objectives. It worked on the demand side, the supply side and the policy side to improve maternal and child health. At the community level the project trained members of community-based organizations (CBOs womens organizations) in the key elements of community-based Integrated Management of Childhood Illnesses (C-IMCI). These CBO members were responsible for raising awareness and promoting behavior change in specific neighborhoods and households using visual aids and other supplies provided by the project. Together they created behavior maps (which became tables
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At the community level, the EIP works with CBOs. In most, but not all cases, there is one CBO per community. In some cases, however, due to the large size or geographical area of the community, more than one CBO was trained. Therefore, the 910 CBOs do not represent the same number of communities.

Plan International USA EIP Final Evaluation Report

after the mid-term evaluation (MTE)) and registers in which key health data about all U5 children was recorded, including information on childhood vaccinations, Vitamin A for children and pregnant women, iron consumption, ITN use and child growth. Table 3. Numbers of CBOs Trained per Region/Phase Region # # CBOs Trained Promoters Phase 1 Phase 2 Total NW 9 128 344 472 East 7 174 101 275 Center 5 105 58 163 Totals 21 407 503 910

The CBOs were trained and supervised by local NGO (LNGO) promoters (and later Plan Promoters see the section on partnerships) who were in turn trained and supervised by Plan staff (Capacity Building Supervisors and Provincial Health Coordinators, who are based in the three regions of the EIP.) In total, 910 CBOs were trained as shown in Table 3. During Phase 1 (20062008), 407 of the more remote and needy communities were targeted and were supervised on a monthly basis. During Phase 2 (20092010), 503 additional CBOs were trained and received monthly supervision while the Phase 1 CBOs were supposed to be visited every other month. Supervision became a significant issue, especially in Phase 2, when the number of CBOs to be supervised became overwhelming for the promoters. In Phase 2 of the project, performance indicators were established for both the CBOs and LNGO/Plan Promoters. The CBO performance indicators (see Annex 8) were used to rate the performance of the CBOs according to the set criteria. Between March-May 2010, the performance of the CBOs was rated; the results are discussed in Section V of this report.

Also at the community level, the project sought to increase access to health care services and products. In this regard, community members were trained as Community Relays for Malaria (CCM/M) and equipped to treat mild cases of malaria and refer more serious cases to the nearest health facility. ACMS (the Cameroon affiliate of PSI) established sale points where products such as ORS (and later zinc) and water guard were sold; their regionally-based promoters also trained CBO members in such things as how to hang a mosquito net. During the first phase of the project, organizational development (OD) activities were carried out to strengthen the institutional capacities of 11 local NGO (LNGO) partners, with an eye toward providing sustained support to the trained CBOs after the project. During the second half of the project, this approach was changed and institutional support was no longer provided. Rather, Plan entered into performance-based contracts with a reduced number of six LNGOs. Also during the second half of the project, and in response to a recommendation of the MTE, the EIP began to more deliberately create links between the staff of the integrated health centers (IHCs) and the CBOs. The heads of the IHC were introduced to the CBO members in their area and CBOs were asked to send a copy of their monthly report to the IHC. Only a very few CBOs regularly send reports to the IHC, however, primarily for lack of the forms, which should be supplied by Plan. CBO members support the work of the IHC by identifying children in need of vaccination and referring sick children to the health center. To reinforce the link between the IHC staff and CBOs it was planned to provide training to IHC heads in C-IMCI. Training in CIMCI was initially only provided to the health care providers in the Northwest region, however,

Plan International USA EIP Final Evaluation Report

because Plan/Cameroon decided that C-IMCI should be showcased in that region and other approaches highlighted in other regions. C-IMCI training for the IHC staff in the Center and East Regions was conducted in September 2010. The EIP also provided much support at the district level to the District Medical Officers and their teams in order to improve the provision of essential services. This included training (IMCI, supervision, health facility assessment surveying (LQAS), Epi Info, and Essential Nutrition Actions), support for the bi-annual Child Health and Nutrition Action Weeks, and some supplies and equipment. IMCI was the approach used to improve the quality of service delivery to children and along with training trainers, the project supported the training and equipping of health care providers in the 11 districts of the EIP project. Table 4 . IMCI Coverage Health District % IMCI Coverage3 Esse 100 Awae 33 Akonolinga 40 Batouri 89 Bertoua 100 Doume 100 Nguelemendouka 33 Bafut 40 Ndop 67 Mbengwi 25 Fundong 83 ACMS supports 25 private health clinics based in Yaound called ProFam, and during the project, about 72 health care providers in these clinics were trained in IMCI, including the clinic owners. Due to high staff turnover, attributed by the ACMS ProFam clinic supervisor to low salaries, at the end of the project only 22 of those trained are still working at ProFam clinics. The ACMS clinic supervisor also pointed out that IMCI is not well suited to the private sector because it is not seen as being cost effective, especially when drugs available at the private clinics are more expensive (since they cannot be purchased at the central pharmacy where the MOH procures their drugs). The attempt to implement IMCI in the ProFam clinics will allow ACMS the opportunity to study the results and learn important lessons regarding IMCI implementation in the private sector. These lessons can then be applied to a future project. Plan regional staff and LNGO promoters attended monthly meetings at the District Health Office and shared their project reports at this level so that all activities taking place at the community level were known at the district level as well. Toward the end of the project, the Government of Cameroon set in motion a decentralization plan which gives much more authority to Local Councils. In keeping with this change, LNGOs
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Refers to the percent of health facilities with staff trained in IMCI and following the protocol.

Plan International USA EIP Final Evaluation Report

and regional Plan staff were encouraged to meet with the Local Councils and inform them about the project and solicit their support. Some LNGOs reported having received fuel money from the Local Council to support field work. Unlike most child survival projects, the EIP was also very active at the national level, helping to create and support IMCI and Nutrition Working Groups, collaborating with UNICEF and WHO, promoting policy changes with regard to IMCI, service delivery approaches (Health and Nutrition Week and ENA), zinc and, in the last year, CCM/pneumonia. The two OR studies were developed and implemented with support from the national level and have, in the case of zinc, and will, in the case of CCM/pneumonia, influence policies at the national level. Partnerships In the EIP project, there were several different types of partnerships: partnership between the three International NGOs (INGOs) Plan, PSI and HKI; partnership between the project (the INGOs) and the MOH at various levels (national, regional, district and local); and partnership between local NGOs (LNGOs) and Plan. As the first two types of partnerships are discussed elsewhere in this document, this section will focus on the partnership between LNGOs and Plan. The EIP design foresaw partnership agreements being entered into with 11 local NGOs. The purpose of the partnerships was to strengthen the capacities of these LNGOs so they could train, support and supervise the CBOs and their work with mothers and pregnant women. Working through LNGOs was also an essential part of the sustainability plan since it was thought that by strengthening the LNGOs as organizations, they would be able to continue to support the community-level work of the CBOs after the project ended. During the first year of the project, an Organization Capacity Assessment (OCA) was conducted to determine the level of capacity of each LNGO and to guide the provision of training and support to build institutional capacity. The initial OCA confirmed that most of the 11 LNGOs were quite weak organizationally and Plan proceeded to provide technical assistance to each LNGO according to their needs. Despite this, by mid-2008, Plan had decided that a few LNGOs were not responding adequately to the organizational development assistance being provided and/or proved untrustworthy. The plan was to not renew the contracts of those LNGOs but rather to employ their promoters directly as EIP (Plan) staff. Plan also decided to find a different OCA tool and to re-administer it after the MTE. Despite the recommendation by the MTE team to re-administer the OCA and continue strengthening LNGOs, the Plan/Cameroon Country Management Team, headed by the Country Director, decided to curtail the provision of organizational development support and renegotiated performance-based contracts with all of the LNGOs (which had been reduced to six) and the 12 newly hired Plan promoters. This decision removed an essential element of the projects sustainability plan since, despite their best intentions, few, if any, of the LNGOs have the means to continue supporting CBOs (they had difficulty doing it even with project funds). Furthermore, because it took a year (from Aug. 2008 to Aug. 2009) to write and finalize the new contracts, support to Phase 1 CBOs was

Plan International USA EIP Final Evaluation Report

suspended for 12 months, and the 503 new CBOs only benefited from eight to 12 months of support. Rather than helping the LNGOs to gain capacity to function effectively and solicit funding for their activities, the project used the LNGOs promoters as sub-contracted staff and set up a performance-based system (see Table 5 below) according to which LNGO and Plan Promoters were remunerated. EIP staff report that while occasionally remuneration was withheld if a certain number of supervisory visits werent made in a given month, this was a rare case and could be made up the following month. Table 5. Minimum Performance Indicators for LNGO and Plan Promoters Items Minimum Performance Indicators Training Train CBOs with respect to their schedule Train CBOs using the curriculum and all other support documents Supervision A health promoter should supervise at least 10 to 15 CBOs per month Work plans LNGOs should submit detailed monthly and quarterly action plans to Plan (Monthly and prior to the implementation of any activity quarterly) Organization Databases should be updated on a monthly basis (# of CBOs of CBO files/ trained/supervised, materials received, etc.); Database Files for each CBO should be updated and classified in chronological order (report, materials received, etc.) Accountability Distribute IEC, training materials to CBOs as soon as received and submit reception attestations to Plan Reporting Submit complete training/supervision/financial reports, following the format given to them and with respect to the time frame, in hard and soft copies This change in strategy begs the question: Wouldnt it have been better for Plan to directly hire all of the promoters needed to train, support and supervise the CBOs rather than work through the LNGOs? In hindsight, the response seems quite clearly, yes, especially since the sustainability strategy during the second half of the project was to rely much more heavily on the IHC staff to support the CBOs in their area. This latter approach seems much more logical in many ways, as the IHC staff should utilize CBOs to reach their own objectives (vaccination, vitamin A coverage, ITN use, etc.), the IHC staff is numerous enough to reach all of the CBOs, and funding (limited as it is) is already available for community outreach activities, which would facilitate supporting the CBOs by IHC staff. In future project designs, then, Plan should more thoroughly examine its commitment and ability to strengthen local NGOs and consider if it wouldnt be more cost- and time-efficient to directly hire promoters to work at the community level and develop the links between the IHC staff and the CBOs. Mission Collaboration Until May 2010, there was no USAID presence in Cameroon and EIP reports were sent to the USAID Regional Office in Accra, Ghana. In April 2010, a Country Program Coordinator, Ms. Aisatou Ngong, was appointed and one of her responsibilities is to oversee such centrally-funded

Plan International USA EIP Final Evaluation Report

projects as the EIP. Upon hearing of her appointment, the Project Coordinator and Plan Cameroon Country Director visited and introduced the project to her and subsequently sent her project reports and invited Ms. Ngong to visit the project, which she did. According to Ms. Ngong, the EIP project is consistent with mission priorities in the region and supportive of the MOHs country priorities. The project has not collaborated on any mission-funded bilateral programs. Changes since the DIP (see Annex 4 for the Work Plan Table) Until the MTE, the project followed the DIP quite closely. In 2008, a few changes were made. Most notably, the projects relationship with the LNGOs changed. Because LNGOs were not performing as effectively as hoped, Plan decided to stop providing organizational strengthening support and entered into performance-based contracts with a reduced number of LNGOs, as described in detail in the previous section. It also decided to hire directly some of the promoters who had been working for those LNGOs. Also after the MTE, it was decided to train the IHC staff in C-IMCI so that they would be in a better position to supervise and support the CBOs. At the time of the final evaluation, only the IHC heads in the NW region had been trained. Plan/HQ reports that the IHC staff in the two other regions were trained in the last month of the project. While it is fortunate that this training has been conducted, the delay is regrettable, as the EIP staff will not be available to reinforce the link between the CBOs and the IHC staff. Contribution to Scale- up The EIP has significantly contributed to scale-up in the areas of IMCI, Roll Back Malaria and nutrition through its work on these national working groups, training and OR. More specifically, the EIP ensured that not only were health care providers within the project area trained in IMCI, but that 90 IMCI trainers nationwide were also trained, so that IMCI could be quickly scaled up if/when support for the training could be secured. To date, 62 health care providers outside the project area have been trained in IMCI. More significant is the Ministrys decision to include IMCI in the pre-service training of nurses, as this will eventually eliminate the need to provide in-service training, which is very expensive and difficult to organize. The Child Health and Nutrition Week is another example of a service delivery strategy that has been adopted nationally by the MOH after having been piloted by the EIP project. Now this approach is being supported by UNICEF, WHO and other organizations. In the area of malaria, the project supported the development and validation of the training manual used to train CCM/Malaria Relays. In total, the project supported the training of 5,973 Malaria Relays nationwide, including 4,084 within the project area. Supporting CCM/Malaria Relays also helped pave the way for consideration of CCM/Pneumonia Relays. Helen Keller International (HKI) worked at the national level and advocated for the recruitment of nutritionists to work in the MOH as well as for the training of nutritionists and dietitians in the University of Ngaoundere. The first training began in 2008, and 15 nutritionists have been trained. These actions will strengthen nutrition activities throughout the country.

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The OR study on the use of zinc in the treatment and prevention of diarrhea was a significant success of the project and resulted in zinc being added to the Essential Drug List, steps being taken to import zinc and ACMS importing zinc for use by IHC staff and community members. The OR Study on CCM/Pneumonia results will also inform the Ministrys decision regarding the scale-up of CCM/Pneumonia. (See Annex 12 for reports on both the zinc and CCM/P OR studies). Also in the area of nutrition, HKIs work on the Essential Nutrition Actions (ENA) has resulted in trainings being conducted outside the project area supported by UNICEF. Health System Strengthening See the section on scale-up and Chapter Five, Discussion of Results, especially regarding IMCI. The EIP strengthened the health system in many ways, as discussed in the Results Section of this report, but its major contribution was in the training provided in IMCI to all health facilities in the 11 target districts. After the training, the project conducted annual health facility assessments to ascertain the extent to which providers were following the IMCI protocol. These results were disaggregated by region and separated out the 25 ProFam clinics in Yaound as shown in Annex 6. As the table shows, impressive improvements were made on almost all indicators, with only two indicators showing poor results: proportion of children who had their nutritional status (vitamin A, weight, etc.) assessed, and proportion of children whose caretakers were counseled on the importance of giving fluids at home. Due to the reassignment of staff by the MOH following IMCI training, at the end of the project only 36.4% of the providers assessed had actually been trained in IMCI. This suggests that new providers are being given an orientation on IMCI by current staff and that regular supervision by the district is having a positive effect on IMCI practice.

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II. Data Quality: Strengths and Limitations The EIP had a very rigorous and comprehensive data collection (monitoring) system that combined the use of quantitative and qualitative information. Tools included: monthly reports submitted by CBOs, LNGO/Plan Promoters and ACMS promoters; and supervision checklists for promoters (LNGO/Plan), CBS and Provincial Health Coordinators. While many of the forms and checklists do collect quantitative data, some areas are made available for more qualitative comments. The collection of qualitative data could be strengthened, however. For example, performance indicators for CBOs (Annex 8) only ask whether growth monitoring was conducted. A more qualitative question (though reflected in a percentage) would be: What percent of all children were weighed? Furthermore, qualitative data needs to be verifiable, so asking if appropriate advice was given (when this cannot be observed) is not particularly helpful. Plan and its partners carried out annual KPC and Health Facility Assessments and used this information to make programmatic adjustments. In turn, the MOH (District Medical Teams) used this information to redirect resources to areas where performance (coverage) was low. The achievements mentioned in this report are not based on MOH/HIS data. The projects two main data collection systems (KPC and Health Facility Assessment) collected information at all levels except at the national level. The two data collection tools employed are typically used to measure normal category Child Survival grants, which seek primarily to have an impact at the community level. When the Expanded Impact (EI) category was created, no other data collection tool or alternative indicators were developed/offered to measure the impact of the project at the national level. Should the Child Survival Health Grants Program decide to continue the EI category, set indicators to measure the scale-up efforts would be beneficial.

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III. Presentation of Results Table 6. Presentation of Quantitative Results Objectives 1


MALARIA (40%) Increase from 11.8% to 60% children age 0-23 months who slept under an ITN the previous night Increase from 15.7% to 60% pregnant women who slept under an ITN the previous night Increase from 11.7% to 60% children age 0-59 months who received a full course of recommended anti-malarial within the 24 hours of onset of fever Increase from 18.5% to 75% women who completed IPT during their current or last pregnancy Increase by 25% the number of net owners who have retreated net at least once in the last year NUTRITION (30%) Decrease from 15.9% to 10 % children age 0-23 months who are under-weight (-2 SD from the median weight-for-age, according to the WHO/NCHS reference population) Increase from 50.8% to 75.8% children age 0-5 months who were exclusively breastfeeding during the last 24 hours Increase from 92.1% to 95% children age 6-9 months who received breast-milk and complementary foods during the last 24 hours Increase from 65.3% to 80% children age 6-9 months who received animal and/or vegetable protein during the last 24 hours
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Indicators
% of children age 0-23 months who slept under an insecticide-treated net the previous night % of pregnant women who slept under an insecticide-treated net the previous night % of children age 0-59 months who received a full-course of recommended anti-malarial (according to the MOHs recently approved home-management protocols) within the 24 hours of the onset of fever % of women who completed Intermittent Preventive Treatment (IPT) during their current or last pregnancy % of net owners who have retreated net at least once in the last year

BLD
11.8%

MT
60.7%

FE
66.4%

Target
60%

15.7%

43.2%

66.7%

60%

11.7%

36.6%

51.9%

60%

18.5%

51.4%

69.6%

75%

No baseline

8%

No data

25% increase over baseline 10%

% of children age 0-23 months who are under-weight (-2 SD from the median weight-for-age, according to the WHO/NCHS reference population)

15.9%

9.4%

9.5%

% of children age 0-5 months who were exclusively breast-feeding during the last 24 hours

50.8%4

63.1%

74.9%

75.8%

% of children age 6-9 months who received breast-milk and complementary foods during the last 24 hours % of children age 6-9 months who received animal and/or vegetable protein during the last 24 hours

92.1%

93.6%

90.2%

95%

65.3%

58.2%

84.1%

80%

The baseline is already significantly higher than the national average because two of the three target regions already had higher than average EBF rates and the project is not being implemented in the provinces with extremely low EBF rates.

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Objectives 10
Increase to 90% children age 6-59 months who received vitamin A supplementation in the prior six months Increase to 80% mothers giving birth in the last 12 months who received two vitamin A supplements within eight weeks post partum Increase from 9.2% to 40% sick children age 0-23 months who received increased fluids and continued feeding during an illness in the past two weeks Increase in 30% points (from baseline) of pregnant women taking iron/ folic acid supplements daily for at least five months during their last pregnancy Increase in 25% points (from baseline) of children 6-59 months of age eating vitamin A rich foods daily during the past week DIARRHEA (10%) Increase from 7.7% to 30% mothers of children age 0-23 months who report that they wash their hands with soap/ash before food preparation, before feeding children, after defecation and after attending a child who has defecated PNEUMONIA (10%) Increase from 65.9% to 80% mothers of children age 0-23 months who know at least two signs of childhood illness (fast breathing and chest indrawing) that indicate the need for treatment Increase from 37.4% to 67.7% children with signs of severe childhood illness who were seen by a qualified public or private provider in the past two weeks IMMUNIZATION (10%)

Indicators
% of children age 6-59 months who received a Vitamin A supplement in the prior six months % of mothers of children age 0-23 months who received two Vitamin A supplements within eight weeks post partum % of sick children age 0-23 months who received increased fluids and continued feeding during an illness in the past two weeks

BLD
80.9%

MT
76.6%

FE
69.3%

Target
90%

11

21.6%

30%

38.3%

80%

12

9.2%

14.6%

13.9%

40%

13

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

27.2%

33.7%

70.8%

60%

14

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

41.3%

86.7%

80.9%

60%

15

% of mothers of children age 0-23 months who report that they wash their hands with soap/ash before food preparation, before feeding children, after defecation and after a attending a child who has defecated

7.7%

15.5%

42.2%

30%

16

% of mothers of children age 0-23 months who know at least two signs of childhood illness (fast breathing and chest in-drawing) that indicate the need for treatment

65.9%

70.4%

77.9%

80%

17

% of children with signs of severe childhood illness who were seen by a qualified public or private provider in the past two weeks

37.4%

51%

74.1%

67.7%

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Objectives 18
Increase from 70.5% to 80% children age 0-23 months who received vaccination coverage for all antigens Increase from 58.9% to 80% mothers of children age 0-23 months who received 2TT during their last pregnancy

Indicators
% of children age 1223 months who are fully vaccinated (against the five vaccine-preventable diseases) before the first birthday % of mothers of children age 0-23 months who received 2TT during their last pregnancy

BLD
70.5%

MT
73%

FE
67.2%

Target
80%

19

58.9%

56.8%

63.2%

80%

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IV. Discussion of the Results A. Malaria (40%) Indicators


% of children age 0-23 months who slept under an insecticide-treated net the previous night % of pregnant women who slept under an insecticidetreated net the previous night % of children age 0-59 months who received a fullcourse of recommended anti-malarial (according to the MOHs recently approved home-management protocols) within the 24 hours of the onset of fever % of women who completed Intermittent Preventive Treatment (IPT) during their current or last pregnancy % of net owners who have retreated net at least once in the last year

Baseline
11.8% 15.7% 11.7%

Midterm
60.7% 43.2% 36.6%

Final
66.4% 66.7% 51.9%

LOP Target
60% 60% 60%

18.5% No baseline

51.4% 8%

69.6% No data

75% 25% increase over baseline

The malaria component of the EIP seeks to reduce the number of malaria cases among children and pregnant women through ITN use and IPT, and to increase access to quality treatment through symptom recognition, timely care seeking, and quality of care improvement and community case management of malaria (CCM/M). A full list of activities is shown in Table 1. As the table above shows, the two indicator targets related to ITN use were achieved. The objective associated with treatment of malaria in children came within eight percentage points of being achieved, and IPT for pregnant women missed its mark by five percentage points. The project decided not to measure ITN re-treatment, as long-lasting bed nets were distributed in a large proportion of the project area. These achievements are due to the projects initiatives on many fronts national, regional/district and community and to the partners combined efforts. At the national level, the EIP was represented on the Malaria Working Group and was instrumental in designing the Community Relay/Malaria (a CHW who is trained in CCM for Malaria only) training curriculum and supporting the training of 5,973 Community Relays/Malaria nationwide, 4,084 of whom are based in the project area. Among these are 546 CCM/M Relays trained by ACMS with matching funds who work in five of the EIP districts The projects support of these activities contributed to the scale-up of the Community Case Management of Malaria (CCM/M) approach throughout the country, greatly improving access to curative services. As mentioned in the MTE report, one problem in this initiative was the failure of the MOH to make ACTs available to the CCM/M relays once they were trained. The kits were only distributed nine months after the training. The final evaluation team interviewed a sample of CCM/M Relays and found that many still experienced long stock outs of ACT and some had difficulty accurately naming the signs of severe malaria and when to refer a patient. Clearly, the issues of supply and supportive supervision still need to be addressed.

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At the regional and district levels, the EIPs training of 346 health care providers working in 171 out of 175 facilities in EIP areas in IMCI ensures the accurate diagnosis and treatment of malaria cases, including severe malaria. Furthermore, Plan and ACMSs contribution of 39,000 ITNs during the first half of the project using funding from another project helped to increase ITN use, especially among children. During the second half of the project, EIP partners did not receive a new supply of ITNs for distribution, and the MOHs efforts in this regard (Rounds 3 and 5 of the Global Fund) focused on distributing ITNs to pregnant women during antenatal consultations. Some facilities provided ITNs to infants born in the district hospital. The work of the CBOs in creating demand for ITNs contributed to the success of this initiative. At the community level, the projects training of approximately 40,600 CBO members in an estimated 910 communities in C-IMCI significantly increased access to information about how to prevent malaria and when and where to seek care. More importantly however, ACMS provided training to CBO members about how to hang an ITN, and the most active members of the CBOs, usually four to seven per community, conducted monthly home visits to each family with children U5 to see if they had a mosquito net hung over the bed and if the child slept under it. The same was done for pregnant women. This very personal and proactive measure goes one crucial step beyond ITN ownership, to ensure ITN use. And lastly, to increase the degree of protection, the project (ACMS) also facilitated the re-treatment of ITNs by establishing sale points for re-treatment kits and promoting the practice during bi-annual Health and Nutrition Weeks. Re-treatment of ITNs was emphasized much less during the second half of the project, however, because the Ministrys Roll Back Malaria Initiative (RBM) distributed only longlasting mosquito nets, making re-treatment less of a concern. The malaria component in the Central Region was also greatly assisted by a malaria project that was funded by Plan Netherlands and Plan France. This five-year project, which began in 2005, has the same objectives as the EIP malaria component and has contributed mosquito nets and funds to support activities similar to those of the EIP. B. Nutrition (30%)
Indicators
% of children age 0-23 months who are under-weight (-2 SD from the median weight-for-age, according to the WHO/NCHS reference population) % of children age 0-5 months who were exclusively breastfeeding during the last 24 hours % of children age 6-9 months who received breast-milk and complementary foods during the last 24 hours % of children age 6-9 months who received animal and/or vegetable protein during the last 24 hours
5

Baseline
15.9% 50.8%5 92.1% 65.3%

Midterm
9.4%

Final
9.5%

LOP Target
10%

63.1% 93.6% 58.2%

74.9% 90.2% 84.1%

75.8% 95% 80%

The baseline is already significantly higher than the national average (23.5%) because two of the three target regions already had higher than average EBF rates and the project is not being implemented in the provinces with extremely low EBF rates.

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% of children age 6-59 month who received a Vitamin A supplement in the prior six months % of mothers of children age 0-23 months who received two Vitamin A supplements within eight weeks post partum % of sick children age 0-23 months who received increased fluids and continued feeding during an illness in the past two weeks. % of mothers of children age 0-32 taking iron/folate supplements daily for at least 5 months during their last pregnancy % of children 6-59 months of age eating vitamin A rich foods daily during the past week.

80.9% 21.6% 9.2%

76.6% 30% 14.6%

69.3% 38.3% 13.9%

90% 80% 40%

27.2%

33.7%

70.8%

60%

41.3%

86.7%

80.9%

60%

The nutrition component of the EIP focused on improving the nutritional status of children U5 and on improving micronutrient intake especially Vitamin A, zinc, iron and folic acid. The target audiences for this components activities were children U5 and pregnant women. The strategies used are cited in Table 1. As the above table shows, out of the nine nutrition indicators, six have been nearly achieved or surpassed. Five of the indicators do not require access to outside resources and therefore are susceptible to change through community-level promotion alone, including indicators having to do with child feeding practices. The other behaviors require access to a resource such as vitamin A or iron/folate. The indicator related to reduced malnutrition (underweight) is associated with many factors. Regarding the reduction in malnutrition, during the MTE it was concluded that the reduction in malnutrition was more likely attributable to reduced morbidity (malaria and diarrhea) than to significant improvements in feeding habits. This conclusion was also supported by anecdotal evidence provided by health center staff who reported reduced incidences of diarrhea and malaria. Recognizing the links between morbidity and malnutrition, during the second phase of the project ,HKI spearheaded the effort to modify the acute malnutrition management protocol to include some elements of IMCI. This should help improve the effectiveness of case management of acute malnutrition in children. During the final evaluation, one District Medical Officer attributed the reduction in malnutrition in the Eastern Region to the efforts of UNICEF and Doctors Without Borders (MSF), which have been more widely active in the region and provide inputs as such Plumpy Nut and CSM (corn, soy, maize mix). That said, when the data from the KPC survey was disaggregated to show the results of the Positive Deviance (PD)/Hearth approach implemented in Ngeulemendouka Health District (where neither UNICEF nor MSF works), the data showed that at baseline, 43.8% of children weighed were malnourished (% of children age 0-23 months who are under-weight: <-2 SD from the median weight-for-age, according to the WHO/NCHS reference population), and by the end of the project only 12.0% of children were malnourished. Rather than use imported commodities to address childhood malnutrition, the EIP project chose a more sustainable approach, PD/Hearth, which teaches mothers to use local foods to recuperate their child. During the life of the project, 1,320 children in three villages in the Ngeulemendouka Health District were weighed, and 621 (47%) were found to be malnourished.

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After participating in PD/Hearth, 584 (94%) of the children were rehabilitated. These results show the potency of PD/Hearth and suggest that it should be applied more widely in areas were malnutrition in children is a prevalent and where long-term sustainable solutions are sought. Child feeding behaviors are being promoted by IHC staff and CBO members who were trained by the project. Three hundred twenty-four (324) health care providers in the EIP area were trained in ENA and all 910 CBOs and IHC staff were trained by the project in C-IMCI. During the second half of the project, 503 CBOs (approximately 17,191 members) were trained in CIMCI using a new curriculum developed and revised by the EIP partners. Despite having made improvements over the prior curriculum based on MTE recommendations to use more participatory learning methods, the four days allotted to learn the material especially such complex tasks as growth monitoring (which was taught in 60 minutes), health education techniques, and health information systems was insufficient. One of the improvements made in the curriculum was the use of a pre-/post-test approach suitable for illiterate populations. The project should be commended for taking on this challenge. Unfortunately, the method devised does not allow the facilitators to know which questions the respondent answered correctly, but only the number of correct and incorrect responses. While this is a vast improvement over not administering any pre-/post-tests, further research into other methods that are more useful is needed. Furthermore, the pre-/post-test questions should be revised to focus on the most common life-threatening problems faced by children (currently three of the 25 questions are on HIV/AIDS). While over 40,000 CBO members were trained over the course of the project, only a handful of CBO members in each village actively promote the key behaviors in their community. These include the CBO President, the secretary (who helps with growth monitoring and maintains the community register) and block chiefs (neighborhood leaders who identify the households in their neighborhoods who have children U5 or pregnant women and promote behavior change through growth monitoring, home visits and group talks). The final evaluation team also found that regardless of the size of the community, the number of CBO members trained remained around 30. In communities with many inhabitants, several CBO groups were selected to make sure the workload of each CBO member did not exceed 10 to 20 households. While this decision was based on guidance about training group size, it was not logical from a programming perspective. Villages with only 97 inhabitants need far fewer trained CBO members than communities with 300 residents or more. In a follow-on project, there should be about one trained CBO member for about 10-15 households with young children. The MTE recommended that additional and better quality visual aids be provided to CBOs to help promote behavior change. In response to this, EIP partners, especially HKI and ACMS, developed two flipcharts and a message booklet. One of the flipcharts contains drawings and photographs on nutrition messages only. This flipchart took into consideration the results of the Doer/Non-doer survey conducted as part of the BEHAVE training during the first half of the project, which indicated that the grandmothers of well-nourished children encouraged exclusive breast feeding, feeding with bush meat, and consumption of food prepared with red palm oil. Specific messages and pictures were created to promote these practices. To further increase access to appropriate visual aids throughout the country, HKI created a data bank of nutrition

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education materials prototypes for use by interested parties. The use of this data bank will go a long way to ensure the standardization of messages and promotion of key behaviors. Regarding community-based growth monitoring and promotion, in most villages children are weighed monthly on a house-to-house basis by the block chief who carries the scale and a small notebook door to door. She, and perhaps the secretary, weigh the child, mark the weight in the notebook and then later record this information in the community register since the register is too large to carry around. Done in this way, the activity is more a data collection exercise than a counseling or screening opportunity. While CBO members are taught to be alert for children who do not gain weight each month, done in this way, they cannot know at the time of the weighing if the weight has increased or decreased or if the weight is normal for the age of the child. This situation puts into question the validity of the data gathered and reported each month by the CBOs. To address this, a separate training (perhaps in-service) on growth monitoring should be provided to select CBO members and those people should be instructed to use the Message Booklet (Chart 23) which contains the Road to Health graph to chart the childs weight and determine actual nutritional status of the child. In some communities visited during the final evaluation, the team found that adult scales, rather than Salter scales, had been distributed by the project. This makes growth monitoring more complex and less accurate, as a mathematical calculation has to be made and the scale is not as sensitive. Furthermore, in some communities a very small percent of the children are weighed each month which means that even if the weighing is accurate, the information only reflects a portion of the under three population. One of the indicators used to measure the performance of CBOs and to evaluate the quality of their growth monitoring work only determines if growth monitoring was conducted and does not specify a target level of coverage/participation, e.g., 80% of children 0-36 months weighed. In a subsequent project, this kind of coverage measurement would be advised. Three of the nutrition indicators did not reach their targets. The two related to Vitamin A coverage relied on the availability of Vitamin A provided by the MOH and stock outs thwarted efforts to achieve higher coverage. With regard to improved feeding of sick children, although sick children are a target audience for CBO home visits, a review of the revised C-IMCI curriculum shows that the message about feeding a sick child is only mentioned once and only in the module on diarrhea. Despite the fact that the message is clearly communicated in the Message Booklet in Chart 15, it seems that the message about feeding a sick child, regardless of the illness, was not communicated strongly enough to promoters or CBO members. The project has also supported nutrition activities at the national and regional levels. These include support for the establishment of a National Nutrition Working Group, an OR study on the introduction of zinc, ENA training for health care providers and PD/Hearth training. The National Nutrition Working Group brings together stakeholders from around the country to develop a strategic plan, to set nutrition policy and to consider means to improve nutritional status among various target audiences. The EIP not only supported members participation in the working group, but EIP staff attended the meetings regularly and influenced decisions. The working group was officially sanctioned by the government in 2008.

