Evaluation : implementation of primary health care in selected provinces in the Sudan

Special evaluation covers the period 1976-3/82 and is based on document review, site visits, and interviews with Ministry of Health (MOH) and other key officials. Progress has been made in the four provinces studied; the project was well planned, receives strong MOH and international support, and is well accepted by the rural and nomadic populations. Ascertainment of the exact number of people served by PCHU's is almost impossible because data on population density and location are scanty and unreliable. However, an estimated 75% of the targeted rural population is already being reached, based on the original ratio of 1 community health worker (CHW) per 4,000 people, or 19% according to revised ratio of 1 CHW/1,000 people. Active community participation was noted in all four provinces in: recruiting and selecting CHU candidates; discussing local health problems; constructing and maintaining PCHU's; and providing assistance to CHW's. Constraints impeding the program have included: the 1981 decentralization and regionalization of the government in Sudan; stringent financial limitations, especially for foreign currency exchange, due to the current financial crisis; weaknesses within the managerial-supervisory component of the MOH infrastructure, including brain-drain to neighboring oil-rich countries; inadequate distribution of health personnel; and problems of transport, communication, and commodities (e.q., drugs at the PCHU-level are in particularly short supply, with virtually no anti-malarials available). Unplanned effects have included: an imbalance between the two program components, preventive/promotive activities (now largely neglected) and curative (strongly emphasized); a change to a vertical health program from the originally designed umbrella-type administrative structure encompassing other activities such as maternal and child health, immunization, TB control, and malaria; and a change in the village perception of the CHW as a community member promoting healthful conditions to a health provider representing government. Extensive recommendations are included.