Save the Children/US : Malawi field office, child survival V -- final evaluation report, August 1989 to August 1993

Final evaluation, prepared by the grantee, Save the Children Federation (SCF), covers the period 8/89-8/93. Utilizing an impressive network of volunteer village health promoters (VHPs), village health committees, and village health supervisors, the project has increased knowledge and practice of its child survival interventions: control of diarrheal diseases, immunizations, growth monitoring and nutrition education, treatment of malaria and acute respiratory infections, antenatal care, child spacing, and HIV/AIDS prevention. (There are still shortcomings in immunization coverage, nutritional status of children, and malaria treatment, however.) A total of 141 drug revolving funds (DRFs) were established in Mbalachanda, and 136 of these are still operating; the communities have assumed ownership of the DRFs, and do not see them as only the VHPs' responsibility. Mkhota communities have also expressed a desire to have DRFs. Unfortunately, the supply of drugs in villages has not been continuous: 45% of VHPs interviewed did not have oral rehydration salts, and even in Mbalachanda (where DRFs are operational) only 66% had chloroquine, 47% aspirin, and fewer than 30% had bactrim, panadol, fansidar, or eye ointment. The shortages may be due to the fact that resupply requires collecting a large amount of money for bulk purchasing from Central Medical Stores. The small buffer stock available in the Mbalachanda project office is not sufficient to ensure continuous drug supplies. SCF has developed supportive relationships with the project communities, a fact which is reflected in the very low attrition rates for VHPs, many of whom have been working for almost 7 years. SCF provided soap as an incentive to the VHPs, which the village health committees state they will not be able to continue (although many of the committees will offer other incentives, such as income-generating activities). However, most VHPs are willing to work, even without the soap incentive. Less positively, some VHPs have had difficulties maintaining community health reporting forms. Sustainability was not given enough attention at the beginning of the project. Prospects are strong at the village level, but seem less certain at the supervisory, health center, and area levels. The MOH was not adequately involved in the design, planning, and the assigning of responsibility for activities; MOH staff feel that information sharing has not been sufficient. The following lessons were learned. (1) Women have been effective community health supervisors and health surveillance assistants. (2) Establishing village-level responsibility for incentives from the beginning of the project is wise since donor-provided incentives, such as soap, may be difficult for villages to sustain. (3) Training of health personnel requires more than single sessions; other methods include refresher training, informal training during monthly meetings, use of skill assessments, and regular supervision. (4) Community-based health projects require intensive sustained levels of effort and work with villages, more than the 3 years allotted for this project. (5) More care should be taken in choosing sites for projects; Mkhota falls under two different Districts and is bisected by a river which making transportation difficult and expensive.