But We Will Always be Here! Assuring Sustainable Benefits After Food Aid Programs_Beatrice Rogers_4.25.13
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But We Will Always be Here! Assuring Sustainable Benefits After Food Aid Programs_Beatrice Rogers_4.25.13
- 1. Beatrice Rogers and JenniferCoates with: Johanna Andrews, Alexander Blau, Ameya Bondre, Jamie Fierstein, Kathryn Houk, Tina Galante, Carisa Klemeyer, Elizabeth Kegode, Leslie Sanchez “BUT WE WILL ALWAYS BE HERE!” ASSURING SUSTAINABLE BENEFITS AFTER FOOD AID PROGRAMS
- 3. Study Rationale 3 Title II programs closing in non-priority countries Little systematic knowledge of whether program impacts are maintained and how to maintain them Effectiveness of Title II programs depends on both short-term impact and long-term sustainability
- 4. Study Objectives 4 1. Determine the extent to which activities, outcomes, and impacts of Title II programs were sustained. 2. Identify program characteristics that make it possible to sustain program activities and effects after the program shuts down. 3. Assess how the process of “exiting” affects sustainability. 4. Provide guidance to future programs on how to exit while ensuring sustainability.
- 5. Key Concepts 5 Sustainability Sustainability of impacts among program participants Diffusion of impacts to new populations Sustainability/ expansion of activities Exit From specific activities
- 6. Key Concepts: Exit Strategy/ Sustainability Plan6 Explicit plan for transition from program support to exit Often called “sustainability plan” in agency documents Specifies approach to exit: phase over (to whom), phase out (of resources) Should include timeline and allocation of responsibility for ensuring progress
- 7. Study Methods Overview 7 1. Qualitative picture of exit strategy implementation around time of agency exit 2. Qualitative inquiry one year after exit: to explore the success of exit strategy in leading to sustainable service provision (where applicable) and beneficiary uptake 3. Qualitative and quantitative data two years after exit to assess sustainability of impacts and outcomes 4. Compare quantitative follow-on data to agency endline survey data to determine sustainability and link to exit strategies
- 8. Analytic Strategy: Associating Exit Strategy with Sustainability of Impacts 8 Agency evaluations did not include control groups for attribution of impact Associations based on: Testing Implementation Pathways Sustainability of desired behaviors and impacts Continuation of service provision and utilization Implementation of an exit strategy Use of Secondary Data To serve as a point of comparison for survey results
- 9. Study Locations • Kenya • Bolivia • Honduras • India Selection Criteria • Programs achieved key impacts on food security and malnutrition • Programs implemented exit strategies • Close-out coincided with study time frame 9
- 10. Conceptualizing Sustainability and Exit10 Sustained Impact Sustained Behaviors and/or Service Utilization SUSTAINE D SERVICE DELIVERY SUSTAIN ED ACCESS SUSTAINE D DEMAND SUSTAINE D RESOURC ES SUSTAINE D CAPACITY SUSTAINED MOTIVATIO N SUSTAIN ED LINKAGE S Program Exit StrategiesProgram Exit Strategies EXTERNALFACTORS
- 11. 11 Critical combination of resources, motivation, and technical and managerial/administrative capacity Programs should be designed with exit in mind Gradual transition to independence with a period of independent operation before exit Importance of linkages - variable Impact at exit is not the same as sustained benefit later on Provision of free resources poses challenges for sustainability Depending on government linkages is risky, and depending on newly entering NGOs poses questions Different technical sectors face different challenges applying these principles Emerging Conclusions
- 13. 13 Title II Program Areas in Bolivia
- 14. 14 2002 20112008-9 Agencie s collect baseline quant data Tufts collects post- program qualitative data 2010 Tufts collects post-program qualitative and quantitative data follow-up quantitative survey replicates agencies’ endline surveys 2004 Agencies collect mid- termquant and qual data Agencies collect endline qual and quant data Study Methods Overview
- 15. 15 1. Maternal and Children Health and Nutrition (MCHN) 2. Water and Sanitation (WatSan) 3. Agriculture/Rural Income Generation (RIG) (after mid- term evaluation change in focus from production to commercialization) 4. Natural Resource Management (NRM) Program Technical Sectors
- 16. 16 Motivate CHWs to continue providing GMP, health promotion and home visits through social prestige and respect; credentialing. Link CHWs to decentralized health services to assure supervision, training, resources Teach mothers to substitute local foods for Title II provided foods MCHN Exit StrategyMCHN Exit Strategy
- 17. 17 Prevalence of stunting declined substantially during Title II and generally remained low after exit: ADRA, CARE, SC: No significant change in stunting since exit FH: Stunting continued to decline significantly after exit While overall stunting in the Departments declined during the period of Title II implementation, the Awardee declines were larger than regional declines and Awardees worked in areas with much higher MCHN Results: Stunting
- 18. 18 Departmental statistics (< 5y)Title II Communities (3–35 mo) Percentage of children stunted (HAZ) Stunting
- 19. 19 GMP participation and prenatal care visits remained high Success of linkages to national government programs: Zero Malnutrition (ZM): nutritional supplements for children under 2; Comprehensive Nutrition Units (UNIs) at healthcare centers Bono Juana Azurduy (BJA) conditional cash transfers for completing prenatal/postpartum care and growth monitoring visits Awardees with both a significant increase in GMP and the strongest malnutrition impacts, CARE and FH, continue to operate after exit GMP participation declined in SC communities, where fewer governmental and NGO resources may be available MCHN Results: Demand for Services Growth Monitoring and Prenatal Care
- 20. 20 Percentage of households taking child < 5y to GMP Growth Monitoring Participation
- 21. 21 Percentage of mothers reporting any prenatal care during last pregnancy Prenatal Care
- 22. 22 Percentage of mothers reporting prenatal care in first 5 months during last pregnancy Prenatal Care (< 5mo)
- 23. 23 Presence of a community health worker remains high Coherent governmental and NGO initiatives likely sustaining CHW presence: Intercultural Family and Community Health Program (SAFCI) Tarija’s “Health Guards” NGOs (Esperanza Bolivia, Plan International) adapt CHWs for their own program activities MCHN Results: Service Delivery
- 24. 24 FH collaborates with UNICEF in some former Title II communities in malnutrition prevention and GMP, with funding from Spain and USAID (Proyecto Integrado de Seguridad Alimentaria, PISA) In some cases local incentives may sustain CHWs Incorporation into water committee; profit-generating women’s groups MCHN Results: Service Delivery
- 25. 25 Percentage of communities reporting CHW presence Community Health Workers (2011)
- 26. 26 EBF increased during the program and has been sustained No cost; reinforced bygov’tprograms (BJA, ZM) All other practices have declined since exit Proper treatment of diarrhea, hygiene Importance of reinforcing behavior change messages: Behaviors not reinforced through home visits/trainings since exit Not prioritized since health system targets services like prenatal visits/GMP Results: MCHN Practices
- 27. 27 Title II Communities National Statistics Percentage of mothers reporting exclusive breastfeeding for child < 6mo Exclusive Breastfeeding
