FINAL EVALUATION REPORT- November 2018 Final Evaluation of INTERSOS intervention in Kandahar province under the framework of: “Multi-sector emergency response for Kandahar province for the conflict affected population (IDPs, returnees, vulnerable (host) communities” implemented from 15/08/2017 to 30/09/2018.

Contents

Abbreviation and Acronyms ................................................................................................................................................. 3

List of Figures And Tables ............................................................................................................................................... 4

Executive Summary .............................................................................................................................................................. 5

Health, Nutrition and WASH context ...................................................................................................................... 5

Final evaluation - Objective and Scope .................................................................................................................... 5

Methodology ......................................................................................................................................................................... 5

KAP Survey ...................................................................................................................................................................... 5

Focus Group Discussion ......................................................................................................................................... 6

Limitation and Challenges ........................................................................................................................................... 6

KAP SURVEY - Key Findings and Results .............................................................................................................. 7

Respondents demographic ......................................................................................................................................... 7

WASH Knowledge, Attitude and Practices ........................................................................................................ 7

Health and Nutrition Knowledge, Attitude and Practices ...................................................................... 13

Beneficiary’s satisfaction .......................................................................................................................................... 19

Satisfaction with INTERSOS Staff ........................................................................................................................ 22

Focus Group Discussion ................................................................................................................................................ 24

Relevance, Appropriateness and Effectiveness of the intervention ............................................... 24

Lessons Learnt ................................................................................................................................................................ 26

FGD Protection team ......................................................................................................................................................... 27

FGD Health team .................................................................................................................................................................. 28

Recommendations .............................................................................................................................................................. 29

Abbreviation and Acronyms ANC Ante Natal care BCC Behavior Change Communication BHC Basic Health Center BPHS Basic Package Health System CHC Comprehensive Health Center CHS Community Health Supervisor CHW Community Health Workers COV Community Outreach Volunteers CP Child Protection DHO District Health Officer DOPH Department Of Public Health FGD Focus Group Discussion GBV Gender Base Violence HF Health Facility HH Household HNO Humanitarian Needs Overview HRP Humanitarian Response Plan IMR Infant Mortality Rate IYCF Infant and Young Child Feeding KAP Knowledge Attitude Practices KII Key Informant Interview MHT Mobile Health Team PHC Primary Health Care PiN People in Need PLW Pregnant and Lactating Women PNC Post Natal care PPHD Provincial Public Health Department PwSN Person with Special Needs RH Reproductive Health U5MR Under five Mortality Rate WASH Water Sanitation and Hygiene WHO World Health Organization

List of Figures And Tables

Figure 1 KAP Survey’ respondents by gender Figure 2 Age Disaggregate data of the respondents Figure 3 Participants attending WASH Hygiene Promotion Session Figure 4 Topic of the HPs session recalled by participants Figure 5 Knowledge on the Key Time when wash hands Figure 6 Practices of the Participants on the handwashing Figure 7 Handwashing Knowledge and Practices Figure 8 Main Water Source Figure 9 Secondary Water Source

Figure 10 Main form of storing drinking water at home Figure 11 Reasons for not using closed items to store water at home Figure 12 Main form of water treatment at HHs level Figure 13 Why no water treatment Figure 14 Handwashing methods Figure 15 Reasons behind not using Soap and Water for handwashing

practices Figure 16 In case of being ill, please where people resort Figure 17 Free health care Figure 18 How payed HC services affect the capacity to resort to them Figure 19 Participants to Health&Nut awareness sessions

Figure 20 Main topics recalled by participants to Health&Nut awareness sessions

Figure 21 Vaccinations of children after participating in Health&Nut awareness session

Figure 22 Nutrition screening after participating in Health&Nut awareness session

Figure 23 Beneficiaries that received ANC Figure 24 N. of ANC visits received Figure 25 Where women deliver Figure 26 PNC in the first month after delivery Figure 27 Beneficiaries received IYCF messages Figure 28 Facilitators of IYCF messages Figure 29 IYCF messages recalled by the beneficiaries Figure 30 People knowing about INTERSOS team deployed in the area

of interest Figure 31 People directly benefiting from INTERSOS services provision

Figure 32 Support received by INTERSOS Figure 33 Percentage of Beneficiaries satisfied with INTERSOS services

provision Figure 34 Reasons why beneficiaries are not satisfied with INTERSOS

services provision Figure 35 Scope of INTERSOS intervention clearly explained to the

beneficiaries Figure 36 Satisfaction with INTERSOS staff behaviour Figure 37 Knowledge of how to report to INTERSOS in case of incident

