CARE-Mozambique : final evaluation -- child survival XII : improving maternal and child health in rural communities of Nampula Province : September 30, 1996 to September 30, 2000 -- FAO-A-00-96-90040-00

The project employed a two-pronged strategy based on qualitative and quantitative research: (1) improving service delivery within the formal health care system by training health center and rural health post staff, as well as non-formal personnel -- community health workers (CHWs) and traditional birth attendants (TBAs); and (2) empowering communities and households to assess and attend to their own health status. Achievements were numerous. The project: (1) trained 91 TBAs and equipped them with birthing kits; (2) trained 67 Ministry of Health (MOH) staff and 46 CHWs in sequential management of childhood illnesses; (3) provided refresher training and equipment to 57 CHWs; (4) established a supervision system to monitor technical competencies of health facility personnel as well as of CHWs and TBAs; (5) provided structural and material support to rehabilitate the health centers and posts as well as basic obstetric equipment; (6) trained 51 community councils (637 individuals) to deliver key health messages employing a comprehensive information, education, and communication (IEC) strategy; (7) established a community referral system to identify early danger signs of childhood illness and pregnancy; (8) promoted and sold mosquito nets; (9) developed an emergency transport system, including SOS alert flags, bicycle ambulances, and plans for medical emergencies; and (10) organized two mobile theater groups to transmit messages. An 8/00 knowledge, practice, and coverage (KPC) survey showed that the project achieved positive behavior changes in all four intervention areas: case management of diarrhea, malaria, and acute respiratory infections, and maternal health. In the latter area, increases were seen in the number of mothers who sought prenatal care, possessed a maternal health card, and received two tetanus shots, as well as in the percentage of pregnant women receiving iron supplements and the number of births attended by a TBA or nurse-midwife. In addition, more pregnant women in project communities reported having a birth plan and having purchased a new razor blade for severing the umbilical cord. The radio projects and education by council members mobilized villagers to improve their access to transport for health-related emergencies. Even people from non-project communities benefitted from the radio projects sponsored by the project. The project also motivated health personnel to gain more knowledge and apply that knowledge in their work. Twenty- two health posts that received equipment and materials enhanced their capacity to serve their clientele. In sum, the project made major strides toward meeting its objectives, despite a lag in community-level achievement during the first 2 years. An opportunity to continue the project's accelerated efforts could bring greater benefits to project communities. A variety of factors, related to health infrastructure, the socioeconomic and political environment in Mozambique, and the level of MOH cooperation and difficulties at the project management level, influenced the attainment of project objectives. Given more time, the project could have overcome more of these challenges. Sustainability of behavior change improvements depends largely on the continued application of knowledge and skills acquired by the health personnel and community members. The cooperation of the MOH could greatly enhance efforts to sustain the project's benefits by providing reinforcement. The report details numerous lessons learned regarding achievement of objectives, community mobilization, communication for behavior change, capacity building of partners, and management. These lessons, especially those in the area of management, serve as recommendations to USAID. Additionally, USAID should not underestimate the importance of building a solid foundation for cooperation with the host government before projects are designed. Efforts to convince the host government of the project's value only at the implementation stage are often unsuccessful.