- 28. 28 Diarrhea Treatment (food and liquid) Percentage of mothers offering same/more food to child during diarrhea Percentage of mothers offering same/more liquids to child during diarrhea
- 29. 29 Percentage of mothers offering same/more food , liquid, orORT to child during last diarrhea episode Diarrhea Treatment (food, liquid, and ORT)
- 30. 30 Percentage of children 12–23 months of age receiving the third dose of DPT or pentavalente vaccine Note: No data available for ADRA in 2002 and 2004 Vaccinations
- 31. 31 Sustainability of impacts and CHW service use due to alignment with government health programs and presence of NGOs for continued support ANC and GMP remain high since exit Behavior change harder to sustain once food rations removed Rations had been provided children < 35 months and pregnant women participating in GMP/health talks Use of health services remains high since exit, but the lack of resources for community training and CHW supervision appears to limit the quality of information provided or the incentive to continue household-level behaviors requiring time/resources MCHN Summary
- 32. 32 Piped waterand latrines Awardee provided inputs for construction of piped water and latrines Elected water committees trained in system maintenance and repair, and in financial management and administration. Beneficiaries provided labor for construction, pay a connection fee and a monthly fee for water use; water cut off for lack of payment; User fees cover maintenance and repairs Some water committees were operating prior to Title II but received training WatSan Exit Strategy
- 33. 33 Vertical linkages to municipal government and horizontal linkages among water committees were part of sustainability plan, not implemented Waterquality testing Water committees would take over water quality testing once awardees left Hand washing and latrine use Hygiene behaviors promoted by community health workers in home visits would continue WatSan Exit Strategy
- 34. 34 Infrastructure continues to be available in Awardee areas Percentage of communities reporting piped water and latrine availability generally maintained Immediate tangible benefit; responds to priority need; successful water committee model; infrastructure coverage is government priority Sanitation and handwashing practices were not sustained after exit Water quality testing also not maintained Results: WatSan
- 35. 35 Percentage of households with piped water Title II Communities Departmental Statistics Piped Water
- 36. 36 Percentage of communities maintaining their own water system (2011) Water System Maintenance
- 37. 37 Percentage of households with latrine Latrine Access
- 38. 38 Percentage of population using hygienic sanitation facilities (with signs of use, Awardee criteria) Latrine Use
- 39. 39 Percentage of caregivers (responsible for food preparation) with proper handwashing practices (awardee criteria) Handwashing Practices
- 40. 40 Percentage of caregivers using soap/detergent Note: No data available for CARE Soap Use
- 41. 41 Percentage of households using any water treatment (boiling, chlorination, SODIS) Note: No data available for FH Water Treatment
- 42. 42 Water and sanitation infrastructure demonstrated greater sustainability than hygiene behaviors and water purification Infrastructure: Tangible benefit, self-financing user fees, community capacity to operate system and maintain accountable administration; not dependent on linkages Behaviors: No immediate, tangible benefit, no financial incentives to motivate implementation, no national program focused on such behaviors, since national priorities are more concerned with visible infrastructure coverage Water quality: no independent operation before exit WatSan Summary
- 44. 44 Rural Income Generation (RIG) Exit Strategy Model farmers were given free agricultural inputs and training in return for training other farmers Model farmers would continue to serve as technical resources Focus on improved production and diversification shifted to commercialization after MTE Farmers associations formed, trained in production and in management, contracting Profits from increased sale would motivate sustained use of practices taught in the program, and profits would cover purchase of inputs
- 45. 45 Results Rural Income Generation (RIG) Agricultural income of farmers increased throughout the program, but fell substantially at follow-up, though remaining substantially higher than baseline Inputs provided free during program now must be purchased Farmers who are members of producer associations (PA) have maintained substantially higher incomes than those who received training but are not PA members National GDP per capita continues to rise according to World Bank indicators
- 46. 46 Mean Annual Income from Agricultural Sales by Farmers Trained in the Program (adjusted for inflation, 2011=100) Agricultural Income
- 47. 47 Mean Annual Agricultural Income: Producer Association Members vs. Non-Members (2011)
- 48. 48 Percentage of trained farmers belonging to a producer association Note: No endline data available for ADRA and FH CARE participation data are only for farmers in promoted value chains Producer Association Membership
- 49. 49 Percentage of trained farmers adopting improved agricultural practices (Awardee criteria) Improved Agricultural Practices
- 50. 50 Percentage of farmers in producer associations is declining Members of producer associations have substantially higher incomes than non- members Qualitative evidence indicates that farmers may drop out of associations because they are unable to meet quality standards More successful farmers may be those able to afford inputs through the profits from marketing Commercialization model is successful for those who can take advantage of it RIG Results Summary
- 51. 51 Use of inputs and promoted practices declining Inputs provided free during life of program now must be purchased; farmers may have become accustomed to receiving these inputs without charge Practices sustained by trained farmers are those returning noticeable benefit and low cost (organic fertilizer, crop rotation) Proportion of farmers adopting improved practices similar among trained and un-trained farmers Individual producers likely copying improved production methods RIG Results Summary
- 52. 52 Sales through an association more likely where associations continue to receive support from external sources (NGOs, foundations, government) Government partners have high rates of turnover, changing priorities, stretched budgets, and shortages of technical staff; partnerships with buyers are more reliable Sustained operation of PAs is more likely when responsibility of negotiating contracts is transitioned gradually, with a period of independent operation RIG Results Summary
- 53. 53 Practices have declined significantly since exit Food for work and free inputs no longer available Motivation is low if tangible benefit is not perceived Continued practices are those that produce tangible benefit and do not require purchased inputs Municipal Natural Resource units are underfunded and understaffed Some activities produced lasting change during the program, but were not continued (forestation, terracing)- phase out Results: Natural Resource Management
- 54. 54 Trained Farmers Adopting at Least Three NRM Practices
- 55. 55 NRM activities largely not sustained after exit Technical capacity was strong; resources and motivation lacking Municipal support was weak or lacking Withdrawal of food and free inputs jeopardized sustainability of activities NRM Results Summary
- 56. Conclusions 56
- 57. Conclusions 57 Impact at exit does not consistently predict sustained impact two years later. There are specific ways to increase the likelihood of sustainability. Provision of free resources poses risks to sustainability.