or miss-practices of INTERSOS staff

Figure 38 Favorite communication/accountability mechanism for the beneficiaries

Executive Summary Health, Nutrition and WASH context Afghanistan is one of the world’s most complex humanitarian emergencies, characterized by escalating conflict, causing over one million people to be living in new and prolonged displacement. On the top of the protracted crisis, during 2018 the country has been stricken by a drought bringing to an overall of 5.5M people in need (PiN) in the country (HRP 2018). Among the different sector of the humanitarian system, Health, Nutrition, and WASH are among the most affected by this combination of natural and man-made disaster. According to the AFG Health cluster (July 2018) 4.6 million were in chronic need of essential primary health care. The protracted and complex crisis affecting the country has furthermore stressed the already fragile health system with a high U5MR (70/1000 live births) and IMR (53/1000) (UNICEF 2018), with measles outbreaks being a major public health concern due to the low routine immunization coverage (U1 population only for the 39% immunized). Apart from the child survival data, also the indicators on maternal health reveal the inconsistency of the Afghan health system, with only 58% of the PLWs receiving at least one antenatal visit and 17% considering the 4 standard visits (UNICEF 2018). Only 50 percent of deliveries take place in health facilities where post-natal care can be provided by trained health staff. On the nutrition sector, the drought has furthermore deteriorated the needs in the country, with an increase from 1.1M people foreseen in the HNO to 1.6M, without considering the 3M reported in chronic needs. Apart from the data on PiN, also the implementation of good practices in nutrition is still far away from global standards: 40% early initiation breastfeeding and 43% of the HHs implementing exclusive breastfeeding practices (UNICEF 2018). Lastly, according to the WASH cluster 1.5 M people are in need of lifesaving WASH interventions. This need is also exacerbated by the poor condition of the health centers in terms of sanitation facilities: according to WHO assessment (2016) more than 25% of the health facilities in the eastern and southern region lack access to water within the premises and over 50% have insufficient sanitation facilities, including places for hand washing with soap by medical staff. Apart from this number, hygiene practices are still beneath the standards, with 1 out of 3 children 6-11 months suffering from diarrhea. Final evaluation - Objective and Scope This final internal evaluation, composed by a KAP survey and FGDs analysis, aims at providing an end-line for the INTERSOS indicators in the Health & Nutrition and WASH component, and it will be used as a tool to inform future programmes, as well as to measure the progress of the implemented program versus the benchmark indicators initially reported. The evaluation also aims at measuring the degree of beneficiaries’ satisfaction with INTERSOS intervention and staff, and identify ways to improve service delivery based on beneficiaries’ feedback. Methodology

KAP Survey Area and sampling: The survey area consisted of the operational areas for WASH and Health&Nutrition programming for INTERSOS in the province of Kandahar. The study took place in the 5 areas covered by the project- 3 districts (Maywand, Zheray, Spin Boldak) and two neighborhoods of Kandahar city (Mirwais Mina and Loya Wala) - covering in total 15 locations (3 village per districts and 3 sub-areas in each Kandahar neighbors). The sampling method used was random sampling. For the Health and Nutrition components, a sample size of 420 individual was calculated based on the target population of the intervention in Kandahar Province (72.466 individuals). The sample size was calculated using the Survey System online calculator, using a 95% confidence level, a 5% margin of error and including an additional 10% to address the eventuality of improper data collection / invalid questionnaires. Furthermore, considering that INTERSOS has been deploying in Kandahar city, and in specific in Loya Wala and Mirwais Mena districts, a WASH team for the promotion of the Hygiene good practices, an additional sample of 140 people (70 in Mirwais Mena and 70 in Loya Wala) has also been considered for the WASH component of the KAP.

Finally, both the five areas, for a total of 560 respondents, were engaged for the beneficiary’s satisfaction component of the survey. Ethic and consent procedure: The respondent’s agreement in participate to the KAP was sought prior to the interview using oral ‘informed consent’. All questionnaires, manually filled by the enumerators, were anonymous and numerically coded before the deployment of the enumerators. Training of data collectors and supervisors: A one day training for the enumerators and supervision team was carried out in INTERSOS Kandahar office on the 16th September 2018, conducted by the M&E officers, Project Manager, and Human Resources. The training focused on the basics of conducting KAP surveys. The participants learned how to use the structured questionnaires by carrying-out out role plays, in order to simulate the real experience, constraint, and questions that could come out during the implementation. Data collection: The survey focused on quantitative data collection. The quantitative information was collected using the printer KAP survey questionnaires, developed by the Kandahar field mission with the supervision of the INTERSOS HQ, and the technical validation of the INTERSOS Health and Nutrition Unit (Annex 1). Data collection was carried out, for all the 5 target locations, over a three day period as follows:

- Spin Boldak, Maywand, Zheray: from the 17th to the 19th. For each target location, on daily basis INTERSOS

deployed 4 enumerators, working in a couple (1 male 1 female), under the direct supervision of the

INTERSOS supervision staff.

- Loya Wala and Mirwais Mena: from the 17th to the 19th. For each target location, considering the limited

sample (focus only on WASH) INTERSOS deployed only one team of enumerators (1 male 1 female) and one

INTERSOS supervisor

Quality control: Data checking and validation for completeness and consistency were carried out at the end of the first day, in order to find-out inconsistency of the questionnaires collected and to work with the enumerators on how to improve the administering of the questionnaires. A final quality control was carried out at the end of the survey period. All data underlined as inconsistent has been shared with the Head of Base and Programme manager, for rectification and cleaning. In order to proceed with the control and the analysis of the answers, a quantitative data framework was set up in Excel for all validated data, including also the additional option for answer 29 and 30 (Annex 2). The main inconsistencies that occurred were identified on: 1. Follow-up questions: While these questions were designed to capture an in-depth information only for a partial

group of the responders - only if YES, or, only if NOT - in the previous question, in many cases the enumerators administered the follow-up questions also to the respondents that were excluded. In this case, the decision taken has been to discard the answers.