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The zinc OR, conducted by HKI, was a pilot research intervention carried out in the Bertoua Health District of the East province between August 2007 and February 2008. The purpose of the research was to study how best to introduce the use of zinc in the country for the management of diarrhea. The study found that: a) the ORS/zinc combination is affordable, b) compliance is acceptable; c) zinc treatment for diarrhea increased the use of ORS/ORT but did not influence the correct use of antibiotics by health personnel; and d) information about zinc is primarily communicated by health care providers and community relays. The report recommends that in addition to treatment being provided at the health centers, diarrhea treatment kits comprised of ORS and 10 zinc tablets be made available to the population through trained CBO members and local pharmacies. As a result of the study, zinc has been included on the list of essential drugs in Cameroon and the process is in place to establish the means of importation. Furthermore, steps are being taken to include the administration of zinc in the IMCI protocols for treatment of diarrhea. ACMS is importing low osmolarity ORS and zinc, and through the health education efforts of IHC staff and CBOs, some mothers are now aware of the added value of zinc in the treatment of diarrhea. The EIP supported the training of 74 health care providers as ENA trainers in the project area. This training has allowed the MOH to train 324 MOH staff and extension workers to more effectively and proactively promote the key nutrition behaviors that CBO members are promoting as a part of C-IMCI. The training of trainers also helped scale up this approach throughout the country, and with assistance from UNICEF, 103 para-medical students and 2,310 community members have been trained in ENA outside the project area. HKI asserts that the ENA work has helped to increase iron supplementation among post-partum women. In reviewing the nutrition indicators, the evaluation team felt that from a design perspective it would be better to focus on behaviors with quite low (below 75%) compliance. The complementary feeding indicator was already above 90% at baseline and therefore did not really merit the attention of this project. C. Diarrheal Disease Control (10%)
Indicators % of mothers of children age 0-23 months who report that they wash their hands with soap/ash before food preparation, before feeding children, after defecation and after a attending a child who has defecated. Baseline 7.7% Midterm 15.5% Final 42.2% LOP Target 30%

Although the EIP partners only chose one indicator to measure their efforts to control diarrheal disease, the projects efforts to prevent diarrhea and reduce its negative consequences focus on hand washing, water treatment, and ORS/ORT administration. The treatment and prevention of diarrhea was also addressed by the OR study described in the nutrition section. Two strategies were used to address diarrhea. Through C-IMCI training CBO members learned to promote hand washing, to use ORS/ORT and to treat their drinking water.

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As the M&E table shows, the EIP surpassed is final target of 30% with regard to hand washing. This is due to a focus on this message during the second half of the project accompanied by new visual aids and improved C-IMCI curriculum in which hand washing is emphasized. Evaluation team members reported that hand washing was not only studied during training events, but also practiced as a model personal hygiene behavior. It appears now that hand washing with soap at least in some circles has become a cultural norm. ACMS was particularly involved in the activities for the control of diarrheal disease (CDD), and it is regrettable that there were not one or two more indicators to measure their efforts. An indicator on ORS use and/or water treatment would have been a valid choice. ACMS increased access to Orasel and later, after the zinc was included on the Essential Drug List, low osmolarity ORS with zinc by establishing 99 sale points in and near the targeted EIP communities, resulting in the sale of 20,000 sachets of ORS (both types). ACMS also helped to reduce exposure to causes of diarrhea by increasing access to potable water through in-home water treatment with Water Guard. Nine hundred sixty-two (962) points of sale for Water Guard have been established by ACMS, with 3,979 bottles of Water Guard sold in the project area. During the second half of the project however, ACMS experienced serious challenges with regard to the supply of Water Guard, which resulted in prolonged country-wide stock outs of the product. When tested by the government authorities, the locally produced Water Guard was not approved for distribution and an entire batch of the product went unused. PSI/HQ subsequently changed its supplier, causing extended and inexplicable stock outages. As a result, during the second half of the project, EIP community members have not had access to Water Guard to treat their drinking water. D. Pneumonia (10%)
Indicators % of mothers of children age 0-23 months who know at least two signs of childhood illness (fast breathing and chest in-drawing) that indicate the need for treatment. % of children with signs of severe childhood illness who were seen by a qualified public or private provider in the past two weeks. Baseline 65.9% Midterm 70.4% Final 77.9% LOP Target 80%

37.4%

51%

74.1%

67.7%

In addition to the recognition of signs of acute respiratory infection (ARI) and timely care seeking promoted by trained CBO members, and improved quality of ARI treatment by IMCIpracticing health care providers, the EIP had hoped that the government would adopt the CCM/P approach following a visit to Senegal and review of case studies from neighboring countries where CCM has proved effective. Instead, the MOH decided that another OR study was needed. At the time of the MTE, the protocol for the CCM/P OR was being developed. The first protocol, developed by a researcher at the Faculty of Medicine and Biological Sciences at the University of Yaound I, was not approved and had to be modified. Finally the MOH approved the protocol and the 12-month CCM/P OR finally got underway in November 2009. It was implemented only in Bafut District in the Northwest Region and entailed a two-day training for 90 Community Relays/health workers the majority of whom were previously trained and

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currently serving as Malaria Community Relays/health workers. The training was based on the booklet Caring for Sick Child. Each CCM/P Community Relay/health worker is responsible for providing care to children with signs of uncomplicated pneumonia living in three communities. They are also supposed to diagnose complicated cases of pneumonia and refer these cases to the health center. Pneumonia education is also among their responsibilities, but in reality the CCM/P focus primarily on their curative tasks, leaving the education responsibilities to the CBOs. The project supported all aspects of the OR implementation, including the initial supply of amoxicillin, which the MOH was then expected to replenish as needed. IHC heads, Plan CBS and the Provincial Health Coordinator are charged with monthly supervision of each Community Relay. A final evaluation of the study was carried out in September 2010 and showed the following results. (See Annex 12 for the full report.) Table 7. Reported Source of Care for Sick Child Source Baseline Mid Term 11/09 5/10 Comm. Relay/Pneumonia 2.4 23.7 Health Facility 49.5 30.2 Traditional Healer 32.7 1.2 Self Medicated 9.7 8.8 Shop Keeper 5.7 5.6

The information shown in Table 7 suggests that among the caregivers interviewed, a large number have begun to seek care from trained CCM of pneumonia community relays. They have greatly decreased their reliance on traditional healers, but at the same time, there are also fewer caregivers seeking care from health facilities. Overall, these results suggest an improvement in access to health care for pneumonia since the CCM/P Community Relays live closer to the population than the health center. Final 9/10 45.3 35.0 1.1 5.4 2.1 Treatment compliance among mothers of pneumonia patients was also quite high at 88.4%. When checking the performance of the relays, their performance was quite encouraging. 97.8% of the relays filled out their monthly report correctly and 10% experienced stock outs of amoxicillin. All of the relays had been supervised during the preceding six months and 92.2% had been supervised in the last month. All of the relays could name two signs of uncomplicated pneumonia, and 95.6% could name two signs of complicated pneumonia. 98.9% of the relays could correctly prescribe the treatment of pneumonia in a child 2-11 months, and 100% could name the correct treatment of an older child age 12-59 months. These results show a significant improvement from the mid-term evaluation. It is clear that strong supervision and on-the-job training which were conducted after the mid-term evaluation improved the knowledge of the community relays. However, there is some concern that the relays do not have many opportunities to practice their treatment skills/knowledge. Several of the relays interviewed during the final evaluation had only treated one to two children in the last quarter. The link between health center staff and the CCM/P relays should also be strengthened. E. Immunization (10%)
Indicators Baseline Midterm Final LOP Target

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% of children age 1223 months who are fully vaccinated (against the five vaccine-preventable diseases) before the first birthday % of mothers of children age 0-23 months who received 2TT during their last pregnancy

70.5%

73%

67.2%

80%

58.9%

56.8%

63.2%

80%

The table above shows that neither immunization indicator was achieved. Given the amount of effort that the MOH and the project invested in increasing vaccination rates, this is likely due to the requirement of the KPC survey that the vaccination card be used as evidence; stock outs of vaccination cards were common during the second half of the project. Mothers recall, a monitoring indicator of the project, suggests that childhood vaccination rates exceed 80%. As with the other intervention areas, the IMCI strategy was meant to improve vaccination coverage rates. The role that IMCI was to play in ensuring that every child is completely immunized through well baby or sick child consultations was hindered, however, by a MOH policy which prohibits providers from opening an entire vial to immunize only one or a few children, and only vials with multiple doses are currently available. Consequently, the IMCI strategy was not able to have a major impact on improving immunization coverage. To compensate for this, and to improve coverage of other services, health care providers typically informed mothers about the next vaccination day being held at the clinic. They also conducted outreach vaccination days where health center staff travel to a specific location and vaccinate all children within a specific radius. CBOs whose registers indicate which children need to be vaccinated are sometimes solicited to help find children in need of vaccinations. In this way, community members contribute to increasing vaccination coverage. During the final evaluation, team members examined CBO registers and found that rather than writing in the actual date the vaccination was given, they only marked a check. While it is preferable that the date be written in, in reality, if the register is primarily used just to identify unvaccinated children, the check would suffice. In addition to this outreach, the EIP developed a strategy called the Health and Nutrition Week. Twice per year for one week, the entire health system in each health area mobilizes to offer a set of services (which varies by health district depending on the need) in every village. During this period, vaccination services are provided in each village; injections being administered from a fixed site and oral doses of polio and Vitamin A being provided during home visits. After only two Health Weeks conducted by the EIP, the MOH adopted this strategy on the national level and Health Weeks are now being conducted bi-annually nationwide with support from many different partners, including international NGOs and bilateral and multilateral agencies. While EIP reports show great improvement in coverage in some districts and lacking coverage in other districts, to date, no cost/benefit analysis has been conducted to determine the costeffectiveness of Health Weeks. In addition to this concern, there are two additional concerns: that this approach may encourage the population to wait for health services to come to them rather than seeking them out on their own (which is the major message of the C-IMCI strategy), and sustainability. Unlike the outreach vaccination activity (strategie avanc), which is budgeted for by the MOH and conducted on a routine basis, the Health and Nutrition Week depends on partners to mobilize the necessary resources even though the MOH also funds a large part of the

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initiative. It would seem that such a massive mobilization would not be necessary if the IMCI and C-IMCI strategies were fully effective. Despite all of these concerns, it should be noted that no outbreaks of childhood illnesses have taken place in the project areas during the EIP. At the community level, trained CBO members are supposed to track immunization coverage using two tools: the behavior map and the community register. The evaluation team attempted to assess the quality of the community health information system and found that while most villages had behavior maps that appeared to be kept up to date (including immunization status of U5), the registers were not as well maintained. More importantly, however, it is not clear that CBO members or IHC staff are using the registers to identify children whose immunization status is not up to date to refer them to the health center.

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V.

Sustained Outcomes, Contribution to Scale, Equity, Community Health Worker Models and Global Learning

A. Sustainability The EIP took sustainability seriously, especially at the outset of the project, as evidenced by the organization of a four-day Child Survival Sustainability Assessment workshop conducted by the Plan CS backstop officer in March 2006. Forty-one (41) people attended this workshop, including MOH representatives from each of the eleven districts. A key element in the sustainability strategy was the role of the LNGOs who were expected to continue to support the CBOs after the project ended. As discussed in the section on local partner strengthening, the focus on the LNGOs as part of the sustainability plan changed midway through the project when institutional capacity building efforts for the six remaining LNGOs were curtailed and performance-based contracts were signed. Without the ability to solicit funds from other donors, the LNGOs do not have the resources they will need to continue to support the CBOs. Based on the MTE recommendation, the sustainability plan was amended (unofficially) to provide for a more active role of the IHC in supporting the CBOs, as their work focuses on health. The final evaluation team found evidence of this strengthened role, but given the limited staff at the IHCs and the rather limited time to reinforce their role, it is not certain if the IHC will be able to provide enough support to the CBOs in their areas. See the section on Community Health Worker Model (below) for its effect on sustainability. All of the scale-up activities mentioned in this report are inherently linked to sustainability; once responsibly for an activity is assumed by the Ministry of Health (or any other permanent entity), it will then be continued by that entity. Examples from the EIP include: The bi-annual Health and Nutrition Week, inclusion of zinc on the Essential Drug List, and inclusion of IMCI in preservice training for nurses. B. Scale- up The EIP was particularly effective in the area of scale-up. In addition to working effectively at the community level to create demand, in each of the intervention areas (malaria, nutrition, diarrhea disease control, immunization, and pneumonia), successes were noted regarding scaleup. With regard to malaria, the project helped to modify the manual used to train CCM/Malaria outreach workers both inside and outside the project area, and 90 CCM/Malaria were trained in the project area. The projects ITN distribution was complemented by that of the Global Fund to extend coverage. Helen Keller International was especially effective in the area of nutrition, helping to establish and support the National Nutrition Working Group. The ENA approach has spread beyond the EIP intervention area and with assistance from UNICEF, providers from other districts have been trained. The zinc OR effort resulted in zinc being included on the Essential Drug List for the

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management of diarrhea, and its use is now being promoted throughout the country. The adoption by the MOH of the Bi-annual Health and Nutrition Week as a means to improve vaccination coverage (and the provision of Vitamin A and other services) is another example of a new approach introduced and initially supported by the project that has been adopted outside the project area and is currently being supported by the MOH and other donors. Although the CCM/P OR study was only implemented in the last year of the project, the results will be used by the MOH to determine whether or not CCM/P will be adopted by the MOH as an official strategy. And finally, the projects assistance in getting IMCI accepted as an official treatment strategy and incorporated into pre-service training of nurses (still being pursued) is another scale-up success. All of these scale-up efforts were effective because the project worked consistently at the national level on various working groups and made it possible for working groups to convene. They used project funds to pilot test different approaches at the local level and demonstrate the effectiveness of the approach. They then disseminated the results, encouraging MOH decisionmakers and international partners such as UNCIEF and WHO to take action. The fact that the project was present at the national, district and village levels and present in three provinces made a significant difference. A smaller project would not likely have demanded the attention of the MOH or international partners such as UNICEF and WHO. C. Equity The main equity issue addressed by the project was gender. It did this by choosing to work with womens groups (CBOs) that already existed in the communities. The project trained, on average, 30 female members of each CBO, thereby strengthening their ability to promote healthy behaviors throughout the community. Interestingly, in the end, the project determined that they also needed the support of men to promote certain behaviors, and in some cases, men were also invited to join the CBOs. D. Community Health Worker (CHW) Models The EIP trained three types of CHWs as shown in Annex 7. The largest and most important group consisted of the 27,000+ CBO members from approximately 910 communities, who were trained in C-IMCI to promote healthy behaviors among a specific number of households per CBO member. Rather than train individuals as CHWs, the EIP decided that by training a preexisting group of women, the chance that they would remain together and continue to work after the project would be greater. They also thought that by training a large number of women (30) from each CBO, they would be creating a critical mass of learned people in the community, which would serve as a more effective strategy of reaching all of the target families in a community. And finally, since most of the selected CBOs already had an income generating raison dtre, it was thought that the issue of remuneration might be avoided. The CBO members were trained, supervised and supported in two phases. About half were selected and trained before the MTE (August 2008), and the remaining half were trained in the

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last year of the project. The CBOs were each supervised by several cadres of project staff and partners, including LNGO promoters who were supposed to visit them each month and Plan CBS and Provincial Health Coordinators and ACMS Promoters. This degree of support undoubtedly had a great deal to do with their performance. Another factor was the clarity of their roles and responsibilities. Although their training wasnt particularly long (four days) or effective, the CBOs eventually mastered the key behaviors they were promoting and the behavior maps helped them stay on target with regard to their work. They were all very clear about what behaviors they were promoting among whom and who was practicing those behaviors and who was not. The Phase 1 CBOs had more time to learn this than the Phase 2 CBOs, who were supported for a shorter period. Based on a recommendation from the MTE, the project developed performance indicators (see Annex 8) for the CBOs to more objectively measure their capacity and performance. Table 8 shows the results of the Performance Ratings for (mostly) the Phase 2 CBOs. Table 8. CBO Performance Ratings 80%- 50% Region Total # >80%6 CBOs NW 190 20% 53% East 184 48% 27% Center 105 16% 36% Total 4797 30% 39%

<50% 25% 23% 47% 29%

Most of the CBO performance indicators monitor the presence of things (meeting minutes, tools, if growth monitoring and home visits were conducted) or actions that are not easily verified (home visits, advice given) rather than the quality of implementation. Therefore, they do not meaningfully measure performance. Simple adjustments to the wording of the indicators would have made them more effective in measuring performance. For example, instead of just asking if a CBO meeting was held, it would be better to ask if a meeting was held with 80% attendance. Likewise, instead of just recording if growth monitoring was done, it is between to record if 80% of all eligible children were weighed. This was a very worthwhile attempt to assess CBO performance. Had this approach been adopted from the outset of the project and used to adjust support to each CBO, the results might have been more useful. Although having chosen pre-existing CBOs may help the groups to continue to remain together, without regular supervisory visits, it is not clear if they will continue to visit households each month to promote and check on behaviors or if they will continue to weigh children. Some CBOs who are not too far from the IHC might be visited, and some LNGO promoters may
6 7

Due to rounding, totals may not add up to 100%. In the NW and East Regions, not all the CBOs were classified. In the Center Region, not only the CBOs for Phase 2 were classified but also some CBOs from Phase 1. This is why the total number of CBOs does not match other references to the CBOs in this report.

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continue to support them, but as with most other projects, ensuring continued support is very difficult. E. Global Learning There are several aspects of the EIP that could contribute to global learning. At the community level, the CHW approach training pre-existing CBO members rather than individuals is a promising practice, as is the behavior map and CBO performance indicators. The project staffs work at the national level is also unusual for a Child Survival Project and contributed significantly to many successes related to scale-up. In this regard, choosing international partners who have experience working at this level (such as ACMS and HKI) and dedicating the time and resources for this is critical.

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VI.

Conclusions and Recommendations

A. Project Successes By most every measure, but especially in the area of scale-up, the EIP has been a success. This is due in large part to strategic partnering and a design that included activities at the national, district and community levels. The strategic partnering piece allowed the project to benefit from the expertise of three international NGOs (Plan, HKI and PSI/ACMS) who had the requisite experience to work effectively at all three levels. Heeding the recommendation of the MTE to strengthen the relationship between the IHC and the CBOs was also critical to the success of the project. The projects behavior change strategy to train CBOs rather than individual CHWs was a key to creating the demand for services and promoting behavior change at the household level. Recommendation: Expanded Impact Projects seeking a similar result will choose their partners strategically, plan activities that improve quality of care, increase access to goods, services and demand in nearly equal measure and will consider training previously formed groups at the community level to promote behavior change. B. Effectiveness of Scale-Up Approach The EIP project worked at the national level to influence policy and promote innovative service delivery approaches by forming and participating in National Working Groups on IMCI, Malaria, and Nutrition. This proved to be a very effective approach, as it got the ear of Ministry decision-makers and also other influencing organizations such as UNICEF and WHO. Because the project was larger than the usual child survival grant, working in three regions and 11 districts, this allowed project leaders to gain the attention and credibility of the working group members. The size of the project also allowed new approaches to be tested in different parts of the country which helped convince decision makers of their potential as national approaches. Recommendation: The Child Survival Health Grant Program should re-create the Expanded Impact category for CS grants to allow private voluntary organizations (PVOs) and NGOs to gain a seat at the national table and to more effectively promote scale-up of innovative approaches. C. Modifications to the interventions to promote policy adoption and make implementation more feasible The EIP project effectively completed the zinc OR study with enough time to play a role in the scale-up of the activity. This was not the case with the CCM/P OR study, which concludes just as the project is ending. Because of this, the project will not be well positioned to help in the scale-up process should the MOH decide to approve CCM/P Recommendation: When planning OR studies, major efforts should be made to conclude the study with at least one year left in the project so that project implementers can play a role in the subsequent decision making and scale-up of the intervention. The EIP projects sustainability plan focused on strengthening LNGOs so they would be able to continue to support the CBO at projects end. The IHC was not initially implicated. While efforts to correct this were made during the final year of the project, this was not enough time to effectively cement the relationship between the CBOs and IHC staff.

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Recommendation: When planning for sustainability during the project design stage, plan to collaborate with entities whose presence and support are sure to continue after support from the project ends. Also be sure to choose partners whose objective is totally in line with that of the project (improved MCH). In the case of the EIP, the role of the IHC level should have been clearer at the outset and efforts to strengthen the link between the CBOs and IHC stronger throughout the life of the project. When designing a project, the implementers each need to be clear about their institutional strengths. For the most part, the EIP enjoyed so much success because each partner brought certain expertise and experience to the table: ACMS social marketing; HKI nutrition and advocacy; Plan community development. The change in strategy with regard to the institutional strengthening of the LNGOs suggests a lack of ability or commitment on the part of Plan to build the capacity of the LNGOs so they would be able to continue to support the trained CBOs at projects end. In addition to knowing about C-IMCI and how to train and support the community-based activities, the LNGOs need to expand their funding base to cover the costs of these activities. The EIP did not attempt to strengthen these capacities rather it changed strategies mid-stream in favor of performance-based contracts. Recommendation: Since the MOHs IHC is the most likely entity to continue to support (if not expand) the CBOs at projects end, in a future project, Plan should consider using Plan Promoters hired by the project, to train, support and supervise the CBOs, gradually turning over responsibility for supporting them over to the IHC staff. Alternatively, if Plan chooses to work through LNGOs, more emphasis should be placed on developing the LNGOs capacity to expand their funding base so their future functioning will be ensured. In either case, when deciding upon the number of promoters needed, a ratio of about one promoter for 10-12 CBOs would be optimal.

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ANNEX 1. Results Highlight INNOVATIVE IDEA: Behavior mapping to improve community diagnosis and action BACKGROUND. The health information system in Cameroon is weak and incomplete, lacking community-based information for appropriate decision making. Each year, 83,000 under-five children die from preventable illnesses. Lack of community mother and child health information and poor health-seeking behaviors hamper efforts to prevent and treat malaria, malnutrition, diarrheal disease, and pneumonia. PROJECT INPUTS. Since 2005, Plan Cameroon, in collaboration with the Ministry of Health, has been implementing a USAID Child Survival Project in 11 health districts. One key component is promoting community action through better identification of local problems and solutions using community registers and behavior mapping. From 2007 to 2009, the project supported communities through capacity building of community members on behavior mapping, diagnosis and action, logistical support to Plan staff and local health promoters for supervision and follow up of trained CBOs, printing and distribution of 16,000 C-IMCI message booklets and flipcharts to CBOs, and distribution of didactic materials (registers, markers, conference paper, etc.) to each CBO. With the assistance of project staff and local health promoters, community members drew up community registers and poster-size maps of their communities to represent all key healthy family behaviors, households and landmarks. The households' fulfillment of four to six healthy behaviors (e.g., hand washing with soap) were tracked on the registers and maps using colored thumbtacks to show the compliance (or non-compliance) in each household, with each color representing a given behavior. With minimal support from project staff, the community volunteers were able to consolidate all the bloc maps during monthly meetings, during which data was analyzed and interpreted, and action plans for the next month were created. MAGNITUDE OF INTERVENTION. By the end of the project (September 2010), behavior mapping was being implemented in 910 communities. RESULTS. Community behavior mapping provided a community-based database for planning and monitoring of health activities, thus complementing the national health information system which lacked a community component. It also helped to increase uptake of maternal and child health services in the community and at facility level. At the end of the project, 14 of 18 indicators had significantly improved over the baseline. For example, the proportion of children 0-23 months who slept under an ITN the previous night increased from 11.8% to 66.4%, the proportion of children 0-59 months who received a full course of recommended anti-malarials (according to MOH protocols) within the 24 hours of the onset of fever increased from 11.7% to 51.9%, the proportion of underweight children decreased from 15.9% to 9.5%, and exclusive breastfeeding among children 0-6 months increased from 50.8% to 74.9%. In addition, the increased access to information is empowering for community members, allowing them to identify inequities in the community, and begin to speak up against them at the local level.

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ANNEX 2. List of Publications and Presentations PAPER # 1 Cameroon: Using Local Maps to Promote Community Diagnosis and Action Joseph Shu Atanga, MD, MPH , Health Program, Plan Cameroon, Yaound, Cameroon Ryan Lander, MPH , Plan USA, Arlington, VA Laban E. Tsuma, MBchB, MPH , Child Survival Unit, Plan, Arlington, VA ABSTRACT More than 83,000 children die each year in Cameroon from preventable illness. Lack of child health information and access to quality care hampers efforts to address the prevention and treatment of malaria, malnutrition, diarrheal disease, and pneumonia. Since 2005, Plan Cameroon (an international, humanitarian, private organization) and the MOH are implementing an USAID-funded child survival project in 11 health districts benefiting 211,473 under-five children and 481,441 women of reproductive age. One of the important project components is to promote community action through a better identification of local problems and solutions. In this regard, the project spearheaded the use of community behavior mapping. In this approach, community members (with the assistance of project staff) drew up poster-size maps of their communities to represent all the households and landmarks. The households in these maps were then split into groups of 10 to 15 households, each group assigned to two to three community members for home visits, direct support and monitoring of healthy behaviors. The household's fulfillment of four to six healthy behaviors (i.e. hand washing with soap) were tracked on the maps by colored thumbtacks placed besides each household to show the compliance (or non-compliance) to the chosen behavior, each color representing a given behavior. For example, the house with all its members sleeping under an insecticide-treated network merited a blue thumbtack in the map. With little support from a project staff, the community volunteers consolidated all the bloc maps during monthly meetings, where data analysis, interpretation and decisions were taken in an action plan for the next month. By the third year of the project (September 2008), behavior mapping was being implemented in 762 communities. Indicators at year 3 had improved over the baseline: ITN use among underfive children was 60.7% up from 11.8%; ITN use among pregnant women was 43.2% up from 15.7%; IPT completion in pregnancy was 51.4% up from 18.5%; exclusive breastfeeding 63.1% up from 50.8% and timely care seeking behavior for suspected malaria to 51% up from 37.4%. A simple and community-owned visual health information system can go a long way to boost community behavior change interventions in a sustainable manner leading to improved maternal and child health.

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ANNEX 2

PAPER # 2 Key determinants/barriers to observing a 10-day regimen treatment with zinc during diarrhea episode in Cameroon Xavier Crespin1,Martin NANKAP1, Shu Joseph Atanga2, Adang Florence3, Tata Japjet Ngoh3, 1 Helen Keller International. Yaound Cameroon, 2 Plan Cameroon, 3 Ministry of Public Health ABSTRACT BACKGROUND: Recent scientific findings showed that zinc supplementation for 10-14 days during an acute diarrhea episode reduces the duration and severity of the episode and reduces the incidence of diarrhea in the following 2-3 months. Based on this, UNICEF/WHO and other partners issued a joint statement in 2004 on the clinical management of acute diarrhea in children under five recommending zinc supplementation for 10-14 days. However, factors affecting compliance to treatment need to be identified and addressed in order to achieve successful scaling-up the use of zinc in the treatment of diarrhea. This is why a study was carried out in 10 health catchment areas of the Bertoua Health District in the East region of Cameroon. AIM: The aim of the study was to identify key determinants of and barriers to mothers compliance with administration of a 10-day regimen of zinc treatment to their child during the childs diarrheal episode. METHOD: A doer / non-doer barrier analysis survey was conducted using individual interviews. Mothers who had accessed zinc either through a health facility or a community-based organization to treat their childs diarrhea episode in the past two weeks were interviewed. The questionnaire consisted of six questions: two questions to explore the perceived positive and negative consequence in completing the treatment; two questions on the perceived self efficacy, two questions on the perceived social acceptability. A total of 60 mothers were involved in the study, 30 of whom had completed the treatment for 10 days (Doers) and 30 who had not (NonDoers). Statistical analysis where performed to compare Doer and Non-Doer responses. RESULTS: The major determinants identified are: no negative consequence perceived; no difficulty to administer the treatment and the self motivation whereas the longer duration of treatment and early cessation of diarrhea are mentioned as barriers to completing a 10-day zinc treatment during diarrhea episode CONCLUSIONS: The identification of key determinants will help in developing BCC activities to address the key factors that affect compliance to treatment, designing messages that are relevant to audience and preparing counseling sessions. Training of frontline health staff and ultimate sensitization of caretakers on these determinants will go a long way to changing key management behaviors and save the lives of many children from diarrheal diseases.

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ANNEX 2

PAPER # 3: Lessons learned in scaling-up Maternal and Child Health and Nutrition Action Week in Cameroon Daniel Sibetcheu1, Martin NANKAP2, Xavier Crespin2, Shu Joseph Atanga3, Denis Garnier4 1 Ministry of Public Health-Cameroon, 2Helen Keller International-Yaound Cameroon, 3 PlanCameroon, 4 UNICEF-Cameroon ABSTRACT BACKGROUND: In Cameroon, the under-five mortality rate is 142 while maternal mortality is estimated to, be 670 maternal deaths per 100,000 live births. During the past decades, isolated interventions such immunization, vitamin A supplementation, and measles campaigns were implemented with very little improvements on the overall mortality rates of vulnerable groups. Within the framework of the Bundled Expanded Impact Child Survival Project funded by USAID, the Government of Cameroon has piloted Maternal and Child Health and Nutrition Action Week in 11 health districts but with technical support of PLAN/HKI/PSI. This approach has brought to mothers and children a package of high impact interventions on their survival. With the support of WHO/UNICEF/HKI/PLAN, this event was scaled-up at national level in July 2008 to enable the country to move progressively towards the achievement of the Millennium Development Goals by offering twice yearly an integrated package to alleviate maternal and child morbidity and mortality. AIM: Identify lessons learned while scaling up Maternal and Child Health and Nutrition Action Week FRAMEWORK: During the month of July 2008, Maternal and Child health and Nutrition Action Week was organized through out the country. The package of interventions included vitamin A supplementation of children (6-59 mo) and post partum women, deworming of children (12-59 mo), polio immunization, tetanus vaccination of women at child bearing age in 50 health districts and for pregnant women, routine immunization, administration of intermittent preventive treatment of malaria to eligible pregnant women and behavior change communication focusing on promotion of exclusive breastfeeding. Data were collected using tally sheet and a survey on sources of information carried out. LESSONS LEARNED: 1. Integration of many interventions at larger scale is feasible and did not compromise the results of traditional interventions like polio immunization and vitamin A supplementation. 2. Scaling-up of MCHNAW has provided the opportunity to bring together more partners and to improve collaboration among participating institutions. 3. MCHNAW is an efficient strategy to promote the concept of high impact interventions for child and maternal survival and therefore the urgent need for integration. 4. MCHNAW can bring additional to routine EPI coverage, access to IPT for pregnant women and vitamin A for post partum women. 5. More resources need to be allocated to community and proximity mobilization which seem to be highly contribute more than printing materials which absorb a large part of social mobilization/communication resources.

