Decentralized health services

The project is being implemented by Management Sciences for Health (MSH) as the primary contractor with Development Group Incorporated as a Subcontractor; the immunization component is implemented by PAHO through a buy-in to the LAC regional project; and all project commodities are procured through a PASA with the U.S. Public Health Service (USPHS). The evaluation covered the period 3/93-12/95. In the accelerated start component, the majority of the required baseline studies were completed satisfactorily and on time. However, the human resources assessment, executed by MSH, was not completed satisfactorily and therefore not accepted. This should be completed in order to identify and/or revise the training strategy and content. Findings and conclusions regarding MH/CS are as follows. (1) The 1994 and 1995 workplans lack specificity in terms of how the numerous activities will serve to address project objectives. (2) No clear strategy for TA or training was articulated. These activities are well documented; however, the link between these activities and changes in service delivery and in turn, the impact on purpose level indicators, is lacking. As a consequence, the assistance provided by MSH is not likely to meet the component"s objectives. (3) Activities for control of diarrheal disease and management/treatment of acute respiratory diseases appear to have advanced satisfactorily. Activities in the area of maternal health, particularly birth spacing and nutrition education, need further emphasis. (4) There has been controversy over the differing roles played by MSH and PAHO in child immunization activities, and communication has been problematic. (5) The process for restructuring MH/CS should be pursued by the Ministry of Health (MINSA), PAHO, USAID/Nicaragua, and the contractor (as appropriate) in a collaborative manner. Findings and conclusions regarding the training and information, education, and communication (IEC) sub-component are as follows. (1) Lack of a human resource data base for the health sector from which to develop a targeted training plan impedes the training effort funded by the Demography and Health Surveys (DHS) project. Despite this, a large amount of training was carried out due to special efforts by the training advisor to identify needs. (2) The out of country training strategy appears to follow a demand driven approach tied to needs articulated by the Local Integrated Health Care Systems (SILAIS), and therefore future training should be assessed as to its relevance to DHS priority areas. In the commodities and logistics sub-component, work performed by the USPHS and MSH is of high quality. Staff are knowledgeable and active in pursuing solutions to problems. However, training of field level warehouse personnel needs to be developed. In regard to other aspects: there is a rate of family planning stockouts; USPHS procurement is satisfactory, except with respect to the price of U.S.-source products; a survey of warehouse conditions is needed; and over-prescription is perceived to be a problem by MINSA officials. The alternative sources of finance component has seen limited progress to date. The planned studies should be executed as soon as possible in order to advance Government of Nicaragua understanding of alternative financing options for the sector. In the management, finance, and decentralization component, the products delivered to date meet the needs of MINSA as it pursues its financial management systems development and decentralization objectives. However, USAID has not finalized the Monitoring and Evaluation Plan that identifies the activities to be undertaken, objectives, indicators, and means of verification necessary to determine progress. (Author abstract)