2. Questions number 29 and 30 of the KAP questionnaire: The total number of respondents did not match the sample. INTERSOS management staff has decided to add the “No answer” option and to consider it as part of the NO answer in the final evaluation.

Focus Group Discussion As the main aim of the KAP survey was to collect quantitative data on the project achievements against original targets, and the degree of satisfaction of the beneficiaries, INTERSOS has decided to develop also two types of Focus Group Discussions (FGD). While the first has engaged relevant local stakeholders, in order to analyze through qualitative data the effectiveness and appropriateness of the activities, the second has been an internal moment of review for INTERSOS team and the field staff on the lessons learned during the implementation. In both cases, the participant agreement in participating to the FGDs was sought prior to the interview using oral ‘informed consent’.

Limitation and Challenges The main limitations are linked to the choice of a random sampling methodology for the KAP survey, which did not allow an in-depth analysis of the data, preventing the possibility of data disaggregation for Mobile Heath Teams and Health Facilities (cluster sample methodology), element that would have supported a better understanding and evaluation of INTERSOS activities.

KAP SURVEY - Key Findings and Results

Respondents demographic

Figure 2 - Age Disaggregate data of the respondents

WASH Knowledge, Attitude and Practices Out of the 560 respondents, 405 attended Hygiene Promotion awareness sessions (72%).

250 260 270 280 290 300

Male

Female

265

295

0 50 100 150 200 250

<20

21-30

31-40

41-50

>50

116

201

131

63

49

Figure 1 - Respondents by gender

Figure 3 - Participants attending WASH Hygiene Promotion Session

In the event of a positive feedback on the previous question, a follow-up question was posed to the respondents to understand which session they can recall. Among the participants the answers were as follows: 32% hand washing; 31% Personal Hygiene; 22% HHs water treatment and 15% importance of using soap during handwashing key times.

Figure 4 - Topic of the HPs session recalled by participants

INTERSOS KAP survey has then tried to measure the knowledge of the respondents versus their actual practices. In order to do so, two questions have been designed on the importance of hand washing practices. While the first one aimed at measuring the knowledge of the respondent on the key times when washing hands; the second aimed at seeing the attitude of the respondent toward these practices.

0 100 200 300 400 500

YES

NOT

405

155

32%

31%

22%

15%

Hand Washing

Personal Hygiene

HHs water treatment

Importance of using soap during key times

Figure 5 - Knowledge on the Key Time when wash hands

Figure 6 - Practices of the Participants on the handwashing

Despite the slight differences between the knowledge and the practice questions, it is possible to verify the consistency of the two among the respondents interviewed and the high percentages of people having both knowledge and practice – between 53% and 95% (total number of respondents was 560). When asked about the main water source used, the most common answers are: (i) ‘tanker truck’, mentioned by 29% (161) of the respondents; (ii) ‘Dug Well with protection ‘, cited by 26% (146) and; (iii) Household connection by 20% (112). Figure 8 summarizes the main water sources as reported. The question was not a multiple choice in order to obtain only the primary source of water.

0 100 200 300 400 500 600

Before Eating

Before Preparing Food

Before Feeding your Children

After Using Latrine

537

351

301

516

0 100 200 300 400 500 600

Before Eating

Before Preparing Food

Before Feeding your Children

After Using Latrine

515

335

299

494

Figure 7 - Main Water Source

When asked about the secondary source of water in the HHs, respondents replied as following:

Figure 8 - Secondary Water Source

Considering the first and second questions together, it is possible to underline how water trucking represents in both cases the major source, followed by dug well with protection and the purchase of water. When asked about the main form of storing water at home, the respondents identified for 48% a closed jar, 23% a closed container and for 6% a closed bucket. In total out of the 560 respondents, 432 (77%) use a closed container to store water at home.

0 50 100 150 200

Spring with protection

Unprotected Spring

Dug Well with Protection

Unprotected Dug well

HouseHold Connection

Buy Water

Tanker truck

Rain Water Collection

Other

80

14

146

25

112

18

161

1

3

0 50 100 150 200 250

Spring with protection

Unprotected Spring

Dug Well with Protection

Unprotected Dug well

HouseHold Connection

Buy Water

Tanker truck

Rain Water Collection

Other

83

60

162

48

112

181

202

10

47

Figure 9 - Main form of storing drinking water at home

Only for the respondents that did not use closed items to store water at home, the KAP survey investigated on the reason behind. Out of the 128 people using open methods to store water at home, 77% don’t have closed storage available at home, while a 23% do not know the importance of using closed items to store the water.

Figure 10 - Reasons for not using closed items to store water at home

Following-up on the importance of using safe water, INTERSOS KAP survey revealed how the main form of water treatment at HH level is boiling (47%) followed by filtration (11%) and chlorination (2%). Out of the 560 respondents 225 (40%) did not use any water treatment at HHs level.

0 50 100 150 200 250 300

Open Jar

Close Jar

Close Bucket

Open Bucket

Close Container

Open Container

99

270

35

21

127

8

23%

77%

Don’t know the importance of close storing system

Closing storage not available

Figure 11 - Main form of water treatment at HHs level

In order to further investigate the non-utilization of any water treatment at HH level, INTERSOS KAP survey asked the reasons behind this choice. Out of the 225 respondents non-utilizing water treatment at home, 77% (140 individuals) do not have items for water treatment; 23% (53 individuals) don’t know the importance of water treatment and finally 15% (23) purchase safe water.