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ANNEX 3. Project Management A. Planning What groups have been involved in project planning? Project planning takes place at three levels: national, region/district and local (community), and EIP project staff are involved at each level. At the national level, the EIP (all three partners) is represented on several working groups where the MOH and other stakeholders take decisions. At the regional/district level, Plans Provincial Health Coordinators, Capacity Building Supervisor, and other Plan staff, along with Plan and LNGO promoters, attend monthly meetings to help plan training events, vaccination outreach activities and the bi-annual Health and Nutrition Weeks. At the community level, each CBO develops a monthly activity plan to guide their work. These are shared with the Plan and LNGO promoters who supervise their work. To what extent is the work plan submitted in the DIP on schedule? See Table 2. Are the projects objectives understood by: field staff and headquarters staff, local level partners, and the community? Yes. Do all parties have a copy of the project's objectives and the monitoring and evaluation plan? Yes. Project objectives are included in the contracts of all Plan promoters and LNGO partners. Furthermore, stakeholders interviewed for the final evaluation were also able to name the five intervention areas. The project has developed an M&E manual, and all EIP staff, LNGOs, and IHCs have a copy. To what extent are project monitoring data used for planning and/or revising project implementation? Each time a KPC survey and integrated health facility assessment are conducted, the results are shared with all the implementing partners (MOH at regional/district levels and LNGOs) and ways to improve faltering indicators are discussed. B. Supervision of Project Staff Was the supervisory system (of project staff) adequate? For the most part, the answer to this question is yes. Each of the three EIP partners, Plan, ACMS and HKI, has adequate supervision systems in place to ensure satisfactory performance. The exception might be supervision of Plans CBS by the Provincial Health Coordinators whose supervisory activities were hampered at times by lack of a means of transportation. Responding to this question in a more comprehensive way is challenging, however, because it requires a definition of project staff. In the first half of the project, the staff of LNGOs would not be considered project staff, but in the second half of the project, the relationship between Plan and the LNGOs changed. Rather than there being a mentoring relationship focused on organizational strengthening, in the second half of the project, Plan entered into performance-

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ANNEX 3

based contracts with the LNGOs and contracted their promoters to carry out specific tasks (training and supervision of CBOs) . This essentially made them into Plan staff even though they also reported to their LNGO. Further to this, after the MTE, the contracts of several LNGOs were not renewed and 12 promoters from these organizations were hired by Plan also on performance-based contracts to support and supervise the CBOs on the EIP. All promoters (seven in the East; nine in the Northwest; and five in the Center Region) are supposed to be supervised by Plans Capacity Building Supervisor (CBS) and/or the Provincial Health Coordinator (PHC) who are also supposed to monitor activities at the community level. Performance is measured by specific performance indicators (see Annex 8), which are more focused on quantity (numbers of supervisory visits) than on quality (in-service training). During the final evaluation, PHCs and others recognized the difficulty PHCs had getting to the field due to a lack of transport. Furthermore, LNGO Promoters reported that it is very difficult for them to supervise all of the CBOs each month given the high promoter-to-CBO ratio (usually 15+). In a future project, transportation for the PHCs needs to be ensured, and the promoter-to-CBO ratio should be limited to 10-12, especially if monthly supervisory visits are required. Is the supervisory system fully institutionalized and can it be maintained? The supervisory systems of the project partners, Plan, ACMS and HKI, will be maintained. Beyond the project partners, the MOH, specifically the Integrated Health Center staff, will not likely be able to supervise/monitor the work of all the trained CBOs in their catchment area due to lack of transport and too few staff in the IHC. Is there evidence that the projects approach to strengthening supervisory systems has been adopted beyond the project? Speaking of supervisory systems outside the EIP partners, several of the District Medical Officers interviewed for the final evaluation, mentioned that they acquired better supervision skills through training provided by EIP. They also mentioned that having been trained to conduct health facility assessments using LQAS, they are now able to more effectively target support to those facilities in need. C. Human Resources and Staff Management Are essential personnel policies and procedures of the grantee and partner organizations in place, to continue project operations that are intended to be sustainable? Although there are no aspects of project operations that depend on Plan, ACMS or HKI personnel policies to be sustained, Plan did provide training to their Community Development Facilitators in C-IMCI so they would be in a position to support the CBOs in communities where other (non-EIP) activities are taking place (which is nearly 100%). Also, interviews with LNGOs revealed that most of them intend to retain their promoters who expect to continue providing support (supervision) to the CBOs after the project ends. During the project some personnel and contract policies of Plan Cameroon posed some problems. Due to HR policies, at the end of the 4th year of the project (Aug. 2009), the Project Coordinator, who had been there from the outset of the project and was a very effective and popular project leader, had to either be hired on a permanent contract, or take a one-month leave of absence before being hired on a new contract. Plan Cameroon was not in a position to hire

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ANNEX 3

him as a permanent staff member, and so had to resort to the second option. However, given the need for the one-month break, as well as the fact that the new contract would start again at the starting rate and result in a salary reduction, the Project Coordinator left the project. Although an internal candidate was found to replace him, the departure of the Project Coordinator still caused disruptions that could have been avoided had Plan/Cameroons personnel policy (and/or the application of it) been more flexible. Plan/Cameroon should also recognize that people working on projects may indeed make very effective regular staff and rather than side-lining them, they should be considered for career advancement within the Plan/Cameroon system. Comment on the projects personnel management system and any changes that have taken place since the DIP was submitted. Are all positions filled? Comment on staff turn-over and impact on project. When the first Project Coordinator left in August 2009, a strategic decision was made to replace him with the person working as the Health Advisor for Plan/Cameroon. This was deemed the best strategy for a number of reasons including the following: many months would have been lost trying to find another suitable candidate, the Health Advisor was someone who was already knowledgeable about the EIP project and could step into the Project Coordinator position more easily than a newcomer, the Health Advisor was already very active in a number of relevant partnerships at the national level, and he was already familiar with Plans systems. Therefore, it was agreed that he would take the position full-time (40 hours per week). Rather than relinquish his Health Advisor position however, he held both positions and later also took on responsibility for a Global Fund project. This was done so he would be guaranteed a continued position within Plan/Cameroon when the EIP ended. To his own admission, holding down these added responsibilities (amounting to over 100% LOE) became overly demanding and stressful. HQ and Project staff noted slow response rates to decisions during the last year and a lack of attention to the project at times. In the future, Plan/Cameroon should ensure that complex projects such as the EIP, where Plan is the lead agency and where lessons learned will be applied nationally and examined by the international child survival community, receive adequate and appropriate staffing, including a full time Project Coordinator. This includes taking measures to ensure that organizational policies do not interfere with project implementation and results. The final evaluation also discovered that the contracts of the five promoters working in the Center Region ended and were not renewed in May 2010, four months before the end of the project. While it is not clear why this was done (not for financial reasons), it is clear that the CBOs in that region required continued support through to the end of the project, as they were not yet sufficiently skilled and established to continue activities on their own. In the future, the phasing out of support needs to be planned more strategically in order to foster sustainability of key activities. The project has experienced unusually high turnover only among the three Provincial Health Coordinators and this is due, according to the current PHCs, to the lack of support provided to them by some Program Unit Managers, and the fact that the EIP did not plan to provide transport or other logistical support to them.

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ANNEX 3

Turnover among the directors of some partner LNGOs also made it difficult to count on high performance among them. Describe the morale, cohesion and working relationships of project personnel and how this affected project implementation. During the first half of the project, morale of the staff was very good. Then, in 2008-2009, Plan/Cameroon underwent a centralization process that resulted in many delays to the project as decisions and actions were moved to Yaound when they used to be taken by Plans regional teams. Delays in payments ensued, as well as delays in the provision of supplies to LNGOs and CBOs. This, combined with the departure of a popular and effective Project Coordinator, less responsive leadership and high turnover among Provincial Health Coordinators caused morale to shrink among Plan personnel. Have plans been developed to facilitate staff transition to other paying jobs at the end of the project? ACMS staff is likely to remain employed working on a new project and on-going activities. Some Plan staff will continue to work for Plan/Cameroon as they are considered permanent staff. Continued employment of other project staff will depend on performance appraisals. Some Plan staff claimed not to be aware of this and were nervous about their futures. D. Financial Management Discuss the adequacy of the grantees and partners financial management and accountability for project finances and budgeting. If the project budget was adjusted, explain why. Do the project implementers have adequate budgeting skills to be able to accurately estimate costs and elaborate budgets for future programming? The experience of all three international partner organizations facilitated financial management. The three lead organizations developed annual budget projections which were based on the operational plans they each developed. They track expenditures on a monthly basis and as of July 2010, Plan had spent 97% of their field budget, ACMS had spent 92% and HKI had consumed 91% of its budget. As a result of the centralization process carried out by Plan/Cameroon in 2008-2009 and the consequent move of regional account managers to Yaound, cash flow problems began and LNGOs and individual Plan Promoters were asked to pre-finance some of their activities. It is not clear how long the cash flow problems persisted or the impact they had on project activities. A few small adjustments were made to the budget to account for changes in activities since the original budget was developed. For example, the MTE recommended that ACMS cease the use of caravans and these funds were used to train additional staff in IMCI. During the first half of the project, the EIP sought to strengthen the LNGOs organizationally and this effort included training in budget design and management. However, due to how weak the LNGOs were organizationally (see Section II on Partnerships), as well as the shift in focus from LNGO organizational development to performance-based contracts, it is not likely that the LNGOs budgeting skills have improved significantly.

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ANNEX 3

Are adequate resources in place to finance operations and activities that are intended to be sustained beyond this cooperative agreement? There are a few activities, especially those that have been officially adopted by the MOH and where additional financial support has been secured, that will continue beyond the life of the project. These include the bi-annual health weeks which are being funded by UNICEF and WHO, the use of zinc in the treatment of diarrhea which has become policy, the training of nurses in IMCI and ENA which has also been adopted as a national policy/protocol, and the distribution of mosquito nets which is supported through the Global Fund. The activity that is less likely to be supported after the project ends is support to the CBOs since the IHCs are under-staffed and have few resources for this. Was there sufficient outside technical assistance available to assist the grantee and its partners to develop financial plans for sustainability? Aside from developing the CSSA frameworks that do not emphasize financial plans, the EIP did not receive any technical assistance to develop financial plans for sustainability. As mentioned previously, during the second half of the project, Plan changed it organizational development approach with regard to the LNGOs. No assistance was provided to them since 2008 to help develop financial sustainability plans or skills so they can continue to support the CBOs. E. Logistics What impact has logistics (procurement and distribution of equipment, supplies, vehicles, etc.) had on the implementation of the project? EIP project staff concluded that the project suffered for lack of sufficient logistical support particularly in the area of vehicles. Due to financial limitations, field staff didnt have sufficient means of transport which hampered supervision. In particular, Plan Provincial Health Coordinators in each region who were not able to conduct as many supervision visits as needed because they had no transport of their own. Is the logistics system sufficiently strong to support operations and activities that are intended to be sustained? As is typical of all child survival projects, the EIP provided substantial support to the MOH which will end on September 30th. Most of the District Medical Officers interviewed for the final evaluation admitted that some/many activities will not be implemented due to resource shortfalls. Some DMOs have options to access funds through other projects/donors. F. Information Management How effective was the system to measure progress towards project objectives? Was there a systematic way of collecting, reporting and using data at all project levels? Cite examples of how project data was used to make management or technical decisions. The project had a very elaborate and complete Health Information System which allowed them

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to collect information at all levels of the project from the community level to the national level. All levels of the project produced monthly reports which provided information about the performance of project implementers and achievement of project objectives (ITN use, malnutrition rates, vaccination coverage, etc). The EIP also carried out an annual KPC survey (using LQAS) and an Integrated Health Facility Assessment (IHFA) that provided feedback on the progress of the project. Data from these reports were used to adjust the focus of the project. DMOs interviewed for the final evaluation report being able to identify weak performing health areas through the IHFA and reallocate resources to these health facilities. Stock outs were identified through the IHFA, and these were addressed. The PD/Hearth was implemented in a district where high levels of malnutrition were identified through the Health Information System. And the approach to post partum Vitamin A supplementation was changed to make the vitamin available during outreach activities. Is the project staff sufficiently skilled to continue collecting project data/information and to use it for project revisions or strengthening? The project trained 11 DMOs to carry out IHFA and KPC surveys and some of them claim to be able to organize and conduct these studies on their own and to use the information. Did the project conduct or use special assessments, mini survey focus groups, etc. to solve problems or test new approaches? Give examples of the research, use of data, and outcomes. The EIP conducted two OR studies, one on the use of zinc in the treatment of diarrhea and the other on CCM/Pneumonia, both of which are discussed in Section V - Results. A Doer/Non-doer survey was also conducted, and the results informed the development of key messages and visual aids. To what extent did the project strengthen other existing data collection systems (i.e. government)? The project sought to strengthen the MOH database by making data from the community available at the district level. Unfortunately, work to link the MOH (especially at the IHC and district levels) started too late, and this linkespecially with regard to data sharingis still not very strong. Do the project staff, headquarters staff, local level partners, and the community have a clear understanding of what the project has achieved? In February and March 2010, the EIP supported meetings at the regional level to share information with the Regional Delegates (Regional Health Officers), other government officials and community representatives about the achievements of the project. A final meeting is also scheduled to take place at the end of September 2010. How have the projects monitoring and impact data been used beyond this child survival project? Data from the EIP monitoring system was used to advocate for the scale-up of the Health and Nutrition Week which the MOH has subsequently adopted for nationwide application. The results of the zinc OR were used in a similar manner and resulted in zinc being added to the Essential Drug List and used nationwide in the treatment and prevention of diarrhea. And finally Plan used project data in the development of a Global Fund Round 9 Malaria proposal which it

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ANNEX 3

was subsequently awarded. G. Technical and Administrative Support External Assistance Provided Each year of the project the Plan USA technical backstop officer visited the project for a week or more to provide technical assistance. The EIP staff appreciated the outside perspective and guidance that he provided. Typically, following each visit, a trip report was written which the staff reviewed and used to make necessary adjustments. In addition to this, an outside consultant led the mid-term and final evaluations. The EIP team felt that sufficient outside assistance was provided. H. Management Lessons Learned Planning While using the DIP as the Bible of the project, it is also important to remain flexible since things will change from year to year. Training To get the most out of the C-IMCI approach, it is important to train men as well as women; training should use very participatory approaches since low-literacy participants learn best this way. It is the responsibility of the trainers to design a curriculum appropriate for lowliteracy participants, not the responsibility for the community to find literate CBO members. When planning training events, negotiate the time with the community members and respect local beliefs and customs. Supervision Supervision should be regular and not only focus on data collection; performance indicators should also include elements of quality. When supervising, dont just meet with the CBO leadership; meet with all (or as many as possible) of the CBO members. Use supervision time to also review technical elements of the training, especially growth monitoring and home visit skills. Human Resources Sometimes personnel policies (2 year contracts) compromise the effectiveness of the project and require creative problem solving to get the best results. No one person should be asked to take on two jobs at the same time; this will result in inadequate performance and support to the project. Plan should accept project-hired staff in the same way that it accepts permanent staff and consider ways to incorporate them into the organization when a project comes to an end. Plan Country Office HR policies need to be examined when planning projects. Where it is seen that significant challenges can result, early actions need to be taken to ensure that the policies do not interfere with the projects success. For instance, key personnel can be hired through Plan International Headquarters, as is done for Chief of Party positions, so that the Country Office HR policies (which vary from country to country) do not cause problems such as those which occurred in this project. In addition, staffing requirements and responsibilities should be realistic to ensure that staff performance and commitment are maintained. Adequate logistical and personnel support are

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ANNEX 3

also essential to achieving strong performance and outcomes on project activities. Financial Management When changes are made that will/may adversely affect cash flow, plans need to be made to ensure the timely provision of cash and supplies. Logistics When planning a future project, a means of transport for each person who needs to do field work should be budgeted for. Project Information The EIP partners were very good about sharing information amongst themselves and with their partners. Better systems need to be in place for internal (within Plan etc) sharing of achievements and lessons learned. Technical Support Within the Plan system the technical backstop person has limited authority over the project because Plan country offices do not report to Plan USA. Plan USA, therefore needs to develop a relationship with the Plan Regional offices to solicit their support when necessary. Describe how the grantee organization (HQ and field management) will share and internalize these lessons. At the international level, PSI (ACMS) plans to present the results of the EIP at their African Child Survival retreat where 15 sub-Saharan countries will be represented. Within Cameroon, when the final evaluation report is submitted the EIP partners will organize a workshop to disseminate and share the results of the project with all stakeholders. Plan and the other partners also expect to establish an EIP library where important documents about and produced by the project will be housed and used by other project staff. How has the project strengthened partnership between implementing partners Plan, HKI and ACMS worked closely together before the EIP and this CS project has only served to further strengthen the partnership. Each partner is keenly aware of the expertise of the other partners and how they complement each other. As a result of the EIP project ACMS and Plan jointly submitted a Global Fund Round 9 malaria proposal and the partners are looking for other opportunities to work together. How has the project contributed to the visibility of each partnership organization? The EIP has allowed each of the partner organizations to increase their visibility and credibility within Cameroon and possibly internationally as well. These days, the biggest grants are awarded to multi-partner bidders and being able to partner effectively is a sought-after attribute. During the life of the project, all three partners were given equal voice and credit on all documents How has the specific expertise of each partner contributed to the global success of the project?

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Combining the different expertise of the three partners definitely contributed to the success of the EIP. Plans extensive experience in community development and its prior child survival project, set the stage for the intervention. Plans prior work with local NGOs was also a key factor. ACMS expertise in social marketing increased access to key commodities (ORS, water guard, ITN) thereby removing a barrier to behavior change. ACMS private clinics (ProFam) provided a testing ground for the introduction of IMCI in the private sector. HKIs expertise in the area of nutrition, nutrition and health education materials, and advocacy played a key role in the project as well.

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ANNEX 4. Work Plan Table


Objectives/Activities Prevent and treat malaria 1. Train community-based health workers in CCM/Malaria 2. IMCI training Objective Met? Yes Activity Status

Yes

3. ITN distribution

Yes

4. Health education materials developed and distributed; mass media campaign 5. Continue to support work of LNGOs and CBOs implementing C-IMCI approach

Yes

Completed 5,973 CCM/Malaria health workers trained; a delay in providing treatment was encountered b/c MOH could not provide the ACTs immediately 346 MOH/ProFam providers trained in IMCI; 171 of 175 facilities in the project area; only 22 ProFam providers out of 120 trained in IMCI are still working in ProFam facilities 39,000 ITNs distributed, complemented by MOH distribution of ITNs; no new ITNs were distributed by the project in the second half of the project Completed 37,421 individual materials distributed (calendars, flipcharts, message booklets, etc) Despite a recommendation in the MTE, Plan decided to curtail organizational development activities with the LNGOs. Instead, Plan signed performance-based contracts with 6 LNGOs and 12 direct-hire promoters so that these promoters could continue to train and supervise additional CBOs. CCM/Malaria CHW training curriculum design

Yes

6. Support to Malaria Working Yes Group Prevent and treat malnutrition including micronutrient deficiencies 1. Continue to support work of Yes See activity 4 above LNGOs and CBOs implementing C-IMCI approach 2. Zinc OR conducted Yes 1/09 MOH approved zinc as an essential drug; steps being taken to import zinc; ORS w/zinc now available for use at community level, treatment protocol being taught to providers 3. Essential Nutrition Action Yes 74 trainers trained; 241 health providers trained in EIP; 83 training trained outside EIP (324 total) 4. National Nutrition Working Yes MOH approval received in August.2008 Group formed, supported and MOH approval received 5. PD/Hearth Training conducted Yes 3 MOH trainers trained; PD/Hearth conducted in 3 communities; 94% recuperation rate Prevent and treat diarrhea 1. Continue to support work of Yes See activity 1 above LNGOs and CBOs implementing C-IMCI approach 2. IMCI training Yes See activity 2/malaria above 3. Zinc OR conducted Yes See activity 2 above 4. Establish sale points for Water Yes 962/99 sales points established after zinc was approved guard and Orasel Orasel with zinc was also sold Prevent and treat pneumonia 1. Continue to support work of Yes See activity 4 above LNGOs and CBOs implementing C-IMCI approach 2. CCM Ops Research protocol Yes CCM OR being implemented; MTE of study conducted in May 2010; will be concluded by 9/10

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3. IMCI training Increased immunization coverage 1. Continue to support work of LNGOs and CBOs implementing C-IMCI approach 2. IMCI training 3. Bi-annual Health and Nutrition Week

Yes Yes

See above See activity 4 above

Yes Yes

See above Adopted by the MOH and now supported by MOH and other partners

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ANNEX 5. Rapid CATCH Table


Indicator Sentinel Measure Child Health and Well-being Percentage of children age 0-23 months who are underweight (-2 SD from the median weight-forage, according to the WHO/NHS reference population) Prevention of Illness/Death Percentage of children age 0-23 months who were born at least 24 months after the previous surviving child Percentage of children age 023 months whose births were attended by skilled health personnel Percentage of mothers with children age 023 months who received at least two tetanus toxoid injections before the birth of their youngest child Percentage of children age 0-5 months who were exclusively breast-feeding during the last 24 hours. Percentage of children age 6-9 months who received breast-milk and complementary foods during the last 24 hours. Percentage of children age 1223 months who are fully vaccinated (against the five vaccinepreventable diseases) before the first birthday Percentage of children age 1223 months who have received measles vaccination before the first birthday Percentage of children age 0-23 months who slept under an insecticide-treated net the previous night. Percentage of mothers with children age 023 months who cite at least two known ways of reducing the risk of HIV infection Percentage of mothers of children age 0-23 months who report that they wash their hands with soap/ash before food preparation, before feeding children, after defecation and after a attending a child who has defecated. Management/Treatment Percentage of mothers of children age 0-23 months who know at least two signs of childhood illness that indicate the need for treatment. Percentage of sick children age 0-23 months who received increased fluids and continued feeding during an illness in the past two weeks. Baseline MTE FE

1.

15.9% (14.9 16.7)

9.4% (8.9 10.7)

9.5% (9.2 11.4)

2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

52.3% (51.9 55.7) 59.9% (58.2 61.7) 58.9% (55.9 61.7) 50.8% (47.9 53.8) 92.0% (90.2 93.7) 70.5% (67.1-73.6) 80.9% (77.9-83.6) 11.8% (10.0-13.9) 65.9% (63.0-68.7)

61.7% (60.9 62.7) 74.1% (69.8 77.4) 58.6% (56.5-60.7) 63.1% (61.2-65.1) 93.6% (92.5-94.5) 83.4% (81.3-85.4) 91.1% (89.4-92.6) 60.7% (58.7-62.7) 66.1% (64.2-68.0)

59.7% (57.5 63.0) 68.5% (60.1 72.8) 63.2% (61.3 63.5) 74.9% (73.9 75.2) 90.2 % (89.2 91.5) 67.2% (67.0 69.1) 84.2% (83.8 84.9) 66.4% (65.4 67.1) 67.4% (64.3 70.1)

7.7% (6.2-9.4)

15.0% (13.7-16.5)

42.2% (40.7 45.2)

13. 14.

65.9% (63.0-68.7) 9.2% (7.4-11.4)

70.4% (68.5-72.2) 14.6% (13.1-16.4)

77.36% (75.1 78.0) 13.9% (12.9 14.6)

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ANNEX 6. Final KPC Report

EXPANDED IMPACT CHILD SURVIVAL PROJECT (EIP) CAMEROON

CHILD SURVIVAL PROJECT XXI COOPERATIVE AGREEMENT NO.: GHS-A-00-05-00015-00

THIRD PROJECT MONITORING REPORT Integrated Health Facility Assessment (IHFA) and Knowledge Practice and Coverage (KPC)
August 2010

LOCATION: CAMEROON (11 HEALTH DISTRICTS) START DATE: SEPTEMBER 30, 2005 END DATE: SEPTEMBER 29, 2010

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Report prepared by Dr Toh Ephraim Ngwa Akonwi Fuh Zacharie Fotso Fokam Ofal Utia James Ngo Ngan Louise Matilda Maboh Tingu Mpiang Mpiang Jacques Ntouba Eric Philomene Oumarou Martin Nankap EIP Coordinator EIP Assistant, Health Information System Provincial Health Coordinator Plan Bertoua PU Provincial Health Coordinator Plan Biteng PU Provincial Health Coordinator Plan Bamenda PU CBS Bamenda PU CBS Bertoua PU CBS Biteng PU MCI Point person, ACMS Nutrition Program Manager HKI

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ABBREVATIONS AHS ACMS ARI CBO CBS CS DHT DMO FE HD Assistant Health Supervisor Association Camerounaise pour le Marketing Social Acute Respiratory Illness Community-Based Organization Capacity Building Supervisor Child Survival District Health Team District Medical Officer Final Evaluation Health District

HIV/AIDS Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome HS IMCI IHFA IPT ITN LQAS LLITN LNGO KPC PC PU PUHC U5 WHO Health Supervisor Integrated Management of Childhood Illnesses Integrated Health Facility Assessment Intermittent Preventive Treatment Insecticide Treated Net Lot Quality Assurance Sampling Long- lasting Insecticide Treated Net Local Non-Government Organization Knowledge, Practices and Coverage Project Coordinator Program Unit Program Unit Health Coordinator Children Under 5 years World Health Organization

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ANNEX 6

I.

INTRODUCTION

The Bundled Expanded Impact Child Survival Project (EIP) implemented by Plan Cameroon, Helen Keller International (HKI) and the Association Camerounaise pour le Marketing Social (ACMS) in collaboration with the Cameroon Ministry of Health (MOH) and local nongovernment organization (LNGO) partners and funded by USAID, is in its fifth year of implementation. The main goal of the project is to support the MOH to scale up all components of Integrated Management of Childhood Illness (IMCI) and Roll Back Malaria in Cameroon. Project interventions cover 11 health districts in three provinces (East, Northwest and Center) with spillover to 55 other health districts in these three provinces and the 177 HDs nationwide. The project is implemented within five domains of intervention: malaria (40% of efforts), malnutrition (30%), diarrhea (10%), ARI (10%), and EPI (10%), each with specific domain objectives. Within the Detailed Implementation Plan (DIP) of the project, two bi-annual monitoring surveys have been scheduled to track the progress made in the implementation of the health facility and the community components of IMCI. The results of these surveys are intended to influence the planning of activities at the community, district, provincial and central levels to foster and maintain good performance, to carry out corrective activities for those indicators not yet meeting expected results and to influence MOH policy to boost the scaling up of IMCI implementation within the country. After the baseline survey was conducted in February 2006, the first monitoring exercise was conducted in April 2007 (Year 2 of the project), the second in 2008 (during the Mid-Term Evaluation of the project). This third monitoring exercise, which took place in the months of June and July 2010 (Year 5 of the project), leads up to the Final Evaluation (FE) of the project. The two main survey methodologies that were used at baseline and planned in the DIP for M&E are the Integrated Health Facility Assessment (IHFA), later replaced by the Rapid Health Facility Assessment (R-HFA) during the Mid-Term Evaluation, and Lot Quality Assurance Sampling (LQAS) to measure knowledge, practices, and coverage (KPC). This report presents the whole process of the third monitoring exercise (preparatory phase, training of surveyors, field data collection, data entry and analysis, and results) and presents a comparative analysis of the results against baseline data and targets set at the start of the project. Conclusions and recommendations are also suggested.

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ANNEX 6

II.

SELECTION OF INDICATORS

The monitoring surveys measure the progress made by EIP implementation interventions in striving to meet the projects end term objectives. The six-month periodicity of these surveys is not enough to expect change in all the EIP indicators. Thus, only a limited number of indicators from those measured during baseline at both the community and the health facility levels were selected and agreed upon among the EIP partners prior to the study.