- 58. Impact Assessment at Exit Can Be Misleading58 Impact assessment at exit does not consistently predict impact two years later. Many activities, practices, and impacts across sectors declined over the two years after exit. These declines are related to inadequate design and implementation of sustainability strategies and exit processes.
- 59. Sustaining service provision and beneficiary utilization of services and practices depends on three critical factors: 1. Resources 2. Technical and Management Capacity 3. Motivation There are often synergies among these three elements. Best practice models have emerged for each – and they are often sector-specific. The relevance of linkages is sector-specific. Specific Ways to Increase the Likelihood of Sustainability59
- 60. Provision of Free Resources Poses Risks to Sustainability60 Withdrawal of food rations or any other free input (as incentive) jeopardizes sustainability without consideration of substitute incentives. Provision of free food rations risks creating unsustainable expectations. Consideration of alternative incentive structure must be incorporated into program design. Beneficiaries receiving free inputs to support program activities may not be willing or able to replace them once project ends.
- 61. MCHN: Exit Strategy Models Lacked Sustained Sources of Resources, Capacity, and Motivation61 Motivation: Withdrawal of food was a disincentive for participation in and provision of growth monitoring. In Kenya, withdrawal of food resulted in reduced participation in growth monitoring. NGO return also reinstated the incentive. In Honduras, withdrawal of food reduced demand participation in growth monitoring, while in Bolivia, the government implemented a cash incentive for growth monitoring and promotion. Overall community health worker (CHW) service provision declined in Kenya, Bolivia, and Honduras with decline in material incentives and
- 62. MCHN: At least four types of resources must be considered in order to sustain CHW service delivery62 1. Resources that helped CHWs do their job, such as weighing scales, report forms, and bicycles, as well as training and supervision from the health sector 2. Resources that they offered the community as an incentive to participate in activities 3. Benefits accrued to the CHWs that incentivized their service, such as access to goats distributed to women’s goat groups 4. CHW time and its converse, the opportunity cost of time spent on CHW activities rather than on other productive labor • No fee for service models were observed in the health sector.
- 63. MCHN: Success of linking to government depended on government capacity and resources 63 Bolivia: Some CHWs continued linkages to health system; public health system provided services. In Honduras, linkages with health system worked until government resources ran out. In Kenya, government did not/could not take the responsibility for supervision, training, or provision of resources resulting in declines in CHW service quality, motivation, and capacity when they were not being reinforced.
- 64. Water system exit strategy demonstrated that motivation, capacity, and resources are all critical to sustainability64 Beneficiaries are motivated to pay for water services that are reliable, convenient, and abundant. Technical and management capacity of water committees permits system to continue operation post-project. Fees paid by consumers provide ensured resources for system maintenance.
- 65. WatSan: Linkages to Government Not Always Needed 65 Linkages were actively avoided by most water committees; independence from government entities that could be unreliable sources of support
- 66. Sustainability of Water Quality Provides a Counterexample…. 66 Motivation for water quality testing is low because benefits are not visible. Therefore willingness to pay was low. Capacity-building activities during the DAPs did not emphasize water quality. Water quality testing was not operating independently at exit. No linkages to support water quality testing were in place at exit.
- 67. Agriculture Sector Exit Strategies Yielded a Mixed Sustainability Story67 Model farmers (extension farmers) lacked motivation, resources, and reinforcement of capacity to continue providing technical assistance after incentives were withdrawn. Service provision largely declined. Producer associations participation rates were variably low/declined. PAs provided concrete benefits in some countries but not all. Commercialization activities produced sustainable
- 68. Improved agricultural practices generally declined when requiring resources provided during the DAP68 Free inputs were provided during program life and Use of these inputs declined when they needed to be purchased after the program
- 69. Engagement in NRM activities and practices declined dramatically after program exit69 Food as pay (FFW) was withdrawn. Resources in the form of inputs (seedlings, etc.) was no longer provided free of charge. Motivation was lacking unless costs were low and direct benefits to farmers were high. Linkages to local government environmental groups were ineffective as those groups lack resources. Positive changes (reforestation, terracing, etc.) were maintained, though activities to expand these changes were not.
- 70. COSAMO in Kenya Was a Model of Sustainability 70 Sustained capacity, motivation, and resources. Sustained beneficiary utilization and impact. Self-financing: No outside seed money and no other external resources needed. Modular training program built solid technical and managerial capacity. There was a gradual withdrawal of NGO after a period of COSAMO group independent operation Linkages were not necessary – could pay for technical assistance of trained resource persons.
- 72. Program Design 72 Sustainability should be built into the design of programs from the beginning. Plans must include: decision about approach (phase out, phase over); explicit benchmarks for progress; timeline; clear allocation of responsibility, graduation criteria Each element — capacity, motivation, and resources — must be considered, with redundancies and contingencies for external shocks built into the plan.
- 73. Project Cycles Should Be Longer and Incorporate Sustainability Benchmarks 73
- 74. Phased Program Implementation74 Sustainable design and initial service delivery, demand creation, and partnership formation Strengthening capacity, developing ensured resources, ensuring appropriate linkages, promoting independent operation Independent operation of program activities and gradual agency withdrawal
- 75. Program Monitoring and Evaluation75 Emphasis on assessment of impacts (e.g., reduction in stunting) can undermine focus on sustainability. Progress toward sustained capacity, motivation, and resources should be measured as process indicators during monitoring. Evaluations should be done at each phase; criteria for assessment will differ by the
- 76. Program Withdrawal (Exit) 76 Phase-over of responsibility must be gradual. Groups should be operating independently (with agency backstopping) before full withdrawal. Community organizations and individuals should be aware of their post-exit roles and responsibilities from the outset. Philo so phy of sustainability should be embedded throughout implementation to withdrawal. Be aware that communities may not commit to independence, in the expectation of new sources of external support.