Figure 12 - Why no water treatment

Always considering the WASH practices among the respondents, INTERSOS KAP survey investigated on the methods used for handwashing. First of all, it is interesting to underline how among all the respondents, all of them have access to a washing point, and secondly how only 326 out 560 (58%) used water and soap to wash their hands, followed by only water (207 individuals - 37%) and ash (26 individuals - 5%).

0 50 100 150 200 250 300

Boiling

Chorine

Filtration

None

264

13

58

225

15%

23%

62%

Purchase of Pure water

Don’t know the importance of water treatment

Don’t have the item for water treatment

Figure 13 - Handwashing methods

Only for the participants not using soap and water as hand washing method, the KAP survey asked the reason behind. 194 out of 234 (83%) don’t have soap available at HH level, while 40 individuals (17%) don’t know the importance of the practice.

Figure 14 - Reasons behind not using Soap and Water for handwashing practices

Health and Nutrition Knowledge, Attitude and Practices On the total sample of 420 individuals engaged in the KAP survey for the component of Health and Nutrition, when asked about where they go in case of illness, 287 individuals (68%) replied to the nearest health facility, 107 (25%) use both HFs and traditional healers, and 9 traditional healers. 17 out of 420 did not reply to the question.

0 50 100 150 200 250 300 350

Water and Soap

Water

Ash

No Washing Point

Other

326

207

26

0

1

83%

17%

Soap not available in the HHs

Don’t know the importance of proper handwashing

Figure 15 - In case of being ill, please where people resort

Among the survey participants, most of them - 381 (91%) did not pay for the Health services, against 39 who did pay.

Figure 16 - Free health care.

Among the respondents who did pay for health services, 62% stated that this element has affected their capacity to resort to health services when ill.

Figure 17 – If payed HC services affect the capacity to resort to them

0 50 100 150 200 250 300

Nearest Health Facilities

Traditional Healers

Both

None

287

9

107

17

9%

91%

YES NO

62%

38%YES NO

Out of the 420 interviewed for the Health and Nutrition component, 304 respondents (72%) participated in Health and Nutrition Awareness session, against 116 (28%) who did not receive any awareness session.

Figure 18 - Participants to Health&Nut awareness sessions

Among the population that did receive awareness session, the main 3 topic that they could recall are: 29% importance of Vaccinations, 21% TB; 20% Nutrition Screening.

Figure 19 - Main topics recalled by participants to Health&Nut awareness sessions

With the aim of measuring the correspondence, if any, between the awareness and the changed practices among the beneficiaries of the intervention, INTERSOS KAP survey asked 2 questions related to (i) vaccinations; (ii) nutrition screening. Out of the 420 respondents, 333 (79%) did vaccinate their children after attending the ad hoc awareness session, while 10 (3%) did not. Furthermore, as underlined in the quality control session of the report, 77 respondents (18%) did not reply to the question. Considering the scope and purpose of the survey, INTERSOS decided to consider these cases as a NO.

72%

28%

YES NOT

18%

12%

20%21%

29%

Referral System First Aid Trauma

Nutrition Screening Tubercolosis

Importance of Vaccinations

Figure 20 – Vaccinations of children after participating in Health&Nut awareness session

Out of the 420 respondents, 258 (61%) did get their children screened after attending the ad hoc awareness session, while 87 (21%) did not. As for the vaccination-related question, the 75 respondents (18%) who did not reply to the question were considered as a NO.

Figura 21 - Nutrition screening after participating in Health&Nut awareness session

Considering the focus of INTERSOS intervention on enhancing the capacity of Kandahar Health services to offer Reproductive Health care, INTERSOS KAP survey measured the practices and the capacity of the beneficiaries to resort to RH care. Out of the 420 respondents, 344 (82%) mentioned that they (or their spouse) had attended antenatal care services before the delivery, against 18% that did not have and/or attend such services.

0 100 200 300 400

YES

NO

No Answer

333

10

77

0 50 100 150 200 250 300

YES

NO

No Answer

258

87

75

Figure 22 - Beneficiaries that received ANC

Among the beneficiaries who did receive Antenatal care (ANC), 131 attended four visits; 122 three visits; 70 two visits and 21 just one visit.

Figure 23 - N. of ANC visits received

When asked about the place of delivery, the respondents cited in 52% of the cases (234 individuals) health facilities; 27% cited Hospital (122 individuals); and 21% at Community level (96 individuals).

Figure 24 - Where women deliver

0 100 200 300 400

YES

NO

344

76

6%

20%

36%

38%

1 ANC 2 ANC 3 ANC 4 ANC

27%

52%

21%

Hospital Health Center Community

In the first month after the delivery, 315 female (75%) received postnatal care, while 105 (25%) did not.

Figure 25 - PNC in the first month after delivery

Apart from the PNC received in the month after the delivery, the KAP survey revealed how among the respondent 347 out of 420 did receive awareness session on IYCF (Infant Young Child Feeding) against 73 individuals who did not receive such messages.