A) Indicators for health care provider assessment


The third round of EIP monitoring used four components of the IHFA developed by BASICS and used during the EIP baseline survey in February 2006. Following the aim of the survey to appreciate the improvement of the health care provider after training received on IMCI, the observation checklist and the caretaker exit interview were the most appropriate with their related indicators. The observation checklist directly reports the achievement of screening, clinical examination, treatment and interpersonal communication tasks, while the exit interview checklist permits to appreciate how well the counseling provided by the health care providers is apprehended by the caretakers sick-child consultations. The observation checklist was amended to determine if health staff had been trained on IMCI and if staff members had been receiving supervisory visits from their immediate supervisor. The indicators were calculated using the formulas provided by the IHFA facilitation guide developed by BASICS. The following indicators were retained: Table 1: IHFA indicators
Management task Screening Indicator Proportion of children who were assessed for all danger signs; Proportion of children who were assessed for all main symptoms; Clinical examination Proportion of assessment tasks completed for sick children with a history of diarrhea; Proportion of assessment tasks completed for sick children with a history of ARI; Proportion of assessment tasks completed for sick children with a history of fever; Formula Cases with all danger signs assessed Total number of cases observed Cases assessed for all main symptoms Total number of cases observed Number of assessment tasks completed for cases with a history of diarrhea Total number of assessment tasks required for sick children with a history of diarrhea Number of assessment tasks completed for cases with a history of ARI Total number of assessment tasks required for sick children with a history of ARI Number of assessment tasks completed for cases with a history of ARI Total number of assessment tasks required Source IHFA observation checklist BASICS

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Management task

Indicator Proportion of children who had nutritional status assessed; Proportion of children whose weight was plotted on a growth chart; Proportion of children who were weighed the day of the survey;

Formula for sick children with a history of ARI Cases assessed correctly for nutrition Total number of cases observed Cases whose weight was plotted on a chart Total number of cases observed Cases whose weights were determined Total number of cases observed Cases whose health worker asked for child's vaccination card Total number of cases observed Cases with a vaccination card needing a vaccination who received an immunization the day of the visit or were referred Cases not up to date Cases with treatment appropriate for diagnosis Total number of cases requiring treatment Number of cases with simple diarrhea who received ORS/RHF Number of cases with simple diarrhea Pneumonia cases who received an appropriate antibiotic Total number of pneumonia cases Malaria cases who received an appropriate antimalarial Total number of malaria cases Simple diarrhea cases who received an antibiotic or an antidiarrheal medication Total number of simple diarrhea cases Cold/allergy/simple cough cases who received an antibiotic Total number of cold/allergy/simple cough cases Number of treatment counseling tasks completed for sick children Total number of treatment counseling tasks required for sick children Cases whose caretakers were told by HW the need to give the same quantity or more liquid at home Total number of cases observed Cases whose caretakers were counseled by HW on the need to continue feeding or breastfeeding at home Total number of cases observed Cases whose caretakers were told at least three messages on when to bring the child back

Source

Immunization

Proportion of children who had vaccination card checked at sick child visit; Proportion of children who needed an immunization who received it on the day of the visit or were referred for vaccination; Proportion of children who received an appropriate medication for the diagnosis made by the health worker; Proportion of children with simple diarrhea who received ORS/RHF; Proportion of pneumonia cases who received an appropriate antibiotic; Proportion of malaria cases who received an appropriate antimalarial; Proportion of children with simple diarrhea who received an antibiotic or an antidiarrheal; Proportion of children with simple URTI who received an antibiotic;

IHFA observation checklist BASICS

Treatment

Interpersonal communication

Proportion of treatment counseling tasks completed for sick children; Proportion of children whose caretakers were counseled on the importance of giving fluids at home; Proportion of children whose caretakers were counseled on the importance of giving food or breastfeeding at home; Proportion of children whose caretakers were given advice on when to return;

IHFA observation checklist BASICS

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Management task

Indicator Proportion of children whose caretakers were told how to administer oral medications;

Formula Total number of cases observed Cases whose caretakers were told how to administer all oral medications Total number of cases given or prescribed oral medications Number of health workers who had received at least one training in the last 12 months Total number of HWs interviewed Health staffs who consulted the children and received a training on IMCI Total number of HWs interviewed Number of HWs who received at least one supervisory visit in the last 6 or 12 months Total number of HWs interviewed

Source

Training and supervision

Proportion of health workers who saw sick children and who had received training in the management of child illness in the last 12 months; Health staffs who consulted the children and received a training on IMCI; Proportion of health workers who had received at least one supervisory visit in the last 6 or 12 months Average number of supervisory visits per year per health facility Proportion of children receiving oral medications whose caretakers knew correctly how to administer the treatment at home Proportion of caretakers who knew how to correctly manage the child at home Proportion of caretakers who knew at least two signs of when to return if the child became worse at home

IHFA exit interview checklist

Management of sick child at home

Caretakers who knew how to give ALL essential medications correctly Total number of caretakers interviewed whose child was given or prescribed oral medication Number of caretakers who knew at least two aspects of home case management Total number of caretakers interviewed Number of caretakers who knew at least two signs of child getting worse at home Total number of caretakers interviewed

IHFA exit interview checklist

B) KPC indicators for key family practices and behaviors


A total of 18 outcome indicators were retained for the KPC survey in the community. These comprised 13 rapid CATCH indicators and five project-specific indicators. For convenience, the indicators are classified below under the following nine categories: anthropometry; child spacing; antenatal and immediate newborn care; breastfeeding and nutrition; infant/childhood immunization; malaria prevention and control; IMCI; HIV/AIDS; and hand washing. Anthropometry 1) Underweight (low weight-for-age) prevalence: Percentage of children aged 0-23 months who are below two standard deviations (-2SD) from the median weight-for-age, according to the WHO/NCHS reference population Child spacing

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2) Less stringent adequate birth interval between two youngest surviving children: Percentage of children aged between 0-23 months that were born at least 24 months after the previous surviving child Antenatal and immediate newborn care 3) Tetanus toxoid coverage: Percentage of mothers of children aged 0-23 months who received at least two tetanus toxoid injections before the birth of their youngest child 4) Skilled delivery health personnel: Percentage of children aged 0-23 months whose delivery was attended to by skilled personnel Breastfeeding and nutrition 5) Exclusive breastfeeding rate: Percentage of infants aged 0-6 months who were exclusively breastfed in the last 24 hours 6) Complementary feeding rate: Percentage of infants aged 6-9 months receiving breast milk and complementary (solid) foods in the last 24 hours 7) Adequate nutritional intake (protein):Percentage of children aged 6-9 months who consumed food rich in protein in the 24 hours preceding the survey 8) Adequate nutritional intake: Percentage of children aged 6-9 months who consumed food rich in oil in the 24 hours preceding the survey 9) Adequate nutritional intake: Percentage of children 6-59 months who received animal and/or vegetable protein during the last 24 hours 10) Immediate breastfeeding: Percentage of children age 0-6 months who were put to breast within one hour of birth 11) Vitamin A supplementation in infants: Percentage of children 6-9 months, who consumed food rich in vitamin A in the 24 hours preceding the survey 12) Post-partum vitamin supplementation: Percentage of mothers who received two vitamin A supplements within eight weeks following delivery. 13) Vitamin A supplementation in children U5: Percentage of children 6-59 months who received Vitamin A in the previous six months 14) Weekly intake of key foods among children U5: Proportion of children 6-59 months with adequate HKI/FFM score Infant/childhood immunization 15) EPI full immunization coverage by first birth day: Percentage of children aged 12-23 months who are fully immunized (i.e. receive BCG, polio 0, 1, 2 and 3, DTP, Hepatitis B 1, 2 and 3) (have vaccination cards or book) according to the vaccination calendar 16) DTP1 coverage: Percentage of children aged 12-23 months who received DTP1 according to the vaccination card or mothers recall by the time of the survey 17) DTP3 coverage: Percentage of children DTP3 according to the vaccination card mothers recall by the time of the survey Malaria prevention and control 18) Child insecticide treated bed net use: Percentage of children aged 0-23 months that slept under an insecticide-treated bed net the previous night 19) Insecticide treated bed net use by pregnant women: Percentage of pregnant women who slept under an insecticide-treated net the previous night

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20) Malaria prophylaxis during pregnancy: Percentage of women who completed Intermittent Preventive Treatment (IPT) during their current or last pregnancy 21) Malaria case management: Percentage of children aged 0-59 months who received a fullcourse of recommended anti-malarial (according to the MOHs recently approved homemanagement protocols) within the 24 hours of the onset of fever IMCI 22) Maternal knowledge of child danger signs: Percentage of mothers who know at least two signs of childhood illness that indicate the need for treatment 23) Increased fluid and continued feeding during illness: Percentage of children aged 0-23 months that received increased fluids and continued feeding during an illness in the past two weeks 24) Treatment seeking: Percentage of children with signs of severe childhood illness that were seen by a qualified public or private provider in the past two weeks 25) Correct treatment of illness: Children with signs of severe childhood illness who received correct treatment at home or at health facility 26) Treatment seeking: Percentage of children age 0-23 months with chest related cough and fast and/or difficult breathing in the last two weeks who were taken to an appropriate health provider 27) Maternal knowledge of child danger signs: Percentage of mothers of children 0-23 months who know at least two signs of childhood illness (fast breathing and chest in drawing) that indicate the need for treatment HIV/AIDS 28) Maternal knowledge of HIV risk reduction: Percentage of mothers with children aged 023 months that cite at least two known ways of reducing HIV infection Hand washing 29) Maternal hand washing behavior: Percentage of mothers of children aged 0-23 months who wash their hands with soap before food preparation, before feeding children, and after attending to a child who has defecated Beneficiary satisfaction of health care services The following aspects were used to determine beneficiary satisfaction: y Waiting time in health facilities y Explanation provided by health worker on childs illness y Treatment received for childs illness y Likelihood of returning to the health facility.

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Table 2: Summary for Rapid CATCH Indicators


Indicators a. Anthropometry 1. Percentage of children age 0-23 months who are under-weight (-2 SD from the median weightfor-age, according to the WHO/NCHS reference population) a. Child spacing Formula No. of children whose weight is -2 SD from the median weight of the WHO/NCHS reference population for their age Total number of children 0-23 months who were weighed

Number of children aged 0-23 whose date of birth is at least 24 2. Percentage of children born at least 24 months after the previous surviving siblings date of birth months after their immediate surviving elder Number of children 0-23 months in the survey who have an older surviving sibling c. Antenatal and immediate new-born care No. of mothers of children age 0-23 months with responses =2 3. Percentage of mothers with children age 0 (twice) or 3 (more than two times) for Rapid CATCH 23 months who received 2 tetanus toxoid Question 8 Mod 1 injections before the birth of their youngest child No. of mothers of children age 0-23 months in the survey No. No. of children age 0-23 months with responses A (doctor), B 4. Percentage of children age 023 months (nurse/midwife) or C (auxiliary midwife) for Rapid CATCH whose births were attended by skilled health Question 14 Mod 1 personnel No. of children aged 0-23 months in the survey 5. Percentage of mothers of children age 0-23 No. of children with Q11=Yes and Q12= More than onece Mod who received two Vitamin A supplements within 1 8 weeks post partum No. of mothers of children aged 0-23 months in the survey 6. Percentage of mothers of children age 0-23 No. of children with Q9 =Yes and 5 or more in Q.10 ticked taking iron/folate supplements daily for at least Mod 1 five months during their last pregnancy No. of mothers of children aged 0-23 months in the survey d. Breastfeeding and nutrition 7. Percentage of children age 0-5 months who No. of infants age 0-5 months with only response A were exclusively breast-feeding during the last 24 (breastmilk) for Rapid CATCH Question 13 Mod 2 hours No. of infants age 0-5 months in the survey No. of infants age 6-9 months with responses A (breastmilk) 8. Percentage of children age 6-9 months who and D (mashed, pureed, solid or semi-solid foods) for Rapid received breast-milk and complementary foods CATCH Question 11 Mod 3 during the last 24 hours. No. of infants age 6-9 months in the survey 9. Percentage of children age 6-9 months who No. of children with (and/or) Yes in either of Q12 consumed food rich in protein in the 24 hours A,B,C,M,N,O,P,Q,R Mod 3 preceding the survey No. of infants age 6-9 months in the survey 10. Percentage of children age 6-9 months who No. of children with K and/or S = "Y" in Q.12 Mod.3 consumed food rich in oil in the 24 hours No. of infants age 6-9 months in the survey preceding the survey 11. Percentage of children age 6-59 months who No. of children with (and/or) H,I,J,K = "Y" in Q.12 Mod 3 received a Vitamin A supplement in the prior 6 No. of children age 6-59 months in the survey months 12. Percentage of children 6-59 months of age HKI/Food Frequency Method score eating vitamin A rich foods daily during the past No. of children age 6-59 months in the survey week. e. Infant/childhood immunization 13. Percentage of children age 1223 months No. of children age 12-23 months who received Polio 3 who are fully vaccinated (against the five (OPV3), DPT3, and measles vaccine before their first birthday, vaccine-preventable diseases) before the first according to the childs vaccination card (as documented in birthday Rapid CATCH Question 15)

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Formula No. of children age 12-23 months in the survey who have a vaccination card that was seen by the interviewer (response 1 (yes, seen by interviewer) to Rapid CATCH Question 14) 14. Percentage of children age 1223 months No. of children age 12-23 months with response 1 (yes) for who have received measles vaccination before Rapid CATCH Question 16 the first birthday No. of children age 12-23 months in the survey f. Malaria Prevention and control No. of children age 0-23 months with response A (child) 15. Percentage of children age 0-23 months who mentioned among response to Rapid CATCH Question 18 and slept under an insecticide-treated net the previous response 1 (yes) for Rapid CATCH Question 19 night No. of children age 0-23 months in the survey Mothers with response Q31=Yes + Q32 = Myself + Q36=Yes + 16. Percentage of pregnant women who slept ( Either (Q33=More than 2 year AND Q35=6) OR Q33=Less under an insecticide-treated net the previous night than two years) Module 1 Total no. of Pregnand women (Q36=Yes) 17. Percentage of women who completed No. of mothers with response Yes for Q29 mod 1 Intermittent Preventive Treatment (IPT) during Total no. of mothers with children aged 0-23 months their current or last pregnancy 18. Percentage of children age 0-59 months who received a full-course of recommended anti- No. of children with 10 or 11 circled for Q.28 malarials (according to the MOHs recently approved home-management protocols) within No. of children with response=F or G for Q.16 the 24 hours of the onset of fever g. Integrated Management of Childhood Illnesses (IMCI) No. of mothers of children age 0-23 months who report at least 19. Percentage of mothers of children age 0-23 two of the signs listed in B through H of Rapid CATCH months who know at least two signs of childhood Question 20 illness that indicate the need for treatment No. of mothers of children aged 0-23 months in the survey No. of children age 0-23 months with response 3 (more than usual) for Rapid CATCH Question 22 and response 2 (same 20. Percentage of sick children age 0-23 months amount) or 3 (more than usual) for Rapid CATCH Question who received increased fluids and continued 23 feeding during an illness in the past two weeks No. of children age 0-23 months surveyed who were reportedly sick in the past two weeks (children with any response A through H for Rapid CATCH Question 21) No. of mothers of children age 0-23 months who mention at 21. Percentage of mothers with children age 0 least two of the responses that relate to safer sex or practices 23 months who cite at least two known ways of involving blood (responses B through I and O) for Rapid CATCH Question 25 reducing the risk of HIV infection No. of mothers of children age 0-23 months in the survey 22. Percentage of mothers of children age 0-23 No. of mothers of children age 0-23 months who mention months who report that they wash their hands responses B through E for Rapid CATCH Question 26 with soap/ash before food preparation, before feeding children, after defecation and after a No. of mothers of children age 0-23 months in the survey attending a child who has defecated No. of children aged 0-23 months with (response for 01, or 02, 23. Percentage of children with signs of severe or 03, or 04, or 05, or 06, or 07 for Q.20) OR (response for 01, childhood illness who were seen by a qualified or 02, or 03, or 04, or 05, or 06, or 07 for Q.22) public or private provider in the past two weeks No. of children aged 0-23 months with response for A or B, or C, or D, or E, or F, or G or H for Q. 16 (module 1)

Indicators

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III. DESIGN OF SURVEY INSTRUMENTS


The survey tools were adapted to meet the survey indicator list. The Rapid CATCH questionnaire used during the Mid-Term Evaluation was adapted: unnecessary questions were removed and more questions were added to meet the requirements of the new indicators. Five modules addressing each age group were developed to meet the LQAS requirement to have a lot sample size of 19 for each indicator. Two indicators might not have met this requirement, as a separate module was not developed for children who had diarrhea to measure the use of ORS and pregnant women who slept under ITN the previous night. The presentation of district level results will be aided by the collection of a sufficient number of responses. The survey tools for Bertoua and Biteng PU were translated into French.

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IV.

PARTNERSHIP FOR SURVEY IMPLEMENTATION

Logistics contribution by the MOH was a valuable expression of partnership during survey implementation. In all health districts, MOH personnel supported training by providing the event space (training hall) and supported data collection by providing vehicles and personnel to facilitate and participate as surveyors. This reduced the facility and vehicle rental costs. In addition to the provision of IHFA facilitators and surveyors, the provincial delegations also provided computers for data entry. The EIP contributed training of surveyors, fuel, coffee breaks and provision of the EPI Info data entry view. The organizational ownership of these surveys is welcomed, as one of the goals of the project is spillover of IMCI from EIP target provinces to other health districts which are not directly covered by EIP. If the provincial delegations succeed in finding other funds, the availability of the IMCI and IHFA facilitators will allow an implementation of IMCI in those districts with little dependency on central-level MOH or EIP.

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V.

DATA COLLECTION

A) Surveyors
The health facility assessment data collection was carried out by qualified health personnel. While Biteng PU used external surveyors, Bertoua and Bamenda hired staff working within EIP target health districts or individuals posted in their respective provincial delegations. Bamenda PU hired individuals with vested interest in IHFA results; the team was mainly comprised of staff posted in the Bamenda provincial delegation of health from the Expanded Program on Immunization (EPI) and other IMCI-related programs. This contributed to the reinforcement of integration of these programs and also served an advocacy role for IMCI at the intermediary level. Prior to field data collection, surveyors were trained for two days on questionnaire administration. Compared to the second round of monitoring, all PUs demonstrated an increased sense of ownership of the EIP, as the training of surveyors was jointly handled by the EIP focal person (M&E) of the Regional Delegation of Public Health. This strategy helped to build a local permanent pool of IHFA surveyors and facilitators. The surveyors who did the data collection in the ProFam network were selected via open tenders, and were trained and supervised by ACMS.

B) Data collection
At least 25 health facilities were expected to be visited within the three days following the training of surveyors. In the end, a total of 97 health care providers, of whom 59 were trained on IMCI, were observed in the 11 EIP target districts and the ProFam target zone as follows: o Bamenda: 24 health care providers o Bertoua: 32 health care providers o Biteng: 18 health care providers o ProFam (Yaound): 23 health care providers Each of the health facilities reached received a team of two surveyors and one supervisor, whose mission was to observe the consultation of each child less than five years presenting with a case of any IMCI condition and administer an exit interview checklist to the caretaker who brought the child. At the end of the day, several questions on any training and supervision received on IMCI were asked to health staff that performed the consultation and the equipment and supplies checklist was applied as appropriate.

C) Data analysis
The data entry masks were prepared by the Plan country office and data entry was completed at the program units. Data sets were forwarded to the Plan country office for data cleansing and analysis. In upcoming IHFA sessions, it is hoped that all PUs will be able to carry out data analysis using EPI Info, as EIP staff from all project sites and District Medical Teams, as well as the focal points of the Provincial Delegation of Public Health, participated in the EPI Info series of training of trainers organized after the survey.

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VI. PRESENTATION OF RESULTS


The overall trends of the third round of IHFA monitoring show an improvement in child health case management by health care providers in EIP target zones. IMCI training undoubtedly explains this progress, as testified by the remarkable improvement by the Bertoua PU, whose frontline health care providers were exposed to IMCI training. Analysis of the results is therefore separated by case management task, and results are disaggregated and presented by project site. This will allow for the planning of corrective interventions such as training and supervision activities based on the weaknesses observed at each individual site. This report serves to compare the baseline, mid-term, and final evaluation surveys.

A) Description of the sample


Of the 97 observed health staff, 41 of the target health facilities were private institutions and 56 were public. Compared to the Mid-Term Evaluation, the proportion of children who complained of diarrhea and vomiting was greatly reduced (35.7% to 28.8%). A detailed description of the sample is presented in the table below. Table 3: Description of the IHFA sample
Health facilities visited Hospital Medicalized health centre Health centers Public Private Health staff observed Medical doctors State registered nurses Midwives Nurses Nurse aids State agents Children observed <6 months 0-11 months 12-23 months 0-23 months 24-59 months Total 0-59 months EIP 97 10 9 78 56 41 97 8 54 3 16 13 3 97 245 138 383 276 659 Bamenda 24 3 3 18 19 5 24 3 11 1 2 7 0 33 100 52 152 90 242 Bertoua 32 4 4 24 22 10 32 4 24 2 2 0 0 30 62 44 106 84 190 Biteng 18 3 1 14 15 3 18 1 10 0 2 2 3 14 37 24 61 47 108 ProFam 23 0 1 22 0 23 23 0 9 0 10 4 0 20 46 18 64 55 119

Table 4: Complaints presented by caretakers EIP Bamenda 190 59 Diarrhea/vomiting Fever/malaria


659 488 28.8% 74.1% 242 168 24.4% 69.4%

Bertoua
72 190 160 37.9% 84.2% 38 108 85

Biteng
35.2% 78.7%

ProFam
21 119 75 17.6% 63.0%

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Cough/Difficult breathing

659 359 659

54.5%

242 159 242

65.7%

190 70 190

36.8%

108 49 108

45.4%

119 81 119

68.1%

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B) Survey results
Screening of the sick child Two indicators were used to assess the effectiveness of screening of the sick child (see Table 5): - Screening for all danger signs permits the consulting nurse to identify children who are critically ill and attend to them or refer immediately. - Screening for all main symptoms helps to ensure the identification of other concurrent illnesses or conditions that the caretaker might not have been aware of, thus increasing the chances of taking care of all of the childs problems in an integrated manner. Table 5: Screening of the sick child
Feb 2006 EIP Apr 2007 July 2010 Feb 2006 Bamenda Apr July 2007 2010 Feb 2006 Biteng Apr 2007 July 2010 Feb 2006 Bertoua Apr 2007 July 2010 Feb 2006 ProFam Apr 2007 July 2010

No.

Indicator SREENING Proportion of children who were assessed for all danger signs Proportion of children who were assessed for all main symptoms

4.8%

47.3%

61.3%

0.5%

43.0%

55.0%

17.5%

31.4%

65.7%

9.8%

35.6%

58.9%

1.0%

67.0%

73.9%

7.8%

60.4%

64.8%

2.2%

54.7%

65.7%

26.3%

31.4%

73.1%

15.2%

38.6%

47.9%

1.0%

95.3%

82.4%

From Table 5 above, the proportion of children who were assessed for all danger signs has increased from 4.8% to 61.3% (p=0.002) nationally. The survey results show a general increase in all three PUs and in ProFam clinics: Bamenda (0.5% to 55.0%) (p<0.00001), Biteng (17.5% to 65.7%, p=0.001), Bertoua (9.8% to 58.9%, p=0.0021), ProFam clinics (1.0% to 73.9%, p=0.003). The results could be attributed primarily to training of more health staff on IMCI and continuous supervision of staff by MOH and stakeholders. The proportion of children who were assessed for all main symptoms has increased tremendously with the following contributions by PU: ProFam clinics (1.0% to 82.4%), Bertoua (15.2% to 47.9%), Biteng (26.3% to 73.1%) and Bamenda (2.2% to 65.7%). The project objective is to have at least 65% of frontline MOH and private providers manage sick children in accordance with the MOH IMCI protocol. The project has contributed to large improvements, and the objectives have been nearly met. The remarkable increases can largely be attributed to IMCI training. Appropriate supervision and assurance that priority is given to frontline staff when planning IMCI training are recommended to help sustain this effort.

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Figure 1: Screening in all EIP zones, by monitoring period


EIP Screening

70.0%

64.8% 61.3% 60.4%

60.0% 47.3% 50.0% Feb 2006 Apr 2007 July 2010

40.0%

30.0%

20.0% 4.8% 7.8%

10.0%

0.0% Proportion of children who were assessed for all danger signs Proportion of children who were assessed for all main symptoms

Clinical examination As demonstrated in Table 6, five indicators were used to assess the completeness of the clinical examination of the sick child: the number of assessment tasks completed for cases with history of each diarrhea, ARI, fever, nutrition status and weight plotting on the growth chart. A thorough clinical examination enables the consulting staff to make the correct diagnosis, to classify illness appropriately and to prescribe the appropriate treatment. See also Figures 2 and 3 for graphical representation of these results.

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Table 6: Clinical examination, nutrition, and immunization


Feb 2006 EIP Apr 2007 July 2010 Bamenda Feb Apr July 2006 2007 2010 Feb 2006 Biteng Apr 2007 July 2010 Feb 2006 Bertoua Apr 2007 July 2010 Feb 2006 ProFam Apr 2007 July 2010

No. Indicator CLINICAL EXAMINATION 3 Proportion of assessment tasks completed for sick children with a history of diarrhea Proportion of assessment tasks completed for sick children with a history of ARI Proportion of assessment tasks completed for sick children with a history of fever Proportion of children who had nutritional status assessed Proportion of children whose weight was plotted on a growth chart Proportion of children who were weighed the day of the survey

41.7%

57.8%

68.3%

33.3%

60.7%

63.1%

49.7%

46.2%

69.2%

41.0%

54.4%

66.1%

49.2%

64.5%

81.3%

52.5%

78.9%

74.9%

48.8%

75.9%

81.0%

56.6%

69.5%

74.1%

56.0%

73.3%

52.5%

56.6%

90.5%

98.8%

40.3%

70.3%

72.1%

31.6%

68.6%

65.7%

36.8%

61.3%

72.9%

48.7%

56.2%

82.6%

49.4%

93.5%

67.6%

8.5%

36.0%

37.5%

0.5%

22.1%

29.3%

29.8%

60.0%

80.6%

12.0%

20.8%

32.6%

7.6%

53.8%

22.7%

20.1%

55.8%

57.5%

23.0%

23.3%

45.5%

40.4%

31.4%

89.8%

20.7%

46.5%

65.3%

3.8%

99.1%

40.3%

87.6%

90.6%

98.2%

88.5%

91.9%

99.2%

77.2%

85.1%

96.3%

85.9%

85.1%

98.4%

93.3%

100.0%

97.5%

IMMUNIZATION 9 Proportion of children who had vaccination card checked at sick child visit 10 Proportion of children who needed an immunization who received it on the day of the visit or were referred for vaccination

50.3%

74.1%

84.2%

47.5%

67.4%

82.6%

50.9%

68.6%

78.7%

65.2%

70.3%

81.6%

41.9%

84.9%

96.6%

48.1%

52.9%

58.6%

44.4%

37.0%

45.5%

72.7%

61.8%

52.1%

14.3%

64.0%

74.2%

13.8%

42.9%

66.3%

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Diarrhea This proportion of assessment tasks completed for sick children with a history of diarrhea moved from 41.7% to 68.3% at national level, with positive progress made in all three PUs and ProFam clinics with the following results: Bamenda PU (33.3% to 63.1%), Biteng PU (49.7% to 69.2%), Bertoua (41.0% to 66.1%), ProFam clinics (49.2% to 81.3%). This good performance is significantly due to the fact that health personnel have realized the benefits of IMCI and are applying these strategies during clinical examinations. However, regular and quality follow-up of health personnel by the District Management Health Teams has also contributed tremendously to this effect. ARI Nationally, the proportion of assessment tasks completed for sick children with a history of ARI has demonstrated a remarkable increase from 52.5% at baseline to 74.9% at the final evaluation. Results disaggregated by PU are as follows: Bamenda PU (48.8% to 81.0%), Biteng PU (56.6% to 74.1%), Bertoua (56.0% to 52.5%), ProFam clinics (56.6% to 98.8%). These results could be attributed to an improvement in knowledge, skills and attitudes of health personnel through IMCI trainings and regular follow-up by MOH staff from regional and district levels, as well as the contribution of other stakeholders. Fever The proportion of assessment tasks completed for sick children with a history of fever increased from 40.3% at baseline to 72.1% at the final evaluation nationally, with progressive performance in all three PUs and ProFam clinics. The following results were obtained: Bamenda PU (31.6% to 65.7%), Biteng PU (36.8% to 72.9%), Bertoua (48.7% to 82.6%), ProFam clinic (49.4% to 67.6%). These results are mainly due to the organization of more refresher courses for health personnel on malaria case management by the National Malaria Control Program and the EIP project. Malnutrition 1. Proportion of children who had their nutritional status assessed There has been a general increase in this indicator nationally, rising from 8.5% at onset of the project to 37.5% at the end of the project. Individual PU contributions are as follows: Bamenda PU (0.5% to 29.3%), Biteng PU (29.8% to 80.6%), Bertoua (12.0% to 32.6%), ProFam clinics (7.6% to 22.7%). However, this increase has been slow in ProFam clinics due to high turnover of trained staff. Generally, this improved performance is due to the implementation by HKI of Essential Nutrition Actions trainings to health personnel during the last year of the project in all PUs. 2. Proportion of children whose weight was plotted on a growth chart The indicator has increased from 20.1% to 57.5%. The survey results show a general increase in all three PUs and in ProFam clinics. The disaggregated results are as follows: Bamenda PU (23.0% to 45.5%), Biteng PU (40.4% to 89.8%), Bertoua (20.7% to 65.3%), ProFam clinics (3.8% to 40.3%). This observed increase in all units could be attributed to more IMCI trainings and continuous

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supervision of trained staff by district and regional teams under the EIP project. More so, remarkable logistic and technical supports (weighing scales, trainings, etc.) from other partners such UNICEF, FAO and UNPFA contributed to improved practices. Immunization 1. Proportion of children who had vaccination card checked at sick child visit There is a great improvement with regards to this indicator in EIP at final evaluation (84.2%) compared to baseline (50.3%). ProFam has registered the highest achievements for this indicator (96.6%). The disaggregated results are as follows: Bamenda PU (47.5% to 82.6%), Biteng PU (50.9% to 78.7%), Bertoua (65.2% to 81.6%), ProFam clinics (41.9% to 96.6%). This result could be explained by the formal training; the formative supervision of district health teams (DHT), and financial support to DHT. 2. Proportion of children who needed an immunization who received it on the day of the visit or were referred for vaccination This indicator has improved at final evaluation (58.6%) for the entire EIP as compared to baseline (48.1%). The disaggregated results are as follows: Bamenda PU (44.4% to 45.5%), Biteng PU (72.7% to 52.1%), Bertoua (14.3% to 74.2%), ProFam clinics (13.8% to 66.3%). Nevertheless, it should be indicated that Biteng PU has scored less than the EIP baseline (72.7%) at final evaluation (52.1%). The drop observed in Biteng might be explained by the fact that there is neglect of this task by some health staffs.

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Figure 2: Achievement of clinical examination and nutrition indicators, by monitoring period


EIP CLINICAL EXAMINATION 1 78.9% 80.0% 68.3% 70.0% 57.8% 60.0% 52.5% Feb 2006 Apr 2007 July 2010 50.0% 41.7% 40.0% 40.3% 36.0% 37.5% 55.8% 57.5% 74.9% 70.3% 72.1%

30.0% 20.1% 20.0% 8.5% 10.0%

0.0% Proportion of assessment tasks completed for sick children with a history of diarrhea Proportion of assessment tasks completed for sick children with a history of ARI Proportion of assessment tasks completed for sick children with a history of fever Proportion of children who had nutritional status assessed Proportion of children whose weight was plotted on a growth chart

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Figure 3: Achievement of nutrition and immunization indicators, by monitoring period


EIP CLINICAL EXAMINATION - 2
98.2% 100.0% 87.6% 90.0% 74.1% 80.0% 70.0% 60.0% 50.0% Feb 2006 40.0% 30.0% 20.0% 10.0% 0.0% Proportion of children who wereProportion of children who had Proportion of children who weighed the day of the survey vaccination card checked at needed an immunization who sick child visit received it on the day of the visit or were referred for vaccination Apr 2007 July 2010 50.3% 52.9% 48.1% 90.6% 84.2%

58.6%

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Treatment As indicated in Table 7, four indicators were used to assess prescription of appropriate treatment: appropriate treatment for diagnosis, ORS/RHF for simple diarrhea, appropriate antibiotic for pneumonia and appropriate antimalarials for malaria. Prescription of appropriate treatment leads to cure of the illness, reinforces the confidence of the mothers/caretakers in the care provider and cuts down on the cost of treatment. See also Figures 4 and 5 for graphical representation of these results. Table 7: Treatment
Feb 2006 EIP Apr 2007 July 2010 Feb 2006 Bamenda Apr 2007 July 2010 Feb 2006 Biteng Apr 2007 July 2010 Feb 2006 Bertoua Apr 2007 July 2010 Feb 2006 ProFam Apr July 2007 2010

No.