- 77. This study is made possible by the generous support of the American people through the support of the Office of Health, Infectious Diseases, and Nutrition, Bureau for Global Health, and the Office of Food for Peace, Bureau for Democracy, Conflict and Humanitarian Assistance, U.S. Agency for International Development (USAID), under terms of Cooperative Agreements GHN-A-00-08-00001-00, AID-OAA- A-11-00014, and AID-OAA-A-12-00005 through the Food and Nutrition Technical Assistance III Project (FANTA), managed by FHI 360. The contents are the responsibility of Tufts University and do not necessarily reflect the views of USAID or the United States Government. 77 Acknowledgments and Disclaimer
- 78. THANK YOU!
Notas do Editor
- Discuss and give examples of potential tradeoffs between impact and sustainability
- Provide guidance to Food for Peace and to Cooperating Sponsors General approaches to planning for program exit Key elements of an exit strategy, including development and implementation How to build sustainability into program design from the beginning This study is a study of ‘delivery science’. GOAL IS TO PROVIDE USABLE GUIDANCE TO PROGRAM IMPLEMENTERS
- Sustainability of QUESTION: IS IT SUSTAINABILITY IF THE COMMUNITY SIMPLY TRANSFERS DEPENDENCE TO A NEW NGO?
- Exit strategy is the same as a sustainability plan. Should be developed early; ideally program design should include plans for exit. We don’t know whether it is important to have an explicit exit strategy with benchmarks and timelines etc. Includes timeline, benchmarks for progress, mechanisms for monitoring and allocation of responsibility for ensuring progress Phase out: program activities stop; benefits/effects are presumed to be lasting without further input Phase over: responsibility for program activities is transferred to another entity Community based organization Government (local to national) Key individuals Another NGO or donor Market based agreements : Phasing to private sector market incentives.
- Also drew on baseline reports to present trends in indicators from start of project, through to endline, and on to the follow-up. We did not use baseline data, only figures from the reports, which created some limitations as we had to use only baseline indicators exactly as defined, and this wasn’t always clear. More flexibility in the endline to follow-on comparisons, since we had data sets for those two time points.
- Point out that agency evaluations didn’t use a control group – mention difficulties of attribution (and what we would be “attributing” in such a study, even if there were a control group.
- Don’t always need sustained participation in activities to get sustained behavior change and you don’t always need sustained behavior change to get sustained impact. Consult slide that was deleted for details.
- Hereafter, Baseline = Awardees collect baseline data (2002) Midterm = primarily monitoring data (2004) Endline = awardee ’s final evaluation survey (2009) Follow-up = our two year later survey (2011)
- MCHN strategies focused on growth monitoring, initially for recuperation of malnourished children and shifting toward prevention after the mid-term evaluation (MTE). Agencies trained community health workers, or teams of community health leaders in the case of STC, to conduct these and related health and hygiene trainings in coordination with municipal and health center partners. Water and sanitation strategies included construction of piped water system s to the household as well as latrine construction , along with technical and administrative training and the organization of community water committees to operate and maintain new constructions. RIG strategies targeted production practices with a focus on improved production of demand-driven products, market linkages, agricultural infrastructure, and the formation of producer associations for sharing information and for collective buying of inputs and marketing of products, both in their raw state and processed . While ADRA was noted for its market-driven orientation from the beginning of the DAP, all of the agencies shifted to a market-oriented value chain focus after the MTE. In addition, ADRA uniquely created Agricultural Service Centers (ASCs), or warehouses, in its four targeted municipalities where producers could consolidate and jointly sell their products more efficiently. The agencies also worked to initiate or strengthen related municipal offices and create partnerships with these offices and other NGOs working toward RIG objectives in their regions. NRM strategies focused on sustainable resource management including soil management, reforestation, and irrigation practices and infrastructure. As for other components, both community and municipal level actors were trained to promote and fund these activities
- ADRA ’s stunting rates for children 3-35 mo declined 19.5 percentage points during Title II, with no significant change in stunting since exit; this compares with a decline of 8.4 percentage points in the department of Chuquisaca where its program was implemented. CARE ’s stunting rates declined 19.9 percentage points during the program, with no significant change in stunting since exit; this compares with much smaller regional declines in its area of intervention of: --8.4 percentage points in Chuquisaca --5 percentage points in Potosi --7.3 percentage points in Tarija FH ’s stunting rates declined 14.9 percentage points, with a further significant decline of 6.8 percentage points since exit; this compares with regional declines in its area of intervention of: --5 percentage points in Potosi --4.3 percentage points in Cochabamba STC ’s stunting rates declined 9.2 percentage points during the program, compared with the La Paz department’s decline of 4.6 percentage points over the same period. While stunting appeared to increase slightly since exit, this increase is not significant.
- FH works with NGOs like UNICEF to provide technical and administrative support to the UNIs to align local health priorities with malnutrition prevention and GMP. FH, in its former Title I communities, is helping to promote a decentralization that will result in establishing UNI-coms, or community based UNIs whose goal is early identification of cases of malnutrition. These outposts will require participation of community based workers such as the CHWs trained by the Title II program. CARE has maintained a presence in Tarija over the past few years to support the steady development of national health programs in the field, which may be the reason for the reductions in stunting and underweight (not significant). STC: the constant political turnover in many STC Altiplano municipalities may have prevented a stable municipal leadership from creating partnerships with external organizations to consolidate programs like ZM in their region. Since many municipal governments depend on external NGOs to assume responsibility for Title II activities, even where they align with explicit national health objectives, sustainability varies among communities with the availability of external funding. STC is the only one that implemented only ONE DAP.