Figure 26 - Beneficiaries received IYCF messages

When asked about who facilitated the IYCF counselling, 45% of the respondents (158 individuals) mentioned the Community Health Workers; 33% medical staff and 22% both.

0 100 200 300 400

YES

NO

315

105

83%

17%

YES NO

Figure 27 - Facilitators of IYCF messages

Finally, when asked about which messages the beneficiaries could recall about the IYCF awareness session, the most common were:

Figure 28 - IYCF messages recalled by the beneficiaries

Beneficiary’s satisfaction Final objective and scope of the KAP survey was to measure the degree of beneficiaries’ satisfaction with INTERSOS intervention and staff during the project implementation. This section of the KAP also aimed at understanding which are, in case of constraint, the ways forward to improve INTERSOS service delivery in Kandahar province. Knowledge of INTERSOS team and services delivered Out of 560 respondents, 462 (82%) had knowledge about the deployment in the area of INTERSOS staff and team.

45%

33%

22%

CHWs Medical Staff Both

29%

23%19%

10%

19%

Importance of breastfeeding

Start Breastfeeding within 1 hour of birth;

Exclusive breastfeeding for 6 months;

Promotion of micronutrient-rich foods and appropriate supplementation;

Introduction of solid/semi-solid foods at six months;

Figure 29 - People knowing about INTERSOS team deployed in the area of interest

Among the total respondents, 440 (79%) directly benefited from the services offered by INTERSOS.

Figure 30 - People directly benefiting from INTERSOS services provision

Among the ones directly benefiting from INTERSOS service provision, the main three services that they did attend/used were: (i) Consultation with Medical staff at HFs; (ii) Hygiene Promotion Session; (iii) Consultation offered by the MHTs.

82%

18%

YES NO

79%

21%

YES NO

Figure 31 - Support received by INTERSOS

Out of the 462 respondents who were aware about the deployment of the INTERSOS team in their dwellings, 94% were satisfied about the services provided (436 individual).

Figure 32 - Percentage of Beneficiaries satisfied with INTERSOS services provision

Among the population that was not satisfied with the services provided, the KAP investigated the reasons behind. The question was a multiple choice in order to leave as much as possible the opportunity to the beneficiaries to state their concerns.

21%

19%

19%

14%

10%

8%

9%

Consulation with medical personell inHealth Facility

Consultation of Mobile Team

Hygiene Promotion Session

Health Awareness session

Distribution of Kits

Protection awareness sessions (Child andWoman rights)

Legal and Psychosocial support

94%

6%

YES NO

Out of the 54 individuals not satisfied: (i) 36% cited the time of the service provision, in relation with the deployment of the team in the field; (ii) 28% cited the location chosen for the deployment of INTERSOS team; 24% cited the type of services provided; and lastly 12% other reasons.

Figure 33 - Reasons why beneficiaries are not satisfied with INTERSOS services provision

Finally, considering the importance of community mobilization in Kandahar province before the start of activities, the KAP investigated if INTERSOS activities, goals and scope were properly explained to the population. Out of the 560 interviewed, 501 replied YES (89%).

Figure 34 - Scope of INTERSOS intervention clearly explained to the beneficiaries

Satisfaction with INTERSOS Staff 518 out of 560 respondents were satisfied with INTERSOS’ staff behavior (92%), while 42 reported problems with that (8%).

36%

28%

24%

12%

Time of the services Location of the services

Type of services provided Other

89%

11%

YES NO

Figure 35 – Satisfaction with INTERSOS staff behaviour

The KAP also sought to measure if the respondents know how to reach INTERSOS in case of issue with the INTERSOS teams deployed, and - if not - which are the favorite instruments to guarantee that accountability. 60% of the respondents (337 individuals) already knew how to reach INTERSOS in case of issue arising.

Figure 36 - Knowledge of how to report to INTERSOS in case of incident/mis-practices of INTERSOS staff

Among the 40% that did know how to reach out to INTERSOS in case of an issue arising with the team deployed, the following were indicated as favorite communication channels: (i) 90 individual cited “report to Community leader”, i.e. 34%; (ii) 88 individuals (33%) cited “phone call to INTERSOS office”; (iii) 44 individuals (17%) cited “Communicate to INTERSOS staff in person”; and (iv) 41 individuals (16%) cited “Reporting to person in charge of HF/MHT”.

92%

8%

YES NO

60%

40%

YES NO

Figure 37 - Favorite communication/accountability mechanism for the beneficiaries

Focus Group Discussion

Relevance, Appropriateness and Effectiveness of the intervention A first FGDs engaged 8 participants, 6 District Health Officers and 2 Health Officers of the PPHD, in order to evaluate through qualitative data the relevance and appropriateness of INTERSOS intervention. In order to do so the questionnaire for the FGD has been divided into two sections:

1. Relevance and appropriateness (3 questions);

2. Effectiveness (4 questions).

Relevance and Appropriateness

1. Was INTERSOS intervention properly designed, as per your understanding and observations?

Considering the whole intervention, all the FGD participants agreed on the fact that it was well planned, due to the combined support to the static facilities that suffer from chronic lack of medical personnel, and to the outreach capacity of the health system through the deployment of the MHTs in remote areas, away from the HFs, with the creation of roving teams. Considering the situation of Kandahar province and the presence of the white areas, and the geographic distribution of the villages in the rural areas, MHTs represent the only option.