Indicator

TREATMENT 11 Proportion of children who received an appropriate medication for the diagnosis made by the health worker 12 Proportion of children with simple diarrhea who received ORS/RHF 13 Proportion of pneumonia cases who received an appropriate antibiotic 14 Proportion of malaria cases who received an appropriate antimalarial 15 Proportion of children with simple diarrhea who received an antibiotic or an antidiarrheal 16 Proportion of children with simple URTI who received an antibiotic

51.7%

68.0%

71.8%

66.1%

70.9%

80.6%

43.9%

77.1%

86.1%

47.8%

56.4%

55.3%

34.3%

73.6%

67.2%

50.0%

70.5%

68.3%

32.0%

60.0%

60.4%

58.3%

75.0%

73.5%

61.5%

43.8%

68.6%

64.3%

94.7%

88.9%

17.6%

64.7%

72.4%

17.7%

17.9%

75.0%

36.4%

85.0%

81.3%

28.6%

74.3%

60.8%

11.5%

80.0%

77.8%

56.9%

63.7%

86.9%

68.4%

60.7%

91.4%

52.6%

42.1%

95.4%

65.6%

65.6%

71.8%

35.3%

71.9%

97.1%

78.3%

36.0%

49.5%

92.0%

60.0%

58.1%

70.6%

25.0%

16.7%

66.7%

31.3%

57.8%

No data

No data

44.4%

72.1%

60.5%

54.7%

82.1%

76.9%

80.5%

33.3%

61.5%

80.0%

28.6%

47.1%

26.9%

No data

No data

28.8%

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1) Proportion of children who received an appropriate medication for the diagnosis made by the health worker Compared to baseline, there is an improvement in EIP areas for this indicator. Indeed, at FE, the EIP registered 71.8% while at baseline EIP scored 51%. The greatest score is observed with Biteng PU (81.6%), which may be attributed to formative supervision of District Health Teams and availability of appropriate drugs. 2) Proportion of children with simple diarrhea who received ORS/RHF EIP registered 68.3% at final survey for this indicator, an increase from the baseline score of 50%. Though there is an improvement compared to baseline, it should be noted that a decrease was observed as compared to the mid-term evaluation (70.5%), which may be explained by ORS stock outs in certain EIP areas. 3) Proportion of pneumonia cases who received an appropriate antibiotic A great improvement has been observed for this indicator in EIP areas during the final evaluation (72.4%) as compared to baseline (17.6%). Among the four project areas, Bamenda observed the greatest improvement (from 17.6% to 75%), while a decrease has been observed in the other project areas. This great improvement in Bamenda may be due to increased awareness of health personnel through IMCI and C-IMCI training, as well as formative supervision. It might be concluded that caretakers of U5 children are now aware of the signs of pneumonia that necessitate treatment and health workers administer appropriate drugs according to treatment protocol. 4) Proportion of malaria cases who received an appropriate antimalarial A general increase was observed from baseline (56.9%) to the final evaluation (86.9%), and all four project areas experienced significant improvement for this indicator. This result could be explained by: - An increased number of caretakers of children U5 utilizing health facilities - Consistent availability of the appropriate drug treatments - Reduction in costs of malaria treatment as a result of MOH decision making While a considerable effort to improve the prescription for diagnosis is globally observed, a resistance to avoid antibiotic for simple upper respiratory tract infections is noticed. The districts will have to monitor and ensure the availability of the IMCI essential drugs in remote health centers as stock outs in these areas may lead to inappropriate prescription.

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Figure 4: Achievement of treatment indicators, by monitoring period (1 of 2)


EIP TREATMENT 1

80.0% 68.0% 70.0%

71.8%

70.5% 68.3% 64.7%

72.4%

60.0%

51.7% 50.0%

Feb 2006 Apr 2007 July 2010

50.0%

40.0%

30.0% 17.6% 20.0%

10.0%

0.0% Proportion of children who received an appropriate medication for the diagnosis made by the health worker Proportion of children with simple diarrhea who received ORS/RHF Proportion of pneumonia cases who received an appropriate antibiotic

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Figure 5: Achievement of treatment indicators, by monitoring period (2 of 2)


EIP TREATMENT 2

90.0%

86.9% 78.3%

80.0% Feb 2006 70.0% 56.9% 63.7% Apr 2007 July 2010 49.5% 50.0% 36.0% 60.5% 54.7% 72.1%

60.0%

40.0%

30.0%

20.0%

10.0%

0.0% Proportion of malaria cases who received an appropriate antimalarial Proportion of children with simple diarrhea who received an antibiotic or an antidiarrheal Proportion of children with simple URTI who received an antibiotic

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Interpersonal communication Table 8: Caretaker counseling


No. Indicator Feb 2006 EIP Apr 2007 July 2010 Bamenda Feb Apr July 2006 2007 2010 Feb 2006 Biteng Apr 2007 July 2010 Feb 2006 Bertoua Apr 2007 July 2010 Feb 2006 ProFam Apr 2007 July 2010

INTERPERSONAL COMMUNICATION 17 Proportion of treatment counseling tasks 42.7% 53.5% completed for sick children 18 Proportion of children whose caretakers were counseled on the 20.6% 40.5% importance of giving fluids at home 19 Proportion of children whose caretakers were counseled on the 26.8% 64.0% importance of giving food or breastfeeding at home 20 Proportion of children whose caretakers were 18.5% 56.1% given advice on when to return SUPPORTING INFORMATION 21 Proportion of children whose caretakers were 82.0% told how to administer oral medications

61.6%

34.9%

58.5%

56.9%

53.5%

55.2%

66.0%

51.4%

48.5%

61.8%

No data

No data

66.9%

46.6%

19.1%

40.7%

50.0%

42.1%

34.3%

38.9%

30.4%

42.6%

51.6%

2.9%

40.6%

38.7%

65.9%

27.3%

61.6%

68.2%

43.9%

54.3%

64.8%

38.0%

56.4%

61.1%

6.7%

76.4%

69.7%

83.6%

18.6%

44.2%

81.8%

29.8%

40.0%

79.6%

27.2%

47.5%

82.1%

4.8%

79.2%

93.3%

89.4%

81.0%

87.1%

87.2%

80.6%

84.9%

82.9%

71.3%

87.1%

87.1%

80.8%

71.0%

95.3%

90.8%

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As shown in Table 7, 81.0% of the health staff who consulted children instructed caretakers on how to administer oral medications; two-thirds of the same sample (61.6%) completed the counseling tasks for the sick children. See also Figures 6 and 7 for graphical representation of these results. This improvement in proportion of treatment counseling tasks completed may be primarily due to training of more health staff on IMCI in 2009 in Bamenda, and continuous supervision of trained staff by district and regional teams in all PUs. At baseline, the proportion of children whose caretakers were told how to administer oral medications was already on a good trend. The indicator continues to fare well even though there is an insignificant drop compared to baseline. Neglected tasks by some health personnel due to heavy workload may be responsible for the drop. The need to complete all counseling tasks rather than just demonstrating the administration of oral medications by the health staff needs to be highlighted during district coordination meetings, as well as during routine supervision, as this will increase the chances of better management and monitoring of the sick child at home. High quality interpersonal communication between care providers and mothers/caretakers is important because it encourages the caretakers to comply with treatment instructions.

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Figure 6: Achievement of interpersonal communication indicators, by monitoring period (1 of 2)

EIP INTERPERSONAL COMMUNICATION - 1

70.0% 64.0% 61.6% 60.0% 53.5% Feb 2006 Apr 2007 July 2010

65.9%

50.0%

42.7% 40.5%

46.6%

40.0%

30.0% 20.6% 20.0%

26.8%

10.0%

0.0% Proportion of treatment counseling tasks completed for sick children Proportion of children whose caretakers Proportion of children whose caretakers were counseled on the importance of were counseled on the importance of giving fluids at home giving food or breastfeeding at home

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Figure 7: Achievement of interpersonal communication indicators, by monitoring period (2 of 2)

EIP INTERPERSONNAL COMMUNICATION - 2


Feb 2006
100.0%

Apr 2007 July 2010


89.4% 83.6% 82.0% 81.0%

90.0%

80.0%

70.0%

60.0%

56.1%

50.0%

40.0%

30.0% 18.5%

20.0%

10.0%

0.0% Proportion of children whose caretakers were given advice on when to return Proportion of children whose caretakers were told how to administer oral medications

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Training and supervision Training for health staff in ENA was implemented in the three PUs. Additionally, there was training of health staff on monitoring and management of childhood illnesses in some of the EIP partners health districts by UNICEF, WFP, UNFPA, and UNHCR. Training of health staff on IMCI was also carried out in Bamenda after the Mid-Term Evaluation. Table 8: Training and supervision
Feb 2006 EIP Apr 2007 July 2010 Feb 2006 Bamenda Apr July 2007 2010 Feb 2006 Biteng Apr 2007 July 2010 Feb 2006 Bertoua Apr 2007 July 2010 Feb 2006 ProFam Apr 2007 July 2010

No.

Indicator

TRAINING 22 Proportion of health workers who saw sick children and who had received training in the management of child illness in the last 12 months Supporting information 23 Health staffs who consulted the children and received a training on IMCI SUPERVISION 24 Proportion of health workers who had received at least one supervisory visit in the last 6 or 12 months

46.9%

71.0%

75.3%

50.0%

79.2%

70.8%

52.4%

55.0%

66.7%

50.0%

51.6%

84.4%

36.0%

100.0%

73.9%

31.4%

59.0%

69.4%

0.0%

45.8%

44.4%

52.4%

60.0%

58.3%

61.1%

35.5%

87.5%

0.0%

100.0%

69.6%

83.2%

75.0%

89.7%

86.2%

50.0%

95.8%

76.2%

50.0%

83.3%

84.6%

90.3%

87.5%

84.0%

100.0%

91.3%

The low turnover of trained personnel in Bertoua PU due to a successful personnel deployment policy is partly responsible for this performance. Also, it was noticed that in Bertoua PU, a cross section of the health staff trained on IMCI are those who work in the consultation post, contributing to the significant increase in the number of health personnel trained on IMCI observed in Bertoua.

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Supervision and follow up of trained staff has witnessed a major boost as the MOH has developed the integrated supervision strategy. Priority needs to be given to frontline staff and those who are really in charge of childhood illnesses in the hospital setting when selecting the trainees of the next IMCI training sessions. See also Figure 8 for graphical representation of these results. Figure 8: Achievement of training and supervision indicators, by monitoring period
EIP TRAINING AND SUPERVISION
Proportion of health workers who saw sick children and who had received training in the management of child illness in the last 12 months Health staffs who consulted the children and received a training on IMCI Proportion of health workers who had received at least one supervisory visit in the last 6 or 12 months
89.7%

90.0%

83.2%

80.0% 71.0% 70.0% 59.0% 60.0% 46.9% 50.0%

75.0%

75.3% 69.4%

40.0% 31.4% 30.0%

20.0%

10.0%

0.0% Feb 2006 Apr 2007 July 2010

Management of sick child at home


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Table 9: Counseling on home management of sick child


Feb 2006 EIP Apr 2007 July 2010 Feb 2006 Bamenda Apr July 2007 2010 Feb 2006 Biteng Apr 2007 July 2010 Feb 2006 Bertoua Apr 2007 July 2010 Feb 2006 ProFam Apr 2007 July 2010

No.

Indicator

MANAGEMENT OF SICK CHILD AT HOME 25 Proportion of children receiving oral medications whose caretakers knew 72.7% 80.3% 74.2% correctly how to administer the treatment at home 26 Proportion of caretakers who knew how to correctly 55.8% 74.1% 73.9% manage the child at home 27 Proportion of caretakers who knew at least two signs of when to return if the child became worse at home

82.3%

85.7%

86.4%

62.5%

78.8%

78.1%

64.8%

77.9%

67.6%

67.6%

79.2%

55.8%

57.8%

79.1%

79.3%

57.8%

68.6%

58.3%

73.8%

66.3%

71.6%

29.5%

79.2%

80.7%

56.5%

78.0%

72.4%

66.7%

74.4%

80.6%

50.9%

68.6%

76.9%

57.6%

75.2%

69.5%

41.0%

86.8%

56.3%

The proportion of children receiving oral medications whose caretakers knew how to correctly administer the treatment at home has been stagnant from baseline to end line (72.7% and 74.2%, respectively). The proportion of health workers who counsel caretakers on how to give medication at home is stagnant, thus contributing to the mild increase in the proportion of mothers who knew how to administer treatment at home. This may also suggest a problem of communication (language, lack of time to explain to the mother, etc.) between the health worker and the caretaker. Furthermore, health personnel are more concerned with treating infection rather preventing it. There was an increase in the proportion of caretakers who know how to correctly manage the child at home from 55.8% at baseline to 73.9% at end line. Also, the proportion of caretakers who knew at least two signs of when to return if the child became worse at home increased from 56.5% to 72.4%. This increase can be attributed to the fact that 83.6% of health workers effectively counsel caretakers on when to return to the health facility. See also Figure 9 for graphical representation of these results.

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There was a significant increase in the proportion of health facilities that witnessed stock outs both of ORS and essential drugs in the previous month. This can be attributed to long distances separating the source from the health facilities. The proportion of facilities with up to date registers increased from 61.5% to 89.7%. This can be attributed to the emphasis of various programs notably the immunization program on the need to have up to date registers so as to be able to track missed out children. Figure 9: Achievement of management of sick child indicators, by monitoring period
EIP MANAGEMENT OF SICK CHILD AT HOME
90.0% 80.3% 80.0% 72.7% 70.0% 74.2% 74.1% 73.9% 78.0% 72.4%

60.0%

55.8%

56.5%

50.0%

40.0%

Feb 2006 Apr 2007 July 2010

30.0%

20.0%

10.0%

0.0% Proportion of children receiving oral medications whose caretakers knew correctly how to administer the treatment at home Proportion of caretakers who knew how to correctly manage the child at home Proportion of caretakers who knew at least two signs of when to return if the child became worse at home

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V. CONCLUSION AND RECOMMENDATIONS A) Conclusion


An overall improvement is observed in the management of childhood illnesses in the health facilities of the 11 health districts within the project zone, as shown by the shift of the various indicators toward more positive outcomes. The p values are almost equal to zero in the majority of indicators while comparing the baseline and July 2010 situations, positively indicating that the IMCI training is positively impacting the management of childhood illnesses by frontline health staff. While a significant improvement is observed within the whole project zone, each program unit will need to improve on its individual areas of weakness. It is noteworthy that the EIP met its target of having 65% of frontline MOH and private providers managing sick children trained on IMCI. Results reveal a coverage of 69.4%, significantly higher than the target (p=0.0001).

B) Recommendations
1. MOH and the project partners will have to ensure that priority is given to frontline staff when planning IMCI training. 2. Supervision teams and training facilitators will also have to emphasize the assessment tasks of nutritional status and continue to raise the health personnels awareness of the need to reduce missed opportunities by using every contact with a child who is due for vaccination to administer the required vaccine. 3. Districts should monitor and ensure the availability of IMCI essential drugs in remote health centers, as stock-out of these leads to inappropriate prescription. 4. The district needs to use all meeting opportunities with frontline staff to discuss areas of weakness. 5. The need to complete all counseling tasks rather than just demonstrating the administration of oral medications by health staff should be highlighted during district coordination meetingd. 6. District and provincial teams, with the support of bundled partners, need to advocate to the MOH to maintain health staff that have received training on IMCI within the EIP zone. 7. The MOH should place more emphasis on supervision and support provided to frontline staff trained on IMCI.

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VI. KEY COMMUNITY AND FAMILY PRACTICES/BEHAVIORS: DATA


COLLECTION
The survey for monitoring selected Rapid CATCH indicators was organized by the health districts with support from the EIP staff.

A) Surveyors
For the final evaluation, the project team opted to involve data collectors who have not been involved in the project before to avoid bias. This helped the implementers to know the level of their performance since they started implementing the project. Inclusion Criteria y Must be literatecan read and write well (at least GCE Ordinary level) y Must write legibly y Have some field or health experience y Must work well as part of a team y Must be available full-time for training, data collection, and tabulation activities y Must be able to organize work and interview forms sufficiently to accurately record answers y Must be physically fit y Knowing the general survey area is an added advantage y Speaking the household local language fluently is an added advantage Prior to the field data collection, the surveyors received a two-day training from the district management team supported by EIP staff. The trainings were done in such a way as to consolidate a pool of local facilitators and surveyors so that during the MoH routine monitoring sessions, the district stakeholders were brought together just for one day to plan the data collection and another day for data analysis.

B) Data collection
As per the LQAS methodology, surveyors were to administer each of the five questionnaire modules to 19 mothers randomly selected within the health area serving as a supervision area. A parallel sampling methodology was used, so that 19 mothers were selected for each module (age group). The health staff and LNGO staff incorporated the data collection into their normal or routine work plans, requiring two to three weeks.

C) Data Analysis
The data collected was processed by the surveyors, who calculated the number of valid answers for the health area under their responsibility. The individual health area results were merged by the district management team, who determined the decision rule for each indicator based on the calculated health district coverage. The district results were merged to generate PU-level coverage data. At the end, merging the different program unit data led to the determination of values for study indicators for the whole project intervention zone. The data analysis was completed in Excel spreadsheets to permit the district teams to calculate indicator values. For the purpose of in-depth analysis, the data was entered again into Epi Info.

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VI. OVERVIEW OF RESULTS


Malaria Table 10: Rapid CATCH indicators for malaria EIP Indicators Malaria % of children age 0-23 months who slept under an insecticide-treated net the previous night % of pregnant women who slept under an insecticidetreated net the previous night % of children age 0-59 months who received a full-course of recommended anti-malarials (according to the MOHs recently approved home-management protocols) within the 24 hours of the onset of fever % of women who completed Intermittent Preventive Treatment (IPT) during their current or last pregnancy 11.8% 15.7% 60.7% 42.3% 66.4% 66.7% 60.0% 60.0%
Baseline Jan. 2006 MTE May 2008 Final July 2010

EIP TARGET EIP target 2010

11.7%

36.6%

51.9%

60.0%

18.5%

51.4%

69.6%

75.0%

1) Proportion of children age 0-23 months who slept under an insecticide-treated net the previous night. The target was met for this objective, largely due to the fact that MOH made bed nets available through Global Fund Rounds 3 and 5. Heavily Indebted Poor Countries (HIPC) funds have also been mobilized for the provision of bed nets. EIP distributed 20,000 LLINs in Bafut and Batouri health districts, and a Plan Cameroon-funded malaria project in Biteng PU distributed 12,000 LLINs in Akonolinga HD. Bertoua has not met the target even though 10,000 LLINs were distributed in Batouri health district and UNHCR distributed bed nets to refugees in Bertoua, Batouri and Kette health districts. It has been observed that some of the LLINs are used by the population for other purposes (fishing) since they are resistant to damage. Moreover, most pregnant women do not like sharing the same bed with their youngest child for fear that they might fall sick. 2) Proportion of pregnant women who slept under an insecticide-treated net the previous night. This indicator surpassed the target, primarily due to free distribution of bed nets to pregnant women by the MOH (and the distribution of bed nets to refugees in Batouri, Kette and Bertoua in the East region). Also, the continuous sensitization of the masses by trained CBO members on the importance of sleeping under ITN may have played a significant part. ACMS also carried out sensitization through mass media campaigns. Aforementioned bed net distribution projects may also have had a significant role in achieving observed results.

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3) Proportion of children age 0-59 months who received a full-course of recommended antimalarial (according to the MOHs recently approved home-management protocols) within 24 hours of the onset of fever Generally, the observed FE value, 51.9%, does not meet the target of 60%. However, Bamenda is faring well, reaching 64.6%; Bertoua levels reach 46.5% and Biteng, 35.9%. This is due to poor sensitization by community relay agents for malaria and CBOs on the necessity of immediate treatment and also to stock out of home kits for the treatment of malaria in Bertoua and Biteng PUs. Community relay agents for malaria were trained but not provided treatment kits, demotivating both the community relays and community members. 4) Proportion of women who completed Intermittent Preventive Treatment (IPT) during their current or last pregnancy There was an observed increase from baseline to FE (18.5% to 69.6%, respectively). This indicator is faring well in Bamenda at 77.2%, Bertoua at 61.9%, and Biteng at 70.6%. However, observed values still do not meet the set target and may be attributed to low ANC attendance and drug stock outs observed in Bertoua and Biteng PUs in the last semester of 2009 and the first semester of 2010. Figure 10: Achievement of malaria indicators, by monitoring period
MALARIA
80.0% Baseline Jan. 2006 MTE May 2008 FINAL Jul 2010 EIP Target 2010 69.6% 66.4% 60.7% 60.0% 51.9% 50.0% 42.3% 40.0% 36.6% 51.4% 60.0% 66.7% 60.0% 60.0%

75.0%

70.0%

30.0% 18.5% 15.7% 11.8% 10.0% 11.7%

20.0%

0.0% % of children age 0-23 months who slept under an insecticidetreated net the previous night. % of pregnant women who slept under an insecticide-treated net the previous night. % of children age 0-59 months who received a full-course of recommended anti-malarials (according to the MOHs recently approved home-management protocols) within the 24 hours of the onset of fever. % of women who completed Intermittent Presumptive Treatment (IPT) during their current or last pregnancy.

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Nutrition Table 11: Rapid CATCH indicators for nutrition EIP Indicators Nutrition % of children age 0-23 months who are under-weight (-2 SD from the median weight-for-age, according to the WHO/NCHS reference population) % of children age 0-5 months who were exclusively breast-feeding during the last 24 hours % of children age 6-9 months who received breast-milk and complementary foods during the last 24 hours % of children age 6-9 months who consumed food rich in protein in the 24 hours preceding the survey % of children age 6-59 months who received a Vitamin A supplement in the prior six months % of mothers of children age 0-23 months who received two Vitamin A supplements within eight weeks post partum % of sick children age 0-23 months who received increased fluids and continued feeding during an illness in the past two weeks % of mothers of children age 0-23 taking iron/folate supplements daily for at least 5 months during their last pregnancy % of children 6-59 months of age eating vitamin A rich foods daily during the past week Anthropometry Percentage of children aged 0-23 months who are underweight. The EIP set as objective to decrease from 15.9% at baseline to 10% the proportion of children who are underweight for their age (<-2 SD from the median weight-for-age, according to the WHO/NCHS reference population). The consolidated data of the three PUs reveals that this indicator has reached the target (9.4 %) as presented in Figure11 below. 15.9% 9.4% 9.5% 10.0%
Baseline Jan. 2006 MTE May 2008 Final July 2010

EIP TARGET EIP target 2010

50.8% 92.1% 65.3% 80.9% 21.6%

63.1% 93.6% 58.2% 76.6% 30.0%

74.9% 90.2% 84.1% 69.3% 38.3%

75.8% 95.0% 80.0% 90.0% 80.0%

9.2%

14.6%

13.9%

40.0%

27.2% 41.3%

33.7% 86.7%

70.8% 80.9%

60.0% 60.0%

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The disaggregated results show that all three PUs have witnessed progress. The most conspicuous progress was seen in Bertoua with an approximate 50% decrease (25.7% to 12.9%), but prevalence remains above 10%. Biteng already exceeded the endline target (5.5%). This progress in Biteng may be attributed to the joint efforts of CBOs and health personnel in the program area. In the East, the latest PD/Hearth sessions in Ngeulemendouka, the contribution of CBO activities, the Program for Management of Global Acute Malnutrition, notably in Bertoua, Kette, Batouri, implemented with the financial and technical support of UNICEF, UNHCR and WFP contributed to the significant outcomes observed. Initially, the latter program covered Central African refugees but has been expanded to Cameroonians, who now represent at least 40% of beneficiaries. Figure 11: Achievement of anthropometric indicators, by PU and monitoring period
Proportion of children who are underweight for their age (<-2 SD from the median weight-forage, according to the WHO/NCHS reference population).
30.0%

25.7% 25.0% Baseline Jan. 2006 MTE May 2008 20.0% FINAL Jul 2010

15.9% 15.0%

15.6% 12.9%

12.3%

10.0%

9.4% 9.53%

9.8% 7.99% 6.4% 5.0% 5.52%

5.0%

0.0% EIP BAMENDA BERTOUA BITENG

Breastfeeding practices Exclusive breastfeeding for children 0-6 months: Percentage of infants aged 0-5 months who were exclusively breastfed in the last 24 hours. The EIP target for this indicator was met (74.9%), and Biteng was a primary contributor to this indicator with 95% coverage. This might be attributed to the C-IMCI BCC interventions through CBOs. This activity was carried out in all PUs and, considering that exclusive breastfeeding is

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one of the BCC indicators with readily palpable outcomes (the mother actually sees the child gaining wait and staying healthy), the behavior was readily adopted by mothers. The promotion of this activity was done in all PUs using diverse IEC material with messages elaborated as revealed by the Doer/Non-doer analysis. Thus, a set of IEC materials (New Mothers Guide, message booklet, nutrition flip charts, and other IEC materials developed by the project) was used in the community to promote this behavior. This is one of the practices that received much emphasis during ENA training. Figure 12: Exclusive breastfeeding, by PU and monitoring period
Exclusive breastfeeding for children 0-6 months: Percentage of infants aged 0-5 months who were exclusively breastfed in the last 24 months.
100.0% Baseline Jan. 2006 90.0% MTE May 2008 FINAL Jul 2010 71.8% 70.0% 63.1% 59.2% 60.0% 50.8% 50.0% 36.8% 53.0% 56.6% 58.9% 73.39% 67.9% 95.0%

80.0%

74.9%

40.0%

30.0%

20.0%

10.0%

0.0% EIP BAMENDA BERTOUA BITENG

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Complementary feeding Proportion of children age 6-9 months who received breast-milk and complementary foods during the last 24 hours. The objective was to increase from 92.1% in the baseline to 95% in the end term the proportion of children 6-9 months receiving complementary food, though 90.2% coverage was achieved at the FE. This may be explained by the fact that some mothers stop breastfeeding as soon as they introduce complementary food or the child refuses complementary food because they prefer to stick to the breast. Also, this data was collected during the cultivation period where mothers do not set enough time to prepare food for children. Though there was not great improvement observed in the proportion of children 69 months receiving complementary feeding, the nutritional quality of the diet has improved, with a 14% increase in the proportion of children consuming protein rich food, a 19% increase in the proportion of children consuming oil rich food, and a 21% increase in the proportion of children 6-59 months consuming Vitamin A rich food. This can be attributed to the fact that the survey was done in the period of availability of red palm oil and dark green leafy vegetables, whose consumption is being promoted in C-IMCI activities at the community level. Figure 13: Breastfeeding and complementary feeding, by PU and monitoring period
Proportion of children age 6-9 months who received breast-milk and complementary foods during the last 24 hours.
95.0% Baseline Jan. 2006 MTE May 2008 94.0% 93.6% FINAL Jul 2010 93.0% 92.0% 92.0% 91.1% 91.0% 90.2% 90.0% 89.4% 88.6% 90.9% 92.38% 92.5% 94.5%

94.4% 94.3%

89.0%

88.0%

87.0%

86.0%

85.0% EIP BAMENDA BERTOUA BITENG

Micronutrient supplementation

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Vitamin A supplementation among children: Percentage of children 6-59 months who received Vitamin A in the prior 6 months. Based on the project target, which is to increase from 80.9% in the baseline to 90% the number of children 6-59 months who received vitamin A supplementation, the EIP did not reach its goal, ending with 69.3% coverage. The prior six months to the survey, there was no specific mechanism in place to ensure mass distribution of vitamin A even though survey results reported coverage of 73.5% in Bamenda, 70.5% in Bertoua and 56.8% in Biteng. This data may be limited since the reporting period might not have been well understood by the mother. The vitamin A supplementation for this semester took place during the Maternal and Child Health Nutrition Action Week that was organized late, a few days after data collection.

Figure 14: Vitamin A supplementation in children, by PU and monitoring period


Vitamin A supplementation among children: Percentage of children 6-59 months who received Vitamin A in the prior 6 months
Baseline Jan. 2006 MTE May 2008
90.0% 80.9% 80.0% 76.6% 73.49% 69.3% 70.0% 68.7% 70.5% 84.2% 85.3% 78.7%

FINAL Jul 2010


77.5% 75.9%

60.0%

56.8%

50.0%

40.0%

30.0%

20.0%

10.0%

0.0% EIP BAMENDA BERTOUA BITENG

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Vitamin A supplementation among women: % of mothers of children age 0-23 months who received two vitamin A capsules within 8 weeks post partum The objective was to increase from 21.6% to 80% the number of mothers of children 0-23 months who received two vitamin A doses within eight weeks post partum. The consolidated results for all three PUs show a slight increase of this indicator from 21.6% in the baseline to 38.3% in the final. This poor performance may be attributed to continuous missed opportunities, mainly during EPI routine activities. However, it is also important to note that the percentage of those having access to vitamin A (at least one dose) at the final evaluation reached 71.4%. While health workers are supposed to give two tablets to the mothers, one to be taken immediately and the other to be taken the next day, the practice by some health facilities who did not receive IMCI training is that they give the mother one and ask the mother to come back the next day for the second tablet. Thus, most mothers dont come back for the second tablet. Based on these numbers, there is clearly a need to provide updated guidance to all health personnel on the provision of post partum vitamin A supplements. Figure 15: Vitamin A supplementation in post-partum mothers, by PU and monitoring period
Vitamin A supplementation among women: % of mothers of children age 0-23 who received two vitamin A capsules within 8 weeks post partum
80% 80.0% Baseline Jan. 2006 70.0% MTE May 2008 FINAL Jul 2010 EIP Target 2010 50.0% 43.7% 40.0% 38.3% 39.92% 57.7% 80% 80% 80%

60.0%

30.3% 30.0% 21.6% 20.0%

28.9%

28.7%

30.3%

20.5% 17.7% 15.4%

10.0%

0.0% EIP BAMENDA BERTOUA BITENG

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Iron and Folic acid supplementation: percentage of mothers of children aged 0-23 months taking iron/folic acid supplement daily at least five months during their last pregnancy In relation to the objective of the project which is to increase from 27.2% to 60% the number of mothers of children aged 0-23 months who take iron/folic acid supplement at least five months during their last pregnancy. The results of final evaluation show that the target of 60% was exceeded, with EIP coverage of 70.8%. All PUs improved from baseline, with the best performance produced by the Bamenda PU (30.6% to 86.1%), followed by Bertoua (14.4% to 65.6%). This might be attributed to the fact that mothers are now more aware of the importance of not only taking iron tablets during pregnancy but also for longer periods. Secondly, formative research in the Doer/Non-doer analysis provided key determinants to completion that were used in BCC. Figure 16: Iron/folic acid supplementation during pregnancy, by PU and monitoring period
Iron and Folic supplementation: percentage of mothers of children aged 0-23 months taking iron/folic supplement daily at least five months during their last pregnancy
90.0% 86.10%

Baseline Jan. 2006 MTE May 2008

80.0% 70.8% 70.0% 60% 60.0% 60% 65.6% 60%

FINAL Jul 2010 EIP Target 2010 60%

50.0%

47.6%

48.0% 43.2%

40.0% 33.7% 30.6% 30.0% 27.2%

37.2%

20.0%

16.1% 14.4%

10.0%

0.0% EIP BAMENDA BERTOUA BITENG

Iron and folic acid supplementation: percentage of mothers of children aged 6-9 months taking iron/folic acid supplement for three months after delivery. Even though there was no specific objective for this indicator; it was monitored because iron supplementation is recommended to improve the nutritional status of lactating women, of whom 43% are anemic. Data shows an increase from 7.8% in baseline to 19.1% in FE. This increase, though mild, could be attributed to the inclusion of iron supplementation as a key component of Essential Nutrition Actions.