- ADRA: participation decreased by 4.1 percentage points from endline to follow-up (p<0.05) but remained high at 86% . The percentage of pregnant women in the target population with at least one prenatal visit in the past calendar year remained the same at 100% for both years, and the percentage of women with at least one prenatal visit before the fifth month of pregnancy was unchanged. The percentage of children under one year old that received the third dose of DPT or pentavalente vaccine did not change from endline to follow-up. Similarly, the DPT/pentavalente vaccines rates for children 12-23 months old remained high at 97.2% at follow-up. The values for all these services are substantially higher than the comparable figures at baseline, suggesting that improvements were maintained after exit. CARE: Participation significantly increased by 3.4 percentage points from endline to follow-up. The percentage of pregnant women in the target population with at least one prenatal visit in the past calendar year dropped slightly but significantly from almost 97% at endline to a still high level of 94% at follow-up. The percentage of women with at least one prenatal visit before the fifth month of pregnancy remained about the same in both years (90%). As was the case with ADRA, the proportion of women receiving any, and timely, prenatal care remained substantially higher at endline and follow-up than at baseline. The percentage of children under one year old that received the third dose of DPT or pentavalente vaccine significantly dropped from endline (61%) to follow-up (46%), but the DPT/pentavalente vaccines rates for children 12-23 months old remained high at 96%, despite a small but significant decrease of 3.1 percentage points. FH: Participation significantly increased by 6.6 percentage points from endline to follow-up (p<0.001); almost 100% of children attended growth monitoring two years after exit, compared with only 22% at baseline. The percentage of pregnant women in the target population with at least one prenatal visit in the past calendar year significantly increased from 84% to 91% (p<0.001). Similarly, the percentage of women with at least one prenatal visit before the fifth month of pregnancy increased from 68% to 75%. At baseline only 50% of women received prenatal care, and only 23% received it before the fifth month; this figure now stands at 75%, with 91% getting at least one prenatal visit in the previous year. DPT/pentavalente vaccines rates for children 12-23 months old significantly increased by 3.3 percentage points (p<0.05), and are now over 98%, compared with 15% at baseline. STC: Participation significantly decreased by 14.2 percentage points from endline to follow-up (p<0.001). Even though the participation rate of 79% is still higher than the 47% at baseline, it is a substantial decline. The percentage of pregnant women in the target population with at least one prenatal visit in the past calendar year remained about the same (84%), and much higher than baseline (56%). The percentage of women with at least one prenatal visit before the fifth month of pregnancy significantly increased from 47% to 59% (p<0.05), up from 31% at baseline. The DPT/pentavalente vaccines rates for children less than one year old and for children aged 12-23 months old remained the same, but the percent completing the DPT/pentavalente by 12-23 months (92%), and was substantially higher than the 41% at baseline.
- Due to BONO BJA
- (National) SAFCI:: encourages healthcare personnel to work alongside local community leaders and families for decentralized health interventions; CHWs become formal local health authorities (ALS) to collect data and prioritze activities (Tarija only) Guardianes de Salud: receive incentives like bicycles and first aid kits to coordinate with local health personnel to conduct GMP and promote prenatal care and vaccinations New organizations ’ shifting focus toward diseases such as Chagas and TB, along with the provision of new incentives like backpacks and flashlights, has in some cases attracted different people to fill these positions, creating some redundancy in the communities and discouraging previously trained CHWs from continuing their previous activities. Threats: tension between the desire to take advantage of local resources to decentralize basic health services and the medical profession ’s hesitancy to cede responsibility continues to limit the breadth and quality of work provided by CHWs who go without needed training and supervision. We observed many CHWs continue to coordinate with local health personnel to conduct GMP activities due to personal motivations (sense of community duty, hopes of professional advancement). However, the lack of supervision and refresher trainings has made it difficult to identify replacements for CHWs who retire or to sustain the quality of information and services provided.
- (National) SAFCI:: encourages healthcare personnel to work alongside local community leaders and families for decentralized health interventions; CHWs become formal local health authorities (ALS) to collect data and prioritze activities (Tarija only) Guardianes de Salud: receive incentives like bicycles and first aid kits to coordinate with local health personnel to conduct GMP and promote prenatal care and vaccinations New organizations ’ shifting focus toward diseases such as Chagas and TB, along with the provision of new incentives like backpacks and flashlights, has in some cases attracted different people to fill these positions, creating some redundancy in the communities and discouraging previously trained CHWs from continuing their previous activities. Threats: tension between the desire to take advantage of local resources to decentralize basic health services and the medical profession ’s hesitancy to cede responsibility continues to limit the breadth and quality of work provided by CHWs who go without needed training and supervision. We observed many CHWs continue to coordinate with local health personnel to conduct GMP activities due to personal motivations (sense of community duty, hopes of professional advancement). However, the lack of supervision and refresher trainings has made it difficult to identify replacements for CHWs who retire or to sustain the quality of information and services provided.
- ADRA: At follow-up, 61% of the ADRA communities sampled reported having a community health worker (CHW) CARE: At follow-up, according to the community survey, 75% of the CARE communities sampled reported having a community health worker (CHW) , compared to 100% at the time of exit. FH:At follow-up, 73% of the FH communities sampled reported having a community health worker (CHW). STC:Only 44% of sampled STC Title II communities reported having a community health worker two years after exit, compared with 61% for ADRA, 73% for FH, and 75% for CARE communities. While the other three agencies had previous experience implementing Title II programs, this last DAP was STC ’s first. STC narrowed its geographic area of intervention and program focus between the MTE and final exit, but this shorter period of operation may have limited their success in sustaining impact. Also, while CARE, ADRA, and FH still maintain some form of contact with former Title II communities conducting new projects since exit, STC no longer maintains a presence in any of its former Title II communities. Whether formal or informal, sustained contact provides a longer period of “exit” in which community actors have time to develop their skills while external support is only gradually withdrawn. STC’s lack of follow up for gradual alignment of MCHN activities with the health system may have limited their sustainability when compared with the other agencies.
- National EBF stats from DHS; while EBF rates also increasing nationally during time of program, agencies achieved much higher rates that have generally sustained high levels: ADRA: Percentage of infants less than 6 months exclusively breastfed during the last 24 hours slightly decreased from endline to follow-up, and this decrease approached significance at alpha=0.0551. EBF did increase substantially from baseline, however, and remains high at 80%. CARE: Percentage of infants less than 6 months exclusively breastfed during the last 24 hours remained nearly the same from endline to follow-up, and a good deal higher than at baseline. FH: Percentage of infants less than 6 months exclusively breastfed during the last 24 hours significantly increased from endline to follow-up (p<0.001), reaching 100%, from a baseline value of 67%. STC: Percentage of infants less than 6 months exclusively breastfed during the last 24 hours was unchanged from endline to follow-up, but increased from the baseline. At baseline, the percent EBF was 75%, and was almost 90% at follow-up.
- ADRA: The percentage of children less than 5 years old with diarrhea in the last two weeks who were treated with ORT or recommended fluids significantly decreased from endline to follow-up (88.6% in 2008 to 79.3% in 2011, p<0.05), but again, the use of ORT remained higher than at baseline. Proper treatment of diarrhea by maintaining or increasing solid food and liquids declined from baseline to follow-up. CARE: The percentage of children less than 5 years old with diarrhea in the last two weeks who were treated with ORT or recommended fluids remained about the same from endline to follow-up (95% in 2008 to 94% in 2011); both figures are substantially higher than the 60% who used ORT at baseline. However, the practice of maintaining or increasing solid food and fluid intake during diarrhea declined significantly. FH: Use of ORT to treat diarrhea declined between endline and follow-up but remained higher than at baseline. STC: there were significant declines in the use of all the practices related to treatment of diarrhea (use of ORT, maintaining solids and liquid intake during diarrhea) between end line and follow up, though not to near the levels that prevailed at baseline.