- In terms of suggestions for the future, the FGD participants mentioned the possibility to modify the schedule for

the MHTs deployment. In particular, they mentioned the option (valid especially for remote and AOG-controlled

areas) of “splitting the team” in two and guaranteeing a constant presence in the field; for instance the MD and

the HP could stay in the field for the first 20 days of the months, and then take a break for 10 days, while the

midwife and the nurse would start deployment around the 10th of the month covering until the end. In the

absence of INTERSOS MD or midwife, this “gap” could be temporarily covered the MHT of another organization.

INTERSOS, DoPH and other health stakeholders will discuss MHT deployment schedule on a case by case

33%

16%17%

34%

Phone call to INTERSOSoffice

Reporting to person incharge of HF/MHT

Communicate withINTERSOS staff in person

Report the problem to thecommunity leader

basis, deciding whether to adopt this solution or the regular one (deployment on a weekly basis from Sunday

to Thursday).

The other evaluated component of INTERSOS health and nutrition intervention was the engagement of CHWs and CHSs for the awareness sessions. For the participants, the use of the CHWs and CHSs represented the best solution to engage with the local communities and raise the awareness on health/nutrition topics. Nevertheless, it was suggested that INTERSOS could improve the monitoring of the awareness sessions, by conducting joint-monitoring mission with the M&E officer of the DoPH and the DHOs. Another element to be considered while engaging with the CHWs is that during the past year INTERSOS has used the CHWs listed in BARAN matrix. Nevertheless, the list is not updated and only contains the CHWs that are present in the areas close to the health Facilities, and not the ones present in the remote areas not covered by health services. These elements create a gap in the implementation and efficiency of the awareness sessions. This element will be taken into consideration by INTERSOS in order to improve the efficiency of the awareness sessions and actually cover fully the target areas. A solution for future intervention could be, once obtained the list of authorized CHWs and CHSs, to cross-check this list with the DHOs, to see if actually these volunteers cover remote areas or not. If not, INTERSOS, together with the DoPH and DHOs, should change the CHWs selection in order to cover the remote areas, away from the HFs. 2. Were the objectives of the intervention relevant to the context and to the needs of local communities?

Delivery of Reproductive Health services Primary Health Care and BCC are relevant objectives given the context of Kandahar and INTERSOS should stick to the implementation and support to these activities. Nonetheless, INTERSOS could pay more attention to trauma services. INTERSOS MHTs work closely to the main road that goes from Spin Boldak to Maywand. Considering the high needs of the trauma services (only basically supported by the BPHS) INTERSOS should enhance, especially in the supported HFs, the provision of trauma services. Finally, all MHTs should be trained and equipped to offer a first trauma emergency response. 3. Was the chosen intervention’ approach the best way to meet the health, nutrition, WASH and protection

needs of affected populations and intended beneficiaries?

While the combination of the support to static HFs and deployment of MHTs is considered the best possible solution to address the needs of the local communities, the FGDs have revealed some concerns about the composition of the team. According to some of the participants, the protection team should be separated from the MHTs because, especially in rural communities, the delivery of protection services and awareness sessions could raise tension between the local communities and the team, element that could jeopardize also the health component of the mobile activities and the provision of services in this sector. The FGD participants proposed two solutions:

- Separate the teams, with the protection team called to act only if and when a case has been identified by the

health team for an internal referral;

- Deploy only part of the protection team with the Mobile clinic, while another part of it is deployed in the supported

Health Facilities.

Considering the second option, according to the FGD participants, as per MoPH policy, there should be an increased attention to the offer of protection services (especially clinical management of rape and GBV-related services) at Health Facility level. In this case, in order to align with this policy, INTERSOS could split its protection team: while one part (2 social workers) could join the MHT, the other two could be deployed in the health centers supported. On the one hand this solution will allow maintaining the mobile component for the maximum outreach, but on the other hand it will also support the implementation of the national strategy on GBV and CMR. At the same time, the combination of the approaches will create a more solid referral system for the support of the cases identified by the mobile teams. Effectiveness

1. There have been some changes in the local community’s health attitude, in the last year?

Especially regarding RH, there has been a significant improvement in terms of the awareness of the local communities

on the importance of these services. An important element that has facilitated the coverage of the RH is related to the

implementation of night-shifts in the HFs. While night shifts were previously done only at the District Hospital of Spin

Boldak, and the Comprehensive Health Centers, thanks to INTERSOS project this service has been made available

also within the BHCs.

The DoPH M&E officer reported how the number of deliveries at the Sanzheray BHC (Zheray district) has increased

from one to six per night, and a similar trend is found in the other BHCs.

Another component that is motivating the beneficiaries to go to the Health Facilities for safe delivery, even if they live

far away from the HFs, is that they know they will receive a baby kit, distributed by INTERSOS.

2. To what extent can these changes/effects be credited to INTERSOS intervention?

INTERSOS, as other organizations working with and within the national health system, has highly supported the

improvement of the health services in the communities, and part of the positive change seen in the last year is due to

the commitment of the organization. In particular, considering RH care, INTERSOS intervention had a considerable

impact thanks to the following:

- The project filled in the high gaps in terms of presence of Midwives, especially in Spin Boldak. The support

granted by the additional staffs in the HFs and the presence of midwives within the MHTs has been crucial.