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Access to iron supplementation at FE Biteng 76.11% Bertoua 27.89% Bamenda 74.5% EIP 60.14% Increased fluid intake: percentage of sick children aged 0-23 months who received increased fluids and continuous feeding during an illness in the past two weeks. This indicator aims to achieve an increase from 9.2% to 40% of the number of sick children aged 0-23 months who receive increase fluids and continuous feeding during an illness in the past two weeks. In spite of the fact that indicator values increased from baseline to end line (9.2% to 13.9%), it is far from the target. No PU met the target, but Biteng witnessed a significant increase from 7.5% to 28.4%. The two other PUs remained stagnant. During illness, a child has poor appetite or might experience vomiting, and mothers are not likely to make a conscious effort towards increasing the quantity of food uptake by sick children. IHFA data shows that less than 50% of medical staff counsel mothers on the importance on giving more fluids and 66% counsel on continuous feeding during an illness episode. Figure 17: Increased fluid/food uptake for sick children, by PU and monitoring period
Increase fluid intake: percentage of sick children aged 0-23 months who received increased fluids and continuous feeding during an illness in the past two weeks
40% 40.0% 40% 40% 40%

35.0%

Baseline Jan. 2006 MTE May 2008 FINAL Jul 2010

30.0%

28.4%

25.0%

EIP Target 2010 18.9% 18.9%

20.0%

15.0%

14.6% 13.9% 12.40% 10.7% 10.8% 9.2% 9.4% 7.5%

10.0%

9.2%

5.0%

0.0% EIP BAMENDA BERTOUA BITENG

Caretaker knowledge on the signs of childhood illness for which to seek for medical care: Percentage of mothers of children age 0-23 months who know at least two signs of childhood illness that indicate the need for treatment

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With regards to the objective, which is to increase from 65.9 % to 80% the number of mothers of children age 0-23 months who know at least two signs of childhood illness that indicate the need for treatment, one can see that in the PUs, there is moderate amelioration (77.9%). Diarrhea Hand washing: Percentage of mothers of children age 0-23 months who report that they wash their hands with soap before feeding children, after defecation and after attending a child who has defecated. The objective of this indicator was to increase from 7.7% to 30%, and the EIP exceeded its target, with 42.2% at FE. The results reveal that all three PUs have a progressive trend from the baseline, with Biteng presenting an exceptional increase (5.6% to 92.4%). Bertoua PU will have to improve on this indicator (FE measured the percentage at 26.3%) through continuous sensitization and supervision of CBOs by stakeholders and MOH. Figure 18: Hand washing by mothers, by PU and monitoring period
Hand washing: Percentage of mothers of children age 0-23 months who report that they wash their hands with soap before feeding children, after defecation and after attending a child who has defecated.
100.0% 92.4% 90.0% Baseline Jan. 2006 MTE May 2008 FINAL Jul 2010 EIP Target 2010

80.0%

70.0%

60.0%

50.0% 42.2% 40.0% 30% 30.0% 22.9% 20.0% 7.7% 15.5% 10.5% 10.0% 5.8% 6.8% 5.6% 16.9% 36.6% 30% 26.3% 30% 30%

0.0% EIP BAMENDA BERTOUA BITENG

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Pneumonia Caretaker knowledge on the signs of childhood illness for which to seek medical care: Percentage of mothers of children age 0-23 months who know at least two signs of childhood illness that indicate the need for treatment The objective of this indicator was to increase from 65.9 % to 80% the percentage of mothers of children age 0-23 months who know at least two signs of childhood illness that indicate the need for treatment. It should be noted that all PUs achieved improved performance from baseline. Nevertheless, only Biteng and Bamenda PUs met the objective by progressing from 70.5% to 82.6% and 62.4% to 80.4%, respectively. Despite the progress made by Bertoua PU, the objective was not attained (66.7% to 73.5%); thus, there is need to strengthen sensitization of the entire population by CBOs, LNGOs and MOH. Figure 19: Knowledge of mothers on signs of illness, by PU and monitoring period
Caretaker knowledge on the signs of childhood illness for which to seek for medical care: Percentage of mothers of children age 0-23 months who know at least two signs of childhood illness that indicate the need for treatment
90.0% 80% 77.9% 70.4% 70.0% 65.9% 62.4% 60.0% 66.7% 61.9% 80.4%80% 76.3% 80% 73.5% 70.5% 82.6% 80% 76.5%

80.0%

50.0%

40.0%

Baseline Jan. 2006 MTE May 2008 FINAL Jul 2010 EIP Target 2010

30.0%

20.0%

10.0%

0.0% EIP BAMENDA BERTOUA BITENG

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Children seen by qualified health personnel: Percentage of children with severe childhood illness who were seen by qualified public or private provider in the past two weeks This indicator generally attained the objective fixed for the project, with progress from baseline (37.4% to 74.1%). Generally, this indicator progressed in all three PUs, with only Bamenda meeting the objective (51.9% to 92.3%). Meanwhile in Biteng (15.0% to 58.9%) and Bertoua (37.3% to 62.9%), this performance is on the increase, but the objective was not attained. Awareness raising of caretakers in Biteng and Bertoua PUs should be strengthened through continuous sensitization by CBOs, LNGOs and MOH staff. Figure 20: Caretaker knowledge on signs of illness, by PU and monitoring period
Percentage of children with severe childhood illness who were seen by qualified public or private provider in the past two weeks
100.0% 92.3% 90.0%

80.0% 74.1% 70.0% 67.7% 61.1% 60.0% 51.0% 50.0% 40.6% 37.3% 51.9% 67.7% 67.7% 62.9% 58.9% 57.5% Baseline Jan. 2006 MTE May 2008 FINAL Jul 2010 EIP Target 2010 67.7%

40.0%

37.4%

30.0%

20.0%

15.0%

10.0%

0.0% EIP BAMENDA BERTOUA BITENG

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Immunization Complete immunization: Percentage of children age 1223 months who are fully vaccinated (against the five vaccine-preventable diseases) before the first birthday Final results show that aggregated, PUs are at 67.2%, down from 70.5% at baseline and not meeting the EIP target of 80%. However, it should be indicated that a general drop for this indicator was observed in all the PUs compared to MTE (73%). Biteng PU registered the lowest value for this indicator (53% to 45.2%) among the three PUs. The drop observed at FE as compared to MTE could be explained by the poor filling of vaccination cards in Bamenda and stock out of vaccination cards in the two other PUs. Thus, once the cards were available, the health personnel could not recall the exact date of the vaccination but could however confirm that the child was vaccinated. So in some cases, you would find VACCINATED instead of the dates of the vaccination. In the LQAS tabulation, once a date was not mentioned, the child was considered as unvaccinated for that vaccine. This is one of the indicators whose performance depends largely on inputs from the MOH rather than just the project. Thus, the vaccination cards were produced by the project in 2008 and distributed, but two years later, the children who received those vaccination cards may have exceeded the age to be considered in the surveys vaccination module. Figure 21: Complete vaccination before first birthday, by PU and monitoring period
EIP complete immunization: Percentage of children age 1223 months who are fully vaccinated (against the five vaccine-preventable diseases) before the first birthday
90.0% 80% 80.0% 73.0% 70.5% 67.2% 86.0% 83.7% 78.1% 80%

Baseline Jan. 2006 MTE May 2008 FINAL Jul 2010 EIP Target 2010 59.4% 59.3%

80% 75.0%

80%

70.0%

60.0%

54.0% 50.0%

53.0% 45.2%

40.0%

30.0%

20.0%

10.0%

0.0% EIP BAMENDA BERTOUA BITENG

Tetanus toxoid coverage: Percentage of mothers with children age 023 months who received at least two tetanus toxoid injections before the birth of their youngest child

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Results at final evaluation indicate a positive trend (63.2%), improved compared to baseline (58.9%) for the entire EIP. But the target was not met (80%). Nevertheless, the TT campaigns funded by Plan in Bamenda and Bertoua have contributed to improving this indicator. Disaggregated data show that Biteng PU among the three PUs has registered the lowest score for this indicator (52.1%). Figure 22: Tetanus toxoid coverage, by PU and monitoring period
Tetanus toxoid coverage: Percentage of mothers with children age 023 months who received at least two tetanus toxoid injections before the birth of their youngest child
80% 80.0% 80% 80% Baseline Jan. 2006 MTE May 2008 FINAL Jul 2010 70.0% 63.2% 60.0% 58.9%58.6% 53.8% 50.9% 50.0% 67.4% 63.5% 61.5% 61.7% 63.7% EIP Target 2010 58.9% 52.1% 80%

40.0%

30.0%

20.0%

10.0%

0.0% EIP BAMENDA BERTOUA BITENG

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VII. USING THE RESULTS


The KPC results will be used by the MOH in the planning of health activities in the districts where the results were collected. These results were the basis for which training was provided to 144 frontline health facility staff in five health districts from the East and 52 frontline health facility staff in the 3 health districts in the Centre. Also, the results have oriented the distribution of services by ACMS in the project area. In terms of new projects and programs, the KPC results were used as a review document in the development of the Global Fund Round 9 proposal for Cameroon. Also, PSI and HKI are using these results as baseline in their new projects with CIDA and WFP, respectively.

VIII. CONCLUSIONS
The final evaluation of the EIP recorded major improvements over the mid-term and baseline. However, some indicators did not perform well at the end of the project. The overall progress of the indicators can be attributed to the following: y All frontline health facility staff from the 11 health districts with which EIP worked have been trained on C-IMCI. y Community health information systems are in place in the whole EIP area. y The Maternal and Child Health Nutrition Action Weeks greatly contributed to the attainment of objectives in immunization. y C-IMCI is already being implemented in all 11health districts. y Counseling is provided by health personnel to caregivers at sick children consultations in health facilities. y Free distribution of LLINs by the project and by the Cameroon Ministry of Public Health in Bafut, Bertoua, Doume, and Nguelemendouka health districts contributed a great deal to the prevention of malaria among children and pregnant women.

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ANNEX 7. Community Health Worker Training Matrix Project Area Type of CHW Official Paid or Government Volunteer or Granteedeveloped CHW grantee volunteer Number Trained over Life of Project 27,391 Focus of Training

All 11 districts in 3 Regions All 11 district in 3 regions Bafut district (pilot activity only)

CBO members

C-IMCI and C-HIS Malaria treatment Pneumonia treatment in children

Malaria Relay (CCM/Malaria)

official

volunteer

5,973

CCM/Pneumonia grantee

volunteer

90

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ANNEX 8. CBO Performance Indicators (as shown on CBO Supervision Form) ACTIVITIES Planning 1. Verify if the CBO has held a meeting last month 2. Verify if the report of the meeting is available 3. Verify there is an action plan (oral or written) for the current month Health promotion Growth Monitoring 4. Check if the CBO has carried out growth monitoring sessions last month 5. Check if the underweight children have been identified 6. Check if actions were taken for those underweight children Home visits 7. Check if the CBO has carried out home visits and the reasons 8. Verify that appropriate actions have been taken for these various reasons Heath Talks 9. Verify if the CBO has carried out at least one health talk last month 10. Check if demonstrations have been made during health talks or at any other occasion Data management 11. Verify the existence of working documents (register, behavior map, reports, our way to health chart) 12. Verify that documents mentioned above are updated 13. Verify if the CBO has analyzed data collected 14. Verify that actions have been taken based on data analysis Monthly report 15. Verify the existence and completeness of monthly reports for the last three months Total SCORE

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ANNEX 9. List of Evaluation Team Members Bonnie Kittle Inak Martin Atanga David Th Meyong Roger Mani Racheal Nkwain Joseph Dr. Ndogmo S. Dr. Eloundou D. Dr. Mebounina D. Dr. Ajabmoh H. Ngo Ngan L. Ofal J. Fotso Fokam Z. Mpiang Mpian J. Maboh M. Ntouba E. Mana C. Perkins S. Bina Paul F Nanda M. Onanina J. Nkoumou M. Dr. Youmba J.C. Oumarou P. Nankap M. Dr. Toh E. Ngwa Chris A. Chang J. Garba D. Berri Ndingue Private Consultant ASAD MECUDA Centre de Recherches MOH, focal pt Center Regional delegation MOH, focal pt NW Regional delegation DMO Mbengwi DMO Esse DMO Batouri DMO Bafut PUHC Bamenda PUHC Biteng PUHC Bertoua CBS Bertoua CBS Bamenda CBS Biteng EIP Intern Peace Corps Volunteer ACMS Promoter ACMS Promoter ACMS Promoter ACMS Communicator ACMS Assistant Director ACMS IMCI Focal Pt HKI Nutrition Program Manager Plan EIP Coordinator EIP Assistant Plan HQ Technical Backstop HAC Fundong COSADI Doume

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ANNEX 10. Evaluation Methodology The final evaluation was implemented in three phases: document review (one day), in-country data collection (13 days) and report writing (seven days). The in-country portion of the work was divided into the team planning meeting (three days) during which time we discussed the project in detail, identified the key informants, developed and reproduced the questionnaires, and determined the sites to be visited and who would interview whom. The large team was divided into three regional teams which were in turn sub-divided to make a total of six teams with four to five people per team. Each sub-team was assigned specific districts and communities to visit following a set of criteria. Each of the six teams visited approximately nine communities/CBOs, one to two DMOs, LNGOs, health center staff, and CCM/Malaria and Pneumonia as shown in the following table. Numbers /Types of People Interviewed Questionnaires NW Center East CBO 9 8 10 7 10 6 DMO 2 0 1 4 1 0 LNGO 3 0 1 2 0 0 IHC 4 2 5 7 6 1 CCM 0 0 0 5 0 0 Malaria 1 2 2 1 2 1 Totals 45 31 27

Totals 50 8 6 25 5 9 103

Following the three days in the field (plus two days for travel), the evaluation team tabulated the results and discussed findings, conclusions and recommendations. On the last day, a presentation of the preliminary results was conducted for key stakeholders, including MOH representatives, USAID, UNICEF and WHO. The report was drafted between August 27 and September 3 and comments from Plan, HKI and ACMS incorporated in to the final draft between September 18 21, 2010.

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ANNEX 11. List of People Interviewed and contacted during Final Evaluation All the people mentioned in the Annex 9 plus the following project beneficiaries. Also Dr. Joseph Shu, Dr. Laban Tsuma, Mr. Casimir Youmba (Plan/Cameroon Acting Director), D. Njoumeni Zakourou, Faculty of Medicine, University of Yaound I, and Ms. Aisatou Ngong, Country Program Coordinator, USAID/Cameroon. Questionnaires CBO DMO LNGO IHC CCM Malaria Totals NW 9 7 2 4 3 2 4 7 0 5 1 1 45 Center 8 10 0 1 0 0 2 6 0 0 2 2 31 East 10 6 1 0 1 0 5 1 0 0 2 1 27 Totals 50 8 6 25 5 9 103

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ANNEX 12. Special Reports CCM of Pneumonia (Attached)

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ANNEX 12. Special Reports Introduction of Zinc for the Treatment of Diarrhea

Helen Keller International/Cameroun ___________________________________________________________________

RESULTS OF OPERATIONAL RESEARCH ON THE INTRODUCTION OF ZINC FOR THE TREATMENT OF DIARRHEA IN CAMEROON

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TABLE OF CONTENTS
I- INTRODUCTION II- RESEARCH OBJECTIVES III- METHODOLOGY 3.1 Quantitative research 3.2 Doer/Non-doer Analysis 3.3 Qualitative research 3.4 Home follow-up IV- INTERVENTION DESCRIPTION 4.1 Advocacy 4.2 Capacity building of the different actors 4.3 Provision and logistics. 4.4 Communication for behavior change 4.5 Services delivered 4.6 Monitoring and evaluation V-MAIN RESULTS 5.1 Advocacy 5.2 Zinc introduction mechanism 5.3 Impact of zinc introduction on the use of ORT/ORS, antibiotics anti-diarrhea drugs. 5.4 Identifying main determinants to acceptance, use and compliance of zinc in the treatment of diarrhea 5.4.1 Price of ORS/zinc 5.4.2 Perception of the risk linked to the administration of zinc 5.4.3 Preparation and administration of zinc and ORS to children 5.4.4 Factors that can limited access to zinc 5.4.5 Determinants of completion to treatment during 10 days 5.4.6 Perception of zinc tablets 5.4.7 Perception of its efficiency 5.5 Identifying the most suitable means to disseminate messages for the use of on zinc in the treatment of diarrhea 5.6 Elaborate , test and produce educative material for the promotion of join ORS/zinc in the treatment of diarrhea

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LIST OF TABLES Table N 1: Zinc and ORS utilization rate in according to the place of treatment Table N 2: Method of zinc administration Table N3: Reasons for the non-administration of zinc during the last diarrhea episode Table N 4: Strategies for improving observance to treatment I.1.1.1.1.1.1 Table N 5: Sources of information on zinc

LIST OF FIGURES Figure N1: Performance of CBOs and health facilities (HF) according to prescription, missed occasions and zinc completion Figure N 2: Use rate of ORS and /or ORT during the project Figure N3: Places of provision in antibiotics

LIST OF ABBREVIATIONS ORS: Oral Rehydration Salt ORT: Oral Rehydration Therapy CBO: Community Based Organization CENAME: Centre National dApprovisionnement en Mdicaments Essentiels ACMS: Association Camerounaise pour le Marketing Social

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I- INTRODUCTION This document presents a synthesis of data collected during operational research on the use of zinc for the treatment of diarrhea in Cameroon. This was a pilot research intervention carried out in the Bertoua Health District of the Eastern province between August 2007 and February 2008. The research was conducted under the leadership of Helen Keller International (HKI) within the framework of the "Bundled Expanded Impact Child Survival Project" funded by USAID in the Bertoua Health District. The treatment protocol examined is a 10-day course with dispersible (in water or milk) zinc tablets (procured from Nutriset) provided during and after diarrhea episodes to children less than five years of age. The WHO/UNICEF 2004 joint statement on the management of childhood diarrhea recommends that in addition to oral rehydration therapy children under 6 months of age receive 10mg per day for 10-14 days (or half tablet of 20mg) and children 6-59 months receive 20mg per day for 10-14 days. This recommendation followed research findings that zinc supplementation for the management of diarrhea was associated with a 25% reduction in the duration of acute diarrhea, a 25% reduction in the incidence of diarrhea and a 36% reduction in the incidence of malaria over 2-3 months following treatment. Use of zinc had also been shown to increase the use of oral rehydration salts (ORS) (by approximately 25%) and reduce the inappropriate use of antibiotics (by approximately 20%). During this research, zinc tablets and ORS were distributed through 16 health facilities and community-based organizations (CBOs) participating in the project in 12 villages of 10 Health Areas. II- RESEARCH OBJECTIVES The general objective of the operational research was to facilitate the introduction of zinc in the management of diarrhea in children of less than 5 years in Cameroon. The specific objectives of the research were to: 1. Determine the best mechanism for introducing zinc for the treatment of diarrhea; 2. Assess the impact of the use of zinc in the treatment of diarrhea on the use of ORT/ORS, antibiotics and other frequently used anti-diarrhea drugs; 3. Identify the main determinants of acceptance, compliance with and completion of the full course of zinc by caretakers at home; 4. Identify the most suitable means for disseminating messages for promoting zinc for the treatment of diarrhea. The results will subsequently be applied to the design, testing and then production of educational materials to promote the joint use of ORS/Zinc in the treatment of diarrhea. III- METHODOLOGY Several approaches were used to collect data. Two cross-sectional quantitative surveys targeting caretakers of children with diarrhea were carried out: one before the intervention (introduction of zinc treatment) and the other five months later. Qualitative tools (in-depth interviews) were used with caretakers of children and health service providers (health personnel, community volunteers and participating community-based organization members). There was also home follow-up of
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mothers who had received zinc for the treatment of diarrhea to examine compliance with treatment. Other information for this report was derived from monitoring/supervision of the different actors and a behaviorial (doer/non-doer) study on compliance to treatment. III.1 Quantitative surveys: This element involved cross sectional baseline and end line surveys: in each case of a sample of 190 mothers whose children had suffered from diarrhea in the two weeks preceding the survey were selected. Information was collected on the following indicators: y ORS/ORT use to treat acute diarrhea episodes in their children, y use of zinc in the treatment of diarrhea, y use of antibiotics and anti-diarrheal drugs during a diarrhea episode, y source for care in the treatment of diarrhea and the reasons for seeking treatment in those places; y knowledge of the treatment of diarrhea with ORS and zinc; y feeding practices during a diarrhea episode; y source of exposure to the intervention (medical or community network); y opinion on the cost of treatment of diarrhea with ORS and zinc. III.2 Doer/Non-doer Analysis This element was designed to: y identify the main determinants of compliance with and completion of the zinc treatment of a diarrheal episode; y identify the main determinants of seeking care from a health facility; and y inform strategies to minimize barriers to the new treatment and promote the positive health care behaviors while scaling up this treatment at the national level. The sample for each question included 30 doers (those who ensured their children completed zinc treatment) and 30 non-doers, and the two groups were compared in relation to various factors influencing adoption of the behavior; perceived self-efficacy (belief in ones capacity to perform a new behavior) in implementing the recommended behavior; and perceived social acceptability (belief that ones community approves of the new behavior). III.3 Qualitative Research The objectives of this element were to: - examine the range of home practices used for the treatment of diarrhea in young children; - examine the factors that impel caretakers of children with diarrhea to seek treatment outside of the home (facilitating factors) and reasons for not seeking treatment (barriers); - describe the sources of treatment for diarrheal diseases (health facility, community network, traditional healers, informal sector drug sellers, etc.); - examine caretakers and health service providers perceptions of ORS and zinc tablets for the treatment of diarrhea; - assess caregivers performance in the management of diarrhea, - identify features associated with the zinc tablets such as taste, appearance and beneficial effects that could help inform the future large scale marketing of zinc tablets;
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examine the prevalence and appeal of non-recommended treatment practices for uncomplicated diarrhea (antibiotics, injections, anti-diarrhea drugs, laxatives, etc.)

Qualitative research involved in-depth interviews with service providers (health staff and community agents), mothers and the participating womens association members. III.4 Home follow-up Home visits were made to 135 mothers whose children were on a diarrhea treatment and data collected on: - the quantity of zinc and ORS prescribed; - the quantity of zinc and ORS purchased; - the quantity of zinc and ORS used; - the number of days of zinc treatment given; - the prescription and use of antibiotics and anti-diarrhea drugs; - the attitude of caregivers in relation to the management of diarrhea in children; - the techniques of preparation and administration of zinc and ORS; - difficulties associated with the administration of zinc and ORS; - risks perceived by parents following the administration of zinc. IV- INTERVENTION DESCRIPTION The pilot interventions that were put in place after the baseline survey consisted of the following: 4.1 Policy Advocacy. This was aimed at securing the approval of the MOH for the use of zinc as an essential element in the management of diarrhea in children below five years in Cameroon. 4.2 Capacity building of the different actors. Forty two health staff and 225 members of village health committees or Community-Based Organizations (CBOs) from all the health areas of the Bertoua health district were trained on the use of zinc for the management of diarrhea in children. 4.3 Provision of Zinc and supplies. The different structures (CBOs and health facilities) were supplied a consignment of zinc blisters and quantities of ORS. In all, 1,720 courses of zinc (10 dose, 20-mg zinc blister packs) and 500 ORS sachets were deployed to the different frontline health providers examined by the research arm of the project. 4.4 Communication for behavior change. Various channels of communication were used, notably interpersonal communication by trained service providers or community members, health education sessions held in health facilities and village associations, and radio broadcasts. 4.5 Treatment protocol. The training recommended the following treatments for diarrhea: - Advice on increased breastfeeding and, for children >6 months, increased feeding and fluid intake during diarrhea; - Use of zinc for the treatment of diarrhea along with ORS for children >6 months.

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The treatment was offered through two networks:  Health facilities (16): Mbethen Integrated Health Center (IHC), Mokolo I IHC, Ghent Boulaye IHC, Moindi IHC, Moundi Catholic Health Center (HC), Belabo Catholic HC, Belabo Medicalised Health Center (MHC), Nkolbikon Catholic HC, Tigaza Catholic HC, Mokolo IV Catholic HC, Bertoua Lutheran HC, Mandjou Community HC and the Bertoua Provincial hospital.  CBOs (12): Boulembe (Dfense-Enfant), Mboulaye 1 (Essayons-voir), Daiguene (Temo Wete), Mbeth 2 (Femmes Dynamiques), Yanda 1 (Solidarit), Dongo (Amour et Confiance), Dimako (Cercle Familial de Dimako), Andom (Amour et Solidarit), Mbelle Panga (Oyili Nama), Mbang 1 (CEFAS), Yoko Betougou, Ekombiti, Yanda 2 (Femmes Dynamiques et Entente). 4.6 Monitoring and evaluation. The evaluation compared behaviors at baseline and at the end of the intervention (endline). Monitoring/supervision missions of health agents were carried out every month and a home follow-up survey was conducted. This report presents the findings as well as conclusions and recommendations. V-MAIN RESULTS The main results are derived from analysis and synthesis of the different data sources. This section presents the results of advocacy and sensitization efforts, then reviews the analyses relating to the five research objectives. 5.1 ADVOCACY Advocacy with government partners to promote zinc treatment for diarrhea began with project start-up; the government incorporated this treatment protocol into the National Nutrition Policy and Program documents developed in December, 2006. In January 2008, zinc was added to the list of essential drugs. Administrative procedures for importing the first stock of zinc are underway in the National Drug Procurement Center. In addition, clinical IMCI training modules have recently been revised to incorporate recommendations for zinc treatment for diarrhea. Revision of community IMCI training modules is still pending. Zinc treatment was also included in the nutrition training curriculum for Cameroons paramedical training schools, as part of the essential nutrition actions under the topic, Feeding sick or severely malnourished children. Scientific meetings, congresses and other workshops were used as forums for advocacy with other actors and/or partners. For instance, during the 10th Congress of the Cameroon Pediatrics Society, the EIP project (HKI) made a presentation on the subject. The issue was also raised during planning and review workshops of the CameroonUNICEF cooperation program, particularly in relation to the programs serving Central African and Chadian refugee children in Cameroon. UNICEF has agreed to support reproduction and diffusion of the national protocol for zinc supplementation in diarrhea in the second semester of 2008. CONCLUSIONS AND RECOMMENDATIONS
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In Cameroon, Zinc is on the list of essential drugs but not yet available in the market (public and private health facilities). Thus continuing advocacy is needed to accelerate procurement, notably through CENAME and/or PSI/ACMS. Outside the pilot zone, service providers are still unaware of this new treatment protocol. Thus partners must mobilize necessary resources for the training of service providers and for the development and production of communication tools that must support this training.

5.2 INTRODUCTION OF ZINC TREATMENT The use of zinc for the treatment of diarrhea was introduced through health facilities and the CBOs. Commercial pharmacies were identified in the research protocol but refused to participate. Of the 190 mothers interviewed at baseline, 81 sought treatment from diarrhea at health centers and 11 sought treatment from CBOs (92 did not seek treatment). For children <6 months of age, none presented at CBOs; at health centers the correct zinc prescription was given in 62% of cases presenting. For children of 6-59 months of age, CBOs the correct zinc prescription was given in 100% of cases; health staff gave the correct prescription in 99% of the cases. However overall, zinc was prescribed in only 38% of cases presenting with diarrhea, while combined zinc/ORS treatment was prescribed in only 37% of all cases of diarrhea. Health workers missed the opportunity to prescribe zinc in 67% of children presenting with diarrhea; CBOs did not miss any cases but received only 11 relevant consultations. Table N 1: Zinc and ORS utilization rate according to the place of treatment Place of treatment (sample n Use rate refers number of diarrhea cases) ORS Zinc ORS/Zinc Health facility (n=81) 66.7% 29.6% 29.6% CBO (n=11) 90.9% 100% 90.9% Total 69.6% 38% 36.9% Source: Quantitative survey The performance of CBOs suggests they may be reliable sources of counseling in and provision of zinc for the management of diarrhea at the community level; however, the sample size was quite small (n=11). Overall 70% of patients of health clinics completed the 10-12 day course of zinc whereas 52% of the patients of CBOs completed the full course. CONCLUSIONS AND RECOMMENDATIONS On the whole, both the health and CBO staff prescribed zinc correctly for children of 6-59 months, although missed opportunities were higher than optimal. CBOs are more accessible to the population than health facilities, and although the completion rate was higher among children seen at the health facility than those consulting the CBOs, making zinc available through the CBOs reduced the median delay in seeking treatment (3 days after the onset of symptoms for the
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health facility vs. 2 days for the CBOs). The delay between the beginning of diarrhea and seeking of treatment at suitable places is still too long, and should be addressed by the communications strategy. Since the action of the two networks is complementary, during the scaling up, we recommend using both while addressing the shortcomings of each through training and communication. It is preferable to involve the commercial pharmacies as well, as more than 10% of mothers sought treatment for diarrhea directly from pharmacies.

Figure N1: Rates of correct prescription, missed opportunities for prescriptions, and completion of treatment at health facilities (HF) and community-based organizations (CBO)

90% 100% 70% 0% 70% 52%

Correct prescription of zinc to children 659 months

Missed opportunities for Completion of prescription of zinc 10 days of treatment

CONCLUSIONS AND RECOMMENDATIONS (cont) As the primary source of money for treatment, men have an important influence over this care seeking behavior (61% of fathers vs. 28% of mothers finance treatment), although it is often the mother who takes action. Thus the communications strategy addressing the management of childhood diarrhea must target fathers. Monitoring/supervision missions revealed that some CBOs sell zinc without the ORS, whereas exit interviews revealed that some health staff sell ORS without the zinc. To change this practice, a diarrhea treatment kit should be conceived, containing, for example:  1/2 of a 20 mg package of zinc (or 1 package of 10mg) + 2 ORS sachets for children of less than six months;  1 package of 20 mg of zinc + 2 ORS sachets for children of 6 to 59 months.
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This kit could well be sold in Cameroon through the same channel as that of the Malaria treatment home kit. The two networks achieved a relatively satisfactory treatment completion rate (67%) even though it remains lower than that observed in a Malian survey (89%). Evidence also suggests that higher completion rates for the minimum 10-day treatment are achieved when the dose promoted is 14 days. Therefore, we recommend a 14-day treatment be promoted in order to maximize completion of at least 10 days of treatment. Further studies should be carried out to examine treatment adhesion after scale up.

5.3 IMPACT OF ZINC INTRODUCTION ON THE USE OF ORT/ORS, ANTIBIOTICS ANTI-DIARRHEA DRUGS. The promotion of zinc and ORS/ORT for the treatment of diarrhea increased the use of ORS/ORT. The figure below shows the use rates both for baseline and endline surveys. Figure N 2: Use rate of ORS and /or ORT during the project
Base line 60% 42,6% 40% 36,3% 30,5% 21,1% 20% 43,7% Endline 59,5%

0% ORS ORT ORS/ORT

In the project zone, the use of ORS or ORT at end line was nearly three times the rate observed in the province in 2004 (20%). In spite of the improvement of the use of ORS/ORT, the frequency of administration of supplementary liquids and feeding during diarrhea remained low. The proportion of mothers who gave more fluids to their children during diarrhea episodes also is low (46%); indeed the proportion is lower than that observed in 2004 (66%) and in 1998 (83%) in the Eastern province. This suggests there has been a decline in the appropriate feeding of the sick child. In the management of diarrhea, antibiotics should be prescribed for children suffering from bloody diarrhea (dysentery). It was only possible to assess the appropriate use of antibiotics if these medications were available/visible at the time of the surveys.
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Seven percent of the sample of children had diarrhea with blood; antibiotics were used correctly in 11% of cases. Ninety-two percent of children with diarrhea had no blood; 94% of the doses of antibiotics observed were taken by children without bloody diarrhea. It is worth noting that the children often presented several symptoms, some of which might justify the use of antibiotics. This operational research was not able to examine these confounding factors. The health facility remains the main source for antibiotics (Figure 3). The proportion of children with diarrhea given anti-diarrhea drugs was 0% and 6% at baseline and end line, respectively. The health facility pharmacy is the main source for the purchase of such treatments. Figure N3: Source for purchase of antibiotics 100% 75% 50% 25% 0% Health facility Pharmacy Store 10% 7% 83%

CONCLUSIONS AND RECOMMENDATIONS The intervention led to an improvement of the use of ORS and/or ORT. Nevertheless, 54% of children did not receive increased fluids during the last episode of diarrhea, and appropriate feeding appears to have declined over time. Therefore, it is necessary to elaborate and implement a communications plan for the treatment of diarrhea taking into account the four rules of managing simple diarrhea. The promotional messages and instructions of managing diarrhea must also clearly indicate that antibiotic therapy is only recommended for diarrhea with blood. The use of anti-diarrhea drugs is rather rare. Reducing the appropriate prescription of antibiotics will require pre- or in-service training of the health staff and pharmacists, who provide most of the prescriptions. Thus, all future training of health personnel should give emphasis to the proper use of antibiotics.

