This final performance evaluation of the Health Service
Delivery (HSD) Activity reviewed the first 4 years of
implementation to understand project effectiveness
in increasing quality of care, increasing demand for
services and strengthening health systems; to identify
lessons learned and missed opportunities; and to
identify factors affecting post-investment sustainability.
Evaluation questions focused on quality of care,
community-focused interventions, health systems
strengthening, fistula prevention and care, genderbased
violence, and leveraging of USAID and other
development partner activities to advance RMNCH+
results in Guinea. Primary mixed-methods data were
collected from key stakeholders and a subset of health
facilities.
HSD activities contributed to substantial progress in
strengthening the system and actors to provide the
integrated care package through provider training
and supervision, environmental and materials support,
and advocacy efforts. Continuing challenges included
training needs and managerial support, human resource
deployment and retention, lack of essential medicines
and commodities, appropriate space for service
provision, and inadequate equipment maintenance.
Systems strengthening achievements contributed to
increased community member utilization, especially
for ANC, family planning, and child health; however,
important disparities and equity gaps remain. Ministry
of Health (MOH) governance, leadership, and ownership
of quality improvement at the facility level remained
insufficient to sustain HSD-supported improvements.
HSD activities contributed to building fistula surgical
capacity and coverage; however, the investment was
small compared to the need and sustainability remains
a significant concern. Similarly, gender-based violencerelated
health and legal services and prevention
activities were made available in targeted areas,
though greater investment and stronger governance
is needed. While HSD activities built on prior USAID
achievements and concurrent programming, flexibility
in USAID programming, and strong government
leadership and coordination is needed. The Standards-
Based Management and Recognition program was
an important driver of quality improvements in family
planning, emergency obstetric care, and infection
prevention and control, and SBM-R recognition
represented high-quality services to health staff and
communities.
Evaluation recommendations include: target client
engagement throughout the continuum of care and
institutionalize functional referral systems (1.1), augment
support for integrated critical services for vulnerable
populations (1.2); support the Government of Guinea to
implement the Community Health Policy and integrate
community health services (2.1); strengthen community
engagement through supporting the community
action cycle, community groups and health posts
(2.2); strengthen social accountability for removing
financial, gender and cultural barriers for vulnerable
groups through addressing service fees and supporting
community health mutuals (2.3); require accountability,
leadership and ownership from implementing partners
for sustainability through results-based accountability
measures (3.1); align SBM-R with existing governmental
quality improvement measures and advocate for an
institutionalized quality improvement approach (3.2);
continue supporting the DHIS2 health information
system to achieve full implementation to facilitate
evidence-based decision making (3.3); scale up support
for pre-service midwifery and nursing education and
skills labs (3.4); strengthen facility-based equipment,
infrastructure, and supply management (3.5); leverage
USAID health sector investments for improved
collaboration, communication and impact between its
projects/activities and others in the health development
field (4.1); incorporate flexibility in project design, and
adapt implementation and outcome measures to
changing needs (4.2); design projects collaboratively
to increase ownership and devolve responsibility to
government partners (4.3); consider demonstrating the
full effectiveness of investment activities by prioritizing
depth of investment (4.4).
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