- One likely cause of the sustained levels is a favorable health system environment that continues to motivate the use of services related to prenatal care and vaccinations. Where appropriate treatment for diarrhea decreased, households may not regard treatment with increased foods and fluids as important especially considered their continued use of appropriate ORT and improved health service access. STC: The increased level of stunting among children 0-24 months, along with the low presence of CHWs and poor behavior utilization numbers may reflect the short STC presence in Title II communities, as it was the only agency to begin Title II during this final round of DAPs, and it no longer maintains any agency presence in its former Title II communities. In addition, as mentioned repeatedly, the behavior utilization outcomes appear difficult to sustain after exit in general, without continued motivation and refresher training. However, the sustained levels of service use may result from both the positive national health environment that continues to provide related services as well as the STC exit strategies that focused on gradually improving municipal and health system capacity to continue technical and financial support for Title II activities after agency exit.
- ADRA: Households would respond that they had ‘potable water’ if they had water in the home, even if they could not vouch for its microbiological quality. The percentage of households with piped water at follow-up was 92.3%, a small but significant decrease from the 99% reported at exit. CARE: The percentage of households reporting having piped water was 72.2% at follow-up, an increase from the 65.4% at endline FH: The percentage of households with potable water rose significantly from endline to follow-up (from 69% in 2008 to 84% in 2011, p<0.001). STC: We do not have data on household piped water systems, but the percentage of communities reporting having a potable water system was 86% at follow-up.
- While sustained, lower coverage than piped water: Latrines do not match the criteria for sustainability of piped water: even if beneficiaries value them, individual beneficiaries must pay for maintenance; there is no fee for service model to provide the resources. ADRA: The percentage of households with latrines decreased from almost 96% at endline to 89% at follow-up (p<0.01). CARE: The percentage of households with latrines hardly changed, from almost 34% at endline to 35% at follow-up, suggesting that households maintained the latrines they had, but no new ones were added. If flush toilets are added to the definition of latrines, then the number of households with such facilities increased between end line and follow up. FH: The percentage of household that had a latrine increased by 42 percentage points, to 80% at follow-up (p<0.001). This suggests that another agency or the government may have intervened to expand these services after Title II program exit. In our qualitative visits, we noted that communities, governments, and NGOs prioritize funding for increased infrastructure coverage, while not always including adequate funding or training for behavior change (hygiene, water treatment etc). UNICEF/PLAN. STC: The percentage of households with latrines significantly increased from almost 32% at endline to 38% at follow-up (p<0.01), still a relatively low number.
- ADRA: Latrine use (with signs of usage), decreased as well, with 29% using latrines at follow-up, compared to 75% at endline (p<0.001). This rate of use is comparable to the rate at baseline, before the intervention. Signs of usage were defined as: Respondent answers yes to question “Do you have a bathroom?”, and Respondent answers yes to question “Does the family use the bathroom?”, and Respondent answers yes to bathroom is completely clean or “does the bathroom have a waste bin”, and Interviewer confirms functionging water tank, the pipe to the toilet tank, the water connection to the tank and sink and the drain of the sink, and Interviewer confirmed signs of usage (soap/detergent, toilet papers, waste bin) Families reporting latrine use (whether or not the interviewer checked for signs of use) also significantly decreased, but the decline was not as extreme (dropped by 15 percentage points); 77% of households reported using their latrines at follow up. CARE: Latrine use (with signs of usage) even among those with latrines, decreased as well, with 85% at endline, compared to 70% at follow-up (p<0.001). FH: Latrine use (with signs of usage), decreased as well with 83% at endline, compared to 42% at follow-up (p<0.001), but the percentage of households reporting latrine use (without the interviewer observing the latrine to check) was maintained at 88.6%, not significantly below the 92.6% reported at endline. STC: Among those who had latrines, latrine use (with signs of usage), significantly increased by almost 6 percentage points (p<0.05) to 40%.
- ADRA: ADRA ’s indicator, “Percentage of caregivers responsible for food preparation with proper hand washing practices” dropped by 43 percentage points from 89.9% to 46.9% at follow-up (p<0.001). With the exception of handwashing before eating, percentages for nearly all handwashing behavior s included in the survey significantly decreased, with the largest drops occurring in the percent handwashing after changing diapers (60% to 15%, p<0.001) and before breastfeeding (43% to 10%, p<0.001). CARE: CARE ’s indicator, “Percentage of caregivers responsible for food preparation with proper hand washing practices” dropped by almost 20 percentage points, from 85% to 65% (p<0.001). Adequate handwashing practices were defined as washing twice a day or more. With the exception of handwashing in the mornings, which actually increased, percentages for nearly all handwashing behaviors included in the survey significantly decreased. The only practices still maintained by more than half the households were washing in the morning, before food preparation, and after using the bathroom. FH: Handwashing was defined as using at least 8 hygiene practices (5 different occasions and 5 different conditions (such as uses clean water, uses some sort of cleaning product, both hands, rub 3 times, clean drying system)). FH ’s indicator, “Percentage of caregivers responsible for food preparation with proper hand washing practices” dropped by almost 64 percentage points from 93% to 29% at follow-up (p<0.001). Percentages for all handwashing behaviors included in the survey significantly decreased, with the largest drops occurring in the percent handwashing before feeding the children (dropped 60 percentage points, p<0.001) and handwashing after cleaning the child’s feces (dropped 47 percentage points, p<0.001). The handwashing practices that were best maintained were washing before food preparation (88%) and before eating (81%). STC: STC ’s indicator, “Percentage of caregivers responsible for food preparation with proper hand washing practices”, defined as at least 3 times a day with soap/detergent, dropped by 53 percentage points from 89% to 36% at follow-up (p<0.001). With the exception of handwashing in the mornings, percentages for nearly every handwashing behavior included in the survey significantly decreased, with the largest drop occurring in the percent handwashing before feeding the children (dropped 36 percentage points, p<0.001) and after using the bathroom (dropped 32 percentage points, p<0.001). The practices that were best maintained were washing before eating and before food preparation.