- The project promoted widely the knowledge among the communities on the importance of RH services;

- Delivery of the baby kits. The incentive has proven its effectiveness and from the analysis made by the DHOs

it is one of the most valued incentives for the communities to come to the HFs for safe delivery.

3. Have goods, services or other subsidies, been delivered or offered at the right time according to the

main target group?

The delivery of the baby kits and the hygiene kits has taken place in the appropriate time. Nevertheless, the provision

of baby kits is still not enough to cover the needs in the communities.

Finally, in order to improve the effectiveness of the baby kits delivery, INTERSOS and the Health System actors in

Kandahar should elaborate a system where the distribution of the kits is not only related to vulnerability criteria, but also

to the accomplishment of the entire cycle of RH services by the PLWs (ANC-safe delivery and PNC) adding also the

immunization of the new-born.

4. What were the major factors influencing the achievement or non-achievement of the purpose of the

program?

- In terms of achieving better health outcomes for the population, the initial project design lacked the inclusion

of the position of vaccinator within the MHTs. However, this was corrected in the course of the project.

- In terms of support for the project implementation, FGD participants pointed out some weaknesses in

INTERSOS organogram in the first months of the project: the absence of dedicated HR staffs in Kandahar, as

well as of senior management staff, slowed down the recruitment process and the decision-making

processes. These issues were both addressed in Q2 of 2018, with the hiring of HR staffs in Kandahar and of

a Head of Base / Program Coordinator who guaranteed constant and timely support for HR issues and

decision-making.

Lessons Learnt Other 6 FGDs have been conducted by INTERSOS for the final evaluation of the project. The FGDs presented in the following section have been developed with the health and the protection staff, in order to gather lessons learnt and to understand from the staff that has been daily deployed into the field where and how to improve for future interventions.

In order to have proper FGDs, considering the high number of field staffs and the different perception of the Health and Protection teams, INTERSOS has decided to separate the FGDs as followed:

- Saturday 29th of September: FGD for the protection staff. The first 2 FGDs (1 for male and 1 for female staff)

were conducted in the morning, while the last one (male staff) in the afternoon, in INTERSOS training facilities;

- Sunday 30th of September: FGDs for the health staff: The first 2 FGDs (1 for male and 1 for female staff) were

conducted in the morning, while the last one (male staff) in the afternoon, in INTERSOS training facilities;

For all the FGDs implemented, the questionnaire was structured around three main components:

1. What worked well?

2. What can be improved? 3. Project Implementation and internal communication flow

FGD Protection team What worked well? The selected locations for the intervention were fine and did enable the local population to resort to the services offered. Furthermore, the mobile component did allow to offer services in areas completely uncovered in the rural district of Kandahar. The composition of the team, both health and protection, did facilitate the identification and internal referral of the cases, in both ways. Also on the composition of the protection and health team, the presence of both male and female staff did allow meaningful access for all the beneficiaries, and especially female ones, to the provided services, facilitating the identification of the cases of CP, GBV, and PSN. With regards to the protection awareness sessions, the FGDs participants mentioned their positive impact especially for child protection, as the awareness and the presence of the team on the ground did persuade the families to enroll their children in school. At the same time, it was evident for the participants how, thanks to the awareness sessions, the beneficiaries became more aware of their right to health, education and legal protection. In this sense, the presence of CoVs, coming from different social groups, and in most cases also selected among the community elders and leaders, did facilitated the spread out of the positive messages about protection. According to the FGDs participant, the capacity of the CoVs and local leaders to trigger a change in the community in relation to the protection concerns is stronger than the one of INTERSOS teams themselves (even if composed by professionals). Finally, the constant presence of INTERSOS intervention in the target villages, and the presence of the network of CoVs did facilitate the establishment of trust-worthy relations among the community and INTERSOS, spreading INTERSOS image as one of an impartial, independent and neutral organization. The main successes underlined by the protection team were:

- Offered protection services in remote areas where various national and international organizations were not

able to provide humanitarian assistance.

- Speak-out about human rights including children rights, women rights in remote communities of Kandahar

province.

- Communities acknowledged the importance of children-rights

- Distribution of kits to support the most vulnerable cases identified.

- Build a trustworthy relationship with the communities through the deployment of a network of Community

Outreach Volunteers

What can be improved? The referral system. Despite the efforts of INTERSOS protection Unit, the team has underlined the need to improve

and maximize the referral possibilities available in the province, building up a proper follow-up system. In specific it will

be important for the team to strengthen the referral system with the Health Facilities for the cases identified by the

protection team that also needs clinical support.

Moreover, INTERSOS could improve its coordination and communication with line departments and stakeholders when

it comes to the protection activities: for instance, there were gaps in communication with BARAN and DOPH regarding

the scope of the protection team, and the aim of the multisector intervention.

