Plan Malawi Maternal and Child Health Project Mid-Term Review

Background

The health service delivery system at all levels in Malawi is still far from reaching its 11.3 million people. Currently 65% have no access to such essential services. This situation is worsened by the fact that the Ministry of health, who is the main provider of these services, does not have enough personnel and drugs to meet the needs of the community. Untrained caregivers under unhygienic conditions treat 70% of the community and especially children. Referral of serious conditions are usually done very late or not done at all because of lack of transport and other communication facilities.

In practical terms, over the last two years (From August 2003 to August 2005) Plan- Malawi maternal and child health program has worked with its partners, including communities, children, other Plan-Malawi projects domains, government, donors and other health related international organizations to achieve results in the following three key strategic areas: -
? Under-five issues that include high child mortality rate due to malaria, acute respiratory infection (ARI) diarrhoea, poor immunization coverage, malnutrition and HIV/AIDS.
? Maternal health issues that include high mortality and morbidity rates due to pregnant related complications such as anaemia, infections, emergency obstetric complications and poor antenatal and postnatal care.
? School and out of school children issues that include communicable diseases, early and unwanted pregnancies, child abuse, HIV/AIDS, orphan hood, and malnutrition.

Purpose/objective

The aim of the evaluation exercise was to determine the effectiveness of strategies used in implementing the project, timeliness of the project, progress made against set objectives and outputs delivered against outputs planned in-order to provide recommendations that will be fed into the last two years of the project.

Objectives:
1. Assess the effectiveness of Community Integrated Management of Childhood Illness in Plan Malawi programme units in terms of: -
? Incidence and types of malnutrition amongst under-five children
? Immunization coverage
? Management of diarrhoea by mothers using Oral Rehydration Therapy.
? Insecticide Treated Nets use by families.
? How accessible Community pharmacies are to families through Primary Health Care.
2. Assess the effectiveness of Safe Motherhood In Plan Malawi programme units in terms of: -
? Family planning services utilization by families.
? Antenatal care services utilization by mothers.
? Support provided to Emergency obstetric care by communities and health facilities.
? Refresher courses provided to Traditional Birth Attendance (T.B.A.).
? Community Based Distributor Agents (C.B.D.A.) trained and number of Community Based Distributor Agents undergone refresher courses.
? Postnatal care services utilization by mothers at Community and health facility level.
? Centers providing Prevention of Mother to Child Transmission (P.M.T.C.T.) of Human Immunodefiency Virus services.
? Support to men's participation in Sexual Reproductive Health.
? Centres providing adolescent Sexual Reproductive Health services.
3. Assess the effectiveness of School Health Promotion activities in Plan Malawi programme units in terms of: -
? Interventions put in place to avoid the spread of Human Immunodefiency Virus and Acquired Immunodefiency Disease amongst out of school youths.
? Capacity building of pupils and parents in dealing with sexual and reproductive health issues.
? Implementation of Participatory hygiene and sanitation transformation activities.
? Support given to schools e.g. first aid kits, IEC materials etc
? Exchange visits among the communities.
? Child to child peer education
? School competition

Methodology

Data collection was conducted in all three Plan program units of Mzuzu, Lilongwe and Kasungu from 29th August to 2nd September 2005. Six communities and a village were sampled in all these three programme units. Respondents included mothers with under- five children, youth in and out of school, members of community based organizations and institutions, village health committees and the community at large. Data was collected using the following techniques and tools:
? Separate focus group discussions using small-scale flexible interview guides were conducted with adolescents and community members to ensure participation in the evaluation exercise.
? Observations were done at the health facilities in Mzuzu and Lilongwe program units and under-five and maternal cards were checked.
? Anecdotal data at health facilities, schools and communities were captured using data entry forms.
? Interviews were conducted with mothers/care takers, village health committees, health workers, community leaders and adolescents using interview schedules.
? Literature review was done by reading the Mother and Child proposal, global strategic direction of the health domain (Plan Malawi) and Plan principles, monitoring reports.

Key findings

Community integrated management of childhood illness is the strategy that has come out very clearly as the most effective strategy at this stage of implementation e.g.
? Immunization coverage is at 72% against the set target of 80%
? The number of mothers who are able to manage diarrhoea at home using ORT has increased to 81% well above the set target of 65%.
? The incidence of malnutrition is at 06% against a set target of less than 10%%.

However the usage of insecticide treated nets, which is at 49% against 60% and accessibility of community pharmacies through PHC, which is at 19% against 80% and the percentage of new babies with normal weight, which was not assessed because of poor record keeping within the facilities posses a lot of challenges. These will require more emphasis in the next two years. Mzuzu PU is leading in performance followed by Lilongwe then Kasungu.

Safe motherhood is the second strategy that has shown effectiveness in terms of e.g.
? The rate of utilization of family planning services which has gone up to 53% against a set target of 60%.

School health promotion has also shown some achievements although there were no set targets and these are in terms of e.g.
? Support to child-to-child peer education activities, which is at 86.2%, school competitions that is at 89.2%, the giving of prizes, which is at 73.7%, and exchange visits that were assessed to be at 67.1%.
Lilongwe PU is leading in performance followed by Mzuzu PU.

The strategies that have been identified, as being behind are safe mother hood and promotion of school health as especially in the following areas:
? Support to emergency obstetric care
? TBA and CBDA training
? Utilization of postnatal care at health facility level
? Provision of PMTCT services in the health facilities
? HIV and AIDS and STI intervention for out of school youth
? Capacity building in sexual and reproductive health issues for parents and teachers.

Recommendations

It is therefore recommended that safe mother hood and promotion of school health strategies will require more emphasis. The issues raised above complement each other; failure in one will lead to failure in other areas even those that have been successfully implemented at this stage of the project.

To effectively use these strategies and achieve the set targets the strategies will require a proper strategic planning with clearly defined planned activities and approaches and persons responsible to carry out those activities at all levels.

In the Mother and Child health proposal, there is a proposal by Plan to contract Community Health nurses and Homecraft workers who would work with mothers in the communities.

For the successful implementation and supervision of the project at community level, it is recommended that these workers should be contracted. In addition to these, each community should have one HSA contracted. These workers will supplement each others efforts in trying to reduce malnutrition in the children and other family key practices in community IMCI which are moving at a very slow pace in achieving the project objectives.