- One hygiene behavior that continues to be implemented in Title II communities, though at decreasing levels since agency exit, is handwashing with soap or detergent. Women in Bolivia often wash their laundry in the handwashing sinks constructed outside the bathrooms, so they may be keeping detergent at the sink for both purposes. The continuation of home visits in some areas (either by CHWs, water committees, or healthcare personnel) may provide continued reinforcement for this practice since soap is more easily observed during a brief household visit than behaviors such as appropriate diarrheal treatment. ADRA: The percentage of caretakers using soap to wash hands also significantly declined (from 96% at endline to 87% at follow-up, p<0.01), but washing with soap was the best-maintained of all the practices, despite the fact that soap costs money, and the other practices do not. FH: The population using soap to wash their hands also significantly declined (p<0.001), but was still practiced by 87% at follow-up. STC: Although the percentage using soap/detergent when washing their hands significantly decreased, the use of soap/detergent remained high at 85%.
- The microbiological quality of the piped water was not a focus of most agencies ’ SPs, so responsibility for water quality testing was not gradually transitioned as was responsibility for delivering piped water. ADRA is the only agency that referred to the importance of transferring responsibility for continued water quality maintenance to an appropriate local actor. Most water committees have not assumed responsibility for water quality testing since the end of the Title II intervention, when the agencies funded and organized this service , largely without involving the water committees . The lack of independent experience in negotiating and prioritizing this activity without external assistance appears to be a factor in its lack of sustainability. Water purification significantly decreased at the household level since exit as well: across ADRA, CARE, and STC communities (FH did not include this topic in its survey), water purification among caregivers significantly decreased. Just as we did not observe any motivation on the part of water committees to maintain water quality analysis activities, so water/sanitation beneficiaries do not seem to prioritize purifying their drinking water. Municipal governments are not providing any further training or support for water quality testing or water purification activities, since they target their own limited funding toward improving water system coverage in their region above ensuring potability of existing water systems. ADRA: Water purification practices among mothers of children under 5 also significantly declined, as the percent of caretakers reporting they do not do anything to the water before use increased by 34.3 percentage points to 50% (p<0.001). The decline in water treatment may be attributable to the cost (in time and resources) of boiling, chlorination, and even solar disinfection. Treating piped water that appears clean may not be a high priority for famili. CARE: Water purification practices among mothers of children under 5 also significantly declined. The percentage of caretakers reporting they do not do anything to the water before use increased by almost 28 percentage points (p<0.001) to 58%. STC: Water purification practices among mothers of children under 5 significantly declined. The percent of caretakers reporting they drink directly from the water source increased by 33 percentage points (p<0.001). Even though the percentage of caretakers that boil the water before use significantly decreased from endline to follow-up, it is important to note that 44% of caretakers still continued to boil the water before use, and just over half used some form of water treatment.
- A Mesa Directiva for a potable water system in Bolivia…. Couldn’t resist putting this one in!!
- Background ADRA: While all of the agencies shifted to a more market-focused RIG program after the MTE, ADRA ’s program had implemented a market approach to production activities since the beginning of the DAP. CARE: For its sustainability plan, CARE opted to focus on three of its six value chains: cheese in Chuquisaca, dried peaches in Potosi, and textiles in Tarija. This targeted approach to exit allowed the agencies to focus technical and financial resources on those value chains they judged to be most likely to be sustainable after exit. STC ’s main sustainability strategy was to strengthen the prioritized value chains and build strategic alliances between producer associations and strategic partners, especially municipal institutions. STC also promoted the establishment of stable long term contracts with buyers, such as the contract between the milk producers and Pil Andino, a dairy company, as a way of ensuring the producers would have both an assured market and access to technical support after the exit of the agency. FH: FH ’s sustainability plan was unique in its graduation of communities where unfavorable conditions made sustainable value chains seem unlikely. At the same time, FH received funding from both USDA and the Interamerican Development Bank (IDB) to continue RIG activities in some of its, as well as CARE’s, former Title II communities. This added funding may contribute to a longer period of time during which associations can develop and practices can continue to be adopted and replicated.
- Background ADRA: While all of the agencies shifted to a more market-focused RIG program after the MTE, ADRA ’s program had implemented a market approach to production activities since the beginning of the DAP. CARE: For its sustainability plan, CARE opted to focus on three of its six value chains: cheese in Chuquisaca, dried peaches in Potosi, and textiles in Tarija. This targeted approach to exit allowed the agencies to focus technical and financial resources on those value chains they judged to be most likely to be sustainable after exit. STC ’s main sustainability strategy was to strengthen the prioritized value chains and build strategic alliances between producer associations and strategic partners, especially municipal institutions. STC also promoted the establishment of stable long term contracts with buyers, such as the contract between the milk producers and Pil Andino, a dairy company, as a way of ensuring the producers would have both an assured market and access to technical support after the exit of the agency. FH: FH ’s sustainability plan was unique in its graduation of communities where unfavorable conditions made sustainable value chains seem unlikely. At the same time, FH received funding from both USDA and the Interamerican Development Bank (IDB) to continue RIG activities in some of its, as well as CARE’s, former Title II communities. This added funding may contribute to a longer period of time during which associations can develop and practices can continue to be adopted and replicated.
- ADRA: The mean income from this production declined from $3,400 at endline to $2,207 at follow-up (p<0.001) in constant 2011 dollars. Although there was a significant decline in the agriculture/livestock income of ADRA project participants, this mean income of $2,207 remains much higher than the starting agricultural/livestock income of $1,610 in 2002. The mean agricultural income of all producers (participants and non-participants) in 2011 was $2,094, still much higher than at baseline. The average agricultural income of all farmers in the communities served by Title II (not only program participants) was lower than that of program participants, but still much higher than at baseline, suggesting that the benefits of the RIG activities extended to those not directly involved in the program. In 2011, 79.8% (n=812) of the farmers had been program participants. CARE: The mean income from this production declined from $2,998 at endline to $1,701 at follow-up (p<0.001) in constant 2011 dollars. Although there was a significant decline in the agriculture/livestock income of CARE participants, the mean follow-up agriculture/livestock income of $1,701 remains higher than the starting agricultural/livestock income of $1,258 in 2002. FH: Of the 659 farmers surveyed in 2011, 467 (70.9%) farmers had participated in some of the Title II program trainings for farmers. The mean agriculture/livestock income for program participants declined from $2,871 at endline to $1,872 at follow-up (p<0.05) (constant 2011 dollars). Although there was a significant decline in the agriculture/livestock income of FH participants, this mean income of $1,872 remains much higher than the starting agricultural/livestock income of $717 in 2002 and more than the $1,305 at the midpoint. Furthermore, the figure in 2008 appears to have been affected by a skewed distribution; the change in the median farm income between 2008 and 2011, while still a decline, is considerably smaller. In 2011, total n = 659; 467 had been Title II program participants. STC: In 2011, 68.2% (n = 438) of the farmers interviewed had been program participants . Among participant farmers, income from agriculture/livestock production declined from $2,684 at endline to $2,104 at follow-up (p<0.001) (constant 2011 dollars). Although there was a significant decline in the agriculture/livestock income of STC participants, this mean income of $2,104 remains much higher than the starting agricultural/livestock income of $922 in 2002 and $1,050 at the midpoint. Among all farmers (participants and non-participants), agriculture income at follow-up was $1,976, compared with the baseline value of $922, demonstrating that non-participants benefited from the dissemination of improved practices and, possibly, marketing opportunities created by value chain development.