5.4 IDENTIFYING MAIN DETERMINANTS TO ACCEPTANCE, USE AND COMPLIANCE TO ZINC IN THE TREATMENT OF DIARRHEA Some factors affecting acceptance, use and the completion of treatment were explored. Notably, the price of medication, perception of the risk linked to the use of zinc, difficulties of its use in accordance with the prescription, perception of the zinc tablets and perception of its efficacy.
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5.4.1 Price of ORS/zinc During the intervention, a blister of 10 tablets for the children 6-59 months (or 5 tablets for the children of less than six months) was sold by health facilities for 100 FCFA and a sachet of ORS was sold separately at a price between 65 and 150 FCFA. The CBOs sold zinc together with 2 ORS sachets at a total price of 300 FCFA. These prices were considered cheap or affordable by 90% of mothers: "For zinc, the price is good, it is accessible"; Affordable price." For a few, the price was dear or difficult to separate from other medicine purchases. All service providers also considered the price of zinc and ORS affordable or cheap. Yes, they always buy the two". The rate of zinc purchase after prescription was 99.2%. The desire to see the child cured was the main motivating factor for the purchase. CONCLUSIONS AND RECOMMENDATIONS The zinc and ORS were considered affordable by a large majority of mothers and by all service providers. The price did not seem to be a limiting factor to the access of zinc and/or ORS. However, price could limit the access to treatment for a minority of children of the community. It would be desirable to set prices such that they are not higher than those used for the pilot phase. Thus, a "diarrhea kit" should be made available to the population at the cost of 300 FCFA. 5.4.2 Perception of the risks associated with administration of zinc The perception of some risks linked to the administration of a drug can influence its acceptance and/or the respect of prescription (dose and duration). During home visits to the children given zinc, 5% of mothers on the first visit and 2% on the second visit, said that zinc provoked some problems in their children. The majority perceived no problems: "I didn't see a problem. On the contrary, I think that it is a good medication for children" declared one mother. Health staff did not record any complaints from parents or observe any side-effects themselves. "No problem. We already used more than 100 tablets." Some of the symptoms noticed could be linked to the diarrhea itself such as vomiting, fatigue/dehydration, convulsions, fever. They were nearly all danger signs indicating it is necessary to seek care in the health facility. CONCLUSIONS AND RECOMMENDATIONS The majority of caretakers and health staff did not perceive any problems in the use of zinc for the treatment of diarrhea. The few problems indicated were danger signs for severe diarrhea (convulsions, fatigue/dehydration, fever, lack of appetite). For these, it is absolutely necessary to look for treatment at the health facility. Mothers should be made aware of the danger signs of diarrhea and the need to seek immediate health care during sensitization meetings or consultations. 5.4.3 Preparation and administration of zinc and ORS to children The zinc tablets are dispersible in a small quantity of water or milk (preferably breastmilk). It is also possible to administer directly into the mouth of older children. The tablet dissolves in water
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and does not need to be crushed. This method of preparation and administration recommended was used in 94% of cases (Table 2). The other methods of administration (dilution in complementary food, in a glass/cup or with other medication) present risks of loss if the child does not drink the whole quantity or if he/she refuses because of the taste.

Table N 2: Method of zinc administration 1st round Method of zinc administration (n=122) Tablet in a tablespoon + water 91% Tablet in a glass/cup of water 2.5% Tablet + breast milk Tablet directly into the mouth Tablet + Metronidazol syrup Tablet in a tablespoon + ORs Tablet in the pap Tablet diluted to make a purgative 0.8% 1.6% 1.6% 0.8% 0.8% 0.8%

2nd round (n=115) 92% 0.8% 2.6% 0.8% 0.8% 2.6% -

It is notable that 23% of the cases during the 1st visit and in 12.2% of the cases during the 2nd visit crushed the tablet before adding water. This could be explained by the lack of demonstration or explanation during consultation, but also due to the tradition of crushing tablets like paracetamol before giving it to children. On the whole, the mothers know that 1 liter of water is necessary for a correct ORS preparation and that it must be used within 24 hours. However for some, measuring the correct quantity of water poses a problem. Difficulties linked to the administration of zinc or ORS to children cited were the refusal by the child and vomiting. CONCLUSIONS AND RECOMMENDATIONS Zinc was prepared and administered correctly by the majority of mothers (95%). However, it should be noted that there was the unnecessary practice of crushing the zinc tablet. One woman indicated a preference for syrup for a child 0-6 months. The following recommendations are made: - Demonstrate the preparation and the administration of zinc and ORS to the mother while preparing the first ORS sachet with her and while administering the first zinc tablet. Educational messages must also explain the process and emphasize the tablets are soluble. - Give clear instructions to the mothers for the management of vomiting (for example, by giving in small quantities) and promote the active administration of ORS or zinc. 5.4.4 Factors that can limited access to zinc

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Among persons that knew of zinc but did not use it to treat diarrhea in their children various reasons were cited (Table 3). Table N3: Reasons for the non-administration of zinc during the last diarrhea episode Factors limiting zinc access in the treatment of diarrhea Number of cases (n=9) Lack of financial means 1/9 Stock Out 1/9 No prescription 5/9 Diarrhea not serious 1/9 Forgot 1/9 The table suggests that the lack of prescription by the service providers limited the access/use of zinc by some children. The stock-out and the lack of financial means appeared as other limiting factors. Some of these factors had also been indicated during the monitoring/supervision or exit interviews. Moreover, certain health personnel prescribed ORS for the treatment of diarrhea without also prescribing zinc, although it was available in the health facility. CONCLUSIONS AND RECOMMENDATIONS The stock-out and the non-prescription of zinc by the health staff for the treatment of diarrhea are important factors that can limit the access of children to this treatment. This suggests the following recommendations: - Make available the "diarrhea treatment kit" in order to avoid the prescription of one without the other; - Put in place a system for regular replenishment of supplies for each distribution network. 5.4.5 Determinants of completion to treatment during 10 days A semi-quantitative survey of behavioral barriers using the "Doers/Non-doer" method was used to explore factors influencing adhesion to the 10-day treatment. Thus doers gave the child a 10-day treatment while non-doers gave the child less than 10 days of treatment. CONCLUSIONS AND RECOMMENDATIONS Three main barriers to following the 10-day treatment were identified: - The level of knowledge on the advantages of the 10-day dose. - The perception that treatment duration is long and the observed rapid recovery of the child. Thus non-doers did not think it useful to continue treatment once the child appeared to be cured. They could not observe the protective benefits of continued treatment. - The self-efficacy of the mother. The doers were more motivated than the non-doers in giving the treatment. Table 4 proposes the strategies to reduce barriers and improve completion to treatment. Table N 4: Strategies for improving observance to treatment Strategies to reduce barriers and improve compliance Determinants/Barriers
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Promotion of preventive and curative advantages of zinc Level of knowledge of the supplementation during diarrhea through various channels: health advantages of prevention personnel, community relays, radio, television, testimony, posters, and treatment brochure. Educational messages on the preventive benefits of 10 days of zinc supplementation for the child and the mother. Promotion of Duration of treatment strategies to reduce refusal by children. considered too long Promotion of ways to recall the duration of treatment. Promotion of the factors that facilitate zinc administration. Increase the motivation of the mothers to give zinc during 10 days Motivation of the mother while promoting the benefits for the mother herself. 5.4.6 Perception of zinc tablets Mothers were interviewed on their perceptions of the taste, size and other properties of the zinc. CONCLUSIONS AND RECOMMENDATIONS Very few parents had an opinion on the taste, appearance or the size of the zinc tablet. One person found the tablet "big:" "I didn't taste", "I don't know "It is a good tablet, easy to dissolve." Some mothers found that the zinc tablets could be mistaken for other tablets: "It is possible to confuse it with quinine 300"; "These tablets resemble paracetamol". But the others thought that confusion is not possible: "No, the packaging is different". To most of the health staff, it would be difficult to confuse it with other tablets because it is the only one that dissolves easily. 5.4.7 Perceptions of efficacy Service providers and caretakers were interviewed for their perception of the efficacy of zinc. CONCLUSIONS AND RECOMMENDATIONS Both parents and service providers found zinc to be an effective treatment for diarrhea. All mothers found that zinc contributes to the treatment of diarrhea in children: "It treats;" "It cures;" "Its action is fast;" "Its already two months that she drank; she is doing very well and she is not very sick as before." Mothers cited the curative effect of zinc and its easy administration as advantages; they did not cite any preventive advantages. The complementary roles of zinc and ORS in the management of diarrhea and the need for both are not well understood by the parents. Service providers also found it to be an effective treatment: "Since we started giving it to the children, the results are positive"; "The results are good. The action is fast: at the end of 2 days the diarrhea stops". Zinc is not regarded as a replacement treatment for the others.
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The role of every medication in the management of diarrhea must be reinforced at the level of the community. 5.5 IDENTIYING THE MOST SUITABLE MEANS TO DISSEMINATE MESSAGES ON THE USE OF ZINC IN THE TREATMENT AND PREVENTION OF DIARRHOEA In the intervention, many parties were trained, notably health staff, radio broadcasters, village health committee members and CBO members. In addition, a radio spot was produced for broadcast in the three community radio stations that operated in the zone (Radio Zenith, Radio Marveille and Radio Aurore). According to the end line survey, 36% of mothers (n=69) had heard of zinc, while it was virtually unknown before the intervention (only one person had heard of it, through a pharmacy poster). The information was received through several sources: health staff constituted the main source of information (55%), followed by the radio (23%). I.1.1.1.1.1.2 Table N 5: Sources of information on zinc Sources of information on zinc Health personnel Radio A neighbor/friend Community agents (CBO or health committee members) Television Another parent Ambulatory seller

% citing 55 23 20 14 4 7 6

CONCLUSIONS AND RECOMMENDATIONS The main sources for messages on zinc were the health staff, the radio and the formal or informal community agents. Before the scaling up, it is important to train the health staff as well as the community agents. Their messages should be reinforced by those of the mass media in the framework of a communication plan. 5.6 DEVELOP, TEST AND REPRODUCE EDUCATIONAL MATERIALS FOR THE PROMOTION OF THE COMBINED USE OF ORS + ZINC IN THE TREATMENT OF DIARRHEA During this period, the project produced only a poster for service providers, presenting the four rules for the management of diarrhea. However, data collected should help inform the production of additional educational materials. CONCLUSIONS AND RECOMMENDATIONS The information collected from both quantitative and the qualitative sources suggest materials must: - Address the determinants of compliance with 10-14 day treatment with zinc;
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- Specify the appropriate use of every "medication" in the treatment of diarrhea; - Review the four rules of managing diarrhea; - Highlight the types of diarrhea requiring an antibiotic therapy. VI- GENERAL CONCLUSION AND RECOMMENDATIONS As a result of project advocacy zinc is now included on the list of essential drugs in Cameroon, but it is not yet available through the official drug procurement channel. During scale-up of its promotion, it will be useful to make a "diarrhea treatment kit" composed of ORS and zinc available to the population through CBOs and health facilities while addressing the shortcomings of staff in both networks through training and communication. It will be important to involve pharmacy operators as well, as more than 10% of mothers go there for diarrhea treatment. Zinc was prepared and administered correctly by large majority of the mothers sampled in our study (95%). However, a minority unnecessarily crushing the zinc tablet before trying to dissolve. Both parents and service providers found zinc to be a good treatment for diarrhea. It was not perceived to be a replacement of treatment with ORS. The majority of the mothers and all the service providers in our sample did not perceive any difficulties in using zinc to treat diarrhea. The few problems cited were rather danger signs of diarrhea (fatigue/dehydration, convulsions, fever, lack of appetite). Stock-outs and the non-prescription of zinc by the health staff for the treatment of diarrhea are the main factors limiting the access of children to this treatment. The price of zinc and of the combination ORS/zinc was considered cheap or affordable by mothers and service providers. The compliance with the 10-day treatment with zinc is of an acceptable level as compared to values obtained elsewhere, but could be improved. We suggest that promoting the14-day treatment may increase observance of at least 10 days of treatment; however, it will be necessary test this hypothesis with further research after the scale-up of treatment. Three main barriers to completion of the 10-day course were identified: the level of knowledge regarding the preventive advantages of zinc; the perception that the duration of treatment is too long; and the self-efficacy of the mother with respect to the treatment. The introduction of zinc led to an increase in the use of ORS/ORT but, did not reduce the incorrect use of antibiotics. These antibiotics are mainly prescribed (incorrectly) by the health staff. The use of anti-diarrheal drugs is rather rare. The main interpersonal sources of information about zinc were health staff and formal or informal community agents. Their messages must be reinforced by the mass media within the framework of a coordinated communications plan.
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GENERAL RECOMMENDATIONS A) To the MOH: accelerate the import procedures to assure adequate supplies of zinc. B) To the other partners (UNICEF, ACMS, HKI, Plan Cameroon etc.) : provide technical and financial support to MOH for a successful introduction of zinc in the treatment of diarrhea in Cameroon

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ANNEX 13. Project Data Form

I.2 Child Survival and Health Grants Program Project Summary I.2.1 Dec-20-2010 I.3 PLAN International (Cameroon) I.3.1 General Project Information
Cooperative Agreement Number: PLAN Headquarters Technical Backstop: PLAN Headquarters Technical Backstop Backup: Field Program Manager: Midterm Evaluator: Final Evaluator: Headquarter Financial Contact: Project Dates: Project Type: USAID Mission Contact: Project Web Site: GHS-A-00-05-00015 Judy Change Luis Tam Toh Ephraim Nyongha Bonnie Kittle Bonnie Kittle Luis Tam 9/30/2005 - 9/30/2010 (FY05) Expanded Impact Paul Hoedom Sossa

I.3.2 Field Program Manager


Name: Address: Toh Ephraim Nyongha Opposite German Embassy Bastos, PO Box 25236, Messa Yaounde Cameroon (237) 99 28 91 75 (237) 22 21 54 57 Ephraim.toh@plan-international.org

Phone: Fax: E-mail: Skype Name:

I.3.3 Alternate Field Contact


Name: Address: Casimir Youmbi Bastos, PO Box 25236, Messa Bastos, PO Box 25236, Messa Yaounde Cameroon

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Phone: Fax: E-mail: Skype Name: USAID Funding: $4,000,000

(237) 94 28 32 75 (237) 22 21 54 57 Casimir.Youmbi@plan-international.org

I.3.4 Grant Funding Information


PVO Match: $1,382,808

I.3.5 General Project Description


This is a Bundled Expanded Impact Program with Heller Keller International and Population Services International Program Goals: 1) To accelerate the scale-up of IMCI/RBM in Cameroon; 2) To disseminate successful program interventions and to integrate IMCI/RBM within Plan, PS and HKIs development programming in Cameroon and the region. Interventions: - Malaria - Nutrition - Control of Diarrheal Diseases - Pneumonia Immunization Strategies: - Promote ITN Use and Retreatment, Intermittent Presumptive Treatment for Pregnant women and home or facilitybased care for sick children within 24 hrs; - Community-based PD/Hearth; Exclusive breast feeding and appropriate complementary feeding and micro-nutrients; - Promote hand-washing, ORS and introduce zinc and POU Water treatment. - Promote Immunization

I.3.6 Project Location


Latitude: 3.80 Project Location Types: Levels of Intervention: Longitude: 12.93 Peri-urban Rural District Hospital Health Center Home Community East North West Centre Program Activities by Location Health District: 11 districts of the 3 provinces (Doume, Bertoua, Nguelemendouka and Batouri in the East; Awae, Esse and Akonolinga in the Center; and Ndop, Fudong, Mbengwi and Bafut in the Northwest), ProFam clinics in Yaound Provincial: 3 provinces (East, Center & North-West) including 55 health districts National: All 10 provinces including 170 districts -operations research on the Community Case

Province(s): District(s):

Sub-District(s): OR Project Title:

I.3.7 Operations Research Information

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Cost of OR Activities: Research Partner(s):

OR Project Description:

management of Pneumonia with oral Amoxicillin $15,554 Ministry of Public health University of Yaounde 1 - Faculty of Medicine and Biomedical Sciences Helen Keller international Association Camerounaise pour le Marketting Sociale (ACMS - PSI local Partner) In Cameroon, infant mortality rate stands at 74 new births, and varies from one region to another (58 in the North West to 111 in the East). This mortality rate is less in Urban regions (68 ) compared to rural regions (91 ). According to the 2004 Demographic Health Survey, infant mortality rate stands at 144. A majority of cases of pneumonia In Cameroon in children less than five years of age is of bacterial origin. In most cases, the main bacterial agents responsible for the advent of severe pneumonia children less than 5 years are Streptococcus pneumonia, Haemophilus influenza type b It is possible and necessary to treat them efficiently with not very expensive antibiotics at home or in the community, provided that households and Community Relays are adequately trained, follow received instructions and administer treatment according to the WHO IMCI protocol. The new WHO approach recommends the Integrated Management of childhood Illnesses using the simple tools. Community IMCI is one of the non clinical approaches that offer treatment services. It consists of giving appropriately trained non professionals (Community Relays) the task of offering treatment services to other members of the community. They will operate under the supervision of trained paramedical and/or medical staff. This new community approach has as aim to minimize the drawbacks due to insufficiencies of health facilities, personnel, geographical, financial, economic and sociocultural barriers that limit access to treatment. While bringing users close to health facilities, this new approach increases the level of education

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and practice via the use of relays from the communities. This strategy thus takes in to consideration the concerns of rural and semiurban populations who are the principal beneficiaries. Consequently, the introduction of IMCI at household or community level in the existing primary health care program remains a priority sanitary policy for the implementation of the three components of IMCI. The Ministry of Public health in collaboration with the Faculty of Medicine and Biomedical Sciences with the technical and financial support of Plan Cameroon carried on an operational research in One health district in the North West Region and is already implementing C-IMCI. This research has as major objective to report the feasibility and the advantages of the community case management of Pneumonia at community level in Cameroon.

I.3.8 Partners
ACMS (PSI) (Subgrantee) HKI (Subgrantee) MOH (Collaborating Partner) Eleven Local NGOs (Collaborating Partner) $1,000,000 $750,000 $0 $0

I.3.9 Strategies
Social and Behavioral Change Strategies: Group interventions Interpersonal Communication Social Marketing Mass media and small media Developing/Helping to develop clinical protocols, procedures, case management guidelines Monitoring health facility worker adherence with evidence-based guidelines Monitoring CHW adherence with evidence-based guidelines Referral-counterreferral system development for CHWs

Health Systems Strengthening:

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Strategies for Enabling Environment: Tools/Methodologies:

Advocacy for policy change or resource mobilization Building capacity of communities/CBOs to advocate to leaders for health BEHAVE Framework Sustainability Framework (CSSA) Rapid Health Facility Assessment LQAS

I.3.10 Capacity Building


Local Partners: Local Non-Government Organization (NGO) National Ministry of Health (MOH) Dist. Health System Health Facility Staff Health CBOs Other CBOs Non-government sanctioned CHWs

I.3.11 Interventions & Components


Immunizations (10%)
- Classic 6 Vaccines - Vitamin A - Surveillance - Cold Chain Strengthening - Mobilization - Community Registers IMCI Integration CHW Training HF Training

Nutrition (30%)
- ENA - Complementary Feeding from 6 months - Hearth - Continuous BF up to 24 months - Growth Monitoring

IMCI Integration

CHW Training HF Training

Vitamin A Micronutrients Pneumonia Case Management (10%)


- Case Management Counseling - Access to Providers Antibiotics - Recognition of Pneumonia Danger Signs

IMCI Integration

CHW Training HF Training CHW Training HF Training

IMCI Integration

CHW Training HF Training

Control of Diarrheal Diseases (10%)


- Water/Sanitation - Hand Washing - ORS/Home Fluids - Feeding/Breastfeeding

IMCI Integration

CHW Training HF Training

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- Care Seeking - Case Management/Counseling - POU Treatment of water - Zinc

Malaria (40%)
- Training in Malaria CM - Access to providers and drugs - Antenatal Prevention Treatment - ITN (Bednets) - Care Seeking, Recog., Compliance - IPT - ACT

IMCI Integration

CHW Training HF Training

Maternal & Newborn Care Healthy Timing/Spacing of Pregnancy Breastfeeding HIV/AIDS Family Planning Tuberculosis Infant & Young Child Feeding

IMCI Integration IMCI Integration IMCI Integration

CHW Training HF Training CHW Training HF Training CHW Training HF Training CHW Training HF Training

IMCI Integration IMCI Integration IMCI Integration

CHW Training HF Training CHW Training HF Training CHW Training HF Training

I.3.12 Operational Plan Indicators


Number of People Trained in Maternal/Newborn Health Gender Female Female Male Male Female Male Female Male Gender Female Year 2010 2010 2010 2010 2011 2011 2012 2012 Year 2010 0 0 0 0 0 Target 8000 Actual Target 0 19174 2504 Actual

Number of People Trained in Child Health & Nutrition

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Female Male Male Female Male Female Male

2010 2010 2010 2011 2011 2012 2012 1000 0 0 0 0

10315 1528

Number of People Trained in Malaria Treatment or Prevention Gender Female Female Male Male Female Male Female Male Year 2010 2010 2010 2010 2011 2011 2012 2012 1000 0 0 0 0 8000 1624 Target Actual 24360

I.3.13 Locations & Sub-Areas


Bafut Health District Fundong Health District Mbengwi Health District Ndop Health District Akonolinga Health District Awae Health District Esse Health District Batouri Health District Bertoua Health District Doume Health District Nguelemendouka Health District Total Population: 83,072 195,931 75,759 212,345 98,134 36,340 30,450 129,025 150,702 57,989 39,234 1,108,981

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I.3.14 Target Beneficiaries

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I.3.15 Rapid Catch Indicators: DIP Submission


Sample Type: LQAS
Underweight Children

Description -- Percentage of children age 0-23 months who are underweight (-2 SD from the median weight-for-age, according to the WHO/NCHS reference population)
Numerator: No. of children age 0-23 months whose weight (Rapid CATCH Question 7) is -2 SD from the median weight of the WHO/NCHS reference population for their age Denominator: Number of children age 0-23 months in the survey who were weighed (response=1 for Rapid CATCH Question 6) Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits

Bafut Health District Fundong Health District Mbengwi Health District Ndop Health District Akonolinga Health District Awae Health District Esse Health District Batouri Health District Bertoua Health District Doume Health District Nguelemendouka Health District
Birth Spacing

11 11 8 15 10 13 12 19 22 15 42

170 98 94 95 95 95 95 95 95 95 96

6.5% 11.2% 8.5% 15.8% 10.5% 13.7% 12.6% 20.0% 23.2% 15.8% 43.8%

3.7 6.2 5.6 7.3 6.2 6.9 6.7 8.0 8.5 7.3 9.9

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Description -- Percentage of children age 0-23 months who were born at least 24 months after the previous surviving child
Numerator: No. of children age 0-23 months whose date of birth is at least 24 months after the previous surviving sibling's date of birth Denominator: Number of children age 0-23 months in the survey who have an older surviving sibling Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits

Bafut Health District Fundong Health District Mbengwi Health District Ndop Health District Akonolinga Health District Awae Health District Esse Health District Batouri Health District Bertoua Health District Doume Health District Nguelemendouka Health District
Delivery Assistance

27 40 27 30 31 30 27 16 17 29 11

77 54 43 45 44 45 43 42 46 52 54

35.1% 74.1% 62.8% 66.7% 70.5% 66.7% 62.8% 38.1% 37.0% 55.8% 20.4%

10.7 11.7 14.4 13.8 13.5 13.8 14.4 14.7 13.9 13.5 10.7

Description -- Percentage of children age 0-23 months whose births were attended by skilled health personnel
Numerator: No. of children age 0-23 months with responses =A ('doctor'), B ('nurse/midwife'), or C ('auxiliary midwife') for Rapid CATCH Question 10D Denominator: Number of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits

Bafut Health District

151

170

88.8%

4.7

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Fundong Health District Mbengwi Health District Ndop Health District Akonolinga Health District Awae Health District Esse Health District Batouri Health District Bertoua Health District Doume Health District Nguelemendouka Health District
Maternal TT

78 83 86 54 48 49 22 48 27 27

98 94 95 95 95 95 95 95 95 96

79.6% 88.3% 90.5% 56.8% 50.5% 51.6% 23.2% 50.5% 28.4% 28.1%

8.0 6.5 5.9 10.0 10.1 10.0 8.5 10.1 9.1 9.0

Description -- Percentage of mothers of children age 0-23 months who received at least two tetanus toxoid injections before the birth of their youngest child
Numerator: Number of mothers of children age 0-23 months with responses=2 ('twice') or 3 ('more than two times') for Rapid CATCH Question 9 Denominator: Number of mothers of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits

Bafut Health District Fundong Health District Mbengwi Health District Ndop Health District Akonolinga Health District

105 59 59 58 52

170 98 94 95 95

61.8% 60.2% 62.8% 61.1% 54.7%

7.3 9.7 9.8 9.8 10.0

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Awae Health District Esse Health District Batouri Health District Bertoua Health District Doume Health District Nguelemendouka Health District
Exclusive Breastfeeding

43 50 57 50 62 66

95 95 95 95 95 96

45.3% 52.6% 60.0% 52.6% 65.3% 68.8%

10.0 10.0 9.9 10.0 9.6 9.3

Description -- Percentage of infants age 0-5 months who were exclusively breastfed in the last 24 hours
Numerator: Number of infants age 0-5 months with only response=A ('breastmilk') for Rapid CATCH Question 13 Denominator: Number of infants age 0-5 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits

Bafut Health District Fundong Health District Mbengwi Health District Ndop Health District Akonolinga Health District Awae Health District Esse Health District Batouri Health District Bertoua Health District

96 51 48 46 28 33 44 22 66

170 98 94 95 95 95 95 95 95

56.5% 52.0% 51.1% 48.4% 29.5% 34.7% 46.3% 23.2% 69.5%

7.5 9.9 10.1 10.0 9.2 9.6 10.0 8.5 9.3

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Doume Health District Nguelemendouka Health District


Complementary Feeding

64 73

95 96

67.4% 76.0%

9.4 8.5

Description -- Percentage of infants age 6-9 months receiving breastmilk and complementary foods
Numerator: Number of infants age 6-9 months with responses= A ('breastmilk') and D ('mashed, pureed, solid, or semi-solid foods') for Rapid CATCH Question 13 Denominator: Number of infants age 6--9 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits

Bafut Health District Fundong Health District Mbengwi Health District Ndop Health District Akonolinga Health District Awae Health District Esse Health District Batouri Health District Bertoua Health District Doume Health District Nguelemendouka Health District
Full Vaccination

155 92 89 90 86 86 87 86 92 86 83

163 98 94 95 95 95 95 95 95 95 96

95.1% 93.9% 94.7% 94.7% 90.5% 90.5% 91.6% 90.5% 96.8% 90.5% 86.5%

3.3 4.7 4.5 4.5 5.9 5.9 5.6 5.9 3.5 5.9 6.8

Description -- Percentage of children age 12-23 months who are fully vaccinated (against the five vaccine-preventable diseases) before the first birthday

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Numerator: Number of children age 12-23 months who received Polio3 (OPV3), DPT3, and measles vaccines before the first birthday, according to the child's vaccination card (as documented in Rapid CATCH Question 15) Denominator: Number of children age 12-23 months in the survey who have a vaccination card that was seen by the interviewer (response=1 'yes, seen by interviewer' for Rapid CATCH Question 14) Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits

Bafut Health District Fundong Health District Mbengwi Health District Ndop Health District Akonolinga Health District Awae Health District Esse Health District Batouri Health District Bertoua Health District Doume Health District Nguelemendouka Health District
Measles

121 83 63 66 14 30 43 15 39 38 38

149 92 75 85 46 48 70 40 68 67 44

81.2% 90.2% 84.0% 77.6% 30.4% 62.5% 61.4% 37.5% 57.4% 56.7% 86.4%

6.3 6.1 8.3 8.9 13.3 13.7 11.4 15.0 11.8 11.9 10.1

Description -- Percentage of children age 12-23 months who received a measles vaccine
Numerator: Number of children age 12-23 months with response=1 ('yes') for Rapid CATCH Question 16 Denominator: Number of children age 12-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits

Bafut Health District

133

149

89.3%

5.0

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Fundong Health District Mbengwi Health District Ndop Health District Akonolinga Health District Awae Health District Esse Health District Batouri Health District Bertoua Health District Doume Health District Nguelemendouka Health District
Bednets

84 69 71 20 37 48 21 51 47 41

85 73 85 46 46 69 40 67 67 43

98.8% 94.5% 83.5% 43.5% 80.4% 69.6% 52.5% 76.1% 70.1% 95.3%

2.3 5.2 7.9 14.3 11.5 10.9 15.5 10.2 11.0 6.3

Description -- Percentage of children age 0-23 months who slept under an insecticide-treated bednet the previous night (in malaria-risk areas only)
Numerator: Number of children age 0-23 months with 'child' (response=A) mentioned among responses to Rapid CATCH Question 18 AND response=1 ('yes') for Rapid CATCH Question 19 Denominator: Number of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits

Bafut Health District Fundong Health District Mbengwi Health District Ndop Health District Akonolinga Health District

17 3 12 2 17

170 98 94 95 95

10.0% 3.1% 12.8% 2.1% 17.9%

4.5 3.4 6.7 2.9 7.7

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Awae Health District Esse Health District Batouri Health District Bertoua Health District Doume Health District Nguelemendouka Health District
Danger Signs

22 21 7 11 9 12

95 95 95 95 95 96

23.2% 22.1% 7.4% 11.6% 9.5% 12.5%

8.5 8.3 5.3 6.4 5.9 6.6

Description -- Percentage of mothers who know at least two signs of childhood illness that indicate the need for treatment
Numerator: Number of mothers of children age 0-23 months who report at least two of the signs listed in B through H of Rapid CATCH Question 20 Denominator: Number of mothers of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits

Bafut Health District Fundong Health District Mbengwi Health District Ndop Health District Akonolinga Health District Awae Health District Esse Health District Batouri Health District Bertoua Health District

111 59 61 54 67 61 73 61 79

170 98 94 95 95 95 95 95 95

65.3% 60.2% 64.9% 56.8% 70.5% 64.2% 76.8% 64.2% 83.2%

7.2 9.7 9.6 10.0 9.2 9.6 8.5 9.6 7.5

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Doume Health District Nguelemendouka Health District


Sick Child

51 63

95 96

53.7% 65.6%

10.0 9.5

Description -- Percentage of sick children age 0-23 months who received increased fluids and continued feeding during an illness in the past two weeks
Numerator: Number of children age 0-23 months with response=3 ('more than usual') for Rapid CATCH Question 22 AND response=2 ('same amount') or 3 ('more than usual') for Rapid CATCH Question 23 Denominator: Number of children surveyed who were reportedly sick in the past two weeks (children with any responses A-H for Rapid CATCH Question 21) Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits

Bafut Health District Fundong Health District Mbengwi Health District Ndop Health District Akonolinga Health District Awae Health District Esse Health District Batouri Health District Bertoua Health District Doume Health District Nguelemendouka Health District
HIV/AIDS

17 4 7 6 5 8 6 5 9 6 7

113 81 52 73 85 89 79 85 69 78 75

15.0% 4.9% 13.5% 8.2% 5.9% 9.0% 7.6% 5.9% 13.0% 7.7% 9.3%

6.6 4.7 9.3 6.3 5.0 5.9 5.8 5.0 7.9 5.9 6.6

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Description -- Percentage of mothers of children age 0-23 months who cite at least two known ways of reducing the risk of HIV infection
Numerator: Number of mothers of children age 0-23 months who mention at least two of the responses that relate to safer sex or practices involving blood (letters B through I & O) for Rapid CATCH Question 25 Denominator: Number of mothers of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits

Bafut Health District Fundong Health District Mbengwi Health District Ndop Health District Akonolinga Health District Awae Health District Esse Health District Batouri Health District Bertoua Health District Doume Health District Nguelemendouka Health District
Handwashing

