Evaluacion de medio periodo : proyecto sector salud II (proyecto no. 522-0216)

Second mid-term evaluation covers the period 5/88-5/95. The project has been extremely successful. The close working relationship between the Ministry of Health (MOH) and USAID has led to substantial administrative reforms. Although there are areas in which the project will not achieve its goals, water system and latrine construction goals have been met or exceeded, the diarrheal disease control program continues to be a great success, water quality laboratories have been completed, and the National Autonomous Water and Sewer Authority has decentralized its services and computerized its warehousing system, which is a model for Central America. New facilities have been constructed in the regions and health center repair goals have been exceeded. The Expanded Program of Immunization (EPI) is one of Latin America"s stars, having reached ambitious coverage goals of more than 90%. Honduras has been officially declared polio free and is close to eliminating measles. The proportion of women seeking prenatal visits and the number of visits have climbed. Family planning commodities are available in clinics with doctors. The Organizational and Functional Development of the Service Production Unit (DOFUPS), an administrative system developed by the health sector projects, has been implemented nationwide, and decentralization is a reality in the MOH. Cost recovery is in place in over 70% of facilities. The MOH has maintained a productive Division of Education, and short-term training goals have been exceeded. The successful programs are completely institutionalized. The use of oral rehydration solution is so widespread that a commercial market has been created. Health care has become an essential element of national politics. Though the U.S. share of donor support has shrunk, many programs will continue even if funding is withdrawn. Some programs have not reached their goals. The reproductive risk strategy is only now being implemented at the local level, and not without problems. High-risk pregnant women are not being identified or given special care, and the referral system does not appear to be working. The community-based acute respiratory infection (ARI) treatment program is only now being initiated on a pilot basis. It is unlikely that these areas will develop quickly without continued project support. The POSAIN (Process for Organizing and Systematizing Child Health Care) system of integrated care for children, including nutrition, is also in the experimental stage. Child malnutrition appears to be increasing, suggesting that mortality goals achieved may not be sustainable. Although many elements of DOFUPS have been implemented, weaknesses can be noted. A health/management information system (H/MIS) that would take advantage of local planning to meet supply, training, and supervision requirements is needed. Supervision has become problematic due to increases in per diem rates with no attendant increases in the budget, and a lack of functioning vehicles. Community participation in health centers is also weak, and service integration at the community level is not yet a reality. Long-term training goals have not been met, although the new M.P.H. program at the National Autonomous University of Honduras is a promising example of local solutions. Many of these problems must be addressed at the implementation level. Some programs lack proven or feasible technologies or adequate local models to emulate. A model health information system for MOH, for example, does not exist. The recommended project extension should address the underdeveloped areas by tackling implementation issues at the level of the health area, health centers, and the community, completing the path started with Health Sector I. By developing sentinel demonstration sites -- linked through regions to the central level -- interventions such as the H/MIS, the reproductive risk strategy, and community-level ARI care, can be effectively implemented, evaluated, and modified. Lessons learned are as follows. (1) The most successful components are those in which there has been the most congruence in U.S. and Honduran government policy, professional and community attitudes, and popular support. The success of these components has permitted dialogue to take place in areas of less congruence, serving both nations" interests. (2) The Health Sector projects" long duration -- from 1980 on -- has permitted close working relationships to be established and long-term goals to be set and achieved. There has been an amazing continuity in goals for PHC, child survival, and administrative reform. (3) Further, this long relationship has produced an environment in which key players in the MOH and USAID have persisted. Even when elections disrupted the MOH, key personnel were able to transfer to USAID-funded projects and maintain linkages, sharing their experience and waiting to return with the next change of government. Projects need to give considerable thought to career issues when working in the health sector.