Challenges Human resources. One of the challenges faced by the protection teams was related to the lack of qualified social workers able to implement case management. This project component was only possible after extensive internal trainings by the Protection Officer and the Senior Protection Advisor. The other challenges related to Human Resources were: the high turn-over of field staffs (with sometimes long gaps), and the scarcity of female staff, enabling female beneficiaries to reach out for the support. For the above-mentioned challenges, the main suggestion offered by the FGDs participants was the need to create a proper schedule for the team training, planning also continuously refresher sessions. Cultural constraints. Protection concerns are a highly sensitive issue in the Afghan culture. Especially in the first months of intervention, considering the delays in the selection and training of CoV, it has been hard for the protection team to implement their activities at community level. Even when all these obstacles were removed, especially on the GBV component, the cultural constraints, and the social stigma present in the communities, have affected the capacity of the team to identify and support the vulnerable cases. Logistic constraints. These were mostly related to the absence of safe spaces where to implement case management and counseling sessions. Not always the communities were willing to offer a safe and private space for the implementation of Case Management. This lack affected the capacity of the team to do their jobs, and / or the willingness of the vulnerable population to speak-out about their concerns. The solution proposed during the FGDs was to supply each team with a tent that can be installed in the target villages and used for the counseling sessions. Project Implementation and internal communication flow. During the FGDs the teams underlined how considering the workload and the needs in the field, the team was well structured. The communication flow among the field team, and the INTERSOS managing staff (Programme, finance and HR department) has been positive. Also the creation of WhatsApp, SMS and email groups did facilitate the communication flow among the team. In relation to the communications with the local communities, after the first months of challenges faced due to the sensitiveness of the protection topics, the acceptance has improved and the community members gave positive feedback in relation to the activities implemented. The teams have been able to reach out also vulnerable groups, such as IDPs, returnees and PwSN. Nonetheless, the participants to the FGDs still cited GBV as one of the hardest protection concerns to identify and address due to cultural/context restrictions.

FGD Health team What worked well? According to FGDs participants, the location of the MHTs did support the health system capacity in Kandahar province. Most of the locations targeted were characterized by lack of other service providers, and by the low-income opportunity for the local dwellers. The deployment of the mobile teams has supported the beneficiaries to have constant and free access to quality health services. Most of the time, the location, which were chosen in coordination with the DoPH, were in proximity of cluster villages, enhancing the attraction capacity of the MHTs. Furthermore, the use of INTERSOS vehicle as an ambulance for the referral of complicated cases has been helpful and appreciated by the communities. At the same time, the deployment into the MHTs of vaccinators and the well-established coordination for the cold chain management, allowed to immunize a high number of children who did not had this opportunity before. Also with regards to the support to the HFs, the team has given during the FGDs positive feedbacks based on the appreciation received from the personnel in charge of the clinics and the patients themselves. The main successes underlined by the health & nutrition team were:

- Availability of drugs for health service provision, both in terms of the qualities of the drugs and in terms of

quantities (drugs are often lacking in the BPHS clinics).

- Positive feedback from communities and HFs staff;

- The ability of INTERSOS to work in remote areas of Kandahar province.

- Support to the immunization campaigns in Kandahar province.

What can be improved?

- The need for INTERSOS team to provide also treatment for the malnutrition cases identified in the field. Even

though the referral to HFs for the treatment has been put in place, the follow-up of the cases, only based on the

presence of the MHTs in the field and direct contact with the beneficiaries, is not enough.

- Increase the number of trainings offered to the medical staff, in particular for midwives, considering the pivotal

role played by this figure within the MHT for the engagement with female beneficiaries (it was suggested that

training for midwives should not only cover RH topics). For the Vaccinators instead, it has been proposed that

they participate in the training session that take place at RMT (Regional Management Team) in Kandahar.

- Timely delivery of the WASH kits. The distribution of the kits only took place in the last months of project

implementation (waiting for amendment approval), on the base of the needs detected by the teams during the

previous months. In the future the distribution should be all along the project cycle.

Challenges Human resources: Lack of trained staff especially during the first months of implementation, and difficulty in hiring female staffs (enabling the female beneficiaries in reaching out for the support). Furthermore, the staff deployed in the HFs reported that, in the initial phase of the deployment, the Health Facility “directors” did not understand properly the Job Description of the deployed staffs (especially the focus on malnutrition for the nurses), and this caused tension among INTERSOS staff and BPHS staffs. Project Implementation and internal communication flow All the participants to the FGDs reported a positive and well-developed internal communication flow within INTERSOS structure. The identification of a team leader for the Mobile teams, as well as the bi-weekly meetings with the management team, have proved to be effective and relevant in order to resolve the issues faced by the field teams. With regards to the communication with the local communities, the participants to the FGDs did not report any challenge: the provision of free qualitative health services has allowed having full access to the remote communities.

Recommendations

- Conduct regularly surveys, KIIs and FGDs to investigate beneficiaries’ satisfaction, as well as to get feedbacks

from the stakeholders on the relevance and effectiveness of activities and approaches. While INTERSOS meets

with them all regularly, the creation of dedicated spaces for such discussions / feedbacks ensure better focus

and outcomes;

- Take into consideration the recommendations emerged during the FGDs for future project design and

deployment of the MHTs and HFs staff (i.e. team composition-logistics constraints- deployment of the protection

team in the HFs);

- Develop an “INTERSOS monitoring plan”, common to all projects, with key outcome indicators to be measured

on a regular basis, so as to monitor the outcomes of the interventions (disregarding the indicators included in

project proposals)

- Advocate with the local stakeholders on the needs and gaps identified.