Evaluation of AID child survival programs : Bolivia case study

In the late 1980's, Bolivia was designated a USAID Child Survival (CS) "emphasis country", and by 1992 CS represented about 60% of USAID's development assistance to Bolivia. This report evaluates the impact of that assistance, with emphasis on three key initiatives: the Community and Child Health project, USAID's major activity with the Ministry of Health (MOH); a series of Self-Financing Health Care projects, which targeted the creation and expansion of a private primary health care organization, PROSALUD; and support for Programa de Coordinacion en Supervivencia Infantil (PROCOSI), which has developed a coordinating organization for health private voluntary organizations. Major findings include the following. (1) The MOH program has greatly expanded coverage of some basic CS services; in particular, basic immunization coverage has risen from less than 10% in 1986 to 55% in 1991. However, the MOH was unable to distribute USAID-provided oral rehydration salts on a national level; as a result, diarrhea continues to be the leading killer of children under five. (2) Coverage by the private sector entities, PROSALUD and PROCOSI, is relatively small, but both provide quality services. PROSALUD in particular provides better services than the MOH and at somewhat lower costs. (3) A major breakthrough is the achievement of sustainability of CS services in several different projects. PROSALUD has shown the feasibility of recovering costs through user fees, even with low-income clients; encouraged by PROSALUD's success, the MOH has also begun to collect fees. Additionally, a USAID-funded debt-for-development swap will generate interest income for PVO health activities on a permanent basis. (4) There is evidence that USAID's CS program, though arriving late on the scene, is beginning to have an impact on reducing child mortality. The greatest opportunities for further reductions lie in the area of diarrheal disease control, and USAID should adjust its program towards this priority.