127 69 64 70 59 70 55 35 61 58 58

170 98 94 95 95 95 95 95 95 95 96

74.7% 70.4% 68.1% 73.7% 62.1% 73.7% 57.9% 36.8% 64.2% 61.1% 60.4%

6.5 9.0 9.4 8.9 9.8 8.9 9.9 9.7 9.6 9.8 9.8

Description -- Percentage of mothers of children age 0-23 months who wash their hands with soap/ash before food preparation, before feeding children, after defecation, and after attending to a child who has defecated
Numerator: Number of mothers of children age 0-23 months who mention responses B through E for Rapid CATCH Question 26 Denominator: Number of mothers of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits

Bafut Health

13

170

7.6%

4.0

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District Fundong Health District Mbengwi Health District Ndop Health District Akonolinga Health District Awae Health District Esse Health District Batouri Health District Bertoua Health District Doume Health District Nguelemendouka Health District 5 7 23 1 14 1 1 4 15 2 98 94 95 95 95 95 95 95 95 96 5.1% 7.4% 24.2% 1.1% 14.7% 1.1% 1.1% 4.2% 15.8% 2.1% 4.4 5.3 8.6 2.1 7.1 2.1 2.1 4.0 7.3 2.9

I.3.16 Rapid Catch Indicators: Mid-term


Sample Type: LQAS
Underweight Children

Description -- Percentage of children age 0-23 months who are underweight (-2 SD from the median weight-for-age, according to the WHO/NCHS reference population)
Numerator: No. of children age 0-23 months whose weight (Rapid CATCH Question 7) is -2 SD from the median weight of the WHO/NCHS reference population for their age Denominator: Number of children age 0-23 months in the survey who were weighed (response=1 for Rapid CATCH Question 6) Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits

Bafut Health District Fundong Health District Mbengwi Health

11 10 6

223 186 236

4.9% 5.4% 2.5%

2.8 3.2 2.0

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District Ndop Health District Akonolinga Health District Awae Health District Esse Health District Batouri Health District Bertoua Health District Doume Health District Nguelemendouka Health District
Birth Spacing

18 16 6 5 71 27 11 20

236 198 91 130 409 248 63 107

7.6% 8.1% 6.6% 3.8% 17.4% 10.9% 17.5% 18.7%

3.4 3.8 5.1 3.3 3.7 3.9 9.4 7.4

Description -- Percentage of children age 0-23 months who were born at least 24 months after the previous surviving child
Numerator: No. of children age 0-23 months whose date of birth is at least 24 months after the previous surviving sibling's date of birth Denominator: Number of children age 0-23 months in the survey who have an older surviving sibling Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits

Bafut Health District Fundong Health District Mbengwi Health District Ndop Health District Akonolinga Health District Awae Health District

95 76 78 120 61 24

120 96 119 157 110 43

79.2% 79.2% 65.5% 76.4% 55.5% 55.8%

7.3 8.1 8.5 6.6 9.3 14.8

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Esse Health District Batouri Health District Bertoua Health District Doume Health District Nguelemendouka Health District
Delivery Assistance

51 131 88 20 31

86 245 143 67 71

59.3% 53.5% 61.5% 29.9% 43.7%

10.4 6.2 8.0 11.0 11.5

Description -- Percentage of children age 0-23 months whose births were attended by skilled health personnel
Numerator: No. of children age 0-23 months with responses =A ('doctor'), B ('nurse/midwife'), or C ('auxiliary midwife') for Rapid CATCH Question 10D Denominator: Number of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits

Bafut Health District Fundong Health District Mbengwi Health District Ndop Health District Akonolinga Health District Awae Health District Esse Health District Batouri Health District Bertoua Health District Doume Health District

207 172 226 232 120 70 65 155 225 67

224 193 236 240 204 91 131 444 282 85

92.4% 89.1% 95.8% 96.7% 58.8% 76.9% 49.6% 34.9% 79.8% 78.8%

3.5 4.4 2.6 2.3 6.8 8.7 8.6 4.4 4.7 8.7

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Nguelemendouka Health District


Maternal TT

94

115

81.7%

7.1

Description -- Percentage of mothers of children age 0-23 months who received at least two tetanus toxoid injections before the birth of their youngest child
Numerator: Number of mothers of children age 0-23 months with responses=2 ('twice') or 3 ('more than two times') for Rapid CATCH Question 9 Denominator: Number of mothers of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits

Bafut Health District Fundong Health District Mbengwi Health District Ndop Health District Akonolinga Health District Awae Health District Esse Health District Batouri Health District Bertoua Health District Doume Health District Nguelemendouka Health District
Exclusive Breastfeeding

128 133 169 137 114 59 78 222 165 46 65

224 193 236 240 204 91 131 444 282 85 115

57.1% 68.9% 71.6% 57.1% 55.9% 64.8% 59.5% 50.0% 58.5% 54.1% 56.5%

6.5 6.5 5.8 6.3 6.8 9.8 8.4 4.7 5.8 10.6 9.1

Description -- Percentage of infants age 0-5 months who were exclusively breastfed in the last 24 hours
Numerator: Number of infants age 0-5 months with only response=A ('breastmilk') for Rapid CATCH Question 13 Denominator: Number of infants age 0-5 months in the survey

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Sub Area Name

Numerator

Denominator

Percent(calculate)

Confidence Limits

Bafut Health District Fundong Health District Mbengwi Health District Ndop Health District Akonolinga Health District Awae Health District Esse Health District Batouri Health District Bertoua Health District Doume Health District Nguelemendouka Health District
Complementary Feeding

144 204 184 162 122 53 67 195 204 71 103

228 209 263 266 183 95 133 473 301 114 125

63.2% 97.6% 70.0% 60.9% 66.7% 55.8% 50.4% 41.2% 67.8% 62.3% 82.4%

6.3 2.1 5.5 5.9 6.8 10.0 8.5 4.4 5.3 8.9 6.7

Description -- Percentage of infants age 6-9 months receiving breastmilk and complementary foods
Numerator: Number of infants age 6-9 months with responses= A ('breastmilk') and D ('mashed, pureed, solid, or semi-solid foods') for Rapid CATCH Question 13 Denominator: Number of infants age 6--9 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits

Bafut Health District Fundong Health District Mbengwi Health District

217 200 235

228 210 263

95.2% 95.2% 89.4%

2.8 2.9 3.7

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Ndop Health District Akonolinga Health District Awae Health District Esse Health District Batouri Health District Bertoua Health District Doume Health District Nguelemendouka Health District
Full Vaccination

260 157 92 130 439 275 109 114

266 173 95 133 474 300 114 125

97.7% 90.8% 96.8% 97.7% 92.6% 91.7% 95.6% 91.2%

1.8 4.3 3.5 2.5 2.4 3.1 3.8 5.0

Description -- Percentage of children age 12-23 months who are fully vaccinated (against the five vaccine-preventable diseases) before the first birthday
Numerator: Number of children age 12-23 months who received Polio3 (OPV3), DPT3, and measles vaccines before the first birthday, according to the child's vaccination card (as documented in Rapid CATCH Question 15) Denominator: Number of children age 12-23 months in the survey who have a vaccination card that was seen by the interviewer (response=1 'yes, seen by interviewer' for Rapid CATCH Question 14) Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits

Bafut Health District Fundong Health District Mbengwi Health District Ndop Health District Akonolinga Health District Awae Health

182 140 143 151 77 59

192 156 162 207 109 63

94.8% 89.7% 88.3% 72.9% 70.6% 93.7%

3.1 4.8 5.0 6.1 8.5 6.0

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District Esse Health District Batouri Health District Bertoua Health District Doume Health District Nguelemendouka Health District
Measles

64 113 66 47 67

93 203 189 64 83

68.8% 55.7% 34.9% 73.4% 80.7%

9.4 6.8 6.8 10.8 8.5

Description -- Percentage of children age 12-23 months who received a measles vaccine
Numerator: Number of children age 12-23 months with response=1 ('yes') for Rapid CATCH Question 16 Denominator: Number of children age 12-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits

Bafut Health District Fundong Health District Mbengwi Health District Ndop Health District Akonolinga Health District Awae Health District Esse Health District Batouri Health District Bertoua Health District Doume Health

182 140 143 151 77 59 65 113 66 49

192 156 162 207 109 63 93 203 189 64

94.8% 89.7% 88.3% 72.9% 70.6% 93.7% 69.9% 55.7% 34.9% 76.6%

3.1 4.8 5.0 6.1 8.5 6.0 9.3 6.8 6.8 10.4

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District Nguelemendouka Health District


Bednets

67

83

80.7%

8.5

Description -- Percentage of children age 0-23 months who slept under an insecticide-treated bednet the previous night (in malaria-risk areas only)
Numerator: Number of children age 0-23 months with 'child' (response=A) mentioned among responses to Rapid CATCH Question 18 AND response=1 ('yes') for Rapid CATCH Question 19 Denominator: Number of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits

Bafut Health District Fundong Health District Mbengwi Health District Ndop Health District Akonolinga Health District Awae Health District Esse Health District Batouri Health District Bertoua Health District Doume Health District Nguelemendouka Health District
Danger Signs

199 137 188 239 163 62 95 145 143 46 64

228 210 263 266 228 95 133 474 302 114 126

87.3% 65.2% 71.5% 89.8% 71.5% 65.3% 71.4% 30.6% 47.4% 40.4% 50.8%

4.3 6.4 5.5 3.6 5.9 9.6 7.7 4.1 5.6 9.0 8.7

Description -- Percentage of mothers who know at least two signs of childhood illness that indicate the need for treatment
Numerator: Number of mothers of children age 0-23 months who report at least two of the

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signs listed in B through H of Rapid CATCH Question 20 Denominator: Number of mothers of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits

Bafut Health District Fundong Health District Mbengwi Health District Ndop Health District Akonolinga Health District Awae Health District Esse Health District Batouri Health District Bertoua Health District Doume Health District Nguelemendouka Health District
Sick Child

166 150 209 212 174 74 101 267 188 80 94

228 210 236 266 228 95 133 474 302 114 126

72.8% 71.4% 88.6% 79.7% 76.3% 77.9% 75.9% 56.3% 62.3% 70.2% 74.6%

5.8 6.1 4.1 4.8 5.5 8.3 7.3 4.5 5.5 8.4 7.6

Description -- Percentage of sick children age 0-23 months who received increased fluids and continued feeding during an illness in the past two weeks
Numerator: Number of children age 0-23 months with response=3 ('more than usual') for Rapid CATCH Question 22 AND response=2 ('same amount') or 3 ('more than usual') for Rapid CATCH Question 23 Denominator: Number of children surveyed who were reportedly sick in the past two weeks (children with any responses A-H for Rapid CATCH Question 21) Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits

Bafut Health District Fundong Health

17 44

145 170

11.7% 25.9%

5.2 6.6

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District Mbengwi Health District Ndop Health District Akonolinga Health District Awae Health District Esse Health District Batouri Health District Bertoua Health District Doume Health District Nguelemendouka Health District
HIV/AIDS

49 18 16 12 31 7 49 12 7

204 157 148 66 98 340 246 104 111

24.0% 11.5% 10.8% 18.2% 31.6% 2.1% 19.9% 11.5% 6.3%

5.9 5.0 5.0 9.3 9.2 1.5 5.0 6.1 4.5

Description -- Percentage of mothers of children age 0-23 months who cite at least two known ways of reducing the risk of HIV infection
Numerator: Number of mothers of children age 0-23 months who mention at least two of the responses that relate to safer sex or practices involving blood (letters B through I & O) for Rapid CATCH Question 25 Denominator: Number of mothers of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits

Bafut Health District Fundong Health District Mbengwi Health District Ndop Health District Akonolinga Health District

183 138 219 203 167

228 210 263 266 228

80.3% 65.7% 83.3% 76.3% 73.2%

5.2 6.4 4.5 5.1 5.7

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Awae Health District Esse Health District Batouri Health District Bertoua Health District Doume Health District Nguelemendouka Health District
Handwashing

77 102 204 172 70 77

95 133 474 302 114 126

81.1% 76.7% 43.0% 57.0% 61.4% 61.1%

7.9 7.2 4.5 5.6 8.9 8.5

Description -- Percentage of mothers of children age 0-23 months who wash their hands with soap/ash before food preparation, before feeding children, after defecation, and after attending to a child who has defecated
Numerator: Number of mothers of children age 0-23 months who mention responses B through E for Rapid CATCH Question 26 Denominator: Number of mothers of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits

Bafut Health District Fundong Health District Mbengwi Health District Ndop Health District Akonolinga Health District Awae Health District Esse Health District Batouri Health District Bertoua Health District

39 29 74 79 28 23 26 37 21

228 210 263 266 228 95 133 474 302

17.1% 13.8% 28.1% 29.7% 12.3% 24.2% 19.5% 7.8% 7.0%

4.9 4.7 5.4 5.5 4.3 8.6 6.7 2.4 2.9

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Doume Health District Nguelemendouka Health District

6 5

114 126

5.3% 4.0%

4.1 3.4

I.3.17 Rapid Catch Indicators: Final Evaluation


Sample Type: LQAS
Underweight Children

Description -- Percentage of children age 0-23 months who are underweight (-2 SD from the median weight-for-age, according to the WHO/NCHS reference population)
Numerator: No. of children age 0-23 months whose weight (Rapid CATCH Question 7) is -2 SD from the median weight of the WHO/NCHS reference population for their age Denominator: Number of children age 0-23 months in the survey who were weighed (response=1 for Rapid CATCH Question 6) Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits

Bafut Health District Fundong Health District Mbengwi Health District Ndop Health District Akonolinga Health District Awae Health District Esse Health District Batouri Health District Bertoua Health District Doume Health District Nguelemendouka Health District

30 14 12 20 11 3 8 83 14 8 11

244 234 216 259 185 89 125 431 234 142 92

12.3% 6.0% 5.6% 7.7% 5.9% 3.4% 6.4% 19.3% 6.0% 5.6% 12.0%

4.1 3.0 3.1 3.3 3.4 3.7 4.3 3.7 3.0 3.8 6.6

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Birth Spacing

Description -- Percentage of children age 0-23 months who were born at least 24 months after the previous surviving child
Numerator: No. of children age 0-23 months whose date of birth is at least 24 months after the previous surviving sibling's date of birth Denominator: Number of children age 0-23 months in the survey who have an older surviving sibling Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits

Bafut Health District Fundong Health District Mbengwi Health District Ndop Health District Akonolinga Health District Awae Health District Esse Health District Batouri Health District Bertoua Health District Doume Health District Nguelemendouka Health District
Delivery Assistance

60 52 69 103 52 27 46 92 70 43 30

85 93 90 137 110 73 61 180 130 72 47

70.6% 55.9% 76.7% 75.2% 47.3% 37.0% 75.4% 51.1% 53.8% 59.7% 63.8%

9.7 10.1 8.7 7.2 9.3 11.1 10.8 7.3 8.6 11.3 13.7

Description -- Percentage of children age 0-23 months whose births were attended by skilled health personnel
Numerator: No. of children age 0-23 months with responses =A ('doctor'), B ('nurse/midwife'), or C ('auxiliary midwife') for Rapid CATCH Question 10D Denominator: Number of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits

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Bafut Health District Fundong Health District Mbengwi Health District Ndop Health District Akonolinga Health District Awae Health District Esse Health District Batouri Health District Bertoua Health District Doume Health District Nguelemendouka Health District
Maternal TT

233 220 222 254 126 66 65 314 220 71 55

247 247 247 266 208 95 133 456 323 152 95

94.3% 89.1% 89.9% 95.5% 60.6% 69.5% 48.9% 68.9% 68.1% 46.7% 57.9%

2.9 3.9 3.8 2.5 6.6 9.3 8.5 4.3 5.1 7.9 9.9

Description -- Percentage of mothers of children age 0-23 months who received at least two tetanus toxoid injections before the birth of their youngest child
Numerator: Number of mothers of children age 0-23 months with responses=2 ('twice') or 3 ('more than two times') for Rapid CATCH Question 9 Denominator: Number of mothers of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits

Bafut Health District Fundong Health District Mbengwi Health District Ndop Health District

178 183 157 161

247 247 247 266

72.1% 74.1% 63.6% 60.5%

5.6 5.5 6.0 5.9

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Akonolinga Health District Awae Health District Esse Health District Batouri Health District Bertoua Health District Doume Health District Nguelemendouka Health District
Exclusive Breastfeeding

95 48 84 252 239 97 66

208 95 133 456 323 152 95

45.7% 50.5% 63.2% 55.3% 74.0% 63.8% 69.5%

6.8 10.1 8.2 4.6 4.8 7.6 9.3

Description -- Percentage of infants age 0-5 months who were exclusively breastfed in the last 24 hours
Numerator: Number of infants age 0-5 months with only response=A ('breastmilk') for Rapid CATCH Question 13 Denominator: Number of infants age 0-5 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits

Bafut Health District Fundong Health District Mbengwi Health District Ndop Health District Akonolinga Health District Awae Health District Esse Health District Batouri Health District

173 168 205 193 197 89 128 284

247 247 247 266 208 95 133 456

70.0% 68.0% 83.0% 72.6% 94.7% 93.7% 96.2% 62.3%

5.7 5.8 4.7 5.4 3.0 4.9 3.2 4.4

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Bertoua Health District Doume Health District Nguelemendouka Health District


Complementary Feeding

219 126 68

323 152 95

67.8% 82.9% 71.6%

5.1 6.0 9.1

Description -- Percentage of infants age 6-9 months receiving breastmilk and complementary foods
Numerator: Number of infants age 6-9 months with responses= A ('breastmilk') and D ('mashed, pureed, solid, or semi-solid foods') for Rapid CATCH Question 13 Denominator: Number of infants age 6--9 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits

Bafut Health District Fundong Health District Mbengwi Health District Ndop Health District Akonolinga Health District Awae Health District Esse Health District Batouri Health District Bertoua Health District Doume Health District Nguelemendouka Health District
Full Vaccination

237 214 234 244 187 81 122 407 280 144 78

247 247 247 266 208 95 133 456 323 152 95

96.0% 86.6% 94.7% 91.7% 89.9% 85.3% 91.7% 89.3% 86.7% 94.7% 82.1%

2.5 4.2 2.8 3.3 4.1 7.1 4.7 2.8 3.7 3.5 7.7

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Description -- Percentage of children age 12-23 months who are fully vaccinated (against the five vaccine-preventable diseases) before the first birthday
Numerator: Number of children age 12-23 months who received Polio3 (OPV3), DPT3, and measles vaccines before the first birthday, according to the child's vaccination card (as documented in Rapid CATCH Question 15) Denominator: Number of children age 12-23 months in the survey who have a vaccination card that was seen by the interviewer (response=1 'yes, seen by interviewer' for Rapid CATCH Question 14) Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits

Bafut Health District Fundong Health District Mbengwi Health District Ndop Health District Akonolinga Health District Awae Health District Esse Health District Batouri Health District Bertoua Health District Doume Health District Nguelemendouka Health District
Measles

224 123 203 151 21 44 39 88 138 91 44

244 184 243 226 78 72 80 226 206 110 67

91.8% 66.8% 83.5% 66.8% 26.9% 61.1% 48.8% 38.9% 67.0% 82.7% 65.7%

3.4 6.8 4.7 6.1 9.8 11.3 11.0 6.4 6.4 7.1 11.4

Description -- Percentage of children age 12-23 months who received a measles vaccine
Numerator: Number of children age 12-23 months with response=1 ('yes') for Rapid CATCH Question 16 Denominator: Number of children age 12-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits

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Bafut Health District Fundong Health District Mbengwi Health District Ndop Health District Akonolinga Health District Awae Health District Esse Health District Batouri Health District Bertoua Health District Doume Health District Nguelemendouka Health District
Bednets

236 195 232 240 160 76 109 345 271 128 87

247 247 247 266 208 95 133 456 323 152 95

95.5% 78.9% 93.9% 90.2% 76.9% 80.0% 82.0% 75.7% 83.9% 84.2% 91.6%

2.6 5.1 3.0 3.6 5.7 8.0 6.5 3.9 4.0 5.8 5.6

Description -- Percentage of children age 0-23 months who slept under an insecticide-treated bednet the previous night (in malaria-risk areas only)
Numerator: Number of children age 0-23 months with 'child' (response=A) mentioned among responses to Rapid CATCH Question 18 AND response=1 ('yes') for Rapid CATCH Question 19 Denominator: Number of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits

Bafut Health District Fundong Health District Mbengwi Health District Ndop Health District

214 186 194 199

247 247 247 266

86.6% 75.3% 78.5% 74.8%

4.2 5.4 5.1 5.2

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Akonolinga Health District Awae Health District Esse Health District Batouri Health District Bertoua Health District Doume Health District Nguelemendouka Health District
Danger Signs

159 79 80 131 243 119 36

209 95 133 456 323 152 95

76.1% 83.2% 60.2% 28.7% 75.2% 78.3% 37.9%

5.8 7.5 8.3 4.2 4.7 6.6 9.8

Description -- Percentage of mothers who know at least two signs of childhood illness that indicate the need for treatment
Numerator: Number of mothers of children age 0-23 months who report at least two of the signs listed in B through H of Rapid CATCH Question 20 Denominator: Number of mothers of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits

Bafut Health District Fundong Health District Mbengwi Health District Ndop Health District Akonolinga Health District Awae Health District Esse Health District Batouri Health District

221 178 216 195 152 83 125 297

247 247 247 266 208 95 133 456

89.5% 72.1% 87.4% 73.3% 73.1% 87.4% 94.0% 65.1%

3.8 5.6 4.1 5.3 6.0 6.7 4.0 4.4

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Sick Child

233 133 77

323 152 95

72.1% 87.5% 81.1%

4.9 5.3 7.9

Description -- Percentage of sick children age 0-23 months who received increased fluids and continued feeding during an illness in the past two weeks
Numerator: Number of children age 0-23 months with response=3 ('more than usual') for Rapid CATCH Question 22 AND response=2 ('same amount') or 3 ('more than usual') for Rapid CATCH Question 23 Denominator: Number of children surveyed who were reportedly sick in the past two weeks (children with any responses A-H for Rapid CATCH Question 21) Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits

Bafut Health District Fundong Health District Mbengwi Health District Ndop Health District Akonolinga Health District Awae Health District Esse Health District Batouri Health District Bertoua Health District Doume Health District Nguelemendouka Health District

21 28 22 13 33 19 12 17 34 21 6

172 163 161 183 94 50 81 299 199 152 72

12.2% 17.2% 13.7% 7.1% 35.1% 38.0% 14.8% 5.7% 17.1% 13.8% 8.3%

4.9 5.8 5.3 3.7 9.6 13.5 7.7 2.6 5.2 5.5 6.4

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HIV/AIDS

Description -- Percentage of mothers of children age 0-23 months who cite at least two known ways of reducing the risk of HIV infection
Numerator: Number of mothers of children age 0-23 months who mention at least two of the responses that relate to safer sex or practices involving blood (letters B through I & O) for Rapid CATCH Question 25 Denominator: Number of mothers of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence Limits

Bafut Health District Fundong Health District Mbengwi Health District Ndop Health District Akonolinga Health District Awae Health District Esse Health District Batouri Health District Bertoua Health District Doume Health District Nguelemendouka Health District
Handwashing

238 185 209 203 135 79 97 171 193 101 53

247 247 247 266 208 95 133 456 323 152 95

96.4% 74.9% 84.6% 76.3% 64.9% 83.2% 72.9% 37.5% 59.8% 66.4% 55.8%

2.3 5.4 4.5 5.1 6.5 7.5 7.6 4.4 5.3 7.5 10.0

Description -- Percentage of mothers of children age 0-23 months who wash their hands with soap/ash before food preparation, before feeding children, after defecation, and after attending to a child who has defecated
Numerator: Number of mothers of children age 0-23 months who mention responses B through E for Rapid CATCH Question 26 Denominator: Number of mothers of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent(calculate) Confidence

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Limits

Bafut Health District Fundong Health District Mbengwi Health District Ndop Health District Akonolinga Health District Awae Health District Esse Health District Batouri Health District Bertoua Health District Doume Health District Nguelemendouka Health District

99 91 101 78 187 92 124 48 97 101 24

247 247 247 266 208 95 133 456 323 152 95

40.1% 36.8% 40.9% 29.3% 89.9% 96.8% 93.2% 10.5% 30.0% 66.4% 25.3%

6.1 6.0 6.1 5.5 4.1 3.5 4.3 2.8 5.0 7.5 8.7

I.3.18 Rapid Catch Indicator Comments

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ANNEX 14. Grantee Plans to Address Final Evaluation Findings In future project designs, then, Plan should more thoroughly examine its commitment and ability to strengthen local NGOs and consider if it wouldnt be more cost- and timeefficient to directly hire promoters to work at the community level and develop the links between the IHC staff and the CBOs. (page 9) For future projects, such as those funded by the Global Fund, Plan will focus more on providing institutional support and capacity building of local NGOs who have the potential of sustaining project activities beyond the life of a project. Plan will negotiate contracts with NGOs and CSOs to supervise directly specific health promoters who will be responsible for project activities and report directly to Plan for these projects. This will ultimately retain Plans control over the activities while enhancing the local NGOs capacity. As mentioned in the MTE report, one problem in this initiative was the failure of the MOH to make ACTs available to the CCM/M relays once they were trained. The kits were only distributed nine months after the training. (page 16) In November 2010, Plan Cameroon received a Global Fund Round 9 grant for malaria. Under the grant, Plan will work to scale up the home-management of malaria and Roll Back Malaria activities over the next five years, and include the provision of ACTs at the community and health facility levels to bolster against future stock-outs. While this is a vast improvement over not administering any pre-/post-tests, further research into other methods that are more useful is needed. Furthermore, the pre-/post-test questions should be revised to focus on the most common life-threatening problems faced by children (currently three of the 25 questions are on HIV/AIDS). (page 19) In the context of the EIP, HIV and AIDS was not an intervention priority, thus explaining why the pre/post-test questionnaire did not focus on HIV and AIDS. However, over time, the MOH has modified the curriculum which now includes core questions on HIV and AIDS. The manual was last revised in 2008, but plans for further revisions in the near future will help ensure that it properly contends with the changing challenges in child health. Despite the fact that the message is clearly communicated in the Message Booklet in Chart 15, it seems that the message about feeding a sick child, regardless of the illness, was not communicated strongly enough to promoters or CBO members. (page 20) The Message Booklet stressed the importance of feeding a sick child regardless of illness type, specifying that caretakers needed to give more liquids than usual and at least the same quantity or greater than usual during illness. The project tracked the change in this behaviour through the indicator Percentage of sick children age 0-23 months who received increased fluids and continued feeding during an illness in the past two weeks. Despite this knowledge, caretakers could not clearly report on the quantity of food given the child, memory recall issues possibly attributing to the stagnant stature of the indicator. Future work in the communities as part of Plans ongoing programs will

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continue to stress the importance of the Message Booklet messages to the promoters and CBO members. During the second half of the project however, ACMS experienced serious challenges with regard to the supply of Water Guard, which resulted in prolonged country-wide stock outs of the product. When tested by the government authorities, the locally produced Water Guard was not approved for distribution and an entire batch of the product went unused. PSI/HQ subsequently changed its supplier, causing extended and inexplicable stock outages. As a result, during the second half of the project, EIP community members have not had access to Water Guard to treat their drinking water. (page 22) Since then, ACMS has overcome these challenges by signing a contract with a new Water Guard supplier who has already delivered their first batch. Currently, all of the project communities have received their supply of Water Guard and stock-out issues have been minimized. However, there is some concern that the relays do not have many opportunities to practice their treatment skills/knowledge. Several of the relays interviewed during the final evaluation had only treated one to two children in the last quarter. The link between health center staff and the CCM/P relays should also be strengthened. (Page 23) The populations awareness of the availability of treatment at the community level and the use of community relays is vital. According to the CCM final evaluation report, the number of mothers of children who sought help from the community relays increased from 2.43% in November 2009 to 45.26% in September 2010, indicating that relays inability to practice their skills is associated to the lack of awareness that these services were available locally. The MOH has now taken over the supervision of CCM/P relays. The CCM/P relays now report directly to the Health center staff, where they also go to renew their amoxicillin stocks. In future projects, such as the RAIN Coca Cola project; Plan Cameroon will only provide institutional support and technical advice for the community and will support the MOHs implementation of the project locally. This example will be scaled up to other projects and thus strengthen the link between the community and the Health centre staff. At the community level, trained CBO members are supposed to track immunization coverage using two tools: the behaviour map and the community register. The evaluation team attempted to assess the quality of the community health information system and found that while most villages had behaviour maps that appeared to be kept up to date (including immunization status of U5), the registers were not as well maintained. More importantly, however, it is not clear that CBO members or IHC staff were using the registers to identify children whose immunization status is not up to date to refer them to the health center. (page 25) The community register was the basic data collection tool in the EIP communities. While it is unclear whether or not the community register is updated and/or used for referring children to health centers, the project actually used the behavior map for engaging the discussions with the community, and ultimately, the register was not used as a tool for referring children to the health facilities, but as a data base to track children who missed

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vaccination campaigns and other health outreach packages. For the referral of children to the health facility, the monthly consolidated behavior map and associated action plans developed by the community was used to improve behavior change around referrals. Thus, at the end of each month, the children who are not practicing a particular behavior were identified on the map and referred. However, the registers information was still utilized for the consolidation of the data during the monthly review meetings. The Secretary of the CBOs is responsible for the upkeep of the register.

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ANNEX 15. Grantee Response to Final Evaluation Findings The EIP is a good example of how individual PVOs with different objectives and expertise can work together towards a common goal. Plan Cameroon and HKI built the capacity of the community members and created a demand for services that were provided by ACMS under the supervision of the MOH, resulting in numerous achievements including: y Developing and then training 33,454 CBO members on key C-IMCI behaviors among pregnant women and mothers of children under age 5 and eleven. y Supported the scale up of IMCI by training national IMCI trainers who then trained 260 health care providers in the EIP project area and 50 providers in other provinces. One hundred thirty three (133) health care facilities out of 175 in three provinces are now practicing IMCI. In addition, IMCI training will now be provided during the pre-service training of all health care providers in Cameroon. y Access to treatment has been increased through the CCM of malaria and pneumonia. The projects operations research on the CCM of pneumonia conducted in partnership with the MoH demonstrated the effectiveness of the approach and provides evidence for the adoption of the protocol nationally. y Supported the establishment of the National Nutrition Working Group who has developed a national nutrition policy and program plan to guide Cameroons efforts in nutrition initiatives. The working group developed a detailed protocol for the administration of Vitamin A, reviewed nutritional IEC materials currently under development, and six national trainers of trainers for ENA have been trained, and who have trained 64 additional trainers at the regional level. y Monthly growth monitoring is now being consistently done by CBOs, who are also continuing to counsel mothers on maternal and child nutrition. y Expanded the capacity of the MOH to implement PD/Hearth training by conducting ToTs on PD/Hearth for Health facility staff in the project area, reaching 584 malnourished children at the community-level and built local capacity to continue to rehabilitate malnourished children at home through promising indigenous practices. y As a result of the successful project OR study on zinc conducted, the MoH approved its inclusion on the Essential Drug List for the management of diarrhea. Ultimately, EIPs success has led to Cameroon attaining further funding from the Global Fund (Round 9) for its fight against malaria. ACT kits will now be consistently available at the community level. The EIP has also set the pace of the community implementation process and has provided a clear example on how the health status of a population could be monitored by members of the community at the community level. While acknowledging the challenges of the field, the EIP has shown that the community can adequately implement health projects and serve as effective vehicles for the promotion of health services and behaviors.

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