- all farmers PA farmers 2008 2011 ADRA 2998 to 3634 CARE 3400 to 3508 FH 2871 to 3232 STC 2684 to 3866 This is ag income only. IF PA members ’higher activity generates employment in other sectors we wouldn’t know.
- ADRA: 29% all of farmers were members of a producer association at follow up, and 15% of those who were not members had previously been members. CARE: The proportion of farmers participating in a farmers association dropped by close to half between endline and follow-up. FH: The percentage of farmers currently in a farmers association remained about the same between endline and follow-up (14.6% and 13.5% respectively). STC: At endline, 23% of participant farmers reported being in a farmers association, while in 2011 20% of participant farmers reported being in a farmers association. Of those farmers who were not in a farmers association in 2011, 5% had been in one before.
- ADRA: Adopting improved practices was defined as: participating farmers having adopted at least 73% of the practices, meaning 11 or more of the 15 practices promoted during the project. Using the definition applied by the agency, the proportion of participating farmers who adopted improved agricultural technologies and practices decreased by almost 43 percentage points from endline to follow-up (p<0.001). Individual practices, however, were sustained in some cases. At endline , about 47% of participants were using fourteen of fifteen practices, and at follow-up the number of practices being used by almost half of participants remained at about 9-11 practices, suggesting that farmers were in fact choosing to use those practices they found cost-effective. FH: In 2011, 21.7% (n=143) of the farmers surveyed had participated in the Rural Income Generation component of the program. The proportion of participating farmers who met this criterion for using improved agricultural technologies and practices did not change between 2008 and 2011 (the small increase was not significant); the proportion using these practices increased substantially from the first measurement at mid-term, 51% compared with 76.2% at follow-up. STC: The proportion of participant farmers who adopted improved agricultural technologies and practices decreased by almost 17 percentage points from endline to follow-up (65% to 48%, p<0.001). With the exception of improved potato practices, the use of each crop ’s improved agricultural practices promoted by the STC project decreased from endline to follow-up.
- While participation in producer associations has declined for all agencies, ADRA and CARE have the highest percentage of producers selling in associations. ADRA was the only agency to focus on value chains from the beginning of its DAP, while the others shifted from production to value-chain and market oriented focus after the MTE. ADRA also targeted a fewer number of associations that were organized around regional Agricultural Service Centers (ASC) instead of around a single product, which may motivate continued association participation for access to facilities and coordinated storage and sales for several different crops. CARE showed the highest participation in associations (at 41%). According to the Final Evaluation, while all of the agencies decided to form strategic partnerships with other organizations in the short time remaining after shifting toward a market-orientation after the MTE, CARE opted to provide a limited technical support for value chains already in a nascent stage of development , using their existing resources . Building upon existing value chains allowed a longer period of time for associations to develop skills while receiving external support and may have contributed to sustained high rates of membership in association s . For farmers to commercialize, credit is often a key resource. In the case of the producer associations, a ccess to credit was rarely sustained after the initial contacts were established between producer associations and banks during implementation; however, this has not proved critical for the sustainability of activities. Some associations continue to receive financial support from the government and from other NGOs after exit, and a few associations with formal contracts may be able to access future lines of credit through their buyers. However, some of the declines in association membership may be attributed to the lack of available credit for those producers unable to meet certain qualifying standards to participate once agency support is withdrawn, especially where municipal or NGO funding is not available.
- While producers may not yet coordinate sale through associations or maintain formal contracts with secure buyers, they may continue to adopt those agricultural practices that appear likely to contribute to increased production, and therefore potential profit .
- Examples of skills needed by associations: accounting, marketing, negotiating contracts/credit
- NRM projects were financed during the life of the program through the provision of Title II food for work to undertake conservation, land improvement, and reforestation activities. Title II also provided inputs (seedlings) and equipment for these projects. The sustainability strategies for the continuation of these activities after exit were based on the expectation (or hope) that communities and individuals would recognize the benefits of these activities, and would continue to implement them without the remuneration represented by food for work. There are some municipal government entities whose responsibilities include NRM, but only a small percentage of communities reported having a natural resources committee (ranging from 25% in ADRA sites to 11% in FH and STC areas), and in general these are under-resourced and do not have technical nor financial capacity to pay for these activities or inputs. NRM activities align well with national and NGO priorities to mitigate the impact of climate change and support rural livelihood; FH, CARE, and ADRA maintain a presence in some former Title II municipalities with new funding that may support certain NRM activities through sustained pressure on municipal governments and NGO partners present in the region
- Difficult to sustain because without mechanisms for self-financing, incentives for participation, or linkages to external support with coherent vision and the resources to back it up, activities lack the combination of factors critical for sustainability While Title II agencies succeeded in sustaining regular coordination with municipal partners throughout their interventions, information sharing and institutional strengthening w ere not sustained once those partners left office and new leaders entered with alternate priorities.
- There are synergies between the 3
- Food incentive was replaced by cash transfer in Bolivia, so not possible to gauge. Food not withdrawn in India;
- The success of sustaining resources through gov’t linkages varied by country depending on gov’t’s capacity, motivation, resources to absorb trained CHWs We did not observe any system in which fee for service generated resources to support service provision.
- alternative sources of care were available to beneficiaries in Bolivia
- Gradual withdrawal and independent operation of water committees contributed to enhanced sustainability
- Ag practices declined if commercial sales did not provide resources for purchase after the program ended (double-check this statement w/Bea)
- Longer duration of operation in a community prior to exit (when agencies also manage expectations of permanence).
- Can require more than one project cycle, or a longer project cycle than is typical for Title II, before reaching transfer and phase-out point. These benchmarks shouldn’t only be triggered by artificial project end-dates but rather by evidence of having achieved capacity, resources, motivation.